Today's generation is facing an increased prevalence of overweight and obesity. It may be genetic or habitual due to overeating of junk foods and sedentary lifestyle. It directly affects an individual personality and health. The main aim of this study is to find out the prevalence of overweight among medical students in a tertiary care center.This is a descriptive cross-sectional study done in 385 students in a tertiary care hospital from 25th January 2020 to 28th February 2021. The sample was collected by simple random sampling method after the approval from the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital. Height in meter and weight in kilogram of students were measured to calculate body mass index. Data were analyzed by using Statistical Package of Social Science software version 16. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.Among 385 students, 75 (19.48%)  were overweight. Fifty-seven (14.85%) males and 18 (4.69%) females were overweight respectively. In total, there were 197 (51.01%) males and 188 (48.99%) females.The current study shows the prevalence of overweight among medical students is slightly higher than in studies done in similar settings. The body condition with excessive or abnormal fat accumulation is overweight and obesity.4 Nowadays, people with any age group, gender, ethnicity and socio-economic background are equally affected.5 But, there are insufficient data of overweight among Nepalese medical students.Overweight is not just aesthetic consideration. The metabolic changes can lead to serious health problems and increase risk of diseases like diabetes mellitus, hypertension, orthopedic complications, psychological disorders etc.Overweight and obesity are common physical problems. So, the objective of this study is to find out the prevalence of overweight among medical students in a tertiary care center.A descriptive cross-sectional study was carried out among undergraduate healthy medical students, aged between 17 to 25 years, in the Department of Physiology of Kathmanduth Jan 2020 to 28th Feb 2021 with approval of the Institutional Review Committee (IRC) of Kathmandu Medical College and Teaching Hospital (reference number: 130120204). The sample was selected by a simple random sampling method. The sample size was calculated by using the following formula,Medical College and Teaching Hospital. The study was started from 252 × p × q / e2n = Z2 × 0.5 × 0.5 / (0.05)2  = (1.96)  = 385where,n = sample size,Z = 1.96 for 95% Confidence Interval (CI),p = prevalence of overweight for maximum sample size, 50%q = 1-pe = margin of error, 5%Based on the above formula, the minimum sample size was 385.2. According to WHO , "Asian Criteria" for BMI cut off point 23-24.99 is overweight, pre-obese ≥25-29.9 and obese ≥ 30. This "Asian Criteria" is used to analyze overweight and obesity in this study.Height in meter and weight in kilogram (kg) of students were measured to calculate Body Mass Index (BMI) by Prestige height and weight measuring scale (Stadiometer). The formula, weight in kg divided by height in meter square was used to calculate the BMI and unit is kg/mData was analyzed by using Statistical Package of Social Science (SPSS) software version 16. Point estimate at 95% CI was calculated along with frequency and proportion and subgroup analysis was done on the basis of gender.In the present study, total 385 students, 75 (19.48%)  were overweight and mean age was 19.95±1.18 .In total, overweight males were 57 (14.81%) and females were 18 (4.67%) respectively. In total, male 197 (51.01%) and female 188 (48.99%) were assessed for BMI for being overweight .6 Another study by Deotale M. had much less prevalence of overweight (9.3%) in medical students.7 A study by Rui Wang showed higher range of overweight (32.3%) than present study which was done in adult population. But the gender specific result was similar higher among male (34.3%) than female (30.2%).8 Kumar A. study showed contrast result of overweight in fifth batch male students, low (1%) than female students (4.9%) but similar finding was there in IVth batch students, overweight male (12.15%) and females were (4.9%).9 Similar result was reported by Thomas E 39.8% overweight in boys and 25.5% in girls. Male showed more prevalence with overweight than girls.10In our findings, the prevalence of overweight was slightly higher than a study done by Kishore S, the study showed 14.6% medical students were overweight.1 Magda Antal 19.6% in girls and 18.1% boys.11In contrast to the current study, the prevalence of overweight is higher in females by Gopalkrishnan 15.7% and 13.7% males.12 Rabanales-Sotos J study showed a bit higher overweight 26.5% than current study13 and Khan ZN showed 10.2% overweight students.14A study by Gabriel L has similar result of overweight 20.26%.This study was conducted only in basic science medical students of an institute Kathmandu Medical College, there were some limitations of the study. The study is confined only to medical students with similar age group and socio-economic backgrounds, so, the result cannot be generalized in population. The larger sample size, wider range of age and socio-economic, education background might have greater value in research.The current study shows the prevalence of overweight students is a bit higher than other similar studies in students. The male students show a higher rate of overweight than female students. It suggests that the prevalence of overweight is gender specific. But a person's age factors, stress level, day to day habits like exercise and eating can influence it. Overweight can lead to serious health problems and can increase the risk of many diseases like diabetes mellitus, hypertension, psychological disorders and many more. If the students can be counseled about the importance of normal BMI and healthy habits, many serious health issues can be avoided.


It is not clear whether pre-existing macrovascular complications  are associated with health outcomes in people with diabetes mellitus hospitalized for COVID-19.We conducted cohort studies of adults with pre-existing diabetes hospitalized for COVID-19 infection in the UK, France, and Spain during the early phase of the pandemic (between March 2020—October 2020). Logistic regression models adjusted for demographic factors and other comorbidities were used to determine associations between previous macrovascular disease and relevant clinical outcomes: mortality, intensive care unit (ICU) admission and use of invasive mechanical ventilation (IMV) during the hospitalization. Output from individual logistic regression models for each cohort was combined in a meta-analysis.2 of 60%, reduced after adjustments for age, sex, type of diabetes, hypertension, microvascular disease, ethnicity, and BMI to adjusted OR 1.53 [95% CI 1.29–1.81]) for the three cohorts. Further analysis revealed that ischemic heart disease and cerebrovascular disease were the main contributors of adverse outcomes. However, proportions of people admitted to ICU  and the use of IMV during hospitalization  were significantly lower for people with previous macrovascular disease.Complete data were available for 4,106 (60.4%) individuals. Of these, 1,652 (40.2%) had any prior macrovascular disease of whom 28.5% of patients died. Mortality was higher for people with compared to those without previous macrovascular disease (37.7% vs 22.4%). The combined crude odds ratio (OR) for previous macrovascular disease and mortality for all four cohorts was 2.12 (95% CI 1.83–2.45 with an IThis large multinational study of people with diabetes mellitus hospitalized for COVID-19 demonstrates that previous macrovascular disease is associated with higher mortality and lower proportions admitted to ICU and treated with IMV during hospitalization suggesting selective admission criteria. Our findings highlight the importance correctly assess the prognosis and intensive monitoring in this high-risk group of patients and emphasize the need to design specific public health programs aimed to prevent SARS-CoV-2 infection in this subgroup.The online version contains supplementary material available at 10.1186/s12933-022-01657-8. The case fatality for COVID-19 has been estimated to be 0.5–1.0% )  people died. Mortality was higher for people with compared to without previous macrovascular disease (37.7% vs 22.4%). The combined crude odds ratio (OR) for previous macrovascular disease and mortality was 2.12 (95% CI 1.83–2.45) . In the multivariable analyses, the estimates were similar after adjusting for age and sex (model 1: OR 0.61 [95% CI 0.49–0.77]) . In the multivariable analyses, the results were similar after adjusting for age and sex (model 1: OR 0.63 [95% CI 0.47–0.85])  were admitted to ICU, and 306  required IMV during hospitalization. The proportions admitted to ICU or treated with IMV during hospitalization were lower for those patients with previous macrovascular disease . The overall odds ratio (OR) for previous macrovascular disease and ICU admission was 0.48 (95% CI 0.31–0.75) in the unadjusted analyses  was associated with higher mortality. These findings remain significant after further adjustments for age, sex, type of diabetes, arterial hypertension, microvascular disease, ethnicity, and BMI. However, the proportions admitted to ICU and treated with IMV during hospitalization were lower for patients with previous macrovascular disease, reflecting clinical decisions around ICU admission.COVID-19 is known to be associated with poorer outcomes for those with long-term conditions such as diabetes, and several potential mechanisms have been proposed . MoreoveA recent meta-analysis, including 158 observational studies with a total of 270,212 participants, of whom 57,801 had diabetes, reported that people with diabetes were at higher risk of COVID-19-related mortality with an OR 1.87 (95% CI 1.61–2.17) and higher risk of ICU admission (1.59 [95% CI 1.15–2.18]) and ventilation requirements (1.44 [95% CI 1.20–1.73]) in comparison to subjects without diabetes . In addi2 vs. 27.6 kg/m2), the mean HbA1c (8.1% vs. 7.7%), which may partially explain the different results regarding the outcomes ), history of hospital admission with diabetic ketoacidosis (OR 2.87 [95% CI 1.85–4.46]), microalbuminuria (OR 1.35 [95% CI 1.16–1.58]), macroalbuminuria 1.92 [95% CI 1.52–2.43]) and severe retinopathy (OR 1.92 [95% CI 1.52–2.43]) . The COR–2.75), houtcomes –15, 19. Our study is limited by the heterogeneity of data collection methods across the nations due to the use of databases that were designed separately and not specifically to answer the study question and, also by missing data. The meta-analysis combines the individual datasets to increase power but masks heterogeneity across nations. The relatively large proportion of people with missing data on one or more variables in the UK and French cohorts has occurred as a consequence of using routinely collected data from clinical practice and could introduce bias if data are not missing at random. As shown in Table In conclusion, this large multinational study of people with diabetes mellitus hospitalized for COVID-19 demonstrates significant associations between previous macrovascular disease and higher mortality and with lower ICU admission and the use of IMV during hospitalization. This study is the first specifically designed to evaluate the association of macrovascular complications  as main exposure with mortality, intensive care unit admission and mechanical ventilation in people with diabetes mellitus hospitalized for COVID-19 in Europe. Our findings highlight the importance correctly assess the prognosis and intensive monitoring in this high-risk group of patients and emphasize the need to design specific public health programs aimed to prevent SARS-CoV-2 infection in this subgroup (i.e. reinforcing vaccination campaigns). Nevertheless, further studies are required to confirm and extend these findings in these and other populations.Additional file 1: Figure S1. Odds ratio for the association between mortality (1A–C), intensive care unit admission (2A–C) and use of invasive mechanical ventilation during the hospitalization (3A–C) and ischemic heart disease in each of the four cohorts and overall. I2 indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C).Additional file 2: Figure S2. Odds ratio for the association between mortality (1A–C), intensive care unit admission (2A–C) and and stroke in each of the four cohorts and overall. I2 indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C).Additional file 3: Figure S3. Odds ratio for the association between mortality (1A–C), intensive care unit admission (2A–C) and peripheral artery disease in each of the four cohorts and overall. I2 indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C).


COVID-19 pandemic has a massively adverse mental health impact and people with pre-existing psychiatric illnesses are one of the most severely affected groups. We intended to study the changes in the patient profile in a psychiatric hospital during the COVID-19 pandemic, comparing it to the period just before the pandemic.Consecutive patients (n = 210) admitted to psychiatric ward under one team during COVID-19 pandemic (February 2020 to January 2022) were compared with patients (n = 234) admitted in the immediate pre-pandemic period (January 2017 to January 2020). Demographic  and clinical variables  were collected from the electronic patient records and analysed.During the pandemic monthly admission rates have gone up by 38.1% over the base rate of 6.32/month. There was no difference in the mean age at admission; or the proportion of patients aged 18–40 years or above in the pre-pandemic and pandemic groups. Similarly the gender composition of patients in the two periods was comparable. Proportion of patients from Asian background increased from 7.7% to 16.8% during pandemic period (p < 0.05). The number of hospital days decreased from 31.97 ± 45.8 days in the pre-pandemic period to 22.44 ± 25.1 days during pandemic (p < 0.05). Along with increased admission rates, it suggested a rapid flow of the admission and discharge during the pandemic. Considering diagnostic composition between pre-COVID-19 and COVID-19 periods, psychotic (27.8% v 26.7%) and mood disorders (18.8% v 23.3%) were the predominant; and substance related disorders (20.5% v 16.7%) were the most common comorbidities. Risk to self was associated with 84.3% admissions during the pandemic compared to 78.6% in the pre-pandemic period; however, risk to others was noted in 13.8% v 22.2% (p < 0.01) respectively. There was no difference in proportions getting admitted under Mental Health Act or being discharged with Community Treatment Order. Interestingly, proportions of patients getting discharged under the care of Home Treatment Team decreased from 31.1% pre-pandemic to 16.5% during pandemic period (p < 0.005).There is an increase in admission rate and decrease in the number of admission days, suggestive of increased demand of clinical resources during pandemic. This could be reflective of the stressful situation and adverse impact on mental health in the pandemic period. As the impact on mental health is expected to continue, there is a need for greater resources both in community and inpatient psychiatric services.


In 2015 a co-operation between the social insurance and the organized sport has been established in order to install Jackpot.fit, a standardized sports club based program, initially in 8 regions in Styria, a federal state of Austria. Inactive adults receive information about the long-term exercise program during a 3-week residential stay in a health resort. We aim to investigate who attends Jackpot.fit, the adherence to the program in 2019 as well as the progress of dissemination of Jackpot.fit since 2016.Participantś personal data were collected by telephone at the registration. Instructors documented the participants' attendance each single session with a standardized form. The number of participating regions as well as courses within the regions were monitored by the evaluator.SD = 9.1 years; BMI = 25.8, SD = 4.3 kg/m2) registered for Jackpot.fit and 84.3% (n = 2212) attended as participants in at least one session. Between September and December 2019, 824 people registered for the courses with an adherence rate as follows: 291 (35.3%) visited 75% or more, 200 (24.3%) between 50% and 74.9% and 232 (28.2%) less than 49.9% of all 638 provided sessions. 101 (12.3%) registered but never attended once. The number of regions rose from 8 in 2016 to 28 in 2019 and the number of courses from 25 to 55 over the same period.Between 2016 and 2019 2624 people (70.8% female; age: M = 57.1, According to the total number of participants, regions, and courses the dissemination moves forward. Further strategies to improve adherence must be developed.The project is supported by the Gesundheitsfonds Steiermark and the Bundessport Förderungsfonds.


The aim of this survey is to investigate T1DM patients’ expectations for and requirements of an ideal mobile self-management app with a special focus on functions for sports and exercise.A total of 251 persons participated in the survey. After checking for completeness and plausibility, the answers of 167 patients diagnosed with T1DM  were analyzed.The key features/aspects that were identified as being “rather important”/”very important” by more than 75% of respondents are: data security (96.4%), integration of further health data  from other apps already installed on their smartphone (92.2%), automatic import of glucose data from other apps (91.6%), individual target setting (87.4%), warnings about abnormal glucose levels (82.6%), warnings about other abnormal health data (81.4%), diary function (80.8%), information on the training session after the workout (80.8%) and displaying/processing of further fitness variables  from other health-related wearable systems (77.8%).This study identifies the most relevant features of an ideal self-management app with functions for sports and exercise targeted at patients with T1DM that should be considered in the development of such an app. The progress of digitalization has a significant impact on the management of diabetes mellitus. The American Diabetes Association (ADA) divides diabetes technology into two basic categories: for administration of insulin, e.g., via insulin pens or pumps, and for the analysis of glucose concentrations, e.g., via glucose meters or continuous glucose monitors (CGM) . DiabeteMany glucose measurement and insulin administration systems can be controlled via mobile apps, and even the range of functions of initially analog devices, such as insulin pens, is widening through digitalization and interconnectivity . In factHowever, independent of diabetes management devices, there are numerous  available mHealth apps for diabetes mellitus patients –5. mHealIdeally, diabetes mobile apps support users in managing their disease and in preventing diabetes-related complications, thereby improving their overall quality of life. Numerous meta-analyses and systematic reviews have shown potential benefits of mHealth apps on glycemic control in patients with diabetes mellitus, resulting in a reduction of glycated hemoglobin (HbA1c) levels , 6–11. IRegular physical activity is an elementary part of a healthy lifestyle for both T1DM and T2DM patients . RegularManaging diabetes is a complex, lifelong task that impacts all areas of life. Among others, mHealth apps for diabetes include the following management tasks: glucose monitoring, insulin delivery, nutrition, physical activity, facilitation of communication with healthcare providers or diabetes support groups, and education –4, 15.Available apps usually only cover between one and three of the above mentioned diabetes management tools, but not the entire range , 15. PatThe quantitative survey was conducted among T1DM patients. An online version of the questionnaire was made available on “surveymonkey.com”. It took approximately 10 min to complete the questionnaire. Data were collected in Germany over a 3-month period from October to December 2019.For inclusion in the survey, participants had to be diagnosed with T1DM. No further exclusion criteria were defined to elicit the highest possible number of responses. Recruitment took place via leaflets in outpatient diabetes treatment and education centers and social media. All subjects participated voluntarily without monetary incentive and provided informed consent for inclusion in the study.To conceptualize the questionnaire, existing diabetes apps were analyzed in terms of functions and content. The top three rated apps available from the Apple App Store were used. We reviewed the functions each individual app includes to facilitate day-to-day diabetes management and what types of diabetes-specific content  are available. The final questionnaire was constructed based on these findings. For the assessment of statements, 4-point Likert rating scales were used . The Int® 2016 for Windows .Before conducting the statistical analyses, the participants’ responses were checked for plausibility. Implausible or inconsistent answers were not considered in further analyses. The collected data were analyzed descriptively. Values are expressed as mean values ± standard deviation or as mean values and 95% confidence interval (95%-CI). In the evaluation, functions which were rated as “rather important” or “very important” by at least 75% of the participants were deemed particularly relevant. The graphs were prepared using Microsoft Office ExcelThe study was in accordance with the regulations of the Ethics Committee of the IST University of Applied Sciences and the guidelines of the Declaration of Helsinki. Patients gave their informed consent by clicking on the webpage. The patient data and responses were recorded anonymously.A total of 251 subjects participated in the survey. After verifying the inclusion criteria and completing a plausibility check, 167 respondents were included in the analyses. Reasons for exclusion were either missing T1DM as well as incomplete or inconsistent responses. Among the included subjects, 65.9% were female and 34.1% were male. The mean age of the sample was 33 ± 12 years (min-max: 8–65 years). The majority of respondents were employees (61.7%), and 6.0% were self-employed. Among the participants, 16.2% were university students at the time of the survey. One respondent (0.6%) was retired. The remaining participants (15.6%) had other employment, such as school pupil or homemaker. The monthly net income of 58.1% of participants was between EUR 1,000 and EUR 3,000. 18.6% reported a lower and 10.2% a higher monthly net income. 13.2% did not provide any information.In terms of physical activity, most participants described themselves as casual exercisers with 1–2 workouts per week (43.1%) or recreational exercisers with 3–4 workouts per week (40.1%). 4.2% of the participants described themselves as competitive athletes (daily training), 12.6% were non-active persons. 41.9% spent 1–3 h per week engaging in physical activity, 28.1% 3–5 h and 19.2% even more than 5 h per week. Only 10.8% of participants engaged in physical activity of less than 1 h per week. 7.2% worked in the field of sports as trainers /coaches.A total of 79.0% of participants said their diet was extremely healthy (3.0%) or somewhat healthy (76.0%), while 21.0% stated that their diet was somewhat unhealthy. No one rated his/her diet as unhealthy. The majority of participants were non-smokers (80.8%), while 19.2% smoked regularly (10.8%) or at least occasionally (8.4%).64.7% of participants used CGM systems exclusively to monitor and control their glucose concentrations, while only 9.6% used glucose meters exclusively. All other participants used a mix of different glucose measurement options.Most participants were users of either Apple iOS (41.3%) or Google Android (58.1%). The number of smartphone apps used by the respondents ranged from 1 to 10 (25.1%), 11–20 (30.5%), 21–30 (26.3%), 31–40 (12.0%), or was over 40 (6.0%).Most of them  strongly agreed or rather agreed with the statement that there is a general need for a sports health app specifically for T1DM patients. 73.1% (95% CI: 66.4 – 79.8%) affirmed that they had a personal need for such an application. The fields of application (multiple answers possible) ranged from “use in sports” , “use at work”  or “use in private daily life” , and “use on vacation” . In this regard, 48.5% (95% CI: 40.9 – 56.1%) would use the application at least once a day. 37.7% (95% CI: 30.3 – 45.1%) would use it several times a week, while 13.8% (95% CI: 8.5 – 19.0%) would use it less than 3 times a week.The maximum price the majority of respondents would pay for such a sports health application ranged from EUR 1–10 , EUR 5–10 ). 8.4% (95% CI: 4.2 – 12.6%) would want to spend less, and 9.6% (95% CI: 5.1 – 14.0%) would spend more money on it. The remaining 11.4% (95% CI: 6.6 − 16.2%) would not purchase such an app at all.The expectations of and requirements for such a sports health app were mainly determined using 4-point Likert rating scales: 1) not at all important, 2) rather unimportant, 3) rather important, (4) very important. Based on the numerical rating, the mean values of the individual statements were calculated and are presented together with the proportional distribution in Figs.  not at a rather u rather iThe key features/aspects that were deemed “rather important”/”very important” by over 75% of respondents were: data security (96.4%), integration of further health data  from other apps on their smartphone (92.2%), automatic import of glucose data from other apps (91.6%), individual target setting (87.4%), warnings about abnormal glucose levels (82.6%), warnings about other abnormal health data (81.4%), diary function (80.8%), information on the completed training session (80.8%) and displaying/processing of further fitness variables  from other health-related wearable systems (77.8%).The survey results provide useful information on desirable features of a T1DM self-management app with functions for sports and exercise.The survey identified a glucose diary as one of the desirable key functions of a self-management app for diabetes mellitus, which is in line with another survey on diabetes self-management apps . In thatIndividual target setting  and app support in assessing health data seem to be of particular interest for the participants. It is important for many participants to be able to individually set reminders, notifications and warnings. These functions have also been identified as key features in another study and in addition to reminders for glucose measurement or insulin delivery or doctor’s visits .The respondents first and foremost expect a comprehensive sports and health app for T1DM patients to integrate relevant health and fitness variables  and to provide individualized and up-to-date support to manage their disease. Although the education and support feature was also rated as an important feature by the participants in this study as well as in a comparable study , only feDecision support on the current evidence base is one of the major problems of many diabetes apps. Diabetes mobile apps are mostly unregulated –4, 20–22The lack of regulation also has an impact on data security. A high level of data security is a key factor in a digital world  and was Many T1DM patients seek support for sports and physical exercise. In healthy individuals, smartphone-based physical activity interventions appear to have positive effects on improving physical and psychosocial factors . For indThe respondents’ ratings of motivational features such as a virtual (diabetes) coach, challenges or a reward system were ambivalent. Some of the respondents considered them to be quite inspiring or could at least imagine that such features might motivate users to pursue a healthy lifestyle, even if they themselves would not use them. Others, however, saw no need for the inclusion of motivational features or expressed concerns about social pressure, frustration and data privacy.The relatively narrow confidence intervals calculated in this study show a comparatively low degree of uncertainty for estimates in the true population.Some limitations must be considered. One of the limitations of this study is the wide age range of the participants, which at the same time covers a large group of potential users. It is irrefutable, however, that 8-year old patients cannot be compared to 65-year-old patients in terms of application use.Although numerous factors were considered that may have influenced response behavior, some may be missing .Future research should focus on how the issues described can be addressed and implemented in the development of mHealth applications. Furthermore, once such a self-management app for T1DM patients has been developed, its effectiveness should be evaluated in clinical trials, which unfortunately has rarely been the case with the currently available mHealth apps for diabetes management .The results of this survey study illustrate that T1DM patients seek a diabetes health app that integrates many relevant factors and functions, such as glucose monitoring, insulin delivery, nutrition, physical activity, etc. in a single app and that allows for interoperability with other apps. Support during sports/ physical exercise is a key feature that should be considered in the development of an ideal app. A high level of data security must be guaranteed to prevent misuse of sensitive personal data.


Introduction: Primary spontaneous pneumothorax (PSP) is a common medical emergency. Its treatment includes simple observation, needle thoracentesis, pleural catheter, video-assisted thoracoscopy (VATS), and open surgery. We aimed to establish the demographic, clinical characteristics, and 12-month recurrence rate of patients with PSP in four hospitals of the Hamad Medical Corporation, Qatar.Materials and methods: We conducted a retrospective analysis of patients >14 years old who were admitted with PSP from January 1, 2017 to December 31, 2019. The patients were followed up for 12 months for the recurrence of PSP.2. Of these, 123 (51.2%) patients were smokers. Chest pain was the most common presenting complaint (82.5%). A total of 59 (23.98%) patients had a small pneumothorax, whereas 187 (76.01%) patients had a large pneumothorax.Results: Out of 246 patients enrolled in this study, 223 (90.7%) were males and 23 (9.3%) were females. Their mean age was 29.1 ± 9.59 years and their mean body mass index (BMI) was 21.7 ± 4.22 kg/mAmong the patients with small pneumothorax, 16 (28.33%) were managed through observation alone, 2 (3.33%) required needle aspiration, 15 (25%) required pleural catheter insertion, and 26 (44.06%) underwent surgical intervention for management. Out of 187 patients with large pneumothorax, 16 (8.6%) were managed through observation, 7 (3.76%) required needle aspiration, 73 (38.1%) required pleural catheter insertion, and 91 (48.6%) underwent surgery.During the 12-month follow-up, 58 patients were lost to follow-up and 5 patients  presented with a recurrence of PSP. Out of 108 patients who underwent VATS, 2 (1.85%) had a recurrence of PSP.Conclusion: PSP is more common in males than in females, with a tendency for younger age onset. The recurrence rate of PSP in our study was 2.66%. Furthermore, the recurrence rate in our patients who underwent VATS was 1.85%. Prospective studies are warranted to compare the success rates of different treatment interventions. It occurs more frequently in men than in women, possibly due to the differences in the associated risk factors, such as smoking and other lifestyle factors. The true incidence of primary spontaneous pneumothorax (PSP) in the expanding modern health system of Qatar remains unknown.Pneumothorax refers to the presence of air in the pleural cavity that leads to a variable degree of lung collapse. Pneumothorax has a significant burden on health systems across the world. The reported incidence of pneumothorax is 18–28/100 000 cases per annum for males and 1.2–6/100,000 for females.PSP is a common medical emergency, mainly affecting young adults who are tall and have a low BMI. It is called PSP, because, at the time of diagnosis, there is no apparent cause, including a trauma/iatrogenic or underlying lung disease. Secondary spontaneous pneumothorax (SSP) almost always occurs in older subjects with an underlying lung pathology or as a result of trauma. Due to the underlying lung pathology, SSP is more difficult to treat. Smoking is the most important modifiable risk factor for the development of PSP. Heavy smokers are therefore at a greater risk than light smokers. A Swedish study reported a 12% higher risk of PSP in smokers than in nonsmokers. The likely pathophysiological mechanism is smoking-induced inflammation. In addition, the reoccurrence of PSP is more common in smokers.The underlying etiology or risk factors that predispose PSP development include smoking, environmental factors, and genetic predisposition, which commonly manifests as apicomedial superficial bullae in the upper lobes. The demonstration of these apical pleural blebs/bullae on computed tomography (CT) or during thoracoscopic examination is approximately 90% in PSP.The most common symptoms include chest pain and shortness of breath. However, patients with small PSP ( < 2 cm at the level of hilum on chest X-ray (CXR) may have minimal or no symptoms. The clinical signs are variable and may include tachycardia, tachypnea, hypoxemia, and reduced breath sounds. Shifted trachea, which is a sign of large or tension pneumothorax, is rare in PSP. The assessment of the severity of PSP is variable among different leading professional medical societies. For instance, the British Thoracic Society defines a “large” pneumothorax as one with a visible rim of pneumothorax >2 cm at the level of hila, between the chest wall and lung margin (>50% of the hemithorax volume involved)  .8 The Different treatment modalities are available, and practices vary among clinicians, institutions, and even according to professional societies’ guidelines. The prescribed treatment may include simple observation with supplemental oxygen, large-bore needle thoracentesis, intercostal drain (ICD) placement, or video-assisted thoracoscopy (VATS).Importantly, Qatar has a population of 2.9 million with expatriates comprising 88% of the total population. Males dominate the population in terms of numbers (74.9%) due to the presence of several expatriate workers, which increases the cumulative population at risk of developing PSP in Qatar.We conducted a cross-sectional, retrospective analysis of patients who were admitted to one of the four hospitals of Hamad Medical Corporation, Qatar, and were diagnosed with PSP from January 2017 to December 2019.The primary outcome of the study was the recurrence of pneumothorax within 12 months after the first episode of PSP. The secondary outcomes included any association between age and recurrence, BMI and recurrence, characteristics of patients with recurrence, and management strategies in patients with recurrence.All patients of age >14 years who were diagnosed with PSP and admitted to one of the four hospitals of Hamad Medical Corporation, Qatar, between January 2017 to December 2019 were included in the study.Patients aged < 14 years and those with SSP were excluded from the study.Data of patients who were diagnosed with PSP between 2017 and 2019 were abstracted from the electronic records of the Hamad Medical Corporation patient data repository. Data collected included demographics such as age, gender, ethnicity, body mass index (BMI), and comorbid conditions. Data related to patients’ pneumothorax included the size of pneumothorax on CXR, the types of interventions performed, and the recurrence of pneumothorax within 12 months of intervention.Descriptive statistics were applied to describe the study cohort's demographic parameters, with continuous variables presented as the means ±  standard deviation or median (interquartile range), as deemed appropriate. In contrast, categorical variables were presented as numbers (percentages). All data were analyzed using the Jamovi version 1.2 .The ethical approval for the study was provided by the Medical Research Center 2. A total of 123 (51.2%) patients were smokers, 103 (42.9%) were nonsmokers, and 14 (5.8%) patients were exsmokers. In terms of comorbidities, only 6 (2.4%) patients had hypertension and 1 (0.4%) had diabetes mellitus  were males and 23 (9.3%) were females. A total of 90 (36.6%) patients were Qatari and 156 (63.4%) were non-Qatari. Their mean age was 29.1 ± 9.59 years and their mean BMI was 21.7 ± 4.22 kg/mmellitus .Chest pain was the most common presenting complaint (82.5%), followed by shortness of breath (55.5%) and cough (17.1%). A total of 59 (23.98) patients had small ( < 2 cm) pneumothorax on the CXR, whereas 187 (76.01%) patients had a large pneumothorax (>2 cm) on the CXR. A total of 35 (14.2%) patients had blebs, while 64 (26.01%) had bullae on the CT thorax .p < 0.0001, CI 2.43–5.61).Among the patients with small pneumothorax, 16 (28.33%) were managed successfully with observation alone, while 2 (3.33%) were treated with needle aspiration, 15 (25%) were managed with a pleural catheter insertion, and 26 (44.06%) required surgical intervention for management . On the 2. Two patients had a history of smoking, while the other 3 were nonsmokers. A statistically significant association was observed between lower age and recurrence (p < 0.001). No such association was observed between BMI and the risk of recurrence. Out of 5 patients with recurrence, 1 had an initial small pneumothorax, while the remaining 4 had large initial pneumothoraces. In 2 patients, the initial large pneumothorax episodes were managed through observation alone. The recurrent episodes were successfully managed with pleural catheter insertion. One patient  had a recurrence involving both lungs. This bilateral pneumothorax was managed in this patient successfully, with bilateral pleural catheter insertion . In 4 of these cases, the recurrence was ipsilateral, while the fifth patient developed bilateral pneumothorax during recurrence. Of the 5, 2 patients were males and 3 were females. Their mean age was 23.8 ± 9.311 years, while their mean BMI was 22.382 ± 3.99 kg/mnsertion .Two patients had a recurrence of pneumothorax after the VAT. One of them had a history of right-sided pneumothorax in 2013, which required VATS performed outside Qatar , which is higher than the global sex ratio. This can be attributed to the peculiar demographic distribution of the population in Qatar, with the majority being young male adult workers from South East Asia. Pneumothorax is more common among males than females because smoking is more prevalent among males, and males start smoking earlier than females. As males have smaller airways than females, airway obstruction, which is characteristic of pneumothorax, may manifest earlier in them. Smoking increases the risk of developing PSP by 22-fold in males. In a Qatar-based study conducted by AlMulla et al., the prevalence of current tobacco use among adult Qataris and non-Qataris was 25.2% and 21.5%, respectively. In another study by Vishal, tobacco use was significantly higher among males (10%) than among females (1.1%). These results may explain the high prevalence of PSP among males in Qatar. Furthermore, in our cohort, 67.8% of Qatari patients were active smokers, while 39.7% of expatriates were active smokers at the time of diagnosis of PSP, with the difference in two proportions being statistically significant (p < 0.001).PSP is more common in men than women, with literature reporting a male-to-female ratio of up to 3.3:1. Paoloni et al. reported that 32% patient of PSP were managed with observation, 20% with aspiration, and 48% with pleural catheter/ICD insertion. In our study, 13% of patients were managed with observation alone, 3.65% with needle aspiration alone, 35.8% with pleural catheter insertion, and 47.6% through definitive management.In a study of 153 patients with spontaneous pneumothorax, 9 patients were initially managed with aspiration alone, 6 with aspiration followed by pleural catheter insertion, 14 with observation, and 124 with pleural catheter insertion. concluded that the recurrence rate in PSP was 32% with a mean duration of follow-up of 3–96 months. A study from Kuwait showed a recurrence rate of 34.6%, with approximately 62.5% of these recurrences occurring within the first year. Our study found that the rate of recurrence was 2.66% in the first year following PSP. An association between BMI and the risk of PSP recurrence remains controversial. A retrospective cohort study conducted by Tan et al. reported that the association between low BMI and the risk of recurrence was statistically significant. Olesen et al. also reported a low body weight ( < 60 kg) as an independent risk factor associated with recurrence. Noh et al. reported no such association between BMI and the risk of recurrence. In our study, no statistically significant association was recorded between BMI and the risk of recurrence.Past studies have reported different rates of recurrence in patients with PSP. A meta-analysis of 29 studies, conducted by Walker et al. reported a more significant proportion of patients having a recurrence of PSP in patients belonging to the younger age group. Noh et al. also reported a higher recurrence rate in younger patients with PSP who underwent wedge resection. In our study too, lower age was associated with an increased risk of recurrence. However, the sample size of patients with recurrence in our study was too small to detect any such difference.Several studies have reported younger age as a risk factor for the recurrence of PSP. Huang et al. In our cohort of patients, VATS was the most frequently performed surgical intervention . At our institution, VATS for PSP invariably involved bullectomy with parietal pleurectomy of the upper hemithorax and scratch pad abrasion of the lower half of the hemithorax. VATS has been reported to be the most common surgical procedure by other studies as well. VATS as a treatment modality after the first episode of PSP has been reported to be safe, with low morbidity, reduced length of stay in the hospital, and better patient satisfaction by several studies.After the first episode, indications for surgical management of PSP included people belonging to high-risk professions  or those living long distances from the nearest hospital. VATS is the surgical procedure of choice by most thoracic surgeons. Tan et al. also reported the risk of recurrence to be significantly lower in patients who had preventive surgical intervention  when compared with those who were managed with nonpreventive interventions . Brysch et Al. reported the recurrence rate of PSP following VATS as 1.3%. Out of 108 patients who underwent VATS in our study, the recurrence rate was 1.85% (2 patients). The mean age in Qatari patients with PSP in our cohort was 25.5 ± 9.5 years. As per 2019 data, nearly 45.8% of the Qatari population belongs to this age group (15–34 years) and therefore are at risk of developing PSP. A low recurrence rate of PSP in our cohort is multifactorial, with the early definitive intervention being one of the factors.Definitive surgical management of PSP with VATS has been reported to have a lower risk of pneumothorax recurrence. A prospective study of 1415 patients reported the incidence of pneumothorax recurrence to be 1.9% after VATS.One major limitation of our study is the loss of follow-up of 58 (23.6%) patients, 38 (65.6%) of which were expatriates. This could be due to the expatriate workers leaving the country. However, it might affect the true recurrence rate of PSP in our study.PSP is more common in smokers, males, and in young adults. The recurrence rate of PSP in our study was 2.66%, which is significantly lower than the one reported in the literature. Furthermore, the recurrence rate in patients who underwent VATS was 1.85%. There is a possible association between lower age and an increased risk of recurrence of PSP. However, the sample size of patients with recurrence is very small and warrants studies with larger sample sizes.This work is original, has not been, and is not under consideration for publication in any other Journal. All authors have reviewed and approved the final version of the manuscript. The study was approved by the MRC Qatar.Available from the corresponding author upon reasonable request.The research protocol for the study was approved by the MRC at Hamad Medical Corporation with protocol ID number (MRC-01-20-836)None of the authors have any conflict of interest to disclose.


The aim of this national population-based, retrospective database study is to compare the comorbidity profiles of systemic lupus erythematosus (SLE) patients and general population controls matched for age, gender, and region and assess the risk of depression or anxiety when controlled for age, gender and adjusted for the Charlson Comorbidity Index (CCI).Claims data of 1051 patients diagnosed with SLE  from the Hungarian National Health Insurance Fund have been analyzed against matched controls (1:5 ratio) with a follow-up of 30 months. The first record of SLE diagnosis was considered the diagnosis date. The odds ratio (OR) and 99.9% confidence interval (CI) of having depression or anxiety among patients with SLE vs. controls have been assessed using logistic regression models.p<0.001], respectively). Both SLE patients and controls diagnosed with depression or anxiety had significantly higher CCI than those without comorbid depression or anxiety (p<0.001). However, SLE patients had a twofold higher risk of depression or anxiety than matched controls when controlled for age, gender, and adjusted for CCI.SLE patients report more comorbidities than the matched general population both in pre- and post-index periods (mean CCI 1.79 vs. 1.15 and 2.78 vs. 1.22 [both Our analysis indicates the enormity of comorbidity burden in SLE, especially that of anxiety and depression. The size and complexity of the comorbidity burden emphasizes the importance of early diagnosis and intervention with comprehensive modalities incorporating attention to comorbidities in SLE patients.The online version contains supplementary material available at 10.1186/s13075-022-02799-6. SLE patients show a 2.2-fold higher risk of depression or anxiety on controlling for age and gender and adjusting for the CCI.The complexity of the burden of the disease requires intervention with new and comprehensive treatment.Clinicians need to regularly evaluate SLE patients for symptoms of depression and anxiety.Systemic lupus erythematosus (SLE) is a chronic, heterogeneous systemic autoimmune disease associated with multiple clinical complications and comorbidities, which may lead to significant organ damage resulting in increased disease burden and mortality –3. Both The European Alliance of Associations for Rheumatology recommends prompt evaluation if comorbidities are suspected in a patient with SLE . CommonlSLE along with any presenting comorbidities may lead to pain , increasComorbid depression and anxiety are associated with low health-related quality of life (HRQoL) and greater work disability and economic burden in patients with SLE –21. TherDe-identified records were obtained from the longitudinal, nationwide database of the Hungarian National Health Insurance Fund (NHIF). This database contains detailed healthcare service records including patient-level demographic data as well as inpatient, outpatient, and prescription drug data for the whole population of Hungary (approximately 10 million people) and is linked by the social security number, a unique patient identifier that enables longitudinal patient pathway analysis.Act No. 80/1997 on mandatory health insurance coverage) and data access is provided for real-world analyses (based on Act 63/2012 on the re-use of public data). Only NHIF had direct access to patient-level data; other parties could only access the data indirectly through NHIF as per NHIF’s data privacy regulations. Due to this regulation, patient-level consent was not required for the analysis.The NHIF handles patient data based on law  code M32*  during tBased on the average amount of prednisone-equivalent steroid dose prescribed in the 6-month index period, patients were classified into four categories .The analysis was done based on the ethical approval of the Committee of Science and Research Ethics of the Medical Research Council of Hungary, approval number 53229-2/2018/EKU dated November 22, 2018.Patient population characteristics of interest included age, gender, comorbidities, age-adjusted CCI, and mortality. Comorbidities based on ICD-10 codes .We calculated means and standard deviations for continuous variables and counts and percentages for categorical variables. In the Base Case Analysis, we assessed the odds ratio (OR) of presence of a wide range of different comorbidities post index period, including depression and anxiety among patients with SLE vs. controls and among SLE patients on different steroid doses vs. no steroid use (with 99.9% CI) using a logistic regression model adjusted for age and gender. We considered each comorbidity independently of each other in separate models. As we aimed for a family-wise error rate of 5%, the comparison-wise alpha was chosen to be 0.1% based on the Bonferroni correction. In the Adjusted Analysis, we applied the above model only for depression and anxiety, with the logistic regression model adjusted for the CCI as well as age and gender. Pre-index CCI is used in the adjustment, to enable the assessment of a cause-and-effect-type relationship. In administrative healthcare data the missing data cannot be discovered, if a diagnosis or intervention is not recorded then imputation is not possible. Therefore, missing data handling was not performed. We performed all the statistical tests using R software . The post-index prevalence of depression, anxiety, and depression or anxiety in patients with SLE was 9.9%, 12.7%, and 17.8%, respectively (Table Rate of patients who were prescribed systemic corticosteroids within 2 years before their SLE diagnosis date was (56.6%); for whom the median time from treatment start to diagnosis was 13 months. After that, steroid use within 2 years after SLE diagnosis was recorded for 85.2% of patients, and 98.6% of the latter remained on steroids for at least one year. Other agents used within 2 years after diagnosis included hydroxychloroquine (46.4%), azathioprine (35.0%), and biologics (5.8%) with rituximab being the most frequently prescribed biologic. Detailed treatment pattern analysis could not be performed as data from inpatient care  were unavailable in the claims data.Based on the steroid use during the index period of 6 months, 19.8% of patients did not receive steroids and 19.0% received high-dose steroids Table .Table 2SCompared with matched controls, patients with SLE in the 2 years post-index period had a significantly greater risk of renal disease (OR 12.19 [99.9% CI 6.83–21.76]), anemia (OR 10.10 [99.9% CI 5.76–17.70]), osteoporosis (OR 7.82 [99.9% CI 5.64–10.84]), pulmonary diseases (OR 2.07 [99.9% CI 1.44–2.99]), liver disease (OR 7.47 [99.9% CI 2.27–24.59]), serious infections (OR 5.89 [99.9% CI 3.63–9.54]), epilepsy (OR 4.33 [99.9% CI 2.06–9.11]), lymphomas (OR 4.30 [99.9% CI 1.11–16.70]), congestive heart failure (OR 4.10 [99.9% CI 2.52–6.67]), other cardiovascular diseases (OR 3.74 [99.9% CI 2.86–4.89]), hypertension (OR 3.59 [99.9% CI 2.72–4.75]), cerebral vascular accident (OR 1.91 [99.9% CI 1.27–2.88]), peptic ulcer (OR 3.83 [99.9% CI 1.80–8.15]), endocrine gland disorders (OR 2.49 [99.9% CI 1.80–3.44]), hypothyroidism (OR 2.95 [99.9% CI 1.91–4.57]), other metabolic disorders (OR 2.25 [99.9% CI 1.68–3.00]), lipidaemia (OR 1.52 [99.9% CI 1.11–2.10]), depression or anxiety (OR 2.36 [99.9% CI 1.72–3.23]), and other mental disorders including dementia (OR 2.11 [99.9% CI 1.35–3.30]) (Supplementary Table SIn most cases (including anxiety and depression), we found no significant difference across any of the 4 strata of steroid treatments on the risk of comorbidities, except for anemia and renal disease. The group with no steroid treatment served as the reference group. Patients with SLE who received >20 mg/day steroid treatment during the index period had a significantly greater risk of presence of anemia (OR 2.83 99.9% CI 1.09–7.35]) and renal disease (OR 3.54 [99.9% CI 1.38–9.06]) in the 2-year post-index period. Patients on steroid doses of 0–7.5 mg/day and 7.5–20 mg/day did not have a significantly greater risk of these comorbidities p<0.001 for both; Supplementary Fig. SSLE patients and controls with depression or anxiety in the post-index period had greater CCI scores calculated before the index period compared with those who did not have comorbid depression or anxiety , anxiety , or both  in the post-index period, than the general population  and anxiety - 25.8% [95% CI 19.2–32.9%]) . Our resPatients with SLE in our study had greater chance of presenting the lymphomas, endocrine gland disorders, metabolic disorders, mental disorders, cardiovascular diseases, pulmonary diseases, renal disease, liver disease, and infections during the post-index periods than the matched controls. This comorbidity profile is comparable with published European data. A recent Finnish study analyzed data of patients with SLE and matched controls from 2000 to 2015 and reported comorbid cardiovascular diseases (33%), malignancies (27%), and neurological diseases (10%) present at diagnosis to be the leading causes of death . A full In our study, patients with SLE receiving a high steroid dose (>20 mg/day) had a greater risk of having anemia or renal disease compared with matched controls. It can mean that the severity of the disease was greater in these patients resulting in higher steroid use and therefore worse renal disease and anemia, but also that steroids may have been used to treat these. We found no difference in the risk of any of the other comorbidities among patients with different steroid doses. Although other studies have examined comorbidities as a function of steroid dose –39, the Comorbidities such as cardiovascular diseases , depressInfections and cardiovascular diseases are reported to be the leading causes of death in SLE –46. In tIn line with recent European guidelines , 50 thatThe main advantage of this study is the full population analysis which enables obtaining deep insights into the burden of SLE. Limited evidence exists on the complete comorbidity profile in patients with SLE with an emphasis on depression and anxiety. This study bridges the knowledge gap by analyzing patients and matched controls in a 1:5 ratio to obtain insights.There are some limitations of this study. The data were collected for health insurance reimbursement claims purposes and not for research. Data on the therapy used during hospitalization of patients with SLE  are unavailable. Hence, we cannot accurately determine the exact disease activity and severity and treatment patterns. No data was available on clinical details such as disease phenotype, disease severity, or patient-reported outcomes either. All comorbidities were identified through claims data; however, misdiagnosis might be possible. Some diagnoses may be present on prescriptions to enable the prescription of certain medications. This is especially true for depression and anxiety. Due to data handling regulations, we could not report patient-level data or aggregate data obtained from less than 10 patients (including patient numbers). This study utilizes claims data from Hungary, and findings may not be generalizable to other populations. When analyzing the effect of steroid dose on comorbidities, the amount of steroid prescribed may be influenced by comorbidities which were present pre-index which can cause confounding. this was not adjusted for in the analysis. Adjusting for the total CCI score in the final set of analyses may mask the influence of specific comorbidities.We observed that most comorbidities have a higher risk of being present in patients with SLE than in matched controls. The greatest risk increase was observed in renal disease, anemia, and osteoporosis. We also observed that depression and anxiety have a higher risk of being present in patients with SLE after controlling for the presence of other comorbidities, suggesting that depression and anxiety, at least partly, are not caused by the higher comorbid nature of SLE patients. Overall, the enormity of comorbidities specifically depression and anxiety emphasize the importance of early diagnosis and intervention incorporating attention to comorbidities in SLE patients.Additional file 1: Supplementary Table S1: Treatments for systemic lupus erythematosus. Abbreviation: ATC – Anatomical Therapeutic Chemical.Additional file 2: Supplementary Table S2: ICD-10 codes for comorbidities. Abbreviations: ICD-10 – International Classification of Diseases, 10th edition.Additional file 3: Supplementary Table S3: Calculation of CCI.Additional file 4: Supplementary Table S4: Risk of comorbidity in SLE patients within 2 years prior diagnosis date and within the 2 years post-index period.Additional file 5: Supplementary Figure S1: Odds ratio of presenting comorbidities within 2 years post-index period for patients with SLE who received different doses of steroids vs. those who did not receive steroids in the index period.Additional file 6: Supplementary Figure S2: Comparison of CCI prior to diagnosis date of individuals presenting depression or anxiety in the post-index period, within SLE patients and matched controls.


Human norovirus is a major virus that causes acute gastroenteritis in all age groups. Recently, norovirus recombinant strains have been reported as the cause of norovirus outbreaks. This study has investigated the distribution of norovirus genotypes and recombinant strains circulating in children hospitalized with diarrhea in Chiang Mai, Thailand from 2017 to 2018. A total of 882 stool specimens were tested for the presence of norovirus GI and GII by reverse transcription-PCR (RT-PCR) assay. Genotypes of the viruses were assessed by partial VP1 nucleotide sequencing and the representative strains were further characterized for norovirus recombinant strains by amplification of ORF1 (RdRp)/ORF2 (VP1 capsid) junction region. From a total of 882 stool samples, 131 (14.9%) were positive for norovirus, of which the majority of norovirus genogroups were norovirus GII, and only one was identified as norovirus GI. A wide variety of norovirus genotypes were detected in this study, including GI.5, GII.2, GII.3, GII.4, GII.6, GII.7, GII.13, GII.14, and GII.17 with the predominance of GII.2 (62.5%) in 2017 and GII.4 (57.0%) in 2018. Nevertheless, it should be noted that GII.4 remained the most predominant genotype (50.4%) in overall prevalence. Analysis of norovirus recombination revealed that several norovirus recombinant strains  had been identified with the predominance of GII.2[P16] in 2017 and changed to GII.4[P16] and GII.4[P31] in 2018. In conclusion, this study reported the detection of a wide variety of norovirus genotypes and several norovirus recombinant strains in Chiang Mai, Thailand from 2017 to 2018.IMPORTANCE In the present study, the prevalence of norovirus infection in children with acute gastroenteritis in Chiang Mai, Thailand between 2017 and 2018 was 14.9%. A variety of norovirus genotypes were detected, including GI.5, GII.2, GII.3, GII.4, GII.6, GII.7, GII.13, GII.14, and GII.17 with the predominance of GII.4 genotype. In addition, several norovirus recombinant strains  had been identified. Our results revealed that GII.2[P16] was a predominant strain till the end of 2017 and then was replaced by GII.4[P16] and GII.4[P31] in 2018. The findings imply that norovirus recombinant strains emerged in Chiang Mai, Thailand and that circulating strains changes over time. Norovirus, family Caliciviridae, is a small non-enveloped with a positive-sense, single-stranded RNA genome of approximately 7.3 to 8.3 kb in length  were positive for norovirus as shown in n = 66). All 66 strains of norovirus GII.4 were GII.4 Sydney variants that showed a close genetic relationship with other GII.4 Sydney variant strains reported previously worldwide with nucleotide sequence identities ranging from 80.7% to 96.9%. The nucleotide sequence identities among 66 GII.4 Sydney strains detected in this study ranging from 91.5% to 100%. The norovirus GII.13 strains, the second most common genotype detected in this study (n = 21), formed a cluster with norovirus GII.13 reference strains with nucleotide sequence identities ranging from 80.7 to 95.1% and showed close similarity sequences with GII.13 strains previously detected in 2017 from Australia and Russia. For norovirus GII.2 (n = 18), all of the strains detected in this study were located in the same branch and were closely related to norovirus GII.2 reference strains reported previously in 2016 and 2017 from Thailand and other GII.2 reference strains from Russia, Australia, and China with the nucleotide sequence identities ranging from 77.8 to 99.6%. Phylogenetic analysis of norovirus GII.6 (n = 11) strains demonstrated that they were closely related to GII.6 reference strains reported previously from Thailand and many countries worldwide including China, Taiwan, Australia, Brazil, and Cameroon with the nucleotide sequence identities ranging from 77.3 to 98.9%. It was observed that norovirus GII.6 strains detected in this study were phylogenetically separated into two clusters based on the year of specimen collection. The strains detected in 2017 were most closely related to the Thai norovirus GII.6 strain detected in Chiang Mai in 2011, while the strains detected in 2018 were clustered together with the norovirus GII.6 Australian strain isolated in 2016. Seven strains of norovirus GII.3 were most closely related to the norovirus GII.3 genotype reported previously from Thailand in 2011 and 2014, Bhutan in 2013 and 2014, and Australia in 2011, with the nucleotide sequence identities ranging from 71.8% to 98.6%. For norovirus GII.14, all five GII.14 strains detected in this study were located closely together in the same branch with norovirus GII.14 reference strains reported previously in 2016 and 2017 from Thailand, Australia, and Russia with the nucleotide sequence identities ranging from 79.6% to 97.8%. One norovirus GII.7 showed a close genetic relationship with GII.7 reference strains reported previously from Thailand, Japan, and Brazil with the nucleotide sequence identities ranging from 76.8% to 97.5%. In addition, one norovirus GII.17 detected in this study shared nucleotide sequence identities ranging from 78.%6 to 98.2% with norovirus GII.17 reference strains reported from Thailand, China, and Australia.The phylogenetic tree of the partial VP1 nucleotide sequences (295 nt) of norovirus GII detected in this study was constructed . The majP-values ranging from 9.2 × 10−14 to 1.7 × 10−2  norovirus GII were found to be recombinant strains. The ORF1/ORF2 junction sequences were analyzed by the SimPlot software and confirmed the recombination breakpoint by the RDP4 program. Seven norovirus recombination patterns including GII.2[P16], GII.3[P16], GII.4[P16], GII.4[P31], GII.6[P7], GII.13[P16], and GII.14[P7] were identified . Twelve 7 × 10−2 . AnalysiIn Thailand, norovirus infections in patients with acute gastroenteritis reported from 2000 to 2016 from several regions of Thailand revealed the overall prevalence of norovirus infection at 15.1% and the infection was more common in infants and young children than in adults . In the The continued surveillance study of norovirus in children with acute gastroenteritis in Chiang Mai has been conducted since 2000  and a wiRecombination is one of the mechanisms for the evolution of norovirus. The norovirus recombinant strains in pediatric patients with acute gastroenteritis in Chiang Mai, Thailand have been serially investigated from 2005 to 2015 . During 18–Surveillance of norovirus was carried out from March 2017 to December 2018 in children younger than 5 years old who were hospitalized with acute gastroenteritis in Chiang Mai, Thailand. A total of 882 stool samples were collected from children admitted to five provincial/sub-provincial hospitals. The inclusion criteria of acute gastroenteritis were sudden passages of loose or watery stools for more than three times per day with the exclusion of bloody stools. All stool samples were stored at −20°C until use. The study was conducted with the approval of the Institutional Research Ethics Committee of the Faculty of Medicine, Chiang Mai University (MIC-2557-02710), and written informed consent was obtained from the participants’ guardians.The viral RNA genome was extracted from the supernatant of 10% fecal suspension in phosphate‐buffered saline (PBS) pH 7.4 using a Geneaid Viral Nucleic Acid Extraction Kit II  according to the manufacturer’s protocol. Reverse transcription was performed using a RevertAid First Strand cDNA Synthesis Kit and random primer . The presence of noroviruses GI and GII were detected by PCR as described previously , 39, 40.To determine the potential recombination event of norovirus strains detected in this study, the partial ORF1 (RdRp)/ORF2 (VP1 capsid) junction region of norovirus strains obtained from norovirus-positive samples was amplified by semi-nested PCR. Briefly, the specific primers JV12Y and G2SKR were used for the first amplification to generate a PCR product size of 1,102 bp, and then semi-nested PCR was performed by using primers P290 and G2SKR to generate a PCR product size of 1,095 bp as described previously , 43. Thehttp://blast.ncbi.nlm.nih.gov/Blast.cgi). The VP1 capsid genotypes of noroviruses GI and GII were determined by using the Human Calicivirus Typing Tool (https://norovirus.ng.philab.cdc.gov/bctyping.html)  and subsequently sequenced . The nucleotide sequences obtained were analyzed using the ClustalX and the BioEdit software programs and then compared with those of other representative reference strains available in the GenBank database using the Basic Local Alignment Search Tool server (ng.html) , 7. The ng.html) . The evoOK598006 to OK598048.The nucleotide sequences of norovirus recombinant strains described in this study have been deposited in the GenBank database under the accession numbers:


With enhanced recovery after surgery protocols, it is now possible to decrease a patient’s length of stay in the hospital and administer adjuvant chemotherapy earlier than before. Our study analyzed 7056 patients who underwent a radical cystectomy and subsequent adjuvant chemotherapy to determine if an earlier timing of adjuvant chemotherapy would affect survival outcomes. We found that earlier time to adjuvant therapy showed a survival benefit, and a benefit persisted regardless of timing when compared to controls.®, Cochrane Central®, Scopus®, and Web of Science® library databases for original articles that looked at timing to adjuvant chemotherapy after radical cystectomy. Primary endpoints were five-year survival, progression free survival, and overall survival. Available multivariable hazard ratios and corresponding 95% CIs were included in the qualitative analysis. The risk of bias was completed for nonrandomized studies. (3) Results: Using PRISMA guidelines, our electronic search resulted in a total of 1862 records. After a detailed review, we selected four studies that addressed the impact of the timing of adjuvant chemotherapy for patients who underwent radical cystectomy. (4) Conclusion: A survival benefit was seen with an earlier administration of adjuvant chemotherapy, albeit a benefit persists for delayed chemotherapy post-radical cystectomy. A safe and ethical approach at this time would be to administer adjuvant chemotherapy as early in the postoperative period as possible, given the known survival benefit of such therapy .(1) Purpose: To assess the survival benefit for different times to adjuvant chemotherapy after a radical cystectomy. (2) Materials and Methods: We systematically searched PubMed The majority of patients had pT3-pT4 disease , and N+ disease . The mean time to AC (TTAC) was 10 weeks; individuals in the > 12 weeks group had inferior OS (HR 1.28 [1.00–1.62]) and cancer-specific survival (HR 1.30 [1.00–1.69]) than those who had a shorter time to AC after surgery. Cisplatin-based regimens were most commonly used (82%), to include gemcitabine-cisplatin (54% [n = 166]), and methotrexate, vinblastine, doxorubicin, cisplatin (21% [n = 66]). Carboplatin-based therapy was used in 17% (n = 43). Information on the dose, number of cycles, and patient-level chart information in 54% of cases (those not treated at a comprehensive cancer center) were not provided  at 31–60 days and 47% [n = 471] at 61–180 days post-RC) had a median income >$62,999  and pN1 disease  or pN2+ disease . A decreased likelihood of early AC initiation was seen in patients with increased age , a Comorbidity Score of 1 , and treatment at an Academic or Research Institution  ), and median survival by 9.5% at 5 years (37.5% [31.4–43.7]), 8.6% at 3 years (46.5% [40.3–52.4]), and 0.3% (85.6% [2.1–3.2)]) at 1 year. Receipt of AC after 45 days and no AC predicted worse OS compared to AC within 45 days  .n = 353) or placebo (n = 356). The median DFS in the nivolumab group was 20.8 months (16.5–27.6) compared to 10.8 months (8.3–13.9) in the control group. Patients alive and disease free at six months were 74.9% in the nivolumab group and 60.3% in the placebo cohort  [n = 406) or assigned patients to observation (n = 403) after they received a RC for MIBC (90%) or a nephroureterectomy with lymph node dissection (10%) for upper tract urothelial carcinoma. The median DFS in the atezolizumab group was 19.4 months (15.9–24.8) compared to 16.6 (11.2–24.8) for observation  [The rationale behind perioperative chemotherapy utilization in patients with MIBC is as follows: the presence of occult micrometastases cannot be accounted for in those with locally advanced disease, and surgery alone is insufficient for cancer control . Currentp = 0.01) [p = 0.017; I2 = 35.6%) and a shorter LOS  [The mean hospital stay after RC at most centers is as high as 9 to 11 days and even as high as 17.4 in a recent European series . In a re = 0.01) . In cont = 0.01) . The Uni = 0.01) . A systeDespite efforts to improve recovery and shorten the length of stay with the adoption of ERAS protocols, RC remains associated with significant morbidity . Donat eSternberg et al., published an intention-to-treat analysis of a multicenter phase 3 RCT in 2015, which aimed to compare survival trends in patients with pT3-T4 or N+ M0 MIBC who received immediate AC versus those who received deferred chemotherapy at relapse . PatientThree studies in this review showed a statistically significant survival benefit in patients post-RC when they received early AC compared to delayed chemotherapy. Four studies showed an increased survival benefit when receiving AC within 90 days . GrunewaAs noted in our review, chemotherapy regimens were heterogeneous in terms of types of drugs and number of cycles used, limiting the generalizability of the data. Prospective literature for AC in MIBC is sparse, and many studies have poor accrual or are underpowered . The neeData regarding the importance of postoperative timing for AC in MIBC is heterogeneous. Patients appear to show a survival benefit the earlier they receive AC, albeit a benefit persists even after receiving delayed AC or systemic treatment at relapse. Therefore, the general adoption of the 90-day window is arbitrary. Additional adequately powered prospective studies are needed to make a definitive conclusion regarding this topic. Nonetheless, given the known 9–11% absolute survival benefit at five years attributable to early TTAC in this cohort, an ethical approach would be maximizing recovery after surgery using ERAS protocols and administering AC as early as possible in the postoperative period.


Tobacco addiction among youth shows an increasing trend while smokeless type is becoming more common. This study aimed to describe the lifestyle of chewing smokeless tobacco among a group of high-risk youth population in Sri Lanka.Tobacco in any form kills millions of people every yearA descriptive cross-sectional study was conducted among a sample of 1431 youths aged between 15 to 24 years residing in urban slums in Colombo Sri Lanka, using a cluster sampling technique combined with probability proportionate to size technique. Data were collected using an interviewer-administered questionnaire. Chewing smokeless tobacco was assessed using betel quid chewing and commercially prepared tobacco and areca nut packet chewing. Current chewer was defined as who had the practice of chewing during past 30 days.The mean age of the study sample was 17.53 (95% CI: 17.40–17.65). Of the 1431 respondents, 57% were males and 43% were females. The prevalence of current smokeless tobacco chewers was 44.9% and among them 90.8% were males and 9.8% were females. Around 31.3% did not have smokeless tobacco chewing practice . Among the current smokeless tobacco chewers 21.5% chew both types of smokeless tobacco products and all of them were males. Male gender  and ever smoking lifestyle  were significant determinants of current smokeless tobacco chewing lifestyle.The study shows a high prevalence of smokeless tobacco use by youth aged between 15 to 24 years who were residing in urban slum areas in the district of Colombo, in Sri Lanka, highlighting this target group for early intervention to reduce the uptake and promote the quitting of this practice.The online version contains supplementary material available at 10.1186/s12889-022-14704-6. Tobacco in any form kills millions of people. According to the World Health Organization (WHO), it kills more than 8 million of people every year. Tobacco use can be either smoking or smokeless type. Smokeless tobacco (SLT) is becoming more widespread globally due to various reasons , 2. ThosGlobally 273.9 million people used some form of SLT in 2019 and more than 80% of the SLT users were from South Asia region. Global prevalence of chewing SLT in 2019 was 4.72% and it showed an increasing trend. Sri Lanka ranked among the top 10 countries with high prevalence of chewing SLT, which was more common among males 13.57%) than females (5.15%) in 2019 [7% than fA range of various SLT products are available globally in different names in different countries , 7. The Smokeless tobacco products are becoming common among youth groups even though there are limited research on that , 6, 10. Risk lifestyles such as smoking tobacco and chewing tobacco are more common among vulnerable populations especially those live in urban slums. The slums are housing units built mostly for long term use and are often single-room dwellings, compactly arranged in back-to-back rooms. Slums do not accommodate all the urban poor, nor are all slum dwellers always poor . The peoChewing SLT lifestyle and its associated factors have not been researched adequately among youth as smoking . There an = Z2p (100-p)/d2) [N = design effect X n, design effect = 1 + (b—1) rho, b = cluster size) [The study was a descriptive cross-sectional study, conducted in the urban slums in two divisional secretariat areas (Colombo and Thimbirigasyaya) in the Colombo district, from February 2016 to August 2016. Sample size was calculated using the prevalence of tobacco usage among youth in Sri Lanka (taken as 23%)  with 5% 0-p)/d2) . Since ter size) . A Sampler size)  and it wSLT chewing was assessed using betel quid chewing and commercially prepared tobacco and areca nut packet (CPTAP) chewing. A current chewer was defined as a participant who had the chewing lifestyle during past 30 days before the survey, and it included both daily and non-daily chewers. A daily chewer was defined as a participant who had the chewing lifestyle daily and a never chewer was a participant who did not have the SLT chewing lifestyle. Those who had the chewing lifestyle but not within past 30 days were defined as non-current chewers. The definitions for the current chewer were the standard definition used in Global School Base Students Health Survey (GSHS) and Global Youth Tobacco Survey (GYTS) , 24.P value < 0.05 was considered as statistically significant. Ethical approval was taken from the faculty of Medicine, University of Colombo, Sri Lanka.Data collection was carried out after obtaining the written informed consent and statistical analysis was done using the SPSS version 21. The results were reported as percentages, odds ratio and 95% confidence interval. Bivariate logistic regression (using enter method) was used to identify independent factors associated with the current SLT chewing lifestyle. A total of 1431 youth was included in the final sample in the study out of which 815 (57%) were males and 616 (43%) were females. The mean age of the study sample was 17.53 (95% CI: 17.40–17.65). Table The mean age at initiation for, current SLT chewers was 14.96 years (SD ± 2.3 years) whereas mean ages at initiation for, current betel quid chewers were15.91 years, (SD ± 2.5 years) and current CPTAP chewers were15.69 years, (SD ± 2.4 years). The age of initiation of current SLT chewing lifestyle ranged from 10 to 21 years.Majority of current SLT chewers  mentioned that the reason for their first use of SLT was influence of their friends. Moreover 22.7% (95% CI-19.7%-26.1%) cited that the reason for their first use was availability of SLT readily at home due to the usage of parents or elder siblings. Another 8.1% (95% CI-6.2%-10.5%) mentioned that they just started without any special reasons and 11.5% (95% CI- 9.3%-14.5%) mentioned that they initiate SLT chewing to experience the joy.n = 642, 95% CI- 42.3%-47.5%) and among them90.2%  were males. Around 21.5%  of current SLT chewing youth had both types of chewing SLT practices and all of them were males. Further 78.5%  of current SLT chewing youth had only one type of chewing SLT practice . Around 31.3%  did not have SLT chewing practices . Figure P < 0.05). Table The prevalence of current SLT chewers was 44.9% (P < 0.05). Among the current users, 48% (95%CI- 42.43% to 53.57%) were daily chewers and the most common type of betel quid was the quid with betel leaves, tobacco, areca nut, and lime .The betel quid chewing lifestyle was significantly higher among males. There were 79.6% (95% CI- 74.8%-83.7%) current male betel chewers compared to 20.4% (95% CI- 16.3%-25.2%) current female betel chewers (p < 0.05). Among the current CPTAP chewers, 57% (95% CI-52.53% to 61.47%) were daily chewers and the most common type used by the chewers was Mawa .Tobacco and areca nut packet chewing (CPTAP) lifestyle was not found among current female tobacco chewers and all current CPTAP chewers were males  conducted in Sri Lanka, which explained that most tobacco users tried their first initiation of tobacco in the age group between 13–15 years . StudiesIn the present study, 44.9% of the study population were reported as current SLT chewers. Around 90.2% of the current SLT chewers was males as in many other studies. The prevalence of SLT usage among people above the age of 15 years varied among countries ranging from 1.1% in Thailand males to 51.5% in Myanmar males . A studyThe National Youth Health Survey (NYHS) 2012/2013 in Sri Lanka, reported the current betel and tobacco chewing prevalence as 6.3%  whereas Around 32.9% current CPTAP chewers were identified among this study sample. A study conducted among adolescents aged 15 years in a rural area in Sri Lanka has identified that there were 7% current areca nut chewers and among them 1% were chewing commercially prepared areca nut packets . MajoritUsually most of substance abuse is common among males and that the same trend is followed with the tobacco chewers. There was significant association between current SLT chewing, and sex in binary logistic regression analysis. Similar results were reported in many studies worldwide , 34, 35.Sri Lanka was the fifth country to sign the WHO FCTC in the South East Asian region and the first country to ratify it in the region. In 2006 National Authority on Tobacco and Alcohol (NATA) act was implemented. In September 2016 act was amended and banned selling, production and import all forms of SLT products. The present study conducted before enacting the NATA act which could be one of the major reasons to have a higher prevalence of SLT usage.Main limitation of the study was that the sample was gathered from urban slums in the district of Colombo, Sri Lanka and the results cannot be extrapolated to the entire youth residing in urban slum areas in Sri Lanka. There may be variation among youth living in urban slum areas in other parts of the country which needs to be studied further .The study showed that the tobacco chewing was significantly high among youth residing in urban slum areas in the district of Colombo, Sri Lanka which was much higher than the nationally reported values for youth. Current SLT chewing lifestyle was significantly associated with sex. Targeted interventions specially focusing to empower youth with relevant skills needed to be implemented to prevent and reduce the fresh uptake of tobacco chewing behavior.Additional file 1.


Insertable cardiac monitors (ICMs) are increasingly used for cardiac rhythm diagnosis with expanding indications. Little has been reported about their use and efficacy.The study sought to evaluate the clinical utility of a novel ICM (Biotronik BIOMONITOR III) including the time to diagnosis in unselected patients with different ICM indications.Patients from 2 prospective clinical studies were included to determine the diagnostic yield of the ICM. The primary endpoint was time to clinical diagnosis per implant indication or to the first change in atrial fibrillation (AF) therapy.A total of 632 patients were included with a mean follow-up of 233 ± 168 days. Of 384 patients with (pre)syncope, 34.2% had a diagnosis at 1 year. The most frequent therapy was permanent pacemaker implantation. Of 133 patients with cryptogenic stroke, 16.6% had an AF diagnosis at 1 year, resulting in oral anticoagulation. Of 49 patients with an indication for AF monitoring, 41.0% had a relevant change in AF therapy based on ICM data at 1 year. Of 66 patients with other indications, 35.4% received a rhythm diagnosis at 1 year. Moreover, 6.5% of the cohort had additional diagnoses: 26 of 384 patients with syncope, 8 of 133 patients with cryptogenic stroke, and 7 of 49 patients with AF monitoring.In a large unselected patient population with heterogeneous ICM indications, the primary endpoint of rhythm diagnosis was achieved in ∼1 in 4, and additional clinically relevant findings was achieved in 6.5% of patients at short-term follow-up.  The available literature on ICMs is focused on specific clinical settings or according to implant indications, but the diagnostic yield of ICMs in populations with heterogenous implant indications is not well reported.NCT04025710) or the ongoing Observation of clinical routine care for patients with BIOTRONIK implantable cardiac monitors (BIO|STREAM.ICM) registry (NCT04075084). Both studies were initiated to satisfy postmarket clinical follow-up requirements for regulatory purposes and their enrollment criteria were minimal, including any clinical indication for an ICM implant, ≥18 years of age, and patient acceptance of remote monitoring. The subject must not be pregnant or be participant of another clinical study. To be included in the present analysis, patients had to have signed informed consent, and to have the insertion of the device plus any follow-up data reported by May 6, 2022. The research was conducted according to the principles of the Declaration of Helsinki with Institutional Ethics Committee approval at each site.The present analysis includes patients with a BIOMONITOR III device inserted as part of the completed BIO|MASTER.BIOMONITOR III study , a miniaturized ICM profile , and a dedicated tool for a simplified injection-like insertion procedure with pocket formation and ICM placement in 1 step.In both the BIO|MASTER.BIOMONITOR III study and BIO|STREAM.ICM registry, the activation of the Home Monitoring feature was mandatory. The BIO|MASTER.BIOMONITOR III study enrolled patients between October 2019 and February 2021, with follow-up visits planned for the first month and at 3 and 12 months. The last patient completed the study on April 6, 2022, and the current publication was initiated when the data of the BIO|MASTER.BIOMONITOR III study were complete. The BIO|STREAM.ICM registry has been enrolling patients since October 2019 and will continue for a longer period. It collects long-term real-life data without mandatory study procedures and follow-ups; a patient completes the study when the investigator decides to explant the ICM or not to use ICM information any further.For the present analysis, ICM indications were classified as (1) syncope or presyncope (hereinafter referred to as syncope), (2) screening for AF after cryptogenic stroke, (3) monitoring and management of AF, and (4) others. Investigators reported when the respective diagnosis had been made based on a detection of the ICM . Specifically, the classification or diagnostic criteria for all arrhythmias and pauses were left to the individual investigator’s discretion. In patients with other indications, a diagnosis was individually compared with the indication, for example, AF detection in patients with palpitations. The primary endpoint of the present analyses was the time to the clinical diagnosis based on ICM information. Only in patients with an ICM for AF management, the primary endpoint was the first relevant change in AF therapy including change of antiarrhythmic medication, direct current cardioversion, or catheter ablation procedures.Data were used as entered until May 6, 2022. For the time-to-event analyses, patients were censored at the last study contact . Other results are presented with standard summary statistics  and as absolute and relative frequencies. In the time-to-event analyses, 6-month and 1-year probability estimates according to Kaplan-Meier are provided with 95% confidence intervals. The analyses were performed using the R statistical software .This study included 632 patients  from 55 investigational sites in 11 countries, predominantly Germany (25.8%), France (17.0%), Spain (8.3%), and Australia (7.3%). The patients were 64 ± 16 years of age and 42.4% were women . The ICMAt the time of data freeze, the 632 patients had a mean follow-up of 233 ± 168 days (median 220 [interquartile range 76-365] days). Of all patients, 583 had an indication other than AF monitoring, and 135 (23.2%) of them received an ICM-based diagnosis for the clinical question for which the device was implanted. More specifically, of 384 patients with syncope indication, 98 (25.5%) received a diagnosis based on the ICM. The ICM-detected arrhythmias were pause (n = 69 [70.4%]), bradycardia (n = 18 [18.4%]), SVT other than AF (n = 5 [5.2%]), VT (n = 3 [3.1%]), AF (n = 1 [1.0%]), and other or not specified (n = 2 [2.0%]). As a result, reported medical interventions included permanent pacemaker implantation (n = 71), medication change (n = 12), catheter ablation (n = 3), and cardioverter-defibrillator implantation (n = 3). The Kaplan-Meier estimates of the proportion of patients with a diagnosis were 22.1% at 6 months and 34.2% at 1 year . In 7 paOf 133 patients with cryptogenic stroke, 18 (13.5%) had an AF diagnosis based on the ICM. In all cases, oral anticoagulation was subsequently prescribed, and 2 patients also underwent catheter ablation for AF. The Kaplan-Meier estimates of the diagnostic yield were 12.6% at 6 months and 16.6% at 1 year . In addiOf 49 patients with an indication for AF monitoring, 19 (38.8%) had a relevant change in AF therapy based on ICM data. Ten patients underwent 11 catheter ablation procedures for AF (n = 7), atrial flutter (n = 2), atrioventricular nodal re-entry tachycardia (n = 1), and frequent premature ventricular complexes (n = 1). Six patients underwent AF cardioversions, and 1 patient was started on a new antiarrhythmic medication. The Kaplan-Meier estimates of the diagnostic yield were 29.2% at 6 months and 41.0% at and 1 year , respectOf 66 patients with other indications, 19 (28.8%) received a diagnosis based on the ICM. The diagnoses were AF (n = 6), SVT (n = 4), pause (n = 3), VT (n = 2), bradycardia (n = 1), sinus tachycardia (n = 1), ventricular extrasystoles (n = 1), and absence of VT recurrence following ablation (n = 1). The Kaplan-Meier estimates of the diagnostic yield were 27.4% at 6 months and 35.4% at 1 year. Concerning different types of indication, 6 of 26 patients with palpitations had heterogeneous arrhythmias diagnosed  and 3 of 7 patients after peripheral embolism had an arrhythmia diagnosis .In our study of 632 patients with heterogeneous ICM implant indications over an average of 233 days of follow-up, we obtained the following principal findings. First, the primary endpoint achieved per implant indication was ∼1 in 4 with 25.6% for syncope, 13.5% for AF in cryptogenic stroke, 38.8% for relevant change in AF management based on AF monitoring, and 28.8% for the remaining indications. Second, additional incidental ICM diagnoses were achieved in 6.5% of the cohort: 26 (6.8%) of 384 patients with syncope, 8 of 133 patients with cryptogenic stroke (6.0%), and 7 (14.3%) of 49 patients with AF monitoring. Third, the overall diagnostic yield of ICM per implant indication ranged from 16.6% to 41.0% at 12 months. Taken together, cardiac rhythm monitoring with ICM appears to contribute to successful diagnosis and resultant management changes that are likely to improve patient outcomes.The most established indication for ICM use is syncope, whereby prolonged monitoring is more likely to yield an arrhythmic diagnosis than intermittent monitoring. In our population, most patients (∼61%) received the device for the clarification of the cause of a syncope or presyncope. In a large meta-analysis of 41 studies of adults who underwent ICM implantation for unexplained syncope, the proportion of subjects finally diagnosed with arrhythmic syncope was 26.5%, ranging from 5.4% to 55.6%.The second-largest group comprised patients with cryptogenic stroke (∼21%). AF detection in our cohort was 12.6% at 6 months and 16.6%  at 1 year. These numbers are slightly higher than those of the landmark Cryptogenic Stroke and Underlying AF (CRYSTAL AF) study ,,,,A relatively small group of patients (∼8%) received the device for the monitoring of known AF, as this indication is not reimbursed in some of the participating countries. This is a relatively new application of ICM, typically in patients after AF ablation, in whom clarification of AF burden can influence disease managment.However, the most interesting results in our study may be those pertaining to the remaining patients. The reason why these patients received their device were symptoms other than syncope that could be a consequence of unknown arrhythmias, or a physician’s interest to describe more precisely known or assumed arrhythmias (to improve diagnosis). In a few cases, the proof of AF was attempted in patients that did not have a cryptogenic stroke but had peripheral embolism. What patients in this heterogeneous indication group had in common was that their symptomatic burden and clinical risks were judged by physicians to be high enough to justify the insertion of an ICM. The ICM contributed to diagnosis in 27.4% of these patients at 6 months and 35.4% at 1 year, which is even numerically slightly higher than the diagnostic yield in patients with syncope.Importantly, a considerable number of patients in our study received an unexpected diagnosis. The ICM provides added benefits due to the embedded algorithms to detect various rhythm-related abnormalities. This result affirms a role for not disabling the built-in algorithms beyond the main indication for the ICM implantation, although this decision may result in an increased ECG classification workload with likely additional device alerts.There are concerns that an invasive procedure should not be easily justified for a purely diagnostic device. The timescale of the time to diagnosis in our cohort makes clear that extracorporeal devices cannot be worn long enough to yield the same diagnoses. However, the low complication rate of approximately 1 serious adverse device effect in 100 patients reported from a previous analysis of our population (which were mostly device extrusions due to insufficient wound closure) is reassuringSome limitations must be noted. First, we combined data from 2 studies with a different design. Further, some patients contribute only a relatively short follow-up duration, as the BIO|STREAM.ICM registry is ongoing. Nevertheless, the large number of patients is a strength, and the knowledge of the diagnostic yield and resultant outcome of the patients are clinically relevant.This study confirms the clinical utility of ICMs in a large population of patients with heterogeneous indications with ∼1 in 4 resulting in relevant diagnosis per implant indication and additional 6.5% achieving additional clinically relevant findings at short-term follow-up.