Major depressive disorder (MDD) imposes a heavy global disease burden. However, current etiology, diagnosis and treatment remain unsatisfactory and no previous study has resolved this problem. Building on the strengths and limitations of previous cohort studies of MDD, the prospective cohort study of depression (PROUD) is a 3-year large-scale cohort study designed to collect multidimensional data with a flexible follow-up schedule and strategy. The goal is to establish a nationally representative, high-quality, standardized depression cohort to support precise diagnosis and treatment of MDD and address the gap in current research.n=4,000). Patients who meet the general eligibility criteria but not the PMC criteria will be included in the naturalistic observation cohort (NOC) of PROUD . A multiple follow-up strategy, including scheduled, remote, telephone, external visits and patient self-reports, will be implemented to collect comprehensive sociodemographic, clinical information, biospecimens, neuroimaging, cognitive function and electrophysiology data and digital phenotypes according to strict standard operating procedures implemented across centers. Trial registration: ChiCTR2200059053, registered on 23 April 2022, http://www.chictr.org.cn/showproj.aspx?proj=165790.PROUD is a patient-based, nationally representative multicenter prospective cohort study with baseline and 3-year follow-up assessments. It will be carried out from January 2022 to December 2026 in 52 qualified tertiary hospitals in China. A total of 14,000 patients diagnosed with MDD, according to the DSM-5 criteria, and aged ≥ 16 years, will be recruited to PROUD. Participants aged 18-65 years who have not received any treatment during a depressive episode will be included in the precision medicine cohort (PMC) of PROUD (PROUD is a prospective cohort study of MDD patients in China. It will provide a comprehensive database facilitating further analyses and aiding the development of homeostatic and precision medicine in China. NESDA is an ongoing longitudinal naturalistic cohort study, investigating the course and consequences of depressive and anxiety disorders. Its design integrated biological and psychosocial perspectives within an epidemiological framework . Patients who meet the general eligibility criteria, but not the PMC criteria, will be included in the naturalistic observation cohort (NOC) of PROUD . There are no restrictions of the treatments and antidepressant agents for NOC cohort of PROUD. An additional 1,000 participants with no psychiatric history will be included as healthy controls (HC) and 1,000 participants with bipolar disorder will be included as diseased controls. The general flow chart of participant selection and evaluation can be found in Fig. The study population comprises MDD patients with diverse sociodemographic characteristics, disease stages and treatment regimens. About 14,000 eligible MDD patients will be recruited from 52 centers. MDD patients who have not received any treatment during the acute phase of the depressive episode will be included in the precision medicine cohort (PMC) of PROUD .Primary school education or above, able to understand the content of the scale.Participation on a voluntary basis and provision of written informed consent.Comorbidities of clinically diagnosed schizophrenia, bipolar disorder, neurodevelopmental disorders, neurocognitive disorders or other major psychiatric diseases.Severe medical conditions precluding participation in the study.Any other conditions considered unsuitable for the study.Males and females aged 18-65 years.A score of ≥14 on the 17-item Hamilton Depression Rating Scale (HAMD-17) at both screening and baseline.Have not taken any antidepressant agents for at least 14 d before screening (fluoxetine therapy should be discontinued at least 28 d before screening).Monotherapy for antidepressants planned.Depressive episodes secondary to a systemic disease or neurological disorder, such as depression due to hypothyroidism.Received modified electric convulsive therapy (MECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS) or vagus nerve stimulation (VNS) within 3 months before screening.Withdrawal of psychotropic drugs did not equate to seven half-life periods before the screening.Women with a positive blood human chorionic gonadotropin (HCG)/urine HCG test; men with reproductive potential and women of reproductive age unable to use contraception effectively and women who plan to become pregnant within 3 months of the start of the study.Participated in any interventional clinical trial 3 months before screening.An overview of data collection and assessments for field visits is shown in Table Sociodemographic information will be collected through a structured self-report questionnaire at baseline, including birth date, gender, height, weight, marital status, education level, occupational status, household income, living area, left-behind children experience and experience of being an only child. Also, data on lifestyle and dietary habits such as defecation, smoking, drinking, dietary habits, water intake and the use of antibiotics and probiotics will be collected. Information will also be collected about the history of the present illness, physical examination results, comorbidities, treatments and adverse events.Participants will be interviewed and diagnosed by a psychiatrist at baseline using the Mini-International Neuropsychiatric Interview (MINI). Diagnosis will be classified according to DSM-5 and MINI as depression with anxious distress, mixed features, melancholic features, atypical features, psychotic features, seasonal pattern or peripartum onset.et al., et al., et al., et al.,The following scales will be used to assess clinical symptoms and function at baseline: the HAMD-17  , one PAXgene® Blood RNA Tube (2 mL) and two EDTA anticoagulation blood tubes (6 mL/tube). Urine samples will be collected with a urine cup (40 mL). A standardized kit (25mL) will be provided to collect fecal samples and maintain their integrity. Saliva samples will be collected with sterile, nuclease-free 5-mL conical screw-cap tubes. All blood, urine and fecal samples will be stored in −80°C freezers and transported through the cold chain to the PROUD biobank.et al., The Chinese Brief Cognitive Test (C-BCT) will be used to assess four cognitive domains: speed of processing, attention, reasoning/problem-solving and working memory. The psychometric properties of the C-BCT are well-established, including large norms, test-retest reliability and consistency across cultures. Moreover, it has been validated against traditional paper-and-pencil tests that assess equivalent domains , diffusion-weighted imaging (DWI), susceptibility-weighted imaging (SWI), resting-state functional MRI (fMRI) and diffusion tensor imaging (DTI). Anatomical and microstructural imaging will include a 3D high-resolution magnetization-prepared rapid gradient-echo (MPRAGE) sequence and a 64-direction diffusion tensor imaging sequence, respectively. Both resting-state and task-based fMRI data will be collected as part of the functional imaging protocol. The task-based BOLD fMRI signal will be used to analyze reward processing and emotional regulation.Quantitative imaging, melanin imaging, arterial spin labelling and task-based fMRI will be optional in the PMC study. The task-based fMRI will include rumination, emotional recognition and social cognition tasks. All MRI scans will be performed using a 3.0T scanner  by trained investigators following a standardized protocol.EEG data will be acquired using standard pre-specified hardware and software. The resting EEG will be recorded in two 5-min sessions while participants are relaxed with eyes open or closed. Event-related potentials (ERPs) will be elicited by activation tasks. The face-word Stroop paradigm was employed to assess cognitive and emotional regulation. The experiment requires a quiet environment with a comfortable temperature and humidity level and electromagnetic shielding. The EEG data will be recorded using the Neuroscan and Brain Products with 64 electrodes.Digital phenotype data, including portable EEG, heart rate, body temperature, sleep and other parameters, will be collected using wearable devices during daily life. Eye movement, gait, voice and facial expressions will be collected in the hospital during the visits, as the collection of these data requires space and specialized equipment.Field visits: All patients will be required to make field visits at baseline and at the end of years 1, 2 and 3 . An external visit will be scheduled if the RFC scores reach certain thresholds. The logic diagram of external visits can be found in Figure The external visit will be in the form of a field visit which consists of the following: (1) Re-evaluation of the relevant module of the MINI; (2) Collection of information on psychiatric history, physical examination results, somatic diseases, treatment and adverse events; (3) Scale assessment; (4) Re-evaluation of the event that prompted the external visit; (5) Cognitive assessment and (6) Collection of biospecimen and multimodal data, including EEG, neuroimaging and digital phenotype data. These data will only be collected once if a patient has two or more risk events of the same type throughout the follow-up period.Early onset rate: a reduction of HAMD-17 total score ≥20% from baseline by the end of week 2.Response rate: a reduction of HAMD-17 score ≥50% from baseline. Additionally, a stable response is defined as a reduction of two consecutive HAMD-17 total scores ≥50% from baseline at weeks 8 and 12.Remission rate: a HAMD-17 score ≤7 in the acute phase. Stable remission is defined as two consecutive HAMD-17 scores ≤7 at weeks 8 and 12.Relapse: a HAMD-17 score ≤7 or a reduction of HAMD-17 score ≥50% at the end of the acute treatment, lasting for <2 months, followed by a HAMD-17 score ≥14 in combination with meeting the diagnostic criteria for MDD of DSM-5.Recurrence: a HAMD-17 score ≤7 at the end of the acute treatment, lasting for >2 months, followed by a HAMD-17 score ≥14 in combination with meeting the diagnostic criteria for MDD of DSM-5.Primary outcomes are depressive symptom changes, as measured by the HAMD-17 total scores in the acute, maintenance and long-term follow-up phases compared with baseline. Clinical efficacy in different phases is defined as follows:Hospitalization for psychiatric episodes or emotional events.Conversion to bipolar disorder: DSM-5-diagnosed manic or hypomanic episodes.High risk of suicide: score on the third item of the HAMD-17 ≥3 or answering “Yes” to item 4 or 5 of the C-SSRS.Adverse effects of drug treatment and cumulative drug exposure.Adherence to treatment, as measured with the PAQ. Not taking prescribed drugs ≥70% of the time is considered to indicate non-adherence.Changes in social functions in the acute, consolidation and maintenance phases compared with those at enrollment.Changes in cognitive function in the acute, consolidation and maintenances phase compared with those at enrollment.Changes in multi-omics, neuroimaging, electrophysiology and digital phenotype indicators.A multi-source central data platform will be established to accommodate the multidimensional data included in the study Figure . ClinicaComprehensive data, amounting to thousands of variables across several modalities, will be collected in this project. Thus, we will be able to perform exploratory, data-driven analyses, and targeted, hypothesis-driven researches. These analyses and researches will help us investigate the trajectory of depression, identify clinical and biological subtypes of MDD, and construct prediction models of primary and secondary outcomes.Several methods will be available to investigate changes in symptoms and facilitate an understanding of the disease trajectory, such as repeated-measures analysis of variance/mixed-effects model, time series analysis, latent variable growth curve model, multi-layer linear model and dynamic Bayesian network model. Cluster analysis, principal component analysis and other algorithms may be used to identify clinical and biological subtypes of depression.Methods considered for the features' selection before the predictive model construction include the least absolute shrinkage and selection operator (LASSO), hierarchical LASSO and elastic net. Machine learning algorithms will then be used to build a model integrating multimodal biomarkers  and clinical features. Receiver operating characteristic (ROC) curve, cross-validity, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) will be calculated to estimate and improve the performance of the model.MDD is responsible for the highest burden of disease of any non-fatal disease worldwide, but its etiological mechanisms remain unclear and we are unable make the correct diagnosis and provide effective treatment with consistency. PROUD aims to accelerate homeostatic and precision medicine by establishing a prospective cohort study. This study has two significant strengths. (1) It will recruit a large, multidimensional cohort representative of the Chinese population: a total of 14,000 patients will be included, recruited from 52 tertiary hospitals across 24 provinces and cities in China. Furthermore, multimodal data will be collected, including clinical phenotypes, multi-omics, neuroimaging, neurophysiology and digital phenotypes. (2) This study will track mood changes and investigate the progression of MDD. External visits will be scheduled automatically whenever certain criteria are met and will be able to capture the patients' mood swings.The present study will develop standard operating and quality control procedures for the collection of multidimensional data, and construct a data platform to ensure standardization and shareability of data. Data from multidimensional sources will be integrated into a central data platform, thus aiding the management and future application of the data.It is clear that this study may also encounter certain difficulties. In response to the Corona Virus Disease 2019 (COVID-19), we have made the “Emergency Plan for Prevention and Control of Novel Coronavirus Pneumonia Outbreak”. If an outbreak strikes, we will actively coordinate resources, prioritize the security of the patients and researchers and try to minimize the impacts on progress while maintaining the quality of the study.In conclusion, the PROUD study will construct and provide a comprehensive database that will facilitate further analyses and studies and the development of homeostatic and precision medicine in China.


Chronic kidney disease (CKD) is a major health problem that has devastating metabolic and bone consequences. Osteoporosis is one of the pivotal metabolic disorders in patients with CKD which can increase the risk of fractures and mortality. Most nephrologists are familiar with management of CKD-Mineral and Bone Disorders (CKD-MBD), however, there is a big gap in diagnosis and management of osteoporosis. This special issue editorial is trying to focus on identifying the mechanisms behind bone loss that will help to precisely improve the outcome of patients with CKD.Poiana et al. reviewed the role of TBS in fracture risk assessment and management of CKD-MBD in dialysis patients. They concluded that TBS might add more information to DEXA measurements and improve the fracture risk assessment.In terms of diagnostic tools, trabecular bone score (TBS) is an emerging analytical tool depends on the gray-level variations of lumbar vertebrae and can be applied to DEXA images to assess bone micro-architecture. Clinical importance of TBS has been proved in patients with osteoporosis. Though, its value in patients with end-stage kidney disease (ESKD) needs to be validated. Patients on maintenance dialysis had an altered bone microarchitecture, however, there are no prospective trials to evaluate TBS role in fracture prediction in ESKD. In this special issue, Okasha et al., the severity of VC increased in patients with advanced CKD. Additionally, they found that serum OPG and phosphorus levels were significant independent predictors of VC.Cardiovascular disease is one of the catastrophic complications in patients with CKD. Both traditional and non-traditional risk factors contribute in the development of cardiovascular calcification (VC) . OsteoprMatuszkiewicz-Rowińska et al., 13 weeks of oral cholecalciferol  was more effective than alfacalcidol (1.5 μg/week) in increasing both 25-(OH)D and 1,25(OH)D levels in patients on maintenance hemodialysis. Moreover, there were no significant differences in serum calcium, phosphate, iPTH, FGF-23, and sclerostin levels over the study period.Vitamin D is crucial for regulation of bone and mineral metabolism . CalcidiGaweda et al., discussed the use of a human comprehensive mathematical tool known as quantitative systems pharmacology modeling. Human biochemical processes can be simulated explaining the interaction between multiple organs and biomarkers. Gaweda et al., validated their model using human data from the Chronic Renal Insufficiency Cohort (CRIC) study  study , 15. WitGupta et al. are summarizing the up-to-date knowledge of FGF-23 and α-Klotho in KTRs and living kidney donors and highlighting the prospective role of this pathway in patients' management in the future.FGF-23, a phosphaturic hormone secreted by osteocytes, and its co-receptor klotho have gained much interest in patients with CKD . FGF-23-Molinari et al., reviewed the possible pathogenesis, biochemical abnormalities, and impact of post-transplant MBD. Additionally, they designed an informative algorithm for post-transplant MBD management.Bone and mineral disorders are common in KTRs with increased risk of fractures. Moreover, management of CKD-MBD in KTRs is challenging due to lack of randomized clinical trials and national/international guidelines. CKD-MBD in KTRs are related to several factors including steroid usage, persistent hyperparathyroidism, low 25-OH-vitamin D as well as high FGF23 which may result in low phosphorus with defective bone formation and mineralization. Some studies demonstrated that hyperparathyroidism is the most predominant renal osteodystrophy (ROD) form , 23, howAll authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Colorectal cancer is a leading cause of cancer deaths. Several screening tests, such as colonoscopy, can be used to find polyps or colorectal cancer. Colonoscopy reports are often written in unstructured narrative text. The information embedded in the reports can be used for various purposes, including colorectal cancer risk prediction, follow-up recommendation, and quality measurement. However, the availability and accessibility of unstructured text data are still insufficient despite the large amounts of accumulated data. We aimed to develop and apply deep learning-based natural language processing (NLP) methods to detect colonoscopic information.This study applied several deep learning-based NLP models to colonoscopy reports. Approximately 280,668 colonoscopy reports were extracted from the clinical data warehouse of Samsung Medical Center. For 5,000 reports, procedural information and colonoscopic findings were manually annotated with 17 labels. We compared the long short-term memory (LSTM) and BioBERT model to select the one with the best performance for colonoscopy reports, which was the bidirectional LSTM with conditional random fields. Then, we applied pre-trained word embedding using large unlabeled data  to the selected model.The NLP model with pre-trained word embedding performed better for most labels than the model with one-hot encoding. The F1 scores for colonoscopic findings were: 0.9564 for lesions, 0.9722 for locations, 0.9809 for shapes, 0.9720 for colors, 0.9862 for sizes, and 0.9717 for numbers.This study applied deep learning-based clinical NLP models to extract meaningful information from colonoscopy reports. The method in this study achieved promising results that demonstrate it can be applied to various practical purposes. Colorectal cancer is a leading cause of cancer deaths –3. CanceWith the rapid adoption of electronic health records (EHRs), hospitals have accumulated a large amount of unstructured text data in EHR systems, such as discharge summaries, radiology reports, operation notes, and pathology reports. The unstructured text data in EHR systems contain clinically significant information, which is vital for comprehensive care. Regarding colonoscopies, the information embedded in the report can be used for various purposes, including colorectal cancer risk prediction, follow-up recommendations, and quality measurement –13. The Natural language processing (NLP) is a computer science subfield that uses computational techniques to learn, understand, and produce human language content . With thResearch data integration is essential in cancer research, and there are many efforts to gather and utilize clinical data, such as OHDSI CDM . AlthougClinical NLP research has recently emphasized the use of deep learning methods, and the publications are increasing yearly. Among deep learning models, recurrent neural network (RNN) has been widely employed in clinical NLP studies . RNN 2828 retainClinical NER is an essential NLP task for extracting meaningful information from clinical narratives. Recently, numerous efforts have been made to combine RNN variants with other techniques, such as embedding techniques , attentiIn previous studies, clinical standard terminologies such as UMLS or SNOMED CT have enriched word embedding using the semantic relations between clinical concepts , 39. AltSeveral studies have been published on clinical NLP for colonoscopy, as shown in Table This study aimed to extract meaningful information from colonoscopy reports using deep learning approach. We applied pre-trained word embedding to a deep learning-based NER model using large unlabeled colonoscopy reports. We compared variants of the long short-term memory (LSTM) and BioBERT  model toThis study used colonoscopies performed at Samsung Medical Center from 2000 to 2015. Data for this study were extracted from DARWIN-C, the clinical data warehouse of Samsung Medical Center, launched in 2016. As shown in Table In general, a colonoscopy report includes various information, such as patient information (indication/reason), procedural information, colonoscopic findings, and assessment  , 56. AmoAs shown in Textbox An open-source web-based text annotation tool was used to create training and test datasets. As shown in Table Figure To prepare a sequence of tokens for the input layer, documents were split into sentences, and sentences were zero-padded to make the input equal in length. Special characters were removed within the criteria that do not alter the number and position of the words and sentences. For the input representation, we assigned each word with an integer value and then converted the unique integer value to a binary vector.The weight matrix of the input word representation was created using Word2Vec , which uNER is a task for identifying meaningful words or phrases in a given text and classifying them into predefined semantic categories. Therefore, we focused on the principle of LSTM  to captuBERT utilizes a transformer network to pre-train a language model by jointly conditioning on both the left and right context in all layers. The transformer model introduces a multi-layer, multi-head self-attention mechanism that has demonstrated superiority over RNNs and LSTMs in exploiting GPU-based parallel computation and modeling long-range dependencies in a text . The oriThe output of the Bi-LSTM was used as input to the CRF layer. CRFs , one of This study conducted three experiments, as shown in Fig. We compared LSTM, Bi-LSTM, Bi-LSTM-CRF, BioBERT, and BioBERT-CRF models with different loss functions and optimizers to select the appropriate model and parameters. For the loss function, Categorical Cross-Entropy (CCE), Kullback–Leibler (KL) divergence , and PoiAs shown in Table The datasets D1, D2, D3, D4, and D5 in Table In Table About 280,668 colonoscopy reports were trained using Word2Vec to demonstrate the effect of pre-trained word embedding. Table As shown in Table As an analysis of errors of this model, the errors came from various reasons, such as vocabulary: synonyms, acronyms, and typos , grammatical mistakes , and incorrect extraction of size and location .This study has shown the feasibility of deep learning-based NLP methods to extract meaningful information from colonoscopy reports. Since there are no publicly available colonoscopy text data, 5,000 out of 280,668 colonoscopy reports were manually annotated using an open-source web-based text annotation tool. In the initial planning phase of this study, we assumed that 275,668 unannotated data could improve performance because it contained real-world synonyms and acronyms used in our institution. We compared LSTM, Bi-LSTM, Bi-LSTM-CRF, BioBERT, and BioBERT-CRF models to select the one with the best performance for colonoscopy reports. Although BioBERT performed much better than Bi-LSTM without a CRF layer, the performance of Bi-LSTM with a CRF layer was slightly higher than others. We applied pre-trained word embedding using large unlabeled data to the Bi-LSTM-CRF model. Therefore, the NER model with pre-trained word embedding performed better for most labels than the model without pre-trained word embedding. Although the deep learning-based NLP method performs much better than the traditional NLP method, the currently available public data is insufficient to cover the characteristics of various medical specialties. The method in this study could be effective in the absence of a shared colonoscopy dataset.This study has the following limitations. First, the study was conducted in a single institution, so it is possible that the model could not handle colonoscopy reports from other institutions. They can differ in many aspects, such as writing patterns, templates, and vocabulary. Although our model may not apply to other colonoscopy reports directly, our approach can be used in others. Second, there are no available colonoscopy datasets to compare the performance of our model. Evaluating the performance of the model is not possible, but we believe that the performance level of our model is sufficient for clinical applications. Third, we need to consider synonyms, acronyms, and typos and be able to process them. There are various synonyms and acronyms to describe colonoscopic findings and anatomical sites; for example, "D-colon", "D colon", "Desc. colon", "DC", "mid-d-colon", and "proximal-d-colon" for descending colon; "T-ileum", "T ileum", "TI", and "T.I." for terminal ileum; and "H-flexure", "H flexure", "H-Fx", and "HF" for hepatic flexure.Realizing the full potential of precision medicine begins with identifying better ways to collect, share, and make decisions based on data . AlthougThis study addresses the first deep learning-based NLP method for NER in colonoscopy reports. It is an important problem for clinical utility, such as cancer risk prediction, follow-up recommendation, and quality measurement. We applied a deep learning-based clinical NER with pre-trained word embedding. The method in this study achieves promising results that demonstrate it can be helpful for various practical purposes, including clinical document summarization and automated structured report generation.


The Veterans Health Administration (VHA) provides care for over 500,000 women. In 2010 VHA instituted a policy requiring each facility to identify a designated women’s health provider (WH-PCP) who could offer comprehensive gender-specific primary care. Access to WH-PCPs remains a challenge at some sites with high turnover among WH-PCPs. Faculty development programs have been demonstrated to foster professional development, networks, and mentorship; these can enhance job satisfaction and provide one potential solution to address WH-PCP turnover. One such program, the VHA’s Women’s Health Mini-Residency (WH-MR), was developed in 2011 to train WH-PCPs through case-based hands-on training.The objective of this program evaluation was to determine the association of WH-MR participation with WH-PCP retention.Using the Women’s Health Assessment of Workforce Capacity-Primary Care survey, we assessed the relationship between WH-MR participation and retention of WH-PCP status between fiscal year 2018 and 2019.N = 2664) at the end of fiscal year 2018 were included.All WH-PCPs , women’s health leadership position, number of clinical sessions per week, and clinical setting .WH-MR participants were more likely to remain WH-PCPs in FY2019 in both unadjusted analyses  and adjusted analyses .WH-PCPs who participate in WH-MRs are more likely to remain WH-PCPs in the VHA system. Given the negative impact of provider turnover on patient care and the significant financial cost of onboarding a new WH-PCP, the VHA should continue to encourage all WH-PCPs to participate in the WH-MR. While the reasons for such high attrition are not fully understood, WH-PCPs do require distinct skills to care for a medically complex patient population in a system that has historically been focused on men.11 Additionally, WH-PCPs are expected to maintain medical expertise through additional continuing educational requirements beyond those required of physicians without the WH-PCP designation2.Although VHA has expanded women-centric healthcare coverage, WH-PCP attrition (14% per year) continues to present a barrier to widespread provision of gender-specific care to women Veterans at some sites.6 and the same holds true for women Veterans. For example, in 2020, women Veterans identified a lack of regular access to a WH-PCP as a barrier to reproductive healthcare within the VHA.12 Such barriers to care almost certainly impact the overall health and well-being of women Veterans.Unfortunately, provider turnover negatively impacts the patient experience in the general population,13 and continuing medical education programs improve physician practices and patient outcomes.14 FDPs also foster the development of professional networks, social support, and mentorship which can enhance job satisfaction and commitment to the institutional mission.16 VHA Office of Women’s Health currently offers a few FDPs aimed at improving women’s health knowledge and clinical skills of primary care providers. Of these programs, the Women’s Health Mini-Residency (WH-MR) national training program is the largest and most intensive. The WH-MR is one mechanism through which VHA providers can become designated WH-PCPs.Faculty development programs (FDPs) provide one potential solution to address challenges in WH-PCP recruitment and retention. Physicians value FDPs,The WH-MR began in 2008 and has trained 4820 providers since its inception . The program offers national trainings each summer: providers from around the country join for 3 days of case-based educational programming. In addition to large group didactic seminars, the WH-MR provides opportunities for facilitated small group case discussion and knowledge application and also simulated gynecological skills practice using both breast and pelvic models and live simulated patients. Each year approximately 500 primary care providers including physicians, nurse practitioners, and physician assistants attend the program, along with 40 teaching faculty. The WH-MR has been highly rated by participants in terms of satisfaction with the program and improvement in comfort with the clinical care of women Veterans . However, the impact of WH-MR on WH-PCP retention remains unknown.Therefore, the objective of this program evaluation was to determine the impact of WH-MR participation on WH-PCPs retention.17 The survey has a 100% response rate as the Women Veteran Program Managers are required to complete it for each WH-PCP.We assessed the relationship between WH-MR participation and retention of WH-PCP status between FY2018 and 2019. Our analysis used data from the Women’s Health Assessment of Workforce Capacity-Primary Care survey (WAWC), an annual survey of VHA WH-PCPs conducted at the end of each federal fiscal year (FY) by Women Veteran Program Managers, a central liaison for women’s health at each VHA medical facility.We included all VHA WH-PCPs nationally who were medical doctors/doctors of osteopathy (MDs/DOs), nurse practitioners (NPs), or physician assistants (PAs). We excluded fellows and those providers who carried the WH-PCP designation but were not active primary care providers (absence of patient panels and/or clinic sessions). Individuals who attended the WH-MR for the first time in FY2019 were excluded from the cohort as the impact of participation in the WH-MR could not be assessed over such a short timeframe. Individuals who retired in FY2019 were also excluded from our analysis of retention as this reason for departure was determined to be different from other factors contributing to turnover.We used data from the FY2018 WAWC survey to identify WH-PCPs at the end of September 30, 2018, and data from the FY2019 survey to assess retention. To confirm that each WH-PCP maintained an active primary care panel of patients, WAWC data were linked with the Patient Care Management Module, in national VHA administrative data  as a function of WH-MR participation. For our multivariable adjusted analysis, we controlled for provider gender, provider degree , women’s health leadership position, number of clinical sessions per week, and clinical setting . Stata SE was used for all statistical calculations.Our cohort included 2664 WH-PCPs in FY2018. The majority of WH-PCPs, 1984 (74.5%), were women and 1856 (69.7%) were physicians, 669 (25.1%) were nurse practitioners, and 139 (5.2%) were physician assistants. Two-thirds (1776) had previously attended the WH-MR. WH-MR participants were more likely to be female, non-physicians, and work in a designated women’s health clinic (Table p < 0.001)  retained the WH-PCP designation status in FY2019, yielding an attrition rate of 19.1% (Table 1) Table . Additio16 This finding is also consistent with data showing VHA providers who perceive themselves and the institution as providing high-quality care report higher job satisfaction and less intention to leave.18Women’s Health Primary Care Providers who participate in VHA’s Women’s Health Mini-Residency are more likely to remain WH-PCPs in the VHA system. The protective effect of the WH-MR is consistent with previous literature demonstrating the value of FDPs.19 FDPs both within and outside of the VHA should consider assessing clinician retention as part of program evaluation data. If found, a positive impact on retention could be utilized as justification of the costs associated with FDPs. The value of dedicated women’s health provider development is increasingly recognized both within and outside VHA. In January 2021, Congress enacted the Johnny Isakson and David P. Roe M.D. Veterans Health Care and Benefits Improvement Act which aims, among other requirements, to increase opportunities for providers to participate in women’s health educational programs including the WH-MR.Further, taking into consideration both the negative patient outcomes and financial cost of turnover,20 Additionally, our finding that WH-PCPs who practiced solely in designated women’s health clinics had higher attrition rates is inconsistent with previous data.8 While this may be in part related to the different time frame of this study, further analysis will be needed to reconcile these results. The VHA should consider additional investigation to better define which specific aspects of the clinical environment most impact provider retention.Beyond the impact of the WH-MR on retention, our data suggest that NPs are more likely to remain WH-PCPs. This has implications for the WH-MR program in terms of both participant recruitment and course content, particularly given that VHA is the largest employer of NPs and grants NPs full practice authority.16 While virtual programming tends to be less expensive than traditional face-to-face programming and eliminates, in part, time away from clinical duties, the saved expenses may be negated if the virtual format does not offer equivalent benefits in terms of retention.This study does have limitations. Given the retrospective study design and cross-sectional nature of these data, it is not possible to determine causation. It is possible that additional, unaccounted for factors may have impacted the differential rates of retention observed. Additionally, we cannot exclude a selection bias, wherein providers with high dedication to women’s health were more likely to attend the WH-MR and thus more likely to remain a WH-PCPs after participation. Qualitative analysis could help to delineate both the perceived benefits of the WH-MR and the underlying reasons driving attendance and participation. Further, as WAWC survey data is reported by Women Veteran Program Managers, we cannot exclude the possibility of misclassification of WH-PCP status and/or WH-MR attendance designation. Finally, this study does not explore the impact of virtual faculty development on provider retention. It is unclear how the transition from face-to-face to virtual programming in the context of the COVID-19 pandemic may have impacted the protective effect of faculty development on retention, especially given that many purported benefits relate to developing shared mission, networking, mentorship, and the development of social supports.As the population of women Veterans continues to grow, the WH-MR offers one potential mechanism through which the VHA can help ensure access to a well-trained WH-PCPs workforce in keeping with an overarching commitment to providing excellent care to all. Future work should explore the perceived benefits of WH-MR participation to help clarify mechanisms for the program’s impact on provider retention. Additionally, other FDPs both within and outside of the VHA should consider assessing impact on provider retention as a marker of effectiveness, potentially to include conduct an analysis of costs associated with recruitment and onboarding compared with those of faculty development.22 the VHA should encourage WH-PCPs to participate in the WH-MR program as a potential mitigation strategy for high rates of WH-PCP attrition. Additionally, further evaluation of the impact of the WH-MR program, to include a more longitudinal or qualitative analysis, is needed to elucidate the perceived benefits of this FDP on retention.Given the high costs of recruitment and on-boarding of new providers, which ranges from $250,000 to $1 million depending on the provider,


In the modern obesogenic environment, heightened reactivity to food-associated cues plays a major role in overconsumption by evoking appetitive responses. Accordingly, functional magnetic resonance imaging (fMRI) studies have implicated regions of the salience and rewards processing in this dysfunctional food cue-reactivity, but the temporal dynamics of brain activation (sensitization or habituation over time) remain poorly understood.Forty-nine obese or overweight adults were scanned in a single fMRI session to examine brain activation during the performance of a food cue-reactivity task. A general linear model (GLM) was used to validate the activation pattern of food cue reactivity in food > neutral contrast. The linear mixed effect models were used to examine the effect of time on the neuronal response during the paradigm of food cue reactivity. Neuro-behavioral relationships were investigated with Pearson’s correlation tests and group factor analysis (GFA).P = 0.028], right lateral amygdala , right nucleus accumbens (NAc)  and left dorsolateral prefrontal cortex (DLPFC) , as well as in the left superior temporal cortex . Habituation of blood-oxygenation-level-dependent (BOLD) signal during exposure to food vs. neutral stimuli was evident in these regions. We have not found any area in the brain with significant increased response to food-related cues over time (sensitization). Our results elucidate the temporal dynamics of cue-reactivity in overweight and obese individuals with food-induced craving. Both subcortical areas involved in reward processing and cortical areas involved in inhibitory processing are getting habituated over time in response to food vs. neutral cues. There were significant bivariate correlations between self-report behavioral/psychological measures with individual habituation slopes for the regions with dynamic activity, but no robust cross-unit latent factors were identified between the behavioral, demographic, and self-report psychological groups.A linear mixed-effect model revealed a trend for the time-by-condition interactions in the left medial amygdala [t(289) = 2.21, β = 0.1, This work provides novel insights into dynamic neural circuit mechanisms supporting food cue reactivity, thereby suggesting pathways in biomarker development and cue-desensitization interventions. Overweight and obesity affect 39% of the adult population, are a leading cause of death in the adults and are considered a public health crisis in the USA and other countries, with more than 1.9 billion adults suffering from overweight, of which 650 million are obese . In lighThe incentive-sensitization theory of obesity postulates that repeated pairings of rewards from food intake and cues that predict imminent food intake result in a hyper-responsivity of rewards circuitry to food cues, which can lead to craving and overeating . Food crFunctional magnetic resonance imaging (fMRI) is a standard tool to investigate the neural correlates of food cravings during cue exposure. These studies reported that neural cue reactivity as indexed by fMRI signals is prospectively associated with food seeking/consumption behavior measured by weight gain  but alsoMost fMRI food cue reactivity studies model the response to a repeated stimulus using a single constant-amplitude regressor, an approach that provides an estimate of the average response amplitude along the fMRI session. However, there is a shred of evidence that cue reactivity triggers a motivational response that has a temporal behavior . In acco2), no current or past history of psychiatric or neurological disorders, no current or past history of eating or substance use disorders, no current psychopharmacological medication, no current pregnancy, and meeting MR-specific inclusion criteria . All participants had normal or corrected-to-normal vision. As we aimed to study food cue reactivity in a sample of overweight/obese adults who have frequent food cravings (≥3 per day during last month), we also excluded people who (1) reported having severe food allergies, (2) reported having special diets, (3) reported gastrointestinal disorders, metabolic, or endocrine disease, or (4) reported lower sensitivity to food cue responsiveness . The study was approved by the ethics committee of the Iran University of Medical Sciences (IR.IUMS.REC.1396.0459).The study database was the same as described in our previous work . After gAfter the screening procedure, each participant was scanned in a single fMRI session. On the screening session, participants completed a battery of baseline assessments {demographic questionnaire, Depression Anxiety Stress Scales-21 , Three-The task consisted of six blocks featuring a series of six food pictures each and six blocks featuring a series of six neutral pictures, used in our previous study . Each pi°, FOV = 256 × 256 mm). For the field map images we used a double-echo spoiled gradient echo sequence .Functional images, field maps and an MPRAGE sequence were acquired on a Siemens Magnetom Prisma 3T scanner using a 20-channel head coil. For the functional MRI we used a T2*-weighted gradient echo planar (EPI) sequence with 43 transversal slices oriented parallel to the AC–PC line . For the structural images we acquired a T1-weighted 3D MPRAGE sequence of 5 min 18 s  standardized space, and spatial smoothing with a 4 mm full-width at half-maximum Gaussian kernel. Times of repetition (TRs) with motion above 3 mm were censored.Functional MRI data were pre-processed with the AFNI software package p < 0.0039 and with a threshold for whole brain multiple comparisons set at p < 0.05 using NN2 clustering, where clustered voxels can share faces and edges  created by modeling onset times for the food conditions and for the neutral conditions with a 25 s BLOCK function, convolved with a standard hemodynamic response function (HRF) to generate two regressors of interest. Six motion correction parameters were included from each subject as nuisance regressors into the first-level model. For each subject, the differential contrasts directly comparing the food to the neutral conditions were then entered into second-level mixed-effects models implemented using AFNI’s 3dMEMA. The whole-brain statistical group maps were corrected for multiple comparisons using a cluster-based approach. A Monte Carlo simulation using the AFNI’s 3dClustSim determined the cluster size threshold of 50 voxels corresponding to corrected statistical results with a voxel-wise bi-sided threshold of nd edges .Time , Condition , and Time × Condition interaction on the whole brain functional activation were analyzed with linear mixed effect (LME) using the function “3dLMEr” of the AFNI software package. Condition , Time , and Time × Condition interaction were included as fixed-effects factors and Subjects as random effect. The resulting statistical group maps of main effect of Time are corrected for multiple comparisons using a cluster-based approach with a voxel-wise bi-sided p-value threshold of p < 0.0033 and a minimum cluster size of k = 40, which corresponds to a cluster-level alpha of p < 0.05 using NN2 clustering. The effects of Condition and time-by-condition interaction on the whole brain functional activation were analyzed with voxel-wise p-value thresholds of p < 0.05 and p < 0.01, respectively. The statistic values for main effects of Time, Condition, and Time × Condition interaction on the whole brain functional activation (generated by 3dLMEr) are represented in the output as chi-square with two degrees of freedom. The fixed number of DFs  for the chi-square statistic, regardless of the specific situation, is adopted for convenience because of the varying DFs due to the Satterthwaite approximation.The effects of lmer in R package lme4) for each subregion in the Brainnetome atlas with fixed effects of Condition  and Time in windows , also adding an interaction term for the two effects , and by-subject random intercepts. Also, the model included motion parameters as a fixed effect, which was defined as the mean Euclidean norm across the entire imaging run and included because of the potential for residual head motion effects after standard correction procedures. The model was “Beta∼Condition * Time + Motion + (1| Subject).” For each subject, mean beta weight values were estimated for all 246 ROIs in the Brainnetome atlas (BNA)  . We thenWe used the group factor analysis (GFA) to explain relationships between groups of variables with a sparsity constraint . GFA useLack of control, Desire, Positive reinforcement, Negative reinforcement, Physiological hunger), and FCQ-Trait subscales ], three demographic measures , and 10 self-report psychological measures . A form suited for GFA was achieved by z-normalizing the variables to have a zero mean and unit variance. To reduce the risk of identifying erroneous latent factors, GFA estimation was repeated 10 times to retain the robust latent factors constant across the sample chains.In total, the model included 34 regions of interest brain activation measures, 14 behavioral measures , hunger , prospective consumption , and decreased food control scores  following food cue-reactivity task. Interestingly, we did not observe any statistically significant changes in anger , awareness , drowsiness , sadness , and happiness ratings  following food cue-reactivity paradigm. Results revealed a significant decrease in anxiety state . Results are illustrated in We investigated the behavioral effects of cue reactivity on craving, hunger, prospective consumption, and food control ratings. As expected, individuals demonstrated increased scores in craving , right lateral amygdala , left STG , right NAc , and left MFG . In addition, the LME models exhibited a significant main effect for time in the left medial amygdala  and left STG  but no significant effect in the right lateral amygdala , left STG , right NAc , and left MFG . Interestingly, the LME models revealed no significant main effect for Condition in the left medial amygdala , right lateral amygdala , left STG , right NAc , and left MFG . As expected, no significant effect of Motion was found for all regions , Anxiety , and Stress ] and overall DASS . The individual habituation slope in the right lateral amygdala was correlated with CES , Emotions subscale of the FCQ-T , and self-reported craving before scanning . The individual habituation slope in the left STG (42) was positively and significantly correlated with self-reported craving before scanning . Finally, the individual habituation slope in the left MFG was negatively and significantly related to FCQ-S subscales [Desire  and Physiological hunger ] and craving self-reports before  and after  scanning. We tested for bivariate correlations between self-report psychological measures , behavioral measures  with individual habituation slopes within the six regions of interest. Here, the individual habituation slope in the left medial amygdala was correlated with DASS subscales [Depression  in overweight and obese people. Notably, dynamic amygdala activity with a similar downward slope over time has been observed in the recent cue-reactivity studies . For exaHabituation of the neural response to repeated exposure to salient visual stimuli is well-documented, both at the animal and human level. Neuroimaging studies consistently report a distinct engagement of the regions supporting salience and rewards processes in the habituation response to the salient cues. However, the pattern of these habituation effects varies, depending on the types of stimuli. Accordingly, our findings reveal a time-by-condition interaction, indicating a temporally dynamic response to the repeated presentation of food cues. The anatomic location of the clusters with significant time-by-condition interaction falls within the medial or lateral amygdala, superior temporal gyrus, nucleus accumbens, and medial frontal gyrus, implicated in the salience and rewards processing. The present study adds to earlier findings that repeatedly viewing salient visual stimuli leads to habituation of limbic subcortical  and cortical  areas.Condition was observed in the STG during the paradigm of food cue reactivity using LME analysis  in food cue reactivity . Our whoanalysis , howeveranalysis . Previouanalysis . In lineBy suppressing the association between the conditioned stimulus and the unconditioned stimulus, food cue exposure treatment, a therapeutic strategy based on the Pavlovian conditioning paradigm, aims to extinguish cravings and prevent future relapses . HoweverThis study is not without limitations. First, because the order was not pseudo-randomized, the participants could predict the type of the next block, which might have an impact on the outcomes. Second, although we didn’t distinguish between high-calorie and low-calorie food images in our cue presentation, research have shown that high-calorie and low-calorie food images may have distinct effects on the brain . Third, In summary, the present results demonstrate for the first time that the regions of the rewards and inhibitory processing show fluctuations to repeated exposure to food visual stimuli consistent with habituation. This study also underscores the importance of examining the temporal dynamics of brain activation in fMRI design and analysis in studies of food cue reactivity, thereby suggesting pathways in biomarker development and cue-desensitization interventions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Iran University of Medical Science (IR.IUMS.REC.1396.0459). The patients/participants provided their written informed consent to participate in this study.PG-A and HE designed the research. PG-A performed the research, analyzed the data, and wrote the manuscript. HE and RM reviewed and edited the manuscript and supervised the manuscript. All authors approved the final manuscript.


Analyses addressed the factorial validity and reliability, the criterion validity (by assessing differences in scores between competition levels), and the concurrent validity  of a Polish Short Form survey.Self-regulated learning entails psychological processes that elite athletes employ to optimize their practice. Although self-regulated learning provides insights into athlete-led practice, research has been limited to few cultures, and the particularities of how SRL surveys perform in new cultural contexts require attention. Moreover, there exists no measure to assess SRL and its relationship to quality sport practice in Polish. Thus, we examined the Short Form of the Self-Regulated LearningN = 324, Mage = 21.4, nfemales = 144, nmales = 180) from amateur, regional, national, and international-elite levels completed the survey, along with concurrent subscales .Athletes , MS-24 , and ACS-90 .Confirmatory factor analysis indicated a two-factor  model . Between-group tests showed international-elite scoring higher than all other groups on metacognitive and motivational subscales. On both subscales, significant trends indicated that more skilled levels consistently reported higher scores than lesser-skilled levels. The short form scores were associated with certain concurrent variables, including GSES (—Sport Practice survey is a promising tool for use in Polish sport and we discuss future avenues of work to enhance its validation. Limitations that inform future research include our reliance on a mixed-sport sample, the lack of priming of obstacles/challenge ahead of self-report, and a lack of consideration of sport-specific practice variables in analyses.On the basis of strong criterion validity, and moderate evidence for concurrent validity, we conclude that the Polish Short Form of the Self-Regulated Learning Self-regulated learning (SRL) has received a lot of recent attention in the sport context . EvidencSelf-report measures of SRL have been investigated in a limited selection of cultural contexts. English versions of Other investigators have adapted versions of the preceding surveys to new cultural contexts. Each time an SRL survey has been translated to a new language and/or cultural context has necessitated a slight adjustment to the survey factor structure (5–6 factors) and item selection (26–48 items). Some changes are attributable to minor linguistic modifications. For instance, Mage = 26.45, SD = 12.66) indicated a two-factor solution—motivation and metacognition subscales—and skill group comparisons among athletes (> 17 years of age), indicating that international athletes scored correspondingly higher than national and provincial athletes on both subscales. Although Wilson et al. presented their Short Form SRL-SP as a viable tool for assessing self-regulated sport practice in applied North American settings with English-speaking athletes, it has yet to be examined in alternative cultural contexts. The current investigation sought to examine this Short Form SRL-SP among Polish athletes.Despite the various self-report SRL tools, the shortest validated surveys have used 26 to 31 items, which may be too long for use in applied sport consultation settings . In respSport expertise researchers have contended that a survey should establish criterion validity by discriminating between multiple, escalating skill groups in a corresponding manner  with noted effect sizes . For exaWhen researchers neglect to examine inter-group skill differences e.g., , this cucf., Despite extensive investigation of various SRL surveys, little work has assessed how the results of these measures correspond to those of similar constructs cf., . SRL embThere are parallels between SRL and facets of the metacognitive self. For example, According to action-control theory, volitional capacities are required to translate goals into behavior and are essential for the initiation of action and monitoring goal-relevant behavior in the face of obstacles . With revia inter-group assessment of Polish athletes of different sport levels, and examined its concurrent validity in relation to parallel scores for general self-efficacy, metacognitive self, and action control.Although the catalog of SRL surveys is being used more widely, research practitioners cannot assume any one of them, including the Short Form SRL-SP, validly applies across cultures without understanding its validity within a specific cultural context. Validity in a sport performance context should be established through the intersection of multiple considerations, including factorial, criterion, and concurrent validity. As such, this investigation specifically examined the Polish version of the Short Form SRL-SP survey’s psychometric characteristics and its constituent themes in a Polish sample, tested the criterion validity of the survey scores via organizational and coach contacts at sports university, clubs, and institutions, and were approached onsite at events or practices around Poland (mainly in Lesser Poland). Participants had to be 18 years of age or older, and actively practicing for and competing in organized sport at either amateur, regional, national, or international-elite levels. We recruited 324 Polish athletes  from diverse sports . To improve the validity of skill grouping  and motivational  self-regulated learning processes . All iteThe GSES  is a 10-The MCS-24  is a 24-The ACS-90 . assesseWe initially assessed for missing values. Three MCS-24 items contained one missing value representing <0.62% of data. These values were missing at random and were thus replaced using randomly generated values within the range of pertinent scales. We conducted confirmatory factor analysis (CFA), using obliminal rotationpost-hoc Dunn tests. Effect sizes for ANOVAs were based on partial eta-squared values interpreted as 0.01 small, 0.06 medium, and 0.14 large. Effect sizes for post-hoc comparisons were based on d values interpreted as.2 small, 0.5 medium, and.8 large  using Kruskal-Wallis ANOVA and .8 large . Prelimir = 0.68 , SRMR = 0.072, CFI = 0.829, and TLI = 0.798. The CFA for the two-factor model showed better fit. The items on the two factors matched the English Short Form SRL-SP  exactly:0.68 see . The two0.68 see . In our metap = 0.06; motivp = 0.58). A one-way Kruskal-Wallis ANOVA for metacognitive scores was significant, H  = 15.58, p = 0.001, partial eta-square = 0.05. Dunn tests showed significant differences between all of the levels with one exception—the regional athletes’ levels were not different from than amateurs  = 23.22, p < 0.001, partial eta-square = 0.07. Post-hoc tests showed significant differences between all of the levels with one exception—the national group was not different from the regional group , MCS-24 (r = 0.25), and the AOF subscale of action control (r = 0.26). Short Form SRL-SP metacognitive scores were significantly correlated with GSES (r = 0.41) and MCS-24 (r = 0.40) scores.The study examined how the Polish version of the Short Form SRL-SP performed according to multiple facets of validity. The Polish short form demonstrated better factorial validity for a two-factor model, comprising a motivational and metacognitive subscale, than a global factor. Based on our sample, the Polish Short Form better lends itself to assessment with two factors, and explains greater variance and fit in the modeled data, which is consistent with what post hoc tests offered evidence of the experts’ advantage. For instance, the international-elite group showed large and medium effects in comparisons to the amateur and regional groups, respectively. The international-elite group also reported small effect size advantages on both subscales over the national group. Moreover, there were generally small to medium effect size differences between all groups across the competitive group simplex. These results are arguably the strongest to date in terms of skill group discrimination  using SRL surveys for several reasons. First, most studies have used two  for metacognitive scores. Effect sizes from the wo e.g.,  or threewo e.g.,  for compwo e.g., . Secondlwo e.g., . Overallwo e.g., , includiwo e.g., .Regarding concurrent validity, our results supported the expectation that both motivational and metacognitive subscales would be positively and substantially correlated with general self-efficacy. The strongest correlations, of medium effect size , were beA medium-sized correlation was found between the Short Form SRL-SP metacognitive subscale score and metacognitive self, that is, athletes’ report of self-awareness of their self-regulatory biases . Biases in situ priming of significant challenges, or hardship, or ruminating bothers, for individuals to manifest self-regulated decision-making (and not hesitation) and continued on-task regulation (rather than volatility).In regard to action vs. state orientation subscales, there was little evidence of concurrent validity with the Short Form SRL-SP subscales. Only one relationship provided significant, the small-sized correlation between the AOF subscale (failure-related action orientation vs. preoccupation) and the motivational subscale. Thus, when athletes indicated a greater capability to refocus following failure/disappointment and to dismiss/disrupt bothersome cognitions, they also reported greater use of self-motivation processes to recruit personal effort and cope with difficulties when tasks become hard. This significant correlation is intuitive because action-control orientation becomes increasingly valuable when individuals confront demands and require resilience during goal-oriented tasks , as woulOur large, mixed-sport sample may also have been unsuited to show the concurrent validity we expected. For example, Although a strength of this investigation was the use of four escalating skill, allowing for more discriminating inferences on the role of SRL processes toward skill group membership, a limitation was the absence of cross-validation of such groups using secondary performance measures or coach ratings. The current study did not specifically assess SRL measures, or the other concurrent measures for that matter, in relation to indices of practice. Indeed, the current study did not examine how differences in amounts of sport-specific practice contribute to sports-level group status, which may be viewed as a limitation. To most fully validate the role of SRL measures in enhancing practice among Polish athletes, studies should be conducted to examine the relation between report on the Polish Short Form SRL-SP and amounts of practice and particularly in relation to indices of quality/purposeful sport practice. Additionally, future researchers could consider examining how Short Form SRL-SP measures mediate the relationship between sport-specific practice and sports-level group status. Finally, there are limits to cross-sectional analyses such as those employed in the current investigation; thus, longitudinal studies are needed to determine causality and effectiveness of SRL processes on the acquisition of better sport performances.Given how mixed results for concurrent and psychometric validity were contextualized by the strong evidence for criterion validity, it seems reasonable for future research to inquire about the practical validity of the Polish Short Form SRL-SP. Practical validity refers to the consideration of how research findings/products, in our case the Polish Short Form SRL-SP, are informed by the perspectives of practitioners, located within the narratives of applied practice, and examined instrumentally by those in practice. Altogether, the multiple forms of validation used in our study provided promising results for the use of a Short Form SRL-SP version among Polish athletes. The results provided evidence for very good criterion validity, showing that scores on the survey resulted in stronger and more consistent skill group differences, corresponding completely across all escalating skill groups, than all prior research works using SRL surveys. Our findings suggest that generally greater engagement in metacognitive and motivational processes of SRL distinguishes the most elite group from lesser-skilled groups. There are also differences between amateur-, regional- and national-level athletes. Evidence toward concurrent validity seemed mixed. On the one hand, we found medium-sized correlations with self-efficacy, and medium and small-sized correlations with metacognitive self, yet the concurrent validity in relation to action control was less robust, with only a small-sized correlation between the failure-related action orientation vs. preoccupation subscale and the motivational SRL-SP subscale.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The University of Physical Education in Krakow (grant 219/BS/INS/2019). The patients/participants provided their written informed consent to participate in this study.MS was responsible for the conceptualization of the research, the research design, participant recruitment, data collection and analysis, statistical analysis, and was a primary contributor to the writing of the first manuscript draft. SW contributed to the data analysis, statistical analysis, and the writing of the manuscript. JB contributed to the research design, was responsible for participant recruitment, and applied his expertise in sport psychology across the manuscript with a focus on the application to sport practice. BY contributed to the data analysis, statistical analysis, and the writing of the manuscript, and edited the final manuscript. All authors contributed to the article and approved the submitted version.A Short Form of the Self-Regulated Learning for Sport Practice Survey SRL-SP SF.”This study was financed by The University of Physical Education in Krakow (grant 219/BS/INS/2019). Title of the project: “Translation and adaptation of 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.


Loneliness is an important public health challenge for all ages. This studyreports time trends of loneliness among adolescents over a 12-year periodand analyses the strength of the associations between loneliness, healthcomplaints, and medicine use.Data were derived from the cross-sectional Finnish Health Behaviour inSchool-aged Children study conducted in 2006, 2010, 2014, and 2018. Thestudy population is based on a random sample of schools with 20,444participants aged 11–15 years. The trends were analysed with aMantel–Haenszel test, and the strength of the associations was evaluated bymixed-effects logistic and linear regressions.An increasing prevalence in frequent loneliness  wasevident over the 12-year study period, especially in girls and 15-year-olds.Among all adolescents, loneliness was associated with a higher risk ofrecurrent health complaints and medicine use to treat the correspondinghealth issues, especially nervousness (odds ratio 5.8) and sleepingdifficulties (odds ratio 7.6).Adolescence is a period of higher risk of frequent loneliness andassociated health complaints. In this study, loneliness was common amongadolescence and an increasing trend of loneliness was observed between2006 and 2018. Also, psychosomatic health complaints and medicine usewere strongly associated with loneliness. Persistent loneliness is asignificant health risk and failure to resolve loneliness beforeentering adulthood may imply significant concerns for futurewell-being. Satisfying social relationships in adolescence are vital for good mental and physicalhealth. From a public health point of view, adolescence is a crucial period forreducing loneliness and preventing negative health outcomes and social exclusion. LonelinLoneliness is associated with various physical and psychological health consequences,especially when it is experienced often or over a prolonged period . Among aAdolescence is also a period in which subjective health complaints become morenumerous. Subjective health complaints, which refer to symptoms experienced by anindividual with or without a defined diagnosis, reflect emotional distress,behavioural difficulties, and non-specific pain, such as headaches, irritability,and nervousness . ArecenIn relation to subjective health complaints, self-reported medicine use byadolescents to treat headaches, stomach aches, nervousness, and sleepingdifficulties is common across countries . Girls hDespite the wide range of research on loneliness, there has been insufficientattention given to the time trends and interactions between loneliness, individualhealth complaints, and medicine use. There is also a lack of knowledge concerningthe extent to which loneliness increases the risk of recurrent individual healthcomplaints and corresponding medicine use. To address these research gaps, thisstudy aims to describe the prevalence and trends of loneliness among 11-, 13-, and15-year-olds in Finland from 2006 to 2018, and analyse the strength of theassociations between loneliness and health complaints, and loneliness and medicineuse.Data were collected from Finnish adolescents in 2006, 2010, 2014, and 2018 aspart of the Health Behaviour in School-aged Children (HBSC) study. The HBSCstudy is an international World Health Organization collaborative study thatuses cross-sectional surveys performed every four years among students aged 11,13, and 15. Samples were chosen from the Finnish school register by means of arandom cluster sampling method. The sampling was adjusted to take into accountthe province, municipality, and size of the school. The primary sampling unitwas the school. Within the school, the class was randomly selected. The HBSCstudy protocol ensures that the sample is nationally representative of thetarget population . The sch2(2) = 1.81; p =0.41); thus, boys and girls comprised similar proportions of each age group.Most participants were European with a Finnish background. The majority wereborn in Finland, and most were living in urban areas.The current study is based on the Finnish national HBSC data collected in 2006,2010, 2014, and 2018 from Finnish-speaking schools. The total number ofparticipants was 20,444. The sample sizes were 5249, 6723, 5925, and 2547 forthe survey years 2006, 2010, 2014, and 2018, respectively. The sample was evenlydistributed by gender and age Loneliness Scale when used as a one-dimensional measure ofloneliness .StudentSubjective health complaints were measured with the HBSC symptom checklist(HBSC-SCL), which is a non-clinical measure of perceived symptoms . The scaMedicine use was examined for each ailment in 13- and 15-year-olds .The medicine use items employed in this study have been validated by parentalreports .Medicinp-value of less than0.001 was considered statistically significant to avoid type-I error.Descriptive analyses were conducted with SPSS 26.0 .Descriptive statistics were used to examine the prevalence and time trends ofloneliness. Linear time trends were tested by the Mantel–Haenszel test fortrends. For all analyses, a conservative p-value was calculated for each association.The goodness-of-fit of the mixed-effects models was tested against that of thefixed-effects models. A significant chibar2 test value indicated thatthe mixed-effects model had a better fit than the fixed-effects model. Themixed-effects logistic regression and mixed-effects linear regression wereconducted with Stata 16 .Mixed-effects logistic regression was first used to separately analyse thestrength of associations between loneliness and individual health complaints,and loneliness and each medicine use. Then, mixed-effects linear regression wasconducted to investigate the relationships between loneliness and thestandardised sum score for health complaints and loneliness, and thestandardised sum score for medicine use. The effects of gender, age, and datacollection year were investigated with the models by including the variables asindependent variables in the regression model. Mixed-effects modelling wasutilised for the analysis in view of the clustering of students in classes. Thesampling procedure was carried out by school level, and only one classparticipated from each school. Class was set as a random effect in themixed-effects equations. The odds ratio (OR) with a corresponding 95% confidenceinterval (CI) and The strength of the associations between loneliness and health complaints andloneliness and medicine use were analysed by mixed-effects logistic regression andmixed-effects linear regression. Frequent loneliness was associated with a higherrisk of experiencing health complaints at least once a week as well as the use ofmedicine to treat the corresponding issues. For students who reported being lonelyvery often, OR values were significantly higher for headache (3.0), stomach ache(3.8), nervousness (7.6), and sleeping difficulties (5.8) compared to adolescentswho were never lonely . FurtherExperiencing loneliness very often was also associated with a higher risk of usingmedicine in the past month to treat a stomach ache (OR 1.5), nervousness (OR 8.4),or sleeping difficulties  to 15%(2018) in the total sample. A linear increasing trend in loneliness was observed in15-year-olds but not in 13- or 11-year-olds. Loneliness was particularly high among15-year-old girls, of whom 25% experienced loneliness quite often or very often in2018. Regression analysis confirmed a strong association between loneliness andsubjective health complaints. The results of this study evidence especially strongassociations of loneliness with psychological health complaints  and medicine use targeting those healthcomplaints .The finding of an increasing trend in loneliness among 15-year-olds is consistentwith recent worldwide Program for International Student Assessment(PISA) surveydata. Twenge et al. have notThe results of this study also reveal gender-related differences in self-reportedloneliness and its associations with subjective health complaints and medicine use.One in four 15-year-old girls reported frequent loneliness, and the regressionanalysis results highlight that girls generally reported more health complaints andmedicine use. These findings correspond with those of cross-national studies on timetrends in subjective health complaints, wherein girls and older adolescentsdisplayed higher rates of both individual  and multAn increasing trend of loneliness was observed among boys as well, although theiroverall level of loneliness was lower than that of girls. Previous research hassuggested that gender-related differences in loneliness could be explained by thefact that indirect scales measuring loneliness tend to indicate higher rates formales, while females are more likely to admit to being lonely when using directmeasures and self-labelling . Boys alThis study also complements current research on adolescent sleep problems in whichadolescents who experienced loneliness very often had a six-fold risk of havingsleeping difficulties and a seven-fold risk of taking medication to treat sleepingdifficulties compared to adolescents who were never lonely . Sleep dLoneliness was associated with a higher risk of all subjective health complaints andmedicine use, which can both be problematic. Recurrent somatic symptoms inadolescence can compromise health and negatively affect aspects of everydayfunctioning, such as school attendance, sleep quality, and the ability to pursuehobbies . InaddiThe cross-sectional design of this study implies some limitations. This research isbased on self-reported survey data collected in 2006, 2010, 2014, and 2018. Sincethe data are cross-sectional, it is not possible to analyse causal relationshipsbetween loneliness, health complaints, and the use of medicine. However, earlierresearch has indicated that adolescents can reliably report perceived healthcomplaints . ThisstMoreover, the HBSC survey does not ask respondents if the medicine they used wasover-the-counter or prescription. Over-the-counter pain medication is readilyavailable, including for adolescents, and the use of melatonin to treat circadianrhythm disorders and insomnia is becoming more common among children and adolescents. MedicinThis study measured loneliness with one question: ‘Do you ever feel lonely?’. Basedon previous research, the use of one item to measure loneliness can yield comparablefindings to that of the widely used UCLA Loneliness Scale when used as aone-dimensional measure of loneliness . While lThis 12-year time trend study highlights an increasing trend in loneliness,especially in 15-year-old girls. Among all adolescents, feelings of loneliness werestrongly associated with headaches, stomach aches, nervousness, sleepingdifficulties, and the use of medicine to alleviate those symptoms. Frequentloneliness was particularly strongly associated with a higher risk of experiencingnervousness and sleeping difficulties as well as the use of medication to treatthese health issues. Although some loneliness during adolescence can be expected,persistent loneliness is not normal and should be identified and addressed as animportant health risk. Failure to resolve loneliness before entering adulthood mayimply significant concerns for future well-being and health throughout one’slifespan. From a public health point of view, school-based interventions and healtheducation efforts might be effective ways to mitigate this problem, as they coverthe entire adolescent population.


The human microbiota is implicated in many disease states, including neurological disorders, cancer, and inflammatory diseases. This potentially huge impact on human health has prompted the development of microbiome engineering methods, which attempt to adapt the composition and function of the human host-microbiota system for a therapeutic purpose. One promising method is the use of engineered microorganisms that have been modified to perform a therapeutic function. The majority of these products have only been demonstrated in laboratory models; however, in recent years more concepts have reached the translational stage. This has led to an increase in the number of clinical trials, which are designed to assess the safety and efficacy of these treatments in humans. Within this review, we highlight the progress of some of these microbiome engineering clinical studies, with a focus on engineered live biotherapeutic products. It is tin axis) .This review focuses on studies that use recombinant or engineered live biotherapeutic products (eLBPs); in particular, highlighting clinical trials that attempt to demonstrate their safety and efficacy in humans. eLBPs are microorganisms that have been genetically modified to perform a specific diagnostic or therapeutic function. Previous reviews have summarised the progress that has been made in developing these methods, but the majority focus on preclinical research, with only a few referring to clinical trials . In thisE. coli Nissle 1917 strain that had a mean residence time of 48 h in human patients (Clostridioides difficile infection (CDI) that does not respond to standard therapy  or a Salmonella subspecies . Attenuated strains of L. monocytogenes have been produced that display reduced virulence. For example, the double-knockout ΔactA/ΔinlB strain, where the genes for tropism and cell-to-cell transmission have been deleted; or the ΔactA/ΔplcB strain (prfA-defective strain secretes a truncated fragment of listeriolysin O (LLO), an immunological pore-forming protein, fused to HPV-16 E7 (L. monocytogenes based eLBP (NCT02853604)  . However2853604) .Advaxis also developed the ADXS31-142 and ADXS31-164 eLBPs. ADXS31-142, intended for the treatment of prostate cancer, was engineered to secrete a fusion of LLO and prostate specific antigen (a serine protease that displays elevated levels during prostate cancer progression) . WhereasSalmonella subspecies are also commonly used, as they can penetrate and preferentially grow within tumour tissues , myeloma (NCT03762291), and neuroblastoma (NCT04049864). tissues . The VXMfactor-2 . This stfactor-2 . A furthfactor-2 . FollowiL. monocytogenes and Salmonella based studies, E. coli Nissle 1917 has been used as a chassis for cancer-targeting eLBPs. Synlogic’s SYNB1891 strain was engineered to target the stimulator of interferon genes (STING) agonists pathway to trigger anti-tumour immunity, via expression of cyclic di-AMP (CDA) (dapA (4-hydroxy-tetrahydropicolinate synthase) and ΔthyA (thymidylate synthesase) knockouts, showing that this dual-auxotroph was able to prevent in vivo proliferation of SYNB1891 in various tumour types . This trial is recruiting patients with advanced/metastatic solid tumours and lymphoma, with the aim to test SYNB1891 alone or in combination with Atezolizumab (an immunotherapy drug). These studies highlight the vast potential eLBPs hold for the treatment of a variety of cancer types.Alongside the MP (CDA) . Alongsiur types . SYNB189E. coli Nissle 1917 strain developed by Synlogic, for the treatment of phenylketonuria (PKU). PKU is a rare disease caused by genetic mutations of the phenylalanine hydroxylase enzyme; which results in elevated levels of phenylalanine in the blood. If left untreated, PKU can cause severe neurological complications. Traditionally, PKU is managed through a phenylalanine-restricted diet, which can have a negative impact on a patient’s quality of life (l-amino acid deaminase (LAAD) enzymes. Following positive results in mouse and non-human primate models of PKU  successfully showed that SYNB1934 was also safe and well-tolerated in healthy adult volunteers. Subsequently, a new clinical trial (NCT04534842) is recruiting patients, in order to perform a head-to-head comparison of the SYNB1618 and SYNB1934 eLBPs.Synthetic biology engineering techniques allow for the creation of eLBPs that can produce non-native molecules, such as human proteins . This al of life . The SYNs of PKU , SYNB161ng units . As discng units . In addi-on-chip  and pred-on-chip ; showing-on-chip . Followi-on-chip . SYNB193E. coli Nissle 1917 based eLBP, referred to as SYNB8802, has been designed to combat enteric hyperoxaluria (EH). EH is caused by excessive absorption of dietary oxalate, which can cause kidney failure. This can be due to genetic defects, or via gastrointestinal conditions that increase oxalate uptake .Another e uptake . Currente uptake . SYNB880in vitro . As within vitro . A phaseE. coli Nissle 1917 strain, was engineered to convert NH3 to arginine in anaerobic conditions; with the strain promoting improved survival in a mouse model of hyperammonia , or defects in ammonia-detoxifying enzymes. SYNB1020, another rammonia . The strL. lactis strain that secreted hIL-10 and was shown to be safe and well-tolerated in an UC patient cohort (NCT00729872). AG014, based on the same L. lactis platform as AG011, was engineered to produce an anti-TNFα antibody fragment of certolizumab (Inflammatory bowel disease (IBD) is a chronic, inflammatory disease of the digestive tract, with two major subtypes: Crohn’s disease and ulcerative colitis (UC). The full mechanisms behind IBD are not yet understood, however there is a general consensus that the microbiota plays an integral role in the development and progression of IBD . Traditiolizumab . AG014 wolizumab .L. lactis strain was engineered to secrete human Trefoil Factor 1. Initially, AG013 was shown to be effective in a hamster based model of radiation-induced OM  in patients with head and neck cancer undergoing chemoradiation therapy. This duced OM . FollowidapA auxotroph for the essential cell wall component diaminopimelate (Currently, many eLBPs in trials are based on the constitutive expression of specific molecules. However, modern engineering tools allow for the development of more complex systems. For example biosensors that sense and respond to environmental cues in a dynamic manner , engineepimelate . Other bpimelate . We expepimelate . As statpimelate . Therefoin vitro and animal model data do not always translate into safe and efficacious treatment in humans. Of the 14 terminated eLBP clinical trials identified during this literature review 50% were terminated due to a reported lack of efficacy or clinical activity in humans. Although undoubtedly more needs to be done to alleviate these problems, considerable research is going into the development of novel model systems that can be used to characterise eLBPs more comprehensively before they reach clinical testing. These include novel animal models (in vivo activity of eLBPs (As evidenced by the number of complete, and ongoing, clinical trials, the development of eLBPs is an exciting application of microbiome engineering research. Despite this, it is important to highlight the issues that can occur when eLBPs enter clinical trials. As shown by the number of terminated and unsuccessful clinical trials, a major issue is that positive l models , innovatl models  and mechof eLBPs . It is hFinally, as discussed in detail by


This study used the revised nursing outcomes classification (NOC) outlined in our previous study, “Core nursing outcomes for otorhinolaryngology head-neck,” for telephone follow-up of patients who had laryngeal carcinoma surgery in China. This randomized controlled trial aimed to compare nurse-led telephone follow-up according to the revised NOC with traditional telephone follow-up.A total of 100 postoperative patients were recruited from March 2018‒March 2020. Patients were randomly assigned to nurse-led telephone follow-up groups as either revised NOC follow-up (n = 51) or traditional follow-up (n = 49). The investigated outcomes included nursing outcomes, quality of life, and self-care abilities.P = 0.018), primarily regarding psychosocial health (P < 0.001) and health knowledge and behavior (P < 0.001). Moreover, patient outcomes in the intervention group were associated with greater improvements in quality of life than those in the control group (P < 0.001), especially for social conditions (P < 0.001), emotional health (P < 0.001), functional status (P < 0.001), and additional attention (P = 0.001). Finally, compared with the control group, significant improvements were observed in self-care abilities in the intervention group (P = 0.002), mainly regarding general self-care abilities (P = 0.016) and development self-care abilities (P < 0.001).The baseline characteristics of patients were well balanced. We noted that improvements in nursing outcomes in the intervention group were significantly better than for those in the control group (This study found that nurse-led telephone follow-up according to the revised NOC improved nursing outcomes, quality of life, and self-care abilities.ChiCTR2100045941.The online version contains supplementary material available at 10.1186/s12912-022-01054-2. Laryngeal carcinomas are the most common type of malignant tumors that receive treatment in otorhinolaryngology departments . The preAfter surgery, laryngeal carcinoma patients may experience physical and mental health problems. The guidance they receive should be normative and professional. Nurse-led telephone follow-up is the most frequently used approach for providing follow-up care that includes individual health guidance and psychological support. Telephone follow-up has already been introduced for patients in various settings, including follow-up after urological surgery, cataract surgery, Mohs micrographic surgery, pelvic floor surgery, and for patients experiencing obstructive sleep apnea –13. ReseThe study was a randomized, observer-blinded, two-armed, single-center trial, and all patients were recruited from the Shanxi Key Laboratory of Otolaryngology, Head and Neck Cancer, China. The ethics committee of the Nursing College of Shanxi Medical University (2020sll002) approved the protocol and amendments, and the study’s sponsor (Yongxia Ding) was responsible for data collection. Moreover, every enrolled patient signed an informed written consent form. Patients were randomly assigned to nurse-led telephone follow-up according to the revised NOC (intervention group) or traditional telephone follow-up (control group), with a 1:1 ratio, using a permuted block randomization method. A statistician generated random allocation sequence, and a research assistant enrolled and assigned patients. The details of the revised NOC were reported in our previous study, which contained 14 core postoperative nursing outcomes and 69 indicators . These iOne hundred patients who had undergone laryngectomy were recruited from March 2018‒March 2020. The following inclusion criteria were applied: (1) laryngeal carcinoma confirmed by pathology, (2) treated with total or partial laryngectomy, and (3) patient understands the questionnaire content. Patients with the following characteristics were excluded: (1) recurrence or metastasis of laryngeal carcinoma within six months; (2) cancer at other sites; (3) serious heart, brain, or kidney disorders; (4) mental health issues under treatment; (5) restricted communication ability in terms of speaking, listening, reading, writing, or other forms of communication; and (6) the primary caregiver works in health care.The general characteristics of patients were obtained from uniform medical records; the information included the patients’ sex, age, educational status, residential location, occupation, marital status, income, smoking history, alcohol history, surgical approach, tube use, and radiotherapy status. The primary endpoint was core nursing outcome scores assessed by the nurse based on physiological health, psychosocial health, health knowledge and behavior, and perceived health ; secondaQuality of life after laryngectomy was assessed using the Chinese version of the Functional Assessment of Cancer Therapy–Head and Neck, which was devised by the Center for Translational Research and Education at Northwestern University, USA . The ChiConnect consists of politely confirming if the person answering the phone is the patient or a family member. (2) The nurse introduces herself and her role and states the purpose of the follow-up. (3) In communicate, the nurse obtains the patient’s consent and cooperation. (4) In ask and respond, the patient is asked the questions from the revised NOC, and the nurse provides health guidance for the patient. (5) Exit consists of the nurse thanking the patient for their cooperation and making an appointment for the next follow-up call.Telephone follow-ups were conducted by four specialist nurses, two nursing management graduate students, and two otolaryngology head and neck surgery graduate students assigned to the intervention and control groups. The specialist nurses were registered nurses specializing in otolaryngology head and neck surgery with (1) at least two years of experience, (2) clinical experience with laryngeal carcinoma, (3) an undergraduate college degree or above, and (4) approval to participate in the study and complete the follow-up tasks in the allotted time. Nurses in the intervention group were trained in motivational communication according to the revised NOC . All of The details for the questions for the telephone follow-up conducted according to the revised NOC are shown in Supplementary file The sample size was calculated based on the trial conducted by Malmstrom et al. ; 41 patit-tests. Moreover, the mean changes in nursing outcomes, quality of life, and self-care abilities between groups were evaluated using independent t-tests. All P values were two-sided, and P < 0.05 is considered statistically significant. IBM SPSS 19.0 was applied for statistical analysis.The investigated outcomes were assessed before discharge and six months after discharge. Furthermore, categorical data were described by event (proportion), whereas continuous data were shown as mean (standard deviation) or median (quartile) based on whether the data met a normal or abnormal distribution, respectively. The chi-square test was applied to assess the differences in baseline characteristics between the intervention and control groups owing to all variables being categorical data. As the data for nursing outcomes, quality of life, and self-care abilities met a normal distribution, comparisons of these variables before and after intervention in each group were assessed using paired Of the 178 patients who underwent laryngectomy between March 2018 and March 2020 at the participating recruitment center, 100 were randomized: 51 to the intervention group and 49 to the control group . Moreover, patients in the intervention group experienced greater improvements in psychosocial health , health knowledge and behavior , and total scores  than those in the control group. However, differences in physiological health  and perceived health  between the intervention and control groups were not statistically significant.The results of the core nursing outcome scores are shown in Table P < 0.05). Moreover, we noted greater changes in social conditions , emotional health , functional status , additional attention , and total scores  in the intervention group compared with the control group. However, the change in physical activity between groups was not statistically significant .The results of quality-of-life scores are presented in Table P < 0.001). Moreover, we noted greater changes in general self-care skills , developed self-care skills , and total scores  in the intervention group than in the control group. However, no significant difference between groups regarding changes in self-care skills with poor health status was observed .Table This study aimed to assess the effects of nurse-led telephone follow-up according to the revised NOC for nursing outcomes, quality of life, and self-care abilities of patients after laryngectomy. A total of 100 patients with diverse characteristics were recruited. This study found greater improvements in psychosocial health, health knowledge and behavior, and total scores for nursing outcomes for patients in the intervention group. Moreover, patients in the intervention group saw significant improvements in social conditions, emotional health, functional status, additional attention, and total scores of quality of life than those in the control group. Furthermore, compared with traditional telephone follow-up, telephone follow-up conducted according to the revised NOC significantly improved general self-care skills, developed self-care skills, and total scores on the Self-Care Agency Scale.Our study found that patients in the intervention group experienced greater improvements in psychosocial health, health knowledge and behavior, and total scores for nursing outcomes. A previous study found that after laryngectomy, patients presented with voice loss and reduced physical function resulting from tracheostomy respiration, which caused long-term changes in daily and professional life . MoreoveWe noted that compared with the control group, patients in the intervention group experienced greater improvements in social condition, emotional state, functional status, additional attention, and in total scores of quality of life. Previous studies revealed negative changes in quality of life for patients with laryngeal carcinoma within the first year after surgery . ImproveNurse-led telephone follow-up according to the revised NOC is associated with greater improvements in general self-care skills, developed self-care skills, and total scores on the Self-Care Agency Scale. Previous studies have found that the use of telephone follow-up provides effective communication between nurses and patients, increases patient compliance, and improves self-care abilities. Moreover, the telephone follow-up in this study, improved patients’ self-care abilities through continuous feedback and supervision, which established and maintained effective self-care behaviors. Finally, the health status of patients varies; thus, a variety of forms of follow-up can play an important role in improving patient health.This study has the following limitations. (1) Patients in this study were recruited from a single center and the sample size was small; hence, the representativeness of the findings was restricted. (2) The nature of the study design meant that blinding of conditions could not be applied to the patients and nurses. (3) Disease status and background treatments were not assessed, and these may have played an important role in nursing outcomes, quality of life, and self-care abilities. (4) Stratified analyses were not performed. The results might have differed according to the patients’ characteristics. Finally, (5) the duration of follow-up was 6 months. Thus, future studies should evaluate the long-term effects of nurse-led telephone follow-up according to the revised NOC or traditional telephone follow-up for laryngeal carcinoma surgery patients.This study found that nurse-led telephone follow-up according to the revised NOC improved nursing outcomes , quality of life , and self-care abilities  compared with traditional telephone follow-up for patients after laryngectomy. Further large-scale randomized controlled trials are warranted to verify the findings of this study and assess the long-term effects of nurse-led telephone follow-up according to the revised NOC.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4