The quality of the diet followed and the confidence and tolerance for adversity as a resilience factor were also improved, representing a medium size effect for this last variable; (4) Conclusions: Despite the limitations of this study as it does not have a control group, the main conclusions are that active video games and motor games can be a motivational resource to follow an active lifestyle, helping to improve health status indicators in young adults.(1) Background: High levels of physical inactivity caused by sedentary digital screen leisure constitute one of the main causes of the high levels of obesity observed in today’s society; (2) Methods: The present study aims to analyse the effect of a 12-week intervention program based on the application of active video games and motor games on health status indicators, problematic use of video games, and resilience capacity in university students. Besides, the content blocks of the Physical Education (PE) field are worked on through these devices, revealing their potential as an Information and Communications Technology (ICT) resource. A longitudinal study with a pre-experimental design with pretest–posttest measurements in a single group ( University stage is defined as a critical risk period regarding maladaptive behaviour which is harmful to human health . This peVO2max), deteriorated physical abilities or deteriorated psychosocial factors such as self-esteem [Problematic use of video games is presented as a risk factor in the development of health problems at a physical and cognitive level in university students ,6. Regarf-esteem ,10.This situation is promoted by high intake of junk food or poor quality diets followed currently , which sSpecifically, resilience is defined as a process through which individuals use personal and environmental elements in order to adapt themselves or redirect traumatic and stressful elements in their daily life . In thisFacing the problem of high indices of overweight produced by physical inactivity, sedentary digital leisure and little adherence to Mediterranean Diet, various authors emphasise the importance of promoting physical-healthy habits based on the practice of hedonistic physical and sporting activities with the aim of creating intrinsic motivations towards these kind of behaviours . Active VO2max). Addressing researches done with active video games, Maddison et al. [In this sense, several studies with similar characteristics have been those carried out by López-Sánchez et al.  or Borren et al.  demonstrn et al.  developen et al. .This research study aims at developing a pilot study based on the application of active video games and motor games in a sample of university students in order to check their effectiveness in the improvement of parameters indicating health levels, with the aim of applying similar processes in school-age children in the future. The sample is made up of future Physical Education (PE) teachers and the interest of the study is based on what is established by the Law of 17 March 2017 which formulates the curriculum corresponding to Primary Education in Andalusia (Spain) which specifies in aim number 7 of the Physical Education subject the importance of using Information and Communications Technology (ICT) as an additional support ,30. SpecVO2max or adherence to the Mediterranean diet?Considering the premise of the existing problem of high sedentary and obesity indices, it can be established that these are propitiated by low levels of physical activity, high rates of sedentary digital leisure and a poor quality of the diet in emerging adulthood. This study presents the following research question in order to address the need to generate alternatives to set an active lifestyle that enables improving health in youth and then to be transferred to lower stages to work with PE content as suggested in previous research ,32: CoulVO2max in men. Women will present greater flexibility and adherence to the Mediterranean diet. The problematic use of video games will be more widespread in men. Women will be more resilient.Hypothesis 1 (H1): The basic descriptive will show a higher prevalence of lean mass and VO2max and the flexibility of university students.Hypothesis 2 (H2): The intervention program will improve the percentage of fat and lean mass, Hypothesis 3 (H3): After the intervention program the problematic use of video games will decrease and it will improve the levels of resilience and adherence to the Mediterranean diet.Following the problems raised and the need to act before it, these hypotheses are proposed in relation to the intervention program developed through active video games:VO2max, adherence to MD, problematic use of video games and resilience in a sample of university students of PE depending on their gender; (b) Verify the effect of an intervention program based on motor games and active video games in the described variables; (c) Analyse the connection between these variables after the performance of the intervention program.Therefore, this study pursues as main goals to: (a) Set the percentage of fat mass and lean mass, flexibility, n = 29) and 38.2% women (n = 18). The average age was 22.53 (SD = 2.19), with a minimum age of 20 and a maximum age of 28. The selection of participants was made on convenience. As inclusion criteria, it was considered that respondents were student of the last year of the degree in Primary Education, as well as not suffering any diseases which could hinder the normal progress of the program. The previous play experience with active video games was not considered.The intervention was performed on a natural group of students of the university degree in Primary Education, therefore creating a pre-experimental design in randomised natural groups—Cluster-Randomized Controlled Trial . In thisHeight was calculated using a SECA-213 stadiometer® (m).Body weight (kg) and Body composition—percentage of fat mass (%) and lean mass (%)—was established by means of electronic weighing scales, using the model Tanita TBF300®. This model needs the variables of gender, age and height, measuring this last one by means of a stadiometer Holtain LTD® and following the protocol established by Portao et al. .2 (kg/m2).Body Mass Index (BMI) was calculated from the arithmetic ratio established by Quetelet —body weiVO2max was measured indirectly with the test “Meter Shuttle Run Test (20mSRT) [VO2max indirectly we used the speed reached in the last stage, using the following formula: VO2max (ml/min/kg) = (6 × FA) − 27.4 [The (20mSRT) . This te) − 27.4 ,38.Flexibility was assessed by means of the sit and reach flexibility test for the upper body . The proAdherence to a Mediterranean Diet, assessed by the questionnaire KIDMED . This teQuestionnaire of Experiences Related to Video games (QERV), validated by Chamarro et al.  for teenConnor–Davidson Resilience Scale (CD-RISC) , for theAd Hoc questionnaire for the record of socio-demographic variables . An item was also included in order to know if the participants suffered any kind of disease which could hinder the involvement in the study.In the first place we asked for the licences needed and the informed consent. Approval of the research by the Human Research Ethics Committee of the University of Granada was requested, being sanctioned with code 462/CEIH/2017. Regarding participants, all of them were adults. An informative letter was provided describing the main characteristics of the study, ensuring anonymity of data and its scientific research purposes. The sample for the study was made up of those participants who decided to take part in it signing the informed consent.The study was accomplished from October to December 2016. For its execution, researchers performed two formative sessions where they detailed the characteristics of the intervention plan, as well as the tasks to be performed by each member of the project. Periodicity of intervention consisted of two weekly sessions lasting two hours each, which were divided into four phases.Concerning phases in each session, the first phase (1) consisted of a short introduction explaining the contents that were going to be worked on lasting about 10 minutes. Arrangement of the working sessions was aimed at working on all of the four educational content blocks defined by the LOMCE , lastingMotor games used during phase 3 were brought together following the content blocks in current legislation ,30. In tIt was expected to obtain a similar internal load through motor games and active video games, since as Miyachi et al.  state, tWe have to emphasise that the intervention program was designed and analysed thoroughly regarding the mentioned characteristics, being created and supervised by professional researchers in the fields of Physical Education, Physical Activity and Sports Sciences and ICT. In the same way, we have to point out that this research study followed the ethical principles for research established by the Declaration of Helsinki. The participants’ right to confidentiality was also observed at all times.Statistical analysis was carried out using the software IBM SPSS® 22.0 . For basic descriptors, frequencies and medians were used, whereas for the study of connections between variables a T-test was used with independent samples and bivariate correlations of Pearson. In order to analyse the effect of the intervention program we used a T-test of related samples and Cohen’s d together with the confidence interval (95%) . NormaliVO2max) statistically significant differences were found, being higher in men (51.12 ± 12.79 vs. 38.54 ± 12.56). The degree to which a Mediterranean diet is followed did not reveal statistical differences regarding gender, although men followed a healthier diet (6.68 ± 2.17 vs. 6.09 ± 2.81). Finally, statistically significant differences were found in the problematic use of video games, being greater in men (35.94 ± 11.01 vs. 24.52 vs. 5.43).Next, the scoring of the different factors forming resilience is shown . In thisp = 0.015), the VO2max (p = 0.008), factor 2 of resilience—confidence and tolerance for adversity— (p = 0.001) and the quality of the diet followed (p = 0.024). For fat mass a lower average value was obtained after the intervention (12.30 ± 5.67 vs. 11.83 ± 5.28), representing a small effect size (d = −0.11). In the case of VO2max higher average values are achieved in the post-test (45.91 ± 15.03 vs. 47.19 ± 13.53), representing a small effect size (d = 0.13). Factor 2—confidence and tolerance for adversity—improved after the application of the program (3.00 ± 0.33 vs. 3.14 ± 0.38), representing a medium effect size (d = 0.42). Finally, scores obtained in the following of the Mediterranean Diet improved in the post-test (6.44 ± 2.44 vs. 7.11 ± 2.20), representing a small–medium effect size (d = 0.32).VO2max and the adherence to a Mediterranean Diet, showing a negative and indirect relation in every case . Regarding lean mass, it correlated positively and directly with VO2max, resilience ability and problematic use of video games , obtaining for all of them statistically significant differences. Finally, a positive and direct relation can be seen between VO2max and adherence to a Mediterranean Diet (r = 0.291).VO2max, the problematic use of video games, quality of the diet and resilience. Other similar studies were carried out by Falbe et al. [This research study analyses the effect of an intervention program based on active video games and motor games in a sample of university students. The program lasted twelve weeks, working on the four content blocks of the Physical Education area. In particular, it was aimed at the improvement of health status indicators such as percentages of fat mass and lean mass or the e et al. , Kahlbaue et al. , Sun [23e et al. , Graf ete et al.  or Troste et al. , all of VO2max. These results are similar to those presented by Carrick–Ranson et al. [VO2max due to their greater systolic volume, lean mass and haemoglobin concentration [The pre-test measurement showed that fat mass was greater in women, whereas lean mass was higher in men. These results seem reasonable given women’s physiological features and the preparation of their bodies for fertility through the release of oestrogens, whereas men have greater muscle mass due to androgenic hormones . Addition et al.  or Zuritn et al. , who pointration .It was also observed that scores obtained by problematic use of video games were higher in men as Espejo et al.  showed. Analysing the effect of the intervention program, a reduction of the percentage of fat mass was disclosed, representing a small size effect. In a similar way Foley et al.  obtainedVO2max, post-intervention assessment displayed a slight improvement finding statistically significant differences. This demonstrates that the combination of active video games and motor games of a moderate intensity enables the improvement of physical shape through aerobic capacity, verified by Bethea et al. [VO2max, it can generate some of the main modifications which could trigger its improvement, such as cardiac output, cardiac capillary density or alveolar gas exchanges [VO2max in a pilot study conducted in female university students using XBOX Kinect® even with a similar training volume (between 30–60 minutes three times per week), justifying the findings found. Nevertheless, it is important to highlight that Roopchand–Martin et al. [VO2max than those employed in this study for some content blocks . Therefore, the importance of regulating the times, load and type of video game in the use of these platforms is emphasized to obtain a greater effect on health indicators [Regarding a et al.  in an inxchanges ,56,57. Ixchanges  obtainedn et al.  used dandicators ,55,58.The program improved the quality of the diet followed by the students, representing a small–medium effect size. Although nutritional contents were not specifically worked on, Schneider et al.  show howAmong resilience factors, the program improved confidence and tolerance for adversity, having a medium effect size. Studies such as those by Hartfiel et al.  demonstrIt is important to point out some of the reasons why the intervention program has not had the expected effect with some variables. First, the sessions made by active video games did not improve the percentage of lean mass. This may be due to the fact that the internal load generated by this exercise is insufficient to generate muscle adaptations such as the increase in muscle cross section or the thickness of type II fibres. For this purpose, it would be necessary to structure a training program with greater intensity based on a structural orientation . Nor wasFinally, it is interesting to point out the main limitations of this research study. Among them, we can highlight the use of a pre-experimental design and the non-use of a control group, which would have helped to control more effectively the effect of the program, eliminating the effect of certain external variables. Regarding design, we must stress the use of a single experimental group instead of three experimental groups, considering a Group1 which received the effect of the program through motor games, a Group2 through the use of active video games and a Group3 through the blending of both; this will be considered in the future, as this study has been a pilot experience with active video games. In fact, a combination of both is used since the number of platforms Xbox 360® was not enough. Another limitation to bear in mind regarding the effect of the program is the fact that it has been performed on university students that follow a relatively active lifestyle. Likewise, it would have been interesting to measure with an accelerometer the level of physical activity implied in the two parts of the main phase of training, which is to be considered for future studies. As future perspectives, we can regard including greater experimental criteria, as well as the possibility of working with school-age children in order to obtain health improvement in high-risk population. In this case, it would be necessary to readjust the duration of the sessions of the intervention program to the schedule of the classes of PE of Primary Education (60–90 minutes).VO2max or the quality of the diet. Nevertheless, this is not effective for the improvement of lean mass, flexibility or problematic use of video games. Therefore, we need to make certain points about the hypothesis:Hypothesis 1 (H1) was partially fulfilled, since lean mass was higher in men and lower in women, observing the opposite tendency for fat mass. In addition, the problematic use of video games was higher in men. On the contrary, the levels of resilience were higher in men, as well as the quality of the diet—not fulfilling what was established.VO2max. Nevertheless, the percentage of lean mass and flexibility did not improve.Hypothesis 2 (H2) was partially fulfilled. The intervention program improved the percentage of fat mass and Hypothesis 3 (H3) was partially fulfilled, since the intervention through active video games improved the quality of the diet but did not decrease the problematic use of video games.Considering the research question, it can be established that an intervention program based on active video games and motor games can improve different health indicators in university students such as fat mass, VO2max, considering the limited intensity in physiological internal load offered by these kind of devices. Additionally, some resilience factors were improved, representing a moderate size effect in confidence and tolerance for adversity, mainly due to the well-being and playful component of these devices. Finally, level of adherence to a MD was improved, due to the promotion of physical and healthy habits in the two phases of intervention.This research study shows how an intervention program based on active video games and motor games can have slight–moderate positive effects in some of the parameters indicating physical and cognitive health in university students. It is revealed that twelve weeks of intervention enabled a slight improvement in the fat mass percentage and VO2max. This pilot study demonstrates some potential benefits of these devices, as well as its usefulness to apply some of the contents developed in the area of Physical Education. In this way, a line of research is opened in order to replicate this study in populations with a higher prevalence of overweight, such as children and adolescents.As a main conclusion, it can be established that active video games are a resource of interest for the realization of physical exercise in the improvement of health in young adults, even though the intervention program had a low effect on most indicators because participants were young adults. Likewise, and despite the limitations described, the literature shows how this type of platform can have an even greater potential effect in children and adolescents, especially linked to the improvement of body composition and


Many older people with frailty are at risk of malnutrition and poor health, yet there is evidence that improving nutrition and weight loss can reduce frailty. This will become more important as the number of older people with frailty increases worldwide in future. Identifying those at risk is challenging due to the difficulty of reaching and screening those older people most at risk, the large number of nutritional assessment tools used, and the lack of consensus on the criteria to make a diagnosis of malnutrition. The management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary, and all care staff have an important role in delivering appropriate nutritional advice and support. This paper will highlight a number of practical approaches that clinicians can take to manage malnutrition in older people with frailty in community and acute settings, including environmental changes to enhance mealtime experience, food fortification and supplementation.  Under nutrition  is common among older people and often poorly recognised and under diagnosed. It is associated with frailty, sarcopenia and poor health outcomes. Importantly, there is increasing interest in the potential of nutritional interventions to improve the poor nutrition and weight loss of frailty, but current evidence is scarce . The current definition of malnutrition from the European Society for Clinical Nutrition and Metabolism (ESPEN) is ‘a state resulting from a lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass and body cell mass) leading to diminished physical and mental function and impaired outcome from disease’ . MalnutrIt has been estimated that 3 million people in the United Kingdom (UK) alone are poorly nourished or at risk of becoming so, with most 93%) living at home . The pre3% livingFrailty is often defined as a loss of biological reserves across multiple organ systems with increased vulnerability to physiological decompensation after a stressor event . FrailtyMalnutrition and frailty are related syndromes . Many frThe causes of malnutrition in older people are multifactorial . ReductiMalnutrition has serious consequences for individuals, society, health, and social care services. Malnutrition is associated with increased risk of frailty, sarcopenia, falls, dependence in activities of daily living (ADL), hospital admission and longer length of stay, with poor wound healing and more complications, increased mortality and poor health-related quality of life . MalnutrThere are a number of practical approaches to the management of malnutrition in frail older people that can be undertaken, starting with early identification of those at risk. The diagnosis of malnutrition can be made following a formal nutritional assessment. However, there has long been a lack of consensus regarding the criteria needed to make a diagnosis of malnutrition. Ongoing work by the Global Leadership Initiative on Malnutrition has recently produced a statement on diagnostic parameters which focuses on intentional weight loss, low body mass index (BMI) and reduced muscle mass as the three phenotypic criteria, and reduced food intake or absorption and inflammation or disease burden as the two aetiologic criteria  32]. . 32]. For a diagnosis of malnutrition, at least one of each set of criteria needs to be met. A grading of severity can then be made based on thresholds for the phenotypic criteria . Nutritional assessment tools such as the Subjective-Global Assessment (SGA) and the Mini-Nutritional Assessment (MNA) aid in diagnosis. However, use of these tools in older people is supported by little evidence ; diagnosBefore formal assessment occurs, a person is often identified to be at ‘nutritional risk’ by a malnutrition screening tool . CurrentThe use of validated malnutrition screening tools in hospital is associated with increased monitoring of oral intake, with algorithms for addition of supplements and dietician referral that can provide individualized nutritional support , to imprThe rise in hospital screening is currently not reflected in the community, despite policy recommendations, and there is a lack of research on attributable clinical outcomes in this setting ,44,45. TThe most commonly used screening tool in studies of malnutrition among community dwelling older people is the MNA-SF . HoweverRecently, Cascio et al.  appraiseA systematic review of malnutrition screening within the care home setting assessed over 20 different tools used and reported the validity of the best performing tools to be only fair . The MNALoss of appetite, or the Anorexia of Ageing, is a known major contributor to malnutrition and may be measurable prior to weight change ,32,52. AThe management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary . Care stIn primary care settings, community healthcare professionals, especially nurses, may be able to deliver opportunistic nutritional advice and education, and there is evidence that this can positively influence the functional outcomes and diet of older people living at home . Group eA range of environmental factors can influence the mealtime experience of older people in different settings. Effective interventions to address these factors could potentially reduce the risk of malnutrition among older people.p = 0.028) among older adults with dementia when their main caregivers received health and nutrition training, compared to the control group [Several studies have explored the role of family, friends and neighbours in improving nutrition of community-dwelling older people, as they have a unique insight into their environment, values, traditions and beliefs . A revieol group . The nutVolunteers can also help reduce malnutrition risk among community-dwelling older adults. A randomised controlled trial among 80 older adults (mean age 83 years) reported that peer volunteers trained to perform strength exercises and have nutrition-related discussions with patients resulted in improved MNA scores and a 25% reduction in prevalence of impaired nutritional status (MNA score < 24) . The stuThere is evidence that people tend to eat more when dining with others rather than alone ,61, an eRecognised barriers to eating well among older people living at home include the affordability and accessibility of food, limited food services, decreasing mobility, and lack of cooking skills ,67. LocaMalnutrition is common among hospitalised older people and in the busy clinical setting of an acute hospital, multiple environmental factors can influence the nutritional intake of older inpatients. These include mealtime interruptions by medication rounds and other clinical activities, inflexible food service practices, unfamiliar food items, time and staffing shortages, and practical issues such as inappropriate placement of food trays and food packaging that is hard to open ,72,73,74Several initiatives have been developed to address these issues. Coloured trays have been used to help staff identify those patients who may need help during mealtimes . AlthougMealtime assistance can also improve nutritional intake among hospitalised older people. A meta-analysis by Tassone et al. reported statistically significant increases in daily energy  and protein  intake in older inpatients receiving mealtime assistance compared to control groups . StudiesA review of the qualitative literature around attitudes, perceptions and experiences of mealtimes among care home residents and staff was conducted by Watkins et al. to better understand factors that may contribute to malnutrition in this setting . One of Observational studies have shown that one-to-one feeding assistance increased oral intake among care home residents ,101 and Several interventions have been explored to address the environmental factors that may increase the risk of malnutrition among older adults in care homes. These include the use of music to alter dining ambience , use of This strategy is based on ‘food first’ principles and involves using energy and protein dense meals (fortification) or snacks (supplementation) to increase dietary calorie and protein intake. Examples include the use of fortified bread ,113, souThere is evidence that offering “finger foods”—foods that can be easily eaten with fingers—can increase the pleasure of eating, increase food consumption and improve autonomy among older people living with frailty and dementia. A study among care home residents showed that finger foods were frequently chosen and consumed . This stOral Nutritional Supplements (ONS) in the form of energy- and protein-dense sip feeds can be effective to improve nutritional intake among malnourished older people including those with frailty . ONS areHowever, the acceptability and intake of ONS are frequently suboptimal in older people , specifiEnteral nutrition is recommended for patients who have a functional gastrointestinal system but are unable to consume their daily required calories over several days . EnteralThe projected increase in the number of older people with frailty underlines the importance of addressing malnutrition to improve the health of this group. The lack of an agreed standardised method to screen for malnutrition risk in older people across settings will continue to prove a challenge when attempting large-scale screening and treatment initiatives and calculating accurate prevalence rates. A complex mix of factors influence nutrition among older people but there are components of everyday practice within hospital and community settings that could be improved to address malnutrition. Clinicians have an important role in addressing these challenges by raising awareness of the issue of malnutrition among older people, developing care pathways and delivering training to key staff, such as primary care staff and healthcare students, to promote early intervention for older people with frailty who are at risk of malnutrition. In particular, studies addressing the impact of nutritional interventions on functional, clinical and patient-centered outcomes are needed.


Hb remained in normal range during the bottom phase, but fell during the decompression; reaching levels of mild anemia (≤13.6 g/dl) the day after the divers’ return to the surface. Hb was significantly lower than the pre-saturation baseline (14.7 ± 1.1 g/dl) on the fifth day post-saturation , before reverting to normal after 6–7 days. At the end of the 12-day post-saturation period, Hb was not statistically different from the pre-saturation baseline. The observed Hb changes, although significant, were modest. While we cannot rule out effect of other factors, the presence of mild anemia may partially explain the transient fatigue that commercial saturation divers experience post-saturation.Commercial saturation divers must acclimatize to hyperbaric hyperoxia in their work environment, and subsequently readjust to breathing normal air when their period in saturation is over. In this study, we measured hemoglobin (Hb) during and following 4 weeks of heliox saturation diving in order to monitor anemia development and the time for Hb to recover post-saturation. Male commercial saturation divers reported their capillary blood Hb daily, before, and during 28 days of heliox saturation to a working depth of circa 200 m ( When the period in saturation ends, they must readjust to breathing normobaric air. These transitions present substantial challenges to the oxygen homeostasis: the vital balance that sustains the body’s energy production while limiting oxygen toxicity  and the maturation of newly formed erythrocytes are widely downregulated  and for 12 days after, using a robust and reliable method. Based on prior reports of hematological responses to prolonged hyperbaric hyperoxia, we hypothesized that the divers’ Hb would decrease and aimed to monitor the potential development of anemia as well as the interval for Hb recovery after hyperbaric heliox saturation.Commercial saturation divers were studied during and after work assignments on the DSV Deep Arctic in the Mediterranean Ocean, August–December 2018. The study protocol was approved in advance by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), approval number 2018/1184. All subjects were informed of the aim and scope and provided written consent before inclusion, and the experimental procedures were conducted according to the Declaration of Helsinki principles for ethical human experimentation.The study subjects were experienced, male saturation divers; cleared for diving after a mandatory pre-dive medical examination and committed to saturation onboard the DSV Deep Arctic. Prior to saturation, the divers prepared for the Hb protocol and performed pre-saturation Hb baseline measurements in the vessel hospital under researcher supervision, using an AA battery-operated HemoCue 201+ device with cuvettes and safety lancets . To test its function in the hyperbaric heliox atmosphere, one HemoCue was compressed to 182 msw with the first dive team. There were no issues with Hb readings in saturation; a total of six Hb devices were used throughout the study without instrument failures or missed readings.2 was kept at 40 kPa in the pressure chamber and increased to 60–80 kPa during bell-runs. During decompression, the ppO2 was increased to 50 kPa until reaching 13 msw; from there up until surface the ppO2 was gradually reduced from 23 to 21%. After surfacing the divers remained on a 24-h watch for signs and symptoms of decompression sickness (bendwatch) before they left the vessel.After their pre-dive medical examination, the divers entered the pressure chambers and were compressed (blown down) over a period of about 6 h until they reached the storage depth of 182–200 msw. Saturation diving was conducted according to the contractor’s procedures; the 28-day saturation profile is illustrated in The divers measured their Hb daily at the start of each work shift, after hydration but before breakfast. Sampling of capillary blood from the third or fourth fingertip was done according to the HemoCue201+ manual, using the third drop of blood from the punctuation site to fill the cuvette. The procedure was repeated in cases of visual bubbles or if the cuvette was incompletely filled. Hb readings were done within 10 min of blood sampling, and each diver used one Hb device and cuvette batch throughout the study. Readings done within the pressure chambers or on land after saturation were reported in writing to saturation control or directly to one of the researchers.RRID:SCR_002865). Hb values deviating >1.5× from the lower or upper quartile were categorized as outliers, leading to exclusion of 5 of 404 data points. For the 399 data points included, normal distribution was confirmed by boxplot and Kolmogorov-Smirnov test. Homogeneity of variances was assessed by Levene’s test, which assumes homogeneity for p > 0.05. For this dataset p = 0.318. One-way repeated measures ANOVA with Bonferroni post hoc adjustment for multiple comparisons was used to assess differences in Hb concentration within the different phases separately: bottom phase, decompression and post-saturation. A linear mixed model with Bonferroni adjustment was used to assess the difference between Hb at pre-saturation baseline, the mean lowest value post-saturation (day 33) and the last day of follow-up (day 40). If Mauchlyʼs test showed that the assumption of sphericity was violated, a Greenhouse-Geisser correction was applied. Differences were considered significant at p < 0.05. Hb levels were graded according to WHO’s classification for adult males , before gradually reverting to normal after 6–7 days. After 12 days of post-saturation follow up, Hb was still below the baseline but the difference was not statistically significant.Commercial saturation divers reported their Hb daily throughout and following a 4-week work period in heliox saturation. The practical set-up for Hb measurements inside a hyperbaric living chamber is shown in In this study, Hb was measured daily through 4 weeks of commercial heliox saturation diving to approximately 200 msw and a follow-up period after, using portable Hb devices operated by the study subjects themselves. While Hb remained normal during the bottom phase of the dive, a drop during the decompression phase progressed into mild anemia in the initial days after saturation. Return to normal Hb occurred within about 1 week. However, after 12 days of post-saturation follow-up, Hb was still slighty lower than pre-saturation.2 variation during bell-runs. It is conceivable that these ppO2 changes are perceived by the body as bouts of relative hyperoxia/hypoxia, triggering EPO production after each bell-run and promoting erythrocyte production (erythropoiesis), equivalent to the theory of the normobaric oxygen paradox . The patients/participants provided their written informed consent to participate in this study.DŁ and IE designed the study and managed data collection. DŁ and AH conducted the statistical analysis. JL, AH, and IE wrote the manuscript. RM reviewed the literature. All authors reviewed and approved the final version.TechnipFMC sponsored helicopter transfers and boarding on the DSV Deep Arctic for DŁ and IE.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The purpose of this study was to prospectively investigate the value of real-time ultrasound elastography (RTE) for the diagnosis of liver fibrosis (LF) in patients with chronic hepatitis B (CHB), to correlate the elastography findings with the histologic stage of LF and to compare RTE findings with those from noninvasive tests of LF calculated using laboratory blood parameters.Liver biopsies, laboratory blood testing, and RTE were performed in 91 patients with CHB. The LF index (LFI) was calculated using a multiple linear regression equation involving 11 parameters, which represented the degree of LF. The higher the LFI is, the greater the degree of LF.r = 0.43, P = 0.006), FIB-4  and LFI  were correlated with the stages of LF. For discriminating stage F0 from F1, only the LFI had significant power (P = 0.026) for predicting stage F1. For discriminating stage F4 from F3, only the LFI had statistically significant power (P = 0.024) in predicting stage F4. The areas under the receiver operating characteristic curves (AUCs) of the LFI for diagnosing significant, advanced LF and liver cirrhosis were significantly higher than those of the APRI and FIB-4, and the LFI had better sensitivity and specificity.The mean aspartate aminotransferase-to-platelet ratio index (APRI) and the mean fibrosis index based on four factors (FIB-4) were significantly different for the 5 stages of LF, respectively. The APRI (The LFI calculated by RTE is reliable for the assessment of LF in patients with CHB and has better discrimination power than the APRI and FIB-4. Hepatitis B virus (HBV) infection remains a severe global public hygiene and clinical problem: approximately 240 million people have HBV in the world. People infected with HBV have increased risk of developing liver fibrosis or cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC) . Liver fAt present, the gold standard for the diagnosis of LF or cirrhosis is liver biopsy , 4. HoweFibroscan, recently reported by many studies, is a noninvasive device that can be used to grade the stage of liver fibrosis or cirrhosis , 9, 14. Real-time ultrasound elastography (RTE) is a new sonography-based noninvasive technique for assessing liver tissue elasticity. RTE detects the propagation speed of shear waves for assessing LF or cirrhosis, which is technically different from Fibroscan , 19–23. In recent, RTE has been reported to be effective in chronic hepatitis C patients . HoweverNinety-one patients who underwent liver biopsy for grading of liver fibrosis at the 900th Hospital of PLA from January 2014 to June 2018 were recruited. All patients were diagnosed as CHB, according to Asian-Pacific clinical practice guidelines about CHB patients management [According to liver ultrasound examination, percutaneous liver penetration was performed using an 18-gauge Tru-Cut™ needle , and samples were taken from liver tissue under the right intercostal of each patient . The bioComplete venous blood samples were taken from every participant with empty stomach within 24 h before elastography. Including platelet count (PLT), routine blood tests were analysed. The following liver biochemistry parameters were determined: aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (γ-GGT), total cholesterol, AST to platelet ratio index. The APRI and FIB-4 were obtained by the following formulas: , 14, 15.Elasticity of liver tissue was detected with real-time tissue elastography by an experienced physician, according to the protocol and literature , 25, 27.t-test or Mann–Whitney U test was used to compare continuous variables between two groups. Comparative analyses of more than two groups were performed using analysis of variance (ANOVA). The correlations of ordinal categorical variables were analysed by Spearman’s rank correlation coefficient analysis. Significant differences were assessed by the chi-squared test and Fisher’s exact test for categorical variables. The correlations of differences were considered statistically significant at P < 0.050. The diagnostic performances of the LFI, APRI, and FIB-4 were assessed by receiver operating characteristic (ROC) curves. The areas under the ROC curves (AUCs) were calculated with 95% confidence intervals. The cut-off values of different noninvasive methods on different LF stages were determined by You Den Index. The cut-off values were chosen at maximizing the sensitivity and specificity and diagnostic accuracy.Statistical analyses were performed using SPSS version 18.0 . Quantitative data are expressed as the means ± standard deviation (M ± SD), while qualitative data are displayed as numbers and percentages. The 9/L, respectively. The means APRI, FIB-4, and LFI were 1.40 ± 0.96, 6.70 ± 2.14 and 3.18 ± 0.84, respectively. According to the METAVIR score, the number of patients in the F0, F1, F2, F3 and F4 stage was 12 (13.19%), 18 (19.78%), 21 (23.08%), 19 (20.88%) and 21 (23.08%).The main demographic and laboratory characteristics of the study patients are presented in Table P = 0.018 and P = 0.006), while the PLT decreased significantly with increasing severity of fibrosis (P < 0.001). The gender ratio at each stage showed a statistically nonsignificant difference. There was no significant difference in AST and ALT according to the stage of fibrosis (Table P < 0.001). These indexes also showed increasing trends with fibrosis stages in CHB patients. The APRI , FIB-4  and LFI  were correlated with the stage of LF, according to Spearman’s rank correlation coefficient analysis.Age and γ-GGT increased significantly with an increasing severity of fibrosis  for predicting stage F1. For discriminating stages F4 and F3, only the LFI had a statistically significant power (P = 0.024) for predicting stage F4.The APRI, FIB-4, and LFI in the patients with significant LF F ≥ F2) were significantly higher than in those with an LF stage ≤F1  was significantly higher than those of the APRI and FIB-4. For predicting liver cirrhosis, the LFI was also superior to the APRI and FIB-4, with an AUC of 0.790, a sensitivity of 82.3% and specificity of 83.7%. The cut-off values of APRI for diagnose F > F1, F2, F3 were 0.58, 1.53, 2.07 respectively. The cut-off values of FIB-4 to predict F > F1, F2, F3 were 4.68, 5.76, 7.83. The LFI cut- off values to predict F > F1, F2, F3 were 2.61, 3.20, 3.92. The sensitivity and specificity of LFI cut-off values to predict the LF stages are better than APRI or FIB-4 to predict the stages.  Fig. a, advancEarly diagnosis and accuracy measurement of the degree of LF or cirrhosis is essential not only for CHB patients making decisions to accept antiviral treatment as soon as possible, but also for controlling disease progression , 21, 28.P = 0.03) and FIB-4 (P < 0.001) were significantly different in different stages of fibrosis [P < 0.001) and FIB-4 (P < 0.001) were significantly different between stages of LF, no significant differences in the APRI and FIB-4 were found between stage F0 and F1 or between stage F3 and F4 in our study or another Egyptian study [The APRI, FIB-4 and LFI could differentiate the stage of LF in CHB patients because these indexes were significantly different for each stage of LF , 31. As fibrosis . Though an study . The APRan study  the LFI an study , 34. Thean study , 34, 35.AUC < 0.7, the accuracy of identify is poor or fail; 0.7 ≤ AUC ≤ 0.9, the accuracy of identify is good; 0.9 < AUC ≤ 1, the accuracy of identify is excellent. The sensitivity or specificity of liver fibrosis measurements higher than 80% are applicable. Given that the APRI and FIB-4 are two readily available noninvasive methods for diagnosing LF, these methods have been recommended to determine the fibrosis stage in resource-limited countries by the WHO guidelines and by many other guidelines –13. TeshThe LFI calculated using RTE with an HI VISION 900 ultrasound system had the highest predictive ability for identifying significant, advanced LF and cirrhosis among the studied noninvasive LF indexes in CHB patients in China, with higher sensitivity and accuracy than the APRI and FIB-4.We acknowledge several limitations in our study. First, our patients were enrolled from a single referral centre, which may be have led to selection bias. Second, the LFI is influenced by several factors, such as patient cooperation with breathing, heart rate and selection of the ROI; thus, further studies with a larger sample population are needed. Third, the degree of fatty infiltration was not investigated. For the resource limitation, the LFI detected by RTE did not compared the results of Fibroscan in this study.In conclusion, the LFI, which was calculated using RTE with an HI VISION 900 ultrasound system, showed a better ability to differentiate the stage of LF than the APRI and FIB-4, especially between stages F0 and F1 and between stages F3 and F4. The LFI had a better predictive ability for identifying significant, advanced LF and cirrhosis than the APRI and FIB-4 in CHB patients in China, with higher sensitivity and accuracy.


Emotions involve subjective experiences, behavioral performances, and physiological responses. Research concerning autonomic states corresponding to different emotions has prevailed for several decades. The present study was designed to investigate how specific emotions influence cardiac activities that reflect autonomic responses. Affective videos selected from a standardized Chinese database were used to induce amused, fearful, angry, and neutral emotions, while electrocardiogram and self-rated emotional experiences were recorded. Heart rate was significantly lower in the amused condition than in the angry, fearful and neutral condition. There were no significant differences among the latter three conditions. The root mean square of successive differences, an index of heart rate variability (HRV), was significantly larger in the amused condition than in the fearful, neutral, and angry conditions. It was also significantly larger in the angry condition than in the fearful condition. There were no significant differences between the fearful and neutral, or angry and neutral conditions. These results revealed that: (1) amusement activates the parasympathetic nervous system, and (2) compared with fear, anger is more likely to be linked with parasympathetic activation. We suggest that HRV, rather than the valence dimension  be regarded as a potential index to discriminate emotions related to approach or avoidance motivation. As the most important entities that serve adaptive functions, emotions allow humans to behave in ways that increase their opportunities to survive and flourish . EmotionHeartbeat is primarily produced by the sinoatrial node, which generates action potentials that course throughout the cardiac tissue, causing regions of the heart muscles to contract in the orchestrated fashion that characterizes a heartbeat. Meanwhile, the heart is innervated by the sympathetic and parasympathetic branches of the autonomic nervous system, which regulate the heart rate by influencing the activity of the sinoatrial node. Activation of sympathetic fibers has an excitatory influence on the firing rate of the sinoatrial node, resulting in increased heart rate. Alternatively, the parasympathetic activation has an inhibitory influence on the pace-making activity of the sinoatrial node and produces decreased heart rate .In addition to the measurements of heart rate, the influence of the autonomic nervous system on the heart can also be indexed by heart rate variability (HRV), which refers to the beat-to-beat variation in heart rate. A growing body of psychological research supports an association between HRV and emotional responses  from Chengdu Medical College participated in the experiment. All participants were free of neurological and psychiatric disorders, and had normal or corrected-to-normal vision. They provided their informed consent prior to the experiment. The local ethics committee approved the experimental protocol.Video clips were used in this experiment to induce angry, fearful, amused, and neutral emotions. These video clips were selected from the standardized Chinese affective video system (CAVS), which was developed at the National Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University. The CAVS includes thirty video clips, which belong to six categories , with each category containing five video clips. Fifty Chinese college students rated these video clips with respect to differentiation, valence and arousal. The pretest for this system showed that the CAVS is reliable across Chinese individuals in emotional inducement . More details about the CAVS are accessible in a previous report by According to their differentiation level, we selected three video clips from each of the amused, fearful, and angry categories. The duration of each video clip ranged between 1 and 3 min. The order of the presentation of the three categories of emotion was counterbalanced across participants, and the three video clips of the same category were presented one by one. In other word, once the order of the presentation of the three specific emotions was determined for each participant, three video clips of one specific emotion would be presented one by one. Between the presentations of every two categories of video clips, a neutral video was presented; thus there were two neutral video clips in total in the experiment. Immediately following the presentation of each video clip, participants were required to evaluate their emotional experience associated with that video clip by selecting from four options: “amused,” “fearful,” “angry,” and “others.” Then the emotion arousal was rated on a 7-point scale.The stimuli were presented and behavioral responses were collected using E-Prime . After the experiment, the participants were paid 30 Yuan RMB (approximately five dollars) for remuneration.Electrocardiogram was recorded from two extended electrodes of eego MyLab , which were placed on the left wrist and ankle. The ECG was amplified using a 0.01–100 Hz band-pass and continuously sampled at 1000 Hz. The off-line analysis was conducted in MATLAB R2013b . On a typical ECG, the main spike is the QRS complex, which is the combination of the Q, R, and S waves occurring in rapid succession. The QRS complex reflects a single event of the depolarization of the right and left ventricles of the human heart; thus, they are usually considered together. To detect the spike of the R wave in each QRS complex, we used the following algorithm. When the voltage difference between two time points with an interval of 25 milliseconds is larger than 500 microvolts, the maximum value within the interval from the former time point up to the one 55 milliseconds later is taken as the spike of the R wave. We selected the last minute of the video clip that elicited the expected emotion with maximum strength according to the evaluation of each participant from the three ones for ECG analysis for each emotion category. In the current study, RMSSD was used as an index of HRV .p-values of all the main effects and interactions were corrected by applying the Greenhouse-Geisser method when needed. Post hoc testing of significant main effects was conducted with Bonferroni correction. Meanwhile, the least significant difference (LSD) method also was used to decrease the probability of making Type II Error when needed. Significant interactions were further examined using simple-effect analysis. Partial eta-squared (ηp2) values were reported to examine the size of effects in ANOVA models, where 0.05 represented a small effect, 0.1 represented a medium effect, and 0.2 represented a large effect . The e effect .F = 16.83, p < 0.001, ηp2 = 0.35]. A post hoc test with Bonferroni correction revealed that the category-matching ratios of amused and neutral video clips were significantly higher than those of angry and fearful video clips , but neither the difference between the former two conditions nor the difference between the latter two conditions were significant   were 0.57, 0.67, 0.96, and 0.91 for angry, fearful, amused and neutral video clips, respectively, . A post hoc test with Bonferroni correction showed that the arousal level of angry and neutral video clips were significantly lower than that of fearful and amused clips , but neither the difference between the former two conditions nor the difference between the latter two conditions were significant (p > 0.05) , fearful (4.99), amused (5.07), and neutral (3.20) video clips . A post hoc test with Bonferroni correction showed that the differences of heart rate were not significant among the angry (82.03), fearful (82.73), amused (78.03) and neutral (83.88) conditions , except the difference between the latter two condition (p < 0.05). A post hoc LSD test with arousal as covariate showed that the heart rate was significantly lower in the amused condition than in the angry, fearful and neutral conditions . There were no significant differences among the latter three conditions   see .F = 5.47, p < 0.01, ηp2 = 0.15]. A post hoc test with Bonferroni correction showed that the differences of RMSSD were not significant among the amused (154.74 milliseconds), fearful (80.81 milliseconds), angry (111.46 milliseconds) and neutral (91.42 milliseconds) conditions , except the difference between the former two condition (p < 0.05). A post hoc LSD test with arousal as covariate showed that the RMSSD was significantly higher in the amused condition than in the fearful, neutral , and angry conditions (p = 0.052). The RMSSD was also significantly higher in the angry condition than in the fearful condition (p < 0.01). There were no significant differences between the fearful and the neutral conditions (p = 0.49), between the amused and the angry conditions (p = 0.42), or between the angry and the neutral conditions (p = 0.15) (see RMSSD was significantly different between the four conditions [.15) see .More than one hundred years ago, William James maintained that discrete emotional experiences could be identified with unique patterns of bodily changes, which are produced by autonomic nervous system activity. This notion was critiqued by Findings from the early research on autonomic activity appeared to be heterogeneous. According to In the present study, we investigated the influence of specific emotions on the pattern of cardiac activities, and found that amusement led to a decreased heart rate. This result is consistent with a meta-analysis that revealed that the heart rate is lower for amusement than that of fear, anger, and neutral emotions . The curMore importantly, the results showed that the HRV was larger in the amusement than anger, fear, and neutral conditions. HRV is related to the activity of the parasympathetic nervous system. Considering the decreased heart rate for amusement, we can infer that amusement selectively activates the parasympathetic nervous system. Since the parasympathetic nervous system and the sympathetic nervous system antagonize each other, the parasympathetic activation inhibits the sympathetic activity. When we are amused, we feel relaxed and contented. This feeling is also regarded as a feature of the parasympathetic activation and the sympathetic inhibition, which helps an organism to reserve mental and physiological resource . The resPost hoc testing of RMSSD was based on the LSD method. Although this method has the advantage of decreasing the probability of making Type II Error, it increases the probability of making Type I Error. When the Bonferroni correction was applied to the post hoc test of RMSSD, the difference between the amused and angry conditions, the difference between the amused and neutral conditions, and the difference between the angry and fearful conditions were not significant. Further research is still needed to clarify if this result was caused by the reason of small sample. Second, the video clips used in this study were selected from the CAVS, which contains six emotion categories. In the six categories, only one category contains a positive emotion, labeled as “” in Chinese or “happiness” in English. The video clips in this category are all comedies, which actually elicit the emotion of amusement. Other positive emotions with similar meanings, such as happiness and contentment, are more strongly elicited by real life events than through watching affective videos. However, these emotions have different influences on autonomic nervous system activity (Limitations still exist in the present study. First, the activity . TherefoTo sum up, amusement elicited by watching video clips led to a decrease in heart rate and increase in HRV, when compared with angry, fearful, and neutral emotions. This suggests that amusement is related to the activation of the parasympathetic nervous system. Furthermore, anger led to increased HRV when compared with fear, suggesting that HRV could discriminate certain kinds of negative emotions. These results indicate that amusement, anger and fear can be differentiated by the ECG signals, contributing to the literature that objectively measures subjective experiences of emotions. Further research is still needed to differentiate between the peripheral physiologies of other specific emotions.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the ethics committee of Chengdu Medical College. The patients/participants provided their written informed consent to participate in this study.YW and QY conceived and designed the experiments. YW performed the experiments. QY analyzed the data. QY and RG wrote the manuscript. Y-JL contributed to the materials and analysis tools.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Prevalence of presbyopia was high, and spectacles improved satisfaction with near vision.The aim of this paper is to assess the eye health needs of school teachers in the Asutifi districts of Ghana. Presenting distance visual acuity was measured in each eye. Those with visual acuity of <6/12 in one or both eyes had subjective refraction. All underwent basic eye examination and near functional vision was assessed for teachers aged ≥35 years using the Near Activity Visual Questionnaire (NVAQ). Teachers with uncorrected presbyopia were given a near correction and NVAQ was assessed again at two weeks. Three hundred teachers were examined with mean (SD) age of 36.5 (9.7) years, 54.3% were male and 6.3% (95% CI: 3.8 to 9.8%) had a presenting acuity of <6/12 in one or both eyes. The estimated prevalence of moderate visual impairment was 0.7% (95% CI: 0.08 to 2.4%). Lens opacities (50%) and refractive error (18%) were the main causes of visual loss. Seventy-five out of 136  of teachers aged ≥35 years were presbyopic, 45.3% (95% CI: 36.9 to 53.7%) of whom had presbyopic correction. Lack of awareness was the major barrier to presbyopic correction. Median Rasch score for teachers given presbyopic correction ( School eye health programs are an efficient way of making eye health accessible to many children worldwide. These programs focus primarily on uncorrected refractive errors, which affect an estimated 12 million children globally [Globally, 1.1 billion people above the age of 35 years are estimated to be living with presbyopia  causing With an increasing aging population, age-related eye conditions such as glaucoma and diabetic retinopathy (DR) are also likely to affect teachers. Diabetes is estimated to increase by 55% from 382 million in 2013 to 592 million by 2035 in adults aged 20–79 years . GlaucomThe work of teachers entails intensive close work to prepare teaching materials and read students’ scripts. Good distance visual acuity is also important to enable them to identify children in the classroom or playground. Uncorrected presbyopia and visual impairment from age-related eye conditions are, therefore, likely to have a negative impact on their ability to teach. The aim of the study was to assess the eye health needs of school teachers in the Asutifi districts of Brong Ahafo region of Ghana. The study area has a total population of about 100,000, and has more than 250 schools with over 1000 teachers ,14. The This was a school-based quantitative cross-sectional study involving teachers. A minimum sample size of 380 was calculated but due to time and resource limitations, convenience sampling based on the size of the school and proximity was used to recruit the 300 teachers who were available and eligible at the time of the visit. Exclusion criteria were a failure to give consent, or visual acuity could not be measured, but this did not apply to any teacher.Visual loss: Presenting visual acuity of less than 6/12 in one or both eyes. The World Health Organization (WHO) categories of visual impairment relate to the visual acuity in the better seeing eye: Not impaired ≥6/12, mild visual impairment (VI) (<6/12 but can see 6/18), moderate VI (<6/18 but can see 6/60), severe VI (<6/60 but can see 3/60), and blind (<3/60).Presbyopia: Inability to read the N8 optotype with both eyes open at 40 cm with distant correction (if required) and an addition of ≥1.00D improved near vision by at least one line.Presbyopia correction coverage (PCC): Met need was the proportion of presbyopic teachers who already had spectacles and could read the N8 optotype at a distance of 40 cm. Unmet need was the proportion of presbyopic teachers who required correction but did not have spectacles and near visual acuity improved vision to N8 at a distance of 40 cm with correction. Presbyopia correction coverage (%) was calculated as met need ÷ (met need + unmet need) × 100.A teacher was said to be at risk of loss of vision from diabetic retinopathy if he or she had a medical history of diabetes. A teacher was said to be a glaucoma suspect if he or she had a vertical cup to disc ratio (VCDR) of more than 0.7 or VCDR asymmetry of more than 0.2 between the two eyes.Demographic data of all the teachers were recorded, including their diabetic status and family history of glaucoma. Presenting distance visual acuity (VA) was measured in each eye using a Snellen chart in ambient outdoor illumination at six meters. A teacher was considered to have read a certain line if they correctly identified half of the letters on that line. Teachers who showed improvement in at least one line with a pin-hole underwent distance refraction by a qualified optometrist. Subjective distance refraction was conducted using a trial lens set. All teachers underwent a basic eye examination using a torch light, with undilated fundoscopy with a direct ophthalmoscope. The cause of visual loss was determined for teachers who presented with VA <6/12 in one or both eyes . Presenting near VA was tested binocularly using a near reading chart (Printer’s Point N5 to N24). The chart was held at eye level at 40 cm with the best distant correction, if required. Teachers who presented with a visual acuity of 6/6 were assumed to be emmetrope and were only assessed for near vision. For teachers unable to read the N8 optotype, spherical plus lenses were added in a trial frame in steps of +0.50 dioptersuntil they could see the N8 comfortably at 40 cm and further plus lenses blurred N8 print. Near vision spectacles were given to teachers with uncorrected presbyopia at no cost. Teachers who required distance correction or bifocals, or who were at risk of glaucoma or diabetic retinopathy or who had lens opacities were referred to the district hospital. A validated near vision visual function questionnaire, NAVQ  was admiTeachers who were given presbyopic correction were followed up after two weeks and re-administered the NAVQ.Data were entered into a database created in Microsoft Access and exported to STATA 14  for analysis. Summary statistics were computed for all baseline variables. Means and standard deviations are reported for normally distributed continuous data, and medians and interquartile ranges for non-normally distributed continuous data. Categorical data are reported as frequencies and percentages. Normality was assessed by inspection of a histogram since the methods used require approximate normality only. Association between categorical variables was assessed using Chi-square tests. The summed NAVQ raw scores for the 10 questions were converted into a Rasch score ranging from 0 to 100 with higher scores indicating greater difficulty with near vision. The Wilcoxon signed rank test was used to assess the significance of observed difference between the median score at baseline and the median score at follow up. All tests were two-tailed, and the level of statistical significance was 0.05.Ethical approval was granted by the research ethics committee, London School of Hygiene and Tropical Medicine (ref: 12109) and the Committee on Human Research, Publication and Ethics in Ghana (ref: CHRPE/AP/126/17). Each teacher provided a written informed consent.Three hundred teachers from two senior high schools and fifteen primary schools with a mean (SD) age of 36.5 (9.7) years (range 21–62 years) were examined. There were more males 163 (54.3%) than females. Most of the teachers (55%) were graduates and the others held diploma certificates. One hundred thirty-six (45.3%) teachers were aged 35 years and above .Overall, 281 (93.7%) of the teachers had a visual acuity equal to or better than 6/12 in both eyes. Nineteen : 3.8–9.8%) had visual loss (presenting VA <6/12 in one or both eyes). More males (15) than females (4) had visual loss in one or both eyes, and lens opacities and refractive error were the main causes . There wTwo hundred ninety-five teachers demonstrated normal acuity, three had a mild visual impairment (VI) and two had moderate VI. The estimated prevalence of moderate VI was 0.7% (95% CI: 0.08%–2.4%). All three teachers with mild VI were male whilst there was a single teacher of each gender with moderate VI. Two of the teachers with mild VI, aged 55 and 58 years, had lens opacities, the other had a refractive error. One of the teachers with moderate VI, aged 59 years had lens opacities, the other had no cause recorded.Five teachers (1.7%) reported to have been diagnosed with glaucoma but only two were taking treatment. Six further teachers (2.0%) were suspected of having glaucoma based on their VCDR. All 11 (3.7%) teachers were referred for glaucoma assessment. Two teachers were diabetic with an average duration of ten years, but neither had signs of diabetic retinopathy. These teachers were advised to go for an annual eye examination at the eye clinic.p < 0.001): 57/61 teachers who were not presbyopic were under 50 years compared with 35/75 of those who were presbyopic. Seventy-five out of 136 teachers aged ≥35 years were presbyopic, giving a prevalence of 55.1% (95% CI: 46.6–63.4%). Presbyopia was significantly associated with age  with an unmet of 54.7%. 21/42 (50%) presbyopic males had correction compared with 13/33 (12%) females. This was not statistically significantly different. Graduate teachers (67.6%) had the highest met need, and coverage tended to increase with age .The most frequent reason for lack of presbyopic correction was lack of awareness, particularly among males (8/11). Several teachers reported that they had lost their spectacles, or they were broken, or they had the wrong prescription. Other reasons were ‘no felt need’ or did not see it as a priority .One hundred thirty-six teachers aged 35 years and above were administered the NAVQ at baseline. Thirty-nine presbyopic teachers with an unmet need who were given presbyopic correction (range +1.00DS to +3.50DS) were followed up after two weeks. Median Rasch scores at baseline and follow up were compared. The median NVFQ score of all 136 teachers at baseline was 23.1 (interquartile range (IQR): 0–43.6). The 61 non-presbyopic teachers had better near visual function  than the 75 presbyopic teachers  0–18.3 and 36.1, IQR: 23.07–52.73, respectively). The near visual function of teachers with presbyopia correction was better than for those without, with an NVFQ score ratio of 2:1 .p < 0.001), with similar improvements in males and females.Before being given a near correction, the median score for the 39 teachers was 46.0 (IQR: 33.3–56.89). Females were more affected by near VI than males, with scores of 52.7  and 41.2 (IQR: 30.3–72.8), respectively. At follow up near visual function had increased significantly, reflected by a 60.6% decline in their median scores to 18.1 (IQR: 0–36.1) (p < 0.001).At baseline 2.6% of the presbyopes with an unmet need reported that they were completely satisfied with their near vision, while 30.8% were very satisfied, 56.4% were a little satisfied, and 10.3% were completely unsatisfied. Two weeks after correction, 53.9% were completely satisfied, 25.6% were very satisfied, 20.5% were a little satisfied and none were unsatisfied. These differences were statistically significant  the prevalence of blindness and severe visual impairment among all ages were 0.74% and 1.07%, respectively . The maiIn this study, several teachers had early lens opacities, two of whom had a mild visual impairment. Although these two teachers were relatively young, risk factors for lens opacities were not explored in this study. None of the teachers required cataract surgery, which in Ghana is usually performed once the visual acuity declines to 6/60 or less, but all were referred. This study supports the findings that presbyopia occurs at an early age in Africa ,17,18 asPresbyopic correction coverage (PCC) among teachers in our study was similar to that in Indonesia where 41% had correction ,6. In thCost was not the major barrier to having presbyopic correction, as has been reported in several population-based studies in Africa and Asia ,20,21, bThis study has shown that overall satisfaction of near vision function among uncorrected presbyopes can be greatly improved by appropriate corrective lenses. After two weeks of correcting their difficulty with near vision, all 39 teachers were satisfied to varying degrees, with no reports of dissatisfaction which was reported by 10.3% of teachers at baseline. The 60.6% reduction in NAVQ scores also demonstrated that the majority of teachers had their near vision improved by spectacles. A similar improvement was observed in Tanzania where threading a needle was used as a performance-based test .The sample size was relatively small, but the study was adequately powered to detect a statistical difference in the proportion of male and female teachers who were presbyopic but was not large enough to detect differences in spectacle coverage by sex. In addition, the convenience sampling used may have led to a sample of teachers which was not representative of all teachers in the region. The two weeks of follow up to assess the impact of presbyopic correction were not adequate as it is possible that some teachers may not have engaged in much near activity within this period and may not have used the spectacles long enough to appreciate change. In assessing the risk of loss of vision from glaucoma and diabetic retinopathy, the researcher relied on self-report by the teachers, and a dilated retinal examination was not undertaken for those known to be diabetic. Data were also not obtained from the referral eye clinic to assess uptake of referral and whether glaucoma was diagnosed amongst those referred as glaucoma suspects.The current study has shown the need to incorporate eye screening of teachers into school health programs in Ghana and elsewhere, and to increase awareness about the causes and management of presbyopia and other eye conditions. The improvement in the overall satisfaction with near vision with presbyopic correction can be used to advocate for refraction services and distribution of affordable spectacles for school teachers above 35 years of age. These programs can also be used to identify teachers who may be at risk of diabetic retinopathy, glaucoma, and other sight-threatening conditions and refer them to an appropriate health facility for assessment and early treatment to prevent sight loss. The screening of teachers would also help in raising the overall awareness of eye health throughout the school and community, which may, in turn, benefit many children in schools and their families.


Heart failure (HF) is a progressive chronic disease affecting 6.5 million Americans and over 15 million individuals globally. Patients with HF are required to engage in complex self-care behaviors. Although the advancements in medicine have enabled people with HF to live longer, they often have poor health-related quality of life and experience severe and frequent symptoms that limit several aspects of their lives. Mobile phone apps have not only created new and interactive ways of communication between patients and health care providers but also provide a platform to enhance adherence to self-care management.The aim of this pilot study was to test the feasibility of a newly developed mobile app (HeartMapp) in improving self-care behaviors and quality of life of patients with HF and to calculate effect sizes for sample size calculation for a larger study.This was a pilot feasibility randomized controlled trial. Participants were enrolled in the hospital before discharge and followed at home for 30 days. The intervention group used HeartMapp (n=9), whereas the control group (n=9) received HF education. These apps were downloaded onto their mobile phones for daily use.P=.01), self-care confidence , and HF knowledge . Quality of life declined among both groups, more so in the control group .A total of 72% (13/18) participants completed the study; the mean age of the participants was 53 (SD 4.02) years, 56% (10/18) were females, 61% (11/18) lived alone, 33% (6/18) were African Americans, and 61% (11/18) used mobile phone to get health information. The mean engagement with HeartMapp was 78%. Results were promising with a trend that participants in the HeartMapp group had a significant mean score change on self-care management (8.7 vs 2.3; t3.38=11, The trends demonstrated in this pilot feasibility study warrant further exploration on the use of HeartMapp to improve HF outcomes.Pilot study, no funding from National agencies, hence not registered. Heart failure (HF) is a progressive disease affecting 6.5 million Americans, with costs exceeding US $39.2 billion annually . PresentPatients who are engaged as decision makers in their care tend to be healthier and have better outcomes . Thus, iAn iterative patient-centered approach was adopted during the design of HeartMapp by leveraging mobile phones to target individualized alerts focused on patient needs to improve self-care and medication adherence, which could be used in a real-life setting as and when needed. HeartMapp also used a Zephyr BioHamess-3 chest strap  that conThis was a pilot randomized controlled trial (RCT). The overall goal of the pilot RCT was to examine feasibility of HeartMapp use by patients with HF and to compute effect sizes for sample size estimation for a larger RCT. The pilot study enrolled 18 participants with HF; the intervention group (n=9) received all 6 features of the HeartMapp, and the active wait-listed control group (n=9) received only HF education (congestive heart failure [CHF] info feature of the HeartMapp). The apps were downloaded onto their mobile phone for daily use. The active wait-listed control group was given access to 4 additional features of the HeartMapp at the 30-day follow-up. Participants were block randomized as .This is a pilot feasibility trial which received no NIH or other organizational funding; hence, it was not registered.Upon obtaining approval by the University’s institutional review board (IRB), participants were recruited from a tertiary hospital. The IRB-approved brochures were made available at inpatient units. The discharge care coordinators referred potential HF participants for the study.A research assistant (RA), a research nurse, approached participants who had indicated interest and were ready for discharge. The RA explained the study requirements and sought consent from the participants using the IRB-approved informed consent document. Consented participants were screened for eligibility. Participants who failed screening were referred for further clinical evaluation. Within 3 to 7 days after discharge, 2 RAs scheduled a time to meet the patients in their home. During the home visit, the RAs confirmed their willingness to participate in the study and collected baseline data.The intervention group had HeartMapp downloaded onto their Android phone or a loaner phone. The participants were trained on HeartMapp features, including daily weighing, symptom assessment, responding to tailored alerts, vital sign monitoring using BioHarness-3 chest strap, HF education (CHF info), and performing breathing exercise and walking. Participants were asked to use HeartMapp daily from home for a total of 4 weeks. The details of the 6 features of the HeartMapp are provided below see .Inclusion criteriaClinical diagnosis of congestive heart failure (CHF) as defined by the International Classification of Diseases (ICD-10 codes) and recent hospitalization for CHFNew York Heart Association (NYHA) classification II-IIIAdults aged 30 years or aboveAbility to speak, understand, and read EnglishVision must be 20/50 or betterAdequate hearingHearing thresholds of 4000 dB HL or betterMust be willing to use the mobile app (HeartMapp or CHF info) and the Bio-Harness-3 chest-worn Bluetooth deviceExclusion criteriaListed for heart transplant as status 1A; or on home milrinone or dobutamine infusionEnrolled in a palliative or hospice care programHistory of stroke within the past yearMajor disability such as aphasiaUncontrolled psychiatric disordersCognition: Montreal Cognitive Assessment score <20Living in a setting where they are not able to independently engage in self-care P<.001) among patients with chronic diseases [The medication tracker allows patients to add and edit their medications and activate reminders to take medications . This feature can also assist home health nurses to update their patients’ medications list collaboratively. Given the success of related product features in other populations , this mechanism may improve behavioral outcomes in HF . In factdiseases .HeartMapp provides a self-care management point-of-care tool where tailored automated reminders are sent to patients to check their weight and complete HF symptom assessment questions. Although symptoms are the hallmarks of severity of HF, patients’ experience of symptom clusters and symptom intensities vary and may reflect the personal and social experiences of illness, cultural differences in the interpretation of symptoms, and responses to the illness—all of which may influence HF self-care practices and care-seeking behavior . EvidencP=.003), and self-care management increased from 57 to 86 (P=.002) at 4 weeks [Once users have registered with HeartMapp with baseline height, weight, and health care provider information, they receive tailored daily prompts and are provided access to the assessment window to check weight, blood pressure, and answer the short questionnaires on HF symptoms. HeartMapp then classifies users via the HF severity index based on the New York Heart Association (NYHA) functional classification . The alg 4 weeks . FurtherPatients with HF have an increased prevalence of cognitive impairment with 4 times higher risk of developing dementia compared with healthy adults of the same age. The etiology is believed to be of vascular origin because of hypoperfusion to the brain resulting from reduced cardiac function. Therefore, HeartMapp includes a memory screener and simple naming tasks to measure cognition using Boston Naming Test criteria with 9-items . PatientP<.001), compared with 21 healthy controls [The exercise feature includes animated biofeedback deep breathing exercises and walking. Deep breathing interventions deployed in HeartMapp use biofeedback mechanism to reset the autonomic nervous system by reducing sympathetic activity and increasing parasympathetic activity ,33. Alsocontrols .HeartMapp encourages walking 3 to 4 times a week and provides feedback to patients on performance. The walking test is a simple measure of functional capacity that predicts survival in patients with moderate HF. Patients with HF who have an ejection fraction of less than 30% have been shown to improve exercise tolerance and physical ability . TherefoPerformance tracking features in the HeartMapp include a graphical module that displays trends in patient performance, including weight, blood pressure, HF symptoms, and physiological measures such as heart rate and exercise activity. These data serve as a tool for triage by home health nurses to understand early decline and thus prevent readmission and or emergency room visits by quickly intervening .Monitoring of vital signs is captured via integration of an open application programming interface (API) from BioHarness-3 from Zephyr technology . BecauseHF education (CHF-info feature) includes 10 educational modules specific for HF and common chronic diseases associated with HF. Evidence indicates that traditional patient education using printed materials does not support self-care skill development; thus, novel patient-teaching strategies and persistent engagement of patients are needed to support the development of tactical and situational skills . The HF-The control group (n=9) received only HF info downloaded onto their mobile phone, as shown in A study coordinator  called all participants 3 times a week during the first week and once a week for the remaining 3 weeks to make sure that they completed their tasks and answered any questions that came up, checked the dashboard daily to monitor participants’ progress, and triaged for further management per protocol. No participants during the study period were referred to a cardiologist (project consultant) for HF symptoms warranting immediate attention.Patient engagement and HeartMapp usage were assessed based on the duration for which the participants accessed HeartMapp features that were timestamped and recorded on a secured website.Self-confidence in using HeartMapp questionnaire, which was designed based on Bandura’s self-efficacy scale [r=.98) [cy scale , was com [r=.98) .usability of HeartMapp questionnaire validated in a prior study (r=.468-.635) [The 68-.635)  has a to68-.635) . This quSelf-Care of Heart Failure Index [r=.56), whereas the scores of Self-Care Management and Self-Care Self-Confidence were (r=.70) and (r=.82), respectively [Self-care behavior in HF was assessed using the re Index  that hasectively . Higher administered Morisky Medication Adherence Questionnaire, with lower score indicating better adherence (r=.83) [Medication adherence was assessed using the 8-item self-  (r=.83) .Atlanta Heart Failure Knowledge Test [r=.84 for patients); higher score indicates better knowledge [The HF-specific knowledge was assessed using the dge Test . This qunowledge .Kansas City Cardiomyopathy Questionnaire (KCCQ) [r=.66-.95) [Participants’ perception about clinical changes in quality of life was measured using the e (KCCQ) . This 23.66-.95) . Lower sPatient Health Questionnaire (PHQ-9), a self-administered depression scale, which scores each of the 9 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as 0  to 3 (nearly every day), was used to examine depression [r=.82) [pression . Higher  [r=.82) .Cumulative Illness Rating Scale that measures illness burden on a 5-point scale with scores ranging from 0 to 56, which demonstrated an interclass correlation coefficient of .78 on illness burden [Functional Social Support Questionnaire (FSSQ) assessed social support (r=.50-.85). The FSSQ uses a 5-point Likert scale (1=much less than I would like and 5=as much as I would like) [Demographic variables including age, gender, ethnicity, and marital status as well as clinical variables on medications, ejection fraction, and NYHA were collected at baseline ,47. Illns burden . The Dukld like) .t-tests were performed to compare mean differences between intervention and control groups and between time points (post- and preintervention scores). Exploratory correlation analyses were performed to evaluate changes in outcome measures relative to baseline performance on assessments.Baseline and 30-day follow-up data were collected at participants’ home. Partial eta squared for effect sizes were computed from group mean differences using linear regression. Furthermore, Of the 20 patients who were screened for eligibility, 1 participant gave us a wrong home address and could not be tracked, and another participant refused to be a part of the study after eligibility screening. All participants met the inclusion criteria, including normal hearing and vision as well as normal cognition with mean MoCA score of 26.3 (SD 2.4). A total of 18 participants met the inclusion criteria and were block randomized to HeartMapp (n=9) and active wait-listed control (n=9) to HF education  on the mobile phone for the first 30 days. Only 13 participants (72%), 7 in the HeartMapp group and 6 in the HF info group completed the 30-day follow-up. As mentioned earlier, an Android phone was loaned for the study period for the participants who did not own a phone.Participants’ mean age was 53.06 years; 56% (10/18) of the participants were females, 61% (11/18) lived alone , 33% (6/18) were African Americans, and 17% (3/18) were Hispanics. Only one participant, 6% had less than high school education, 89% (16/18) had non-ischemic cardiomyopathy, and 67% (12/18) had HF for over a year. Mean ejection fraction was 28%, 67% (12/18) were in HF stage C, and 61% (11/18) were in NYHA class II  of participants rated cardiac condition as severe to extremely severe (3-4) burdensome; whereas 17% (3/18) reported severe burdensome for endocrine problems (diabetes), 11% (2/18) rated severe burdensome for psychiatric problems and kidney diseases. All participants owned a mobile phone, one participant owned an Apple phone, and 63% (11/18) used a mobile phone to get health information.t-test was used to compute mean change scores of HeartMapp and control group at baseline and 30-day follow-up (30-day score-baseline score) for the 72% (13/18)) participants (7 HeartMapp and 6 control group) who completed the 30-day follow-up. The results showed statistical significance in few of the outcomes.Mean for baseline and 30-day follow-up scores were computed, which demonstrated an improvement in almost all outcomes. An independent P=.01); self-care confidence improved by 7 points in HeartMapp group compared with an increase of 2 points among controls (P=.03). Mean score change on HF knowledge among HeartMapp group was 3 points, whereas the control group declined (P=.04). Quality of life measured by KCCQ declined by 2 points in HeartMapp group, whereas the control group declined by 9 points (P=.18). Medication adherence improved among both groups  and its associated error that is accounted for by that effect (or interaction) . The parSeven participants from HeartMapp group who completed the 30-day follow-up were asked to rate the HeartMapp usability questionnaire that assessed HeartMapp features and self-confidence in using HeartMapp questionnaire see .The details on participants’ access to HeartMapp features were stored and time stamped on a secure website for analysis. A mean of 78% engagement with HeartMapp was noted among all participants randomized to HeartMapp. Of the nine participants randomized to HeartMapp, 43% (4/9) accessed HeartMapp daily and completed the assessment of HF symptoms and exercise  daily. Five participants accessed HeartMapp features over 24 days or 80% of the time. The multivariate regression analysis did not predict any association with patient engagement or HeartMapp access time with HF outcome. However, other features of the HeartMapp were accessed by participants inconsistently. The features consistently accessed were the medication tracker and breathing exercise. The least accessed feature was the vital signs monitoring using the chest-worn Bluetooth device (BioHarness-3).Assessment of open-ended questions using descriptive and thematic analysis suggested that 86% (8/9) of the participants preferred a wrist-worn Bluetooth device. The chest-worn Bluetooth device (BioHarness-3) was reported by more than half of the participants (>50%) as uncomfortable, and all the participants reported poor battery life, with the need to charge the device twice a day. This indicated noncompliance in using the chest strap.The result of this pilot study is promising in that the HeartMapp intervention showed trends in improving several HF outcomes, especially self-care management, self-care confidence, and HF knowledge. A comprehensive review of 34 commercially available mobile apps for HF symptom monitoring and self-care rated Heart Failure Health Storylines, Symple, ContinuousCare Health App, WebMD, and AskMD as the highest performing apps and recommended future studies to test the usability and effectiveness of the available apps . On the A systematic review on remote telemonitoring interventions reduced the relative risk of all-cause mortality (0.60-0.85) and HF-related hospitalizations (0.64-0.86) compared with usual care. Improvements in HF-related hospitalizations appeared to be more pronounced in patients with stable HF , indicating appropriate selection of patients who are not in the refractory or end-stage HF . This isA pilot study that offered text messaging to HF patients after discharge demonstrated significant improvement in HF self-management , as seenThe result of this pilot study indicated that only 72% of participants completed the 30-day follow-up, which is very low and the reason most reported was the use of BioHarness-3 chest strap. An attrition rate of 35% has been reported in prior studies among HF population . Those wOne in 6 (15%) consumers in the United States currently uses wearable technology, mostly smart watches or fitness bands . Over 80This pilot study only enrolled a small sample of 18 HF patients, with only 72% completing the 30-day follow-up; thus, the results are not generalizable. The small number of participants rated high satisfaction with the ease of using HeartMapp, which supported the results of the prior usability study  supporteThere is currently an urgent unmet need for HF-targeted patient-centered interventions that are easy to use by older adults with HF who experience cognitive difficulties and lack social support. Participants in this study reported that HeartMapp is easy to use. However, there is need for updates on integrating a wrist-worn Bluetooth device for monitoring of vital signs, which the team is currently addressing. In the current market, there are a few other apps being tested that track patients’ self-care such as weight and symptoms. HeartMapp not only tracks patient performance, it provides alerts and feedback on patient performance; it also provides interventions to perform deep breathing exercises and to encourage physical activity. HeartMapp also includes HF-related education. Further exploration in a larger trial is warranted to test the feasibility of utilizing HeartMapp over time to improve short-term and long-term HF outcomes.


Herein we report the first example of a facile biomineralization process to produce ultra-small-sized highly fluorescent aqueous dispersions of platinum noble metal quantum clusters (Pt-NMQCs) using a multi-stimulus responsive, biomimetic intrinsically disordered protein (IDP), Rec1-resilin. We demonstrate that Rec1-resilin acts concurrently as the host, reducing agent, and stabilizer of the blue-green fluorescent Pt-NMQCs once they are being formed. The photophysical properties, quantum yield, and fluorescence lifetime measurements of the synthesized Pt-NMQCs were examined using UV-Vis and fluorescence spectroscopy. The oxidation state of the Pt-NMQCs was quantitatively analyzed using X-ray photoelectron spectroscopy. Both a small angle X-ray scattering technique and a modeling approach have been attempted to present a detailed understanding of the structure and conformational dynamics of Rec1-resilin as an IDP during the formation of the Pt-NMQCs. It has been demonstrated that the green fluorescent Pt-NMQCs exhibit a high quantum yield of ~7.0% and a lifetime of ~9.5 ns in aqueous media. The change in photoluminescence properties due to the inter-dot interactions between proximal dots and aggregation of the Pt-NMQCs by evaporation was also measured spectroscopically and discussed. Metal nanoclusters (MNCs), comprised of only a few to a few tens of metal atoms, bridge the evolution of properties of isolated atoms to nanoparticles (NPs). They have the potential to exhibit unusual chemical, optical, electronic, and physical properties, which are drastically different from those of the bulk metal, NPs, or of the atom itself . PecisioOver the last decades or so significant progress has been made in the use of a supramolecular approach for the preparation of engineered NPs ,15. The Drosophila melanogaster resilin gene and expressed as a water-soluble protein in Escherichia coli . T. Tg calc reports ,47. g of pristine Rec1-resilin and nanobioconjugates obtained by P(r) fit was also validated using a shape-independent polymer excluded volume (PEV) model fit  fit results. The fit also returned a Porod exponent (m) value of 2.3 ± 0.1  for the pure Rec1-resilin, and 2.0 ± 0.1 (signature of swollen Gaussian coil) for the nanobioconjugates. The Porod region corresponds to a probed range smaller than the scattering objects and the scattering radiation potentially examines the local structure. The observed conformational transformation of pure Rec1-resilin and nanobioconjugates was further assessed using a Kratky plot . T. Tg of ptky plot . The Kratky plot . The in-tky plot ) of prisy) of the generated green fluorescent Pt-NMQCs was calculated using Equation (3) [Nem and PNab are the number of emitted and absorbed photons by the fluorescent Pt-NMQCs, measured using a fluorescence spectrophotometer.The centrifuged blue fluorescent Pt-NMQCs-Rec1-resilin nanobioconjugate dispersion (145 mg/L of Pt) was incubated at room temperature (~20 °C) for a long period of time in the dark to study the evolution of nucleated Pt-NMQCs with time. The incubated supernatant developed green fluorescence after eight weeks A, indication (3) :Qy = PNey of the synthesized green fluorescent Pt-NMQCs was measured as ~7.0% in water. The Pt-NMQCs-Rec1-resilin nanobioconjugates exhibited three radiative transition lifetimes (τ) 0.74 ± 0.05 ns, 3.77 ± 0.05 ns, and 9.48 ± 0.63 ns  between two different sized QDs. This work highlights the application of an IDP as a multifunctional template, and the method applied in this work can be generally extended to generate engineered sub-nanoparticles of other NMQCs, such as silver, copper, palladium, and their alloys. The resilin-directed sub-nanoclusters can be potentially applied as multifunctional nanoconjugates in the field of biosensors, bioimaging, and catalysis, owing to the unusual multi-stimuli responsiveness, non-specific interactions, and conformational dynamics of the IDP.