Mental health and insomnia problems in healthcare workers after the COVID-19 pandemic:A multicenter cross-sectional study

BACKGROUND Healthcare workers(HCWs)are at increased risk of contracting coronavirus disease 2019(COVID-19)as well as worsening mental health problems and insomnia.These problems can persist for a long period,even after the pandemic.However,less is known about this topic.AIM To analyze mental health,insomnia problems,and their influencing factors in HCWs after the COVID-19 pandemic.METHODS This multicenter cross-sectional,hospital-based study was conducted from June 1,2023 to June 30,2023,which was a half-year after the end of the COVID-19 emergency.Region-stratified population-based cluster sampling was applied at the provincial level for Chinese HCWs.Symptoms such as anxiety,depression,and insomnia were evaluated by the Generalized Anxiety Disorder-7,Patient Health Questionnaire-9,and Insomnia Severity Index.Factors influencing the symptoms were identified by multivariable logistic regression.RESULTS A total of 2000 participants were invited,for a response rate of 70.6%.A total of 1412 HCWs[618(43.8%)doctors,583(41.3%)nurses and 211(14.9%)nonfrontline],254(18.0%),231(16.4%),and 289(20.5%)had symptoms of anxiety,depression,and insomnia,respectively;severe symptoms were found in 58(4.1%),49(3.5%),and 111(7.9%)of the participants.Nurses,female sex,and hospitalization for COVID-19 were risk factors for anxiety,depression,and insomnia symptoms;moreover,death from family or friends was a risk factor for insomnia symptoms.During the COVID-19 outbreak,most[1086(76.9%)]of the participating HCWs received psychological interventions,while nearly all[994(70.4%)]of them had received public psychological education.Only 102(7.2%)of the HCWs received individual counseling from COVID-19.CONCLUSION Although the mental health and sleep problems of HCWs were relieved after the COVID-19 pandemic,they still faced challenges and greater risks than did the general population.Identifying risk factors would help in providing targeted interventions.In addition,although a major proportion of HCWs have received public psychological education,individual interventions are still insufficient.

A NEW INSULIN-SENSITIVITY INDEX FOR EPIDEMIOLOGICAL STUDY

Insulin sensitivity(IS) is an important parameter in the study of the relationship between the

A Clinical Epidemiological Study of the Quantitative Diagnosis Scale of Blood Stasis Syndrome

Objective： To establish the diagnosis scale of blood stasis syndrome （BSS） and explore the idea and method of using scale to research the quantitative diagnosis of Chinese medicine （CM） syndrome. Methods： Combining the modern epidemiology, consulting the access of quality of life scale, and colligating multi-angle methods to make the scale. Results： The scale had relatively good reliability and validity and could be used to estimate the degree of stasis and analyse the curative effect. Conclusions： It was a reference for CM syndrome diagnosis that combines screening methods of scale entry with quantitative diagnosis to establish the quantitative diagnosis scale.

An Epidemiological Study of Knee Osteoarthritis.

2,063 adults people of a Beijing suburban village were surveyed for osteoarthritis of the knees. Questionnaire was completed in all. 799 (38.7% responded to have knee joint pain. 311 with knee joint pain and 212 without knee joint

EPIDEMIOLOGICAL STUDY OF PRIMARY SJOGRNE'S SYNDROME IN CHINA

It was stated in the WHO technical report on rheumtaic diseases (Serial 816, 1992) that the prevalence of Sjogren’s syndrome (SS) in the general population is unknown. Same thing holds true in China. An epidemiological study of primary SS (I°SS) on 2066 adult people in a Beijing Suburb village was carried out, using questionnaire and serological examinations (antinuclear antibodies, rheumatoid factor, anti-SSA and anti-SSB antibodies) as the primary screening tool. Those who answered bad dryness of mouth as indicated by difficulties in swallowing dry food or presence of rampant caries and those who showed at least one positive serological test among the three, were subjected to oral (salivary

An epidemiological study on tbe road traffic accidents from hills of north India

Road traffic injuries are increasingly being reported as an important cause of morbidity and disability worldwide.Various epidemio-logic factors related to road traffic crash cases were examined to identify potential targets for future preventative strategies.This hospital-based descriptive study collected relevant information by use of a predesigned and pretested questionnaire given to total of 401 consecutive individuals that received nonfatal injuries from road traffic crashes who reported to the Indira Gandhi Medical College Hospital in Shimla,India between June 2005 to May 2006.The percentage of cases corresponding to preselected catego-ries were compared using chi-square analyzes to determine statistical significance.A majority of the injured victims included in this study were between 20-49 years of age,with a male to female ratio of 5.3:1.The largest numbers of victims were employees and occupants of transport vehicles.Human error was the most reported cause of crash,and the most common mode of crash was skid-ding and/or rolling down.The highest proportion of crashes occurred on curved roads.The most at-risk population in Shimla,India for receiving nonfatal traffic-related injuries is males between 20 and 49 years of age who utilize transport vehicles.As the majority of nonfatal injuries occur in passengers of light transport vehicles(LMVs)in accidents at road curves,road safety strategies should target these locations and the drivers of these vehicles in order to most effectively protect their occupants.

Creatine kinase in the diagnosis and prognostic prediction of amyotrophic lateral sclerosis:a retrospective case-control study

Creatine kinase is a muscle enzyme that has been reported at various levels in different studies involving patients with amyotrophic lateral sclerosis.In the present retrospective case-control study,we included 582 patients with amyotrophic lateral sclerosis and 582 age-and sexmatched healthy controls.All amyotrophic lateral sclerosis participants received treatment in the Department of Neurology,West China Hospital,China,between May 2008 and December 2018.Serum creatine kinase levels in patients with amyotrophic lateral sclerosis were significantly higher than those in healthy controls.Subgroup analysis revealed that serum creatine kinase levels in men were higher than those in women in both amyotrophic lateral sclerosis patients and healthy controls.Compared with patients with bulbar-onset amyotrophic lateral sclerosis,patients with limb-onset amyotrophic lateral sclerosis had higher creatine kinase levels.Spearman's correlation analysis revealed that serum creatine kinase levels were not correlated with body mass index,Amyotrophic lateral Sclerosis Functional Rating ScaleRevised score,or progression rate.After adjusting for prognostic covariates,higher log creatine kinase values were correlated with higher overall survival in the amyotrophic lateral sclerosis patients.We also investigated the longitudinal changes in serum creatine kinase levels in 81 amyotrophic lateral sclerosis patients;serum creatine kinase levels were decreased at the second blood test,which was sampled at least 6 months after the first blood test.Together,our results suggest that serum creatine kinase levels can be used as an independent factor for predicting the prognosis of amyotrophic lateral sclerosis patients.This study received ethical approval from the Ethics Committee of West China Hospital,China(approval No.2015(236))on December 23,2015.

Analysis on the Epidemiological Characteristics of Escherichia coli O157:H7 Infection in Xuzhou,Jiangsu,China,1999

Objective： To determine epidemiologic features of an Escherichia coli O157：H7 outbreak occurred in Xuzhou, Jiangsu Province, China in 1999, and assess the incidence of E. coli O157：H7 in diarrhea patients and host animals and its relationship with disease onset, and provide a scientific basis for establishing prevention and control strategies. Methods： Epidemiological, microbiological, and molecular methods were performed to identify risk factors and describe the ecology of E. coli O157：H7 in the enviromnent. Results： From May to September, in 1999, 99 cases of E. coli O157：H7 infection were confirmed. Fifty-six patients were enrolled in the case-control study. Bad personal health habits and poor sanitary conditions in the kitchen were associated with increased risks of infection, whereas hand washing was protective. The household survey indicated that residents in the epidemic region during the outbreak had higher than expected rates of diarrhea. The total E. coli O157：H7 carrier rate in the livestock was 12.36%（22/178）, specifically 19.15% in cattle, 12.50% in goat, and 11.11% in swine. Numerical analysis of pulsed-field gel electrophoresis（PFGE） profiles divided strains into two clusters with 77.5% homology. One cluster contained 11 strains isolated from diarrheal patients, foods, and animals. The other cluster comprised 10 strains from patients and environment. Conclusion： In a large outbreak of E. coli O157：H7 infection among predominantly elderly residents in Xuzhou, high rates of carriage of E. coli O157：H7 among host animals most likely resulted in contamination of the environment, thereby leading to the outbreak. Effective and preventive control measures should be taken to avoid contamination, including environmental and family health improvement, good personal hygiene, and safe food handling practices.

Epidemiological Studies on Cystic Echinococcosis in China─A Review

In the four decades from 1951 to 1990, the six provinces or autonomous regions (Xinjiang, Gansu, Qinghai, Ningxia, Xizang and Nei Monggol) reported a total of 26 065surgical cases of hydatid disease, most of which were reported in the recent decade. About one third of the patients was children and adolescents under 15 years old. So far, cystic hydatid infections of local origin have been confirmed in 22 provinces, autonomous regions and municipalities in the whole nation. Findings of X-ray examination and real-time B-mode ultrasonography in agricultural and pastoral areas of Xinjiang, Gansu, Qinghai,Ningxia and Xizang showed that the morbidity rate of hydatidosis in human population varied between 0.5% and 4.5%. The main animal intermediate host in all these regions is sheep, the morbidity of which varied between 3.3% and 90%. The infection rate of adult Echinococcus granulosus in dogs varied between 7% and 71%. The high-risk period for humans contracting hydatid disease is the pre-school age. Direct contact of children with dogs and ingestion of water, vegetables and foods contaminated by worm eggs are the chief mode of transmission for human hydatidosis. The common practices of home slaughter and of feeding dogs on offal containing hydatid cysts facilitate the life cycIe of the parasite.On the basis of hydatid control efforts for several years, the Ministry of Public Health promulgated officially the '1992-1995 National Programme for Hydatid Disease Control'in April, 1992, and pilot studies in which the control of hydatidosis is composed of extensive health education, sanitation of slaughtering and management and deworming of dogs are being established.Cystic echinococcosis has wide distribution in China and is a major public health problem in hyperendemic areas, poses a great threat against people's health and influences the development of livestock husbandry. This problem has received great attention from the medical and veterinary departments. In the rencent decade great efforts have been made in the epidemiology, parasitology and clinical treatment of echinococcosis, resulting in a better understanding of the disease and procedures effective in bringing about control of the disease

Epidemiologic Study of Cancer Mortality among Chloroprene Workers

Both case-control and cohort studies were undertaken from July 1,1969 to June 30,1983 to ascertain whether exposure to chloroprene increases the risk of cancer.Fifty-five cases of cancer deaths were verified,16 of which had histories of exposure to chloroprene ranging from 3 to 23 years(median 11 years)with a latent period of 8-27 years,except for one case of 3 years(median 12.5 years).Fifty-four pairs were obtained by matching the cancer deaths to noncaneer deaths in accordance with strict requirements.The odds ratio for the paired data was 13,x^2=8.64,P <0.005.The average age at death from cancer of workers exposed to chloroprene was 12.7 years younger than that of unexposed workers,t'=2.98,P<0.001.The total cohort consisted of 1213 persons,among whom 149(11.6%)had histories of exposure for over 25 years,381(31.5%) for over 20 years,and 852(70.2%) for over 15 years.The SMR for the total cohort was 2.38(P <0.01),and all SMRs for the high-exposure occupations were of significance(P<0.05or P<0.01),in contrast to those of the low-exposure groups whose SMRs were low or zero.Thus, a dose-response relationship existed.Among the high-exposure occupations,maintenance me- chanics seem to have the highest risk of cancers,and SMRs for liver,lung,and lymphatic cancers were significant in this group.These results suggested that chloroprene exposure increases the risk of developing cancer.1989 Academic Press,Inc.

Multi-centric Study on Clinical Epidemiology Is the Key Link in Treating Hypertension with Integrative Chinese and Western Medicine

General survey ofhypertension has beencarried out in our coun—try for three times.Thelast time was in 1999,with the result showingthat in our country theincidence of hyperten-sion among people over15 years old was11.26％.The incidencehas been raised by 25％

Situation analysis of cutaneous leishmaniasis in an endemic area,south of Iran

Objective: To update current situation of the cutaneous leishmaniasis(CL) in Kazerun County,southwest of Iran and to analyze the epidemiological aspects of the disease during 2005-2015,Methods: Data on CL were obtained from the Health Center of Kazerun County,and then were analyzed and mapped using SPSS and Arc GIS 10.3,Results: A total of 700 cases of CL were recorded during the study period with an overall decreasing trend from 2005 to 2015,More than 60% of the patients were inhabitants of rural areas and males were infected more than females,Although there was not a significant difference between gender,job categories,residence and CL infection(P>0.05),age groups were significantly different(P<0.05),But there was no significant correlation between monthly cases of the disease with average temperature(P>0.05),Most of the acute lesions were found to be present on the hand,leg and face,respectively,The average CL incidence in the study area was calculated as 24.9/100 000 population,A hot spot for the disease was found in southern part of the area(P<0.05),Conclusions: This study revealed that CL is present in Kazerun country,Thus,effective monitoring and sustained suveillance system is crucial in counteracting the disease,and if possible,to eliminate it.

Survey data analysis of the related risk factors of echinococcosis in Inner Mongolia of China and Mongolia

Objective:The aim of the study is to analyze the risk factors of hepatic echinococcosis in mass epidemiological studies in Inner Mongolia of China and Mongolia and provide a basis for related authorities to make appropriate preventive measures.Methods:Eight areas in Inner Mongolia and Zamyn-Üüd region of Mongolia were selected as epidemiological fields.By distributing epidemiological questionnaires to local residents and performing serological examinations and abdominal ultrasound examinations,the data results were collected and analyzed to obtain the risk factors.Results:In this research,there were 7,373 cases of valid data in the area of Inner Mongolia and 1,500 cases in the area of Mongolia.The mean age of the whole survey samples was 52.86±13.90,and the ratio of the female(58.35%)was much higher than that of the male(41.65%).Both univariate analysis and multivariate analysis in this study showed that the female(14.7%)had a higher risk of hepatic echinococcosis than the male(10.9%).From the perspective of profession,children,educators and medical personnel had a lower incidence,herdsmen had the highest positive rate of the disease(15.8%).Living in pastoral areas,having been to pastoral areas,eating uncooked food and drinking unboiled water,raising dogs and surrounding activities of foxes and voles can also increase the risk of positivity.Conclusions:Our findings demonstrate that the most important risk factor of hepatic echinoccosis is unhealthy lifestyles and customs in farmers and herdsmen.It is possible to provide a basis for related authorities to make effective protective measures aiming at hepatic echinococcosis.

Sex Hormones Affect Aging Process by Influencing Lipid Profiles, Cellular Immunological Function and Lipid Peroxides and Oxidation System

Objectives To investigate the correlation between sex hormones(SH) and aging. Methods Through epidemiological investigation in our country, the levels of SH were measured by radioimmunoassy; lipid profile, glucose and apolipoprotein by automatic biochemic analytical instrument; T cell subsets by flow cytometer; and MDA, SOD were evaluated by the thiobarbituric acid (TBA) test and the nitrite method modified by Oyanagui respectively using spectrophotometry. Results In men, the serum levels of follicle stimulating hormone ( FSH)、luteinizing hormone(LH) increased significantly with aging, but serum prolactin(PRL) and progesterone(P) levels remained unchanged in all life; Both testosterone (T) and free testosterone (FT) all decreased greatly with aging, but 17β - estradiol( 17β - E_2) was reverse ; E_2 was negatively correlated with T and E_2/T increased with aging. The level of serum total cholesterol (TC) increased with aging, but triglycerides (TG) remain unchanged; compared with young group, high - density lipoprotein cholesterol ( HDL - C) ; HDL - C/TC of other groups decreased significantly, but low - density lipoprotein cholesterol ( LDL - C ) changed inversely; HDL- C/LDL- C reduced slightly with aging and showed no difference between groups. Apolipoprotein A1 (apoA1) and apoB all enhanced greatly with aging; meanwhile the ratio of apoA1/apoB decreased. The concentration of serum glucose (GLU) was unchanged in all life. To compare with those in the young group, CD3 + , CD4 + in other groups reduced greatly, CD4 + remained unchanged. Meanwhile, CD8 + increased significantly with aging. Compared with the young group, serum malondialdehyde(MDA) value of the old ones increased obviously, but the activity of superoxide dismutase(SOD) was reverse. By partial correlation analysis (controlling BMI, FSH, LH and PRL), TC、 LDL-C、apoA1、apoB、CD8 + 、MDA of men all presented a positive correlation with E_2/T respectively, their correlation coefficients (γ) were 0. 262、0. 136、 0. 532、0. 379、0. 394、0. 234 (P < 0. 001 ) ; HDL - C、 HDL- C/TC、HDL- C/LDL- C、CD3 + 、CD4 +/CD8 + 、SOD showed a negatively correlation with E_2/T respectively, γequaled - 0.563、- 0.332、- 0.654、- 0.1530、-0.4140、-0.236(P<0.001). In women, the serum concentrations of FSH、LH increased significantly after menopause; PRL increased little with aging; compared with young group, E_2 and P in postmenopausal groups reduced obviously, E_2/P revealed significant reduce with aging. T enhanced significantly after menopause, but nor did FT. E_2, P and the ratio of E_2/P were negatively correlated with age respectively by bivariate correlation analysis, and a positive relation between T and age. After 70 years old, the level of TC increased obviously, and so did that of TG after menopause; HDL decreased with aging, but LDL increased after 70, with the result that the ratios of HDL- C/TC and HDL- C/LDL- C all reduced with aging; apoA1 decreased gently after 70, but apoB increased signifi- cantly after menopause; correspondingly, the ratio of apoA1/apoB declined obviously. The concentration of GLU increased with aging. CD3 + and CD4 + didn't change until 60, but reduced after 60. Compared with the young groups, CD8 + remained unchanged, CD4 +/CD8 + reduced greatly with aging, CD4 + and CD8 + presented a negatively correlation with age respectively. The value of MDA in serum of women increased notably after 70 years old, but SOD activity already decreased significantly from 60. By partial correlation analysis (controlling BMI, FSH, LH and PRL), HDL-C、CD4 +、CD4 +/CD8 + showed a certain correlation with E_2/P respectively; γ were 0. 245、 0.157、0. 154 ( P <0.05 ) ; TG、 LDL、 apoB、 apoA1/ apoB、SOD presented a negatively correlation with E_2/P respectively, γ were 0. 452、 0. 236、 0.321、 0. 135、 0.156、0.154、0.426 ( P < 0.05 ). Conclusions The Disequilibrium of SH had correlations with lipid profile, cellular immunological function and lipid peroxides and oxidation system; these suggested SH took an important role in the process of aging.

Clinical patterns and characteristics of uveitis in a secondary hospital in southern China

AIM: To investigate the characteristics of uveitis in a secondary hospital in southern China.METHODS: We reviewed all records of patients with uveitis at Hengli Hospital from January 2008 to December2011. Demographic data, past history, ophthalmic examinations and other laboratory tests were analyzed.RESULTS: One hundred and ninety-nine uveitis patients were enrolled in this study, including 134(67.3%) males and 65 females(32.7%) with an average age of 41.0 ±15.1y. The anatomical distribution included103(51.8%) cases of anterior uveitis, followed by panuveitis(65, 32.7%), posterior uveitis(29, 14.6%) and intermediate uveitis(2, 1.0%). Of the 98(49.2%) non-idiopathic cases, there were 10.1% Behcet’s disease,9.5% Vogt-Koyanagi-Harada(VKH) syndrome, 7.5%infectious uveitis, 7.5% traumatic uveitis and 3.5%postoperative uveitis.CONCLUSION: Idiopathic anterior and posterior uveitis,Behcet’s disease, VKH syndrome, infectious uveitis and traumatic uveitis are the most common uveitis entities in a secondary hospital in southern China. Additional measures should be taken to prevent infectious and traumatic uveitis.

Studies on the Epidemiology and Etiology of Moldy Sugarcane Poisoning in China

Moldy sugarcane poisoning, an acute fatal food poisoning of unknown etiology, has occurred in 13 provinces in China. The epidemiological characteristics and clinical features were described. Evidence from laboratory studies indicates that 3-nitropropionic acid roduced by the fungus Arthrinium Spp. is the etiological factor of this food poisoning.

E-Cigarette: A New Tobacco Product for Schoolchildren in Paris

Objectives: To explore if the dramatic decrease in price of e-cigarette has transformed this new product into a product used for tobacco initiation among a teenage population. Methods: The authors added a question in 2012 on e-cigarette in the yearly survey on tobacco consumption in Paris schoolchildren. The study is conducted on a randomly selected sample from 2% of classes since 1991. Results: 277 (8.1%) of the 3409 schoolchildren studied (including 575 non responders to this question) reported having had an experience with e-cigarette. Experimentation rate is 6.4% among the 12 - 14-year-old, 11.8% among the 15 - 16-year-old and 9% among the 17-year-old schoolchildren. Among the 12 - 14- year-old schoolchildren, 64.4% of e-cigarette experimentation was by non-smokers. Of the 17-year-old teenagers who had used e-cigarettes, 12.4% were non-smokers. For the whole population, 33.2% of those having tried e-cigarette are non-smoker, 22.7% occasional smoker, 3.6% ex-smoker and 40.4% daily smoker. Those who experiment cannabis, shisha or binge-drinking are more frequently users of e-cigarette. In the smoker group, there is an inverse trend of rela- tionship between the readiness to quit tobacco and the rate of use of e-cigarette. Conclusion: For teenager’s, e-cigare- ttes have become not a product to aid quit tobacco but a product for experimentation and initiation of cigarette use. Regulation is urgently needed to control the emergent use of this new tobacco product by children.

Fine particulate matter and cardiorespiratory health in China:A systematic review and meta-analysis of epidemiological studies

This review aimed to systematically summarize the epidemiological literature on the cardiorespiratory effects of PM_(2.5)published during the 13^(th) Five-Year Plan period(2016-2020)in China.Original articles published between January 1,2016 and June 30,2021 were searched in PubMed,Web of Science,the China National Knowledge Internet Database and Wanfang Database.Random-or fixed-effects models were used to pool effect estimates where appropriate.Of 8558 records identified,145 met the full eligibility criteria.A 10μg/m^(3) increase in short-term PM_(2.5)exposure was significantly associated with increases of 0.70%,0.86%,0.38%and 0.96%in cardiovascular mortality,respiratory mortality,cardiovascular morbidity,and respiratory morbidity,respectively.The specific diseases with significant associations included stroke,ischemic heart disease,heart failure,arrhythmia,chronic obstructive pulmonary disease,pneumonia and allergic rhinitis.The pooled estimates per 10μg/m^(3) increase in long-term PM_(2.5)exposure were 15.1%,11.9%and 21.0%increases in cardiovascular,stroke and lung cancer mortality,and 17.4%,11.0%and 4.88%increases in cardiovascular,hypertension and lung cancer incidence respectively.Adverse changes in blood pressure,heart rate variability,systemic infiammation,blood lipids,lung function and airway infiammation were observed for either short-term or long-term PM_(2.5)exposure,or both.Collectively,we summarized representative exposure-response relationships between short-and long-term PM_(2.5)exposure and a wide range of cardiorespiratory outcomes applicable to China.The magnitudes of estimates were generally smaller in short-term associations and comparable in long-term associations compared with those in developed countries.Ourfindings are helpful for future standard revisions and policy formulation.There are still some notable gaps that merit further investigation in China.

Danish cohort of monozygotic inflammatory bowel disease twins: Clinical characteristics and inflammatory activity

AIM: To describe the establishment of a Danish inflammatory bowel diseases (IBD) twin cohort with focus on concordance of treatment and inflammatory markers.METHODS: We identified MZ twins, likely to be discordant or concordant for IBD, by merging information from the Danish Twin Register and the National Patient Register. The twins were asked to provide biological samples, questionnaires, and data access to patient files and public registries. Biological samples were collected via a mobile laboratory, which allowed for immediate centrifugation, fractionation, and storage of samples. The mean time from collection of samples to storage in the -80&#x02005;&#x000b0;C mobile freezer was less than one hour. The diagnoses where validated using the Copenhagen diagnostic criteria.RESULTS: We identified 159 MZ IBD twin pairs, in a total of 62 (39%) pairs both twins agreed to participate. Of the supposed 62 IBD pairs, the IBD diagnosis could be confirmed in 54 pairs. The cohort included 10 concordant pairs, whereof some were discordant for either treatment or surgery. The 10 concordant pairs, where both pairs suffered from IBD, included eight CD/CD pairs, one UC/UC pair and one UC/IBDU pair. The discordant pairs comprised 31 UC, 5 IBDU (IBD unclassified), and 8 CD discordant pairs. In the co-twins not affected by IBD, calprotectin was above 100 &#x003bc;g/g in 2 participants, and above 50 &#x003bc;g/g in a further 5 participants.CONCLUSION: The presented IBD twin cohorts are an excellent resource for bioinformatics studies with proper adjustment for disease-associated exposures including medication and inflammatory activity in the co-twins.