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We demonstrate a high-peak-power master oscillator power amplifier burst-mode laser system that generates microsecond burst duration pulses at 355 nm with a GHz-adjustable intra-burst pulse frequency. In the fiber seed, a high-bandwidth electro-optic modulator is employed to modulate a continuous-wave (CW) laser into a pulse train at GHz frequency. To acquire a microsecond rectangular burst pulse envelope, two acousto-optic modulators are used to chop the CW pulse train and generate a pre-compensation burst envelope. A three-stage neodymium-doped yttrium aluminum garnet amplifier boosts the burst-mode fiber seed’s burst energy of 1.65 J at 1064 nm. To achieve a high-power ultraviolet (UV) burst-mode laser, sum frequency generation in a LiB3O5 crystal is employed to convert the wavelength, achieving over 300 kW of peak power at 1.15 μs/10 Hz. The intra-burst pulse frequency of the UV burst laser can be adjustable from 1 to 10 GHz with a sinusoidal waveform. To the best of our knowledge, this paper represents the highest reported microsecond UV burst-mode laser in terms of output energy and peak power with the GHz-adjustable intra-burst frequency. The high-power microsecond UV burst-mode pulse laser can be directly used as a light-driven source in large-bandwidth/high-power microwave photonic systems, providing a long pulse width and high peak power laser while significantly improving the system’s multi-parameter adjustment capability and adaptability.
Ultrasonic scalpels are widely used in urological surgery. Although portable ultrasonic scalpels are convenient to use and install, the existing evidence on their safety and effectiveness is scarce. This study aimed to compare the safety and effectiveness of portable ultrasonic scalpels in urological surgery with traditional ultrasonic scalpels to aid clinical decision-making.
Methods
A multicenter, prospective, non-randomized controlled trial was conducted from February to August 2023 in three tertiary hospitals in China. The intervention group included 90 prospectively enrolled patients undergoing urological surgery during the same period of hospitalization: 45 with portable ultrasonic scalpels and 45 with traditional scalpels. Demographic and clinical data of patients in the study were collected. Data on quality of life were obtained using the EuroQol EQ-5D-5L scale preoperatively, at discharge, and one month and three months after surgery. Descriptive analysis and a generalized linear model were used in the data analysis.
Results
A total of 82 patients were included in the study: 39 in the intervention group and 43 in the control group. The average hospital stay and intraoperative and postoperative blood loss in the intervention group were lower than in the control group (p>0.05). From baseline to discharge, the decrease in quality-adjusted life-years (QALYs) in the intervention group was smaller (–0.134 versus –0.287; p<0.05) than in the control group. During the follow-up period, there were no significant differences in the changes in QALYs between the two groups. The decline in QALYs was significantly influenced by variables such as intraoperative blood loss and surgical site.
Conclusions
There were no significant differences in baseline characteristics or changes in QALYs between the intervention and control groups. Portable ultrasonic scalpels in urological surgery may be as equally effective as traditional scalpels with respect to clinical outcomes, with additional benefits in reducing QALY decline at discharge. Further research with large samples and long-term follow-up should be conducted.
CEOs who develop strong clan values as a result of exposure to clan culture in early life wish to bring honor to their clan, motivating them to engage in increased CSR activities. We propose that the influence of CEOs' clan values on CSR is subject to contextual boundaries. Specifically, we predict that the positive relationship between CEOs' clan values and CSR results primarily in an improved level of institutional CSR and varies with CEOs' personal attributes such as overseas experience and hometown identity. An analysis of a longitudinal sample of Chinese publicly listed firms for 2010–2019 provides strong support for our predictions. The implications for upper echelons theory and CSR research are discussed.
Timing of food intake is an emerging aspect of nutrition; however, there is a lack of research accurately assessing food timing in the context of the circadian system. The study aimed to investigate the relation between food timing relative to clock time and endogenous circadian timing with adiposity and further explore sex differences in these associations among 151 young adults aged 18–25 years. Participants wore wrist actigraphy and documented sleep and food schedules in real time for 7 consecutive days. Circadian timing was determined by dim-light melatonin onset (DLMO). The duration between last eating occasion and DLMO (last EO-DLMO) was used to calculate the circadian timing of food intake. Adiposity was assessed using bioelectrical impedance analysis. Of the 151 participants, 133 were included in the statistical analysis finally. The results demonstrated that associations of adiposity with food timing relative to circadian timing rather than clock time among young adults living in real-world settings. Sex-stratified analyses revealed that associations between last EO-DLMO and adiposity were significant in females but not males. For females, each hour increase in last EO-DLMO was associated with higher BMI by 0·51 kg/m2 (P = 0·01), higher percent body fat by 1·05 % (P = 0·007), higher fat mass by 0·99 kg (P = 0·01) and higher visceral fat area by 4·75 cm2 (P = 0·02), whereas non-significant associations were present among males. The findings highlight the importance of considering the timing of food intake relative to endogenous circadian timing instead of only as clock time.
This study examined the sour grapes/sweet lemons rationalization through 2 conditions: ‘attainable’ (sweet lemons) and ‘unattainable’ (sour grapes), reflecting China’s 2019-nCoV vaccination strategy. The aim was to find ways to change people’s beliefs and preferences regarding vaccines by easing their safety concerns and encouraging more willingness to get vaccinated. An online survey was conducted from January 22 to 27, 2021, with 3,123 residents across 30 provinces and municipalities in the Chinese mainland. The direction of belief and preference changed in line with the sour grapes/sweet lemons rationalization. Using hypothetical and real contrasts, we compared those for whom the vaccine was relatively unattainable (‘sour grapes’ condition) with those who could get the vaccine easily (‘sweet lemons’). Whether the vaccine was attainable was determined in the early stage of the vaccine roll-out by membership in a select group of workers that was supposed to be vaccinated to the greatest extent possible, or, by being in the second stage when the vaccine was available to all. The attainable conditions demonstrated higher evaluation in vaccine safety, higher willingness to be vaccinated, and lower willingness to wait and see. Hence, we propose that the manipulation of vaccine attainability, which formed the basis of the application of sour grapes/sweet lemons rationalization, can be utilized as a means to manipulate the choice architecture to nudge individuals to ease vaccine safety concerns, reducing wait-and-see tendencies, and enhancing vaccination willingness. This approach can expedite universal vaccination and its associated benefits in future scenarios resembling the 2019-nCoV vaccine rollout.
We report a numerical investigation of a previously noticed but less explored flow state transition in two-dimensional turbulent Rayleigh–Bénard convection. The simulations are performed in a square domain over a Rayleigh number range of $10^7 \leq Ra \leq 2 \times 10^{11}$ and a Prandtl number range of $0.25 \leq Pr \leq 20$. The transition is characterized by the emergence of multiple satellite eddies with increasing $Ra$, which orbit around and interact with the main vortex roll in the system. Consequently, the main roll is squeezed to a smaller size compared with the domain and wanders around in the bulk region irregularly and extensively. This is in sharp contrast to the flow state before the transition, which is featured by a domain-sized circulatory roll with its vortex centre ‘condensed’ near the domain's centre. Detailed velocity field analysis reveals that there exists an abrupt increase in the energy fluctuations of the Fourier modes during the transition. Based on this phase-transition-like signal, the critical condition for the transition is found to follow a scaling relation as $Ra_t \sim Pr^{1.41}$ where $Ra_t$ is the critical Rayleigh number for the transition. This scaling relation is quantitatively explained by a phenomenological model grounded on the bistability behaviour (i.e. spontaneous and stochastic switching between the two flow states) observed at the edge of the transition. The model can also account for the effects of aspect ratio on the transition reported in the literature (van der Poel et al., Phys. Fluids, vol. 24, 2012).
The femtosecond laser filament-induced air laser plays a significant role for the remote sensing of air pollutants. The spatial distributions of air laser intensity were investigated experimentally in previous studies. However, the mechanism of the air laser propagation properties inside the filament plasma has not been quite clear yet. Moreover, few studies have been dedicated to the reproduction of the air laser profile from nitrogen molecules propagating in the filament plasma based on the numerical simulation method. In this study, the lasing action of the air laser from the transition of the first negative (0,0) band of nitrogen ions at 391 nm was simulated during the femtosecond laser filamentation. The beam profile of the air laser changes from a Gaussian or super-Gaussian shape to an outer ring structure by increasing the filament length or nitrogen ion density, which is in accord with the previous experimental result. A multiple-diffraction effect has been proposed to clarify the mechanism of the outer rings beam pattern formation, which is induced by the dynamical interaction between the lasing effect and diffraction effect of the air laser propagating inside the filament plasma. In addition, the amplified air laser power as a function of both the filament length and nitrogen ion density was investigated. Our study would pave the way to improve the energy conversion efficiency and directivity of remote air lasers, which would be significant for remote sensing applications.
We present a systematic study on the effects of small aspect ratios $\varGamma$ on heat transport in liquid metal convection with a Prandtl number of $Pr=0.029$. The study covers $1/20\le \varGamma \le 1$ experimentally and $1/50\le \varGamma \le 1$ numerically, and a Rayleigh number $Ra$ range of $4\times 10^3 \le Ra \le 7\times 10^{9}$. It is found experimentally that the local effective heat transport scaling exponent $\gamma$ changes with both $Ra$ and $\varGamma$, attaining a $\varGamma$-dependent maximum value before transition-to-turbulence and approaches $\gamma =0.25$ in the turbulence state as $Ra$ increases. Just above the onset of convection, Shishkina (Phys. Rev. Fluids, vol 6, 2021, 090502) derived a length scale $\ell =H/(1+1.49\varGamma ^{-2})^{1/3}$. Our numerical study shows $Ra_{\ell }$, i.e. $Ra$ based on $\ell$, serves as a proper control parameter for heat transport above the onset with $Nu-1=0.018(1+0.34/\varGamma ^2)(Ra/Ra_{c,\varGamma }-1)$. Here $Ra_{c,\varGamma }$ represents the $\varGamma$-dependent critical $Ra$ for the onset of convection and $Nu$ is the Nusselt number. In the turbulent state, for a general scaling law of $Nu-1\sim Ra^\alpha$, we propose a length scale $\ell = H/(1+1.49\varGamma ^{-2})^{1/[3(1-\alpha )]}$. In the case of turbulent liquid metal convection with $\alpha =1/4$, our measurement shows that the heat transport will become weakly dependent on $\varGamma$ with $Ra_{\ell }\equiv Ra/(1+1.49\varGamma ^{-2})^{4/3} \ge 7\times 10^5$. Finally, once the flow becomes time-dependent, the growth rate of $Nu$ with $Ra$ declines compared with the linear growth rate in the convection state. A hysteresis is observed in a $\varGamma =1/3$ cell when the flow becomes time-dependent. Measurements of the large-scale circulation suggest the hysteresis is caused by the system switching from a single-roll-mode to a double-roll-mode in an oscillation state.
Pi-d2, which encodes a potential serine-threonine receptor-like kinase (RLK) membrane-spanning protein consisting of 825 amino acids, confers resistance to Magnaporthe oryzae strain ZB15 via an unidentified recognition mechanism. In this study, the Pid2 alleles of 303 rice (O. sativa) varieties from China's Yunnan region were amplified and sequenced in order to produce 24 haplotypes and 16 translation variants. Six of twenty-four alleles possessing the resistant site at the 441st amino acid were chosen for evaluating blast resistance by transforming into the blast-vulnerable rice variety Nipponbare. After being infected with 11 strains of M. oryzae, all transgenic lines exhibited resistance to ZB-15, whereas resistance to other strains varied. Notably, Pi-d2_H23 and Pi-d2_H24 exhibited resistance to all M. oryzae strains tested, indicating that these two alleles may have a broader resistance spectrum to M. oryzae. Alignment of these alleles’ amino acid sequences revealed that the differences in blast resistance spectra were primarily related to the amino acids present in the PAN domain at position 363 (valine/alanine). These findings suggested that the two extracellular signal recognition domains of PI-D2, B-lectin and PAN, may play a role in the identification of M. oryzae effectors. The present results provide insight into the mechanism of interaction between RLKs and M. oryzae.
Using thermal convection in liquid metal, we show that strong spatial confinement not only delays the onset Rayleigh number $Ra_c$ of Rayleigh–Bénard instability but also postpones the various flow-state transitions. The $Ra_c$ and the transition to fully developed turbulence Rayleigh number $Ra_f$ depend on the aspect ratio $\varGamma$ with $Ra_c\sim \varGamma ^{-4.05}$ and $Ra_f\sim \varGamma ^{-3.01}$, implying that the stabilization effects caused by the strong spatial confinement are weaker on the transition to fully developed turbulence when compared with that on the onset. When the flow state is characterized by the supercritical Rayleigh number $Ra/Ra_{c}$ ($Ra$ is the Rayleigh number), our study shows that the transition to fully developed turbulence in strongly confined geometries is advanced. For example, while the flow becomes fully developed turbulence at $Ra\approx 200Ra_c$ in a $\varGamma =1$ cell, the same transition in a $\varGamma =1/20$ cell only requires $Ra\approx 3Ra_c$. Direct numerical simulation and linear stability analysis show that in the strongly confined regime, multiple vertically stacked roll structures appear just above the onset of convection. With an increase of the driving strength, the flow switches between different-roll states stochastically, resulting in no well-defined large-scale coherent flow. Owing to this new mechanism that only exists in systems with $\varGamma <1$, the flow becomes turbulent in a much earlier stage. These findings shed new light on how turbulence is generated in strongly confined geometries.
This experiment was conducted to investigate whether dietary chenodeoxycholic acid (CDCA) could attenuate high-fat (HF) diet-induced growth retardation, lipid accumulation and bile acid (BA) metabolism disorder in the liver of yellow catfish Pelteobagrus fulvidraco. Yellow catfish (initial weight: 4·40 (sem 0·08) g) were fed four diets: the control (105·8 g/kg lipid), HF diet (HF group, 159·6 g/kg lipid), the control supplemented with 0·9 g/kg CDCA (CDCA group) and HF diet supplemented with 0·9 g/kg CDCA (HF + CDCA group). CDCA supplemented in the HF diet significantly improved growth performance and feed utilisation of yellow catfish (P < 0·05). CDCA alleviated HF-induced increment of hepatic lipid and cholesterol contents by down-regulating the expressions of lipogenesis-related genes and proteins and up-regulating the expressions of lipololysis-related genes and proteins. Compared with the control group, CDCA group significantly reduced cholesterol level (P < 0·05). CDCA significantly inhibited BA biosynthesis and changed BA profile by activating farnesoid X receptor (P < 0·05). The contents of CDCA, taurochenodeoxycholic acid and glycochenodeoxycholic acid were significantly increased with the supplementation of CDCA (P < 0·05). HF-induced elevation of cholic acid content was significantly attenuated by the supplementation of CDCA (P < 0·05). Supplementation of CDCA in the control and HF groups could improve the liver antioxidant capacity. This study proved that CDCA could improve growth retardation, lipid accumulation and BA metabolism disorder induced by HF diet, which provided new insight into understanding the physiological functions of BA in fish.
The effects of monolaurin (ML) on the health of piglets infected with porcine epidemic diarrhoea virus (PEDV) have not been fully understood. This study aimed to investigate its role in blood biochemical profile, intestinal barrier function, antioxidant function and the expression of antiviral genes in piglets infected with PEDV. Thirty-two piglets were randomly divided into four groups: control group, ML group, PEDV group and ML + PEDV group. Piglets were orally administrated with ML at a dose of 100 mg/kg·BW for 7 d before PEDV infection. Results showed that PEDV infection significantly decreased D-xylose content and increased intestinal fatty acid-binding protein content, indicating that PEDV infection destroyed intestinal barrier and absorption function. While it could be repaired by ML administration. Moreover, ML administration significantly decreased plasma blood urea nitrogen and total protein content upon PEDV infection. These results suggested ML may increase protein utilisation efficiency. ML administration significantly decreased the number of large unstained cells and Hb and increased the number of leucocytes and eosinophils in the blood of PEDV-infected piglets, indicating ML could improve the immune defense function of the body. In the presence of PEDV infection, ML administration significantly increased superoxide dismutase and catalase activities in blood and colon, respectively, indicating ML could improve antioxidant capacity. Besides, ML administration reversed the expression of ISG15, IFIT3 and IL-29 throughout the small intestine and Mx1 in jejunum and ileum, indicating the body was in recovery from PEDV infection. This study suggests that ML could be used as a kind of feed additive to promote swine health upon PEDV infection.
The relationships between childhood weight self-misperception and obesity-related factors particularly health markers have not been extensively discussed. This study aims to examine the associations between weight self-misperception and obesity-related knowledge, attitudes, lifestyles and cardio-metabolic markers among Chinese paediatric population.
Design:
Cross-sectional study.
Setting:
Data sourced from a national survey in Chinese seven provinces in 2013.
Participants:
Children and adolescents aged 5–19 years.
Results:
Of the total 14 079 participants, there were 14·5 % and 2·2 % participants over-estimated and under-perceived their weight, respectively. Multi-variable logistic regression was applied to calculate OR and 95 % CI (95 % Cl) of obesity-related behaviours and cardio-metabolic markers by actual and perceived weight status. Individuals who perceived themselves as overweight/obese were more likely to have prolonged screen time, insufficient dairy intake and over sugar-sweetened beverages consumption (all P < 0·05), regardless of their weight. Furthermore, actual overweight/obese individuals had higher odds of abnormal cardio-metabolic markers, but a smaller magnitude of association was found among weight under-estimators. Among non-overweight/obese individuals, weight over-estimation was positively associated with abdominal obesity (OR: 10·49, 95 % CI: 7·45, 14·76), elevated blood pressure (OR: 1·30, 95 % CI: 1·12, 1·51) and dyslipidemia (OR: 1·43, 95 % CI: 1·29, 1·58).
Conclusions:
Weight over-perception was more prevalent than under-estimation, particularly in girls. Weight over-estimators tended to master better knowledge but behave more unhealthily; both weight over-perception and actual overweight/obesity status were associated with poorer cardio-metabolic markers. Future obesity intervention programmes should additionally pay attention to the population with inaccurate estimation of weight who were easily overlooked.
Many studies suggest that both psychotherapy and drug therapy are effective in the treatment of bipolar disorders (BDs). However, the pathophysiology of both types of intervention has not been established definitively.
Methods
An activation likelihood estimation meta-analysis was performed to identify the distinct brain activity alterations between psychotherapy and drug therapy for the treatment of BDs. Articles were identified by searching databases including PubMed, Embase, Cochrane Library, and Web of Science databases. Eligible studies on BDs were published up until 10 June 2021.
Results
21 studies were included and we conducted a meta-analysis for different therapies and imaging tasks. After receiving psychotherapy, BD patients showed increased activation in the inferior frontal gyrus (IFG) and superior temporal gyrus. While after taking drug therapy, BD patients displayed increased activation in the anterior cingulate cortex, medial frontal gyrus, IFG, and decreased activation in the posterior cingulate cortex. The regions of brain activity changes caused by psychotherapy were mostly focused on the frontal areas, while drug therapy mainly impacted on the limbic areas. Different type of tasks also affected brain regions which were activated.
Conclusions
Our comprehensive meta-analysis indicates that these two treatments might have effect on BD in their own therapeutic modes. Psychotherapy might have a top-down effect, while drug therapy might have a bottom-up effect. This study may contribute to differential diagnosis of BDs and would be helpful to finding more accurate neuroimaging biomarkers for BD treatment.
We present an experimental study of Rayleigh–Bénard convection using liquid metal alloy gallium-indium-tin as the working fluid with a Prandtl number of $Pr=0.029$. The flow state and the heat transport were measured in a Rayleigh number range of $1.2\times 10^{4} \le Ra \le 1.3\times 10^{7}$. The temperature fluctuation at the cell centre is used as a proxy for the flow state. It is found that, as $Ra$ increases from the lower end of the parameter range, the flow evolves from a convection state to an oscillation state, a chaotic state and finally a turbulent state for $Ra>10^5$. The study suggests that the large-scale circulation in the turbulent state is a residual of the cell structure near the onset of convection, which is in contrast with the case of $Pr\sim 1$, where the cell structure is transiently replaced by high order flow modes before the emergence of the large-scale circulation in the turbulent state. The evolution of the flow state is also reflected by the heat transport characterised by the Nusselt number $Nu$ and the probability density function (p.d.f.) of the temperature fluctuation at the cell centre. It is found that the effective local heat transport scaling exponent $\gamma$, i.e. $Nu\sim Ra^{\gamma }$, changes continuously from $\gamma =0.49$ at $Ra\sim 10^4$ to $\gamma =0.25$ for $Ra>10^6$. Meanwhile, the p.d.f. at the cell centre gradually evolves from a Gaussian-like shape before the transition to turbulence to an exponential-like shape in the turbulent state. For $Ra>10^6$, the flow shows self-similar behaviour, which is revealed by the universal shape of the p.d.f. of the temperature fluctuation at the cell centre and a $Nu=0.19Ra^{0.25}$ scaling for the heat transport.
According to Hamilton's rule, matrilineal-biased investment restrains men in matrilineal societies from maximising their inclusive fitness (the ‘matrilineal puzzle'). A recent hypothesis argues that when women breed communally and share household resources, a man should help his sisters' household, rather than his wife's household, as investment to the later but not the former would be diluted by other unrelated members (Wu et al., 2013). According to this hypothesis, a man is less likely to help on his wife's farm when there are more women reproducing in the wife's household, because on average he would be less related to his wife's household. We used a farm-work observational dataset, that we collected in the matrilineal Mosuo in southwest China, to test this hypothesis. As predicted, high levels of communal breeding by women in his wife's households do predict less effort spent by men on their wife's farm, and communal breeding in men's natal households do not affect whether men help on their natal farms. Thus, communal breeding by women dilutes the inclusive fitness benefits men receive from investment to their wife and children, and may drive the evolution of matrilineal-biased investment by men. These results can help solve the ‘matrilineal puzzle'.
The relationship of a diet low in fibre with mortality has not been evaluated. This study aims to assess the burden of non-communicable chronic diseases (NCD) attributable to a diet low in fibre globally from 1990 to 2019.
Design:
All data were from the Global Burden of Disease (GBD) Study 2019, in which the mortality, disability-adjusted life-years (DALY) and years lived with disability (YLD) were estimated with Bayesian geospatial regression using data at global, regional and country level acquired from an extensively systematic review.
Setting:
All data sourced from the GBD Study 2019.
Participants:
All age groups for both sexes.
Results:
The age-standardised mortality rates (ASMR) declined in most GBD regions; however, in Southern sub-Saharan Africa, the ASMR increased from 4·07 (95 % uncertainty interval (UI) (2·08, 6·34)) to 4·60 (95 % UI (2·59, 6·90)), and in Central sub-Saharan Africa, the ASMR increased from 7·46 (95 % UI (3·64, 11·90)) to 9·34 (95 % UI (4·69, 15·25)). Uptrends were observed in the age-standardised YLD rates attributable to a diet low in fibre in a number of GBD regions. The burden caused by diabetes mellitus increased in Central Asia, Southern sub-Saharan Africa and Eastern Europe.
Conclusions:
The burdens of disease attributable to a diet low in fibre in Southern sub-Saharan Africa and Central sub-Saharan Africa and the age-standardised YLD rates in a number of GBD regions increased from 1990 to 2019. Therefore, greater efforts are needed to reduce the disease burden caused by a diet low in fibre.
Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention.
Methods
360 psychosis patients aged 26–55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years.
Results
Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001–0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004–0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year.
Conclusions
Specialized EI treatment for psychosis patients aged 26–55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.