To assess the relationship between the presence and generosity of state‐level Earned Income Tax Credits (EITC) and multiple self‐reported measures of general health.Data on state‐level tax credits and covariates were obtained from the National Bureau of Economic Research and University of Kentucky Center for Poverty Research, respectively. These data were merged with Behavioral Risk Factor Surveillance System survey records from 1993‐2016.Using difference‐in‐differences approaches and survey‐weighted Poisson regression that accounted for clustering of observations and included state and year fixed‐effects, we assessed relationships between EITC and self‐reported overall health, frequent mental distress, and frequent poor physical health in the prior 30 days. Covariates included state minimum wage, state GDP, and adoption of Medicaid expansion. Sensitivity analyses revealed that parallel trends were plausible; there were no significant lead and lag effects.Analyses were restricted to respondents with no more than a high school diploma or equivalent because less‐educated adults are more likely to be low‐wage earners and therefore qualify for EITC.n = 2 884 790), each additional 10‐percentage‐point increase in the generosity of state EITC—relative to the federal credit—was associated with fewer reports of frequent mental distress  and frequent poor physical health . When restricted to individuals interviewed during the three months when tax rebates are commonly disbursed, the magnitude of the association between EITC and prevalence of reported frequent mental distress was greater .Among adults with no education beyond high school (The generosity of state EITC policies is positively associated with significant reductions in frequent mental distress and poor physical health, especially during months when the credit is received. Interventions to reduce poverty may positively impact health by reducing material hardship and stress. Increased generosity of state Earned Income Tax Credits benefits statewide physical and mental health of all adults with no more than a high school education—benefits are not limited to single mothersPositive impacts of state Earned Income Tax Credits are most pronounced in early spring when the benefits are received especially the effect on frequent mental distressSocial policies such as the state Earned Income Tax Credits influence people beyond economic outcomes and maybe another way to improve health and reduce disparitiesEarned Income Tax Credit is known to promote employment and is largest anti‐poverty program for working‐age AmericansEarned Income Tax Credit has previously been found to improve maternal and child health outcomes such as reduced complications in complications healthier birth weight and better child development outcomes1Many risk factors for suboptimal health share poverty as an upstream determinant.Poverty can compromise health via different pathways.The co‐occurrence of mental and physical health concerns may be caused by shared upstream determinants like poverty. This may be partially explained by the physiological manifestation of stress, or allostatic load, causing long‐term damage to one's health.The federal Earned Income Tax Credit (EITC) was introduced in 1975 as a federal tax credit to low‐earning working families.Much of prior literature on the intersection of EITC and health has focused on maternal and child health, reflecting the primary target population of the policy.The relationship between EITC and adult health more broadly has not been well studied.Since 1993, 19 states and the District of Columbia have created refundable EITCs or made existing EITCs refundable.We assessed the prevalence of reported poor overall health, frequent mental distress, and frequent poor physical health in relation to state EITC among US adults with no postsecondary education. The knowledge generated by this investigation can inform policymakers of the health benefits of EITC implementation and generosity, which go above and beyond the policy's direct outcomes of employment, income, and reduced poverty.22.1We utilized cross‐state variation in the existence and generosity of state EITC and compared repeated cross‐sections from the Behavioral Risk Factor Surveillance System (BRFSS) to assess general health outcomes annually in the United States from 1993 to 2016. Conducted by the Centers for Disease Control and Prevention (CDC), BRFSS uses random digit dialing to survey noninstitutionalized adults at least 18 years of age about health‐related risk behaviors, chronic health conditions, and use of preventive services. In the earliest years of BRFSS, some states sporadically failed to participate or submit survey responses to CDC resulting in a loss of three‐state‐years of data: Wyoming in 1993, Pennsylvania in 1994, and Washington DC in 1995.We restricted our analysis to adults who had no more than a high school education or GED equivalent, a population of workers who are most likely to be affected by state EITCs. Annual earnings would be the most direct measure of eligibility for the EITC, but it is problematic to restrict the sample by an outcome directly affected by the policy and plausibly on the path between the policy and health. Education is a reasonable proxy for EITC eligibility, while also not being affected directly by the policy.2.2The outcomes of interest included the following: (a) suboptimal overall health, (b) frequent mental distress (FMD), and (c) frequent poor physical health (FPPH). Participants were first asked to rate their overall health on a Likert scale from 1 to 5, with 1 indicating excellent health and 5 indicating poor health  and state GDP (in 2010 inflation‐adjusted dollars). We elected to include minimum wage as a measure of a low‐wage worker's earning potential. The state GDP served as an indicator of the overall economic productivity in a state; after including state and year fixed‐effects, any large changes in the state GDP represent changes in the fiscal landscape that are unique to that state. These financial covariates were obtained from the University of Kentucky Center for Poverty Research (UKCPR) database.While they are important factors in health, we intentionally excluded direct measures of employment and insurance from our models. The EITC can operate through employment which would then potentially impact insurance status. Due to the possible endogeneity of these values and the potential for them to act as mediators on the causal pathway, we did not include them in the models.2.5i indexed individuals, t years, and j states. itjY was one of three general health outcome measures. tjEITC denoted a continuous variable, for which each one‐unit increase represents a 10‐percentage‐point increase in the state refundable EITC . tjX was a vector of state‐year covariates and j and t were state and year fixed‐effects, respectively.This analysis used a difference‐in‐differences approach, comparing the change in prevalence of each health outcome across states with more and less generous EITC benefits as the benefits changed. In fully adjusted models, we included state and year fixed‐effects and time‐varying state‐level covariates hypothesized to be related to both EITC generosity and health. We used survey‐weighted Poisson regression and the margins command to calculate prevalence differences (PDs) and 95% confidence intervals (CIs). These models took the following form:For difference‐in‐differences models to produce unbiased estimates of the causal effect of the policy, the parallel trends assumption must be plausible. The assumption is that the trends in the outcomes being studied would be parallel in state with and without an EITC before the implementation of the policy and continue the same trend if not for the implementation of the policy. It is not possible to observe the counterfactual after implementation, but it is conventional to examine parallel trends prior to the intervention as evidence of the plausibility of the assumption. We assessed parallel trend assumptions visually Appendix  and quanWe anticipate that effects of EITC on mental distress and physical health would operate through stress reduction and thus would take effect shortly after receipt of cash. It follows that if the state EITC impacts mental distress, this effect should be stronger in the months immediately following receipt. To consider the shorter‐term effects of EITC, additional analyses restricted BRFSS responses to interviews conducted during the tax season months of February‐April.3From 1993 to 2016, 28 states did not have an EITC and 3 states had an EITC for the entire period, while 19 states and the District of Columbia implemented a refundable EITC or transitioned from a nonrefundable EITC to a refundable credit , FMD (P = .980), or FPPH (P = .670) suggesting that the parallel trends assumption was plausible. None of the lead terms were statistically significantly associated with decreased reports of poor health suggesting that differences in outcomes following the introduction of EITC are not attributable to existing trends.When testing parallel trends assumptions, we found no indication of an interaction between future EITC status and calendar year on reported suboptimal overall health  in addition to the lessened burden of strained financial resources could impact health in the longer‐term.In addition to the transfer of funds, EITC has been successful as an anti‐poverty measure by further incentivizing employment and decreasing unemployment rates.Finally, though the additional increase in funds through either cash transfer or increased employment may allow for further contact with the health care system, it is also important to consider the role of insurance. In the US, insurance status is tied to employment. While many part‐time and low‐wage workers may not be eligible for employer‐sponsored insurance, some EITC beneficiaries may qualify. Increased insurance coverage allows individuals to seek necessary health care treatment and can make prescription drugs more affordable directly improving health outcomes. Individuals may have improved mental health if they are insured and less worried about their inability to meet their own health care needs in addition to the needs of their dependents.4.1The “Healthy Days” metric, as a self‐reported measure, is intrinsically subjective. It is important to note that the results indicate shifts in perceived health; while perceived well‐being is arguably more important than diagnosed poor health, the two are not interchangeable. Healthy Days Measures appropriately map onto detailed health inventories, indicating that misreporting and discrepancies between perceived and measurable health status are likely to be minimal.In 2011, a new sampling and weighting structure was added to BRFSS.There could be measurement error in educational attainment used as a proxy for being most likely affected by EITC. Only the individual surveyed reported their educational attainment making it plausible for those with no more than a high school education to be residing with a college graduate. Similarly, having no postsecondary education does not mean that an individual does not have a high‐paying job and completion of college does not guarantee high wages. Nonetheless, the restriction to individuals with less educational attainment allowed us to focus on a population likely to be eligible for EITC while avoiding restrictions that might be a consequence of EITC such as income or employment. These are quasi‐experimental estimates, which could suffer from unobserved differences between states that have more and less generous EITCs. States that enact generous social policies, such as the EITC, may be more likely to have other policies that benefit low‐income households. These policies can vary from state to state, especially over the nearly three‐decade long study period. While it is unlikely that most of these policies were implemented simultaneously with EITC, they may have contributed to residual confounding.5During 1993‐2017, 20 states implemented refundable state Earned Income Tax Credit policies designed to increase employment and household income among lower‐earning workers. We found that these policies significantly reduced frequent mental distress and poor physical health among less‐educated adults—especially during months when the credit was most likely to be received. Interventions to reduce poverty may improve health by reducing material hardship and stress.No disclosures were reported.Ms Morgan had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.Concept and design: Morgan, Hill, Mooney, Rivara, Rowhani‐Rahbar.Acquisition, analysis, or interpretation of data: Morgan, Hill, Mooney, Rivara, Rowhani‐Rahbar.Drafting of the manuscript: Morgan.Critical revision of the manuscript for important intellectual content: Morgan, Hill, Mooney, Rivara, Rowhani‐Rahbar.Statistical analysis: Morgan.Administrative, technical, or material support: Morgan, Hill, Mooney, Rivara, Rowhani‐Rahbar.Supervision: Rowhani‐Rahbar, Rivara, Hill, Mooney.The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.Supplementary MaterialClick here for additional data file.Appendix S1–S5Click here for additional data file.


We addressed the implications of limb loss and regeneration for multispecies interactions and their impacts on ecosystem engineering in freshwater stream environments.We included regenerative and nonregenerative crayfish as well as fish predators in a 2 × 2 factorial design to assess the effects on water turbidity of interactions between crayfish ecosystem engineers differing in regenerative status and their fish predators.We demonstrated that crayfish limb loss and predation risks lead to more turbidity in field and mesocosm conditions. Moreover, ongoing regeneration of crayfish increased turbidity, while fish presence seemed to hinder crayfish turbidity‐inducing behaviors (such as tail‐flipping and burrowing) in the mesocosm experiment.We confirmed that greater numbers of crayfish produce a greater amount of turbidity in situ in streams.Although mechanical burrowing crayfish capacities may depend on crayfish burrowing classification , our work emphasizes the implication for turbidity levels of crayfish autotomy in freshwater streams. We addressed the implications of limb loss and regeneration for multispecies interactions and their impacts on ecosystem engineering in freshwater stream environments. We demonstrated that crayfish limb loss and predation risks lead to more turbidity in field and mesocosm conditions. Although mechanical burrowing crayfish capacities may depend on crayfish burrowing classification , our work emphasizes the implication for turbidity levels of crayfish autotomy in freshwater streams. Second, if predators influence this ecosystem engineering process, we predict that crayfish‐induced bioturbation will be further increased in the presence of a predatory fish, in an attempt to provide more protection against predation.22.1Our field experiment was conducted in the Green River drainage of the Ohio River watershed in Kentucky, USA (Subregion Hydrologic Unit Code 4‐digit: 0511). This area is located at the convergence of the Cincinnati Arch with the Appalachian Basin, resulting in a highly diverse assemblage of freshwater species  on the crayfish bioturbation process. Mesocosm experiments allow us more control of environmental variation. The site was the University of Kentucky's Ecological Research and Education Center (EREC) field station in Lexington, Kentucky. The same completely randomized design was used for a single block (see below), with fifteen 40 gallon plastic tanks placed under shade cloth mesh and half dug into the ground to mimic stream conditions in slow‐moving water flow under canopy. The substrate in each tank was a mix of gravel and sand similar to what was found in the streams in the field.2.2Faxonius rusticus, Girard 1852; Crandall & De Grave, Ambloplites rupestris, a known predator of crayfish), then used the fish and crayfish to establish a predator enclosure–exclosure experiment in the field. Before addition to the enclosures, crayfish were measured from the back of the orbit to the center of the dorso‐posterior margin of the carapace . Fish were measured from the tip of the snout to the tip of the longer lobe of the caudal fin . All fish behaved normally in the enclosures and were all healthy at the end of the experiment.We used kick sampling  and garden stakes Figure . The strThe study design was a randomized complete block, with three replicates of five treatments within each stream location for each of the three remaining stream locations. Each enclosure–exclosure in each block of 15 was placed at least five meters from each other and never directly downstream from one another (staggered placement); thus, each replicate and treatment was not influenced by other replicates and treatments. Treatments were as follows: (a) fish and crayfish excluded—control (C); (b) fish excluded, unmanipulated crayfish added (UM); (c) fish excluded, regenerating crayfish (limb autotomized) added (R); (d) fish added, unmanipulated crayfish added (FUM); and (e) fish added, regenerating crayfish added (FR). Treatments were added into the enclosure–exclosure placed in a slow water flow area. We shoveled 5 cm of substrate over the bottom surface of each, effectively sealing them to the streambed by embedding the bottom mesh into the sediment.We quantified the crayfish bioturbation process by sampling turbidity (in NTU using a LaMotte 2020we Turbidity Meter) directly downstream of the enclosure–exclosure channels (to prevent the influence of nearby/upstream outside factors) every week, starting a week after setting up the experiment. The turbidity meter processed a small water sample at the field site. Moreover, we gathered water samples from the downstream end of the enclosures to prevent influences on subsequent measurements. This experiment ran from September 12 to October 13, 2015. Both field and mesocosm experiments lasted four weeks, yielding 48 temporal data points per treatment (4 locations (3 field sites and 1 mesocosms site) * 3 replicates * 4 weeks). We also assessed how body size affects regeneration and bioturbation processes. Fish slightly larger than the crayfish were chosen when paired in the enclosure‐exclosure in the field experiment or in the artificial pools in the mesocosms experiment. This size pairing included fish large enough to be perceived as a predation threat by crayfish, while not large enough to actually consume the crayfish. Finally, neither fish nor crayfish were expected to grow significantly during the experiment duration.2.4All analyses were conducted in R  and Akaike weights . Although the Akaike weights of all models add up to 1, alternate Akaike weights for individual variables do not generally sum to 1; these individual‐variable sums are between 0 and 1, where 0 denotes a lack of importance and 1 a high importance of the considered variable in the model set . All models derived from the parent model were compared using the corrected Akaike Information Criterion , respectively.https://doi.org/10.5061/dryad.58k2h35).Our study protocol and procedures were ethically reviewed and approved by the Institutional Animal Care and Use Committee at the University of Kentucky (protocol #2015‐2068). All the data and R script with packages used in this work are available on Dryad , “G” (Turbidity ~ Treatment + Date), and “F” , may reflect the relatively small sample size. Finally, we found no relationships between the turbidity and the number of crayfish at the end of the experiment at each individual stream  compared to larger scale (between streams). We also showed that crayfish limb loss and predation risk lead to more turbidity in field and mesocosm conditions. Furthermore, larger crayfish induce more turbidity than smaller crayfish under mesocosm conditions. Finally, experimental removal of a crayfish chela did increase turbidity. However, we did not find an effect of fish size on turbidity in the field or mesocosm experiments. Nonetheless, fish presence seems to hinder crayfish turbidity‐inducing behaviors in the mesocosm experiment, despite an overall turbidity increase. The direct influence of crayfish number and size on turbidity confirms the importance of crayfish as turbidity‐inducing organisms in freshwater streams. Nonetheless, several results were unexpected and deserve closer attention.Crayfish burrowing behaviors have been linked to increased soil respiration .R script, packages, and data are available on Dryad (


More mothers of overweight than normal weight children correctly identified the child's current weight status  and preferred an overweight/obese body size for the child , and both groups selected overweight/obese silhouettes as healthy for children. More than half of mothers in both groups wanted their child to be larger than the current size. Mothers said that increasing consumption of fruits, vegetables, meat, milk, grains, fizzy drinks and fatty foods could facilitate weight gain, but many cannot afford to purchase some of these foods. Their desired strategies for increasing weight indicate that body size preferences may drive food choice but could be limited by affordability.Overweight in mothers and children in sub‐Saharan Africa is rapidly increasing and may be related to body size perceptions and preferences. We enrolled 268 mother–child (6–59 months) pairs in central Malawi; 71% of mothers and 56% of children were overweight/obese, and the remainder were normal weight. Interviewers used seven body silhouette drawings and a questionnaire with open‐ and closed‐ended questions to measure mothers' perceptions of current, preferred and healthy maternal and child body sizes and their relation to food choices. Overweight/obese and normal weight mothers' correct identification of their current weight status (72% vs. 64%), preference for overweight/obese body size (68% both) and selection of an overweight/obese silhouette as healthy (94% vs. 96%) did not differ by weight status. Fewer overweight/obese than normal weight mothers' preferred body silhouette was larger than their current silhouette (74% vs. 29%,  Mothers more accurately identified their own body size than their children's. Estimates for their children were more accurate if the child was overweight/obese.Mothers preferred overweight/obese body sizes for themselves and for their children, especially if the child was already overweight/obese. Nearly all mothers said a large body size was healthy.Mothers described a mix of healthy  and unhealthy  foods that they could eat or feed their child to facilitate weight gain.Double duty messages emphasizing healthy foods and foods that contribute to overweight/obesity among mothers and children are needed. Culturally competent communication about healthy and unhealthy body sizes is also needed.1Globally, two billion adults and 38 million children under 5 years of age are overweight or have obesity  of mothers and used the standard cut‐offs for normal weight (18.5 kg/m2 ≤ BMI < 25 kg/m2) and overweight or obesity (BMI ≥ 25 kg/m2). We calculated weight‐for‐heightz‐scores(WHZ) for children using the World Health Organization (WHO) growth standard and used the WHO cut‐offs for normal weight (−2 SD < WHZ ≤ +2 SD) and overweight Which figure would you want your figure to look like? (Preferred body size)Which figure do you think shows a healthy woman? Each body silhouette drawing was printed separately on cardstock and laminated. The interviewer mixed the body silhouettes and laid them out in a random order before each question  separately for the mother to make selections for herself and then again for her child. The specific questions related to selection of the silhouettes for women were as follows:If the answers to Questions 1 and 2 were different, ask:How does the difference between your current figure and the figure you would like to have influence what types of food and drinks you buy?If the answers to Questions 1 and 3 were different, ask:How does the difference between your current figure and the figure you believe is healthy influence what types of food and drinks you buy?What types of food or drinks will help you get to (or stay at) the figure you would like to have? Probe: How will these types of food and drinks help you do that? How often are you able to buy them? What keeps you from buying them more often?Open‐ended questions in the questionnaire were used to understand mothers' body size selections and how they were related to food choices. Questions about food choice included:A similar set of questions were used to obtain information about mothers' preferences for child body size and food choices.2.4We performed chi‐squared tests comparing body size perceptions to actual body size by normal versus overweight status separately for mothers and children. We calculated the difference between the selected current and preferred body silhouette numbers for mothers and children to quantify how many preferred a smaller, the same or a larger body size and conducted chi‐squared tests comparing the difference by mother and child weight status. We also used chi‐squared tests to examine differences in the mother's selections of child current, preferred and healthy body silhouettes by the mother's weight status. We calculated descriptive statistics for participants' socio‐economic characteristics, including age, maternal education (secondary or higher vs. primary or no education), household assets , household food insecurity access score (HFIAS) as a continuous variable  were normal weight, and 190 (71%) were overweight/obese; 118 children (44%) were normal weight, and 150 (56%) were overweight/obese. Their socio‐economic characteristics are shown in Table 3.1p = .195), and 26% underestimated their weight status . About two thirds of mothers selected an overweight/obese silhouette as their preferred size , and nearly all mothers selected an overweight/obese silhouette as a healthy size , with no significant differences in either of these outcomes by weight status. Half of all mothers selected the largest body silhouette as healthy.We found no significant differences by weight status in mothers' selections of body silhouettes representing their current, preferred and healthy body size Figure . Overallp < .001; Figure Significantly more normal weight than overweight/obese mothers wanted a larger body size based on the difference between their silhouette selections for preferred and current sizes  who preferred Silhouette 5 said, ‘I want to look fat and people should know that I eat well’. An overweight mother (ID 124) who preferred Silhouette 6 explained, ‘The woman [with a large body] looks strong and healthy. It seems she cannot fall sick and she can work the way she wants’.Among the mothers who preferred a normal weight body silhouette or whose preferred body silhouette was smaller than their selected current silhouette, most said they wanted a normal weight body because they associate large body sizes with physical and health issues. An overweight mother (ID 155) who preferred Silhouette 2 said, ‘I want to get slimmer. [When you are heavy] you get tired when walking and you look older than your age’. A normal weight mother (ID 321) who preferred Silhouette 3 explained, ‘Having a big body makes you get diseases like [high] blood pressure and sugar, so a medium one is fine’. Medium was defined most often as Silhouettes 3 through 5, which represents the middle of our silhouette range but includes one normal weight silhouette (3) and two overweight silhouettes (4 and 5).N = 205) listed a variety of foods they could eat to achieve this. Some talked about specific foods that could help them do this, whereas others talked about eating a variety of foods to gain or maintain weight and be healthy. The most common foods mothers mentioned were green leafy vegetables (64%), fruits (53%), meat (44%), nsima , milk (33%), fizzy drinks , porridge (27%), beans (24%), maheu  and groundnuts or foods containing groundnuts  who wanted to increase her body size said,Mothers who wanted to maintain their body size or become larger N = 05 listedI would change to eating foods with oil, tomato, and onion and not just boil [them] as I do right now. I would be buying soya porridge with milk added [and] green leafy vegetables with oil [and] tomato so that I reach that point. The food would be of different food groups and thus cause the body to get bigger.eat from different food groups—eat fruits, green leafy vegetables, porridge, soybeans, and milk. These foods add vitamins [to the body]. It makes a person healthy. I buy some of these foods. I buy green leafy vegetables every day. Fish, I buy every week. Meat, I do not buy very often because it's expensive.Many mothers who preferred a larger body size said that eating some of the types of foods that would make them gain weight, like meat, was not feasible because of their cost. A normal weight mother (ID 282) explained, ‘I can't afford to change what I eat because I do not have money for better foods’.A normal weight mother (ID 199) who wanted a larger body size said that she would:N = 63), nearly all of whom were overweight/obese, described ways they could lose weight, such as eating foods with less fat or oil (30%), eating lemons or adding lemon juice to food (24%), drinking lots of water (14%), eating food with bicarbonate of soda added  and eating less meat or lean meat ; fruit ; milk (14%); fish and meat (13%); fizzy drinks and juice (11%); and beans, porridge and thobwa  as foods that would help them attain a smaller body size . The majority of mothers selected an overweight/obese silhouette as representing a healthy size for a child, with no difference by child weight status . Fifty‐nine percent of mothers selected the largest child silhouette as healthy. Although fewer mothers of overweight/obese than normal weight children preferred a larger body size for their child based on the difference between their silhouette selections for preferred and current sizes, there was no significant difference by child weight status . Sixty‐two percent of overweight/obese mothers versus 72% of normal weight mothers preferred an overweight/obese body silhouette for their child (p = .123). Ninety‐one percent of overweight/obese mothers versus 94% of normal weight mothers selected an overweight/obese silhouette as healthy for their child (p = .693).We found no significant differences in mothers' selections of child current, preferred and healthy body silhouettes by the mother's weight status. Forty‐seven percent of overweight/obese mothers versus 54% of normal weight mothers selected an overweight/obese current body silhouette for their child  who selected Silhouette 6 as preferred for her child said, ‘The picture [Silhouette 6] looks good and the baby is healthy and doesn't fall sick and plays a lot’. The mother of an overweight child (ID 269) who preferred Silhouette 5 for her child explained, ‘The picture [Silhouette 5] shows a big body baby, which is what everyone wants’.Some mothers preferred a normal weight body size for their child because they believe that a medium body size is good, or they worried about problems related to overweight. Mothers' selection of what they considered a ‘medium’ body silhouette for their child ranged from Silhouette 1 to 6, but the term ‘medium’ was used most to describe Child Silhouette 3, which represents normal weight. A mother of a normal weight child (ID 155) who preferred Silhouette 3 said, ‘I want my son to look medium, as he is’. A few mothers of overweight children realized that being overweight could be difficult for the child. A mother with an overweight child (ID 264) who preferred Silhouette 2 explained, ‘A child faces many challenges when they are very fat, and it is hard to be active’.N = 240) described how they could feed them a variety of foods to achieve this. The most commonly mentioned foods were porridge (64%), fruit (47%), milk (39%), nsima (38%), green leafy vegetables (35%), meat (28%), groundnuts (27%), sweetened yogurt (26%), fizzy drinks and maheu (25%) and rice  who preferred Silhouette 5 said, ‘I give him porridge, Kamba puffs [packaged maize snack], Sobo [locally produced fizzy drink], and chips’. When asked about their reasons for wanting to give their child certain foods, mothers usually said that they help the child gain weight, stay healthy and be strong. They also explained that the foods have vitamins that help with growth. For example, the mother of an overweight child (ID 247) who preferred Silhouette 6 said she gives her son ‘maheu, yogurt, juice, soya bean porridge, nsima, and vegetables so he will grow fat and will be protected from infections’. Mothers' responses about the frequency of purchasing the foods they said will help the child maintain or gain weight varied widely. Because they lack funds, the majority said they buy the desired foods once or twice a month, irregularly, when they have money or not at all. The mother of an overweight child (ID 254) explained, ‘We do buy [those foods], but it's once in a while due to money problems’.Mothers who wanted their child to maintain or gain weight N = 40 descriN = 28) listed foods similar to those who wanted their child to maintain or gain weight, such as porridge (54%); fruit, nsima and fizzy drinks (36%); sweetened yogurt (29%); meat and green leafy vegetables (25%); groundnuts (18%); and milk and rice  who selected Silhouette 7 as healthy explained, ‘The body shows a child who is fed well and very fat, hence she is healthier than others’.4With overweight and obesity increasing in Malawi  or should avoid (such as less fats/oil) to attain their goal, which were not included on the food lists of mothers who wanted to maintain or gain weight. The types of foods listed by mothers who wanted their child to have a smaller body size compared with those who wanted their child to maintain or gain weight contained the same foods with several of them in a similar relative order. The number of mothers who wanted their child to lose weight was small, so the rank order of foods for that group should be interpreted with caution. Packaged and fried snacks, which are commonly purchased for children, were described by mothers in open‐ended responses but included infrequently in lists of foods. Fizzy drinks and meat appeared on food lists for mothers and children regardless of whether a body size increase or decrease was desired. Fizzy drinks and meat are among the foods that many mothers said they could not purchase often because they are unaffordable, suggesting that the food lists may represent, in part, mothers' ideal food choices.One of the key innovations of this study was linking body size perceptions and preferences to food choice, which has been touched on only briefly in previous research in sub‐Saharan Africa  as healthy, so some women may perceive that eating more of all food groups will make them healthy, which is equated for many of them with having a large body size. The mix of food items included on the women's lists points to the need for nutrition education not only to focus on a balanced diet but also to guide healthy food choices by including messages on foods and beverages that are not healthy and for which intake should be limited. The health system in Malawi has been focused on undernutrition but needs to pivot toward ‘double duty’ nutrition messages that address undernutrition and also work toward preventing overweight/obesity and diet‐relatednon‐communicable diseases (World Health Organization, This study had some limitations. Our sample was enrolled in specific mother–child weight status categories and was divided evenly between urban and rural areas. This purposeful enrolment improved the efficiency of sampling and allowed us to make comparisons between normal weight and overweight individuals, which was one of our primary research questions. However, our sample does not represent all women and children in Malawi. Compared with the 2015–2016 Malawi Demographic and Health Survey, a greater percentage of mothers in our study had some secondary education or higher (NSO & ICF, In conclusion, this study showed that Malawian women are fairly accurate at assessing their own weight status but less accurate at estimating their children's. They generally prefer to have larger body sizes for their child, whereas a preference for a larger body size for themselves was more common for normal weight women. Only one third of overweight/obese women wanted a smaller body size, suggesting gaps in knowledge of the adverse health consequences of overweight/obesity in this sample. The types of foods women would like to eat or feed to their child to increase weight are a mix of healthy and unhealthy foods. These findings could contribute to plans for developing interventions for obesity prevention in Malawi to achieve the Ministry of Health's goals. For example, the selection of the largest body silhouette as ‘healthy’ and the range of silhouettes selected as ‘medium’ suggest that programmes could try to increase knowledge about which silhouettes represent healthy body sizes and increase awareness of the negative health consequences of overweight and obesity. Double duty messages emphasizing which foods are healthy and unhealthy for mothers and children are also needed. In addition, more research on the links between body size preferences and food choice is needed in other parts of sub‐Saharan Africa and other low‐income countries. Future research on factors related to body size preferences should be driven by behavioural theory, such as the theory of reasoned action or the transtheoretical model Ajzen, , to bettThe authors declare that they have no conflicts of interest.VLF, CT and LMJ designed the study. CT and JCP oversaw data collection. VLF conducted the analysis and drafted the manuscript. All authors contributed to the final version of the manuscript.


Although papillary squamotransitional cell carcinoma is an uncommon variant of cervical squamous cell carcinoma, due to the complex papillary structure and the challenge in detecting stromal invasion, its timely diagnosis and treatment are very important.Papillary squamotransitional cell carcinoma (PSTCC) is extremely rare and presents with a spectrum of morphologies. PSTCC may present as an in situ tumor with or without an invasion, but usually, it displays both features. Here we report a 60‐year‐old woman, diagnosed with PSTCC of the uterine cervix. Class II radical hysterectomy in papillary squamotransitional cell carcinoma of the uterine cervix. She was hypertensive under medical treatment and negative for other drug and disease history. The patient had no history of Pap smear in recent years. On admission vital signs were normal. On physical examination, a fragile exophytic lesion was obvious in the posterior lip of the cervix. Rectovaginal septum and parametrium examination were normal. Laboratory tests and chest x‐ray were normal. Abdominal and pelvic magnetic resonance imaging (MRI) demonstrated 36 × 20 mm mass with enhancement and restriction in the post lip of cervix with invasion to the posterior fornix without involvement of parametrium. Exocervix tumor had involved the endocervix as an exophytic lesion Figure . On the 3In cervical cancer, PSTCC of the uterine cervix represents a distinct morphological subtype.Considering that it is difficult to detect invasion in the biopsy,Papillary squamotransitional cell carcinoma is significantly less likely than squamous cell carcinoma to express high‐risk HPV (50% vs. 90%), according to a retrospective study of 12 patients.Postmenopausal bleeding or abnormal Pap smear are common clinical presentations of this tumor in elderly women.In a histomorphological and immunohistochemical study of nine PSTCC cases, among the five cases that underwent further work‐up, two cases had Stage IB1, two cases had Stage IIB, and one patient had Stage IIIA disease. In all of these cases, a radical hysterectomy was performed and further treatment was provided at a tertiary care center. Following an 18‐month follow‐up, one patient died of hydronephrosis due to the tumor spreading to the bladder wall and blocking the ureteral opening.The short follow‐up period of the patient was a significant limitation of this study. Considering the patient's 20‐month follow‐up after surgery, a longer follow‐up is necessary to detect a recurrence. An in‐depth study of this case as well as other cases will be required to determine the biological and clinical characteristics of the tumor.4Although PSTCC cervix is a rare neoplasm with a high tendency for late recurrences and metastasis, its diagnosis is critical to determine its clinical and pathological features and prognostic differences with other histological types and initiate treatment as soon as possible.Maliheh Arab: Conceptualization. Zanbagh Pirastehfar: Conceptualization; investigation; project administration; writing – original draft; writing – review and editing. Noushin Afshar Moghaddam: Supervision. Masoomeh Raoufi: Supervision.None.The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.Our institution does not require ethical approval for reporting individual cases or case series.Written informed consent was obtained from the patient for the publication of this case report as well as accompanying images. A copy of the written consent is available for review by the editor‐in‐chief of this journal.


Dear editor,Erythema annulare centrifugum (EAC) is an inflammatory skin disease with unknown etiopathogenesis.We report the case of a 74‐year‐old female who presented to our outpatient clinic with annular erythematous plaques with central clearing, slightly raised edge, non‐scaly that merged into polycyclic lesions scattered all over the entire body surface for 10 months Figure . IncomplTreatment of an associated underlying disease can lead to the resolution of EAC; if a cause cannot be identified, no specific therapies are available.Our research group declares no conflict of interest.We obtained informed consent from the patient for the use of clinical and photographic data.


Ailuropoda melanoleuca). Signal detection theory propounds that animals choose the substrate and location of their scent marks so that the signals released are transmitted more widely and last longer. We believe that pandas trade‐off scent‐marking because they are an energetically marginal species and it is costly to generate and mark chemical signals. Existing studies only indicate where pandas mark more frequently, but their selection preferences remain unknown. This study investigates whether the marking behavior of pandas is consistent with signal detection theory. Feces count, reflecting habitat use intensity, was combined with mark count to determine the selection preference for marking. The results showed that pandas preferred to mark ridges with animal trails and that most marked tree species were locally dominant. In addition, marked plots and species were selected for lower energy consumption and a higher chance of being detected. Over 90% of the marks used were the longest‐surviving anogenital gland secretion marks, and over 80% of the marks were oriented toward animal trails. Our research demonstrates that pandas go out of their way to make sure their marks are found. This study not only sheds light on the mechanisms of scent‐marking by pandas but also guides us toward more precise conservation of the panda habitat.Inter‐animal communication allows signals released by an animal to be perceived by others. Scent‐marking is the primary mode of such communication in giant pandas ( This study provides a more rigorous approach to the study of scent marking in giant pandas and concludes that it is indeed consistent with signal detection theory. ChemicaCrocuta crocuta; Gorman, Panthera pardus; Rafiq et al., Lycaon pictus; Claase et al., The signal detection theory propounds that animals select scent‐mark signal deposit substrates, resulting in a wider range and longer retention of the released signal Alberts, . This chAiluropoda melanoleuca) are typically solitary mammals that rarely come into direct contact with other individuals except for the rutting season when they form gatherings , forest musk deer (Moschus berezovskii), and leopard.This study was conducted in Shaanxi Foping National Nature Reserve Figure  in the Q2.2We established a sample line near Sanguanmiao, the core area of the reserve, where the panda density is known to be high and thus with a high number of panda scent marks . Urine marks cause a green bark with a musky smell, and AGS marks turn the bark brown. To determine if marked trees were repeatedly marked, each marked tree in the sample line was monitored every other week. The musky smell of urine marks disappeared after about 5 days, which allowed us to determine if the same area was repeatedly marked. For AGS marks, a small piece of bark was cut in the middle of the marked area, leaving out the light‐colored bark underneath, and it was monitored to see if it was again covered with AGS marks to determine if it was repeatedly marked , Yaupon pine (Pinus tabulaeformis), and Huashan pine , bamboo cover , and slope  were lower in marked plots than in control plots. However, tree density  and tree cover  were higher in marked plots than in control plots. Shrub density  and shrub cover  were not significantly different between both groups . DBH was greater in scent‐marked trees than in control trees, but the difference was not significant . Straight line distance from the tree to the center of the trail (SDT) was significantly shorter in marked trees than in control trees , DBH (p = .82), and SDT  and several other carnivore and ungulate species investigate bear smell on rubbing trees  was much higher than trees marked only once , but significant differences were not detected between the variables of either. We speculate that the more prominent position and wider field of view of repeatedly marked trees may also increase the chances of the signal being found by both other pandas and other species. Alternatively, these locations may be associated with other essential resources in the home range of the individual, making them more frequent in specific areas  also show similar sex differences in scent‐marking behaviors , whose perianal gland scent marks reflect their fertility  is influenced by the presence or absence of males, and it is worth exploring whether the same behavior occurs in pandas ; formal analysis ; writing – original draft . Ronald R. Swaisgood: Writing – review and editing . Wei Wei: Resources ; writing – review and editing . Hong Zhou: Writing – review and editing . Feiyun Yuan: Funding acquisition . Mingsheng Hong: Writing – review and editing . Han Han: Supervision ; writing – review and editing . Zejun Zhang: Supervision ; writing – review and editing .The authors declare no conflict of interest.Appendix S1.Click here for additional data file.


The COVID‐19 pandemic has had disproportionate impact on vulnerable populations including those with learning disabilities. Assessing the incidence and risk of death in such settings can improve the prevention of COVID‐19. We describe individuals who tested positive for SARS‐CoV‐2 while residing in care homes for learning disabilities and/or autism and investigate the risk of death compared with individuals living in their own homes.Surveillance records for COVID‐19 infections in England from 02 February 2020 to 31 March 2022 were extracted. Data on property type, variant wave, vaccination, hospitalisation and death were derived through data linkage and enrichment. Care home residents with learning disabilities and/or autism and diagnosed with COVID‐19 were identified and analysed, and logistic regression analyses compared the risk of death of individuals living in private residence. We assessed interaction parameters by post‐estimation analyses.A total of 3501 individuals were identified as diagnosed with SARS‐CoV‐2 whilst living in 632 care home properties for learning disabilities and/or autism. Of the 3686 episodes of infection, 80.4% were part of an outbreak. The crude case fatality rate was 2.6% and 0.6% among care home residents with autism and/or learning disabilities and their counterparts in households, respectively.The post‐estimation analyses found over eight times the odds of death among care home residents in 60 years old compared with their counterparts living in private homes.Care home residents with learning disabilities and/or autism have a greater risk of death from COVID‐19. Optimising guidance to meet their needs is of great importance. Residents in care homes are likely to have risk factors such as being of older age or having comorbidities, which make them vulnerable to severe COVID‐19 outcomes. Additionally, these settings are high risk for COVID‐19 transmission due to large household sizes and close contact with multiple carers. As such, attention has been focused on reducing the risk of transmission in the adult social care sector. However, much of the guidance has been geared towards care homes offering long‐term care to older people,Adults and children residing in care homes specialising in learning disabilities and/or autism experience intersections of risk; some may have underlying risk factors for severe COVID‐19 outcomes, while living in a care home setting where transmission of COVID‐19 is more likely. Existing societal inequalities can be amplified during outbreaks and pandemics, leading to increased vulnerability to infectious diseases. Previous studies highlight how COVID‐19 impacts people with learning disabilities and/or autism accessing healthcare and public health information.The risk of serious infection and death from COVID‐19 is likely to vary among people with learning disabilities, given the varied nature of these conditions and level of care required. A study conducted by Perera et al. on COVID‐19 deaths among people with intellectual disabilities in the United Kingdom and Ireland concluded that there is a need to stratify guidance based on the risk of severe outcomes so that appropriate levels of shielding can be applied.In this paper, we identify and describe individuals who tested positive for SARS‐CoV‐2 while residing in long‐term care facilities specialised in learning disabilities and/or autism. We investigated the risk of death among individuals in these settings compared with individuals living in their own homes.22.1The UK Health Security Agency (UKHSA) is responsible for collecting data on all notifications of COVID‐19 infection in England via the Second Generation Surveillance System (SGSS).2.2When booking tests or reporting COVID‐19 results, individuals are asked for the residential address of the person being tested. We enhanced residential addresses of all COVID‐19 episodes through geospatial address matching to obtain a Unique Property Reference Number (UPRN) and a Basic Land Property Unity (BLPU) class, which indicates the property type based on local authority permitted use.A BLPU class of RI01, a Care Quality Commission (CQC) ID indicating a care home, and/or addresses with a mention of ‘care home’ were used to identify individuals residing in care homes at the time of infection diagnosis. Individuals where the reinfection was not at the same property type were excluded from the analyses.To determine which cases were living in long‐term care facilities for learning disabilities and/or autism, we identified residential care settings (excluding shared living and positive lives settings) from the CQC list of providers where the sole service users were people with learning disabilities and/or autism. CQC is a statutory regulator that evaluates, inspects and regulates health and social care services in England.2.3All COVID‐19 episodes were linked to the UKHSA's Hospital‐Onset COVID (HOCOVID) dataset, which pulls daily feeds on hospitalised individuals with a positive SARS‐CoV‐2 test from the Secondary Uses Service and the Emergency Care Data Set to obtain information on hospital admissions.2.4The data were linked to the National Immunisation Management System that UKHSA uses to record COVID‐19 vaccination status for all individuals with a National Health Service (NHS) number in England.2.5Wild type: 02 February 2020–30 July 2020.Alpha: 31 July 2020–30 April 2021.Delta: 01 May 2021–30 November 2021.Omicron BA1: 01 December 2021–28 February 2022.Omicron BA2: 01 March 2022–31 March 2022.To account for the variants circulating at the time of infection, the following time periods were allocated as different waves of COVID‐19 variants throughout the study period and were calculated based on the earliest positive specimen date of the last episodeFurthermore, throughout the study period, access to testing varied. There was limited access to testing at the beginning of the pandemic when the wild variant was circulating.2.6Data for the collation of COVID‐19 death data are obtained from four sources: reporting from NHS hospitals via a dedicated COVID‐19 patient notification system; direct notification to UKHSA from local Health Protection Teams; NHS Demographic Batch Service tracing of COVID‐19 positive test data against the NHS Spine; ONS registered deaths with COVID‐19 mentioned on the death certificate. The COVID‐19 deaths dataset includes all deaths that occurred within 28 days of the earliest positive COVID‐19 test of the most recent COVID‐19 episode.2.7We first evaluated the total number of individuals who experience one or more SARS‐CoV‐2 infections while living in a care home for learning disabilities and or autism. Numbers of cases were observed over time, by age group and whether they were involved in an outbreak (two or more cases within 14 days of the previous case resident at the same UPRN).Both residential care home cases and individuals in private residential dwellings who have tested positive for COVID‐19 were described by age, sex, ethnicity, region, hospitalisation status and vaccination status.To evaluate the excess risk of death, univariable and multivariable logistic regression analysis, comparing the odds of death among of those living in residential care for service users with learning disabilities and/or autism who had tested positive for COVID‐19 with those with COVID‐19 cases living in a private residence, was evaluated.Age, sex, ethnicity, IMD, region, number of COVID‐19 hospitalisations , vaccination status, month and year of the episode, variant wave and the maximum number of episodes, which could act as confounders, were considered for regression adjustment in the final multivariable model.Three interaction parameters were assessed to identify the interaction between individuals with learning disabilities and living in a care home with the age group of COVID‐19 cases, with the variant wave and with the vaccination status. We calculated adjusted odds ratios using a post‐estimation analysis to estimate the odds of death among individuals with a learning disability and/or autism by age group and variant wave. We also conducted a sensitivity analysis evaluating the odds of death among unvaccinated during the period where wild type and alpha variants were dominant as there were a higher proportion of unvaccinated individuals during these periods.33.1From 02 February 2020 to 30 March 2022, a total of 3501 (0.02%) individuals' resident in a care home specialising in learning disabilities and/or autism tested positive for COVID‐19. During the same period, 15,403,464 (99.98%) cases in individuals living in a private residential dwelling were identified. Figure Of the 3501 care home residents with learning disabilities and/or autism, 3317 individuals had a single infection of SARS‐CoV‐2, while 183 individuals had a reinfection and 1 individual had three episodes, totalling to 3686 infections of which 5.0% were reinfections Table . A totalA total of 90 individuals living in care homes for autism and/or learning disabilities died compared with 92,352 living in residential dwellings leading to a crude CFR of 2.57% and 0.6%, respectively Table .Of the 3686 infections occurring in care homes for learning disabilities and/or autism, 2962 (80.4%) were part of an outbreak where two or more cases occurred at the same residential address within a 14‐day period compared with 8,689,178 (53.7%) among individuals living in private dwellings Table . The 296Most care home cases resided in a facility with 5–20 beds with 48% of cases and episodes occurring in care homes with 5–9 beds. The proportion of episodes involved in an outbreak increased with care home bed size Table . A sligh3.2The postestimation analysis found that the odds of death were 9.7 and 8.4 times greater among individuals <40 years old and 40–59 years old living in a care home for learning disabilities and/or autism compared with those living in a private setting in the same age groups, respectively  states that residential care for autistic adults should be provided in smaller community‐based units with no more than six residents per unit, which may explain the greater number of cases in smaller care homes in this study.In this study we evaluated the odds of death among individuals residing in a care home for people with learning disabilities and/or autism compared with those living in private dwellings as the recording of COVID‐19 deaths is a representative estimate among the two populations. However, although there was free access to community testing throughout the study period, care homes routinely tested both residents and staff members and therefore could have detected more cases, particularly cases with mild infection or asymptomatic, factors which could have reduced the estimated CFR.By observing different interactions, we found that individuals residing in a care home for learning disabilities and/or autism had a disproportionally increased risk of death, particularly among those 40 years old and younger where the odds of death was close to 10 times higher than age‐matched counterparts living in their own home. This concurs with previous research that used different methods for identifying cases with learning disabilities.Upon reviewing the interaction of variant waves on the risk of death, a significant difference was only observed during the alpha wave where the risk of death was nearly twice as high among those residing in a care home specialising in learning disabilities and/or autism versus those living in private dwellings. The first two waves of the COVID‐19 pandemic had a substantial impact on elderly people living in care homes specialising in disabilities and/or autism where high numbers of death occurred, most likely due to the limited knowledge on COVID‐19 at the time, high transmission through frequent close contact, no vaccination available and shortages in masks and personal protective equipment for carers. Changes in adult social care guidance, the introduction of COVID‐19 vaccines and the varying disease severity with each variant may have resulted in the insignificant odds of death between those living in care homes for learning disabilities and/or autism and individuals in residential dwellings in following waves of infection.Furthermore, individuals living in care homes for learning disabilities and/or autism that were unvaccinated or with an unknown vaccination status had four times the odds of death compared with those unvaccinated or with unknown vaccination status living in residential dwellings. This was also observed during the wild type and alpha variant waves when vaccinations were either not available or the first vaccinations were being rolled out in England. The odds of death among vaccinated individuals were not significantly different for those with learning disabilities and/or autism in care homes versus their counterparts residing in residential settings, thus indicating that the vaccination programme may have helped reduce inequities in the burden of disease.To evaluate cases living in care homes specialising in learning disabilities and/or autism, we used the CQC register of regulated facilities. It is possible that some care homes have been missed due to information on the CQC website being out of date due to changing care facilities. It was necessary to only include care homes with the single service users of individuals with learning disabilities and/or autism; therefore, this study cannot draw conclusions for those living in care homes serving multiple service user types. Furthermore, in these analyses we only analyse individuals that had a single infection or where the reinfection was at the same property type. Any cases that may have lived in both a care home and private residence throughout the study period would not have been included; however, the impact of this is likely to be minimal due to the small number of cases living in these two settings, which accounts for approximately 5% of care home infections.Our study does have some further limitations. Deaths reported by ONS or NHS England without a test result or with a test result that did not match to the line list of COVID19 patients were unable to be linked to receive information on their type of residence and were therefore not included in the analyses. It is likely that these individuals are more likely to have resided in residential dwellings due to increased testing in care home facilities, which may overestimate the odds of death. That being said, a CQC report indicated a total of 195 deaths COVID‐19 deaths between 2019 and 2020 among individuals with learning disabilities of whom some may be autistic and where learning disability was indicated on the death notification form.Due to the nature of the data, we were unable to identify learning disabilities and/or autism at the individual case level; therefore, we could not compare individuals with such disabilities living in private homes and institutional settings. Further linkage to datasets, such as GP records would be useful to further identify individuals and compare the risk of COVID‐19 among individuals across various property types. Finally, further information on the severity of learning disability of the cases to stratify risk within these residences would be of value.Previous studies show that there remains a significant gap on where people with learning disabilities reside in any health records. Evidence generation of the impact of COVID‐19 on those with learning disabilities and/or autism in England, by initiatives such as the Learning Disabilities Mortality Review and OpenSAFELY, have emphasised that people living with learning disabilities and/or autism experience risk differently based on several factors, including type of residence.Our study adds value to understanding the necessity of rapid infection control in specialised care homes in order to reduce COVID‐19 infection and mortality. The novel approach of linking address information from cases to obtain information on property types could in future help identify cases and clusters of COVID‐19 and any other disease for more rapid public health evaluation. Our study indicates that individuals residing in a care home for learning disabilities and/or autism have experienced greater risk of death from COVID‐19 compared with individuals living in private residences. However, risk is not uniform and factors influencing risk must be considered when designing accessible public health guidance, vaccination and healthcare to better protect this population from COVID‐19.Elise Tessier: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; validation; visualization; writing–original draft; writing–review and editing. Harriet Webster: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; validation; visualization; writing–original draft; writing–review and editing. Nurin Abdul Aziz: Conceptualization; investigation; methodology; formal analysis; validation; visualization; writing–original draft; writing–review and editing. Joe Flannagan: Conceptualization; investigation; methodology; project administration; resources; writing–review and editing. Asad Zaidi: Conceptualization; data curation; formal analysis; software; visualization; writing–review and editing. Andre Charlett: Formal analysis; investigation; methodology; software; validation; visualization; writing–review and editing. Gavin Dabrera: Conceptualization; investigation; methodology; project administration; supervision; writing–original draft; writing–review and editing. Theresa Lamagni: Conceptualization; project administration; supervision; writing–original draft; writing–review and editing.We declare no conflicts of interest.https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/irv.13139.The peer review history for this article is available at Table S1. The total number of care home cases and controls testing positive for SARS‐CoV‐2 by age, sex, ethnicity, region, number of beds within a care home, hospitalisation status, death by 28 days, and vaccination status in England from 02 February 2020 to 31 March 2022.Click here for additional data file.Table S2. Total number of care home cases and episodes that were part of an outbreak in England from 02 February 2020 to 31 March 2022.Click here for additional data file.


Between 17 and 19 November 2022, under the auspices of the Italian Society of Sports Cardiology (SIC Sport), the first international congress of SIC sport entitled “Sport and Heart ‐ From science to clinical practice ‐ First International Congress on sport cardiology” was held in Rome. The conference was held under the direction of the Chairman Professor Luigi Sciarra, president of the SIC Sport. The congress offered a unique opportunity to delve deeper into the interrelationship between sport and cardiology issues by bringing together leading academics, experienced clinicians, and marketing industry experts. Given the growing interest in sport cardiology, this special issue wants to highlight some of the main topics covered over the course of the 3 days. Even though the first records of academic interest toward physical activity date back to the fifth century BC, with the father of sport medicine Herodicus, it wasn't until the 1970s that sport cardiology developed into a specialty of its own.The International Sport Cardiology Congress covered a wide range of new challenges currently being faced by the medical community, such as how to gather the stock of existing cardiovascular preparticipation screening (PPS) and the integrated policy approaches that have been put into practice in Italy and throughout Europe.Professor Christopher Cannon, from Harvard Medical School, opened the Congress with his magisterial lecture on “Cardiovascular risk and physical activity in the Third Millennium”; providing the modern concept of physical exercise as an appropriate therapy that should be prescribed to reduce cardiovascular risk in many clinical settings. In healthy population groups, moderate to vigorous physical activity was associated with longer life expectancy,Going straight to the heart of the conference, challenging clinical scenarios in athletes were discussed as congenital heart diseases or acquired cardiac diseases and the possibilities and risks concerning competitive sports participation. The invited speakers suggested replacing the binary yes‐or‐no eligibility in sports with a more nuanced approach, using a large amount of data from the studies. This emerging updated information demonstrates the risk of some cardiac conditions seems to be lower than previously projected. Fundamentally, it appears mandatory to reduce the risk of sudden cardiac death (SCD) while simultaneously avoiding unnecessary sports restrictions. For these reasons, the PPS for cardiovascular diseases carried out before any physical activity is crucial and in this field, Italy has shown up to have a leading history, since 1982 until our days.An entire session was dedicated to discussing the European Union Recovery and Resilience Plan: a wide‐ranging response aimed at mitigating the economic and social impact of the coronavirus pandemic and making European economies and societies better geared to future challenges. During this session, a cross‐country analysis highlighted a range of interrelated areas such as “Investing in digital health literacy” to assess Health Resilience.The conference also dealt with topics like telemedicine, which has become an integral component of everyday clinical practice for patients with cardiovascular diseases, as well as rapid advances in wearable technologies and real‐time monitoring, which offer practical applications for medical and preventive support in dealing with athletes' care. Medical technology industry representatives at the conference highlighted the importance of the latter, wearables and real‐time monitoring, as the key areas for synergies between practitioners and Med‐Tech.In conclusion, sport cardiology is a rapidly evolving discipline. This congress has represented a small step forward toward a better understanding of how recommendations are likely to change at an increasingly fast pace, too. The time has come to adopt the notion of individualized medicine in sport cardiology. One that promotes safety, without unnecessary limitations for the athlete, through a patient‐centered approach and shared decision‐making.


Co‐trimoxazole prophylaxis is recommended for children born to women with HIV to protect those who acquire HIV from opportunistic infections, severe bacterial infections and malaria. With scale‐up of maternal antiretroviral therapy, most children remain HIV‐exposed uninfected (HEU) and the benefits of universal co‐trimoxazole are uncertain. We assessed the effect of co‐trimoxazole on mortality and morbidity of children who are HEU.We performed a systematic review (PROSPERO number: CRD42021215059). We systematically searched MEDLINE, Embase, Cochrane CENTRAL, Global Health, CINAHL Plus, Africa‐Wide Information, SciELO and WHO Global Index Medicus for peer‐reviewed articles from inception to 4th January 2022 without limits. Ongoing randomized controlled trials (RCTs) were identified through registries. We included RCTs reporting mortality or morbidity in children who are HEU receiving co‐trimoxazole versus no prophylaxis/placebo. The risk of bias was assessed using the Cochrane 2.0 tool. Data were summarized using narrative synthesis and findings were stratified by malaria endemicity.We screened 1257 records and included seven reports from four RCTs. Two trials from Botswana and South Africa of 4067 children who are HEU found no difference in mortality or infectious morbidity in children randomized to co‐trimoxazole prophylaxis started at 2–6 weeks of age compared to those randomized to placebo or no treatment, although event rates were low. Sub‐studies found that antimicrobial resistance was higher in infants receiving co‐trimoxazole. Two trials in Uganda investigating prolonged co‐trimoxazole after breastfeeding cessation showed protection against malaria but no other morbidity or mortality differences. All trials had some concerns or a high risk of bias, which limited the certainty of evidence.Studies show no clinical benefit of co‐trimoxazole prophylaxis in children who are HEU, except to prevent malaria. Potential harms were identified for co‐trimoxazole prophylaxis leading to antimicrobial resistance. The trials in non‐malarial regions were conducted in populations with low mortality potentially reducing generalizability to other settings.In low‐mortality settings with few HIV transmissions and well‐performing early infant diagnosis and treatment programmes, universal co‐trimoxazole may not be required. However, despite this marked progress, there were an estimated 150,000 new HIV infections among children in 2020 . Co‐trimIn 2000, the World Health Organization (WHO) first recommended the use of co‐trimoxazole for infants born to women with HIV in sub‐Saharan Africa, regardless of infant HIV status . This reHowever, since the majority of children exposed to HIV now remain uninfected , 13, it 22.1This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta‐Analyses (PRISMA) guidelines and the search strategy was pre‐registered on the International Prospective Register of Systemic Reviews  Appendix .2.2We systematically searched OvidSP MEDLINE, OvidSP Embase, Wiley Cochrane CENTRAL Database , OvidSP Global Health, Ebsco CINAHL Plus, Ebsco Africa‐Wide Information, SciELO and WHO Global Index Medicus. Our original search was from inception to 27th January 2021 without language limits; the search was repeated on 4th January 2022 and these updated results are presented. We also searched for ongoing randomized controlled trials (RCTs) through clinicaltrials.gov and the WHO International Clinical Trials Registry Platform and for relevant conference abstracts from the International AIDS Society, the International Workshop on HIV & Pediatrics, the Workshop on Children and Adolescents with Perinatal HIV Exposure, and the Conference on Retroviruses and Opportunistic Infections from the past 5 years. Reference lists of eligible studies and review articles were hand‐searched and selected experts in the field were contacted to identify any additional unpublished research. The full search strategy is shown in Appendix We included RCTs that examined the use of co‐trimoxazole prophylaxis given at any dose, duration, frequency or formulation (intervention) compared to placebo or no treatment (control) among children who are HEU , tuberculosis, malaria, toxoplasmosis and other parasitic infections, severe bacterial infections; (4) treatment‐related adverse events and serious adverse events ; (5) child growth and development; or (6) antimicrobial resistance and microbiome. Studies were limited to humans. We excluded studies that examined children with HIV or with unknown HIV status.Inclusion criteria: trials had to be published in a peer‐reviewed journal and examine one or more of the following outcomes, separately or as a composite: (1) all‐cause mortality; (2) all‐cause hospitalization; (3) infectious morbidity, including but not limited to diarrhoea, pneumonia, Citations from all databases were transferred to EndNote and de‐duplicated separately by two authors (CJW and CE), who then screened the remaining titles and abstracts independently for inclusion; any conflicts in article selection were resolved through mutual discussion. Full‐text articles were obtained for all selected abstracts meeting the eligibility criteria and two reviewers (CJW and CE) assessed each full‐text article for eligibility to determine the final study selection. Differences were resolved through a third reviewer (AJP).2.3Study characteristics and data including population demographics, intervention, follow‐up and pre‐specified outcomes were extracted from studies meeting the inclusion criteria independently by two reviewers (CJW and CE). Study investigators were contacted for unreported data and additional details where necessary. The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias 2.0 tool  by the s2.4χ2 and I2 statistics, and publication bias using a funnel plot where there were at least five trials.We first performed a narrative synthesis of data from eligible studies. Data were displayed by outcome measure; measures of effect were included as reported by the individual studies. Crude and adjusted results were included using the adjustments outlined in each study. Outcomes were assessed as they had been analysed using intention‐to‐treat principles. We stratified by age at randomization as per the primary and secondary research questions and by malaria endemicity . Where there were studies reporting the same outcomes with the same hypotheses, we planned to do a random‐effects meta‐analysis. We planned to assess statistical heterogeneity using the 2.5The GRADE approach was used to assess the overall quality of evidence and recommendations of the systematic review . GRADE t33.1n = 1177) and trial registers (n = 80). After removing duplicates and screening for exclusions  considered whether co‐trimoxazole was superior to placebo, starting from 14 to 34 days of age and continuing to 15 months of age. Mortality was assessed up to 18 months. Among the 20% of breastfed children, this trial had a second randomization to either 6 or 12 months of breastfeeding. The South African trial  and n = 63 [South Africa]) but sample selection criteria were unclear. Finally, none of the studies in Uganda were blinded with potential for detection bias and there were concerns over selection and attrition bias in one . ALS is supported by the Fogarty International Center of the National Institutes of Health under award number 1K43TW010683.Supporting informationClick here for additional data file.


We report a 20‐year‐old man with neurofibromatosis type 1 presenting with frequent episodes of suprapubic pain. The episodes started 6 months ago, occurred 1 h a day, and were not related to urination. A prostate‐sparing cystectomy with orthotopic diversion was performed. Histopathological assessment of the specimen confirmed bladder plexiform neurofibromatosis.  The altered gene products play a role in the dysregulation of tumor suppression. Neurofibromatosis type 1 (NF1), neurofibromatosis type 2, and schwannomatosis are three types of the disease, which differ regarding the age of onset, clinical manifestations, and gene loci.NF1, also known as von Recklinghausen disease, is the peripheral type of the disease affecting several systems in the body. It manifests at birth or early childhood with classic symptoms of multiple hyperpigmented (café‐au‐lait) macules, intertriginous freckling, cutaneous neurofibromas, and varying levels of cognitive impairment. Although NF1 is mainly inherited as an autosomal dominant pattern, sporadic mutational change is also frequent.Regarding the very rare nature of bladder involvement in NF1 and the lack of sufficient data about its diagnostic and treatment approaches, formulating the diagnosis in the first place, and providing accordant management is of great importance. Therefore, this case report aims to lead the audience's mind toward bladder involvement as one of the rare but important complications of NF1, to be able to take timely relevant measures. Herein we report a case of NF1 with diffused bladder involvement in a 20‐year‐old man who presented with frequent episodes of suprapubic pain but did not complain of any urinary symptoms.2A 20‐year‐old man was referred to the department of Urology, affiliated with Isfahan University of Medical Sciences, complaining of frequent episodes of suprapubic pain. The pain episodes had started 6 months ago, occurred once a day, lasted approximately 1 h, were accompanied by nausea and constipation, and were not related to urination. He denied any lower urinary tract symptoms (LUTS), gross hematuria, or significant weight loss since the beginning of the symptoms.The patient had a past medical history of sporadic neurofibromatosis with no positive family history. He had previously undergone outpatient surgical removal of some of the cutaneous neurofibromatosis tumors on the forearm and back Figure , as wellA physical exam noted an overweight individual compatible with his age. All of the vital signs were within the normal range. There was mild tenderness in the suprapubic region and various café‐au‐lait lesions were observed on the abdomen, feet, shoulder, and forearms Figure . Other sA multi‐detector computed tomography (MDCT) of the abdomen and pelvis with contrast medium injection was performed to further investigate the cause of the chronic suprapubic pain. The results revealed diffused bladder wall thickening, as well as a high attenuated lobular marginated mass in size of 83*76 mm involving the superior and posterior parts of the bladder protruding into the lumen and causing a pressure effect Figure .Since the patient had previously experienced visceral neurofibroma, bladder neurofibroma was considered our first differential diagnosis; however, other bladder tumors could not be ruled out without histopathological confirmation.A pre‐operative biopsy for detecting the tumor type was not indicated since tumor excision was necessary due to the significant impact of chronic pain on the patient's quality of life. Given the tumor's large size, an open laparotomy approach was conducted in order to excise the tumor and investigate other adjacent structures. Under general anesthesia, in the supine position, the bladder was approached by a mid‐line sub‐periumbilical laparotomy. After resecting the adjacent fascia, a large mass with invasion to the dome, trigone, and posterior part of the bladder was detected. In addition, the bladder appeared deformed and tumorous with several adhesions to the rectum and peri‐vesical fat; therefore, resection of the primary tumor alone did not seem to be effective, and we intended to perform a prostate‐sparing cystectomy along with orthotopic urinary diversion, using approximately 60 cm of the ileum with proper vascular base.The resected specimen was sent to the pathology department. Macroscopic evaluation demonstrated a urinary bladder measuring 14*8*4.5 cm on the external surface containing serosal and muscular walls and multiple masses with the largest diameter of 2 cm Figure . HistopaThe postoperative course was uneventful and the patient was discharged 5 days later in good general condition. On an outpatient follow‐up visit after 6 months, the pain was completely resolved and he did not complain of any urinary symptoms.3Bladder involvement in NF1 is very rare and mostly affects the age group of 7 to 28 yearsClinical manifestations are often associated with the mass effect and include irritative LUTS, hematuria, and recurrent urinary tract infection.No definitive criteria have been established for diagnosing bladder neurofibromatosis; however, the diagnosis is initially formed based on clinical and radiological findings and later confirmed by histopathology. Both magnetic resonance imaging (MRI) and CT‐scan could be used to identify the tumor. Data regarding the representative radiological findings is scares. Castillo et al. described bladder wall thickening as the most distinctive radiological feature.MRI is believed to be the imaging of choice, especially in cases of abdomino‐pelvic involvement. It is superior to CT‐scan regarding its ability in distinguishing benign and malignant lesion as well as identifying small neurofibromas with rather atypical features.Histopathologically, bladder involvement usually exhibits diffuse proliferation of uniform neurofibromas containing multiple nests of medium‐sized spindle cells with elongated wavy nuclei and myxoid stroma. In addition, mast cells could be present in small numbers within the stroma.In general, there is a 30% chance that a neurofibroma would undergo malignant degenerationRegarding the variable clinical manifestations and the difference in severity and type of bladder involvement, every patient must be approached individually in terms of management modalities. Surgical excision of the tumor seems to be the most adopted method.In conclusion, contrary to the majority of the literature, the distinguishing feature of our case was the absence of any urinary symptoms despite the great occupation of the bladder. One should always rule out malignancy in cases of bladder involvement. This article emphasizes the importance of timely identification of bladder neurofibromatosis and having a holistic vision while choosing the appropriate management option.The presented figures have been created by the authors who confirm that they are original and not copied from elsewhere.Saina Paymannejad: Investigation; validation; visualization; writing – original draft; writing – review and editing. Pardis Rafei Dehkordi: Investigation; methodology; project administration; visualization; writing – original draft. Reza Kazemi: Conceptualization; methodology; project administration; resources; supervision.The authors would like to express their gratitude to the study patient who signed written consent for publishing this information.This report did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Paternal mental health in pregnancy and postpartum has been increasingly highlighted as important both in its own right, but also as crucial for the development of children. Rates of help‐seeking among fathers is low, possibly due to conceptualising their own difficulties as stress rather than problems with mood. The relationship between paternal stress and child outcomes has not been investigated.This study used data from the Finnish CHILD‐SLEEP birth cohort. Data were available for 901 fathers and 939 mothers who completed questionnaires on demographics, stress, anxiety and depression at 32 weeks gestation, 3 months, 8 months and 24 months postpartum. Parental report of child emotional and behavioural problems was collected at 24 months.Around 7% of fathers experienced high stress (over 90% percentile) at each timepoint measured in the perinatal period, rising to 10% at 2 years postpartum. Paternal stress measured antenatally, at 3 and 24 months was associated with child total problems at 24 months, while paternal depression and anxiety were not related to child outcomes when in the same model. After adjusting for concurrent maternal depression, anxiety and stress, an association remained between paternal stress at each timepoint and child total problem scores at 24 months. The strongest association was with paternal stress at 3 months . There were stronger relationships between paternal stress and boys' rather than girls' total problem scores, although the interactions were not statistically significant.Paternal stress is an important manifestation of perinatal distress and is related to child mental health, particularly when present in the early postpartum months. Paternal stress should therefore be assessed in the perinatal period, which presents opportunities for early intervention and prevention of difficulties for both father and child. The transition to parenthood can be difficult for parents and the exacerbation or onset of mental health problems are common in men and women. While the impact of maternal perinatal  mental health problems on children is well researched , monthly income after taxes , number of other children in the family (‘0’ vs. ‘1’ vs. ‘two or more’) and smoking during pregnancy  were asked as part of the prenatal questionnaire. Birthweight, sex and birth date of the index child were collected from the hospital registers and information on daycare use was collected postnatally.For all standard scales up to 20% missing items were permitted, and missing items were replaced with the scale mean. The cut‐offs were defined based on prenatal timepoint and the same cut‐offs were used for each measurement point. The same cutoffs were used at all points for mothers and fathers.In the last month, how often have you felt that you were unable to control the important things in your life?In the last month, how often have you felt confident about your ability to handle your personal problems? (reverse coded)In the last month, how often have you felt that things were going your way? (reverse coded)In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?In the last month, how often have you felt ‘stressed’?Stress was measured by a 5‐item version of the Perceived Stress Scale  to indicate increased anxiousness  was used to assess children's social‐ and emotional problems as well as competencies  and comprises subscales of externalising  and internalising problems  as well as items concerning dysregulation, maladaptive and atypical behaviours. Sum scores were calculated by adding the items together; higher problem scores indicate higher risk for social–emotional problems. The cut‐off ≥14 for the total problem scale was selected based on Finnish and international studies . Mothers that were more stressed, depressed or anxious antenatally were more likely to drop‐out at 24 months (p < .01), while among fathers none of these measures were associated with non‐participation at 24 months (p > .10). For the 939 children included in the present study, there were 901 fathers and 939 mothers with at least some relevant data available for the present analyses; using listwise deletion valid N varied in the analyses according to the measure and timepoint  focus on clinically meaningful scores according to the study question and (ii) to avoid violations in normality assumptions related to linear models. Separate analyses were conducted for the four timepoints. The analyses were adjusted first for (a) child's age, sex, birth weight, paternal age, education, number of other children in the family, and then in addition also for (b) concurrent paternal stress, depression and anxiety .In order to investigate whether paternal stress had an independent association with children's emotional problems over and above maternal contributions, we adjusted the logistic regression analyses of paternal stress for (a) concurrent maternal stress  and then also for (b) concurrent maternal depression and anxiety at each time‐point. These analyses were conducted for the total sample and for boys and girls separately. Interactions with paternal stress and child sex were investigated in terms of BITSEA total, externalising and internalising problems in logistic regression. These analyses were adjusted for child's age, sex, birth weight, paternal age, education and number of other children in the family.In a logistic regression model, we analysed the relative importance of father's stress at the four timepoints when predicting child's elevated BITSEA total score and calculated the correlations between the four stress measures. We constructed classes of comorbidities from father's distress measures and cross‐tabulated these against child's elevated BITSEA total score. Finally, we ran a stepwise logistic regression model  with all father's and mother's distress variables from all four timepoints and all background variables as candidate predictors of child's elevated BITSEA total score at 24 months.Table The sample of children were 52.9% male and 48.7% were not in daycare , at 3 months (OR 2.47) and 24 months (OR 2.41) was significantly associated with child problems at 24 months  first for maternal stress and then also with mother's anxiety and depression Table . Paternap > .05) at all timepoints.In terms of subscales with all factors adjusted for, there were no significant associations between paternal stress and externalising problems, but paternal stress scores at 3 months (OR 2.65) were independently associated with child internalising problems. In the fully adjusted models, paternal stress measured in pregnancy, at 3 and 24 months was associated with total problem scores in boys, but only at 8 months in girls , but sensitivity analyses showed that this did not affect the results. However, while there was comorbidity between stress, depression and anxiety, our data indicated that father's stress has an independent role  relative to child emotional symptoms at 24 months.Child data were from parent report which may have introduced bias, although regarding the father, the risk of bias was reduced as parental report on the child was by the mother alone (in 69% of the cases) or mother and father together (30%). The associations between child problems and parental distress may also be reciprocal, particularly at later timepoints, which should be kept in mind when interpreting the results. However, prenatally reported stress scores are independent of the child's behaviour. Moreover, some shared variance is related to persistent stress (i.e. the correlations across the timepoints). It is possible that there are genetic factors influencing the associations, and the expression of distress in both child and parent, which this study did not measure. It was not possible to conduct clinical interviews to establish levels of distress or child symptoms.One of the most compelling of our results was the robust effect of paternal stress over and above paternal depression and anxiety. This emphasises and further elaborates the idea that for a father it is not necessarily mood symptoms that should be targeted for screening in the perinatal period. Furthermore, we also found that paternal stress had an independent effect on child's emotional problems after accounting for maternal stress, depression and anxiety. This result is especially interesting given our earlier findings suggesting that maternal, not paternal depression is of importance in relation to child's emotional problems  between father's stress measures from the four timepoints.Table S3. Percentages of children with elevated BITSEA total score at 24 months by comorbidities of father's stress, depression and anxiety at different timepoints.Table S4. (a) Results from a stepwise  logistic regression model with all father’s and mother’s distress variables from all four timepoints and all background variables as candidate predictors to be selected to the model predicting child’s elevated BITSEA total score at 24 months. Selected variables to the model in each step. (b) Results from a stepwise  logistic regression model (see Table S4a). Variables not entered to the model after final step (step 2).Click here for additional data file.


Castalia ambigua in relation to combinations of two co‐occurring different morphotypes (Morphotype I with an elongated shell and Morphotype II with a rounded shell), and three different densities . Horizontal movements (cm) were calculated by summing changes in the position of each specimen and the shell exposure at the sediment–water interface was obtained by measuring (mm) the exposed part of the shell. Castalia ambigua presented different patterns of shell exposure and horizontal movements linked with shell shape and density. Castalia ambigua Morphotype I remained less exposed with 4 mussels. In contrast, this morphotype was more exposed and tended to aggregate in treatments with 8 and 16 mussels, similar to observations of Morphotype II at all densities. Morphotype II is mainly found in low hydrodynamic energy habitats, suggesting that patches with high densities may stabilize the substrate around the shells of Morphotype I, which is associated with high hydrodynamic energy habitats. We suggest that these patterns may be associated with intrinsic factors of the species, such as reproduction, sexual dimorphism and feeding. Moreover, additional studies using other mussel species belonging to the families Hyriidae and Mycetopodidae are important, since the behavior of these mussels in the sediment may provide useful information on their functional roles in river ecosystems.Information on freshwater mussel behavior in the sediment is scarce worldwide, especially in the Amazon. Laboratory experiments were used to measure the responses of the single mussel species  Castalia ambigua to density in the two morphotypes: the morphotype associated with high hydrodynamics is more exposed and with higher mussel densities and the morphotype associated with low hydrodynamic energy is more exposed at all densities. We suggest that higher densities may provide stability and allow greater exposure even in high hydrodynamic energy habitats.Our results suggest a differential response in movement and shell exposure of the freshwater mussel  All mussels were placed in a container with a sediment layer and water from their habitat in the Caeté River, transported to the laboratory and maintained in aerated aquarium.We collected the specimens of n Figure , we colle et al. , which r2.2Prior to the experiments, we cultivated microalgae in the laboratory as food for the mussels, using a liquid NPK  gardening supplement, which resulted in excellent microalgal growth . Three microcosms (replicates) were maintained simultaneously for each combination of morphotype and density: for example, three microcosms for MI with D4, and so on. All microcosms were maintained for 6 days, with three observations made on days two, four, and six. A total of 81 observations (9 combinations × 3 replicates × 3 days of observations) were obtained for the experiment, similar to that obtained by Allen and Vaughn  were calculated by summing changes in the position of each mussel, using 5 × 5 cm grids that were placed over the microcosms without touching the water. The average values of shell exposure at the sediment–water interface were estimated by measuring (mm) the exposed part of each mussel shell using a caliper (precision of 0.05 mm).2.3C. ambigua varied between the three mussel densities and among the two morphotypes. The treatments Morphotype  and Density  were used as fixed effects. The random effect was included with the factor Replicate (n = 3 replicates) nested in the factor Day  as a repeated measure. Mixed‐effects models provide a flexible and powerful tool for modeling the within‐group correlation often present in repeated measures data . In this combination, all mussels remained with only the posterior margin above the sediment. Burrowing is an important behavioral response of many mussel species to persist during periods of high flow . In these combinations, we observed more horizontal movements and a tendency for aggregation  were males. In contrast, specimens with rounded anterior–posterior margins and laterally inflated shells (Morphotype II) were females. We did not identify the sex of the mussel specimens used in this study because we returned them to their original habitat, since populations of C. ambigua are drastically declining in the Caeté River ; investigation ; methodology ; writing – original draft (lead); writing – review and editing . Diego Simeone: Conceptualization ; investigation ; methodology ; writing – review and editing . Colin Robert Beasley: Conceptualization ; formal analysis (lead); methodology ; writing – review and editing .This project did not receive any funding for the research itself.The authors declare that they have no conflicts or financial interest.