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Objectives: Central-line–associated bloodstream infection (CLABSI) has been the leading cause of healthcare-associated infections (HAIs) in the intensive care unit (ICU) setting. Previous studies have shown that a care bundle is effective in reducing CLABSI rates; however, the data on long-term sustainability and cost savings of bundled care are limited. Methods: From January 2011 to December 2020, a prospective surveillance was performed to monitor CLABSI at a university hospital in northern Taiwan. To reduce the CLABSI rate, a hospital-wide bundled care program for CLABSI prevention was implemented in 2013. We evaluated the long-term effect of the care bundle on CLABSI incidence and length of stay in the ICU. Results: During the study period, the overall CLABSI incidence decreased from 8.22 per 1,000 catheter days before the care bundle was implemented to 6.33 per 1,000 catheter days in 2020 (P for trend <.01). The most common pathogens causing CLABSI were gut organisms (1,420 of 2,363, 60.1%), followed by environmental organisms (734 of 2,363, 31.1%) and skin organisms (177 of 2,363, 7.5%). The decreasing trend was statistically significant in the incidence of CLABSI caused by skin organisms (P for trend < .01), but not in the incidence of CLABSI caused by environmental organisms (P for trend = .86) or gut organisms (P for trend = .06). In the multivariable analysis, implementation of this care bundle was independently associated with a decrease in the CLABSI rate (RR, 0.77; 95% CI, 0.66–0.88). Compared with patients without CLABSI, patients with CLABSI had a longer average ICU length of stay (27 vs 17 days). Conclusions: A sustainable reduction in the incidence of CLABSI caused by common commensals could be achieved through a cost-saving bundled care program.
In vitro rearing of honey bee larvae is ideal for bioassay studies; no honey bee stable cell lines are available. Inconsistency of internal development staging of reared larvae and a susceptibility to contamination are common problems encountered. Standardized protocols on rearing larvae in vitro to make the larvae growth and development more similar to that of natural colonies are necessary to ensure the accuracy of experimental results and promote honey bee research as a model organism. Here, we concluded that when larval fasting weight was >160 mg, the time point of gut emptying can be defined as the critical point separating the larval and prepupal stages. In this way, we can conduct precise studies on the prepupal stage, such as organ remodeling during metamorphosis. Simultaneously, we further verified that recombinant AccApidaecin in genetic engineered bacteria added to the larval diet upregulated antibacterial peptide gene expression, and did not stimulate the stress response in larvae, nor did it affect the pupation rate or eclosion rate. This demonstrated that feeding recombinant AccApidaecin can enhance the individual antibacterial ability at the molecular level.
While burgeoning research on China's state–society relations has paid attention to the Party, little is known about how the Party interacts with diverse actors and involves itself at the grassroots level in a specific region. This article delineates Party-advancement strategies at the community level in Shenzhen since 2013. To reclaim its leading role at the grassroots level, the Party opted for “Party–government disaggregation” by framing community governance as a Party-building affair, separating the government's affairs from those of the Party and “kicking” the government out of the community. Under the rubric of “reshaping Party–mass relations,” the Party penetrated deep into the community by innovating a “centre-periphery” organizational system, absorbing community elites in a top-down way and using a “service delivery taking the lead” method in a reciprocal exchange. In the end, the Party-governance structure, in which Party–mass relations are at the core, was reframed in the communities.
Dormancy-breaking requirements and level of morphophysiological dormancy (MPD) were determined for seeds of Ilex formosana and I. uraiensis from the subtropical region, and seeds of I. rotunda from both the subtropical and tropical regions of Taiwan. We hypothesized that some Ilex species would have deep simple MPD broken by warm stratification. Germination of seeds and embryo growth was monitored at 30/20, 25/15, 20/10, 15/5°C and at 25°C. Seeds were cold-stratified and then incubated at 25/15°C, and seeds treated with GA3 and GA4 were incubated at 25/15°C. Fresh seeds reached 50% germination after 11–45 weeks of warm stratification. Pre-treatment with GA increased germination percentages of I. formosana and I. rotunda (tropical) but not I. uraiensis and I. rotunda (subtropical), while cold stratification did not promote germination of either species but increased the germination rate of I. rotunda (tropical). Embryo length in seeds of all species increased ≥710% prior to root emergence, and growth occurred during warm stratification. The positive response to GA and relatively short time for beginning of germination and to reach 50% germination indicate non-deep simple MPD in seeds of I. formosana and I. rotunda (tropical). The negative response to GA and long time for beginning of germination and to reach 50% germination indicate deep simple MPD in seeds of I. uraiensis and I. rotunda (subtropical). Thus, in both the subtropical and tropical regions of Taiwan, the seeds of Ilex species have non-deep simple and deep simple MPD that are broken by warm stratification. Furthermore, GA treatment increases the germination rate and percentage of Ilex seeds with non-deep simple MPD, and cold stratification promotes the seed germination rate of Ilex species with non-deep simple MPD in tropical region.
In recent years, the incidence of teratospermia has been increasing, and it has become a very important factor leading to male infertility. The research on the molecular mechanism of teratospermia is also progressing rapidly. This article briefly summarizes the clinical incidence of teratozoospermia, and makes a retrospective summary of related studies reported in recent years. Specifically discussing the relationship between gene status and spermatozoa, the review aims to provide the basis for the genetic diagnosis and gene therapy of teratozoospermia.
Evidence on the long-term comparative effectiveness of posttraumatic stress disorder (PTSD) psychotherapies in adults remains unknown. Therefore, we performed an extensive network meta-analysis of randomised controlled trials (RCTs) to determine the comparative effectiveness of psychotherapies for people diagnosed with PTSD.
Methods
A comprehensive search was conducted in Cochrane library, Embase, Medline-OVID, PubMed, Scopus, and Psych-Info until March 2021. Studies on the effectiveness of cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation reprocessing (EMDR), narrative exposure therapy (NET), prolonged exposure (PE), cognitive behavioural therapy (CBT), present-centred therapy (PCT), brief eclectic psychotherapies (BEP), psychodynamic therapy (PDT) or combination therapies compared to no treatment (NT) or treatment as usual (TAU) in adults with PTSD were included. Frequentist and Bayesian approaches were used for analysis in R-software.
Results
We included 98 RCTs with 5567 participants from 18 897 studies. CPT, EMDR, CT, NET, PE, CBT, and PCT were significant to reduce PTSD symptoms (SMD range: −1.53 to −0.75; Certainty: very low to high) at immediate post-treatment and ranked accordingly. Longitudinal analysis found EMDR (1.02) and CPT (0.85) as the significant therapies with large effect size in short-term and long-term follow-up, respectively. NET and CPT showed higher proportion of loss of PTSD diagnosis (RR range: 5.51–3.45) while there were no significant psychotherapies for retention rate compared to NT.
Conclusions:
Our findings provide evidence for improving current guidelines and informing clinical decision-making for PTSD management. However, the best PTSD treatment plan should be tailored to patients' needs, characteristics, and clinician expertise.
The identification of herbicide tolerance is essential for effective chemical weed control. According to whole-plant dose–response assays, none of 29 pond lovegrass [Eragrostis japonica (Thunb.) Trin.] populations were sensitive to penoxsulam. The effective dose values of penoxsulam causing 50% inhibition of fresh weight (GR50: 105.14 to 148.78 g ai ha−1) in E. japonica populations were much higher than the label rate of penoxsulam (15 to 30 g ai ha−1) in the field. This confirmed that E. japonica was tolerant to penoxsulam. Eragrostis japonica populations showed 52.83- to 74.76-fold higher tolerance to penoxsulam than susceptible barnyardgrass [Echinochloa crus-galli (L.) P. Beauv.]. The mechanisms of tolerance to penoxsulam in E. japonica were also identified. In vitro activity assays revealed that the penoxsulam concentration required to inhibit 50% of the acetolactate synthase (ALS) activity (IC50) was 12.27-fold higher in E. japonica than in E. crus-galli. However, differences in the ALS gene, previously found to endow target-site resistance in weeds, were not detected in the sequences obtained. Additionally, the expression level of genes encoding ALS in E. japonica was approximately 2-fold higher than in E. crus-galli after penoxsulam treatment. Furthermore, penoxsulam tolerance can be significantly reversed by three cytochrome P450 monooxygenase (CytP450) inhibitors (1-aminobenzotriazole, piperonyl butoxide, and malathion), and the activity of NADPH-dependent cytochrome P450 reductase toward penoxsulam in E. japonica increased significantly (approximately 7-fold higher) compared with that of treated E. crus-galli. Taken together, these results indicate that lower ALS sensitivity, relatively higher ALS expression levels, and stronger metabolism of CytP450s combined to bring about penoxsulam tolerance in E. japonica.
Studies of ‘food globalisation’ have traced the dispersal of cereals across prehistoric Eurasia. The degree to which these crops were accompanied by knowledge of soil and water preparation is less well known, however. The authors use stable isotope and archaeobotanical analyses to trace long-term trends in cultivation practices on the Loess Plateau (6000 BC–AD 1900). The results indicate that ancient farmers cultivated grains originating in South-west Asia and used distinct strategies for different species. Barley was integrated into pre-existing practices, while wheat was grown using novel soil and water management strategies. These distinct approaches suggest that the spread of prehistoric crops and knowledge about them varied by local context.
The mitochondrial genome provides important information for phylogenetic analysis and an understanding of evolutionary origin. In this study, the mitochondrial genomes of Ilisha elongata and Setipinna tenuifilis were sequenced, which are typical circular vertebrate mitochondrial genomes composed of 16,770 and 16,805 bp, respectively. The mitogenomes of I. elongata and S. tenuifilis include 13 protein-coding genes (PCGs), 22 transfer RNA (tRNA), two ribosomal RNA (rRNA) genes and one control region (CR). Both two species' genome compositions were highly A + T biased and exhibited positive AT-skews and negative GC-skews. The genetic distance and Ka/Ks ratio analyses indicated that 13 PCGs were affected by purifying selection and the selection pressures were different from certain deep-sea fishes, which were most likely due to the difference in their living environment. Results of phylogenetic analysis support close relationships among Chirocentridae, Denticipitidae, Clupeidae, Engraulidae and Pristigasteridae based on the nucleotide and amino acid sequences of 13 PCGs. Within Clupeoidei, I. elongata and S. tenuifilis were most closely related to the family Pristigasteridae and Engraulidae, respectively. These results will help to better understand the evolutionary position of Clupeiformes and provide a reference for further phylogenetic research on Clupeiformes species.
Caregiver-mediated intervention (CMI), based on parent skills training, is a family-mediated intervention model for children with neurodevelopmental disorders, in particular autism spectrum disorder. This study aimed to evaluate the effectiveness of CMI.
Methods:
Thirty-three children (aged 22–69 months from our department) and their caregivers participated in a two-week training course of ten 90-minute lessons. Caregivers were encouraged to try their best to apply intervention skills in both home routines and play routines to encourage the development of cognition, motion, social adaptability, and behavior of children. Demographic information, video-recorded data, and diagnostic scales were collected at two key time points: baseline and post-training (PT – within six months).
Results:
Three aspects were assessed – primary variables, secondary variables, and correlation analyses. Results showed an improvement in PT in (1) Adult/Child Interaction Fidelity Rating (P < 0.01) and (2) adaptability of Gesell Developmental Scale and stereotyped behaviors and limited interests of Autism Diagnostic Observation Schedule (P < 0.05, P < 0.01). Moreover, a negative correlation occurred between caregiver skill improvement and parent education (P < 0.05), but without correlations with other demographics.
Conclusions:
As an efficacious family intervention for both children and their caregivers, CMI is worth being generalized widely.
Electronic skin (e-skin) is playing an increasingly important role in health detection, robotic teleoperation, and human-machine interaction, but most e-skins currently lack the integration of on-site signal acquisition and transmission modules. In this paper, we develop a novel flexible wearable e-skin sensing system with 11 sensing channels for robotic teleoperation. The designed sensing system is mainly composed of three components: e-skin sensor, customized flexible printed circuit (FPC), and human-machine interface. The e-skin sensor has 10 stretchable resistors distributed at the proximal and metacarpal joints of each finger respectively and 1 stretchable resistor distributed at the purlicue. The e-skin sensor can be attached to the opisthenar, and thanks to its stretchability, the sensor can detect the bent angle of the finger. The customized FPC, with WiFi module, wirelessly transmits the signal to the terminal device with human-machine interface, and we design a graphical user interface based on the Qt framework for real-time signal acquisition, storage, and display. Based on this developed e-skin system and self-developed robotic multi-fingered hand, we conduct gesture recognition and robotic multi-fingered teleoperation experiments using deep learning techniques and obtain a recognition accuracy of 91.22%. The results demonstrate that the developed e-skin sensing system has great potential in human-machine interaction.
To investigate the association between folate levels and the risk of gestational diabetes mellitus (GDM) risk during the whole pregnancy.
Design:
In this retrospective cohort study of pregnant women, serum folate levels were measured before 24 gestational weeks (GW). GDM was diagnosed between 24th and 28th GW based on the criteria of the International Association of Diabetes and Pregnancy Study Groups. General linear models were performed to examine the association of serum folate with plasma glucose (i.e. linear regressions) and risk of GDM (i.e. log-binomial regressions) after controlling for confounders. Restricted cubic spline regression was conducted to test the dosage–response relationship between serum folate and the risk of GDM.
Setting:
A sigle, urban hospital in Shanghai, China.
Participants:
A total of 42 478 women who received antenatal care from April 2013 to March 2017 were included.
Results:
Consistent positive associations were observed between serum folate and plasma glucose levels (fasting, 1-h, 2-h). The adjusted relative risks (RR) and 95 % CI of GDM across serum folate quartiles were 1·00 (reference), 1·15 (95 % CI (1·04, 1·26)), 1·40 (95 % CI (1·27, 1·54)) and 1·54 (95 % CI (1·40, 1·69)), respectively (P-for-trend < 0·001). The positive association between serum folate and GDM remained when stratified by vitamin B12 (adequate v. deficient groups) and the GW of serum folate measurement (≤13 GW v. >13 GWs)
Conclusions:
The findings of this study may provide important evidence for the public health and clinical guidelines of pregnancy folate supplementation in terms of GDM prevention.
Previously, we provided an evidence that l-Leucine supplementation facilitates growth performance in suckling piglets with normal birth weight. However, it remains hitherto obscure weather breast-fed piglets displaying intra-uterine growth restriction (IUGR) show a similar effect in response to l-Leucine provision. In this study, 7-d-old sow-reared IUGR piglets were orally administrated with l-Leucine (0, 0·7, 1·4 or 2·1 g/kg BW) twice daily for 2 weeks. Increasing leucine levels hampered the growth performance of suckling IUGR piglets. The average daily gain of IUGR piglets was significantly reduced in 1·4 g/kg BW and 2·1 g/kg BW l-Leucine supplementation groups (P < 0·05). Except for ornithine and glutamine, the plasma concentrations of other amino acids were abated as l-Leucine levels increased (P < 0·05). Leucine supplementation led to reduction in the levels of urea, blood ammonia, blood glucose, TAG and total cholesterol, as well as an elevation in the level of LDL-cholesterol in suckling IUGR piglets (P < 0·05). In addition, 1·4 g/kg BW of l-Leucine enhanced the mRNA expression of ATB0,+, whereas decreased the mRNA abundances of CAT1, y + LAT1, ASCT2 and b0,+AT in the jejunum (P < 0·05). Concomitantly, the jejunum of IUGR piglets in l-Leucine group contains more ATB0,+ and less SNAT2 protein than in the control (P < 0·05). Collectively, l-Leucine supplementation impairs growth performance in breast-fed IUGR piglets, which may be associated with depressed nutritional conditions and alterations in the uptake of amino acids and the expression of amino acid transporters in the small intestine.
The impact of the dietary potential inflammatory effect on diabetic kidney disease (DKD) has not been adequately investigated. The present study aimed to explore the association between dietary inflammatory index (DII) and DKD in US adults.
Design:
This is a cross-sectional study.
Setting:
Data from the National Health and Nutrition Examination Survey (2007–2016) were used. DII was calculated from 24-h dietary recall interviews. DKD was defined as diabetes with albuminuria, impaired glomerular filtration rate or both. Logistic regression and restricted cubic spline models were adopted to evaluate the associations.
Participants:
Data from the National Health and Nutrition Examination Survey (2007–2016) were used, which can provide the information of participants.
Results:
Four thousand two-hundred and sixty-four participants were included in this study. The adjusted OR of DKD was 1·04 (95 % CI 0·81, 1·36) for quartile 2, 1·24 (95 % CI 0·97, 1·59) for quartile 3 and 1·64 (95 % CI 1·24, 2·17) for quartile 4, respectively, compared with the quartile 1 of DII. A linear dose–response pattern was observed between DII and DKD (Pnonlinearity = 0·73). In the stratified analyses, the OR for quartile 4 of DII were significant among adults with higher educational level (OR 1·83, 95 % CI 1·26, 2·66) and overweight or obese participants (OR 1·67, 95 % CI 1·23, 2·28), but not among the corresponding another subgroup. The interaction effects between DII and stratified factors on DKD were not statistically significant (all P values for interactions were >0·05).
Conclusions:
Our findings suggest that a pro-inflammatory diet, shown by a higher DII score, is associated with increased odd of DKD.
Resistant starch (RS) has received increased attention due to its potential health benefits. This study was aimed to investigate the effects of dietary corn RS on immunological characteristics of broilers. A total of 320 broiler chicks were randomly allocated to five dietary treatments: normal corn–soyabean (NC) diet group, corn starch diet group, 4 %, 8 % and 12 % RS diet groups. This trial lasted for 42 d. The relative weights of spleen, thymus and bursa, the concentrations of nitric oxide (NO) and IL-4 in plasma at 21 d of age, as well as the activities of total nitric oxide synthase (TNOS) and inducible nitric oxide synthase (iNOS) in plasma at 21 and 42 d of age showed positive linear responses (P < 0·05) to the increasing dietary RS level. Meanwhile, compared with the birds from the NC group at 21 d of age, birds fed 4 % RS, 8 % RS and 12 % RS diets exhibited higher (P < 0·05) relative weight of bursa and concentrations of NO and interferon-γ in plasma. Birds fed 4 % RS and 8 % RS diets showed higher (P < 0·05) number of IgA-producing cells in the jejunum. While compared with birds from the NC group at 42 d of age, birds fed 12 % RS diet showed higher (P < 0·05) relative weight of spleen and activities of TNOS and iNOS in plasma. These findings suggested that dietary corn RS supplementation can improve immune function in broilers.
This study is performed to figure out how the presence of diabetes affects the infection, progression and prognosis of 2019 novel coronavirus disease (COVID-19), and the effective therapy that can treat the diabetes-complicated patients with COVID-19. A multicentre study was performed in four hospitals. COVID-19 patients with diabetes mellitus (DM) or hyperglycaemia were compared with those without these conditions and matched by propensity score matching for their clinical progress and outcome. Totally, 2444 confirmed COVID-19 patients were recruited, from whom 336 had DM. Compared to 1344 non-DM patients with age and sex matched, DM-COVID-19 patients had significantly higher rates of intensive care unit entrance (12.43% vs. 6.58%, P = 0.014), kidney failure (9.20% vs. 4.05%, P = 0.027) and mortality (25.00% vs. 18.15%, P < 0.001). Age and sex-stratified comparison revealed increased susceptibility to COVID-19 only from females with DM. For either non-DM or DM group, hyperglycaemia was associated with adverse outcomes, featured by higher rates of severe pneumonia and mortality, in comparison with non-hyperglycaemia. This was accompanied by significantly altered laboratory indicators including lymphocyte and neutrophil percentage, C-reactive protein and urea nitrogen level, all with correlation coefficients >0.35. Both diabetes and hyperglycaemia were independently associated with adverse prognosis of COVID-19, with hazard ratios of 10.41 and 3.58, respectively.
OBJECTIVES/GOALS: Intraocular pressure is the most significant risk factor for glaucoma. Mechanosensitive proteins may have a critical role in transducing mechanical stimuli that ultimately lead to death of retinal ganglion cells. Our goal is to use genetic and functional approaches to discover mechanosensitive ion channels that mediate the progression of glaucoma. METHODS/STUDY POPULATION: Association data, obtained using a logistic regression model that included age, gender and population substructure as co-variates, for 2,576 SNPs located in the PIEZO1 and PIEZO2 genomic regions were extracted from the NEIGHBORHOOD genome-wide association study results for primary open angle glaucoma (POAG) (3,853 cases and 33,480 controls) and the subset of cases with intraocular pressure (IOP) measurements > 21mmHg (high-tension, HTG) (1868 cases and 33,480 controls). Rare coding PIEZO1 and PIEZO2 variants were evaluated using logistic regression and SNP data from the Human Exome array in 2606 POAG cases and 2606 controls and the subset of 1868 HTG cases and 2606 controls. Immunohistochemistry was used to characterize the expression of Piezo1 and Piezo2 in mouse eye sections. RESULTS/ANTICIPATED RESULTS: Exome data analysis identified two protein-altering variants associated with lower glaucoma risk (P<0.05): a PIEZO1 missense allele (Arg1527His; OR= 0.18, P= 0.001) and a variant disrupting a splice donor site (c.1107+1G>C; OR=0.38, P= 0.02), that prematurely truncates the protein. Investigation of the NEIGHBORHOOD GWAS dataset identified nominal association with common PIEZO2 variants (minor allele frequency > 0.3) in POAG overall (top SNP rs264179, P= 0.008) and in the HTG subgroup (top SNP rs264160, P= 0.001). The associated PIEZO2 SNPs are significantly associated with gene expression in lymphocytes (P< 1x10-8) with the risk allele correlated with decreased gene expression. Piezo1 and Piezo2 are expressed in many ocular tissues in the mouse, including cornea, ciliary body and retina. DISCUSSION/SIGNIFICANCE: We identify rare, protein-altering PIEZO1 variants associated with lower glaucoma risk and show that Piezo1 and Piezo2 are broadly expressed in the eye. Common variants influencing PIEZO2 expression also show nominal association with POAG risk. Inhibition of Piezo1 or augmentation of Piezo2 could be novel therapeutic strategies for glaucoma.
Subthreshold depression (sD) negatively impacts well-being and psychosocial function and is more prevalent compared with major depressive disorder (MDD). However, as adults with sD are less likely to seek face-to-face intervention, internet-based cognitive-behavioral therapy (ICBT) may overcome barriers of accessibility to psychotherapy. Although several trials explored the efficacy of ICBT for sD, the results remain inconsistent. This study evaluated whether ICBT is effective in reducing depressive symptoms among Chinese adults with sD.
Methods
A randomized controlled trial was performed. The participants were randomly assigned to 5 weeks of ICBT, group-based face-to-face cognitive-behavioral therapy (CBT), or a waiting list (WL). Assessments were conducted at baseline, post-intervention and at a 6-month follow-up. The primary outcome measured depressive symptoms using the Center for Epidemiological Studies Depression Scale (CES-D). Outcomes were analyzed using a mixed-effects model to assess the effects of ICBT.
Results
ICBT participants reported greater reductions on all the outcomes compared to the WL group at post-intervention. The ICBT group showed larger improvement on the Patient Health Questionnaire-9 (PHQ-9) at post-intervention (d = 0.12) and at follow-up (d = 0.10), and with CES-D at post-intervention (d = 0.06), compared to the CBT group.
Conclusions
ICBT is effective in reducing depressive symptoms among Chinese adults with sD, and improvements in outcomes were sustained at a 6-month follow-up. Considering the low rates of face-to-face psychotherapy, our findings highlight the considerable potential and implications for the Chinese government to promote the use of ICBT for sD in China.
Little is known about how sociodemographic and clinical factors affect the caregiving burden of persons with schizophrenia (PwSs) with transition in primary caregivers.
Aims
This study aimed to examine the predictive effects of sociodemographic and clinical factors on the caregiving burden of PwSs with and without caregiver transition from 1994 to 2015 in rural China.
Method
Using panel data, 206 dyads of PwSs and their primary caregivers were investigated in both 1994 and 2015. The generalised linear model approach was used to examine the predictive effects of sociodemographic factors, severity of symptoms and changes in social functioning on the caregiving burden with and without caregiver transition.
Results
The percentages of families with and without caregiver transition were 38.8% and 61.2%, respectively. Among families without caregiver transition, a heavier burden was significantly related to a larger family size and more severe symptoms in PwSs. Deteriorated functioning of ‘social activities outside the household’ and improved functioning of ‘activity in the household’ were protective factors against a heavy caregiving burden. Among families with caregiver transition, younger age, improved marital functioning, deteriorated self-care functioning, and better functioning of ‘social interest or concern’ were significant risk factors for caregiving burden.
Conclusions
The effects of sociodemographic and clinical correlates on the caregiving burden were different among families with and without caregiver transition. It is crucial to explore the caregiver arrangement of PwSs and the risk factors for burden over time, which will facilitate culture-specific family interventions, community-based mental health services and recovery.