Tg close to andfar from the interface. Various techniques can selectively probe interfaces,however, often at the expense of sample designs very specific to asingle experiment. Here, we show how to translate results on confinedthin film Tg to a “nacre-mimetic”clay/polymer Bragg stack, where periodicity allows to limit and tunethe number of polymer layers to either one or two. Exceptional latticecoherence multiplies signal manifold, allowing for interface studieswith both standard Tg and broadband dynamicmeasurements. For the monolayer, we not only observe a dramatic increasein Tg (∼ 100 K) but also use X-rayphoton correlation spectroscopy (XPCS) to probe platelet dynamics,originating from interfacial slowdown. This is confirmed from thebilayer, which comprises both “bulk-like” and clay/polymerinterface contributions, as manifested in two distinct Tg processes. Because the platelet dynamics of monolayersand bilayers are similar, while the segmental dynamics of the latterare found to be much faster, we conclude that XPCS is sensitive tothe clay/polymer interface. Thus, large Tg shifts can be engineered and studied once lattice spacing approachesinterfacial layer dimensions.Studies of glass transition underconfinement frequently employsupported polymer thin films, which are known to exhibit differenttransition temperature  Tg and photon correlation spectroscopy (PCS), both of which requirespecific adaptations to probe thin films and their interfaces. ForPCS, poor signal from dynamic light scattering8 warrantsits extension to the X-ray domain (XPCS) for interface studies.9 For DS, supported (but not free-standing10) ultrathin film studies were enabled early11 by the DS capacitor geometry; however, spatiallyresolved (labeling-type) studies are reported much later, and theyachieved only 15 nm resolution.12 Clearly,a narrow choice of techniques combined with a challenging object ofstudy creates an impasse to be resolved.Confinement studieson the glass transition temperature Tg,2 freque13 In particular, when applying analytical methodsthat require labeling, it however turned out to be challenging toreproduce the labeling of each individual thin film with sufficientprecision in such a thin film stack. Consequently, the approach hasnot gained much popularity as a universal strategy. However, on theone hand, advanced nanofabrication techniques allow for improved reproducibilitybetween successive polymer layers. On the other hand, the need foralternative experimental methods has become more acute because confinementstudies have been focusing on dimensions where measurement becomesever more challenging. Indeed, particularly interesting is the molecularmonolayer and few-layer domain, where a high-viscosity region (oftentermed “irreversibly adsorbed layer” or “Guiselinbrush”)14 dominates, and relative interfacecontribution is most important. In order to address this regime, ourstudy will be based on a stacked thin film system, where the numberof single polymer layers sandwiched between two (hydrophilic) wallsis precisely tunable. The monolayer case is interesting for obtainingthe highest Tg modification respectiveto bulk, whereas examining higher layer numbers is useful for comparisonand deeper understanding. Indeed, by balancing contributions arisingfrom bulk-like and interface regions, an instance of the molecularmultilayer case will allow us to confirm two distinct Tg values from a standard DSC measurement. Similar observationshave been made (using other methods) for free surfaces15 and buried interfaces16 but without the corroborative broadband dynamic data presented here.Thus, our study uses a “stacked thin film” approach13 based on a much more reproducible fabricationtechnique to present the first evidence for a “double Tg” situation from conventional DSC measurements.Regarding the studyof dynamics under extreme confinement, a conceptuallystraightforward strategy to boost signal at least from supported thinfilms is to place several layers separated by confining spacers ontop of each other. This approach was somewhat prominent in early thinfilm confinement studies and allows achieving thermal mass sufficientfor standard differential scanning calorimetry (DSC) experiments.17 or graphene oxide,18 nanocomposites became available offering a high specific interfacearea between nanofillers and polymers. If individual nanosheets canbe preserved during compounding, for example, by solution blending,the specific interface area increases with the filler content /montmorillonite), it has already been demonstratedthat Tg is dependent on the hydrationlevel.20 For a poly(ethylene oxide)/fluorohectoritesystem, the immobilized  and mobile polymer populations(segregated) were quantified, and the confined polymer dynamics werefollowed by nuclear magnetic resonance.21 For such partial phase-segregated nanocomposite systems, the segregatedpolymer phase may be “extincted” by applying a nanofiller/polymerratio corresponding exactly to one of the intercalated domains . For this one-dimensional(1D) crystal (“Bragg stack”), the height of the gallerybetween the walls is in the range of the diameter of polymer chains.Because the cross-section of polymer chains is elliptical, like forpolyvinylpyrrolidone ,22 preventing the formation of coils in the confined space.The PVP chains with 360 monomers are about 90 nm long (contour length),while the average diameter of the confining nanoplatelets is almostfour times that length . The confinement is, however, genuinely two-dimensional, so thatloops are always possible, but chain entanglements are not allowedin the monolayer case. For the double layer, chains are expected tocross from top to bottom, allowing for chain interpenetration.With the advent of various ultrathin filler materials, like nanoclays content 1a. Two c content 1a. Τhe d content 1b. With  domains 1c,d. Thione PVP, 1 are muc23 this material was characterizedwith a focus on its high thermoelastic anisotropy, where XRD data in the dry state. At these elevated temperatures,increased direct current (DC) conductivity of the material has previouslybeen seen to be a challenge for DS, with no clear observation of theα-, but only β- and αβ-processes claimed.25 Along with the strong X-ray signal of the Braggstack, particularly around the first-order (001) diffraction peak,this suggests the use of XPCS for dynamic characterization. Indeed,the latter has already been applied to inorganic superlattices26  as well as various colloid dynamics studies on clay plateletsin suspension.31 However, the use of XPCS here is warranted foremost because, aswe will argue, it exhibits selective interface sensitivity.Recently,Tg. Here, at a scan rate of 10 K/min, DSC shows broad glass-rubbertransition around Tg = 537 ± 9 K(bottom trace of 32 increasewith respect to TPVP = 437 ± 1 K(25 A similarly large Tg increase was recently reported16 for poly 2-vinyl pyridine (P2VP) in the vicinityof a glass substrate but can be confirmed here for a true nanocomposite,not a labelled thin film. Alternatively, the large Tg increase can also result from the slowdown due to thecomplexation of Na+ by PVP because the clay layers carrya permanent negative charge that is compensated by Na+ residingin the interlayer space concomitantly with PVP. Thus, the Na+–PVP interaction was reflected in small but significant shiftsof relevant bands in the infrared spectrum . This is in line with observations on polymer electrolytes:for bulk polypropylene oxide (PPO)/NaCF3SO3 electrolyteswith the monomer/Na ratios of 30:1 and 16:1, the PPO Tg upshift was about 9 and 19 K, respectively.34 For the extremely confined monolayer hybrid Bragg stack with a 5:1monomer/Na+ ratio, the observed PVP Tg increase (∼ 100 K) is, however, clearly much higherthan that anticipated (∼ 60 K) based on such a polymer electrolyteeffect. Either way, and regardless of quantitative considerations,the general trend of a slowdown is well known to be that for attractive(hydrophilic) interfaces.35 The very broadDSC step compared to bulk PVP  than that in the bulk PVP , reflecting the loss of theinternal degrees of freedom because of the extreme confinement andcomplexation of PVP with Na+.The monolayer sample 1c repres37 ± 1 K2, right spectrum S4. This Tg upshiftin the monolayer sample is that the resulting high temperature rangeinvolved renders DS inapplicable because of increased DC contribution.Conversely, the need for broadband dynamic data is reinforced by thefailure of the temperature-modulated (TM) DSC traces to locate Tg for all but the highest heating rates are represented by g2 = α*exp(−2*[Γ(q)*t]β) + A, with α, Γ(q),β, and A (∼ 1) being the contrast, relaxationrate, stretching exponent, and baseline, respectively. The shape ofthe structural relaxation function S = [g2-A]1/2 is that of a compressed exponentialwith β = 1.5 ± 0.2, which is seen to be reassuringly insensitiveto temperature variations collective dynamics. Often, it is accompanied by a hyperdiffusive behavior (Γ ∼ q). For the dynamics ofpolymer melts probed by single gold nanoparticle motion, the XPCSrelaxation function is a single exponential with a diffusive rateat high temperatures.42 With temperaturedecreasing toward Tg, the relaxation functionbecomes that of a compressed exponential, with β increasingup to 1.8 close to the polymer Tg, andthe dynamics changing from diffusive to hyperdiffusive. Regardingthe dynamics of the present hybrid Bragg stack, they bear resemblanceto those in the above-mentioned ferroelectric PbTiO3/SrTiO3 superlattice26 and those in anisotropic(peanut-shaped) magnetic colloids aligned normal to an external magneticfield.43 In the former, the XPCS resultsfrom fluctuations of disordered domains are also described using acompressed exponential function. In the colloidal crystal, XPCS structuralrelaxation along the magnetic field direction (Bragg direction) iscompressed at low q with a ballistic rate behavior.Although no clear consensus seems to have emerged in the communityon the microscopic mechanism responsible,44 the compressed exponential is thus not unexpected in the presentsystem.The downside of the high ng rates 2 left. Ipatterns 3a over t= 1/Γare summarizedin the Arrhenius plot of Tg asdetermined by DSC (537 K) where the first XPCS speckle pattern serieswas obtained at 553 K with ∼ 3 h acquisition time  is expectedly much longer than segmental relaxation τs = 20 s, which corresponds to TM-DSC at a heating rate of10 K/min (τ(T = Tg)/τs ∼ 540), and it can easily be corroborated by estimatingfrom theory. The proper formula for doing so is notknown because the q-dependence of τ cannot be deduced from observationslimited to behavior around the first-order diffraction peak . Such aq-dependent τ(q) study around the first-orderdiffraction peak would be more appropriate for a low Tg polymer layer like polyethylene oxide. However, forthe sake of simplicity, assuming heuristically platelet motion tobe diffusive47 according to τ = 1/(D*q2) = (16*η*R)/(kB*T*q2) and using the plateletdiameter R = 340 nm and the Boltzmann constant kB, we calculate viscosity η ∼ 5*107 Pa*s at 553 K. This value is within the viscosity range reportedfor bulk PVP with a molecular weight of 44–54 kg/mol near Tg (433 K).48 In thisestimation, we ignored the thermodynamic slowdown47 of the collective τ(q) at qbi at which the structure factor attains itsmaximum value  is actually composed of a double step. The additionaltransition at Tg,h = 551 ± 9 K withΔCp,h ∼ ΔCp,1/3 is up to the experimental uncertainty similar intemperature to the monolayer case (Tg =537 ± 9 K as above), which it also resembles in its absence fromslower heating rate runs  associated with the glass transition process.51 The computed ξ (∼ 0.8 nm) fromthe DSC traces of Figure S8,is smaller than the galley heights of the bilayer hybrid stack shownin We surmise that the origin of this large from DSC 2, middleate runs 2, left. Tg,l from DSC, there is interestin examining the segmental PVP dynamics. We can now utilize DS tothis end because the PVP composition fraction in the bilayer is higher,and the temperature range suggested by Tg,l is more amenable to examination by DS than in the monolayer case.Indeed, a weak but sufficient dielectric permittivity signal is inevidence (ε(ω) spectra, as shown in /dlnω from the Kramers–Kronigrelationship), where electrode-polarization at low frequency was capturedby a power law.52 In the fitting procedure,a sum of two Havriliak–Negami (HN) functions (Methods) wasused at a given temperature, corresponding to the α/β-and γ-processes. The two processes exhibit different temperaturedependences on cooling, as shown in the top and bottom panels of Tg,l, only the high-frequency γ-processis resolved (T = 393 K), although the tail of theα-process can be seen at low frequencies (solid line). Above Tg,l, the main process dominates the ε(ω)spectra of the bilayer. At 513 K, the faster γ-process (dottedline at high frequencies) was included in the fitting procedure, andan additional slower process appears (dotted line at low frequencies)that is associated with the ionic conductivity (electrode polarizationeffects). The relaxation frequency of the γ-process conformsto an Arrhenius temperature dependence . With respect to the α-process, its characteristicschange with temperature, from a VFT dependence at higher temperatures.Because of this discrepancybetween the platelet dynamics fromXPCS and pendence S9. With pendence S9. With s= τoexp[(E/R)/(T-T0)] with the limiting high-temperaturetime τo = 10–12 s as the fixedparameter, and activation energies E/R and the ideal glass transition temperature T0 as the adjustable parameters. From this representation ofDS times, E/R = 4000 ± 200K and T0 = 330 ± 10 K. T0 is low compared to Tg,l , which results in a near-Arrhenius behavior and indicates astrong glass former. The shape of the DS α-process is characterizedby a stretching exponent β = 0.6, suggesting a moderately broadrelaxation distribution in contrast to the very broad DSC trace. Thisfinding corroborates the notion that DS probes a single Tg,l. At temperatures below Tg,l, DS reveals an additional very broad secondary relaxation process(γ) shown in Figure S9). Finally, the temperature dependence of the segmental dynamicsof the bilayer is very similar to that of bulk PVP (E/R = 3200 ± 200 K and T0 = 331 ±6 K), only shifted upward in temperature by Tg,l-TPVP = 44 K.25For the VFTfit, the definition is τTg,h.Indeed, the XPCS data for monolayer and bilayer are quite similar,with the Arrhenius fits for both intersecting for τmono(Tg = 537 K) = 10,770 s at the monolayer Tg, as determined by DSC. Thus, we infer thata Tg process comparable to that of themonolayer persists in the bilayer as the Tg,h process, alongside a new Tg,l process.Hence, the most evident explanation to reconcile the XPCS and DS datasetsis to associate them with two different relaxation processes in thepolymer, as also reported for polyelectrolytes.34 However, considering previous results,16 these relaxation processes are most readily interpreted as pertainingto bulk-like  to probe local dynamics. Platelets hereseem to fulfill a double role of both marker and confinement devicefor the polymer.While comparing segmental dynamics for bilayer andbulk PVP isstraightforward, this is less evident for the absolute values of plateletand segmental relaxation times. The much higher temperature of XPCS3c comparulk-like 1d and inE/R of structuraland segmental relaxations. For the bilayer XPCS times /((1-(T0/T))2 at T = Tg,l is easily computedto be 40,550 K, which matches the Arrhenius fit of the XPCS bilayerdata (Tg). However, there is unfortunately some inconsistencybetween the XPCS slopes from the monolayer and bilayer sample, withthe former found to be 22,000 ± 2300 K, which leads to theirintersecting around Tg, as mentioned above.Such a flattening of the apparent Arrhenius energy is not to be expectedfrom the VFT curve, considering the hypothesis of similar  Tg values, although it is sometimes observedas a confinement effect56 on approachingthe length scales of the cooperative dynamics.After dwelling on the differences between theXPCS and DS results,considering similarities can help us verify their consistency. Whileoffsets here are difficult to compare quantitatively, this is moreobvious for the VFT activation energy CS times 3c, a rep DS data 4b. Alteryerdata 3c witha23 elastic anisotropy of the nanocompositefrom Brillouin light scattering (BLS). In the so-called shoving model58 for the local segmental relaxation time τs ∼exp(G(T)Vc/RT), the total Arrhenius activation energy E = G(T)Vc  can beestimated from the shear modulus G(T) and the characteristic volume Vc. Theapplication of this formula to an anisotropic system, exhibiting bothout-of-plane shear moduli ⊥G andin-plane shear moduli ||G, would requiredirect access to direction-dependent local segmental dynamics. Tothe best of our knowledge, we are not aware of such experiments. Turningto structural dynamics, anisotropy effects can be addressed by thevector nature of q. For the ordered concentratedsuspensions of magnetic anisotropic colloidal particles, XPCS revealeddifferent collective dynamics along and perpendicular to the externalmagnetic field direction.43 The formerdirection is along the assembled colloidal chains, and here, it correspondsto the out-of-plane direction. Normal to the Bragg plane, shear moduli ⊥G ∼ 1 GPa are lower but closeto that of the pure polymer (GPVP ∼2.5 GPa)23 and nearly identical between both samples,ruling out a change of slope due to anisotropy. Using PVP densityρ = 1200 kg/m3, monomer molecular weight M = 0.111 kg/mol, Vc ∼ M/ρ, and neglecting any G(T) temperature dependence  or molecular weight effect correction,58 the corresponding Arrhenius temperature estimateis 11,100 K, about half of what was found from the XPCS Arrheniusfits but clearly the right order of magnitude. ||G is much higher, that is, 25.1 GPa (bilayer) and 32.9 GPa(monolayer), which one might expect to see reflected in the Arrheniusenergies deduced from DS, which measure an isotropic average. In theDS experiment, the field orientation is normal to the Bragg planes,as with XPCS, but this is only expected to influence the observedrelaxation times in very special cases, for example, liquid crystals,60 but affects only intensity in, for example,crystalline polymers.61 However, as wesaid, the observed agreement between the “isotropic”DS and “anisotropic” XPCS is quite good; hence, we canconclude that mechanical anisotropy does not seem to impact our resultsin a significant way.Apparent Arrheniusenergies can also be related to our recentlyreportedTg increasebut also to access a regime where signal contributions could be balancedin such a way as to give rise to an appearance of two distinct Tg values from bulk-like and interface regionsin the DSC traces. This resembles results reported in previous studies16 but with two additional broadband dynamic data sets (from DS andXPCS) for each Tg to strengthen our case.Depending on the priorities, one could now try to improve on the experiment:while nacre-mimetics benefit from self-assembly methods and the achieved Tg shift will be a hard rival, they are limitedto certain polymer/filler combinations. Thus, alternative fabricationmethods, such as layer-by-layer deposition, should be explored, whichmight also offer nearly unlimited tunability of gallery spacing. Amongdifferent fillers, graphene, already the subject of simulations inhybrid stack geometries,62 might be anattractive substitute for mica by virtue of its thick adsorbed layer,63 which in turn might facilitate characterization using differenttechniques. Finally, we also hope that this study will be a bridgebetween basic and applied research: Indeed, the present system illustratesan application for confinement effects through its large Tg increase, which could render it a potential alternativeto traditional high-temperature thermoplastics, such as polyimides.We have shown how aclay/polymer Bragg stack enabled by advancedand very reproducible molecular-scale self-assembly techniques canbe used to conduct studies of glass transition under confinement onpolymer thin films. Particularly, for the challenging problem of interfacialdynamics, it had formerly often been necessary to deploy very creativetechniques using specifically modified samples to do the same. A shift toward fewer experimental methodsand more universally accommodating sample designs can be anticipatedwith an increasing maturity of the discipline, if suitable new modelsystems can be identified. By virtue of their supporting characterizationusing a variety of techniques, we believe that we have shown thatnacre-mimetics are a strong candidate. For the problem of interfaces,the tunability of the Bragg stack periodicity  has allowed us not only to find a composite witha very high (∼ 100 K) Figure S1) in order to speed up diffusion dynamics sufficiently to reach timescaleseasily observable in an XPCS experiment. Mixing the hectorite suspensionwith varying amounts of an aqueous PVP solution, followed by spraycoating, 1D crystalline hybrid Bragg stack films were obtained. Twosamples with a hectorite content of 40 vol % (60 wt %) and 31 vol% (50 wt %), respectively, were prepared . These correspond to monolayer andbilayer PVP, respectively, as can be shown by XRD. Indeed, for bothcompositions, a rational 00l series up to the 7th and 10th order was observed with a d-spacing of23 Å for the monolayer and 30 Å for the bilayer . Indeed, PVP is elliptical with vander Waals radii of the shorter and longer principle axis of 1.0 and1.3 nm, respectively. This allows to correlate the observed d-spacings with a monolayer of PVP oriented with the longerprinciple axis along the stacking direction (dmono = 23 Å) and a bilayer of PVP with the shorter principleaxis oriented along the stacking direction (dbi = 30 Å). Taking the different orientations of the PVPchains in the monolayer and bilayer sample into account, the interfaceof the hectorite nanoplatelets with the PVP chain varies (indicatedby Hec-PVP and Hec-PVP*). Moreover, for the bilayer sample, a secondbulk-like region is created  was reduced at this stageto 340 nm by ultrasonication S1 in ordmono = 3.55°and 2 × θbi = 2.72°, corresponding to latticespacings of dmono = 23 Å and dbi = 30 Å (qmono = 2.732 nm–1 and qbi = 2.094 nm–1) for the monolayer and bilayer samples,respectively with temperature was compensated for by appropriate readjustments.At the end of the experiment, visual inspection did not reveal anychange in the sample appearance, so no decomposition seemed to haveoccurred.For the XPCS experiment, the samples werevacuum-dried at 100 °Cfor a week to remove any residual water and then transported to thesynchrotron in a desiccator. The measurement was performed in thesecond experimental hutch of the P10 beamline at Petra III  at a photon energy of 8.7 keV. The X-rays were focused toa spot of < 5 μm and detected using an Eiger X4M detectorat approximately 5 m distance. The samples (thin strips of dimensions∼ 2 × 10 × 0.03 mm) were mounted on a specially designedcopper holder placed in reflection geometry under vacuum, while employingtemperature control of the sample environment. On the goniometer,we proceeded to set angles of 2 × θectively 1c,d. A r= ε’–iε”,where ε’ is the real part and ε” is theimaginary part, was obtained as a function of frequency ω and temperature T, that is, ε*. Importantly, the real and imaginary parts do not crosswithin the investigated frequency/temperature range , excluding the possibility of the process beingdue to ionic relaxation. 64k indicates the processunder investigation, Δεk(T) is the relaxation strength, τHN,k is the relaxationtime of the equation, mk and nk  describe thesymmetrical and asymmetrical broadening of the distribution of relaxationtimes, and ε∞ is the dielectric permittivityat the high-frequency limit. The relaxation times at maximum lossτmax have been analytically obtained from τHN in the HN equation following:To support the XPCS measurements, only for the bilayer,DS characterizationwas performed as a function of temperature in the range from 357 to526 K using a Novocontrol Alpha frequency analyzer. In all cases,the complex dielectric permittivity ε* re range S11, excl”, thederivative of the real part of the dielectric permittivity (dε’/dlnω ∼ (2/π)*ε”) was used.52 This procedureprovides somewhat narrower peaks and suppresses the ionic conductivityas well, as shown in Figure S12). We haveemployed this approach to locate the frequency maxima of the dynamicprocesses. Subsequently, fits were performed in the dielectric lossrepresentation with fixed frequency maxima from the derivative approachhaving free shape parameters. Because of the number of parametersinvolved, certain fitting criteria were employed. The parameters forthe low-temperature γ-process were kept constant to the bulkPVP values. All the dielectric loss curves were fitted several timesstarting from different initial parameters until they converged tothe same final values. Subsequently, the parameters  were further optimized. Minimization was madein Origin Lab 9.0 using the Levenberg–Levenberg–Marquardtalgorithm (this iterative procedure combines the Gauss–Newtonand the steepest descent method). The respective number of iterationsand tolerance were typically 500 and 10–15, respectively.In addition to the measured ε–1. The cooling rate (q) was typically 20 K/min, yielding a q to thesubsequent heating rate (m) ratio between 2 and 6.65 As for the heating rates, we have employed β = (ΔT/nP)60 s·min–1  that ensures 6 cycles within one periodfor the transition zone in bulk PVP. For the much broader transitionsin the hybrid Bragg stacks, the number of cycles is even higher. Finally,for DMA, several (> 10) samples were stacked on top of each other,loaded into a metal clamp and fused by heating to 250 °C. Then,the 30–350 °C range and frequencies between 0.2 and 20Hz were scanned during the measurements. Argon atmosphere and vacuum-driedsamples were used for all of the above-mentioned three methods.The glass transition of the dried monolayer, bilayer, and PVP sampleswas recorded by modulated DSC measurements with an amplitude of 1K and for oscillation periods in the range from 20 to 60 s with thecorresponding heating rates from 10 to 3.3 K·min


Descriptive statistics were performed on all questions. Linear regressions were used to examine the relation between media consumption, wellbeing and stress. Almost all respondents classified their health status as “good” or better (92.5%). The average sedentary and physical activity time was 7.2 ± 3.5 h/day and 8.8 ± 10.7 h/week, respectively. Respondents slept for 7.5 ± 1.3 h/night on weekdays and for 8.5 ± 1.5 h/night on weekends, but many were “sometimes” or more frequently overtired (53.1%). Daily duration of playing video games (230.4 ± 159.3 min/day) and watching livestreams and videos with (102.6 ± 101.7 min/day) and without gaming content (72.9 ± 88.5 min/day) were much higher than watching regular television (18.9 ± 49.1 min/day) or reading analog media (32.1 ± 53.5 min/day). In terms of stress and wellbeing, most players reported low stress levels (13.8 ± 5.7) and reached a moderate average score of 60.1 ± 16.4 out of 100 points in the WHO-5 Well-Being Index. Linear regressions revealed no relevant significant associations. The results indicate good subjective health and health behavior of the target group. However, the high amounts of screen-based media-consumption, as well as the moderate stress and wellbeing levels show potential for improvement. In addition, the target group consumed high amounts of digital media in reference to gaming, while traditional media consumption was distinctly low. Consequently, media campaigns that address health promotion in this target group should use the platforms of digital media instead.The popularity of video gaming and eSports is increasing rapidly. However, most research focuses on the economical features and psychological consequences of gaming and only little is known about the health behavior of the players. Therefore, this study is a follow-up of the eSports Study 2019 and further investigates the health and health behavior of video game and eSports players in Germany. This cross-sectional study, conducted between April and September 2019, includes 1038 players (91.2% male; 23.0 ± 5.4 years; body mass index: 24.8 ± 5.0 kg/m Video gaming and competitive video gaming, also known as eSports, have been gaining global attention in recent years. Various structures such as federations and organizations are emerging, global companies are investing in eSports and general gaming, as well as eSports, is becoming increasingly popular in society as a recreational activity. The numbers of the global eSports audience and active eSports players are rising every year Newzoo, . AccordiThe growing interest in video gaming and eSports has also resulted in some significant downsides. Due to the potentially addictive characteristics of excessive gaming, the World Health Organization (WHO) came to include gaming disorder as a diagnosable disorder in the 11th International Classification of Diseases (ICD-11) in 2018 , various video game and eSports related platforms, as well as in-person during live events . In addition, the authors' contacts to eSport organizations were used to further disseminate the study. In order to recruit potential participants, an explanation of the aim of the study, eligibility criteria and an incentive (chance to win one out of five €25 Amazon vouchers) were given during the distribution. The data collection took place from April 5 to September 13, 2019.The current study is a follow-up of the eSports Study 2019 .Participants were eligible for the study if they were living in Germany, understood the German language and were actively playing video games or eSports. At the beginning of the survey, an information sheet specifying the purpose of the study was displayed and consent to participate was obtained. Afterwards, a filter question was displayed to verify the current country of residence. For participants who did not live in Germany, the survey ended and they were excluded.Questback GmbH, Cologne, Germany). The questionnaire contained a total of 41–43 questions, depending on participants' answers to the filter questions.The questionnaire was designed to examine video game and eSports players in terms of demographics, video gaming behavior, media usage, health behavior, stress and wellbeing. It was administered via the online survey tool Unipark ,former professionals ,amateurs ,regular players ,occasional players ,non-players.The non-players were excluded from all analyses. If participants were amateurs, former professional players or professional players, they received an additional question about their income from price money or player salaries in the last 12 months:“no income,”“1–500€,”“501–1,000€,”“1,001–2,500€,”“2,501–5,000€,”“5,001–10,000€,”“more than 10,000€,”“prefer not to say.”Furthermore, all players were asked about their favorite eSports genre (semi-open-ended question) and had to specify how much time they usually spent on the following media each day (hours and minutes):“playing eSports games,”“playing other video games,”“watching live-streams and videos on demand (VOD) with gaming-related content,”“watching live streams and videos on demand (VOD) without gaming-related content,”“communicating via messenger services or voice chat,”“using social media,”“browsing the web,”“watching television,”“listening to music/radio,”“reading print media.”To avoid excessive entries, the hours were limited to 23 and the minutes to 59 in this section.The questions on health behavior refer to the last 4 weeks. These include:Overall health status ,Duration of moderate to vigorous physical activity (hours per week),Duration of sedentary time (hours per day),Average time of falling asleep on weekdays and the weekends (hours and minutes),Average time of getting up on weekdays and the weekends (hours and minutes),Number of awakenings during the night.Physical activity was described as activities in which the pulse rate increased at least slightly or participants became slightly out of breath. Examples given were cycling, fitness training, playing soccer or climbing stairs. This includes physical activities at work as well as during leisure time. Sedentary time was recorded as sitting or resting, excluding nighttime sleep.EBF-24 A/3 . Wording and rating of these questions were designed with reference to the “went to bed later than planned because of the game,”“thought about the game during the day,”“thought about the game when going to sleep,”“got tired of the game,”“had a good time with friends in the game,”“had a good time with friends away from the game,”“slept restlessly,”“were overtired,”“couldn't fall asleep because of the game.”Perceived Stress Scale  or implausible (reporting daily sleep time <4 or > 16 h). One missing value was allowed for each of the topics on demographics, video gaming behavior, media usage and health behavior, but the respective participants were excluded from the analyses of the respective question. Missing values within the PSS and WHO-5 resulted in exclusion of the participants from the analyses of the respective topic. Participants who did not provide information on height or weight were excluded from all analyses.The body mass index (BMI) was calculated weight and height of the participants. Additionally, the duration of “playing eSports games” and “playing other video games” was summarized as “active gaming overall”. The sleep duration on weekdays and weekends was calculated for everyone based on the respective time of getting up and going to bed.Following the manual, the points from the WHO-5 were summed up and multiplied by four to obtain the final score . Whilst a higher WHO-5 score indicates a healthier wellbeing of the person, a value below 50 marks questionable scores and further medical examinations should be sought  and wellbeing, and subjective health status. For this purpose, media usage variables with screentime were summarized and health status was recoded into a dichotomous characteristic with the parameters “good or better” and “bad or worse”. The level of significance for all analyses was set at p < 0.05. All statistical analyses were conducted using IBM SPSS Statistics 26 .Descriptive statistics were applied to all data. For each player status, numerical data were described by means and standard deviations, ordinal and nominal data by frequencies. All data were checked for normal distribution. If a non-normal distribution was present, statistical differences between the groups or between two time points were calculated by the Kruskal-Wallis-test, Fisher's exact test or Wilcoxon-test. Otherwise, an ANOVA was performed. The flow chart of the participation progress is depicted in n = 947; 91.2%) and well-educated. Two thirds of the participants were university students  or working in full-time jobs , while the other third were pupils  and apprentices . Overall, the average BMI of the sample was 24.8 m2/kg, which can be classified as normal weight.n = 130; 12.8%), “very good”  or “good”  health status. Only a few had a “fair”  or “poor”  health status  exceeded the WHO recommendations of 2.5 h of physical activity per week. The average amount of sedentary time was 7.2 (± 12.4) hours per day. No statistically significant differences between player groups were found in the data on health behavior.Overall, the participants reported to be physically active for about 8.8 (± 10.7) hours per week and the majority (p = 0.04), amateurs  and regular players . On weekends (8.5 ± 1.5), the total sample slept ~1 h longer than on weekdays . During the night, all participants woke up more than once on average, and the regular players (1.2 ± 1.9 h/night) woke up significantly less often than the occasional players .n = 271; 28.9%), “rarely”  or “sometimes” . Furthermore, about half reported that they were “sometimes”  or more often  overtired.With regards to the information on restless sleep, the majority of players specified “never” (p < 0.05). Additionally, the amateurs  spent significantly more time on media than the regular players .The media usage of the sample is displayed in tactical shooters, followed by multiplayer online battle arenas and sports and racing simulations . The favorite game genres were ulations .p = 0.04) and the regular players , they played significantly more eSports games. Concerning watching VODs with gaming reference, only the occasional players (74.3 ± 84.8 min/day) differed from the regular players  and amateurs .Regarding the time spent with gaming, statistically significant differences were found between the player groups see . For exap < 0.001). Regarding the online non-gaming media, messaging accounts for the highest time span (182.5± 185.2 min/day), followed by the use of social media (86.6 ± 124.6 min/day). The professional players (260 ± 186.6 min/day) communicated via messenger services significantly more often than the occasional players  and regular players did . Likewise, the use of social media was highest among professional players (152.0 ± 141.8 min/day) and differed significantly from occasional  and regular players' usage .As seen in p = 0.02) and amateurs .Traditional media consumption was the lowest in the sample . While m = 3.89, p < 0.001] as well as on weekends  were found  = 4.48, p < 0.001]. Therefore, the score of the PSS increased by 4.8 for every hour which the participants spent playing non-eSports video games.Furthermore, statistically significant minor correlations between media usage and the PSS scores were found . In this case, the final score of the WHO-5 increased by 0.6 for every hour the participants spent playing eSport video games, and by 1.8 for every hour spent on analog media.There are also significant correlations between media usage and the WHO-5  as well as the subjective health status [p < 0.01] were found . Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.KR, IF, and CG: conceptualization. KR, MS, PB, CT, and KW: data curation. KR and KW: formal analysis. IF and CG: funding acquisition, project administration, and supervision. KR, MS, PB, IF, CT, KW, and CG: investigation and writing—review and editing. KR: methodology. IF: resources. KR, MS, PB, CT, KW, and CG: validation. KR, MS, and IF: visualization. KR and MS: writing—original draft. All authors contributed to the article and approved the submitted version.The present study is part of the esportwissen.de-project, which was financially supported by the AOK Rhineland/Hamburg. The funders had no influence on the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.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.


This review investigated whether the adjunctive use of antioxidants with periodontal therapy improves periodontal parameters in patients with type 2 diabetes. A systematic and extensive literature search for randomized controlled trials (RCTs) conducted before April 2021 was performed on the PubMed, Cochrane Library, and Web of Science databases. The risk of bias was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed to quantitatively evaluate the clinical outcomes following periodontal therapy. After independent screening of 137 initial records, nine records from eight RCTs were included. The risk-of-bias assessment revealed that all RCTs had methodological weaknesses regarding selective bias, although other risk factors for bias were not evident. This meta-analysis of two RCTs showed that periodontal pocket depths were significantly reduced in the groups treated with combined non-surgical periodontal therapy and melatonin than in those treated with non-surgical periodontal therapy alone. The present systematic review and meta-analysis suggest that the adjunctive use of melatonin, resveratrol, omega-3 fatty acids with cranberry juice, propolis, and aloe vera gel with periodontal therapy significantly improves periodontal disease parameters in patients with type 2 diabetes, and melatonin application combined with non-surgical periodontal therapy might significantly reduce periodontal pocket depth. However, there are still limited studies of melatonin in combination with non-surgical periodontal therapy in Type 2 diabetic patients, and more well-designed RCTs are required to be further investigated. Periodontitis is an inflammatory and infectious disease caused by dental plaque ,2. ConsiNox1, Nox2, Nox4, and p47 in diabetes model rats  OR “diabetes insipidus”[MeSH Terms] OR “diabet*”[Title/Abstract] OR “dm 1”[Title/Abstract] OR “dm i”[Title/Abstract] OR “dm 2”[Title/Abstract] OR “dm ii”[Title/Abstract] OR “glycated hemoglobin a”[MeSH Terms] OR “a1c”[Title/Abstract] OR “hb a1c”[Title/Abstract] OR “hba1c”[Title/Abstract] OR “blood glucose”[MeSH Terms] OR “blood sugar”[Title/Abstract] OR ((“glucose”[Title] OR “sugar”[Title]) AND (“level”[Title] OR “control”[Title])) OR “hyperglycemia”[MeSH Terms] OR “hypoglycemia”[MeSH Terms] OR “glycemi*”[Title/Abstract] OR “glycaemi*”[Title/Abstract] OR “hyperglyc*”[Title/Abstract] OR “hypoglyc*”[Title/Abstract]) AND  OR “aloe vera”[Title/Abstract]) OR (“melatonin”[MeSH Terms] OR “melatonin”[Title/Abstract] OR “melatonins”[Title/Abstract] OR “melatonine”[Title/Abstract] OR “melatonins”[Title/Abstract]) OR (“propolis”[MeSH Terms] OR “propolis”[Title/Abstract]) OR (“coenzyme q10”[Supplementary Concept] OR “coenzyme q10”[All Fields] OR “coenzyme q10”[All Fields] OR “ubiquinone”[MeSH Terms] OR “ubiquinone”[All Fields] OR (“coenzyme”[All Fields] AND “q10”[All Fields])) OR (“polyphenol s”[All Fields] OR “polyphenoles”[All Fields] OR “polyphenolic”[All Fields] OR “polyphenolics”[All Fields] OR “polyphenols”[MeSH Terms] OR “polyphenols”[All Fields] OR “polyphenol”[All Fields]) OR (“curcumin”[MeSH Terms] OR “curcumin”[All Fields] OR “curcumin s”[All Fields] OR “curcumine”[All Fields] OR “curcumins”[All Fields])). A similar search strategy was applied to all the databases. Additional electronic searches were performed in the Journal of Periodontology, Journal of Clinical Periodontology, Journal of Periodontal Research, and Antioxidants, to increase the likelihood of identifying relevant papers .In the first stage, the titles and abstracts of all retrieved articles were screened for potentially eligible studies. Full-length articles of the identified studies were examined in detail according to the eligibility criteria for inclusion in this review. Two reviewers (RM and KM) independently performed the screening process. In case of a disagreement between the reviewers, a consensus was reached through discussion. The following studies were included:1. RCTs examined the efficacy of antioxidants on periodontal parameters in patients with both type 2 diabetes and periodontitis.2. Studies with periodontal treatment with non-surgical therapy, such as scaling and root planing (SRP), or surgical therapies such as flap procedures, as interventions.3. Studies in which participants were allocated to experimental and placebo/control groups.4. Studies with outcome variables including clinical parameters for periodontitis such as probing pocket depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP).5. Studies published in English.The exclusion criteria were as follows:1. Review articles, case reports, descriptive studies, opinion articles, abstracts, animal experiments, and in vitro studies.2. Clinical studies conducted on participants with diabetes other than type 2 diabetes, such as type 1 diabetes.3. Studies that included endodontic treatment for apical periodontitis.The risk of bias was evaluated in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, using the following parameters: adequacy of sequence generation; allocation concealment; blinding of participants, personnel, and outcome assessors; incomplete outcome data; and selective outcome reporting . Data containing fundamental information and outcomes, including publication information, country, study design, sample size, participant characteristics, randomization method, allocation concealment, blinding measures, intervention and placebo or control approach, laser parameters and regimen, outcome measurements, follow-up duration, patients lost to follow-up, and the occurrence of any adverse events were collected.2 statistic, at an alpha level of 0.10. The meta-analysis was performed using REVMAN 5.3. For the hypothesis test, an alpha value of 0.05 in a two-tailed Z-test was considered statistically significant.The weight of each study included in the meta-analysis was determined by the reported standard deviation and sample size. The effect size was estimated and reported as the mean difference with a 95% confidence interval (CI) for PPD. Because each analysis included a small number of studies, the variance between the studies was poorly estimated. Thus, a fixed effects model was adopted for the analysis . HeterogAfter excluding duplicates from the results of the hand search, 137 reports were identified after the initial search. During the first stage, 124 reports were excluded based on the evaluation of titles and abstracts . Second, after screening the full texts of the remaining 13 articles, four reports were excluded for irrelevant outcome measurement , insuffiThe study characteristics and parameters related to diabetes and periodontitis are shown in The results of the methodological quality assessment are shown in Two melatonin supplementation studies compared SRP alone to SRP plus melatonin therapy (3 mg) over 2 months. Anton et al. showed that the administration of melatonin significantly decreased the mean values of BOP, PPD, and CAL post-intervention . Bazyar p < 0.00001)  .In this systematic review, significant improvement in periodontal parameters was reported, compared with SRP alone, following four antioxidant interventions, namely melatonin ,54, propIn contrast, administration of vitamin C ,58 and cConsidering the severity and activity of periodontal disease on antioxidant effects in adjunct with periodontal therapy, deep PPD was reported at the baseline in the studies of vitamin C ,58 and aPPD did not change before and after SRP in the control group of several studies ,54,60. AHigh HbA1c values are correlated with severe diabetic complications, and reductions in HbA1c levels reduce morbidity and mortality from diabetes ,82. All Apart from periodontal disease and type 2 diabetes, other comorbidities, noticeable change in consumption of medications, or any medication that can affect the periodontal status or the beneficial antioxidants intervention were not reported in all the subjects in the included studies. Furthermore, all the studies excluded the use of insulin treatment as an exclusion criterion, except for one study on oral propolis  that 8% Our meta-analysis revealed that groups that underwent melatonin treatment showed significantly improved PPD compared to the control groups ,54. ConsThis systematic review and meta-analysis has several limitations. First, it is desirable to compare antioxidants by type or application protocol, because the mechanisms by which antioxidants act on periodontal tissue might differ depending on the type of antioxidant. However, in this review, because the number of available articles was limited, we did not categorize studies by the type of antioxidant or application protocol. Second, although acceptable, bias assessment indicated that all studies included in this systematic review had methodological weaknesses. Third, the number of available studies was insufficient to confirm the efficacy of each antioxidant as an adjunct to periodontal therapy in patients with type 2 diabetes. The present meta-analysis showed the benefit of adjunctive use of melatonin supplementation in non-surgical periodontal therapy. However, the assessment should be interpreted carefully as only two RCTs could be included in the meta-analysis, and the number of subjects was insufficient. Overall, the small number of included studies contributed to various limitations in this systematic review and meta-analysis. To accumulate evidence regarding the effect of antioxidants in combination with periodontal therapy in patients with type 2 diabetes, more well-designed RCTs with sufficient sample sizes based on the power calculation should be conducted with reference to Cochrane’s risk-of-bias assessment criteria.The present systematic review and meta-analysis suggests that the adjunctive use of antioxidants with periodontal therapy significantly suppresses periodontal disease parameters in patients with type 2 diabetes, and indicates that melatonin application combined with non-surgical periodontal therapy might significantly reduce periodontal pocket depth.


Flavobacteriia, because they are main responders during these blooms and have an important role in the degradation of polysaccharides. A cultivation-based approach was used, obtaining 44 lytic flavobacterial phages (flavophages), representing twelve new species from two viral realms. Taxonomic analysis allowed us to delineate ten new phage genera and ten new families, from which nine and four, respectively, had no previously cultivated representatives. Genomic analysis predicted various life styles and genomic replication strategies. A likely eukaryote-associated host habitat was reflected in the gene content of some of the flavophages. Detection in cellular metagenomes and by direct-plating showed that part of these phages were actively replicating in the environment during the 2018 spring bloom. Furthermore, CRISPR/Cas spacers and re-isolation during two consecutive years suggested that, at least part of the new flavophages are stable components of the microbial community in the North Sea. Together, our results indicate that these diverse flavophages have the potential to modulate their respective host populations.It is generally recognized that phages are a mortality factor for their bacterial hosts. This could be particularly true in spring phytoplankton blooms, which are known to be closely followed by a highly specialized bacterial community. We hypothesized that phages modulate these dense heterotrophic bacteria successions following phytoplankton blooms. In this study, we focused on  Marine bacteriophages outnumber their hosts by one order of magnitude in surface seawater and infect 10–45% of the bacterial cells at any given time . They haFlavobacteriia belong to the main responders [Flavobacteriia to low molecular weight compounds and thus they are important for the carbon turnover during phytoplankton blooms [Polaribacter, Maribacter, and Tenacibaculum succeed each other in a highly dynamic fashion [Phages are also well known for modulating bacterial communities in temperate coastal oceans. Here, the increase in temperature and solar radiation in spring induces the formation of phytoplankton blooms, which are often dominated by diatoms , and aresponders , 17 and sponders , 19. Thesponders –22. Thisn blooms , 23–25.  fashion , 19, yet fashion , whereas fashion .Alphaproteobacteria , Ga, GaAlphaa , and Cya e.g., –36) have haveAlphdnaviria , 37. Pharibacter , Flavobaacterium , 40, Croeibacter , or Nonlonlabens  and inclFlavobacteriia, doubling the number of known hosts.In the context of a large project investigating bacterioplankton successions during North Sea spring bloom season, we isolated and characterized new flavophages, with the purpose of assessing their ecological impact and diversity. In total, more than 100 phage isolates were obtained, sequenced, annotated, and classified. This diverse collection is here presented in the context of virus and bacterioplankton abundances. Metagenomes obtained for Helgoland waters of different size fractions were mapped to all newly isolated flavophage genomes, testing the environmental relevance of the flavophage isolates. This study indicates that flavophages are indeed a mortality factor during spring blooms in temperate coastal seas. Furthermore it provides twelve novel phage-host systems of six genera of Bacteroidetes cell numbers and total virus abundances (SI file Bacteroidetes cell numbers were determined by 16S rRNA targeted fluorescence in situ hybridization (FISH) with specific probes . The water depth was fluctuating from 7 to 10 m over the tidal cycle. In 2017, a weekly sampling was conducted over five weeks starting on March 14 (Julian days 73–106) and covered the beginning of a spring phytoplankton bloom. In 2018, a weekly sampling was conducted over eight weeks starting on March 29 and ending on May 24 (Julian days 88–145). It covered the full phytoplankton bloom. Additional measurements were performed to determine the chlorophyll concentration, total bacterial cell counts, absolute  SI file . Viruses SI file . The Bac SI file .Phage isolates were obtained either after an intermediate liquid enrichment step or by direct plating on host lawns SI file  Table 1.Cellulophaga phages (except Ingeline) and Maribacter phages a ChIP-seq (chromatin immunoprecipitation DNA-sequencing) library was prepared. This was done to generate a NGS library for ssDNA phages and due to library preparation issues with the Maribacter phages for Illumina and PacBio. For the other phages a DNA FS library was prepared. The raw reads were quality trimmed and checked, then assembled using SPAdes  and eluted in TE buffer (after ). The DNv3.13.0, ) and Tadv3.13.0, . The genv3.13.0, , but notftp://ftp.ncbi.nlm.nih.gov/genomes/genbank/viral/, downloaded on 17.03.2021), the GOV2 dataset, IMG/VR2, as well as further environmental datasets [Several publicly available datasets of cultivated and environmental phage genomes were queried for sequences related with the flavophages isolated in this study, in a multistep procedure SI file . The datdatasets , 45–50. www.virclust.icbm.de), ViPTree [e-value >0.0001 and bitscore <50; (ii) hierarchical clustering based on protein clusters, agglomeration method “complete”, 1000 bootstraps, tree cut at a distance of 0.9. The parameters for VICTOR were “amino acid” data type and the “d6” intergenomic distance formula. In addition to phylogenetic trees, VICTOR used the following predetermined distance thresholds to suggest taxon boundaries at subfamily (0.888940) and family (0.985225) level [http://gravity.cvr.gla.ac.uk, [Papillomaviridae and Polyomaviridae (VMRv34).To determine the family-level classification of the flavophages, we used VirClust  level . Furthera.ac.uk, ) was usehttp://tree.bio.ed.ac.uk/software/figtree/).To determine the intra-familial relationships, smaller phage genome datasets corresponding to each family were analyzed using (i) nucleic acid-based intergenomic similarities calculated with VIRIDIC  and (ii)All phage genomes analyzed in this study were annotated using a custom bioinformatics pipeline described elsewhere , with mohttps://img.jgi.doe.gov/cgi-bin/vr/main.cgi). Third, WIsH [To determine potential hosts for the environmental phage genomes, several methods were used. First we did, a BLASTN  search ”.The genomes of bacteria from which phages were isolated were sequenced with Sequel I technology  SI file . After gCapnocytophaga as outgroup [For phylogenetic analysis, a neighbor joining tree with Jukes-Cantor correction and a RAxML tree  were caoutgroup . AfterwaCRISPR spacers and cas systems were identified in the host genomes by CRISPRCasFinder . ExtractThe IMG/VR  web serva measurements  and 12 species (95% similarity threshold)  and Flavobacterium . Part of the cultivated flavobacterial phages in the “Duneviridae” and “Winoviridae” are currently classified by ICTV in three genera in the families Siphoviridae and Myoviridae. However, because the Siphoviridae and Myoviridae families are based on phage morphologies, they are being slowly dissolved and split into new families, based on sequence data [Hierarchical clustering with VirClust placed the new dsDNA, tailed flavophages into 9 clades of similar rank with the current eleven ies Fig. . Similaries Fig.  and 9. Ties Fig. , which wfamilies . In agrefamilies . Therefonce data .Table 2CUsing a 70% threshold for the intergenomic similarities at nucleotide level indicated, that Harreka, Nekkels, Gundel, Peternella, Leef and Ingeline phages form genera on their own, tentatively named here “Harrekavirus”, “Nekkelsvirus”, “Gundelvirus”, “Peternellavirus”, “Leefvirus” and “Ingelinevirus”. The other new flavophages formed genera together with isolates from this study or with previously isolated flavophages, as follows: the genus “Freyavirus” formed by Danklef and Freya, the genus “Callevirus” formed by Calle, Cellulophaga phage phi38:1, Cellulophaga phage phi40:1, and the genus “Mollyvirus” formed by Molly and Colly SI file –15.Cellulophaga, separately from other ssDNA phage families, the Microviridae, Inoviridae, and Plectroviridae. This was supported also by GRAViTy  Danklef and Freya, part of the family “Forsetiviridae”, infected Polaribacter sp. R2A056_3_33 and HaHaR_3_91, respectively; and (ii) Leef, part of the family “Helgolandviridae”, infected Polaribacter sp. AHE13PA . For Leef, PhageTerm predicted genome ends of type Cos 3′  Nekkels, part of the family “Assiduviridae”, infected Cellulophaga sp. HaHa_2_1; (iii) Ingeline, part of the family “Duneviridae”, and Omtje, part of the family “Obscuriviridae”, infected Cellulophaga sp. HaHaR_3_176 (SI file Polaribacter sp. AHE13PA (Nekkels) and Cellulophaga sp. HaHa_2_1  (SI file Four Cellulophaga phages were obtained: (i) Calle, part of the family “Pervagoviridae”, infected  SI file . The virThe genome size ranged from ~6.5 kbp (Omtje) to ~73 kbp . The G + C content varied between 31.2 and 38.1% , a potential virulence factor against eukaryotes. Ingeline encoded an integrase and a LuxR gene, pointing toward a potential temperate life style. Calle had 20 tRNAs and one tmRNA gene Fig. .Olleya sp. HaHaR_3_96; (ii) Peternella, part of “Winoviridae”, infected Winogradskyella sp. HaHa_3_26; (iii) Gundel, part of “Pachyviridae”, infected Tenacibaculum sp. AHE14PA and AHE15PA; and (iv) Molly and Colly, part of “Molycolviridae”, infected Maribacter forsetii DSM18668  Harreka, part of “Aggregaviridae”, infected  SI file . All virIn these phages we recognized several structural, DNA replication and modification, and nucleotide metabolism genes Fig. . With rePotential endolysins were a N-acetylmuramoyl-L-alanine-amidase in Molly and Peternella and a L-alanine-D-glutamine-peptidase in Gundel. Harreka had a glycoside-hydrolase of the GH19 family. In the genomic vicinity of the potential lysins, several proteins having 1–4 TMDs were found, including a holin in Peternella Table .Additional features of these phages were: (i) ten tRNA genes in Gundel; (ii) a relatively short (199 aa) zinc-dependent metallopeptidase, formed from a lipoprotein domain and the peptidase domain in Molly, and (iii) a YopX protein in Harreka Fig. .Bacteroidetes phylum  domains  include members for whose genomes were assembled from environmental metagenomes Fig. . We havelum Fig.  and 7, l SI file  Table 8. SI file  Table 9.lum Fig. . In addi SI file  Table 10Integrase encoding genes were found on all environmental phages from the “Forsetiviridae”, and some of the genomes from “Winoviridae”, “Pachyviridae”, “Helgolandviridae” and “Duneviridae”. LuxR encoding genes were found in many genomes from “Helgolandviridae”, “Duneviridae” and “Forsetiviridae”, and one had also a transporter for the auto-inducer 2 Fig.  Table 10Polaribacter sp. HaHaR_3_91 and Polaribacter sp. R2A056_3_33 genomes. Spacers from the first strain matched Freya genomes. From the second strain, several spacers matched Danklef genomes, one matched Freya and another Leef  from the 2016 and 2018 spring blooms. We found five of the new flavophages in the cellular metagenomes from the 2018 spring phytoplankton bloom, at three different time points Table . The comPolaribacter sp. was found in the >10 µm and 0.2–3 µm fractions, at different time points during the bloom, including the same two samples in which its phages  and their relatives were detected. At the beginning of the bloom, in April, significantly more phages than hosts were present in the >10 µm fraction. The phage/host genome ratio was 384 for Freya, and 74 for Danklef. One and a half months later, only relatives of Freya, Danklef, and Leef were found, the phage/host ratio being lower than 0.1. Discrimination between the different Polaribacter strains was not possible, due to their high similarity (>98% ANI). Olleya sp. was found in the 0.2–3 µm and >10 µm fractions, at low abundances and dates preceding the detection of its phage, Harreka. Cellulophaga sp., the host for Ingeline, was not found  through long concatemers  , Ingeline (pectin lyase) and Nekkels  suggests that their bacterial hosts, ro-algae –83, servribacter –86. Bactribacter –89. In pr matrix , 91. It Polaribacter, Cellulophaga and Olleya, as well as the Polaribacter and Olleya genomes themselves in the particulate fraction of the cellular metagenomes. Therefore, it is likely that these bacteria are associated with particles, protists, phytoplankton or zooplankton. Spacers in metagenomes matching Nekkels, a Cellulophaga phage, suggest an association with red macro-algae -phages [The presence of integrases and LuxR genes in phages from the “Helgolandviridae” and “Duneviridae” Fig.  Table 10)-phages , 94. ThiCellulophaga, although not detected in the cellular metagenomes, were present in high abundance (at least 100 plaque-forming units ml−1) in the viral fraction of our samples, as revealed by successful isolation by direct-plating without previous enrichment. This apparent gap between the presences in either the viral or cellular fraction, could be either explained by phage lysis prior the metagenome collection, or by the fact that their host habitat was not sampled for metagenomics. A potential explanation is that members of the genus Cellulophaga are known to grow predominantly on macro-algae [All of our flavophages, except Molly and Colly, replicated successfully at different times throughout the 2018 phytoplankton bloom. The isolation by enrichment or direct-plating indicated their presence in the viral fraction, and the retrieval by read-mapping indicated a likely presence inside the host or association with surfaces. Calle and Nekkels, infecting ro-algae . The detCellulophaga, the host of Ingeline, was not detected throughout the spring bloom. However, because Ingeline was detected presumably in the particle fraction and thus might be inside its host, we can hypothesize that either its host was in a low abundance, or its genome was degraded under the phage influence. Either way, it points toward Ingeline being in a lytic cycle at the time of detection. For Freya, Danklef, and their relatives, the high phage to host genome ratios (as high as 454×) from April suggest that these phages were actively replicating and lysing their cells. In contrast, when they reappeared in May, these phages were not only three orders of magnitude less abundant than in April, but also approximately ten times less abundant than their host. This indicates that in May, only a small proportion of the Polaribacter cells were infected with relatives of Freya and Danklef, either in a lytic or a temperate state.For flavophages with temperate potential, the ratio between phage and host normalized read abundance can be used to predict their lytic or temperate state in the environmental samples. Polaribacter strains after the April infection and differs from the genotypic changes previously observed for marine phages, which were at the species level [Polaribacter phages by the CRISPR/Cas spacers, and for Omtje and Ingeline, by their isolation in two consecutive years.A temporal dynamics in phage populations is also reflected in the appearance of Freya and Gundel. Moreover, it is reminiscent of the boom and bust behavior previously observed with T4-like marine phages . In addies level . PersistThe North Sea flavophages isolated in this study display a very high taxonomic, genomic and life style diversity. They are a stable and active part of the microbial community in Helgoland waters. With their influence on the dynamics of their host populations by either lysis or with regard to specific bacterial population by substrate facilitation, they are modulating the carbon cycling in coastal shelf seas. The increase in bacterial numbers, reflected in the phage numbers and the ratio of phage to bacterial cells, indicate that phages actively replicate through the 2018 phytoplankton bloom, matching previous observations of the North Sea microbial community . Our reaSI_File_1SI_File_2SI_File_3SI_File_4SI_File_5SI_File_6SI_file_7


Nurses’ knowledge regarding palliative and end-of-life (EOL) care has been documented, but the competence of nurses in Taiwan has not been deeply analyzed and may affect the use of EOL care.We aimed to (1) assess the palliative care knowledge, competence and attitude of nurses in a general hospital and (2) examine the paths connecting nurses’ demographic characteristics, previous experiences, knowledge, competence, and attitude.A correlational, cross-sectional survey design was implemented to recruit 682 eligible nurses. The questionnaires included demographic information and palliative and EOL care knowledge, attitude, and competence scales. Path analysis was employed for statistical analysis using structural equation modeling.r = 0.48, p < 0.001), but “negative perception” was not significantly correlated with competence . “Positive perception”  and competence  were not related to palliative knowledge. “Negative perception”, however, was negatively associated with palliative knowledge .Overall, 76% of the questions assessing palliative and hospice knowledge were answered correctly. Nurses’ palliative attitudes were divided into “positive perception” and “negative perception”. “Positive perception” was highly correlated with competence (This study suggests continuing education to decrease nurses’ “negative perception” attitude regarding the provision of information to patients and families to provide better palliative and EOL care.Nurses’ attitudes and competences with respect to palliative care and EOL care are critical. Areas for further research and advanced palliative and EOL care-related education and training are suggested and may be applied in future clinical interventions. Palliative care practices have developed rapidly in health care facilities in the past decade. The definition of palliative care has been extended; the concept of end-of life (EOL) care differs throughout the world, and nurses’ knowledge, attitudes, and contributions to EOL care vary . In TaiwPrevious research has focused on nurses’ care delivery in intensive care units  and on cAccording to a previous study , a modifPrevious research has noted that inadequate confidence in nurses may influence the quality of palliative care they provide . In partThe purposes of the present study were to (1) assess the palliative care knowledge, competence and attitudes of nurses in a general hospital and (2) examine the paths connecting nurses’ previous EOL experience, competence, attitude perception, and knowledge.A cross-sectional study, purposive sampling, and a structured questionnaire survey were adopted to collect data at a general hospital in southern Taiwan. All the paper surveys were provided to eligible participants and put in an envelope. A structural equational modeling (SEM) approach was employed to analyze the path of EOL experience, competence, attitude perception, and knowledge.df) =50, a desired power = 80%, and reasonable H1, the sample size is estimated to be 351  is commonly used as an index to assess the entire model data-model fit; the null hypothesis (H0), referred to as the model, fits well , and the alternative hypothesis (H1), referred to as the model, fits inadequately . Given a model with degrees of freedom . The researcher contacted eligible participants about the aims of the study, and each participant submitted a written consent form. All the participants filled out the instruments (paper-based) and put them in a provided envelope. The investigator collected all the data from different working units in the general hospital. Data were collected from August to December 2017.Data for the survey study were gathered using instruments developed by The nurse demographic questionnaire included items related to age, gender, marital status, education, rank, work unit, and professional experience.α was .84 in this study.The palliative care knowledge questionnaire was developed by α of 0.77 was found for this study.We adopted the Nurses’ Palliative Attitude Scale developed by We used a scale that we developed ourselves  to evaluThe data were analyzed using SPSS  version 18.0 and IBM SPSS Amos for Windows version 22.0. The data were screened for missing data, skewness and kurtosis for normality. Less than 1% of the data entries were missing, and they were corrected with the original paper-based questionnaires. For the 14-item attitude scale, two items (items 7 & 8) showed skewness values -.61 and -.74, two items (items 8 & 9) showed kurtosis values .94 and -.63; the remaining 12 items showed skewness and kurtosis values less than ±.5. For the 15-item competence scale, their skewness and kurtosis values were all less than ±.5. The results indicate symmetrical distribution. Furthermore, both the attitude and competence scales were five-category measurements, and maximum likelihood estimation was employed to assess the relationship among attitude, competence, and knowledge using SEM . Descriptive statistics, i.e., frequencies, percentages, and averages, were utilized to report on the analyzed variables.N = 682) was randomly divided into two groups, Group 1 (N1 = 343) and Group 2 (N2 = 339). Group 1 was used to conduct exploratory factor analysis (EFA) for the two scales, the Nurses’ Palliative Attitude Scale and the Nurses’ Competence Scale. Based on the EFA results, confirmatory factor analysis (CFA) was applied to assess the psychometric components of the two scales in Group 2 (N2 = 339) and to examine the paths among the exogenous variables , the mediators , and the endogenous variable . Statistical significance was set at p < 0.05. Several model fitness indices were employed to assess the fitness of the measurement model, including the normed chi-square , RMSEA 0.08−0.05, and comparative fit index (CFI) >0.95  >0.95 .n = 682) were registered nurses, and the response rate was 97.8%. The studied characteristics of the participants included age, marital status, education, rank, work unit, and professional experience ; only 33 males participated (4.8%). The average age of the participants was 29.2 years, more than half were single, and 82.6% had a college degree. Regarding their rank at the hospital, the lowest level, N, accounted for the majority of all ranks . The nurses’ work units included the following: the general ward  was the most common unit, followed by the intensive care unit  and emergency room . The majority of the nurses had 3-5 years of professional experience . Regarding coursework or experience related to palliative care , and the majority of the nurses had cared for palliative patients  and had taken palliative care coursework .All the participants , with a range from 28 to 75. Scores on the Nurses’ Palliative Attitude Scale did not significantly differ among work units . As showThe average score on the Nurses’ Competence Scale was 46.89 (SD 8.59), with a range from 18 to 90. Scores on the Nurses’ Competence Scale significantly differed among work units . As showr = 0.49, P < 00.001). The more palliative knowledge nurses had, the more competence  they felt. Moreover, competence dealing with patients’ symptoms in EOL care was correlated with older nurses .In df = 91, p <  0.001, supporting the appropriateness of EFA. According to the scale content, two factors, i.e., “positive perception” and “negative perception” toward palliative care, were proposed. Ten items were related to “positive perception”, and four items were related to “negative perception”. For the competence scale, the KMO was 0.76, and Bartlett’s test yielded a value of 5337.07, df = 105 (P < .001), sufficient for conducting EFA. According to the scale content, a two-factor measurement model with 15 items was proposed and tested using SEM. Nine items (1–9) were related to the “legislative competence” factor, and six items (10–15) were related to the “professional care competence” factor.Factor analysis of this attitude scale yielded a Kaiser-Meyer-Olkin (KMO) value of 0.76, and Bartlett’s test yielded a value of 2742.53, The Group 1 sample was randomly selected to explore the hypothesized measurement model. The results for the original measurement model revealed inadequate model fit. Six items from the positive perception factor and one item from the negative perception factor showed factor loadings <.6, and these items were removed; they were: “1) I would not feel uncomfortable discussing the condition of a terminally ill patient with other healthcare professionals”; “7) I would be willing to sign an NFR order for my family, if necessary”; “8) I would be willing to sign an advance directive for palliative and hospice care”; “12) I need to acquire more knowledge of palliative and hospice care”; “13) I feel comfortable sharing my experience in palliative and hospice care with other healthcare professionals”; and “14) I feel comfortable sharing my experience in palliative and hospice care with relatives and friends.” Three items showed adequate factor loadings (.74–.87) with the positive perception factor: “2) I would not feel uncomfortable discussing death and dying with families of terminally ill patients”; “3) I would not feel uncomfortable discussing death and dying with terminally ill patients”; “4) I would not feel uncomfortable assisting families of terminally ill patients in submitting an NFR order”; and “5) I would not feel uncomfortable assisting terminally ill patients in submitting an NFR order.”One item with a factor loading <.60 was removed from the negative perception factor; the item was “6) I would be afraid to tell my family member that he/she were dying.” The remaining three items of the negative perception factor showed factor loadings of .64 - .93, and they were: “9) I would feel upset all day long if I provided care to terminally ill patients”; “10) I feel suffocated all day long if I provide care to terminally ill patients”; and “11) I feel deeply grieved if a terminally ill patient whom I care for is approaching death.”χ2 = 458.67, df = 201, p<0.001, NC = 458.67/201 = 2.28, RMSEA = 0.06, and CFI = 0.96).One item from the “legislative competence” factor that showed a factor loading <.6 was removed; it was “I can explain the fundamental concept of hospice and palliative legislation to others.” The remaining eight items of the legislative competence factor assessed nurses’ perceived self-competence in legislative aspects of hospice and palliative care. For example, item 2 was, “I would be able to respond to concern about advance directives for people and their families.” The other factor, “EOL care competence”, contained six items to assess nurses’ perceived competence in EOL care, such as physical problems, family conflicts, and grieving. The final EFA model consisted of a two-factor attitude scale with 7 items and a two-factor competence scale with 14 items . The finp < .01). As seen in β =  − .18, p = .02) in Group 1. However, “positive perception” attitude, “legislative competence”, and “EOL care competence” were not significantly associated with EOL care knowledge. EOL care experience was negatively associated with “negative perception” attitude  and positively associated with EOL care knowledge .Path analysis was employed to examine the paths among nurses’ attitudes, competences, and knowledge regarding palliative care. EOL care experience was a significant variable associated with nursing knowledge of palliative care. Nurses who reported experience caring for palliative patients obtained higher EOL care knowledge scores than those without such experience . On the other hand, EOL care experience was negatively associated with “negative perception” attitude  in Group 2. In contrast to the path result in Group 1, one item on the competence scale (Question 10) was related to both the “legislative competence” and “EOL care competence” factors; the factor loadings were .36 and .52, respectively. Question 10 was “I would be able to resolve conflicts in EOL care preferences within the family for a terminally ill patient.” Finally, the structure of the measurement model was similar in both Groups 1 and 2, including with respect to the factor loadings and model fit indices.As shown in This study examined the knowledge, attitudes, and competence of nurses in providing palliative and EOL care. Several important results of this study are as follows: (1) a description of the palliative care knowledge, competence and attitudes of nurses at a general hospital; (2) the psychometric components, i.e., positive and negative perceptions of nurses’ palliative attitudes, are constructed in the EFA measurement model; (3). relationships are identified among previous experience, attitude perceptions, competence, and knowledge in the CFA path models.First, regarding the palliative care knowledge test, only 76% of the questions were answered correctly, which supports the need for continuing education that furnishes the knowledge nurses need to provide qualified EOL care. In Taiwan, although families need support and treatment information to make appropriate decisions for their ill loved ones, the determination that a patient is at the EOL stage is usually made by physicians. Although an NFR may be considered, it is a sensitive issue in Chinese culture; therefore, physicians may not always suggest it as an option. Under these circumstances, who is obligated to provide families or patients with further information to help them decide between treatment and palliative care? Nurses’ competence and attitudes should be improved to enhance the quality of palliative and EOL care.Second, our findings suggest that nurses’ attitudes could be categorized as positive and negative perceptions toward palliative attitudes. Positive perception is weakly negatively correlated with negative perception and moderately positively correlated with nurses’ competence. Negative perception attitude is not significantly correlated with nurses’ competence. Positive perception attitudes are more important than negative perception attitudes in contributing to nurses’ competence.Third, our results suggest that nurses’ competence is not significantly related to palliative knowledge, which is in contrast to our hypotheses. Of several predictors, nurses’ negative perceptions and previous experience caring for EOL patients were significantly related to their knowledge. Our study showed that nurses who had palliative and EOL care experience had better attitudes toward EOL care than those without experience, which was consistent with a previous study . HoweverAdditionally, nurses with attitudes characterized as “negative perception” were more likely to lack palliative care knowledge and may need more continuing education to manage the challenges of caring for EOL patients. This explains why a “negative perception” attitude in nurses significantly impacted nurses’ knowledge. Since the measurement of attitude was developed from This study was conducted at a local general hospital, and the findings cannot be generalized to other hospitals. All the questionnaires were developed by Nurses who have received continuing education related to palliative care had higher scores on the knowledge test, reflecting the effectiveness of continuing education. Future palliative care education programs for health care providers should include sharing palliative care experiences, discussing principles and legislation, determining appropriate referrals, and promoting nurses’ competence in caring for palliative and EOL patients. Furthermore, the development of standardized guidelines for EOL care in all hospital settings should be considered.Administrators need to promote knowledge of palliative and EOL care among nurses to improve nurses’ competence in providing qualified palliative care. Recently, efforts to improve palliative care in hospitals and health care facilities have increased. However, while expertise in palliative care is increasing, unmet needs remain.The attitude and competence scales used in this study could be used in different health care settings to determine the educational needs of nurses. These brief scales can help identify nurses’ educational needs in various health centers. This study supports several preliminary examinations of the differences in palliative care competence at the participating local health center. Areas for further research, advanced palliative care-related education and training are suggested and may be applied to future clinical interventions.10.7717/peerj.11864/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.11864/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.11864/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.11864/supp-4Supplemental Information 4Click here for additional data file.


A previous study reported that cancer survivors exhibit decreased postural stability compared to age-matched controls. Another study showed that cancer survivors have a lower quality of life (QOL) compared to healthy subjects, and there was a significant relationship between muscle strength and QOL in cancer survivors. We aimed to investigate differences in the associations between balance function and QOL in cancer survivors and healthy subjects.Forty-one cancer survivors and 33 healthy subjects were included. Balance function was evaluated using the timed up and go test, and body sway was tested using a force platform. QOL was assessed using the medical outcome study 36-item short-form health survey.P < .05). There was a significant association between body sway and QOL (P < .05) among cancer survivors. However, healthy subjects had subscales for QOL related to the body sway test parameters more frequently than cancer survivors (P < .05).Cancer survivors exhibited significantly higher timed up and go and lower QOL than that of healthy subjects (Cancer survivors’ balance function may have little effect on QOL, unlike in healthy subjects. Other study showed that cancer survivors have a lower quality of life (QOL) than that of healthy subjects, and there was a significant association between muscle strength and QOL in cancer survivors. Cancer survivors with peripheral neuropathy had decreased balance function and worse QOL scores than those without peripheral neuropathy, particularly in the domain of physical functionality. Thus, balance function may be related to QOL among cancer survivors. We aimed to investigate differences in the associations between balance function and QOL, comparing cancer survivors to healthy subjects.A previous study reported that cancer survivors exhibit decreased postural stability compared to age-matched controls.2This was a prospective, observational study of balance function and QOL in cancer survivors and healthy subjects. Subjects were recruited between August 2017 and September 2018. Forty-one cancer survivors and 33 healthy subjects were included, all of whom were assessed once. The survivors’ cancer diagnoses included breast (n = 22), colorectal (n = 3), acute leukemia (n = 3), endometrial (n = 2), thyroid (n = 2), lung (n = 1), retroperitoneal sarcoma (n = 1), Ewing sarcoma (n = 1), tongue (n = 1), cervical (n = 1), ovarian (n = 1), bladder (n = 1), testicular (n = 1), and malignant lymphoma (n = 1). The time since the cancer diagnosis of all survivors was >1 year. The Niigata University of Health and Welfare Institutional Committee on Human Research  approved the study. Written informed consent was obtained from all subjects.2.12.1.1 The time taken to complete the test was recorded. Participants performed the TUG twice, and the faster of the 2 measurements was used for analysis.Timed up and go (TUG) is a reliable, valid test for quantifying functional mobility.2.1.22), environmental CoP area (cm2), rectangular CoP area (cm2), and root mean square (RMS) of the CoP (cm2) were calculated.Body sway was measured using a gravicorder force platform  to investigate postural stability among the subjects. Subjects stood for 30 seconds while looking at a 3 cm-diameter round mark placed 2 m away at eye level. The center of pressure (CoP), as the index for postural stability, was measured once using the gravicorder at a 20-Hz sampling rate. Tasks were performed with eyes both opened and closed. The total CoP length (cm), length per area -related QOL was assessed using the medical outcome study 36-item short-form health survey. The 36-item short-form health survey assesses physical and mental health components across 8 domains: physical functioning (PF), physical role function (PR), bodily pain, GH, vitality, social functioning, emotional role functioning, and mental health. This self-administered questionnaire is widely used, particularly among cancer survivors.2.3t test for continuous variables and Pearson chi-squared test for ordinal variables. Two-tailed unpaired t tests were used to compare balance function and QOL between the 2 groups. Pearson r was used to evaluate the association between balance function and QOL. Statistical analysis was performed using SPSS 19.0J . P-values < .05 were considered statistically significant.The results are presented as means ± standard deviations. We compared demographic data between cancer survivors and healthy subjects using Student 33.1No significant difference was observed in the mean age (±standard deviation), male-to-female ratio, mean height, bodyweight, or body mass index between the 2 groups Table .3.2P < .05, Table P > .05), regardless of the testing conditions .TUG time was significantly higher in the cancer survivors than in the healthy subjects (3.3P < .01). No significant differences in other subscales were observed between the 2 groups.PF, PR, and GH were significantly lower in cancer survivors than in healthy subjects . However, the other parameters were not significantly associated with the QOL subscales. When healthy subjects had their eyes open, the environmental CoP area and rectangular CoP area were significantly correlated to PF (P < .05). Similarly, with their eyes closed, the CoP length and environmental CoP area were significantly correlated to PF (P < .05). When healthy subjects had their eyes open, the CoP length, environmental CoP area, rectangular CoP area, and CoP RMS were significantly correlated to GH (P < .05). With eyes both opened and closed, the environmental CoP area and rectangular CoP area were significantly correlated to emotional role function and PR (P < .05). When healthy subjects had their eyes open, the environmental CoP area was significantly correlated to mental health (P < .05).When cancer survivors had their eyes open, the length per area, environmental CoP area, rectangular CoP area, and CoP RMS were significantly correlated to PF (4In this study, we showed that cancer survivors had longer TUG times and lower QOL regarding some subscales compared to those of healthy subjects. Furthermore, we found that body sway parameters were significantly correlated to some QOL subscales in both groups. However, healthy subjects had QOL subscales related to the body sway parameters more frequently than cancer survivors. This suggests that there are characteristic differences in balance function and QOL among cancer survivors and healthy subjects.,8 One study showed that cancer survivors exhibited longer mediolateral RMS and increased CoP velocity than those of age-matched healthy subjects. Another study showed that adult survivors of childhood cancer who were treated with <12 years of chemotherapy had significantly poorer postural control compared to healthy subjects. However, there was no significant difference in postural control between those treated with >12 years of chemotherapy and healthy subjects. To date, few studies have investigated postural stability among cancer survivors, the results of which are not in agreement.TUG has been used to assess mobility and requires both static and dynamic balance. Our findings suggest that cancer survivors have decreased mobility balance function when compared to healthy subjects. However, there were no significant differences in the body sway test parameters, which measured postural stability between the 2 groups. We initially expected that cancer survivors would have a more prominent relationship between any parameter in the body sway test and QOL than the healthy subjects would. However, cancer survivors had a minimal relationship between some parameters in the body sway test and QOL when compared to healthy subjects. Our study has a limitation. Our study group was relatively small, and was recruited from a single region, therefore reducing the statistical effectiveness of the findings.One study investigated the relationship between postural stability and QOL in elderly adults and reported that QOL could be explained by postural sway variables.5 cancer survivors’ QOL tends to rely on muscle strength opposed to balance function. Future studies should focus on a single cancer diagnosis and use a larger sample size for improved analysis.Cancer survivors had significantly increased TUG and decreased QOL; however, there were no significant differences in the body sway tests between the 2 groups. There was an association between the body sway parameters and QOL among cancer survivors; however, these associations were weaker than those observed among healthy subjects. Cancer survivors’ balance function may have little effect on QOL, unlike in healthy subjects. As previously reported,The authors are grateful to the study participants and physical therapy students for their help in the collection of muscle strength and balance function data.Conceptualization: Shinichiro Morishita.Data curation: Ryo Hirabayashi, Atsuhiro Tsubaki.Formal analysis: Shinichiro Morishita.Funding acquisition: Shinichiro Morishita.Investigation: Shinichiro Morishita, Ryo Hirabayashi, Atsuhiro Tsubaki, Osamu Aoki.Methodology: Shinichiro Morishita, Osamu Aoki.Project administration: Shinichiro Morishita.Supervision: Shinichiro Morishita, Tetsuya Tsuji.Validation: Hideaki Onishi.Visualization: Hideaki Onishi.Writing – original draft: Shinichiro Morishita, Jack B. Fu, Tetsuya Tsuji.Writing – review & editing: Shinichiro Morishita, Jack B. Fu, Tetsuya Tsuji.


Renal cell carcinoma (RCC) is the most common type of kidney cancer and is the second most common urologic neoplasm. Vaginal metastasis from RCC is extremely rare clinically.A 56-year-old woman presented with intermittent vaginal bleeding that had persisted for 1 month. Enhanced computed tomography examination suggested a vaginal mass (3 × 2 × 2 cm), right kidney tumor (15 × 12 × 10 cm), and an inferior vena cava tumor thrombus. During gynecologic examination, the mass was necrotic and caused uncontrollable vaginal bleeding.Based on clinical and imaging examinations and the pathology, she was diagnosed as vaginal metastasis from RCC.The patient received percutaneous transcatheter arterial embolization to stop uncontrollable vaginal bleeding, and then treated with targeted therapy.Vaginal bleeding disappeared after interventional embotherapy. However, disease progressed, and the patient died 9 months later.In cases of vaginal bleeding, the possibility of metastatic renal cell carcinoma should be considered. Percutaneous transcatheter arterial embolization is an effective and novel treatment for uncontrollable vaginal bleeding caused by vaginal metastasis of RCC. Vaginal metastasis from RCC is extremely rare, with fewer than 90 cases reported to our knowledge. Here, we present the case of a 56-year-old woman who presented with severe vaginal bleeding caused by vaginal metastasis of RCC. The uncontrolled vaginal bleeding was cured using interventional embolotherapy.Renal cell carcinoma (RCC) accounts for 3% to 5% of all adult malignancies worldwide and 80% of cancers involving the kidneys.2A 56-year-old woman presented to our department with a complaint of intermittent vaginal bleeding for 1 month. She had undergone left nephrectomy for severe left hydronephrosis 10 years ago and had no history of hypertension, diabetes, or hyperlipidemia. Her mother had a history of rectal cancer surgery.T 37.2 °C, P 76 times/min, R 19 times/min, BP 118/62 mmHg. Abdominal physical examination revealed a wasted, anemic appearance with a flat abdomen, and no pressure or rebound pain. Gynecological examination revealed a vaginal mass located in the anterior vaginal wall, 3 cm from the vaginal opening, measuring approximately 3 cm × 2 cm × 2 cm.Vital signs: Laboratory examination findings: HGB 87 g/L, Cr 144 μmol/L, BUN 8.9 mmol/L, ALB 34.8 g/L, UA 651 μmol/L, TCHO 2.79 mmol/L, PT 14.8S, ATPP 45.3S, D-Dimer 1.28 μg/mL.Enhanced computed tomography (CT) examination suggested a vaginal mass (measuring approximately 3 × 2 × 2 cm), right kidney tumor (measuring approximately 15 × 12 × 10 cm), and inferior vena cava tumor thrombus (Fig. During gynecologic examination, the mass was necrotic and detached by itself with a hemorrhage of approximately 400 mL. Intravaginal gauze plugging was performed to stop bleeding, followed by selective bilateral internal iliac artery angiography. The angiogram showed that bleeding was predominantly on the right side. Embolization microspheres were used to embolize the right uterine artery and bilateral internal pudendal arteries, followed by embolization using spring coils Fig. .Pathology of the mass suggested clear cell carcinoma Fig. . ImmunohThe vaginal bleeding disappeared after interventional embolotherapy using digital subtraction angiography. The disease progressed after 6 months of sunitinib treatment. For financial reasons, no other targeted drugs were used, and the patient died 3 months later due to renal failure.3 RCC metastasis can occur in any organ, most commonly in the lungs, lymph nodes, bones, and liver. Malignant tumors originating in the vagina are rare, and squamous cell carcinoma is the most common pathological type. Metastatic carcinoma accounts for approximately the majority of cases and should be prioritized in the absence of primary evidence. Common sites of vaginal metastasis reported by conventional investigations are the cervix, uterus, ovaries, colon, pancreas, and stomach. Vaginal metastasis from RCC is extremely rare, with fewer than 90 cases reported to our knowledge. Some patients experience vaginal bleeding as the first symptom. Therefore, the presence of vaginal bleeding needs to be evaluated to determine the presence of metastasis from RCC.,5 The mechanism of metastasis of RCC to the vagina is still unknown, and the paths could include the bloodstream, lymphatic metastasis, urethral implant, and so on, with the bloodstream being the common route. Blood from the lower vaginal segment returns from the vaginal vein, forms a venous plexus with the uterine vein, converges into the internal iliac vein, and is injected into the inferior vena cava. Genital vein reflux is also a metastatic route for RCC, and the left side is directly refluxed to the renal vein; thus, vaginal metastasis of RCC is likely to occur on the left side. Mulcahy demonstrated retrograde flow of contrast medium from the renal vein to the genital vein in several patients with RCC and vaginal metastases.RCC is the most common type of kidney cancer and is the second most common urologic neoplasm. Synchronous metastasis occurs in 18% of patients with RCC at diagnosis and metachronous metastatic disease develop in 50% of RCC patients after nephrectomy.,10 For cases with multiple metastases and advanced stages, where the chance of radical treatment is lost, systemic treatment and tumor reduction surgery are the mainstay.In this case, the patient's left kidney was resected 10 years ago, and CT imaging supported the diagnosis of right kidney cancer. Pathology suggested clear cell carcinoma, and immunohistochemistry revealed the expression of CaIX, CD10, vimentin, and CD8/18. These findings were consistent with the diagnosis of metastatic RCC. The incidence of vaginal metastatic cancer is increasing because of inferior vena cava tumor thrombus and impaired reflux. The vaginal blood supply comes from the internal iliac artery, and metastases are rich in blood supply and grow rapidly, making them prone to hemorrhagic necrosis and causing uncontrollable hemorrhage. Surgical treatment or radiotherapy is feasible for isolated vaginal metastatic lesions or local recurrence of renal cancer after surgery, surgical treatment, or radiotherapy is feasible. Further surgical treatment was refused because the patient had an isolated kidney and could not undergo long-term postoperative hemodialysis. The patient was treated with targeted sunitinib therapy. The patient's prognosis was poor due to the advanced stage of the disease at the time of detection.In the patient, enhanced CT suggested a significant aneurysm blood supply, post-dissection hemorrhage, and pseudoaneurysm formation. Internal iliac arteriography using digital subtraction angiography can directly display the pseudoaneurysm and locate the bleeding site for subsequent embolotherapy. Percutaneous transcatheter arterial embolization is an effective and novel treatment for uncontrollable vaginal bleeding caused by vaginal metastasis of RCC. The median lifespan of a patient with RCC-associated vaginal metastasis is approximately 19 months.4Herein, we report a case of rare vaginal metastasis from RCC with severe vaginal bleeding as the first symptom. Percutaneous transcatheter arterial embolization is an effective and novel treatment for uncontrollable vaginal bleeding caused by vaginal metastasis of RCC. In cases of vaginal bleeding, we should have to keep in mind the possibility of metastatic renal cell carcinoma.Conceptualization: Qian Lin.Data curation: Jia Miao.Investigation: Qinghua Zhang.Methodology: Peng Jia.Writing – original draft: Zhihai Geng, Qian Lin.Writing – review & editing: Zhihai Geng, Qian Lin.