Eficacia de una intervención digital compleja en la ganancia ponderal gestacional y la actividad física en gestantes con obesidad

[spa] INTRODUCCIÓN: La obesidad durante el embarazo es un problema de salud pública en nuestra sociedad. Las gestantes con obesidad y ganancia excesiva de peso gestacional tienen mayor riesgo de presentar complicaciones maternas y perinatales. El uso de Apps móviles y pulsera durante el embarazo puede contribuir a promover estilos de vida saludables y, por tanto, mejorar la salud materna y neonatal. OBJETIVOS: Evaluar la efectividad de una intervención digital compleja, en gestantes con obesidad, con el uso de una pulsera de actividad física y la provisión de consejos de salud y soporte virtual de una matrona a través de una APP, respecto a la ganancia ponderal gestacional, la actividad física, los hábitos alimentarios; así como analizar su impacto en los resultados maternos y perinatales. Además, se estudió la frecuencia de uso, la usabilidad y la satisfacción con las Apps móviles utilizadas por las mujeres del grupo de intervención. MÉTODOS: Se realizó un ensayo clínico paralelo aleatorizado con dos brazos 1:1 con grupo intervención (GI) y grupo control (GC). Se incluyeron 150 gestantes con obesidad preconcepcional. El grupo de intervención recibió una intervención digital compleja “Pas & Pes” que consistía en el uso de una pulsera de actividad (Mi band 2© y Mi Fit©) y la recepción de consejos de salud mediante una App, y el soporte virtual de una matrona (Hangouts©), además del control prenatal habitual. El grupo control recibió solo el control prenatal habitual. Se utilizaron las versiones validadas en español del “International Physical Activity Questionnaire Short Form”, la “System Usability Scale” y el “Cuestionario de hábitos alimentarios para pacientes con sobrepeso y obesidad”. La satisfacción se midió en una escala tipo Likert de 1 a 5 puntos. Las pruebas estadísticas fueron bilaterales y se evaluaron a un nivel α de 0,05. Los análisis se realizaron con SPSS v. 25 y SAS v. 9,4. RESULTADOS: Se analizaron un total de 137 gestantes (91,3% del total). La ganancia ponderal gestacional mediana en el grupo de intervención fue de 7,0 kg (Q1=3,8-Q3=11) frente a 9,5 kg (Q1=6-Q3=14) en el grupo control, (p=0,014). La ganancia ponderal gestacional media ajustada por semana fue de 0,5 kg/semana [intervalo de confianza (IC) del 95 %=-0,2 a -0,05] en el grupo de control y de 0,3 kg/semana (IC 95 %=0,2 a 0,4) en el grupo intervención (p=0,002). En el tiempo 1 (35-37 semanas de gestación), las mujeres del grupo de intervención tuvieron una mediana más alta de actividad física que las mujeres del grupo de control, 1.950 frente a 1.386 múltiplo de la tasa de gasto metabólico-min/semana (MET-min/sem) (p=0,007), respectivamente. En el grupo intervención la puntuación media de los hábitos alimentarios fue mayor que en el grupo control [(3,51 ± 0,37) versus (3,33 ± 0,40) puntos; (p=0,009)]. No se observaron diferencias entre los grupos de estudio en la incidencia de resultados maternos y perinatales. Respecto a la intervención digital, el 61% (36) de las gestantes utilizó la pulsera de actividad a diario y la usabilidad de la App Mi Fit© fue valorada como excelente por el 74,6% (44). Todas las mujeres del grupo de intervención utilizaban la aplicación Hangouts© al menos una vez a la semana. La media de la escala de satisfacción con la App de consejos de salud y el apoyo de la matrona virtual fue de 4,8 ± 0,6 sobre 5 puntos. CONCLUSIONES: El uso de una intervención digital compleja mostró ser efectiva en una menor ganancia ponderal gestacional, en un aumento de la actividad física y en la mejora de los hábitos alimentarios. No se hallaron diferencias en las complicaciones perinatales maternas entre ambos grupos. La satisfacción con la intervención y la usabilidad de la App fue muy elevada.[eng] BACKGROUND: Obesity during pregnancy is a public health problem in our society. Pregnant women with obesity and excessive gestational weight gain (GWG) present a higher risk of maternal and perinatal complications. The use of mobile Apps and a wristband during pregnancy may contribute to promoting healthy lifestyles and, thus, improving maternal and neonatal health. OBJECTIVE: To evaluate the effectiveness of a complex digital intervention, using a smartband and an App for health advice with virtual midwife’ counselling, on gestational weight gain, physical activity and eating habits. The secondary objectives are to assess the impact of these interventions on maternal and perinatal outcomes and identify the frequency of use, usability and satisfaction with the mobile Apps used by the women in the intervention group. METHODS: A randomized parallel clinical trial with two arms in a 1:1 ratio with intervention group (IG) and control group (CG) was conducted. 150 pregnant women with pre-pregnancy obesity were included. The intervention group received a complex digital intervention called Pas & Pes. The intervention was delivered with a smartband (Mi band 2© and Mi Fit©) linked to an App with the virtual midwife to provide personal health information (Hangouts©), and also the standard prenatal care. The control group only received standard control prenatal care. The validated Spanish versions of the International Physical Activity Questionnaire Short Form, the System Usability Scale and the Questionnaire of eating habits for patients with overweight and obesity were used. Satisfaction was measured on a 1-5 points Likert scale. Statistical tests were two-sided and evaluated at an α level of 0.05. Analyzes were performed using SPSS v. 25 and SAS v. 9.4. RESULTS: 137 (91.3% of the total) women were analyzed. The mean gestational weight gain in the intervention group was 7.0 kg (Q1=3.8-Q3=11) versus 9.5 kg (Q1=6-Q3=14) in the control group, p=0.014. The adjusted mean gestational weight gain per week was 0.5 kg/week (95% confidence interval [CI]=-0.2 to -0.05) in the control group and 0.3 kg/week (95% CI=0.2 to 0.4) in the intervention group (p= 0.002). In time 1 (35-37 gestational weeks), women in the intervention group had a higher mean physical activity than women in the control group (1,950 metabolic equivalent of tasks [METs]-min/week vs. 1,386 METs/min-week (p=0.007), respectively. The mean score for eating habits was higher in the IG than in the CG [(3.51 ± 0.37) versus (3.33 ± 0.40) points; p=0.009]. No differences were observed between the study groups in the incidence of maternal and perinatal outcomes. In the intervention group, 61% (36) of the pregnant women used the smartband daily, and 74.6% (44) evaluated the usability of the Mi Fit© App as excellent. All women in the intervention group used the Hangouts© App at least once a week. The mean of the satisfaction scale with the health counselling App and virtual midwife support was 4.8 ± 0.6/5 points. CONCLUSIONS: The use of a complex digital intervention was effective in a lower gestational weight gain, in an increase in physical activity and in the improvement of eating habits. No differences were found in maternal perinatal complications between study groups. Satisfaction with the intervention and the usability of the App was very high

How has the announcement of the Covid-19 pandemic and vaccine impacted the market?

As COVID-19 has hit the whole world hard, finding a vaccine that alleviates its effects has been one of the most anticipated events in 2020. This work studies the impact of the two main events in 2020 on companies’ stock exchange activities: announcing COVID19 as a world pandemic and announcing the first coronavirus vaccine. This study was carried out by an event study methodology using Nasdaq-100 data. Ordinary Least Squares (OLS) and quantile (Q) regression were used to obtain the returns expected from shares and to assess if there were any significant differences in the reactions of the analysed sectors on the market in each event window. The obtained empirical results show different share performances by sectors. Specifically, only those shares from the technology sector positively and significantly reacted to the first announcement. However, the opposite can be stated of the second event insofar as confidence in financial markets recovered to a greater extent in the sectors hardest hit by the first announcement. These conclusions are meaningful for companies, investors and governments to make better decisions or to adopt new policies

Percepciones sobre el uso de la aplicación Microsoft Teams en la docencia: Perspectiva de los docentes y de los estudiantes

[EN] As a consequence of the Covid-19 pandemic, at the Polytechnic University of Valencia (UPV) a synchronous non-face-to-face teaching model was implemented through the Microsoft Teams application in the second semester of the 2019/20 academic year. In the first semester of the 2020/21 academic year, a hybrid teaching model, also guided with this application prevailed. The objective of this work is to comprehend how teachers and students perceived and experienced the integration of the Microsoft Teams application in teaching, especially to find out its effectiveness as a teaching tool. The results shown that teachers experienced concerns with the implementation of Teams in teaching, although it mostly ceased, and they also consider that both hybrid and synchronous non-face-to-face teaching using Teams are effective in the teaching process, but not so much in the learning process. However, students stated that the traditional teaching model is more effective than a hybrid teaching employing the Microsoft Teams application.[ES] Como consecuencia de la pandemia del Covid-19, en la Universitat Politècnica de València (UPV) se implantó un modelo docente no presencial síncrono a través de la aplicación Microsoft Teams en el segundo cuatrimestre del curso 2019/20. En el primer cuatrimestre del curso 2020/21 predominó un modelo docente híbrido guiado también con dicha aplicación. El objetivo de este trabajo es conocer la percepción, tanto de los docentes como de los estudiantes, sobre la incorporación de la aplicación Microsoft Teams en la docencia, especialmente para averiguar si éstos la consideran una herramienta eficaz. Los resultados sobre la percepción de los docentes concluyen que, éstos sintieron una preocupación con la incorporación del Teams en la docencia, aunque ésta mayoritariamente desapareció, y también consideran que, tanto la docencia híbrida como la no presencial síncrona impartidas con el Teams son eficaces en el proceso de enseñanza, pero no tanto en el proceso de aprendizaje. Sin embargo, desde el punto de vista de los estudiantes, estos consideran más efectiva la docencia tradicional que la híbrida a través de la aplicación Microsoft Teams.Alcaide González, MÁ.; Poza Plaza, EDL. (2021). Percepciones sobre el uso de la aplicación Microsoft Teams en la docencia: Perspectiva de los docentes y de los estudiantes. En IN-RED 2021: VII Congreso de Innovación Edicativa y Docencia en Red. Editorial Universitat Politècnica de València. 950-961. https://doi.org/10.4995/INRED2021.2021.13711OCS95096

Analysis of thermal resistance in exterior walls in five locations based on concrete incorporating waste

El objetivo de este trabajo es exponer los resultados de la aplicación de las Normas IRAM de Acondicionamiento Térmico de Edificios y Etiqueta de Eficiencia Energética de Calefacción en el análisis de muros de bloques y placas de hormigón con material reciclado aptos para uso en emprendimientos sociales y generación de empleos verdes. El análisis se realiza con un software para el cálculo de Transmitancia Térmica, cuyos valores determinan el Nivel de Etiquetado de Eficiencia Energética. Se propusieron 5 sectores del país, geográficamente distantes, de manera de obtener resultados que contemplaran situaciones extremas de temperaturas. La intención es obtener la mejor alternativa constructiva que alcance el nivel de Eficiencia Energética A, además se plantea un promedio entre el nivel aceptable (B) y el nivel óptimo (A), determinando una situación intermedia de espesor de aislación, siendo ésta la variable a modificar, respondiendo a requerimientos económicos posibles de inversión en la construcción.The aim of this paper is to present the results of the application of IRAM thermal conditioning of Buildings and Energy Efficiency Label Heating in analyzing concrete block and boards walls with recycled material suitable for use in social entrepreneurship and generation of green jobs. The analysis is performed with software for calculating thermal transmittance, whose values determine the level of energy efficiency labeling. 5 sectors of the country, geographically distant, in order to get results that contemplate temperature extremes were proposed. The intention is to obtain the best constructive alternative to reach the level of Energy Efficiency In addition an average between the acceptable level (B) and the optimal level (A) arises, determining an intermediate status of insulation thickness, this being the variable to change, responding to potential economic investment requirements in construction.Eje: Materiales y técnicas de construcción sustentable (actas).Facultad de Arquitectura y Urbanism

Post-fire Management Effects on Sediment (Dis)Connectivity in Mediterranean Forest Ecosystems: Channel and Catchment Response

[Abstract] Forest fires and post-fire practices influence sediment connectivity (SC). In this study, we use the ‘aggregated index of connectivity’ (AIC) to assess SC in five Mediterranean catchments (198–1090 ha) affected by a wildfire in 2012 in south-eastern Spain. Two temporal scenarios were considered, immediately after the fire and before post-fire management, and 2 years after the fire including all practices (hillslope barriers, check-dams, afforestation, salvage logging and skid trails). One LiDAR (light detection and ranging)-derived digital elevation model (DEM, 2 m × 2 m resolution) was generated, per scenario. The five catchment outlets were established as the computation target (AICоᴜᴛ), and structural and functional SC were calculated. Index outputs were normalized to make the results of the non-nested catchments comparable (AICɴ₋оᴜᴛ). The output analysis includes the SC distribution along the catchments and at local scale (929 sub-catchments, 677 in the burned area), the hillslope and channel measures' effect on SC, and a sedimentological analysis using observed area-specific sediment yield (SSY) at 10 new (built after post-fire practices) concrete check-dams located in the catchments (SSY = 1.94 Mg ha⁻¹ yr⁻¹; σ = 1.22). The catchments with more circular shapes and steeper slopes were those with higher AICɴ₋оᴜᴛ. The structural SC maps – removing the rainfall erosivity influence – allowed evaluating the actual role played by the post-fire practices that reduced SC (x̅ = − 1.19%; σ = 0.41); while functional SC was linked to the actual change of SC (x̅ = + 5.32%; σ = 0.62). Hillslope treatments resulted in significant changes on AICɴ₋оᴜᴛ at sub-catchment scale with certain disconnectivity. A good and positive correlation was found between the SSY and the changes of AICɴ₋оᴜᴛ. However, the coarse DEM resolution explained the lack of effect of the rock check-dams – located on the secondary channels – on AICɴ₋оᴜᴛ. AICɴ₋оᴜᴛ proved to be a useful tool for decision making in post-fire restoration, but an optimal input data is still necessary to refine calculations.European Cooperation in Science and Technology; CA18135Gobierno de Castilla-la Mancha; Sbply/16/180501/ 000109This study was supported by funds provided to the VIS4FIRE Spanish R&D project (RTA2017-00042-C05-00) co-funded by the “Instituto Nacional de Investigación y Tecnología Agraria” (INIA) and FEDER programme. This study was done in the frame of the European Cooperation in Science and Technology (COST) action CA18135 ‘FIRElinks’ (Fire in the Earth System:Science & Society). J. González-Romero holds a scholarship (Sbply/16/180501/000109) from the Regional Government of Castilla-La Mancha/European Social Fund (ESF, EU)

Quality More Than Quantity: The Use of Carbohydrates in High-Fat Diets to Tackle Obesity in Growing Rats

This research was supported by funds provided by the Abbott Laboratories S.A.Childhood obesity prevention is important to avoid obesity and its comorbidities into adulthood. Although the energy density of food has been considered a main obesogenic factor, a focus on food quality rather that the quantity of the different macronutrients is needed. Therefore, this study investigates the effects of changing the quality of carbohydrates from rapidly to slowly digestible carbohydrates on metabolic abnormalities and its impact on obesity in growing rats fed a high-fat diet (HFD). Growing rats were fed on HFD containing carbohydrates with different digestion rates: a HFD containing rapid-digesting carbohydrates (OBE group) or slow-digesting carbohydrates (ISR group), for 4 weeks and the effect on the metabolism and signaling pathways were analyzed in different tissues. Animals from OBE group presented an overweight/obese phenotype with a higher body weight gain and greater accumulation of fat in adipose tissue and liver. This state was associated with an increase of HOMA index, serum diacylglycerols and triacylglycerides, insulin, leptin, and pro-inflammatory cytokines. In contrast, the change of carbohydrate profile in the diet to one based on slow digestible prevented the obesity-related adverse effects. In adipose tissue, GLUT4 was increased and UCPs and PPARg were decreased in ISR group respect to OBE group. In liver, GLUT2, FAS, and SRBP1 were lower in ISR group than OBE group. In muscle, an increase of glycogen, GLUT4, AMPK, and Akt were observed in comparison to OBE group. In conclusion, this study demonstrates that the replacement of rapidly digestible carbohydrates for slowly digestible carbohydrates within a highfat diet promoted a protective effect against the development of obesity and its associated comorbidities.Abbott Laboratories S.A

Post-fire Management Effects on Hillslope-Stream Sediment Connectivity in a Mediterranean Forest Ecosystem

[Abstract] Forest fires intensify sediment transport and aggravate local and off-site consequences of soil erosion. This study evaluates the influence of post-fire measures on structural and functional sediment connectivity (SC) in five fire-affected Mediterranean catchments, which include 929 sub-catchments, by using the “aggregated index of connectivity” (AIC) at two temporal scenarios: I) immediately after the fire and before implementing post-fire practices (‘Pre-man’), and II) two years after the fire (‘Post-man’). The latter includes all the emergency stabilization practices, that are hillslope barriers, check-dams and afforestation. The stream system was set as the target of the computation (STR), to be representative of intense rainfall-runoff events with effective sediment delivery outside the catchments. Output normalization (AICN) allows comparing the results of the five basins between them. The sedimentological analysis is based on specific sediment yield (SSY) –measured at the check-dams installed after the fire –, and this data is used for output evaluation. Stream density and slope variables were the most influential factors on AICN-STR results at the sub-catchment scale. Post-fire hillslope treatments (barriers when built in high densities and afforestation) significantly reduced AICN-STR in comparison with untreated areas in both structural and functional approaches. Despite the presence of hillslope treatments, the higher erosive rainfall conditions resulted in higher AICN-STR values in the Post-man scenario (functional approach). A positive and good correlation was found between the measured SSY and the AICN-STR changes due to the post-fire practices and vegetation recovery, showing the good correspondence of the computation results and the real sediment dynamics of the studied catchments. Overall, AICN demonstrated to be a useful and versatile tool for post-fire management, which needs further research to optimize its applicability.The authors thank the Regional Government of Castilla-La Mancha (Junta de Comunidades de Castilla-La Mancha) for supporting the study and providing information about the undertaken measures in the burned area. This study was supported by funds provided to the VIS4FIRE Spanish R&D project (RTA 2017-00042-C05-00) co-funded by the “Instituto Nacional de Investigación y Tecnología Agraria” (INIA) and FEDER programme. This study was done in the frame of the European Cooperation in Science and Technology (COST) action CA18135 ‘FIRElinks’ (Fire in the Earth System: Science & Society). J. González-Romero holds a postdoctoral contract supported by the European Social Fund (ESF, EU). The authors declare no conflict of interest. E. Peña holds a scholarship (2020-PREUCLM-16032) from the UCLM and the European Social Fund (FSE). Pedro Antonio Plaza Álvarez holds a predoctoral fellowship from the Spanish Ministry of Education, Culture and Sport (FPU16/03296)Universidad de Castilla-La Mancha; 2020-PREUCLM-1603

Historia y pensamiento en torno al género

Presentación. Montserrat Huguet y Carmen González Marín(Universidad Carlos III de Madrid.).- I. HISTORIA. La polifacética imagen de las mujeres en la Unión Soviética en los años veinte y treinta, Laura Branciforte (Universidad Carlos III de Madrid).- Ellas y el mundo. Documentando el tiempo, Montserrat Huguet (Universidad Carlos III de Madrid).- Emilia sale de su jardín: la silenciosa conquista del espacio público por las artistas de la casa, Laura Sanz (Universidad Carlos III de Madrid).- María Victoria del Pozzo, una italiana en el trono español, Carmen Bolaños Mejías (Universidad Nacional de Educación a Distancia).- Representaciones de la madre: la madre de Woody Allen, la de Philip Roth, incluso la de Otto Weinenger (la madre judía), Maya Siminovich (Grupo Kóre de Estudios de Género).- II. PENSAMIENTO. Violencia de género y la hipótesis de la violencia anómica, Carlos Thiebaut(Universidad Carlos III de Madrid).- La construcción política de las identidades: un alerta de género, María Luisa Femenías (Universidad Nacional de La Plata).- Los accidentes del espacio público, Carmen González Marín (Universidad Carlos III de Madrid).- More equal than others. Igualdad y diferencia en la teoría de género, Rocío Orsi Portalo (Universidad Carlos III de Madrid).- Nombrar lo innombrable. La autorrepresentación lingüística de grupos gays no convencionales, Alberto Bustos Plaza (Universidad de Extremadura).- Sobre el género gramatical y sus implicaciones sociológicas, M.ª Elena Azofra Sierra (Universidad Carlos III de Madrid

Inflammation-related molecules in tears of patients with chronic ocular pain and dry eye disease

Producción CientíficaThe purpose of this study was to analyze inflammation- and pain-related molecules in tears of patients suffering from chronic ocular pain associated with dry eye (DE) and/or a previous corneal refractive surgery (RS). Based on history, symptomatology, and clinical signs, the subjects (n = 180, 51.0 ± 14.7 years, 118 females, 62 males) in this cross-sectional study were assigned to one of five groups: DE and chronic ocular pain after RS (P/DE-RS, n = 52); asymptomatic subjects, i.e., without DE and chronic ocular pain, after RS (A-RS, n = 30); DE and chronic ocular pain without previous RS (P/DE-nonRS, n = 31); DE, no pain, and no previous RS (DE-nonRS, n = 35); and asymptomatic subjects with no previous RS (controls, n = 32). The tear concentrations of 20 cytokines and substance P (SP) were analyzed by immunobead-based assay and enzyme-linked immunosorbent assay, respectively. We found that tear levels of interleukin (IL)-10 and SP were increased in the RS groups. There were significant differences in IL-8/CXCL8 among the five groups. Nerve growth factor (NGF) tear levels were significantly higher in P/DE-RS than in DE-nonRS and controls. IL-9 had the highest percentage of detection in the P/DE-RS and P/DE-nonRS groups, while macrophage inflammatory protein (MIP)-1α, IL-2, and interferon (IFN)-γ were higher in the P/DE-RS, A-RS, and P/DE-nonRS groups. IL-17A was detected only in the A-RS group. Moderate correlations were observed in the A-RS, P/DE-nonRS, DE-nonRS and controls groups. A positive correlation was obtained between growth related oncogene concentration and tear break-up time (rho = 0.550; p = 0.012), while negative correlation was found between monocyte chemoattractant protein-3/CCL7 and conjunctival staining (rho = −0.560; p = 0.001), both in the A-RS group. IL-10 correlated positively with ocular pain intensity (rho = 0.513; p = 0.003) in the P/DE-nonRS group. Regulated on Activation Normal T Cell Expressed and Secreted/CCL5 correlated negatively with conjunctival staining (rho = −0.545; p = 0.001) in the DE-nonRS group. SP correlated negatively with corneal staining (rho = −0.559; p = 0.001) in the controls. In conclusion, chronic ocular pain was associated with higher IL-9 tear levels. IL-10, SP, MIP-1α/CCL3, IL-2, and IFN-γ were associated with previous RS. Higher levels of IL-8/CXCL8, MIP-1α/CCL3, IL-2, and IFN-γ were associated with DE-related inflammation, while NGF levels were related to chronic ocular pain and DE in RS patients. These findings suggest that improved knowledge of tear cytokines and neuromodulators will lead to a more nuanced understanding of how these molecules can serve as biomarkers of chronic ocular pain, leading to better therapeutic and disease management decisions.Ministerio de Ciencia, Innovación y Universidades (grants SAF-2016-77080-P, FPU17/02715 and FPU15/01443

LDL particle size and composition and incident cardiovascular disease in a South-European population: The Hortega-Liposcale Follow-up Study.

The association of low-density lipoprotein (LDL) particle composition with cardiovascular risk has not been explored before. The aim was to evaluate the relationship between baseline LDL particle size and composition (proportions of large, medium and small LDL particles over their sum expressed as small-LDL %, medium-LDL % and large-LDL %) and incident cardiovascular disease in a population-based study. Methods: Direct measurement of LDL particles was performed using a two-dimensional NMR-technique (Liposcale®). LDL cholesterol was assessed using both standard photometrical methods and the Liposcale® technique in a representative sample of 1162 adult men and women from Spain. Results: The geometric mean of total LDL particle concentration in the study sample was 827.2 mg/dL (95% CI 814.7, 839.8). During a mean follow-up of 12.4 ± 3.3 years, a total of 159 events occurred. Medium LDL particles were positively associated with all cardiovascular disease, coronary heart disease (CHD) and stroke after adjustment for traditional risk factors and treatment. Regarding LDL particle composition, the multivariable adjusted hazard ratios for CHD for a 5% increase in medium and small LDL % by a corresponding decrease of large LDL % were 1.93 (1.55, 2.39) and 1.41 (1.14, 1.74), respectively. Conclusions: Medium LDL particles were associated with incident cardiovascular disease. LDL particles showed the strongest association with cardiovascular events when the particle composition, rather than the total concentration, was investigated. A change in baseline composition of LDL particles from large to medium and small LDL particles was associated with an increased cardiovascular risk, especially for CHD