Background: Post-traumatic stress disorder (PTSD) is a psychiatric illness that is very prevalent in both civilian and military environments. The clinical course, regardless of management, is chronic for a number of patients, especially veterans. Persistent PTSD symptoms interact with representations of the person and their body, and may negatively impact rehabilitation. Sport is known to help psychiatric patients such as those suffering from PTSD, as it improves the connection with the body, and supports physiological and emotional regulation. However, the impact of sport on self-representations has not yet been studied. The first aim of this study is to explore person and body representations in a population of military veterans suffering from chronic PTSD, as a function of clinical severity. Second, it aims to explore how a 9-day sport program, which includes an element of socio-professional rehabilitation, changes representations of the person and their body.Methods: This exploratory qualitative study examined the self-representation of veterans with chronic PTSD before a sport rehabilitation program. Veterans were given the prompts “body” and “person” and asked to free associate. PTSD severity and the mind–body connection were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5, and the Freiburg Mindfulness Inventory, respectively. Parasympathetic activity was recorded at rest. A subgroup of the population volunteered to participate in a post-program session to record the same semantic, psychological, and physiological variables.Results: Although before the program, veterans gave more negatively than positively valenced words, no relation was observed between the overall number of negative words and PTSD severity. Post-program, changes were observed in terms of valence. Specifically, some negatively-valenced categories of words disappeared, and some positive categories appeared. At the same time, there was a fall in PTSD severity, an increase in the mind–body connection, and a decrease in parasympathetic activation.Conclusions: This study highlighted that veterans with chronic PTSD have a negative representation of the self. A dedicated, 9-day program that included regular sport improved self-representations related to both the person and their body, and reduced PTSD symptoms. The findings underline the importance of ensuring that programs for patients suffering from chronic PTSD should include sporting activity, and highlight the benefits. Sport appears to be a path to the reappropriation of a positive image of the self, by improving the representation of the body. This relationship could be consistent with improved interoception, but our results need further investigation. Post-traumatic stress disorder (PTSD) is an adaptive condition that can occur following one or more traumatic events that involve direct or indirect confrontation with death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence . AccordiIn the general population, the lifetime prevalence of PTSD ranges from 1 to 7%, depending on the sample . While sOne of the many impacts of PTSD is to destabilize the individual's identity. Notably, it can “impact the resources a person brings to identity work” . StudiesOne reason for this may be the lack of clarity regarding concepts related to identity. The idea of identity is closely related to that of appraisal or beliefs about the self and the world. Although identity and the self are closely-related concepts, identity is considered to consist of representations and feelings, while the self is considered as a purely cognitive concept, the “self-concept” , which iWhether it be the self-concept or the self-presentation, both are based on the self-referential processing (SRP). SRP is an embedded process that consists of relating information to the self , 24, whiTo the best of our knowledge, little is known about the physiological correlates of SRP. At the same time, the physiological correlates of interoception are beginning to be described: the quality of interoception has been shown to be partly related to heart rate variability (HRV), notably high vagal tone –28. HRV In this context, a recent review  highlighFinally, studies consistently report reduced HRV in people with PTSD. Such findings suggest autonomic inflexibility due to sympathetic overactivity and/or parasympathetic insufficiency , 35. TheIn response to the lack of knowledge about self in the context of PTSD, and the lack of validated interventions that aim to improve the self-image, this study is the first to evaluate the verbal valence and semantics that veterans use to talk about themselves and their bodies, as a function of PTSD severity. First, we hypothesize that we will observe a correlation between the number of negative words used in verbal responses related to both the person and his or her body, and the clinical severity of PTSD symptoms. Second, we evaluate the therapeutic effects and psychophysiological processes observed during a sport's program organized by the French Army for veterans with PTSD. Here, we hypothesize that practicing sport decreases the severity of PTSD symptoms, through processes that improve the person's self-representation, and an improvement in the psychophysiological mind–body connection.Cellule d'aide aux blessés de l'armée de Terre). Five to six courses take place each year, with 8–12 participants. In addition to medical care, the aim is to support the recovery of psychologically injured soldiers, in order to facilitate their reintegration into civilian life. The program runs over a 9-day period, and is composed of group and individual physical activities, and professional exercises.The population included in this exploratory study consisted of 47 veterans who had been on sick leave due to PTSD for over 6 months, between May 2018 and April 2021. This group had been enrolled on a professional reinsertion course following a recommendation regarding their suitability from their referring psychiatrist. These courses are organized by the French Army's wounded soldiers' unit . All subjects received information on the protocol, and gave written consent prior to participation.For the full cohort of 47 veterans, baseline semantic, psychological and physiological data were collected before the program began. A subgroup of 26 individuals volunteered to participate in an experimental session at the end of the program. For this group, semantic, psychological and physiological data were evaluated twice (pre- and post-program).Domaine les Gueules Cassées , for water sports. The daily program consists of around 3 h of sporting activities, and one or two practical, individual and group workshops focused on PTSD information, or coaching in professional skills.The program takes place either in a small village in the Écrins National Park in France, for multisport activities such as hiking, mountain biking, climbing, canyoning, and orienteering, or in the Whatever the multisport program or the water sport program, each sport activity is supervised by a qualified sports instructor and begins with an explanation of the session and a warm-up and ends with a debriefing on the session. The main goal of each session is to get in touch with the sensations of the body without the idea of performance. Concerning the multisport program, the first day is a 2-h walk of about 6 km to get back into shape. If the conditions are favorable, the schedule for the classic program is as follows. The veterans have a climbing session on the second and fourth days. The level of difficulty of the climbing routes is progressive from 4 to 5+ according to the International Union of Mountaineering Associations. For days 3 and 5, the activity is a mountain bike activity in the mountains. The last 3 days are organized with a canyoning activity lasting all the day, and according to the preferences of the veterans of the climbing or the mountain bike activity. The last day is reserved for the orientation race of about 3 h with a difference in altitude of 400 m. The water sport program combines the discovery of swimming with fins and scuba diving. In order to reduce, or even eliminate the anxiety that is described with diving because of the environment, and the use of complex equipment, a very progressive training program was implemented with the recommendations of the Divers Alert Network. The protocol did not include any long dives at depths >20 m. The first two dives take place in a swimming pool. This make it easy to evaluate the level of anxiety of veterans, and to form homogeneous groups for dives in the sea. Throughout the course, the depths reached increased very gradually, and the ratio of veterans to monitors varies from two to one to one to one .Professional activities focused on preparing a curriculum vita, coaching for professional resources and some role-playing for team building. During their free time, participants can join in group activities such as table soccer, pool, or other games, or simply relax. Civilian or military experts in human resources and social reinsertion conduct the workshops. A military psychologist is present at all times to provide support for symptoms of anxiety or substance dependence if one veteran asks for an emotional support during the 9-day program. There is no systematic psychotherapeutic treatment. All participants completed the full program.Sociodemographic information included age, gender, social environment, and total number of major stressors encountered in either the professional or the personal environment.Two self-report questionnaires were used. The PTSD Check List Scale (PCL5) , 38 was The Freiburg Mindfulness Inventory-14 (FMI) was selected to assess the mind–body connection, as mindfulness has been consistently associated with higher interoceptive awareness . The FMIThe free association method was used to record verbal representations reported by the individual about themselves and their physical body. This method was initially developed in the field of psychoanalysis, and has more recently been adopted by cognitive and social psychology . It is uHRV was assessed during a 5-min period at rest by electrocardiogram (ECG) signals captured using the PHYSIONER system . This clinical and research device uses a 250 Hz sampling rate to accurately detect R-wave peaks. The R–R interval corresponds to the beat-to-beat interval of the instantaneous heart rate, and temporal, frequential or non-linear analyses can be used to extract HRV information. For clarity, we chose to use only one feature: RMSSD . The benefits of using RMSSD include: (1) its resistance to the influence of breathing frequency, which is a problem in frequential measures ; and (2)Statistical analyses were performed using Statistica software . Data are expressed as a number and percentage (%) for qualitative variables, and as the mean (M) and standard deviation (SD) for quantitative variables. The reliability of each psychological measurement (self-administered PCL5 and FMI questionnaires) was gauged by computing Cronbach's alpha . All werIn the first step, we used the PCL5 median to categorize veterans into two groups: one where scores were above the median (the Severe PTSD Group), and another where scores were below the median (the Moderate PTSD Group). This qualitative inductive analysis used a manifest analysis with description of what the informants actually say with the objective to stay very close to the text, to use the words themselves, and to describe the visible and obvious in the text . First, t-test, or the non-parametric Kruskal–Wallis test for quantitative data.Between-group comparisons of sociodemographic, psychophysiological, and semantic data were performed using Pearson's chi-square test for variables with several modalities, and either Student's The second step concerned subjects who had volunteered for the post-program session. Here, the aim was to evaluate the effects of the program on the words used to describe themselves and their body, with respect to their valence and semantic characteristics, PTSD symptoms, FMI scores, and RMSSD. A separate Wilcoxon non-parametric analysis was run, given the non-homogeneity of variance (Levene's test).p < 0.05. A trend was considered to be present when p < 0.10.In each step, Bravais-Pearson correlation analyses were used. The statistical threshold for significance was set at Four individuals were excluded from the analysis as they did not complete the questionnaires, leaving a total of 43 patients who had been suffering from PTSD for more than 6 months. The average duration of sick leave was 12 months (SD: 9.4). All of the population was male. Their average age was 33.95 years (SD: 6.02). Of these, 29 (67.44%) were living with a partner, eight (18.6%) were single, and six (13.95%) were divorced. Fourteen (35%) had at least one child. Mean number of major stressors encountered in either the professional or the personal environment was 3.3 (SD: 1.54) and 2.15 (SD: 1.49) respectively.All subjects had a PCL5 score equal to, or above 33. Mean clinical severity (PCL5) was 61.42 (SD: 12.36). No correlation was found between the PCL5 score and the overall FMI score or its sub-scores, or between the PCL5 score and RMSSD.The median PCL5 score for the group was 61. Twenty-one subjects were classified as suffering from moderate PTSD. The mean score within this group was 50.9 (SD: 5.6). Twenty-two participants were classified as suffering from severe PTSD, including one subject with a PCL5 score equal to the median. Here, the mean was 71.45 (SD: 7.71). There was no difference between the two groups in terms of age or duration of sick leave. RMSSD tended to be higher for the moderate group compared to the severe group, while no difference was observed for the overall FMI score, or its sub-scores, between the two groups .X2 = 6.64, p = 0.01).As shown in Regarding the 142 words associated with the person, 39% were positive and 61% were negative. Patients in the severe group gave 78 words in reference to themselves, 37% of which were positive and 63% negative. Patients in the moderate group gave 64 words, 42% of which were positive and 58% were negative. No difference between groups was observed, either in terms of the total number of words, or in terms of the number of positive and negative words. Seven overall categories were identified, which were split into subcategories according to their positive or negative valence. These seven categories were: cognitive, behavioral, affective, volitional, moral, relational and identity .X2 = 3.96, p = 0.04). Specifically, 42.05% of negative words were given by members of the severe group, compared to 35.22% for the moderate group. On the other hand, 12.5% of positive words were produced by the moderate group, compared to 10.22% for the severe group. Six overall categories were identified, and each was split into two subcategories according to their positive or negative valence. The six categories were: good or poor evaluation of the body, good or poor level of energy, relaxed or tense body, dys/functional, positive/ negative physical image, physical pain or not  in this group.The average age of the 26 volunteers who agreed to participate in the post-program sessions was 34.3 (SD: 6.51), and the mean PCL5 score was 58.56 (14.45). Pre-session, a moderate positive correlation was observed between the FMI-A score and RMSSD (p = 0.01). However, in only one case did the post-session score fall under the cut-off of 33. The decrease in the PCL5 score was associated with an increase in the mean overall FMI score , the mean FMI-P score , and the mean FMI-A score . A decrease in RMSSD was also observed . Strong positive correlations were observed pre- and post-session for the PCL5 score, the overall FMI score, and its sub-scores . No correlation was observed pre- and post-session for RMSSD. At post-session, a moderate positive correlation was observed between the overall FMI score and RMSSD .Following the program, the mean PCL5 score was 52.8 (14.54). A significant decrease was observed .Pre-session, participants gave 127 words to describe themselves and their body; of these, 37.8% were positive, and 62.2% were negative. Post-session, 111 words were given; none of these were considered neutral, 59.45% were positive, and 40.54% were negative. The analysis of the valence of these words found an increase in the total number of positive words (both referring to the person and their body) between pre- and post-session . Pre-session, participants gave 76 words to describe themselves; of these 46% were positive, and 54% were negative. Post-session, 66 words were given; 68% were positive, and 32% were negative. The analysis found a significant increase in the number of words with positive valence . Turning to representations of the body, 51 words were given pre-session; of these, 25% were positive, and 75% were negative. Post-session, 45 words were given; of these, 47% were positive, and 53% were negative. The analysis identified evidence of a trend with respect to an increase in the number of words with positive valence . These representations provided an insight into SRP among veterans.Our overall population was divided into two groups consisting of those with either severe or moderate PTSD. Between-group comparisons were carried out at the vagal level, and with respect to the mind–body connection, as both are known to be related to interoception. The analysis showed that those with moderate PTSD tended to have a higher level of parasympathetic functioning, but that this was not associated with differences in terms of the mind–body connection. Further comparisons of representations of the self-showed that, contrary to our hypothesis, those in the severe group did not produce more negative words than those in the moderate group. We conclude that the self-representation appears to be independent of PTSD severity for veterans who have suffered from PTSD for at least 6 months. With regard to interoception, no connection could be identified between the introspective evaluation of the self, and the psychophysiological evaluation of interoception.For subjects who participated in the post-program session, the analysis found that participation in the course was associated with a decrease in clinical PTSD severity, and an increase in the mind–body connection, notably the acceptance dimension. Although RMSSD decreased post-session, we found no relationship with the pre-session level. However, a moderate positive correlation was found between post-session RMSSD and the mind–body connection. Thus, we conclude that the main effects of the sports program related to subjective evaluations of PTSD severity, and mind–body functioning. However, our results are too tenuous to draw any conclusions in terms of interoception improvement.In accordance with our second hypothesis, the benefits of the program were associated with a positive change in the self-representation. First, we observed a general increase in positive representations, for both the person and their body. While both increased, the increase was higher for the person than the body. Second, the categories changed. For person representations, the category of “negative moral” disappeared. For body representations, the “painful” category disappeared and a positive word appeared in the “relaxed/tense” category. Furthermore, the opening/closing body category emerged, and one word was classified as positive (opening).These positive changes appeared at the end of the 9-day sports program, and suggest that these veterans may have reconnected with aspects of their previous identity and sense of self. They also appear to have a more positive relationship with their body, suffer less pain, be more relaxed, and be more dynamic. However, here again, the introspective evaluation of the self through the analysis of words could not be related to an improvement in variables related to interoception, especially as post-program, parasympathetic activity decreased. This decrease in RMSSD at the end of the program appears to be inconsistent with the observed clinical improvement, the better body–mind connection, and the emergence of a more positive self-representation.HRV is a widely-accepted indicator of psychological stress . HoweverThis exploratory study has several limitations. The first is the population, which is only composed of male veterans. This implies that any generalization to other populations must be undertaken with caution. Second, the small number of subjects means that the analysis lacks statistical power. Third, several limitations relate to the evaluation of interoception. In this study, we indirectly assessed interoceptive sensitivity, which refers to the degree to which the individual feels engaged by interoceptive signals, with a mind–body connection scale. Our subjective measure of interoceptive sensitivity needs to be supplemented by a behavioral task in order to complete the assessment. This is all the more important given that subjective sensitivity to interoceptive signals does not account for cerebral activation. The latter observation makes any interpretation of the relationship between the benefits of the program for interoception, and improvements in the self-representation, questionable. Turning to the physiological interoception assessment, RMSSD was only recorded at rest, and this measure should be supplemented with measures of vagal reactivity and recovery. Finally, three limitations come from the protocol. The effects of the 9-day program on self-representations and symptomatology are not controlled. The program included both workshops and sports, the observed benefits could be attributed to the workshops, the sporting activities, or both. Self-selection bias could be due to the post-program sample. These three methodological limitations make any generalization of the results questionable.This exploratory study aimed to provide an insight into how military veterans evaluate their self. Most representations of the self, notably the person and their body, are negative, illustrated by the violence of some of the words used by the cohort of veterans. At the same time, the negativity of these words was found to be unrelated to clinical PTSD severity. Sport could be a way to reappropriate a positive image of the self. The findings of this study suggest that sport could be used to improve the individual's representation of the person her or himself, by improving the representation of the body. Although this relationship could be consistent with better interoception, our results are inconclusive on this point.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study received the agreement from the Sud-Mediterranée III personal protection committee before the start of inclusions, 10 of September 2018 (NTC03995992). All the subjects received information on the protocol and gave their written consent prior to their participation. The patients/participants provided their written informed consent to participate in this study.MT designed the study. AB, AD, CM-K, DL, GL, SJ, and MT planned and participated in word and statistical analyses. CB, GL, AB, SJ, and MT recorded the data. CB, CM-K, DL, and MT participated in all stages of writing and proofreading. All authors took an active part in the process and read and approved the final manuscript.The work was supported by a grant  from the Gueules Cassées.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: The global burden of dementia has increasingly shifted to low- and middle-income regions that lack essential data for monitoring epidemiological progression, and policy and planning support. Drawing upon data that have emerged since the last known estimates published in 2015, this study aims to update dementia estimates in the Latin America and Caribbean (LAC) region for the years 2020, 2030, and 2050 through the application of a recently validated Bayesian approach for disease estimates useful when data sources are scarce.Methods: A comprehensive parallel systematic review of PubMed, EMBASE, PsycINFO, Global Health, and LILACS was conducted to identify prospective population-based epidemiological studies on dementia published in English from 2013 to 2018 in LAC. English and non-English data cited by a recent review on dementia estimates in LAC were also examined for additional data. A Bayesian normal-normal hierarchical model (NNHM) was developed to estimate age-specific and age-adjusted dementia prevalence in people aged 60+. Using age-specific population projections from the UN, the total number of people affected by dementia for the years 2020, 2030, and 2050 were estimated.Results: 1,414 studies were identified, of which only 7 met the inclusion criteria. The studies had 7,684 participants and 1,191 dementia cases. The age-standardized prevalence of all forms of dementia in LAC was 8% (95% CI: 5–11.5%) in people aged 60+. The estimated prevalence varied with age, increasing from 2.5% (95% CI: 0.08–4.0%) in the 60-69 age group, to 9.4% (95% CI: 5.4–13.2%) in the 70–79 age group and 28.9% (95% CI: 20.3–37.2%) in the ≥80 age group. The number of people age 60 and older living with dementia in LAC in 2020 was estimated at 6.86 (95% CI: 4.3–9.8) million, 9.94 (95% CI: 6.16–14.15) million in 2030, and 19.33 (95% CI: 12.3–13.6) million in 2050.Conclusion: We project an upward disease trajectory for dementia in LAC countries. The projection is likely an underestimation of the true dementia burden given the underrepresentation of rural and socio-economically deprived populations. More research is urgently needed to improve the accuracy of disease estimates, guide clinicians to improve evaluations for earlier recognition of dementia, and support the development of effective policies for improving dementia prevention, diagnosis and clinical management in LAC's diverse and aging communities. Dementia is an age-related neurocognitive disorder that has become a leading cause of morbidity and mortality in later life. In 2015, there were an estimated 47 million dementia cases globally, costing an estimated US$818 billion . As the Previous studies that estimated the prevalence of dementia in LAC have been conducted as part of larger multi-regional dementia prevalence estimates , 4–6. AnTo make the best use of the scarce data, in recent years, modelers have turned away from the traditional frequentist analytic approach in favor of Bayesian methods which are considered more suitable for meta-analyzing small datasets [k ≥ 2 ]. By allThe overall aim of this study is to provide an updated estimate of the prevalence of dementia for LAC with improved accuracy. By way of a comprehensive systematic review of a larger number of academic and non-academic databases, we aim to identify data that has emerged from the LAC region since 2013. The total number of dementia cases in LAC will be estimated for the years 2020, 2030, and 2050. The study will also explore the newer Bayesian Random-Effects Meta-Analysis (Bayesmeta) in R . It is h*) AND  AND  adapted to the syntax requirements of the specific database  were prospective and population-based; (ii) contained original data on incidence, prevalence and/or mortality of dementia; (iii) used internationally recognized diagnosis of dementia [i.e., Diagnostic and Statistical Manual of Mental Disorders (DSM)  or InterWithin the systematic review process from the databases, we excluded: (i) duplicates within and between the databases; (ii) studies with no original numerical estimates ; (iii) studies of LAC populations outside of LAC; (iv) non-human studies; (v) studies with no clear denominator or inappropriate standardized rates; (vi) studies of non-community-based populations  and (vii) non-English language studies.Quality assessment was conducted by YX and KV using a modified version of the Joanna Briggs Institute (JBI) Critical Appraisal checklist for prevalence studies .For each eligible study, the following data were extracted: (i) study country of origin; (ii) sampling method; (ii) screening tool(s); (iii) diagnostic tool(s); (iv) sample size (denominator); and (v) the number of dementia cases (numerator) and/or unweighted dementia prevalence. Where available, we also extracted incidence data, mortality data, prevalence data by urban vs. rural population, age group, gender and types of dementia.Using the Bayesmeta package of R (version 3.5.2) , 13, a B2, 0.152, and 0.32 for age groups 60–69, 70–79, and 80 and over, respectively. To account for the variability in prevalence estimates with increasing age, the variance was widened in each subsequent group due to the reduction in sample sizes in the older age groups. Prevalence was then pooled for groups 60–69, 70–79, and 80 and over, and 95% credible intervals were calculated.The foremost step was to sort the number of screened participants and the number of people with dementia (PWD) identified from each study into 10-year group bins. Any participant over the age of 80 was allocated into an “80 and over” bin. Our variance was then set to 0.09To test the sensitivity of the Bayesmeta package, we used the Just Another Gibbs Sampler (JAGS) , an openThe searches yielded a total of 1,414 articles; 1,082 after removing duplicates. Of the remaining articles 1,041 articles were further excluded based on the title and abstract relevance and 41 full-text articles were then analyzed based on our set inclusion/exclusion criteria, study design and use of case definitions. Of these, only 7 studies met all inclusion criteria and were retained for meta-analysis see  and SancAs Based on Bayesian NNHM estimates, the prevalence of dementia for people aged 60 and above in LAC was 8% . As expected, the prevalence of dementia increased with age, from 2% (1–4%) for the 60–69 age group to almost 30%  for the 80 and over age group . Apart fOf the seven studies, two reported breakdowns of prevalence by sex , 29. No By applying the UNDP population projection , the numThis study updated the estimates of the burden of dementia in LAC using the latest epidemiological data from the region. To our knowledge, this is the first comprehensive systematic review that has exclusively focused on modeling the prevalence of dementia in LAC. Our results confirmed a high dementia prevalence of 8% in LAC, and a substantial (2.8-fold) increase in the number of dementia cases over the next three decades. The results also indicate that an increasing majority of the cases will fall upon the oldest (≥80) age group. This will place tremendous strains on the already fragile local health and social systems, as well as families and individuals.While the cost of dementia might seem low in monetary terms in LMICs relative to HICs, the lack of publicly funded formal assistance means the majority of the cost is borne by families , 30. WomAlarmingly, the high prevalence reported in our study is a likely underestimation of the true prevalence of dementia in LAC. Risk factors of dementia, including illiteracy, low educational attainment, hypertension, obesity and diabetes, have been shown to disproportionately affect socio-economically deprived populations . LAC is The lack of data representativeness is largely a manifestation of the lack of research investment in the region resulting in data scarcity. Despite the comprehensiveness of our searches, only seven new cross-sectional studies from six of LAC's 52 countries/territories were identified. These studies together form a small sample of <8,000 people for a region with more than 70 million people over the age of 60 . Data scThe lack of research investment also reflects a missed opportunity to capitalize on the unique populations  offered by LAC, which could significantly enhance our understanding of the roles various population characteristics could play in the progression and risk factors of disease development . In addiStrengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines developed in 2007 for the accurate and complete reporting of observational epidemiological studies  Checklist, in which Bennett et al. (A number of strengths and limitations of this study merits further mention. We have aimed to validate the Bayesmeta approach for data projections in the setting of data scarcity in this as well as our prior work . However studies , 39. Thet et al.  which prThe results of this systematic review suggest that the LAC region is on an upward disease trajectory in terms of burden of dementia. There is a need for more dementia and dementia subtype epidemiological research in this region, especially from the less resourceful countries, in order to accurately estimate dementia prevalence and the health needs of a varied and diverse population. There is a need for greater globalization of knowledge with a greater emphasis placed on the amount and quality of evidence produced. With the trend of demographic aging in the coming decades, the prevalence and burden of dementia will continue to increase. This will have serious implications for the economy, healthcare systems and the communities in LAC. In particular, there may be additional burdens placed on caregivers and strain on healthcare facilities to meet demands of an aging population. Despite the comprehensive scope of our review, rural and socio-economically deprived populations, including indigenous, illiterate and low-literacy populations were underrepresented in these data. This is likely to have skewed our results toward underestimating the true burden in this region. Such information is paramount for guiding clinical practice, which will allow not only for improved evaluations in early dementia diagnosis but also guide the development of effective policies for improving dementia prevention, diagnosis and clinical management in LAC's aging communities.The original contributions generated for the study are included in the article/KC and YX conceptualized the paper. YX and KV carried out the systematic review. YX, CA, and SA performed the analytic calculations. YX, KV, AP, and KC wrote the manuscript with input from all authors. All authors have discussed the results and reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


ABSTRACT IMPACT: The Summer Foundation on Research gave undergraduate students the opportunity to do research despite the new normal - COVID-19 pandemic. OBJECTIVES/GOALS: The COVID-19 pandemic prevented domestic and international undergraduate students from attending in-person Mayo Clinic Summer Undergraduate Research Programs. Mayo decided to redesign this program as a virtual, 4-week Summer Foundations in Research (SFIR) program. The goal of this program was to give students a scientific research experience. METHODS/STUDY POPULATION: The SFIR included an Introduction to Experimental Design, Dialogue methodology for communicating science, scientific mentoring, asynchronous online modules and a Resiliency component. Evaluations of the program were undertaken to gather feedback for program improvement and to assess the educational and mental health impact on participants. These evaluations asked student to rate each section of the program. Additionally, students were encouraged to provide their own comments and feedback. Statistical analysis of quantitative data was performed using excel. The qualitative data was studied using the identification, analysis and interpretation of patterns method per the student’s comments on each of the questions addressed in the survey. RESULTS/ANTICIPATED RESULTS: These evaluations revealed positive outcomes across program components: 66% of the participants found the Resiliency component extremely worthwhile, 80% of participants liked the experimental design and 70% liked the educational courses. Qualitative data showed that mentor/mentee interactions were highly valued, and both participants and faculty suggested increasing the amount of time devoted to these interactions. Small group discussions gave students the opportunity to get to know other peers and encouraged further discussions about science and the community. Participants suggested minor improvements to the program, such as re-creating the online modules specific for undergraduate students, increasing 1-to-1 and small group’s discussion, and increasing the length of the program. DISCUSSION/SIGNIFICANCE OF FINDINGS: Despite the quick pivot of the SFIR program, the re-design and new format supported the development of participants’ resilience skills and training as future scientists during a particularly challenging time. Mayo is committed to continuing this program as an early step in a pathway to careers in research.


In the past several decades obesity has become one of the greatest health burdens worldwide. Diet high in fats and fructose is one of the main causes for the prevalence of metabolic disorders including obesity. Promoting brown or beige adipocyte development and activity is regarded as a potential treatment of obesity. Mondo family transcription factors including MondoA and carbohydrate response element binding protein (ChREBP) are critical for nutrient-sensing in multiple metabolic organs including the skeletal muscle, liver, adipose tissue and pancreas. Under normal nutrient conditions, MondoA and ChREBP contribute to maintaining metabolic homeostasis. When nutrient is overloaded, Mondo family transcription factors directly regulate glucose and lipid metabolism in brown and beige adipocytes or modulate the crosstalk between metabolic organs. In this review, we aim to provide an overview of recent advances in the understanding of MondoA and ChREBP in sensing nutrients and regulating obesity or related pathological conditions. The epidemic of obesity has emerged as a worldwide public health issue. In 2017, the Global Burden of Disease Study estimated that high body mass index (BMI), one of the leading risk factors, accounted for 4.72 million deaths and 148 million disability-adjusted life-years (DALYs) . EnhanciThe Mondo family transcription factors, comprised of MondoA  and carbohydrate response element binding protein , belong to the basic helix-loop-helix leucine zipper (bHLH/LZ) family , 13. UpoInitially identified as glucose sensors, Mondo family has more extensive regulatory functions in metabolic homeostasis. Therefore, their role in physiological and pathological conditions has gained growing interest. In this review, we will discuss how MondoA and ChREBP sense and respond to nutrient availability, focusing on the involvement of Mondo family in obesity and related diseases.ChREBP is widely expressed in metabolic organs, predominantly in liver, also in adipose tissues, pancreas, intestine, kidney, relatively low in skeletal muscle .ChREBP is regulated by multiple nutrient molecules, among which glucose and its metabolites are major determinants. In the presence of high glucose, glucose 6-phosphate (G6P), the first intermediate in glycolysis binds to the GRACE domain of ChREBP , 23. MorChREBP regulates many enzyme genes in glycolysis and lipogenesis, including liver type pyruvate kinase (L-PK), acetyl-CoA carboxylase (ACC), fatty acid synthase (FAS), ATP-citrate lyase (ACLY), stearoyl-CoA desaturase-1 (SCD1) and glycerol-3-phosphate dehydrogenase (GPDH) –30. In a2+/Mn2+-dependent 1K (PPM1K) transcript levels in liver ], desaturation , elongation , and triglyceride synthesis   Figure–69, therObesity is the excessive accumulation of fat caused by imbalance between energy intake and consumption. It is the major risk factor for many metabolic disorders such as type 2 diabetes, fatty liver and cardiovascular diseases . Regardede novo lipogenesis is also involved in the regulation of systemic insulin sensitivity and thermogenesis, both of which play key roles in mediating metabolic adaptations   . In matuue (BAT) , 80.To date, the role of ChREBP in regulating thermogenic adipocyte function has been indicated in a growing body of literatures Figure 4MondoA is expressed predominantly in skeletal muscle which makes up ~40% of body weight and is responsible for ~80% of glucose uptake , 85. Thevia suppression of insulin action , from National Natural Science Foundation of China ; the Shanghai Municipal Science and Technology Major Project (19JC1410200); National Key R&D Program of China (2019YFA0906100); National Key Research and Development Program of China (No. 2016YFC1304800); Shanghai Jiao Tong University School of Medicine and Innovative research team of high-level local universities in Shanghai (SSMU-ZDCX20180400); The Program for Professor of Special Appointment (Eastern Scholar) at Shanghai Institutions of Higher Learning and Construction; Plan of Laboratory Technical Team in Shanghai Universities (SYjdyx19019).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


LinkAGES: Colorado is a collaborative group of multi-sector organizations  that uses a capacity-building approach to support the offering of intergenerational programs and evaluation of outcomes over time and across programs. Since 2018, LinkAGES has implemented 20 intergenerational programs involving various activities , across settings, and across modalities (in-person and online). Ages of program participants ranged from 5 months to 96 years old. This study evaluated change in connectedness between generations over time. Participants (n=118) completed pre- and post-program ratings on social connection  on a 4-point Likert scale. Paired sample t-test results indicated that programs significantly improved engagement and perceived impact. Using multiple regression analyses, we tested change over time for each outcome controlling for participant age group, program host setting, and program modality. A greater positive change in level of engagement occurred for older adults and in-person programs. Additionally, feelings of connection and perceived impact significantly improved over time when controlling for age group, program modality, and program host setting, with age group as a significant covariate. This study demonstrates the impact of intergenerational programs on social connectedness across a wider network of organizations than much of the extant literature. While the positive outcomes are promising and consistent across LinkAGES programs and existing literature, further exploration of age group differences should be considered.


Cavitary peripheral pulmonary lesions (PPLs) are often diagnosed via transthoracic needle biopsy. However, today, radial probe endobronchial ultrasound (RP‐EBUS) is widely used to diagnose PPLs. The efficacy and safety of RP‐EBUS‐guided transbronchial lung biopsy (RP‐EBUS‐TBLB) used to diagnose cavitary PPLs remain poorly known. We investigated the utility of RP‐EBUS‐TBLB using a guide sheath (GS) without fluoroscopy to diagnose PPLs.Of 743 RP‐EBUS procedures conducted to diagnose PPLs performed at our institution from January 2019 to October 2020, we analyzed 77 cavitary PPLs. TBLB was performed using RP‐EBUS with a GS without fluoroscopy. The diagnostic accuracy and complications were assessed. All lung lesions with a definitive diagnosis were included in analyses.n = 34), 29 (85.3%) were diagnosed successfully. Of benign lesions (n = 43), 37 (86.0%) were diagnosed successfully. In multivariate analyses, a thicker cavity wall  and EBUS imaging with the probe within the lesion  independently affected diagnostic success. The likelihood of success increased with increasing thickness of the cavity wall . The specimens obtained for molecular confirmation of malignancy were satisfactory. There were four cases of infection (5.2%) and three cases of pneumothorax (3.9%).The overall diagnostic accuracy was 85.7% (66/77). Of malignant lesions (RP‐EBUS‐TBLB of cavitary PPLs affords high diagnostic accuracy with acceptable complication rates. (A) Computed tomography (CT) scan of a 58‐year‐old man with a 16‐mm diameter spiculated cavitary nodule in the left upper lobe. (B) Radial probe endobronchial ultrasound (RP‐EBUS) revealed the EBUS image within the lesion; biopsy was performed using a brush and forceps. Histology revealed an adenocarcinoma. (C) CT scan of a 59‐year‐old man with a 32‐mm diameter cavitary mass in the left upper lobe. (D) RP‐EBUS yielded an EBUS image within the lesion, and biopsy was performed. Histology and microbiology specimens revealed pulmonary tuberculosis. A pulmonary cavity is a gas‐filled space within a zone of pulmonary consolidation, a mass, or a nodule. A cavity may reflect necrosis, cystic dilation of a lung region in patients with benign diseases and necrosis, internal cyst formation, or internal desquamation of tumor cells in patients with malignant diseases.Transthoracic needle biopsy (TTNB) has commonly been used to diagnose PPLs. The diagnostic accuracy is close to 90%,Diagnosis of the cavitary PPLs is different from that of the noncavitary PPLs, which means that the cavitary wall should be targeted for biopsy. However, its diagnostic efficacy and the safety of RP‐EBUS for diagnosing cavitary PPLs remain poorly known. In this study, we analyzed the clinical utility of RP‐EBUS in terms of diagnosing cavitary PPLs.n = 66), clinical course (n = 1), sputum microbiology (n = 5), liver biopsy (n = 1), EBUS‐transbronchial needle aspiration (n = 3), and surgical resection (n = 1). Four cases with indefinite diagnoses  were excluded from the diagnostic accuracy analyses. A study flowchart is presented in Figure Of 743 RP‐EBUS procedures performed to evaluate PPLs at Yeungnam University Hospital from January 2019 to October 2020, we performed a retrospective observational study on 81 consecutive patients who underwent RP‐EBUS‐TBLB to explore cavitary PPLs. Of the biopsied lesions, 77 were definitively diagnosed according to biopsy results (All patients underwent thin‐section chest computer tomography (CT)  prior to biopsy. Three pulmonologists  reviewed the images before the procedure and defined the pathways to be used when accessing cavitary PPLs. The bronchus sign of CT was defined as a bronchus leading to the target lesion. The distance from the lesion to the pleura was the shortest distance evident in the axial CT scan.All bronchoscopy procedures were performed by one of the three pulmonologists (above). A 4‐mm diameter bronchoscope  was used to attain the target lesions. After the lesions were revealed by RP‐EBUS, biopsy specimens were collected using a brush and biopsy forceps. All RP‐EBUS‐TBLB procedures were performed using a guide sheath (GS) but without X‐ray fluoroscopy.Representative data on RP‐EBUS‐TBLB patients with cavitary PPLs are shown in Figure A final diagnosis of malignancy was made based on the definite histological or cytological evidence of malignancy. Benign lung lesion was diagnosed according to the following criteria: identification of definite benign features , regression of the lesion with medical treatment, and a stable size for at least 12 months. The lesions initially diagnosed as malignant by RP‐EBUS and finally diagnosed with malignancy were considered true positives. The lesions initially diagnosed as benign by RP‐EBUS and finally diagnosed as benign were considered true negatives. Initial benign results that were finally diagnosed with malignancy were considered false negatives. To explore factors affecting diagnostic accuracy, we divided the study population into two groups: a diagnostic success group (true‐positive and true‐negative results) and a diagnostic failure group . We calculated the diagnostic accuracy by dividing the number of diagnostic successes by the total number of cases.t test or the Mann–Whitney U test and are expressed as means ± standard deviations. Categorical variables were compared using the chi‐square or Fisher's exact test and are described as frequencies (percentages). Univariate and multivariate logistic regression analyses were performed to identify factors affecting the diagnostic accuracy. The factors evaluated in multivariate analyses were those significant at the p < 0.1 level in univariate analyses. We used the linear‐by‐linear association test to analyze the diagnostic accuracy by cavity wall thickness. We employed the Kruskal–Wallis test to compare the numbers of specimens by cavity wall thickness. In all analyses, a two‐tailed p value <0.05 was considered statistically significant. All statistical procedures were performed using SPSS software .Continuous variables were compared using the Student This study was conducted in accordance with the tenets of the Declaration of Helsinki, and the protocol was reviewed and approved by the Institutional Review Board of Yeungnam University Hospital (no. 2020‐09‐025). The requirement for informed patient consent was waived because of the retrospective study design.n = 23, 29.9%) was the most common underlying lung disease. The mean predicted FEV1% was 80.9 ± 17.8. Most lung lesions were in the right lower lobe  and the mean distance from the pleura to the lung lesion was 8.9 ± 10.2 mm. The mean cavity wall thickness was 12.3 ± 5.4 mm. The bronchus sign was positive on CT in 68 patients (88.3%) and EBUS images within the lesion were apparent in 67 (87.0%) patients. The mean procedural time was 17.7 ± 7.1 min.Of the 743 RP‐EBUS procedures performed for PPL diagnosis in our institution from January 2019 to October 2020, 77 cavitary PPLs were included in this study. The baseline characteristics of the 77 patients are listed in Table n = 34), 29 (85.3%) were diagnosed successfully via RP‐EBUS‐TBLB. Squamous cell carcinoma of the lung  was the most common definitive malignant diagnosis. Of the 34 malignant lesions, 21 (61.8%) brushing cytology and 27 (79.5%) histology samples were diagnostic. In terms of brushing cytology, adenocarcinoma (90.9%) was more often diagnosed than squamous cell carcinoma (50.0%). False‐negative lesions (n = 5) were diagnosed as malignant by liver biopsy (n = 1), surgical resection (n = 1), and EBUS transbronchial needle aspiration (n = 3).The final diagnoses and diagnostic accuracys by the type of sample are shown in Table n = 43), 37 (86.0%) were diagnosed successfully by RP‐EBUS‐TBLB. Of these, nontuberculous mycobacterial lesions  were the most common, followed by tuberculosis  and lung abscesses . For the 43 benign lesions, one (2.3%) brushing cytology and 24 (55.8%) histology tests were diagnostic, as were 24 (55.8%) microbiology tests. The diagnostic accuracies of RP‐EBUS‐TBLB used to evaluate cavitary PPLs in terms of diagnosing pulmonary tuberculosis and nontuberculous mycobacterial lesions were 85.7% and 80.0%, respectively. All lung abscesses, aspergillosis cases, and inflammatory lesions were successfully diagnosed histologically. The false negatives (n = 6) were diagnosed on the basis of sputum microbiology results (n = 5), and clinical judgment was informed by radiological monitoring (n = 1).Of the benign lesions (The diagnostic performance of RP‐EBUS‐TBLB in terms of cavitary PPLs is summarized in Table p = 0.001), a bronchus sign evident in chest CT , and an EBUS image within the lesion  were significantly associated with diagnostic success. The cavity PPL size did not differ between the two groups . Multivariate analyses revealed that a thicker cavity wall  and an EBUS image within the lesion  independently enhanced diagnostic success. The probability of success increased with increasing thickness of the cavity wall   Figure . Diagnos) Figure .The proportions of specimens that allowed molecular study in patients diagnosed with malignancies by RP‐EBUS‐TBLB are listed in Table We encountered four cases of infection (5.2%) and three of pneumothorax (3.9%) in the 77 patients who underwent RP‐EBUS‐TBLB. Among the four cases of infection, three recovered with antibiotics and one developed empyema requiring chest tube insertion. All three patients with pneumothorax recovered following oxygen therapy.We found that that RP‐EBUS‐TBLB was very accurate and safe when used to diagnose cavity PPLs. The diagnostic accuracy was 85.7% and the complication rate was 9.1% (infection 5.2% and pneumothorax 3.9%). Analyses of brushing cytology and microbiology samples, in addition to histology samples, increased the diagnostic rates of both malignant and benign lesions. A thicker cavity wall (≥10 mm) and an EBUS image within the lesion independently enhanced success. The probability of success increased with increasing thickness of the cavity wall, and all obtained specimens allowed molecular evaluation. To the best of our knowledge, this is the largest study to date that has analyzed the utility of RP‐EBUS‐TBLB in terms of diagnosing cavitary PPLs. Furthermore, this is the first study to reveal the positive relationship between cavity wall thickness and diagnostic rate in the diagnosis of cavitary PPLs.A pulmonary cavity is a gas‐filled space within a zone of pulmonary consolidation, a mass, or a nodule. Cavities in patients with benign lung disease may be caused by necrosis , cystic dilation of a lung structure, or displacement of lung tissue by a cystic structure. Cavities in patients with malignant lung disease may be caused by treatment‐related necrosis, internal cyst formation, or internal desquamation of tumor cells with subsequent liquefaction.Prior to the introduction of RP‐EBUS, TTNB was commonly used to diagnose cavitary PPLs. In a previous study, CT‐guided fine needle aspiration biopsy of cavitary pulmonary lesions was associated with a high diagnostic accuracy (96.1%).Only one prior study has analyzed the utility of RP‐EBUS in terms of cavitary PPL diagnosis (50 lesions).In this study, we analyzed 77 cavitary PPLs. In agreement with the previous study,As in the previous study,Only a few studies have explored the feasibility of molecular studies of lung cancer confirmed via RP‐EBUS. One study reported that specimens obtained via RP‐EBUS‐TBLB using a 1.8‐mm diameter biopsy forceps allowed analyses of EGFR mutational status, and ALK and PD‐L1 IHC, in more than 90% of adenocarcinoma cases.Our RP‐EBUS‐TBLB complication rates (3.9% for pneumothorax and 5.2% for infection) are higher than those of previous RP‐EBUS‐TBLB studies. One study on 965 PPLs reported an overall complication rate of 1.3%: 0.8% pneumothorax and 0.5% pulmonary infection.Our work had several limitations. First, this was a single‐center retrospective study on a small number of cavitary PPL patients; the results cannot be generalized. Second, we performed biopsy without fluoroscopic guidance to diagnose PPLs and this may have affected the diagnostic accuracy. The use of fluoroscopy help to check whether the forceps are within the lesion and assist TBLB in the lower lobe lesions, increasing the diagnostic accuracy. Third, all procedures were performed by three pulmonologists, who may have differed (to some extent) in competence. However, all had at least 5 years of experience in performing many respiratory procedures and all used standardized protocols. Thus, among‐examiner differences are unlikely to be significant.RP‐EBUS‐TBLB of cavitary PPLs affords a high diagnostic accuracy with an acceptable complication rate. A thicker cavity wall (≥10 mm) and EBUS imaging when the probe lay within the lesion independently enhanced the diagnostic success rates. The success rate increased with increasing thickness of the cavity wall. Most specimens were sufficiently large to allow molecular malignancy confirmation.This study was conducted in accordance with the tenets of the Declaration of Helsinki, and the study protocol was reviewed and approved by the Institutional Review Board of Yeungnam University Hospital (YUH IRB no. 2020–09–025). The need for informed patient consent was waived because the study was retrospective in nature.Not applicable.No authors have any conflicts of interest to report.


Life skills are abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life. Life-skills training programs conducted within the school curriculum are effective in preventing the onset and escalation of substance use among adolescents. However, their dissemination is impeded due to their large resource requirements. Life-skills training provided via mobile phones may provide a more economic and scalable approach.The goal of this study was to test the appropriateness  and short-term efficacy of a mobile phone–based life-skills training program to prevent substance use among adolescents within a controlled trial.SmartCoach included online feedback and individually tailored text messages provided over 22 weeks. The contents were based on social cognitive theory and addressed self-management skills, social skills, and substance use resistance skills. Linear mixed models and generalized linear mixed models, as well as logistic or linear regressions, were used to investigate changes between baseline and 6-month follow-up in the following outcomes: 30-day prevalence rates of problem drinking, tobacco use, and cannabis use as well as quantity of alcohol use, quantity of cigarettes smoked, cannabis use days, perceived stress, well-being, and social skills.The study design was a two-arm, parallel-group, cluster-randomized controlled trial with assessments at baseline and follow-up assessments after 6 and 18 months. This report includes outcomes measured up to the 6-month follow-up. The efficacy of the intervention was tested in comparison to an assessment-only control group. The automated intervention program P<.05) and another three outcomes  showing beneficial developments of borderline significance (P<.10).A total of 1759 students from 89 Swiss secondary and upper secondary school classes were invited to participate in the study. Of these, 1473 (83.7%) students participated in the study; the mean age was 15.4 years (SD 1.0) and 55.2% (813/1473) were female. Follow-up assessments at 6 months were completed by 1233 (83.7%) study participants. On average, program participants responded to half (23.6 out of 50) of the prompted activities. Program evaluations underlined its appropriateness for the target group of secondary school students, with the majority rating the program as helpful and individually tailored. The results concerning the initial effectiveness of this program based on 6-month follow-up data are promising, with three of nine outcomes of the intention-to-treat analyses showing beneficial developments of statistical significance (ie, quantity of alcohol use, quantity of tobacco use, and perceived stress; The results showed good acceptance of this intervention program that could be easily and economically implemented in school classes. Initial results on program efficacy indicate that it might be effective in both preventing or reducing substance use and fostering life skills; however, data from the final 18-month follow-up assessments will be more conclusive.ISRCTN Registry ISRCTN41347061; https://doi.org/10.1186/ISRCTN41347061 During adolescence numerous biological, psychological, and social transitions take place, which determine a young person’s development and future ,2. TheseThe prevalence of lifetime and recent alcohol and tobacco use increases sharply in both genders from 11 to 15 years of age . The proA systematic review of studies, which examined the efficacy of prevention, early intervention, and harm reduction in adolescents for tobacco, alcohol, and illicit drugs, illustrated the effectiveness of taxation, public consumption bans, advertising restrictions, and minimum legal age. Additionally, promising effectiveness of preventive interventions, which provide life-skills training in educational settings, was shown . Using sLife-skills intervention programs to prevent substance use -14 primaDigital interventions have great potential to overcome the above-mentioned obstacles that hinder successful program implementation and larger-scale dissemination of life-skills training in schools. These programs have a large reach at low cost and offer the ability to deliver uniquely personalized content automatically, which can be accessed anytime and anywhere. Furthermore, digital interventions might be more appealing for adolescents because they can better ensure privacy and tailor contents to their needs. A systematic review of digital alcohol and other drug prevention programs  identifiA promising way of delivering preventive services, besides conventional personal computers, is to do so remotely by using mobile technologies. Almost all (99%) adolescents between the ages of 12 and 19 years in Switzerland, as in most other developed countries, own a mobile phone. Compared to services that can only be accessed at particular times or places, they provide a targeted and confidential means of intervention delivery . Mobile Ready4life is a mobile phone–based life-skills training program for substance use prevention. Its acceptance and potential effectiveness was tested within a pre-post study in Switzerland  each) after program completion. Participants were able to compare their number of credits with that of other program participants in their group  at any time from an individual profile page. As can be seen in At baseline, demographic variables  as well as type of school  were assessed.To obtain the number of program participants who unsubscribed from the program within the program runtime of 6 months, we analyzed the log files of the MobileCoach system, in which all incoming and outgoing text messages were recorded. Using these log files, we also assessed the number of activities performed  during the program. At follow-up, we assessed another aspect of SMS usage by asking the participants whether they usually (1) read through the text messages thoroughly, (2) took only a short look at them, or (3) did not read the text messages.very good, good, less than good, bad, and don’t know.Furthermore, we evaluated whether (1) the number of received text messages was felt to be appropriate, (2) the duration of the program was adequate, (3) the participants would recommend the program to others, (4) the text messages were comprehensible, (5) the text messages were helpful, and (6) the text messages were perceived as individually tailored. Finally, program participants were asked to rate the program and different program elements, using the response categories Baseline and follow-up assessments included the following:Problem drinking and alcohol use in the preceding 30 days, assessed by the short form of the Alcohol Use Disorders Identification Test–Consumption Items (AUDIT-C) . This tenot having smoked a puff within the past 30 days according to the criteria of the Society for Nicotine and Tobacco Research [The 30-day point prevalence rate for smoking abstinence .Quantity of cigarettes smoked in the preceding 30 days, assessing by the number of smoking days and the typical number of cigarettes smoked per smoking day.Cannabis use in the preceding 30 days, assessed by an item of the HBSC  study  addressiPerceived stress, assessed by a single item from the Swiss Juvenir study —“How oftWell-being, assessed by the 5-item World Health Organization Well-Being Index (WHO-5) , with thSocial skills, assessed by the brief version of the 10-item Interpersonal Competence Questionnaire (ICQ-10)  addressiThe primary outcomes, according to the study protocol , are (1)t tests and Mann-Whitney U tests for continuous variables. The same tests were applied to assess whether participants who were lost to follow-up differed from those who responded, as a function of the study group.Descriptive statistics were used to present indicators of program use and evaluation. In order to examine baseline differences between participants of the intervention and control groups, we performed chi-square tests for categorical variables as well as r>0.20). Binary variables were imputed using logistic regression, categorical variables using multinomial logit models, and continuous variables using predictive mean matching. We examined 50 data sets and no systematic bias in convergence was revealed; thus, the final inferences were derived from this solution.We analyzed data according to the intention-to-treat (ITT) principle. For the ITT analyses, we used multiple imputation procedures as described elsewhere . We impuNext, we calculated the intraclass correlation (ICC) for primary and secondary outcomes. In our study, the ICC determines the extent to which study outcomes vary across classrooms. If an ICC is close to 0, standard regressions provide unbiased coefficients, whereas an ICC higher than 0 indicates that hierarchical models are needed to avoid a type I statistical error. In previous studies, ICCs between 0.05 and 0.10 were considered negligible ,41. HoweP<.05 on two-sided tests were considered statistically significant. Analyses were performed using SPSS, version 25 (IBM Corp), and R, version 3.6.1 (The R Foundation). Multiple imputation was conducted with the mice (multivariate imputation by chained equations) package in R [Within LMMs and GLMMs, we modeled a random intercept for school class, while predictors and covariates were identical to logistic or linear regressions. Analyses of binary outcomes focused on follow-up values. Independent variables included baseline values for the binary variables of interest, group as a predictor, and variables for which baseline differences were observed as covariates. Analyses of continuous outcomes included change in score from baseline to follow-up as the dependent variable. Independent variables included group as a predictor and variables for which baseline differences were observed. We included in all models a covariate that modeled the possible effect of the lockdown measures undertaken in Switzerland between February 28 and June 22, 2020, because of the COVID-19 pandemic. During this period, several parts of students’ lives were affected , which may have had an effect on our outcomes. The results from the imputed data set were cross-checked with the nonimputed data set. Results with a type I error rate of age in R , and LMMage in R .Baseline characteristics for the study sample are shown in Baseline differences between the intervention and control groups were revealed for immigration background, education, prevalence of tobacco smoking and problem drinking, quantity of alcohol use, and perceived stress.df=1; P=.01) and problem drinking  at baseline than controls.Concerning attrition bias, the analysis revealed that intervention group participants who were lost to follow-up reported more frequent tobacco use  program participants withdrew their participation. A total of 50 activities  were prompted over the 6-month program. The mean number of activities carried out by participants was 23.6 (SD 15.9). A total of 9.6% (72/750) of participants did not take part in any of the activities prompted by the program. Low engagement with the program was established for 149 out of 750 (19.9%) students, who interacted with it only 1 to 10 times. A total of 14.0% (105/750) of the participants interacted 11 to 20 times, 13.3% (100/750) interacted 21 to 30 times, 24.9% (187/750) interacted 31 to 40 times, and 18.3% (137/750) interacted 41 to 50 times.read the SMS messages thoroughly, 27.0% (152/563) reported that they took a quick look at the SMS messages, and 1.6% (12/563) chose the predefined response category I did not read the SMS messages. The number of text messages received was rated as appropriate by 78.6% (442/562) of participants; 12.0% (90/562) would have preferred fewer messages, and 5.3% (30/562) would have preferred more text messages. Three-quarters of the participants rated the total length of the program as adequate ; 7.5% (42/561) would shorten the program, and 12.7% (95/561) would extend the program. Over half of the participants  would recommend the program to others, while 32.5% (182/560) would not.Of 597 participants with valid follow-up data, 563 (94.3%) answered the question regarding whether they had read the text messages. Of these, 70.9% (399/563) indicated that they Almost all participants reported that the text messages were comprehensible . Participants were also asked if the text messages were helpful, and 384 out of 550 (69.8%) agreed that they were. A majority  indicated that they perceived the text messages as individually tailored to them.very good or good by 83.6% (469/561) of the participants. Out of the specific program elements, the prizes, the text messages in general, the web-based feedback, and the quiz questions received the best evaluations, with more than 82.2% (461/561) of participants rating them as good or very good. The picture and message contests received the poorest ratings: 44.9% (252/561) of the participants rated them as good or very good.The results of the complete-case (CC) and ITT analyses examining prevalence of problem drinking, tobacco smoking, and cannabis use are displayed in P=.01) but not in the ITT analysis . The prevalence of tobacco smoking also showed a steeper increase for controls (from 15.1% to 18.5%) compared to those who received the intervention (from 12.1% to 14.5%) from baseline to the 6-month follow-up, but this effect was not significant, neither in the ITT analysis  nor in the CC analysis . No significant group effect was observed for the pre-post difference in prevalence of cannabis smoking .In the 30 days preceding the 6-month follow-up assessment, prevalence of problem drinking increased by 2.5% (from 15.2% to 17.7%) in the intervention group and by 3.4% (from 20.7% to 24.1%) in the control group, relative to that observed at baseline. This group effect was significant in the CC analysis  from baseline to the follow-up assessment. Further, a significant group effect was observed for pre-post differences in cigarette smoking  and reported stress . No significant group effect was observed for frequency of cannabis smoking . Pre-post differences in well-being  and social skills  also did not differ significantly between groups.Quantity of alcohol consumed per month decreased by 0.6 standard drinks in the intervention group and increased by 0.7 standard drinks in the control group  4 out of 5 secondary school students (84%) participated in the study, showing a high interest in this interventional approach; (2) overall program use and engagement was good; and (3) initial results on program efficacy showed a significant intervention effect for some of the considered outcomes, including quantity of alcohol consumed per month, quantity of cigarettes smoked per month, and reported stress.This study tested the appropriateness and initial effectiveness of SmartCoach program and/or the associated study. Given the program duration of 22 weeks and that program participants needed to indicate their mobile phone number, this high participation rate of 84% is remarkable. Compared to the related ready4life program for life-skills training among vocational school students, the participation rate was similar, with 82% of students present within the school classes that could be recruited [The proactive invitation for program and study participation in secondary and upper secondary schools, in combination with the offer of a low-threshold mobile phone–based intervention, permitted us to reach 4 out of 5 adolescents for participation in the ecruited . In contecruited -47 and aecruited ,49. Thisecruited ,51.SmartCoach was similar: the mean number of activities carried out by participants in the ready4life life-skills training program among vocational school students was 15.5 out of 39 possible activities [Concerning program use and engagement, the overall results were positive, with the majority of students (95%) remaining registered for the program for the total duration of 6 months and, on average, with program participants responding to half (mean of 23.6 out of 50) of the prompted activities. Program evaluations underlined its appropriateness for the target group of secondary school students, with the majority rating the program as helpful and individually tailored. However, 10% failed to engage in any of the 50 program activities, and another 20% showed low engagement, with less than 10 program interactions. Based on these findings, there is clearly room for improvement in terms of active program engagement, particularly concerning the picture and message contests, which received the poorest ratings among all program elements. The poor rating for this highly interactive element might be due to the limitations of mobile phone text messaging to receive and send pictures, which could be implemented more elegantly within a chat-based native smartphone app; however, direct comparisons of coaching programs based on SMS text messaging and smartphone apps concerning engagement and efficacy are still pending . Comparetivities ; within tivities .SmartCoach program, this could include more flexibility concerning timing and extent of the intervention . Furthermore, the provision of the right type of support at the right time by adapting to an individual’s changing internal and contextual state, as conceptualized in just-in-time adaptive interventions (JITAIs) [Further measures to increase program engagement based on the recommendations from a recent review  might be(JITAIs) , has the(JITAIs) .P<.05) and another three outcomes  showing beneficial developments of borderline significance (P<.10). As the metric measures of substance use are more sensitive to change than the binary prevalence measures, which present the main outcomes of this study and provided the basis for the power calculations, these initial results are not conclusive for the effects of the primary outcomes of this study.The results concerning the initial effectiveness of this program based on 6-month follow-up data are promising, with three of nine outcomes of the ITT analyses showing beneficial developments of statistical significance (ie, stress, quantity of alcohol use, and quantity of tobacco use; The main limitations of this study are as follows:Power calculations were based on the 18-month follow-up assessment ; therefoAll data relied on self-report and the associated possibility that results may have been influenced by social desirability and a potential recall bias. Measures used to avoid under- or overreporting of substance use included assurance of confidentiality and anonymous assessments conducted via online survey and without personal contact, which may have increased the reliability of self-reported data.Cluster randomization according to school class did not result in a balancing of all baseline characteristics.There was selective attrition in the intervention group for persons with higher tobacco use and problem drinking at baseline. Although multiple imputations were used to compensate for this imbalance as much as possible, it would be interesting to investigate the reasons for this selective attrition. It is possible that the program reinforced cognitive dissonance and, associated with this, created a reactance toward the program. For future programs, this would mean that content should be chosen very carefully in this respect.Some of the follow-up assessments were conducted during the lockdown restrictions due to the COVID-19 pandemic. This might have affected the generalizability of the results; however, this potential effect was addressed by the inclusion of a corresponding dummy covariate within all outcome analyses.The results could not be generalized to secondary and upper secondary schools in Switzerland, as we recruited a convenience sample of school classes willing to participate in the study. However, the comparison of substance use prevalence rates among a representative sample of 15-year-old students in Switzerland  and the This is the first study that tested the appropriateness and efficacy of a mobile phone–delivered life-skills training program for substance use prevention among adolescents within a controlled trial. Our results suggest that this program, which delivers individualized messages and interactive activities integrated within a friendly competition, is both appropriate and promising in its effectiveness. Given that the program could be presented and introduced by research workers to students within one school lesson, it could be easily and economically implemented.Our initial results indicate that the program might be effective in both preventing or reducing substance use and fostering life skills, such as coping with stress. However, data from the final 18-month follow-up will provide more robust results, including regarding potential moderators and mediators of program efficacy. Concerning moderators, it would be of particular interest to examine whether individuals with higher levels of substance use could also benefit from life-skills training programs. It would also be of particular interest to test which of the life skills addressed and successfully modified might prevent or decrease substance use.