Survival of adults with rheumatoid arthritis associated interstitial lung disease - A systematic review and meta-analysis.

BACKGROUND: Rheumatoid arthritis associated interstitial lung disease (RA-ILD) is associated with high levels of morbidity and mortality. The primary aim of this systematic review was to determine the duration of survival, from time of diagnosis of RA-ILD. METHODS: Medline (Ovid), Embase (OVID), CINAHL (EBSCO), PubMed, and the Cochrane Library were searched for studies that reported duration of survival from time of diagnosis of RA-ILD. Risk of bias of included studies was assessed based upon 4 domains of the Quality In Prognosis Studies tool. Results for median survival were presented by tabulation and discussed qualitatively. Meta-analysis of cumulative mortality at 1 year, >1y to ≤3 years, >3 years to ≤5 years, and >5 years to≤ 10 years was undertaken, for total RA-ILD population, and according to ILD pattern. RESULTS: 78 studies were included. Median survival for the total RA-ILD population ranged from 2 to 14 years. Pooled estimates for cumulative percentage mortality up to 1 year were 9.0% (95% CI 6.1, 12.5, I2 88.9%), >1 to ≤3 years 21.4% (17.3, 25.9, I2 85.7%), >3 to ≤ 5 years 30.2% (24.8, 35.9, I2 87.7%), and > 5 to ≤ 10 years 49.1% (40.6, 57.7 I2 85.0%). Heterogeneity was high. Only 15 studies were rated as low risk of bias in all 4 domains assessed. CONCLUSION: This review summarises the high mortality of RA-ILD, however the strength of conclusions that can be made is limited by the heterogeneity of the available studies, due to methodological and clinical factors. Further studies are needed to better understand the natural history of this condition.

Rethink Vape: Development and evaluation of a risk communication campaign to prevent youth E-cigarette use.

INTRODUCTION: E-cigarettes are now the most common form of tobacco use among adolescents, and use is associated with increased risk of initiation of cigarette smoking. This project used a community-engaged research process to develop and pilot a risk communication campaign to prevent youth vaping. METHOD: The research team worked with a 36-member Teen Advisory Council and a 19-member Expert Panel. Together, the team employed survey (N = 674) and focus group (N = 82) methodologies, and hired a marketing company to partner on development of the campaign. Campaign concepts were developed, eliminated, and/or modified through an iterative process of feedback and refinement. The final campaign included video ads (https://bit.ly/2QMR8gH) a microsite (rethinkvape.org), and social media sites (@rethinkvape). The campaign communicated three messages to teens: what's in the vapor, health risks, and connections to big tobacco. Prior to launch of the campaign, a randomized controlled 2 (time) × 2 (group) online experiment was conducted to evaluate the campaign (N = 268). RESULTS: Repeated measures mixed analyses of variance indicated that vaping knowledge, perceptions of risk, and anti-vape intentions significantly increased among teens viewing the Rethink Vape Materials compared to their own baseline, while control participants did not change. Following evaluation, the team launched a 6-week online media campaign with a teen-targeted geo-fence radius to deliver 3,838,465 impressions, 770,443 completed video views, and 18,316 clicks in mobile app, Snapchat, YouTube, and Spotify platforms. The majority of placements exceeded industry standards, with mobile pre-roll and Snapchat as top performers. CONCLUSIONS: The e-cigarette campaign showed promising signs of effectiveness and scalability.

Population-Level Outcomes with a 2-Step Approach for Gestational Diabetes Screening and Diagnosis.

OBJECTIVES: To examine outcomes associated with alternative glucose thresholds in a 2-step approach for screening and diagnosing gestational diabetes mellitus (GDM). METHODS: We studied 178,527 pregnancies between 2008 and 2012 in Alberta, Canada. They were categorized retrospectively as normal 50 g screen (n=144,191); normal 75 g oral glucose tolerance test (OGTT) (n=21,248); abnormal at glucose thresholds suggested by the International Association of Diabetes and Pregnancy Group (IADPSG) (HAPO 1.75, n=4308); abnormal at glucose thresholds associated with an odds ratio of 2.0 for adverse events in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. This latter group, which would have been treated for GDM based on customary care, was further divided into those with 1 (HAPO 2-1 n=5528) or 2 or more abnormal glucose values (HAPO 2-2 n=3252). Main outcomes were large for gestational age (LGA), induced labour and Cesarean-section rates. RESULTS: LGA rates were 8.2%, 10.5%, 14.2%, 11.8% and 16.5% among normal 50 g, normal 75 g OGTT, HAPO 1.75, HAPO 2-1, and HAPO 2-2 groups, respectively. Labour induction and caesarean-section rates were 29.6% and 36.2% in the IADPSG, 38.2% and 36.8% in the HAPO 2-1 group, and 42.3% and 41.1% in the HAPO 2-2 groups, respectively. Excessive maternal weight (≥91 kg) was associated with a higher risk for all adverse outcomes. CONCLUSIONS: The 2-step approach effectively identifies pregnancies at low risk for adverse outcomes. Labelling influences induction practice. Any glucose intolerance increases risk for adverse outcomes, and pregnancies with highest (2 or higher) abnormal glucose values remain at greatest risk. Further research is needed to determine whether glycemic thresholds for GDM diagnosis should incorporate information about maternal weight.

The Microbiome of the Built Environment and Human Behavior: Implications for Emotional Health and Well-Being in Postmodern Western Societies.

It is increasingly evident that inflammation is an important determinant of cognitive function and emotional behaviors that are dysregulated in stress-related psychiatric disorders, such as anxiety and affective disorders. Inflammatory responses to physical or psychological stressors are dependent on immunoregulation, which is indicated by a balanced expansion of effector T-cell populations and regulatory T cells. This balance is in part driven by microbial signals. The hygiene or "old friends" hypothesis posits that exposure to immunoregulation-inducing microorganisms is reduced in modern urban societies, leading to an epidemic of inflammatory disease and increased vulnerability to stress-related psychiatric disorders. With the global trend toward urbanization, humans are progressively spending more time in built environments, thereby, experiencing limited exposures to these immunoregulatory "old friends." Here, we evaluate the implications of the global trend toward urbanization, and how this transition may affect human microbial exposures and human behavior.

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study.

AIMS: People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population. METHODS: We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control. RESULTS: In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control. CONCLUSIONS: Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Evaluation of the Current Practices of Noise-Induced Hearing loss (NIHL) Awareness Training in the South African Mining Industry

ABSTRACT This study aimed to evaluate the current practices in relation to best practice criteria and make recommendations for improvements to noise-induced hearing loss (NIHL) awareness training in the South African mining industry. A survey tool based on fi ndings of a literature review on best practice for NIHL awareness training was developed for use in interviews; with managers responsible for NIHL awareness training at the mines. Thirty managers were interviewed in the survey at mines representative of different sizes and different commodities. Results indicate that NIHL awareness training is not treated as a priority training area. Only 20 of NIHL awareness training programmes had a theoretical basis in health promotion or adult education. Employees received; on average; 15 minutes of training per annum. Evaluation of employee knowledge only occurred at 40 of the mines surveyed. Recommendations were made to address the factors identified in the evaluation of the current practices in the South African mining industry regarding NIHL awareness training needing to be aligned with best practice

Association between participation in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes.

AIMS: To determine the association between participation in a brief introductory didactic diabetes education programme and change in HbA1c among individuals with newly diagnosed diabetes. METHODS: We identified a population-based cohort of adults newly diagnosed with diabetes between October 2005 and June 2008 in Calgary, Canada, and conducted a retrospective cohort study by linking administrative and laboratory data with programme attendance data. We matched individuals who attended the programme within the first 6 months after diagnosis with those who did not attend, based on their propensity scores. We measured the change in HbA1c between time of diagnosis and 6-18 months later to determine the association between programme participation and change in HbA1c . RESULTS: HbA1c was measured at baseline and follow-up for 7793 individuals, including 803 programme participants. After propensity score matching, programme participation was associated with a significantly greater adjusted mean reduction in HbA1c between baseline and follow-up of 3.3 mmol/mol (95% CI 2.2-4.3) or 0.30% (95% CI 0.20-0.39). There was a significant interaction between baseline HbA1c and programme participation-the difference in adjusted mean reduction in HbA1c associated with programme participation ranged from 2.7 mmol/mol (0.25%) at baseline HbA1c of 53 mmol/mol (7%) to 6.2 mmol/mol (0.56%) at baseline HbA1c of 97 mmol/mol (11%). CONCLUSION: Despite its brevity, participation in a diabetes education programme was associated with an additional reduction in HbA1c in newly diagnosed people that was comparable with that reported in trials of programmes targeted at those with prevalent diabetes.

Effect of a dairy- and calcium-rich diet on weight loss and appetite during energy restriction in overweight and obese adults: a randomized trial.

BACKGROUND/OBJECTIVES: A diet rich in dairy and calcium (Ca) has been variably associated with improvements in body composition and decreased risk of type 2 diabetes. Our objective was to determine if a dietary pattern high in dairy and Ca improves weight loss and subjective appetite to a greater extent than a low dairy/Ca diet during energy restriction in overweight and obese adults with metabolic syndrome. SUBJECTS/METHODS: A total of 49 participants were randomized to one of two treatment groups: Control (low dairy, ≈ 700 mg/day Ca, -500 kcal/day) or Dairy/Ca (high dairy, ≈ 1400 mg/day Ca, -500 kcal/day) for 12 weeks. Body composition, subjective ratings of appetite, food intake, plasma satiety hormones, glycemic response and inflammatory cytokines were measured. RESULTS: Control (-2.2 ± 0.5 kg) and Dairy/Ca (-3.3 ± 0.6 kg) had similar weight loss. Based on self-reported energy intake, the percentage of expected weight loss achieved was higher with Dairy/Ca (82.1 ± 19.4%) than Control (32.2 ± 7.7%; P=0.03). Subjects in the Dairy/Ca group reported feeling more satisfied (P=0.01) and had lower dietary fat intake (P=0.02) over 12 weeks compared with Control. Compared with Control, Dairy/Ca had higher plasma levels of peptide tyrosine tyrosine (PYY, P=0.01) during the meal tolerance test at week 12. Monocyte chemoattractant protein-1 was reduced at 30 min with Dairy/Ca compared with Control (P=0.04). CONCLUSIONS: In conclusion, a dairy- and Ca-rich diet was not associated with greater weight loss than control. Modest increases in plasma PYY concentrations with increased dairy/Ca intake, however, may contribute to enhanced sensations of satisfaction and reduced dietary fat intake during energy restriction.

Audit of anticoagulant thromboprophylaxis in hospitalized oncology patients.

BACKGROUND: Venous thromboembolism (VTE) is a significant problem in oncology patients. VTE prophylaxis is underutilized in hospitalized medical patients, but there are few data for the appropriateness and frequency of its use in the oncology subgroup. We aimed to document local practice. METHODS: A cross-sectional chart review of all hospitalized patients cared for by the Christchurch Hospital Oncology Service was carried out during two defined 4-week periods. Assessment for indications and contraindications to prophylactic anticoagulation was based on the 2004 American College of Chest Physicians evidence-based consensus guidelines. RESULTS: Of 113 admissions to the oncology service, 38 (33.6%) had indications for prophylactic anticoagulation. However, 23 of these also had contraindications, leaving only 15 (13%) admissions where prophylactic anticoagulation was deemed appropriate. Only one was appropriately given prophylactic anticoagulation. CONCLUSION: Only a minority of hospitalized oncology patients are appropriate for prophylactic anticoagulation. Where it is suitable, however, it is poorly utilized locally. Local promotion of VTE prophylaxis and further study of this subgroup of hospitalized medical patients may improve uptake of this practice and attenuate morbidity from VTE.

Effect of fibrates on postprandial remnant-like particles in patients with combined hyperlipidemia.

We have investigated the effect of standard doses of two fibrates, gemfibrozil and fenofibrate, on fasting and postprandial remnant-like particles (RLP) in subjects with combined hyperlipidemia. Forty-eight subjects participated; of these, 14 underwent a Vitamin A-fat loading test before and after 6 months of treatment with gemfibrozil (n = 8) and fenofibrate (n = 6). Blood was drawn every 2h for 12h after the test meal. The postprandial response was calculated as the area under the curve (AUC). There was no difference in fasting levels and pre-treatment AUC for triglycerides (TG), RLP cholesterol (RLP-C), RLP triglycerides (RLP-TG) and retinyl palmitate (RetP) between the two treatment groups. There was also no difference in the treatment effect on all parameters between the two treatment groups. Combining the two treatment groups, treatment resulted in a significant reduction in fasting levels and AUC of all four parameters. Assigning the difference observed between pre-treatment AUC of the combined study group and AUC of a normolipidemic (NL) control group as 100%, fibrate treatment resulted in decreases in AUC for TG, RLP-C, RLP-TG and RetP of 68, 69, 69 and 94%, respectively. These results indicate that fibrates are effective agents in reducing the postprandial increase in remnant lipoprotein particles.

Population genetics of two rare perennials in isolated wetlands: Sagittaria isoetiformis and S. teres (Alismataceae).

We investigated genetic structure in two closely related perennial plants that occur in isolated wetlands: Sagittaria isoetiformis, restricted to the southeastern Coastal Plain of North America, and S. teres, endemic to the northeastern Coastal Plain. Using horizontal starch-gel electrophoresis, we screened 527 individuals from 11 populations of S. isoetiformis and 367 individuals from seven populations of S. teres. A high proportion of the 16 loci were polymorphic (%P(S) = 93.8% in S. isoetiformis and %P(S) = 75.0% in S. teres), with higher mean numbers of alleles per polymorphic locus and effective alleles per locus in S. isoetiformis (AP = 3.27, A(E) = 1.90) than in S. teres (AP = 2.58, A(E) = 1.30). Species- and population-level expected heterozygosities were higher in S. isoetiformis (H(ES) = 0.399, H(EP) = 0.218) than in S. teres (H(ES) = 0.177, H(EP) = 0.101). Jackknife estimates of F statistics indicated moderate levels of inbreeding in S. teres (F(IS) = 23.1%). Strong differentiation characterized these geographically isolated populations (G(ST) = 39.9% in S. isoetiformis, and G(ST) = 26.1% in S. teres). Genetic identities varied substantially within (I = 75%, range = 0.558-0.963 in S. isoetiformis; I = 89%, range = 0.776-0.963 in S. teres) and among species (I = 81%, range = 0.506-0.882), leading to the discrimination of four regional population clusters using nonmetric multidimensional scaling (NMDS). It appears that S. isoetiformis and S. teres are a progenitor-derivative species pair.

Effect on lipid, complete blood count and blood proteins of a standardized preparation for drawing blood: a randomized controlled trial.

OBJECTIVE: To compare a standardized recommended procedure for drawing blood to measure blood lipid and lipoprotein levels with the procedure commonly used in clinical practice. The aim was to see if hemoconcentration and spuriously elevated lipid levels could be avoided. DESIGN: An open randomized crossover clinical trial. SETTING: The University of Calgary. PATIENTS: Twenty-five patients with dyslipidemia. INTERVENTIONS: Blood drawing using a standardized procedure in which the patient remained seated for 5 minutes before blood collection and tourniquet use was minimized or avoided. MAIN OUTCOME MEASURES: Differences in lipid levels between the usual clinical procedure and the recommended procedure for drawing blood. RESULTS: Prior to drawing blood, laboratories have sat patients for an average of 1.4 minutes (95% CI, 0.9 to 1.9) and used a tourniquet in every patient. In the standardized procedure, patients rested for an average of 5.6 minutes (95% CI 5.0 to 6.2), and a tourniquet was used briefly in only 3 of 23 patients. There were no differences in lipid and lipoprotein values and no clinically significant difference in hemoglobin or albumin levels or in the calculation of hemoconcentration. CONCLUSIONS: Efforts to rest patients and avoid tourniquet use when drawing blood for assessment of lipid levels are unlikely to be useful.

Permanent cardiac pacing after a cardiac operation: predicting the use of permanent pacemakers.

BACKGROUND: The need for permanent cardiac pacing after cardiac operations is infrequent but associated with increased morbidity and resource utilization. We identified patient risk factors for pacemaker insertion to enable development of a predictive model. METHODS: Data were collected prospectively for 10,421 consecutive patients who had cardiac operations between January 1990 and December 1995. Two hundred fifty-five patients (2.4%) were identified as having received a permanent pacemaker during the same hospitalization. Logistic regression analysis was performed to determine the independent, multivariate predictors of permanent pacing. The predictive accuracy and precision of the logistic regression model was evaluated in the 1996 database of 2,236 consecutive patients by the calculation of Brier scores. RESULTS: Eight independent predictors of permanent pacemaker requirement were identified. The factor-adjusted odds ratios (OR) with 95% confidence interval (CI) associated with each predictor are as follows: (1) valve replacement surgery (aortic: OR 5.8, CI 3.9-8.7; mitral: OR 4.9, CI 3.1-7.8; tricuspid: OR 8.0, CI 5.5-11.9; double: OR 8.9, CI 5.5-14.6; and triple: OR 7.5, CI 2.9-19.3); (2) repeat operation: OR 2.4, CI 1.8-3.3; (3) age 75 years or older: OR 3.0, CI 2.0-4.4; (4) ablative arrhythmia operation: OR 4.2, CI 1.9-9.5; (5) mitral valve annular reconstruction: OR 2.4, CI 1.4-4.2; (6) use of cold blood cardioplegia: OR 2.0, CI 1.2-3.6; (7) preoperative renal failure: OR 1.6, CI 1.0-2.6; and (8) active endocarditis: OR 1.7, CI 0.9-3.0. A model for postoperative permanent pacemaker requirement using the eight predictors was formulated and tested (Brier score = 0.017+/-0.003; Z = 0.18). CONCLUSIONS: The proposed predictive model correlated highly with actual pacemaker use, which suggests that the requirement for pacing results from either operative trauma or increased ischemic burden. Preoperative identification of patients at increased risk of conduction disturbances may allow for earlier detection and improved treatment. Patients requiring postoperative pacing had increased morbidity and length of stay.

Intraoral reconstructive techniques.

A multitude of reconstructive options are possible for the patient afflicted with an intraoral malignancy. The reconstructive technique chosen depends on the stage of the disease and the extent of the soft- and hard-tissue defects after extirpation. A graded approach is applied to reconstruction. If local tissues are not available for reconstruction, the surgeon must look to more distant sites in choosing a reconstructive procedure. Microsurgical transfer of composite tissues have allowed us a high degree of success in effecting immediate one-stage closure of complex three-dimensional wounds.

The genetics and pathophysiology of type II and gestational diabetes.

The development of both type II diabetes and gestational diabetes is probably governed by a complex and variable interaction of genes and environment. Molecular genetics has so far failed to identify discrete gene mutations accounting for metabolic changes in NIDDM. Both beta cell dysfunction and insulin resistance are operative in the manifestation of these disorders. Specific and sensitive immunoradiometric assays found fasting hyperproinsulinemia and first-phase hypoinsulinemia early in the natural history of the disorder. A lack of specificity of early radioimmunoassays for insulin resulted in measuring not only insulin but also proinsulins, leading to overestimation of insulin and misleading conclusions about its role in diabetes. The major causes of insulin resistance are the genetic deficiency of glycogen synthase activation, compounded by additional defects due to metabolic disorders, receptor downregulation, and glucose transporter abnormalities, all contributing to the impairment in muscle glucose uptake. The liver is also resistant to insulin in NIDDM, reflected in persistent hepatic glucose production despite hyperglycemia. Insulin resistance is present in many nondiabetics, but in itself is insufficient to cause type II diabetes. Gestational diabetes is closely related to NIDDM, and the combination of insulin resistance and impaired insulin secretion is of importance in its pathogenesis.

High frequency of mutations in the human lipoprotein lipase gene in pregnancy-induced chylomicronemia: possible association with apolipoprotein E2 isoform.

Partial deficiency in lipolysis usually results in only mild disturbances of lipid levels. However, when this is associated with impairment of the uptake of remnant particles and increased production of triglyceride-rich lipoproteins stimulated by environmental factors such as during normal pregnancy, chylomicronemia may ensue. We have previously reported a patient who had approximately 12% of normal LPL activity and developed severe chylomicronemia during pregnancy (Ma et al. 1993. J. Clin. Invest. 91: 1953-1958). Here we report four new patients with pregnancy-induced chylomicronemia. In the nonpregnant state, these patients had mild to modest elevation of triglyceride levels ranging from 80 to 623 mg/dl (0.9-7.0 mmol/l) but during the third trimester they became severely chylomicronemic with triglyceride levels ranging from 2314 to 14,596 mg/dl (26 to 164 mmol/l). Three of these four patients had partial lipoprotein lipase (LPL) deficiency. The molecular characterization of the LPL gene in these three patients with partial LPL deficiency revealed four novel unpublished mutations. Patient #1 is a compound heterozygote for Leu252Arg and Ala261Thr mutations which are associated with 25% of normal LPL activity. In addition, she has an apoE3/2 genotype. Patient #2 is a heterozygote for a Asn291Ser substitution with 69% of LPL activity and also has an apoE3/2 genotype, while patient #3 is a heterozygote for a Trp382Stop mutation with 54% of normal LPL activity and has an apoE4/2 genotype. The fourth patient (#4) with pregnancy-induced chylomicronemia does not have LPL deficiency and has an apoE3/3 genotype. The previously reported patient (#5) who had 12% of normal LPL activity due to homozygosity for a Ser172Cys mutation also has an E3/3 genotype. Our data suggest that mutations in the LPL gene that cause partial LPL deficiency might be a frequent factor in the pathogenesis of pregnancy-induced chylomicronemia.

Sequentially linked free flaps in head and neck reconstruction.

Free tissue transfer has become a useful technique for reconstructing complex three-dimensional defects following the extirpation of head and neck malignancies. This technique, however, may be limited by inadequate vascularity in the recipient site when a patient has been subjected to operative procedures or radiation therapy. The use of serial flaps, with the first flap connected sequentially to the second, reduces the need for dual recipient vessels in a surgical field when two flaps are required for reconstruction. Although this procedure is more technically demanding than more traditional approaches, it can provide a satisfactory, reliable one-stage composite reconstruction under these difficult circumstances. Results have been functionally and aesthetically superior to those achieved with pedicled one-flap reconstructive methods.