Key Considerations for Designing Clinical Studies to Evaluate Digital Health Solutions

Evidence of clinical impact is critical to unlock the potential of digital health solutions (DHSs), yet many solutions are failing to deliver positive clinical results. We argue in this viewpoint that this failure is linked to current approaches to DHS evaluation design, which neglect numerous key characteristics (KCs) requiring specific scientific and design considerations. We first delineate the KCs of DHSs: (1) they are implemented at health care system and patient levels; (2) they are "complex" interventions; (3) they can drive multiple clinical outcomes indirectly through a multitude of smaller clinical benefits; (4) their mechanism of action can vary between individuals and change over time based on patient needs; and (5) they develop through short, iterative cycles-optimally within a real-world use context. Following our objective to drive better alignment between clinical evaluation design and the unique traits of DHSs, we then provide methodological suggestions that better address these KCs, including tips on mechanism-of-action mapping, alternative randomization methods, control-arm adaptations, and novel end-point selection, as well as innovative methods utilizing real-world data and platform research.

Risk Factors Associated With Bullying in Context of a Territory Exposed to Armed Conflict: A Cross-sectional Study

School violence and bullying are current and problematic events during adolescence. They are likely to have a marked presence in places highly exposed to armed conflict and violent environments, representing a double public health problem. The study aims to estimate the prevalence of different types of school violence perpetrated and experienced by school adolescents in a community with a history of exposure to armed conflict. Two thousand one hundred eighty-five school adolescents from a municipality in Colombia (males = 54.1%, 14-16 years = 38.6%) participated in the study. Nine educational institutions were included. A systematic random sampling was designed, with a proportional allocation of 35% within each school year from sixth to eleventh grade. The School Coexistence and Circumstances Affecting it-ECECA survey was applied. The prevalence and risks of bully and bullying were estimated. RRa were calculated with the 95% confidence interval adjusted for the other confounding variables. Analyses were constructed from generalized linear models, under the Poisson family and a logarithmic link function. We found a 9.3% of bullying victimization and a 3.5% prevalence of bully. A higher risk of bully was found among males, persons between 10 and 14 years of age, residents of rural or urban dispersed areas, residents of violent neighborhoods, alcohol consumers at school, and victims of aggression in childhood (RRa > 1.0, p-values <.05). The risk of victimization of bullying was higher in students younger than 15 years old, as residents of urban areas, having a history of childhood aggression, suffering abuse by a close person, and as alcohol users at school. This study provides evidence of risk factors for aggression and bullying that have implications for possible prevention measures in multiple social domains, including the individual, the family, and the school environment.

Discriminant analysis of ecological factors influencing sarcopenia in older people in South Korea

This study aimed to investigate the ecological system factors that influence discrimination of sarcopenia among older individuals living in contemporary society. Data analysis included information from 618 older adults individuals aged 65 years or older residing in South Korea. To assess variations in ecological system factors related to SARC-F scores, we conducted correlation analysis and t-tests. Discriminant analysis was used to identify factors contributing to group discrimination. The key findings are summarized as follows. First, significant differences at the p < 0.001 level were observed between the SARC-F score groups in various aspects, including attitudes toward life, wisdom in life, health management, social support, media availability, sports environment, collectivist values, and values associated with death. Further, service environment differences were significant at p < 0.01 level, while social belonging and social activities exhibited significance at p < 0.05. Second, factors influencing group discrimination based on the SARC-F scores were ranked in the following order: health management, attitudes toward life, fear of own death, wisdom in life, physical environment, sports environment, media availability, social support, fear of the own dying, collectivist values, service environment, social activities, and social belonging. Notably, the SARC-F tool, which is used for sarcopenia discrimination, primarily concentrates on physical functioning and demonstrates relatively low sensitivity. Therefore, to enhance the precision of sarcopenia discrimination within a score-based group discrimination process, it is imperative to incorporate ecological system factors that exert a significant influence. These modifications aimed to enhance the clarity and precision of the text in an academic context.

Floral resource partitioning of coexisting bumble bees: Distinguishing species-, colony-, and individual-level effects

Resource partitioning is considered a key factor in alleviating competitive interactions, enabling coexistence among consumer species. However, most studies have focused on resource partitioning between species, ignoring the potentially critical role of intraspecific variation in resource use. We investigated floral resource partitioning across species, colonies, and individuals in a species-rich bumblebee community in the diversification center of bumblebees. We used a total of 10,598 bumblebees belonging to 13 species across 5 years in the Hengduan Mountains of southwest China. First, we evaluated the influence of a comprehensive set of floral traits, including both those related to attractiveness (flower color and shape) and rewards (pollen, sugar ratio, nectar volume, sugar concentration, and amino acid content) on resource partitioning at the species level in bumblebee-plant networks. Then, we explored intraspecific resource partitioning on the colony and individual levels. Our results suggest that bumblebee species differ substantially in their use of the available floral resources, and that this mainly depends on flower attractiveness (floral color and shape). Interestingly, we also detected floral resource partitioning at the colony level within all commonest bumblebee species evaluated. In general, floral resource partitioning between bumblebee individuals decreased with species- and individual-level variation in body size (intertegular span). These results suggest that bumblebee species may coexist via the flexibility in their preferences for specific floral traits, which filters up to support the co-occurrence of high numbers of species and individuals in this global hotspot of species richness.

Individual variation in life-history timing: synchronous presence, asynchronous events and phenological compensation in a wild mammal

Many animals and plants have species-typical annual cycles, but individuals vary in their timing of life-history events. Individual variation in fur replacement (moult) timing is poorly understood in mammals due to the challenge of repeated observations and longitudinal sampling. We examined factors that influence variation in moult duration and timing among elephant seals (Mirounga angustirostris). We quantified the onset and progression of fur loss in 1178 individuals. We found that an exceptionally rapid visible moult (7 days, the shortest of any mammals or birds), and a wide range of moult start dates (spanning 6-10× the event duration) facilitated high asynchrony across individuals (only 20% of individuals in the population moulting at the same time). Some of the variation was due to reproductive state, as reproductively mature females that skipped a breeding season moulted a week earlier than reproductive females. Moreover, individual variation in timing and duration within age-sex categories far outweighed (76-80%) variation among age-sex categories. Individuals arriving at the end of the moult season spent 50% less time on the beach, which allowed them to catch up in their annual cycles and reduce population-level variance during breeding. These findings underscore the importance of individual variation in annual cycles.

Weight management in rural health clinics: Results from the randomized midwest diet and exercise trial

Introduction

Rural living adults have higher rates of obesity compared with their urban counterparts and less access to weight management programs. Previous research studies have demonstrated clinically relevant weight loss in rural living adults who complete weight management programs delivered by university affiliated interventionists. However, this approach limits the potential reach, adoption, implementation, and maintenance of weight management programs for rural residents. Weight management delivered through rural health clinics by non-physician clinic associated staff, for example, nurses, registered dieticians, allied health professionals, etc. has the potential to improve access to weight management for rural living adults. This trial compared the effectiveness of a 6-month multicomponent weight management intervention for rural living adults delivered using group phone calls (GP), individual phone calls (IP) or an enhanced usual care control (EUC) by rural clinic associated staff trained by our research team.

Methods

Rural living adults with overweight/obesity (n = 187, age ∼ 50 years 82% female, body mass index ∼35 kg/m2) were randomized (2:2:1) to 1 of 3 intervention arms: GP, which included weekly ∼ 45 min sessions with 7-14 participants (n = 71), IP, which included weekly ∼ 15 min individual sessions (n = 80), or EUC, which included one-45 min in-person session at baseline.

Results

Weight loss at 6 months was clinically relevant, that is, ≥5% in the GP (-11.4 kg, 11.7%) and the IP arms (-9.1 kg, 9.2%) but not in the EUC arm (-2.6%, -2.5% kg). Specifically, 6 month weight loss was significantly greater in the IP versus EUC arms (-6.5 kg. p ≤ 0.025) but did not differ between the GP and IP arms (-2.4 kg, p > 0.025). The per participant cost per kg. weight loss for implementing the intervention was $93 and $60 for the IP and GP arms, respectively.

Conclusions

Weight management delivered by interventionists associated with rural health clinics using both group and IP calls results in clinically relevant 6 months weight loss in rural dwelling adults with overweight/obesity with the group format offering the most cost-effective strategy. Clinical trial registration: ClinicalTrials.gov (NCT02932748).

Mapping individual structural covariance network in development brain with dynamic time warping

A conspicuous property of brain development or maturity is coupled with coordinated or synchronized brain structural co-variation. However, there is still a lack of effective approach to map individual structural covariance network. Here, we developed a novel individual structural covariance network method using dynamic time warping algorithm and applied it to delineate developmental trajectories of topological organizations of structural covariance network from childhood to early adulthood with a large sample of 655 individuals from Human Connectome Project-Development dataset. We found that the individual structural covariance network exhibited small-worldness property and the network global topological characteristics including small-worldness, global efficiency, local efficiency, and modularity linearly increase with age while the shortest path length linearly decreases with age. The nodal topological properties including betweenness and degree increased with age in language and emotion regulation related brain areas, while it decreased with age mainly in visual cortex, sensorimotor area, and hippocampus. Moreover, the topological attributes of structural covariance network as features could predict the age of each individual. Taken together, our results demonstrate that dynamic time warping can effectively map individual structural covariance network to uncover the developmental trajectories of network topology, which may facilitate future investigations to establish the links of structural co-variations with respect to cognition and disease vulnerability.

Effects of the Individual and Pair Housing of Calves on Long-Term Heifer Production on a UK Commercial Dairy Farm

Pair housing of pre-weaning dairy calves has previously demonstrated positive impacts on their growth, health and behaviour, but longer-term effects on production are still relatively unknown. This study followed a cohort of 431 Holstein heifers, recruited from a single UK commercial dairy farm, from weaning until either culling or the end of their first lactation. All animals were allocated to either individual or pair housing as a pre-weaning calf. Following weaning, all heifers were similarly managed through group housing, feeding with total mixed rations, the use of automatic heat detection for artificial insemination and weighing every two months until conception. Farm staff identified disease occurrences, which were treated following standard operating procedures. First-lactation monthly milk recording was used to measure milk yields and somatic cell counts. Overall mortality (voluntary and involuntary) was 26.6%, with a decreased hazard of exiting the herd if the heifer was pair housed as a calf (HR 0.70; p = 0.067). The voluntary cull rate was highest in the post-insemination period (13.0%) due to poor fertility. Heifers that were pair housed as calves had significantly increased odds of developing udder health issues as a primiparous cow (OR = 1.93, p = 0.022). Despite this, the 305-day milk yields were not associated with the housing group. However, the total milk produced per calf recruited into the original study was greater for pair-housed compared with individually housed calves (8088 kg vs. 7115 kg; p = 0.071), which is likely due to the significantly higher hazard of individually housed calves exiting the herd prematurely.

Rest reduces venous lactate levels significantly in patients in outpatient clinic

Lactate is produced in the human body during physical activity and elimination takes time with a half-life of approximately 18 min. We, therefore, investigated the potential impact of resting time (RT) duration on lactate concentration in our outpatient venipuncture clinic for all lactate requests during a 4½-year period. All samples drawn for venous lactate analysis during a 4½-year period in our hospital outpatient venipuncture clinics were included in this study. RT was reported electronically at each visit. Results from a total of 831 samples were obtained for further analysis. We found varying lactate concentrations across resting time <15min (median 1.6 mmol/L, IQR[1.2-2.1] mmol/L), between <15 min and >30 min (median 1.4 mmol/L, IQR[1.0-1.9] mmol/L) and for >30 min (median 1.3 mmol/L, IQR[1.0-1.7] mmol/L). There was a significant difference between <15 min versus 15-30 min (p = 0.015), which gives a 17.7% higher lactate from 15-30 min to <15 min. There was a significant 28.3% increase in mean lactate concentration from >30min to <15min (p < 0.0001) when corrected for age. We found that lactate concentration was dependent on RT in the outpatient clinic. The difference was clinically significant. Based on the results of this study, we, therefore, conclude that a 15 min waiting time before venipuncture for lactate sampling in an outpatient clinic is of clinical importance.

Determinants of the unmet needs for information, education and communication on sexual health among single youths in Burundi

The prevalence of HIV/AIDS among young people aged 15-24 in urban areas is at least 12 times higher among girls than boys in Burundi, while it is twice as high in Rwanda. The gap between the two countries could be narrowed if Burundi's single young people were provided with sufficient information about their sexual health through appropriate channels. The aim of this study was to examine the social and individual "determinants" of unmet needs for sexual health information, education and communication (IEC) among unmarried young boys and girls aged 15-24 in Burundi, using data from the 2016 Demographic and Health Survey (DHS). Data were analyzed at the bivariate level using cross-tabulations and chi-squared tests, and at the multivariate level using binary logistic regression methods. According to the results of the study, the 'determinants' of the phenomenon studied are, for both sexes, the size of the household, the age of the youths, their level of education, their knowledge of where to take the HIV/AIDS test and their region of residence; only in the case of boys do we find, in addition, the age of the head of the household, his level of education and the adolescents' exposure to the media; similarly, only in the case of girls do we find their economic activity and their perception of HIV/AIDS. Multisectoral IEC actions on sexual health for young people should therefore be strengthened in Burundi.

Do you see the pattern? Make the most of sensor data in dairy cows

Sensors are increasingly being used to monitor animal behaviour. Data handling methods have, however, lagged behind the continuous data stream to some extent, often being limited to summarizing data into daily averages at group level. This research reflection presents our opinion of the neglected application of 24-h pattern analysis. Recent studies of dairy cow behaviour have demonstrated that additional ways of analysing data improve our understanding of animal behaviour and add value to data that were already retrieved. The terminology for the described 24-h patterns differs between these studies, making them difficult to compare. Thus, diurnal, circadian, daily, periodicity and 24-h pattern are all terms used to describe dairy cow activities over a 24-h period. Several studies have shown that the 24-h behavioural pattern at herd level is relatively consistent over time, and that with well-established management routines, a specific herd signature will be evident. However, within a herd, individual cows may have individual 24-h patterns with more or less variability. Recent studies suggest that deviations from herd and/or individual 24-h patterns can be used to describe cow robustness, as well as to predict disease. We strongly believe that individual and herd 24-h patterns provide a great deal of information about behaviour and that these patterns offer opportunity for more precise and timely health management and welfare monitoring.

Effects of Individual and Pair Housing of Calves on Short-Term Health and Behaviour on a UK Commercial Dairy Farm

Social pair housing of calves has previously demonstrated positive impacts for calves, so this study aimed to compare the health and behaviour of calves kept in individual compared to pair housing on a single commercial UK dairy farm. A total of 457 Holstein and Jersey heifer calves were recruited and systematically allocated to individual and pair housing. Weekly visits were conducted up to 8 weeks of age, with weight and presence of clinical disease measured using both a standardized scoring system and thoracic ultrasonography. A subset of calves (n = 90) had accelerometers attached to monitor activity, with CCTV placed above a further 16 pens to allow behavioural assessments to be made via continuous focal sampling at 1 and 5 weeks of age. During the study, there was a mortality rate of 2.8%, and an average daily liveweight gain (ADLG) of 0.72 kg/day, with no significant effect of housing group (p = 0.76). However, individually housed calves had increased odds of developing disease (OR = 1.88, p = 0.014). Accelerometer data showed that housing group had no effect on lying times, with a mean of 18 h 11 min per day (SD 39 min) spent lying down. The motion index was significantly higher in pair-housed calves (F_1,83 = 440.3, p < 0.01), potentially due to more social play behaviour. The total time engaged in non-nutritive oral behaviours (NNOBs) was not impacted by housing group (p = 0.72). Pair-housed calves split their time conducting NNOBs equally between inanimate objects and on their pen mates' body. Individually housed calves spent significantly more time with their head out of the front of the pen (p = 0.006), and also engaged in more self-grooming than pair-housed calves (p = 0.017), possibly due to a lack of socialization. The overall findings of this study indicate that within a UK commercial dairy management system, pair-housed calves were healthier and more active than individually housed calves, while housing group did not influence ADLG or the occurrence of NNOBs.

Objective and subjective career success: individual, structural, and behavioral determinants on European hybrid workers

Introduction

In the current worldwide labor context, where a disruption took place and employees experience.

Methods

Participated in this study 739 European hybrid workers who fulfilled an online assessment protocol.

Results

Results indicate that higher ages, higher educational levels, being married, having children, working.

Discussion

This study makes a unique contribution to the extant research on hybrid workers' careers, specifically.

Factors Affecting High Body Weight Variability

Background

High body weight variability (BWV) is associated with many metabolic and cardiovascular diseases in adults. The study was designed to explore the baseline characteristics associated with high BWV.

Methods

Using a nationally representative database from the Korean National Health Insurance system, 77,424 individuals who underwent five health examinations between 2009 and 2013 were enrolled. BWV was calculated using the body weight recorded at each examination, and the clinical and demographic characteristics associated with high BWV were investigated. High BWV was defined as the highest quartile of coefficient variation in body weight.

Results

Subjects with high BWV were younger, more commonly women, less likely to have a high income, and more likely to be a current smoker. Young people under the age of 40 years were more than twice as likely to have high BWV compared with those over 65 years (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.88 to 2.50). The incidence of high BWV was higher in women than in men (OR, 1.67; 95% CI, 1.59 to 1.76). Men with the lowest income had a 1.9-fold higher risk of high BWV compared to men with the highest income (OR, 1.97; 95% CI, 1.81 to 2.13). A high BWV in women was associated with heavy alcohol intake (OR, 1.50; 95% CI, 1.17 to 1.91) and current smoking (OR, 1.97; 95% CI, 1.67 to 2.33).

Conclusion

Young people, women, low income, and unhealthy behaviors were independently associated with high BWV. Further research is needed on the mechanisms linking high BWV to detrimental health outcomes.

Addressing the Relationship between Leaf Nitrogen and Carbon Isotope Discrimination from the Three Levels of Community, Population and Individual

The carbon, nitrogen and water cycles of terrestrial ecosystems are important biogeochemical cycles. Addressing the relationship of leaf nitrogen (N) and carbon isotope discrimination (Δ) will enhance the understanding of the links between these three cycles in plant leaves because Δ can reflect time-integrated leaf-level water-use efficiency (WUE) over the period when the leaf material is produced. Previous studies have paid considerable attention to the relationship. However, these studies have not effectively eliminated the interference of environmental factors, inter-species, and inter-individual differences in this relationship, so new research is necessary. To minimize these interferences, the present work explored the relationship at the three levels of community, population, and plant individual. Three patterns of positive, negative and no relationship were observed across communities, populations, and individuals, which is dependent on environmental conditions, species, and plant individuals. The results strongly suggested that there is no general pattern for the relationship between leaf N and Δ. Furthermore, the results indicated that there is often no coupling between leaf-level long-term WUE and leaf N in the metabolic process of carbon, N and water in leaves. The main reason for the lack of this relationship is that most plants do not invest large amounts of nitrogen into photosynthesis. In addition, the present study also observed that, for most plant species, leaf N was not related to photosynthetic rate, and that variations in photosynthetic rates are mainly driven by stomatal conductance.

Individual, Peer, and Family Correlates of Depressive Symptoms among College Students in Hong Kong

In this study, an ecological model and developmental psychopathology theory focusing on an ontogenic system (hopelessness) and microsystems (peer alienation and childhood abuse and trauma) was adopted to examine the individual, peer, and family correlates of depressive symptoms among college Chinese students in Hong Kong, China. A cross-sectional survey research design with a convenience sampling procedure was used to examine a sample of college students (n = 786) aged 18 to 21 years old in Hong Kong. Among them, 352 respondents (44.8%) reported having depressive symptoms, with a Beck Depression Inventory-II (BDI-II) score of 14 or above. The results of this study indicated that childhood abuse and trauma, peer alienation, and hopelessness were positively related to depressive symptoms. The underlying arguments and implications were discussed. The study results provided further support for the ecological model and the developmental psychopathology theory on the predictive roles of individual, peer, and family correlates of adolescent depression.

Superior fixation strength of coronoid process replacement using individually designed 3D printed prosthesis with curved cemented intramedullary stem

BACKGROUND

Coronoid fractures frequently occur as part of complex elbow injuries and account for 2-15% of the cases with dislocations. Comminuted fractures and non-unions necessitate surgical treatment. Considering the latest technological advancements, the aim of this study was to investigate the fixation strength of coronoid replacement using an individualized 3D printed prosthesis with curved cemented intramedullary stem versus both radial head grafted reconstruction and coronoid fixation.

METHODS

Twenty-four human cadaveric paired forearms were stripped of soft tissue and their CT scanned ulnas were randomized to four groups for coronoid replacement (prosthesis group), radial head grafted reconstruction (radial head group), fixation (fixation group) or no treatment (intact group). The ulnas in all groups except the intact one were osteotomized at 40% of the coronoid height and either replaced with a 3D printed stainless-steel coronoid prosthesis with curved cemented intramedullary stem, individually designed based on the contralateral scan (prosthesis group), reconstructed with an ipsilateral radial head autograft fixed with two anteroposterior screws (radial head group), or coronoid process fixed in situ with two anteroposterior screws (fixation group). All specimens were biomechanically tested under ramped quasi-static axial loading.

RESULTS

Bone mineral density was not significantly different among the groups (p=0.95). Stiffness and failure load in the prosthesis group was significantly higher compared to all other groups (p≤0.04) and in addition it was significantly lower in the fixation group compared to the intact group (=0.03), with no further detected significant differences among the groups (p≥0.72). Absorbed energy to failure in the prosthesis group was significantly more compared to both radial head and fixation groups (p≤0.04) but not versus the intact group. Failure deformation at the osteotomy site was not significantly different among the groups (p=0.26).

CONCLUSIONS

Coronoid process replacement using an anatomically shaped individually designed 3D printed prosthesis with curved cemented intramedullary stem seems to be an effective method to restore the coronoid buttress function under axial loading. This method provides superior fixation strength over both radial head grafted reconstruction and screw fixation.

Clinical update and commentary on psychiatric care for patients experiencing workplace bullying

OBJECTIVE

To provide a brief clinical research update and commentary advice on the practical psychiatric care of patients suffering workplace bullying.

CONCLUSIONS

While there is empirical research on the prevalence and impacts of workplace bullying, there is a relative dearth of clinical research into psychiatric patient care. Accordingly, we provide commentary on practical considerations that assist in psychiatric care planning and delivery.

Intraindividual variance of lower limb rotation in patients with bilateral knee osteoarthritis

Purpose

To determine the side-to-side difference in intraindividual rotation alignment of patients with bilateral varus-type knee osteoarthritis (OA) and compare it with control subjects.

Methods

This retrospective study enrolled 60 patients with bilateral varus-type knee OA and 50 control subjects. All cases underwent bilateral lower limb CT angiography. Bilateral femoral and tibial rotation alignment were measured, and the overall lower limb rotation was calculated by two different methods. Method 1 was calculated by subtracting angle of the femoral torsion from the tibial torsion and method 2 was determined by relative rotation of the femoral neck angle to bimalleolar angle. The intraindividual variance and differences between the two groups were analyzed.

Results

Both OA and control samples showed significant differences between right and left for all measurements. Femoral torsion for control group was 10.4 ± 5.5°, tibial torsion was -22.1 ± 6.1°, and overall leg rotation by method 1 was -15.6 ± 7.2° and method 2 was -11.7 ± 8.2°. Femoral torsion, tibial torsion, method 1, and method 2 in the patients with OA were 8.2 ± 6.3°, -18.6 ± 4.1°, -14.9 ± 7.9°, and -10.4 ± 7.6°, respectively. Patients with OA showed a more pronounced retroversion in the femur (p = 0.008) and more internal rotation in the tibia (p < 0.001). No statistical significance of both methods was found between the two groups. Patients with OA had a greater median side-to-side absolute difference in all measurements, though the differences of both two methods of overall lower limb rotation were not statistically significant.

Conclusions

The discrepancy of side-to-side differences of bilateral lower limb rotation ought to be noticed with caution in diagnosing and treating rotational deformities of the lower limb, especially for patients with bilateral knee OA.

Individual and Social Level Factors Influencing Repeated Pregnancy among Unmarried Adolescent Mothers in Katavi Region-Tanzania: A Qualitative Study

Adolescents’ pregnancy rates are still high in Tanzania, despite the efforts made by the national campaign. Within two years after the first pregnancy, adolescent mothers are more at risk of repeat conception. Repeated pregnancies are associated with increased maternal and perinatal outcomes. Katavi is a leading region in the country, with 45% adolescent pregnancy. Studies are scarce on factors influencing repeated pregnancy among unmarried adolescent mothers in the region. Therefore, this study explored the individual and social level factors influencing repeated pregnancy among unmarried adolescent mothers in the Katavi Region. An exploratory qualitative study, using key informant interviews (KIIs) was adopted for 16 participants. The study participants were unmarried adolescent mothers, aged 15–19 years, who were purposively sampled. Thematic analysis was used to analyze qualitative data. QSR Nvivo version 14 was used to analyze these data. The study established the individual factors influencing repeated pregnancy, which were inadequate sexuality knowledge, individually perceived barriers to contraceptive use, and the guarantee for marriage. Furthermore, the social factors identified were the power of decision-making, peer pressure, and the parent–child relationship. Inadequate education on sexuality is observed as a crucial factor influencing repeated pregnancy. Parents as primary educators should be encouraged to talk with their children, especially adolescent girls about sexual education.

Are individual or group interventions more effective for long-term weight loss in adults with obesity? A systematic review

Guidelines recommend individual and group interventions for weight loss, based on preference. Our 2009 systematic review compared long-term effectiveness of individual or group approaches to the same intervention, but there are new randomized controlled trials (RCTs) of high-quality data. We updated and expanded our previous systematic review. We searched Medline and Embase from 1966 to May 2021, and a clinical trial register from 1966 to 2017. Review Manager (5.4.1) was used to conduct meta-analysis. Ten RCTs were included. The primary outcome, mean weight change at final follow-up, was -1.33 kg (95% confidence interval CI: -2.04, -0.62; 10 trials, 2169 participants), favouring group interventions (p < .001). For the secondary outcomes, attainment of ≥5% body weight loss at final follow-up, the risk ratio (RR) was 1.36 (95% CI 1.05, 1.77; three trials, 1520 participants), favouring group interventions (p = .02); attrition at final follow-up was similar between group and individual arms of trials, RR 0.93 (95% CI 0.82, 1.07) (p = .31). Group interventions can be more effective than individual interventions for long-term weight loss in adults with obesity. However, few studies were included in the clinically relevant, secondary outcome measures. Research on delivering group processes in weight management is needed.

Nitrogen rates and plant density interactions enhance radiation interception, yield, and nitrogen use efficiencies of maize

The contributions of the different leaf layers to maize yields identified as middle leaf > lower leaf > upper leaf, where the vertical photosynthetically active radiation (PAR) in the canopy gradually decreases. We hypothesized that the allocation of more PAR and nitrogen (N) to the highest contributing leaves will would be beneficial for higher yields and N use efficiencies. The N application rate and plant density effectively regulated the canopy light and N distribution. We evaluated the interactive effects of N rate and plant density on the agronomic and ecophysiological characteristics of leaves at different orientations in a 2019/2020 field experiment. In this study, an N application rate of 180 kg ha^-1 coupled with a plant density of 82,500 plants ha^-1 achieved the highest yield and N recovery efficiency (NRE). In contrast to the traditional farming practices in northern China, the density was increased and N rate was reduced. Densification from 52,500 to 82,500 plants ha^-1 increased the population leaf area index (LAI) by 37.1% and total photosynthetically active radiation (TPAR) by 29.2%; however, excessive density (from 82,500 to 97,500 plants ha^-1) drastically reduced the proportion of TPAR by 28.0% in the lower leaves. With increased density, the leaf areas and angles of the upper leaves decreased much more than those of the other leaves, which allowed the middle and lower leaves to access more light, which manifested a smaller extinction coefficient for light (K _L). A high yield (>1,000 kg ha^-1) of maize could be achieved simultaneously with higher NRE; however, it was negatively correlated with internal N use efficiency (IE_N). Higher N concentrations and lower total performance index (PI _total ) in the lower leaves may be an important rationale for the reduction of IE_N in high-yielding maize. Additionally, decreased N rate without yield reduction under higher densities was primarily attributed to the more uniform vertical N distribution [a smaller extinction coefficient for N (K _N)]. These results suggest that the N fertilizer rate can be moderately reduced without a reduction in maize yield under high plant densities in northern China.

Who is More Likely to Report Medical Insurance Fraud in the Two Scenarios of Whether It Results in a Direct Loss of Individual Benefit? A Cross-Sectional Survey in China

Purpose

An individual’s willingness to report is largely related to whether he or she is a direct victim. This study takes two scenarios of whether medical insurance fraud results in a direct loss of personal benefit and explores the differences in individuals’ willingness to report and influencing factors in the two scenarios.

Methods

In this study, questionnaires were used and participants were selected from 571 individuals in eastern, central, and western China. Analysis was performed using descriptive statistics and logistic regression models.

Results

51.0% of individuals were willing to report when no direct loss of personal benefit was caused, and conversely, 78.3% of individuals were willing to report when direct loss of personal benefit was caused. The factors influencing the attitude dimension of individuals toward whistleblowing behavior were consistent in the two scenarios. In contrast, there were significant differences among the influences in the perceived behavioral control, consequence perception, and subjective norm dimensions.

Conclusion

There were significant differences in the willingness of individuals to report medical insurance fraud and the factors influencing it in both scenarios. The most significantly influencing factor difference was perceived behavioral control, a dimension that had an effect only when it did not result in a direct loss of personal benefit. When an individual’s direct interests are at stake, the individual’s fear for his or her safety is not a deterrent to his or her willingness to report. And when there is no loss of direct personal benefit, individuals care more about government measures to protect whistleblowers. There are differences in the subjects that influence individuals’ willingness to report in the two scenarios. The factors influencing the attitude dimension are the same in both scenarios, and the more supportive the attitude toward the whistleblower, the stronger the individual’s willingness to report will be.

Phenotypic, epigenetic, and fitness diversity within plant genotypes

Plant plastic responses to environmental variation, at scales smaller than the individual plant size, promote phenotypic and epigenetic diversity among repeated structures within genotypes. Different epigenetic marks in the somatic line can translate to the germline and seeds, generating a fitness patchwork in the progeny with unexplored effects on plant evolutionary dynamics.