Risk factors for development of incipient and overt diabetic nephropathy in patients with non-insulin dependent diabetes mellitus: prospective,observational study.

OBJECTIVE: To evaluate putative risk factors for the development of incipient diabetic nephropathy (persistent microalbuminuria) and overt diabetic nephropathy (persistent macroalbuminuria) in patients with non-insulin dependent diabetes. DESIGN: Prospective, observational study of a cohort of white, non-insulin dependent diabetic patients followed for a median period of 5.8 years. SETTING: Outpatient clinic in tertiary referral centre. SUBJECTS: 191 patients aged under 66 years with non-insulin dependent diabetes and normoalbuminuria (urinary albumin excretion rate < 30 mg/24 h) who attended the clinic during 1987. MAIN OUTCOME MEASURES: Incipient and overt diabetic nephropathy. RESULTS: Fifteen patients were lost to follow up. Thirty six of the 176 remaining developed persistent microalbuminuria (30-299 mg/24 h in two out of three consecutive 24 hour urine collections) and five developed persistent macroalbuminuria (> or = mg/24 h in two out of three consecutive collections) during follow up. The five year cumulative incidence of incipient diabetic nephropathy was 23% (95% confidence interval 17% to 30%). Cox''s multiple stepwise regression analysis revealed the following risk factors for the development of incipient or overt diabetic nephropathy: increased baseline log urinary albumin excretion rate (relative risk 11.1 (3.4 to 35.9); P < 0.0001); male sex (2.6 (1.2 to 5.4); P < 0.02); presence of retinopathy (2.4 (1.3 to 4.7); P < 0.01); increased serum cholesterol concentration (1.4 (1.1 to 1.7); P < 0.01); haemoglobin A1c concentration (1.2 (1.0 to 1.4); P < 0.05); and age (1.07 (1.02 to 1.12); P < 0.01). Known duration of diabetes, body mass index, arterial blood pressure, serum creatinine concentration, pre-existing coronary heart disease, and history of smoking were not risk factors. CONCLUSION: Several potentially modifiable risk factors predict the development of incipient and overt diabetic nephropathy in normoalbuminuric patients with non-insulin dependent diabetes.     

Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

Background:Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability.Methods:We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity.Results:Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19–1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14–2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability.Interpretation:Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

A successful public health response to the COVID-19 pandemic requires accurate and timely identification of, and support for, high-risk groups. There is increasing recognition that marginalized groups, including congregate care residents, racial and ethnic minorities, and people experiencing poverty, have elevated incidence of COVID-19.^1,2 Older age and comorbidities such as diabetes are also risk factors for severe COVID-19 outcomes.^3,4 One potential high-risk group that has received relatively little attention is people with disabilities.The World Health Organization estimates there are 1 billion people with disabilities globally.⁵ In North America, the prevalence of disability is 20%, with one-third of people older than 65 years having a disability.⁶ Disabilities include physical disabilities, hearing and vision impairments, traumatic brain injury and intellectual or developmental disabilities.^5,6 Although activity limitations experienced by people with disabilities are heterogeneous,^5,6 people with disabilities share high rates of risk factors for acquiring COVID-19, including poverty, residence in congregate care and being members of racialized communities.^7–9 People with disabilities may be more reliant on close contact with others to meet their daily needs, and some people with disabilities, especially intellectual developmental disabilities, may have difficulty following public health rules. Once they acquire SARS-CoV-2 infection, people with disabilities may be at risk for severe outcomes because they have elevated rates of comorbidities.¹⁰ Some disabilities (e.g., spinal cord injuries and neurologic disabilities) result in physiologic changes that increase vulnerability to respiratory diseases and may mask symptoms of acute respiratory disease, which may delay diagnosis.^11–13 There have also been reports of barriers to high-quality hospital care for patients with disabilities who have COVID-19, including communication issues caused by the use of masks and restricted access to support persons.^14–17Some studies have suggested that patients with disabilities and COVID-19 are at elevated risk for severe disease and death, with most evaluating intellectual or developmental disability.^13,18–26 Yet, consideration of disability-related needs has largely been absent from the COVID-19 response, with vaccine eligibility driven primarily by age and medical comorbidity, limited accommodations made for patients with disabilities who are in hospital, and disability data often not being captured in surveillance programs.^14–17 To inform equitable pandemic supports, there is a need for data on patients with a broad range of disabilities who have COVID-19. We sought to evaluate standard clinical outcomes in patients admitted to hospital with COVID-19²⁷ (i.e., in-hospital death, intensive care unit [ICU] admission, hospital length of stay and unplanned 30-d readmission) for patients with and without a disability, overall and stratified by age. We hypothesized that patients with a disability would have worse outcomes because of a greater prevalence of comorbidities,¹⁰ physiologic characteristics that increase morbidity risk^11–13 and barriers to high-quality hospital care.^14–17     

Cardiovascular risk reduction over time in patients with diabetes or pre-diabetes undergoing bariatric surgery: data from a single-center retrospective observational study

Background

Bariatric surgery is effective in remission of obesity comorbidities. This study was aimed at comparing CVD risk between morbidly obese patients with type 2 diabetes and pre-diabetes before and after bariatric surgery as well as assessing comorbidities.

Methods

This is a retrospective observational study with 105 patients with type 2 diabetes (DMbaseline) and prediabetes (preDMbaseline) who underwent Roux-en-Y gastric bypass. Data were collected preoperative and then at 3,6,12,18,24,36,48, and 60?months after surgery. Anthropometric, cardiovascular and glycemic parameters were assessed. CVD risk was calculated using the Framingham Risk Score.

Results

Prior to surgery, 48 patients had type 2 diabetes, while 57 had pre-diabetes. Mean age was 48 (9.2) and mean BMI was 52 (7.4). 26.1% of patients had a high CVD risk. CVD risk decreased in patients with type 2 diabetes and prediabetes at month 12 after surgery compared to the baseline risk (p?<?0.001). BMI, body fat percentage, fasting plasma glucose, HbA1c, c-peptide, HOMA-IR, LDL-c, systolic blood pressure, and diastolic blood pressure decreased during the first year after surgery. From the 12th month until the 60th, they showed a flat trend, or a very mild increase in some cases. 3.2% of patients maintained high CVD risk at 60?months. Type 2 diabetes remission was 92%. No patient of the preDMbaseline group developed type 2 diabetes.

Conclusion

Bariatric surgery reduces CVD risk in type 2 diabetes and pre-diabetes. Given that patients with type 2 diabetes benefit the most, more studies are necessary to consider pre-diabetes as a criterion for metabolic surgery in patients with BMI?≥?35?kg/m².

     

Risk factors for mortality in end-stage kidney disease patients under online-hemodiafiltration: three-year follow-up study

The aim of this work was to evaluate the predictors of mortality in a group of end-stage kidney disease (ESRD) patients under dialysis, by performing a three-year follow-up study. From the 236 patients included in this study, 54 patients died during the three-year follow-up period. Our data showed that the risk of death was higher in patients presenting lower levels of mean cell hemoglobin concentration, transferrin, and albumin. Our study showed that poor nutritional status and an inflammatory-induced iron depleted erythropoiesis are important factors for mortality in these patients.     

Risk factors for cardiovascular mortality in patients with systemic lupus erythematosus,a prospective cohort study

Introduction

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Cardiovascular disease (CVD) is common and a major cause of mortality. Studies on cardiovascular morbidity are abundant, whereas mortality studies focusing on cardiovascular outcomes are scarce. The aim of this study was to investigate causes of death and baseline predictors of overall (OM), non-vascular (N-VM), and specifically cardiovascular (CVM) mortality in SLE, and to evaluate systematic coronary risk evaluation (SCORE).

Methods

208 SLE patients were included 1995-1999 and followed up after 12 years. Clinical evaluation, CVD risk factors, and biomarkers were recorded at inclusion. Death certificates and autopsy protocols were collected. Causes of death were divided into CVM (ischemic vascular and general atherosclerotic diseases), N-VM and death due to pulmonary hypertension. Predictors of mortality were investigated using multivariable Cox regression. SCORE and standardized mortality ratio (SMR) were calculated.

Results

During follow-up 42 patients died at mean age of 62 years. SMR 2.4 (CI 1.7-3.0). 48% of deaths were caused by CVM. SCORE underestimated CVM but not to a significant level. Age, high cystatin C levels and established arterial disease were the strongest predictors for all- cause mortality. After adjusting for these in multivariable analyses, only smoking among traditional risk factors, and high soluble vascular cell adhesion molecule-1 (sVCAM-1), high sensitivity C-reactive protein (hsCRP), anti-beta2 glycoprotein-1 (abeta2GP1) and any antiphospholipid antibody (aPL) among biomarkers, remained predictive of CVM.

Conclusion

With the exception of smoking, traditional risk factors do not capture the main underlying risk factors for CVM in SLE. Rather, cystatin C levels, inflammatory and endothelial markers, and antiphospholipid antibodies (aPL) differentiate patients with favorable versus severe cardiovascular prognosis. Our results suggest that these new biomarkers are useful in evaluating the future risk of cardiovascular mortality in SLE patients.     

Risk factors for preeclampsia in women from Colombia: a case-control study

Background

Preeclampsia (PE) is a multi-causal disease characterized by the development of hypertension and proteinuria in the second half of pregnancy. Multiple risk factors have been associated with the development of PE. Moreover, it is known that these risk factors vary between populations from developed and developing countries. The aim of this study is to identify which risk factors are associated with the development of preeclampsia (PE) among Colombian women.

Methods

A multi-centre case-control study was conducted between September 2006 and July 2009 in six Colombian cities. Cases included women with PE (n = 201); controls were aged-matched pregnant women (n = 201) without cardiovascular or endocrine diseases for a case-control ratio of 1∶1. A complete medical chart, physical examination and biochemical analysis were completed before delivery. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) of potential risk factors associated with PE.

Results

The presence of factors present in the metabolic syndrome cluster such as body mass index >31 Kg/m2 (OR = 2.18; 1.14–4.14 95% CI), high-density lipoprotein <1.24 mmol/L (OR = 2.42; 1.53–3.84 95% CI), triglycerides >3.24 mmol/L (OR = 1.60; 1.04–2.48 95% CI) and glycemia >4.9 mmol/L (OR = 2.66; 1.47–4.81 95%CI) as well as being primigravidae (OR = 1.71; 1.07–2.73 95% CI) were associated with the development of PE, after adjusting for other variables.

Conclusion

Factors present in the cluster of metabolic syndrome and primigravidity were associated with a greater risk of PE among Colombian women. Understanding the role of this cluster of risk factors in the development of PE is of crucial importance to prevent PE and remains to be determined.     

Risk factors for benign breast disease: a 30-year cohort study.

Data on the menstrual history, family history and degree of obesity of 1374 Vancouver nursing students were collected in 1945 and from 1947 to 1956. In 1979, 768 of these women were located; 726 (94%) responded and participated in a follow-up study, providing information on their subsequent medical history and on breast-related problems. No major differences were found between the early histories of these participants and those who were not located or did not respond. Among the respondents 215 gave a history of symptoms compatible with benign breast disease; in 107 this diagnosis was confirmed by biopsy. By age 50 the cumulative risk for benign breast disease was 17% for biopsied and 31% for symptomatic disease. Biopsied benign breast disease was associated with premenstrual breast discomfort, irregular menses, a history of abortions, a family history of both benign and malignant breast disease, lack of use of oral contraceptives, a low index of obesity and small breasts, obesity and breast size being independent. Factors associated with symptomatic benign breast disease were usually associated with a greater likelihood of biopsy for symptomatic disease; hence, the relative risks for biopsied disease were generally greater than those for symptomatic disease. Although the risk factors for benign breast disease differ from those for breast cancer, the findings are consistent with the hypothesis of excessive circulating estrogen.     

Fellowship training,workload, fatigue and physical stress: a prospective observational study

BackgroundFatigue in physician trainees may compromise patient safety and the well-being of the trainees and limit the educational opportunities provided by training programs. Anecdotal evidence suggests that the on-call workload and physical demands experienced by trainees are significant despite duty-hour regulation and support from nursing staff, other trainees and staff physicians.MethodsWe measured the workload and the level of fatigue and physical stress of 11 senior fellows during 35 shifts in the critical care unit at the Hospital for Sick Children in Toronto. We determined number of rostered hours, number of admissions and discharges, number and type of procedures, nurse:patient ratios and related measures of workload. Fellows self-reported the number of pages they received and the amount of time they slept. We estimated physical stress by using a commercially available pedometer to measure the distance walked, by using ambulatory electrocardiographic monitoring to determine arrhythmias and by determining urine specific gravity and ketone levels to estimate hydration.ResultsThe number of rostered hours were within current Ontario guidelines. The mean shift duration was 25.5 hours (range 24–27 hours). The fellows worked on average 69 hours (range 55–106) per week. On average during a shift, the fellows received 41 pages, were on non-sleeping breaks for 1.2 hours, slept 1.9 hours and walked 6.3 km. Ketonuria was found in participants in 7 (21%) of the 33 shifts during which it was measured. Arrhythmia (1 atrial, 1 ventricular) or heart rate abnormalities occurred in all 6 participants. These fellows were the most senior in-house physician for a mean of 9.4 hours per shift and were responsible for performing invasive procedures in two-thirds of their shifts.InterpretationEstablished Canadian and proposed American guidelines expose trainees to significant on-call workload, physical stress and sleep deprivation.Recognition that clinician fatigue may promote ineffective care and lead to adverse patient outcomes^1,2,3 has provided a compelling rationale for the enforcement of resident duty-hour guidelines. Although these guidelines permit trainees to work more hours — both continuously and cumulatively — than other nonphysician groups,² they represent an effort to reduce physician work hours and promote patient safety.The current Professional Association of Internes and Residents of Ontario–Ontario Council of Teaching Hospitals (PAIRO–OCOTH) agreement⁴ has been in place since July 2000. This agreement limits residents to a maximum of 7 in-house on-call periods of up to 24 hours (plus a handover period) in 28 days. Call periods are nonconsecutive, should not include more than 2 weekend days in the 28-day cycle and are followed by “relief of service until the next working day.”The PAIRO–OCOTH agreement also requires the provision of sleeping facilities — implicitly suggesting that on-call trainees may rest during in-house call. Rest may mitigate the effects of long duty hours.² However, experience suggests that on-call shifts are physically demanding and that opportunities for rest and sleep are limited.⁵Although recognition of the relation between trainee duty-hours and fatigue and patient and physician safety is increasing,^2,5,6 direct assessment of workload, physical stress and the impact of staff and junior physician support has been limited. To evaluate the work environment of trainees, we conducted a prospective study in the critical care unit of a university-affiliated tertiary care centre.     

Tuberculous meningitis in children: a retrospective study of 79 patients,with an analysis of prognostic factors.

A study of 79 cases of tuberculous meningitis in children, with an emphasis on prognostic factors, was conducted by means of a review of hospital records and completion of a follow-up questionnaire. The survival rate was 62%. Stage 3 disease (with severe changes in the sensorium and often severe neurologic abnormalities) at the time of admission, age 3 years or less, associated miliary tuberculosis and delay in the initiation of therapy correlated significantly with poor outcome. Severe neurologic complications in the acute phase were also related to poor outcome and severe sequelae. General recommendations pertaining to treatment are made.     

Comparison of cancer incidence among patients with rheumatic disease: a retrospective cohort study

Introduction

Rheumatic diseases (RDs) are associated with different cancers; however, it is unclear whether particular cancers are more prevalent in certain RDs. In the present study, we examined the relative incidence of several cancers in a single homogeneous cohort of patients with different RDs.

Methods

Patients (N = 3,586) diagnosed with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), dermatomyositis (DM) or polymyositis were included. Cancer diagnosis was based on histopathology. The 2008 Korean National Cancer Registry served as the reference for calculating standardized incidence ratios (SIRs).

Results

During the follow-up period of 31,064 person-years, 187 patients developed cancer. RA and SLE patients showed an increased risk of non-Hodgkin’s lymphoma (SIR for RA patients = 3.387, 95% confidence interval (CI) = 1.462 to 6.673; SIR for SLE patients = 7.408, 95% CI = 2.405 to 17.287). SLE patients also had a higher risk of cervical cancer (SIR = 4.282, 95% CI = 1.722 to 8.824). SSc patients showed a higher risk of lung cancer (SIR = 4.917, 95% CI = 1.977 to 10.131). Endometrial cancer was increased only in patients with DM (SIR = 30.529, 95% CI = 3.697 to 110.283). RA patients had a lower risk for gastric cancer (SIR = 0.663, 95% CI = 0.327 to 0.998). The mean time between the RD and cancer diagnoses ranged from 0.1 to 16.6 years, with the shortest time observed in patients with DM (2.0 ± 2.1 years).

Conclusions

Different RDs are associated with particular cancers. Thus, cancer surveillance tailored to specific RDs might be beneficial.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-014-0428-x) contains supplementary material, which is available to authorized users.     

Association of dietary risks,behavioural and lifestyle factors,and the magnitude of disability burden among Australian cancer patients: An observational epidemiology study

BackgroundCancer patients are confronted with a variety of other health-related issues, including physical disability, poor quality of life, and psychological challenges. This study aims to quantify the association of dietary, behavioural and lifestyle risk factors and comorbidities on the magnitude and distribution of disability burden among cancer patients in Australia.MethodsThis study comprised a sample of 2283 cancer patients drawn from the latest nationwide Australian National Health Survey conducted in 2017–18. Negative binomial regression models were used to estimate the incidence rate ratio (IRR) of the number of disabilities and its associations.ResultsForty-five percent of cancer patients experienced at least one disability. The magnitude of disability was significantly associated with sugar-sweetened drink consumption ≥ 3 days per week (IRR= 1.12, 95% CI: 1.02–1.26), a lack of physical activity (IRR = 1.69, 1.38–2.07), frequent or regular alcohol consumption (IRR = 1.95, 1.84–2.08), poor health status (IRR = 1.99, 1.78–2.24) and the presence of five or more chronic comorbid conditions (IRR = 3.59, 2.90–4.46). Cancer patients who consumed vegetables at least two or more times per day had a 10% lower risk of disability burden (IRR = 0.90, 0.82–0.99).ConclusionsThis study shows the association of diet, behavioural, and lifestyle risk factors on the degree of disability burden among cancer patients, highlighting the need for bold and effective policies. The findings will inform the implementation of evidence-based lifestyle interventions and offer a foundation for evaluating their influence on cancer survivors’ health.     

Evidence of compliance with and effectiveness of guidelines for noninvasive prenatal testing in China: a retrospective study of 189,809 cases

In China,the medical guidelines recommend performing noninvasive prenatal testing (NIPT) with caution for pregnant women aged 35 years or older.However,the Mother and Child Health Care Law suggests that all primiparous women whose age is older than 35 years undergo prenatal diagnosis.These two inconsistent suggestions/recommendations have made obstetricians confused about whether to offer NIPT to these older pregnant women.To face this issue and find out the solution we performed a retrospective study of 189,809 NIPT samples collected from 28 provincial-leveled administrative units in China.Of 1,564women with high-risk pregnancies who underwent NIPT,459 (29.3%) did not participate in follow-up.The compound sensitivity and specificity of NIPT for trisomies 21,18 and 13 detection was 99.1%(95%CI,98.0%-99.6%) and 99.9%(95%CI,98.8%-99.9%),respectively.In secundiparous women,NIPT showed high sensitivity and specificity similar to that in primiparous women.The observed risk for trisomies 21 and 18 significantly increased when the maternal age was 39 and older.After the publication of the current NIPT policy,the follow-up rate at our center was 97.9%;however,a large number of women are not in maternal and infant care networks nationwide,and that makes the follow-up rate outside our center relatively low.Our study shows that to balance the prevention of major aneuploidies and the limited resources for prenatal diagnosis,the cut-off age of 35for invasive prenatal diagnosis might be unnecessary.Although the NIPT guidelines are well written,how to practice it effectively,especially in less industrialized areas,is worth discussing.     

Plasma CC16 levels are associated with development of ALI/ARDS in patients with ventilator-associated pneumonia: a retrospective observational study

Background

Asthma is a difficult diagnosis to establish in preschool children. A few years ago, our group presented a prediction rule for young children at risk for asthma in general practice. Before this prediction rule can safely be used in practice, cross-validation is required. In addition, general practitioners face many therapeutic management decisions in children at risk for asthma. The objectives of the study are: (1) identification of predictors for asthma in preschool children at risk for asthma with the aim of cross-validating an earlier derived prediction rule; (2) compare the effects of different treatment strategies in preschool children.

Design

In this prospective cohort study one to five year old children at risk of developing asthma were selected from general practices. At risk was defined as 'visited the general practitioner with recurrent coughing (≥ 2 visits), wheezing (≥ 1) or shortness of breath (≥ 1) in the previous 12 months'. All children in this prospective cohort study will be followed until the age of six. For our prediction rule, demographic data, data with respect to clinical history and additional tests (specific immunoglobulin E (IgE), fractional exhaled nitric oxide (FENO), peak expiratory flow (PEF)) are collected. History of airway specific medication use, symptom severity and health-related quality of life (QoL) are collected to estimate the effect of different treatment intensities (as expressed in GINA levels) using recently developed statistical techniques. In total, 1,938 children at risk of asthma were selected from general practice and 771 children (40%) were enrolled. At the time of writing, follow-up for all 5-year olds and the majority of the 4-year olds is complete. The total and specific IgE measurements at baseline were carried out by 87% of the children. Response rates to the repeated questionnaires varied from 93% at baseline to 73% after 18 months follow-up; 89% and 87% performed PEF and FENO measurements, respectively.

Discussion

In this study a prediction rule for asthma in young children, to be used in (general) practice, will be cross-validated. Our study will also provide more insight in the effect of treatment of asthma in preschool children.     

Prophylaxis for Pneumocystis pneumonia in patients with rheumatoid arthritis treated with biologics,based on risk factors found in a retrospective study

Introduction

Pneumocystis pneumonia (PCP) is one of the most prevalent opportunistic infections in patients undergoing immunosuppressive therapy. In this article, we discuss risk factors for PCP development in patients with rheumatoid arthritis (RA) during the course of biologic therapy and describe a prophylactic treatment for PCP with trimethoprim/sulfamethoxazole (TMP/SMX). We also evaluate the effectiveness and safety of the treatment.

Methods

We retrospectively analyzed 702 RA patients who received biologic therapy and compared the characteristics of patients with vs. without PCP to identify the risk factors for PCP. Accordingly, we analyzed 214 patients who received the TMP/SMX biologic agents as prophylaxis against PCP at the start of treatment to evaluate their effectiveness and safety.

Results

We identified the following as risk factors for PCP: age at least 65 years (hazard ratio (HR) = 4.37, 95% confidence interval (CI) = 1.04 to 18.2), coexisting pulmonary disease (HR = 8.13, 95% CI = 1.63 to 40.0), and use of glucocorticoids (HR = 11.4, 95% CI = 1.38 to 90.9). We employed a protocol whereby patients with two or three risk factors for PCP would receive prophylactic treatment. In the study with 214 patients, there were no cases of PCP, and the incidence of PCP was reduced to 0.00 per 100 person-years compared with that before the procedure (0.93 per 100 person-years). There were no severe adverse events induced by the TMP/SMX treatment.

Conclusions

RA patients with two or three risk factors for PCP who are receiving biologic therapy can benefit from safe primary prophylaxis.     

Risk factors analysis for neglected human rickettsioses in rural communities in Nan province,Thailand: A community-based observational study along a landscape gradient

In this study, we estimated exposure for Scrub typhus (STG), Typhus (TG) and Spotted fever groups (SFG) rickettsia using serology at a fine scale (a whole sub-district administration level) of local communities in Nan Province, Thailand. Geographical characteristics of the sub-district were divided into two landscape types: lowland agricultural area in an urbanized setting (lowland-urbanized area) and upland agricultural area located close to a protected area of National Park (upland-forested area). This provided an ideal contrast between the two landscapes with low and high levels of human-altered habitats to study in differences in disease ecology. In total, 824 serum samples of participants residing in the eight villages were tested by screening IgG ELISA, and subsequently confirmed by the gold standard IgG Immunofluorescent Assay (IFA). STG and TG IgG positivity were highest with seroprevalence of 9.8% and 9.0%, respectively; whereas SFG positivity was lower at 6.9%. Inhabitants from the villages located in upland-forested area demonstrated significantly higher STG exposure, compared to those villages in the lowland-urbanized area (chi-square = 51.97, p < 0.0001). In contrast, TG exposure was significantly higher in those villagers living in lowland-urbanized area (chi-square = 28.26, p < 0.0001). In addition to the effect of landscape types, generalized linear model (GLM) analysis identified socio-demographic parameters, i.e., gender, occupation, age, educational level, domestic animal ownership (dog, cattle and poultry) as influential factors to explain the level of rickettsial exposure (antibody titers) in the communities. Our findings raise the public health awareness of rickettsiosis as a cause of undiagnosed febrile illness in the communities.     

Effect and safety of Chinese herbal medicine granules in patients with severe coronavirus disease 2019 in Wuhan,China: a retrospective,single-center study with propensity score matching

BackgroundChinese herbal medicine (CHM) has been used for severe illness caused by coronavirus disease 2019 (COVID-19), but its treatment effects and safety are unclear.PurposeThis study reviews the effect and safety of CHM granules in the treatment of patients with severe COVID-19.MethodsWe conducteda single-center, retrospective study on patients with severe COVID-19 in a designated hospital in Wuhan from January 15, 2020 to March 30, 2020. The propensity score matching (PSM) was used to assess the effect and safety of the treatment using CHM granules. The ratio of patients who received treatment with CHM granules combined with usual care and those who received usual care alone was 1:1. The primary outcome was the time to clinical improvement within 28 days, defined as the time taken for the patients’ health to show improvement by decline of two categories (from the baseline) on a modified six-category ordinal scale, or to be dischargedfrom the hospital before Day 28.ResultsUsing PSM, 43 patients (45% male) aged 65.6 (57–70) yearsfrom each group were exactly matched. No significant difference was observed in clinical improvement of patients treated with CHM granules compared with those who received usual (p = 0.851). However, the use of CHM granules reduced the 28-day mortality (p = 0.049) and shortened the duration of fever (4 days vs. 7 days, p = 0.002). The differences in the duration of cough and dyspnea and the difference in lung lesion ratio on computerized tomography scans were not significant.Commonly,patients in the CHM group had an increased D-dimer level (p = 0.036).ConclusionForpatients with severe COVID-19, CHM granules, combined with usual care, showed no improvement beyond usual care alone. However, the use of CHM granules reduced the 28-day mortality rate and the time to fever alleviation. Nevertheless, CHM granules may be associated with high risk of fibrinolysis.     

Risk factors of recurrence in small-sized, node negative breast cancer in young women: a retrospective study in Chinese population

We aimed to investigate risk factors of local and distant recurrence in small-sized, node negative breast cancer in women <35 years in a Chinese cohort. Between January 1994 and January 2007, 107 patients with pathologically confirmed small-sized (?1 cm), node negative breast cancer who did not receive neoadjuvant or adjuvant chemotherapy were included. The 5-year recurrence-free survival (RFS) was estimated according to different prognostic variables. With a median time of 60 months (range, 8–60 months) follow-up, local and distant recurrence were observed in 25 cases (23.4%). By univariate analysis, HER-2 positivity, triple negative (TN), and high Ki-67 index (?14%) were risk factors of a lower RFS (hazard ratio (HR) 6.680, 95% confidence interval (CI) 2.350–18.985, P<0.0001 for HER-2 positive; HR 4.769, 95%CI 1.559–14.591, P=0.006 for TN; HR 6.030, 95%CI 2.659–13.674, P<0.0001 for high Ki-67 index). Patients with grade 3 tumors had a lower RFS (HR 2.922, 95%CI 1.096–7.791, P=0.032) compared with those with grade 1 or grade 2 tumors. By multivariate analysis, HER-2 positivity (HR 10.204, 95%CI 3.391–30.704, P<0.0001), TN (HR 10.521, 95% CI 3.152–35.113, P<0.0001) and high Ki-67 index (HR 10.820, 95%CI 4.338–27.002, P<0.0001) remained risk factors of RFS. In this cohort, HER-2 positivity, triple negative and high Ki-67 index were independent risk factors of RFS in young patients with T1a,bN0 breast cancer. Subsequent pregnancy did not affect RFS.     

Recent food shortage is associated with leprosy disease in Bangladesh: a case-control study

Background

Leprosy is remaining prevalent in the poorest areas of the world. Intensive control programmes with multidrug therapy (MDT) reduced the number of registered cases in these areas, but transmission of Mycobacterium leprae continues in most endemic countries. Socio-economic circumstances are considered to be a major determinant, but uncertainty exists regarding the association between leprosy and poverty. We assessed the association between different socio-economic factors and the risk of acquiring clinical signs of leprosy.

Methods and Findings

We performed a case-control study in two leprosy endemic districts in northwest Bangladesh. Using interviews with structured questionnaires we compared the socio-economic circumstances of recently diagnosed leprosy patients with a control population from a random cluster sample in the same area. Logistic regression was used to compare cases and controls for their wealth score as calculated with an asset index and other socio-economic factors. The study included 90 patients and 199 controls. A recent period of food shortage and not poverty per se was identified as the only socio-economic factor significantly associated with clinical manifestation of leprosy disease (OR 1.79 (1.06–3.02); p = 0.030). A decreasing trend in leprosy prevalence with an increasing socio-economic status as measured with an asset index is apparent, but not statistically significant (test for a trend: OR 0.85 (0.71–1.02); p = 0.083).

Conclusions

Recent food shortage is an important poverty related predictor for the clinical manifestation of leprosy disease. Food shortage is seasonal and poverty related in northwest Bangladesh. Targeted nutritional support for high risk groups should be included in leprosy control programmes in endemic areas to reduce risk of disease.     

Risk factors for multiple myeloma: A hospital-based case-control study in Northwest China

BackgroundThe distinctive racial/ethnic and geographic distribution of multiple myeloma (MM) suggests that both family history and environmental factors may contribute to its development.MethodsA hospital-based case–control study consisting of 220 confirmed MM cases and 220 individually matched patient controls, by sex, age and hospital was carried out at 5 major hospitals in Northwest China. A questionnaire was used to obtain information on demographics, family history, and the frequency of food items consumed.ResultsBased on multivariate analysis, a significant association between the risk of MM and family history of cancers in first degree relatives was observed (OR = 4.03, 95% CI: 2.50–6.52). Fried food, cured/smoked food, black tea, and fish were not significantly associated with the risk of MM. Intake of shallot and garlic (OR = 0.60, 95% CI: 0.43–0.85), soy food (OR = 0.52, 95% CI: 0.36–0.75) and green tea (OR = 0.38, 95% CI: 0.27–0.53) was significantly associated with a reduced risk of MM. In contrast, intake of brined vegetables and pickle was significantly associated with an increased risk (OR = 2.03, 95% CI: 1.41–2.93). A more than multiplicative interaction on the decreased risk of MM was found between shallot/garlic and soy food.ConclusionOur study in Northwest China found an increased risk of MM with a family history of cancer, a diet characterized by low consumption of garlic, green tea and soy foods, and high consumption of pickled vegetables. The effect of green tea in reducing the risk of MM is an interesting new finding which should be further confirmed.