The impact of primary headaches on disability outcomes: a literature review and meta-analysis to inform future iterations of the Global Burden of Disease study

BACKGROUND

The burden and disability associated with headaches are conceptualized and measured differently at patients' and populations' levels. At the patients' level, through patient-reported outcome measures (PROMs); at population level, through disability weights (DW) and years lived with a disability (YLDs) developed by the Global Burden of Disease Study (GBD). DW are 0-1 coefficients that address health loss and have been defined through lay descriptions. With this literature review, we aimed to provide a comprehensive analysis of disability in headache disorders, and to present a coefficient referring to patients' disability which might inform future GBD definitions of DW for headache disorders.

METHODS

We searched SCOPUS and PubMed for papers published between 2015 and 2023 addressing disability in headache disorders. The selected manuscript included a reference to headache frequency and at least one PROM. A meta-analytic approach was carried out to address relevant differences for the most commonly used PROMs (by headache type, tertiles of medication intake, tertiles of females' percentage in the sample, and age). We developed a 0-1 coefficient based on the MIDAS, on the HIT-6, and on MIDAS + HIT-6 which was intended to promote future DW iterations by the GBD consortium.

RESULTS

A total of 366 studies, 596 sub-samples, and more than 133,000 single patients were available, mostly referred to cases with migraine. Almost all PROMs showed the ability to differentiate disability severity across conditions and tertiles of medication intake. The indexes we developed can be used to inform future iterations of DW, in particular considering their ability to differentiate across age and tertiles of medication intake.

CONCLUSIONS

Our review provides reference values for the most commonly used PROMS and a data-driven coefficient whose main added value is its ability to differentiate across tertiles of age and medication intake which underlie on one side the increased burden due to aging (it is likely connected to the increased impact of common comorbidities), and by the other side the increased burden due to medication consumption, which can be considered as a proxy for headache severity. Both elements should be considered when describing disability of headache disorders at population levels.

Prevalence of unmet health care need in older adults in 83 countries: measuring progressing towards universal health coverage in the context of global population ageing

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutilization of needed services or widening inequalities. Asking people whether or not their needs for health care have been met, as part of a household survey, is a pragmatic way of capturing this information. This analysis examined responses to self-reported questions about unmet need asked as part of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries. Noting the large variation in questions and response categories, the results point to low levels (less than 2%) of unmet need reported in adults aged 60+ years in countries like Andorra, Qatar, Republic of Korea, Slovenia, Thailand and Viet Nam to rates of over 50% in Georgia, Haiti, Morocco, Rwanda, and Zimbabwe. While unique, these estimates are likely underestimates, and do not begin to address issues of poor quality of care as a barrier or contributing to unmet need in those who were able to access care. Monitoring progress towards UHC will need to incorporate estimates of unmet need if we are to reach universality and reduce health inequalities in older populations.

Time-Trends in Air Pollution Impact on Health in Italy, 1990-2019: An Analysis From the Global Burden of Disease Study 2019

Objectives: We explored temporal variations in disease burden of ambient particulate matter 2.5 μm or less in diameter (PM_2.5) and ozone in Italy using estimates from the Global Burden of Disease Study 2019. Methods: We compared temporal changes and percent variations (95% Uncertainty Intervals [95% UI]) in rates of disability adjusted life years (DALYs), years of life lost, years lived with disability and mortality from 1990 to 2019, and variations in pollutant-attributable burden with those in the overall burden of each PM_2.5- and ozone-related disease. Results: In 2019, 467,000 DALYs (95% UI: 371,000, 570,000) were attributable to PM_2.5 and 39,600 (95% UI: 18,300, 61,500) to ozone. The crude DALY rate attributable to PM_2.5 decreased by 47.9% (95% UI: 10.3, 65.4) from 1990 to 2019. For ozone, it declined by 37.0% (95% UI: 28.9, 44.5) during 1990-2010, but it increased by 44.8% (95% UI: 35.5, 56.3) during 2010-2019. Age-standardized rates declined more than crude ones. Conclusion: In Italy, the burden of ambient PM_2.5 (but not of ozone) significantly decreased, even in concurrence with population ageing. Results suggest a positive impact of air quality regulations, fostering further regulatory efforts.

Place of therapeutic cannabis in France and safety data: A literature review

OBJECTIVES

To date, very few cannabis-based specialities are authorised on the French market despite a growing demand from patients and health professionals. The objective of this study is to review the tolerance profile and the French legislative status of the two main cannabinoids used for therapeutic purposes: tetrahydrocannabiol (THC) associated with psychoactive effects and non-psychoactive cannabidiol (CBD).

METHODS

This review is based on relevant articles retrieved by a search in Google Scholar and PubMed databases and on an assessment of the legal texts and summaries of product characteristics available in France.

RESULTS

Evidence for the tolerability of CBD during chronic use is reassuring, but a significant risk of drug interactions exists. THC use appears to be associated with a higher proportion of serious adverse effects, including neuropsychological and cardiovascular effects. Inhaled cannabis appears to be associated with greater toxicity than the oral route. These data are presented together with the pharmacokinetic and pharmacodynamic data of THC and CBD.

CONCLUSION

The literature reports several frequent but rarely serious adverse effects of CBD during chronic use as well as a significant risk of drug interactions. THC use seems to be associated with a higher proportion of serious adverse effects compared to CBD, particularly at the neuropsychological and cardiovascular levels. Health professionals should be up to date on the particularities of therapeutic cannabis in terms of efficacy, safety and drug interactions.

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

METHODS

We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

FINDINGS

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

INTERPRETATION

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

FUNDING

Bill & Melinda Gates Foundation.

Investigating the Relationship between Parental Education, Asthma and Rhinitis in Children Using Path Analysis

Parental socioeconomic position (SEP) is a known determinant of a child's health. We aimed to investigate whether a low parental education, as proxy of SEP, has a direct effect on physician-diagnosed asthma, current asthma and current allergic rhinitis in children, or whether associations are mediated by exposure to other personal or environmental risk factors. This study was a secondary data analysis of two cross-sectional studies conducted in Italy in 2006. Data from 2687 adolescents (10-14 years) were analyzed by a path analysis model using generalized structural equation modelling. Significant direct effects were found between parental education and family characteristics (number of children (coefficient = 0.6229, p < 0.001) and crowding index (1.1263, p < 0.001)) as well as with exposure to passive smoke: during pregnancy (maternal: 0.4697, p < 0.001; paternal: 0.4854, p < 0.001), during the first two years of children's life (0.5897, p < 0.001) and currently (0.6998, p < 0.001). An indirect effect of parental education was found on physician-diagnosed asthma in children mediated by maternal smoking during pregnancy (0.2350, p < 0.05) and on current allergic rhinitis mediated by early environmental tobacco smoke (0.2002; p < 0.05). These results suggest the importance of promotion of ad-hoc health policies for promoting smoking cessation, especially during pregnancy.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review

Background

Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies.

Methods

We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021.

Results

We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables.

Conclusions

Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13925-z.

Rules and ward climate in acute psychiatric setting: Comparison of staff and patient perceptions

The ward climate or atmosphere refers to its material, emotional and social conditions. A good ward climate in psychiatric settings can influence the mood, behaviour and self-concept of patients and staff members and improve patient outcomes. Many studies have examined the relationship between ward climate and aggression, but only a few have investigated the effect of a ward's environment, rules and activities. This multicentric observational study aimed to assess the relationship between the rules/activities and the climate of four acute psychiatric units of Northern Italy. The Essen Climate Evaluation Scheme (EssenCES) questionnaire, which was administered to patients and staff, was used to evaluate the different dimensions of ward atmosphere. There was a good response rate (79%) in patients and staff members who completed the questionnaire (114 patients and 109 staff). Safety perception appeared to be quite different in patients and staff. The patients who were authorized to have more visiting hours and more time to use their mobile phone had higher scores on Experienced Safety subscale. A negative correlation between the Therapeutic Hold and Experienced Safety subscales was found in the staff members, and this was due to their negative perception. The ward climate seemed to be affected by the unit's rules, especially with respect to visits and the smartphones use. Nurses need to be aware of the importance of ward climate and how their own perception may differ from and that of patients: this gap could lead to decisions detached from the patients' needs.

Social Network and Environment as Determinants of Disability and Quality of Life in Aging: Results From an Italian Study

Background

The increase in life expectancy is leading to a worldwide increase in chronic diseases and disability, with significant concern about their management and long-term care. Investigating the aging process using a bio-psychosocial perspective is essential to understanding how to reduce disability and improve the quality of life of aging people. This study aims to explore the role of social networks and built environment as predictors of disability and quality of life in the Italian population aged over 50 years.

Materials and Methods

The research protocol is composed of several tools: World Health Organization Disability Assessment Scale 2.0 (WHODAS 2.0), World Health Organization Quality of Life Assessment in Aging (WHOQOL-AGE), Social Network Index (SNI), the Courage Built Environment Self-Reported Questionnaire (CBE-SR), and collection of sociodemographic information and information on health system coverage.

Results

A total of 431 people were administered the protocol, and among them, 209 were males and 222 were females, with a mean age of 70 years. The majority of the sample reported earning a middle or high school diploma, and 60.6% of the sample declared to have a good health status. The results showed that people with a good social support network have higher levels of functioning and quality of life. However, the built environment did not significantly predict either disability or quality of life.

Conclusions

These results could provide elements for dialogue with institutions and policymakers. This is fundamental to develop active policies aimed at the implementation of services and systems to promote healthy aging process.

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990-2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.

FINDINGS

In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (-33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [-28·4 to 3·4]) and for type 1 diabetes (-13·6% [-29·3 to 8·9]).

INTERPRETATION

Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.

FUNDING

Bill & Melinda Gates Foundation.

Time of onset and/or diagnosis of ADHD in European children: a systematic review

BACKGROUND

Attention-Deficit/ Hyperactivity Disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Symptoms related to this disorder cause a significant impairment in school tasks and in the activities of children's daily lives; an early diagnosis and appropriate treatment could almost certainly help improve their outcomes. The current study, part of the Models Of Child Health Appraised (MOCHA) project, aims to explore the age at which children experience the onset or diagnosis of ADHD in European countries.

METHODS

A systematic review was done examining the studies reporting the age of onset/diagnosis (AO/AD) of ADHD in European countries (28 European Member States plus 2 European Economic Area countries), published between January 1, 2010 and December 31, 2019. Of the 2276 identified studies, 44 met all the predefined criteria and were included in the review.

RESULTS

The lowest mean AO in the children diagnosed with ADHD alone was 2.25 years and the highest was 7.5 years. It was 15.3 years in the children with ADHD and disruptive behaviour disorder. The mean AD ranges between 6.2 and 18.1 years.

CONCLUSIONS

Our findings indicate that there is a wide variability in both the AO and AD of ADHD, and a too large distance between AO and AD. Since studies in the literature suggest that an early identification of ADHD symptoms may facilitate early referral and treatment, it would be important to understand the underlying reasons behind the wide variability found.

TRIAL REGISTRATION

PROSPERO registration: CRD42017070631 .

Quality of child healthcare in European countries: common measures across international databases and national agencies

Background

The evaluation of child healthcare is not yet widely explored, especially from a cross-country comparison perspective. The routine adoption of measures by national assessment agencies is under-investigated. Though the guiding principles developed at international level call for a child-centric multi-dimensional evaluation of child care, its feasibility is hampered by the availability of robust and harmonized data.

Methods

To explore the data availability, international databases (IDBs) were scrutinized and measures dealing with child health-related issues were collated. In parallel, an ad hoc questionnaire was administrated to 30 Country Agents (CAs) to gather measures routinely adopted at local level. To facilitate the comparison of measures, a three-level conceptual map was developed.

Results

The IDBs yielded at 207 measures that pertained mainly to non-health determinants of health, whereas the 352 measures obtained from CAs focused on process and outcome. A set of 33 common measures that related to immunization, morbidity and mortality were identified.

Conclusions

A limited set of measures used both in IDBs and at national level identify common areas of concerns that certainly capture crucial issues with child prevention and health outcomes. However, they are far from satisfying a child-centric multi-dimensional approach to the evaluation of child well-being and well-becoming. There is room for improvement at both international and national levels. IDBs should include and harmonize measures that concern the provision of child-centric services and encompass physical, social and mental development. At the national level, efforts towards the inclusion of measures that concern non-health determinants of health should be pursued.

[The result of application's monitoring of NEWS score in a surgery unit of a North Italy hospital]

INTRODUCTION

In a hospital in Northern Italy was decided to experiment a new standardized methodology for detection and evaluation of vital parameters and effective communication between healthcare professionals, with the applications of NEWS score. Then it was necessary to evaluate the application and usefulness of the score in the specific contest. The aim of this project was adopting a validated and standardized methodology for detecting vital parameters to identificate early the signs and symptoms of a possible clinical deterioration and to create an effective communication between professionals. In the end it was necessary to monitor the correct application of the NEWS score to evaluate the usefulness of extending the score in surgical units.

METHODS

The indicators were identified and monitored, consulting a sample of medical Gynecologic records of the 2019. The sample size useful for having a confidence level of 95% was identified, which, according to the Sample Size Calculator, known the population of 865 patients, corresponds to 160 sample units. An ad hoc data set was then developed for data collection.

RESULTS

The correctness of the execution of clinical monitoring according to the parameters provided by the score is 75%, while the completeness of score's recording is 99% of the sample analyzed. The days of hospitalization in which there is a score≥5 are 10, equal to 1.5%. An in-depth study of cases with a score ≥5 showed that in 9 out of 10 cases the doctor was alerted.

DISCUSSION

The NEWS score is useful in the early identification of risk situations, in rapid and objective communication and in the timely activation of interventions to prevent complications. Furthermore, the application of the score does not involve a waste of time than that used for the collection of vital parameters.

Quality of life improvement in children with attention-deficit hyperactivity disorder reduces family's strain: A structural equation model approach

OBJECTIVES

The objective of the study is to analyse how the quality of life of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) impacts the relationship between disease severity and family burden.

METHOD

The data collected by a longitudinal, observational study involving 1478 children with ADHD residing in 10 European countries (aged 6 to 18 years) were analysed to evaluate the relationships between ADHD severity, the children's quality of life and family burden.

RESULTS

The disorder's severity directly and indirectly affected the children's health-related quality of life (HRQoL) and family burden. The degree of family burden was modulated by the children's HRQoL.

CONCLUSIONS

One of the primary causes of the stress experienced by parents of children with ADHD is their perception of the child's reduced HRQoL and not the symptom severity itself. Efforts to minimize symptom severity cannot alone reduce family burden.

Variability in the assessment of children's primary healthcare in 30 European countries

Background

The high variability in the types and number of measures adopted to evaluate childcare across European countries makes it necessary to investigate country practices to identify trends in setting national priorities in the assessment of child well-being.

Objective

This paper intends to investigate country practices under the lens of variability to explore possible trends in setting national priority in the evaluation of childcare. In particular, it analyses variability considering to what extent this depends on the tendency of adopting a broad vision (i.e. selecting measures for a larger variety of aspects) or whether this is influenced by the choice of adopting an in-depth approach (i.e. using more measures to analyse a specific aspect)

Methods

An ad hoc questionnaire was administered to a national expert in each country and yielded 352 measures. To analyse variability, the breadth in the number of aspects considered was explored using a convergence index, while the depth in the distribution of measures in each aspect was investigated by computing a coefficient of variation. Countries were grouped by adopting a hierarchical clustering approach.

Results

There is a high variability across countries in the selection of measures that cover different aspects of childcare. Preferences in the distribution of measures are significant even at the domain level and in countries that use a limited number of measures and become more evident at the category and sub-category levels. The statistical analysis clusters countries in four main groups and two outliers. The in-depth distribution of measures focused on a specific aspect shows a homogeneous pattern, with the identification of two main groups of countries.

Conclusions

A limited set of measures are shared across countries hampering a robust comparison of paediatric models. The selection of measures shows that the evaluation is closely related to national priorities as resulting from the number and types of measures adopted. Moreover, a range of a reasonable number of measures can be hypothesized to address the quality of childcare under a multi-dimensional perspective.

Effect of South Africa's interim mandatory salt reduction programme on urinary sodium excretion and blood pressure

•

Thirty percent reduction in population salt intake by 2025 is recommended by WHO.

•

South Africa introduced mandatory maximum sodium limits in processed foods in 2016.

•

A countrywide impact evaluation assessed change in salt intake after two years.

•

Salt intake measured using 24hr Na excretion dropped by 1.15 g per day.

•

Ongoing evaluation is necessary as more stringent targets were implemented in 2019.

South Africa implemented legislation in June 2016 mandating maximum sodium (Na) levels in processed foods. A pre-post impact evaluation assessed whether the interim legislative approach reduced salt intake and blood pressure. Baseline Na intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) Wave 2 (Aug-Dec 2015). 24-hour urine samples were collected in a random subsample (n = 1,299; of which n = 750 were considered valid (volume ≥ 300 mL and creatinine ≥ 4 mmol/day (women) or ≥ 6 mmol/day (men))). Follow-up urine samples were collected in Wave 3 (Jun 2018-Jun 2019), with replacements included for those lost to follow-up (n = 1,189; n = 548 valid). In those aged 18 − 49y, median salt intake was 7.8 (4.7, 12.0) g/day in W2 (n = 274), remaining similar in the W3 sample (7.7 (4.9, 11.3) g salt/day (n = 92); P = 0.569). In older adults (50 + y), median salt intake was 5.8 (4.0, 8.5) g/day (n = 467) in W2, and 6.0 (4.0, 8.6) g/day (n = 455) in W3 (P = 0.721). Controlling for differences in background characteristics, overall salt intake dropped by 1.15 g/day (P = 0.028). 24hr urinary Na concentrations from a countrywide South African sample suggest that salt intakes have dropped during the interim phase of mandatory sodium legislation. Further measurement of population level salt intake following stricter Na targets, enforced from June 2019, is necessary.

Identifying co-occurrence and clustering of chronic diseases using latent class analysis: cross-sectional findings from SAGE South Africa Wave 2

OBJECTIVES

To classify South African adults with chronic health conditions for multimorbidity (MM) risk, and to determine sociodemographic, anthropometric and behavioural factors associated with identified patterns of MM, using data from the WHO's Study on global AGEing and adult health South Africa Wave 2.

DESIGN

Nationally representative (for ≥50-year-old adults) cross-sectional study.

SETTING

Adults in South Africa between 2014 and 2015.

PARTICIPANTS

1967 individuals (men: 623 and women: 1344) aged ≥45 years for whom data on all seven health conditions and socioeconomic, demographic, behavioural, and anthropological information were available.

MEASURES

MM latent classes.

RESULTS

The prevalence of MM (coexistence of two or more non-communicable diseases (NCDs)) was 21%. The latent class analysis identified three groups namely: minimal MM risk (83%), concordant (hypertension and diabetes) MM (11%) and discordant (angina, asthma, chronic lung disease, arthritis and depression) MM (6%). Using the minimal MM risk group as the reference, female (relative risk ratio (RRR)=4.57; 95% CI (1.64 to 12.75); p =0.004) and older (RRR=1.08; 95% CI (1.04 to 1.12); p<0.001) participants were more likely to belong to the concordant MM group, while tobacco users (RRR=8.41; 95% CI (1.93 to 36.69); p=0.005) and older (RRR=1.09; 95% CI (1.03 to 1.15); p=0.002) participants had a high likelihood of belonging to the discordant MM group.

CONCLUSION

NCDs with similar pathophysiological risk profiles tend to cluster together in older people. Risk factors for MM in South African adults include sex, age and tobacco use.

Determinants of change in blood pressure in Ghana: Longitudinal data from WHO-SAGE Waves 1-3

The prevalence of hypertension is increasing in low- and middle-income countries, however statistics are generally derived from cross sectional surveys that utilize different methodologies and population samples. We investigated blood pressure (BP) changes over 11-12 years in a large cohort of adults aged 50 years and older (n = 820) included in the World Health Organization's Study on global AGEing and adult health (WHO-SAGE Ghana) Wave 1 (2007/8) with follow up in Wave 3 (2019). Participants' BP were measured in triplicate and a survey completed at both time points. Survey instruments collected information on sociodemographic characteristics, lifestyle, health behaviors and chronic conditions. While no significant difference was found in systolic BP between Waves 1 and 3, diastolic BP decreased by 9.7mmHg (mean = 88.6, 15.4 to 78.9, 13.6 respectively) and pulse pressure increased by 9.5mmHg (44.8, 13.7 to 54.3, 14.1). Awareness of hypertension increased by 37%, from (20% to 57%), but no differences were found for the proportion of hypertensives receiving treatment nor those that had controlled BP. Mixed effects modelling showed a decrease in diastolic BP was associated with increasing age, living in rural areas and having health insurance. Factors associated with an increased awareness of hypertension were residing in urban areas, having health insurance and increasing body mass index. While diagnosis of hypertension has improved over time in Ghana, there is an ongoing need to improve its treatment in older adults.

Salt-reduction strategies may compromise salt iodization programs: Learnings from South Africa and Ghana

OBJECTIVES

Universal salt iodization has been adopted by many countries to address iodine deficiency. More recently, salt-reduction strategies have been widely implemented to meet global salt intake targets of <5 g/d. Compatibility of the two policies has yet to be demonstrated. This study compares urinary iodine excretion (UIE) according to 24-h urinary sodium excretion, between South Africa (SA) and Ghana; both countries have implemented universal salt iodization, but in Ghana no salt-reduction legislation has been implemented.

METHODS

Participants from the World Health Organization's Study on Global Ageing and Adult Health Wave 3, with survey and valid 24-h urinary data (Ghana, n = 495; SA, n = 707), comprised the sample. Median 24-h UIE was compared across salt intake categories of <5, 5-9 and >9 g/d.

RESULTS

In Ghana, median sodium excretion indicated a salt intake of 10.7 g/d (interquartile range [IQR] = 7.6), and median UIE was 182.4 µg/L (IQR = 162.5). In SA, both values were lower: median salt = 5.6 g/d (IQR = 5.0), median UIE = 100.2 µg/L (IQR = 129.6). UIE differed significantly across salt intake categories (P < 0.001) in both countries, with positive correlations observed in both-Ghana: r = 0.1501, P < 0.0011; South Africa: r = 0.4050, P < 0.0001. Participants with salt intakes <9 g/d in SA did not meet the World Health Organization's recommended iodine intake of 150 µg/d, but this was not the case in Ghana.

CONCLUSIONS

Monitoring and surveillance of iodine status is recommended in countries that have introduced salt-reduction strategies, in order to prevent reemergence of iodine deficiency.

Predicting steady-state endoxifen plasma concentrations in breast cancer patients by CYP2D6 genotyping or phenotyping. Which approach is more reliable?

In previous studies, steady-state Z-endoxifen plasma concentrations (ENDOss) correlated with relapse-free survival in women on tamoxifen (TAM) treatment for breast cancer. ENDOss also correlated significantly with CYP2D6 genotype (activity score) and CYP2D6 phenotype (dextromethorphan test). Our aim was to ascertain which method for assessing CYP2D6 activity is more reliable in predicting ENDOss. The study concerned 203 Caucasian women on tamoxifen-adjuvant therapy (20 mg q.d.). Before starting treatment, CYP2D6 was genotyped (and activity scores computed), and the urinary log(dextromethorphan/dextrorphan) ratio [log(DM/DX)] was calculated after 15 mg of oral dextromethorphan. Plasma concentrations of TAM, N-desmethyl-tamoxifen (ND-TAM), Z-4OH-tamoxifen (4OH-TAM) and ENDO were assayed 1, 4, and 8 months after first administering TAM. Multivariable regression analysis was used to identify the clinical and laboratory variables predicting log-transformed ENDOss (log-ENDOss). Genotype-derived CYP2D6 phenotypes (PM, IM, NM, EM) and log(DM/DX) correlated independently with log-ENDOss. Genotype-phenotype concordance was almost complete only for poor metabolizers, whereas it emerged that 34% of intermediate, normal, and ultrarapid metabolizers were classified differently based on log(DM/DX). Multivariable regression analysis selected log(DM/DX) as the best predictor, with patients' age, weak inhibitor use, and CYP2D6 phenotype decreasingly important: log-ENDOss = 0.162 - log(DM/DX) × 0.170 + age × 0.0063 - weak inhibitor use × 0.250 + IM × 0.105 + (NM + UM) × 0.210; (R2  = 0.51). In conclusion, log(DM/DX) seems superior to genotype-derived CYP2D6 phenotype in predicting ENDOss.

Salt and potassium intake among adult Ghanaians: WHO-SAGE Ghana Wave 3

Though Ghana has high hypertension prevalence, the country lacks current national salt consumption data required to build and enhance advocacy for salt reduction. We explored the characteristics of a randomly selected sub sample that had valid urine collection, along with matched survey, anthropometric and BP data (n = 839, mean age = 60y), from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE), Ghana Wave 3, n = 3053). We also investigated the relationship between salt intake and blood pressure (BP) among the cohort. BP was measured in triplicate and 24 h urine was collected for the determination of urinary sodium (Na), potassium (K), creatinine (Cr) and iodine levels. Hypertension prevalence was 44.3%. Median salt intake was 8.3 g/day, higher in women compared to men (8.6, interquartile range (IQR) 7.5 g/day vs 7.5, IQR 7.4 g/day, p <  0.01), younger participants (18-49 y) compared to older ones (50+ y) (9.7, IQR 7.9 g/day vs 8.1, IQR 7.1 g/day, p <  0.01) and those with higher Body Mass Index (BMI) (> 30 kg/m2) compared to a healthy BMI (18.5-24.9 kg/m2) (10.04, IQR 5.1 g/day vs 6.2, IQR 5.6 g/day, p <  0.01). More than three quarters (77%, n = 647) of participants had salt intakes above the WHO maximum recommendation of 5 g/d, and nearly two thirds (65%, n = 548) had daily K intakes below the recommended level of 90 mmol. Dietary sodium to potassium (Na: K) ratios above 2 mmol/mmol were positively associated with increasing BP with age. Population-based interventions to reduce salt intake and increase K consumption are needed.

Correcting for Intra-Individual Variability in Sodium Excretion in Spot Urine Samples Does Not Improve the Ability to Predict 24 h Urinary Sodium Excretion

Given a global focus on salt reduction efforts to reduce cardiovascular risk, it is important to obtain accurate measures of salt intake on a population level. This study determined firstly whether adjustment for intra-individual variation in urinary sodium (Na) excretion using three repeated 24 h collections affects daily estimates and whether the use of repeated spot urine samples results in better prediction of 24 h Na compared to a single collection. Twenty three community-dwelling men and women from South Africa (mean age 59.7 years (SD = 15.6)) participating in the World Health Organization Study on global AGEing and adult health (WHO-SAGE) Wave 3 study collected 24 h and spot early morning urine samples over three consecutive days to assess urinary Na excretion. INTERSALT, Tanaka, and Kawasaki prediction equations, with either average or adjusted spot Na values, were used to estimate 24 h Na and compared these against measured 24 h urinary Na. Adjustment was performed by using the ratio of between-person (sb) and total (sobs) variability obtained from repeated measures analysis of variance. Sensitivity of the equations to predict daily urinary Na values below 5 g salt equivalent was calculated. The sb/sobs for urinary Na using three repeated samples for spot and 24 h samples were 0.706 and 0.798, respectively. Correction using analysis of variance for 3 × 24 h collections resulted in contraction of the upper end of the distribution curve (90th centile: 157 to 136 mmoL/day; 95th centile: 220 to 178 mmoL/day). All three prediction equations grossly over-estimated 24 h urinary Na excretion, regardless of whether a single spot urine or repeated collections corrected for intra-individual variation were used. Sensitivity of equations to detect salt intake equivalent values of ≤5 g/day was 13% for INTERSALT, while the other two equations had zero sensitivity. Correcting for intra-individual variability in Na excretion using three 24 h urine collections contracted the distribution curve for high intakes. Repeated collection of spot samples for urinary Na analysis does not improve the accuracy of predicting 24 h Na excretion. Spot urine samples are not appropriate to detect participants with salt intakes below the recommended 5 g/day.

Predictors of pain in general ageing populations: results from a multi-country analysis based on ATHLOS harmonized database

BACKGROUND

Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people, and with increasing trends in general populations. Different risk factors for pain have been identified, but generally from studies with limited samples and a limited number of candidate predictors. The aim of this study is to evaluate the predictors of pain from a large set of variables and respondents.

METHODS

We used part of the harmonized dataset of ATHLOS project, selecting studies and waves with a longitudinal course, and in which pain was absent at baseline and with no missing at follow-up. Predictors were selected based on missing distribution and univariable association with pain, and were selected from the following domains: Socio-demographic and economic characteristics, Lifestyle and health behaviours, Health status and functional limitations, Diseases, Physical measures, Cognition, personality and other psychological measures, and Social environment. Hierarchical logistic regression models were then applied to identify significant predictors.

RESULTS

A total of 13,545 subjects were included of whom 5348 (39.5%) developed pain between baseline and the average 5.2 years' follow-up. Baseline risk factors for pain were female gender (OR 1.34), engaging in vigorous exercise (OR 2.51), being obese (OR 1.36) and suffering from the loss of a close person (OR 1.88) whereas follow-up risk factors were low energy levels/fatigue (1.93), difficulties with walking (1.69), self-rated health referred as poor (OR 2.20) or average to moderate (OR 1.57) and presence of sleep problems (1.80).

CONCLUSIONS

Our results showed that 39.5% of respondents developed pain over a five-year follow-up period, that there are proximal and distal risk factors for pain, and that part of them are directly modifiable. Actions aimed at improving sleep, reducing weight among obese people and treating fatigue would positively impact on pain onset, and avoiding vigorous exercise should be advised to people aged 60 or over, in particular if female or obese.

Comparison and validation of different models and variable selection methods for predicting survival after canine parvovirus infection

BACKGROUND

Canine parvovirus (CPV) represents one of the major infections in dogs. While supportive therapy significantly reduces mortality, other approaches have been reported to provide significant benefits. Unfortunately, the high cost of these treatments is typically a limiting factor. Consequently, a reliable prognostic tool allowing for an informed therapeutic approach would be of great interest. However, current methods are essentially based on 'a priori' selection of predictive variables, which could limit their predictive potential.

METHODS

In the present study, the predictive performances in terms of CPV enteritis survival likelihood of an operator-validated logistic regression were compared with those of more flexible methods featured by automatic variable selection. Several anamnestic, clinical, haematological and biochemical parameters were collected from 134 dogs at admission in a veterinary practice. Animal status was monitored until dismissal or death (mortality=21.6%).

RESULTS

The best automatic variable selection method (random forest) showed excellent discriminatory capabilities (AUC=0.997, sensitivity=0.941 and specificity=1) compared with the logistic regression model (AUC=0.831, sensitivity=0.882 and specificity=0.652), when evaluated on a fully independent test data set. The implemented approaches allowed to identify antithrombin, serum aspartate aminotransferase, serum lipase, monocyte and lymphocyte count as the clinical parameter combination with the highest predictive capability, thus limiting the panel of required tests.

CONCLUSION

The model validated in the present study allows prompt prediction of disease severity at admission and provides objective and reliable criteria to support the clinician in selection of the therapeutic approach.

Determinants of mobility in populations of older adults: Results from a cross-sectional study in Finland, Poland and Spain

OBJECTIVE

To identify the determinants of mobility among people aged 50+ from Finland, Spain and Poland.

STUDY DESIGN

Observational cross-sectional population study.

MAIN OUTCOME MEASURES

A mobility score was based on responses to items referring to body movements, walking, moving around and using transportation. Determinants of mobility were entered in hierarchical regression models in the following order: sociodemographic characteristics, health habits, chronic conditions, description of general state of health, vision and hearing, social networks, built environment.

RESULTS

Complete data were available for 3902 participants (mean age 65.1, SD 9.8). The final model explained 64.7% of the variation in mobility. The most relevant predictors were: pain, age and living in Finland, presence of arthritis, stroke and diabetes, high-risk waist circumference, physical inactivity, and perceiving the neighborhood environment as more exploitable.

CONCLUSIONS

Our results provide public health indications that could support concrete actions to address the modifiable determinants of mobility. These include the identification and treatment of pain-related problems, increasing the level of physical activity and the improvement of neighborhood features in terms of presence of general utility places or means of transportation. These factors can be modified with short- to medium-term interventions and such a change could improve the mobility of ageing population, with evident benefits for health.

The Diagnostic Yield of Array Comparative Genomic Hybridization Is High Regardless of Severity of Intellectual Disability/Developmental Delay in Children

Microarray-based comparative genomic hybridization is a method of molecular analysis that identifies chromosomal anomalies (or copy number variants) that correlate with clinical phenotypes. The aim of the present study was to apply a clinical score previously designated by de Vries to 329 patients with intellectual disability/developmental disorder (intellectual disability/developmental delay) referred to our tertiary center and to see whether the clinical factors are associated with a positive outcome of aCGH analyses. Another goal was to test the association between a positive microarray-based comparative genomic hybridization result and the severity of intellectual disability/developmental delay. Microarray-based comparative genomic hybridization identified structural chromosomal alterations responsible for the intellectual disability/developmental delay phenotype in 16% of our sample. Our study showed that causative copy number variants are frequently found even in cases of mild intellectual disability (30.77%). We want to emphasize the need to conduct microarray-based comparative genomic hybridization on all individuals with intellectual disability/developmental delay, regardless of the severity, because the degree of intellectual disability/developmental delay does not predict the diagnostic yield of microarray-based comparative genomic hybridization.

Two Years Follow up of Domain Specific Cognitive Training in Relapsing Remitting Multiple Sclerosis: A Randomized Clinical Trial

Cognitive rehabilitation in multiple sclerosis (MS) has been reported to induce neuropsychological improvements, but the persistence of these effects has been scarcely investigated over long follow ups. Here, the results of a multicenter randomized clinical trial are reported, in which the efficacy of 15 week domain specific cognitive training was evaluated at 2 years follow up in 41 patients. Included patients were randomly assigned either to domain specific cognitive rehabilitation, or to aspecific psychological intervention. Patients who still resulted to be cognitively impaired at 1 year follow up were resubmitted to the same treatment, whereas the recovered ones were not. Neuropsychological tests and functional scales were administered at 2 years follow up to all the patients. Results revealed that both at 1 and at 2 years follow up more patients in the aspecific group (18/19, 94% and 13/17, 76% respectively) than in the specific group (11/22, 50% and 5/15, 33% respectively) resulted to be cognitively impaired. Furthermore patients belonging to the specific group showed significantly less impaired tests compared with the aspecific group ones (p = 0.02) and a significant amelioration in the majority of the tests. On the contrary patients in the aspecific group did not change. The specific group subjects also perceived a subjective improvement in their cognitive performance, while the aspecific group patients did not. These results showed that short time domain specific cognitive rehabilitation is a useful treatment for patients with MS, shows very long lasting effects, compared to aspecific psychological interventions. Also subjective cognitive amelioration was found in patients submitted to domain specific treatment after 2 years.

Widowhood, Socio-Economic Status, Health and Wellbeing in Low and Middle-Income Countries

Using data on women aged 50 and over from the WHO's Survey of Ageing and Adult Health for China, Ghana, India, the Russian Federation and South Africa (N=17,009), we assess associations between widowhood and socio-economic, health and quality of life deprivations. We find variations in the prevalence and timing of widowhood across the study countries, and associations between widowhood and being in the poorest wealth quintile for all five countries. For other deprivations, national experiences varied, with stronger and more consistent effects for India and China. These findings challenge generalised claims about widowhood and call for more contextualised analysis.

Germ line polymorphisms as predictive markers for pre-surgical radiochemotherapy in locally advanced rectal cancer: a 5-year literature update and critical review

PURPOSE

Locally advanced rectal cancer is currently treated with pre-surgical radiotherapy and chemotherapy. Approximately one-half of patients obtain a relevant shrinkage/disappearance of tumour, with major clinical advantages. The remaining patients, in contrast, show no benefit and possibly need alternative treatment. To provide the best therapeutic option for each individual patient, predictive markers have been widely researched. This review was undertaken to evaluate recent progress made in this field.

METHODS

A systematic literature search was performed using PubMed and Scopus database, focused on germ line gene polymorphisms as biomarkers and response and toxicity as outcomes. Because an exhaustive previous review was available describing findings up to 2008, we restricted our analysis to the last 5 years.

RESULTS

Ten original research articles were found, reporting promising results for some candidate genes in drug metabolism (TYMS, MTHFR), DNA repair (XRCC1, OGG1, CCND1) and inflammation (SOD2, TGFB1)/immunity (IL13) pathways, but with no firm conclusion. All the studies had small sample size and were defined as exploratory. This review highlights pivotal molecular, clinical, genetic and statistical issues in the investigation of genetic polymorphisms as outcome predictors for rectal cancer and offers suggestions for future development.

CONCLUSIONS

What emerges is a clear need for new proposals, especially in view of the increasing evidence for tumour-host and gene-gene interactions during anticancer treatment, together with stronger adherence to proper methodological requirements.

A RCT Comparing Specific Intensive Cognitive Training to Aspecific Psychological Intervention in RRMS: The SMICT Study

BACKGROUND

Specific cognitive rehabilitation in multiple sclerosis (MS) resulted to be effective compared to no treatment. So far the possible role of an aspecific psychological intervention on cognition has not been investigated.

OBJECTIVE

The aim of the SMICT RCT was to compare the efficacy of a specific cognitive training with an aspecific psychological intervention in relapsing-remitting MS patients.

METHODS

From a sample of 150 patients, with the same disability and immunomodulatory therapy, submitted to neuropsychological examination, 45 impaired in at least one test were included and 41 randomized to have either a specific cognitive training for the impaired function (22) or to an aspecific psychological intervention (19) for 4 months, starting after baseline examination. Neuropsychological tests and functional scales were administered at baseline and 1 year later.

RESULTS

After 1 year, the mean number of pathological tests was significantly lower in the specific treatment group, compared to the aspecific group. Memory and attention/speeded information processing functions were mostly improved. Depression and quality of life were not different between groups at follow up.

CONCLUSION

Our study demonstrates that an intensive and domain specific cognitive approach results to be more effective than aspecific psychological intervention in patients with MS.

Linkage Analysis of Genomic Regions Contributing to the Expression of Type 1 Diabetes Microvascular Complications and Interaction with HLA

We conducted linkage analysis to follow up earlier work on microvascular complications of type 1 diabetes (T1D). We analyzed 415 families (2,008 individuals) previously genotyped for 402 SNP markers spanning chromosome 6. We did linkage analysis for the phenotypes of retinopathy and nephropathy. For retinopathy, two linkage peaks were mapped: one located at the HLA region and another novel locus telomeric to HLA. For nephropathy, a linkage peak centromeric to HLA was mapped, but the linkage peak telomeric to HLA seen in retinopathy was absent. Because of the strong association of T1D with DRB1*03:01 and DRB1*04:01, we stratified our analyses based on families whose probands were positive for DRB1*03:01 or DRB1*04:01. When analyzing the DRB1*03:01-positive retinopathy families, in addition to the novel telomeric locus, one centromeric to HLA was identified at the same location as the nephropathy peak. When we stratified on DRB1*04:01-positive families, the HLA telomeric peak strengthened but the centromeric peak disappeared. Our findings showed that HLA and non-HLA loci on chromosome 6 are involved in T1D complications' expression. While the HLA region is a major contributor to the expression of T1D, our results suggest an interaction between specific HLA alleles and other loci that influence complications' expression.

Using linkage analysis to detect gene-gene interaction by stratifying family data on known disease, or disease-associated, alleles

Detecting gene-gene interaction in complex diseases is a major challenge for common disease genetics. Most interaction detection approaches use disease-marker associations and such methods have low power and unknown reliability in real data. We developed and tested a powerful linkage-analysis-based gene-gene interaction detection strategy based on conditioning the family data on a known disease-causing allele or disease-associated marker allele. We computer-generated multipoint linkage data for a disease caused by two epistatically interacting loci (A and B). We examined several two-locus epistatic inheritance models: dominant-dominant, dominant-recessive, recessive-dominant, recessive-recessive. At one of the loci (A), there was a known disease-related allele. We stratified the family data on the presence of this allele, eliminating family members who were without it. This elimination step has the effect of raising the “penetrance” at the second locus (B). We then calculated the lod score at the second locus (B) and compared the pre- and post-stratification lod scores at B. A positive difference indicated interaction. We also examined if it was possible to detect interaction with locus B based on a disease-marker association (instead of an identified disease allele) at locus A. We also tested whether the presence of genetic heterogeneity would generate false positive evidence of interaction. The power to detect interaction for a known disease allele was 60–90%. The probability of false positives, based on heterogeneity, was low. Decreasing linkage disequilibrium between the disease and marker at locus A decreased the likelihood of detecting interaction. The allele frequency of the associated marker made little difference to the power.

Genome-wide association study of blood pressure extremes identifies variant near UMOD associated with hypertension

Hypertension is a heritable and major contributor to the global burden of disease. The sum of rare and common genetic variants robustly identified so far explain only 1%–2% of the population variation in BP and hypertension. This suggests the existence of more undiscovered common variants. We conducted a genome-wide association study in 1,621 hypertensive cases and 1,699 controls and follow-up validation analyses in 19,845 cases and 16,541 controls using an extreme case-control design. We identified a locus on chromosome 16 in the 5′ region of Uromodulin (UMOD; rs13333226, combined P value of 3.6×10⁻¹¹). The minor G allele is associated with a lower risk of hypertension (OR [95%CI]: 0.87 [0.84–0.91]), reduced urinary uromodulin excretion, better renal function; and each copy of the G allele is associated with a 7.7% reduction in risk of CVD events after adjusting for age, sex, BMI, and smoking status (H.R. = 0.923, 95% CI 0.860–0.991; p = 0.027). In a subset of 13,446 individuals with estimated glomerular filtration rate (eGFR) measurements, we show that rs13333226 is independently associated with hypertension (unadjusted for eGFR: 0.89 [0.83–0.96], p = 0.004; after eGFR adjustment: 0.89 [0.83–0.96], p = 0.003). In clinical functional studies, we also consistently show the minor G allele is associated with lower urinary uromodulin excretion. The exclusive expression of uromodulin in the thick portion of the ascending limb of Henle suggests a putative role of this variant in hypertension through an effect on sodium homeostasis. The newly discovered UMOD locus for hypertension has the potential to give new insights into the role of uromodulin in BP regulation and to identify novel drugable targets for reducing cardiovascular risk.

Hypertension is the leading contributor to global mortality with a global prevalence of 26.4% in 2000, projected to increase to 29.2% by 2025. While 50%–60% of population variation in blood pressure can be attributable to additive genetic factors, all the genetic variants robustly identified so far explain only 1%–2% of the population variance indicating the presence of additional undiscovered risk variants. Using an extreme case-control strategy, we have discovered a SNP in the promoter region of the uromodulin gene (UMOD) to be associated with hypertension (minor allele protective against hypertension). We then validated this association using large-scale population and case-control studies, where similar extreme criteria for selection of cases and controls have been used (21,466 cases and 18,240 controls). As the locus was related to uromodulin, a protein exclusively expressed in the kidneys, we show that the association is independent of renal dysfunction. We also show preliminary evidence that the SNP allele which is protective against hypertension is also protective against cardiovascular events in 26,654 Swedish subjects followed-up for 12 years. The newly discovered UMOD locus for hypertension has the potential to give unique insights into the role of uromodulin in BP regulation and to identify novel drugable targets.

Injuries and illnesses in working dogs used during the disaster response after the bombing in Oklahoma City

OBJECTIVES

To determine characteristics of working dogs used during the disaster response after the bombing in Oklahoma City and risk factors for injuries and illnesses of those dogs, and to document recommendations for future disaster responses.

DESIGN

Survey.

STUDY POPULATION

Information for 74 working dogs used at the bombing site.

PROCEDURES

Dog handlers were identified and asked to complete a questionnaire. Questions were asked about the training and use of each dog, use of paw protection, injuries and illnesses incurred, possible effects after completion of duty at Oklahoma City, and handler's experience.

RESULTS

Data were obtained for all 74 dogs used at the site. Handlers of 69 of 74 (93%) dogs responded. The dogs had been extensively trained and were used 491 dog-days at the site, with 46 dogs used in search, 14 in patrol, 12 in explosive-detection duty, and 2 in search/patrol. Fifteen (22%) dogs became ill. Nineteen (28%) dogs incurred 20 injuries. Footpad injuries constituted 18 of the injuries. Only 16 of 69 (23%) dogs were provided with paw protection. Dogs were more likely to be injured when they were used in a search capacity, were used during the first 2 days after the bombing, were German Shepherd Dogs, or were older.

CLINICAL IMPLICATIONS

Although working in a high-risk environment, injuries to dogs were few, and most were minor. Specific recommendations could facilitate use of dogs in disaster situations and improve safety for those dogs.

Likelihood of introducing selected exotic diseases to domestic swine in the continental United States of America through uncooked swill

To help policy makers determine the need for current regulations (which require cooking of swill prior to feeding to swine), an assessment of the likelihood of exposing domestic swine in the continental United States of America (USA) to selected foreign animal disease agents by feeding uncooked swill was carried out. The hazard was assumed to originate from contraband food items entering the USA and subsequently being discarded in household waste. Such food waste may be collected by licensed waste feeders and fed to swine. This study showed that, of the four diseases studied, the probability of exposure was highest for the classical swine fever (hog cholera) virus. The median annual likelihood of one or more contaminated loads of swill being fed to swine in the continental USA was estimated as follows: classical swine fever virus: 0.063, foot and mouth disease virus: 0.043, swine vesicular disease virus: 0.005, African swine fever virus: 0.005.

Hairy leukoplakia: Epstein-Barr virus receptors on oral keratinocyte plasma membranes

Hairy leukoplakia (HL) is an oral white lesion associated with, and probably caused by, the Epstein-Barr virus (EBV) among persons who are seropositive for infection with human immunodeficiency virus. A unique feature of HL is its localization to the lateral portion of the tongue. To determine site differences for EBV receptors according to epithelial phenotype, these receptors were mapped in oral mucosa with the use of monoclonal antibodies HB5 and B2(specific for the Complement Fraction 3d/EBV receptor on B lymphocytes). Immunoperoxidase and immunofluorescence techniques were employed with the use of both cytologic suspensions and frozen tissue sections of oral epithelium. Pericellular plasma membrane immunoreactants were localized to upper spinous layer cells of the parakeratin phenotype; basal and parabasilar layers as well as all strata of orthokeratinized epithelia were negative. Those cells harboring EBV DNA as detected by in situ hybridization corresponded to cells with C3d/EBV receptors.