Disease activity-guided dose optimisation including discontinuation of TNF-inhibitors in rheumatoid arthritis is effective for up to 10 years: an observational follow-up of the DRESS study.

OBJECTIVES: To investigate safety and effectiveness of disease activity-guided dose optimisation of TNF-inhibitors in rheumatoid arthritis over 10 years. METHODS: Observational long-term extension of a randomised study of participants who completed the 3-year extension of the DRESS-study. After the randomised phase (month 0-18), disease activity-guided dose optimisation was allowed for all. Main outcomes were mean time-weighted DAS28-CRP; biological and targeted synthetic anti-rheumatic drug (b/tsDMARD) use per year as proportion of daily defined dose; proportion of patients reaching discontinuation; durability, effectiveness of subsequent dose reduction attempts; and radiographic progression between 3 and 10 years using the Sharp-van der Heijde score. RESULTS: 170 patients were included of whom 127 completed 10-year follow-up. The mean disease activity remained low (DAS28-CRP 2.13, 95% confidence interval 2.10-2.16), whilst the b/tsDMARD dose reduced from 97% at baseline (95%CI 96% to 99%, n = 170)% to56% at year 10 (49% to 63%, n = 127). 119 of 161 participants (74%) with an optimisation attempt reached discontinuation, with a median duration of 7 months (interquartile range 3-33 months), and 25 participants never had to restart their b/tsDMARD (21%, 14% to 29%). The mean dose reduction after dose optimisation was 48% (n = 159) for the first optimisation attempt and 33% for subsequent attempt (n = 86). 48% (41/86) of participants had radiographic progression exceeding the smallest detectable change (5.7 units), and progression was associated with disease activity, not b/tsDMARD use. CONCLUSION: Long-term disease activity-guided dose optimisation of TNF-inhibitors in rheumatoid arthritis, including discontinuation and multiple tapering attempts, remains safe and effective.

Finding logic models for sustainable marine development that deliver on social equity.

Sustainable development is often represented as contributing to desirable outcomes across economic, environmental, and social goals, yet policies and interventions attempting to deliver sustainable development often disagree on the order in which these categories of goals should be addressed. In this Essay, we identify and review 5 approaches (called logic models) for sustainable development in ocean systems based on existing policies and interventions and consider the evidence for their contributions to equity-the ultimate goal of sustainable development according to the UN Sustainable Development Goals (SDGs). Two of the 5 logic models prioritize economic growth and lead to social and environmental benefits, 2 prioritize environmental health as a prerequisite for sustainable economic and social benefits, and the final logic model is community driven and prioritizes social dimensions. Looking towards the 2030 maturation of the SDGs, we will need to understand what models are best suited to deliver on equity gains and prevent future inequities in development and how best to operationalize them.

Pregnancy- and obstetric-related risk factors for urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life: A systematic review and meta-analysis.

INTRODUCTION: Risk factors for pelvic floor disorders are often related to pregnancy and delivery. Consistent evidence is needed to develop prevention strategies targeting risk factors. The objective of this study is to identify which pregnancy- and/or obstetric-related risk factors can predict urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life by means of a systematic review and meta-analysis. MATERIAL AND METHODS: Systematic review Prospero number: CRD42019131758. Literature searches of PubMed, EMBASE, CINAHL, and Cochrane Library were conducted according to PRISMA guidelines (April 2020). Prospective cohort studies describing more than two pregnancy- and/or obstetric-related risk factors on urinary incontinence, fecal incontinence (including flatal incontinence), or pelvic organ prolapse were eligible. Risk of bias was assessed (using Quality In Prognosis Studies [QUIPS]). Studies with high risk of bias were excluded. Data were extracted and checked for accuracy with the CHARMS checklist. Sub-groups were used to distinguish between a short- and long-term follow-up period: <18 months (shortterm) and >18 months (long-term) postpartum. Odds ratios were calculated from reported prevalence rates. Log odds ratios were calculated using SPSS v.24. Variables were pooled using RevMan5. RESULTS: Data were extracted from nineteen studies for urinary incontinence, nine for fecal incontinence, and two for pelvic organ prolapse. Multivariate analysis was not possible because of the heterogeneity of the population and outcome measures. Pooled univariate risk factors for urinary incontinence were: urinary incontinence during pregnancy, instrumental vaginal delivery, episiotomy, tears, and constipation. Pooled univariate risk factors for fecal incontinence were: fecal incontinence during pregnancy, maternal age over 35 years, prenatal body mass index over 30 kg/m2 , instrumental vaginal delivery, a spontaneous vaginal delivery, oxytocin augmentation, and when the weight of the newborn was more than 4000 g. Both studies for pelvic organ prolapse had a short-term follow-up period and cesarean section was the only risk factor that could be pooled. CONCLUSIONS: Pregnancy- and obstetric-related risk factors predicting pelvic floor disorders postpartum are multifactorial and differ between pelvic floor disorders. The strongest risk factor for incontinence later in life was incontinence during pregnancy. Better quality research with long-term follow up is needed on this topic.

Association between chorionicity and preterm birth in twin pregnancies: a systematic review involving 29 864 twin pregnancies.

BACKGROUND: The perinatal mortality and morbidity among twins vary by chorionicity. Although it is considered that monochorionicity is associated with an increased risk of preterm birth in twin pregnancies, no systematic review exists evaluating this association. OBJECTIVES: This systematic review was undertaken to assess the association between preterm birth and chorionicity in twin pregnancies. SEARCH STRATEGY: We searched the electronic databases from January 1990 to July 2019 without language restrictions. SELECTION CRITERIA: All studies on twin pregnancies where chorionicity and preterm birth were evaluated were included. DATA COLLECTION AND ANALYSIS: Findings are reported as odds ratios with 95% confidence intervals. The estimates are pooled using random-effects meta-analysis. MAIN RESULTS: From 13 156 citations, we included 39 studies (29 864 pregnancies). Monochorionicity was significantly associated with increased risk of preterm birth at ≤28, ≤32, ≤34 and <37 weeks in women asymptomatic and symptomatic for preterm labour (odds ratio [OR] 2.14, 95% CI 1.52-3.02, I2  = 46%, OR 1.55, 95% CI 1.27-1.89 I2  = 68%, OR 1.47, 95% CI 1.27-1.69, I2  = 60%, OR 1.66, 95% CI 1.43-1.93, I2  = 65%, respectively). Among those asymptomatic for preterm labour, significantly increased odds of preterm birth were seen for monochorionicity at gestations ≤34 weeks (OR 1.85, 95% CI 1.42-2.40, I2  = 25%) and <37 weeks (OR 1.75, 95% CI 1.22-2.53, I2  = 61%). Sensitivity analysis showed significantly increased odds of spontaneous preterm birth at ≤34 and <37 weeks for monochorionicity (OR 1.25, 95% CI 1.01-1.55, I2  = 0% and OR 1.41, 95% CI 1.13-1.78, I2  = 0%). CONCLUSIONS: Monochorionicity is significantly associated with preterm birth at all gestations. TWEETABLE ABSTRACT: In twin pregnancies, monochorionicity is associated with an increased risk of preterm birth at all gestations.

Speaking across boundaries to explore the potential for interdisciplinarity in ecosystem services knowledge production.

Conservation is likely to be most successful if it draws on knowledge from across the natural and social sciences. The ecosystem services concept has been called a boundary object in that it facilitates development of such interdisciplinary knowledge because it offers a common platform for researchers, policy makers, and practitioners. However, a question that remains is to what extent the interdisciplinary knowledge needed is provided by disciplinary diversity within the field. We asked where is knowledge on ecosystem services produced, how interdisciplinary is this knowledge, and which disciplines facilitate the greatest disciplinary integration? We defined interdisciplinarity as the extent to which published research draws on knowledge that crosses disciplinary borders and used citations as a quantitative indicator of communication among disciplines, based on journal classification. We used disciplinary diversity, richness, and heterocitation as measures of interdisciplinarity and betweenness centrality as a measure of disciplinary integration. Our data set contained 22,153 publications on ecosystem services, published from 1983 to 2018. We found that ecosystem services research matured; average yearly output growth was 33.8%, more than the 8-9% growth in scientific output across all fields. Over time, the network clustering coefficient, measuring connectedness of individual disciplines, rose from 0.388 to 0.727, suggesting increased density in the network of citations. Researchers in the field published more articles (3566 in 2018 alone) across more disciplines (77 unique disciplines in 2018). However, this growth was not mirrored by an increase in the diversity (stable at 0.7-0.9) or richness (averaging 0.35 unique disciplines per citation) of citation patterns. Heterocitation scores, or out-of-group citations, for arts, humanities, social sciences, and law ranged from 56% to 64%, which was lower than we expected, although this may serve to protect the integrity of social science disciplines and attract broader engagement from within. Ultimately, a small number of productive disciplines are central to supporting disciplinary integration. However, opportunities exist for conservation practice to draw on a broader field of research, to realize the potential that the diverse body of knowledge of interdisciplinary work offers.

Comunicación Más Allá de las Fronteras para Explorar el Potencial de la Interdisciplinariedad en la Producción de Conocimiento sobre los Servicios Ambientales Resumen Es probable que la conservación sea más exitosa si parte del conocimiento que proviene más allá de las ciencias naturales y sociales. El concepto de servicios ambientales ha sido considerado un objeto fronterizo pues facilita el desarrollo de dicho conocimiento interdisciplinario ya que ofrece una plataforma común para los investigadores, los formuladores de políticas y los profesionales. Sin embargo, todavía permanece la pregunta de cuánto del conocimiento interdisciplinario requerido es proporcionado por la diversidad de disciplinas dentro del campo. Preguntamos en dónde se produce el conocimiento sobre los servicios ambientales, cuán interdisciplinario es este conocimiento, y cuáles disciplinas facilitan la mayor integración disciplinaria. Definimos a la interdisciplinariedad como el grado al que los estudios publicados usan conocimiento que cruza las fronteras disciplinarias y usamos a las referencias como indicadores cuantitativos de la comunicación entre las disciplinas con base en la clasificación de revistas. Usamos la diversidad, riqueza y heterogeneidad de referencias de disciplinas como medidas de la interdisciplinariedad y la centralidad de la intermediación como medida de la integración de disciplinas. Nuestro conjunto de datos incluyó 22,153 publicaciones sobre los servicios ambientales, publicadas entre 1983 y 2018. Descubrimos que el estudio de los servicios ambientales maduró; el crecimiento de la producción anual promedio fue 33.8%, más que el crecimiento de 8-9% en la producción científica en todas las áreas de estudio. Con el tiempo, el coeficiente de agrupación de redes, medida de la conectividad entre las disciplinas individuales, creció de 0.388 a 0.727, lo que sugiere un incremento en la densidad dentro de la red de referencias. Los investigadores pertenecientes al área de estudio de los servicios ambientales publicaron más artículos (3,566 tan sólo en el 2018) en varias disciplinas (77 disciplinas únicas en 2018). Sin embargo, este crecimiento no fue igualado con un incremento en la diversidad (estable a 0.7-0.9) o en la riqueza (con un promedio de 0.35 disciplinas únicas por referencia) de los patrones de referencias. Los puntajes de heterogeneidad de referencias, o citas fuera de grupo, para las artes, humanidades, ciencias sociales y leyes variaron entre 56% y 64%, que fue menos de lo esperado, aunque esto tal vez funcione para proteger la integridad de las disciplinas de las ciencias sociales y atraer una participación más amplia desde adentro. Finalmente, un número pequeño de disciplinas productivas son centrales para el respaldo a la integración disciplinaria. Sin embargo, las oportunidades existen para que la práctica de la conservación considere a un campo más amplio de áreas de estudio y para que se revele el potencial que tiene el conjunto de conocimiento diverso que ofrece el trabajo interdisciplinario.

The influence of group values and behavior on adolescent male perceptions of and use of homophobic language.

INTRODUCTION: The pervasive and derogatory use of homophobic language is a threat to safe, respectful, and inclusive school environments. Group membership has been shown to influence how students use homophobic language. Previous qualitative studies have largely approached the use of this language from the theoretical framework of hegemonic masculinity. In contrast, the current study actively challenged all assumptions about the use of this language. METHOD: This study was conducted in a public high school located in a rural conservative Christian community in the Intermountain West (USA). Using hermeneutic qualitative methodology to assess individual perceptions of homophobic language, 20 randomly selected 12th-grade male students (17-18 years of age) were individually interviewed. RESULTS: Three distinct groups emerged during our interviews: students on the debate team, students who strongly identified with a conservative religion, and students on popular athletic teams. Membership in specific peer groups influenced how students participated in or abstained from using homophobic language. Contrary to the prevailing research that pairs religiosity with negatively biased attitudes toward LGBTQIA, in this study, participants' religious beliefs appeared to be associated with respecting others' feelings and a decreased likelihood of using homophobic language. CONCLUSIONS: After summarizing this study's findings, we conclude with implications for practice. To more effectively deter the use of homophobic language, we encourage school-based interventions that target specific groups of adolescents and consider the social context in which homophobic language occurs.

A Pilot Study of the Effect of Green Kiwifruit on Human Intestinal Fermentation Measured by Hydrogen and Methane Breath Testing.

We investigated the impact of the ingestion of two green kiwifruit (Actinidia deliciosa var. Hayward) and one Royal Gala apple on breath hydrogen and methane production in humans. Consumption of two green kiwifruit led to no evidence of carbohydrate malabsorption (0/20), whereas consumption of one apple was associated with carbohydrate malabsorption in 6/20 participants (P = .008). There were no significant differences in the area under the curve for hydrogen or methane breath concentrations after consumption of the two fruits. Rates of lactose and fructose breath tests in this cohort were within expected parameters. Green kiwifruit are not associated with clinically significant carbohydrate malabsorption compared with apples in this pilot study.

Urinary proteins, vitamin D and genetic polymorphisms as risk factors for febrile urinary tract infection and relation with bacteremia: a case control study.

OBJECTIVE/PURPOSE: Febrile urinary tract infection (UTI) is a common bacterial disease that may lead to substantial morbidity and mortality especially among the elderly. Little is known about biomarkers that predict a complicated course. Our aim was to determine the role of certain urinary cytokines or antimicrobial proteins, plasma vitamin D level, and genetic variation in host defense of febrile UTI and its relation with bacteremia. METHODS: A case-control study. Out of a cohort of consecutive adults with febrile UTI (n = 787) included in a multi-center observational cohort study, 46 cases with bacteremic E.coli UTI and 45 cases with non-bacteremic E.coli UTI were randomly selected and compared to 46 controls. Urinary IL-6, IL-8, LL37, ß-defensin 2 and uromodulin as well as plasma 25-hydroxyvitamin D were measured. In 440 controls and 707 UTI patients polymorphisms were genotyped in the genes CXCR1, DEFA4, DEFB1, IL6, IL8, MYD88, UMOD, TIRAP, TLR1, TLR2, TLR5 and TNF. RESULTS: IL-6, IL-8, and LL37 are different between controls and UTI patients, although these proteins do not distinguish between patients with and without bacteremia. While uromodulin did not differ between groups, inability to produce uromodulin is more common in patients with bacteremia. Most participants in the study, including the controls, had insufficient vitamin D and, at least in winter, UTI patients have lower vitamin D than controls. Associations were found between the CC genotype of IL6 SNP rs1800795 and occurrence of bacteremia and between TLR5 SNP rs5744168 and protection from UTI. The rare GG genotype of IL6 SNP rs1800795 was associated with higher ß-defensin 2 production. CONCLUSION: Although no biomarker was able to distinguish between UTI with or without bacteremia, two risk factors for bacteremia were identified. These were inability to produce uromodulin and an IL6 rs1800795 genotype.

Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy-resistant provoked vestibulodynia: a feasibility study.

INTRODUCTION: The current approach to women with provoked vestibulodynia (PVD) comprises a multidimensional, multidisciplinary therapeutic protocol. As PVD is considered to be a chronic pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as an additional therapy for women with otherwise therapy-resistant PVD. AIMS: The aims of this study were to evaluate whether TENS has a beneficial effect on vulvar pain, sexual functioning, and sexually-related personal distress in women with therapy-resistant PVD and to assess the effect of TENS on the need for vestibulectomy. METHODS: A longitudinal prospective follow-up study was performed on women with therapy-resistant PVD who received additional domiciliary TENS. Self-report questionnaires and visual analog scales (VASs) were completed at baseline (T1), post-TENS (T2), and follow-up (T3). MAIN OUTCOME MEASURES: Vulvar pain, sexual functioning, and sexually-related personal distress were the main outcome measures. RESULTS: Thirty-nine women with therapy-resistant PVD were included. Mean age was 27 ± 5.6 years (range: 19 to 41); mean duration between TENS and T3 follow-up was 10.1 ± 10.7 months (range: 2 to 32). Vulvar pain VAS scores directly post-TENS (median 3.4) and at follow-up (median 3.2) were significantly (P < 0.01) lower than at baseline (median 8.0). Post-TENS, sexual functioning scores on the Female Sexual Functioning Index questionnaire had improved significantly (P = 0.2); these scores remained stable at follow-up. Sexually-related personal distress scores had improved significantly post-TENS (P = 0.01). Only 4% of the women who received TENS needed to undergo vestibulectomy vs. 23% in our previous patient population. CONCLUSION: The addition of self-administered TENS to multidimensional treatment significantly reduced the level of vulvar pain and the need for vestibulectomy. The long-term effect was stable. These results not only support our hypothesis that TENS constitutes a feasible and beneficial addition to multidimensional treatment for therapy-resistant PVD, but also the notion that PVD can be considered as a chronic pain syndrome.

[Renal infarction in two patients with acute abdominal pain]. / Nierinfarct bij 2 patiënten met acute buikpijn.

BACKGROUND: Renal infarction is a condition not known to every physician, with often non-specific symptoms. The diagnosis is therefore often not considered initially in patients with acute abdominal pain. CASE DESCRIPTIONS: In a 77-year-old man a renal infarction was found by chance on a CT-scan performed performed for the evaluation of dyspnoea. Previously he had visited the emergency unit with abdominal pain, in retrospect attributable to renal infarction. A 61-year-old man initially labelled as suffering from gastro-enteritis was diagnosed correctly with renal infarction after his renal function deteriorated and the lactate dehydrogenase (LDH) activity increased. CONCLUSION: A raised serum creatinine level and LDH activity are classic indicators of renal infarction. In addition, most patients have haematuria. Typical wedge-shaped perfusion defects are visible on a CT-scan with intravenous contrast. Timely diagnosis of renal infarction is important both for the prevention of recurrence of thromboembolic complications and for potential revascularisation. The diagnosis of renal infarction should be included in the differential diagnosis in patients with acute abdominal pain.

Clinical relevance of diagnosing vertebral fractures by vertebral fracture assessment.

Low bone mineral density and the presence of vertebral fractures are independent predictors for future vertebral and non-vertebral fractures. Combining the conventional measurement of bone mineral density of spine and hips with the morphometry of the thoracal and lumbar vertebrae on lateral images using dual energy x-ray absorptiometry scanners, a technique called vertebral fracture assessment, facilitates detection of vertebral fractures in those patients at older age and with clinical risk factors for osteoporosis. Particularly, the finding of one or more vertebral deformities in patients with osteopenia is clinically important, because this might prompt the start of anti-osteoporotic treatment.

Asthma in Medicaid managed care enrollees residing in New York City: results from a post-World Trade Center disaster survey.

The collapse of the World Trade Center on September 11, 2001, released a substantial amount of respiratory irritants into the air. To assess the asthma status of Medicaid managed care enrollees who may have been exposed, the New York State Department of Health, Office of Managed Care, conducted a mail survey among enrollees residing in New York City. All enrollees, aged 5-56 with persistent asthma before September 11, 2001, were surveyed during summer 2002. Administrative health service utilization data from the Medicaid Encounter Data System were used to validate and supplement survey responses. A total of 3,664 enrollees responded. Multivariate logistic regression models were developed to examine factors associated with self-reported worsened asthma post September 11, 2001, and with emergency department/inpatient hospitalizations related to asthma from September 11, 2001, through December 31, 2001. Forty-five percent of survey respondents reported worsened asthma post 9/11. Respondents who reported worsened asthma were significantly more likely to have utilized health services for asthma than those who reported stable or improved asthma. Residence in both lower Manhattan (adjusted OR = 2.28) and Western Brooklyn (adjusted OR = 2.40) were associated with self-reported worsened asthma. However, only residents of Western Brooklyn had an elevated odds ratio for emergency department/inpatient hospitalizations with diagnoses of asthma post 9/11 (adjusted OR = 1.52). Worsened asthma was reported by a significant proportion of this low-income, largely minority population and was associated with the location of residence. Results from this study provide guidance to health care organizations in the development of plans to ensure the health of people with asthma during disaster situations.

Looking for an accurate mirror: a model for the relationship between media use and anorexia.

Quantitative research suggests a relationship exists between anorexia and media messages which depict a "thin-ideal" female stereotype. Despite growing support for that relationship, little is known about the psychological processes and mechanisms involved in that relationship. This study used qualitative methods to explore those processes and mechanism to create a model for understanding the relationship between anorexia and media use. Interviews from 28 female participants were analyzed and coded for temporal, situational, and motivational relationships between the anorexic behaviors and media use. Results suggest an interactive, circular model similar to models used to explain other compulsive and addictive processes.