Osteoporosis is the most common metabolic bone disease. Recent studies have shown that malnutrition can promote the development of osteoporosis. However, the incidence of malnutrition in patients with osteoporosis and the relationship between malnutrition and all-cause mortality has not been adequately studied. Therefore, our study investigated the relationship between malnutrition and all-cause mortality in patients with osteoporosis.We analyzed data on 7,700 adults ≥20 years of age during National Health and Nutrition Examination Survey (NHANES) 2005-2010. Each patient was assigned to one of three groups: normal nutritional status, mild malnutrition, and moderate to severe malnutrition. Survival curves and univariate and multivariable cox regressions based on the NHANES recommended weights were used to assess the association between malnutrition status and mortality. Moreover, cox proportional hazards regression analyses were performed on the matched pairs.p = 0.039] at mild malnutrition status and 2.70  at moderate to severe malnutrition status. The cox model after matching indicated that malnutrition was still a high mortality risk than no malnutrition .Overall, 7,700 eligible individuals with osteoporosis were included in the final analysis, and the mean age was 52.0 ± 0.4 years. From the Kaplan–Meier curves for long-term all-cause mortality of malnutrition, worsening malnutrition status was associated with higher incidence of all-cause mortality. In the fully adjusted models, the adjusted hazard ratio (aHR) was 1.54 [95% confidence interval (CI), 1.02–2.31, Poor malnutrition status, common in osteoporotic patients, is strongly associated with a risk for all-cause mortality comparable to that seen with normal nutritional status. These findings highlight the importance of risk stratification for nutritional status in osteoporotic patients and the implementation of strategies that is now available to help prevent malnutrition in these patients. Osteoporosis is the most common metabolic bone disease. It has a prevalence of 18.3% and affects approximately 1.2 billion people worldwide  score and all-cause mortality in patients with osteoporosis by using the 2005-2010 National Health and Nutrition Examination Survey (NHANES).The NHANES is a nationally representative cross-sectional survey recursively conducted in the U.S. by the National Center for Health Statistics (NCHS) every 2 years, with 5,000 individuals sampled in each survey. The survey, at every survey period, obtains written informed consent from all participants and approval from the Ethics Review Board of the NCHS .n = 17,132). Of these participants, 9,432 were excluded based on the following: (i) insufficient data to diagnosis osteoporosis; and (ii) patients without serum albumin and reliable body information. Thus, 7,700 patients were enrolled in the present study.As shown in 2 -determined bone mineral density (BMD) of the total femur, femoral neck, trochanter, intertrochanter, Ward's triangle, total spine, and vertebrae L1–L4. Patient diagnosis of osteoporosis was confirmed if one of three criteria was met: (1) femur neck BMD <0.558 g/cm2 ; (2) T-s2 . NRI was2  and cons2 , patient2 test for categorical variables.We used the NHANES-recommended weights to account for planned oversampling of specific groups. The continuous variables were expressed as the mean ± standard deviation, and the categorical variables were presented as counts (percentages). Baseline characteristics between the three malnutrition groups were compared using an ANOVA for continuous variables and an χEach patient was assigned to one of three groups: normal nutritional status, mild malnutrition, and moderate to severe malnutrition. To evaluate the association between different malnutrition status and mortality, we used Kaplan Meier estimates to calculate cumulative survival probabilities for all-cause mortality and univariate and multivariate cox regression analyses. Both the estimates and probabilities are based on the NHANES-recommended weights. Afterwards, hazard ratio (HR) and 95% confidence interval (CI) were calculated. Model 1 was a crude model unadjusted for potential confounders. Model 2 was adjusted for demographic factors, including age, sex, and race/ethnicity. Model 3 was further adjusted for body mass index (BMI), congestive heart failure (CHF), diabetes mellitus (DM), hypertension, and cancer. Restricted cubic splines were used to evaluate linear and non-linear associations. To demonstrate the reliability of the results, we matched the basic characteristics of the normal nutritional and malnutrition groups using propensity score matching. Moreover, cox proportional hazards regression analyses were performed on the matched pairs. We further explored the relationship between different malnutrition status and mortality in different subgroups . All data analyses were performed using Survey package in R software .2. Most of the patients were female (58.6%), and 76.4% were of the Non-Hispanic White. According to the NRI scoring criteria, 7,700 patients were divided into three groups: normal nutritional status, mild malnutrition, and moderate to severe malnutrition. Nine hundred thirty-five patients suffered from mild malnutrition, while 640 patients had moderate to severe malnutrition. Patients with malnutrition were older and were more likely to be female. Compared with those with normal nutritional status, the higher the level of malnutrition, the higher the incidence of CHF, DM, hypertension, and cancer. More data on the baseline characteristics of study population are shown in Overall, 7,700 eligible individuals with osteoporosis were selected from the publicly available NHANES and included in the final analysis. Their mean age was 52.0 ± 0.4 years. There were 269 (2.6%) patients with CHF, 897 (7.8%) patients with DM, 2,895 (32.2%) patients with hypertension, and 946 (11.9%) patients with cancer. The average BMI of the population was 26.9 ± 0.1 kg/mp < 0.001 for all models]. In the fully adjusted models, the adjusted hazard ratios (aHR) were 1.54  at mild malnutrition status and 2.70  at moderate to severe malnutrition status . In addition, in the diabetes subgroup, moderate to severe malnutrition increased the risk of mortality by 899% (p < 0.001).Subgroup analysis showed that in most subgroups, the malnutrition group was associated with a higher risk of mortality . For theAs far as we know, this is the first study to examine the mortality risk of malnutrition in the population of patients with osteoporosis. In this study, malnourished patients with osteoporosis accounted for nearly one-fifth of the included population according to NRI score. Our study reported that the malnourished osteoporotic population has a higher all-cause mortality risk compared to the osteoporotic population with normal nutritional status.Malnutrition may affect the prognosis of patients with osteoporosis through major mechanisms. Malnutrition is a complex state that includes a decrease in protein reserves and a collapse in calories which can weaken immune defenses. Decreased immune defenses are a key factor in the development and progression of many chronic diseases . An incrThere were some interesting results. In the age subgroup of patients with osteoporosis, patients older than 65 years who developed mild malnutrition was also significantly associated with a higher risk of mortality. It was found that in elderly people older than 65 years old, bone density is susceptible to nutritional status, which in turn indicates that malnourished elderly patients are prone to osteoporosis. Once a fracture occurs, complications, such as blood hypercoagulation, complicating embolism, and lung infection due to slow bone recovery in old age, and prolonged bed rest, will lead to the death of the patient . In addiExercises and medications have an important role in the prevention and treatment of patients with osteoporosis , 19. In This study has several limitations. First, our outcome event was restricted to all-cause mortality, but it was an unbiased and clinically relevant outcome. In addition, the sample size of our study was large enough to demonstrate a strong association between malnutrition and osteoporosis. Second, our study was a retrospective analysis that used data from the 2005-2010 NHANES, which may have poor timeliness. Third, only one assessment method, NRI, was used to assess the malnutrition level of patients. We used a single evaluation method, which has some limitations. Hence, data may be biased. However, NRI has higher objectivity and accuracy compared with other evaluation methods.Our study discussed the effect of different nutritional status on the prognosis of patients with osteoporosis and found that the poor malnutrition status common in these patients is strongly associated with a risk for all-cause mortality that is comparable to that seen in normal nutritional status. These findings highlight the importance of risk stratification for nutritional status in osteoporotic patients and the implementation of strategies that are now available to help prevent malnutrition in these patients.https://www.cdc.gov/nchs/nhanes/.Publicly available datasets were analyzed in this study. This data can be found at: The survey obtains written informed consent from all participants and approval from the Ethics Review Board of the NCHS. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.XHSG participated in formulating the research question, design of analyses, interpretation of the data, drafting the manuscript, revising the manuscript, and the approval of the final version. JLX participated in the design of analyses, revision of the manuscript, and approved the final version. SSS contributed to the interpretation of the data, drafting the manuscript, revision of the manuscript, and the approval of the final version. YL, LLC, JYD, JJW, JBT, and JMX revised the manuscript and approved the final version. WHW participated in formulating the research question, design of analyses, the revision the manuscript, and approved the final version. LTC participated in formulating the research question, design of analyses, revision of the manuscript, and approved the final version. KHC participated in formulating the research question, design of analyses, data analysis, interpretation of the data, and approved the final version. All authors read and approved the final version of the manuscript and are responsible for all aspects of the manuscript.This research was funded and supported by the Young and Middle-aged Expert Fund for Outstanding Contributions to Hygiene and Health in Fujian Province.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations.This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978–2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group.Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 – 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975–2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B , and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch).Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.The online version contains supplementary material available at 10.1007/s00384-022-04280-x. Although functional outcomes are clinically relevant, long-term outcome parameters should be taken into consideration as well before selecting a pouch design. Besides pouch function and complexity of surgical construction, failure-free pouch survival is a relevant factor in determining the most optimal anatomical pouch design. When it comes to failure-free pouch survival, studies comparing long-term results subdivided by pouch design did not report major differences between S and J pouches ..11].Patients with long-term postoperative complications after primary IPAA surgery were standardly referred back and followed in the conducting centre, and surgical treatments for PF were standardly performed in the conducting centre. Patients who underwent redo surgery within three months after initial IPAA surgery were included in this study in case the ileoanal pouch remained functional. Postoperative follow-up time was calculated starting from the day of construction (1- and modified 2 staged IPAA) of the pouch or closure of the defunctioning ileostomy (2 and 3-staged IPAA). Patients who were impossible to follow were censored at time of last date of follow-up.J-pouch: In our practice, we construct relatively small pouches of two ileal loops of 10 cm in length. The apex of the pouch is generally stapled to the rectal cuff , according to pouch volume and amount of anastomoses. Pouch-length was mentioned in reports of primary IPAA- procedures, pouch resection specimens, pouch endoscopies or redo pouch procedures. Patients with an unknown pouch-design were excluded from analyses.p values were under 0.05. Statistical analyses were performed using SPSS .Categorical outcomes were expressed as percentage. Continuous variables of secondary outcomes showing normal distribution were expressed as mean with standard deviation (SD) and/or range, continuous variables with no normal distribution were expressed as median with interquartile range (IQR). To compare categorical data, the Chi-square test was used for statistical significance. For comparing continuous data with normal distribution, the independent samples T-test was used. In case continuous data was not normally distributed, the Mann–Whitney U test was used to compare continuous variables. Variables were excluded from statistical analyses if the percentage of missing data exceeded in 30% of all cases. All data were analysed through complete case analyses. Pouch survival over time was described in years, analysed using Kaplan–Meier analysis and compared with the log-rank test. PF-free survival was calculated as the interval (in years) between date of first fecal stream through the pouch and date of PF or date of last follow-up. Date of ileostomy surgery was selected as PF date in case a defunctioning ileostomy without closure preceded the PF procedure. Differences were considered statistically significant if two-sided the A total of 213 pouches were created between 1979 and 2000. Thirteen patients were excluded as their pouch-design was not specified. The remaining 200 patients underwent IPAA surgery for UC (72.0%), polyposis/malignancy (17.5%), and indeterminate colitis (5%). The majority of IPAA surgeries were performed via a one- (39.4%) or modified two-stage (31.1%) approach. Rectal dissections were performed via posterior meso-rectal excision with anterolateral close rectal dissection.A total of 181 (90.5%) pouches had a J (n = 25) or B (n = 148) pouch design. In eight patients, reports did not distinguish J- from B- designs. Nineteen (9.5%) pouches were constructed with an S (n = 2) or septated (SP) design (n = 17). S/SP pouches were constructed earlier when compared to J/B pouches (median operation year 1987 vs 1994). A larger proportion of patients with S/SP pouches underwent IPAA surgery for polyposis  and more patients with an S/SP pouch underwent two- or three- stage IPAA surgery (p < 0.01). Further baseline characteristics are displayed in Table Intra-luminal septa were present in SP pouches as a result of creating multiple side-to side anastomoses during pouch construction Fig. . MoreoveThe overall median follow-up was 27.0 years IQR 23.3 – 29.0), with a significantly longer follow-up period for S/SP pouches . PF occurred in 45 (22.5%) patients, with a higher PF rate for S/SP pouches when compared to J/B pouches . This difference persists in consideration of SP pouches only  An overall mean failure-free pouch survival of 29.4 (CI 27.6–31.2) years was reported, with a shorter mean failure-free pouch survival for S/SP pouches when compared to J/B pouches . Ten- and 20- year survival rates for patients with S/SP pouches compared to J/B pouches were 63.2% and 57.9% vs. 91.6% and 85.8% respectively (p < 0.01). Survival curves are displayed in Fig. .3 – 29.0No differences between S/SP and J/B pouches were reported for incidence of septic- , pouch body-  or inlet issues . A significantly higher proportion of S/SP pouches developed outlet issues . Four out of the 8 patients with an S/SP design had a megapouch  when compared to the J pouch and B shaped adaptions. We demonstrated an overall 79% PF rate in the S/SP pouches after a median of 13 years. Overall PF rates were relatively high (23%) as pouches in this cohort were created in the early days of pouch surgery. The remarkably high failure rate in the S/SP pouches (79% vs. 17% in J/B design) is mainly the result of mechanical outlet issues, as clarified by the proposed sub-classification demonstrating causes for PF. Kinking of the efferent loop and intussusception in combination with oversizing of the pouch caused these outlet problems , 13. RedThe median shorter postoperative follow-up period for the cohort with J/B pouches when compared to S/SP pouches could have introduced a bias in favor of the J/B pouch. However, failure-free pouch survival rates after both 10 and 20 years of follow-up are higher for J/B pouches. This difference in survival rate does not refute the potential bias in favor of J/B pouches through medical and surgical innovations that occurred during the time period from when the S/SP was favoured to the period when common construction of the J/B design was introduced. Data on pouches other than J pouches are extremely sparse since the J- design has been widely applied in the past decades. Available literature reports similar and inevitable differences in cohort volume and follow-up period between J and S pouches , 13. NevLongitudinal pouch length was reported in 37.5% of patients. Both missing data and variation in (post)operative stage during measurement precluded drawing firm conclusions on optimal pouch length. In the current study, S/SP pouches had a significantly larger pouch size when compared to J/B pouches. Conceptually, S/SP pouches have been constructed larger and presumably dilated over time due to evacuation problems. J/B pouches were routinely constructed with a longitudinal length of ± 10 cm in our tertiary centre, and demonstrated a lower incidence of failure when compared to the larger constructed S/SP pouches. A median longitudinal pouch length of 13.5 cm was found for J and B pouches in either endosopcic, surgical or pouch resection reports. This finding supports the hypothesis of dilatation of pouches after long-term functionality.A larger proportion of S/SP pouches were constructed for polyposis. Although patients with pouches constructed for polyposis generally have superior long-term outcomes when compared to pouches constructed for UC, differences in pouch failure rates were strongly in favor of J/B pouches .Although surgical techniques surely have improved during and after the study period, the reported median follow-up of 27 years after primary IPAA surgery was longer than currently available literature on long-term outcomes per pouch design , 13. AltConfounding variables such as primary sclerosing cholangitis, obesity and acute postoperative anastomotic leakage which could have interfered with results of the current study were missing from patient reports. However, missing data were expected and inevitable due to the studied period of the current study. Both missing data and heterogenuous and small sample sizes in the S/SP cohort specifically precluded more reliable multi-variable or sub-analyses. The difference in surgical skills of the various surgeons constructing pouches within the study period is another bias potentially affecting outcomes. Besides, functional data was not assessed and follow-up data might be incomplete due to the retrospective nature. Follow-up visits were not standardly indicated after pouch surgery for patients in this cohort. However, our hospital is the main referral clinic for pouch-related problems in the Netherlands. Therefore, we expect that the vast majority of patients with PF that underwent pouch-surgery in our hospital were referred back and included in the follow-up of this study.This study assessed causes for PF for S/SP and J/B designs separately and elaborated on features and outcomes of different pouch designs. PF rates of the J and B pouch were higher when compared to more recently created J pouches, as many surgical and medical innovations occurred the past 20 years. However, long-term results of the J pouch and B-shaped adaptions were far superior when compared to the S and septated pouches. Mechanical outlet issues caused PF in S/SP pouches remarkably more frequently, due to the oversizing in combination with intussusception of pouch-wall and—septa and kinking of the efferent loop. Results of the current study indicate oversizing a pouch should possibly be avoided, as larger designs include a risk of mechanical outlet obstruction. Moreover, Miratashi et al. demonstrated an improved pouch-function in shorter constructed pouch-sizes . We hypoSupplementary file1 (TIF 5024 KB)Supplementary file2 (PDF 212 KB)Below is the link to the electronic supplementary material.


To examine the potential mechanisms underlying social deficits in Turner Syndrome, we administered the empathic accuracy task (EAT) -a naturalistic social cognition task- and a (control) visual-motor line-tracking task to 14 girls with TS was compared to 12 age-matched typically developing girls . Empathic accuracy was compared across positive and negative emotionally valanced videos. We found that TS differs from TD on empathic accuracy ratings for negative videos; no differences were detected for the positive videos or for the control line tracking task. Thus, our findings suggest impaired detection of negatively valanced empathic interactions in TS and may help inform the future development of social-cognition treatment strategies for girls with TS. Turner syndrome (TS) is a disorder in human females in which part or all of the genetic material from one X-chromosome is absent. Girls with TS display a variety of physical, developmental and cognitive abnormalities. These include cardiovascular problems  difficulties may be present , ages 12 through 17 years of age were recruited from a larger study, which examined longitudinal brain changes associated with TS. Participants with TS were recruited nationally and TD participants were recruited from the San Francisco Bay area. Inclusion criteria for TS included genetic confirmation of Turner syndrome with a 45X karyotype. Controls with developmental delays and significant medical and/or psychiatric illness were excluded from participating in the study. Participant pubertal stage was assessed via self-report on the Tanner scale which includes ratings of breast and pubic hair development  for adolescents and administered it to all study participants. For the EAT, we selected our videos from a pool of stimuli and choose videos of late-adolescent female volunteers ages 18–19, who appeared younger than their age. Videos were between 90 and 150 s in duration and were presented as mp4 files embedded within the task stimuli, which were presented to participants by Psychtoolbox via MATLAB R2017b. We chose three positive and three negative videos that included topics applicable to adolescents. Positive video topics included telling a boyfriend or girlfriend “I love you” for the first time (Video 1), excelling at a sports competition (Video 3), and spending quality time with one’s family (Video 6). Negative video topics included death of a pet (Video 2), moving away from home for the first time (Video 4), and breaking up with a romantic partner (Video 5). We only presented videos of female volunteers since we were interested in learning how empathic accuracy may influence social relationships in girls with TS. Age related preferences for friends occur in girls, such that younger teen girls primarily have same sex friendships (85% of best friends are of the same sex in grades six through seven). With age, adolescents form more opposite sex friendships  using the right and left arrow keys on a keyboard. One line trial was shown prior to the six empathy videos and a second line trial was shown after the empathy videos.MATLAB R2017b was used to perform time series downsampling and calculations. Continuous empathy ratings obtained from participants were downsampled from 30 Hz to match the 10 Hz sampling frequency of the target’s ratings. Onsets for the participant and target ratings were aligned. Statistical procedures included calculating empathic accuracy by obtaining the Pearson’s correlation between the participant and targets’ continuous ratings for each task. Fisher’s r to z conversion was then used to convert correlation coefficients to z-scores See Fig. . Video 1p = 0.005) and intelligence  separately. To examine differences in group performance on each of the videos, we conducted a one-way MANOVA that included empathic accuracy z-scores for Videos 2–6 as dependent variables.To assess whether developmental stage and intelligence , Verbal Comprehension Index (VCI) and Perceptual Reasoning Index (PRI) should be included as a covariate within our primary analyses, separate Pearson correlations were used to examine the relationships between empathic accuracy (z-scores) with age and IQ scores. Separate Spearman’s rho correlations were used to examine the relationship between the empathic accuracy (z-scores) and the participant’s average Tanner score (the average of Tanner breast and pubic hair ratings were obtained). Significance across these correlations was determined by a Bonferroni correction, which was applied to control for multiple tests for developmental stage  and a Mann Whitney U test revealed no significant differences in groups on average Tanner stage  = 10.54, p = 0.00), PIC: F  = 11.63, p = 0.00); See Table p < 0.005). However, uncorrected p-values of p < 0.05 were observed for Video 3 for both age  and Tanner score  .The average r value for all participants on the empathic accuracy task prior to z-transformation was 0.65. SD = 0.29). A one way ANOVA revealed no significant differences between the two groups in age F1,24) = 1.97, ,24 = 1.9,24 = 1.99. A one 2 = 0.52). Between group effects revealed a significant difference for negative Video 5  = 4.26, p = 0.05, partial η2 = 0.15, TS mean = 0.90, SD = 0.21, TD mean = 1.11, SD = 0.30) and a trend towards significance and a medium effect size for negative Video 2  = 3.77, p = 0.064, partial η2 = 0.14, mean TS = 0.88, SD = 0.43, TD mean = 1.25, SD = 0.53). Significant between group differences were not found for positive Video 3  = 0.10, p = 0.75, partial η2 = 0.04, TS mean = 0.54, SD = 0.53, TD mean = 0.48, SD = 0.51), negative Video 4  = 0.23, p = 0.64, partial η2 = 0.01, TS mean = 0.95, SD = 0.58, TD mean = 0.85, SD = 0.46) or positive Video 6  = 0.31, p = 0.58, TS = 0.91, SD = 0.32, TD mean = 0.98, SD = 0.25).Figure p = 0.41, partial η2 = 0.08; Line 1 TS mean = 2.23, SD = 4.2; Line 1 TD mean = 2.49, SD = 3.8; Line 2 TS mean = 2.10, SD = 1.00; Line 2 TD mean = 2.40, SD = 0.77).Data were excluded from one TS participant who refused to complete the line-tracking task See Fig. . When exWe found evidence supporting our hypotheses that girls with TS differ from TD girls on empathic accuracy. Specifically, girls with TS as compared to TD controls demonstrated significantly lower empathy accuracy for the negative video about the death of the target’s dog, a trend towards lower accuracy for the negative video about moving away from one’s home for the first time. Though significant differences were not observed for the negative video about experiencing a breakup, girls with TS performed slightly better in comparison to TD controls. The positive video about being told “I love you” for the first time was excluded due to poor agreement across all participants. For the remaining positive videos, no group differences were found. However, for the positive video about excelling at a sports competition, girls with TS performed slightly better than TD controls and for the positive video about spending quality time with one’s family, TS participants performed slightly worse than the TD control participants See Fig. . TherefoOur results showing lower empathic accuracy for two of our three negatively valanced videos is consistent with the extant literature, which demonstrates impaired affect recognition for negative emotions in TS  than the positive videos . These results differ from a recent study in which participants rated empathic accuracy according to the video’s degree of emotional intensity  instead of valence; our study only examined emotional valence but not emotional intensity . Furthermore, they suggest that empathy accuracy differences could be associated with the emotional valence conveyed within the videos, although these findings are not definitive. Nonetheless, our empathy accuracy results in TS may contribute to the development of treatments aimed at improving social-emotional function in affected girls, such as the development of targeted empathy training. For example, if definitive deficits in empathy accuracy for negatively valanced stories is found in TS, then treatments aimed at helping girls with TS process their own negative emotions could be tested in order to determine whether this change in self emotion processing will impact empathy for negative emotions in another.Our study has several limitations. First, our sample size was small and we implemented a cross sectional design. Future studies should examine the impact of development by examining empathic accuracy longitudinally with larger samples. More study is needed in order to decipher the full extent of empathic deficits present in TS. Additionally, to further examine the full extent of empathy deficits in TS, the task should be pre-experimented to examine not only the valence but also the arousal, intensity and larger context of the stimuli. Results may be additionally influenced by the individual characteristics of study participants such as whether the participant can relate to the situation conveyed within the video and the participant’s own attachment style. They could also be influenced by the individual characteristics of the targets, such as the target’s sex, race, class and ethnicity, which would be important to examine in future studies. Specifically, one weakness of this study includes the potential generalisability of our stimuli to adolescent girls with TS. We chose to present videos of young looking targets who are just above 18 since they were old enough to consent to the use of their videos as research stimuli. However, because girls with TS tend to have friends who are either their age or younger, this may decrease the validity of how empathy influences friendships in girls with TS. Thus, future studies should examine empathy accuracy in girls with and without same age target stimuli. Moreover, another study weakness includes our limited range and number of stimuli, which should be increased for future replications of this study. We included only six videos, one of which was excluded due to poor agreement while another video was included despite it indicating moderate agreement. Therefore, further replication of this study should include a larger range of videos with good agreement.This is the first known study to examine empathic accuracy in girls with Turner syndrome as compared to age-matched controls. As hypothesized, we found between-group differences in empathic accuracy. Group differences did not appear to be due to visual-spatial deficits involved in rating the task, as demonstrated by intact accuracy for both groups on a visual moving line tracking task. Thus, our results suggest that the previously detected deficits for negative emotions may influence empathic accuracy abilities in TS during negatively valanced empathic interactions. However, more research is needed in order to identify the mechanisms underlying our findings. These deficits may help explain social cognition deficits and social anxiety in TS and could contribute to the development of novel treatments for the social deficits present in girls with this condition.


Coexistence theories develop rapidly at the ecology forefront, outpacing their experimental testing. I discuss the reasons for this gap, call on interdisciplinary researchers to construct a road map for coexistence research, and recommend the actions that should be implemented therein. Coexistence theories outpace their experimental testing. I argue that this imbalance results from a combination of interdisciplinary gaps, a disparity in research approaches, and the limited accessibility of the theory to experimentalists. I call on interdisciplinary researchers to construct a road map for coexistence research, recommend the actions that should be implemented therein, and illustrate how multiple mechanisms can be integrated under the same coexistence terms, thus constructing a research landscape that can create uniformity in their experimental designs. Since t2Experiments that test coexistence mechanisms are common in various fields, including microbial ecology, plant ecology, behavioral ecology, physiological ecology, evolutionary biology, community ecology, disease ecology, and spatial ecology. Interdisciplinary perspectives enable progress and are a cornerstone of science. However, in coexistence studies, due to the independent development of the mechanistic theories and the use of discipline‐specific terminologies and mechanistic formulations in the models, the potential of interdisciplinary approaches has been superseded by miscommunication and a tendency to “reinvent the wheel.” This miscommunication is represented in Table My perspective has emerged from personal experience. During my training as an experimental behavioral and community ecologist, coexistence studies focused on what we termed “the two obligatory coexistence requirements”: environmental heterogeneity and trade‐offs. My initial research area dealt mainly with resource, habitat, and temporal partitioning mechanisms, and to prove coexistence, my colleagues used habitat‐selection‐derived techniques Morris, . Later, ∗ prediction of the resource‐ratio mechanism  covariance between environment and competition must change between the resident  and invader (when the species is at low densities) states and (ii) buffered population growth so that for each species, growth under favorable conditions compensates for the unfavorable conditions Chesson, . However5I propose moving coexistence research forward in a more mechanistic manner by restoring the coexistence experiments that go beyond purely phenomenological approaches to ones pursuing more specific mechanisms. This should proceed in parallel with continuous progress in the phenomenological approaches. My original intention was to bring the various coexistence mechanisms under the same umbrella. However, from the multiple, sometimes contrasting, comments that I have received on my initial ideas, I realized that this is not a “one‐person job.” I therefore call on coexistence theoreticians, modelers, and experimentalists from different disciplines to join hands, keep an open mind, and construct a road map for coexistence experiments that will cross interdisciplinary barriers, study approaches, and model systems. Below, I recommend the actions that should be implemented in future interdisciplinary discussions.integrating all mechanisms under the same coexistence terms. In Table First, let's improve communication and merge the multiple discoveries by define the underlying assumptions and predictions in an operational way. Miller et al. ; Funding acquisition (lead); Investigation (lead); Project administration (lead); Writing – original draft (lead); Writing – review & editing (lead).The author declares no competing interests.


Haptosquilla trispinosa was able to easily distinguish several colours, including blue of both high and low saturation, from greys. The animals did show a decrease in performance over time in an artificially lit environment, indicating plasticity in colour discrimination ability. This rapid plasticity, most likely the result of a change in opsin  expression, has now been noted in several animal lineages (both invertebrate and vertebrate) and is a factor we suggest needs attention and potential re-examination in any colour-based behavioural tests. As for stomatopods, it remains unclear why they achieve poor colour discrimination using the most comprehensive set of spectral sensitivities in the animal kingdom and also what form of colour processing they may utilise.Stomatopod crustaceans, or mantis shrimps, are known for their extensive range of spectral sensitivity but relatively poor spectral discrimination. Instead of the colour-opponent mechanism of other colour vision systems, the 12 narrow-band colour channels they possess may underlie a different method of colour processing. We investigated one hypothesis in which the photoreceptors are proposed to act as individual wave-band detectors, interpreting colour as a parallel pattern of photoreceptor activation, rather than a ratiometric comparison of individual signals. This different form of colour detection has been used to explain previous behavioural tests in which low-saturation blue was not discriminated from grey, potentially because of similar activation patterns. Results here, however, indicate that the stomatopod  Summary: Stomatopods are able to distinguish both high and low saturation colours from greys, but this ability decreases over time under artificial lighting, suggesting plasticity in their colour vision. Mantis shrimp, or stomatopods, possess perhaps the most complex retina of all visual systems known . With 12While early behavioural tests demonstrated colour vision in stomatopods based on the von Frisch colour from greys paradigm , more reOdontodactylus scyllarus, could not discriminate a light blue feeding container from greys  by the dioptric crystalline cone elements, photoreceptor tiering and, in rows 2 and 3, photostable colour filters  Fig. 1A. While tThere are several hypotheses previously suggested to explain how mantis shrimps may process colour information. Based on initial anatomical evidence, it was originally proposed that photoreceptor signals outside the ultraviolet (UV) range, may be compared within each of the four colour-sensitive midband rows (1–4) C. This iAn alternative idea is that stomatopods may analyse colour information in a manner similar to the processing of auditory information by the cochlea, examining the chromaticity of light within each spectral band as a continuum of frequency, rather than using opponent processing . InsteadHaptosquilla trispinosa, to determine whether all low-saturation colours, not just blue , were collected on the shallow reefs around Lizard Island Research Station (LIRS) (GBRMPA permit no. G17/38160.1) during August 2018, 2019 and 2020. They were individually housed in aquaria with small PVC tubes to use as burrows and fed small pieces of raw shrimp. Experiments requiring training were conducted either at the LIRS, under shaded but natural daylight, or at the University of Queensland (UQ), on a 12 h:12 h light:dark cycle with salinity between 32 and 35 ppm. The UQ aquarium lights consist of fluorescent tubes combined to provide illumination as close as possible to natural daylight , the ratchet-end of the cable tie making a convenient small feeding dish and flat end on which to attach various coloured or neutral density (ND) filters , plus the distractor(s) cable tie(s)  presented in a pseudo-random order. After the second week, the animals that reached approximately a 70% rate of cable tie feeding were used for testing. Animals that did not participate were considered untrainable and were removed. This method is further described in Tests in which cable ties were not in contact with food were conducted once a day, 5 times a week. Additionally, mantis shrimp were trained once a week with food present to reinforce the behaviour. The stomatopods were given approximately 3 min to make a decision or were considered to not have participated. A trial began when the barrier inserted between the burrow and the stimulus  was liftThe combination of coloured cable ties and ND filters was made using a random number generator. Enough experiments were conducted so that each combination occurred at least once during all testing trials but not more than 3 times during both training and testing. The trials were ordered such that the target cable tie was not in the same location for two  or three  consecutive trials. If a mantis shrimp participated ≤2 times per week, for more than 1 week, it was considered untrainable, and therefore replaced.P<0.001), though no left/right bias was observed (P>0.5). Only one distractor was used in later experiments to prevent this bias, and in three-way choices, results were adjusted to account for this bias. These tests were exclusively conducted in captivity at UQ, beginning at least 3 months post-capture.In experiment 1, we investigated the original barcode hypothesis, the expectation being that the mantis shrimp might either find discrimination tests more difficult or fail them for all low-saturation colours. Animals were tested across eight colour types . Stomatopods were given a 3-choice test, with two ND distractors. However, after a while it was noted that animals significantly preferred the middle position of the target cable tie  1 week at LIRS; (2) weeks 1–10 at UQ under artificial lighting; and (3) in the final weeks of testing (weeks 10–20) at UQ. Animals at LIRS were trained and tested for 1 week, 3 times a day.All naive-choice tests were conducted in the LIRS aquarium system under natural lighting in which freshly caught animals were given 24 h to acclimate. Two-choice tests were conducted across all colours : (A) high-saturation preference, (B) low-saturation preference, (C) preference for high or low saturation, and (D) preference for colour versus ND grey. In high- and low-saturation tests (A and B), individuals were given a random pair of red, orange, green or blue stimuli of the same saturation type. In the saturation preference test (C), individuals were given a high- and low-saturation stimulus of a single colour. Finally, for colour versus grey preference (D), animals were given a randomised colour  and neutral grey  pair. Each individual was only used once in each experiment type; some were used in two different experiments because of collection restrictions. Individuals were given 30 min to make a choice. If an individual did not participate, it was tested again with the same choice for up to two additional sessions, and then replaced.Ability to learn the task was evaluated with a simple binomial test . This approach compares the number of times the mantis shrimp chose a particular stimulus with the number of times they would be expected to choose it by chance. Individuals were included in the analysis only if they were successful more often than expected by chance during training trials, as well as those that participated in at least 10 trials in experiment 1, and at least 3 trials at LIRS or 5 trials at UQ in experiment 2. Animals were assumed to have learned the task if they selected the target stimulus more often than chance. Experiment 3 analysis was also performed with a binomial test to determine significance between the two choices.Data from experiments 1 and 2 were analysed using the general linear mixed effects model package in R . There was an overall trend towards better performance with less saturated colours (P<0.05) and blue (P<0.0001), but not orange (P>0.05) or green (P>0.1) ( colours A. This w (P>0.1) .Fig. 5.Table S1A). These ND distractors were similar in brightness to the target stimuli (P>0.5).An average of 9 individuals per colour type participated in an average of 36 trials . There was no significant variation between individuals , all animals were able to learn the task successfully (P<0.001). In the second 10 week period in captivity (weeks 11–20), accuracy was severely diminished. During this time, animals were not able to choose the coloured stimulus significantly more than chance for all colours (P>0.05) ((P>0.05) .Table 2H. trispinosa became significantly less successful at selecting the correct stimuli after spending time in artificial light (P<0.001). After the first 10 weeks in captivity, animals became less effective at selecting red and blue high-saturation stimuli (P<0.05). In addition, animals learning highly saturated blue were more successful at LIRS in natural light than in the artificial lab light (P<0.05)  .Table 3P<0.0001). Animals did significantly better in trials with ND 0 (GLMM P<0.0001), when trained to green and blue , and at LIRS and in the first 10 weeks at UQ  (Table S1B).Individual variance in the linear mixed model was less than 0.2, and lower for most colours and time periods, except for highly saturated blue and at LIRS (approximately 0.5). On average, 6 individuals were used per colour with an average of 5 trials each at LIRS; 7 individuals per colour with 17 trials each during the first 10 weeks at UQ; and 5 individuals with 10 trials each during the second 10 weeks at UQ . AnimalsHaptosquilla trispinosa were given a 2-choice test to determine whether there was an innate preference for any of the colours or colour types. There was a significant preference for red  and aversion to green (P<0.05) among highly saturated colours (Table S2). colours A. No preP<0.05) but had no preference between saturation types for the other colours (Table S2). When stomatopods were given a choice between a colour filter and ND filter, they preferred the ND filter to all colours (P<0.05), but this was not significant when colours were analysed separately (P<0.05) .Other individuals were given a choice between the high- and low-saturation stimuli of each colour. Animals preferred low-saturation to high-saturation blue  failed on.The aim of this study was to examine colour processing in The results of our study did not clarify this debate in stomatopod vision . InteresH. trispinosa could learn to discriminate both high- and low-saturation colours from grey. This was an unexpected result as we originally proposed that all low-saturation colours would be harder to discriminate based on the results of Haptosquilla trispinosa demonstrated relatively poor discrimination of high-saturation orange and blue colours, compared with other colours; however, we suggest this was due to length of time spent in captivity, rather than being an accurate reflection of their visual capabilities. Extended time in captivity may reduce visual capacity as a result of the light spectrum being more limited than natural daylight, or possibly other influences such as a restricted diet . The preference for longer wavelengths is similar to the results of O. scyllarus. The nature of the tests conducted was different, but this comparison highlights a potential difference in colour behaviour between species. In addition, we found that H. trispinosa had no preference among low-saturation colours  females prefer males whose yellow claws are also UV reflective , and a degradation of performance over time kept in captivity .To find out whether the ability to distinguish both low- and high-saturation colours is more widespread among stomatopods, we repeated experiments 1 and 2 with Although the set of experiments described here have further explored the colour discrimination of stomatopods, even the basics of the colour processing mechanism remain unclear. It is possible that stomatopods use a combination of multiple mechanisms to process colour information in different behavioural contexts, including opponency and photoreceptor activation comparisons, or barcode analysis. In addition, although the retinal design and underlying structures are largely similar in all mantis shrimp species with six-row midbands, different species may process colour differently .Given that mantis shrimps display species-specific colour markings during encounters between and within species on the reef , it is wWhile the results of the experiments here have not led to firm conclusions, what is clear is that a number of previous experimental protocols in colour vision experimentation may need adjusting. The fact that vision changes over evolutionarily short time spans (reviewed in


Malnutrition is associated with adverse clinical outcomes in patients with inflammatory bowel disease (IBD), however, malnutrition screening is not routinely performed. This study aimed to identify the prevalence of malnutrition in patients with IBD and compare the accuracy of patient completed screens to a gold-standard malnutrition assessment tool: the dietitian-completed subjective global assessment (SGA).This cross-sectional study was conducted at 2 hospitals and 2 ambulatory care clinics in Alberta, Canada. Patients with IBD completed 4 malnutrition screening tools: abridged patient-generated SGA (abPG-SGA), Malnutrition Universal Screening Tool (MUST), Canadian Nutrition Screening Tool (CNST), and Saskatchewan IBD–nutrition risk (SaskIBD-NR). Risk of malnutrition was calculated for each tool and differences were compared between IBD subtype and body mass index (BMI) categories. Sensitivity and specificity, negative and positive predictive values (NPV and PPV), and area under the receiver operating characteristic curve (AUC) were calculated compared to SGA.n = 149) and ulcerative colitis (n = 96) participated in this study. Overall prevalence of malnutrition using SGA was 23% and malnutrition risk for CNST, abPG-SGA, SaskIBD-NR, and MUST was 37%, 36%, 36%, and 27%, respectively. Overall, the abPG-SGA had the highest sensitivity (83%), PPV (53%), and NPV (94%), and largest AUC (0.837) compared to SGA. For patients with a BMI ≥25 kg/m2, sensitivity and PPV of the abPG-SGA decreased to 73% and 41%, respectively, with a AUC of 0.841.Patients with Crohn’s disease (Malnutrition is prevalent in patients with IBD and using malnutrition risk screening tools such as the abPG-SGA may be useful to identify patients who would benefit from further assessment. Despite the recommendation for malnutrition screening, this is performed infrequently in clinical practice.5 There are several possible explanations for this including lack of IBD validated malnutrition screening tools applicable to both over- and underweight, and limited resources for implementing malnutrition screening in busy clinical settings.6Under and over nutrition are frequently observed complications in patients with inflammatory bowel disease (IBD) and are predictors of poor clinical outcomes in IBD including increased rates of infection, longer hospital stays, prolonged recovery time after surgery, and higher healthcare costs.7 The European Society of Clinical Nutrition and Metabolism (ESPEN)8 has proposed the SGA as a tool to diagnose malnutrition. Two studies have evaluated the association between SGA and clinical outcomes in IBD, with discordant results.10 One study associated SGA status with length of hospital stay,9 and the other study did not find correlations between SGA and hospitalizations, disease complications, or need for surgery.10 Nutrition assessment (including SGA assessment) is detailed and resource intensive, and typically conducted by a registered dietitian (RD) to confirm nutrition diagnosis and management. As RD access is a finite resource, it is not possible for all patients with IBD to be referred for nutrition assessment.In general populations, the subjective global assessment (SGA) is a validated nutrition assessment tool, and was predictive of major outcomes such as hospital length of stay, mortality, and postoperative outcomes.Malnutrition risk screening is intended to be a simple and rapid process used to identify patients who may benefit from a referral to a RD for detailed assessment and intervention. Early data demonstrate patients with IBD may be accurately able to self-screen for malnutrition. If true, this could enhance compliance with IBD malnutrition screening recommendations.11 were previously demonstrated, supporting the conclusion that both the patient and healthcare professional completed MUST screens will produce similar results when applied.Very good levels of agreement between the patient completed Malnutrition Universal Screening Tool (MUST) and the healthcare practitioner completed MUST screen in outpatients with IBDThe work to date has not however compared the performance characteristics of malnutrition self-screening tools to a health professional completed malnutrition assessment tool such as the SGA.12 compared to risk of malnutrition using patient reported screening tools. Patient completed screening tools included the abridged patient-generated SGA (abPG-SGA),13 Saskatchewan IBD–nutrition risk tool (SaskIBD-NR),14 the MUST,11 and the Canadian Nutrition Screening Tool (CNST)15; (2) to assess the accuracy of patient completed screening tools against SGA criteria; and (3) to compare results between participants with a body mass index (BMI) ≥25 to under 25, between IBD type and in- and outpatients. There is no accepted bedside gold-standard malnutrition assessment tool for patients with IBD. The ESPEN guideline3 acknowledged the detrimental outcomes associated with malnutrition, however did not recommend specific malnutrition assessment tools. SGA is a valid tool to diagnose malnutrition in general populations,8 and therefore is chosen as the gold-standard malnutrition assessment tool for this study.Accordingly, the aims of this cross-sectional study were to: (1) identify the proportion of patients who meet criteria for malnutrition using SGA criteriaThis was a cross-sectional study conducted at 2 hospitals and 2 IBD specialty clinics in Alberta, Canada from May 2017 to March 2018. Approval was obtained from the Health Research Ethics Board at the University of Alberta (Pro00073470) and the University of Calgary (REB17-0890). Written informed consent was obtained from all patients prior to study participation.All patients were 18 years and older and diagnosed with Crohn’s disease (CD) or ulcerative colitis (UC). Patients were ineligible if they were pregnant or had chronic renal failure on dialysis, chronic pulmonary disease on home oxygen, congestive heart failure with an ejection fraction <40%, were unable to provide informed consent and/or had English language difficulties.Participants independently completed the 4 screening tools  and provided demographic data  using an online or paper survey using the REDCAP data capture system. Patients were approached for participation at either an outpatient clinic at the University of Alberta or Calgary or if they were admitted to hospital and agreed to participate by trained research assistants. While a variety of malnutrition screening tools have been reported in the broader literature, the selected tools were of interest due to previous validation in outpatient settings in other disease types. The characteristics and scoring classifications for the 4 malnutrition screening tools are summarized in After this was completed a dietitian, blinded to previously completed data, performed a physical and nutrition assessment used to calculate SGA.16 for CD and the partial-Mayo score17 for UC were scored by the treating physician. These scores were then classified into 1 of 4 disease activity categories including remission, mild, moderate, or severe disease.18To assess disease activity, the Harvey–Bradshaw Index (HBI)12 Based on this evaluation patients are then classified as well-nourished (A), moderately malnourished (B), or severely malnourished (C). For more information and training on how to perform a SGA please see https://nutritioncareincanada.ca/resources-and-tools/hospital-care-inpac/assessment-sga.To diagnose malnutrition using SGA includes an evaluation of the history of recent nutrient intake , weight changes , severity of gastrointestinal symptoms affecting oral intake , functional capacity , and a physical examination of body fat, muscle mass, and presence of edema .14 and a malnourishment prevalence of 30%. With a precision of 0.10, the required sample size was approximately 180 patients using a validated nomogram for estimating the sensitivity and specificity of a medical test.19The primary aim of the current study was to calculate the sensitivity and specificity of the patient-led malnutrition screens compared to SGA for malnutrition. To calculate the sample size an estimated sensitivity of 83% of the screening tools was used as per similar studiest-test and categorical differences were evaluated with a Pearson’s chi-square test. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) for each of the patient completed malnutrition screens were calculated and compared to SGA. For these analyses, 2 levels of risk were considered “at risk of malnutrition” or “not at risk of malnutrition” for each screening tool. In addition, a receiver operating characteristic curve (ROC) analysis was used to identify the area under the curve (AUC) and to examine optimal cut-points for each screening tool as a continuous measure compared to SGA. Statistical significance was set at P < .05. Statistical analysis was performed using SPSS statistical software .All statistical analyses were completed 3 ways: for the sample as a whole and divided by BMI and IBD type. Continuous variable differences between the groups were evaluated with an independent 2-sided 2, 51% were male, 16% were current smokers, 82% were outpatients, and 21% had been hospitalized for an IBD-related event in the past 12 months. Patients with a BMI ≥25 kg/m2 were significantly older (P = .04), more likely to be a smoker, an outpatient, and on biologics . Patients with a BMI <25 kg/m2 had a higher disease activity (P < .05) and less of an appetite (P = .03). Fewer patients with UC compared to CD were smokers (P = .001), and a greater proportion of UC patients were hospitalized inpatients (P = .008), on 5-aminosalicylic acid (P < .001) with greater disease activity (P = .001). Additional baseline patient demographic and health characteristics are summarized in 2 compared to BMIs ≥25 kg/m2 (P = .005) and had a diagnosis of UC compared to CD (P = .007).Two hundred forty-nine patients were recruited for this study and all patients who were recruited completed the screening tools, height and weight measurements, and dietitian-led SGA assessment. Four patients were excluded from analyses due to missing data or inaccurate diagnosis of IBD. This left a final sample of IBD 149 (61%) CD and 96 (39%) UC patients. Mean age and BMI for all patients with IBD were 42 (SD = 16) years and 26.2 (5.4) kg/mP < .05). In addition, hospitalized patients compared to outpatients were much more likely to be classified as malnourished using SGA .For all patients with IBD, HBI, and partial-Mayo scores were significantly higher in the “at risk of malnutrition” groups for all patient completed malnutrition screening tools and for SGA (P < .001). The MUST had the highest specificity at 81.8% compared to the abPG-SGA specificity of 77.7%.The accuracy of the screening tools compared to SGA criteria is summarized in 2, the sensitivity of the abPG-SGA was highest at 88.6% with a PPV of 62.0%, a NPV of 93.4% with an AUC of 0.831 (P < .001). The SaskIBD-NR screening tool had the highest specificity of 76.3% compared to 75.0% in the abPG-SGA.For patients with a BMI <25 kg/m2, the sensitivity of the abPG-SGA was highest at 72.7% with a PPV of 41.0%, a NPV of 93.7%, and an AUC of 0.841. The MUST screening tool had the highest specificity at 90.2% in contrast to 79.5% in the abPG-SGA. In patients with a BMI ≥25 kg/m2 the ROC analysis identified a cut-point of 3.5, versus the cut-point of 6.0 used in this study, improved the sensitivity of the abPG-SGA to 86.4% (95% CI = 66.7–95.3) with a small decrease in specificity and PPV to 72.3% (63.4–79.8) and 38.0% (25.9–51.8), respectively, while NPV increased to 96.4% (90.0–98.8).In patients with a BMI ≥25 kg/mP < .001), respectively.In both IBD subtypes , the abP2 to 32.3% in UC patients; more patients were classified as malnourished who had a BMI <25 kg/m2 and who had UC. The higher prevalence of malnutrition observed in UC patients may in part be explained by a higher proportion being hospitalized inpatients with greater disease severity; risk of malnutrition was positively associated with higher disease severity for all the patient completed tools (P < .05). In this population, we concluded the patient-led abPG-SGA appeared to be superior to the other tools to identify patients at risk of malnutrition in need of further assessment. The CNST may also be a useful tool in inpatients versus outpatients . While the performance characteristics of the patient-led abPG-SGA compared to SGA has not been determined previously in patients with IBD, a Chinese study in 78 patients demonstrated that fat free mass indices negatively correlated with long-form PG-SGA scores and disease activity.21Similar to our study, data in oncology patients demonstrates high sensitivity (80%–94%) and good specificity (72%–78%) of the abPG-SGA for detecting malnutrition.2 (88.6%); however sensitivity decreased to 72.7% in those with a BMI ≥25 kg/m2. Changing the cut-point of the abPG-SGA to 3.5 from 6 increased sensitivity to 86.4% with only a small decrease in specificity (−7.2%) in the higher BMI group. Using these criteria in those with a BMI ≥25 kg/m2, the abPG-SGA only misclassified 3 patients as not being at risk of malnutrition who had a SGA B or C, and identified 31 patients as at risk of malnutrition who were classified as well-nourished, SGA A. Misclassification of risk may either lead to under-recognition of malnutrition risk and failure to refer to a nutritional professional for timely and detailed malnutrition assessment and therapy, or increased unnecessary RD referrals increasing healthcare costs.For the patient completed screening tools the patient-led abPG-SGA had the highest level of sensitivity to detect risk of malnutrition in patients with BMI <25 kg/mStudy strengths included the sample size, multicenter recruitment, and use of multiple nutrition screening and assessment methods to identify risk and prevalence of malnutrition. Limitations include that the study population was limited to 2 hospitals and 2 outpatient IBD tertiary Canadian centers, was largely Caucasian, and may not reflect the age, disease type, patient status, or BMI characteristics of other populations. It remains to be seen whether these tools will have similar test characteristics in different populations of patients, including a cohort representing only hospitalized patients, and this requires further evaluation. Furthermore, we have not addressed the Global Leadership Initiative on Malnutrition (GLIM) nutrition assessment criteria in this manuscript. The nutrition community has expressed concerns about a lack of gold-standard nutrition assessment tool that can be applied at the bedside to identify malnutrition in IBD. The GLIM criteria offer a promising solution to this clinical gap. The GLIM criteria include both phenotypic  and etiologic  criteria for the diagnosis of malnutrition and this combined approach may guide nutrition interventions and expected outcomes. While the GLIM criteria concepts are encouraging as a malnutrition diagnostic tool, as they consider dietary, clinical and muscle measures, these have not been validated in general clinical populations, or in IBD. Moreover, a hierarchy for determining the components to include in the GLIM assessment has not been provided. Further validation of the GLIM is required before it can be considered as the gold standard from which to diagnose malnutrition.Given the moderate to high prevalence of malnutrition in patients with IBD, patient self-screening for risk of malnutrition is a promising approach to identify high risk patients who may benefit from malnutrition assessment and intervention by a nutrition care professional. Incorporating patient completed malnutrition screening tools into routine clinical practice may reduce the burden of malnutrition and its consequences, without imposing strain on existing limited resources. The abPG-SGA is a promising malnutrition screening tool in patients with IBD and can be completed by patients in the waiting room or in hospital. Future research directions include the cost–benefit analysis of using malnutrition screening tools to identify malnutrition risk, and ability of these tools to predict IBD-related clinical outcomes.otab043_supp_Supplementary_Table_S1Click here for additional data file.


Autonomic arousal is believed to be an underlying reinforcer for problematic gambling behavior. Theories suggests that near-misses  are structural characteristics affecting emotion and motivation while increasing gambling persistence.Psychophysiological responses to different outcomes in gambling were investigated in a community-based sample of young adults. Furthermore, sex differences in responses to different gambling outcomes were investigated.Young adults (n=270) performed a simplified virtual slot machine producing wins, two types of near-misses (before/after payline) and full-misses, with simultaneous measurements of heart rate (HR) and skin conductance responses (SCR). Self-reports of perceived chance of winning, pleasure and motivation to play were given by the participants on each trial.Near-misses were associated with the largest HR acceleration compared to wins and full-misses, and larger HR deceleration and SCRs compared to full-misses. Differential autonomic and subjective reports were observed for near-misses subtypes, suggesting that near-misses are processed differently depending on their position before or after payline. Females showed larger SCR responses and increased motivation following wins compared to males.Slot machine gambling outcomes elicit differential physiological and subjective responses in young adults. Specifically, near-misses produce larger autonomic responses compared to regular full-misses. However, near-misses are complex, multifaceted events producing various emotional responses depending on their characterization. Males and females respond differently to wins, highlighting the importance of considering sex differences in experimental research on autonomic responses in gambling.No significant relationships.


SD = 1.28) before COVID-19-pandemic-related lockdown, and Study 2 was conducted with 1,204 high school students  during COVID-19-pandemic-related lockdown. A path analysis was carried out to analyze the significance of indirect effects from LB use to gambling behavior and problem gambling through video gaming and problem video gaming. In both the studies, results showed that LB use exerted significant and positive direct effects on video gaming frequency, problem video gaming, and gambling frequency. Moreover, LB use had indirect significant and positive effects on problem gambling through video gaming frequency, problem video gaming, and gambling frequency. Findings attest that LB use can be related to problem gambling through a greater involvement in videogames. Thus, a specific subtype of young gamblers can develop Gambling Disorder symptoms from the use of LBs and through an intense use of video games. Practical implications for prevention and treatment are discussed.Loot Boxes (LBs), i.e., virtual items embedded within video games with numerous features reminiscent of gambling, are increasingly widespread among adolescents. LB use is associated with problem gambling in youth, but few studies have been conducted on the association between LB use and gambling behavior considering adolescents. Thus, the mechanisms underlying this relationship are not clear. As LB use is a significant and positive risk factor for video gaming severity, and video gaming is associated with problem gambling, we hypothesized that LB use would be related to gambling frequency and problem gambling through the intermediary role of video gaming frequency and problem video gaming. We tested our hypothesis before COVID-19-pandemic-related lockdown and during COVID-19-pandemic-related lockdown, in Italy. Study 1 was conducted with 1,078 high school students (39% boys, mean age = 16.46,  Loot Boxes (LBs) can be defined as virtual items embedded within video games that players can open with real-world money to get the chance of obtaining one or more virtual rewards. One of the main characteristics of LBs is that the reward is subjected to chance; therefore, players do not know which virtual reward they will get from their purchases. Features of LBs vary across games. Some of them give advantages in multiplayer games as reward , while obecause they require no player skill and have a randomly determined outcome.” This similarity was confirmed by Money transactions and the chance-based nature of LBs have led researchers to examine if LBs can represent a form of gambling, that can be defined as an activity that takes place when an item of value, usually money, is staked on the outcome of an event that is, to some degree, unpredictable . In thisGambling activities, such as sport bets, scratch cards, or cards for money, are widely spread among adolescents with 60% or more of them that wagered at least once a year . SeveralConsistent with the theoretically hypothesized association, some studies have found a relationship between LB use and problem gambling e.g., . In adulHowever, despite some research, relatively few studies have been conducted on LB use in general with adolescents, as highlighted by recent reviews , and, spConcerning the association of LB use with video gaming, since LBs have video games features and they are embedded into video games, some studies have tried to better understand the relationship that LBs have with video gaming, both in terms of frequency and severity. Overall, these studies observed that LBs spending is associated with video gaming frequency  and the With regard to the relationship between the use of video games and gambling behavior, this topic has received increasing interest in the last 30 years, with some studies that have found an overlap between these two behaviors among the juvenile population. In summary, we know from the literature that: (i) LB use is associated with gambling behavior e.g., ; (ii) LBWe expected to find that video-gaming behavior would be the mediator between LB use and gambling behavior. In other terms, we predicted that an intense use of LBs would be associated with intense video gaming behavior and, in turn, with a great involvement in gambling and, consequently, with a high level of gambling problem severity. To verify this kind of relationships among the variables, we developed two studies with Italian adolescents. In Study 1, we investigated the adequacy of the predicted model before COVID-19-pandemic-related lockdown. In Study 2, we analyzed the same model in a different historical period, i.e., during COVID-19-pandemic-related lockdown. In this regard, Italy has been the first European country to be affected by the virus in March 2020, and the first to adopt restrictive measures of social distancing. The COVID-19 pandemic led to many changes in people’s daily lives, not only because of the mandatory quarantine and restrictions that involved social estrangement, but also because of the fear of getting infected, which influenced individuals’ mental health . RestricAs for gambling, among the government’s restriction measures, most gambling activities with physical presence were banned from 12 March to 12 June, 2020 , as wellThus, given the specificity of the pandemic period, characterized by a high stimulation of video gaming and mostly online gambling, we aimed at take advantage from this particular situation to verify the explanation power of LB use on gambling through video gaming even in times in which youth had potentially more time to game and gamble, especially under the stressful conditions characterizing the pandemic. If Loot Boxes exerted a robust effect, it would have prevailed even during the pandemic. In sum, we hypothesized that both during a usual lifetime for adolescents and during a period of extensive stimulation to Internet and video gaming, an intense use of LBs would lead adolescents to high video gaming behavior and, in turn, to a great involvement in gambling and, consequently, to a high level of gambling problem severity.Adolescents seem to be increasingly involved in LBs, and research highlights that the familiarity with the LBs is related to video gaming and gambling. However, the mechanisms of these relationships are not clear yet. In response to this gap, the aim of Study 1 was to deeply investigate the relationships between the use of LBs, video gaming behavior, and gambling behavior among adolescents by testing the adequacy of a path model in which LB use was seen as the independent variable, video gaming frequency, problem video gaming, and gambling frequency were considered as mediators, and problem gambling was conceptualized as the outcome variable. We also aimed at having more detailed information about these three behaviors in a wide sample of Italian adolescents. This study was conducted before the beginning of the COVID-19-related pandemic.Mage = 16.46, SD = 1.28, range: 13–20 years) attending eight public high schools in urban  and suburban centers in the North East of Italy (Veneto). Specifically, 9% (n = 98) of adolescents attended professional training centers, 8% (n = 90) of adolescents attended a professional high school, 46% (n = 500) of adolescents attended a technical school, and 36% (n = 390) a lyceum. High school in Italy consists of 5 years of education. The sample included 10% (n = 110) first-year students, 12% (n = 132) second-year students, 22% (n = 232) third-year students, 45% (n = 483) fourth-year students, and 11% (n = 121) fifth-year students. The collaboration with schools was part of a larger regional gambling prevention program . Once the schools agreed to participate, the detailed study protocol was approved by the institutional review boards at each school. Written informed consent was requested from the students’ parents, assuring them that the data would be handled confidentially. The research was conducted at school, during school time, during September–December 2019.Participants were 1,078 adolescents  Have you opened a loot box during your video gaming sessions?; (3) Have you bought a loot box, or a key to unlock it, during your video gaming sessions? In order to have a quantitative measure of LB use, in the scoring phase, an LB use index was computed by summing the responses  to the above-reported questions.To assess LB use, the three following questions were administered to high school students: (1) Video Gaming Scale – For Adolescents  they engaged in a list of 16 game genres, based on a previous game genre classification , few times (1), and many times (2). The advantage of using this instrument is that the scoring system has been developed by applying Item Response Theory (IRT), in order to have a measure of problem gaming that took into account the severity of each symptom described by the items. Thus, the total score represents a weighted score based on the specificity of the items endorsed (in terms of its own severity and discrimination power) and the response endorsed (few times or many times). The IRT-based score allows for the classification of adolescents into non-problem, at-risk, and problem video gamers. The VGS-A is an efficient tool to assess mid-to-high levels of the DSM-5 Gaming Disorder criteria in adolescents.To investigate video gaming behavior, the s VGS-A;  was empls VGS-A; . Both sefication . By summGambling Behaviour Scale for Adolescents  of participation during the last year in ten gambling activities . Based on their responses to this section, participants were identified as non-gamblers (no gambling behavior) or gamblers  to Often (2). Based on the responses to this section, it is possible to derive an Item Response Theory-based score for each respondent. Following this IRT-based scoring procedure, respondents can be classified into non-problem gamblers, at-risk gamblers, and disordered gamblers. The GBS-A has been shown to be unidimensional and useful for mid-to-high levels of Gambling Disorder severity  of the participants found at least one LB during video game playing sessions, 73% (n = 791) opened it, and 25% (n = 268) purchased it. By summing responses to the three items, the obtained composite score, i.e., the LB use, had an average value of 2.29 (SD = 0.53).Most of the participants were familiar with the LBs. Over the last 12 months, 76% (n = 986) declared to play video games in the last 12 months. Video gamers had a mean age of 16.47 years  and 65% (n = 639) of them were males. The most practiced game genres were Action games, followed by First Person Shooter games, Real Time Strategy games, and Sport games. Concerning video gaming, most of the participants . Console , computer , and tablet  were less used.Adolescents reported to play video games mostly by using smartphones (n = 708) were non-problem video gamers, while 23% (n = 223) were at-risk video gamers, and 5% (n = 54) were problem video gamers.Regarding problem gaming, almost three-quarter of the video gamers  of the participants gambled on at least one gambling activity over the last 12 months. Gamblers had a mean age of 16.49 years  and 67% of them (n = 510) were males. Among the gamblers, 25% (n = 194) were regular gamblers. The most engaged activities resulted to be Scratch cards, Bingo, and Cards for money. The prevalence of gamblers on each gambling activity is reported in With respect to gambling, findings showed that 71% (n = 66) of the gamblers were non-problem gamblers, 10% (n = 73) were at-risk gamblers, and 2% (n = 20) were problem gamblers.As concerns problem gambling, 88% . As hypothesized, LB use had a significant and positive direct effect on video gaming frequency, problem video gaming, and gambling frequency. Moreover, video gaming frequency exerted a significant and positive direct effect on problem video gaming and gambling frequency, which, in turn, had a positive direct effect on problem gambling .Results also showed significant and positive indirect effects: (i) from LB use to problem video gaming, passing by video gaming frequency; (ii) from LB use to gambling frequency through problem video gaming; and (iii) from LB use to problem gambling through problem video gaming. Moreover, video gaming frequency had significant positive indirect effects on gambling frequency and problem gambling with the intermediary role of problem video gaming, and problem video gaming exerted a significant and positive indirect effect on problem gambling through gambling frequency .The aim of Study 1 was to investigate the relationship between the use of LBs, video gaming behavior, and gambling behavior among adolescents. Secondary objectives regarded the analysis of these behaviors in a wide sample of adolescents.Findings attest that the majority of the sample knows LBs and one out of four students purchased them while playing video games. Our data confirm and extend the previous scan research studies with adolescents . ConsistIn response to the necessity to better investigate the relationship between LB use, video gaming, and gambling , our finTo verify if the set of relationships among LB use, video gaming, and gambling in adolescents found in Study 1 maintained also during the pandemic lockdown, a period of extensive stimulation to Internet and video gaming, we also conducted a study during COVID-19-pandemic-related lockdown. Indeed, both internationally and nationally, in this period, there has been an increase of video gaming behavior among the younger generations  with enhMage = 16.10, SD = 0.65, range, 15–19 years) attended 26 public high schools in urban and suburban centers in the Center of Italy (Tuscany). In detail, 5% (n = 65) of adolescents attended professional training centers, 16% (n = 195) of adolescents attended a professional high school, 33% (n = 398) of adolescents attended a technical school, and 45% (n = 546) attended a lyceum. All the students were attending the second year of high school. In detail, 41% of the schools were located in the center of Tuscany, 21% of the schools were in the North-West of the Region, and 38% of the schools were placed in the South-East of Tuscany.One thousand two hundred and four adolescents , in which the issue of video gaming and micro-economic transitions inside video games was investigated. The project was approved by the institutional review boards at each school. Written informed consent was requested from the students’ parents. As the study was conducted during May–June 2020, period in which the Italian high schools were under the remote teaching regime, the research was conducted during school time but through an online administration. In other terms, students were at their own homes, and they completed the research protocol through an online platform.The instruments used were the same employed in Study 1. Socio-demographic information, such as gender, age, and school, was still requested.LB use was assessed through the same three questions. However, to have a response related to the period of the COVID-19-related pandemic, the questions were explicitly referred to the last 12 months, instead of the last 12 months, as in Study 1. By summing the responses , we obtained a measure of LB use.The VGS-A  was usednever, once in the month, sometimes in the month, sometimes in the week, and daily. Overall, with the first section, we investigated the presence of a gambling behavior, gambling frequency by gambling activity, and in general, as well as the presence of a regular gambling behavior. Through the second section, consisting of items assessing the DSM-5 diagnostic criteria for Gambling Disorder, we derived a quantitative measure and a categorical variable about the severity of gambling behavior.The GBS-A  was emplThe above-described scales were administered through an online link with a Google Forms. Students were at home. They were required to work individually. The order of presentation was the following: GBS-A, VGS-A, and the questions about the LB use. Administration of the instruments was realized by the intervention providers of the PRIZE project, and it required ~40 min.n = 623) of adolescents encountered at least one loot box playing video games, 52% (n = 605) opened it, and 9% (n = 110) purchased it. The mean score of the LBU was 1.16 (SD = 1.09).More than half of the sample had some experience with the LBs. Specifically, 54%  resulted to play video games. Video gamers had a mean age of 15.56 years , and 62% (n = 657) of them were males. The most practiced game genres were First Person Shooter games, followed by Action games and Sport games. Most of the participants . Console , computer , tablet , and handheld console  were less used.The most used device to play video games was the smartphone (n = 811) were non-problem video gamers, 19% (n = 194) were at-risk video gamers, and 3% (n = 31) were problem video gamers.The majority of the video gamers  of the participants gambled on at least one gambling activity. Gamblers had a mean age of 15.62 years  and 61% of them (n = 434) were males. Among the gamblers, 25% (n = 176) were regular gamblers. The most engaged activities resulted to be Online gambling activities, Scratch cards, and Bingo. The prevalence of gamblers on each gambling activity is reported in Concerning gambling, 60% (n = 579) were non-problem gamblers, 11% (n = 78) were at-risk gamblers, and 5% (n = 35) were problem gamblers.Eighty-four percent of the gamblers  from LBU to problem video gaming, passing by video gaming frequency; (ii) from LBU to gambling frequency through problem video gaming; (iii) from LBU to problem gambling through problem video gaming; (iv) from video gaming frequency to gambling frequency and problem gambling with the intermediary role of problem video gaming; and (v) from problem video gaming to problem gambling through gambling frequency .In Study 2, we aimed at verifying if the set of relationships among LB use, video gaming, and gambling in adolescents found in Study 1, i.e., before the COVID-19-related pandemic, was still adequate considering the high stimulation of the Internet and video games that occurred during the COVID-10 pandemic. First, concerning the prevalence of the behaviors under attention in this work during this specific time frame, we found that more than half of the sample knows LBs and 9 % of the students purchased them while playing video games. The large majority of adolescents played video games, especially, First Person Shooter games, Action games, and Sport games, and mainly by using the smartphone. As for gambling. 60% of the participants gambled on at least one gambling activity, with a quarter of them that was regular gamblers. The most engaged activities resulted to be Online gambling games, Scratch cards, and Bingo. With respect to the COVID-19-specific research studies, the prevalence of video gamers is in line with data available , as wellFindings of Study 2 indicated that the path model verified in Study 1 concerning the relationships between LB use and problem gambling through video gaming frequency, problem video gaming, and gambling frequency was still adequate in time of pandemic. Comparable coefficients with respect to Study 1 were found for direct and indirect effects. Thus, we supported our hypothesis that, even in a period of increased invitations and stimulation of using the Internet and video games, higher use and familiarity with the LBs makes adolescents more at risk of developing symptoms of problem gaming by spending more time on the video games. As a consequence, youth are at risk of becoming more involved in gambling and to develop pathological gambling.Two recent reviews  clearly gamblified”; in turn, gambling activities have increasingly adopted some features of gaming  had similar structural characteristics . For exaf gaming , creatinf gaming . FollowiThe results provide important implications from a practical perspective in terms of prevention and treatment. For prevention, although several preventive approaches exist in literature , currentPolitical reflections can be drawn from the present work, in line with what is supported by other researchers . Being LSome limitations characterized this work. First, both the studies have a correlational nature. The cross-sectional design does not allow us to establish temporal and causal relationships between the variables. Moreover, although the role of the various variables in the path model  was based on previous research findings, future longitudinal studies should be important to give robustness to our findings. Second, although the same instruments have been used in Study 1 and Study 2, the pandemic does not allow for a traditional paper and pencil in-person administration of the scales. Thus, there is not a completely equal situation in terms of assessment across the two studies. Future studies should further support and extend our model, for instance by including in the model other relevant variables. In this regard, as The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Schools’ Committees. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.CP and MD: conceptualization. FS, MV, and MD: data curation and investigation, methodology, and writing—original draft. MD: statistical analysis. CP and ES: supervision and writing—review and editing. All authors contributed to the article and approved the submitted version.Study 1 was funded by the Veneto Region connected to the funding assigned by DGR n. 749, 28 May 2018. The regional funding concerns the prevention and contrast of pathological gambling. Study 2 was funded by the Tuscany Region  through ANCI TOSCANA .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.