Can Timely Outpatient Visits Reduce Readmissions and Mortality Among Heart Failure Patients?

BACKGROUND

Outpatient follow-up after a hospital discharge may reduce the risk of readmissions, but existing evidence has methodological limitations.

OBJECTIVES

To assess effect of outpatient follow-up within 7, 14, 21 and 30 days of a hospital discharge on 30-day unplanned readmissions or mortality among heart failure (HF) patients; and whether this varies for patients with different clinical complexities.

DESIGN

We analyzed medical records between January 2016 and December 2021 from a prospective cohort study. Using time varying mixed effects parametric survival models, we examined the association between not having an outpatient follow-up and risk of adverse events. We used interaction models to assess if the effect of outpatient follow-up visit on outcomes varies with patients' clinical complexity (comorbidities, grip strength, cognitive impairment and length of inpatient stay).

PARTICIPANTS

Two hundred and forty-one patients with advanced HF.

MAIN MEASURES

30-day all-cause (or cardiac) adverse event defined as all cause (or cardiac) unplanned readmissions or death within 30 days of an unplanned all-cause (or cardiac) admission or emergency department visit.

KEY RESULTS

We analyzed 1595 all-cause admissions, inclusive of 1266 cardiac admissions. Not having an outpatient follow-up (vs having an outpatient follow-up) significantly increased the risk of 30-day all-cause adverse event. (risk [95% CI] - 14 days: 35.1 [84.5,-1.1]; 21 days: 43.9 [48.2,6.7]; 30 days: 31.1 [48.5, 7.9]) The risk (at 21 days) was higher for those with one co-morbidity (0.25 [0.11,0.58]), mild (0.67 [0.45, 1.00]) and moderate cognitive impairment (0.38 [0.17, 0.84]), normal grip strength (0.57 [0.34, 0.96]) and length of inpatient stay 7-13 days (0.45 [0.23, 0.89]).

CONCLUSION

Outpatient follow-up within 30 days after a hospital discharge reduced risk of 30-day adverse events among HF patients, the benefit varying according to clinical complexity. Results suggest the need to prioritize patients who benefit from outpatient follow-up for these visits.

Pharmacological management of fragile X syndrome: a systematic review and narrative summary of the current evidence

INTRODUCTION

Fragile X syndrome (FXS) is the most common inherited cause of Intellectual Disability. There is a broad phenotype that includes deficits in cognition and behavioral changes, alongside physical characteristics. Phenotype depends upon the level of mutation in the FMR1 (fragile X messenger ribonucleoprotein 1) gene. The molecular understanding of the impact of the FMR1 gene mutation provides an opportunity to target treatment not only at symptoms but also on a molecular level.

METHODS

We conducted a systematic review to provide an up-to-date narrative summary of the current evidence for pharmacological treatment in FXS. The review was restricted to randomized, blinded, placebo-controlled trials.

RESULTS

The outcomes from these studies are discussed and the level of evidence assessed against validated criteria. The initial search identified 2377 articles, of which 16 were included in the final analysis.

CONCLUSION

Based on this review to date there is limited data to support any specific pharmacological treatments, although the data for cannabinoids are encouraging in those with FXS and in future developments in gene therapy may provide the answer to the search for precision medicine. Treatment must be person-centered and consider the combination of medical, genetic, cognitive, and emotional challenges.

Age and co-morbidities as independent risk factors of infections leading to hospital admission in the last year of life among the elderly: A retrospective registry-based study

Background

The immune system declines with age, but the impact of chronological age may be affected by sex, co-morbidities, and sociodemographic factors.

Objective

The article aims to study infections associated with hospital admission in the elderly in their last year of life and the impact of age, sex, co-morbidities, and sociodemographic factors.

Method

A retrospective study based on registry data covering all care visits in Stockholm Region, Sweden, for 7 years was conducted. All deceased subjects with at least one hospital admission with infection as the main diagnosis in the last year of life were compared with subjects with no such admission. Subjects were categorized into three different age-groups 65-79, 80-89, and 90 years and above. Co-morbidity was measured by the Charlson Comorbidity Index (CCI) and sociodemographic factors were assessed using the 'Mosaic-system'. Subjects living in nursing homes were analyzed separately. Uni- and multivariable logistic regressions were conducted.

Results

Of the 55,238 subjects in the study population, 14,192 (26%) had at least one hospital admission due to infection in the last year of life. The risk of having a severe infection increased with age, adjusted odds ratio (OR): 1.30 (1.25-1.36), and 1.60 (1.52-1.69) for the age-groups 80-89 and ≥ 90 compared to the age-group 65-79. The most important factor for infection was a high co-morbidity score; adjusted OR: 1.75 (1.68-1.82). Male sex and living in a less affluent area were weaker risk factors for infections.

Conclusion

Chronological age and co-morbidities are independent risk factors of infections associated with hospital admission in the last year in life while male sex and sociodemographic factors have less impact.

Co-Morbidities of Irritable Bowel Syndrome in a Racially and Ethnically Diverse Population

Introduction: Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction (DGBI), and associated co-morbidities worsen quality of life. Research concerning IBS co-morbidities in different racial/ethnic groups is very sparse. This study aimed to determine the prevalence rates of co-morbidities and possible differences in a multiracial/ethnic IBS cohort. Methods: Based on ICD-9-coded IBS diagnosis, 740 outpatients (≥18 years) were included in this retrospective study at Boston Medical Center. Demographics and ICD-9-coded co-morbidities were extracted from electronic records. Descriptive statistics and multiple logistic regression were used for data analyses. Results: The most prevalent co-morbidities in this IBS cohort included gastroesophageal reflux disorder (GERD) (30%), depression (27%), anxiety (23%), (chronic obstructive pulmonary disease) COPD/asthma (16%), and obesity (10%). GERD was more prevalent in Hispanics and Blacks (p = 0.0005), and non-ulcer dyspepsia (NUD) was more prevalent in Blacks and Asians (p = 0.003). Higher rates of diabetes mellitus type 2 (DMT2) (p = 0.0003) and depression (p = 0.03), but not anxiety (p = 0.9), were present in Blacks and Hispanics. GERD was significantly associated with Hispanics (p = 0.003), dependent on age, overweight, and obesity. NUD was significantly associated with Blacks (p = 0.01) and Asians (p = 0.006), independent of sex, age, and BMI. Cancer of the thyroid, ovaries, and testis occurred at a five-fold higher rate than expected. Conclusions: Significant racial/ethnic differences exist for IBS co-morbidities in this study cohort, including depression, DMT2, GERD, and NUD. Certain cancers were found to be more frequent in this IBS sample as compared with the general population.

Evaluation of Age and Gender-Related Patterns in Clinical Features and Hematological Findings Among Hypothyroidism Patients in the Al-Jouf Region of Saudi Arabia: A Hospital-Based Study

BACKGROUND

The prevalence of hypothyroidism is high in Saudi Arabia and the contributing factors are iodine deficiency and lack of balanced nutrition. This study aims to correlate the gender, age, and presence of co-morbidities with the laboratory findings and clinical presentation.

METHODOLOGY

A cross-sectional study was done in the hospitals of the Al-Jouf region. The files of the patients diagnosed with hypothyroidism from the last two years were retrieved by non-probability consecutive sampling technique. IBM SPSS Statistics for Windows, Version 23, (Released 2015; IBM Corp., Armonk, New York, United States) was used for data entry and analysis. Descriptive statistics were presented as frequencies and proportions (for qualitative variables) and mean and standard deviation (SD) (for continuous data). Associated factors were identified through a chi-square test. A p-value less than 0.05 was considered statistically significant.

RESULTS

Most of the patients were females within the age group of 36 to 50 years. Significant differences were observed between male and female patients with respect to the FT4 levels, hemoglobin (Hb) levels, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) values, and RBC counts (p-values of <0.001, <0.001, <0.001, <0.001, <0.001 and <0.001, respectively). However, no significant differences were observed between male and female patients in the TSH levels and hematocrit values. Most of the patients were euthyroid (77.24%). The pattern of thyroid function status did not show significant differences with respect to the gender of participants and the different age groups (p-values of 0.447 and 0.775, respectively). The most common co-morbidities observed were diabetes and hypertension. No significant association between the co-morbidities and the pattern of thyroid function status was observed. The most common symptoms were epigastric pain, fatigue, constipation, drowsiness, altered bowel habits, and weight gain.

CONCLUSION

This hospital-based study provides valuable insights into some epidemiological characteristics, clinical features, and hematological findings in hypothyroidism patients of the Al-Jouf region. Significant differences were observed between male and female patients with respect to the FT4 levels, Hb levels, MCV, MCH, MCHC values, and RBC counts. The findings strengthen the existing knowledge base and emphasize the importance of timely detection and management of hypothyroidism in this population. Implementation of salt iodination programs and a timely evaluation of the hematological parameters is recommended. Further research is warranted to delve into the hidden mechanisms and long-term ramifications of hematological changes associated with hypothyroidism.

The role of co-morbidities in the development of an AEFI after COVID-19 vaccination in a large prospective cohort with patient-reported outcomes in the Netherlands

BACKGROUND

The effect of a preexisting comorbidity on the occurrence of adverse events after immunization (AEFIs) has been studied poorly. In this longitudinal cohort study, we assess the association between co-morbidities and the occurrence of AEFIs after COVID-19 vaccination. Also, we described the occurrence of flare-ups and their manifestation after COVID-19 vaccination in people with rheumatic diseases.

RESEARCH DESIGN AND METHODS

We performed multivariable logistic regression to investigate the association between the occurrence of AEFIs and 10 common comorbidities using patient-reported data from people vaccinated with the AstraZeneca, Johnson&Johnson, Moderna, or Pfizer vaccine.

RESULTS

Occurrence of any AEFI, injection site reactions, headache, fatigue, and/or malaise was significantly associated with presence of comorbidities, including psychological disorders, musculoskeletal disorders, and endocrine disorders after the first and second doses (OR ranges 1.23-1.77). One participant with rheumatoid arthritis experienced a flare-up after receiving the first dose of the AstraZeneca vaccine.

DISCUSSION/CONCLUSION

The results showed that the odds of reporting an AEFI after COVID-19 vaccination is significantly higher in the presence of some comorbidities whilst flare-ups are uncommon after receiving COVID-19 vaccination in people with rheumatic disease. In-depth research is needed to validate our results and unravel the observed associations from a mechanistic perspective.

Prevalence of Age-Related Sensorineural Hearing Loss and Related Factors in Elderly Patients Attending Tertiary Hospital in Tanzania

PURPOSE

Age-related sensorineural hearing loss (SNHL), is a progressive, usually bilateral hearing loss that occurs in elderly. It is correctable using rehabilitative hearing devices, which can vastly improve the older person's quality of life. This study aimed to find out the prevalence and related factors of age-related sensorineural hearing loss among elderly patients in Tanzania.

METHODS

A total of 380 elderly patients who received Otorhinolaryngology (ORL) services at Muhimbili tertiary hospital were enrolled. Participants were screened for hearing loss and interviewed by the structured questionnaire followed by otoscopic examination and Pure tone Audiometry (PTA).

RESULTS

This study included 182(47.9%) males, and 198 (52.1%) females. The prevalence of SNHL was 27.6%, males were mostly affected 57(31.3%) p = 0.574. Bilateral SNHL was found 90 (85.7%) p = 0.026, and the severity of age-related SNHL was found to increase as age increases.

CONCLUSION

Sensorineural hearing loss among the elderly was prevalent, mostly bilateral, and the severity increases with age. Confounding factors such as hypertension, diabetes mellitus (DM), cigarette smoking, and ototoxic medication may have contributed. Elderly should be screened for hearing loss especially on the individuals with other co-morbidities for early diagnosis and management in order to improve the quality of life of the elderly.

International AIDS society conference 2023 summary

AIM

This article summarizes key research presented at the International AIDS Society (IAS) Conference in Brisbane, held in July 2023.

CO-MORBIDITIES

The REPRIEVE Trial as a conference highlight, demonstrating significantly fewer major cardiovascular events amongst people with HIV who were randomized to pitavastatin compared to placebo. Key data on weight, hypertension and incident diabetes are also summarized.

ANTIRETROVIRAL THERAPY

Novel data on doravirine and islatravir are described as are trials demonstrating efficacy dolutegravir/lamivudine first-line in people without baseline resistance testing and in suppressed switch amongst people with historic lamivudine resistance.

HIV CURE

The sixth case of HIV cure secondary to stem cell transplantation is summarized, as are new insights into the central nervous system as an HIV reservoir.

Understanding the Burden of 30-Day Readmission in Patients With Both Primary and Secondary Diagnoses of Heart Failure: Causes, Timing, and Impact of Co-Morbidities

Although efforts to reduce 30-day readmission rates have mainly focused on patients with heart failure (HF) as a primary diagnosis at index hospitalization, patients with HF as a secondary diagnosis remain common, costly, and understudied. This study aimed to determine the incidence, etiology, and patterns of 30-day readmissions after discharge for HF as a primary and secondary diagnosis and investigate the impact of co-morbidities on HF readmission. The National Readmission Database from 2014 to 2016 was used to identify HF patients with a linked 30-day readmission. Patient and hospital characteristics, admission features, and Elixhauser-related co-morbidities were compared between the 2 groups. Readmitted patients in both groups were younger, male, with lower household income, higher mortality risk, and higher hospitalization costs. Over 60% of readmissions were for reasons other than HF, and greater than 1/3 had more than 2 readmissions within 30 days, with a median time to readmission of 12 days. Both cohorts had high readmission rates and high rates of readmission for causes other than HF. Our findings suggest that efforts to reduce 30-day readmission rates should be extended to patients with secondary HF diagnosis, with surveillance extending to 2 weeks postdischarge to identify patients at risk.

Descriptive Analysis of Pre-existing Data on Eosinophilic Esophagitis and Associated Morbidities in Cleveland Clinic Abu Dhabi, United Arab Emirates

BACKGROUND

Data on eosinophilic gastrointestinal disorders (EGIDs) are limited in the United Arab Emirates.

OBJECTIVE

This study aimed to describe the distribution of eosinophilic gastritis/gastroenteritis (EoG/EGE) and eosinophilic esophagitis (EoE) among patients whose data are recorded on the Cleveland Clinic Abu Dhabi (CCAD) systems.

METHODS

Anonymized aggregate data were obtained from the Clinerion Patient Network Explorer (PNEx®) network installed at the CCAD on patients diagnosed with EoG/EGE (n=17, of whom 11 (64.7%) were females) or with EoE (n=118, of whom 35 (29.7%) were females) between 2015 and 2022; 63 (53.4%) were diagnosed between 2020 and 2022.

RESULTS

The vast majority of EoE patients visited the gastroenterology clinic (111, 94.1%), followed by the primary care (70, 59.3%), the emergency medicine (60, 50.8%), and the immunology (59, 50%) units. A total of 84 patients with EoE also presented with another type-2 inflammatory condition including allergic rhinitis, food allergy, and atopic dermatitis. Proton pump inhibitors and corticosteroids were widely prescribed, and four patients with EoE have been commenced on biologics since 2020. However, heterogeneity of medication use was identified, warranting local clinical practice guidelines.

CONCLUSION

A referral network could be established with local and regional reach, which relies on a multidisciplinary approach for the management of EoE and associated type 2 co-morbidities. More studies are needed to better depict the clinical picture of patients with EGIDs in general and EoE, in particular, in terms of diagnosis, pharmacological treatment, non-medical interventions, disease course, and patient-reported outcomes.

Obesity-associated Airway Hyperresponsiveness: Mechanisms Underlying Inflammatory Markers and Possible Pharmacological Interventions

Obesity is rapidly becoming a global health problem affecting about 13% of the world's population affecting women and children the most. Recent studies have stated that obese asthmatic subjects suffer from an increased risk of asthma, encounter severe symptoms, respond poorly to anti-asthmatic drugs, and ultimately their quality-of-life decreases. Although, the association between airway hyperresponsiveness (AHR) and obesity is a growing concern among the public due to lifestyle and environmental etiologies, however, the precise mechanism underlying this association is yet to establish. Apart from aiming at the conventional antiasthmatic targets, treatment should be directed towards ameliorating obesity pathogenesis too. Understanding the pathogenesis underlying the association between obesity and AHR is limited, however, a plethora of obesity pathologies have been reported viz., increased pro-inflammatory and decreased anti-inflammatory adipokines, depletion of ROS controller Nrf2/HO-1 axis, NLRP3 associated macrophage polarization, hypertrophy of WAT, and down-regulation of UCP1 in BAT following down-regulated AMPKα and melanocortin pathway that may be correlated with AHR. Increased waist circumference (WC) or central obesity was thought to be related to severe AHR, however, some recent reports suggest body mass index (BMI), not WC tends to exaggerate airway closure in AHR due to some unknown mechanisms. This review aims to co-relate the above-mentioned mechanisms that may explain the copious relation underlying obesity and AHR with the help of published reports. A proper understanding of these mechanisms discussed in this review will ensure an appropriate treatment plan for patients through advanced pharmacological interventions.

Common co-morbidities in polymyalgia rheumatica and giant cell arteritis: cross-sectional study in UK Biobank

Objective

The aim was to determine prevalent co-morbidities in cases with PMR or GCA compared with matched controls.

Methods

This was a nested, cross-sectional case-control study within the UK Biobank, which recruited participants aged 40-69 years. Case status was defined as self-reported prior diagnosis of PMR or GCA. Ten controls per case were matched for age, sex, ethnicity and assessment centre. Associations with selected self-reported co-morbidities were studied using conditional logistic regression.

Results

Of PMR (n = 1036) or GCA (n = 102) cases, 72% were female, 98% White, and 58% reported current use of glucocorticoids. Mean age was 63 years. At the time of the assessment visit, compared with controls, PMR/GCA cases were more likely to report poor general health and at least several days of low mood in the past 2 weeks. PMR was associated with hypothyroidism [odds ratio (OR) = 1.34; 95% CI = 1.07, 1.67] and ever-use of HRT (OR = 1.26; 95% CI = 1.07, 1.47). Regarding common co-morbidities, PMR and GCA were both associated with hypertension (PMR: OR = 1.21; 95% CI = 1.06, 1.39; GCA: OR = 1.86; 95% CI = 1.23, 2.81) and cataract (PMR: OR = 1.51; 95% CI = 1.19, 1.93; GCA: OR = 3.84; 95% CI = 2.23, 6.60). Additionally, GCA was associated with depression (OR = 3.05; 95% CI = 1.59, 5.85). Neither condition was associated with diabetes.

Conclusion

Participants with a history of PMR/GCA, including those not currently taking glucocorticoids, rated their health as poorer than matched controls. Some previously described disease associations (hypothyroidism and early menopause) were replicated. Hypertension and cataract, both of which can be exacerbated by long-term glucocorticoid therapy, were over-represented in both diseases, particularly GCA.

Simian immunodeficiency virus-infected rhesus macaques with AIDS co-develop cardiovascular pathology and encephalitis

Despite effective antiretroviral therapy, HIV co-morbidities remain where central nervous system (CNS) neurocognitive disorders and cardiovascular disease (CVD)-pathology that are linked with myeloid activation are most prevalent. Comorbidities such as neurocogntive dysfunction and cardiovascular disease (CVD) remain prevalent among people living with HIV. We sought to investigate if cardiac pathology (inflammation, fibrosis, cardiomyocyte damage) and CNS pathology (encephalitis) develop together during simian immunodeficiency virus (SIV) infection and if their co-development is linked with monocyte/macrophage activation. We used a cohort of SIV-infected rhesus macaques with rapid AIDS and demonstrated that SIV encephalitis (SIVE) and CVD pathology occur together more frequently than SIVE or CVD pathology alone. Their co-development correlated more strongly with activated myeloid cells, increased numbers of CD14+CD16+ monocytes, plasma CD163 and interleukin-18 (IL-18) than did SIVE or CVD pathology alone, or no pathology. Animals with both SIVE and CVD pathology had greater numbers of cardiac macrophages and increased collagen and monocyte/macrophage accumulation, which were better correlates of CVD-pathology than SIV-RNA. Animals with SIVE alone had higher levels of activated macrophage biomarkers and cardiac macrophage accumulation than SIVnoE animals. These observations were confirmed in HIV infected individuals with HIV encephalitis (HIVE) that had greater numbers of cardiac macrophages and fibrosis than HIV-infected controls without HIVE. These results underscore the notion that CNS and CVD pathologies frequently occur together in HIV and SIV infection, and demonstrate an unmet need for adjunctive therapies targeting macrophages.

Cosmetic Injectable Treatments Improve Quality of Life in Patients With Multiple Serious Medical Comorbidities

Full facial rejuvenation with multi-modal cosmetic treatments can improve quality of life, leading to improvement in confidence and psychological function. These combination treatments are frequently administered at the same or sequential sessions and include neuromodulators and fillers. In patients with significant recent weight loss and other medical comorbidities, these treatments can help restore self-confidence and provide the encouragement they need to continue treatment for their comorbidities. We present a case report of a 71-year-old woman who experienced significant weight loss of 40 lbs (33% body weight) during the course of treatment of multiple medical comorbidities, including surgical intervention for compression fractures. Due to her facial appearance caused by this excessive weight loss, she experienced poor self-esteem as measured by the FACE-Q scales. She was treated cosmetically with 21cc of hyperdilute calcium hydroxyapatite (diluted in a 1:3 ratio; 7cc of calcium hydroxyapatite total) and neuromodulators to replace lost facial volume over three visits. At three months after her last treatment, her FACE-Q scores improved two-and-a-half-fold and fivefold on the psychological function and aging appraisal, respectively. Cosmetic treatments can dramatically improve the quality of life in patients with multiple medical co-morbidities. This population of patients is often excluded from clinical trials or other studies, representing a population for which we have little data on the efficacy of cosmetic treatments.

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding

AIMS

In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB).

METHODS

We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding.

RESULTS

A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings (n=50, 20%; n=29, 11.7%; and n=28, 11.3%, respectively). Of the participants, 93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180).

CONCLUSIONS

We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Socio-demographic profile and clinical co-morbidities of cannabis users attending a tertiary care hospital in India: A retrospective case record study

Context

Cannabis use has been the most commonly used illicit psychoactive substance in India. Increasing use of cannabis has been associated with an increased risk of co-morbid psychotic spectrum disorders with worse outcomes. This risk increases with increased use in a dose-dependent manner. A very complex association exists between cannabis use and mental illness hence it is essential to understand the relationship between the two to facilitate better care and management.

Aim

The present study was conducted to assess the socio-demographic profile and psychiatric co-morbidities of cannabis users attending a tertiary mental health establishment in Goa.

Materials and Methods

A retrospective case record study was carried out among self-reported cannabis users attending services at a tertiary mental health establishment from June 2021 to June 2022. Data regarding cannabis use, clinical profile, and socio-demographic profile of the individuals was obtained and analyzed using appropriate statistical tests.

Results

One hundred and sixty-four cannabis users were evaluated which consisted of 140 males and 24 females, the mean age being 28 years with a standard deviation of 7.68. Ganja was the most commonly used form smoked as joints. The median age of initiation was 18 with females starting at a later age than males. Later initiation was associated with using lower quantities. Concurrent alcohol and nicotine use was present in 90% of the cases. The most commonly associated diagnosis was substance-induced psychosis.

Conclusions

Cannabis use in individuals with mental illness is more common in males and an early age of initiation was linked to earlier age of onset of psychiatric illness.

Factors affecting hospital discharge outcomes in patients with community-acquired pneumonia: a retrospective epidemiological study (2014-2021)

BACKGROUND

In patients with community-acquired pneumonia (CAP), the risk and protective factors influencing discharge outcomes have not been fully elucidated. Therefore, we aimed to investigate the factors affecting discharge outcomes and provide a theoretical basis for improving the cure rate of patients with CAP.

METHODS

We describe a retrospective epidemiological study of patients with CAP conducted from 2014 to 2021. We used age, sex, co-morbidities, multilobar involvement, severe pneumonia, the main abnormal symptoms present on admission, and pathogen-targeted therapy as variables that may affect discharge outcomes. These variables were included in subsequent logistic regression analyses. Discharge outcomes were divided into remission and cure.

RESULTS

Of a total of 1008 patients with CAP, 247 patients were discharged as remission. The results of multivariate logistic regression analyses showed that age >65 years, smoking history, co-morbidity of chronic obstructive pulmonary disease, co-morbidity of chronic heart disease, co-morbidity of diabetes, co-morbidity of malignancy, co-morbidity of cerebrovascular disease, pleural effusion, hypoxemia, respiratory failure, electrolyte disturbances, and severe pneumonia were independently associated with poor discharge outcomes (all P < 0.05), while pathogen-targeted therapy (odds ratio: 0.32, 95% confidence interval: 0.16-0.62) was found as a protective factor.

CONCLUSIONS

Age > 65 years, the presence of co-morbidities, the presence of admission symptoms such as electrolyte disturbances, and severe pneumonia are associated with a poor discharge outcome, while pathogen-targeted therapy is associated with a good discharge outcome. Patients with CAP with a defined pathogen are more likely to be cured. Our results suggest that accurate and efficient pathogen testing is essential for CAP inpatients.

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19

BACKGROUND

We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients.

METHODS

The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV).

RESULTS

Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60 years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%.

CONCLUSIONS

Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death. The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death.

Association of Pre-Pregnancy Obesity and COVID-19 with Poor Pregnancy Outcome

BACKGROUND AND OBJECTIVES

During the COVID-19 pandemic, a possible overlap of obesity and COVID-19 infection has raised concerns among patients and healthcare professionals about protecting pregnant women from developing a severe infection and unwanted pregnancy outcomes. The aim of this study was to evaluate the associations of body mass index with clinical, laboratory, and radiology diagnostic parameters as well as pregnancy complications and maternal outcomes in pregnant patients with COVID-19.

MATERIALS AND METHODS

Clinical status, laboratory, and radiology diagnostic parameters and pregnancy outcomes were analyzed for pregnant women hospitalized between March 2020 and November 2021 in one tertiary-level university clinic in Belgrade, Serbia, due to infection with SARS-CoV-2. Pregnant women were divided into the three sub-groups according to their pre-pregnancy body mass index. For testing the differences between groups, a two-sided p-value <0.05 (the Kruskal-Wallis and ANOVA tests) was considered statistically significant.

RESULTS

Out of 192 hospitalized pregnant women, obese pregnant women had extended hospitalizations, including ICU duration, and they were more likely to develop multi-organ failure, pulmonary embolism, and drug-resistant nosocomial infection. Higher maternal mortality rates, as well as poor pregnancy outcomes, were also more likely to occur in the obese group of pregnant women. Overweight and obese pregnant women were more likely to develop gestational hypertension, and they had a higher grade of placental maturity.

CONCLUSIONS

Obese pregnant women hospitalized due to COVID-19 infection were more likely to develop severe complications.

Effects of clinical, comorbid, and social determinants of health on brain ageing in people with and without HIV: a retrospective case-control study

BACKGROUND

Neuroimaging reveals structural brain changes linked with HIV infection and related neurocognitive disorders; however, group-level comparisons between people with HIV and people without HIV do not account for within-group heterogeneity. The aim of this study was to quantify the effects of comorbidities such as cardiovascular disease and adverse social determinants of health on brain ageing in people with HIV and people without HIV.

METHODS

In this retrospective case-control study, people with HIV from Washington University in St Louis, MO, USA, and people without HIV identified through community organisations or the Research Participant Registry were clinically characterised and underwent 3-Tesla T1-weighted MRI between Dec 3, 2008, and Oct 4, 2022. Exclusion criteria were established by a combination of self-reports and medical records. DeepBrainNet, a publicly available machine learning algorithm, was applied to estimate brain-predicted age from MRI for people with HIV and people without HIV. The brain-age gap, defined as the difference between brain-predicted age and true chronological age, was modelled as a function of clinical, comorbid, and social factors by use of linear regression. Variables were first examined singly for associations with brain-age gap, then combined into multivariate models with best-subsets variable selection.

FINDINGS

In people with HIV (mean age 44·8 years [SD 15·5]; 78% [296 of 379] male; 69% [260] Black; 78% [295] undetectable viral load), brain-age gap was associated with Framingham cardiovascular risk score (p=0·0034), detectable viral load (>50 copies per mL; p=0·0023), and hepatitis C co-infection (p=0·0065). After variable selection, the final model for people with HIV retained Framingham score, hepatitis C, and added unemployment (p=0·0015). Educational achievement assayed by reading proficiency was linked with reduced brain-age gap (p=0·016) for people without HIV but not for people with HIV, indicating a potential resilience factor. When people with HIV and people without HIV were modelled jointly, selection resulted in a model containing cardiovascular risk (p=0·0039), hepatitis C (p=0·037), Area Deprivation Index (p=0·033), and unemployment (p=0·00010). Male sex (p=0·078) and alcohol use history (p=0·090) were also included in the model but were not individually significant.

INTERPRETATION

Our findings indicate that comorbid and social determinants of health are associated with brain ageing in people with HIV, alongside traditional HIV metrics such as viral load and CD4 cell count, suggesting the need for a broadened clinical perspective on healthy ageing with HIV, with additional focus on comorbidities, lifestyle changes, and social factors.

FUNDING

National Institute of Mental Health, National Institute of Nursing Research, and National Institute of Drug Abuse.

Exploration of Sex and Age-Based Associations in Clinical Characteristics, Predictors of Severity, and Duration of Stay among COVID-19 Patients at the University Hospital of Saudi Arabia

COVID-19 infection has a spectrum of variable clinical severity between populations because of their characteristic demographic features, co-morbidities, and immune system reactions. This pandemic tested the healthcare system's preparedness, which depends on predictors of severity and factors related to the duration of hospital stays. Therefore, we carried out a single-center, retrospective cohort study in a tertiary academic hospital to investigate these clinical features and predictors of severe disease and study the different factors that affect hospital stay. We utilized medical records from March 2020 to July 2021, which included 443 confirmed (positive RT-PCR) cases. The data were explained using descriptive statistics and analyzed via multivariate models. Among the patients, 65.4% were female and 34.5% were male, with a mean age of 45.7 years (SD ± 17.2). We presented seven age groups with ranges of 10 years and noticed that patients aged 30-39 years old comprised 23.02% of the records, while patients aged 70 and above comprised 10%. Nearly 47% were diagnosed as having mild, 25% as moderate, 18% as asymptomatic, and 11% as having a severe case of COVID-19 disease. Diabetes was the most common co-morbidity factor in 27.6% of patients, followed by hypertension (26.4%). Our population's predictors of severity included pneumonia, identified on a chest X-ray, and co-morbid conditions such as cardiovascular disease, stroke, ICU stay, and mechanical ventilation. The median length of hospital stay was six days. It was significantly longer in patients with a severe disease and who were administered systemic intravenous steroids. An empirical assessment of various clinical parameters could assist in effectively measuring the disease progression and follow-up with patients.

interrogans Serogroup Australis Sequence Type 24 in a Cat and Survey of Leptospira Exposure in Outdoor Cats

Leptospirosis is one of the most widespread zoonotic diseases and can infect both humans and animals worldwide. The role of the cat as a susceptible host and potential environmental reservoir of Leptospira is still not well understood, due to the lack of obvious clinical signs associated with Leptospira spp. infection in this species. This study aims to describe the first European detection of Leptospira interrogans serogroup Australis ST 24 in a young outdoor cat with a severe comorbidity (feline panleukopenia virus). In addition, the results of a preliminary study conducted in 2014-2016 are presented (RC IZSVE 16/12), which reports an investigation of Leptospira exposure of outdoor cats in Northeast Italy by means of serological investigation and molecular evaluation of urine. The animals included in the survey are part of samples collected during active and passive surveillance (diagnostic samples). The study reported a seroprevalence of 10.5% among outdoor cats and the serogroups identified were Grippotyphosa, Icterohaemorrhagiae, Bratislava, Canicola and Ballum. Symptomatic cats reported high MAT titres (ranging from 1:800 to 1:1600) towards antigens belonging to the serovars Grippotyphosa (1:800), Bratislava (1:1600), Icterohaemorrhagiae (1:200) and Copenhageni (1:200-1:800). In one subject, urine tested positive for Leptospira PCR. Cats with high antibody titres for Leptospira and/or positivity on molecular test suffered from immunosuppressive comorbidities (feline immunodeficiency virus and feline leukaemia virus; feline herpesvirus and lymphoma; hyperthyroidism). The overall prevalence of serum antibodies against Leptospira found in free-ranging cats (10.53%, 95% CI: 4.35-16.70%) and the identification of L. interrogans ST 24 in a young cat with immunosuppressive disease (feline panleukopenia virus) suggest the possibility of natural resistance to clinical leptospirosis in healthy cats. In a One Health perspective, further studies are needed to better define the pathogenesis of leptospirosis in cats and their epidemiological role as environmental sentinels or possible carriers of pathogenic Leptospira.

A Cross-Sectional Clinical Investigation of Organisms Causing Vaginal Discharge in Patients in Rural Tamil Nadu, India

Background and aims Abnormal vaginal discharge is a prevailing gynecological problem among women in the reproductive age group. Vaginal discharges have multiple etiologies, and the present study was conducted with the objective of determining the prevalence of common organisms causing vaginal discharge and correlating with its various types of clinical presentations in those women attending a rural health centre of a medical college in Tamil Nadu, India. Materials and methods The study was a cross-sectional descriptive study, conducted in a rural health center of a teaching hospital in Tamil Nadu, India, from February 2022 to July 2022. All the patients clinically having the symptoms of vaginitis and with a discharge were included in this study, and postmenopausal women and pregnant women were excluded. Data was collected from a total of 175 patients. Results The mean (SD) age of the study population was 34.8 (6.9) years. Almost half, 91 (52%), of the study participants were in the age group of 31-40 years. Bacterial vaginosis was found in 74 (42.3%) and was the most common cause of abnormal vaginal discharge in our study participants, followed by vulvovaginal candidiasis, 34 (19.4%). There were significant associations between high-risk sexual behavior and the presence of co-morbidities with abnormal vaginal discharge. Conclusion The most common causes of abnormal vaginal discharge were found to be bacterial vaginosis followed by vulvovaginal candidiasis. The study results help to initiate early appropriate treatment for effective management of a community health problem.

Induced Depressive Disorder Following the First Dose of COVID-19 Vaccine

INTRODUCTION

Several COVID-19 vaccines have been implemented. However, some side effects of the vaccine have been reported, which are sometimes very harmful. Reported cases and data are still very limited regarding the psychiatric side effects of the COVID-19 vaccine. To our knowledge, only one case has been reported. In this paper, we report the case of a patient who presented an acute depressive episode 24 hours after receiving his first dose of the BNT162b2mRNA vaccine.

CASE REPORT

The case was a 26-year-old man with a history of Down syndrome with moderately good autonomy for daily routine tasks. The patient, who presented hypothyroidism at 10 years old and schizophrenia at 15 years old, was doing well before the vaccination and received his first dose of the BNT162b2mRNA vaccine. Twenty-four hours later, he presented depressive symptoms that resolved spontaneously after one week. Then, fifteen days later, the symptoms reappeared, and the episode lasted for 5 weeks. The patient received 10 mg/day of escitalopram besides his usual treatment. The depressive symptoms improved considerably by the second day of treatment.

DISCUSSION

The presented case illustrated significant diagnostic challenges, especially when taking into account the sequential relationship between the COVID-19 vaccine and the occurrence of depressive symptoms. A single case of depression has been reported after the administration of the COVID-19 vaccine. Scientific evidence suggests the important role of the immune system in the pathophysiology of various psychiatric disorders, including depression.

CONCLUSION

Health professionals must take into consideration the potential psychiatric side effects even being rare so far, especially in vulnerable subjects. Further studies are required to establish the causal effects of depressive symptoms occurring during the weeks following the COVID-19 vaccine bolus injection.

Predictors of COVID-19 severity and outcomes in Indian patients with rheumatic diseases: a prospective cohort study

Objective

There is dearth of data regarding the outcomes of coronavirus disease 2019 (COVID-19) among rheumatic and musculoskeletal disease (RMD) patients from Southeast Asia. We report the clinicodemographic profile and identify predictors of COVID-19 outcomes in a large cohort of Indian RMD patients.

Methods

This prospective cohort study, carried out at the Postgraduate Institute of Medical Education and Research, Chandigarh (a tertiary care centre in India), included RMD patients affected with COVID-19 between April 2020 and October 2021. Demographic and clinical and laboratory details of COVID-19 and underlying RMD were noted. Predictors of mortality, hospitalization and severe COVID-19 were identified using stepwise multivariable logistic regression.

Results

A total of 64 severe acute respiratory syndrome coronavirus-2-infected RMD patients [age 41.5 (19-85) years; 46 (72%) females] were included. Eighteen (28%) patients had severe COVID-19. Twenty-three (36%) required respiratory support [11 (17%) required mechanical ventilation]. Thirty-six (56%) patients required hospitalization [median duration of stay 10 (1-42) days]; 17 (27%) required intensive care unit admission. Presence of co-morbidities [odds ratio (OR) = 4.5 (95% CI: 1.4, 14.7)] was found to be an independent predictor of COVID-19 severity. Co-morbidities [OR = 10.7 (95% CI: 2.5, 45.4)] and underlying lupus [OR = 7.0 (95% CI: 1.2, 40.8)] were independently associated with COVID-19 hospitalization. Ongoing rheumatic disease activity [OR = 6.8 (95% CI: 1.3, 35.4)] and underlying diagnosis of lupus [OR = 7.1 (95% CI: 1.2, 42.4)] and SSc [OR = 9.5 (95% CI: 1.5, 61.8)] were found to be strong independent predictors of mortality. Age, sex, underlying RMD-associated interstitial lung disease and choice of immunosuppressive therapy were not associated with COVID-19 severity or adverse outcomes.

Conclusion

The presence of co-morbidities was independently associated with COVID-19 severity and hospitalization. Ongoing rheumatic disease activity and the presence of lupus or SSc independently predicted mortality. Age, sex, type of immunosuppressive therapy and presence of RMD-associated interstitial lung disease did not affect COVID-19 severity or outcomes in Indian RMD patients.

Metabolic Syndrome: The Constellation of Co-morbidities, A Global Threat

BACKGROUND

Metabolic syndrome, also referred to as Syndrome X or obesity syndrome is a cluster of diseases prevalent worldwide in both developed and developing countries. According to WHO, it is referred to as a pathological condition wherein multiple disorders are manifested in the same individual. These include hypertension, hyperglycemia, dyslipidemia and abdominal obesity.

AIMS

Metabolic syndrome is one of the most serious non-communicable health hazards that have gained pivotal importance in the present scenario. The increasing prevalence affecting around 25 % of the world populace, mainly attributes to the acceptance of western culture, i.e. the intake of highcalorie food along with a substantial decrease in manual labor and adoption of sedentary lifestyles. Therefore, its timely prevention and management are the dire need in the present scenario.

METHODS

For successful accomplishment of the present review, an exhaustive analysis was performed utilizing a pool of previous related literature. The terms used during the search included 'metabolic syndrome, prevalence, etiology, current pharmacotherapy for metabolic syndrome, etc. PUBMED, Medline and SCOPUS were explored for the study of abstracts, research and review papers in the quest for related data. The articles were downloaded and utilized for a meta-analysis study approach.

CONCLUSION

In this review, an attempt was made to apprehend and summarize the epidemiology and treatment strategies for metabolic syndrome with a better understanding of its pathogenesis. It was postulated that an early diagnostic approach and subsequent line of treatment is required to prevent the deterioration of an individual's health and life.

An Increase in Specialist Treatment for Onychomycosis: An Unexplained Tendency. A Retrospective Study of Patients Treated for Onychomycosis in Danish Hospitals from 1994 to 2018

Onychomycosis is a common disease with a significant negative impact on quality of life. While the disease is usually manageable in general practice, a proportion of patients need specialist treatment in academic hospital clinics. However, it is an unknown question whether the incidence in those needing specialist treatments is changing. Furthermore, the comorbidity burden in this patient population severely affected by onychomycosis has never been characterized. We conducted a retrospective study on patients treated for onychomycosis in Danish hospitals from 1994 to 2018. The cohort was observed for 24 years, and the data comprise 7.2 million Danes and their hospital diagnoses. A disease trajectory algorithm was used to examine the comorbidity burden in the cohort. A total of 2,271 patients received hospital treatment for onychomycosis during the time period, of which 1358 (59.8%) were men. The data show an increase in the incidence of hospital-treated cases since 2012 and that the most common comorbidities in this patient population include cardiovascular disease, alcohol-related diagnoses, and diabetes. One explanation of the increase in specialist treatment may include a general increase in patients with decreased resilience to fungal disease. This lack of resilience may both include an increasing elderly population with atherosclerosis, diabetes, and immunosuppression but also a potential increase in patients treated with immunosuppressive agents. Another possible explanation may include a shift in patient expectations in the case of treatment failure. Thus, patients may have an increasing demand for specialist treatment. While our data document an increase in the number of patients in need of specialist treatment for onychomycosis, we suggest future research to examine the general incidence of onychomycosis but also whether this increase in an apparently recalcitrant disease may be attributed to increased antifungal resistance, more specialist treatment options, or increased attention to dermatomycoses.

The not so hidden impact of interictal burden in migraine: A narrative review

Migraine is a highly prevalent neurological disease of varying attack frequency. Headache attacks that are accompanied by a combination of impact on daily activities, photophobia and/or nausea are most commonly migraine. The headache phase of a migraine attack has attracted more research, assessment tools and treatment goals than any other feature, characteristic, or phase of migraine. However, the migraine attack may encompass up to 4 phases: the prodrome, aura, headache phase and postdrome. There is growing recognition that the burden of migraine, including symptoms associated with the headache phase of the attack, may persist between migraine attacks, sometimes referred to as the "interictal phase." These include allodynia, hypersensitivity, photophobia, phonophobia, osmophobia, visual/vestibular disturbances and motion sickness. Subtle interictal clinical manifestations and a patient's trepidation to make plans or commitments due to the unpredictability of migraine attacks may contribute to poorer quality of life. However, there are only a few tools available to assess the interictal burden. Herein, we examine the recent advances in the recognition, description, and assessment of the interictal burden of migraine. We also highlight the value in patients feeling comfortable discussing the symptoms and overall burden of migraine when discussing migraine treatment needs with their provider.

The effect of race and co-morbidities on Alzheimer's disease based on Medicare data

INTRODUCTION

Alzheimer's disease (AD) incidence is thought to be higher among Black than White individuals.

METHODS

We studied the US Medicare population from 2000 to 2018. Cox regression was used to determine the roles of race and co-morbidities for AD incidence.

RESULTS

We studied 11,880,906 Medicare beneficiaries, with 774,548 AD cases. Hazard ratios (HRs) by increasing numbers of co-morbidities (1-7) were 1.51, 2.00, 2.55, 3.16, 2.89, 4.77, and 5.65. Among those with no co-morbidities, Black individuals had a lower rate than those who are White (HR = 0.69), while among those with one more co-morbidities, Black individuals had a higher rate (HR = 1.19). The presence of hypertension increased AD rates by 14% for White individuals, but 69% for those who are Black.

DISCUSSION

More co-morbidities was strongly associated with higher AD rates. The higher rates for Black versus White individuals was apparent only for those with co-morbidities and appears driven both by more co-morbidities, and the greater effect of hypertension.

HIGHLIGHTS

Black individuals have been shown to have higher Alzheimer's disease (AD) rates than those who are White. Some co-morbidities are known to increase AD risk. Among those In Medicare data with no co-morbidities, Black individuals have less risk than those who are White. Among those with co-morbidities, Black individuals have higher rates than those who are White. Hypertension results in a much stronger increase in AD risk for Black versus White individuals.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations: strengths and concerns for future needs

Chronic Obstructive Pulmonary Disease (COPD) is already the third leading cause of death worldwide and simultaneously a major cause of morbidity and mortality. Global initiative for Chronic Obstructive Lung Disease (also known as GOLD) committee, has been created in 1997 to increase the awareness regarding the burden of COPD. GOLD recommendations have been contributing to diagnosis, management and therapy of COPD since 2001. Through these years, by reviewing published articles, GOLD aimed to provide state-of-the-art information not only for pulmonologists, but also for non-respiratory physicians, and to encourage research on COPD. From 2011, GOLD annual reports have changed the way of COPD evaluation from based entirely on spirometric parameters to more clinical indices, such as the assessment of symptoms and dyspnea alongside with exacerbations. Moreover, according to recent developments in pathophysiology of COPD, there is a trend in identifying new pre-clinical stages, contributing to prevention and early COPD treatment. In the field of therapeutic algorithms, changes turn to a more personalized approach. However, it is not clear in what extent this personalized disease management would be feasible and the real challenge for current recommendations is to include more patient characteristics such as co-morbidities and multidimensional scores in disease evaluation.

Factors Modulating COVID-19: A Mechanistic Understanding Based on the Adverse Outcome Pathway Framework

Addressing factors modulating COVID-19 is crucial since abundant clinical evidence shows that outcomes are markedly heterogeneous between patients. This requires identifying the factors and understanding how they mechanistically influence COVID-19. Here, we describe how eleven selected factors (age, sex, genetic factors, lipid disorders, heart failure, gut dysbiosis, diet, vitamin D deficiency, air pollution and exposure to chemicals) influence COVID-19 by applying the Adverse Outcome Pathway (AOP), which is well-established in regulatory toxicology. This framework aims to model the sequence of events leading to an adverse health outcome. Several linear AOPs depicting pathways from the binding of the virus to ACE2 up to clinical outcomes observed in COVID-19 have been developed and integrated into a network offering a unique overview of the mechanisms underlying the disease. As SARS-CoV-2 infectibility and ACE2 activity are the major starting points and inflammatory response is central in the development of COVID-19, we evaluated how those eleven intrinsic and extrinsic factors modulate those processes impacting clinical outcomes. Applying this AOP-aligned approach enables the identification of current knowledge gaps orientating for further research and allows to propose biomarkers to identify of high-risk patients. This approach also facilitates expertise synergy from different disciplines to address public health issues.

Development of Food Group Tree-Based Analysis and Its Association with Non-Alcoholic Fatty Liver Disease (NAFLD) and Co-Morbidities in a South Indian Population: A Large Case-Control Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a global problem growing in parallel to the epidemics of obesity and diabetes, with South Asians being particularly susceptible. Nutrition and behaviour are important modifiers of the disease; however, studies to date have only described dietary patterns and nutrients associated with susceptibility to NAFLD.

METHODS

This cross-sectional case-control study included 993 NAFLD patients and 973 healthy controls from Trivandrum (India). Dietary data was collected using a locally validated food frequency questionnaire. A tree-based classification categorised 2165 ingredients into three levels (food groups, sub-types, and cooking methods) and intakes were associated with clinical outcomes.

RESULTS

NAFLD patients had significantly higher consumption of refined rice, animal fat, red meat, refined sugar, and fried foods, and had lower consumption of vegetables, pulses, nuts, seeds, and milk compared to controls. The consumption of red meat, animal fat, nuts, and refined rice was positively associated with NAFLD diagnosis and the presence of fibrosis, whereas consumption of leafy vegetables, fruits, and dried pulses was negatively associated. Fried food consumption was positively associated with NAFLD, whilst boiled food consumption had a negative association. Increased consumption of animal fats was associated with diabetes, hypertension, and cardiovascular outcomes among those with NAFLD, whereas consumption of wholegrain rice was negatively associated with these clinical-related outcomes.

CONCLUSIONS

The tree-based approach provides the first comprehensive method of classifying food intakes to enable the identification of specific dietary factors associated with NAFLD and related clinical outcomes. This could inform culturally sensitive dietary guidelines to reduce risk of NAFLD development and/or its progression.

Trained Immunity and HIV Infection

Findings that certain infections induce immunity not only against the causing agent, but also against an unrelated pathogen have intrigued investigators for many years. Recently, underlying mechanisms of this phenomenon have started to come to light. It was found that the key cells responsible for heterologous protection are innate immune cells such as natural killer cells (NKs), dendritic cells, and monocytes/macrophages. These cells are 'primed' by initial infection, allowing them to provide enhanced response to subsequent infection by the same or unrelated agent. This phenomenon of innate immune memory was termed 'trained immunity'. The proposed mechanism for trained immunity involves activation by the first stimulus of metabolic pathways that lead to epigenetic changes, which maintain the cell in a "trained" state, allowing enhanced responses to a subsequent stimulus. Innate immune memory can lead either to enhanced responses or to suppression of subsequent responses ('tolerance'), depending on the strength and length of the initial stimulation of the immune cells. In the context of HIV infection, innate memory induced by infection is not well understood. In this Hypothesis and Theory article, we discuss evidence for HIV-induced trained immunity in human monocytes, its possible mechanisms, and implications for HIV-associated co-morbidities.

A novel epidemiological scoring system for the prediction of mortality in COVID-19 patients

BACKGROUND

Most of the reported risk score models for coronavirus disease 2019 (COVID-19) mortality are based on the levels of inflammatory markers, comorbidities or various treatment modalities, and there is a paucity of risk score models based on clinical symptoms and comorbidities.

METHODS

To address this need, age, clinical symptoms and comorbidities were used to develop a COVID-19 scoring system (CSS) for early prediction of mortality in severe COVID-19 patients. The CSS was developed with scores ranging from 0 to 9. A higher score indicates higher risk with good discrimination quality presented by Mann Whitney U test and area under receiver operating characteristic curve (AUROC).

RESULTS

Patient age of ≥60 y, cough, breathlessness, diabetes and any other comorbidity (with or without diabetes) are significant and independent risk factors for non-survival among COVID-19 patients. The CSS showed good sensitivity and specificity (i.e. 74.1% and 78.5% at CSS≥5, respectively), with an overall diagnostic accuracy of 82.8%, which was close to the diagnostic accuracy detected in the validation cohort (81.9%). In the validation cohort, high (8-9), medium (5-7) and low (0-4) CSS groups had 54.80%, 28.60% and 6.5% observed mortality, respectively, which was very close to the predicted mortality (62.40%, 27.60% and 5.2%, respectively, by scoring cohort).

CONCLUSIONS

The CSS shows a positive relationship between a higher score and proportion of mortality and, as its validation showed, it is useful for the prediction of risk of mortality in COVID-19 patients at an early stage, so that referral for triage and admission can be predetermined even before admission to hospital.

Frailty and sarcopenia among Turkish people aged 40 and above living with HIV

BACKGROUND

People living with HIV face a variety of challenges, including accelerated ageing and geriatric syndromes. In this study, we aimed to examine the prevalence of frailty and sarcopenia among Turkish people living with HIV.

METHODS

In total, 100 people living with HIV were recruited in this study. Frailty was determined using Fried's frailty phenotype, and we calculated the Charlson Comorbidity Index, Veterans Aging Cohort Study (VACS) index, fracture risk assessment tool scores, and Mini-Mental State Exam scores. We determined muscle mass using bioelectric impedance analysis, gastrocnemius muscle thickness using ultrasonography, and muscle strength using handgrip strength.

RESULTS

The mean ± standard deviation age was 50.0 ± 8.3 years. In total, 11% of the patients were frail. The risk of comorbidity and mortality, VACS index, and 5-year mortality risk was significantly higher in the frail group, as was sarcopenia. Fat-free muscle mass and handgrip strength were correlated with gastrocnemius muscle thickness. Gastrocnemius muscle thickness suggestive of sarcopenia was defined as 13.05 mm. The cognitive impairment rate was 5% and was associated with physical frailty.

CONCLUSION

Frailty is common and associated with higher morbidity and mortality rates among Turkish people living with HIV.

Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization

The goal of our study was to evaluate the burden of endometriosis in the community by comparing healthcare resource utilization, total direct medical costs, infertility, and comorbidity rates of women with and without a diagnosis of endometriosis. A retrospective case–control study was performed using the databases of a 2.1 million-member nationwide healthcare plan. The study population included women aged 15–55 years enrolled in the healthcare plan. Women with a diagnosis (ICD-9) of endometriosis were compared to controls without diagnosed endometriosis. Women were individually matched (1:4) on age and residence area. Patient characteristics were described, including infertility, comorbidities, and annual healthcare resource utilization. Total direct medical costs were analyzed in a generalized linear model adjusting for age. Women with endometriosis (n = 6146, mean age ± SD: 40.4 ± 8.0 y) were significantly more likely than controls (n = 24,572) to have a lower BMI and a higher socioeconomic status. After adjusting for BMI and socioeconomic status, endometriosis was significantly associated with infertility (OR = 3.3; 95% CI 3.1–3.5), chronic comorbidities, higher utilization of healthcare services (hospitalization: OR = 2.3; 95% CI 2.1–2.5), pain medications, and antidepressants. Women aged 15–19 y with endometriosis had substantially higher utilization of primary care visits (57.7% vs. 14.4%) and oral contraceptive use (76.9% vs. 9.6%). Direct medical costs associated with endometriosis were higher than those for controls (OR = 1.75; 95% CI 1.69–1.85). Endometriosis is associated with a high burden of comorbidities, increased healthcare resource utilization, and excess costs, particularly for younger patients whose healthcare needs may differ widely from the older population.

Pharmacotherapy of obesity in complex diseases

More than 40% of adults in the United States suffer from obesity. Obesity is inextricably linked to many chronic illnesses like type-2 diabetes mellitus, hypertension, hyperlipidemia, heart disease, sleep apnea, stroke, and cancers. When used in combination with lifestyle modifications, pharmacotherapy has a vital role in treating obesity and improves short-term and long-term outcomes. A growing number of physicians are now interested in obesity medicine, and many of them are seeking guidance on how to treat complex patients with co-morbidities. This review provides a practical guide to the use of anti-obesity medications across various obesity-related comorbidities. It provides a general review of the currently approved anti-obesity medications and effective combinations. It discusses the highlights of the major trials and recent studies assessing the benefits of anti-obesity medications in comorbid conditions such as type-2 diabetes mellitus, psychiatric disorders, cardiovascular diseases, hypertension, renal diseases, and liver diseases. This review briefly examines the aspects of recognizing and addressing iatrogenic weight gain; discusses the precautions and prescribing considerations of anti-obesity medications, including side effects and possible dose adjustments in various comorbid conditions; and provides an expert opinion on an individualized choice of the best anti-obesity medication.

The aging lung face to COVID-19

Coronavirus disease 2019 (COVID-19) has so far killed many people; with the majority of deaths occurring in people over the age of 65 years. It has been noted that the severity and outcome of COVID-19 depends in part on the patient's age. The combination of three factors could explain this ascertainment: the first is linked the lung aging, the second is the associated comorbidities in elderly subjects and the third is the particularities of COVID-19. Here we emphasize the modifications linked to pulmonary aging and their role in worsening the COVID-19 disease.

Acute and Long-Term Outcomes of ST-Elevation Myocardial Infarction in Cancer Patients, a 'Real World' Analysis with 175,000 Patients

BACKGROUND

Acute myocardial infarction (AMI) and cancer are common and serious diseases. As the prognosis and treatment of both diseases has improved, more cancer patients will suffer an AMI. Unfortunately, data on these "double hit" patients is scarce.

METHODS

From the largest public German health insurance, anonymized data of all patients with pre-existing cancer who were hospitalized due to ST-elevation MI (STEMI) between 2010 and 2017 were analyzed and followed-up until 2018.

RESULTS

Of 175,262 STEMI patients, 27,213 had pre-existing cancer (15.5%). Most frequent were skin (24.9%), prostate (17.0%), colon (11.0%), breast (10.9%), urinary tract (10.6%), and lung cancer (5.2%). STEMI patients with malignancies were older and presented more often with coronary three-vessel disease, atrial arrhythmias, chronic kidney disease, chronic heart failure, cerebrovascular and peripheral artery disease (PAD, each p < 0.001). They showed more often previous AMI, percutaneous coronary interventions (PCI), cardiac surgery, and stroke (all p < 0.001). Acute PCIs were applied between 2 and 6% less frequently compared to those without cancer. In-hospital adverse events occurred more frequently in cancer. Eight-year survival was 57.3% (95% CI 57.0-57.7%) without cancer and ranged between 41.2% and 19.2% in distinct cancer types. Multivariable Cox regression for all-cause mortality found, e.g., lung cancer (HR 2.04), PAD stage 4-6 (HR 1.78), metastasis (HR 1.72), and previous stroke (HR 1.44) to have the strongest impact (all p < 0.001).

CONCLUSION

In this large "real world" data, prognosis after STEMI in cancer patients was markedly reduced but differed widely between cancer types. Of note, no withholding of interventional treatments in cancer patients could be observed.

Characteristics of Patients with Obstructive Sleep Apnea at High Risk for Cardiovascular Disease

Background and Objectives: To evaluate the influence of obstructive sleep apnea (OSA)-related symptoms on prevalent cardiovascular disease (CVD) in a large clinical population of patients. Materials and Methods: A total of 2127 patients (mean age 55 years, 24% women) underwent diagnostic polysomnography and were evaluated using the Epworth sleepiness scale (ESS), the Athens Insomnia Scale (AIS), and the Beck Depression Inventory (BDI). We investigated the predictive value of OSA-associated symptoms for prevalent cardiovascular disease, after adjustment for relevant confounding factors including age, obesity, and co-morbidities. Results: Patients with OSA and CVD were older and had a higher Body Mass Index (BMI); the percentage of obese patients was also higher (83% vs. 70%, p < 0001). They also had greater neck, waist, and hip circumferences and a higher waist-to-hip ratio. Excessive daytime sleepiness (ESS ≥ 10) [odds ratio (95% CI) 1.112 (0.708–1.748), p = 0.64], insomnia symptoms (AIS ≥ 6) [odds ratio (95% CI) 0.748 (0.473–1.184), p = 0.21], frequent awakenings [odds ratio (95% CI) 1.599 (1.019–2.508), p = 0.06], and nocturia [odds ratio (95% CI) 1.359 (0.919–2.009), p = 0.124] were not associated with CVD after adjustment for the previous confounders. On the other hand, depressive symptoms (BDI ≥ 10) independently predicted prevalent CVD [odds ratio (95% CI) 1.476 (1.154–1.887), p = 0.002]. Further analysis in subgroups stratified by age, BMI, and gender demonstrated that depressive symptoms predicted prevalent CVD but only in the subgroup of younger (age group < 60 years), obese (BMI group ≥ 30), and male (OR = 1.959, 95% CI = 1.209–3.175, p = 0.006) OSA patients. Conclusions: OSA patients with CVD were more likely to complain of less typical OSA symptoms and depressive symptoms compared to patients without CVD in this large clinical patient cohort, supportingthecomplexity and heterogeneityof OSA.

Clinical and Laboratory Factors in Predicting Mortality Among COVID-19 RT-PCR Positive Patients: A Retrospective Observational Study From a Tertiary Care Center

BACKGROUND

In coronavirus disease 2019 (COVID-19) patients, risk stratification based on clinical presentation, co-morbid illness, and combined laboratory parameters is essential to provide an adequate, timely intervention based on an individual's conditions to prevent mortality among cases.

METHODS

A retrospective observational study was carried out from June to October 2020, including all reverse transcription-polymerase chain reaction (RT-PCR) positive COVID-19 non-survivors and control group survivors randomly selected after age and sex matching. Clinical and demographic information was collected from the medical records. Categorical variables were expressed by frequency and percentage. To explore the risk factors associated with mortality, univariable and multivariable logistic regression models were used.

RESULTS AND DISCUSSIONS

All non-survivors (n = 100) and 100 survivors (out of 1,018) were analyzed. Male gender (67.4%) was the independent risk factor for COVID-19 infection. Advanced age group, diabetes, cardiovascular, neurological, and hypertensive co-morbidities were statistically associated with mortality. Cardiac arrest and acute kidney injury (AKI) were the most common complications. Mortality is significantly associated with lymphopenia and raised lactate dehydrogenase (LDH), as shown by higher odds. In addition, raised neutrophils, monocytes, aspartate aminotransferase (AST), serum creatinine, interleukin 6 (IL-6), and C-reactive protein (CRP) are also significantly associated with mortality. The most common causes of death were respiratory failure (84%) and acute respiratory distress syndrome (77%). Of the non-survivors, 92% received corticosteroids, 63% were on high-flow nasal cannula oxygen therapy, 29% were mechanically ventilated, and 29% received tocilizumab.

CONCLUSION

Serial monitoring of neutrophils, lymphocytes, D-dimer, procalcitonin, AST, LDH, CRP, IL-6, serum creatinine, and albumin might provide a reliable and convenient method for classifying and predicting the severity and outcomes of patients with COVID-19.

Hospitalised versus outpatient COVID-19 patients' background characteristics and comorbidities: A systematic review and meta-analysis

This study aimed to systematically assess COVID-19 patient background characteristics and pre-existing comorbidities associated with hospitalisation status. The meta-analysis included cross-sectional, cohort, and case-series studies with information on hospitalisation versus outpatient status for COVID-19 patients, with background characteristics and pre-existing comorbidities. A total of 1,002,006 patients from 40 studies were identified. Significantly higher odds of hospitalisation were observed in Black individuals (OR = 1.33, 95% CI: 1.04-1.70), males (OR = 1.59, 95% CI: 1.43-1.76), and persons with current/past smoking (OR = 1.59, 95% CI: 1.34-1.88). Additionally, individuals with pre-existing comorbidities were more likely to be hospitalised [asthma (OR = 1.22, 95% CI: 1.02-1.45), COPD (OR = 3.68, 95% CI: 2.97-4.55), congestive heart failure (OR = 6.80, 95% CI: 4.97-9.31), coronary heart disease (OR = 4.40, 95% CI: 3.15-6.16), diabetes (OR = 3.90, 95% CI: 3.29-4.63), hypertension (OR = 3.89, 95% CI: 3.34-4.54), obesity (OR = 1.98, 95% CI: 1.59-2.46) and renal chronic disease (OR = 5.84, 95% CI: 4.51-7.56)]. High heterogeneity and low publication bias among all factors were found. Age was not included due to the large variability in the estimates reported. In this systematic review/meta-analysis for patients with COVID-19, Black patients, males, persons who smoke, and those with pre-existing comorbidities were more likely to be hospitalised than their counterparts. Findings provide evidence of populations with higher odds of hospitalisation for COVID-19.

The Omic Insights on Unfolding Saga of COVID-19

The year 2019 has seen an emergence of the novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease of 2019 (COVID-19). Since the onset of the pandemic, biological and interdisciplinary research is being carried out across the world at a rapid pace to beat the pandemic. There is an increased need to comprehensively understand various aspects of the virus from detection to treatment options including drugs and vaccines for effective global management of the disease. In this review, we summarize the salient findings pertaining to SARS-CoV-2 biology, including symptoms, hosts, epidemiology, SARS-CoV-2 genome, and its emerging variants, viral diagnostics, host-pathogen interactions, alternative antiviral strategies and application of machine learning heuristics and artificial intelligence for effective management of COVID-19 and future pandemics.

COVID-19-Associated Case Fatality Rate in Subjects Under 18 Years Old in Mexico, up to December 31, 2020

Background: The emergence of the SARS-CoV-2 and the COVID-19 have become a global health crisis. The infection has been present in all the social sectors. Subjects under 18 years are one of them. The objective was to analyze the case fatality ratio of COVID-19 cases in the Mexican population under 18 years of age registered in the National Epidemiological Surveillance System from March 2020 to December 31, 2020. Material and Methods: The design is cross-sectional, quantitative, and analytical. All the suspected cases of respiratory viral disease, with a real-time polymerase chain reaction (RT-PCR) test result, aged from 0 to 17 years, were included. Descriptive statistics are presented for all the variables. Epidemiological curves were designed. The chi-squared test and its P-values were obtained to show the relationship between comorbidities and death. The case fatality ratio was computed for each comorbidity, sex, and age group. Multivariable logistic regression models were fitted to study the effect between comorbidities with the fatality of cases, adjusting for sex and age group as potential confounders. The alpha value was fixed to 0.05 to assess significance. Results: The number of records for this study was 167,856. Among them, 48,505 were from SARS-CoV-2-positive patients (28.90%), and 119,351 (71.10%) were negative. Of those who died, males (55.29%) (P < 0.05) and those under 2 years of age (50.35%) (P < 0.05) predominated. Unlike in older populations, from the comorbidities considered risk factors for death by COVID-19, only immunosuppression showed a statistically significant effect on the fatality of cases after adjustment by the other related variables. Sex and age group were not confounders for the models in those under 18 years old. Pneumonia, being younger than 5 years, and immunosuppression are related to death. Conclusion: The case fatality ratio in those under 18 years old is low. Special attention must be paid to those children under 5 years. The development of pneumonia is a warning indicator while treating them. On the other hand, having an open database of cases allows the researchers to analyze the impact of COVID-19 in different population sectors, which has clear benefits for public health.

Hearing impairment among children in Sweden with foreign-born parents and natives: A national Swedish study

AIM

We aimed to estimate the risk of hearing impairment in children and adolescents with foreign-born parents, compared to natives.

METHODS

A nationwide study of 1,923,590 (51.4% boys) individuals aged 0-17 years of age in Sweden. Hearing impairment was defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2015. We used Cox regression analysis to estimate relative risk (hazard ratios with 99% confidence intervals) of incident hearing impairment in children with foreign-born parents compared to Swedish-born natives. Cox regression models were stratified by sex and adjusted for age, co-morbidities and socioeconomic status.

RESULTS

A total of 20,514 cases (53.7% boys) with extended sensorineural hearing impairment were registered, also including noise-induced hearing impairment and that from other causes, and 6172 cases (50.0% boys) with conductive hearing impairment. The risk of extended sensorineural hearing impairment was higher in boys with parents from Asia, especially from Iraq, fully adjusted HR (99% CI) 1.30 (1.17-1.4), and lower in boys with parents from Nordic countries, South Europe, and North America.

CONCLUSION

The risk of extended sensorineural hearing impairment was higher in boys with parents from Asia, in particular Iraq.

Validity and Responsiveness of the Generic Health-Related Quality of Life Instrument (VetMetrica™) in Cats With Osteoarthritis. Comparison of Vet and Owner Impressions of Quality of Life Impact

Validity is not an inherent property of a measurement scale and so evidence for validity relating to its use for particular purposes, with defined populations and in specified contexts must be accumulated. We have published the development of a web-based, generic health-related quality of life instrument (VetMetrica™) to measure the affective impact of chronic disease in cats and provided evidence for its validity in a mixed population of cats, some of which, according to veterinary judgement, were healthy and others of which were suffering from chronic conditions likely to affect their quality of life, often with multiple co-morbidities present. The first aim of the current study was to demonstrate the construct validity of the VetMetrica™ generic instrument when used with cats suffering from osteoarthritis, by testing the hypothesis that the health-related quality of life profile of cats with different severities of osteoarthritis would differ and by demonstrating convergent validity between the health-related quality of life profile scores and independently quantified vet-assessed pain and quality of life impact scores. The latter involved simple correlation analysis and investigation of the relationship between health-related quality of life domain scores and vet-assessed scores, when adjusted for other potential explanatory variables including number of comorbidities and age. Responsiveness-the ability to detect clinically relevant change-is an essential quality for an evaluative instrument and it also provides evidence for "longitudinal validity". Therefore, a second aim of this study was to demonstrate that changes in health-related quality of life domain scores concurred with the clinician's impression of change over time in the health status of cats with osteoarthritis, thus providing evidence for the instrument's responsiveness. Previously, we have reported disagreement between owner and vet impression as to health status in cats in general, but not in relation to any specific disease. Accordingly, the third study aim was to investigate the extent of agreement or disagreement between owner impression of the impact of osteoarthritis on their cats' quality of life and vet impression of such impact. Fifty one percentage of cat owners believed their cats to be perfectly healthy despite a clinician diagnosis of osteoarthritis.

The Impact of Non-Ophthalmic Factors on Intravitreal Injections During the COVID-19 Lockdown

Purpose

Early on in the COVID-19 pandemic, it was difficult to know what factors would affect patient and physician decision-making regarding ophthalmic care utilization. The purpose of this study is to investigate the effect of non-ophthalmic factors on patient decision-making to receive intravitreal injections during the COVID-19 lockdown.

Patients and Methods

Data on patients who had intravitreal injection appointments at a tertiary care Veterans Health Administration clinic during a seven-week period (March 19, 2020-May 8, 2020) of the COVID-19 outbreak in Los Angeles County were collected and compared to patients who had intravitreal injection appointments during the same time period in 2019. Demographic characteristics, injection diagnoses, visual acuities, body mass indices, co-morbidities, and psychiatric conditions of patients and clinic volumes were tabulated and compared between the two time periods.

Results

There were 86 patients in the injection clinic in 2020 compared to 176 patients in 2019. The mean age and gender of patients in the injection clinic did not differ between 2019 and 2020. Compared to 2019, the number of patients who identified as Hispanic or Latino remained nearly the same, but the number of patients who identified as White, Black, or Asian or Pacific Islander decreased by nearly half. In 2020, a greater proportion of patients came to the injection clinic for neovascular age-related macular degeneration (56.5% vs 39.3%, p=0.017), but a decreased proportion of patients diagnosed with a heart condition (OR 0.57, 95% CI 0.33, 0.96), chronic obstructive pulmonary disease (OR 0.43, 95% CI 0.21, 0.91), or asthma (OR 0.09, 95% CI 0.01, 0.70) came to the injection clinic.

Conclusion

The COVID-19 pandemic was associated with behavioral changes in eyecare utilization influenced by race and systemic co-morbidities. These data can be used to design and implement strategies to address disparities in essential ophthalmic care among vulnerable populations.

Having a co-morbidity predicts worse outcome in early rheumatoid arthritis despite intensive treatment: a post hoc evaluation of the pragmatic randomized controlled CareRA trial

OBJECTIVES

To quantify the prevalence of co-morbidities in patients with early RA and determine their prognostic value for effectiveness outcomes in a randomized trial.

METHODS

We included patients from the 2-year pragmatic randomized CareRA trial, who had early RA (diagnosis < 1 year), were DMARD naïve and then treated-to-target with different remission induction schemes. Prevalence of co-morbidities was registered at baseline and the Rheumatic Diseases Comorbidity Index (RDCI; range 0-9) was calculated. We tested the relation between baseline RDCI and outcomes including disease activity (DAS28-CRP), physical function (HAQ index), quality of life (SF-36 domains) and hospitalizations over 2 years, using linear mixed models or generalized estimating equations models.

RESULTS

Of 379 included patients, 167 (44%) had a RDCI of minimum 1. RDCI scores of 1, 2 or ≥3 were obtained in 65 (17%), 70 (19%), and 32 (8%) participants, respectively. The most frequent co-morbidity was hypertension (22%). Patients with co-morbidities had significantly higher HAQ (β = 0.215; 95% CI: 0.071, 0.358), DAS28-CRP (β = 0.225; 95% CI: 0.132, 0.319) and lower SF-36 physical component summary scores (β =-3.195; 95% CI: -4.844, -1.546) over 2 years than patients without co-morbidities, after adjusting for possible confounders including disease activity and randomized treatment. Patients with co-morbidities had over time lower chances of achieving remission (OR = 0.724; 95% CI: 0.604, 0.867) and a higher risk of hospitalization (OR = 3.725; 95% CI: 2.136, 6.494).

CONCLUSION

At disease onset, almost half of RA patients had at least one clinically important co-morbidity. Having co-morbidities was associated with worse functionality and disease activity outcomes over 2 years, despite intensive remission induction treatment.

TRIAL REGISTRATION

Clinical trials NCT01172639.

Lessons from studying roundworm and whipworm in the mouse: common themes and unique features

Ascaris lumbricoides, the roundworm, and Trichuris trichiura, the whipworm, are human intestinal nematode parasites; both are soil-transmitted helminths, are often placed together in an epidemiological context and both remain neglected despite high prevalence. Our understanding of parasitic disease continues to be enhanced through animal models. Despite the similarities between whipworm and roundworm, there are key differences between the two species and these have influenced the application of their respective animal models. In the case of T. trichiura, the fact that a murine equivalent, T. muris completes its life cycle in a mouse model has greatly enhanced our knowledge of whipworm biology, pathogenicity and immunology. In contrast, A. lumbricoides and its porcine equivalent, Ascaris suum, lack a rodent model in which the life cycle is completed. However, evidence continues to accumulate demonstrating that mice represent useful models of early Ascaris infection, a key stage of the life cycle. The use of mouse models for both Ascaris and Trichuris has a long history with early pioneers discovering fundamental aspects of each parasite's biology. Novel technologies and perspectives, as outlined in this special issue, demonstrate how through the prism of mouse models, we can continue to explore the similarities and differences between roundworms and whipworms.