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  • Volcanism, volcanic ash, and its role in forest ecology and management

    Volcanism, volcanic ash, and its role in forest ecology and management

    Mark Kimsey, the Director of the Intermountain Forestry Cooperative, discusses volcanism, volcanic ash, and their roles in forest ecology and management

    Volcanism and the Pacific Northwest, U.S.

    Plate tectonics, the Ring of Fire, and volcanism have shaped and continue to shape Earth’s landscapes, particularly along the Pacific Rim. Volcanism has shaped the skylines and landscapes of the North American Pacific Coast; depositing during eruptive events, volcanic tephra ranging in centimeters to tens of meters in depth. One particular eruptive event that dramatically changed Northwest U.S. ecological history was the repeat and final circular ring fissure eruption of Mount Mazama (known currently as Crater Lake) in southwestern Oregon State approximately 7,700 years ago (Fig. 1).

    This final eruption reached nearly 50 kilometers (30 miles) into the atmosphere, with downwind deposition affecting all western and Rocky Mountain States and the three western Canadian Provinces. Evidence of Mount Mazama volcanic ash has been found globally. It is estimated in this final eruptive event that over 120 cubic kilometers (~30 cubic miles) of volcanic tephra was produced, enough to cover the entire State of Oregon (or the entire UK!) to a depth of 45 centimeters (1.5 ft). To this day, many regional western United States landscapes have deep volcanic ash deposits (termed andic soils) (Kimsey et al., 2011).

    Figure 2. Plant available water in a fine-textured volcanic ash soil (andic) overlaying a coarse- textured glacial till soil (non-andic) in Northern Idaho, United States. Andic soil properties extend to approximately 45 cm in depth. Inset micrograph: volcanic glass particle (courtesy of the University of Idaho Soil Characterization Laboratory, Moscow).

    Key soil properties of volcanic ash

    Soil volcanic ash has unique soil characteristics given its violent origin. If looked under a microscope, the majority of soil particles look like glass shards shot through with holes (vesicles). In addition, downwind volcanic ash deposition tends to have smaller particle sizes, falling primarily in the silt category (0.002 – 0.05 mm). These two primary features of volcanic ash lead to significantly higher soil water holding capacity, relative to other non-volcanic-ash-derived soils (Fig. 2).

    Figure 3. Vegetation community shifts by increasing fine-textured volcanic ash depth and purity across the Intermountain Northwest, United States (Kimsey et al., 2007).
    Figure 3. Vegetation community shifts by increasing fine-textured volcanic ash depth and purity across the Intermountain Northwest, United States (Kimsey et al., 2007).

    The role of volcanic ash in forest ecology and management

    The ability of these volcanic ash soils to hold two to three times the plant available water relative to other soil parent materials is the primary key to changing the productivity and species composition of Western United States forest ecology. The presence of fine-textured volcanic ash has been linked to vegetation plant community shifts and increased growth rates, supporting plant species that require more plant-available water than would have been typically available in geologically derived regional soils found across the Mediterranean and Continental climates of the Western United States (Figs. 3 and 4).

    Given the significant influence of volcanic ash on forested ecosystems, it is important for natural resource managers to map and incorporate their presence into silvicultural management information systems. Volcanic ash, or soils with similar water retention characteristics, are a relatively non-renewable resource that must be protected to maintain their ecological and silvicultural importance, particularly in regions that experience, or will experience, droughty conditions.

    Figure 4. Influence of volcanic ash on mixed conifer growth rates across the Intermountain Northwest, United States (research data provided by the Intermountain Forestry Cooperative).
    Figure 4. Influence of volcanic ash on mixed conifer growth rates across the Intermountain Northwest, United States (research data provided by the Intermountain Forestry Cooperative).

    References

    • Kimsey, M., M.T. Garrison-Johnston, and L. Johnson. 2011. Characterization of volcanic ash-influenced forest soils across a geoclimatic sequence. Soil Sci. Soc. Am. J. 75:267-279.
    • Kimsey, M., B. Gardner, and A. Busacca. 2007. Ecological and topographic features of volcanic ash-influenced forest soils. p. 7-21 In Page-Dumroese, et. al. (eds.) Proceedings – Volcanic Ash-Derived Forest Soils of the Inland Northwest: Properties and Implications for Management and Restoration. Nov. 9-10, 2005, Coeur d’Alene, Idaho. USDA Forest Service. Rocky Mountain Experiment Station. Fort Collins, CO.

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  • Guillermo del Toro Praises Kim Novak as Vertigo Star Gets Venice Award

    Guillermo del Toro Praises Kim Novak as Vertigo Star Gets Venice Award

    “Vertigo” star Kim Novak was honored with a Golden Lion for Lifetime Achievement on Monday at the Venice Film Festival, where the reclusive Hollywood diva made her first public appearance in decades since leaving the limelight in the mid 1960s.

    She was welcomed with a warm protracted ovation before Guillermo del Toro took the stage to deliver a glowing tribute.

    Novak, 92, became the world’s top box office draw during the late ‘50s and early ‘60s thanks to films now considered classics such as Joshua Logan’s “Picnic” (1955), Otto Preminger’s “The Man with the Golden Arm” (1955), George Sidney’s Pal Joey (1957) and, of course, Alfred Hitchock’s “Vertigo” (1958), in which she plays dual characters in the role of her lifetime.

    After listing the top directors Novak worked with, del Toro singled out the single aspects of her career that struck him the most: “Most impressive is the fact that she was capable of projecting frailty, power, mystery. To appear, endearing, dynamic, mythical and phenomenal. And with all those wonderful arresting performances, she always carried a little bit of warmth, a little bit of heartbreak and a little bit of mystery.”

    Del Toro added: “Over time, she made her performances her own. Remarkably, she also chose to slow down, to take a break at the peak of her powers and to seek personal fulfillment raising horses and as a lyricist and a painter.”

    In 1966, the Hollywood star withdrew from acting and retired to her ranch in Oregon to dedicate herself to painting and to her horses, only working sporadically in film since then.

    “Oh my God! This is so beautiful,” said the visibly moved Novak. “I am receiving this. But it’s the same as if you were,” she said, gesturing towards the audience. Then she exclaimed: “You are me!”

    “First of all, I’d like to thanks the Gods up there. Not one in particular. Just all of them. It’s such a gift that they waited until the end of my lifetime [for me] to get this,” Novak added.

    “I want to thank my dad for being my moral compass,” she added. “And my mom. I was very shy and she would make me look in the mirror and make me say, ‘You are the captain of your own ship!’ That is something I think we all need to say. We all need to make our voices heard.”

    As part of the tribute, Venice premiered the documentary biopic “Kim Novak’s Vertigo,” directed and written by Alexandre O. Philippe. The doc blends rare archival footage with personal reflections from Novak and glimpses into her reclusive life along Oregon’s wild Rogue River, tracing “her path from mid-century cinema icon to fiercely private artist,” as the doc’s synopsis puts it.

    “It’s really about the spirals in her life,” said the director during a press conference prior to the awards ceremony. “In fact, if you really want to get into it, the movie has a spiral structure. At the end of each act we come back to this idea of why she left Hollywood; but at the end of each act it’s a different reason.”

    So why did Novak agree to be part of “Kim Novak’s Vertigo”?

    “I wanted her to have one more pow in her life,” said Sue Cameron, Novak’s manager and close friend who also serves as the doc’s executive producer. “It was not easy, really. But she felt secure with him [Philippe], so she said yes.”

    “It’s a challenge,” added “Kim Novak’s Vertigo” producer Terri Piñon about bringing Novak to Venice for the tribute and the doc’s launch, which will be followed by an appearance at the Deauville American Film Festival in France. “She wants to be home with her horses and her dogs. But she’s willing to help the film team and be here.”

    Cameron pointed out that Novak still exercises with weights every day.

    “She has a 13-acre ranch with three islands on it and horses. She rides the horses, she walks around the meadows. She does not give up. This is not someone who acts her age. And she is determined to not accept her age,” Cameron went on. “She was working out with weights this morning!”

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  • A new insurance solution for risks in interdependent carbon capture and storage value chains

    A new insurance solution for risks in interdependent carbon capture and storage value chains

    Carbon capture and storage (CCS) has a major role to play in efforts to decarbonize, particularly for hard-to-abate industries, such as steel and cement, that face significant challenges in achieving net-zero targets.

    Uncertainties impacting transition finance

    To support the anticipated scale and pace of CCS deployment, innovation is required from the insurance community to offer new solutions for a wider set of risks.

    As investment in carbon capture and storage continues to grow, a clear distinction is emerging between end-to-end capture and storage projects and value chains split across separate entities, such as carbon dioxide (CO2) emitters, transporters, and storers. In the latter case, government support has been crucial to provide certainty and encourage investment.

    For inter-dependent chains, a key trend is the rise of large-scale cluster models, where various emitters capture their own CO2 and pay to utilize shared third-party transport and storage infrastructure, leveraging economies of scale.

    This aggregation of CO2 volumes (before injection at a centralized storage site) has prompted operators to set CO2 specifications for each development. Creating these specifications is not only a risk management issue; it has cost implications that can impact project viability. Requiring very pure CO2 streams may limit customer options, as the cost of capture could become prohibitively high in some cases.

    As each part of the removal chain is highly interdependent, any interruption at one point can impact the whole operation.

    “The technology for working with CO2 is not new,” says Maria Arana, Marsh’s Climate and Sustainability Leader, Europe. “What is new is the kind of contractual frameworks created by implementing that technology at scale in a CCS value chain of separate but interdependent parties.”

    Risks relating to CO2 specification

    As recently explored in a conversation between Marsh colleagues Amy Barnes, Head of Climate and Sustainability and Energy and Power, and Hannah Jennings, CCS global leader, contaminants in CO2 can increase the risk of degradation and damage to the transportation infrastructure. For instance, excessive water content can lead to the formation of carbonic acid, resulting in potential corrosion. Additionally, the presence of low-level impurities within the CO2 stream can alter its behavior, potentially exceeding the design parameters of the associated infrastructure.

    To effectively mitigate these risks, stringent specifications are being developed and agreed upon across each specific value chain, from capture to ultimate storage. Compliance with these specifications will be monitored at relevant intervals to ensure safe and reliable operations following the aggregation of CO2 volumes.

    Even with robust risk management, insurance can help transfer residual risks. For example, if physical damage occurs due to the inadvertent introduction of off-spec CO2 into the system, existing risk transfer solutions can be adapted to cover the resulting damage. 

    Non-damage triggers

    However, this new business ecosystem can lead to potential losses beyond physical damage. For example, control protocols along the CCS value chain are designed to detect off-spec CO2. If detected, risk mitigation procedures may include venting the CO2 to prevent damage.

    “When a cement plant, for example, in the past simply emitted CO2 into the atmosphere, they did not have to think about the molecular stability driven by impurities of that CO2,” explains Maria Arana. “When they capture the CO2 they emit and feed it into a CCS value chain, it becomes critical to have quality control processes and to think about what happens if a contaminated batch is detected at any point in the value chain. The consequences could be both serious and complex. Typically, the infrastructure operator at the place and moment of detection will have strict protocols to initiate a purposeful venting process to avoid further contamination or damage to the infrastructure.”

    With the risks identified, various off-take agreements between CCS stakeholders allocate the associated liabilities. While there is no universally accepted standard for how this liability is contractually allocated, but two key complexities are often considered.

    • The timing of when the title of the CO2 and/or care and custody changes.
    • Situations, particularly in Europe, where mixing and blending occur, meaning multiple emitters share a single transport and storage infrastructure.

    “The contracts are often structured in such a way that if one of the emitters is found to have provided off-spec CO2, it will be liable for cleaning and remediation costs, as well as any financial losses incurred by the other emitters,” says Maria Arana.

    Off-spec CO2 liability insurance

    In partnership with HDI Global, Marsh has launched a new insurance product designed to cover this specific risk in interdependent CCS value chains.

    This innovative solution can provide:

    1. Coverage for defense costs associated with litigation, which may be commenced before the party responsible for contributing off-spec CO2 is identified.
    2. For an insured found to have contributed off-spec CO2, coverage for:

    a. Carbon credits losses of co-emitters.
    b. Other financial losses incurred by co-emitters.
    c. Remediation and decontamination costs for the facilities involved.

    Towards a whole value chain approach

    As companies play their part in the transition to net-zero, it is essential for them to anticipate, mitigate, and transfer residual risks associated with carbon capture and storage.

    This new solution complements Marsh’s existing solution that offers non-damage coverage for unexpected leakages from the storage site itself, underwritten by Canopius and Hiscox.

    “Many of the new risk concerns come back to the element of interdependence in the ecosystem, with multi-stakeholder value chains,” says Hannah Jennings. “With these innovative solutions, we hope to enable the CCS industry and support our clients in their efforts to decarbonize.”

    For more information, please contact a Marsh representative.

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  • Associations of Sleep Duration and Social Jetlag with Dry Eye Disease

    Associations of Sleep Duration and Social Jetlag with Dry Eye Disease

    Introduction

    Dry eye disease (DED) is a multifactorial disorder of the ocular surface characterized by loss of tear film homeostasis. Common symptoms include eye fatigue, foreign body sensation, and ocular dryness.1 Globally, the prevalence of DED ranges from 5% to 50%, depending on the population and diagnostic criteria used.2 In Asia, the estimated prevalence of DED across various populations was approximately 20.1%,3 while studies reported a prevalence of 13% in Brazil and 41% in Mexico.4 Although DED has traditionally been more common in adults, its prevalence among children in China has increased in recent years, likely due to environmental changes and evolving lifestyle patterns. Owing to differences in survey methods, geographic regions, and diagnostic standards, the estimated prevalence of pediatric dry eye varies from 6.6% to 20%,5 a relatively high rate by global comparison. The etiology of DED in children and adolescents is multifactorial, involving environmental exposures, underlying health conditions, and dietary habits. 6 Among lifestyle-related contributors, disruption of the circadian rhythm has also been implicated in the development of dry eye. 7

    High-quality sleep is essential for maintaining overall health and plays a critical role in supporting both physical and mental well-being.8 Healthy sleep is characterized by subjective satisfaction, appropriate timing of sleep and wakefulness, sufficient duration, high efficiency, and sustained alertness during the day.9 Increasing evidence suggests that sleep disorders have become a major global public health concern, with approximately 150 million individuals affected worldwide.10 Matricciani et al11 analyzed data on sleep duration from 690,747 children aged 5 to 18 years across 20 countries between 1905 and 2008, revealing that children and adolescents now sleep over one hour less per night on average. This long-term declining trend has been observed in regions including Asia, Canada, the United States, and Europe. In mainland China, the prevalence of sleep problems among children has also risen significantly over the past two decades, currently affecting nearly 40% of school-aged children.12 Recent studies have confirmed a positive association between insufficient sleep and the prevalence of DED.13 For example, Hanyuda et al14 reported that individuals with shorter sleep duration had a higher prevalence of dry eye. Another study found that individuals who slept fewer than five hours per night had a 20% higher prevalence of dry eye compared to those who slept more than six hours.15 Furthermore, a bidirectional relationship between sleep and DED has been suggested. Not only inadequate sleep increased the risk of dry eye, but patients with DED also experienced poorer sleep quality and longer sleep latency, highlighting a reciprocal influence between the two conditions.16

    Social jetlag, a form of chronic circadian rhythm disruption, is defined as the difference between the midpoint of sleep on school or workdays and that on free days, such as weekends—that is, the misalignment caused by discrepancies in sleep onset time, wake time, and sleep duration between weekdays and weekends.17 Based on the Morningness-Eveningness Questionnaire (MEQ), circadian typology can be categorized into three chronotypes: morning type (M-type), intermediate type (N-type), and evening type (E-type).18 This phenomenon is commonly observed among children and adolescents,19 and research suggests it can emerge as early as infancy, even in children aged 0 to 6 years.20 As students advance to higher grade levels, academic demands often lead to more pronounced discrepancies in sleep patterns between weekdays and weekends.21 For example, one study reported that the average social jetlag among adolescents in the United States reached up to 2.5 hours.22 Individuals with high levels of social jetlag often stay up late on weekends, resulting in increased screen exposure and reduced outdoor activity during the day—behavioral patterns that are recognized risk factors for dry eye. Social jetlag reflects a misalignment between the endogenous biological clock and the socially imposed sleep–wake schedule. This circadian disruption may impair lacrimal gland function, indicating that social jetlag exerts a combined influence through both behavioral and physiological mechanisms.

    Despite growing interest in sleep and ocular health, current research offers limited evidence on the relationship between social jetlag and dry eye. Therefore, this study aims to investigate the prevalence of dry eye among children and adolescents aged 9 to 19 years in Fengyang County, Anhui Province, and to evaluate their sleep duration and social jetlag patterns. Furthermore, it seeks to analyze the associations and potential interaction effects between these sleep-related factors and the risk of dry eye. The findings are expected to provide scientific evidence supporting the development of sleep-based interventions for the prevention of dry eye and the promotion of ocular health in the pediatric population.

    Methods

    Study Population

    Between November and December 2023, a stratified random sampling method was employed based on school level and urban–rural distribution. One primary school, two junior high schools, and four senior high schools were respectively selected from rural and urban areas in Fengyang County, Chuzhou City, Anhui Province, China. Within each selected school, one class was randomly chosen from grades 4–6, 7–9, and 10–12. A total of 2341 students aged 9–19 years underwent dry eye examinations and completed a structured questionnaire. Students below Grade 4 and those with a history of ocular surgery, ocular trauma, glaucoma, conjunctivitis, or who declined to participate in the study were excluded. After further excluding participants with incomplete questionnaires or missing dry eye assessments, a total of 1993 students were included in the final analysis. The present study was approved by the Medical Ethics Committee of Anhui Medical University (YX2022058) and was carried out according to the tenets of the declaration of Helsinki. All participants (or their legal guardians) provided written informed consent prior to the commencement of the study. To protect participant privacy, all data were anonymized and used solely for the purposes of this research.

    Dry Eye Assessment and Diagnosis

    Dry eye evaluation in children and adolescents was conducted by the same trained professional in a clinical setting. Tear film breakup time (TBUT) was used as the primary parameter for determining the presence of dry eye. A fluorescein sodium strip was moistened with one drop of sterile saline. The strip was gently applied to the subject’s lower conjunctival sac. Participants were instructed to blink several times and then maintain a primary gaze. Using a slit-lamp biomicroscope with cobalt‑blue illumination and a wide slit beam, the examiner recorded the time from the last blink to the appearance of the first dark spot on the tear film. This interval was recorded as the tear film breakup time (TBUT). Students also completed the Dry Eye Questionnaire‑5 (DEQ‑5).23 The Cronbach’s coefficient of the DEQ‑5 was 0.843, representing a high degree of internal consistency. Dry eye was diagnosed based on the 2013 diagnostic criteria from the Chinese Ophthalmological Society Cornea Disease Group. Diagnosis required at least one subjective symptom (dryness, foreign-body sensation, burning, fatigue, discomfort, or visual fluctuation) and a TBUT of ≤ 5 s.

    Sleep Duration

    The children’s and adolescents’ bedtime and wake‐up time on school days and weekends were measured using a self‐reported questionnaire. School‐day mean daily sleep duration and weekend mean daily sleep duration were calculated. The average daily sleep duration was determined by the formula: (average daily sleep duration on school days × 5 + average daily sleep duration on weekends × 2) /7. Previous studies have indicated that a sleep duration ≥ 9 hours may be considered protective against dry eye.24 Based on this threshold, participants were classified into two groups: < 9 h and ≥ 9 h of sleep.

    Social Jetlag

    Bedtime and wake‑up times on school days and weekends for children and adolescents were collected using self‑reported questionnaires. For each participant, the midpoint of sleep was calculated separately for school days (MSW) and weekend days (MSF) as wake‑up time minus half of the nighttime sleep duration. Social jetlag (SJL) was then defined as the absolute difference between the weekend and school‑day midpoints of sleep: ie, SJL = |MSF − MSW|. This approach is widely used in chronobiological research to quantify circadian misalignment. Currently, there is no universally accepted standard for defining social jetlag. Many studies use a ≥ 1 h threshold as the cutoff.25 For this reason, participants in the present study were classified into two groups: those with social jetlag < 1 h and those with ≥ 1 h.

    Covariates

    Demographic data including sex, age, residential setting, monthly household income per capita, and parental education level were collected using a self-developed questionnaire. Dry eye–related risk behaviors, encompassing contact lens use, artificial tear usage, duration of outdoor exposure, and screen time on both school days and weekends were also assessed. Sleep quality was assessed by an item from Pittsburgh sleep quality index.

    Statistical Analysis

    A database was established using EpiData 3.1 for questionnaire entry. Statistical analyses were performed using SPSS 23.0 software. Differences in sociodemographic characteristics between the DED and non-DED groups were assessed using chi-square tests for categorical variables and independent-samples t-tests for continuous variables. DED (yes = 1, no = 0) was treated as the dependent variable, and sleep duration and social jetlag were the primary independent variables. Given that sleep quality has been shown to play a crucial role in regulating lacrimal gland function and maintaining ocular surface immune balance, Model 2 in the logistic regression analysis included sleep quality as a covariate to control for its potential confounding effects on the relationship between sleep duration, social jetlag, and DED. Binary logistic regression models were used to examine the independent and interactive associations of sleep duration and social jetlag with the risk of DED A two-sided p-value of less than 0.05 was considered statistically significant.

    Results

    Participant Characteristics

    Among 1993 participants, the prevalence of dry eye was 51.0%. Stratified by school level, the rates were 33.3% (81/243) in primary school, 51.8% (357/689) in middle school, and 54.5% (578/1,061) in high school. These differences were statistically significant (P < 0.05). Female students had a higher prevalence of DED than male students (Table 1).

    Table 1 Comparison of Dry Eye Disease Prevalence Across Sociodemographic and Ocular Characteristics in Children and Adolescents (N = 1993)

    Comparison of Dry Eye Disease Prevalence by Sleep Duration and Social Jetlag Groups

    The prevalence of DED was significantly higher in the group with sleep duration < 9  h compared to those with ≥ 9  h, and likewise, participants with social jetlag ≥ 1 h demonstrated a significantly higher rate of DED compared to those with < 1  h (both P < 0.05) (Table 2).

    Table 2 Prevalence of Dry Eye Disease by Sleep Duration and Social Jetlag Groups Among Students Aged 9–19 Years

    Binary Logistic Regression Analysis of Independent Associations of Sleep Duration and Social Jet Lag with Dry Eye Disease in Children and Adolescents Aged 9–19 Years

    Binary logistic regression models were used to examine the associations of sleep duration and social jetlag with DED in children and adolescents. In Model 1 (unadjusted), sleep duration < 9 hours was significantly positively associated with DED (OR= 1.35; 95% CI:1.10–1.65), and social jetlag ≥ 1 hour was also significantly associated with DED (OR=1.28; 95% CI:1.07–1.53). After adjusting for sleep quality in Model 2, these associations remained statistically significant (P < 0.05).

    Binary Logistic Regression Analysis of the Interaction Between Sleep Duration and Social Jetlag on Dry Eye Disease Among Children and Adolescents Aged 9–19 Years

    Binary logistic regression models were employed to assess the association of the interaction between sleep duration and social jetlag with DED in children and adolescents. In Model 1 (unadjusted for confounders), only the group with sleep duration ≥ 9 h combined with social jet lag ≥ 1 h showed a significant positive association with DED (OR=1.73, 95% CI: 1.32–2.27). After adjusting for sleep quality in Model 2, this association remained statistically significant (OR=1.77, 95% CI: 1.35–2.33). This effect size was visualized using forest plots (Figures 1 and 2), which clearly depict the odds ratios and confidence intervals across the four sleep pattern combinations under both unadjusted and adjusted models.

    Figure 1 Forest plot showing the associations of sleep duration, social jetlag, and their interaction with dry eye disease.

    Abbreviations: OR, odds ratio; CI, confidence interval; Ref, reference group; h, hours.

    Notes: Model 1: Unadjusted logistic regression. ORs and 95% CIs are shown for each subgroup. The reference group was participants with ≥9 h of sleep and <1 h of social jetlag.

    Figure 2 Forest plot showing the associations of sleep duration, social jetlag, and their interaction with dry eye disease.

    Abbreviations: OR, odds ratio; CI, confidence interval; Ref, reference group; h, hours.

    Notes: Model 2: Adjusted for sleep quality. ORs and 95% CIs are shown for each subgroup. The reference group was participants with ≥9 h of sleep and <1 h of social jetlag.

    Discussion

    This study is the first to demonstrate the statistical association of sleep duration and social jet lag with DED in children and adolescents. The prevalence of DED in this study was notably higher at 51%, compared with previous domestic questionnaire-based and clinic-verified cross-sectional surveys of primary and secondary students, which reported rates of 13.86%–21.37%.26,27 This discrepancy may be attributed to regional differences, as most participants in our study were from townships, and to methodological variations in dry eye assessment across studies.

    The present study found that sleep duration of less than 9 hours significantly increased the risk of DED in children and adolescents. Numerous prior studies have reported an association between sleep duration and dry eye. One study indicated that the prevalence of insomnia was higher among DED patients, and the severity of insomnia was significantly correlated with dry eye symptoms.13,28 Lee et al29 found that, compared with the optimal sleep group (6–8 h/d), the mild short-sleep group (~5 h/d) and severe short-sleep group (≤ 4 h/d) had 1.20-fold and 1.29-fold higher prevalence of dry eye, respectively.This trend indicates an increase in DED prevalence with shorter sleep duration. The proposed mechanism is that reduced sleep leads to longer eyelid-opening time, increasing exposure to dry environments and accelerating tear evaporation.29 Additionally, sleep provides essential nutrition and repair to the ocular surface. Inadequate sleep suppresses parasympathetic activity governing the accessory lacrimal glands, leading to reduced tear secretion.30 Moreover, it has been proposed that sleep deprivation may induce dry eye by causing abnormal microvilli morphology in corneal epithelial cells; this effect is driven by the sequential downregulation of PPARα, TRPV6 expression, and Ezrin phosphorylation.31 Adequate sleep duration may play a protective role in alleviating dry eye among children and adolescents. Therefore, it is recommended that this population maintain sufficient sleep, with both schools and parents collaborating in supervision to safeguard ocular health.

    This study also found that social jetlag ≥ 1 hour was associated with an increased risk of dry eye in children and adolescents, with a higher incidence observed in the ≥ 1 hour group. Social jetlag represents a form of circadian rhythm disruption, which not only contributes to the onset of various diseases but also plays a role in regulating physiologic homeostasis of the ocular surface.32 There are currently few studies examining the association between social jetlag and dry eye in children and adolescents. However, previous research has demonstrated that jetlag can disrupt the circadian rhythm of lacrimal gland secretion. One study examined the effects of jetlag on mice. Compared with control mice, those subjected to jetlag treatment showed impaired extraorbital lacrimal glands in terms of mass, cell size, and secretory response. Jetlag was found to disrupt the circadian rhythm of the lacrimal gland’s transcriptomic profile, structural integrity, and secretory function.33 Existing evidence indicates a close relationship between circadian rhythm disruption and dry eye.34 Ocular tissues have been shown to contain intrinsic core molecular circadian clock systems and exhibit coordinated circadian rhythmic activities.35 One study found that chronotype was an independent risk factor for dry eye, college students with evening-type reported more severe dry eye symptoms.36 Disruption of circadian rhythms may increase the risk of dry eye in children and adolescents through several potential mechanisms: (1) Circadian disruption can downregulate the expression of the corneal transmembrane mucin MUC4 via the core clock gene BMAL1, leading to mucin‑deficient dry eye.37 (2) Inflammatory status on the ocular surface exhibits circadian fluctuations, likely linked to daily changes in tear dynamics and ocular surface temperature.38 In mice, DNA replication in corneal epithelial cells peaks in the morning and declines in the afternoon/evening, suggesting circadian modulation of mitosis and epithelial renewal.39 (3) The suprachiasmatic nucleus (SCN) synchronizes the body’s circadian rhythm via light input from the retina. It regulates melatonin and cortisol levels through two distinct pathways: the hypothalamic–pineal–melatonin axis and the hypothalamic–pituitary–adrenal axis. Melatonin can alleviate dry eye symptoms by modulating macrophage polarization, reducing oxidative stress, exerting anti‑inflammatory effects, and enhancing the mucin MUC4. Circadian rhythm disruption leads to imbalances in these hormone levels.37

    In this study, we observed that the group with sleep duration ≥ 9 hours combined with social jetlag ≥ 1 hour was positively associated with dry eye disease (DED). These findings suggest that even with adequate sleep duration, a substantial degree of social jetlag is still linked to an increased risk of DED among children and adolescents. This may indicate that, compared to insufficient sleep alone, misaligned sleep timing between school days and weekends exerts an even greater adverse effect on ocular surface health. Therefore, maintaining regular sleep patterns and establishing consistent sleep–wake schedules may serve as modifiable behavioral strategies to reduce the risk of DED in this population. Notably, the group with sleep duration < 9 hours and social jetlag ≥ 1 hour showed a marginally significant association with DED (p = 0.086). Although this result did not reach the conventional threshold for statistical significance, the direction and magnitude of the effect were consistent with our research hypothesis. The lack of significance may be attributable to limited sample size or data variability, suggesting that this association warrants further investigation in future studies with larger or stratified samples. In addition, although we adjusted for several covariates in the regression models, we acknowledge the potential presence of multicollinearity among them. For example, within specific age groups, variables such as myopia status and screen time may be highly correlated. Future research is needed to disentangle the individual contributions of these factors and to assess their potential interactions more precisely.

    This study has several limitations. First, as a cross-sectional analysis, it cannot establish causal relationships. Future longitudinal studies are warranted to determine whether sleep duration and social jetlag causally contribute to the development of dry eye disease (DED) in children and adolescents. Second, both sleep duration and social jetlag were self-reported by participants, which may be subject to recall bias—particularly in younger populations where memory and reporting accuracy may be limited. The use of wearable devices in future studies may help obtain more precise and objective sleep data. Third, although several covariates were adjusted for, other potentially important confounding factors—such as pre-sleep behaviors and psychological status—were not assessed. Fourth, the study sample was drawn from a single geographic area. Differences in socioeconomic and educational backgrounds may affect the generalizability of our findings.

    Despite these limitations, the results highlight practical implications for sleep hygiene education in youth. Schools and parents should collaborate to implement behavioral interventions aimed at improving sleep patterns. These may include setting screen curfews, encouraging regular bedtimes and wake times, and reducing weekday–weekend sleep variability, all of which may help mitigate social jetlag and lower the risk of DED in children and adolescents.

    Conclusion

    In summary, children and adolescents who slept less than 9 hours per night had a 37% higher prevalence of dry eye disease (DED), while those with social jetlag ≥1 hour had a 28% higher prevalence. Notably, even among individuals with adequate sleep duration, the presence of significant social jetlag was still associated with an increased risk of DED. Despite the limitations, our findings provide preliminary evidence to support school-based and family-level interventions. Schools and parents should work together to promote adequate nightly sleep and consistent sleep–wake schedules to safeguard ocular health in youth. However, the underlying mechanisms linking sleep disturbances and dry eye remain poorly understood. Large-scale prospective cohort studies in pediatric populations are needed to elucidate causal relationships, which may ultimately inform the development of early behavioral interventions for DED prevention.

    Data Sharing Statement

    The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

    Author Contributions

    Conceptualization: Shuman Tao, Heting Liu; Methodology: Yuzhu Luo, Yuting Gao, Zhong Guan; Data Curation: Yuzhu Luo, Yuting Gao; Formal Analysis: Yuzhu Luo; Investigation: Yuzhu Luo, Yuting Gao, Zhong Guan; Writing – Original Draft: Yuzhu Luo; Writing – Review & Editing: Shuman Tao, Heting Liu, Yuting Gao, Zhong Guan; Supervision: Shuman Tao, Heting Liu; Funding Acquisition: Shuman Tao; Project Administration: Shuman Tao.

    All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    This study was funded by the National Natural Science Foundation of China (82273653), the Research Project of Center for Big Data and Population Health, Institute of Health and Medicine, Hefei Comprehensive National Science Center (JKS2023011) and the Cultivation Program for Scientific and Technological Talents of the Second Affiliated Hospital of Anhui Medical University (2024PY01).

    Disclosure

    The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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  • Transfer Deadline Day LIVE: Liverpool agree £35m Marc Guehi deal, £21.7m Man United signing flies in on private jet, Chelsea to secure £92.5m double exit + Muani and Elliott news

    Transfer Deadline Day LIVE: Liverpool agree £35m Marc Guehi deal, £21.7m Man United signing flies in on private jet, Chelsea to secure £92.5m double exit + Muani and Elliott news

    By HARRY BAMFORTH, LIVE SPORTS COVERAGE REPORTER and SIMON JONES and WILL PICKWORTH, SPORTS REPORTER and CRAIG HOPE, CHIEF FOOTBALL REPORTER and LEWIS STEELE, FOOTBALL REPORTER and JACK GAUGHAN, NORTH WEST SPORTS REPORTER and ADRIAN BISHOP, SPORTS REPORTER

    Updated:

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  • Tobacco smoking and the risk of aortic aneurysm in the UK biobank

    A total of 495,993 participants were included in the analytical dataset. When compared to never smokers, a higher proportion of current smokers were women than men. In addition, current smokers were younger, more deprived, and had lower education levels. We found few differences in smoking prevalence by ethnicity, physical activity, body mass index, height and connective tissue disease (Table 1). During an average of 12.3 years (6.1 million person-years) follow-up, a total of 3,353 incident aortic aneurysm cases were identified, including 778 thoracic, 1,985 abdominal, 26 thoracoabdominal and 519 unspecified aortic aneurysms. Of the total, 121 ruptured and 3,232 were non-ruptured aortic aneurysm cases, and 184 aortic aneurysm deaths occurred.

    Table 1 Population characteristics by smoking status.

    Smoking and aortic aneurysm

    The hazard ratios (95% CIs) of aortic aneurysm overall for current, former and ever vs. never smokers were 4.32 (3.93–4.76), 1.70 (1.56–1.84), and 2.15 (1.99–2.32), respectively. There was a strong dose-response relationship between increasing number of cigarettes per day and aortic aneurysm with HRs (95% CIs) of 3.62 (2.84–4.62), 5.66 (4.93–6.50), and 5.67 (4.93–6.52) for < 10, 10-<20 and ≥ 20 cigarettes per day vs. never smokers and a significant linear trend (ptrend = < 0.001). Pack-years of smoking was positively associated with aortic aneurysm risk with HRs (95% CIs) of 1.37 (1.18–1.60), 1.64 (1.44–1.88), 2.47 (2.19–2.80), and 3.77 (3.43–4.14; ptrend = < 0.001) for < 10, 10-<20, 20-<30, and ≥ 30 pack-years vs. never smokers. Similarly, greater duration of smoking was associated with dose-dependent increases in risk among current smokers and former smokers, with HRs (95% CIs) 2.52 (1.66–3.84), 3.48 (2.78–4.35), 5.86 (5.24–6.56; ptrend = < 0.001) for < 10, 10-<20, and ≥ 20 years in current smokers and 1.09 (0.95–1.24), 1.61 (1.40–1.84), and 3.18 (2.87–3.53; ptrend = < 0.001) for the same comparison in former smokers. Younger age (< 16 vs. ≥16 years) at starting smoking was slightly more strongly associated with aortic aneurysm both in former smokers (2.11, 1.87–2.37 vs. 1.79, 1.62–1.96) and current smokers (5.62, 4.87–6.47 vs. 4.82, 4.29–5.42). Years since quitting smoking was associated with a dose-dependent reduction in risk of aortic aneurysm with HRs (95% CIs) of 0.77 (0.69–0.87), 0.50 (0.44–0.57), 0.32 (0.28–0.37), and 0.23 (0.20–0.27; ptrend = < 0.001) for < 10, 10-<20, 20-<30, ≥ 30 years vs. current smoking, and which at ≥ 30 years duration approached that of never smokers (0.22, 0.20–0.25) (Table 2).

    Table 2 Smoking and aortic aneurysm.

    Smoking and aortic aneurysm subsites (thoracic, abdominal, thoracoabdominal and unspecified site)

    When analyses were conducted separately for thoracic, abdominal, thoracoabdominal and unspecified site aortic aneurysms, strong positive associations were observed for current vs. never smokers and abdominal (8.90, 7.79–10.16), thoracoabdominal (11.64, 4.20-32.25), and unspecified site (2.06, 1.61–2.65) aortic aneurysms, but no clear association was observed for thoracic aortic aneurysm (1.13, 0.88–1.44), and there was significant heterogeneity by subsite (pheterogeneity<0.0001) (Table 3). Similar trends were observed for ≥ 20 cigarettes/day vs. never smoking for abdominal (12.32, 10.34–14.68), thoracoabdominal (21.59, 6.14–75.96), and unspecified site (2.48, 1.65–3.72), and thoracic (0.99, 0.60–1.62) aortic aneurysms (pheterogeneity<0.0001), and for ≥ 30 pack-years vs. never smoking for abdominal (7.24, 6.35–8.26), thoracoabdominal (8.02, 2.73–23.55), unspecified site (1.63, 1.26–2.10), and thoracic (1.17, 0.93–1.48) aortic aneurysms (pheterogeneity<0.0001). Consistent with these findings, ≥ 20 years duration of smoking among current smokers vs. never smoking was positively associated with abdominal aortic aneurysm (11.47, 9.89–13.30), thoracoabdominal (11.88, 3.53–39.92), unspecified site (2.51, 1.84–3.44), but not thoracic (1.25, 0.88–1.77) aortic aneurysm (pheterogeneity<0.0001), and for the same comparison in former smokers positive associations were observed for abdominal (5.76, 5.00-6.63), thoracoabdominal (4.70, 1.40-15.79), unspecified site (1.48, 1.12–1.97), but not thoracic (1.06, 0.82–1.37) aortic aneurysm (pheterogeneity<0.0001). Younger age at starting smoking (< 16 vs. ≥16 years) was more strongly positively associated with abdominal aortic aneurysm both in former (3.72, 3.18–4.35 vs. 2.97, 2.59–3.40) and current (12.28, 10.31–14.64 vs. 10.04, 8.61–11.71) smokers when compared to never smokers, while for thoracoabdominal (8.64, 1.59–46.86 vs. 9.80, 2.88–33.28), and unspecified site (2.28, 1.50–3.46 vs. 2.19, 1.58–3.03), the associations were limited to current smokers and no association was observed for thoracic aortic aneurysms (pheterogeneity<0.0001 for both former and current smokers). Longer duration of quitting smoking was inversely associated with risk of abdominal aortic aneurysm (0.14, 0.11–0.17 for ≥ 30 years), thoracoabdominal (0.12, 0.02–0.97 for 10-<20 years), and unspecified site (0.46, 0.32–0.68), but not thoracic (0.89, 0.64–1.24) aortic aneurysms (pheterogeneity<0.0001) (Table 3).

    Table 3 Smoking and aortic aneurysm subtypes.

    Smoking and ruptured and non-ruptured aortic aneurysm

    The HR (95% CIs) for current vs. never smokers was 10.47 (6.12–17.90) for ruptured aortic aneurysm and 4.19 (3.80–4.62) for non-ruptured aortic aneurysm (pheterogeneity=0.01) (Table 4). The HRs of ruptured and non-ruptured aortic aneurysm relative to never smokers were 13.29 (6.40-27.61) and 5.51 (4.77–6.36) for ≥ 20 cigarettes/day (pheterogeneity=0.02), 7.51 (4.40-12.84) and 3.68 (3.35–4.05) for ≥ 30 pack-years (pheterogeneity=0.01), 10.12 (5.47–18.71) and 5.77 (5.14–6.47) for ≥ 20 years duration in current smokers (pheterogeneity=0.08), 6.36 (3.63–11.14) and 3.10 (2.79–3.44) for ≥ 20 years duration in former smokers (pheterogeneity=0.01), and 4.96 (2.68–9.16) and 2.04 (1.81–2.30) for < 16 years age at starting smoking in former smokers and 15.65 (7.73–31.71) vs. 5.41 (4.68–6.25) for < 16 years age at starting smoking in current smokers (pheterogeneity=0.008), respectively. The HRs for ≥ 30 years of smoking cessation vs. current smoking was 0.10 (0.04–0.23) for ruptured and 0.24 (0.21–0.26) for non-ruptured aortic aneurysm (pheterogeneity=0.002) (Table 4).

    Table 4 Smoking and ruptured aortic aneurysm, non-ruptured aortic aneurysm and aortic aneurysm mortality.

    Smoking and aortic aneurysm mortality

    The HR (95% CIs) for current vs. never smokers was 8.78 (5.75–13.38) for aortic aneurysm mortality (Table 4). The HRs of aortic aneurysm mortality relative to never smokers were 11.94 (6.86–20.79) for ≥ 20 cigarettes/day, 7.09 (4.67–10.76) for ≥ 30 pack-years, 10.95 (6.90-17.36) for ≥ 20 years duration in current smokers, 4.75 (3.01–7.51) for ≥ 20 years duration in former smokers, and 3.58 (2.17–5.92) and 12.73 (7.38–21.98) for < 16 years age at starting smoking in former and current smokers, respectively. The HR for ≥ 30 years of smoking cessation vs. current smoking was 0.16 (0.09–0.30) for aortic aneurysm mortality (Table 4).

    Stratified analyses and sensitivity analyses

    In stratified analyses, interactions were observed when the analyses of smoking status were stratified by age (p < 0.001), sex (p < 0.001), BMI (p = 0.002), but not for hypertension (p = 0.89) (Supplementary Table 1). Stronger associations for current vs. never smokers were observed among older vs. younger participants (≥ 60 vs. <60 years) (5.13, 4.58–5.75 vs. 2.84, 2.37–3.41), for men vs. women (5.43, 4.47–6.60 vs. 4.09, 3.67–4.57), for those with normal BMI vs. those with overweight or obesity (5.39, 4.48–6.48 vs. 4.13, 3.58–4.75 vs. 3.81, 3.17–4.59), but associations were similar in those with vs. without hypertension (4.32, 3.86–4.84 vs. 4.45, 3.71–5.34) (Supplementary Table 1).

    Further adjustment for prevalent bicuspid aortic valve at baseline did not alter the results of the main analysis (results not shown).

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  • BREAKING: Tottenham make stunning deadline day offer for Bukayo Saka

    BREAKING: Tottenham make stunning deadline day offer for Bukayo Saka

    With an ankle injury to Dominic Solanke now looking potentially more serious than first suggested and Richarlison seemingly made out of spun sugar, hopes and dreams, Tottenham Hotspur are now looking for reinforcements at the forward position. Towards that, Cartilage Free Captain can EXCLUSIVELY reveal that Fabio Paratici and Daniel Levy have sanctioned a stunning approach for Arsenal striker Bukayo Saka.

    A source close to both parties said Spurs are initially offering Alfie Whiteman, a ham sandwich and unlimited free stadium karting tickets to give Saka an out; work continues on personal terms, with Spurs reportedly willing to put him on weekly wages similar to that of “fellow promising talent” Pape Matar Sarr.

    Reached on his cellphone while chugging a quintuple espresso and snorting a line of adderall, Paratici said this move was intend to both strengthen Tottenham and also give Saka an escape hatch from the dreadful tactics of Mikael Arteta.

    “Bukayo Saka is an outstanding young player, and we at Tottenham Hotspur feel a player of his obvious skills and caliber deserves to be on a team that wins in Europe. I have no further comment at this time.”

    — Fabio Paratici, probably

    When it was pointed out that Saka is an Arsenal player born and bred having come up through their academy, Paratici is said to have quipped “Well, so was Harry Kane and that didn’t matter much, did it? Anyway, COYS.”

    More updates as this story develops.

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  • Scientists unlock quantum version of Bayes’ rule in physics breakthrough

    Scientists unlock quantum version of Bayes’ rule in physics breakthrough

    image: ©koto_feja | iStock

    An international team of researchers have successfully derived a quantum version of Bayes’ rule, a cornerstone of probability theory

    Their discovery was published on August 28, 2025, in Physical Review Letters and examines how beliefs are updated in the quantum world, where normal physics rules no longer apply

    The research was conducted by Professor Valerio Scarani from the Centre for Quantum Technologies and the National University of Singapore, Assistant Professor Ge Bai from the Hong Kong University of Science and Technology, and Professor Francesco Buscemi from Nagoya University in Japan.

    Understanding Bayes’ rule

    Bayes’ rule was developed in the 18th century by mathematician Thomas Bayes and is a method used to update the probability of a hypothesis based on new evidence. It’s used across a range of fields from medical diagnosis and weather forecasting to data science and machine learning.

    Put simply, Bayes’ rule enables individuals to update their expectations in response to new information becoming available. For example, if a person believes they might have the flu and then receives a positive test result, Bayes’ rule helps quantify how much more likely it is that they are actually sick.

    This rule is grounded in the idea of conditional probability. It works by updating an individual’s prior belief to a new belief (called the posterior) that takes new information into account.

    Bayes’ role in the quantum world

    Although the classical Bayes’ rule is well understood, its application in the quantum realm has remained elusive. Quantum systems behave differently from classical ones; they are governed by probabilities and wavefunctions that describe the likelihood of finding a particle in a particular state.

    Previously, researchers had proposed several quantum analogues of Bayes’ rule, but none had been derived from a fundamental principle of quantum mechanics. The team adopted a new approach by focusing on how beliefs should adapt in response to new quantum measurements, while maintaining as close a connection as possible to the principle of minimum change.

    The principle of minimum change

    The principle of minimum change states that when new information is received, beliefs should be adjusted as little as necessary to fit the latest facts. In classical Bayes’ rule, this is reflected mathematically by minimising the distance between the original and updated probability distributions.

    To translate this into the quantum domain, the team employed a concept known as quantum fidelity, which measures the closeness of two quantum states to each other. Their goal was to maximise fidelity, or in other words, find the slightest change in belief that still accounts for the observed data.

    This led them to derive a quantum Bayes’ rule by maximising fidelity between two mathematical objects representing the forward and reverse processes of measurement and belief update.

    Connecting to the Petz map

    The team found that in specific scenarios, their newly derived equations matched a well-known mathematical tool in quantum information theory, known as the Petz recovery map. This map, introduced in the 1980s, was considered a promising candidate for a quantum version of Bayes’ rule due to its valuable properties. Still, it had never been derived from first principles before.

    Now, with this new research, researchers have not only validated the Petz map’s role in quantum reasoning but also opened the door to new applications, such as quantum error correction and quantum machine learning.

    Quantum potential: What does this mean for the future?

    The researchers are now exploring whether the principle of minimum change can lead to other quantum analogues by applying it to different mathematical measures. Their findings could further close the gap between classical and quantum reasoning, contributing to the foundation of future quantum technologies.

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  • Court orders detention of 3 over alleged TSMC trade secret theft

    Court orders detention of 3 over alleged TSMC trade secret theft

    Taipei, Sept. 1 (CNA) The Intellectual Property and Commercial Court (IPCC) has ordered one former employee and two current employees of Taiwan Semiconductor Manufacturing Co. (TSMC) be detained and held incommunicado for allegedly stealing sensitive trade secrets involving the company’s advanced 2 nanometer process.

    The ruling was handed down after the three suspects — Chen Li-ming (陳力銘), an ex-TSMC engineer, Wu Ping-chun (吳秉駿) and Ko Yi-ping (戈一平), who currently worked as engineers for the chipmaker — were referred to the IPCC on Monday morning.

    A three-judge panel at the IPCC ruled that the three deleted their communications records after their conduct involving the alleged theft of TSMC’s advanced 2nm process was discovered, so there are reasonable fears they could continue to destroy evidence and collude with one another in making false statements.

    The judges said that as the three suspects’ conduct potentially harmed national security and affected market competition, they should be detained to make sure the future court hearings proceed smoothly.

    On Aug. 27, the Taiwan High Prosecutors Office Intellectual Property Branch indicted the three suspects for their roles in the alleged theft of trade secrets and violation of the National Security Act by obtaining national core technology secrets for use abroad.

    Prosecutors are seeking prison terms of 14 years, nine years, and seven years, respectively for Chen, Wu and Ko.

    Chen is a former TSMC engineer working at Tokyo Electron Ltd. (TEL), a Japan-based supplier to TSMC. During the second half of 2024 and the first half of 2025, Chen asked Wu and Ko to provide trade secrets they had access to, under the guise of helping TEL secure more TSMC supplying contracts, according to prosecutors.

    TSMC detected the irregularity and filed a lawsuit against the three in early July. Prosecutors launched searches and raids related to the case from July 25-28 and secured approval from the IPPC to detain them men the investigation.

    The case was referred to the IPCC on Monday, and a hearing was needed to decide whether the three suspects could continue to be detained.

    TEL said in late August that an internal investigation has so far found no evidence that confidential information about TSMC’s 2nm was leaked to a third party.

    TSMC is developing the 2nm process, which is scheduled to start mass production in the second half of this year. Currently, the 3nm process is the latest technology for TSMC to begin commercial production.

    (By Lin Chang-shun and Frances Huang)

    Enditem/AW

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  • Rate of Post-Stroke Depression and Associated Factors in Saudi single

    Rate of Post-Stroke Depression and Associated Factors in Saudi single

    Turki Aljuhani,1,2 Shahd Alsubaie,3,4 Abrar M Al-Mutairi,5 Abdulmajeed S Altheyab,1,2 Abdulrahman M Alsahali,1 Abdulrahman S Alhamdan,1 Falah M Alqahtani,1 Lafi H Olayan,2,6 Mohammed Senitan7

    1Department of Occupational Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 11481, Saudi Arabia; 2King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia; 3Department of Rehabilitation, Ministry of National Guard – Heath Affairs, Riyadh, 11481, Saudi Arabia; 4Saudi Central Board for Accreditation for Healthcare Institution, Riyadh, 12264, Saudi Arabia; 5Research Unit, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 11481, Saudi Arabia; 6Anesthesia Technology Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 11481, Saudi Arabia; 7Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, 11673, Saudi Arabia

    Correspondence: Turki Aljuhani, Department of Occupational Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 11481, Saudi Arabia, Tel +96611429999, Email [email protected]

    Purpose: Stroke is a significant global health concern, with post-stroke depression (PSD) affecting approximately 30% of patients and contributing to reduced quality of life and increased mortality. In Saudi Arabia, data on PSD frequency and associated factors remain limited in relation to the rehabilitation of stroke patients, highlighting the need for further investigation. The study’s aims to investigate the rate of PSD and the factors that influence PSD.
    Methods: This feasibility study was conducted at the Neurorehabilitation Unit of King Abdulaziz Medical City in Riyadh, Saudi Arabia (October 2023–October 2024), and included stroke patients aged 18– 80 years. Data on stroke severity (NIHSS), functional independence (FIM), Hospital Anxiety and Depression Scale (HADS), and Short-Form Health Survey (SF-36) were collected using validated Arabic tools. All the analyses were performed with the significance level set at p < 0.05.
    Results: Out of the 37 participants, the frequency of anxiety and depression was 59.5% at admission, and it decreased to 40.5% at discharge from rehabilitation services. Functional independence improved significantly, with a 9.5-point increase in FIM scores. The mean differences (- 1.54 ± 4.3 p=0.03) and categorical differences between the initial and discharge HADS scores were significant (p=0.02).
    Conclusion: We found a high rate of depression and anxiety among stroke patients at admission. Rehabilitation services can lead to the improvement of depression and anxiety in stroke patients, from initial admission to discharge, with emotional health as a factor for better outcomes.

    Keywords: anxiety, depression, rehabilitation, stroke, functional independent measure, emotional health

    Introduction

    Stroke is a significant global health concern, affecting approximately 12.2 million individuals globally resulting in 6.6 million deaths in 2019.1 Recent data indicate that stroke prevalence has increased among both males and females with advancing age, with around 9.4 million Americans self-reporting a history of stroke between 2017 and 2020.2

    In Saudi Arabia, the prevalence of stroke shows considerable variation across studies, ranging from 29 to 57.6 per 100,000 populations.3,4 This disparity may reflect differences in study methodologies or population demographics. With an aging population, the incidence of stroke in Saudi Arabia is expected to rise further, increasing the burden on healthcare systems.5 Stroke can lead to significant physical, sensory, and cognitive impairments, often resulting in diminished quality of life.

    One of the most frequent and debilitating complications after stroke is post-stroke depression (PSD). PSD is associated with reduced functional ability, poorer quality of life, and increased mortality.6 Globally, PSD affects approximately 30% of stroke patients, persisting for up to five years’ post stroke.7,8 A recent systematic review estimated the prevalence of PSD to be around 27%.9 However, this prevalence has varied across regions; for example, it was 47% in Iran but 31% in Sub-Saharan Africa.10,11 Furthermore, post stroke anxiety (PSA) affects around 20 to 25% of stroke patients and can negatively impact the rehabilitation process and quality of life for patients.12,13 Depression and anxiety post stroke are highly related condition and can coexist in many stroke patients.14 In Saudi Arabia, data on PSD remain limited. Only two studies have reported PSD rates of 70.6% and 76.5%, but these studies had small sample sizes, did not follow up with participants, and were completed at one point only.15,16 Another study was conducted during the COVID-19 pandemic, and it reported a lower PSD prevalence of 36%, though the pandemic’s impact on mental health might have influenced these findings.17

    Mechanism that associated stroke with PSD are investigated with hypotheses related the cause to; stroke lesion site, amino acid neurotransmitters, and neuroinflammation.18 As for the stroke lesion location and its relation to PSD evidence suggested that specific brain regions such as the prefrontal cortex, limbic area, and basal ganglia can disturb the pathway which may lead to PSD.19 The monoamine neurotransmitters is considered the main biological factor that link PSD to stroke. If distributed occur at the hypothalamic-pituitary-adrenal axial, glutamate and gut-brain circuits this can lead to PSD.20,21 Lastly, studies proposed that elevated levels of inflammatory mediators are associated with PSD.22,23

    PSD contributes to increased physical disability, cognitive impairment, higher mortality risk, and a greater likelihood of falls.6,24,25 It also impedes rehabilitation progress, resulting in poorer quality of life and challenges in returning to work.17,25–27 Common risk factors for PSD include stroke severity, cognitive impairment, physical disability, and functional dependency.17,28,29 Patients with aphasia are at particularly high risk, with more severe aphasia correlating with more pronounced PSD symptoms.30,31 Additionally, a history of depression, psychiatric illness, and living alone further increase the likelihood of developing PSD.32

    This study aims to shed light on the current practice of stroke rehabilitation in Saudi Arabia and identify barriers that may hinder recovery—particularly post-stroke depression. Our objective is to track patients throughout their rehabilitation admission and at discharge to better understand how PSD evolves and impacts recovery.

    Although some studies in Saudi Arabia have reported on PSD, there is still a lack of data regarding its frequency and associated factors within rehabilitation settings. A deeper understanding of PSD and its predictors is crucial for designing individualized and effective interventions in neurorehabilitation. Furthermore, no prior study in the region has included a follow-up to examine changes in depression levels throughout the rehabilitation process. Therefore, this study investigated the prevalence of PSD and explored clinical factors linked to its occurrence. To our knowledge, this is the first study in Saudi Arabia—and the broader Middle East—to examine PSD and its associated factors within a neurorehabilitation context.

    Materials and Methods

    Study Design

    This predictive correlational feasibility study was conducted at the Neurorehabilitation Unit (NRU) of King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, between October 1, 2023, and October 31, 2024, focusing on stroke patients admitted to the NRU with pre and post assessments of rehabilitation outcomes.

    A non-probability convenience sampling method was used to recruit adult stroke survivors aged 18 to 80 years who met the inclusion criteria Figure 1

    Figure 1 Flowchart of the recruitment process in the Neurorehabilitation Unit.

    Eligibility Criteria

    Patients were excluded if they had severe cognitive impairment (defined as a Montreal Cognitive Assessment [MoCA] score of ≤10), recurrent stroke or dementia diagnosed before the stroke, surgically treatable lesions on CT scans (eg, brain tumors), other central nervous system (CNS) conditions causing depression (eg, Parkinson’s disease), severe aphasia, severe comorbidities (eg, end-stage renal disease), or a prior history of psychiatric disturbances. Clinical data were extracted from electronic health records using the BestCare health record system to ensure accuracy and reliability.

    Ethical considerations were prioritized, with data collection initiated after obtaining Institutional Review Board (IRB) approval from the King Abdullah International Medical Research Center (KAIMRC) (Reference Number: SP34R/055/05). Informed consent was secured from patients and their families, ensuring confidentiality, privacy, and adherence to ethical research standards.

    Outcome Measurement

    All participants were assessed for the following: 1) stroke severity at the time of admission using the National Institute of Health Stroke Scale (NIHSS),33,34 2) functional independence at admission and discharge using the Functional Independence Measure (FIM), focusing on items such as eating, grooming, bathing, toileting, and upper and lower body dressing,35 3) self-reported depression and anxiety using the Hospital Anxiety and Depression Scale (HADS) at both admission and discharge,36 and 4) emotional and physical well-being at discharge using the 36-item Short Form Health Survey (SF-36).37 Questions related to the physical well-being asked about activities such as claiming stairs, walking. While mental well-being asked questions regarding the person’s such as if they feel clam, cheerful.

    Both the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short Form Health Survey (SF-36) were administered using their validated Arabic versions. The Arabic-translated form of the HADS has been utilized in this study due to its validation across various medical settings.38,39 The HADS consists of an anxiety subscale (7 items, assessed on a 4-point Likert scale) and a depression subscale (7 items, assessed similarly). The Arabic version demonstrates strong internal consistency, with Cronbach’s alpha values ranging from 0.70 to 0.835. Scores for each subscale were calculated by summing the relevant items, with a maximum score of 21 for each subscale. A score of 0–7 is categorized as normal, 8–10 as mild, 11–14 as moderate, and 15–21 as severe for each subscale for depression and anxiety.40 Both the HADS and SF-36 initial assessment were administered in day 5 or 6 after admission, while the discharge assessments were completed after 20 days on average.

    Statistical Analysis

    Descriptive analyses were performed, presenting categorical variables as frequencies and percentages. A one-way ANOVA test was used to assess the association between depression levels, as measured using the HADS, and variables including age, length of stay, NIHSS, FIM, SF-36 physical health, and emotional health. Spearman’s rank correlation test was used to assess the correlation between emotional well-being and physical functioning with depression. The McNemar test was used to assess changes in HADS classifications between admission and discharge (pre–post assessment). Lastly, multivariable logistic regression was conducted to examine the association between HADS scores at discharge, adjusting for relevant covariates including age and NIHSS scores, with adjusted odd ratio (AORs) and 95% confidence intervals (CI). A p-value <0.05 was considered statistically significant. All the statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS V.25.0, SPSS Inc., Chicago, IL).

    Results

    Participants Demographics

    A total of 37 participants were included in the current study. The most common exclusion criteria were low cognitive ability and aphasia. The majority of participants were male (62.2%), and 83.8% had ischemic stroke. Most participants had comorbidities, including hypertension (75.7%) and diabetes (73.0%). The average age of participants was 59 years, with an average length of stay of 22 days in the NRU. Participant characteristics are presented in Table 1.

    Table 1 Participants Characteristics

    Initial and Discharge Hospital Anxiety and Depression Scale & Short Form Health Survey Correlation with Hospital Anxiety and Depression Scale

    There was a statistically significant difference between the initial and discharge scores of the HADS (- 1.54 ± 4.3 p=0.03). The mean difference in total scores decreased by 1.54 at discharge (Table 2). In Addition, a Spearman correlation was conducted between the HADS scores at discharge and emotional and physical Short Form Health Survey SF-36. There was a moderate significant correlation between the SF-36 emotion and HADS at discharge, with the increase of emotional well-being correlated to decrease of HADS scores (p= 0.03, CI: −0.76, −0.17). Moreover, a weak negative non-significant correlation was found between SF-36 physical and HADS scores at discharge (Table 3).

    Table 2 Initial and Discharge Hospital Anxiety and Depression Scale

    Table 3 Spearman Correlation Between SF-36 and Discharge Hospital Anxiety and Depression Scale Scores

    Rate and Severity Level of Hospital Anxiety and Depression Scale

    The rate of depression or anxiety was 59.5% at admission among all participants, which decreased to 40.5% at discharge, with seven participants reporting no issues by the end of the rehabilitation sessions. In addition, the severity of depression and anxiety varies initially and at discharge with lower rate of severity at discharge (53.5% mild and 33.3% moderate in compared to 45.5% mild and 45.5% moderate cases) (Supplementary Table 1). To test the significant change in the proportion of patients with each category initially and at discharge we used a paired chi-square test) (Table 4). There was a significant difference between the HADS initial, and discharge based on the present of depression and anxiety and the severity levels.

    Table 4 Initial and Discharge Hospital Anxiety and Depression Scale Based on the Severity Level

    Functional Independent Measure Scores

    Scores of the FIM initial assessment to discharge was statistically significant (p= 0.001), with an increase of 9.5 points between the initial and discharge scores (mean initial= 17.76, mean discharge= 27.32).

    Factors Associated with Initial and Discharge Hospital Anxiety and Depression Scale Scores

    The HADS scores at both initial assessment and discharge were grouped into categories: normal (no depression or anxiety), mild, moderate, and severe depression or anxiety. There was no association between the initial HADS scores and other variables (age, FIM, and initial NIHSS) (Table 5). However, the SF-36 emotional health score was significantly associated with HADS scores at discharge (p = 0.01) (Table 6).

    Table 5 Association Between Initial Hospital Anxiety and Depression Scale Scores and Variables

    Table 6 Association Between Discharge Hospital Anxiety and Depression Scale Scores and Variable

    Factors Influencing Discharge Hospital Anxiety and Depression Scale Scores

    A binary logistic regression was used to determine factors that may increase the likelihood of depression or anxiety based on the HADS discharge scores. Table 7 illustrates the variables, showing that SF-36 emotional health scores significantly increased the likelihood of depression or anxiety (OR = 0.93, CI = 0.89–0.98, p= 0.01).

    Table 7 Variables Influencing the Hospital Anxiety and Depression Scale

    Discussion

    This study explored the frequency and severity of depression and anxiety among stroke patients admitted to a neurorehabilitation unit, alongside factors associated with these mental health outcomes at discharge. Consistent with the previous literature, we observed a high prevalence of mood disorders at admission, with 59.5% of patients exhibiting symptoms of depression and/or anxiety.24,41 This aligns with previous research that identified stroke survivors as being at an elevated risk of mood disorders due to the physical and psychological burden of the condition.27,28 The previous literature showed that the prevalence of PSD varies widely, ranging between 20% and 65%, depending on the population studied, the assessment measures used, and the definitions of depression applied.9,41,42 However, significant improvements were observed in anxiety and depression levels, with a reduction in the admission to discharge rate in our findings. Initially, most participants reported mild to moderate symptoms, which shifted to predominantly mild symptoms by discharge. Furthermore, functional independence measure scores showed significant improvement during rehabilitation. While no associations were found between initial HADS scores and variables such as age or stroke severity, emotional health, as measured by the SF-36, was significantly correlated with HADS scores at discharge.

    Our findings are particularly consistent with studies conducted in the Saudi Arabia context, where high rates of PSD have been reported. For example, Abuadas et al42 reported that more than two-thirds (70.6%) of a sample of stroke survivor patients in Saudi Arabia experienced depression, and Alharbi et al43 reported comparable results. These findings underscore the significant psychological burden experienced by stroke survivors in the region and highlight the importance of culturally contextualized research and interventions.

    Rehabilitation was associated with a statistically significant reduction in depression and anxiety symptoms, with the rate dropping to 40.5% at discharge. Most participants moved from moderate to mild severity levels, suggesting that structured neurorehabilitation can effectively mitigate mood disturbances. Improvements in functional independence likely contributed to this positive trend, with an average gain of 9.5 points from admission to discharge.

    This is in line with the work of a recent study that involved 1,440 stroke survivors and demonstrated that moderate- or high-intensity physical activity correlates with lower levels of depressive symptoms in stroke survivors. This suggests that non-pharmacological approaches, particularly those emphasizing physical and social engagement, may therefore play a pivotal role in emotional recovery.44

    Interestingly, our study found no significant association between initial HADS scores and clinical factors such as age, NIHSS, or initial FIM scores. This enhancement in physical functionality likely contributes to the reduction in depression and anxiety symptoms, as greater independence can foster a sense of accomplishment and control, which are critical for mental well-being., However, emotional health, as assessed by the SF-36, emerged as a predictor of depression and anxiety outcomes at discharge. Binary logistic regression analysis confirmed that higher SF-36 emotional well-being scores were associated with a lower likelihood of depressive and anxious symptoms. However, this finding should not be a surprise, given that the SF-36 emotional items have some similarity with the HADS items, which can cause correlation between both outcomes.

    Multiple studies reported that the rehabilitation program helps alleviate depressive symptoms, with better functional outcomes leading to improvement in PSD.45,46 However, evidence has illustrated that the efficiency of functional recovery for stroke patients with PSD is poorer than for those without depression. This suggests that PSD has an impact on functional recovery.47,48 In addition, the severity of depression measure via HADS can contribute to the functional outcomes with better functional outcomes in patients with mild or low severity scores.49

    In terms of clinical implications, our results emphasize the need for routine screening and the management of depression and anxiety in stroke patients, particularly during admission and discharge from rehabilitation programs. Implementing targeted psychological interventions, such as cognitive-behavioral therapy (CBT) or stress management techniques, alongside physical rehabilitation, could further enhance patient outcomes. Moreover, the significant role of emotional health as a predictor of mood disturbances underscores the value of integrating psychosocial support into stroke care plans. Moreover, it is recommended to train rehabilitation staff on how to identify signs of depression and or anxiety as well as the impact on mental well-being on the client’s performance in rehabilitation sessions.

    This study has some strengths: it examined patients at an early rehabilitation stage, followed up with participants pre and post rehabilitation, and administrated self-reported assessments at two points in time.

    Limitation

    This study also has several limitations. The small sample size (n=37) limits the generalizability of its findings. The use of a non-probability convenience sampling method may have introduced selection bias. The study’s strict inclusion criteria contributed to the small sample size and excluded stroke patients who may have PSD. The correlation between SF-36 emotion and HADS scores can overlap; the similarity of the items in both assessments may limit the impact of the findings. Another limitation is the lack of consideration of participants past medical and mental health history, social support networks, medication use (including antidepressants), lesion location, or stroke laterality, all of which are known to influence the development and severity of post-stroke depression, which could have influenced the rate and severity of depression and anxiety. Furthermore, this study was conducted in a single tertiary rehabilitation center, which may have limited the generalizability of the findings across other healthcare settings, including rural or non-specialized facilities. Future research should include larger, more diverse samples and adopt longitudinal designs to better understand the temporal dynamics of mood disorders in stroke survivors.

    Past medical history can play an important part in the results, for example insomnia and the history of lack of sleep are linked to PDS. Evidence supports the link that pre-stroke insomnia may predict PSD.50,51 Moreover, patients with insomnia are more likely to have a more depression symptoms post stroke.52,53 Thus, future studies should explore the association between insomnia pre, post stroke and PSD in the Saudi population.

    Our results suggest the importance of screening stroke patients for depression and anxiety prior to rehabilitation to optimize stroke recovery in patients in Saudi Arabia. In addition, these results support enhancing the rehabilitation team’s awareness of depression and/or anxiety for early identification and potential referral to a specialist.

    Conclusion

    In conclusion, this study highlights the high prevalence of depression and anxiety among stroke patients upon admission and the significant improvements associated with inpatient rehabilitation. Emotional health emerged as a key factor influencing mental health outcomes, reinforcing the need for integrated, holistic approaches to stroke care. Routine screening, early intervention, and enhanced team awareness are recommended to optimize both emotional and functional recovery.

    Abbreviations

    PSD, Post-Stroke Depression; PSA, Post Stroke Anxiety; NRU, Neurorehabilitation Unit; NIHSS, National Institute of Health Stroke Scale; FIM, Functional Independence Measure; SF-36, 36-item Short Form Health Survey; HDAS, Hospital Anxiety and Depression Scale; CBT, Cognitive-Behavioral Therapy.

    Data Sharing Statement

    The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

    Ethical Approval and Consent to Participation

    All methods were performed in accordance with the ethical standards established in the Declaration of Helsinki and its subsequent amendments or comparable ethical standards. This study was approved with approval and consent of the Ethics Committee of King Abdullah International Medical Research Center (IRB approval number: SP34R/055/05). Informed consent was obtained from all participants before their involvement in the study, ensuring that they were fully aware of the study’s purpose, procedures, potential risks, and benefits. Informed consent was obtained from all subjects involved in the study.

    Acknowledgments

    The authors thank all the patients, physical therapists, and occupational therapists who contributed to the data collection.

    Funding

    This research received no external funding.

    Disclosure

    The authors report no conflicts of interest in this work.

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