Onchocerca volvulus infection in a rural population in Ituri province, Democratic Republic of Congo.A high prevalence of epilepsy has been observed in many onchocerciasis endemic regions. This study is to estimate the prevalence of active epilepsy and exposure to O. volvulus was assessed by testing for IgG4 antibodies to an O. volvulus antigen  in individuals aged 3 years and older.In August 2016, a community-based cross-sectional study was conducted in an onchocerciasis endemic area in the rural health zone of Logo, Ituri Province. Households within two neighbouring health areas were randomly sampled. To identify persons with epilepsy, a three-stage approach was used. In the first stage, all individuals of the selected households were screened for epilepsy by non-medical field workers using a validated 5-item questionnaire. In the second and third stage, suspected cases of epilepsy were examined by non-specialist medical doctors, and by a neurologist, respectively. A case of epilepsy was defined according to the 2014 International League Against Epilepsy (ILAE) guidelines. Exposure to CI]: 3.6–5.8). The highest age-specific epilepsy prevalence estimate was observed in those aged 20 to 29 years (8.2%). Median age of epilepsy onset was 10 years, with a peak incidence of epilepsy in the 10 to 15 year-old age group. OV16 test results were available for 912 participants, of whom 30.5%  tested positive. The prevalence of OV16 positivity in a village ranged from 8.6 to 68.0%. After adjusting for age, gender and ivermectin use, a significant association between exposure to onchocerciasis and epilepsy was observed  (P < 0.001).Out of 1389 participants included in the survey, 64 were considered to have active epilepsy   contains supplementary material, which is available to authorized users. Please see Additional file In 2016, an estimated 14.6 million people were infected with onchocerciasis worldwide, with over 99% of cases occurring in sub-Saharan Africa  × {[p (1 – p)] / d2}  / d2} . For an )] / d2}  and a taData collection tools were developed in the open source software ‘Open Data Kit’  and EpiCContinuous variables were analysed using medians and interquartile ranges, whereas categorical variables were analysed using frequencies and percentages. The prevalence of epilepsy was calculated by dividing the number of epilepsy cases confirmed in stage 3 by the total number of individuals screened in stage 1.To calculate incidence estimates of epilepsy in the study population, cases of epilepsy identified in stage 2 were asked to provide an estimate of the number of months that they had been living with the diagnosis of epilepsy. All subjects with confirmed epilepsy with an onset of seizures within the 12 months prior to the survey, were included into the calculation of epilepsy incidence. Estimates of epilepsy incidence were calculated by dividing the number of incident cases in the previous 12 months by the summed person-years of the population at risk in these 12 months. Person-time at risk was estimated using the following formula: {[ / 2] × }. Age, gender and area-specific prevalence and incidence rates were calculated.O. volvulus  and epilepsy and whether individuals living at higher/lower altitude (per 1000 m) had a higher risk of having epilepsy or being positive for O. volvulus infection. Additionally, the effect of the number of neighbouring individuals with epilepsy (within 250 m distance) on the individual risk of having epilepsy or being OV16 positive was investigated. Adjusted odds ratios and their corresponding 95% confidence intervals (CIs) were calculated.In order to examine spatial aggregation of epilepsy cases and to test whether any location-specific variables influenced the presence of the disease, a joint point-referenced spatial hierarchical model based on Lindgren et al.  was fittTo account for the correlation (clustering) of individuals within households, villages and health areas, a household, village and health area random effect was included in the model, as well as a spatially structured random effect to account for the correlation of observations across space. This spatially structured random effect was modelled using a stochastic partial differential equation (SPDE), similar to what is used in geostatistical models to estimate the spatial range . This can be viewed as some sort of spatial aggregation where observations within the spatial range are considered spatially autocorrelated, whereas observations outside the range, are considered independent (correlation < 0.1).All statistical analyses were performed using the R statistical computing environment . Fittingn = 1133) were fathers or husbands for 711 (62.8%) subjects, mothers or wives for 354 (31.2%) subjects and brothers, sisters, aunts and grandmothers for the remaining 68 (6.0%) subjects.A total of 256 households agreed to participate in the study, corresponding to 1403 individuals. Of these individuals, 14 (1%) refused to participate. Households were dispersed over 20 villages, covering two health areas: Draju  and Kanga  ; 34.5% were younger than 10 years; 51.3% were females (Table CI: 5.8–8.4) were suspected of having epilepsy  (95% CI: 3.7–5.9). The reasons for ruling out epilepsy at this stage were febrile convulsions (n = 4), sleep disorders with night terrors (n = 1), vertigo (n = 1), headache (n = 1), misinterpretations of screening questions (n = 4) and epilepsy being no longer present (n = 1).In stage 2, 77 (79.4%) of the 97 individuals with suspected epilepsy were examined by a general practitioner; 65 (84.4%) of them were confirmed to have epilepsy  (95% CI: 2.4–4.2). The reasons for ruling out epilepsy at this stage were febrile convulsions (n = 2), hyperventilation (n = 1), sleep disorders (n = 1) and only one episode of seizures (n = 1).Only 49 (75.4%) of the 65 persons suspected of having epilepsy in stage 2 were seen by the neurologist (DM), of whom 44 (89.8%) were confirmed to have active epilepsy  (95% CI: 3.6–5.8).An additional 20 out of 36 people who were not seen by the neurologist, had at least 3 positive answers on the epilepsy screening questionnaire or had been previously told by a doctor to have epilepsy. Therefore, a total of 64 individuals were considered to be cases of epilepsy, corresponding to a prevalence of 4.6% (95% The median age of persons with epilepsy was 17.0 years IQR: 13–28) and 14 years (IQR: 7.0–30.0) for persons without epilepsy. The highest epilepsy prevalence (8.2%) was observed in the 20–29-year age group (Table 8 and 14 P = 0.20)  with epilepsy had ever been treated with ivermectin. Epilepsy prevalence was slightly, but not significantly, higher in Draju 5.4%) compared to Kanga (3.9%) (.4% compaCI: 3.8–13.4) per 1000 person-years. Age-specific incidence was 6.5 (95% CI: 1.7–17.8) per 1000 person-years for those below the age of 10, and 19.6 (95% CI: 8.6–38.8) per 1000 person-years for those aged 10 to 19 years. Gender specific incidence was 6.2 (95% CI: 2.0–15.1) per 1000 person-years for males, and 8.9 (95% CI: 3.6–18.5) per 1000 person-years for females. Epilepsy incidence was 9.8 (95% CI: 4.0–20.4) per 1000 person-years in Draju health area and 5.6 (95% CI: 1.8–13.5) per 1000 person-years in Kanga health area.In ten subjects, seizures appeared for the first time during the 12 months preceding the survey, corresponding to an annual incidence of epilepsy of 7.5 ; 15 (31.3%) were between ten and 15 years old  reported to have daily seizures. Generalized tonic-clonic seizures were the most common type of seizures . Absences were present in 4/44 individuals (9.1%). Although ‘head nodding’ was recorded in 15 (27.8%) of 54 subjects, a diagnosis of probable nodding syndrome could only be upheld in eight (14.8%) of 54 individuals with epilepsy. No specific trigger could be identified in 26/31 individuals (83.9%). Twenty (37.0%) of 54 subjects had other family members suffering from epilepsy.Two persons (9.5%) had a low body mass index-for-age, eight 38.1%) presented with low height-for-age (Table 8.1% presIn 49 of 50 persons (96%) with epilepsy there was no history of birth trauma. In two (4.1%) of 49 persons with epilepsy, there was a history of prematurity, two (4.2%) had suffered from a head trauma in the past, one (2.0%) from meningitis and four (8.2%) had recovered from severe malaria; two (6%) had experienced febrile convulsions. Developmental delays before the onset of epilepsy were noted in seven (14.6%) of 48 individuals (not in table).Thirty-one (64.6%) of 48 subjects with confirmed epilepsy reported to have ever been treated with anti-epileptic drugs, mainly with phenobarbital  and phenytoin . Seven (22.6%) were treated continuously, 24 (77.4%) at irregular intervals; 20/48 (41.7%) reported to have ever used traditional medicine to treat epilepsy.OV16 tests were performed in 912 (65.7%) subjects ; 16 (1%) refused to have the test performed, 97 (7%) were younger than 3 years and 364 (26%) were absent when their household was visited. The following results only relate to those persons for whom OV16 test results were available.CI: 27.6–33.6). The proportion of positive test results increased with increasing age groups until the age of 40 (Table P = 0.014).OV16 test results were positive in 278 (30.5%)  of 3.19 . The results also showed that OV16 positivity, but not the presence of epilepsy, was significantly associated with lower altitude. For every 1000 m increase in altitude, the odds of being OV16 positive was approximately 90% lower than the odds of being OV16 negative .The results from the spatial analysis  showed a significant association between epilepsy and exposure to OR = 2.19, 95% CI: 1.69–2.82). The odds of being OV16 positive increased by approximately 15% for each additional OV16 positive case within the neighbourhood (250 m distance) . Spatial aggregation/autocorrelation of cases was found within approximately 400 m for epilepsy and 300 m for OV16. Outside of this range, the correlation became negligible.A significant neighbour effect was noted for both epilepsy and OV16 seropositivity. The odds of being positive for epilepsy increased by more than 100% for each additional case of epilepsy within the neighbourhood (250 m distance)  and incidence (7.5 per 1000 person-years) in two health areas of the Logo health zone (Ituri Province), although this is lower than the prevalence of 6% reported in a survey in Draju Village in 2015 . The latO. volvulus as the trigger of nodding syndrome, is that this disease does not exist in onchocerciasis endemic regions outside of Uganda, South Sudan and Tanzania. This study suggests that nodding syndrome may be underdiagnosed in onchocerciasis endemic regions, simply because it has never been investigated. During a recent epilepsy prevalence study in the Mbam Valley, an onchocerciasis endemic region in Cameroon, persons presenting with nodding type of seizures were observed as well ) sampled at high altitude in this study.Our study has several limitations. A three-stage approach was used to identify cases with epilepsy, but attrition between survey stages was high. A similar problem was reported by Ngugi et al., during epilepsy surveys in 5 demographic surveillance sites in Africa . They adTaenia Solium antigens .Furthermore, the epilepsy screening questionnaire used in this study was only validated in Mauritania, but not locally. In addition, laboratory investigations and neuro-imaging to identify alternative causes of epilepsy, such as neurocysticercosis, and video-electro-encephalograms to document the type of seizures, were not performed. However, neurocysticercosis does not seem to be a frequent cause of epilepsy in this area, because the onset of this form of epilepsy is generally after the age of 20 , 31. MorBias may have been introduced in our study in several ways. As epilepsy was only reported, but not observed, we cannot exclude the possibility of response bias. Age at epilepsy onset, and resulting incidence estimates, may have been prone to recall bias. Additionally, interviewers in the validation and confirmation stage were aware of the potential epileptic status of participants, which could have introduced information bias. Moreover, detailed clinical examinations were only performed in subjects with suspected epilepsy. Although epilepsy prevalence was calculated at village level, little inference can be made from these estimates, due to the low number of individuals sampled from each village.O. volvulus, as indicated by the low percentage of OV16 positive children. At repeated visits to the area, it was difficult to find actively biting anthropophilic blackflies. Interviews with local people revealed that in recent years, exposure to blackflies has decreased. The current O. volvulus transmission zones seem to be limited to recently identified valley bottoms with riverine gallery forest or banana tree edges, located within flight range of blackflies. We hypothesize that deforestation in the area over the last 30 years has caused a decrease in the blackfly population, because the local O. volvulus vector is forest dependent .Another point that needs to be addressed, is the low, but still ongoing transmission of However, given the ongoing onchocerciasis transmission and the high prevalence of epilepsy in the health areas included in this study, a CDTI programme needs to be established, together with a decentralised system to treat persons with epilepsy. This will require task shifting of the clinical management of epilepsy to lower cadres and an increase of access to anti-epileptic treatment. In collaboration with Malteser International , which hO. volvulus were observed in the rural health areas of Draju and Kanga . There is an urgent need to implement a CDTI programme and to scale up an epilepsy treatment and care programme.A high prevalence of epilepsy and a significant association between epilepsy and exposure to Additional file 1:Multilingual abstract in the five official working languages of the United Nations. (PDF 248 kb)Additional file 2:Village-specific prevalence of epilepsy. (PDF 11 kb)Additional file 3:Percentage of individuals with a positive OV16 antibody test result by village. (PDF 11 kb)


Since the physiological uptake pattern of FDG around a joint prosthesis is not fully elucidated, we determined the physiological FDG uptake in non-infected total hip prostheses.Background and purpose — max and SUVpeak) by volume of interests (VOIs) at 8 different locations around the prosthesis.Patients and methods — Patients treated with primary total hip arthroplasty (1995–2016) who underwent a FDG-PET/CT for an indication other than a suspected PJI were retrospectively evaluated. Scans were both visually and quantitatively analyzed. Semi-quantitative analysis was performed by calculating maximum and peak standardized uptake values (SUVmax in the cemented group was 2.66 (95% CI 2.51–3.10) and in the uncemented group 2.87 (CI 2.65–4.63) (Median difference = –0.36 [CI –1.2 to 0.34]). In uncemented prostheses, there was a positive correlation in time between the age of the prosthesis and the FDG uptake (rs = 0.63 [CI 0.26–0.84]).Results — 58 scans from 30 patients were analyzed. In most hips, a diffuse heterogeneous uptake pattern around the prosthesis was observed  and most uptake was located around the neck of the prosthesis. The median SUVInterpretation — Our study provides key data to develop accurate interpretation criteria to differentiate between physiological uptake and infection in patients with a prosthetic joint. Diagnosing a periprosthetic joint infection (PJI) can be a clinical challenge, especially for chronic and low-grade infections. The preoperative diagnostic work-up, e.g. serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), synovial culture, and several synovial biomarkers can be false negative or false positive  scintigraphy is currently considered as the gold standard, because of its high specificity for infection , which can be combined with computed tomography (CT) for exact anatomical localization (the CT part) of the accumulation of FDG  were collected retrospectively. Patients were included only if they had no clinical signs  of a PJI at the time the FDG-PET/CT scan was performed. The included patients were divided into 2 groups, cemented and uncemented.All FDG-PET/CT scans were performed with an EARL accredited scanner, Siemens Biograph MCT 64 or 40 slice . Patients were instructed to fast for at least 6 hours prior to the administration of FDG. Blood glucose levels were measured before injection of the FDG and had to be below 11 mmol/L. The acquisition of the scan started after a resting time of approximately 60 minutes after 3 MBq/kg FDG administration. All scan acquisition parameters were according to existing guidelines from the European Association of Nuclear Medicine (EANM) , diffuse homogeneous (relative constant uptake around the prosthesis), focal (1 spot with high intensity), and no uptake. In addition, when there was extension of FDG uptake in the soft tissues surrounding the prosthesis this was recorded.For the semi-quantitative analysis, volumes of interests (VOIs) were created in each scan at 8 different locations around the prosthesis . From these VOIs the maximum and peak standardized uptake value  were determined.max and SUVpeak at the 8 regions was calculated, as a representative of the uptake of the whole prosthesis (meanSUVmax and meanSUVpeak). These values were corrected for background SUV, using the mean SUV (SUVmean) of the liver (meanSUVmax/liver ratio and meanSUVpeak/liver ratio). Finally, the correlation of the 4 variables between the age of the prosthesis and FDG uptake was determined.The mean of the SUVhttps://www.statsdirect.co.uk/) was used for calculating the confidence intervals (CI) for both the difference in mean values and the correlation coefficient. Since in clinical practice a PJI can occur in any joint prosthesis, regardless of the age of the prosthesis, all values were considered practically relevant and included in the CI. Continuous variables were presented as means (SD) or . Not normally distributed data were presented with the median and interquartile ranges (IQR) or with the CI of the mean. Differences between groups were calculated with the Mann–Whitney U-test. Correlation between the age of the prosthesis and the SUV uptake was calculated with Spearman’s rho. Differences in uptake between the locations were calculated with Friedman’s ANOVA. In the case of a statistically significant result, Wilcoxon’s signed rank test was used for post hoc calculation. A p-value <0.05 was considered significant, without correction for multiple comparisons. Effect size estimates (r) for Mann–Whitney U and Wilcoxon signed rank test was calculated as r = z ⁄ √N , medium (0.3–0.5), and small (< 0.3). Moreover, to overcome the problem of correlated observations, additional analyses were done with only the last available scan of each patient.IBM SPSS statistics version 20  was used for statistical analysis. Additionally, StatsDirect version 3 . None of the authors has had funding that might pose a conflict of interest in connection with the submitted article.max = 2.57 [IQR 2.08–3.21]) and non-oncological indicated scans (meanSUVmax = 3.01 [IQR 2.32–3.95]).Finally, 33 patients, with 42 total hip prostheses and 58 FDG-PET/CT scans, were included . The indThe cemented group consisted of 38 prostheses scanned in 21 patients (median age 73 years [IQR 66–79]). 19 of these prostheses were scanned once in 15 different patients. 7 cemented hip prostheses in 5 patients were scanned twice, with a median time between the 2 scans of 1 year (IQR 0.4–3.9). 1 hip prosthesis was scanned 5 times within a duration of approximately 4 years. The uncemented group consisted of 20 scans from 12 patients (median age 52 years [IQR 50–67]). 9 patients (11 prostheses) were scanned once. 2 patients with 3 prostheses were scanned twice (median time between 2 scans: 0.2 years [IQR 0.1–0.2]), and 1 hip prosthesis in a different patient was scanned 3 times within a duration of 9 months.Visually, 39/42 prostheses showed uptake of FDG around the prosthesis. Diffuse heterogeneous uptake  was the max in the cemented group was 2.7 (CI 2.5–3.1) and in the uncemented group 2.9 (CI 2.7–4.6) (median difference –0.36 [CI –1.2 to 0.34]). Also, without correlated observations the groups were similar. Other variables did not differ statistically significantly between groups either: meanSUVpeak , meanSUVmax/liver ratio , meanSUVpeak/liver ratio . The background uptake (SUVmean) in the liver was for the cemented group 2.9 (IQR 2.6–3.3), for the uncemented group 2.7 (IQR 2.3–3.0). The age of the patient did not statistically significantly influence the FDG uptake in either the cemented group  or the uncemented group . The SUVmax at the 8 different locations around the prosthesis is given in r = [range –0.57 to –0.87], p < 0.001) and the uncemented group . Furthermore, other locations with increased uptake were observed at the lateral and medial acetabulum and the greater and lesser trochanter. The tip of the prosthesis showed minimal uptake. In addition, minimal uptake was observed at the femur–prosthesis interface of uncemented hip prostheses. FDG uptake in this location was absent in 34/38 cemented hip prostheses. The uptake between the cemented and uncemented prostheses was significantly different at the femur–prosthesis interface location  . FDG uptake at other locations was similar between the cemented and uncemented prostheses.The median value of the meanSUVmax: sr = 0.63 [CI 0.26–0.84], p = 0.003; meanSUVpeak: sr = 0.61 [CI 0.24–0.83], p = 0.004; meanSUVmax/liver ratio: sr = 0.63 [CI 0.26–0.84], p = 0.003; meanSUVpeak/liver ratio: sr = 0.65 [CI 0.29–0.85], p = 0.002). This was also observed in the results without correlated observations . The FDG uptake in the uncemented prostheses remains stable for the early years, but an increase was observed after approximately 13 years.The median time between the hip arthroplasty and the FDG-PET/CT scan was 3.9 years (IQR 1.2–9.1) in the cemented group and 6.6 years (IQR 1.6–15) in the uncemented group. In the cemented group, no relation was found between FDG uptake and the age of the prosthesis. However, a moderate relationship was found between FDG uptake and the age of the prosthesis in the uncemented group . This resr = –0.43, p = 0.03 ). After 5 years, the cemented prostheses show a relatively stable FDG uptake pattern over time.In general, the cemented total hip prostheses showed a mild decline in FDG uptake in the first 5 years after implantation  and/or subtle aseptic loosening, although no differences in implant survival between cemented and uncemented total hip prosthesis are described in the literature  reactive inflammation due to a foreign body and a PJI.SG: including patients, analysis of the data, interpretation and presentation of the results, main author. AG, PJ, and MW-B: study design, writing of the manuscript and supervising SG in analyzing and presenting the data. RB: analyzing the data and critical review of the manuscript. JP and GK: critical review of the manuscript. DVG: statistical analysis.Acta thanks Zohar Keidar and Samantha Terry for help with peer review of this study.


IntroductionCoronary artery aneurysms (CAA) are not commonly seen in the general population, with an incidence of approximately 0.37% to 2.53%. Patients are typically asymptomatic but symptomatic presentation varies from dyspnea and angina to myocardial infarction or even sudden cardiac death.MethodsWe conducted a retrospective analysis using the National Inpatient Sample Healthcare Cost and Utilization Project (NIS-HCUP) database to query individuals with the diagnosis of CAA with the International Classification of Disease (ICD) code 414.11 in all discharge diagnoses for the years 2006-2014. History of Kawasaki disease was determined by ICD code 446.1.ResultsFrom 2006 to 2014, there were 23,033 patients identified with CAA, correlating to approximately one case per 10,000 patients or an incidence of close to 0.01%. Of this, 1,405 or approximately 6.1% of these patients had Kawasaki disease. The mortality rate of CAA was 1.79%. In terms of demographics, Caucasians were the most likely to develop CAA, with 73.8% of cases. The mean age was 61.2 years, with a mean length of stay of 5.1 days. The average cost of admission was $70892. The presence of perivascular disease (15.5% vs 4.5% p<0.05), hypertension (66.1% vs 39.1% p<0.05), chronic lung disease (20.2% vs 15.1% p<0.05), diabetes (21.7% vs 15% p<0.05), renal failure (11% vs 8.8% p<0.05), coagulopathy (6.2% vs 3.4% p<0.05), and obesity (13.1% vs 8.2% p<0.05) were all risk factors for CAA as compared to those without. It was noted that weight loss (3.28% vs 1.91% p<0.05), electrolyte abnormalities (18.2% vs 15.5% p<0.05), and blood loss (2.1% vs 0.9% p<0.05) were protective of CAA.ConclusionCAA risk factors appear to be similar to those of coronary artery disease risk factors, with hypertension, diabetes, perivascular disease, and renal failure. Additionally, obesity was noted to be a risk factor but weight loss appeared to be protective. Interestingly, Kawasaki disease was seen at almost similar rates as these cardiac risk factors. The incidence of CAA we found, of almost 0.01%, is much less than in the quoted literature, however, previous studies did not have as many cases as our study. Coronary artery aneurysms (CAA) or coronary artery ectasias are not common, with a quoted incidence of 0.37%-2.53% . ClinicaData sourceData were queried via the National Inpatient Sample (NIS) developed in part by the Healthcare Cost and Utilization Project (HCUP). The NIS database is one of the largest publicly available all-payer databases in the United States. The dataset per year represents approximately 35 million hospital admissions nationally.Study populationWe queried the NIS database from the year 2006 to 2014 to look at individuals with the diagnosis of CAA with the International Classification of Disease (ICD) code of 414.11 in all discharge diagnoses for the years 2006-2014.VariablesPatients diagnosed with CAA were then analyzed to look at demographics. This included in-hospital mortality, age, and gender. Total hospital charges and length of stay were also analyzed. We additionally identified the average income quartile calculated from the patient's residential zip code as well as the number of procedures performed during the hospitalization. In-hospital mortality scores were based on the Elixhauser Comorbidity Index, which is a dichotomous method of categorizing the comorbidities of patients based on ICD codes. Comorbidities were established using the Elixhauser-determined comorbidities. History of Kawasaki disease was determined by ICD code 446.1.Statistical analysisStatistical analyses were performed using SAS software, version 9.4 . Data were weighted as provided by HCUP in order to generate national estimates. Categorical variables were analyzed using chi-square analysis and continuous variables were tested using analysis of variance (ANOVA). For further delineation of the analysis, multivariate regression was also used to determine inter-racial discrepancies and disparities. The level of statistical significance (α) was chosen as 5%.Through the timeframe of our study from 2006-2014, 333,933,821 hospital admissions were analyzed. During this timeframe, there were 23,033 patients who had CAA, correlating to almost one case per 10,000 patients. Of this amount, 1,405 patients or approximately 6.1% of patients were found to also have Kawasaki disease. In terms of demographics, females represented 29.98% of patients . In addition, Caucasians were found to be the most frequent race involved, with a total of 14,336 patients comprising 73.8% of total CAA patients. During the study period, 412 patients died with CAA during their hospitalization, correlating to a mortality rate of approximately 1.79%. The average age of patients with CAA was 61.2 years, with the average length of stay during the hospitalization being 5.12 days. The average total cost billed for the hospitalization for patients with CAA was roughly $70,892, with the average income quartile indicated by the patient’s zip code as 2.47. The number of procedures on average during a CAA patient’s stay was 4.68. The determination of the Elixhauser mortality index score was a mean of 2.94 with a readmission index score of 9.65.When comparing the presence of the various Elixhauser comorbidities between the general population as well as with patients with CAA, there was no statistical difference in the presence of having hypothyroidism, peptic ulcer disease, lymphoma, or deficiency anemias Table . The preAtherosclerosis has been a well-established risk factor for CAA for decades owing to the histologic features of lipid deposition as well as calcification and fibrosis -4. OtherWe also noted that the presence of chronic lung disease was associated with a higher risk of CAA. Interestingly, pulmonary circulation disorders were noted to be less prevalent in those with CAA as compared to their counterparts. The Elixhauser coding for pulmonary circulation disorders does include cor-pulmonale, which is the end-stage for chronic lung disease, however, it does also include pulmonary embolism . Given tAlthough we found that drug abuse history appeared to be more protective of CAA, it is noted in the literature that cocaine is a possible risk factor and, therefore, it is difficult to conclude this comorbidity to truly be protective -12. AddiIt has been documented that if untreated, Kawasaki disease may progress to CAA in up to 25% of patients -14. RemaAlthough it is cited that the five-year mortality rate of patients with CAA is 71%, we found the mortality rate during this time frame to be only 1.79%, albeit during only one hospitalization . Lastly,CAA risk factors include those similar to coronary artery disease with hypertension, diabetes mellitus, perivascular disease, and renal failure. Also, chronic lung disease and obesity were seen as risk factors while weight loss, electrolyte abnormalities, as well as a history of blood loss were noted to be protective of CAA. We found a lower incidence of CAA than that typically described in the literature. Additionally, the rate at which we found Kawasaki to be associated with CAA was much less than that documented previously.Our study has several limitations. The first is that we used retrospective data using billable codes. Being that coding may not be exact for each patient, it is possible that this may have influenced our conclusion about associated comorbidities with CAA. The main limitation of the Elixhauser Comorbidity Index score is that it is based on ICD-9 codes, which do not distinguish between complications occurring during a hospitalization vs a chronic comorbid condition. In conclusion, our study sheds light on the additional comorbidities associated with CAA that are not typically known as well as those that may be noted to be protective.


This study assessed state-specific smoking cessation behaviors among US adult cigarette smokers aged 18 years or older. Estimates came from the 2014–2015 Tobacco Use Supplement to the Current Population Survey . Prevalence of interest in quitting ranged from 68.9% (Kentucky) to 85.7% (Connecticut); prevalence of making a quit attempt in the past year ranged from 42.7% (Delaware) to 62.1% (Alaska); prevalence of recently quitting smoking ranged from 3.9% (West Virginia) to 11.1% (District of Columbia); and prevalence of receiving quit advice from a medical doctor in the past year ranged from 59.4% (Nevada) to 81.7% (Wisconsin). These findings suggest that opportunities exist to encourage and help more smokers to quit. Quitting smoking is one of the most important steps smokers can take to improve their health.During 2014–2015, as many as 6 in 7 US adult cigarette smokers were interested in quitting smoking ; 3 in 5 made a past-year quit attempt (42.7%–62.1%); 1 in 9 recently quit smoking (3.9%–11.1%); and 4 in 5 received advice to quit smoking in the past year from a medical doctor (59.4%–81.7%). These findings underscore the importance of comprehensive state tobacco control programs and barrier-free, proactively promoted access to cessation treatments to help smokers quit successfully. Quitting smoking is one of the most important steps smokers can take to improve their health . PreviouData came from the 2014–2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), a cross-sectional, household-based survey of noninstitutionalized US adults aged 18 years or older in the 50 US states and DC  to 10 (extremely interested); a response from 2 to 10 was considered to indicate an interest in quitting. Current smokers who made a quit attempt in the past year reported having stopped smoking for 1 or more days or reported having made a serious attempt to stop smoking even for less than 1 day within the past year; former smokers who quit within the past year were included in this group. Recent successful smoking cessation was defined as former smokers who quit smoking within the past year and remained quit for 6 months or longer. Recent successful cessation was assessed among current smokers who initiated smoking 2 or more years ago and former smokers who quit within the past year, a definition consistent with the Healthy People 2020 definition  for all 50 states and DC. Quartiles were mapped for each indicator. Statistical analyses were performed by using SAS-callable SUDAAN, version 11.0.1 (Research Triangle Institute).During 2014–2015, the proportion of current cigarette smokers who were interested in quitting ranged from 68.9%  in Kentucky to 85.7% (81.3%–90.2%) in Connecticut . For thiThe proportion of current and former smokers who made past-year quit attempts ranged from 42.7% (35.9%–49.5%) in Delaware to 62.1% (56.7%–67.5%) in Alaska. Eight of 13 states in the lowest quartile (≤50.9%) , panel BThe proportion of smokers who recently successfully quit ranged from 3.9% (1.9%–5.9%) in West Virginia to 11.1% (7.1%–15.0%) in DC. Seven of 13 states in the lowest quartile (≤6.7%) , panel CThe proportion of smokers who received advice to quit from a medical doctor ranged from 59.4% (52.6%–66.2%) in Nevada to 81.7% (77.5%–85.9%) in Wisconsin. Six of 13 states in the lowest quartile (≤66.9%) , panel DConsistent with national estimates , this stThe marked variations observed across states may be attributable, in part, to differences among states in the presence of proven population-based interventions , state tobacco control program funding levels, and access to proven cessation treatments such as counseling and medication –9. HowevThis study is subject to limitations. First, data were self-reported, and neither smoking nor cessation was validated biochemically. However, self-reported smoking status correlates with serum cotinine measurements . Second,Cessation behaviors among US adult cigarette smokers vary substantially by state. Opportunities exist to accelerate the implementation of proven population-based interventions and to increase smokers’ access to and use of proven cessation treatments to motivate and help more smokers to quit ,8.


Three bacterial species were used in our study: Streptococcus gordonii, Fusobacterium nucleatum, and Porphyromonas gingivalis. Bacteria were grown in an anaerobic chamber in brain heart infusion broth and incubated at 37 °C. Bacterial samples with an OD of 0.5 were irradiated with the Er:YAG laser at 2940 nm using a 400-µm Varian tip. The experiment was repeated four times using these parameters: 40 mJ, 40 Hz, and 1.6 W for 20 seconds with the 300 µs short pulse duration in contact mode. Treatment groups consisted of the following: (1) no treatment, (2) 0.5% H2O2 alone, (3) 0.5% NaOCl alone, (4) 0.03% CHX alone, (5) Er:YAG irradiation alone, (6) Er:YAG irradiation with 0.5% H2O2, (7) Er:YAG irradiation with 0.5% NaOCl, and (8) Er:YAG irradiation with 0.03% CHX. Microbial viability was determined through plating and colony counts and calculated into CFU/ml. Statistical analysis was done using a two-tailed paired t-test. The use of the Er:YAG laser alone failed to show statistically significant antibacterial activity against any of bacteria. The most effective mono-treatment with irrigation solutions for all three bacteria were 0.5% H2O2 and 0.5% NaOCl (p < 0.001 for each solution). Irrigation with 0.03% CHX was most effective against F. nucleatum (p < 0.01) and less against P. gingivalis and S. gordonii and showed the least antibacterial action alone but improved significantly in combination therapy (p < 0.05). The combined treatment with the Er:YAG showed the greatest and most significant improvement in the reduction of bacterial viability compared to any other treatment group (p < 0.05 for each combined treatment). Irradiation with the Er:YAG laser with the addition of 0.5% H2O2, 0.5% NaOCl, or 0.03% CHX under a short working time (20 s) resulted in a significant reduction of bacterial viability for all three bacterial species compared with any single treatment option. The combination of irradiation with the Er:YAG laser with the addition of 0.5% H2O2, 0.5% NaOCl, or 0.03% CHX resulted in a larger reduction of bacterial survival when compared to monotherapies with antimicrobial solutions or laser. The combination of the Er:YAG laser with a low concentration irrigant solution of 0.5% H2O2, 0.5% NaOCl, or 0.03% CHX could be an effective treatment protocol for the reduction of periodontal pathogens and thus suitable treatment for non-surgical periodontal therapy.The erbium-doped yttrium aluminum garnet (Er:YAG) laser is used to treat periodontal disease; however, its effectiveness at killing oral bacteria is not well known. Furthermore, the compounding effect of the combination of a laser treatment and irrigation methods with antimicrobials on bacterial viability is yet to be determined. The purpose of this in vitro study was to evaluate the effect of the Er:YAG laser with irrigation using chlorhexidine (CHX), hydrogen peroxide (H Porphyromonas gingivalis and Tannerella forsythia [Fusobacterium nucleatum and Prevotella intermedia provide an attachment bridge for several pathogenic bacteria as well as reduce oxygen tension, thus providing a hospitable environment for the development of bacterial complexity in dental plaque biofilms [Streptococcus gordonii, are the ones associated with the healthy state of the host and provide attachment sites for later colonizers [Periodontitis is a chronic, multifactorial, polymicrobial inflammatory condition initiated by bacteria in dental plaque biofilms, eventually leading to inflammation and bone loss . It is oorsythia . Bacteribiofilms ,4,5. Earlonizers ,7. Recenlonizers ,8. Periolonizers . Periodolonizers . The frelonizers ,12. Altelonizers ,14,15,16Lasers have been used for decades in various fields of dentistry, including periodontal and peri-implant therapy ,22,23,242O2 photolysis in conjunction with mechanical therapy for the treatment of periodontitis is an effective non-surgical treatment modality resulting in a reduction of pocket depth and counts of P. gingivalis [2O2), and sodium hypochlorite (NaOCl) are yet to be tested in combination therapy with an Er:YAG laser. At 0.2% concentration, CHX showed effective inhibition in vitro against P. gingivalis and F. nucleatum [2O2 resulted in a reducing pocket of more than 4 mm, with no effect on bleeding and other gingival indexes [Only a small number of studies has explored the effectiveness of laser irradiation in combination with antiseptic therapy ,32. Finducleatum . The use indexes . Sodium  indexes , as well indexes .2O2, NaOCl, and CHX solutions on three oral bacteria representing the different functions within different complexes the diseased biofilm: S. gordonii , P. gingivalis , and F. nucleatum (bridging bacterium). We hypothesized that a combination treatment would generate an additive bactericidal effect compared to laser or chemical irrigation alone. The concept of combining antiseptic agents with Er:YAG laser irradiation and studying the effect on bacterial viability is yet to be investigated more comprehensively. The purpose of this in vitro study was to evaluate the effectiveness of the combination therapy of Er:YAG laser irradiation with low concentrations of HP. gingivalis, Pg (W83), F. nucleatum, Fn (ATCC 25566), and S. gordonii, Sg (ATCC 10558). They were individually grown but treated in parallel. Freezer stock (−80 °C) of the bacterial species were streaked onto blood agar plates  and incubated at 37 °C in an anaerobic chamber consisting of 10% CO2, 10% H2, and 80% N2 for 48 hours. A single colony-forming unit (CFU) was used to inoculate 3 ml of brain heart infusion (BHI) broth. The inoculum was incubated overnight in an anaerobic environment at 37 °C. The optical density (OD) of the cultures was measured with a spectrophotometer at 660 nm (OD660) and normalized to an OD of 0.5. Then, these cultures were aliquoted into a 96-well plate. Thus, 75 μL of each of the cultures was aliquoted to 16 wells/bacterial strain of the 96-well plate to facilitate experiments done with eight treatment groups in duplicate. For treatment, chemicals were added in the form of concentrated stock solutions  directly to the bacteria cultures in the plate at concentrations specified per study group. After the addition of chemical treatments, the 96-well plate was removed from the anaerobic chamber and placed into a sterile biological safety hood. To check the effect of aerobiosis on growth of bacteria, the control cells were moved to the anaerobic chamber without treatment. Laser irradiation was performed on the appropriate samples aerobically. Following laser irradiation, the 96-well plate was placed immediately back into the anaerobic chamber where each treated well was diluted 1:10 into fresh BHI broth. Additional dilutions were performed and inoculated onto blood agar plates. The plates were incubated for 2–7 days anaerobically at 37 °C. Viable colonies were counted for each plate, calculated into CFU/ml, and converted into log form for statistical analysis.Three oral bacterial species implicated in the colonization of the periodontal pocket and progression of periodontal disease were used in this study: The Er:YAG laser was set to normal periodontal clinical settings with a short working time of 50 seconds. The samples were irradiated by Er:YAG laser at 2940 nm , using a 400-µm Varian fiber tip of cylindrical quartz at parameters: 40 mJ; 40 Hz; 1.6 W for 20 seconds, with the 300 µs short pulse duration in contact mode. Irradiation was performed with a disinfected aluminum foil barrier to isolate treated wells from contamination.Fn alone or Pg alone or Sg alone)Group 1: bacteria alone  + H2O2 (0.5%)Group 2: bacteria  + NaOCl (0.5%)Group 3: bacteria  + CHX (0.03%)Group 4: bacteria  + laser Er:YAG aloneGroup 5: bacteria  + laser Er:YAG + H2O2 (0.5%)Group 6: bacteria  + laser Er:YAG + NaOCl (0.5%)Group 7: bacteria Fn alone or Pg alone or Sg alone) + laser Er:YAG + CHX (0.03%)Group 8: bacteria . Combined treatment with the Er:YAG laser and irrigation solutions using 0.5% NaOCl, 0.5% HP. gingivalis are shown in P. gingivalis had a higher sensitivity to antimicrobial irrigation alone when compared to the other two bacterial species. The most effective mono-treatment with irrigation solutions for P. gingivalis were 0.5% H2O2 and 0.5% NaOCl . Treatment with 0.03% CHX showed a statistically significant diminished bacterial load (p < 0.01); however, the average bacterial load was decreased by only 1.73 Log (CFU/mL). The use of Er:YAG laser alone failed to show statistically significant antibacterial activity against P. gingivalis, but the combined (laser/irrigation) treatment showed further strengthening of antimicrobial action of irrigation solutions. The difference was not statistically significant for existing strong antibacterial 0.5% H2O2 and 0.5% NaOCl monotherapies (p > 0.05 each), but a weak antibacterial effect of 0.03% CHX was synergistically pushed well into the range of statistical significance (p < 0.01) (The results of single and combined treatments against  < 0.01) .F. nucleatum are shown in P. gingivalis, treatment with 0.5% H2O2 and 0.5% NaOCl in solo irrigation treatment had strong antibacterial effect (p < 0.001 for each solution). Irrigation with 0.03% CHX alone also showed statistically significant antibacterial action (p < 0.01). The overall bacterial load drop reached an average of 5.71 Log (CFU/mL), which is a strong effect when compared between bacterial species . The laser alone did not significantly lower the bacterial viability, but it did improve the antibacterial effects of irrigants in combined therapy. Although this finding was not significant for 0.03% CHX (p > 0.05), the combined therapy of Er:YAG with 0.5% H2O2 and 0.5% NaOCl notably lowered the number of bacteria below the limits of detection for each of the combined treatments , the combined treatment with the Er:YAG laser showed the greatest and most significant improvement in the reduction of bacterial viability compared to any other treatment group (p < 0.05 for each combined treatment). Again, 0.03% CHX showed the least antibacterial action alone but improved significantly in combination with laser therapy (p < 0.05) ( < 0.05) .2O2 or 0.5% NaOCl, it showed a notable reduction in bacterial viability regardless of the bacteria tested. The addition of laser irradiation to each of the irrigation treatment modalities resulted in a statistically significant reduction of bacteria as compared to the use of antibacterial solutions alone for S. gordonii. For P. gingivalis, the statistically significant decrease in bacterial viability following the addition of the laser was found for the CHX solution only. A visible decrease in bacterial viability was noted for the other study groups following the addition of laser irradiation. For F. nucleatum, the combination of Er:YAG laser irradiation and 0.5% H2O2 or 0.5% NaOCl reduced the levels of viable bacteria below the limit of detection. In summary, the results indicate that the Er:YAG laser alone had limited antibacterial effect, but in combination with 0.5% HOur study shows that Er:YAG laser treatment with the addition of three antiseptic agents at low concentrations is an effective antimicrobial treatment. In clinical practice, the Er:YAG laser and antiseptic solutions are used as adjunct to mechanical periodontal therapy. Human histological studies have shown that treatment with an Er:YAG laser results in favorable healing, the formation of new attachment, and may result in radiographic bone regeneration . The mec2O2 combination treatment generated an additive bactericidal effect resulting in a more effective reduction of bacterial viability when compared to the laser irradiation or chemical irrigation alone. A 0.1–0.5% solution of NaOCl has been proposed as an antiseptic oral irrigation due to its rapid bactericidal action, relative non-toxicity at suggested concentrations, no color, no staining, very low cost, and no known contraindications [.Irradiation with the Er:YAG laser facilitates root debridement and has positive effects on tissue repair, resulting in greater probing depth reduction and gains in clinical attachment level that are sustained for up to three years compared to flap surgery . Variousications . Thus, i2O2 on an animal model simulating clinical conditions resulted in no mucosal irritation or abnormal findings macroscopically or microscopically. Hydroxyl radicals released from H2O2 by photolysis are powerful oxidizing agents that are capable of inducing lethal oxidative damage to microbes [Photolysis at even higher concentrations of 3% Hmicrobes . The lacmicrobes .Irradiation by most surgical lasers exerts photo-thermal effects on target tissues and cells that are capable of killing bacteria by evaporation, destruction, and denaturation, resulting in their devitalization or inactivation ,46,47,48This study was not without limitations. We intended to determine only the effect on bacterial viability, and thus no host factors were considered. Due to the physical size of the laser, bacterial cultures had to be moved from the anaerobic environment for treatment purposes. All treatment groups were handled identically in that process and thus can be compared among themselves. In addition, all bacterial species were shown to be able to withstand oxygen exposure, which further reduces the significance of the oxygen exposure in this study. Our study only examined three bacterial species, and thus further studies are needed studying more complex microbial mixtures to determine the effectiveness of the combined therapy. Some treatment groups resulted in no detectable colonies, making comparisons more difficult. However, such data underscored the effectiveness of the treatment. The findings of this study could be easily and safely applied to clinical use, as these treatment modalities already exist in clinical practice as monotherapies. Combination therapies of an Er:YAG laser and a dilute oxidative solution appear to be more effective and could be implemented into non-surgical periodontal therapy as a non-invasive treatment facilitating a decrease in the bacterial viability. The Er:YAG laser has also been used for treatment of peri-implantitis with similar exposure settings ,53. ClinThis is the first study demonstrating that the Er:YAG laser irradiation with the energy of 40 mJ, 40 Hz, and 1.6W for 20 seconds together with a very low concentration of 0.5% hydrogen peroxide or 0.5% sodium hypochlorite provides superior results in antibacterial effects on oral bacteria than the same treatments delivered as monotherapies. The most clinically relevant finding is that the use of laser treatment in combined therapy with a weak irrigation solution has a stronger effect than each treatment as monotherapy, and the common implementation of such combined modality may improve treatment outcomes.


In the Commonwealth of Independent States (CIS) countries epidemiology of Bronchial Asthma (BA) is poorly characterized. The objective of this analysis is to present the prevalence, burden and risk factors associated with BA in the CIS countries as part of the CORE study (Chronic Obstructive REspiratory diseases).A total of 2842 adults (≥18 years) were recruited  in 2013–2015 during household visits. A two-step cluster random sampling strategy was used. All respondents were interviewed about respiratory symptoms, smoking, medical history. Two definitions were used: (i) “doctor diagnosed asthma” when the respondent reported that he/she had ever been diagnosed with BA by a doctor, (ii) “wheezing symptoms” (when the respondent reported wheezing at the ATS Respiratory Symptoms Questionnaire during the study) using GINA (2012) recommendations. Chi-square tests were used to assess differences in proportions. Binary logistic regression was used to estimate odds ratios (OR) and 95% CI for association between risk factors and BA.p < 0.05) more frequently in respondents with BA compared to those without BA across all participating countries.Prevalence of “doctor diagnosed asthma” was 12.5, 19.0 and 26.8 per 1000 persons, and prevalence of “wheezing symptoms” was 74.4, 254.8 and 123.4 per 1000 in Ukraine, Kazakhstan, and Azerbaijan, respectively. Statistically significant relationship with “wheezing symptoms” was shown for smoking (OR 1.99 (CI 1.22–3.27) in Ukraine, 2.08 (CI 1.54–2.81) in Kazakhstan, 8.01 (CI 5.24–12.24) in Azerbaijan); overweight/obesity (OR: 1.66 (CI 1.02–2.72); 1.94 (CI 1.44–2.62); 1.77 (CI 1.18–2.68), respectively) and dusty work (OR: 3.29 (CI 1.57–6.89); 1.68 (CI 1.18–2.39); 2.36 (CI 1.56–3.59), respectively), and for tuberculosis in Azerbaijan (OR: 10.11 (CI 3.44–29.69)). Co-morbidities like hypertension, cardiovascular diseases, abnormal blood lipids and a history of pneumonia occurred significantly  the prevalence of doctor diagnosed asthma was significantly lower compared to prevalence of wheezing symptoms underlining that BA is likely to be underreported in these countries. The information provided in this paper will be helpful for healthcare policy makers in CIS countries to instruct BA management strategies and to allocate healthcare resources accordingly. Bronchial asthma (BA) is prevalent throughout the world, with increasing prevalence particularly in developing countries, and associated with a high level of societal burden . The rapDespite of relatively low mortality rate compared to other chronic diseases, the main burden of asthma is disability, particularly among people aged less than 45 years; for people of older age groups and children premature death due to asthma also contributes to the burden of disease . Based oPreviously published studies evaluating the prevalence of BA have demonstrated that BA prevalence varies across different countries/populations –21., AltTaking into account the lack of large epidemiologic analyses of BA prevalence in the CIS countries, the CORE study (Chronic Obstructive REspiratory diseases in CIS countries) has been conducted to address the gap in the epidemiological estimate of main chronic respiratory diseases and their risk factors in the selected cities of the CIS region. The aim of the CORE study was to evaluate country-specific prevalence of COPD (chronic obstructive pulmonary disease), BA and allergic rhinitis in order to obtain a clear “epidemiological picture” in selected CIS countries. In this paper, data obtained on the prevalence and burden of BA will be presented. Also, potential relationship between the presence of BA and its risk factors will be assessed.Rationale and design of the CORE study  have been described previously .CORE study is a multinational, cross-sectional population-based epidemiological study carried out in major cities Kiev, Ukraine; Almaty, Kazakhstan; Baku, Azerbaijan, from the first half of 2013 till the end of 2015. The study enrolled subjects who were ≥ 18 years old, had ≥10 year of residence in selected city and provided a written informed consent for participation in the study.Subjects who were not able to answer the study questionnaires  were excluded from the study. Subjects in whom spirometry could not be performed were also excluded (spirometry was required for COPD diagnosis in this study).Doctor diagnosed asthma: When self-reported by the respondent (the respondent reported that he/she had ever been diagnosed with BA by a doctor while completing the study questionnaire). Respondents answered the following questions to identify “doctor diagnosed asthma”:We used two definitions of asthma based on the study questionnaire and/or reporting wheezing as the ATS Respiratory Symptoms Questionnaire. Spirometry abnormalities alone were not classified as asthma diagnosis.Has a doctor ever told you that you have bronchial asthma)?If YES, please, indicate number of exacerbations during the last year.2.Does your chest ever sound wheezy or whistling?”).Wheezing symptoms: When the respondent reported wheezing at the ATS respiratory symptoms questionnaire (answered positive to the question: “The data were collected from participants during household visits. Study Executive Committee randomly selected streets for household visits in each city (country) applying stratified random cluster sampling procedure. Each city administrative district was divided into squares (on the map). 93 streets in each city were necessary to recruit 10 participants from a street . The relevant number of streets in each district was determined proportionally to the district population. If the number of streets selected in a certain district was not a whole number, it was rounded down to the integer below, and additional number of streets  was obtained from the district(s), chosen randomly. A similar strategy was applied to map squares within districts, and the average number of streets per square to be sampled was determined. The streets within each map square for sampling were selected randomly by the Study Executive Committee.Investigators (interviewers) performed household visits to collect the data. The interviewers visited households sequentially, starting with the 1st apartment of the 1st number of the house in the selected street, and continuing in ascending order. Data were collected from 10 subjects per street, and stratification by age was applied: 5 subjects aged 18–39 years old and 5 subjects aged ≥40 years old from the selected street were enrolled. When the potential participant was not available during the visit of interviewer, the interviewer performed up to three additional visits after 6 p.m. on working days and during all day on weekends.At every household the interviewers assessed eligibility of all inhabitants. Participants who consented and were eligible for the study provided their socio-demographic information and medical history, underwent weight/height measurement and completed the study questionnaires, as described previously .Socio-demographic data were collected to describe the characteristics of the overall study population, including gender, age and ethnicity distribution, body mass index (BMI), smoking status and alcohol intake. BA prevalence data were collected using the case definition described above and the impact of age, gender and severity was assessed. Additionally, the type and frequency of co-morbidities was investigated and association between BA and its related risk factors  was evaluated. Allergic rhinitis was identified as a part of the CORE study (when the respondent reported presence of watery runny nose (during the last 12 months) alone or in combination with any of the following: sneezing, nasal obstruction, nasal itching, or conjunctivitis at the Allergic Rhinitis Questionnaire), and will be subject of a separate publication.p < 0.050. Statistical analysis was performed using IBM SPSS Statistics software  version 21.0 and R software version 3.1.2 .The prevalence of BA, as the number of BA individuals divided by total number of subjects included in the study, are expressed as a number per 1000 for each country. Prevalence was calculated in the subject population with valid data. 95% confidence intervals (CI) were calculated for each frequency using the Clopper-Pearson method . Chi-squ2, and in Kazakhstan, 25.7 (5.1) kg/m2, and it was 26.4 (5.3) kg/m2 in Azerbaijan. 33.7% participants in Ukraine, 40.2% in Kazakhstan, 26.0% in Azerbaijan were current or past smokers. See Table A total of 2842 adult subjects were included in the CORE study . Women were predominant across three countries: 58.2% in Ukraine; 63.2% in Kazakhstan and 58.3% in Azerbaijan. The mean age was slightly above 40 years in all participating countries. The majority of participants were Caucasian in Ukraine (99.7%) and Azerbaijan 100%), and almost two-third of participants in Kazakhstan were Asian (62.8%). The mean BMI was at the boundary of overweight in Ukraine, 25.0 (5.1) kg/m00%, and Subjects who fulfilled the definitions used in this study for BA are shown in Table The estimated prevalence of wheezing symptoms among the adult population was 74.4 (95% CI 58.4–93.1) per 1000 in Ukraine, 254.8 (95% CI 227.1–284.1) per 1000 in Kazakhstan and 123.4 (95% CI 103.0–146.2) per 1000 in Azerbaijan. The prevalence of doctor diagnosed asthma was lower than the prevalence of wheezing symptoms: 12.5 (95% CI 6.5–21.7), 19.0 (95% CI 11.3–29.9) and 26.8 (95% CI 17.4–39.4) per 1000, in Ukraine, Kazakhstan and Azerbaijan, correspondingly. See Fig. We estimated the BA prevalence in the subgroups by age, sex or ethnicity, when possible, as seen in Table The following prevalence values of doctor diagnosed asthma were observed in the age group ≥65 years old in Ukraine and Kazakhstan: 55.6 (95% CI 15.3–136.2) per 1000 and 44.1 (95% CI 9.2–123.6), respectively; in age group 40–64 years old in Azerbaijan: 33.9 (95% CI 18.7–56.2). The following prevalence values of wheezing symptoms were observed in the population aged ≥65 years in Ukraine and Kazakhstan: 238.8 (95% CI 143.1–358.6) per 1000 and 318.2 (95% CI 208.9–444.4) per 1000, respectively, and in age group 40–64 years old in Azerbaijan: 171.9 (95% CI 136.8–211.8) per 1000. See Fig. The prevalence of doctor diagnosed asthma was 17.4 (95% CI 7.0–35.6) per 1000 in males vs 9.0 (95% CI 2.9–20.8) per 1000 in females in Ukraine; 20.1 (95% CI 8.1–41.0) per 1000 in males vs 18.4 (95% CI 9.2–32.7) per 1000 in females in Kazakhstan; 30.8 (95% CI 16.0–53.3) per 1000 in males vs 23.9 (95% CI 12.8–40.6) per 1000 in females in Azerbaijan. The prevalence of wheezing symptoms was 75.8 (95% CI 51.7–106.4) per 1000 in males vs 73.4 (95% CI 52.9–98.6) per 1000 in females in Ukraine; 290.7 (95% CI 243.2–341.8) per 1000 in males vs 233.8 (95% CI 200.1–270.2) per 1000 in females in Kazakhstan; 226.8 (95% CI 186.1–271.8) per 1000 in males vs 49.6 (95% CI 33.0–71.4) per 1000 in females in Azerbaijan  per 1000 in Asians and 17.2 (95% CI 6.3–37.1) per 1000 in Caucasians. At the same time, prevalence of wheezing symptoms was 295.3 (95% CI 247.5–346.8) per 1000 in Caucasians and 232.1 (95% CI 198.5–268.4) per 1000 in Asians.Does your chest ever sound wheezy or whistling?” 49/70 (Ukraine) 117/237 (Kazakhstan), and 91/115 (Azerbaijan) had wheezy or whistling during the last 12 months. 52, 147, 109 respondents in Ukraine, Kazakhstan, Azerbaijan, respectively, reported the duration of their symptoms. Interestingly, among them, 22/52 respondents in Ukraine, 64/147 in Kazakhstan and 56/109 in Azerbaijan reported symptoms duration > 5 years; others reported shorter duration. For reference, as displayed in Table Analysis of the ATS Respiratory Symptoms Questionnaire (section “Wheezing”) showed that among respondents who answered positive to the question: “p = 0.005), Kazakhstan (OR 2.08 (CI 1.54–2.81) p ˂0.001), Azerbaijan (OR 8.01 (CI 5.24–12.24) p ˂0.001); between BA and overweight/obesity in Ukraine (OR 1.66 (CI 1.02–2.72) p = 0.041), Kazakhstan (OR 1.94 (CI 1.44–2.62) p < 0.001), Azerbaijan (OR 1.77 (CI 1.18–2.68) p = 0.006); between BA and dusty work in Ukraine (OR 3.29 (CI 1.57–6.89) p = 0.001), Kazakhstan (OR 1.68 (CI 1.18–2.39) p = 0.004), Azerbaijan (OR 2.36 (CI 1.56–3.59) p < 0.001); between BA and tuberculosis in Azerbaijan (OR 10.11 (CI 3.44–29.69) p < 0.001); and between wheezing symptoms and allergic rhinitis in Ukraine (OR 5.05 (CI 2.42–10.55) p < 0.001), Kazakhstan (OR 4.71 (CI 3.02–7.36) p < 0.001), Azerbaijan (OR 3.58 (CI 2.12–6.06) p < 0.001). See Fig. Relationship between the presence of BA (wheezing symptoms) and smoking status (current/past smoker), alcohol intake , BMI (BMI ≥ 25 kg/m2), tuberculosis (ever been diagnosed), dusty work, open fire cooking and allergic rhinitis was investigated and statistical significance was found between wheezing symptoms and smoking in Ukraine (OR 1.99 (CI 1.22–3.27) p < 0.05) than in those without BA , especially for hypertension, cardiovascular diseases, abnormal blood lipids and a history of pneumonia. Allergic rhinitis (which was identified as a part of this study as a presence of watery runny nose (during the last 12 months) alone or in combination with any of the following: sneezing, nasal obstruction, nasal itching, or conjunctivitis) was also observed more frequently (p < 0.001) in the respondents with BA compared to those without BA in all countries. See Table While completing the study questionnaire the respondents were asked to report the presence of other chronic medical conditions except for respiratory diseases. Co-morbidities were reported by 44.2% respondents in Ukraine, 23.5% respondents in Kazakhstan and 54.6% respondents in Azerbaijan. The respondents with BA  were compared to the respondents without BA by the rate of co-morbidities. The rate of co-morbidities in the respondents with BA was higher  was 12.5, 19.0 and 26.8 per 1000 in Ukraine, Kazakhstan, and Azerbaijan, respectively, but the prevalence of BA symptoms (wheezing) identified during the study was much higher, 74.4, 254.8 and 123.4 per 1000, respectively. There were between country variations in the prevalence of wheezing; possible reasons for them may be a topic for future research. The number of respondents having wheezing/whistling during more than 5 years, based on ATS Respiratory Symptoms Questionnaire, was approximately 2–3.5-fold higher than the number of respondents who reported doctor diagnosed asthma. These findings underline that people with wheezing may have underdiagnosed BA and the majority of respondents could have been diagnosed with asthma for the first time during the study.Statistically significant relationship was shown between smoking, overweight/obesity, dusty work and allergic rhinitis and BA symptoms (wheezing) in three countries. Co-morbidities were significantly more frequent in respondents with BA compared to those without BA.In all studied countries the prevalence of doctor diagnosed asthma and wheezing had a tendency to increase with age . However, this finding can be related to greater opportunity to be diagnosed with asthma in older people and to the fact that the study collected data on wheezing ever experienced by a respondents in their life, not current or recent wheezing. There is no clear relationship between aging and prevalence of BA in adult population in other studies .In all three countries doctor diagnosed asthma and wheezing were slightly more prevalent in men than in women. Some studies also confirm this observation , but difAs for ethnic-related differences in prevalence of BA (Kazakhstan), a trend to higher prevalence of doctor diagnosed asthma and lower prevalence of wheezing symptoms in Asians compared to Caucasians was observed. In some other studies, Asians had a greater risk of asthma than Caucasians . HoweverThe prevalence of doctor diagnosed asthma in this study  was significantly lower than the global estimation reported by To et al. [Prevalence estimates of wheezing symptoms in our study was 74.4 per 1000 in Ukraine, 254.8 per 1000 in Kazakhstan and 123.4 per 1000 in Azerbaijan. The value in Kazakhstan was close to that obtained in the Russian GARD study  . It is well known that modifiable factors such as obesity and smoking have been associated with the development of asthma , 30–41. This study has several strengths. It is a multi-national, cross sectional, population-based study with a sample size using consistent methodology across all countries, providing a standardised measure of prevalence in the CIS countries. In addition, the case definition of BA used is based on both (i) doctor diagnosed asthma and (ii) wheezing symptoms using a validated questionnaire. This study could facilitate the recognition of BA in CIS countries using a standardized methodological approach and will allow preparation of interventions to optimize management of patients with BA.We acknowledge that the current study has several limitations. The method of districts and streets sampling may not ensure completely random selection of streets and participants. Relatively small number of BA patients limits the analysis of risk factors associated with BA and can limit the power for specific type of within-the-city analysis, such as detailed subgroup analyses. The subjectivity of the diagnostic criteria based on symptoms can lead to over or underdiagnosis. Spirometry was performed in the study (for COPD diagnosis) but its results were not used for confirmation or exclusion of BA diagnosis. Respondents with contraindications for spirometry  were not enrolled in the study that may lead to underestimating of BA prevalence.The city population may not be representative of each country in general, because risk factors and healthcare provision  may vary within the country. Particularly, results may only reflect the urban agglomerations studies and not represent the whole country, because rural areas could have different medical care level or living and working conditions for people.Some data can be incomplete due to lack of relevant information from participants, as a lot of study data were collected from respondents themselves. The number of respondents included in the prevalence calculation, especially for age- and ethnicity subgroups, is quite small, that could be another limitation of the study.In conclusion, in Ukraine, Kazakhstan and Azerbaijan the prevalence of doctor diagnosed asthma is significantly lower than prevalence of wheezing symptoms underlining that BA is likely to be underreported in these countries. The information provided in this paper will be helpful for healthcare policy makers in CIS countries to instruct BA management strategies and allocate healthcare resources accordingly.


In this paper, seizure types, and epilepsy syndromes are elucidated as per ILAE (2010) classification. A brief outline of the antiepileptic drug regimens used and the outcome of seizure control in a two -year period is presented. The applicability of the ILAE classification in resource limited countries has been revisited.This is a descriptive prospective study, in which 202 patients were enrolled. The Cohort group was seen and evaluated by a pediatric neurologist at the Pediatric neurology Outpatients Department (OPD). Epilepsy was classified using the International League Against Epilepsy (ILAE) classification (2005–2009) report. All patients had an Electroencephalogram (EEG) at the start of the study, and this was repeated as deemed appropriate. Brain imaging (MRI) was done to patients when indicated. Treatment decisions were made by pediatric neurologists. Outcomes were categorized into four groups: fully recovered, well controlled, partially controlled and uncontrolled.+ 2.7 years. Male to female ratio was 1.7: 1. Thirty five (17.3%) patients had generalized onset seizures, 46(22.8%) had focal onset seizures, 104(51.5%) had a specific epilepsy syndrome, and 17(8.4%) patients were unclassified. 170 (84.2%) patients were on mono-therapy on their initial visit, 30(14.8%) were on two Antiepileptic Drugs (AEDs) while two (1.0%) patients were on poly-therapy. After 2 years; 155(76.7%) patients were on mono-therapy, 36(17.8%) on two AEDs while ten were (4.0%) on polytherapy. One eighty (88.2%) patients were controlled. Fifteen (7.4%) of them were off medication after being seizure free for 2 years. Twenty (9.8%) have partial control, while two (1.0%) patients were uncontrolled. Patients with focal epilepsy, those on polytherapy and those with abnormal imaging had poor prognosis.The mean age is 10.5 The ILAE classification can be used in resource limited countries. Childhood epilepsies have a good prognosis provided they are well classified and treated. The prevalence of epilepsy is particularly high in Africa with an estimated mean prevalence of 15 per 1000 .There haThis is a descriptive prospective study conducted between 2016 and 2017. The sample size calculation was based on a previous survey conducted at Khartoum State in 2015 which identified 303 children out of 74,959 school children with epilepsy and the prevalence rate was reported as 4/1000. In Phase I of this study the epilepsy was initially classified into generalized, focal and unclassified [A diagnosis of epilepsy in this study is retained if the patient had at least two or more epileptic seizures unprovoked by any immediate cause . can be static or progressive, recent or long standing, global or specific. It includes assessment of gross motor, fine motor, communication, vision, hearing, social and psychomotor skills .Any delay in the acquisition of the motor skills that can easily be remembered by the parents like delayed neck control, sitting and walking .Any delay in acquiring skills elated to the production and/or perception of the oral symbols used for language .. However, 50(16.5%) patients continued their follow-up in their locality or nearby clinics, 31(10.2%) had incomplete clinical data so they were excluded. Eighteen (5.9%) patients lost their follow up and we were unable to trace them while one (0.3%) patient died following a road traffic accident. In this study, we report on 202 patients whose follow up continued for 2 years.The present study was part of a population- based study of prevalence of epilepsy in school children in Khartoum- SudanThe cohort group was seen and evaluated by the Pediatric neurologists 1&2 at the OPD at Fath El- Rahman El-Basher Center; the referred clinic for Gafer Ibn Auf Specialized Hospital for children in Khartoum- Sudan.For each patient, epilepsy was classified using the ILAE Commission on classification and terminology 2005–2009 Report . FactorsAll patients had an EEG at the start of the study, and that was repeated as deemed appropriate. The EEGs were done using the 10–20 system with photic stimulation and hyperventilation procedures done when indicated; none of the patients had undergone a video-telemetry EEG or an ambulatory EEG recording as these are unavailable in the study setting The majority of patients (89%) had sleep EEGs  and very few EEGs were done whilst awake or sleep deprived. The EEGs were interpreted and reported by an adult neurophysiologist with special interest in pediatrics EEGs.The MRI was the modality of brain imaging requested as and when indicated. The MR imaging studies were performed at different centers, where the imaging protocols were variable. All images of patients in this study included at least one sagittal view and one axial sequence 1.5 T. All patients were studied with T1-T2 and FLAIR -weighted sequences. The final report was that agreed by the radiologist who finally reviewed all the images. MRI of the brain was done for patients with any impairment in development, those suspected to have behavioral and/or educational problems, those with focal seizures associated with focal neurological deficit and for patients with uncontrolled seizures.Treatment decisions were made by pediatric neurologists as per the international recommendations for the specific seizure type, taking into consideration the age of the patient, sex, tolerability, formulations, availability and affordability of AEDs in our setting. Other modalities of treatment e.g. ketogenic diet and epilepsy surgery are not available in Sudan. We tried at least two first-choice AEDs in mono-therapy  before using a polytherapy regimen. In children who experienced 2 years free of seizures, the AED(s) were withdrawn gradually.The majority of patients were seen three-monthly to check for seizures frequency, duration, drug side effects and dose adjustments of the AEDs. However, some patients were seen more frequently on an individual basis, especially if they have refractory seizures and/or other co-morbidities For the purpose of this study, the outcomes were categorized into four main groups; ‘Fully recovered’- if no seizures occurred for the last 2 years and AEDs were tapered, ‘Good’ controlled if seizures occur less than once per month. ‘Partial seizure- control’ if there is a decrease in seizure frequency and duration by more than 50% with seizures occurring every month (but not every week) during the last 6 months and lastly an ‘Uncontrolled group’ if there is no change in the seizure frequency, if it is decreased by less than 50% in the last 6 months or got worse.Sex, age at onset of seizure, perinatal history, family history of epilepsy, epilepsy types, number of AEDs, MRI/ Brain findings were used as determinant to outcome.P-value was considered significant if its value is less than 0.05.Data analysis was performed using SPSS software package version 23. The quantitative variables were presented as mean and standard deviation. Qualitative variables were described in the form of frequency and percentage. Standard test of significance (Chi-Square Test) was used. + 2.7 years. The majority 101(49.5%) were more than 10 years of age. One hundred ninety (94.05%) were known to have epilepsy while 12(5.95%) were newly diagnosed. One hundred twenty six (62.4%) were male and 76(37.6%) were female with a ratio of 1.7: 1.The study included 202 patients with epilepsy, with an age range of 6–14 years. The mean age is 10.5 Forty eight (23.8%) had prenatal complications of whom 21(43.7%) suffered from Pregnancy Induced Hypertension (PIH), 15(31.3%) were affected by gestational diabetes, nine (%18.7) had complications related to Intrapartum haemorrhage and three (6.25%) were suffering from Oligohydramnios. The majority − 195(96.5%) of the study group were delivered at term, five (2.4%) were preterm and two (1.1%) were postdates. Seventeen (8.4%) patients had developmental impairment during early childhood, the majority 10(58.8%) had isolated motor impairment and seven (41.2%) had speech delay. All of them had brain atrophy on their brain images. Visual problems were reported in 12(5.9%) patients and Hearing impairment in four (1.9%) patients. Consanguinity  rate was found to be 54% and 69(34.2%) patients had a positive family history of epilepsy (sibling or first degree cousin).Thirty four (16.8%) patients had seizure onset before the age of 1 year, 49(24.1%) between 1 and 5 years, 81(40.1%) between 5 and 10 and 38(18.8%) had seizures onset after the age of 10 years.The EEG background was normal in all patients. Generalized epileptiform discharges were recorded in the EEG of 61 (30.2%) patients, 88(43.6%) had focal seizure discharges. Fifty three (26.2%) patients had no evidence of epileptiform discharges in their first EEG of whom 20(37.7%) demonstrated evidence of epileptiform activity in the second EEG when done with sleep deprivation.MRI of the brain was done to 118(58.4%) patients, it was abnormal in 65(55.1%), of whom 29(24.5%) had diffuse brain atrophy, 11(9.3%) had Mesial temporal sclerosis(MTS), seven (5.9%) had thin corpus callosum, five (4.2%) had evidence of infarction, four (3.3%) had congenital arachnoid cyst, four(3.3%) had hydrocephalus (with VP shunt) three(2.5%) had arrested hydrocephalus and three(2.5%) had hemi-atrophy.One hundred eighty five (91.5%) patients had their initial epilepsy classification revised after history, clinical examination, EEG findings and the result of the MRI of the brain in addition to other investigations.Thirty-five 17.3%) patients had generalized onset seizures, 46(22.8%) had focal onset seizures, 104(51.5%) had a specific epilepsy syndrome, and 17(8.4%) patients had unclassified seizures. Each group was further reclassified (Table 7.3% patiOne hundred and seventy (84.2%) patients were on mono-therapy on their initial visit, 30(14.8%) were on two AEDs while two (1.0%) patients were on poly-therapy. The most commonly used AEDS was Sodium Valproate (used by 130 (64.3%) patients) followed by Carbamazepine 87(43.0%), Phenbarbitone 19 (9.4%) and four (1.9%) patients on Topiramate.At the initial evaluation visit 42 (20.8%) patients had good seizure control, 50(24.8%) had partial control (decrease in seizure frequency and duration by more than 50%) while 110(54.4%) had uncontrolled seizures .After 2 years; 155(76.7%) patients were on mono-therapy, 36(17.8%) on two AEDs while ten (4.0%) on polytherapy. The commonly used AED 90(44.5%) was Sodium Valproate followed by Carbamazepine 60(29.7%), Levetiracetam 57(28.2%) and Lamotrigene in 40(19.8%) patients. Fifteen (7.4%) patients fully recovered, 165(81.7) were well controlled, twenty (9.8%) had partial control, while two (1.0%) patients were uncontrolled  respectively.The correlation between seizure control and other variables was tested using Chi-Square Test and p value = 0.002). Patients who had normal MRIBrain imaging had good seizure control and vice versa. .Using Chi- Square test, patients on mono-therapy showed good seizure control when compared to those on two or more AEDs . Patients with generalized seizures showed better control in comparison to those with focal seizures and epilepsy syndromes , we were able to classify 91.6% of epilepsies and epileptic syndromes. This was similarly reported by Eiji Oka et al. from Japan and Matti Sillanpää et al. from Finland who stated that (91%) of the patients (under 16 years) could be classified using ILAE (1989) [, we wereAlmost half of the patients in the study had focal onset seizures a finding that is similar to the results from sub-Saharan Africa –14 and eThe commonest epilepsy syndrome in this study was ECTS, which was noted in 12.4% of patients. High prevalence of ECTS was also found in studies from Sweden and Italy –18 whereSeveral reports, including this study, have highlighted the relatively high frequencies of additional neurological deficits in children with epilepsy , 20. In Over the last decade; epidemiological studies have demonstrated that the prognosis of many childhood epilepsies is more favorable with 70–80% eventually reaching remission . The proDue to mounting evidence that Phenbarbitone and Topiramate can negatively impact the cognitive function in this subset of children, both were tapered and alternatives were offered , 28. AltThe ILAE classification can be used in resource limited countries. Childhood epilepsies have a good prognosis if well classified and treated. Further studies are needed to review long term remission, probability of recurrence after AEDs withdrawal and the impact of seizures on school performance and behavior.


Introduction: Orofacial pain and dysfunction include a broad range of disturbances among which pain and insomnia are some of the most common complaints. Sleep strengthens physiological and psychological resilience and is an absolute requirement for health. Insomnia is a common symptom or sleep disorder, yet data on its prevalence is sparse. Here we extracted data from the insomnia severity index which was part of the web-based interdisciplinary symptom evaluation (WISE) tool given to a large sample of patients seeking care at an orofacial pain unit for analyzing insomnia prevalence in this clinical population.Material and methods: Anonymized data were available from 952 patients who consulted the Orofacial Pain Unit at the Center of Dental Medicine, University of Zurich, Zurich, Switzerland between January 2017 and December 2018. Prevalence data for insomnia stratified by gender and 10 age groups (decades) were calculated. The distribution of four insomnia severity grades was determined, also stratified by age and gender.Results: 952 patients (290 men: 30.5%) with a mean age of 44.8 ± 17.4 years completed a WISE. Three hundred and fifty-two (37.0%) patients with a mean age of 45.8 ± 16.7 years positively responded to a screening question for insomnia and/or hypersomnia. Insomnia was severe in women from the 2nd to 8th decade, ranging from 4.3% (3rd decade) to 14.5% (6th decade), and moderately severe from the 2nd to 9th decade, ranging from 18.8% (6th decade) to 27.8% (2nd decade). In men, severe insomnia was present from the 3rd to 7th decade, ranging from 2.3% (7th decade) to 4.4% (4th decade) and moderately severe insomnia from the 3rd to 7th decade, ranging from 4.6% (7th decade) to 12.2% (5th decade).Conclusions: This is the first study reporting on insomnia in a large sample of patients seeking care at an orofacial pain unit. One in three patients reported some form of sleep disturbances, which for almost half of them was moderate to severe insomnia. The gender ratio was almost equal throughout adulthood, yet younger and older women were more frequently affected and experienced higher insomnia severity than men. Orofacial disorders can be painful or painless and with or without functional impairment. They include a broad range of disturbances with heterogeneous etiologies in dental, mucosal, musculoskeletal, and neuronal tissues. These conditions can be summarized under the umbrella term orofacial pain and dysfunction (OPD). According to community based surveys, the prevalence of OPD varies greatly, from 5 to 57% depending on the study period, population, location, and other factors . ChronicHealthy sleep was recently defined in a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society as “adequate duration, good quality, appropriate timing and regularity, and the absence of sleep disturbances or disorders” . Sleep sFor this paper, we used data collected by the web-based interdisciplinary symptom evaluation (WISE) which is a new self-report instrument designed to obtain computer guided patient information related to orofacial disorders of diverse etiologies and comorbid conditions . The WISAnonymized data were extracted from WISE completed by 952 patients who consulted the Orofacial Pain Unit at the Center of Dental Medicine, University of Zurich, Zurich, Switzerland between January 2017 and December 2018. Patients completed the WISE prior to their first appointment. The symptoms of our study population varied from painless yet burdening functional disorders to painful conditions with widely varying orofacial pain location, quality, time pattern, and related disability.For questionnaires to be analyzed, patients must have clicked a checkbox indicating their consent that their anonymized data can be used for research. According to Swiss law, the analysis of strictly anonymized data does not require approval by an ethics committee. We compared the clinic population that completed the WISE with the clinic population that did not complete it or did not give consent to use the data for research.t-test with Welch's correction, since equality of variance was not assumed.Using the software SPSS version 23, we calculated prevalence data for insomnia stratified by gender and age group (decades). The distribution of four insomnia severity grades was determined stratified by age and gender. Means were compared between genders using an independent sample p > 0.05) (p > 0.05).The population of the 952 patients completing the WISE  had a mean age of 44.8 ± 17.4 years . It consisted of 290 men (30.5%) with a mean age of 44.3 ± 16.5 years  and 662 women (69.5%) of 45.0 ± 17.8 years . The gender ratio therefore was 1:2.3. Mean ages between genders did not differ ( > 0.05) , 2. The  > 0.05) . The genp > 0.05) (Three hundred and fifty-two (37.0%) patients with a mean age of 45.8 ± 16.7 years  reported “trouble falling or staying asleep or sleeping too much” on the WISE checklist and the ISI was presented to these. The 97 men (10.2%) in this group had a mean age of 43.5 ± 13.8 years  and the 255 women  of 46.7 ± 17.6 years . The gender ratio therefore was 1:2.6. Neither age nor gender distribution differed between patients with insomnia and all patients ( > 0.05) , 4. For  > 0.05) .The distribution of ISI scores, its gender ratios (in brackets), and its ratios within each gender [in square brackets] according to increasing severity grades were: 5.9% (1:2.8) [1:1], 15.3% (1:2.6) [1:1.1], 11.5% (1:2.8) [1:1.2] to 4.3% (1:2.9) [1:1.3] .The patients responding positively to the screening question on insomnia and/or hypersonia are listed in In this paper, we analyzed complaints of insomnia in a large sample of 952 patients seeking care at an orofacial pain unit, covering a broad age range. A first main study finding was that 37.0% of those patients reported sleep disturbance in the form of insomnia and/or excessive daytime sleepiness (hypersomnia). Secondly, women across a broader age range than men were affected by insomnia. Thirdly, when taking into consideration the proportions within gender, the ratios of insomnia between men and women were almost equal in young and middle-aged adults, yet higher in female teenagers and adolescents as well as older women.p > 0.05)  , 2. Also > 0.05) . The une > 0.05) . Among a > 0.05) . If the The proportions within each gender had also relatively balanced ratios in the population of the 3rd, 5th, 6th, and 9th decade . Men expThe distribution of the three ISI categories (scores ≥ 8) per decade and by gender is displayed in N = 510) and 10.9 in the chronic pain group , both of which are lower than the mean ISI score of 13.8 identified in our sample of OPD. None of the above-mentioned studies analyzed insomnia severity across the life span.Comparing our results to other studies is difficult due to the restricted use of the ISI or other validated tools for analyzing insomnia in large cohorts. We mostly identified studies using other types of self-reports that were not validated for grading insomnia severity. Hence, insomnia prevalence's ranging from 5 to 50% reported in those works have to be interpreted with caution –25. An eOur analysis has some noteworthy limitations: it is cross-sectional, i.e., insomnia was captured at one point in time. Hence, the results do not allow inferring potential time-related dynamics. As only few studies report high quality prevalence data of insomnia in persons suffering from pain , 41, theAlso, no statements can be made regarding possible associations of insomnia complaints with the patients' chief complaints and/or diagnoses, co-morbidities  or other confounding factors , since we did not take these aspects into account. Specifically, the assessment of somatic and/or psychological co-morbidities known to influence sleep  would have offered information on possible cause-effect relationships, yet this effort was outside the scope of this work. Finally, insomnia could also be secondary to the use of medication or substance use, both of which were not controlled as a co-factor in the study.Nonetheless, future research should focus on cross-sectional and longitudinal interactions of insomnia, psychopathology and other associated factors in patients with OPD .This is the first study reporting on insomnia in a large sample of patients referred to an orofacial pain unit. 37.0% of patients responded positively to a screening question for insomnia and/or hypersomnia. For almost half of them, insomnia was moderate to severe. The gender ratio was almost equal throughout adulthood, yet younger and older women were more affected and experienced higher severity than men.According to Swiss law, the analysis of strictly anonymized data does not require approval by an ethics committee.MM and DE: study design, data analysis, manuscript writing. NL: data collection. BS: study design, data collection. AW: data colectivo. AG: study design.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.