Childhood obesity, dental caries, and periodontal disease are major public health problems due to their adverse impact on the growth and development of children. Obesity and oral health are associated as both share some common risk factors.The specific aim of the study was to determine the correlation, if there is any, between obesity and oral health in children.A cross-sectional survey was conducted in five districts of West Bengal, India. A total of 1,227 school-going children of 6 to 12 years were examined from the districts of Howrah, Hooghly, West Midnapore, South 24-parganas, and North 24-parganas. Following indices were analyzed: Decayed-missing-filled teeth (DMFT), decayed, extracted, filled teeth (deft), simplified oral hygiene index (OHI-S). Depending on their nutritional status, subjects were categorized as being normal weight, overweight, and obese. Logistic regression analysis were applied to the study to find out the association between the above-mentioned dental indices and independent variables: Gender and nutritional status.A positive association was found between obesity and oral health status in children.Considering the results of this study, it was concluded that obesity is related to oral hygiene status of children. In order to improve oral hygiene status in children, dietary modifications need to be done.How to cite this article: Halder S, Kaul R, Angrish P, Saha S, Bhattacharya B, Mitra M. Association between Obesity and Oral Health Status in Schoolchildren: A Survey in Five Districts of West Bengal, India. Int J Clin Pediatr Dent 2018;11(3):233-237. Furthermore, dental caries and periodontal disease have traditionally been considered one of the greatest public health burdens because of their adverse impact on the growth and development of children.34 Oral health and obesity share common risk factors, as both are associated with unhealthy dietary habits—sugary soft drinks, snacks, and sugar-rich diets. Therefore, the World Health Organization (WHO) emphasizes the need to adopt a unified approach for the promotion of general and oral health instead of the previous single-level strategies.4 The “common risk factor” approach has been proposed as more rational, cost-effective, sustainable, and affordable.4 The period from childhood to adolescence is a critical stage of life during which children acquire important behavioral habits relevant to their general and oral health.5 Unhealthy dietary habits established in childhood tend to be carried throughout adulthood. Increased urbanization and economic development in most countries have led to adverse dietary change toward higher consumption of sugar and fat and reduced the intake of dietary fiber and this impairs oral health as well as increases the body mass index (BMI).6 Obesity is abnormal or excessive fat accumulation that may impair health.7“EAT TO LIVE, DON’T LIVE TO EAT” becomes an important thought of human life as obesity is increasing day by day. Obesity and oral health are correlated as both share some common risk factors like dietary, genetic, socioeconomic, and lifestyle issues.8 An association may exist between dental caries and obesity particularly in children, as they can withstand sweets more than the adult, the “Bliss Effect.”9 To measure the intensity or extent of dental caries in terms the number of teeth WHO recommends DMFT/deft index.Etiologically sugar (sucrose) and some other carbohydrates are well documented to be the main dietary culprits in dental caries. Per capita sugar consumption directly varies with dental caries prevalence in any nation which has been observed during World War II.The aim of the study was to determine the correlation, if there is any, between obesity and oral health in schoolchildren.A total of 1,227 school-going children of 6 to 12 years participated from five districts of West Bengal, namely Howrah, Hooghly, 24-Parganas north, 24 Parganas south, and Midnapore (West). Children aged less than 6 years and more than 12 years Children with any congenital defects Children with persistent medical problems (continuous use of sugar-containing drug is a compulsion) Children with defects of enamel /dentin other than dental caries History of any periodontal treatment within last 6 monthsThe study design was placed before ethical committee of Dr R Ahmed Dental College and Hospital, Kolkata for permission to undertake the study.Each selected school was contacted individually to obtain permission of the Head of the Institution after clarifying the aim of the study. Nature and purpose of the study were explained to parents in their preferred language. Its voluntary nature and strict confidentiality were assured. Parents were informed about the purpose of the study and they signed an informed consent form.This cross-sectional study included 1,227 school-going children  of age group 6 to 12 years. Stratified random sampling was done. Under the source of natural light in the room, dental caries was examined with mouth mirror and dental explorer. Dental caries was assessed as per the WHO Geneva Criteria 1997. To measure the intensity or extent of caries in terms of the number of teeth, WHO recommends DMFT/deft index. No radiograph was taken. Debris and calculus were examined by dental explorer and mouth mirror and assessed by OHI-S index according to Green and Vermillion (1964). The tooth was not cleaned of debris, nor was compressed air used, but where visibility was obscured by excess debris or moisture, this was removed with gauze or cotton roll.2.The height and weight of participants dressed in light clothing without shoes were determined. Standing height was measured using a wall mounted stadiometer. The BMI was calculated as follows: BMI = weight in kg divided by height in meter square. The BMI was categorized according to WHO criteria (2004). Underweight was classified as BMI < 18.50, normal BMI 18.50-24.99, overweight >25.00, and obese >30 kg/mDescriptive and interferential analysis was done for the data using Statistical Package for the Social Sciences version 19.0. The level of significance was set at ≤0.05.The cross-sectional study sample consisted of 1,227 children of age group 6 to 12 years, selected randomly from different private and government schools of five districts of West Bengal, according to the inclusion criteria.For evaluation, the mean and standard deviation (SD) for the values of all the variables were computed and tabulated. Logistic regression analysis was applied to the study to find out association between the above-mentioned dental indices and independent variables: Gender and nutritional status. Chi-square test was done to find if any significant statistical correlation between two variables was there or not.Caries distribution in different BMI group is analyzed in The results show that BMI is positively associated with the deft, DMFT, and OHI-S.10 It has been characterized by energy and metabolism imbalance and is responsible for the onset of multiple health complications.9Childhood obesity and dental caries are both ubiquitous. Increased calorie intake associated with sugars and other carbohydrates, especially when added with physical inactivity, has been implicated in childhood obesity.12 and Bailleul-Forestier et al.13 Hong et al12 conducted a study to determine the association between obesity and dental caries in 2- to 6-year-old US children where 1,507 children were examined. Statistically significant association between caries and obesity was found for 60-72 months age group.The present study found a positive correlation between BMI and dental caries  had a high level of caries incidence. There was a significant association between BMI and DMFT indices (p = 0.01) in the obese group.Bailleul-Forestier et al14 and Sadegi and Elizadeh15 where caries incidence was positively correlated with BMI.This observation supported the findings of Willer-shausen et al16 found a different result, but in their study, only 3-year-old children were examined and caries prevalence was not significantly correlated with BMI. At the age of 3, there are some important factors, such as bottlefeeding and there is still major parental control over it. It is not the time for children to eat away from home.Chen et alDiet and socioeconomic status (SES) is closely related to BMI and dental health. Level of parental education and family income influence the food choice via availability of the resources to purchase a higher quality of food and awareness for nutritious alternatives.17 which leads to high BMI as well as dental caries.For a low-income family, price takes a larger role than taste and quality of food. Young people from lower SES consume cheaper snacks and sweets and eat less fruit and vegetables than the higher socioeconomic group ,18 Thus, the diet may exert an effect on caries locally and obesity generally. In relation to dental caries, it is important to emphasize the character of diet and number of times consumed rather than quantity.19Diet plays an important role in developing both dental caries and obesity. Diet refers to the customary allowance of food and drink taken by any person from day to day and nutrition concerns the effect of diet on metabolic process of the body.20 found a positive correlation among obesity/overweight status and dental caries. But they considered diet as a risk factor for both obesity and dental caries in adolescents of Udupi district, South India. There was a significant difference in the frequency of sugar consumption between the BMI groups. Obese group of children had more caries than the overweight and low-normal-weight children. There was an association between caries experience and sugar consumption more than once/ day .Honne et al21 He investigated the relationship between oral health and obesity in adolescents in Sharjah city, United Arab Emirates. Analysis of the final model suggests that there is no clear relationship between obesity and dental caries, but that the consumption of soft drinks was a leading predictor for both.Soft drink consumption was the leading predictor for both dental caries and BMI in the study of Khadri et al.22 stated that certain ethnic groups have better quality of diet than others, mainly because of their cultural background.Ethnicity and racial variations also influence the diet pattern and consequently obesity and oral health. Kranz et al21 evaluating the role of sociodemographic indicators, BMI was shown to be correlated with respect to ethnicity, Arabs had marginally higher BMI in comparison with other nationalities in United Arab Emirates.In the study of Khadri et al21 the relationship between obesity and level of physical activity showed that physical inactivity was more prevalent among obese.Physical inactivity is directly linked with high BMI. With the advent of advanced technologies, children prefer indoor activities, such as television watching, and playing computer and video games. Increased calorie intake with sugar and other carbohydrates, when added with physical inactivity, leads to obesity and dental caries. In the study of Khadri et al,American Physical Activity Guideline, Australian Physical Activity Guideline, American Academy of Pediatrics, WHO, and International Obesity Task Force—all recommended restriction of sedentary activity to not more than 2 hours per day.The factors like SES, diet, race, and ethnicity are not considered in this study. Also the study period is limited to collect the data from a larger sample size. Despite all limitations, it is evident from the present study that there is a positive correlation between obesity and oral health status. They have common risk factors and require a comprehensive multidisciplinary approach to pediatric patients by both medical and dental health care professionals.Mean DMFT score was lower than mean deft. The DMFT in underweight was 0.09, in normal weight 0.26, in overweight 0.69, and in obese 0.64, whereas deft was 1.80, 2.15, 4.01, and 3.50 respectively.There is a statistically significant positive correlation between BMI with DMFT (r = 0.034) and BMI with deft (r = 0.114) (p <0.01) for both.The deft and DMFT value did not have any significant correlation with the gender variation (r = 0.125) for deft, and (0.003) for DMFT, (p = 0.17) for deft, and (0.95) for DMFT.Another cofactor considered for oral health status was OHI-S. In females, it was 0.55 in underweight, 0.62 in normal weight, 1.07 in overweight, and 0.99 in obese. In males, it was 0.45, 0.25, 1.03, and 1.22 respectively. There was a statistically significant (p <0.01) positive correlation between BMI and OHI-S (r = 0.028). The value of OHI-S varied significantly (r = 0.189 and p<0.01) with gender variation.Overall, the association between obesity and oral health status was found positive. Considering the limitations of the present study, a positive association is found to exist between oral health status and obesity.As our results indicate, being at risk of overweight or overweight is a potential risk factor for developing periodontal disease; promotion of healthy nutrition and physical activity in children and adolescents are necessary to prevent oral pathology, which can further affect the general health and well-being.


Graves' ophthalmopathy (GO) is the most common extra-thyroid manifestation of Graves' disease (GD). The Clinical Activity Score (CAS) has been widely used to evaluate GO inflammation severity and response to treatment; however, it is quite subjective. Infrared thermography (IRT) is a portable and low-cost device to evaluate local temperature and assess inflammation. The aim was to evaluate ocular temperature by IRT as an instrument for measuring inflammatory activity in GO and its correlation with CAS. This is a cross-sectional study involving 136 consecutive GD patients  with 62 healthy controls. Patients with active ophthalmopathy were prospectively evaluated. Exophthalmometry, CAS, and thermal images from caruncles and upper eyelids were acquired from all subjects. p<0.0001; upper eyelids, p<0.0001), and it was positively correlated with CAS . No difference in temperature was found between other groups. Patients with active ophthalmopathy were prospectively evaluated after 6 or 12 months of the treatment and a significant difference was found in ophthalmometry (p=0.0188), CAS (p=0.0205), temperature of caruncles (p=0.0120), and upper eyelids (p=0.0066). All eye areas of thermal evaluation had higher temperatures in GD patients with active ophthalmopathy (caruncles, IRT was an objective and simple tool for evaluation and follow-up of inflammation in GO, allowed evidencing patients with significant inflammatory activity, and had a good correlation with the CAS score. Graves' ophthalmopathy (GO) is the most common and serious extra-thyroid manifestation of Graves' disease (GD), affecting about 50% of patients, and is usually bilateral, but may be unilateral , 2. The The assessment of GO is performed through physical examination, to determine the ocular inflammation degree and proptosis . ProptosSeveral imaging techniques are currently used to access GO, such as ultrasound, computer tomography, and magnetic resonance, though these techniques are expensive, are poorly available, depend on experienced technician, and can expose patients to contrast agents and radiation –9. In thThe primary aim of the study was to evaluate ocular temperature by IRT as an instrument for measuring inflammatory activity in GO and its correlation with CAS.This is a cross-sectional clinic-based study involving 136 consecutive GD patients followed at the Thyroid Disease Unit at a tertiary Service of Endocrinology and a control group composed of 62 healthy individuals. One hundred and ninety-eight subjects were included  and divided into 4 groups according to clinical characteristics. Basically, 12 patients present with GD with active ophthalmopathy (CAS ≥ 3/7), 62 patients with GD and inactive ophthalmopathy (CAS < 3), 62 patients with GD and without apparent ophthalmopathy, and 62 healthy controls with normal thyroid function and from an iodine sufficient area. Patients from the group of active ophthalmopathy were reassessed during follow-up. Exclusion criteria were any acute infectious or inflammatory disease, history of recent cardiovascular events , malignant neoplasia, heart failure (NYHA III or IV), severe hepatic disease, severe kidney disease , hepatitis B, C, and HIV infection, and any other acute or chronic ocular diseases .Data were collected from August 2017 to March 2018, and all participants gave their written informed consent and ethical committee approval for the study was obtained according to Declaration of Helsinki, Human Research Ethics Committee in Lausanne, No. 204/14). Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient (CAAE: 71204117.2.0000.5404).Clinical characteristics and biochemical data were recorded by chart review. Clinical data collected were age, age at diagnosis, gender, smoking habits, use of levothyroxine or methimazole, treatment with radioiodine, comorbidities, including other autoimmune or chronic disease, disease duration, and time of follow-up. Biochemical data collected were serum thyroid stimulating hormone (TSH) , free thyroxine (fT4) , thyroglobulin antibodies (TgAb) (RV < 115 mUI/L), thyroid peroxidase antibodies (TPOAb) (RV < 35 UI/mL), and TSH receptor antibodies (TRAb)  were measured by electrochemiluminescence immunoassay .Clinical eye evaluation was elaborated to define the degree of ophthalmopathy activity, the measure of proptosis, and temperature by IRT. CAS assessed the degree of inflammation and was calculated from 7 items, with 1 point assigned to each alteration presented: spontaneous orbital pain, gaze-evoked orbital pain, eyelid swelling, eyelid erythema, conjunctival redness, chemosis, and inflammation of caruncle or plica. A CAS of 3 or higher indicates an active ophthalmopathy. For patients' follow-up, 3 more items are included in CAS evaluation, which is increase of ≥ 2 mm in proptosis, decrease in the ocular excursion in any one direction of ≥ 8°, and a decrease of acuity equivalent to 1 Snellen line. We did not use the additional points on follow-up visits of patients with active ophthalmopathy .Proptosis was evaluated with an exophthalmometer routinely used in our service. It is an instrument composed of a lateral rod with marking in centimeters as a ruler that connects to a front rod, forming an angle of 90°. The lateral rod is adjusted to the temporal region of the patient, and then it is possible to measure the distance between the outer corner of the eye and the cornea .Local temperature of the caruncle (right and left) and upper eyelid (right and left) were obtained using a FLIR ONE camera  attached to an iPhone 6 . Images were analyzed in the FLIR Tools application. All subjects were advised not to smoke, drink alcohol or coffee, or use make-up 24 hours before the exam. They were evaluated in a calm, quiet, and controlled temperature room (set at 24°C), with no interference from the outside. They were comfortably seated on a stretcher, and after 10 minutes of rest, clinical evaluation with CAS and exophthalmometry was done. After that, the thermometer sensor was focused on the interest areas, at a distance of 20 centimeters, and images with temperature were captured. Firstly, the right eye (caruncle and upper eyelid) and then the left eye (caruncle and upper eyelid) were evaluated. Patients were advised not to blink and move during the examination. The three evaluations were done on the same day, one followed by the other, by the same physician.Patients with active ophthalmopathy were prospectively reassessed with CAS, ophthalmometry, and IRT at caruncles and upper eyelids after at least 6 months of treatment, by the same physician and technique described above. U test and Kruskal-Wallis test were used to compare numerical variables, followed by the Dunn post hoc test to identify the differences. To correlate the numerical variables with temperatures, Spearman correlation coefficient was used. To compare variables between the two evaluations of patients with active GO, ANOVA was used for repeated measures. Data were transformed into ranks. The significance level was set at p < 0.05.Statistical analyses were carried out in the Statistical Analysis System (SAS), System for Windows, version 9.4. SAS Institute Inc., 2002-2008, Cary, NC, USA. To describe sample profile according to the study variables, frequency tables of categorical variables with absolute (n) and percentage (%) values were used, and descriptive statistics of numerical variables, with median (interquartile range). To compare categorical variables, the Qui-square test and, when necessary, Fisher's exact test were used. Mann-WhitneyWe analyzed 198 patients, of which 12 (6.06%) had GD with active ophthalmopathy (CAS ≥ 3/7), 62 (31.31%) had GD with inactive ophthalmopathy (CAS < 3), 62 (31.31%) had GD without ophthalmopathy, and 62 (31.31%) healthy controls.  p<0.0001) and methimazole users  than the inactive ophthalmopathy and without ophthalmopathy groups of GD, respectively. This group also have a lower TSH value , a higher percentage of patients with history of smoking , as well as in currently smoking  than the patients with inactive ophthalmopathy, patients without ophthalmopathy and healthy control group, respectively.The group with active ophthalmopathy had a higher rate of a detectable TRAb  than the active ophthalmopathy and without ophthalmopathy groups, respectively. The healthy control group had a lower fT4 value when compared with the GD patient groups .GD patients with inactive ophthalmopathy had a higher percentage of levothyroxine users .The group of GD patients with ophthalmopathy, active or inactive, had significantly greater measures of proptosis when compared to GD patients without ophthalmopathy and healthy controls ; moreover, it was positively correlated with CAS score in Spearman's correlation , shown in All eye areas of thermal evaluation had higher temperatures in GD patients with active ophthalmopathy when compared to other groups , CAS , temperature of caruncles , and temperature of upper eyelids . No significant difference was found in TSH and fT4 at prospective analysis. All patients with active ophthalmopathy were prospectively evaluated after at least 6 months of treatment employed in each case, and a significant difference was found in exophthalmometry , instead of 5 or 6 thermal areas in other studies. However, the 2 analyzed thermal areas found a similar result than the analysis in multiple areas, being more practical and fast to carry out. Another point is that we did not evaluate body temperature because all of our samples were obtained of patients from outpatient clinics and have no evidence of other acute diseases than GO. In contrast to the pitfalls, our study is the first to analyze 3 distinct populations of patients with GD and a healthy control group.In conclusion, we found that IRT in association with CAS was an excellent evaluation mechanism for patients with active eye disease. Additionally, IRT device is an objective, simple, and portable tool that can be coupled to a smartphone, allowing a comparison between temperatures and images during follow-up.Our study demonstrated that IRT was an objective and simple tool for evaluation and follow-up of inflammation in GO and had a good correlation with severity of CAS score. However, a large-scale investigation is indispensable to confirm our results.


Training to construct the DL model using deep convolutional neural network algorithms was provided using ultrawide-field fundus images. The SVM uses scikit-learn library with a radial basis function kernel. The diagnostic abilities of DL and the SVM were compared by assessing their sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic curve for CRVO. For diagnosing CRVO, the DL model had a sensitivity of 98.4% , 94.3–99.8%) and a specificity of 97.9%  with an AUC of 0.989 . In contrast, the SVM model had a sensitivity of 84.0%  and a specificity of 87.5%  with an AUC of 0.895 . Thus, the DL model outperformed the SVM model in all indices assessed . Our data suggest that a DL model derived using ultrawide-field fundus images could distinguish between normal and CRVO images with a high level of accuracy and that automatic CRVO detection in ultrawide-field fundus ophthalmoscopy is possible. This proposed DL-based model can also be used in ultrawide-field fundus ophthalmoscopy to accurately diagnose CRVO and improve medical care in remote locations where it is difficult for patients to attend an ophthalmic medical center.The aim of this study is to assess the performance of two machine-learning technologies, namely, deep learning (DL) and support vector machine (SVM) algorithms, for detecting central retinal vein occlusion (CRVO) in ultrawide-field fundus images. Images from 125 CRVO patients ( Central retinal vein occlusion (CRVO) is a vascular disease of the eye and a known cause of significant visual morbidity, including sudden blindness . PathogeThus, it is important to treat CRVO patients in an ophthalmic specialty center immediately after the onset to preserve visual function. However, establishing a large number of such centers is impractical because of rising public healthcare costs, a problem that is burdening several nations worldwide .Recent remarkable advances in medical equipment include the ultrawide-field scanning laser ophthalmoscope, the Optos 200T× . The Optos can easily and noninvasively provide wide-field fundus images  without Image processing approaches using two machine-learning algorithms, namely, deep learning (DL) and support vector machines (SVMs), have retained investigator attention for years because of their extremely high-performance levels; in fact, increasing number of studies have assessed their applications in medical imaging –14. NoneOptos images of patients with acute CRVO and those without fundus diseases were extracted from the clinical database of the ophthalmology departments of the Tsukazaki Hospital, Tokushima University Hospital, and Hayashi Eye Hospital. These images were reviewed by a retinal specialist and stored in an analytical database. Of the 363 fundus images selected, 125 were from CRVO patients and 238 were from non-CRVO healthy subjects.K-fold cross validation in this study, and it has been described in detail elsewhere [K groups, and (K − 1) groups were used as training data, whereas one data group was used for validation. This process was repeated K times until each of the K groups became a validation dataset. The number of groups (K) was calculated using Sturges' formula (K = 1 + log2 N). Sturges' formula is used to decide the number of classes in the histogram [We used lsewhere , 18. Briistogram , 20. ThuImages in the training dataset were augmented by adjusting for brightness, gamma correction, histogram equalization, noise addition, and inversion so that the amount of training data increased by 18-fold. The deep convolutional neural network (DNN) model, as detailed below, was created and was trained using preprocessed image data.This study was conducted in compliance with the principles of the Declaration of Helsinki and was approved by the ethics committees of Tsukazaki Hospital, Tokushima University Hospital, and Hayashi Eye Hospital.A DNN model called the Visual Geometry Group-16 (VGG-16)  was usedThe VGG-16 model comprises five blocks and three fully connected layers. Each block includes convolutional layers followed by a max-pooling layer with decreasing position sensitivity but greater generic recognition . FlattenFine tuning was used to increase the learning speed and achieve higher performance with lower quantitates of data , 27. We https://keras.io/ja/) was run on TensorFlow (https://www.tensorflow.org/) written in Python and was used to build and evaluate the model. We trained the model using the CPU of Core (TM) i7-8700K by Intel and the GPU of GeForce GTX 1080 Ti by NVIDIA.The weights of block 5 and the fully connected layers were updated using the optimization momentum stochastic gradient descent algorithm  , 29. Of C” of the SVM algorithm and parameter “γ” of the radial basis function were determined by grid search using quadrant cross validation, and the combination with the highest average correct answer rate was selected. The parameter values tested for C were 1, 10, 100, and 1000 and those for γ were 0.0001, 0.001, 0.01, 0.1, and 1. The final learning model was generated using the optimized parameter values of C = 10 and γ = 0.0001.We used the soft-margin SVM implemented in the scikit-learn library using the radial basis function kernel . We reduReceiver operating characteristic (ROC) curves for CRVO were created on the basis of the ability of the DL and SVM models to distinguish between CRVO and non-CRVO images, and the models were compared using area under the curve (AUC), sensitivity, and specificity values.https://raghakot.github.io/keras-vis/).A heat map of the DNN focus site was created and classified using gradient-weighted class activation mapping . Next, ct-test, whereas Fisher's exact test was used for comparing the gender ratio and the ratio of the right to left eye images.Patient demographic data such as age were compared using Student's t-test was used to compare AUCs between the DL and the SVM models.The 95% confidence interval (CI) of AUC was obtained as follows. Images judged to exceed a threshold were defined as positive for CRVO, and the ROC curve was created. We created nine such models and nine ROC curves. For determining AUC, the 95% CI was obtained by assuming normal distribution and using the average and standard deviation of the nine ROC curves. For estimating sensitivity and specificity, optimal cutoff values, which are the points closest to the point at which both sensitivity and specificity are 100% in each ROC curve, were used . The senWe used 125 CRVO images from 125 patients  and 238 non-CRVO images from 202 subjects  in this analysis. No significant differences were detected between these two groups with respect to age, gender ratio, and left-right eye image ratio .P < 0.001) , its specificity was 97.9% , and the AUC was 0.989 ; in contrast, sensitivity of the SVM model was 84.0% , its specificity was 87.5% , and the AUC was 0.895 . In ROC curves, AUC of the DL model was significantly higher than that of the SVM model (< 0.001) .A composite image, comprising the fundal image superimposed with its corresponding heat map, was created by the DNN, and these images showed that DNNs could accurately identify crucial areas in the fundal images; a representative composite image is presented in The fundamental aim of this study was to explore the possibility of early detection of CRVO from Optos fundus photographs using DL-based algorithms. If screening for CRVO is possible noninvasively and without the use of mydriatic agents, this approach would be medically viable. Currently, it is unreasonable to expect ophthalmologists to interpret all Optos-acquired fundus images because of associated medical resource costs. Therefore, a DL model that can accurately diagnose conditions based on ultrawide-field fundus ophthalmoscopy images without the need for human input can be used to screen and diagnose a very large number of patients at a very low cost.Here, we have used DL technology to identify Optos images that show presence of CRVO. Our results show that the DL model has higher sensitivity, specificity, and AUC values than the SVM model for detecting CRVO in Optos-derived fundus photographs.Further, using heat maps, we show that DNN could accurately identify an area around the optic disc in the non-CRVO images, whereas in CRVO images, it focused on the area around the optic disc and could highlight retinal hemorrhages. This result implies that the proposed DNN model may be able to identify CRVO by focusing on areas with suspected retinal hemorrhages. It is known that DL algorithm-based models can automatically learn local feature values of images and generate classification models , 29, 31.In recent years, a number of studies have addressed that CNN hugely outperforms classic ML algorithms in image classification tasks , 32–34. Despite the above, our study has a few limitations. First, we have only compared images of normal retinas with CRVO retinas and did not include images of other retinal diseases. Based on the image examples presented in this study, it may be expected that a CNN algorithm should easily be able to classify between the two types of images. To use this model under clinical conditions, further development and testing to ensure accurate identification of multiple conditions other than CRVO would be essential. Additionally, clarity of the eye may decrease in patients with mature cataract or severe vitreous hemorrhage, and in such cases, analysis of images captured using Optos may be difficult. Thus, future studies should extensively evaluate the performance and versatility of DL using larger samples and with images of other fundus diseases.In conclusion, the DL model performed better than the SVM model in terms of its ability to distinguish between CRVO and normal eyes using ultrawide-field fundus ophthalmoscopic images. This technology has significant potential clinical usefulness as it can be combined with telemedicine to reach large areas where no specialist care is available.


Objective: Cardiovascular disease, the leading cause of death worldwide, and diabetic retinopathy, the main cause of blindness in economically active populations, share clinical risk factors, and pathophysiological features. The aim of this study is to examine the association between diabetic retinopathy, cardiovascular disease, and common risk factors in patients with type 1 diabetes.Design and Methods: This nested case-control study was performed in patients from the Brazilian Type 1 Diabetes Study Group, a nationwide survey that was conducted in Brazil and enrolled 1,760 patients with type 1 diabetes. A total of 342 patients were selected (57 cases with macrovascular disease and 285 controls who were matched for duration of diabetes and gender).Results: In the exploratory analysis, stratified by cardiovascular disease, the following variables were statistically significant: age (p=0.037), hypertension (p=0.035), high BMI (p = 0.046), diabetic retinopathy (p = 0.003), and chronic kidney disease (p = 0.026). By multivariate logistic regression, patients with diabetic retinopathy were more likely to develop cardiovascular disease . Although to a lesser extent than diabetic retinopathy, higher BMI levels were also related to an increase in the risk of cardiovascular disease of 1.08 .Conclusion: The presence of diabetic retinopathy indicates a greater risk for cardiovascular disease in Brazilian patients with type 1 diabetes. Further studies are warranted to determine whether a noninvasive exam, such as fundoscopy, could help identify patients who show an increased risk for cardiovascular disease. According to the World Health Organization (WHO), cardiovascular disease (CVD) is the main cause of death worldwide, accounting for nearly 31% of all mortalities . In adulHyperglycemia has injurious effects that are related to macrovascular complications (as reflected by CVD) and microvascular disease . Intensive diabetes treatment reduces the risk of any cardiovascular disease event by 42%, compared with traditional therapy, as shown by the Diabetes Control and Complication Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC), a study with 17 years of follow-up . In addiDiabetic retinopathy is the most common microvascular chronic complication and remains the leading cause of blindness in the working-age population . Due to Despite the significance of CVD as the major cause of death and reduction in life expectancy in patients with type 1 diabetes, the routine screening of asymptomatic patients is not recommended according to the American Diabetes Association (ADA) statement. The advanced cardiac test such as: calcium score, pharmacologic stress echocardiography and exercise ECG testing with or without echocardiography are not cost-effective. Therefore, any benefit of non-invasive screening methods to identify patient subgroup at risk of CVD is interesting .The aim of our study was to examine the association between DR with CVD and its risk factors in patients with type 1 diabetes.This case-control study included 342 patients with type 1 diabetes , nested in the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG). Detailed information on the main study has been published elsewhere . Briefly2)], and blood pressure.A standardized questionnaire was administered, and clinical and demographic data were collected, such as age, gender, duration of diabetes, years of formal education, smoking (defined as the current use of 1 or more cigarettes per day), physical activity, alcohol consumption, self-reported ethnicity, diet, and hospitalization due to any cause in the past year. Economic status was stratified into high-, middle-, low-, and very-low-income, according to the Brazilian Economic Classification Criteria . The parData from medical records were also analyzed, and hypertension was defined, as reported by the patient, as at least 2 previous episodes of blood pressure ≥140/80 mm Hg, measured by a health professional. CVD was defined as positive information in the patient's medical records on 1 or more of the following conditions: coronary artery disease , peripheral vascular disease, and cerebrovascular disease.Laboratory data were measured in a central laboratory, and the following ADA goals were adopted with regard to achieving adequate clinical and metabolic control : Good gl2 (ml/min/1.73 m2).Renal function was assessed using the CKD-EPI equation  in adult2) or elevated urinary albumin excretion . Creatinine was measured using a colorimetric assay kit (Biosystems).Chronic kidney disease (CKD) was defined as the presence of a low estimated glomerular filtration rate  and the ethics committee of each participating center. Informed consent forms were signed by the patient or his legal guardians. The research was conducted in accordance with the Helsinki Declaration.The quality of the study was assessed using the checklist “Strengthening the Observational Report on Epidemiology” (STROBE) .t-test and presented the data as standard deviation (SD) of the means for the others continuous variables that presented normal distribution. For categorical variables, we used chi-square test and presented the data as frequencies (percentage). We used Fisher's exact test for variables that presented cells with <5 elements, which occurred only in the smoking variable. Binary logistic regression was performed to assess the predisposing factors to CVD, considering variables with p < 0.2 in the univariate analysis and several clinically relevant variables. The following covariates were included: LDL cholesterol, hypertension (yes/no), BMI, smoking status (yes/no), HbA1c, DR (present/absent), age, economic status, years of formal education, and self-reported ethnicity (white/not white).Initially, an exploratory analysis was performed to evaluate the relationship between CVD, DR, and certain clinical and social risk factors. For continuous variables, we performed the parametric test and those that did not present normal distribution were submitted to the Mann-Whitney test. Median and interquartile range [IQR] data were used for these variables. The variables with nonparametric distribution were: HbA1c, HbA1c mmol, triglycerides, HDL cholesterol, LDL cholesterol, and years of formal education. We performed the student's p < 0.05 was considered to be statistically significant.Exploratory Forward-Wald stepwise logistic regression was performed to determine the variables that contributed more to the discrimination between groups. Nagelkerke R-squared values were also calculated. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated when indicated. Two-sided All analyses were performed using SPSS, version 20 .Of the 1,644 patients, 57 presented with macrovascular disease and were considered “cases,” constituting 3.46% of all patients. The 285 controls were matched for gender and duration of diabetes. The clinical and demographic characteristics of the study population are shown in p = 0.037); had a greater prevalence of hypertension (p = 0.035), DR (p = 0.003), and CKD (p = 0.026); had a higher BMI (p = 0.046) and were more likely to be users of statins compared with patients without CVD. CVD was not associated in the exploratory analysis with years of formal education, economic status, self-reported ethnicity, use of angiotensin-converting enzyme (ACE) inhibitor, HbA1c, triglyceride levels, HDL cholesterol, LDL cholesterol, or smoking status. The results are shown in In the exploratory analysis, patients with CVD were older (p-0.015) more likely to present with CVD. BMI was also associated with 1.08-fold  greater odds of having CVD. The independent variable included in the final adjusted multivariate binomial logistic regression model, explained 66% (Nagelkerke R) of the variance for the presence of CVD. The results of crude odds ratio and unadjusted p-value are described in Multivariate logistic regression was performed to determine the effects of social and clinical risk factors for CVD, wherein patients with DR were 2.16 times  and control (6.3%) groups and this might have influenced our results. This small number could be related to the fact that the percentage of adult smokers in Brazil has been significantly decreasing and according to the most recent data, it has a national average of 14.7% .The strength of our study is that it included patients with type 1 diabetes which in general is not as studied as type 2 diabetes.The study has some limitations. It was a cross-sectional study and so we cannot confirm causal associations between DR and its risk factors. Further, we evaluated DR by indirect ophthalmoscopy. Seven-field stereoscopic photography is considered the standard approach by the Early Treatment Diabetic Retinopathy Study (ETDRS) , but stuThe strong association between DR and CVD showed in our study suggests that presence of DR may be indicative of an increased risk for CVD. The presence of this ocular complication can identify those patients with type 1 diabetes who should be screened for CVD.Cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes; thus, any effort toward its prevention is valuable. Fundoscopy could help to identify patients who are at higher risk of CVD. However, further studies are needed to understand the association between DR with CVD and the function of DR as a predictor of this significant and fatal comorbidity.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.MG was the principal investigator of the study, designed the study and the survey questionnaire, supervised the project, and reviewed the manuscript. LGNM conducted statistical analysis, conducted the literature review, and drafted the manuscript. DS, MP, BB, and LHM helped to conduct statistical analysis and reviewed the manuscript. PM, KD, TM, AP, FM, FL, and FKM were responsible for collecting data on diabetic retinopathy in each center. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Multivariate linear regression showed that age was the only independent variable for IVCmax (mm) in female children, height was the only independent variable for IVCmax in male children, and age was the only independent variable for Ao in both females and males. IVCmax/Ao was not significantly influenced by the subjects’ characteristics. In conclusion, IVCmax and Ao were more susceptible to subjects’ characteristics than IVCmax/Ao. IVCmax/Ao could be a reliable and practical parameter in Chinese children as it was independent of age, height, and weight.Ultrasound-measured inferior vena cava (IVC) and abdominal aorta (Ao)-associated parameters have been used to predict volume status for decades, yet research focusing on the impact of individual physical characteristics, including gender, height/weight, body surface area (BSA), and age, assessed simultaneously on those parameters in Chinese children is lacking. The aim of the present study was to explore the impact of individual characteristics on maximum IVC diameter (IVCmax), Ao, and IVCmax/Ao in healthy Chinese children. From September to December 2015, 200 healthy children from 1 to 13 years of age were enrolled. IVCmax and Ao diameters were measured by 2D ultrasound. We found that age (years), height (cm), weight (kg), waist circumference (cm), and BSA (m Diarrheal diseases and associated complications are major worldwide health threats to children, especially children under the age of 5 . DehydraSonographic inferior vena cava (IVC) parameters have been used to guide fluid management in adults for decades because of their unique features, including safety, rapidity, non-invasiveness, and portability –13. InThe aim of the present study was to explore the impact of individual characteristics on IVCmax/Ao, and IVC and Ao diameter in healthy Chinese children.This cross-sectional descriptive study was designed based on the Declaration of Helsinki II and was approved by the Medical Ethics Committee of TungWah Affiliated Hospital of Sun-Yat Sen University. A statement of informed consent was obtained. Participants' guardians were notified of the aim and procedures of this study by reading the consent form before signing the informed consent. The measurement was performed after the assent by the children.From September to December 2015, we recruited 200 healthy children aged from 1 to 13 years. Participants lived in the local community and were visiting TungWah Affiliated Hospital for routine comprehensive health check-ups during the study enrollment period. Exclusion criteria included: age over 13 years, dyspnea, pyrexia, dehydration, and other obvious signs of unhealthiness, fasting period of less than 4 h, poor quality imaging due to patient's limited acoustic window, and lack of parental approval. Neither the children nor their guardians received remuneration for their participation in the present study.0.425 × H0.725) × 0.007184.The demographic information of participants was obtained, including age, gender, and history of congenital disease. The anthropometric measurements were performed in each participant with light clothes and no shoes. Waist circumference was measured midway between the lower rib and the iliac crest, while the participant was standing erect with relaxed abdominal muscles. The tape was non-extensible and positioned horizontally and paralleled to the floor. Then, weight was measured on a scale. Body surface area (BSA) was calculated using the DuBois formula: BSA = . US was performed using a Toshiba Aplio 500 Ultrasound System , equipped with 3.5 MHz convex probe. The IVC diameter (IVCmax) was measured with the transducer placed inferior to the xiphoid, and in order to obtain the long axis image of the IVC, the transducer was processed along the midline. The measurement procedure was recorded in 15 s B-mode  video clips to ensure that respiratory variations were accounted for and the points of IVCmax were captured. The measurement of IVCmax was performed just proximal to the hepatic veins, where the anterior and posterior walls of the IVC are easily seen and parallel to each other during the end exhalation period. The Ao diameter was taken in a similar manner during systole, 3 to 5 mm above the celiac trunk, from one interior wall to the opposite interior wall. All the US measurements were performed by an ultrasound specialized physician with more than 10 years of experience in cardiovascular US.Data are reported as means±SD and 2 SD range or proportions, whichever was appropriate. Normality of continuous variables was assessed by histogram plots and the one-sample Kolmogorov-Smirnov test with P>0.05 indicating an adequate approximation of normal distribution. Pearson coefficients were obtained from correlation tests between continuous variables, with transformations used before analysis, as necessary. Multivariate linear regression  was used to test the independent association of previously correlated variables with the IVCmax and Ao. All statistical analyses were performed using Statistical Package for Social Sciences version 19.0 . All P values were two-tailed, and those <0.05 were considered statistically significant.The relevant individual characteristics of the 200 children and IVCmax, Ao, and IVCmax/Ao are shown in The measurements of IVC and Ao are presented in To determine the independent influence of individual characteristics on IVCmax in females I (Supplementary Table S1), three regression models were used. Multiple regression model 1 had IVCmax as a dependent variable, and age as a sole independent variable. Model 2 was similar but height and weight were added as independent variables. Lastly, model 3 used BSA as an independent variable instead of height and weight to test whether BSA improved the statistical stability and goodness of fit of the model. Model 1, model 2, and model 3 had similar multiple R values . After adjusting for confounders, age (years) was the only independent variable for IVCmax (mm) in females ; neither BSA nor "height and weight" independently influenced IVCmax in females.2=0.58).However, in the three similar multiple regression models used to test independent variables for IVCmax in males (Supplementary Table S1), height (mm) was the only significant independent variable for IVCmax . The entire model accounted for 58% of the variability in the IVCmax (adjusted R2=0.8) and 72% in males (adjusted R2=0.72).The independent variables for Ao were also tested with the aforementioned three multiple regression models (Supplementary Table S2), and age (years) was the only independent variable for Ao in both females and males . The model accounted for 80% of the variability in the Ao in females .We investigated the impact of individual characteristics on IVCmax/Ao, IVCmax, and Ao diameter in 200 healthy Chinese children. In our previous study, we investigated the impact of individual characteristics on collapsibility index (CI) in adults and found that its ability to detect intravascular volume was influenced by age, BMI, and baseline CI . HoweverTaneja et al.  correlat2=0.517, R2=0.079 for IVCmax and R2=0.759, R2=0.256 for Ao in children and adults, respectively). In contrast, the impact on IVCmax/Ao was weak in both children and adults . Similarly to our study, Stenson et al. (The impact on IVCmax and IVCmax/Ao in adults has been previously studied by Gui et al. . Comparan et al.  investign et al. . CompariThere are some limitations in this study. Firstly, our data were collected in a single center in China. Thus, the sample size of our study was limited and may not apply to all Chinese children. Secondly, the volunteers enrolled in our study were physically active, healthy, and were visiting for routine comprehensive health check-ups, which might have led to some selection bias. Therefore, we have no long-term organ function or outcome data and the IVCmax/Ao relationship in children with dehydration or fluid resuscitation. However, the data in our study could serve as normal control values to guide clinical practice in Chinese children with diarrhea, dehydration, or other diseases.pdf].Click here to view [


Business owners are faced with complex problems and are required to make decisions on a daily basis. The purpose of this study was to investigate complex problem solving (CPS) between experts and novices and to explore the competing theories of expert-rigidity versus expert-adaptability, as part of exploring which theory better explains crystallized intelligence. Participants were 140 business owners, business management undergraduate students and psychology students. Each participant managed a highly complex simulated chocolate company. Decisions and systems data were automatically saved in log files. Results revealed that small business owners performed best, followed by business students and then psychology students. A process analysis revealed that experts compared to novices spent more time initially exploring the complex situation. Experts were found to have greater flexibility in their decisions, having made the most personnel and advertising changes in response to situational demands. Adaptability and flexibility were predictive of performance, with results supporting the adaptability/flexibility theory of expertise. This study shows the influence of expertise on complex problem solving and the importance of flexibility when solving dynamic business problems. Complex business simulations are not only useful tools for research, but could also be used as tools in training programs teaching decision making and problem solving strategies. How does an experienced business leader compared to a novice balance production numbers and demand on the market? Which strategies do experts and novices use to expand their company’s position in the market? Are business experts reacting to changes in the market with flexibility? Do experts and novices differ in their information collection strategy? The current study investigates complex problem solving (CPS) behavior in a complex and uncertain, business simulation of a chocolate company called CHOCO-FINE. The research focus was to empirically investigate the role of expertise in CPS strategies by comparing experts and novices over time, contributing to the literature on prior knowledge in CPS as outlined in the editorial to this Special Issue.The first attempts to use simulations pertaining to complex and uncertain problems as part of investigating participants’ decision making occurred some years ago. In Europe, computer-simulated complex problems, also called micro-worlds or virtual environments, were developed to investigate how participants dealt with uncertainty and complexity ,2,3,4,5.In the United States, similar research using simulated problems also increased in popularity, developing under the label dynamic decision making (DDM) ,8. SinceIn both the CPS and DDM traditions , simulatFrequently, management strategies are investigated using case studies, retrospective analyses of historic data, the scenario technique and self-reports to evaluate decision outcomes; among these, survey type measures are the most widely used . One limAs previously mentioned, the focus of the current study is to empirically investigate the role of expertise in CPS over time. The topic of expertise is related to this special issue on intelligence and CPS, because expertise is highly related to crystallized intelligence. Crystallized intelligence refers to knowledge and experience learned in a specific cultural environment ,17. In aIn many areas, such as business management, expert level performance cannot be accounted for by stable heritable characteristics, but instead can be attained through learning and deliberate practice . EricsonIt is self-evident that experts perform better in their domain of expertise than novices, and there are several reasons why experts are more successful. First, experts have more elaborate knowledge in their domain of expertise; both declarative and procedural knowledge. Second, experts know, due to their procedural knowledge, what decisions to make, when to make decisions and when to change their decision-making approach. As part of their declarative and procedural knowledge, experts perform better at identifying possible solutions compared to novices . Third, It is unclear, however, if expertise leads to rigidity or flexibility in CPS. Does crystallized intelligence or expertise make someone’s decisions more rigid or more flexible? Research on expert-novice comparisons has shown contradictory findings. Some theories, such as the rigidity model, suggest that an increase in expertise is related to an increase in rigidity ,23. OthePsi which is often used as an abbreviation for Psychology). Previous research on experts has found that they have larger and more complex schemata pertaining to a specific domain [Two additional components of knowledge requiring discussion are declarative and procedural knowledge. One aspect about expertise is that it is characterized by enormous declarative knowledge. Declarative knowledge refers to facts and informational knowledge about a specific domain. This type of knowledge is stored and organized in elaborate schemata ; or tempc domain ,29.Another aspect related to expertise is procedural knowledge. Procedural knowledge is the knowledge of how to perform tasks and activities. This knowledge often requires problem solving strategies, specific to a task . WheBoth experts’ depth of declarative and depth of procedural knowledge influence their problem solving. It is unclear, however, if declarative and procedural knowledge might lead to more “fixed” paths or allow the development of multiple perspectives and flexibility in approaching a task; an increase in perspectives may lead to a more flexible problem solution and decision making.What evidence speaks for rigidity in experts’ decision making? When experts emphasize their reliance on past experience and developed schemata to make decisions, they often apply “old” decisions to the current problem, failing to acknowledge essential differences between old and new situations. The literature refers to this inflexible decision making behavior as a mental set failure ,33, the What evidence speaks for flexibility in experts’ decision making? Experts’ elaboration of declarative and procedural knowledge consists not only of one-way solutions, but often of a number of possible alternative solutions . In sum, there is some evidence speaking for the rigidity of experts and some evidence speaking for the flexibility of experts. In the current study, the flexibility and rigidity of experts and novices will be studied in the dynamic process of decision making and CPS.Gathering information and exploring the problem is a crucial step in CPS and allows for the development of a mental model of the situation . In someExperts have been shown to search in broader and greater depth for information  and to fHow will performance differ between experts, semi-experts and novices in the CHOCO-FINE micro-world simulation?Are there differences in rigid and flexible decision making between experts, semi-experts and novices?What are the differences between experts, semi-experts and novices in their initial search and exploration for information in the CHOCO-FINE micro-world simulation?What are the effects of in-depth exploration and flexibility on CPS performance?The goal of the current study is to extend previous research and to focus on actual CPS behavior through the use of the complex and uncertain micro-world CHOCO-FINE. The study will focus on crystallized intelligence and successful and failing strategies of novices and experts, further exploring the contradicting theories on expert rigidity versus flexibility. Based on the research discussed, the following four research questions were developed:M = 28.69, SD = 11.95) and varied between groups, F = 90.25, p < .001, ƞ2p = .57 .Participants were 72 psychology undergraduate students (novices), 50 business undergraduate students from the same university in the Southeastern United States (semi-experts) and 28 small business owners (experts) from the community where the university is located. Data of three participants were not included (2 psychology students and one business owner) because they had in Month 1 already −$3,000,000,000 total monies, probably due to input mistakes. Data for seven participants were not saved or stored automatically due to computer problems resulting in a total of 140 participants: 66 psychology undergraduate students (novices), 49 business undergraduate students (semi-experts) and 25 small business owners (experts). Participants’ ages ranged from 18 to 59 years  = 29.81, p < .001. Gender distributions for the respective groups were as follows: small business owners , business students  and psychology students . Since performance in CHOCO-FINE, i.e., total monies at Month 19, neither correlated significantly with gender , nor with age , gender and age were not included as covariates in the following analyses. We only include age and gender in the regression analyses to test Research Question 4.Regarding gender, 63% of all participants were female and 37% were male. The gender distribution also differed significantly among the three groups, χAll subjects gave their informed consent for inclusion before they participated in the study. The study was approved by the Ethics Committee of the University of North Florida Institutional Review Board (IRB# 10-059).The micro-world used for the current research should be knowledge-rich and reflect the complexity of the business world, to some degree, including areas such as market, competitors, advertising, staffing, production and product profiles. We chose the highly complex, uncertain and dynamic simulation CHOCO-FINE for the current study. It was originally developed by Dörner  in coopeFor each simulated month, the participant gathers information and makes decisions effecting the success of their company. The participant can analyze changes that occurred, gather further information, make decisions and proceed to the next month. The user interface of the program consists of 3 screens see : (1) theThe production screen shows 6 machines, their capacities per half day, which kinds of chocolates can be produced on each of them and the 20 work days of the month, divided into 2 half days. The marketing screen shows a stylized city map with the different districts and quarters shown in pie charts. The size of the pies corresponds with the sizes of the local market. The marketing window provides several options to gather information, conduct market research and make decisions regarding advertising, product design, prices or the hiring of sales representatives.(1)Performance: Performance was operationalized as total monies at the end of each month. Total monies at Month 19 was chosen as the performance variable for the correlations.(2a)Decision-making/problem-solving areas: The focus on specific decision-making areas was operationalized through the amount of money spent during each month for each of the three decision-making areas: advertising, personnel and market research. For advertising, participants could have chosen general overall brand advertising or specific advertising for specific chocolates or specific product profile components. For market research, participants had access to view and purchase information related to their own products and clients, as well as their competitor products and clients. Regarding personnel, participants had expenses, such as salaries, hiring, firing and relocating.(2b)Decision-making changes: The changes in each specific decision-making area were operationalized through the number of changes from one month to the next month relative to the total number of months completed. Change were coded as binary, either as a “0” if no change happened from one month to the next month, or as “1” if a change happened. For example, 10 changes in representatives in 19 months would result in .53.(3)Exploration: Depth of exploration was operationalized as time spent working on the first two months of the simulation. Participants were able to control proceeding to the next month of the simulation by clicking the “continue” button after all decisions for the month were made. At first, we considered only taking the first month, but since 20% of all participants spent less than 10 min for both months and since the first month also requires adjustment to the screens, we decided that taking the first two month would provide a clearer picture on exploration.After an initial 30 min to become familiar with the simulation, each participant worked individually on the CHOCO-FINE simulation for almost 2 h. An instruction sheet describing the CHOCO-FINE simulation was distributed to each participant and kept for the duration of the simulation. The variables were operationalized in the following way.After completion of CHOCO-FINE, participants received a demographic survey including questions referring to gender, age, education and professional background.The participants were given a brief introduction to the three computer screens and commands of the simulation, followed by 20 min to explore the simulation with an instructional guide. Once the simulation was restarted, participants began working in their role as CEO, participating in the simulation for an average of two hours.Every single decision a participant made during CHOCO-FINE was automatically saved in computer files. The CPS strategies were operationalized (see above) and tallied from the participants’ saved computer files by the second and third author .One indicator of the face validity of CHOCO-FINE is the results from the survey distributed to the business owners. As mentioned previously, the survey refers to the simulation’s overall realism through its eight parts: market, products, production, competitors, clients, pricing, advertisement, research and development. Results of the ratings of the eight parts on the five-point Likert scales indicate medium to high realism of the eight different micro-world parts  = 1.82, p = .005, ƞ2p = .23. The main effects are therefore qualified. The main effect of months was significant, Wilks’ Lambda = .29, F = 14.67, p < .001, ƞ2p = .71, indicating that overall, participants lost money; over time, performance decreased. The main effect for expertise was significant, F = 3.10, p = .049, ƞ2p = .05, indicating that business owners lost less money compared to business and psychology students.Research Question 1 investigated the performance differences between experts, semi-experts and novices in the CHOCO-FINE micro-world simulation. A mixed between-within subjects analysis of variance (ANOVA) was run to investigate differences among the 19 months and among the three groups  in total monies. From the 140 participants, total monies of one month for one person were removed because they were less than −$9 million. The interaction between months and groups was significant, Wilks’ Lambda = .59, z-score for business owners and business students comparison of intercept = 0.06, of slope = 0.30; z-score for business owners and psychology students comparison of intercept = −0.17, of slope = 0.63; z-score for business students and psychology students comparison of intercept = −1.09, of slope = 1.84.We also analyzed the performance data using growth mixture modeling in the Mplus software  to compaAs The results also showed how difficult it is to manage the complexity of CHOCO-FINE for all participants. The account balance range of individual participants was from −5.8 million to +3.6 million. Only 9% of all participants had an account balance higher than 2.1 million in Month 19, thus improving the company’s balance compared to the initial situation of 2.1 million.Research Question 2 investigated if there are differences in rigid and flexible decision making between experts, semi-experts and novices, further exploring the expertise-rigidity model and the expertise-flexibility model and investigating: (a) the focus on different areas in CHOCO-FINE; and (b) the changes in decision making.(a)Three main areas were investigated; advertising, market research and personnel.A mixed between-within subjects ANOVA was run to investigate differences among the 19 months and among the three groups in advertising expenses see . Thirty-F = 3.61, p = .03, ƞ2p = .05, the three groups differed significantly. Pairwise comparisons showed that business owners spent significantly more than business students (p = .02) and psychology students (p = .01). Business students and psychology students did not differ from each other (p = .84).When comparing only the main effect for group in advertising expenses in the first three months, To compare expenses for market research, a mixed between-within subjects ANOVA was run to investigate differences among the 19 months and among the three groups see . ThirteeF = 7.01, p = .001, ƞ2p = .10, the three groups differed significantly. Pairwise comparisons showed that business owners spent significantly less than business students (p = .001) and psychology students (p = .001). Business students and psychology students did not differ from each other (p = .90).When comparing only the main effect for group in market research expenses in the first three months, Comparing personnel expenses, a mixed between-within subjects ANOVA was run to investigate differences among the 19 months and among the three groups see . Twenty-F = 1.79, p = .17, ƞ2p = .03, the three groups did not differ significantly.When comparing only the main effect for group in personnel expenses in the first three months, z-score comparing the intercepts for personnel expenses, z = 10.546, p < .001.We additionally conducted growth mixture modeling in the Mplus software  to compaF = .59, p = .56, ƞ2p = .01; did not differ in personnel, F = 1.47, p = .23, ƞ2p = .02; but did differ marginally in expenses for market research, F = 2.47, p = .09, ƞ2p = .04.In sum, whereas spending varied among the 19 months, experts did not differ significantly from novices in expenses for advertising, for market research and for personnel. Differences only appeared when comparing expenses for the first three months; business owners spent less for market research, but more for advertising compared to business students and psychology students. When comparing the means of all expenses for Months 1 to 19, the three groups did not differ in advertising, (b)Changes in decision making.Experts compared to novices are expected to change their CPS approach more often and adapt to changing situations. We calculated the number of changes in the three areas of advertising, market research and personnel (indicated by changes in their monies spent for each area in each month) and divided it by the number of months completed. A binary value of one indicated that in each of the months, the participants made changes see .p < .001) and business students (p < .001). Psychology and business students did not differ significantly from each other (p = .78). Regarding market research, a one-way between-groups ANOVA showed that the three groups differed significantly in the proportion of months they made market research changes. Pairwise comparisons with Bonferroni adjustment showed that business owners made significantly fewer changes than psychology students (p = .03). Psychology and business students did not differ significantly from each other (p = .19), as well as business students and business owners (p = .89). Most participants, however, did not search for and spend money towards market research. Regarding personnel, a one-way between-groups ANOVA showed that the three groups differed significantly in the proportion of months they made personnel changes. Pairwise comparisons with Bonferroni adjustment showed that business owners made more changes compared to both psychology students (p < .001) and business students (p < .001). Psychology and business students did not differ significantly from each other (p = 1.00).Regarding advertising, a one-way between-groups ANOVA showed that the three groups differed significantly in the proportion of months they made advertising changes. Pairwise comparisons with Bonferroni adjustment showed that business owners made more changes compared to both psychology students  spent significantly more time than business students , p = .03, and spent significantly more time compared to psychology students , p = .002, but business students did not differ from psychology students (p = .84).Information in CHOCO-FINE  is free and provided on the main screen. For specific information regarding the market, products, competitors and customers, participants have to access the market research screen and pay for the information. Research Question 3 explored if there are differences between experts, semi-experts and novices in their initial search and exploration for information, therefore spending more time in the first two months of CHOCO-FINE to explore the simulation. A one-way between-groups ANOVA showed that exploration time differed significantly between groups. Pairwise comparisons with Bonferroni adjustment revealed that business owners  between performance and CPS strategies see . Mean exF = 4.37, p < .001, explaining 27% of the variance in performance (R2 = .27). Gender, expenses for personnel and personnel changes significantly predicted performance  and female participants , however, did not show significant differences, t(127) = −1.13, p = .26.A multiple regression was run to detect the influence of the variables on performance. Tolerance values were between .44 and .93, and variance inflation factors VIF were between 1.08 and 2.27, revealing that multicollinearity was not a problem. The model including the seven variables was significant, ance see . CompariThe goal of the current study was to extend previous research and to focus on the following: (a) actual CPS behavior in a complex, uncertain and dynamic business micro-world; (b) to investigate those CPS strategies in business experts and novices empirically and over time, addressing the potential influence of crystallized intelligence on CPS; (c) to explore the competing theories on expert-rigidity versus expert-flexibility; and (d) to explore the role of problem exploration in CPS.Regarding Research Question 1, experts performed better than novices in CHOCO-FINE. As expected, business owners performed best, followed by business students and followed by psychology students. It is noteworthy, though, that 90 percent of all participants had problems managing the chocolate company and lost money. One reason could be the lack of market research considered by participants. In most months, two thirds of the participants did not inquire market research information regarding their own product profiles, their own clients, their competitors and their competitor’s products. The importance of information searching has also been shown to improve performance in other areas, such as with tax professionals . We willResearch Question 2 further investigated the competing theories of expert rigidity versus expert flexibility. First, we compared the expenses in advertising, market research and personnel among the three groups over 19 months. The three groups never differed. Comparing only the first three months, business owners spent more money on advertising and less on market research compared to business and psychology students. They recognized how crucial advertising is. Yet, they later spent less money on advertising than business students and psychology students. Potentially, their advertising has become more targeted and focused on specific products or clients. Regarding market research, business owners spent less than business students and psychology students. One reason could be that they relied on their experiences and knowledge regarding the market. The differences in their strategic approach might again be due to differences in declarative and procedural knowledge between novices and experts. One could interpret the finding of differences in the first three months and none over the entire 19 months as differences in cognitive schemata between business owners, business students and psychology students. Schematic differences may have influenced the CPS approach more so earlier in the simulation than later on. In the second half of the simulation, the situation characteristics of CHOCO-FINE may have been more dominant and “overpowered” the influence of the schemata on decision making.Concerning changes in their strategies from month to month, there were significant differences in advertising changes, market-research changes and personnel changes among the three groups. Regarding market research, business owners made fewer changes than psychology students. Yet, since almost two thirds of all participants did not spend money for market research in a given month, market research in CHOCO-FINE did not play a central role among most participants. Whereas business owners changed their approach to advertising and personnel almost every month and adapted their decisions to the current situation, business and psychology students tried to follow a multi-month strategy and changed their decision-making approach every other or every third month. Decision making that follows the same approach and is not changed when the situation changes has been called methodism  and can Lack of flexibility is typically related to an increase in expertise and more rigid schemata as some researchers claim . In the Research Question 3 investigated whether experts spent more time than novices gathering initial information during the first two months of CHOCO-FINE as part of exploring the simulation. A detailed problem analysis is necessary when dealing with a complex, dynamic and uncertain problem situation, such as CHOCO-FINE . Indeed,The differences in exploration time refer more to the discovery of the company’s general information  and not to specific market research (clients and competitors), because the three groups did not differ significantly in their market research expenses for the first three months. Perhaps it is not too surprising that business and psychology students did not conduct much market research, but why did the business owners not engage in more market research? One reason could be related to sample characteristics of the business owners in the current study. All business owner participants were small business owners. It is possible that in their businesses, market research is not as crucial compared to mid-size or larger companies. Small business owners have direct contact with their customers and therefore receive direct feedback from them. Future research could compare small business owners with managers/executives from large companies to clarify the relationship between market research and the size and kind of business.The more in-depth search for information of experts was also shown in other research. Strohschneider and Schaub , for exaAlthough the regression analyses did not provide strong evidence, and we have to acknowledge the low power due to the relatively small sample size, it is exactly the changes in CPS that are predictive of overall performance (Research Question 4). In a complex and dynamic situation like CHOCO-FINE, one must observe the situation in detail An open question still refers to the generalizability of simulation data to real-world behavior in general and CPS in particular. Future research could for example investigate the predictive validity of simulation performance and real-world performance.This study contributes to the lack of empirical research on successful and failing CPS strategies in business experts and novices, the influence of prior knowledge and crystallized intelligence on CPS as mentioned in the Introduction to this Special Issue on Intelligence and CPS . AdditioThe findings related to expert-novice comparisons are especially interesting, relevant and directly applicable to training programs in CPS. Danner and colleagues  suggest Novices could learn from the successful strategies of experts. For example, novices can learn not to engage in action right away, but to, instead, spend time analyzing a problem situation and to always be aware that the situation can change as decisions must be adopted.The results of the current study together with research on crystallized intelligence and expert-novice differences  show tha


Non-contributory pension programs in the developing world seek to provide older adults with an income that may improve their health and wellbeing in old age by enabling access to health care and better nutrition. There is no previous evidence of the effects of non-contributory pensions on frailty, a comprehensive measure of health and well-being of the oldest old. We aimed to estimate the effects of non-contributory pension programs on frailty of older adults in the state of Yucatan, Mexico. We use rich panel data, including objective markers and self-reported assessments of health and well-being, for 944 adults at least 70 years of age in two communities of Yucatan, Mexico. The first wave was collected in 2008; the second wave was collected in 2010, 18 months after implementation of a monthly state pension in one community and 12 months after a federal pension paid every two months in the other. We found the state pension led to a statistically significant decrease in the severity of frailty for women, but the federal pension was associated with an increase. We found no statistically significant change in the frailty index for men in either community. Among explanations for these findings are monthly payments being more likely to be spent on health care, medicines, and more regular food expenditures, enabling women who previously lacked independent means of support to increase their longer-term health. The federal program paid every two months led to irregular patterns of food expenditure and increased ownership of durable goods but had no effects on health care utilization, subsequently leading to deterioration in longer-term health for women. Mexico is aging rapidly. From 2010 to 2050, the population 60 years and older is projected to increase from 8.9% to 21.5% of the total population [Poverty in old age is common in middle- and low-income countries . In MexiMexican workers contribute to a three-party  public social security system and receive social security benefits when they retire. Most workers—52.1%—are, however, in the informal sector and do not contribute to social security . InformaIn many low- and middle-income countries, governments have introduced safety net programs that provide cash and other benefits such as a basic food basket, free meals, and subsidies to help pay for utilities, health insurance, or health care –12. For Programa 70 y Más (70 y Más), to all older persons not receiving any other social security benefits or state-level non-contributory pensions in 2012, and to all such persons at least 65 years of age in 2013, when the program was renamed Programa Pensión para Adultos Mayores [Unconditional cash-transfer schemes or non-contributory pensions for older adults are the main means for providing income security in old age in at least 40 countries around the world including Argentina, Brazil, Bangladesh, Mexico, and South Africa , 15. The Mayores . Prior tPrevious research has found mixed effects of non-contributory pensions on social and health outcomes. In Mexico, the federal government non-contributory pension program (NCP) that disburses pension payments every two months, has reduced poverty , improveIn Brazil, NCP have reduced poverty –29 and hAltogether, research across several countries indicates NCP can reduce poverty but have less conclusive effects on health . Among pIn recent decades, several indicators of health and well-being of older adults have been developed to better describe the heterogeneity of this population and its chronic conditions, functional disability, sensory impairment, and other ailments. The first comprehensive assessments focused on individual ability to function independently as measured by the ability to perform daily and instrumental activities of daily living ,38 incluRegarding the difficulties in measuring the relationship between income and health, we note establishing causality here is notoriously difficult because it can run both ways . That iWe analyze the effect of NCP on frailty, a more-comprehensive measure of health and functional ability using biomarkers. We use rich panel data collected in the state of Yucatan, Mexico, including objective markers and self-reported questions on health and wellbeing, collected before (August-November 2008) and after (June-August 2010) the introduction of two NCP, one state and one federal. The communities where these programs were introduced are similar in their location, socioeconomic and demographic characteristics, and pensions that older adults received. We therefore expect the introduction of the pension programs to have similar effects. We attribute differences in the outcome variables to the state program paying its benefit more frequently than the federal one.In addition to increasing purchasing power, NCP income can enable better food availability and purchase and use of medicines and health services, including education, nutrition, and other care programs. We hypothesize that, by reducing financial constraints, the NCP improved food intake and use of health care services, with these in turn having longer-term effects on nutrition, health, and wellbeing, ultimately stabilizing or even reducing the level of frailty for recipients.Reconocer Urbano, a state-level program in Yucatan, and 70 y Más , a federal program across Mexico. Reconocer Urbano was rolled out in stages with an experimental design to evaluate its impact on the health and well-being of older adults by town. The experimental design included two communities with similar socioeconomic and demographic characteristics and geographic location in the northeastern part of the state: Valladolid  and Motul .Our research focuses on the effects of two NCP programs: The introduction of the NCP in the state of Yucatan was done in three phases. The first phase included localities with less than 6,500 inhabitants; the second phase was for localities with less than 20,000 inhabitants; and the third phase was for localities with 20,000 inhabitants or more. Eleven cities in the state qualified for the third phase of the program . From these cities, we conducted a cluster randomized controlled trial design by matched pairs of towns with similar characteristics using the 2005 Mexican Census. Among those pairs, one was randomly chosen, Valladolid and Motul; within that pair, Valladolid was randomly chosen to start the state program non-contributory pension in 2008.As shown in We identified participants for the pension program by screening all households with adults 70 or older. We did so in partnership with the National Institute of Statistics in Mexico (INEGI). INEGI provided us with maps of the evaluation communities, updated the maps as necessary (with a cartographer accompanying our data-collection team), helped train the data-collection team, and provided quality assurance during the listing process. In screening the selected communities, interviewers listed each household to identify age-eligible respondents and, using a brief form, collected first and last names, age, date of birth, gender, and preferred interview language (Spanish or Mayan). A detailed description of the study design, sampling frame, and follow-up procedures has been previously published .70 y Más, and households with adults 70 years and older in Motul, but not in Valladolid, became eligible for the federal NCP of MXN$1,000 (or US$105.60 at 2014 PPP), paid every two months. In short, both the state and federal programs provide a very similar benefit but at different frequency: monthly for the state program and every two months for the federal program.Valladolid started receiving a state NCP of MXN$550  in December 2008, paid monthly to persons 70 and older. Prior to this, we conducted baseline surveys (W1) between August and November 2008 among all households with persons 70 or older in Valladolid and Motul. In July 2009, the federal government expanded its program Reconocer Urbano and 12 months after Motul started receiving 70 y Más. We calculated response rates using American Association for Public Opinion Research guidelines [Reconocer Urbano was replaced by the program Reconocer Universal, and rolled out to all older adults in Yucatan.We conducted a follow-up survey (W2) in June and July 2010, 18 months after Valladolid began receiving idelines . ResponsThe survey questionnaires we used were comparable to those for the Mexican Health and Aging Study (MHAS) and the U.S. Health and Retirement Study (HRS), and included a comprehensive assessment of health, disability, and socioeconomic characteristics. The surveys also collected anthropometric measurements  and performance measures  for age-eligible respondents. We built a team of bilingual  data collectors for this research project. We provided the interviewers more than 250 hours of training in general interviewing techniques, question specifications, refusal, informed consent, the use of proxy respondents and secondary informants, guidelines for handling common problems, data confidentiality and safeguarding, field safety, issues in surveying identified respondents, and protocols for managing case assignments. We also trained and certified all data collectors in collecting anthropometric measurements and biomarkers following the standardized protocols and equipment of HRS [The original sample consisted of 1,186 men and 1,265 women in both communities. Of those, 1,136 men and 1,215 women responded to the W1 survey, with the remaining 4.1% of the sample not interviewed because of refusal or changed address since the initial listing. Of those responding to the W1 survey, 793 men and 854 women responded to the W2 survey as well, with the remaining 29.9% not interviewed at W2 because of death, refusal or changed address. After dropping cases with missing information for our frailty index (discussed below), we had a final working sample of 470 men and 474 women.2008-0513-CR07) for the surveys. The study complied with U.S. and Mexican requirements and standards for conducting ethical research. An informed-consent form that followed the Helsinki Declaration II was provided to each participant. Informed written consent was obtained separately for anthropometric and biomarker assessments. We obtained oral consent for the general interview, while for anthropometric and biomarker measurements we obtained written informed consent. Participants who did not provide their consent in either were not interviewed [The Internal Review Board at RAND Corporation revised and approved the protocol  test that evaluates major depressive episodes as defined by the revised third edition of the ociation . ParticiWe assessed walking speed with a timed 12-feet-long walk test. Interviewers placed measuring tape for the walk and made sure participants were wearing appropriate footwear before asking them to complete the walk at their usual pace. The test was completed two times and the faster time recorded. Classifying men and women separately, we coded as 1 those unable to perform the test or who were in the lowest quintile in walking time for those of similar height group  fixed at baseline.We assessed self-reported physical activity using the question “On average during the last month, have you exercised or done hard physical work three or more times a week?” This question includes sports, heavy household chores, or other physical work. We scored as 1 those who responded “No” to this question.After generating these criteria, we constructed a summary measure of deficits (0–5). Following Fried and colleagues , we clasOur covariates include age, age squared, marital status , total years of formal education, number of household members, whether respondent lives alone , study wave , whether respondent lives in Vallodolid and received the state pension (1) or Motul and received the federal pension (0), and an interaction variable between W2 and the indicator for the state program . We also included other baseline covariates that could affect the risk of frailty. These include number of chronic conditions, health insurance , health care utilization, nutrition, and a local poverty index. Chronic conditions include cancer, hypertension, diabetes, respiratory problems, liver disease, stroke, and heart disease. Health care utilization is the number of doctor visits in the last three months. Nutrition includes questions: “How often do you eat meat, poultry or fish”, “How often do you eat fruits or vegetables”, “How often do you eat tortilla, bread, crackers or other cereals”, each with a four-point scale ranging from never (1) to at least once per day (4). The poverty index, a continuous variable with values from -1.098 to 1.409, where higher values indicate higher poverty levels, was computed by the Mexican National Population Council (CONAPO) at the level of the AGEB, a basic geo-statistical area of a group of blocks within a geographic area .We calculated descriptive statistics of outcomes and estimated the impact of the non-contributory pension program by comparing the differences between the towns receiving state and federal programs using differences-in-mean outcomes between W1 and W2 (pre vs post estimator). We compare the change in outcomes for the two programs (difference-in-differences or DID estimator) to identify the causal effect of the state program with respect to the federal program, assuming both towns follow common trends or similar natural tendency in the absence of treatment. The common-trends assumption allows the confounded time trend of the pre-versus-post estimators to drop out when conducting the DID analysis that identifies the causal effect. Differences in levels between towns are corrected by the DID estimator but both towns must follow similar trends before the introduction of the NCP .Oportunidades, an unconditional cash transfer program for households in poverty . There were no programs besides the NCP implemented differentially for the two towns.Both towns had similar characteristics at baseline and had similar economic trends see  Tables. Yit is the outcome of interest for individual i in wave t, wt is a dummy variable for wave , P is a program dummy , and Xit includes demographic characteristics and health related outcomes that could affect the risk of frailty. The parameter β3 measures the difference in the treatment effects between W1 and W2 for the state and federal programs. The role of covariates is to improve the precision of the difference-in-difference estimate β3. We estimate robust and clustered standard errors at the household level.To test multiple hypotheses, we apply a Holm-Bonferroni correction . In thisThe estimated coefficient of the interaction between W2 and the indicator for Valladolid, the state-program town, shows the regression equivalent of the mean differences in the changes between the groups’ results. We also use a non-parametric statistical procedure, propensity score matching (PSM), to compare individuals with similar characteristics in the state- and federal-program towns, and use the same set of variables for PSM that were used in the OLS regressions. We estimated propensity scores using a probit model. To assess potential sample selection issues, we conducted four robustness analyses: (a) we compared W1 characteristics of individuals who died prior to W2 with those who remained alive to assess the effects of mortality bias; (b) we compared W1 characteristics of individuals who did not complete W2 with longitudinal respondents to assess sample attrition bias; (c) we compared characteristics (age and gender collected in the listing) of the not-completed and completed interviews between the listing and W1; (d) we analyzed item non-response per variable in the frailty index to assess the quality of the data and other potential bias.The final working sample at baseline consisted of 528 adults 70 years and older (54.3% women) in Valladolid, the state-program town, and 416 (44.9% women) in Motul, the federal-program town. Respondents reported an average of 0.5 (±0.7SD) chronic conditions each, and 70% to 79% reported access to health insurance. On average, respondents report one doctor visit (±1.5SD) in the previous three months. Men and women report similar frequency of consumption for meat, poultry or fish, (2.8 or at least once a week with ±0.7SD), for fruits or vegetables (2.8 or at least once a week with ±0.8SD), and for tortilla, bread, or crackers (3.9 or at least once a day with ±0.3SD). The average AGEB-level poverty index is higher (0.4 with ±0.5SD) in Motul, the federal-program town, than in Valladolid, the state-program town (0.1 with ±0.5SD), and the differences are statistically significant. Nevertheless, as mentioned in the methods section, differences in levels are corrected by the DID estimator and do not bias results of our analysis. There were differences between Valladolid and Motul in most of our frailty measures, but these differences were not statistically significant. As expected, we observe substantial differences between men and women in the level of frailty. In Valladolid 21.6% of women and 25.9% of men were not frail at baseline; in Motul, 23.0% of women and 29.4% of men were not frail .Overall, the frailty index showed an important improvement for women receiving the state pension. In comparison to those who received the federal program, women who received the state program decreased their frailty severity by -0.43 . There were no statistically significant changes for men in the level of frailty by whether they received the federal or state program.We find our results in Regarding potential sample-selection issues, we found that those who died after W1 were on average older and that differences in age between deceased and surviving respondents were similar in both towns. As earlier noted, we found few statistically significant differences in socioeconomic characteristics between the state- and federal-program towns. We also found no evidence of attrition bias, i.e., differences in socioeconomic characteristics between attriters and those remaining in the panel were not statistically significant in either town Click here for additional data file.S2 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.