In Study 2 (n = 968 students), a confirmatory factor analysis supported the eight-item two-factor correlated model  that was invariant across gender. Reliability coefficients indicated an acceptable level of reliability for the two factors of the CTS-PE. A structural equation modelling showed that externally and internally controlling teaching behaviours positively predicted need frustration, and negatively need satisfaction. The current study gathered evidence to consider the CTS-PE as a valid and reliable instrument to assess students’ perceptions of PE teachers’ externally and internally controlling teaching behaviours. The CTS-PE provides PE teachers with deeper insights into the negative psychological experiences associated with externally and internally controlling teaching behaviours in PE.There are no validated instruments to date that have examined the students’ perceptions of externally and internally controlling teaching practices in physical education (PE). Grounded in self-determination theory, the objective of this research was to provide validity and reliability evidence of the Controlling Teaching Scale for Physical Education (CTS-PE) to assess the external and internal faces of controlling teaching in PE through two sequential studies. In Study 1 ( In the school physical education (PE) setting, the teaching behaviours of the teachers can play a key role in shaping students’ learning and motivational experiences involved in the teaching and learning process ,2. SpeciConsistent with the SDT perspective, controlling teaching behaviours are characterised by those behaviours that focus on ignoring students’ viewpoints, pressuring them to think and behave in a specific manner, using rigorous standards as a reference, and making them feel that they must strictly comply with their teachers’ instructions ,9 ResearExternally controlling teaching refers to classroom social environments where students feel forced to strictly fulfil requirements and demands imposed by the teachers . For insRegardless of the nature of controlling teaching behaviours, SDT ,13 holdsTo the best of our knowledge, there are no validated instruments to date that have examined the external and internal nature of controlling teaching in the PE setting in the SDT framework. So far, a host of measures were developed with each conceptualising PE teachers’ controlling teaching distinctly. Specifically, some slightly modified PE unidimensional scales assessed teachers’ controlling teaching in global terms ,25, in dIn an initial attempt to measure students’ perceptions of external and internal controlling teaching behaviours from PE teachers, De Meyer et al. , with thBuilding on SDT, the distinction between externally and internally controlling teaching may provide a deeper understanding of the differential role that teacher’s controlling teaching behaviours could have on students’ motivational experiences, as well as affective, cognitive, and behavioural outcomes in PE . NonetheIn Study 1, we aimed to examine, via exploratory factor analysis (EFA), the internal composition and structure of the initial pool of 12 items comprising the original version of the CTS-PE . In accon = 241), aged from 12 to 16 years old , from a public secondary school belonging to one medium-sized city in the northeast of Spain. Regarding their educational level, 43 students were in first grade of compulsory secondary education, 81 were in second grade, 24 were in third grade, 38 were in fourth grade, and 55 students were in first grade of post-compulsory secondary education. Most of the students were Caucasian and of middle social, cultural, and economic class. The students received two weekly lessons of compulsory PE with a duration of 60 min. The classes were given by two different PE specialist teachers (2 men) who claimed to have obtained a Bachelor of Science in Physical Education and Sport Sciences and a Professional Master’s program of Education (post-primary PE). This research obtained approval by the Committee for Clinical Research of Aragon (PI15/0283).The sample included 118 male and 123 female secondary school students  to ensure the correct understanding of the items.A cross-sectional design was used to examine the psychometric properties of the CTS-PE . The guiOn the other hand, the researchers contacted the school board and PE teachers at each school involved for their collaboration in this research. Only those students who returned the parents-signed written informed consent participated in this study. Prior to completing a paper-and-pencil questionnaire, the researchers explained to the students that their participation was voluntary and confidential. The questionnaire was administrated in a quiet classroom environment in the absence of the PE teacher and in the presence of the researchers, who were available to answer any question that the participants may have. The average time taken to complete the set of questionnaires was approximately 15 min.Prior to data analysis, we detected 12 missing values, which were removed. To evaluate the robustness of running an EFA, the data were inspected by the Kaiser-Meyer-Olkin (KMO) statistic, which is appropriate with values over 0.80 , and Bar2 [df = 66] = 1850.30, p < 0.001) gathered evidence to support the robustness of running an EFA in the CTS-PE. This last analysis provided a two-factor solution that accounted for 64.77% of the item’s total variance. The results from both the Kaiser-Meyer-Olkin statistics (KMO = 0.91) and Bartlett’s sphericity test  was initially proposed for the externally controlling teaching factor, its high factor loading in the internally controlling teaching subscale suggests that the concept of punishment could be understood by students in a differentiated way. Most students may perceive that the use of punishments focused not only on shouting and verbal reprimands , but also on signs of disapproval and withdrawal of attention . Item 2  proposed for the externally controlling teaching factor, loaded also in the internally controlling teaching factor, which might suggest that the threatens to give bad grades by the teacher could be ambiguous for most students. Getting bad grades could be interpreted as an incentive to behave adequately , but also as a way of appealing to feelings of self-esteem  given the importance to get good grades for most of the students. Item 11  proposed for the internally controlling teaching factor, loading also in the externally controlling teaching factor. This might suggest that act strictly could be confusing for most of the students given that it could also be complemented by strategies focused on command, directives, or expressions like “you should”  in PE lessons. Item 12 , initially proposed for the internally controlling teaching factor, did not load in any factor, suggesting that their content could not be understood by students as a controlling teaching behaviour. Taking into consideration the quantitative results and the qualitative interpretation of the items, we decided to remove all problematic items from the final version of CTS-PE. Therefore, an eight-item two-factor solution was proposed for further analyses in Study 2.The purpose of Study 1 was to explore the internal composition and structure of the initial pool of 12 items proposed for the CTS-PE . This stThe results from both the EFA and the qualitative analysis of item content supported an eight-item two-factor solution. Four items belonged to the externally controlling teaching subscale, while the four other items to the internally controlling subscale. This solution was similar to that obtained in the preliminary analyses conducted by De Meyer et al. . AlthougM = 14.09, SD = 1.52), who were enrolled in five different public secondary schools from one medium-sized city situated in the northeast of Spain, participated in this study. With respect to their educational level, 166 students were in first grade of compulsory secondary education, 318 were in second grade, 122 were in third grade, 144 were in fourth grade, and 218 were in first grade of post-compulsory secondary education. Most students were Caucasian and belonged to a middle social, cultural, and economic class. Regardless of their educational level, all students received two one-hour weekly PE sessions, which were taught by nine different PE specialist teachers (eight men and one woman). They self-reported holding a Bachelor of Science in Physical Activity and Sport Sciences and a Professional Master’s program of Education (post-primary PE).A total of 968 secondary school students (479 boys and 489 girls), aged between 12 and 18 years old  identified in the EFA from Study 1.To assess students’ perceptions of autonomy, competence, and relatedness need satisfaction in PE, we used the Spanish PE version of the Basic Psychological Needs in Exercise Scale ; while tA cross-sectional design was adopted to provide validity and reliability evidence for the eight-item solution of the CTS-PE . Data cop < 0.01) [2/df) coefficient, Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Incremental Fit Index (IFI), Standardised Root Mean Square Residual (SRMR), and Root Mean Square Error of Approximation (RMSEA) with its 90% confidence interval (90%CI). The model fit was evaluated by values below 5 for χ2/df, above 0.95 for CFI, TLI, and IFI in conjunction with values less than 0.080 and 0.060 for SRMR and RMSEA, which indicate a good fit to data [Prior to data analysis, 21 missing values were found and removed. To provide internal validity evidence of the CTS-PE, a CFA and a multi-group analysis were conducted. To perform a CFA, the maximum likelihood estimation method together with 5000-bootstrap samples were used due to the violation of the multivariate normality assumption  . The goo to data . Standar to data . Inter-f to data .To examine the measurement invariance across gender, a multi-group analysis was conducted in accordance with the methodological approach described by Putnick and Bornstein . This prp < 0.01) [In order to provide predictive validity evidence of the CTS-PE, a SEM analysis was used following the two-step approach proposed by Kline . The fir < 0.01) . Finally < 0.01) , and IBM < 0.01)  were use2  = 76.29, p < 0.001; χ2/df = 4.02; CFI = 0.99; TLI = 0.98; IFI = 0.99; SRMR = 0.025; RMSEA = 0.056 . Standardised residual covariances ranged from −1.51 to 1.58. p < 0.001). The correlation among externally and internally controlling teaching was 0.74.The eight-item two-factor correlated model obtained a good fit to the data: χAcceptable internal consistency values were found for the externally controlling teaching  and the internally controlling teaching  factors.2  = 366.35, p < 0.001; χ2/df = 4.32; CFI = 0.96; TLI = 0.95; IFI = 0.96; SRMR = 0.038; RMSEA = 0.060 . Standardised regression weights were between 0.66 and 0.85 (M = 0.78), each reaching the level of statistical significance (p < 0.001). Correlations among factors ranged from −0.67 to 0.74  = 366.35, p < 0.001; χ2/df = 4.52; CFI = 0.96; TLI = 0.95; IFI = 0.96; SRMR = 0.038; RMSEA = 0.060 . β = 0.18, p = 0.002; β = 0.41, p < 0.001), and negatively BPN satisfaction . The total variance explained by this model was 33% and 32% for BPN frustration and BPN satisfaction, respectively.The second step of SEM was to analyse the proposed theoretical hypothesis model. This obtained appropriate goodness-of-fit measures: χt-tests found that while boys scored significantly higher in BPN satisfaction, girls obtained significantly higher values in BPN frustration. Instead, there were no significant differences between boys and girls in the externally and internally controlling teaching values.The objective of Study 2 was to examine the psychometric properties of the eight-item two-factor correlated model previously found for the CTS-PE in Study 1. The results offered initial evidence to consider the CTS-PE as the first valid and reliable measure to evaluate students’ perceptions of externally and internally controlling teaching behaviours from PE teachers.The results from the CFA for the CTS-PE provided psychometric support for the eight-item two-factor correlated model. The standardised residual covariances did not exceed 2.58 as an absolute value, implying the absence of misspecification in the instrument’s internal structure, as well as of substantial discrepancies between the theoretical two-factor correlated model tested and the data observed. Furthermore, all standardised regression weights displayed values over 0.50 with each reaching the statistical significance level, indicating thus that each item adequately captured the meaning of the subscale aiming to measure. The inter-factor correlation showed a moderate association between the externally and internally controlling teaching subscales, consistent with the one in De Meyer et al.’s study . This moThe findings that emerged from the gender invariance analysis, displayed that the eight-item two-factor correlated model was invariant between groups of male and female secondary school students. This means that the CTS-PE held equally for boys and girls, allowing one to examine the possible gender differences in students’ perceptions of externally and internally controlling behaviours from teachers in the PE setting. It is important also to highlight that these results are, particularly, interesting because they offered the first evidence to date of the measurement invariance across gender of this instrument. With regard to the instrument’s reliability analysis, satisfactory values were found for each of the two subscales. The Cronbach’s alpha values obtained were similar to those reported by prior research , while tConsistent with the SDT’s tenets and prior research conducted in PE ,17,20,21The objective of this SDT-based research was to examine the psychometric properties of the CTS-PE  using a This research offered some interesting and useful findings, but also had some limitations that should be acknowledged. Firstly, as a non-probabilistic sampling method was applied in this study to recruit the study sample, the results obtained should be interpreted carefully, which makes it impossible to generalise them to a broader population. Additional research is required to examine the psychometric properties of the CTS-PE in other education stages , students enrolled in different types of school , and students from distinct social, cultural, and economic contexts to extend the psychometric body of evidence for this scale. Secondly, this research only examines the psychometric properties of the CTS-PE in the Spanish context, hence the need to develop future studies that provide new validity and reliability evidence of this instrument in other linguistic contexts . Thirdly, although the hypothesized model, to test the predictive validity evidence, was based on the SDT framework, this research adopted a cross-sectional design, not allowing us to establish causal relationships between the variables studied. Further research in the PE context could use longitudinal or experimental designs to explore the impact of externally and internally controlling teaching behaviours on students’ need satisfaction and frustration, motivation, and adaptive affective, behavioural, and cognitive outcomes.The CTS-PE will enable us to more deeply and comprehensively examine the differentiated role that the external and internal faces of controlling behaviours from PE teachers could have on motivational processes  and affective, behavioural, and cognitive outcomes exhibited by students in their PE lessons. Furthermore, this will allow us to provide PE teachers with helpful and valuable information on motivational risks associated with externally and internally controlling behaviours in order to refrain from using these motivating practices, which may suppose an advance in the improvement of the quality both of the instructional practices in the school PE, and the initial and continuous education programmes for PE teachers. Thus, the issue of teacher’s externally and internally controlling behaviours deserves a particular attention in planning both initial education programmes for PE pre-service teachers and continuous professional development programmes for in-service teachers.The present research provided psychometric evidence in support of the CTS-PE, in its eight-item two-factor correlated model, as the first valid and reliable measure to assess Spanish students’ perceptions of externally and internally controlling teaching behaviours from teachers in the context of the secondary school PE. Therefore, this scale can contribute to a better understanding of potential risks associated with the development of externally and, particularly, internally controlling behaviours from teachers on students’ psychological and motivational outcomes in PE lessons. Further studies are required to determine whether the two distinguishable faces of controlling teaching behaviours influence the students’ motivational processes and dynamics involved in the PE lessons in the same way.


Introduction: The COVID-19 pandemic is asking health care workers (HCWs) to meet extraordinary challenges. In turn, HCWs were experiencing tremendous psycho-social crisis as they have had to deal with unexpected emotional requirements (ERs) arising from caring for suffering and dying patients on a daily basis. In that context, recent studies have highlighted how HCWs working during the COVID-19 outbreak manifested extreme emotional and behavioral reactions that may have impacted their mental health, increasing the risk for developing post-traumatic stress symptoms.Purpose: The aim of the study was to investigate post-traumatic stress symptoms, such as intrusion symptoms, as a potential mediator of the link between ERs and crying at work, and whether rumination moderates the relationship between ERs and intrusion-based PTS symptoms among HCWs who have had to deal with patients dying from COVID-19.Methods: An online cross-sectional study design was performed. A total of 543 Italian HCWs (physicians and nurses) participated in the study. Participation was voluntary and anonymous. We used the SPSS version of bootstrap-based PROCESS macro for testing the moderated mediation model.Results: ERs had an indirect effect on crying at work through the mediating role of intrusion symptoms. Results from the moderated mediation model showed that rumination moderated the indirect effect of ERs on crying at work via intrusion symptoms, and this effect was significant only for high rumination. Furthermore, when we tested for an alternative model where rumination moderates the direct effect of ERs on crying at work, this moderation was not significant.Conclusions: As the second wave of the COVID-19 pandemic is ongoing, there is an urgent need for decision-makers to rapidly implement interventions aimed at offering timely psychological support to HCWs, especially in those contexts where the risk of emotional labor associated to patients dying from COVID-19 is higher. According to Kniffin et al. , “the imIn fact, from the moment the World Health Organization .“Fick, According to Lyon , crying Rumination is common after traumatic events Watkins, , and it The main purpose of this study was to examine whether PTS symptoms is a potential mediator of the link between ERs and crying at work, and whether rumination is a moderator of the link between ERs and PTS symptoms among HCWs who have had to deal with patients dying from COVID-19 :Hypothesis 1: the relationship between emotional requirements and crying at work will be mediated by PTS symptoms.Hypothesis 2: rumination on the pandemic will moderate the strength of the relationship emotional requirements and crying at work will be mediated by PTS symptoms, such that the mediated relationship is stronger under high rumination than under low rumination.An online survey was conducted using LimeSurvey and disseminated by sharing the link of the survey through social networking platforms. The inclusion criteria were as follows: (1) being a nurse or physician in Italy, and (2) having worked with patients who died from COVID-19. The link contained an invitation to join an online survey entitled “Health professionals and the Coronavirus SARS-COV-2 pandemics: an explorative study.” On the first page, we described the study's objectives, the time necessary to complete the survey (<10 min), the inclusion criteria, and the ethical issues behind the study. Participants received information about their involvement in the study together with a guarantee (1) that it was voluntary, (2) that it was anonymous, and (3) that no information that could identify respondents would be collected. Only individuals who agreed to the study's conditions completed the survey. The survey was available online from March 27 to May 31, 2020.f2 = 0.15 (R2 = 0.30) was expected in this study. Assuming an alpha level of 0.05, using a two-tailed test for multiple regression random effects model, seven predictors, and a desired power of 0.95, a power analysis using G*Power 3.1.9 , by adapting one item from the Emotion Work Requirements  to determine the significance of the effects based on 5000 random samples Hayes, . When thA total of 2759 Italian HCWs agreed to participate in the survey with 1621 (59%) completing the survey . As our main inclusion criteria were being nurses/physicians in Italy and working with patients who died from COVID-19, a total of 543 were included in the study.M = 42.87, SD = 10.94. Concerning profession, 381 (70%) were nurses and 162 (30%) were physicians. Regarding working region, 329 (60.59%) reported working in Northern Italy . Concerning patient's death, 113 (20.81%) reported that one of their patients had died from COVID-19, 202 (37.20%) reported that from two to five patients had died from COVID-19, 94 (17.31%) reported that six to 10 patients had died from COVID-19, and 134 (24.68%) reported that more than 10 patients had died from COVID-19.The study population consisted of 353 (65.0%) females and 190 (35.0%) males. Participants ranged from 22 to 71 years of age, Means, standard deviations, kurtosis, skewness, and intercorrelations between all variables are presented in p < 0.001] and direct  effects of ERs on crying at work. Therefore, these results partially confirmed an indirect effect of ERs on crying at work through the mediating role of intrusion symptoms. This model explained 19% of variance in crying at work , p < 0.001], which suggested that the indirect effect of ERs on crying at work was linearly related to rumination  and high (+1 SD) rumination in Patient death can be an emotionally stressful event that may increase the risk of experiencing mental health problems  as a moderator of the relationship between ERs and intrusion. To our knowledge, the moderating role of rumination is still understudied in pandemic literature, and it suggested that rumination about the pandemic may exacerbate the effect of ERs on PTS symptoms. Specifically, we found that among HCWs exposed to patient death, the relationship between ERs and intrusion symptoms was stronger when rumination was higher. Our results are in line with the general assumption that rumination plays a significant role in worsening stressor–strain relationship , we followed a practical criterion, keeping our survey short (< 10 min). However, single-item measures are very common in occupational health psychology and epidemiological studies, and there is general agreement that they are valid and reliable (Fisher et al., As a third wave of the COVID-19 pandemic represents an imminent global risk, government and hospital management should consider to rapidly implement regional and national interventions for protecting HCWs' well-being. The lessons learned from this pandemic should help decision-makers to promote readiness in offering timely psychological support to HCWs treating patients with COVID-19. In this phase, it is crucial that decision-makers developed awareness of the impact of this pandemic on the HCWs' mental health. Inefficacious and/or late interventions may represent a point of no return for many health care work force.The raw data pertaining to analyses performed in this study are available from the authors upon reasonable request.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. This study was developed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. No treatments or false feedbacks were given, and no potential harmful evaluation methods were used. Participation was completely voluntary, and participants could drop out at any time without any negative consequences. All data were stored only using an anonymous ID for each participant. Written online informed consent to participate in the survey was obtained by clicking on “I accept”.IPo, MG, FM, and IPi designed the study, developed the survey, and managed the online survey and the data. IPo wrote the methods. IPi and FM helped to prepare the references and helped with first draft of the manuscript. IPo and MG supervised the analysis. FM, IPi, ED'A, GF, and MC revised the final version of the manuscript. All authors read and approved the final version of the 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.


It is well established that persons with a severe mental illness (SMI) have a greater risk of physical comorbid conditions and premature mortality. Most studies in the field of community mental health care (CMHC) have only focused on improving cardiovascular health in people with a SMI using lifestyle approaches. Studies using organizational modifications are rather scarce. This systematic review aimed to synthesize and describe possible organizational strategies to improve physical health for persons with a SMI in CMHC. The primary outcome was Health-related Quality of Life (HR-QOL). Results suggested modest effects on quality of life and were inconsistent throughout all the included studies. Despite these findings, it appears that a more integrated approach had a positive effect on health outcomes, patient satisfaction and HR-QOL. The complexity of the processes involved in community care delivery makes it difficult to compare different models and organizational approaches. Mental health nurses were identified as possible key professionals in care organization, but no clear description of their role was found. This review could provide new insights into contributing factors for integrated care. Future research targeting the identification of the nurses’ role and facilitating factors in integrated care, in order to improve treatment and follow-up of somatic comorbidities, is recommended. Premature mortality in persons with a severe mental illness (SMI), such as schizophrenia, bipolar disorder or schizoaffective disorder, is high. Due to increased comorbidity with chronic medical conditions such as obesity, diabetes and cardiovascular impairment, it is now well established that persons with a SMI have on average a decline in life expectancy of between 15 and 20 years of age ,4,5,6.Presently, because of mental healthcare reforms worldwide, there is an increasing shift of residential mental health services into community mental health services, which is in line with the 2020 Mental Health Act of the World Health Organization. According to this health act the importance of an integrated health approach, targeting both mental and physical health, is pivotal .However, a major problem in existing evidence targeting medical health problems in persons with a SMI is that most studies focus on lifestyle interventions as a way of optimizing physical health in persons with a SMI ,9,10. ItWhilst some research has been carried out on interventions focusing on physical health in people with SMI, to our knowledge no recent review has systematically studied the effect of specific modifications to healthcare organization, models of collaborative care and care coordination for persons with a SMI in a community mental health setting (CMHS), except for a Cochrane systematic review published in 2013 to assess the effects solely of collaborative care for persons with a SMI, primarily focusing on hospital admissions and quality of life as outcomes .We conducted a systematic review of the evidence answering the following research questions: (1) which modifications in health care organization  in a CMHS are effective in improving the health-related quality of care & biometric outcomes , lipid profile, glucose and blood pressure)? and (2) who are the specific stakeholders in these organizational interventions (disciplines and tasks)?A systematic search was conducted between November 2019 and January 2020, using two electronic databases . Both searches made use of the same search strategy. The systematic review for all relevant literature was conducted using the PRISMA framework for systematic reviews ,16.The search strategy included the electronic databases Pubmed and Web of Science, using the following search string: AND  OR “schizophrenic” OR “bipolar” OR “schizoaffective” OR “bipolar disorder”(MeSH Terms) OR “psychotic disorders“ (MeSH Terms) OR “schizophrenia” OR “bipolar” OR “psychosis” OR “psychotic”) AND .To be included after a conscientious database search, studies needed to fulfill the following limits, inclusion and exclusion criteria. Limits: The search strategy was limited to articles published in English or Dutch between November 2009 and March 2020. Studies were considered eligible if the following inclusion criteria were met: (a) the intervention at hand should target somatic conditions in persons with a SMI living at home and/or under treatment at a CMHS; (b) the intervention consisted of an organizational modification  in screening/assessment, follow-up or communication concerning comorbid somatic conditions; (c) the study was interventional . Interventional studies are found to be more accurate in assessing the direct impact of an intervention and less susceptible to bias than observational or qualitative study designs ; (d) theA quality assessment was completed using the CONSORT and ROBINS-1 appraisal tools to determine the methodological rigor and risk of bias. Both the CONSORT and ROBINS-1 tool are recommended by the Cochrane Collaboration in the appraisal of interventional studies ,16,18.Data was extracted according to the search strategy, the time frame of the search, interventions, selected outcomes, populations and the study setting. Data-analysis was performed by description of study characteristics, interventions and outcomes. No quantitative data analysis or data-pooling was performed. Results were reviewed by the co-authors to improve correct interpretation, relevance and comprehensiveness of the findings ,20.n = 325) and after reading titles and abstracts (n = 178) the search resulted in 12 articles that were eligible for inclusion. After reading full texts, three articles were added to the review [The systematic literature search produced 3173 results in the database Pubmed. A total of 17 articles were included in this review ,35,36,37e review ,32,35. Be review . The floA quality assessment was performed to identify differences in the trustworthiness of the results. As recommended by CHOCRANE, the CONSORT checklist was used for assessing interventional studies . For theA detailed overview of study characteristics can be consulted in p = 0.002, d = 0.7) and severity of symptoms . No significant effects were detected on medication adherence and length or severity of manic symptoms.Van der Voort et al.  evaluatep = 0.01), comprehensiveness of care  and community orientation of the provider  compared to controls. The intervention group showed significant improvement in subscales ‘coordination of information’ and ‘utilization’ of the Primary Care Assessment Tool .Rogers et al.  evaluatep < 0.001; group-time interaction). Although the SF-36 showed a significant improvement in both mental (p < 0.001) and physical components (p = 0.003) in the intervention group, this was not significant in comparison with the control groups [A study evaluated the effect of a behavioral health home, located at a CMHS, providing care for cardiometabolic risk factors and comorbid conditions. Using weekly supervision meetings, care was delivered by a part-time nurse practitioner with prescribing authority and a full-time nurse care manager . Other caregivers made weekly rounds in the CMHS to improve integration of services. The intervention group showed significant differences compared to the TAU group in different domains: Proportion of indicated services received, diabetes care, prevention services in the intervention group, and primary care visits all increased significantly (l groups .p < 0.001). Regarding cardiovascular risk, a significant decrease in Framingham Risk Score was observed (8.4 (95% CI = 0.4–9.41) vs. 7.8 (95% CI = 6.93–8.75); p = 0.0353).Gutierrez-Rojas et al.  determinp = 0.002). At 12-month follow-up, the intervention group had twice as many indicated physical examination activities , screening tests , more than four times as many educational interventions  and more than six times as many indicated vaccinations . The intervention group also had a significantly greater improvement in having a usual source of care  [The ACTIVATE Mind and Body program was designed to raise awareness in the public mental health, primary care and non-governmental sectors about the physical and oral health care needs of people with SMI. The intervention included distribution of care guidelines for managing physical comorbidities to GP clinics and public mental health facilities and the development of a website for both health professionals and community members that provided mental health clinicians with the possibility of linking people with SMI to general practices The intervention group showed an increase in monthly rates of referrals for short, long and total GP consultations compared to the control group ( < 0.05) .p < 0.001), screening tests , educational interventions , and vaccinations . Compared to the control group, participants had an improved source of usual care. They also were more likely to visit the medical doctor, access to integrated cardiovascular care improved and more previously undiagnosed conditions were identified. A significant effect was also found on the mental health subscale of the SF-36 Quality of life scale .Eight of the included studies implemented an intervention that consisted of training healthcare professionals in providing care coordination and management. In the Primary Care Access, Referral, and Evaluation (PCARE) study of Druss et al. , two fulThe IMPaCT study assessed the effect of care coordination for persons with SMI in order to improve global health and substance use. Care coordinators in the intervention group were given a four-day IMPaCT training course based on the manualized implementation of IMPaCT. At 12-month and 15-month follow-up, no significant results were revealed in Quality of Life for both the mental and physical components. Of the secondary outcomes there was only a significant improvement in HDL cholesterol ,43.p = 0.01, Cohen’s d = 0.39) and a decrease in LDL-values . Kilbourne et al. (2013) also assessed the effect of the intervention on biometric somatic outcomes and physical health related quality of life (SF-12) in persons with a bipolar or schizo-affective disorder and a comorbid somatic condition. Participants in the intervention group showed a significant decrease of systolic  and diastolic  blood pressure compared to the control group. Although a significant decrease in manic symptoms  was observed in the intervention group, other outcomes did not differ significantly.In the study of Kilbourne et al. , the Lif2, p < 0.001; d = 0.2) and weight . Systolic blood pressure increased significantly . Results also showed a significant decrease in red flags on the questionnaire for BMI, pulse, foot care, sleep and breast checks [A study in Thailand implemented the Health Improvement Profile (HIP) developed by White et al.  and altet checks .p = 0.41). For secondary outcomes also no significant differences were found at 12-month follow-up. At 24 months follow-up, however, results were similar (10-year risk of CVD was 8.7% (SD 6.0%) in the CHANGE group vs. 7.7% (SD 5.7%) in the care coordination group, and 8.0% (SD 6.3%) in the treatment as usual group (p = 0.24) [Two related studies evaluated the effect of the CHANGE-trial respectively at 12 months and 24 months follow-up. The trail consisted of a comparison between lifestyle coaching, Care Coordination (both combined with TAU), and TAU. Both lifestyle coaching and care coordination were manually based interventions. Lifestyle coaching, for example, offered home visits to improve physical activity in daily life. Care coordination was provided by a trained psychiatric nurse to improve access to primary care. Analysis showed no significant effect on the Copenhagen mean age-standardized 10-year risk of CVD (8.4% (SD6.7%) in the CHANGE group vs. 8.5% (SD7.5%) in the care coordination group, and 8.0% (SD6.5%) in the treatment as usual group ( = 0.24) ,43).p = 0.049).Chwastiak et al.  pilot tep = 0.02) and activation scale .The Harp intervention, implemented by Druss et al. , was a pp = 0.018) [Another intervention, named the “Living Well”, targets self-management tasks for various conditions. The intervention was delivered either by two mental health peers or a mental health provider and a peer co-leader. Outcomes showed, after a short period of significant decrease, no significant effects at follow-up on the SF-12 Scale. At 12-month follow-up, the intervention group had significantly higher mean scores on the 18-item Multidimensional Health Locus of Control  .The “Bridge” intervention, studied by Kelly et al. , with imp < 0.001).Sajatovic et al.  developeThe present study intends to determine the effect of organizational modifications on physical healthcare in persons with a SMI situated in Community Mental Health Care. Main outcomes of interest were primarily Health Related Quality of Life and biometric results. Secondly, the disciplines and tasks of persons involved in the included interventions were studied.After analysis, the majority of the included studies (n = 14) implemented organizational modifications in order to improve the integration of physical healthcare and mental health services. Results could be divided into three categories: implementing a health care model that was innovative for the specific context, offering formal training, or offering coaching/educational services.Most of the included studies organized manual-based training for health care providers. In terms of health-related quality of life, interventions that offered training in care coordination showed a modest effect on physical or health related quality of life or both. Interventions that offered a training program to health care workers about a model of care showed no clear effect on health-related quality of life. Effects of training on biometric outcomes were small, clinically not relevant and inconsistent over the different studies. One study that specifically targeted diabetes in people with SMI, however, showed clinically relevant results on levels of HbA1c .These findings seem to be in contrast with previous research on training of health care workers in the general population, that shows a more direct link between training of community based health care professionals and somatic outcomes of patients involved ,46. OtheSome of the included studies aimed, after training caregivers, to evaluate interventions that considered Care Coordination as a stand-alone intervention, with modest results ,32. One Of the six included studies that considered implementing a new model of health care delivery, outcome measures were mostly limited to biometric outcomes and access to health care services ,31,34,35Three studies used the Framingham Risk score as an indicator for cardiovascular risk assessment and noted a significant decrease in cardiovascular risk ,31,34. WOf the four studies that assessed Quality of Life as an outcome, three found a significant result on the applied (sub)-scales. Two studies found a significant increase in both the mental health and the physical health component of the SF-36, of which the improvement in the mental health component can be considered of clinical relevance ,31. ThisAn important observation is the fact that many new models that are constructed and implemented are often based on the Chronic Care Model and the Rainbow Model, altered to mental health settings, but with modest effects on somatic outcomes. The literature, however, underlines the importance of rigorous implementation of these models ,61. EspeThe effects of educational or coaching interventions analyzed in this review are inconsistent in the Quality of Life and biometric outcomes. Most interesting is the finding that interventions that solely implement educational programs do not show a difference in outcomes compared to interventions that combine educational efforts with coaching, and other supportive contacts seem to have a more consistent effect on outcomes, such as Health Related Quality of Life and accessibility of primary care ,27,36. AAs mentioned in the previous paragraph, peer-coaches or peer-led interventions are potentially valuable assets in improving physical health in persons with a SMI. Two recent systematic reviews emphasize the added value of peer-interventions in improving physical health in persons with a SMI. The most important outcomes were the improvement in self-management in health care and the support of peer-navigators. However, outcomes remained unclear and more research is needed to confirm these results ,69.In one study, nurses received training in and practiced the Health Improvement Profile , showingStructured cooperation with GPs and keeping them and informed also seems to be crucial in achieving better health outcomes ,29. In tAlthough it was not described in the articles included in this literature review, the role of family carers could be of importance in improving physical health. Their role is often missed by research but can contribute to improvement in health status by assisting patients in their appointments and with their mobility. In addition, it should be mentioned that family carers often feel marginalized themselves by healthcare professionals, so their role needs greater acknowledgement ,84.Aside from professional roles and family carers, the quality of social relationships could also have an influence on physical health outcomes. For example, although not specifically addressing people with a SMI, research has shown the effect of social contacts on improvement of physical health and thus could implicate a topic of interest for future research .Although our synthesis concludes in favor of a more integrated approach in improving physical health in persons with a SMI, the literature underlines the identification of a comprehensive model of integrated care to guide further development and evaluation of future interventions . A focusFrom an economic perspective, the effect of organizational modifications, training or educational interventions on health economics remain unclear, as only one study reported a mean higher cost. In general, it is difficult to determine cost-effectiveness of integrated care models ,51,81,88Policy makers have a crucial role in promoting and facilitating physical health in persons with a SMI, because they are often perceived as a possible barrier or facilitator. Policy makers should invest in comprehensive, accessible healthcare for persons with a SMI, if possible in combination with easier access to housing/labor. At the macro-level, investments should be made in digital shared patient records, while policy at the meso- and/or micro-level should support the integration different services at the same location. The use of a universal and transparent framework could support policy makers in the development and funding of a more collaborative and integrated approach .This review has several limitations that need to be mentioned. First, most of the results showed a moderate risk of bias which makes it difficult and inconclusive to make any general assumptions about potential effectivity of the mentioned interventions. Secondly, because of the comparison of different interventions and the great variety in outcomes, it is difficult to interpret and compare, and results should only be seen as indicative. Third, it needs to be mentioned that collaborative or integrative care approaches are complex interventions with a variety of possible influencing factors, especially in community settings. Therefore, results need to be interpreted merely as guiding instead of as certain. Another result of this complexity is the impact on the level of evidence, which is rather low in the included studies.This review examined possible strategies to improve physical health in persons with a severe mental illness in community settings. The literature shows modest effects on quality of life, but not consistently over different studies. No clear outcomes were shown, although it seems a more integrated approach has a positive effect on health outcomes and Health-related Quality of Care, and the use of peer-interventions could improve commitment to health services. Although, in most studies, nurses have a central role in care organization and delivery, their tasks and role concerning physical health in community mental health care can be an interesting topic for future research. The role of peers and the quality of social contacts should also not be overlooked. Overall, research targeting integrated care in the treatment and follow-up of somatic comorbidities, possibly using digital tools, is recommended. Authors should discuss the results and how they can be interpreted in the perspective of previous studies and of their working hypotheses. The findings and their implications should be discussed in the broadest context possible. Future research directions may also be highlighted.


Background: Minorities’ Diminished Returns (MDRs) refer to systemically weaker effects of socioeconomic status (SES) indicators on various developmental, behavioral, and health outcomes of ethnic minorities compared to non-Hispanic (non-Latino) Whites. Similar MDRs also exist for the effects of parental education on the school performance of ethnic minority youth. Aim: To assess whether regression toward the mean (RTM) has any role in explaining the diminished effects of parental education on the school performance of Black and Hispanic youth relative to non-Hispanic White youth. Materials and methods: Data for this cross-sectional study came from the Monitoring the Future survey , a nationally representative survey of American youth in 12th grade. The sample included 10,262 youth who were 12th graders . The independent variable was parental education with five categories: Some high school, High school graduate, Some college, College graduate, and Graduate school. The outcome was self-reported school performance measured as grade point average (GPA). Ethnicity was the effect modifier. Analysis of variance (ANOVA) and the Tukey Post Hoc test was used to analyze the data. Data visualization (line graphs) was used to visualize the shape of youth GPA as a function of parental education levels across ethnic groups. Results: While a perfect stepwise increase was seen in youth school performance as a result of parental education improvement, this pattern differed considerably across ethnic groups. Such a perfect stepwise increase in youth school performance as a result of the incremental increase in parental education was missing for Black and Hispanic youth. The shape of the association between parental education and youth school performance ruled out regression toward the mean (RTM) as an explanation for the observed diminished effects of parental education on the school performance of Black and Hispanic youth. Conclusion: Diminished returns of parental education on the school performance of Black and Hispanic youth cannot be explained by regression toward the mean. Other factors and contextual processes, such as segregation, discrimination, racism, and poor quality of schools in urban areas, should be investigated in future research. The lIn line with the MDRs phenomenon, educational achievement differentially translates to tangible outcomes for non-Hispanic White families and Black families ,2. AmongMDRs are frequently exhibited in youth. MDRs of family SES on youth outcomes is a mechanism by which ethnic disparities are transmitted from one generation to the next ,10,18. MResearchers have explored several potential underlying mechanisms to explain the MDRs phenomenon. One potential explanation is the close proximity of high SES Hispanic and Black families to non-Hispanic White families, which means an increase in discriminatory experiences . ExtensiWhy MDRs exist is still unclear. Some scholars have attributed the MDRs to the lower quality of education in urban areas where most Black and Hispanic children and youth attend schools. Structural and institutional racism impact the practices and preferences of the labor market . As sociIn brief, RTM can be characterized by the high likelihood of values close to the average (mean) of the dependent value for extreme levels of an independent variable ,35,36. RThis study aimed to investigate the role of RTM in explaining MDRs of parental education on school performance (academic achievement) of ethnic minority youth. The hypothesis was that RTM does not explain the MDRs of parental education on school performance in ethnic minority groups. To produce generalizable results, a nationally representative sample of non-Hispanic White, Black, and Hispanic youth was used.This cross-sectional study is a secondary analysis of existing data from the Monitoring the Future (MTF-12th grade) survey. The MTF is a nationally representative survey of American 12th-grade students. The primary aim of the study is to examine the epidemiology and risk factors of youth substance use in the United States. The MTF-12th grade enrolls a national sample of 12th graders that are being followed into adulthood. In the United States, almost 3.8 million students are enrolled in the 12th grade . The MTFThe 2017 MTF-12th grade study enrolled individuals who were enrolled in their 12th grade. Exclusion criteria: Not reporting school performance, not reporting ethnicity, not reporting education for either parent, not having any parent in the household, not reporting the number of parents in the household, not being in 12th grade, and Hispanic ethnicity (measured as self-identified). The analytical sample in this study was 10,262 youth.Ethnicity. Ethnicity was measured as self-identified. Ethnicity in the current study was a nominal variable, and the moderator variable .Parental education. Parental education was a five-level variable as below: 1 = “Some high school,” 2 = “Completed high school,” 3 = “Some college,” 4 = “Completed college,” 5 = “Graduate or professional school after college.” This variable was a nominal variable.School Performance. Participants’ school performance was measured by asking participants to report their grade point average (GPA). The exact item was, “What is your current overall school performance?” The possible answers were 9 = A (“93–100”), 8 = A- (“90–92”), 7 = B+ (“87–89”), 6 = B (“83–86”), 5 = B- (“80–82”), 4 = C+ (“77–79”), 3 = C (“73–76”), 2 = C- (“70–72”), and 1 = D (”69 or below”). School performance was a continuous measure, with a potential range from 1 to 9. A higher score indicated better school performance.The investigator used SPSS 23.0  for data analyses. School performance, a continuous variable, was the outcome. Parental education, a 5-level categorical variable, was the independent variable. Ethnicity was the moderator. Analysis of variance (ANOVA) was used to analyze the data. ANOVA was followed using the Tukey Post Hoc test. Line graphs were used for data visualization. We graphed mean school performance (GPA) by parental education and by ethnicity. In our visualization, RTM would be a potential explanation for MDRs, only if the data showed less than expected effects of the SES resource  at the right tail of the distribution . That is, RTM would be a possible explanation if and only if diminished returns were most pronounced at the highest level of parental education. However, if diminished returns are consistent throughout all levels of parental education, then RTM can be ruled out as an explanation for MDRs. In other words, if MDRs are seen for any incremental increase in parental education, then RTM is ruled out as an explanation.The MTF study protocol is approved by the University of Michigan Institutional Review Board (IRB). All participants gave a written consent/assent, depending on their age at the time of the survey. For the participants who were younger than 18 years old, their parents also signed informed consent.The sample was composed of 10,262 youth who were all 12th graders. This sample was composed of Hispanics (22.75%), non-Hispanic Blacks (14.90%), or non-Hispanic Whites (62.35%). The sample contained slightly more females (51.6%) than males (48.4%) .We drew five line-graphs. These graphs present mean youth school performance based on parental education. The first two graphs are for the overall sample, first pooled, and then separate lines for each ethnic group. Then, we added three similar graphs; one for Blacks, one for Hispanics, and one for non-Hispanic Whites. In the first graph, there was a perfect stepwise increase in GPA as parental education improved in the pooled sample. As the second graph shows, however, this stepwise increase in GPA could be seen for non-Hispanic White youth but not Black or Hispanic youth. The last graphs also showed the most significant deviation for the form of shape for Black youth. For Black youth, a major anomaly could be seen, which was not due to the end tale of the distribution (highest education) but the lowest educational level. As such, our data visualization ruled out the RTM as an explanation for the observed diminished effects (MDRs) of parental education on the school performance of Black and Hispanic relative to White and non-Hispanic youth .This study documented a stepwise increase in school performance for the overall sample of youth. However, such a stepwise increase in school performance as a result of an increase in parental education was absent for non-Hispanic Black and Hispanic youth. As our data visualization showed, RTM seems not to be a plausible explanation for the observed diminished effects of parental education on the school performance of non-Hispanic Black and Hispanic youth relative to non-Hispanic White youth.While each additional level of parental education always resulted in a significant enhancement of the 12th graders’ school performance in the US, this effect was diminished for ethnic minorities. In addition, MDRs could be seen at all levels of parental education, not merely at the extreme high of parental education, which would be expected if RTM was the reason behind the MDRs. That is, the effect of parental education on youth school performance was always smaller at all thresholds for ethnic minorities, when compared to Whites and non-Hispanics. Thus, RTM is ruled out as the statistical explanation for MDRs.A large body of research has documented MDRs of various SES indicators for Hispanics and Blacks compared to Whites and non-Hispanics ,5,46,49.For youth, MDRs of parental education results in the trans-generational transmission of ethnic inequalities ,10,18. MAs shown by Bumpus, Umeh, and Harris , Black yThe difference in the shape of the association between parental education and school performance across ethnic groups is not limited to the right tail of the distribution and can be seen across education levels. This pattern rules out RTM as an explanation for MDRs. We have previously argued that MDRs may be due to racism and discrimination in the US education system and labor market. As a result of racism, segregation, and social stratification, schools have fewer resources in the areas where ethnic minorities receive an education ,59. AnotThe US social system has increased the psychosocial cost of upward social mobility for Black and Hispanic families. Being charged with extra costs for their upward social mobility, Black families gain less from their education. Upward social mobility is qualitatively different for ethnic groups, being more difficult for Blacks than non-Hispanic whites ,2. HistoAt each level of family SES, Hispanic and Black parents face disproportionately higher levels of environmental and societal problems in their daily lives. Hispanic and Black families with high SES still experience high levels of discrimination that reduces their outcomes ,61,62. IDue to existing MDRs ,2, equalSome solutions are increasing political participation of power, social justice, reduction of segregation, and affirmative action policies, as well as reducing any form of discrimination across institutions. Such efforts should be multi-level and include schools, correctional settings, and policing. A decline in stop and frisk, mass incarceration, and affirmative action may be needed.There is a need for future research. Religious aspects, involvement in sports, parenting, and availability of resources are linked to ethnicity and youth behavior. Future research should test if MDRs of SES in Black families may be related to any of the above factors. Differential engagement in sports, for example, may explain why high SES Black, Hispanic, and non-Hispanic White youth have different GPA school averages. This study is limited in a few ways. First, the outcomes were self-reported. There is a need to conduct future studies to replicate these findings using administrative data. Second, the only SES indicator in this study was parental education. Parental income, wealth, and family status are other SES indicators that need to be investigated. Furthermore, we only explored the association between parental education and GPA without studying why this association varies across ethnic groups. In addition, GPA was self-reported in this study. Some research could apply other sources such as administrative and school data. Some research suggests that self-reported GPA is valid and reliable, however, it is not perfect. Finally, GPA is not the only indicator of school performance. School performance includes multiple aspects of academic success that depend on behavioral, cognitive, and emotional characteristics. Despite these limitations, this is the first study to rule out RTM as an explanation of MDRs.Compared to White and non-Hispanic youth, Black and Hispanic youth gain less school performance from an increase in their parental education. For non-Hispanics and Whites, however, a perfect stepwise increase can be seen in youth school performance as parental education improves; this stepwise pattern may not exist in Black and Hispanic youth. Given that the stepwise increase in school performance is perfect for non-Hispanic and White but not in Black and Hispanic youth, and as the anomaly in shape was not limited to the end of the distribution, RTM is ruled out. Thus, RTM should not be regarded as an explanation for MDRs. Future research may explore the contextual causes of MDRs.


S. aureus (S.a) and P. aeruginosa (P.a). Furthermore, our objective was to evaluate if the basic elements of Ti-35Nb-7Zr alloy have any influence on bone marrow stromal cells, the source of stem cells, and observe if these metals have properties to induce cell differentiation into osteoblasts.An effective biomaterial for bone replacement should have properties to avoid bacterial contamination and promote bone formation while inducing rapid cell differentiation simultaneously. Bone marrow stem cells are currently being investigated because of their known potential for differentiation in osteoblast lineage. This makes these cells a good option for stem cell-based therapy. We have aimed to analyze, in vitro, the potential of pure titanium (Ti), Ti-35Nb-7Zr alloy (A), niobium (Nb), and zirconia (Zr) to avoid the microorganisms 6 cells/ml) with the microorganisms S. aureus (S.a) and P. aeruginosa (P.a) were cultured for 24 h on the samples and submitted to an MTT test.Bone marrow stromal cells (BMSC) were obtained from mice femurs and cultured in osteogenic media without dexamethasone as an external source of cell differentiation. The samples were divided into Ti-35Nb-7Zr alloy (A), pure titanium (Ti), Nb (niobium), and Zr (zirconia) and were characterized by scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). After predetermined periods, cell interaction, cytotoxicity, proliferation, and cell differentiation tests were performed. For monotypic biofilm formation, standardized suspensions (10p < 0.05). In contrast, no statistical difference was observed between the samples as regards mineralization nodules. Lower biofilm formation of S.a and P.a. was observed on the Nb samples, with statistical differences from the other samples.All samples presented cell proliferation, growth, and spreading. All groups presented cell viability above 70%, but the alloy (A) showed better results, with statistical differences from Nb and Zr samples. Zr expressed higher ALP activity and was statistically different from the other groups (Our results suggest that the basic elements present in the alloy have osteoinductive characteristics, and Zr has a good influence on bone marrow stromal cell differentiation. We also believe that Nb has the best potential for reducing the formation of microbial biofilms. This solution was then removed and 300 μl of dimethylsulfoxide (DMSO—Sigma-Aldrich) remained in the wells under incubation in a stove at 37 °C. Subsequently, the plate was stirred on an orbital table. One hundred microliters aliquots from each well were transferred to a 96-well plate (Greiner) and absorbance was measured on a spectrophotometer (Biotech EL808IU) using a wavelength of 570 nm.The strains P < 0.05), then analyzed by a multiple comparison test (Tukey). All statistical analyses were performed using GraphPad Prism software, version 6.00 The data were analyzed by one-way ANOVA and if the differences were significant (Energy-dispersive X-ray spectroscopy (EDS) gave the composition of the samples in percent of elements detected. The alloy presented a composition mainly of titanium, followed by the other compounds, niobium, and zirconia Fig. a. FigureAfter 7 days of culture, the cell adhesion, morphology, and spreading on all the materials were observed through the SEM images, as demonstrated in Fig. p < 0.05).All groups presented cell viability above 70%, which was considered satisfactory according to ISO 9001/2000. It was possible to observe in the graphs shown in Fig. Cell proliferation was observed after 24 h of culture, showing stained nuclei. DAPI coloration was observed on all samples. After quantification, our results showed no statistical difference between the groups. Figure p < 0.05). The Ti group, despite having the lowest result, did not present a statistical difference between groups A and Nb . In the quantification of the P. aeruginosa biofilm, the Nb presented the lowest biofilm values again, differing statistically from the Ti and Zr groups (p < 0.05). On the other hand, the Ti group showed the highest biofilm formation result for P. aeruginosa, differing statistically only from Nb.The MTT test measures the number of viable bacteria by the reduction reaction of the tetrazolium bromide (MTT). After 24 h of culture, the monotypic biofilms of Currently, one of the most recurrent problems in the field of implantology is bacterial contamination, which can lead to implant loss. At the time of surgery for implant placement it is impossible to ensure an environment totally free of microorganisms, and the failure of dental implants can occur due to the adhesion of bacterial and biofilm formation disrupting or avoiding the bone integration process. As some studies have showed, the capacity of the host in developing a good inflammatory response and the characteristics of the biomaterial, including its composition, are directly involved in the successful process of wound healing and osseointegration –26.Commercially, pure Ti and its alloys have been the main choice of biomaterials for bone implants, but mechanical and biological factors may impair their performance. Therefore, studies have been directed towards the production of new titanium alloys, with the addition of others metals, aiming to improve their characteristics, especially with respect to the modulus of elasticity and long-term cytotoxicity , 28. SevHowever, most studies with biomaterials and bone devices have not tested the ability of the metals individually in preventing bacterial contamination without compromising their capacity for cell proliferation and production of bone matrix. Jeyachandran et al.  affirm tAdequate interactions between the biomaterial and bone environment are required and are initiated by cell adhesion on the surface of the implant, followed by proliferation and differentiation in osteoblasts for subsequent production of the mineralized extracellular matrix, thus promoting the fixation of the implant, a process called osseointegration . The SEMThe choice of bone stromal cells and media without dexamethasone was proposed based on the use of these live cells therapeutically to increase bone repair and regeneration , 45 and Alkaline phosphatase (ALP) is one of the early proteins that regulate bone mineralization, and tests that evaluate alkaline phosphatase activity are considered a primary parameter indicative of cell differentiation into osteoblasts . The resIn our study, all biomaterials showed ALP activity, but Zr was the only sample that presented a statistical difference from the others groups. Matrix mineralization is the final event of bone formation . In studS. aureus with statistical differences. Zhao et al. [Staphylococcus aureus was identified as an initial colonizer of dental implants and is the one bacterium which has the ability to attach to almost any type of titanium surface. In fact, we observed the presence of S. aureus on the samples with titanium. However, in our results, pure titanium showed a high affinity to P. aeruginosa which agreed with the results of Truong et al. [P. arginosa and S. aureus can be observed on titanium surfaces, and they believe that these microorganisms may be associated with implant failure. Some studies have shown TiNbZr as a good option due to its excellent mechanical, bioactivity, and corrosion protection [P. arginosa and S. aureus. However, Nb was selected in our study as the best material to prevent bacteria contamination, since it showed low affinity for both biofilms and, therefore, we believe it has antimicrobial proprieties.The success or failure of dental implants is directly related to the degree of integration of the implant material with the surrounding soft and hard tissues , 54 verso et al.  showed io et al.  assert tg et al. . Albertig et al.  showed iotection , 59. ComOur study allowed us to conclude that none of the metals alone  or the alloy (Ti-35Nb-7Zr) has all the properties individually to avoid microbial biofilm formation and induce cell differentiation. However, we confirmed that all samples and titanium alloys have osteoinductive potential and can induce BMSC differentiation. We also determined that Zr has the best potential for this purpose. It was suggested that Nb could also contribute to the avoidance of bacterial formation and we believe that, when it is incorporated into an alloy, it can help prevent bacterial contamination. Furthermore, the use of dexamethasone should be further analyzed as an inductor of cell differentiation in research using biomaterials, because the use of this drug can cover up the osteoinductive proprieties of the biomaterials. The use of BMSC from mice femurs, in our view, proved the potential of these cells to differentiate into osteoprogenitor cells, making them a possible source of bone tissue therapy.


To investigate mortality in adults with intellectual disabilities: rates, causes, place, demographic and clinical predictors.Cohort study with record linkage to death data.General community.961/1023 (94%) adults  with intellectual disabilities, clinically examined in 2001–2004; subsequently record-linked to their National Health Service number, allowing linkage to death certificate data, 2018.Standardised mortality ratios (SMRs), underlying and all contributing causes of death, avoidable deaths, place, and demographic and clinical predictors of death.294/961 (30.6%) had died; 64/179 (35.8%) with Down syndrome, 230/783 (29.4%) without Down syndrome. SMR overall=2.24 ; Down syndrome adults=5.28 , adults without Down syndrome=1.93 ; male=1.69 , female=3.48 . SMRs decreased as age increased. More severe intellectual disabilities increased SMR, but ability was not retained in the multivariable model. SMRs were higher for most International Statistical Classification of Diseases and Related Health Problems, 10th Revision chapters. For adults without Down syndrome, aspiration/reflux/choking and respiratory infection were the the most common underlying causes of mortality; for Down syndrome adults ‘Down syndrome’, and dementia were most common. Amenable deaths (29.8%) were double that in the general population (14%); 60.3% died in hospital. Mortality risk related to percutaneous endoscopic gastrostomy/tube fed, Down syndrome, diabetes, lower respiratory tract infection at cohort-entry, smoking, epilepsy, hearing impairment, increasing number of prescribed drugs, increasing age. Bowel incontinence reduced mortality risk.Adults with intellectual disabilities with and without Down syndrome have different SMRs and causes of death which should be separately reported. Both die younger, from different causes than other people. Some mortality risks are similar to other people, with earlier mortality reflecting more multimorbidity; amenable deaths are also common. This should inform actions to reduce early mortality, for example, training to avoid aspiration/choking, pain identification to address problems before they are advanced, and reasonable adjustments to improve healthcare quality. Thorough methods of case ascertainment for intellectual disabilities at baseline.Individual verification of intellectual disabilities and its severity, and detailed health assessments at baseline.Longitudinal design.Large cohort size and study duration, and successful record linkage for 94% of participants.Limitations include that the study was conducted in only one part of Scotland, and the reliance on recorded cause of death from death certificates.People with intellectual disabilities die at a younger age than other people; on average, 20 years younger,Previous studies on death in people with intellectual disabilities had limitations such as small sample sizes, or non-representative populations. More recently, there have been large-scale studies which are more representative, having been drawn from intellectual disabilities registers, or social security or primary care data with record linkage to death certification. These have been undertaken in parts of Sweden, Australia, England, Finland, Canada, Ireland and USA.5–19 The10.1136/bmjopen-2019-036465.supp1Supplementary dataIn view of the methods that studies have used for population identification , they provide little information on the socioclinical factors that influence SMR, or the risk factors associated with death, beyond that of age and sex. Three studies reported SMR by level of intellectual disabilities, with, broadly speaking, higher SMR with more severe intellectual disabilities.There is less consistency regarding the most common certified underlying causes of death in adults with intellectual disabilities, partly as some studies do not report these separately for children and adults, or by age ranges. Additionally, studies group causes of death in different ways , which can affect prevalence rankings between studies. Pneumonia, other respiratory diseases and diseases of the nervous system were reported to be the most common in one study,2Overall, the existing body of literature on mortality in adults with intellectual disabilities does not include more detailed information on level of intellectual disabilities, nor separate out the population with, from those without, Down syndrome (for whom causes of death may differ), nor investigate health and demographic predictors of death other than age and sex, and is inconsistent with regard to causes of death. A better understanding of these factors may provide a pathway to action to reduce the observed earlier mortality in adults with intellectual disabilities.This study aims to investigate the rates, causes, place and demographic and clinical associations with mortality in adults with intellectual disabilities, with and without Down syndrome.The adult (aged 16+ years) intellectual disabilities population living within the NHS Greater Glasgow area was identified through multiple sources between 2000 and 2001. General practitioners were financially incentivised to identify their registered patients with intellectual disabilities, and all 631 (100%) did so. Adults were also identified via the intellectual disabilities health and social work services including day services, the Health Board register and records of financial payments for any service by social work. This process led initially to an overidentification, such as people with IQ scores in the 70–80 range with additional complex health needs. All were systematically reviewed by nurses in the intellectual disabilities health service, and this group were removed. Thus, a register was compiled, and subsequently updated annually via general practices, with central support from the intellectual disabilities health service, until 2017 when services were redesigned. The identified adult prevalence of intellectual disabilities within the area was 3.33 per 1000 in 2000–2001.International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10).ICD-10 (Diagnostic Criteria for Research),Diagnostic and Statistical Manuel of Mental Disorders-IV-TRDiagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities.With initial piloting in 2001, each participant had a detailed assessment of their general and mental health, and demographic factors, completed 2002–2004. One of the six specially trained, registered nurses reviewed each person’s primary health care records, then used a semistructured tool, the C21st Health Check, to assess clinical factors and the level and cause of intellectual disabilities. In addition to a review of existing health problems and all bodily health systems, a physical examination was undertaken, including assessment of vision and hearing, measurement of height and weight and a phlebotomy protocol followed. All information was then reviewed by the nurse with one of three general practitioners with a special interest in intellectual disabilities, and any further investigations that were indicated were completed. Previously known, and newly identified, conditions were then classified using the Each person in Scotland is given a number unique to them at birth or first registration with a general practitioner, which is used in almost all subsequent health service encounters, and on certification of death. The numbers are held on the Community Health Index (CHI) database at National Services Scotland. These CHI numbers provided a means to record link each participant with National Records for Scotland death certification data. This linkage was performed in 2018, and the linked data were held in the NHS Greater Glasgow & Clyde (NHS GG&C) Safe Haven. Data on immediate, underlying and contributory causes of deaths by ICD-10 codes, age at death and place of death were extracted.In order to provide finer granularity of cause of death, two clinical academics then grouped specific causes of death into narrower groupings than those provided by ICD-10 chapter headings . This apAll statistical analyses were conducted using R for Windows V.3.3.0 or SAS V.9.3 and were performed within the NHS GG&C Safe Haven environment. Due to disclosure principles of the Safe Haven, results with counts of less than five cannot be released; these have been referred to as <5 throughout. Similarly, if it is deemed possible that participants may be identified from the results, these may be omitted. Details are provided if this occurred.Data were summarised for the population of adults aged 16+ years with intellectual disabilities. Categorical variables were summarised with the number and percentages of people falling into each category and the number of missing data. Continuous variables were summarised with the number of observations and those missing, the mean and SD, and the minimum and maximum values, unless otherwise stated.Participant characteristics were summarised overall and for those alive and those deceased. For those who are deceased, their data including age at death, underlying/contributing causes of death, and location of death were summarised for those with and without Down syndrome. Location codes for place of death are provided where available. We assumed those with the code for non-institutional location to have died at home. Due to small numbers, location codes have been grouped together for NHS hospitals, home, and other hospitals/care facilities including hospices.Mortality incidence rates have been calculated using the number of deaths in the cohort divided by the number of person years alive within the study period multiplied by 100 000, overall and for those with and without Down syndrome. SMRs were calculated using population data for those aged 15 and over within NHS GG&C in 2010.Deaths were also analysed for those that could be considered as deaths that would have been avoidable. The Office for National Statistics (ONS) published a definition of avoidable mortality,To determine the demographic and clinical factors associated with death in adults with intellectual disabilities, time to event analyses were explored using univariate Cox Proportional Hazards models. Variables were selected as potentially relevant on the basis of what is known on causes of death in people with intellectual disabilities, the 20 most common physical health conditions reported in the adult population with intellectual disabilities,Demographics—nine variables.Clinical conditions—33 variables.Service use—three variables.Prescriptions—five variables.All 50 variables were then permitted entry in to a single multivariable analysis using stepwise regression methods, in order to identify a model containing the statistically significant factors associated with death. Age at date of the health assessment was entered into the model as a continuous measure. Results from the univariate Cox Proportional Hazards models  and the This study was designed to respond to the growing concern expressed by people with intellectual disabilities, their families and third sector organisations about the early deaths of people with intellectual disabilities. The Scottish Learning Disabilities Observatory, where this research was undertaken, has a specific remit for people with intellectual disabilities. Its steering group includes partners from third sector organisations, including Down syndrome Scotland, and people with intellectual disabilities, who approved the work plan for this project prior to it commencing. Results from this study will be disseminated for people with intellectual disabilities in an easy-read version via the Scottish Learning Disabilities Observatory.Of note, 962 of the original 1023 (94.0%) adults with intellectual disabilities who were assessed were linked to a CHI number enabling the extraction of relevant death data. Reasons for the unlinked 61 people could be due to moving out of the area, or a recording mistake. One further participant was removed from the analysis due to inaccurate recording of dates, leaving 961 adults in the cohort (93.9%). Of these 961 adults, 294 (30.6%) had a record of death. The mean age at death was 61.0 years (SD=7.0 years). Of the 961 adults, 64 (35.8%) of the 179 adults with Down syndrome and 230 (29.4%) of the 782 adults without Down syndrome had a record of death. Their mean age of death was 56.9 years (SD=4.3 years) for the adults with Down syndrome, and 62.2 years (SD=7.5 years) for the adults without Down syndrome. Mortality incidence for the cohort during the study period was 3049.0 per 100 000 person years follow-up, with 3832.1 per 100 000 for those with Down Syndrome and 2885.0 for those without Down syndrome.Compared with the general population, the SMR was 2.24  overall; 5.28  for adults with Down syndrome, 1.93  for adults without Down syndrome; 1.69  for men and 3.48  for women. SMRs were higher the more severe the level of intellectual disabilities, with people with profound intellectual disabilities having an SMR of 4.14 . SMR was high for all age groups ; this decreased as age increased. SMRs were high for most ICD-10 chapter groups of conditions, particularly so for congenital malformations at 17.26 , diseases of the digestive system at 16.13 , mental and behavioural disorders at 12.64  and external causes at 11.08 . Details are shown in Cause of death data was available from death certificates for 262 (89.1%) of 294 participants who had died, which include 57 (89.1%) participants with Down syndrome, and 205 (88.7%) participants without Down syndrome. According to the ONS list of avoidable deaths, 102 (38.9%) of the 262 deaths were avoidable; most notably, respiratory infection and epilepsies ; 78  died in an NHS Hospital, 70 (26.7%) died at home, and 34 (13.0%) died within other hospitals/care facilities. This was similar for both the adults with Down syndrome: 31 (54.4%) in an NHS hospital, 17 (29.8%) at home, and nine (15.8%) within other hospitals/care facilities; and the adults without Down syndrome: 127 (62.0%) in an NHS hospital, 53 (25.9%) at home, and 25 (12.2%) within other hospitals/care facilities.The results from the univariate cox proportional hazards models indicated that of the original 50 potential variables, factors associated with risk of death were  as folloDemographics–age at the time of the health assessment, more severe learning disabilities, accommodation type (not living with family carer), not having day-time occupation, and being a smoker .Clinical conditions–having spastic quadriplegia, hearing impairment, visual impairment, diabetes, percutaneous endoscopic gastrostomy/tube fed, constipation, ataxia/gait disorder, osteoporosis, hypertension, dysphagia, dyspnoea, gastro-oesophageal reflux disorder, lower respiratory tract infection, total number of physical health disorders, not having impaired mobility, not having urinary incontinence, not having bowel incontinence, and not having autism .Service use—number of general practitioner consultations in the previous 12 months, total number of different types of health professionals providing care at the time of the clinical assessment (but not number of accident and emergency attendances in the previous 12 months).Prescriptions—antiepileptic drugs, total number of different types of drugs .As far as we are aware, this is the first population-based study of adults with intellectual disabilities to report in detail the factors associated with time to death, and to describe their causes of death, and quantify the SMR separately for adults with and without Down syndrome. This is important, since adults with Down syndrome form a notable proportion of all adults with intellectual disabilities (19% in this cohort), and because they have a different pattern of clinical conditions compared with other adults with intellectual disabilities.Clearly, this pattern of causes of death differs from that seen in the general population, in whom the most common underlying causes of death are heart disease, then dementia, then lung cancer in men, and dementia, then heart disease, then stroke in women.We found an overall SMR of 2.24; 5.28 in the adults with Down syndrome and 1.93 for the adults without Down syndrome. SMRs were higher for most ICD-10 chapter groupings of conditions. It was higher in the women than the men, as has been previously reported in most , but not34While accommodation type (not living with a family carer), ability level, not having day-time occupation, having spastic quadriplegia, visual impairment, constipation, ataxia/gait disorder, osteoporosis, hypertension, dysphagia, dyspnoea, gastro-oesophageal reflux disorder, total number of physical health disorders, not having impaired mobility, not having urinary incontinence and not having autism, number of general practitioner consultations in the previous 12 months, total number of different types of health professionals providing care at the time of the health assessment and antiepileptic drugs were related to time of death on univariate analyses, they were not retained in the multivariable model.The majority of the adults with intellectual disabilities, with and without Down syndrome, died in an NHS hospital.The overall SMR we report, higher SMR in women than men and higher SMR at younger age groups is similar to the majority of previous reports. Most mortality studies with people with Down syndrome have been conducted with children. Previous reports of children and adults (combined) gave an SMR=5.5,For the cohort overall, respiratory infection and aspiration/reflux/choking were the most common all contributing causes of death. These conditions feature in previous studies on causes of death,19Previous research from other countries has highlighted that listing Down syndrome or intellectual disabilities as the underlying cause of death obscures actual causes of death for this population.Studies that investigated avoidable deaths in adults with intellectual disabilities found them to be more common than in the general population, due to deaths that would have been amenable to good care. Avoidable deaths have been reported in 44.7% of deaths of people with intellectual disabilities in England (mostly amenable deaths—figure not reported),5The strengths of the study include the thorough methods of case ascertainment for intellectual disabilities at baseline with verification of intellectual disabilities and its severity, suggesting results are generalisable in other high-income countries. While our identification of the population will not have identified everyone with intellectual impairment (an IQ<70), in view of the multiple sources used we believe it will have identified the adults with intellectual disabilities . Additionally, there were detailed clinical assessments at baseline, and a longitudinal design. The size of the cohort and the duration of follow-up is also a strength, as is the successful record linkage for 94% of participants. Our study does have limitations, specifically that the study was only conducted in one region of Scotland, and the reliance on death certificate data to obtain cause of death. Additionally, the characteristics and health of the participants was collected in 2002–2004. The health conditions we investigated tend to be long-standing or remitting/relapsing conditions, and psychotropic prescribing also once initiated tends to be long-standing in people with intellectual disabilities. However, it is possible that extent of neighbourhood deprivation, type of accommodation, employment and civil status (though few marry) might have changed for some people between 2002 and 2004 and 2018; we have no further information to check this. There were no concerns regarding the proportional hazards assumption in the multivariable model. The linkage was also reliant on the accuracy of the CHI number as a sole source of linkage.It is important to know the factors that are associated with risk of death, and the common causes of death in this population, as these then inform the actions needed to reduce the unacceptably high SMRs experienced by people with intellectual disabilities. Awareness of these factors may provide a pathway to action to reduce the observed earlier mortality in adults with intellectual disabilities. It is not adequate to solely rely on the public health interventions available to everyone, even when they are accessible. Aspiration, reflux and choking could, and should, be avoided by raising awareness of its consequences (death), and putting in place training on simple measures related to feeding, positioning, food consistency, and when to seek health advice from speech and language therapy, physiotherapy, nursing, and medical advice. Carers need to be aware of how the adults they care for express pain, so that conditions such as gastrointestinal ulcers are attended to, prior to the extreme point of perforation and so treatable conditions such as constipation and urinary tract infections are managed before they lead to respiratory distress and sepsis. Quality of care is important; adults with intellectual disabilities need just as good care for their diabetes and epilepsy (and other conditions) as the rest of the population, with reasonable adjustments to address accessibility, and accessible smoking cessation programmes.Further research on larger samples is needed, particularly with regard to replicating and extending our findings on the factors that are associated with risk of death, and any sex differences in them, so that practitioners can focus on actions to improve the life expectancy of adults with intellectual disabilities, with and without Down syndrome.