Achieving carbon neutrality is a major strategy to combat climate change and achieve sustainable development. Training engineering undergraduates with sustainable development literacy is an important way to achieve this goal in the field of higher education. Based on the college impact model, this research surveyed 1070 engineering undergraduates in Chinese universities to explore the influence of institutional support on undergraduates’ sustainable development literacy, and the empirical analysis was conducted using Structural Equation Modeling. The results showed that institutional support positively and significantly influenced the sustainability development literacy of engineering undergraduates, and student engagement had a mediating role in the relationship between institutional support and sustainability development literacy. Relevant recommendations for cultivating engineering undergraduates with high-level sustainability development literacy are proposed here. The most important driver of current global climate change is the emission of carbon dioxide and other greenhouse gases due to human activities, which is one of the most pressing challenges in the world’s environmental problems today. The global carbon neutrality target set by the Paris Agreement has set the direction of development for countries to reduce carbon emissions. As the second largest economy and educational power in the world, China has always been a strong advocate and active practitioner of the concept of sustainable development, and pledged to achieve a carbon peak by 2030 and carbon neutrality by 2060. Sustainable development (SD) has been a key strategy to combat climate change and achieve carbon neutrality. The Brundtland report defines sustainable development as “the ability to meet the needs of present without compromising the ability of the future generations to meet their own needs” . To safeAs a beacon of social progress and development, higher education institutions (HEIs) should take the lead in exploring the direction of human progress and provide the world with the knowledge base and value guidance of sustainable development. Sustainable development first reached prominence in higher education with the Talloires Declaration in 1990 . This deDue to the nature of engineering disciplines, engineering education is at the forefront of responding to the sustainable development of society. As the fourth industrial revolution continues to advance, systematic changes in industrial production patterns and human lifestyles are occurring, resolving the conflicts between humans and nature and promoting the sustainable development of industry and society. At present, China has built the world’s largest higher engineering education system , with thToday, learning outcomes for sustainable development in higher education are still a point of contention. In the higher education literature on this topic, the learning objectives of sustainability education have many labels, such as competencies  or literReviewing previous research, some scholars have begun to examine the teaching and learning of sustainability in higher education by studying pedagogy  or learnTo address these limitations of existing research, this study constructs a model of factors influencing engineering undergraduates’ sustainable development literacy based on the theory of the college impact model and explores three key questions to be addressed: (1) to examine the effects of three aspects of institutional support  on engineering undergraduates’ sustainable development literacy; (2) to examine the mediating role of two aspects of student engagement  in the relationship between institutional support and engineering undergraduates’ sustainable development literacy; and (3) to explore the moderating role of gender in the relationship between institutional support, student engagement and sustainable development literacy of engineering undergraduates. The focus of this study is to conduct a survey for 1194 engineering undergraduates to assess the effectiveness of higher education institutions in developing learning outcomes and cultivation pathways for the sustainable development of engineering undergraduates. It also proposes policy recommendations on how to improve the sustainable development literacy of engineering undergraduates and provides a reference theoretical basis and research to promote the sustainable development of engineering education and the achievement of China’s carbon neutrality goals.The college impact model focuses on the influence of colleges and universities on individual student development, and is widely used to analyze the impact of the college environment on student development and the ability to improve while enrolled in college. Research on the impact of college on students links student development to the college environment, individual student characteristics, and learning behaviors, focusing on the “interactive effects” of student engagement and the college environment ,34. The Sustainability education for engineering undergraduates is comprehensive and transformative, involving learning outcomes, instructional practices and institutional environments. The purpose of this study is to comprehensively discuss the relationship between institutional factors and the sustainable development literacy of engineering undergraduates. Pascarella’s general model for assessing change has a high degree of fit with the content of this study; thus, the study used this theoretical model as the basis for establishing initial model. By combing through the relevant literature over the years, Pascarella et al.  found thIn the college impact model, institutional support is a key factor in student learning outcomes and has a direct impact on student competency development. Morly  has founFormal curriculum is an important way to promote student learning or learning sustainability. Research has shown that students can be systematically provided with sustainability knowledge through the integration of sustainability topics into the curriculum. Horvath et al.  found a Promoting students learning about sustainability requires consideration not only of the level of student exposure to sustainability-related content, but also of the instructional practices employed to promote learning of sustainability-related content. The pedagogical approaches represent the general character or guiding principles of designing learning processes in sustainability education. Cotton and Winter proposed a number of instructional practices to promote students’ sustainable development competences, such as group discussions, stimulus activities , debates, critical incidents , case studies, and problem-based learning . HoweverAccording to the theory of the college impact model and the existing empirical research on sustainable development literacy, this study categorizes supportive environment, sustainability curriculum, and instructional practice as institutional support factors, and proposes the following hypothesis:H1. Institutional support has a significant positive effect on sustainable development literacy.The college impact model states that institutional support not only affects student learning outcomes directly, but also indirectly by influencing student engagement . Astin dAlthough the classroom is the primary site of education for sustainable development implementation in higher education institutions, less research has focused on student engagement experiences in the classroom. Education for sustainable development often focuses too narrowly on instilling knowledge about sustainable development, but rather on appropriate pedagogy that truly engages learners in learning about sustainable development. Classroom experiences where students are actively reflecting and learning are essential to learning about sustainability. Howell used the flipped classroom survey to conclude that students’ knowledge of sustainability in the course was enhanced through reflective and active learning. Over 90% of students agreed that in-class active learning exercises made the classes more engaging and the material more memorable than usual .In addition to formal classroom learning, the learning experiences students have outside of the classroom are important to their overall learning. The term “extracurricular” is typically used to denote learning activities outside of a formal curriculum . The disBased on the college impact model and available empirical evidence, this study suggest that institutional support may first influence students’ engagement in sustainability learning and then increase their sustainability literacy. Therefore, this study proposes the following hypothesis:H2. Student engagement mediates the relationship between institutional support and sustainable development literacy.The college impact model states that students’ background characteristics  may make a difference in students’ college experiences as well as their learning outcomes. From a sociocultural perspective of learning, learning outcomes may vary depending on students’ background characteristics because of the role these characteristics  play in shaping students’ learning experiences, values, and ultimately their engagement in the learning process . Thus, mFor sustainability learning outcomes, Olsson and Gericke  found thH3. Gender significantly moderates the relationship between institutional support, student engagement, and sustainable development literacy.To test the questionnaire’s quality, 158 pilot questionnaires were distributed to fourth-year engineering undergraduates in Beijing before we formally issued the questionnaires. According to the analysis of the collected data, the design of some constructs and some ambiguous questions were revised. The formal questionnaires were randomly distributed among fourth-year engineering undergraduates from colleges and universities nationwide. Respondents of the survey were mainly from traditional engineering majors such as materials engineering, mechanical engineering, chemical engineering, and civil engineering. A total of 1194 questionnaires were collected via the internet, excluding invalid questionnaires such as those with too short a response time  and those with regular responses . Finally, 1070 valid questionnaires were collected, and the effective rate of the collected questionnaires is 89.6%. Among the participants, there were 532 female fourth-year engineering undergraduates, accounting for 49.7% of the total sample population, and 538 male fourth-year engineering undergraduates, accounting for 50.3% of the total sample population.The questionnaire used in this study consists of two parts. The first part is about the undergraduates’ demographic information, including gender, birthplace, education, parents’ engineering background, family income, school, and class. The second part is about factors influencing the sustainability literacy of the engineering undergraduates. The questionnaire includes 31 questions to measure variables. The tools for measurement were designed on the basis of the college impact model and were revised according to the research hypotheses and expert suggestions.The detailed statistical analysis of the subjects is shown in Education for Sustainable Development Goals: Learning Objectives published by UNESCO in 2017 ). The existence of total effect was supported. The total indirect effect IS→SE→SDL, p < 0.05, bias-corrected confidence interval (CI) does not include 0 (CI of IS→SE→SDL = [0.170 0.288]). The existence of total indirect effect was supported.As shown in Gender is a dichotomous variable, and Amos used multigroup analysis to compare the difference in the regression coefficients between gender. The premise of comparing the difference is that the factor loadings should remain equal, indicating that males and females have the same perception of the questionnaire . Next, t211,0.95 = 3.388 < 19.675) and no significant difference in the structural path coefficients . Therefore, there was no moderating effect for gender.The results of the analysis are presented in This empirical study found that institutional support has a significant, positive, direct impact on the sustainable development literacy of engineering undergraduates. Specifically, if colleges and universities provide comprehensive and strong environmental support for undergraduate engineering education and create a good curriculum experience for students, students’ sustainable development literacy will be significantly improved. As mentioned earlier, according to the college impact model and existing research on sustainable development literacy , a suppoConsistent with the findings of existing studies ,41,42, aThis study further found that in addition to the presence of a significant direct positive effect, institutional support had an impact on students’ sustainable development literacy through the mediating role of student engagement. This is consistent with Pascarella’s theoretical model  and exisThis study found that there is no significant moderating effect of gender on the relationship between sustainable development literacy and student engagement, which is not consistent with the conclusions of some previous studies. Previous studies  argued tThe results of this study differ from previous studies ,60, possBased on the theory of the college impact model, this study constructed a model of the factors influencing the sustainable development literacy of engineering undergraduates, while extending the scope of the college impact model and verifying the applicability of the college impact model to the study of sustainable development learning outcomes. Although institutional support is considered a key educational factor in developing students’ sustainable development literacy, there is limited quantitative evidence on the relationship between institutional support  and sustainable development literacy among engineering undergraduates. This study verified the significant positive effect of institutional support on the sustainable development literacy of undergraduate engineering students. The findings of this study have practical implications for sustainability in engineering education, and higher education institutions can adopt curriculum revision, with the introduction of new courses and engaged pedagogy to incorporate sustainability goals into their teaching areas.Furthermore, the college impact model states that institutional support not only affects student learning outcomes directly, but also indirectly by influencing student engagement. Therefore, this study used student engagement as a mediating variable between institutional support and engineering undergraduate students’ sustainable development literacy, which also indirectly influenced student engagement. The study found that student engagement partially mediated the relationship between institutional support and sustainable development literacy, suggesting that the active academic engagement of students as dynamic subjects is an important bridge between external educational resources and individual sustainable development literacy. Therefore, it is important to increase the motivation of engineering undergraduates to actively engage in sustainable development activities in future engineering education. Expanding student engagement requires the establishment of student-centered teaching practices. It is necessary to improve the participation of engineering undergraduates by innovating education and teaching methods and constructing more flexible teaching modes. To further cultivate their sustainable development literacy and ability, in the teaching process of sustainable higher engineering education, all the teachers should advocate the learner-centered teaching method and highlight the central position of engineering undergraduates.Additionally, this study incorporated gender as a moderating variable in the college impact model, thus providing a more comprehensive view of the mechanisms of institutional support and student engagement on sustainability literacy in the context of engineering education. Based on the empirical analysis of this study, women and men have the same expectations for learning sustainable professional knowledge, and can actively participate in the process of classroom teaching by fully exerting their own subjective initiative, thus improving the effect of knowledge learning. This study helps promote the diversification of engineering education students. Promoting diversity and pluralism in the engineering education student body is also an important sustainability issue in its own right, and engineering education has long been committed to increasing the participation of people, including women and minorities, in engineering education and engineering careers because the participation of diverse populations brings new ideas and ways of thinking to the development of the engineering field.The study examined the factors influencing undergraduate students’ sustainable development literacy. Based on the college impact model, a questionnaire survey was conducted among 1070 randomly selected fourth-year engineering undergraduate students at Chinese universities to explore the impact of institutional support on undergraduate students’ sustainable development literacy, and the structural model of sustainable development literacy was effectively tested. The results show that the direct effect of institutional support, sustainability curriculum, and instructional practice is significant on sustainable development literacy among engineering undergraduates. Student engagement significantly mediates institutional support and sustainable development literacy. Furthermore, gender significantly moderated the relationship between student engagement and sustainable development literacy, and males are significantly higher than females in this pathway relationship. Based on the empirical analysis and practical experience, it is suggested to cultivate engineering undergraduates with a high level of sustainability development literacy.The study has some enlightenments for educators and administrators to integrate sustainable development literacy into higher engineering education, but there are still some limitations. First, the variables of the study are mainly based on the college impact model; however, in educational practice, many other relevant influencing factors should be involved, such as learning motivation, self-efficacy, peer effects, etc., for a more in-depth explanation. The influence of these factors on students’ sustainable development literacy needs to be further analyzed. Second, the study only surveyed undergraduates in engineering majors. However, sustainable development literacy is necessary for all students, and the sample size should be enriched to test influencing factors such as interdisciplinary vision and disciplinary variation in future study.


Button battery ingestion (BBI) is common in children and its prevalence has increased in the last decades. BBI can be responsible for very severe and potentially fatal complications if not promptly detected. We describe the successful management of two cases of BBI that occurred in two previously healthy infants. Both patients presented with vague symptoms and no witness of foreign body ingestion. The prolonged time of exposure to the corrosive effects of disk batteries was responsible for the development of tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). We demonstrate how prompt diagnosis and management are crucial for the infants’ survival. Foreign body ingestion is common in the pediatric population. Button batteries can be found in many household objects, such as remote controls, games and toys, hearing aids, watches, calculators, and flashlights. The prevalence of button battery ingestion (BBI) has increased during the last decades ,2. DespiA 12-month-old baby male was admitted to the pediatric emergency department with a history of fever, cough, respiratory distress, progressive dysphagia, and sporadic non-bilious vomiting. The patient was febrile (38 °C) at the admission, heart rate of 100/min, and respiratory rate of 30/min. Laboratory tests were normal. Chest X-ray showed the presence of a metallic foreign body projecting adjacent to the trachea and the presence of bilateral pulmonary opacities. Esophagoscopy and bronchoscopy confirmed the presence of a metallic object at the level of the middle esophagus and revealed the presence of a tracheoesophageal fistula (TEF) at the tracheal bifurcation. The patient was successfully managed with endoscopic retrieval of the battery A,B. Subs2 73%) and was promptly resuscitated by the rescuers’ team. Parents referred the baby had been febrile for the previous 9 days with associated dysphagia. A contrast-enhanced CT angiography (CTA) was performed, and it showed contrast medium leakage into the stomach, with the presence of an aorto-esophageal fistula (AEF) at the upper thoracic part of the esophagus , BBI frequency has increased over the last decades. Up to 2021, 271 severe cases and 69 fatal cases related to BBI have been reported. Among fatal cases, 26 were caused by AEF 37.6%) and 13 by TEF (18.8%) 7.6% and . PredictMost major events are related to unwitnessed ingestion 56.2%) and delayed diagnosis [.2% and dSevere complications usually occur when button batteries remain lodged into the esophagus, a condition that can potentially lead to ulceration, perforation, and fistulization with surrounding tissues. BBI complications include pneumonia, mediastinitis, hemorrhage, esophageal ulceration and perforation, sepsis, tracheoesophageal fistula, and aorto-esophageal fistula .The clinical presentation is often non-specific, and BBI should be considered in the differential diagnosis in previously healthy infants who present with dysphagia, vomiting, fever, cough, or irritability, especially if symptoms have a sudden onset . In bothChest X-ray represents the first diagnostic tool to attest the presence of a foreign body, its location, size, and shape, and it may help distinguish disk batteries from other metallic objects  .Both the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPHGAN) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPHGAN) recommend immediate endoscopic retrieval when the button battery is detected in the esophagus ,9. However, our first case demonstrated that a tracheoesophageal fistula was present despite the prompt endoscopic retrieval, probably due to prolonged contact duration between the battery and the esophageal wall. TEF mortality related to BBI accounts for 11.4% and the management options include a conservative approach, to allow for spontaneous TEF closure or surgical repair. Despite no recommendations or guidelines are currently available, some authors have suggested that a conservative approach is favorable when a patient’s clinical condition is stable, in order to minimize surgery-related complications and recurrences. Moreover, they suggested that a conservative approach should last at least 8 weeks prior to opting for surgical repair. However, a prolonged watchful waiting strategy in these patients may increase the risk for reflux aspiration and respiratory distress . The choOnce the disk battery passes into the stomach or bowel, the transit is generally without complications, but patients still need clinical monitoring and repeated X-rays to check for the battery progression .However, the finding of a disk battery in the stomach or bowel should not let the guard down against the presence of BBI-related complications. In fact, our second case presented with hematemesis, melena, hemodynamic instability, and the presence of AEF was reported when the disk battery was lodged in the colon .In the presence of such symptoms, a contrast-enhanced CT scan should be timely performed in order to assess the presence of this rare and life-threatening complication and to transfer the patient to a cath-lab or operation room ,13,15. In our case, first-line aortic angiography failed to detect the presence of the fistula, probably due to compression made by a massive clot surrounding the nasogastric tube at the level of AEF. This case further emphasizes the importance of CTA for pre-operative assessment of AEF, since it allowed for the extraluminal assessment of the aorta and to identify the location and the size of the fistula.AEF is a very rare and generally fatal BBI-related complication. According to scientific literature, only nine other cases have been diagnosed and successfully managed, with the survival of the patient . In all Clinicians should be aware of severe complications that derive from BBI even days or weeks after button battery removal, due to persistent alkaline-induced liquefactive necrosis. A high level of guarding should be kept in presence of a battery with a diameter >20mm (3V), with prolonged time of impaction, and in patients younger than five years old .In conclusion, BBI can lead to life-threatening complications and diagnosis can often be challenging due to unwitnessed or nonspecific clinical presentation. In presence of sudden onset symptoms in previously healthy little patients, the possibility of foreign body ingestion and BBI should always be considered. Radiological examinations, including X-rays and CT scans, followed by endoscopy are necessary, either to confirm the presence of the foreign body or to assess the presence of complications. Aorto-esophageal fistula and trachea-esophageal fistula are two potentially fatal events related to BBI that should always be carefully excluded. We demonstrated how important early diagnosis and prompt treatment were for patients’ survival.


The essential factors of information-aware systems are heterogeneous multi-sensory devices. Because of the ambiguity and contradicting nature of multi-sensor data, a data-fusion method based on the cloud model and improved evidence theory is proposed. To complete the conversion from quantitative to qualitative data, the cloud model is employed to construct the basic probability assignment (BPA) function of the evidence corresponding to each data source. To address the issue that traditional evidence theory produces results that do not correspond to the facts when fusing conflicting evidence, the three measures of the Jousselme distance, cosine similarity, and the Jaccard coefficient are combined to measure the similarity of the evidence. The Hellinger distance of the interval is used to calculate the credibility of the evidence. The similarity and credibility are combined to improve the evidence, and the fusion is performed according to Dempster’s rule to finally obtain the results. The numerical example results show that the proposed improved evidence theory method has better convergence and focus, and the confidence in the correct proposition is up to 100%. Applying the proposed multi-sensor data-fusion method to early indoor fire detection, the method improves the accuracy by 0.9–6.4% and reduces the false alarm rate by 0.7–10.2% compared with traditional and other improved evidence theories, proving its validity and feasibility, which provides a certain reference value for multi-sensor information fusion. Heterogeneous multi-sensors play an important role in information perception, the acquired data may contain some ambiguous and conflicting information due to the limitations of multi-sensor devices’ measurement accuracy and the complexity of the working environment, which may result in inaccurate data-fusion decisions . ConsequDetermining the BPA function is an important step in evidence theory, which influences the accuracy of fusion results to some extent. Many researchers have proposed various methods for determining BPA functions ,14,15. TThe directions for improving the accuracy of traditional evidence theory fusion can be divided into two major areas: improvement of combination rules ,21 and iIn order to more accurately measure the relationship between evidence and the characteristics of evidence itself, and improve the accuracy of data fusion, this paper proposes an improved evidence-theory method based on multiple relationship measures and focal element interval distance. We combine the Jousselme distance, cosine similarity and the Jaccard coefficient to calculate the similarity between the evidence, and we use the Hellinger distance between the evidence determination intervals to measure the certainty of the evidence. Based on these calculations, the evidence weight coefficients are then jointly improved. Finally, the original evidence is average-weighted and fused by using the Dempster rule to produce the result. In addition, we analyze the results of the arithmetic examples to demonstrate the validity of the proposed improved evidence theory. By using the aforementioned improved evidence theory along with cloud model, we developed a multi-sensor data-fusion method. The BPA functions corresponding to each data source are determined based on the cloud model, which converts the collected quantitative data into stereotypical concepts. The fusion results are obtained by fusing each BPA function by using the improved evidence theory mentioned above.Multi-sensor data-fusion technology can combine relevant information within multiple sensors, thereby increasing the safety and reliability of the overall system. The proposed multi-sensor data-fusion method can be utilized in multi-sensor systems in various fields, such as fault-determination systems, target identification systems, environmental monitoring systems, and intelligent firefighting systems, among others. Due to external factors or their own aging faults, one or more sensors may acquire incorrect information, causing the fusion results to be contradictory to the facts. The proposed method overcomes the problem, improves the handling of ambiguity in sensor data, increases the reliability of data fusion results, and makes it easier for people to make appropriate decisions. We establish an early indoor fire detection model to test the efficacy of the proposed strategy. The proposed method improves accuracy by 0.7–10.2% and reduces false alarm rate by 0.9–6.4% when compared to the traditional evidence theory and other improved evidence theories. It has better fusion performance, which provides some reference value for multi-sensor data fusion.This section provides a brief overview of D-S evidence theory and the cloud model.X be a quantitative domain  of m(A) > 0, then A is called a focal element within the identification framework m(A) reflects the degree of trust of the evidence in A. In particular, the condition We call t) of Θ  , where mm(A), Bel(A) is defined as the confidence function, which is the sum of the potential probability assignments of all subsets of A, indicating the degree of certainty of the proposition A, as shown in Equation (3): For recognition framework Pl(A) is the likelihood function of A, as defined in Equation (4), indicates the degree of trust that does not deny A,A, [A, and [The intervals of evidence are shown in K is the coefficient of evidence conflict between K value indicates the greater the degree of evidence conflict, and the values of K range from 0 to 1. Let Based on the above theoretical knowledge, this paper proposes a heterogeneous data-fusion method based on a cloud model and improved evidence theory. In order to obtain the BPA function of evidence more accurately, we consider the ambiguity of multi-sensor data when completing data transformation by using the cloud model. To improve the reliability of the fusion results, we propose a new method for measuring the similarity of evidence and improve the evidence by combining the similarity and certainty of evidence together. The specific method for determining the BPA function and calculating the similarity of evidence and the certainty of evidence are described in this section, and finally the overall steps of the method are proposed.n classes of data, forming n bodies of evidence, i.e., ith class of data measured by the system. Based on the knowledge gained from the cloud model, the membership degree ith class of data relative to the jth evaluation index under the kth judgment within the same acquisition cycle of the multi-sensor system, i data relative to the jth evaluation index obtained in Equation (1), and It is assumed that the multi-sensor system’s data information is pre-processed to extract k is the number of times the multi-sensor acquires data in the same acquisition cycle, when k is greater than 1, the membership of class i data with respect to the jth evaluation index can be determined by the maximum of the k affiliation values when the feature parameters have multiple values:The multi-sensor membership matrix can be calculated based on the membership degree ith  class of data of the multi-sensor for the jth  evaluation index, and the elements in each column represent the membership of all data information collected by the multi-sensor system at a certain time for the jth  evaluation index.The elements in each row in Equation (9) represent the membership of the ith characteristic parameter, ith piece of evidence, and jth evaluation index of the ith piece of evidence.The obtained membership matrix K, Pignistic probability distance, Jousselme distance and cosine similarity, and so on. The computation of the conflict coefficient K is given in (6), and assuming that the evidence bodies Pignistic probability distance Classical measures for describing the relationship between evidence include: conflict coefficient m is the BPA function of A.Pignistic probability distance is a measure of conflicting relationships between evidence. Let the recognition frame 2.Jousselme distance D is a Assuming that 3.Cosine similarity The Jousselme distance is a measure of the conflicting relationships of the evidence, and the higher its value, the greater the conflict between the evidence.The cosine similarity can be used to calculate the similarity of the evidence. The greater the cosine similarity, the greater the confidence between the evidence.The accuracy of the various measurements is examined based on the above computation by calculating the measures under different conditions in conjunction with Example 1.Example 1.Suppose there are identification frames The body of evidence under Situation 1 is identical, and its conflict coefficient K is calculated by using Equation (6), yielding 0.75, which contradicts the fact, whereas cosine similarity and the Jousselme distance yield 1, which is consistent with the fact. Situation 2’s evidence is radically different, and the Jousselme distance metric produces 0.707, which is inconsistent with the facts, whereas the cosine similarity computation yields 0, which is consistent with the facts. Because it is impossible to determine whether the body of evidence From the above analysis, the cosine similarity measure is more accurate when measuring evidence with only a subset of single focal elements, and less accurate when faced with evidence containing a subset of multiple focal elements. Wang et al.  combinedAssuming the identification framework According to Equation (15), the local similarities of the evidence under different situations in Example 1 are: 1, 0, 0.244, and 0.470, all of which are more consistent with the facts. Based on the local similarity The properties of the evidence itself can be measured based on the degree of certainty of the evidence. In probability theory, the Hellinger distance is a complete distance metric defined in the space of probability distributions and can be used to measure the similarity between two probability distributions. It has the advantage of stability and reliability compared to other metrics. Deng et al.  measuredSuppose Assuming the identification framework Normalizing the resulting determinacy Step 1: After pre-processing the data from sensors, the BPA function of each data source related to the body of evidence is calculated by integrating the cloud model and each data evaluation index.Step 2: With the obtained BPA function of each evidence, the weight Step 3: With the weights Step 4: Based on the weights m,Step 5: Use Dempster’s fusion rule to perform n − 1 fusion for evidence body m.Based on the above study, the specific steps of the proposed method in this paper are given as follows, and the flow chart is shown in In this section, the proposed improved D-S evidence theory method based on similarity and certainty, as well as the proposed overall method of heterogeneous data fusion based on cloud model and evidence theory, are evaluated and simulated to demonstrate the feasibility and effectiveness of the proposed method in this paper.In this section, four common conflicting, normal, and multi-quantity single-focal and multi-focal element evidences are fused based on the proposed improvement method, comparing traditional evidence theory, classical improvement methods, and similar improvement methods, and demonstrating the effectiveness of the proposed methods in this paper through Examples 2–4. We take the methods proposed by Deng Z.  and WangExample 2.In evidence theory, there are four common sorts of conflicts: complete conflict, 0 trust conflict, 1 trust conflict, and severe conflict , and theThe global similarity Example 3.A, B, and C, with identification frame m1 to m5. Assume the radar identification library contains three radar model data The global similarity To verify the effectiveness of the improved method proposed in this paper, the evidences are fused by using Murthy , Deng Y.Example 4.1 to m5, and the distribution is shown in With the identification frame The proposed improved method’s fusion of normal evidence is compared to the traditional evidence theory to demonstrate the proposed improved method’s superior performance in dealing with normal data, and the fusion results are shown in According to the above examples, the similarity and certainty-based evidence theory fusion algorithm proposed in this paper performs better in handling both normal and conflicting evidence bodies, demonstrating the improved method’s rationality and effectiveness.To demonstrate the feasibility and effectiveness of the proposed data-fusion method, the heterogeneous data-fusion method combining cloud model and the proposed improved evidence theory in this paper is used for indoor early fire detection in this subsection.It has been discovered that the combination of temperature, smoke concentration, and CO concentration has superior detection performance in fires , and then et al.  proposedn et al. , the cloThe length, width and height of the room are 5, 5, 3 m;The room has a sofa, wooden bed and wooden table, in the upper left corner of the room from the wall 1 m set CO, temperature and smoke sensor group;Set the vent: room left wall with 1 × 1 m window, room directly opposite the sofa with 1.2 × 2 m door;2.The fire burning material is n-Heptane, the center of combustion is the center of the wooden bed, the burning area is 1 mPyroSim fire simulation software provides a visual user interface for fire dynamic simulation (FDS) and can more accurately predict the distribution of characteristic parameters such as fire smoke and temperature , so thisBy setting different heat release rate and heat ramp up time to simulate the occurrence of open fire and negative fire in the room, the starting room temperature is 30 °C, the simulation time is 30 s, and the data acquisition frequency is 2 Hz. Based on the proposed data-fusion method, a fire detection model is built. The initial fire detection probability is estimated by combining CO concentration, smoke concentration, and temperature data. The probability of smoldering fire and open flame within the initial fire detection probability is also added, and if it is greater than 0.75, the fire occurred in the room. To determine whether a fire has occurred, the early open fire data from this simulation are fused using the traditional D-S evidence theory, the methods proposed by Murphy , Deng Y.A smoldering fire’s combustion features include the emission of a significant amount of black smoke from the combustion point prior to the appearance of the evident fire. The determination of whether a fire has occurred is made possible by combining data on smoldering fires based on the traditional D-S evidence theory, the methods proposed by Murphy , Deng Y.To further verify the effectiveness of the proposed fire detection method, we obtained different CO concentration, smoke concentration and temperature data by setting different combustibles, combustion locations, heat release rates, and heat ramp-up times. Then we made our own fire dataset, which included 1000 positive samples and 1000 negative samples. Based on the traditional evidence theory, classical improvement method, similarity improvement method and the proposed method in this paper, the homemade samples are fused to calculate the accuracy rate and false alarm rate of detection. Assuming that TP represents the number of samples correctly judged to be fires, FN represents the number of samples not correctly judged to be fires, FP represents the number of samples misreported to be fires, and TN represents the number of samples correctly judged to be fires that did not occur. The accuracy and false alarm rates (FAR) are calculated as Equation (22):It is evident that when applied to indoor fire detection, the proposed heterogeneous data-fusion method has better fire detection performance and can simultaneously improve the timeliness and accuracy of detection, proving its feasibility and effectiveness in multi-sensor data fusion.In this paper, a multi-sensor heterogeneous data fusion strategy based on the cloud model and improved evidence theory is presented, which can better cope with the ambiguity and conflict of heterogeneous multi-sensor gathered data. The cloud model is used to estimate the BPA function of each data source’s associated evidence. Evidence similarity is calculated by using multi-relationship measures, evidence certainty is measured by using interval distance, the body of evidence is jointly improved by combining the evidence’s similarity and certainty, and the improved body is fused by using Dempster’s rule. The usefulness of the improved evidence theory technique is validated in this research, and the results show that the proposed method performs better when dealing with both conflicting and normal evidence. The method is used for indoor fire detection in light of the issues of prolonged duration and low accuracy. Compared to traditional evidence theory, classical improvement method, and similar improvement method, the proposed method improves detection speed by 0.5–3 s, accuracy by 0.7–10.2%, and reduces the false alarm rate by 0.9–6.4%, which has better detection performance. It also provides a specific reference value for multi-source information fusion.In future work, we intend to test the feasibility of the proposed method on other multi-sensor acquisition information systems, as well as investigate how to combine homogeneous and heterogeneous data fusion algorithms to fully exploit effective data information and improve data fusion accuracy.


As many of our study subjects are elite college athletes with the GP.Mur blood type, we contemplated their upbringings and career dilemmas, especially during the difficult COVID-19 pandemic. Beyond individual sports talent, the pandemic particularly tests personal characteristics and socioeconomic support for becoming an athlete. This opinion article discusses the factors that attract children and teens to athletic careers. The most important attribute for the making of athletes is polished sports talent, followed by psychological, environmental, and incentive factors. Our laboratory studies a red blood cell (RBC) type called GP.Mur, which is rare in most parts of the world besides Southeast Asia. Intriguingly, the prevalence of the GP.Mur blood type is relatively high among Taiwanese elite athletes. The highest frequency of the GP.Mur blood type worldwide is found among Taiwan’s Ami people . Though the Ami constitute only 0.6–0.8% of the Taiwanese population, from records of national track-and-field games in the past century, 10–60% of the medalists were Ami. Biologically, GP.Mur expression supports blood CO The choice of one’s career path is a complex issue, which is more difficult for gifted elite athletes who began training and competition at an early age. In this opinion article, we will discuss the making of an athlete in Taiwan from physical/genetic attributes  and psychological/environmental/incentive attributes, with emphases on imagery and family influence/tradition.2 respiration, which conceivably benefits exercise metabolism. In Taiwan, junior athletes who have won competitions at national and international games are granted scholarships and are invited to continue their training at top sports universities. Like piano prodigies, their athletic talents are often revealed at a young age. Different from piano prodigies though, their athletic careers are limited by age  and injury. When elite athletes no longer meet the cutoff for national/international games and/or have other considerations, they have to prepare for a career change to other sport-related or unrelated areas, often while they are still in college. For the making of one’s athletic career, we will discuss (1) the attributes of potential sport talents, using two examples: the well-studied ACTN polymorphism and the commonly observed GYPB/GYP.Mur polymorphism in Taiwan; and (2) the attributes of one’s mentality and environment. We will also discuss the interplay among these attributes in the contexts of the COVID-19 pandemic and GP.Mur-associated athleticism in Taiwan.We study the biology and physiology of the GP.Mur blood type in Taiwan. GP.Mur is a unique Southeast Asian phenotype (rare outside Southeast Asia), with 2–6% prevalence in different regions of Taiwan ,2, but wSince February, 2020, the COVID-19 pandemic and related public health measures have forced the reduction of sporting events, tournaments, and even gym/training classes in most parts of the world . This ha2max directly. This is because CPET face masks and gas tubes are shared equipment, so any residual infectious particles on the shared equipment may not be eliminated by standard cleaning protocols.In 2021 (the second year of the COVID-19 pandemic), most international games were either resumed after a postponement  or were unaffected. The Taiwan Centers for Disease Control (TW-CDC) maintained its rigid public health measures, and all international games that were planned to be held in Taiwan from 2020 to the spring of 2022 were canceled. During the same period (late 2020–early 2022), the Taiwan Sports Administration, under the advice of the TW-CDC, discouraged elite athletes from going overseas for competitions held in other countries. Many elite athletes needed to fight against this government policy by promising to take any risks themselves, in order to participate in overseas tournaments. At the 2021 Asian Karate Federation (AKF) championship tournaments in Kazakhstan, more than half of the Taiwan karate team members unfortunately contracted Omicron after the competition, despite the fact that all the team members had been vaccinated . Like elThe restrictions on international games were lifted as Taiwan relaxed its border control in the summer of 2022. The YONEX Taipei Open 2022 (a Badminton World Federation (BWF) world tournament) was the first international games to be held in Taiwan since the beginning of the pandemic. Currently, the precautionary measures against COVID-19′s spread via sport games are quite different ; the public health regulations depend on the type of sport and on the national policy of the country where the games are held. The pandemic impacts individual Taiwanese athletes to different extents. In the beginning of the outbreak (the spring of 2020), schools were closed abruptly and all sports training and coaching classes were halted for the summer. The Taiwan National Intercollegiate Athletic Games of 2020 were postponed from spring to winter. Noticeably, at the postponed intercollegiate games, student-athletes who trained by themselves or through online coaching generally did not perform well. The situation is similar to a recent report describing the plummet of math and reading scores among elementary school children during COVID-19 lockdowns in the USA . StudentOn the other hand, the performance of Taiwanese elite athletes (including those of college age) who need to accumulate world ranking scores has not been much affected by the lockdowns. Conceivably, their psychological strength, from becoming world-ranking athletes , manifeACTN and (2) GYPB/GYP.Mur (the latter gene variant encoding GP.Mur). However, it would be a stretch to describe these variant genes as “sport genes”.The most essential attribute to become an elite athlete is one’s polished sports talent, with a suitable physical build for the type of sport competition that one aims for. Such qualities are, by and large, genetically determined. We will discuss two gene polymorphisms related to potential sport talents: (1) ACTN3 alleles was initially found to be associated with differential muscle utilities for sprinting versus endurance sports: the RR/RX genotypes likely benefit speed and power athletes, whereas the XX genotype likely benefits endurance athletes [ACTN3 RR/RX genotypes express alpha-actinin-3 in the Z disc of their myofibers, whereas people with the homozygous ACTN3 R577X (XX) genotype do not express alpha-actinin-3 at all. The absence of alpha-actinin-3 in humans is not detrimental to health. In fact, 25% of Asians, 18% of Caucasians, and 3% of African Americans carry the XX genotype and lack alpha-actinin-3 protein in their myofibers. The RR/RX/XX polymorphism of athletes ,18,19,20ACTN3 molecular studies using genetically “knocked-out” mouse models revealed a more complex picture than researchers initially thought. Knock-out, or removal of ACTN3 gene expression, reduces the fraction of fast myofibers in total muscles and lowers the total muscle mass of genetically modified animals. Not surprisingly, −/−ACTN3 mice show weaker skeletal muscle strength than wild-type mice [ACTN3 gene doping does not enhance muscle function, instead it induces toxicity that is harmful to the gene-doped muscles [ACTN3 genotypes and sport types [However, further ype mice . In a mo muscles . There art types ,24,25,26rt types . The conBesides individual sports talents, there are other essential attributes for the making of elite athletes: (1) an environment that helps nurture one’s sports talents; and (2) one’s mentality, which is largely driven by personal interests, psychological traits, willpower/motivation , intelliACTN3 mentioned above, GYP.Mur-encoded GP.Mur has been suggested as a potentially characteristic phenotype for athleticism in Taiwan. GP.Mur, traditionally known as Miltenberger subtype III (Mi.III), is the protein entity of a special blood type that is found in 1–7% of Southeast Asians but is considered rare in other ethnic populations ) [Similar to hinese)) ,33. Southinese)) ,35,36,37hinese)) . The Amia antigen (a main marker of the GP.Mur blood type) [GYP.Mur in the Ami people) could be a consequence of the founder effect. However, this phenomenon is affected by increasing human migratory activities , as demonstrated in Australia [However, the regional and worldwide distribution of the GP.Mur phenotype is changing. The Australian Red Cross Blood Service recently did a survey on a blood donor population and found 0.22% of the donors express the Miod type) . This reod type)  and is lustralia ,39 and iustralia . Sports Illustrated in the 1960s [From the perspectives of physical build and strength, Ami people are not distinct from other Taiwanese in terms of muscular or anthropometric characteristics . Yet, frhe 1960s ,44, was he 1960s ,46,47,48−/HCO3− transporter, a functional membrane protein that allows the HCO3− anion to pass through the cell membrane (ions or charged molecules cannot pass through a lipid membrane because of a tremendous thermodynamic energy barrier). Physiologically, HCO3− transport via band 3 supports blood CO2 metabolism and respiration [2 in human circulation is present in the form of soluble HCO3− before CO2(g) is exhaled from the lungs. More band 3 expressed on the GP.Mur RBC surface means more efficient HCO3− transport in and out of the RBCs and expedited blood CO2 metabolism.In 2009, in collaboration with a renowned proteomics research group in the USA, we identified significantly more band 3 protein expressed on the surface of GP.Mur RBCs, using an at-the-time novel system biology approach . Band 3 piration , becausekMk types); all these illnesses present lower blood CO2 respiration, mild acidosis, and, consequently, anemia due to low band 3 function in HCO3− transport [−/HCO3− exchange, superior intracellular pH homeostasis, and more resilient RBC membrane structure to osmotic stress [2 respiration than those without the special blood type in this test [2 respiration in these subjects with GP.Mur could enable them to recover from physical stress faster than the control subjects.The clinical relevance of band 3 was first discovered in cases of hereditary band 3 deficiency or dysfunction  and Mransport ,52,53,54ransport ,56. In cc stress ,57,58. This test . Intereshis test ,46,47,48Is there indeed a correlation between the physiological advantage associated with the GP.Mur blood type and the making of an elite athlete? Though the historical record  surveyed the distribution of the GP.Mur blood type on several athletic teams. NTSU is one of the top three athlete-training schools in Taiwan that recruits the best student-athletes from the winner pools of international, national, and regional games. Their survey did not find any GP.Mur+ athletes on the golf team or the jump team in NTSU. Among the 28 sprinters that specialized in short-distance hurdles, 9 of them (32%) bore the GP.Mur blood type, and 2 of the 9 GP.Mur+ sprinters were not Ami . The prevalence of the GP.Mur phenotype was drastically different on different sports teams. At another top-ranking sport university in Taiwan—the University of Taipei—there are elite athletes with the GP.Mur blood type that specialize in jumping, javelin, karate, judo, soccer, basketball, soft tennis, triathlon, cycling, canoeing, and weight-lifting. However, we have not yet found an elite athlete with GP.Mur on the golf, archery, or swimming teams. The latter was a surprise, as our biochemical work points to the potential benefits of GP.Mur protein expression for respiration . From coThe other two sports that lack GP.Mur+ athletes are gold and archery; most Taiwanese do not learn either sport before college. Golf is a more popular but also a more costly sport. Thus, choosing a specialty for an athlete also depends on the environment that one grew up in, e.g., the expertise of their first sports coach at the elementary or junior high school, and the influences and imagery from their families, their communities, and online media.Kano [A 2012 NTSU survey found 28% of their baseball team members bore GP.Mur (7/25), which is ~6–7 times higher than the prevalence of GP.Mur in the general Taiwanese population. All seven of these GP.Mur+ baseball players are Ami, but there are two other Ami on the baseball team who do not have the GP.Mur blood type. The Ami’s baseball talents were first uncovered by Japanese ruling officials in Taiwan over a century ago (as seen in the movie Kano ). NowadaOne notable distinction between baseball players and sprinters in Taiwan is their career paths, which are strongly influenced by individual athletic talents, personality, and realistic incentives. In contrast to the fun of ball games and the relatively longer career span of a baseball player, the competing years of a sprinter usually end before their college graduation . It is cThe professional baseball league in Taiwan has been booming for more than two decades. Taiwan’s professional baseball league was also the first in the world to be out of COVID-19 lockdown, resuming play in an “empty stadium” in April 2020 . Though Athletes in group games such as baseball, basketball, and even boxing are generally more receptive to cheers and emotional responses from the audience and teammates. This is in contrast to athletes trained for solo competition such as triathlons, marathons, and even swimming, who are more used to practicing in solitude. Thus, one’s personality is perhaps the second-most-important determinant, following inborn sport talents, for choosing one’s career path. The challenges of COVID-19 lockdowns accentuated the importance of certain personality traits, since the practice of social distancing is psychologically stressful particularly for some athletes. As with other careers, athletes may also “work (train) from home” to avoid infection. Athletic training in solitude is, thus, a test of persistency and motivation  and of flexibility or even independent problem-solving skills (creativity/intelligence) ,7,29. OvSports performance is more than a manifestation of “sports gene” expression; it is a highly motivated and well-orchestrated human behavior. What drives a child with tremendous sports potential to become a runner or a baseball player is highly individualized. Though the sports talents in the Ami or GP.Mur+ people have been observed for more than a century, fewer of them are pursuing athletic careers nowadays, as shown in the decreasing percentages of Ami medalists since the 1990s . This drA child’s gift of inborn athletic advantages  conceivably could help the child to be selected into a sports team more easily (as shown in a hypothetical plot in Therefore, one’s athletic career is highly individualized, often likened to running a “one-person company” with a diverse advisory board. How the company performs and how long it lasts depend on how the company is managed and developed. Besides one’s athletic performance, environmental and community supports are essential, but individual character and determination, which are shaped by personal beliefs and thoughts, are likely the ultimate attributes to deciding one’s athletic career. We noticed interesting tattoos on some of our athlete subjects, when they were tested on a treadmill for exercise cardiopulmonary functions. A waterweed-like tattoo on a professional soccer player once caught our attention, and later we learned that it represents a special grass from his hometown far away. His teammate has tattoos on both arms: on one arm is the symbol of a cross and on the other arm is an unknown English word, which was explained as being the name of his grandmother, whom he missed very much. These tattoo imageries are endearingly personal and almost spiritual. Despite that retirement or career change is unavoidable for athletes, the sports talent that once flourished in competition never really perishes; it has just been transformed as one pursues new directions in life. A friend who taught artistically gifted children once said that talented kids are not gifted in just one area but are often gifted in many areas. Indeed, the development of one’s athletic talent helps cultivate other talents and characteristics, such as grit . In spit


This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP.An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0–10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0–10).After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT.There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective. This report is part of a series of articles that are the product of the International Urogynecology Consultation (IUC) sponsored by the International Urogynecological Association (IUGA). This is a 4-year, 4-chapter project with 16 reports dedicated to reviewing and summarizing the world’s literature on pelvic organ prolapse (POP). This report is from the third year and chapter of the project, which is dedicated to reviewing the literature on non-surgical management of POP. Years 1 and 2 were dedicated to defining the epidemiology of POP and the evaluation of patients with POP. The fourth or final chapter will evaluate the surgical treatment of POP. This report focuses on reviewing the literature on conservative treatment of patient with POP employing pelvic floor muscle training.POP is a common condition in women. The reported prevalence varies widely 1–65%) based on whether its presence is ascertained by symptoms 1–31%), pelvic examination (10–50%) or both 20–65%) [–65% base0–65% [–61%, pelvi2O increase in pressure during maximal voluntary contraction, the odds for prolapse was reduced by 13%  [POP is caused by a combination of impairment of the pelvic floor muscles (PFM) and the connective tissue . The ass1, 0.94) .Kegel (1952)  postulat(1) Women learn to consciously contract the PFM before and during increases in intra-abdominal pressure (IAP)  and continue to perform such voluntary contractions as a behavior modification to prevent descent of the pelvic floor during these episodes.(2) Women are taught to perform regular strength training to improve ‘firmness’ and structural support of the pelvic floor over time. These two hypotheses co-exist as they both build on an anatomical and biomechanical understanding of the function of the PFM, i.e., a voluntary contraction of the PFM constricts the levator hiatus, elevates and stabilizes the pelvic floor into a higher position. This results in an immediate effect during the PFM contraction of lifting the bladder neck and stabilizing the pelvic floor , 24. ThiWhat is the evidence for PFMT in prevention of POP in the general female population?What is the evidence for early intervention of PFMT in the peripartum period for treatment of POP?What is the evidence for PFMT in treatment of POP in the general female population?What is the evidence for PFMT pre- and post POP surgery?What is the evidence for PFMT on associated conditions in women with POP?What is the evidence for long-term effect of PFMT in treatment of POP?This narrative review summarizes the current evidence for PFMT in the treatment and prevention of POP with the following research questions:To complete an exhaustive literature search on this topic, the authors brainstormed search terms they felt most relevant to POP and selected the items listed below. This list of terms was presented at the IUGA annual scientific meeting in 2020 for input from the general membership. No additional terms were suggested as a result of that meeting. The search strategy included the following: Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases were searched for period January 1, 1996, to December 31, 2021, to identify studies. The keywords were combinations of “pelvic organ prolapse” or “urogenital prolapse” and “bulge” or “heaviness,” “exercise therapy,” “hypopressive exercise,” “kegel,” “long term,” “pelvic floor muscle training,” “pelvic floor exercise,” “peripartum,” “postpartum,” “pregnancy,” “prevention,” “symptomatic prolapse” and “treatment outcome”. Limitation was set on fully published randomized controlled trials (RCTs) or full publications with at least an English language abstract. The search also included the extended abstracts from International Continence Society (ICS) meetings. Finally, the authors hand-searched publications from International Consultation on Incontinence (ICI) , NICE  of PFMT on POP. However, two studies focused on secondary prevention, as they included women who had not sought health care for assessment or treatment of the condition , 38 and In the unblinded RCT of Wiegersma et al. (2014)  PFMT wasBoth studies found statistically significant positive short-term effects on symptoms of POP, but not on POP-Q stage. Significant differences were maintained in some of the measures of symptoms at the 2-year longitudinal follow-up .Wu et al. (2018)  reportedIn the secondary analysis of an assessor-blinded RCT with PFMT alone compared with only teaching and assessment of PFM strength for UI, 175 primiparous women with and without POP 6 weeks postpartum were included . No effeTable There is some variation in the content of the PFMT interventions for POP in these trials. All the PFMT programs for POP included strength training of the PFM. In the study of Wiegersma et al. 2014) , the par , the paThe training period varied between 4 weeks and 2 years, and number of visits with the physical therapist varied between 4 and 18. PFMT was taught individually in all but one trial , who didFor short-term effect of PFMT, the RCTs showed PFMT to be effective in treating POP, demonstrating statistically significant improvement in POP symptoms , 48, 49 Table Table Only one of the RCTs showed any benefit of adding PFMT to surgery for POP . The latThe results of PFMT on sexual dysfunction, bladder and anorectal symptoms for women with POP are presented in Tables P < 0.01). Some participants reported increased control, strength and awareness of the pelvic floor, improved self-confidence, sensation of a "tighter" vagina, improved libido and orgasms, resolution of pain with intercourse and heightened sexual gratification for partners. Additionally, the study found that participants who described improved sexual function obtained the greatest increases in pelvic floor muscle (PFM) strength (mean 16 ± 10 cmH2O) and endurance (mean 150 ± 140 cmH2O s) (P < 0.01).Tables The results related to PFMT on bladder and bowel symptoms in women with POP are shown in Tables We defined “long term” as follow-up of at least 6 months after cessation of the intervention conducted in the original RCTs. There are a limited number of studies on the long-term effects of PFMT for POP Tables , 4 and 5Adverse effects of PFMT in women with POP are almost non-existent, and, if present, mostly not related to the PFMT.This narrative review found no primary prevention RCTs on PFMT for POP and sparse evidence on early interventions in the general female population and the peripartum period. PFMT has been shown to significantly improve POP symptoms and associated pelvic floor complaints. Anatomic POP has been shown to improve by one POP-Q stage. It is unclear how clinically relevant this is because there are insufficient data describing the elevation of the leading edge of prolapse from beyond to above the hymen with PFMT. Studies included women with POP-Q stage I to III POP, and the effect was generally reported for all stages together, and not separated between stages, possibly because of low sample sizes. One pilot feasibility RCT showed significant benefits of PFMT as an adjunct to surgery but this was not proven in the nine other studies. Long-term data are sparse, and results are inconsistent.Given the anatomical and biomechanical rationale and evidence for PFMT to change pelvic floor morphology , it is tSomewhat surprisingly, studies have found that POP is also prevalent in nullipara women . As vagiThe effect of PFMT in the general female population with POP showed overall positive short-term results on POP symptoms, and in most of the studies measuring anatomical POP, the prolapse improved one stage , 46, 48.This review found only three RCTs comparing PFMT with a pessary, highlighting the need for further high-quality RCTs for this comparison. The level of evidence for pessaries as an effective intervention for POP was level three evidence in the 2017 ICI systematic review  and thisMany of the RCTs on PFMT in women with POP also evaluated the effect on comorbidities such as sexual dysfunction, bladder and anorectal symptoms and found positive results. However, none of the studies had these comorbidities as primary outcomes and the studies included women with and without these symptoms. The power of the studies not finding an effect may be too low for these secondary analyses. Most studies used general validated instruments for the overall conditions, and more detailed information on the effect of UI and AI was not always available.Sexual dysfunction in women is frequently associated with pelvic organ prolapse (POP) . In a sySome of the studies assessing bladder and anorectal symptoms had a relatively short duration of the PFMT protocol as they were investigating perioperative PFMT , 71, 75 It is somewhat counterintuitive that PFMT does not seem to be effective pre- and post-POP surgery. This is despite evidence that it is effective in the treatment of POP . HoweverFurthermore, the recurrence rate following traditional surgery for POP is approximately 30% , 89, andThere are general challenges to long-term studies of any intervention due to loss-to follow-up, co-interventions, treatment switching and competing events , 94. ForThere are challenges in adherence to long-term PFMT when there is no structured follow-up regimen or encouragement for further training after the initial supervised PFMT. This could explain the diminishing effect. Furthermore, if there was no short-term effect of a PFMT program , 71, 75,At present, one can question whether today’s health services for non-surgical interventions for POP are optimal. In a focus group study of 22 women receiving prolapse care through urogynecology services in the UK , the autThe results of the present narrative review support the conclusion of the ICI 2017 with 1A evidence/recommendation for PFMT in treatment of POP in the general female population . In addi*Provide proper information about the pelvic floor, exercise physiology and evidence for how PFMT can improve pelvic floor morphology and POP*Teach proper PFM contraction technique and assess whether the woman can do a correct contraction  and give immediate feedback of performance*Use validated outcome measures to assess POP symptoms, stage of POP (POP-Q) and comorbidities before and after treatment*Offer individual weekly visits or group training with a physical therapist for at least 6 months with additional home training*Teach women at risk for POP strategies to reduce IAP during activities of daily living*Use motivational strategies to favor adherence*Strength training regimens should follow general principles for strength training (3 sets of 8-12 close to maximum contractions at least 3-4 times/week and continue for at least 4 months)*Register adherence to both supervised PFMT and home training*Assess PFM variables  before and after treatment*Recommend a suitable PFMT maintenance program with intensity of the contraction being the most important factor (8-12 contractions 1-2 times/week)*Primary and secondary prevention studies in the general female population and studies in women with POP within 12 months after childbirth*Monitoring long-term adherence and study predictors of success of PFMT for POP including pelvic floor biological/anatomical factors


Dirofilaria immitis is a mosquito-borne filarial nematode, which infects primarily wild and domestic canids, causing cardiopulmonary dirofilariasis. The aim of the present study was to determine the prevalence and characterize molecular features of D. immitis in road killed canids, northern Iran.Canis familiaris), and 35 golden jackals (C. aureus) were necropsied in both Mazanderan and Guilan provinces, northern Iran. The molecular analyses were conducted based on the cytochrome oxidase (Cox) 1 and 18S ribosomal RNA (rRNA) genes.The carcasses of 53 road killed canids including 18 dogs . The prevalence of D. immitis was no statistically significant between males and females in both dogs and jackal (P > 0.05). Comparison of the Cox1 gene sequences with available data in the GenBank illustrated 100% similarity with D. immitis isolates from different hosts in European, Asian, and South American continents. Moreover, the 18S rRNA gene sequences showed 100% identity with dog isolates from Japan and French Guiana.The heartworm infection was found in 55.6% of dogs and 22.9% of jackals. Our study revealed significantly higher prevalence of D. immitis in dogs and jackals of northern Iran. Developing control programs to prevent transmission of the disease is necessary for dogs and humans in the study areas.This study confirms the high prevalence of  Dirofilaria immitis, Leidy, 1856 (Spirurida: Onchocercidae), heartworm, is a mosquito-borne filarial nematode that infects wild and domestic canids, felids, and humans [Aedes, Armigeres, Culex, Anopheles, and Mansonia [D. immitis often reside in the pulmonary arterial system and the heart of canids and felids. However, humans are less suitable hosts, in which the parasites usually do not mature sufficiently to produce microfilariae [Mansonia , 3. AdulD. immitis infection in humans usually causes pulmonary nodules, and in fewer cases, ocular and subcutaneous involvements [D. immitis was detected in the heart and major blood vessels of humans in few cases, as well [The main clinical symptoms of canine dirofilariasis include persistent cough, dyspnea, lethargy, weight loss, diminished exercise tolerance, coughing up blood, abdominal distention, and in advanced forms of the disease can lead to congestive heart failure, intravascular hemolysis, and pulmonary thromboembolism, which are often fatal if remain untreated , 4. D. ilvements , 5–7. D. as well .D. immitis infection in canids is mostly based on microscopy to detect microfilariae in stained blood smear and modified Knott’s technique, but serological tests and molecular methods are the other employed methods [Diagnosis of  methods , 10.D. immitis is mostly found in subtropical and temperate areas in the world, where there is a population density of canine reservoirs and mosquito vectors [D. immitis in jackals in some parts of Iran [D. immitis infection have been reported in cats [D. immitis infection of mosquitoes in Iran is high and Cx. theileri is the main vector of D. immitis in the country [ vectors , 11. Sev vectors –21. Ther of Iran , 23. In  in cats , 25. Mor country ..Human dirofilariasis has a dramatically increasing trend in European and American countries , 27, andD. immitis infection in canids especially jackals from the northern parts of the Iran, where environmental conditions are suitable for sustaining and expanding the infection. Therefore, the purpose of this study was to determine the prevalence of D. immitis obtained from road killed canids in northern Iran and investigate their genetic diversity using partial mitochondrial cytochrome oxidase subunit 1 (Cox1) and 18S ribosomal RNA (rRNA) genes.Recently, molecular methods are applied for reliable identification and phylogenetic analysis of canine filarial nematodes. Nevertheless, there are limited epidemiological and molecular information about 2 and have humid subtropical climate with mean annual rainfall of 1359 mm for Guilan province and about 1000 mm for Mazanderan province. The average relative humidity is about 80%, which reaches a maximum in autumn and winter, and decreases in summer and spring [A cross-sectional study was conducted from October 2017 to September 2019, in both Guilan (37. 2774 N 49. 5890 E) and Mazanderan  provinces, north of Iran. These provinces are located in southern border of the Caspian Sea and their southern parts are surrounded by Alborz mountains , and 35 golden jackals (C. aureus) were collected from both Mazanderan and Guilan provinces, northern Iran. The carcasses were examined for the presence of adult D. immitis worms in the heart and pulmonary artery. The obtained specimens were preserved in 70% ethanol for parasitological and molecular examinations. For determination of morphological characteristics, the nematodes were stained by lactophenol and azocarmine as a temporary mount [In current study, a total of 53 carcasses of road killed canids including 18 dogs (n = 18) was washed three times in distilled water to remove ethanol. Next, total genomic DNA was extracted using a commercial DNA extraction kit , according to the manufacturer’s instructions and kept at − 20 °C until use. PCR reactions were performed in 30 μL volumes containing 2X red PCR premix , 20 pmol of each primer and 1 μL of extracted DNA. The forward primer COIintF (5′ -TGATTGGTGGTTTTGGTAA-3′) and the reverse primer COIintR (5′-ATAAGTACGAGTATCAATATC-3′) were used to amplify an about 689 bp fragment of the Cox1 gene [Cox1 gene were an initial denaturing step of 94 °C for 5 min and 35 cycles followed by denaturing step at 94 °C for 30 s, annealing step of 52 °C for 45 s, and 60 s of extension at 72 °C, and 72 °C for 7 min as a final extension. The thermal PCR profiles for 18S rRNA gene consisted of initial denaturation at 95 °C for 6 min followed by 30 cycles of 95 °C for 60 s (denaturation), 58 °C for 20 s , and at 72 °C for 45 s (extension) with a final extension of 72 °C for 10 min. The PCR products were separated by electrophoresis on a 1.5% agarose gel and visualized using a UV transilluminator . The amplification products were sent to a domestic sequencing company  for sequence determination using the Sanger method.For DNA extraction, one worm of each infected canids . The sequences of 18S rRNA and Cox1 genes were submitted to the GenBank database (Accession Numbers: MZ266347- MZ266364 for Cox1 and MZ265267-MZ265284 for 18S rRNA gene). Phylogenetic analysis was performed with sequences obtained in the present study along with the reference sequences, which were deposited in the GenBank database, using Maximum-Likelihood algorithm and Tamura-3-parameter model in the MEGA 6.0 software. The reliability of the phylogenetic trees was supported with bootstrap value based on 1000 replications.The sequence results were edited and trimmed using Chromas version 2.01  and compared to the GenBank database using the BLAST programs (D. immitis was found in 10 of dogs (55.6%) and eight of jackals (22.9%) . The rate of infectivity in male and female dogs was 53.8% (7/13) and 60% (3/5), respectively, and was no statistically significant (P > 0.05). In addition, in jackals, 20% (4/20) of the males and 26.7% (4/15) of the females were infected with the D. immitis and no statistically significant difference was seen between the infection and the gender (P > 0.05). Only three (8.57%) of 35 jackals were puppies and the remaining 32 (91.43%) were adults. All of 18 dogs were adults, as well. One of three jackal puppies and seven out of 32 adult jackals were infected with heartworm  and 6.7% (1/15), respectively. A statistically significant difference was found between the two provinces regarding infection rates of dogs (P = 0.043); but not jackals (P > 0.05).In Guilan province, 75% (9/12) of dogs and 35% (7/20) of jackals were infected with Male and female heartworms were identified based on the body length and morphological characteristics. Male worms are shorter than female and their coiled posterior end shows the presence unequal spicules and pre-anal papillae, but the females are larger and straight on both ends Fig. . The ranD. immitis obtained from this study was 0% based on the partial Cox1 and 18S rRNA genes. The intra-species distance rate within our sequences of D. immitis and those available in the GenBank amounted to 0–0.7% and 0–2.9% for Cox1 and 18S rDNA fragments, respectively. Inter-generic differences based on the partial Cox1 gene between our sequences of D. immitis with D. repens, Railliet & Henry, 1911 (Spirurida: Onchocercidae), Acanthocheilonema viteae, Krepkogorskaja, 1933 (Spirurida: Onchocercidae), Loa loa, Cobbold, 1864 (Spirurida: Onchocercidae), Brugia malayi, Brug, 1927 (Spirurida: Onchocercidae), and Wuchereria bancrofti, Seurat, 1921 (Spirurida: Onchocercidae) were 10–10.3%, 16%, 12.5%, 17.1% and 15.2%, respectively. Also, the nucleotide divergence based on the partial 18S rRNA gene between our sequences of D. immitis with D. repens, B. malayi, W. bancrofti, L. loa, Onchocerca cervicalis, Railliet & Henry, 1910 (Spirurida: Onchocercidae), A. viteae, and A. reconditum, Grassi, 1889 (Spirurida: Onchocercidae) was 3–3.3%, 3.1%, 3%, 3.1%, 3.1%, 3.6% and 3.7%, respectively.The genetic divergence within the specimens of Cox1 gene indicated our sequences of D. immitis, obtained from jackals and dogs (MZ266347-MZ266364), presented 100% homology with D. immitis isolated from dogs (KR870344 and KT960976), cat (KT282097), jackal (KT351851), and human (MH920260) in Iran, dog isolates of D. immitis from Thailand (MK250759 and MT027229), Italy (FN391553 and AM749229), China (EU159111) and Australia (AJ537512), jackal isolate from Italy (DQ358815), fennec fox isolate (MN945948) from USA and also Culex pipiens Linnaeus, 1758 (Diptera: Culicidae) isolate (LC107816) from Spain. In addition, our sequences had 99.3–99.6% and 99.5% similarity with dog isolates of D. immitis from Thailand  and Italy (AM749228), respectively. The phylogenetic construction based on the Cox1 gene illustrated that all D. immitis isolates obtained in this study placed along with other isolates of D. immitis from different hosts and countries in one major clade with high statistical support  had 100% similarity with D. immitis isolated from dogs in Japan (AB973230 and AB973231) and French Guiana (MN795081). Also, the sequences presented 99.9% with dog (MK673810) and re fox (MK673809 and MK673810) isolates of D. immitis from France. Additionally, our sequences had 97.1% identity with mosquito isolate of D. immitis (AF182647) from USA. According to phylogenetic analysis based on the 18S rRNA gene  and Mazandaran (50%) provinces in the southern coasts of the Caspian Sea [D. immitis varies among different regions of the world due to some epidemiological factors, such as the distribution of the mosquito species, mosquito population density, environmental temperature, dog population density, and age of host [This study updates our understanding about the situation of pian Sea . These ppian Sea . The lowpian Sea , Tehran pian Sea , Lorestapian Sea , Kermanspian Sea , and Tabpian Sea  could bepian Sea . The pre of host .D. immitis was detected in 22.9% of road killed jackals. This parasite has previously been reported in 8.9% (4/45) golden jackals from North Khorasan, northeast Iran [D. immitis in jackals (Canis aureus) has been reported in some European countries [D. immitis was also detected in 7.32% of jackals [In this study, ast Iran . In a si in 8.9% /45 goldeountries . The hea jackals . This wiD. immitis in dogs was significantly higher than jackals. Similar to our finding, Vafae Eslahi et al. (2017) showed that heartworm infection in dogs (25.9%) is higher than golden jackals (9%) in northern Iran [D. immitis infection in jackals (8.9%) was much higher than dogs (0%), and foxes (0%) [The present study revealed that ern Iran . Howeverxes (0%) . Likewisxes (0%) .D. immitis and sex in both dogs and jackals. Similar findings were indicated in most other studies on dogs [The results of this study showed that there was no statistically significant difference between infectivity with  on dogs , 43–46 a on dogs . Meanwhi on dogs , 47.D. immitis in dogs was significantly higher found in Guilan province. Also, the infection rate in jackals of Guilan province was more than Mazandaran; however, the difference was not statistically significant. Similar to our results, other studies also reported a significantly higher rate of heartworm infection in dogs in Guilan province than Mazandaran province, both located in the southern coasts of the Caspian sea [In the present study, pian sea , 21. AltD. immitis isolates obtained from dogs and jackals based on the Cox1 and 18S rRNA genes. Comparisons of our sequences and those available in the GenBank showed that the interspecific variation of the 18S rRNA gene (0–2.9%) is higher than Cox1 gene (0–0.7%).In last few decades, DNA sequence-based methods have been widely applied as useful tools to assess genetic variations, identification, classification, and phylogenetic analysis of filarial nematodes , 48, 49.Cox1 gene illustrated that our samples clustered with the major D. immitis group consisting of isolates from different hosts and geographically areas in European, Asian, and South American continents. Our Cox1 sequences had 100% similarity with most previously reported D. immitis sequences from Iran and other countries including Thailand, Italy, China, Australia, Spain, and the USA. Within this major clade, only four isolates form Thailand and Italy exhibited 0.4–0.7% differences to our sequences. This finding along with other studies [Cox1 gene among D. immitis isolates in various geographic locations.The phylogenetic tree based on the  studies , 48 indiD. immitis in the GenBank are low; however, the phylogenetic analysis showed that our sequences were grouped with 100% identity with dog isolates from Japan and French Guiana. Moreover, the pairwise homology analysis revealed a single nucleotide polymorphism (SNP) (T/C) in dog and fox isolates from France, which was responsible for separating them in the tree.Available 18S rRNA sequences of D. immitis in dogs and jackals in northern Iran. Consequently, the transmission risk of the filarial nematode with zoonotic potential must be informed to physicians and veterinarians in the regions. Hence, it is recommended that an accurate and consistent screening and treatment program should be conducted among dogs in the study area. Our study provided the genetic structure of D. immitis based on both Cox1 and 18S rRNA genes, with no polymorphism found among the two canids in the different geographic locations. Providing additional genetic markers as well as obtaining more isolates from various geographical region would be useful for gaining a better understanding of genetic variation among populations of D. immitis.The results of the current study confirm high prevalence of


Components of intensive care include resuscitation, cardiorespiratory stabilization, reversal of organ/system dysfunction or failure, treatment of the underlying pathology, weaning from external support of vital organs, and supportive interventions  aimed at paving the way to an uneventful recovery and rehabilitation. Depending on patient values, goals and preferences, the holistic intensive treatment(s) may be limited or withdrawn and replaced/followed by end-of-life care interventions for the prevention or alleviation of any distressing symptoms  .https://gdt.guidelinedevelopment.org, accessed on 30 May 2022) [Current treatment recommendations for specific subgroups of critically ill patients are based on a systematic and rigorous evaluation of published evidence, including the results of randomized controlled trials (RCTs). When the Grading of Recommendations, Assessment, Development and Evaluation approach is adopted, evidence quality is rated as high, moderate, low, or very low and evidence profiles (summaries) are generated using the online Guideline Development Tool (ay 2022) .2O during low-tidal volume ventilation in ARDS [Over the past decade, and especially over the past 3 years of the coronavirus disease 2019 (COVID-19) pandemic, several potentially beneficial interventions were tested in multicenter RCTs. Relevant published evidence has already been partly systematically reviewed and/or meta-analyzed. Pertinent, prominent examples include (1) noninvasive techniques of respiratory support , prone positioning (for ≥16 consecutive hours per day with lung-protective ventilation) and veno-venous extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS) of varying severity ,8,9,10;  in ARDS ; (3) adj in ARDS ,14,15,16 in ARDS ,18,19;  and the tidal volume to end-expiratory lung volume ratio  in severe ARDS ,36. In c2 , and the2 .During the COVID-19 pandemic, intensive care practice was guided by the prompt issuance of guidelines including recommendations based on both direct and indirect  evidence  and by aThe COVID-19 mass casualty crisis and dismal outcomes of severe CARDS have also prompted the introduction and/or preliminary evaluation of interventions such as awake prone positioning and pronation during ECMO, respectively. Recent physiological data suggest that awake pronation may reduce the respiratory rate and work of breathing in CARDS patients supported by continuous positive airway pressure . HoweverThe COVID-19-associated, compelling need for new and effective life-sustaining and curative interventions in the presence of periodic healthcare systems’ saturation has also prompted the issuance of ethical guidelines including evidence-based recommendations about advance care planning, shared decision making, and rationing of resources ,48. EthiThe current special issue on “Key Advances in the Treatment of the Critically Ill” primarily aims to highlight major aspects of the rapidly evolving knowledge of the mechanisms and pathophysiology of critical illness (including COVID-19), and the rapidly accumulating evidence on the efficacy of new life-sustaining and/or therapeutic interventions. Reports on the ethics of end-of-life decisions and practices are also encouraged.