Rangifer tarandus granti) across Alaska, USA and the Yukon, Canada. First, we characterized caribou behavior. Second, we tested if videos could be used to quantify changes in the probability of eating events. Third, we estimated summer diets at the finest taxonomic resolution possible through videos. Finally, we compared summer diet estimates from video collars to microhistological analysis of fecal pellets. We classified 18,134 videos from 30 female caribou over two summers (2018 and 2019). Caribou behaviors included eating (mean = 43.5%), ruminating (25.6%), travelling (14.0%), stationary awake (11.3%) and napping (5.1%). Eating was restricted by insect harassment. We classified forage(s) consumed in 5,549 videos where diet composition (monthly) highlighted a strong tradeoff between lichens and shrubs; shrubs dominated diets in June and July when lichen use declined. We identified 63 species, 70 genus and 33 family groups of summer forages from videos. After adjusting for digestibility, monthly estimates of diet composition were strongly correlated at the scale of the forage functional type . Using video collars, we identified (1) a pronounced tradeoff in summer foraging between lichens and shrubs and (2) the costs of insect harassment on eating. Understanding caribou foraging ecology is needed to plan for their long‐term conservation across the circumpolar north, and video collars can provide a powerful approach across remote regions.Summer diets are crucial for large herbivores in the subarctic and are affected by weather, harassment from insects and a variety of environmental changes linked to climate. Yet, understanding foraging behavior and diet of large herbivores is challenging in the subarctic because of their remote ranges. We used GPS video‐camera collars to observe behaviors and summer diets of the migratory Fortymile Caribou Herd ( Rangifer tarandus granti) across Alaska, USA and Yukon, Canada. Using video collars, we identified (1) a pronounced tradeoff in foraging between lichens and shrubs and (2) the costs of insect harassment on eating in summer.Summer diets are crucial for subarctic herbivores and are affected by weather, insect harassment and a variety of environmental changes linked to climate. We used GPS video‐camera collars to observe behavioral patterns and summer diets of migratory caribou ( Caribou are an important cultural, socioeconomic and ecological resource across the circumpolar north . To improve efficiency, we classified videos using two phases. In the first phase (in blue), volunteer observers (citizen scientists) viewed videos to identify caribou behaviors and other supplemental information see Appendix ppendix A22.12 region across east‐central Alaska and north‐central Yukon  forests, deciduous forests, shrubland and herbaceous tundra .2.3n = 18) or tranquilizer dart . Caribou were then fitted with a GPS‐Iridium collar integrated with a camera and pre‐programmed with a drop‐off mechanism programmed to release on September 10 each study year .During March and April of 2018 and 2019, a total of 30 adult female  caribou were captured from a helicopter with a netgun (Video collars were programmed to record videos during daylight hours (14–18 h/day). For all programming periods from May to September, collars recorded a 9‐s video and GPS location every 20 min during daylight hours Appendix ppendix A2.4We classified caribou behavior from videos into states of eating, ruminating, travelling, stationary awake, napping and others. We explored differences in behavior between/across (1) individuals, (2) years and (3) months, and contrasted frequencies of videos classified into different behaviors using one‐way Chi‐square goodness‐of‐fit contingency tests , as a second estimate of summer caribou diet. Fecal pellet collection was targeted in areas with locations from GPS radiocollared females. Such locations represented an unknown mix of ages and sexes, though predominantly females based on GPS collar locations. Fecal samples were obtained from up to 25 distinct pellet groups and combined into a composite sample for each collection site. Unlike the video diet analysis, the composite fecal sample was the sampling unit during microhistological analyses .We tested the taxonomic resolution between diet composition estimates from video collars and microhistology. We focused on the seven forage functional types (FFT) that occurred across both video collar and fecal data sets: 2.7.2We measured apparent dry‐matter digestibility , and two collars malfunctioned and stopped recording videos . We used data from collars prior to death or failure. We obtained a total of 176,150 videos over two summers (2018 and 2019). We viewed and collected behavioral data from 45.34 h of video footage that consisted of 18,134 videos . We worked with 91 volunteer observers who qualified through the evaluation process and logged approximately 604 h of effort to classify the 18,134 videos. Video quality was subjectively classified as fair, good or excellent in 91% of video clips, poor in 8% and extremely obstructed in 1%. In most of the “extremely obstructed” videos, data could reliably be collected; most obstructions (71%) occurred as caribou foraged on ground‐level vegetation, neck or jaw fur obstructing the view, or as caribou napped (11%).3.2χ2 = 7.55, df = 5, p = .18); therefore, we lumped data between years. Behavior did vary across months  and individual females , ruminating 25.6%), travelling (14.0%), being stationary awake (11.3%), napping (5.1%) and others , forbs (6.4%), graminoids (7.0%), ground‐level vegetation (8.7%), lichen (39.4%), moss (0.4%), mushroom (1.7%), shrubs (36.7%) and unknown forages , Salix pulchra (8%) and Betula nana/glandulosa , forbs (3.8%), graminoids (11.6%), lichen (59.4%), moss (6.7%) and shrubs . Dominant lichens belonged to the Cladina/Cladonia genera (38.4%). Lichen dominated the diet across all months , lichen , graminoids  and forbs  for 167 plant samples across four forage functional types: shrubs . Diet estimates for monthly lichen  were not correlated between the video collar and microhistological methods; however, estimates for monthly shrub  were marginally statistically significant.We found a positive correlation between the proportions of forage functional types estimated across months  higher dietary diversity by discerning forage types at finer taxonomic levels than fecal sampling and (2) a strong temporal tradeoff in the consumption of lichen and shrubs. Our work demonstrates video collars are useful, especially in remote regions like the arctic, to document behavior and diet.n = 14) classified >300 videos. Similar to Thompson et al.  alter forage selection and induce behavioral responses by caribou  and tabanids (Tabanidae). In addition, caribou collar temperature  evolved stripes to confuse and prevent flies from landing and probing for blood  may be susceptible to overuse during phases of high caribou abundance, although shrubs can recover quickly from periods of intense grazing. However, both diet methods showed a high diet content of lichen during summer. Macander et al. ; data curation (lead); formal analysis (lead); investigation ; methodology (lead); project administration ; supervision ; visualization (lead); writing–original draft (lead); writing–review and editing (lead). Gabrielle Coulombe: Data curation ; methodology (supporting); project administration (supporting); writing–original draft (supporting); writing–review and editing (supporting). Jim Herriges: Conceptualization ; data curation ; funding acquisition (lead); investigation (supporting); methodology (supporting); project administration (supporting); resources ; writing–review and editing . Torsten Bentzen: Conceptualization ; data curation ; funding acquisition (supporting); investigation (supporting); methodology (supporting); resources ; writing–review and editing . Michael Suitor: Conceptualization ; data curation ; funding acquisition (supporting); investigation (supporting); methodology (supporting); resources ; writing–review and editing . Kyle Joly: Formal analysis (supporting); funding acquisition (supporting); methodology (supporting); resources (supporting); writing–review and editing . Mark Hebblewhite: Conceptualization ; data curation (supporting); formal analysis (supporting); funding acquisition (supporting); project administration (supporting); resources (supporting); supervision (supporting); writing–review and editing .


HCN4 activity in bone marrow mesenchymal stem cells (BMSCs). The sample of BMSCs was divided into six groups: a control group, a high-dose SFI group (0.25 ml/ml), a middle-dose SFI group (0.1 ml/ml), a low-dose SFI group (0.05 ml/ml), an adenovirus-encoded control vector group, and an adenovirus-encoded HCN4 group. Cell ultrastructure was observed using a transmission electron microscope. Quantitative reverse transcription PCR (RT-qPCR) was performed to detect HCN4 expression, and HCN4 activity was detected using the whole-cell patch clamp technique. An enzyme-linked immunosorbent assay was performed to detect cAMP content. Application of flow cytometry confirmed that the isolated cells showed BMSC-like phenotypes. Differentiation of BMSCs in both the SFI and the adenovirus-encoding HCN4 groups occurred according to the cellular ultrastructure. Application of the whole-cell patch clamp technique revealed that SFI could activate the inward pacing current of BMSCs in a concentration-dependent manner. The RT-qPCR results showed that HCN4 expression was significantly higher in the high-dose SFI group than in the medium- and low-dose groups, whereas the cAMP content in the overexpressed HCN4 group decreased significantly; this content in the high-dose SFI group increased significantly. In conclusion, SFI promotes HCN4 activity in BMSCs, which could explain its treatment effect when administered to patients with cardiovascular diseases.We investigated the effects of Shenfu Injection (SFI) on  Sick sinus syndrome (SSS) refers to a group of heart rhythm disorders caused by problems relating to the sinus node. Currently, there is no effective treatment for SSS, and an electronic pacemaker is required to support heart function in SSS patients . HoweverTbx18-induced phenotypic transformation of bone marrow mesenchymal stem cells (BMSCs) into pacemaker-like cells [HCN4 gene is the molecular basis of pacemaker current, which, through depolarization, provides a large proportion of inward current and plays an important role in the generation and autonomous regulation of the heart rate [With advancing gene and cell therapy techniques, the potential development of biological pacemakers is a topic of considerable interest . Given tke cells , 7. The art rate . Moreoveart rate , 11 and art rate .Panax ginseng (red ginseng) and processed lateral roots of Aconitum carmichaelii (aconite) [HCN4 activity in BMSCs. The findings of this study have important implications for the use of SFI in the treatment of heart diseases.Shenfu Injection (SFI) is a well-known modern Chinese medicinal preparation derived from a traditional formulation known as the “Shenfu Decoction.” This injectable herbal drug is prepared from steamed roots of aconite) . Aconiteaconite) –16. In Caconite) , 18, wheaconite) ; its effThe protocol for the use of rabbits in this study was approved by the ethics committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine . Before the surgical procedure, the rabbits were anesthetized with isoflurane. Following the surgery, the animals were euthanized via an intravenous injection of sodium pentobarbitone.2. The surface markers of the BMSCs  were identified to confirm the phenotype of the isolated cells [Under aseptic conditions, bone marrow was harvested from the tibia and femur condyle of one anesthetized male New Zealand rabbit  as described in a previous study . The boned cells , 22.HCN4 group. SFI was purchased from China Resources Sanjiu Medical and Pharmaceutical Co., Ltd (Batch No. 18100401003). The cells in the SFI groups were treated with SFI for five days, while those in the adenovirus-encoding groups were transfected with the viruses for 48 h before the experiments were performed.The cells were apportioned into six groups for the experiments: a control group, a high-dose SFI group (0.25 ml/ml), a middle-dose SFI group (0.1 ml/ml), a low-dose SFI group (0.05 ml/ml), an adenovirus-encoding control vector group, and an adenovirus-encoding HCN4 or adenovirus-encoding control vector was prepared by the Zhonghong Boyuan Company . The HCN4 sequence (NM_001082707.1) was obtained from NCBI and integrated into the adenovirus following a procedure described in a previous study [5/well) were seeded into 6-well plates and cultured at 37°C in an incubator with 5% CO2. After 24 h, 1 μl of adenovirus  encoding HCN4 was added to the cells in a 5% CO2 incubator at 37°C. Monitoring of the fluorescence intensity and cell state was conducted on the second day, and the cells were used in subsequent experiments 48 h after transfection.Adenovirus-encoding us study . BMSCs  on the cell membrane per unit of surface area was calculated according to the membrane capacitance displayed on the Axon200B patch clamp amplifier. The activation curve of the pacemaker ion current of BMSCs was drawn with the pCLAMP software, version 10.7.After transfection or drug treatments, BMSCs were digested with 0.01% EDTA and 0.25% trypsin. BMSCs were patched using the voltage clamp mode at −70 mV. The 2O, 9.5 μl; cDNA, 1 μl; upstream primer, 1 μl; downstream primer, 1 μl; and 2 × SYBR Green PCR Master Mix, 12.5 μl. The reaction steps were as follows: predenaturation, 95°C for 10 min; denaturation, 95°C for 10 s; annealing, 58°C for 30 s; extending, 72°C for 30 s; 40 cycles. The primer sequences were obtained from General Biosystems Co., Ltd. (Anhui). The relative HCN4 expression was determined using the 2−△CT method. The following primers were used: HCN4 F 5′-GCTGTCAAAGTGGAGGGAGG-3′, HCN4 R 5′-GCGAGAATTTGTTGACCCCG-3′; GAPDH F 5′-CCACTTTGTGAAGCTCATTTCCT-3′; and GAPDH R 5′-TCGTCCTCCTCTGGTGCTCT-3′.After transfection or drug treatments, the cell homogenate was collected to extract the total RNA following a procedure described in a previous study . The conThe cAMP level was detected with an enzyme-linked immunosorbent assay (ELISA) kit, following the manufacturer's instructions , as described in a previous study .P < 0.01).All data were expressed as mean ± standard deviations (SD) and analyzed using the GraphPad Prism 7 software. Significant differences among groups were analyzed by one-way ANOVA followed by a Tukey test  are pluripotent adult stem cells, which are prominent in the bone marrow. The differentiation of MSCs into special cardiomyocytes to treat bradyarrhythmias, such as SSS, is a promising approach , 31. Thechannels , it is achannels , 34. HCNial node . The HCNl pacing . Our resHCN4. In the high-dose SFI group, the expression and activity of HCN4 increased along with cAMP content. However, we found that the cAMP content decreased in the overexpressed HCN4 group. In the absence of cAMP, multiple HCN4 channel domains and membrane-related intracellular factors in hamster ovary cells reportedly reduce the self-inhibition of HCN4 channel [HCN4 activation. In this study, decreased cAMP content in the overexpressed HCN4 group also signaled the activation of cell hyperpolarization which is in a cAMP-independent pathway.SFI is widely used in the treatment of various diseases and has cardiovascular protective effects. For example, by regulating apoptosis, it can reduce myocardial dysfunction after resuscitation . Moreove channel , which iWe used SFI to investigate the effect of the Yi Yang Wen Yang method on the biological characteristics of BMSCs as well as “cell biological pacing” and “gene biological pacing.” The findings of this study highlight the function of a traditional Chinese medicine on SSS and provide an experimental and theoretical basis for elucidating the role of traditional Chinese medicine in stem cell differentiation and transplantation in the treatment of major cardiovascular diseases. However, the study had certain limitations. First, in vitro experiments were carried out to investigate the effects of SFI on pacemaker function. In vivo experiments should also be conducted to validate our conclusion. Second, the differentiation of BMSCs should be examined using more indices.HCN4 channel gene in BMSCs.In conclusion, SFI can induce the differentiation of BMSCs and improve the biological function by inducing the expression of the


The results showed that they were involved in video games, particularly boys and adolescents, with high rates of GD symptoms. The parents also spent a considerable amount of time playing video games. A path model that explained the mechanisms through which parental variables were related to their offspring’s time spent on video games and GD symptoms, controlling for gender and age, was verified. Overall, the findings indicate the importance of educating parents to behave effectively with respect to video games and monitor their offspring’s video gaming habits.It is mainly children and adolescents who are involved in video gaming. The lockdown caused by the COVID-19 pandemic may have further increased their use of video games and, consequently, the risk of gaming disorder (GD) symptoms. However, currently, we do not have exhaustive knowledge of this issue. To fill this gap, the current study aims to analyze video gaming habits in children and adolescents during the lockdown, starting in March 2020 in Italy, the first European country affected by the pandemic. Specifically, we aim to understand how variables related to parents—for instance, knowledge of their offspring’s life, the monitoring of their video gaming habits, and parental use of video games—are related to their offspring’s time spent on video games and GD symptoms. A web-based survey involving parents ( The popularization of the internet and the invention of smartphones has had a significant impact on the use of various types of electronic devices for video games (VGs). Indeed, the VG industry has shown a very rapid increase over the last decade , so muchThe prevalence of video gamers among the juvenile population seems to be even higher, as reported by several studies, indicating that around 90% of adolescents use VGs , with thhttps://www.bigfishgames.com/us/en/play-apart-together.html (accessed on 2 March 2021)). Due to these incitements, after the introduction of lockdown and quarantine measures, European mobile game downloads reached a record high (an increase of 19%) in March 2020 . Based on the response, children and adolescents were classified as video gamers/non-video gamers. Parents were also asked to indicate their son/daughter’s favorite type of VG, classified into different genres [never, a few times, many times) their son/daughter used the listed devices  to play VGs. In the scoring phase, options (“sometimes” and “many times”) were collapsed in order to obtain an affirmative or negative answer regarding the use of devices and a versatility score indicating the number of different devices used to game. Then, parents were asked to report at what time of day  their son/daughter played VGs; in this way, it was possible to detect the prevalence of video gamers at single moments during the day and to obtain a versatility score indicating the number of different moments per day spent on gaming. Moreover, parents were asked to indicate how many hours a day and how many days a week their son/daughter played VGs. In order to determine the time spent on VGs, we multiplied the hours per day spent on VGs [never, a few times, many times) their son/daughter played in the listed social conditions . The VGS-P is divided into two sections; the first is related to video gaming habits, while the second is to investigate the symptoms of pathological video gaming based on DSM-5. Both sections referred to the period of lockdown. More specifically, in the first section, parents were asked to report whether their son/daughter had used VGs during the isolation period [t genres . Then, tt on VGs . Finallynever), 1 (few times), and 2 (many times). The scoring system was developed by applying item response theory (IRT) in order to have a measure of GD that takes into account the severity of each symptom described by the items [non-problem, at-risk, and problem video gamers.The second section of the VGS-P is composed of nine items, each one developed in order to reveal one of the nine symptoms listed in DSM-5, provided on a 3-point Likert scale: 0  they used the listed devices  to play VGs. For the purpose of analysis, the options of “sometimes” and “many times” were collapsed in the scoring procedure in order to obtain an affirmative or negative answer regarding the use of devices; in this way, a versatility score was obtained. Then, parents were asked to report at what time of day  they played VGs. Moreover, parents were asked to indicate how many hours a day and how many days a week they played VGs; in order to determine time spent on VGs, we calculated how many hours a week they played VGs [never, a few times, many times) they played in the listed social conditions . Then, parents were asked to report if they had used VGs during the isolation period [ VG used . Subsequayed VGs . FinallyParental Knowledge subscale of the Parental Monitoring Scale [“Do you know which friends your son/daughter hangs out with in his/her free time?” was modified to “Do you know which friends your son/daughter connects with or phones?”; the item “What does your son/daughter usually do after school?” was modified to “What does your son/daughter usually do after online lessons?”. Cronbach’s alpha for this sample was 0.89.Subsequently, they were asked to answer questions related to their knowledge of their son/daughter and the monitoring of their video gaming habits, always referring to the period of lockdown. To investigate parental knowledge, The ng Scale ,64 was utotally false) to 5 , and investigated parental monitoring of their child’s video gaming habits. Examples of the items are: “I allow my son/daughter to play only at certain times of the day” and “I allow my son/daughter to play online”. The scale resulted in being unidimensional . All the factor loadings were significant at the 0.001 level and ranged from 0.36 to 0.62. Cronbach’s alpha was adequate considering the low number of items: 0.60 .Concerning parental monitoring, since, to the best of our knowledge, there is no available tool investigating parental monitoring in relation to video game behavior addressed to parents, five ad hoc items were developed by referring to the period of lockdown. Items were evaluated on a 5-point Likert scale, ranging from 1   using man = 387) of the parents still worked. Among them, 69% (n = 245) were smart-working, i.e., they worked from home. Parents belonged to families of an average of four members , with about two sons/daughters . During the lockdown, in each house  there were, on average, four cohabitants . There were about six open spaces in each house   and four electronic devices . During the lockdown, 70% (n = 271) were video gamers. They spent, on average, about 12 h a week on gaming . The preferred genres of VGs were first-person shooter (31%), sandbox (14%), and management (11%) games. They used, on average, about two different devices for playing VGs . The most used devices were smartphones (62%), followed by home game consoles and tablets (54%), handheld games consoles (29%), and computers (22%). They played VGs at about two different times on a typical day . The majority of children gamed during the afternoon (72%), before dinner (56%), and after lunch (43%) or in the morning (34%). Fewer children gamed after waking up (8%), before falling asleep (6%), or during dinner (2%) or lunch (1%). Concerning GD symptoms, the mean score on the VGS-P was 6.84 . Based on the individual score, 46% of the children (n = 123) were classified as non-problem video gamers, 35% (n = 94) as at-risk video gamers, and 19% (n = 50) as problem video gamers. The most widespread symptoms were preoccupation , lying , and escape . The results with regard to video gaming based on gender are reported in Among children, the results showed that 89% (n = 232) were video gamers. They spent, on average, about 18 h a week on gaming . The preferred genres of VGs were first-person shooter (35%), sports (26%), and simulation (7%) games. They used, on average, about two different devices for playing VGs . The most used devices to game were home game consoles (81%) and smartphones (79%), followed by computers (34%), tablets (32%), and handheld games consoles (22%). They played VGs at about two different times in a typical day . The majority of adolescents gamed in the afternoon (71%), before dinner (61%), or after lunch (61%). A consistent proportion of them played VGs in the morning (27%) and before falling asleep (20%). Fewer adolescents gamed after waking up (10%) or at dinner (4%) and lunch (2%). Concerning GD symptoms, the mean score at the VGS-P was 7.19 . Based on these scores, 43% of the adolescents (n = 99) were non-problem video gamers, 36% (n = 83) at-risk video gamers, and 22% (n = 50) problem video gamers. The most widespread symptoms were preoccupation , lying , and inability to control their video gaming habits . The results regarding video gaming based on gender are reported in Among adolescents, the results showed that 94% (n = 204) of parents played VGs during the lockdown. On average, they spent about 7 h a week  on video gaming. Thirty-seven percent . The most used devices to play VGs were smartphones (51%), followed by home game consoles (26%), tablets (20%), and computers (14%). The majority of parents play VGs after waking up (38%), with fewer numbers of them playing VGs at lunch (9%), during the afternoon (1%), or at dinner (1%). The majority of them are used to playing VGs alone (88%). Forty-five percent of parents gamed with their son/daughter, 20% with their partner, and 14% with their friends. The preferred genres of VGs were puzzles (14%), sports (13%), and board/card (9%) games. They used, on average, about one device for playing VGs , time spent on gaming (-), and the related GD symptoms (-). With regard to age, we hypothesized a significant and negative covariance with parental knowledge of their son/daughter’s life and also a significant and negative direct effect on parental monitoring over their son/daughter’s video gaming habits and a significant and positive direct effect on time spent on gaming.The model showed a good fit to the data . All coefficients were statistically significant in the expected directions. Specifically, the results revealed that parental knowledge of their son/daughter’s life and the parents’ time dedicated to gaming—negatively inter-correlated—had significant direct and positive and negative effects, respectively, on parental monitoring of their son/daughter’s video gaming habits. In turn, parental monitoring of their son/daughter’s video gaming habits was directly and negatively related to time spent on VGs, which was also affected by the parents’ time dedicated to gaming, and had a direct and positive effect on GD symptoms a. MoreovThe results also showed five significant indirect effects: from parental knowledge of their son/daughter’s life to time spent on VGs (-) and on GD symptoms (-); from the parents’ time dedicated to gaming to time spent on VGs (+) and on GD symptoms (+); and from parental monitoring on their son/daughter’s video gaming habits to GD symptoms (-) b. FurtheThe aim of this study was twofold, the first being to analyze video gaming behavior in children and adolescents during the COVID-19 pandemic and the related lockdown, taking advantage of this period to better investigate the role of parents, who are most at-home due to the lockdown, with respect to their offspring’s video gaming. To this end, we tested a path model that took into account the effects of parental knowledge of their son/daughter’s life habits, parental video gaming behavior, and parental monitoring of their son/daughter’s video gaming habits and time spent on VGs on GD symptoms. Concerning video gaming, we found that the time spent gaming was higher than that recorded before the COVID-19 outbreak for both children  and adolOverall, the crucial role of parenting practices for juvenile video gaming is consistent with existing research showing that parental monitoring acts as a protective factor against the development of pathological gaming ,76. The Practical and ethical implications can be derived from this study. Parents of children and adolescents should urgently acquire and adopt effective monitoring strategies that can be helpful to avoid the development of addictive behaviors related to VGs. To this end, the first step could be to develop parental training programs designed to foster parental ability to regulate their offspring’s behavior in relation to gaming. For instance, interactive, two-way mediation seems to be the best method to have a significant effect on the frequency of VG playing . It woulEspecially in this pandemic period, parents must provide alternative avenues for social interaction between adolescents in order to maintain their learning motivation and to monitor and regulate their gaming time, thus minimizing addiction risks . MoreoveSeveral limitations can be identified in this study. As this is a cross-sectional study, further evidence is needed to confirm the parents’ role. Moreover, although the instruments used are characterized by good psychometric properties in terms of dimensionality, internal consistency, and criterion validity, the convergent validity of the VGS-P has not been investigated, and, overall, the instruments are not standardized and are based on a hetero-evaluation. In this regard, there may be some differences between what parents reported and what the offspring really did or experienced with respect to video gaming behavior. At the same time, we did not assess the children’s and adolescents’ perception of parental monitoring, while previous research has demonstrated that parents and sons/daughters can have a different perception of parental monitoring of the use of VGs , with pa


By statistics, we find that the two types of wrinkles are categorized by their orientations. Our results demonstrate that the local strain effect with different directions can tune the superconducting order parameter of LiFeAs very differently, suggesting that the band shifting induced by directional pressure may play an important role in iron-based superconductivity.For iron-based superconductors, the phase diagrams under pressure or strain exhibit emergent phenomena between unconventional superconductivity and other electronic orders, varying in different systems. As a stoichiometric superconductor, LiFeAs has no structure phase transitions or entangled electronic states, which manifests an ideal platform to explore the pressure or strain effect on unconventional superconductivity. Here, we observe two types of superconducting states controlled by orientations of local wrinkles on the surface of LiFeAs. Using scanning tunneling microscopy/spectroscopy, we find type-I wrinkles enlarge the superconducting gaps and enhance the transition temperature, whereas type-II wrinkles significantly suppress the superconducting gaps. The vortices on wrinkles show a C The evolution of superconductivity in LiFeAs with respect to pressure or strain remains elusive. Here, the authors observe different response of superconducting states due to different orientations of local wrinkles on the surface of LiFeAs. The large orbital degrees of freedom, as well as the presence of intertwining orders hinder a microscopic understanding of the pairing mechanism in FeSCs (refs. 6). As a perturbation method, external pressure can lift the ground state degeneracy and offer detailed information about how the unconventional superconductivity evolve with other electronic orders. For example, an in-plane resistivity anisotropy7 and a spin excitation8 have been observed in electron-doped BaFe2As2 under uniaxial pressure; in FeSe with external pressure, the magnetic order could emerge and coexist with the high-temperature superconductivity9, while enhanced spin fluctuation is evidenced as well10. Among FeSCs, LiFeAs is unique as its phase diagram is not intervened by any magnetic or nematic order, which provides an appropriate platform to detect the relationship between pressure and superconductivity in strong correlated system12.The origin of superconductivity in iron-based superconductors (FeSCs) remains elusive despite intensive research efforts over a dozen yearsTc of LiFeAs declines linearly with increase of pressure amplitude, with no derived order, such as magnetism or nematicity observed11. However, when the uniaxial strain is applied to the specific lattice direction, stabilized sematic electronic state emerges, and suppresses the paring strength of superconductivity12. These divergent reports demonstrate that, compared with hydrostatic pressure, the orientation-dependent strain would trigger quite different influences on LiFeAs. Given the existence of multiple Fermi surfaces in the Brillouin zone, as well as the physical regime of corelated interactions in this material, the superconducting order parameter affected by orientation-dependent strain are intricate. Therefore, more experimental observations are required.Under hydrostatic pressure, transport measurements reveal the transition temperature 14, the spatial feature of superconducting vortices observed on wrinkles confirms the existence of local strains. While the wrinkle orientations are continuous, the associated SC gap size has an abrupt jump at a certain angle of orientation, which is likely the consequence of Lifshitz transition.In this work, by using scanning tunneling microscopy/spectroscopy (STM/S), we report the observation of orientation-dependent superconductivity at two types of wrinkles on LiFeAs surface. The tunneling spectra show an increase of superconducting (SC) gaps on type-I wrinkles and a reduction on type-II wrinkles. Compared to wrinkle-free region, temperature-dependent measurements of the SC gap show that the gap-closing temperature on type-I wrinkle region is enhanced by 20–30%, but it remains almost unchanged on type-II wrinkle region. Although wrinkles are a commonly consequence of relieving transverse strain induced by the change of atom coordination16), the cleavage of LiFeAs crystal occurs at a nonpolar plane between the two Li layers 21. Two types of wrinkles are observed on LiFeAs surface  taken at the wrinkle-free region (black curve), type-I (red curve) and type-II wrinkles (blue curve) on the surface, as marked by the crosses in Fig. I/dV spectrum shows multigap features of LiFeAs, with a large gap of ~5.8 meV (possibly come from the inner-hole pocket at the Γ point) and a small gap of ~2.9 meV (possibly come from the outer-hole pocket at the Γ point), which are consistent with previous reports26. Intriguingly, the tunneling spectrum on type-I wrinkle yields a coherence peak at 7.3 meV and a shoulder at 3.6 meV, and type-II wrinkle exhibits a single V-shaped gap of 2.5 meV. We note that electron doping27 and application of external pressure12 normally lead to reduction of SC gap or Tc, thus the increase of SC gaps is not commonly observed in LiFeAs.There is remarkable differences between the type-I and II wrinkles in their LDOS. Figure I/dV spectra line-cut across and along the wrinkles, as displayed in Fig. 1 start to shift to higher energies when getting close to the wrinkle edge and show the constant values of ±7.3 meV across the wrinkle  distribution. It is evident that the type-I wrinkle has larger SC gap sizes compared with the wrinkle-free region. Also, the edges of the wrinkle  and gradually closes at ~20.5 K . In Fig. We next perform the temperature-dependent d5 K Fig. , while t5 K Fig. . The SC 5 K Fig. . We note4 symmetry of the Fermi surface of dxy band29  map  sink down below the Fermi level on the type-II region.Further analysis indicates that the switch of the superconductivity on two-type wrinkles is coincidence with the band structure changing under different orientations of local strain. First, the bump features in Fig. le Figs.  and 4d, We note that in previous reports which utilize the external global pressure, only suppressions of superconductivity were found either in the hydrostatic pressure or uniaxial strain, while we simultaneously observed the enhancement and suppression of superconductivity on type-I and type-II wrinkles, respectively. In addition, our results reveal that the unique orientation-dependence of gap size separated by an abrupt jump Fig. , which mTc and the ratio 2Δ/kBTc for wrinkle-free, type-I and type-II wrinkles. The ratios are similar for wrinkle-free and type-I wrinkles, indicating that the paring strength at type-I wrinkle region is close to that at the wrinkle-free region. Therefore, the increase of DOS at type-I wrinkle as proposed here is reasonable. On the other hand, Δ2 at type-II wrinkle is small and the ratio at type-II wrinkle (~3.4) is close to the weak-coupling BCS regime, suggesting that the Tc at type-II wrinkle may be induced by the bulk superconducting proximity effect. Another possible explanation is that the dxz as well as dyz bands sink below EF, and only the smaller gap of dxy is observed (tunneling at the STM junction is insensitive to the M point), since the gap function in the FeSCs is found to be approximately proportional to cos(kx)cos(ky)31. In this way, Tc is not driven by Δ2 which is much smaller than the global superconducting pairing strength.In the Supplemental Table dxz/dyz bands split possibly due to the spin-orbit coupling28, with dyz crossing EF and dxz sinking below , both the dyz and dxz band sink below EF, leaving only the dxy band crossing EF , in which the EF only passes the dxy band possibly. We perform density functional theory (DFT) calculations and find the existence of compressive or tensile strain indeed has strong effect on shifting the local dxz band  and Fe (ref. 39), a nematicity order emerges under strain. At the wrinkle locations of LiFeAs, the C4 symmetry is broken, suggesting the existence of local strain which may also induce the nematicity order. Therefore, the nematicity order would be another possible origin of our observations. Nevertheless, we cannot rule out other scenarios of superconducting changing41 and further theoretical understanding of the microscopic mechanism is required.Based on the observations discussed above, we propose a possible scenario that the local strain on wrinkle causes the shifting of bands around Г point Fig. . In bulklow Fig. . When loint Fig. . The enh EF Fig. . In thisIn summary, we have identified two types of wrinkles on LiFeAs surface. The orientation-dependent wrinkles accompanied with local uniaxial strains have very different influence on the superconductivity at the nanoscale, with one gets an enhancement while the other is suppressed. A possible Lifshitz transition scenario is proposed to explain these two distinct states of superconductivity in the vicinity of wrinkles on LiFeAs. Our observations suggest that the change of electronic structure induced by strain has strong influence for unconventional superconductivity in LiFeAs.27. LiFeAs crystals were mounted at a STM sample holder by epoxy in a glove box and transferred to a ultra-high vacuum chamber where they were cleaved in-situ, and then immediately transferred to a STM scanner at 4.7 K. STM/S measurements were operated at 0.45 K by 3He single-shot technique (Unisoku). Polycrystal tungsten tips were etched chemically and calibrated on Au(111) surface before use. All STM images were acquired in the constant-current mode. The differential conductance (dI/dV) spectra and maps were obtained by a standard lock-in amplifier at a frequency of 973.0 Hz, with a modulation voltage of 0.2 mV. Magnetic fields were applied perpendicular to the samples.High-quality LiFeAs single crystals were synthesized by using the self-flux method−10 mbar, where samples were cleaved in-situ. A commercial qPlus tuning fork sensor in frequency modulation mode with Pt/Ir tip was used to obtain the data. The resonance frequency was about 27.9 kHz and the stiffness was about 1800 N/m. The STM topography images were acquired in the constant-current mode. The constant-high and constant-force AFM modes were used to measure the real topography features of two types of wrinkles.The nc-AFM measurements were conducted at liquid He temperature with a base ultra-high vacuum lower than 2 × 1044, and the generalized gradient approximation (GGA)45 for the exchange-correlation functional is used. In order to simulate the tensile and compressive strain in the Fe-Fe direction and Fe-As direction respectively without causing a lot of calculations, we have established two different crystal models  method encoded in the Vienna Ab initio Simulation Package (VASP)Supplementary InformationPeer Review File


Malnutrition is a major health issue among Bangladeshi under-five (U5) children. Children are malnourished if the calories and proteins they take through their diet are not sufficient for their growth and maintenance. The goal of the research was to use machine learning (ML) algorithms to detect the risk factors of malnutrition  as well as their prediction.This work utilized malnutrition data that was derived from Bangladesh Demographic and Health Survey which was conducted in 2014. The selected dataset consisted of 7079 children with 13 factors. The potential risks of malnutrition have been identified by logistic regression (LR). Moreover, 3 ML classifiers (support vector machine (SVM), random forest (RF), and LR) have been implemented for predicting malnutrition and the performance of these ML algorithms were assessed on the basis of accuracy.The average prevalence of stunted, wasted, and underweight was 35.4%, 15.4%, and 32.8%, respectively. It was noted that LR identified five risk factors for stunting and underweight, as well as four factors for wasting. Results illustrated that RF can be accurately classified as stunted, wasted, and underweight children and obtained the highest accuracy of 88.3% for stunted, 87.7% for wasted, and 85.7% for underweight.This research focused on the identification and prediction of major risk factors for stunting, wasting, and underweight using ML algorithms which will aid policymakers in reducing malnutrition among Bangladesh’s U5 children. Malnutrition is one of the most serious health and welfare issues in any developing country, including Bangladesh. Malnutrition is referred to a lack of, excess, or imbalance in an individual’s energy and/or nutrient intake . MalnutrIn the case of Bangladesh, malnutrition affects more than half the population . A totalChild malnutrition is a hot topic in the field of public health as well as epidemiology globally. There were lots of studies about U5 malnutrition around the world. In previous studies, they focused only on the identification of the risk factors of malnutrition using classical model like logistic regression –3, 11–21th nationwide DHS, covering the entire population. The list of enumeration areas (EA) of the 2011 census population was provided by the bureau of statistics (BBS). The samples of households of BDHS, 2014 were collected using two-stage stratified sampling. In the 1st stage, 600 EAs were chosen at random, proportional to their number, and only 30 households were chosen using systematic sampling. Approximately 18, 000 ever-married women (age: 15–49 years) were selected for an interview and 17,863 (99%) women were successfully interviewed [This work utilized malnutrition data that has been derived from BDHS, 2014 which was conducted in 2014 and freely available online. It was the 7This study was based on an analysis of existing public domain survey datasets that are freely available online with all identifier information removed. The survey was approved by the Ethics Committee in Bangladesh. The authors were granted permission to use the data for independent research purposes.In this work, we have considered three types of response variables as stunted, underweight, and wasted, which were measured based on height-for-age Z-score (HAZ), weight-for-height Z-score (WHZ), and weight-for-age Z-score (WAZ). Using WHO AnthroPlus , the Z-scores were determined on the basis of age, weight, and height . ChildreAll categorical data was expressed as number (%). The chi-square analysis was implemented to assess the relationship between various selected explanatory variables and malnutrition . If the explanatory variables were statistically significantly associated with malnutrition, these significant variables were fed to LR model. LR based model was implemented to determine the risk factors of malnutrition. The significant risk factors were selected on the basis of p-value (p<0.05). Then three well-known and popular ML algorithms which were available in literature as support vector machine (SVM) , logistiThe overview of ML-based study was depicted in There are various kernels in SVM. As a result, the kernel of SVM must be optimized. In this work, we implemented SVM with 4 kernels: linear, RBF, Poly-2, and sigmoid. We tuned the hyper-parameters of these kernels using grid search methods. We optimized the kernel based on accuracy and chose the kernel with the highest accuracy. It was observed that RBF kernel provided the highest accuracy of 88.1% for stunted, 86.0% for wasted, and 85.6% for underweight compared to other kernels see . That isAccuracy and AUC were used to evaluate the efficiency of ML algorithms. Since the BDHS dataset was categorical, it was a very tedious task to choose a predictive model that could be accurately classified with the highest accuracy and AUC. The comparison of the efficiency of ML algorithms is depicted in The AUC of the ML algorithms was presented in The goal of this research was to identify risk factors for malnutrition and predict it using ML algorithms. Previously, only two studies on ML-based prediction of malnutrition status were conducted in Bangladesh, but they had lower accuracy , 24. In Male children historically provided more parental attention. This has recently changed. The government of Bangladesh has adopted some polices, including stipends and free education to improve female education. Our findings also revealed that the children whose father’s had no education, only primary and secondary education, were at a higher risk of being wasted and underweight than children whose father had a higher education . This stMany researches have been conducted on U5 malnutrition around the world. Among these few studies, there were two studies performed on stunted, wasted, and underweight , 24 and The main strength of this work is to extract high-risk factors of stunted, wasted, and underweight using a logistic regression model and make a decision based on the p-value. We used three ML algorithms  to predict stunted, wasted, and underweight children. Among them, RF-based classifier outperformed comparison to previous studies published in the literature. This work has some limitations. This work was only conducted on BHDS, 2014 cross-sectional data and no any post hoc analysis like Bonferroni correction was performed. In the future, we would like to consider pooled data as well as more factors to get precise results. We will also use principal component analysis, Fisher discriminant analysis, and mutual information for feature extraction of stunted, wasted, and underweight. We also attempt to use more ML algorithms in conjunction with deep learning classifiers and compare their results to this current work.Malnutrition is one of the most serious health and welfare issues in Bangladesh. The prevalence and risk factors of stunted, wasted, and underweight were investigated in this work and their status predicted using ML algorithms. LR results illustrated that five factors  were statistically significant for stunted and underweight, while four factors  for wasted. Results also indicated that RF classifier obtained the highest accuracy of 88.3% for stunted, 87.7% for wasted and 85.73% for underweight. This work suggests that LR-RF based combination may be accurately classified and predict stunted, wasted, and underweight and yield higher accuracy.


Strock, MD (Video).Please watch a video commentary on “Subpectoral Implant Repositioning With Partial Capsule Preservation: Treating the Long-Term Complications of Subglandular Breast Augmentation”


Mycobacterium marinum (M. marinum) is a pathogen that causes skin and soft tissue infections in people who work with contaminated water, such as fish handlers. M. marinum infection is mostly limited to patients with compromised immune systems. As per current guidelines, susceptibility testing is not routinely recommended, although sporadic cases have been reported with resistance to routinely prescribed anti-tuberculous drugs. We report a case of a 61-year-old male taking adalimumab with ulcerative skin and soft tissue infection with positive interferon-gamma release assays (IGRA) identified as M. marinum and the treatment challenges involved in this case. Mycobacterium marinum (M. marinum) was first isolated in an aquarium in Philadelphia in 1926 from tubercles obtained at necropsy of dead saltwater fish [M. marinum is a pathogen known to cause skin and soft tissue infections in persons working with contaminated water, such as fish handlers [M. marinum infection is mostly limited to patients with compromised immune systems [M. marinum and the treatment challenges involved in this case.handlers . M. mari systems . As per  systems . We repoA 61-year-old male working as a plumber presented with a significant history of psoriasis with psoriatic arthritis on adalimumab taken for three months with prior negative IGRA. His adalimumab was discontinued due to an ulcerative skin lesion. His previous medical history was significant for hyperlipidemia, squamous cell carcinoma, recurrent skin cancer requiring surgical resections was referred to our office for non-tuberculosis mycobacterium (NTM) skin and soft tissue infections (SSTI). The patient had developed a skin lesion atypical to his other recurrent skin lesions on his right distal forearm on the palmar aspect. The lesion was started as a small blister-like lesion which upon removal/resection two months prior became ulcerative Figures . He trieM. marinum and treatment was adjusted to azithromycin and rifampin based on current guidelines. He developed diffuse diarrhea requiring a medication adjustment to ethambutol and rifampin. This was further adjusted to rifabutin and ethambutol based on susceptibility testing -specific peptide antigens ESAT-6, CFP-10, and TB7.7, which are located in a specific genomic area in MTB, called the region of difference (RD1). The RD1 is present in mycobacteria belonging to the Mycobacterium tuberculosis complex  and very few NTM species also share the RD1 of MTB . Infection with these strains can potentially result in a positive QuantiFERON-TB Gold test (QFT) result [M. marinum are cell wall-associated lipid phthiocerol dimycocerosates, phenolic glycolipids, and ESAT-6 secretion system 1 (ESX-1) [M. marinum SSTI given his prior negative result before starting adalimumab and subsequent positivity with infection.Interferon-gamma releasing assay is a test used widely for screening tuberculosis. It measures the release of gamma interferon by white blood cells. The limitation of the IGRA as a test is the inability to differentiate between latent tuberculosis infection and active tuberculosis. The QuantiFERON-TB-Gold test is based on response to the ) result . The vir (ESX-1) . We feelM. marinum skin infections. Susceptibility testing is recommended if initial treatment fails. Though resistance potential is very low to standard anti-tuberculosis medications, some resistant cases have been reported earlier. As evidenced in our case, initial empiric treatment options based on 2007 guidelines revealed multiple resistances to sulfonamide, tetracycline, and even rifampin [As per the American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) guideline, initial susceptibility testing is not required for rifampin . In patirifampin . CompliaM. marinum SSTI cases. We assert that until guidelines are updated, susceptibility testing should be obtained to guide therapy, especially in severe infections. Routine screening with IGRA in nonendemic areas is problematic. Strong consideration for culture analysis should be stressed as the gold standard for the diagnosis and speciation of NTM organisms. As discussed previously, the cross-reactivity potential with IGRA and aforementioned NTM organisms is frequently overlooked. This could lead to additional testing for MTB in patients presenting with atypical NTM infections. We hope this case serves to highlight the importance of knowing cross-reactivity to certain NTM pathogens exists clinically.Our case illustrates effective second-line therapy based on susceptibilities and can serve as a model for future


This study was aimed to assess nutritional aspects of Indian children suffering from EB and to evaluate the effect of severity of EB on the severity of malnutrition. In this study, pediatric EB patients were evaluated prospectively for baseline nutritional status using anthropometric parameters and WHO growth charts, and its correlation with disease severity using instrument for Scoring Clinical Outcomes for Research of Epidermolysis Bullosa-iscorEB. In second phase, an individualized diet chart was given to meet the energy, protein and micronutrients needs and its effects were observed after 6 months. The median age of participants was 3 years (IQR-9). Of 57 patients, malnutrition was seen in 40.35% patients (22.81%-moderate and 17.54%-severe), and significantly correlated with iscorEB . On bivariate regression analysis, iscorEB was independently associated with moderate-to-severe malnutrition . iscorEB enabled the identification of patients with moderate-to-severe malnutrition with an Area Under Receiver Operating Curve (AUROC) of 0.72 . In phase 2, there was significant improvement in nutritional status in children with recessive dystrophic EB (RDEB) and dominant dystrophic EB (DDEB) subtype (p < 0.0001). The severity of malnutrition in EB children significantly correlates with disease severity, and is an independent predictor of moderate-to-severe malnutrition.WHO defines malnutrition as severe if the  According to WHO, malnutrition refers to imbalance between the supply of protein and energy and body’s demand for them to ensure optimal growth and function. WHO categorizes malnutrition as severe if the z-score (weight for height and height for age) are less than – 3 Standard deviation (SD), moderate if z-score (weight for height and height for age) are between – 2 and – 3 SD, mild malnutrition if values are between – 2 SD to – 1SD1. The definitions for malnutrition were revised in the year 2006 by WHO to include six categories for undernutrition—stunted and severely stunted, underweight and severely underweight, and wasted and severely wasted2. The nutritional needs are increased for patients with epidermolysis bullosa (EB) due to chronic inflammation, recurrent secondary infection, and systemic involvement. Reduced food intake and enhanced nutritional needs together contribute to malnutrition in EB patients, leading to interruption in growth, puberty and wound healing. Hence, many children severely affected with EB have a varying degree of retardation of growth with the majority of them unable to meet the 5th percentile curves for weight/height3. In EB, children with minimal blisters and no gastrointestinal system involvement, the nutritional needs are comparable to those of age and sex-matched healthy children4. Since there is a lack of data regarding the frequency of malnutrition among children with EB from the developing world, this study was aimed to assess nutritional aspects of Indian children suffering from EB and to evaluate the effect of severity of EB on the severity of malnutrition.Over the years, the definition of pediatric malnutrition has undergone conceptual change with an emphasis on etiology-related definitions and etiology-related interventions, and the role of . The study was started and conducted after approval of the study protocol by the Institute’s Ethics Committee according to the guidelines set up by ICMR (1994) and Helsinki declaration (modified 2000). After obtaining written informed assent/consent from the children/parents, patients (aged less than 18 years) with the clinical diagnosis of EB were grouped into major subtypes—epidermolysis bullosa simplex (EBS), junctional epidermolysis bullosa (JEB), dystrophic EB (DEB) including both recessive dystrophic EB (RDEB), dominant dystrophic EB (DDEB), and Kindler syndrome (KS)—according to Clinical Diagnostic Matrix (CDM) and confirmation by transmission electron microscopy and/or immunofluorescence antigen mapping5.This was a single center, prospective longitudinal study conducted over a period of 18 months (July 2017 to December 2018) at the Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh6. Besides, physical examination was focused on the anthropometric examination like weight, height, head circumference, mid-arm circumference, and weight for age, height for age, weight for height and body mass index (BMI) and comparison with the age-appropriate World Health Organization (WHO) growth charts to assess whether the child had any features of malnutrition7. They were categorized into having severe malnutrition if the z-score (weight for height and height for age) are less than – 3 Standard deviation (SD), moderate if z-score are between – 2 and – 3 SD, mild if values are between – 2 SD to – 1SD1. Table A detailed history followed by a complete physical examination was recorded in case record proforma. The severity of EB was calculated using ‘iscorEB’, including clinician and patient scoreThe objective of the nutritional advice for children with Epidermolysis Bullosa (EB) was to provide more than adequate macronutrients as well as micronutrients, minimize the nutritional deficiencies, improve bowel functions, enhance immunological status, optimize wound healing, promote proper body growth as well as pubertal and sexual development and also is to minimize the stress caused by prolonged feeding time.8. After this, an individualized diet chart was given to meet the energy, protein and other nutrients needs of the child with EB and also more emphasis were given for frequent follow ups to monitor the improvement of the child  to improve their child’s taste and intake and given recipe handouts written in Hindi/English/Punjabi.Since frequency, quantity and consistency of meals/feeds are very important factors while giving nutritional advice to children with EB, parents were advised to give small frequent meals/feeds customized to local tastes. In each follow up visit, patients with EB were assessed for the present intake and calculated as per the ICMR food values and then advised modified diets/feeds as per the child’s need.10, daily supplementation of a common commercially available multivitamin syrup was also supplemented. Micronutrient deficiency detected in laboratory evaluation was treated as per pediatrician advice. Esophageal dilation was done in patients with esophageal strictures detected on barium swallow by a pediatric gastroenterologist. Patients were followed up every month for at least 6 months. Repeat anthropometry and laboratory investigations were done at 6 months.Based on the 2010 recommendations of the Indian Council of Medical ResearchThe normality of quantitative data was checked by measures of Kolmogorov Smirnov tests of normality. Normally distributed data were compared using one-way ANOVA followed by post hoc multiple comparisons test. For the skewed data such as the baseline clinical and anthropometric variables, the Kruskal–Wallis test followed by the Mann–Whitney test was applied Table . For comPGIMER Chandigarh Institute’s Ethics Committee NK/4227/MD/1544-45. The study was started and conducted after approval of the study protocol by the Institute’s Ethics Committee according to the guidelines set up by ICMR (1994) and Helsinki declaration (modified 2000).Sixty-two patients with EB were screened and 57 eligible patients were included in the study as shown in the flow chart Fig. . Of the Table Thirty-four (59.6%) patients had normal/mild malnutrition, 13 22.8%) patients had moderate and 10 (17.5%) patients had severe malnutrition. Out of 30 children aged below 5 years, 51.8% were underweight (low weight for age), 40% were stunted (low height for age) and 43.47% were wasted (low weight for height). There was no significant difference in the frequency of mild/normal, moderate and severe malnutrition among the various subtypes of EB . Severe malnutrition was most commonly seen in 9 dystrophic EB patients—7 RDEB (30.4%), 2 DDEB (8.7%), and 1 JEB (4.3%) patient. A moderate degree of malnutrition was seen in 6 RDEB (26.08%), 3 DDEB (13.04%), 2 JEB (8.7%) and 2 EBS (8.7%) patients. Higher iscorEB (56.72 ± 23.85) scores were seen in those with severe malnutrition compared to those with moderate malnutrition (40.00 ± 23.12) and normal/mild malnutrition , There was a statistically significant correlation between malnutrition and iscorEB with a moderate strength  and iscorEB (p = 0.005) but not with age (p = 0.15), gender (p = 0.71), disease subtype (p = 0.12), and dental involvement (p = 0.07). On bivariate regression analysis, only iscorEB was independently associated with moderate to severe malnutrition . iscorEB enabled the identification of patients with moderate to severe malnutrition with an AUROC of 0.72 . Of the 57 patients, 34 who followed dietary advice as advised by a dietician experienced a significant increase in mean weight and height (P < 0.0001). Mean follow-up duration was 6 months. Mean weight increased from 15.53 ± 15.02 kg to 17.87 ± 14.71 kg, and mean height increased from 92.64 ± 36.94 cm to 97.55 ± 34.14 cm. Similarly, baseline weight for age increased significantly from − 1.74 ± 1.13 to − 1.33 ± 1.10 at the end of 6 months with a corresponding increase in Z-scores (P = 0.01). Height for age increased from − 1.47 ± 0.98 to − 1.28 ± 1.11; and weight for height increased from − 1.43 ± 1.19 to − 1.04 ± 0.97 but improvements in these parameters were statistically non-significant  Table . Among t11, reflects the delay in presentation to a tertiary care institute with specialized EB services in a developing country due to poor access to health care, and a lack of information and knowledge about the disease among parents and primary care physicians. There was a male predominance in the present study (M:F = 1.3:1) comparable to another Indian study by Hiremagalore et al.13.The nutrition in the first few years of the life of a child is crucial concerning the overall growth and development and any factor that interferes with adequate nutritional intake during this period predisposes to significant failure to thrive. In the present study, malnutrition was seen in 40.35% patients, and significantly correlated with severity of disease. In fact, the disease severity was an independent determinant of severity of malnutrition. Also, there was significant improvement in nutritional status in children with dystrophic EB (RDEB) and dominant dystrophic EB (DDEB) with dietary advice. In our study, the median age at presentation of 3 years though comparable to other Indian studies13, which showed that 35.7% of Indian children below 5 years were underweight, 38.4% were stunted, 21% were wasted. Compared to children in NFHS 4 survey, a higher frequency of EB children was underweight and wasted with a slightly higher frequency of stunting. This can be attributed to a wide range of gastrointestinal complications affecting EB children in 69.2% of patients with moderate malnutrition and 90% of patients with severe malnutrition. Dental involvement was seen in a much higher proportion of patients with moderate to severe malnutrition although it did not achieve statistical significance. In EB patients, reduced food intake and enhanced nutritional needs together contribute to significantly enhanced risk of malnutrition, leading to interruption in growth, delayed puberty and wound healing9. Hence, the management of such comorbidities can help improve the nutritional status of EB children. Severe malnutrition was seen predominantly in females (M:F ratio = 2:3). This female predominance in malnutrition is multifactorial and is also reported in NFHS survey14.Pediatric malnutrition can be illness-related and non-illness-related. Since there was no control group in the present study, we compared our data with the data in the National Family Health Survey 4(NFHS 4)17. On correlating malnutrition with iscorEB, there was a statistically significant correlation with a moderate strength of association. Additionally, iscorEB was found to have an independent association with malnutrition  with a much stronger association at a cut-off level of 24.5. Since the disease severity goes hand in hand with malnutrition risk, it also alerts the treating physician about the need for an urgent nutritionist or pediatric gastroenterologist consultation.Severe malnutrition was most commonly seen in RDEB (26.9%), followed by DDEB (25%), and JEB (12.5%). However, the disease subtype was not found to have a significant bearing on the frequency of malnutrition (p = 0.10). Few previous studies on this aspect have also reached similar conclusions with the frequency of malnutrition and failure to thrive being higher in patients with recessive dystrophic EB and junctional. Birge et al. found that out of 80 EB children, only 22% with EBS were having malnutrition whereas 77% with dystrophic EB and 57% with junctional EB had malnutrition. Fine et al. reported that 39% of RDEB, 2% of DDEB, 78% of children with JEB Herlitz type and 43% of those with non-Herlitz type were found to have malnutrition18, 25.8% of pediatric EB patients were anemic and mostly seen in RDEB and JEB generalized severe type. Nearly 30% of patients had vitamin D deficiency. Mean iscorEB was higher in those with deficiency followed by those with insufficient levels (45.12 ± 27.61) compared to those with sufficient vitamin D levels (26.20 ± 22.97) but was not statistically significant (P < 0.259). Hypocalcemia could be due to decreased dietary intake or decreased absorption and thus affecting bone mineralization. The cause for hypermagnesemia could not be identified and patients did not manifest any symptoms. These observations are similar to other studies23.The mean iscorEB was found to be higher in those with moderate and severe anemia compared to those with mild anemia. According to the Australasian EB registryTo ensure supplementation of required calories, proteins and fibers, consistency, frequency, type of food were individualized based on age, severity of EB, severity of dysphagia. The total amount of calories was slowly built up by gradually increasing every week to reach the required level. This helped to overcome difficulties in dietary intake in children. For those with dysphagia, esophageal dilation was done which helped to increase the dietary intake to required level.24. Since our follow up duration was only 6 months, an extended follow-up period might show even greater improvement in stunting and other anthropometric parameters. The improvement in nutrition especially in those with malnutrition by offering 100% to 150% of the EER and 115–200% of the estimated average requirement of protein underscores the increased demands to be met in EB children compared to their normal counterparts. Improvement in the frequency of malnutrition following dietary advice highlights the importance of diet in the management of overall growth and severity of disease in EB children. Better dietary intake helps to counter the detrimental effects of disease complications and increased demands because of the chronic inflammatory state. The barriers towards attaining normal nutritional status in 29.4% of patients in spite of dietary management could be the complications associated with the disease, inadequate parental education, and poor socioeconomic status and lack of initiative and encouragement at home for the same.After following dietary advice for 6 months, there was a significant improvement in weight and height compared to baseline. After following dietary advice for 6 months, 29.4% had malnutrition . A study by Zhang et al. in infants found improvement in weight for age, height for age and weight for height scores after following dietary advice for 9–18 months when compared with the control groupDespite our best efforts, our study had a few limitations. The results should be validated in a much larger group in the developing world preferably in a multicentric setting. Moreover, the effect of dietary advice was not compared with the control group as the children normally tend to gain weight and height during this period of growth and development.Moderate to severe malnutrition is common in children with EB and significantly correlates with disease severity as assessed by iscorEB. IscorEB was found to be independently associated with moderate to severe malnutrition. There was significant improvement in nutritional status in overall study cohort, especially in children within RDEB and DDEB subtype after dietary change.Supplementary Information.


Few studies assess the malnutrition risk of older Mexican adults because most studies do not assess nutritional status. This study proposes a modified version of the Mini Nutritional Assessment (MNA) to assess the risk of malnutrition among older Mexicans adults in the Mexican Health and Aging Study (MHAS). Data comes from the 2012, 2015, and 2018 waves of the MHAS, a nationally representative study of Mexicans aged 50 and older. The sample included 13,338 participants and a subsample of 1911 with biomarker values. ROC analysis was used to calculate the cut point for malnutrition risk. This cut point was compared to the definition of malnutrition from the ESPEN criteria, BMI, low hemoglobin, or low cholesterol. Logistic regression was used to assess predictors of malnutrition risk. A score of 10 was the optimal cut point for malnutrition risk in the modified MNA. This cut point had high concordance to identify malnutrition risk compared to the ESPEN criteria (97.7%) and had moderate concordance compared to BMI only (78.6%), and the biomarkers of low hemoglobin (56.1%) and low cholesterol (54.1%). Women, those older than 70, those with Seguro Popular health insurance, and those with fair/poor health were more likely to be malnourished. The modified MNA is an important tool to assess malnutrition risk in future studies using MHAS data. Malnutrition has been identified as a risk factor for adverse events among older adults. Further, malnutrition among older adults may present before a specific health condition , and havLow socioeconomic status ,8 and poDespite the greater malnutrition risk of older Mexican adults , few stuOne of the barriers for the study of malnutrition among older adults in Mexico is that the longest running nationally representative survey of the population 50 and older in Mexico, the Mexican Health and Aging Study (MHAS), does not assess nutritional status directly. The MHAS is a comprehensive population-based study of aging and health in Mexico, thus limiting the opportunity for a full nutritional assessment. Although the MHAS does not apply a full nutritional assessment, it includes several measures that, when used together, result in a modified version of the Mini Nutritional Assessment (MNA). The MNA is a widely used tool to screen the nutritional status of community-dwelling older adults, and it provides a validated and detailed assessment that goes beyond considering BMI and weight loss only ,19. ThusWe used the 2012 wave of the MHAS to conduct this study to provide a nationally representative cross-section of the population aged 50 and older in Mexico. We also used the 2015 and 2018 waves of the MHAS to provide data on mortality for those in the 2012 wave. In addition, we used a subsample of the 2012 cohort that provided a blood sample to measure biomarkers and measured height and weight. The final sample included 13,338 individuals aged 50 and older on whom we had all the information needed to assess nutritional status. The sample size of the subsample for the biomarker analysis was 1911 individuals.One main difference between the MNA and the modified MNA is the time reference: in the MHAS, respondents are asked similar questions but using the previous two years as the point of reference. In addition, there were differences on specific items. For example, the weight loss item in the modified MNA was assessed as change in 5 kg or more instead of 3 kg or more. The MHAS only assessed changes of 5 kg or more and did not assess if there was any change between 1 and 5 kg. Thus, no one received a score of “2” in the modified MNA. The stress and acute disease item was assessed with the closest measure of psychological distress in the MHAS , and the closest measure of acute disease . Due to differences in the time span, as well as other differences on specific items asked between the original MNA and the MHAS modification, we did not consider the cut points of malnutrition, at risk for malnutrition, and normal nutrition from the original MNA.We used receiver operating characteristic (ROC) analysis to calculate the optimal cut point for malnutrition risk. In order to create the ROC curve, we examined the effectiveness of the modified MNA in 2012 to predict mortality by 2018. We calculated the ROC curve based on mortality because this is an outcome highly associated with malnutrition  and servWe also conducted logistic regression models to assess the odds of dying with a 1-unit increase in the modified MNA score, as well as the odds of dying for those identified as at risk for malnutrition compared to those with normal nutritional status, based on the cut point determined as described above.Sensitivity Analysis: Comparison to other nutritional screenings.(1)2BMI 18.5 kg/m(2)in addition to either of these conditions:(2a)BMI 20 if younger than 70, or BMI 22 if 70 or older(2b)Fat Free Mass Index (FFMI) 15 for women and 17 for menUnintentional weight loss greater than 10% over an indefinite time, or 5% in the past 3 months ESPEN criteria: The ESPEN criteria categorizes older adults at risk for malnutrition if either of these alternatives is met :(1)BMI 1After the optimal cut point was defined, we conducted sensitivity analysis to compare the concordance of the modified MNA cut point to other validated measures used to assess nutritional status: the ESPEN criteria, BMI, and biomarkers. This sensitivity analysis was restricted to the subsample with biomarker information. We compared how many of those classified at risk for malnutrition, based on the modified MNA, were also classified as with malnutrition based on these measures.Biomarkers: We used low cholesterol or low hemoglobin as proxies for malnutrition as previous studies have indicated . Partici2, as a proxy for malnutrition.BMI only: We used underweight, defined as BMI 18.5 kg/mWe used both alternatives to classify older adults using the MHAS data. The BMI values used for the first alternative were obtained using measured height and weight and imputed for missing values by the MHAS research team. In the second alternative, unintentional weight loss was defined as answering yes to the question “weight loss greater than 5 kg in the previous two years” to meet the MNA criteria for weight loss greater than 10% over an indefinite time. We considered that 5 kg or more is more than 10% of weight, given that the mean weight in the MHAS population is 70 kg (SD: 13.7). The second alternative was classified based on the 2a alternative of BMI differences, considering age. This is because FFMI  is not measured in the MHAS. Individuals who met alternatives 1 or 2 were defined as at risk for malnutrition.We used a logistic regression model to assess the predictors of malnutrition risk using the modified MNA. We included the following demographic and health covariates associated with malnutrition: sex, age , education , health insurance status , locality size , and self-reported health .The sample characteristics are described in The results from the ROC analysis showed that the best cut point for the modified MNA score was 10.5, which was rounded down to 10. Those with an MNA score of 0–10 were defined as at risk for malnutrition, and those with scores 11–14 were defined as having normal nutritional status. A total of 40.4% of the sample was classified as at risk for malnutrition. This cut point (0–10) was able to predict mortality by 2018 with moderate to high accuracy. The AUC for having a score of 10 or lower was 0.61, the sensitivity was 60.5%, the specificity was 62.5%, the positive predictive value was 18.8%, and the negative predictive value was 91.7%.A 1-point increase in the modified MNA scale was associated with a 15% decrease in the 6-year odds of mortality (Odds Ratio (OR): 0.85, 95% Confidence Interval (CI): 0.83; 0.87)  and thosFurther, when compared to other measures of nutritional status, the modified MNA cut point had moderate to high concordance. In the subsample with biomarker information, the sensitivity of the modified MNA cut point was 93.2% compared to the ESPEN criteria, 78.6% compared to BMI of underweight, 54.1% compared to the objective marker of low cholesterol, and 56.1% compared to low hemoglobin. The specificity of the cut point was also moderate, close to 60% for all of the measures .Results based on the modified MNA  showed tThe results from this study show that the modified MNA, using MHAS data, can be used as an important source of information regarding the nutritional status of older Mexican adults. Our evidence shows that the modified MNA was significantly associated with greater odds of 6-year mortality as a total continuous score, as well as based on the proposed cut point for “at risk for malnutrition”.The proposed cut point had high sensitivity and moderate specificity to predict 6-year mortality. The modified MNA performed with high sensitivity compared to other measures of nutritional status, such as the ESPEN criteria and BMI of underweight only. More than 90% of those classified as at risk for malnutrition with the modified MNA were also classified as malnourished based on the ESPEN criteria. The sensitivity of the modified MNA cut point was lower for the BMI of underweight only, biomarkers of malnutrition (low cholesterol and low hemoglobin), but had moderate concordance with these . The specificity of the modified MNA was also moderate/low compared to these measures.Based on the modified MNA, we estimate that 40% the MHAS sample is at risk for malnutrition. Evidence from a study of Mexican adults 60 years and older from the U.S./Mexico border that applied the original MNA also showed half of the sample was at risk for malnutrition (50.2%) and that the prevalence of malnutrition was 8.6% for women and 6.3% for men . AnotherThe results of this study show that the predictors of malnutrition risk, in older Mexican adults, include both socioeconomic and health factors. The main predictors of malnutrition risk were having Seguro Popular insurance, having lower education, and reporting fair or poor health. Previous work in Mexico also highlighted that, in addition to similar health risk factors, socioeconomic factors, such as not having a pension, reporting lack of money to live on , and illMeasuring nutritional status can be demanding in population-based surveys. One of the strengths of this study is that we used data from a nationally representative study of older Mexican adults that does not directly evaluate nutritional status, and we modified the MNA for potential incorporation into research of nutritional status among older adults in Mexico. The results from this study also help identify target populations in Mexico for interventions to potentially decrease the risk of malnutrition.Our approach has limitations, such as the inability to assess further nutritional information, such as short-term changes, and whether weight loss was intentional or unintentional. Further, the MNA cut point proposed in this study has low specificity and may overestimate false positives. This low specificity is seen because mortality is only a proxy for malnutrition. This measure would likely be higher if nutritional status was measured with the original MNA and compared to this modified version. Because of this limitation, the proposed cut point should not be used to assess the prevalence of malnutrition in the population but only as a marker for malnutrition risk. In addition, we recommend that, if the MHAS user wants to study malnutrition risk with the cut point of 10, they should acknowledge the limitation of the sensitivity and specificity of the proposed cut point. We recommend that one way to avoid this limitation is to treat the modified MNA as a continuous score.In summary, our study showed that approximately 40% of Mexican adults aged 50 and older are at risk for malnutrition, according to the modified MNA. Further, the main risk factors for malnutrition in this population include dimensions of both socioeconomic and health status. The modified MNA proposed in this study can be used to capture a comprehensive picture of malnutrition risk among older adults in Mexico and can inform future work with the MHAS aiming to incorporate nutritional status, thus contributing with a framework that is replicable by other investigators.


The health and nutrition of the global adolescent population have been under-researched, in spite of its significant size (1.2 billion). This study investigates the prevalence and associated factors of malnutrition  among adolescents living in South Asia. The sample analysed was 24,053 South Asian schooled adolescents aged 12–15 years that participated in the cross-sectional Global School-Based Student Health Survey (GSHS) between 2009 and 2016. The prevalence of stunting, thinness and overweight was calculated using the World Health Organization (WHO) Child Growth Reference 2007. Associations between the three forms of malnutrition and their possible associated factors were assessed with binary logistic regression analysis using bootstrapping as a resampling method. The overall prevalence of stunting in South Asia was 13%, thinness was 10.8% and overweight was 10.8%. In the logistic regression model of the overall pooled sample, the factors associated with adolescent malnutrition were: age, hygiene behaviours, social support, sedentary behaviour, and tobacco use. A substantial proportion of stunting, thinness and overweight was found among school-going South Asian adolescents, indicating that the double burden of malnutrition is present in this population. Future research should seek to further understand the relationship between all forms of malnutrition and its associated factors in the adolescent population. The growing challenge of populations experiencing multiple forms of malnutrition has drawn special attention from the global health community in the last three decades . This coEarly life undernutrition may result in increased odds of childhood mortality, reduced capacity for physical work, lower school performance, and greater susceptibility to infectious diseases . Adult oEarly stages in life are critical windows for addressing nutritional burden and preventing the consequences of intergenerational malnutrition . AdolescIn the South Asian context, the prevalence of undernutrition in children and adolescents remains considerably high compared to other regions, despite a decline over the past three decades ,15,16. IA more comprehensive picture of the double burden of malnutrition in all South Asian countries is essential to improve adolescent health and nutritional status in this context. This study aims to address these gaps in knowledge by examining country and regional prevalence of the burden of stunting, thinness and overweight  among South Asian adolescents aged 12–15 years. Additionally, this study investigates malnutrition associated factors and their association with these three forms of malnutrition.The Global School-based student Health Survey (GSHS) is a cross-sectional school-based survey conducted among students living in LMIC that uses standardised procedures to assess health behaviours and protective factors such as alcohol use, dietary behaviours, drug use, hygiene, mental health, physical activity, other protective factors, sexual behaviours, tobacco use, and violence and unintentional injury. The GSHS samples are representative of all students in a given country. Further details on the GSHS are published elsewhere . We selehttps://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-school-based-student-health-survey Accessed on 19 August 2021), and they were approved by the national government’s administrative body and the corresponding institutional ethics board review [GSHS surveys employ a two-stage sample design where the first sampling units are clusters and the second sampling units are elements of those clusters. More specifically, the first level of the GSHS sample selection process was schools, that were independently selected within each country. In the second stage, classrooms were selected within each school, and a questionnaire was completed by each attending student . The GSHd review . This stThe GSHS uses core questionnaire modules, core-expanded questions, and country-specific questions that are combined to form a questionnaire that the students completed during one regular class period. Fifty-six health behaviours and protective factors  were collected, but not all of these variables are included in the South Asian surveys. In this analysis, variables were included if they were: (1) collected across all South Asian countries, and (2) relevant within existing established frameworks on adolescent nutritional status ,14,34,35Anthropometric measurements (height in cm and weight in kg) were collected by trained GSHS survey staff. Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Adolescent malnutrition indicators (outcome variables) were assessed based on the WHO growth reference for school-aged children and adolescents  and the p < 0.05. Maps displaying prevalence of stunting, thinness and overweight among South Asian students were created using Tableau.To account for the GSHS two-stage sample design, this analysis applied the sampling weights, clustering, and stratification using the svy command in Stata v16 . Prevalep < 0.05, using chi-squared test). Collinearity was assessed to identify pairs of health behaviour variables that were correlated . In addition, we computed other collinearity diagnostic measures  using collin command in Stata. None of the covariates were identified to be strongly collinear. Regression was used to examine the associations between malnutrition indicators and health behaviour variables. Binary logistic regression was applied to predict the outcome variable informed by a set of health behaviour variables—potential associated factors—calculating odds ratios (ORs). Manual backward stepwise regression was used to develop multivariable logistic regression models of the predictors of malnutrition in South Asian students aged 12–15 years. Only significant health behaviour variables  were retained in the reduced model, except for age, sex and country, which were considered traditional confounders. Full and reduced models (only including explanatory variables identified as significant using backward stepwise regression) of stunting, thinness and overweight at the South Asian and country level were examined. The bootstrap resampling method was used for a more accurate estimation of the standard errors in logistic regression.Bivariate analysis checked the independent association of each health behaviour variable to the outcome  (p = 0.06). There was no significant association between sex and stunting in any of the South Asian countries except from Pakistan where stunting in girls was more likely than in boys (p < 0.001).The overall prevalence of adolescent stunting in South Asia was 13%—this ranged from 3.9% in Pakistan to 28.2% in Afghanistan (χ< 0.001) a. Table 2 = 159.5, p = 0.04) (p = 0.11). The proportion of students who were thin did not differ by sex in Pakistan, Afghanistan, Bangladesh, India, Maldives and Sri Lanka. However, there was a significant effect of sex on thinness in Nepal (p = 0.03), and Bhutan (p = 0.001) with boys being thinner than girls (p = 0.001).The overall prevalence of adolescent thinness in South Asia was 10.8%—this ranged from 1.5% in Bhutan to 18.6% in Sri Lanka (χ = 0.04) b. Table 2 = 109.14, p = 0.2) (p = 0.3). The association between sex and overweight was not significant in Afghanistan, Bangladesh, Nepal, and Sri Lanka. In contrast, results indicated a significant difference between sexes in the remaining countries. Boys were more likely to be overweight in India (p = 0.01) and Maldives (p = 0.02), while girls were more likely to be overweight in Pakistan (p = 0.001) and Bhutan (p = 0.002).The overall prevalence of adolescent overweight in South Asia was 10.8%—this ranged from 8% in Pakistan to 19% in Afghanistan (χp = 0.2) c. Table p < 0.05) apart from washing hands before meals and after toilet.p = 0.03) and tobacco use (p = 0.04) were significantly associated with stunting in the pooled sample (p = 0.01) (p = 0.001), sedentary behaviour (p = 0.009), and tooth brushing (p = 0.005).The bivariate analysis showed that anxiety (d sample . Sedenta = 0.01) . The fol = 0.01) : tobaccop < 0.001). Students living in Afghanistan , Bangladesh , India , Maldives , Nepal , Sri Lanka , and Bhutan  exhibited a greater risk of being stunted than students living in Pakistan. Peer support was negatively associated with stunting .The multivariable logistic regression reduced model of the pooled sample  showed tp = 0.003) versus being 12 years old; living in Afghanistan , India , Maldives , Sri Lanka  and Bhutan  versus living in Pakistan; sedentary behaviour ; and tooth brushing .In the reduced model for thinness , severalp = 0.006), 14 years  and 15 years old  were less likely to be overweight than their peers aged 12 years old. Students living in Afghanistan , India , Maldives , Sri Lanka , and Bhutan  versus those living in Pakistan had significantly greater odds of being overweight than students living in Pakistan. Several factors were also associated with overweight: tobacco use , tooth brushing , washing hands with soap , and parental involvement in school .In the reduced model for overweight , South AIn addition to the pooled sample models, full and reduced models of the three forms of malnutrition at country level were also examined. Factors associated with malnutrition indicators varied across countries and no clear trend was identified .In this secondary data analysis of the GSHS, we estimated the prevalence of the double burden of malnutrition among in-school adolescents in South Asian countries . This study showed that the overall prevalence of stunting in South Asia was 13%, thinness was 10.8% and overweight was 10.8%, with significant geographical variations in stunting and thinness. Sex was not associated with adolescent malnutrition indicators in the pooled sample; however, it was within some countries . Prevalence of health behaviours was calculated showing substantial differences across South Asian countries. We identified factors associated with malnutrition at the South Asian level: age, hygiene behaviours, social support, sedentary behaviour, and tobacco use.Firstly, we calculated the prevalence of stunting, thinness and overweight in South Asia. The present findings suggest that adolescents in South Asia are affected by the double burden of malnutrition, consistent with global trends ,29, and This study demonstrates some significant associations between sex and adolescent malnutrition indicators. Pakistani girls were more likely to be stunted and overweight in comparison to boys. There was a significant relationship between malnutrition indicators and sex in Bhutan with boys being thinner than girls and girls being more overweight than boys. Findings also showed a significant effect for sex in India, Maldives and Nepal. Despite these associations in our sample, there is no distinct sex disparity trend. This is consistent with findings from previous reviews on underweight  and overTo our knowledge, no previous analyses have calculated adolescent malnutrition indicators at a country level in the eight South Asian countries. Our results are not directly comparable with previous publications ,48,49,50Secondly, the prevalence of health behaviours was examined in this study. We compared our results with other GSHS publications where possible . Only 14.3% of South Asian adolescents consumed the recommended fruit and vegetable intake (5/day). A study using GSHS datasets in 65 low-income and middle-income countries reported a higher percentage (25.7%) of adolescents who met the recommendations of daily fruit and vegetable intake . FeelingWe report a lower overall prevalence of tobacco use (5.3%) in comparison to previous GSHS publications in Seychelles (22%) , ThailanThe prevalence of physically active adolescents at the South Asian level was 27.1% in this study. However, findings from the Africa region (16.6%), the Americas region (16.2%) and the Western Pacific region (13.8%)  indicateResults from the pooled sample showed that 54% of the adolescents reported brushing their teeth twice a day with large country variations ranging from 30.2% in Pakistan to 77.1% in Maldives. Pengpid and Peltzer (2014) found that daily brushing recommendations were met by 77.6% of adolescents from four Southeast Asian Countries . The preThe prevalence of students reporting that they had at least one close friend in our pooled sample was 91.9%, similar prevalence was reported in Latin America and the Caribbean (92%)  and in AHalf of the adolescents in this sample reported the presence of supportive parental figures . Maldives and Bhutan presented the lowest levels of parental support whereas the highest rates of perceived parental support were found in Sri Lanka. One in three adolescents in the Caribbean  reportedThirdly, several health behaviours were found to be associated with adolescent malnutrition indicators  in multivariable logistic regression models of the pooled sample. We found that variables representing hygiene behaviours were associated with malnutrition. Tooth brushing was associated with two forms of malnutrition (thinness and overweight). In other South Asian studies, poor oral health predicted overweight ,68,69 anInterestingly, this study did not find a significant association between sedentary behaviour and overweight. By contrast, previous research from Sri Lanka found association between sedentary behaviour and being overweight among school children . NeverthIn this analysis, tobacco use was found as a significant predictor for overweight. It is difficult to contextualise this finding because no studies were found on the association between smoking and nutritional status in South Asia, possibly due to a predominantly smokeless society and social taboos. Pengpid & Peltzer (2016) confirmed an association between tobacco use and overweight among girls in the AESAN member countries .Peer support and parental involvement in school were associated with malnutrition at the South Asian level. Peer support was a protective factor against stunting while parental involvement in school protected against being overweight. Peers and parents have a great impact on adolescent food choices ,73, espeFruits and vegetable consumption, psychological distress and physical activity have previously been associated with nutritional status, especially overweight, among South Asian adolescents ,78,79. HThe use of the GSHS is both a strength and a limitation. Regarding the strengths of the GSHS, there are no other global quality health surveys on South Asian adolescents up to date in which data is nationally representative and methodology is standardised across countries. This survey collects height, weight and BMI that are anthropometric measurements widely used to calculate malnutrition indicators and monitor prevalence at the population level. In terms of limitations, the cross-sectional, non-interventional design limits any causal interpretation, although the observed prevalence and associations could be used to generate hypotheses. Second, data on certain aspects of adolescents’ circumstances were not available in the GSHS, such as household socioeconomic status, ethnicity, religion, and rural/urban setting, so adjusting and stratifying the analysis to explore further inequalities among these subgroups was not possible. Third, GSHS does not collect nutritional biomarkers data, thus micronutrient deficiency as a form of malnutrition was not included in this analysis. The exclusion of micronutrient deficiencies from the malnutrition burden leads to underrate its impact on adolescent health and nutrition . Fourth,This particular analysis also has limitations. Some important variables such as frequency of hunger, carbonated soft drink consumption and frequency of eating at fast-food restaurants were not included in this analysis due to the inclusion criteria, that is, only explanatory variables collected in the eight South Asian countries. Survey data were collected between 2008 and 2016, so comparisons between South Asian countries should be made with caution. Despite these limitations, this study is the first, to our knowledge, to examine the relationship between the double burden of malnutrition and associated factors among South Asian adolescents using a large pool of nationally representative data, although more research is needed to confirm these associations.The prevalence of the double burden of malnutrition at the population level among schooled adolescents living in South Asia is a nutritional problem of public health importance. This study highlights the urgent need for addressing the double burden of malnutrition in South Asian schooled adolescents and investigating further malnutrition risk and protective factors. Determining the magnitude of the double burden among adolescents is important for the development of appropriate double-duty actions to accelerate progress towards ending malnutrition in all its forms.