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Short stature or short legs is associated with cardiometabolic disease. Few studies have addressed this issue in children, incorporated repeated measures, or studied modern cohorts.
We examined if change in total height, leg length and trunk length between two time points from early (median: 3.2 years) to mid-childhood (median: 7.7 years), with and without adjustment for concurrent change in adiposity (subscapular plus triceps skinfold thickness), was associated with mid-childhood cardiometabolic risk in 315 boys and 295 girls from Project Viva. The main outcome was a cardiometabolic risk score based on sex-specific internal z-scores for systolic blood pressure, waist circumference, homeostatic model assessment of insulin resistance, triglycerides and high-density lipoprotein-cholesterol.
Mean (SD) total height was 97.9 (4.5) cm in boys and 97.1 (4.7) cm in girls in early childhood and 129.1 (7.2) cm in boys and 128.3 (7.9) cm in girls in mid-childhood. Trunk length constituted about half of total height. In linear regression models adjusted for parental anthropometry and socio-demographics, faster growth in total height, leg length and particularly trunk length, were associated with higher cardiometabolic risk in mid-childhood. Per 1 cm annual increase in trunk length, the cardiometabolic risk score was 0.23 z-score (95% confidence interval [CI] 0.08, 0.39) higher among boys and 0.47 z-score (95% CI 0.33, 0.60) higher among girls. Estimates were attenuated after adjusting for adiposity (boys: 0.03 z-score, 95% CI -0.11, 0.18; girls: 0.32 z-score, 95% CI 0.19, 0.45).
Citation: Haugaard LK, Baker JL, Perng W, Belfort MB, Rifas-Shiman SL, Switkowski K, et al. (2016) Growth in Total Height and Its Components and Cardiometabolic Health in Childhood. PLoS ONE 11(9): e0163564. https://doi.org/10.1371/journal.pone.0163564
Editor: Junwen Wang, Mayo Clinic Arizona, UNITED STATES
Received: June 21, 2016; Accepted: September 11, 2016; Published: September 22, 2016
Copyright: © 2016 Haugaard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Institutional restrictions prohibit public availability of the data, but we will consider sharing the data upon request. Data are from the Project Viva study whose authors may be contacted at e-mail: Project_Viva@hphc.org.
Funding: This work was supported by the US National Institutes of Health (K24 HD069408, R37 HD 034568, P30 DK092924) and the Danish Heart Association (n 13-04-R95-A4441-22745). The sponsors of this study had no role in the data collection, study design, data analysis, data interpretation or the writing of the paper.
Competing interests: The authors have declared that no competing interests exist.
Slower fetal and infant growth followed by faster growth during childhood is positively associated with a higher risk of later coronary heart disease (CHD) and diabetes [1–3]. Studies investigating growth have mainly focused on weight gain, whereas linear growth has received far less attention. A Finnish cohort study found positive associations of growth in total height from birth to age 7 years with risk of adult CHD in girls, but not in boys [4, 5]. Likewise, a Danish cohort study reported associations of growth in total height from 7 to13 years, in both sexes, with higher risk of adult CHD . Similarly, investigators from the Avon Longitudinal Study of Parents and Children found positive relations between faster linear growth from infancy to age 10 years with systolic blood pressure at 10 years. However, studies in adults [7–14] and a few in children [15–17] have consistently shown that shorter leg length is associated with higher cardiometabolic risk. Because pre-pubertal linear growth occurs more in the legs than in the trunk, leg length may be a particularly sensitive indicator of early growth-influencing exposures such as nutrition, illness, and living circumstances [3, 18]. Therefore, assessing relations in childhood of height components with biomarkers of cardiometabolic risk, such as systolic blood pressure, waist circumference, insulin resistance and blood lipids may provide important insights into the origins of cardiometabolic disease.
Although all studies investigating height components aim to examine how pre-pubertal growth is associated with cardiometabolic risk, studies using repeated measures during childhood are lacking. Moreover, many of the prior studies included populations at substantial nutritional or socioeconomic risk, which may not be generalizable to modern populations in developed settings. Given the contradictory findings of both faster overall linear growth and shorter leg length being associated with higher cardiometabolic risk, we hypothesized that faster pre-pubertal growth, compared to normal growth, would be associated with higher cardiometabolic risk in childhood, and that these associations might be stronger for growth in trunk length than for growth in leg length. Furthermore, we hypothesized that the associations could be influenced by adiposity. We therefore investigated how growth in total height and its components between two time points in childhood were related to mid-childhood cardiometabolic risk, including whether the associations differed by concurrent changes in adiposity, in the Boston-area Project Viva cohort, a well-nourished population.
Participants were enrolled in Project Viva, during early pregnancy between 1999 and 2002, from obstetric practices of Atrius Harvard Vanguard Medical Associates in eastern Massachusetts . Of the 2128 singleton births, 992 attended an in-person visit in both early (median: 3.2 years) and mid-childhood (median: 7.7 years). From this analysis, we excluded children with mothers with a pre-pregnancy history of type I or type II diabetes (n = 6), whose gestational age at birth was less than 34 weeks (n = 13), and who reported diabetes (n = 2). Of these, we excluded 361 children who did not provide a blood sample at the mid-childhood visit. Thus our sample for analysis was 610 children (315 boys and 295 girls). Compared with the 610 participants in this analysis, the 1518 non-participants were somewhat less likely to have college-educated mothers (63% v. 68%) and to have annual household income exceeding $70,000 (57% v. 62%). However race/ethnicity, parental anthropometrics, and maternal age and marital status were similar. The study was approved by the Institutional Review Board of Harvard Pilgrim Health Care, and all procedures were conducted in accordance with established ethical standards. All mothers provided written informed consent, and children provided verbal assent at mid-childhood.
At in-person visits, trained research assistants measured standing and sitting heights to the nearest 0.1 cm using a wooden stadiometer (Shorr Productions, Olney, MD). We calculated leg length as the difference between standing and sitting heights. The research assistants also measured weight to the nearest 0.1 kg using an electronic scale (early childhood visit: Seca model 881, Seca Corporation, Hanover, Maryland, USA; mid-childhood visit: Tanita, Arlington Heights, IL), waist circumference at the level of the iliac crest using a non-stretchable measuring tape (Hoechstmass Balzer GmbH, Sulzbach, Germany), and subscapular and triceps skinfold thickness with Holtain calipers (Crosswell, Crymych, Pembrokeshire, UK). We calculated the sum of the two skinfold thicknesses to estimate overall adiposity.
Cardiometabolic risk parameters
For each child, we obtained up to five blood pressure measurements at one-minute intervals using an automated oscillometric recorder (Dinamap Critikon, Tampa, FL). The collection and storage of blood samples have been reported elsewhere [19, 20]. We measured fasting insulin using an electrochemiluminescence immunoassay. Fasting glucose was measured enzymatically (Roche Diagnostics, Indianapolis, IN). We calculated insulin resistance by using the homeostatic model assessment (HOMA-IR = fasting insulin [μU/mL] x fasting glucose [mg/dL]/405). Triglycerides and HDL-cholesterol were measured enzymatically with correction for endogenous glycerol.
The main outcome was a mid-childhood cardiometabolic risk score [20–22] derived as the mean of five sex-specific z-scores for systolic blood pressure, waist circumference, log-transformed HOMA-IR, log-transformed triglycerides and HDL-cholesterol (scaled inversely). A positive score indicates a higher cardiometabolic risk and a negative score indicates a lower cardiometabolic risk than the cohort average. We also examined components included in the cardiometabolic risk score individually.
Additional participant characteristics
At enrollment, we collected information on maternal age, height, pre-pregnancy weight, date of last menstrual period, education, marital status, household income and child’s sex via questionnaires and interviews. Mothers also provided information on the father’s height and weight. We calculated body mass index (BMI, kg/m2) for both parents. From hospital delivery records we collected information on sex, birthweight and delivery date. At the early childhood visit, parents reported the child’s race/ethnicity by choosing one or more of the following racial/ethnic groups when asked: “Which of the following best describes your child’s race or ethnicity?”: Hispanic or Latina, white or Caucasian, black or African American, Asian or Pacific Islander, American Indian or Alaskan Native, and other (please specify). At the mid-childhood visit, mothers reported signs of puberty, and we determined pubertal status on the basis of whether the mothers answered “no”, “barely started”, or “yes, definitely/complete” to development of body hair or breasts in girls, and in boys to development of body hair, deepening of voice, or development of facial hair.
We examined the correlations between early and mid-childhood anthropometrics using Spearman correlations. Given potential sex differences in cardiometabolic risk and childhood growth, we conducted analyses separately for boys and girls [23, 24], even though we only found sex-interactions for the associations between growth in leg length and cardiometabolic risk score (p = 0.02 when using the likelihood ratio test). We first examined bivariate relationships of early to mid-childhood growth in total height, leg length and trunk length, each expressed as cm/year, as well as early to mid-childhood change in adiposity (change in subscapular plus triceps skinfold thickness [mm/year]), with the mid-childhood cardiometabolic risk score. We then used multivariable linear regression models to examine associations of growth in total height and its components with cardiometabolic risk score and the individual cardiometabolic biomarkers. Before entering exposures as continuous variables in regression models, we ensured linearity of associations by examining exposures in sex-specific quartiles.
In the multivariable linear regression analysis, we started with base models including child’s age at each visit, child’s race/ethnicity, and baseline (early childhood) total height, leg or trunk length (Model 1). In the models for annual growth in leg length and trunk length we then added growth in the other height component to investigate the independent contributions of each (Model 2). Additionally, we adjusted for height and BMI of both parents (Model 3), and our final model also included marital status in pregnancy and level of maternal education, as potential socioeconomic confounding factors (Model 4). Higher effect estimates for the association between growth in total height and mid-childhood cardiometabolic risk score were observed for both sexes when excluding baseline total height in the model (S1 Table). This could potentially be caused by multicollinearity in the model between baseline total height and growth in total height. However, the widths of the confidence intervals were similar, which is not expected in the presence of multicollinearity. The change in effect estimate seen with the inclusion of baseline total height in our model could then be because baseline height also influences cardiometabolic risk. As the exclusion of baseline total height did not change our overall conclusions, and because dropping baseline leg or trunk length only minimally affected their associations with the cardiometabolic risk score, we included the respective baseline height component in our models. The interpretation is thus that we, in our models, investigate the effect of linear growth on cardiometabolic risk regardless of the child’s starting point. We also considered adjustment for birth weight for gestational age, household income, maternal pregnancy smoking status, duration of breastfeeding as well as pubertal status but their inclusion in the final model did not change estimated associations or conclusions. Thus we did not include them in the analyses.
As in our previous work investigating height components in Project Viva, we based our conclusions on models that included growth in ‘absolute’ leg length and trunk length . Some studies have used ratios (e.g. sitting height ratio and leg-to-trunk ratio), which are relevant when used in a clinical setting, but it can be challenging to interpret their coefficients when they are used in a regression, as e.g. a positive association of leg-to-trunk ratio with a chosen outcome could be due to either an increase in leg length or a decrease in trunk length.
As children with faster linear growth may accumulate more adipose tissue (S2 Table), we assessed the extent to which change in overall adiposity explained our findings by adding annual change in sum of skinfold thicknesses in the final model. We included all the cardiometabolic outcomes in native, untransformed, units after having examined the residuals from each model to make sure that the assumption of all cardiometabolic outcomes being normally distributed was reasonable.
We performed a series of sensitivity analyses: We investigated associations of total height and its components with systolic blood pressure and waist circumference in the larger group of children with at least one available outcome (n = 971), and as we found similar results we report everything for the smaller subgroup with additional information on blood outcomes (n = 610). As black children typically have longer legs than white children of the same age , we conducted an analysis for black (59 boys and 51 girls) and white (196 boys and 189 girls) children separately. The estimates were generally similar and we chose to adjust rather than stratify by race in our main analysis. Due to very low numbers of other race/ethnicities these were not included in the analysis.
To account for missing data, we performed multiple imputation for all 2128 mother-child pairs in Project Viva. We then limited the analysis to the 610 included participants. We provided information about the number of imputed values for all variables along with descriptive data for the 470 participants in the complete case analysis in S3 Table. We used SAS (Proc MI) to impute 50 values for each missing observation and combined multivariable modeling estimates using Proc MI ANALYZE in SAS version 9.3 (SAS Institute, Cary NC). An alternative approach, using only participants with all covariate data (complete case), yielded similar results.
We included 315 boys and 295 girls in the main analyses (Table 1). Boys were on average 0.8 cm taller than girls at both the early and the mid-childhood visit. Between the two visits (∆time: 2.0–7.5 years for boys, 1.3–7.4 years for girls) the annual growth in leg length and trunk length were almost the same in boys and girls, and as expected, gain in leg length (4.0 cm/y in both sexes) was larger than gain in trunk length (2.7 cm/y in boys and 2.9 cm/y in girls). The correlation between leg and trunk length was stronger in mid-childhood than in early childhood (Spearman correlation coefficients 0.62 and 0.42, respectively). Girls had similar blood pressure, but a greater increase in sum of skinfold thicknesses, higher levels of HOMA-IR and triglycerides, and lower levels of HDL-cholesterol than boys, and in mid-childhood more girls than boys had evidence of having entered puberty (11.0% vs. 6.9%). Additional information on the anthropometric and age variables as well as their mutual correlation coefficients is provided in S4 and S5 Tables.
By definition, the mean cohort-specific cardiometabolic risk score was 0. When investigating quartiles of linear growth we found that boys who were in the 3rd quartile and girls who were in the 4th quartile of growth in trunk length had a mean mid-childhood cardiometabolic risk score of 0.12 and 0.27 z-score, respectively, which were the highest scores observed across the quartiles of linear growth (Table 2). Children in the 4th quartile of change in overall adiposity had the highest observed cardiometabolic risk scores (boys: 0.50 z-score; girls: 0.56 z-score).
In both sexes the minimally adjusted multivariable linear regression analyses showed that greater increases in total height, leg length, and trunk length were positively associated with mid-childhood cardiometabolic risk score (Table 3, Model 1). In Model 2, additional adjustment for growth in the other height component strengthened the association for growth in leg length in girls, whereas minor changes were observed in boys. The association for growth in trunk length remained the same in both sexes after adjustment for leg length. Further adjustment for parental anthropometrics slightly strengthened the associations for growth in leg length in girls, but did otherwise not affect the associations in both sexes (Model 3). Adjustment for socioeconomic factors had essentially no influence on the associations (Model 4).
In general, associations with each of the five cardiometabolic outcomes were stronger for growth in trunk length than for growth in total height or leg length, although they were all largely in the same direction (Table 4). A 1 cm/year increase in trunk length among boys was associated with a 2.2 mmHg (95% confidence interval [CI] -0.2, 4.5) higher systolic blood pressure, a 4.8 cm (95% CI 3.0, 6.6) greater waist circumference, a 0.56 (95% CI 0.14, 0.97) higher HOMA-IR, a -0.57 mg/dL (95% CI -4.49, 3.36) lower HDL cholesterol-level, but a -2.06 mg/dL (95% CI -9.41, 5.29) lower level of triglycerides. In girls, a 1 cm/year increase in trunk length was associated with a 5.2 mmHg (95% CI 3.3, 7.1) higher systolic blood pressure, a 4.8 cm (95% CI 3.1, 6.4) greater waist circumference, a 0.86 (95% CI 0.50, 1.22) higher HOMA-IR, a 7.32 mg/dL (95% CI 0.95,13.70) higher level of triglycerides and a -4.31 mg/dL (95% CI -7.73, -0.90) lower HDL cholesterol-level.
In boys, it was especially the positive associations of growth in total height and its components with waist circumference along with the slightly weaker associations with systolic blood pressure and HOMA-IR that contributed to the higher cardiometabolic risk score in mid-childhood, whereas for girls the positive associations of growth in total height and its components with systolic blood pressure, waist circumference and HOMA-IR, almost equally contributed to the higher cardiometabolic risk score (Fig 1). The pattern was almost similar for boys and girls, but appeared stronger in girls. In girls, adjusting for change in adiposity attenuated the associations of total height and its components with cardiometabolic risk score with approximately 25%, whereas among boys all associations disappeared when adjusting for change in overall adiposity (Fig 2). The only associations that were not changed were associations of linear growth with systolic blood pressure among girls (results not shown).
Growth is expressed as cm/year. All outcomes are in z-scores. Associations are adjusted for child's age at the early (median age 3.2 years) and mid-childhood (median age 7.7 years) visit, race/ethnicity, baseline height component (early childhood), rate of growth in other height component, maternal height and pre-pregnancy body mass index, paternal height and body mass index, mother's education and marital status in pregnancy.
Abbreviations: HOMA-IR, homeostatic model assessment of insulin resistance; HDL, high-density lipoprotein. Gain in adiposity is assessed as the change in sum of subscapular and triceps skinfold thickness (mm/y) and growth is expressed as cm/year. The cardiometabolic risk score is composed of the mean of five sex-specific internal z-scores for systolic blood pressure, waist circumference, log-transformed HOMA-IR, log-transformed triglycerides and inverted HDL-cholesterol. Associations are adjusted for child's age at the early (median age 3.2 years) and mid-childhood (median age 7.7 years) visit, race/ethnicity, baseline height component (early childhood), rate of growth in other height component, maternal height and pre-pregnancy body mass index, paternal height and body mass index, mother's education and marital status in pregnancy
In this longitudinal study of US children, faster linear growth as assessed by annual increases in total height, leg length, and trunk length from early to mid-childhood was associated with a higher cardiometabolic risk in mid-childhood, with strongest associations observed for increases in trunk length. These associations were primarily due to positive associations with three of the five cardiometabolic risk score components: systolic blood pressure, waist circumference, and HOMA-IR. The associations were considerably stronger in girls, who also had a higher mean level of HOMA-IR, than in boys. The associations were largely unchanged when accounting for parental anthropometrics, suggesting that the observed associations are primarily due to factors other than genetics. In boys, the associations were explained by relationships of linear growth with overall adiposity, whereas this was only partly the case in girls.
Prior work in Project Viva demonstrated that growth in trunk length from early to mid-childhood is associated with an increase in systolic blood pressure during the period . In this study we extended those results by 1.) showing that linear growth in both sexes from early to mid-childhood is associated with a generally higher cardiometabolic risk, and 2.) trunk length growth is associated with an adverse cardiometabolic state more strongly than is increase in leg length.
In our prior work, we hypothesized that children with greater trunk length have higher blood pressures because an additional pressure is needed to overcome gravity to perfuse the brain . Even though we still find the strongest associations with trunk length and cardiometabolic risk in the current study, we do not think that a higher hydrostatic pressure explains the associations with components other than systolic blood pressure. In addition, our finding of change in overall adiposity explaining the associations with systolic blood pressure in boys does not favor this hypothesis, rather it suggests that, at least in part, factors that promote linear growth also promote fat accumulation, which in turn lead to adverse cardiometabolic outcomes. The most important external factor influencing linear growth is nutrition, with protein being the most essential single nutrient. Protein intake is associated with different specific growth hormones, e.g. insulin-like growth factor 1, which in turn has been found to be associated with risk of cardiometabolic disease [25, 26]. It was however beyond the scope of our study to investigate potential mediation through protein intake or hormone levels in childhood.
In contrast to our findings, among pre-pubertal children in 1937–1939 in the Boyd Orr cohort, leg length, but not trunk length, was associated with CHD in adulthood [15, 16]. Those results, however, were not based on repeated measurements or adjusted for adiposity. It is possible that underlying factors for the association between leg length and CHD seen in the historical Boyd Orr cohort, e.g. malnourishment, were not present to the same extent in our modern, well-nourished cohort. Moreover, it is possible that surrogate outcomes of cardiometabolic risk in childhood are not perfect predictors of adult cardiovascular disease even though a compound cardiometabolic risk score has been found to be a valid tool for detecting subclinical atherosclerosis in children  as well as predicting type 2 diabetes and cardiovascular outcomes in adults [22, 28].
Some studies among adults have found that trunk length is associated with insulin resistance and type 2 diabetes [8, 29, 30], a condition that is increasing in children and adolescents, especially among girls . In one study the association persisted after adjusting for current BMI , but in another study the association disappeared when adjusting for waist circumference . In our study, growth in trunk length was associated with higher HOMA-IR, and this association was explained by concurrent adiposity in boys, but only partially in girls. This finding aligns with findings in the Early Bird study, a cohort study of 300 schoolchildren in the UK, where higher levels of HOMA-IR existed among taller and faster- growing girls . As in our study, girls’ HOMA-IR levels were higher than in boys at age 5 years, regardless of levels of adiposity and physical activity . The authors suggested that HOMA-IR is a marker of linear growth as well as of adiposity, and that pre-pubertal girls are at higher risk of developing type 2 diabetes early in life because they are intrinsically more insulin resistant than boys [23, 24].
Other authors hypothesized that early onset of puberty explains why both faster pre-pubertal linear growth and shorter leg length in adulthood are associated with later cardiometabolic diseases . Girls reach puberty earlier than boys, which might explain the higher insulin resistance among girls. Our results do not support that hypothesis, as adjusting for puberty status did not change the results. However, only 6.9% boys and 11.0% girls had signs of having entered puberty, so longer follow-up is needed to further address this issue. Furthermore, adipose pre-pubertal children also experience faster linear growth, but it is still unclear whether their final height will be greater than that of their non-adipose peers [32–34].
Strengths of this study include repeated measurements of detailed anthropometry, consideration of parental anthropometry, and the availability of several different childhood cardiometabolic biomarkers. Although prospective evidence suggests that height components are related to later cardiometabolic disease, most research that includes markers of cardiometabolic health has been cross-sectional and has examined individual markers rather than a summary cardiometabolic risk score. Furthermore, we have not found any modern cohort studies investigating associations of childhood height components, or growth in height components, with cardiometabolic health.
There are also limitations to this study. Project Viva represents a relatively well-educated and high-income population despite its diverse racial and ethnic backgrounds, which means that findings may not be generalizable to lower socio-economic populations and settings in developing countries. Furthermore, we assumed, for practical reasons, that total height and sitting height provide sufficient information to partition stature into trunk and leg length. Calculating leg length from total height and sitting height, instead of measuring leg length from the greater trochanter to the floor, increases the measurement error as it is based on two measurements instead of one, which could bias the results for leg length towards the null. Moreover, buttock fatness may lead to overestimation of trunk length and consequently underestimation of leg length in overweight children  which could have biased our results in favor of stronger associations for trunk versus leg length. By adjusting for overall adiposity gain, however, we minimize this issue. We assumed the same rate of linear growth for every year between the two visits. This assumption is reasonable in a cohort of largely pre-pubertal children .
More rapid linear growth from early to mid-childhood, particularly in trunk length, was associated with higher cardiometabolic risk in mid-childhood, indicating that it may be of great importance to also consider linear growth when evaluating cardiometabolic biomarkers in childhood. The higher cardiometabolic risk was due to associations with not only systolic blood pressure but also waist circumference and HOMA-IR, suggesting a potential higher risk of developing hypertension, type II diabetes, and possibly cardiovascular disease later in life. The associations were explained by relationships of linear growth with overall adiposity in boys, but this was only partly the case for girls.
S1 Table. Multivariable linear regression models showing associations of growth in total height and its components from early to mid-childhood with cardiometabolic risk score in mid-childhood without adjusting for baseline total height or height component (610 participants from Project Viva).
Abbreviations: CI, confidence interval. Model 1: Adjusted for child’s age at the early and mid-childhood visit and child’s race/ethnicity. Model 2: Model 1 + rate of growth in other height component (i.e. rate of growth in leg length adjusted for rate of growth in trunk length and vice versa). Model 3: Model 2 + maternal pre-pregnancy body mass index and height and paternal body mass index and height. Model 4: Model 3 + maternal education and marital status in pregnancy. Growth is calculated as the difference in the respective variable between early and mid-childhood visit, divided by the time elapsed in years. The cardiometabolic risk score is composed of the mean of five sex-specific internal z-scores for systolic blood pressure, waist circumference, log-transformed HOMA-IR, log-transformed triglycerides and inverted HDL-cholesterol.
S2 Table. Associations of growth in total height and its components from early to mid-childhood with change in adiposity (610 participants from Project Viva).
Abbreviations: CI, confidence interval; y, year. All estimates are adjusted for child's age at both the early and mid-childhood visit, race/ethnicity, baseline height component (early childhood), rate of growth in other height component, maternal height and pre-pregnancy body mass index, education and marital status in pregnancy, and paternal height and body mass index (Model 4). Growth/Change is calculated as the difference in the respective variable between early and mid-childhood visit, divided by the time elapsed in years.
S3 Table. Number of imputed values for parental and child characteristics of 610 Project Viva participants as well as characteristics of 470 participants with unimputed information on all variables.
Abbreviations: BMI, body mass index; HDL, high-density lipoprotein; HOMA-IR, homeostatic model assessment of insulin resistance; y, year. Change is calculated as the difference in the respective variable between early and mid-childhood visit, divided by the time elapsed in years. The cardiometabolic risk score is composed of the mean of five sex-specific internal z-scores for systolic blood pressure, waist circumference, log-transformed HOMA-IR, log-transformed triglycerides and inverted HDL-cholesterol.
S4 Table. Additional descriptive characteristics of 610 Project Viva Participants.
Abbreviations: n, number; SD, standard deviation; SE, standard error; y, year
We are deeply grateful to the mothers and children who participated in Project Viva as well as the Project Viva staff. This work was supported by the US National Institutes of Health (K24 HD069408, R37 HD 034568, P30 DK092924) and the Danish Heart Association (n 13-04-R95-A4441-22745). The sponsors of this study had no role in the data collection, study design, data analysis, data interpretation or the writing of the paper. All authors declare no conflicts of interest
- Conceptualization: LKH JLB WP MBB SRS KS EO MWG.
- Formal analysis: LKH SRS.
- Funding acquisition: LKH.
- Methodology: LKH JLB WP MBB SRS KS EO MWG.
- Project administration: EO MWG.
- Supervision: EO MWG.
- Writing – original draft: LKH.
- Writing – review & editing: LKH JLB WP MBB SRS KS EO MWG.
- 1. Barker DJ, Osmond C, Forsen TJ, Kajantie E, Eriksson JG. Trajectories of growth among children who have coronary events as adults. The New England journal of medicine. 2005;353(17):1802–9. Epub 2005/10/28. pmid:16251536.
- 2. Bhargava SK, Sachdev HS, Fall CH, Osmond C, Lakshmy R, Barker DJ, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood. The New England journal of medicine. 2004;350(9):865–75. pmid:14985484; PubMed Central PMCID: PMC3408694.
- 3. Bogin B, Varela-Silva MI. Leg length, body proportion, and health: a review with a note on beauty. Int J Environ Res Public Health. 2010;7(3):1047–75. pmid:20617018; PubMed Central PMCID: PMC2872302.
- 4. Forsen T, Eriksson JG, Tuomilehto J, Osmond C, Barker DJ. Growth in utero and during childhood among women who develop coronary heart disease: longitudinal study. Bmj. 1999;319(7222):1403–7. pmid:10574856; PubMed Central PMCID: PMC28284.
- 5. Eriksson JG, Forsen T, Tuomilehto J, Winter PD, Osmond C, Barker DJ. Catch-up growth in childhood and death from coronary heart disease: longitudinal study. Bmj. 1999;318(7181):427–31. pmid:9974455; PubMed Central PMCID: PMC27731.
- 6. Silventoinen K, Baker JL, Sørensen TIA. Growth in height in childhood and risk of coronary heart disease in adult men and women. PloS one. 2012;7(1):e30476. pmid:22291964; PubMed Central PMCID: PMC3265486.
- 7. Lawlor DA, Davey Smith G, Ebrahim S. Association between leg length and offspring birthweight: partial explanation for the trans-generational association between birthweight and cardiovascular disease: findings from the British Women's Heart and Health Study. Paediatric and perinatal epidemiology. 2003;17(2):148–55. pmid:12675781.
- 8. Lawlor DA, Ebrahim S, Davey Smith G. The association between components of adult height and Type II diabetes and insulin resistance: British Women's Heart and Health Study. Diabetologia. 2002;45(8):1097–106. pmid:12189439.
- 9. Smith GD, Greenwood R, Gunnell D, Sweetnam P, Yarnell J, Elwood P. Leg length, insulin resistance, and coronary heart disease risk: the Caerphilly Study. J Epidemiol Community Health. 2001;55(12):867–72. pmid:11707479; PubMed Central PMCID: PMC1731819.
- 10. Weitzman S, Wang CH, Pankow JS, Schmidt MI, Brancati FL. Are measures of height and leg length related to incident diabetes mellitus? The ARIC (Atherosclerosis Risk in Communities) study. Acta diabetologica. 2010;47(3):237–42. pmid:19774332.
- 11. Ferrie JE, Langenberg C, Shipley MJ, Marmot MG. Birth weight, components of height and coronary heart disease: evidence from the Whitehall II study. International journal of epidemiology. 2006;35(6):1532–42. pmid:16931524.
- 12. Langenberg C, Hardy R, Kuh D, Wadsworth ME. Influence of height, leg and trunk length on pulse pressure, systolic and diastolic blood pressure. Journal of hypertension. 2003;21(3):537–43. pmid:12640247.
- 13. Gunnell D, Whitley E, Upton MN, McConnachie A, Smith GD, Watt GC. Associations of height, leg length, and lung function with cardiovascular risk factors in the Midspan Family Study. J Epidemiol Community Health. 2003;57(2):141–6. pmid:12540691; PubMed Central PMCID: PMC1732388.
- 14. Tilling K, Lawlor DA, Davey Smith G, Chambless L, Szklo M. The relation between components of adult height and intimal-medial thickness in middle age: the Atherosclerosis Risk in Communities Study. American journal of epidemiology. 2006;164(2):136–42. pmid:16707651.
- 15. Gunnell DJ, Davey Smith G, Frankel S, Nanchahal K, Braddon FE, Pemberton J, et al. Childhood leg length and adult mortality: follow up of the Carnegie (Boyd Orr) Survey of Diet and Health in Pre-war Britain. J Epidemiol Community Health. 1998;52(3):142–52. pmid:9616418; PubMed Central PMCID: PMC1756683.
- 16. Whitley E, Martin RM, Davey Smith G, Holly JM, Gunnell D. The association of childhood height, leg length and other measures of skeletal growth with adult cardiovascular disease: the Boyd-Orr cohort. J Epidemiol Community Health. 2012;66(1):18–23. pmid:20736489.
- 17. Regnault N, Kleinman KP, Rifas-Shiman SL, Langenberg C, Lipshultz SE, Gillman MW. Components of height and blood pressure in childhood. International journal of epidemiology. 2014;43(1):149–59. pmid:24413933; PubMed Central PMCID: PMC3937979.
- 18. Leitch I. Growth and health. Br J Nutr. 1951;5(1):142–51. pmid:14886531.
- 19. Oken E, Baccarelli AA, Gold DR, Kleinman KP, Litonjua AA, De Meo D, et al. Cohort Profile: Project Viva. International journal of epidemiology. 2014. pmid:24639442.
- 20. Cespedes EM, Rifas-Shiman SL, Redline S, Gillman MW, Pena MM, Taveras EM. Longitudinal associations of sleep curtailment with metabolic risk in mid-childhood. Obesity. 2014;22(12):2586–92. pmid:25234485; PubMed Central PMCID: PMC4236242.
- 21. Eisenmann JC, Laurson KR, DuBose KD, Smith BK, Donnelly JE. Construct validity of a continuous metabolic syndrome score in children. Diabetol Metab Syndr. 2010;2:8. pmid:20181030; PubMed Central PMCID: PMC2830968.
- 22. Viitasalo A, Lakka TA, Laaksonen DE, Savonen K, Lakka HM, Hassinen M, et al. Validation of metabolic syndrome score by confirmatory factor analysis in children and adults and prediction of cardiometabolic outcomes in adults. Diabetologia. 2014;57(5):940–9. pmid:24463933.
- 23. Wells JC, Cole TJ. Height, adiposity and hormonal cardiovascular risk markers in childhood: how to partition the associations? International journal of obesity. 2014;38(7):930–5. pmid:24509503; PubMed Central PMCID: PMC4088335.
- 24. Murphy MJ, Metcalf BS, Voss LD, Jeffery AN, Kirkby J, Mallam KM, et al. Girls at five are intrinsically more insulin resistant than boys: The Programming Hypotheses Revisited—The EarlyBird Study (EarlyBird 6). Pediatrics. 2004;113(1 Pt 1):82–6. pmid:14702453.
- 25. Perkins JM, Subramanian SV, Davey Smith G, Ozaltin E. Adult height, nutrition, and population health. Nutr Rev. 2016;74(3):149–65. pmid:26928678; PubMed Central PMCID: PMCPMC4892290.
- 26. Kajantie E, Fall CH, Seppala M, Koistinen R, Dunkel L, Yliharsila H, et al. Serum insulin-like growth factor (IGF)-I and IGF-binding protein-1 in elderly people: relationships with cardiovascular risk factors, body composition, size at birth, and childhood growth. J Clin Endocrinol Metab. 2003;88(3):1059–65. pmid:12629086.
- 27. Pandit D, Chiplonkar S, Khadilkar A, Kinare A, Khadilkar V. Efficacy of a continuous metabolic syndrome score in Indian children for detecting subclinical atherosclerotic risk. International journal of obesity. 2011;35(10):1318–24. pmid:21772245.
- 28. Hillier TA, Rousseau A, Lange C, Lepinay P, Cailleau M, Novak M, et al. Practical way to assess metabolic syndrome using a continuous score obtained from principal components analysis. Diabetologia. 2006;49(7):1528–35. pmid:16752171; PubMed Central PMCID: PMCPMC3505191.
- 29. Schooling CM, Jiang C, Lam TH, Thomas GN, Heys M, Bmbs, et al. Height, its components, and cardiovascular risk among older Chinese: a cross-sectional analysis of the Guangzhou Biobank Cohort Study. Am J Public Health. 2007;97(10):1834–41. pmid:17761579; PubMed Central PMCID: PMC1994197.
- 30. Johnston LW, Harris SB, Retnakaran R, Gerstein HC, Zinman B, Hamilton J, et al. Short leg length, a marker of early childhood deprivation, is associated with metabolic disorders underlying type 2 diabetes: the PROMISE cohort study. Diabetes care. 2013;36(11):3599–606. pmid:24089539; PubMed Central PMCID: PMC3816896.
- 31. Ehtisham S, Hattersley AT, Dunger DB, Barrett TG, British Society for Paediatric E, Diabetes Clinical Trials G. First UK survey of paediatric type 2 diabetes and MODY. Arch Dis Child. 2004;89(6):526–9. pmid:15155395; PubMed Central PMCID: PMC1719947.
- 32. De Leonibus C, Marcovecchio ML, Chiavaroli V, de Giorgis T, Chiarelli F, Mohn A. Timing of puberty and physical growth in obese children: a longitudinal study in boys and girls. Pediatric obesity. 2014;9(4):292–9. pmid:23713062.
- 33. Zheng W, Suzuki K, Sato M, Yokomichi H, Shinohara R, Yamagata Z. Adolescent growth in overweight and non-overweight children in Japan: a multilevel analysis. Paediatric and perinatal epidemiology. 2014;28(3):263–9. pmid:24641668.
- 34. Kleber M, Schwarz A, Reinehr T. Obesity in children and adolescents: relationship to growth, pubarche, menarche, and voice break. J Pediatr Endocrinol Metab. 2011;24(3–4):125–30. pmid:21648278.
- 35. Bogin B, Varela-Silva MI. Fatness biases the use of estimated leg length as an epidemiological marker for adults in the NHANES III sample. International journal of epidemiology. 2008;37(1):201–9. pmid:18184670.
- 36. Tanner JM. Normal growth and techniques of growth assessment. Clin Endocrinol Metab. 1986;15(3):411–51. pmid:3533329.

domain: literature


text: Hey Everybody, Rick here...I know this is NOT a Bond film. But the fact that Sean Connery was in this movie and we made mention about it quite a bit in the episode....well...I could not resist dropping it in this week. I have never had the time or the opportunity to sit down and watch this movie but it looks pretty weird. That said, here is the trailer. Enjoy? And join us tomorrow for Part 2 or Episode 50!

domain: entertainment


text:
// Home / Outdoor Activities / ANWB-walk "Heeswijk-Dinther - Brabantse bossen en een burcht"
ANWB-walk "Heeswijk-Dinther - Brabantse bossen en een burcht"
This page shows a few pictures of walk number 89 out of the many nice walks described in the "ANWB Wandelroutebox Nederland" (ISBN 9789018029944), Around the town of Heeswijk, The Netherlands. The box is available from the ANWB or for example from bol.com. All texts are in Dutch.
The distance of the walk is 12.5 km.
Some pictures of the walk
Here are some pictures of the walk to give you an impression, taken in January 2014.
Some deer in a garden in Fokkershoek.
Heeswijk Castle (Kasteel Heeswijk).
Approach to Heeswijk Castle (Kasteel Heeswijk).
Walking away from Heeswijk Castle (Kasteel Heeswijk).
Leigraaf canal near Kameren.
Bicycle lane (interesting when it is actually busy with bikes ....).

domain: geography


text:
Often, simply getting close to a subject addresses many of these challenges, and sure enough Read includes a fantastic chapter on the subject. Wildlife. ABA Blog A multi-authored blog from the American Birding Association with a focus on all things birding. Vanderpoel's effort was the last made without the major contribution of eBird and birding groups on Facebook, which significantly enhanced the quality and quantity of rare bird alerts. Laura Keene - 763 (2016) 5. First, do not panic! Famously gregarious, Cedar Waxwings are all about community. How to Know the Birds: No. Open in app; Sign up. Nate is an aviâ¦ By Nate Swick|2020-01-22T15:20:00-05:00January 10th, 2020|. New Jersey's 1st Wood Sandpiper, South Dakota's 1st Painted Redstart, and Florida's 1st Hermit Warbler. A Crimson-collared Grosbeak (ABA Code 4) continues in Texas. Yve Morrell. Given the explosive growth of digital bird photography in the last decade or so, there have been surprisingly few titles devoted to the topic despite the proliferation of birding books in the same time span. ABA's Birding News >> Georgia Georgia bird news by date. Log in; Kk. Essentially, Read pulls back the curtain on some really cool tricks of the trade here, which I think nicely illustrates the sharing nature of birding (versus, say, the mystery of a magic trick and taboo of sharing the secret behind it). Last week's Siberian Accentor (ABA Code 4) in Washington joins the familiar La Sagra's Flycatcher (4) in Florida and long-staying Garganey (4) in California in the continuing category. The folks at the feeding station are masked and socially distanced. 212-979-3070 â to hear updated recordings of unusual bird sightings in Greater New York. I love her opening statement that she considers âfield craft, creative vision, and determination as contributing far moreâ¦ than having the newest camera or biggest lens.â Read then states, and I fully agree, that photographers often want to talk about gear or get advice on what equipment to buy. Rare Bird Alert: November 13, 2020 - American Birding Association aba.org. By Nate Swick|2020-09-24T16:12:37-04:00September 25th, 2020|. The American Birding Association is a non-profit 501(c)(3) organization that provides leadership to birders by increasing their knowledge, skills, and enjoyment of birding. Updated on November 24, 2020, 2:20 am | View page in digest format ("Siler-style"). The ABA Blog is Dead; Long Live The ABA Blog! If they are not around when you arrive, it sometimes pays to wait. Want to easily find posts that mention ABA rare birds? The amazing Eared Quetzal irruption continues and New Mexico gets into the fun with its 1st record. Rare birds show up all the time, that is why you must always be on the lookout for unusual birds. As is typically the case, we ease into the rare bird world at the top of the year. GROUP GUIDELINES: This group is for sharing rare and notable reports from the ABA Area. So we are changing too. You can even comment like you did before (and we encourage that!). August means vagrant kites and wandering waders, but an Alabama state 1st South Polar Skua is a fantastic highlight of a weather-full week in the ABA Area. Weekend reads NBC News. Even experienced photographers will gain nuggets of wisdom and validation from a master of Marie Readâs caliber, not to mention enjoying the inspiring selection of photos and easy-to-follow prose. Or just browse the lists below. But the bird of the week was a stunning adult Steller's Sea Eagle (ABA Code 4) at Denali NP in Alaska. At the complete and official CT Birds archive. It's La Sagra's season in south Florida, with a bird showing up right on time in the Florida Keys. On the Surfbirds website. I haven't carried a field guide with me when birding in over 35 years--I've memorized all the birds I am likely to see. Some of my favorite photos are in this chapter, paired with a wide shot of the feeder, perch, and sometimes the blind setup used to get them. Read has chapters to address these areas, including âFocusing and Image Sharpness,â âSeeing the Light,â âExposure,â âComposition Basics,â as well as chapters on âThe Big Picture,â âWeather, Water, and Mood,â âShooting Outside the Box,â and âOn the Wingâ (flight shots). Continuing rarities in the ABA Area include a Garganey (ABA Code 4) in California, both La Sagra’s Flycatcher (4) and Antillean Palm-Swift (5) in Florida, and a Streak-backed Oriole (4) continuing to visit a feeder in Arizona. Iâd have no hesitation recommending this book to anyone heading out birding with camera in hand. GROUP GUIDELINES: This group is for sharing rare and notable reports from the ABA Area. And Black-throated Gray Warblers and Neotropic Cormorants continue to turn up across the east. The last chapter has lots of creative ideas for what to do with oneâs photos now that all of the other steps from gear selection through editing have been thoroughly addressed. Thank you, Marie Read, for distilling your expertise and vision into such an accessible form in this terrific book. If you have any questions, please email [email protected]. Onward and upward! In 1991 the business was purchased by Allen Hale and moved to Virginia. Ranging from online sharing and making cards or calendars to entering contests and giving talks, I quite enjoyed this section as a beautiful way to wrap up the whole package presented in this book. For example, bridge cameras have most (if not all) of the shooting modes and options that DSLRs have, even if many folks donât commonly access them. But the internet is a different place these days and media consumption has changed.
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domain: hobby


Question Asked: How do I preform a coolant flush?
July 08, 2012, 05:20 PM
I'm DYI-ing a coolant flush, just need some help per this specific car, I get how to do it, just need help looking for the right things, ie the lower drain.
Problem Reported: AC Blower Inop Due to Failed Resistor
September 15, 2010, 10:07 PM

The HVAC blower motor may stop working at one or more speeds due to a faulty blower motor resistor block. Our technicians recommend to confirm the resistor is at fault by first checking the operation of the switch.


Advanced Sockets Application Program Interface (API) for IPv6, May 2003
- File formats:
- RFC 2292
- W. Stevens
- ipv6 (int)
Discuss this RFC: Send questions or comments to the mailing list [email protected]
This document provides sockets Application Program Interface (API) to support "advanced" IPv6 applications, as a supplement to a separate specification, RFC 3493. The expected applications include Ping, Traceroute, routing daemons and the like, which typically use raw sockets to access IPv6 or ICMPv6 header fields. This document proposes some portable interfaces for applications that use raw sockets under IPv6. There are other features of IPv6 that some applications will need to access: interface identification (specifying the outgoing interface and determining the incoming interface), IPv6 extension headers, and path Maximum Transmission Unit (MTU) information. This document provides API access to these features too. Additionally, some extended interfaces to libraries for the "r" commands are defined. The extension will provide better backward compatibility to existing implementations that are not IPv6-capable. This memo provides information for the Internet community.
For the definition of Status, see RFC 2026.
For the definition of Stream, see RFC 8729.


text:
Implementation of the Short-Term Assessment of Risk and Treatability over two phases
Received 30 January 2017
Accepted for publication 1 June 2017
Published 16 August 2017 Volume 2017:10 Pages 321—326
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 2
Editor who approved publication: Dr Scott Fraser
Erik Kroppan,1 Kåre Nonstad,1 Runar Busch Iversen,1 Erik Søndenaa1,2
1Department Brøset, St. Olavs Hospital, 2Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
Background: Over the last decade, the Short-Term Assessment of Risk and Treatability (START) has provided a strong evidence base to predict a range of problem behaviors. The implementation of START and adaptation of the services to the use of START have so far been sparsely described in the literature. The purpose of this study was to describe the continuation and the interdisciplinarity of risk assessments through the two phases.
Methods: Over a period of 10 years, the forensic mental health services at Brøset has implemented START in two phases: initially with implementing the instrument (2005–2009) and secondarily by customizing the instrument to everyday treatment and planning (since 2009). This implementation was based on data from 887 START assessments for 181 patients over a decade (2005–2015).
Results: The results showed that the number of START assessments has been stable throughout the past 10 years and the interval between the ratings has decreased significantly (p<0.05). The involvement by diversity of professionals has increased significantly over the two implementation phases.
Conclusion: This study also addressed the continuity and organization of the implementation process and presented an overview of how START has been widespread in the service through treatment. The results showed an increased multidisciplinary participation and a continuing rate of assessments as the implementation progressed from assessment to a combined assessment–treatment phase.
Keywords: violence risk assessment, treatment planning, mental health, multidisciplinary healthcare
Risk analysis has gained increasing importance for mental health nurses working in secure/forensic inpatient services.1 During the last 20–30 years, research and development of various schemes, tools and instruments have been carried out to help health care providers to better work with high violence risk.2,3 Such tools are meant to incorporate not only static/historical factors but also dynamic factors relating to the individual’s risk for violence against others.4 Despite their popularity, structured judgment schemes have been criticized for their strong focus on the presence of factors that are associated with an increased risk, while ignoring the presence of protective factors that may diminish risk.5 Although clinicians have sought to bring out the positive characteristics in their patients and aimed to provide external support, the introduction of positive treatment models such as the Good Lives Model6 has recently been more explicitly incorporated into treatment.7
The Short-Term Assessment of Risk and Treatability (START)3,8 is a structured clinical judgment instrument that aims to support the assessment of patients with mental illness for a diversity of adverse outcomes through the assessment of dynamic risk and protective factors (termed as Vulnerabilities and Strengths). The tool was developed in Canada and has been adapted and validated to services in the UK, Australia, the Netherlands, Ireland and Norway.9 START is a clinical assessment focusing on dynamic variables, including vulnerabilities and possible strengths. It aims to help mental health professionals with structuring the risk assessment processes in practice and organize the health care services to reduce risk and increase strengths in the patient. Importantly, START aims to guide risk formulation for a range of adverse outcomes that are faced by people with mental disorders in addition to violence, namely, self-harm, suicide, self-neglect, victimization, substance abuse and unauthorized leave.9 Moreover, information from START assessments may be useful by facilitating the discussions, decision-making and risk communication in the treatment team.3,10 START ratings have demonstrated a high internal consistency, inter-rater reliability and convergent validity with other risk measures.9 In this meta-analysis, there was limited information about the variability of START ratings over time. Inter-rater reliability and convergent validity with other established assessments of risk and protective factors have been found to be good, and studies have shown a high acceptance by mental health professionals.9 In a Norwegian study,11 results indicated that START was a valid violence risk assessment tool. Risk estimates of START have shown strong predictive validity for various aggressive outcomes and good predictive validity for self-harm9 and ultra short-term assessments of violence risk such as the Dynamic Appraisal of Situational Aggression (DASA)12 and the Brøset Violence Checklist (BVC),13 which assess risk for the subsequent day. No rationale is offered in the START manual8 for deciding a 3-month inter-assessment period. Studies about the predictive validity of START have used different follow-up periods varying from 30 days to 1 year,9 but there are limited data to determine whether the length of a follow-up period moderates the effect size of predictive outcomes. One study found the START Vulnerabilities scale to be a significant predictor of aggressive outcomes at periods of 1, 3, and 6 months using receiver operating characteristic (ROC) curve analysis (area under the curve [AUC] range 0.74–0.83) but did not examine the tool’s Strengths scale and its specific risk estimate (SRE) or nonaggressive outcomes.14 Wilson et al15 have reported statistically significant AUC values for the Strengths scale, Vulnerabilities scale and SRE for violence at 3-, 6-, 9- and 12-month periods following assessment; again, these studies only examined aggressive and sexually inappropriate behaviors and not the full range of START outcomes. This is an important question since more accurate prediction over one period of time compared with another would have implications for the frequency with which reassessment is conducted. This information is useful since risk management procedures that involve restrictive practices should be adapted to the individual’s level of risk at any given time. Furthermore, reassessment at too short intervals may impair valuable resources.16 It is important to study the period following assessment in which patients do not expose risk outcomes (the so-called survival period) since such engagement might in itself secure reassessment. In clinical mental health services, it is important to remember that the goal of risk assessment is not simply to predict the likelihood of violent behavior but to reduce its risk. Therefore, the risk assessment tool must be implemented in a sustainable manner, findings from the risk assessment tool must be communicated accurately and completely and information derived from the risk assessment process must be used to support risk management and rehabilitation.17 According to Otto and Douglas,5 the new challenge for structured clinical risk assessment instruments is to ensure fidelity of application. Design of a risk assessment instrument may be easier than ensuring its true-to-purpose application in forensic, civil mental health and correctional settings.18
Implementation over two phases
Implementation refers to the process of putting a procedure into practice.19 The implementation of assessment tools is primarily focused on evidence-based tools that have been developed and validated. No matter how precise the assessment tool is, it will fail if it is not implemented correctly or used consistently.20 The implementation of risk assessment tools as a continuum gives a large number of challenges as described by Nonstad and Webster.18 In summary, a validated tool for assessing violence risk relies on the implementation and the value of assessing risk depends upon several factors beyond the quality of the tool.
Implementation of research comprises the study of processes and strategies that integrate evidence-based treatments into routine use in care settings. Understanding these processes is crucial for improving care, and systematic, empirical research on implementation is needed.19 There is considerable evidence-based literature for the usefulness of structured clinical instruments for assessing risk in the mental health services. In stark contrast to this evidence, there is sparse research on methods of implementing these instruments. Research on implementation requires outcomes that are conceptually and empirically distinct from those measuring the validity of an assessment. These include the assessments’ penetration within an organization, its acceptability to and adoption by different stakeholders, the feasibility of its use and its sustainability over time within the service system setting.19
A process of implementation of risk assessment tools has been suggested by Vincent et al,20 following eight steps from a preparation phase until the final step of making the risk assessment practice sustainable. Implementation is further divided into two time periods: 1) pre-implementation – after staff received training on a risk assessment tool but prior to implementation of a clear office policy training about how to use the tool in decision-making, and 2) post-implementation – after office policies and training on the use of the tool in decision-making occurred and were applied in practice.
The preparation of getting ready to implement involves numerous stakeholders both at the administrative and clinical levels. The first step in the process of implementing START at the clinic in St. Olav’s Hospital, Brøset, was to introduce and describe START to the staff. The aim was to obtain trust among the staff and explain the usefulness of using a structured professional judgment tool in the everyday clinical setting. Through a general introduction of START and many informal discussions/meetings, the majority of the staff realized the opportunities that the instrument had concerning risk assessment, risk management, multidisciplinary cooperation and planning. The ideas of START were developed in the ward between the START group and the staff. After START was presented to the staff, the instrument was introduced and described to the management of the hospital. The aim was to have the necessary support in the organization when implementing the tool.
At the further steps of a suggested implementation, establishing stakeholders, preparing the tool, preparing a policy for decision-making, training, pilot testing, full implementation and ongoing tasks for sustainability, the service organized a dedicated START group put together by a multidisciplinary professional group. A system of monitoring, educational support, supervision and research was formally established, as well as routines twice a year reports. A survey of the staff confidence in using the START showed that between 75 and 90% of the staff found START useful or needed as a professional tool.21 National White papers have demanded violence risk assessments including START as a recommended tool in mental health specialist services. START was familiar in the universities and services of other regions, and neighboring countries have received training from members of the START group.
While START has been used internationally and there is some evidence for its feasibility, utility and predictive value, the implementation and maintenance in the application of the tool have not been investigated. The current study aimed to describe the continuation and the multidisciplinarity of risk assessments through two phases: 1) structuring the use of START (2005–2009), and 2) combining risk assessment with treatment planning (since 2009). The compliance of assessments was studied based on the rating frequency and professional involvement. A brief comparison between assessment practices for short-term and long-term patients was conducted as we hypothesized a higher rating frequency in short-term patients.
Setting and implementation of START
St. Olav’s Hospital, Brøset, serves regions in the central and northern parts of Norway with 1.2 million inhabitants.
This implementation study of START was performed in 2015 based on data from 887 START assessments for 181 patients over a decade (2005–2015). The study was carried out at the Regional High Secure Hospital Brøset in Trondheim, Norway. The unit has 18 beds, and most of the patients are short-term patients referred from general psychiatric care units because of severe mental disorders combined with severe behavioral problems, mainly of a violent nature. Since the introduction of START, a total of 99 separate nurses have been involved in the ratings. New staff members have been educated and engaged in the ratings throughout the years. A majority of the staff have had formal training in risk assessment. Approximately 30 patients are admitted per year, mostly on an involuntary basis. Nursing staff on the wards constitute 78.5 full time equivalents (FTEs), of which 33 are psychiatric nurses. The units are staffed with 2.5 FTE psychologists, 2.5 FTE psychiatrists, and 2.5 occupational therapists (OTs). The admission period varies from a few days to one patient staying for the whole registered period (median=91 days). Figure 1 illustrates the distribution.
Figure 1 The length of admissions at the security forensic mental health unit at Brøset (n=174).
Integrated within the hospital is a research and educational unit that has responsibilities to both perform research affiliated with the Norwegian University of Science and Technology, Trondheim, Norway, and teach duties to the forensic psychiatric units, low-security units and prison system in the region.
Treatment plans, security measurements and START were collected on a regular basis. According to the assessment protocol of Brøset, the first START should be accomplished within 3 weeks after admission. Later, a START assessment should be made every second month. Treatment planning and security measurements are independently written and adjusted throughout the admission. All data were organized by the first author who has the mandate of being the nursing supervisor of risk management at the hospital. The first author also loaded the data and prepared it for analysis.
START comprises 20 dynamic items, each scored by a multidisciplinary team on two 3-point scales in terms of both risk factors (Vulnerabilities) and protective factors (Strengths): 0 indicates no/minimal vulnerability or strength evident, 1 indicates moderate vulnerability/strength, and 2 indicates high vulnerability/strength. The teams of raters then make a risk evaluation (low, moderate or high) about the likelihood of each of seven risk outcomes occurring over the next 3 months: violence to others, self-harm, suicide, substance abuse, victimization, self-neglect and unauthorized leave. All START ratings are dated, and the multidisciplinarity of rating teams is described.
Treatment planning is based on the terminology of START and is adapted to be evaluated by the consecutive START assessments. The plans serve as clinical guidelines to the staff.
Leveling security on a scale from 0 to 7 is a measure of considering the treatment outcomes throughout the admission period. All patients are set on level 0 when they are admitted, and the levels are dynamically evaluated. At level 0, the patient has very limited access to self-determined activities, and at level 7, there are less limitations and the care mostly concerns necessary agreements between the hospital regime and the patient. These levels were rated independently from the risk assessments.
All data were loaded into the Statistical Package for the Social Sciences (SPSS) version 19 and analyzed by the means of statistical methods. Demographic analysis provided information about the length of admissions. Chi-square tests were used to compare the multidisciplinarity of START assessment over two time periods, and analysis of variance (ANOVA) was used to study the persistence of START ratings and comparisons between short- and long-term patients.
The study was based on clinical data, and an application for ethical approval was made. The Norwegian Regional Committee for Medical and Health Research Ethics (central region) described the study as quality assurance and evaluation, which does not require approval.
One of the aims in implementing START was to make it useful as a multidisciplinary tool. The multidisciplinary teams consisted of psychiatric nurses, OTs, psychiatrists and psychologists, of whom the psychiatric nurses have been involved in all START ratings. The participation of the other professionals was studied for the two time periods 2005–2009 and 2009–2015 (Table 1).
Table 1 The multidisciplinarity of START assessments over two time periods: 2005–2009 (Period 1) and 2009–2015 (Period 2)
Abbreviations: START, Short-Term Assessment of Risk and Treatability; OT, occupational therapist; MD, medical doctor.
To implement START, regular training was considered as the main target. All patients were assessed within 2–3 weeks after their admission. The interval between the START ratings was further studied. An overview of the total number of ratings is given in Table 2. The time intervals between START ratings were studied and compared between the two periods. The mean interval through period 1 (n=315) was 56.45 days (SD=32.6), and at period 2 (n=375), it was 51.99 days (SD=23.9). An independent t-test showed a significant difference in the time interval between the two periods (t=2.07; p=0.04).
The patients of the forensic unit at Brøset were admitted for both short- and long-term periods. The long-term patients were convicted for serious offenses, primarily homicide. We studied the interval of START ratings and compared long-term patients (admitted for >1 year) with short-term patients. A total of 38 patients were admitted for >1 year, giving an interval of START ratings with a mean of 57.9 days (SD=28.4). Short-term patients (n=144) were rated with intervals of 43.8 days (SD=21.5). The difference in intervals of START ratings between short- and long-term patients was significant using an independent t-test (t=6.2; p<0.001).
START was implemented over the last 11 years at the Regional Secure Mental Health Services, Brøset. From the results, it was found that the assessment tool has involved an increasing multidisciplinary team and the treatment is today based on professional evaluations from START. To enable the services to benefit from this tool, there has been an objective of keeping a high frequency of ratings, and as most patients are defined as short-term patients (admitted for <1 year), the monitoring effect has been of increased relevance. The results showed that the number of START assessments has been stable throughout the past 10 years and the interval between the ratings has even decreased. According to the manual, START is suited to a 3-month interval of assessment, but as most of the present patients are admitted for short periods, the interval is also shorter. For some patients, the only assessments are at the time of admission and the time of leaving the ward. For others, the progress through the hospitalization needs to be monitored as treatment plans are outdated.
Considerations about the implementation have been the main objective of this article, and there are several factors that may have influenced the way START is working at the services. In concordance to the phases and steps described by Vincent et al,20 there was a shift in 2009 when the implementation of the risk assessment was connected to the treatment planning and integrated into the electronic patient journal system. The content of the steps suggested by Vincent et al20 was followed, but the initial steps were more interwoven. At the initial phase promoting START, education, consulting stakeholders, translation and adaptation into Norwegian language and establishing routines for application were parallel priorities. Prior to this change, all stakeholders were involved and became confident with using START.
A large number of factors may have added to the success of the present implementation process. First, the staff were involved at an early stage of implementation, with some of the staff members as START supervisors. A broad educational program was given to all staff members independent of their professional position. All new employees at the service were educated in the principles of risk assessment in general and specifically with START. Second, the infrastructure of a few experienced supervisors and experts within the assessment and management of risk with a multidisciplinary professional background had served as both internal and external promoters for the continuing efforts. The certainty that good practice depends upon continuing processes with shared knowledge had been stressed during the whole implementation period.
Many services have initiated risk assessments based on mandates from the health authorities or collaborating parts, and numerous attempts have failed. Such failure may depend on several mistakes as described by Nonstad and Webster.18 However, a unit with a high degree of patient turnover, as there is in the studied population, calls for a higher intensity of assessment. Through the quantity of training with medium- to short-term admissions, the staff will be both experienced assessors and able to document changes during treatment.
Risk assessment and management using a single assessment tool (START) may be too general for certain patients or patient groups, i.e., sexual offenders or patients with learning disabilities. On the other hand, the treatment culture and professional identity which evolved by implementing START benefit patients who might have been treated evidentially better. The implementation of START is a continuing effort at the present service where two challenges seem most prominent: 1) making staff more confident in transferring the assessments into treatment plans, and 2) creating a continuity of the START principles when the patients are leaving the secure mental health services and later being treated at a less restrictive level of the mental health services. This paper has not presented the patient outcomes based on the introduction of the treatment plans and electronic journal. However, these data are available and will be presented in a future paper.
The implementation of START has been studied as a result of the maintained intensity of START ratings and the multidisciplinary participation. Over two periods of this 10-year implementation, the multidisciplinary participation has increased and the frequency of the assessments has been maintained at 3–4 months.
The authors report no conflicts of interest in this work.
Gray NS, Benson R, Craig R, et al. The Short-Term Assessment of Risk and Treatability (START): a prospective study of inpatient behavior. Int J Forensic Mental Health. 2011;10(4):305–313.
Douglas KS, Hart SD, Webster CD, Belfrage H. HCR-20v3: Assessing Risk for Violence: User Guide. Burnaby, BC: Mental Health, Law, and Policy Institute, Simon Fraser University; 2013.
Webster C, Martin M, Brink J, Nicholls T, Middleton C. Manual for the Short-Term Assessment of Risk and Treatability (START), Version 1.0 (consultation ed.). Ontario, Canada, Port Coquitlam, BC: St. Joseph’s Healthcare Hamilton; Forensic Psychiatric Services Commission; 2004.
Kroppan E, Nesset MB, Nonstad K, Pedersen TW, Almvik R, Palmstierna T. Implementation of the Short Term Assessment of Risk and Treatability (START) in a forensic high secure unit. Int J Forensic Mental Health. 2011;10(1):7–12.
Otto RK, Douglas KS. Handbook of Violence Risk Assessment. Abingdon: Routledge; 2011.
Ward T, Brown M. The good lives model and conceptual issues in offender rehabilitation. Psychol Crime Law. 2004;10(3):243–257.
de Vries Robbé M. Protective Factors. Validation of the Structured Assessment of Protective Factors for Violence Risk in Forensic Psychiatry [PhD thesis]. Nijmegen: Radbout University; 2014.
Webster C, Martin M, Brink J, Nicholls T, Desmarais S. Short-Term Assessment of Risk and Treatability (START). Clinical Guide for Evaluation Risk and Recovery (Version 1.1). Ontario: St Joseph’s Healthcare Hamilton; 2009.
O’Shea LE, Dickens GL. Short-Term Assessment of Risk and Treatability (START): systematic review and meta-analysis. Psychol Assess. 2014;26(3):990.
Doyle M, Lewis G, Brisbane M. Implementing the Short-Term Assessment of Risk and Treatability (START) in a forensic mental health service. Psychiatrist. 2008;32(11):406–408.
Nonstad K, Nesset MB, Kroppan E, et al. Predictive validity and other psychometric properties of the Short-Term Assessment of Risk and Treatability (START) in a Norwegian high secure hospital. Int J Forensic Mental Health. 2010;9(4):294–299.
Ogloff JR, Daffern M. The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law. 2006;24(6):799–813.
Almvik R, Woods P, Rasmussen K. The Brøset Violence Checklist sensitivity, specificity, and interrater reliability. J Interpers Violence. 2000;15(12):1284–1296.
Chu CM, Thomas SD, Ogloff JR, Daffern M. The predictive validity of the Short-Term Assessment of Risk and Treatability (START) in a secure forensic hospital: risk factors and strengths. Int J Forensic Mental Health. 2011;10(4):337–345.
Wilson CM, Desmarais SL, Nicholls TL, Hart SD, Brink J. Predictive validity of dynamic factors: assessing violence risk in forensic psychiatric inpatients. Law Hum Behav. 2013;37(6):377.
Whittington R, Bjørngaard JH, Brown A, Nathan R, Noblett S, Quinn B. Dynamic relationship between multiple START assessments and violent incidents over time: a prospective cohort study. BMC Psychiatry. 2014;14(1):1.
Desmarais SL, Singh JP. Risk Assessment Instruments Validated and Implemented in Correctional Settings in the United States. Lexington, KY: Council of State Governments; 2013.
Nonstad K, Webster CD. How to fail in the implementation of a risk assessment scheme or any other new procedure in your organization. Am J Orthopsychiatry. 2011;81(1):94–99.
Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009;36(1):24–34.
Vincent GM, Guy LS, Grisso T. Risk Assessment in Juvenile Justice: A Guidebook for Implementation. Massachusetts: Systems and Psychosocial Advances Research Center Publications and Presentations; 2012.
Kroppan E. Structured Risk Assessment in Psychiatric Nursing and Therapeutic Intervention Based on START [master thesis]. Levanger: HINT; 2014.
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.


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domain: travel


text:
Issn Print: 0042-4900
Publication Date: 2017/10/28
Keeping reptiles and amphibians as pets: challenges and rewards
G. M. Burghardt
Author Information: Departments of Psychology and Ecology and Evolutionary Biology University of Tennessee,, Knoxville, TN 37996-0900,, USA
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Abstract unavailable for this article.

domain: psychology


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Story….is a story for everyone around those who are reading or listening but the person who lived that story. For that person, it’s a treasure of memories.
We are sharing our treasure with you.
It was the month of December; we get up early morning and started getting ready for the day. After doing all the necessary stuff, we walked down the stairs planning about a car trip and approaching the car that we parked daily on the roadside near our house.
It comes as a shock…….the big space that our car keeps occupied…..was all empty. In simple clear words, it was stolen. And the agony begins……the search, police report, etc. All in our shocked brain….what the hell has happened.
We plan a lot of things but life introduced you to the actual you and your right plans.
After a month, this how we planned our first adventure trip in the month of January that is Kedarkantha, it was chilled winters with backpacks, trekking shoes on, and walking on a snow-clad path sharing a lovely time with unknown people. After an hour those unknown smiling faces, are like a family. We shared, we laughed, and we lived that mesmerizing nature together. Not to miss, scrumptious food, bonfire, clear sky with bright moonlight, and sleeping in a tent. What a wonderful experience. That moment I felt it is not just a trek…..it is the life we were missing in the cities.
That’s what attracts us and that leads to the chadar trek and many more.
We have a lot to share with you, but before that we want you to explore the experience and live your treasure story with Mount Heavens.
Let me introduced you to Mount Heavens!
With the aim of Exploration and betterment of the trekking industry, love for nature, we dreamt of a trekking company that makes Treks a life-changing experience, that’s how Mount Heavens came to life.
As we all know every industry has some pros and cons, this industry also has some cons which have to be resolved, with the aim of this……. Mount Heavens promise you safe and well-equipped treks ahead.
When the spirits are looking for something sparkling, when hopes are high, when you are willing to live your dream days, if you believe in magical nature, just mount the heavens with “Mount Heavens”
Mount Heaven’s motto is to build a family rapport with locals, harness nature, and facilitate trekkers to have a life-changing experience with the help of local guides!


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domain: artistic


text:
An elderly couple in Kirklees have been scammed out of £14,000 by a bogus police officer in Fenay Bridge.
On December 29, the scammer told the pair they were investigating bank employees committing fraud and needed them to withdraw cash.
A courier then went to their home to collect the money.
Ramona Senior, in charge of West Yorkshire Police’s Economic Crime Unit said: “These types of fraud are especially heartless as the criminals prey on vulnerable people they perceive to be more trusting.
“They look to take advantage of a victim’s trusting nature but can leave them very heavily out of pocket.
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“Such crimes can also leave an emotional scar too and despite our ongoing work through Programme Precision and with partners to tackle all types of fraud, people should remain vigilant.
Police are now asking people to be on their guard against fraudsters pretending to be from trusted institutions such as a bank or the police.
Such frauds happen when criminals contact their victims (usually by email or phone) and say there is a problem – usually with their bank account.
They tell their victim they need to withdraw money – and not to tell the bank staff as they claim they are part of the problem.
They send a courier round to the property to collect the cash.
Neither the police nor a bank will ever ask people to withdraw money in this way.
“To prevent such crimes from happening knowledge is a very important tool," said Ms Senior.
“If you get a call you are suspicious of then call your bank back – but wait five minutes from hanging the suspect call up and don’t use a phone number they provide. You could also use a different line altogether."
She added: “The fraudsters can be quite convincing, so I would also urge people with vulnerable relatives and friends to tell them about the risks and how to protect themselves.”
West Yorkshire Police supports a national initiative with UK banks to help protect communities against such frauds.
Since April 2020, the banking protocol, which enables bank staff to identify possible fraudulent activity and then alerts police as it is happening, has prevented over £940,000 worth of fraud.
Download the YorkshireLive app to customise the news that matters to you and get the latest updates first.

domain: law


Ireland and Munster Rugby are delighted to announce that Conor Murray has signed an IRFU contract extension, which will see him continue his career in Ireland up to at least the end of July 2024.
The 32-year-old scrum half made his international debut against France in August 2011 in a Rugby World Cup warm-up game. He has since gone on to represent his country at three Rugby World Cups (2011, 2015 and 2019).
Murray has won 92 caps for Ireland, winning three Six Nations Championship titles to date (2014, 2015 and 2018).
He has toured with the British & Irish Lions on three occasions and, during the summer, he was made tour captain in the absence of the injured Alun Wyn Jones.
He has played in eight Test matches for the Lions across the three tours (2013, 2017 and 2021).
The Limerick man made his Munster debut against Connacht in 2010. He has represented his native province on 153 occasions, scoring 170 points and winning a Celtic Cup title in 2011.
David Nucifora, the IRFU Performance Director, said: “Conor has had some challenges in the past few seasons but has put some niggling injuries behind him to play a central role with Munster, Ireland and the Lions.
“He is a popular figure in every squad he is involved in and adds a huge amount of experience and value to younger players coming through.”
I’m delighted and grateful to be able to continue living this dream of playing here in Ireland.
“With my home province Munster and the national squad, I truly believe there’s huge potential of success and that there will be many more big days ahead.”


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Oregon Gov. John Kitzhaber has called on SAG-AFTRA to halt the planned closure of its Oregon Local.
The Democrat said the decision to close the office was "problematic" and asked SAG-AFTRA Executive Director David White to reconsider.
The governor's involvement in the anti-closure effort, which has been simmering in Oregon and other states since the union's national board announced the closure of 10 of its 25 local offices April 22, shows how important the branch was to the area's entertainment industry.
With filming in Oregon on the rise, Kitzhaber noted in his May 28 letter that the state's latest budget proposal includes doubling funding for the Oregon Film and Video Tax Credit program to $12 million annually.
"I would normally not engage in internal union operations such as the location of local union offices. However, this situation goes beyond local union operations and more akin to a local business leaving Oregon: this is an economic development issue. Your union's presence in this state is an economic asset for Oregon, and closing this office is problematic for Oregon as would be the loss of any business," Kitzhaber wrote.
"Oregon is invested in your industry and your local members. I urge SAG-AFTRA to reconsider its decision to leave Oregon without a local office so that we can continue to grow this industry, create good jobs, and increase SAG-AFTRA membership in our state."
The union said it appreciated the governor’s support, but didn’t indicate it would reconsider the closure decision.
"We love the fact that Governor Kitzhaber is so supportive of our members and appreciate his desire to expand the work of our industry in Oregon," a SAG-AFTRA spokesperson said in a statement.
"We agree with him and expect to continue our good work with his offices to advance the interests of our membership. Whether or not we have a physical office in this state will not change this fact. We are working to bring more effective services and support to all SAG-AFTRA members, wherever they live and work around the globe."
That wasn’t enough to satisfy local activists. Mary McDonald-Lewis, the Portland Local co-president who has led the anti-closure effort, on Friday again questioned the decision to shutter the locals.
"David White has heard from the highest voices in our state, including our governor and our producer partners," she said in a statement, noting the support of Vince Porter, executive director of the Governor's Office of Film & Television.
"Our membership has doubled in recent years, even before we merged. Our state brought in $145 million dollars in film, TV and commercial revenue.” McDonald-Lewis said. "So what’s the real reason national SAG-AFTRA is trying to shut us down?"
The Portland office is set to close tonight, May 31, after Nathaniel Applefield, the Local's executive director, received a letter from the union's legal department ordering him and anti-closure advocates off the premises at 5 p.m., according to the group.
Still, they plan to hold a party marking the office's demise. "This is our house," said McDonald-Lewis. "We’ll leave when the party’s over." Chrisse Roccaro, a national co-representative for Portland, added, "The band doesn't even set up until 6." The group slated to perform? General Strike.
The other offices slated for closure are in New Orleans, Michigan, Colorado, Nevada, the Twin Cities, San Diego, Houston-Austin, Arizona-Utah and New Mexico, whose state office is set to shutter June 14.
Meanwhile, the deadline for SAG-AFTRA members to submit their ballots on the commercials contracts deal is Friday at 5 p.m. Pacific.

domain: economics


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http://www.marriott.com/hotels/maps/travel/hkghv-renaissance-hong-kong-harbour-view-hotel/?directPageRequest=trueMarriott International, Inc.Explore a world of flavors at our Wanchai restaurants. From contemporary Italian cuisine, Scala, to Cantonese fare at Dynasty, our Hong Kong Michelin-starred restaurant, at Renaissance Harbour View delicious experiences await.
Café Renaissance is the perfect place for all-day dining with a wide range of international food selections. Located on the Mezzanine floor, the 220-seat café serves breakfast, lunch and dinner buffets plus à la carte menu daily and brunch on weekends.
You should spend some time to discover The Lounge during your stay. The cozy and spacious lounge introduces a tempting array of signature beverages and upscale snacks with its daily enchanting live entertainment to guests for enjoyment.
Showcasing authentic Cantonese cuisine, Dynasty, the award-wining Chinese restaurant in Wan Chai, creates delightful lifestyle destination for unique dining experience set against the backdrop of Victoria Harbour.
Open for lunch and dinner
Dress code: Smart Casual
Phone: +852 2802 8888
Retail is a newly-established integration of Grab & Go and gift shop. Located at the upper lobby, Retail serves a wide range of beverages, exquisite pastries, wraps, yogurt and salads.

domain: food


text:
Although generally regarded safe, infections and thrombotic events have occurred with PICC use, necessitating study to guide future clinical prophylaxis and management” McAuliffe et al (2016).
INTRODUCTION: Peripherally inserted central catheters (PICC) have been increasingly used for administration of chemotherapy, antibiotics and blood products in patients with haematological malignancies. Although generally regarded safe, infections and thrombotic events have occurred with PICC use, necessitating study to guide future clinical prophylaxis and management.
AIM: 1) Determine the incidence of PICC associated thrombosis in patients with haematological malignancies 2) To identify clinically significant risk factors contributing to these complications.
MATERIALS AND METHODS: This was a cohort study, conducted in Cork University Hospital, between January 2010 and June 2015. After ethical approval Picture Archiving and Communication System (PACS) in radiology was used. All adult patients with PICC inserted under haematology were identified. A total of 90 patients with haematological malignancies who had PICC line placement were included. Patients’ charts were reviewed in the medical record department. Data was collected using proforma sheets. This included patients demographs, type of malignancy, size of the PICC line, and total days of insertion. Haematological laboratory parameters were also recorded. The main outcome measures were PICC associated thrombosis and/or infection
RESULTS: Of 131 PICC placements in a total of 90 patients. Out of these total PICC episodes 28.2% developed complications (n=37) and lead to removal. Thrombosis was found in 14.5% (n=19), 13.7% developed infection (n=18) and remaining were without complications. Of those with thrombosis (n=19), 7 patients had a diagnosis of Multiple Myeloma and 6 had Acute Myeloid Leukaemia. Whereas those with PICC associated infection (n=18), 5 had Non-Hodgkin’s lymphoma and 5 had Acute Lymphoid Leukaemia. Diagnosis was significantly associated with complication (p=0.019). The mean age of patients who has PICC associated thrombosis was 51.6 years (±8.1 years). PICC removal as a result of complications was associated with increasing PICC lumen size; 30% of 5-French PICCs necessitated removal whereas 79.2% of 6-French PICCs necessitated removal (p=0.01). In addition, increased PICC lumen size was associated with clinically evident thrombophlebitis; 30% of 5-French PICCs displayed thrombophlebitis vs. 77%of 6-French PICCs displayed thrombophlebitis (p=0.017). Decreased in PICC lumen size was shown to influence the risk of complications; of 5 French catheters, 20% had thrombosis and 15% had infection, vs. 6 French catheters (13% and 13% respectively). Men were found to experience complications earlier with 80% of men having complications 1-50 days post PICC insertion and 12% 51-100 days post insertion.
CONCLUSIONS: The risk of complications of PICC line insertion is relatively high in patients with haematological malignancies. Our institute thrombosis rate is similar to other studies. Haematological diagnosis was significantly associated with complication risk. Increased PICC lumen size was associated with higher removal rates as a result of complications and clinical signs of thrombophlebitis.
McAuliffe, E., O’Shea, S. and Khan, M.I. (2016) PO-02 – Retrospective audit of the Peripherally Inserted Central Catheter (PICC) associated thrombosis in patients with haematological malignancies at Cork University Hospital. Thrombosis Research. 140(Suppl 1). p.S176.
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domain: medical


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UPDATE 09/08/2016 6.40pm: Read Only Memories' PS4 and Vita release has been delayed at least a month.
"We are anticipating a mid/late September release and will certainly keep you posted as we know more," a marketing rep told us.
"We're very sorry for the delay and any inconvenience."
ORIGINAL STORY 23/06/2016 5pm: Acclaimed cyberpunk adventure Read Only Memories is slated for a PS4 and Vita release on 16th August.
For those unfamiliar with the game, it's set in 2064 Neo San Francisco and follows the exploits of a person looking for their kidnaped friend Turing, who just so happens to be the world's first sapient machine.
Unlike most point-and-click adventures, Read Only Memories will contain multiple solutions to its puzzles. It will also feature branching story paths and the way you choose to overcome obstacles will influence how characters react towards you down the line. You can also create your own character and choose their name, pronouns, and even diet.
This PlayStation version of Read Only Memories - now called 2064: Read Only Memories - has been enhanced since its launch last October on PC, Mac and Linux. It now features rewritten dialogue, revamped puzzles, new animations, and voice acting.
In fact, the voice cast is now made up of 29 different actors including The Walking Dead's Melissa Hutchinson (Clementine in The Walking Dead), UpUpDownDown's Austin Creed (a.k.a. WWE superstar Xavier Woods) making his video game debut, and Sarah Elmaheh (Katie from Gone Home).
"One of the things we're most excited about is not only the amazing and talented cast of well-known game personalities and voiceover talent, but also how we were able to work with an incredibly diverse cast, some of whom are unknown names, but are representative of the characters in the game," said developer Midboss founder Matt Conn. "We worked hard to find people of color and a LGBT folks to play those characters in the game. We really wanted to stay true to these characters and who they are on every level."
"2064 is a really special game that's not only super accessible, but also deals with complex issues," Hutchinson added. "Turing was an incredibly fun character to do voice acting for and I can't wait for everyone to fall in love with them and the game's story like I did."
2064: Read Only Memories will cost $19.99 (or your local equivalent) with a 10 per cent launch discount. It will support Cross-Buy for PS4, Vita and PC.
If you'd like to give the original Read Only Memories a go without spending money, there's a free demo available on Steam.