Context and aims: Many musicians suffer for their art, and health is often compromised during training. The Health Promotion in Schools of Music (HPSM) project has recommended that health education should be included in core curricula, although few such courses have been evaluated to date. The aim of the study was to design, implement and evaluate a compulsory health education course at a UK conservatoire of music.Methods: The course design was informed by a critical appraisal of the literature on musicians' health problems and their management, existing health education courses for musicians, and the HPSM recommendations. It was delivered by a team of appropriately-qualified tutors over 5 months to 104 first-year undergraduate students, and evaluated by means of questionnaires at the beginning and end of the course. Thirty-three students who had been in their first year the year before the course was introduced served as a control group, completing the questionnaire on one occasion only. Items concerned: hearing and use of hearing protection; primary outcomes including perceived knowledge and importance of the topics taught on the course; and secondary outcomes including physical and psychological health and health-promoting behaviors. The content of the essays written by the first-year students as part of their course assessment served as a guide to the topics they found most interesting and relevant.Results: Comparatively few respondents reported using hearing protection when practicing alone, although there was some evidence of hearing loss, tinnitus, and hyperacusis. Perceived knowledge of the topics on the course, and awareness of the risks to health associated with performing music, increased, as did self-efficacy; otherwise, there were negative effects on secondary outcomes, and few differences between the intervention and control groups. The topics most frequently covered in students' essays were managing music performance anxiety, and life skills and behavior change techniques.Conclusion: There is considerable scope for improving music students' physical and psychological health and health-related behaviors through health education, and persuading senior managers, educators and students themselves that health education can contribute to performance enhancement. Although many classical musicians derive positive emotions from their music making and find their profession meaningful  have been defined as symptoms that have a negative impact on the ability to play , which can produce noise-induced hearing loss (NIHL) and/or cause other disorders and symptoms such as tinnitus, hyperacusis, distortion, and diplacusis, some of which are incurable  published “A Sound Ear,” offering practical guidance and training for symphony orchestras  and trying to improve broader socio-economic, political and environmental living conditions by building supportive environments, encouraging community action, informing public health policies and ensuring that health services are oriented toward achieving population health outcomes. Life skills include stress management and emotional self-regulation, communication, and interpersonal skills, decision making, problem solving, critical thinking, and creative thinking WHO, . Given tThe US-based Health Promotion in Schools of Music (HPSM) project 2004–2006) resulted from a collaboration between the University of North Texas and the Performing Arts Medicine Association, and aimed to prevent musicians' playing-related occupational injuries. Their consensus-based recommendations aim to incorporate health-supportive environments and better educational programmes as part of professional music training, and include adopting a health promotion framework; developing and offering an undergraduate occupational health course for all music majors; educating students about hearing loss as part of ensemble-based instruction; and assisting students through active engagement with health care resources   explore students' hearing and use of hearing protection; (b) design an evidence-based health education course; (c) assess the effects of the course on primary outcomes  and secondary outcomes ; and (d) identify the topics most salient to students on the basis of the issues they chose to engage with in their course assessment.The course reflected all HPSM recommendations other than the adoption of a single health promotion framework. Its curriculum was informed by the findings of research on MPA and PRMDs; the findings of evaluations of other courses designed to improve musicians' health; theories and models deriving from health psychology Taylor, ; discussInterventions designed to prevent and/or mitigate MPA were reviewed systematically by Burin and Osorio , see alsFew evaluations of health courses for musicians have been published, although they are delivered worldwide  and consisted of ten weekly 1-hour lectures delivered to the whole cohort (104 students) and eight weekly 1-hour seminars delivered to ten small groups of 10–15 students. Seven of the lectures and five of the seminars related, broadly, to health and wellbeing.How to practice more effectively, was delivered by the Head of the School of Strings. Topics included deliberate practice; listening back to self-recordings; appraising ideal performances and designing exercises for overcoming identified weaknesses.Lecture 1, How to rehearse more effectively, was delivered by the Head of Chamber Music with live illustrations from a first-year piano trio. Topics included warming up and rehearsing as a group; overcoming technical difficulties and problems with rhythm, articulation, bowing and breathing; intonation in groups with and without piano; learning how to identify errors, and to give and receive constructive criticism; the use of recordings when developing interpretations; responding and listening to the music while playing; interacting with the audience.Lecture 2, Introduction to health and wellbeing, was delivered by the first author. Topics included the findings of recent research on the prevalence and symptoms of, and risk factors for MPA, PRMDs and hearing loss; healthy lifestyles  and health-promoting behaviors ; behavior-change strategies focusing on the concept of life skills as defined by WHO  and restriction . Behavior change techniques included goal setting and self-monitoring  and mental preparation.Lecture 7, Life skills for musicians; the performing arts medicine specialist facilitated all those entitled General ergonomics: How do I improve my posture? The remaining seminars were entitled Injury prevention and management, including hearing protection; Preparation for performance; and Successful careers: Time management, finances, life on tour and were facilitated by a range of tutors including the fourth author.Ten groups of students  each took part in five seminars that were intended to reflect the content of the seven lectures. The first author facilitated all ten seminars entitled Students were required to submit a portfolio of assessments including a 1,000-word essay in response to both the following questions: (1) Looking back on the Health and Wellbeing component of Artist Development 1, what new information, useful for your own music-making, have you learned from one lecture or one workshop/seminar?; (2) How have you been able to put this information into practice when making music ?A mixed-methods approach to evaluation was adopted: quantitative analyses of within-subject data gathered at baseline and post-intervention, and between-group data (intervention vs. controls); and qualitative, semi-structured interviews  Health-related quality of life (HRQoL): four items from the 15D scale  Health-promoting behaviors: the Health Promoting Lifestyle Profile II questionnaire  Self-efficacy , which might facilitate both engagement in health-promoting behaviors and maintenance of healthy habits  Emotional states during the previous week: the Positive and Negative Affect Schedule  Perceived stress: the Perceived Stress Scale  Frequency and severity of PRMDs: two items adapted from Ackermann and Driscoll (g) Driscoll , measurePerceived exertion, to evaluate the amount of physical effort respondents needed to complete their daily practice routines: the Borg Rating Scale  le Borg, , which rThe respondents' 1,000-word essays, written for the purposes of course assessment, also served as a source of data.p = 0.05. Confidence intervals of 95% were used throughout. Missing data were handled using listwise deletion for the exploration of changes across time and between groups.Quantitative data were analyzed using IBM SPSS 22. Descriptive and inferential statistics are presented. Statistical significance was considered at r = Z/√N . The paired-samples sign test was run when the assumption of symmetrical distribution was not met.For within-subject analyses, Wilcoxon Signed-Rank tests for paired samples were run, because the assumptions for normality were not met. Effect sizes were calculated using the following formula: U-tests for independent samples were used, while effect sizes were calculated using the following formula: η2 = Z2/(N−1) . For normally distributed data, independent t-tests were conducted.For between-group analyses, Mann-Whitney Respondents' essays were anonymised and their titles  categorized using open (bottom-up) coding, according to course topics covered.SD = 1.34). Twenty-nine (36.3%) were singers, 19 (23.8%) were string players, 17 (21.3%) were wind and brass players, 11 were pianists (13.8%), three were composers (3.8%), and one was a percussionist (1.3%). The mean number of years they had sung, or played their main instrument, was 9.4 . They reported carrying out a mean of 14.3 h of personal practice per week .Of a total of 104 first-year undergraduate students enrolled on the course, only 13 did not complete the baseline questionnaire (12.5%). Of the 91 students who did, 81 (90%) completed the same questionnaire post-intervention: an attrition rate of only 10%. The mean age of these 81 respondents  was 19 years  completed the questionnaire either online or as hard copy in March–April 2018. Fifteen were string players (46.9%), six were keyboard players (18.8%), six were wind and brass players (18.8%), three were singers (9.4%), and two were composers (6.3%). Information on main instrument was missing for one respondent. They had played their main instruments for a mean of 12 years .Thirty-three third-year undergraduate students  with a mean age of 22 , and during their own performances (8% of the intervention group and 12% of controls). By contrast, 20% of the intervention group and 30% of controls reported using hearing protection while rehearsing with other people, and 19% of the intervention group and 36% of controls used it while listening to other people's performances. Seventy percent of those who did use hearing protection used reusable soft ear plugs. Of those whose instruments can be muted, 17.5% of the intervention group and 22.2% of controls reported using the mute “often” or “always.”Fifty-six percent of the respondents in the intervention group who used hearing protection, but only 33% of controls, reported having got used to wearing them right away; another 33% of controls said it had taken them “weeks/months/years” to get used to them.The most frequently-reported problems experienced by respondents in the intervention and control groups were a decrease in their ability to hear other players (26.8 and 45.5% respectively). The next most frequently-reported problems were difficulty inserting ear plugs (21.4% of intervention group responses) and hindrance to the player's own performance (33.3% of control group responses). The questionnaire included an invitation to report other problems: responses included “not being able to hear details in the sound;” “made listening to my sound more difficult;” “can't sing with them in;” “I felt isolated and anxious over the sounds I was making and tuning;” “I can hear my mouth moving—very distracting;” and “hear myself from within my mouth when playing”.Tinnitus was reported by 8% of the intervention group and 21% of controls, and hyperacusis by 6% and 22% respectively. Only one member of the intervention group experienced distortion and no-one reported diplacusis.While only 36% of the intervention group and 47% of controls had had a hearing test in the previous 10 years, only 10% of the former and none of the latter had been diagnosed with hearing loss.Descriptive and inferential statistics are shown in Table Z = −4.32, p < 0.001); effective rehearsing strategies ; learning and memorizing strategies ; ergonomics and posture ; managing MPA ; life skills and behavior change techniques ; presentation skills . Small to medium effect sizes associated with these changes varied between r = 0.18 and r = 0.42  but the difference between means did not reach significance.There were statistically significant increases from baseline to post-intervention in mean ratings for perceived knowledge of all topics covered in the course: effective practicing strategies , and tended to give higher ratings for the perceived importance of ergonomics and posture  although the difference between means did not reach significance. Otherwise, there were no differences between the ratings of the intervention and control groups, nor changes from baseline to post-intervention.Respondents rated their knowledge of effective learning and memorizing strategies, post-intervention, higher than controls . There were no significant differences between the ratings of respondents, post-intervention, and controls.There was a significant increase from baseline to post-intervention in ratings for one of the three items: awareness of performance factors related to musculoskeletal injuries associated with learning and playing an instrument/singing  and how to deal with the health and safety issues associated with learning and playing a musical instrument . There were no significant differences between the ratings of respondents, post-intervention, and controls. There was, however, a trend such that the former rated their knowledge of sound intensity levels higher than the latter , although the difference between means did not reach significance.There were significant increases from baseline to post-intervention in ratings for both items: knowledge of sound intensity levels associated with hearing loss , distress , and lack of vitality . In comparison with respondents post-intervention, controls experienced more severe depression , distress , and lack of vitality .While means at baseline and post-intervention were low, there were nevertheless significant increases in ratings representing sleep problems  and subscales at T1 with the following alphas: HR = 0.83; PA = 0.81; NU = 0.73; SG = 0.84; IR = 0.78; SM = 0.67) and at T2 for the entire scale  and subscales: HR = 0.81; PA = 0.80; NU = 0.75; SG = 0.87; IR = 0.82; SM = 0.72). The grand mean of all scores on HPLPII was 2.53 (SD = 0.36), indicating that respondents reported engaging in health-promoting behaviors “sometimes” or “often” , although the grand mean at baseline was only 3.0 (SD = 0.41), lower than found in previous research in the UK . Ratings increased significantly from baseline to post-intervention , although the mean at baseline was 3.89 (SD = 0.65), higher than those reported by Kreutz et al. (SD = 0.75) and 3.51 (SD = 0.74) respectively. There was a trend such that ratings for negative affect increased , although significance was not reached; once again, the mean at baseline was 1.77 (SD = 0.59), lower than the means reported in the UK and South African research, which were 2.09 (SD = 0.73) and 2.40 (SD = 0.81) respectively. In comparison with respondents post-intervention, controls experienced lower positive affect  and higher negative affect .The PANAS scale showed good internal reliabilities at T1  and T2 . Ratings for positive affect decreased significantly from baseline to post-intervention .The PSS scale showed good internal reliability at T1 and T2 . There was no significant difference between mean ratings at baseline and post-intervention, but in comparison with respondents, post-intervention, controls reported higher levels of stress , although controls reported their daily practice routine to require more  effort .There was a significant decrease from baseline to post-intervention  control group than in the (first-year) intervention group. Ten percent of the intervention group had been diagnosed with hearing loss, although minorities of respondents in both groups reported having had hearing tests in the previous 10 years.Although respondents were more likely to use hearing protection when rehearsing with others and attending concerts, comparatively few members of either group used hearing protection, or, if appropriate, the mute on their instrument, while practicing alone. This could affect hearing, since private practice can cause over-exposure to risky levels of sound: O'Brien et al. , for exaThe majority of users preferred reusable soft ear plugs to single-use soft plugs and the much more expensive custom-made versions; over half the intervention group users and a third of control group users reported getting used to them immediately while the remainder needed more time, persisted despite discomfort, or gave up using them. Typical problems with ear plugs included decreased ability to hear others, hindrance to own performance, difficulties with insertion and the sensation of pressure in the ear.These findings support the results of recent research investigating the perceived advantages and disadvantages of using ear plugs, how they are used and musicians' strategies for wearing them  decreased significantly from baseline to post-intervention, and were higher for controls. Means were so low, representing “very very” to “very” light, although not surprisingly low, given that perceived exertion measures the level of physical effort and that scores for both frequency and severity of PRMDs were also low. For example, some exercise-based interventions have been associated with a positive impact on both PRMDs and RPE in the past (Ackermann et al., Finally, the categorization of student assignments to the topics covered in the course indicated those that respondents found of most interest or direct relevance to them, at this point in their studies: predominantly managing MPA and life skills and behavior change techniques.The strengths of the study include the design and evaluation of the course, which was more rigorous than the majority of those reviewed above. First, the content of the course was based on a critical appraisal of the available literature on interventions to improve the health of musicians, theories from health psychology, and a clear conceptualization of health education, according to the WHO definition, as opposed to health promotion. Second, the course was compulsory. This partially explains the low attrition rate and reduces the likelihood of selection bias, although completion of questionnaires was not itself mandatory. The findings are therefore likely to be both more realistic and generalizable than evaluations of optional courses. Indeed, Spahn et al.  suggest The limitations of the study must also be acknowledged. First, we would have increased the rigor of our approach by consulting a wider variety of health professionals when we designed the course, given its high level of interdisciplinarity. Second, the authors did not have the final say on the content of all the lectures and sessions delivered, other than those we delivered ourselves, and could not therefore monitor the extent to which the course as a whole was evidence-based. Our impression from reading the materials with which we were provided by tutors, and the students' essays, suggests that, on the whole, the evidence base was satisfactory. As a general point, we would nevertheless argue that justification is needed to include popular practices with little research evidence to support their use, such as the Alexander Technique (Klein et al., In the absence of a national curriculum for health, all institutions of higher education must develop their own approaches to health education, as do many university music departments and music conservatoires. The questions posed by Ralph Manchester in 2006 remain pertinent: “Who will develop this course? What topics will be included in the syllabus? Who will teach it? Will it be offered to freshmen or seniors, or can it be taken during any year? Can one course meet the needs of performance majors, music education majors, and others? Should we develop some minimal national requirements?” (Manchester, teaching. Indeed the first HPSM declaration includes the unsubstantiated claim that performance injuries are preventable (Manchester, Although it has been argued for the last 25 years that health education for musicians should be evidence-based Zaza,  and one The topic of how music students, too, can be convinced that health education is a vital part of their training remains largely unexplored. Framing the objectives of health education courses as “performance-enhancing” rather than “preventative” is likely to be more attractive to students. After all, from the musician's perspective, performance quality is an outcome worth pursuing, and such a strategy could even be self-reinforcing, leading to greater self-efficacy and reduced anxiety Kenny, . It remaResearchers carrying out similar studies in future should consult the best available literature when designing courses and make more use of iterative processes. They should employ rigorous approaches to investigate the effectiveness of complex programmes, including exploring the acceptability of a course; piloting it; recruiting active control groups; and using a range of measures such as validated questionnaires, objective measures and qualitative data. They should conduct follow-up studies after longer periods, given that physical and psychological health are determined, at least in part, by health-promoting behaviors that individuals take time to establish (Barton and Feinberg, Although the course described in the present study did not have the hoped-for impact on secondary outcomes including reported health-related behaviors, reduced PRMDs and stress, it was associated with improvements in primary outcomes relevant to health education, namely the perceived knowledge of topics covered in the course and awareness of health risks. Furthermore, the study itself is the first evaluation of a health education course for musicians that documents the process of designing the course on the basis of a rigorous assessment of the available evidence, and its incorporation in the “real world” context of a music conservatoire.This study was carried out in accordance with the recommendations of the Conservatoires UK research ethics committee. The protocol was approved by the Conservatoires UK research ethics committee. All participants gave written informed consent in accordance with the Declaration of Helsinki.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.RM and JGi contributed to the design of the course, delivered some of the course sessions, and designed the study and procedures. RM collected the data, and analyzed the quantitative data. RM and JGi drafted the manuscript. All authors edited the manuscript, read and approved the submitted version.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.


With gastrointestinal tract as the origin, gastrointestinal stromal tumor (GIST) is recognized as the very widespread mesenchymal tumor. A precise prognostic model of survival is required to guide the treatment options of patients with GIST. This study was designed to map the overall survival (OS) and cancer-specific survival (CSS) of GIST patients. According to the Surveillance, Epidemiology, and End Results (SEER) program database, we acquired the data of 6,713 patients with GIST who were diagnosed between 2004 and 2014. We randomly separated the patients into training  and validation  groups. To assess the prognostic impact of multiple clinical parameters, the Kaplan-Meier approach and the Cox proportional hazards regression model were adopted, where essential prognostic variables were combined to create nomograms. The consistency index and curve of calibration had been adopted to assess nomogram discrimination ability and prediction accuracy. A multifactor analysis of the training cohort showed that age, gender, size of tumor, location, and primary surgery were remarkably related to survival, and these variables were applied to create nomograms. The nomogram demonstrated excellent accuracy in estimating 2-, 3-, and 5-year OS and CSS, with a C-index of 0.740  for OS and 0.743  for CSS. In the validation cohort, the nomogram-predicted C-index was 0.741 for OS  and 0.746  for CSS. All calibration curves showed good consistency between predicted and actual survival. A new nomogram was created and verified to predict the OS and CSS of patients with GIST. These new prognostic models can help enhance the accuracy of survival outcome predictions, thus facilitating to provide constructive therapeutic suggestions. With the gastrointestinal tract as the cause, gastrointestinal stromal tumor (GIST) is seen as the very widespread mesenchymal tumor, and most patients with GIST exhibit activation of the KIT and platelet-derived growth factor receptor (PDGFRA) mutations , 2. SurgDue to the rareness of GIST, large databases like the Surveillance, Epidemiology, and End Results database (SEER database) can be used to be an excellent database to explore these tumors. The SEER database is kind of a population-based cancer registration system of the USA taking 28% Americans into account. The database can function as a resource for examining familiar cancer incidence and result patterns. Thanks to the wide range of data on cancer, the SEER database is a distinctive resource to study special malignancies. Nomograms are graphical representations of mathematical models, where information about certain features is used together to estimate specific endpoints. The handy graphical display of the nomogram makes it possible to make easy and rapid predictions in clinical practice . By inteIn this research, to determine the risky variables related to the overall survival (OS) and cancer-specific survival (CSS) of patients with GIST, patient records from the SEER Cancer Registry were acquired and used to establish nomogram for the prediction of the prognoses of patients with GIST.Data extracted from the SEER registry database of the National Cancer Institute were used in this research. The SEER database gathers information related to cancer prevalence, incidence, factors based on population, mortality, major tumor features, and management at 18 registries in the USA.∗ Stat software (Version 8.3.2) to analyze the data from patients who were diagnosed between 2004 and 2014, which represented the patients with GIST patients who were studied in this analysis. For each patient, the following data was acquired: year of diagnosis, age at diagnosis, gender, race, size of tumor, location, surgery of primary, information of survival, and reason lead to death. A total of 6713 patients with GIST were inconsistently separated into two groups . Patients in the SEER database who were classified as American Indians / Alaska Aboriginal or Asian / Pacific Islanders were categorized into the “others” race category to conduct the analysis.We used SEER The training group was used to establish a line diagram. One of the main endpoints of interest was OS, which was identified as the time from diagnosis to death from any cause. In the OS analysis, patients who remained alive at the last follow-up were considered as censored observations. The other major endpoint of interest was CSS, which was defined as the time from diagnosis to death due to GIST. In the CSS analysis, patients who died of other causes or remained alive at the last follow-up were classified with respect to their last examination.p < 0.05) and applied to construct nomograms of OS and CSS.Kaplan-Meier and Cox proportional hazards regression models were adopted to identify survival-associated variables. Significant variables that associated with survival were investigated in univariate or multivariate analysis  calculations, but seems kind of proper for censored data . Larger To carry out statistical analyses, IBM SPSS statistics 22 software  was used. The Kaplan-Meier method and Cox proportional hazards regression model were adopted to identify survival-related variables. We investigated the variables that remarkably correlated with survival in univariate or multivariate analyses.http://www.r-project.org/), a nomogram was constructed. We used “RMS” R library (cran.r-project.org/web/packages/rms) to develop survival models. The bilateral p values <0.05 reveal that it owns the statistical significance.With the multivariate analysis results as the basis, by means of R 3.4.1 software  and validation (n = 2014) groups. The median follow-up times were 45 months (1 to 131 months), 2 years, 3 years, and 5 years, with OS rates of 84.4%, 79.4%, and 70.1%. The 2-, 3-, and 5-year CSS rates were 92.4%, 89.2%, and 83.6%.p < 0.05). The Cox proportional hazards regression model was used to deeply study the impacts of different factors. The OS and CSS multivariate analyses identified higher hazard ratios (HRs) for the following features: older age, male gender, size of tumor > 10 cm, nongastric location, and no surgery of the primary tumor (p < 0.05)  .All remarkable independent factors of the Cox proportional hazards regression in the training group were included in the prognostic nomogram. Generally, there were excellent OS and CSS rates for younger patients, female, smaller tumors, stomach positions, and patients receiving primary tumor surgery. With the help of the nomogram, prognoses can be effectively predicted based on personal patient features.The verification of the nomogram was carried out by a 1000 resampling bootstrap analysis, in internal and external way. The analysis of the internal validation group (training group) demonstrated that the C-index of OS estimate was 0.740 , and the predictive value of CSS was 0.743 . Analogously, the C-index values to evaluate OS and CSS were 0.741  and 0.746  , in the Accurate risk stratification of GIST is critical for treatment selection and prognosis assessment. Several classification systems to prognosticate GIST have been proposed. The two most widely accepted risk classification systems are the US National Institute of Health (NIH) criteria and the Armed Forces Institute of Pathology (AFIP) criteria. The NIH consensus classification system, based on tumor size and mitotic count, is commonly used to assess patient prognosis after surgical resection . The AFIThe nomogram, a graphical display of a mathematical model, combines biological and clinical variables for the identification of the probability of clinical events. Compared with the existing tumor staging system, nomograms achieve more excellent prediction precision and prognostic value –23. BaseSince the SEER project includes data from a large number of hospitals and almost 30% of the overall population of the country, the contained data should allow the widespread application of nomogram in clinical practice decisions.Taking the relatively long-term survival potential of GIST into consideration, the death of patients with GIST is often due to non-GIST causes. Therefore, the OS predictions may not accurately reflect the long-term survival of GIST. Thus, when predicting the CSS of GIST, other causes of death should be considered.In this research, a nomogram was established with 6713 patients the basis from the SEER database and used to predict the 2-, 3-, and 5-year OS and CSS rates of patients with GIST based on five important factors: age at diagnosis, gender, size of tumor, location, and primary tumor surgery. The aim of this study was to effectively predict patient prognosis from concrete patient features. The nomogram's discrimination performance was assessed by an internal bootstrap resampling approach. The C-index showed the ability of nomogram to estimate OS and CSS rates of patients with GIST at 2, 3, and 5 years.As demonstrated in the nomogram, age as well as gender was associated with OS and CSS, regardless of size of tumor and location. In previous studies, age was proven a significant predictor and prognostic variable , 27. OurGIST can take place along every part of the gastrointestinal tract and is highly widely related to the stomach (60-70%) and small intestine 25-30%). The contribution of colorectal GIST (5-10%) and esophageal GIST (1%) to the overall incidence is very small . Recentl%. The coThere are several restrictions to this study. Firstly, as a retrospective study, it suffers from inherent and inevitable biases. Therefore, in order to confirm the results, large-scale, randomized, and controlled studies are needed. Second, the mandatory use of Imatinib or other new, targeted agents in the high-risk group of GIST patients after surgery modifies substantially the clinical outcome and the prognosis of OS and CSS. However, the SEER database offers no data on important treatments, like tyrosine kinase inhibitors. In addition, many other factors that may affect patient prognosis, such as histological grade, mitotic index, tumor rupture, and the existence of mutation of the KIT gene and exon mutation  as well as with the PDGRA mutation . Moreover, new mutations have been described that may influence the clinical outcome and the response to therapy with new drugs of GIST, such as BRAF mutation, SDH deficiency, and NF-1 mutant –35. HoweCurrent studies demonstrate that age, gender, size of tumor, location, and primary tumor surgery are absolute risk variables for survival GIST patients. According to specific patient characteristics, the OS and CSS rates at 2, 3, and 5 years could be accurately predicted with the aid of nomograms, which can facilitate the ability of clinicians to determine extremely risky patients and perform more accurate survival assessments.We created and examined a new nomogram that can evaluate OS and CSS in patients with GIST, and these brand-new prognostic methods can help improve survival predictions and facilitate reasonable treatment recommendations.


Lactobacillus strains in decreasing infant cry and fuss in this population. Infants aged 4–12 weeks received L. rhamnosus 19070-2 and L. reuteri 12246 in a daily dose of 250 × 106 CFU, 3.33 mg of fructooligosaccharide, and 200 IU of vitamin D3  or just vitamin D3  for 28 days. Cry and fuss time were measured with validated Baby’s Day Diary on days 0 and 28. At baseline, mean (SD) duration of cry and fuss time was comparable in the probiotic and control groups: 305 (81) vs. 315 (90) min., respectively (p = 0.450). On day 28, mean cry and fuss time became statistically different: 142 (89) vs. 199 (72), respectively (p < 0.05). Mean change in cry and fuss time from day 0 through day 28 was −163 (99) minutes in the probiotic and −116 (94) minutes in the control group (p = 0.019). Our findings confirm that lactobacilli decrease cry and fuss time and provide a dietary support in exclusively breastfed infants with colic.Infant colic is a common condition of unknown pathogenesis that brings frustration to families seeking for effective management. Accumulating evidence suggests that some single strains of lactobacilli may play a positive dietary role in attenuation of colic in exclusively breastfed infants. The objective of this study was to evaluate a mixture of two  Infant colic (IC) represents a temporary self-limited condition, which occurs in about one of five infants within the first months of life, and is characterized by inconsolable cry and fuss of unknown cause . Wessel Clostridium difficile, Klebsiella pneumoniae, and Escherichia coli in their intestines and lesser microbial diversity than their non-colic counterparts . The rationale for the higher dose of probiotic in this statement was largely based on the results of studies in adults that cannot be directly translated for young infants. In IC, other investigators reported the positive effects of probiotics at daily doses of 108 CFU [9 CFU/day did not exert the effect in IC [The effect of lactobacilli was documented at a daily dose significantly lower than one advocated by some regulatory authorities for probiotics . In our  108 CFU ,15,17,27ct in IC , suggestSleep duration, as a tertiary outcome measure, did not change in the study and was within normal limits for age . Three oThe role of breast-feeding modality on the positive effect of lactobacilli in infant colic is not understood. The situation is aggravated with the fact that breast-feeding itself did not affect the occurrence of colic ,34 despiThe strength of our study was the randomized double blind controlled prospective parallel group design and the use of validated EPDS for measurement of maternal depression, and BDD for monitoring infant cry and fuss. The BDD tool was checked across sound records and found a reliable method for observation of infant cry and fuss . DespiteThe study limitation was the inclusion of infants that were treated with antibiotics or/and received probiotics before inclusion in the study. The number of such infants was small , and all these interventions were finished more than seven days before study enrollment. The effect of this was known neither in our study nor in the referenced literature. Any history of antibiotic or probiotic use served exclusion criteria in the Canadian study . In two The weakness of the study was the use of not validated 28-day study diary. The diary contained questions about maternal diet and possible gastro-intestinal upset symptoms in the infant. It was not known how much this truly reflected real life events. None of the infants received any treatments for colic during the study period. However, prior to the study more than 30% of infants received any type of treatment of colic that included simethicone or a similar drug, lactase, herbal medicine or homeopathic formulation. No consistent results were obtained for the efficacy of all the listed interventions except for fennel tea . Only onAnother limitation was due to the inclusion of infants with hypoxic-ischemic encephalopathy, whose brain injure may obscure colic or otherwise interfere with cry and fuss patterns in infants. Particularly, these infants may present transient behavioral abnormalities, such as poor feeding, irritability, or excessive crying or sleepiness in an alternating pattern. However, we included only infants with a mild course of the pathology, which recovers within a few days without consequences. . PotentiNotably, that in this study we assessed pre-existed functional conditions/episodes to avoid labelling them as intolerance events. Indeed, regurgitation was seen in 55% and 63% of all infants before enrollment the study, in the probiotic and control groups, respectively. According to previous estimates, the infant may have functional regurgitation in up to 67% that meet our data . As per The significance of our findings is difficult to assess, as the frequency of gastro-intestinal symptoms was not pre-screened. It remains unknown if this was due to probiotic effect, or pre-study features of infants in two groups.L. reuteri 12246, L. rhamnosus 19070-2, and FOS mixture to its separate constituents or their combinations. Most of previous studies explored a role of L. reuteri [L. rhamnosus [L. reuteri-based showed consistent beneficial effects in breastfed infants, the study with L. rhamnosus showed no effect in nonhomogeneous group of breast- and formula-fed infants. Our infants were all exclusively breastfed, so the role of L. rhamnosus is difficult to discuss. Reduction in the manifestation of IC in the study of infants fed with FOS fortified formula also prevents from extrapolation of beneficial results obtained [Finally, our study design did not permit ascribing positive effect of  reuteri ,17,27, Lhamnosus , and FOShamnosus . While Lobtained . In thisobtained .L. rhamnosus 19070-2 and L. reuteri 12246 decreases cry and fuss time, and provides useful dietary support in exclusively breastfed infants with colic.Our findings confirm that oral use of a mixture of


This study aims to investigate the differences in the utilisation of preventive health services among standard, nonstandard workers, the self-employed, and unpaid family workers.th and 5th Korea National Health and Nutrition Examination Survey, a nationwide survey conducted from the year 2007 to 2012. Economically active workers between the ages of 25 and 64 were grouped into standard, nonstandard, the self-employed, and the unpaid family workers . Outcome variables are the uptake of preventive health services including influenza vaccination, regular medical check-up, and four types of cancer screenings. We used multivariate logistic models.We used the 4Overall, non-standard workers, the self-employed, and unpaid family workers were less likely to use the preventive health care compared to the standard workers. In particular, the self-employed were less likely to use all the six services compared to the standard workers and showed the lowest level of uptakes among the four working groups. Moreover, the service uptake of the non-standard workers was lower than that of standard workers in all services; except the colon cancer screening. On the other hand, unpaid family workers showed mixed results. While the uptake of influenza vaccination and regular health screening were lower, participation to the cancer screening was not lower compared to that of standard workers.There were gaps in the utilisation of preventive services among workers depending on their employment types. Access to preventive health care services of nonstandard workers, the self-employed, and unpaid family workers should be prioritised. Labour conditions are essential social determinants to health –4. It isFrom the governmental perspective, improving the workers’ health and reducing the health gap among the workers are two essential issues , 13. AccHealth gaps among workers also do matter. Literature shows that ‘non-standard workers’, including part-time, temporary, and daily workers, are more likely to have poor self-rated health  and poorIn South Korea, the estimated coverage of occupational health services (OHS) was about 70% in the early 2010s . The labDespite the comprehensiveness of previous studies on the preventive health utilisation of workers, the self-employed and unpaid family workers have not been accounted for . A studyThe study investigates the gaps in the preventive health care use by the employment types. Section 2 sketches a general background regarding the preventive services. Section 3 describes the methodology. Section 4 provides the results of the empirical analysis. Finally, Section 5 discusses the implications of the findings and the limitations of the study.South Korea has achieved universal population health coverage in 2000 with the National Health Insurance Service (NHIS). In addition to the role as social health insurance, the NHIS has promoted the preventive health further to include three main programs; regular health check-ups, cancer screenings, and vaccine programs.First of all, people receive medical check-ups in three different ways; NHIS-type for employees, NHIS-type for non-employees, or the private voluntary type. As stated above, all employees are supposed to receive the ‘NHIS-type’ medical check-up. It provides basic health check-ups that include; general consultation, blood pressure, lab test, eye and oral examination, and chest x-ray. The interval of check-up depends on the type of work and the risk of the work environment. Workers working in dangerous environments need to get evaluated every six months while others are checked annually . The oveSecondly, the NHIS has been providing cancer screenings since 1999. It is not explicitly designed only for the working population, but for the entire population. Since the year 2005, anyone who wa-s eligible for each cancer screening could receive a screening, either free of charge for medical aid recipients or with a 10% user-charge. The trend of cancer screening rates for all four cancers  had increased steadily between 2004 and 2011 . Data frLastly, the National Immunization Program (NIP) provides essential vaccination for children and seasonal influenza vaccination for high-risk groups. For the influenza vaccination, those over 65, the low-income, the disabled, and soldiers are eligible for free vaccinations while the others need to pay about 15–25 USD (1 USD: 1000 KRW) . The vachttps://knhanes.cdc.go.kr). Since the data, which is publicly available, were analysed anonymously, the institutional review board approval was waived for this study.The Korea National Health and Nutrition Examination Survey (KNHANES) is a nationally representative cross-sectional health survey conducted by the Korea Center for Disease and Control and Prevention in South Korea. Beginning in 1998, KCDC had carried out the survey once every three years, then made it annual in 2006. It used a multi-stage clustered probability design using 192 primary sampling units (PSUs) from over 200,000 PSUs. The survey comprises four different sections including a health survey, health behaviour survey, lab data, and nutrition survey. All respondents have agreed to the use of provided information and contact for a potential follow-up. Detailed information about the survey is available . The datWe categorised workers into four groups. ‘Standard workers (SWs)’ refers to workers with a full-time and permanent contract. ‘Nonstandard workers (NSWs)’ include part-time jobholders, temporary, and daily workers. Those who run their businesses are defined as ‘the self-employed (SE)’ . Lastly,th and 5th of KNHANES. The total number of the participants were 23,632 and 24,173, respectively. Due to the limited age between 25 and 64, the total population was 27,498. Among these, only economically active workers were included in the study population. The study periods were between 2007 and 2012. We used the 4We used the Andersen Model which explains the gaps in healthcare access . The oriSince the outcomes are binary, all the models are multivariate logit models. We used STATA/SE 14 .Most study participants were married (80.53%), were living in the urban area (77.28%), had the National Health Insurance services (98.72%), had private health insurance (84.78%), were never diagnosed with a chronic disease (76.25%), were free from notable depressive symptoms (87.98%), and had day duties (85.72%).Each employment group showed several distinguishable proportions for the given factors. The proportion of SWs was prominently higher in the “urban” group (47.75%), “higher education” group (62.17%), and “non-manual” working condition group (65.69%). SWs were also the majority among the population “with National Health Insurance” group (43.56%), as well as those “with private health insurance” group (45.56%). Only a small proportion of the participants were the recipients of Medical-aid (1.28%), but interestingly 57.75% of the recipients were NSWs. The groups that the SE took comparatively higher proportion were the “suburban” group (42.66%), the “primary education” group (38.59%), and the “evening or night duty” group (49.52%). The groups that UFWs had relatively greater percentage were the female group (13.44%), the “suburban” group (16.36%), and the “primary education” group (18.80%). Regarding income, the highest percentile of the “richest” group were SWs (49.10%), while there was not much difference in the “poorest” group for the proportions of SWs, NSWs, and the SE .Regarding regular health checks, about 72.63% of SWs received the medical check-up while the other three groups were marked between 48.91% to 53.38%. With the vaccination, all four groups ranged between 21.02% and 25.98%. Regarding cancer screening, UFWs seemed to have the highest proportion of getting screened, followed by the SE. SWs and NSWs showed lower proportions of getting cancer screening in all four areas.Socioeconomic factors had effects on service utilisation. Female workers were more likely to get vaccinated, but less likely to get the regular health screening and colon cancer screening. Income-related gaps existed in the regular health screening and cancer screenings, but not for the influenza vaccination. Marital status, particularly in the ‘never-married group’, was associated with the lower uptake in all four services. Living in the suburban area showed heterogeneous association on the service utilisation. Education showed the various effect of the type of services. People with higher education year were less likely to get vaccinated, but more likely to get the other services. Interestingly, Medical aid recipients did not show higher uptake except for the vaccination, compared to people with the National health insurance services. Having private indemnity health insurance was associated with higher uptakes in all four services.With health-related factors, having at least one chronic disease was associated with a higher uptake in all four services. Interestingly, having a depressive symptom that last for more than two weeks was associated with lower uptake of regular health screenings , stomach cancer screenings , and colon cancers .Concerning work-related factors, manual workers were less likely to get the regular health checks and cancer screenings, but not in vaccinations. Workers who have fixed duty hours in the evening or night had the lower uptake of regular health screening and cancer screening. Interestingly, people pulling shift or having split work were more likely to get vaccinated , regular health check , and stomach cancer screening .Lastly, there was a yearly effect in the service utilisation. Compared to the baseline year, which was2007, the vaccine uptake rate improved in the year 2011 and 2012. An earlier and more substantial year effect was observed in colon cancer screening from 2009 and onwards. When the eligibility criteria on the age were controlled, it also had an influence on the service utilisation. The strongest impact was observed in the stomach cancer screenings  compared to the results in the colon cancer screenings .Compared to the four outcomes in the previous analysis, there was some similarity in the effects of socioeconomic factors and work-related factors on the uptake of female cancer screenings. For example, higher education, higher income, living with a spouse, and having private health insurance were associated with the higher uptake of the services. Regarding work-related factors, workers with evening or night shifts were associated with the lower uptake, but ‘pulling a shift or having a split work' did not make a difference.Differences were observed in local factors, health-related factors, and year effects. There was a regional gap in the uptake of cervical cancer . Moreover, unlike the positive and negative impacts of health-related factors in the previous analysis, neither having chronic disease nor depressive symptoms were associated with cervical and breast cancer screening. Unlike the colon cancer screening, there has been no improvement in the uptake of these two screenings since 2007.Our study suggests that, in a nationally represented population of economically active South Korean workers, NSWs were less likely to receive all services, excluding colon cancer screening, compared to standard workers. The SE were also less likely to uptake all six services whereas UFWs were less likely to receive vaccination and regular health screening compared to SWs.Currently, regular health examination at least once a year is a requirement for employment subscribers by the labour law. If this requirement is not met, the employer is fined from 50,000 KRW up to 150,000 KRW (about 50 to 150 USD) per person . HoweverConcerning the influenza vaccination and cancer screenings, the gaps between SWs and the others were smaller than the gap in regular health checks. This is owed to the NHIS vaccination program and cancer screening program in South Korea which have contributed to improving the outcomes throughout the years. And yet, the gaps in the cancer screenings between SWs and the SE still must be acknowledged. According to a previous research, the two main reasons workers were unable to visit any clinic were ‘lack of time’ (68%) and ‘no substitute worker available in the business’ (18%) . Given tSocioeconomic gaps also must be noted. Among the four areas covered in On the other hand, workers with chronic diseases were more likely to get vaccinated, and this finding is consistent with previous studies , 36. ThiThe current study has several limitations. First of all, due to the cross-sectional nature of this study, findings are not causal estimation . We haveOur study elucidates gaps existing in the utilisation of the preventive services based on their employment status in South Korea. From the results of our study, improving access to preventive health services for NSWs, the SE, and UFWs seems to be an essential step to take. A study showed that the primary physician’s recommendation is one of the most powerful influences that enhances the uptake of cancer screenings . In addiIn conclusion, there are gaps in the utilisation of preventive services among South Korean workers depending on their types of employment. Therefore, improving access to preventive health care services for NSWs, the SE, and UFWs should be prioritised.


Background: Although an etiology of Kawasaki disease (KD) is unknown, an aberrant innate immune system in predisposed individuals has been proposed to play a key role in the development of KD vasculitis. Various etiological pathogens have been proposed as the trigger of KD and a scaled injury preceding symptom onset has been reported as one of them. Here, we report a 17-month-old Japanese female who was hospitalized due to high fever lasting for 4 days with infection ruled out as a cause. On admission, she displayed severe sunburn all over her body following a prolonged period of outdoor play 5 days ago. On the 5 day of illness, she developed complete KD. Serum levels of high mobility group box 1, a representative for damage-associated molecular patterns (DAMPs), were elevated during acute phase and continued to decrease during subacute phase. This unique course suggested the inflammatory process of KD involving innate immunity via DAMPs. Kawasaki disease (KD) is an acute, febrile and systemic vasculitis that primarily occurs in infants and young children . AlthougVarious etiological pathogens have been proposed as the trigger of KD, but none have been decisively established . In prevHere, we describe the case of a 17-month-old female who developed complete KD following scaled injury due to severe sunburn. Although the patient presented a severe ill condition on admission, she achieved complete defervescence along with the improvement of clinical manifestations after a single course of intravenous immunoglobulin (IVIG).9/L, with 68.0% segmented neutrophils and C-reactive protein (CRP) concentration of 15.3 mg/dL. Urinalysis and abdominal ultrasonography results were normal and rapid diagnostic test for adenovirus was negative. She was hospitalized and received intravenous cefotaxime, but symptoms did not improve. On the next day of hospitalization (5th day of illness), conjunctival hyperemia, erythema of the trunk of the body, redness of the lips, strawberry tongue, cervical lymphadenopathy, and redness at the Bacille Calmette-Guérin inoculation site emerged  and 9.3 kg (0.3 SD for corrected age), respectively. She was not on any medications. She had no contact with potential sources of infection in the 2 weeks prior to her admission. Her family members had been all well during the period. At the initial visit, she showed high fever of 40.4°C with infection ruled out as a cause. She displayed severe sunburn on large area of her body; first- and second-degree thermal skin injuries accounted for 32 and 29% of her body, respectively . Brunet  emerged . Fulfill emerged . Nose, tWe report the first case of children who developed complete KD after sunburn injury. Released DAMPs, such as HMGB1, due to the severe sunburn injury might be involved in inflammatory vasculitis and the clinical manifestations of KD.KD is a self-limiting disease, even in patients with KD who have severe CALs . During The current immunological concept on infectious diseases or infection-associated immune-mediated diseases, including KD, may have limitations to explain the immunopathogenesis of the diseases. However, same host immune cells and immune proteins are involved in all pathologic lesions of the diseases , 3. It wIn conclusion, this is a single case, but it is unique since it suggests the inflammatory process of KD, involving the DAMPs.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Institutional Review Board of Saiseikai Shimonoseki General Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.SO and SH led conceptualization and design of the analysis, analyzed and interpreted data, and drafted the initial manuscript. AM, YO, RH, SF, and YI contributed to data collection and critically reviewed the manuscript. Each author listed on the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for the manuscript. This manuscript has not been published or presented elsewhere in part or in entirety, and is not under consideration by another journal.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.


Cows housed indoors with cubicles are probably more restricted in their choice of lying posture and orientation compared with cows housed on pasture. We therefore studied lying postures on pasture in Uruguay and the Netherlands, and in cubicles in the Netherlands, also recording orientation on pasture in Uruguay and divider and bedding type in Dutch cubicles. Cows on pasture in Uruguay showed more long postures, lying on their belly with the neck stretched, and, per herd, cows preferred a specific lying orientation. Dutch cows on pasture showed more wide postures, lying on their side with three legs stretched, while in cubicles they showed more narrow postures, lying on their side with folded hind legs. More long and less short postures were seen in cubicles with soft floors and English dividers; more narrow postures were seen in cubicles with concrete floors. Wide postures were seen more in cubicles with mattresses and free-hanging dividers. We conclude that since cows in cubicles show more narrow postures than on pasture and cannot choose lying orientation, their choice in showing preferred behavior is restricted. More research is needed to study the consequences of restricted choice in lying behavior on the health and welfare of dairy cows.Cows housed indoors with cubicles are probably more restricted in their choice of lying posture and orientation compared with cows housed on pasture. We therefore compared lying postures on pasture in Uruguay and the Netherlands with lying postures in cubicles in the Netherlands, also recording orientation on pasture in Uruguay and divider and bedding type in Dutch cubicles. We visited one farm with four herds in Uruguay, doing live observations, and 25 Dutch farms, taking pictures of cows. Observations of 205 cows on pasture in Uruguay showed more long postures, lying on their belly with their neck stretched. Two herds preferred lying towards north and south, while one herd preferred west and east. Pictures of 217 cows on pasture in the Netherlands showed more wide postures (lying on the side with three or four legs stretched out). Pictures of 527 cows in cubicles in the Netherlands showed more narrow postures (lying on the side with hind legs folded). More long postures (lying on the belly with a stretched neck) and less short postures (lying with the head folded back) were seen in cubicles with soft floors and English dividers; more narrow postures were seen in cubicles with concrete floors. Wide postures were seen more in cubicles with mattresses and free-hanging dividers. We conclude that since cows in cubicles show more narrow postures than on pasture and cannot choose their orientation, their choice in showing preferred behavior is restricted. More research is needed to study the consequences of restricted choice in lying behavior on the health and welfare of dairy cows. Since the 1960s, most dairy cows in Europe and the USA have been housed in cubicles. Cubicles are partitioned places for the cows to lie down, separated by dividers. Cubicles have neck rails and brisket boards to keep the cows within the cubicle, and have them urinating and defecating outside the cubicle. Bedding materials within the cubicles can consist of sand or other soft materials, mats or mattresses, or sawdust on concrete floors. In loose housing systems with cubicles, cows enjoy freedom of movement, which is good for animal welfare . In a stFurthermore, in a cubicle, barn cows cannot choose in which direction to lie. It is reported that it matters to the cow in what direction she lies in relation to the magnetic axis of the earth ,5. GenerBedding material can affect lying time and ease of lying down, and thus the health and welfare of cows . In a stOur hypothesis is that cows on pasture are not restricted in their choice for a lying posture, and therefore on pasture will lie oriented towards the north and show more long and wide postures than in cubicles, while cows in cubicles might show more narrow and short postures. We expect cubicle design to influence lying postures, with more long and wide postures in more comfortable cubicles. The aims of the present study were (1) to determine the preferred orientation of cows lying on pasture in outdoor systems, (2) to investigate the postures of dairy cows lying on pasture versus in cubicles, and (3) to assess the relationship between cubicle design and lying posture. In this study, lying postures were recorded of dairy cows on 26 different farms—25 Dutch farms with a cubicle housing system and pasturing in summer, and one farm in Uruguay where cows were kept on pasture night and day, year-round. All cows were Holstein Friesian. Dutch as well as Uruguayan cows are high-producing animals, with an annual milk yield of 8000–10,000 kg per cow. The Uruguayan farm housed approximately 200 cows, while the Dutch farms varied in size. No selection for high or low of farm size or milk yield of the cows was done. Dutch farms were selected by snowball sampling: Farmers that were willing to cooperate brought in other farms that wanted to join the study. Four lying postures were distinguished , La Estanzuela, Uruguay, a dairy farm with 205 Holstein Friesian cows. This farm had a pasture-based system and was visited several times per day between 8 March and 13 April 2010 by two observers. Data were collected in the pasture during a period of six weeks. Four different herds were observed: herd 1 contained approximately 20 pregnant, non-lactating cows, while herds 2, 3, and 4 were non-pregnant and lactating and consisted of approximately 35 cows, 130 cows, and 20 cows, respectively. Cows were observed three to four hours after the start of morning milking (5.00 am.), when most of the cows were lying. The observations were done live, through binoculars, at a distance as far away as possible, and as a result the interference between the observers and the herd was insignificant. The shoulders of the cow were used as reference for determining which direction the cows were facing: north, south, east, or west. When the shoulders were pointing in the northern quarter, “north” was scored, and the same principle was used for the other orientations . In the Netherlands, 25 dairy farms with Holstein Friesian cows participated in the study. The average farm size was 99 ± 43 cows, with a range from 55 to 200 cows. The Dutch farms were visited in two rounds. The first 14 farms were visited once between 17 November 2011 and 19 January 2012, while the cows were housed indoors. During each visit, four hours were spent in the barn recording the postures of dairy cows that were lying down. In this time, the observers made three rounds through the barn to record cow postures. In order not to disturb the cows, the animals were photographed from outside of the feeding fence so that posture was visible, but cow numbers were not recorded. This resulted in a dataset of a varying number of lying postures of cows, with some cows recorded two or three times. Another 11 farms were visited twice between September 2016 and February 2017, once while the cows were on pasture and once while the cows were indoors. During each visit, postures of all lying cows were recorded. Observers again photographed cows from outside the feeding fence in order not to disturb the cows, but this time cow numbers were recorded if visible. Type of bedding material and type of cubicle divider was recorded for the Dutch farms in both rounds. Bedding material was categorized into three categories: soft bedding , hard floor (concrete) with (a thin layer of) sawdust, and mats or mattresses with sawdust. Three categories of cubicle dividers were distinguished: R-shaped dividers, free-hanging or U-shaped dividers, and English dividers see . No infoPosture data were recorded on one farm in Uruguay with four herds, and on 25 Dutch farms. In Uruguay, herd 1 was visited 10 times, while the other three herds were visited 20 times, resulting in 2116 live recordings of lying postures and orientations of cows on pasture. In 2011–2012, 14 Dutch dairy farms were visited once, resulting in 537 photographs of lying postures of cows in cubicles. In 2016–2017, 11 Dutch dairy farms were visited twice, resulting in 488 photographs of lying postures of cows, 271 in cubicles and 217 on pasture. During the Dutch farm visits in 2011–2012, no cow numbers were recorded, and observers walked three times through the barn to take photographs. Therefore, it was uncertain if observers recorded the same cow repeatedly during the same farm visit. That is why, for these data, only the observations of one walking round per visit were retained. We selected the round that resulted in the most recordings, to retain the largest amount of data. This resulted in 262 recordings. During the Dutch farm visits in 2016–2017, cow numbers were read from the neck collars and recorded by the observers  and only one round of observations was made during each visit; for those data, the observations of unidentified cows were removed, as well as repeated recordings of the same cow on the same day. This resulted in 265 recordings. In Uruguay, cow numbers were also read from the neck collars by the observers, always using binoculars. Recordings of unidentified cows were removed, reducing the data from 2116 to 1306 recordings; furthermore, repeated recordings of the same cows on one observation day were removed; this reduced the data to 357 recordings. In the end, the data added up to 1101 recorded postures—527 in cubicles and 217 on pasture in the Netherlands, and 357 on pasture in Uruguay. All 2116 Uruguay records were used to determine the observed lying orientation of the cows. To compare lying posture of the cows indoors and outdoors, and to determine the relation with bedding material and divider type, the data were reduced to unique cow numbers per observation day, to avoid repeated recordings of the same cow.To determine the preferred orientation of the cows on pasture in Uruguay, a non-parametric one sample chi-square test was used. The null hypothesis was that cows have no preferred orientation, so the observed probability was compared to the hypothesized probability of 0.25 for the four orientations—north, east, south and west. Furthermore, a chi-square test was used to determine whether orientation of the cows differed between the herds. To determine which groups differed from each other, adjusted residuals (ARs) were calculated using a post hoc test .To determine whether outdoor lying postures of the cows on pasture in Uruguay differed within the farm, a non-parametric one-sample chi-square test was used. Again, the null hypothesis was that cows have no preferred lying posture, and therefore the observed probability was compared to the hypothesized probability of 0.25 for the four lying postures of long, short, wide, and narrow. Furthermore, a chi-square test was used to determine whether postures of the cows differed between the herds within the farm. To determine which groups differed from each other, adjusted residuals were calculated using a post hoc test. Indoor and outdoor postures for the Dutch cows were compared using a chi-square test. To determine which groups differed from each other, adjusted residuals were calculated as post hoc test.To determine the relation between lying posture and cubicle properties, a chi-square test was used, where lying postures were compared between cows in cubicles with three cubicle divider types and three types of bedding materials. To determine which groups differed from each other, adjusted residuals were calculated using a post hoc test. This analysis was done only using data from the indoor observations.p values were <0.05, and when adjusted residuals (ARs) were >1.96 or <−1.96.All analyses were performed using SPSS Statistics 24 for Windows. Results were considered significant when p < 0.000)  = 9, < 0.000) .p = 0.01) and herd 3 , most cows in herd 4 were oriented towards the north and south , and most cows in herd 2 were oriented towards the west and east .When testing preference for orientation within each herd in a one-sample chi-square test with the null hypothesis of equal preferences of 25% per orientation, all herds show significant preferences. Most cows were oriented towards the north in herd 1 . Cows showed mostly long postures (p < 0.05) in all four herds, with less short, wide, and narrow postures (p = 0.455). Lying postures of cows on pasture in Uruguay did not occur with equal probabilities within herds . Cows in cubicles showed more short postures (AR = 3.1) and cows on pasture showed more wide postures (AR = 4.5). Fully outstretched postures were not seen in the cubicles; however, a posture with both hind legs and one front leg open were also considered a “wide” posture. Indoor and outdoor postures are shown in When comparing lying postures from cows on pasture (n = 217) and in cubicles (n = 574) in the Netherlands, we found that lying postures differed between indoors and outdoors . On soft floors, more long postures were observed (AR = 4.4) and less short (AR = −3.2) or wide (AR = −2.4) postures. On hard (concrete) floors, more narrow postures were observed (AR = 5.0) and less long (AR = −3.7) or wide (AR = −2.4) postures. Finally, on mats or mattresses, more short (AR = 2.7) and wide (AR = 3.7) postures were seen, and less long (AR = −2.2) or narrow (AR = −2.3) postures. For the Dutch cows lying in cubicles, mostly long (39.1%) and narrow (33.2%) postures were observed, while short (12.0%) and wide (15.7%) postures were seen less often. Relations between lying posture, bedding type, and cubicle dividers were calculated only for the indoor observations on the Dutch farms. Of the 517 observations, 214 (41%) were of soft bedding , 49 (9%) were of hard floors (concrete with sawdust), and 264 (50%) were of mats or mattresses with sawdust. Bedding type was related to the lying postures of the cows  (Pearsonp < 0.001). Wide postures were observed more in cubicles with U-shaped dividers (AR = 4.6) and less in cubicles with R-shaped dividers (AR = −3.0) or English dividers (AR = −2.5). Short postures were seen more in cubicles with R-shaped dividers (AR = 6.8) and less with U-shaped (AR = −3.8) or English (AR = −2.2) dividers. Long postures were seen more in cubicles with English dividers (AR = 2.2) and narrow postures were seen less in cubicles with R-shaped dividers (AR = −2.2). Of the 517 observations, 117 (22%) were of R-shaped cubicle dividers, 284 (54%) were of free hanging or U-shaped dividers, and 126 (24%) were of English dividers. Divider type was related to the lying postures of the cows  (Pearsonp = 0.000). More long postures were seen on soft floors with English dividers (AR = 4.6), more short postures were seen on mats or mattresses with R-shaped dividers (AR = 6.9), more wide postures were seen on mats or mattresses with U-shaped dividers (AR = 4.4) or English dividers (AR = 3.2), and more narrow postures were seen on hard floors with R-shaped dividers (AR = 3.1) or English dividers (AR = 3.8). Of the nine possible combinations of bedding material and bedding type, eight were observed: soft floors with R-, U-, or English dividers, concrete floors with R- or English dividers, and mats or mattresses with R-, U-, or English dividers . Lying pIt was reported  that wheCows lying on pasture in Uruguay showed mostly long postures, while cows in the Netherlands showed more wide postures on pasture, and more short postures in cubicles. This might indicate that cows in cubicles are restricted by the limited space of the cubicle, while on pasture they have enough room for long or wide postures. Short or wide postures were observed less than long and narrow postures, and it seems that these are the less-preferred postures for dairy cows. This is in line with a study with cows on compost bedding, where hardly any cows laid flat on their sides . In the The wide postures that we recorded were defined as both hind legs open and one or two of the front legs open. The completely outstretched posture, with all four legs open, was not seen in the cubicles and only once on pasture in the Netherlands. In Uruguay, no distinction was made between a wide posture with one or with two legs open, so we cannot distinguish between those two postures in the analysis. There might be a difference for the cow between lying with one or with two front legs open; in cubicles, stretching out two front legs is more difficult, if not impossible, especially if there is a brisket board present. This could explain why this posture was not observed in the cubicles. It seems that cows are less restricted in their lying behavior when they have a soft surface to lie down on (such as mattresses with sawdust or deep-litter bedding), and when dividers are shaped in a certain way. English-type dividers offer the cows more space to stretch their legs than R-shaped dividers. U-shaped or hanging dividers are supposed to offer the cows even more room to put their legs. The cows did show more wide postures in cubicles with those dividers, but less long postures. In Uruguay, live observations were done by one observer, using binoculars. No repeated observations were done, so no intra-observer reliability analysis could be carried out. It would have been better to use two observers and to calculate an inter-observer reliability, but we did not have more observers available at that time. In the Netherlands, photographs were taken and analyzed by multiple observers. A reliability analysis was done at the start of the study. We did not expect the agreement to decrease after the initial moderate agreement  between trainer and observers. Following the first reliability test, no more reliability tests were carried out during the study. When we checked the reliability after the study, however, the agreement between observers and the veterinarian was fair . This was lower than expected. It was not possible to check the inter-observer reliability afterwards, since the observers that carried out the initial coding of the photographs were not available anymore. The reason that the agreement was fair to moderate might be that the different postures were sometimes difficult to distinguish from each other. For example, the long postures, with cows lying on their abdomen, and the wide or narrow postures, with cows lying on their ventral side, might resemble each other when the spine of the cow is in between both postures. This might explain the rather low kappa value between the observers and the veterinarian. For categorizing the pictures, it was important how the spine of the cow was positioned, while in our study we were more interested in whether or not the body and legs of the cow were stretched out and relaxed. For future research, a different set of pictures separating different lying postures for dairy cows might be developed, based on relaxation of the body and legs and not on position of the spine. When assessing welfare, the freedom to show natural behavior is one of the criteria for good welfare . In the


Colorectal cancer is a major public health problem. A way to decrease this cancer is through dietary behavioural changes. The aim of this study was to determine the effects of education on dietary behaviour based on the health belief model (HBM) using multimedia.n = 48) and a control group (n = 50). The HBM group received an audiovisual compact disc (CD) that contained information about nutritional behaviour of colorectal cancer (CRC) prevention based on HBM that lasted 45 min. Both groups completed questionnaires regarding demographic factors, knowledge and HBM constructs, and a three-day dietary recall at the beginning of the study, 1 week after, and 3 months after the education. The outcome of this study was measured by the amount of food servings consumed and dietary micronutrient intake.In this clinical trial study, 98 participants were randomly allocated to an HBM group (P < 0.001), severity (P < 0.001), and benefits (P < 0.001) were perceived to be higher, and knowledge (P < 0.001) was increased in the HBM group compared to control group 3 months after education. There was a significant increase in fruit and vegetable (P < 0.001) and dairy (P = 0.001) intake and a significant decrease in red meat servings (P = 0.016) in the HBM group compared to the control group. Also, intake of vitamin D (P < 0.001), folate (P < 0.001), calcium (P = 0.008), and dietary fibre (P < 0.001) was increased in the HBM group compared to the control group 3 months after education.At the baseline, there were no significant differences between groups regarding demographic factors. Findings showed that self-efficacy (Education plans based on HBM and implemented through multimedia can change nutritional beliefs and behaviours for the prevention of colorectal cancer. About one million new cases of colorectal cancer (CRC) are detected every year worldwide . Recent Today, it is estimated that 30%–40% of CRC cases are linked to nutrition and other lifestyle factors . The incDietary interventions are difficult to develop and evaluate because they frequently require changes in complex behaviours . BehavioBased on this model, if people believe that they are susceptible to diseases, such as CRC (perceived susceptibility); understand the risk depth and severity of CRC complications in their life (perceived severity); consider proposed ways, including healthy eating, that can decrease risk or severity of CRC (perceived benefits); and are able to overcome obstacles for action, including cost and difficulty of healthy eating (perceived barriers), they will be more likely to participate in health-improvement programs .In several studies, the effectiveness of verbal education on the preventive nutritional behaviour of osteoporosis, based on HBM, has been confirmed –23, as wNowadays, researchers have utilised technological developments to provide interventions for health promotion. Multimedia allows for users to easily interact with content due to its dynamic and attractive graphical effects and use of various visual and audio media. Through this method, the learner will find an opportunity to practice and reach a proficiency level. So, given the increasing use of computers as a communication tools, we can teach educational concepts in a charming and diverse atmosphere with the help of multimedia , 26.Considering the importance of nutritional behaviour in preventing CRC, this study aimed to determine the effect of education, using multimedia based on HBM, on nutritional behaviour for CRC prevention.This clinical trial study was performed from November 2017 to March 2018 to evaluate the effects of HBM-based education on nutritional behaviours of CRC prevention in people over 50 years-old covered by three health centres in Bushehr, a city in the southwestern province of the same name in Iran.The inclusion criteria of this study included being older than 50 years, having no history of CRC in their family, having a compact disc (CD) player, being able to read and write, and having a willingness to participate in the study, and exclusion criteria included inability to continue participation for at least 3 months.β = 90% power test and α set at 0.05 (two-tailed). In this formula, μ and S represent mean and standard deviation of total energy  in post-treatment between the HBM group and the control group, respectively, as in Abood’s study ; thus, people were divided into two groups based on the order in which they answered their telephones, so that the first person was assigned to the HBM group, the second to the control group, and so on.From the 50 participants in the HBM group, two people were not willing to continue participation in the study and were excluded. Ultimately, 48 people in HBM group and 50 people in the control group completed the study see .At the beginning of the study, participants in both groups completed a written consent form and questionnaires, which collected demographic information, knowledge, and HBM constructs, and a three-day dietary recall. Completion of the questionnaire required 30 to 45 min. Then, the HBM group members received an audiovisual CD that contained 45 min of material. The following topics were covered by this educational CD:Information about CRC; the prevalence and incidence of this cancer; and points about risk factors, including unhealthy dietary habits, such as a shift to a low-fibre diet with high fat and the consumption of ready meals, and their effective roles in the development of CRC (perceived susceptibility).Tips about complications and problems associated with CRC and the high cost of treatment (perceived severity).Information about the benefits of increasing the consumption of fruits and vegetables, the benefits of a high-fibre diet, the benefits of restricting meat and high-fat foods, the need to receive adequate levels of vitamin D, and the benefits of consuming foods containing folate and calcium for the prevention of CRC (perceived benefits).Providing educational videos on how to cook a variety of healthy, non-meat and vegetable-based foods (increasing self-efficacy through performance accomplishment as well as reducing perceived barriers).Follow-up on nutritional behaviour was done every 2 weeks in the first month and once in the second month by telephone, and people who changed their diet received verbal persuasion . The educational CD was auto-run and was displayed by clicking on any field. A week after package delivery, researchers contacted each person to ensure that the educational CD had been opened by asking questions about its content. The participants of the control group did not receive training materials until the end of the study. Participants in both groups, 1 week after the completion of the first phase of questionnaires, completed the questionnaires related to knowledge and HBM constructs and, 3 months after the second stage, completed questionnaires related to knowledge, HBM constructs, and a three-day dietary recall.The final questionnaire included three sections comprised of demographic factors, questions regarding the patient’s knowledge and HBM constructs, and a three-day dietary recall questionnaire. The first section of the questionnaire evaluated demographics and predisposing factors for CRC, including history of constipation (disposing of dry stool less than three times a week), gastrointestinal disorders, physical activity , and use of tobacco (use of cigar or water pipes in the past month).The section related to knowledge and HBM constructs included 64 items. Knowledge regarding CRC was evaluated by 10 items, which included right answers (1 point) and wrong answers (0 points). The HBM construct questionnaire include perceived susceptibility (six items), perceived severity (15 items), perceived self-efficacy (10 items), perceived benefits (nine items), and perceived barriers (14 items). Items related to perceived susceptibility, and severity constructs were extracted from Tahmasebi et al.’s study ; items oThe third section of the questionnaire measured the nutritional behaviour with a three-day dietary recall questionnaire. The questionnaire was completed through a semi-structured interview. In the interview, subjects were asked to recall their diet diaries over the last 3 days, which included two working days and one holiday. In this study, dietary micronutrients intake was calculated by Nutritionist IV software; additionally, the number of food servings consumed, the intake of dietary micronutrients , and saturated fatty acids were evaluated.Ten experts, including eight health education specialists and two nurses whose research area was CRC, were asked to evaluate content validity of the constructs using the content validity ratio (CVR). For this purpose, the panel assessed each item using a three-point Likert-type scale, where 1 = essential, 2 = useful but not essential, and 3 = unessential. For the 10-expert panel, a CVR score of 0.62 or higher indicates good content validity . The CVRt-test, repeated measurement ANOVA, a Wilcoxon signed-rank test, and a Mann-Whitney test were used for data analysis. The Chi-square test was used to compare the two groups with respect to the qualitative variables, and an independent t-test was utilised for quantitative variables such as age. Paired sample t-test was used to compare knowledge and constructs between two time points in each group. The repeated measurement ANOVA was used to compare the mean scores of constructs within and between the groups. The Mann-Whitney test was used to evaluate the mean difference of food servings and dietary micronutrients intake before (baseline) and 3 months later (second follow-up) in the two groups, and a Wilcoxon signed-rank test was used to evaluate the mean difference of food servings and dietary micronutrients intake at the baseline and three month later in each group because mean differences did not have normal distribution. A P-value of less than 0.05 was considered statistically significant.The data was analysed by the Statistical Package for the Social Sciences software, version 22.0. Descriptive statistics, a Chi-square test, independent and paired To observe ethics in the research, participants could be excluded from the study at any time, and all the information collected was confidential and anonymous. Written informed consent was received from all participants.P = 0.055). The mean (SD) BMI in the HBM group and control group was 26.77 (3.95) and 27.46 (4.17), respectively (P = 0.404). Also, in terms of predisposing factors for CRC, the two groups were similar. For instance, in the HBM group 20.8% (n = 10) of participants and in the control group 12% (n = 6) smoked (P = 0.282). Other demographic characteristics and predisposing factors of CRC are shown in In total, 48 participants in the HBM group and 50 participants in the control group completed this study. At the baseline test, there were no significant differences between the HBM and control groups regarding demographic and predisposing factors. For instance, the average age of participants in the HBM group was 55.60 (4.17), and the average age in the control group was 57.74 (6.43) (P = 0.356) and perceived barriers (P = 0.118). The results demonstrated an increase in knowledge, perceived severity, perceived self-efficacy, and perceived benefits. Based on the paired t-test, there were significant changes in baseline and 1 week later, baseline and 3 months later, and 1 week and 3 months later in knowledge, severity, and benefit (P < 0.001). Also, there were significant changes in baseline and 3 months later, and 1 week and 3 months later in self-efficacy (P < 0.001).Also, the participants in the HBM and the control groups were similar in their health beliefs related to CRC and nutritional behaviour of CRC prevention at baseline. However, the differences between the two groups were statistically significant after education in several constructs refer to . CompariP = 0.746) and perceived barriers (P = 0.099), but knowledge, perceived severity, self-efficacy, and benefits were perceived to be higher in the HBM group compared to the control group  and dairy intake (P = 0.001) in the HBM group after education. Also, there was a significant increase in micronutrients, such as vitamin D (P = 0.003), folate (P = 0.003), calcium (P = 0.026), and dietary fibre (P = 0.011) in the HBM group. In the control group, the results demonstrated a significant increase in bread serving intake (P = 0.006) and red meat (P = 0.045), and significant decreases in fruit and vegetable (P = 0.002) and white meat servings (P = 0.011) after education. Also, there was a significant decrease in vitamin D (P = 0.004), folate (P < 0.001), and dietary fibre (P < 0.001) in the control group after education  and dairy servings (P = 0.001) as well as vitamin D (P < 0.001), folate (P < 0.001), calcium (P = 0.008), and dietary fibre intake (P < 0.001) increased, while red meat servings (P = 0.016) decreased in the HBM group compared to the control group (see Comparison of the mean differences of food servings and dietary micronutrient intake before and 3 months after education in both groups showed that the mean difference in fruit and vegetable (roup see .The goal of this study was to evaluate an HBM-based nutrition intervention for CRC prevention in people over 50 years-old in Iran. The intervention was designed to change dietary behaviour in a positive manner by modifying specific health beliefs while increasing nutrition knowledge and improving dietary behaviours related to CRC through multimedia education. Health beliefs, except perceived susceptibility and perceived barriers, significantly changed.Intervention with the use of the educational CD was successful and appears to be associated with producing significant increases in nutrition knowledge and significantly decreasing red meat consumption while increasing fruit and vegetable, and dairy intake. In this study, micronutrients, such as vitamin D, folate, calcium, and dietary fibre, increased, but education failed to reduce energy intake and consumption of saturated fat. This supports our hypothesis that a health education program based on HBM can be effective in promoting the adoption of nutritional behaviours to prevent CRC.Increasing the participants’ knowledge of the need for CRC prevention is likely to improve the participants’ healthy behaviour . ParticiAmong the constructs of the health belief model, the perceived susceptibility and barriers were not changed after education. Previous studies of the relationships between healthful behaviours and HBM constructs have also noted that perceived susceptibility and healthful behaviours are not always related , 37, andAn extensive review of the literature has shown that the strongest predictor of nutrition-related behaviour change is the benefit-cost ratio, so that when a concrete change in nutrition behaviour occurs, the perceived benefits of the behaviour outweighs the perceived barriers , 37, 39.In this study, multimedia education based on HBM increased the consumption of fruits and vegetables and dairy products and increased the intake of micronutrients, including vitamin D, folate, calcium, and dietary fibre. In Manios’s study, education based on HBM increased consumption of dairy products and intake of calcium and vitamin D . Also, iIn Abood’s study, an increase in the perceived benefits of a healthy diet reduced fat intake but was not effective in changing the consumption of fruits and vegetables , which cThe present study may have limitations. Because diet was not observed, self-report bias may have occurred. Nevertheless, self-report, because of its practicality and realism, is the norm in nutrition studies. Also, some participants delayed their use of the educational CD, citing having too much work to do as the reason why. Also, we do not claim that completely random selection was performed, but random allocation into the two groups was done.According to the results obtained, it seems that design and implementation of a training program using HBM has positive impacts on the changes of dietary behaviour for CRC prevention, and the use of multimedia, due to its charm and ease of use, seems to be a desirable medium for changing nutritional behaviour.