In contrast-enhanced abdominopelvic CT (CE-APCT) for oncologic follow-up, ultrahigh-resolution CT (UHRCT) may improve depiction of fine lesions and low-dose scans are desirable for minimizing the potential adverse effects by ionizing radiation. We compared image quality and radiologists’ acceptance of model-based iterative (MBIR) and deep learning (DLR) reconstructions of low-dose CE-APCT by UHRCT.vol: 4.2 ± 1.6 mGy) by UHRCT. We used paired t-test to compare objective noise and contrast-to-noise ratio (CNR) and Wilcoxon signed-rank test to compare radiologists’ subjective acceptance regarding noise, image texture and appearance, and diagnostic confidence between MBIR and DLR using our routine protocol  for reference.Using our high-resolution (matrix size: 1024) and low-dose  protocol, we scanned phantoms to compare the modulation transfer function and noise power spectrum between MBIR and DLR and assessed findings in 36 consecutive patients who underwent CE-APCT . Compared with the routine protocol, subjective noise was similar or better by DLR, and other subjective characteristics were similar or worse by MBIR.Phantom studies demonstrated higher spatial resolution and lower low-frequency noise by DLR than MBIR at equal doses. Clinical studies indicated significantly worse objective noise, CNR, and subjective noise by DLR than MBIR, but other subjective characteristics were better (Image quality, except regarding noise characteristics, and acceptance by radiologists were better by DLR than MBIR in low-dose CE-APCT by UHRCT. Since March 2017, our institution has employed an ultrahigh-resolution computed tomography (UHRCT) scanner to improve the in- and through-plane spatial resolution of CT images. The clinical utility of UHRCT has been shown in CT examinations of the temporal bone, chest, and Adamkiewicz artery and virtual bronchoscopy and coronary angiography . HoweverTo overcome these potential limitations, deep learning (DLR) and model-based iterative (MBIR) reconstruction techniques have become clinically available for use in combination with UHRCT . MBIR isWe therefore undertook phantom and clinical pilot studies by UHRCT to compare findings between MBIR and DLR in CE-APCT for oncologic follow-up obtained utilizing a high-resolution and LD (HR & LD) protocol using our routine protocol as reference. We evaluated the image quality and radiologists’ acceptance of MBIR and DLR and attempted to determine the appropriate HR & LD protocol that would yield the least radiation exposure.In this study, we mainly aimed to (1) determine the HR & LD protocol with MBIR and/or DLR to achieve the lowest radiation dose and the similar low-frequency noise to that using the routine protocol in the phantom study and (2) assess validity of this HR & LD protocol based on image quality and radiologists’ acceptance using the routine protocol as reference in the clinical pilot study.Our institutional review board approved this clinical study, and we obtained written informed consent from all patients.We assessed spatial resolution by the task-based modulation transfer function (TTF) using a quality assurance phantom  that included inserts of various materials to provide different levels of image contrast . We focused on the acrylic insert of the lowest positive contrast, almost equivalent to the contrast between soft tissue and fat attenuations, for oncologic follow-up by CE-APCT. To assess image noise characteristics by the noise power spectrum (NPS), we utilized an original abdomen phantom comprising an elliptical cylinder  made of epoxy-based and polyurethane resin   for each protocol recorded as a dose report.We performed helical scanning of the 2 phantoms with a UHRCT scanner  using automatic exposure control (AEC) and parameters for our routine and HR & LD protocols, which are summarized in Table We reconstructed the phantom images using a standard kernel (FC03) and an HIR algorithm  for those acquired with the routine protocol and using an MBIR algorithm  and a DLR algorithm  for those acquired with the HR & LD protocol. Table For the DLR, as shown in Fig. http://www.jsct-tech.org/; Excel 2016, Microsoft). On an axial image of the acrylic insert in the quality assurance phantom, we radially acquired and averaged profile curves crossing the circular edge to obtain its edge-spread function. TTF was calculated by Fourier transformation using line-spread function obtained by differentiating the edge-spread function to assess the intermediate-contrast in-plane spatial resolution with non-linear algorithms, such as HIR, MBIR, and DLR, at various noise levels. Our method to determine NPS in the epoxy-based resin part is described elsewhere . In our study, noisier UHRCT images probably enhanced these benefits by DLR. In contrast, spatial resolution by MBIR is easily degraded in low-dose and/or low-contrast situations [Reporting clinical study findings, Akagi and colleagues  observedelvic CT . We firs 18 mGy) , 23. Thi 18 mGy) , 25. Pregorithms , 26–35. Our study was limited as follows. In the phantom study, we assessed TTF only using the single intermediate contrast, almost equivalent to image contrast between attenuations of soft tissue lesions  and intra- and retroperitoneal fat, instead of multiple contrasts including a low contrast for metastases within solid organs. In the clinical study, it included only a small study population at a single institution, and the smaller BW and BMI of our Japanese patients compared with those of average-sized patients in Western countries may have affected our findings. In addition, we assessed only image quality in CE-APCT but did not examine lesion delineation or diagnostic performance. Further studies to assess the clinical usefulness of our results should include examination of lesion delineation and diagnostic performance in a larger cohort at multiple institutions.vol: approximately 4 mGy) by UHRCT, DLR yields better image qualities, with the exception of noise characteristics, and greater acceptance by radiologists than the use of MBIR. Particularly, lower low-frequency noise is likely to produce less coarseness of image texture and better acceptance by radiologists at the low dose by DLR than by MBIR.In CE-APCT at a low dose (CTDI


According to the social cognitive theory, social support and self-efficacy may interact with each other i.e. compete or account jointly for better adaptation. This study examined the nature of the interaction between coping self-efficacy and received social support in daily lives of patient-caregiver dyads after cancer treatment. We tested whether the effect of daily fluctuations in coping self-efficacy and received support on daily affect was synergistic (positive jointed effect), compensatory (positive competing effect), or interference (negative competing effect).A dyadic daily-diary study conducted for 28 days after hospital discharge following hematopoietic cell transplantation.Coping self-efficacy, received support, and positive and negative affect were measured in 200 patient-caregiver dyads. The analysis was based on the actor-partner interdependence moderation model using multilevel structural equation modeling.Statistically significant effect of interaction between daily coping self-efficacy and received support on negative affect was found, although only in the caregivers. In that group, higher daily received support compensated for lower daily coping self-efficacy but had a negative effect when coping self-efficacy was significantly higher than typical. Also, direct beneficial effects of higher daily coping self-efficacy and received support on caregiver positive affect were found. In the patients, higher daily coping self-efficacy was directly associated with better daily affect.Diverse effects of daily coping self-efficacy and received social support were found—the interference effect in the caregivers and the main effect of coping self-efficacy in the patients. Higher daily coping self-efficacy and optimal received social support may provide resilience against affect disturbance after cancer treatment. Adaptation to a chronic disease is a complex process involving numerous factors which fluctuate over time . UndoubtAs far as individual resources are concerned, self-efficacy beliefs have often attracted the attention of the researchers. Both, perceived (i.e. the perceived capability to manage one’s functioning) and coping self-efficacy  are central components of self-evaluation, which—according to the social cognitive theory—is a crucial mechanism for self-regulation and effective adaptation in stressful circumstances , 4. PrevFunctional social support has been identified as the main social resource which facilitates adaptation to chronic disease . ConceptOne hypothesis about mixed effects of received support on well-being has roots in the social cognitive theory . AccordiTo sum up, most research so far has focused either on the effects of self-efficacy or received support on patient or caregiver adaptation to chronic diseases. To the best of our knowledge, only a few studies have investigated the interplay between self-efficacy and support. In addition, researchers rarely based their studies on the dyadic approach  in this The present analysis explores the nature of the interaction effect of daily fluctuations in coping self-efficacy and received support on patient and caregiver daily emotional well-being (i.e. positive and negative affect) following intensive cancer treatment . The stuHCT is one of the most aggressive but effective forms of treatment for hematological neoplasms . It starThe present study tested three alternative hypotheses about the effects of daily fluctuations in self-efficacy and received support on daily fluctuations in the affect: higher than typical level of one resource (received support) (a) has a positive effect on daily affect , or (b) has a negative effect on daily affect , or (c) higher than typical level of both resources (received support and self-efficacy) has a combined positive effect on daily affect (synergistic effect). Besides the interaction effects, the main effects were also investigated. Based on the social cognitive theory and previous findings, positive main effects of both, daily fluctuations in self-efficacy and received support, were anticipated.a) first HCT , (b) age: >18 years, (c) no history of other major disabling medical or psychiatric conditions. The caregivers were appointed by the patients. Eligibility criteria for the caregivers included (a) close contact and taking care of the patients during the post-HCT outpatient period, (b) age: >18 years, and (c) no history of major disabling medical or psychiatric conditions. Out of the 561 patients who met the study criteria, 285 patients gave their written informed consent and completed individual background questionnaires . Among the caregivers, 252 caregivers consented to participate and completed background questionnaires (on the first daily-diary day). Daily assessment took place during the post-HCT outpatient period, which started on day 1 after hospital discharge and lasted 28 consecutive days. All participants were instructed how to complete the diary (particularly with regard to timing and independent diary entries). All dyads completed self-reporting web-based (12.5%) or paper-and-pencil (87.5%) diaries in the evening, each entry took 6–8 minutes. Every evening the participants received a short text message as a reminder. They were also contacted three times during the study period so that the researchers could address any difficulties or emerging questions. Paper versions were returned after the 28-day period. The study protocol was approved by the Ethical Review Board at SWPS University of Social Sciences and Humanities, Faculty of Psychology in Warsaw (Ref. No. 24/2014).Recruitment for the study was conducted in one clinic, approximately two days after admission and before the conditioning treatment. Eligibility criteria for the patients included (N = 200) and non-completers (N = 52). Allogeneic HCT was associated with an increased likelihood of belonging to the non-completers group as compared to autologous HCT; B = .98, SE = .36, p < .001. In the final sample, dyads were mostly married or cohabiting, had at least secondary education, and were in their mid-40s. The patients were mostly male, while the caregivers were mostly female. The majority of the patients were diagnosed with lymphomas and had undergone autologous transplantation.Of the 252 dyads who gave written informed consent, six patients were deemed not eligible for HCT, 17 died during hospitalization, three dyads withdrew their consent, 17 did not return the diaries after the 28-day period, and nine dyads completed fewer than five diary-days. The final sample comprised 200 patient-caregiver dyads . Sample The participants completed six items from the Coping Self-efficacy Scale (CSE)  adapted The participants completed six items from the Berlin Social Support Scale (BSSS)  adapted The participants rated how they felt on a given day using a 7-point scale ranging from 1  to 7 (“very strongly”). They assessed six positive affect items  and six negative affect items . Based on the Circumplex Model of Emotion by Larsen and Diener , the adjMultilevel structural equation modeling (MSEM) was used to explore the interaction effect of daily fluctuations in coping self-efficacy and received support in patient-caregiver dyads. MSEM estimated within-dyad fluctuations  and between-dyad differences  simultaneously. The present study focused on the within-dyad fluctuations only. The analysis was based on the actor-partner interdependence moderation model  and was One hundred and forty-one dyads (70.5%) completed at least 26 diary-days. Mean number of diary-days was 26.21±4.47 and 25.68±4.45 for the patients and the caregivers, respectively. Missing data were below 11% (ranging from 7.1% for patient daily coping self-efficacy to 10.8% for caregiver received support). The final dataset consisted of 4,674 daily reports from 200 dyads. Missing data analysis revealed no significant associations between missing records and the analyzed variables . Missing data were handled during model estimation using a full information maximum likelihood method, which is the most recommended tool for missing data management .The results of the concurrent multilevel structural equation modeling are shown in As far the main actor and partner effects are concerned, in line with earlier predictions, higher than typical daily coping self-efficacy and received support were significantly associated with higher daily positive affect and lower negative affect in the caregivers . In the patients, only daily fluctuations in coping self-efficacy contributed significantly to their better concurrent affect, both positive and negative (path a1). In addition, patient-reported daily fluctuations in coping self-efficacy were predictive of higher same-day positive affect and lower negative affect in the caregivers (path p1). The abovementioned associations were not observed in the patients. Instead, caregiver-reported daily fluctuations in received support were associated with better concurrent affect in the patients, both positive and negative (path p4). Patient-reported higher than typical daily received support contributed to lower positive affect in the caregivers.In the lagged analysis , only thThis study aimed to address the gap in our understanding of the interaction effect of self-efficacy beliefs and received support in dyads facing cancer treatment. To the best of our knowledge, this has been the first attempt to investigate daily fluctuations in coping self-efficacy, received support, and their interaction effect on patient-caregiver affect following HCT. The findings demonstrate beneficial effect of days with higher than typical coping self-efficacy and received support in both, patients and caregivers, as well as an interference rather than synergistic or compensatory effect of those resources in the affected dyads.The interplay between daily fluctuations in coping self-efficacy and received support contributed significantly to caregiver fluctuations in daily negative affect only, suggesting the interference interaction effect of the resources. Higher daily received support was associated with higher caregiver negative affect on days when self-efficacy was much higher than typical, indicating optimal daily received support on typical or lower self-efficacy days. In comparison, earlier studies found the interference effect in patient populations , 29. It Alternatively—since negative effect was detected on days with fluctuation towards much higher than typical efficacy beliefs and the beliefs were declarative—extremely high self-efficacy could have been illusory and did not translate into the use of high received support. Caregiver burden may have resulted in strong feelings of pressure, also to manage external and internal demands. Extremely high daily pressure and self-efficacy could have coexisted and jointly limited the possibility to use support. By comparison, prior longitudinal research in cancer patients indicated that perceived self-efficacy may elicit received support, resulting in better outcomes . SimilarInterestingly, the interference effect emerged in negative affect and same-day analysis only. Most likely, this is due to the distinct mechanisms of positive and negative affect elicitation . FluctuaWhen analyzing the effect of the resources separately, higher than typical daily coping self-efficacy was significantly associated with better same-day daily affect in both, patients and caregivers, while beneficial effects of higher daily received support were observed in caregivers only. The obtained results are consistent with the social cognitive theory  and earlIn our study, higher daily coping self-efficacy in the patients also contributed to better same-day affect in the caregivers. Similar results, although not related to within-dyad effects, were found in prostate cancer patients and their caregivers . A possiThe results of our study could be encouraging for dyadic intervention research in HCT recovery. Firstly, daily fluctuations in coping self-efficacy and received support may be associated with affect fluctuations in cancer populations. This finding expands earlier cross-sectional and longitudinal research on self-efficacy beliefs and support receipt in disease contexts. Secondly, our findings suggest that enhancement of coping self-efficacy beliefs in patients and their caregivers may by beneficial for both parties and foster their daily well-being. Then, high coping self-efficacy beliefs could be launched on a specific day or occasion. Previous intervention studies demonstrated the usefulness of self-efficacy enhancement programs in cancer patients and their caregivers –52. HoweThe generalizability of the study results to all cancer patients and their caregivers is limited due to the specificity of the HCT procedure. The experience of HCT and its consequences goes beyond the experience of patients treated with standard chemo-/radiotherapy, post-surgery, newly diagnosed or cancer survivors, i.e. the focus groups of most studies. So, further daily-dyadic studies on the interplay between individual and social resources in other cancer populations are needed. Secondly, women were overrepresented among the caregivers. Despite controlling for gender, it is possible that the effects in the caregivers are more representative of women. Thirdly, three-quarters of the patients underwent autologous HCT, which is characterized by shorter hospitalization and separation from the family as compared to allogeneic HCT. That may have affected the study findings, despite controlling for transplant type. Next, self-reports were collected at a relatively high frequency (28 consecutive days), which could have biased the results . Also, most dyads completed paper diaries whose filling time is more difficult to monitor than electronic ones. Finally, the analysis was limited to investigating interaction effect of day-by-day fluctuation in coping self-efficacy beliefs and received support. Future research is needed to test the possible indirect paths in the associations between daily fluctuations in coping self-efficacy, received support, and affect within patient-caregiver dyads.Our study has been the first report of the effect of the interplay between daily fluctuations in coping self-efficacy beliefs and received support in patient-caregiver dyads undergoing a demanding cancer treatment. In the caregivers, daily received support varied in its positive and negative role, which depended on daily fluctuations in efficacy beliefs, whereas the patients benefited from high daily self-efficacy.S1 Tablep < .05; **p < .01; ***p < .001.Legend: PA, positive affect, NA, negative affect. *(PDF)Click here for additional data file.


Every one-unit increase in E-DII was associated with a 1.4 increase in MetS . In other adjusted models, the most pro-inflammatory E-DII quartile (Q4) was positively associated with total blood cholesterol and triglycerides (p < 0.001), LDL-c (p = 0.007), diastolic blood pressure (p< 0.002), mean arterial pressure (p < 0.006), waist circumference (p < 0.008), and Framingham risk score (p < 0.001). However, the previously identified associations with pulse wave velocity and BMI were no longer evident in the models. These findings suggest that more pro-inflammatory diets may contribute to poorer cardiometabolic health. Promoting healthier diets with a lower inflammatory potential may help to prevent or slow development of cardiometabolic disorders.Low-grade systemic inflammation is implicated in metabolic syndrome (MetS) and cardiometabolic diseases. Diet is hypothesized to be an important low-grade inflammation modifier. However, few studies have examined the association of dietary inflammation with MetS and cardiometabolic risk in Latin American populations and their findings are inconsistent. Our cross-sectional study examined the association of dietary inflammatory potential with MetS and cardiometabolic risk components in 276 urban Ecuadorian women. Dietary inflammation was evaluated using an energy-adjusted Dietary Inflammatory Index (E-DII), divided into quartiles (Q). E-DII scores ranged from −4.89 (most anti-inflammatory) to 4.45 (most pro-inflammatory). Participants in the most pro-inflammatory (Q4) compared to the least inflammatory E-DII quartile (Q1) had a 4.4 increased adjusted odds for MetS (95% C.I. = 2.0, 9.63;  Cardiometabolic disorders, such as type 2 diabetes (T2D), cardiovascular disease (CVD), stroke, and fatty liver disease, pose a major and growing global public health challenge. These are characterized by the presence of a common group of metabolic risk factors including obesity, impaired glucose regulation, and dyslipidemia . PopulatChronic low-grade inflammation is an important feature of cardiometabolic disease. It is caused by exposures that promote excessive production of oxygen-reactive species (ROS), generation of pro-inflammatory cytokines, adipokines, and other pro-inflammatory responses ,5. Over Diet appears to be an important modifiable modulator of low-grade systemic inflammation. Published studies from diverse populations suggest that the frequent consumption of energy-dense, micronutrient- and fiber-poor diets such as the “Western diet” appears to promote oxidative stress, innate immune system activation, and pro-inflammatory/anti-inflammatory cytokine ratio imbalance, which over time, can lead to chronic low-grade inflammation and cardiometabolic derangements .A growing body of evidence suggests that the frequent consumption of fruits and vegetables, whole grains, nuts and legumes, fish, olive oil, and other minimally processed foods such as is characteristics of the “Mediterranean” and “DASH” (Dietary Approaches to Stop Hypertension) diets are associated with less systemic inflammation and lower cardiometabolic risk ,13,14,15Compared to single foods or nutrients, overall dietary patterns tend to be more informative about the habitual diet of individuals and effects on nutrition and health. However, knowing an individual’s general diet pattern provides only limited information on its overall inflammatory potential . The DieCohort and cross-sectional studies investigating the association between energy-adjusted Dietary Inflammatory Index E-DII scores with MetS and/or individual cardiometabolic risk biomarkers have reported mixed findings for diverse populations from North America ,21,22, EExamination of the dietary inflammation potential of Latin America diets and their relationship with MetS and cardiometabolic risk factors is an important topic of inquiry. While countries in different regions of Latin America have very different diet, two features that most share in common is a declining intake of fresh fruits and vegetables, and whole-grains and an increasing consumption of energy-dense, micronutrient-poor processed/ultra-processed foods and beverages high in saturated and trans-fats, sugars and other refined carbohydrates, red meats, and sodium ,38. ThesEcuador has a high population burden of metabolic and other chronic diseases. In 2019, heart disease, T2D, and cerebrovascular disease ranked among the top five causes of mortality in adults over the age of 30 years . A 2014 We conducted a study to characterize the inflammatory potential of the diets of Ecuadorian women using an energy-adjusted E-DII and to investigate the association of E-DII scores with MetS and individual cardiometabolic risk factors including waist circumference, body mass index (BMI), blood glucose, blood lipids , blood pressure, and pulse wave velocity, an indicator of endothelial dysfunction . Our working hypothesis was that compared to women with less inflammatory diets, those whose diets were more pro-inflammatory would show evidence of MetS as well as individual anthropometric (higher BMI and waist circumference), laboratory , and clinical cardiometabolic risk components .We analyzed data collected during a previous study of maternal-child dyads in Quito, Ecuador. The sampling methods and participant inclusion criteria used in the survey-design study have been previously described in detail . BrieflyParticipants provided their written and oral informed consent prior to the start of data collection. The study was conducted following Declaration of Helsinki guidelines. The protocol was approved by the University of Texas at El Paso Institutional Review Board (#604134) and Bioethics Committee (COBI) of the Central University of Ecuador. All study participants received oral and written interpretations of their lab, diet, and health screenings. Those identified with clinically abnormal results were referred to public health system facilities for free follow-up care.Face-to-face interviews were used to collect data on participant and household sociodemographic characteristics, health history, lifestyle (smoking), and usual dietary intakes. In addition, data were collected on cardiometabolic risk factors including anthropometric, clinical, and laboratory indicators.A structured questionnaire, validated in prior nutritional and health studies in Ecuador was used to collect data on the sociodemographic characteristics of the women participants and their households ,44. ThesWe used a semi-quantitative FFQ to evaluate participant dietary intake that was previously developed and validated during a prior study of women living in low-income neighborhoods in the same highland Ecuadorian city (Quito) . The FFQ6, vitamin B12, vitamin C, vitamin D, vitamin E, folic acid, beta carotene, grams of alcohol, caffeine, garlic, onion, black tea, pepper, flavan-3-ol, flavones, flavanols, flavanones, isoflavones, and anthocyanins. Six components included in the original DII  were not analyzed in our study because data on them were not available from the FFQ. The values for the 39 foods and food constituents used in the study were obtained from the USDA Agricultural Research Service Nutrient Data Laboratory databases . We obtained the E-DII by estimating the energy-adjusted intakes of each food item using the FFQ. Each participant’s energy-adjusted dietary inflammatory index (E-DII) was calculated using the updated method published by Shivappa and associates [In our study, we calculated the E-DII using data collected from participant FFQs. These included 39 of the 45 foods, nutrients, and phytochemicals contained in the original DII . These i2. Waist circumference was measured using a semiflexible anthropometric measuring tape .Data on participant anthropometric characteristics were collected using published protocols . ParticiBlood pressure (BP) was measured following the American Heart Association recommended protocol . Seated A second measurement was made 10 min later and the average of the two values was recorded. In addition, we calculated mean arterial pressure (MAP), i.e., the average BP over a cardiac cycle, using a published formula: MAP = DBP + 1/3 (SBP − DBP) . In addiData on pulse wave velocity (PWV), a measure of vascular endothelial dysfunction  were collected on all participants by a trained, experienced physician-scientist (RA) using the SphygmoCor XCEL  and following the protocol published by Nordstrand and associates .Capillary blood samples obtained from participant fingertips were used to measure fasting blood glucose and lipids . Samples were analyzed using the Cholestech Cholestech L-D-X System  following manufacturer specifications. The instrument was calibrated prior to each measurement session.We used the joint International Diabetes Federation/U.S. National Heart, Lung, and Blood Institute/American Heart Association/World Heart Federation harmonized criteria for MetS . MetS waWe calculated the cardiovascular risk of the women participants using the Framingham Risk Score algorithm. This is a gender-specific algorithm that estimates the 10-year cardiovascular risk of an individual .2 test for categorical variables. Binary logistic regression models were used to examine the unadjusted and adjusted associations of the E-DII quartiles with MetS. We used linear regression to examine the unadjusted and adjusted associations for cardiometabolic risk indicators across E-DII quartiles. We also assessed the association of the E-DII with participant cardiovascular risk using the Framingham Risk Score (FRS) algorithm [Three of the women in the study were missing FFQ data so their E-DIIs could not be calculated. For that reason, we did not include them in any of the analyses. The summary statistics for participant and household sociodemographic characteristics were analyzed as proportions or mean ± SD. The E-DII scores were analyzed as both continuous variables and quartiles for the risk indicators of interest in this study. Differences in sociodemographic characteristics by E-DII quartiles were analyzed using students’ independent t-test or one-way analysis of variance (ANOVA), as appropriate, for continuous variables and Xlgorithm  using lip values < 0.05 (2-tailed test) were considered as statistically significant.The adjusted models controlled for variables previously identified in the literature as potential confounders ,53,54,55per capita income of the participants averaged $125 US dollars/month. None of the women participants reported being cigarette smokers. In our study, E-DII scores ranged between −4.89 and 4.45. We transformed the continuous scores into quartiles (Q): Q1 was the most anti-inflammatory (−4.89 to −3.43), Q2 was anti-inflammatory (−3.42 to −1.63), Q3 was pro-inflammatory (−1.62 to 1.16), and Q4 was the most pro-inflammatory (1.17 to 4.45).As Nearly one-quarter (24.6%) of the participants met the criteria for MetS. The covariate-adjusted models (Model 2), showed similar results for the positive associations of E-DII Q4 scores with total blood cholesterol, LDL-C, and triglyceride levels. It was also positively associated with diastolic blood pressure, mean arterial pressure, and waist circumference. However, the previously identified associations with pulse wave velocity and BMI were no longer evident in the models.p < 0.01).To the best of knowledge, this is the first study to examine the relationship of dietary inflammatory potential, as measured by energy-adjusted Dietary Inflammatory Index (E-DII) scores, with MetS and cardiometabolic risk biomarkers in an Ecuadorian group, in this case, urban adult women. It also is one of only a few to do so in a Latin American country. The study findings indicated that women with most pro-inflammatory diets had an odds for MetS that was increased nearly three-fold compared to those having diets which were the least inflammatory, i.e., anti-inflammatory, even after adjustment for potential confounders. For the most part, these relationships were dose-response since the odds of MetS increased with increasing dietary inflammation. Our study also identified positive associations between E-DII scores and levels of triglycerides and total cholesterol in fasting blood, and waist circumference. They also identified a positive association between E-DII and Framingham Risk scores suggestive of higher CVD risk.The E-DII score range (−4.89 to 4.45) recorded for the Ecuadorian women in the sample was similar to those recorded for other Latin American studies examining the association of E-DII scores with Mets and/or cardiometabolic components in Bogota, Colombia (−3.71 to 3.64) , CuernavAround a quarter of the Ecuadorian women in our study met the criteria for MetS. This figure is similar to the 31% reported for Ecuadorian women aged 18–59 years from a recent national survey . The robOur findings on the association of more pro-inflammatory E-DII scores with abdominal obesity and total blood cholesterol were consistent with those of the cross-sectional study of Mexican adults published by Denova-Gutiérrez et al. , nearly The cross-sectional study published by Camargo-Ramos and associates , classifOne possible reason for the difference in findings between our study of Ecuadorian women and the above studies is that none of them studies stratified their analyses by sex. This could account for some of differences in our findings on cardiometabolic risk indicators as these are reported to cluster by gender and reproductive hormone status  ,57.Age is another factor that is tightly linked to MetS and cardiometabolic risk. Our findings on the relation of E-DII scores with both MetS and individual risk factors differs from those reported for much younger Brazilian women and men, all of whom were in their early to mid-20s . SpecifiOur findings on the association of E-DII scores with MetS and/or cardiometabolic risk components in Ecuadorian women are consistent with some but not studies that reported on women or stratified their results by sex in non-Latin American populations. For example, our findings on the relationship of E-DII scores with MetS concur with those published on women participants in a South Korean study  but diffThe reasons for the differences in findings reported by our study and that of other authors inside and outside of Latin America are not immediately evident. It is likely some of the discrepancies may be the result of methodological differences including those related to study design, sample size and power, statistical analysis, biomarker measurement methods, variation in the number of E-DII food parameters used, and those related to dietary assessment such as the instrument used , the specific foods, and length of time covered by those assessments. For example, some of the anti-inflammatory items such turmeric, saffron, ginger and rosemary that were referenced in the original E-DII are never or very rarely consumed in Ecuador especially among low-income women such as the study participants.Population differences could also be responsible for the between-study differences. In addition to the previously noted factors such as age ,59 sex/hOur population-based study had strengths and limitations. One its strengths was that the anthropometric, laboratory, and clinical cardiometabolic biomarkers were collected from participants by well-trained investigators following standard protocols. This approach reduces measurement error, memory bias, and other potential sources of error that often occurs in studies using self-reported data. In addition, the semi-quantitative FFQ used in the study was population-specific, developed for women living in low-income neighborhoods in Quito, and it contained a wide variety of 133 commonly eaten foods, beverages, and spices. We also used the comprehensive USDA food composition database to analyze the nutrients, flavonoids, and other food components from the FFQ for the E-DII analysis. Furthermore, we adjusted for potential confounders and effect modifiers using multivariate linear and logistic regression models.per capita income, and/or BMI, it is possible that, confounding could have occurred due to unmeasured factors.One of the limitations of our study was its cross-sectional design which does not allow for the establishment of causal or temporal relationships. Also, as non-probabilistic sampling was used to select participants, it may not be representative of women living in other areas of Quito. As with any type of self-reported dietary assessment method, measurement error caused by recall bias, social bias, or other types of bias could have occurred. In addition, since the FFQ covered only the prior 12-months women’s longer-term intake of specific foods could have been under-or over-estimated. In addition, the E-DII scores in this work were based on 29 nutritional parameters rather than the full 45 contained in the original E-DII . This ocIn conclusion, our study findings suggest that the consumption of more pro-inflammatory diets appears to promote poorer cardiometabolic health as indicated by MetS, individual cardiometabolic risk components, and Framingham Risk Scores. Prospective studies should be undertaken to confirm the present study findings and elucidate the role of diet in promoting chronic low-grade inflammation and cardiometabolic risk in pre-menopausal women including those living in populations undergoing nutritional and epidemiologic transition. These can help to inform public health policy and the design of clinical interventions featuring diets with lower inflammatory potentials that can prevent or decelerate development of cardiometabolic disorders in women.


Glutaric aciduria type II (GA II) also known as multiple acyl-CoA dehydrogenase deficiency is an inborn metabolic disorder belonging to the family of organic acidurias. It is a disorder that interferes with the body's ability to break down proteins and fats to produce energy. Tandem mass spectrometry (TMS) acts as a screening tool, while the diagnosis of GA-II with ketosis is confirmed by a combination of tests like organic acids, quantitative random urine, and a full urine panel. Early diagnosis, compliance to specialized diet, affordability, and regular follow-ups are required to tackle this potentially life-threatening condition. Herein, we report a case of glutaric aciduria type-II with ketosis in a 4.5 months old male infant who was managed with a low-protein diet, which was free of tryptophan, lysine, and other specific dietary supplements. Glutaric aciduria type II (GA II) is an autosomal recessive disorder of fatty acid, amino-acid, and choline metabolism. It results from the deficiency of any one of the three molecules: the alpha (ETFA) or beta (ETFB) sub-units of electron transfer flavoprotein, or electron transfer flavoprotein dehydrogenase (ETFDH) . The forA 4.5-month-old male infant presented to the pediatric outpatient department (OPD) with complaints of intermittent abnormal posturing, lethargy, excessive crying for nine days, and cough with coryza for seven days. He was admitted for five days in a private hospital where-in blood investigations were done and supportive treatment in form of IV fluids and anti-convulsants were started, but as his symptoms persisted he was referred to our hospital. There were no complaints of fever, vomiting, seizures, rash, or diarrhea. The child was a firstborn out of a second-degree consanguineous marriage. There was no significant birth history, past medical history, or family history. He was fully immunized as per his age and a bacillus Calmette-Guérin (BCG) scar was present. As per the mother, developmental history was normal but due to intermittent posturing, we were not able to elicit the milestones. His vitals on admission were normal. The examination did not show any dysmorphic features. Anterior fontanelle was normal. Anthropometry was normal except for weight (less than the third centile). His central nervous system (CNS) examination showed intermittent right hemidystonic posturing and orofacial grimacing which disappeared on sleep, confirming that it was an extrapyramidal symptom. Other systemic examination findings were normal. Laboratory investigations were normal except for low Hb (8.9 gm/dL). The peripheral blood picture showed a normocytic and normochromic blood picture. Chest X-ray showed right-sided consolidation. MRI scan of the brain showed frontotemporal atrophy, dilated Sylvian fissures with open opercula typically seen as a batwing appearance. These features were suggestive of glutaric aciduria Type II. Tandem mass spectrometry, a metabolic screening tool, showed low free carnitine, acetylcarnitine, and octadecanoyl carnitine Table . As it wThe infant was prescribed a low protein diet free of tryptophan and lysine. Biotin, carnitine, and riboflavin were also supplemented with amino-acid modified infant formula along with other supportive treatments in form of anti-convulsants and drugs to decrease abnormal movement. At the time of discharge, the patient’s relatives were explained about his condition and poor prognosis but eventually, we lost follow-up.The prevalence of GA-I is 1-in-5600 while that of GA-II is 1-in-2,00,000 in both males and females .Our patient presented with movement disorder in form of right hemidystonic posturing with orofacial grimacing, which disappeared during sleep. MRI scan of the brain showed frontotemporal atrophy, dilated Sylvian fissures with open opercula typically seen as a batwing appearance. These features were suggestive of glutaric aciduria type II. Similar features are seen in other conditions such as idiopathic external hydrocephalus, severe developmental delay, and non-accidental injury . AcylcarThis case report briefly highlights the various aspects of diagnosis and management of this rare disease. The high costs of investigation panels and therapeutic foods remain an obstacle for recognizing and treating this disease in a resource-poor setting. Moreover, GA-II in the neonatal form with or without congenital anomalies is said to be associated with poor prognosis and high mortality. Hence, further research is required for better treatment modalities.


Introduction: A recent clinical study revealed that Ninjin'yoeito (NYT) may potentially improve cognitive outcome. However, the mechanism by which NYT exerts its effect on elderly patients remains unclear. The aim of this study is to evaluate the effect of Ninjin'yoeito on regional brain glucose metabolism by 18F-FDG autoradiography with insulin loading in aged wild-type mice.Materials and Methods: After 12 weeks of feeding NYT, mice were assigned to the control and insulin-loaded groups and received an intraperitoneal injection of human insulin (2 U/kg body weight) 30 min prior to 18F-FDG injection. Ninety minutes after the injection, brain autoradiography was performed.Results: After insulin loading, the 18F-FDG accumulation showed negative changes in the cortex, striatum, thalamus, and hippocampus in the control group, whereas positive changes were observed in the NYT-treated group.Conclusions: Ninjin'yoeito may potentially reduce insulin resistance in the brain regions in aged mice, thereby preventing age-related brain diseases. With a global aging population, health issues caused by aging and age-related diseases have become inevitable challenges to all countries. Understanding the functional changes of organs that occur as a result of aging is essential to prevent age-related diseases, such as Alzheimer's disease (AD) and Parkinson's disease (PD) . In partInsulin resistance is one of the major underlying mechanisms in abnormal glucose tolerance . Accumulrehmannia roots, Atractylodes rhizomes, poria sclerotium, cinnamon bark, astragalus root, Citrus unshiu peel, polygala roots, schisandra fruit, and Glycyrrhiza. NYT extract is approved by the Japanese Ministry of Health, Labor and Welfare as a Kampo medicine for the decline in physical strength, fatigue, anorexia, night sweats, cold extremities, and anemia  is a traditional Japanese medicine (Kampo medicine) and a multicomponent formulation composed of 12 crude drug extracts from ginseng, Japanese angelica roots, peony roots, d anemia . It is ad anemia . Ninjin-tic mice . Moreovesistance . Interessistance . Furthersistance . On the sistance . Therefo18F]-Fluoro-2-deoxy-2-D-glucose (18F-FDG), a molecular imaging probe, is widely used in nuclear medicine for evaluating tissue glucose utilization and glucose metabolism (18F-FDG autoradiography (ARG) with insulin loading in aged mice.The glucose analog  × 100%. Blood samples for glucose concentration measurement were obtained from all groups. When the blood glucose concentration decreased and displayed as “low” after insulin loading, we defined this blood glucose concentration as 20 mmol/dl which is the detection limit of blood glucose meter.The four subgroups of mice  compared with that in the control group /18F-FDG uptake level before insulin loading] × 100%. The 18F-FDG accumulation showed negative changes in the cortex, striatum, thalamus, and hippocampus in the control group, whereas positive changes were observed in the treatment group  deposition in the frontal and temporal areas . Studiesvia epithelial cells of the proximal colon ] and therefore cannot reliably define specific regions within the mouse brain  could not.The small-animal PET system  with a spatial resolution of 1.63 mm was installed in our preclinical facility . Prior tThe limitations of our study were as follows. The number of animals per group was small. We only performed image analysis of the coronal sections of the mouse brain, and we did not perform image analysis of the sagittal sections. We consider that more accurate quantitative image information from different sections can be obtained if ARG image analysis of the sagittal sections is performed in this study.In summary, Ninjin'yoeito may potentially reduce insulin resistance in the brain regions in aged mice, thereby preventing age-related brain diseases.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The entire experimental protocols were approved by the Laboratory Animal Care and Use Committee of Fukushima Medical University  and performed in accordance with the Guidelines for Animal Experiments at Fukushima Medical University.JZ designed the study and wrote the manuscript. RI, NU, CT, and SS performed animal studies. YO performed bait prescription. KT performed radiolabeling and QC examination. HI and YM contributed to the interpretation of the results. GN, SZ, and KS critically revised the manuscript for important intellectual content. All authors have reviewed the manuscript.RI and YO were employed by the company Tsumura & Co. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Neoadjuvant (chemo) radiotherapy is used as a standard treatment for locally advanced rectal cancer (LARC), but there is no general consensus on either the efficacy of postoperative adjuvant chemotherapy in patients with LARC after neoadjuvant treatment and surgery, or whether the addition of oxaliplatin to adjuvant chemotherapy provides survival benefits.  We performed a meta-analysis of data from the PubMed and Embase databases. We included patients with LARC who received neoadjuvant (chemo) radiotherapy and curative surgery. Overall survival (OS), disease-free survival (DFS), toxicity, and compliance were analyzed in the oxaliplatin/fluorouracil- (OX/FU-) based group compared with the FU-based group, and in the chemotherapy group compared with the observation group.  Twenty studies were included in the analysis. Our results indicated that adjuvant chemotherapy prolonged OS  in patients with LARC treated with neoadjuvant (chemo) radiotherapy and surgery compared with those in the observation group. Subgroup analysis showed the same results in both the ypStage II and ypStage III groups. Compared with those in the observation group, patients in the chemotherapy group also showed an increase in DFS . No significant increase was observed in OS  or DFS  when oxaliplatin was added to FU-based adjuvant chemotherapy, as compared with the FU-based treatment, and subgroup analysis also indicated no survival benefits in the clinical stage II, clinical stage III, ypStage II, and ypStage III groups.  For patients with LARC who have already received neoadjuvant (chemo) radiotherapy and curative surgery, adjuvant chemotherapy improves OS over that in the observation group. Adding oxaliplatin to FU-based adjuvant chemotherapy does not confer survival benefits beyond those from FU-based adjuvant chemotherapy. Colorectal cancer is the second most frequent cancer in women and the third most frequent cancer in men . To dateAn oxaliplatin-based adjuvant chemotherapy regimen for LARC patients who have received neoadjuvant treatment has been mainly extrapolated from results achieved with oxaliplatin-containing adjuvant chemotherapy in lymph node-positive colon cancer patients , 10, a sIn this meta-analysis, we sought to summarize and further assess the survival benefits of postoperative chemotherapy following neoadjuvant treatment and curative surgery for patients with LARC and examine the role of oxaliplatin in adjuvant chemotherapy.This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines  patients were diagnosed with rectal cancer; (ii) all patients received preoperative (chemo) radiotherapy; (iii) all patients underwent surgical resection of rectal cancer; (iv) studies compared chemotherapy with observation or compared postoperative OX/FU-based chemotherapy with FU-based chemotherapy ; and (v) the outcomes of studies included OS, DFS, toxicity, or compliance. Studies were excluded according to the following criteria: (i) studies of patients diagnosed with diseases other than rectal cancer; (ii) studies of patients who did not receive preoperative (chemo) radiotherapy; (iii) studies that compared preoperative OX/FU-based therapy with preoperative FU-based therapy; (iv) reviews, meta-analyses, and case reports; and (v) studies without outcomes relevant to this analysis. Two reviewers assessed all studies independently, and the final selected studies were determined on the basis of agreement between the two reviewers.Two researchers completed the extraction of suitable data after reviewing the full text of included studies, and all disagreements were settled by discussion. The detailed information extracted from studies included author, year of publication, country, study design, number of patients, age, follow-up duration, TNM stage, tumor location from anal verge, neoadjuvant treatment regimen, adjuvant treatment regimen, type of surgery, median interval from surgery to adjuvant chemotherapy, and study outcomes including OS, DFS, compliance (completion of planned number of cycles), and toxicity .The primary endpoints were DFS and OS. The secondary endpoints were compliance and toxicity. We evaluated the primary endpoint with the hazard ratio (HR) and 95% confidence interval (CI). Then, we calculated the pooled risk ratio (RR) with 95% CI to assess toxicity. If a study did not provide the HR or 95% CI directly, we used published data to obtain the statistics by using the methods reported by Tierney et al. .I2 > 50% or p < 0.1; otherwise, we used a fixed-effects model [p value ≤ 0.05.We analyzed the overall OS and DFS for the OX/FU-based group versus the FU-based group, and the chemotherapy group versus the observation group. Additionally, we conducted subgroup analysis according to study design, pathologic tumor stage after neoadjuvant treatment (ypTNM), preoperative clinical tumor stage (cTNM), and neoadjuvant treatment regimen. Statistical analysis of compliance and toxicity was performed on the basis of data from the studies. According to the heterogeneity, we used a random-effects model when ts model . Publicats model , 26. FinAll analyses were performed in Stata software, version 12.0 .A total of 4741 studies were retrieved by the electronic search in total . A total of 4067 studies remained after the elimination of duplicates. Subsequently, 3914 articles were removed on the basis of the eligibility criteria according to the titles and abstracts, after which 153 articles were retained. After further reading and evaluation of the full text, 20 studies were ultimately included in this meta-analysis, including seven randomized controlled trials (RCTs) and 13 non-RCTs (nRCTs) , 27–36. Twenty studies on 30662 patients were enrolled in the meta-analysis. Among the included studies, eight were from Europe, four from the USA, three from China, three from Korea, one from Canada, and one from Israel. Regarding the interventions, four studies had two arms containing an OX/FU-based group and FU-based group, 13 studies contained a chemotherapy group and observation group, and the other three studies contained an OX/FU-based group, FU-based group, and observation group. In terms of the neoadjuvant treatment regimen, preoperative long-course radiation with chemotherapy was conducted in 18 studies, long-course radiation alone or with chemotherapy was conducted in one study, and short-course radiation alone or with chemotherapy was used in one study. The follow-up duration of most studies was more than 3 years, four studies had longer durations of more than 5 years, and only two studies had durations of less than 1 year. The detailed baseline characteristics and study quality of the included studies are listed in p = 0.906, p = 0.906, p = 0.782, − and ypN+ patients . To investigate the specific patient group that would benefit from adding oxaliplatin to adjuvant chemotherapy, we further conducted a subgroup analysis based on ypStage. The OX/FU-based group did not show an increase in DFS over that in the FU-based group in either the ypStage II or ypStage III groups  [Our results indicated a significantly increased OS in patients receiving chemotherapy  .− patients who received adjuvant chemotherapy had better OS than those in the observation group . Further analysis based on ypStage showed that adjuvant chemotherapy contributed to better OS in both the ypStage II group and ypStage III , and similar results were also found in further analysis based on ypStage . In OX/FU-based chemotherapy versus FU-based chemotherapy, there was no benefit in either RCTs or nRCTs when oxaliplatin was added . The details are shown in In the chemotherapy group versus the observation group, nRCTs indicated a significant difference in OS, whereas RCTs showed a limited clinical benefit in terms of OS after adjuvant chemotherapy, and the results were not statistically significant  could not be conducted, owing to an insufficient number of studies. Thus, future large-scale, prospective clinical studies are needed to explore the influence of neoadjuvant treatment strategy, including preoperative short-course radiotherapy, preoperative long-course radiotherapy, and long-course chemoradiation, on the relationship between adjuvant chemotherapy and survival benefits. Such an understanding may lead to more effective and suitable clinical treatment strategies for patients with LARC.There are several limitations to the current research. First, this was a retrospective analysis, and the potential for confounding on the basis of patient selection could not be eliminated. Second, we were unable to obtain the personal details of patients, although this information might have enabled better control of the confounding factors. Third, the heterogeneity in the study that could not be eliminated by subgroup analysis might have affected external authenticity to some extent. Moreover, some patients may have better pathological responses to neoadjuvant treatment, thus, achieving ypStage1 or even ypStage 0 after neoadjuvant treatment; however, the survival benefit of adjuvant chemotherapy still remains unclear for these patients in clinical practice. Unfortunately, we could not perform further analysis because the data for patients with ypStage 0 or I after neoadjuvant treatment were insufficient. In addition, we were unable to perform more subgroup analyses because of the insufficient number of studies. Finally, the recent guidelines for adjuvant chemotherapy regimens are mainly based on pStage. Differences exist between ypStage and pStage, and, thus, chemotherapy guided by ypStage might require further exploration. Future studies are needed to further investigate and resolve these problems.Compared with observation, adjuvant chemotherapy was found to prolong OS in patients with LARC after neoadjuvant (chemo) radiotherapy and curative surgery. However, no survival benefit was observed with the addition of oxaliplatin to FU-based adjuvant chemotherapy compared with FU-based adjuvant chemotherapy.


Although of great value to understand the treatment results for mental health problems obtained in clinical practice, studies using naturalistic data from children and adolescents seeking clinical care because of complex mental health problems are limited. Cross-national comparison of naturalistic outcomes in this population is seldomly done. Although careful consideration is needed, such comparisons are likely to contribute to an open dialogue about cross-national differences and may stimulate service improvement. The aim of this observational study is to investigate clinical characteristics and outcomes in naturalistic cohorts of specialized child and adolescent mental health outpatient care in two different countries.Routinely collected data from 2013 to 2018 of 2715 outpatients in the Greater Area of Brisbane, Australia (CYMHS) and 1158 outpatients in Leiden, the Netherlands (LUMC-Curium) were analysed. Demographics, clinical characteristics and severity of problems at start and end of treatment were described, using Children's Global Assessment Scale (CGAS), Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the parental Strength and Difficulties Questionnaire (SDQ-P).Routine outcome measures  showed moderate to severe mental health problems at start of treatment, which improved significantly over time in both cohorts. Effect sizes ranged between 0.73-0.90 (CYMHS) and 0.57-0.76 (LUMC-Curium). While internalizing problems  were more prevalent at CYMHS, externalizing developmental problems  prevailed at LUMC-Curium. Comorbidity (>1 diagnosis on ICD10/DSM-IV) was relatively similar: 45% at CYMHS and 39 % at LUMC-Curium. In both countries, improvement of functioning was lowest for conduct disorder and highest for somatoform/conversion disorders and obsessive-compulsive disorders (OCD). Overall, 20-40% showed clinically significant improvement , but nearly half of patients still experienced significant symptoms at discharge.This large-scale outcome study showed both cohorts from Australia and the Netherlands improve during the course of treatment on clinician- and parent-reported measures. Although samples were situated within different contexts and differed in patient profiles, they showed similar trends in improvement per diagnostic group. While 20-40% showed clinically significant change, many patients experienced residual symptoms reflecting increased risk for negative outcome into adulthood. We emphasize cross-national comparison of naturalistic outcomes faces challenges, although it can similarly reveal trends in treatment outcome providing direction for future research: what factors determine discharge from specialized services; and how to improve current treatments in this severely affected population. This is illustrated by studies using naturalistic data from specialist child and adolescent mental healthcare services (CAMHS), showing the proportion of patients with reliable improvement, recovery or deterioration  across CAMHS. Since they also have similar levels of economic development, social and demographic profiles and health outcomes , as measured by symptom reduction  and improvement of global functioning (CGAS). Analyses of cohorts focused on a profile of presenting patients, prevalence rates of diagnoses, completion rates and effect sizes of ROM, the proportion of patients with clinical significant change, and change of global functioning among diagnostic groups. Findings are discussed in the light of contextual factors of both organisations. The aim is to open up conversations about the observed similarities and differences in the context of two specialist tertiary CAMHS within Australia and the Netherlands. Thereby this study contributes to the country-specific evidence on the effectiveness of outpatient treatments, and to insights on cross-cultural trends of treatment outcome of youth with complex mental health needs.This study described clinical characteristics and outcomes of child psychiatric outpatient treatment in two countries  with complex and severe mental health problems. They provide community- and hospital-based services in a catchment area comprising 6 00 000 youth across the Greater Brisbane and Pine River regions in Queensland (CYMHS) and 1 62 000 youth in the northern part of the province ‘Zuid-Holland’ (LUMC-Curium). They both work in the presence of – and in collaboration with other mental healthcare providers in the region. Both organisations do not focus on the population with intellectual disabilities, however, comorbid psychiatric symptoms of these patients may be treated. Patient-data and ROM-data (collected at baseline and at case reviews) were registered in online records. In Australia this collection process is regulated in specific guidelines  in the selection of patients, with the exception that we focused on a different timeframe, and that we included data from the Eating Disorder-team at CYMHS. These exceptions were made to make selections of CYMHS and LUMC-Curium more comparable.For the current comparison study we followed the same procedure as described by Lu Diagnose-Behandel-Combinatie (Netherlands)). DBC-registrations span no longer than maximally one year and multiple consecutive DBC's could contribute to a continuous period of care. Therefore, in both samples ‘episodes of care’ have been combined into ‘clinical episodes’ of care for the patient. The start of a clinical episode is defined as ‘admission to CAMHS, without any contact in the previous 3 months’, the end as ‘discharge from CAMHS, without contact in the following 3 months’. To be able to compare outcomes before and after outpatient treatment, we excluded clinical episodes of less than 30 days, youth with inpatient admissions during their clinical episode, and patients without any psychiatric diagnosis (no F-Code in ICD-10 or no Axis I/Axis II diagnosis in DSM-IV)  .Fig. 1.Outpatient care at CYMHS was provided by seven community teams and the Eating Disorder-team, of which 2715 patients were included. At LUMC-Curium outpatient care was provided by several specialised teams, of which 1158 patients were included .Table 1Demographic data included gender, age at start, duration of episode and country of birth. In Australia, ‘indigenous status’, is reported, referring to the first nation people of Australia, i.e., ‘Aboriginal’ or ‘Torres Strait Islander’  to 100 (excellent functioning) , conduct problems (CPS), hyperactivity (HAS), peer problems (PPS) and prosocial behaviour (PSS) Goodman, . Items aet al., et al., et al., et al., et al., et al., et al., the absolute fit indices provided sufficient evidence supporting descriptive comparisons of Australian and Dutch SDQ-P subscale- and total-scale scores.For the psychometric properties of measures, see Appendix B. Cross-national intraclass correlation coefficient (ICC) was 0.61 for CGAS, and 0.84 for HoNOSCA total score . A  AMHOCN,  were used) using the pooled standard deviation from the start- and end-of-treatment means, taking the correlation between means into account , a series of McNemar's tests is used on CGAS, HoNOSCA-items and SDQ-P(TDS), to report on the proportion of patients with clinical significant change. For an individual patient it means the patient shifts from a dysfunctional to a functional population  and 905 (78%) patients, respectively. Of these, 2% at CYMHS and 4% at LUMC-Curium were deemed invalid, due to missing data. Mean total scores improved significantly in both cohorts with effect sizes of 0.84 (CYMHS) and 0.57 (LUMC-Curium) .p = 0.000), and from 4.4 (SD 2.0) to 3.1 (SD 2.3) at LUMC-Curium (p = 0.000). A list of the HoNOSCA-items is found in Appendix C. At discharge, significantly less patients scored in the clinical range on all of the 13 HoNOSCA-items at CYMHS. At LUMC-Curium, also all items showed a significant difference, except items 4 and 11 (Matched start- and end-of-treatment scores were available for 1851 (68%) patients at CYMHS, and for 321 (28%) patients at LUMC-Curium. The mean number of clinically significant items per patient decreased from 5.3 (SD 2.0) at start to 3.4 (SD 2.5) at end-of-treatment at CYMHS  patients and 499 (43%) patients, respectively. Parental completion rates (SDQ-P) were lower compared to the clinician-rated measurements . PatientExploration concentrated on the proportions of patients showing clinical relevant change on CGAS. At CYMHS and at LUMC-Curium, the largest ΔCGAS was seen in patients with somatoform, conversion or dissociative disorders and OCD.This study investigated clinical characteristics and treatment outcomes of child psychiatric outpatient care in Australia and the Netherlands. The results reveal both organisations differed in patient profiles and prevalence rates of diagnostic groups. However, similar trends were found. In both countries, patients presented with moderate-to-severe problems and showed significant improvement over time. Improvement was clinically relevant in 20–40% of patients, dependent on diagnostic group, and reported by both clinician  and parents (SDQ-P). A significant proportion of patients experienced residual symptoms.et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., The similarities observed between the countries and organisations align with outcomes in prior studies of outpatients with severe and complex mental health problems. First, severity of problems at start-of-treatment was high in both cohorts , reflecting the specialised settings, similar to other specialised CAMHS  makes data possibly biased (Wolpert and Rutter,


Primary antibody deficiencies represent by far the largest group of primary immunodeficiencies (PID) at 56% (ESID Registry), however the proportion of patients in whom antibody deficiency represents a component of their condition is greater still at around 75% . It has Abolhassani et al. who identified the most significant partial haplotype linked with the unsolved CVID as W*01:01:01-DMA*01:01:01-DMB*01:03:01:02-TAP1*01:01:01. Beside the high number of BTK mutations so far described  whose remission of HLH episodes was finally achieved after he received monthly Ig replacement therapy as the only treatment for HLH.In recent years, our understanding of genetics of primary antibody deficiencies (PAD)  further Coopmans et al. who suggested that an assessment of the endocrine axis should be considered since a high prevalence of both anterior pituitary and end-organ endocrine dysfunction  were identified in adult PAD patients causing a considerable health burden. A detailed description of CVID-associated non-infectious complication was reported by Ho and Cunningham-Rundles. Autoimmunity, chronic lung disease, lymphoid hyperplasia/splenomegaly, liver disease, granulomas, gastrointestinal disease, lymphoma and other malignancies were found in two third of CVID patients. These complications may be present in the same patient, and progress to a wide spectrum of associated sequelae. An aggressive multidisciplinary approach may reduce such progression. Further exacerbations, as for permanent lung damage and bronchiectasis, may develop even in the absence of known infections, as shown by Wall et al. Similarly, in the liver, granulomas and nodular regenerative hyperplasia progressing to portal hypertension .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is limited national representative evidence on determinants of women’s acceptance of wife-beating especially; community level factors are not investigated in Ethiopia. Thus, this study aimed to assess individual and community-level factors associated with acceptance of wife beating among reproductive age women in Ethiopia.p value less than 0.05 at the final model.Secondary data analysis was done on 2016 Ethiopian Demographic and Health Survey data. A total of 15,683 weighted reproductive age group women were included in the analysis. Multi-level mixed-effect logistic regression analysis was done by Stata version 14.0 to identify individual and community-level factors. An adjusted odds ratio with a 95% confidence interval was used to show the strength and direction of the association. Statistical significance was declared at Individual-level factors significantly associated with acceptance of wife-beating among women were; being Muslim follower , Being married , attending primary, secondary and higher education , ,  respectively. From community level factors, living in Somali [AOR = 0.2 95% CI = ], Addis Ababa  and Dire Dawa  were 80%, 70% and 50% less likely accept wife-beating when compare to women who live in Tigray region, respectively. Live in high proportion of poor community , live in low proportion of television exposure communities  were significantly associated with acceptance of wife-beating among women in Ethiopia.Educational status, religion, marital status, region, community-level wealth, and community level of television exposure had a statistical association with women’s acceptance of wife-beating. Improving educational coverage, community-level of media exposure, community-level wealth status and providing community-friendly interventions are important to reduce the acceptance of wife-beating among women in Ethiopia. Gender-based violence (GBV) is any harm or suffering that is perpetrated against a woman or girl, man or boy and that harms the physical, sexual or psychological health, development, or identity of the person –4. GBV iIntimate partner violence is high when society accepts it –26. BeliStudies in Ethiopia have also shown that about one-half to two-third of women experience one or other forms of spousal abuse at least once in their lifetime –33. IntiIn Ethiopia, different researches have been done on the prevalence and/or factors associated with women's attitude towards wife-beating. Age, residence, educational status, and religion are determinant factors identified by scholars , 42–46. 0 and 150 North latitude and 330 480 and East longitudes. This study used 2016 EDHS data set which was collected by the Central Statistical Agency (CSA) . δ2 of the null model is used as a reference.ICC shows the variation in acceptance of wife-beating among women due to community characteristics. The higher the ICC, the community characteristics are more relevant to understand individual variation for acceptance of wife-beating. It is calculated as Multicollinearity was checked among explanatory variables by using standard error at a cutoff point ± 2. No Multicollinearity is the standard errors were between ± 2. The log-likelihood test was used to estimate the goodness of fit of the adjusted final model (model-III) in comparison to the preceding models (model-I and model-II) individual and community model adjustments respectively. The analysis was done by using the SVY Stata commands to control the clustering effect of complex sampling (stratification and multistage sampling procedures).A total of 15,683 reproductive age  women weIn the final model (model-III) educational status, religion, marital status, region, community-level wealth, and community-level of television exposure had a statistical association with women acceptance of wife beating.The odds of women acceptance on wife beating was 1.3 times more among participants who are Muslim religion followers as compared to Orthodox religion followers . Women who were attending primary education, secondary education and higher education were 20%, 60% and 70% less likely accept wife beating when compared with not attend school , ,  respectively.The odds of women acceptance on wife beating was 1.3 times more among married women when compared with never married women . Women who were living in Somali, Addis Ababa and Dire Dawa were 80%, 70% and 50% less likely accept wife beating when compare to women who live in Tigray region [AOR = 0.2 95% CI = ],  and  respectively.Women who live in a high proportion of poor communities were 1.2 times more likely accepted wife-beating than women who live in a low proportion of poor communities . Women who live in a low proportion of television exposure communities were 1.4 times more accept wife-beating than women who live in a high proportion of television exposure community   and community-level factors: were determinant factors of wife-beating acceptance among reproductive age women in Ethiopia.As educational attainment increases the acceptance of wife-beating is reduced. The finding is consistent with previous researches. In Ethiopia, refusing wife-beating was differed by educational attainment . A studyMuslim religion follower women were more accepting wife-beating than Orthodox religion follower women. Similarly, in previous research conducted in Ethiopia, Muslims are accepting wife-beating than Orthodox . In reseCurrently married women tend to accept wife-beating than never-married women. The finding is supported by research in Ethiopia . This isThere is a regional variation in acceptance of wife-beating among women. Women who live in Addis Ababa, Dire Dawa, Harari, and Somali region are less likely to accept wife-beating when compared with women who live in Tigray region. Cultural, religious values, and norms may be different across the regions . CulturaWhen a high proportion of poor people lived in the cluster, the acceptance of wife-beating increased. This is also supported by a study conducted in sub-Saharan African countries , 72. ThiWhen a low proportion of people espoused to television in the cluster, the acceptance of wife-beating increased. The finding is consistent with a search conducted in Ethiopia  and seveThe result of this study was more representative than other studies and the model considered different levels of analysis as the outcome was affected by community-level variables. Despite this strength, the result may be prone to recall bias because the data were collected from history of event.After computing multi-level analysis, low educational status, being married, Muslim religion followers, region, live in high a proportion of poor community, live in a high proportion of non-television exposed community had a statistical association with acceptance of wife-beating among reproductive age group women in Ethiopia. Improving universal access to education is important to reduce the prevalence as well as health and health-related complications of the acceptance of wife-beating. Advocacy and behavioral change communication should be area of concern for different organizations who are working on women reproductive health to tackle the acceptance as well as the consequences of gender-based violence. Since the acceptance of wife-beating is different across community, better to develop community sensitive approaches for different communities.


Non-technical skills (NTS) are essential for safe surgical practice as they impact workflow and patient outcomes. Observational tools to measure operating room (OR) teams’ NTS have been introduced. However, there are none that account for the specific teamwork challenges introduced by robotic-assisted surgery (RAS). We set out to develop and content-validate a tool to assess multidisciplinary NTS in RAS.Stepwise, multi-method procedure. Observations in different surgical departments and a scoping literature review were first used to compile a set of RAS-specific teamwork behaviours. This list was refined and expert validated using a Delphi consensus approach consisting of qualitative interviews and a quantitative survey. Then, RAS-specific behaviours were merged with a well-established assessment tool on OR teamwork (NOTECHS II). Finally, the new tool—RAS-NOTECHS—was applied in standardized observations of real-world procedures to test its reliability (inter-rater agreement via intra-class correlations).Our scoping review revealed 5242 articles, of which 21 were included based on pre-established inclusion criteria. We elicited 16 RAS-specific behaviours from the literature base. These were synthesized with further 18 behavioural markers (obtained from 12 OR-observations) into a list of 26 behavioural markers. This list was reviewed by seven RAS experts and condensed to 15 expert-validated RAS-specific behavioural markers which were then merged into NOTECHS II. For five observations of urologic RAS procedures (duration: 13 h and 41 min), inter-rater agreement for identification of behavioural markers was strong. Agreement of RAS-NOTECHS scores indicated moderate to strong agreement.RAS-NOTECHS is the first observational tool for multidisciplinary NTS in RAS. In preliminary application, it has been shown to be reliable. Since RAS is rapidly increasing and challenges for effective and safe teamwork remain at the forefront of quality and safety of surgical care, RAS-NOTECHS may contribute to training and improvement efforts in technology-facilitated surgeries.The online version contains supplementary material available at 10.1007/s00464-021-08474-2. In surgery, non-technical skills (NTS) have been shown to be associated with surgeons’ technical performance –3, quickObservational tools are commonly used to quantify and evaluate OR teamwork behaviour and NTS . SeveralIn the past decade, there has been a tremendous growth in the use of robotic technologies. Yet, RAS adds unique challenges—both technical and non-technical—compared to conventional surgery , 16. Dur(1a) Synthesis and compilation of RAS-specific teamwork behaviours through the combination of exploratory observations and a scoping review of the current literature base; with subsequent pre-selection of behavioural markers through internal consensus process;(1b) Refinement and final selection of RAS behavioural markers through expert validation; synthesis of expert validated behavioural markers with finalization of RAS-NOTECHS.Development of RAS-NOTECHS—an observational tool for the assessment of NTS during RAS that comprises RAS-specific behaviours which are validated by RAS experts, with sub goals of:(2)Establishing initial reliability of RAS-NOTECHS in real-world RAS procedures.Specifically, our study aimed for the following objectives:We drew up a multi-step procedure to develop a tool for measuring NTS in RAS settings and to test this new tool for content validity and reliability. We used a sequential mixed methods design including direct observations, a scoping review, expert interviews, an expert survey, and structured observations.The study was approved by the Ethics Committee of the Medical Faculty, Munich University (Nr. 19-696). All participants received written and verbal information prior to data collection. Participation was voluntary and written consent was obtained.OxfordNOTECHS II . RAS-NOTECHS ratings and the behaviour checklist were assessed for each phase, respectively. Intra-class correlation (ICC) estimates with 95% confidence intervals were calculated for the overall RAS-NOTECHS rating as well as for each RAS-NOTECHS dimension . We calculated ICCs for the overall as well as of each RAS-NOTECHS dimension, respectively. Following the definition by Koo, Li , indicating strong agreement [A moderate degree of correlation was found for the scores of the complete RAS-NOTECHS  as well as for scores of RAS-NOTECHS dimensions greement , 45.The aim of this study was to develop a tool for measuring teamwork of RAS teams as well as to test its reliability. A systematic, stepwise and mixed-methods procedure was applied. RAS-NOTECHS encompasses relevant behavioural markers for effective OR teamwork in RAS. Thus, our study results contribute to the current literature base in several ways:First, we introduce a new observational tool that allows assessment of teamwork behaviours in RAS. Robot-facilitated surgery is rapidly growing and surgical technology is advancing with an increasing demand and use across different procedures –48. SincSecond, drawing upon a scoping review of the current scientific literature base on teamwork in RAS, we systematically identified a comprehensive set of behaviours that are deemed critical for successful collaboration in RAS. Further, this extended set of behaviours was evaluated by clinicians from surgery, nursing, and anaesthesia. The result of the consensus process is a validated set of RAS-critical behaviours. It comprises teamwork behaviours that are assessable, tangible and can be utilized for training, simulation, and teamwork improvement measures , 49–52.Our obtained behavioural markers are to some extent similar to behaviours OR teams show in conventional surgical settings . Yet, we deem that these behaviours are more critical in robotic settings as they may compensate for the unique challenges to NTS and teamwork introduced by RAS , 37. AddDespite our focus on potential RAS-related barriers and obstacles to NTS as we elicited in Table While we aimed to identify behaviours indicating good or poor teamwork, we found that some were only applicable if a negative behaviour or event preceded, i.e., actually compensated for obstacles of the robotic setup , 37, 40:We found RAS-NOTECHS to be a reliable teamwork assessment tool throughout the first applications in real-world procedures. Inter-rater agreement was at least moderate in all dimensions which is similar to other studies using NTS observational tools in surgery , 49. OurThird, given the key role of NTS in technology-facilitated surgery and the high pace of technological innovations in surgery, we deem that our multi-step approach may serve as a blueprint for similar attempts to capture teamwork behaviours in high-technology care settings. Given the increasing role of new technology in the OR, multi-disciplinary and inter-professional teamwork will remain crucial for a safe and efficient delivery of surgical care , 57. We Our study has some limitations. First, we conducted our observations (step 1 and 6) in four university or teaching hospitals in Germany, all working with da Vinci surgical systems. This may limit our proposed behaviours, as possible differences between countries or across robotic systems were not identified. Notwithstanding, our scoping review accounted for variety in RAS practice as the included articles originated from various countries. Just one article specified dealing with a different robotic system, which was, however, similar in setup and resulting challenges . The da Second, bias inherent to observational studies may have occurred, i.e., participant reactivity and observer bias . Also, sThird, for expert validation we used a convenience sample of OR staff from only two surgical departments. Our sample size of experts may incur bias concerning institutional practices that are idiosyncratic to specific departments. Our geographically restricted sample of experts and imbalance across professions may have influenced the results of our Delphi consensus study. However, the opinions and behaviours of our experts are in line with the results of our literature review. Future research should investigate how teamwork behaviours in RAS depend upon set-ups .Last, we may have possibly missed some relevant literature in our scoping review . However, most of the extracted behaviours were consistently mentioned in several of included publications. Additionally, all interviewed expert clinicians deemed the set of behaviours comprehensive. Hence, we assume that all relevant behaviours have been identified. Our scoping review is a first step in examining the literature base of specific NTS in RAS. In the future, methodological quality of included studies may be evaluated and taken into account. In fact, a previous systematic review on a topic comparable to ours concluded that the available literature base on NTS within RAS has methodological limitations .With regard to implications for future research, RAS-NOTECHS can be applied during observation of real-life procedures and correlated with procedure or patient outcomes in order to expand the current knowledge about the effect of NTS on quality of healthcare delivery. RAS-NOTECHS may assist in assessing effects of teamwork trainings by comparing RAS-NOTECHS scores before and after a training session . In heaFuture research should consider potential influences on RAS teamwork that we did not specifically address in the development and validation of RAS-NOTECHS, such as low- vs. high-complexity procedures, team familiarity , and dealing with intraoperative events or disruptions .With regard to implications for surgical practice, the set of RAS-specific behaviours itself can serve as a basis for teaching teamwork in RAS. We found that OR staff already perform most of the identified behaviours in open surgery, but to a lesser extent compared to RAS, implicating that almost no new skills need to be taught in RAS-NTS training. In fact, our findings advocate that existent skills need to be considered and targeted in RAS-training and education. To this end, already existing and applied training approaches might be adapted , 65, 66.Our new knowledge might be taken into account for the future design of robotic surgical technologies in order to facilitate intraoperative teamwork. We found that many RAS-specific behaviours are necessary to compensate for challenges introduced by the surgical robot, such as obstructed views between console surgeon and the rest of team, bulky equipment , difficuIn our study, we introduce RAS-NOTECHS—the first behavioural rating system for multidisciplinary NTS in RAS. We deployed a stepwise mixed-methods approach combining the current evidence base, expert knowledge, and real-life observations. RAS-NOTECHS is reliable and can be used to identify RAS-specific behavioural markers in real-life procedures. Our study provides assessment methodologies for future research investigating the role of NTS for safety and quality of delivery of surgical care in technology-facilitated teamwork.Supplementary file 1 (DOCX 73 kb)Below is the link to the electronic supplementary material.