Evidence-Based Complementary Benefit of the Vascular Surgeon Among the Team of Renal Transplantation; a Single Center Experience.

BACKGROUND: In a kidney transplant tertiary referral center; we compared 3 operating team configurations of different surgical specialties to highlight the effect of the operating surgeon's specialty on various operative details and procedural outcome. METHODS: A total of 50 cases of living donor transplantations were divided into 3 main groups according to the operating surgeons' specialty, the first group (A) includes 12 patients exclusively operated on by urologists with advanced training in transplantation, the second group (B) includes 35 patients operated by combined surgical specialties; a urologist and a vascular surgeon both with advanced transplantation training, and a third group (C) includes 3 cases where the transplant operation commenced with operating urologists as in group (A) but required intraoperative urgent notification of a vascular surgeon to manage unexpected intraoperative technical difficulties or major complications. Cases were studied according to operative details, anastomosis techniques, ischemia times, total procedure time, recovery of urinary output, intensive care unit (ICU) stay, postoperative surgical complications and serum creatinine level for up to 3 years of follow-up. RESULTS: Study of operative details revealed that total duration of graft ischemia was significantly shorter in group (B) and significantly longer in group (C) (P value 0.001), Total procedural duration also varied significantly between the 3 groups, group (B) being the shortest while group (C) was the longest (P value less than 0.001). Technically; group (A) used only end to end arterial anastomosis as a standard technique, while group (B) used both end-to-end and end-to-side anastomoses as required per each case. End to side anastomosis in group (B) yielded better immediate graft response in the form of change in color, texture, earlier and more profuse postoperative urine volumes (P value 0.025). Furthermore, anastomosis to common and external iliac arteries (group B) yielded earlier and higher urine volumes than the internal iliac artery (P values 0.024 and 0.031 respectively). Group (B) recorded significantly less postoperative perigraft hematomas and lymphoceles compared to the other 2 groups. Equal rates of urine leaks, ICU stay, creatinine levels, patient and grafts survival rates among groups (A) and (B), while postoperative recovery and ICU stay duration were more lengthy in the complicated group (C). CONCLUSIONS: A vascular surgeon operating in a transplantation team would deal comfortably and efficiently with various vascular related challenges and complications, thus avoiding unnecessary time waste, complications and costs.

The Effect of Superficial Venous Incompetence Treatment on Combined Segmental Deep Venous Reflux.

BACKGROUND: The aim of this study was to assess the role of treatment of superficial venous reflux (SVR) in patients with combined deep segmental venous reflux as regards clinical symptoms as well as reflux improvement of the deep veins. METHODS: We reviewed 80 patients, retrospectively selected on the inclusion criteria and having combined SVR and segmental deep venous reflux who underwent SVR ablation. The contralateral limb of 44 patients was used as a control group, asked to wear compression stockings for 3 months during day time with no surgical intervention. Duplex ultrasounds follow-up was performed at 3, 6, and 12 months postoperatively. Clinical severity of venous disease was graded from C1 to C6 according to the CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification. Duplex ultrasound was done in both supine and standing positions with non-weight-bearing of the examined limb. The venous reflux time, the venous flow volume and the peak venous flow velocity were registered. Removal of SVR was performed using either conventional surgery or radiofrequency ablation. The patient was required to wear compression stockings during the day time for the following weeks. RESULTS: During the follow-up period, all patients were improved clinically as regards pain, edema, and ulcer healing. All patients included in this study had no signs of residual SVR. Corrected deep venous segment reflux was in 36 (45%). Similar data at 3, 6, and 12 months postoperatively after SVR removal. The popliteal vein reflux responded less than the femoral vein reflux did. CONCLUSIONS: Treatment of the SVR eliminates segmental deep venous reflux in a good percentage of patients regardless of the treatment modality. Also, symptoms improvement and ulcer healing were documented, and hence, more studies are recommended to evaluate this role.

The immediate impact of the COVID-19 pandemic on polio immunization and surveillance activities.

In addition to affecting individual health the COVID-19 pandemic has disrupted efforts to deliver essential health services around the world. In this article we present an overview of the immediate programmatic and epidemiologic impact of the pandemic on polio eradication as well as the adaptive strategic and operational measures taken by the Global Polio Eradication Initiative (GPEI) from March through September 2020. Shortly after the World Health Organization (WHO) declared a global pandemic on 11 March 2020, the GPEI initially redirected the programme's assets to tackle COVID-19 and suspended house-to-house supplementary immunization activities (SIAs) while also striving to continue essential poliovirus surveillance functions. From March to May 2020, 28 countries suspended a total of 62 polio vaccine SIAs. In spite of efforts to continue poliovirus surveillance, global acute flaccid paralysis (AFP) cases reported from January-July 2020 declined by 34% compared with the same period in 2019 along with decreases in the mean number of environment samples collected per active site in the critical areas of the African and Eastern Mediterranean regions. The GPEI recommended countries should resume planning and implementation of SIAs starting in July 2020 and released guidelines to ensure these could be done safely for front line workers and communities. By the end of September 2020, a total of 14 countries had implemented circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak response vaccination campaigns and Afghanistan and Pakistan restarted SIAs to stop ongoing wild poliovirus type 1 (WPV1) transmission. The longer-term impacts of disruptions to eradication efforts remain to be determined, especially in terms of the effect on poliovirus epidemiology. Adapting to the pandemic situation has imposed new considerations on program implementation and demonstrated not only GPEI's contribution to global health security, but also identified potential opportunities for coordinated approaches across immunization and health services.

Progress Toward Measles and Rubella Elimination - India, 2005-2021.

In 2019, India, along with other countries in the World Health Organization (WHO) South-East Asia Region,* adopted the goal of measles and rubella elimination by 2023,† a revision of the previous goal of measles elimination and control of rubella and congenital rubella syndrome (CRS) by 2020§ (1-3). During 2017-2021, India adopted a national strategic plan for measles and rubella elimination (4), introduced rubella-containing vaccine (RCV) into the routine immunization program, launched a nationwide measles-rubella supplementary immunization activity (SIA) catch-up campaign, transitioned from outbreak-based surveillance to case-based acute fever and rash surveillance, and more than doubled the number of laboratories in the measles-rubella network, from 13 to 27. Strategies included 1) achieving and maintaining high population immunity with at least 95% vaccination coverage by providing 2 doses of measles- and rubella-containing vaccines; 2) ensuring a sensitive and timely case-based measles, rubella and CRS surveillance system; 3) maintaining an accredited measles and rubella laboratory network; 4) ensuring adequate outbreak preparedness and rapid response to measles and rubella outbreaks; and 5) strengthening support and linkages to achieve these strategies, including planning and progress monitoring, advocacy, social mobilization and communication, identification and utilization of synergistic linkages of integrated program efforts, research, and development. This report describes India's progress toward the elimination of measles and rubella during 2005-2021, with a focus on the years 2017-2021.¶ During 2005-2021, coverage with the first dose of a measles-containing vaccine (MCV) administered through routine immunization increased 31%, from 68% to 89%. During 2011-2021, coverage with a second MCV dose (MCV2) increased by 204%, from 27% to 82%. During 2017-2021, coverage with a first dose of RCV (RCV1) increased almost 14-fold, from 6% to 89%. More than 324 million children received a measles- and rubella-containing vaccine (MRCV) during measles-rubella SIAs completed in 34 (94%) of 36 states and union territories (states) during 2017-2019. During 2017-2021, annual measles incidence decreased 62%, from 10.4 to 4.0 cases per 1 million population, and rubella incidence decreased 48%, from 2.3 to 1.2 cases per 1 million population. India has made substantial progress toward measles and rubella elimination; however, urgent and intensified efforts are required to achieve measles and rubella elimination by 2023.

Poliovirus Immunity among Children Aged 6-11 and 36-48 Months in 14 Polio High-Risk Provinces of Afghanistan: A Health-Facility-Based Study.

Afghanistan is one of two countries where wild poliovirus (WPV) type 1 remains endemic. We conducted a facility-based cross-sectional survey of antipoliovirus antibodies in children in 14 provinces of Afghanistan. The provinces were selected based on programmatic priorities for polio eradication. Children aged 6-11 and 36-48 months attending outpatient clinics were enrolled in the study. We collected venous blood, isolated serum, and conducted neutralization assays to detect poliovirus neutralizing antibodies. A total of 2086 children from the 14 provinces were enrolled. Among the enrolled children, 44.3% were girls; the median age in the 6-11-month group was 9.4 months, and in the 36-48-month group, it was 41.8 months. The most common spoken language was Pashtu (70.8%). Eighty-two percent of children were fully immunized against all the diseases in the vaccination schedule of Afghanistan. In the children aged 6-11 months, seroprevalence to poliovirus type 1 (PV1) was 96.5% and seroprevalence to poliovirus type 3 (PV3) was 93%; in children aged 36-48 months, seroprevalence to PV1 was 99.5% and to PV3 was 98%. Antipoliovirus antibody prevalence for poliovirus type 2 (PV2) was 70.5% in the younger group compared with 90.9% in the older children. Children from Herat and Laghman provinces had almost 100% seroprevalence to PV1, and other provinces also had high prevalence, ranging from 92.0% to 99.0%. A similar finding was seen for antibodies against PV3, ranging from 88% to 100% by province. On the contrary, antibodies to PV2 were low, ranging from 53% for children in the Khost province to around 89% in Kunduz. There was a cluster of 18 seronegative children in the Nuristan province. Overall, the polio eradication program of Afghanistan has been successful in achieving high seroprevalence of poliovirus neutralizing antibodies in the parts of the country included in this study.

Progress Toward Measles Elimination - South-East Asia Region, 2003-2020.

In 2013, member states of the World Health Organization (WHO) South-East Asia Region* (SEAR) adopted the goal of measles elimination and rubella and congenital rubella syndrome control† by 2020 (1). In 2014, to provide impetus toward achieving this goal, the Regional Director declared measles elimination and rubella control one of the Regional Flagship Priorities. In 2019, SEAR member states declared a revised goal of eliminating both measles and rubella§ by 2023 (2). The recommended strategies to achieve elimination include 1) achieving and maintaining ≥95% coverage with 2 doses of measles- and rubella-containing vaccine in every district through routine or supplementary immunization activities¶ (SIAs); 2) developing and sustaining a sensitive and timely case-based surveillance system that meets recommended performance indicators**; 3) developing and maintaining an accredited laboratory network; 4) achieving timely identification, investigation, and response to measles outbreaks; and 5) collaborating with other public health initiatives to achieve the preceding four strategies. This report updates a previous report and describes progress toward measles elimination in SEAR during 2003-2020 (3). In 2002, coverage with the first dose of a measles-containing vaccine in routine immunization (MCV1) was 70%, and only three countries in SEAR had added a second routine dose of measles-containing vaccine in routine immunization (MCV2). During 2003-2020, all countries introduced MCV2, and estimated coverage with MCV1 increased 35%, from 65% to 88%, and coverage with MCV2 increased 1,233% from 6% to 80%. Approximately 938 million persons were vaccinated in SIAs. Annual reported measles incidence declined by 92%, from 57.0 to 4.8 cases per 1 million population, and estimated deaths decreased by 97%; an estimated 9.3 million deaths were averted by measles vaccination. By 2020, five countries were verified as having achieved measles elimination. To achieve measles elimination in the region by 2023, additional efforts are urgently needed to strengthen routine immunization services and improve measles-containing vaccine (MCV) coverage, conduct periodic high-quality SIAs, and strengthen measles case-based surveillance and laboratory capacity.

Change in unemployment by social vulnerability among United States counties with rapid increases in COVID-19 incidence-July 1-October 31, 2020.

OBJECTIVE: During the COVID-19 pandemic, the unemployment rate in the United States peaked at 14.8% in April 2020. We examined patterns in unemployment following this peak in counties with rapid increases in COVID-19 incidence. METHOD: We used CDC aggregate county data to identify counties with rapid increases in COVID-19 incidence (rapid riser counties) during July 1-October 31, 2020. We used a linear regression model with fixed effect to calculate the change of unemployment rate difference in these counties, stratified by the county's social vulnerability (an indicator compiled by CDC) in the two months before the rapid riser index month compared to the index month plus one month after the index month. RESULTS: Among the 585 (19% of U.S. counties) rapid riser counties identified, the unemployment rate gap between the most and least socially vulnerable counties widened by 0.40 percentage point (p<0.01) after experiencing a rapid rise in COVID-19 incidence. Driving the gap were counties with lower socioeconomic status, with a higher percentage of people in racial and ethnic minority groups, and with limited English proficiency. CONCLUSION: The widened unemployment gap after COVID-19 incidence rapid rise between the most and least socially vulnerable counties suggests that it may take longer for socially and economically disadvantaged communities to recover. Loss of income and benefits due to unemployment could hinder behaviors that prevent spread of COVID-19 (e.g., seeking healthcare) and could impede response efforts including testing and vaccination. Addressing the social needs within these vulnerable communities could help support public health response measures.

Estimation of oral poliovirus vaccine effectiveness in Afghanistan, 2010-2020.

BACKGROUND: Afghanistan is one of two countries with endemic wild poliovirus type 1 (WPV1). The oral poliovirus vaccine (OPV) is the predominant vaccine used for polio eradication. Although OPV has been administered in routine childhood immunization and during frequent supplementary immunization activities, WPV1 continues to circulate in Afghanistan and case incidence has been increasing since 2017. We estimated the effectiveness of OPV in Afghanistan during 2010-2020. METHODS: We conducted a matched case-control analysis using acute flaccid paralysis (AFP) surveillance data from 29,370 children < 15 years with AFP onset between January 1, 2010 and December 31, 2020. We matched children with confirmed WPV1 (cases) with children with non-polio AFP (controls) by age at onset of paralysis (+/- 3 months), date of onset of paralysis (+/- 3 months), and province of residence, and compared their reported OPV vaccination history to estimate the effectiveness of OPV in preventing paralysis by WPV1 using conditional logistic regression. To account for changes in OPV formulations provided over the analysis period, we stratified the analysis based on dates of the global switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) in April 2016. RESULTS: Between January 1, 2010 and December 31, 2020, there were 329 WPV1 cases in Afghanistan. The per-dose estimated effectiveness of OPV against WPV1 was 19% (95% CI: 15%-22%) and of ≥ 7 doses was 94% (95% CI: 90%-97%). Before the global switch from tOPV to bOPV, the per-dose estimated effectiveness of OPV was 14% (95% CI: 11%-18%) and of ≥ 7 doses was 92% (95% CI: 85%-96%). After the switch, the per-dose estimated effectiveness of OPV against WPV1 was 32% (24%-39%) and of ≥ 7 doses was 96% (95% CI: 90%-99%). DISCUSSION: OPV is highly effective in preventing paralysis by WPV1; these results indicate that continued WPV1 transmission in Afghanistan is due to failure to vaccinate, not failure of the vaccine. Although difficult to implement in parts of country, improving the administration of OPV in routine immunization and supplementary immunization activities will be critical for achieving polio eradication in Afghanistan.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Characteristics associated with negative attitudes toward mental illness among US veterinarians.

OBJECTIVE: To explore associations between demographic, occupational, and mental health characteristics and negative attitudes toward mental illness among veterinarians. DESIGN: Cross-sectional survey. SAMPLE: 9,522 veterinarians employed in the United States. PROCEDURES: Data from a previously conducted voluntary, anonymous, web-based survey were used. Negative attitude was defined as slight or strong disagreement with 2 statements: "Treatment can help people with mental illness lead normal lives" (treatment effectiveness) and "People are generally caring and sympathetic to people with mental illness" (social support). Multivariable logistic regression was used to identify variables associated with negative attitudes. RESULTS: Of the 9,522 respondents, 6,585 (69.2%) were female, 4,523 (47.5%) were 40 to 59 years old, 291 (3.1%) had a negative attitude toward treatment effectiveness, and 4,504 (47.3%) had a negative attitude toward social support. After adjusting for other variables, negative attitude toward treatment effectiveness was significantly more likely in males, those with 10 to 19 (vs 1 to 9) years of practice experience, solo practitioners, those in government (vs "other") practice, those with evidence of serious psychological distress, and those reporting suicidal ideation after veterinary school and significantly less likely in those receiving mental health treatment. A negative attitude toward social support was significantly less likely in males and significantly more likely in 40 to 59 (vs 20 to 39) year olds, childless respondents, solo practitioners, those without membership in a veterinary association, those with evidence of serious psychological distress, those reporting depression during or after veterinary school, and those reporting suicidal ideation after veterinary school. CONCLUSIONS AND CLINICAL RELEVANCE: Characteristics such as age, sex, practice setting, and mental illness history might be useful to consider when targeting interventions to support and educate veterinarians about mental illness.

Spatial Clustering of Suicide and Associated Community Characteristics, Idaho, 2010-2014.

INTRODUCTION: In 2015, Idaho had the fifth highest suicide rate in the United States. Little is known about the characteristics of areas in Idaho with high suicide rates. To aid suicide prevention efforts in the state, we sought to identify and characterize spatial clusters of suicide. METHODS: We obtained population data from the 2010 US Census and the 2010-2014 American Community Survey, analyzed data on suicides from death certificates, and used a discrete Poisson model in SaTScan to identify spatial clusters of suicide. We used logistic regression to examine associations between suicide clustering and population characteristics. RESULTS: We found 2 clusters of suicide during 2010-2014 that accounted for 70 (4.7%) of 1,501 suicides in Idaho. Areas within clusters were positively associated with the following population characteristics: median age ≤31.1 years versus >31.1 years (multivariable-adjusted odds ratio [aOR] = 2.4; 95% confidence interval [CI], 1.04-5.6), >53% female vs ≤53% female (aOR = 2.7; 95% CI, 1.3-5.8; P = .01), >1% American Indian/Alaska Native vs ≤1% American Indian/Alaska Native (aOR = 2.9; 95% CI, 1.4-6.3), and >30% never married vs ≤30% never married (aOR = 3.4; 95% CI, 1.5-8.0; P = .004). CONCLUSION: Idaho suicide prevention programs should consider using results to target prevention efforts to communities with disproportionately high suicide rates.

Antlion optimizer-ANFIS load frequency control for multi-interconnected plants comprising photovoltaic and wind turbine.

This paper proposes optimal load frequency control (LFC) designed by Adaptive Neuro Fuzzy Inference System (ANFIS) trained via antlion optimizer (ALO) for multi-interconnected system comprising renewable energy sources (RESs). Two systems are modeled and investigated; the first one has two plants of grid connected photovoltaic (PV) system with maximum power point tracker (MPPT) and thermal plant while the second comprises four plants of thermal, wind turbine and grid connected PV systems. ALO is employed to get the optimal gains of Proportional-Integral (PI) controller such that the integral time absolute error (ITAE) of frequency and tie line power deviations is minimized. The input and output of the optimized PI controller are used to train the ANFIS-LFC with Gaussian surface membership functions. Different load disturbances are studied and the results are compared with other reported approaches. The obtained results confirmed the accuracy and reliability of the proposed approach in designing LFC for multi-interconnected power systems.

Characteristics of Persons With Repeat Syphilis-Idaho, 2011 to 2015.

During 2011 through 2015 in Idaho, 14 (7%) of 193 persons with early syphilis had repeat syphilis. Persons with repeat infections were more likely to have had secondary or early latent syphilis (P = 0.037) and be infected with human immunodeficiency virus (P < 0.001) compared with those having 1 infection.

Anxiety symptoms and risk of dementia and mild cognitive impairment in the oldest old women.

OBJECTIVES: Research is limited and findings conflict regarding anxiety as a predictor of future cognitive decline in the oldest old persons. We examined the relationship between levels of and changes in anxiety symptoms, and subsequent dementia and mild cognitive impairment (MCI) in the oldest old women. METHOD: We conducted secondary analyses of data collected from 1425 community-dwelling women (mean age = 82.8, SD ±3.1 years) followed on average for five years. The Goldberg Anxiety Scale was used to assess anxiety symptoms at baseline, and an expert clinical panel adjudicated dementia and MCI at follow-up. Participants with probable cognitive impairment at baseline were excluded. RESULTS: At baseline, 190 (13%) women had moderate/severe anxiety symptoms and 403 (28%) had mild anxiety symptoms. Compared with those with no anxiety symptoms at baseline, women with mild anxiety symptoms were more likely to develop dementia at follow-up (multivariable-adjusted odds ratio = 1.66, 95% confidence interval 1.12-2.45). No significant association was observed between anxiety symptoms and MCI. CONCLUSION: In the oldest old women, our findings suggest that mild anxiety symptoms may predict future risk of dementia, but not MCI. Future studies should explore potential biological mechanisms underlying associations of anxiety with cognitive impairment.

Anxiety symptoms and risk of cognitive decline in older community-dwelling men.

BACKGROUND: Previous research regarding anxiety as a predictor of future cognitive decline in older adults is limited and inconsistent. We examined the independent relationship between anxiety symptoms and subsequent cognitive decline. METHODS: We included 2,818 community-dwelling older men (mean age = 76.1, SD ±5.3 years) who were followed on an average for 3.4 years. We assessed anxiety symptoms at baseline using the Goldberg Anxiety Scale (GAS; range = 0-9). We assessed cognitive function at baseline and at two subsequent visits using the Modified Mini-Mental State Examination (3MS; global cognition) and the Trails B test (executive function). RESULTS: At baseline, there were 690 (24%) men with mild anxiety symptoms (GAS 1-4) and 226 (8%) men with moderate/severe symptoms (GAS 5-9). Men with anxiety symptoms were more likely to have depressed mood, poor sleep, more chronic medical conditions, and more impairment in activities of daily living compared to those with no anxiety symptoms. Compared to those with no anxiety symptoms at baseline, men with any anxiety symptoms were more likely to have substantial worsening in Trails B completion time (OR = 1.56, 95% CI 1.19, 2.05). The association was attenuated after adjusting for potential confounders, including depression and poor sleep, but remained significant (OR = 1.40, 95% CI 1.04, 1.88). CONCLUSION: In cognitively healthy older men, mild anxiety symptoms may potentially predict future decline in executive functioning. Anxiety is likely a manifestation of an underlying neurodegenerative process rather than a cause.

Prevalent peripheral arterial disease and inflammatory burden.

BACKGROUND: Strong evidence implicates inflammation in the development of atherosclerotic heart disease but less is known about peripheral arterial disease (PAD). Our objective was to test the hypothesis that a composite index of inflammatory burden is associated with PAD. METHODS: Cross-sectional analysis of a randomly-selected group of 903 community-dwelling men in the MrOS cohort recruited between 2000 and 2002. Using blood samples, we measured seven cytokines and related these levels to prevalent PAD (ankle-brachial index (ABI) <0.9) both individually and as part of an "inflammatory burden score" (a composite sum of the number of pro-inflammatory cytokines in the highest quartile). RESULTS: Overall, 6.75% of men had ABI <0.9. The odds of prevalent PAD were higher in men with the highest quartile (Q4) levels of interleukin-6 multivariable (MV) adjusted (odds ratio (OR) =3.95 (95% CI, 1.4-11.3), tumor necrosis factor alpha OR = 4.44 (95% confidence interval (CI), 1.5-12.8), and C-reactive protein OR = 3.63 (95% CI, 1.4-9.4) compared to men in Q1. The magnitude of the association of these cytokines with PAD was similar to the effect of being 10 years older, OR = 2.41 (95% CI, 1.16-3.7). These significant effects persisted after additional MV adjustment for smoking except for CRP. Men with the highest inflammatory burden score (≥3) had 3.6 (95% CI, 1.5-8.7) increased odds of PAD, p trend = 0.03. After smoking adjustment the linear trend was borderline statistically significant (p trend = 0.10). CONCLUSION: Inflammatory burden is associated with prevalent PAD, an association similar to aging 10 years. The inflammatory effects of smoking contributes to the underlying association between inflammation and PAD.

Suggested avenues to reduce the stigma of mental illness in the Middle East.

BACKGROUND: Stigma toward mentally ill individuals acts as a barrier to accessing care and receiving treatment. AIM: To review current evidence pertaining to stigma toward mental illness in the Middle East in order to inform effective and sustainable interventions in this region. METHODS: We conducted a systematic literature search using the PubMed database and evaluated all identified studies according to specific inclusion criteria. RESULTS: Stigma toward individuals with mental illness does exist in the Middle East. Stigmatizing attitudes are particularly high toward culturally proscribed mental illnesses like alcohol abuse and lower for other disorders such as depression and psychosis. CONCLUSIONS: We propose the following initiatives to reduce stigma toward mental illness in the Middle East: (a) educate families to enable them to support their affected relatives, (b) increase cooperation between psychiatrists and faith healers and (c) educate young people in schools to increase their awareness and understanding of mental illnesses and to combat negative stereotypes.