High Level Research Articles

Enhancing Learning Engagement in the Flipped Classroom using a Video-Annotation Tool

In the realm of academia, there has been a burgeoning interest in examining student engagement within the context of the flipped classroom approach, particularly at the higher education level. Nevertheless, research pertaining to a pivotal facet of this pedagogical methodology—namely, student engagement during the individualized, at-home preparatory phase—remains limited. Within this void, the primary objective of this study is to delve into the prospective benefits offered by a video annotation tool in augmenting students’ level of engagement during this autonomous study phase. Throughout the course of this investigation, a bespoke questionnaire was crafted, grounded in a multifaceted framework for evaluating student engagement, with a specific emphasis on dissecting four distinct dimensions: behavioral, emotional, agentive, and cognitive. This questionnaire is geared towards gauging student engagement within the domain of the Flipped Classroom model that relies on video-based instructional content—a facet heretofore poorly explored within the scholarly literature. Both quantitative and qualitative data were collected by administering the aforementioned questionnaire to a cohort of 68 undergraduate engineering students at Politecnico di Milano (Italy), all within the authentic context of a case study. The outcomes stemming from this empirical inquiry showcase a noteworthy enhancement in student engagement, with particular prominence accorded to the realms of emotional and agentive engagement. Moreover, this study establishes that the interactivity and proactive involvement necessitated by the video annotation tool do not obstruct students’ behavioral and cognitive engagement levels. In summation, this research endeavors to illuminate the potentiality of bridging a pivotal juncture in the Flipped Classroom paradigm, specifically the phase characterized by independent at-home study. This bridge is facilitated by the utilization of a video annotation tool designed to heighten student engagement. This transformative approach effectively transmutes the traditionally passive at-home study phase of the Flipped Classroom into an active experience, thereby enhancing the overall efficacy of this pedagogical approach.

How do rest-pause and sarcoplasma stimulating training models affect metabolic and psychoaffective responses in bodybuilding athletes compared to traditional training?

Strength training (ST) is a strategy to enhance quality of life through increased strength, muscle hypertrophy, and functional capacity. Training systems are associated with manipulation of volume and intensity, generating different stimuli, such as Rest-Pause (RP) and Sarcoplasmic Stimulating Training (SST). These systems induce greater mechanical and physiological stress, leading to increased strength and muscle hypertrophy. However, the metabolic and psycho-affective effects of advanced systems in experienced practitioners remain inconclusive. The purpose of the study is to analyze the acute effects of RP, SST, and Traditional (TMS) systems on metabolic and psycho-affective responses in adult men. This experimental crossover study assessed 15 subjects (30.38 ± 2.06 years; 88.40 ± 6.50 kg; 1.74 ± 0.07 cm) experienced in ST, evaluated under TMS, RP, and SST during flat bench press and leg press 45° exercises. Body composition, muscular strength via 1-RM testing, lactate concentration (LAC), and psycho-affective measures (Rating of Perceived Exertion-RPE; Visual Analog Scale-VAS; Feeling Scale-FS) were determined. Statistical analysis was performed using the Minitab software, with p ≤ 0.05, IC-95%). The finals results showed SST exhibited a 38.10% lower LAC concentration post-training session compared to TMS, while RP showed 37.20% lower LAC concentration than TMS post-session. Average RPE values for RP and SST were higher (8.50 ± 1.10 and 8.60 ± 0.90, respectively) than TMS (6.00 ± 1.10). VAS displayed higher average values for RP and SST (8.00 ± 2.00 and 8.00 ± 1.00, respectively) compared to TMS (5.00 ± 1.00), with affective ratings indicating positive values for TMS and values between 0 and -5 for RP (40%) and SST (60%) post-training sessions, suggesting that RP and SST induced less affective response than TMS. The results lead to the conclusion that manipulation of training volume and intensity led to higher RPE and pain (VAS). The data suggest that inappropriate prescription of these systems could lead to greater displeasure, leading us to hypothesize that a higher likelihood of discontinuation from strength training programs would occur, suggesting that greater repetition volumes (RP and SST) should be targeted at individuals with a higher training level.

Use of Complementary and Alternative Medicine by Greek Patients with Inflammatory Bowel Disease.

Complementary and alternative medicine (CAM) is regularly used by several patients with inflammatory bowel disease (IBD) in many countries. Data concerning the use of CAM in Greek patients with IBD are lacking. This study aimed to determine the prevalence and indicators of CAM use in Greek IBD patients. Adult patients with IBD attending our specialized IBD department in "Metropolitan General" Hospital, Holargos, Greece, completed a special questionnaire regarding the use of CAM. Several clinical and epidemiological characteristics were recorded. The results were compared with a disease-control group (patients with irritable bowel syndrome or gastroesophageal reflux disease). The study outcome was the prevalence of CAM use in both groups. In this study, 270 patients, of whom 128 were female, with IBD (Crohn's disease 134 and ulcerative colitis 136) and a median age of 42.3 ± 17.5 years (range 31-52), and 138 patients serving as the disease control group were analyzed. The prevalence of previous and current CAM use in patients with IBD was 36.3% versus 27.5% in the control group (no significant differences). No significant differences were also noticed between the patients with either CD or UC. In the multivariable analysis, university education and treatment with steroids and TNF-α inhibitors were independent social indicators of CAM use. The percentage of CAM use by the Greek patients with IBD was quite high, similar to other European countries. Although numerically higher, this percentage was not significantly different compared with the disease control group. The use of CAM in IBD patients in Greece is associated with a higher educational level, and treatment with steroids and TNF-α inhibitors.

Beyond Transparency Statements: Explaining the Impact of Efficiency and Auditing on the Disclosure of Public Information

Transparency has become a key element for public entities as a mechanism of reliability and accountability. In addition, the continuous auditing of these entities, as well as the efficient provision of public services, are important elements that can have an impact on a greater degree of transparency. In this paper, the aim is to measure how these factors influence the level of municipal transparency through an analysis of a sample of 143 Spanish municipalities with more than 50,000 inhabitants using the generalized model of moments. The results show that an efficient and highly audited municipality offers a higher level of public information and influences other political and socioeconomic factors.

Impact of the digital trade on lowering carbon emissions in 46 countries

Digital trade, as one of the vanguards of the global technological revolution and industrial transformation, empowers low-carbon economic cooperation on a global scale. This study based on panel data from 2007 to 2021 of 46 countries with varied development levels, constructed a multi-dimensional indicator system from six aspects: trade potential, digital infrastructure, digital innovation, digital skills and security, scale of digital trade, and digital trade environment, aim to measure the development level of digital trade and explore its impact on carbon emissions, followed by a heterogeneity analysis. The research results indicate that there are significant differences in the development levels of digital trade among countries with different economic strengths. Countries with stronger economic power and larger trade scales have a higher level of digital trade development, while less developed regions lag in digital trade. As the level of digital trade development increases, the impact of digital trade on carbon emissions will also change. Overall, digital trade exhibits a pronounced low-carbon effect, while its impact varies among countries with different development levels.

The hybrid immunity defined by weaker immune imprinting of people living with HIV has a stronger neutralizing response against Omicron variants. A suggested explanation for fewer symptoms in people living with HIV after SARS-CoV-2 variants breakthrough infection

AimsHuman immunodeficiency virus(HIV) co-infection may cause different immune imprinting, which leads to different hybrid immunity and clinical manifestations of coronavirus disease 2019. This study aims to evaluate the immune imprinting from wild-type(WT) vaccination in people living with HIV(PLWH) and analyze its effect on hybrid immunity and clinical manifestations. Materials and methodsWe enrolled 118 PLWH to compared the differences of BA.5-specific immune response in different immune modes. 20 vaccinated healthy individuals(HC) and 30 vaccinated PLWH were matched to compare the differences of the status of Omicron infection, serum neutralizing antibody levels against WT and BA.5, and specific lymphocytes expression, separately. Key findingsHybrid immunity had a higher level of BA.5 IgG than either vaccine immunity only or natural immunity only in PLWH but didn't have a higher level of BA.5-specific lymphocytes responses. PLWH had fewer symptoms than HC after breakthrough infection. The neutralizing inhibition rate of PLWH was higher for BA.5 and lower for WT, while the neutralizing inhibition rate of HC was higher for WT and lower for BA.5. The difference value of specific B lymphocytes/memory B cells/follicular helper T cells of PLWH was greater than that of HC. SignificanceHybrid immunity of PLWH has a higher level of Omicron-specific IgG without a higher level of Omicron-specific lymphocytes due to immune imprinting. However, there is a stronger neutralizing ability against variants of PLWH due to the weaker immune imprinting of PLWH than that of healthy people, which may lead to fewer symptoms in PLWH after breakthrough infection.

Reduced vancomycin susceptibility in Staphylococcus aureus clinical isolates: a spectrum of less investigated uncertainties

BackgroundStaphylococcus aureus clinical isolates with vancomycin MICs of 2 µg/ml have been associated with vancomycin therapeutic failure and the heterogenous vancomycin-intermediate S. aureus (hVISA) phenotype. While carriage of van genes has usually been associated with higher level of MIC and frank vancomycin resistance, the unrecognized risk of hetero-resistance is frequently underestimated. Methods used for assessing vancomycin susceptibility have also shown different concordance and variable performance and accessibility in routine clinical diagnostics posing a challenge to inform treatment selection in hospital settings.MethodsA total of 195 clinical samples were obtained among which 100 S. aureus isolates were identified. Ninety-six MRSA isolates have been identified using cefoxitin disc and mecA gene detection. The vanA and vanB genes have been screened for in the studied isolates using conventional PCR amplification. Examination of reduced vancomycin susceptibility has been performed using vancomycin screen agar, Broth Micro Dilution method (BMD), and VITEK2. Blood isolates were screened for hVISA using PAP-AUC method.ResultsVancomycin screening agar applied to 96 MRSA isolates revealed 16 isolates with reduced vancomycin susceptibility. Further MIC testing revealed that 7 isolates were VISA and only 1 isolate was identified as VRSA using both BMD MIC method and VITEK2. Among 24 tested blood isolates, 4 isolates (16.7%) revealed the hVISA phenotype as identified using PAP-AUC method. Using PCR, vanA gene was identified in 5 S. aureus isolates (5%). Three of them were VSSA while the other two isolates were VISA.ConclusionIn this study, we report the very low prevalence of VRSA among the tested S. aureus clinical isolates (1%) and the existence of hVISA phenotype among studied S. aureus blood isolates at the rate of 16.7% in our setting. Fifty percent (8/16) of isolates that demonstrated reduced vancomycin susceptibility using vancomycin agar screen tested susceptible using both broth dilution method and VITEK2. These finding together with the concerning silent carriage of vanA gene among VSSA and VISA (5%) may underly hidden and uninvestigated factors contributing to vancomycin treatment failure that warrant cautious vancomycin prescription.

The Role of Indigenous Plants in Sustaining Food Sources in Lesten Village, Gayo Lues Regency, Indonesia

The Gayo tribe in Lesten Village has historically relied on plants to fulfill their nutritional needs. Expanding knowledge about diverse plant-based food sources offers a promising strategy for addressing future food insecurity. A dependence on conventional plant species has often resulted in inadequate food supplies, highlighting the need for alternative approaches that incorporate a broader range of plant resources to mitigate food scarcity. Located within the Leuser mountain buffer landscape, Lesten Village in Gayo Lues Regency, Aceh Province, represents a key agricultural area with significant potential to benefit the local community. This study aimed to document and analyze the plant species used as food sources by the Lesten Village community. Data collection combined qualitative and quantitative methods, including exploration, direct observation, and semi-structured interviews. The results revealed that female respondents had a higher level of knowledge about plant use as food sources. Notably, 52.9% and 55.7% of these respondents were aged 50 years or older. The community in Lesten utilized a total of 51 plant species from 26 families as food ingredients. Vegetables constituted the largest category (34%), followed by spices (30%), fruits (21%), and carbohydrates (15%). Fruits were the most frequently used plant part for food (61%). The species with the highest use value was Cacica papaya (1.07). Additionally, the traditional food with the highest fidelity level was serbet (62.82%). These findings emphasize the importance of integrating a diverse range of plant resources into food systems to enhance food security and stimulate economic development in the region.

Polycystic ovary syndrome: Fertility, prenatal care, pregnancy, and postpartum care.

Polycystic ovary syndrome (PCOS) is a complex, heterogeneous reproductive endocrinopathy affecting 8% to 13% of women in their reproductive years. PCOS has a vast array of clinical manifestations, including metabolic complications, biochemical and phenotypical hyperandrogenism, menstrual cycle dysfunction, and anovulation resulting in infertility. Understanding the relationship of the disorder's pathophysiologic and clinical manifestations is key to successfully managing patients with PCOS. Patients may have different prenatal, perinatal, and postnatal experiences than those who do not have PCOS, and may require a higher level of care or treatment plan adjustments.

The prevalence of malocclusion and oral health-related quality of life among 12- and 15-year-old schoolchildren in Shanghai, China: a cross-sectional study

BackgroundMalocclusion is one of the three major oral diseases and may cause deterioration in oral health-related quality of life (OHRQoL). This study aims to determine the prevalence of malocclusion by gender and its impact on quality of life among 12- and 15-year-old children in Shanghai.MethodsThis study summarizes the data obtained in the Shanghai Oral Health Epidemiological Survey conducted in 2019. Random cluster sampling was used to select students in Shanghai. A total of 1591 12-year-old children and 747 15-year-old children were included. Each student underwent an oral examination and completed a questionnaire. The Index of Complexity, Outcome and Need (ICON) was adopted to measure the objective severity of malocclusion and Child Oral Health Impact Profile (COHIP) was applied to evaluate quality of life of schoolchildren. Comparisons of COHIP scores were performed among different treatment needs and difficulties by t-test and analysis of variance (ANOVA).ResultsNo significant difference was found between genders except that the prevalence of deep overbite in 12-year-old boys (1.11 ± 0.95) was significantly higher than that in girls (0.93 ± 0.88) while the prevalence of crossbite among 12-year-old girls (26%) is significantly higher than boys (20%). Malocclusion in 15-year-old children was descended compared with 12-year-old. 15-year-old students demonstrates larger impact of malocclusion on oral health than 12-year-old group except self-image. Health impacts (COHIP) increase significantly as the malocclusion becomes severer except self-image in 12-year-old group.ConclusionsIn Shanghai, the severity of malocclusion in 15-year-old children was less than 12-year-old children. Malocclusion has greater influence on oral health of 15-year-old children than 12-year-old children. Severer malocclusion generally correlates with higher level of oral health impacts in schoolchildren.

Can Negative Emotions on Social Media Predict Corporate Financial Risks: Perspective from Baidu Tieba

The intrinsic relationship between social media and corporate development has emerged as one of the key research topics today. Most current studies focus on the positive impacts and opportunities that social media can bring to enterprises. However, there remains a lack of a unified explanation for the influence of negative news on social media on businesses. Consequently, the research theme of this paper is to explore whether negative sentiments on social media can predict corporate financial risks. Firstly, this paper collects data related to bearish posts on social media and financial risks of enterprises. Subsequently, regression analysis is conducted on the data using SPSS. The results reveal that, under the condition of controlling the asset-liability ratio, negative posts on social media do have an impact on corporate financial risks, with a greater number of negative posts correlating to a higher level of financial risk for the enterprise. This paper fills a gap in understanding the negative implications of social media on certain aspects of businesses and provides data support for researching the influence of negative sentiments on social media on corporate financial risks.

Factors influencing environmental and circular economy disclosure of Viet Nam listed companies

This study examines the environmental and circular economy disclosures (ECED) level and factors influencing this level of 32 Vietnamese listed companies from 2018 to 2022. The content and frequency analyses are performed to determine the level of ECED, and regression analysis is to investigate the influencing factors. Drawing on a sample of 160 sustainable development and annual reports following the Global Reporting Initiative frameworks (GRI), the study evidenced that 32 listed companies paid great attention to the GRI 300 category (on environment topics) with the top three GRI standards 302 (energy), 307 (environmental compliance), and 303 (water and effluents), respectively. In addition, the Feasible Generalized Least Square method results showed that the companies with government ownership and Big4 audit services had a higher level of ECED. In comparison, larger companies had a lower disclosure level. Meanwhile, companies in the manufacturing sector with foreign shares and the independence of the Board of Directors did not affect the disclosure information disclosure level in the studied sample.

Developing a gender measure and examining its association with cardiovascular diseases incidence: a 28-year prospective cohort study

BackgroundCardiovascular diseases (CVD) are the leading cause of morbidity and mortality worldwide. Examining gender (socio-cultural) in addition to sex (biological) is required to untangle socio-cultural characteristics contributing to inequities within or between sexes. This study aimed to develop a gender measure including four gender dimensions and examine the association between this gender measure and CVD incidence, across sexes.MethodsA cohort of 9188 white-collar workers (49.9% females) in the Quebec region was recruited in 1991–1993 and follow-up was carried out 28 years later for CVD incidence. Data collection involved a self-administered questionnaire and extraction of medical-administrative CVD incident cases. Cox proportional models allowed calculations of hazard ratios (HR) and 95% confidence intervals (CI), stratified by sex.ResultsSex and gender were partly independent, as discordances were observed in the distribution of the gender score across sexes. Among males, being in the third tertile of the gender score (indicating a higher level of characteristics traditionally ascribed to women) was associated with a 50% CVD risk increase compared to those in the first tertile (HR = 1.50; 95% CI: 1.24 to 1.82). This association persisted after adjustment for several CVD risk factors (HR = 1.42; 95% CI: 1.16 to 1.73). Conversely, no statistically significant association between the third tertile of the gender score and CVD incidence was observed in females (HR = 0.79, 95% CI: 0.60–1.05).ConclusionsThe findings suggested that males within the third tertile of the gender score were more likely to develop CVD, while females with those characteristics did not exhibit an increased risk. These findings underline the necessity for clinical and population health research to integrate both sex and gender measures, to further evaluate disparities in cardiovascular health and enhance the inclusivity of prevention strategies.

Characteristics of applicants with a first-time recognition of need for long-term care

Abstract Background The increasing number of care-dependent individuals requires approaches to prevent care dependency or reduce loss of independence. Long-term care assessments can provide valuable insights into this. In Germany, the Medical Service is responsible for the long-term care assessment (care level) that focuses on limitations in independent living. Objectives The aim of this contribution is to describe initial applicants with identified need for long-term care. Materials and methods The nationwide database consists of long-term care assessments conducted by the German Medical Service of health insured people aged 60 and above who received a care level (1=smallest till 5= largest limitations) for the first time in 2021. Long-term care-relevant information is analyzed descriptively. Results 339,486 individuals with an average age of 79.6 years (SD: 8.4) were analyzed. The age distribution shows that the 80-89 age group comprises half of the sample (49.9%), whereas those aged 90+ encompass the smallest proportion of the sample (9.3%). More women than men received a care level (59.0% women vs. 41.0% men), with women predominant in care level 1-2 and men in the higher care level 3-5. Overall, approximately half of the sample received care level 2, 32.4 % received care level 1. Care levels 3-5 were assessed less frequently (16.2 % vs. 4.8 % vs. 1.7 %). The most frequent care-relevant diagnoses were senility (R54), polyarthrosis (M15), and dementia (F03). Conclusions Over three quarters of initial applicants are classified into the lowest care levels (1 and 2). Accordingly, tertiary prevention measures are recommended, as these may delay the further progression into a higher care level. Key messages • Over three quarters of initial applicants for long-term care are classified into the lowest care levels. Accordingly, tertiary prevention measures may recommended to delay further care progression. • The most frequent care-relevant diagnoses were senility (R54), polyarthrosis (M15), and dementia (F03).

Impact of allogenic Fecal Microbiota Transplantation (FMT) on lipid parameters in patients with metabolic syndrome (MetS): a meta-analysis

Abstract Background Metabolic Syndrome (MetS) has long been considered a formidable global health concern, and impaired lipid metabolism has been one of its crucial clinical manifestations. Fecal Microbiota Transplantation (FMT) has emerged as a potential therapeutic strategy for MetS, nevertheless, prior meta-analyses have not only yielded conflicting outcomes, but as well predominantly centered on glycemic parameters, leaving the potential impact of FMT on lipid metabolism remained unexplored. Purpose This meta-analysis systematically assessed the influence of allogenic FMT on lipid parameters in MetS patients, unraveling its potential as an innovative therapeutic modality for MetS. Methods A meta-analysis was performed to explore the impact of allogenic FMT on lipid parameters (low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], total cholesterol [TCHO] and triglycerides [TG]) in patients with MetS. Terms regarding FMT and metabolic syndrome were searched in PubMed/Medline, EMBASE, Web of Science, the Cochrane Library, and Scopus from the inception of the databases until 31 August 2023. Ten randomized controlled trials (RCTs) were included and mean difference (MD) of parameters were pooled using a fixed effects model. Subgroup analyses according to follow-up durations were performed, and this study was registered in PROSPERO. Results A total of 532 patients in 10 studies were included. Patients undergoing allogenic FMT manifested significantly higher HDL-c level compared with control group (receiving placebo or autologous FMT, pooled MD 0.06 [95% CI: 0.02, 0.10]), and the result remained consistent in the subgroup with 4 to 6 weeks of follow-up (MD 0.07 [95% CI: 0.02, 0.10]). Though overall pooled result did not manifest a significant LDL lowering effect (MD -0.08 [95% CI: -0.21, 0.05]), in subgroup analyses, a significantly lowered LDL level was observed at 12 weeks of follow-up (MD -0.34 [95% CI: -0.60, -0.08]). No significant difference was observed between allogenic FMT and control group concerning TCHO ant TG levels regardless of lengths of follow-up. Conclusions An overall higher level of HDL-C and lowered LDL-C at 12 weeks of follow-up was observed in MetS patients receiving allogenic FMT. The results indicated that gut microbiota from lean, healthy donors may display a beneficial effect on modulating lipid metabolism in patients with MetS. Allogenic FMT manifested promising therapeutic impact and could serve as a viable intervention for MetS patients. Future large-scale RCTs are required for further validation.

Health literacy and individuals’ perception regarding Heart Failure management: patient perspective

Abstract Background Heart failure (HF) is a multidimensional disease that has a significant impact on the quality of life of people with this condition and the person’s level of health literacy is a key element in disease management. Therefore, this analysis aims to assess the correlation between the level of health literacy of people with HF and their level of concern about managing the disease, their perception about quality of life, and access to healthcare. Methods Cross-sectional study conducted through a survey among adults with HF, residents, and healthcare consumers in Portugal. The survey comprised 6 questions on health literacy (HLS-EU-Q6); 9 dimensions of concerns in HF management (4-level scale ranging from “not concerned” to “very concerned”); quality of life and access to healthcare perceptions (5-level scale ranging from “very bad” to “very good”). Concerns global score was calculated based on 9 dimensions of concerns about HF management. The statistical analysis included Spearman’s and Pearson’s correlations. Results A total of 428 responses were analysed. Respondents had a mean age of 70 years, 52.1% were men and 67.9% have secondary education. 47.0% of respondents perceived their access to healthcare as “good”, 63.3 % perceived their quality of life as “reasonable” and 61% have low levels of health literacy. Individuals with a higher health literacy level tended to have lower levels of concerns regarding HF management (r=-0.133; p = 0.006); individuals with a higher level of health literacy tended to have a better perception of their access to healthcare (ρ = 0.145; p = 0.003) and quality of life (ρ = 0.220; p < 0.001). Conclusions The findings reinforce that overcoming health literacy obstacles must continue to be a focus of healthcare systems and institutions to enhance healthcare access, quality of life, and chronic disease management. These efforts may result in better health outcomes, promote health equity and general well-being in this population. Key messages • Individuals with Heart Failure with higher levels of health literacy report less concerns about the management of their condition. • Individuals with Heart Failure and lower levels of health literacy have a worst perception of their access to healthcare and quality of life. Health literacy promotion must continue to be a priority.

Estimation of Environmental Burden of Disease related to Arsenic exposure in European Populations

Abstract Background Arsenic (As) exposure poses significant health risks to exposed populations, with exposure occurring predominantly via diet for the general population as recently referred by the European Food Safety Authority. This study assesses the environmental burden of disease (EBD) for three cancer types related to arsenic, across Europe. Methods A literature review was conducted to 1) identify the dose-response function (DRF) to assess the cancer risk in European populations, and 2) define EBD approaches applicable to the available data. Country-specific data (Belgium, Denmark, Portugal) for EBD calculation (exposure, socioeconomic status, health outcomes) were gathered. Disability-Adjusted Life Years (DALY) estimations were performed by calculating attributable cases (AC). Results Two main references are used for DRF: the United States Food and Drug Administration DRF for assessing bladder and lung cancer risks, and the United States Environmental Protection Agency DRF for skin cancer. Preliminary results for Belgium indicate that inorganic arsenic dietary exposure ranges from 0.084 [0.080 - 0.088] to 0.102 [0.097 - 0.107] µg/kg body weight per day, varying with education level. Stratified estimates suggest that individuals with higher educational attainment (ISCED levels 5 & 6) have a marginally higher average daily intake of arsenic compared to those with lower educational attainment (ISCED levels 0, 1 & 2). DALY attributable to inorganic arsenic exposure follow the same trend as exposure levels, i.e. individuals with a higher education level bear a higher burden of disease than individuals of the low education stratum. This concerns the three studied cancers. Conclusions This study quantifies DALY related to inorganic arsenic from dietary exposure for different European countries. Our findings will contribute to better target public health policies and interventions for arsenic risk mitigation. Key messages • Exposure to inorganic arsenic is confirmed in European countries. • EBD studies guide action priorities to tackle chemical risk factors.

Prognostic value of peak heart rate on cardiopulmonary exercise testing in patients with chronic heart failure

Abstract Backgrounds Many factors are known to be related to impaired exercise capacity or worse clinical outcomes in patients with chronic heart failure (CHF). Peak heart rate achievement by cardiopulmonary exercise testing (CPET) can be easily obtained on CPET. However, less data is available regarding the impact of peak heart rate on exercise capacity or long-term clinical outcomes in patients with CHF. Purpose We sought to investigate whether lower heart rate during peak exercise displayed poorer exercise capacity and worse clinical outcomes in patients with CHF. Methods We examined consecutive 435 patients with CHF referred for CPET in our university hospital between 2013 and 2018. The primary outcome was a composite of all-cause death or hospitalization due to worsening heart failure. Patients were divided into two groups according to the optimal cut-off value of peak heart rate based on receiver operating characteristic curve analysis. Results Patients with lower peak heart rate (≤112/min, n=164) were older and, higher brain natriuretic peptide level compared to those with higher peak heart rate (>112/min, n=271). Heart rate during peak exercise was significantly correlated with peak oxygen consumption (peak V̇O2) (Figure 1A), peak workload achievement (Figure 1B), and ventilatory efficiency (V̇E/V̇CO2 slope) (Figure 1C). There were 80 patients with events over a median follow-up period of 3.4 (Interquartile range 0.7–5.6) years. Patients with lower peak heart rate had about 3.0-fold higher risk of events compared to those with high peak heart rate (hazard ratio [HR] 3.17; 95% confidence interval [CI], 2.01–4.98) (Figure 2). In a multivariable Cox regression, 10 bpm-decreased in peak heart rate was associated with 12% increased adverse events (HR 0.88; 95%CI, 0.78–0.98). Conclusions Peak heart rate achievement on CPET was associated with reduced exercise capacity and worse clinical outcomes, suggesting that peak heart rate is useful for risk stratification in patients with CHF. Further study is required to identify therapies targeting peak heart rate to improve the exercise capacity or clinical outcomes in patients with CHF.Figure1Figure2

Low levels of apolipoprotein M are associated with increased risk of ventricular arrhythmias

Abstract Background Ventricular arrhythmia (VA) is a frequent cause of sudden cardiac death (SCD). Treatment to prevent SCD includes device therapy with implantable cardioverter defibrillator (ICD). Although the electrophysiology underlying VA have been described, the molecular understanding of VA risk remains unclear. Purpose To identify proteins that are associated with higher and lower risk of VA. Methods SMASH 1 Study was a prospective observational study of 490 patients treated with ICD. The plasma proteome was analyzed with the Olink Explore 384 Cardiometabolic platform at study inclusion, and patients were followed for mean 3.1± 0.7 years. VA events were defined as adjudicated ventricular fibrillation or sustained ventricular tachycardia registered from ICD recordings and clinical events were recorded from electronic health records. Protein concentrations were quantified relatively as normalized protein expression on a log2-transformed concentrations where a large number represents higher protein level in the sample. Results The mean age was 66±12 years, 83% were male and 51% had a primary prevention ICD-indication. Episode(s) of VA occurred in 137 patients (28%) during follow-up. In total, 353 distinct proteins were successfully analyzed in all patients. Among these, high B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels were associated with a higher risk of VA, while Apolipoprotein M (APOM) was the only protein significantly associated with a lower risk of VA after multiple testing using Benjamini-Hochberg correction (Figure, Panel A). After adjusting for age, sex, body mass index, coronary artery disease, heart failure, renal function, left ventricular ejection fraction and antiarrhythmic medication, only low APOM levels remained significantly associated with VA: HR 0.51 (95%CI 0.32-0.79] per log unit increase, p=0.003. Patients in the lowest quartile of APOM had a particularly high risk of incident VA: HR 2.26 (95%CI 1.60-3.19), p=3.61x10-6, compared to quartile 2-4 (Figure, Panel B). High APOM levels were also associated with a lower risk of HF hospitalizations (HR 0.25 [95%CI 0.16-0.40], p<0.001) and all-cause mortality (HR 0.36 [95%CI 0.22-0.60], p<0.001), and these associations remained significant in adjusted models. Conclusions Low levels of APOM are associated with a greater risk of incident VA, independently of established risk factors. Low APOM also predicted risk of HF hospitalizations and mortality in our cohort, which suggest protective cardiovascular effects of APOM. Figure: Association of individual proteomic measures with risk of ventricular arrhythmias (VA).A:Volcano plots of the associations of individual plasma proteins with incident VA. The dotted line represents the significance level at false discovery rate <0.05 and the red dots are significant proteins after multiple testing using Benjamini-Hochberg correction.B: Risk of VA by quartile of Apolipoprotein M.

The connection site of the Bachmann bundle to the left atrium affects atrial electrical and anatomical remodeling

Abstract Background A common route for the propagation of the conduction system from the right atrium to the left atrium (LA) is via the Bachmann bundle (BB) which is a parallel-aligned muscular structure. It is empirically known that the site of conduction from BB to LA differs depending on the patient. Purposes To clear the clinical significance of differences in the BB conduction sites in patients with atrial fibrillation (AF). Methods We studied 182 patients (90 non-paroxysmal AF, 121 males, and 68.2 ± 10.0 years) who received catheter ablation for AF. Clinical data, echocardiographic data, and blood samples were evaluated. High-density LA mapping during high right atrial pacing was constructed. The site of conduction from BB to LA, the global activation time, LA mean voltage, the abnormal conduction zone (ACZ), and the conduction block (CBZ) were evaluated. The conduction from BB was connected to the region surrounded by the left atrial roof line, the carina of the right pulmonary vein, and the base of the left atrial appendage in all patients (Figure 1). This area was divided into four regions (right-roof, mid-roof, right-anterior, and mid-anterior area), and BB conduction sites were classified into each area by three independent observers who did not know clinical data. Global activation time for the LA was calculated by subtracting the earliest from the latest activation within the LA. Isochronal activation maps were created at a 5-ms interval setting, and ACZ (Figure 2) and CBZ were identified on the activation map by locating a site with isochronal crowding of ≥3 isochrones and ≥8 isochrones, which were calculated as ≤27 cm/s and ≤10 cm/s. Results The conduction from BB was observed in 45 patients in the right-roof area, 24 in the mid-roof, 76 in the right-anterior, 23 cases in the mid-anterior, and 14 in multiple sites. Global activation time (right-roof 108±20, mid-roof 107±16, right-anterior 105±19, and mid-anterior 117±20ms, P=0.0781) was more prolonged and left atrium diameter was larger (42.1±6.6, 42.6±8.5, 42.5±6.6, and 46.4±6.6mm, P=0.0718) in patients with mid-anterior BB connections. LA mean voltage (4.90±1.94, 5.72±2.62, 4.13±1.58, and 4.88±1.96mV, P=0.0032) was higher and plasma brain natriuretic peptide level (139±138, 67±59, 128±139, and 164±197pg/mL, P=0.0861) was lower in patients with mid-roof BB connections. ACZ (41/45 91%, 20/24 83%, 73/76 96%, and 23/23 100%, P=0.0904) and CBZ (1/45 2%, 0/24 0%, 8/76 11%, and 2/23 9%, P=0.0850) appearance rates were lower in patients with mid-roof BB connections. Conclusion The connection site of the Bachmann bundle to the left atrium may affect atrial electrical and anatomical remodeling in patients with atrial fibrillation.