Ethnic differences in CT derived abdominal body composition measures: a comparative retrospect pilot study between European and Inuit study population

Understanding ethnic variations in body composition is crucial for assessing health risks. Universal models may not suit all ethnicities, and there is limited data on the Inuit population. This study aimed to compare body composition between Inuit and European adults using computed tomography (CT) scans and to investigate the influence of demographics on these measurements. A retrospective analysis was conducted on 50 adults (29 Inuit and 21 European) who underwent standard trauma CT scans. Measurements focused on skeletal muscle index (SMI), various fat indices, and densities at the third lumbar vertebra level, analyzed using the Wilcoxon-Mann-Whitney test and multiple linear regression. Inuit women showed larger fat tissue indices and lower muscle and fat densities than European women. Differences in men were less pronouncehd, with only Intramuscular fat density being lower among Inuit men. Regression indicated that SMI was higher among men, and skeletal muscle density decreased with Inuit ethnicity and age, while visceral fat index was positively associated with age. This study suggests ethnic differences in body composition measures particularly among women, and indicates the need for Inuit-specific body composition models. It higlights the importance of further research into Inuit-specific body composition measurements for better health risk assessment.

Efficacy and Safety of Bariatric Surgery in Dutch People Living with HIV: a Retrospective Matched Cohort Analysis

PURPOSE

Obesity is rising among people with HIV (PLWH), sparking interest in bariatric surgery (BS) for this group. Yet, large-scale comparative research on BS outcomes in PLWH is lacking.

METHODS

We performed a retrospective, matched cohort analysis in PLWH and HIV uninfected controls. Subjects were retrieved from the Dutch Audit for Treatment of Obesity (DATO) registry. Matching (1:7 ratio) included age (± 5-years), sex, body-mass index (BMI) of ± 3 kg/m2, surgery type, and associated health problems (AHPs) at baseline. The primary endpoint was total weight loss percentage (%TWL) ≥ 20% achieved at 1-year post-BS. Secondary endpoints were cumulative %TWL achieved at 2-years post-BS, a reported remission or improvement in AHPs post-BS, and surgical complications, both at 1-year post-BS. Comparisons were performed using conditional logistic regression.

RESULTS

Twenty-seven PLWH and 168 controls were included. At 1-year post-BS, 89% PLWH achieved ≥ 20%TWL, compared to 94% of controls (p = 0.4). Cumulative %TWL at 2-years post-BS were 82% and 92% in PLWH and controls, respectively (p = 0.2). Improvement rates in hypertension and type 2 diabetes mellitus were 50% and 86% in PLWH, versus 87% and 87% in controls. Full remission occurred in 20% and 71% of PLHIV, versus 49% and 44% of controls, respectively. No improvement or remission was observed for dyslipidaemia in PLHIV compared to 54% improvement and 29% remission in controls. Surgical complications were 0% in PLHIV and 13% (n = 21) in controls.

CONCLUSION

Efficacy and safety outcomes of BS were similar between PLWH and controls except for the lack of improvement in dyslipidaemia in PLWH.

Impact of benzodiazepine use on the risk of occupational accidents

Benzodiazepines (BZDs) are drugs commonly used for treating insomnia and anxiety. Although they are known to induce cognitive and psychomotor impairments, their effect on the risk of causing accidents at work remains understudied. The objective of this study is to estimate this risk by differentiating between the recommended use and overuse of these drugs (i.e., uninterrupted use for four months). The data come from the French National Health Data System, which provide a population composed of French people who had at least one work accident (WA) from 2017 to 2019 (approximately 2.5 million people). A linear probability model with two-way fixed effects is used to deal with time-constant heterogeneity and the time effect independent of individuals. The results show a reduction in the risk of WA after a short period of BZD use (one month) compared with no use at all, but the risk of WA increases when treatment exceeds the recommended duration. The intensity of use results in a greater risk of WAs: a 1% increase in BZD use (expressed as the amount reimbursed) leads to a 4.4% (p<0.001) increase in the monthly risk of WAs. Moreover, we see an increase in risk in the month following the treatment discontinuation (+3.6%, p<0.001), which could be due to rebounding and catch-up effects. Health professionals and BZD users should be made aware of the WA risk induced by the use of BZDs, particularly after prolonged use and after discontinuation of treatment. This study provides more evidence for the need to limit the duration of BZD treatment.

The Fremantle Back Awareness Questionnaire: cross-cultural adaptation, reliability, and validity of the Italian version in people with chronic low back pain

BACKGROUND AND AIM

There is evidence to suggest that assessing back-specific altered self-perception may be useful when seeking to understand and manage low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is a patient-reported measure of back-specific body perception that has never been adapted and psychometrically analysed in Italian. Hence, the objectives of this research were to cross-culturally adapt and validate the Italian version of this outcome measure (namely, the FreBAQ-I), to make it available for use with Italians suffering from chronic LBP.

METHODS

The FreBAQ-I was developed by forward and backward translation, review by a committee skilled in patient-reported measures and test of the pre-final version to assess its clarity, acceptability, and relevance. The statistical analyses examined: structural validity based on Rasch analysis; hypotheses testing by investigating correlations of the FreBAQ-I with the Roland Morris Disability Questionnaire (RMDQ), a pain intensity numerical rating scale (PI-NRS), the Pain Catastrophising Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) (Pearson's correlations); reliability by internal consistency (Cronbach's alpha) and test-retest repeatability (intraclass correlation coefficient, ICC (2,1)); and measurement error by determining the minimum detectable change (MDC). After the development of a consensus-based translation of the FreBAQ-I, the new outcome measure was delivered to 100 people with chronic LBP.

RESULTS

Rasch analysis confirmed the substantial unidimensionality and the structural validity of the FreBAQ-I. Hypothesis testing was considered good as at least 75% of the hypotheses were confirmed; correlations: RMDQ (r = 0.35), PI-NRS (r = 0.25), PCS (r = 0.41) and TSK (r = 0.38). Internal consistency was acceptable (alpha = 0.82) and test-retest repeatability was excellent (ICC (2,1) = 0.88, 95% CI: 0.83, 0.92). The MDC95 corresponded to 6.7 scale points.

CONCLUSION

The FreBAQ-I was found to be a unidimensional, valid, and reliable outcome measure in Italians with chronic LBP. Its application is advised for clinical and research use within the Italian speaking community.

Influence of Disease-Related Stigma on Patients' Decisions to Upload Medical Reports to the German Electronic Health Record: Randomized Controlled Trial

BACKGROUND

The rollout of the electronic health record (EHR) represents a central component of the digital transformation of the German health care system. Although the EHR promises more effective, safer, and faster treatment of patients from a systems perspective, the successful implementation of the EHR largely depends on the patient. In a recent survey, 3 out of 4 Germans stated that they intend to use the EHR, whereas other studies show that the intention to use a technology is not a reliable and sufficient predictor of actual use.

OBJECTIVE

Controlling for patients' intention to use the EHR, we investigated whether disease-specific risk perceptions related to the time course of the disease and disease-related stigma explain the additional variance in patients' decisions to upload medical reports to the EHR.

METHODS

In an online user study, 241 German participants were asked to interact with a randomly assigned medical report that varied systematically in terms of disease-related stigma (high vs low) and disease time course (acute vs chronic) and to decide whether to upload it to the EHR.

RESULTS

Disease-related stigma (odds ratio 0.154, P<.001) offset the generally positive relationship between intention to use and the upload decision (odds ratio 2.628, P<.001), whereas the disease time course showed no effect.

CONCLUSIONS

Even if patients generally intend to use the EHR, risk perceptions such as those related to diseases associated with social stigma may deter people from uploading related medical reports to the EHR. To ensure the reliable use of this key technology in a digitalized health care system, transparent and easy-to-comprehend information about the safety standards of the EHR are warranted across the board, even for populations that are generally in favor of using the EHR.

Attitudes of the Portuguese population towards advance directives: an online survey

BACKGROUND

Advance directives (ADs) were implemented in Portugal in 2012. Although more than a decade has passed since Law 25/2012 came into force, Portuguese people have very low levels of adherence. In this context, this study aimed to identify and analyse the attitudes of people aged 18 or older living in Portugal towards ADs and to determine the relationships between sociodemographic variables (gender/marital status/religion/level of education/residence/whether they were a health professional/whether they had already drawn up a living will) and people's attitudes towards ADs.

METHODS

An online cross-sectional analytical study was conducted using a convenience sample. For this purpose, a request (email) that publicized the link to a -form-which included sociodemographic data and the General Public Attitudes Toward Advance Care Directives (GPATACD) scale-was sent to 28 higher education institutions and 30 senior universities, covering all of mainland Portugal and the islands (Azores and Madeira). The data were collected between January and February 2023.

RESULTS

A total of 950 adults from completed the online form. The lower scores (mean 1 and 2) obtained in most responses by applying the GPATACD scale show that the sample of the Portuguese population has a very positive attitude towards ADs. The data showed that women, agnostics/atheists, health professionals and those who had already made a living will had more positive attitudes (p < 0.001) towards ADs. There were no statistically significant differences in the attitudes of the Portuguese population sample towards ADs in relation to marital status, education level, and residence.

CONCLUSION

The results obtained enable us to confirm that this sample of the Portuguese population has a positive attitude towards ADs. We verify that there are certain fringes of this sample with certain sociodemographic characteristics (women, agnostics/atheists, health professionals and those who had already made a living will) that have a more positive attitude towards ADs. This data could facilitate the implementation and adjustment of relevant measures, particularly in the field of health education and aimed at groups with less favourable attitudes, to increase the effectiveness of voluntary exercise of citizens' autonomy in end-of-life care planning.

Phylogenetics and phylogeography of Euphorbia canariensis reveal an extreme Canarian-Asian disjunction but limited inter-island colonization

Euphorbia canariensis is an iconic endemic species representative of the lowland xerophytic communities of the Canary Islands. It is widely distributed in the archipelago despite having diasporas unspecialized for long-distance dispersal. Here, we reconstructed the evolutionary history of E. canariensis at two levels: a time-calibrated phylogenetic analysis aimed at clarifying interspecific relationships and large-scale biogeographic patterns; and a phylogeographic study focused on the history of colonization across the Canary Islands. For the phylogenetic study, we sequenced the ITS region for E. canariensis and related species of Euphorbia sect. Euphorbia. For the phylogeographic study, we sequenced two cpDNA regions for 28 populations representing the distribution range of E. canariensis. The number of inter-island colonization events was explored using PAICE, a recently developed method that includes a sample size correction. Additionally, we used species distribution modelling (SDM) to evaluate environmental suitability for E. canariensis through time. Phylogenetic results supported a close relationship between E. canariensis and certain Southeast Asian species (E. epiphylloides, E. lacei, E. sessiliflora). In the Canaries, E. canariensis displayed a west-to-east colonization pattern, not conforming to the "progression rule", i.e. the concordance between phylogeographic patterns and island emergence times. We estimated between 20 and 50 inter-island colonization events, all of them in the Quaternary, and SDM suggested a late Quaternary increase in environmental suitability for E. canariensis. The extreme biogeographic disjunction between Macaronesia and Southeast Asia (ca. 11,000 km) parallels that found in a few other genera (Pinus, Dracaena). We hypothesize that these disjunctions are better explained by extinction across north Africa and southwest Asia rather than long-distance dispersal. The relatively low number of inter-island colonization events across the Canaries is congruent with the low dispersal capabilities of E. canariensis.

[Framework for evaluating the performance of local healthcare: international experiences and prospects for Italy.]

The Italian National healthcare service currently lacks a synthetic framework for measuring the primary care legislative reform established by the National recovery and resilience plan and the legislative reform, Decree number 77/2022. This paper explores the existing international and national literature on primary care' monitoring and evaluation systems with the purpose of drawing guidelines to build up a global and systematic framework. The 2022 World health organization framework is the most advanced reference point as a result of more than twenty years of theoretical and field research. Indeed, it can be regarded as the basic model to be adapted to the specificities of the current Italian legislation and organization.

Darwin, Haeckel, and the "Mikluskan gas organ theory"

A previously unknown reference to the Russian ethnologist, biologist, and traveler Nikolai N. Miklucho-Maclay (1846-1888) was discovered in correspondence between Charles Darwin (1809-1882) and Ernst Haeckel (1834-1919). This reference has remained unknown to science, even to Miklucho-Maclay's biographers, probably because Darwin used the Russian nickname "Mikluska" when alluding to this young scientist. Here, we briefly outline the story behind the short discussion between Darwin and his German counterpart Haeckel, and highlight its importance for the history of science. Miklucho-Maclay's discovery of a putative swim bladder anlage in sharks, published in 1867, was discussed in four letters between the great biologists. Whereas, Haeckel showed enthusiasm for the finding because it supported (his view on) evolutionary theory, Darwin was less interested, which highlights the conceptual differences between the two authorities. We discuss the scientific treatment of Miklucho-Maclay's observation in the literature and discuss the homology, origin, and destiny of gas organs-swim bladders and lungs-in vertebrate evolution, from an ontogenetic point of view. We show that the conclusions reached by Miklucho-Maclay and Haeckel were rather exaggerated, although they gave rise to fundamental insights, and we illustrate how tree-thinking may lead to differences in the conceptualization of evolutionary change.

The importance of need-altruism and kin-altruism to blood donor behaviour for black and white people

BACKGROUND

Need-altruism (a preference to help people in need) and kin-altruism (a preference to help kin over non-kin) underlie two hypotheses for voluntary blood donation: (i) Need-altruism underlies motivations for volunteer blood donation and (ii) Black people express a stronger preference for kin-altruism, which is a potential barrier to donation. This paper tests these hypotheses and explores how need- and kin-altruism are associated with wider altruistic motivations, barriers, and strategies to encourage donation.

METHODS

We assessed need- and kin-altruism, other mechanisms-of-altruism (e.g., reluctant-altruism), barriers, strategies to encourage donation, donor status, and willingness-to-donate across four groups based on ethnicity (Black; White), nationality (British; Nigerian), and country-of-residence: (i) Black-British people (n = 395), and Black-Nigerian people (ii) in the UK (n = 97) or (iii) across the rest of the world (n = 101), and (v) White-British people in the UK (n = 452). We also sampled a Black-Nigerian Expert group (n = 60).

RESULTS

Need-altruism was higher in donors and associated with willingness-to-donate in non-donors. Levels of kin-altruism did not differ between Black and White people, but need-altruism was lower in Black-British people. Kin-altruism was associated with a preference for incentives, and need-altruism with a preference for recognition (e.g., a thank you) as well as an increased willingness-to-donate for Black non-donors. Need-altruism underlies a blood-donor-cooperative-phenotype.

CONCLUSION

Need-altruism is central to blood donation, in particular recruitment. Lower need-altruism may be a specific barrier for Black-British people. Kin-altruism is important for Black non-donors. The blood donor cooperative phenotype deserves further consideration. Implications for blood services are discussed.

Disability Among Older Immigrants in the United States: Exploring Differences by Region of Origin and Gender

Rapid aging in American society will be disproportionately concentrated among the foreign-born. Immigrants in the United States (U.S.) are a heterogeneous population, yet little is known regarding their differences in disability later in life by region of origin. We use data from the National Health Interview Survey on respondents ages 60+ (n = 313,072) and employ gender-specific logistic models to predict reports of any activity of daily living (ADL) disability. After accounting for socioeconomic factors, compared to their U.S.-born non-Hispanic (NH) White counterparts, the odds of reporting ADL disability were higher among U.S.-born respondents that are Hispanic, NH Black, and NH Multiracial as well as respondents with Mexican, Puerto Rican, Cuban, Russian/former Soviet, Middle Eastern, East Asian, and South Asian origins. Also, Dominican, African, and Southeast Asian women-and European men-reported high odds of ADL disability. Our results highlight heterogeneity in the disability profiles of foreign-born older adults in the U.S..

Duration of Residence and Hypertension in Black Foreign-Born Residents: NHIS, 2004-2017

BACKGROUND

Black Americans have the highest prevalence of hypertension in the USA. Black immigrants, who, by definition, have time-limited exposure to the USA, may provide insight into the relationship between exposure to the US environment, Black race, and hypertension.

METHODS

This is a cross-sectional analysis of pooled National Health Interview Survey (2004-2017) data of foreign-born White European and Black adults (N = 11,516). Multivariable robust Poisson regressions assessed the relationship between self-reported hypertension and duration of the residency (< 5, 5-9, 10-14, ≥ 15 years) among Black, Black African, Black Caribbean, and White European foreign-born residents.

RESULTS

In multivariable analyses-controlling for age, sex, education, poverty-to-income ratio, insurance status, recent encounter with a clinician, and BMI-Black foreign-born residents (PR = 1.40, 95% CI = 1.03, 1.90) and Black Africans (10-14 years.: PR = 1.70, 95% CI = 1.13, 2.56; ≥ 15 years.: PR = 1.56, 95% CI = 1.04, 2.34) with a duration of residency of at least 15 and 10 years, respectively, had a greater prevalence of hypertension than those with duration less than 5 years. A nonsignificant positive association between a duration of residency of at least 15 years (compared to less than 5 years) and self-reported hypertension was observed for White Europeans (PR 1.49, 95% CI = 0.88, 2.51) and Black Caribbeans (PR = 1.09, 95% CI = 0.69, 1.72).

CONCLUSION

Duration of residency is particularly associated with hypertension among Black Africans after migration to the USA. This discrepancy may be explained by differences in primary care utilization and awareness of hypertension diagnoses among recent African immigrants, along with greater stress associated with living in the USA.

Sex matters in the association between cardiovascular health and incident dementia: evidence from real world data

BACKGROUND

Cardiovascular health has been associated with dementia onset, but little is known about the variation of such association by sex and age considering dementia subtypes. We assessed the role of sex and age in the association between cardiovascular risk and the onset of all-cause dementia, Alzheimer's disease, and vascular dementia in people aged 50-74 years.

METHODS

This is a retrospective cohort study covering 922.973 Catalans who attended the primary care services of the Catalan Health Institute (Spain). Data were obtained from the System for the Development of Research in Primary Care (SIDIAP database). Exposure was the cardiovascular risk (CVR) at baseline categorized into four levels of Framingham-REGICOR score (FRS): low (FRS < 5%), low-intermediate (5% ≤ FRS < 7.5%), high-intermediate (7.5% ≤ FRS < 10%), high (FRS ≥ 10%), and one group with previous vascular disease. Cases of all-cause dementia and Alzheimer's disease were identified using validated algorithms, and cases of vascular dementia were identified by diagnostic codes. We fitted stratified Cox models using age parametrized as b-Spline.

RESULTS

A total of 51,454 incident cases of all-cause dementia were recorded over a mean follow-up of 12.7 years. The hazard ratios in the low-intermediate and high FRS groups were 1.12 (95% confidence interval: 1.08-1.15) and 1.55 (1.50-1.60) for all-cause dementia; 1.07 (1.03-1.11) and 1.17 (1.11-1.24) for Alzheimer's disease; and 1.34 (1.21-1.50) and 1.90 (1.67-2.16) for vascular dementia. These associations were stronger in women and in midlife compared to later life in all dementia types. Women with a high Framingham-REGICOR score presented a similar risk of developing dementia - of any type - to women who had previous vascular disease, and at age 50-55, they showed three times higher risk of developing dementia risk compared to the lowest Framingham-REGICOR group.

CONCLUSIONS

We found a dose‒response association between the Framingham-REGICOR score and the onset of all dementia types. Poor cardiovascular health in midlife increased the onset of all dementia types later in life, especially in women.

Genetic diversity of variants involved in drug response among Tunisian and Italian populations toward personalized medicine

Adverse drug reactions (ADR) represent a significant contributor to morbidity and mortality, imposing a substantial financial burden. Genetic ancestry plays a crucial role in drug response. The aim of this study is to characterize the genetic variability of selected pharmacogenes involved with ADR in Tunisians and Italians, with a comparative analysis against global populations. A cohort of 135 healthy Tunisians and 737 Italians were genotyped using a SNP array. Variants located in 25 Very Important Pharmacogenes implicated in ADR were extracted from the genotyping data. Distribution analysis of common variants in Tunisian and Italian populations in comparison to 24 publicly available worldwide populations was performed using PLINK and R software. Results from Principle Component and ADMIXTURE analyses showed a high genetic similarity among Mediterranean populations, distinguishing them from Sub-Saharan African and Asian populations. The Fst comparative analysis identified 27 variants exhibiting significant differentiation between the studied populations. Among these variants, four SNPs rs622342, rs3846662, rs7294, rs5215 located in SLC22A1, HMGCR, VKORC1 and KCNJ11 genes respectively, are reported to be associated with ethnic variability in drug responses. In conclusion, correlating the frequencies of genotype risk variants with their associated ADRs would enhance drug outcomes and the implementation of personalized medicine in the studied populations.

Evidence of the association between increased use of direct oral anticoagulants and a reduction in the rate of atrial fibrillation-related stroke and major bleeding at the population level (2012-2019)

BACKGROUND

The introduction of direct-acting oral anticoagulants (DOACs) has shown to decrease atrial fibrillation (AF)-related stroke and bleeding rates in clinical studies, but there is no certain evidence about their effects at the population level. Our aim was to assess changes in AF-related stroke and major bleeding rates between 2012 and 2019 in Andalusia (Spain), and the association between DOACs use and events rates at the population level.

METHODS

All patients with an AF diagnosis from 2012 to 2019 were identified using the Andalusian Health Population Base, that provides clinical information on all Andalusian people. Annual ischemic and hemorrhagic stroke, major bleeding rates, and used antithrombotic treatments were determined. Marginal hazard ratios (HR) were calculated for each treatment.

RESULTS

A total of 95,085 patients with an AF diagnosis were identified. Mean age was 76.1±10.2 years (49.7% women). An increase in the use of DOACs was observed throughout the study period in both males and females (p<0.001). The annual rate of ischemic stroke decreased by one third, while that of hemorrhagic stroke and major bleeding decreased 2-3-fold from 2012 to 2019. Marginal HR was lower than 0.50 for DOACs compared to VKA for all ischemic or hemorrhagic events.

CONCLUSIONS

In this contemporary population-based study using clinical and administrative databases in Andalusia, a significant reduction in the incidence of AF-related ischemic and hemorrhagic stroke and major bleeding was observed between 2012 and 2019. The increased use of DOACs seems to be associated with this reduction.

[Suicides among children, adolescents, and young adults during the COVID-19 pandemic - An analysis of police data from three German federal states]

OBJECTIVE

The COVID-19 pandemic severely affected young people, resulting in increased psychological distress and rising prevalence rates for mental disorders. There is concern that completed suicides have increased in addition to the observed increase in suicide attempts.

METHOD

The study is based on the police crime statistics (01/2017 to 12/2022) of three federal states in Germany, representing 13% of Germany's overall population. Suicide counts and rates for the child, teenage, adolescent, and young adult age groups were compared between the pre-pandemic and pandemic periods using chi-squared tests.

RESULTS

860 people under age 30 died from suicide. Suicide rates did not differ between the pre-pandemic and pandemic periods in any of the age groups studied.

CONCLUSION

So far, there has been no discernible increase in suicides among young Germans. Ongoing suicide monitoring is recommended.

Informal care and mental health in Germany: What are the differences between non-migrants and ethnic German immigrants? A longitudinal comparative analysis

OBJECTIVE

In aging Germany, a large part of care is provided by informal caregivers. We aimed to analyze the main drivers of the mental health of caregivers and their intersection with migration status.

METHODS

Using panel data covering 18 years (n = 25,659 individuals, aged 16 to 103 years; mean age of 49.5 years) and applying linear regression models we investigated the association between informal caregiving and mental health. We compared non-migrant Germans (NMG) and ethnic German immigrants (EGI), who are the oldest immigrant group in Germany. Informal caregiving was defined as living with a person in need of care or by providing care for ≥2 h per day; the main health outcomes were mental health and mental health changes, measured by a metric scale of six items.

RESULTS

Even accounting for selection into caregiving, short-term care seemed to be disadvantageous only for NMG, while long-term care was generally associated with poorer mental health, with a particular disadvantage for EGI. Socio-economic characteristics and personality traits affected mental health changes, but only weakly the caregiving-health association.

CONCLUSION

Informal caregiving presents a health burden which is not explained by socio-economic characteristics and personality, but by migration status. Policies to promote health in an aging society need to consider differences in short- and long-term care provision and between migrants and the non-migrants.

Age estimation based on the metamorphosis of the clavicle end: A test of Falys and Prangle method in two contemporary samples

Upon finding skeletal unidentified remains, four are the questions that must be answered: age, sex, ancestry, and stature. Regarding age estimation, clavicle has received special attention because medial epiphysis is the last epiphysis, among long bones that ossifies. Falys and Prangle proposed a method of age estimation based on three degenerative characteristics-surface topography (TOP), Porosity (POR) and Osteophyte formation (OST)-evaluated on the sternal end of the clavicle according to the descriptions and the illustrations provided in the original article producing satisfactory results. The current study aims to test the applicability of the Falys' and Prangle's method on 174 individuals from two contemporary samples, one from Greece (Cretan osteological Collection and Athens Forensic Anthropology Lab collection) and one from Thailand (Osteological collection in Chiang Mai). Composite scores were calculated, inter and intra- observer error were estimated by kappa statistics and regression equations of the original study were tested in our sample and in subsamples divided by sex and population. The Greek sample gave more accurate estimates compared to the Thai sample. Regressions of known sex gave slightly better results in most cases. When individuals <40 years old were excluded, classification increased for both Thai and Greeks. The results of this pilot study indicate that there are morphological features on the clavicle that are highly correlated with age. Thus, there is a scope of expanding research on the morphological features of the collar bone.

The Italian version of Edinburgh Handedness Inventory: Translation, transcultural adaptation, and validation in healthy subjects

Lateralization is a key aspect of brain architecture and handedness is its primary manifestation. The Edinburgh Handedness Inventory (EHI) and the laterality quotient (LQ) assess the direction and consistency of handedness and require translation and cross-cultural adaptation to guarantee construct validity. We developed a standardized Italian EHI version. The developed Italian version was tested on 202 Italian subjects, classified into three hand types based on their LQs: right, mixed, and left. The frequency of left-handedness in Italians and other populations was compared to previous data. LQs from the twenty- and the ten-item original inventories were also compared. We conducted a factorial analysis. Mcdonald's Omega tested internal consistency. The prevalence of left-handedness was 6.4%, consistent with prior findings in Italian samples and other EHI translations. Age was the only socio-demographic variable that significantly affected the LQ. The internal consistency of the Italian EHI was excellent. Handedness is a feature of several cognitive functions and some neuropsychological diseases; it is influenced by socio-demographic and cultural factors and the instrument used to assess it. To provide a consistent and comparable evaluation of the construct, we recommend using this validated Italian translation of the EHI.

High Incidence of CPLANE1-Related Joubert Syndrome in the Products of Conceptions from Early Pregnancy Losses

Background

The fetal monogenic causes of early pregnancy losses (EPLs) are mainly unknown, with only a few articles on the subject published. In our previous study of EPLs using whole-exome sequencing analysis, we confirmed a genetic diagnosis of CPLANE1-related Joubert syndrome (JS) in three EPLs from two couples and identified a relatively common CPLANE1 allele among our population (NM_001384732.1:c.1819delT;c.7817T>A, further after referred as “complex allele”). Pathogenic variants in the CPLANE1 (C5orf42) gene are reported to cause JS type 17, a primary ciliopathy with various system defects.

Aims

To examine the hypothesis that the CPLANE1 “complex allele,” whether homozygous or compound heterozygous, is a common cause of EPLs in our population.

Study Design

Cohort study/case-control study.ontrol study.

Methods

In this study, we used polymerase chain reaction-based methods to screen for CPLANE1 “complex allele” presence among 246 euploid EPLs (< 12 gestational weeks) from families in North Macedonia. We also investigated the impact of this allele in 650 women with EPLs versus 646 women with no history of pregnancy loss and at least one livebirth, matched by ethnic origin.

Results

We found a high incidence of JS in the total study group of EPLs (2.03%), with a considerably higher incidence among Albanian families (6.25%). Although not statistically significant, women with EPLs had a higher allele frequency of the CPLANE1 “complex allele” (AF = 1.38%) than the controls (AF = 0.85%; p = 0.2). Albanian women had significantly higher frequency of the “complex allele” than the Macedonians (AF = 1.65% and 0.39%, respectively; p = 0.003).

Conclusion

To the best of our knowledge, this is the highest reported incidence of fetal monogenic disease that might cause EPLs. Targeted screening for the CPLANE1 “complex allele” would be warranted in Albanian ethnic couples because it would detect one JS in every 16 euploid EPLs. Our findings have a larger impact on the pathogenesis of pregnancy loss and contribute to a better understanding of the pathogenicity of the variants in the CPLANE1 gene.

Investigating the individual and joint effects of socioeconomic status and lifestyle factors on mild cognitive impairment in older Italians living independently in the community: results from the NutBrain study

OBJECTIVES

Despite extensive research, a clear understanding of the role of the interaction between lifestyle and socioeconomic status (SES) on cognitive health is still lacking. We investigated the joint association of socioeconomic factors in early to midlife and lifestyle in later life and Mild Cognitive Impairment (MCI).

DESIGN

Observational cross-sectional study.

SETTING

NutBrain study in northern Italy.

PARTICIPANTS

773 community-dwelling adults aged 65 years and older (73.2 ± 6.0 SD, 58.6% females) participating in the NutBrain study (2019-2023).

MEASUREMENTS

Three SES indicators (home ownership, educational level, occupation) and five lifestyle factors (adherence to Mediterranean diet, physical activity, smoking habits, social network, leisure activities) were selected. Each factor was scored and summed to calculate SES and healthy lifestyle scores; their joint effect was also examined. The association with MCI was assessed by logistic regression controlling for potential confounders. Sex-stratified analysis was performed.

RESULTS

In total, 24% of the subjects had MCI. The multivariable logistic model showed that a high SES and a high lifestyle score were associated with 81.8% (OR0.182; 95%CI 0.095-0.351), and 44.1% (OR0.559; 95%CI 0.323-0.968) lower odds of having MCI, respectively. When examining the joint effect of SES and lifestyle factors, the cognitive benefits of a healthy lifestyle were most pronounced in participants with low SES. A healthier lifestyle score was found to be significantly associated with lower odds of MCI, only in females.

CONCLUSIONS

According to our findings, SES was positively associated with preserved cognitive function, highlighting the importance of active lifestyles in reducing socioeconomic health inequalities, particularly among those with a relatively low SES.

TRIAL REGISTRATION

Trial registration number NCT04461951, date of registration July 7, 2020 (retrospectively registered, ClinicalTrials.gov).

[Impact of a multicomponent program with nonpharmacological therapies for patients with chronic pain]

INTRODUCTION

25.9% of Spanish people suffer from chronic pain. An integrated, interdisciplinary approach is recommended, with pharmacological and non-pharmacological therapies, involving patients in their self-care.

OBJECTIVE

To evaluate the effectiveness and impact on resources of a program with non-pharmacological therapies in the control of non-oncological chronic pain in the short and medium term.

MATERIAL AND METHODS

Quasi-experimental before-after study, follow-up 3-6 months, measuring: pain, well-being, quality of life, self-esteem, resilience, anxiety/depression (validated scales); patient-reported outcomes of workshop impact on pain management, habits and mood; ED and office visits; drug consumption and employment status.

RESULTS

One hundred and forty-two patients completed the program; 131 (92.3%) were women, age: 56.0. Decreased: pain (scale 0-10) (start: 6.0; end of workshop: 4.0; 3 months: 5.0); anxiety (12.9; 10.4; 8.8) and depression (12.3; 7.23; 6.47) (scales 0-21). They increased: well-being (scale 0-10) (4.0; 6.0; 4.0); quality of life (scale 0-1) (0.418; 0.580; 0.536); health status (scale 0-100) (47.5; 60.0; 60.0); self-esteem (scale 9-36) (24.1; 27.5; 26.7); resilience (scale 6-30) (14.8; 17.4; 18.6). Patient-reported outcomes were performed by 136 patients at the end of the workshop and 79 at 3 months: pain decreased (end of program: 104, 76.5%; 3 months: 66, 83.5%); medication decreased (96, 76.2%; 60, 78.9%); habits improved (112, 88.2%; 69, 90.8%). Forty patients (37.4%) reduced visits to the emergency room, 40 (37.4%) reduced scheduled visits. Overall satisfaction: 9.8 out of 10.

CONCLUSIONS

Patients learn to mitigate their pain, participate in their self-care and improve their quality of life, self-esteem and emotional state. The effects remained for 3-6 months.

Quality assessment and community detection methods for anonymized mobility data in the Italian Covid context

We discuss how to assess the reliability of partial, anonymized mobility data and compare two different methods to identify spatial communities based on movements: Greedy Modularity Clustering (GMC) and the novel Critical Variable Selection (CVS). These capture different aspects of mobility: direct population fluxes (GMC) and the probability for individuals to move between two nodes (CVS). As a test case, we consider movements of Italians before and during the SARS-Cov2 pandemic, using Facebook users' data and publicly available information from the Italian National Institute of Statistics (Istat) to construct daily mobility networks at the interprovincial level. Using the Perron-Frobenius (PF) theorem, we show how the mean stochastic network has a stationary population density state comparable with data from Istat, and how this ceases to be the case if even a moderate amount of pruning is applied to the network. We then identify the first two national lockdowns through temporal clustering of the mobility networks, define two representative graphs for the lockdown and non-lockdown conditions and perform optimal spatial community identification on both graphs using the GMC and CVS approaches. Despite the fundamental differences in the methods, the variation of information (VI) between them assesses that they return similar partitions of the Italian provincial networks in both situations. The information provided can be used to inform policy, for example, to define an optimal scale for lockdown measures. Our approach is general and can be applied to other countries or geographical scales.

Cross-cultural adaptation and psychometric validation of a Spanish version of the Maryland Assessment of Recovery Scale (MARS-12)

The aim of this study was to adapt and validate a Spanish version of the Maryland Assessment of Recovery Scale (MARS-12). It was carried out in strict accordance with internationally recognized guidelines for test adaptation. A preliminary Spanish version of the MARS-12 was first produced through a standardized translation/back-translation process, ensuring semantic, linguistic, and contextual equivalence with respect to the original scale. Its psychometric properties were then examined in a sample of 325 people with serious mental illness recruited from six different provinces in the Basque Country (northern Spain) and Catalonia (north-eastern Spain). They were users of a total of 20 community rehabilitation and psychiatry services. Confirmatory factor analysis supported a unidimensional structure, consistent with the original scale. Scores on the MARS-12 were positively correlated (.83) with scores on the Questionnaire about the Process of Recovery, supporting convergent validity, while validity evidence based on relationships with other variables was provided by positive correlations between MARS-12 scores and scores on the Dispositional Hope Scale (.82) and on the three dimensions of the Multidimensional Scale of Perceived Social Support (range .30 to .41). Reliability of MARS-12 scores was high (McDonald's ω = .97), as was temporal stability across a one-week interval (.89). The Spanish version of the MARS-12 is a valid and reliable scale that may be used by mental health professionals to assess recovery among Spanish people with serious mental illness.

Infographics on risks associated with COVID-19 and the willingness to get the AstraZeneca vaccine: two randomized online experiments

BACKGROUND

Germans hesitated to get vaccinated with AstraZeneca in the COVID-19 pandemic after reports of blood clots.

METHODS

In two preregistered online experiments with stratified randomization (Study 1 N = 824, Study 2: N = 1,056), we tested whether providing evidence-based benefit-risk information reduces the perceived risk of the AstraZeneca vaccine and the perceived probability of blood clots due to the AstraZeneca vaccine and increases the vaccination intention. In Study 1, participants saw no infographic (control) or one of two infographics (low vs. high exposure risk varied by the underlying incidence rates). Study 2 additionally varied the infographic design displaying the risk information (presented as table, circle icons, or manikin-like icons).

RESULTS

The infographic decreased the risk perception of the vaccine compared to no infographic (Study 1: Cohens d = 0.31, 95% CI [0.14, 0.48]; Study 2: Cohens d = 0.34, 95% CI [0.06, 0.62]), but it did not influence the perceived probability of blood clots due to the AstraZeneca vaccine (Study 2: Cohens d = 0.05, 95% CI [-0.23, 0.33]). Also, the infographic design did not affect the perceived probability of blood clots (Study 2). The vaccination intention was not affected by viewing the infographic (Study 1: Cohens d = 0.04, 95% CI [-0.13, 0.21]; Study 2: Cohens d = 0.04, 95% CI [-0.24, 0.32]) nor the presented infection rate (Study 1: Cohens d = 0.07, 95% CI [-0.09, 0.24], Study 2: Cohens d = 0.01, 95% CI [-0.12, 0.15]) but by risk perceptions, sociodemographic characteristics, confidence in the AstraZeneca vaccine, and preference for alternative vaccines.

CONCLUSIONS

The evidence-based benefit-risk information helped putting the risk of vaccinations into perspective. Nevertheless, objective risk information alone did not affect vaccination intention that was low due to the preexisting lacking vaccine confidence.

The frequency of pathogenic variation in the All of Us cohort reveals ancestry-driven disparities

Disparities in data underlying clinical genomic interpretation is an acknowledged problem, but there is a paucity of data demonstrating it. The All of Us Research Program is collecting data including whole-genome sequences, health records, and surveys for at least a million participants with diverse ancestry and access to healthcare, representing one of the largest biomedical research repositories of its kind. Here, we examine pathogenic and likely pathogenic variants that were identified in the All of Us cohort. The European ancestry subgroup showed the highest overall rate of pathogenic variation, with 2.26% of participants having a pathogenic variant. Other ancestry groups had lower rates of pathogenic variation, including 1.62% for the African ancestry group and 1.32% in the Latino/Admixed American ancestry group. Pathogenic variants were most frequently observed in genes related to Breast/Ovarian Cancer or Hypercholesterolemia. Variant frequencies in many genes were consistent with the data from the public gnomAD database, with some notable exceptions resolved using gnomAD subsets. Differences in pathogenic variant frequency observed between ancestral groups generally indicate biases of ascertainment of knowledge about those variants, but some deviations may be indicative of differences in disease prevalence. This work will allow targeted precision medicine efforts at revealed disparities.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among Italian and Immigrant Pregnant Women: A Multicenter Survey

Objectives: To compare the utilization of prenatal services between immigrant and Italian women during the COVID-19 pandemic. Methods: A cross-sectional survey was conducted at 3 maternity care centers in Italy. Results: We included 1,312 women, 1,198 (91.3%) were Italian and 114 (8.7%) were immigrants. A significantly higher proportion of Italians underwent 8 or more prenatal care visits (64.4% vs. 54.4%, p = 0.03) and more immigrants than Italians attended their appointments at hospital settings (45% vs. 18%, p < 0.001). Regarding prenatal course, Italians were more likely than immigrants to attend a non-hospital setting or an online class (49.6% and 30.2% vs. 34.9% and 11.6%, p = 0.008). A higher influenza vaccine uptake among immigrants compared with Italians was observed (39.5% vs. 19.8%, p < 0.001). Among women not receiving certain prenatal services, immigrants were more likely to state COVID-19 pandemic was the main reason for non-compliance. Conclusion: Immigrant pregnant women were more likely to receive prenatal services at a hospital setting than their Italian counterparts. Among women who did not comply with prenatal services, immigrants were more likely to cite the pandemic as their main reason.

Cross-cultural perspectives on intelligent assistive technology in dementia care: comparing Israeli and German experts' attitudes

BACKGROUND

Despite the great benefits of intelligent assistive technology (IAT) for dementia care - for example, the enhanced safety and increased independence of people with dementia and their caregivers - its practical adoption is still limited. The social and ethical issues pertaining to IAT in dementia care, shaped by factors such as culture, may explain these limitations. However, most studies have focused on understanding these issues within one cultural setting only. Therefore, the aim of this study was to explore and compare the attitudes of Israeli and German dementia experts toward IAT in dementia care, to contribute to a more cultural-comparative perspective.

METHODS

Semi-structured interviews were conducted with 35 experts (15 Israelis and 20 Germans) in key roles in health and community services for people with dementia as well as in the fields of dementia and IAT (e.g., computer science, electrical/biomedical engineering, ethics, nursing, and gerontology). Thematic content analysis was used to analyze the data.

FINDINGS

Israeli and German experts identified the same social accelerators in the development and implementation of IAT in dementia care (i.e., changes in family structure and social digitization) and benefits of adopting IAT (e.g., enhancing the safety of people with dementia and increasing their independence). However, there were differences in inhibitor/risk assessments between the two groups. Namely, economic considerations and the cognitive capacity of people with dementia were identified by both groups as inhibitors, while Israeli experts additionally reported stigma and ageism. Whereas both groups agreed that IAT might reduce human connection, and that the technology is not yet reliable enough, German experts highlighted concerns regarding privacy; in contrast, Israeli experts prioritized safety over privacy.

CONCLUSIONS

Our research findings allow for the identification of relevant similarities but also important differences between German and Israeli experts' perspectives. As such, an important basis has been provided for a more in-depth discussion regarding where, why, and how culturally-sensitive technology development is needed.

The organization of ethnocultural attachments among second- generation Germans

Recent research suggests that two ethnocultural "identities"-such as ethnic identity or national identity-can be compatible (positively correlated) or in conflict (negatively correlated) within and across immigrant-origin groups. In the present article, I advance a more cognitively oriented framework for using correlational patterns to map how immigrant-origin people organize their attachments to a variety of ethnocultural categories. In explaining the value of this framework, I embark on a multistage empirical illustration. First, I perform a correlational class analysis (CCA) using a sample of second-generation Germans and a vector of 13 identity-related indicators. Second, I use a series of linear regressions and a descriptive visualization to clarify the results of my CCA. Third, I fit two multinomial logistic regressions that demonstrate how social attributes-and specifically, religion and ethnicity-impose constraints on the latent schemes that second-generation Germans follow to organize their ethnocultural "identities."

Cancer mortality in Germany-born Americans and Germans

INTRODUCTION

Comparing cancer mortality and associated risk factors among immigrant populations in a host country to those in their country of origin reveals disparities in cancer risk, access to care, diagnosis, and disease management. This study compares cancer mortality between the German resident population and Germany-born individuals who migrated to the US.

METHODS

Cancer mortality data from 2008-2018 were derived for Germans from the World Health Organization database and for Germany-born Americans resident in four states (California, Florida, Massachusetts, and New York) from respective Departments of Vital Statistics. We calculated age-standardized mortality rates (ASMRs) using the European standard population and standardized mortality ratios (SMR) compared to the German resident population along with 95% confidence intervals (CIs).

RESULTS

Germany-born American males had lower ASMRs (253.8 per 100,000) than German resident population (325.6 per 100,000). The difference in females was modest, with ASMRs of 200.7 and 203.7 per 100,000, respectively. For all cancers, Germany-born American males had an SMR of 0.72 (95% CI: 0.70-0.74) and females 0.98 (95% CI: 0.95-1.00). Male SMRs among Germany-born Americans were significantly below one for oral cavity, stomach, colorectal, liver, lung, prostate, and kidney cancer. Among females, SMRs were below one for oral cavity, stomach, colorectal, gallbladder, breast, cervix uteri, and kidney cancer. For both sexes, SMRs were over one for bladder cancer (1.14 for males, 1.21 for females). Mortality was higher for lung cancer (SMR: 1.68), non-Hodgkin's lymphoma (1.18) and uterine cancer (1.22) among Germany-born American females compared to the German resident population.

CONCLUSION

Germany-born American males but not females showed lower cancer mortality than German resident population. Disparities may stem from variations in risk factors (e.g., smoking and alcohol use) as well as differences in screening practices and participation, cancer treatment, besides some residual potential "healthy immigrant effect".

Associations of dimensions of anger with distress following traumatic bereavement

OBJECTIVE

A prior study with people exposed to a traumatic event indicated that posttraumatic anger is a multidimensional construct that consists of five factors comprising anger at (a) the criminal justice system, (b) other people, (c) the self, and (d) a perpetrator and (e) a desire for revenge. Preliminary evidence shows that anger at the self and perpetrators is related to posttraumatic stress disorder (PTSD) symptoms. Expanding the focus from trauma victims to people exposed to a traumatic loss of a significant other, for example, due to road traffic accidents, may enhance our knowledge on factors that are amenable to change in the treatment of prolonged grief disorder (PGD) and PTSD.

METHOD

We examined the (a) factor structure of the 20-item Posttraumatic Anger Questionnaire in 209 Dutch people bereaved by road traffic accidents using confirmatory factor analysis and (b) associations between the posttraumatic anger factors and PGD and PTSD using structural equation models.

RESULTS

The expected five-factor structure of the Posttraumatic Anger Questionnaire was supported. Anger at the self was related to greater PGD (β = .35) and PTSD (β = .50) symptoms over and above known risk factors of distress. A desire for revenge (β = .20) was uniquely and positively associated with PTSD symptoms.

CONCLUSION

Pending replication of our findings in longitudinal studies, we conclude that anger subtypes relate differently to distress after traumatic loss. Anger toward the self seems the most detrimental type of anger and may therefore be an important target in treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[Intercultural adaptation of the PUKSoPC in German language : A scale for perceived control in patients with Parkinson's disease]

BACKGROUND

The level of perceived control in people with Parkinson's disease plays a significant role in affecting their quality of life. Simpson et al. developed a scale of perceived control specific to Parkinson's disease called the Parkinson's UK Scale of Perceived Control (PUKSoPC). In this work, we present a cross-culturally adapted German translation of the original English version.

METHODS

After receiving approval by the original authors, an internationally established procedure was used for cross-cultural adaptation. Firstly, the original English version was translated into German independently by two bilingual neuroscientists, who then agreed on a consensus version. This was tested on 10 people with Parkinson's disease and independently back translated into English by two different neuroscientists. After forming a consensus version, this English version was compared with the original version by all four translators. Differences between the versions resulted in modifications to the German translation so that the back translation matched the original as closely as possible. The final version was approved by two of the original authors and clinically tested on 50 people with Parkinson's disease.

RESULTS

During the translation process, the four translators agreed on a culturally adapted German version of the PUKSoPC. Testing of the final version on 50 people with Parkinson's disease did not reveal any linguistic or content-related problems.

CONCLUSION

The linguistically validated German version of the PUKSoPC presented in this paper is now freely available for measuring the levels of perceived control in people with Parkinson's disease to advance both research and clinical practice.

Public events knowledge in an age-heterogeneous sample: Reminiscence bump or bummer?

The reminiscence bump describes an increased recollection of autobiographic experiences made in adolescence and early adulthood. It is unclear if this phenomenon can also be found in declarative knowledge of past public events. To answer this question, we assessed public events knowledge (PEK) about the past 6 decades with a 120-item knowledge test across six domains in a sample of 1,012 Germans that were sampled uniformly across the ages of 30-80 years. General and domain-specific PEK scores were analyzed as a function of age-at-event. Scores were lower for public events preceding participants' birth and stayed stable from the age-at-event of 5-10 years onward. There was no significant peak in PEK in adolescence or early adulthood, arguing against an extension of the reminiscence effect to factual knowledge. We examined associations between PEK and relevant variables such as crystallized intelligence (Gc), news consumption, and openness to experience with structural equation models. Strong associations between PEK and Gc were established, whereas the associations of PEK with news consumption and openness were mainly driven by their link to declarative knowledge. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Diabetes mellitus and obesity among South Asians with ischemic stroke across three countries

BACKGROUND

Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients.

METHODS

The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke.

RESULTS

The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m2 compared with South Asian patients (37% vs 21%, p < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p < 0.001), 3.61 (95% CI: 2.90-4.51, p < 0.001), and 5.24 (95% CI: 3.93-7.00, p < 0.001), respectively.

CONCLUSION

South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations.

Estimates of protection levels against SARS-CoV-2 infection and severe COVID-19 in Germany before the 2022/2023 winter season: the IMMUNEBRIDGE project

PURPOSE

Despite the need to generate valid and reliable estimates of protection levels against SARS-CoV-2 infection and severe course of COVID-19 for the German population in summer 2022, there was a lack of systematically collected population-based data allowing for the assessment of the protection level in real time.

METHODS

In the IMMUNEBRIDGE project, we harmonised data and biosamples for nine population-/hospital-based studies (total number of participants n = 33,637) to provide estimates for protection levels against SARS-CoV-2 infection and severe COVID-19 between June and November 2022. Based on evidence synthesis, we formed a combined endpoint of protection levels based on the number of self-reported infections/vaccinations in combination with nucleocapsid/spike antibody responses ("confirmed exposures"). Four confirmed exposures represented the highest protection level, and no exposure represented the lowest.

RESULTS

Most participants were seropositive against the spike antigen; 37% of the participants ≥ 79 years had less than four confirmed exposures (highest level of protection) and 5% less than three. In the subgroup of participants with comorbidities, 46-56% had less than four confirmed exposures. We found major heterogeneity across federal states, with 4-28% of participants having less than three confirmed exposures.

CONCLUSION

Using serological analyses, literature synthesis and infection dynamics during the survey period, we observed moderate to high levels of protection against severe COVID-19, whereas the protection against SARS-CoV-2 infection was low across all age groups. We found relevant protection gaps in the oldest age group and amongst individuals with comorbidities, indicating a need for additional protective measures in these groups.

Infant mortality in Italy: large geographic and ethnic inequalities

BACKGROUND

Neonatal and infant mortality rates are among the most significant indicators for assessing a country's healthcare and social development. This study examined the trends in neonatal, post-neonatal, and infant mortality in Italy from 2016 to 2020 and analysed differences between children of Italian and foreign parents based on areas of residence, as well as the leading causes of death. Special attention was given to the analysis of mortality in 2020, the first year of the Covid-19 pandemic, and its comparison with previous years.

METHODS

Data from 2016 to 2020 were collected by the Italian National Institute of Statistics and extracted from two national databases, the Causes of Death register and Live births registered in the population register. Neonatal, post-neonatal, and infant mortality rates were calculated using conventional definitions. The main analyses were conducted by comparing Italian citizens to foreigners and contrasting residents of the North with those of the South. Group comparisons were made using mortality rate ratios. The main causes of death were examined, and Poisson log-linear regression models were employed to investigate the relationships between mortality rate ratios for each cause of death and citizenship, place of residence and calendar year.

RESULTS

In Italy, in 2020, the neonatal mortality rate was 1.76 deaths per thousand live births and it was 55% higher in foreign children than in Italian children. Foreign children had a higher mortality rate than Italians for almost all significant causes of death. Children born in the South of Italy, both Italian and foreign, had an infant mortality rate about 70% higher than residents in the North. Regions with higher infant mortality were Calabria, Sicily, Campania, and Apulia. In the South, mortality from neonatal respiratory distress and prematurity was higher. In the first months of 2020, between March and June, the first Covid-19 wave, Italy experienced an increase in neonatal and infant mortality compared to the same period in 2016-2019, not directly related to SARS-CoV-19 infection. The primary cause was neonatal respiratory distress.

CONCLUSIONS

The neonatal and infant mortality rates indicate the persistence of profound inequalities in Italy between the North and the South and between Italian and foreign children.

Suicide in the press: an analysis of newspaper coverage of adolescent versus adult suicides in Italy

BACKGROUND

An association between sensationalized media reporting and subsequent increase in suicidal behavior has been documented, and adolescents are especially vulnerable to imitative influences. The aims of this study were to examine the characteristics of the articles reporting adult and adolescent (under age 18) suicides in the Italian press and to assess adherence to the World Health Organization (WHO) guidelines for responsible reporting. Methods: The print versions of the three newspapers with the widest national distribution in Italy were searched for all the articles on incident suicides printed over a 7-month period (July 2022 to February 2023). Articles were examined for adherence to the WHO guidelines. Results: Overall, 213 articles were identified, reporting on 122 individual suicide cases (88.5% adults and 11.5% adolescents). Of the articles, 78.9% were on adults and 21.1% on adolescents, with a ratio articles/suicide cases of 1.6 for adults and 3.2 for adolescents (p < 0.0001). Adolescent suicide articles had more words (mean 612.5 ± SD 275.6) than adult ones (462.1 ± 267.7, p = 0.001). Potentially harmful reporting features were present in both the adult and adolescent articles (12-82%). Few articles (0-15%) included protective features. Articles on adolescents were more adherent to the WHO guidelines for omitting specific information of suicide method and location. Conclusions: Significant differences were found in the press reporting of adolescent versus adult suicides, with adolescent suicides receiving more attention in terms of the number of articles and article length. Suicide press reporting can be improved. A close collaboration between journalists and suicide prevention experts may be beneficial.

Socioeconomic differences in dietary habits in Italy before and during COVID-19 pandemic: secondary analysis of a nationwide cross-sectional study

BACKGROUND

Several socioeconomic conditions may influence subjects' adherence to healthy eating habits. Food consumption may be influenced by external stress during crisis periods; however, the effects of these events on food habits are difficult to predict. Also, a pandemic crisis like the recent COVID-19 pandemic may have influenced dietary habits and food consumption. The objective of this study was to compare the dietary habits of Italian people before the COVID-19 pandemic with those belonging to the year 2020 in a nationwide population sample.

MATERIALS AND METHODS

Information on dietary habits has been obtained from the multi-purpose survey on families' "Aspects of daily life", carried out in Italy by the Italian National Statistics Institute (ISTAT). We analyzed data coming from 2016 and 2020 editions of the survey (43,000 subjects each year). We used population attributable fraction (PAF) adjusted for age, defined as the proportional reduction in unhealthy diet that would occur if all participants had had a higher education, assuming higher educated individuals as more socially advantaged. Prevalence association for each dietary exposition has been calculated through logistic regression.

RESULTS

Looking at aggregated data from 2016 and 2020 both men and women showed a high prevalence of unhealthy dietary habits. Regarding men, excessive consumption of eggs, pork meat, and bovine meat was characterized by a PAF attributable to socioeconomic conditions to an extent greater than 30%. Women showed the same trend. Focusing on different years of investigation, in 2020, during the COVID-19 pandemic, men and women increased their consumption of eggs, cooked fats, snacks, and sweets, and reduced consumption of fruits and vegetables. Additionally, women increased the assumption of dietary products and meat. Both sexes registered an increase in overweight and obese subjects in 2020.

CONCLUSIONS

To our knowledge, this study was the first in our country to use a yearly, nationwide sample to analyze dietary habits by examining specific types of various foods on a nationwide scale and establishing a correlation between these habits and the COVID-19 pandemic. Our results showed unbalanced dietary habits of the Italian population with an excess of consumption of several foods like eggs, cooked fats snacks, and sweets with low consumption of fruits and vegetables. Socioeconomic differences influence food choices but in a complex way since they seemed to affect some wrong dietary habits but not others, especially regarding fruits and vegetables assumption where differences were less evident among social classes. Outside stressors like a crisis period such as the COVID-19 pandemic seem to have an important role in both men and women regarding the assumption of so-called "junk food".

Legalisation of euthanasia and assisted suicide: advanced cancer patient opinions - cross-sectional multicentre study

OBJECTIVES

The French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled out physician-assisted suicide. The aim of this work was to gather the opinion of patients on continuous sedation and the legalisation of medical assistance in dying and to explore determinants associated with favourable and unfavourable opinions.

METHODS

This was a French national prospective multicentre study between 2016 and 2020.

RESULTS

331 patients with incurable cancer suffering from locally advanced or metastatic cancer in 14 palliative care units were interviewed. 48.6% of participants expressed a favourable opinion about physician-assisted suicide and 27.2% an unfavourable opinion about its legalisation. Regarding euthanasia, 52% of patients were in favour of its legalisation. In univariate analysis, the only factor determining opinion was belief in God.

CONCLUSIONS

While most healthy French people are in favour of legalising euthanasia, only half of palliative care patients expressed this opinion. Medical palliative care specialists were largely opposed to euthanasia. The only determining factor identified was a cultural factor that was independent of the other studied variables. This common factor was found in other studies conducted on cohorts from other countries. This study contributes to the knowledge and thinking about the impact of patients' personal beliefs and values regarding their opinions about euthanasia and assisted suicide.

TRIAL REGISTRATION NUMBER

NCT03664856.

Genetic proxies for antihypertensive drugs and mental disorders: Mendelian randomization study in European and East Asian populations

BACKGROUND

Mental disorders are among the top causes of disease burden worldwide. Existing evidence regarding the repurposing of antihypertensives for mental disorders treatment is conflicting and cannot establish causation.

METHODS

We used Mendelian randomization to assess the effects of angiotensin-converting-enzyme inhibitors (ACEIs), beta blockers (BBs), and calcium channel blockers (CCBs) on risk of bipolar disorder (BD), major depression disorder (MDD), and schizophrenia (SCZ). We used published genetic variants which are in antihypertensive drugs target genes and correspond to systolic blood pressure (SBP) in Europeans and East Asians, and applied them to summary statistics of BD (cases = 41,917; controls = 371,549 in Europeans), MDD (cases = 170,756; controls = 329,443 in Europeans and cases = 15,771; controls = 178,777 in East Asians), and SCZ (cases = 53,386; controls = 77,258 in Europeans and cases = 22,778; controls = 35,362 in East Asians) from the Psychiatric Genomics Consortium. We used inverse variance weighting with MR-Egger, weighted median, weighted mode, and Mendelian Randomization Pleiotropy RESidual Sum and Outlier. We performed gene-specific analysis and utilized various methods to address potential pleiotropy.

RESULTS

After multiple testing correction, genetically proxied ACEIs were associated with an increased risk of SCZ in Europeans (odds ratio (OR) per 5 mmHg lower in SBP 2.10, 95% CI 1.54 to 2.87) and East Asians (OR per 5 mmHg lower in SBP 2.51, 95% CI 1.38 to 4.58). Genetically proxied BBs were not associated with any mental disorders in both populations. Genetically proxied CCBs showed no benefits on mental disorders.

CONCLUSIONS

Antihypertensive drugs have no protection for mental disorders but potential harm. Their long-term use among hypertensive patients with, or with high susceptibility to, psychiatric illness needs careful evaluation.

The effects of effort-reward imbalance on the job, overcommitment, and income on life satisfaction in Germany from a longitudinal perspective

BACKGROUND

The effort-reward imbalance at work model offers a theoretical and analytical framework to estimate the subjective perception of work-related stress. High demands and low rewards in return can harm mental and physical health, well-being, and life satisfaction. According to the theory, overcommitment partially explains why employees endure such straining jobs. In Germany, cultural and economic aspects of labor differ between East and West. Incomes are lower in the East, while work centrality there is higher. In this article, the effects of effort-reward imbalance, overcommitment, and income on life satisfaction as well as their interactions with region were analyzed to gain a clearer picture of regional disparities regarding life satisfaction and the generality of this work stress model in Germany.

METHODS

Data from 3848 participants from 2006 to 2011 of the German Socio-Economic Panel were analyzed. Within-between models were estimated, including fixed and random effects of the continuous form of effort-reward imbalance to predict subjective life satisfaction. Time-variant covariates - e.g., overcommitment or income - as well as time-constant variables - e.g., region, sex, education - were integrated. Differences in regional labor markets between East and West Germany were considered.

RESULTS

Easterners exhibited higher imbalances and overcommitment than Westerners, indicating worse working conditions. Higher imbalances and overcommitment were associated with lower life satisfaction within and between participants, whereas for income only random effects were supported. While region did not moderate the effect of work stress, East Germans' life satisfaction benefitted more from a higher income.

CONCLUSION

The importance of internal work structures in terms of recognition, adequate pay, advancement opportunities, or time pressure were underlined. As compared to the West, Easterners' life satisfaction benefitted more from higher income but not more from a lower imbalance or lower overcommitment. The interplay between materialistic and nonmaterialistic rewards at work should be focused on in the future.

Associations of non-alcoholic fatty liver disease and cirrhosis with liver cancer in European and East Asian populations: A Mendelian randomization study

BACKGROUND

The positive relationships of non-alcoholic fatty liver disease (NAFLD) and cirrhosis with liver cancer were shown in previous observational studies, while further Mendelian randomization (MR) investigations are needed to confirm the possible causal associations.

AIMS

This study aimed to explore whether NAFLD and cirrhosis were causally related to liver cancer using MR in European and East Asian populations.

METHODS AND RESULTS

For European populations, NAFLD data were obtained from a genome-wide meta-analysis (8434 patients and 770 180 controls). The data on chronic elevation of alanine aminotransferase (cALT), a proxy of NAFLD, were derived from Million Veteran Program (68 725 patients and 95 472 controls). Cirrhosis data were collected from two sources: a genome-wide association study of five cohorts (4829 patients and 72 705 controls) and FinnGen (1931 patients and 216 861 controls). Liver cancer data were collected from FinnGen (304 patients and 174 006 controls). For East Asian populations, the data on cirrhosis (2184 patients and 210 269 controls) and hepatocellular carcinoma (1866 patients and 195 745 controls) were obtained from Biobank Japan. Three, 41, seven, six, and three single-nucleotide polymorphisms were used for NAFLD (European), cALT (European), cirrhosis (European-five cohorts), cirrhosis (European-FinnGen), and cirrhosis (East Asian), respectively. We used inverse-variance weighted as the primary method to calculate the odds ratio (OR) and 95% confidence interval (CI). Among European populations, genetically-predicted NAFLD, cALT, cirrhosis (five cohorts), and cirrhosis (FinnGen) were positively associated with liver cancer, with ORs (95% CIs) of 6.62 (3.81-11.50) (p < .001), 2.59 (1.70-3.94) (p < .001), 3.38 (2.41-4.75) (p < .001), and 2.62 (1.20-5.72) (p = .015). Among East Asian populations, there was also a positive association between genetically-predicted cirrhosis and hepatocellular carcinoma (OR = 2.12; 95% CI = 1.78-2.52; p < .001).

CONCLUSION

This study utilized MR to complementarily confirm the positive connections of NAFLD and cirrhosis with liver cancer, as identified in earlier observational research. Subsequent MR investigations involving more liver cancer cases are needed.

MESuSiE enables scalable and powerful multi-ancestry fine-mapping of causal variants in genome-wide association studies

Fine-mapping in genome-wide association studies attempts to identify causal SNPs from a set of candidate SNPs in a local genomic region of interest and is commonly performed in one genetic ancestry at a time. Here, we present multi-ancestry sum of the single effects model (MESuSiE), a probabilistic multi-ancestry fine-mapping method, to improve the accuracy and resolution of fine-mapping by leveraging association information across ancestries. MESuSiE uses summary statistics as input, accounts for the diverse linkage disequilibrium pattern observed in different ancestries, explicitly models both shared and ancestry-specific causal SNPs, and relies on a variational inference algorithm for scalable computation. We evaluated the performance of MESuSiE through comprehensive simulations and multi-ancestry fine-mapping of four lipid traits with both European and African samples. In the real data, MESuSiE improves fine-mapping resolution by 19.0% to 72.0% compared to existing approaches, is an order of magnitude faster, and captures and categorizes shared and ancestry-specific causal signals with enhanced functional enrichment.

First Case of Medically Assisted Suicide in Italy Set New Legal Perspectives

Abstract

The first act of assisted suicide in Italy was recently carried out. This event is an absolute novelty for the country, affected by recent legislative changes aimed only at introducing the right to interrupt health treatments and, therefore, carry out exclusively omissive end-of-life acts. These normative provisions lay their foundations in a cultural context centered on the protection of the right to life and health; however, the cases that have occurred over time, including the famous story of DJ Fabo, have led the Constitutional Court to re-evaluate these dictates, introducing in 2019 the right to resort to assisted suicide procedures within well-defined areas, including incurability of the condition, the serious suffering of the individual and the retained ability to stand trial. The case addressed concerns a quadriplegic subject who was the victim of a road accident. Following consultation with a specialized institution, the subject made the decision to undergo an assisted sui-cide procedure in Italy. Having obtained the authorization from the competent authorities, he started a fundraiser to finance the devices and drugs required and, finally, he died. The opening by Italy towards the assisted suicide procedure represents a great step towards a broad context, as well as a decisive act for the purpose of protecting the right to self-determination of the individual. However, the current legislative framework presents significant criticalities and shortcomings. In first place, the dissonance between the laws in force and the judicial sentences is likely to generate problems of uneven application of the rules in a country dominated by the principle of Civil Law. Furthermore, the need for the applicant to fully self-finance the procedure clearly clashes with the constitutional principle of free access to care. Then emerges the need for a guideline document regarding the completion of the procedure itself, the times, methods and drugs implied, in order to significantly reduce the decision-making process by the ethics committees that still weighs on each individual case. Finally, conside-ring what has been observed on the subject of voluntary termination of pregnancy, it is necessary to ask what will be the general orientation of the doctors called to perform the act and whether they will be given the opportunity to express their refusal. The case analyzed could represent the beginning of a new era for Italian culture, but the large-scale application of assisted suicide procedures requires the introduction of legislative provisions that definitively eliminate the critical issues that have emerged so far.

Predictors of Nursing Home Placement in a Cohort of European People with Alzheimer's Disease and Other Dementia Cases Enrolled in SCU-B or Non SCU-B Centers: The RECage Study

Background

Nursing home placement (NHP) can be the final step of patients with Alzheimer's disease.

Objective

We aimed to identify NHP predictors among 508 people with dementia with a 3-year follow-up.

Methods

We analyzed data from the international observational RECage study, involving 508 people with especially Alzheimer's disease and comparing a cohort enrolled by five centers with a Special Care Unit for BPSD (behavioral and psychological symptoms of dementia) and another one enrolled by six centers lacking this facility. The tertiary objective of the study was to assess the possible role of the SCU-B in delaying NHP. We assessed the relationship of the baseline characteristics with NHP by means of univariate analysis followed by Cox's multivariate model.

Results

Patients' mean age was 78.1 years, 54.9% were women. Diagnosis mean age was 75.4 (±8.32) years; the main diagnosis was Alzheimer's disease (296; 58.4%). During follow-up, 96 (18.9%) patients died and 153 (30.1%) were institutionalized without a statistically significant difference between the two cohorts (p = 0.9626). The mean NHP time was 902 (95% CI: 870-934). The multivariable analysis without death as a competing risk retained four independent predictors of NHP: age increase (hazard ratio (HR) = 1.023, 95% CI: 1.000-1.046), patient education level increase (HR = 1.062, 95% CI: 1.024-1.101), Neuropsychiatric Inventory total increase (HR = 1.018; 95% CI: 1.011-1.026), and total Mini-Mental State Examination as a favorable factor (HR = 0.948, 95% CI: 0.925-0.971). Gender (females versus males: HR = 1.265, 95% CI: 0.899-1.781) was included in the final Cox's model for adjusting the estimates for.

Conclusions

Our data partially agree with the predictors of NHP in literature including the effect of high education level. No caregivers' factors were statistically significant.

Clinical trial registration

NCT03507504.

Identifying Stigmatizing Language Used by Israelis and Germans With a Mild Neurocognitive Disorder, Their Relatives, and Caregivers of People With Alzheimer's Disease

OBJECTIVES

The purpose of the study was to examine and compare the dementia-related discourse and language used by people with mild neurocognitive disorder (MND), their family members, and family caregivers of people with Alzheimer's disease in Israel and Germany.

DESIGN

This secondary qualitative analysis included focus groups and semistructured interviews. Thematic analysis was used to reveal the main discourses and stigmatic language used regarding dementia and people with dementia.

SETTING

Israeli and German stakeholders.

PARTICIPANTS

Forty-four Israeli and 44 German participants: 28 people with MND, 20 family members of people with MND, and 40 family caregivers of people with Alzheimer's disease.

RESULTS

Two main discourses were identified: the tragedy and the biomedical discourse. The tragedy discourse included several subthemes: "Dementia as the worst-case scenario," "Nothing can be done about dementia," and "People with dementia are not human." The biomedical discourse stressed pathologic aspects of the condition. Similarities and differences were found between Israeli and German participants.

CONCLUSIONS

The study indicates that, despite culture and language differences, the use of stigmatic discourse and stigmatizing language is common among people with close exposure to dementia in Israel and Germany. Efforts should be increased to develop a person-centered and dementia-friendly language.

Universality in eye movements and reading: A replication with increased power

Liversedge, Drieghe, Li, Yan, Bai and Hyönä (2016) reported an eye movement study that investigated reading in Chinese, Finnish and English (languages with markedly different orthographic characteristics). Analyses of the eye movement records showed robust differences in fine grained characteristics of eye movements between languages, however, overall sentence reading times did not differ. Liversedge et al. interpreted the entire set of results across languages as reflecting universal aspects of processing in reading. However, the study has been criticized as being statistically underpowered (Brysbaert, 2019) given that only 19-21 subjects were tested in each language. Also, given current best practice, the original statistical analyses can be considered to be somewhat weak (e.g., no inclusion of random slopes and no formal comparison of performance between the three languages). Finally, the original study did not include any formal statistical model to assess effects across all three languages simultaneously. To address these (and some other) concerns, we tested at least 80 new subjects in each language and conducted formal statistical modeling of our data across all three languages. To do this, we included an index that captured variability in visual complexity in each language. Unlike the original findings, the new analyses showed shorter total sentence reading times for Chinese relative to Finnish and English readers. The other main findings reported in the original study were consistent. We suggest that the faster reading times for Chinese subjects occurred due to cultural changes that have taken place in the decade or so that lapsed between when the original and current subjects were tested. We maintain our view that the results can be taken to reflect universality in aspects of reading and we evaluate the claims regarding a lack of statistical power that were levelled against the original article.

Residual Lung Abnormalities in Survivors of Severe or Critical COVID-19 at One-Year Follow-Up Computed Tomography: A Narrative Review Comparing the European and East Asian Experiences

The literature reports that there was a significant difference in the medical impact of the coronavirus disease (COVID-19) pandemic between European and East Asian countries; specifically, the mortality rate of COVID-19 in Europe was significantly higher than that in East Asia. Considering such a difference, our narrative review aimed to compare the prevalence and characteristics of residual lung abnormalities at one-year follow-up computed tomography (CT) after severe or critical COVID-19 in survivors of European and East Asian countries. A literature search was performed to identify articles focusing on the prevalence and characteristics of CT lung abnormalities in survivors of severe or critical COVID-19. Database analysis identified 16 research articles, 9 from Europe and 7 from East Asia (all from China). Our analysis found a higher prevalence of CT lung abnormalities in European than in Chinese studies (82% vs. 52%). While the most prevalent lung abnormalities in Chinese studies were ground-glass opacities (35%), the most prevalent lung abnormalities in European studies were linear (59%) and reticular opacities (55%), followed by bronchiectasis (46%). Although our findings required confirmation, the higher prevalence and severity of lung abnormalities in European than in Chinese survivors of COVID-19 may reflect a greater architectural distortion due to a more severe lung damage.

Association between COVID-19 and sensorineural hearing loss: Evidence from a Mendelian randomization study in European and East Asian population

BACKGROUND

Long coronavirus disease (COVID), characterized by persistent and sometimes debilitating symptoms following a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has garnered increasing attention as a potential public health crisis. Emerging evidence indicates a higher incidence of hearing loss in individuals who have had COVID 2019 (COVID-19) compared to the general population. However, the conclusions were inconsistent, and the causal relationship between COVID-19 and sensorineural hearing loss remains unknown.

METHODS

To addresses this outstanding issue, we performed Mendelian randomization analysis to detect the causal association between COVID-19 and hearing loss using the largest genome-wide association study data to date in the European population and confirmed the results in the East Asian population. Comprehensively sensitive analyses were followed, including Cochran's Q test, Mendelian randomization (MR)-Egger intercept test, MR-pleiotropy residual sum and outlier, and leave-one-out analysis, to validate the robustness of our results.

RESULTS

Our results suggested that there is no causal association between COVID-19 and the risk of hearing loss in the European population. Neither the susceptibility, hospitalization, and severity of COVID-19 on hearing loss (inverse variance weighted method: odds ratio (OR) = 1.046, 95% confidence interval (CI) = 0.907-1.205, p = .537; OR = 0.995, 95% CI = 0.956-1.036, p = .823; OR = 0.995, 95% CI = 0.967-1.025, p = .76). Replicated analyses in the East Asian population yielded consistent results. No pleiotropy and heterogeneity were found in our results.

CONCLUSION

In conclusion, our MR results do not support a genetically predicted causal relationship between COVID-19 and sensorineural hearing loss. Thus, the associations observed in prior observational studies may have been influenced by confounding factors rather than a direct cause-and-effect relationship. More clinical and mechanism research are needed to further understand this association in the future.