Polycystic ovary syndrome: associations with cardiovascular disease

Polycystic ovary syndrome (PCOS), characterized by abnormal menstrual periods, elevated androgen levels and polycystic ovary morphology on ultrasound, is the most common endocrine disorder among females. PCOS is associated with cardiovascular disease (CVD) risk factors including diabetes, obesity, metabolic syndrome, adverse pregnancy outcomes such as pre-eclampsia and psychosocial distress including depression. Previous evidence on the association between PCOS and CVD is inconclusive but the latest 2023 International Evidence-Based PCOS Guideline identifies PCOS as a risk factor for CVD. This review will discuss the relationship between PCOS and CVD along with current direction for CVD screening and prevention among individuals with PCOS.

60 Years of the 3Rs symposium: Lessons learned and the road ahead

When The Principles of Humane Experimental Technique was published in 1959, authors William Russell and Rex Burch had a modest goal: to make researchers think about what they were doing in the laboratory - and to do it more humanely. Sixty years later, their groundbreaking book was celebrated for inspiring a revolution in science and launching a new field: The 3Rs of alternatives to animal experimentation. On November 22, 2019, some pioneering and leading scientists and researchers in the field gathered at the Johns Hopkins Bloomberg School of Public Health in Bal-timore for the 60 Years of the 3Rs Symposium: Lessons Learned and the Road Ahead. The event was sponsored by the Johns Hopkins Center for Alternatives to Animal Testing (CAAT), the Foundation for Chemistry Research and Initiatives, the Alternative Research & Development Foundation (ARDF), the American Cleaning Institute (ACI), the International Fragrance Association (IFRA), the Institute for In Vitro Sciences (IIVS), John "Jack" R. Fowle III, and the Society of Toxicology (SoT). Fourteen pres-entations shared the history behind the groundbreaking publication, international efforts to achieve its aims, stumbling blocks to progress, as well as remarkable achievements. The day was a tribute to Russell and Burch, and a testament to what is possible when people from many walks of life - science, government, and industry - work toward a common goal.

Hip arthroplasty practice across the Organisation for Economic Co-operation and Development (OECD) over the last decade

INTRODUCTION

There are large variations in the number of hip replacements performed between countries, demonstrating large health inequalities; however, there has been limited research on this variation. The aims of this paper were to compare rates of hip replacements using Organisation for Economic Co-operation and Development (OECD) data for the period 2008-2018. The study also compared changes in the number of hip replacements in the total population and in only those aged over 65, and looked for a correlation of health expenditure and gross domestic product (GDP) with rates of hip replacements.

METHODS

The OECD collects annual data from all member countries on the numbers of hip replacements, healthcare expenditure and GDP. Data analysis was undertaken using STATA. Descriptive statistics and Pearson's correlation coefficient were performed.

RESULTS

The mean number of hip replacements performed in OECD countries in 2018 was 191.5 per 100,000 population per year. The largest number was 310.6 in Germany and the lowest was 8.6 in Mexico. There has been a 21.7% increase in the mean number of hip replacements across OECD countries. There was a moderate and significant Pearson coefficient of 0.468 (p = 0.009) between the number of hip replacements performed per 100,000 population in 2018 and GDP per person, and a strong and significant correlation with health expenditure (R = 0.784, p < 0.001). There was a moderate correlation (R = 0.645, p = 0.003) between the percentage change in the number of hip replacements performed per 100,000 population and the percentage change in healthcare expenditure per person between 2008 and 2018.

CONCLUSIONS

There is 36-fold variation in the practice of hip replacements across the OECD and the number of hip replacements has increased by more than 20% over the past decade. The number of hip replacements performed appears to be correlated with health expenditure in each country and may indicate a need that can only be met by increasing health expenditure.

The 35th annual advances in contrast ultrasound international bubble conference, Chicago 2021: synopsis and take-home messages

The 35th Annual Advances in Contrast Ultrasound International Bubble Conference convened in Chicago, IL, USA, on September 30th to October 1st, 2021. It featured a range of novel research from animal studies to clinical applications in multiple organ systems, demonstrating the utility of contrast enhanced ultrasound (CEUS). A multidisciplinary group of experts on the use of CEUS, including physicians, basic scientists, engineers, and industry partners, convened to discuss cutting edge research and new applications for CEUS. The conference demonstrated the wide range of CEUS uses and potential uses, including cardiac risk stratification, sonothrombolysis, peripheral vascular reperfusion, liver and renal mass evaluation, lymphatic evaluation, sentinel node identification, and CEUS use in pediatrics. The International Contrast Ultrasound Society uses this information to continue advocating for the safe and appropriate use of CEUS.

The effect of non-oncology drugs on clinical and genomic risk in early luminal breast cancer

BACKGROUND

An effect of non-oncology medications on cancer outcome has been proposed. In this study, we aimed to systematically examine the impact of commonly prescribed non-oncology drugs on clinical risk and on the genomic risk [based on the Oncotype DX recurrence score (RS)] in early breast cancer (BC).

EXPERIMENTAL DESIGN

We collected data on clinical risk (stage and grade), genomic risk (Oncotype DX RS), and on non-oncology medications administered to 1423 patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative BC during the month of their surgery. The influence of various medications on clinical and genomic risks was evaluated by statistical analysis.

RESULTS

Out of the multiple drugs we examined, levothyroxine was significantly associated with a high Oncotype DX RS (mean 24.78; P < 0.0001) and metformin with a low Oncotype DX RS (mean 14.87; P < 0.01) compared with patients not receiving other non-oncology drugs (mean 18.7). By contrast, there were no differences in the clinical risk between patients receiving metformin, levothyroxine, or no other non-oncology drugs. Notably, there was no association between the consumption of levothyroxine and metformin and proliferation marker (Ki67) levels, but both drugs were significantly associated with progesterone-related features, suggesting that they influence genomic risk through estrogen-dependent signaling.

CONCLUSIONS

The results of this study indicate a significant impact of metformin and levothyroxine on clinical decisions in luminal BC, with potential impact on the clinical course of these patients.

Echocardiographic predictors of mortality and morbidity in COVID-19 disease using focused cardiovascular ultrasound

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Focused TTE is a critical diagnostic tool to limit exposure in COVID-19.

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Largest COVID-19 cohort to date showing strong prognostic power of RV parameters.

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RV dilation significantly associated with increased mortality in COVID-19.

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RV dysfunction significantly associated with shock in COVID-19.

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LV abnormalities did not provide prognostic information in COVID-19.

Background

Focused transthoracic echocardiography (fTTE) has emerged as a critical diagnostic tool during the COVID-19 pandemic, allowing for efficient cardiac imaging while minimizing staff exposure. The utility of fTTE in predicting clinical outcomes in COVID-19 remains under investigation.

Methods

We conducted a retrospective study of 2,266 hospitalized patients at Rush University Medical Center with COVID-19 infection between March and November 2020 who received a fTTE. fTTE data were analyzed for association with primary adverse outcomes (60-day mortality) and with secondary adverse outcomes (need for renal replacement therapy, need for invasive ventilation, shock, and venous thromboembolism).

Results

Of the 427 hospitalized patients who had a fTTE performed (mean 62 years, 43% female), 109 (26%) had died by 60 days. Among patients with an available fTTE measurement, right ventricular (RV) dilation was noted in 34% (106/309), 43% (166/386) had RV dysfunction, and 17% (72/421) had left ventricular (LV) dysfunction. In multivariable models accounting for fTTE data, RV dilation was significantly associated with 60-day mortality (OR 1.93 [CI 1.13–3.3], p = 0.016). LV dysfunction was not significantly associated with 60-day mortality (OR 0.95 [CI: 0.51–1.78], p = 0.87).

Conclusions

Abnormalities in RV echocardiographic parameters are adverse prognosticators in COVID-19 disease. Patients with RV dilation experienced double the risk for 60-day mortality due to COVID-19. To our knowledge, this is the largest study to date that highlights the adverse prognostic implications of RV dilation as determined through fTTE in hospitalized COVID-19 patients.

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Benzocaine-related methaemoglobinemia after transoesophageal echocardiography: a rare, life-threatening complication

Methaemoglobinemia is an uncommon but potentially life-threatening complication of topical benzocaine use that requires prompt identification in patients who undergo transoesophageal echocardiography (TEE). In this case, a 21-year-old patient who had sustained a stroke with residual right-sided weakness a few days prior to presentation underwent TEE to evaluate for intracardiac shunt. She required intubation as part of her poststroke care with some instrumentation to the posterior oropharynx. Shortly after TEE, the patient experienced sudden onset respiratory distress and hypoxia that did not improve with supplemental oxygen. Chest X-ray did not reveal any acute cardiopulmonary process. Arterial blood gas co-oximetry panel with methaemoglobin level confirmed the diagnosis of methaemoglobinemia. The patient promptly received methylene blue, recovered quickly and did not have any additional episodes of hypoxia.

Hypertension in older adults: Assessment, management, and challenges

Hypertension in older adults is related to adverse cardiovascular outcomes, such as heart failure, stroke, myocardial infarction, and death. The global burden of hypertension is increasing due to an aging population and increasing prevalence of obesity, and is estimated to affect one third of the world's population by 2025. Adverse outcomes in older adults are compounded by mechanical hemodynamic changes, arterial stiffness, neurohormonal and autonomic dysregulation, and declining renal function. This review highlights the current evidence and summarizes recent guidelines on hypertension, pertaining to older adults. Management strategies for hypertension in older adults must consider the degree of frailty, increasingly complex medical comorbidities, and psycho-social factors, and must therefore be individualized. Non-pharmacological lifestyle interventions should be encouraged to mitigate the risk of developing hypertension, and as an adjunctive therapy to reduce the need for medications. Pharmacological therapy with diuretics, renin-angiotensin system blockers, and calcium channel blockers have all shown benefit on cardiovascular outcomes in older patients. Given the economic and public health burden of hypertension in the United States and globally, it is critical to address lifestyle modifications in younger generations to prevent hypertension with age.

The 34th Annual Advances in Contrast Ultrasound International Bubble Conference, Chicago 2019: synopsis and take-home messages

The 34th annual Advances in Contrast Ultrasound (ACU) International Bubble Conference convened in Chicago, IL, USA, on September 5–6, 2019 to feature new directions of research, preclinical and first-in-man clinical trials, and novel clinical applications highlighting the diversity and utility of contrast enhanced ultrasound (CEUS). An expert group comprising clinicians, engineers, basic scientists, government officials, attorneys, and industry partners convened to collaborate on cutting-edge ultrasound enhancement technology. Utilizing this information, the International Contrast Ultrasound Society (ICUS) continues to have cause to advocate for the safe and appropriate use of CEUS with expanding indications and applications.

Small Cell Lung Cancer Invading the Left Atrium With Subsequent Malignant Embolic Stroke: A Case Report and Review of Literature

Cardiac tumors are uncommon, and the vast majority of them are metastases from extracardiac sources. Metastatic spread to the heart causes symptoms by mechanical obstruction of circulation, direct myocardial invasion, or distal embolization. We herein report a case of a 58-year-old male who presented to the hospital with multilobar intracranial embolic infarcts who was found to have small cell lung cancer (SCLC) with invasion of the left atrium and pulmonary artery resulting in malignant embolic stroke. Cerebral tumor thromboembolism from SCLC is extremely rare. This case demonstrates the thromboembolic risk associated with metastatic endoluminal cardiac tumors.

Evaluation of the 1st metatarso-sesamoid joint using standing CT - The Stanmore classification

BACKGROUND

Little is understood about the role that relative sesamoid displacement and chondral wear have on outcome after hallux valgus (HV) surgery. All existing methods to evaluate relative sesamoid displacement have limitations and furthermore, there have been no radiographic studies evaluating metatarso-sesamoid joint wear. Standing CT scan circumvents many of the existing problems in evaluation of relative sesamoid displacement, and also enables the first radiographic study assessing metatarso-sesamoid joint wear.

METHODS

Fifty feet (in 43 patients) with symptomatic HV (Group A) were compared with a control group of 50 feet (50 patients) (Group B). All images were standardised to enable reproducible measurements. The hallux valgus angle, Intermetatarsal angle, sesamoid rotation angle, sesamoid position and metatarso-sesamoid joint space were measured in all patients.

RESULTS

The intra and inter-observer reliability correlation showed that the standing CT assessment of sesamoid position (1.000), rotation (0.991) and metatarso-sesamoid joint space (0.960) were highly reproducible. There was a highly significant difference (p<0.0001) in sesamoid position, sesamoid rotation and metatarso-sesamoid joint space between Group A and Group B.

CONCLUSIONS

Standing CT has been shown to be a reproducible and accurate method of assessing the relative sesamoid displacement and metatarso-sesamoid joint space narrowing. The results have been used to propose a novel standing CT based classification of hallucal sesamoids, considering the degree of displacement and wear. This classification may ultimately facilitate research to provide new insight into the effect relative sesamoid displacement and chondral wear have on outcomes from hallux valgus surgery.

Team-based model for non-operating room airway management: validation using a simulation-based study

BACKGROUND

Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios.

METHODS

Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group).

RESULTS

Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively].

CONCLUSIONS

Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.

Consensus statement on the need for innovation, transition and implementation of developmental neurotoxicity (DNT) testing for regulatory purposes

This consensus statement voices the agreement of scientific stakeholders from regulatory agencies, academia and industry that a new framework needs adopting for assessment of chemicals with the potential to disrupt brain development. An increased prevalence of neurodevelopmental disorders in children has been observed that cannot solely be explained by genetics and recently pre- and postnatal exposure to environmental chemicals has been suspected as a causal factor. There is only very limited information on neurodevelopmental toxicity, leaving thousands of chemicals, that are present in the environment, with high uncertainty concerning their developmental neurotoxicity (DNT) potential. Closing this data gap with the current test guideline approach is not feasible, because the in vivo bioassays are far too resource-intensive concerning time, money and number of animals. A variety of in vitro methods are now available, that have the potential to close this data gap by permitting mode-of-action-based DNT testing employing human stem cells-derived neuronal/glial models. In vitro DNT data together with in silico approaches will in the future allow development of predictive models for DNT effects. The ultimate application goals of these new approach methods for DNT testing are their usage for different regulatory purposes.

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An increased prevalence of neurodevelopmental disorders in children is observed.

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There is very limited information on neurodevelopmental toxicity (DNT) induced by environmental chemicals.

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A new framework is required for assessment of chemicals with the potential to disrupt brain development.

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In vitro DNT data together with in silico approaches should be used for regulatory purposes.

Israel transcutaneous bilirubin nomogram predicts significant hyperbilirubinemia

OBJECTIVE

We constructed a transcutaneous bilirubin (TcB) nomogram to represent major sectors of the Israeli population. We studied the risk of hyperbilirubinemia, defined as meeting the requirements for phototherapy, per percentile risk category.

STUDY DESIGN

Newborns ⩾36 weeks gestation were tested daily for TcB, using Drager JM-103 devices, during birth hospitalization. A nomogram was constructed and divided into four risk groups and validated by calculating the need for phototherapy for each group.

RESULTS

A total of 3303 measurements were performed on 1059 consecutive newborns including Ashkenazi, Sephardic and mixed Ashkenazi/Sephardic Jews, Arab and Ethiopian Jewish. Phototherapy risk increased progressively and more than 100-fold, from 0/225 in the <40th percentile group through 27/120 (22.5%) for those >95th percentile (relative risk (95% confidence interval) 102 (6 to 1669) for those >95th percentile compared with those <40th percentile). The optimal risk for discriminating the need for phototherapy was >75th percentile (sensitivity 93.33, specificity 59.47).

CONCLUSION

The risk of significant hyperbilirubinemia increased progressively with increasing percentile. Newborns >75th percentile groups are at high risk for phototherapy and should be closely monitored.

Evaluation of C1q Status and Titer of De Novo Donor-Specific Antibodies as Predictors of Allograft Survival

De novo donor-specific antibodies (dnDSAs) that develop after renal transplantation are independent predictors of allograft loss. However, it is unknown if dnDSA C1q status or titer at the time of first detection can independently predict allograft loss. In a consecutive cohort of 508 renal transplant recipients, 70 developed dnDSAs. Histologic and clinical outcomes were correlated with the C1q assay or dnDSA titer. C1q positivity correlated with dnDSA titer (p < 0.01) and mean fluorescence intensity (p < 0.01) and was more common in class II versus class I dnDSAs (p < 0.01). C1q status correlated with tubulitis (p = 0.02) and C4d status (p = 0.03) in biopsies at the time of dnDSA development, but not T cell-mediated rejection (TCMR) or antibody-mediated rejection (ABMR). De novo DSA titer correlated with Banff g, i, t, ptc, C4d scores, TCMR (p < 0.01) and ABMR (p < 0.01). Post-dnDSA graft loss was observed more frequently in recipients with C1q-positve dnDSA (p < 0.01) or dnDSA titer ≥ 1:1024 (p ≤ 0.01). However, after adjustment for clinical phenotype and nonadherence in multivariate models, neither C1q status nor dnDSA titer were independently associated with allograft loss, questioning the utility of these assays at the time of dnDSA development.

Multiple Cardioembolic Strokes Caused by Caseous Calcification of the Mitral Annulus

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Mitral annular calcification (MAC) is a common echocardiographic finding, estimated at around 14%, and occurs especially in elderly women.

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Caseous calcification of the mitral annulus (CCMA) is a rare subvariant of MAC, with an echocardiographic prevalence of 0.6% and necropsy prevalence of about 2.3%.

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CCMA, just like MAC, is believed to be associated with a high calcium score, coronary artery disease, aortic valve disease, atrial fibrillation, and hypertension.

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CCMA can be confused echocardiographically with infective endocarditis, tumors, and cysts.

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The decision for surgical treatment of CCMA is based on clinical judgment with factors such as valvular dysfunction and/or the propensity for stroke.

A Controlled Trial of Iron Therapy in Sideropenia

It has been shown that there is a high incidence of latent iron deficiency (sideropenia) in the female population. To assess the role of this deficiency as a cause of symptoms a double blind trial of iron and placebo therapy was carried out on 20 sideropenic women presenting with symptoms.

The incidence of all the symptoms studied fell and there was no significant difference between iron and placebo in producing improvement.

A significant rise in haemoglobin level occurred only in response to iron therapy and this was reversed on cessation of iron. No significant changes in haemoglobin occurred in response to the placebo.

It has been concluded that while iron has no specific effect on the symptoms associated with sideropenia, it will produce a significant rise in haemoglobin level, reverse biochemical defects and, in a minority, prevent development of iron deficiency anaemia.

Knee surgery and its evidence base

INTRODUCTION

Evidence driven orthopaedics is gaining prominence. It enables better management decisions and therefore better patient care. The aim of our study was to review a selection of the leading publications pertaining to knee surgery to assess changes in levels of evidence over a decade.

METHODS

Articles from the years 2000 and 2010 in The Knee, the Journal of Arthroplasty, Knee Surgery, Sports Traumatology, Arthroscopy, the Journal of Bone and Joint Surgery (American Volume) and the Bone and Joint Journal were analysed and ranked according to guidelines from the Centre for Evidence-Based Medicine. The intervening years (2003, 2005 and 2007) were also analysed to further define the trend.

RESULTS

The percentage of high level evidence (level I and II) studies increased albeit without reaching statistical significance. Following a significant downward trend, the latter part of the decade saw a major rise in levels of published evidence. The most frequent type of study was therapeutic.

CONCLUSIONS

Although the rise in levels of evidence across the decade was not statistically significant, there was a significant drop and then rise in these levels in the interim. It is therefore important that a further study is performed to assess longer-term trends. Recent developments have made clear that high quality evidence will be having an ever increasing influence on future orthopaedic practice. We suggest that journals implement compulsory declaration of a published study's level of evidence and that authors consider their study designs carefully to enhance the quality of available evidence.

Simulation as a set-up for technical proficiency: can a virtual warm-up improve live fibre-optic intubation?

BACKGROUND

Fibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual 'warm-up' has been used to prime a practitioner's skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents.

METHODS

Clinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents.

RESULTS

Thirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 (SD 3.2) s vs. 57 (SD 3.2) s, P<0.0002) and a 26% decrease for CA2s (mean 23 (SD 1.7) s vs. 31 (SD 1.7) s, P=0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 (SD 1.2) vs. 37.6 (SD 1.2), P=0.0079) and 5.1 points for CA2s (37.7 (SD 1.1) vs. 42.8 (SD 1.1), P=0.0125). Crossover period and sequence did not show a statistically significant association with performance.

CONCLUSIONS

Virtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills.

Rates and determinants of progression to graft failure in kidney allograft recipients with de novo donor-specific antibody

Understanding rates and determinants of clinical pathologic progression for recipients with de novo donor-specific antibody (dnDSA), especially subclinical dnDSA, may identify surrogate endpoints and inform clinical trial design. A consecutive cohort of 508 renal transplant recipients (n = 64 with dnDSA) was studied. Recipients (n = 388) without dnDSA or dysfunction had an eGFR decline of -0.65 mL/min/1.73 m(2) /year. In recipients with dnDSA, the rate eGFR decline was significantly increased prior to dnDSA onset (-2.89 vs. -0.65 mL/min/1.73 m(2) /year, p < 0.0001) and accelerated post-dnDSA (-3.63 vs. -2.89 mL/min/1.73 m(2) /year, p < 0.0001), suggesting that dnDSA is both a marker and contributor to ongoing alloimmunity. Time to 50% post-dnDSA graft loss was longer in recipients with subclinical versus a clinical dnDSA phenotype (8.3 vs. 3.3 years, p < 0.0001). Analysis of 1091 allograft biopsies found that dnDSA and time independently predicted chronic glomerulopathy (cg), but not interstitial fibrosis and tubular atrophy (IFTA). Early T cell-mediated rejection, nonadherence, and time were multivariate predictors of IFTA. Independent risk factors for post-dnDSA graft survival available prior to, or at the time of, dnDSA detection were delayed graft function, nonadherence, dnDSA mean fluorescence intensity sum score, tubulitis, and cg. Ultimately, dnDSA is part of a continuum of mixed alloimmune-mediated injury, which requires solutions targeting T and B cells.

Vitamin D, asthma prevalence and asthma exacerbations: a large adult population-based study

BACKGROUND

The impact of low vitamin D status on asthma, asthma morbidity and control is unclear. We aimed to investigate in adults the associations between serum 25-hydroxyvitamin D level and prevalent asthma as well as asthma exacerbations.

METHODS

A cohort of Israeli adults aged 22-50 years with documented vitamin D status were extracted from Clalit Health Services (HMO) between July 1, 2008 and July 1, 2012. Among this population, those with physician-diagnosed asthma and asthma exacerbations were identified. Asthma exacerbations were defined as any of the following: prescription for oral corticosteroids, >5 prescriptions for short acting beta agonists and more than four visits to a physician for asthma. Logistic regression models assessed the associations between vitamin D and both asthma and asthma exacerbations.

RESULTS

Approximately 308 000 members with at least one vitamin D measurement were included in the cohort. Among them, 6.9% (21 237) had physician-diagnosed asthma vs 5.7% in the general population. Serum 25-OHD levels across both groups were similar. However, among those with vitamin D deficiency, the odds of having an exacerbation were 25% greater compared to those with levels in the normal range. This association remained significant after controlling for known confounders.

CONCLUSION

While there was no significant association between vitamin D status and physician-diagnosed asthma, there was a strong association with asthma exacerbations. The presented evidence supports vitamin D screening in the subgroup of asthmatics that are uncontrolled and experience recurrent exacerbations.