Data-Driven Clustering Reveals a Link Between Symptoms and Functional Brain Connectivity in Depression

BACKGROUND

Depression is a complex disorder with large interindividual variability in symptom profiles that often occur alongside symptoms of other psychiatric domains, such as anxiety. A dimensional and symptom-based approach may help refine the characterization of depressive and anxiety disorders and thus aid in establishing robust biomarkers. We use resting-state functional magnetic resonance imaging to assess the brain functional connectivity correlates of a symptom-based clustering of individuals.

METHODS

We assessed symptoms using the Beck Depression and Beck Anxiety Inventories in individuals with or without a history of depression (N = 1084) and high-dimensional data clustering to form subgroups based on symptom profiles. We compared dynamic and static functional connectivity between subgroups in a subset of the total sample (n = 252).

RESULTS

We identified five subgroups with distinct symptom profiles, which cut across diagnostic boundaries with different total severity, symptom patterns, and centrality. For instance, inability to relax, fear of the worst, and feelings of guilt were among the most severe symptoms in subgroups 1, 2, and 3, respectively. The distribution of individuals was 32%, 25%, 22%, 10%, and 11% in subgroups 1 to 5, respectively. These subgroups showed evidence of differential static brain-connectivity patterns, in particular comprising a frontotemporal network. In contrast, we found no significant associations with clinical sum scores, dynamic functional connectivity, or global connectivity.

CONCLUSIONS

Adding to the pursuit of individual-based treatment, subtyping based on a dimensional conceptualization and unique constellations of anxiety and depression symptoms is supported by distinct patterns of static functional connectivity in the brain.

Trends in Deaths from Rheumatic Heart Disease in the Eastern Mediterranean Region: Burden and Challenges

Rheumatic heart disease (RHD) is a preventable disease that is prevalent in developing regions of the world. Its eradication from most of the developed world indicates that this disease can be controlled and eliminated. Aim: To conduct an in-depth analysis of the trends and challenges of controlling RHD in the Eastern Mediterranean region (EMR). Methodology: Global data from the World Health Organization (WHO) data banks were retrieved for total deaths and age standardized death rate per 100,000 (ASDR) by age group, sex, and year (from 2000 to 2015). The data was compared with the five other WHO regions of the world. We also performed in-depth analysis by socio-economic groups in relation to other attributes in the region related to population growth, illiteracy, and nutritional status. Indicators of service delivery were correlated with ASDR from RHD. Findings: Prevalence of RHD in 2015 in the EMR region was one-third of that of the total deaths reported in the Asian and West Pacific regions. The total deaths for the region peaked twice: in early adulthood and again later in old age, and was higher in females than in males. There was a rising trend in deaths from RHD from 2000 to 2015. The highest total deaths were reported from Egypt, Pakistan, Iran, Afghanistan, and Yemen, representing 80% of the total death rates for the region (35,248). The highest ASDR was Afghanistan (27.5), followed by Yemen (18.78) and Egypt (15.59). The ASDR for RHD was highest in low income countries. It correlated highly, in all income groups, with anemia during pregnancy. Conclusions: Trends and patterns of deaths from RHD in the EMR have shifted to a later age group and are linked with poverty related to inequalities in development and service delivery for certain age groups and gender.

Effectiveness of transcutaneous electrical nerve stimulation for the treatment of migraine: a meta-analysis of randomized controlled trials

Background

Migraine is now ranked as the second most disabling disorder worldwide reported by the Global Burden of Disease Study 2016. As a noninvasive neurostimulation technique, transcutaneous electrical nerve stimulation(TENS) has been applied as an abortive and prophylactic treatment for migraine recently. We conduct this meta-analysis to analyze the effectiveness and safety of TENS on migraineurs.

Methods

We searched Medline (via PubMed), Embase, the Cochrane Library and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials, which compared the effect of TENS with sham TENS on migraineurs. Data were extracted and methodological quality assessed independently by two reviewers. Change in the number of monthly headache days, responder rate, painkiller intake, adverse events and satisfaction were extracted as outcome.

Results

Four studies were included in the quantitative analysis with 161 migraine patients in real TENS group and 115 in sham TENS group. We found significant reduction of monthly headache days (SMD: -0.48; 95% CI: -0.73 to − 0.23; P < 0.001) and painkiller intake (SMD: -0.78; 95% CI: -1.14 to − 0.42; P < 0.001). Responder rate (RR: 4.05; 95% CI: 2.06 to 7.97; P < 0.001) and satisfaction (RR: 1.85; 95% CI: 1.31 to 2,61; P < 0.001) were significantly increased compared with sham TENS.

Conclusion

This meta-analysis suggests that TENS may serve as an effective and well-tolerated alternative for migraineurs. However, low quality of evidence prevents us from reaching definitive conclusions. Future well-designed RCTs are necessary to confirm and update the findings of this analysis.

Systematic review registration

Our PROSPERO protocol registration number: CRD42018085984. Registered 30 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0868-9) contains supplementary material, which is available to authorized users.

Recognizing Depression from the Microbiota⁻Gut⁻Brain Axis

Major depression is one of the leading causes of disability, morbidity, and mortality worldwide. The brain⁻gut axis functions are disturbed, revealed by a dysfunction of the brain, immune system, endocrine system, and gut. Traditional depression treatments all target the brain, with different drugs and/or psychotherapy. Unfortunately, most of the patients have never received any treatment. Studies indicate that gut microbiota could be a direct cause for the disorder. Abnormal microbiota and the microbiota⁻gut⁻brain dysfunction may cause mental disorders, while correcting these disturbance could alleviate depression. Nowadays, the gut microbiota modulation has become a hot topic in treatment research of mental disorders. Depression is closely related with the health condition of the brain⁻gut axis, and maintaining/restoring the normal condition of gut microbiota helps in the prevention/therapy of mental disorders.

Strategic proposal for a national trauma system in France

In this road map for trauma in France, we focus on the main challenges for system implementation, surgical and radiology training and upon innovative training techniques. Regarding system organisation: procedures for triage, designation and certification of trauma centres are mandatory to implement trauma networks on a national scale. Data collection with registries must be created, with a core dataset defined and applied through all registries. Regarding surgical and radiology training, diagnostic-imaging processes should be standardised and the role of the interventional radiologist within the trauma team and the trauma network should be clearly defined. Education in surgery for trauma is crucial and recent changes in medical training in France will promote trauma surgery as a specific sub-specialty. Innovative training techniques should be implemented and be based on common objectives, scenarios and evaluation, so as to improve individual and team performances. The group formulated 14 proposals that should help to structure and improve major trauma management in France over the next 10 years.

Methylation-reprogrammed Wnt/β-catenin signalling mediated prenatal hypoxia-induced brain injury in foetal and offspring rats

Prenatal hypoxia (PH) is a common pregnancy complication, harmful to brain development. This study investigated whether and how PH affected Wnt pathway in the brain. Pregnant rats were exposed to hypoxia (10.5% O₂) or normoxia (21% O₂; Control). Foetal brain weight and body weight were decreased in the PH group, the ratio of brain weight to body weight was increased significantly. Prenatal hypoxia increased mRNA expression of Wnt3a, Wnt7a, Wnt7b and Fzd4, but not Lrp6. Activated β‐catenin protein and Fosl1 expression were also significantly up‐regulated. Increased Hif1a expression was found in the PH group associated with the higher Wnt signalling. Among 5 members of the Sfrp family, Sfrp4 was down‐regulated. In the methylation‐regulating genes, higher mRNA expressions of Dnmt1 and Dnmt3b were found in the PH group. Sodium bisulphite and sequencing revealed hyper‐methylation in the promoter region of Sfrp4 gene in the foetal brain, accounting for its decreased expression and contributing to the activation of the Wnt‐Catenin signalling. The study of PC12 cells treated with 5‐aza further approved that decreased methylation could result in the higher Sfrp4 expression. In the offspring hippocampus, protein levels of Hif1a and mRNA expression of Sfrp4 were unchanged, whereas Wnt signal pathway was inhibited. The data demonstrated that PH activated the Wnt pathway in the foetal brain, related to the hyper‐methylation of Sfrp4 as well as Hif1a signalling. Activated Wnt signalling might play acute protective roles to the foetal brain in response to hypoxia, also would result in disadvantageous influence on the offspring in long‐term.

Prevalence and risk factors for HBV and HCV in prisoners in Iran: a national bio-behavioural surveillance survey in 2015

OBJECTIVES

To provide more accurate estimates of the prevalence of Hepatitis B (HBV) and Hepatitis C (HCV) and their contributing factors among prisoners in Iran.

METHODS

Cross-sectional study of 6200 Iranian prisoners in 2015. Data were collected through questionnaires and interviews. HBV infection and HCV exposure status of the participants was determined by HBsAg and HCV antibodies blood tests using enzyme-linked immunosorbent assay (ELISA). Data were analysed in STATA-12.

RESULT

Prevalence of HCV exposure was 9.48% (95% CI: 8.73-10.27), and prevalence of HBV was 2.48% (95% CI: 2.07-2.89) in the general prison population. In multivariate analysis, the most important risk factor for HBV was a history of drug use in lifetime (adjusted odds ratio, AOR: 1.8, 95% CI: 1.17-3.02). The main risk factors for HCV exposure were a history of drug use in lifetime (AOR: 4.08, CI: 2.56-6.27), age over 30 (AOR: 2.68, CI: 2.01-3.56), and having tattoos (AOR = 1.67, CI: 1.35-2.07).

CONCLUSION

Although vaccination is used to control HBV among prisoners, prevalence of HCV exposure is alarming in the prison population of Iran, especially among people who inject drugs. Eliminating viral hepatitis in Iran by 2030 requires a national commitment and rapid measures for targeting this high-risk group. Given the increased efficiency of HCV treatment in recent years, prisons provide an opportunity to access patients for treatment.

A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: Study protocol for The RELIEF Study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for seeking medical care. Manipulative therapies are a common treatment for LBP. Few studies have compared the effectiveness of different types of manipulative therapies. Moreover, the physiologic mechanisms underlying these treatments are not fully understood. Herein, we present the study protocol for The Researching the Effectiveness of Lumbar Interventions for Enhancing Function Study (The RELIEF Study).

METHODS AND STUDY DESIGN

The RELIEF Study is a Phase II RCT with a nested mechanistic design. It is a single-blinded, sham-controlled study to test the mechanisms and effectiveness of two manual therapy techniques applied to individuals (n = 162; 18-45 years of age) with chronic LBP. The clinical outcome data from the mechanistic component will be pooled across experiments to permit an exploratory Phase II RCT investigating the effectiveness. Participants will be randomized into one of three separate experiments that constitute the mechanistic component to determine the muscular, spinal, and cortical effects of manual therapies. Within each of these experimental groups study participants will be randomly assigned to one of the three treatment arms: 1) spinal manipulation, 2) spinal mobilization, or 3) sham laser therapy. Treatments will be delivered twice per week for 3-weeks.

DISCUSSION

This data from this will shed light on the mechanisms underlying popular treatments for LBP. Additionally, the coupling of this basic science work in the context of a clinical trial will also permit examination of the clinical efficacy of two different types of manipulative therapies.

The role of personality, disability and physical activity in the development of medication-overuse headache: a prospective observational study

Background

Factors associated with development of medication-overuse headache (MOH) in migraine patients are not fully understood, but with respect to prevention, the ability to predict the onset of MOH is clinically important. The aims were to examine if personality characteristics, disability and physical activity level are associated with the onset of MOH in a group of migraine patients and explore to which extend these factors combined can predict the onset of MOH.

Methods

The study was a single-center prospective observational study of migraine patients. At inclusion, all patients completed questionnaires evaluating 1) personality (NEO Five-Factor Inventory), 2) disability (Migraine Disability Assessment), and 3) physical activity level (Physical Activity Scale 2.1). Diagnostic codes from patients’ electronic health records confirmed if they had developed MOH during the study period of 20 months. Analyses of associations were performed and to identify which of the variables predict onset MOH, a multivariable least absolute shrinkage and selection operator (LASSO) logistic regression model was fitted to predict presence or absence of MOH.

Results

Out of 131 participants, 12 % (n=16) developed MOH. Migraine disability score (OR=1.02, 95 % CI: 1.00 to 1.04), intensity of headache (OR=1.49, 95 % CI: 1.03 to 2.15) and headache frequency (OR=1.02, 95 % CI: 1.00 to 1.04) were associated with the onset of MOH adjusting for age and gender. To identify which of the variables predict onset MOH, we used a LASSO regression model, and evaluating the predictive performance of the LASSO-mode (containing the predictors MIDAS score, MIDAS-intensity and –frequency, neuroticism score, time with moderate physical activity, educational level, hours of sleep daily and number of contacts to the headache clinic) in terms of area under the curve (AUC) was weak (apparent AUC=0.62, 95% CI: 0.41-0.82).

Conclusion

Disability, headache intensity and frequency were associated with the onset of MOH whereas personality and the level of physical activity were not. The multivariable LASSO model based on personality, disability and physical activity is applicable despite moderate study size, however it can be considered as a weak classifier for discriminating between absence and presence of MOH.

Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa

With increased numbers of older people a higher burden of neurological disorders worldwide is predicted. Stroke and other cerebrovascular diseases do not necessarily present with different phenotypes in Africa but their incidence is rising in tandem with the demographic change in the population. Age remains the strongest irreversible risk factor for stroke and cognitive impairment. Modifiable factors relating to vascular disease risk, diet, lifestyle, physical activity and psychosocial status play a key role in shaping the current spate of stroke related diseases in Africa. Hypertension is the strongest modifiable risk factor for stroke but is also likely associated with co-inheritance of genetic traits among Africans. Somewhat different from high-income countries, strokes attributed to cerebral small vessel disease (SVD) are higher >30% among sub-Saharan Africans. Raised blood pressure may explain most of the incidence of SVD-related strokes but there are likely other contributing factors including dyslipidaemia and diabetes in some sectors of Africa. However, atherosclerotic and cardioembolic diseases combined also appear to be common subtypes as causes of strokes. Significant proportions of cerebrovascular diseases are ascribed to various forms of infectious disease including complications of human immunodeficiency virus. Cerebral SVD leads to several clinical manifestations including gait disturbance, autonomic dysfunction and depression. Pathological processes are characterized by arteriolosclerosis, lacunar infarcts, perivascular spaces, microinfarcts and diffuse white matter changes, which can now all be detected on neuroimaging. Except for isolated cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL, hereditary arteriopathies have so far not been reported in Africa. Prevalence estimates of vascular dementia (2-3%), delayed dementia after stroke (10-20%) and vascular cognitive impairment (30-40%) do not appear to be vastly different from those in other parts of the world. However, given the current demographic transition in both urban and rural settings these figures will likely rise. Wider application of neuroimaging modalities and implementation of stroke care in Africa will enable better estimates of SVD and other subtypes of stroke. Stroke survivors with SVD type pathology are likely to have low mortality and therefore portend increased incidence of dementia.

Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke

OBJECTIVE

Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology.

METHODS

We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed.

RESULTS

A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006).

CONCLUSIONS

Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.

Cardiac complications after stroke: protocol for a systematic review and meta-analysis

INTRODUCTION

Stroke is the second most common cause of death after ischaemic heart diseases and the third leading cause of disability worldwide. The contribution of cardiac complications to the mortality of patients with stroke is variable across studies, ranging from 12.5% to 22.7%. Many of these cardiac complications are preventable, and early recognition and adequate management guided by appropriate up-to-date knowledge of their relative incidence and fatality can help to improve patients' outcomes. This systematic review aims to summarise the available data on the burden of cardiac complications after stroke.

METHODS AND ANALYSIS

This review will include all cross-sectional, case-control and cohort studies and clinical trials published between 1 January 1950 and 31 December 2017, involving adults and/or children, and reporting on the prevalence, the incidence and/or the mortality of cardiac complications after stroke. Two reviewers will independently screen titles and abstracts of records retrieved from PubMed, Excerpta Medica Database, ISI Web of Science and the Cumulative Index to Nursing and Allied Health Literature for eligibility, and then assess the risk of bias and quality of reporting to select the studies which will be included. All authors will contribute to the retrieval of full texts of eligible records and data extraction. Heterogeneity across studies will be evaluated by the χ2 test on Cochran's Q statistic. Study-specific estimates of the prevalence, incidence and mortality of cardiac complications after stroke across studies will be pooled through random-effect or fixed-effect meta-analysis depending on the source of the heterogeneity, after stabilising the variance of individual studies using the Freeman-Tukey double arcsine transformation. Visual analysis of funnel plots and Egger's test will be done to detect small-study effect.

ETHICS AND DISSEMINATION

This review and meta-analysis will be based on published data and will therefore not require a specific ethical clearance. The results will be published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42018082551.

Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica

Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.

Education in Vaccinology: An Important Tool for Strengthening Global Health

Over the past 20 years, education of scientists and public health professionals in Vaccinology has increased dramatically. There are now many international, regional, and national courses that provide education in vaccinology. The proliferation of these courses and the high number of applications submitted demonstrate the increasing and continuous need for improved education in this field since, generally, comprehensive vaccinology training is not offered to medical and/or biological sciences students as part of their Universities courses and consequently there is insufficient knowledge of vaccine topics among health-care providers. Multidisciplinary vaccinology courses have not only educational purposes but they may also contribute to strengthening the development, testing, and use of vaccines, which remain the most efficient tool for infectious disease prevention. The courses available have a varied focus and prioritize topics based on the trainees’ different levels of professional exposure and requirements. Overall, they might be classified in two key categories: (i) courses targeting students who, after their university studies in Medicine, Biology, etc., develop a strong interest in vaccines, would like to learn more about the various aspects of vaccinology, and potentially develop a career in this field (postgraduate courses); (ii) courses targeting postdoctoral professionals, who already have a sufficiently broad knowledge of vaccinology, but would like to develop stronger skills to be able to play a leading role in decision-making for vaccine development (advanced professional courses). Both postgraduate and professional courses are available and are based on comprehensive curricula. In the future, particular attention should be paid to include in the training curricula topics that might help vaccine development, efficient and sustainable vaccine introduction through epidemiologically sound vaccination programs, and best practices to address associated challenges, including vaccine hesitancy which could become a threat to successful implementation of vaccination programs, particularly in developed countries. In addition, it appears that the next phase of vaccinology training could benefit from a global and more structured platform that could facilitate exchanges and collaboration and amplify the current capacity for disseminating vaccine education for future vaccinology leaders around the world. This would be favored by synergizing the efforts currently devoted to vaccinology education. To initiate this process of analysis and systematization, a multinational effort is needed.

[Overview of indicators in the context of environment and health]

BACKGROUND

Evidence-based political measures need reliable information about the health status of a population and the determinants affecting health. Here, environment and health indicators can provide helpful additional insights.

AIM

This article provides an overview of existing indicators in the field of environment and health.

MATERIALS

There are single indicators and indicator sets describing solely the environment or health as well as some indicators integrating both aspects.

RESULTS

The indicator sets cover classical epidemiological indicators but also summary measures of population health, which combine mortality and morbidity as well as simple descriptions of the exposure towards environmental risks. The indicator sets mostly cover water and air quality related aspects. For some of the indicators their influence on health is also presented. Furthermore, environment related health indicators are part of sustainability indicator sets. There are indicators on the international, European, national, and municipal level.

DISCUSSION

All indicator sets aim to support policy-making by advising on measures and setting priorities in the area of environment and health protection. However not all indicators reflect the effect of the environment on health adequately. Therefore, further development of the existing indicators is necessary to reflect current progress (e. g. political needs) and to include new scientific evidence in the field of environment and health. A continuous provision, review, and interpretation of meaningful indicators is required to identify trends and to react to these in order to protect the environment and health. This is necessary to adequately pursue the precautionary principle.

High Out-of-Pocket Health Spending in Countries With a Mediterranean Connection

In this study, we analyzed healthcare provision and health expenditure across six Mediterranean countries that adopt the National Health System (Beveridge model) and that form part of the European Union (EU) with the main aim being that of analyzing and comparing out-of-pocket health spending in countries with a European Mediterranean connection. To this end, we considered various economic indicators and statistics to derive commonalities and differences across these countries and also compared trends in these indicators to those observed across the rest of the EU. We then analyzed these findings in light of other data related to the quality of healthcare delivery and the infrastructure of the health system and discussed recent developments in healthcare within each country and the main challenges faced by the respective health systems. The results show that on average, Mediterranean countries spend less on total healthcare expenditure (THE) than the EU average, both as a proportion of GDP, as well as in per capita terms. This is primarily driven by lower-than-EU-average public funding of healthcare. The 2008/2009 macro-economic and financial crisis had a significant impact on the countries under review, and explains the persistent reductions in public health spending as part of the austerity measures put in force across sectors. On the flipside, Mediterranean countries have a higher presence of private health providers in total funding, thereby explaining the higher Out-of-Pocket (OOPs) health expenditures in these countries relative to the EU-average. With regard to the overall health infrastructure in these countries, we observed that although the supply of physicians is largely in line with the rest of the EU, there is under-supply when it comes to hospital beds. This may be symptomatic of lower government funding. Nonetheless, all countries score highly in the evaluation of the quality of health services, as recorded by international rankings like the WHO's 2000 metric, whereas health system performance indicators, namely mortality rates and life expectancy reveal favorable health outcomes in the Mediterranean EU countries. The findings in this paper may be seen in light of the Mediterranean region's lifestyle in terms of diet, health behavior, health beliefs and shared culture. In particular, the higher out-of-pocket expenditure may reflect the tendency for one-to-one relationships with private clinicians and the pursuit of person-centered care (1). Additionally, the Mediterranean people may not be as disciplined as their European counterparts in accessing and using the public health sector. The lower THE also reflects the fact that the Mediterranean countries are less wealthy than the more economically-advanced European countries.

Matching Inhaler Devices with Patients: The Role of the Primary Care Physician

Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic obstructive pulmonary disease (COPD). A range of factors, including age, dexterity, inspiratory capacity, cognitive ability, health literacy, and ethnicity, can impact a patient's ability and intention to use their device. Treatment success can also be influenced by patient preferences and perceptions. Therefore, it is important that healthcare professionals effectively match inhaler devices to individual patients' needs and abilities and empower patients by including them in treatment decisions. Physicians must, therefore, fully understand the characteristics of each device, as well as their patients' demographic characteristics and comorbidities. Following device selection, patient training and education, including a physical demonstration of the device, are key to eliminate any critical errors that may impact on health outcomes. Inhaler technique should be frequently rechecked. This review will examine the important role of primary care providers in the selection of appropriate inhaler devices and provision of training for patients with COPD and asthma to optimize correct inhaler use and adherence. An overview of the key features of available devices and of the factors to consider when selecting devices will be provided in the context of current asthma and COPD guidelines.

Disparities in Chronic Kidney Disease Prevalence among Males and Females in 195 Countries: Analysis of the Global Burden of Disease 2016 Study

BACKGROUND

Chronic kidney disease (CKD) imposes a substantial burden on health care systems. There are some especially vulnerable groups with a high CKD burden, one of which is women. We performed an analysis of gender disparities in the prevalence of all CKD stages and renal replacement therapy (defined as impaired kidney function [IKF]) in 195 countries.

METHODS

We used estimates produced by the Global Burden of Disease (GBD) Study 2016 revision using a Bayesian-regression analytic tool, DisMoD-MR 2.1. Data on gross domestic product based on purchasing power parity per capita (GDP PPP) was obtained via the World Bank International Comparison Program database. To estimate gender disparities, we calculated the male:female all-age prevalence rate ratio for each IKF condition.

RESULTS

In 2016, the global number of individuals with IKF reached 752.7 million, including 417.0 million females and 335.7 million males. The most prevalent form of IKF in both groups was albuminuria with preserved glomerular filtration rate. Geospatial analysis shows a very heterogeneous distribution of the male:female ratio for all IKF conditions, with the most prominent contrast found in kidney transplant patients. The median male:female ratio varies substantially according to GDP PPP quintiles; however, countries with different economic states could have similar male:female ratios. A strong correlation of GDP PPP with dialysis-to-transplant ratio was found.

CONCLUSIONS

The GBD study highlights the prominent gender disparities in CKD prevalence among 195 countries. The nature of these disparities, however, is complex and must be interpreted cautiously taking into account all possible circumstances.

Diabetes-related lower-extremity complications are a leading cause of the global burden of disability

Globally ~435 million people have diabetes [1], and an estimated 19-34% (~83-148 million people) of those will be expected to develop foot ulcers in their lifetime [2]. Foot ulcers are typically precipitated by other diabetes-related lower-extremity complications, (DRLECs) including peripheral neuropathy and peripheral vascular disease [2,3]. Collectively, DRLECs are a leading cause of infection, hospitalization and amputation outcomes [2-5], yet, these outcomes are readily preventable with evidence-based care [6,7]. This suggests the burden caused by DRLECs is a large, yet reducible, cause of the global burden of disease. This article is protected by copyright. All rights reserved.

Distinct Hypericum perforatum L. total extracts exert different antitumour activity on erythroleukemic K562 cells

Total flower extracts of Hypericum perforatum L. obtained with 3 different solvent systems were tested on tumour cell line cultures by comparing two groups of plants harvested in different times and places. The extracts, characterized according to the spectroscopic profile and the hypericin content, were tested on the growth and apoptotic death of K562 cells, a human erythroleukemic cell line. Growth and apoptosis were analysed by viable cell count, flow cytometry, and fluorescence microscopy at 6, 24, and 48 hr of culture following 1 hr exposure to the extracts under investigation. Here, we show that Hypericum extracts are able to reduce the growth of K562 cells and induce different degrees and kinetics of apoptosis according to the group of plants of origin. Also, we highlighted interesting differences in terms of efficacy among the extracts, with some samples losing their effectiveness along the culture time and others able to maintain or even increase their efficacy. Furthermore, the data herein obtained confirm the role of non hypericin compounds that are present in different proportions in the two plant groups and in the extracts analysed.

Early Childhood Caries: Epidemiology, Aetiology, and Prevention

Early childhood caries (ECC) is one of the most prevalent diseases in children worldwide. ECC is driven by a dysbiotic state of oral microorganisms mainly caused by a sugar-rich diet. Additionally, poor oral hygiene or insufficient dental plaque removal leads to the rapid progression of ECC. ECC leads not only to dental destruction and pain with children, but also affects the quality of life of the caregivers. Children with extensive ECC are at high risk to develop caries with the permanent dentition or will have other problems with speaking and/or eating. To prevent ECC, several strategies should be taken into account. Children should brush their teeth with toothpastes containing gentle ingredients, such as mild surfactants and agents showing antiadherent properties regarding oral microorganisms. Parents/caregivers have to help their children with brushing the teeth. Furthermore, remineralizing and nontoxic agents should be included into the toothpaste formulation. Two promising biomimetic agents for children's oral care are amorphous calcium phosphate [Ca_x(PO₄)_yn H₂O] and hydroxyapatite [Ca₅(PO₄)₃(OH)].

The prevalence of substance use among Russian, Somali and Kurdish migrants in Finland: a population-based study

Background

Substance use is a well-known public health problem, but population-based research on migrants’ substance use in Europe is limited. Factors related to the cultural background and current life situation might influence substance use among migrants. Here, the prevalence of substance use in Russian, Somali and Kurdish migrants in Finland is reported in comparison with the general population, and the associations between substance use and socio-economic and migration-related background factors among migrants are analysed.

Methods

Cross-sectional data from the Finnish Migrant Health and Wellbeing Study (Maamu) and comparison group data of the general Finnish population (n = 1165) from the Health 2011 Survey were used. The survey participants were of Russian (n = 702), Somali (n = 512), and Kurdish (n = 632) origin. Substance use included self-reported alcohol use within previous 12 months (AUDIT-C questionnaire), current and lifetime daily smoking and lifetime use of cannabis and intravenous drugs.

Results

Binge drinking was less prevalent among all migrant groups than in the general Finnish population (Russian men 65%, p < 0.01; Russian women 30%, p < 0.01, Somali men 2%, p < 0.01, Kurdish men 27%, p < 0.01, Kurdish women 6%, p < 0.01, general population men 87% and women 72%). Current daily smoking was more prevalent among Russian (28%, p = 0.04) and Kurdish (29%, p < 0.01) migrant men compared with the reference group (20%). Younger age and employment were associated with binge drinking among migrants. Socio-economic disadvantage increased the odds for daily smoking in Russian, Somali and Kurdish migrant men. Several migration-related factors, such as age at migration and language proficiency, were associated with substance use.

Conclusions

Binge drinking is less common among migrants than in the Finnish general population. However, current daily smoking was more prevalent among Russian and Kurdish migrant men compared with the general population. Younger age, level of education, employment, duration of residence in Finland and language proficiency were associated with binge drinking and daily smoking with varying patterns of association depending on the migrant group and gender. These findings draw attention to the variation in substance use habits among migrant populations.

Smoking, Blood Pressure, and Cardiovascular Disease Mortality in a Large Cohort of Chinese Men with 15 Years Follow-up

BACKGROUND

To examine the joint effects of smoking and blood pressure on the risk of mortality from cardiovascular disease (CVD) in a cohort of Chinese men.

METHODS

This study followed a cohort of 213,221 men over 40 years of age who were recruited from 45 district/counties across China between 1990⁻1991, and whose cause-specific mortality was examined for 15 years, up to 31 December 2005. We calculated hazard ratios for all-cause mortality and CVD, ischemic heart disease (IHD), and stroke mortality for the combined sets of smoking status and blood pressure levels using the Cox proportional hazard model, adjusting for potential individual-level and contextual-level risk factors.

RESULTS

During the 15 years of follow-up, 52,795 deaths occurred, including 18,833 deaths from CVD, 3744 deaths from IHD, and 11,288 deaths from stroke. The risk of mortality from CVD, IHD, and stroke increased significantly, with increased systolic blood pressure (SBP), diastolic blood pressure (DBP), and with more pack years of smoking. Compared with never-smokers with normal blood pressure, the hazard ratios and 95% CI of CVD, IHD, and stroke mortality for those who smoked over 20 pack years with hypertension were remarkably increased to 2.30 (95% CI: 2.12⁻2.50), 1.78 (95% CI: 1.48⁻2.14), and 2.74 (95% CI: 2.45⁻3.07), respectively.

CONCLUSION

There was a combined effect on the risk of CVD, IHD, and stroke mortality between smoking and hypertension. The joint efforts on smoking cessation and lowered blood pressure should be made to prevent cardiovascular disease mortality in Chinese men.

Views and Experiences of Persons with Chronic Diseases about Strategies that Aim to Integrate and Re-Integrate Them into Work: A Systematic Review of Qualitative Studies

The effectiveness of strategies targeting professional integration and reintegration strongly depends on the experiences of participants. The aim of this systematic literature review is to synthesize European qualitative studies exploring views and experiences of persons with chronic conditions regarding strategies for integration and reintegration into work. The systematic search was conducted in Medline, PsycINFO, CDR-HTA, CDR-DARE and Cochrane Systematic Reviews. Overall, 24 studies published in English between January 2011 and April 2016 were included. Most studies were carried out in Nordic countries or in the UK, and most participants were persons with either mental or musculoskeletal disorders. Ten themes emerged: individual and holistic approach, clarity of strategy and processes, timing of rehabilitation processes, experience with professionals, at the workplace and with peer groups, changes in the understanding of health and work, active involvement in the process, competencies development and motivating aspects of work. Findings highlight, among others, the need to actively involve participants in the return to work process and to provide timely and clearly structured processes and interventions. This review provides stakeholders key information to develop, plan, implement and evaluate interventions to integrate and re-integrate persons with chronic conditions into work in Europe.

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

Background: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries.

Objectives: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends.

Methods: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories.

Findings: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance’s perception of the health sector’s absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement.

Conclusion: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments.

May Measurement Month 2017: an analysis of blood pressure screening results worldwide

BACKGROUND

Increased blood pressure is the biggest contributor to the global burden of disease and mortality. Data suggest that less than half of the population with hypertension is aware of it. May Measurement Month was initiated to raise awareness of the importance of blood pressure and as a pragmatic interim solution to the shortfall in screening programmes.

METHODS

This cross-sectional survey included volunteer adults (≥18 years) who ideally had not had their blood pressures measured in the past year. Each participant had their blood pressure measured three times and received a a questionnaire about demographic, lifestyle, and environmental factors. The primary objective was to raise awareness of blood pressure, measured by number of countries involved, number of people screened, and number of people who have untreated or inadequately treated hypertension (defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or both, or on the basis of receiving antihypertensive medication). Multiple imputation was used to estimate the mean of the second and third blood pressure readings if these were not recorded. Measures of association were analysed using linear mixed models.

FINDINGS

Data were collected from 1 201 570 individuals in 80 countries. After imputation, of the 1 128 635 individuals for whom a mean of the second and third readings was available, 393 924 (34·9%) individuals had hypertension. 153 905 (17·3%) of 888 616 individuals who were not receiving antihypertensive treatment were hypertensive, and 105 456 (46·3%) of the 227 721 individuals receiving treatment did not have controlled blood pressure. Significant differences in adjusted blood pressures and hypertension prevalence were apparent between regions. Adjusted blood pressure was higher in association with antihypertensive medication, diabetes, cerebrovascular disease, smoking, and alcohol consumption. Blood pressure was higher when measured on the right arm than on the left arm, and blood pressure was highest on Saturdays.

INTERPRETATION

Inexpensive global screening of blood pressure is achievable using volunteers and convenience sampling. Pending the set-up of systematic surveillance systems worldwide, MMM will be repeated annually to raise awareness of blood pressure.

FUNDING

International Society of Hypertension, Centers for Disease Control and Prevention, Servier Pharmaceutical Co.

Emerging Biosensing Technologies for Neuroinflammatory and Neurodegenerative Disease Diagnostics

Neuroinflammation plays a critical role in the onset and progression of many neurological disorders, including Multiple Sclerosis, Alzheimer's and Parkinson's diseases. In these clinical conditions the underlying neuroinflammatory processes are significantly heterogeneous. Nevertheless, a common link is the chronic activation of innate immune responses and imbalanced secretion of pro and anti-inflammatory mediators. In light of this, the discovery of robust biomarkers is crucial for screening, early diagnosis, and monitoring of neurological diseases. However, the difficulty to investigate biochemical processes directly in the central nervous system (CNS) is challenging. In recent years, biomarkers of CNS inflammatory responses have been identified in different body fluids, such as blood, cerebrospinal fluid, and tears. In addition, progress in micro and nanotechnology has enabled the development of biosensing platforms capable of detecting in real-time, multiple biomarkers in clinically relevant samples. Biosensing technologies are approaching maturity where they will become deployed in community settings, at which point screening programs and personalized medicine will become a reality. In this multidisciplinary review, our goal is to highlight both clinical and recent technological advances toward the development of multiplex-based solutions for effective neuroinflammatory and neurodegenerative disease diagnostics and monitoring.

Impact of new DAA therapy on real clinical practice: a multicenter region-wide cohort study

BACKGROUND

Management of chronic hepatitis C (CHC) has significantly accelerated in the last few years. Currently, second generation direct acting antivirals (DAAs) promise clearance of infection in most of patients. Here we present the results of the first analysis carried out on data of Lazio clinical network for DAAs.

METHODS

The study was designed as a multicenter cohort: a) to assess the evolution of treatment during the first 24 months of the activity of the Clinical Network; b) to report overall efficacy of treatments; c) to analyze potential factors associated with lack of virological response at 12 weeks after therapy (SVR12); d) to evaluate the variation of ALT at baseline and 12 weeks after therapy in those who achieved SVR12 in comparison to those who did not. Analyses of efficacy were carried out with multilevel mixed effect logistic regression model. ALT temporal variation was assessed by mixed effect model mixed models with random intercept at patient's level and random slope at the level of the time; i.e. either before or after therapy.

RESULTS

Between 30 December 2014 and 31 December 2016 5279 patients started a DAA treatment; of those, 5127 (in 14 clinical centers) had completed the 12-week follow-up. Overall proportion of SVR12 was 93.41% (N = 4780) with no heterogeneity between the 14 clinical centers. Interruption as the consequence of severe side effect was very low (only 23 patients). Unadjusted analysis indicates that proportion of SVR12 significantly changes according to patient's baseline characteristics, however after adjusting for potential confounders only adherence to current guidelines, stage of liver diseases, gender, transplant and HIV status were independently associated with the response to therapy. Analysis of ALT temporal variation showed that ALT level normalized in most, but not, all patients who achieved SVR12.

CONCLUSION

Our study confirmed the extraordinary efficacy of DAAs outside clinical trials. The advantage of DAAs was particularly significant for those patients who were previously considered as difficult-to-treat and did not have treatment options before DAAs era. Intervention based on network of select centers and prioritization of patients according to diseases severity was successful. Further studies are needed to establish whether clearance of HCV after DAAs therapy can arrest or even revert liver fibrosis in non-cirrhotic patients and/or improve life quality and expectancy in those who achieve SVR12 with cirrhosis.

Global Asbestos Disaster

Introduction: Asbestos has been used for thousands of years but only at a large industrial scale for about 100–150 years. The first identified disease was asbestosis, a type of incurable pneumoconiosis caused by asbestos dust and fibres. The latest estimate of global number of asbestosis deaths from the Global Burden of Disease estimate 2016 is 3495. Asbestos-caused cancer was identified in the late 1930’s but despite today’s overwhelming evidence of the strong carcinogenicity of all asbestos types, including chrysotile, it is still widely used globally. Various estimates have been made over time including those of World Health Organization and International Labour Organization: 107,000–112,000 deaths. Present estimates are much higher. Objective: This article summarizes the special edition of this Journal related to asbestos and key aspects of the past and present of the asbestos problem globally. The objective is to collect and provide the latest evidence of the magnitude of asbestos-related diseases and to provide the present best data for revitalizing the International Labor Organization/World Health Organization Joint Program on Asbestos-related Diseases. Methods: Documentation on asbestos-related diseases, their recognition, reporting, compensation and prevention efforts were examined, in particular from the regulatory and prevention point of view. Estimated global numbers of incidence and mortality of asbestos-related diseases were examined. Results: Asbestos causes an estimated 255,000 deaths (243,223–260,029) annually according to latest knowledge, of which work-related exposures are responsible for 233,000 deaths (222,322–242,802). In the European Union, United States of America and in other high income economies (World Health Organization regional classification) the direct costs for sickness, early retirement and death, including production losses, have been estimated to be very high; in the Western European countries and European Union, and equivalent of 0.70% of the Gross Domestic Product or 114 × 10⁹ United States Dollars. Intangible costs could be much higher. When applying the Value of Statistical Life of 4 million EUR per cancer death used by the European Commission, we arrived at 410 × 10⁹ United States Dollars loss related to occupational cancer and 340 × 10⁹ related to asbestos exposure at work, while the human suffering and loss of life is impossible to quantify. The numbers and costs are increasing practically in every country and region in the world. Asbestos has been banned in 55 countries but is used widely today; some 2,030,000 tons consumed annually according to the latest available consumption data. Every 20 tons of asbestos produced and consumed kills a person somewhere in the world. Buying 1 kg of asbestos powder, e.g., in Asia, costs 0.38 United States Dollars, and 20 tons would cost in such retail market 7600 United States Dollars. Conclusions: Present efforts to eliminate this man-made problem, in fact an epidemiological disaster, and preventing exposures leading to it are insufficient in most countries in the world. Applying programs and policies, such as those for the elimination of all kind of asbestos use—that is banning of new asbestos use and tight control and management of existing structures containing asbestos—need revision and resources. The International Labor Organization/World Health Organization Joint Program for the Elimination of Asbestos-Related Diseases needs to be revitalized. Exposure limits do not protect properly against cancer but for asbestos removal and equivalent exposure elimination work, we propose a limit value of 1000 fibres/m³.

Effect of Fremanezumab Compared With Placebo for Prevention of Episodic Migraine: A Randomized Clinical Trial

IMPORTANCE

Fremanezumab, a fully humanized monoclonal antibody that targets calcitonin gene-related peptide, may be effective for treating episodic migraine.

OBJECTIVE

To assess the efficacy of fremanezumab compared with placebo for prevention of episodic migraine with a monthly dosing regimen or a single higher dose.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled, parallel-group trial conducted at 123 sites in 9 countries from March 23, 2016 (first patient randomized), to April 10, 2017, consisting of a screening visit, 28-day pretreatment period, 12-week treatment period, and final evaluation at week 12.

PARTICIPANTS

Study participants were aged 18 to 70 years with episodic migraine (6-14 headache days, with at least 4 migraine days, during 28-day pretreatment period). Patients who had previous treatment failure with 2 classes of migraine-preventive medication were excluded.

INTERVENTIONS

Patients were randomized 1:1:1 to receive subcutaneous monthly dosing of fremanezumab (n = 290; 225 mg at baseline, week 4, and week 8); a single higher dose of fremanezumab, as intended to support a quarterly dose regimen (n = 291; 675 mg of fremanezumab at baseline; placebo at weeks 4 and 8); or placebo (n = 294; at baseline, week 4, and week 8).

MAIN OUTCOMES AND MEASURES

The primary end point was mean change in mean number of monthly migraine days during the 12-week period after the first dose.

RESULTS

Among 875 patients who were randomized (mean age, 41.8 [SD, 12.1] years; 742 women [85%]), 791 (90.4%) completed the trial. From baseline to 12 weeks, mean migraine days per month decreased from 8.9 days to 4.9 days in the fremanezumab monthly dosing group, from 9.2 days to 5.3 days in the fremanezumab single-higher-dose group, and from 9.1 days to 6.5 days in the placebo group. This resulted in a difference with monthly dosing vs placebo of -1.5 days (95% CI, -2.01 to -0.93 days; P < .001) and with single higher dosing vs placebo of -1.3 days (95% CI, -1.79 to -0.72 days; P < .001). The most common adverse events that led to discontinuation were injection site erythema (n = 3), injection site induration (n = 2), diarrhea (n = 2), anxiety (n = 2), and depression (n = 2).

CONCLUSIONS AND RELEVANCE

Among patients with episodic migraine in whom multiple medication classes had not previously failed, subcutaneous fremanezumab, compared with placebo, resulted in a statistically significant 1.3- to 1.5-day reduction in the mean number of monthly migraine days over a 12-week period. Further research is needed to assess effectiveness against other preventive medications and in patients in whom multiple preventive drug classes have failed and to determine long-term safety and efficacy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02629861.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Cardiovascular disease and brain health: Focus on white matter hyperintensities

Diseases affecting the brain contribute to a substantial proportion of morbidity and mortality in the general population. Conditions such as stroke, dementia and cognitive impairment have a prominent impact on global public health. Despite the heterogeneous clinical manifestations of these conditions and their diverse prognostic implications, current evidence supports a role for cardiovascular disease as a common pathophysiological ground. Brain white matter hyperintensities (WMH) are patchy white matter signal hyperintensity on T2-weighted magnetic resonance imaging sequences commonly found in elderly individuals. WMH appear to have a vascular pathogenesis and have been shown to confer an increased risk of stroke and cognitive decline. Indeed, they were proposed as a marker for central nervous system frailty. Cardiovascular diseases seem to play a key role in the etiology of WMH. Carotid atherosclerosis and atrial fibrillation were shown to be associated with higher WMH burden, while adequate blood pressure control has been reported reducing WMH progression. Aim of the present work is to review the available evidence linking WMH to cardiovascular disease, highlighting the complex interplay between cerebral and cardiovascular health.

Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study

BACKGROUND

The age-specific association between blood pressure and vascular disease has been studied mostly in high-income countries, and before the widespread use of brain imaging for diagnosis of the main stroke types (ischaemic stroke and intracerebral haemorrhage). We aimed to investigate this relationship among adults in China.

METHODS

512 891 adults (59% women) aged 30-79 years were recruited into a prospective study from ten areas of China between June 25, 2004, and July 15, 2008. Participants attended assessment centres where they were interviewed about demographic and lifestyle characteristics, and their blood pressure, height, and weight were measured. Incident disease was identified through linkage to local mortality records, chronic disease registries, and claims to the national health insurance system. We used Cox regression analysis to produce adjusted hazard ratios (HRs) relating systolic blood pressure to disease incidence. HRs were corrected for regression dilution to estimate associations with long-term average (usual) systolic blood pressure.

FINDINGS

During a median follow-up of 9 years (IQR 8-10), there were 88 105 incident vascular and non-vascular chronic disease events (about 90% of strokes events were diagnosed using brain imaging). At ages 40-79 years (mean age at event 64 years [SD 9]), usual systolic blood pressure was continuously and positively associated with incident major vascular disease throughout the range 120-180 mm Hg: each 10 mm Hg higher usual systolic blood pressure was associated with an approximately 30% higher risk of ischaemic heart disease (HR 1·31 [95% CI 1·28-1·34]) and ischaemic stroke (1·30 [1·29-1·31]), but the association with intracerebral haemorrhage was about twice as steep (1·68 [1·65-1·71]). HRs for vascular disease were twice as steep at ages 40-49 years than at ages 70-79 years. Usual systolic blood pressure was also positively associated with incident chronic kidney disease (1·40 [1·35-1·44]) and diabetes (1·14 [1·12-1·15]). About half of all vascular deaths in China were attributable to elevated blood pressure (ie, systolic blood pressure >120 mm Hg), accounting for approximately 1 million deaths (<80 years of age) annually.

INTERPRETATION

Among adults in China, systolic blood pressure was continuously related to major vascular disease with no evidence of a threshold down to 120 mm Hg. Unlike previous studies in high-income countries, blood pressure was more strongly associated with intracerebral haemorrhage than with ischaemic stroke. Even small reductions in mean blood pressure at a population level could be expected to have a major impact on vascular morbidity and mortality.

FUNDING

UK Wellcome Trust, UK Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, Chinese Ministry of Science and Technology, and the National Science Foundation of China.

[Epidemiological studies with environmental relevance in Germany]

Our environment is a major factor in determining health and well-being throughout life, from conception into old age. This overview illustrates the most important epidemiological studies and health monitoring systems in Germany, which investigate environmental influences in various population subgroups and estimate related health effects. Environmental factors examined in each study are described. The mentioned studies in children and adults build the basis for predictions and preventive measures. The number of the assessed environmental factors, the depth of the examinations as well as the (phenotypical) characterization of the study participants differ. Still, the obtained data build a base for important future research. However, for this, a permanent and Germany-wide assessment of environmental factors is necessary.The proportion of the European population living in urban areas is projected to increase in the future. Therefore, environmental factors such as air pollution, air temperature, and noise, but also social inequality, are likely to have a negative effect on health and quality of life of the population. The challenge of the aging population as well as potential adaptation processes to the diverse environmental stimuli requires multidisciplinary approaches. From an environmental epidemiology view, the collected data from the described studies are of immense value because only with this data can associations between environment and health be investigated and public health-relevant preventive measures be identified.The NAKO health study will be the largest resource of health data and should therefore be included in future activities related to the investigation of environmental health effects in Germany.

Traditional Chinese medication Tongxinluo attenuates apoptosis in ox-LDL-stimulated macrophages by enhancing Beclin-1-induced autophagy

In advanced atherosclerosis, a large number of necrotic core increases plaque vulnerability, which leads to the occurrence of acute atherothrombotic cardiovascular events. Macrophage apoptosis plays an important role in secondary necrosis. The present study aimed to examine and describe the effect of the traditional Chinese medication Tongxinluo (TXL) on macrophage apoptosis in advanced atherosclerotic plaques and to explore its mechanism. By observing the effect of TXL on ox-LDL-stimulated macrophage apoptosis, it was shown that TXL significantly inhibited ox-LDL-induced apoptosis of macrophages by enhancing autophagy. Therapeutic mechanism of TXL included increasing the expression of Beclin-1 and improving the dissociation of Bcl-2-Beclin-1 Complex. Apolipoprotein E knockout (apoE-/-) mice with a high fat diet were divided into four groups: saline group (Saline gavage), low dose TXL group (0.38 g/kg/d, gavage), medium dose TXL group (0.75 g/kg/day, gavage), and high dose TXL group (1.5 g/kg/day, gavage). 4 weeks after carotid-artery surgery, lentiviral of Beclin-1 silencing was injected through the tail vein. TXL treatment significantly reduced macrophage apoptosis dose-dependently and the result was blocked by Beclin-1 silencing. In addition, the increased Lc3b dots by TXL almost localized to macrophages in advanced atherosclerotic plaque. Compared with the same dose of TXL shBeclin-1 group, plaque area and vulnerability index of TXL groups decreased. The anti-apoptosis effects of TXL on atherosclerosis was related to the improvement of autophagy via Beclin-1.

Determinants of Schistosoma mansoni in Sanja health center, north West Ethiopia

BACKGROUND

In developing countries, Schistosoma mansoni is one of the chronic but neglected tropical diseases. In sub-Saharan Africa, the disease affects over 250 million people with nearly 800 million are at risk. In Ethiopia, Schistosoma mansoni is one of the most prevalent parasitic diseases. The aim of this study was to determine the prevalence and identify the determinant factors of Schistosoma mansoni, in terms of some socio-demographic variables and risk factors.

METHODS

A cross-sectional parasitological survey was conducted at Sanja health center, northwest Ethiopia from June 1 to June 30, 2015. A total of 228 study participants were included in the study. The participants were selected using systematic random sampling technique. Stool specimens were collected and examined using Kato-Katz methods. Structural questionnaires were used to collect data on socio-demographic variables and risk factors by face to face interviews. The major risk factors and demographic determinants of the infection status of Schistosoma mansoni were identified by using descriptive and ordinal logistic regression techniques.

RESULTS

The overall prevalence of Schistosoma mansoni was 16.67% (95%CI: 11.83-21.51%). Covariates such as no habit of swimming in rivers has lower risk (AOR = 0.022: 95%CI: 0.011-0.764), no frequency of swimming in rivers (AOR = 0.022: 95%CI: 0.0024-0.207), and 1 to 2 frequency of swimming (OR = 0.302: 95%CI: 0.097-0.941), washing clothes in rivers (AOR = 0.194: 95%CI: 0.046-0.0.811) and bathing in the river (AOR = 0.09: 95%CI: 0.010-0.815) were the most important determinant factors (P-value < 0.5) of Schistosoma mansoni in Sanja health center.

CONCLUSION

In this study, the prevalence of Schistosoma mansoni was found to be high. Swimming habits, frequency of swimming, washing clothes, and bathing in rivers were found to be significant predictors of Schistosoma mansoni. Provisions of a safe water supply in the area and health education about the transmission of the Schistosoma mansoni infection are required.

Noncommunicable diseases and their common risk factors in Curitiba, Brazil: results of a cross-sectional, population-based study

OBJECTIVE

To describe the estimated prevalence of noncommunicable diseases and their common risk factors among the adult population of Curitiba, Paraná, Brazil, based on results of the EPIdemiology of CURitiba: EvaluAtion of Noncommunicable diseases (EPICUREAN) study.

METHODS

This was a cross-sectional, population-based survey of 1 103 residents of Curitiba, grouped by age (18 - 39 years of age, 40 - 59, and ≥ 60 years), conducted in August 2013 - August 2014. Household interviews, anthropometry, blood pressure measurements, and fasting capillary glycemia were performed during two visits to each participant. The analyses included frequency distribution and prevalence estimates of main outcomes. Prevalence estimates, weighted by age and sex, were presented as absolute numbers and percentages.

RESULTS

Prevalence estimates for self-reported depression were 21.2%; hypertension, 31.2%; diabetes, 9.1%; self-reported dyslipidemia, 21.7%; obesity, 21.2%; current smoking, 16.1%; binge drinking, 23.4%; and insufficient physical activity, 35.1%. Prevalences of diabetes and hypertension were higher among individuals with less schooling and the elderly. Binge drinking and leisure-time physical activity were more prevalent in young adults. Men presented higher prevalences of overweight, current smoking, and harmful use of alcohol. Obesity and moderate- to-severe risk of depression were more frequent among women and those with lower income.

CONCLUSIONS

The prevalence of NCDs and common risk factors among the adult population of Curitiba are high and reveal a gradient of vulnerabilities by age, sex, education level, and income. To address health inequities and meet the needs of different population groups, the health system should monitor NCDs and risk factors and implement equitable public health policies.

New-onset diabetes mellitus among patients with glomerular diseases

BACKGROUND

Glomerulonephritis commonly causes kidney failure. Immunosuppressant treatment may be diabetogenic, but data on hyperglycaemia in glomerulonephritis treated with usual clinical care are scant.

AIM

To assess the epidemiology, risk factors and outcomes for new-onset diabetes among patients with glomerular disease (NODAG).

METHODS

A single-centre retrospective cohort of nondiabetic adults diagnosed with glomerulonephritis between January 2011 and July 2015. Clinical, laboratory and pharmacotherapy data were retrieved from electronic medical records. Using modified American Diabetes Association criteria, the primary outcome of NODAG was present if fasting venous glucose was ≥7 mmol/L for at least two readings, HbA1c was ≥6.5% or if patient required antidiabetic medications. Secondary outcomes were end-stage renal disease, cardiovascular disease and death.

RESULTS

NODAG occurred in 48 patients (10.7%); 22 required antidiabetic medication at median 6.2 (interquartile range 1.7, 20.0) months after glomerulonephritis diagnosis. Patients with NODAG had higher prebiopsy fasting glucose, greater proteinuria and lower fasting high-density lipoprotein cholesterol levels. Methylprednisolone and cyclophosphamide were more commonly used among patients with NODAG. In multivariate logistic regression, greater proteinuria (odds ratio 1.08 (95% confidence interval 1.01, 1.16), P = 0.02) and methylprednisolone use (odds ratio 4.02 (95% confidence interval 1.76, 9.18), P = 0.001) were significantly associated with NODAG, independent of the triglyceride/high-density lipoprotein cholesterol ratio as a surrogate measure of insulin resistance. Median follow up was 39.6 (26.9, 57.2) months. Secondary outcomes were not significantly different in patients with and without NODAG.

CONCLUSION

Proteinuria and methylprednisolone were associated with incident diabetes among patients with glomerular disease treated with usual care. At-risk patients should be appropriately counselled and monitored for hyperglycaemia.

Frequency and Associated Factors of Bone Fractures in Russians: The Ural Eye and Medical Study

With information about frequency of bone fractures in Russia mostly missing, we assessed the frequency of previous bone fractures in a Russian population. The population-based study Ural Eye and Medical Study included 5899 (80.5%) out of 7328 eligible individuals (mean age: 59.0 ± 10.7 years; range: 40–94 years). The history of previous bone fractures was assessed in a standardized interview for 5397 (91.5%) individuals. Mean frequency of any previous bone fracture was 1650/5397 (30.6%; 95% confidence interval (CI): 29, 3, 31.8). In multivariate analysis, higher frequency of bone fractures was associated with male sex (P < 0.001; odds ratio (OR): 1.67; 95% CI: 1.41, 2.00), urban region (P < 0.001; OR: 1.45; 95% CI: 1.23, 1.72), higher prevalence of vigorous activity during leisure (P < 0.001; OR: 1.42; 95% CI: 1.20, 1.68), current smoking (P = 0.001; OR: 1.46; 95% CI: 1.16, 1.82) and higher prevalence of cardiovascular disease (P = 0.007; OR: 1.29; 95% CI: 1.07, 1.56), low blood pressure episodes with hospital admission (P = 0.001; OR: 2.08; 95% CI: 1.37, 3.16), tumbling (P < 0.001; OR: 2.58; 95% CI: 1.37, 3.16) and thoracic spine pain (P < 0.001; OR: 1.43; 95% CI: 1.18, 1.73). In women, menopause (P < 0.001; OR: 2.17; 95% CI: 1.47, 3.22) was additionally associated. The most common single-bone fractures involved leg and knee (229/5397; 4.2%), hand in general (n = 169; 3.1%) or hand wrist only (n = 97; 1.8%), arm (n = 94; 1.7%) and ankle (n = 67; 1.2%). Severe fractures included spine (n = 35; 0.6%), os sacrum (n = 10; 0.2%), skull (n = 6; 0.1%), pelvis (n = 5; 0.1%) and hip (n = 22; 0.4%). Most frequent combined fractures included as most important part the leg (n = 90; 1.7%), spine (n = 18; 0.3%), and hip (n = 18; 0.3). These data give hints on the epidemiology of bone fractures in Russia.

Determinants of catastrophic healthcare expenditure in Peru

The aims of this study were to assess factors associated with catastrophic healthcare expenditure (CHE) and the burden of out-of-pocket (OOP) payments for specific healthcare services in Peru. We used data from 30,966 households that participated in the 2016 National Household Survey (Encuesta Nacional de Hogares, ENAHO). Participants reported household characteristics and expenditure on ten healthcare services. CHE was defined as healthcare spending equal to or higher than 40% of the household's capacity to pay. The associations of various household characteristics and OOP payments for specific healthcare services with CHE were assessed in logistic regression models. Poorer, rural and smaller households as well as those with older adults and individuals with chronic conditions had greater odds of facing CHE. According to the estimates from the adjusted regression model, healthcare services could be grouped into three groups. Medical tests, surgery and medication were in the first group with odds ratios (ORs) between 6.43 and 4.72. Hospitalisation, outpatient, dental and eye care were in the second group with ORs between 2.61 and 1.46. Child care, maternity care and other healthcare services (such as contraceptives, rehabilitation, etc.) were in the third group with non-significant ORs. Many Peruvian households are forced to finance their healthcare through OOP payments, burdening their finances to the extent of affecting their living standards.

Long-term follow-up on biological risk factors, adiposity, and cardiorespiratory fitness development in a physical education intervention: a natural experiment (CHAMPS-study DK)

Background

Schools are a key setting for large-scale primordial non-communicable disease prevention in young people, but little data on sustainability of impacts on cardiometabolic risk markers is available.

Methods

Six and a half year follow-up of a natural experiment. In 2008, six public schools in the municipality of Svendborg (Denmark) augmented their curricular physical education (intervention) and four matched schools served as controls. At long term follow up in 2015 n = 312 participants aged 5–11 years had complete data (33% of children providing necessary baseline data). The intervention, that consisted of a trebling of weekly physical education lessons and courses provided to physical education teachers, was provided at intervention schools up until 6th grade. Participants attended 6th to 10th grade at follow-up. Differences in the homeostasis model assessment of insulin resistance, blood pressure, triglycerides, cholesterol ratios, cardiorespiratory fitness, waist-circumference, and a composite score of these, between participants attending intervention and control schools were analysed by mixed linear regression models. Differences in physical activity at follow-up was analysed cross-sectionally (no baseline available) in n = 495.

Results

Compared to controls, children at intervention schools had a non-significant − 0.07 (− 0.32 to 0.18) standard deviations lower composite risk score 6.5 years after project initiation. Likewise, no statistically significant differences between intervention and control schools were found for any of the other outcomes (p-values ≥ 0.41). However, six of seven outcomes were in a direction favouring intervention schools. No statistically significant differences between intervention and control schools were observed for physical activity outcomes (p-values ≥ 0.13).

Conclusions

An augmented physical activity program including 270 min of weekly physical education provided for three to seven years did not materialize in statistically significant differences in established risk markers in children from intervention compared to control schools. As the intervention was discontinued after 6th grade, the post-intervention effect of augmented physical education throughout adolescence is unknown. School-based physical activity programs may benefit from incorporating instruments for behaviour translation to leisure time in their intervention models to increase the probability of achieving public health relevance.

Trial registration

ClinicalTrials.gov Identifier: NCT03510494.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5524-4) contains supplementary material, which is available to authorized users.

Self-rated wellbeing and physical activity associations in European older adults

BACKGROUND

Physical activity and self-rated wellbeing have important benefits to health. However, scientific knowledge regarding their relationship among older adults is scarce. Thus, the aim of this study was to examine the associations between physical activity frequency and several dimensions of self-rated wellbeing, in a representative sample of European older adults from 28 countries.

METHODS

This study is based on the European Social Survey round 6, 2012. It had a total sample size of 12,341 older adults (5100 men, 7241 women) with mean age 73.8 ± 6.6 years. Information was collected through a questionnaire, filled-in during an hour-long face-to-face interview. Physical activity was accessed using the question "On how many of the last 7 days you were physically active continuously for 20 minutes or longer?" and six dimensions of self-rated wellbeing were used.

RESULTS

Physical activity in the last 7 days was linearly related with all dimension of the self-rated wellbeing and with wellbeing total score for both sexes (men, β = 0.09, 95% CI: 0.07 to 0.10, p < .001; women, β = 0.10, 95% CI: 0.09 to 0.11, p < .001).

CONCLUSIONS

Physical activity promotion should be stressed as a meaningful strategy to improve people's wellbeing overall. This strategy has special importance when considering the older adult population.