We present a series of network analyses aiming to uncover the symptom constellations of depression, anxiety and somatization among 2,796 adult primary health care attendees in Goa, India, a low- and middle-income country (LMIC). Depression and anxiety are the leading neuropsychiatric causes of disability. Yet, the diagnostic boundaries and the characteristics of their dynamically intertwined symptom constellations remain obscure, particularly in non-Western settings. Regularized partial correlation networks were estimated and the diagnostic boundaries were explored using community detection analysis. The global and local connectivity of network structures of public versus private healthcare settings and treatment responders versus nonresponders were compared with a permutation test. Overall, depressed mood, panic, fatigue, concentration problems and somatic symptoms were the most central. Leveraging the longitudinal nature of the data, our analyses revealed baseline networks did not differ across treatment responders and nonresponders. The results did not support distinct illness subclusters of the CMDs. For public healthcare settings, panic was the most central symptom, whereas in private, fatigue was the most central. Findings highlight varying mechanism of illness development across socioeconomic backgrounds, with potential implications for case identification and treatment. This is the first study directly comparing the symptom constellations of two socioeconomically different groups in an LMIC.

This article argues that the current approach of the European Court of Human Rights (ECtHR) to evaluating scientific evidence is lacking and hampers its ability to properly handle cases involving questions of science, and particularly environmental cases which are replete with them. It identifies three problem areas in relation to the ECtHR's adjudication of such cases: the evaluation of evidence proving the causation of harm; the extent of the Court's deference to the determinations made by national authorities; and the Court's evaluation of evidence adduced by the respondent State in justifying its conduct as being in line with the standard of due diligence. Several cases that illustrate the recurring problem of the lack of science-based reasoning in the Court's judgments are then identified, highlighting the shortcomings of its approach. Such issues have an impact upon the legitimacy of the ECtHR, and it is therefore imperative that it engages more robustly with scientific evidence. The article suggests the best way to do this would be for the ECtHR to make more use of its power to seek assistance from independent scientific experts in environmental cases.

We hypothesized that children receiving medium-chain triglyceride ketogenic diet (MCTKD) experience similar seizure reduction despite lower ketosis compared with classic ketogenic diet (CKD). Children initiating CKD or MCTKD were enrolled in a prospective observational study. Forty-five children completed 6 months of KD (n = 17 MCTKD, n = 28 CKD). The proportion achieving ≥50% seizure reduction was 71% CKD group and 59% MCTKD group; ≥90% reduction was 32% and 36% in CKD and MCTKD groups, respectively. CKD had higher urine ketones (≥8 mmol/L: 79% vs. 36%, p = 0.005). Children receiving MCTKD experience similar seizure control to CKD despite lower urine ketone measures.

Jeffrey L. Dunoff and Mark A. Pollack's article is an important and very welcome contribution to the discussion about judicial values. The authors argue that with respect to judicial independence, transparency, and accountability “judicial systems face inherent trade-offs, such that any given court can maximize two, but not all three, of these features.” In our eyes, the article's most important contribution is its holistic view: it shows why these three judicial values can only be understood in their interconnectedness. It is, for instance, not meaningful to make a statement about the correlation between transparency and independence without also taking accountability into the equation. This is because the effect of transparency on independence can only be understood if information about judicial accountability is at one's disposal. In the past, these judicial values have often been analyzed in an isolated manner, thereby leading to wrong conclusions. The Judicial Trilemma will hopefully help in shifting the discourse from isolated to holistic views on independence, transparency, and accountability. Moreover, Dunoff and Pollack lay the groundwork for a meaningful normative discussion of these three judicial values. Any debate about how to structure (international) courts should henceforth take Dunoff and Pollack's holistic view as a basis for discussion.

This prospective cohort study was conducted in eighteen Canadian hospitals with the aim of examining factors associated with nutritional decline in medical and surgical patients. Nutritional decline was defined based on subjective global assessment (SGA) performed at admission and discharge. Data were collected on demographics, medical information, food intake and patients’ satisfaction with nutrition care and meals during hospitalisation; 424 long-stay (≥7 d) patients were included; 38 % of them had surgery; 51 % were malnourished at admission (SGA B or C); 37 % had in-hospital changes in SGA; 19·6 % deteriorated (14·6 % from SGA A to B/C and 5 % from SGA B to C); 17·4 % improved (10·6 % from SGA B to A, 6·8 % from SGA C to B/A); and 63·0 % patients were stable (34·4 % were SGA A, 21·3 % SGA B, 7·3 % SGA C). One SGA C patient had weight loss ≥5 %, likely due to fluid loss and was designated as stable. A subset of 364 patients with admission SGA A and B was included in the multiple logistic regression models to determine factors associated with nutritional decline. After controlling for SGA at admission and the presence of a surgical procedure, lower admission BMI, cancer, two or more diagnostic categories, new in-hospital infection, reduced food intake, dissatisfaction with food quality and illness affecting food intake were factors significantly associated with nutritional decline in medical patients. For surgical patients, only male sex was associated with nutritional decline. Factors associated with nutritional decline are different in medical and surgical patients. Identifying these factors may assist nutritional care.

Ready-to-use modified-texture food (rMTF) products are commercially available and may have greater appeal than conventional in-house or commercial bulk modified-texture food (cMTF) products. A nine-month pilot study using a prospective interrupted time-series design where participants (n = 42) served as their own controls investigated the impact of cMTF + rMTF on weight goals, weight, food intake, and co-morbidity. Seventy-four per cent of participants achieved their weight goals at the end of six months on rMTF and, although insignificant, participants did have a trend towards weight gain while on rMTF (OR 3.5 p = .16). Main-plate food intake (grams) was not significantly different over time, but a downwards trajectory suggests decreased consumption that was compensated for by a significantly higher fat intake during the intervention period (p = .01). Increased co-morbidity and a decreasing volume of food consumed are common in older adults with dysphagia, and enhanced food products are needed to meet nutrient needs. Methodological issues encountered in this study can provide guidance for future work.