People can be overly optimistic not only about their own future but also for the people with whom they identify. Furthermore, interpersonal perception generally forms along two universal dimensions, i.e. warmth and competence. In this study, we created four fictional characters that would map onto each quadrant of the two-dimensional space of warmth and competence, i.e. one in-group member (high on both warmth and competence) and three out-group members . We then asked respondents to assess the likelihood of each character experiencing a series of identical desirable and undesirable events in order to uncover potential optimistic biases. Our study had two goals. First, we wanted to balance the target desirable and undesirable events on four key characteristics, i.e. event frequency, controllability, emotional intensity and personal experience with the event. Second, we wanted to investigate whether stereotypes of warmth and competence could influence the respondents’ likelihood estimates for each character. We show that respondents manifested a strong desirability bias, expecting more desirable than undesirable events for the in-group member and the reverse pattern for the extreme out-group member. More important, we show that, within desirable and undesirable events, respondents anchored their judgments for the in-group member on their personal experience with the target events, further revealing an egocentric bias, but turned to stereotypical knowledge in the form of warmth and competence to judge out-group members. Implications for both social perception and optimism research are discussed. Probabilities are a fundamental aspect of experience. Events ranging from the large and consequential  to the mundane (‘‘Will the train be on time?”) are all characterized by a lack of certainty, falling along a continuum of likelihood. An event’s perceived likelihood is then critical in influencing the choices we make regarding the event. For instance, we are more likely to participate in a medical procedure if we believe to have a high rather than low chance of being cured.unrealistic optimism and reviewed two main types of unrealistic optimism: absolute and comparative. Unrealistic absolute optimism refers to a personal estimate for a future event that is optimistically inaccurate as compared to an objective standard, e.g. overestimating one’s likelihood of winning the lottery in comparison with the actual statistical odds of winning. Unrealistic comparative optimism also involves a personal likelihood that is favorable, but the comparison is made to the likelihood for a reference person, e.g. assessing one’s own likelihood of winning the lottery as greater than a colleague’s likelihood of winning. The current study focuses on unrealistic comparative optimism. While absolute optimism results solely from biased personal likelihoods, comparative optimism may result from a distortion in personal likelihoods of future events, a distortion in the perceived likelihood of the comparison target, or both.Often there can be a discrepancy between what people expect will happen in general and what they think is likely to happen to them personally , 2. ReseOptimistic biases are particularly resistant to outside influence, for instance when tempted with large incentives for making accurate estimations , 18. NevOne question that arises is whether simultaneously balancing different event characteristics influences the emergence of the optimistic bias. Past studies have predominantly investigated one event characteristic at a time e.g. –34). The. The34])Another question that emerges is whether individuals estimate the likelihoods of events differently for different reference targets, above and beyond influences from event characteristics. Independent lines of research on the optimistic bias have investigated likelihood estimates for oneself and the average other , 37, andThe following two sections will describe the two sets of moderators of the optimistic bias, i.e. event characteristics and reference target characteristics. We will then describe the social psychological model used to improve the conceptualization and predictive power of the reference target. We will finally bring all this information together and state our hypotheses in the last section of the introduction.The most scrutinized event characteristics that moderate overoptimistic beliefs have been the target event’s perceived controllability , 32, 33,There is compelling evidence that an event’s perceived frequency also has a considerable influence on whether optimistic beliefs are formed, with rare events more strongly triggering comparative optimistic beliefs than common events , 27, 53.Additionally, an event’s perceived desirability is hypothesized to play an important role when judging the chances of experiencing them , 42, 58.biased sampling of events, several other methodological concerns have been voiced, such as scale attenuation and minority underrepresentation ) Table 1). To compare the results on social optimism bias with those related to personal optimism bias, the estimates for oneself experiencing the target events were also considered.In line with previous research on comparative optimism , 45, 66,r = .94, p < .0005), the student character  and the elderly character . Similarly, scores of personal experience with the events were significantly associated with the likelihood estimates for the self , the student character  and the elderly character . Only the perceived controllability of an event was significantly associated with the likelihoods for the businessperson  and the alcoholic character .For desirable events, ratings of perceived event frequency significantly correlated with the likelihood estimates for the self  and the student character , as did ratings of personal experience . Only the perceived controllability of an event was significantly associated with the likelihood estimates for alcoholic character . Table 1 lists all Pearson correlation coefficients and their respective significance levels.For undesirable events, ratings of event frequency significantly correlated with likelihood estimates for the self . Because emotional intensity was strongly associated with event valence, and because event frequency was highly correlated with personal experience, we only chose three event characteristics to be included as predictors in the regression models: personal experience with the event, perceived controllability and emotional intensity.2 = .97) and the student character  = 15.04, p < .0005, adjusted R2 = .737) and the alcoholic character  = 7.59, p = .004, R2 = .568) but not the elderly character  = 6.69, p = .007, R2 = .532) or the businessperson  = 2.00, p = .168, adjusted R2 = .167). Likelihood estimates for the self were significantly predicted by scores of personal experience (p < .0005) but not event controllability (p = .666) or emotional intensity of events (p = .957). Similarly, likelihood estimates for the student were significantly predicted by personal experience (p < .0005) but not event controllability (p = .995) or emotional intensity (p = .666). Finally, likelihood estimates for the alcoholic character were significantly predicted by event controllability (p = .002) but not by the personal experience of the participants with the events (p = .013) or the emotional intensity of events (p = .190). Regression coefficients and standard errors for the desirable events can be found in Table 2.For desirable events, the multiple regression model with personal experience, event controllability and emotional intensity was statistically significant in predicting likelihood estimates for the self  = 139.83, p < .0005, adjusted R2 = .86) and the student character  = 16.73, p < .0005, adjusted R2 = .76) but not the elderly character  = 1.14, p = .374, adjusted R2 = .03), the businessperson  = 1.71, p = .218, adjusted R2 = .13) or the alcoholic character  = 3.18, p = .063, adjusted R2 = .30; Table 3). Likelihood estimates for self were significantly predicted by scores of personal experience (p < .0005) but not event controllability (p = .227) or emotional intensity of the events (p = .020). Similarly, likelihood estimates for the student character were significantly predicted by scores of personal experience (p < .0005) but not event controllability (p = .206) or emotional intensity of the events (p = .201). Regression coefficients and standard errors can be found in Table 3.For undesirable events, the multiple regression model with personal experience, event controllability and emotional intensity was statistically significant in predicting likelihood estimates for the self  = 32.33, p < .0005, adjusted Rwarmth and competence, two universal dimensions of social perception [Past literature has shown that people are overly optimistic about the chances of experiencing future events not only for themselves but also for people close to them and for those with whom they identify , 37. Howrception , 108. Thrception , 91, 103rception , 89.We first show that, within each character, participants expected desirable and undesirable events to occur differentially as a function of warmth and competence, even after balancing target events on key characteristics such as frequency, controllability, emotional intensity and personal experience. Respondents forecasted desirable events to occur more often than undesirable events for the student character and the elderly character but not for the businessperson or the alcoholic character. The expectation for more likely desirable events than undesirable events was strongest for the in-group member followed by the warm-but-less-competent out-group member. However, the competent-but-cold out-group member was expected to experience desirable and undesirable events with equal chances. The extreme out-group member  was uniquely rated as having more chances of experiencing undesirable events than desirable events, mimicking the expectation for the in-group member but in the opposite direction. This pattern of findings mirrors the literature on desirability bias, which has shown that the respondents’ desires and motives influence how they generate likelihood estimates for future events , 58, 59.With the current results, we show that the desirability bias also operates on certain out-group members, albeit at a significantly reduced magnitude. The respondents expected more desirable than undesirable events for the warm mixed out-group member (i.e. the elder) but not the cold mixed out-group member (i.e. the businessperson). This is in line with the prediction that the warmth dimension holds more weight than the competence dimension in social perception , 118. Indesirability bias, in line with previous research [In summary, we show that a specific form of optimistic bias was present in our respondents, which we term research , 58, 59.Our results also suggest that, within desirable and undesirable events, and across characters, stereotypes of warmth and competence consistently bias respondents’ likelihood estimates for out-group members, whereas likelihood judgments for oneself and the in-group member are influenced by the respondents’ personal experience with events. The hypotheses of comparative optimism in line with stereotypes of warmth and competence were supported for the three out-group characters. The univalent out-group member was rated with the least chances of experiencing desirable events and the highest chances of going through undesirable situations. The mixed out-group members were rated intermediately between the univalent out-group member and the in-group member. However, the predictions of comparative optimism regarding the in-group member’s likelihood estimates were only partially confirmed. Our student participants expected the fellow student character to have the highest chances of experiencing desirable events, as predicted. For undesirable situations, however, and contrary to predictions, participants also expected the fellow student character to have significantly high chances of experiencing them . According to the SCM, the in-group member should be perceived as capable of not only maximizing positive outcomes but also minimizing negative outcomes by taking necessary preventive measures . AdAt face value, the unconfirmed predictions for the in-group member during undesirable events (as contrasted with the supported predictions for desirable events) could be interpreted as selective comparative pessimism. Although the literature points to an overall comparative optimistic bias among respondents, cases of comparative pessimism have been documented and several explanations have been put forth , 120. Ondifferential amounts of information and differential accessibility of information are interrelated and refer to the fact that respondents simply have more information  about themselves and others that they know directly, such as in-group members, and that they can access this information more readily than information about lesser-known others such as out-group members. The account of differential sources of information further extends this assumption by claiming that respondents use different types of knowledge when they think about themselves and close others, and when they think about lesser-known others. People rely on episodic memories to simulate future situations involving themselves and close others [Instead of explaining the results for the in-group member as selective comparative optimism and comparative pessimism, depending on the event’s valence, we suggest that other mechanisms may play a role in this pattern of findings. Specifically, the effects of event frequency and personal experience on likelihood estimates for oneself and in-group members can be accounted for by cognitive/egocentric biases such as differential sources of information, and differential amounts and accessibility to information , 123. The others –127 and e others . Howevere others , 130. The others , 132.In summary, we argue that cognitive/egocentric biases such as differential sources of information, differential amounts and access to information, can more readily explain the collective pattern of results for the in-group member for both desirable events and undesirable events. The fact that personal experience and event frequency significantly predicted the likelihood estimates for the in-group member but for none of the out-group members implies that respondents base their estimates for the latter on other factors. One such factor is the event’s perceived controllability. Likelihood estimates for the mixed character of the businessperson and the univalent out-group character were both correlated with and were predicted by the event’s controllability. For example, likelihood estimates for the univalent out-group member increased for undesirable events as the event’s perceived controllability also increased. For desirable events, likelihood estimates decreased as the perceived controllability increased. One might ask how the controllability of an event could influence likelihood estimates for out-group members, in particular. As argued above, respondents use stereotypical knowledge to assess future situations for out-group members , 130 andThe lack of definitive proof for comparative optimism for the in-group member in relation to out-group members adds to the recently voiced concerns about the true prevalence of comparative optimism , 66, 68.Our study presents several strengths and some limitations. First, we successfully addressed several methodological confounds that have been recently voiced , 67, 68 between dimensions but not within dimensions. For example, the two characters designated as warm should differ in overall scores of perceived warmth from the two characters designated as cold, but they should not differ from one another. In our sample, the manipulation check revealed that the four characters differed between dimensions, as expected, with main effects of warmth and competence. However, there were also significant differences within dimensions. Specifically, the two warm characters (student and elder) differed in their levels of (high) warmth, the two competent characters (student and businessperson) differed in their levels of (high) competence, whereas the two less competent characters  differed in their levels of (low) competence. As a result, throughout the manuscript we used the terms “high” and “low” in relation to the dimensions of competence or warmth in a relative manner rather than absolute. For instance, the student character, designated as high on warmth and high on competence, was, in fact, rated second highest in warmth (after the elder) and second highest in competence (after the businessperson). As such, the student character was considered “high” in warmth relative to the businessperson and the alcoholic, and “high” in competence relative to the elder and the alcoholic.Despite these strengths, we acknowledge some limitations of our experimental manipulations. The manipulation check of the SCM characters revealed a significant degree of entanglement between the dimensions of warmth and competence. The two-dimensional space provided by warmth and competence should ideally be inhabited by four stereotypes that differ within dimension differences is our use of direct questions to capture the perceived warmth and competence of the characters. In the SCM research, it is customary that questions assessing warmth and competence are asked indirectly through proxy constructs such as trustworthiness and intelligence, respectively, and an aggregate score is then computed for each SCM dimension [within dimension differences. Specifically, we performed four ANCOVAs on the designated target dimension (e.g. competence) while controlling for differences in the non-target dimension (e.g. warmth). These results confirmed the initial three-way ANOVA, in that the warmth- and competence-informed hypotheses strongly hold for the three out-group members but not the in-group member.One likely factor that might have contributed to the imension , 137. Toimension , 139. Seimension . The mosimension , 112. WeAnother limitation pertaining to our experimental manipulation is that the four fictional characters may also differ on dimensions other than warmth and competence. Future studies could match the characters more closely on as many dimensions as possible. We note, however, that a perfect match would be unreasonable to expect. Because our sample consisted predominantly of women, we cannot make strong generalizations about our findings. Future studies could balance the gender distribution and include gender and a between-subjects factor in the analyses.Lastly, we acknowledge that the lack of neutral situations in our study limited our conclusions about the magnitude of motivational and cognitive/egocentric biases that respondents engage in, such as the desirability bias and differential sources of information, respectively. A much stronger case could be made for the effects of cognitive/egocentric biases if the respondents evaluate the self and in-group members in neutral events also as a function of their personal experience with the target events, as they did with desirable and undesirable events. Similarly, the case for a desirability bias could be further strengthened if respondents evaluate desirable events to occur more often than neutral events, and undesirable events less often than neutral events. Thus, future studies can include neutral events along with desirable and undesirable events, equally balanced on key characteristics.In conclusion, we showed that respondents manifest a particular type of optimistic bias, which we refer to as desirability bias, even after controlling for key event characteristics such as frequency, controllability, emotional intensity and personal experience. The magnitude and the direction of the desirability bias for the four fictional characters were contingent on stereotypes of warmth and competence, two universal dimensions of social perception. Specifically, participants expected that the in-group member and the two mixed out-group members would experience significantly more positive events than negative events, all other things being equal. The magnitude of this desirability bias was highest for the in-group member, followed by the warm-but-not-competent out-group member and, lastly, by the cold-but-competent out-group member. For the univalent negative out-group, the desirability bias manifested in the opposite direction, with participants expecting significantly more negative events than positive. The finding of a desirability bias for the in-group member suggests motivational forces to approach desirable events and avoid negative events, which, in turn, lead to overestimation and underestimation of likelihood estimates, respectively , 58, 62.These results have several implications for both optimism research and SCM research. First, our findings raise the possibility that comparative optimism for the self and in-group members is not ubiquitous and that a narrower definition of optimism may be more appropriate (i.e. as desirability bias: expecting more desirable events than undesirable events). Future studies should, foremost, include in their analyses both desirable and undesirable events, balanced on key event characteristics. Second, both motivational biases (i.e. expecting more desirable events to happen than undesirable events) and cognitive/egocentric biases  influence different facets of likelihood estimates. Researchers should thus consider both accounts when designing their experiments and interpreting their findings. Third, the dimensions of warmth and competence could help explain likelihood estimates when the comparison target is an out-group member. Past research on overoptimistic beliefs has focused on “the average other” as a comparison target and has quantified the optimistic bias for oneself as a function of social closeness and similarity to the comparison target , 51, 69.Regarding the Stereotype Content Model, our results showed that stereotypes of warmth and competence more readily explain estimate likelihoods for out-group members than for oneself and the in-group member. The mismatch between the SCM predictions and our findings for the in-group member could be due to at least two reasons. First, it is possible that the cognitive/egocentric biases that drive the evaluations of the in-group member are strong enough to override the warmth- and competence-informed predictions of the SCM for the in-group member. Past research has singled out the potency of cognitive-egocentric biases when explaining the overoptimistic beliefs for oneself , 122 andWe also suggest potential lines of future research. For example, one can use an Implicit Association Test to measure the degree to which the four fictional characters are automatically associated with positive and negative concepts. As a manipulation check of the stereotypes associated with the fictional characters, this test can be implemented at the end of the main task. One can also experimentally reduce the implicit prejudice associated with the four social characters and investigate any ensuing changes in the likelihood estimates. A reduction in implicit prejudice can be prompted by a brief direct contact with a stereotyped person, e.g. elderly person or alcoholic, in an ecologically valid real-life interaction with that person (e.g. ). AlternS1 Analysis(DOCX)Click here for additional data file.S2 Analysis(DOCX)Click here for additional data file.S1 Discussion(DOCX)Click here for additional data file.S1 Fig(PNG)Click here for additional data file.S2 Fig(PNG)Click here for additional data file.S3 Fig(PNG)Click here for additional data file.S4 Fig(PNG)Click here for additional data file.S5 Fig(PNG)Click here for additional data file.S6 Fig(PNG)Click here for additional data file.S7 Fig(PNG)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 Data File(XLSX)Click here for additional data file.


Background: Chronic headache is one of the most common pain conditions, often leading to symptomatic drug overuse. The aim of this study was to provide data on symptomatic drug consumption in an Italian outpatient population and to describe how the clinical picture of headache may change after headache experts take charge of the care of affected individuals.Methods: A total of 199 adults complaining of chronic headache were recruited through 32 pharmacies in the Pavia health district. Participants underwent four evaluations: a baseline assessment (T0) and three follow-up evaluations performed by a neurologist at 3, 6, and 12 months . On each occasion, they underwent a complete neurological assessment and received therapeutic adjustments to achieve better management of their headache.Results: On the basis of a preliminary telephone interview, the prevalence rates of chronic headache and medication overuse headache (MOH) were 16 and 12%, respectively. At 12 months of follow-up, we observed a significant decrease in the frequency of attacks , in the number of days/month with headache  and in single attack duration . Careful headache management resulted in a significant decrease in analgesic consumption  and a significant increase in quality of life, measured using the Migraine Disability Assessment Scale (MIDAS) and Headache Under-Response to Treatment (HURT) scales (p < 0.001).Conclusions: Headache management by a specialist is more effective than self-treatment, resulting in an overall benefit for headache patients. Headache is a common pain condition, responsible for varying degrees of disability depending on the frequency, duration and intensity of the attacks. The chronic forms, which in most cases have evolved from migraine and tension-type headache, are associated with higher levels of healthcare demand and drug consumption .Chronic headache (CH), defined as headache occurring on at least 15 days per month, has a variable prevalence worldwide: 1.0–3.9% in the Asia-Pacific region , 3.7% inThe published evidence on the effect of specialized treatment in outpatients complaining of headache is still limited , 23. TheA sample of 32 pharmacies, representative of the local health district of Pavia  , joined the study under the terms of an agreement with the local board of pharmacists. Pharmacies located in the district's urban, rural and hill regions were equally represented. Before the enrollment phase started, pharmacists attended a compulsory three-part theoretical-practical course on headache and appropriate/inappropriate use of symptomatic and preventive drugs (each part lasted 2 h). To recruit headache sufferers for the study, the participating pharmacies' clients were targeted, over a 30 days period, by a press/media campaign entitled “Headache Month.” Headache sufferers wishing to take part were carefully informed by the pharmacists about the project and were invited to answer the following three initial screening questions: “How often do you get a headache?”; “How many analgesics do you take (type and number of doses)?”, “Are you already under the care of a specialist?”. They were also asked to leave their phone number or e-mail address, subject to signing a consent form. A few days later, they were contacted for a telephone interview conducted by a headache expert (IDC) from the C. Mondino Foundation: the users' sociodemographic characteristics were collected, and the features of their headache and drug consumption/overuse were verified. Afterwards, the participants underwent a series of four assessments carried out by two neurologists with specific expertise in headache (FA and IDC): a baseline evaluation (T0), during which they received a diagnosis and therapeutic program, and three follow-up assessments, at 3, 6, and 12 months . On each occasion, the participants underwent a complete neurological assessment and received therapeutic adjustments, if necessary, aimed at achieving optimal management of their headache. Moreover, at T0 the participants were given an ad hoc paper headache diary; the diary data collected at T3, T6, and T12 were used for statistical evaluation.Pain severity was recorded according to a 0–10 numeric rating scale (NRS) . Therapeutic response was evaluated in terms of headache frequency, severity, duration, and symptomatic drug consumption. Self-assessment questionnaires, i.e., the Headache Under-Response to Treatment (HURT)  and the This study was approved by the local ethics committee. All the participants gave written informed consent for their participation in the study.Each of the participants was a client of one of the local pharmacies involved in the study, who, after receiving detailed information about the study from the pharmacist, filled in the project participation card. The criteria for inclusion in the present study were a history of primary headache (regardless of the frequency and characteristics of attacks), adulthood, willingness, and ability to give written informed consent. There were no particular exclusion criteria apart from the presence of secondary headaches and other chronic pain conditions.The primary study outcome was modification of the severity and frequency of the headache attacks and of symptomatic drug consumption, achieved through expert management of the headache. The specialist care was also evaluated for efficacy, in terms of disability reduction, and for perceived quality as assessed using patient self-administered questionnaires. As secondary outcomes of the study we also analyzed reasons for poor compliance and patient dropouts.The Kolmogorov-Smirnov test was used to investigate the distribution normality of the different variables and, thus, to choose the correct statistical tests. The Chi-square test (χ2) was used to analyze revisions, at T0, of the initial diagnoses made on the basis of the preliminary telephone interview. Repeated measures ANOVA was used to compare the primary outcome variables across the four time points . The effects of time on headache features  and on subjective assessment scales (MIDAS and HURT) were measured using linear regression models. The effects of age, gender, disease duration and headache onset on dropout behavior were evaluated with a logistic regression analysis. The Kruskal-Wallis test was used to detect potential significant differences  at each time point between dropouts and non-dropouts. All statistical analyses were performed using the R software.n = 8), lack of consent (n = 36), incorrect contact details (n = 5) and failure to answer the phone call (n = 24). Thus, the total number of participants recruited and included in the analysis was 199: 172 women (86%) and 27 men (14%), with a mean age of 45 ± 12 years (62% were in the 40–60 years age range and 30% were aged 20–40 years).A total of 272 cards were collected by the pharmacies and sent to the headache specialist to be used for the telephone interview. Of these, 73 were excluded for the following reasons: participant too young  and low (37%) frequency of attacks. Moreover, on the basis of the phone interviews, 126 of the 199 patients experienced five or more days with headache per month (63%) and thus needed preventive therapy.p = 0.281; 10 ± 12 vs. 12 ± 16, p = 0.856, respectively).At the first face-to-face evaluation (T0) most of the patients reported that they used symptomatic drugs: on medical prescription (52%), as self-medication, i.e., over-the-counter drugs (34%) or both (14%), and 28% were already receiving preventive therapy. Moreover, 25% of the patients already presented overuse of symptomatic drugs . The headache frequency (days/month) and monthly symptomatic drug consumption declared during the telephone interview were generally confirmed at the first specialist assessment  and to diagnosis of the previously unspecified forms.The diagnoses made on the basis of the telephone interview and those formulated after the first face-to-face assessment differed significantly, particularly with regard to migraine without aura and cluster headache . Indeed,p < 0.001) and in headache days/month . Single attack duration was also already decreased at the first follow-up appointment , while pain intensity remained unchanged over time except for a small but significant reduction at T3 . Analysis with linear regression models confirmed a significant effect of time on the reduction of both headache load and related disability (p < 0.001).Over the 12 months follow-up, we observed a significant decrease in all the variables considered as primary outcomes of the study . In partp = 0.014) as well as an increased quality of life, as shown by a reduction in MIDAS scores , and better patient-rated quality of the received care, as assessed by HURT   . Unfortup = 0.006)  .In this study, we assessed the effect of expert headache management on headache attack severity and frequency and on symptomatic drug consumption in patients previously self-medicated or cared for by their general physician. Previous studies have investigated this issue, but in small populations and only in patients suffering from MOH; moreover, their participants were mainly enrolled among patients of general physicians or from headache centers , 19. ThiThe headache management provided by the specialists resulted in a significant improvement in the frequency, duration and severity of attacks, and hence in a lower disease burden for the patients. This observation is consistent with previous studies suggesting that targeted therapy and a multidisciplinary treatment guided by a specialist are effective in treatment-resistant patients , 19. In Among the 199 interviewed patients, 25% presented medication overuse, involving analgesics in 60% and triptans in 40% of cases, while 12% met the diagnostic criteria for MOH. In the general population, the prevalence of MOH ranges from 0.5 to 7.2% –35, whilReasons leading patients to abandon therapeutic follow-up are still poorly known. A study in patients with cluster headache identified prolonged clinical remission as a major determinant of dropout status . In our Specialist intervention resulted in a significant reduction of the impact of headache on daily quality of life  from as early as the first follow-up assessment. At the same time point, the participants felt the treatment to be more effective . This is consistent with the results of a previous study in European headache centers, which reported an increase in subjectively perceived effectiveness in 70% of patients followed by a specialist .In conclusion, the findings of this study suggest that headache management by a specialist is more effective than self-treatment, in particular in chronic headache or MOH patients, resulting in an overall benefit. This further supports the clinical utility of a network involving headache specialists, general physicians and trained pharmacists, which could detect individuals who might benefit from targeted multidisciplinary treatment provided by headache centers. From this point of view, the pharmacist may act as a first-line health provider in the community for individuals in need of specialist attention. Future studies should focus on potential differences of an interregional or intercultural  nature, and on differences between different countries.The datasets generated for this study are available on request to the corresponding author.This study was approved by the local ethics committee. All the participants gave their written informed consent to their participation in the study.Headache is a common pain condition, responsible for varying degrees of disability. Its chronic forms, in particular, are associated with high levels of healthcare demand and drug consumption. Moreover, high intake of symptomatic drugs may promote nociception facilitation mechanisms that lead to the development of MOH. In this scenario, self-medication is an important risk factor for overuse, especially among patients not previously evaluated by a physician. This study shows that management by specialists in headache centers is more effective than self-treatment, particularly in chronic or MOH patients, resulting in an overall benefit, both in terms of disability and the need for symptomatic drugs. Our findings support the clinical utility of a network involving headache specialists, general physicians and trained pharmacists, which could detect individuals who might benefit from targeted multidisciplinary treatment. In this scenario, the pharmacist may act as a first-line health provider in the community for individuals in need of specialist attention.FA: study concept and design. FA and ID: clinical consultant and data collection. MC: statistical analysis and interpretation of data. MC and FA: drafting of the manuscript. FA and AC: critical revision 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.


To evaluate the translations, cross-cultural adaptation procedures and measurement properties of the Western Ontario Rotator Cuff Index (WORC), when it is adapted for different cultures.A systematic review was performed, considering different cultural adaptions of the WORC accessible through MEDLINE, CINAHL, EMBASE and/or Google Scholar. Included were prospective cohort studies that used an adapted version of the WORC to measure QoL in patients with rotator cuff disorders. All studies were evaluated according to the current guidelines for cross-cultural adaptations and measurement properties.The search retrieved 14 studies that met the inclusion criteria. According to the recommended guidelines for cross-cultural adaptations, 8 studies performed 100% of the steps, 2 studies performed 80% of the steps and 4 studies used previously translated measures. When evaluating the studies’ psychometric properties based on the quality criteria, none of the studies reported all recommended measurement properties. All of the studies reported the measurement property of reliability, but none of the studies reported agreement. Internal consistency was fully reported by 15% of studies. Construct validity was reported by 43% of studies. Only one study reported 100% of the cross-cultural adaption guidelines and 83% of the quality criteria.Although the majority of studies demonstrated proper adaptation procedures, testing of the measurement properties were inadequate. It is recommended that the current adapted versions of the WORC undergo further testing before use in clinical practise, and researchers continue to adapt the WORC for different cultures as it proves to be an appropriate instrument for assessing rotator cuff pathology. Shoulder pain is one of the most commonly reported musculoskeletal problems that result in the restriction of work and/or social activities –3. RotatMeasuring QoL can help to determine prognosis and evaluate treatment outcomes in patients with RCDs –4. In orWhile there are a variety of PROs for evaluating and detecting changes in a patient’s clinical condition over time, most were developed in English –8. Due tFor an adapted measure to be applied to the intended population, careful attention to word change and question structure is required –8. The cAlthough the WORC has strong psychometric properties , 2, 13 iWe conducted a systematic review of studies that addressed the translation process and psychometric testing of the WORC in different cultures. The systematic searches were performed in the following key electronic databases: MEDLINE (Ovid), EMBASE, EBSCO- Host (CINAHL), and Google Scholar. Search terms and Boolean operators (AND or OR) used were: Western Ontario Rotator Cuff Index AND validation OR translation OR cross-cultural adaption AND different languages . This search strategy and electronic databases are frequently reported in other systematic reviews. The searches were not limited by publication date. The final search was April 12th, 2019, and registered on PROSPERO. (No.CRD42018100201) A flow diagram of the search strategies are provided in Fig. Studies were considered eligible for inclusion if they assessed a cross-cultural adaption of the WORC and its measurement properties in a specific language. Studies must be published as a full manuscript in a peer – reviewed journal. Thesis and dissertations, books and abstracts from conferences were excluded. There were no language restrictions.Guidelines for the process of Cross-Cultural Adaption of Self-report Measures [. These cross-cultural adaption guidelines state an accurate translation must include an initial translation, synthesis of translations, back-translations, reviews by the expert committee and the pre-test version of the instrument. We also extracted data relating to the measurement properties of each study. These measurement properties were evaluated according to the Quality Criteria for Measurement Properties of Health Status Questionnaires [Demographics of each study were extracted to include information on patient age, sex, and pathology. Data regarding the translation and cross-cultural adaptations were extracted to assess each design. The translation methods for each study were classified according to the Measures . These connaires . This quonnaires . Shouldeonnaires –8. See AData extraction and ratings were performed by the first author (R.F.) and then reviewed by an independent reviewer (G.N.). Any disagreements between the rater and independent reviewer were discussed to reach a consensus. Any disagreements in data extraction and ratings were discussed with the third and senior author (J.M.) to reach a consensus.In this study, the limitations lie within the inclusion criteria, as this review was limited to the use of peer-reviewed journal articles only. Keeping consistent with other published systematic review protocols –8, this From the search strategies, 113 studies were retrieved but only 14 met eligibility criteria. The 14 versions represent 11 different languages/cultures; Chinese , Dutch –18, Frenn = 30) had more than 50 patients. Patients were treated for a partial or a full rotator cuff tear, tendinopathy, impingement syndrome or calcific tendonitis.Table Guidelines for the Process of Cross-Cultural Adaptions of Self-Report measures [Table measures . From thmeasures , 25, 27.measures , 25, 27.measures , 25, 27.measures  study pemeasures , 25, 27.measures , 25, 27.measures  study pemeasures , Polish measures , Portugumeasures  and Swedmeasures  studies measures  were usemeasures , 15–26 .measures .Table 2Quality Criteria for Measurement Properties of Health Status Questionnaire [Table ionnaire  for eachionnaire , 24–27. ionnaire , 26, 27 ionnaire –23, 25 dionnaire , 25 follionnaire  was ableionnaire , 22, 26 ionnaire , 22, 25 ionnaire , Polish ionnaire , Swedishionnaire  and Frenionnaire  studies ionnaire  followedThis systematic review evaluated the cross-cultural adaption procedures and measurement properties reported in 14 adapted versions of the WORC , 15–27. . While the co-existence of calcific tendonitis with rotator cuff tear is not uncommon, calcific tendonitis is a non-degenerative condition that does not result in the tendon becoming torn or pathologic [The primary outcome of the WORC is to evaluate disability related to RCDs and its effects on health-related quality of life . Therefothologic , 31. Sinthologic .One issue that made the ratings less certain, was the lack of detail provided for the cross-cultural adaption processes used in the individual studies. Five studies , 24, 26 The back-translation step is often overlooked, but is critical according to the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ‘s guidelines . CurrentReliability was evaluated in all studies and performed correctly according to the quality criteria. All studies in this review reported an Interclass Correlation Coefficient (ICC) value of over 0.70, which the quality criteria rates as excellent . HoweverAgreement is another important measurement property that further evaluates the degree of which repeated measures applied to patients provide similar answers. It is easier to clinically interpret than the property of reliability, and provides the absolute error of measurement . In thisAccording to the quality criteria, responsiveness is a measure of longitudinal validity, and should be able to distinguish clinically important change from measurement error . ResponsCeiling and floor effects are another important measurement property according to the quality criteria . CeilingConstruct validity was performed according to quality criteria in only a few studies , 20, 25.This review demonstrates that there were many inconsistencies with some of the reported measurement properties in the various adaptions of the WORC. In the systematic review of the cross-cultural adaption and measurement properties of the McGill Pain Questionnaire , it was Based on the findings from this review, the French-Canadian study  had perfFinally, this review demonstrated that while the WORC is a favourable tool for measuring QoL for rotator cuff disorders, there are other disease specific instruments such as the Rotator Cuff Quality of Life Index (RC-QOL). However, these two instruments differ by the items they are trying to evaluate. The RC-QOL focuses on more physically demanding activities such as mopping the floor, carrying 10lbs etc. unlike the WORC . FurtherThe WORC was able to be successfully translated for different cultures, however, the evaluation of the measurement properties was not sufficient. Therefore, further validation of the adapted versions of the WORC is required before routine use in clinical practice. This review has shown that by continuing to adapt the WORC, more cultures will be able to benefit from this PRO.Additional file 1: Figure S1. Scoring system for the cross-cultural adaptions.


Treatment duration had a positive relationship with school functioning, r(60) = 0.28, p < 0.05. All other correlations were statistically non-significant. The effects of the available psychosocial variables of gender, ethnicity, and religion were examined on scores from the Pediatric Quality of Life Inventory (PedsQL). Ethnicity had a significant effect on social functioning, U = 292.00, p < 0.05, r = 0.3 (medium effect size). Specifically, Chinese  had significantly higher scores on social functioning than others . The remaining comparisons were statistically non-significant. The current findings added to QoL research, and provided an impetus for more research in the area of HRQoL for children with leukemia in Singapore.There has been a paradigm shift in health service delivery to a more holistic approach, which considers Quality of Life (QoL) and overall functioning. Health-Related Quality of Life (HRQoL) is a multidimensional construct that encompasses physical functioning as well as psychosocial aspects of emotional and social functioning. This study explored factors related to HRQoL in Asian pediatric patients with leukemia in Singapore. The available variables included: age, treatment duration, household income, gender, ethnicity, religion, diagnosis, and phase of treatment. It is hypothesized that the relationships will be significant. In the current study, there were 60 patients  with leukemia; their ages ranged from 1 to 21 years . The hypothesis was partially supported. Age had a significant positive relationship with physical functioning,  Health services are increasingly embracing holistic approaches to healthcare delivery, which consider Quality of Life (QoL) and overall functioning . Due to Review of relevant research suggested that children undergoing cancer treatment may experience reduced QoL, in the initial period after cancer diagnosis, prior to improving progressively, and again after the first year of treatment . DeterioConclusions concerning QoL drawn from prior studies conducted in the West are not easily generalizable to Asian populations due to the culturally sensitive nature of the construct of QOL . StudiesHowever, it remains unclear about the generalizability of the results to the local sample of children in Singapore with leukemia, regarding the specific contribution of demographic variables and treatment-related factors to HRQoL This research question is relevant and useful to healthcare clinicians working with the recovery paradigm in health service delivery, to assist in service planning for optimal holistic health outcomes in local children with leukemia. Pertinent research in the local population could inform greater capacity in clinicians to recognize demographic and treatment-related variables associated with deterioration of QoL, and to tailor early interventions accordingly, so as to minimize the impact on children’s QoL and their overall functioning.Recent local research on adults suggested that various demographic factors, e.g., education level contributed to QoL in adult patients with chronic illness ,15. ReceThis study aims to address the current gap in local literature by examining the available variables namely treatment-related variables and demographic characteristics such as ethnicity , age 1010,15,24,Ethics approval was obtained from the Domains-Specific Review Board of a large teaching hospital in Singapore (IRB protocol#: DSRB 2013/01150). A sample of 60 pediatric patients diagnosed with leukemia were recruited at outpatient clinics, day therapy programs, and pediatric oncology wards at a large teaching hospital in Singapore from January to May 2010. Although the public hospital is geographically located in the west, the hospital receives referrals for delivery of a specialist multidisciplinary service for pediatric patients with leukemia from all regions in Singapore. Convenience sampling was employed for the cross-sectional pilot study. Eligibility criteria for the study included the following: (a) pediatric patients between 1 to 21 years of age diagnosed with leukemia , (b) able to understand English and/or Mandarin, and (c) absence of co-morbidities. Exclusion criteria included (a) having other co-morbidities and (b) the absence of a parent/caregiver.The patients’ subjective Health-Related Quality of Life (HRQoL) was investigated with the use of an adapted pictorial version of the Pediatric Quality of Life Inventory (PedsQL) 4.0 [Clinical staff conducted the recruitment. After parental consent and participants’ assent was obtained, the questionnaires were then administered via an iPad. After completion of the questionnaires, participants and parents/caregivers were thanked for their participation.In the current study, there were 60 patients  diagnosed with leukemia. Their ages ranged from 1 to 21 years (Mean (M) = 8.03, Standard Deviation (SD) = 4.55). The demographics and characteristics of the participants are presented in The survey included items on demographic background and the following questionnaire. The questionnaire was adapted into a pictorial format, with reference to PedsQL 4.0 [The PedsQL 4.0 , with weThe data were analyzed using SPSS Version 25  with the alpha level set at 0.05. The description of the HRQoL scores on the Pediatric Quality of Life Inventory (PedsQL) for the sample of 60 children is presented in r(60) = 0.28, p < 0.05, Physical Health, r(60) = 0.28, p < 0.05, and the Total Scale Score on the PedsQL, r(60) = 0.29, p < 0.05. Treatment duration had a positive relationship with School Functioning, r(60) = 0.28, p < 0.05. All other correlations were statistically non-significant. A series of Pearson product-moment correlation coefficient was conducted to explore the bivariate relationships between age, treatment duration, monthly household income, and scores from the PedsQL. Age had a significant positive relationship with Physical Functioning, p < 0.05, r = 0.3 (medium effect size). Specifically, Chinese  had significantly higher scores on Social Functioning than Others . The remaining comparisons were statistically non-significant. A series of two Kruskal-Wallis Tests was conducted to examine the effects of Diagnosis (B-Cell ALL versus T-Cell ALL versus AML/MPAL) and Treatment Phase (Maintenance versus Completed Treatment versus Induction versus Others) on PedsQL scores. All comparisons were statistically non-significant. The Mann-Whitney U Tests and the Kruskal-Wallis Tests are presented in A series of three Mann-Whitney U Tests were conducted to examine the effects of the available psychosocial variables of Gender , Ethnicity (Chinese versus Others), and Religion (Yes versus No) on scores from the PedsQL. Ethnicity had a significant effect on Social Functioning, U = 292.00, This study explored factors related to HRQoL in Asian pediatric patients with leukemia in Singapore. The available demographic and treatment-related variables included: age, treatment duration, household income, gender, ethnicity, religion, diagnosis, and phase of treatment. It is hypothesized that the relationships would be significant. The hypothesis was partially supported. Age had a significant positive relationship with physical functioning, physical health, and the total HRQoL score. Treatment duration had a positive relationship with school functioning. Ethnicity had a significant effect on social functioning; specifically, Chinese had significantly higher scores on social functioning than others. The comparisons were statistically non-significant for all other variables. However, the results should be interpreted with caution. Given the exploratory nature of the study, the Type I error was not controlled for using the Bonferroni adjustment. Once controlled, the results could be non-significant.The finding that the effects of diagnosis and treatment phase on HRQoL scores were not significant was contrary to another study done in Japan  for chilThe results show that age had a significant positive relationship with physical functioning and physical health, and the total HRQoL score was consistent with a recent study  that fouIn view of the importance of educational attainment and academic performance in Asian contexts , there hThe finding that ethnicity had a significant effect on social functioning is consistent with local large-scale research underscoring the strengths and vulnerabilities of Singapore’s diverse ethnic cultures . The finSome limitations of the present study need to be considered. These include the lack of an adequate control condition, preventing any comparisons from being done. Hence, future studies should aim to match clinical data with data collected from healthy populations to provide a more holistic interpretation of potential variables influencing QoL. Given the cross-sectional design of the study, causality was unable to be demonstrated; future research should consider a longitudinal design to understand how QoL changes in relation to various variables over time. Furthermore, the questionnaire used in the pilot study was a pictorial version adapted with reference to PedsQL 4.0 [In addition, a review of relevant research suggested that children undergoing cancer treatment might experience reduced autonomy, poor psychological status, and depression, especially during the initial 3 to 6 months after cancer diagnosis which could result in reduced HRQoL . A wide This pilot study explored factors related to HRQoL in Asian pediatric patients with leukemia in Singapore. Results indicated that age had a significant positive relationship with physical functioning, physical health, and the overall HRQoL of pediatric patients with leukemia. Treatment duration had a positive relationship with school functioning. Ethnicity had a significant effect on social functioning; specifically, Chinese had significantly higher scores on social functioning than others. The comparisons were statistically non-significant for all other variables. The current findings were interpreted in the context of other studies in the area. The outcomes from the pilot study added to QoL research, and provided an impetus for more research in the area of HRQoL, with local pediatric patients with severe and chronic disorders, namely, leukemia.


Background and Objectives: The growing burden and deleterious health consequences of allergic diseases, especially of allergic rhinitis (AR) and atopic dermatitis (AD), in developed countries remains an important public health issue. The current study aimed to assess the prevalence and to identify the risk factors of atopic dermatitis and allergic rhinitis among residents of Pohang-Si and Yeongdeok-Gun, two municipal areas in South Korea. Materials and Methods: A cross-sectional study was conducted in both municipal areas between 12 November and 13 December 2017. A total of 302 subjects were recruited from 100 households , by system extraction according to district code numbers. Data were collected using International Study of Asthma and Allergies in Childhood (ISAAC) Standard Questionnaires for children and a health questionnaire for adults. Risk factors were identified by multivariate logistic regression analysis. Results: Of the 302 study participants, 12.9% and 25.5% had AD and AR, respectively. The significant factors associated with AD by multivariate logistic regression analysis were age ≥19 years (aOR (adjusted odds ratio) 6.9; 95% CI  (2.9–16.37)), residence in Pohang-Si ), and family history of allergic disease ). Similarly, the significant factors associated with AR were male gender ), age ≥19 years ), residence in Pohang-Si ), and family history of allergic disease ). Conclusion: The present study shows that age ≥19 years, residence in Pohang-Si, and family history of allergic disease are risk factors for AD and AR, and that, additionally, male gender is a risk factor of AR. Understanding the risk factors of allergic diseases can aid the design and implementation of evidence-specific strategies to reduce the long-standing problems associated with allergic disease. Allergic diseases represent growing health and economic burdens worldwide ,2, and hAir pollution, climate change, and global warming are factors that underlie the increasing prevalence of allergic diseases, and the higher level of air pollution in developed countries has also been reported to be positively associated with allergic diseases ,14. AccoThis cross-sectional study was conducted in Pohang-Si and Yeongdeok-Gun between 12 November and 13 December 2017. To adjust for the effect sizes of residential area and housing type on allergic disease, we selected Pohang-Si  as a representative urban area, and Yeongdeok-Gun  as a representative rural area. To address housing type, one apartment area and one housing area were arbitrarily selected in each area. Fifty households (25 apartments and 25 houses) were selected in each area by system extraction using district code numbers. Surveyed households were individually visited and information on the residents was obtained using questionnaires. We aimed to enroll at least one participant below 19 years of age and one above 19 years of age from the selected households. All eligible participants were recruited when more than two participants were found in a household. Study participants who had experienced respiratory infection within the months preceding the study or had a history of smoking were excluded from the study.For data collection, we adapted a questionnaire from the Korean version of the International Study of Asthma and Allergies in Childhood (ISAAC) Standard Questionnaire for children, and we designed a self-developed questionnaire for adults in consultation with experts such as medical doctors specializing in allergies and clinical immunology and an epidemiologist. We also adopted information for a questionnaire for adults based on a previously published paper from a South Korean study that made use of questions similar to the ISAAC Standard Questionnaires . Survey The main outcome variables were the presence of atopic dermatitis and allergic rhinitis, which was determined by the responses to standardized parent- and self-reported questions, and the doctor’s diagnosed evidence. Furthermore, a study participant was considered to have had AR as defined by having a runny, itchy or stuffed nose without a cold in the last 12 months, and AD as defined by having an itchy rash that persisted for at least 6 months and was located in the antecubital or popliteal fossae, wrists, ankles, neck or face during the last 12 months . Gender,We assert that ethical issues such as data fabrication, data falsification, and double publication were properly addressed. Since this study falls within the rules and regulations of the Korean Bioethics and Safety Act ) set by the Ministry of Health and Welfare of South Korea, additional approval from an institutional review board or ethical committee is not necessary. All study subjects provided informed consent before study recruitment, and all personal identifiers were removed prior to data analysis.p value < 0.1) were entered into the multivariate analysis. Odds ratios (ORs) are reported with 95% confidence intervals (CIs), and statistical significance was accepted for p values < 0.05. Questionnaire responses were coded and entered into Excel. Statistical analysis was performed using SPSS for Windows . Univariate analysis was performed using the chi-square test to subject general characteristics and environmental factors as independent variables. Categorical variables with significant differences in the experience of allergic disease diagnoses ) to have atopic dermatitis than those aged <19 years. Those residing in Pohang-Si were 2.5 times more likely ) to have atopic dermatitis than those residing in Yeongdeok-Gun. Likewise, study participants with a family history of allergic disease were 2.3 times more likely ) to have atopic dermatitis. On the other hand, males were 2.3 times more likely ) to have allergic rhinitis than females, those aged ≥19 years were 4.4 times more likely ) to have allergic rhinitis than those aged <19 years, those living in Pohang-Si were 2.8 times more likely ) to have allergic rhinitis than those living in Yeongdeok-Gun, and those with a family history of allergic disease were 6.7 times more likely ) to have allergic rhinitis than their counterparts.This study revealed that of the 302 study subjects, 12.9 % and 25.5% had AD and AR, respectively. Of the 132 subjects from Pohang-Si, 20.5% and 38.6% had AD and AR, respectively, while only 7.1% and 15.3% of the 170 subjects from Yeongdeok-Gun had AD and AR. In addition, subjects aged ≥19 years, those residing in Pohang-Si, and those with a family history of allergic disease had higher odds ratios of AD and AR, while male gender had a higher odds ratio of AR.Two previous nationwide studies conducted in South Korea reported AR prevalence of 27% and 17.2 % ,17, whicViews differ regarding whether age is a risk factor of allergic diseases ,27. One A number of studies have demonstrated an association between family history of allergic disease and the occurrence of atopic diseases in offspring ,28,29,30Despite our efforts, the study has some limitations that require consideration. Firstly, we reported the prevalence and associated risk factors of only two allergic diseases as determined by subject self-reporting and we lacked information about non-allergic diseases. Furthermore, the method used did not rule out the co-existence of AR, AD, and other allergic diseases, and did not provide information on the types of allergens. Secondly, a relatively small number of subjects were enrolled, and thus, the generalizability of our findings should be considered with caution. Nevertheless, we believe that our findings add to current knowledge and aid the design of customized preventive strategies, such as the creation of general awareness about allergic diseases with an intensive focus on risk groups.This study showed that age of ≥19 years, residence in Pohang-Si, family history of allergic disease, and male gender were found to be factors significantly associated with AD and AR, and in addition, male gender was found to be significantly associated with AR. Understanding the risk factors of allergic diseases aids the design and implementation of evidence-based strategies aimed at reducing the long-standing problem of allergic disease. Further studies are required to identify the common urban allergens and other risk factors responsible for atopic dermatitis and allergic rhinitis.


Background and Objectives: The mean platelet volume (MPV) represents a possible marker of platelet activation. There is an association between the platelet count (PC) and inflammation and platelet reactivity. We assessed the association between the MPV/PC ratio and circadian alterations in blood pressure (BP). Material and Methods: One hundred and twenty subjects in total, 80 hypertensive subjects and 40 healthy subjects (controls), were enrolled in the study group. Twenty four hour ambulatory BP monitoring (ABPM) was applied to all subjects. According to ABPM results, the hypertensive subjects were separated into two groups, such as dippers (n = 40) and non-dippers (n = 40). In all subjects, the collection of venous peripheral blood samples was performed on admission for PC and MPV measurements. Results: The two groups exhibited similar clinical baseline characteristics. A significantly higher MPV/PC ratio was determined in non-dippers compared to that in dippers and normotensives. The higher MPV/PC ratio was observed in non-dippers in comparison with that in dippers and normotensives . A receiver operating characteristic (ROC) curve analysis showed that the optimum cut-off value of the MPV/PC ratio for predicting non-dipping patterns in hypertensive patients was 0.036 . According to the cut-off value, sensitivity and specificity were found to be 95% and 95%, respectively. Conclusions: The higher MPV/PC ratio was determined in non-dipper hypertensive subjects in comparison with that in dipper hypertensive subjects. An elevation of platelet activity and an increase in thrombus burden are reflected by an increase in the MPV/PC ratio. The MPV/PC ratio may underlie the increase in cardiovascular risk in non-dippers compared to that in dippers. Blood pressure (BP) and heart rate undergo circadian changes during the day. It is possible to utilize ambulatory blood pressure monitoring (ABPM) for detecting circadian rhythms of BP parameters correlated with an adverse cardiovascular prognosis. Among healthy individuals, a nighttime decrease of 10–20% in daytime BP is defined as “dipper,” whereas a decrease of <10% is defined as “non-dipper” . In prosThe mean platelet volume (MPV) represents a possible marker of platelet activation, and an elevated MPV is related to an increase in cardiovascular mortality in subjects with acute coronary syndrome . In prevThe MPV/PC ratio represents a novel marker for cardiovascular risk. Azab et al.  indicateIn this research, it was aimed to assess the relationship between the MPV/PC ratio and circadian changes in BP.n = 17, mean age of 51.6 ± 15 years), were included in the study group. Twenty four hour ABPM was applied to all patients. In accordance with the findings of ABPM, the hypertensive subjects were separated into two groups as 40 dippers  and 40 non-dippers . ABPM results confirmed that the control group patients were normotensive, with dipper profiles.One hundred and twenty subjects in total, 80 hypertensive subjects and 40 healthy controls  ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg and/or usage of antihypertensive drug therapy . After hThe criteria for exclusion from the study were as follows: secondary hypertension, cardiac failure, renal or hepatic dysfunction, systemic inflammatory diseases, infectious diseases, stroke, valvular diseases, arrhythmias, drug use that may influence platelet number and function hematological abnormalities, coronary artery diseases and diabetes mellitus.Clinical BP measurements were performed in the morning by a mercury sphingomanometer, and the average of three measurements was utilized. Prior to the measurements, the individual rested for a minimum of 5 min. Each individual was instructed not to drink tea or coffee for 1 h prior to the test and not to smoke for 30 min prior to the test. During BP measurements, the arm of the patient was supported at heart level, and BP measurement was performed in a sitting position. The measurements were performed on both arms, and the highest value was recorded ,17.2).Clinical and demographic features, such as sex, age, smoking habits, and the use of antihypertensive drugs, were recorded. Recording of fasting blood glucose levels, creatinine levels, and fasting serum lipid status, such as total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglyceride levels, was also performed. Calculation of the body mass index (BMI) was performed using the following formula: weight (kg) divided by height squared , and written informed consent was acquired from all the subjects included in the study.A Tracker NIBP2  oscillometric monitoring device was used for conducting ABPM. Using this device, daytime BP was measured and recorded for 24 h at intervals of 15 min. The measurement of nighttime BP was performed every 30 min at night. The cuff of the ABPM device was placed on the nondominant arm in case the BP difference between the two arms was less than 10 mmHg in the clinical BP measurement and on the arm of the highest measurement in case the difference was higher than 10 mmHg. Care was taken to ensure that the difference between the clinical BP measured at the office and the value measured by the device was not higher than 5 mmHg . The recn = 4). Patients were asked to keep a diary of occupational activities, sleep, and awake time, as well as the time of meals : 0.98, A significant difference was found in the usage of antihypertensive drugs among dipper and non-dipper patients. No drug use was recorded among normotensives .Endothelial damage and dysfunction, insulin resistance, inflammatory and platelet activation, and coagulation abnormalities contribute to the pathophysiology of hypertension, resulting in an increase in the risk of a prothrombotic state ,19. It iBP measurement is the most significant step in the diagnosis and treatment of hypertension. The BP values obtained in the office reflect only the measurements at that moment in time and do not provide information on 24 h BP. BP exhibits diurnal changes. Due to decreased sympathetic activity during nocturnal sleep and increased vagal tone, BP decreases significantly and increases rapidly upon morning waking. The definitions of “dipper” and “non-dipper” are based on the prognostic importance of decreased BP at night ,4,5,6. PSome previous studies revealed an association between MPV and hypertension in various groups of patients. Nadar et al.  revealedThe MPV represents a marker of platelet size and activation, and an increase in its level indicates activation of large platelets ,22,23,24A number of previous studies revealed a relationship between increased MPV and increased cardiovascular events ,27,28. APrevious research reported chronic rather than acute alterations in the MPV, suggesting that these alterations were associated with chronic diseases, such as hypertension . Some stIt was shown that non-dipper hypertensive patients are more susceptible to develop vascular damage in comparison with dippers . The nonAzab et al.  indicatePrevious studies indicated that the MPV and PC were inversely related in healthy populations ,14,15. TNumerous studies have reported that non-dippers are of a higher risk group for atherosclerotic events and for high incidence of target organ damage in comparison with dippers ,4,5,6,7.The higher MPV/PC ratio was found in non-dipper hypertensive subjects in comparison with that in dipper hypertensive subjects. An increase in the MPV/PC ratio indicates an elevation of platelet activity and an increase in thrombus burden. The MPV/PC ratio may underlie the increased cardiovascular risk in non-dippers compared to that in dippers.


The prevalence of abdominal obesity is increasing worldwide. Adults with abdominal obesity have been reported to have increased risk of cardiometabolic disorders.2) with abdominal obesity examined in the framework of the Swiss–Hungarian Cooperation Programme had increased metabolic risk compared to participants without abdominal obesity.The aim of this study was to examine whether non-obese subjects (body mass index (BMI) < 25 kg/mA cross-sectional study was carried out in 5228 non-obese individuals. Data were collected between July 2012 and February 2016. Descriptive statistics, Pearson’s correlation analysis and multiple logistic regression models were applied, odds ratios (OR) with 95% confidence interval (CI) being the outcomes.607 (11.6%) out of the 5228 non-obese individuals had abdominal obesity. The correlation analysis indicated that the correlation coefficients between BMI and waist circumference (WC) were 0.610 in males and 0.526 in females. In this subgroup, the prevalence of high systolic blood pressure, high fasting blood glucose, and high total cholesterol and triglyceride levels were significantly higher. The logistic regression model based on these data showed significantly higher risk for developing high systolic blood pressure , low HDL cholesterol , and high trygliceride level .There was a very high, significant, positive correlation between WC and BMI. Abdominal obesity was found to be strongly related to certain metabolic risk factors among non-obese subjects. Hence, measuring waist circumference could be recommended as a simple and efficient tool for screening abdominal obesity and related metabolic risk even in non-obese individuals. Obesity is one of the major public health concerns of our era: its prevalence has increased significantly in the past decades both globally , 2 and iIn Hungary, many people live with a high risk of metabolic syndrome, which promotes the development of atherosclerotic vascular diseases and type 2 diabetes mellitus (T2DM) , mainly Body mass index (BMI) is widely used to monitor the prevalence of obesity because the risk of coronary heart disease, ischemic stroke, and T2DM rises in parallel with the increase in the BMI . UnfortuNonetheless, several reports suggest that the measurement of waist circumference (WC) can compensate the above described limitation of BMI since WC is more closely related to visceral fat content, and thus to metabolic risks. Previous research shows that on the one hand, normal weight individuals with abdominal obesity can have metabolic risk factors, and therefore being candidates for having elevated risk for metabolic syndrome  or cardiThere is, however, limited information about the usefulness of WC measurement in identifying cardiometabolic risk factors in a large study sample. Therefore, in our study, we aimed to examine whether non-obese subjects with no chronic conditions but abdominal obesity had a higher chance of having related metabolic risk factors, such as elevated blood pressure, high fasting blood glucose, high cholesterol, high low-density lipoprotein (LDL), low high-density lipoprotein (HDL), and high triglyceride levels, compared to persons with no abdominal obesity.The programme, named ‘Public Health Focused Model Programme for Organising Primary Care Services Backed by a Virtual Care Service Centre’ (the Programme), has been an innovative health promotion and public health project, launched in July 2012 in Hungary in Swiss–Hungarian cooperation. The aim of the Programme was to provide efficient preventive services, contributing thereby to the improvement of the general health status of the population, and the reduction of social health inequality . An elem2) scores, 7292 subjects were excluded. The final sample was formed by 5228 non-obese individuals, who were divided into two groups according to the WC. The two groups were formed based on the definition and thresholds – WC >102 cm in men and WC >88 cm in women – of Adult Treatment Panel III (ATP III), which presents the National Cholesterol Education Program’s (NCEP’s) updated recommendations for cholesterol testing and management [It was a cross-sectional study conducted in adult persons taking part in the Programme, living in the two vulnerable regions of Hungary (located in the North Eastern part of the country). The target population comprised 32 655 adults, and the health data of 20 441 successfully recruited adult persons were recorded between July 2012 and February 2016. First, subjects who had hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease (COPD), and/or cancer were excluded. Then, further subjects were excluded because of the lack of their BMI and/or WC data, the characteristics of these 12520 Hungarian adult subjects are shown in Additional Table nagement . There wThe HSA involved a health interview, physical examination , and laboratory tests. The data collected and the questions applied in the HSA are shown in Additional file Based on the definition of metabolic syndrome , laboratsquare of the body height, and expressed in units of kg/m2. Subjects with a BMI <25 kg/m2 were classified as non-obese, whereas those with BMI ≥25 kg/m2 were classified as obese according to the WHO definitions [The public health professionals followed the WHO STEPS (STEPwise approach to surveillance) protocol to measure the WC, that is, the measurement is made at the approximate midpoint between the lowest rib and the iliac crest . BMI wasinitions .high blood pressure, was applied [Blood pressure was measured by electronic blood pressure monitor after a five-minute rest. The classification of the American Heart Association, systolic blood pressure ≥140 mmHg regarded as  applied .A chi-square test was performed to show the basic characteristics of the two groups. Pearson’s correlation analysis was carried out to analyze the correlation between BMI and WC. A multiple logistic regression model was used to define the association between the metabolic risk factors and abdominal obesity with adjustments for age and gender. Metabolic risk factors were used as dependent variables, and abdominal obesity was defined as an independent variable. Odds ratios (OR) and 95% confidence intervals (CI) are presented for high systolic blood pressure, high fasting blood glucose, high total cholesterol, low HDL cholesterol, high LDL cholesterol, and high triglyceride levels. A p-value lower than 0.05 was considered statistically significant. Statistical analysis was performed by using the SPSS 24.0 software.The final sample involved 5228 non-obese subjects. Out of them, 607 subjects (11.6%) had abdominal obesity (HWC group), and there were 4621 subjects (88.4%) with no abdominal obesity (NWC group) . The Pearson’s correlation coefficients between WC and BMI were 0.610 in males and 0.526 in females.According to the results of the multiple logistic regression models, older people had significantly higher odds for developing most of the metabolic risk factors. Subjects in the age group of 30–44 years were significantly more likely to have high systolic blood pressure, high fasting blood glucose, high total cholesterol, and high LDL cholesterol levels compared to the 18–29 year age group  among non-obese subjects. Our study also presented a very high, positive correlation between BMI and WC, which is consistent with other studies , 24.Subjects with abdominal obesity were proved to have significantly higher prevalence of high systolic blood pressure, high fasting blood glucose, high total cholesterol, and high triglyceride levels than subjects in the NWC group.The risk for having high systolic blood pressure, high fasting blood glucose, high total cholesterol, and high LDL cholesterol levels was age-dependent, these levels were significantly higher in the age group of 30–44 years, and the risk was also significant in the older age groups. In case of high triglyceride level, an increased risk was found in the age groups 45–59 and 60–74 years. In general, as individuals grow older, the body fat content increases, especially in the abdominal region, which may be the cause of the elevated metabolic risk . TherefoOur results are in line with the findings of other researchers , 27. In It is well-known that obesity is strongly related to metabolic, CV, and other diseases . The heaIt is very important to measure body weight, height, and WC in a professional and reliable way, for example, during health examinations, as in self-reported health interviews, the subjects tend to underestimate their weight and/or overestimate body height .Obviously, there are differences in the recommendations regarding the screening of obesity in the world. The Obesity Society Guidelines (2013) for Managing Overweight and Obesity in Adults do not recommend measuring the WC . The U.SThe logistic regression model also showed that the risk for elevated LDL cholesterol level was lower in patients with abdominal obesity. This is consistent with a study  in whichUsing the BMI alone to identify metabolic risks, several patients with increased risk but normal BMI would be missed. To measure WC is particularly important above 30 years of age and in males, irrespective of their BMI.The strengths of our study were the large sample size, the measurement of WC by trained health personnel, and the interpretation of the results of a new, innovative model programme in terms of screening in primary care in Hungary.Our limitations involve that the study was not representative (selection bias), and we could not determine cause-and-effect relationships due to the cross-sectional type of this study.Finally, not all laboratory parameters were available for each subject. In this analysis, we applied the definition of ATP III to classify the patient as having abdominal obesity  thresholds). As we did not have information on which patients had cholesterol lowering therapy, we could not exclude them from the present analysis, although this therapy might modify the measured LDL cholesterol levels and model calculations based on them.Our results suggest that screening of abdominal obesity by applying a simple, professionally performed measurement of WC might be a suitable predictor of metabolic syndrome, potentially more practical than, e.g., BMI.The prevention of metabolic syndrome and the possible outcomes, such as CVDs and diabetes, would be especially beneficial in the Hungarian population, where CVDs are the leading causes of death, and the morbidity of T2DM is continuously increasing.Additional file 1: Table S1. Characteristics of 12,520 Hungarian adult subjects – the data of who were recorded in the framework of the Swiss–Hungarian Cooperation Programme (2012–2016).Additional file 2. The data collected and the questions applied in the HSA.


Proviisori act as pharmacy owners and managers. They follow a five-year (M.Sc. Pharm.) degree course with a six-month traineeship. Farmaseutti, who follow a three-year (B.Sc. Pharm.) degree course , can dispense medicines and counsel patients in Finland. The B.Sc. and the first three years of the M.Sc. involve the same course. The current pharmacy curriculum (revised in 2014) is based on five strands: (1) pharmacy as a multidisciplinary science with numerous opportunities in the working life, (2) basics of pharmaceutical sciences, (3) patient and medication, (4) optional studies and selected study paths, and (5) drug development and use. The learning outcomes of the pharmacy graduates include (1) basics of natural sciences: chemistry, physics, technology, biosciences required for all the students (B.Sc. and M.Sc.), (2) medicine and medication: compounding of medicines, holism of medication, pharmacology and biopharmaceutics (side-effects and interactions), patient counseling, efficacy and safety of medicines and medication, (3) comprehensive and supportive interactions of the various disciplines of pharmacy education and research: the role and significance of pharmacy as a discipline in society, the necessary skills and knowledge in scientific thinking and pharmaceutical research, and (4) basics of economics and management, multidisciplinarity, hospital pharmacy, scientific writing skills, management skills. In addition, teaching and learning of “general skills”, such as the pharmacist’s professional identity and the role in society as a part of the healthcare system, critical and creative thinking, problem-solving skills, personal learning skills and life-long learning, attitude and sense of responsibility, and communication skills are developed in direct association with subject-specific courses. Professional specialization studies in industrial pharmacy, and community and hospital pharmacy are given at the post-graduate level at the University of Helsinki.The Pharmacy Education in Europe (PHARMINE) project studies pharmacy practice and education in the European Union (EU) member states. The work was carried out using an electronic survey sent to chosen pharmacy representatives. The surveys of the individual member states are now being published as reference documents for students and staff interested in research on pharmacy education in the EU, and in mobility. This paper presents the results of the PHARMINE survey on pharmacy practice and education in Finland. Pharmacies have a monopoly on the dispensation of medicines. They can also provide diagnostic services.  The Pharmacy Education in Europe (PHARMINE) consortium surveyed pharmacy practice and education in the member states of the European Union (EU), including Finland, between 2008 and 2011, with an update in November 2018. The methodology used in the PHARMINE study and the main results obtained were already published [PHARMINE went on to study the legal and administrative context of pharmacy practice and education. In the EU, pharmacy practice and education fall under two jurisdictions: European and national. EU legislation is confederal in structure. Freedom of movement and of exercise of profession is the cornerstone. To ensure this, there is a system of automatic recognition of professional qualifications for sectoral professions such as not only pharmacists, but also nurses, midwives, doctors, dentists, architects, and veterinary surgeons. To work in another EU member state, such professionals apply to the relevant authority of that country, providing proof of the qualifications obtained in their home state. Such procedures are regulated by directives issued by the European Commission of the EU. The latter are ordinances laying down the broad imperatives on the practice and education of the given profession . An EU dIn parallel to the above pan-national system, member states may introduce national legislation relating for example to specialized practice, and to ownership and management of pharmacies. Pharmacy education and training in Europe is also influenced by the Bologna agreement on the harmonization of European degree courses, and student and staff exchange . The BolThe idea behind the Bologna recommendations is to improve student mobility, with the development of tools to promote student exchange programs like the European Credit Transfer and Accumulation System (ECTS). This provides credits to students for defined learning outcomes. ECTS are coupled to a Diploma Supplement that describes the nature, level, context, content, and status of the studies that were successfully completed by a student. This system allows students to validate studies carried out at their host university by their home university. This paper looks at how the EU directive and the Bologna recommendations apply to Finland, a country that has been a member of the EU for quite some time (membership 1995). In order to place practice within the general health situation in Finland compared to Europe, it can be noted that Finland has a compulsory, tax-based healthcare system, which provides comprehensive coverage for the entire resident population. The central government and municipalities are the main players in the organization of healthcare. At the national level, the Ministry of Social Affairs and Health issues framework legislation on health and social care policy and monitors implementation. At the local level, the municipal health committee, council, and executive board make decisions on the planning and organization of care. Municipalities (317 in 2016) are also responsible for health promotion and disease prevention, primary medical care, medical rehabilitation, and dental care. The country is divided into 20 hospital districts, each of which is a federation of municipalities responsible for arranging and coordinating specialized care within their area. There is an ongoing major reform in health and social care in Finland currently, which will probably cause numerous changes in arrangements and responsibilities in the area . In 2015, the total healthcare expenditure in Finland was €19.8 billion, with an annual growth of 1.2%. This means 9.4% of gross domestic product. Specialized medical care costs were €6.9 billion and basic medical care costs were €3.7 billion. Drug costs and medical supplies were €2.5 billion (+4.0% compared to 2014). Public funding covered 74.6% (−1% compared to 2014) and private funding covered 25.4% of healthcare costs in Finland in 2016 [○practice ;○legislation;○education and training;pharmacy:harmonization with the EU sectoral directive on pharmacy  and withInformation was obtained from academics and practicising pharmcists (the authors) and from internet sources (university websites) on the following:Electronic survey methodology was used; data were collected in 2010 and revised in 2017–2018. Sampling was performed by sending the survey to all pharmacy departments, pharmacy orders and chambers, associations of industrial, hospital, and other specialization pharmacists, and associations of pharmacy students. Collection of data in any specific country took between six and 12 months. Data collection was performed electronically using standard survey platforms. We attempted at all times to collect objective, if possible, numerical data.The information is presented in the form of tables in order to facilitate legibility. This presentation was developed in association with the Pharmacy journal editorial board; it is based on the organization of the PHARMINE survey , and wasIn order to follow the terminology of Finnish pharmacy degrees, three major personnel categories can be separated from each other as follows:Pharmacy personnel in FinlandProviisori) = Pharmacists who dispense medicine and counsel patients; the degree is a requirement for pharmacy owners and managers—a five-year university education.M.Sc. Pharm. (Farmaseutti) = Pharmacists who dispense medicine and counsel patients in pharmacies but cannot own a pharmacy or be a head manager in a pharmacy—a three-year university education.B.Sc. Pharm. (Lääketeknikko) = Supporting personnel in pharmacies taking care of medicine storage, logistics, invoicing, and cash services—a 2–3-year upper secondary vocational education.Pharmacy technician  and five-year (M.Sc. Pharm.) degrees each with a job profile following graduation. This topic is discussed in detail later.The number of pharmacists working in hospitals is lower than the EU average. The ratio of the actual number compared to the linear regression estimation is 1.94,  is 2.83, thus reflecting the importance of medicinal science subjects. The overall ratio of MEDISCI/CHEMSCI (years 1–5) is 0.73. In the EU, some HEIs such as Spain have a “balanced” course with a medicinal sciences/chemical sciences index of 1.2. Others have more “medical” courses, such as Ireland and the Netherlands, with indices of 2.6 and 1.6, respectively [Finland adopted the Bologna system with a two-tier degree system, the use of ECTS, etc.The number of Erasmus and other exchange students increased steadily over the past 5-10 years.Finland conforms to the different aspects of the EU directive with a five-year degree and a six-month traineeship. Suitable balance between theoretical studies and practical excercises is to be found in order to reach the curriculum objects and learning outcomes of the B.Sc. and M.Sc. degrees.○a first-cycle degree  with “international recognition of the first cycle degree as an appropriate level…”, providing the qualifications needed for immediate employment.○the above will be followed with a Master degree , and eventually a Ph.D. degree (four years)University education will haveQualifications in both cycles can be obtained in several EU countries; in an “extreme” case , a foreign B.Sc. could be accepted as a requirement for acceptance into the Finnish M.Sc. program.We developed pharmacy education in Finland based on teacher and student feedback, and also based on the field-specific feedback from societal stakeholders including community pharmacists, hospital pharmacists, industrial pharmacists, and drug authority experts, and also according to the recommendations and suggestions of the EAFP (European Association of Faculties in Pharmacy)-based PHARMINE and PHAR-QA projects. One main point (but not the only point) is the close correspondence of the Finnish system to the spirit of the essential points of the original Sorbonne 1998 declaration , as follThe main conclusions/implications to be drawn from this survey of pharmacy education and training in Finland are that it follows EU directives and additionally provides a description of the two-tier Sorbonne/Bologna B.Sc./M.Sc. model. Possible biases in our study could involve flaws in the representativity of the survey methodology. However, given that Finland is a relatively small EU country with but three pharmacy departments , we estimate that such biases are of little importance.


To synthesize the literature on the effect of provision of personalised cancer risk information to individuals at population level risk on accuracy of risk perception and psychological responses.A systematic review and random effects meta-analysis of articles published from 01/01/2000 to 01/07/2017.We included 23 studies. Immediately after provision of risk information 87% of individuals were able to recall the absolute risk estimate. Less than half believed that to be their risk, with up to 71% believing their risk to be higher than the estimate. Provision of risk information increased accuracy of perceived absolute risk immediately after risk information compared with no information (pooled RR 4.16 (95%CI 1.28–13.49), 3 studies). There was no significant effect on comparative risk accuracy (pooled RR 1.39 (0.72–2.69), 2 studies) and either no change or a reduction in cancer worry, anxiety and fear.These findings highlight the complex cognitive processes involved in the conceptualisation of risk.Individuals who appear to understand and are able to recall risk information most likely do not believe it reflects their own risk. Although providing individuals with a personalised risk estimate in isolation is unlikely to lead to behaviour change ,2, persoHowever, the general population does not easily understand the concept of risk ,6, with Previous reviews have shown that provision of cancer-based risk information in genetic counselling centres can increase accuracy of risk perception while leading to either no change in psychological outcomes or psychological benefits . Individ2a priori established study protocol (available on request). Reporting followed the PRISMA statement . SJS is supported by the Medical Research Council www.mrc.ac.uk [Unit Programme number MC_UU_12015/1]. The University of Cambridge has received salary support in respect of SJG from the NHS in the East of England through the Clinical Academic Reserve. The views expressed are those of the authors and not necessarily those of the NHS, Department of Health or the US NIH. All researchers were independent of the funding body and the funder had no role in data collection, analysis and interpretation of data; in the writing of the report; or decision to submit the article for publication.JUS is funded by a The contributions of authors to the manuscript are as follows: a) study concept and design: Usher-Smith, Griffin, Silarova; b) acquisition, analysis or interpretation of data: Usher-Smith, Bayne, Fairey, Silarova, Griffin, Sharp, Klein, Sutton; c) drafting of the manuscript: Usher-Smith, Bayne, Fairey; d) critical revision of the manuscript for important intellectual content: Griffin, Klein, Silarova, Sharp, Klein, Sutton; e) obtained funding: Usher-Smith, Griffin.All data are available from the reports or authors of the primary research. No additional data is available.None.