Oostwoud Wijdenes and Medendorp), by resolving the surprise in the spiking pattern of the cortical areas via temporal coupling of neuronal activities, given the external events involved in the interaction.Humans execute movements to manipulate their physical surroundings to improve their survival chances. Successful interaction of the brain with the surroundings, which produces purposeful movements, depends on many factors, some of which are highlighted by the contributions in this special issue. The control of movements during an interaction with the physical environment is simplified by a grouping of muscles, called muscle synergies, which serve as the functional unit and can be used across task conditions , using a two-segment model of the human arm. In contrast to dynamic models, in which the second-order differential equations define the velocities and accelerations of different limb segments, the authors use steady states of the motor system in forced interactions as the chief elements of analysis. It is assumed that the CNS defines the equilibrium states in the motor interaction of the organism with the environment, while movements result from the transitions between a series of equilibrium states. Authors hope that a pattern of the torque effects can provide some simplification of both descending motor programs and their integration at the spinal level.In their paper, Josa et al. have studied the effect of action constraints on distance estimation. Authors report that subjects' distance estimation from a cart to a target depended on the weight of the cart, loaded with books or empty. The subjects overestimated the distance when the cart was loaded with books. This, the authors argue, is consistent with the embodied perception theories, which suggest that perception depends on the constraints of potential action.Avraham et al. (B) investigated the effect of applying a 150 ms delay in visual feedback from the left visual workspace on lateral movements and visual perception of the mid-point of horizontal lines. The authors observed hypermetric movements on the left side, which returned to the baseline during adaptation. In another study by Avraham et al. (A), also with visual feedback of hand movement (movement of the cursor) was delayed by 150 ms, in right or left or both workspaces. The hand movement was followed by drawing circles in the desired direction without any visual feedback. Avraham et al. observed that “delay presented in left and both delay caused symmetrical elongation only to left initiated circles and right delay caused symmetrical elongation to both left and right initiated circles.” Both works underscore the importance of the representation of the time-axis in voluntary movements of the right hand. Presenting the delay in visual feedback also shifts the representation of time-axis, which could be responsible for hypermetric or elongated movements. These findings also suggest that a representation of the time-axis in the left hemisphere may be responsible for the laterality of hemispheres since the delay of the visual feedback in the right workspace (processed by the dominant left hemisphere) leads to symmetrical elongation of the left and right initiated circles.Sorrentino et al. studied the development of spatial memory in children aged 4–6 years, which required collecting nine colored balls in buckets arranged in three different configurations, namely, Matrix, Cluster, and Cross. The trial ended when all nine colored balls were collected or 30 visits, wrong or correct visits were made, including revisits. The authors found that declarative spatial memory improved with age and movements. Findings showed spatial ability depended on the complexity of the environment.Chauhan et al. present two versions of hierarchical Saccade Velocity Driven Oscillatory Network models. In these two hierarchical models, the output of one layer is used as input for computing the output of the next layer. First, a saccade trajectory map is generated according to decreasing order of saliency of different locations of an image. The saliency is based on three features: intensity, color, and orientation. The saliency trajectory map is processed by the saccade direction layer, which computes the animal's current saccade direction projection on the preferred direction. The computation in the next layer, called the path integration layer, incorporates an amplitude function, resulting in oscillations. The path integration layer projects to the output SC layer, which exhibits a grid-like pattern by extracting the principal components of the oscillatory response. The periodicity in the weights of the principal component due to oscillations corresponds to grid cells in the entorhinal cortex that fire action potentials in navigating animals. The authors argue that oscillations are critical for grid cell generation. Oscillations encode the position information in their respective phase. This is also supported by animal studies that showed a key role for theta oscillations in the normal grid cell activity in the entorhinal cortex , NF1, and NF2, corresponding respectively to the primary visual cortex and middle temporal area. In this model, the lateral connections in the neural fields are trained by unsupervised asymmetric Hebbian learning, to process sequential information in motion stimuli. Neurons in NF1 respond to the direction of the component motion, such as gratings and edges, and the neurons in NF2 respond to the direction of motion of the whole pattern. Additionally, information about the stimulus's temporal sequence is preserved in the network dynamics. Interestingly, translational random dot stimuli flow motion was decoded by a classifier with an accuracy of 90% on the test data, which is a biologically plausible range for most human activities involving interactions with moving objects. The success of neural networks in the above neurobiologically plausible models  suggests that many functions of the brain are due to hierarchical processing of information by different higher brain areas and may be driven by learning from experience, similar to neural networks.Krüger and Hermsdörfer studied duration and fingertip position variability in reaching movements involving touching a target with the right index fingertip at a fixed distance. The targets were manipulated according to three conditions: forced choice with certain and uncertain targets, and a third free choice target. Consistent with previous literature, authors reported that “within-subject between trial variability of fingertip position showed an increase-decrease pattern across the time course of movement execution, with low variability at movement end.” The initial increase in the “between trial variability” is consistent with an increase in the entropy of neuronal spiking in cortical motor areas. However, near the end of the movement, coinciding with the interaction with the external world, there is reduced “between trial variability,” suggesting an increase in correlated activities, which is likely due to an increased probability of the task-specific activation of temporally coupled pairs of neurons. This time course of the change in variability from the beginning to the end of the task is consistent with the role of an initial increase in entropy followed by an increase in mutual information (a measure of correlation), representing information underlying purposeful action  and individual control policy (ICP). The CGP represents all muscles controlled by a single peripheral nerve, and the IGP represents individual muscles. The synergy between two control policies is optimized by feedback gain signals according to the feedback signals to produce the movements adapted to a novel context. Feedback signals via the cortico-basal ganglia-thalamic-cortical circuit may help in monitoring the movement in a novel context for successful interaction. Learned motor skills may be stored in the premotor area as a circuit pattern, which may be activated in a novel context. The success of movements in novel conditions, given the use of learned motor skills, will be determined by the maximum decrease in entropy in overall cortical spiking firing patterns, which may depend on the temporal coupling of a slightly different set of pairs of neuronal activities. This may occur due to temporal coupling of neuronal activities, caused by signals from proprioceptors relayed by the cerebellum to the cortex as well as activities in cortical motor areas, reflecting actual interactions in novel conditions, which will lead to the modulation of the learned motor skill.Cohn et al. have proposed the feasibility theory wherein a high-dimensional feasible activation space is a family of valid solutions representing muscle activation patterns, such as muscle synergies, for a given motor task. The authors argue that due to the dependence on anatomical constraints of the nervous system and musculoskeletal system, the feasible activation space contains valid solutions, i.e., prescriptive synergies for executing movements. Feasible activation space may also provide a framework for analyzing how learned motor skills may be modified in novel situations .Oshima et al. present experimental evidence showing that humans adapt to different speeds of locomotion–walking and running–by altering the spatial coordination patterns, while the temporal coordination pattern remains unaffected by different speeds. Their findings based on the study of the motion of the legs indicate that the control of temporal patterns is independent of the control of spatial patterns. This is consistent with the identification of orthogonal components, which include patterns of muscle contractions, called synergies and temporal components from the analysis of electromyograms by standard multidimensional factorization algorithms ; thus, motor adaptation in the spatial domain is affected by feedback in the temporal domain.Various contributions to this Frontiers Research Topic suggest that voluntary motor control depends on two independent components: (1) prior, such as muscle synergies, detected by electromyogram analysis, and (2) instantaneous sensorimotor interaction, which leads to temporal coupling of neural events in desynchronized brain states. Moreover, the temporal coupling of neural events depends on an accurate representation of physical time-dimension in the brain, in addition to sensorimotor interactions between the brain and physical surroundings. A successful sensorimotor interaction will result in the temporal coupling of neuronal activities that would reduce the entropy in the patterns of neuronal activities, given a particular task, contributing to smooth voluntary motor control. Future works should investigate how the temporal coupling of neuronal activities and different measures of surprise play a role alongside prior in voluntary movements.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The study aimed to evaluate the contribution of building problems to mold proliferation in dwellings. We investigated 503 dwellings of patients suffering from respiratory diseases, whose attending physicians had requested a home inspection if the area of mold was equal to at least one square meter. After careful visual evaluation and basic environmental measurements performed by a trained technician, environmental issues were classified into building defects, accidental water damage, and condensation. Data analysis demonstrated that building defects were the pre-eminent cause of mold proliferation. Among the building defects, water infiltration through leaks in roofs or walls was the leading cause. These results highlight the need for health professionals managing patients with respiratory diseases to be able to request a home inspection, and for city health authorities to commission professionals who can focus on building problems and find ways to address them. Mold proliferation has been identified in around 20% of dwellings in Europe  and the Several governmental and nongovernmental organizations around the world have issued guidelines on the health impacts of indoor mold ,4,5. HomIn practical terms, when a home inspection is performed, the technician should be able to identify the leading cause of mold proliferation.This paper aimed to identify the leading causes of mold proliferation, following home visits to buildings with mold problems. This issue is crucial because it affects the way in which the building will be managed: either through remediation undertaken by professionals in the case of structural defects, or simple adjustments or counseling in the case of inappropriate occupant behavior.Five hundred and three dwellings with mold were studied. A dwelling was considered to have mold if the sum of the surfaces with mold in the living areas  was equal to at least 1 square meter . The inThe technician first performed a careful visual inspection of the dwelling. In each room, they located possible sources of air pollution by checking the condition of the joinery and heaters, maintenance of combustion appliances, looking for spots of mold, and checking the ventilation. They also had a discussion with the tenant concerning the living habits of the family and, in particular, the use of cleaning products.The technician then completed a questionnaire regarding the above items, and also the number of occupants.-A Qtrack to measure ambient temperature and relative humidity ;-A mural hygrometer );-A light paper sheet and a smoke canister to check the efficiency of mechanical ventilation .Then, various types of equipment were used in the living room and the patient’s bedroom, as follows:-Building defects: rising dampness, water infiltration through leaks in the roof and/or external walls, thermal bridge;-Accidental water damage resulting from a sudden disruption of the water pipes;-Vapor condensation on walls and/or ceiling. Measurement of wall humidity allowed the cause of mold development to be identified as either vapor condensation  or a water leak .At the end of the visit, environmental issues were classified into three different groups:The study group included 67 dwellings without structural defects, and 436 with at least one defect. The mean number of occupants per dwelling was equal to 6.25, although the mean figure for this area is 2.5 [This study has strengths and limitations. Its strengths are the large sample size and the standardization of the visits performed by a single trained technician. Nevalinen et al., have demonstrated that occupants missed signs of current or previous mold problems in 15% of houses surveyed . In addiExisting literature has highlighted many different risk factors for mold development: age of the building , number From the abovementioned results, it is clear that building problems are the number one cause of mold proliferation. Indeed, in addition to the “building problems” category, such problems also feature in the “condensation” category when condensation is caused by thermal bridges, and a lack of proper ventilation systems.To the best of our knowledge, this is the first demonstration of the pre-eminence of building problems as the main causes of mold proliferation. Inappropriate building usage is shown to be merely a contributory factor. Therefore, city health authorities and home inspections should first focus on possible building defects. Similarly, health professionals who manage patients suffering from respiratory diseases that may be related to mold proliferation should advise these patients to ask for a home inspection, because it is unlikely that the common advice they offer, concerning ventilation and cleaning moldy surfaces, will resolve the issue.In this study, we aimed to identify the causes of mold proliferation in dwellings. In inner-city high-rise buildings, building problems are the main cause of mold proliferation. This result is likely to apply to this type of building in other locations, but not necessarily to other types of housing in other climates. These findings point to the need for home inspections by professionals so that the defects identified can be correctly addressed.


Ear diseases are illnesses which represent a relevant group of morbidity. Otitis media, for instance, still is a public health problem today.To correlate hospital morbidity of ear diseases according to data from the Information Technology Department of the Public Health Care System -SUS (DATASUS), through the Hospital Information System (SIH) with the Human Development Index (IDH) from each unit of the federation. To assess the use of this official data in the creation of otologic public health care policies.Brazilian states were classified according to their respective IDH values. The percentage population from each state was calculated in relation to the entire population of the country, as well as the percentage of hospital admission caused by ear diseases (SIH) for each state in relation to their total number. The hospital admissions from each state were correlated with their respective IDH values.The state of São Paulo, the third largest IDH was responsible for 38.82% of hospital admissions caused by ear diseases, although its population represents 21.64% of the national population. States with lower IDH had lower hospital admission rates for ear diseases.SIH, a DATASUS tool, even with limitations, can be an instrument used to create public policies concerning ear diseases. Ear diseases represent a relevant group of diseases. Otitis media, for instance, is one of the most prevalent disorders, which today still represents a worldwide public health problemDespite its still high prevalence, the situation used to be worse. The reduction in ear diseases and, especially, its complications have some explanations. Much of this reduction is credited to a better access the population has to medical care, as well as a shorter time interval between initial signs and symptoms and the medical consultation, when compared to the past.An efficient public policy to improve medical care concerning ear diseases is only possible when one starts from the epidemiological understanding of this group of diseases.Official morbimortality data in Brazil are made available by DATASUSThe present study aims at correlating the hospital morbidity of ear diseases in the different Brazilian States with the HDIDATASUS encompasses the SUS (SIH/SUS) Hospital Information System as one of its elements. The SIH is based on filling out the Hospital Admission Authorization Form (AIH). We used the TabNet software from the DATASUS website to create the Tables, considering the number of hospital admissions caused by diseases of the ear and of the mastoid apophysis (Chapter VIII from the ICD-10) per state. This system has data from January of 2008 through August of 2010The HDI is a comparative measure which uses three aspects: wealth, education and average life expectancy. It is a standardized means of assessment and a measure of the well-being of the population. We used the latest HDI value assigned to each Brazilian state as a means to express the socioeconomic conditions of the respective populationsThe population from each State was obtained from the IBGE - The Brazilian Institute of Geography and StatisticsThe states were considered in ascending order in relation to their respective HDIs. We then calculated the percentage values of hospital admission per ear disease in each State in relation to the total number.Thus, we compared the percentage value of hospital admission regarding each State with the percentage value of its respective population, correlating it with the respective values of the HDI.The State of São Paulo, third highest HDI, was responsible for 38.82% of the hospital admissions caused by ear diseases, although the population represented 21.64% of the national population.The State of Alagoas, with the lowest HDI, was responsible for only 0.38% of the hospital admissions caused by ear diseases, and its population represents 1.65% of the national population.The etiology and the factors contributing to pathology are fundamental to understand it and, thus, work on its possible treatment.Numerous studies have been and continue being carried out in an attempt to unveil the impact of socioeconomical status in disease development. Many of these have concluded that a greater disease expression is associated with a lower socioeconomical statusDespite their high prevalence throughout the world, we have seen a recent reduction in ear diseases prevalence. Much is attributed to improvements in sanitary conditions and better access to medical care and drug therapy, even if it is still insufficient in many places. Otological complications have also been associated with a worse socioeconomical statusAn efficient public policy can be created when policy makers are acquainted with the epidemiology associated with a given disease. In Brazil, SUS  data is organized by DATASUS, which provides for free access to a broad data base. In it, for instance, we find information on ear and mastoid morbidity as of January of 2008The HDI is a measure created in 1990, and it has been used by the United Nations Program for Development in order to assess the socioeconomical status of countriesWhen we analyze the percentage levels of hospital admission per otologic disease concerning each state of the country  with theThese observations are in contrast with the literature because better socioeconomical conditions have been directly associated with better values in the health indicators.Ear morbidity is greatly associated with disease chronification - most of the times a delay in medical care and/or difficult access to treatment. Thus, it is expected that the morbidity caused by ear disease in a given population reflects, in part, its socioeconomical status. Nevertheless, considering the SIH data, the possible relation is exactly the opposite.The better interpretation of such results must be another one. The otological morbidity measured by SIH actually reflects hospital morbidity. In other words, since it is based on AIH forms, the data obtained from such system depicts only otological patients with diseases requiring hospital stay. They omit and disregard all of those who have ear diseases, whom did not require or it was not possible to have a hospital approach.Since most ear-related hospital admissions happen because the patients will be submitted to surgical treatment, the results from the present study enable us to draw other conclusions. The state of São Paulo, with 21.64% of the Brazilian population, had 38.82% of the hospital stays, almost double of what was to be expected, should the division be more equal. This says that in the state of São Paulo, the public health care system is able to surgically treat its otologic patients in a higher number when compared to the national average. On the other hand, the state of Alagoas, with 1.65% of the population, had only 0.38% of the hospital admissions.The results show us that in our states with low HDI, there are lower rates of hospital admission and, therefore, do not offer much surgical treatment to their otologic patients. If we compare this to the epidemiological data provided by the Brazilian Association of Otorhinolaryngology, we see that those are states with lower numbers of ENT physiciansThe importance of this SUS data system is undeniable. Based on its data, one can identify material and personnel problems and needs and, therefore, propose solutions. Nevertheless, we know that errors do exist, especially concerning information gathering. It is widely known that in many places the AIH forms are incorrectly filled out, because the physicians do not know how to do it, or because they do not give importance to public health care policies. The reliability and reproducibility of the data generated by the SUS information system are fundamental for the creation of reliable public health care policies.According to hospital morbidity data associated with ear diseases  available at the SIH, from January of 2008 through August of 2010, the number of hospitalizations is higher (in percentage numbers) in states with higher HDI and lower in those with lower HDI. This reflects the need for personnel and material in the poorer states of the country, which offer less surgical treatment to their ear diseased patients. Therefore, even with limitations, the official information generated by this SUS information system can serve as a tool in the creation of ear-related public health care policies.


We analyze the incipient development of short supply chains for fresh fruit and vegetables from conventional agri-food chains, leading to the emergence of hybrid chains. We have sought to answer the research question of how and why hybrid food supply chains has been initiated by studying this phenomenon in south-eastern Spain. We analyzed the 20 main Spanish fruit and vegetable exporters, identifying the 9 that have developed short channels. Subsequently, we conducted a case study of the one considered most relevant, identifying the stages of this short chain, analyzing the tasks to be performed in the different phases of the SCS, studying which are common to both and where the differences in the processes arise. The results show the synergies that make them coexist successfully, such as the sharing of personnel, infrastructures and services, complementarity in the product range, thus avoiding food waste, or knowledge of consumer tastes and needs. Agri-Food Supply Chain (ASC) has undergone many modifications throughout history; it was originally local due to production, information and transport constraints. The advances in plant nutrition, crop management technologies, task mechanization and professionalization allowed the increase in agricultural production and surpluses generation with orientation towards external market. The growth of certain crops in geographic areas with favorable conditions has led to the development of local agglomerations of companies, recognized as agri-food clusters .At the same time, food distribution systems have been concentrated to achieve economies of scale to supply population concentrated in large cities. Thus, improvement of agricultural production and transport systems has shaped the current ASC model characterized by mass production and distribution. The dominant ASC model is an extensive network of interconnected operators comprising specialized farmers, warehouses, handling companies, intermediaries, wholesalers, and retailers that bring the product to the final consumer.Supply Chain (SC) is understood as a series of operations that ensure that goods are produced and distributed in the right quantities, delivered to the chosen locations in the shortest possible time, with the objective of satisfying consumer needs . The ASCShort Agri-food Supply Chain (SASC) emerge as a more sustainable option for agricultural products. The SASC is an ASC formed by a limited number of economic actors, committed to cooperation, local economic development and socio-economic relations between producers and consumers in a close geographical area .SASC can change the “industrial modes” of food production and develop supply chains that can “shorten” the industrialized, complex and rationally organized Long Food Supply Chain . This acSSCs are beginning to arouse interest in the literature, as according to  they offASCs have traditionally been considered as independent models to the SASC . HoweverSpecifically, we focus on the agri-food cluster of fresh fruit and vegetables in Southeast Spain, where traditional agri-food chains have a structure of association of farmer who performs the functions of handler and marketers . It shouThis new marketing channel has a hybrid form. On the one hand, it shortens the normal flow of the traditional channel (the farmers’ organization companies reach the end consumer without intermediaries). On the other hand, it is not a direct channel to the consumer . Individual farmers do not have the productive or organizational capacity to supply the needs of the consumers individually  and must collaborate with other farmers to meet the needs of customers. In addition, this new way of marketing from a hybrid chain solves the problems and challenges recently found by  of shortThe scope of hybrid chains for these highly perishable products was initially conceived for a local approach but has been extended to the entire national territory with relative success. The process of creating short chains initiated by the innovative farmers´ organization who have developed hybrid chains contributes to establishing direct and close relations between producer and consumer. We found in the literature some precedents in the construction of hybrid chain from the retailer side. The construction of a hybrid fresh produce chain in which innovative retailers adopt hybrid supply chain strategies by leveraging their relationships with other links in the chain to shorten the conventional chain generates efficient advantages in time and product variety . AccordiThe main objective of this research is to analyze the process of the emergence of short supply chains within the long agri-food supply chains in the fruit and vegetable cluster of south-eastern Spain. This will help us to find out why and how these chains have started the process of moving closer to the market. An intermediate objective is to analyze the main Spanish fruit and vegetable exporters by identifying those that have developed a short channel. We started from the hypothesis that hybrid supply chains share stages of the chain by analyzing the tasks that have to be performed in the different stages of the SCS, studying which are common to both and where the differences and synergies in the processes with conventional chains arise.This study represents an evolution in the concept of hybrid chains towards sustainability. There is a new direct chain from a handling-marketing company to consumer. This is a shortening of the traditional chain by eliminating the figure of the retailer and performing the function of supplying the end consumer directly by the SASC, and this has not been studied before from this perspective. We will first analyze the causes that lead to the emergence of hybrid chains in which conventional supply chains are developing a short direct sales channel due to the facilities provided by digitalization and online commerce, as well as the need to create value by increasing commercial margins and providing a solution to the distance between the consumer and the producer. To this end, we will analyze, in depth, the operating structure of an innovative SASC, discovering the synergies between the two coexisting chains that give rise to hybridization. We will review the growth of this paradigm in the sector within the specific agri-food cluster of fruit and vegetables in which it is located, exploring whether this trend can be replicated in the rest of the agri-food industry and thus be extrapolated to other agri-food clusters.Most food sales and distribution are conducted by large conventional food supply chains, which represent a network of food-related organizations within which products move from producers to final customers . These SThe advancing digitization of ASCs allows SC members to be highly connected, win efficiency and traceability, and respond to customer needs and legal and regulatory requirements . It enabToday’s food system faces major challenges in terms of sustainable development in economic, social, and environmental dimensions . These cA differentiating characteristic of Fruit and Vegetable ASC is that their products are highly perishable. Regarding these types of products, consumers give priority to fresh products with a reasonable price, which implies an accurate supply chain management that becomes even more complex if there are intermediaries involved . The exiConsumers are increasingly demanding an orientation towards territorialism in agriculture  because There is no shared and unique definition of SASC, but all of them highlight the closeness between producers and customers. The length of the SC is determined by the proximity between farmers and consumers and can be assessed through different parameters: (1) by its area of location (geographic); (2) the number of intermediaries needed to access the consumer (steps); (3) the period needed to complete the delivery from farmer to consumer (time); and (4) the type of relations between the members of the SC (communication).Usually, most of these parameters evolve in a similar way. More geographic proximity is often associated with fewer intermediaries, shorter time to market, and better communication. Thus, each definition usually focusses on one or more of the above parameters. For example, Regulation (EU) No 1305/2013 of the European Parliament And Of The Council defined SASC as: “a supply chain involving a limited number of economic operators committed to cooperation, local economic development and close geographical and social relations between producers, processors and consumers” .Face-to-face: where producers sell their products directly to the consumer in a face-to-face manner, such as farmers’ markets, farm gate sales, produce collection systems, and box systems.Spatially proximate: where products are produced and sold through local market channels in the specific region of production, including farm shop groups, food outlets, local food retailers, and consumer cooperatives.Spatially extended: where products are sold not only to local consumers but also to consumers in other regions. In this case, labeling and certification schemes could be used to differentiate these products by emphasizing quality such as designation of origin.Thus, SASCs can be classified according to different criteria such as the spatial proximity of their members  distinguDirect on-farm sales: allows face-to-face relations between producer and consumer.Pick-up of own produce in the field: consumers collect produce on their own directly from the field.Box scheme: farmers’ cooperatives and local consumer groups ensure regular procurement of seasonal food sustainably grown in or around the local community.Farmers’ markets: these are markets, usually located in urban areas and held periodically, where a group of farmers come together and where each producer sells his or her agri-food product directly to individual customers.Collective farm shops: farmers come together to jointly set up and run a shop in a market town or in suburban or urban areas where they sell their local produce.Community Supported Agriculture: involves consumers and local farmers participating in a common agreement; consumers commit to buying seasonal food from producers, who deliver it regularly to consumers’ homes.Collective buying groups: organized consumers who choose to buy commonly directly from selected producers.If we incorporate other criteria such as the organizational forms adopted and social interactions for performing activities by producers or consumers , they dihttps://www.canalhoreca.com, accessed on 21 October 2022). This results in hybrid supply chains [These SASCs are often presented as an alternative model to traditional SCs that can also coexist with traditional ASCs . Howevery chains .In this sense, ref.  present Our analysis focused on the Fresh Fruit and Vegetables sector, which in Spain accounted for 8.6% of the total agri-food industry in 2019 . The SpaIn addition, an extensive network has developed in parallel, consisting of handling-marketing companies, wholesalers, transport companies, support organizations , and different auxiliary industries with specialized research and transfer centers that give rise to an important business cluster .Marketing is conducted through handling-marketing companies with whom the farmers normally maintain stable relationships. These handling-marketing companies receive fruits and vegetables from multiple farmers and prepares them  for delivery to their customers.These handling-marketing companies play a central role in the agri-food chains of south-eastern Spain as they maintain stable relationships with farmers. Handling-marketing companies are cooperatives whose members are farmers or they are trading companies with close relationships with farmers. In both cases, farmer collaboration relationships cover areas such as the sale of seeds, plant nutrition products, pest treatment, technical advice, price information, etc. Approximately 80% of fruit and vegetable production is exported, a situation that has remained stable over the last 3 years .In a first stage, we conducted a systematic search for Fruit and Vegetable ASCs that have developed similar SASC in the selected study area. We have tried to test the hypothesis that a trend is beginning in conventional supply chains to develop a short chain that co-exists with the traditional supply chain. This gives rise to a change of paradigm that we call hybrid supply chains.In order to select the sample, we based it on the 2020 Alimarket ranking of Spanish Fruit and Vegetables exporters and we reviewed specific information of the 20 main vegetable exporters operating in the area. For this purpose, we analyzed the websites of these companies , specific consumer blogs and news in the media. Additionally, we phoned those exporters for which we found no evidence of sell their products directly to end consumers .We identified 9 SASC that have basically emerged in the last 5 years. A detailed study was made for 10 months reviewing online sales platforms of each of them, reviewing their product catalogue, ordering system, delivery logistics, and frequency. Where necessary, a more detailed analysis was conducted with company visits and interviews. Interviewees were carefully selected to ensure that they were people with the capacity to provide comprehensive information. Data has been triangulated where possible with reports in the specialized press and interviews with experts and business associations in the sector. The results obtained have been anonymized to protect the data and the confidentiality of the companies studied.In a second stage, one of the 9 SASCs identified previously was selected to conduct a case study of a handling-marketing company where a SASC has been developed within a long ASC. This company was selected because it is a reference in the fruit and vegetable sector in the south-east of Spain, characterized by its innovative orientation. Top management was contacted by the middle of 2021 and agreed to participate in the study. The company in question, which is a second-tier cooperative, is interested in studying the improvement of its supply chain in the short term and is even participating in some research projects on the subject.The case study followed the methodological approach proposed by  to analyFirstly, we conducted a mapping of the state of the value chain, information flows, and relationships within and between the companies that constitute the value chain analyzing from the input and primary production and the rest of the phases in depth. In order to identify the phases of the SASC, semi-structured interviews and working meetings with the different SASC supply chain professionals in the fruit and vegetable sector were held over a period of 8 months (in a 6-step process).The key agent study case analysis began at the end of 2021, holding a joint meeting with the company’s middle management and heads of functional areas , external logistics services provided by the company, in which their collaboration with other agents in the value chain was contrasted. This first step ended with an interview with the business development manager where we reviewed all the information provided by the key agents of the case study and we elaborated the detailed proposal of VC phases.Later, we conducted semi-structured interviews with competitor companies, selected from the initial sample of the main vegetable exporters operating in the area that had developed a short chain, analyzing their structure and considering the common information provided until an agreed phase proposal was reached.At the beginning of 2022, we contacted the main association of producers and marketers to consult their opinion according to their experience and knowledge of the sector, generating a new proposal of phases.Once the above processes had been completed, a group of 3 university professors/researchers who are experts in the sector were contacted and invited to contribute their joint proposal for the links in the fruit and vegetable supply chain.Subsequently, a global meeting was held via videoconference with representatives of each of the individual proposals to reach a consensus proposal. The reason for the meeting was explained to them and they were provided with the 4 proposals above. This was followed by a constructive discussion until we came up with a consensual phasing scheme representing the simplified functioning of the short and long chains.Finally, the research team  adapted this proposal for terminological adequacy and for generalization to other similar organizations.Below we present the results of the study of the Fruit and Vegetable Supply Chains included in the list of the 20 main exporters located in the study area that have developed SASC in the last 5 years, becoming hybrid chains. Their main characteristics have been analyzed and are shown in X1: Second-degree cooperative, with the association of numerous first-degree cooperatives. It launched its online sales in 2019, according to news from the specialized magazine [magazine . ThroughThe variable multi-product box offered by this cooperative requires special attention because of its originality and the possibilities of matching fruit and vegetables supply and demand. One of the criteria for selecting the composition of the variable multi-product box is the overproduction of a specific product or size at certain times of the season. Initially, they conducted a test phase in which they were only marketed to the cooperative’s employees; it was a success and they created an electronic platform for weekly marketing with direct delivery to consumers’ homes.X2: Cooperative specialized in marketing of fresh tomatoes. It was one of the first to launch its online sales in 2018, according to Origen, the magazine of rural flavor [l flavor . It offeX3: Business group dedicated to the commercialization of fruit and vegetables in more than 30 countries. Its online sales started in 2011 with reduced activity and it has renewed in 2021 [X4: Value chain specialized in organic farming. It has an online shop where consumers can buy fruit and vegetables of pre-prepared and pre-cooked convenience food products  since May 2018 according to news in the specialized press. Customers can buy products available in the digital platform with flexibility (from one package to a complete basket). It can be picked up at the warehouse (free of charge) or shipped throughout the Iberian Peninsula, including shipping costs if the minimum purchase amount is exceeded (for example 25€). The order is delivered by a courier company that sends the product to the customer’s address within 24 h.X5: Important cooperative that started its online sales in 2020, according to news communicated by Cadena Ser [dena Ser . It has X6: First degree cooperative with almost 1000 farmer members, characterized by bringing the farmer closer to the market. In recent years, it has strengthened its offer of organic and integrated production . It has opened physical shops (supermarket type) in two of its four locations, the last one in April 2019, and is preparing a future online sale of its own products. In the physical shops, the general public can buy the company’s horticultural products, including pre-prepared and canned products, as well as a limited range of external products (as a supermarket). It is open all year round, although during the summer season .X7: Limited company marketing and exporting melons, brassica, and lettuce. It emphasizes differentiation through traditional varieties where flavor is enhanced. It has recently started its online shop with a differentiated range of products for the summer season, mainly melons in multiple formats, with boxes of one or several varieties weighing between 5 and 10 kg. Home delivery in mainland Spain with postage included in the sales price. In the winter season it incorporates leafy vegetables and reduces the variety of melons on offer.X8: Fruit and vegetable cooperative with more than 400 farmer members and marketing in more than 30 countries. It currently has four fruit and vegetable shops open for sale to local consumers, the first of which was opened in 2011, in places close to its handling centers where it sells vegetables, fruit and vegetables, conventional and organic, mostly from its farmers as well as its pre-prepared convenience food products (manufactured since 2008 and expanded in 2020), complemented by a reduced range of food products. It has conventional business hours during which orders placed by telephone can be picked up in the shop. It also offers a personalized service for local hotel and restaurants that includes products delivery.X9: Agricultural supply and production business group that is starting to market a small range of pre-prepared convenience food products (canned vegetables) online on a specific platform and is planning to include some fresh vegetables.Of the 20 main vegetable exporters in Spain, 45% have already developed a SASC, thus initiating their contact to the end consumer, confirming the hypothesis of what is beginning to be a significant trend among traditional ASC in the area. Furthermore, the rest of the main Spanish vegetable exporters that have not yet started, are planning to do so in the near future.We selected X1 for the case study for the reasons already given. Next, we describe each phase of the ASC in our case study, paying special attention to the tasks that need to be conducted in each phase, reviewing which are common to traditional and SASC, and in particular, the adaptations that need to be made in some processes that are susceptible to generating incremental innovations:Input: This is the reception of inputs from the agricultural production activity and packaging materials for marketing. Intensive fruit and vegetable production requires a wide range of goods and services such as irrigation systems, agricultural machinery, plastics and packaging, seeds, seedlings, insects (for integrated pest management), plant nutrition products, phytosanitary fertilizers and technical assistance. In addition, materials for marketing preparation, cardboard, and plastic packaging are included.The inputs for agricultural production are usually common to both chains, but the packaging for processing and transport in the two chains is often different, due to differences in proximity, transport temperature, and product mix in the short chain.Primary production : consists of the production process of the horticultural crop . It requires the following tasks: farm preparation, planting, crop growth, harvesting and end of crop [ of crop .The agricultural production model used is based on the combination of simple but very efficient technologies, such as drip irrigation, plastic greenhouses, sand-soil technique, biological pest control, which requires continuous training, multiple inputs and technical advice. This phase of agricultural production is the same for both types of ASCs .Transport of products to the handling centers and processing: In this phase, which is common to both ASC the operations of coding, sorting and storage of farmer’s fruit and vegetables is conducted. Handling centers are typically close to farms and each farmer brings its harvest with his own vehicles to its usual handling center. In the conventional channel, the handling and packaging centers usually perform the following processes: reception of the fruits and vegetables from the greenhouses, storage and refrigeration, cleaning, classification, packaging, palletization, storage and refrigeration, and transport to their destination [tination . In bothOrder preparation: This phase is different for SASC and conventional ASC. In SASC, packaging and outbound logistics requires centralization in a dispatch center. Therefore, sometimes selected fruits and vegetables must be transported from the center of origin to the common dispatch center. This is followed by packaging, palletization, storage, and cooling. However, in the conventional ASC, internal transport is usually not necessary. Packing, palletization, storage, and refrigeration are conducted directly in the same center where the farmer takes his harvest. In ASCC, packaging is usually standardized, but when the product is a box with a mixture of fruits and vegetables, its content often varies according to crops’ seasonality.In long ASC, order preparation is standardized and more easily planned, although requires different packaging for each product and customer. The order preparation process is highly automated and involves strict refrigeration control to keep the cold chain of the food.Digital marketing and Information Technologies (IT) service team: This phase is transversal to the entire ASC. In traditional ASC, digital marketing is mainly informative. Commercial activity is focused on high-volume customers, with personalized relationships planned for the medium and long term, with frequent framework agreements for supplying customers/companies throughout the year and in their own packaging. IT allows different levels of integration with customer depending on the trust and stability of their relationships.In SASCs, there is direct interaction with consumers, generating a large number of relationships and a greater flow of information. They plan and execute promotional campaigns and communication strategies in social media such as Facebook, Instagram, updated blogs, newsletters, and videos, using influencers to help sales. They are in charge of informing about new products by defining strategies, objectives, and priorities and communication managed into a marketing platform. They also have powerful tools for market analysis. Planning needs have to be reviewed and updated at very short notice (weekly) to incorporate information on supply  and demand .Distribution: this essentially consists of bringing the product from the handling center to the customer. Delivery to customers is usually subcontracted to specialized transport companies, although it follows different processes depending on the type of short or long chain. More than 80% of traditional ASC is exported, requiring long-distance transport, normally with road transport companies with large fleets of refrigerated trucks, generally with products of the same category. However, delivery to customers in SASC is conducted by small delivery vans  contracted to external transport agencies, as these are national deliveries .Consumers and customer service: This basically consists of attending to the needs of customers. In this stage there are major differences since in the long ASC, the main customers are large distribution chains and wholesalers. The communication system is relatively formal [y formal . In contIn the south-east of Spain, some of the main producer groups or marketing companies of fruit and vegetable products are developing short agri-food channels for fresh fruits and vegetables (pre-prepared convenience food products of their own production) as a viable initiative for the domestic market. The national  customer has come to value freshness and flavor with guarantees of food safety and compliance with all the quality protocols required by the international market.The first advances were made through physical shops, but since 2018, handling-marketing companies (with stable supply and cooperative relationships with producers of fresh fruit and vegetables) are betting on virtual shop to develop SASC. In this regard, ref.  suggesteBuilding trusting relationships in an online environment is a key element for the adoption and development of e-commerce . The inaAfter a process of proposal and discussion with various types of experts, we have identified seven stages in this new SASCs that share part of the activities with the conventional ASC. It is remarkable that, depending on the composition of the experts involved, the proposals broke down in greater detail the stages in which these experts were involved. For example, in the first proposal where the seed companies participated they proposed differentiating the stage of seed selection from the rest of the supplies. The final proposal is the one shown in the right-hand column of The first three stages of the process  are essentially common to both channels. However, the packaging used for the short channel is usually different from that used for the long channel. The divergences between the two channels start to occur at the order processing stage.From order processing, the functioning of both channels is different because the competitive orientation of the products changes. The long channel is in a phase of maturity of the product life cycle where a large part of the products in the long channel are considered commodities. Cost efficiency is pursued and a high volume of production is worked with . HoweverAlthough the storage of handled products is performed in shared facilities between the short and long channels, physical distribution is outsourced and performed by specialized companies. Finally, digital marketing and customer service efforts support both channels, although digital marketing is more focused on SASC. In the long ASC, the interaction of the sales team (by telephone and in person) is more common.In the case study, we have identified that there are synergies between the short and the long channel. In addition to trust that comes from size and certification of the handling-marketing company, the most important synergies are based in co-operative coexistence strategies : resourcSome of the main innovative fruit and vegetable handling-marketing companies are betting on the short channel in a business venture with strengths and weaknesses. On the demand side, individual consumers have demonstrated their willingness to pay more for high-quality food products  and the On the supply side, the handling-marketing companies that have started the SASC focus on supplying their products to the local/national market. Currently, their priority objective is to meet the needs and tastes of the consumer rather than profitability. These short chains can be extended into medium chains by extending these relationships to regional supermarkets, restaurants, public, and private institutional buyers . This isThe growth in size of the handling-marketing companies and their stable collaboration with farmers  is allowCurrently, the development of the SASC hardly interferes with the traditional ASC, as more than 80% of its market is export, but the increase in volume and geographical extension of SASC may require its adaptation. SASC represents a very small volume of business in relation to the total turnover of the traditional ASC, although it does provide handling-marketing companies a global vision of the market, as it brings them closer to consumer. SASCs also have to be careful in their approach to the market so that large-scale distribution, which is the main customer of traditional ASC, does not perceive them as a threat.SASCs results have yet to be evaluated in the medium and long term as they have many pending issues to improve: adjust its product portfolio, standardization of specific SASC processes , use of biodegradable or reusable packaging, or increase consumer loyalty. Many of these improvements will enable better planning and control of SASC.According to , SFSCs hThe study has focused on a fruit and vegetable cluster with specific characteristics : short pThe SASCs for fresh fruit and vegetables that are emerging in south-east Spain have their origin in handling-marketing companies which are farmers’ cooperatives or trading companies with close relationships with farmers. These handling-marketing companies, integrated in traditional ASC, have additionally developed their own SASC in contact with final consumer. SASC coexist with traditional ASC and share many stages of the SC leveraging convergence of interests developing hybrid SC. These hybrid SCs emerge from the supply side and can benefit from economies of agglomeration, scale, and scope that contribute to the sustainability of the agricultural model with various options to meet customer needs. For example, this type of hybrid SC facilitates the fight against food waste by quickly disposing of sizes or products that at a given moment do not meet the standards set in the long chain but are in perfect nutritional and physical condition.Concentration in agricultural production allows effective and efficient access to the necessary advanced technologies . Mass production for large, export-oriented SCs require homogeneity and compliance with specifications  which facilitates the reduction in production costs. However, agricultural production, because of its natural character, have components of heterogeneity . SASCs are more suited to variability in agricultural production, as their product specifications can be more flexible and change rapidly. The flexibility and agility of short chains allows access to customer segments that particularly value certain product attributes . According to , this inThis new paradigm of hybrid chains in which short and long fruit SCs coexist is a sustainable innovation and it is beginning to set a clear trend in long fruit and vegetable SCs. Its results still need to be better assessed as some issues of SASC, such as the geographical scope or the range of products to be offered, are highly variable, despite the fact that in our study we found clear advantages derived from synergies in common processes.


In Brazil, the right to healthcare and the incorporation of best scientific evidence in public health are universally guaranteed by law. However, the treatment offered to patients with mental disorders in custodial hospitals in this country has not been rigorously evaluated.To analyze the psychiatric diagnoses and treatments implemented in three Brazilian custodial institutions.This was a retrospective, cross-sectional and descriptive study on patients held in custody in three Brazilian institutions, as judicially-determined safety measures due to their mental disorders, and the tools used in diagnoses and treatments. These institutions are in Rio de Janeiro and the Federal District.The data from medical and judicial records that were made available were assessed regarding the diagnoses that were made and the instruments that were used.None of these inpatients were evaluated using validated tools, and only a few medical records presented clear descriptions of the cases. No patient with substance involvement had undergone laboratory toxicological assays. It was not possible to verify the adequacy of treatments because the procedures were inadequately described in the records.No standardized protocols or instruments for diagnosing mental health disorders or assessing use of psychoactive substances had been applied among the inpatients at these custodial institutions in Rio de Janeiro and the Federal District. The treatments that were prescribed to these inpatients consisted mainly of drugs. Moreover, Brazilian law no. 12,401 (2011) and law no. 10,216 (2001) both give legal support for the use of the best scientific evidence in public healthcare as the basis for diagnosing and treating diseases in this country.6 In most cases, custodial hospitals are not integrated with the Brazilian National Health System.5In the Brazilian penal system, individuals who cannot be criminally responsible due to mental disorders cannot be penalized. Instead, security measures should be taken, and treatment should be provided. Thus, individuals with mental disorders who are considered dangerous and have committed a crime are not sent to prison in Brazil: they must comply with security measures in a custodial hospital, where patients like these should receive treatment. However, a large proportion of the inpatients at custodial hospitals for psychiatric treatment in Brazil do not receive proper medical-psychological care.To the best of our knowledge, no studies have verified whether the diagnoses reported in the medical records of inpatients at these Brazilian custodial hospitals, and the treatment that these patients received, were in accordance with the recommendations and/or best scientific evidence from well-conducted clinical trials.To analyze the psychiatric diagnoses and the treatments implemented in three institutions within the Brazilian Criminal Justice System through descriptive and exploratory mapping of the available reports and medical records on mental-insanity and cessation-of-dangerousness examinations.This was a cross-sectional descriptive study on the diagnoses made and treatments used for inpatients, both men and women, at custodial and psychiatric treatment hospitals for individuals who had in some way conflicted with the law and required security measures . This study was conducted between March 2011 and June 2012 at an institution in Brasília, Federal District (DF), and between 2012 and 2013 at custodial hospitals in the state of Rio de Janeiro (RJ).The present study was based on legal reports and other data included in the inpatients’ medical records. The investigation was conducted at two institutions in RJ and one in DF: the custodial and psychiatric treatment hospitals Heitor Carrilho, in the municipality of Rio de Janeiro, RJ, and Henrique Roxo, in Niterói, RJ; and the psychiatric ward of a women's penitentiary in Brasília, DF .All data collected during the search were obtained through personal visits to the three participating institutions, by the principal investigator and three assistants (who had previously been trained). Copies of all documents required were made. -Pre-formulated data collection forms were used in the present study to gather the variables described below. No data were obtained over the phone.This study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), under protocol no. 38313812.2.0000.5505, on December 18, 2014. The privacy of all participants was respected, and their identities were kept confidential. The researchers involved did not contact the participants, and the analysis was limited to assessment of documents in the medical records. Thus, there was no need for a free and informed consent statement.The present study did not receive any form of funding from either public or private sources. The authors, who are all public employees, did not have any conflict of interest to declare regarding this study.th version (ICD-10).7 They included users of psychoactive substances who had received a diagnosis of chemical dependency and were considered not criminally responsible, in accordance with article 26 of the Brazilian penal code.8All legal medical reports and data available from the medical records of inpatients at the three custodial units within the period studied were included. The participants in the present study were individuals with mental disorders in accordance with the International Classification of Diseases 108 Such patients are considered semi-responsible for their criminal actions.Patients diagnosed with sociopathy/psychopathy were excluded because of the differentiated treatment recommended in the penal code (sole paragraph of article 26 and article 98).In the Federal District, the study was started by collecting reports and medical records that were documented in the judicial processes relating to the inpatients in the psychiatric unit.All inpatients treated at the three institutions were identified and all documents on them that were available were evaluated .One of the custodial and psychiatric treatment hospitals in RJ  was going through a process of deinstitutionalization (concluded in 2013). At the time of this study, inpatients for whom a report declaring positive cessation of dangerousness had been issued were being released. The inpatients whose families could not be located by the hospital team remained at the institution as sheltered individuals and no longer as inpatients, but still receiving assistance from the healthcare team. Thus, the Henrique Roxo Hospital became the entrance to the penal system, while the Heitor Carrilho Hospital became the exit. The entire release process is now conducted at the latter hospital, involving examinations to assess cessation of dangerousness for all inpatients who, according to the team, were in a condition that allowed them to be released. All inpatients in Rio who were included in the present study had gone through both institutions and for this reason were analyzed together.The data gathered from the legal medical reports and medical records were used to define sociodemographic and family profiles, diagnoses, duration of hospitalization and therapeutic measures applied. Therapeutic projects, i.e. descriptions of treatment plans that were drawn up for individual implementation, were also included if they existed. The following data were collected:demographic data such as nationality, age, gender or sex of the patient, marital status, educational level, profession, address and place of birth.dates in which diagnostic evaluations, medical examinations and hospitalization for psychiatric treatment took place.mental insanity examinations that were performed: types, dates and methods (anamnesis or interview), and the instruments used for these evaluations.9use of mental insanity examinations and structured interviews conducted by means of an instrument such as SCID ;diagnoses stated in the mental insanity report and in the examination regarding cessation of dangerousness, and the security measures adopted.reports from the psychosocial department and social care teams.11 in examinations regarding cessation of dangerousness, to assess the risk of violence and security measures.use of the Historical Clinical Risk Management of Violence (HCR-20) scaletherapeutic measures adopted: types of medications prescribed (with dosage and period) and psychotherapy.In cases of divergence between the reports on mental insanity and cessation of dangerousness and the reports from the psychosocial sector or the medical-psychological care teams of the establishments, the findings from the report on mental insanity were given precedence.The inpatient profile and the diagnoses and treatments received were summarized in order to facilitate comparison with the recommendations that are presented in the scientific literature.During the study period, several visits to each of the three treatment centers were needed, in order to identify cases and gain access to data. Because of the precarious situation of the infrastructure, personnel  and care provided for inpatients at all three locations, many documents were missing from the inpatients’ individual files. Most of the files only included the reports from the examination for cessation of dangerousness, without the mental insanity examination. Information regarding the mental disorder that motivated hospitalization was incomplete, insufficient or absent from the reports on custodial patients. Moreover, the code of the International Classification of Diseases (ICD) was missing in many cases.The deactivation of the Heitor Carrilho Hospital hampered the process of gathering filed data. To overcome this difficulty, hospital personnel  were contacted to search for information on the patients’ situation. In 23 out of the 78 cases at Heitor Carrilho, the inpatients had grown old and had been living at the hospital for many years. Although in these cases the patients met the requirements for being released, the social care teams had been unable to contact their families to receive them, and so they remained at the institution.In the Federal District, due to the singularity of the treatment center, it was possible to obtain mental insanity examinations and those regarding cessation of dangerousness for almost all inpatients in the feminine psychiatric unit of the local penitentiary system. However, there were no individual medical records showing whether the treatments were being properly followed.12During the period studied, 109 inpatients were identified at these three institutions. The characteristics of these individuals are described in Both in the Federal District and in Rio de Janeiro, most of the inmates were men; they were either single or widowed and had low educational levels. The data on inpatients at the two hospitals in RJ were combined in the same spreadsheet, since these hospitals are under the same management.Information on the mental disorders that led to hospitalization were incomplete, insufficient or absent in the medical records of the custodial inpatients.Limitations found due to lack of documentation and adequate medical records are described in numbers in The heterogeneity of descriptions of diagnoses in the inpatients’ records is shown in The examinations and diagnoses regarding mental insanity and cessation of dangerousness that were conducted, with or without designation of ICD codes, are compared between Rio de Janeiro and the Federal District in Most diagnoses were based on either anamnesis alone or anamnesis and interviews with a family member, as shown in The present study was the first exhaustive survey in Brazil on the care received by patients with mental disorders and/or chemical dependency who had been involved with conflicts with the law and who, for this reason, were inpatients at three custodial hospitals between 2011 and 2013. However, despite numerous visits to each center to obtain documentation, and contacts with administrative personnel, no comparison between the current guidelines for diagnoses and treatments and what was being practiced at these institutions was possible, simply because of the huge gaps in the records. This alone is an example of inadequacy in relation to what is recommended in international guidelines: these individuals who had committed crimes were considered to present mental disorders, but the documentation of the diagnostic process was either flawed or absent, thus indicating that there may have been a considerable amount of subjectivity in their evaluations. Judging by what was reported at these institutions, these patients had not been receiving diagnoses in accordance with standardized instruments and, therefore, their treatments could not be reviewed with regard to fulfillment of the recommendations in the literature.13This blatant negligence in the documentation of these three custodial institutions alone demonstrates some of the aspects of the precarious situation within which these patients were being treated in Brazil.14 A complete psychiatric examination usually includes an interview with the patient; interviews with third parties ; physical examination, with emphasis on neurological, endocrine and cardiac assessments; complementary examinations, including laboratory tests; functional tests and imaging examinations; and neuropsychological tests.14Anamnesis is only one of the elements of a psychiatric examination.17 This demonstrates the importance of using structured interviews, which are objective instruments for measuring mental functions, including the risk of violence.17Evaluators need to use their knowledge of psychopathology and, hopefully, the best scientific evidence available, to make a diagnosis.16The diagnosis of mental disorders may also be based on clinical data, structural neuroimaging examinations  and functional tests . Nonetheless, psychological and neuropsychological tests are very helpful, especially for making differential diagnoses between primary psychiatric disorders  and neurological diseases.16The present study showed that standardized diagnostic instruments or structured questionnaires to assess custodial inpatients were not being used at the institutions investigated. Not even family members had been interviewed, in more than half of the cases in DF and in all cases in Rio. A psychometric examination was performed on only two patients, with no description of the method or instrument applied. This means that diagnoses such as “schizophrenia”, “mental retardation”, “alcohol addiction” or others in this sample were based exclusively on the analysis of an expert examiner, who only used interviews to reach this conclusion.19 there are objective criteria that should be followed, in order to define a diagnosis of mental disorder.20 These include the presence of a certain number of symptoms over a defined period, to characterize the psychopathological condition. Psychiatric diagnoses and classifications of mental disorders were a matter of controversy over the course of the 20th century.17According to manuals such as ICD-10 and DSM,18 and the one recommended by the World Health Organization (WHO), the Classification of Mental and Behavioral Disorders of ICD-10 . This latter system has two versions: the Clinical Descriptions and Diagnostic Guidelines (“Blue Book”) and the Diagnostic Criteria for Research (“Green Book”).7 The system established by the APA was created in 1980 and has been revised over the years. It is now in its fifth version.18 The DSM is a particularly objective instrument and is the system that best meets clinical needs, although it has not been officially adopted in Brazil. Thus, when performing a forensic analysis, Brazilian doctors must apply the classification proposed by WHO, the ICD-10, using its Chapter V, “Mental and Behavioral Disorders”.7 However, the ICD codes in the medical records analyzed in the present study were mostly either deficient or nonexistent. Thus, many patients may have been hospitalized without a diagnosis.There are currently two major diagnostic systems: the one proposed by the American Psychiatric Association (APA), called the Diagnostic and Statistical Manual of Mental Disorders (DSM);22 These instruments include the following:Over the past 20 years, standardized instruments have been developed to assess either dangerousness or the possibility that patients may commit violent acts under certain circumstances.24Psychopathy Checklist-Revised (PCL-R): This instrument was based on the classical concept of psychopathy and contains 20 items that were chosen to assess behaviors and emotional traits that are characteristic of a psychopathic personality.26Barratt Impulsiveness Scale (BIS-II): This was developed to measure the three main components of impulsivity: motor component, cognitive component and absence of planning.10Historical Clinical Risk Management of Violence (HCR-20): This instrument was specially developed to evaluate the risk of future violent behavior in psychiatric and criminal populations. It contains historical, clinical and risk management subscales, and lists risk factors such as previous violence, young age during first violent incident, instability in relationships, work-related problems, problems regarding substance use and others.10 for example, offers the option of 10 different levels of risk of violence and could give a more objective and realistic estimate of an inpatient's situation, but it was not used in any of the cases analyzed. HCR-20 was considered to be a good predictor for violent behavior after release, in an analysis on a community of men with psychiatric disorders.17In the present study, there was no documentation regarding any use of any instrument for assessing levels of dangerousness (or cessation of dangerousness) among the inpatients. The HCR-20 scale,This is yet another phenomenon that contributes towards perpetuation of hospitalization, as opposed to measures for resocialization and social reintegration, which are greatly emphasized in the anti-asylum movement. These individuals committed crimes but were considered not criminally responsible for their actions due to mental disorders, and they remained imprisoned even though they may have a low level of dangerousness.16 One of these studies27 also showed that there were significant heterogeneities in applying Canadian law and in the forensic procedures regarding these cases, such that individuals affected by mental disorders can be detained for longer in some provinces than in others.16In Canada, cases of individuals who are not criminally responsible on account of mental disorders (NCRMD) were recently reviewed in a set of studies conducted in three provinces.We consider that evaluating the accuracy of diagnostic instruments is paramount. The sensitivity and specificity of these instruments should be assessed in appropriate studies, through identification of true-positive, false-positive and true-negative cases. In this manner, appropriate conduct at diagnostic, institutional and therapeutic levels can be implemented with greater safety.31 The inpatient records were frequently unclear and occasionally absent. It was unclear whether some medications were being used because of their capacity to prevent psychotic events or because they promote an anxiolytic or sedative effect, thereby controlling patients’ behavior, for example. In turn, it was also unclear whether anticonvulsants were used for epileptic conditions or as mood stabilizers.33 However, considering custodial hospitals within the context of healthcare, it needs to be borne in mind that while more advanced technologies can promote better treatment results, physicians still need to be trained to use them.4The therapeutic measures recommended and those noted in the inpatient records evaluated differed greatly.29 Judges in Brazil operate only on the basis of their trust in the healthcare professionals who advise them: whatever they determine is then practiced for an indeterminate time.The findings from the present study indicate that there is a need for legal professionals  to have knowledge in the field of evidence-based mental health and to be able to perform searches in the available databases.In the field of research, there is a clear need for better training for specialized professionals, for application of instruments that have been validated internationally to assess individuals with mental disorders. In the present study, it was seen that the professionals involved in making diagnoses and administering treatments among the inpatients apparently had not received any training or, if they had, they were not using the instruments available. Partnerships between custodial institutions and universities could assist with this problem, through identifying weaknesses in the system and proposing solutions. Universities can benefit these institutions through providing training and, in return, would find a fertile field for research within psychiatry. This idea needs to be tested through meticulously designed studies, which could include psychiatric reexaminations on patients (which was not possible in the present study).The flowchart  illustraThis flowchart  shows thThus, it became more difficult to establish a pathological profile for these inpatients who were subject to security measures. The visits made to the institutions showed, as presented in the Results section, that the lack of human resources determined the lack of individual medical records. There were absences of remedial therapists and there were some reports on cessation of dangerousness without any mental insanity examination. All of this indicates the inadequacy of the situation in relation to what is recommended by the international guidance: for instance, with regard to subjects who are considered to have a mental illness and who are therefore unaccountable before the law.This novel analysis corroborates the hypothesis that the treatments applied were not based on the current scientific evidence. Standardized instruments to assess the level of dangerousness of the inpatients at the custodial institutions were not used, either. This lack of evidence-based diagnoses makes adequate treatment impossible. There were also no standardized records regarding the recommended treatments and whether these were pharmacological.Based on the sparse and incomplete documentation of the diagnoses presented in the medical reports, the largest proportion of the inpatients were diagnosed as having schizophrenia, with no further details, followed by the proportion with a diagnosis of use of psychoactive substances, but with no supporting toxicological screenings. This finding makes it difficult to establish a psychopathological profile for inpatients who are subject to security measures at these institutions, and to ensure quality treatment.The lack of scientific support for these diagnoses and treatments from the best scientific evidence reveals a flaw in the integration of the fields of medicine and law. This ultimately compromises the human rights of inpatients at custodial hospitals in Brazil. These inpatients are entitled by law to the most effective and safe treatment, but the present study demonstrated that this has not been practiced.


To show by the example of the Optimized Mixed Diet (OMD) for children and adolescents in Germany, how the different food and nutrient profiles of the traditional daily meals complement each other to achieve daily nutrient intakes that meet the Dietary References V.The 7-day menu plan of the OMD with the usual 5 daily meals in Germany was used. The total nutrient intake from all meals was compared with the nutrient references. Then the composition of the meals was optimized.Although the cooked meal (lunch) provides only 25% of the daily energy intake, it is relatively rich (>25% of the daily intake) in most vitamins and minerals, which distinguishes it from the other meals. The cold main meals  are rich in calcium and vitamin B2, due to the preferential use of milk in these meals. The two snacks each provide 12.5% of the daily energy intake.People eat foods but not nutrients and they eat foods as meals; this holds especially true for children and adolescents. A well-calculated menu plan can assure the nutrient adequacy of an OMD where the different food and nutrient profiles of the meals complement each other in a modular system. Guidelines for meals could facilitate flexible coordination of family meals and meals in childcare centers and schools. Different meal types set varied stimulus patterns at different levels , which may open up long-term health benefits. The foundations for lifelong health are set in childhood and adolescence. A key requirement is a healthy diet from the beginning, ensuring an adequate energy supply with all the nutrients necessary for health, growth, development, and performance , 2. Prevwww.dge.de), or the my plate system in the USA (www.choosemyplate.gov). However, in order to realistically calculate the daily nutrient intake for comparison with the nutrient references, the exact amounts of the recommended individual foods in the daily diet must be known.Dietary Reference Values (DRV) or Dietary Reference Intakes (DRI), reflect the scientific knowledge about the nutrient needs of the different age groups across the life cycle . To becoThe German FBDG for children and adolescents, named the Optimized Mixed Diet (OMD) , are basIn earlier publications we have shown, that reference values for daily nutrient intake were met by the OMD seven day menu plan in all age groups of children and adolescents , 8. HereThe development of the OMD started with a 7-day menu comprising the usual 5 daily meals for children and adolescents in families in Germany. For an exemplary age group 4–6 years), the average nutrient intake from each of the meals was calculated and the sum of all meals per day was compared with the respective daily reference nutrient values. In this way, potential needs for optimization of food selection or food amounts became visible. Subsequently, meal-specific food and nutrient profiles were obtained  at meals and in between mealssugary products  limited to morning and afternoon snack at home to facilitate subsequent tooth brushingThe individual foods were grouped in nutritionally and practically useful groups, the amounts per food group and meal of the 7 days were summed and averaged per day  Table 1Table 1. cold meals (breakfast and dinner), milk or dairy products make up the highest proportions of the total meal amount. In addition, fruit or raw vegetables, as well as cereal flakes (as muesli) or a sandwich (bread) are consumed. Practical examples of cold meals are muesli of cereal, fruit and yogurt, a sausage sandwich with a glass of milk and an apple, a cheese sandwich with a raw vegetable salad or a pasta salad with tomatoes, cucumbers and yogurt dressing.In the two main cooked meal  are potatoes, rice or noodles, with plenty of vegetables, also as raw vegetable salad. A small portion of meat is on the menu about three times a week, a meal with fish once a week. On the other days, there are vegetarian dishes with pulses or cereals and vegetables as main ingredients.The main components of the snacks are usually eaten in the morning  and in the afternoon. They consist mainly of fruit or raw vegetables, bread or cereal flakes and a portion of milk or a dairy product. Occasionally, sweets, cookies or cakes are accepted.The two A no-energy drink, preferably tap water, accompanies each meal and should also be available in between.The energy percentage of the meals in the daily diet was fixed with 25% for each of the main meals  and 12.5% for each of the two snacks. While absolute food amounts (g/d) vary with age and sex due to varying energy requirements, food group proportions (%) in the meals are independent of age  Table 1Table 1.To calculate the energy and nutrient intake, a common software  was used. Nutrient values were obtained from the German Food Code and Nutrient Data Base (BLS) , which has already repeatedly been used for nutrient intake calculations across Europe in the HELENA study . The BLSThe cold meals are especially rich in calcium and Vitamin B2, due to the preferential use of milk in these meals. The snacks show a balanced nutrient profile, which is achieved by upgrading the usual afternoon snack of sweets or cakes with the repeated use of cereals, raw vegetables and fruit.People eat foods but not nutrients and they eat foods as meals. Nutrition recommendations are usually given by FBDG in a qualitative or semi-quantitative way for the whole day or even more generally. Meals, with their different profiles, more accurately reflect the daily dietary practices and the various typical eating occasions. Beyond their typical contribution to a total healthy diet, meals provide an important setting for social gathering and for communication . The OMDThe meals in a mixed diet have specific food profiles that result in specific nutrient profiles. This means that the individual meals cannot, and need not, fully reflect a healthy daily diet on their own. Finally, it is important that the meals form a modular system that completes to a daily nutrient intake that is consistent with the nutrient references.There is no convincing evidence for a certain number of daily meals for health promotion and disease prevention . The OMDThe sequence of meals in the OMD may vary throughout the day depending on the needs of the family or child. For example, the cooked main meal provided as lunch in the OMD menus, can be exchanged for the cold main meal in the evening. The two meals during the morning (breakfast and mid-morning snack) can be interchanged for example in older children who often have a later chronotype than younger children  and do nMeals are diverse by nature, thus corresponding to cultural food patterns and eating traditions, especially in rich countries. Diversity results from the different shares of food groups in the different daily meals and, in addition, from variability of the foods within a food group on different days, e.g. a cereal breakfast or a bread breakfast on two different days.Recent work on chronobiology, pleasure of eating and long-term physical health suggests benefits of diversity between and within meals. For example, since physiological mechanisms are generally subject to diurnal regulation, it is to be expected that the time of day is also important for postprandial physiology. This may have consequences not only for wellbeing but for risk reduction and long-term health , 16.Additionally, differentiated meal compositions help to anticipate and remember mealtime as a social experience and a joyful event , 18.Children grow into these specific roles and meanings of meals in the family. They could probably benefit from a broader view of meals. For example, hedonistic attitudes toward food have been hypothesized to promote healthier food choices in children compared with food-related attitudes .The breakdown of FBDG into meals to facilitate practical nutritional counseling may cover different social areas. For example, communicating healthy eating through meals could be of practical importance for children and adolescents. who eat meals outside the family in day care centers (younger children) and schools  .The OMD's modular meal system shows that it is not acceptable in a mixed diet to set standardized nutrient proportions for individual meals, e.g., 1/3 of the daily nutrient references for each hot meal in day care or school, without jeopardizing the balanced daily nutrient intake of the modular system.It is the diversity of meals that facilitates balance in daily nutrient intake. The OMD makes this possible while maintaining the meal habits in Germany. In the case of changes in meal habits , adjustments could easily be made and nutrient adequacy evaluated.People eat foods, but not nutrients, and they eat foods as meals. Using the example of the meals of the OMD in Germany, the results provide benchmarks for the composition of all meals of the day for children and adolescents while preserving the existing nutrition culture. Meal-Based Dietary Guidelines could facilitate the flexible coordination of family meals with daycare and school food service to achieve a balanced daily diet in a practical way. Different meal types also open up the possibility of setting varied stimulus patterns at different levels , which not only lead to more enjoyment when eating, but can also open up long-term health benefits.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.MK designed the study. MK, HK, and KS analyzed data and drafted the manuscript. TL supervised the project. All authors contributed to interpretation of the data and revisions of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.