Diabetes mellitus (DM) was prone to happening in posterior circulation infarction (POCI) and DM also has the impact on the lipids, our study was to investigate the correlation between lipid compositions and POCI.Data was collected from the patients with acute ischemic stroke (AIS) hospitalization in Affiliated Drum Tower Hospital of Nanjing University Medical School from October 2008 to May 2012. Lipids and other risk factors in the different populations were investigated in relation to occurrence of POCI based on the infarction location.Six hundred ten patients with AIS were included in this study, which had 428 with anterior circulation infarction (ACI) and 182 with POCI. Elevated Triglyceride (TG) and decreased High density lipoprotein cholesterol (HDL-C) were seen in the POCI of total populations and AIS without DM compared to the ACI, but not in the populations of AIS with DM, so did the elevated TG/HDL-C ratios. Also, the percent of low HDL-C level and high TG level were higher in POCI group than that in ACI group. Furthermore, single factors logistic regression demonstrated that TG, HDL-C and TG/HDL-C ratio were correlated to the POCI whatever in the total populations or AIS without DM, but this kind of trend just maintained in the populations of AIS without DM after adjusting by relative interference factors.Dyslipidaemia was prone to happening in POCI compared to ACI in the non-diabetic populations, which was correlated to the pathogenesis of POCI. Acute ischemic stroke (AIS) was divided into anterior circulation infarction (ACI) and posterior circulation infarction (POCI) according to the infarction location, a difference was made between ACI and POCI in terms of clinical manifestations and prognosis. Despite POCI just accounting for 20% of AIS, and it would have a relatively good outcome, but it had high rate of recurrence. About the risk factors, was there has any difference between ACI and POCI, the conclusions was inconsistent.As the important risk factors of AIS, diabetes mellitus (DM) had obvious impact on both of subtypes, but DM was more prone to linked with POCI , which wDiabetes mellitus had obvious impact on the lipids, which mainly reflects in the rise of Triglyceride (TG) and fall of High density lipoprotein cholesterol (HDL-C) , 7. BothThere was more percentage of DM in the POCI, also, DM would have the impact on the expression of lipids. Based on the background above, we wonder if there would have more dyslipidaemia in the POCI compared to the ACI, which maybe act as the important pathogenic factors of POCI.Data for this retrospective study was collected from the hospitalization patients of department of neurology in Affiliated Drum Tower Hospital of Nanjing University Medical School from October 2008 to May 2012, AIS was defined as symptom onset within7 days. The study was approved by our institutional committee. Patients who were found with pre-stroke impairment or insulin-dependent diabetes mellitus were excluded. At admission, plain CT scan of the head was done to rule out haemorrhage and MRI was done to identify the new infarction and the location of the lesion, otherwise such patients would also be excluded. The stroke subtype (ACI and POCI) was defined based on the classification of Bogousslavsky’s .Hypertension and DM were defined as participants with history of relative disease or new diagnosis according to the China hypertension and DM standard (just non-insulin-dependent diabetes were included), while atrial fibrillation (AF) was defined as participants with history of AF or new diagnosis by electrocardiogram.Venous blood was collected following overnight fasting for at least 12 h, and analyzed by a solid-phase chemiluminescent immunometric assay on Immulite 2000 with the manufacturer’s reagents as directed to detect total bilirubin (Tbil), direct bilirubin (Dbil), blood glucose (BG), uric acid (UA), TG, total cholesterol (TC), HDL-C, Low density lipoprotein cholesterol (LDL-C).p < 0.05.Statistical analyses were performed with SPSS 17.0 software. The results are expressed as constituent ratio for categorical variables (χ2 test) and as mean ± SEM for the continuous variables (t-test) depending on their normal distribution. The level-risk relationship was expressed as an OR, with a corresponding 95% CI, through logistic regression. Level of significance for statistical purposes was stated at Six hundred ten patients with AIS were included in the trial, among them, 385 were male and 225 were female, whose age range from 15 to 92. There were 202 patients who had DM coexisted with AIS. Infarction happened to the ACI was 428, and POCI was 182.P = 0.001), the same trend was existed in hypertension and BG. While AF and Dbil were more prevalent in ACI. Also, the difference of TG and HDL-C between ACI and POCI was significant, as shown in Table There was 29% of DM in the ACI, while 42.9% in the POCI, the difference was significant P = 0.00, the samDM would have the impact on express of lipids , which hHDL cholesterol concentrations were grouped into 3 levels: < 1.03, 1.03–1.53 and > 1.53 mmol/l. We analyzed the difference of distribution of HDL-C between the POCI and ACI whenever in the total or AIS without DM populations, and found that, the percent of low HDL-C level was higher in POCI group than that in ACI group. Also, TG concentrations were grouped into 2 levels: < 1.7 and > 1.7 mmol/l, we found, the percent of high TG level was higher in POCI group than that in ACI group both in the total or AIS without DM populations (Fig. Dyslipidaemia in the POCI was mainly resulted from the change of TG and HDL-C, while the ratio of TG/HDL-C could be used as the marker in prognosis of vascular events , so we cAll the patients of AIS, were divided into two groups named ACI and POCI based on the location of infarction. To study the risk factors of POCI, we first performed the single-factor logistic regression, and found that TG, HDL-C and TG/HDL-C ratio were correlated to the POCI, but after multivariable logistic regression analysis, the correlation was disappeared Table .Table 3RPopulations of AIS without DM were also divided into ACI and POCI, logistic regression demonstrated that TG, HDL-C and TG/HDL-C ratio were correlated to the POCI, whatever in the single-factor or multivariable logistic regression Table .Table 4ROur investigation was a retrospective study of patients with AIS in which the correlation between POCI and lipids was evaluated. We first confirmed that there was more percentage of DM in the POCI compared to the ACI, while DM would have the impact on the expression of lipids, which has been identified in our previous study . We hypoThe association between DM and POCI has been proved in previous studies , 16. In Dyslipidaemia was prone to happening in the diabetic populations , 18, whiLow levels of HDL-C had been proved correlated with AIS –25, but Perhaps this kind of infarction location difference also shown difference of the expression of HDL-C and TG, but compared to the influence of DM, the former is negligible, and finally determined that there had no difference of HDL-C and TG between ACI and POCI in the diabetic patients. In order to confirm whether our hypothesis was right, we studied the risk factors of POCI in total and patients without DM.We observed the elevated TG/HDL-C ratio in the POCI rooted from the rise of TG and fall of HDL-C, then, logistic regression demonstrated it was correlated to the POCI just in the non-diabetic populations, which indicated that elevated TG/ HDL-C ratio was an important risk factor in the pathogenesis of POCI in the non-diabetic populations. Elevated TG and decreased HDL-C were thought to be asatherogenic dyslipidaemia  and the Our current study provided the evidence that high level of TG and low level of HDL-C, furthermore, elevated TG/HDL-C ratio, were correlated to the occurrence of POCI in the non-diabetic populations. We would certainly give enough attentions to the dyslipidaemia in the diabetic patients , but to


Background: Even though it is well-known that iron deficiency is the result of chronic kidney disease (CKD), whether iron will affect kidney function and disease in the general population is not clear. We thus conducted a nationwide cross-sectional study using data from the China Health and Nutrition Survey (CHNS) to assess the relationship of iron status with estimated glomerular filtration rate (eGFR) and CKD among general adults.Methods: A total of 8,339 adults from the China Health and Nutrition Survey in the wave of 2009 were included to assess the association between iron status and eGFR/CKD. Serum ferritin (SF), transferrin, soluble transferrin receptor (sTfR), and hemoglobin (Hb) were measured. The relationship of iron status and eGFR was evaluated by using multi-variable linear regression model. The effect of iron status on the odds of CKD was calculated by logistic regression model.Results: For the association between iron status and eGFR, every 100 μg/L increase in SF was correlated with 0.26 ml/min per 1.73 m2 (95% CI: 0.08–0.44) decrease in eGFR, and every 5 mg/L increase in sTfR was associated with a decrease of 6.00 ml/min per 1.73 m2 (95% CI: 3.79–8.21) in eGFR. There were no significant associations between Hb or transferrin with eGFR. For the association between iron status and CKD, every 5 g/L increase in sTfR was associated with an odds ratio of 3.72 (95% CI: 2.16–6.13) for CKD. The concentrations of Hb were associated with the odds of CKD in a U-shaped manner, with the lowest risk in the Hb range of 136–141 g/L. There was a positive correlation between SF concentration and CKD prevalence but not in a dose–response manner. The odds of CKD for participants in the highest tertile increased by 28% (98% CI: 1–63%) compared with those in the lowest tertile.Conclusion: The concentration of SF and sTfR was positively correlated with the odds of CKD, and Hb was associated with the odds of CKD in a U-shaped manner. Further large prospective researches are warranted to confirm these findings. Affected by the global population aging, chronic kidney disease (CKD), the 17th leading cause of death worldwide –4. MoreoAs an oxidative stressor, body iron overload may transform less active free radicals into more active hydroxyl radicals. The activated radicals can have an effect on DNA, proteins, lipids, and metabolite profiles, thus leading to tissue damage and dysfunction . On the It is well-known that iron depletion is a consequence of CKD, and the supplementation of iron has been widely used as prevention and treatment of anemia in patients with CKD . HoweverThe participants were from the China Health and Nutrition Survey (CHNS), which has been elucidated in detail in previous publications , 16. Brin = 86), iron markers , diet (n = 104); with pregnancy status (n = 63); or without physical examination (n = 442) were excluded. Consequently, 8,339 participants were finally included to assess the relationship of iron status and eGFR/CKD.2 was defined as CKD  and age in years.2). The structured questionnaires were adopted to collect information on gender, age, educational level, smoking, and drinking habit. Three consecutive 24-h dietary recalls (2 work days and 1 weekend) at the individual level, or weighted food stocks for the same 3 days at the household level were selected to evaluate diet intakes  was calculated as weight (kg) divided by the square of height  for categorical variables or mean (SD) for continuous variables.All statistical analyses were conducted using R 3.3.2. , and two-sided Multivariable linear regression model was adopted to investigate the relationship of iron status and eGFR. We used logistic regression model to calculate the effect of iron status on the odds of CKD. Three models were adopted: Model 1, without any adjustment; Model 2, adjusting for age , gender , educational level , smoking habits (never or ever), drinking (yes or no), total energy intake , protein intake , fat intake , and carbohydrate intake ; Model 3, further adjusting for CKD (not for the relationship between iron status and CKD) and BMI . We used deciles to draw the dose-response relationship between iron status and eGFR/CKD.2), smoking status (never or ever), and drinking (yes or no). Each potential modifier was examined in a separate model by adding a multiplicative interaction term .Subgroup analyses were also conducted to investigate whether the associations were modified by sex , age (<60 or ≥60 years), BMI  in eGFR, and every 5 mg/L increase in sTfR was associated with a decrease of 6.00 ml/min per 1.73 m2 (95% CI: 3.79–8.21) in eGFR. There were no significant associations between Hb or transferrin and eGFR.The associations between iron status and eGFR are presented in The associations between iron status and odds of CKD are presented in Subgroup and sensitivity analyses generally yielded similar results .To the best of our knowledge, this is the first study to investigate the relationship between SF, transferrin, sTRF, and Hb levels with eGFR and odds of CKD in the same population in general Chinese population. We found that both SF and sTfR were negatively correlated with eGFR. Correspondingly, SF and sTfR were positively associated with the prevalence of CKD. Moreover, we also observed a U-shaped association between Hb and the prevalence of CKD.Even though it is well-known that iron deficiency is the result of CKD, whether iron status is associated with the risk of CKD in general population is unclear. Several studies previously investigated the associations between iron status and CKD/renal function in general population with insosistent results –31, and sTRF, uninfluenced by inflammation degree, has been identified as a better indicator of iron deficiency because it helps to diagnose iron deficiency that coexists with anemia of chronic disorders. Unfortunately, a limited number of studies investigated the association between transferrin/sTRF/Hb and CKD. However, our finding of the positive association between sTfR and CKD is consistent with Alam et al., who observed high sTRF levels in patients with CKD than those without CKD . This asThe potential mechanism for the relationship of iron status and CKD/eGFR is unclear. It appears that inflammation and oxidative stress are two of the key factors linking the association of iron with CKD. SF, an acute phase protein, was associated with systemic inflammation and total body iron storage . PreviouOur study has several important strengths. First is the population-based, large-scale, national study design. The CHNS selected a large group of provinces, covering about 56% of the Chinese population, and these selected provinces represented a wide range of demographic and economic disparities in China . AnotherThe study also has some limitations. First, the cross-sectional study design makes it impossible for us to investigate the causal association between iron status and eGFR/CKD. It is also possible that the association is due to impaired iron absorption and/or having received more iron given anemia among patients with CKD. Further prospective cohort studies are warranted to verify the association. Second, we lack information on economic status. However, we adjusted the effect of education, which is an important indicator of individuals' income. Third, we excluded 868 (9.43%) adults with missing information in our data analysis. Potential selection bias cannot be ruled out. However, there is no evidence suggesting that the participants who were included and excluded had significantly different levels of SF (137.72 vs. 141.04 μg/L), transferrin (2.87 vs. 2.94 g/L), sTfR (1.47 vs. 1.47 mg/L), or Hb (141.38 vs. 140.98 g/L).In conclusion, we found that SF and sTfR were positively correlated with the prevalence of CKD, and Hb was negatively correlated with the prevalence of CKD in the general population. Further prospective studies are warranted to verify this causal association in populations with high risk of CKD, as well as to clarify the potential mechanisms.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the University of North Carolina at Chapel Hill, and the National Institute of Nutrition and Food Safety and the Chinese Centre for Disease Control and Prevention. The patients/participants provided their written informed consent to participate in this study.YZ and ZY were the project lead for the current study. XiaL, NL, and LC searched the database and extracted data. YZ, XZ, and XinL conducted data and statistical analysis. YZ wrote the manuscript. KY and YC provided significant advice about the manuscript. ZY and ZW reviewed and revised the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Solid pseudopapillary tumors (SPTs) of the pancreas are uncommon neoplasms, first reported in 1934, well described by Frantz in 1959, and later further characterized by Hamoudi in 1970. Ninety percent of these tumors occur in young females in their second to third decade of life. An interesting case of a persistent solid pseudopapillary neoplasm is described in this report.Case presentation: A 24-year-old woman from a Middle Eastern country presented with an 8.2 × 7.6 cm heterogeneous-enhancing lesion growing within the uncinate process of the pancreas. She had first experienced symptoms at the age of 12 years. Imaging studies showed that the mass closely abutted the superior mesenteric vein as well as the superior mesenteric artery (SMA). The patient underwent an open cholecystectomy and a classic pancreaticoduodenectomy. During the resection, the SMA was transected due to tumor adherence. The vessel was subsequently reapproximated in an end-to-end manner. On the first postoperative day, thrombosis of the SMA occurred and a bile leak developed. The patient returned to the operating room for SMA embolectomy and for repair of a hepaticojejunostomy leak, with redo of the biliary-enteric anastomosis. Histopathological examination showed solid pseudopapillary-arranged cells and cystic areas, showing strong cellular immunoreactivity for CD56, CD10, vimentin, and β-catenin, and weak diffuse staining for synaptophysin. The tumor stained negative for chromogranin A, trypsin, AE1/AE3, and E-cadherin. Molecular genetic analysis was negative for the MYB gene deletion. At nearly 1 year of follow-up, the patient is well with no evidence of tumor recurrence.Conclusion: SPTs of the pancreas should be included in the differential diagnosis of pancreatic tumors, especially in young women. Ninety percent of SPTs occur in young women in their second to third decade of life.6 One hypothesis posits that the tumor is related to sex hormones, although this theory has not been confirmed. Surgical resection is the mainstay of therapy and an adequate surgical resection generally results in long-term tumor-free survival. SPTs can be quite different from other pancreatic tumors in radiological and pathological findings. The cellular origin of SPTs and tumorigenesis, while now thought to be embryonic in origin, remains an enigma.Solid pseudopapillary tumors (SPTs) of the pancreas are a rare neoplasm accounting for 0.13–2.76% of all pancreatic tumors.A 24-year-old woman from a Middle Eastern country presented to the Jefferson Pancreas, Biliary and Related Cancer Center for evaluation of a recurrent pancreatic mass. She complained of right upper quadrant fullness, and physical examination revealed a remote right subcostal incision. At the age of 12 years, she had first developed decreased appetite, weight loss, fatigue, pruritus, and subsequently became jaundiced. Medical records from that episode revealed that an endoscopic biliary stent was placed with surgical exploration through a right subcostal incision and partial resection/enucleation of a pancreatic mass. In the intervening 12 years, the mass had persisted and enlarged, although the patient was asymptomatic, having neither anorexia, pruritus, nor jaundice.Routine hematology and basic chemistry panels were normal. The tumor marker cancer antigen 19-9 was mildly elevated at 89 U/mL (<35 U/mL). An abdominal computed tomography (CT) scan with contrast revealed an 8.2 × 7.6 cm heterogeneous-enhancing lesion, prominently involving the uncinate process of the pancreas . The panThe patient underwent an open cholecystectomy and a difficult classic pancreaticoduodenectomy. The operative time was 12 h and the estimated intraoperative blood loss was 1500 mL. There was no evidence of metastasis, but the tumor had adhered extensively to the SMV and portal vein and surrounded the SMA. We were able to accomplish the separation of the tumor from the venous structures without incident; however, separating the tumor from the SMA proved challenging. At one point, the SMA was transected due to adherence of the tumor. The SMA was subsequently reapproximated in an end-to-end manner with good arterial Doppler signals distal to the anastomosis.MYB gene deletion.Pathological analysis of the surgical specimen revealed the tumor to be a solid pseudopapillary neoplasm . All surOn the first postoperative day, the patient had a small amount of bile visible in the operatively placed drains, she was fluid seeking, and her abdomen was somewhat distended. Due to the suspicion of a vascular insult related to the SMA reconstruction, an abdominal CT with intravenous contrast was obtained and revealed an intraluminal thrombus in the proximal SMA, ∼1.5 cm from its origin off the aorta, causing near complete occlusion of the SMA . She wasOn the fourth postoperative day, an upper gastrointestinal series with water-soluble contrast instilled into the stomach through a nasogastric tube revealed no contrast extravasation, and both the afferent and efferent limbs of the duodenojejunostomy were grossly patent.The patient and her family were instructed on the home management of the large abdominal incision and superficial wound infection. Healing occurred over the next 4 months. Telehealth monitoring was used by our nursing experts to communicate with the patient on a regular basis, with mobile phone images documenting the status of the wound.She returned to Philadelphia for a follow-up visit after 6 months. At that time, the patient appeared well, her wound was completely healed, and an abdominal CT scan with contrast showed normal after pancreaticoduodenectomy anatomy, without any evidence of recurrent or persistent tumor.7 as in the case herein reported. SPTs have a low-grade malignant potential and a good prognosis.8 Interestingly, SPTs can mimic malignant pancreatic tumors with hypermetabolism of FDG on positron emission tomography (PET) scanning.9 Typically, the radiographical appearance of SPTs is a well-defined encapsulated tumor that contains a mixture of solid and cystic components. In fact, most patients are asymptomatic with no abnormalities or physical signs, and the lesion is generally detected incidentally on imaging or physical examination. The size of the mass and its location (compressing adjacent organs) may lead to vague abdominal discomfort. Obstruction of the bile duct or intestine, jaundice, pancreatitis, or spontaneous tumor rupture are rare occurrences. Nakamura et al.10 described a rare case of SPT, which resulted in occlusion of the splenic vein, leading to the development of gastric varices and left-sided extrahepatic portal hypertension.SPTs are most often located at the head of the pancreas,11 Interestingly, Nakahara et al. described an unusual case of SPT in a young woman refusing surgery.12 During a 10-year follow-up period, the maximum diameter of the tumor gradually decreased from 4.5 to 1.5 cm, and the authors posited that some degenerative changes such as hemorrhage and necrosis, followed by absorption, resulted in the natural shrinkage of the tumor. Goh et al.13 suggest that the malignant potential of SPTs is difficult to predict by gender, age, or tumor size without surgery or biopsy, but that the diagnosis of SPTs should be suspected when a young female has a mass of pancreatic origin. In addition, if one finds a large, centrally calcified, well-encapsulated, mixed cystic/solid mass by CT/MRI, the diagnosis of an SPT should be suspected.Surgical resection of SPTs is the mainstay of therapy, and a complete surgical extirpation most often results in long-term survival. Almost 95% of SPTs can be cured by complete excision with margin-negative resection.14 In general, the neoplastic cells in SPTs are negative for chromogranin A. Occasionally, as in our case, immunoreactivity for synaptophysin is seen. In our case, the immunohistochemical findings were positive for CD56, CD10, vimentin, and β-catenin, and weakly positive for synaptophysin. However, the tumor was negative for chromogranin A and trypsin and also negative for AE1/AE3 and E-cadherin. In addition, the molecular genetics showed the tumor to be negative for the MYB gene deletion . Chromogranin A and synaptophysin are both general markers for neuroendocrine tumors and are typically reported together. In our case, chromogranin A was negative, and there was only weak diffuse staining for synaptophysin, indicating that the tumor contained scattered neuroendocrine cells. CD56 is also a marker for neuroendocrine lesions, but synaptophysin is more specific and less sensitive to neuroendocrine differentiation. Burford et al.15 suggest that fine-needle aspiration samples tested for expression of CD10 and the characteristic expression of E-cadherin/β-catenin are highly specific for distinguishing SPTs from pancreatic endocrine neoplasms. Cytokeratins (AE1/AE3) are intermediate filament (IF) proteins used for the cytoskeleton. AE1/AE3 are expressed and regulated in most epithelial cells. These markers are expressed in many tumors and may be helpful in identifying the origin of a neoplasm. In certain situations, IF vimentin is a useful marker to assess the primary site of a tumor and it has a relationship with dedifferentiation and carcinogenesis in the epithelial cells, suggesting that it may be a useful marker for pancreatic SPT precursor cells.On hematoxylin–eosin staining, SPTs are histologically characterized by solid pseudopapillary-arranged cells and cystic areas. SPTs may often mimic endocrine tumors of the pancreas, with morphological features including nest formation and tumor cells with eccentric nuclei. The characteristic immunohistochemical features of SPTs are CD10, CD56, and vimentin positivity. Importantly, beta-catenin has nuclear expression in all reported cases of SPTs.In conclusion, SPTs have characteristic pathological and radiological features and should be included in the differential diagnosis of pancreatic tumors, especially in young women.


To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process.The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients’ engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored.d = 0.32) and reduction of symptoms . No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC , which was associated with better treatment outcomes.At T1, 200 patients participated , and at T2 175 patients . At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (β 7.553, p = 0.038, 95%CI:0.403–14.703, Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention. Although the beneficial effects of Shared Decision Making (SDM) in mental health care are supported by several studies –5, to daTo stimulate the shift towards SDM from the start of treatment, GGz Breburg, a specialist mental health organisation in the southern part of the Netherlands, invested in the development and implementation of a novel multi-facetted digital SDM intervention in the intake process . This inThis trial aimed to investigate the effects of SDM-Digital Intake (SDM-DI) on the primary outcome Decisional Conflict (DC), which refers to the degree to which patients were engaged in and felt comfortable about important clinical decisions ,19, and The Medical Ethics Committee of VU University Medical Centre Amsterdam, The Netherlands reviewed the study and declared that the Medical Research Involving Human Subjects Act (WMO) did not apply to this study (reference number: 2015.434). All participating patients gave written informed consent before filling in the research questionnaires.http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5677). Results are presented in accordance with the CONSORT statement for cluster randomised controlled trials [This study was a two-arm matched-pair cluster randomised controlled trial. To keep contamination to a minimum, we used a cluster design at team level with pairs of similar teams within the same department, treating a similar population of patients in the same geographical catchment area, which is considered a good procedure in RCTs evaluating interventions at clinicians’ level . In thisd trials .This trial was conducted in four outpatient departments of the specialist mental health care organisation GGz Breburg located in the southern part of the Netherlands. The SDM-DI intervention was intended to be suitable for patients with various diagnoses , and was therefore tested in two outpatient departments specialised in depression and anxiety disorders, and two outpatient departments specialised in personality disorders. Each of the two departments, which were specialised in the same patient group, where working in separate catchment areas. The four participating departments consisted of two multidisciplinary intake-teams each, in which initial treatment decisions are made.In total eight intake teams from four departments operating in two catchment areas participated in this trial. Research assistants consecutively invited each new patient, for whom a full intake (SDM-DI or IAU) was planned, to participate in this study. Patients were excluded if they did not speak or read the Dutch language or were incapable to complete questionnaires because of cognitive functioning or an ongoing crisis. Patients enrolled after receiving face to face and written information about the study given by the research assistants, and after giving written informed consent.Cluster randomisation at the level of the four pairs of intake teams was performed using computer-generated random numbers. According to the matched-pair cluster randomised design, the randomisation sequence was performed per block of two intake-teams using a SPSS-syntax which generated a random number . This syntax was prepared by a data manager with no involvement in this trial. The random allocation sequence was conducted by the co-author IE, prior to the start of the intervention and data collection of this study, independent of the participating teams and the primary researcher MM, who coordinated and conducted the trial.Four teams were randomised to the intervention group and four teams to the control group. To reduce the risk of contamination from the intervention to the control condition, the participating teams had their own multidisciplinary team consultation. Furthermore, clinicians and patients participated in one condition. Patients who were planned for an intake consultation with clinicians of the intervention group, were automatically assigned to the intervention and received SDM-Digital Intake (SDM-DI). Patients who had the first intake appointment with clinicians of the control group, followed the intake as usual (IAU). Planning of these intake consultations was conducted by secretaries with no involvement in the study, according to the availability of time in the agendas of patients and intake clinicians. There was no influence of other factors on this planning process.Due to cluster randomisation at team level and the nature of the intervention , blinding of the clinicians and patients was not feasible. To reduce the risk of bias, research assistants, independent of the research team and participating teams, performed the inclusion of patients and carried out the data collection. During the inclusion process, the independent research assistants were blinded to the allocation of the condition.The multi-facetted intervention, called SDM-Digital Intake (SDM-DI), aimed to target both sides of the dyad, i.e. patients as well as professionals, in order to foster SDM. SDM-DI is formed by a digital intake approach incorporating a blended eHealth intervention integrated with Routine Outcome Monitoring (ROM), support of peer workers and training of clinicians. Patients participating in the intervention group were also stimulated to involve a relative in their intake process. The intervention is briefly described below. A comprehensive description can be found elsewhere .Two eHealth modules were offered in order to explore treatment needs, expectations and preferences of patients aiming to support patients in preparing themselves, along with relatives, for the intake consultations. The initial ROM, which measured symptom severity, was integral part of the eHealth modules. ROM implies regular measurements of clinical outcomes during treatment, which provides feedback on the patients’ progress in treatment. The initial ROM is regularly planned in the intake process ,18. WhilThe results of the completed modules and ROM were visible for patients and clinicians as well. Patients were stimulated to use their own feedback reports, with personalised graphics about their mental health problems and the impact on daily life, to prepare the intake consultations and bring them to these consultations. The assertion was that patients who were better prepared for the intake, would be more able to actively participate in the dialogue with their intake clinicians about choices in treatment. To make sure that patients and clinicians have sufficient time to discuss the preparation by eHealth and ROM, in the intervention group, the first intake consultation was extended from 60 to 90 minutes.The clinicians of the intervention group followed a training of three half-day sessions aimed to stimulate and facilitate the new way of working. The training was given by a trainers couple formed by a peer worker and clinician and contained explanations of, instructions on and exercises in recovery supported care and the application of SDM  using eHThe control group consisted of an Intake As Usual (IAU), which means that patients in the control group did not follow the blended eHealth intervention, did not complete the initial ROM in the eHealth portal, had no digital access to their own ROM results and could not consult a peer worker in the intake process. The time of the first intake consultation in the control group was standard 60 minutes. Furthermore, the intake clinicians of the control group did not follow training in recovery supported care and the application of SDM using eHealth and ROM. In both arms, the multidisciplinary team consultation fulfilled the usual role of checking the quality of the treatment choices.To prevent socially desirable answers and an undesired influence of the research team or clinicians on the results several precautions were taken. First, data were collected by independent research assistants. Second, the outcomes, Decisional Conflict (DC), patient participation, SDM process and working alliance, were measured with separate instruments that were included for research purposes only. Third, the results on these research instruments were not visible for patients and clinicians during intake and treatment. The research instruments were completed two weeks (T1) and two months (T2) after intake, and thus measured both the effects of the intervention. Furthermore, two weeks after intake (T1), clinicians answered questions about SDM regarding their patients. Patients and clinicians received a link by email to complete the questionnaires and if necessary received, after 7, 9 and 14 days, reminders by email or phone. If patients did not use internet, they received paper questionnaires by post.The other outcomes no-show, drop-out and symptom severity (i.e. ROM) were derived from the electronic patient records. Participants in the intervention and control group completed the regular initial ROM measurement at baseline (T0) and the follow up ROM measurements at T1 and T2.Decisional Conflict (DC) was measured in patients using the revised, validated Decisional Conflict Scale (DCS) , which wWe used the following validated self-report questionnaires to measure the secondary outcomes: Patient Participation Questionnaire (PPQ) , the patTo check the intervention integrity, process variables were collected. These variables report the degree of completion of eHealth modules and the frequency of consulting peers.Patients’ and clinical characteristics were collected at baseline. The following data were registered in the Electronical Patient Records (EPR): gender, age, educational level, primary diagnosis, symptom severity, motivation to start treatment , length of previous treatment (at GGz Breburg in weeks) and length of waiting time (from registration to first intake consultation in weeks).A sample size calculation prior to the study  was perfA sample size of 65 patients per arm was needed to obtain an usual power of β = .80 with an alpha set at 0.05 (two tailed) . AdjustmWe calculated ,30 that The analyses were conducted using intention-to-treat principles. Multi-level analyses were performed in MLwiN 2.21 software. The other analyses were performed in SPSS 19.0.Descriptive analyses were conducted in order to analyse patients’ characteristics and intervention integrity. Attrition analyses were performed by means of a logistic regression analysis in order to test for selective drop-out between T1 and T2. If participants had answered at least 80% of the items on a questionnaire, missing items were imputed with the mean value of the completed items.d) were calculated by dividing the between-group difference by the pooled SD. The thresholds for interpreting the effect size were: Small 0.00–0.32, Medium 0.33–0.55 and Large ≥ 0.56 [To correct for possible clustering of the data and to handle missing data , the anaThe differences in patients’ and clinicians’ views on the application of Shared Decision Making (SDM-Q-9) and agreement with clinical decisions (DC VAS) were tested using dependent t-tests. Furthermore, post-hoc analyses were performed for the primary outcome Decisional Conflict (DC). We assessed potential effect modification by primary diagnoses, motivation for treatment, previous treatment and waiting time. Interactions were tested for significance at a p-value of 0.1. We also investigated the influence of intervention integrity on DC. Finally, we explored the influence of applying SDM on the primary outcome DC and the association between DC and symptom severity.Inclusion started in October 2016 and ended in June 2017, when the required sample size was reached. Follow-up measurements were completed in August 2017. Eight teams  of four departments from one specialist mental health care organisation participated in the trial. As shown in The dropout rate of patients between T1 and T2 was 13% . Numbers of dropout were not significantly different between the conditions and dropout rates were not significantly associated with any patient characteristics . Reasons for dropout were: 1) no longer willing to fill out research questionnaires  (80%), 2) not responding to reminders (17%), 3) death during study period (3%).Tables diff 2.746, sd 3.873, p<0.001, 95%CI 2.234 to 3.258).In the intention-to-treat analyses, no significant differences between SDM-DI and IAU on the total scale and subdomains of the primary outcome DC were found . We founThe overall effect (T1 and T2) and the difference at T1 on the secondary outcome  the degrdiff 11.456, sd 28.739, p<0.001, 95%CI 7.310 to 15.602).Looking at the clinicians’ reported SDM-Q-9, completed at T1, the results did not differ significantly between the two conditions. When comparing the patients’ and clinicians’ reported SDM-Q-9 at T1, irrespective of the condition, clinicians scored more positive about the application of SDM (meand = -0.43).Regarding severity of symptoms , the overall effect (T1 and T2) and the difference at T1 were not significant between the two arms . Howeverd = 0.13) did not differ between the two arms. In the intervention group the treatment drop out percentage was 4.3% (4 patients) and in the control group 2.8% (3 patients). The mean number of no-shows of treatment consultations was in each arm the same (mean 0.02 per patient).Finally, we found no significant effects of SDM-DI on the secondary outcomes : workingSubgroup analyses  for the d = -1.31). We also explored the influence of DC on treatment outcomes. We found significant positive associations between less DC at T2 and better clinical outcomes at T2 . This effect size was medium (d = 0.45). Although, 77% of the patients in the intervention group completed the first eHealth module and 39% the second module, we found no association between the degree of completion of the eHealth modules and the level of patient reported DC (p = 1.000). Finally, peer workers were hardly consulted. Therefore, we could not explore the association between the frequency of consulting peer workers and the primary outcome of this trial.Exploratory analyses revealed that, irrespective of the condition, a better application of SDM, according to the patient reported SDM-Q-9, led to significantly less DC  with a large effect size (No adverse or unintended effects of the SDM-DI intervention or IAU were reported.d = 0.32). At T1, the differences in the SDM-Q-9 scores, reported by patients and clinicians, between the two arms were not significant. Looking at treatment outcome, measured by the SQ-48, we found a significant positive intervention effect at T2. Patients of the intervention group, reported more symptom reduction at T2, with a medium effect size (d = -0.43). The other secondary outcome parameters, patient participation, working alliance and treatment adherence did not differ between the two arms. Irrespective of the condition, a better application of SDM according to patients was associated with less DC (d = -1.31), which in turn had a positive influence on treatment outcome (d = 0.45).This study presents the results of a cluster randomised controlled trial on the effects of SDM-Digital Intake (SDM-DI) in specialist mental health care aimed to foster Shared Decision Making. Compared to the Intake As Usual (IAU), no significant effect of SDM-DI was found on the primary outcome Decisional Conflict (DC) reported by patients and also no significant influence was shown on the DC VAS scale reported by patients and clinicians. However, at T2 compared to the control group, patients in the intervention arm reported a significantly better application of SDM  participated in this trial. The participating departments were specialised in the treatment of patients with mood, anxiety and personality disorders. Except of patients who did not speak and read the Dutch language or were unable to answer questionnaires, because of an ongoing crisis or cognitive functioning, all patients were asked to participate. Moreover, the population of 200 participating patients, which was in balance between the two arms, was larger than the estimated sample size of 176. Taken together, it is reasonable to assume that the study results are generalizable to the patient population with mood, anxiety and personality disorders treated in Dutch specialist mental health care. Regarding the exclusion criteria and the focus of the intervention on three diagnosis groups, the current study might not be generalizable to a broader patient population with other diagnoses and patients who were incapable to answer questionnaires.To our knowledge, no previous RCT has investigated a multi-facetted intervention aimed to improve SDM in specialist mental health care, targeting both patients’ and clinicians’ behaviour during the intake process. Although previous research ,14,15 poThe lack of effects in the intervention arm on the primary outcome and some of the secondary outcome parameters, might be explained by the fact that the uptake of SDM-DI in the intervention arm was not sufficient. Possibly, regarding the less than optimal intervention integrity and no significant effect on the secondary outcome patient participation, more support was needed on the patients’ side of the dyad to foster a higher level of patient participation in decision making, which in turn might reduce DC. Whereas, due to the training in SDM skills, clinicians participating in the intervention group actually applied the SDM-steps during intake consultations. Hence, compared to the control group, patients in the intervention group reported a higher level of SDM applicated by clinicians, while this is probably not enough to influence patient reported DC. Nevertheless, patients in the intervention group reported less symptom severity, while we hypothesized this improvement in treatment outcome as a result of reduced DC. In line with this expectation, explorative analyses showed the association between less DC and less symptom severity. A possible explanation of the positive findings on symptom severity in the intervention arm without a change in DC might be that the personalised, recovery oriented attention which was applied in the intervention group, could also influence treatment outcome directly. Looking at the level of DC among patients , we can To improve the uptake of the intervention, more time and efforts are needed to change the attitudes of clinicians and patients more fundamentally towards SDM ,11,37,38At the same time, we have limited insight in what happened with patients while following the eHealth modules and we also know less about patients’ preferences about using eHealth and peer support. We only have insight in the percentage technically completed eHealth modules and the fact that peer workers were hardly contacted in the intake process. In future research, it would be interesting to explore these user patterns and preferences, and also investigate the associations between the use of eHealth and peer support with patients characteristics, the level of participation in decision making and treatment outcome. This could give us more insight in which way of working with eHealth and peer support works for whom.Although, this is a negative trial and we found limited effects of SDM-DI on the secondary outcomes, it was encouraging to find that, irrespective of the condition, a better application of SDM, leads to less DC experienced by patients, which in turn was associated with more symptom reduction. This finding was in line with previous, national research to shared decision making using ROM in Dutch specialist mental health care, where the positive influence of a higher level of SDM on reduced DC, and the effects on treatment outcomes were also shown .This innovative study stimulated SDM at both sides of the patient-clinician dyad using a combination of digital and face-to-face methods, i.e. digital exploration of patients’ treatment needs and preferences facilitated by ROM, peer support and training of clinicians. The trial showed no effects of SDM-DI on Decisional Conflict, patient participation, working alliance and treatment adherence. However, compared to the control group, in the intervention group positive effects were reported regarding the application of SDM and symptom severity, which is the most important outcome of treatment. Furthermore, irrespective of the condition, this study demonstrated that when SDM was applied well, this approach led to less Decisional Conflict, which in turn had a positive influence on treatment outcome. Taken together, the study results pointed out that the application of a SDM intervention in the intake process targeting both patients’ and clinicians’ behaviour is a promising approach, which requires thorough implementation and continuation during treatment. Additionally, further exploration is needed to find out which interventions would help patients and clinicians best to foster patient participation in decision making about treatment.http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5677).The trial is registered in the Dutch trial register with number: NTR5677 and registration date: 17 January 2016 Click here for additional data file.S1 CONSORT Checklist(DOCX)Click here for additional data file.


Opioids are commonly used for the management of postoperative pain, but their use is limited by important adverse events, such as respiratory depression and the potential for addiction. Multimodal opioid-sparing analgesia regimens can be effectively employed to manage postoperative pain and reduce exposure to opioids. Gabapentinoids  represent an attractive class of drugs for use in multimodal regimens. The American Pain Society recommends the use of gabapentinoids during the perioperative period; however, evidence to inform such a recommendation is unclear.I2 index.We will conduct a systematic review and meta-analysis of randomized clinical trials evaluating the use of systemic gabapentinoids, in comparison to other analgesic regimens or placebo in adult patients undergoing surgery. We will search MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Web of Science, and ClinicalTrials.gov databases for relevant citations. Our primary outcome will be intensity of postoperative acute pain (12 h). Our secondary outcomes will be postoperative pain intensity at 6, 24, 48 h, and 72 h, cumulative dose of opioids administered within 24, 48, and 72 h following surgery, the length of stay, chronic pain, and adverse events. Two investigators will independently select trials and extract data. We will evaluate the risk of bias of included trials using the Cochrane risk of bias tools. We will represent pooled continuous data as weighted mean differences and pooled dichotomous data as risk ratios with a 95% confidence interval. We will use random effect models and assess statistical heterogeneity with the Our study will provide the best level of evidence to inform the effect of gabapentinoids in the management of postoperative acute pain.CRD42017067029PROSPERO The online version of this article (10.1186/s13643-018-0906-3) contains supplementary material, which is available to authorized users. Because of their numerous adverse events  and their potential for addiction, reducing opioid administration is a core element in the domain of postoperative pain management –3. In thThe American Pain Society supports the use of gabapentinoids as a part of multimodal analgesia . HoweverOur primary objective is to evaluate the analgesic effect of gabapentinoids in perioperative care in adult surgical patients compared to placebo or any other analgesic regimen. Our secondary objectives are to assess its effect on the opioid use, the length of stay and the incidence of chronic pain. We will also evaluate the incidence of adverse events.http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017067029). The manuscript reporting the results of the systematic review will be written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P2015) recommendations [Our study is a systematic review and meta-analysis of randomized controlled trials and our protocol was prepared according to the methodological recommendations of the Cochrane Handbook for Systematic Reviews and Meta analyses . This prndations .Our primary outcome measure is postoperative pain intensity 12 h after surgery or at the time of hospital discharge if earlier. We decided to prioritize dynamic (during movement) pain over rest pain if both are reported, because this type of pain is more relevant for patients and it is associated with better recovery . We seleOur secondary outcome measures are the postoperative pain intensity at different time points , the cumulative dosage of intravenous (IV) morphine equivalent (ME) over the first 24, 48, and 72 h following surgery, and the lengths of stay . For the measure of pain intensity, if data at the specific time point are unavailable, the following intervals will be considered: 0–6 h, 7–12 h (primary outcome), 13–24 h, 25–48 h, and 49–72 h. We will also evaluate the incidence of postoperative chronic pain (defined as lasting for 3 months or more). In case the incidence of chronic pain is not reported but the incidence of complex regional pain syndrome (CRPS) is, this data will be used. The incidence of postoperative adverse events such as dizziness, fall or ataxia, delirium, addiction or abuse, visual disturbance, respiratory failure (respiratory insufficiency or respiratory depression), and nausea and/or vomiting (PONV) will be considered.We will include trials comparing the systemic use of gabapentinoids  to a placebo or any other type of drug used for the management of perioperative acute pain. Our study population will be adult patients (more than 80% of patients are 18 years of age or older) undergoing elective or emergent surgery under any type of anesthesia. To be included, trials should have studied the perioperative use of gabapentinoids (defined as being started at any moment between 1 week prior to and 12 h after surgery) and have evaluated at least one of our outcomes of interest. We will exclude trials comparing the use of gabapentinoids to regional analgesia . Cross-over trials and trials including patients already receiving gabapentinoids for a chronic pain condition will not be considered for inclusion. We will use no language restriction.We will search MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ClinicalTrials.gov databases for randomized control trials published to date. We will generate Medical Subject Headings (MeSH), Emtree terms, and free text words to identify articles. We will divide vocabulary themes into three main text term categories: 1) perioperative (surgery or anesthesiology), (2) gabapentinoids , and (3) RCTs. The search strategy will be reviewed by an information specialist, and we will validate its quality according to PRESS 2015 guideline . Bibliog perioperWe will create a standardized data abstraction form with Microsoft Excel and carry out a pilot test on the first ten trials. Two reviewers (MV and XS) will then independently extract data. A third reviewer (AFT) will be consulted in cases of disagreements, and all reviewers will be involved in reaching a common consensus. We will contact the authors when relevant information is missing.We will extract the following study characteristics: years of publication, countries, number of centers participating (multicenter vs single center), total number of patients randomized, and the number of patients analyzed in each group. As for the patient and surgery characteristics, we will extract the following: age, sex, prior chronic use of opioids and dependence, preoperative pain, type of surgery and anesthesia, type of population (geriatric or not), follow-up period, and surgery setting . As for the intervention and comparator, we will extract the type, timing, and dose of the first gabapentinoid and comparator intake and the daily dosage, including the duration of treatment. For co-analgesia, we will include information about drugs, routes of administration, and regimen (regular vs. on request). Information concerning outcomes, such as postoperative acute (rest or dynamic) and chronic pain, cumulative ME administration, and length of stay in different hospital units , will be collected. Reported adverse events will be extracted, including dizziness, fall or ataxia, delirium, addiction or abuse, visual disturbance, respiratory failure, and PONV. In addition, we will extract information concerning study duration, conflict of interest, funding sources from pharmaceutical industry, and risk of bias items. When results are only presented on a diagram or a graph, data will be extracted using a web application (WebPlotDigitizer) .For every time point, pain measurement scores and standard deviation will be converted to a 100-point scale . OutcomeTwo independent reviewers (MV and XS) will evaluate the methodological quality of included trials using the Cochrane Collaboration’s tool for assessing risk of bias . This toI2 index [I2 greater than 50% indicative of significant heterogeneity. If deemed appropriate, we will conduct a meta-regression to analyze the effect of the cumulative dosage of gabapentinoids until 12 h after surgery using R software [R software [Data will be analyzed with Review Manager; version 5.3.5  using random effects models (Mantel-Haenszel for binary outcomes and inverse variance for continuous outcomes). We will represent pooled continuous data as weighted mean differences (WMD) with a 95% confidence interval and pooled dichotomous data as risk ratios (or odds ratio (OR) in the case of rare events if deemed appropriate). We will perform subgroup and sensitivity analyses to evaluate the robustness of our findings and potential sources of heterogeneity. We hypothesize that the following factors may explain heterogeneity: type of funding , type of surgery , type of follow-up (inpatient or ambulatory surgery), type of population , type of anesthesia , type of drug , the dosage regimen , low dose , or both and single or multiple intake), timing of the intervention , context of pain assessment , type of comparator , type of co-analgesia , and the overall risk of bias  , 39. We I2 index . We willsoftware . We willsoftware . To facisoftware . If apprsoftware , 43. We software .Gabapentinoids are widely used as an off-label treatment for the relief of chronic pain condition and are increasingly used for the management of postoperative acute pain, while the level of evidence supporting such usage is unclear . Our sysOur study will provide an accurate synthesis of the level of evidence for the perioperative use of gabapentinoids.Additional file 1:Search strategy for MEDLINE/Ovid. (DOCX 85 kb)


Background and Objectives: Many epidemiological studies have shown a positive association between black carbon (BC) and the exacerbation of allergic rhinitis and allergic asthma. However, none of the studies in Serbia examined this relationship yet. The aim of this study was to examine the associations between BC and emergency department (ED) visits for allergic rhinitis and allergic asthma in the Užice region of Serbia. Materials and Methods: A time-stratified case-crossover design was applied to 523 ED visits for allergic rhinitis and asthma exacerbation that occurred in the Užice region of Serbia between 2012–2014. Data regarding ED visits were routinely collected in the Health Center of Užice. The daily average concentrations of BC were measured by automatic ambient air quality monitoring stations. Odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were estimated using conditional logistic regression adjusted for the potential confounding influence of weather variables . Results: Statistically significant associations were observed between ED visits for allergic rhinitis and 2-day lagged exposure to BC  and allergic asthma and 3-day lagged exposure to BC . Conclusion: Exposure to BC in the Užice region increases the risk of ED visits for allergic rhinitis and asthma, particularly during the heating season.  AtmosphThe terms black smoke (BS), elemental carbon (EC), soot, BC, Abs (absorption coefficient) and light-absorbing carbon are used in different studies referring to different methods to measure or express concentrations of BC particles, which is the generic term for any of the different metrics above . It is important to distinguish the terms BC and carbon black (CB). Both are formed after the incomplete combustion of hydrocarbons but differ in their constituents and percent carbon contents . While BTime-series studies provide sufficient evidence of an association of short-term variations in BC concentrations with short-term changes in all-cause and cardiovascular mortality ,8, a carEpidemiologic studies indirectly suggest that the inhalation of BC impairs lung function in children. Using the carbon content of airway macrophages as a marker of individual exposure to BC, Kulkarni et al.  found diDuring the latter half of the 20th century, the prevalence of allergic asthma and many other allergic diseases has increased and continues to increase worldwide, particularly in low and middle-income countries . All stuThe International Study of Asthma and Allergy in Childhood (ISAAC) reports demonstrated a wide range of potential risk factors, including outdoor air pollution .The aim of this study was to assess the short-term effect of BC exposure on allergic rhinitis and asthma exacerbations in the Užice region of Western Serbia.The study was conducting in the Zlatibor District, Western Serbia, over a two-year period . The main city of the district is Užice, situated on both sides of the river Đetinja, with an average elevation of 411 m above sea level, surrounded by the Dinaric mountains Zlatibor, Tara, and Zlatar. The city of Užice (including Sevojno), with 78,040 inhabitants; Čajetina, with 14,745 inhabitants; and Kosjerić, with 12,090 inhabitants, were included in this study . There are three different climates in this region, from moderate-continental to mountain and high-mountain  climates. While Užice and Sevojno are heavy industrial centers, the mountain Zlatibor, thanks to the specific continental and Mediterranean air currents, a so-called wind rose, is considered an air spa suitable for the treatment of and recovery from many diseases, including asthma. We obtained routinely collected emergency department (ED) visits data for allergic rhinitis, allergic asthma, and allergic asthma with coexisting allergic rhinitis, from the Health Center Užice, either from the EDs (ambulances or home care) in Užice, Sevojno, and Kosjerić, or from a general hospital in Užice. The medical records of all patients were provided retrospectively, and the subjects’ age, gender, diagnosis, and date of visit were recorded. The inclusion criteria were adults aged 18 years and older with the diagnosis of allergic rhinitis , allergic asthma , or asthma with coexisting allergic rhinitis. Patients with worsening conditions due to respiratory infections or asthma types other than allergic asthma were excluded from this study. This study was approved by the Ethics Committee of the Health Center Užice .3) were measured by three automatic ambient air quality monitoring stations located in Užice, Sevojno, and Kosjerić. The BC concentration was measured with reflectometer, a standardized, traditional, and cheap method. According to the OECD standard [3).Average daily concentrations of BC in micrograms per cubic meter  was obtained from the automatic meteorological station located on Zlatibor mountain . A time-stratified case-crossover analysis was used to assess the risk of ED visits for allergic rhinitis, asthma, and asthma with coexisting allergic rhinitis due to exposure to BC. The "case-crossover" design is a specific type of case-control study with each case being its own control. This has the advantage as inherent control for potential confounding variables caused by fixed individual characteristics, such as sex and age. "Time-stratified" indicates the method by which the control periods were chosen. In this study, every seventh day before and after the event day was considered a control. The event day is termed lag 0, the day before the event day lag 1, the day before lag 1 is lag 2, and the day before lag 2 is lag 3.Nominal and ordinal data was described by absolute and relative frequencies, whilst median and interquartile range (IQR) were used for numerical data. To assess differences between groups, Chi-square test and Mann–Whitney test were applied where appropriate.10, PM2.5 and weather variables was assessed by non-parametric Spearman’s rank correlation.The degree of association between BC, PM2, and humidity on the previous day (lag-1). The results of the analyses were expressed as odds ratios (ORs) with their accompanying 95% confidence intervals (CIs). The ORs were calculated in relation to air pollution concentration based on the daily mean level of BC pollutant presented by the IQR. Conditional logistic regression models were applied for each allergic disease. Different lag periods were included to detect an early , potential delayed  or cumulative effect of exposure. To control potential confounding factors , two models were made: The first model was adjusted for temperature, humidity, and air pressure on the same-day (lag-0); and the second model was adjusted for temperature, temperaturep < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 21.0 software . A value of A total of 523 ED visits  occurred during the study period (2012–2014). The mean age of these patients was 45.95 ± 17.24. The majority of patients were female (62.5%) and in the cold seasons (76.3%). More than one third of patients (38%) had one or more comorbidities  . 3) during the cold seasons. Daily concentrations of BC and weather variables in the Užice region are shown in Correlations between BC, PM, and weather variables are shown in 10 (ρ = 0.75) and between BC and PM2.5 (ρ = 0.68), whilst a strong inverse correlation existed between BC and temperature (ρ = 0.67).A strong positive correlation was seen between BC and PMBC concentration was higher during the cold season compared to those during the warm season in all three years of the study period . p < 0.001)  in comparison with the non-heating season , and this difference was statistically significant (< 0.001) .Estimated ORs (crude and adjusted for weather conditions) with 95% CI for ED visits for allergic rhinitis, asthma, and asthma with allergic rhinitis based on a 2-day or 3-day lagged exposure to BC and actual p values are displayed in p = 0.024–0.049), and between 3-day lagged exposure to BC and ED visits for asthma , whilst we failed to find statistically significant associations between BC exposure and asthma with coexisting allergic rhinitis   .To our knowledge, this is the first study to investigate an association between BC and hospital ED visits for respiratory allergic diseases in Serbia. We performed a time-stratified case-crossover study to assess the effects of the daily concentration of BC on ED visits for allergic rhinitis and allergic asthma after controlling for weather conditions in the Užice region from 2012 to 2014. The results suggest a positive association between ambient exposure to BC and ED visits for allergic rhinitis and asthma. p = 0.024–0.049), and asthma exacerbation on lag 3  more than three-fold. However, we are aware that the actual p values, apart from allergic rhinitis, were very close to 0.05 and considered to be marginal and that caution in interpreting the results is warranted. Our results are in accordance with many previous studies that reported positive associations between BC and ED visits or hospital admissions for asthma [10, PM2.5, and BS (mainly fine particles of primary origin), except for children in the 0–14 age group, and there were no important seasonal interactions. Recently, Liang et al. [We found that IQR concentration of BC in the Užice region increase the risk for allergic rhinitis exacerbation on lag 2 . Janssen et al. [2.5. These findings are in accordance with the evidence that combustion-related components of PM are more harmful than the non-combustion fractions [2.5. In our study, positive and strong correlations were observed between BC and both PM2.5 and PM10 concentrations. Several studies showed that the health effects associated with an IQR increase of BC were similar but not exactly the same with PM2.5 [Health effects associated with exposure to PMtion μg/m. Janssenn et al.  found thractions . As a coractions , BC may tion μg/m. Janssenth PM2.5 ,39,40. It is important to note that current methods of measuring BC and EC need standardization to facilitate comparison between various study results .The results of our study unambiguously indicate that BC was responsible for the acute exacerbation of allergic rhinitis and allergic asthma in the Užice region of Serbia. Considerably greater concentrations of BC in the observed period were recorded in the winter months, as well as during the heating season (from September 15 to April 15) when there were more ED visits due to acute worsening of allergic rhinitis and asthma. A possible explanation for this can be the geographical location of the city of Užice, which is situated in the valley of the river Đetinja above which are the raising hills of the mountain Jelova Gora, whose altitude is 500 m and more above sea level . Above the southern edge of the basin, from the right bank of the river Đetinja, a very steep hill Zabučje rises, with peaks over 700 m above sea level. Therefore, the bottom of the Užice basin is 100 m lower than its surroundings on the north side, and 300 m lower on the southern side. The east-west oriented basin has only one slope that is significantly warmed, and it is the south-oriented side of the mountain Jelova Gora.Such a terrain configuration significantly influences the creation of local wind systems, especially in combination with common regional winds of low intensity. The south-oriented slopes, which are sunny during the day, emit accumulated heat in the evening, stimulating the circulation of warm air along the slopes and the entry of cooler air into the center of the basin. The winds from the east and west directions ventilate the basin, while winds from the north create stationary vortices, thus preventing basin ventilation. During the winter, conditions for temperature inversions are created when cold air falls to the bottom of the basin and a front of warmer air lies above it. With such temperature inversion, vertical air circulation is prevented, so all emitted pollutants are accumulated in the lower layer. Suspended particles, soot, and other air pollutants in winter create a smog that, even when sunny, reflects light, which prevents the warming of the lower air layers and their rise from the basin. At night, the air is further cooled, so the cold air remains trapped in the basin. Consequentially, episodes of high air pollution occur, especially during the heating season in the Užice region. Most days in which the temperature inversion conditions are present are recorded in December and January. Due to global climate change, the number of days with temperature inversion has increased significantly, which is particularly evident in the 2012–2014 years. By analyzing the results, we came to the conclusion that despite the implementation of a series of pollution reduction measures, temperature inversion in high percentage neutralizes the implemented measures.Furthermore, the Užice architecture, with its characteristic high buildings, also influences air circulation and thus the transport and concentration of the pollutants. Such structures represent obstacles to air flow, as well as surrounding hills above the city. Another effect, so-called a "canyon street effect”, appears in the central streets of the city. This effect makes ventilation difficult or contributes to the creation of vortices in which the air recirculates and holds captured emitted pollutants. Such climatic and topographic characteristics of Užice favor the increased concentration of pollutants emitted, from individual fireplaces, central heating stations, and traffic.The appearance of thick fogs, resulting in air quality deterioration, is characteristic of the industrial complex in Sevojno and Krčagovo. Twenty-eight percent of the total number of households in the central parts of Užice, Krčagovo, and Sevojno, get its heat supply from the city’s central heating plant. This plant, with its 13 boilers rooms in operation, together with individual household boiler rooms and individual fireplaces (which use solid fossil fuels), are one of the largest sources of air pollution in the city. Due to the poor quality of fossil fuels, poor and irregular maintenance of the above-mentioned combustion places, smoke gases emitted into the atmosphere contain harmful and hazardous substances, such as combustion-related particles, known as BC particles. It is estimated that there are around 16,000 individual fireplaces in the city area. Combustion products from these furnaces predominantly remain in the lowest parts of the atmosphere because of relatively low chimneys, the specific configuration of the terrain, and unfavorable air mass flow. The type and quality of energy sources, as well as the combustion process itself, is difficult to modify, because 70% of the inhabitants use wood and coal for heating in individual furnaces. In many household furnaces, completely inappropriate waste materials are used for combustion, like waste oils, textiles, etc., thus further increasing the concentration of pollutants and endangering the environment. Inspection services do not have the legal authority to perform inspection in individual households. Considering the geographic position of the Užice, the directions of two main state roads that pass through the central area of the city and a dense network of urban roads and a large volume of traffic through the city center, the traffic in Užice represents a significant source of air pollution, including BC.There are several advantages of our study. Firstly, we studied the novel population. Secondly, the time-stratified case-crossover design used in the present study, in which cases serve as their own control, has been demonstrated as a suitable method for assessing brief changes in risk associated with transient exposures. Also, the reported ORs have been adjusted for the possible confounding influence of weather variables. However, there are several methodological limitations. The relatively low number of cases did not allow proper evaluation of potential sex and age differences. Furthermore, the regional measurements of BC pollution from fixed-site monitoring stations were taken as the measurements of exposure to BC pollutant for each individual in this study. In addition, we did not adjust for the confounding influence of the levels of other air pollutants and aeroallergens that could lead to a change in risk. Taking into consideration all limitations, our study supports the association between exposure to BC and ED visits for allergic rhinitis and allergic asthma in the Užice region of Western Serbia. Considering the importance of the geographical location of the study area as a combination of an industrial region and a climatic health resort suitable for the treatment of respiratory diseases, the results of our study are of great public health importance. The analysis of the short-term effect of outdoor BC on allergic rhinitis and allergic asthma exacerbation in the Užice region may significantly contribute to the establishment of relevant public policy in Western Serbia. According to WHO recommendations , particu2.5 in the Užice region. Because of the environmental health risks associated with BC, understanding exposure levels to BC and regulations to reduce total BC emissions is a high priority of the Serbian Environmental Protection Agency and other stakeholders in Serbia.In addition, we hope that the present study provides evidence to support the regular monitoring of BC and PM


Reliability was assessed for internal consistency and via test-retest. Convergent validity was evaluated by comparing the effect sizes among known groups with different levels of mental health knowledge, the correlation with mental health-related instruments, and the item discrimination index. A final version of a 35-item EMHL test was obtained with two parts: (i) a binary choice format (yes/no) for the identification of mental disorders; (ii) a multiple choice question with four possible answer options. Internal consistency was acceptable in the first part  and almost acceptable in the second part . The test-retest evaluation supported the stability of the test . No ceiling and floor effects were found. The EMHL test scores discriminated between known groups with different levels of mental health knowledge and it is associated with several-related constructs of MHL. Conclusions: The EMHL test is a relevant measure for assessing MHL in adolescents into Spanish context with acceptable validity and stability.There is evidence of the effectiveness of implementing mental health literacy (MHL) programs. However, there are substantial limitations in the instruments available for measuring MHL. This study aimed to develop and validate the EspaiJove.net MHL test (EMHL) for Spanish adolescents by assessing its psychometric properties. The development of the EMHL test was conducted using item pool generation and a pilot study. A convenience sample of students aged 13–15 years ( It is estimated that 75% of all people suffering from a mental disorder have experienced the onset at 25 years old ,2 and 50MHL is defined as “a set of knowledge and beliefs about mental disorders which aid their recognition, management or prevention” . MHL invEspaiJove.net: a space for mental health” (EspaiJove.net) [Some MHL interventions for adolescents and young people have been developed in recent years in several countries ,9,10,11.ove.net)  has beenA systematic review of the measurement properties of tools measuring MHL  showed tEspaiJove.net mental health literacy (EMHL) test for the assessment of MHL in Spanish. The EspaiJove.net intervention consists of a universal MHL intervention which aims to promote mental health, prevent mental disorders, and facilitate help-seeking behaviors among secondary school students in the Spanish context.To our knowledge, no specific MHL questionnaire has been properly validated. The aim of this study is to develop and validate the EspaiJove.net. The item pool generation from EspaiJove.net thematic module contents include: (1) The concepts of mental health and mental disorders, (2) mental health multidisciplinary team network and the use of health services, (3) healthy and risk behaviors in mental health, (4) social skills and antisocial behavior, bullying and cyber-bullying, (5) anxiety, (6) depression, (7) self-harm and suicidal behaviors, (8) eating disorders, (9) alcohol and substance use, and (10) psychotic disorders.The EMHL test is a maximum performance test (criterion-referenced test—CRT) based on thematic content from The EMHL test development process involved two phases, as shown in To obtain the EMHL total test score for each part of the test, the formula (A-E)/(n-1) is used, where A = number of correct answers, E = number of errors , and n = number of options for each item. Then, for the first part of the EMHL test, the formula is (A-E)/(2-1), and for the second part it is (A-E)/(4-1), where each correct answer adds one point to the total score, and each incorrect answer results in zero points  . To faciN = 355) in 6 schools in Barcelona, Spain, and the informed consent signed by both adolescents and parents. Exclusion criteria included: (1) Students with special educational needs and/or with cognitive problems; and (2) no understanding of Spanish or Catalan. Nurses and psychologists who were members of the EspaiJove.net team informed the participants about the content of the study and administered the EMHL test.The validation process was performed through the administration and analysis of the final version of the EMHL test to a non-randomized convenience sample of high school students aged 14/15y, high school students, and the parents of all students participating in the study was requested.We hypothesized specific variables to associate them with the level of MHL, with varying degrees of strength.Stigma was measured using two questionnaires: (1) the Scaling Community Attitudes toward the Mentally Ill (CAMI) Spanish version  which coMental health. The strengths and difficulties scale (SDQ) was used . The SDQHealth-related quality of life (HRQoL). The 5-level EQ-5D is a brief, multi-attribute, generic, preference-based health status measure ,22. We uBullying and cyberbullying. We developed a 4-item scale to assess bully victims and the bullying behaviors of perpetrators specifically for this study. Two items assess whether an adolescent has been bullied or cyberbullied and two items have bullying or cyberbullying behaviors. We hypothesized that adolescents who have been bullied or bullies themselves would have lower mental health knowledge.n = 213). We hypothesized that some groups, in particular health professionals and teachers, would have significantly higher mental health knowledge than high school students.We recruited high school teachers, nursing and psychology university students, primary care physicians and nurses, and mental health professionals   coefficient ,25 as anThe ability of the EMHL test’s uncorrected total score was assessed to distinguish among different groups. Differences across known groups were assessed with the ANOVA parametric test. The magnitude of the association was estimated with the effect size (ES) to compare average differences in the MHL mean between subgroups in categorical variables. The cutoffs and the interpretation of ES were low (|0.20| ≤ ES ≥ |0.50|), moderate (|0.50| < ES ≥ |0.80|), and high (ES > |0.80|) ,29. In tD ≤ 0.0), inadequate (D > 0.0– < 0.20), low (D ≥ 0.20– < 0.30), acceptable (D ≥ 0.30– < 0.40), and strong (D ≥ 0.40) discrimination.The item discrimination index was also assessed, and it evaluates how well an individual question sorts the sample out between those who have mastered the material and those students who have not. It is based on comparing the performance of the extreme groups (low and high) in the test scores. The number of participants who have been successful in the high group (mastered) was compared to those in the low proficiency group (non-mastered). We selected 36% of the sample. The discrimination capacity of each item was assessed by these cut-offs: items that must be deleted  version 22.0  and MicrAmong the 355 high school students, 178 (50.1%) were women (four subjects were missing), and 56 (15.8%) were non-Spanish nationals, with mean (SD) age at 14.5 (0.66).p < 0.001) in both total scores, which was most likely due to the large sample size studied. We assumed that both parts of the EMHL test have a normal distribution of total scores  = 0.422(0.072–0.639), p = 0.012.The no-item category was missing. A visual inspection of item response frequencies showed very few skewed distributions in both parts of the EMHL test. Nevertheless, the Kolmogorov-Smirnov normality test showed as significant for uncorrected and corrected total scores . For the first part of the EMHL test, all groups had a significant and moderate magnitude of association compared with high school students . In the second part of the EMHL test, teachers, university students and primary care physicians and nurses had a significant and moderate magnitude of association compared with high school students , and a significant and high magnitude of association when we compared with mental health professionals  (see 001) see .r = −0.246; p < 0.01), and a very weak but significant correlation for HRQoL in the anxiety/depression domain of EQ-5D-5L , and in the emotional symptoms domain of SDQ .r = −0.222; p < 0.01) and RIBS’ future behavior , and a very weak and significant correlation in the conduct problems domain of SDQ , HRQoL in the self-care domain of EQ-5D-5L and bullying behaviors . Other domains and scales were not significantly related to both parts of the total scores from the EMHL test.In the second part of the EMHL test, high school students with higher uncorrected scores for MHL had a weak strength and significant correlation for CAMI’s Authoritarianism dimension  see .D = 0.33), and item 4  has low levels of discrimination (D = 0.24) . In the second part of the test, only item 18 (delusions) has an acceptable level of discrimination (.24) see .EspaiJove.net intervention, and more generally, to evaluate the knowledge and belief about mental health and mental disorders, knowledge of the risk behaviors of a mental disorder and the help-seeking behaviours. Accordingly with the developmental process, the EMHL test has been developed to deliver a clinically relevant measurement adapted to the Spanish context, supported by extensive recommendations by mental health experts and taking into account the opinion of adolescents, using non-offensive and adolescent-adapted vocabulary which was delivered via the content on the EspaiJove.net universal MHL intervention. Regarding the validity of the results, the EMHL test demonstrated it was capable of distinguishing between known groups with different levels of mental health knowledge, correlated with some variables related to mental health, related-behaviors and HRQoL, and it has the capacity to differentiate between those adolescents who have mastered the materials of the EspaiJove.net and those who have not. So, these results suggest that this test will be appropriate for the assessment of its efficacy after the intervention. However, some reliability measures showed slightly low scores in the EMHL test.This study described the development of the EMHL test and its psychometric properties in a sample of Spanish adolescents, showing good validity properties and stability over time. The EMHL test is a measure created to assess the effectiveness of EspaiJove.net intervention, and among the adult population with an estimated higher level of MHL. However, internal consistency showed low results for the second part of the EMHL test, although it almost reached the ≥0.70 value which is considered to be acceptable. Internal consistency ranges from poor to fair in both parts of the EMHL test, where the same results have been demonstrated in corrected item-to-total correlations. Furthermore, two items  have negative values recommending to delete both items. However, the opinions of mental health professionals considering both items as clinically relevant, recommend to keep them in the EMHL test. According to a previous systematic review of the quality of developed MHL instruments [The score distribution for the EMHL test showed that it has an appropriate ceiling and floor effect and stability over time, where less 6% of the adolescents answered all the items correctly in both parts of the EMHL test, respectively. Regarding reliability, these results suggest that this test can be used over time for the assessment of the efficacy of interventions aimed at increasing MHL among Spanish adolescents, such as the truments , out of truments ,15, and truments ,35,36,37Both parts discriminated between wide ranges of groups  with different levels of mental health knowledge. The discriminative capacity of the EMHL test between these groups makes it possible to conduct studies among youths, even in the adult population and to conduct studies that assess the effectiveness of MHL interventions aimed at increasing the level of mental health knowledge up to that of mental health professionals which would be the gold standard of MHL and expertise. Although most validity measures showed poor or fair reliability, such as stigma-related with CAMI’s authoritarianism dimension, mental health symptoms and HRQoL, the EMHL test also demonstrated significant correlations between many mental health-related constructs, as our a priori hypotheses regarding the pattern of correlations between MHL and mental health-related stigma, emotional symptoms, anxiety and depression HRQoL, conduct problems and bullying behaviors were generally satisfied. As predicted, adolescents with higher MHL levels had less mental health-related stigma, anxiety and depression HRQoL, conduct problems and bullying behaviors, and higher emotional symptoms. Unexpectedly, higher self-care HRQoL correlated with higher MHL levels. This unexpected correlation is probably related to the positive mental health items in the EMHL test. These results suggest that higher scores of MHL using the EMHL test have an impact on these constructs.Our study has several strengths, including a large sample size, as well as the fact that the EMHL test addresses a gap in the assessment of adolescent MHL. Methodologically, this study proposes an evaluation method for MHL that has been scarcely explored so far. The CRTs are generally used in education to find out to what extent each subject dominates the criterion of interest. In this case, the selection of items is not based on individual differences and the variability of answers but on the purpose of the test: to identify those students who manage the domain and those who do not. Therefore, the CRTs’ decisions are based on acceptable performance rather than the relative position .On the other hand, our study has some limitations. Although this instrument has been developed for the Spanish context, the EMHL test has been developed with adolescents living in Barcelona, so further validation should be assessed in other cities, regions and settings. Secondly, the broad scope of the EMHL test and the complexity of multiple choice questions could diminish its reliability. However, we consider that adolescents who know key questions about mental health prevention, and which they consider to be useful, are more important and clinically relevant than the consistency of the test assessed statistically.EspaiJove.net intervention, it could be a promising tool to inspire other MHL measurements.As a result, this study provides a new valid instrument for the evaluation of MHL interventions. Although the EMHL test is only used for the


Maintaining physical activity is necessary to promote health in our daily lives. The Ecological Model of Active Living was proposed to examine whether individuals participate in active living. The purpose of this study was to understand the determinants of physical activity and create a predictive path model of the intrapersonal, perceived environment, behavior settings, and policy environment domains. Data were obtained from open government data and questionnaires, including the International Physical Activity Questionnaire, Health Belief Model Inventory, Physical Activity Neighborhood Environment Survey, and Accessibility of Open Spaces. Participants comprised 1085 healthy adults who completed a self-reported internet survey. An analysis of the intrapersonal domain revealed that the variables of female, an older age, and a low educational level, and individuals with obesity or cardiometabolic diseases presented lower odds ratios for active living. We found significant statistical support for our path model , with a predictive power of 23.1%. The predictive path model is a good approach to quantitatively measure the impacts of various determinants on active living that suggests further lines of research in approaches for modeling relationships. The World Health Organization identifies physical inactivity as the fourth leading cause of death. The definition of physical activity (PA) is any kind of bodily movement that requires energy expenditure . PhysicaA socio-ecological model is commonly used to explain the determinants of healthy behaviors. Changes in policy, the environment, and individuals affect and support healthy behaviors . Sallis The intrapersonal domain contains three elements: individuals’ demographic and biological characteristics, and psychological effects. Personal attitudes and beliefs predict whether individuals engage in healthy behaviors. According to knowledge, socio-psychological, and structural elements, individuals have their own personal attitudes, health beliefs, and healthy behaviors . The HeaThe living environment is the foundation of residents’ daily lives, PA, and social interactions . The walPublic open space (POS) systems should be taken into consideration. POS systems provide spaces for recreation and leisure activities and are also important destinations for residents to interact with each other, such as sport facilities, parks, and community centers. Transportation systems that support commutes by bike or on foot are also POS systems. These characteristics of POS systems encourage residents to participate in PA . The catCreating a healthy environment is the ultimate mission of government. Redesigning walkable and health-supportive environments promotes active lifestyles by residents . Policy To sum up, PA is a key strategy for promoting health and preventing disease. It is important to increase PA and build active lifestyles  from psyCan elements of the intrapersonal domain  and cardiometabolic diseases) predict active living?Can the path model for the Ecological Model of Active Living , perceived environment, behavior setting, policy environment, and active living domains) be accepted?Therefore, the main purpose of this study was to create a predictive path model that refers to domains from the Ecological Model of Active Living. The path model is comprised of the intrapersonal, perceived environment, behavior setting, and policy environment domains, in order to determine relationships between the correlates and latent variables of PA. Impacts of the intrapersonal domain  on active living are also considered. The research questions were as follows:Participants were healthy individuals without physical or mental disabilities in Taiwan. Using convenience sampling, we posted an internet survey on social media and other websites from November 2016 to June 2017. Because of possible biases in internet surveys, we only selected participants between 18 and 60 years, in order to better model the distribution of the adult population. Moreover, according to Hill (1998), if the population exceeds 100,000 and the margin of error is 3%, the number of participants in samples should be greater than 1067 to be representative of the population in an internet survey . In totaThe personal questionnaire had five parts. The first concerned personal health information. Participants’ background information included gender, age, residence, personal income, educational level, height, and weight. Participants were also asked whether they had chronic diseases, including hypertension, diabetes, and hyperlipidemia.The International Physical Activity Questionnaire Long Form (IPAQ) is used to measure participants’ PA over the preceding 7 days. The IPAQ assesses the intensity, duration, and frequency of four domains including recreation, domestic and gardening activities, work, and transport. The current study used only two domains which could be influenced by factors of the Ecological Model of Active Living. According to the scoring protocol and participants’ self-reported transport and recreational domains of PA, metabolic equivalents of task (METs) were calculated as a participant’s weekly energy expenditure. The IPAQ Taiwanese version was shown to have good content validity and test-retest reliability . This stHayslip et al.  developeThe Physical Activity Neighborhood Environment Survey (PANES) is used to measure self-reported walkability in the perceived environment domain. The PANES was developed by Sallis and Saelens . The itep<0.05). Cronbach’s α of the accessibility questionnaire was 0.762.The questionnaire on the accessibility of open spaces for PA was developed for the behavior setting domain, and refers to part 2 of the Neighborhood Environment Walkability Scale-Traditional Chinese long version (NEWS-C). Items in the NEWS-C are related to various facilities and services in the neighborhood  . All 11 OGD were used for measurements in the policy environment domain which were separate from the internet survey. The goals of OGD are to integrate public departments and improve public services . OGD aren = 246). Based on the sum of transport and recreational PA, participants were divided into two patterns of living, inactive living (light: PA <600 MET-min/week) and active living (moderate to vigorous: ≥600 MET-min/week) [t-test, and logistic regression. Scores of transport and recreational PA, subscales of the HBMPA, PANES, accessibility, and WI were transformed into Z-scores in the path analysis. Smart-PLS 3.0 software was used to create a path model.After data were collected, incomplete responses or missing data, outliers, and participants not aged 18~60 years were excluded (in/week) . The meat-test between the two groups. There were significant differences in age, benefits of exercise, barriers to exercise, perceived walkability, accessibility, WI, and PA between the active and inactive living groups.Demographic characteristics of 1085 participants stratified into active living and inactive living groups are shown in R2 of the logistic regression model was 0.05.Results of the logistic regression for the intrapersonal domain are shown Results of the path model of our Ecological Model of Active Living are illustrated in t = 13.67, p<0.001), and the R2 value was 0.113, while that between policy environment and behavior setting domains was 0.087 , with an R2 value of 0.008. The coefficient of determination was considered a weak predictor of the perceived environment and behavior setting domains. The path coefficient between the intrapersonal and active living domains was 0.368 , that between the perceived environment and active living domains was 0.074 , and that between the behavior setting and active living domains was 0.238 , with an R2 value of 0.231, which indicated that it was a moderate predictor of active living. All path coefficients were significant in this path model. The Normed Fit Index (NFI) was 0.96 (>0.90), and the standardized root mean square residual (SRMR) value was 0.041 (<0.08), so this path model of active living was accepted.The path coefficient between the policy environment and perceived environment domains was 0.336 Click here for additional data file.