How does the brain represent and process different types of knowledge? The Dual Hub account postulates that anterior temporal lobes (ATL) support taxonomic relationships based on shared physical features (mole – cat), while temporoparietal regions, including posterior middle temporal gyrus (pMTG), support thematic associations (mole – earth). Conversely, the Controlled Semantic Cognition account proposes that ATL supports both aspects of knowledge, while left pMTG contributes to controlled retrieval. This study used magnetoencephalography to test these contrasting predictions of functional dissociations within the temporal lobe. ATL and pMTG responded more strongly to taxonomic and thematic trials respectively, matched for behavioural performance, in line with predictions of the Dual Hub account. In addition, ATL showed a greater response to strong than weak thematic associations, while pMTG showed the opposite pattern, supporting a key prediction of the Controlled Semantic Cognition account. ATL showed a stronger response for word pairs that were more semantically coherent, either because they shared physical features  or a strong thematic association. These effects largely coincided in time and frequency . In contrast, pMTG showed non-overlapping effects of semantic control demands and thematic judgements: this site showed a larger oscillatory response to weak associations, when ongoing retrieval needed to be shaped to suit the task demands, and also a larger response to thematic judgements contrasted with taxonomic trials . Consequently, time-sensitive neuroimaging supports a complex pattern of functional dissociations within the left temporal lobe, which reflects both coherence versus control and distinctive oscillatory responses for taxonomic overlap (in ATL) and thematic relations (in pMTG). Other frameworks propose a single semantic store, which encompasses these different aspects of knowledge , while those with lesions in ATL produce more categorical errors   . Howeverthe task .Neuroimaging evidence has also implicated temporoparietal areas in the retrieval of knowledge about thematic relations and events, in line with the Dual Hub account, although there is some diversity across studies, with activation peaks in pMTG, AG and superior temporal sulcus . Converscushion-cat in the weak thematic condition), it is necessary to guide retrieval away from highly related but irrelevant concepts such as fabric and dog and focus on specific information that links cats to cushions , supports the controlled retrieval of conceptual information . Both lecushions .In summary, the Dual Hub account suggests that ATL represents taxonomic knowledge while pMTG (and AG) represent thematic knowledge e.g., . In contvs thematic, as anticipated by the Dual Hub theory) or controlled retrieval demands . To anticipate, we observed both of these patterns. We found that ATL is sensitive to both the overlap of physical features that tend to be shared across taxonomically-related items (taxonomic > thematic judgements), and to the strength of co-occurrence for concepts that are found or used together (strong > weak thematic). pMTG showed the opposite pattern: this site responded more strongly to thematic trials relative to taxonomic trials, irrespective of difficulty, and also to weak compared with strong thematic trials, when demands on controlled retrieval are thought to be increased.We tested whether the functional distinction between ATL and pMTG is best characterised in terms of type of relationship . This sample size was selected in line with other similar studies. The study was conducted in accordance with the Research Ethics and Governance Committee of the York Neuroimaging Centre, University of York, UK, and written informed consent was obtained. One participant was excluded from the analysis because their accuracy on catch trials was poor (less than 75%).2.2vs taxonomic) and when the taxonomic trials were harder (strong thematic vs taxonomic). We were also able to compare thematic associations differing in difficulty (weak vs strong associations). These contrasts tested the key predictions of both the Dual Hub and the Controlled Semantic Cognition accounts. To select the stimuli, participants who did not take part in the MEG experiment (n = 30) were asked to rate word pairs on three questions probing 1: Thematic relatedness (co-occurrence): “How associated are these items? For example, are they found or used together regularly?”; 2: Taxonomic relatedness : “Do these items share similar physical features?” and 3: “How easy overall is it to identify a connection between the words?”. Ratings were made on a Likert scale from 1 to 7 . Selected word pairs were rated as highly similar on one type of relationship and not the other . Similarly, items that are thematically related also co-occur with a shared set of words . The Controlled Semantic Cognition account proposes that ATL extracts conceptual knowledge from the sum of all our experiences – and the similar linguistic contexts seen for items with overlapping physical features and strong thematic links can provide a proxy for this. A comparison of word2vec across conditions found higher semantic similarity for strong versus weak thematic trials, and also for taxonomic versus weak thematic trials, even though these conditions were matched on behavioural performance and rated difficulty .2.3We presented 95 target words in the three semantically-related conditions: the first word in the pair differed across conditions, while the second word – the target triggering the semantic decision – was the same across conditions  was used to present the stimuli and to record responses on catch trials. Stimuli were back-projected onto a screen with a viewing distance of ∼75 cm, so that letter strings subtended ∼1° vertically and ∼5° horizontally at the retina. We presented light grey letters on a dark grey background such that the screen luminance was in the mesopic range, and a neutral density filter was used to minimize glare.2.5Before MEG data acquisition, participants' head shape and the location of five head coils were recorded with a 3D digitizer (Fastrak Polhemus). The head coils were used to localise the position of the head within the helmet before and after the experiment. For each participant, a high-resolution structural T1-weighted anatomical volume was acquired in a GE 3.0 T Signa Excite HDx system  at the York Neuroimaging Centre, University of York, with an 8-channel head coil and a sagittal-isotropic 3-D fast spoiled gradient-recalled sequence. The 3D digitized head shape of each participant was used for the co-registration of individual MEG data onto the participant's structural MRI image using a surface-based alignment procedure .MEG data were collected in a magnetically shielded room, with participants seated in an upright position, using a whole-head 248-channel, Magnes 3600 , with the magnetometers arranged in a helmet shaped array. Data were recorded in continuous mode, with a sampling rate of 678.17 Hz and pass-band filtered between 1 and 200 Hz. MEG signals were subjected to a global field noise filter subtracting external, non-biological noise detected by the MEG reference channels, and converted into epochs of 1500 ms length, starting 800 ms before the target onset. All channels from all trials were inspected visually in an artefact rejection process. Data from three noisy channels were automatically rejected. Additional trials were rejected if eye blinks, movement artefacts or external noise sources were evident. On average, 10.9% of trials were rejected .The procedures were not pre-registered prior to the research being conducted.2.6There were two stages to the analysis. We first characterised the response to semantically-related trials across the whole brain . This analysis examined the neural response in terms of total oscillatory power, at a coarse frequency and time resolution, to establish the location of peak responses within the semantic network. In a second phase of the analysis, we contrasted the response for taxonomic and weak thematic trials (matched for difficulty), taxonomic and strong thematic trials , and strong versus weak thematic trials (differing in control demands but matched on semantic decision type). These contrasts were performed at a fine frequency and time resolution within Points of Interest (POI). The locations were selected on the basis of their importance to theories of semantic processing and defined with reference to peak responses in the whole-brain beamforming data.For both whole-brain and POI analyses, the neural sources of the brain activity were reconstructed with a modified version of the vectorised, linearly-constrained minimum-variance (LCMV) beamformer  implemen2.6.1The brain's response to semantically-related trials was characterised within broad frequency ranges and across 200 ms time periods . The purpose of this analysis was to identify local peaks in oscillatory power within theoretically-relevant brain regions, which were then investigated in more detail in a POI analysis (see below). Our research question concerned how the brain's response to the second word changed as a function of its relationship to the first word. We therefore analysed the whole-brain beamforming data by contrasting “active” and “passive” time windows of 200 ms duration from the onset of the second word . In the passive time window (−700 to −500 ms relative to the onset of the second word), participants observed the  nonius (fixation) lines.A 3D lattice of points was constructed across the whole brain with 5-mm spacing, and beamformers were used to compute the total power using the Neural Activity Index  – an estIn order to determine whether the difference between conditions or time-windows was statistically significant for each point on the lattice, we built up a null distribution by randomly relabelling the two time points for each participant and each voxel, using the permutation procedure developed by 2.6.2We placed POIs in brain regions (i) showing a strong oscillatory response in the whole-brain beamforming data across conditions and (ii) for which the Dual Hub and Controlled Semantic Cognition accounts make different predictions. Two temporal lobe sites met these requirements and are the focus of the analysis below. There was a local peak in left ATL, in the 200–400 ms time window and 25–35 Hz frequency band, located within aSTG . This site was close to coordinates previously implicated in verbal semantic tasks . aSTG isWe also selected a site in pMTG  showing a strong oscillatory response at 5–15 Hz and 25–35 Hz from 200 ms after the onset of the second word. This pMTG site was close to a peak for semantic control in a meta-analysis of neuroimaging studies . pMTG isTwo other POI locations are provided in supplementary analyses. AG did not show a significant response in our whole-brain beamforming analysis and therefore the selection of a POI in this region was not strongly motivated. However, given the contrasting predictions that this site should respond to thematic over taxonomic relations  and to strong over weak thematic associations (from the Controlled Semantic Cognition account), we placed a POI in AG at coordinates implicated in ‘automatic’ semantic processing by a recent meta-analysis  . There wWe elected to examine left-hemisphere sites since (i) fMRI and patient studies reveal a greater contribution of the left hemisphere to semantic processing in general ; and ii. Time-frWe computed generalized linear mixed models (GLMM) to compare time-frequency representations across conditions using PROC MIXED in SAS . Time–frequency plots of signal change were treated as two dimensional arrays of small time-frequency tiles, indexed in the model by three main effects, each of which is defined as a class variable: time, frequency and the interaction between time and frequency. Therefore, random effects were included in each GLMM to account for the fact that each participant's time–frequency plot is made up of multiple time-frequency tiles. We also controlled for time-frequency  co-variance in the spectrogram by assuming the estimates of power followed a Gaussian distribution: consequently a Gaussian link function was used in the model. The time-frequency  variability was integrated into the model by specifying an exponential spatial correlation model for the model residuals . The timt test to examine the null hypothesis that the LS-Mean for signal change between conditions was equal zero in each time-frequency tile, and the procedure automatically controls for multiple comparisons . This method has been used in multiple peer-reviewed papers  the response was significantly different from baseline in at least one of the two contributing conditions at p < .01. In addition, since our statistical models were corrected for multiple corrections at each site, but not across the four POIs and three task contrasts, we also applied a cluster-size correction designed to control the probability of false positives across twelve analyses. For different fill rates , we estimated the probability of obtaining different numbers of contiguous tiles by chance, assuming that the tiles showing a significant difference were randomly distributed over time-frequency space. This simulation is shown in p < .05. Consequently, only significant clusters containing six or more tiles are enclosed by the statistical contours.The statistical contours characterising condition differences encompass time-frequency tiles fulfilling both of the following criteria: a) the difference between conditions reached The analyses were not pre-registered prior to the research being conducted.33.1The behavioural data from the catch-trials showed a significant difference in RT and accuracy between the strong and weak thematic conditions, while the taxonomic and weak thematic conditions were matched for behavioural performance see .Fig. 2Ac3.2There were extensive changes in total oscillatory power, following onset of the second word in the pair, relative to the baseline period see . These c3.3increased oscillatory power in the task relative to the passive period, while blue colours depict task-induced power decreases relative to this baseline. Regions of time-frequency shown in green are unchanged relative to the passive period. For the difference plots , red-yellow colours indicate regions where the power of condition A exceeds condition B , while blue colours indicate where the power in condition B exceeds condition A . The statistical contours indicated by solid black lines indicate regions fulfilling three criteria: i) there was a significant change from baseline in at least one of the conditions (at p < .01), (ii) the conditions were significantly different from each other (p < .05), (iii) the significant cluster included six or more contiguous tiles . If criterion iii) was not met, the black line remains dashed.For each site and contrast, we present evoked power across time and frequency for (i) taxonomic and strong thematic trials (TOP ROW), (ii) taxonomic and weak thematic trials (MIDDLE ROW) and (iii) strong versus weak thematic trials (BOTTOM ROW). The difference between these conditions is shown in the left-hand column. For the individual conditions, red-yellow colours indicate 3.3.1This site showed a strong evoked response to the presentation of the second word across conditions see . This revs weak thematic trials) and thematic co-occurrence between two successive words – is consistent with view that this site responds more to semantically coherent inputs, irrespective of the type of feature that drives this coherence. Differences in difficulty did not provide an adequate explanation for this pattern .Statistical contrasts revealed a stronger response to taxonomic than both strong and weak thematic relations within the first 75 ms at 30–40 Hz, which could not be explained in terms of difficulty or semantic coherence as measured by word2vec. This response  is predicted by the Dual Hub account. In addition, the main broadband semantic response in aSTG showed an effect of semantic coherence across different tasks and contrasts. This site was sensitive to strength of association within thematic trials, with a stronger oscillatory response for strong versus weak thematic trials . This difference commenced at 200 ms after the onset of the second word and lasted for the rest of the epoch, from 12-22 Hz. The effect of strength of association within thematic trials also overlapped with the contrast between taxonomic versus weak thematic trials. aSTG showed a stronger response to taxonomic trials (with higher word2vec scores), from 400-600 ms from 15-25 Hz. The observation that aSTG showed sensitivity at the same time and frequency to two contrasts in which word2vec differed – reflecting shared physical features . This effect of strength of association in pMTG is consistent with fMRI studies, which have repeatedly observed greater activation in left pMTG  for weak relative to strong associations that require more controlled retrieval . An over3.3.3vs weak thematic trials) and item co-occurrence , in line with predictions for a semantic store that is sensitive to both types of conceptual relationship (as anticipated by the CSC framework). There was also an early gamma band response to taxonomic relations that could not be explained in terms of overall semantic coherence: this finding taken in isolation is consistent with the Dual Hub account, although this framework might anticipate that this effect would last for a longer duration, and modulate the main task response.The two temporal lobe sites showed opposite effects of difficulty (irrespective of the type of relation). Also, at different times and frequency bands, they showed opposite effects in contrasts between thematic and taxonomic relations (irrespective of difficulty). aSTG showed a larger oscillatory response for taxonomic relative to thematic judgements, and for strong versus weak thematic judgements, while pMTG showed the contrary pattern . The main response to the task within aSTG was stronger for pairs of items that were more semantically coherent (according to word2vec scores) – in other words, where the pattern of semantic retrieval elicited by the first word was more relevant to the conceptual link between the two words that participants were required to retrieve. This effect could be driven by overlapping physical features  and to task demands (taxonomic > strong thematic relations). These effects of difficulty were highly overlapping in time and frequency , consistent with a role for pMTG in semantic control across tasks. Stronger oscillatory power in pMTG was also seen for thematic versus taxonomic decisions in the beta band, across both strong and weak thematic conditions. This suggests there is a separate response in pMTG, which is stronger for thematic than taxonomic decisions, and which can be observed even when the thematic task is easier.4mole-catvscushion-cat), and (ii) for easier and harder thematic pairs with different levels of associative strength . We contrasted the predictions of the Dual Hub theory (which anticipates a dissociation between semantic sites by type of judgement) and the Controlled Semantic Cognition account (which anticipates a dissociation according to semantic control demands). Dual Hub theory predicts that ATL is important for taxonomic relationships while left pMTG and/or AG support thematic knowledge  for taxonomically and thematically-associated word pairs  and semantic control demands within the left temporal lobe. The response in aSTG (within ATL) was stronger for (i) taxonomic judgements, relative to thematic judgements, as well as for (ii) strong versus weak thematic judgements. In complete contrast, pMTG showed a stronger oscillatory response for (i) thematic versus taxonomic judgements and for (ii) weak versus strong thematic judgements. Many although not all of our findings can be accounted for by the suggestion that ATL is sensitive to the semantic coherence between successive concepts, while pMTG supports controlled semantic processes, which shape the dynamic pattern of retrieval that follows the first word to identify semantic overlap with the second word. We can define semantic coherence as the extent to which the meanings of two items are consistent with each other – with word2vec ratings providing a numeric estimate of this variable. Since we have knowledge of both the physical features of concepts and their associations, coherence is relevant for both taxonomically-linked and thematically-linked pairs. Strongly-associated words generate more coherent patterns of activation than weakly-associated words because the past co-occurrence of these concepts will have strengthened the link between them; moreover, taxonomic pairs, which share many physical features, are more semantically coherent (and have higher word2vec scores) than difficulty-matched thematic pairs, which share few features. By this view, ATL is not only sensitive to taxonomic relations, but its response is modulated more generally by the degree to which items generate coherent patterns of semantic activation. Moreover, when coherence is low and the first word does not establish a pattern of semantic retrieval consistent with the link to be retrieved, there is a strong requirement to shape ongoing retrieval, recruiting pMTG. This proposal potentially explains both contrasts of strong versus weak thematic and taxonomic versus weak thematic conditions at both sites. However, it does not provide an explanation for the early response to taxonomic overlap in ATL, or the separate responses seen in pMTG to difficulty and thematic decisions. Below, we discuss the contributions of each site to semantic cognition, and seek to explain findings consistent with both the Dual Hub and Controlled Semantic Cognition frameworks.We observed functional dissociations relating to Our results, taken together, are inconsistent with the view that difficulty, as measured by behavioural performance, is sufficient to explain functional dissociations within the semantic system: 4.1In this study, aSTG showed a stronger evoked response for taxonomic than thematic judgements, but this site was also sensitive to strength of association. The Dual Hub theory suggests that ATL contributes to taxonomic aspects of conceptual knowledge ; for exared and boat, compared with cup and boat . It is possible to account for these overlapping effects of strength of association and type of semantic relation in aSTG in terms of a single neurocognitive effect – semantic coherence – common to both contrasts . Both of these differences reflected a more sustained oscillatory response when the two words had a greater overlap in their meanings (as indexed by word2vec) consistent with the hypothesis above that semantic coherence in ATL gives rise to a more stable and self-reinforcing pattern of retrieval, irrespective of whether this overlap relates to shared physical features or a frequently-occurring common context.4.2pMTG is implicated in diverse aspects of semantic cognition. By one view, it acts as an interface between lexical and conceptual representations, allowing semantic access from language – although fMRI studies show a multimodal response to both verbal and non-verbal semantic tasks . Second,There are several ways that these findings might be explained. One possibility, anticipated by the Controlled Semantic Cognition framework, is that a ‘hub and spoke’ architecture for semantic representation interacts with semantic control processes. By this view, pMTG might be a ‘spoke’ representing action features or multimodal aspects of event knowledge, as well as a key region in the network underpinning semantic control. Since MEG lacks the spatial resolution to separate proximal sources, there could be distinct regions of pMTG associated with processing thematic relations (irrespective of difficulty) and semantic control. This possibility is consistent with our observation that the effects of thematic judgements and difficulty were non-overlapping in time-frequency. The thematic > taxonomic contrast occurred within the beta band, which has been associated with the retrieval of action semantics and syntactic binding processes – aspects of cognition which may relate to thematic processing . This conceptual context can then promote relevant features and associations . In contrast, the items in taxonomic trials do not co-occur within a specific spatiotemporal context, potentially reducing recruitment of pMTG at from 300-400 ms in the beta band; instead shared physical features – potentially detected at a very early time-point in ATL – might provide evidence of a link between the concepts , given that action/event understanding and semantic control recruit similar neural networks in functional neuroimaging studies . We prevpolice-lamp, ongoing semantic retrieval from the first word  is not highly related to the meaning of the second item (light), and therefore, to determine these words are in fact related, it is necessary to (i) identify a linking context (from 250-400 ms in the beta band) and (ii) use this linking context to selectively focus retrieval on features relevant to the conceptual overlap between the two words . Although weak thematic associations had the highest control demands in this study, the taxonomic trials in our experiment also required participants to selectively focus on shared physical features of the probe and target , as opposed to dominant associations, such as the fact that lamps are found on desks). Therefore semantic selection processes from 400 ms in the alpha band are not restricted to thematic trials. In line with this proposal, a recent study found that the degree of feature overlap between the items in taxonomic judgements modulated pupil size (as a marker of cognitive control), even more than strength of association for thematic judgements . This pattern is consistent with the suggestion that the activation of a linking context can then guide the selection of semantic information in pMTG. However, this account remains highly speculative and in need of further investigation.4.3The two temporal lobe sites sensitive to semantic coherence (aSTG) and contextually-guided retrieval (pMTG) respectively fell within distinct large scale networks. To aid interpretation of the MEG findings, we characterised these networks using measures of intrinsic connectivity measured by fMRI at rest see . When thpMTG showed stronger intrinsic coupling to brain areas implicated in semantic control – namely IFG and pre-supplementary motor area; regions that showed reliable activation across different contrasts tapping semantic control in the meta-analysis of 4.4Our analysis examined oscillatory dynamics from the onset of the second word within a pair, when semantic retrieval was already underway; consequently timings are unlikely to be comparable to studies presenting single items. Moreover, we used whole-brain beamforming to localise peak responses within regions-of-interest identified from the fMRI literature. This approach cannot uncover a role for other sites, and MEG is likely to lack the spatial resolution needed to examine functional dissociations within ATL and posterior temporal cortex. In addition, while we have characterised the oscillatory dynamics underpinning semantic retrieval in different circumstances, we lack an overarching explanation of the functional significance of oscillations at specific frequencies. It has been argued that low and high frequency oscillations may reflect different underlying processes, with high frequency oscillations (>30 Hz) reflecting local interactions within a neural population, and low frequency oscillations (<30 Hz) underpinning coordination of distributed neural populations . This is4.5coherence of both concrete features and thematic links, while pMTG shows stronger recruitment when it is necessary to identify a linking context, and/or to focus retrieval on specific aspects of knowledge.While aSTG and pMTG showed a stronger response to taxonomic and thematic semantic decisions respectively, in line with the version of the Dual Hub theory proposed by vcs.ynic.york.ac.uk/naf/naf.The study in this article earned an Open Materials badge for transparent practices. Materials for the study are available on the Open Science Framework (osf.io/mz52c) and analysis code is available at Catarina Teige: Conceptualization, Data curation, Formal analysis, Writing - original draft. Piers L. Cornelissen: Conceptualization, Methodology, Supervision, Visualization, Writing - review & editing. Giovanna Mollo: Supervision, Methodology. Tirso Rene del Jesus Gonzalez Alam: Formal analysis. Kristofor McCarty: Methodology. Jonathan Smallwood: Conceptualization, Writing - review & editing. Elizabeth Jefferies: Conceptualization, Project administration, Writing - review & editing.


Standard precautions are essential to prevent pathogen transmission and nosocomial infections. We assessed learning effect (primary outcome) and satisfaction (secondary outcome) of watching a 5-min humorous “edutainment (=education and entertainment) video” on Standard Precautions compared to reading a written standard operating procedure (SOP) or receiving no intervention.This randomized controlled trial was executed at the University Hospital Zurich, Switzerland, a tertiary care centre with a state-of-the-art infection prevention programme. Healthcare providers (HCPs) of different medical departments were 1:1:1 randomized to watching the edutainment video (video group), reading the SOP (SOP group), or no study-specific intervention (no-intervention group). Online questionnaires included a knowledge assessment about Standard Precautions at time point (TP) 1 immediately after intervention, TP2 after 1 month, and TP3 after 3 months. Information about HCPs’ satisfaction with the learning method was collected. Variables were assessed within and between groups using the appropriate non-parametric tests. Predictors for knowledge of Standard Precautions were assessed by uni- and multivariable linear regression.p < .001 and 0.001, TP3 p = 0.036 and 0.048). In the multivariable analysis, being member of the video group was an independent predictor for better knowledge scores. The video was rated higher than the SOP regarding satisfaction with learning experience, and video group participants more frequently indicated they would recommend their learning method to colleagues.Overall, 363 predominantly female (78.2%) HCPs were included. At TP 1 and TP3, the video group scored better on the knowledge assessment against both the SOP and the no-intervention group  contains supplementary material, which is available to authorized users. Standard precautions are designed to ensure safety for healthcare providers (HCPs), patients and visitors . They arKnowledge about Standard Precautions among HCPs is oftentimes limited –4, and tIn recent years, online learning (e-learning) and internet were used as an important resource for education, and became a progressively growing part of HCP education. E-learning – defined as educational intervention mediated electronically via the Internet  – has beThe IPC team of the University Hospital Zurich, Switzerland, created an educational video clip to improve HCP knowledge about Standard Precautions with the help of a professional film-making staff. As it is well known that emotions help learners to focus and facilitate uptake of information into long-term memory , we chosKirkpatrick proposed a “four-level model” for evaluating training programs : ‘ReactiThe study was conducted at the University Hospital Zurich, Zurich, Switzerland, a 950-bed tertiary-care teaching hospital covering all medical specialties except pediatrics and orthopedics. The University Hospital Zurich has 7200 employees, and around 67% thereof are working in patient care. We invited all hospital ward managers, heads of operating room personnel and therapists, as well as heads of several medical departments, to participate in the study with their entire team of HCPs, both registered and in training. We enrolled the teams based on the order of their replies and considering all professions to be represented. Ethical approval for this quality assessment and improvement project with anonymous data collection was not necessary according to the Swiss law on research on humans.intervention from here on - or no specific task (no-intervention group). Participants in all three groups answered a questionnaire at three time points: At time point (TP1) right after the intervention in December 2016, 1 month later at time point 2 (TP2) in January 2017, and 3 months later at time point 3 (TP3) in March 2017. The survey was designed using the software package Survey Monkey©. At each TP, participants were invited by an email linked to the web-based survey. Participants with incomplete or missing responses to the survey were reminded after 1 week. Only participants answering all questions in the questionnaire were invited to participate at the following TP.Using a computer-generated code, we randomly assigned the participants in a 1:1:1 ratio to either watch the video (video group), to read the SOP (SOP group) - both study tasks called At TP1, participants were asked for demographic information, a subjective self-assessment of their familiarity with Standard Precautions, the University Hospital Zurich infection prevention and control concept (a collection IPC-relevant SOP on the intranet), and the SOP document “Standard precautions – the basics”. According to their randomization group, the participants were then asked to either watch the video, read the SOP, or neither of both. They were then asked to evaluate their satisfaction with the video/SOP, and to answer 32 knowledge assessment questions , professional appearance, respiratory hygiene, aseptic technique, environmental cleaning, and device disposal and reprocessing.https://www.youtube.com/watch?v=uHzwbdBoZVg]. The screenplay was written in collaboration of the IPC team and a film director. The video was filmed with a professional film team including a director, a director of photography, a gaffer, a sound engineer, a costume designer, a make-up artist, two professional actors and 15 extras. Hospital-known infection prevention team members took part in the video. Humor was emphasized as central feature of this “edutainment” video. The scenes were set inside an airplane with passengers appearing as patients. The plot was a “mash-up” between an in-flight safety video and infection prevention instructions. The audience witnesses a cabin crew/infection prevention team member giving instructions to a novice cabin crew member/healthcare provider.“Welcome on board – Infection prevention at the University Hospital Zurich” is a 5-min video about Standard Precautions [“Standard precautions – the Basics” is a three page, 600-word SOP, which was designed for high usability in iterative rounds of design and user testing. In the “Top-Section”, the main messages of the document are summarized. Then, the six topics are elaborated serially, in short and well-structured sections. For clarity and comprehensibility reasons, the word count of every section is reduced to the minimum. Where considered beneficial, the text is illustrated with iconic visualizations. The SOP has been accessible and promoted among all HCP on the University Hospital Zurich intranet website since June 2016 as part of all infection prevention and control SOPs  and 3 months (TP3) after the intervention to test the long-term effect of the video, the assessment of the HCP’s satisfaction with the video and the SOP, and evaluation of independent predictors of ‘good knowledge’ about Standard Precautions.All employees responding to our invitation were included in this study. Variables were assessed within and between the assigned groups at and between the different TPs using non-parametric tests . Predictive factors for higher scores on the knowledge assessment were analyzed using uni- and multivariable linear regression analysis. As an evaluation of the teaching methods, answers regarding satisfaction were measured using a six-point Likert-type scale and compared by using Student’s t-test with Welch approximation.Sensitivity analyses for performance on the knowledge assessments were conducted including only participants answering the questionnaires at all three time points, participants who dropped out after TP1 or TP2, and excluding participants who were re-exposed to the video between TPs.Statistical analysis was performed using Stata 15.1 SE .Of 680 invited HCP, 363 (53.4%) participated in the study at TP1. Thereof, 276 (76.0%) and 191 (52.6%) completed the questionnaires at TP2 and TP3, respectively. The dropout rate from TP1 → TP2 and TP1 → TP3 was 13.8 and 37.9% for the video group, 37.0 and 57.1% for the SOP group, and 21.1 and 46.9% for the no-intervention group, respectively. The study flowchart and the number of participants at each time point are illustrated in Fig. The participants were predominantly female (78.2%) with a median age of 34 years. The majority were nurses (65.3%), had a work experience of at least 5 years (60.6%), and considered themselves familiar with at least ‘some elements’ of Standard Precautions (78.8%). Through the randomization process, all 3 study groups were balanced on these demographic and professional characteristics.p = .001). In the pairwise comparison, the SOP group also scored better than the no-intervention group (p = .006). At TP2, there was no difference between the three groups (p = .364). At 3 months follow-up (TP3), the video group again scored better (mean of 27.63 correct answers (86.3%)) than the SOP (mean of 26.55 correct answers (83.0%)) and the no-intervention group (mean of 26.47 correct answers (82.7%)) (p = .045).Figure Table Results remained categorically equal when analyzing only drop-out participants, participants completing all three surveys, and excluding participants who were re-exposed to video (data not shown).p = .003), members of the video group (p < .001), and those participants who described themselves as being familiar with the University Hospital Zurich infection prevention and control concept (p = .032). Univariate and multivariate estimates are shown in Table By using uni- and multivariable linear regression models, we found independent associations of higher knowledge scores at TP1 for female sex p = .00, membersp = .049) . Compliance and engagement with Standard Precautions assessed by self-evaluation, were equally stimulated by both interventions.Table This randomized controlled study found that watching the edutainment video “Welcome on board”, combining educational and entertaining elements, resulted in higher knowledge scores in Standard Precautions than reading the SOP or no intervention, immediately after the interventions and at 3 months follow-up. Participants of the video group reported a higher satisfaction and recommended their teaching aid (i.e. edutainment video) more often to colleagues than participants from the SOP group.Many of the elements of Standard Precautions seem to be well known to HCPs in our hospital, as the no-intervention group already scored high. Still, after watching the video “Welcome on board”, video group participants scored a mean of two points higher than participants of the no-intervention group. This difference reached statistical significance, and is, in our opinion, clinically relevant. Knowing all elements of Standard Precautions is essential for patient and HCP safety - every single item may make a difference during routine hospital work. The video group scored also higher than the group reading the SOP, demonstrating the superior effectiveness of watching the video compared to having purposefully read the SOP.E-learning techniques teaching IPC topics have shown positive results. Other than our study, all of these studies feature interactivity , 16, 21,The higher scoring of the video group was mainly driven by higher scores in 10 of the 32 knowledge questions. These questions dealt with topics prominently addressed in the video - almost exclusively through humor -, such as wearing PPE when suctioning a patient, compliance with cough etiquette, and professional appearance. Banas et al. stated in a review about humor in education, that appropriate humor attracts and sustains attention and produces a relaxed and productive learning environment . Our finTo assess the long-term effect of the video against the SOP and no intervention, we reapplied the same knowledge questions in a randomized sequence 1 and 3 months after the intervention. In the no-intervention and SOP groups, we saw an incremental increase in scores at consecutive TPs. This might be explained by the exposure to the questionnaire itself or by the increasing engagement of the participants with Standard Precautions, supported by the fact that roughly half of all participants declared being stimulated to use Standard Precautions by participating in our study (data not shown). The video group scored highest both 1 and 3 months after the intervention. Subjectively, the video participants tended to rate the video to better ‘sink into long-term memory’ than the SOP group participants and felt to remember more of the video elements after 1 month compared to the SOP elements. This suggests that the edutainment video might have a more favorable long-term effect than reading the SOP.Educational videos are only useful if watched. Hypothesizing that higher satisfaction leads to higher utilization, we also assessed the participants’ satisfaction with the teaching material. Interestingly, both, the video and the SOP intervention, were rated positively. Still, the video was rated higher in terms of entertaining effect and appealing emotions, and was generally considered to be the better teaching aid compared to the SOP. More members of the video group talked to a colleague about the video or even recommended other HCPs to watch the video than SOP group members reading the SOP. Also, the fact that the video-group had the lowest dropout rate can be interpreted as a sign of relatedness and sustained attention to the topic. Still, if those who watched the video actually shared it with others, e.g. via social media, leading to a ‘viral’ spread among peers, has to be assessed in future studies.Our study has limitations. First, participant blinding is not feasible in educational studies and recall bias may be unavoidable in this setting. Second, the knowledge assessment questionnaire contained four questions whose topics were not or only rudimentarily addressed neither in the video nor the SOP and two questions whose content was only addressed in the SOP and not the video. We included these questions with the argument that both the video and the SOP not only explicitly but also implicitly teach IPC topics. Still, we carefully minded to not include questions only covered in the video to not bias the results in favor of the video group. Third, drop-out rate was considerable, especially in the SOP group. Still, sensitivity analysis showed equal results when analyzing only drop-out participants or participants completing all three surveys, respectively. Last, and most importantly, better knowledge of Standard Precautions alone does not necessarily lead to higher adherence to Standard Precautions .We demonstrated that an edutainment video on Standard Precautions is not only entertaining but also educational by finding highest knowledge scores in the video group. Transporting the content in a humorous way seemed to lead to especially high scoring. The video was preferred over the SOP regarding emotional and entertainment values, and was more often recommended to colleagues. This study addressed the first two levels of Kirkpatrick’s “four-level model” for evaluating training and education programs, ‘learning effectiveness’ and ‘reactions of participants’; further research is needed to evaluate the effect of edutainment videos on ‘behavior’ and ‘impact on patients’ or HCWs’ health’.Additional file 1:Study questionnaire time point 1 (immediately after intervention). (DOCX 24 kb)Additional file 2:Study questionnaire time point 2 (1 month after intervention) and 3 (3 months after intervention). (DOCX 22 kb)Additional file 3:Standardmassnahmen Übersicht. (DOCX 137 kb)Additional file 4:Participants satisfaction with their assigned teaching method at time point 2. (DOCX 18 kb)Additional file 5:Participants satisfaction with their assigned teaching method at time point 3. (DOCX 18 kb)


Ruminal microbes are vital to the conversion of lignocellulose-rich plant materials into nutrients for ruminants. Although protozoa play a key role in linking ruminal microbial networks, the contribution of protozoa to rumen fermentation remains controversial; therefore, this meta-analysis was conducted to quantitatively summarize the temporal dynamics of methanogenesis, ruminal volatile fatty acid (VFA) profiles and dietary fiber digestibility in ruminants following the elimination of protozoa . A total of 49 studies from 22 publications were evaluated.The results revealed that defaunation reduced methane production and shifted ruminal VFA profiles to consist of more propionate and less acetate and butyrate, but with a reduced total VFA concentration and decreased dietary fiber digestibility. However, these effects were diminished linearly, at different rates, with time during the first few weeks after defaunation, and eventually reached relative stability. The acetate to propionate ratio and methane production were increased at 7 and 11 wk after defaunation, respectively.Elimination of protozoa initially shifted the rumen fermentation toward the production of more propionate and less methane, but eventually toward the production of less propionate and more methane over time.The online version of this article (10.1186/s40104-018-0305-6) contains supplementary material, which is available to authorized users. In return, protozoa serve important functions in the rumen microbial ecosystem, such as predation, competition for nutrients, and involvement in symbiotic relationships with other microorganisms ) production, whereas propionate production is accompanied by [H] consumption ; the excectively , 4. Prop animals , 30. In  animals  and Weim animals  observed4, VFA profiles and dietary fiber digestibility implied a series of complex changes in the ruminal ecosystem over the course of defaunation. Nguyen et al. [4 emissions lasted 11 wk and 12 wk, respectively. When sudden major changes are made in the diet, it takes approximately 2 wk for the new microbial population balance to become established [2-producing microbes that generate acetate, butyrate and/or H2 as primary end products [4 production, which may confirm an earlier theory of Weimer [The time-related variations in CHn et al.  reportedablished ; the mucablished . Hristovablished  noted thablished  found thablished , 36; defablished  and the ablished  found thproducts , 39. Thef Weimer  indicatif Weimer , 42. As f Weimer  regardin4 production and shifting ruminal VFA profiles to more propionate were gradually lost over time, and the effects eventually became disadvantageous. Therefore, elimination of rumen protozoa adversely affects the energy supply of animals over the long-term.The present meta-analysis summarized the temporal dynamics of methanogenesis, ruminal fermentation and dietary fiber digestibility in ruminants after defaunation, and the results showed that defaunation adversely affected dietary fiber digestibility and the ruminal VFAs available to the host animals, although the effects were lessened over time. Furthermore, the energy advantages of defaunation gained by reducing CHAdditional file 1:Figure S1. Forest plot showing the results of the subgroup meta-analysis of the anti-methanogenic effect size of defaunation, grouped by faunation state and duration of defaunation (11 wk). BF = born and reared protozoa free; AF = artificial defaunation; SMD = standardized mean difference; 95% CI = 95% confidence interval. * I-squared = percentage of heterogeneity across studies; P-value of SMD = 0. Figure S2. Funnel plot for the effect size of defaunation on CH4 production in (A) all studies, (B) short-term defaunation, (C) long-term defaunation, and (D) refaunation. The P-value of publication bias is presented. SMD = standardized mean difference, se = standard error. (DOCX 1373 kb)


In 2008, the NutriAction study showed that (risk of) malnutrition was highly prevalent (57%) among Belgian older people living in the community or in a nursing home. In 2013, this study was repeated to re-evaluate the occurrence of malnutrition, as well as mobility problems and dependence in activities of daily living (ADL).Health care professionals (HCPs) associated with homecare organizations and nursing homes across Belgium were invited to screen their patients and complete an online questionnaire. Nutritional status, presence of pre-specified comorbidities, mobility, and ADL dependency were assessed.p < 0.001).In total, 3299 older patients were analysed: 2480 (86.3 ± 6.3 years) nursing home (NH) residents and 819 (82.7 ± 6.1 years) community dwelling (CD). Overall, 12% was malnourished (MNA-SF score < 8) and 44% was at risk of malnutrition (MNA-SF 8–11). The highest prevalence of (risk of) malnutrition was observed in NHs (63%) and in patients with dementia  or depression . Of all malnourished individuals, 49% was recognized as malnourished by HCPs and 13% of the malnourished recognized themselves as such. Mobility  and ADL dependency (Belgian KATZ score) were impaired in older people with (risk of) malnutrition in comparison with individuals with normal nutritional status  contains supplementary material, which is available to authorized users. Older people show benefit from an optimal nutritional status, which sustains lean body mass, especially muscle; this in turn supports mobility, resilience, and resistance to potential disease. However, the risk of malnutrition increases with aging due to the presence of (multiple) chronic diseases, dementia, depression, and age-related anorexia caused by loss of appetite, swallowing difficulties, and alterations in taste sensibility –4. MalnuA meta-analysis on the prevalence of malnutrition  score < 17) in older adults showed that 3% of community dwelling older adults were malnourished [2 [The notion that disease-related malnutrition is a problem in industrialized countries has caught the attention of policy makers. In 2003 the European Council issued a resolution appendix with recommendations regarding assessment of nutritional status and nutritional care in the hospital setting . However2 . This is2 .In 2013, the Belgian NutriAction screening was repeated to re-evaluate the prevalence of malnutrition 5 years after the first screening and to characterize patients with (risk of) malnutrition according to care setting and comorbidities. In addition, the ability of health care professionals to recognize malnutrition and the health burden of malnutrition on mobility and dependence in activities of daily living was assessed. Another goal was to reinforce awareness of the existence of malnutrition and the need to treat it among involved health care professionals.For this cross-sectional study (NutriAction II), general practitioners (GPs) and nurses associated with homecare organizations for community dwelling patients, and HCPs in nursing homes in Belgium were approached to assess the nutritional status of people aged 70 years and older under their care, from February until April 2013. There were no exclusion criteria. GPs, nurses and other HCPs received a standardised instruction on how to complete the online questionnaire developed for this screening.The NutriAction II project was approved by the ethical committee of the University Hospital of Antwerp and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.The privacy of participants was guaranteed according to Belgian legislation by anonymising the data. Informed consent was obtained from all individual participants included in the study.Nurses, GPs, and other HCPs responsible for the care of the participants at home or in nursing homes performed the screening and completed the online questionnaire. For NutriAction II, the 2008 questionnaire  was sligTo establish the ability to recognize malnutrition, the HCP was asked prior to nutritional assessment if he or she considered the older person under assessment malnourished. The person assessed was also asked if he or she considered his- or herself malnourished. Mobility was assessed as the ability of the patient to climb stairs (15 steps) and to walk outside for 5 min without taking a rest (yes/no). Independence in Activities of Daily Living (ADL) was assessed using the Belgian Katz ADL questionnaire with the familiar physical functions  and two additional cognitive functions (orientation in time and space) . The BelThe 2013 questionnaire furthermore contained questions about number and type of medications used, recent hospitalisations (< 3 months), and could be used to compare screening instruments for (risk of) malnutrition. However, these items are outside the scope of this paper, see for all details the online resource containing the full Dutch 2013 questionnaire (ESM_1).t test, or ANOVA, when three groups were compared. The Chi-square test was used for categorical variables. Statistical significance was considered for p values < 0.05. All analyses were performed in SPSS (IBM SPSS Statistics Version 19).The prevalence of malnutrition and risk of malnutrition were reported in the different care settings (nursing homes and community dwelling). The distribution of nutritional status  was also reported within a selection of medical conditions. Continuous variables were expressed as mean ± SD, proportions were expressed as n (%). For continuous variables, differences between groups were analysed using the Student Nurses, GPs, and other HCPs associated with eight homecare organizations and from 36 nursing homes, participated in the study. This sample is representative for older people in Belgium. A total of 3641 persons were screened; 342 individuals were excluded, based on age < 70 years or on double entry. This left 3299 older people for analysis, of whom 819 (25%) were community dwelling (CD) and 2480 (75%) were nursing home residents (NH). The majority of the population was female (76%). The mean age was 85.4 ± 6.4 years. Characteristics are shown per setting, i.e., NH or CD, in Table Individuals in the NH population had on average more comorbidities than the CD individuals Table . In the p < 0.001; Table The prevalence of (risk of) malnutrition in the total study population was 56% . The prevalence of (risk of) malnutrition was higher in NH residents compared to CD individuals .Prior to nutritional assessment, only half (49%) of the malnourished patients in the total study population were recognized as malnourished by the HCPs. This percentage was similar for CD and NH older individuals (p = 0.011).Seven per cent of the included older people used an oral nutritional supplement (ONS). The use of ONS was more common among the NH than the CD population Table . Only 20p < 0.001). Of the CD population, malnourished older adults were less able to climb stairs than those with normal nutritional status (Table p < 0.001). Of the CD population, older adults with malnutrition were less able to walk for 5 min without interruption, than those with normal nutritional status . Nursing home residents were more dependent in ADL than the community dwelling older adults Table . FurtherThe overall prevalence of (risk of) malnutrition in older individuals with homecare or residing in nursing homes, determined with the MNA-SF (cut-off ≤ 11), was similar (56%) to the observed prevalence with the previous NutriAction screening in 2008 (57%) . The obsIn general, comorbidities were more prevalent in nursing homes than in the community, and were higher with worsening of nutritional status. We speculate that malnourished individuals with more comorbidities are less able to live independently and, therefore, are more prevalent in the nursing home. Of the total population, 49% suffered from the neuropsychological comorbidities depression and/or dementia. In nursing homes, this was 58%, compared to 20% in community dwelling older individuals. In demented or depressed older people, the prevalence of (risk of) malnutrition seems higher than for other comorbidities. This was observed in both settings (community and nursing home). This observation supports the finding by Valentini et al.  that theDespite the high prevalence of (risk of) malnutrition, only 7% of all older individuals consumed oral nutritional supplements (ONS). In the nursing homes, only half of the malnourished and less than one-fifth of those at risk of malnutrition were recognized as such, and even less of them received ONS. This suggests that even when a low nutritional status is recognized, this not necessarily results in intervention with medical nutrition. The higher percentage of ONS-fed nursing home residents compared to community dwelling older adults, however, suggests a slightly higher awareness of health care practitioners in nursing homes of the prevalent risk of malnutrition and need for treatment. Another explanation could be that ONS is more accessible in nursing homes.This result is less favorable than the observation by Streicher et al. , who useSelf-awareness regarding nutritional status of older community dwellers and nursing home residents was even lower. This may be caused by the large number of neuropsychological compromised older individuals, because demented and depressed older adults may be less able to acknowledge their own nutritional status.In line with findings by Cereda et al. , we obseSince a considerable percentage of those with a normal nutritional status in our study was compromised in mobility  and performance (68% could not climb stairs), other factors beyond malnutrition may also play a role. Another known important contributor to functional performance, if not most important, is reduced physical activity with aging . A combin = 3299) from both the community dwelling setting and nursing homes were included. This resulted in a representative sample of older individuals in both nursing homes and at home. In addition, this required the involvement of a variety of health care professionals, which supported the secondary aim to increase awareness among them of the existence of, and need to treat malnutrition. Another ‘strength’ is application of the MNA-SF, used in both screenings in 2008 and 2013, a well-established and validated malnutrition screening tool in older people. Furthermore, the 2013 NutriAction study yielded additional information about the prevalence of malnutrition within a variety of comorbidities. In addition, the recent NutriAction provides information about (self) recognition of malnutrition, and the relationship between nutritional status and functional performance of the included older adults.The strength of this study is that a large number of older people  malnutrition within comorbidities was limited to pre-specified conditions, and should be interpreted with caution, since comorbidities may overlap and as such affect nutritional status differently. Multivariate regression analysis may be necessary to unravel the contribution of different (combinations of) comorbidities to nutritional status. However, in this paper, we focused on the prevalence of malnutrition to raise awareness rather than to analyse the contribution of comorbidities to nutritional status. In addition, use of the Belgian KATZ score makes it less easy to compare ADL dependency results of this study with results of other studies. Finally, the inclusion of demented people may have complicated the evaluation of self-recognized malnutrition.The prevalence of malnutrition has remained stable among Belgian older people in the period 2008–2013. Malnutrition remains a major problem, despite all awareness initiatives by the government and nutrition-focussed organisations. Malnutrition is especially prevalent in nursing homes and in those with comorbidities such as depression and dementia. Health care professionals and patients themselves greatly underestimate malnutrition in older people, both in the community and in nursing homes. Malnutrition is associated with mobility problems and dependence in ADL, and therefore may accelerate the transformation of frailty into disability. In the future, nutritional screening could be complemented with screening for frailty and functional limitations.Below is the link to the electronic supplementary material.Supplementary material 1 (PDF 230 KB)Supplementary material 2 (DOCX 31 KB)


The relevance of body composition (BC) to performance in sport has long been appreciated with special concern on the total and regional proportion of fat and muscle. Dual-energy X-ray absorptiometry (DXA) is able to accurately measure BC, but it may not be easily available in practice; anthropometry has long been used as a simple and inexpensive field method to objectively assess BC. The aim of this study was twofold: first, to develop and validate a sport-specific anthropometric predictive equation for total body fat mass (FM) and lean mass components in female handball players to be used in the sport setting; second, to cross-validate in female team handball players several independently developed, predictive equations for BC in female athletes.n = 60) of randomly selected players using demographic and anthropometric variables. The developed equations were used to predict DXA outcomes in an independent validation sample (n = 25).A total of 85 female team handball players  of different competitive levels underwent anthropometry and a whole-body DXA scan. Multiple linear regression analysis was used to develop predictive equations in a derivation sample (P < 0.001) models were developed for total body FM , percentage FM , fat-free soft tissue mass (FFSTM) , fat-free mass . All models were robust to collinearity. Each developed equation was successfully validated in the remaining 25 players using correlation analysis, mean signed difference, t-test, and Bland–Altman plot. The whole dataset of team handball players (n = 85) was used to cross-validate several predictive equations independently developed by others in female athletes. Equations significantly  over- or underestimated the corresponding DXA measurements.Statistically significant (It is concluded that in team female handball players the anthropometric equations presented herein are able to estimate body fat and FFSTM with accuracy. Several BC predictive anthropometric equations developed in different female athletic populations revealed inaccurate when tested in team handball players. These results should be of use for coaches, physical trainers, and nutritionists when evaluating the physical status of female team handball players. Team handball  is a popular team sport practiced worldwide by about 18 million players in more than 150 international federations . HandbalThe evaluation of body composition (BC) is a key issue in sports science as well as sports practice with special reference to the body content of fat and skeletal muscle. The total and regional BC is related to performance  as well Several different methods and tools are available to assess BC with these methods ranging in costs, practicality and accuracy. Dual-energy X-ray absorptiometry (DXA) is currently considered the gold standard in accurately measuring BC in terms of FM, fat-free soft tissue mass (FFSTM), bone mineral content (BMC), and FFM (sum of FFSTM and BMC)  and its Despite the worldwide diffusion of handball, to the best of our knowledge there are no handball-specific anthropometric equations available to predict BC in handball players. Preliminary work conducted in our laboratory on a small sample of female handball players showed that available predictive equations developed using DXA in athletic populations are not accurate in predicting BC in handball participants. Therefore, in the current study we recruited a number of female handball players to develop and validate sport-specific anthropometric predictive equations for body fat and lean mass components using DXA as the criterion. Further, we cross-validated in female handball players several independently DXA-developed predictive equations for %FM or FFM in female athletes . The obsf2 = 0.15)   in multin = 32), A2 (n = 38), B (n = 17). According to playing position, the participants encompassed 30 wings, 32 backs, 15 pivots, 10 goalkeepers. All measurements were taken at the beginning of the competitive season in October. During pre-season, A1 players had been training an average of eight sessions a week, 3.5 h per session; A2 and B players had been training an average of three sessions a week, 2.0 h per session. All participants had at least 1 year of competitive handball experience. At the time of measurements all participants were in good health and have had no major injury in the last 6 months.Participants were playing in six different teams participating in the following Italian national championships ordered from the highest to lowest competitive level: A1 (2. The following lengths (L) and breadths (B) were measured with a Harpenden anthropometer : shoulder-elbow L, elbow-wrist L, thigh L, tibialelaterale to floor L, transverse chest B, anterior–posterior (A–P) chest B, elbow B, wrist B, knee B, and ankle B. Body circumferences (C) were measured with a fiberglass tape at the upper arm (relaxed), waist, hip, thigh, and calf sites. Skinfold (SF) thickness was measured in duplicate with a Harpenden calliper  at the triceps, axillary, subscapular, suprailiac, abdominal, anterior thigh, and calf site. The average of the two readings was the measure. If the two measures differed by more than two mm, a third measurement was taken, and the two closest were then averaged and recorded as the score. All measurements were taken by an experienced anthropometrist according to standard procedures  and stature was measured with a Harpenden stadiometer  at the nearest 0.01 m, according to the ocedures .Fat mass (g), %FM, FFSTM (g), BMC (g), and FFM (g) were measured using a DXA scanner , according to the manufacturer’s procedures. To avoid possible baseline drift, the scanner was checked daily against a standard anthropomorphic spine phantom supplied by the manufacturer. All scans were performed by one operator, in order to ensure consistency. In our lab the precision error (percent coefficient of variation with repositioning) of whole-body DXA measurements is 1.1%, 2.3%, 0.5%, and 2.8% for BMC, FM, FFSTM, and %FM, respectively. All participants were asked about possible pregnancy prior to DXA scan measurements. In the case of possible pregnancy the participant was excluded from the study. During scanning, participants wore lightweight clothing with no metal or reflective material, and removed all metal accessories.A total of 85 participants completed all measurements  and were used in analysis.n = 60) and a validation sample (n = 25). Continuous variables in the two groups were compared with the Student’s t-test for paired samples. The equality of proportion of players in the two groups according to the competitive level  or the playing position  was assessed with the Pearson Chi-squared test. Correlation between variables was assessed with the Pearson’s correlation coefficient r. Sport-specific predictive equations were developed in the derivation sample by running backward multiple regression analyses with DXA-measured BC outcomes  as the dependent variable and anthropometric and demographic variables as the predictors. Predictor variables were selected up to a maximum of eight using both of the following criteria: (i) higher significant correlation (r) with the dependent variable and (ii) r value >0.200. The probability of F-to-enter was set at ≤0.05 for inclusion and ≥0.10 for exclusion of predictor variables. Adjusted R2 and standard error of the estimate (SEE) were used to assess the goodness-of-fit of the prediction model. Homoscedasticity of data was assessed by both plotting the residuals of multiple regression analysis against the predicted values and the Koenker test (f2), (R2 is the coefficient of determination and Rk−12 is the coefficient of determination in the absence of p. According to Cohen’s guidelines (f2 = 0.02), medium (f2 = 0.15) and large (f2 = 0.35). The developed equations were used to predict DXA outcomes in the validation sample. The validity of the developed equations was evaluated with the correlation coefficient r, the coefficient of determination (R2), the Student’s t-test, the mean signed difference (MSD) and the Bland–Altman plot. The same procedure was used to cross-validate against DXA measurements several BC predictive equation independently developed in female athletes  with a two-way mixed single measures model and absolute agreement. For regression analysis, the 85 participants were randomly assigned to a derivation sample (ker test . The prest (f2),  for a giidelines , effect athletes . Statistathletes  on the bn = 85) as well as the derivation (n = 60) and validation (n = 25) samples are summarized in t-test) as well as distribution across competitive levels and playing positions (Pearson Chi-squared test)  .The test-retest ICC  with 95% confidence interval (CI) for the anthropometric measurements was 0.993 (95% CI [0.946–1.000]) indicating excellent reliability .n = 60) are presented in P < 0.001). Adjusted R2 ranged from 0.798 (FFM) to 0.943 (FM). For all models, the Durbin–Watson statistics was between 1.5 and 2.5 and the variance inflation factor was <5.000 for each predictor, indicating robustness to collinearity. The Koenker test for homoscedasticity of data was not significant (P > 0.05) for all models. Post hoc power analyses revealed that the statistical power for regression analyses in this study exceeded 0.99, suggesting good model sensitivity to Type II error as well as that the models were adequately powered to detect the true effect of the predictor variables. In the validation sample, (n = 25) the correlation between DXA-measured and predicted BC variables was statistically significant for all of the developed equations  and no significant difference was found on t-test . However, the Student’s t-test showed a systematic error between predicted BC variables and the corresponding DXA measurements for all equations . In particular, the equation of Body composition variables estimated with anthropometric equations specifically developed in female athletes  and DXA Evaluating and monitoring BC is a key issue in sports practice due to its link to performance and injury risk prevention. The results of this study offer a novel, handball-specific, DXA validated tool for estimating BC in female handball players using anthropometry, thereby filling a knowledge gap in the literature. Moreover, results showed that DXA-developed BC predictive equations obtained on different female athletic populations  might befΣSF2 = 9.53 and 7.84; fhipC2 = 7.09 and 2.25, respectively). This was unsurprising, because both anthropometric variables are closely associated with total body adiposity in female athletes . Validation of the two developed equations in a different sample of female handball players showed excellent agreement between predicted and measured FM and %FM values. Two anthropometric predictors namely, sum of SF and hip C, showed the largest effect size in predicting FM and %FM  with a four-compartment model as the criterion; the predictor variables were age, stature, and hip and waist C with a predicted residual error sum of squares (PRESS) R2 of 0.52 and PRESS SEE of 3.35%. In female handball players, this equation significantly (P < 0.001) underestimated %FM with a moderate MSD of −1.89%. This discrepancy may be due to the limited number of participating athletes in the study of P < 0.001) underestimated %FM vs. DXA measurement (MSD = −2.83). However, both female (mean %FM = 18.7) and male (mean %FM = 11.7) participants in the study of 2) as the sample of handball players participating in the current study. Predictors of FFM were body mass, and the abdominal and thigh SF; in the regression model, R was 0.98 and SEE was 1.1 kg. When used in handball players, the equation of P < 0.001) overestimated DXA-measured FFM with a MSD = +4,723 g. A reason for such a large discrepancy may be found in the markedly different BC between the two samples, with athletes in the Warner’s study showing a much larger FFM (50 ± 5.9 vs. 42.3 ± 5.59 kg) and %FFM (79.7% vs. 65.2%) vs. the handball players participating in the current study, indicating that the two samples are probably composed by different types of athletes. In fact, the participants recruited by First, the equation of 2) similar to those found in the handball players participating in the current study. The predictors were body mass and stature; the developed model had R = 0.961 and SEE = 1.6 kg. The equation of P < 0.001) overestimated FFM vs. DXA FFM with MSD = +2,945 g. Once again, this discrepancy may be explained by the much larger FFM (49 ± 6.0 vs. 42.3 ± 5.59 kg) and %FFM (78.4% vs. 65.2%) in athletes participating in the study of Finally, also the predictive equation for FFM of This study has some limitations that should be mentioned. First, this is a single-center study and, therefore, some caution should be applied when expanding our results to the generality of female handball players; caution should also be applied when using the equations developed in our group of handball players to predict BC in elite athletes. In fact, data in the literature  show than = 222) group of players of the Greek league (This work, however, has a number of strengths to be highlighted. A main strength of the study is the use of DXA, a reference standard for assessing BC. Moreover, the female handball players participating in this study had demographic characteristics and %BF similar to those shown by a large (k league  as well k league  showing In conclusion, this work produced a set of validated anthropometric sport-specific predictive equations able to accurately estimate BC components in female handball players. Cross-validation against DXA of several independently developed predictive equations for %FM and FFM in female athletes revealed that they are not accurate when used in female handball players. Sports professionals will therefore benefit from using the predictive equations proposed therein as a rapid and non-invasive tool for assessing and monitoring BC in female handball players.10.7717/peerj.5913/supp-1Supplemental Information 1Click here for additional data file.


The legislatures of Colombia and Ecuador have reserved seats for their non-resident citizens (emigrants). This paper analyses the relationship between the formal, descriptive, and substantive dimensions of emigrant representation in their homeland legislatures. The analysis compares the legislative work of emigrant MPs (EMPs) with the legislative work of non-emigrant MPs (NEMPs) in Ecuador and Colombia. It presents a mixed methods approach that combines a quantitative text analysis based on an original dataset –composed of 35,446 floor speeches– with in-depth interviews with six EMPs. The results show that emigrant-related issues are significantly more salient in the legislature of Ecuador and Colombia suggesting that the effect of emigrant-reserved seats is correlated to the size of the external district. Furthermore, the analysis reveals that EMPs have a ‘mixed agenda’ composed by emigrant and domestic-related issues. Finally, the article shows that the probability of classifying a speech as emigrant-related increases when it is given by an EMP and not a NEMP. This effect is stronger in Ecuador than in Colombia. All in all, the article shows evidence that configurations that allocate several EMPs are more efficient in achieving substantive representation. In 1991, Colombia included a provision in its new Constitution that granted non-resident citizens the possibility to elect their own representatives in the lower legislative house. In 2008, almost two decades after Colombia’s constitutional change, Ecuador also extended active and passive electoral rights to non-residents, reserving six special seats for emigrants MPs  in the National Assembly. Up to 2018, 15 countries in the world have created special seats for emigrants in their legislative houses , with in-depth interviews of six EMPs. In the analysis, I test whether the presence of emigrant special representatives in the legislative houses has an impact on the substantive representation of emigrant-related issues. In addition to this, I test whether the different configurations of emigrant special representation that exist in Ecuador and Colombia are significant in explaining the substantive representation of emigrant-related issues.The theoretical background of this paper is built upon two different strands of the literature that, until now, have not been sufficiently interconnected: the literature on political representation and the literature on political transnationalism.This paper takes the multidimensional concept of ‘political representation’ as proposed by Pitkin  as a thethe presence of emigrant parliamentarians (EMPs) in a legislative house translates into substantive representation of emigrant-related issues in the legislative process (H1).Classic studies in political sciences have studied, for instance, the effect of district size on representation or the differences between majoritarian and proportional electoral designs Rae, . There hStudies focused on emigrant special representation are scarce within the literature of political transnationalism. In general, scholars have treated this topic as an appendix to research about external active voting. However, it is possible to find some exceptions to this trend. Lafleur  inquiredthat in order to achieve substantive representation and avoid a ‘containment effect’, it is necessary to reach a critical mass of emigrant parliamentarians (H2a).Conveniently enough for the scope of this paper, the use of special seats is not limited to emigrants. In fact, this mechanism is broadly used around the world to assure the presence in legislative chambers of ethnic, racial or religious minorities .The claims made from critical mass theory, however, have been contested by some scholars who have argued that, even in parliaments in which a given minority has not reached a ‘critical mass’, substantive representation could be still achieved. In fact, some have observed that substantive representation is greater when the minority is still significantly underrepresented in a legislature. For instance, Rouse  found ouTo conduct this analysis, I selected two countries, Ecuador and Colombia, that have allocated seats for emigrants in at least one of their legislative houses, but that differ in the number of seats reserved. Ecuador has six seats reserved to emigrants and Colombia between one and two.Revolución Ciudadana, which was initiated in 2006 and consolidated with a new constitution in 2008, migration has been a highly salient topic in the political and public agenda in Ecuador. During the Correísmo, Ecuadorian migrants were portrayed as victims of the severe economic and political crisis that took place at the end of the 90s . Thus, it includes a mix of MPs with more and less seniority (the maximum number of periods that Ecuadorian MPs can serve is two). Also, all of them were members of Alianza PAIS, the political movement in the Ecuadorian government. To stand as a candidate for an emigrant seat, the Ecuadorian law requires previous residence abroad. Thus, all EMPs are members of the Ecuadorian diaspora. Nevertheless, during the time they serve in the National Assembly, they move back to Quito, as they are required to be present in the legislative debates.sui generis external territorial district, but as the inclusion of a minority that otherwise would be excluded from the Colombian House of Representatives.Colombia started to adopt emigrant policies much earlier than Ecuador. In fact, Colombia was one of the first countries in the region that granted political rights to non-residents when in 1962 emigrants were allowed to vote for presidential elections . To measure the second indicator of emigrant substantive representation, I apply quantitative text analysis based on dictionary coding, which is a supervised approach successfully implemented by other scholars to code a large sets of documents with high reliability  affects the substantive representation of emigration-related issues in the speeches of the individual MPs in the floor discussion. I assume that MPs representing these districts may also have an interest in representing the emigrant community, since a significant part of the well-being of their constituency is shaped by the access to remittances. To this end, I use a nominal variable composed of three categories: NEMP (coded as 0), EMP (coded as 1) and EDMP (coded as 2). To define the districts that are highly affected by emigration, I use the distribution of remittances across regions. Districts receiving more than 5% of the total country remittances are coded as highly affected by emigration.9The substantive representation of emigrant-related issues in floor speeches could be also affected by other variables that, for this particular research, are included as controls. Firstly, it is also possible that the performance of individual MPs is conditioned by their relationship with the party in government. EMPs representing a party that is also part of the government will have less interest of mentioning emigrant issues. MPs are code as 0 if they represent a party in the opposition and 1 if they represent a party in the government.In this analysis, I implement a mixed methods approach . Interestingly, the model also shows that there is a difference between legislative periods: all other variables being equal, a speech given in the period 2013–2017 is more likely to be classified as emigrant-related than a speech pronounced during the period 2009–2013 . Model 1b shows similar results as Model 1a. The results for Colombia are similar. Model 2a and 2b suggest that being an EMP is also correlated significantly with the probability of given an emigrant-related speech . As in Ecuador, speeches given during the second legislative period (when Colombia added an extra emigrant representative) are more likely to be classified as emigrant-related . Being an EDMP does not significantly increase the probability of giving an emigrant-related speech during the floor discussions in Colombia or Ecuador. Finally, beyond legislative period, control variables do not have any significant effect on the classification of a speech as an emigrant-related intervention.12In the case of Ecuador, Model 1a shows that, as expected, being an EMP significantly increases the odds-ratio of dedicating floor speeches to approach an emigrant-related issue .Several EMPs from both countries mentioned that a big part of their work was monitoring the government and mediating on behalf the emigrant community to express their demands to the executive. As a Colombian EMP expresses it “… it is about awareness work, to create the awareness that there are Colombians abroad and they have to be involved (…) tell the Ministries, the institutions, that there are Colombians abroad and they have to work for them”.Finally, the interviews confirmed that both Ecuadorian and Colombian EMPs campaigned abroad to get elected mostly on issues that affected the diaspora abroad, as captured by the dictionary codes . Also, they confirmed that they conduct district work by keeping ties with their emigrant communities via social networks and overseas travels –the latter being mostly self-funded in Ecuador and only partially in Colombia.Research on the substantive representation of non-resident citizens in their states of origin is scarce. However, investigating this particular topic is essential to gain new insights about the formal-descriptive-substantive link of political representation. This study tested the existing theories about minority representation, such as critical mass, on a group –emigrants– that has, up to now, been neglected in the literature of political representation. I implemented an innovative mixed-methods research design that combines a quantitative text analysis of more than 35,000 floor speeches with personal interviews with emigrant special representatives. The detailed inspection of floor speeches emerged as a valid and valuable source of information to assess substantive representation. It allowed me to compare different groups of representatives without previous sampling, enhancing the robustness of the measurements.Scholars have argued that a system of special representation for non-resident citizens is fair because it allows large communities of emigrants to participate in the political systems of their state of origin, while at the same time controlling the effect that emigrants could have over homeland politics . Even though NEMPs target the emigrant community in their floor speeches, it was proved that EMPs dedicate relatively more of their time in plenary sessions tackling emigrant issues. Nevertheless, the degree of substantial representation differs considerably across both countries. In Colombia, where there are only one or two EMPs, the salience of emigration is significantly lower than in Ecuador, a country with six EMPs. In the same line, the statistical models also suggest that in both countries, being a member of the EMP group, increases the predicted probability of giving a speech explicitly related to emigrant policies. In line with H2a, this effect is stronger in Ecuador than in Colombia. The low salience in Colombia is evidence of the existence of a certain ‘containment effect’ (in line with H2a), but also can be influenced by other factors such as the prominence of other issues (e.g. the peace process). Furthermore, another possible explanation of this difference can be found in the formal rules that shape emigrant special representation in each country. The clear territorial connotation of the Ecuadorian system  increases the pressure on the special representatives to incorporate the demands of the non-resident community into their legislative work. This territorial link, however, is weaker in Colombia, where emigrant special representation was granted as a mechanism to give voice a minority group and not a territorial entity.Secondly, the results do not show a clear marginalization effect of EMPs in any of the countries. In fact, the Colombian EMPs were shown to participate significantly more, on average, than other MPs. In Ecuador, the difference in the number of speeches given by EMPs and NEMPs does not follow a clear pattern.Thirdly, the qualitative analysis suggests that, although EMPs prioritize emigrant issues in their legislative agenda, those are not the only substantive issues that they address. Thus, there is clear evidence that EMPs have a ‘mixed agenda’ that includes emigrant issues as a priority, but not exclusively so. Moreover, the analysis shows that they dedicate plenty of effort to introducing the migration perspective in non-emigrant specific topics , in monitoring the actions of the executive power regarding the wellbeing of emigrants and in mediating between the demands of their constituency and the government.All in all, the results suggest that, as predicted, there is a certain ‘containment effect’ in the case of Colombia and that higher numbers of EMPs lead to a better substantive representation of the interests of non-resident citizens (H2a). There is no evidence to confirm that underrepresented numbers of EMPs represent better emigrant interests by holding an underlying symbolic power (H2b). However, these claims should be tested further by including more countries in the analysis and more legislative periods. Future research should also explore the effect of emigrant special representation on symbolic representation Pitkin,  or the oFinally, on a methodological note, the study here presented had one limitation. For the Colombian case, the results are based on the work of two EMPs meaning that the findings can be highly affected by the profile of single individuals. Over time, when more legislative periods are concluded, this study should be replicated in order to prove if its findings stand the test of time.