The prevalence of metabolic syndrome has increased over the last few decades in adolescents and has become an important health challenge worldwide. This study analyzed the relationships between metabolic risk factors (MRF) and physical activity (PA) and physical fitness (PF) in a sample of Azorean adolescents.A cross-sectional school-based study was conducted on 417 adolescents (243 girls) aged 15-18 from the Azorean Islands, Portugal. Height, weight, waist circumference, fasting glucose, HDL-cholesterol, triglycerides, and blood pressure were measured. A sum of MRF was computed, and adolescents were classified into three groups: no MRF, one MRF and two or more MRF. PA was assessed by a sealed pedometer. PF was assessed using five tests from the Fitnessgram Test Battery. Dietary intake was obtained using a semi-quantitative food frequency questionnaire.Mean daily steps for girls and boys were 7427 ± 2725 and 7916 ± 3936, respectively. Fifty-nine percent of the adolescents showed at least one MRF and 57.6% were under the healthy zone in the 20 m Shuttle Run Test. Ordinal logistic regression analysis showed that after adjusting for sex, body mass index, socio-economic status and adherence to a Mediterranean diet, adolescents who were in the highest quartile of the pedometer step/counts (≥9423 steps/day) and those who achieved the healthy zone in five tests were less likely to have one or more MRF .Daily step counts and PF levels were negatively associated with having one or more MRF among Azorean adolescents. Our findings emphasize the importance of promoting and increasing regular PA and PF to reduce the public health burden of chronic diseases associated with a sedentary lifestyle. Metabolic Syndrome (MetS) comprises a major risk for chronic disease and is rapidly increasing in prevalence worldwide in association with rising childhood obesity and a sedentary lifestyle . EmerginRegular PA is reported to be a protective factor against several diseases, such as obesity, hypertension, type II diabetes,  and MetSStudies examining the association between CRF and clustered metabolic risk in youth report an inverse relationship, indicating that as the CRF increases, the risk of an unfavorable metabolic risk profile is reduced . Indeed,Associations between increased CRF and several MRF have been repeatedly found. However, the information about the relationship between the overall PF levels with MRF is scarce. To our knowledge, there is only one study that has compared coronary heart disease risk factors to PA measured objectively by pedometry , and, toData for the present study derived from a longitudinal school-based study, the Azorean Physical Activity and Health Study II, aimed to evaluate PA, PF, overweight/obesity prevalence, health related quality of life and related factors beginning in 2008. Study design and sampling are reported elsewhere . For thiAll participants in this study were informed about the objectives of the work, and the parent or guardian of each participant provided written informed consent. The study was approved by the faculty and the Portuguese Foundation for Science and Technology ethics committee and conducted in accordance with the Declaration of Helsinki for Human Studies of the World Medical Association.2) and used to define thinness, normal weight, overweight and obese group [Height was measured to the nearest millimeter in bare or stocking feet with the adolescent standing upright against a stadiometer . Weight was measured to the nearest 0.10 kg, lightly dressed using a portable electronic weight scale (Tanita Inner Scan BC 532). Body mass index (BMI) was calculated as weight/height squared  was measured using the Dinamap adult/pediatric vital signs monitors, model BP 8800 . Measurements were taken by nurses, all adolescents required to sit and rest for at least five minutes prior to the BP test. The participants were in a seated, relaxed position with their feet resting flat on the ground. Two measurements in the right arm were taken, after five and ten minutes of rest. The mean of these two measurements was considered. If the two measurements differed by 2 mmHg or more, a third measure was taken.Blood samples were collected from the antecubital vein between 8:00 and 10:00 a.m. in a sitting position after ten hours of fasting. The blood samples were drawn in vacuum tubes gel (Sarstedt) in order to obtain values of plasmatic high-density lipoprotein cholesterol (HDL-cholesterol), triglycerides (TG) and glucose. After resting at room temperature for about 30 minutes, the samples were centrifuged for 10 minutes at 3000 rpm to obtain serum. Samples were divided into aliquots, separated within 30 minutes, and stored at -80°C until analyzed. The following analyses were measured on a Cobas Integra 400 Plus, (ROCHE): HDL-cholesterol using the precipitation of the Apolipoprotein B containing lipoproteins with dextran-magnesium-chloride; TG using the Glycerokinase-Glycerolphosphateoxidase-Peroxidase (GK-GPO-POD) method; and glucose using the hexokinase method. The biochemical evaluation of all participants from the different islands was conducted in the same laboratory.Since there is no consensus regarding the establishment of a universal criterion for the definition of MetS in children and adolescents, it was decided to compute a sum of MRF based on five cut-off points of the MetS International Diabetes Federation criteria  using thThe highest level of parental education (in completed years of education) was considered as a proxy of socio-economic status. Similar procedures had previously been applied in the Portuguese context .Dietary intake was obtained using a semi-quantitative food frequency questionnaire regarding the previous 12 months comprised of 82 food and beverage items . A MeditPhysical activity (PA) was assessed objectively using a sealed pedometer  worn over seven consecutive days. Participants with fewer than three days (two weekdays and one weekend day) of activity recorded were eliminated from the data analysis (74 adolescents) in accordance with previous findings . AnotherSeveral studies have shown that in adolescence low CRF is a predictor of cardiovascular disease risk factors ,23,24; at tests with Bonferroni corrections were performed to compare sexes in continuous variables.Descriptive data are presented as means and standard deviation unless otherwise stated. All variables were checked for normality and appropriately transformed if necessary. The HDL-C, TG, systolic BP, and WC were logarithmically transformed. Independent sample 2 = 5.72, p = 0.573; second model: χ2 = 8.10, p = 0.151). Data were analyzed using the Stata 10.0 software  and SPSS for Windows (version 17.0). A p value under 0.05 denoted statistical significance.Ordinal logistic regression was used to verify the relationship between MRF , with PA, and overall PF levels (independent variables). Two models were created for analysis. The first model analyzed the relationship between the MRF and PA, and the second model analyzed the relationship between MRF and overall PF levels. Both models were adjusted for sex, BMI, socio-economic status and adherence to the Mediterranean diet. The assumption of proportional odds for both models was examined using the Brant test  were less likely to have one or more MRF compared to those who were in the UHZ, after adjusting for sex, BMI, socio-economic status and adherence to a Mediterranean diet  (Table The main findings from this study indicate that adolescents who are more active (≥9423 steps/day) and those who achieve the HZ in five tests have lower odds for having one or more MRF. Other important findings of the study indicate that 59% of the participants showed at least one MRF and 57.6% were UHZ in the 20mSRT.In this study, the mean daily step counts were 7427 for girls and 7916 for boys. These results are below the ranges of steps/day reported for adolescents by previous authors . A threeth quartile was 9423 steps/day, which is close to the step count cut-off of 10,000 proposed for adults, [Given the lack of recommended step counts for the adolescent population, we decided to divide the mean step counts/day into quartiles adjusted to the adolescent's age. In this study, it was observed that the value of the 4 adults,  and as aThough this study has not examined PA intensity, Wild et al.  showed tReduction in PA is linked to increases in childhood/adolescent obesity  and MetSThe lack of PF has also been associated with the development of cardiovascular disease risk factors in youth, such as lipid disorders, high BP and insulin resistance, among others . Our resRuiz et al. have also shown an inverse association between CRF and clustered MRF in 9-10-year-old Swedish and Estonian children . ReinforRegarding the relationship between PA and CRF levels with MRF, our study indicated that although Azorean adolescent girls had similar step counts to boys, they had lower CRF levels and had more prevalence of MRF. A partial explanation for these differences could be the fact that boys, in general, are more vigorous in PA ,36; therThe main strength of the current study is that PA was assessed objectively by pedometers, which are a valid and reliable measure. Moreover, walking is one of the most common forms of PA and is easily captured by a pedometer. Their relatively low cost and ease of administration make them attractive for use in field-based PA studies. The use of field tests for PF assessment, which can be administered in school settings where a large number of participants can be tested simultaneously, enhances participant motivation, making it a valuable tool for studying PF in youth. Another aspect to note is the specificity of the place of the study, which was conducted in the Azores Islands. Some studies have been published on Azorean adults -39, but In conclusion, the results of this study indicate that adolescents who were more active (≥9423 steps/day) and those who achieved the HZ in five tests were less likely to have one or more MRF, after adjusting for sex, BMI, socio-economic status and adherence to a Mediterranean diet. Our findings emphasize the importance of promoting and increasing regular PA and PF to reduce the public health burden of chronic diseases associated with a sedentary lifestyle. Further research is warranted to quantify how much PA and PF are needed to prevent and reduce the risk in those who already have one or more MRF, highlighting potential sex and BMI differences.The authors declare that they have no competing interests.CM, RS and JM have made substantial contributions to conception and design of data. CM and RS and have carried out the data collection, statistical analysis, interpretation of data and wrote the manuscript. JCFJ, SV, LSM, AIM and PCS have been involved in drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/214/prepub


The prevalence of sexual dysfunction in patients with COPD is high and its significance has not been sufficiently stressed. The aim of this study is to investigate the incidence of erectile dysfunction (ED) and the factors affecting its frequency in COPD patients.Seventy patients with COPD and 68 healthy volunteers were included in the study. The International Index of Erectile Function questionnaire was used to evaluate ED, and the Beck Depression Inventory was used to evaluate depression.2) and body mass index (BMI) were lower in the COPD group. Blood tests revealed higher levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. Testosterone level was lower but it was not statistically significant. Various degrees of ED were detected in 78.6% of COPD patients and 55.8% of the controls. Depression was more common in the COPD group. There was a negative correlation between forced expiratory volume in 1 sec (FEV1) level and ED and between SaO2 and ED in the COPD group. A positive correlation was noted between age and ED in both groups. No significant correlation was found among hormonal status and FEV1, ED, depression, SaO2, or BMI.The smoking rate was higher and oxygen saturation (SaOThe present study provides further confirmation that COPD is a risk factor for erectile dysfunction. When establishing a treatment plan for improving the pulmonary function of COPD patients, sexual dysfunction and depression, which are usually neglected but diminish quality of life, should also be addressed. Chronic Obstructive Pulmonary Disease (COPD) is a chronic, treatable, and preventable disease characterized by persistent airflow limitation. It occurs as a result of long-term exposure to harmful particles or gases (mainly cigarette smoke) that lead to increased inflammatory response in the airway . The infDuring the evaluation of COPD patients, physicians generally ignore some significant comorbidities, such as sexual dysfunction. A previous study demonstrated that 87% of patients with COPD do not discuss their sexual problems with their physicians and 78% do not share these problems with their wives . Few stu2), measured from the finger, were recorded.This study was conducted on 70 COPD patients and 68 healthy volunteers who had been referred to the KahramanmarasSutcu ImamUniversity, Medical School Pulmonary Disease Clinic and the AfsinStateHospital, Pulmonary Clinic. The approval for this study was obtained from the Ethical committee of the University. All participants signed an informed consent form prior to the study. Healthy volunteers were patients who had been referred to the Pulmonary Disease Clinic because of cough and chest pain of less than 4 weeks. They had no history of any chronic disease, and no other serious health problem was detected after the physical, laboratory, and radiological examinations. Patients who had coronary heart disease, diabetes mellitus, history of alcoholism, impaired health, or who were receiving any hormonal or psychological treatments were excluded from the study. The selected patients filled out a questionnaire in order to identify their socio-demographic status. Body mass index (BMI) and oxygen saturation (SaO1), forced vital capacity (FVC), and FEV1/FVC were measured. A post-bronchodilator FEV1/FVC ratio less than 70% of the predicted value confirmed the diagnosis of COPD. The severity of COPD was graded based on the GOLD classification as mild, moderate, severe, and very severe [A pulmonary function test (PFT) was performed in compliance with American Thoracic Society criteria using a spirometry device  . Post-brThe International Index of Erectile Function (IIEF-5) is a self-applied five-question index developed by Rosen et al.  that is Venous blood samples were obtained from all participants to measure total testosterone levels, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. The levels of testosterone, estradiol, and FSH were measured by enzyme-linked immunosorbent assay (ELISA) using a Thermo Scientific ® Multiskan FC (Finland), and LH was measured using the chemiluminescent method with an Immulite® 2000 (Siemens USA).The Beck Depression Inventory Scale (BDI) is a 21-question, multiple-choice, self-applied inventory developed by Beck et al. . It evalt-test, Pearson correlation, one-way analysis of variance, and chi-square tests were applied, and p less than 0.05 was considered significant.Findings were evaluated using the SPSS 17.0 software package. Data were expressed as the mean, range, and standard deviation. For the statistical assessment, independent A total of 138 male subjects, 70 patients with COPD and 68 control volunteers, were included in the study. Socio-demographic information of all participants are presented in Table Oxygen saturation was lower in the COPD group, and the difference was statistically significant (p = 0.000). Although total testosterone level was lower in the COPD group compared to the controls, the difference was not significant (p = 0.17). In the COPD group, FSH, LH, and estradiol levels were significantly higher compared to the control group  Table .Evaluation of IIEF-5 scores showed that 55 (78.6%) of the COPD patients and 38 (55.8%) of the controls had various degrees of ED, and the difference was statistically significant (p = 0.000) Figure . The num1 and ED . There was no correlation between the level of FEV1 and BDI scores , but a negative correlation was found between FVC and BDI scores .In the control group, no correlation was demonstrated between FEV1 and ED, FEV1 and the BDI score, or ED and the BDI score.In the COPD and control group, a moderate negative correlation was found between FEV1, ED, depression, SaO2, and BMI (p > 0.005). However, a negative correlation was found between SaO2 and ED and between SaO2 and BDI in the COPD group . Likewise, a negative correlation was found between SaO2 and ED in the control group .In both COPD and control group, there was no significant correlation between hormone levels and FEVAge was correlated with both depression and ED in the control group, . On the other hand, there was a positive correlation between age and ED in the COPD group , while no correlation was detected between age and depression .Sexuality is a lifelong necessity in order to pursue human well-being . FactorsCOPD is not only a pulmonary obstructive disease but also a chronic illness, which presents with various comorbidities involving multiple organs . Some ofSexual activity causes an increase in the cardiopulmonary load. Energy spent during orgasm is equal to the energy required for walking with a speed of 5–6 km/h or continuous stair climbing for 3–4 minutes ,29. Decr2 and testosterone levels in COPD patients. Furthermore, they demonstrated a significant rise in LH and FSH and an important decline in testosterone levels during exacerbation in COPD patients. In our study, the levels of LH, FSH, and estradiol were significantly higher; however, the decline in testosterone levels was insignificant in the COPD patients. Similar to the study by Karadag et al. [1 score and hormone levels. This possibly was due to the lower number of severe COPD patients in our study.In males, testosterone is secreted mainly from the gonads. LH is released from the pituitary gland and controls the secretion of testosterone from Leydig cells. FSH contributes to an increase of testosterone secretion by inducing the maturation of Leydig cells . In male2. ED incidence is reported to rise as the blood oxygen level decreases in healthy individuals ascending to a high altitude [Another factor leading to the sexual problems in COPD patients could be the low level of SaOaltitude . In a pialtitude , decreas1; however, no significant correlation was found. On the other hand, we found a negative correlation between depression and FVC. We assume that an increased depressive status in the COPD patients contributed to the worsening ED.Anxiety and depression are among the most common comorbidities in COPD. Janssen et al.  demonstrSome limitations were noted during the evaluation of the results. The most important ones are the absence of the following parameters: the BODE index, the six-minute walking test, the partner status information, and the arterial blood gas test in both the study and the control group.GOLD guidelines do not contain information regarding sexual dysfunction in the comorbidities sections. Consequently, physicians who follow the GOLD guide usually do not ask patients whether they have any sexual complaints. This is an important limitation to patients’ quality of life. Sexual dysfunction and depression should be carefully questioned when recording the history of patients with COPD, and this information should be used in therapy planning.The data set supporting the results of this article is included within the article.BMI: Body mass index; COPD: Chronic obstructive pulmonary disease; ED: Erectile dysfunction; FSH: Follicle-stimulating hormone; LH: Luteinizing hormone; PFT: Pulmonary function test.The authors declare that they have no competing interests.HK, BS participated in the performing the study. HK, NK conceived of the study, and participated in its design and coordination and helped to draft the manuscript. MK carried out biochemical analysis. SR performed the statistical analysis. All authors read and approved the final manuscript.


Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Studies report poorer outcome for patients who undergo emergency compared with elective surgery, both for their initial hospital stay and their long-term survival. Advanced tumor pathology and tumors with unfavorable histologic features may provide the basis for the difference in outcome. The aim of this study was to compare the clinical and pathologic profiles of emergency and elective surgical cases for colorectal cancer, and relate these to gender, age group, tumor location, and family history of the disease. The main outcome measure was the difference in morphology between elective and emergency surgical cases.In total, 976 tumors from patients treated surgically for colorectal cancer between 2004 and 2006 in Stockholm County, Sweden  were analyzed in the study. Seventeen morphological features were examined and compared with type of operation (elective or emergency), gender, age, tumor location, and family history of colorectal cancer by re-evaluating the histopathologic features of the tumors.P<0.0001 for AJCC stage III to IV, N stage 1 to 2/3, and vascular invasion). In a multivariate analysis, all these differences, with the exception of peri-tumor lymphocytic reaction, remained significant .In a univariate analysis, the following characteristics were found more frequently in emergency compared with elective cases: multiple tumors, higher American Joint Committee on Cancer (AJCC), tumor (T) and node (N) stage, peri-tumor lymphocytic reaction, high number of tumor-infiltrating lymphocytes, signet-ring cell mucinous carcinoma, desmoplastic stromal reaction, vascular and perineural invasion, and infiltrative tumor margin (Colorectal cancers that need surgery as an emergency case generally show a more aggressive histopathologic profile and a more advanced stage than do elective cases. Essentially, no difference was seen in location, and therefore it is likely there would be no differences in macro-environment either. Our results could indicate that colorectal cancers needing emergency surgery belong to an inherently specific group with a different etiologic or genetic background. Colorectal carcinoma (CRC) is the third most common form of cancer worldwide. Around 15 to 30% of CRCs present as a surgical emergency, with the most common causes being obstruction (78%), perforation (10%), or bleeding 4%) . Rectal % . RectaPatients undergoing acute surgery are generally older than elective cases  and some studies have shown a female predominance . Both young (<40 years) and old (>80 years) patients with CRC more often present as an emergency, probably because both groups are at risk of having their symptoms regarded with indifference .Many studies report a poorer outcome for patients who undergo emergency surgery, both during their initial hospital stay and for their long-term survival ,2,5-7. EPatients undergoing emergency surgery tend to have more advanced cancers (American Joint Committee on Cancer (AJCC) stages III and IV), with more tumor (T)3 and T4 tumors and more node (N)1 and N2 cases compared with electively managed patients . Accordiet al. [Many studies have found no difference in the morphological profiles of emergency and elective CRCs ,8-10. Hoet al.  found thIn a previous study , we founThe aim of this retrospective study was to compare the clinical and pathologic profiles of CRC cases, treated surgically either as an emergency or electively, with gender, age group, tumor location, and family history of CRC.This study was approved by the local Ethics Committee at Karolinska Institutet (no. KI Dnr 02–489), and informed consent was obtained from all participants.University clinics, district general hospitals, and general hospitals participated in the study. In total, 2573 consecutive patients treated surgically for CRC at the eight hospitals in Stockholm County between 2004 and 2006 were assessed for the study. Of these patients, 308 died before being asked to participate. Other reasons for exclusion were that patients were too ill or too old. Finally, 1205 patients  were included in the study. In 976 cases, tumors were available for re-evaluation. Medical records containing information on type of operation could be found for all but two cases.Recruitment of patients was carried out either by the individual surgeons after surgery or by us, using a list provided by the Stockholm-Gotland Oncology Center where all cancers in Stockholm County are registered. A letter was sent to each patient with information on the study and a request that they participate. All patients who showed interest in participating were contacted over the telephone for informed consent and thereafter included in the study. A family history of cancer was taken from all study participants, and all CRC diagnoses in the family were verified by medical records or death certificates.In this study, an emergency case was defined as a patient who underwent emergency CRC surgery because of perforation, obstruction, or bleeding, regardless of the time elapsed from hospital admission to operation. All other cases were considered elective. Most cases were discussed at a post-operative multidisciplinary consensus conference, where they were classified as having undergone emergency or elective surgery. Perforation was defined as pneumoperitoneum on preoperative radiography. Obstructive tumors were defined as tumors causing ileus, regardless of whether the occlusion was partial or total. Bleeding was defined as blood loss from the tumor causing such severe anemia that the patient had to be treated surgically.Data on gender, age, and tumor location were obtained for all cases. It was possible to obtain information about family history of CRC in 962 cases. Familial CRC was defined as patients with one or more first-degree or second-degree relatives with CRC, who did not fulfill the Amsterdam criteria for Lynch syndrome (LS) or who had evidence of heredity for familial adenomatous polyposis (FAP). Eight patients with LS were found in our sample, but no case of FAP.All tumors were re-evaluated using a standardized protocol that included information on patient gender, age at operation, name of hospital and pathology department, date of diagnosis, date of re-evaluation, and name of re-evaluating pathologist. Information on tumor location and multiple co-existing tumors was gathered from the original pathology report and from the Stockholm-Gotland Oncology Center Register.All macromorphologic parameters, including tumor size in three dimensions, were obtained from the original pathology report . The number of positive and negative lymph nodes and the number of blocks taken (including large sections) were noted.In all 976 cases, slides stained with hematoxylin and eosin (H&E) were obtained from the participating pathology departments. In one case, only biopsy tissue could be retrieved, and in a further 24 cases, the specimen was taken at polypectomy or local resection. All cases were re-evaluated by one experienced gastrointestinal pathologist (SG).The micromorphologic parameters assessed were tumor grade, stage, medullary features, mucin production, mucinous type, Crohn-like peri-tumor lymphocytic reaction, tumor- infiltrating lymphocytes (TILs), desmoplasia, tumor necrosis, vascular invasion, perineural growth, co-existing polyps, budding, and type of tumor margin. The exact definition of such features and methods of assessing them has been outlined in detail in our previous report . Becauseb) from linear regression. The significance level was set at P<0.05.Analyses were made using SPSS Statistics . The associations between clinical and pathologic features and type of surgery, gender, age group, tumor location, and family history were examined using univariate, multiple binary, and multinomial logistic regression analyses for categorical outcomes, and linear regression analysis for continuous outcomes. The associations between type of surgery and gender, age group, tumor location, family history were examined using similar analyses. Results are presented as odds ratios (ORs) from logistic regression, and as regression coefficients  with varimax rotation was performed to form a concise description for all variables included in the study. This analysis seeks a few underlying dimensions (factors) that account for patterns of variation among the variables in the study, in this case the clinical and pathologic parameters such as type of surgery, gender, age, tumor location, family history, and morphologic features. Variables with a loading of greater than 0.40 are usually applied as meaningful factor loadings. If a variable has a meaningful loading on more than one component, that variable should be ignored in the interpretation.The total number of patients examined was 976, of whom 53 had multiple co-existing cancers. Most (86.6%) of cases were elective (n = 845) and 13.2% were emergency (n = 129) cases. In two cases, the type of operation could not be defined. For all but two of the emergency cases, the indication for surgery was found in the medical records: 16% (n = 21) because of perforation, 73% (n = 94) because of obstruction, and 4% (n = 5) because of bleeding. In seven cases, the reason for the emergency surgery was not stated.Of the 976 patients, 52.6% were men (n = 513) and 47.4% were women (n = 463). Mean age was 69.2 years . The majority (77.4%) of cases were sporadic CRCs (n = 755) and 20.5% were familial (n = 200). In 13 cases, there was no information on any family history. Eight cases were known to have LS based on the Amsterdam criteria or screening; seven of these were in the elective group and one in the emergency group.The tumor localization distributions for the elective and the emergency group are shown in Figure P = 0.001), vascular invasion , perineural invasion , and an infiltrative tumor margin . There was no difference in mucin production. However, when the mucinous tumors of both groups were compared, those in the emergency group were more likely to have a signet-ring cell component . Compared with the elective patients, the emergency patients had more tumors of AJCC stages II to IV (P<0.0001 for stages III and IV) than stage I. They also had more T stage 3 and 4 tumors and more N-stage 1 and 2/3 tumors (P<0.0001 for both N1 and N2/3). Desmoplasia was also more common in the emergency group , as was a Crohn-like lymphocytic reaction . In contrast to elective cases, emergency cases were less likely to have greater than 30 TILs per 10 high-power fields (HPFs) .As shown in Table P<0.0001) was seen for multiple tumors (OR = 3.154), perineural invasion (OR = 2.500), an infiltrative tumor margin (OR = 2.452), AJCC stage III versus I (OR = 6.932), N1 vs N0 (OR = 3.186), and N2/3 versus N0 (OR = 2.679). Crohn-like lymphocytic reaction was the only feature where nature of surgery had no significance.In this comparison Tables  and 3, tP<0.0001). The significant result remained when comparing rectal tumors with the right colon . In a multivariate analysis, none of the factors gender, age group, or family history were associated with nature of surgery. Location remained a significant factor with OR = 0.054 and P<0.0001 for having emergency surgery for a tumor in the rectum compared with the right colon.In a univariate analysis of the association between tumor location and the nature of surgery, the only significant result was seen for tumors in the rectum, where there was a much lower risk for having to undergo emergency surgery compared with the cecum  as shown in Table The novel finding of this study is that according to both univariate and multivariate analyses, cases of CRC treated surgically as an emergency are more likely to have multiple tumors. To our knowledge, this has not previously been reported in the literature.P = 0.001 and OR = 2.500, P<0.0001 respectively, in the multivariate comparison). Lymphovascular invasion in turn, would increase the probability of lymph-node metastases, as indicated by the N stage.Emergency tumors tended to be of higher AJCC stage (II to IV), T stage (T4), and N stage N1 to 2/3) which is in line with previous reports /3 which . This isInterestingly, there was no difference in mean tumor diameter between the emergency and the elective groups, nor was there any difference in the frequency of mucinous tumors or tumors showing necrosis. Large, mucinous, or necrotic tumors would be expected to be more disposed to causing obstruction or perforation, resulting in emergency surgery. The perforations associated with colon cancer are mainly due to a direct mechanism of local destruction at the site of the tumor, which does not necessarily mean that the tumor itself has to reach a certain size to achieve this destruction. In about one-third of the cases of perforated colon, the perforation is located proximal to the cancer . This isP = 0.001 in the multivariate analysis). This type of mucin-producing tumor, with mucin pools filled with cells displaying a large cytoplasmic mucin vacuoles, might make the tumor less cohesive and firm, and thereby more prone to perforation -CRC phenotype, which is seen in most cases of LS and in approximately 12 to 17% of sporadic CRCs. MSI tumors have a unique clinical picture and pathologic phenotype, with a better prognosis and a different response to chemotherapy -22. ApprThree MSI-associated features, namely multiple tumors, signet-ring cell carcinomas, and a Crohn-like lymphocytic reaction, were more common in the emergency group, whereas a large number of TILs and a circumscribed tumor margin were more common in the elective cases. No difference was seen between the groups for poor differentiation, mucin production, or medullary tumors, which also belong to the MSI spectrum . Thus thAs mentioned above, vascular invasion was more common in the emergency cases in our study. It seems likely that emergency tumors, being more locally advanced, will show a higher frequency of both vascular and perineural invasion. This is reflected in reports showing a worse prognosis for CRCs treated surgically as emergency cases ,2,5-7. AP<0.0001 in the multivariate comparison). This finding is also in accordance with the fact that locally aggressive tumors cause perforation.Finally, the emergency cases also displayed a higher frequency of tumors with an infiltrative margin  of requirement of emergency surgery for a rectal cancer, compared with a right-sided colon cancer. This significant difference remained in the multivariate comparison . This finding is not unexpected and is in line with the clinical picture of rectal cancer and its surgical management.We also looked at the effect of gender, age group, tumor location, and family history on the nature of surgical presentation. In a univariate analysis, only tumor location was found to be a significant factor, with a highly significantly lower risk  together with vascular invasion, perineural invasion, and tumor margin. This is not unexpected as these are all features related to the extent of tumor spread and tumor aggressiveness. Mucin production and mucinous type were included in the same component (factor 2). Grade of differentiation (negative correlation with well/moderate differentiation), number of TILs, and medullary type are all features related to the MSI-CRC phenotype (factor 3). Crohn-like peri-tumor lymphocytic infiltrate, which is also an MSI feature, was not included in this factor. Tumor diameter and desmoplasia were grouped together (factor 4). Desmoplastic reaction is generally thought to be a feature favoring the host by encapsulating the tumor, but there are conflicting reports . Factor One weakness of our study is that it was retrospective for both the enrollment of patients and the histopathologic re-evaluation of tumor tissue. Furthermore, because informed consent was necessary for inclusion, patients who died soon after surgery could not be included. However, this is one of the largest studies on emergency surgery for CRC of its kind. By having a single experienced pathologist re-evaluate all cases, we also avoided the problem of inter-observer variability. Furthermore, we had access to the family history of our patients and thereby were able to relate this information to the nature of surgery.Several differences were found between CRCs treated surgically as an emergency and those treated electively. The emergency group had a higher frequency of multiple tumors and a more aggressive histopathologic profile and more advanced stage. Because the distribution of emergency and elective cases was essentially the same between the right and the left colon, the observed differences cannot primarily be attributed to differences in macro-environment or tumor location between the two groups. It is known that emergency colorectal surgery is associated with a poorer outcome and higher recurrence and mortality rates. This has traditionally been considered to be a technical and surgical problem, consequently leading to a more frequent use of adjuvant chemotherapy in such cases. Our study suggests that the complexity of the issue probably involves a more aggressive nature of the tumor itself. If future studies are able to classify the genetic background of these tumors, more precise and adequate colon cancer treatment will become feasible.AJCC: American joint committee on cancer; CRC: Colorectal carcinoma; FAP: Familial adenomatous polyposis; H&E: Hematoxylin and eosin; MSI: Microsatellite instability; N: node; OR: Odds ratio; T: tumor; TILs: Tumor-infiltrating lymphocytes.The authors declare that they have no competing interests.SG participated in the design of the study, recruitment of the histopathologic tissue, analyses, and interpretation of the data. He performed histopathologic re-evaluations and drafting of the manuscript. EB was mainly responsible for statistical analyses and contributed to reviewing of the draft. AL was the principal investigator in the major ‘Low risk colorectal cancer study’, of which the present study was a spin-off; contributed to the analyses and interpretation of the data, and to the critical review of the draft. UL participated in the conception and design of the study, analysis of the medical records, recruitment of the patients into the elective and emergency groups, interpretation of the results, and critical review of the draft. All authors have approved the final version of the manuscript prior to submission.


Recent studies have shown an association between weather and climatic factors with mortality, cardiovascular and infectious diseases. We used historical data to investigate the impact of seasonal temperature and precipitation on total mortality in Uppsala, Sweden, during the first two stages of the demographic transition, 1749–1859.We retrieved mortality and population numbers of the Uppsala Domkyrka parish from digitised parish records and obtained monthly temperature and precipitation measures recorded in Uppsala during that time. Statistical models were established for year-to-year variability in deaths by annual and seasonal temperature and precipitation, adjusting for longer time trends. In a second step, a model was established for three different periods to study changes in the association of climate variability and mortality over time. Relative risks (RR) with 95% confidence intervals (CI) were calculated.p=0.07). The significant effect of springtime precipitation for mortality was present only in the first two periods (1749–1785 and 1786–1824). On the contrary, the overall effect of autumn precipitation was mainly due to its relevance during the last period, 1825–1859 . At that time, higher winter precipitation was found to decrease mortality.Precipitation during spring and autumn was significantly associated with annual mortality . Higher springtime temperature decreased annual mortality, while higher summer temperature increased the death toll; however, both were only borderline significant (In urban Uppsala, during the 18th and 19th century, precipitation appeared to be a stronger predictor for mortality than temperature. Higher spring precipitation decreased and higher autumn precipitation increased the number of deaths. However, this association differed before and during the early stages of industrialisation. Further research shall take age-specific differences into account, as well as changes in socio-economic conditions during that time. Sweden went through fundamental changes from the 18th and early 19th century to the turn of the 20th century, when the country developed from a predominantly agricultural society to one characterised by rapid industrial development. The turning point occurred around 1850, exemplified by economic reforms facilitating industrial development. The utilisation of new technology was another important factor; in 1849 the first steam-driven sawmill was established in Tunadal outside Sundsvall . Both feThe average life expectancy increased in men from 32.9 years in the mid-18th century to 43.9 years 100 years later; in the beginning of the 20th century, it was 58.8 years. The respective ages for women were 36.2, 47.4, and 62.2 years  and transmission of infectious agents and diseases . Apart fBased on modern data, a seasonal pattern of mortality has been observed, the highest numbers of deaths occurring normally during the cold season . Cold weIn the last centuries, wealth and health in Sweden were to a large degree dependent on regional or national agricultural production, which was prone to high fluctuations due to weather-related harvest failures, albeit to a decreasing degree towards the end of the 19th century. Poor nutritional conditions made the population more vulnerable to infectious diseases. War and crop failures in the 18th century led to famines and consequently high incidences of infectious diseases. In the 19th century, Sweden suffered from several cholera outbreaks with high number of deaths over a short period , 18.During the last centuries, climatic fluctuations and trends accompanied considerable economic, social, and demographic changes. After the medieval warm period, Eurasia experienced a ‘little ice age’ that started around 1300 and ended in the late 19th century –20. WintAnthropogenic climate change due to industrialisation followed the ‘little ice age’ in the 20th century, leading to increasing average temperature and increased precipitation in some regions, particularly the northern regions –23. TodaThe extent to which the colder average temperature during the ‘little ice age’ was associated with increased mortality in Sweden is not known. It is also necessary to disentangle the effect of climate change over several centuries from socio-economic changes occurring at the same time.Most research so far focuses on the relationship between short-term changes in weather (weather variability) and human health. A range of studies using modern data have been conducted on the role of ambient temperature and precipitation for human health and mortality both in high- and low-income countries , 16, 17.The aim of this study was to analyse the association between climatic variability and annual mortality in urban Uppsala, Sweden, between 1749 and 1859 . We were in particular interested in the association between seasonal temperature and precipitation with annual mortality.www.ddb.umu.se) at Umeå University, containing annual population data aggregated at the parish level. The establishment of Tabellverket in 1749 provided Sweden with the oldest national population statistics in the world. The clergy, or parish ministers, were instructed to send in annual population statistics, which were first compiled at the regional level and then incorporated into the national surveys that were constructed by the Table Commission. Between 1749 and 1859, the clergy delivered parish population data, consisting of two statistical serials: In the population form, size and composition of the parish population was documented about every fifth year, and in the annual mortality form, demographical events such as births and deaths were documented. Data available from Tabellverket include for all parishes the number of men and women, number of births and number of deaths . For the 1800s, they include also socio-economic information such as household sizes, the economic standard of households, and occupational groups in the parish, although for women, the latter information is less reliable. While deaths were recorded annually, information about population size is available until 1830 for only every fifth year on average.We used parish registers (‘Tabellverket’) of the Demographic Database , a rather large parish at that time with several thousand inhabitants, for which complete data are available, were used.We used average annual and monthly temperature and precipitation in Uppsala. Early regular recordings of temperature and precipitation were started in Uppsala around 1722, followed by Stockholm, Umeå, and Tornedalen. In a number of studies, the reliability and validity of early measurements and proxy measures have been analysed, and validated data imputed from these original measures have been provided , 24–27.Average annual and seasonal temperatures were calculated based on monthly averages. No missing values occurred for monthly temperature. Cumulative precipitation per season was calculated by monthly values; if 1 month was missing, it was substituted by the mean of two other months. If 2 months were missing, the seasonal sum was missing (between 6 and 8% of the four seasons). To facilitate interpretation, we converted the sum value of precipitation from mm into cm. Winter included January and February; springtime, March to May; summer, June to August, and autumn, September to November. We excluded the climate measures of December, as they would affect annual death counts during the same year only minimally.Year to year variability in deaths was studied in relation to annual and seasonal climate variability. We considered long-time  changes in numbers of annual deaths more likely to originate from demographic changes (population growth) and decreasing mortality rates owing to changing disease patterns and higher life expectancy. Therefore, to adjust for time-varying confounders, we de-trended annual death numbers by including the expected number of annual deaths as an offset in the regression models. The expected number of deaths was estimated by introduction of a time trend function in a regression model to explain annual death numbers. The time trends function described the mortality changes catching decadal to decadal fluctuations, and leaving year-to-year variability to be explained by the climate variability variables.The association of annual and seasonal temperature and precipitation with the de-trended annual deaths was assessed by linear regression. For this, we applied a generalised linear model (GLM) with a negative binomial function (quasi-Poisson function), with log numbers of expected deaths as an offset variable. Models were first calculated for annual temperature and precipitation separately and together, first for both sexes, then sex-stratified. In a second step, we used seasonal temperature and precipitation separately and in combination; the full model contained climate variables for all four seasons. In a final step, the full model was calculated for three different periods separately  to study changes in the association of climate variability and mortality over time.P-values between 5 and 10% were considered borderline significant.Relative risks (RR) with 95% confidence intervals (CI) were calculated, α was set at 5%. Based on the distribution of seasonal temperature and precipitation and the effect size of the GLM, we calculated the percentage change of death numbers for an interquartile range (IQR) increase in seasonal temperature (°C) and precipitation (cm).The software SPSS version 19 was used to conduct the analyses.Between 1749 and 1859, Uppsala – like most places in Sweden – experienced high annual fluctuations in mortality, while the population increased only moderately before the 1830s, after which it almost doubled until 1859. In 1750, there were 2,826 people living in Uppsala Domkyrka parish . Until 1859, the number had increased to 8,473  . UnusualRelated to these demographic trends, the socio-economic context changed. The number of larger households (5–15 persons) increased rapidly after the 1830s; at the same time, the number of poor and very poor households decreased, and more households were rated as being well-off. More and more men were employed in the manufacturing sector, although fluctuations over time were large. In women, on the other hand, after a peak in 1800 of employment in the manufacturing sector, numbers decreased . The service sector became a larger employer for both sexes since the 1840s, while there was no clear trend in the agriculture sector (data not shown).No trends of temperatures were observed, but the climate became much wetter, especially since the 1840s . Median p=0.330) and by precipitation 1.004 per centimetre increase . Also in sex-stratified analyses, no effect of annual climate was observed . Higher springtime temperature decreased annual mortality, while higher summer temperature increased the death toll; both were however only borderline significant . None of the other parameters reached statistical significance. Sex-stratified analyses showed generally similar associations between the annual climate conditions and mortality for men and women, although spring precipitation reached full statistical significance only in women, while spring temperature was significantly associated with mortality only in men  decreased the annual number of deaths by 7.6% (95% CI 0.07–14.59%), and an increase of autumn precipitation by 6.6 cm increased the number of deaths by 12.6% (95% CI 2.86–23.28%). In 1750, Uppsala Domkyrka parish recorded 103 deaths. A decrease by 7.6% would equal a reduction of that number by 8 deaths, respectively a reduction by 28/10,000 inhabitants. A 12.6% increase in annual deaths would amount to ca. 12 excess deaths in that year; or 44 excess deaths per 10,000 inhabitants.p=0.037).The significant effect of spring precipitation for mortality was present only in the first two periods (1749–1785 and 1786–1824), but not in the last one . Higher p=0.08). Thus, alhough this association was only borderline significant, it was comparably large. At the same time, winter precipitation was found to decrease mortality statistically significantly .Neither in the first nor the second period, autumn precipitation showed significant associations with mortality. However, the significant effect of autumn precipitation, which was found for the whole observation time, was mainly due to its relevance during the last period, 1825–1859 . In the last period, when the association was largest, overcrowding in urban settlements had become a more common phenomenon, giving probably rise to the spread of airborne diseases such as influenza. At that time, a humid autumn climate could have had an impact on mortality through such diseases rather than because of harvest failure with following malnutrition and food-borne diseases. Analyses of cause-specific mortality on an annual or monthly basis could bring more light into this issue; available data for this parish are, however, limited.The protective effect of spring precipitation during the 18th and early 19th century was not present during the last decades 1825–1859). In the mid-1800s, average precipitation was much higher than in the decades before; therefore, the association with mortality might be absent because rainfall reached sufficient levels in all or most years of that period. Another explanation can be the decreasing dependency of the population on local agricultural production or a change to crops that were less sensitive to spring time conditions. However, Sundin and Willner observed that a strong connection between harvest and mortality, partly via local food prices, was present up to the 1860s in Sweden . On the contrary, higher amounts of autumn rain  might have facilitated disease transmission related to hygiene practise and indoor crowding. Rainfall might also lead to rotting of harvest and thereby contribute to higher mortality rates. Different pathways from climate variability to mortality have to be considered, accounting for different societal and socio-economic circumstances, and during different seasons.These historical records of population and meteorological data can highlight the role of environmental factors on human health at the time of demographic and epidemiological transition. More sophisticated models should take changes in socio-economic conditions and agricultural practices during that time into account to analyse opposing or synergetic effects on mortality. Further analyses should also investigate age-specific climate impacts, as well as cause-specific mortality to understand better causal mechanisms in the relation between climate variability and health.


QUALIDEM is a dementia-specific Qol-instrument from The Netherlands. The aim of this study is to evaluate the scalability and internal consistency of the German version of the QUALIDEM.Quality of life (Qol) is a widely selected outcome in intervention studies. The QUALIDEM consists of nine subscales that were applied to a subsample of 378 people with mild to severe dementia and six consecutive subscales that were applied to a subsample of 256 people with very severe dementia. Scalability, internal consistency and distribution scores were calculated for each predefined subscale using the Mokken scale analysis.This secondary data analysis is based on a total sample of 634 residents with dementia from 43 nursing homes. The care relationship, positive affect, negative affect, restless tense behavior, positive self-image, social relations and feeling at home, were scalable (0.31 ≤ H ≤ 0.65) and internally consistent (Rho ≥ 0.62). The subscales social isolation (H = 0.28) and having something to do (H = 0.18) were not scalable and exhibited insufficient reliability scores (Rho ≤ 0.53). For people with very severe dementia, five subscales, care relationship, positive affect, restless tense behavior, negative affect and social relations, were scalable (0.33 ≤ H ≤ 0.65), but only the first three of these subscales showed acceptable internal consistency (Rho 0.59 – 0.86). The subscale social isolation was not scalable (H = 0.20) and exhibited poor internal consistency (Rho = 0.42).In people with mild to severe dementia, seven subscales, QUALIDEM subscales for people with mild to severe dementia and three subscales for people with very severe dementia. The subscales having something to do (mild to severe dementia), negative affect (very severe dementia), social relations (very severe dementia) and social isolation (both versions) produced unsatisfactory results and require revision.The results show an acceptable scalability and internal consistency for seven  Qol hasoncerns” . One earoncerns” ,8. Basedoncerns” . Those athe multidimensional evaluation of the person-environment system of the individual, in terms of adaption to the perceived consequences of the dementia’ [dealing with own disability, developing an adequate care relationship with the staff, preserving an emotional balance, preserving a positive self-image, preparing for an uncertain future, developing and maintaining social relationships and dealing with the nursing home environment[In 2005, Ettema et al. defined the Qol of people with dementia based on a literature review that specified dementia-specific Qol as ‘ementia’ . Based oementia’ dealing wvironment. This movironment. During vironment,15.Qol-AD [D-Qol [QUALIDEM [QUALIDEM, these instruments do not sufficiently focus on the Qol domains that are judged important for people with dementia [The majority of these instruments have been developed in English-speaking countries (particularly the USA and the UK). In Germany, Qol has recently been characterized as a nursing outcome by the medical service of the statutory long-term care insurance program. . Only onQol-AD , D-Qol [D [D-Qol ,21 and QQUALIDEM . These idementia .QUALIDEM has been evaluated in terms of psychometric properties with a focus on the psychosocial domains of dementia-specific Qol [QUALIDEM is recommended for Qol assessment in the late stage of disease [The ific Qol . The insific Qol  and was ific Qol . Consequ disease  and for  disease . Its foc disease  and judgQUALIDEM was developed and validated between 2005 and 2007 in the Netherlands. It consists of two consecutive versions for people with mild to severe and very severe dementia. The stages of dementia severity are classified according to the Reisberg scale, the Global Deterioration Scale (GDS) and Functional Assessment Staging (FAST), the last of which ranges from 1 (no cognitive impairment) to 7 points (very severe dementia) [The ementia) .care relationship, positive affect, negative affect, restless tense behavior, positive self-image, social relation, social isolation, feeling at home and having something to do.a) The Qol of people with mild to severe dementia (FAST = 2–6) is assessed by the 37-item version covering nine domains: positive self-image, feeling at home and having something to do cannot be assessed in people with very severe dementia (FAST = 7). The second version of the QUALIDEM comprises 18 items covering six domains of Qol: care relationship, positive affect, negative affect, restless tense behavior, social relation and social isolation.b) The domains The response options for all items are “never”, “rarely”, “sometimes” and “frequently”. In 2008, the QUALIDEM was translated to German by a certified agency using forward-backward translation. The back-translated version was verified by the questionnaire’s first author, whose comments were taken into account for the adaption of the German version. In an exploratory investigation, the German QUALIDEM indicates construct validity measured by factor analysis and moderate to high internal consistency .QUALIDEM, based on a large sample. The study followed a confirmatory methodological approach that has been used successfully by other studies in The Netherlands [This paper outlines the evaluation of scalability  and internal consistency of the German herlands ,26. AddiA secondary data analysis of three German studies was performed. The data were collected from a pre/post-test evaluation of quality instruments in nursing homes  ,29, a clThe ethical committee of the German Society of Nursing Science approved the study protocol of the Qol-Dem project. Guidelines for the good practice of secondary data analysis AGENS  were appData collection took place between October and December 2008 for the InDemA study, between January and March 2009 for the STI-D study and between September and November 2010 for the Leben-QD I study. The total sample comprises 634 residents with dementia from 43 nursing homes located in the area of Frankfurt/Main  and in North-Rhine Westphalia .The inclusion criteria for the residents were the following: Mini Mental Status Examination (MMSE)  score ≤ Caregivers with different formal qualifications (registered nurses and nursing assistants) retrospectively filled in the questionnaires, with the answers referring to the last two weeks of observation. The caregivers were highly involved in the care of the people with dementia. To ensure standardization, the data collection was initiated by trained external research assistants .In the InDemA and STI-D studies, the Mini Mental Status Examination (MMSE) was used for the assessment of the dementia severity. The MMSE ranges from 1 to 30 points  . The MMSIn all studies, the activities of daily living were assessed with the Physical Self Maintenance Scale (PSMS) . This inFor the description of residents’ care dependency, levels defined by the German statutory Long-term Care Insurance were used (ranging from 1 = low to 3 = high). The sample characteristics of age and gender were assessed with single items.QUALIDEM data. The Mokken scale analysis is established in the context of scale development, which has been widely used in nursing [H as an indicator for the scalability of each subscale. The scalability of a single item in relation to the other items in the scale or an item set is expressed by the value Hi. According to Watson et al. [H scores is applied: 0.30 – 0.39 = weak scale, 0.40 – 0.50 = medium scale, and > 0.50 strong scale. Hi scores for each item should be non-negative for the Mokken model to hold. Additionally, the Hi values should be > 0.30. Items that fail these Hi levels have weak discrimination power and are not scalable [The Mokken scale analysis is a non-parametric iterative method for identifying unidimensional sets of polytomous items from a multidimensional item bank. It provides additional information about the relationship between items. The Mokken scale analysis is a method of item response theory (IRT), which is based on the following assumptions: unidimensionality, local independency and monotonicity. The method evolved from the Guttman analysis for investigating hierarchies of items within scales . In cont nursing ,40, psyc nursing ,42 and q nursing ,26,43,44n et al. , the folscalable .QUALIDEM are represented in the German data. Based on the existing subscales, Loevinger’s Hi was calculated for each item of an item set, and H was calculated for each subscale. These calculations were performed for each of the three primary studies and for the total sample using the Mokken package for the software R [Mokken’s confirmatory scalability analysis was used to investigate whether the subscales of the original Dutch version of the ftware R ,47. The ftware R .QUALIDEM was assessed with the coefficient Rho. This coefficient is not as prone to bias as Cronbach’s alpha [The internal consistency of the ’s alpha . A Rho s’s alpha . For comQUALIDEM scores, the 10th, 25th, 50th (median), 75th and 90th percentiles were calculated for each subscale for people with mild to severe dementia and for those with very severe dementia, grouped by gender and age. The subscale scores were transformed to values between 0 and 100. Cronbach’s alpha, percentile, means, standard deviations and the missing value analysis were performed using SPSS version 18.To investigate the distribution of the QUALIDEM versions, the sample was divided in two subsamples of 378 people with mild to severe dementia and 256 people with very severe dementia  from a maximum of 13986 possible responses were missing in the total sample  and having something to do (H = 0.18). Overall, the H values were stable in relation to the scalability level between the three primary studies. With the exception of the items 13, Indicates that he or she is bored, 20, Openly rejects contact with others, 26, Finds things to do without help from others, 32, Calls out, and 38, Enjoys helping with chores on the ward, all the items in the adopted subscales were all scalable.The results are presented in Table social isolation (H = 0.20). Between the primary studies, the difference in the H values varied from 0.11 for restless tense behavior and social isolation to 0.36 for negative affect. Items 16, Is rejected by other residents, 20, Openly rejects contact with others, 22, Has tense body language and 32, Calls out, were not scalable   Table .The results in Table care relationship (81–78), positive affect (75–67), negative affect (78–67) and restless tense behavior (67–56) exhibited higher scores for people with mild to severe dementia than for people with very severe dementia. The Qol domains social relations and social isolation exhibited no difference in medians. The analysis of the 3 age groups demonstrated a stable distribution of the Qol scores for all subscales. With respect to gender, the median scores of men were higher in the subscales positive affect, negative affect, restless tense behavior and social isolation than the median scores of the women. In contrast, the subscales, care relationship, social relations, feeling at home and having something to do exhibited higher median scores for women.For all subscales, the median for participants was ≥ 50 regardless of the dementia severity, which reflects relatively high scores in general. The median in the subscales H values were stable with respect to the scalability level, independent of the nursing institution or primary study. The subscales social isolation and having something to do were not scalable. These results are largely comparable to a previous Dutch study in which the subscale social isolation was not scalable and the subscale having something to do was weakly scalable [social isolation, could not be identified in the German version of the QUALIDEM through an explorative factor analysis [social isolation might be explained by item 32, Calls out. Calling out is not necessarily an expression of social isolation, as it could be an expression of pain or stress without social isolation. The negative result for the subscale having something to do can be explained by the different meanings of the representing items. Item 26, Finds things to do without help from others, assesses an ability , whereas Item 38, Enjoys helping with chores on the ward, indicates a social behavior and mood/emotions. Item 13, indicating that he or she is bored, was not scalable, whereas the corresponding subscale, feeling at home, was scalable. Previous studies revealed different results [The results for the 37-item version for mild to severe dementia revealed that 7 of 9 subscales were scalable and internally consistent. The scalable . Consistanalysis . The res results ,22,26. TQUALIDEM revealed that only the three subscales care relationship, positive affect and restless tense behavior were scalable and internally consistent. The Rho scores for the mentioned subscales varied between 0.86 (good) and 0.59 (just acceptable). This result is consistent with previous Dutch studies [negative affect and social relations) and not scalable . The H values varied between the different primary studies, depending on the subscale, and no pattern was discernible. The insufficient internal consistency for these three subscales [social isolation, is consistent with previous results [negative affect, consists of 2 items, and the subscale, social relations, consists of three items. This difference could be a reason for the weak internal consistency. With respect to the Hi values for each item, item 22, has tense body language, was not scalable. This finding is consistent with the results of Bouman et al. [Hi value of 0.29 for this item.The analysis for the 18-item version of the  studies ,26 and t studies . The rem results ,26. The The investigation of distributional scores identified relatively high Qol scores in general. For all subscales, 50% of the participants reached a score of 50 or higher, regardless of dementia severity. This result raises the question of the QUALIDEM’s sensitivity for change, which has not been assessed. Information on responsiveness is scarce in general , which hcare relationship, positive affect, negative affect and restless tense behavior than did people with very severe dementia. In the latest review investigating the influence of cognition on health-related quality of life (HRQL) in dementia, no convincing evidence was found that lower cognitive abilities are associated with a lower HRQL [At the 50th percentile, people with mild to severe dementia exhibited higher Qol scores in the subscales wer HRQL . In a rewer HRQL . Dependiwer HRQL . The difwer HRQL ,55, our QUALIDEM is based on a proxy-assessment, which is preferred in advanced dementia and for longitudinal Qol evaluation [affect, self-esteem, attachment, security and privacy, social contact and physical and mental health. Little attention was paid to the domains financial situation and being useful/giving meaning to life. The consistency of QUALIDEM subscales and the Qol domains nurses focus on underpins the validity of the instrument. To what extent these results are transferable to Germany remains unclear because of the differing training programs for caregivers in Germany. The evidence of proxy-ratings appears to contradict the possible assumption that the reported high Qol values are affected by the perspective of the Qol assessment.The skewed distribution towards high Qol values raises the question of the validity of the data. The Qol assessment using the aluation . Proxy-raluation  and attialuation . In sevealuation ,58. Proxaluation , Dutch cQUALIDEM subscales [QUALIDEM that are comparable to the mentioned investigation [Our analysis is based on a large sample of people with dementia at all stages of the disease. Some sub-analyses are based on a small sample size of n = 50. The large correlation with previous findings with respect to the scalability and internal consistency of the adopted subscales supports the validity of the study results ,26. Thesubscales . There atigation . Based otigation , the pathaving something to do (mild to severe dementia), negative affect and social relations (both very severe dementia), the extent to which rewording of the items produces better scalability and internal consistency should be explored. The clarity and selectivity of the items of these subscales in particular must be taken into account, as the interpretation of the current items can differ. For example, item 12, responds positively when approached, is not a precise item of the subscale social relations, as the wording of this item is similar to items from the subscale positive affect. This finding is emphasized by a high factor loading on positive affect in a previous exploratory study [social isolation should be omitted in the future because it was neither scalable nor internally consistent and represents a duplication of the content in the subscale social relations.Our study demonstrates the acceptable scalability and internal consistency for seven subscales for people with mild to severe dementia and three subscales for people with very severe dementia exhibit robustness in different subpopulations. These results are largely consistent with previous findings. Concerning the subscales ry study . The sub13, indicating that he or she is bored, which is not scalable in its present format. The presented percentile scores provide orientation values for comparisons with future studies. The relatively high Qol values for all subscales underline the need for further investigation of the QUALIDEM. Such investigations must be theory-based validity tests that will be part of the Qol-Dem study. Methodological questions such as the possible influence of proxy characteristics  and the decision-making process of proxies through the Qol assessment of people with dementia in general should be taken into account in future research. In the next steps of the Qol-Dem project, the inter-rater and intra-rater reliability and validity (criterion and construct) of the German version of the QUALIDEM will be comprehensively investigated. These studies will result in a broader understanding of the quality of the QUALIDEM, which could be used for the development of a more advanced version of the instrument.A revision is recommended for item The authors’ declare that they have no competing interests.Study design: MND, SB, MH, GM, Data collection and handling: MND, JN, DH, OD, Data analysis: MND, OD. Manuscript preparation: MND, OD, MH, GM, DH, JN, SB. All authors read and approved the final manuscript.


To examine the association of education with body mass index (BMI) and waist circumference (WC) in the European Prospective Investigation into Cancer and Nutrition (EPIC).This study included 141,230 male and 336,637 female EPIC-participants, who were recruited between 1992 and 2000. Education, which was assessed by questionnaire, was classified into four categories; BMI and WC, measured by trained personnel in most participating centers, were modeled as continuous dependent variables. Associations were estimated using multilevel mixed effects linear regression models.2 lower BMI compared with women with lowest education level. For men, a statistically significant, but less pronounced difference was observed (1.3 kg/m2). The association between WC and education level was also of greater magnitude for women: compared with the lowest education level, average WC of women was lower by 5.2 cm for women in the highest category. For men the difference was 2.9 cm.Compared with the lowest education level, BMI and WC were significantly lower for all three higher education categories, which was consistent for all countries. Women with university degree had a 2.1 kg/mIn this European cohort, there is an inverse association between higher BMI as well as higher WC and lower education level. Public Health Programs that aim to reduce overweight and obesity should primarily focus on the lower educated population. Overweight and obesity are growing problems worldwide with a prevalence of overweight and obesity of 60% for European women and 70% for men in the age group of 45-59 years . Being oAlthough body mass index (BMI) is the most commonly used anthropometric measure of obesity, other measures such as waist circumference (WC) are increasingly being used. WC is of special interest since previous evaluations of the European Prospective Investigation into Cancer and Nutrition (EPIC) have shown that WC was stronger related to overall mortality than BMI . EPIC-PAEPIC is an ongoing multi-centre prospective cohort study consisting of 23 centres in 10 countries . From 1992 to 2000, more than 500,000 individuals (in majority 35 to 70 years of age) were recruited from the population living in a defined geographical region. Recruitment procedures have been described in detail by Riboli et al. [Of the total cohort of 519,931 apparently healthy subjects, we excluded subjects with missing information on dietary and non-dietary variables , BMI , or education , subjects with an extreme ratio of energy intake to energy expenditure , pregnant women (n = 623), and subjects with implausible anthropometric measurements (n = 376). The analytical cohort consisted of 141,230 men and 336,637 women.In most EPIC centres height and weight were measured at recruitment following a standardized procedure and is described in detail elsewhere . In Fran2, underweight; BMI ≥ 18.5 to < 25 kg/m2, normal weight; BMI ≥ 25 to < 30 kg/m2, overweight; BMI ≥ 30 kg/m2, obese.BMI was calculated as weight (kg) divided by height (m) squared. We used the following BMI categories: < 18.5 kg/mEducational level, based on highest school level reached , was used as a proxy for SES. This variable was categorized into: (1) primary school or less; (2) vocational secondary education; (3) other secondary education; and (4) university degree.Recruitment age, smoking, physical activity, alcohol consumption, total energy intake and marital status were taken into account as co-variables. Smoking status was categorized as current, former, never and missing. To adjust for the level of physical activity, a five-level validated variable  was created . InformaThe associations between BMI, WC and education were examined for the total EPIC cohort and by country. All analyses were carried out by sex. The association between education and BMI or WC across all countries was estimated using multilevel mixed linear models with random intercepts and coefficients both at the centre and country level. The analysis by countries was done depending on the number of study centres per country. For countries with only one centre , adjusted linear models were run. For countries with more than one study centre , adjusted mixed linear models with random intercept at centre level were used to assess the association between highest education level and BMI/WC.In all models, BMI and WC were modelled as continuous variables. Education level was the independent variable and modelled using a categorical variable. Age at recruitment and total energy intake were entered in the models as continuous variables while physical activity, smoking, and alcohol consumption were entered in the models as categorical variables. Further adjusting for marital status did not change our results and was not included in the final models. Secondary analyses were performed by age group (age at recruitment </≥ 60 years), smoking status, categories of alcohol consumption (0-<6/≥6 g/day), as well as by BMI (</≥25 kg/m2) and WC . All stThe distribution of educational levels varies widely in the EPIC cohort Table . The perBaseline characteristics of the study participants are shown in Table 2 lower BMI (Table 2). Crude results were similar compared with fully adjusted models. The difference between lowest and highest education group was larger in younger than in older women. The difference in BMI was also stronger in younger men, but less pronounced than in women. In women, the difference between highest and lowest educational group was stronger in never than in current smokers, but the confidence intervals were wide and overlapping. We observed strongly attenuated associations of education with BMI in non-obese subjects. In women, but not in men, the difference between highest and lowest education status was still statistically significant in non-obese subjects, but the difference was merely 0.5 BMI units.Compared to women with lowest education, women with a university degree had a 2.12 kg/mMI Table . For menThe direction of the overall association between BMI and education was consistent in all countries, although the strength of the association differed between countries. In women the association was weakest in the French cohort and strongest in the Greek cohort Figure . In men,The association between WC and education level was stronger for women than for men: compared with the lowest education level, the average waist circumference was statistically significantly lower by 5.20 cm for female participants in the highest category Table . For menThese associations were observed in most countries, but the magnitude of the effect differed between countries. In females, the association was weakest in the British centers and strongest in women of the Greek cohort; no statistically significant difference was observed in French women Figure . In almoWC is a measure of central adiposity, while BMI is generally considered as an indicator of overall obesity. In this European cohort, we observed that higher educated participants had lower BMI and as well as smaller WC. However, when adjusting WC for BMI, the association of education with WC was strongly attenuated, indicating that BMI is a good indicator of the association between education and obesity.This inverse association between BMI and educational level is in line with results in other studies ,3,13-15,2 in women and of 1.28 kg/m2 in men when comparing highest with lowest educational level. Although Molarius et al. [Overall, we observed a difference in BMI of 2.12 kg/ms et al. ,27 did ns et al. . For mens et al. ,27. In oOur study includes a large sample size and participants from ten European countries. However, for some centers, i.e., France, Oxford, and Norway, only self-reported information was available. Assuming an underreporting of weight and WC in these centers that is stronger in less than better educated individuals, this would cause a weaker association between BMI and WC and SES compared with other centers. This is what we indeed observed Figures , 3 and 4Education was used in our analysis as an indicator of SES. Low educational levels may influence obesity-related behaviour such as diet and physical activity, which may be caused by lack of knowledge . CompareIn all European EPIC cohorts, there was an inverse association seen between BMI as well as WC and education level. Our results confirm previous literature on SES and BMI; as well add new information for the association between WC and level of education.Public Health Programs that aim to reduce overweight and obesity should primarily focus on the lower educated population, such that these programs are better targeted to the addressed population group.The authors declare that they have no competing interests.PHMP: principal investigator of the EPIC-PANACEA project and guarantor of the article; ER: overall coordinator of the EPIC study, which was conceptualized, designed, and implemented in collaboration with the main investigators in the collaborating countries as follows: Denmark (KO and A Tj), France (FC-C), Germany (RK), Greece (ATr), Italy , Netherlands (HBB-d-M and PHMP), Spain , Sweden (JM), and United Kingdom (NW and K-TK) ; SH, SRo and JL: conceived the current study; SH and SRo: responsible for the design of the study, analyses of data, interpretation of results; SH drafting of the manuscript, taking into account the comments and suggestions of the coauthors; contributors from the collaborating centers : provided the original data, information on the respective populations, and advice on study design, analysis, and interpretation of the results; and all coauthors: had the opportunity to comment on the analysis and interpretation of the findings and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/169/prepub


This study attempted to examine the relationship between poverty and adolescent developmental outcomes in the family and personal domains in 3,328 Chinese secondary school students in Hong Kong. Developmental outcomes included positive youth development constructs, problem behaviors, perceived family interaction, and parental parenting. Results showed that adolescents experiencing poverty did not differ from nonpoor adolescents in terms of risk behavior and in most indicators of positive youth development. On the other hand, adolescents with economic disadvantage displayed lower levels of positive identity, family interaction, and perceived paternal parenting than did those without economic disadvantage. In 2009, Hong Kong was ranked the first in wealth disparity in the world . The pooWhat is the effect of poverty? In the multidimensional perspective proposed by the United Nations , what ma Various studies have shown that adolescent mental health problems were associated with poverty. Eamon  studied  Identity formation is a very important stage of adolescents. After reviewing the literature on identity and poverty, Phillips and Pittman  argued t Limited opportunities brought forth by poverty also impair the future orientation of poor adolescents. McLoyd et al.  reviewed Apart from poorer mental health, adolescents in poverty were also found to have higher propensity to delinquent behaviors , 16, suc According to the family stress model, it is proposed that “economic hardship adversely affects children's psychological adjustment indirectly through its impact on the parent's behavior toward the child” , 21. Ham Although poverty is a hot issue in the territory in the past decade which can be reflected from the establishment of the Commission on Poverty and the Community Care Fund, Hong Kong lacks comprehensive study on the influence of poverty on adolescent development. Focusing on adolescents' potentials instead of their deficits is a current trend, and researchers have put efforts in evaluating the effects of positive youth development programs toward adolescent development . As indiThe present study is part of a large longitudinal study aiming at tracking the developmental trends based on different positive youth development indicators and risk behaviors among Hong Kong adolescents over time. A total of 28 secondary schools in Hong Kong were randomly selected to participate in the study. In this paper, data pertinent to the relationship between economic situation of the respondents and adolescent development in the first wave of a six-year longitudinal are presented.N = 225) while those who did not receive CSSA formed the nonpoor group . For the remaining 465 respondents, they did not indicate whether they were receiving CSSA and thus their data were not included in this study.All Secondary 1 students in the selected school were invited to complete a questionnaire anonymously. A total of 3,328 students recruited from 28 secondary schools responded to the questionnaire . These included 1,719 boys, 1,572 girls, and 37 students did not indicate their gender. Most students were born in Hong Kong (78.1%), 19.9% of the participants came from Mainland China, and 2.0% were from other places. The background demographic information of the participants is summarized in  Data collection was conducted by a trained research assistant in classroom settings with standardized instructions. At each measurement occasion, the purposes of the study were introduced and confidentiality of the data collected was repeatedly ensured for all participants. School, parent, and student consent had been obtained prior to data collection. Participants responded to the questionnaires in a self-administered format with sufficient time given. The questionnaire took roughly 30 to 45 minutes to complete. The research assistant was present throughout the administration process to answer possible questions from the participants.In the school year of 2009-2010, the participants responded to a comprehensive youth development questionnaire including both existing instruments and scales developed by the first author. Participants were invited to respond to a composite questionnaire asking them about different aspects of their development. The following only highlights those measures related to the present study.Questions on gender, age, place of birth, number of family members, parents' marital status, parents' educational level, and family financial situation were asked.The CPYDS is an instrument assessing different positive youth development constructs. It consists of 15 subscales which include bonding (BO), resilience (RE), social competence (SC), recognition for positive behavior (PB), emotional competence (EC), cognitive competence (CC), behavioral competence (BC), moral competence (MC), self-determination (SD), self-efficacy (SE), clear and positive identity (SI), beliefs in the future (BF), prosocial involvement (PI), prosocial norms (PN), and spirituality (SP). Each construct has three items in the questionnaire. Except spirituality which is a measure of a 7-point scale, all other constructs assess the respondents in a 6-point Likert scale (1 = strongly disagree to 6 = strongly agree). The higher scores in the scale denote higher levels of psychosocial competence. Details of the items can be seen in Shek et al. . Using mThe respondents were asked if they had performed the following problem behaviors and the frequency they performed such behaviors in the past one year on a six-point Likert scale : stealing, cheating, truancy, running away from home, damaging others' properties, assault, having sexual intercourse with others, gang fighting, speaking foul language, staying outside the home overnight without parental consent, strong arming others, and trespasses .Eight items were used to assess the participants' frequency of using different types of substance in the past half a year, including alcohol, tobacco, ketamine, cannabis, cough mixture, organic solvent, pills , and heroin. Participants rated the occurrence of these behaviors on a six-point Likert scale .Family functioning domains including communication, conflict, and harmony of respondents were assessed by 9 items. This 9-item measure is a simplified version of the Chinese Family Assessment Instrument developed by the first author . In the There were 17 items assessing paternal parenting, including paternal knowledge , paternal expectation , paternal monitoring , satisfaction with paternal control , paternal psychological control , and father-child relationship . Participants rated the paternal parenting in a 4-point Likert scale . Reliability analysis of the 17 items showed that this scale was reliable .Identical items for paternal parenting were used to assess the maternal parenting, including maternal knowledge (2 items), maternal expectation (2 items), maternal monitoring (3 items), satisfaction with maternal control (3 items), maternal psychological control (4 items), and mother-child relationship (3 items). Participants rated their relationship with their mothers in a 4-point Likert-scale . Reliability analysis of the 17 items showed that this scale was reliable .M = 12.77, SD =  .84 for the poor group and M = 12.55, SD =  .70 for the nonpoor group; t = 4.47, P < .0001). Because of the possible confounding effect of age, multivariate analysis of covariance was performed to examine the differences between the poor group and nonpoor group on the developmental variables to control for the effect of age.An examination of the characteristics of the poverty and nonpoverty groups showed that there was no difference between the two groups in terms of gender ratio. Yet, there were significant differences between the two groups in terms of age  = 4.3, P < .01, Wilks' Lambda =  .99, partial eta squared =  .007. When the dependent variables were examined separately with the Bonferroni adjustment (P = .013), the only difference found was in the score of PIT (positive identity): F = 13.18, P < .001, partial eta squared =  .006. PIT is the mean score of beliefs in the future (BF) and clear and positive identity (SI). The mean scores indicated that the poor group reported a lower level of PIT  than did the nonpoor group . Regarding positive youth development qualities, a MANCOVA was carried out with the poor group versus the nonpoor group as the independent variable, the scores of CPYDS subscales  as dependent variables, and age as the covariate see . There wF = 20.65, P < .001. When the results for the dependent variables were examined separately, significant group effects were found in both family interaction and paternal parenting. The mean scores indicated that the poor group had lower scores on family interaction  than did the nonpoor group . The poor group also had worse perceived paternal parenting  than did the nonpoor group . The effect size of the differences ranged from low to moderate levels.Regarding differences between the two groups on family processes , a MANCOVA was performed with poor group versus nonpoor group as the independent variable, the family interaction, paternal parenting, and maternal parenting as the dependent variables, and age as the covariate see . ResultsThe present study attempted to find out the relationship between poverty and adolescent developmental outcomes, parental control, and family communication. Compared to adolescents experiencing economic disadvantage, adolescents not experiencing economic disadvantage had higher scores in PIT . This finding is consistent with the Western literature which suggests that adolescents in poverty are more likely to be pessimistic about their future lives . It can In line with other studies , 14 thatHaving reviewed the conceptual and methodological issues in studying the relationship between adolescent development and economic disadvantage, Leung and Shek , 8 propo Regarding the family factors, there were significant differences between the two groups in family interaction and paternal parenting, and these results were in line with Shek's studies , 23. Fat There are several strengths of this study. First, a large sample was involved which was randomly selected from schools in Hong Kong. Second, validated instruments were used to assess individual and family processes. Third, a wide range of personal and family adjustment measures were included in the study. Despite these strengths, several limitations of the study should be noted. First, caution must be made about the operational definition and classification of “poor” adolescents in the present study. As stated before, we simply categorized those respondents who had received CSSA as the poor group, but this may not be the best classification. According to the statistics of the Hong Kong Council of Social Services , 25.8% oDespite the above limitations, the present study gives us some idea about the performance of poor adolescents in different positive youth development constructs. There is a need to find out some means to alleviate the adverse effects of poverty on adolescents. School-based positive youth development programs such as the Project P.A.T.H.S. in Hong Kong may be a way out because there is evidence showing that universal positive youth development programs can help enhance different psychosocial competencies of participants –38 and a