Genuine Increase Research Articles

Does declining social connection, and increased reported loneliness, explain the apparent increase in depressive and other mood disorders, particularly among younger people?

There is much conjecture about which social factors underpin an apparent increase in the incidence of psychological distress, depression and other mood disorders, self-harm and suicidal behaviour and presentations for mental health care (in economically-developed countries). These concerns are particularly focused on younger birth cohorts, where the epidemiological evidence appears strongest for a genuine increase in incidence of mood disorders and self-harming behaviours (Twenge et al., 2019).

Sustained and Universal Fertility Recuperation in Kazakhstan

The fertility rates of Kazakhstan have reversed to levels not seen for several decades. The striking fertility increase poses questions regarding the extent to which this new development is shared across socio-demographic groups and the nature of fertility recuperation. The current study employs UNICEF Multiple Indicator Cluster Survey data and event-history modelling to analyse parity progressions to one, two, three, and four children. The results suggest a sustained fertility increase that is not merely associated with the recuperation of delayed first births, but a genuine increase across all birth orders. This pattern is evident for both main ethnicities in Kazakhstan and across educational groups. The gradual increase of higher-order births, especially among ethnic Kazakhs, indicates a reversed fertility transition and also that the previous fertility decline in the 1990s was not part of a general transition towards below-replacement fertility but rather a reflection of economic crisis after the collapse of the Soviet Union.

A twin study of genetic and environmental contributions to attention-deficit/hyperactivity disorder over time.

Attention-deficit/hyperactivity disorder (ADHD) is an increasingly commonly diagnosed neurodevelopmental condition. One possibility is that this reflects a genuine increase in the prevalence of ADHD due to secular environmental changes, yet this hypothesis remains untested. We therefore investigated whether the genetic and environmental variance underlying ADHD, and traits of ADHD, has changed over time. We identified twins born from 1982 to 2008 from the Swedish Twin Registry (STR). We linked the STR with the Swedish National Patient Register and Prescribed Drug Register to identify diagnoses of ADHD and prescriptions of ADHD medication for these twins. We also utilized data collected from participants in the Child and Adolescent Twin Study in Sweden (CATSS), born from 1992 to 2008. Their parents completed a structured ADHD screening tool, which was used to measure traits of ADHD and assign broad screening diagnoses of ADHD. We used the classical twin design to test whether the degree to which variation in these measures was influenced by genetic and environmental variation changed over time. We included 22,678 twin pairs from the STR and 15,036 pairs from CATSS. The heritability of ADHD in the STR ranged from 66% to 86% over time, although these fluctuations were not statistically significant. We observed a modest increase in variance in ADHD traits, from 0.98 to 1.09. This was driven by small increases in the underlying genetic and environmental variance, with heritability estimated as 64%-65%. No statistically significant changes in variance in screening diagnoses were observed. The relative contribution of genetic and environmental factors to ADHD has remained stable over time, despite its increasing prevalence. Thus, changes in the underlying etiology of ADHD over time are unlikely to explain the increase in ADHD diagnoses.

The intrinsic variability of the Indonesian Throughflow

The Indonesian Throughflow (ITF) carries an annual average of about 15 Sv of water from the Pacific through the Indonesian Seas Into the Indian Ocean, and its year-to-year variation ranges from 1 to 4 Sv. A 10-member ensemble of 41-year integrations of a semi-global eddy-resolving oceanic general circulation model is examined to explore the intrinsic (chaotic) variability of the ITF transport and associated flow. It is found that the annual-mean ITF transport is different by about 1 Sv between the ensemble members at several years. The characteristic vertical and horizontal structures of the ensemble anomaly (deviation from the ensemble average) are described. These structures and the basin-scale spread of the anomaly suggest that the intrinsic variability of the ITF is a genuine increase or decrease of the classical ITF rather than variability due to local eddies or nonlinear currents within the Indonesian Seas. The lagged correlation of the intrinsic component of the ITF transport with sea-surface height and barotropic streamfunction suggests that the intrinsic variability may come from zonal jets in the western subtropical North Pacific.

A surge in human metapneumovirus paediatric respiratory admissions in Western Australia following the reduction of SARS-CoV-2 non-pharmaceutical interventions.

Western Australian laboratory data demonstrated a decrease in human metapneumovirus (hMPV) detections through 2020 associated with SARS-CoV-2-related non-pharmaceutical interventions (NPIs), followed by a subsequent surge in metropolitan region in mid-2021. We aimed to assess the impact of the surge in hMPV on paediatric hospital admissions and the contribution of changes in testing. All respiratory-coded admissions of children aged <16 years at a tertiary paediatric centre between 2017 and 2021 were matched with respiratory virus testing data. Patients were grouped by age at presentation and by ICD-10 AM codes into bronchiolitis, other acute lower respiratory infection (OALRI), wheeze and upper respiratory tract infection (URTI). For analysis, 2017-2019 was utilised as a baseline period. hMPV-positive admissions in 2021 were more than 2.8 times baseline. The largest increase in incidence was observed in the 1-4 years group (incidence rate ratio (IRR) 3.8; 95% confidence interval (CI): 2.5-5.9) and in OALRI clinical phenotype (IRR 2.8; 95% CI: 1.8-4.2). The proportion of respiratory-coded admissions tested for hMPV in 2021 doubled (32-66.2%, P < 0.001), with the greatest increase in wheeze (12-75% in 2021, P < 0.001). hMPV test percentage positivity in 2021 was higher than in the baseline period (7.6% vs. 10.1% in 2021, P = 0.004). The absence and subsequent surge underline the susceptibility of hMPV to NPIs. Increased hMPV-positive admissions in 2021 can be partially attributable to testing, but test-positivity remained high, consistent with a genuine increase. Continued comprehensive testing will help ascertain true burden of hMPV respiratory diseases.

Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis

In the past decade, there have been extensive efforts in the Western world to raise public awareness about mental health problems, with the goal of reducing or preventing these symptoms across the population. Despite these efforts, reported rates of mental health problems have increased in these countries over the same period. In this paper, we present the hypothesis that, paradoxically, awareness efforts are contributing to this reported increase in mental health problems. We term this the prevalence inflation hypothesis. First, we argue that mental health awareness efforts are leading to more accurate reporting of previously under-recognised symptoms, a beneficial outcome. Second, and more problematically, we propose that awareness efforts are leading some individuals to interpret and report milder forms of distress as mental health problems. We propose that this then leads some individuals to experience a genuine increase in symptoms, because labelling distress as a mental health problem can affect an individual's self-concept and behaviour in a way that is ultimately self-fulfilling. For example, interpreting low levels of anxiety as symptomatic of an anxiety disorder might lead to behavioural avoidance, which can further exacerbate anxiety symptoms. We propose that the increase in reported symptoms then drives further awareness efforts: the two processes influence each other in a cyclical, intensifying manner. We end by suggesting ways to test this hypothesis and argue that future awareness efforts need to mitigate the issues we present.

Is early-onset cancer an emerging global epidemic? Current evidence and future implications.

Over the past several decades, the incidence of early-onset cancers, often defined as cancers diagnosed in adults <50 years of age, in the breast, colorectum, endometrium, oesophagus, extrahepatic bile duct, gallbladder, head and neck, kidney, liver, bone marrow, pancreas, prostate, stomach and thyroid has increased in multiple countries. Increased use of screening programmes has contributed to this phenomenon to a certain extent, although a genuine increase in the incidence of early-onset forms of several cancer types also seems to have emerged. Evidence suggests an aetiological role of risk factor exposures in early life and young adulthood. Since the mid-20th century, substantial multigenerational changes in the exposome have occurred (including changes in diet, lifestyle, obesity, environment and the microbiome, all of which might interact with genomic and/or genetic susceptibilities). However, the effects of individual exposures remain largely unknown. To study early-life exposures and their implications for multiple cancer types will require prospective cohort studies with dedicated biobanking and data collection technologies. Raising awareness among both the public and health-care professionals will also be critical. In this Review, we describe changes in the incidence of early-onset cancers globally and suggest measures that are likely to reduce the burden of cancers and other chronic non-communicable diseases.

P144 Phalangeal microgeodic syndrome: is this very rare condition becoming more common?

Abstract Background/Aims Phalangeal microgeodic syndrome (PMS) is a rare condition with only a handful of published case reports. Most of these cases are recognised in childhood, typically in Japan. It presents with pain and dusky discolouration in the digits, distinct from Raynaud’s phenomenon in that the colour change is fixed and pain constant. Symptom onset is related to cold exposure with first presentation usually occurring in winter. Features on magnetic resonance imaging (MRI) are striking and characteristic, with a distinct pattern of bone marrow oedema. Methods We report five cases of MRI-proven PMS all identified in the last 12 months, with symptom onset during the winter. The patients were all female, aged between 25 and 79. One patient was already under the care of rheumatology with an established diagnosis of systemic lupus erythematosus (SLE), but the remainder were de novo referrals presenting specifically with pain and discolouration of the digits. One patient developed symptoms 2 days after receiving the first dose of Pfizer/Biontech RNA vaccine against COVID-19. One patient had to self-isolate following a COVID-19 contact and developed symptoms shortly thereafter, although there was no proven infection in the affected individual. Results Four out of five cases were managed conservatively, with advice on maintaining core and peripheral temperature and skin integrity. Without any specific therapy, these four cases improved spontaneously to coincide with increasing seasonal temperatures. The fifth case with existing SLE was treated with intravenous pamidronate and subsequently with a calcium channel blocker, with some improvement in symptoms. Conclusion In these authors’ experience, it would seem PMS is increasing in incidence. It is unclear if this relates to wider availability and image quality of MRI, clinician bias due to personal experience of more cases or a genuine increase. The winter 2020/21 was particularly cold with sub-zero conditions lasting well into May, which may have impacted on this flurry of new cases. We have identified one prior case report which describes PMS in a patient with existing connective tissue disease. Our patient with SLE appeared to have a more severe clinical presentation requiring additional medical therapy to control the symptoms compared with the four cases where PMS was a stand-alone condition. Dermatological manifestations of acute COVID-19 infection are well documented in children and include chilblain-like lesions and acrocyanosis. Any association between COVID-19 and PMS is purely hypothetical and would require more study to identify any true relationship. Disclosure L. Parker: None. M. Ahmad: None. S. Mukherjee: None. P. McAlinden: None.

Incidence of myelodysplastic syndromes in Finland 1997–2016

Myelodysplastic syndromes (MDS) are a diverse group of clonal hematopoietic stem cell diseases that may progress to acute myeloid leukemia. Here, we present incidence of myelodysplastic syndromes based on a nationwide, registry-based study. A total of 1906 MDS cases were reported to the Finnish Cancer Registry during 1997-2016. We analysed the age-standardized incidence rates using the new European standard population, incidence trend and changes in trend by sex, age group and calendar year using Poisson regression and joinpoint regression. The average age-standardized incidence rate was 3.92 per 100,000 person-years. The incidence of MDS increased in a linear-quadratic fashion across 10-year age groups and was higher among men (5.43 versus 3.14 per 100,000). The incidence trend increased during the first 15 years followed by a decline towards the end of the study period. A similar trend was found in subgroups by sex and age. Our results show a similar or slightly higher MDS incidence in Finland as in other Western countries, with an increasing trend, but some decrease in the end. The increasing incidence may reflect improved reporting and coding, or there could be a genuine increase in MDS over time.

Does Certainty of Genuine Treatment Increase the Drug Response in Alzheimer's Disease Patients: A Meta-Analysis and Critical Discussion.

Non-specific treatment effects, such as expectations, contribute to the effectiveness of pharmacological treatments across diseases. However, the contribution of expectancy, i.e., certainty of receiving treatment, in patients with Alzheimer's disease (AD) is unknown. The aim is to investigate whether certainty of receiving a genuine treatment influences the response to active treatment in AD patients. The efficacy of active treatments in open-label trials, where patients are certain of receiving treatment (100%certainty), was compared to the same active treatments in randomized controlled trials (RCT), where patients are uncertain of receiving treatment or placebo (50%certainty). In the seven open-label trials, there was no significant difference between post- and pre-treatment scores (difference in means = 0.14, 95%CI [-0.51; 0.81], p = 0.66). In the eight RCT trials, there was a significant difference between post- and pre-treatment (difference in means = -0.91, 95%CI [-1.43; -0.41], p < 0.001). There was a statistically significant difference between open-label and RCT trials (difference = 1.06, 95%CI [0.23; 1.90], p = 0.001). Patients with AD did not benefit from certainty of receiving genuine treatment. This could be due to the nature/progression of the disease, but it could also be related to an order effect in the practice of running AD trials, where RCTs are conducted prior to open label. These findings have implications for the understanding of non-specific treatment effects in AD patients as well as for the design of clinical trials that test pharmacological treatments in AD.

What\u2019s Worrying Our Students? Increasing Worry Levels over Two Decades and a New Measure of Student Worry Frequency and Domains

BackgroundThe frequency and severity of mental health problems in student populations have been a growing cause for concern worldwide, and studies have identified measures of a number of mental health symptoms that have been steadily increasing in frequency and intensity over the past 20–25 years.MethodsIn two studies we investigate the levels and domains of pathological worrying in university student participants. Study 1 is a retrospective study of Penn State Worry Questionnaire (PSWQ) data collected between 2001 and 2019. Study 2 describes the development of the Student Worry Questionnaire, a short and easily delivered measure of student worrying that identifies both frequency of worry as well as the student-relevant domains across which worrying occurs.ResultsStudy 1 revealed a steady increase in student worry scores of around 20% between 2001 and 2019, with a significant positive correlation between year of data collection and mean PSWQ score. The domain scores in Study 2 indicated that academic work was a significantly higher worry than any of the other domains, and worries about intimate relationships and ‘what people think of me’ were also worries that scored higher than either financial or health worries.ConclusionsThe present studies indicate that pathological worrying can be added to the list of anxiety- and stress-related symptoms that have been shown to be on the increase in student populations in recent decades, and we discuss whether these increases represent a greater willingness to report symptoms or a genuine increase in experienced symptoms over time.

True Motives: Prosocial and Instrumental Justifications for Behavioral Change in Organizations

When organizations want their employees to adopt behaviors that advance prosocial and instrumental aims, which motive should they express? A groundswell of recent work suggests that highlighting prosocial actions inspires and motivates employees. Building on this work, we embed a field experiment in the context of an organizational change initiative (Study 1). A large university sought to change the behavior of administrative employees who purchase office supplies, encouraging them to place orders of at least $50, referred to as “bundling.” We exploit the fact that the organization could justify the same behavior in contrasting ways. We randomly assign employees to view either a prosocial (“limiting pollution”), instrumental (“limiting costs”), or mixed motive (“limiting pollution and limiting costs”) for caring about bundling each time they access the organization’s procurement system. We then evaluate changes in employees’ behavior by comparing a six-month baseline to a six-month experimental period, covering 10,169 purchases in 556 offices. Contrary to expectations from related research, the instrumental motive was most effective for changing behavior, leading to significantly more bundling than the prosocial motive. Two follow-up vignette experiments probe theoretical mechanisms. They indicate that an instrumental motive seems more genuine (i.e., reflecting the organization’s true motive) than a prosocial motive (Study 2) and that seeming genuine increases individuals’ intention to bundle (Study 3). This research reveals that prosocial justifications can be less effective than instrumental ones and suggests that perceptions of genuineness may shape the effectiveness of behavioral change efforts in organizations. This paper was accepted by Yuval Rottenstreich, decision analysis.

The Internal Language of Proteins

The question of whether proteins share a common language across the major branches of life is an intriguing one. Adding to the growing body of evidence that there have been genuine increases in complexity over the course of evolutionary history, Lijia Yu et al. investigated the arrangements of protein domains, considering them as a kind of grammar that orders the internal structure of proteins.

Stage-specific incidence trends of melanoma in an English region, 1996-2015: longitudinal analyses of population-based data.

The aim of this study was to examine temporal trends in overall and stage-specific incidence of melanoma. Using population-based data on patients diagnosed with melanoma in East Anglia, England, 1996-2015, we estimated age-standardized time trends in annual incidence rates for each stage at diagnosis. Negative binomial regression was used to model trends over time adjusted for sex, age group and deprivation, and to subsequently examine variation in stage-specific trends by sex and age group. The age-standardized incidence increased from 14 to 29 cases/100 000 persons (i.e. 4% annually). Increasing incidence was apparent across all stages but was steepest for stage I [adjusted annual increase: 5%, 95% confidence interval (CI): 5-6%, and more gradual for stage II-IV disease (stage II: 3%, 95% CI: 2-4%; stage III/IV: 2%, 95% CI: 1-3%)]. Stage II-IV increase was apparent in men across age groups and in women aged 50 years or older. Increases in incidence were steeper in those aged 70 years or older, and in men. The findings suggest that both a genuine increase in the incidence of consequential illness and a degree of overdiagnosis may be responsible for the observed increasing incidence trends in melanoma in our population during the study period. They also suggest the potentially lower effectiveness of public health awareness campaigns in men and older people.

An update on the epidemiology of ANCA-associated vasculitis.

ANCA-associated vasculitis (AAV) includes granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Epidemiological studies in AAV are important in understanding possible aetiologic mechanisms and facilitating healthcare planning. However, epidemiological studies present a number of challenges including clear definition of cases differentiated from other clinical disorders, and identification of cases due to the rarity of AAV. The aim of this review is to summarize different aspects on the epidemiology of ANCA-associated vasculitis from different geographical areas throughout the world. During the past three decades, development of classification criteria worldwide, including the ACR classification of 1990, the Chapel Hill consensus definitions updated in 2012 and the EMA algorithm has facilitated epidemiology studies in AAV. The available epidemiological studies reported in AAV suggest that incidence and prevalence may have increased over the past 30 years. Possible explanations for this increase may be a genuine increase in incidence, the evolution of classification criteria and the definition, and availability and wider use of ANCA serology to aid diagnosis, and greater physician awareness through education. The age-specific incidence for the whole group of AAV showed a clear increase with age. However, there has been a clear shift in the peak age at onset towards a higher age during the last 20-30 years. In addition, variation in incidence of AAV between men and women has been clearly evident in a number of epidemiological studies.

Secure Trust-Based Blockchain Architecture to Prevent Attacks in VANET.

Vehicular ad hoc networks (VANET) are also known as intelligent transportation systems. VANET ensures timely and accurate communications between vehicle to vehicle (V2V) and vehicle to infrastructure (V2I) to improve road safety and enhance the efficiency of traffic flow. Due to its open wireless boundary and high mobility, VANET is vulnerable to malicious nodes that could gain access into the network and carry out serious medium access control (MAC) layer threats, such as denial of service (DoS) attacks, data modification attacks, impersonation attacks, Sybil attacks, and replay attacks. This could affect the network security and privacy, causing harm to the information exchange within the network by genuine nodes and increase fatal impacts on the road. Therefore, a novel secure trust-based architecture that utilizes blockchain technology has been proposed to increase security and privacy to mitigate the aforementioned MAC layer attacks. A series of experiment has been conducted using the Veins simulation tool to assess the performance of the proposed solution in the terms of packet delivery ratio (PDR), end-to-end delay, packet loss, transmission overhead, and computational cost.

What do aggregate saving rates (not) show?

Abstract The aggregate saving indicator does not directly reflect changes in individuals’ microeconomic behavior. From the official statistics’ point of view, households choose between spending, which generates additional income and consumption in the economy, and setting money aside, which does not. Formally, households may not (if the authors disregard housing investment) choose to save, because the aggregate saving statistical indicator is a residual concept defined as the ensuing difference between aggregate disposable income and consumption. It measures the change in net worth, which, in a closed economy, may only be generated by the production of capital goods and an increase in inventories. Using an agent-based model, the authors show that shocks unrelated to structural changes in households’ behavior may generate positively correlated fluctuations in the aggregate saving rate, productivity growth and lending. Meanwhile, a genuine increase in the average individual propensity to save is not necessarily associated with a higher aggregate saving rate.

Perceptual Surprise Improves Action Stopping by Nonselectively Suppressing Motor Activity via a Neural Mechanism for Motor Inhibition.

Motor inhibition is a cognitive control ability that allows humans to stop actions rapidly even after initiation. Understanding and improving motor inhibition could benefit adaptive behavior in both health and disease. We recently found that presenting surprising, task-unrelated sounds when stopping is necessary improves the likelihood of successful stopping. In the current study, we investigated the neural underpinnings of this effect. Specifically, we tested whether surprise-related stopping improvements are due to a genuine increase in motor inhibition. In Experiment 1, we measured motor inhibition in primary motor cortex of male and female humans by quantifying corticospinal excitability (CSE) via transcranial magnetic stimulation and electromyography during a hybrid surprise-Go/NoGo task. Consistent with prior studies of motor inhibition, successful stopping was accompanied by nonselective suppression of CSE; that is, CSE was suppressed even in task-unrelated motor effectors. Importantly, unexpected sounds significantly increased this motor-system inhibition to a degree that was directly related to behavioral improvements in stopping. In Experiment 2, we then used scalp encephalography to investigate whether unexpected sounds increase motor-inhibition-related activity in the CNS. We used an independent stop-signal localizer task to identify a well characterized frontocentral low-frequency EEG component that indexes motor inhibition. We then investigated the activity of this component in the surprise-Go/NoGo task. Consistent with Experiment 1, this signature of motor inhibition was indeed increased when NoGo signals were followed by unexpected sounds. Together, these experiments provide converging evidence suggesting that unexpected events improve motor inhibition by automatically triggering inhibitory control.SIGNIFICANCE STATEMENT The ability to stop ongoing actions rapidly allows humans to adapt their behavior flexibly and rapidly. Action stopping is important in daily life (e.g., stopping to cross the street when a car approaches) and is severely impaired in many neuropsychiatric disorders. Therefore, finding ways to improve action stopping could aid adaptive behaviors in health and disease. Our current study shows that presenting unexpected sounds in stopping situations facilitates successful stopping. This improvement is specifically due to a surprise-related increase in a neural mechanism for motor inhibition, which rapidly suppresses the excitability of the motor system after unexpected events. These findings suggest a tight interaction between the neural systems for surprise processing and motor inhibition and yield a promising avenue for future research.

Electron and Proton Heating in Transrelativistic Magnetic Reconnection

Abstract Hot collisionless accretion flows, such as the one in Sgr A* at our Galactic center, provide a unique setting for the investigation of magnetic reconnection. Here protons are nonrelativistic, while electrons can be ultrarelativistic. By means of 2D particle-in-cell simulations, we investigate electron and proton heating in the outflows of transrelativistic reconnection (i.e., σ w ∼ 0.1 – 1 , where the magnetization σ w is the ratio of magnetic energy density to enthalpy density). For both electrons and protons, we find that heating at high β i (here β i is the ratio of proton thermal pressure to magnetic pressure) is dominated by adiabatic compression (“adiabatic heating”), while at low β i it is accompanied by a genuine increase in entropy (“irreversible heating”). For our fiducial σ w = 0.1 , the irreversible heating efficiency at β i ≲ 1 is nearly independent of the electron-to-proton temperature ratio T e / T i (which we vary from 0.1 up to 1), and it asymptotes to ∼ 2 % of the inflowing magnetic energy in the low- β i limit. Protons are heated more efficiently than electrons at low and moderate β i (by a factor of ∼7), whereas the electron and proton heating efficiencies become comparable at β i ∼ 2 if T e / T i = 1 , when both species start already relativistically hot. We find comparable heating efficiencies between the two species also in the limit of relativistic reconnection ( σ w ≳ 1 ). Our results have important implications for the two-temperature nature of collisionless accretion flows and may provide the subgrid physics needed in general relativistic MHD simulations.

Comment on “The Boom and Bust of the RMB's Internationalization: A Perspective from Cross‐Border Arbitrage”

Zhang and Zhang (2017) assess the achievements and prospects of the Renminbi (RMB) internationalization. Their paper focuses on analyzing the role of cross-border arbitraging activities in the RMB's internationalization measured by cross-border RMB settlements in trade and investment and RMB deposits in the offshore market. They explain how the RMB internationalization was pushed forward from 2010 to 2015H1, and slowed down afterwards. Meanwhile, the role that cross-border arbitraging activities played during this cycle was critically highlighted. Zhang and Zhang provide many interesting observations. I have a number of comments regarding their main arguments and methodologies. Cross-border arbitraging activities must have played a critical role in expanding cross-border RMB settlements in trade and investment and RMB deposits in the offshore market from 2010 to 2015H1. However, Zhang and Zhang have not yet presented a clear assessment of the extent to which cross-border arbitraging activities, relative to other factors such as China's trade and output growth and capital account liberalization, have contributed to the RMB internationalization. They suggest that “cross-border arbitrage could only partly explain the fast development of RMB internationalization, and the rest of the fast development would be driven by the genuine increase in the demand for RMB assets by foreigners and for trade and investment settlement.” A formal test based on an econometric technique could be used to estimate the degree of the contribution that cross-border arbitraging activities made to the expansion of the cross-border RMB settlements and RMB deposits in offshore markets. Related to this point, changes in China's overall exports and imports, in addition to cross-border arbitrage flows, must be a major cause of changes in the RMB's usage in trade settlements. As pointed out by Zhang and Zhang, an expectation of a RMB appreciation (depreciation) and the onshore-offshore interest rate spread influenced the cross-border arbitrage flows in RMB settlements in trade and investment as well as RMB deposits. Zhang and Zhang's Figure 5 also provides evidence that the exchange rate spread between the onshore (CNY) and the offshore (CNH) markets was positively related to the ratio of RMB payments in imports to exports. The widening of the spread induces more cross-border arbitrages: if there is an expectation of a RMB appreciation (depreciation), more RMB payments would take place on the import (export) side. However, it should be noted that the ratio of RMB payments in imports to exports must be also related to the relative change in total exports and imports. Concerning the “bust of RMB internationalization” since 2015H2, Zhang and Zhang focus on analyzing the impact of the new exchange rate regime, and subsequent changes in exchange rates and interest rate arbitrage activities. As they have discussed, China shifted its exchange rate regime on 11 August 2015 towards a more flexible, market-determined system. This new policy had to do with balancing capital outflows and supporting export competitiveness amid a weakening growth environment and an overvalued currency. Increasing exchange rate flexibility also strengthened China's efforts to add the Renminbi to the International Monetary Fund's (IMF's) Special Drawing Rights (SDR) basket. Right after the new policy was implemented, the value of the RMB depreciated significantly in the following weeks, sending shockwaves through global financial markets, and then stabilized largely due to stronger foreign exchange intervention by the People's Bank of China (PBOC). However, since then a prolonged fall in the currency's value and net capital outflows has occurred despite the government's interventions. Zhang and Zhang claim that several factors including an increasing in expectation of a RMB depreciation, a decline of the onshore-offshore interest rate spread, a rise in domestic systemic financial risks, stronger capital account controls, and the PBOC's interventions in the offshore market, weakened cross-border arbitraging activities, causing the “bust of RMB internationalization.” A more explicit investigation of the independent effect of each of these factors on the change in the flows in RMB-denominated trade and capital flows during the “bust” period would be useful to assess the future prospects of the RMB internationalization. Given China's continuous economic growth and greater global influence, the RMB will likely emerge as a new international currency (Lee, 2014). However, this is contingent on achieving high capital account convertibility and developing a more efficient financial system. Zhang and Zhang suggest that to pursue a more sustainable RMB internationalization, the Chinese government should maintain robust economic growth, avoid a financial crisis, liberalize the capital account in a gradual and cautious way, accelerate domestic financial reform, and integrate the RMB internationalization with Asian monetary cooperation. Additionally, it is recommended to set the priorities and adequate sequencing among these objectives. For instance, the government can carry out domestic financial reforms more actively, followed by a gradual capital-account liberalization and RMB internationalization.