A self-administered questionnaire was used to measure the self-reported health status of the elderly, evaluations to CSCs, demographic characteristics, and information on sports programs; (3) Results: The results of multiple logistic regression showed that domains of general evaluation for sports (OR = 1.942 and 95% CI 1.336~2.824), benefits of sports (OR = 1.659 and 95% CI 1.344~2.047), and management in sports (OR = 1.273 and 95% CI 1.011~1.603) were important for club members aged 60–64, the young-old, and the old-old, respectively. With a reduced model for elderly members, stratified analyses showed a significant impact of service quality for sports on active aged people in the benefits and management domains, regardless of sociodemographic information or club participation behavior; (4) Conclusions: The findings suggest that the services encountered in sports are key to promoting health in a community. Service quality in age segmentation should be considered to promote and manage active aging in the future With the emergence of an increasingly aged society, healthy active aging is becoming a robust trend by which we can evaluate the quality of life in old age. Several indicators for active aging have been added to the original definition first postulated by Rowe and Kahn ,2, such Several health promotion strategies have been designed to increase sports participation among older people, advocate for health-promoting activities, and support the development of national and local programs ,18. AlthThe best predictors of satisfaction in evaluating a healthcare service system were advanced age and self-reported health. Studies have indicated a relationship between health utilization, health outcomes, and customer satisfaction, but results show inconsistency due to the heterogeneity of age and health status ,35. FuncIn 2002, the Japanese government began building comprehensive community sports clubs (CSC) in all communities to create a lifelong active society and sport-friendly environment for all citizens. The main goals of the CSC project include providing convenient and affordable sports complexes for all residents in a community and creating a sports environment accessible to residents of all ages, genders, and ability levels, thus facilitating social activities. The number of CSCs has achieved great growth year-on-year a decade after the policy was implemented. The number and established percentage of CSCs in 2002, 2013, and 2019 were 541 (13.1%), 3493 (79.0%), and 3604 (80.5%), respectively  [41]. InTrends in gerontology demonstrate the significant relationship between active aging, age groups, and gender. Demographic differences among older individuals encourage policymakers to properly attend to the needs of the aging population. Certain characteristics, including young-old age, male gender, no disability, and high education level, are most often correlated with active aging ,46,47; hPast studies have shown a positive association between service quality and health status of the elderly in the long-term care industry, but rarely in the sports industry ,34,35,38This cross-sectional study used a convenience sample of 545 senior Japanese CSC members over 60 years of age, recruited from eight CSCs in Nerima, a ward in Tokyo, and Otsuki, a city in Yamanashi Prefecture, Japan. With the permission of the Tokyo governmental unit, this study delivered a questionnaire to five CSC leaders. Then, after completing the questionnaire, the CSCs returned it to the Tokyo Bureau of Sports, who in turn forwarded it to the author. For the three CSCs who agreed to participate, the author acted as a sports volunteer and directly observed the operations of the CSCs for a month. Then, the questionnaires were delivered at the end of each sports program the following week in CSC. The final total was 545 participants over 60 years of age from eight CSCs. The response rate was 70.32% (545/775 senior members). After two participants were eliminated due to incomplete sociodemographic or healthy aging scale assessment data, 543 participants were analyzed in this study. These two study sites were selected based on their total population, percentage of older residents, number of CSCs, and number of older CSC members. The central reason for including the Nerima district in Tokyo, with 709,262 citizens and seven CSCs , was selA positive and active aging scale, developed to measure the self-reported health status of older people, evolved from the Japanese version of the Philadelphia Geriatric Center Morale Scale . An 11-iThe independent variable, service quality for sports scale (SQS), was measured to investigate the evaluations of senior club members. The SQS scale has good internal consistency and validity, with a Cronbach’s α coefficient of 0.92 and confirmatory factor analysis of the revised scale  . An 11-iConfounding factors included sociodemographic characteristics and information on sports programs. The sociodemographic characteristics considered were gender, age group, educational level, living arrangements, living area, and employment status. The age group was based on the participant’s age at the time of enrollment in this study. Living arrangements were defined based on other members of each participant’s household; possible classifications included living alone, with a married partner, with two generations, etc. Living area and employment status variables were both dichotomized into rural/urban and employed/not employed, respectively. In addition, information on sports program variables included length of memberships, participation frequency, number of club memberships, travel time to CSCs, and time of visiting the CSCs. Sample questions included “How often do you participate at the CSC?” and “How long is the trip from home to the CSC?” The length of membership was calculated from the date when participants enrolled in the CSC. The number of club memberships was defined by asking participants “In how many CSCs do you participate?” and dividing the answer into 1 (current CSC only) and 2+ (more than one CSC).p-value of <0.05 was considered statistically significant. These analyses were performed using SAS for Windows, version 9.4 .Categorical variables were expressed as a frequency and percentage, while numerical variables were displayed using mean and standard deviation. A chi-square test was carried out to examine the categorical variable and HA group differences. An independent sample t-test was conducted to examine the bivariate association between the HA group and numerical or categorical variables. A multiple logistic regression analysis was performed to determine the association between HA and the study variables, including sociodemographic information, information on sports programs, and SQS. The model-selection strategy of the multiple logistic regression analysis was based on univariate tests and backward selection. Multivariate-adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were analyzed. Furthermore, based on different age groups, stratified analyses were presented to moderate the association between HA and various factors, including sociodemographic, information on sports program, and SQS variables. A two-sided n = 218, 55.19%), people 60–65 years old , college graduates , those living alone , and those living in rural areas  ; in addition, favorite attendance time for HA group was between 12:00 p.m. and 3:00 p.m. (p = 0.039). The healthy agers were also associated with other factors related to CSC sport participation, including longer club memberships (3.57 ± 3.02), more frequent participation weekly , more than one club membership , and closer than 10 min to the CSC , compared to the opposite group. In addition, more than half of the HA group was positively associated with sports service satisfaction . The HA group had a significantly higher score of SQS in benefits, access, interaction, and management domains, compared to the no HA group (p < 0.001)  were classified as HA. The average score on the healthy aging scale was 43.94. Variables of gender and age group were not significantly different between HA group. The HA group primarily included women ( 59.62%) . Peak at< 0.001) .n = 365) and the significant variables in Model I demonstrated similar results (Model II). A slightly higher association was observed between HA and living arrangements/number of club memberships in Model II than in Model I based on stratified age groups. Age showed impacts on HA. For all senior members, a multiple logistic regression analysis demonstrated that living arrangements, educational level, number of club memberships, SQS-benefits, and SQS-management were significantly associated with HA . Living n = 365). For the SQS-benefits domain, the highest HA scores were found in participants living alone who fell into the higher SQS-benefits score (score ≥ 12.55). A less obvious relationship between HA scores and SQS-benefits was observed among participants living with 2+ generations. The highest HA scores were observed among participants with higher SQS-benefits scores, regardless of their education status and number of CSC memberships  and worldwide (0.4%–95%) ,67. In tThe demographic background results displayed the age segmentation of members. Concerning the core of active aging, previous studies have highlighted the importance of habitual sports and exercise participation as an indicator of health and active aging. In this study, over half of senior members (53.96%) exhibited healthy active aging through sports participation at CSCs. Regular sports activity can reduce the risk of physiological deficits and chronic disease, improve general well-being and mental and cognitive health, and enhance productivity and social integration ,68. AmonThe results of this study showed a strong relationship between service quality and healthy aging . A highen = 142) account for 79.78% of senior members (n = 178). Many female members formed friendships through the CSC and socialize after their sports programs. Participating at CSCs made senior women feel they were contributing to their community. Liechty indicated that even though leisure constraints are often related to increases in age, this is not true for females [Although increasing numbers of elderly customers are engaging in sports and health activities in their communities, few studies have focused on service quality in sports, particularly for people over 60 years of age . For sen females . Older wn = 269, 49.54%). They are primarily motivated to attend CSCs to gain benefits from sports, resulting in disease prevention and decreases in health expenditures. The benefits SQS domain included health promotion, relaxation, and friendship establishment, which are, unsurprisingly, associated with a positive aging attitude for the young-old participants. These individuals were in the discovery and innovation stage and still had the energy to engage in leisure and sports activities. The average retirement age of Japanese laborers is 65 for men, and 60 for women [The results displayed the age segmentation of members and differences in evaluating CSCs. The majority of CSC senior members are participants aged 65–74, known as young-old participants  were more likely to participate in organized sports activities in friendly sports environments, compared to participants in the 65–69 group . The manOne primary goal in this study was to explore the strength of association between service quality for sports and confounding healthy active aging attitude factors. Our findings have revealed a high strength of association among demographic factors such as living alone, having graduated from college, and having more than one club membership and both management and benefit SQS domains on healthy active aging. Interestingly, our findings showed that individuals living alone who more highly evaluate the benefit of sports have a 7.74 times greater likelihood of healthy active aging than elderly participants living with 2+ generations with a lower evaluation . ElderlyDemographic factors such as age, gender, marital status, and socioeconomic status (SES) are the most common determinants associated with or influencing people’s general health. SES, which encompasses education, wealth, and occupation level, is of high relevance for self-reported health status and life expectancy ,84,85. NOne further noteworthy result involves the number of CSC club memberships. Senior members generally go to CSCs to exercise on weekday mornings, but they still have opportunities to participate in other clubs, if available. Sirven and Debrand revealed that social engagement enhanced participant health status and highlighted the positive relationship between membership numbers at social or sports clubs and self-reported health outcomes . The JapThis study has several limitations. First, it is only a cross-sectional study with a purposive convenience sample of 545 participants in Tokyo and its neighboring area, which may limit the interpretability of the causality between service quality for sports and healthy active aging. Our findings confirmed the stratified effect of age segmentation on the association between service quality for sports and healthy active aging, but the representation is still warranted. Second, the study focused on Tokyo and Yamanashi prefecture in eastern Japan, which raises the issue of the findings’ generalizability. Thus, future studies should examine the active aging model and service quality in other Japanese communities and in other Asian countries with similar sociocultural backgrounds. Finally, this study utilized a self-designed questionnaire to represent healthy active aging, rather than using an objective assessment tool such as senior fitness tests or history of chronic disease, which may have improved the accuracy. Furthermore, it is necessary to establish a model of active aging among Asians using both qualitative and quantitative approaches and develop a supportive sports environment for the elderly.This study highlighted the importance of service quality for sports provided to senior members to promote healthy active aging. The association between SQS and demographic variables on healthy active aging is confirmed in this study. Most importantly, providing high-quality sports services within age segmentation according to the needs of physical aging or sports expectations is critical to the senior, young-old, and old-old elderly in the health and sports industry. The growth of well-managed community sports organizations plays an essential role in improving elderly residents’ access to health and sports participation. Consequently, this study suggests that CSC managers or future studies consider the uniqueness of the senior customer when delivering sports services. The application of the service encounter in sports is a key trend for future active aging study. Designing programs with opportunities for interaction and communication during exercise would be optimal to decrease disadvantages associated with aging. To summarize, service quality is strongly related to satisfaction and healthy active aging; therefore, segmenting the elderly into heterogeneous customer types is necessary for future planning.


Understanding the influence of landscape pattern changes on water yield (WYLD) and nutrient yield is a key topic for water resource management and nonpoint source (NPS) pollution reduction. The annual WYLD and NPS pollution were estimated in 2004 and 2015 with the calibrated and validated Soil and Water Assessment Tool (SWAT) in the Hun-Taizi River watershed. The impact of land use and landscape pattern changes on the annual WYLD and NPS loading changes were analyzed with a boosted regression tree (BRT) and redundancy analysis (RDA). The results showed that WYLD had a positive correlation with dry farmland and built-up area; however, a negative correlation with paddy field and water area, with the relative contribution of 42.03%, 23.79%, 17.06%, and 13.55%, respectively. The change in nutrient yield was positively correlated with changes in dry farmland, built-up area, and water area but negatively with forestland, according to the BRT model. Landscape patterns had an important influence on WYLD and NPS pollution. A large unfragmented forestland may improve water quality, while a large concentrated dry farmland results in water quality deterioration due to NPS pollution. Water quality is more likely degraded when land uses are complex and scattered with many small patches in a forestland dominated watershed. Water yield (WYLD) is of great importance as it supplies water resources to human beings and natural resources . Under tThe relationship between NPS pollution and landscape pattern changes has substantial implications for TN and TP yield control. Field monitoring and model prediction are the two main methods used to calculate NPS. However, field monitoring is expensive, time-consuming, and regionally characterized, limiting the development of the method. With the development of geographic information systems (GIS), remote sensing (RS), and computer technology, many hydrological models have been developed to simulate hydrological processes and water quality. Many physically distributed models have been successfully developed for NPS simulation, such as annualized agricultural nonpoint source ; areal nThe SWAT model is widely used to simulate streamflow, sediment yield, and NPS loading effectively, which are greatly affected by changes in rainfall, land use, and landscape pattern during a short period . With urIn recent years, urban sprawl has accelerated in the Hun-Taizi River watershed due to the policy of “Revitalization of Old Industrial Bases in Northeast China” proposed in 2003. The policy has caused considerable land use and landscape pattern changes . With th4 km2, was selected as the study area. The Hun-Taizi River watershed is a subbasin of the Liao River and consists of the Hun River , the Taizi River , and the Daliao River (96 km in length) that flows into the Bohai Sea through Yingkou city. The study area has a warm temperate semihumid monsoon climate with an average annual temperature of 8.7 °C, and the mean maximum and minimum temperatures were 28.9 and −15.7 °C in July and January, respectively, from 1980–2016. The average annual precipitation of the last 30 years in the watershed was approximately 700 mm (ranging from 610–780 mm), although 70% of the precipitation falls in the monsoon season (June to September). The intra-annual distribution of streamflow is similar to that of precipitation, with more than 70% occurring from June to September. There are four main reservoirs , which are the most important sources of drinking water and irrigation water for Liaoning Province. The study area covers most of the central Liaoning Urban Agglomeration, which is one of ten urban agglomerations in China, and includes the cities of Shenyang, Anshan, Fushun, Benxi, Liaoyang, and Yingkou. The study area had a residential population of 1.86 × 107 and produced 47.03% of the total gross domestic product (GDP) of Liaoning Province in 2016 [The Hun-Taizi River watershed , in the central part of Liaoning Province, northeastern China , coverin in 2016 .The SWAT model (United States Department of Agriculture (USDA), Texas, USA) is a physically based, long-term, continuous, semidistributed watershed-scale hydrological model developed by the Agriculture Research Service (ARS) of the United States Department of Agriculture (USDA) operating on daily or monthly time steps . The SWAIn this study, the modified soil conservation services curve number  was used to estimate surface runoff from daily precipitation, and a modified rational method was used to quantify peak runoff rates. The SWAT model simulates nutrient transport and transformation with the QUAL2E model at each hydrologic response unit (HRU). The Penman–Monteith method was used to calculate potential evapotranspiration (PET), the Muskingum method was used to route channel flow, and Manning’s formula was used to determine the watershed concentration time.The database for the SWAT model is presented in In this study, the Hun-Taizi River watershed was divided into 55 subbasins, with the threshold area being set at 35,000 ha with a total area of 2,774,045 ha. The slope of the land was grouped into four grades . The land uses, soil map, and land slopes overlapped with each other with thresholds of 2% each to define the HRUs. In total, 1846 HRUs were defined with uniform parameters and variables being used in each unit.Before the SWAT model is applied, it has to be properly calibrated and validated for ascertaining the reliability and accuracy of the model. An automatic parameter estimation procedure SWAT-calibration and uncertainty program , was used to calibrate and validate the model . Conside2 and the Nash-Sutcliffe efficiency coefficient (ENS) [2 and ENS greater than 0.9, 0.75–0.9, 0.5–0.75, 0.25–0.5, 0–0.25, and below 0 correspond to model performances of “excellent”, “very good”, “good”, “fair”, “poor”, and “unsatisfactory”, respectively [The Rnt (ENS)  have beeectively ,32,33.A “fixing-changing” method ,35 was uBoosted regression tree (BRT) was chosen to analyze effect factors of WYLD and nutrient yield, which is a flexible regression modeling technique that can accommodate different types of variables and missing data, and is immune to the influence of extreme outliers and the inclusion of irrelevant variables, can fit complex nonlinear relationships, and automatically handle interaction effects between predictors . The BRTThe changes in WYLD and nutrient yield across two simulations was developed by using land use maps for 2004 and 2015, as the dependent variables. The independent variables were the six land use types changes . For this study, three BRT models were constructed to analyze the relative contribution of changes in individual land use to WYLD, TN, and TP yields. BRT models are developed in the R software (version 3.6.1), specifically by using its package “gbm”, with “gbm” functions. The BRT models used in this study have a learning rate of 0.005, a bag fraction of 0.5, a tree complexity of 5, and a 10-fold cross validation . In addiLandscape metrics are usually used to describe landscape spatial patterns . AccordiThe redundancy analysis (RDA) approach was used to analyze the relationship among landscape pattern changes and WYLD as well as nutrient yield changes in each subbasin. A detrended correspondence analysis (DCA) was first performed to select the most suitable ordination method. As the gradient length was less than 3 (1.79), the RDA was selected. Then, the major factors that affected the dependent variables were chosen according to the contribution and significance values by using the interactive forward-selection method. Finally, the RDA was conducted based on the selected environmental factors. The analysis was undertaken using the universal vegetation quantitative analysis software CANOCO 4.5 ,42. Trip2 and ENS were greater than 0.5, which implied that the SWAT model’s performance was “good” for the nine hydrological stations of the study area  and in the validation period (2011–2014) . The valudy area . The meaudy area . The ENSNS and R2 values, indicated that the calibrated and validated model could successfully describe monthly streamflow and nutrient yield in the study area.The model showed better results in simulating hydrological processes than in simulating TN and TP yields, which may be because the runoff parameters were adjusted first, nutrients were subsequently adjusted, and errors induced in adjusting parameters could be transferred and extended to the simulation . Overall−2 in 2004 to 50.88 kg km−2 in 2015. The TP yield was 22.88 kg km−2 in 2015, with an increase of 6.97 kg km−2 in comparison to that in 2004.The simulated annual WYLD and nutrient yield with the validated SWAT model showed an increasing trend from 2004 to 2015 . The WYL2 per year, respectively. Conversely, dry farmland, built-up area, and wetland increased with an annual growth by 96.06, 40.57, and 6.10 km2, respectively. Wetland was not considered in further analyses due to their area being less than 1% of the basin. The spatial distribution of land use changes mainly occurred in the midstream and downstream areas and were mainly in the farmland and built-up area . The selected variables explained 52.28% of the variation in WYLD and nutrient yield. The first two RDA ordination axes explained more than 90% of the total correlation among the landscape and WYLD and nutrient yield (p = 0.01).Prior to the RDA, the landscape indexes were selected based on values of significance and importance . The resThe percentage of landscape (PLAND) of forestland (PLANDfor), PLAND of dry farmland (PLANDdry), Perimeter area fractal dimension (PAFRAC), Landscape shape index (LSI), 2Largest patch index (LPI), LPI of forestland (LPIfor), LPI of dry farmland (LPIdry), Aggregation index (AI), AI of forestland (AIfor), AI of dry farmland (AIdry).At the class level, the correlations between changes in WYLD and nutrient yield as well as changes in largest patch index (LPI) of dry farmland (LPIdry), aggregation index (AI) of dry farmland (AIdry) and the percentage of landscape (PLAND) of dry farmland (PLANDdry)were positive; otherwise, they were negative for LPI of forestland (LPIfor), AI of forestland (AIfor) and PLAND of forestland (PLANDfor) . At the Our results showed that forestland was the dominant land used in the Hun-Taizi River watershed, which was mainly distributed in the mountain hills, and it was negatively correlated with WYLD and TN and TP yields. These results are consistent with the results of many previous studies ,43,44. TDry farmland was positively correlated with TN and TP yields because conventional agricultural activity (tillage or excessive fertilization) increases the risk of soil erosion and excessive nutrient applications . The incThe results revealed that the larger the water area, the more severe the NPS pollution was. This finding differs from those of previous studies that concluded that a larger water area would have higher water quality ,49. ThisThe paddy field could reduce WYLD with a relative contribution of 23.42%; however, this reduction was not significant in terms of nutrient yield. NPS loading from the paddy field largely depends on management practices and precipitation . FarmersAt the class level, WYLD and nutrient yield were negatively correlated with the LPI and AI of forestland and positively correlated with the LPI and AI of dry farmland , which iAt the landscape level, our findings showed that WYLD and nutrient yield were positively correlated with LSI and PAFRAC but negatively correlated with LPI and AI ,44,54. PForestland is the dominant land use in the study area, which occupies the mountain areas in the upper watershed, and an increase in the proportion of unfragmented forestland with a large patch area was positively related to water quality. Therefore, increasing the area and concentration of the forestland is of great significance for water conservation and control of NPS pollution. According to the results of this study, dry farmland is the major source of NPS pollution, and the AI and LPI of dry farmland had a strong negative impact on water quality. Therefore, encouraging farmers to rationally use chemical fertilizers and pesticides, as well as conservation tillage would help to reduce nutrient loss. Landscape planning, such as increasing patch aggregation and decreasing landscape fragmentation, should be considered to improve watershed water quality.The SWAT model was widely used to study the influence of land use or climate changes to the streamflow, sediment, or TN and TP yields. To ensure the accuracy of the SWAT model, it was calibrated and validated under the real condition while the model was used to simulate the future hydrology or NPS loading under different land use scenarios or future climate scenarios ,56,57. IWith population growth, economic development, and urban sprawl, the built-up area greatly increased in the Hun-Taizi River watershed . A largeThe built-up area has a great influence on water quality at smaller scales ,61. Howe2 and ENS were greater than 0.5) and TN, respectively. The SWAT model performed better in simulating the hydrological process than in simulating nutrient yield due to the accumulated parameter errors (runoff parameters adjusted first and then nutrient parameters).The SWAT model performance was “good” and “fair” for simulating streamflow with TP (RWYLD was strongly correlated with dry farmland, built-up area, paddy field, and water area, with contributions of 42.03%, 23.79%, 17.06%, and 13.55%, respectively. Forestland was the dominant land use in the catchment and was negatively correlated with WYLD and NPS loading due to its ability to reduce surface runoff and soil erosion and absorb pollutants. Human activities were the main cause of NPS pollution. Dry farmland and built-up area were the main sources of NPS pollution, while paddy field had no significant effect on nutrient yield because they were always flooded and acted as a pool. The water area was positively correlated with NPS loading, indicating that NPS pollution was the main reason for water quality degradation.Landscape patterns had an important influence on WYLD and NPS pollution. Large unfragmented forestland may improve water quality, while large concentrated dry farmland may adversely affect water quality. NPS pollution will be severe when various land uses have a complex shape and are dispersed and fragmented in a forestland-dominated watershed. Forestland plays an important role in controlling NPS pollution. The results of this study can help resource managers and government policy makers develop scientific and effective strategies for land use and water resource management. The BRT and RDA methods are simple and feasible and can be used in other basins of China.


The purpose of this study was to validate optimized algorithm parameter settings for step count and physical behavior for a pocket worn activity tracker in older adults during ADL. Secondly, for a more relevant interpretation of the results, the performance of the optimized algorithm was compared to three reference applicationsMissActivity versus MOXAnnegarn, activPAL, and Fitbit. The protocol was video recorded and analyzed for step count and dynamic, standing, and sedentary time. Validity was assessed by percentage error (PE), absolute percentage error (APE), Bland-Altman plots and correlation coefficients.In a cross-sectional validation study, 20 older adults performed an activity protocol based on ADL with MOXFor step count, the optimized algorithm had a mean APE of 9.3% and a correlation coefficient of 0.88. The mean APE values of dynamic, standing, and sedentary time were 15.9%, 19.9%, and 9.6%, respectively. The correlation coefficients were 0.55, 0.91, and 0.92, respectively. Three reference applications showed higher errors and lower correlations for all outcome variables.This study showed that the optimized algorithm parameter settings can more validly estimate step count and physical behavior in older adults wearing an activity tracker in the trouser pocket during ADL compared to reference applications. In the past decade, activity trackers have been used more frequently by a relatively young and physically active population . In addiSeveral studies have shown that older adults are most interested in step count and amount of physical behavior as outcome variables for physical activity . Recent Recently, an adjustable classification algorithm was published to optimize algorithm performance . ThroughThe first purpose of this study was to validate these optimized algorithm parameter settings for step count and physical behavior expressed as dynamic, standing, and sedentary time in older adults with a normal pattern wearing an activity tracker in their trouser pocket during simulated ADL. Secondly, to have a more relevant interpretation of the validation results, the performance of the optimized algorithm parameter settings for older adults was compared to the algorithm where the adjustable classification algorithm originates from and two frequently used activity trackers.A cross-sectional validation study was performed in which the optimized algorithm parameter settings were validated and compared to the algorithm where the adjustable classification algorithm originates from and two activity trackers.Twenty older adults were recruited from several local associations for older adults  in the South of the Netherlands. Participants were included if they were older than 65 years and didn’t meet the Dutch physical activity guidelines (a minimum of 150 min of moderate-intensity per week ). ExclusA participant-determined sequence activity protocol was developed based on ADL. To simulate free-living, participants were free to choose the order and duration of a series of daily activities. The activity protocol, shown in The MOX Activity Logger   containsTwo commonly used activity trackers, the activPAL  and the Fitbit Alta HR  were used as reference for a more relevant interpretation of the validation results. Based on the recommendations of the manufactures the activPAL is worn on the dominant leg ten centimetres above the patella (activPAL) and the Fitbit is worn on the non-dominant wrist .2) and facilities. Demographic data were collected  by two researchers, either DU (physiotherapist) or WB (application engineer). Thereafter, the participants performed the 10 MWT to calculate their average walking speed. After the 10 MWT, participants were fitted with the MOX, the activPAL, and the Fitbit. The same MOX, activPAL, and Fitbit were used for all participants.Participants were measured at the Human Performance Laboratory of Maastricht University  or at Zuyd University of Applied Science . Both laboratories are comparable in size , where the adjustable classification algorithm originates from. The second one is the classification algorithm with application specific adjustable parameters itself . For the Fitbit, step count and active minutes   using Matlab  with two algorithms. The first one is the activity classification algorithm presented and validated by k [MET]) , were reData analysis was performed using SPSS Statistics  and Prism (GraphPad Prism 8.2.1(441); GraphPad Software, San Diego, CA, USA).Descriptive statistics of the participant characteristics were presented as a number (percentage) for the categorical variable gender and as a mean  for the continuous variables age, body length, body weight, and average walk speed.r ≥ .90) in order to guarantee a robust gold standard  and Bland-Altman plots with limits of agreement. It was hypothesized that there was a strong correlation between observers , mean difference, the percentage error (PE), the absolute percentage error (APE), and the smallest detectable change (SDC) were used to gain insight into the algorithm’s and activity trackers’ performance compared to video observations.Formula 1 and 2 show the calculation of PE and APE for each variable. A PE or APE of less than 10% was considered acceptable . FormulaMissActivity, MOXAnnegarn, activPAL, Fitbit versus the video observations regarding the variables step count, dynamic, standing, and sedentary time. It was hypothesised that there would be at least a substantial correlation (r ≥ .60)  . A paireTwenty older adults were recruited for this study. The participant characteristics are displayed in P < .001 95% CI 0.95–0.99). The inter-observer reliability of dynamic, standing, and sedentary time were also high , ,  respectively. The limits of agreement for step count (−58 to 62 steps), dynamic (−49 to 41 s), standing (−49 to 40 s) and sedentary time (−26 to 28 s) showed no systematic differences. A third observer had to be included in two cases.The inter-observer reliability of the video observations calculated for step count was high  steps, the activPAL had a mean step count of 385 (336–433) steps and the Fitbit had a mean step count of 731 (590–873) steps. The values of the percentage error and the absolute percentage error are presented in MissActivity, an overestimation in the activPAL and underestimation in the Fitbit. If the limits of agreement for the activPAL and Fitbit Alta HR are corrected for their respective bias they are −141 to 140 and −183 to 183, respectively.Descriptive statistics for each activity tracker are shown in MissActivity and MOXAnnegarn, two outliers were detected for standing time, both outliers were visible in the Bland-Altman plots. The video recordings were re-watched and, in both participants, the MOX was incorrectly worn. One of these outliers was also statistically detected with the z-score (5% with a z-score of >2.58). One outlier for the activPAL was detected for dynamic time, the outlier was visible in the Bland-Altman plot and was detected with the z-score (5% with a z-score of >3.29).The mean dynamic, standing, and sedentary time during the activity protocol counted by the video observations were 422 (387–457), 668 (579–757), and 1716 (1452–1981) seconds, respectively. On average the total protocol lasted 45 (40–51) min. For the MOXMissActivity without outliers was 405 (338–473), 696 (504–889), and 1692 (1383–2001) seconds, respectively. For the MOXAnnegarn the mean dynamic, standing, and sedentary time was 152 (131–174), 927 (712–1141), and 1715 (1392–2038), respectively. For the activPAL, the mean dynamic, standing, and sedentary time was 309 (255–364), 1256 (859–1645), and 1234 (946–1522) seconds respectively. The mean dynamic time for the Fitbit was 1 (0–3) minutes.The mean dynamic, standing, and sedentary time for the MOXsupplementary file 1. The PE and APE for physical behavior are shown in supplementary file 2).Descriptive statistics without outliers for each activity tracker are shown in MissActivity without outliers (The Bland-Altman plots of the MOXoutliers  show a sMissActivity) can more validly measure step count and physical behavior expressed as dynamic, standing, and sedentary time in older adults wearing an activity tracker in their trouser pocket during ADL based on a test combination of PE, APE, correlation coefficients, and paired sample t-test compared to the MOXAnnegarn, activPAL, and Fitbit.This study showed that the optimized algorithm parameter settings  and an APE of <10%. Only the variable dynamic time had a slightly lower correlation coefficient of 0.55 and the variables dynamic and standing time had a mean APE of 15.9% and 19.9%. These results are supported with additional analyzes of the specificity, sensitivity, and accuracy (supplementary file 2). This can be explained by the fact that the activities in the activity protocol were classified into dynamic, standing, and sedentary behavior as a whole. For example, by definition, the video observations classified changing linens as dynamic behavior, however during this activity it is possible that the participant performed a sequence of standing and dynamic behavior .The variables step count and sedentary time showed good validity in comparison with the gold standard. It was hypothesised that all variables of the MOXAnnegarn, activPAL, and Fitbit showed lower validity compared to the gold standard and the MOXMissActivity. It is clear that these target group and wear location specific classification algorithms cannot be applied outside of their specific context. The results for the activPAL are in line with a recent study showing a low validity during short stepping bouts and activities with low walking speeds, such as shuffling, picking, transitions, and kneeling in older adults . Future work could include a larger sample size, although several validity studies have been performed with a sample size of 20 .A strength of this study is the use of the participant-determined sequence activity protocol to validate the algorithm. This activity protocol simulates free-living since participants were free to choose the order and duration of the activities they performed. To simulate the free-living situation as best as possible activities that are frequently performed by older adults are included in the activity protocol. Furthermore, this study follows the recommendations made by From previous research it is known that consumer-grade activity trackers can’t measure step count and physical behavior validly during low walking speeds, which often occurs in older adults and during ADL . ApparenFor an activity tracker to be useful in daily life, validity is important, but feasibility is equally important. In a future feasibility study, development of a user-friendly user-interface of the MISS Activity will be addressed. The validated algorithm together with the user-interface will be called the Measure It Super Simple (MISS) Activity .This study showed that the optimized algorithm parameter settings can more validly estimate step count, dynamic, standing, and sedentary time in older adults with a normal gait pattern wearing an activity tracker in their trouser pocket during a participant-determined sequence activity protocol with activities of daily living compared to reference applications with generic activity tracker algorithms. For future studies and clinical practice an algorithm should ideally be optimized to the target population. Future work will include the development of a target group-specific user-friendly application.Click here for additional data file.Supplemental material, Supplementary_file_1_v3. for The Validation of a Pocket Worn Activity Tracker for Step Count and Physical Behavior in Older Adults during Simulated Activities of Daily Living by Darcy Ummels, Wouter Bijnens, Jos Aarts, Kenneth Meijer, Anna J. Beurskens and Emmylou Beekman in Gerontology and Geriatric Medicine


To assess the prevalence of sarcopenic obesity and its association with functionality, lifestyle, biomarkers, and morbidities in older adults.2. For men, a fat percentage ≥27% and ASMMI <7.26 kg/m2 was defined as sarcopenic obesity. Multivariate analysis was performed using a multinomial regression model , with sarcopenic obesity as the outcome.The study analyzed cross-sectional data from 270 older adults who participated in phase III of the Frailty in Brazilian Older People Study . They took part in a home interview surveying socioeconomic, demographic, lifestyle, morbidities, and functional data. Blood was collected for biochemical marker analysis and participants’ body composition was determined by dual-energy X-ray absorptiometry. For women, the diagnosis of sarcopenic obesity was defined at a body fat percentage ≥38% and appendicular skeletal muscle mass index (ASMMI) <5.45 kg/mThe prevalence of sarcopenic obesity was 29.3%. In the final fitted model, the variables that displayed statistically significant association with sarcopenic obesity were lower gait speed, self-reported medical diagnosis of arthrosis or arthritis, and high levels of glycemia.The study showed a high prevalence of sarcopenic obesity in non-institutionalized older adults in Brazil. The finding that this condition was associated with modifiable risk factors may provide insights into measures directed at prevention and reduction of the risk of sarcopenic obesity in this population subgroup. The diagnosis of sarcopenic obesity (SO) considers the simultaneous presentation of high fat mass and low muscle mass; it represents the confluence between two body-composition phenotypes: sarcopenia and obesity. In recent years, obesity and sarcopenia have come to be considered as global epidemics, having a substantial impact on older adults’ quality of life, mainly through the synergistic effects of these two factors.Globally, and in Brazil, the prevalence of SO in older adults has increased in recent years -7. HowevStudies using anthropometric measurements and electrical bioimpedance to diagnose SO have tended to find prevalence values ranging from 2% to 25% -11. StudThe DXA assessment of body composition is less likely to be influenced by body water content than other methods. Measurements obtained by this method has been considered as a reference standard in validation studies of methods and equations used to assess body composition. This method offers good validity and reliability and is a non-invasive technique for collecting information on various human body tissue types -24.Prior studies have found an association between SO and functionality, sedentarism, biomarkers such as C-reactive protein (CRP), glucose, and albumin, and diabetes mellitus ,20,25,26More recently, there has been increasing interest in elucidating the relationship between biomarkers and SO ,27. In sSO is associated with increased morbidity, mortality, reduced quality of life, increased hospital admissions, and higher health costs ,29. HoweAccordingly, the objective of this study was to evaluate the prevalence of SO in older adults in Brazil, and to investigate its association with functionality, lifestyle, particular biomarkers, and physical morbidity.The methodology of the Frailty in Brazilian Older Adults study , was described elsewhere . BrieflyThe data analyzed in the present study were obtained from the phase III database recorded in 2013. From the phase I sample, 136 individuals were excluded due to death and 102 individuals for the following reasons: MMSE score of ≤13; institutionalization; wheelchair user or bedbound; pacemaker user; difficulty in walking; or severe cognitive changes reported by the family. After these exclusions, 609 individuals were eligible, and attempts were made to contact them to request participation. Of these, 64 could not be located, and 143 refused to take part. Thus, 402 older adults constituted the final sample; these individuals participated in home interviews, following the phase I protocol.For blood tests and body composition evaluation, all 402 individuals were invited to visit the clinical analysis and nutritional evaluation laboratories of Rio de Janeiro State University . Transport was offered to those with difficulty in traveling from home. Three hundred individuals agreed to proceed with the study; the blood test was performed on 297 and the DXA examination on 270 .Weight and height were measured for all participants while barefoot and wearing light clothing, using the methods described by Lohman et al. . Height i.e., lean tissue (kg), from the arm and leg regions, and dividing by the square of the height (meters) . Fat mass and lean mass were analyzed. The upper and lower limbs were isolated from the trunk and head by lines drawn by the software, which could then be manually adjusted with precision. Appendicular muscle mass was evaluated by means of the appendicular skeletal muscle mass index (ASMMI), obtained by adding lean mass, (meters) .2 for men, and <5.45 kg/m2 for women  ,36, and or women ,36.In order to evaluate the dependent variable, SO, participants were categorized as eutrophic, non-sarcopenic obese, or sarcopenic obese.Factors potentially associated with SO were grouped into three groups: 1) functional variables and physical morbidities , 2) biomarkers , and 3) lifestyle variables .Gait speed was evaluated by measuring the time taken by the individual to walk 4.6 meters at their habitual pace. A chronometer was started at the moment the individual placed a foot on the starting mark and lifted the other off the ground. Individuals with gait speeds of 0.8 m/s or less were considered as displaying gait slowing .Muscular strength was evaluated by taking three measurements at regular intervals of 1 minute using a hydraulic dynamometer  in the dominant hand. The grip was adjusted according to the participant’s sex: position 2 for women and position 3 for men. The mean value of the three measurements was calculated and analyzed with adjustment for the individual’s sex and BMI. Individuals in the first performance quintile were considered to have low hand-grip strength .Instrumental Activities of Daily Living (IADLs) were assessed using the Lawton scale , for sevPhysical morbidities—diabetes mellitus and arthrosis/arthritis—were investigated by self-reporting in answer to the question: “Has a doctor ever told you that you have the following health problems: diabetes mellitus (Yes/No) and arthrosis/arthritis (Yes/No)?”.CRP levels were considered abnormal at >0.5 mg/dl; albumin was considered low at <3.5 g/dl; and glycemia was considered high at >100 mg/dl. The participant’s blood samples were collected by trained technicians, by vacuum venipuncture, after a 12-hour fast. Participants abstained from physical exercise for 24 hours before collection, and from consuming alcohol in the 72 hours before collection.The lifestyle variables examined were tobacco use (current smoker/ever smoked and stopped/never smoked), walking for exercise (Yes/No), and consuming alcohol on a daily basis (Yes/No).The socioeconomic and demographic variables: age, sex, income, schooling, and race were included as covariables.Age was recorded in years, in three age groups . Income source was described as retired, pensioners, and/or with other sources of income. Individual income from work, retirement benefit, or pension was recorded in minimum wages (MWs) at the time of interview and was categorized as 0-2 MWs; 2.1-5 MWs; and >5 MWs. Education was recorded in years and was categorized as illiterate, 1-5 years; 6-11 years, and ≥12 years. Race was categorized as white and Afro-descendent.For descriptive analysis, absolute and relative frequencies were calculated for the categorical variables. To evaluate the dependent variable, individuals were categorized as eutrophic, non-sarcopenic obese, and sarcopenic obese. A bivariate analysis was performed, using the chi-square test, to investigate the association between SO and the independent variables.Subsequent multivariate analysis was performed by multinomial logistic model, which yielded crude and adjusted odds ratios (ORs) as measures of association, together with their respective 95% confidence intervals (95%CI). That model was used to identify associations of functional variables, morbidities, biochemical markers, and lifestyle with SO.p<0.20 in the bivariate analysis were included in the multivariate models. We evaluate the fit of the model using the deviance statistic and the pseudo-R of Nagelkerke. Statistical analysis was conducted using the statistical package SPSS for Windows, version 19.Independent variables that returned The study followed the recommendations of Resolution 196/96 of the Ministry of Health’s National Health Council , and was approved by the National Research Ethics Committee , in opinion No. 120.700/2012. All participants signed a declaration of free and informed consent.This study examined 270, predominantly female, older adults, of mean age 77.5 years (SD=5.92). The prevalence of SO was 29.3% (n=78). Most participants were white, with an income ranging from 2.1 to 5 MW, and were in the 75-84 year age group. Almost half had 6-11 years’ education, while about one-third had more than 12 years’ education .p<0.0001)  .Among the lifestyle variables, a high prevalence of SO was observed in older adults who had stopped smoking and who drank alcohol daily, but these findings lacked statistical significance. SO was also present in more than one-quarter of older adults who did not walk for exercise, but this was not statistically significant .Analysis of the biomarkers showed that about one-fifth of older adults with SO also had hypoalbuminemia, about one-third had hyperglycemia, and about one-quarter had elevated CRP levels .In terms of functional variables, among individuals with SO, more than 30% had lower gait speed, more than one-third had reduced hand-grip strength, and about one-third were dependent according to the IADLs .p<0.001). The percentage of fat in obese individuals was exceeded when wishing with sarcopenic obsession. Individuals with SO also had lower mean muscular mass index values than obese individuals (p<0.001).In This study found a high prevalence of SO and obesity among older adults in Brazil. These results corroborate other Brazilian and international studies ,26,27,30The present study found a higher prevalence of SO among men 65.3%) than among women 34.6%). This was a similar trend to that found by Batsis et al. , in a cr.6%. This.3% than Thus, the prevalence of SO is not yet clearly established and can vary by a factor of as much as 26, mainly because of the use of different evaluation methods, criteria, and cut-off points applied to determine muscle mass and fat mass . This vaMoon et al. , in a stvice versa  among non-institutionalized older adults, can serve as an alert to the greater risk of such older adults developing SO in the near future. The prevalence of SO and obesity is probably associated with the specific characteristics of our sample, which included older individuals and mostly women. Indeed, in other studies, the proportion of SO and obesity increased with age, most likely due to hormone-related body composition changes, reaching higher values in individuals over 75 years of age.p<0.005). Moreira et al. .Our findings in relation to elevated glycaemia were in agreement with the findings of the study in Korea by Hwang et al. , which eIt remains unclear whether the presence of arthrosis/arthritis precedes SO or whether individuals with SO are at higher risk of developing arthritis/arthrosis. The possibility of bidirectionality between such events should not be discarded as it is quite plausible. However, we found no other study that has evaluated the role of arthrosis/arthritis in the development of SO. Tyrovolas et al.  analyzedThis study had some limitations. Its cross-sectional design did not enable temporal or causal associations to be shown, leading to the possibility of reverse causation among the findings. This possibility cannot be excluded, given the bidirectionality of the phenomena studied. Another limitation involved the use of walking as physical exercise to assess the physical activity of the participants. This assessment is insufficient to assess the set of physical activities that are performed, and thus may have led to underestimation of this parameter. Additionally, there may have been information bias resulting from the self-reported physical morbidity data. The scarcity of studies and the great variability of diagnostic methods and criteria for SO placed limitations on data comparability. Moreover, the FIBRA-RJ study involves a closed cohort. This fact prevented the sample from being recomposed after losses occurred during the follow-up and exclusions during data collection. Despite these limitations, the specificities of the FIBRA-RJ sample has the advantage in terms of providing knowledge about the body composition phenotypes present in the elderly population.To the best of our knowledge, no previous study had evaluated the prevalence of SO and its associations with functionality, lifestyle, biomarkers, and physical morbidity in Brazil, using the DXA method. Data quality was assured by team training, data quality supervision and control immediately upon completion of the data collection protocols, and prompt correction of any errors. Lastly, evaluation of body composition by the DXA method, which is considered to be a reference method, provided greater precision and validity to the study findings.In summary, this study revealed a high prevalence of obesity and SO among older adults in Brazil. The high prevalence of both these two body composition phenotypes are cause for concern, because obese older adults can become sarcopenic obese. The finding that slower gait, hyperglycemia, and arthrosis are associated with the presence of SO underscores the possibility that early intervention and prevention of these modifiable risk factors can assist in preventing obesity and SO in older adults.Despite limited data comparability due to cultural and racial differences, and diversity in cut-off points and diagnostic criteria, the results of various different studies reinforce the association between lower gait speed, hyperglycemia, and SO in older adults. To improve research in this field and ensure better data comparability, it is of prime importance that consensus on the diagnosis of SO be established.Campos GC contributed with significant participation in the study design, data collection, analysis, interpretation of data and preparation of the article. Lourenço RA contributed with significant participation in the study design, preparation or revision of the manuscript and approval of the final version of the manuscript for publication. Lopes CS contributed with significant participation in the study design, preparation and review of the analysis and manuscript and approval of the final version for publication.


Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense and caused devastating epidemics during the 20th century. Due to effective control programs implemented in the last two decades, the number of reported cases has fallen to a historically low level. Although fewer than 977 cases were reported in 2018 in endemic countries, HAT is still a public health problem in endemic regions until it is completely eliminated. In addition, almost 150 confirmed HAT cases were reported in non-endemic countries in the last three decades. The majority of non-endemic HAT cases were reported in Europe, USA and South Africa, due to historical alliances, economic links or geographic proximity to disease-endemic countries. Furthermore, with the implementation of the ‘Belt and Road’ project, sporadic imported HAT cases have been reported in China as a warning sign of tropical diseases prevention. In this paper, we explore and interpret the data on HAT incidence and find no positive correlation between the number of HAT cases from endemic and non-endemic countries. This data will provide useful information for better understanding the imported cases of HAT globally in the post-elimination phase.Human African trypanosomiasis (HAT) is caused by  Two subspecies are able to infect humans: Trypanosoma brucei gambiense causes a chronic form of HAT in West and Central Africa, while Trypanosoma brucei rhodesiense is the pathogenic agent for the acute form of the disease in Eastern Africa , also known as sleeping sickness, is a neglected tropical disease, which is found in 36 African endemic countries  in endemic countries and non-endemic countries during the period between 1990 and 2018.Trypanosoma brucei’, ‘Trypanosoma brucei gambiense’, ‘Trypanosoma brucei rhodesiense’, ‘Human African trypanosomiasis’ to identify papers published between Jan 1, 1990 and Dec 31, 2018 on Human African trypanosomiasis cases in non-endemic countries. Additionally, we reviewed relevant articles cited in those references and included them as primary sources when appropriate.We searched PubMed for the terms ‘et al., et al., Human African trypanosomiasis was first described around the 14th century, but it can probably be considered as endemic in African regions since the appearance of humans. In the 20th century, because of the socio-economic impact caused by HAT, effective measures were taken to control the disease. This resulted in it reaching a very low, generalized, transmission by the mid-1960s with a minimum of 4,435 cases declared in Africa in 1964 WHO, b. HoweveT. b. gambiense  in the DRC, led to a sharp increase in total number of gambiense-HAT cases. In addition, new cases of gambiense-HAT in Angola also sharply increased during this period due to civil war, like 6726, 8275 and 6610 new cases were reported in 1996, 1997 and 1998, respectively  , Cameroon (5 cases), Chad (28 cases), Congo (15 cases), Côte d'Ivoire (3 cases), Equatorial Guinea (4 cases), Gabon (9 cases) and South Sudan (12 cases), respectively. To our knowledge, there are no reported gambiense-HAT cases in other West and Central Africa countries. However, during 2017, there were only 27 reported new cases of rhodesiense-HAT in Eastern African endemic areas, these were distributed in Uganda (13 cases), Malawi (7 cases), United Republic of Tanzania (3 cases), Zambia (3 cases) and Zimbabwe (1 case), respectively.According to reports from WHO, less than 1500 new cases of HAT  . FurtherT. b. gambiense, and 24 new cases of T. b. rhodesiense. It was exciting that the number of reported gambiense-HAT cases from the Democratic Republic of the Congo was down to 660 and the HAT cases from every other country numbered fewer than 100 , Uganda (4 cases) and Zambia (5 cases), respectively in 2018.Based on the latest reports from WHO WHO, a, 2019b,than 100 . Surpriset al., et al., rhodesiense-HAT and 4 cases of gambiense-HAT and another 2 indeterminate cases . Therefore, by the time they were diagnosed, the disease had developed into the second stage. Due to historical or economic links with endemic countries and frequent travel to endemic countries, citizens from Europe have more chances of becoming infected with trypanosomes. More than half of the cases  were diagnosed in European countries . In addition, another 2 cases were reported in North America (including one in Canada and one in USA) and South America (Argentina), respectively. The remaining 4 cases were identified in Asia. Interestingly, with the exception of 1 case from Israel, the other 3 HAT cases were all diagnosed in China, which is now starting to appear as a non-DEC with increasing numbers of imported HAT cases during the period of 2011–2018.The human African trypanosomiasis cases in non-endemic countries from 1990 to 2010 have been collected in previous reports  were reported in non-endemic countries between 1990 and 2000 , 20% (8 cases) and 20% (8 cases), followed by Cameroon , Equatorial Guinea, Nigeria, Central African Republic and Uganda , Sudan  and one uncertain case (2.5%) which may have originated from Nigeria or Gabon. To our surprise, as many as 7 and 3 cases were exported from Gabon and Cameroon, respectively, despite numbers of indigenous cases being as low as 305 and 174 in these two countries from 2001 to 2010. In addition, although only 6 indigenous cases were reported in Nigeria, 1 case of exported HAT has been reported between 2011 and 2018. There seems to be a general lack of association between incidence and exported infections across many endemic countries.However, the majority of HAT cases were 990–2018 . The couP = 0.62) between the two groups  that shows higher numbers of incoming tourists in East African DEC countries  compared with West African DEC countries   when the comparative datasets are offset by 4 years (i.e. DEC data from 1990 to 2014 compared year by year with non-DEC data from 1994 to 2018). Significant correlations are additionally found when comparisons are offset by 3–7 years. Such a delay between the endemic peaks could be attributed to the relatively long incubation period in T. b. gambiense infections, a delay in diagnosis or reporting of cases in the recipient non-DEC or a generic delay in reporting back to WHO. Comparable significant correlations were found when this analysis was carried out separately on T. b. gambiense data  but no correlation at all was seen when analysing T. b rhodesiense non-DEC case data . This broad analytical approach has many flaws but suggests that more detailed case information and better stratification of the data might tell us more about the role of HAT carriers or the reporting processes in non-DEC cases.Interestingly, an inspection of the data presented in T. b. gambiense and T. b. rhodesiense maybe spill over to humans  . However, in some rural areas where trypanosomiasis is prevalent, the overall performance of peripheral health systems is often weak and characterized by unskilled staff, low attendance and low coverage.Sleeping sickness, also known as HAT, is a neglected disease that impacts 70 million people living in 1.55 million kmgambiense-HAT requires a turmoil-free socio-political context. However, the elimination of rhodesiense-HAT poses challenges because of the vast animal reservoirs.Furthermore, political instability and insecurity are inescapable challenges in an elimination programme. Gambiense-HAT does not spread easily and humans are the only significant reservoir. The successful elimination of et al., Therefore, the strengthening of health systems to implement the activities included in the elimination strategies is essential. Past and current experiences show that HAT elimination is difficult and will require more effort, time, and money than initially anticipated. History teaches us that falling case numbers can result in a decline in donor and control agency interest, opening the door to swift and severe recrudescence , the opposite is true for imported cases in non-endemic countries, where 72% of cases are caused by


The aim was to determine the survival of tooth-coloured restorative materials in proximal restorations of primary teeth at 24 months of follow-up and the influence of the following variables: use of coating, use of cavity conditioner, use of rubber dam isolation, the cavity form, the dentist’s experience and the methodological characteristics of the studies. We conducted a search until May 2019, obtaining 16 articles from which 30 independent studies were extracted, which were considered as units of analysis. Four outcome measures were extracted from each study: retention, marginal integrity, anatomic form, and absence of recurrent caries. Separate meta-analyses were carried for each outcome and multiple meta-regression model was applied. The outcomes with the highest mean success rates were absence of recurrent caries and anatomic form. The type of material significantly influenced success rates. The best materials were resin-based material plus total-etching adhesion and resin-modified glass ionomer cement (RMGIC), and the worst high viscosity glass ionomer cement (HVGIC). Atraumatic restorative treatment (ART) had a lower success rate than the conventional cavity form. RMGIC had the best clinical performance and HVGIC the worst. The form of the cavity, blinding and the experience of the operator were the variables that influenced success rates. Proximal primary molar restorations should be performed with RMGIC as it combines good mechanical performance of the resins together with the prevention of secondary caries of glass ionomers. Dental caries, according to the WHO, remains the most frequent chronic disease in early childhood in most communities around the world, having a negative impact on the quality of life of both the child and their family, and is considered a public health problem3.The Global Burden of Disease 2015 study5. Currently, restorative treatments for primary teeth include a wide variety of tooth-coloured materials such as glass ionomer cements (GIC), resin-modified glass ionomer cement (RMGIC), high viscosity glass ionomer cement (HVGIC), compomers and composite resins (CR). In general, composites are recommended in children with a low risk of caries, compomers in children with a moderate risk and glass ionomers in children with a high risk6.The toxic effects on the patient, health professionals and the environment, the increasing prevalence of minimal intervention restorative approaches and the increased demand for aesthetics, have reduced the use of amalgam as the material of choice for the restoration of primary teeth7 due to their ability to adhere to the dental structure, low polymerization contraction, lack of postoperative sensitivity, biological compatibility and the anti-cariogenic effects of fluoride release8. However, their low resistance to fracture and wear does not make them suitable materials for proximal restorations, with a failure rate of 6.6–60% at 36 months9. RMGICs, whose composition includes resin, improve the physical and aesthetic properties of GICs, while maintaining their potential for fluoride release12. HVGICs maintain the mechanical properties offered by resins  without containing resins, and have performed well in reconstructions of the posterior sector in primary and permanent dentition14.GICs are good materials for the primary dentition15, this has led paediatric dentists to search for alternatives. Compomers and giomers, which present the mechanical and aesthetic properties of a composite together with the ability to release fluoride, have been used in proximal cavities of primary teeth20.CRs have been used as a substitute for amalgams, with good short-term performance in both occlusal and proximal restorations. However, due to the problems derived from polymerization contraction  and because these materials are very sensitive to the technique used and require a demanding placement protocol19. The success rate of the restoration depends on the properties of the material, the level of the risk of caries, the state of the tooth affected, the characteristics of the patient and the dentist’s ability in the use of the materials and in handling the child’s behaviour21.Paediatric dentists have, therefore, a wide range of materials for the restoration of proximal cavities, or class II, in primary teeth. In choosing the material, one important factor should be considered: the longevity/survival of the restoration, since the replacement of failed restorations is a problem for patients, professionals and public health systems22. A 2009 systematic review studied all types of restorative materials used in primary dentition , all types of cavities (classes I to V) and different cavity preparations  with a follow up of >6 months. They could only include three studies and these did not provide sufficient evidence to make any recommendations about which filling material to use21. A systematic review and meta-analysis, published in 2016, analysed the survival time of adhesive restorations  for class I and II of primary molars, and concluded that there was weak evidence that adhesive materials with a resin component have similar survival rates for 24 months and up to 48 months and that there was no evidence that adhesive materials with a resin component in the formula had a greater survival rate than glass ionomer cement24. A systematic review studied, in 2018, the survival of restorations  placed using different materials in primary teeth with at least one year of follow-up. They found large variations in the annual failure rates (0–29.9%) due to the differences in the techniques and material evaluated. The lowest annual failure rate was in class I restorations using a rubber dam and those using CR (1.7–12.9%) and the highest success rate was for stainless steel crowns (96.1%)21.A 2007 meta-analysis of 21 studies concluded that, of the coloured restorations in primary molar proximal lesions followed for at least 1 year, RMGIC had the highest clinical success rates, although only one RMGIC product was assessableIt is necessary to determine the success rate of tooth-coloured materials used in the restorations of proximal classes of temporary teeth, including those marketed in recent years, such as HVGIC and giomers. Therefore, the main objective of this meta-analysis was to determine which tooth-coloured restoration material is most suitable for proximal fillings in primary teeth. The question posed was: What will the survival of different tooth-coloured restorative materials in proximal restorations of primary teeth be at 24 months? The secondary objective was to determine factors influencing the success of the tooth-coloured restoration material at 24 months. The null hypothesis of our study was that the success rate at 24 months of proximal restorations of primary teeth does not depend on the tooth-coloured material used.25. Supplementary File The meta-analysis was carried out according to the PRISMA  method26, the studies to be included in this meta-analysis the studies had to meet the following criteria:Participants: primary teeth with proximal caries in children aged 2–14 years.in vivo.Interventions: tooth-coloured proximal (or class II) restorations  evaluated Comparisons: Not applicable.Outcomes: Success rate at 24 months of follow-up for retention, marginal integrity, anatomic form, and absence of recurrent caries.Study designs: randomized controlled trials (RCTs), non-randomized controlled trials (nRCTs), and uncontrolled trials.Using the components of the Participants, Interventions, Comparisons, Outcomes, and Study designs (PICOS) systemin vitro studies, observational studies, studies of permanent teeth, studies evaluating the survival of materials in classes I, III, IV and V, studies dealing only with amalgam or cermet restorations or stainless steel crowns, and studies with a follow up other than 24 months.In addition, published and unpublished studies were accepted. We excluded reviews, clinical cases, We exhaustively searched the following electronic databases: PubMed, MEDLINE, SciELO, Embase, Scopus, WOS, LILACS and BBO. We also carried out a manual search to find studies not included in the electronic databases. We adapted the search strategy to the requirements of each database. The references of the studies recovered were also reviewed to identify studies that might fulfil the selection criteria. The search languages were English, Spanish and Portuguese, and the search covered 1985 to May 2019. We included the following search terms, making the appropriate adaptations to the language required by the different databases: “survival”, “durability”, “primary”, “deciduous”, “teeth”, “class II”, “proximal”, “occlusoproximal”, “composite”, “compomer”, “glass ionomer”, “high viscosity glass ionomer”, “resin modified glass ionomer” and “giomer”.Studies were selected in a three-stage procedure. First, the title of the study was considered. Studies that appeared in the results of more than one database were only taken into account once, and all duplicate studies were eliminated. Secondly, we read the abstracts of the articles. If the summary did not provide sufficient information to make a decision about its inclusion or exclusion, we reviewed the entire study before making the final decision. Thirdly, we considered the full text to determine its inclusion or exclusion. Selection was made independently by two authors . Subsequently, the authors discussed studies in which there were discrepancies until a consensus was reached.The most relevant data were extracted from the articles and included in a database which collected the main characteristics of the intervention and the evaluation criteria of the restoration materials. The complete database is shown in Supplementary Dataset file. For the extraction of the results, within the same article, each restoration material, or the same material under different experimental conditions, was considered as an independent study.All materials were classified into five types: resin-based materials bonded using total etching ; resin-based materials bonded with a self-etching adhesive ; open-sandwich technique (RMGIC as base plus composite); RMGIC; and HVGIC.27, USPHS modified by Ryge and Snyder in 197328, USPHS modified by Ryge in 198032, USPHS modified by Van Dijken in 198635, USPHS modified by Ryge in 1980 and ART modified criteria36, own system35, FDI criteria20.To compare the results of the studies, the evaluation criteria of the different systems used were unified into four categories .Complete isolation with rubber dam.Cavity form, differentiating between cavities made according to ART principles  and conventional cavities (cavities made by using rotary instruments and burrs).Operator experience, considering non-graduate student as inexperienced and graduate dentists as experienced.The most relevant characteristics of the intervention studied were:The following patient characteristics were extracted: mean and SD of age (in years) and sex . The following methodological characteristics were extracted: design , random assignment, blinded assessment, reporting bias, and sample size. Financial sources and year of the study were also extracted. To check the reliability of the extraction of the study characteristics, two independent coders doubly coded all studies. The results were highly satisfactory overall, with kappa coefficients ranging between 0.927 and 1.0 (mean = 0.993) for categorical variables, and intra-class correlations between 0.805 and 1.0 (mean = 0.979) for continuous variables. Inconsistencies between the coders were resolved by consensus.Lp = Ln [p/(1 − p)], with p being the success rate, Ln the natural logarithm, and Lp the logit event rate. In each meta-analysis, a random-effects model was assumed38 and, consequently, the logit event rates were weighted by the inverse variance, defined as the sum of the within-study and between-studies variance. The latter was estimated using the DerSimonian and Laird method39. The sampling variance of each logit event rate, V (Lp), was calculated as: V (Lp) = 1/(np) + 1/[n (1 − p)], with n being the sample size. Subsequently, the results were back-transformed to success rates to facilitate interpretation by means of: p = eLp/(eLp + 1), with e being the base of the natural logarithm40. In each meta-analysis, the 95% confidence limits around the mean success rate were computed using the method proposed by Hartung41. The heterogeneity of the success rates was assessed by constructing a forest plot and calculating the Q statistic and the I2 index. I2 values of about 25%, 50%, and 75% can be considered as reflecting low, moderate, and high heterogeneity42. To test whether publication bias was a threat to the validity of the meta-analytic results, funnel plots were constructed applying the trim-and-fill method43.From each sample, the proportions of success at 24 months were extracted for the four outcome measures: retention, marginal integrity, anatomic form, and absence of recurrent caries. Separate meta-analyses were made for each outcome. To normalize the distribution of the success rates, they were transformed using the logit event rate: 45. The improved F statistic proposed by Knapp and Hartung46 was applied to test the significance of the moderator variables. QE and QW statistics were applied to examine model misspecification for the continuous and categorical moderators, respectively. The proportion of variance accounted for by the moderator variables was estimated using R2, an index that takes into account the total and residual between-studies variance47. Finally, to identify the study characteristics that best explained variability of the success rates, a multiple meta-regression model was applied. The moderator variables included in the model were selected taking into account both statistical and practical significance achieved in the previous analyses. All statistical analyses were carried out with the metafor package for R48.If studies were found to have heterogeneity, moderator analyses were carried out using meta-regressions and weighted ANOVAs for continuous and categorical variables, respectively, assuming a mixed-effects modelFigure Study in permanent teeth: 4.Systematic review: 8.Did not evaluate restoration survival: 2.In vitro study: 9.Study of restorations class I, III, IV or V: 4.Follow-up time <24 months: 6.Follow-up time >24 months: 2.Comment on an article: 1.Seventy-one articles were accepted due to the title and, after reading the corresponding abstracts, 36 were excluded, due to:51.Study in permanent teeth: 363.Insufficient information on evaluation of material performance: 1464.Language other than English, Spanish, Portuguese: 1. 65.Did not evaluate restoration survival: 166.Identical to a previously selected item: 1. One article was found with a different title but with the same authors and an identical sample. We excluded one of the two articlesAfter complete reading of the remaining 35 articles, 20 were excluded due to:One more article was located by manual search.37.Finally, 16 articles were selected for reviewet al.28, was published in 1995, and the last, by Sengul and Gurbuz20, in 2015. Seven were randomized controlled studies37, five were controlled non-randomized trials31, and four were uncontrolled, non-randomized trials35. Randomization was correct in seven37 articles and incorrect or undefined in the remaining nine35. Among the articles with correct randomization, this was done by computer in three32.The 16 articles included in the meta-analysis were published over a 20-year period. The first, carried out by Andersson-Wenckert 37. In 14 articles there was no reporting bias37, and 15 articles did not declare whether there were conflicts of interest or not37. The source of funding was public in six of the articles37 and private or mixed in the remaining 1036. Thirty independent studies were extracted from the 16 articles selected. The most important characteristics of each study are shown in Table In nine studies, the dentists who evaluated the restorations were unaware of the material used, as they were triple blindedQ and I2) for each outcome. The absence of recurrent caries and anatomic form were the outcomes with the highest mean success rates . The mean success rates for marginal integrity and retention were 0.898 and 0.879, respectively. As retention was the main outcome, Fig. Q statistic was significant (p < 0.0001) for all four outcomes and the I2 indices were >75% in all cases , accounting for 37% of variance. A marginally significant result was found for anatomic form , explaining 36% of variance. Specifically, better results were found for resin-based material plus total-etching adhesion (p+ = 0.949), RMGIC (p+ = 0.956), and open sandwich restoration (p+ = 0.950), in comparison with resin-based material plus self-etching adhesion (p+ = 0.824) and HVGIC (p+ = 0.671). A marginally significant result was also found for anatomic form (p = 0.051), accounting for 51% of variance (Table p+ = 0.759).Regarding categorical moderators, Table  p+ = 0.99, RMGIC  p+ = 0.99, RMGIC p < 0.001), accounting for 46% of variance: the mean retention success rate was lower for ART (p+ = 0.649) than for conventional cavity design (p+ = 0.936). Similar results were found for marginal integrity . Of the methodological variables analysed, assessor blinding was significantly associated with retention success rates , suggesting residual heterogeneity among the success rates after including the moderator. Similar results were found for marginal integrity, anatomic form, and recurrent caries success rates , the form of the cavity , and assessor blinding .The predictors included in the meta-regression models for explaining success rates were selected as a function of both statistical and practical significance achieved in the previous results of the ANOVAs and simple meta-regressions. A moderator variable was included in the model when the k = 27. The results are shown in Table p = 0.001), accounting for 45% of variance. However, once the other predictors were controlled for, none showed a significant association with the success rates. This may be due to collinearity among the predictors. Inspection of the bivariate correlations between the predictors showed a significant association between the form of the cavity and the type of material , as ART usually uses HVGIC material. When the form of the cavity was removed from the meta-regression model, the type of material (dichotomized) was significant (p = 0.029) as was the full model, F  = 7.34, p = 0.001, accounting for 49% of the variance. Sample size and assessor blinding were not significant in the multiple meta-regression model.Due to missing data in some variables, the number of studies included in the meta-regression was p = 0.051), with 22% of variance accounted for, while neither predictors were significant once the influence of each on the other was controlled for. Cavity form and assessor blinding were included in the meta-regression model for anatomic form success rates. A significant association was found for the full model (p = 0.005) and 61% of variance was accounted for. In addition, the cavity form was significantly associated with anatomic form success rates (p = 0.017) after controlling for assessor blinding. With respect to recurrent caries, three moderators were included in the meta-regression model: use of coat, cavity form, and assessor blinding. The full model was significant (p = 0.007), with 83% of variance accounted for. Of the three moderators, only the use of coat was negatively associated with recurrent caries success rates (p = 0.022).The results of the multiple meta-regressions for marginal integrity, anatomic form, and recurrent caries success rates are shown in Supplementary Tables 67, and the EU banned its use, from July 1, 2018, for the restoration of primary teeth, in children aged <15 years, and pregnant or breastfeeding women68, paediatric dentists need to know what the best alternative material for the restoration of primary teeth is. Therefore, this meta-analysis tried to answer the question: which tooth-coloured restoration material has the best clinical behaviour in proximal restorations of primary teeth at 24 months? We chose proximal restorations because they have the highest failure rate, especially when functional, due to the presence of antagonistic teeth52.Since the FDA advised, in July 2010, that dental amalgam should not be used in children aged <6 years, due to its greater sensitivity to the potential toxic effects of mercury53. Moreover, after that time many studies have reported a high level of failure, depending on clinical variables and patient related factors. In general, the annual failure rate was 17% for restorations in primary molars69, although some studies recorded losses of around 50% at 24 months of follow up57. The success rate for class II in primary teeth was 68% at 18 months70 and 52´58% at 36 months71. This way, a study found that after a 7-year follow-up, only 1% of initial restorations completed the study72.We studied the success rate at 24 months ought to the dropout rates of study subjects increase over time because there is a marked increase in the rates of physiological exfoliation, characteristic of childhood growthFor better understanding of the results, the materials used in the studies analysed were divided into five groups: materials containing resin bonded with total etching ; resin-containing materials bonded with a self-etching adhesive , RMGLC, HVGIC, and open sandwich technique . Regardless of the material used, retention of proximal restorations was the most affected, with 12.5% of restorations lost within 24 months of placement. Marginal integrity, conservation of the anatomical shape and the absence of secondary caries, in descending order, were affected to a lesser extent.21. Unifying all the materials included in the study in materials that contain resin and those that do not, the meta-analysis showed that those containing resin had a higher success rate in the four clinical categories studied. RMGIC had the highest success rate followed by resin-based materials used with total etching and self-etch adhesives. The material with the lowest success rate was HVGIC. Although only retention was significant, the trend in all clinical categories studied  was the same.The success of a restoration depends on factors such as the material used, the state of the tooth, the experience of the operator and, the patient’s collaboration. This last aspect is of paramount importance in paediatric dentistry, since children’s behaviour largely determines the selection of the material and the technique to be used to restore a tooth, conditioning, finally, the wide variations in the success rate between the different materials and studies9. Another study also observed a better performance of RMGICs compared with conventional GICs and composites for class II primary teeth, arguing that RMGICs combine the best properties of both materials: on the one hand they have the good mechanical properties of composites and, on the other, the self-adhesive properties of GICs73. Vitremer  was the RMGIC used in the largest number of studies included in our meta-analysis. Of the five studies, in four it was used together with Vitremer Primer , a light cure adhesive that contains, among other things, 2-hydroxyethyl methacrylate monomer (45–55%) and the copolymer of acrylic and itaconic acids (10–30%). The joint use of the Primer gives it a greater adhesive capacity and reduced sensitivity to the exchange of water with the surrounding environment by rapid photopolymerization72.A meta-analysis showed that RMGIC performed better than conventional GIC for class II restorations in primary teeth74 or failures in 30% of class II ART restorations during the first month using HVGIC52. A study that compared the use of HVGIC using ART versus a conventional cavity technique concluded that, for HVGIC, there is a greater risk with ART cavities than with conventional cavities in primary tooth decay treatments, and success rates in classes II are worse than in class I75. This association between the poor results of ART and the poor clinical performance of HVGIC is strongly supported by our results, in which the bivariate correlations between predictors revealed a strong relationship  between the cavity form and the type of material. This may be due to the peculiarities of the ART technique, which uses HVGIC as a restorative material and does not allow complete isolation, meaning saliva contamination of the operative field is very frequent76 and the survival of multi-surface restorations could be more dependent on the material, operator and control of the operative field than single-surface restorations57. However, in a randomized controlled study 10 year follow-up to evaluate the durability and clinical performance of a HVGIC (processed with a resinous coating) compared with a micro filled composite resin in conventional class I y II cavities, in permanent teeth isolated with cotton rolls and suction devices, no significant differences were found for both restorative materials in terms of marginal adaptation, anatomical form, secondary caries, postoperative sensitivity, surface texture, and retention. The HVGIC could be also considered a good alternative to amalgam77.HVGIC showed, in our study, the worst retention rate (0.671), similar to other studies that found a 65% survival rate in multi-surface ART restorations using HVGICin vitro” studies, adhesion to enamel and dentin of materials containing composites are very sensitive to salivary contamination, although the results of “in vivo” studies are unclear. A systematic review found that, in the longevity of direct dental restorations made with a tooth-coloured material in primary teeth, the use of a rubber dam did not influence the results compared with the use of roll of cotton together with a saliva ejector78. A meta-analysis concluded that there are few studies with a very low quality of evidence on the advantages of using the rubber dam compared to cotton rolls together with a saliva ejector on the survival of restorations and neither, the previous application of cavity conditioner nor the final application of coating on the glass ionomer, influenced the success of the clinical variables studied79.Although we found a higher retention success rate when the dentist was experienced, we found no influence of the type of isolation. In “Our results showed that, of all the methodological variables used, the type of trial, randomization, reporting bias and the source of funding did not influence the retention, marginal integrity, anatomic form and absence of recurrent caries success-rates, indicating that the type of study did not influence the results of the different materials and supports our decision not to use quality scales, where the type of study is decisive in the final score, to decide the inclusion of the works in our meta-analysis, but include all studies that met the inclusion criteria considering as an independent study each of the materials used or each of the different experimental conditions used with the same material.Evaluator blinding was important in determining the success of the restoration in the four clinical criteria evaluated in the opposite direction as expected, since when the evaluator knew the material the degree of success measured was lower than when they did not. The influence that we have observed in the triple blind indicates that in the next studies that are carried out, the evaluator must be masked. Meta-regression of each moderator variable showed only the sample size had a significant negative association with the estimated retention success rate indicating that, as the sample size increased, the retention success rate fell. One of the limitations of the studies included in our meta-analysis was the small sample size : studies were initiated with a small sample size with a high loss rate, which was very high at 24 months. Multiple meta-regressions to determine the predictors that explained the success of proximal restorations showed a similar behaviour for retention, marginal integrity, anatomic form, and recurrent caries success rates. All included the cavity form and assessor blinding as predictors. In addition, the sample size, the type of material and the use of coat were predictors of the index of retention.80, we unified the criteria used in the selected articles into four categories: retention, marginal integrity, anatomic form and absence of recurrent caries. This enabled comparison of the studies and elimination of the bias that the use of different evaluation systems could introduce.A possible bias is the different criteria used in the studies to assess the clinical performance of the restorations. Thirteen used the various modifications of the USPHS criteria, one study used the USPHS criteria plus ART criteria, one study used the FDI criteria and one study used an own system. As there may be differences in the assessment of success depending on the criteria used, and the lack of sensitivity of the ART criteria in detecting improvements in the clinical performance of the materials currently used for dental restorationsAfter RMGIC, the material that presented the best results was the open-type sandwich method followed by resin-containing materials adhered with the total etching technique. The sandwich method, which uses RMGIC as a cavitary base material and composite as a surface material, seems to have the advantages of both materials. However, only one study was included in this meta-analysis, and therefore further studies are required to determine whether the good results are maintained. Likewise, studies that combine the speed and simplicity of the ART technique with RMGICs, which had the best clinical behaviour in proximal restorations at 24 months, are required.In conclusion, the null hypothesis of our meta-analysis was disproved, as the index of success of proximal restorations in primary teeth at 24 months was found to depend on the type of coloured material used. The materials with the highest success rates were those that contained resin. Of these, RMGIC performed best. The highest failure rate was for HVGIC and with the cavity made using ART, which were significantly correlated. The shape of the cavity, triple blinding and the experience of the operator had the most influence on the success rates of proximal restorations.Supplementary Dataset .Supplementary file 1.Supplementary file 2.Supplementary file 3.Supplementary file 4.