To compare the performance of Epworth Sleepiness Scale (ESS) and tiredness symptom with the apnea-hypopnea index (AHI) in a population referred to home sleep tests.This correlational study assessed adult patients through questionnaires and respiratory polygraphy (RP). We estimated sensitivity (S), specificity (Sp), predictive values (PV), odds ratio (OR) adjusted multivariate model and area under ROC curve for each sex and severity.p<0.0001. ESS > 10 was found in 25% of population: 8±5.15 in men vs. 7.6±5.1 in women, p<0.001. 12% of men (as compared to 31.5% of women) with ESS > 10 had a normal AHI. 72% of women reported tiredness (vs. 66.1% of men). The R2 between Epworth Scale and AHI showed: 0.022 (CI95%: 0.111-0.185) p<0.0001 in men and 0.0019 (CI95%: -0.004 to 0.092) p>0.074 in women. Logistic regression showed Epworth Sleepiness Scale >10 for each AHI severity category (OR between 1.38 and 1.31 with p<0.05) and tiredness for AHI >30 ev/h only in men (p<0.004).We analyzed 4424 patients, 2761 (62.4%) men and 1663 women, aged 53.6 (42-65 years old) with BMI of 31.3 (25.5-36.1). 78.4% had AHI >5 events/hour. RP (ev/h) indicators were (men vs. women): AHI of 22.8±19.2 vs. 13.2±13.3, ODI of 22.7±19.9 vs. 14.0±13.7, and T <90%: 19.3±26.1 vs. 15.6±25.3. Men presented higher severity levels, night-time hypoxemia and CPAP indications (52.2 vs. 29.2%) Epworth Sleepiness Scale >10 demonstrated a low screening performance only when present in male patients. Tiredness performed worse. Due to its limited value in the identification of sleep apnea patients, subjective somnolence should be considered in the context of an objective evaluation. Obstructive sleep apnea-hypopnea syndrome (OSA) has emerged as a public health concern due to its high prevalence in the general population and the associated high morbidity and mortality rates,OSA diagnostic criteria are based on an Apnea-Hypopnea Index (AHI) of >5 events per hour (ev/h) associated with excessive daytime sleepiness and/or cardiovascular or metabolic comorbidities. In middle-aged individuals, OSA prevalence2,Traditionally, OSA diagnosis is confirmed with polysomnography (PSG) though a duly validated respiratory polygraphy (RP) is also accepted in populations with a high/low clinical likelihood of suffering from OSA7-13,Excessive daytime sleepiness is a relevant symptom because of its direct impact on patients’ quality of life10Current tools to assess excessive daytime sleepiness include self-administered subjective scales based on validated questionnaires against reference methods and objective tests like the Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test. But, besides limited availability in some contexts, they are time consuming and must be conducted in a proper setting.In routine clinical practice, referral centers continue to use subjective sleepiness scales  because their implementation is inexpensive and does not require complex training/equipment.The subjective sleepiness scale known as Epworth Sleepiness Scale (ESS)A systematic literature search by Sil and Barr found 5 studies that reported a significant correlation between ESS and AHI and 11 studies that showed no correlation. In addition to the fact that the statistical tools used in these studies were heterogenous , OSA was defined by either PSG AHI (with inconsistent cut-off points) or the comparison of ESS score with the multiple sleep latency test resultsThere is not much available information about ESS’ performance in OSA patients in Argentina. A validation study conducted in a small patient population using PSG,23-In spite of these limitations, ESS scores >10-12 points are considered significant before a diagnostic test8To compare the performance of ESS score, tiredness symptom and AHI in the population referred to home sleep tests.This is a retrospective correlational study based on a convenience sampling conducted at a Respiratory Medicine Center between January 2013 and December 2018 (6 years) in adult patients suspected of sleep disorders on the grounds of three cardinal symptoms: frequent snoring, excessive daytime sleepiness, or partner-observed apneas.All study procedures conducted on human participants were followed pursuant to the standards of the national and institutional research committee and the Declaration of Helsinki of 1964, as amended. The protocol was approved by the ethics and institutional review committee (protocol number: CRI#968).Patients with more than one RP recording were included only once . ExclusiRP recordings were taken at night (1 night only) at patients’ homes using a self-administered technique . Patients received proper training on the use of the device at the hospital the morning before the test. The training session lasted 20 minutes and was delivered by nurses with experience in sleep medicine. Additionally, patients received an instruction manual with pictures and information on how to set the device.RP devices used in this study were Apnea Link Plus-Air  and Alice Night One . All polygraph data from at least three basic signals: pulse oximetry, thoracic effort band, and nasal pressure canula. Ancillary signals included body position, actigraphy, and snoring.Tracings were included/excluded through manual edition under AAMS standards2) were systematically collected. Obesity was defined as BMI >30 kg/m2. Daytime sleepiness was assessed with a validated Spanish translation of the current ESS version and OSA probability with Berlin and STOP-BANG (SBQ) questionnaires15,26,Tiredness (T) was assessed with the SBQ question specifically related to this symptom.When patients picked up the RP devices at our center, age, sex and anthropometric variables  was used to calculate Sensitivity (S), Specificity (Sp), Positive Predictive Value (PPV) and Negative Predictive Value (NPV).tiredness) for the identification of patients through AHI severity in a logistic regression model, we conducted a multivariate analysis and a Student’s t test or χ2 test/Fisher Test for quantitative or qualitative variables respectively. Once prediction variables were obtained, we used a multivariate forward stepwise analysis. The dependent variables were: Epworth Sleepiness Scale Value (dichotomous) and tiredness (present or absent); the independent variables being: sex, BMI (> or <30 kg/m2), history of hypertension, depression diagnosis, sex, age and Berlin questionnaire (high or low risk) to obtain odds ratio (OR) and confidence interval (CI 95%) for AHI severity classification. Finally, ROC (AUC-ROC) curves were estimated using the Hosmer-Lemeshow goodness-of-fit test. A p value <0.05 was considered statistically significant.To include variables correlating ESS scores >10< and T  and Prism 7.04 .2 (25.5-36.1). The most frequently reported symptoms were snoring in men and sleepiness in women. The study included 5743 patients. After the selection process , we analp<0.001). Conventional RP indicators (ev/h) showed (men vs. women): AHI: 22.8±19.2 vs. 13.2±13.3; ODI: 22.7±19.9 vs. 14.0±13.7; and T <90% (as % of TRT): 19.3±26.1 vs. 15.6±25.3 (AHI >5 ev/h was found in 78.4% of patients and severe OSA was observed in 26.4% in men and 9% in women (5.6±25.3 .vs. 29.2%) p<0.0001.Male patients presented higher levels of severity, nighttime hypoxemia, and higher rates of CPAP therapy prescription  and ESS scores >10 was present in 50% and 40.7% of women and men respectively (12% of men ectively  and 3.p<0.0001 in men and 0.0019 (CI95%: -0.004 to 0.092) p>0.074 in women (Correlation between ESS and AHI showed a Rin women .Adjusted Logistic Regression showed the predictive capacity of ESS scores >10 for each severity category (OR between 1.38 and 1.31) and sleepiness for AHI >30 ev/h exclusively in men .This study carried out in a large sample shows a low correlation between subjective somnolence symptoms and objective indicators obtained by the home sleep test, which show the limited usefulness of subjective questions to identified sleep apnea patients or estimate their severity.-Several studies have assessed the relationship between ESS score and AHI in different populations28Patients suffering from sleep apnea may ignore the alterations in their breathing patterns during sleep, as clinical signs are often reported by their roommates or partners. Therefore, this population is hardly aware of the cardiovascular and/or metabolic risk they face.,This study was conducted on patients suspected of OSA referred to our unit to undergo a specific sleep test. One fourth of our sample revealed ESS scores >10 and high OSA prevalence >78%). It is worth considering that both the traditional classification of severity is only an approximation%. It is ,20,34,ESS questionnaire is routinely used to assess subjective sleepiness in patients with a clinical suspicion of OSA, though several scientific studies have consistently shown its low sensitivity15ESS is frequently used in our units and, therefore, we want to learn more about its performance in our population and its relationship with home-based RP results, another routine practice at our center.While the American Academy of Sleep MedicineIn 2008, Rosenthal & DolanIn a local study using PSG and a clinical questionnaire adjusted for age, BMI, and respiratory distress index, Nigro et al.OR analysis for different ESS cut-off points shows that male patients with ESS scores >10 are at a higher risk of high AHI. Logistic regression adjusted for confounders like obesity, neck circumference, sex, depression, Berlin questionnaire risk, hypertension, and age showed an OR between 1.3 and 1.4 in men, with areas under the curve with limited discrimination value (0.63 to 0.64). Even though an OR of 1.4 is statistically significant, its clinical impact may be limited in the actual identification of patients with sleep apnea,Very few studies have used logistic regression and they have also found a low degree of correlation between ESS and AHI25,Osman at al.34As is appreciated in the literature, the clinical correlation is of great value when simplified tests are used.The use of daytime sleepiness and tiredness symptoms is widespread in different sleep units around the world, because it allows the clinician to check the correlation of sleep study results with self-reported symptoms. However, due to its low correlation with objective indicators, the usefulness of this strategy may only be verified in symptomatic patients.Our study was conducted on patients from one single center using retrospective analysis, with the limitations inherent to this type of study design. Geographic, social, and cultural factors make it difficult to extrapolate our results to other populations and health systems.The identification of respiratory events in RP recordings could also be a limitation of our study because AHI was calculated by manual reading. Thus, such index is the result of the addition of the number of apneas/hypopneas per hour of recorded time, i.e. a quotient of the number of observed events and time of exposure.ESS had a limited value in the identification of patients’ severity and should be considered in the context of an objective evaluation together with AHI. In our experience, ESS scores > 10 have a limited discrimination capacity and are useful especially in male patients. Tiredness as a symptom performed even worse and was useful only when reported by male patients with severe OSA.


Despite a dramatic reduction in HCV drug costs and simplified models of care, many countries lack important information on prevalence and risk factors to structure effective HCV services.A cross-sectional, multi-stage cluster survey of HCV seroprevalence in adults 18 years and above was conducted, with an oversampling of those 45 years and above. One hundred forty-seven clusters of 25 households were randomly selected in two sets . A multi-variable analysis assessed risk factors for sero-positivity among participants ≥45. The study occurred in rural Moung Ruessei Health Operational District, Battambang Province, Western Cambodia.A total of 5098 individuals and 3616 households participated in the survey. The overall seroprevalence was 2.6% (CI95% 2.3–3.0) for those ≥18 years, 5.1% (CI95% 4.6–5.7) for adults ≥ 45 years, and 0.6% (CI95% 0.3–0.9) for adults 18–44. Viraemic prevalence was 1.9% (CI95% 1.6–2.1), 3.6% (CI95% 3.2–4.0), and 0.5% (CI95% 0.2–0.8), respectively. Men had higher prevalence than women: ≥18 years male seroprevalence was 3.0 (CI95% 2.5–3.5) versus 2.3 (CI95% 1.9–2.7) for women. Knowledge of HCV was poor: 64.7% of all respondents and 57.0% of seropositive participants reported never having heard of HCV.p< 0.001), low education (higher than secondary school OR 0.7 [95% CI 0.6–0.8]), any dental or gum treatment (OR 1.6 [95% CI 1.3–1.8]), historical routine medical care , and historical blood donation or transfusion (blood donation after 1980 OR 0.4 [95% CI 0.2–0.8]); blood transfusion after 1990 OR 0.7 [95% CI 0.4–1.1]).Risk factor characteristics for the population ≥45 years included: advancing age . This survey suggests high HCV prevalence in certain populations in Cambodia and can be used to guide national and local HCV policy discussion. Until very recently, the global Hepatitis C Virus (HCV) epidemic, responsible for an estimated 71 million chronic infections and 30% of the 1.34 million deaths due to viral hepatitis, was largely thought insurmountable .However, recent developments are restructuring the public health approach to HCV. Two common DAAs, Sofosbuvir (Sof) and Daclatasvir (Dac), have reduced dramatically in cost  ) Table  and for Among adults ≥45 years old, geographic variation in seroprevalence was noted at the level of the health center catchment area, ranging from the lowest prevalence, in Prey Svay, of 3.0 (CI95% [1.3–4.6]) to the highest in Prey Toch, at 9.4 (CI95% 6.7–12.1]) (Table .1) , reported never having heard of HCV.4.7%, repTable p< 0.001) and was associated with socio-economic status, being lower among people who achieved an education level higher than secondary school than those who never attended school (OR 0.7 [95% CI 0.6–0.8]); there was also some evidence that seroprevalence was lower among people with an ID poor card 1 compared to those not part of a welfare program . Seroprevalence was higher among people who had their first medical injection before 1990 (injection after 1990 OR 0.7 [95% CI 0.6–0.9]),their first surgery before 1990 (surgery after 1990 OR 0.7 [95% CI 0.5–0.9]); people who donated blood for the first time before 1980 (blood donation after 1980 OR 0.4 [95% CI 0.2–0.8]),a blood transfusion for the first time before 1990 (blood transfusion after 1990 OR 0.7 [95% CI 0.4–1.1]); and those who had dental and gum treatment (OR 1.6 [95% CI 1.3–1.8]). The degrees of freedom of the model was high (30) given the number of events (216). Nevertheless, the p-value of the Hosmer Lemeshow test that assesses the goodness-of-fit of the model was less than 0.05.Seroprevalence increased with age  and among those with less education, that there is sometimes wide geographic variability in HCV estimates, and that HCV disease is poorly understood even among the seropositive.n=483), found double (5.2%) the seroprevalence of this cohort, though our survey confirmed several findings of that survey as well  [The prevalence rates found were similar to estimates from some previous studies, but substantially different from others. The 2.6% prevalence seen in this population was far lower than the 14.7% seen in blood donors in 2009, and was half the rates (5.8 and 5.2%) from observational studies of people living with HIV (PLHIV) [valence) . NotablySurveys in nearby Thailand have similarly found a wide range of HCV prevalence among different regions and groups. A recent large-scale survey of the general population in Phetchabun of adults aged 35–64 found 6.9% anti-HCV positive , though Predictably, HCV seroprevalence was especially linked (among those ≥45 years) to routine medical care , and procedures occurring prior to 1990 and 1980: injections, surgery, blood donation and transfusion. Though these findings may speak to historic trends, the fact that the study cannot determine when transmission occurred in this population means it is critical to generally reinforce infection prevention and control (IPC) measures in healthcare facilities and among staff at all levels.Furthermore, programs for HCV screening and treatment should particularly consider older populations. Systematic testing of those aged ≥45 years, and treatment for the viraemic positives would contribute to the goal of HCV elimination in Cambodia and could substantially reduce the existing reservoir of HCV in the general population. Increasing overall awareness of HCV in the general population through information, education and communication (IEC) will also be a critical component of decreasing transmission and prevalence.There have been many obstacles on the road to HCV elimination. For years, effective drugs were lacking, and then cost-prohibitive. Now, simplified care models make HCV interventions more efficient and cost-effective. Establishing baseline prevalence rates and identifying groups at highest risk for seropositivity using statistically rigorous methods like the ones described here provides the necessary evidence for HCV elimination programs.The results of this study are sufficiently representative, demographically and geographically, to provide policy-relevant guidance on HCV screening strategies, treatment and elimination in Cambodia, and to contribute to global conversations on HCV epidemiology, treatment and disease reduction or elimination .There are several limitations to this study. There were not enough seropositive participants under 45 years to conduct a meaningful analysis of risk factors for infection in this age group. Also, children were not included. The timing of initial HCV infection cannot be identified and therefore it is not possible to describe historical HCV epidemiology from this survey.Although the study ensured that all participants were provided with transport for follow-up testing and to initiate care and treatment, the study design did not maintain data regarding uptake of care or initiation of treatment. This decision was made after deliberation and taken in light of ethical concerns that participants could feel unfairly pressured to participate in the survey if they were to be followed through the course of their decision regarding treatment initiation, since MSF both conducted the survey and, in collaboration with the MOH, provided treatment.Moreover, the survey is not representative of all Battambang Province or of other regions in Cambodia, and the surveyed geographic area may have had unique characteristics  and should not be considered representative of other regions. Care should be taken when interpreting results, though these findings point to important potential infection trends and are the most robust rural HCV estimates in the country to date.This study provides the first large-scale general adult population prevalence data on HCV infection in Cambodia. The primary conclusions fill gaps in the understanding of HCV epidemiology in Cambodia with more precision and power than currently existing data. The results show high prevalence in adults age ≥45 years and confirm the link between high prevalence and increasing age, lower socio-economic status and past routine medical interventions (particularly those before 1990 and 1980). This survey serves as an alert to the potentially high prevalence of HCV infection in Cambodia and can be used to guide national and local HCV policy discussion.


Tuberculosis is a serious health risk, for people living with human immune deficiency virus worldwide, and the burden of TB/HIV infection is still high in Ethiopia in particular. Therefore, the aim of this study was to determine the predictors of tuberculosis infection among adults visiting anti-retroviral treatment center in East and West Gojjam, northwest, Ethiopia.Institution based unmatched case-control study was employed to determine the predictors of tuberculosis infection among adults visiting anti-retroviral treatment center in east and west Gojjam, Northwest, Ethiopia from March 7–April 15, 2017. Just about 552 participants were participated in the study (139 Cases and 413 controls). Cases were confirmed with active TB and infected with HIV, and controls were HIV positive adults with non-TB. All cases in each health facility who confirmed by acid-fast bacilli, culture and gene expert were considered as TB positive. However, controls were selected by using simple random sampling technique through the above diagnostic criteria and the data were collected with Face to face interview as well as patient medical record were utilized, and the quality of the data were assured, checked, coded, cleaned and entered in EPI-Data version 3.1 and exported to SPSS version 20 for the analysis.m2 , CD4 count ≤200 cells/μl  and between 201 and 499 cells/μl , bedridden and ambulatory , respectively. TB history in the family  were predictors for TB infection. Taking CPT  and having early WHO clinical stage I or II  had protective effect against TB infection.Of the total sample (556), just about 552(99.2%) were participated in the study. 47.5% were females and 58.9% were rural dweller. Behavioral and modifiable biological risk factors: alcohol users , BMI < 18.5 kg/2, CD4 count < 499 cells/μl, bedridden and ambulatory and TB history were predictors for TB-HIV co-infected adults. Strengthen screening more frequently, CPT Prophlaxysis and treated promptly important to reduce TB co-morbidity.From this study, it has been concluded that alcohol users, BMI < 18.5 kg/m Mycobacterium tuberculosis co-infection is one of the major global challenges in the prevention of TB and accounts for 33% HIV related deaths  were candidate in the initial logistic regression models of multivariate analysis. The crude and adjusted odds ratios together with their corresponding 95% confidence intervals were computed. A P-value < 0.05 considered as statistically significant with the outcome variable.The data were checked for completeness and consistencies, and cleaned, coded and entered using Epi-Data V.3.1computer program and exported to statistical package for social science (SPSS) version 20 for analysis. The whole data were cleaned to minimize data entry errors and observed the unities of the data. Inconsistencies were verified using cross tabulation. Descriptive frequency statistics were run to see the general distribution of the data. Frequencies and proportions used to describe the study subjects in relation to the study variables. Multiple logistic regressions were used to review the predictors of TB in HIV infected adults as the most important statistical method of analysis by using backward logistic regression variable selection techniqueAmong 556 selected study participants, 552 study subjects (139 cases (25.2%) and 413 controls (72%) were responded and the overall response rate were 99.2% (96.5% for cases and 99% for controls). A higher percentage of women observed in the study participants 301(54.5%). Sixty-six (47.5%) of the cases and 235 (57%) of the controls were females. The median age of the participants was 32.5 years and IQR of 25–41.75. Seventy-six (54.7%) of the cases and 249 (60.3%) of the controls were rural residents. More than 2/3 of the study participants were completed primary school and above; 66.9% in the cases and 71.67% in the controls (Table Thirty one 22.3%) of the cases and 48 (11.6%) of the controls were chewing chat. Among the environmental variables 87 (62.6%) of the cases and 300 (72.6%) of the controls were lived in mud/soil types of floor in the house (Table 2.3% of t4 cell counts ≤200 cells/μl. One hundred three (74%) of the cases and 125 (30.3%) of the controls had BMI of less than 18.5 m2/kg (Table The median CD4 count of the study participants were 393.5 cells/μl and IQR of 210.5–624.00. Sixty-two (44.6%) of the cases and 103 (39.5%) of the controls had CD4 count ≤200cells/μl and 201-499cells/μl (crude OR (COR) 2.55;95%CI 1.615,4.016 and 12.01;95%CI 6.388,22.588) times more likely exposed for TB infection among HIV positive adults as compared to CD4 count of ≥500cells/μl  was independent predictor of increased TB infection as compared to patients that did not drink alcohol. However, WHO clinical stage I or II  and cotrimoxazole preventive therapy  had protective effect against tuberculosis infection. But, monthly income, chat chewing, hemoglobin level, asthma and types of floor in the house were lost their statistical significance in multivariate analysis  was associated with increased TB infection in this study; this is parallel to a study done in South India [4 count ≤200 cells/μl and between 201 and 499 cells/μl were about 2.34 and 2.63 times more likely to develop TB as compared to CD4 count ≥500 cells/μl respectively. This is comparable with previous reports conducted [Low body mass index LBMI< 18.5 kg/ m.5 kg/ m2th India , South Ath India  and soutth India . This mith India , 27. Theonducted , 28–33. onducted , 32, 34.In addition, our findings indicating that cotrimoxazole preventive therapy had protective effect against TB infection were also consistent with previous research reports , 35, 36.4 cell count <500cells/μl, BMI < 18.5 k g/m2 were predictors of increased tuberculosis infection among HIV infected adults visiting ant-retroviral treatment centers in East and West Gojjam Zone and attention is given for these predictors for TB diagnosis. However, this imitated that in early WHO clinical stag I or II and using cotrimoxazole preventive therapy is necessary to reduce the overall risk of TB infection among HIV positive individuals. Hence, these findings supply momentum to strengthen tracing of TB household and member contacts screening.This study indicated that drinking alcohol, previous TB history in the family, functional status being bedridden and ambulatory, CD


Background: This study aimed to estimate the prevalence of diabetes and prediabetes in adults in Kuwait. Methods: The Kuwait Diabetes Epidemiology Program was a nationally representative, cross-sectional study of diabetes and obesity in Kuwait conducted between 2011 and 2014. The survey sampled 4937 adults in Kuwait aged 20 years or more and recorded participants’ demographics, behaviours, medical history, physical measurements and blood biochemical measurements. Prediabetes was defined as fasting plasma glucose between 6.1 and 6.9 mmol/L or HbA1c between 6 and 6.4% (42–47 mmol/mol). Diabetes was defined as self-reported history with prescribed glucose-lowering medication or FPG ≥7mmol/L or HbA1c level ≥6.5% (≥48 mmol/mol). Results: The overall adjusted prevalence of diabetes was 19.1%. The overall adjusted prevalence of prediabetes was 13.5%. Diabetes prevalence was 5.4%, 14.2%, 38.7% and 64.8% in adults aged 20–29, 30–44, 45–59 and 60 years or more, respectively. Diabetes prevalence was 22.4% in men and 14.4% in women. Prediabetes prevalence was 14.8% in men and 11.5% in women. In Kuwaitis, diabetes and prediabetes prevalence was 21.8% and 11.1%, respectively, while prevalence in non-Kuwaitis was 18.2% for diabetes and 14.3% for prediabetes. Conclusion: These findings illustrate the severe public health challenge posed by diabetes in Kuwait. The global prevalence of diabetes continues to rise. The prevalence of diabetes was estimated by the International Diabetes Federation (IDF) to be 9.3% in 2019, increased from 4.6% in 2000 in adults aged 20–79 years  and 14.9% , respectively. The adjusted prevalence of diabetes was 19.1% , and the adjusted prevalence of prediabetes was 13.5%  . When thThe adjusted prevalence of diabetes in men was 22.4%, higher than the 14.4% found in women . LikewisKuwaiti men and Kuwaiti women had near identical diabetes prevalence (21.9% vs. 21.7%), and the prevalence of diabetes in Kuwaiti men (21.9%) was comparable to the 22.5% found in non-Kuwaiti men . However2, and an elevated waist–hip ratio increased the risk of diabetes by 2.45 times. Sex and medical history were also associated with diabetes. Risk of diabetes was significantly higher in men than women (OR = 1.78). Individuals who self-reported a previous diagnosis of hypertension and dyslipidaemia had a diabetes odds ratio of 2.29 and 2.58, respectively. Individuals with a family history of diabetes also had more than double the risk of diabetes (OR = 2.25). Finally, a lower education level was also associated with a higher risk of diabetes; adults educated to a high-school level or lower had an odds ratio of 1.53 relative to adults with a university education. Factors associated with diabetes and prediabetes in Kuwaiti nationals can be found in The factors associated with prediabetes were also significantly associated with diabetes. The risk of diabetes in adults aged 45–59 was 2.91 times than in adults aged 20–29. Adults age 60 years or more had a diabetes odds ratio of 5. Obese adults were 1.82 times more prone to have diabetes than adults with a BMI < 25kg/mIn this nationally representative cross-sectional study, the estimated prevalence of diabetes was 19.1% and the estimated prevalence of prediabetes was 13.5%. Diabetes prevalence was higher in men than in women, and in Kuwaitis than in non-Kuwaitis. In addition, diabetes prevalence increased steeply with age; almost two-thirds of adults aged 60 years or more had diabetes and over three-quarters had either diabetes or prediabetes. Obesity, elevated waist–hip ratio and lower education level were all associated with diabetes. These results place Kuwait amongst the countries with the highest diabetes prevalence in the world.A few other previous studies have also reported on diabetes prevalence in Kuwait. A 2006 WHO STEPS cross-sectional study of 1970 Kuwaiti adults aged 20–65 reported a diabetes prevalence of 17.9% . A subseWe found that diabetes prevalence among non-Kuwaitis was 18.2%. Although high, this was lower than the prevalence among Kuwaitis. While non-Kuwaiti men had a similar diabetes prevalence to Kuwaiti men, non-Kuwaiti women had half the diabetes prevalence compared to Kuwaiti women. Amongst non-Kuwaiti Arabs, which are the largest expatriate community in Kuwait, diabetes prevalence was 19.1%, which was slightly higher than diabetes prevalence reported in Egypt 16.8%) , Syria . The WHS+ was conducted between 2008 and 2009 in Kuwait and other countries in the region and surveyed 2518 citizens and 1310 expatriates aged 18 years or older in Kuwait . HoweverThe estimated adjusted prediabetes prevalence in this study was 13.5%, defined as a study-recorded FPG of 6.1–6.9 mmol/L or an HbA1c of 6.0–6.4% in individuals without treated diabetes. The estimated prediabetes prevalence in the 2014 WHO STEPS study, defined as a study-recorded FPG of 6.1–6.9 mmol/L or an HbA1c of 5.7–6.4% in individuals without treated diabetes, was 19.4%. Using this expanded definition, the estimated adjusted prediabetes prevalence in this study was 30.2%, which, although high, was lower than the reported 37.5% crude prediabetes prevalence in the United States . There iDiabetes prevalence is high across the Middle East. A recent meta-analysis of 50 studies in 15 Middle Eastern countries with a pooled population of 4.3 million people estimated the combined prevalence of diabetes in the region was 14.6% . Israel The association between obesity and diabetes is well established  and obesThe staggering increase in diabetes prevalence with age is alarming. Almost two-thirds of adults aged 60 years or above had diabetes in this study, over three times higher than the global estimate for adults over 60 years. In fact, the estimated diabetes prevalence reported here outpaces the estimated global prevalence at every age group . EstimatOur study strengths include the large sample size and the nationally representative study population. KDEP was the first cross-sectional survey to assess HbA1c and FPG levels amongst both nationals and expatriates in Kuwait. However, KDEP did not include a 2 h oral glucose tolerance test (2hrOGTT), often considered the most reliable and sensitive method for diagnosing diabetes . As a reIn conclusion, Kuwait has one of the largest diabetes burdens in the world. The high rates of diabetes, obesity and associated comorbidities across all segments of society impose a substantial burden on Kuwait’s health system. A sugar excise tax on sodas and energy drinks was introduced by the Gulf Cooperation Council in 2017, and Kuwait was set to implement the tax in 2020 . Public


Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication that mainly occurs in patients with type 1 diabetes mellitus and is the foremost cause of death in these children. Overall mortality in children with DKA varies from 3.4% to 13.4% in developing countries. There is a need to understand outcomes among children with DKA in sub-Saharan African countries. Study Methods. This was a retrospective study carried out among children aged 0–18 years admitted with DKA at KNH between February 2013 and February 2018. The study site was the central records department at KNH. The inclusion criteria were children aged 0-18 years admitted with a diagnosis of DKA based on the ISPAD guidelines biochemical criteria.  To determine the death rate and clinical outcomes of children and adolescents aged 0-18 years managed for DKA at Kenyatta National Hospital (KNH).  Out of the 159 files reviewed, the median age of children was 13 years (IQR 10-15). 41.1% of patients had severe DKA while 35.7% had moderate DKA. We reported a mortality of 6.9% while 93.1% of children recovered and were discharged home. The median duration of hospital stay was 8 days. High risk of mortality was reported among children who had high serum creatinine (OR 5.8 (95% CI 1.6-21.2)), decreased urine output (OR 9.0 (95% CI 2.2-37.3)), and altered level of consciousness (OR 5.2 (95% CI 1.1-25.1)).  DKA-associated mortality in our study was low at 6.9%. High serum creatinine, decreased urine output, and altered level of consciousness were associated with a significantly higher risk of mortality. Early recognition and treatment in patients with new-onset diabetes are essential in the prevention of this life-threatening complication of diabetes [etonuria . Patientetonuria . DKA is etonuria . The moretonuria , 7. Howeetonuria . Timely Kenyatta National Hospital is the largest national referral facility in Kenya and is affiliated to the University Of Nairobi College Of Health Sciences as a teaching hospital. Children seen at this facility with DKA are mainly referrals from lower-level health facilities. Children aged 12 years and below are admitted to the paediatric wards while older children are admitted to medical wards.This was a retrospective observational study conducted over a 5-year period (February 2013-February 2018).Hyperglycemia (random blood glucose) >11 mmol/L (≈200 mg/dL)).Venous blood pH < 7.3 or bicarbonate < 15 mmol/LKetonuria >2 Plus in urine samplesThe study population consisted of children aged 0-18 years admitted with DKA at KNH during the study period with a diagnosis of DKA based on the following biochemical criteria as per the ISPAD guidelines.Children with a clinician's diagnosis of DKA but with missing data on some of the diagnostic parameters stated above were excluded.Proportion of children admitted with DKA who diedAverage length of hospital stayFactors associated with mortality among children with DKAWe reviewed the medical records of 159 children admitted with DKA during the 5-year period preceding the study. All children who met the eligibility criteria during this period were recruited. The median age of children was 13 years (IQR 10-15), and 91 (57.2%) were females. Forty-nine (30.8%) children aged less than 12 years were admitted to the paediatric ward while 19 (12%) were admitted to the paediatric ICU.Out of 68 admissions to the paediatric ward, only 16 (10%) were below 6 years of age. Seventy children (44%) aged twelve years and above were admitted to the medical wards, and 21 (13.2%) were admitted to the main intensive care unit (ICU).Out of the 159 children, 103 (64.8%) had a previous diagnosis of diabetes (prior to the current admission) while 56 (35.2%) were newly diagnosed. Among those previously diagnosed, 88 (85.4%) were on mixtard insulin and 11 (10.7%) were on Lantus+short-acting insulin, and for 4 (2.5%) children, their records did not indicate the type of insulin they were on .Out of the 159 children admitted with DKA, 23 (41.1%) had severe DKA, 20 (35.7%) had moderate DKA, and 13 (23.2%) had mild DKA . Only 6 Out of the 159 children admitted, 11 died giving a mortality rate of 6.9%. Six (3.8%) of the deaths occurred in the paediatric ward while 5 (3.1%) were from the medical ward .15% of the study population had high serum creatinine while 12% had reduced urine output at some point during the inpatient period. Seventy-six patients (47.8%) manifested some signs of altered level of consciousness during the same period while 88 (55.3%) of the children had temperature readings above 37.5 degrees Celsius at one point or another during the inpatient stay. Normal temperature readings were noted throughout the inpatient stay for 68 (42.8%) children, and 3 (1.9%) had no temperature readings documented.High serum creatinine, low urine output, and altered consciousness were all associated with a higher risk of mortality. Children with high creatinine had a fivefold higher risk of mortality compared to those with normal creatinine (OR 5.8 (95% CI 1.6-21.2)), those with decreased urine output had a 9-fold higher risk (OR 9 (95% CI 2.2-37.3)), and children with altered consciousness were 5 times more likely to die compared to those who remained alert throughout the entire inpatient period (OR 5.2 (95% CI 1.1-25.1)). We found no association between mortality and age, sex, DKA severity, admission ward, type of insulin, missed insulin doses, or the presence of fever .We reported only 1 death among children aged below 6 years and did not find a significant association between this age category and the risk of mortality (OR 1.13 (95% CI 0.13-9.43)) .We reported 8 (5%) deaths among children with previously diagnosed diabetes and only 1 (1.9%) death among children with newly diagnosed diabetes. Hitherto, we found no significant association between the time of diagnosis and mortality (OR 1.5 (95% CI 0.38-5.85)) .The overall median duration of hospital stay for children was 8 days (IQR 5-13). Children admitted to the paediatric and main hospital ICUs had a similar median stay of 5 days . The median stay in the medical and pediatric wards was 10 (IQR 6-14) and 8 days (IQR 5-10), respectively. The summary data on the duration of hospital stay is presented in In this study, out of 159 children admitted with DKA, we reported a mortality rate of 6.9%. This mortality is high compared to that reported in studies from developed countries that have reported mortality rates of 0.15%-0.31% among children admitted with DKA . The morFrom our study results, we noted that children with high serum creatinine were 5 times more likely to die while those with anuria were 9 times more likely to die. Renal failure has been largely recognized to be an independent risk factor for mortality in DKA in studies conducted in India and other parts of the world . IntrinsAltered consciousness was independently associated with a fivefold higher risk for mortality in our study (OR 5 (95% CI 1.1-25.1)). Altered consciousness is a common presentation of cerebral edema which has been associated with approximately 43% mortality in children with DKA in developing countries , 12. In We noted a lower mortality rate of 3.1% among older children and adolescents admitted to the medical wards compared to 3.8% among younger children admitted to the paediatric ward; however, this difference in mortality was not statistically significant. Although mortality in children younger than 6 years was low at 0.6%, we had only 16 children within this age category with 1 death reported. A study done by Kao et al. on the incidence and trends of DKA in children and adolescents with type 1 diabetes in British Columbia, Canada, reported that younger age at diagnosis (<5 years) was associated with a greater risk of DKA at the time of diabetes diagnosis . We alsoTemperature above 37.5 degrees, an indicator of possible infection, was not independently associated with mortality in our study. This finding contradicts what was reported in the study conducted in Chennai, India, where infection was identified as a significant risk factor and a contributor to poor outcomes in children with DKA . We repoWe sought to determine the length of hospital stay (LOS) as a proxy indicator of the quality of DKA management offered at KNH. The median duration of hospital stay was 8 days and was similar at 8 (IQR 6-14) and 10 –10 days DKA-associated mortality in our study was high at 6.9%. Increased serum creatinine, decreased urine output, and altered level of consciousness were significantly associated with a high mortality in our setup. We reported a long duration of hospital stay among children admitted with DKA with a median stay of 7 days.The key to achieve a good outcome and prevent mortality is the prevention of DKA itself through early recognition, through support and supervision, and through proper blood glucose management in those with established diabetes. It is important that healthcare workers treating children and adolescents with diabetes and DKA follow the guidelines in the management of DKA.


We propose to study the epidemiological aspects of North African psoriasis and determine the cardiovascular comorbidities and addictive behaviors associated with psoriasis. This is a North African case-control study which was conducted over a five year period (October 2008 through August 2013), involving 671 psoriatic patients and 1,242 controls identified in various Algerian, Tunisian and Moroccan university hospitals. For each patient, epidemiological characteristic, addictive behaviors, and cardiovascular pathologies associated with psoriasis were noted. Six hundred and seventy one psoriasis patients and 1,242 controls were included in this study. The average age was 47.24 years and the M/F sex-ratio was 1.11 (354 men and 317 women). Statistical analysis showed that psoriasis patients were more likely to develop addictive behaviors than controls , together with dyslipidemia (30.1% of patients p < 10-5), obesity (23.8% of patients p < 10-4), hypertension (22.3% of patients p < 10-5), diabetes (21.7% of occurrences p < 10-5) and metabolic syndrome (37.4% of patients p<10-5). The relative risk for developing psoriasis was 1.9 in hypertensive patients, 1.7 in diabetic patients, 3.9 in dyslipidemic patients, 1.8 in obese patients, 2.6 in those with metabolic syndrome, 2.1 in smokers and 2.8 in alcoholics. Our work confirms the high incidence of addictive behaviors and of cardiovascular and metabolic comorbidities during the North-African psoriasis, hence the need for a multidisciplinary comprehensive care based on a guideline suited to the characteristics of North-African psoriatic patients. Psoriasis is a chronic inflammatory and visible skin disease occurring in a particular genetic ground . It is oThis was a North African matched case-control study involving 671 patients with psoriasis and 1,242 controls identified in various Algerian , Tunisian  and Moroccan  university hospitals, focusing on a population aged over 18. Controls were also attending various dermatology departments for skin diseases other than psoriasis. They were matched to the cases on age and gender. Data was prospectively collected over a 5 year period (October 2008-August 2013). Psoriasis diagnosis based on the anamnestic and clinical data or confirmed by histology if in doubt. All clinical forms of psoriasis were included and no exclusion criteria were retained for enrollment. Controls were excluded from the study if they had been treated with local or systemic corticosteroids. For each patient, we had filled in an information sheet including the epidemiological characteristics , assessment of addictive behaviors  and whether or not psoriasis was associated with cardiovascular diseases . Blood pressure was taken as the average of the two measurements after the patient was allowed to rest for 15 minutes. Hypertension is defined as a blood pressure greater than or equal to 140/90 mm Hg. The following blood tests were conducted on patients after 12 hours of fasting  and low density lipoprotein cholesterol (LDL cholesterol). Those with a fasting blood glucose level equal to or greater than 1.26 g/l were considered diabetic. Dyslipidemia was retained in patients with elevated levels of one or more serum lipids  and/or reduced HDL cholesterol levels. Dyslipidemia is defined as triglyceride level ≥ 1.7 mmol/l (1.5 g/l) and/or total cholesterol level ≥ 6.45 mmol/l (2.5 g/l) and/or LDL cholesterol ≥ 4.13 mmol/l in the absence of cardiovascular risk factors or LDL cholesterol ≥ 3.35 mmol/l in the presence of cardiovascular risk factors. According to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) definition, metabolic syndrome is present if three or more of the following five criteria are met: waist circumference ≥80cm for women and ≥94cm for men; hypertriglyceridemia ≥1.70 mmol/l (150 mg/dl); high-density lipoprotein (HDL) cholesterol level < 1.23mmol/l (40 mg/dl) for men < 1.29 mmol/l (50 mg/dl) for women; high blood pressure: systolic ≥ 130mm Hg or diastolic ≥ 85mm Hg; Hyperglycemia ≥ 6.1 mmol/l(110 mg/dl). Patients, receiving a hypolipemiant, antihypertensive or antidiabetic treatment at the time of examination, were considered carriers of the disease for which they were treated. Statistical analysis was performed using SPSS.Six hundred and seventy one psoriatic patients and one thousand two hundred and forty-two control subjects were included in this study. The average age was 47.24 years and the M/F sex-ratio was 1.11 (354 men and 317 women). Research on addictive behaviors revealed that 30.2% of patients were smokers compared to 16.9% of control subjects (p <10-5) and that 8.1% of patients were alcoholics . Analysis of cardiovascular risk factors showed that hypertension was found in 22.3% of patients (versus 13.1% of controls p <10-5), diabetes in 21.7% of cases (versus 13.8% p <10-5), dyslipidemia in 30.1% of patients (versus 9.9% of controls p <10-5), obesity in 23.8% of patients (versus 14.2% of controls p<10-4) and the metabolic syndrome in 37.4% of patients (versus 18.3% of controls p <10-5). The relative risk for developing psoriasis was 1.9 in hypertensive patients, 1.7 in diabetic patients, 3.9 in dyslipidemic patients, 1.8 in obese patients, 2.6 in those with metabolic syndrome, 2.1 in smokers and 2.8 in alcoholic patients .-5) and 8.1% of patients were alcoholics . Our results may underestimate actual alcohol use, since some patients may be reluctant to report their actual consumption, as has been observed in most epidemiological studies involving patients with psoriasis. Our results are different from other epidemiological studies, firstly because they come from other countries, primarily European, where social drinking habits are quite different from ours and also due to the lack of accuracy in our study with respect to the definition and quantification of alcohol consumption, which have not been assessed. Recent studies have shown that psoriasis was associated with increased obesity-related inflammatory markers, such as TNFα, interleukin 6 and interleukin 8 in adipose tissue. TNFα will lead to decreased adiponectin secretion (CK secreted by adipose tissue) [Our work confirms the high incidence of addictive behaviors and cardiovascular and metabolic comorbidities during North-African psoriasis. Psoriasis is a common skin disease in the Maghreb that is often under-diagnosed . It is a tissue) ,18.This decrease in adiponectin will improve insulin resistance but also increase triglycerides, LDL-C cholesterol and decrease HDL-C. This hyperlipidemia induces obesity, thereby triggering proinflammatory cytokine production by adipocytes and macrophages and establishing a vicious circle ,18. Studet al [We can assume that obesity (which is found in 23.8% of our psoriatic patients) may be the factor linking psoriasis to alterations in lipid metabolism. It has been demonstrated that adipocytes influence the lipid profile by increasing the levels of pro-inflammatory cytokines, in particular TNF-α and IL-6, which may affect the rate of free fatty acids, cholesterol and lipids . Howeveret al , where tOur work confirms the high incidence of addictive behaviors and of cardiovascular and metabolic comorbidities during the North-African psoriasis, hence the need for a multidisciplinary comprehensive care based on a guideline suited to the characteristics of North-African psoriatic patients.Psoriasis is now considered as a systemic disease;The association of psoriasis with hypertension, obesity, diabetes, metabolic syndrome and dyslipidemia is reported in the world;Psoriatic patients have more addictive behaviors than normal population.It has allowed us to assess the prevalence cardiovascular comorbidities and addictive behaviors associated with psoriasis;Our study suggests that metabolic syndrome is present in our population as frequently as in developed countries and should be evaluated and treated.The authors declare no competing interests.


We studied 476 primary index patients and their 1,975 household contacts, of whom 4.5% were later identified as having pertussis. When contacts started chemoprophylaxis within <21 days after the primary patient’s symptom onset, the treatment was 43.9% effective. Chemoprophylaxis started >14 days after primary patient’s symptom onset was less effective. We recommend that contacts of persons with pertussis begin chemoprophylaxis within <14 days after primary patient’s symptom onset.We retrospectively assessed the effectiveness of azithromycin in preventing transmission of pertussis to a patient’s household contacts. We also considered the duration between symptom onset in the primary patient and azithromycin administration. We categorized contacts into 4 groups: those treated within  After decades of decline  of Catalonia and Navarre from January 1, 2012, through December 31, 2013. We followed up on the household contacts 28 days after symptom onset in the index patient.B. pertussis infection confirmed by culture or real-time PCR of nasopharyngeal samples. We categorized household contacts as persons regularly living in the same household or persons in the home for >2 hours during the transmission period (<21 days after symptom onset in the primary patient or >5 days after the patient’s start of treatment).The index patient was the first patient with pertussis reported to the ESU in each household and the primary patient was the first patient with pertussis in each household, regardless of whether or when his or her case had been reported. In most situations, the index and primary patients were the same person; for our study, we excluded instances when the index and primary patients were different persons. The ESU prescribed the postexposure intervention for every index patient and their contacts. Our study included only patients with >2 weeks, paroxysmal cough, posttussive vomiting, inspiratory stridor, and apnea). Staff collected vaccination statuses and laboratory results  from the contacts’ medical records and determined a person’s vaccination status using the vaccination records of each autonomous community. We categorized each contact as fully vaccinated (>4 doses of vaccine), incompletely vaccinated (<4 doses), unvaccinated (no dose), incompletely vaccinated because of age (i.e. children <18 months of age who had received recommended doses), and unvaccinated because of age (i.e. children <2 months of age). Because few contacts >18 years of age had vaccination records, we analyzed this variable only in contacts <18 years of age.ESU staff conducted telephone interviews to gather information about each contact’s age, sex, relationship to the index or primary patient, receipt of chemoprophylaxis and start date, vaccination history, and presence of pertussis symptoms  with a laboratory-confirmed case.At 28 days after symptom onset in the primary patient, we categorized contacts as follows: healthy contact, no clinical symptoms of pertussis; primary patient, the first patient at a specific address ; co-primary patient, symptom onset within 2  and Student t-test (for continuous variables). We then studied the effectiveness of chemoprophylaxis in preventing pertussis in persons classified as healthy contacts or secondary patients after 28 days of follow-up. We excluded co-primary and tertiary patients from the analysis because they might not have been infected by primary patients. We evaluated the characteristics of persons who did or did not receive chemoprophylaxis using χWe calculated the effectiveness of azithromycin for 5 days using the formula effectiveness = (1 − relative risk) × 100. We considered effectiveness according to the duration between symptom onset in the primary patient and start of chemoprophylaxis. We classified this duration into 4 categories: 1–7 days, 8–14 days, 15–21 days, and >21 days after illness onset in the primary patient.https://www.ibm.com), and Epi Info . We used unconditional logistic regression to estimate effectiveness adjusted by vaccination status. We also assessed effectiveness according to the age of contacts , degree of relationship (cohabitants vs. persons in the home >2 hours), and type of relationship with the primary index patient . We analyzed the data using SPSS Statistics 18.0 . All contacts and family members gave informed written consent to participate.From January 1, 2012, through December 31, 2013, the ESU detected 688 cases of pertussis, of which 524 (76.2%) were primary index cases. Of these, 476 (90.8%) case-patients had reported data on the administration and outcome of chemoprophylaxis for 2,051 contacts. We excluded 76 contacts because they were co-primary patients (65 persons) or tertiary patients (11 persons). Therefore, our final study consisted of 1,975 household contacts of 476 primary index patients (hereafter primary patients).<18 years of age were completely vaccinated (65.7% had received >4 doses and 6.1% were completely vaccinated in accordance with recommendations for their age).Of the 1,975 contacts we analyzed, 53.5% were female. The mean age was 33.9 (SD ± 20.5) years; 2.2% of contacts were <1 year of age (the most vulnerable group), 34.7% were 19–40 years of age, and 35.4% were >40 years of age. A total of 76.5% of contacts lived with the primary patient; 23.4% of contacts were mothers, 21.5% were fathers, and 19.6% were siblings of the primary patient . Most of<21 days after symptom onset of the primary patient: 309 (18%) were treated within <7 days, 544 (31.6%) within 8–14 days, 413 (24%) within 15–21 days, and 393 (22.8%) in >21 days. At 28 days after symptom onset in the primary patient, pertussis had developed in 4.5% of contacts, including 1% of those who had received chemoprophylaxis <7 days and 7.6% of those who received it >21 days after symptom onset in the primary patient  contacts who received chemoprophylaxis, 1,266 (73.6%) were treated within  patient . The 1,7 patient .<21 days after symptom onset in the primary patient. Chemoprophylaxis was ineffective (−39.0% [95% CI −157.0% to 25.0%]) when administered after >21 days (Chemoprophylaxis was 43.9% (95% CI −1.8% to 69.1%) effective when administered >21 days .<18 years of age, 87.6% (298/340) received chemoprophylaxis, which was 44.1% (95% CI −42.2% to 77.7%) effective. Comparison of contacts <18 years of age who did and did not receive chemoprophylaxis within <21 days showed that chemoprophylaxis was 44.1% (95% CI −59.5% to 80.4%) effective in completely vaccinated persons (≥4 doses) and 50% (95% CI −248.0% to 92.8%) effective in incompletely vaccinated persons. This difference was not significant, although the statistical power was very low (16% for completely vaccinated and 8% for unvaccinated persons) (Of contacts persons) .<7 days, 46.4% (95% CI −8.1% to 73.4%) for those who received it within 8–14 days, and 11.8% (95% CI −71.5% to 54.6%) for those who received it within 15–21 days. When we adjusted the results by vaccination history, we found the reduction over time resembled the declining effectiveness  for contacts who received it within tiveness .<21 days after symptom onset in the index patient , lower than the 62.1% found in the previous study in Catalonia and Navarre  association between vaccination status and chemoprophylaxis effectiveness; for example, vaccine effectiveness might wane in some age groups or be bolstered in persons not cohabiting  with the primary patient. The effectiveness of chemoprophylaxis should be more closely investigated in children <1 year of age, in whom pertussis is particularly serious.Our finding that azithromycin was ineffective when administered >14 days after symptom onset in the primary patient suggests that physicians should not initiate chemoprophylaxis after that time. This strategy might reduce costs, potential adverse effects, and risk for azithromycin resistance (The limited effectiveness of chemoprophylaxis in reducing pertussis transmission highlights the importance of patient isolation until 21 days after symptom onset, or 5 days after treatment initiation (Our study was subject to several limitations. It lacked the statistical power to estimate the effectiveness of chemoprophylaxis in terms of contact age, degree of home contact, and relationship with the primary patient. We used self-reported data on treatment, so we cannot verify whether contacts complied with treatment. We also cannot rule out the possibility that undetected infected persons could have altered transmission dynamics. Finally, confirmatory laboratory testing was not conducted for 40.4% of secondary patients. However, we believe the probability of misclassification is very low.In conclusion, our results show azithromycin chemoprophylaxis for pertussis had low effectiveness when initiated >14 days after symptom onset in the primary patient. Therefore, public health services should expedite chemoprophylaxis in homes where contacts of suspected patients have risk factors for this disease.


Currently, there are no records of the current status of rheumatologists in Ecuador.  The purpose of this study is to get to know the current status of rheumatologists in Ecuador, focusing on education, working conditions, productivity, distribution of time between work activities, and job satisfaction.  A digital survey was created using the Google Forms platform. It was distributed to all rheumatologist members of the Ecuadorian Society of Rheumatology. The data analysis was carried out using the statistical program SPSS v.23®.  A total of 64 surveys were received. The response rate was 86.48%. 62.5% were men and 37.5% women, with an average age of 40.76 ± 9.18. The main workplace was state/public hospital (56.3%). The average working hours per week were 40.35 ± 25.72. Most rheumatologists in Ecuador (62.5%) received their training abroad. 79.7% of rheumatologists earn less than $ 49,000 annually. The mean retirement age was 66.51 ± 6.7, and 54.7% have a retirement plan. The average satisfaction of Ecuadorian rheumatologists was 5.4 ± 1.33 [0–7]; 17.2% are very dissatisfied with their annual income.  This is the first recorded data on the characteristics of rheumatologists in Ecuador. Most rheumatologists obtained their specialist degree abroad. In general, rheumatologists in Ecuador are satisfied with their clinical practice and dissatisfied with their annual income and job security. The migMost rheumatologists in Ecuador receive an annual income of less than $ 30,000, which is significantly less than that found in other studies. According to data from the Ecuadorian Ministry of Public Health, an Ecuadorian doctor receives $ 1,676 to$ 2,967 per month, which is equivalent to an average of $ 28,000 per year . In HogaThis is the first reported data of rheumatologists in Ecuador. 63% completed their rheumatology fellowship abroad. In general, they are satisfied with their clinical practice, but they are dissatisfied with their annual income and job security. We consider that this study will enhance the interest of rheumatology in Ecuadorian young medical doctors.


If subjective improvement is defined as an improvement in mMRC grade or CAT score by 1 or 3 points, respectively, 25 patients (46.3%) have significantly improved after 6 months of treatment. Out of these, all have improved in CAT score. The tolerability of nintedanib was similar in elderly and younger patients. These findings suggest that CAT scores could be useful in the subjective assessment during nintedanib treatment, and that nintedanib is safe and efficient for the treatment of the elderly population. The efficacy of nintedanib treatment in patients with idiopathic pulmonary fibrosis (IPF) was demonstrated in phase III trials. However, there is limited data on the significance of nintedanib in elderly patients aged ≥75 years. We have retrospectively evaluated 54 newly nintedanib-treated patients including 32 elderly individuals. Potential changes in modified medical research council (mMRC) grade and COPD (chronic obstructive pulmonary disease) assessment test (CAT) score, as well as in forced vital capacity (FVC) were obtained 6 months before, at the time of, and 6 and 12 months after initiation of nintedanib treatment. Significant differences were observed in CAT scores between 6 months before treatment and baseline ( CO) <40%, oxygen desaturation ≤88% during 6-min-walk test (6MWT), extent of honeycombing on high-resolution computed tomography (HRCT), and pulmonary hypertension. Additionally, a multidimensional index and staging system for IPF has been developed, using gender (G), age (A), and 2 lung physiology variables , whereby IPF patients with GAP stage ≥2 are considered to have a poor prognosis ) to calculate a total score ranging from 0 to 8, and patients were classified as GAP stage I (0 to 3 points), stage II (4 to 5 points), and stage III (6 to 8 points) ) or median (range) for continuous variables, and percentages  for categorical variables. The differences in background between 2 groups were evaluated using Fisher’s exact test for categorical variables, and Mann–Whitney U test for continuous variables. Differences in efficiency and adverse events were evaluated using Fisher’s exact test for the efficacy in PROs and adverse events, Mann–Whitney U test for the rates of change in FVC, and repeated measures ANOVA for the changes in FVC. In the analysis of factors that could affect the changes in FVC and PROs, multiple linear regression analysis and logistic regression analysis were applied, respectively. n = 3 (5.6%); grade 1, n = 12 (22.2%); grade 2, n = 31 (57.4%); grade 3, n = 6 (11.1%); grade 4, n = 2 (3.7%). The mean CAT score was 12.85 . The starting dosage was reduced to 200 mg/day in 19 (35.2%) patients.Baseline characteristics of this study are summarized in p = 0.852). The starting dosage was reduced in 14 out of 32 (43.8%) elderly and in 5 out of 22 (22.7%) younger patients (p = 0.151). Significantly higher baseline GAP scores were observed in elderly  compared to younger patients  (p = 0.026), indicating a poorer expected prognosis in the former. There were no significant differences between groups in mMRC, Japanese severity stage, FVC, %FVC, existence of honeycombing or emphysema, previous pirfenidone treatment, or the reduction in the initial nintedanib dosage.The mean CAT score was 12.78  in elderly and 12.95  in younger patients  and within groups  as after 6 months. Subjective improvement was not associated with age or the existence of honeycombing or emphysema in either group.Thus, CAT played an important and superior role in detecting subjective improvements in response to nintedanib treatment irrespective of age.p < 0.001), and between 6 and 12 months after baseline (p = 0.00684). Significant differences (worsening) within the younger group were observed between 6 months prior to baseline and baseline (p < 0.001), between baseline and 12 months after (p = 0.0161), and between 6 and 12 months after baseline (p = 0.0117). No significant differences in FVC changes were found between groups during the 12 months of nintedanib treatment.The mean FVC of all 54 patients 6 months prior to, at the time of, and 6 and 12 months after nintedanib treatment initiation were 2501.5 mL , 2286.3 mL , 2266.3 mL , and 2230.4 mL , respectively. As shown in The mean ΔFVC − 6M%, ΔFVC + 6M% and ΔFVC + 12M% in all 54 patients were −8.64% , −1.42%  and −2.66% , respectively . The meaThese results demonstrate the efficacy of nintedanib in reducing the decline in FVC during the 12-month follow-up and are in accordance with the phase III INPULSIS trials  and theiAmong the elderly patients, the mean mMRC grades at each time point were 1.72 , 1.84 , 1.72 , and 1.72 , respectively A. The meIn the younger patients, the mean mMRC grades at each time point were 1.82 , 1.86 , 1.82 , and 1.82 , respectively A. In thip = 0.0435), between baseline and 6 months after (p = 0.0435), and between baseline and 12 months after (p = 0.0435) (p < 0.001), between baseline and after 6 months (p < 0.001), and between baseline and after 12 months (p < 0.001) (p = 0.585 for both). Taken together, CAT scores provided a more detailed assessment compared with mMRC during nintedanib treatment, irrespective of age.While there was no significant difference in the mMRC grade among younger patients between each time point, significant differences were observed among elderly patients between 6 months prior to baseline and baseline ( 0.0435) A. On the< 0.001) B. There To understand better, the reasons behind the observed improvement in PROs, the relationship between PROs and FVC was examined further (summarized in p < 0.001). Similar results were obtained for the 12-month follow-up, in which 10 (76.9%) out of 13 patients with stable or improved ΔFVC + 12M reported improvement in CAT score, whereas 15 (36.6%) out of 41 patients with declined ΔFVC + 12M showed such improvement (p = 0.023).In 17 and 13 patients, FVC values were stable or improved after 6 or 12 months of nintedanib treatment, respectively. In contrast, FVC values in 37 and 41 patients declined after 6 or 12 months, respectively. There was no significant correlation between ΔFVC + 6M or ΔFVC + 12M and mMRC grade. In contrast, 14 (82.4%) out of 17 patients with stable or improved ΔFVC + 6M also improved in CAT score, while only 11 (29.7%) out of 37 patients with declined ΔFVC + 6M showed such improvement  by nintedanib treatment. These findings suggest that the CAT score could be useful in the subjective assessment of IPF during nintedanib treatment.p = 1.000).IPF-AEs were observed in 2 (6.3%) elderly patients and 1 (4.5%) younger patient, but could be resolved by pulse corticosteroid therapy. There was no significant difference in the incidence of IPF-AE between groups (p > 0.05), suggesting that the tolerability of nintedanib in elderly patients was the same as in younger patients.In total, 40 patients (74.1%) experienced ≥1 adverse event. Adverse events included diarrhea in 31 patients (57.4%), nausea in 11 (20.4%), and elevation of aminotransferases in 14 (25.9%). No patient’s death as well as hospitalization was observed during the observation period. While 4 (12.5%) and 3 (9.4%) elderly patients and 2 (9.1%) and 1 (4.5%) younger patients had comorbidities of ischemic heart disease and cerebral infarction, respectively, which were stable and treated more than 12 months prior to the nintedanib introduction, no acute myocardial infarction or cerebral infarction were observed during the observation period. Diarrhea occurred in 17 (53.1%) elderly patients and 14 (63.6%) younger patients, nausea in 6 (18.8%) and 5 (22.7%), and elevation of aminotransferases in 8 (25.0%) and 6 (27.3%), respectively. There were no significant differences in adverse events or in the incidence of such between groups , FVC, and adverse events. Multiple linear regression analyses were applied to detect factors affecting the improvement in PROs .p = 0.0482 and 0.0188, respectively), no factors could be found that affected the changes in mMRC grade after 12 months. Moreover, smoking habits and a baseline mMRC grade ≥2 affected the changes in CAT scores after 6 and 12 months of treatment .While logistic regression analyses demonstrated that the existence of honeycombing and the baseline mMRC grade affected the changes in mMRC grade after 6 months of treatment , while there was no factor that affected the changes in FVC after 12 months.Baseline GAP points (raw data) and FVC affected the changes in FVC after 6 months (p = 0.0426), and that baseline Japanese severity stage affected the incidence of nausea and elevation of aminotransferases .Logistic regression analyses revealed that the reduced starting dosage of nintedanib (100mg twice daily) affected the incidence of diarrhea (p = 0.0125).Multiple linear regression analyses demonstrated that the baseline Japanese severity stage also affected the improvement in PROs (mMRC grade and CAT score) after 6 months of treatment  patients exhibited stable or improved FVC after 6 months of nintedanib treatment and FVC was sustained in 13 patients (24.1%) for at least 12 months. The PANTHER-IPF trial demonstrated that immunosuppressive treatment deteriorates the prognosis of IPF . ExperimThe introduction of pirfenidone or nintedanib at an early stage of IPF is widely accepted based on the results of phase III trials ,13,14. HRegardless of the aforementioned clinical trials, in some cases antifibrotic treatment is initiated after the disease has already progressed. One reason could be the fear of adverse events, with a lack of clear and visible efficacy. While an increase in adverse events to pirfenidone has indeed been reported in elderly patients , the effThe most reproducible and accessible way to measure IPF disease progression is the evaluation of lung function through FVC, and the assessment of FVC is widely accepted as a primary endpoint in clinical trials. Because the baseline FVC does not allow to predict the development of IPF and the FVC of patients with preserved lung function equally deteriorates over time , the folThe underlying mechanism responsible for the improvement in FVC remains unclear. Nintedanib is a multikinase inhibitor that blocks platelet-derived growth factors and downstream signals, such as phosphatidylinositol-4,5-bisphosphate 3-kinase , which aSymptoms of IPF that may not be reflected by FVC function such as cough, dyspnea, and fatigue affect QOL and life expectancy and should, therefore, be fully considered in the treatment of IPF . This coIn addition to subjective symptoms and FVC, also IPF-AE should be considered with care, as it is the main cause of death in IPF patients . NintedaThe current study has some limitations. Since it was a retrospective observational investigation with a small sample size, the bias may be higher as compared to studies with larger populations. Therefore, the treatment strategy for elderly IPF patients with nintedanib should be confirmed in prospective randomized trials with larger sample sizes.Taken together, we demonstrate the efficacy and tolerability of nintedanib in the treatment of elderly IPF patients. We also found that nintedanib exhibited positive effects on PROs, and that CAT score, also reflecting FVC changes, is superior to mMRC grading in assessing these effects, regardless of age. Seventeen and 13 patients out of 54 showed stable or improved FVC after 6 or 12 months of nintedanib treatment, respectively. The changes in CAT score were in accordance with these objective outcomes. Therefore, CAT scores may be useful in monitoring nintedanib treatment efficacy regardless of age.


Colposcopy serves as a subjective examination of the cervix with low sensitivity to detect cervical intraepithelial dysplasia (CIN) grade 2 or worse (CIN2 +). Dynamic spectral imaging (DSI) colposcopy has been developed to provide an objective element to cervix examinations and has been proven to increase sensitivity of detecting CIN2 + . We aimed to assess the performance of the DSI color map and compared it to histological diagnoses of cervical biopsies in determining the CIN grade present.Women were included in a consecutive, prospective manner at Randers Regional Hospital, Denmark. Women were eligible to participate if they were referred for colposcopy due to abnormal cervical smear (threshold:  ≥ ASCUS) or follow-up after previously diagnosed CIN. All women had four biopsies taken, one directed by colposcopists alone prior to viewing the DSI color map, one directed by the worst color on the respective DSI color map, and two additional biopsies. All biopsies were analyzed separately. We calculated sensitivity, specificity, positive predictive values, and negative predictive values (NPVs) with 95% confidence intervals (CIs).A total of 800 women were recruited. Of these, 529 (66.1%) were eligible for inclusion. The sensitivity of the DSI color map was found to be 48.1% (95% CI 41.1–55.1) in finding CIN grade 2 or worse (CIN2 +) when compared to the histological diagnosis of the DSI directed biopsy. This was 42.5% (95% CI 36.7–48.5) when compared to the final histological diagnosis of all four cervical biopsies and with an NPV of 53.5% (95% CI 50.5–56.5).The worst color indicated by the DSI map might not consistently reflect the true grade of cervical dysplasia present. Thus, even though the DSI color map indicates low-grade changes, colposcopists should still consider taking biopsies from the area as high-grade changes might be present.Trial registration: NCT04249856, January 31 2020 (retrospectively registered). Colposcopy has been used since the 1920s to examine the uterine cervix by magnifying the transformation zone. Potential signs of precancerous cervical lesions are evaluated and cervical punch biopsies are taken to provide a histological diagnosis of any cervical intraepithelial neoplasia (CIN) or carcinoma. In many countries, however, biopsies are not mandatory part of every colposcopy procedure ; consequNew digital technologies have been developed to provide a more objective, reproducible evaluation of the cervix and to assist colposcopists in choosing the area(s) to biopsy. One such technology is dynamic spectral imaging (DSI) colposcopy , which can increase the sensitivity of CIN2 + detection by colposcopy from 55 to 88% . The DSIIt is essential that the DSI color map directs colposcopists to the most worrisome area(s) to improve the detection of CIN and prevent precancerous cervical lesions from being missed in women. The objective of this study is therefore twofold: (1) to compare the worst color on the DSI color map to the histological diagnosis of the biopsy taken from the worst indicated area and (2) to compare the worst color on DSI color map to the final histological diagnosis (FHD) found by four cervical punch biopsies. These comparisons determine whether the DSI color map can correctly guide the colposcopists in taking biopsies from the most severe intraepithelial lesions.Women were included in a prospective, consecutive, non-randomized manner at the outpatient clinic of Randers Regional Hospital between 1 February 2017 and 31 December 2019. All colposcopy referrals were considered, including women screened by invitation in the national screening program and women examined with symptoms. Women were eligible to participate if they were over 18 years of age and were referred to colposcopy with an abnormal cervical smear that is, atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSILs), atypical squamous cells favoring high grade (ASC-H), high-grade squamous intraepithelial lesions (HSILs), atypical glandular cells (AGCs), adenocarcinoma in situ (AIS), adenocarcinoma (ACC), or squamous cell carcinoma (SCC). In women above the age of 29 and an ASCUS cytology sample, HPV testing was routinely performed. Women who underwent a follow-up colposcopy due to a previous CIN diagnosis were also included. Women who had cervical punch biopsies less than six months prior were excluded. Other exclusion criteria were previous cervical conization, current pregnancy or pregnancy in the prior three months, and previous pelvic radiation therapy. Women with a non-visible transformation zone and those with one or more cervical biopsies unsuitable for pathological analysis were excluded from the analysis. Women eligible to participate were identified by colposcopists who informed them about the study. The participants gave oral and written consent and provided information on their height, weight, smoking habits, previous pregnancies, contraception use, and human papillomavirus (HPV) vaccination status in a short baseline data sheet.DySIS Medical Instructions for Use, the colors cyan, blue, and green were considered to represent low-grade cervical changes, whereas red, yellow, and white were considered to represent high-grade cervical changes (CIN2 +) . Biopsy number two was marked according to the area the DSI color map indicated as the worst. Biopsy numbers three and four were then marked as additional biopsies and taken from two quadrants not represented in the first two biopsies. If the colposcopist and DSI color map agreed on the worst area, one biopsy was taken from that area and then three additional biopsies. All biopsy records were stored in the DSI system. Each biopsy was taken with 3-mm forceps and placed in a separate container with the corresponding number and sent for analysis, which was made by one of two gynecological pathologists in the Pathology Department of the Regional Hospital in Randers. Pathologists were blinded to number and origin of the biopsy and each biopsy diagnosis was recorded separately. The final histological diagnosis (FHD) was based on the worst of the four cervical punch biopsies, and the participants were subsequently treated according to the Danish national guidelines  i.e. seeColposcopists recorded their own clinical backgrounds , type of transformation zone seen , visible signs of dysplasia, and their own colposcopic impressions.We defined low-grade referrals as women referred due to ASCUS or LSIL cytology or follow-up colposcopy due to previous CIN grade 1 (CIN1) diagnoses. High-grade referrals were defined as women referred to colposcopy due to ASC-H, HSIL, AIS, AGC, ACC, SCC, or for a follow-up colposcopy due to previous CIN2 + diagnoses. We also chose to classify ungradable CIN with CIN2 in our analysis, as these women were most likely to have follow-ups in six month intervals, which was the same as the recommended follow-up time for CIN2 in the national guidelines.Sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated with 95% confidence intervals (CIs). We assumed the FHD based on the four cervical punch biopsies to represent the true dysplasia grade. Our previous study showed a concordance of 95% between the FHD and the conization specimen . Stata 1The Central Denmark Region Committees on Biomedical Research Ethics determined that the project was exempt from approval; it was viewed as a quality-improvement study (jr.nr. 1-10-72-262-16). The study was approved by the Danish Data Protection Agency (jr.nr. 1-16-02-534-16).A total of 800 women were examined by DSI colposcopy at our department during the study period. Of these, 529 66.1%) fulfilled all the study inclusion criteria   had an FHD of CIN2 + . For low-grade referrals, this was 37.3%, and for high-grade referrals, it was 72.3%. Conization by LEEP was performed in 186 women (35.2%). We found a concordance of 95.7% between the histological diagnosis of the cone specimen and the FHD based on the four cervical punch biopsies in this subgroup. Women found with CIN2 who did not undergo conization were managed conservatively and followed after six months, in accordance with national guidelines. In the 287 women who had a FHD of CIN2 + we calculated the percentage yield of CIN2 + for each additional biopsy based on whether the colposcopist and the DSI map agreed on the most abnormal area, see Fig. Colposcopists recorded the worst color observed on the DSI color map as 28.2% (n = 149) cyan, 23.2% (n = 123) blue, 15.7% (n = 83) green, 13.4% (n = 71) red, 7.4% (n = 39) yellow, and 12.1% (n = 64) white, meaning that 67.1% (n = 355) of the women were indicated to have low-grade cervical dysplasia and 32.9% (n = 174) to have high-grade cervical dysplasia by the DSI color map.We compared the worst color indicated by the DSI color map to the histological diagnosis of the DSI-directed biopsy, the distribution between which can be seen in Table The DSI color map had a sensitivity of 48.1% (95% CI 41.1–55.1) and a specificity of 77.0% (95% CI 72.0–81.4) to correctly identify CIN2 + when compared to the DSI-directed biopsy. For low-grade referrals, sensitivity was 44.1% (95% CI 32.1–56.7), and for high-grade referrals, sensitivity was 50.0% (95% CI 41.4–58.6). The PPV of the DSI color map compared to the DSI-directed biopsy alone was 57.5% (95% CI 51.4–63.2), and the NPV was 69.6% (95% CI 66.5–72.5)  and a specificity of 78.5% (95% CI 72.8–83.5) to correctly identify CIN2 + when compared to the FHD. The PPV was 70.1% (95% CI 64.0–75.6), and the NPV was 53.5% (95% CI 50.5–56.5). For low-grade referrals, sensitivity was 37.3% (95% CI 27.9–47.4), and for high-grade referrals, it was 45.4% (95% CI 38.1–52.9), with specificity being 79.5% (95% CI 72.7–85.3) for low-grade referrals and 76.1% (95% CI 64.5–85.4) for high-grade referrals , 99 (37.6%) had an FHD of CIN2 + . In these women who were referred with low-grade cytology but had a high-grade FHD (99 women), the DSI color map showed low-grade colors as the worst in 62 of them (62.6%). More specifically, cyan was the worst color in 28 (28.3%), blue in 19 (19.2%), and green in 15 (15.2%). Of these 99 women, 38 had CIN3 + , and 52.6% of these CIN3 + diagnoses (20 of 38) had colors indicating low-grade disease as the worst color on the DSI color map.We further calculated performance variables based on the histological diagnosis of the DSI-directed biopsy compared to the FHD of all four biopsies. The DSI-directed biopsy had a sensitivity for CIN2 + detection of 72.5% (95% CI 66.9–77.6); this was 66.7% (95% CI 56.6–75.7) for low-grade referrals and 76.9% (95% CI 70.1–82.8) for high-grade referrals. The NPV was 75.4% (95% CI 71.7–78.7) for all, 83.4% (95% CI 79.3–86.9) for low-grade referrals, and 62.8% (95% CI 56.5–68.8) for high-grade referrals.In total, seven women (1.3%) were diagnosed with cervical cancer following the colposcopy examination. In these women, the worst colors indicated by the DSI color maps were as follows; two cyan , one blue (SCC stage IB), one green (SCC stage IA1), one red (one SCC stage IA1), one yellow (SCC stage 2B), and one white (SCC stage IA1). Cervical cancer stages were classified according to the The International Federation of Gynecology and Obstetrics (FIGO) 2009 classification. In all the seven cancer cases high-grade histological disease was identified by both the CDB and the DSI directed biopsies.We found that the DSI color map yielded a sensitivity of 42.5% to correctly identify high-grade dysplasia (CIN2 +) irrespective of the referral diagnosis, compared to the FHD based on four biopsies as the golden standard. This was 37.3% for low-grade referrals and 45.4% for high-grade referrals. Furthermore, comparing the histological diagnosis of the DSI-directed biopsy to the FHD we found the sensitivity to be 72.5%. The NPV was only 53.5% compared to the FHD and was especially low in high-grade referrals: 34.8%.Louwers et al.  found thAceto-white epithelium can represent a wide range of changes on the cervix and is not always representative of precancerous lesions.  DSI techColposcopy guidelines from the UK and USA state that women with normal colposcopic impressions who are referred with low-grade cytology can be observed without biopsies , 2. In oTo the best of our knowledge, no other country but Denmark recommends four biopsies to be taken in all women, and neither has any other study published on DSI technology included four biopsies. In Wales, Budithi et al.  reportedAs mentioned earlier, the main strength of this study was that all women had four biopsies performed, so we could limit verification bias and approach the true dysplasia grade as close as possible without performing unnecessary conizations. With our study design, we provided the histological diagnosis from each biopsy taken and correctly indicated the degree of cervical dysplasia from the specific area indicated by the DSI color map. The pathologists analyzing the biopsies did not know which biopsy represented which area. However, one limitation of this design is that a single biopsy indicating high-grade disease would influence the FHD, meaning it was not possible to calculate specificity when comparing the histological diagnosis of the DSI-directed biopsy to the FHD, as no biopsy would be considered a false positive, which further limits the statistical comparison of sensitivities, as the different gold standards are not independent of each other. Intra- and interobserver variability in the pathological grading of CIN is another limitation of the study . In addiIt is important to correctly diagnose the degree of cervical dysplasia to be able to offer women conservative management safely. This might allow longer time periods between follow-ups in the future; however, further research is still needed to determine this.We found that the worst color indicated by the DSI color map might not be correct in reflecting the worst grade of cervical dysplasia present in women referred with abnormal cervical cytology. Thus, our results show colposcopists should be cautious to avoid misinterpreting colors indicating low-grade dysplasia without biopsy, as there could still be high-grade disease present. Multiple biopsies are recommended.Additional file 1: Detailed distribution of worst DSI colors and histological diagnoses of the DSI-directed biopsies.Additional file 2: Detailed distribution of worst DSI colors and final histological diagnosis of all four cervical biopsies.