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This study determined the gluten content of foods and meals consumed by coeliac disease (CD) patients who adhere to a gluten-free diet, and to estimate the total daily intake of gluten of these patients. CD patients fulfilling defined inclusion criteria were preselected and approached for participation in the study. Duplicate portions (DP) of foods and mixed dishes were collected from the CD patients for evaluating complete daily food intake during two individual days. Also, for these days, written food records were completed by the participants. From each DP, a laboratory sample was prepared and analysed for its gluten concentration and total daily gluten intake was calculated. Each individual’s total daily intakes of energy and macronutrients were calculated using the Dutch food composition database. In total, twenty-seven CD patients participated, seven males and twenty females, aged between 21 and 64 years. In thirty-two (6 %) of 499 food samples collected in total, more than 3 mg/kg gluten was present. In four of these thirty-two samples, the gluten concentration was above the European legal limit of 20 mg/kg and three of the four samples had a gluten-free label. The maximal gluten intake was 3·3 mg gluten/d. The gluten tolerance for sensitive CD patients (>0·75 mg/d) was exceeded on at least six out of fifty-four study days. To also protect these sensitive CD patients, legal thresholds should be re-evaluated and the detection limit of analytical methods for gluten analysis lowered.
This paper aimed to: retrospectively analyse single-centre results in terms of surgical success, respiratory outcomes and adverse events after short-term follow up in obstructive sleep apnoea patients treated with upper airway stimulation; and evaluate the correlation between pre-operative drug-induced sleep endoscopy findings and surgical success.
A retrospective descriptive cohort study was conducted, including a consecutive series of obstructive sleep apnoea patients undergoing implantation of an upper airway stimulation system.
Forty-four patients were included. The total median Apnoea–Hypopnea Index and oxygen desaturation index significantly decreased from 37.6 to 8.3 events per hour (p < 0.001) and from 37.1 to 15.9 events per hour (p < 0.001), respectively. The surgical success rate was 88.6 per cent, and did not significantly differ between patients with or without complete collapse at the retropalatal level (p = 0.784). The most common therapy-related adverse event reported was (temporary) stimulation-related discomfort.
Upper airway stimulation is an effective and safe treatment in obstructive sleep apnoea patients with continuous positive airway pressure intolerance or failure. There was no significant difference in surgical outcome between patients with tongue base collapse with or without complete anteroposterior collapse at the level of the palate.
Research concerning the psychometric properties of the WHO Quality of Life Assessment Instrument (WHOQOL-100) in general populations of psychiatric outpatients has not been performed systematically.
To examine the content validity, construct validity, and reliability of the WHOQOL-100 in a general population of Dutch adult psychiatric outpatients.
A total of 533 psychiatric outpatients entered the study (438 randomly selected, 85 internally referred). Participants completed self-administered questionnaires for measuring quality of life (WHOQOL-100), psychopathological symptoms (SCL-90), and perceived social support (PSSS). In addition, they underwent two semi-structured interviews in order to obtain Axis-I and Axis-II diagnoses, according to DSM-IV.
The drop-out percentage was low (7.1%). Of the 24 facets of the WHOQOL-100, 22 had a good distribution of scores, leaving out the facets physical environment and transport. Exploratory factor analysis revealed a four-factor structure, which was similar to earlier findings in patients with specific somatic diseases and depressive disorders. Various—a priori expected—positive and negative correlations were found between facets and domains of the WHOQOL-100, and dimensions of the SCL-90 and the PSSS-score, indicating good construct validity of the WHOQOL-100. The internal consistency of all facets and the four domains of the WHOQOL-100 was good (Cronbach’s alpha’s ranging from 0.62 to 0.93 and 0.64 to 0.84, respectively). Sparse and relatively low correlations were found between demographic characteristics (age and sex) and WHOQOL-100 scores.
Content validity, construct validity, and reliability of the WHOQOL-100 in a population of adult Dutch psychiatric outpatients are good. The WHOQOL-100 appears to be a suitable instrument for measuring quality of life in adult psychiatric outpatients.
Microglia express the TSPO (TranSlocalor PrOtein) receptor formerly known as the PBR (peripheral benzodiazepine receptor). The densitiy of the TSPO is dependent on the inflammatory state of microglia. The radiopharmaceutical [11C]PK11195 binds in excess to the TSPO in activated microglia. We showed that the hippocampus of psychotic patients experienced significantly more [11C]PK11195 binding than the hippocampus of healthy controls. To elucidate the effect of antipsychotic medication on brain inflammation the herpes encephalitis rat model was chosen, because of pathophysiological similarity: Herpes simplex virus preferentially infects hippocampus. In adult rats 10E5 pfu of HSV-1 (clinical strain) was administered intranasally. After 3–5 days sickness behavior developed. At the 6th day and at the 13th day after inoculation a [11C]PK11195 PET scan was performed. Drugs were delivered by osmotic minipumps (haloperidol, clozapine, saline). Only clozapine treatment delayed sickness behavior. Clozapine treatment reduced the inflammation in the mesecephalon and immediate surrounding regions after 6 days and reduced dissemination of inflammation to brain cortex at 13 days after inoculation.
In a herpes infection model clozapine exerts potent antiinflammatory effects on microglia. The hippocampus might be the link between infectious pathology and inflammation in schizophrenia patients.
Intermittent explosive disorder (IED) is characterised by impulsive anger attacks that vary greatly across individuals in severity and consequence. Understanding IED subtypes has been limited by lack of large, general population datasets including assessment of IED. Using the 17-country World Mental Health surveys dataset, this study examined whether behavioural subtypes of IED are associated with differing patterns of comorbidity, suicidality and functional impairment.
IED was assessed using the Composite International Diagnostic Interview in the World Mental Health surveys (n = 45 266). Five behavioural subtypes were created based on type of anger attack. Logistic regression assessed association of these subtypes with lifetime comorbidity, lifetime suicidality and 12-month functional impairment.
The lifetime prevalence of IED in all countries was 0.8% (s.e.: 0.0). The two subtypes involving anger attacks that harmed people (‘hurt people only’ and ‘destroy property and hurt people’), collectively comprising 73% of those with IED, were characterised by high rates of externalising comorbid disorders. The remaining three subtypes involving anger attacks that destroyed property only, destroyed property and threatened people, and threatened people only, were characterised by higher rates of internalising than externalising comorbid disorders. Suicidal behaviour did not vary across the five behavioural subtypes but was higher among those with (v. those without) comorbid disorders, and among those who perpetrated more violent assaults.
The most common IED behavioural subtypes in these general population samples are associated with high rates of externalising disorders. This contrasts with the findings from clinical studies of IED, which observe a preponderance of internalising disorder comorbidity. This disparity in findings across population and clinical studies, together with the marked heterogeneity that characterises the diagnostic entity of IED, suggests that it is a disorder that requires much greater research.
Epidemiological studies indicate that individuals with one type of mental disorder have an increased risk of subsequently developing other types of mental disorders. This study aimed to undertake a comprehensive analysis of pair-wise lifetime comorbidity across a range of common mental disorders based on a diverse range of population-based surveys.
The WHO World Mental Health (WMH) surveys assessed 145 990 adult respondents from 27 countries. Based on retrospectively-reported age-of-onset for 24 DSM-IV mental disorders, associations were examined between all 548 logically possible temporally-ordered disorder pairs. Overall and time-dependent hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Absolute risks were estimated using the product-limit method. Estimates were generated separately for men and women.
Each prior lifetime mental disorder was associated with an increased risk of subsequent first onset of each other disorder. The median HR was 12.1 (mean = 14.4; range 5.2–110.8, interquartile range = 6.0–19.4). The HRs were most prominent between closely-related mental disorder types and in the first 1–2 years after the onset of the prior disorder. Although HRs declined with time since prior disorder, significantly elevated risk of subsequent comorbidity persisted for at least 15 years. Appreciable absolute risks of secondary disorders were found over time for many pairs.
Survey data from a range of sites confirms that comorbidity between mental disorders is common. Understanding the risks of temporally secondary disorders may help design practical programs for primary prevention of secondary disorders.
Current feed evaluation systems often assume that fermented starch (i.e. resistant starch (RS)) yields less energy than digested starch. However, growth rates of pigs fed low and high RS diets are often the same when feed is available ad libitum. This may be explained by its effect on digestive processes changing feeding behavior, and consequently energy utilization. This study aims to investigate the effect of RS on nutrient digestion and digesta passage rate in pigs, in combination with its effect on feeding behavior and growth performance under ad libitum conditions. In experiment 1, 20 male pigs (40 ± 2.82 kg) were fed diets containing either 50% waxy maize starch (low in RS (LRS)) or high-amylose maize starch (high in RS (HRS)), and soluble and insoluble indigestible markers. After 14 days of adaptation to the diets, pigs were fed hourly to reach steady state (6 h), dissected, and digesta were collected from eight segments. From the collected samples, nutrient digestion and passage rate of the solid and liquid digesta fraction were determined. In experiment 2, 288 pigs (80 ± 0.48 kg; sex ratio per pen 1 : 1; boar : gilt) were housed in groups of 6. Pigs were ad libitum-fed one of the experimental diets, and slaughtered at approximately 115 kg. Feed intake, growth and carcass parameters were measured. Ileal starch digestibility was greater for LRS-fed than for HRS-fed pigs (98.0% v. 74.0%; P < 0.001), where the additional undigested starch in HRS-fed pigs was fermented in the large intestine. No effects of RS on digesta passage rate of the solid or liquid digesta fraction and on feeding behavior were observed. Growth rate and feed intake did not differ between diets, whereas feed efficiency of HRS-fed pigs was 1%-unit higher than that of LRS-fed pigs (P = 0.041). The efficiency of feed used for carcass gain did not differ between diets indicating that the difference in feed efficiency was determined by the non-carcass fraction. Despite a 30% greater RS intake (of total starch) with HRS than with LRS, carcass gain and feed efficiency used for carcass gain were unaffected. RS did not affect digesta passage rate nor feeding behavior suggesting that the difference in energy intake between fermented and digested starch is compensated for post-absorptively. Our results indicate that the net energy value of fermented starch currently used in pig feed evaluation systems is underestimated and should be reconsidered.
Antidepressant medications (ADMs) are widely used and long-term use is increasing. Given this extensive use and recommendation of ADMs in guidelines, one would expect ADMs to be universally considered effective. Surprisingly, that is not the case; fierce debate on their benefits and harms continues. This editorial seeks to understand why the controversy continues and how consensus can be achieved.
‘Position’ paper. Critical analysis and synthesis of relevant literature.
Advocates point at ADMs impressive effect size (number needed to treat, NNT = 6–8) in acute phase treatment and continuation/maintenance ADM treatment prevention relapse/recurrence in acute phase ADM responders (NNT = 3–4). Critics point at the limited clinically significant surplus value of ADMs relative to placebo and argue that effectiveness is overstated. We identified multiple factors that fuel the controversy: certainty of evidence is low to moderate; modest efficacy on top of strong placebo effects allows critics to focus on small net efficacy and advocates on large gross efficacy; ADM withdrawal symptoms masquerade as relapse/recurrence; lack of association between ADM treatment and long-term outcome in observational databases. Similar problems affect psychological treatments as well, but less so. We recommend four approaches to resolve the controversy: (1) placebo-controlled trials with relevant long-term outcome assessments, (2) inventive analyses of observational databases, (3) patient cohort studies including effect moderators to improve personalized treatment, and (4) psychological treatments as universal first-line treatment step.
Given the public health significance of depression and increased long-term ADM usage, new approaches are needed to resolve the controversy.
Misalignment of day/night and feeding rhythms has been shown to increase fat deposition and the risk for metabolic disorders in humans and rodents. In most studies, however, food intake and intake patterns are not controlled. We studied the effects of circadian misalignment on energy expenditure in pigs while controlling for food intake as well as intake patterns. Twelve groups of five male pigs were housed in respiration chambers and fed either during the day (10.00–18.00 hours; DF) or night (22.00–06.00 hours; NF), bihourly the same sequential meals, representing 15, 10, 25, 30 and 20 % of the daily allowance. Paired feeding was applied to ensure equal gross energy intake between treatments. Apparent total tract digestibility, energy balances and heat partitioning were measured and analysed using a mixed linear model. Apparent total tract energy and DM digestibility tended to be lower for NF-pigs than DF-pigs (P < 0·10). Heat production was 3 % lower for NF-pigs than DF-pigs (P < 0·026), increasing fat retention by 7 % in NF-pigs (P = 0·050). NF-pigs were less active than DF-pigs during the feeding period, but more active during the fasting period. RMR was greater for DF-pigs than NF-pigs during the fasting period. Methane production was 30 % greater in NF-pigs than DF-pigs (P < 0·001). In conclusion, circadian misalignment has little effect on nutrient digestion, but alters nutrient partitioning, ultimately increasing fat deposition. The causality of the association between circadian misalignment and methane production rates remains to be investigated.
Physicochemical properties of diets are believed to play a major role in the regulation of digesta transit in the gastrointestinal tract. Starch, being the dominant nutrient in pig diets, strongly influences these properties. We studied transport of digesta solids and liquids through the upper gastrointestinal tract of ninety pigs in a 3 × 3 factorial arrangement. Dietary treatments varied in starch source (barley, maize and high-amylose maize) and form (isolated starch, ground cereal and extruded cereal). Mean retention times (MRT) of digesta solids ranged 129–225 min for the stomach and 86–124 min for the small intestine (SI). The MRT of solids consistently exceeded that of liquids in the stomach, but not in the SI. Solid digesta of pigs fed extruded cereals remained 29–75 min shorter in the stomach compared with pigs fed ground cereals (P < 0·001). Shear stress of whole digesta positively correlated with solid digesta MRT in the stomach (r 0·33, P < 0·001), but not in the SI. The saturation ratio (SR), the actual amount of water in stomach digesta as a fraction of the theoretical maximum held by the digesta matrix, explained more variation in digesta MRT than shear stress. The predictability of SR was hampered by the accumulation of large particles in the stomach. In addition, the water-holding capacity of gelatinised starch leads to a decreased SR of diets, but not of stomach digesta, which was caused by gastric hydrolysis of starch. Both of these phenomena hinder the predictability of gastric retention times based on feed properties.
Rheological properties of digesta play a role in digesta passage kinetics through the gastrointestinal tract, in turn affecting nutrient absorption kinetics. Therefore, we studied the effects of diet viscosity on digesta passage and physicochemical properties in pigs. Twenty male growing pigs (35 kg body weight at the start) were assigned to one of five diets with increasing dietary concentrations of β-glucans (BG; from 0 % to 10 %), in exchange for maize starch. After a 17-day adaptation period, pigs were euthanised and the mean retention time (MRT) of digesta solids (TiO2) and liquids (Cr-EDTA) in the stomach, and proximal and distal half of the small intestine was quantified. In the stomach, the MRT of liquids, but not of solids, increased when dietary BG level increased (6 min per % dietary BG, P = 0.008 and R2 = 0.35). Concomitantly, stomach DM content (5 g/kg per % dietary BG, P < 0.001 and R2 = 0.53) and apparent digesta viscosity (56 Pa × s at 1/s shear rate per % dietary BG, P = 0.003 and R2 = 0.41) decreased. In the proximal half of the small intestine, no effects of dietary BG level were observed. In the distal half of the small intestine, water-binding capacity (WBC) of digesta increased (0.11 g/g digesta DM per % dietary BG, P = 0.028 and R2 = 0.24) and starch digestibility decreased (0.3% per % dietary BG, P = 0.034 and R2 = 0.23) when dietary BG level increased. In the colon, apparent digesta viscosity at 45/s shear rate increased (0.1 Pa × s per % dietary BG, P = 0.03 and R2 = 0.24) in the proximal half of the colon, and digesta WBC increased (0.06 g/g digesta DM per % dietary BG, P = 0.024 and R2 = 0.26) in the distal half of the colon when dietary BG level increased. To conclude, increasing dietary BG level caused the MRT of liquids, but not that of solids, to increase in the stomach, resulting in reduced separation of the solid and liquid digesta fractions. This caused dilution of the stomach content and reduction in digesta viscosity when dietary BG levels increased. Effects of dietary BG level on physicochemical properties in the proximal small intestine were absent and may have been due to a low DM content. The WBC of digesta in the distal small intestine and colon increased when dietary BG level increased, as did apparent digesta viscosity in the proximal colon. This likely reflects the concentration of BG in digesta when moving through the gastrointestinal tract.
Although anorectal Chlamydia trachomatis (CT) infections are frequently diagnosed in men who have sex with men (MSM) and women, the reason for this infection often remains unexplained, as anal sex is not always reported. Oropharyngeal infections inoculating the gastrointestinal (GI) tract may contribute to anorectal-CT infections, as evidence in animals suggests that chlamydia bacteria undergo GI passage; however, no evidence exists in humans. Longitudinal patient clinic-registry data from MSM (n = 17 125) and women (n = 4120) from two Dutch sexually transmitted infection clinics were analysed. When adjusting for confounding socio-demographics, co-infections and risk behaviour, previous (from 3 weeks up to 24 months) oropharyngeal CT was not a risk factor for subsequent anorectal CT in women (odds ratio (OR) 0.46; 95% confidence interval (CI) 0.18–1.18; P = 0.11) and MSM (OR 1.33; 95% CI 0.86–2.07; P = 0.204). Despite the large dataset, the numbers did not allow for the estimation of risk in specific subgroups of interest. The role of the GI tract cannot be excluded with this epidemiological study, but the impact of preceding oropharyngeal CT on anorectal-CT infection is likely limited.
With increasing numbers of children growing up with conditions that are associated with acquired brain injury, efficient neuropsychological screening for cognitive deficits is pivotal. Brief self-report measures concerning daily complaints can play an important role in such screening. We translated and adapted the pediatric perceived cognitive functioning (PedsPCF) self- and parent-report item bank to Dutch. This study presents (1) psychometric properties, (2) a new short form, and (3) normative data for the short form.
A general population sample of children and parents was recruited. Dimensionality of the PedsPCF was assessed using confirmatory factor analyses and exploratory bifactor analyses. Item response theory (IRT) modeling was used to evaluate model fit of the PedsPCF, to identify differential item functioning (DIF), and to select items for the short form. To select short-form items, we also considered the neuropsychological content of items.
In 1441 families, a parent and/or child participated (response rate 66% at family level). Assessed psychometric properties were satisfactory and the predominantly unidimensional factor structure of the PedsPCF allowed for IRT modeling using the graded response model. One item showed meaningful DIF. For the short form, 10 items were selected.
In this first study of the PedsPCF outside the United States, studied psychometric properties of the translated PedsPCF were satisfactory, and allowed for IRT modeling. Based on the IRT analyses and the content of items, we proposed a new 10-item short form. Further research should determine the relation of PedsPCF outcomes with neurocognitive measures and its ability to facilitate neuropsychological screening in clinical practice.
This study aimed to examine in vivo starch digestion kinetics and to unravel the mechanisms of starch hydrolysing enzymes. Ninety pigs (23 (sd 2·1) kg body weight) were assigned to one of nine treatments in a 3×3 factorial arrangement, with starch source (barley, maize, high-amylose (HA) maize) and form (isolated, within cereal matrix, extruded) as factors. We determined starch digestion coefficients (DC), starch breakdown products and digesta retention times in four small-intestinal segments (SI1–4). Starch digestion in SI2 of pigs fed barley and maize, exceeded starch digestion of pigs fed HA maize by 0·20–0·33 DC units (P<0·01). In SI3–4, barley starch were completely digested, whereas the cereal matrix of maize hampered digestion and generated 16 % resistant starch in the small intestine (P<0·001). Extrusion increased the DC of maize and HA maize starch throughout the small intestine but not that of barley (P<0·05). Up to 25 % of starch residuals in the proximal small intestine of pigs was present as glucose and soluble α(1–4) maltodextrins. The high abundance of glucose, maltose and maltotriose in the proximal small intestine indicates activity of brush-border enzymes in the intestinal lumen, which is exceeded by α-amylase activity. Furthermore, we found that in vivo starch digestion exceeded our in vitro predictions for rapidly digested starch, which indicates that the role of the stomach on starch digestion is currently underestimated. Consequently, in vivo glucose release of slowly digestible starch is less gradual than expected, which challenges the prediction quality of the in vitro assay.
The passage rate of solids and liquids through the gastrointestinal tract differs. Increased dietary nutrient solubility causes nutrients to shift from the solid to the liquid digesta fraction and potentially affect digesta passage kinetics. We quantified: (1) the effect of three levels of dietary nutrient solubility (8, 19 and 31 % of soluble protein and sucrose in the diet) at high feed intake level (S) and (2) the effect of low v. high feed intake level (F), on digesta passage kinetics in forty male growing pigs. The mean retention time (MRT) of solids and liquids in the stomach and small intestine was assessed using TiO2 and Cr-EDTA, respectively. In addition, physicochemical properties of digesta were evaluated. Overall, solids were retained longer than liquids in the stomach (2·0 h, P<0·0001) and stomach+small intestine (1·6 h, P<0·001). When S increased, MRT in stomach decreased by 1·3 h for solids (P=0·01) and 0·7 h for liquids (P=0·002) but only at the highest level of S. When F increased using low-soluble nutrients, MRT in stomach increased by 0·8 h for solids (P=0·041) and 0·7 h for liquids (P=0·0001). Dietary treatments did not affect water-binding capacity and viscosity of digesta. In the stomach of growing pigs, dietary nutrient solubility affects digesta MRT in a non-linear manner, while feed intake level increases digesta MRT depending on dietary nutrient solubility. Results can be used to improve predictions on the kinetics of nutrient passage and thereby of nutrient digestion and absorption in the gastrointestinal tract.
Differential tree seedling recruitment across forest-savanna ecotones is poorly understood, but hypothesized to be influenced by vegetation cover and associated factors. In a 3-y-long field transplant experiment in the forest-savanna ecotone of Ghana, we assessed performance and root allocation of 864 seedlings for two forest (Khaya ivorensis and Terminalia superba) and two savanna (Khaya senegalensis and Terminalia macroptera) species in savanna woodland, closed-woodland and forest. Herbaceous vegetation biomass was significantly higher in savanna woodland (1.0 ± 0.4 kg m−2 vs 0.2 ± 0.1 kg m−2 in forest) and hence expected fire intensities, while some soil properties were improved in forest. Regardless, seedling survival declined significantly in the first-year dry-season for all species with huge declines for the forest species (50% vs 6% for Khaya and 16% vs 2% for Terminalia) by year 2. After 3 y, only savanna species survived in savanna woodland. However, best performance for savanna Khaya was in forest, but in savanna woodland for savanna Terminalia which also had the highest biomass fraction (0.8 ± 0.1 g g−1 vs 0.6 ± 0.1 g g−1 and 0.4 ± 0.1 g g−1) and starch concentration (27% ± 10% vs 15% ± 7% and 10% ± 4%) in roots relative to savanna and forest Khaya respectively. Our results demonstrate that tree cover variation has species-specific effects on tree seedling recruitment which is related to root storage functions.
Studies investigating the underlying mechanisms of hallucinations in patients with schizophrenia suggest that an imbalance in top-down expectations v. bottom-up processing underlies these errors in perception. This study evaluates this hypothesis by testing if individuals drawn from the general population who have had auditory hallucinations (AH) have more misperceptions in auditory language perception than those who have never hallucinated.
We used an online survey to determine the presence of hallucinations. Participants filled out the Questionnaire for Psychotic Experiences and participated in an auditory verbal recognition task to assess both correct perceptions (hits) and misperceptions (false alarms). A hearing test was performed to screen for hearing problems.
A total of 5115 individuals from the general Dutch population participated in this study. Participants who reported AH in the week preceding the test had a higher false alarm rate in their auditory perception compared with those without such (recent) experiences. The more recent the AH were experienced, the more mistakes participants made. While the presence of verbal AH (AVH) was predictive for false alarm rate in auditory language perception, the presence of non-verbal or visual hallucinations were not.
The presence of AVH predicted false alarm rate in auditory language perception, whereas the presence of non-verbal auditory or visual hallucinations was not, suggesting that enhanced top-down processing does not transfer across modalities. More false alarms were observed in participants who reported more recent AVHs. This is in line with models of enhanced influence of top-down expectations in persons who hallucinate.
The UN Sustainable Development Goals (SDGs) and targets are an important achievement. They largely reflect the worldview of Modernity, with its emphasis on scientific and planning rationality and emancipatory ideals. This worldview is no longer evident and dominant, and it is time to systematically explore complementing worldviews. Explicit use of worldviews, as sets of values and beliefs, and ethics enriches the interpretation and implementation of the SDGs. This facilitates the engagement of citizens in their real-world diversity and the development of respect for and empathy and cooperation with people holding other values, beliefs and morals. Dialogue around ‘the middle road’ can give guidance to just, fair and sustainable development pathways.
One of the Sustainable Development Goals, number 10, is about reducing inequality within and between countries. This paper argues that the existing structure of the (international) financial system is, for various reasons, one of the determinants of (growing) inequality. This should receive more attention.