Associations of body fat and skeletal muscle with hypertension.

Hypertension is known to be associated with obesity, while its relationship to skeletal muscle, SM (SM; a marker of general health and body function), remains uncertain. We analyzed population-based data of 22 591 men (mean age: 51.6 ± 16.9 years) and 27 845 nonpregnant women (50.6 ± 16.9 years) from Scottish Health Surveys (2003, 2008-2011) and Health Surveys for England (2003-2006, 2008-2013) including 2595 non-insulin- and 536 insulin-treated diabetic patients. Compared with normotensive individuals (no hypertension history with normal systolic [SBP < 140 mm Hg] and diastolic blood pressure [DBP < 90 mm Hg]), percent body fat (BF%) was significantly higher and percent SM lower (P < 0.001) in undetected (no hypertension history with raised SBP ≥ 140 and/or DBP ≥ 90 mm Hg), controlled (hypertension history with normal BP), uncontrolled (hypertension history with raised BP), and untreated hypertension. The prevalences of hypertension within BF% quintiles were 11.8%, 24.8%, 41.4%, 56.8%, and 71.6% and SM% quintiles were 67.5%, 53.3%, 39.5%, 27.4%, and 18.5%. Compared to referent groups (lowest BF% quintile or highest SM% quintile), odds ratio (age, sex, smoking, ethnicity, country, survey year, and diabetes adjusted) for having all types of hypertension in the highest BF% quintile was 5.5 (95% confidence interval = 5.0-5.9) and lowest SM% quintile was 2.3 (2.2-2.5). Compared with those without diabetes, individuals with diabetes had a 2.3-fold-2.6-fold greater risk of hypertension, independent of confounding factors and BF% or SM%. The associations of hypertension with BF% were higher than those with body mass index (BMI). In conclusion, both BF and SM should be considered when analyzing results from health surveys, rather than relying on BMI which does not discriminate between the two.

Yoga for stroke rehabilitation.

BACKGROUND: Stroke is a major health issue and cause of long-term disability and has a major emotional and socioeconomic impact. There is a need to explore options for long-term sustainable interventions that support stroke survivors to engage in meaningful activities to address life challenges after stroke. Rehabilitation focuses on recovery of function and cognition to the maximum level achievable, and may include a wide range of complementary strategies including yoga.Yoga is a mind-body practice that originated in India, and which has become increasingly widespread in the Western world. Recent evidence highlights the positive effects of yoga for people with a range of physical and psychological health conditions. A recent non-Cochrane systematic review concluded that yoga can be used as self-administered practice in stroke rehabilitation. OBJECTIVES: To assess the effectiveness of yoga, as a stroke rehabilitation intervention, on recovery of function and quality of life (QoL). SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched July 2017), Cochrane Central Register of Controlled Trials (CENTRAL) (last searched July 2017), MEDLINE (to July 2017), Embase (to July 2017), CINAHL (to July 2017), AMED (to July 2017), PsycINFO (to July 2017), LILACS (to July 2017), SciELO (to July 2017), IndMED (to July 2017), OTseeker (to July 2017) and PEDro (to July 2017). We also searched four trials registers, and one conference abstracts database. We screened reference lists of relevant publications and contacted authors for additional information. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared yoga with a waiting-list control or no intervention control in stroke survivors. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies. We performed all analyses using Review Manager (RevMan). One review author entered the data into RevMan; another checked the entries. We discussed disagreements with a third review author until consensus was reached. We used the Cochrane 'Risk of bias' tool. Where we considered studies to be sufficiently similar, we conducted a meta-analysis by pooling the appropriate data. For outcomes for which it was inappropriate or impossible to pool quantitatively, we conducted a descriptive analysis and provided a narrative summary. MAIN RESULTS: We included two RCTs involving 72 participants. Sixty-nine participants were included in one meta-analysis (balance). Both trials assessed QoL, along with secondary outcomes measures relating to movement and psychological outcomes; one also measured disability.In one study the Stroke Impact Scale was used to measure QoL across six domains, at baseline and post-intervention. The effect of yoga on five domains (physical, emotion, communication, social participation, stroke recovery) was not significant; however, the effect of yoga on the memory domain was significant (mean difference (MD) 15.30, 95% confidence interval (CI) 1.29 to 29.31, P = 0.03), the evidence for this finding was very low grade. In the second study, QoL was assessed using the Stroke-Specifc QoL Scale; no significant effect was found.Secondary outcomes included movement, strength and endurance, and psychological variables, pain, and disability.Balance was measured in both studies using the Berg Balance Scale; the effect of intervention was not significant (MD 2.38, 95% CI -1.41 to 6.17, P = 0.22). Sensititivy analysis did not alter the direction of effect. One study measured balance self-efficacy, using the Activities-specific Balance Confidence Scale (MD 10.60, 95% CI -7.08,= to 28.28, P = 0.24); the effect of intervention was not significant; the evidence for this finding was very low grade.One study measured gait using the Comfortable Speed Gait Test (MD 1.32, 95% CI -1.35 to 3.99, P = 0.33), and motor function using the Motor Assessment Scale (MD -4.00, 95% CI -12.42 to 4.42, P = 0.35); no significant effect was found based on very low-grade evidence.One study measured disability using the modified Rankin Scale (mRS) but reported only whether participants were independent or dependent. No significant effect was found: (odds ratio (OR) 2.08, 95% CI 0.50 to 8.60, P = 0.31); the evidence for this finding was very low grade.Anxiety and depression were measured in one study. Three measures were used: the Geriatric Depression Scale-Short Form (GCDS15), and two forms of State Trait Anxiety Inventory (STAI, Form Y) to measure state anxiety (i.e. anxiety experienced in response to stressful situations) and trait anxiety (i.e. anxiety associated with chronic psychological disorders). No significant effect was found for depression (GDS15, MD -2.10, 95% CI -4.70 to 0.50, P = 0.11) or for trait anxiety (STAI-Y2, MD -6.70, 95% CI -15.35 to 1.95, P = 0.13), based on very low-grade evidence. However, a significant effect was found for state anxiety: STAI-Y1 (MD -8.40, 95% CI -16.74 to -0.06, P = 0.05); the evidence for this finding was very low grade.No adverse events were reported.Quality of the evidenceWe assessed the quality of the evidence using GRADE. Overall, the quality of the evidence was very low, due to the small number of trials included in the review both of which were judged to be at high risk of bias, particularly in relation to incompleteness of data and selective reporting, and especially regarding the representative nature of the sample in one study. AUTHORS' CONCLUSIONS: Yoga has the potential for being included as part of patient-centred stroke rehabilitation. However, this review has identified insufficient information to confirm or refute the effectiveness or safety of yoga as a stroke rehabilitation treatment. Further large-scale methodologically robust trials are required to establish the effectiveness of yoga as a stroke rehabilitation treatment.

Nutritional intervention and impact of polyphenol on glycohemoglobin (HbA1c) in non-diabetic and type 2 diabetic subjects: Systematic review and meta-analysis.

Polyphenols have been extensively studied for their antioxidant and anti-inflammatory properties. Recently, their antiglycative actions by oxidative stress modulation have been linked to the prevention of diabetes and associated complications. This article assesses the evidence for polyphenol interventions on glycohemoglobin (HbA1c) in non-diabetic, pre-diabetic, and type 2 diabetes mellitus (T2DM) subjects. A systematic review of polyphenols' clinical trials on HbA1c in humans was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis. Thirty-six controlled randomized trials with HbA1c values were included. Polyphenols (extracts, supplements, and foods) were supplemented (28 mg to 1.5 g) for 0.7 to 12 months. Combining all subjects (n = 1954, mean baseline HbA1c = 7.03%, 53 mmol/mol), polyphenol supplementation significantly (P < 0.001) lowered HbA1c% by -0.53 ± 0.12 units (-5.79 ± 0.13 mmol/mol). This reduction was significant (P < 0.001) in T2DM subjects, specifically (n = 1426, mean baseline HbA1c = 7.44%, 58 mmol/mol), with HbA1c% lowered by -0.21 ± 0.04 units (-2.29 ± 0.4 mmol/mol). Polyphenol supplementation had no significant effect (P > 0.21) in the non-diabetic (n = 258, mean baseline HbA1c = 5.47%, 36 mmol/mol) and the pre-diabetic subjects (n = 270, mean baseline HbA1c = 6.06%, 43 mmol/mol) strata: -0.39 ± 0.27 HbA1c% units (-4.3 ± 0.3 mmol/mol), and -0.38 ± 0.31 units (-4.2 ± 0.31 mmol/mol), respectively. In conclusion, polyphenols can successfully reduce HbA1c in T2DM without any intervention at glycemia, and could contribute to the prevention of diabetes complications.

Pharmacological regimens for eradication of Helicobacter pylori: an overview of systematic reviews and network meta-analysis.

BACKGROUND: Approximately half of the world's population is infected with Helicobacter pylori (H.pylori), a bacterium shown to be linked with a series of gastrointestinal diseases. A growing number of systematic reviews (SRs) have been published comparing the effectiveness of different treatments for H.pylori infection but have not reached a consistent conclusion. The objective of this study is to provide an overview of SRs of pharmacological therapies for the eradication of H.pylori. METHODS: Major electronic databases were searched to identify relevant SRs published between 2002 and February 2016. Studies were considered eligible if they included RCTs comparing different pharmacological regimens for treating patients diagnosed as H.pylori infected and pooled the eradication rates in a meta-analysis. A modified version of the 'A Measurement Tool to Assess Systematic Reviews' (AMSTAR) was used to assess the methodological quality. A Bayesian random effects network meta-analysis (NMA) was conducted to compare the different proton pump inhibitors (PPI) within triple therapy. RESULTS: 30 SRs with pairwise meta-analysis were included. In triple therapy, the NMA ranked the esomeprazole to be the most effective PPI, followed by rabeprazole, while no difference was observed among the three old generations of PPI for the eradication of H.pylori. When comparing triple and bismuth-based therapy, the relative effectiveness appeared to be dependent on the choice of antibiotics within the triple therapy; moxifloxacin or levofloxacin-based triple therapy were both associated with greater effectiveness than bismuth-based therapy as a second-line treatment, while bismuth-based therapy achieved similar or greater eradication rate compared to clarithromycin-based therapy. Inconsistent findings were reported regarding the use of levofloxacin/moxifloxacin in the first-line treatment; this could be due to the varied resistant rate to different antibiotics across regions and populations. Critical appraisal showed a low-moderate level of overall methodological quality of included studies. CONCLUSIONS: Our analysis suggests that the new generation of PPIs and use of moxifloxacin or levofloxacin within triple therapy as second-line treatment were associated with greater effectiveness. Given the varied antibiotic resistant rate across regions, the appropriateness of pooling results together in meta-analysis should be carefully considered and the recommendation of the choice of antibiotics should be localized.

How Do Diabetes Models Measure Up? A Review of Diabetes Economic Models and ADA Guidelines.

Introduction: Economic models and computer simulation models have been used for assessing short-term cost-effectiveness of interventions and modelling long-term outcomes and costs. Several guidelines and checklists have been published to improve the methods and reporting. This article presents an overview of published diabetes models with a focus on how well the models are described in relation to the considerations described by the American Diabetes Association (ADA) guidelines. Methods: Relevant electronic databases and National Institute for Health and Care Excellence (NICE) guidelines were searched in December 2012. Studies were included in the review if they estimated lifetime outcomes for patients with type 1 or type 2 diabetes. Only unique models, and only the original papers were included in the review. If additional information was reported in subsequent or paired articles, then additional citations were included. References and forward citations of relevant articles, including the previous systematic reviews were searched using a similar method to pearl growing. Four principal areas were included in the ADA guidance reporting for models: transparency, validation, uncertainty, and diabetes specific criteria. Results: A total of 19 models were included. Twelve models investigated type 2 diabetes, two developed type 1 models, two created separate models for type 1 and type 2, and three developed joint type 1 and type 2 models. Most models were developed in the United States, United Kingdom, Europe or Canada. Later models use data or methods from earlier models for development or validation. There are four main types of models: Markov-based cohort, Markov-based microsimulations, discrete-time microsimulations, and continuous time differential equations. All models were long-term diabetes models incorporating a wide range of compilations from various organ systems. In early diabetes modelling, before the ADA guidelines were published, most models did not include descriptions of all the diabetes specific components of the ADA guidelines but this improved significantly by 2004. Conclusion: A clear, descriptive short summary of the model was often lacking. Descriptions of model validation and uncertainty were the most poorly reported of the four main areas, but there exist conferences focussing specifically on the issue of validation. Interdependence between the complications was the least well incorporated or reported of the diabetes-specific criterion.

Derivation and validation of simple anthropometric equations to predict adipose tissue mass and total fat mass with MRI as the reference method.

The reference organ-level body composition measurement method is MRI. Practical estimations of total adipose tissue mass (TATM), total adipose tissue fat mass (TATFM) and total body fat are valuable for epidemiology, but validated prediction equations based on MRI are not currently available. We aimed to derive and validate new anthropometric equations to estimate MRI-measured TATM/TATFM/total body fat and compare them with existing prediction equations using older methods. The derivation sample included 416 participants (222 women), aged between 18 and 88 years with BMI between 15·9 and 40·8 (kg/m2). The validation sample included 204 participants (110 women), aged between 18 and 86 years with BMI between 15·7 and 36·4 (kg/m2). Both samples included mixed ethnic/racial groups. All the participants underwent whole-body MRI to quantify TATM (dependent variable) and anthropometry (independent variables). Prediction equations developed using stepwise multiple regression were further investigated for agreement and bias before validation in separate data sets. Simplest equations with optimal R (2) and Bland-Altman plots demonstrated good agreement without bias in the validation analyses: men: TATM (kg)=0·198 weight (kg)+0·478 waist (cm)-0·147 height (cm)-12·8 (validation: R 2 0·79, CV=20 %, standard error of the estimate (SEE)=3·8 kg) and women: TATM (kg)=0·789 weight (kg)+0·0786 age (years)-0·342 height (cm)+24·5 (validation: R (2) 0·84, CV=13 %, SEE=3·0 kg). Published anthropometric prediction equations, based on MRI and computed tomographic scans, correlated strongly with MRI-measured TATM: (R (2) 0·70-0·82). Estimated TATFM correlated well with published prediction equations for total body fat based on underwater weighing (R (2) 0·70-0·80), with mean bias of 2·5-4·9 kg, correctable with log-transformation in most equations. In conclusion, new equations, using simple anthropometric measurements, estimated MRI-measured TATM with correlations and agreements suitable for use in groups and populations across a wide range of fatness.

Comparative effectiveness of antiviral treatment for hepatitis B: a systematic review and Bayesian network meta-analysis.

OBJECTIVE: A wide variety of competing drugs are available to patients for the treatment of chronic hepatitis B. We update a recent meta-analysis to include additional trial evidence with the aim of determining which treatment is the most effective. METHODS: Twelve monotherapy or combination therapy were evaluated in treatment-naive individuals with hepatitis B e antigen (HBeAg) positive or negative patients. Databases were searched for randomized controlled trials in the first year of therapy. Bayesian random effects network meta-analysis was used to calculate the pairwise odds ratios, 95% credible intervals and ranking of six surrogate outcomes. RESULTS: In total, 22 studies were identified (7508 patients): 12 studies analysed HBeAg-positive patients, six analysed HBeAg-negative patients, and four evaluated both. Tenofovir was most effective at increasing efficacy in HBeAg-positive patients, ranking first for three outcomes and increased odds of undetectable levels of hepatitis B virus (HBV) DNA compared with seven other therapies (such as lamivudine: odds ratio 33.0; 95% credible interval 7.0-292.7). For HBeAg-negative patients, the large network (seven therapies) ranked entecavir alone or in combination with tenofovir highly for reduction in HBV DNA and histologic improvement. In the smaller network (three therapies), tenofovir ranked first for undetectable HBV DNA and histologic improvement. No data existed to directly or indirectly compare these treatments. CONCLUSION: For HBeAg-positive patients tenofovir is the most effective at increasing efficacy, whereas for HBeAg-negative patients, either tenofovir or entecavir is most effective. Further research should focus on strengthening the network connections, in particular comparing tenofovir and entecavir in HBeAg-negative patients.

Multimodal secondary prevention behavioral interventions for TIA and stroke: a systematic review and meta-analysis.

BACKGROUND: Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions. STRATEGY: Searches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines. RESULTS: Twenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (-6.24 to -2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (-3.19 to -0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (-6.69 cm, -11.44 to -1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (-1.20, -1.77 to -0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants). CONCLUSIONS: There are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required. REVIEW REGISTRATION: PROSPERO CRD42012002538.

Chemical stability of heparin, isopropanol, and ethanol line lock solutions.

BACKGROUND: Ethanol line locks are used in the US to prevent catheter associated bloodstream infections. Heparin precipitates in solution with ethanol. However, isopropanol may reduce precipitate formation. We aimed to determine the chemical stability of heparin, isopropanol, and ethanol line lock for a 10 day period at 2-8°C and 25°C. METHODS: Forty samples were prepared for analysis. Each sample was prepared identically using a 5 ml syringe capped with a Combi-stopper: 1 ml 70% isopropanol, 1 ml 70% ethanol, and 1 ml heparin sodium 10 IU/ml. Twenty syringes were stored at 2-8°C and 20 at 25°C. Analysis was carried out on days 1, 3, 6, 8, and 10 with a single syringe from each condition being tested in duplicate. Samples were assessed visually. Sub-visible particle count analysis was carried out using a CLIMET particle counting system. Heparin concentration was analysed using an anti-Xa assay. Ethanol and isopropanol concentrations were analysed by gas chromatography. RESULTS: Samples remained clear and colourless throughout the study. Sub-visible particle counts remained within limits specified in British Pharmacopoeia 2013 when stored at 2-8°C and 25°C, 60% humidity for up to 10 days. There was no significant change in ethanol or isopropanol concentration during the study. However, heparin activity fell by >10% after 1 day storage and to 65% of original activity after 10 days. CONCLUSIONS: This study shows that addition of isopropanol to heparin and ethanol prevents precipitation. However, this solution shows a progressive decline in heparin activity over time making it unsuitable for extended shelf life.

Complications following incident stroke resulting in readmissions: an analysis of data from three Scottish health surveys.

BACKGROUND AND AIMS: Stroke is widely recognized as the major contributor to morbidity and mortality in the United Kingdom. We analyzed the data obtained from the three consecutive Scottish Health Surveys and the Scottish Morbidity records, with the aim of identifying risk factors for, and timing of, common poststroke complications. METHODS: There were 19434 individuals sampled during three Scottish Health Surveys in 1995, 1998, and 2001. For these individuals their morbidity and mortality outcomes were obtained in 2007. Incident stroke prevalence, risk factors for a range of poststroke complications, and average times until such complications in the sample were established. RESULTS: Of the total of 168 incident stroke admissions (0·86% of the survey), 16·1% people died during incident stroke hospitalization. Of the remaining 141 stroke survivors, 75·2% were rehospitalized at least once. The most frequent reason for readmission after stroke was a cardiovascular complication (28·6%), median time until event 1412 days, followed by infection (17·3%, median 1591 days). The risk of cardiovascular readmission was higher in those with 'poor' self-assessed health (odds ratio 7·70; 95% confidence interval 1·64-43·27), smokers (odds ratio 4·24; 95% confidence interval 1·11-21·59), and doubled with every five years increase in age (odds ratio 1·97; 95% confidence interval 1·46-2·65). 'Poor' self-assessed health increased chance of readmission for infection (odds ratio 14·11; 95% confidence interval 2·27-276·56). CONCLUSIONS: Cardiovascular events and infections are the most frequent poststroke complications resulting in readmissions. The time period until event provides a possibility to focus monitoring on those people at risk of readmission and introduce preventative measures, thereby reducing readmission-associated costs.

Derivation and validation of simple equations to predict total muscle mass from simple anthropometric and demographic data.

BACKGROUND: Muscle mass reflects and influences health status. Its reliable estimation would be of value for epidemiology. OBJECTIVE: The aim of the study was to derive and validate anthropometric prediction equations to quantify whole-body skeletal muscle mass (SM) in adults. DESIGN: The derivation sample included 423 subjects (227 women) aged 18-81 y with a body mass index (BMI; in kg/m(2)) of 15.9-40.8. The validation sample included 197 subjects (105 women) aged 19-83 y with a BMI of 15.7-36.4. Both samples were of mixed ethnic/racial groups. All underwent whole-body magnetic resonance imaging to quantify SM (dependent variable for multiple regressions) and anthropometric variables (independent variables). RESULTS: Two prediction equations with high practicality and optimal derivation correlations with SM were further investigated to assess agreement and bias by using Bland-Altman plots and validated in separate data sets. Including race as a variable increased R(2) by only 0.1% in men and by 8% in women. For men: SM (kg) = 39.5 + 0.665 body weight (BW; kg) - 0.185 waist circumference (cm) - 0.418 hip circumference (cm) - 0.08 age (y) (derivation: R(2) = 0.76, SEE = 2.7 kg; validation: R(2) = 0.79, SEE = 2.7 kg). Bland-Altman plots showed moderate agreement in both derivation and validation analyses. For women: SM (kg) = 2.89 + 0.255 BW (kg) - 0.175 hip circumference (cm) - 0.038 age (y) + 0.118 height (cm) (derivation: R(2) = 0.58, SEE = 2.2 kg; validation: R(2) = 0.59, SEE = 2.1 kg). Bland-Altman plots had a negative slope, indicating a tendency to overestimate SM among women with smaller muscle mass and to underestimate SM among those with larger muscle mass. CONCLUSIONS: Anthropometry predicts SM better in men than in women. Equations that include hip circumference showed agreement between methods, with predictive power similar to that of BMI to predict fat mass, with the potential for applications in groups, as well as epidemiology and survey settings.

Predicting muscle mass from anthropometry using magnetic resonance imaging as reference: a systematic review.

Identification and management of sarcopenia are limited by lack of reliable simple approaches to assess muscle mass. The aim of this review is to identify and evaluate simple methods to quantify muscle mass/volume of adults. Using Cochrane Review methodology, Medline (1946-2012), Embase (1974-2012), Web of Science (1898-2012), PubMed, and the Cochrane Library (to 08/2012) were searched for publications that included prediction equations (from anthropometric measurements) to estimate muscle mass by magnetic resonance imaging (MRI) in adults. Of 257 papers identified from primary search terms, 12 studies met the inclusion criteria. Most studies (n = 10) assessed only regional/limb muscle mass/volume. Many studies (n = 9) assessed limb circumference adjusted for skinfold thickness, which limits their practical applications. Only two included validation in separate subject-samples, and two reported relationships between whole-body MRI-measured muscle mass and anthropometry beyond linear correlations. In conclusion, one simple prediction equation shows promise, but it has not been validated in a separate population with different investigators. Furthermore, it did not incorporate widely available trunk/limb girths, which have offered valuable prediction of body composition in other studies.

A meta-analysis of the risk of boys with isolated cryptorchidism developing testicular cancer in later life.

BACKGROUND: Significant variability exists for the relative risk (RR) of testicular malignancy in isolated cryptorchidism. OBJECTIVE: To perform a meta-analysis to clarify the true magnitude of this risk, allowing clinicians to better counsel patients and their families. SETTING: Secondary research conducted by undergraduate researchers, clinical academics and a clinical statistician. DESIGN, DATA SOURCES, AND METHODS: A search of the English literature was performed for studies relating to testicular cancer and cryptorchidism, published between 1 January 1980 and 31 December 2010, using Embase and Medline databases. 735 papers were identified and analysed by four authors independently in accordance with our inclusion and exclusion criteria. Studies reporting an association between cryptorchidism and subsequent development of testicular malignancy were included. Genetic syndromes or other conditions which predisposed to the development of cryptorchidism were excluded. Pooled estimates and 95% CIs for the RRs were calculated. RESULTS: Nine case-control studies and three cohort studies were selected. The case-control studies included 2281 cases and 4811 controls. Cohort studies included 2 177 941 boys, with a total of 345 boys developing testicular cancer (total length of follow-up was 58 270 679 person-years). The pooled RR was 2.90 (95% CI 2.21 to 3.82) with significant heterogeneity (p<0.00001; I(2)=89%). CONCLUSION: Boys with isolated cryptorchidism are three times more likely to develop testicular cancer. The limitations of this study must be acknowledged, in particular, possible publication bias and the lack of high-quality evidence focusing on the risk of malignancy in boys with isolated cryptorchidism.

Spoilt for choice: implications of using alternative methods of costing hospital episode statistics.

In the absence of a 'gold standard' to estimate the economic burden of disease, a decision about the most appropriate costing method is required. Researchers have employed various methods to cost hospital stays, including per diem or diagnosis-related group (DRG)-based costs. Alternative methods differ in data collection and costing methodology. Using data from Scotland as an illustrative example, costing methods are compared, highlighting the wider implications for other countries with a publicly financed healthcare system. Five methods are compared using longitudinal data including baseline survey data (Midspan) linked to acute hospital admissions. Cost variables are derived using two forms of DRG-type costs, costs per diem, costs per episode-using a novel approach that distinguishes between variable and fixed costs and incorporates individual length of stay (LOS), and costs per episode using national average LOS. Cost estimates are generated using generalised linear model regression. Descriptive analysis shows substantial variation between costing methods. Differences found in regression analyses highlight the magnitude of variation in cost estimates for subgroups of the sample population. This paper emphasises that any inference made from econometric modelling of costs, where the marginal effect of explanatory variables is assessed, is substantially influenced by the costing method.

Achieved levels of HbA1c and likelihood of hospital admission in people with type 1 diabetes in the Scottish population: a study from the Scottish Diabetes Research Network Epidemiology Group.

OBJECTIVE: People with type 1 diabetes have increased risk of hospital admission compared with those without diabetes. We hypothesized that HbA(1c) would be an important indicator of risk of hospital admission. RESEARCH DESIGN AND METHODS: The Scottish Care Information-Diabetes Collaboration, a dynamic national register of diagnosed cases of diabetes in Scotland, was linked to national data on admissions. We identified 24,750 people with type 1 diabetes during January 2005 to December 2007. We assessed the relationship between deciles of mean HbA(1c) and hospital admissions in people with type 1 diabetes adjusting for patient characteristics. RESULTS: There were 3,229 hospital admissions. Of the admissions, 8.1% of people had mean HbA(1c) <7.0% (53 mmol/mol) and 16.3% had HbA(1c) <7.5% (58 mmol/mol). The lowest odds of admission were associated with HbA(1c) 7.7-8.7% (61-72 mmol/mol). When compared with this decile, a J-shaped relationship existed between HbA(1c) and admission. The highest HbA(1c) decile (10.8-18.4%/95-178 mmol/mol) showed significantly higher odds ratio (95% CI) for any admission (2.80, 2.51-3.12); the lowest HbA(1c) decile (4.4-7.1%/25-54 mmol/mol) showed an increase in odds of admission of 1.29 (1.10-1.51). The highest HbA(1c) decile experienced significantly higher odds of diabetes-related (3.31, 2.94-3.72) and diabetes ketoacidosis admissions (10.18, 7.96-13.01). CONCLUSIONS: People with type 1 diabetes with highest and lowest mean HbA(1c) values were associated with increased odds of admission. People with high HbA(1c) (>10.8%/95 mmol/mol) were at particularly high risk. There is the need to develop effective interventions to reduce this risk.

Categorizing stroke prognosis using different stroke scales.

BACKGROUND AND PURPOSE: Stroke severity and dependency are often categorized to allow stratification for randomization or analysis. However, there is uncertainty whether the categorizations used for different stroke scales are equivalent. We investigated the amount of information retained by categorizing severity and dependency, and whether the currently used cut-offs are equivalent across different stroke scales. METHODS: Stroke severity and dependency have been categorized as mild, moderate, or severe. We studied 2 acute stroke unit cohorts, measuring Scandinavian Stroke Scale (SSS), modified Rankin Scale (mRS), Barthel Index (BI), and modified National Institutes of Health Stroke Scale (mNIHSS). Receiver operating characteristic (ROC) curves were examined to determine the ability of full and categorized scales to predict death and dependency. A weighted kappa analysis assessed agreement between the categorized scales. RESULTS: When scales are categorized, the area under the ROC curve is significantly reduced; however, the differences are small and may not be practically important. BI, mRS, and SSS all have excellent agreement with each other when categorized, whereas mNIHSS has substantial agreement with mRS and BI. CONCLUSIONS: Little predictive information is lost when stroke scales are categorized. There is substantial to almost perfect agreement among categorized scales. Therefore the use and categorization of a variety of stroke severity or dependency scales is acceptable in analyses.

The GOAL study: a prospective examination of the impact of factor V Leiden and ABO(H) blood groups on haemorrhagic and thrombotic pregnancy outcomes.

Factor V Leiden (FVL) and ABO(H) blood groups are the common influences on haemostasis and retrospective studies have linked FVL with pregnancy complications. However, only one sizeable prospective examination has taken place. As a result, neither the impact of FVL in unselected subjects, any interaction with ABO(H) in pregnancy, nor the utility of screening for FVL is defined. A prospective study of 4250 unselected pregnancies was carried out. A venous thromboembolism (VTE) rate of 1.23/1000 was observed, but no significant association between FVL and pre-eclampsia, intra-uterine growth restriction or pregnancy loss was seen. No influence of FVL and/or ABO(H) on ante-natal bleeding or intra-partum or postpartum haemorrhage was observed. However, FVL was associated with birth-weights >90th centile [odds ratio (OR) 1.81; 95% confidence interval (CI(95)) 1.04-3.31] and neonatal death (OR 14.79; CI(95) 2.71-80.74). No association with ABO(H) alone, or any interaction between ABO(H) and FVL was observed. We neither confirmed the protective effect of FVL on pregnancy-related blood loss reported in previous smaller studies, nor did we find the increased risk of some vascular complications reported in retrospective studies.

Does the prevention of complications explain the survival benefit of organized inpatient (stroke unit) care?: further analysis of a systematic review.

BACKGROUND AND PURPOSE: Systematic reviews have shown that organized inpatient (stroke unit) care reduces the risk of death after stroke. However, it is unclear how this is achieved. We tested whether stroke unit care could reduce deaths by preventing complications. METHODS: We updated a collaborative systematic review of 31 controlled clinical trials (6936 participants) to include reported interventions and complications during early hospital care plus the certified cause of death during follow up. Each secondary analysis used data from between 7 and 17 studies (1652 to 3327 participants). Complications were grouped as physiological, neurological, cardiovascular, complications of immobility, and others. Bayesian hierarchical models were used to estimate odds ratios for features occurring in stroke units versus conventional care. RESULTS: Based on the data of 17 trials (3327 participants), organized (stroke unit) care reduced case fatality during scheduled follow up (OR: 0.75; 95% credible intervals: 0.59 to 0.92), in particular deaths certified as attributable to complications of immobility (0.59; 0.41 to 0.86). Stroke unit care was associated with statistically significant increases in the reported use of oxygen (2.39; 1.39 to 4.66), measures to prevent aspiration (2.42; 1.36 to 4.36), and paracetamol (2.80; 1.14 to 4.83) plus a nonsignificant reduction in the use of urinary catheterization. Stroke units were associated with statistically significant reductions in stroke progression/recurrence (0.66; 0.46 to 0.95) and in some complications of immobility: chest infections (0.60; 0.42 to 0.87), other infections (0.56; 0.40 to 0.84), and pressure sores (0.44; 0.22 to 0.85). There were no significant differences in cardiovascular, physiological, or other complications. CONCLUSIONS: Organized inpatient (stroke unit) care appears to reduce the risk of death after stroke through the prevention and treatment of complications, in particular infections.