Although infantile fever is harmless in most cases, many parents feel insecure when having to deal with it because important information is often missing. For educational purposes, an information video on fever in children was developed, which is also intended to serve as an onboarding element of a health app. The aim of the present work was to record the attitude of parents and adults on the topic of fever before and after the presentation of the information video, as well as its evaluation.Between May and November 2020, a total of 123 adults from three groups with different backgrounds  were interviewed using a questionnaire that was completed before and after the one-time presentation of an educational information video clip.Several significant outcomes were recorded in attitude change toward managing fever, with no significant difference between groups. After viewing the informational video clip, 74% of participants would take body temperature rectally more often. In the after-questionnaire, 83% of participants agreed that they would now be more cautious about using fever-reducing medications. Before the video clip, 75% of the participants thought fever was “rather useful”; after, 93%. The level of temperature played a minor role as a reason for fever reduction. The information content and quality of the video were rated positively.  This study shows that a short information video is capable of bringing about a subjectively perceived intentional change in the attitude to dealing with fever, motivating a change in behavior, and reducing uncertainty in dealing with fever. Since the change in attitude was measured immediately after viewing the video clip, no statement can be made about the medium to long-term effect.The information video clip can be classified as a short-term fever education tool for which at least short-term effective is demonstrated. Long-term and possible synergistic effects when integrated into a health app with further information still needs to be investigated. With the entry into force of the “Digital Health Care Act” (DVG) on December 19, 2019, the “app on prescription” for patients was introduced into health care. This means that approximately 73 million insured persons in the statutory health insurance system are entitled to a supply of Digital Health Applications (DiGA). There is a complex field of tension arising from the diverse possibilities of the technology and the different interests of the many stakeholders. At the same time, however, it is also becoming clear how great the benefits of mobile technologies are when they are used appropriately  shows information about fever in cartoon style (see figure 1 The 4:19 minute video clip  meaningful” , while another comment indicated just the opposite. The question “Did the clip change anything in your attitude towards fever?” was answered yes by 58% of the TN; in the corresponding free text field “Yes and indeed” mainly knowledge about symptoms and behavior in fever, as well as a more relaxed attitude towards fever and less fear were mentioned; the latter in the sense that “fever can be seen as something positive”. Overall, 80% of responding TNs indicated basic interest in a health app on the topic of fever. When asked what the participants would use such an app for, they indicated “safety in dealing with fever/symptoms”, “valid information about fever”, “warning of possible dangers and recommendations for action (e.g. visit to the doctor/physician)”.The study shows that a short informational video clip is able to bring about an intentional change in attitude towards the management of fever. The effect of the video is reflected in the significant changes in the responses, as well as in the comments of the free text fields. However, an overall score in the sense of a primary endpoint cannot be formed for this, since there is no weighting basis of the individual items to be aggregated, accordingly they are considered individually and categorically. In 58% of the TN, the video intervention led to a general change in attitude towards fever, 83% would now be more reluctant to “use antipyretic drugs such as paracetamol or ibuprofen” on their own initiative, and fever was finally rated as rather useful by almost all (98%). The TNs also developed a greater awareness of the symptoms for which medical consultation is necessary. Overall, TNs were less likely to reduce fever quickly, and if they did, they were also significantly more open to using less invasive home remedies to reduce fever or increase comfort, such as calf wraps or foot baths. Antipyretics, which are often used too uncritically . The vidIn recognizing possible warning signs, significant changes can be seen in some cases: before the video, 72% of the TN would have sought medical advice for “skin rash”; this figure increased to 89%. However, other studies have shown that the educational use of media such as videos alone is not very effective; instead, they would need to be embedded in an educational program . Video iIt is interesting to note that there was no significant difference in the increase in knowledge between the groups. It is possible that the video clip can convey its information content regardless of the previous education of the audience, which would need to be verified with the participation of people from further educational levels. Since this study asked, among others, young students, almost half of whom (47%) are in advanced semesters in the field of human medicine, it could be assumed that this group has an above-average health literacy. Nevertheless, an increase in knowledge could also be recorded among the medical students, just as in the other groups. Only three out of 45 students had children, which could also have an effect on the response behavior. For the other two groups, it should also be noted that most of the TN were childless, with a total of only 29 parents among the TN. The recruitment of parents for this study proved to be particularly difficult, as contact restrictions due to the Corona pandemic meant that no parents' evenings took place at schools and kindergartens, where they were originally supposed to have taken place.The video was positively evaluated by the participants. The pace of the video was designed to make the information accessible to as many people as possible. Since many of the participants presumably have a high level of health literacy through their studies, the increase in speed desired by some medical students could have a negative impact on the accessibility of the video for people with lower health literacy. In this case, the inclusion of additional groups would be useful.The change in attitude was recorded immediately after viewing the video. Here it would be interesting to see whether this also remains constant over a longer period of time. However, it should be noted that the video clip should be viewed as one component of a more complex health app, which was studied in isolation in this case. It can be assumed that parents will take advantage of the opportunity to watch the video clip repeatedly as needed, thus reinforcing the learning effect. Especially if the information thematized in the video clip, in the case of a feverish child, can be applied immediately. The video clip was thus viewed in a neutral test situation, while it may be that parents with acutely feverish children would absorb the information offered with increased attention. The app already offers the video clip during onboarding. In case of fever, it can be watched again. In the future, further observation of the parents' behavior metadata within the app will be of interest in order to discuss in which specific situations the video is used and whether any further effects are discernible, as well as to verify the previously mentioned statements.Under the conditions of the COVID-19 pandemic, recruitment of subjects was extremely difficult, which meant that the number of TN in the subgroups was not large enough to illuminate representative comparisons between the groups in depth. Accordingly, these had to be combined into an overall cohort, reducing the breadth of possible conclusions. The effect of the video was measured immediately after the first viewing, this is a narrow sample and does not allow statements about a possible long-term effect, which may well be relevant when asking about attitude change. In addition, the attitude is asked purely by self-assessment, which entails a structural subjectivity, a possibility to balance this would be behavioral observation in a controlled setting, which was not possible under the given circumstances.In summary, the video clip on the management of fever provided a significant gain in knowledge and an intentional change in attitude. Thus, a tool was created that successfully communicated contextually relevant information related to childhood fever. The educational video clip is easily accessible, engaging, and subject to self-direction, allowing it to be accessed whenever needed. It can be described as an effective fever education tool. The synergistic effect by integrating it into a health app with further information should be further explored.https://www.sagst.de/]; 80% Federal Ministry of Education and Research (BMBF) (Fkz: 01GY1905) [https://www.gesundheitsforschung-bmbf.de/de/fieberapp-register-aufbau-eines-registers-zur-information-und-selbstdokumentation-der-9014.php]. The funding is composed of: 20% Software AG Foundation [All described studies and evaluations were performed with the approval of the responsible ethics committee of the University of Witten/Herdecke (application no. 139/2018), in accordance with national law, and in accordance with the Declaration of Helsinki of 1964 .The authors declare that they have no competing interests.


Palliative care adds significant burdens to healthcare workers. In neuropalliative care (NPC), additional challenges include patient symptom burdens, such as impairments in mobility, cognition, and communication. After one year of operating the first NPC ward in Germany, we assessed burdens, resources, and the number of deaths perceived as stressful. NPC physicians and nursing staff were compared with the team of other neurological wards, including a stroke unit. The assessment took place between March 2022 and May 2022. All 64 team members were contacted; the responder rate was 81%. The perceived burden was high but did not differ between groups. There were no differences between the NPC- and the neurological wards in the number of deaths perceived as stressful. However, rather than the number of deaths, the circumstances of dying influence the perceived distress. The resources mentioned were similar between groups, with the team and private life being most important. Communication difficulties were frequently cited as stressful, whereas successful communication was identified as a resource. Palliative care becomes increasingly relevant as the number of patients suffering from advanced incurable diseases increases due to demographic change, longer life expectancy, and improved medical care . This alIn Germany, burdens and protective factors of palliative care teams were studied in 2009 by Müller and colleagues, and in 2020 by Ateş and colleagues ,13. In 2However, these factors have not been investigated in NPC teams so far. Here, we investigated whether pooling of neurologically severely ill patients in a NPC ward puts particular demands on healthcare workers in comparison to teams on other neurological wards, including a stroke unit. We assessed the relevance of and responses to stress factors, including the number of deaths per week, and resources for day-to-day work. p-values less than 0.050 were considered statistically significant. Where necessary, significance levels were corrected for multiple testing using Bonferroni correction.We surveyed physicians and nursing staff on the NPC ward and the other neurological wards, including the stroke unit (neuro ward) of the Department of Neurology, Campus Virchow-Klinikum in Berlin (Germany), between March 2022 and May 2022. Approval was given by the human resources department (Charité–Universitätsmedizin Berlin). A slightly adjusted version of the questionnaire by Ateş et al.  was usedp = 0.1). However, the mean experience in palliative care was significantly higher on the NPC ward . Most survey participants worked full-time. Respondents worked 5.5 h of overtime per week, with no difference between groups (p = 0.8). About one-third of the respondents of both groups lived alone, and 20-30% were involved in the care of relatives. A statement about the age or sex distribution cannot be made because anonymization precluded the evaluation of these demographic variables.Overall, we contacted 64 persons, 23 working on the ward for neuropalliative care (NPC ward), and 41 working on other neurological wards, including the stroke unit (neuro ward). Fifty-two (=81%) persons completed the questionnaire. The response rates were sufficient for valid team analysis, with 87% on the NPC ward and 78% on the neuro ward. For a detailed sample description, see p = 0.106). However, nearly one-fourth of all team members noted that rather than the number of deaths, the circumstances of dying were of greater importance for stress prevention. One team member stated: “Accompanying dying patients, provided that the therapy concept had been discussed well, is an honor that fills me with pride.”The mean number of deaths per week that was personally endurable without becoming overburdened did not differ . The most burdening factors on both wards differed only slightly. The factors perceived as “much” or “very much burdening” by at least one-third of both teams are shown in Too little staff”, “High documentation effort”), excessive demands on one’s own work , therapy-associated factors , lack of time in various contexts , as well as social/communication factors “Particularly difficult relationships with patients and relatives”, “Communication difficulties”, and “Conflicts in the (affected) families”.We measured potential burdening factors on an organizational, personal, collegial, and patient- and relative-specific level . OverallToo many patients” , “No time to address wishes and problems of those affected” , “Socially isolated patients” , “Low/lack of family support” , and “Patients with good prognosis rejecting suggested therapies” . Neither team felt (very) much burdened with “Too few patients”, less than one-fifth with “Feelings of guilt” and “Accompanying deceasing patients for too short a time”, and less than one-fourth with an “Accumulation of deaths” and “Memories of deceased persons in their own environment”.Regarding the significant differences in perceived burden, the NPC team was less burdened with “n = 8, neuro ward n = 5) considered dealing with patients with amyotrophic lateral sclerosis (ALS) to be personally burdening, and, nearly similarly frequently, tumor diseases . Less frequently (n = 3 in each group), care for patients with dementia was considered personally distressing.Only a few respondents took the opportunity to specify diseases that they found difficult to care for. Of these, 13 . On the NPC ward, nearly three-quarters stated that they rarely or never had to take on too much responsibility, while on the neuro ward, over two-fifths had to do so sometimes, and nearly a quarter often or always. In contrast, around half of the respondents of each group sometimes “Wished for more responsibility”. “Interprofessional work meets expectations” often or always in 60% of the respondents of the NPC ward, and only in 37% of the neuro ward. On the NPC ward, nearly two-thirds of the respondents never or rarely “Failed to partake in educational opportunities due to lack of resources,” while on the neuro ward, nearly one-third failed to do so often, and one-quarter each sometimes or rarely. For detailed results, see Overall, there was a high “p = 0.091). In both groups, the most frequent symptoms were “Work-to-rule”. “Excessive talkativeness”, “Irritability”, and “Accusations”. The overall least frequently shown symptoms in both wards were “Crying”, “Refusal of new admissions”, and “Lack of involvement with other or new patients”. Regarding the differences between both groups, “Increased interprofessional tensions” occurred less often on the NPC ward .We measured symptoms of stress possibly shown/exhibited when faced with death . Overallp = 0.55); for detailed results, see Team”; “Humor”; several aspects of “Private life”, such as “Family”, and “Meeting friends”; and “Experiencing nature”. “Supervision”, “Offers for self-care”, “Worldview/faith”, “Empathy of others”, and “Team activities” were rated as (very) important in around half of the cases. “Rituals” and the “Team” seemed to be non-significantly more important on the NPC ward, whereas “Sports” was non-significantly more important on the neuro ward.There were no significant differences in individual resources across both groups . In the neuro team, over half of the respondents perceived the conditions as unchanged  improved conditions significantly more often than the neuro team (nchanged C.Rushed respectively under time pressure” and “Completely exhausted after work” (very) often . Overall, 40% (NPC ward) and 44% (neuro ward), respectively, reported that “Sleep disturbances” occurred (very) often. In total, 35% of the respondents on both wards felt “Depressed” and had “Physical pain” (very) often. However, around one-third felt “Calm and balanced” and had “Lots of energy” (very) often .There were no significant differences in physical and mental distress symptoms within the last four weeks between the NPC ward and the neuro ward . OverallIn Germany, burdens and protective factors of palliative care teams were studied in 2009 by Müller and colleagues and in 2020 by Ateş and colleagues ,13. So fIn 2009, the original idea behind the survey of palliative care units in Germany was the question of how much death a team can tolerate . The meaSense of purpose at work” on the NPC ward was slightly less pronounced than on the palliative care wards in Ateş et al., and the teams on both wards were less “Satisfied with their jobs” than the teams on the palliative care wards surveyed by Ateş and colleagues (95–98%) [unmanageable workload”. To improve satisfaction and the subjective workload, more control and self-determination of the employees of the job-demand-control model could be helpful. How those aspects can be implemented in an inpatient context remains to be discussed. “Not being able to take part in educational offers due to lack of resources” did not appear to be a major problem on either ward. Despite the high relevance given to interprofessional work in palliative care [Satisfaction with interprofessional work” did not differ significantly between the two wards. However, “Excessive responsibility” occurred less frequently on the NPC ward and on the palliative care wards in Ateş et al. [The “(95–98%) . Furtherive care , “Satisfş et al. .Communication difficulties” should be specified through qualitative studies, communication skills ought to be improved through in-service training, and regular multidisciplinary meetings must be implemented [Difficult relationships with patients and their relatives” should obtain a more prominent role in the education of healthcare professionals. Regarding the “Documentation effort”, the relevance of the documentation needs to be made clear, and double documentation should be eliminated. To make work more efficient and free up more “Time”, inefficient processes should be identified and optimized, and digital solutions should be implemented where possible. Undergoing the additional palliative care qualification might reduce therapy-associated burdening factors on a (neuro)palliative care ward. “Demands on one’s work” should be regularly made aware of and compared with reality. Diverging demands should be communicated and worked on, as excessive demands are known stressors that can lead to a gratification crisis , less job satisfaction, and ultimately poorer health [Too many patients” and “No time to address wishes and problems of those affected” was lower on the NPC ward not only compared to the neuro ward but also the palliative care wards in Ateş et al. [Socially isolated patients” and “Low/lack of family support”. In Ateş et al., the staff of the palliative care wards was also similarly less burdened with that than the staff of the other services. This difference and its cause should be further investigated.The staff of the NPC ward was not more burdened than the staff of the neuro ward, which is consistent with the existing literature. However, similar to the literature, our survey also showed a high overall sense of burden ,9,10,11.lemented . Furtherr health . Consistr health . Qualitaş et al. . Since tExcessive talkativeness” and “Irritability” were among the most frequently occurring symptoms in the 2009 and 2020 surveys by Ateş and Müller and colleagues, and the former in a 2007 U.K. study [Work-to-rule” seemed to be a greater issue in our sample than in the wards questioned by Ateş and Müller and colleagues [Increased inter-professional tensions” occurred less frequently on the NPC ward than on both our neuro ward and the wards surveyed by Ateş and colleagues [With few exceptions, the team reactions to the burden of deaths were similar across both wards, especially the most common ones. “K. study ,13,17. Hlleagues ,13. “IncFeeling rushed” and “Feeling completely exhausted after work”, were consistent with previous results of Ateş and colleagues [Feel calm and balanced” and “Full of energy” [All surveyed physical and mental distress symptoms occurred (very) often in over one-third of the participants within the last four weeks, and there were no differences between the two wards. The most common symptoms, “lleagues . However energy” .Team activities outside working hours” were only considered as (very) important by about half of the respondents, but team activities could be included in working hours, as “The team” itself was one of the most important resources. They could, for example, be combined with “Rituals”, also a relevant resource indicated. Possible scenarios would be regular joint breakfasts or a joint farewell to deceased patients. “Private life” should be empowered; no permanent accessibility should be required, and precise substitution schedules for absences should exist. “Experiencing nature” could be supported by outdoor team activities or cheaper and easier access to public transport. A green area of retreat could also be created for the staff, such as a balcony or terrace. Interestingly, on the NPC ward, “Supervision” was rated as (very) important by only half of the respondents, while on the palliative care wards in Ateş et al., more than 90% felt this way [Supervision” was repeatedly reported to be an essential source for personal and team well-being [Nearly half of the respondents on both wards regarded every surveyed resource as (very) important, which supports the relevance of the resources queried. Again, the most important resources barely differed, neither between the NPC ward and the neuro ward nor between the NPC ward and the palliative care wards surveyed by Ateş et al. . These rthis way . This dill-being ,19.There were no significant differences in the estimated consistency of the respective team. However, Ateş et al., found that the team tended to be considered slightly more sustainable . The devOverall, the results must be interpreted with caution. Due to the study’s small sample size and monocentric structure, there is relevant potential for type 2 errors, and there were unmeasured possible confounders . In addition, statistically significant results must be interpreted in consideration of multiple testing; we included the Bonferroni-adapted significance levels to adjust for type 1 errors.However, in the absence of other neuropalliative care units in German-speaking countries, there was no possibility of increasing the sample size, and, as our sample was small, anonymization could not have been guaranteed when collecting more sociodemographic data. The questionnaire only surveyed the subjective perception, which does not depict the objective situation. However, subjective perception can relevantly influence and predict physical and mental health .Since the surveyed NPC ward was operated for one year only and compared to established wards, the results may be reevaluated in another survey after a longer period of operation. When comparing the results to the studies by Müller and Ateş and colleagues, one has to consider that they also surveyed other professional groups and volunteers and that three-quarters of respondents worked part-time . HoweverThe NPC team was not more burdened than the team of the neurological ward, including the stroke unit. Although work was generally considered meaningful and often satisfying, the overall perception of burden was high in both groups. Relevant burdening factors should be identified on a regular basis to be able to address them before relevant overload occurs. The circumstances of death seem to be more relevant than the number of deaths alone. Similar resources were identified that need to be empowered. Communication is simultaneously a relevant burdening factor and a potential resource. Measures should be taken to strengthen communication skills and encourage effective and appreciative communication within a multiprofessional team and with patients and their relatives.


Gut-associated protozoa are a heterogenous group of microbes that frequently reside within humans. The role of commensal intestinal protozoa and their interaction with the human organism is a highly complex topic, and an area of research that has been largely neglected. We argue that some protozoa species might be beneficial inhabitants of the gut that can significantly impact human health and disease. Here, we aimed to comprehensively review existing literature on the conflicting outcomes of protozoa colonization, their interaction with the bacterial microbiota, and the crosstalk between the protozoa and the host immune system. Moreover, we emphasize the importance for future studies to investigate these aspects of protozoa colonization that will undoubtedly increase our understanding of complex interactions between intestinal protozoa, other microbiota organisms, and the human host.The human gastrointestinal microbiota contains a diverse consortium of microbes, including bacteria, protozoa, viruses, and fungi. Through millennia of co-evolution, the host–microbiota interactions have shaped the immune system to both tolerate and maintain the symbiotic relationship with commensal microbiota, while exerting protective responses against invading pathogens. Microbiome research is dominated by studies describing the impact of prokaryotic bacteria on gut immunity with a limited understanding of their relationship with other integral microbiota constituents. However, converging evidence shows that eukaryotic organisms, such as commensal protozoa, can play an important role in modulating intestinal immune responses as well as influencing the overall health of the host. The presence of several protozoa species has recently been shown to be a common occurrence in healthy populations worldwide, suggesting that many of these are commensals rather than invading pathogens. This review aims to discuss the most recent, conflicting findings regarding the role of intestinal protozoa in gut homeostasis, interactions between intestinal protozoa and the bacterial microbiota, as well as potential immunological consequences of protozoa colonization. The mammalian gut harbors a vast number of viruses, bacteria, fungi, and protozoa (single-celled eukaryotes), collectively referred to as the microbiota . DynamicSince most studies have concentrated on gut-resident bacteria as the main component of the microbiota, the mechanisms and consequences of intestinal protozoa colonization have only recently begun to be clarified ,15,16,17Giardia lamblia, Entamoeba histolytica, and Cryptosporidium spp. are among the most common enteric protozoa parasites that significantly contribute to acute gastroenteritis and diarrheal disease globally [Blastocystis spp., Entamoeba spp., and various other protozoa genera in healthy individuals across human populations [Dientamoeba and Enteromonas are common residents of the human gut, at least in some parts of the world [globally ,32. Theiglobally ,34,35,36globally ,37. Lokmhe world .Blastocystis spp. is one of the most prevalent protozoa found in humans, with an estimated 1 billion colonized individuals worldwide [Blastocystis was predominantly characterized as a parasitic protozoa [Blastocystis has been associated with the etiology of irritable bowel syndrome (IBS) [Blastocystis, either in healthy subjects or IBS patients [Blastocystis infection has been inconsistently reported to be higher in either immunocompetent or immunocompromised individuals depending on the study [Blastocystis has mainly been investigated as a causative agent in disease propagation, with limited information about its distribution in a healthy population. With recent advances in sequencing technologies and an increased number of epidemiological surveys, it has become evident that the presence of Blastocystis is a common occurrence in both healthy and symptomatic individuals, which inevitably questions its alleged pathogenicity [Blastocystis subtypes (ST) have been identified, of which nine are found in humans (ST1-ST9), with ST1–ST4 accounting for up to 90% of all occurrences [Blastocystis subtype variation and pathogenic potential. For instance, ST2 was suggested to be a non-pathogenic type [Blastocystis subtypes and colorectal cancer (CRC) [Blastocystis ST1, 2, and 3 were observed between CRC and non-cancer individuals, a rare ST7 was identified in CRC patients [orldwide ,40. Histprotozoa , but conme (IBS) ,55,56,57me (IBS) . In contpatients ,60. Simihe study ,62. One genicity ,64. To durrences . Recent nic type , while Snic type ,68. A ster (CRC) . Althougpatients .Blastocystis have also been proposed. Colonization with Blastocystis is associated with higher microbial diversity and richness, both of which are suggested to benefit intestinal health [Blastocystis presence [Blastocystis is more common in healthy subjects than in patients with active IBD, IBS, or CRC, supporting that Blastocystis might be considered a component of the healthy intestinal microbiota [Blastocystis subtype prevalence and relative abundance in a Western population cohort. They found that 30% of the healthy population was Blastocystis carriers compared to only 9% in an IBD patient cohort, with a significant association between Blastocystis subtype and microbiota composition [Blastocystis alters the gut microenvironment in a protective manner, which may, in turn, promote faster recovery from intestinal inflammation [Blastocystis colonization can be partially attributed to some unexplored variables such as the diversity of intra-subtypes within a subtype, background microbiota composition, host genetics, and diet [At the other end of the spectrum, beneficial roles for l health ,70. Addipresence . Severalcrobiota ,71,72,73position . Moreoveammation ,76. The and diet .Blastocystis colonization on human gastrointestinal health is much more complex than originally envisioned, with the outcome depending on the context and the specific subtype of the protozoa. Thus, it is essential for future studies to elucidate and characterize the contrasting consequences of colonization of different Blastocystis subtypes.Overall, it is becoming evident that the impact of Blastocystis spp., colonization with Dientamoeba fragilis has been reported to exert conflicting roles in gut homeostasis. In contrast to other intestinal protozoa whose colonization prevalence is generally considered higher in the emerging nations, D. fragilis has been identified more frequently in the developed world [D. fragilis has frequently been associated with disease [D. fragilis colonization in healthy subjects compared to patients with digestive symptoms. Similar to the reported effects of Blastocystis colonization, a recent study by Rasmussen et al. showed that colonization with D. fragilis is associated with greater gut microbiota diversity compared to non-carriers [D. fragilis have been identified, with type 1 accounting for the majority of confirmed cases. There are minor phenotypic differences between the two subtypes and their distinction is solely based on genetic diversity. It should be noted that these subtypes have only recently been characterized and many studies have not differentiated between them. It remains unknown whether there is a difference in virulence and pathogenic potential among the two subtypes, which might explain the controversial reports regarding the consequences of D. fragilis colonization [Like ed world ,79. Howeed world . The pre disease , just as disease ,73,74. P disease , Denmark disease , and Bel disease , have uncarriers . Thus fanization .Entamoeba species, the majority of which are generally accepted as commensal organisms [E. histolytica, E. bangladeshi, E. dispar, E. hartmanni, E. moshkovskii, E. coli, and E. polecki, with E. histolytica as the only one with well-established pathogenicity [Entamoeba occurrence in humans is estimated at 3.5%. However, the prevalence of commensal Entamoeba spp. has largely been underestimated due to high morphological and genetic similarity with the invasive E. histolytica [Entamoeba organisms, is not always sufficient for differentiating between the invasive E. histolytica and non-pathogenic strains of Entamoeba [Entamoeba spp. is overall more common than infections with E. histolytica [Entamoeba spp. in asymptomatic subjects compared to cases with intestinal symptoms, with E. dispar identified as the predominant species [Entamoeba spp. display higher gut microbiota diversity [Entamoeba-colonized individuals show a shift in the microbiota composition towards a more eubiotic composition, characterized by a decrease of genera associated with autoimmune and inflammatory disease and a corresponding increase of species linked to beneficial effects on intestinal health [Other common intestinal inhabitants with a worldwide distribution are rganisms . Currentgenicity . The wortolytica ,84. Micrntamoeba . Increastolytica . A recen species . In agreiversity . Additiol health .Blastocystis. Therefore, their importance in human health and disease appears to be largely dependent on the characteristics of a particular species. Furthermore, assessment of the clinical significance of commensal protozoa species in humans relies on appropriate detection methods and accurate species differentiation [Overall, colonization with the above-mentioned protozoa species seems to be of commensal or beneficial nature, especially considering that their colonization is linked to an increase of microbiota diversity, as opposed to infections with pathogenic protozoa species, which often lead to decreased microbiota diversity . Howeverntiation . DNA-basntiation . On the ntiation . With rentiation .Blastocystis colonization is a higher abundance of specific taxa within Firmicutes, especially those from the Clostridia class, such as Ruminococcaceae and Prevotellaceae families, and a general decrease of Bacteroides abundance [Blastocystis carriers show a significant decrease of Enterobacteriaceae and Proteobacteria when compared to Blastocystis-free subjects [Proteobacteria and several species within the Enterobacteriaceae family can be considered “pathogenic” and linked to microbial dysbiosis associated with the development and pathogenesis of IBD [Blastocystis is strongly associated with the abundance of archaeal organisms, primarily Methanobrevibacter smithii [M. smithii has been shown to play an important role in human health, supporting the digestion of glycans through the removal of bacterial fermentation end products [M. smithii, together with members of the Faecalibacterium and Roseburia genera that are also enriched in Blastocystis-colonized individuals [Blastocystis- and Entamoeba- colonized individuals, has been associated with a healthy and balanced microbial ecosystem [Blastocystis selectively reduces the abundance of pathogenic bacteria and induces compositional changes to the microbiota that might be beneficial for the maintenance of intestinal homeostasis.The various communities of intestinal bacteria play a fundamental role in determining human health. It is generally suggested that high intestinal microbial diversity is a hallmark of a healthy and resilient gut microbiota . Emerginbundance ,74,92. Fsubjects ,71. Intes of IBD ,94,95. M smithii ,71,74. Mproducts . M. smitividuals ,70, incrividuals . Butyratividuals ,98. Butyividuals ,99,100. cosystem . This stBlastocystis colonization and eubiotic microbial profile have also been described. Several studies have reported a decrease of Bifidobacterium in individuals colonized with Blastocystis [Bifidobacterium spp. have been associated with homeostatic functions within the gut, including protection of the epithelial barrier and regulation of inflammation [Blastocystis exhibited markedly reduced abundance of the highly beneficial Akkermansia spp. compared to children that were Blastocystis-free [Akkermansia spp. and Bifidobacterium spp. in obese Blastocystis-colonized adults [Akkermansia spp. has emerged as one of the important health-promoting microbes, with functions spanning from maintenance of the gut lining to protection against inflammation [Blastocystis colonization has been associated with a decline of Lactobacillus spp. [Lactobacillus spp. in Blastocystis-colonized individuals [Blastocystis subtype. Of note, the importance of Blastocystis subtype characterization when investigating the relationship between Blastocystis colonization and gut microbiota composition has been recently emphasized in a study demonstrating an inverse association between Blastocystis subtypes and Akkermansia spp. relative abundance [Blastocystis ST3 showed a negative correlation, whereas Blastocystis ST4 was strongly positively correlated to Akkermansia and M. smithii abundance [Blastocystis ST4 was shown in a separate study to ameliorate colonic inflammation in murine colonization models via compositional changes to the gut microbiota that included expansion of Akkermansia, as well as modulation of host-immune responses [Blastocystis ST7 in diarrhea patients has been recently shown to be associated with decreased microbiota diversity and bacterial composition changes, characterized by significant enrichment of bacteria belonging to the Enterobacteriaceae family as well as Escherichia coli, compared to non-infected patients [Blastocystis colonization on gut microbiota composition and structure is subtype-specific, highlighting the importance of Blastocystis subtype characterization in future studies.On the other hand, adverse associations between tocystis ,101. Bifammation . Accorditis-free . These rammation ,104. In lus spp. , Caudet bundance . Blastocbundance . Accordiesponses . Furtherpatients . These rD. fragilis colonization is limited. However, a study conducted in Denmark investigating the microbial profile in D. fragilis-positive children revealed 16 bacterial genera that were significantly more abundant in colonized children [D. fragilis carriers were Victivallis, Oscillibacter and Coprococcus, whereas Flavonifractor was enriched in non-colonized children. After the removal of D. fragilis by metronidazole treatment, the abundance of Flavonifractor increased while other bacteria, such as Coproccocus, were reduced in previously colonized children that were cleared of D. fragilis. Evaluating microbiota composition after metronidazole treatment should be done cautiously since this drug is effective against most anaerobic bacteria [Flavonifractor, which kept increasing in children that lost D. fragilis [Flavonifractor has frequently been associated with disease due to its ability to degrade beneficial anti-carcinogenic flavonoids [Flavonifractor plautii in the intestinal microbiota has been identified as the key bacterium associated with sporadic young-onset CRC [D. fragilis appears to be linked to beneficial changes in the composition of gut bacteria, thus potentially exerting protective effects against dysbiosis-related diseases.Research on microbiota composition associated with children . Some ofbacteria . Howeverfragilis . Flavoniavonoids . Recentlnset CRC ,108. TheEntamoeba spp. results in increased microbiota diversity and compositional changes, characterized by an increase of Firmicutes taxa, such as Ruminococcaceae, coupled with a significant decrease of Bacteroides [Firmicutes to Bacteroides causes loss of microbial diversity as well as dysbiosis linked to the progression of IBD, CRC, and type 2 diabetes [Entamoeba coli exhibit a significant enrichment of Akkermansia in their gut microbiota compared to non-colonized children [Coprococcus and Alistipes was observed in colonized children [Coprococcus is an important anaerobic and butyrate-producing bacterium [Coprococcus has been implicated in the pathogenesis of CRC [Coproccocus, as well as other butyrate-producing bacteria, play an important role in language development and cognitive functions in preadolescent children [Colonization with teroides ,86. Intediabetes ,110. Recchildren . Moreovechildren . Coprocoacterium , and decs of CRC . Furtherchildren .Cryptosporidium, where increased infection severity corresponded with a decreased level of fecal SCFA content [Together, these studies indicate that commensal gut protozoa significantly remodel the intestinal bacterial niche, potentially creating a favorable microenvironment beneficial for the host. A common observation across the different protozoa species seems to be an enrichment of SCFA-producing bacteria. Importantly, this is in contrast to what has been demonstrated for pathogenic protozoa, e.g.,  content .Cryptosporidium [However, it is mechanistically unclear how protozoa influence bacterial composition in the gut microbiota. The possibilities include direct modulation e.g., via preferential feeding on specific bacterial species or secretion of metabolites that modulate the fitness of specific bacteria ,115. On poridium . This suResearch studies describing the interaction between commensal protozoa species and the mammalian immune system are scarce. Most of the available reports are based on in vitro studies as well as animal models. Although these likely do not fully reflect human (patho)physiology, they still provide valuable insights into potential immunological consequences of intestinal protozoa colonization.Blastocystis ST4 attenuates colonic inflammation in a dextran sulfate sodium (DSS)-induced colitis mouse model via induction of T helper (Th) 2 cells and T regulatory (Treg) cells [Blastocystis ST4 showed a decrease of tumor necrosis factor-α expressing (TNF) CD4+ T-cells and an upregulation of signature Th2 cytokines interleukin (IL)-4, IL-5, and IL-13, as well as the anti-inflammatory cytokine IL-10 [Ruminococcaceae and Roseburia, was observed following Blastocystis ST4 colonization. Analysis of the SCFA content in feces from colitic mice that had received fecal matter transplant from Blastocystis ST4-colonized mice revealed enrichment of 6 SCFAs  compared to mice that received fecal matter transplant from Blastocystis-free mice [Foxp3 locus in CD4+ T cells. Moreover, butyrate was shown to induce gene expression changes in dendritic cells, characterized by decreased expression of pro-inflammatory cytokines and, consequently, prompting Treg differentiation [Recently, it was shown that colonization with g) cells . Mice cone IL-10 . Additioree mice . Importaree mice . SCFAs iree mice ,131. SCFree mice . It has ntiation . Thus, oBlastocystis ST4 could decrease the growth of the common pathogen Bacteroides vulgatus by inducing reactive oxygen species and the expression of genes associated with oxidative stress. Moreover, a significant reduction in intestinal epithelial permeability was observed in co-cultures with Blastocystis ST4, suggesting that this Blastocystis subtype protects the intestinal barrier from opportunistic bacterial species, at least in vitro [Tritrichomonas musculis (T. musculis), a commensal of the rodent microbiota and the closest ortholog to D. fragilis, can protect against the mucosal bacterial infection with Salmonella typhimurium via induction of intestinal epithelium-derived IL-18 and inflammasome activation. However, due to sustained inflammation characterized by increased numbers of IFN-γ-producing CD4+ Th1 and IL-17-producing Th17 cells within the colonic tissue, mice colonized with T. musculis were more susceptible to experimental gut inflammation and cancer [A recent in vitro study showed that in vitro . In agred cancer .Blastocystis ST7 has been suggested to have immunocompromising functions, and several potential virulence factors have been identified that could support the notion of pathogenicity. Antigens from Blastocystis ST7 have been reported to induce the mitogen-activated protein kinase-dependent expression of pro-inflammatory cytokines such as IL-1β, IL-6, and tumor necrosis factor, in macrophages, mouse intestinal explants, and colonic tissue [Blastocystis ST7 has a significantly higher activity of cysteine proteases compared to other Blastocystis subtypes. Cysteine proteases are a characteristic feature of parasitic protozoa  that have been shown to facilitate invasion of host tissue, as well as immune evasion [Entamoeba histolytica utilizes cysteine proteases for degradation of colonic mucins and extracellular matrix components that lead to separation of epithelial cells, consequently breaching the epithelial barrier and enabling the protozoa to invade the host tissue [Blastocystis ST7, no evidence of a similar mechanism has been found in other protozoa species thus far. While Blastocystis ST4 did not change the epithelial permeability, Blastocystis ST7 induced significant epithelial barrier disruption in epithelial cell lines as well as degradation of IgA [Blastocystis on immune modulation, with ST7 emerging as a major immune-compromising subspecies.On the other hand, c tissue . Further evasion . For inst tissue ,137. Addt tissue . Besidesn of IgA ,139. TakBlastocystis ST3 can protect from intestinal inflammation, but only after prolonged colonization time. Short-term exposure experiments, where rat colitis was induced 3 weeks post-colonization with Blastocystis ST3, revealed no difference on disease activity; in contrast, long-term exposure (13 weeks post-colonization) resulted in faster recovery and protection from colitis [Blastocystis ST3 supports a more balanced intestinal microbial ecosystem that is more suitable to control disturbances.Another important factor that has been often overlooked in experimental studies of protozoa colonization models is the dynamic temporal change that occurs to the microbiota and gut immunity. For example, it has been recently shown that  colitis . This miBlastocystis transmission have shown no adverse effects in recipients after colonization [Intestinal protozoa have co-evolved with humans, and their interactions with the human host seem to be highly dynamic and variable, with some species and subtypes exhibiting beneficial properties, while others manifest adverse immunomodulatory effects. The fact that many of these protozoa species cause dormant persistent colonization that often leads to life-long affiliation with their host, points towards commensalism or even symbiosis rather than parasitism. In line with that, colonization with intestinal protozoa appears to significantly increase the diversity of the gut microbiota and selectively modulate the composition of different bacterial communities. Some outstanding questions remain as to whether a therapeutic impact might be achieved by diversification of the human gut via controlled colonization with commensal protozoa strains or by FMT from protozoa-colonized healthy donors to patients with IBD or other gastrointestinal diseases. FMT is an emerging therapy with a successful track record against severe intestinal bacterial infections and a potential therapeutic candidate against diseases associated with microbial dysbiosis . Currentnization ,141. Inv


Orthostatic Hypotension (OH) and malnutrition, are common health problems in elderly hypertensive patients. This study aimed to analyze the relationship between malnutrition and OH in elderly hypertensive patients.This is a cross-sectional single-center study. All participants underwent a Comprehensive Geriatric Assessment (CGA), in which malnutrition was defined according to the Global Leadership Initiative on Malnutrition (GLIM) criteria based on four different methods of diagnosing muscle mass loss. Furthermore, the accuracy of these methods was verified by Receiver Operating Characteristic (ROC) analysis. Univariate and multivariate logistic regression analyses were used to identify risk factors for OH in elderly hypertensive patients.For GLIM criteria, when Fat-Free Mass Index (FFMI) was the gold standard for muscle mass loss, the Area Under ROC Curve (AUC) values for Upper Arm Circumference (UAC), Calf Circumference (CC), and Hand Grip Strength (HGS) were 0.784, 0.805, and 0.832, with moderate accuracy in diagnosing malnutrition. Multivariate analysis showed that females, Diabetes Mellitus (DM), diuretics, and malnutrition diagnosed by GLIM-UAC were risk factors for OH in elderly hypertensive patients.Prompt detection of malnutrition in the elderly and attention to changes in UAC may be critical. Similarly, we should strengthen medication and disease management in elderly hypertensive patients. According to the World Health Organization (WHO), the global population over the age of 60 will exceed 1.2 billion by 2025. The aging process in the elderly often leads to a degradation of the function of the blood pressure regulatory system, which results in a significant increase in the incidence of Orthostatic Hypotension (OH) . AvailabMoreover, malnutrition is an important geriatric syndrome, which refers to insufficient, excessive, or abnormal nutrient intake, resulting in incompatibility with the body’s nutritional needs, adversely affecting the body’s morphological functions, and ultimately leading to adverse events such as sarcopenia and frailty –13. In aMalnutrition and malnutrition risk were risk factors for OH in a study using a Mini-Nutrition Assessment (MNA) as a diagnostic method . And it Our observational study was conducted at the Zhejiang Hospital, Hangzhou, China, from 15 to 2015 to 18 February 2020. According to the Declaration of Helsinki, each subject provided written informed consent before conducting this study.All patients completed the Comprehensive Geriatric Assessment (CGA), which involved an investigation of disease and medication history. Disease investigations included OH, HTN, Coronary Heart Disease (CHD), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus (DM). Drug investigations included Angiotensin-Converting Enzyme Inhibitor (ACEI), Angiotensin Receptor Blocker (ARB), Beta-Blocker (BB), Calcium Channel Blocker (CCB), Psychotropic, and statins. At the same time, questionnaires including Mini-Mental State Examination (MMSE), Instrumental Activities of Daily Living (IADL), and 15-item Geriatric Depression Scale (GDS-15) were completed.The diagnosis of OH and HTN was conducted based on blood pressure measurements. We diagnosed OH with a transition from supine to standing, a 20 mmHg drop in systolic blood pressure, and a 10 mmHg drop in diastolic blood pressure within three minutes of the test . And theOur study used the latest consensus, GLIM, to diagnose malnutrition. GLIM is based on MNA-SF  to compl2 [Because of the complexity of indicators to monitor the inflammatory state, it was not considered in this study. And disease burden referred to most chronic organ diseases, including heart failure, COPD, chronic kidney or liver disease, and cancer . Muscle 2 . CC and Data analysis was completed using IBM SPSS software Version 26.0 for Windows. Quantitative variables were expressed as mean ± standard deviation. Quantitative variable distributions were assessed using the Kolmogorov-Smirnov test. Differences between quantitative variables were analyzed using Student’s t-test and nonparametric tests (Mann-Whitney) for variables that did not follow a normal distribution. Receiver operating characteristic (ROC) curves were estimated for each muscle mass loss diagnosed method of GLIM. The area under the curve of ROC (AUC) was used to estimate the discriminative ability. The indications for the diagnostic values were as follows: 0.5, none; 0.5 to 0.7, poor; 0.7 to 0.9, moderate; and 0.9 to 1, 2, good. We designed a multivariate logistic regression model. The dependent variable was OH. A multiple logistic regression model included factors identified as potentially significant (p < 0.05) in univariate analysis. A P-value of < 0.05 was considered statistically significant.In the datasets, we enrolled 532 patients, 157 patients were excluded because of incomplete clinical data (n = 132), active tumor (n = 10), and clinical diagnosis of acute heart, liver, and kidney injury (n = 15). The final study population consisted of 375 patients.Table The incidence of malnutrition risk with MNA-SF ≤ 11 points was 42.67%. And the overall malnutrition rate was 45.07%. Patients who met each criterion met the malnutrition status are shown in Table After controlling for potential confounders, univariate and multivariate analyses to assess risk and protective factors for OH in elderly hypertensive patients. OH was associated with gender, DM, and GLIM-UAC in hypertensive patients. Male was its protective factor (Odds Ratio (OR) 0.433; 95% Confidence Interval (CI) 0.241–0.780; p = 0.005). DM, diuretics and GLIM-UAC were risk factors , ,  (Table To our knowledge, the results of our research showed that the prevalence of malnutrition and OH were 45.07% and 18.13%. CC, UAC, and HGS all three screening tools had a moderate effect in diagnosing malnutrition. It also revealed that malnutrition diagnosed by GLIM-UAC, DM, female and long-term use of diuretics were risk factors for OH in hypertensive elderly patients.Our study used the latest consensus, GLIM, to diagnose malnutrition. This is an easy way for clinicians to apply the available tools and methods . In our Previous studies have reported that both malnutrition and malnutrition risk were associated with OH , 25. OurOur findings proposed that long-term diuretic use and DM were risk factors for OH. Diuretics increase natriuresis and lead to a decrease in urine output, especially in the elderly. Loop diuretics also increase venous volume, which reduces venous return and cardiac output. Several studies reported a significant association of diuretics with OH , 37. TheThis study has certain clinical significance. Considering the risk factors derived from the results, medication and disease management should be included in the actual health management of older adults, especially those with HTN, DM and chronic diuretic use. In addition, nutritional screening should be strengthened, and early detection and diagnosis of malnutrition may facilitate the detection of OH. However, there were some limitations in the present study. First, our study is a cross-sectional, single-center study, and observed associations could not establish a causal nexus between malnutrition and OH. And next, the specific types of diuretics and the intake amount of nutrients such as vitamins and proteins were not analyzed and compared. Further prospective studies are needed to explore the relationship between OH and malnutrition in elderly hypertensive hospitalized patients.This study demonstrated that CC, UAC, and HGS have moderate to moderate accuracy in diagnosing malnutrition in elderly hypertensive populations. We also found malnutrition diagnosed by GLIM-UAC, females, DM, and long-term diuretic use were risk factors for OH in elderly hypertensive patients. Therefore, management of disease, medication and nutritional status is necessary.


The change in physiological parameters and subjective feelings according to the speed of drinking alcohol has not been reported to date. The aim of this randomized crossover pilot study was to investigate the objective and subjective effects of different speeds of alcohol ingestion in healthy volunteers. Accordingly, 11 male and 7 female healthy Japanese adults were asked to consume 480 mL of beer at three different drinking speeds . According to the objective measurement, the transient increase in blood alcohol and serum uric acid concentrations was most inhibited at a drinking speed of 20 mL/5 min. Acetate, lactate, pyruvate, and lactate/pyruvate ratios did not differ between the three drinking speeds. Stimulant feelings measured by the subjective scores of the Brief Biphasic Alcohol Effects Scale did not differ between the three speeds. However, the sedative feeling score obtained at a drinking speed of 20 mL/5 min  was significantly weakened in comparison with those obtained at drinking speeds of 40 and 80 mL/5 min. Therefore, a slower consumption of alcohol mitigated the subjective sedative feeling. The effects of slower alcohol consumption may be caused by the slower slope of the increasing trend of blood alcohol concentration. Alcohol consumption causes various physiological and pharmacological effects in the human body that can lead to many health problems ,2,3. AddConsidering the acute harmful effects of alcohol, drinking slowly is recommended. Under conditions of slow drinking, alcohol is absorbed more slowly, possibly reducing the BAC . Howevern = 11, women: n = 7) were enrolled.This clinical trial conformed to the principles of the Declaration of Helsinki, and the protocol was approved by the Suda Clinic Institutional Review Board . Volunteers were recruited from employees working at Asahi Group Research and Development Center . Written informed consent was obtained from all participants. The inclusion criteria were as follows: healthy Japanese men and women aged 20–64 years and provision of written informed consent prior to participation. Conversely, volunteers who could not drink 480 mL of beer were excluded. Ultimately, 18 participants . The 18 participants were randomly allocated to groups 1, 2, and 3, with 6 participants per group. All experiments for three patterns of drinking speed  were conducted in all groups in a random order in the sequence summarized in A commercially available beer , containing carbohydrates was used as the test beverage to avoid the induction of hypoglycemia  due to aFollowing blood collection, we mixed 0.5 mL of blood samples with 0.5 N of perchloric acid (2.5 mL) and prepared supernatants by centrifugation. Subsequently, BAC was measured by headspace gas chromatography according to the procedures described by Okada and Mizoi . We also0–150) from 0 to 150 min of the score–time curves of subjective stimulant and sedative feelings.Alcohol produces both stimulant and sedative sensations ,19,20. M0–150 of the scores, were analyzed using one-way ANOVA followed by Bonferroni post hoc test as paired analyses of parametric data; different letters in the figures indicate statistically significant differences. These data are presented as means ± standard deviation. Pearson’s simple linear regression analysis was used to evaluate the correlations of maximal blood alcohol concentration (BAC-max) with each maximal score of subjective feeling. A value of p < 0.05 was considered significant.All statistical data were analyzed using BellCurve for Excel 3.20 . Temporal changes from 0 min to 150 min of each blood or serum concentration were analyzed for each variable using repeated-measures ANOVA. Differences among the three drinking speeds of the maximal changes in each blood or serum parameter and B-BAES scores, as well as the AUC0–150 of each blood or serum parameter. All drinking speeds indicated a significant temporal change in all parameters. The maximal change in BAC at the drinking speed of 20 mL/5 min was significantly lower than that at 80 and 40 mL/5 min 75 min after the start of drinking , although the BAC values 150 min after the start of drinking were similar among the three drinking speeds. The maximal changes in acetate, lactate, pyruvate, and lactate/pyruvate ratios were not significant among the three drinking speeds. The maximal changes in uric acid concentrations at a drinking speed of 20 mL/5 min were significantly lower than at drinking speeds of 40 and 80 mL/5 min .All participants underwent three experiments for the three drinking speeds. Final analyses were conducted using data from 18 healthy participants aged 36.3 ± 9.9 years. 0–150 of the stimulant and sedative feelings. The time that reached the maximal score differed between the three drinking speeds. The stimulant feelings increased until finishing drinking alcohol and decreased thereafter .We examined whether differences in the speed of consuming 480 mL of beer affected BAC, biochemical indices, and subjective feelings in a crossover pilot trial in 18 healthy subjects. Considering that the objective and subjective effects caused by alcohol consumption vary widely among individuals, a crossover study was employed to ensure that participants’ backgrounds did not differ when comparing the effects of different drinking speeds. Results showed that BAC transition in the consumption of 480 mL of beer for 30 min was almost the same as that for 60 min. At a drinking speed of 20 mL/5 min, although the participants had finished 280 mL after 75 min, the BAC (0.13 mg/mL) was only less than half of that (0.34 mg/mL) at the other drinking speeds. Smith et al. observed increasing maximal BAC and BAC-AUC with increasingly rapid portal-vein infusions of identical alcohol doses in rats . The BACAcetate is a metabolite of ethanol, and the lactate/pyruvate ratio, which reflects NADH/NAD+ ratio as a redox state, transiently elevates after alcohol ingestion . DespiteAlcohol consumption reportedly increases the subjective stimulation scores during the initial increase in BAC and increases subjective sedation scores during the declining phase of BAC values ,27. The n = 18) might have reduced the statistical power and increased the risk of type II error, particularly regarding the statistical differences in multiple comparisons between the sedative feelings at drinking speeds of 40 and 80 mL/5 min. Evidence of effects caused by the difference in speed of consuming alcohol could be acquired by conducting clinical trials with an appropriate sample size. Furthermore, differences in the amount of alcohol consumed could also affect the results, although a moderate amount of beer (480 mL) was consumed in this study. Additional studies are required to clarify the health effects resulting from the difference in speed of alcohol consumption.This study is subject to some limitations. First, a power analysis for calculating the required number of study participants was not performed during the planning phase of the study. The modest sample size (We confirmed that drinking slowly moderates the increase in BAC. Drinking slowly did not change the stimulant feeling but weakened the sedative feeling. This practice also suppressed the transient increase in serum uric acid concentration. Results suggest that these changes were caused by the slower slope of the increasing trend of BAC resulting from slow alcohol drinking. Drinking slowly could reduce the objective and subjective acute effects of alcohol; hence, slow drinking is recommended. Further studies are required in the future.


The numerous consequences caused by malnutrition in hospitalized patients can worsen their quality of life. The aim of this study was to evaluate the prevalence of malnutrition on the elderly population, especially focusing on women, identify key factors and develop a malnutrition risk predictive model. The study group consisted of 493 older women admitted to the Asunción Klinika Hospital in the Basque Region (Spain). For this purpose, demographic, clinical, laboratory, and admission information was gathered. Correlations and multivariate analyses and the MNA-SF screening test-based risk of malnutrition were performed. Additionally, different predictive models designed using this information were compared. The estimated frequency of malnutrition among this population in the Basque Region (Spain) is 13.8%, while 41.8% is considered at risk of malnutrition, which is increased in women, with up to 16.4% with malnutrition and 47.5% at risk of malnutrition. Sixteen variables were used to develop a predictive model obtaining Area Under the Curve (AUC) values of 0.76. Elderly women assisted at home and with high scores of dependency were identified as a risk group, as well as patients admitted in internal medicine units, and in admissions with high severity. Several factors may contribute to an older individual suffering from nutrient deficiencies and other imbalances. For example, sensory disturbances, functional disabilities, and social isolation that typically accompany aging all increase the likelihood that a person will develop unhealthy eating habits. What is more, the mere fact of being female is one of the risk factors for developing these habits ,2,3,4,5,Several scientific societies as well as national and international organizations call for the early detection of malnutrition, enabling the health system to mitigate negative associated health consequences by proactively implementing corrective measures to address the patient’s nutrient deficiency. In Spain, some studies, which focused on the elderly population, show the nutritional status to which this population is exposed both living at home as well as in the institutional environment. The PREDyCES study  is an example of the observations made regarding patients’ nutritional status . This grCurrently, nutritional questionnaires are used to detect malnutrition in older adults. The most widely used for this population is the Mini Nutritional Assessment (MNA) questionnaire . HoweverIt is essential to consider the most suitable variables to design an efficient predictive model for the risk of malnutrition. Some studies have reported that several physiological changes associated with age, socio-economic status, and neuropsychological factors may contribute to insufficient dietary intake ,19,20. RHowever, these studies have some limitations: (i) lack of sufficient data for a representative sample, (ii) focus on a specific population with a particular disease or condition, (iii) usage of non-validated measures to determine malnutrition, (iv) ignore other potential factors, such as living conditions, or (v) focus on developing countries. In addition, although some studies have been carried out in the last years to develop models for the prediction of malnutrition, few studies focus on older hospitalized people, and do not focus on women cases, and the approaches centered in this population have limitations regarding their predictive capacity. For instance, in the case of the models developed by Muñoz et al. , a nutriTo overcome these limitations, the current observational study aimed at identifying the key factors that contribute to malnutrition in the older adults, further studying the situation with women, and using those key factors to develop an efficient model for predicting the risk of malnutrition in this population. Furthermore, a statistical analysis was carried out to assess the effect of malnutrition on hospital admission, such as length of stay (LOS) and readmission.The observational study was promoted by Asunción Klinika Hospital, located in Tolosa (north of Spain), between January 2019 and December 2019. All subjects were screened according to the following inclusion and exclusion criteria.Inclusion criteria: Age > 65 years old; admitted in Asunción Klinika Hospital during 2019; and accepted the informed consent.Exclusion criteria: people with morbid obesity, bulimia, and anorexia nervosa; patients whose clinical situation prevented the collection of study variables; patients on hemodialysis; and refusal to participate in the study.Following the Joint Commission for Accreditation of Healthcare Organization’s guidelines (2011), the nutritional assessment has been performed systematically within the first 24–48 h of the patient’s admission.The data collected to assess its effect on malnutrition were studied from two different perspectives: patient factors and hospitalization factors.Patient factors contain three main categories: demographic information, clinical information, and laboratory information.Demographic information included age (in years), sex (dichotomous variable), and potentially relevant information regarding living conditions. This last data point served to determine (i) the accessibility of their home and (ii) whether they have support at home. First, examining the home’s physical accessibility such as whether the apartment requires the use of steps or has an elevator is important since it can affect isolation [solation . SecondlClinical information was recorded as follows: height (cm) was asked of the patient if they could easily recall it; otherwise, the length of the forearm was taken, and their height was estimated [2. Other clinical information gathered included whether there was a presence of artificial nutrition in the diet, level of functional independence determined by the Barthel Index [stimated . Currentel Index  ranging Laboratory information included serum albumin, total cholesterol level and total lymphocyte count. Lymphocytes were measured several times during the patient’s hospital stay, however, within this study only the first documented measurement has been considered. Note that these three measurements are also used to measure CONUT malnutrition screening test [ing test .Additionally, hospital admission information was collected to determine firstly the effect that the type of admission (whether the admission is programmed or an emergency) may have on malnutrition  and, secondly the effect that malnutrition may have on further complications .The causalities involved the hospital unit in admission, diagnosis-related group (DRG) severity, and admission type. The hospital unit variable included ten different hospital units or departments: Anesthesia (ANES), Cardiology (CARD), Surgery (SUR), Gynecology (GINE), Internal Medicine (IM), Neurology (NEUR), Otorhinolaryngology (ORL), Traumatology (TRAU), Intensive Care Unit (ICU), and Urology (URO). Nevertheless, less than 1% of the individuals in the study were assigned to ANES, GINE, ORL, and ICU sections; thus, they were not considered for the study. DRG severity for each patient range from 1 (low severity) to 4 (high severity), and admission type was distinguished between surgical procedure and medical procedure.The studied consequences that could be derived from malnutrition included length of stay (LOS), readmission, surgical wound dehiscence, nosocomial infection, and ulcer complications at admission. However, since less than 1% of the population from the study suffered surgical wound dehiscence, nosocomial infection, or ulcer complications at admission, only LOS and readmission were presented. LOS was calculated based on the duration of hospitalization by subtracting day of admission from day of discharge (measured in days). Readmission was calculated if the same patient was admitted within 30 days after being discharged.For the present study we performed the MNA-SF malnutrition screening test since it is validated, reliable, and intuitive to those carrying out the assessment ,29.This screening test is the method recommended by ESPEN ,30. It iData collected during the study were documented by documentarists, and consequently, missing values were limited, and few inconsistencies were found. Two height measurements, collected in cm, were incongruent (lower than 30 cm) and have not been considered. Two patients were not assessed with MNA-SF, and therefore, they have not been considered in the study. Each instance corresponds to hospital admission. Therefore, if one patient had more than one admission, the patient information could have been used in more than one instance (for each admission).p < 0.001. The ANOVA method performs better if the distribution of the numerical variable follows a normal distribution, which is not the case in this study . Therefore, we normalized the principal variable (MNA-SF) for the analysis.To identify the effect of each factor on malnutrition, several bivariate analyses were carried out by exploring the relationships between the MNA-SF variable and each of the other attributes in the dataset. For the bivariate analyses, in the case of a categorical variable with a numerical one, the one-way analysis of variance (ANOVA) was used to determine whether there were any statistically significant differences between the means of the analyzed variables. In the case of two numerical variables, correlations were calculated using the Pearson coefficient. Results of the study were considered statistically significant when ilk test  result wIn order to design an efficient predictive model, first, a recursive feature elimination (RFE) algorithm was used to obtain an optimum number of variables. For the design of this algorithm, a random forest model and a repeated cross-validation resampling method were used. After this selection, various machine learning (ML) algorithms were used to develop the different risk predictive models. In this process, 80% of the data (798 patients’ data) were used for training the models, and 20% (200 patients’ data) for the testing. To select the final models to be validated in a future study, the main indicators  of all the obtained models were compared.Of the 1000 patients included in the study, two were not evaluated with MNA-SF, so the following results consider 998 patients’ information, of which 505 were males and 493 were females with a mean age of 81 years old . The following As it is presented in p > 0.001). This may be caused by the implicit relation in the dataset between sex factor and age and marital status, since the mean age of women in the dataset is elder, and this is also related to the marital status with higher number of widowed women than men . However, other factors, such as the assisted, BMI, Barthel and serum albumin do present p < 0.001.Further study has been carried out to determine which factors contribute to malnutrition on older women , since tAs presented in p-value for LOS and readmission clinical outcomes. Malnourished patients demonstrated a significantly higher LOS rate (9.76 ± 8.34 days), compared to the LOS for patients with risk of malnutrition (7.77 ± 6.43 days) and with well-nourished patients (6.46 ± 5.53 days), while it does not seem to have a significant effect on readmission rates.Finally, The accuracy results for the RFE analysis ranged from 55% to 67%, as shown in Being three the possible values of the predicting parameter MNA , two final models were developed: (i) a model designed for the prediction of no risk vs risk or high risk of malnutrition (as a group), and (ii) a second model, in the case of obtaining the second option in the first model, for the prediction of risk vs high risk of malnutrition see . To creaFinally, the two models with the highest AUC values were selected: the random forest model for the first prediction and the gradient boosting model for the second one with AUC values of 0.758 and 0.735 respectively.green shows the number of patients the model has stratified correctly. The two contiguous diagonals in yellow present when the model failed with a “low” error (E1), i.e., normal vs. risk; risk vs. malnourished. Finally, the orange positions show “high” errors (E2), i.e., normal vs. malnourished. As a result, we have an accuracy of 52% . This value may seem discrete, but on the other hand, the prevalence of the E2 error, which is the one to be avoided, is 5%.After combining the two models according to the scheme in In the present population-based cohort study of older adults aged ≥65, 44.4% of the studied population is well nourished, whereas 41.8% is at risk of malnutrition and 13.8% has malnutrition based on the MNA-SF screening test. This picture comes out worse when it comes to women with 36.1% of women well nourished, 47.5% at risk and 16.4% with malnutrition, as also presented in [In this observational study we examined the association between risk of malnutrition and a wide range of variables including demographic, clinical (chronic diseases) and laboratory data. From the demographic point of view, our findings suggested that older age, female gender, having assistance at home, and being dependent (via Barthel index) are all factors associated with malnutrition. However, it is important to note that the MNA-SF screening test applied in our study makes use of BMI, and asks for mobility, which is related with BARTHEL and assisted living factors of our study. Therefore, we cannot say that BMI is a key indicator of malnutrition, and BARTHEL and assisted living factors may also be influenced by the MNA-SF mobility question.p < 0.001, is close to it with a value of p = 0.007, and hence, we should consider it since it may contribute patients to be more isolated [Regarding architectural barriers, although the absence of elevator does not have isolated , and henNote that from the clinical point of view, some of the studied patient factors are causative risk factors, such as age, sex and assisted, and others are consequences of malnutrition, such as BMI value. However, other factors may not be clear, such as the dependency situation , since they could be both causative and consequence factors of malnutrition or the case of albumin, as both  are related to inflammation which can describe the association but not the causality between them as described by Evans et al. .p < 0.001, only patients with pressure ulcers seem to have a higher risk of malnutrition, but multimorbidity shows a p = 0.003, which is close to the value, aligned with the literature [Considering the threshold of terature . HoweverRegarding hospitalization factors, the present study demonstrates the high impact of the type of admission on malnutrition. The hospital unit factor, which is highly related with the patient diagnosis, shows that patients admitted in cardiology, neurology, traumatology, and urology have a lower prevalence of malnourished patients, while in internal medicine units, the number is higher. This way, internal medicine seems to be a unit with higher risk of malnourishment. DRG severity is another factor that is highly related to malnutrition, where more severe patients show a higher risk of malnutrition. Besides, medical admissions are also highly correlated with malnutrition, since they are more related to medical conditions that affect the patient as a whole, while surgical admissions are inversely related, since they used to be programmed admissions. To the best of our knowledge, this is the first study in the Basque Region to evaluate the risk of malnutrition in the elderly population when admitted to the hospital. Other studies in Spain examining the risk of malnutrition ,32 suggeAs expected, the Barthel index, which determines the dependency level of a person, is associated with malnutrition. However, chronic diseases do not seem to influence the risk of malnutrition in the elderly population. In addition, increased age correlates with malnutrition. This could also be related to cognitive functioning, as suggested by Katsas et al. , since ip < 0.001). On the other hand, age seem to have a higher impact on men (p < 0.001) than women, although for women it is close to p < 0.001 (p = 0.002). For this reason, we conclude that age and sex are the primary factors that contribute to malnutrition, but not marital status in and of itself. In addition, we analyzed the distribution of the MNA variable for both sex factors (woman and man), finding worse nutritional conditions for the female gender. This higher prevalence of malnutrition risk among women may be related to social issues related to social and financial living as suggested in [Aligned with other studies, we found that women had a higher risk of malnutrition than men ,3,4,5. T p = 0.00. For thiAdditionally, the results show that malnutrition is associated with longer hospital LOS, aligned with ,11,40. TRegarding readmissions, in contrast with , this stFinally, identifying all these risk factors has led to the development of a model to predict the risk of malnutrition in hospitalized older adults. Agreeing with , fewer fAmong the limitations of this study is the lack of availability of each separate MNA-SF response to examine answers independently. Information regarding cognitive functioning, education level, and socioeconomic status has not been collected, which could also be of interest to the current study. Throughout the study, information regarding complications, such as surgical wound dehiscence, nosocomial infection, and ulcer complications upon admission was collected to determine the impact of malnutrition on patients. Nevertheless, since the number of patients that suffered these complications was too small, no conclusions could be drawn, and consequently, these results have not been presented in the study.Regarding the strengths of the study, we used a representative sample of older adults admitted to the hospital, with almost 50% of them women, in contrast with other studies which used specific subgroups of older people. Additionally, the results show a clear correlation of the factors with a higher impact on malnutrition, and we also examined the primary reason why, since the sample data may influence the results.The findings of the present research emphasize the urgent need for physicians and clinical institutions to be aware of the high prevalence of malnutrition in elderly patients, with a greater focus on women, and the influence of the admission information in malnutrition. Therefore, health experts should perform nutritional screening for all older adults as part of secondary prevention, with a special focus on more vulnerable populations, such as widowed elderly women who require assistance at home, those who are considered dependent as categorized by the Barthel index, or patients admitted in internal medicine with high DRG severity. To those who are more vulnerable, nutrition counseling and support should be offered.The main risk factors identified for the prevalence of malnutrition are female gender, being assisted at home, having high scores of dependency, no access to an elevator, and presenting pressure ulcers and multimorbidity. In addition, patients with malnutrition showed a significant increase in hospital LOS with respect to patients who are well nourished, although it is also related with the admission DRG severity. Although the developed malnutrition risk predictive models present fair accuracy results, further research needs to be conducted to validate them clinically.


The probability of each result decreased with an improvement in the mother’s level of schooling. This indicates an urgent requirement for interventions to be implemented by policymakers in order to manage children’s mortality rates. These interventions can include the introduction of educational programs for older adults, children’s dietary programs, and income generation initiatives . It is hoped that this paper can foster the utilization of copula methodology in this field of science with the use of cross-sectional data.Notwithstanding the interventions implemented to address child mortality, anaemia and malnutrition remain a concern for the future of developing countries. Anaemia and malnutrition contribute a high proportion of the causes of childhood morbidity in Africa. The objective of this study is to jointly model anaemia and malnutrition using a copula geo-additive model. This study is a secondary data analysis where a Demographic and Health Survey of 2016 data from Angola, Malawi, and Senegal was used. The descriptive analysis was conducted in SPSS and the copula geo-additive model analysis was performed in R 3.63. The results showed that female children are notably associated with anaemia and a malnourished status (female estimate = 0.144,  Notwithstanding the interventions implemented to address child mortality, anaemia and malnutrition remains a concern for the future of developing countries . AnaemiaStatistically, malnutrition is reported to impact children the most as approximately three million children die annually due to a lack of nutrition .In Angola, anaemia and malnutrition are the foremost causes of child death. The number of children affected by malnutrition is reported to be increasing, with approximately eighty-five thousand children being severely malnourished. In the report issued by the World Vision (2020) , Angola In addition, a study to understand the nutritional shortages in children under five in Angola by Fernandes et al. (2013)  found thSenegal is among the other African developing countries experiencing malnutrition . Food inIn a study by Diouf et al. (2021)  in SenegIn Malawi, poor diets, a lack of food, and infectious diseases are among the contributors to malnutrition . Twenty-In a Malawian study to evaluate the effect of fish farming on health status by Aiga et al. (2009) , it was Anaemia among under five-year-old Malawian children is related with a child’s age, fever, the mother’s level of education, and residing in poor household . The stuAnaemia is a community well-being challenge that affects high-, middle-, and low-income countries and holds the potential for momentous hostile health consequences, as well as negatively affecting progress on economic and social development. Anaemia ensues from several effects, the important contributor being iron shortage. Almost 50% of anaemia outcomes are due to iron shortage, but the percentage differs among population clusters and in different areas ,21. It iAnaemia in Malawi, Senegal, and Angola was revealed to be associated with household wealth status, the mother’s level of schooling, and the age of the child, whereas, malnutrition was found to be associated with the type of residence, mother’s level of schooling, household wealth status, and child’s age ,24.Little is known about the main factors related with anaemia and malnutrition in developing countries. Various statistical techniques and methods have been employed to evaluate factors related with anaemia and malnutrition. Fewer studies have been conducted to jointly model malnutrition and anaemia. The studies that have been published on this topic have used different statistical approaches and, hence, were aimed at different objectives . A studyThus, the objective of this study is to jointly model anaemia and malnutrition using a copula geo-additive model. The significance of the study includes broadening the academic theory in the understanding of the factors associated with malnutrition and anaemia, which are modelled jointly, and mapping the results. This will assist the policymakers of Malawi, Senegal and Angola in drawing up strategies to manage mortality resulting from malnutrition and anaemia.This paper is a secondary data analysis where data from a Demographic and Health Survey of 2016 from Angola, Malawi, and Senegal were used. Since this is secondary data, there was no ethical approval required. The data were attained by submitting a written application to DHS Micro for consent.The Angola data were collected between October 2015 and March 2016 to attain socio-economic, demographic, and other information. A sample of 16,109 households was selected, which were made up of 14,379 females aged between 15 and 49 and 5684 males aged between 15 and 54. Success rate for males and females was 94% and 96%, respectively.The Malawi data had a total sample of 27,516 houses of which 26,564 of the total sample were occupied and interviewed successfully. The technique employed to calculate the sample population was conducted in two stages. The first stage was 850 SEAs (standard enumeration areas) incorporating 677 SEAs in rural areas and 173 in urban areas. The second stage, a 33 houses per rural cluster and 30 per urban cluster, was selected with equal chance selection.The Senegal data were implemented to respond to the well-being challenges, monitoring the progress of implemented measures, public health challenges, and community challenges. A total of 4437 households was selected, which were made up of 8865 females aged 15–49 and 3527 males aged 15–59 who were successfully interviewed. A sample of 5722 children under five years were weighed and measured to ascertain their nutritional status; 5239 under five-year-old children aged between 6 and 59 months were examined for anaemia, and 5237 were tested from the exam microscopic for malaria.The differences in sample sizes from Angola, Malawi, and Senegal do not limit the capability to interpret the multivariate analysis because the statistical power of any test is limited by small sample size. In this study, all the three sample sizes are adequate.The Demographic and Health Survey data from Angola, Malawi, and Senegal were merged to create a pooled sample ,26,27,28The dependence variables  were obtained from the weight-for-age (WAZ) and anaemia level variables in the DHS data.A child is classified as malnourished when the WAZ is less than −3.0 and nourished when the WAZ is greater than −3.0. In contrast, a child is classified as anaemic when the haemoglobin level of a child is less than 9.9 g per dL, and a child is classified as not anaemic when the haemoglobin of the child is greater 9.9 g per dL.Demographic, health, environmental, and socio-economic fundamentals of living were identified as the important factors in malnutrition and anaemia. The framework employed to select the independence variables was similar to that used by ,29.The community variable incorporated in the study was a type of resident . Household variables incorporated in the study were mother’s level of schooling , household size , sex of household head , wealth index , birth interval , marital status . The household wealth index is calculated based on the living standards. It calculates household’s assets such as ownership of living stock, water and sanitation facilities, and household construction material. The full method used is explained in the paper by Khulu and Ramroop .Individual level variables were sex of child , child’s age in months , childbirth order .D1, D2, …, dD) and its marginals are continuous, then the marginals’ cumulative distribution functions (CDFs) In this study we employed a Copula model to jointly model malnutrition and anaemia. Copulas models are functions that allow us to isolate the marginal distributions from the dependency structure of a given multivariate distribution . This teUsing the likelihood integral transformation to the component, the random vectorThe Copula of One of the advantages of copula modelling is that it joins multivariate distribution functions to one dimensional margined distribution function. This type of modelling is in contrast with the Pearson’s linear correlation coefficient when predicting the dependence structures between dependent and predictor variables.Copula selection and parameter estimation is an imperative stage when adopting a copula approach to study multivariate behaviour because an appropriate fitting confirms that both the dependence structure and the dependence strength are properly signified. The dependence structure is reflected by the chosen copula family, while the dependence strength is estimated by the copula parameters. Hence, selecting an appropriate copula family and the estimation of copulas parameters require special attention. The marginal distributions and copulas have a low rate of correct classification when sample size is small; the rate of correct classification increases with increasing sample size.1.2.3.Archimedean copulas form a huge family of copulas with number convenient properties and they allow for many dependence structures. Let Now let The Archimedean copulas are symmetric, that is The most-used Archimedean copulas areI.Clayton copulaFor II.Gumbel copulaThe Gumbel copula has an upper tail dependence.III.Frank copulaFrank copulas display the properties of radial symmetry and do not have a tail dependence.The simple visualisation comparing the most-used Archimedean copulas is displayed in Suppose Z:The suitable model was identified based on the lowest Akaike information criterion (AIC) value. AIC is suggested to be a good criterion for ascertaining the best fit for copula model . FurtherIC value . The AICGJRM . To complete the mapping, each country’s boundaries were obtained from DHS program and were thereafter saved as shapes in QGIS 3.4 software . These shapes were imported into R 3.63 software for results’ mapping.The cross-tabulation analysis was conducted in SPSS and the multivariate analysis was conducted in R 3.6.3 package The occurrence of anaemia or malnutrition or both in children were seen to decrease as the mother’s level of education improved. No differences in the occurrence of anaemia or malnutrition or both were seen for the child’s birth order as well as their birth interval. The occurrence of anaemia or malnutrition or both were seen to be lower in the households that were not poor.After selecting the copula, the authors further selected the link function using the AIC. The results in GJRM  was used to obtain the results. Factors that were found to be not significant in the first step of the model selection were excluded from the final model. Seven factors were incorporated in the last copula modelThe results of the fixed effects are based on the Gumbel copula and c  link function. The R 3.63 package p-value = 0.104 for malnourished; rural place estimate = 0.053, p-value = 0.152 for anaemia). A child’s age was found to be significantly related with a child’s anaemia status at all age categories but had no significant effect on the child’s malnourished status.The marginal model results of the fixed effects are displayed in p-value = 0.027 for anaemia; female estimate = −0.105, p-value = 000 for malnourished). Furthermore, the probability of each result reduced with an improvement in the mother’s level of schooling. A single improvement in the household’s wealth index was significantly related with the decrease in the likelihood of exposure to malnutrition and anaemia.Being female was found to be significantly related with both a child’s anaemia status and malnourished status  . Child’sThe limitations of this study include employing the available similar variables from the three countries’ DHS data. This resulted in important variables being excluded that exist in one country’s DHS data but not on the other; variables such as iron deficiency, etc. Hence, future studies must include the study of more developing African countries or other countries with higher child mortality rates. Other non-nutritional factors including sickle cell disease, alpha thalassemia, and parasitic infections can aggravate the anaemia of malnutrition and iron deficiency and affect growth ,36. ThusThis will assist in formulating a general policy of managing mortality and how that policy can assist in reducing the child mortality rate for African countries. Furthermore, when the next phase of demographic and health survey (DHS) data is made available, it can be combined with the data used in this study to see whether there are changes in malnutrition and anaemia risk over time, and the effect of interventions.https://www.R-project.org/). The results of the mapping showed that there is an association between malnutrition and anaemia. This implies that the policymakers of Angola, Senegal, and Malawi can control anaemia through interventions to control malnutrition. This will save countries’ resources from being used to implement interventions for both malnutrition and anaemia.This study presents another statistical method for jointly modelling malnutrition and anaemia. The analysis and the mapping of the results were completed in R 3.63 software (R Core Team (2021). R: A language and environment for statistical computing Vienna, Austria. The stronger association between malnutrition and anaemia was observed in the north-west districts of Angola when compared to other districts. This suggests that for better control of malnutrition and anaemia, the government needs to target that part of the country. The regions in Senegal and Malawi have lower probabilities and these are distributed fairly across the regions.Based on the fixed effects analysis, the mother’s level of schooling, the sex of the child, and the household wealth index are significant factors of malnutrition and anaemia. These results are consistent with other studies on child mortality ,32,33,34The literature on copula modelling is still increasing; however, it is particularly applied in actuarial science, survival analysis, and finance. It is hoped that this paper can foster the utilization of copula methodology in this field of science with the use of cross-sectional data. Hence, the future direction of research from this study is to consider the use of longitudinal data.