The Effect of Childhood Poly-Victimization on Adulthood Aggression: The Mediating Role of Different Impulsivity Traits.

This study investigated the effect of the poly-victimization pattern of traumatic childhood experiences on aggression via the impulsivity traits positive urgency, negative urgency, lack of perseverance, lack of premeditation, and sensation-seeking in 102 poly-victims of childhood trauma (71.57% were females; Mage = 35.76; SDage = 15.91). Analyses with poly-victimization as an independent variable, impulsivity traits as parallel mediators, (1) reactive aggression or (2) proactive aggression as dependent variables, and gender as a covariate revealed that the poly-victimization did not have a direct or indirect effect on reactive or proactive aggression, nor did it have an effect on any of the impulsivity traits. Moreover, lack of premeditation had a positive direct effect on reactive aggression, while gender was a significant covariate in both models, with males reporting more aggression than females. Findings suggest that the poly-victimization does not influence impulsivity traits and aggression in adulthood. However, in males, the poly-victimization had a positive and moderate correlation with reactive aggression and negative urgency, while these correlations were absent in females. This finding implies that males are more vulnerable to the adverse effects of childhood poly-victimization than females.

The impact of childhood maltreatment on aggression, criminal risk factors, and treatment trajectories in forensic psychiatric patients.

Introduction: Children's development into healthy well-functioning adults can be negatively affected by adversity. Adverse childhood experiences (ACEs) have been shown to lead to a variety of poor life outcomes, ranging from mental health problems (e.g., anxiety or suicidality) through problematic health behaviors to serious physical diseases and even early death. ACEs can also make people more prone to aggressive behavior, criminality, and recidivism. In this study, we investigated the association between ACEs, specifically childhood maltreatment (CM), and forensically relevant factors; aggression, criminal risk factors, and treatment trajectories, as little is known about these associations in forensic psychiatric patients. Methods: The study includes data derived from two studies in The Netherlands, of which the first study enrolled 128 patients residing in a Forensic Psychiatric Center (FPC) and the second study included 468 patients who were released unconditionally from FPCs between 2009 and 2013. We expected that more CM would be correlated with higher levels of aggression, higher clinical risk factor scores, and less decrease in clinical risk factor scores over time. To investigate this, we applied correlational analyses and linear growth curve modeling on risk assessment scores and self-report as well as staff report questionnaires on CM and aggression. Results: Consistent with our first hypothesis, patients with higher CM scores also had higher aggression and risk assessment scores. The effect sizes were small to medium (0.12 to 0.34). Unexpectedly, CM did not influence the course of these treatment trajectories, however, we found that patients with histories of CM had a significantly longer length of stay in a forensic facility than patients without CM (respectively, 10.8 years and 9.3 years on average). Discussion: This study underlines the importance of carefully examining the history of ACEs and CM in forensic psychiatric patients and considering this in forensic risk assessment and risk guided treatment. More research is needed to draw conclusions about whether and how histories of ACEs should be considered and targeted during treatment trajectories.

Occurrence and localization of FOXP3 + cells in kidney biopsies in lupus nephritis and ANCA-associated vasculitis.

The study aims to increase the understanding regarding the role of regulatory T cells (Tregs) in lupus nephritis (LN) and ANCA-associated vasculitis (AAV) by comparing their localization in renal tissue and changes following immunosuppressive therapy. Kidney biopsies from 12 patients with LN and 7 patients with AAV were examined. Kidney biopsies had been performed both at active disease and following immunosuppressive treatment. Clinical data was collected at both biopsy occasions. Expression of Forkhead Box P 3 (Foxp3) in renal tissue was assessed by immunohistochemistry. An arbitrary scale was used to estimate the number of Foxp3+ cells. In LN, 8/12 (67%) had positive tissue staining for Foxp3 at baseline, most pronounced in inflammatory infiltrates, but also interstitially and in a peri-glomerular pattern. At second biopsies, after immunosuppressive treatment, 4/12 (33%) still had detectable Foxp3+ cells, found in persisting inflammatory infiltrates and some in the interstitium. Patients with a good clinical response to treatment had high grade of Foxp3+ cells in first biopsies. In AAV, only 2/7 (29%) had positive staining for Foxp3 at baseline, in inflammatory infiltrates and to a lesser extent in the interstitium, despite large areas of inflammatory infiltrates in all patients. At follow-up, 2/7 (29%) biopsies were positive for Foxp3. Our data show a higher presence of Foxp3+ cells in renal tissue from LN patients compared to AAV, suggesting that Tregs may be differently involved in the control of inflammatory mechanisms in these diseases. These findings could have further implication for therapeutic approaches aiming at restoring the immunological tolerance. Key Points • Foxp3+-cells are present in larger amount in renal tissue in lupus nephritis vs. ANCA-associated vasculitis. • Our data suggest that Foxp3+ regulatory T cells are involved in the control of inflammatory processes in lupus nephritis.

Verification of the sampling procedure for radioactivity analysis of waste and industrial material.

In accordance with ISO/IEC 17025:2017, the testing laboratory needs to verify its ability to properly perform methods. For radiological testing, the sampling does not affect the results directly, but it has to ensure that sample adequately represents the tested material. To verify the procedure, a sampling of red mud and bauxite ore was conducted. All samples were measured in identical geometry by HPGe spectrometer. The counting rates per unit mass in the recorded spectra were compared. For each measurement series, the mean and standard deviations of respected peaks were calculated, as well as average and standard deviation of all series. The obtained results of each individual series were considered satisfactory, i.e. sampling procedure ensures the representativeness of the bulk material, if it is within ± two standard deviations of the average of the mean values.

Why Are Data Missing in Clinical Data Warehouses? A Simulation Study of How Data Are Processed (and Can Be Lost).

In recent years, the development of clinical data warehouses (CDW) has put Electronic Health Records (EHR) data in the spotlight. More and more innovative technologies for healthcare are based on these EHR data. However, quality assessments on EHR data are fundamental to gain confidence in the performances of new technologies. The infrastructure developed to access EHR data - CDW - can affect EHR data quality but its impact is difficult to measure. We conducted a simulation on the Assistance Publique - Hôpitaux de Paris (AP-HP) infrastructure to assess how a study on breast cancer care pathways could be affected by the complexity of the data flows between the AP-HP Hospital Information System, the CDW, and the analysis platform. A model of the data flows was developed. We retraced the flows of specific data elements for a simulated cohort of 1,000 patients. We estimated that 756 [743;770] and 423 [367;483] patients had all the data elements necessary to reconstruct the care pathway in the analysis platform in the "best case" scenarios (losses affect the same patients) and in a random distribution scenario (losses affect patients at random), respectively.

Distribution of Natural Radionuclides and 137Cs in Urban Soil Samples from the City of Novi Sad, Serbia-Radiological Risk Assessment.

This work presents the natural radioactivity distribution of 21 surface soil samples taken in the city of Novi Sad, Serbia. The analysis for radioactivity was performed using a gas low-level proportional counter for gross alpha and gross beta activity, while the specific activities of radionuclides were determined using HPGe detectors. The gross alpha activity of 20 samples was below the minimum detectable concentration (MDC), while in 1 sample it was 243 Bq kg-1; the gross beta activity ranged from the MDC (11 samples) to 566 Bq kg-1. The gamma spectrometry measurements showed naturally occurring radionuclides 226Ra, 232Th, 40K, and 238U in all investigated samples, with average values (Bq kg-1) of 33.9, 36.7, 513.8, and 34.7, respectively. Natural radionuclide 235U was detected in 18 samples with activity concentrations in the range of 1.3-4.1 Bq kg-1, while in the other 3 samples, the values were below the MDC. The artificial 137Cs radionuclide was detected in 90 percent of the samples, with a maximum value of 21 Bq kg-1, while the other artificial radionuclides were not detected. Based on the obtained concentrations of natural radionuclides, hazard indexes were estimated, and radiological health risk was assessed. The results present the absorbed gamma dose rate in the air, annual effective dose, radium equivalent activity, external hazard index, and lifetime cancer risk.

"In conferences, everyone goes 'health data is the future' ": an interview study on challenges in re-using EHR data for research in Clinical Data Warehouses.

More and more hospital Clinical Data Warehouses (CDWs) are developed to gain access to EHR data. The rapid growth of investments in CDWs suggest a real potential for innovation in healthcare. However, it is still not confirmed that CDWs will deliver on their promises as researchers working with CDWs face many challenges. To gain a better understanding of these challenges and how to overcome them, we conducted a series of semi-structured interviews with EHR data experts. In this article, we share some initial results from the ongoing interview study. Two main themes emerged from the analysis of the transcripts of the interviews: the importance of infrastructures in terms of data and how it is generated, and the difficulty to make care, clinical research, and data science work together. Finally, based on the experts' experience, several recommendations were identified when using a CDW.

Does sports participation affect the mediating role of impulsivity in the association between adverse childhood experiences and aggression?

Introduction: Adverse childhood experiences (ACEs) and self-reported aggression have often been associated, however, the mediating and moderating mechanisms underlying this association are not fully understood. In addition, less is known about potential factors that could serve as protection against the development of aggressive behavior. In this study, we investigated a moderated mediation model of sports participation and five impulsivity traits including positive and negative urgency, sensation seeking, and lack of premeditation and perseverance, in the association between ACEs and two forms of aggression. Methods and results: The sample comprised 651 (68.5% females) individuals from a Dutch community ranging in age from 18 to 82 years (M = 34.08). Contrary to our expectations, sports participation did not affect the associations of ACEs, the five impulsivity traits, and reactive and proactive aggression, except the association between ACEs and lack of premeditation. Specifically, the detrimental effect of ACEs on the propensity to act without thinking, increases among individuals with lower levels of sports participation. In addition, it was also found that sports participation directly contributed to higher levels of sensation seeking. Finally, after controlling for sociodemographic variables, the positive association between ACEs and reactive aggression was significantly mediated by negative urgency, lack of perseverance, and lack of premeditation, while the positive association between ACEs and proactive aggression was significantly mediated by lack of premeditation and positive urgency. Conclusion: The findings of this study add to the body of knowledge about the role of sports participation and impulsivity traits in the development of both forms of aggression, however, replication studies among multiple populations are needed before firm conclusions can be drawn.

Violent Recidivism and Adverse Childhood Experiences in Forensic Psychiatric Patients With Impaired Intellectual Functioning.

Accurate risk assessment and insight into which factors are associated with recidivism are essential for forensic correctional practice. Therefore, we investigated whether the Historical, Clinical, and Future-Revised (HKT-R [Historisch Klinisch Toekomst-Revised]) risk assessment instrument could predict violent recidivism over a 2-year follow-up period in forensic psychiatric patients with intelligence quotient (IQ) < 80. We refer to these patients as intellectually disabled (ID) and patients with IQ ≥ 80 as non-ID. Additionally, the associations of the 14 clinical HKT-R factors with ID versus non-ID group membership were investigated, as well as a possible moderating role of adverse childhood experiences (ACE) in these associations. The final sample encompassed 748 forensic psychiatric patients (15.9% were patients with ID) who were unconditionally released from highly secured Dutch forensic psychiatric institutions between 2004 and 2014. The results showed that the HKT-R total score (AUC = 0.705, 95% confidence interval [CI] [0.527, 0.882]) and the clinical domain (AUC = 0.733, 95% CI [0.579, 0.886]) had a large effect size for predictive validity for 2-year violent recidivism, while the future domain (AUC = 0.653, 95% CI [0.524, 0.781]) and the historical domain (AUC = 0.585, 95% CI [0.397, 0.772]) had a medium effect size for predictive validity for 2-year violent recidivism in ID patients. It was also found that lower levels of self-reliance and social skills were associated with ID, indicating that treatment should prioritize these skills. However, ACE was not associated with ID, nor did it moderate the associations of the clinical HKT-R factors with ID. This study contributes to the understanding of both risk assessment and treatment of forensic psychiatric patients with ID.

The Moderating Roles of Resilience and Coping Strategy on Well-Being of Victimized Forensic Workers.

Previous research on workplace victimization has often disregarded forensic psychiatric populations and not yet been extended to the coronavirus pandemic. The present study expected the isolation of the government-issued lockdown to increase aggressive behavior in forensic patients, ultimately decreasing the general well-being of victimized forensic workers. Possible buffering protective factors (resilience and active coping) and enhancing risk factors (avoidant coping and passive coping) were investigated with the intention of optimizing the general well-being of at-risk forensic workers. The valid sample (N = 311) consisted of Dutch and Belgian forensic workers (74.6% females) with at least 9 hours of weekly patient contact, and with a mean age of 37.99 (SD = 12.20). Participants reported the number of violent incidents in the past 2 months, as well as completed a questionnaire battery including measures of well-being, resilience, and coping strategies. A significant increase of victimization during the lockdown compared to after it was lifted was found, however, the study did not find evidence to support that this negatively influenced the worker's general well-being. Active coping was found to be a significant moderator and protective factor for the general well-being of victimized forensic workers. In contrast, resilience, avoidant and passive coping were not significant moderators in this association. The present study has valuable clinical implications that could lead to preparatory and preventative measures for forensic workers at risk of being victimized. Future research may investigate constructs such as life satisfaction and post-traumatic growth, as well as be broadened into prison populations.

The Role of Dynamic Risk and Protective Factors in Predicting Violent Recidivism: Intellectual Ability as a Possible Moderator?

This study investigated which risk and protective factors, based on the 14 clinical indicators of the Historical-Clinical-Future Revised, significantly predicted violent recidivism in a sample of 315 male forensic psychiatric patients. Additionally, it was investigated whether these associations were moderated by intellectual ability. Regarding risk factors, a stronger influence of risky network members, and higher levels of hostility, impulsivity, and addiction significantly predicted violent recidivism. Likewise, regarding protective factors, poorer social and labor skills, and a lower degree of patient's acceptance of crime responsibility were significant predictors of violent recidivism. Contrary to our expectations, better coping skills and more insight into risky behaviors that can lead to relapse also contributed significantly to an increased likelihood of violent recidivism. Intellectual ability had no significant moderating effect on the associations between the factors and violent recidivism. The results offer an insight into which factors need to be prioritized during treatment.

The Long-Term Changes in Dynamic Risk and Protective Factors Over Time in a Nationwide Sample of Dutch Forensic Psychiatric Patients.

The long-term changes of dynamic risk and protective factors have rarely been studied in forensic psychiatric patients. We utilized a latent growth curve analysis to investigate trajectories of risk and protective factors over time in all 722 male forensic psychiatric patients who were unconditionally released between 2004 and 2014 from any of 12 Dutch forensic psychiatric centers (FPCs). The study covered the period from juridical observation until unconditional release. Moreover, we investigated whether these trajectories differ between patients depending on their psychiatric diagnosis namely substance use disorders (SUD), psychotic disorders, and cluster B personality disorders (PDs). In addition, we also investigated whether SUD may influence changes in risk and protective factors in a group of psychotic and cluster B PDs patients, respectively. Overall, findings suggest that all changes in dynamic risk and protective factors could be depicted by two phases of patients' stay in the FPCs. Specifically, most changes on dynamic risk and protective factors occurred at the beginning of treatment, that is, from the time of juridical assessment up to the time of unguided leave. Moreover, the moment of unguided leave could be considered the 'turning point' in the treatment of offenders. We also found that SUD and psychotic patients changed the most in the first phase of their stay, while cluster B PDs patients changed the most in the second phase. However, SUD did not modify changes in risk and protective factors in psychotic and cluster B PDs patients. These findings may help improve offender treatment and crime prevention strategies.

A Latent Class Analysis of Forensic Psychiatric Patients in Relation to Risk and Protective Factors.

Forensic psychiatric patients form a very heterogeneous population regarding psychopathology, criminal history, and risk factors for reoffending. Therefore, the present study aimed to investigate whether there are more homogeneous classes of forensic patients based on DSM-IV-TR Axis I and II diagnoses and previously committed offenses, by means of explorative latent class analysis (LCA). It was also investigated which risk and protective factors are significantly more prevalent in one class compared to other classes. The study sample contained 722 male forensic psychiatric patients who were unconditionally released between 2004 and 2014 from high-security forensic clinics. Data were retrospectively derived from electronic patient files. Five distinctive patient classes emerged: class with only Axis II diagnosis, class with multiple problems, antisocial class, psychotic class, and intellectually disabled class. These classes differed significantly in risk and protective factors. This study contributes to the understanding of patient classes and provides directions for future, class-tailored interventions.

Associations Between Resilience, Psychological Well-Being, Work-Related Stress and Covid-19 Fear in Forensic Healthcare Workers Using a Network Analysis.

Forensic healthcare workers deal with patients with severe psychiatric and behavioral problems that put them at an increased risk of developing work-related stress and burnout. Working with this target group of patients during the Coronavirus disease 2019 (Covid-19) pandemic with far-reaching restrictive measures can negatively affect the psychological well-being of forensic workers. Research suggests that resilience can buffer workplace stress and contribute positively to psychological well-being. However, research on resilience, psychological well-being and work-related stress among forensic healthcare workers is still lacking. Therefore, in this study, we investigated the interrelations between psychological well-being and resilience on the one hand and work-related stress and Covid-19 fear-related symptoms on the other hand. Self-report data were obtained from 318 healthcare workers (73.9% women) working in three Forensic Psychiatric Centers (M age = 44.20, SD = 14.31) and are in direct contact with forensic patients. The data were analyzed using network analysis. Consistent with previous research, the results showed that workplace stress and fear associated with the Covid-19 pandemic can be detrimental to workers' psychological well-being, while resilience can serve as a protective factor against being personally attacked or threatened by patients at the workplace. Last but not least, we identified highly central symptoms, namely tremors due to the fear of the coronavirus and anxiety when other people coughing, which would be the best candidates for future treatment targets. This knowledge can help clinicians optimize interventions to reduce workplace stress and fear due to the pandemic. Future studies should aim to replicate our findings in a larger and more representative sample of forensic healthcare workers.

The Complex Associations Between Early Childhood Adversity, Heart Rate Variability, Cluster B Personality Disorders, and Aggression.

Early childhood adversity can cause an imbalance in the autonomic function, which may in turn lead to the development of trauma-spectrum disorders and aggressive behavior later in life. In the present study, we investigated the complex associations between early adversity, heart rate variability (HRV), cluster B personality disorders, and self-reported aggressive behavior in a group of 50 male forensic inpatients (M age = 41.16; SD = 10.72). Structural Equation Modeling analysis revealed that patients with cluster B personality disorders were more likely to have adverse early childhood experiences and reduced sympathetic dominance in response to a threat than patients without cluster B personality disorders. In addition, HRV and cluster B personality disorders did not significantly mediate the association between early childhood adversity and self-reported aggressive behavior. These findings are important for clinical practice to facilitate specific treatment programs for those affected.

Investigating the Interaction between Energy Consumption, Quality of Service, Reliability, Security, and Maintainability of Computer Systems and Networks.

The Conference on Energy Consumption, Quality of Service, Reliability, Security, and Maintainability of Computer Systems and Networks (EQSEM) was held as a virtual conference on October 20-21, 2020. This paper summarises the objectives and proceedings of this conference. It then briefly presents the keynotes and other papers which were presented. Then, in the context of the EU-funded research project SDK4ED which motivated this conference, we outline several solutions that are being developed for managing the potential inter-dependencies and corresponding trade-offs between design-time and runtime qualities in software applications, and review the key functionalities that have been implemented within the SDK4ED integrated platform as of this writing. Then, we briefly introduce four papers among those presented at the EQSEM Conference that are included in this issue of the journal SN Computer Science, presenting relevant research achievements of the SDK4ED Project on software maintainability, reliability, and energy efficiency.

Individual Differences in Cross-System Physiological Activity at Rest and in Response to Acute Social Stress.

OBJECTIVE: Individual differences in long-term cardiovascular disease risk are related to physiological responses to psychological stress. However, little is known about specific physiological response profiles in young adults that may set the stage for long-term increased cardiovascular disease risk. We investigated individual differences in profiles of resting cardiovascular physiology and stress reactivity, combining parasympathetic, sympathetic, and hemodynamic measures. METHODS: Participants (n = 744, 71% women, mean [standard deviation] age = 20.1 [2.4] years) underwent the Trier Social Stress Test, while blood pressure (systolic blood pressure, diastolic blood pressure), electrocardiograms (interbeat interval), and impedance cardiograms (preejection period, left ventricular ejection time) were recorded. Respiratory sinus arrhythmia was derived from the combination of the electrocardiogram and the impedance cardiogram. A three-step latent profile analysis (LPA) was performed on resting and reactivity values to derive clusters of individual physiological profiles. We also explored demographic and health behavioral correlates of the observed latent clusters. RESULTS: For resting physiology, LPA revealed five different resting physiology profiles, which were related to sex, usual physical activity levels, and body mass index. Five cardiovascular stress reactivity profiles were identified: a reciprocal/moderate stress response (Cr1; 29%), and clusters characterized by high blood pressure reactivity (Cr2: 22%), high vagal withdrawal (Cr3; 22%), autonomic coactivation (parasympathetic nervous system and sympathetic nervous system; Cr4; 13%), and overall high reactivity (Cr5; 12%). Men were more likely to belong to the high reactivity (Cr5) cluster, whereas women were more likely to have autonomic coactivation (Cr4). CONCLUSIONS: We identified five cardiovascular physiological reactivity profiles, with individuals displaying generalized hyperreactivity, predominant vagal withdrawal, autonomic coactivation, or blood pressure-specific hyperreactivity. Longitudinal studies are needed to determine whether these profiles are useful in early detection of individuals at high risk for cardiovascular disease.

A process modelling approach to assess the impact of teledermatology deployment onto the skin tumor care pathway.

BACKGROUND: Teledermatology was raised as a potential answer to increase access and decrease delay for skin cancer management. However, its influence on non-melanoma skin cancer (NMSC) care pathway has never been studied. OBJECTIVES: To compare conventional care pathway to teledermatology (TD) in NMSC care pathways using a process modelling approach. PATIENTS AND METHODS: A period study including three groups was conducted in a department of dermatology. During the first period from January till February 2013 a NMSC care pathway was mapped for a group a prior TD integration. During the second period from September 2016 till October 2018, the NMSC care pathway was determined for patients managed by a conventional care process and after TD diagnosis. Patients characteristics, type of tumors and processes were compared using time as a key performance indicator. Mean were reported with their ± SD. Linear regression was performed using time between multidisciplinary consultation and surgery as outcome adjusted on sex, age and cancer type. RESULTS: During the first period (prior to TD) 89 NMSC patients were managed (mean age = 76 yr old ± 13) during the second period, 36 patients NMSC were managed after TD, mean age of 89 years old ± 6 and 954 patients in a conventional process, mean age of 78 years old ±12. In comparison between the two periods patient's age, sex and cancer distribution significantly differed while the rate of surgery was not significantly different (p = 0.967). Linear multivariate regression using time between multidisciplinary consultation and surgery as outcome adjusted on sex age and cancer type displayed that during the second period patients in the TD group spent 17.6 days more [0.98,34.25] while patient in the conventional care process group had 9.8 days [1.85,17.74] more than patient in the study period 1, (p = 0.04, p = 0.02) without significant difference for age and sex (p = 0.29, p = 0.51). Patients with a SCC had a decreased time between multidisciplinary consultation and surgery of -12.97 days [-17.43, -8.5], p < 10-3. CONCLUSION: Interestingly, patients managed by TD were significantly older than those managed using a conventional care pathway. Unexpectedly their total time spent in the process was not shorter. The results of this analysis illustrated the interest of using process modelling approach to assess the impact of a healthcare innovation integration and to further rethink coordination and care pathways for NSMC post TD.

Management and Marketing in Health Institutions.

In the last decades radical changes in the health care market have happened. Customers continuously require a higher level of quality of service and they become more careful and demanding in the decision process, market intelligence is continuously growing, competition and quality of services are dramatically increasing, as well as the external influences of various lobbyists in many parts of the world. Also, it is important to mention the fact that there are many initiatives for change in many branches of health care delivery, as well as many innovative models for providing health services that change the traditional role of healthcare institutions. In these conditions in order to be competitive on the global market and to create satisfied and loyal consumers of health services, health institutions need to introduce a marketing management concept which is completely in accordance with actual trends on the global market as well as needs and demands of services consumers.

Longitudinal Network Structure and Changes of Clinical Risk and Protective Factors in a Nationwide Sample of Forensic Psychiatric Patients.

In this study, we investigated network configurations of 14 Clinical risk and protective factors in a sample of 317 male forensic psychiatric patients across two time points: at the time of admission to the forensic psychiatric centers (T1) and at the time of unconditional release (T2). In terms of network structure, the strongest risk edge was between "hostility-violation of terms" at T1, and between "hostility-impulsivity" at T2. "Problem insight-crime responsibility" was the strongest protective edge, and "impulsivity-coping skills" was the strongest between-cluster edge, at both time points, respectively. In terms of strength centrality, "cooperation with treatment" had the highest strength centrality at both measurement occasions. This study expands the risk assessment field toward a better understanding of dynamic relationships between individual clinical risk and protective factors and points to the highly central risk and protective factors, which would be the best for future treatment targets.