Special Populations Research Articles

Status of survivorship care among young adult survivors of leukemia or lymphoma.

491 Background: Young adults (YA) have been identified by the American Society of Clinical Oncology as a special population having unmet needs during the transition into survivorship care (SC). These include concerns with financial/insurance status and care coordination, which are compounded further by racial, ethnic, gender, and socioeconomic disparities. The primary aim of this analysis was to describe the proportion of YA survivors, who had been diagnosed in childhood (<18 years) or young adulthood (≥ 18 years), engaging in SC after treatment for leukemia or lymphoma. Methods: The present analysis was part of a fully remote, multi-site, randomized effectiveness-implementation trial on financial distress, which closed to recruitment in April 2023. At trial entry, participants were aged 18- 39 years, ≥3 years post-diagnosis, and in remission. 45% were diagnosed in childhood; 55% as YA. At baseline, participants reported their current SC status. Operationally, SC was defined as care that addresses prevention, surveillance, intervention for the consequences of treatment, and care coordination; a treatment summary (TS) was defined as a document summarizing all cancer treatment received. Using chi-square tests participants were compared by receiving SC and having a TS versus not. Results: The cohort included 130 YA from 18 states who were a mean age of 30 years (SD=5), 60% female, 33% Hispanic, 22% non-Hispanic/non-White (NHNW), and 53% were ≥10 years from diagnosis.Being in SC and having a TS were each endorsed by 46% of participants. Those receiving SC were significantly more likely to be non-Hispanic White (NHW) or have at least a college education compared to those not receiving SC; there were no differences in age at diagnosis or insurance (see Table). There were no statistically significant differences by age group at diagnosis or other characteristics by whether they received a TS. Conclusions: Fewer than half of YA were in SC or had a TS. Providers should encourage long-term follow up care, especially with survivors at further risk based on health care disparities. Clinical trial information: NCT05620979 .[Table: see text]

Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter?

The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.

Hong Kong Guangdong Rheumatology Meeting

The availability of biological or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) has revolutionized the treatment of rheumatoid arthritis (RA). Given the changing landscape of RA management with the ever-expanding armamentarium of advanced therapeutic agents, guidelines are important to provide clinicians with recommendations for decisions frequently faced in clinical practice. To reflect the latest developments in RA research, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) updated their RA management guidelines in 2021 and 2022, respectively. While the general principles of management are largely similar, there are a few divergent recommendations. Two circumstances of particular attention include the polarized view on systemic glucocorticoid bridging and the position of Janus kinase (JAK) inhibitors in the RA treatment cascade. On the other hand, the EULAR recommendations might appear more directly applicable, whereas the ACR counterpart provides treatment guidance in special at-risk populations. In this presentation, the two latest recommendations from ACR and EULAR will be compared, highlighting the salient differences. The supporting literature will also be discussed, including the latest studies attempting to address the controversies in the management of patients with RA.

Adapting an anti‐bullying programme for UK special schools

AbstractBullying is a public health priority but to date, there is a lack of evidence‐based anti‐bullying programmes or interventions designed for use in special schools. KiVa is a successful anti‐bullying programme for mainstream schools currently used in 23 countries. This brief paper outlines the co‐development and adaptation of two KiVa lessons into KiVa‐SEND lessons and their implementation in two special schools in the UK. One school supports pupils with a primary need of Autism, the other supports pupils with severe and complex learning disabilities. Engagement with the lessons was high from both pupils and staff; the content was perceived as acceptable by staff, complementing the curriculum and perceived as suitable for their pupils. Minor adjustments need to be made to ensure all pupils can comprehend and access the concepts. Further development of the KiVa‐SEND programme and testing its potential effectiveness to reduce bullying and associated negative outcomes in special schools is now warranted. Key Points There is a lack of evidence‐based anti‐bullying programmes for use in special schools. This paper details the piloting of an adaptation of KiVa (a successful, evidence‐based anti‐bullying programme for mainstream schools) for use in special schools. The adaption (KiVa‐SEND) was a co‐design between a couple of special school teachers, and educational and psychological researchers to ensure the materials and approach were in line with school requirements and teaching practices. The KiVa‐SEND lesson engagement was excellent from the 12 staff and 62 learners involved and the materials were deemed acceptable via direct feedback and researcher observations. Suggestions were provided on how to make the materials even more suitable for diverse learning needs. KiVa‐SEND has the potential to be embedded within the special school curriculum and then be tested for its effectiveness at reducing bullying and associated negative outcomes of bullying amongst the special school population.

Abstract 218: Evaluating Thrombectomy Candidacy in Large Core Strokes: Lessons from the SELECT2 Trial at Our Institution

Introduction Reperfusion therapy for patients with large vessel occlusion stroke includes thrombolytics and mechanical thrombectomy. Candidacy for thrombectomy depends on patient factors under active investigation. Historically, patients with large strokes have been excluded from major trials evaluating thrombectomy due to concern that thrombectomy would pose considerable risk with limited benefit. However, new evidence from the Select‐2 Trial found improved modified Rankin scale scores and higher rates of functional independence at 90 days following large stroke in patients who underwent thrombectomy versus medical therapy alone. We explored if patients presenting with large stroke at our institution resemble those in the Select‐2 Trial and, how many previously excluded patients could have possibly benefitted from thrombectomy. Methods Patients presenting as a code stroke at our institution from 1/2022 to 7/2022 were retrospectively analyzed. Large strokes, defined as CTP volume greater than 50mL, were identified. Background information included age, sex, race, and prior stroke. Regarding patient stroke presentation, the following data were gathered: NIHSS, LVO status, CTA results, CTP, tPA, thrombectomy status, TICI score, and discharge status. Our patients included in this study were compared to the patients included the Select‐2 Trial. Mortality rates and NIHSS at discharge were compared between thrombectomized and non‐thrombectomized patients at our institution. Results Of the 365 code strokes activated at our institution during the study period, 26 met criteria for a large stroke. Of those 26, 13 met all criteria for inclusion in SELECT‐2. Only 9 of the 26 patients received thrombectomy, including 7 of 13 patients otherwise meeting SELECT‐2 criteria. 6 patients were excluded from thrombectomy who would have met criteria for SELECT‐2. Of the 9 who underwent thrombectomy, one expired, and the average NIHSS calculated from physical exam at discharge of surviving patients was 13. Of the 17 who did not undergo thrombectomy, seven expired and the average NIHSS at discharge was 19.4. Of large stroke patients, average age was 69.5 years (SD 11.0), similar to Select‐2 (median age 66). Average NIHSS at presentation was 19 (SD 6.55), similar to Select 2. Compared to SELECT2 enrollment, our patients were more likely to be female (50% vs 41%), Black (50% vs 25%), have a history of prior stroke (38% vs. 9%). LVO was identified on 23 of 26 patients. Of these 23, 17 MCA, 3 ACA, 6 ICA, and 2 carotid terminus occlusions were identified (6 had tandem occlusions). The average rCBF volume was 102.3 mL (SD 64.3) compared to median estimated ischemic core volume of 80mL in Select 2. Conclusion The patients presenting to our institution with large stroke resemble those included in the Select 2 trial, which demonstrates positive outcomes following mechanical thrombectomy for this special population. Patients with large strokes are frequently excluded from receiving treatment with mechanical thrombectomy. Analysis of a larger data set, including large stroke patients from 2018 to 2022, is currently pending. In light of the Select 2 trial, patients in our community and in our referral basis stand to benefit from an institutional practice of offering thrombectomy to those presenting with large stroke.

Perceptions of pregnant women on COVID-19 and COVID-19 vaccine associated risks

Introduction: COVID-19 impacted the health and life of many people affecting certain special populations more than others. The main objective of this study was to analyze the perception of pregnant women in the UAE on COVID-19 infection, COVID-19 vaccination, harassment, discrimination, and health risks. Materials & Methods: The study design was exploratory cross-sectional research. A Google Form survey was created and circulated to pregnant or recently pregnant women in the United Arab Emirates. The survey elements were harassment, discrimination, and health risks perceived by pregnant women related to their pregnancy and COVID-19 infection. Alpha value was set at 0.05. SPSS version 26 (Armonk, NY) was used for data analysis. Results: A total of 117 pregnant women completed the survey. Among the 117, 63% of the pregnant women were fully vaccinated with at least two doses of COVID-19 vaccination. Less of the fully vaccinated pregnant women contracted COVID-19 while being pregnant (p-value <0.05). Pregnant women who contracted COVID-19 had a statistically significant increase (p-value <0.05)in their perceived harassment, discrimination and risk to health/welfare. More of these negative factors were on the fully vaccinated but still contracted with COVID-19 group and least with fully vaccinated who did not contract COVID-19 when they were pregnant. Conclusions: Perceptions of pregnant women on COVID-19 and COVID-19 vaccines showed concerns that needs to be studied further. Perceived health issues related to the infection and vaccine need multifaceted interventions.

Adequacy of the WHOQoL-BREF to Assess the Quality of Life of Victims of Armed Conflicts.

There is a deterioration in the quality of life (QoL) of survivor victims of warlike conflicts. Because there is a need to guarantee the effectiveness of assessment tools for these populations, we studied the adequacy of the World Health Organization Quality of Life Questionnaire (WHOQoL-BREF) to assess the QoL of 1,136 surviving victims of the armed conflict in Colombia. Although this questionnaire has yielded promising results, questions remain about its psychometric suitability for specific populations. We used model modification at the item level, comparisons of models with different factor structures, and dimensionality analysis to address the psychometric problems encountered. Dimensionality analysis using a bifactor model suggests that WHOQoL-BREF total scores might be a more appropriate way of reporting results when model fit adequacy is not reached. Conclusions are offered on the psychometric properties of the WHOQoL-BREF, the evaluation of special populations, and possible strategies to address future questionnaire modifications.

Silk fibroin based flexible and self-powered sensor for real-time monitoring of abdominal respiration

Personal health monitoring is very important for the health operation of special populations, like newborns and the old. But how to construct a sensor that can achieve real-time monitoring without the need for an external power supply still faces serious challenges. In this paper, a flexible, breathable and self-powered sensor based on triboelectric nanogenerators (TENG) was designed. Silk fibroin (SF) and poly (vinylidene fluoride-co-hexafluoropropylene) (PVDF-HFP) fiber membranes were prepared by electro-spinning, and a u-shaped circuit was sprayed on one side of the fiber membrane as the electrode. Separating by an elastic silicone ring of the two fiber membranes, the all-fiber and self-powered sensor with a simple structure, good stability, and high output performance was developed. The as prepared sensor can instantly light up hundreds of LEDs by hand tapping. The sensor prepared in this work may have some potential applications in wearable devices and energy systems for real-time monitoring of abdominal breathing.

Clinical trial trends over the last 5 years among the BRICS (Brazil, Russia, India, China, and South Africa) nations.

Although the Americas and Europe have historically dominated the global research landscape, emerging economies - Brazil, Russia, India, China, and South Africa (BRICS) have significantly increased their contributions in recent years. This article studies clinical trial trends in the BRICS nations between 2018 and 2022 and compares it with trends in the G7 nations (comprising Canada, France, Germany, Italy, Japan, the UK, the USA, and the European Union). This will help stakeholders in planning drug development strategies. Data were collected from the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the World Bank database. An electronic search was done for the total number of trials registered between January 1, 2018, and March 15, 2023. Information was analyzed based on the year of registration, therapeutic area, type of intervention, sponsorship, and type of special population. The trial density indices (TDIs) were calculated based on population (Xi) and gross domestic product (GDP) (Yi) using author-derived formulae. Altogether 2, 77, 536 trials from the BRICS and G7 were registered. China and the US had the most trials among the BRICS and G7, respectively. Between 2018 and 2022, the gap between the BRICS and G7 steadily reduced. The most common indication for clinical trials among the BRICS was cancer. Based on population, the TDI was the highest in China and the lowest in Russia. In proportion to the GDP, the TDI was maximum in Russia and minimum in India. There is a remarkable reduction in the gap in clinical trial trends between the BRICS and G7 nations. Among the BRICS, India and China are at the forefront in drug development. There is scope for improvement in trial density based on India's population and GDP. Stakeholders are likely to utilize the strengths of the BRICS as an attractive destination for investment in this area.

Current Situation and Future Development of Education for Children in Ecological Migrant Areas in Ningxia

The issue of ecological migration has been concerned for a long time. As one of the first regions to implement ecological migration projects, Ningxia has a special multi-ethnic population, and its education problems cannot be ignored. From the perspective of schools, this paper analyses the current situation of exclusion and isolation of new immigrant children in schools and the lack of holistic education for children. From the perspective of families, it analyses the situation of parents of new immigrants having low expectations for their childrens education and the situation of educational differences due to different ethnic beliefs. The paper positively puts forward the ideas that teachers are expected to teach their students according to their abilities; school is ought to strengthen its infrastructure, obey the rules and regulations in the society and provide extensive training for teachers. Moreover, it is necessary to quicken the social integration of new immigrants and residents. It is hoped that with the implementation of these measures can accelerate the progress of friendly relations between indigenous people and new migrants and provide a good educational environment for children.

Influenza's burden: an umbrella review about complications, hospitalizations and mortality

Abstract Background Influenza virus infection is a major cause of morbidity and mortality worldwide, placing high costs to health systems, yet the quantification of its clinical burden remains debated and undervalued. We conducted an umbrella review to provide a summary of current knowledge on the topic. Methods We searched PubMed-MEDLINE, Web of Science, and the Cochrane library for both systematic reviews and metanalysis of observational studies reporting quantitative assessment of seasonal influenza clinical burden in terms of complications, hospitalizations, and deaths, published up to 30th April 2022. English records were considered for inclusion. We collated together quantitative measures across different outcomes. Results We identified 17 systematic reviews and 10 systematic reviews with meta-analyses published between 2005 and 2022, which included 1321 primary studies conducted from 1918 to 2020 and covering more than 15 million subjects. Of the 27 systematic reviews, 9 (33%) focused on the general population of all ages, 3 (11%) on subjects aged 18 years or older, and 10 (37%) on the paediatric population. Lastly, three reviews (11%) focused on pregnant women, and 2 (7%) on other special populations. Twenty-one (78%) reviews included studies from different countries. Preliminary results show children aged ≤5 years, and adults aged ≥65 mostly contribute to the morbidity and mortality burden of influenza: the hospitalization rate for influenza-related complications is higher in paediatric subjects than in adults (0.27-10% vs 0.02-0.43%) while the highest mortality rate occurs in over65, ranging from 0.12% at community level to 13% among inpatients. Results suggest also a triggering role by influenza for hearth attack in at-cardiovascular risk patients. Conclusions Despite variability in estimates, depending on the setting, the geographic area, and the population considered, influenza carries a significant clinical burden, especially - but not only - in fragile groups. Key messages • Influenza still poses a significant threat to health systems, which should be addressed with appropriate preventive strategies. • The best preventive strategy to reduce the flu burden is vaccination, especially in at-risk groups.

Surge of Midazolam Use in the Midst of Lorazepam Shortage.

Lorazepam is a widely prescribed benzodiazepine that is used to manage anxiety, insomnia, and status epilepticus and is used for pre-anesthetic care as well as several off-label indications including aggression, alcohol withdrawal, panic disorder, chemotherapy-associated anticipatory nausea, and catatonia. Recent increases in demand, manufacturing changes, and quality control issues have resulted in a shortage of injectable and oral lorazepam, prompting clinicians to use alternatives. One such alternative is midazolam, a drug that has been used primarily in the intensive care unit and anesthesia settings. This article examines the significant pharmacologic differences between lorazepam and midazolam. In addition, this article provides dosage guidelines based on the current scientific knowledge and recommendations for conversion equivalencies. The clinical preference for lorazepam can be attributed to its simpler metabolism with no active metabolites, better suitability for patients with less severe hepatic and renal impairment, less risk of adverse reactions, fewer drug-drug interactions, and greater desirability for special populations. In periods of shortages, midazolam has been shown to be effective for a number of off-label uses. To manage conditions that have not been extensively studied, clinicians may opt to use conversion equivalencies, with the caveat that guidelines may vary greatly between institutions and online sources; therefore, it would be best to start low and titrate slowly. Our goal is to aid clinicians in safely and effectively prescribing midazolam during the shortage of injectable lorazepam so that patients are provided the same effects and benefits.

Bacterial bone and joint infections in children with leukaemia or following haematopoietic cell transplant: A systematic review of published cases

BackgroundBone and joint infections (BJI) are common in immunocompetent children, however in children with acute leukaemia the epidemiology, optimal diagnostic pathway and medical and surgical treatment is poorly described. We review the presentation, management and outcomes of BJI in this special population. MethodsSystematic literature review of BJI in children with acute leukaemia was performed using Medline, EMBASE and PubMed databases from 1946 to June, 2023. Titles and abstracts were independently screened by 3 reviewers. Studies were included if they reported data on children (≤18 years) with leukaemia who had a diagnosis of osteomyelitis (radiological diagnosis) or septic arthritis (culture proven or managed as infection by treating clinician). ResultsTwenty-two articles describing 33 episodes of confirmed or suspected bacterial BJI were included. Of these, microbiological diagnosis was confirmed in 27 episodes (82%) and included Gram-positive (9/33), Gram-negative (8/33), mycobacterial (5/33), Mycoplasmatota (1/33) and polymicrobial (4/33). The femur was the most common site of infection (33%) and there were 18 episodes (55%) of multifocal disease. Duration of treatment varied from 3 weeks to 2.5 years in patients with culture confirmed infection (82%) and from 3 to 8 weeks in patients with culture-negative infection (18%). Clinical cure was documented in 31 episodes (94%). ConclusionBone and joint infections in children with acute leukaemia are often caused by atypical pathogens, with a higher predilection for multifocal disease and/or involvement of unusual sites in comparison with immunocompetent children. It is unclear whether this population requires prolonged antibiotic treatment due to periods of intensive chemotherapy or neutropenia. Monitoring response to therapy may be challenging as inflammatory markers such as CRP and ESR may take longer to normalise, making it difficult to assess for clinical cure.

Outcomes at 18–24 Months of Infants with Birth Weight under 500 g Born in Korea during 2013–2017: A Nationwide Cohort Study

Introduction: This study aimed to investigate the outcomes of infants at 18–24 months born in the Korean Neonatal Network with a birth weight <500 g. Methods: The anthropometric and neurodevelopmental data of infants with a birth weight <500 g at a gestational age of ≥22 weeks who were registered in the Korean Neonatal Network 2013–2017 and followed up at a corrected age of 18–24 months were reviewed. Neurodevelopmental impairment was defined as the presence of any of the following: (1) cerebral palsy; (2) severe visual impairment; (3) hearing impairment; or (4) cognitive impairment. Cognitive impairment was defined as (1) a Bayley Scales of Infant Development-II Mental Development Index score <70; and (2) Bayley Scales of Infant and Toddler Development-III Cognitive and Language Composite scores <85. Cognitive testing was performed for infants with suspected problems upon clinician’s referral to developmental specialists. Results: At a median corrected age of 20 months, 26/52 (50%) of included infants had neurodevelopmental impairment. Cerebral palsy, severe visual impairment, wearing of glasses, hearing impairment, and cognitive impairment occurred in 22%, 0%, 8%, 5%, and 57% of the included infants, respectively. The proportions of infants with <2 standard deviations of weight, length, and head circumference were 54%, 52%, and 56%, respectively. The majority (70%) of infants were rehospitalized, and the most common cause was respiratory problems. Conclusion: Half of infants with a birth weight <500 g in Korea may exhibit neurodevelopmental impairment and growth retardation at a corrected age of 18–24 months. Multidisciplinary follow-up along with continuous rehabilitation will be needed to improve neurological and physical development in this special population.

Medicaid and the Children's Health Insurance Program: Optimization to Promote Equity in Child and Young Adult Health.

The American Academy of Pediatrics envisions a child and adolescent health care system that provides individualized, family-centered, equitable, and comprehensive care that integrates with community resources to help each child and family achieve optimal growth, development, and well-being. All infants, children, adolescents, and young adults should have access to this system. Medicaid and the Children's Health Insurance Program (CHIP) provide critical support and foundation for this vision. Together, the programs currently serve about half of all children, many of whom are members of racial and ethnic minoritized populations or have complex medical conditions. Medicaid and CHIP have greatly improved the health and well-being of US infants, children, adolescents, and young adults. This statement reviews key program aspects and proposes both program reforms and enhancements to support a higher-quality, more comprehensive, family-oriented, and equitable system of care that increases access to services, reduces disparities, and improves health outcomes into adulthood. This statement recommends foundational changes in Medicaid and CHIP that can improve child health, achieve greater equity in health and health care, further dismantle structural racism within the programs, and reduce major state-by-state variations. The recommendations focus on (1) eligibility and duration of coverage; (2) standardization of covered services and quality of care; and (3) program financing and payment. In addition to proposed foundational changes in the Medicaid and CHIP program structure, the statement indicates stepwise, coordinated actions that regulation from the Centers for Medicare and Medicaid Services or federal legislation can accomplish in the shorter term. A separate technical report will address the origins and intents of the Medicaid and CHIP programs; the current state of the program including variations across states and payment structures; Medicaid for special populations; program innovations and waivers; and special Medicaid coverage and initiatives.

Regular Humoral and Cellular Immune Responses in Individuals with Chronic Myeloid Leukemia Who Received a Full Vaccination Schedule against COVID-19.

Individuals with chronic myeloid leukemia (CML) constitute a unique group within individuals with oncohematological disease (OHD). They receive treatment with tyrosine kinase inhibitors (TKIs) that present immunomodulatory properties, and they may eventually be candidates for treatment discontinuation under certain conditions despite the chronic nature of the disease. In addition, these individuals present a lower risk of infection than other immunocompromised patients. For this study, we recruited a cohort of 29 individuals with CML in deep molecular response who were on treatment with TKIs (n = 23) or were on treatment-free remission (TFR) (n = 6), and compared both humoral and cellular immune responses with 20 healthy donors after receiving the complete vaccination schedule against SARS-CoV-2. All participants were followed up for 17 months to record the development of COVID-19 due to breakthrough infections. All CML individuals developed an increased humoral response, with similar seroconversion rates and neutralizing titers to healthy donors, despite the presence of high levels of immature B cells. On the whole, the cellular immune response was also comparable to that of healthy donors, although the antibody dependent cytotoxic activity (ADCC) was significantly reduced. Similar rates of mild breakthrough infections were observed between groups, although the proportion was higher in the CML individuals on TFR, most likely due to the immunomodulatory effect of these drugs. In conclusion, as with the healthy donors, the vaccination did not impede breakthrough infections completely in individuals with CML, although it prevented the development of severe or critical illness in this special population of individuals with OHD.

A Successful Practice of Controlling Large Community Cluster Infection of COVID-19 in Special Population by Chinese Herbal Decoction FeiDuQing

A Successful Practice of Controlling Large Community Cluster Infection of COVID-19 in Special Population by Chinese Herbal Decoction FeiDuQing

The Development of Trauma-Informed Community Partnerships: A Mixed Method Social Network Study

ABSTRACT Trauma-informed communities establish cross-sector coalitions that advocate for the use of trauma-informed practices. Whether and how communication occurs within newly established trauma-informed communities is unclear. We collected qualitative data and social network data from six trauma-informed community partnerships that received funding to build community capacity to address trauma across a range of special populations in Los Angeles county. We identified three communication network sub-types and highlight contributions of network leadership in setting the tone for cross-partnership communication. While partnership leaders shared the goal of strengthening cross-organizational communication, social network results illustrated a need to develop strategies that target these goals.

Relapses in Illicit Drug Use Among Probationers: Results in a Risk Group of Public Health Services in Bavaria.

Objective: We aimed to identify in this study time trends of relapses in the illicit consumption of narcotics in a special at-risk population of former drug users under a public health perspective. Methods: In a pooled dataset of 14 consecutive calendar years (2006-2019), the use of seven different narcotic substances was studied in 380 persons with a total of 2,928 urine samples which were analyzed using a valid marker system for narcotic residues. Results: During the entire observation period, the relapse rate for cannabinoids and opiates was the highest despite abstinence requirements. It was noticeable that the relapses across all narcotics groups occurred primarily during the first 3years of the probation period (90%) with a decrease in illegal consumption during the following years of the observation period. Conclusion: Special attention should be paid to probationers at the beginning of the probation period to develop more effective prevention strategies for substance abstinence by all involved actors in public health services.

Physical Exercise and Health, 2: Benefits Associated With Different Levels and Patterns of Activity.

Physical activity and leisure time exercise are associated with well-documented health benefits. Cohort studies and meta-analyses of such studies show that the benefits of physical activity are dose-dependent, arise at even low levels of activity, improve sharply from low to higher levels of activity, peak at very high levels of activity, and plateau thereafter. The benefits are apparent regardless of how the activity is accrued, from vigorous movements in very short intervals during everyday activities across the course of a day to vigorous, "weekend warrior" exercise, accumulated mostly during 1-2 days in a week. An earlier article in this column discussed terminology, guidance, benefits, and risks in the context of exercise and health. This article states and explains the guidance about exercise for adults and for special populations such as the elderly, discusses general limitations of cohort studies, examines how many steps of walking a day suffice to improve health outcomes and at what level a ceiling is reached, considers at what speed these steps need to accrue, examines the benefits of exercise patterns such as vigorous intermittent lifestyle physical activity and weekend warrior workouts, discusses a study that examined different combinations of exercise, and explains the reasons behind the paradox that fitter persons need to perform apparently harder workouts to meet the exercise guidance. Some niche issues are also discussed, such as a role for isometric exercise, the use of caffeinated and energy beverages before exercise, the use of target heart rate as a measure of exercise intensity, how to grade an exercise session that varies in intensity, and the importance of load-bearing, stability, balancing, and flexibility exercises. It must be understood that exercise is a lifetime commitment that provides benefits that pills cannot. Health care professionals need to recommend activity and discourage sedentariness in all patients whom they see.