MHOv/O was identified using the Adult Treatment Panel criteria. Dietary patterns previously derived in this study population were: Fast Food/Dessert, Traditional-Lebanese and High-Protein. The proportion of MHOv/O in the study sample was 37.2%. Females, higher education and high level of physical activity were positively associated with odds of MHOv/O. Subjects with higher adherence to the Traditional-Lebanese pattern had higher odds of MHOv/O . No significant associations were observed between the Fast Food/Dessert and the high-protein patterns with MHOv/O. Follow-up studies are needed to confirm those findings and understand the mechanisms by which the Traditional-Lebanese pattern may exert a protective effect in this subgroup of overweight and obese adults.This study aimed to examine the proportion and socio-demographic correlates of Metabolically Healthy Overweight and Obesity (MHOv/O) among Lebanese adults and to investigate the independent effect of previously identified dietary patterns on odds of MHOv/O. Data were drawn from the National Nutrition and Non-Communicable Disease Risk Factor Survey (Lebanon 2008–2009). Out of the 337 adult participants who had complete socio-demographic, lifestyle, dietary as well as anthropometric and biochemical data, 196 had a BMI ≥ 25 kg/m Obesity is generally associated with numerous metabolic disorders such as insulin resistance (IR) and type 2 diabetes , hyperteThe prevalence of MHO varies according to the definitions used to characterize this phenotype and could reach up to 40% among obese adults ,14. GiveIn Lebanon, similarly to other Eastern Mediterranean countries, the rate of overweight and obesity among adults is reported to follow an escalating secular trend, with its prevalence estimates increasing from 54.4% to 65.0% over the past decade . Such ann = 1331). From these participants, 337 subjects provided written consent and gave a blood sample. Comparison of subjects who gave blood and those who did not showed that both groups were comparable across the sociodemographic characteristics except for marital status (62% of respondents vs. 50% of non-respondents are married). In addition, significantly higher proportions of overweight and obesity were found among those who gave blood as compared to those who did not . (Unpublished data). Of these 337 subjects, 196 were overweight and obese individuals (BMI ≥ 25 kg/m2), and their data are included in this study . Data for this study were drawn from the cross-sectional National Nutrition and Non-Communicable Disease Risk Factor Survey (2008–2009) described elsewhere . In brieAt the participants’ homes, data collection was conducted by trained field workers, phlebotomists and dietitians. Data collection procedures followed the WHO STEP wise approach to Surveillance (STEPS)  and inclSocio-demographic characteristics were age, sex, marital status, education level, crowding index, and family history of obesity. Crowding index was defined as the average number of people per room, excluding the kitchen and bathroom. Previous studies have shown that a higher crowding index was correlated with a lower socioeconomic status ,29,30. TAnthropometric measurements obtained included weight, height and waist circumference, all of which were obtained using standardized protocols. The percent body fat was computed using skinfold thickness measurements according to the Durnin and Womersley formula . Blood pMetabolic and biochemical assessments were measured after an overnight fast and included serum triglycerides, HDL and LDL-cholesterol, fasting blood glucose, fasting blood insulin, and CRP. Details regarding blood collection and analysis were described elsewhere . Dietary patterns in the study population: Previous work by our research group derived dietary patterns among survey participants who had complete socio-demographic, lifestyle, dietary as well as anthropometric and biochemical data . The FFQ2) were included in the analyses of this study.Accordingly, three dietary patterns were identified: Fast Food/Dessert, Traditional-Lebanese, and High Protein. The Fast Food/Dessert pattern consisted mainly of hamburger, shawarma, pizza and pies, falafel sandwiches, desserts, as well as carbonated beverages and juices. The Traditional-Lebanese pattern was identified as a variant of the Mediterranean diet  and inclTo date, there is no consensus on the MHO phenotype’s definition. A commonly used definition is The Adult Treatment Panel criteria for the metabolic syndrome (ATP-III) criterion, which was used in this study. Accordingly, an overweight or obese subject was classified as MHOv/O if he/she had one or none of the following: triglycerides ≥1.7 mmol/L; systolic blood pressure (BP) ≥130 mm·Hg; diastolic blood pressure ≥85 mm·Hg; fasting blood glucose ≥5.6 mmol/L; and HDL- cholesterol <1.04 mmol/L for men and <1.29 mmol/L for women. Overweight and obese subjects with more than one of these conditions were classified as Metabolically Unhealthy Overweight and Obese (MUHOv/O).Descriptive statistics for socio-demographic, lifestyle, anthropometric, and biochemical characteristics of study participants were presented as means ± SD and proportions for continuous and categorical variables, respectively. Chi-square and independent t-tests were used to compare MHO and MUHOv/O groups. The association of each of the characteristics of study participants with MHOv/O was assessed using simple logistic regression analysis. In order to evaluate the determinants of MHOv/O, a multiple logistic regression model was used. In this model, variables were included if they were significantly associated with the outcome in the univariate analysis. Simple and multiple logistic regression models were also used to evaluate the associations between the dietary patterns of the study population and the odds of the MHOv/O phenotype. In these models, scores of the dietary pattern were the independent variable (grouped as low adherence-1st tertile- and high adherence-2nd and 3rd tertile), and MHOv/O phenotype as dependent variable (MHOv/O vs. MUHOv/O). These models were adjusted for variables found to be significantly associated with MHOv/O. Tests for linearity (Tolerance > 0.4) of the covariates included in the regression models were performed. Normality of the residuals was assessed by the histogram of standardized residuals and normal probability plot in all regression models. All analyses were undertaken using SPPS software version 22 .The proportion of MHOv/O in the study population was 37.24%, 95% CI (30.78–44.19). Descriptive characteristics of the study population and their association with MHOv/O, as derived by simple logistic regression, are shown in Correlates of the MHOv/O status were examined by multiple logistic regression, and the resulting OR and their corresponding 95% CI are presented in The OR and 95% CI for the association of adherence to these dietary patterns with the odds of MHOv/O are presented in This study is the first in Lebanon and the region to assess the proportion and correlates of MHOv/O and investigate its association with dietary patterns among overweight and obese adults. The results showed that the proportion of MHOv/O in the current study sample is 38.2%, implying that approximately one out of three overweight/obese individuals is considered metabolically healthy. This proportion is higher than a recent estimate from a prospective cohort of 4397 adults in Spain, where prevalence of MHOv/O was found to be 28.7% [The findings of this study showed that, even though BMI and percent body fat were not associated with MHOv/O, a negative association between waist circumference and MHOv/O was observed. Recognizing waist circumference as a proxy measure of visceral adiposity , these fIn this study, investigation of the correlates of MHOv/O showed that female gender, higher education levels, and higher physical activity are significantly associated with higher odds of this phenotype. The fact that MHOv/O status was positively associated with female gender is in line with what has been reported in other investigations on MHO  and may In the present study, we have opted to use the dietary pattern approach in investigating the association between diet and the MHOv/O phenotype. Previous studies conducted by our group on a national sample of Lebanese adults, which included normal weight, overweight and obese subjects, documented a positive association between metabolic syndrome and adherence to the Fast Food/Dessert pattern, a pattern that contains most of the food groups characteristic of the “Western Pattern” ,48 and wThe findings of this study ought to be considered within the context of its limitations. First, we have included in our sample both overweight and obese individuals and not only obese. Descriptive statistics, however, have demonstrated that there was no significant difference in BMI between MHOv/O and MUHOv/O, indicating that overweight individuals did not have higher odds of belonging to the MHOv/O phenotype over obese participants. Second, the MHOv/O state may not be a stable phenotype, and there remain open questions related to whether MHOv/O represents a transient phenotype changing with aging and behavioral and environmental factors . Third, In conclusion, the study showed that overweight and obese subjects with higher adherence to the Traditional-Lebanese dietary pattern had higher odds of belonging to the MHOv/O phenotype, independent of other socio-demographic, lifestyle characteristics. These findings suggest that the Traditional-Lebanese dietary pattern, a variant of the Mediterranean diet, may be associated with offset or delayed development of adiposity-related metabolic abnormalities. In this context, interventions and strategies aiming at preserving and promoting the traditional diet could be proposed in Lebanon. It is important to note that, even though this study has identified factors that modulate the odds of MHOv/O, maintaining a healthy body weight remains the most impactful public health recommendation to decrease metabolic abnormalities and associated diseases.


Background: Numerous studies have explored how patients and their caregivers cope with amyotrophic lateral sclerosis (ALS), but the literature completely lacks research on the psychological impact of the disease on patients’ children. The aim of our study was to investigate the emotional and psychological impact of a parent with ALS on school-age children and adolescents in terms of problem behavior, adjustment, and personality characteristics.Methods: The study involved 23 children  with a parent suffering from ALS, and both their parents. Children were matched for age, gender, and birth-order with a control group of children with healthy parents. They were administered the Youth Self Report (YSR) questionnaire and the Rorschach Comprehensive System, and their healthy parent completed the Child Behavior Checklist (CBCL).Results: Findings clearly showed that, compared with controls, children with a parent who had ALS had several clinically significant adverse emotional and behavioral consequences, with emotional and behavioral problems, internalizing problems, anxiety and depressive symptoms. Children of a parent with ALS scored higher than controls for the Total Problems, Internalizing Problems, Anxious/Depressed and Withdrawn/Depressed scales in the YSR. A relevant percentage of children fell within the clinical range (42.9%) and borderline range (28.6%) for Internalizing Problems. The Rorschach CS confirmed the substantial impact of ALS in a parent on their offspring in terms of internalizing behavior and depression, with adjustment difficulties, psychological pain, and thought problems.Conclusion: Our findings indicate that school-aged children and adolescents with a parent who has ALS are vulnerable and carry a substantially higher risk of internalizing behavior, depressive symptoms, and reactive problems than children with healthy parents. Families affected may need support to cope with such an overwhelming disease. Amyotrophic lateral sclerosis (ALS) is a degenerative disease involving both upper and lower motor neurons, and leading relentlessly to progressive muscle atrophy and weakness, dysphagia and dysarthria. In most cases, patients die within 3–5 years of the disease’s onset, usually due to respiratory failure . SecondaThere is no effective cure for ALS, so medical treatment is focused on physical symptom management . The impAmyotrophic lateral sclerosis is overwhelming and challenging for caregivers and families as well. When Patients with ALS have to cope with serious restrictions and changes in their daily life. They need assistance with eating and dressing, nursing care, and mobility, that is often provided by a family member, and the patient’s partner in nearly 80% of cases . The proAlthough many studies have explored how patients and their caregivers cope with ALS, the literature completely lacks any research on the specific psychological impact of such a devastating disease on the patients’ children. It is important to investigate this issue in the case of ALS because the consequences of a parent’s severe illness on their offspring can sometimes be dramatic, as already reported for a variety of diseases. In particular, the impact on children of a parent suffering from a chronic medical condition (CMC), i.e., a disease lasting at least 3 months and involving one or more apparata , such asAccording to the extant literature, a CMC in a parent involves the whole family and has a great impact on the parent’s children . Long-teMore in general, children of an ill parent were reported to experience high levels of stress and to be at higher risk of health-related and social-emotional problems, such as somatic complaints, social isolation, excessive concern about becoming ill themselves, anxiety, depressive affects, and low self-esteem . A meta-Among the studies on children with parents suffering from neurological CMCs, the case of MS has been the most thoroughly investigated . These sGiven these premises, the present study had three main objectives. First, we aimed to verify whether school-age children and adolescents who have a parent with ALS are more at risk of problem behavior, as measured by self-report questionnaires, than children of healthy parents. Consistently with the extant literature on CMCs in parents, we expected children with a parent who had ALS to display more internalizing and/or externalizing problems than controls. Second, we aimed to explore the psychological adjustment of children with a parent suffering from ALS by administering a performance-based task, the Rorschach test, scored using the Comprehensive System CS; . Like FlSD = 3.98 years, range: 5–17 years), six were females (26.1%), 17 were male (73.9%). The children belonged to 12 families in which one parent had ALS and the healthy spouse was the patient’s main caregiver. The ill parent was the mother in five families, the father in seven.The study group consisted of 23 children with a parent suffering from ALS. The mean age of the children was 10.62 years  were administered the Youth Self Report .T scores to ascertain clinical, borderline, and normal ranges: T score below 60 = normal; between 60 and 63 = borderline; and 64 or above = clinical . Forty-five Rorschach protocols were collected because one child in the study group refused to complete the Rorschach task. Exner’s CS was used to administer and interpret the Rorschach protocols , and theTable 2).To obtain inter-scorer reliability, 10 protocols set were selected at random and scored independently by the two judges. Inter-scorer reliability was calculated by percentage of agreement and iota for 10 response segments. Iota is chance-corrected reliability coefficient that is equivalent to Cohen’s kappa for a multivariable test scored by two or more raters , 2004. TTo prevent chance findings arising from multiple comparisons, we restricted the Rorschach variables analyzed in this study , as in tSeveral indexes were used to assess respondents’ ideational processes and cognitive resources, namely variables regarding reality testing , and variables regarding thought problems . We also used the intellectualizing index (2AB + [Art + Ay]) to examine variables that might reflect defensive mechanisms, such as the tendency to take refuge in fantasy (Ma/Mp), or to minimize emotional experiences. All these variables were analyzed as frequencies (considering the number of responses), and/or as categories when the frequency exceeded a cutoff validated in the CS.Finally, we analyzed the Psychopathological Constellation indexes. When positive, these indexes point to the presence of depressive symptoms (DEPI), the risk of suicidal behavior , inadequate coping abilities , obsessive cognitive processing , paranoid thoughts , and thought disturbance .Patients with possible, probable, or definite ALS – according to the El Escorial criteria for its clinical diagnosis  – and thU test for continuous variables and Pearson’s chi square for categorical variables. The Mann–Whitney U test was preferred to other parametric statistics because non-parametric tests require few if any assumptions about the shapes of the underlying population distributions and are more robust with small sample size , medium (d = 0.50), or large (d = 0.80). Cohen’s d values of 1.30 and above were classed as very large , and intraclass correlation coefficients (ICCs) to assess pairwise agreement between informants (absolute agreement). Pearson’s correlation coefficient indicates a poor agreement when lower than 0.30, a moderate agreement between 0.30 and 0.50, and a good agreement when higher than 0.50 . The study group scored significantly higher than the control group for: Anxious/Depressed , Withdrawn/Depressed , Internalizing , and Total Problems . The differences for Aggressive Behavior  neared statistical significance, while no differences emerged for Externalizing Problems or any of the other syndrome and social competence scales (Table 3). The effect sizes relating to the scales with significant differences were large (d > 0.8), and for Internalizing Problems Cohen’s d was very large .Analyzing the scores for Internalizing, Externalizing, and Total Problems in terms of their clinical relevance, we found 6 (42.9%) of 14 children with a parent who had ALS were in the clinical range on the Internalizing scale, 4 (28.6%) were borderline, and only 4 (28.6%) were in the normal range. Conversely, none of the 14 children in the control group was in the clinical range, 2 were borderline, and 12 were in the normal range. The difference between the two groups was statistically significant , and Total problem  scales.No such differences emerged between the groups in terms of their distribution in the Externalizing  of the children in the two groups were compared using the Mann–Whitney p = 0.078), less well controlled or modulated emotional experiences (FC), undesirable self-image (a lower GHR than controls), and less healthy and adaptive understanding of others (GHR < PHR). They had less adequate reality testing results , more distorted perceptions (X-%) and signs of serious mediational impairments . These children with a parent suffering from ALS also showed more signs of thought disturbance .The children with a parent suffering from ALS had several variables that, interpreted in accordance with the CS, were indicative of a less adequate psychological functioning than the children in the control group. They showed signs of more self-disgust, shame, emotional distress, and guilt , more negative or blemished features about the self and the world , more preoccupation with the body, health or illness , they more frequently exhibited human movements indicative of general mental abilities, including planning, imagination, and empathy (M > 0). They also tended to minimize emotional experiences by intellectualizing [2AB + (Art + Ay)]. None of the children with a parent suffering from ALS used fantasies as an integral part of their defense system (Ma < Mp).p = 0.053) – is interpreted as a tendency toward affective problems. Similarly, the index of disturbed thinking and distorted perceptions, Perceptual-Thinking Index (PTI), was significantly higher in the study group than in the control group, and 9 of the 22 children in the study group who completed the Rorschach Test (40.9%) had a PTI ≥ 3, a categorical cutoff that has been found correlated with high thought disorder scores in other tests  was significantly higher in the study group, and significantly more children in the study group  than in the control group  came above the clinical threshold (DEPI > 4) indicating a higher probability of subclinical or clinical depression. Three children in the study group, but none in the control group, had a DEPI > 4 associated with a CDI ≥ 4 : this association – which neared statistical significance . The statistical comparisons yielded no significant differences between the two groups for the syndrome and general scales of the CBCL: Anxious/Depressed , Withdrawn/Depressed , Somatic Complaints , Social Problems , Thought Problems , Attention Problems , Rule-Breaking Behavior , Aggressive Behavior , Internalizing , Externalizing , and Total Problems .We compared the two groups of children in terms of their emotional and behavioral problems and competences as reported by their healthy parents using the CBCL . More in detail, children with an ALS parent were described as being significantly less competent in: activities , Social , and Total Competence .On the other hand, parents of the children in the study group returned significantly lower scores than parents of children in the control group for all competence scales of the CBCL except School . The ICCs generated similar results . Wilcoxon Signed Ranks Tests identified no significant differences between the healthy parents’ and their children’s assessments of the latter’s Internalizing , Externalizing , and Total problem T scores .Then we applied Pearson’s correlation and ICCs to examine the agreement between the scores obtained by the children in the study group and their healthy parents. Moderate to high Pearson’s correlations were found for Internalizing, Externalizing, and Total Problems , and scores that neared a statistically significant difference on the Aggressive behavior scale of the YSR. Notably, all the corresponding effect sizes were either large  or very large , indicating that the differences between the scores obtained by the two groups were very clear. A substantial percentage of children with an ALS parent fell within the clinical (42.9%) and borderline (28.6%) ranges for Internalizing problems according to the YSR cutoffs; the difference vis-à-vis the control group was statistically significant.d = 0.25; 95% CI ). The very large effect size (d = 1.31) for self-reported internalizing problem in our sample led us to hypothesize that ALS in parents may have a significantly worse fallout on their children’s adaptation than other chronic illnesses. While this issue requires further investigation, two preliminary one-sided outlier tests, carried out to detect whether the effect size for self-reported internalizing problem in our sample is an outlier with respect to the distribution of effect scores reported by Q-test: p = 0.048; Grubb’s test: p = 0.017).On the whole, our results are in line with the extant literature suggesting that children can be strongly affected by having a chronically ill parent, especially in terms of internalizing problems  and relaHaving a parent with ALS did not increase the scores for somatic complaints in our study group, as reported in other studies concerning CMCs, and MS in particular. p = 0.066, d = 0.70); increasing the size of the sample would probably make this difference statistically significant. As a possible explanation for this result, there is the interesting suggestion from Contrary to our expectations, we found no significant differences between our study and control groups in terms of externalizing problems (as reported in many other studies on children with parents suffering from CMCs). To clarify this result, we should consider that the Externalizing score in the YSR consists of two clinical subscales for Rule-Breaking Behavior and Aggressive Behavior. While there were clearly no differences between our two groups of children for the first subscale, on the second the study group revealed higher levels of aggressive behavior than the controls, and the difference neared statistical significance with a medium effect size  scored above the clinical threshold pointing to a higher likelihood of subclinical or clinical depression. It is worth emphasizing that the percentage of children above the clinical threshold for depression in the Rorschach CS (45.5%) was very similar to the percentage of children identified by the YSR as having internalizing problems above the clinical cut-off (42.9%). In other words, the self-report and projective measures converged in indicating that more than 40% of children with a parent suffering from ALS have internalizing-depressive problems.Second, the structural summary of the children in our study group (obtained with the Rorschach CS) revealed several indicators of difficult adjustment and psychological pain. In their projective responses, these children showed more self-disgust, shame, emotional distress, and guilt. They also experienced more negative or blemished features about the self and the world, an undesirable self-image, less well controlled or modulated emotional experiences, and a less healthy and adaptive understanding of others. The Rorschach CS also generated projective indexes of preoccupations with the body, health and illness that did not emerge from the YSR. A psychodynamic interpretation of this inconsistency might be that these children were worried and scared about their parent’s body, health or illness (as indicated by the Rorschach projections), and they coped with their concern by unconsciously adopting defense mechanisms such as repression, denial, or dismissal. In fact, previous research has shown that physical evidence of a parent’s illness and treatment  or the situation  that could help to explain the differences in problem behavior between the study group and the controls. A last, potential limitation lies in that we considered more than one child from the same family, thus violating the assumption of statistical independence of our observations. Having said that, we must remember that ALS is a relatively rare disease and it is consequently very difficult to obtain a large number of participants.Despite its limitations, to the best of our knowledge this exploratory study is the first to address the impact of ALS in a parent on a child’s adjustment. We believe that the severe psychological consequences of having a parent with ALS emerging from the present study mean that the families affected may need support to cope with such an overwhelming disease.Design and conceptualization of the study: AP, GS, VC. Coding of data: AP, FB. Statistical analysis and interpretation of the data: VC. Drafting the manuscript: VC, FB. Revising the manuscript for intellectual content: VC, FB, EB, MS, MM, CF, GQ, GS, AP. Final approval of the version to be published: VC, FB, EB, MS, MM, CF, GQ, GS, AP. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: VC, FB, EB, MS, MM, CF, GQ, GS, and AP.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.


To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey.Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts.Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9–570.8 and aOR: 165.4; 95% CI: 98.0–279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3–0.8.Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs. Our corresponding study cities were Adana, Ankara, Balikesir, Bursa, Erzurum, Gaziantep, Istanbul, Izmir, Kayseri, Samsun, Trabzon and Van respectively. Within the urban districts of each city, the Turkish Statistical Institute randomly selected either 10 sampling points for the three major cities  or five such points for the smaller cities. Around each sampling point, our fieldworkers visited the closest bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. The fieldworkers gradually expanded the search until one or two of each type of public venue had been located around each sampling point and a pre-specified target number of venues of each type had been located in each study city. The target numbers, which had been set by a consensus panel before the field work began (available from the corresponding author), took into account the size of the city, the rarity of the type of venue and the allocated fieldwork duration – of two weeks in each major city and one week in each smaller city. A letter from the Ministry of National Education authorized access to schools. All other venues allowed public access. The fieldwork was conducted in December 2012–January 2013 in Ankara, Istanbul and Izmir and in May–July 2013 in the rest of the study cities. Institutional review boards at the Johns Hopkins University in Baltimore (United States of America) and at Doğuş University in Istanbul (Turkey) approved the study protocol.In this cross-sectional observational study, we studied public venues in one city in each of the twelve first-level subdivisions used in Turkey by the European Union’s Following a standardized protocol, trained fieldworkers conducted all the observations working in pairs and visited each study venue during the venue’s regular working hours. In each visited venue, the fieldworkers followed a standard itinerary and evaluated a pre-specified number of study locations. In government buildings, hospitals, schools, shopping malls and universities, the locations included – when present – the main entrance, a corridor, a stairwell, a waiting room or common area, classrooms, offices that were open to the public, a toilet area near a dining area and a dining area. In hospitality venues, the fieldworkers entered the venue, sat as customers, visited the toilet area and observed the other areas available in the venue. Fieldworkers also observed the outdoor area near the main entrance as well as any gardens or patios that belonged to the venues. In each study location, the fieldworkers recorded the number of people present, the number of people smoking, the presence or absence of cigarette butts, cigarette sales, ashtrays and no-smoking signs, the visibility of any no-smoking signs – i.e. whether the fieldworkers considered such signs to be obvious or tucked away where few visitors would notice them – and whether the no-smoking signs they saw, if any, included information on fines for smoking in the venue. As the legislation on the prohibition of smoking in Turkey did not apply to outdoor areas, at the time of the fieldworkers’ visits, any sign posted at the entrance to a venue was assumed to apply to the venue’s indoor locations.2.5). We measured for 5 minutes outside the venue – at least 10 m from the entrance – for 20 minutes in the main bar area, for 5 minutes on the patio or terrace if present and, finally, for 5 minutes outside the venue but near the entrance.,In each of a random subset of 72 bars/nightclubs, we used a SidePak AM510 personal aerosol monitor  to measure air concentrations of particulate matter with a diameter of less than 2.5 μm  and hospitals , for example, smoking was observed in a much greater proportion of the dining areas than of the non-dining areas. Among the indoor non-dining areas of schools, smoking was observed in two main entrances, two offices, two toilet areas and a fire escape. Within the shopping malls, smoking was observed in five non-dining locations: a main entrance, a hallway/walkway, a toilet area, a fire escape and a tailor’s shop.In the non-hospitality venues that had both dining and non-dining areas, smoking was observed either more or less often in the dining area than in the non-dining areas – depending on venue type . In bothSmoking was observed in just four (6.0%) of the 67 cafes but in 63 (79.7%) of the 79 bars/nightclubs . Among tr = 0.85 for ashtrays and 0.82 for cigarette butts; further information available from the corresponding author). In bars/nightclubs, the PM2.5 concentrations in indoor air were found to be moderately correlated with the number of smokers observed .Ashtrays were seen in about one of every five dining areas in government buildings and hospitals , about oP < 0.001; The proportions of venues in which indoor no-smoking signs were observed ranged from 54.5% (73/134) for schools to 85.8% (103/120) for coffee houses , with noAfter adjustment for any ashtrays, signs and cigarette sales, the proportions of traditional coffee houses and bars/nightclubs in which smoking and cigarette butts were observed were still higher than the corresponding values for the non-hospitality study venues – although the apparent strength of these associations was weakened by the adjustment . The preP < 0.001) and 62.2% (61/98) versus 32.9% , respectively  in which cigarette butts were observed was very high, ranging from 77.6% (52/67) around cafes to 98.9% (88/89) around hospitals. Outdoor cigarette butts were found predominantly on the ground.r = 0.49) and smokers and cigarette butts (r = 0.37) observed in outdoor locations were moderate (further information available from the corresponding author). The PM2.5 concentrations in the outdoor air near the main entrances and on the patios and terraces of bars/nightclubs were moderately positively correlated with the number of smokers observed in the same locations (r = 0.55). After adjustment, bars/nightclubs, presence of ashtrays and presence of cigarette sales were found to be associated with the observation of outdoor smoking, and ashtrays and cigarette sales were found to be associated with the observation of cigarette butts outdoors (The correlations between the numbers of smokers and ashtrays (outdoors .In this evaluation of compliance with smoke-free legislation across 12 cities in Turkey, we found good compliance in the non-dining areas of government buildings, hospitals and universities – since smoking was observed in 2% or less of such areas. Smoking was also observed in less than 10% of the non-dining areas studied in cafes, malls, restaurants and schools. However, compliance appeared to be poor in coffee houses and the dining areas of government buildings and hospitals and very poor in bars/nightclubs. Smoking appeared to be especially common in the outdoor locations close to bars/nightclubs, coffee houses, hospitals, malls and universities.In Turkey, hospitality venues were given a period of 18 months to adopt the new smoke-free legislation.2.5 concentrations were strongly associated with the presence of ashtrays.Our results indicate that outdoor and – especially – indoor ashtrays could be major facilitators of smoking in urban Turkey. The presence of an ashtray in an area where smoking is prohibited provides a conflicting message. In a study of 75 hospitality venues in five cities in Greece, PM2.5 concentrations recorded indoors in other studies in Turkey that used convenience sampling and were limited to hospitality venues.,,–The general lack of compliance seen in the hospitality venues we studied is consistent with the high PMIn several other countries, as in Turkey, compliance with smoke-free legislation has been found to be lower in hospitality venues than in other public places. In India, for example, 65% of the educational institutions and health-care facilities were found to be free of people smoking compared to 37% of the eateries.We used a guide on compliance studiesSome of the strengths of our study include the use of a systematic protocol and training and the random sampling strategy followed in each city. As fieldworkers were unable to observe areas of the studied government buildings, hospitals and universities that are inaccessible to the public, levels of compliance in these areas remain unknown. Bars/nightclubs were generally evaluated in the evening whereas coffee houses were generally evaluated in the afternoon. Compliance in the coffee houses during the evening may also have been poor. We found no major differences between the major cities that we studied and the smaller cities. However, the major cities were evaluated in the winter – when more people spend time inside and indoor compliance could be worse than in the summer. We are unable to determine if our results are representative of other cities, towns and communities in Turkey or whether compliance in rural areas of Turkey is similar to that which we recorded.Widespread smoking behaviour contributes to maintaining the social acceptability of smoking.


In recent years, forensic scientists have become increasingly interested in the detection and interpretation of organic gunshot residues (OGSR) due to the increasing use of lead- and heavy metal-free ammunition. This has also been prompted by the identification of gunshot residue- (GSR-) like particles in environmental and occupational samples. Various techniques have been investigated for their ability to detect OGSR. Mass spectrometry (MS) coupled to a chromatographic system is a powerful tool due to its high selectivity and sensitivity. Further, modern MS instruments can detect and identify a number of explosives and additives which may require different ionization techniques. Finally, MS has been applied to the analysis of both OGSR and inorganic gunshot residue (IGSR), although the “gold standard” for analysis is scanning electron microscopy with energy dispersive X-ray microscopy (SEM-EDX). This review presents an overview of the technical attributes of currently available MS and ionization techniques and their reported applications to GSR analysis. Scanning electron microscopy (SEM) for the analysis of inorganic gunshot residues (IGSR) was introduced in 1974 by the Aerospace Corporation –8 and haFor these reasons, it has become necessary to refocus on the full informational content of GSR as a forensic trace and not only on those compounds that are easily analysed by SEM-EDX. In other words, it may be necessary in some cases to not only analyse IGSR but also analyse organic GSR (OGSR). The information derived by the combined IGSR and OGSR analysis has the potential to overcome the issues related to false positives and false negatives identified above. As a result, significant efforts have been made to improve the detection of OGSR and many of these methods rely upon mass spectrometry (MS).Mass spectrometry is a highly sensitive and selective analytical technique used to detect and quantify elements and/or compounds and elucidate organic structures . Anotherm/z); and the detector, where the signal is amplified and transformed into a spectral form. Different ion sources, analyzers, and detectors have been developed providing different sensitivities and resolutions.A mass spectrometer can be divided into three sections: the ion source, where gaseous species desorbed from condensed phases are ionized; the analyzer, where the generated ions are separated according to their mass-to-charge ratio , atmospheric pressure chemical ionization (APCI), and desorption electrospray ionization (DESI) .Following ionization, a mass analyzer separates the ions based on their mass-to-charge ratio. Several mass analyzers exist, which are distinguished by the interaction between the ions produced and electric and/or magnetic fields, which leads to their separation.The final step involves a detector, which is most commonly an electron multiplier. Analyte ions reaching the detector collide with a charged anode generating a cascade of electrons which are released and detected .m/z range to scan, sensitivity, resolution, vacuum system, and gas supply. Additional considerations include whether or not a fragmentation pattern is required and analysis costs.When selecting an MS, a variety of important factors should be considered such as the This review provides an overview of the technical attributes and analytical properties of different MS techniques and their reported applications to GSR analysis. A list of analytical techniques which have been applied to GSR analysis and their abbreviations can be found in Although all organic compounds found in ammunition can contribute, OGSR mainly originates from propellant powder . SmokeleSensitivity and selectivity play an extremely important role in the detection of OGSR as organic additives are in low abundance and consequently occur only in very low concentrations in real case samples, typically in the microgram to nanogram range. DPA, for example, is present at around 1% or below in smokeless powder and has been detected at the low microgram to nanogram level in OGSR , 28–30. Compounds of interest in OGSR are usually present in complex sample matrices. As a result, separation is typically required before detection. Most MS techniques are coupled with chromatographic systems such as GC or LC. The high mass resolution of some spectrometers may avoid the necessity for full baseline separation unless isomers are present .The following section discusses reported MS ionization techniques for OGSR analysis.In EI ionization, electrons are emitted from a hot filament and accelerated through 70 eV before interaction with the molecule of interest. Since the energy required for ionization is much lower than the kinetic energy of the electron, EI generally leads to a strong fragmentation pattern and the molecular ion may have a low abundance or may not be present at all. Therefore, this method is considered a hard ionization technique. The ions produced are repelled and focused by plates with defined potentials before entering the analyzer .m/z produce different signals) + with m/z 241 and the product ion [M-(N(C6H5)(CH3))−]+, m/z 134, detected in multiple reaction monitoring mode (MRM). These precursor and fragment ions were selected as the abundance of the product ion should be maximal and interference from the actual sample was avoided. The latter was confirmed as no samples taken from the hands of volunteer shooters showed any interference with MC using these two ions. Optimising the QqQ-MS conditions, collision gas flow rate, and the focusing lens, a detection limit of 60 pg injected for MC was obtained with excellent linearity (R2 > 0.999) and reproducibility. The method was sufficiently sensitive and selective to detect MC in all hand swabs of shooters even after 100-fold dilution, eight hours after shooting, or when hands were washed under running water (no soap) before collection and enabled the direct analysis of the extracts in less than five minutes. However, strong absorption of MC onto the injection tube and the instrument increased the detection limit − and [NO3]− at m/z 163 and 62, respectively. For MC, the same two ions described above with three additional fragmentation ions at m/z 106, 77, and 51 were used as characteristic ions. Eight samples each from hands of shooters and nonshooters were analysed; the two groups were easily distinguished by this method. Detection of MC concentration was time-sensitive; after two hours only 25% of the initial concentration of MC could be detected; however, only minimal changes were observed from two to eight hours [Wu et al. extended the above tandem QqQ-MS technique to analyse NG . Three iht hours .Tong et al. extended the QqQ-MS/MS method to the detection of DPA, 4-nDPA, 4-NDPA, N-nDPA, and 2,4-DNDPA. DPA in combination with its nitrated and nitroso derivatives is considered unique to smokeless powders and therefore of high evidential value, but not when found alone. These nitrated and nitroso species arise from the decomposition of nitrocellulose and nitroglycerine in smokeless powders . Here, aThe studies by Wu et al. and Tong et al. demonstrate the great advantage offered by MS/MS enabling the possibility of omitting a preceding chromatography step. This is possible since the selectivity is greatly enhanced and interference can mostly be eliminated , 31, 45.Another study focusing on DPA and its derivatives as well as AK II, EC, and MC using a new sample preparation with SPE was conducted by Laza et al. . Swabs mAll previous studies proved the utility of ESI-QqQ only for the detection of additives present in OGSR. Perret et al. extended this and developed an LC-QqQ tandem MS method for the combined analysis of explosives and stabilizers in OGSR . These iThe previous studies demonstrate that the use of ammonium salts can be beneficial for OGSR detection as it can improve sensitivity and selectivity and the formation of adducts can make extensive sample preparation redundant , 43, 44.ESI is applicable to a wide range of compounds present in OSGR and has been extensively applied with single and tandem MS. However, particularly when compared to APCI, this technique has some drawbacks such as limited ionization of nitroaromatics and generally lower response for nitrocontaining explosives , 46, 47.Atmospheric pressure chemical ionisation like ESI is a soft ionization technique that can be applied under atmospheric pressure and therefore can be easily coupled with LC or CE instruments. The interface is very similar to ESI, except that vaporization takes place under heating instead of applied voltage.μL (with 10 μL injected). However, when simulated real case samples obtained from motor oil extracts were studied, only qualitative results could be obtained due to matrix effects [The differences between ESI and APCI coupled to a QIT-MS for the combined detection of nitramines, nitrate esters, and nitroaromatics, that is, NG, PETN, RDX, HMX, tetryl, TNT, 2,4-DNT, TNB, and 1,3-DNB, were studied by Tachon et al. . An LC s effects .Another study using LC separation and negative mode APCI coupled to a QIT-MS for the detection of 21 explosives covering nitroaromatics, nitramines, and nitrate esters was conducted by Holmgren et al. . ChlorinThe mass accuracy of ToF instruments can enable the relatively confident identification of a great number of compounds, including isomers. In ToF, ions are separated on the basis of the influence of their mass-to-charge on their relative velocities. Kinghorn and Milner tested the suitability of ToF-MS for a wide range of explosives some of which can be found in OSGR. ESI and APCI in both positive and negative modes were evaluated for nitroaromatics, nitramines, nitrate esters, and peroxides. As identified by Tachon et al. also using QIT-MS , neitherThe feasibility of using LC-tandem QqQ-MS for the quantitative analysis of OGSR was also studied by Yang et al. . An LC-QDeTata et al. applied tandem QToF-MS coupled with LC for the identification of over 50 organic explosives and propellants . In compAs discussed above, APCI has been successfully applied to the ionization of nitrate esters, nitramines, and nitroaromatics. Another ionization technique with promising features for analysis of organic explosives is APPI . The str+ was found to be the main distinguishing component. Principal component analysis (PCA), a multivariate data reduction technique, classified all five tested powders using only three randomly selected mass spectra as a training set. A great advantage of coupling ESI with laser vaporization was that no sample preparation of the smokeless powders was required [In an attempt to overcome limitations observed with alternate methods, LEI coupled with a ToF-MS was evaluated for the characterization of smokeless powders . The smorequired .Mahoney et al. also utilised PCA when examining the application of ToF secondary ion mass spectrometry (ToF-SIMS) for the differentiation of three different smokeless powders and six black powders based on full scan positive ion ToF-SIMS spectra . Compoun in-situ analysis of various surfaces under ambient conditions requiring minimal sample pretreatment [In 2004, a new ionization technique, called DESI, was introduced and has since been applied to the analysis of a wide range of organic compounds including some present in GSR –59. Thisreatment , 61. Whereatment . It may 3 for MC and EC, respectively. The developed method was able to distinguish between 10 shooters and 10 nonshooters by the analysis of their hands for MC and EC. Spiking skin with possible interfering substances including milk, soft drinks, and dust showed that the method was sufficiently sensitive to detect MC. MC could still be detected from hands after 12 hours and after six hand washings under running water [Zhao et al. coupled a QIT-MS instrument in tandem MS mode to a DESI source for the detection of MC and EC from different surfaces including hands, hair, glass, rubber gloves, leather gloves, towel, medical gauze, and adsorbent cotton . DESI wang water .The ambient ionization technique of DESI coupled to QToF was evaluated for DPA, EC, and MC by Morelato et al. . A rangeIt is interesting to note that Zhao et al.  could deRecently, Thomas et al. developed a UHPLC method coupled to a QqQ-MS which enabled the detection of 20 compounds present in OGSR . A dual A summary of different MS based analytical techniques applied to OGSR analysis can be seen in The identification of IGSR is commonly achieved by the detection of Pb, Ba, and Sb in discrete GSR particles using SEM-EDX since particles containing these three elements are considered as characteristic for GSR. Other commonly found metals in lead- and heavy-metal containing ammunition are silicon, calcium (Ca), aluminium (Al), cupper (Cu), iron (Fe), sulfur, phosphorus (rare), zinc (Zn), nickel, potassium (K), and tin. However, particles containing these metals in combination with only one or two of the metals characteristic for GSR, that is, Pb, Ba, or Sb, are not considered characteristic of GSR as their presence may be nonfirearm related. Only whole particle populations can provide a better understanding of the origin of a particle . The feaThis part of the review is divided into sections discussing the applicability of different mass analyzers to IGSR detection.+, could be detected, offering additional information about the elemental composition of GSR particles. The sensitivity for Ba, K, and Ca was greater and the possibility to etch the particle surface allowed further information in regard to elemental distribution. A disadvantage of ToF-SIMS in comparison to SEM-EDX is the lack of high resolution imaging capabilities. Consequently, ToF-SIMS appeared as a potential technique for complementary analysis of IGSR only when just two- or one-component particles can be detected by SEM-EDX [Offering low limits of detection and high surface sensitivity, ToF-SIMS was examined for its feasibility as a complementary technique to SEM-EDX by Coumbaros et al. . In some SEM-EDX .+ ions are accelerated by a radio-frequency coil and collide with analyte atoms. This collision results in a transfer of energy to the entire gas and the resulting plasma is directed through an interface into a mass spectrometer [138Ba are the minor isotopes of lanthanum (0.089%) and cerium (0.250%). However, these isotopes have not been measured in GSR samples and can thus be neglected. Lead has four isotopes at masses 204, 206, 207, and 208. The lead isotope ratios cannot be predicted and may be indicative of the origin of the lead. In order to reduce errors resulting from the differences in isotopic distribution, the intensities of the three isotopes at 206, 207, and 208 are commonly added together [Inductively coupled plasma-mass spectrometry was commercially introduced in 1983 and since then has been applied in different fields including forensic chemistry . In the trometer . The bultrometer . For GSRtogether . The abitogether , 68. The121Sb, 138Ba, and 206+207+208Pb. The developed ICP-MS method offered excellent linearity for all three elements. Cotton swabs (two swabs per sample) were extracted with 10% (v/v) HNO3 solution with heating. This was followed by mixing and centrifugation which showed no uncorrected matrix effects from swab constituents. Consequently, this method gave nearly quantitative recovery results for all three IGSR elements. The use of internal standards reduced signal enhancement due to instrumental drift and signal suppression due to easily ionisable elements, in this case sodium (Na). This is important as Na can be present in GSR samples due to its presence in bleached swabs and as it is a major constituent of human perspiration. The developed method exhibited excellent precision and good accuracy and was able to detect Sb, Ba, and Pb down to 0.5 ng, 0.2 ng, and 1.4 ng, respectively, per swab pair using a 10 mL extraction volume . These 121Sb, 138Ba, and 208Pb were quantified. All swab samples showed concentrations of the three IGSR in the μg range allowing the differentiation between samples taken from nonshooter sand shooters. The detection of other elements present in GSR samples was thought to be of value for profiling GSR; however this was not further studied [These findings were confirmed in another study by Bakowska et al. . The aut studied .6Li), scandium (45Sc), 115In, yttrium (89Y), terbium (159Tb), and 209Bi through a “Y-piece” to the nebulizer. A similar extraction procedure as reported by Koons [μg/swab (Sb from AK-47) and 5.6 μg/swab (Pb from AK-47) [The analysis of gunshot residue taken from an AK-47 or another type of rifle by ICP-MS was studied by Wang . The autby Koons  was usedm AK-47) .The analysis of gunshot wounds has also been achieved using ICP-MS , 71. Gun3. The authors proposed a mathematical model to describe the relationship between the concentration of Sb, Ba, and Pb and shooting distance between 20 and 80 cm. The results suggested that a quadrant cut from the cotton tissue in 4 cm radial position from the entrance hole gave the best results for the estimation of the shooting distance. The concentration of only one element could also be used for estimation of shooting distance [Santos et al. used ICP-MS to investigate the relationship between the radial pattern of the GSR deposit around the bullet entrance hole  and the firing distance . Using adistance .206Pb/207Pb and 208Pb/207Pb were monitored for eight different primers and plotted against each other. The results demonstrate that for six out of eight primers it was possible to obtain a clear differentiation. The authors stated, however, that ICP-MS does not appear suitable for daily casework as it is a destructive technique [Steffen et al. used ICP-Q-MS to determine if primers could be differentiated by quantitative differences in their Pb-isotope ratios . The ratechnique .Although the analysis times using ICP-MS compared to SEM-EDX are relatively short, sample preparation requires time consuming digestion processes. Another drawback is the fact that ICP-MS is a bulk analysis technique and elemental information of discrete GSR particles cannot be obtained . Therefoμm [μm diameter, and therefore careful data interpretation is required to avoid incorrect conclusions. For example, adjacent particles containing individual heavy metal species may appear to be a single entity with the characteristics of GSR.Abrego et al. studied the detection of seventeen isotopes (15 elements) considered to be present in particles either characteristic or consistent with GSR  from GSRμm . This spThe combination of ICP and MSF-MS offering high mass resolution has also been applied to IGSR analysis.μg/L) were found to be significantly higher than the concentrations before shooting (up to 0.17 μg/L) and could be used as a tool for indicating the potential presence of GSR. The developed method including EDTA swabs and ICP coupled with an MSF-MS instrument achieved LODs of 0.045 μg/L, 0.507 μg/L, and 0.117 μg/L for Sb, Ba, and Pb, respectively.Reis et al.  developeThe developed collection and analytical method was further tested for the detection of IGSR from 9 mm and 0.40 in. calibre pistols . The higFreitas et al. examined the use of ICP-MSF-MS to study the possibility of differentiating weapons and ammunition based on the IGSR detected on different fabrics . The resA number of aspects of ICP-MS have contributed to the increasing interest in the application of this technique to IGSR analysis. The high sensitivity offered by ICP-MS is superior to that offered by SEM-EDX for inorganic GSR, for example, Sb, Ba, and Pb. Limits of detection in spiked swabs were in the low nanogram range, which is lower than concentrations expected in GSR samples (40–500 ng)  enablingMass spectrometry has been increasingly investigated in the field of GSR analysis for application to both inorganic and organic GSR.m/z ratio, that is, isomers, are to be analysed. The great advantages offered by tandem MS explain its increasing use in OGSR analysis and other fields. The most sensitive tandem MS technique is QqQ-MS/MS allowing the identification and detection of OGSR in the low nanogram to picogram range, which is sufficiently sensitive for real case samples.The most common collection technique applied to OGSR is swabbing during which there is the potential for simultaneous collection of interfering substances on skin or garments. Therefore, a chromatograph is commonly placed in front of the MS instrument to separate the compounds of interest from any interference still present after extraction. The use of tandem mass spectrometry offers outstanding sensitivity and selectivity and chromatographic separation may only be necessary when compounds with similar The ionization of the broad range of compounds present in OGSR has proven challenging as different ionization techniques may be required to obtain optimal results for all compounds. Hard ionization techniques, that is, EI, are only used in conjunction with GC for SPME analysis of volatiles in GSR, assisting with the estimation of time since discharge , 32. TheDifferent techniques mainly based on ToF-SIMS and ICP-MS have been evaluated for their applicability to ISGR analysis. Although these techniques may offer advantages in certain casework situations, for example, the collection and analysis of IGSR from decomposing tissues, and may detect the metals of interest with higher sensitivity, the method of choice for IGSR analysis remains SEM-EDX. Reasons for this include the relatively simple sample preparation, the capability for retrieval of elemental and morphological information for single GSR particles, and the fact that it is a nondestructive technique. Therefore, it seems unlikely that MS techniques will replace SEM-EDX in any foreseeable future.While discussion for OGSR and IGSR was presented separately above, it must be remembered that these are two aspects of the same informational content borne by the GSR trace. The ability to analyse both aspects, hence potentially indicating the simultaneous presence of OGSR and IGSR, would greatly strengthen the value of the results. Finally, it is worth pointing out that any technique is only as good as it answers the questions being asked. Continuing research is required to realise the full potential of advanced analytical methods such as those presented here for application in the forensic sciences.


To test the independent and interactive associations of physical activity (PA) and screen time (ST) with self-reported mental health and sleep quality among Chinese college students.Data were collected in October, 2013. The gender, age, residential background, body mass index (BMI), perceived family economy and perceived study burden were obtained from a total of 4747 college students . The outcomes were self-reported PA status, ST, anxiety, depression, psychopathological symptoms and sleep quality. Analyses were conducted with logistic regression models.OR=1.38, 95%CI: 1.15-1.65), depression , psychopathological symptoms  and poor sleep quality . High PA was insignificantly negatively associated with anxiety, depression, psychopathological symptoms and poor sleep. Low PA and high ST were independently and interactively associated with increased risks of mental health problems and poor sleep quality .Overall, 16.3%, 15.9% and 17.3% of the students had psychological problems, such as anxiety, depression and psychopathological symptoms, respectively. The prevalence of poor sleep quality was 9.8%. High ST was significantly positively associated with anxiety (Interventions are needed to reduce ST and increase PA in the lifestyles of young people. Future research should develop and measure the impacts of interventions and their potential consequences on sleep, health, and well being. Physical inactivity is the greatest public health problem of the 21st century –6. A groIt is well known that economic and technological improvements increase screen time (ST) among young students in developing countries. Meanwhile, evidence for an independent effect of ST on health has been emerging . IncreasMental health problems presents a growing concern on college campuses . CollectThe aim of this study was to examine (i) associations of PA and ST with self-reported mental health and sleep quality; and (ii) the interactive effects of PA and ST on mental health and sleep quality among Chinese college students.This study was conducted in October 2013 and was approved by the Ethics Committee of Anhui Medical University. Written informed consents was obtained from all of the participants. The participants in this study were drawn from a cross-sectional survey that was conducted at Anhui Medical University, which is located in central China. Participants were recruited by the random cluster method. Six schools were randomly selected, and individuals attending grades 1 through 3 were assessed. All classes in 6 schools and 3 grades were enrolled in this survey. A total of 4915 college students were selected for in this study, resulting in the receipt of 4858 (98.8%) questionnaires, 4747 (97.7%) of which were valid.A self-administered questionnaire containing information on sociodemographic indicators, height, weight, PA, ST, mental health and quality of sleep was administered during a 20~30 min session in the classroom. The following socio-demographic characteristics were obtained: age, gender, residential background , self-reported family economy and self-reported study burden.PA was assessed with a reliable measure used extensively in the United States as part of the Youth Risk Behavior Survey. The question is as follows: ‘On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?’ The responses range from 0 to 7 days. High PA was defined as at least three days per week of exercise. The Physical Activity Rank Scale-3 (PARS-3) was used to assess the PA rank of the college students . The PARThe subjects also reported ST using the following question: How many hours per day do you spend on the computer (including playing video or computer games or using a computer for something) and watching TV/video programs on a usual weekday and weekend day, respectively? ‘ The present study categorized ST as ≤2 h/d and >2 h/d.To fully assess the psychological problems, the mental health of the participants was assessed, including anxiety, depression and psychopathological symptoms. Anxiety was assessed using the self-rating anxiety scale (SAS), which is a standard assessment instrument that has been examined for reliability and validity in the Chinese population . A totalSleep problems were measured by the Pittsburgh Sleep Quality Index (PSQI) , which iStatistical analysis was performed using SPSS version 13.0 . The chi-square and t tests were performed to assess differences in the characteristics between males and females for the categorical and continuous variables, respectively. The logistic regression model was performed to explore the independent and interactive relationship between PA, ST and various psychological problems and poor sleep quality. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for the explanatory factors and adjusted for confounding factors, including gender, age, residential background, BMI, perceived family economy and perceived study burden. A P < 0.05 was considered to be statistically significant.Of the 4747 participants, 41.6% were males with a mean age of 19.26 years (SD = 1.40), and 58.4% were females with a mean age of 19.22 years (SD = 1.41). Overall, 16.3%, 15.9% and 17.3% of the students had anxiety, depression and psychopathological symptoms, respectively. The prevalence of poor sleep quality was 9.8%. A majority of the students reported a low PA level. Compared to the females, the males had a significantly higher age, BMI, higher prevalences of a rural residential background and perceived study burden and psychopathological symptoms. Nevertheless, compared to the males, the females had significantly higher prevalences of low PA and poor sleep quality .As shown in The interaction effects of PA and ST with the various psychological problems and poor sleep quality are shown in The findings of this study suggest that high ST is significant positively correlated with anxiety, depression, psychopathological symptoms and poor sleep quality. Meanwhile, low PA and high ST are associated with a reduced prevalence of mental health problems and poor sleep quality.Increasing evidence is suggesting that PA is associated with numerous health benefits –30. In gScreen-based technologies are ubiquitous among modern youth and are frequently used, and the consequences of excessive ST on general health, PA, and cognitive and social development have been proven in adolescents and youth –39. A prOur study also provides interesting information with regard to sleep quality among college students in China. Poor sleep is highly prevalent among college students , and is There are some limitations to the present study. First, the cross-sectional design limits the power with which the causal relationships can be determined. Longitudinal studies are needed to understand the causal relationships of PA and ST with mental health and sleep quality. Another limitation that may have affected our results is the fact that the PA and ST levels were assessed by self-reported questionnaires; thus, recall and reporting biases could not be avoided. Third, the question about PA did not specify the type and intensity. Lastly, our study assessed anxiety, depression and symptoms but not clinically diagnosed depression; therefore, different associations may exist when diagnosed mental health is considered as the variable of interest.Despite the above limitations, the present study highlights the importance of associations of PA and ST with mental health and sleep in Chinese college students. Our results suggest that high ST is significant positively associated with anxiety, depression, psychopathological symptoms and poor sleep quality. Meanwhile, low PA and high ST are associated with increased risks of mental health problems and poor sleep quality. Our findings may suggest that interventions are needed to reduce ST and increase PA in the lifestyles of young people. Future research should develop and measure the impacts of interventions and their potential consequences on sleep, health, and well being.


Leishmania donovani in a child and the first cluster with adult cases reported in Europe.Leishmaniasis is endemic in more than 95 countries and is the only tropical/subtropical vector-borne disease that has been endemic in Southern Europe for decades. To the best of our knowledge, this is the first case of cutaneous leishmaniasis by L. donovani in a Paphos village, in Cyprus. A 6-year-old boy (Case number 1) had a persistent lesion in the left angle of his upper lip, a 60-year-old woman (Case number 2) presented with a 2cm-diameter glabella lesion on her forehead, a 60-year-old man (Case number 3) developed a lesion on his moustache area and a 40-year-old woman (Case number 4) had a lesion on her neck. In Case number 3 the lesion was self-cured; the other cases recovered after surgical resection followed by liposomal amphotericin B (Case numbers 1 and 4) or thermotherapy and liposomal amphotericin B (Case number 2).We describe a familial cluster of four cutaneous leishmaniasis cases among Greek Cypriots caused by L. donovani, shows that the sand fly species responsible for transmitting this parasite species is found in the area around the three neighbouring houses involved. The factors favourable for the survival, spread and contact of the vector with people could be assessed in this area for the establishment of preventative measures to safeguard public health.This familial cluster of cutaneous leishmaniasis, due to the anthroponotic  Leishmania and is endemic in 95 countries [Leishmaniasis, a vector-borne disease, is caused by protozoans of the genus ountries -4. TransLeishmania infantum, the most widely circulating species, causing over 90% of the cases of zoonotic CL and VL. The other is Leishmania tropica causing anthroponotic CL, encountered sporadically in Greece and in eastern Mediterranean countries. In Cyprus, only two human cases of VL were reported between 1935 and 2006 [Leishmania donovani species.In Southern Europe, until recently, two species were identified as causing leishmaniasis in humans. One of these species is L. donovani, in Cyprus.We present the first familial cluster of CL cases due to A child and three adults from an extended family, who lived in neighbouring houses, were involved in a cluster of CL detected in a small village in the district of Paphos, where most cases of leishmaniasis in Cyprus since 2005 have been diagnosed.Case number 1, a 6-year-old Greek Cypriot boy, was referred to our hospital because of a small ulcerative lesion next to the left angle of his lips  were normal. His liver and renal function was also normal. The lesion was surgically removed and the resected tissue was sent for histopathology, culture and polymerase chain reaction (PCR) testing for ymodemes , revealeL. donovani[Case number 2, a 60-year-old Greek Cypriot woman (the child’s godmother who lives next door) developed a 2cm diameter erythematous papule on her glabella, simultaneously to this child’s illness. Culture and PCR of lesion material (as described above) were positive for  donovani and subs donovani, provide donovani. She wasCase number 3, a 60-year-old Greek Cypriot man (the child’s godfather and husband of Case number 2) had developed a typical CL ulcer on his face, on the right, above the moustache area. He refused to visit the doctor and the lesion persisted for more than 1 year; it self-resolved leaving a small scar. No material was available for testing.Case number 4, a 40-year-old Greek Cypriot woman (the child’s aunt) who resided in a house next to the child’s, had developed a lesion in her neck area approximately 1 year earlier. She had already been treated, with surgical removal of the lesion followed by liposomal amphotericin B and at the time of the study the scar was evident. The doctor who had treated her described the ulcer on her neck as a typical CL lesion.L. donovani, especially within households, have been reported in large population studies in endemic countries [L. donovani including a 6-year-old boy in Cyprus. Human cases of this anthroponotic species were detected for the first time in Europe in 2006 when the first six cases were diagnosed in the Republic of Cyprus [L. donovani in a child and the first cluster with adult cases of CL by L. donovani reported in Europe.Clustering of cases of CL or VL caused by anthroponotic species, such as ountries ,4,10. WeLeishmania epidemiology since two different, parallel, transmission cycles appear to be involved. In the first transmission cycle, L. infantum causes canine leishmaniasis, with 11.9% overall seroprevalence in dogs. Although dog seropositivity for L. infantum reached 33.3% in some areas, no human VL or CL cases among Greek Cypriots have been detected [L. donovani[L. donovani in Cyprus. Recent studies, by multilocus microsatellite typing, showed that the L. donovani MON-37, isolated from human cases in Cyprus, bear substantial genetic differences to L. donovani MON-37 isolates from India, Israel, Sri Lanka and Kenya [In Cyprus, there is a paradox with respect to  donovani,11. Manynd Kenya . Howevernd Kenya .Leishmania growth.Diagnosis of CL depends on the clinical signs, epidemiological information, PCR and culture of infected tissue, or finding the intracellular parasite in biopsy material from the periphery of the lesion. It is not always possible to culture the parasite (gold standard method) since other microorganisms from the wound may infect the culture material and stop Leishmania species involved [Leishmania lesions appear to respond well to local treatment using cryotherapy, thermotherapy or surgical removal, in combination with chemical treatment; mainly meglumine antimoniate or amphotericin B but pentamidine isethionate, paromomycin, and antifungals are also used [Leishmania drug resistance to meglumine antimoniate has been reported in some areas [Leishmania species. In particular, it has proved effective for the treatment of paediatric VL caused by L. infantum in the Mediterranean region [L. donovani in India [Treatment for CL depends on the involved  and the involved . Leishmalso used . Antimonme areas ,17 it shn region , and L. in India .L. donovani MON-37 in an infant originating from a neighbouring village [The child, Case number 1, was managed successfully with surgical resection of the affected area and a short course of liposomal amphotericin B. Our decision to use the above treatment was supported by our previous experience of successfully treating a case of VL due to  village ,9,11.L. donovani and L. tropica, treatment is very important in order to stop transmission from person to person through the reservoir.Treatment of CL is important because it limits skin scarring but it also reduces the risk of metastatic infection. For anthroponotic species, like It appears that most of the CL and VL cases in Cyprus are found in a few villages in the district of Paphos. Detection of areas with clusters of cases may help in the study of the conditions favouring the epidemiology of the disease so that intervention measures could be targeted in high-risk areas. In our study, all four patients lived in three neighbouring houses, suggesting that transmission of the parasite occurred inside or in close proximity to these houses. The area in question is currently under investigation regarding the seasonal distribution of the sand fly fauna (the vector of the disease) in relation to the characteristics of the microenvironment which favour their survival, spread and contact with people. Lessons from this familial cluster and its environmental risk-factor assessment may prove beneficial to safeguard public health and implement successful preventive and public health measures that could also be applied in other areas and countries.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. An additional written informed consent was obtained from the parents of Case number 1 for publication of this case report and the accompanying image. Copies of the written consents are available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.Leishmania donovani. MA performed the laboratory testing and interpreted the results. MGK and ESS drafted the case report. All authors contributed to the writing of the final manuscript. All authors read and approved the final manuscript.MGK was responsible for the conception of the case report, acquisition of clinical data and clinical treatment. YA, VC, and AM contributed to the collection of epidemiological data regarding Dr Maria Koliou is a paediatric infectious disease specialist at the Archbishop Makarios Hospital in Cyprus. Her research interests include zoonoses affecting mainly the countries of the Mediterranean.


Hemophagocytic syndrome is a rare and potentially fatal disorder characterized by pathological immune activation associated with a primary familial disorder, genetic mutations, or occurring as a sporadic condition. The latter can be secondary to infections, malignancies, or autoimmune diseases. Clinically, patients present signs of severe inflammation, with unremitting fever, cytopenias, spleen enlargement, phagocytosis of bone marrow elements, hypertriglyceridemia, and hypofibrinogenemia. Increased suspicion is determinant to timely initiate treatment in an attempt to alter the natural history. The authors present three clinical cases of this syndrome, with a brief review of the diagnostic criteria and treatment. Hemophagocytic syndrome (HPS) is a potentially fatal hyperinflammatory disease induced by a pathologic immune activation, with proliferation of well-differentiated macrophages/histiocytes and increased phagocytic activity . This enHPS affects approximately 1.2 million people per year. However, incidence can be underestimated since diagnosis is often missed . PRF1, UNC13D, STX11, and STXBP2, respectively. All these genes encode proteins involved in lymphocyte cytotoxicity [ RAB27A gene), Chediak-Higashi (mutations in LYST gene), and Hermansky-Pudlak 2 (mutations AP3B1 gene), also predispose to HPS [FHL is associated with mutations in genes with an autosomal recessive trait. When HPS is the only manifestation of the disease, in FHL 2–5 the related mutations aretoxicity . Some hee to HPS . Secondae to HPS . The mosα, soluble interleukin-2-receptor (sIL-2R), tumor necrosis factor, IL-1, or IL-6, has been consistently reported. An alternative hypothesis involves failure to remove antigen, which results in ongoing stimulation of the immune system [The pathogenesis of HPS remains poorly understood; however, uncontrolled macrophage and T-helper 1 (Th-1) lymphocyte activation seems to be crucial. Overproduction of cytokines involved in Th-1 lymphocyte and macrophage activation, such as interferon-e system , 6.The clinical features of HPS include unremitting high fever, hepatosplenomegaly, cytopenias, high fasting triglycerides, and ferritin levels. The hallmarks of the disease are usually found in the bone marrow with the presence of numerous well-differentiated macrophages phagocytosing hematopoietic cells . However Rickettsia conorii, Leptospira, Borrelia burgdorferi, and Salmonella typhi. Active tuberculosis infection was also excluded. The condition extended for 3 months, with no response to treatment and clinical deterioration with unremitting fever. The patient was admitted to hospital where he began broad spectrum antibiotics  and prednisolone 40 mg/m2. Repeated serologies and bacteriologic cultures were inconclusive. A thoracoabdominal CT scan showed a soft spleen enlargement . The main clinical suspicion was an occult infection. Blood tests showed persistent and worsening pancytopenia, with hepatic cytolysis and cholestasis, elevated ferritin, and triglycerides  with daily fever (>38°C), weight loss, and progressive asthenia. Physical examination was not remarkable. The GP suspected infection and prescribed oral antibiotics. Blood tests showed pancytopenia  with negycerides . A bone ycerides . Despiteμg/L made the suspicion of HPS. Further tests revealed elevated α-chain IL-2 soluble receptor and low fibrinogen levels , but after ten months treatment was interrupted due to pancytopenia. Drug toxicity was suspected, but pancytopenia persisted after stopping the treatment. A first bone marrow biopsy was inconclusive. The patient's hematologic cell counts continue to drop  and a nen levels . A new bn levels . At thisn levels . She comA 66-year-old man with no relevant medical history began fever, night sweats, and odynophagia, associated with submandibular lymph node growth. Blood tests were remarkable for pancytopenia with elevated levels of ferritin, triglycerides, and liver enzymes with signs of liver dysfunction and coagulopathy . A thoraμg/L are highly sensitive and specific for the diagnosis of HPS, and levels >30 000 μg/L can be 100% specific in the absence of iron metabolism disturbances. However, not all patients have hemophagocytosis at disease onset and the diagnosis should not be delayed because of this [μg/L are present in half of the patients. About one-third can present with CNS involvement, and, in the presence of any neurologic symptoms, it should promptly be excluded [Hemophagocytic syndrome is a rare hyperinflammatory disease, with a dismal prognosis if not promptly treated . High clexcluded . In summα-chain of soluble IL-2 receptor were not measured, due to the rapid evolution and clinical deterioration.All three cases presented are secondary forms of HPS. In case 1, HPS seems to be secondary to abdominal peritonitis, which likely triggered immune activation. Colon cancer was a less probable cause since solid malignancies rarely cause HPS . In addiIn case 2, myelodysplastic syndrome assumes a relevant role as a possible trigger of HPS. Reactivation of tuberculosis was also considered since infections are known triggers of HPS. Pancytopenia was installed during ongoing tuberculosis treatment, in a phase where infection was not yet controlled.α-chain IL-2 soluble receptor. In this case, 6 of 8 diagnostic criteria were also present.However, a diagnosis of myelodysplastic syndrome was also made, and the development of prolonged fever not responding to antibiotics and no infectious focus, together with the elevated ferritin, raise the possibility of the presence of another entity beside myelodysplastic syndrome, HPS. When this diagnosis was suspected, the investigation was completed with the measurement of the In case 3, T cell lymphoma is the most likely culprit and HPS was a simultaneous diagnosis. The patient also presented with high levels of ferritin. However, in the initial phase, lymphoma was thought to be responsible for the patient's condition and the diagnosis of HPS came later with medullar evaluation, needed for staging T cell lymphoma. The rapid deterioration and dismal outcome were more likely attributable to HPS than to the lymphoma itself and T cell lymphomas are one of the most common hematologic causes of HPS. In this case, 5 of 8 criteria of HPS were present. When diagnosis was made, the patient initiated etoposide and corticosteroids treatment, but, due to the fast progression to multiorgan failure, probably because the immune cascade could not be controlled anymore, the patient died in a few days.All of our cases had at least 5 of the 8 criteria of HPS. Although the diagnosis was made in the three cases, in two of them, it was not possible to initiate treatment on time, maybe not only because of the advanced and accelerated phase of the inflammatory cascade, impossible to revert, but also due to a delayed diagnosis, especially in cases 1 and 3, and the rapid clinical deterioration. In all the cases, and as described in the literature, the unusual elevated levels of ferritin were the discriminatory sign and the crucial point to suspect HPS, because the other symptoms and criteria lack sensitivity and specificity to HPS and can be present in many other clinical entities. Levels of ferritin as high as those verified here are present in patients with iron metabolism disease, which was not fit or plausible in any of those cases. However, the moment of confirmation of the diagnosis in all the cases was with the evidence of phagocytosis in bone marrow.The three cases described here represent the dismal prognosis of HPS with fatal outcome in a short period of time, reflecting fast disease progression when diagnosis is not timely suspected and effective treatment promptly started. Despite the fact that prognosis of HPS improved in the last years, it still remains very poor with 50% mortality and with a two-month survival if left untreated . BecauseIn conclusion, the authors highlight the importance of high clinical suspicion of this syndrome, despite its rarity and complexity. Levels of ferritin are simple and inexpensive to measure and can greatly increase the suspicion of HPS, with unusual high values.A high index of suspicion in selected patients remains the most powerful tool for the diagnosis and timely treatment of the disease. Further research on the pathophysiology of HPS is needed to support the development of better treatments that can improve patient outcome .