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On the one hand, human behavior and its determinants can be seen in terms of a relatively simple “input-output” system. On the other hand, it is also possible to envisage a more complex interplay between behavior and its determinants unfolding at multiple environmental levels. A key premise of this chapter is that planned behavior change programs should target not only the individual but also the environmental influences on behavior at the interpersonal, organizational, community, and societal levels. Each environmental level encompasses physical, social, and cultural dimensions. Two key ecological assumptions help us to identify intervention targets for promoting behavior change. First, behavior influences, and is influenced by, multilevel environmental factors; second, individual behavior both shapes and is shaped by the environment. The socioecological approach and the accompanying range of theoretical approaches described in this chapter do justice to both perspectives. This approach enables researchers to apply insights from theoretical frameworks at the individual, interpersonal, organizational, community, and societal levels. The resulting multilevel interventions can target complex phenomena such as power differences, social networks, diffusion of innovations, organizational change, coalition building, and policy processes.
Conscription records are considered to be the best sources for studying heights over cohorts. This article discusses the various steps and selection mechanisms involved in the conscription system of the Netherlands, which was more or less similar to the systems found in other European countries. Starting with a birth cohort of 4,436 boys, we run a series of regressions on the likelihood to be registered at all and to have one’s height recorded. We discuss the effects of cohort attrition through mortality and migration, and explore familial, social, and religious reasons for evading registration and (medical) examination. We find various kinds of selections, but their effects on the distribution and averages of heights are limited. Thus, heights culled from conscripts records are indeed an excellent indicator of a cohort’s biological standard of living. However, researchers focusing on social variation in height need to be aware of the unequal opportunities to evade registration and measurement.
Apathy is common in Parkinson's disease (PD) but its underlying white matter (WM) architecture is not well understood. Moreover, how apathy affects cognitive functions in PD remains unclear. We investigated apathy-related WM network alterations and the impact of apathy on cognition in the context of PD.
Apathetic PD patients (aPD), non-apathetic PD patients (naPD), and matched healthy controls (HCs) underwent brain scans and clinical assessment. Graph-theoretical and network-based analyses were used for group comparisons of WM features derived from diffusion spectrum imaging (DSI). Path analysis was used to determine the direct and indirect effects of apathy and other correlates on different cognitive functions.
The aPD group was impaired on neural integration measured by global efficiency (p = 0.009) and characteristic path length (p = 0.04), executive function (p < 0.001), episodic memory (p < 0.001) and visuospatial ability (p = 0.02), and had reduced connectivity between the bilateral parietal lobes and between the putamen and temporal regions (p < 0.05). In PD, executive function was directly impacted by apathy and motor severity and indirectly influenced by depression; episodic memory was directly and indirectly impacted by apathy and depression, respectively; conversely, visuospatial ability was not related to any of these factors. Neural integration, though being marginally correlated with apathy, was not associated with cognition.
Our results suggest compromised neural integration and reduced structural connectivity in aPD. Apathy, depression, and motor severity showed distinct impacts on different cognitive functions with apathy being the most influential determinant of cognition in PD.
Treatment with psychotropic drugs is frequently associated with obesity, dislipidemia, hyperglycaemia and hypertension, resulting in the development of the metabolic syndrome which in turn is an important risk factor for cardiovascular disease and type 2 diabetes mellitus. The atypical antipsychotics clozapine and olanzapine have the most pronounced effect on metabolic parameters. Over the past years, several studies using the definitions of the so called Third Adult Treatment Panel (ATP-III) of the National Cholesterol Education Program, demonstrated a high prevalence of metabolic syndrome in schizophrenic patients treated with atypical antipsychotics.
The present study includes a total of 96 clozapine-treated inpatients. A total of 34 patients had to be excluded because of refusal tot participate (n=23) or not meeting the DSM-IV criteria for psychotic disorders (n=11). Finally, 62 patients (male: 46; female: 16; mean age: 49 ± 14.2 years; mean duration of clozapine treatment: 9.2 years; current dose: 331.5mg daily) were evaluated according to ATP-III criteria. Other parameters that were collected comprised co-medication, smoking status and alcohol use.
Metabolic syndrome was found in 60% of the patients and was associated with female gender. No association was found between metabolic syndrome and duration of clozapine treatment. Frequencies of the individual components were 92% for dyslipidemia, 43% for obesity, 36% for hypertension, 18% for impaired fasting glucose and 18% for diabetes mellitus type 2.
Metabolic syndrome is highly prevalent among patients with psychotic disorders who are treated with clozapine. Additional factors like unhealthy life stile, inactivity and co-medication, emerge as major treatment targets.
Cardiovascular disease is the most common cause of death in patients with severe mental illness (SMI). Patients are more likely to be overweight and to have hypertension, dyslipidemia, hyperglycemia and diabetes mellitus. Antipsychotic medication can induce or worsen these cardiovascular risk factors.
Accessibility to healthcare and adequate somatic treatment is limited in patients with SMI.
Prevalence of inadequate treatment for metabolic cardiovascular risk factors in patients treated with antipsychotic medication.
A health monitor was introduced as a screening instrument in a schizophrenia treatment and recovery program (so called F-ACT) at the outpatient departments. Assesment included physical and laboratory examination, demographics, DSM-IV diagnoses, remission-criteria, social functioning, use of medication and drugs.
Over a period of 18 months (2009–2010), 520 of the 600 patients included in the F-ACT were evaluated. Preliminary analysis shows that 452 patients met DSM-IV criteria of schizophrenia and other psychotic disorders. All patients were treated with at least one antipsychotic agent. Metabolic syndrome according to ATP-III was present in 50% of patients (60% abdominal obesity, 58% hypertension, 24% hyperglycemia, 52% high triglycerides, 49% low HDL-cholesterol). Rates of non-treatment ranged from 78% for hypertension, 85% for dyslipidemia and 48% for diabetes mellitus. Rates of inadequate treatment ranged from 69% for hypertension and 83% for dyslipidemia.
1. Metabolic cardiovascular risk factors are highly prevalent in patients treated with antipsychotics
2. Inadequate treatment of metabolic cardiovascular risk factors is common
3. There is a need to improve the cooperation between psychiatrists and general practitioners
The aim of this study is to evaluate the effectiveness of 12-week treatment with aripiprazole in a broad range of patients suffering from schizophrenia by using a variety of physicians, caregivers and patients scales.
Subjects and methods
A total of 361 in- or outpatients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for schizophrenia received open-label aripiprazole (10–30mg per day) in this 12-week, prospective, multicentre, uncontrolled study. The primary endpoint was the Clinical Global Impression-Improvement (CGI-I) scale which measured effectiveness of study medication, including efficacy, safety and tolerability. A variety of physician-, patient- and caregiver-rated parameters were measured to gain a complete view of the effectiveness of aripiprazole.
The effectiveness of aripiprazole treatment was demonstrated in a broad range of schizophrenia patients (CGI-I score of 3.0; 95% confidence interval: 2.8, 3.2: last observation carried forward [LOCF]) as the upper bound of the 95% CI was less than 4 (score of “no change”). Both patient and caregiver PGI-I scores (LOCF: 95% CI: 2.79, 3.09 and, 95% CI: 2.74, 3.17, respectively) corroborate this finding. Aripiprazole had a positive effect on disease severity by study end, as assessed by an increase of the (physician-rated) CGI-S scores, with 57.3% of patients having improved disease, one-third maintaining their condition (30.8%) and 11.3% with worsening symptoms (LOCF). The Investigator Assessment Questionnaire (IAQ) showed a great improvement (>50% of patients). Patients reported significantly improved quality of life and overall, 71% of patients and 67% of caregivers preferred aripiprazole to their previous antipsychotic medication (LOCF; P<0.0001 over time).
Aripiprazole was effective in a broad range of patients with schizophrenia.
Cognitive bias modification (CBM) interventions are strongly advocated in research and clinical practice.
We aimed to examine the efficiency of CBM for clinically relevant outcomes, along with study quality, publication bias and potential moderators.
We conducted two meta-analyses of randomized controlled trials of CBM interventions for clinically relevant outcomes, one for patients with mental health problems and one for all populations. We included randomized controlled trials of CBM interventions, which reported clinically relevant outcomes assessed with standardized instruments. We examined the quality of the trials, as well as possible publication bias and possible moderators.
We identified 49 trials and grouped outcomes into anxiety and depression. ESs were small considering all the samples, and mostly non-significant for patient samples. ESs became non-significant when outliers were excluded and after adjustment for publication bias. The quality of the RCTs was sub-optimal. Publication year was consistently negatively associated with ESs. More sessions were associated with smaller ES, as were the absence of participant compensation and, respectively, the non-exclusively laboratory based delivery of the intervention. The quality of the RCTs was not optimal and quality was negatively associated to outcomes for depression and general anxiety.
Our results indicate that CBM may have small effects on mental health problems, but it is also very well possible that there are no significant effects. Research in this field is hampered by small and low-quality research, and by risk of publication bias, and much of the positive outcomes is driven by extreme outliers.
Hyperthermia (i.e. heating of tumor tissue to 40–43°C) is used in clinical oncology to enhance the therapeutic effect of chemotherapy and radiotherapy. Many tumor sites are heated either by a single RF or MW antenna positioned on the tumor location, or by a phased array positioned around the patient. Superficial tumors are generally heated with MW antennas (434–2450 MHz) and deep-seated tumors with RF antennas (70–150 MHz). These devices cover the major, more common tumor sites, but more rare locations require more dedicated applicators. We discuss dedicated RF systems aiming for heating semi-deep-seated tumors in the leg, breast, and upper thorax. Clinical results show that adequate heating is possible with these systems, with achieved temperatures in the therapeutic range.
The taskforce appointed in 2016 to undertake a review of the legal sector in Kenya highlighted a decline in public service and pro bono work as one of the challenges facing the legal profession in the country. In its report, the taskforce made several proposals to tackle the problem, all directed at qualified lawyers. This article seeks to contribute to the deliberations anticipated from the findings of the taskforce, by suggesting instead that the problem of a declining public service ethic be addressed by targeting law students. Bringing students face to face with real clients and their needs can play an important role in broadening their horizons and shaping their beliefs about, and attitudes towards, the different possible careers they can pursue with their education. The article specifically recommends clinical legal education as a practical and comprehensive means by which students can be encouraged from early on to have an interest in pro bono and public service work.
B vitamins involved in one-carbon metabolism have been implicated in the development of inflammation- and angiogenesis-related chronic diseases, such as colorectal cancer (CRC). Yet, the role of one-carbon metabolism in inflammation and angiogenesis among CRC patients remains unclear. The objective of this study was to investigate associations of components of one-carbon metabolism with inflammation and angiogenesis biomarkers among newly diagnosed CRC patients (n 238) in the prospective ColoCare Study, Heidelberg. We cross-sectionally analysed associations between twelve B vitamins and one-carbon metabolites and ten inflammation and angiogenesis biomarkers from pre-surgery serum samples using multivariable linear regression models. We further explored associations among novel biomarkers in these pathways with Spearman partial correlation analyses. We hypothesised that pyridoxal-5’-phosphate (PLP) is inversely associated with inflammatory biomarkers. We observed that PLP was inversely associated with C-reactive protein (CRP) (r –0·33, Plinear < 0·0001), serum amyloid A (SAA) (r –0·23, Plinear = 0·003), IL-6 (r –0·39, Plinear < 0·0001), IL-8 (r –0·20, Plinear = 0·02) and TNFα (r –0·12, Plinear = 0·045). Similar findings were observed for 5-methyl-tetrahydrofolate and CRP (r –0·14), SAA (r –0·14) and TNFα (r –0·15) among CRC patients. Folate catabolite acetyl-para-aminobenzoylglutamic acid (pABG) was positively correlated with IL-6 (r 0·27, Plinear < 0·0001), and pABG was positively correlated with IL-8 (r 0·21, Plinear < 0·0001), indicating higher folate utilisation during inflammation. Our data support the hypothesis of inverse associations between PLP and inflammatory biomarkers among CRC patients. A better understanding of the role and inter-relation of PLP and other one-carbon metabolites with inflammatory processes among colorectal carcinogenesis and prognosis could identify targets for future dietary guidance for CRC patients.
Maternal and child health are intrinsically linked. With accumulating evidence over the past two decades supporting the developmental origins of health and diseases hypothesis, it is now widely recognised that nutrition in the first 1000 d sets the foundation for long-term health. Maternal diet before, during and after pregnancy can influence the developmental pathways of the fetus and lead to health consequences later in life. While maternal and infant mortality rates have declined significantly in the past two decades, the growing burden of obesity and chronic non-communicable diseases in women of reproductive age and children is on a rapid rise worldwide, in developed and developing countries. A key contributory factor is malnutrition, which is a consequence of consuming poor quality diets. Suboptimal macronutrient balance and micronutrient inadequacies can lead to undesirable maternal body composition and metabolism, in turn influencing the health of the mother and leading to longer-term metabolic and cognitive health consequences in the infant. The GUSTO (Growing Up in Singapore Towards healthy Outcomes) study, a mother–offspring multi-ethnic cohort study in Singapore, has contributed to this body of evidence over the past 10 years. This review will illustrate how nutritional epidemiological research through a birth cohort has illuminated the importance and urgency of maternal and child nutrition and health in a modern, industrialised setting. It underscores the importance of a number of critical nutrients during pregnancy, in combination with healthy dietary patterns and appropriate meal timing, for optimal maternal and child health.
Cultural intelligence (CQ) refers to an individual’s capability to function effectively in situations characterized by cultural diversity. Unlike many cultural competency models that are developed inductively, CQ offers a theoretically derived and comprehensive framework based on the theory of multiple loci of intelligence. CQ comprises four factors – metacognitive, cognitive, motivational, and behavioral CQ. Since our review in 2011, there has been much theoretical and methodological advancement. In this chapter, we provide a comprehensive and up-to-date review of research on CQ, with a focus on these recent developments. They include an expanded conceptualization of CQ with more granular subdimensions; a new performance-based measure of CQ to complement report-based assessments; and a broader nomological network at the individual, dyadic, team, and firm level of analyses. We conclude with ideas for future research, and suggest ways to leverage on emerging technologies to advance the conceptualization, measurement, and applications of CQ.
Blockchain technology has rapidly emerged as a decentralized trusted network to replace the traditional centralized intermediator. Especially, the smart contracts that are based on blockchain allow users to define the agreed behaviour among them, the execution of which will be enforced by the smart contracts. Based on this, we propose a decentralized booking system that uses the blockchain as the intermediator between hoteliers and travellers. The system enjoys the trustworthiness of blockchain, improves efficiency and reduces the cost of the traditional booking agencies. The design of the system has been formally modelled using the CSP# language and verified using the model checker Process Analysis Toolkit. We have implemented a prototype decentralized booking system based on the Ethereum ecosystem.
Pro-vitamin A carotenoids namely α-, β-carotene and β-cryptoxanthin have potential roles in neurocognitive development, but current literature on these carotenoids mainly focused on preventing cognitive decline in the elderly. This study examined the associations of maternal plasma pro-vitamin A carotenoids concentrations with offspring cognitive development up to 54 months in the GUSTO mother-offspring cohort study.
Materials and Methods
Maternal plasma pro-vitamin A carotenoids concentrations at delivery were determined by ultra-performance liquid chromatography. At age 24 months, the Bayley Scales of Infant and Toddler Development (BSID-III) was used to assess children's development for the following domains: cognitive, receptive and expressive language, and fine and gross motor. At age 54 months, the Kaufman Brief Intelligence Test (KBIT-2) was used to assess children's verbal and non-verbal intelligence. Associations of maternal pro-vitamin A carotenoids with offspring cognitive development at each time point were examined in 419 mother-offspring pairs using linear regressions adjusted for confounders (e.g. maternal demographics, antenatal mental health and breastfeeding duration).
Median (IQR) maternal plasma concentrations (mg/L) were: α-carotene 0.052 (0.032–0.081), β-carotene 0.189 (0.134–0.286), and β-cryptoxanthin 0.199 (0.123–0.304). In 24 months old infants, higher maternal β-cryptoxanthin (per SD increment) were associated with higher scores in most of BSID-III domains: cognitive [β 0.18, (0.08, 0.28) SD], receptive language [β 0.17 (0.07, 0.27) SD], fine motor [β 0.16 (0.06, 0.27) SD], and gross motor [β 0.16 (0.06, 0.27) SD]. Additionally, a 1-SD increment in maternal β-carotene concentrations were associated with 0.16 SD higher scores in BSID-III cognitive domain (95%: 0.04, 0.28), which was attenuated after adjusting for breastfeeding duration. No significant associations were observed between maternal α-carotene concentrations and BSID-III in children at 24 months of age, or between maternal pro-vitamin A carotenoids and KBIT-2 in children at 54 months of age.
Our study provides novel data suggesting a role of maternal pro-vitamin A carotenoids, especially β-cryptoxanthin, in offspring early cognitive development. This adds support to the importance of consuming sufficient amounts of red- and orange-coloured fruit and vegetables (rich sources of β-cryptoxanthin and β-carotene) during pregnancy. Further studies are required in other mother-offspring cohort with larger sample sizes, and intervention trials to confirm an effect of pro-vitamin A carotenoids on neurocognitive development.
Recent evidence suggests that synchronizing eating-fasting schedules with body's circadian rhythms or day-night cycles is important for metabolic health. Besides food quantity and quality, food timing may contribute to weight regulation. However, it is unclear if this factor during pregnancy can influence maternal weight retention after childbirth. Using data from a prospective cohort, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study, we examined the associations of maternal circadian eating pattern and diet quality in pregnancy with substantial postpartum weight retention (PPWR) at 18 months. We assessed 687 pregnant women for their circadian eating pattern (night-eating, night-fasting and eating episodes) and diet quality (Healthy Eating Index) based on information derived from 24-h dietary recall at 26–28 weeks’ gestation. Night-eating was defined as > 50% of total energy intake during 1900–0659 h; night-fasting duration was determined based on the longest fasting interval between consumption of a calorie-containing food or beverage during 1900–0659 h; eating episodes were defined as events that provided ≥ 210 kJ with time intervals between eating episodes of ≥ 15 min; diet quality was ascertained using the Healthy Eating Index which measures adherence to the Singapore dietary guidelines for pregnant women. PPWR was calculated by subtracting the weight at the first antenatal clinic visit from weight at 18-month postpartum. Substantial PPWR was defined as weight retention of 5 kg or more. Adjusting for maternal age, ethnicity, education, parity, night shift, mood, body mass index and total energy intake, multivariable binary logistic regression analysis was performed to estimate odds ratio (OR) of substantial PPWR in relation to circadian eating pattern and diet quality. Of 687 women, 110 (16%) had substantial PPWR. After confounders adjustment, night-eating (OR 1.95; 95% confidence interval 1.05, 3.62) and lower diet quality (1.91; 1.17, 3.10) were independently associated with higher odds of substantial PPWR. No associations with substantial PPWR were observed for night-fasting duration and number of eating episodes. During pregnancy, women with higher caloric consumption at night and lower diet quality had a greater likelihood of substantial PPWR. These findings suggest that aligning eating time with day-night cycles and adherence to dietary guidelines during pregnancy may help to alleviate overweight and obesity risk in postpartum life. There is a possibility that these eating patterns persist beyond pregnancy and pose implications for long-term obesity development. Further investigation on this area is required.
This study examined the quantity and quality of parental linguistic input to toddlers with moderate hearing loss (MHL) compared with toddlers with normal hearing (NH). The linguistic input to eighteen toddlers with MHL and twenty-four toddlers with NH was examined during a 10-minute free-play activity in their home environment. Results showed that toddlers with MHL were exposed to an equivalent amount of parental linguistic input compared to toddlers with NH. However, parents of toddlers with MHL used less high-level facilitative language techniques, used less mental state language, and used shorter utterances than parents of toddlers with NH. Quantity and quality measures of parental linguistic input were positively related to the expressive language abilities of toddlers with MHL.
Consumption of sugar-sweetened beverages (SSB) by infants and young children are less explored in Asian populations. The Growing Up in Singapore Towards healthy Outcomes cohort study examined associations between SSB intake at 18 months and 5 years of age, with adiposity measures at 6 years of age. We studied Singaporean infants/children with SSB intake assessed by FFQ at 18 months of age (n 555) and 5 years of age (n 767). The median for SSB intakes is 28 (interquartile range 5·5–98) ml at 18 months of age and 111 (interquartile range 57–198) ml at 5 years of age. Association between SSB intake (100 ml/d increments and tertile categories) and adiposity measures (BMI standard deviation scores (sd units), sum of skinfolds (SSF)) and overweight/obesity status were examined using multivariable linear and Poisson regression models, respectively. After adjusting for confounders and additionally for energy intake, SSB intake at age 18 months were not significantly associated with later adiposity measures and overweight/obesity outcomes. In contrast, at age 5 years, SSB intake when modelled as 100 ml/d increments were associated with higher BMI by 0·09 (95 % CI 0·02, 0·16) sd units, higher SSF thickness by 0·68 (95 % CI 0·06, 1·44) mm and increased risk of overweight/obesity by 1·2 (95 % CI 1·07, 1·23) times at age 6 years. Trends were consistent with SSB intake modelled as categorical tertiles. In summary, SSB intake in young childhood is associated with higher risks of adiposity and overweight/obesity. Public health policies working to reduce SSB consumption need to focus on prevention programmes targeted at young children.