Based on meta-analyses results, it is currently acknowledged that there is an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD) undergoing inhaled corticosteroids (ICS) treatment. However, this is not found to be true in those with asthma. No data on this risk are available for COPD patients involved in pulmonary rehabilitation program (PR).For 1 year, we prospectively studied 2 cohorts of COPD patients—undergoing PR and not undergoing PR. The first group included 438 patients undergoing PR of which 353 were treated with ICS, and 85 were treated with bronchodilators only. The second group was comprised of 76 COPD patients who were treated with ICS, but not PR. The control group consisted of 49 ICS-treated patients with asthma. The diagnosis of pneumonia, when suspected, had to be confirmed with a chest x-ray.Overall, 6 cases of pneumonia were diagnosed in the first study group: 5 ICS-treated patients and 1 patient treated only with bronchodilators. This corresponded to a rate of 1.41 and 1.17%, respectively, compared to a rate of 6.6% in COPD patients not treated with PR, which was significantly higher (p = 0.029) than that in the first study group. No case of pneumonia was registered among patients with asthma.These findings suggest that a significantly lower incidence of pneumonia is found in COPD patients treated with ICS and PR than in patients treated with ICS but not with PR. This observation deserves to be investigated in large populations of PR-treated COPD patients, possibly in multi-centric cohort studies. According to the guidelines of chronic obstructive pulmonary disease (COPD) management, inhaled corticosteroids (ICS) should be prescribed only to patients with a severe or very severe disease stage 3 or 4), as assessed by a forced expiratory volume in 1 s (FEV1) lower than 50% of the predicted value or by frequent (more than 2/year) exacerbations  or 4, as.In a meta-analysis, a 12-month budesonide treatment did not increase the risk of pneumonia . AccordiThe study prospectively evaluated a cohort of COPD patients undergoing PR based on the insufficient control of the disease despite appropriate drug treatment . To be aIn 2016, all PR patients underwent four or 6-month interval rehabilitative treatments depending on the severity of the disease. PR was performed as previously described . The proDifferences in incidence of pneumonia were analyzed by the Chi squared test, a p value lower that 0.05 being regarded as positive.The cohort study included 438 COPD patients undergoing PR, of which 353 were treated with ICS or ICS-LABA combinations, and 85 patients were treated only with bronchodilators. Of those patients treated with ICS, 246 received fluticasone/salmeterol; 64 beclomethasone/formoterol, 26 budesonide/formoterol, 8 fluticasone/vilanterol, 4 fluticasone, and 5 ciclesonide. The group of COPD patients not receiving PR included 76 subjects treated with ICS or ICS-LABA combinations of which 42 received fluticasone/salmeterol, 16 beclomethasone/formoterol, 11 budesonide/formoterol, 5 fluticasone/vilanterol, 1 beclomethasone/formoterol, and 1 fluticasone. The control group of patients with asthma included 49 subjects of which 13 received fluticasone/salmeterol, 12 beclomethasone/formoterol, 12 budesonide/formoterol, 6 fluticasone/vilanterol, 3 fluticasone/formoterol, 2 budesonide and 1 ciclesonide. The initial pharmacological regimen was maintained throughout the study. The patients treated with ICS only were given this prescription because the spirometric values were near to normality, but had frequent exacerbations. Table There is clear evidence in the literature that the use of ICS in COPD patients increases the risk of pneumonia –7. BasedAccording to a meta-analysis, PR has several potential benefits, e.g., relieving dyspnea and fatigue, improving exercise capacity, and health-related quality of life, thus enhancing the sense of control that individuals have over their condition. The authors stated that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted . InsteadAlso, the risk of pneumonia is affected by the extent of the subjects physical activity. In fact, in a large population of 109,352 runners and 40,798 walkers, higher doses of running and walking (with no difference between the two) were associated with a lower risk of pneumonia, and a mortality rate decrease of 13%. This outcome appeared to be independent of the effect of exercise on cardiovascular diseases . However


The QoLKAMON study evaluated quality of life, efficacy and treatment safety in HIV patients receiving lopinavir/ritonavir in monotherapy (MT) versus continuing combined antiretroviral triple treatment with a boosted protease inhibitor (TT).This was a 24-week, open-label, multicentre study in virologically-suppressed HIV-infected participants (N = 225) with a 2:1 randomization: 146 patients who switched to MT were compared with 79 patients who remained on a TT regimen. The primary endpoint was change in patient-reported outcomes in quality of life as measured by the MOS-HIV and EQ-5D questionnaires. Secondary endpoints included treatment adherence, patient satisfaction, incidence of adverse events and differences in plasma HIV-1 RNA viral load (VL) and CD4 cell counts.Baseline quality of life, measured with the MOS-HIV score, was very good  and suffered no change during the study in any of the arms , without statistically significant differences when compared. In regards to adherence to therapy and patient satisfaction, some aspects  improved significantly with MT. There were also no differences in the incidence and severity of adverse events, even though 22.8% of those in the MT arm switched their treatment when they were included in the study. Moreover, there was also no significant difference between the immunological and virological evolution of MT and TT. In the MT arm, the VL was always undetectable in 83% of patients (vs 90.7% in the TT arm) and there were only 6.7% of virological failures with VL > 50 copies/mL (vs 2.3% in the TT arm), without resistance mutations and with resuppression of VL after switching back to TT.In a new clinical trial, monotherapy as a treatment simplification strategy in HIV-1 infected patients with sustained viral suppression has demonstrated quality of life, safety and efficacy profiles comparable to those of conventional triple therapy regimens. With the introduction of highly active antiretroviral therapy (HAART), HIV-1 infection has evolved from a fatal disease to a manageable chronic condition. Central goals of current HIV research are to avoid side effects associated with long-term therapy, promote patient comfort and compliance, and reduce economic costs. The standard treatment with three antiretroviral agents, usually two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) plus either a boosted protease inhibitor (PI), an integrase inhibitor (II), or a non-nucleoside reverse transcriptase inhibitor (NNRTI) , 3. FurtDuring the last decade, the use of simplification regimens , initiatHowever, poor treatment satisfaction is a significant risk factor for loss of viral control in patients undergoing antiretroviral therapy, including MT , 26. To The primary objective was to compare quality of life in patients who started MT with LPV/r versus patients continuing on TT containing a PI.Secondary objectives were to compare MT vs TT with regard to treatment satisfaction, adherence, tolerability, regimen safety and virological and immunologic efficacy.This was a phase IV national, open-label, multicentre, controlled, randomized (2:1), 24-week follow-up trial in HIV infected patients. The study was conducted at 31 different Spanish hospitals and was sponsored by the Sociedad Andaluza de Enfermedades Infecciosas (SAEI). The trial protocol was approved in advance by Ethics Committees from each participating hospital, and by a Reference Ethics Committee, representing all of them, the CCEIBA  in November 2009. It met the ethical principles specified in the Declaration of Helsinki and international good clinical practice guidelines, and was registered in December 2009 under EudraCT number 2009-014430-25. The authors confirm that all ongoing and related trials for this drug/intervention are registered. Written informed consent was obtained from each patient prior to any study procedures being performed. A pseudorandom number generator algorithm , 28 was Patients over 18 years of age, with a positive HIV-1 antibody and/or PCR test, receiving any TT containing a boosted PI, and with undetectable VL  during the six months prior to enrolment were eligible for this study. For women with childbearing potential, a negative urine pregnancy test in the initial screening was mandatory. Patients were ineligible if any of the following conditions were present: pregnancy or nursing, acute hepatitis, documented resistance to LPV/r or failure on a PI therapy, concomitant therapy with drugs contraindicated for use with LPV/r, known history of drug addiction or chronic alcohol consumption, current active opportunistic infection or documented infection within 4 weeks of screening, renal disease with creatinine clearance <60 mL/min, concomitant use of nephrotoxic or immunosupressor drugs including corticosteroids, interleukin-2 or chemotherapy, prior medical history of psychiatric disorders such as depressive syndrome, schizophrenia or psychotic disease. Patients took Kaletra (lopinavir 200mg/ritonavir 50mg), 2 tablets bid. A protocol amendment modified the initial exclusion criterion (CD4 cell count nadir < 100 cells/μL) to allow any CD4 cell nadir, provided that the current CD4 count was > 250 cells/μL. In total, 46 patients had a nadir < 100 cells/μL.ad-hoc questionnaire developed to assess satisfaction in patients switching to a simplified regimen, addressing general health status, treatment, illness control, side effects, number of pills and doses, and dietary differences. This questionnaire has two dimensions, the first one related to the degree of treatment satisfaction and the second one to the assessment of factors determining patient satisfaction [Patients’ overall quality of life was assessed using the Medical Outcomes Study HIV Health Survey (MOS-HIV) and EQ-5D questionnaires . The MOSsfaction .Safety was determined by the incidence of treatment adverse events, differences between arms in vital signs and clinical laboratory data, especially regarding HIV-1 RNA levels and CD4 cell counts. Adverse events were graded according to Common Toxicity Criteria . SeriousThe virological efficacy was assessed in different ways. Strict virological failure was defined by two consecutive measurements of plasma HIV-1 RNA > 500 copies/mL separated by at least two weeks. During virological failure, HIV genotyping was performed to determine resistance mutations. In the MT arm, virological rebounds were not considered as therapeutic failure if there was no evidence of LPV/r genotypic resistance and viral suppression could be reinduced with the addition of two NRTIs, leading to a subsequent decrease in VL of at least tenfold in four weeks and to < 50 copies/mL of HIV-1 RNA after 16 weeks. However, an ITT analysis in which analogous reintroduction meant a failure was also performed. The ability of the two strategies to maintain VL lower than 50 and 200 copies/mL was also assessed, and major virological efficacy was defined as undetectable VL during the whole follow-up period and at week 24.Patients were assessed at baseline, week 12, and week 24. At each time point, the following were obtained: a clinical assessment, list of concomitant medications, adverse events, GEEMA, VAS and CESTA questionnaires, VL, CD4 cell count, liver enzymes, biochemistry and hematologic values. MOS-HIV and EQ-5D questionnaires were completed at the first and last assessments. An extra set of data was collected on week 4 for the experimental arm, that included VL and CD4 cell count, GEEMA, VAS, and CESTA questionnaires, and information on concomitant medications and adverse events.P = 0.05. Baseline characteristics of study groups were also compared using an analysis of variance (ANOVA). The main endpoint was ascertained from all the MOS-HIV scores and EQ-5D questionnaire outcomes. The odds ratio of virological rebound was calculated.Sample size calculations for the current study were based on the expected difference between the two treatment arms. It was estimated, according to the literature , that inFor all analyses, the primary population included all patients from the control arm and those from the experimental arm who received at least one dose of LPV/r . In some particular cases, such as MOS-HIV evaluation, an analysis of covariance (ANCOVA) was used for comparisons between both treatment arms, including baseline values, sex, and age as covariates.Between February 2010 and June 2011, 225 patients were identified as eligible for the study and were randomized: 146 patients switched to MT and 79 patients remained on TT. At the beginning of the study, 77.2% of patients in the TT arm were taking lopinavir/ritonavir, while the remaining patients were taking fosamprenavir, saquinavir, atazanavir, darunavir, and nelfinavir. Furthermore, 90% of them were using two NRTIs, the most common being TDF/FTC (53%), followed by ABC/3TC (19%). Overall, 129 patients in the MT arm and 68 patients in the TT arm were still in the study at week 24 . Of the Baseline characteristics of the patients included in the study were not significantly different between the two groups, TT and MT, in the majority of measured parameters . Mean agAt baseline, the mean MOS-HIV overall scores were 83.0 ± 10.5 in the MT arm and 82.3 ± 11.3 in the TT arm . An analConcerning the EQ-5D questionnaire, the baseline scores were 81.8 ± 18.2 in the MT arm and 82.6 ± 15.7 in the TT arm . The ANCAdherence rates  were similar in both boosted PI-based regimens with no significant change over time . At the beginning and end of the study, 74.1% and 70.1% of patients in the MT arm and 70% and 69.4% of patients in the TT arm were fully adherent to treatment, respectively. When all the items included in the GEEMA questionnaire were analysed separately, there were statistical differences only in the number of doses missed within the last week, which were more numerous in the TT arm  . In the Comparing both treatment arms, there was a significant difference in the mean score measuring the change in dimension 1 , and specifically, a significantly greater satisfaction with the number of pills taken daily (P <0.001) among the patients in the monotherapy arm versus the TT arm .There was no significant difference in the incidence of adverse events between treatment arms. Total and serious adverse events were reported in 17.8% and 4.1% of patients from MT versus 14.3% and 1.3% from TT (P = 0.573 and P = 0.426). The non-serious adverse events were mild in 81.1% and 58.8% in MT and TT arms respectively and considered unrelated to treatment in 83.8% and 82.4% of cases .There were no significant differences for haematological parameters, vital signs and anthropometric measures over time either in each arm or between arms.As to maintaining virological suppression, there were no significant differences between MT and TT arms. In the ITT analysis , the percentages of patients with undetected VL (< 50 copies/mL) at any time during the study period were similar in both treatment arms . Likewise, there was a similar percentage of subjects who, at the end of the study, had VL < 50 copies/mL . No significant differences were found in the virological failure rate considering VL > 500 copies/mL , VL > 200 copies/mL , or VL > 50 copies/mL , nor for the percentage of patients with VL < 200 copies/mL at any time during the study . Furthermore, there were no statistical differences in adherence and virological failure between arms .Furthermore, the number of detectable VLs over time did not show significant differences . The risk of virological rebound was similar for both arms: the OR of MT versus TT was 1.429 (CI 95% 0.772–2.646) for VL > 50 copies/mL; and 1.762 (CI 95% 0.584–5.315) for VL > 200 copies/mL.Genotype testing showed no LPV/r resistance in MT patients with virological failure. All of them regained virological suppression after restarting prior antiretroviral treatment.Regarding the development of the immune response, although there was no statistical difference in total cell counts of CD4 cells/μl, the CD4 percentage of total lymphocytes showed a significant difference between arms .LPV/r monotherapy is one of the best known options of tailored therapeutic approaches for patients with persistently suppressed HIV viremia in which fewer than the recommended standard of three antiretrovirals are used . The priIt is well known that adherence is a determinant factor of antiretroviral treatment efficacy and, as such, it is an important variable that must be determined. High rates of adherence were observed in all patients. The GEEMA and VAS questionnaires did not show any statistical difference between the two arms.The degree of patient satisfaction with the monotherapy regimen, measured by the dimension 1 of the CESTA questionnaire, was significantly greater than in the TT arm. This dimension registers satisfaction with general health status and treatment, disease control, absence of side effects, number of pills, dosage schedule, and dietary restrictions. This result could reflect the advantages of treatment simplification. Particularly, there was greater acceptance of the number of pills taken by the patients in the experimental arm.In this study, there were no significant differences in adverse events and viral rebounds between treatment arms. In contrast with other studies, a low lymphocyte nadir (less than 200 or less than 100 cells/μl) was not shown to be a risk predictor for VL detection or for virological failure.However, although the difference was not significant, TT has been shown to be more efficient than monotherapy in maintaining HIV-1 suppression, with fewer blips and viral rebounds . As in oWith regard to development of the immune response, the fact that the fraction of CD4/total lymphocytes increased to a greater extent in the TT arm has uncertain significance, and no conclusions can be drawn. Although an increase in the percentage of CD4 cells may be associated in some cases with a decrease in the percentage of CD8 cells, and thus with a decrease in immunological activation, no other activation parameters were measured to further evaluate this feature.Almost 85% of ITT population in the MT arm had a VL of < 50 copies/mL at the end of the study. This outcome could be an indication that the monotherapy simplification strategy with LPV/r in stable, controlled HIV-1 patients is safe and efficient. While this conclusion is not novel, it reinforces results from previous studies  and suppPreviously, the MONARK trial had analysed quality of life as a secondary endpoint in antiretroviral-naive patients in MT , with tha priori. Longer follow-up periods and a greater number of patients may be needed to demonstrate any change. There has also been a delay in the publication of this article due to the desire to elaborate on virological data outcomes. This prolonged the data collection period to perform a post-hoc analysis and rewrite the article for publication. This delay has led to a loss of interest in the study drug since the study was carried out. However, this study is important as it offers new data on the efficacy and safety of MT that could be extrapolated to darunavir.The slight differences in patients’ treatment adherence, quality of life, and satisfaction shown by our study suggest that switching from standard TT to MT may be beneficial. However, a more obvious gain in quality of life was expected in the monotherapy arm, considering the simplification of the treatment, despite the twice-a-day administration. These results may also be due to limitations, such as a reduced statistical power due to sample size, the subjective nature of the assessment tools, short follow-up and cohort characteristics. Indeed, the study was carried out on patients who were already tolerating a stable antiretroviral regimen, with a high quality of life at baseline (VAS score over 80%), so the probability of showing differences was low In summary, we showed that both regimens exhibited high overall health scores, satisfaction and treatment adherence, and did not lead to significant differences from baseline in VL or CD4 cell counts. Our results are in general agreement with previous studies and support the effectiveness of LPV/r as a suitable LDR for some patients, in light of the evidence for maintained HIV-1 suppression and potential to avoid the side effects associated with nucleoside analogue-containing regimens. This strategy also preserves future treatment options in case of failure, and reduces the economic costs of antiretroviral therapy, while maintaining a very good quality of life.S1 Fig(DOC)Click here for additional data file.S1 TableSome of the questions from the last visit, for the ITT population.(DOC)Click here for additional data file.S2 TableQuestions from dimension 1 at last visit. Intent-to-treat analysis.(DOC)Click here for additional data file.S1 File(DOC)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.S4 File(XLSX)Click here for additional data file.S5 File(XLSX)Click here for additional data file.


To evaluate the prevalence of metabolic syndrome (MetS) and its individual components within sex-, body mass index (BMI)- and age combined clusters. In addition, we used the age-adjusted blood pressure thresholds to demonstrate the effect on the prevalence of MetS and elevated blood pressure.Cross-sectional data from 74,531 Western European participants, aged 18–79 years, were used from the Dutch Lifelines Cohort Study. MetS was defined according to the revised NCEP-ATPIII. Age-adjusted blood pressure thresholds were defined as recommended by the eight reports of the Joint National Committee .19.2% men and 12.1% women had MetS. MetS prevalence increased with BMI and age. Independent of BMI, abdominal obesity dominated MetS prevalence especially in women, while elevated blood pressure was already highly prevalent among young men. Applying age-adjusted blood pressure thresholds resulted in a 0.2–11.9% prevalence drop in MetS and 6.0–36.3% prevalence drop in elevated blood pressure, within the combined sex, BMI and age clusters.We observed a gender disparity with age and BMI for the prevalence of MetS and, especially, abdominal obesity and elevated blood pressure. The strict threshold level for elevated blood pressure in the revised NCEP-ATPIII, results in an overestimation of MetS prevalence. The metabolic syndrome (MetS) is nowadays frequently used to identify individuals at higher risk for future type 2 diabetes (T2D) and cardiovascular disease (CVD) . RecogniPreviously, we observed that besides abdominal obesity, elevated blood pressure was the most common abnormality contributing to the prevalence of MetS, within all BMI classes , 7. ElevDespite the prevalence of MetS is well known in various populations, there is no in-depth information available about the prevalence of MetS and the individual components within particular combined subgroups of sex, BMI and age. The Lifelines cohort is the largest population-based study in the Netherlands and therefore particularly suitable to evaluate these detailed prevalence estimates. Our second aim was to demonstrate the influence of age-adjusted blood pressure thresholds on the prevalence estimates of MetS and elevated blood pressure.Lifelines is a population-based cohort study examining in a unique three-generation design the health and health-related behaviours of persons living in the North of the Netherlands. The adult population participating in Lifelines was found to be broadly representative for the adults living in the three northern provinces of the Netherlands . BetweenN = 92,409). We excluded individuals who had no verified data on medication use or missing data on variables needed to calculate the body mass index or on the variables used to diagnose MetS. A total of 74,531 individuals were included in the study.For this study, we used cross-sectional data, collected between 2006 and 2013, of subjects from Western European descendent (according to self-reported information in the questionnaire) and aged ≥18 and <80 years (2)), which was categorized as normal weight (<25 kg/m2), overweight (25–30 kg/m2) and obesity (≥30 kg/m2).A standardized protocol was used to obtain blood pressure and anthropometric measurements such as height, weight and waist circumference. Blood pressure was measured every minute during a period of 10 min with an automated DINAMAP Monitor . The average of the final three readings was recorded for systolic and diastolic blood pressure. Anthropometric measurements were taken in light clothing and without shoes. Body weight was measured to the nearest 0.1 kg. Height and waist circumference were measured to the nearest 0.5 cm. Waist circumference was measured in standing position with a tape measure all around the body, at the level midway between the lower rib margin and the iliac crest. Body weight and height were used to calculate BMI (weight (kg)/height . Fasting blood glucose was measured using a hexokinase method.According to the revised NCEP-ATPIII (R-ATPIII) , at leasAccording to the most recent hypertension guideline from the eighth report of the Joint National Committee JNC 8, 2014), non-diabetic individuals between 18 and 60 years should be treated to a target blood pressure <140/90 mmHg and individuals ≥60 years to a target blood pressure of <150/90 mmHg. Accordingly, age-adjusted thresholds for elevated blood pressure were considered at: 4, non-di. MetS deAll medications used by participants were self-reported and classified according to the Anatomical Therapeutic Chemical (ATC) classification system. Diagnosis of T2D was based on self-report and verified with self-reported medication use. Newly diagnosed T2D was based on a single fasting blood glucose level ≥7.0 mmol/L. A CVD history was defined as self-reported previously sustained myocardial infarction, stroke or vascular intervention.Based on the participants’ responses to the self-administered questionnaires, data were assessed on education level, smoking, alcohol consumption and physical activity. Education level was categorized as low , medium (higher secondary education) or high . Smoking status was defined as non-smoker, former smoker and current smoker  . AlcoholP values even when absolute differences are small.The prevalence of MetS (according to the R-ATPIII and R-ATPIII updated) and each metabolic risk factor were reported in subgroups that were defined by sex, BMI  and age decades . Results are expressed as counts and/or proportions (%). All data analyses were conducted using IBM SPSS Statistics, version 23 (IBM Corporation). In our analysis, we chose to focus on absolute differences and not on statistical significance, because the large study sample of Lifelines may produce low Supplementary Table 1A, B and C  men (mean age 45 ± 13 years) and 41,800 (56.1%) women (mean age 45 ± 12 years). Among the male participants, 12,691 (38.8%) were normal weight, 15,677 (47.9%) were overweight and 4363 (13.3%) were obese. Among female participants, these numbers were 21,460 (51.3%), 13,893 (33.2%) and 6447 (15.5%), respectively. Clinical, demographic and lifestyle characteristics of the study population can be found in The age-, sex- and BMI-specific prevalence of MetS according to the R-ATPIII and R-ATPIII updated criteria are shown in Supplementary Table 2A, B and C. In men below the age of 60 years, the most common MetS component was elevated blood pressure (49.6%), followed by increased triglycerides (24.1%) and decreased HDL cholesterol (22.1%). In women below the age of 60 years, abdominal obesity (39.0%), elevated blood pressure (25.2%) and decreased HDL cholesterol (18.5%) were the most common MetS components. However, in older adults (≥60 years), the sex differences in the various MetS components were diminished. In both sexes, elevated blood pressure (75.9% in men and 69.2% in women), abdominal obesity (35.6% in men and 60.9% in women) and impaired fasting glucose (32.2% in men and 23.8% in women) were the most prevalent.The MetS component ‘elevated blood pressure’ showed the most pronounced increase with age. Across the entire cohort, the prevalence of elevated blood pressure  increased from 23.3% in the youngest age group (18–29 years) to 84.4% in the oldest age group (70–79 years). In men below the age of 60 years, elevated blood pressure was present in a much higher percentage compared to women (independent of BMI). Among individuals aged ≥60 years, the percentages of men and women with elevated blood pressure were roughly similar  and 2.Supplementary Table 1A, B and C depict the absolute blood pressure levels in the various age and BMI groups, and the percentage of participants using antihypertensive drugs. With increasing age and higher BMI, the use of antihypertensive drugs increased, and this was comparable between men and women. The age-adjusted prevalence estimates of elevated blood pressure were closer to the estimates for antihypertensive drug use. In other words, the ratio of those having an elevated blood pressure based on their measured blood pressure values vs the use of antihypertensive drugs decreased.In Prevalence of abdominal obesity became higher with increasing age and was higher among women than men. In normal weight women, the prevalence of abdominal obesity increased from 6.0% to 24.9% with age. This percentage was much lower among normal weight men, namely 0.1–3.0%. The sex difference was also present in overweight (9.5–39.6% in men and 51.0–77.8% in women) and obese individuals, although among obese individuals essentially all had a waist circumference above the defined cut-offs for abdominal obesity .The prevalence of decreased HDL cholesterol gradually fell with increasing age in both men and women . In contIn Western European individuals living in the Netherlands, the prevalence of MetS risk factors differed by sex, age and BMI. Elevated blood pressure and abdominal obesity were the two most frequently present risk factors, and their contribution to the diagnosis of MetS greatly overrides the other three components. Furthermore, the age-adjusted thresholds for elevated blood pressure better approximated the treatment of hypertension in clinical practice.This is one of the largest studies in the Netherlands, in which the prevalence of MetS was meticulously assessed. Similar to other observations, we found that the prevalence of MetS increases with age, up to the seventh age decade , 18, 19,In some studies, prevalence estimates for MetS are found to plateau or drop off after the sixth or seventh age decade in both sexes , 23, or The observed trend of increasing MetS prevalence with age can be explained by the large number of people developing metabolic complications by the time they are aged ≥60 years . Due to the age-related rises of blood pressure, abdominal obesity and glucose a more similar make-up of MetS was seen in the elderly, whereas in younger people, the MetS profile was more heterogeneous and differed more by sex. As reported previously, abdominal obesity was already highly prevalent in younger women and much more common than in men , 4, 5, wThe clinical utility of MetS has been criticized for quit some years , 34. CriCompared to the other MetS components, the prevalence of elevated blood pressure was remarkably high in our study. A threshold of ≥130/85 mmHg seems very strict, especially for the older subjects where the natural course of blood pressure changes with ageing is not taken into account . Since aOver the last decades, several guidelines have tried to define the optimal cut-off levels for treatment of hypertension with lifestyle adjustment and medication. In the most recent JNC 8 treatment guideline for hypertension, it is advised to aim for a blood pressure <140/90 mmHg in non-diabetic adults (<60 years), whereas blood pressure values <150/90 mmHg were advised for elderly (≥60 years) . In the Several long-term follow-up studies have shown that cardiovascular risk gradually increases with rising blood pressure , 43, 44.The ‘elderly’ is a difficult definition, because this subgroup is not a simple age range, but includes groups with a different level of overall health. Treatment of hypertension is therefore more complex in the elderly compared to the general population. Lowering systolic blood pressure below 140 mmHg or even below 130 mmHg to reduce cardiovascular risk is supported by data from respectively, the HOT study and the INVEST study , 50. AltWhile at first sight the decision of the JNC 8 to recommend age-specific treatment targets is in line with the available evidence, there is some criticism as well. The JNC 8 mainly used data from randomized clinical trials, while evidence from observational studies, systematic reviews or meta-analyses were excluded . Still, There are several strong points, which characterize our study. We used data of 74,531 Dutch participants, of only Western European descent, from whom high-quality data on anthropometric and clinical measurements were obtained. The large number of participants allowed us to explore trends within detailed clusters of sex, BMI and age, which has not been done before. However, the findings of our study are limited by the cross-sectional data, and therefore, no trends in the development of clinically significant endpoints, such as T2D and cardiovascular morbidity and mortality, could yet be established. Although Lifelines is a relatively young cohort, it is one of the largest cohort studies to date, which is prospectively collecting follow-up data on a wide range of subjects. The Lifelines Cohort Study will therefore add a valuable contribution to strengthen evidence upon complex research questions.In this representative sample of a Dutch adult population, we observed a gender disparity with age and BMI for the prevalence of MetS and, especially, the blood pressure and waist circumference component. The observed sex differences tended to diminish in older adults. Due to the strict selected threshold level in the R-ATPIII, the blood pressure component is much higher in the (elderly) population compared to the other MetS components. This update of the MetS prevalence and its individual components in the Dutch population show that there is an ongoing burden of risk factors associated with development of T2D and CVD.Table S1Click here for additional data file.The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.https://www.bioshare.eu/content/bioresource-impact-factor.The Lifelines Cohort Study, and generation and management of GWAS genotype data for the Lifelines Cohort Study is supported by the Netherlands Organization of Scientific Research NWO (grant 175.010.2007.006), the Ministry of Economic Affairs, the Ministry of Education, Culture and Science, the Ministry for Health, Welfare and Sports, the Northern Netherlands Collaboration of Provinces (S N N), the Province of Groningen, University Medical Center Groningen, the University of Groningen, Dutch Kidney Foundation and Dutch Diabetes Research Foundation. This work was supported by the National Consortium for Healthy Ageing, and funds from the European Union’s Seventh Framework program (FP7/2007–2013) through the BioSHaRE-EU (Biobank Standardisation and Harmonisation for Research Excellence in the European Union) project, grant agreement 261433. J V van Vliet-Ostaptchouk was supported by a Diabetes Funds Junior Fellowship from the Dutch Diabetes Research Foundation (project no. 2013.81.1673). Lifelines (BRIF4568) is engaged in a Bioresource research impact factor (BRIF) policy pilot study, details of which can be found at:


To date, few studies have focused on the clinical and allergic characteristics of asthma in the elderly, defined as asthma in people aged 60 or over. Thus, we propose to identify and study the clinical and allergic characteristics and comorbidities of patients with asthma among the elderly.A retrospective, observational, descriptive study was developed in five clinics and hospitals in Argentina. Allergy Physicians analyzed their patients’ medical records in 2014 and included those adults over the age of 60, who had been diagnosed with asthma according to the GINA guidelines. Clinical and allergic characteristics were analyzed.p <  0.05).It is worth mentioning that almost half of the patients with LOA had allergies at the nasal level.A total of 152 patients diagnosed with asthma, of whom 73% were women and 11% ex-smokers, were included in this study, with a mean age of 66 years. Only 10.5% of the participants had onset asthma past the age of 60. Regarding asthma severity, 74.3% were diagnosed with moderate persistent asthma, and 7.2% with severe persistent asthma. Eighty-four percent of the patients were treated with an inhaled corticosteroid (ICS) along with a long-acting β 2-adrenergic agent (LABA). More than half of the patients had two or more comorbidities simultaneously. Allergic comorbidities were the most frequent comorbidities, followed by arterial hypertension. Among allergic comorbidities, most patients presented allergies at the nasal level. There were no significant differences between the subpopulations of patients with late-onset asthma (LOA) and asthma with onset before the age of 60, i.e. early onset asthma (EOA) in most of their clinical characteristics. However, it was observed that EOA accounted for a higher percentage of patients with nasal allergies as compared to LOA (71% vs 46%, These results may provide a better understanding of the clinical characteristics of asthma in the elderly in Argentina, thus, enabling the development of future therapeutic strategies and a better quality of life for our elderly asthma patients. In the past, asthma was mainly considered a childhood illness. However, recent epidemiological studies indicate that new incident asthma can occur at any age, and it is in fact highly prevalent in the older adult population and its prevalence ranges from 4.5% to 12.7%. According to the current demographic trends, a 100% increase in the number of people over the age of 65 is expected in the next 20 years [The mainstay of asthma management at any age is to achieve and keep the disease under control. The pharmacological control depends on the clinical and allergic characteristics of the disease, and, in addition, symptoms may be influenced by age-related factors such as an increased frequency of comorbidities and patients prescribed with multiple drugs simultaneously. In addition, specific problems associated with the management of asthma in the elderly have been described, such as improper use of the inhaler, poor adherence to treatment, increased adverse effects, and declining response to medications. The study of the clinical characteristics of asthma in the elderly is of utmost importance in terms of providing evidence to identify those diagnostic and therapeutic methods that are safe and effective , 3.Comorbidities are considered to be some of the key characteristics of geriatric patients and contribute to the clinical complexity of the elderly. In addition, they contribute to poor asthma management outcomes in this group as compared to younger asthmatic patients. The presence of comorbidities has been shown to influence the quality of life of the elderly with asthma, which in turn affects adherence to treatments. In this context, specific comorbidities may also prevent the correct use of inhaler devices, for example, in patients suffering from arthritis, orthodontics, dementia, etc , 4.Knowing the epidemiology of asthma is essential for the planning of health services, but our knowledge about this disease is still incomplete. Historically, clinical studies on asthma have frequently excluded the elderly population, and there are still few observational epidemiological studies which could shed light on the nature or the pathophysiology of the disease. Consequently, it is imperative to study the clinical and allergic characteristics of asthma in the elderly, on the one hand, and their comorbidities, on the other hand, in order to propose new therapeutic and diagnostic strategies, and ultimately, to improve the patients’ quality of life , 5.Therefore, we aim to identify and study the clinical and allergic characteristics, as well as the medical and allergic comorbidities of asthma in patients over the age of 60 in Argentina.A retrospective, observational, descriptive study was developed in five clinics and hospitals in Argentina: Allergy and Respiratory Diseases Research (InAER), Autonomous City of Buenos Aires, Argentina; Hospital Area General De Agudos Dr. Ricardo Gutierrez, La Plata, Argentina; Allergy and Immunology Service, Hospital San Roque, Cordoba, Argentina; Private Medical Centers, Ramos Mejia, Buenos Aires, Argentina. Allergists analyzed their patients’ medical records for three months in 2014, and included those aged 60 or older diagnosed with asthma, according to the GINA guidelines. It should be noted that some patients did not present reversibility in the cross-section of this study, although prior to the diagnosis of asthma they did present it, according to the GINA guidelines.For each asthmatic patient over 60 years, researchers gathered the following information: 1) age, sex and race; 2) smoking status; 3) age at the onset of asthma, defined as the age at which the patient is diagnosed with asthma; 4) asthma severity (according to the GINA guidelines); 6) Pulmonary function values; 7) positive reaction to the Skin Prick Test (SPT) ; 8) exacerbation triggers ; 9) total serum IgE (IgE ˃ 100 UI/ml were considered subjects with high IgE); 10) eosinophil count ,; 11) current treatment they receive; 12) dose of inhaled corticosteroids; 13) Medical comorbidities , dyslipidemia, coronary heart disease, diabetes, pulmonary hypertension, other cardiovascular diseases) and allergic conditions , eosinophilic esophagitis).t and Fisher’s Exact Test, as appropriate. P values below 0.05 were considered to be statistically significant.Data are expressed as a percentage, except for the age of onset and the time span with asthma, which are presented as mean and standard deviation (SD). The clinical characteristics of the EOA and LOA subpopulations were compared using unpaired Student A total of 152 patients with a defined diagnosis of asthma were included in this study, with a mean age of 66 (SD 6.5) years, of whom the majority were women (73%). Regarding the racial characteristics of the participants, all of them were were Caucasian. None of the patients were currently smokers, and only 11% had previously smoked. The mean age of onset of asthma symptoms was 33.4 (SD 22.9) years, with an average of 34.2 years (SD 21.9) (Table p <  0.0001) (Table Late-onset asthma (LOA), defined as the onset of asthma after the age of 60, was observed in 10.5% of the patients, with a mean age of onset of 69.2 (SD 6.8) years, having had asthma for an average of 7.3 (SD 4) years. On the other hand, the mean age of onset of symptoms in patients with asthma with an onset before the age of 60 (EOA) was 29 (SD 12.4) years, having had the disease for 37.4 (21 years); both the age of onset of asthma and the time span with asthma were significantly different between both subpopulations  was 73%, and FEV1/forced vital capacity (FVC) was 69%. In addition, 39% presented normal values of FEV1 (higher than 80%), with 59% reversibility. Among the LOA patients, we found that 50% had normal FEV1 (mean FEV1 of 71%), and 62% were reversible. While among the EOA patients, 37% had normal FEV1 (mean FEV1 of 73%), and 58% were reversible, with no statistical difference between the EOA and LOA populations , only 4% did not present any positive response. Among the allergens investigated, mites (70%), fungi (58%) and pollen (32%) were included , exercise 39%) and aeroallergens (21%). Also, 31% of the patients presented other triggers not included among the mentioned ones, such as dyes, perfumes and temperature changes. On the other hand, 4% of the patients did not present any triggers  along with a long-acting β-adrenergic agent. Sixty percent of all patients used fluticasone and salmeterol, while 24% used budesonide and formoterol. The ICS dose was greater than 1000 mg/day in 24% of the patients. On the other hand, 16% had not been prescribed any specific treatment for asthma. The main rescue treatment option chosen by the patients was fast-acting β-adrenergic agonists, with salbutamol being the most widely used one (91%), and only a few of the patients used ipratropium bromide. On the other hand, 9% of the patients did not use any rescue treatment. Among the EOA and LOA patients, no significant differences were observed in terms of the treatments used , followed by hypertension (45%), GERD (16%), diabetes (12%), obesity (9%), coronary diseases (8%), osteoarthritis, arthritis (7%), hypothyroidism (7%), Chagas disease (4%), and dyslipidemia (3%). Other comorbidities were also found, such as gastritis, celiac disease, breast cancer and pulmonary hypertension, but only in a few patients. There were no significant differences in the percentages of these comorbidities between the EOA and LOA patients . However, it is worth noting that almost half of the patients with LOA had chronic rhinosinusitis or allergic rhinitis. Among the patients with EOA, we observed that a similar proportion of patients had seasonal rhinitis, perennial rhinitis and chronic rhinosinusitis , while 13% had chronic rhinosinusitis and perennial rhinitis. Only a small percentage of patients had chronic rhinosinusitis and seasonal rhinitis [Among allergic comorbidities, patients mainly had nasal allergies 68%). Among them, mainly perennial rhinitis (23%), seasonal 18%) or chronic rhinosinusitis (15%), and, in addition, some patients presented chronic rhinosinusitis and perennial rhinitis simultaneously (12%). Only a few patients had chronic rhinosinusitis and seasonal rhinitis (1%). Other allergic comorbidities were uncommon, such as allergic conjunctivitis, sinusitis, nasal polyposis, eczema, chronic or acute urticaria, and intolerance to NSAIDs. Twenty-nine percent of the patients did not present any of the comorbidities sought. On the other hand, EOA patients represented a higher percentage of patients with nasal allergies as compared to LOA  and eosinophils (6.1%) were higher than those reported in the study by Inoue et al.  . One pos1 (73%), and FEV1/FVC (69%) were similar to those obtained by Park et al. and Inoue et al., who reported values of 75% and 66%, and 81% and 72%, for FEV1 and FEV1/FVC, respectively. In both studies it was observed that values are significantly lower than when compared to non-elderly asthmatics. It is important to emphasize that the population described in this study presents an average age lower than the average age of the patients described in the studies of Inoue et al. and Park et al. , and the duration of the illness is much longer . In this sense, Inoue et al. demonstrated that asthma in the older adult is characterized by an airway obstruction that is independent of age per se and the duration of the disease [On the other hand, the values obtained from FEVAs with other populations of elderly asthma patients, most patients are treated with ICS along with a long-acting β-adrenergic agent , 6, 7. AMost patients presented comorbidities, as described for older asthmatic adults . Howevern = 16) in the LOA group.However, the comorbidities found match what has been previously reported for this population with a high frequency of arterial hypertension and allergic comorbidities, and, to a lesser extent, diabetes mellitus, cardiovascular diseases, and osteoarthritis or arthritis , 6, 7. ORecruitment was in Allergy Units, although many asthmatics are also treated by primary care Physicians, Pulmonologists and internists. Also, not all the population had skin tests performed and/or diagnosis and treatment of upper airway punctuated. On the other hand, some of these patients may also display an ASTHMA-COPD overlap syndrome . FinallyThese results may provide a better understanding of the clinical characteristics of asthma in the elderly, and thus enable the development of future therapeutic strategies and a better quality of life for our elderly asthmatic patients.


Phaseolus vulgaris) capable of nodulating and fixing nitrogen when inoculated onto bean  has been widely used as a natural genetic engineer to transform plants of agricultural interest  , supplemented with appropriate antibiotics. Liquid cultures for inoculation were grown in LB at 30°C with shaking at 200 rpm  and 10% SDS. After treatment with a mix of 1:1 phenol-chloroform, DNA was precipitated with absolute ethanol. Genomes were sequenced by Macrogen . For each strain, libraries of 3 kilobase pairs (kb) were prepared and run on an Illumina HiSeq2000 to obtain 100–base pair (bp) mated pair reads. Total read counts were 13,969,230 and 17,424,244 for CCGM10 and CCGM11, respectively; filtered read counts were 6,951,885 and 8,690,792, with genome coverage of 121 × and 152 ×. Assembly was performed with SOAPdenovo2  to detect closely related strains. The genomes of selected strains were compared with genomes of CCGM10 and CCGM11 using Proteinortho version 5, with BLAST parameters E < 1E-5; 30% identity, and 70% coverage. The organisms selected for comparison were A. pusense IRBG74; A. pusense HPC(L), also known as R. pusense; and A. fabrum C58, also designated A. tumefaciens.The A. pusense strains CCGM10 and CCGM11 were registered at GenBank with the provisional accessions LNZW00000000 and MAPG00000000, respectively.The genomes of A. pusense strains CCGM10 and CCGM11 are listed in Table The main characteristics of the genomes of A. pusense IRBG74. The chromosomes were highly conserved, but the symbiotic plasmid of strain IRBG74 was not shared (not shown), and some regions were exclusive to the chromosomes of the reference strain. The genomes of A. pusense HPC(L) and that of A. fabrum C58, the model organism of the genus, were also included in the comparison.A structural analysis of the genomes of these strains revealed very high conservation of both the linear and circular chromosomes, as shown in Figure Agrobacterium and Rhizobium. Plasmid D harbored numerous genes with homologs in Roseomonas mucosa , and ubiquinone synthesis. Plasmid D was especially enriched with genes involved in transcription, replication, and intracellular trafficking. Other notable genes encoded factors associated with secretion system IV, chemotaxis (cheBRW and methyl-accepting proteins mcp), transcriptional regulators and sensors, and genes for the redox response involving flavodoxin and glutathione. In addition, the plasmid contained a 500 bp segment homologous to the T-DNA segment of plasmid pTi.Next, we analyzed the functions of genes in the plasmids of strain CCGM10 Table . PlasmidarcACD, argF, speD, and the universal stress protein uspA. Plasmid A contained some genes involved in chemotaxis and glycerol utilization. In addition, we identified clusters of genes involved in conjugal plasmid transfer and replication (repABC family) in plasmids pC, pD, and pE.Plasmid C was rich in genes involved in trafficking and ion transport, and it also harbored genes related to defense (toxin-antitoxin pairs) and central metabolism, such as fixGHS, fixNOQP, nifURS, nodLN, and fixR. A. fabrum C58 harbored homologs of these genes. However, some other genes not present in the C58 genome, such as the fixLJK cluster, were present in plasmid D. FixLJ are transcriptional regulators of nifA, the general activator of nitrogen fixation; FixK is regulator of the fixNOQP operon . These genes may represent the remnant of a complete gene cluster related to nitrogen fixation.In the circular chromosome, we identified the following genes involved in nitrogen fixation: A. pusense strains, which were isolated from nodules but lack genes for nodulation. First, we have isolated 10 other rhizobial strains from nodules of non-inoculated plants; seeds from plants inoculated with two selected strains, CCGM1 or CCGM7, yielded positive signals for specific rhizobial gene markers . A README file explains the content and mode of use.The files containing the genomic sequences and the data resulting from our analyses are available and can be accessed freely at our server by ftp  and from DGAPA-PAPIIT-UNAM (IN208216 and IN206914). The agencies had no role in the design of the study or the analysis or interpretation of the results.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.


Brassica chinensis L.) to tetracycline, cephalexin, and sulfamethoxazole at 50% minimum inhibitory concentration (MIC) levels and MIC levels, respectively, was conducted to explore plant growth, antibiotic uptake, and the development of antibiotic resistance in endophytic systems. The three antibiotics promoted pakchoi growth at 50% MIC values. Target antibiotics at concentrations ranging from 6.9 to 48.1 µg·kg−1 were detected in the treated vegetables. Additionally, the rates of antibiotic-resistant endophytic bacteria to total cultivable endophytic bacteria significantly increased as the antibiotics accumulated in the plants. The detection and quantification of ARGs indicated that four types, tetX, blaCTX-M, and sul1 and sul2, which correspond to tetracycline, cephalexin, and sulfamethoxazole resistance, respectively, were present in the pakchoi endophytic system and increased with the antibiotic concentrations. The results highlight a potential risk of the development and spread of antibiotic resistance in vegetable endophytic systems.Antibiotic contamination in agroecosystems may cause serious problems, such as the proliferation of various antibiotic resistant bacteria and the spreading of antibiotic resistance genes (ARGs) in the environment or even to human beings. However, it is unclear whether environmental antibiotics, antibiotic resistant bacteria, and ARGs can directly enter into, or occur in, the endophytic systems of plants exposed to pollutants. In this study, a hydroponic experiment exposing pakchoi ( Antibiotic pollutants and their environmental impacts have become a mounting concern owing to their broad usage and persistence in the environment. A large range of veterinary and human antibiotics have been detected in soil, animal manure, sediment, municipal or industry wastewater, surface water, groundwater, and drinking water samples ,3,4,5,6.Once antibiotics are released into agricultural lands, crops are exposed to them due to their persistence, and the level of exposure depends on the physicochemical properties of the compounds, sorption potential, and environmental conditions ,17. EvenTo date, the majority of research on the impact of antibiotic contamination in plants has focused on evaluating the toxicity of antibiotics to plants or detecting the ability of antibiotics to accumulate in plants. Limited knowledge is available regarding the potential effects of antibiotic stress on the development and spread of antibiotic resistance, including antibiotic-resistant bacteria and antibiotic-resistant genes (ARGs), in plant endophytic systems. There is a diverse range of endophytic bacteria, which includes pathogens, mutualists, and commensals that grow within the roots, vasculature, and aerial tissues of plants . RecentlBrassica chinensis L.), a frequently consumed vegetable in China, was selected and planted in a hydroponic system and exposed to different antibiotics. Then, the antibiotic uptake and its effects on plant growth and the presence of AREB and ARGs in the endophytic system were investigated and evaluated. The findings will facilitate a more accurate assessment of the potential risks of antibiotic contamination to food quality and environmental health.To assess possible consequences, pakchoi , an enzyme in the folic acid synthesis pathway. Two genes, sul1 and sul2, mediated by transposons and plasmids, and expressing DHPS highly resistant to sulfonamide, have been found [Tetracycline , cephalexin , and sulfamethoxazole  were purchased from Dr. Ehrenstorfer GmbH  and selected to represent the different classes of antibiotics  based on their frequent usage in the local livestock farms in Xinxiang City, China . Tetracyon genes . β-lactaon genes . Sulfonaen found .Methanol, acetonitrile, formic acid, and acetone of HPLC grade were purchased from Fisher Scientific . Other chemicals were of analytical grade and obtained from Yaohua Chemical Reagent Factory . Ultrapure water was supplied using a Millipore Milli-Q system . Oasis HLB cartridges  purchased from Waters  were used for the extraction and purification of the target antibiotics. Individual stock standards were prepared by dissolving antibiotics separately in methanol and were stored at −20 °C in brown vials.B. chinensis L.) were used for this study. TC, CPL, and SMX were separately added into the hydroponic solution of the test system at two concentrations: 50% of minimum inhibitory concentration (MIC) of each antibiotic, and the MIC of each antibiotic [A hydroponic experiment with antibiotic treatments was performed in an experimental greenhouse in the College of Life Sciences, Henan Normal University, China, during the autumn of 2016. Seeds of pakchoi ; (3) CPL-treated ; and (4) SMX-treated . Each treatment was designed with three replicates, and a total of 21 hydroponic tanks were used in the present study. Additionally, each tank had nine cylindrical holes (4 cm depth and 3 cm diameter) in its cover containing sponges (3 × 3 × 2.5 cm) in individual cylinders as a rooting medium. Five uniform seeds were planted per hole and irrigated with half-strength Hoagland solution every 2 days until the roots of the seedlings were immersed in the solution. Finally, only one or two strong seedlings were selected to leave in each hole, and they were grown directly in nutrient solution.Prior to testing, the seeds were surface-sterilized in 0.1% sodium hypochlorite solution for 10 min and then rinsed with sterile deionized water . Seeds oDuring the experiment the room conditions were maintained at 25 ± 2 °C in daylight and 18 ± 2 °C at night, with a relative humidity between 65% and 70%. Each planter was equipped with an electric aeration pump and was aerated for 2 h every day. Because of evapotranspiration from the vessels, lost water was supplemented with fresh nutrient solution without the addition of extra antibiotics. Pakchoi was harvested after 55 days of cultivation. Then, the sponges attached to the vegetables were trimmed off. The plants were rinsed first with tap water and then with deionized water and dried on adsorbent paper. The growth parameters and abundance of endophytic bacteria were measured immediately. Antibiotic analyses and DNA extraction from endophytic bacteria were completed within two weeks of sampling.0 indicates the measurement of the control treatment and Mt indicates the measurement of the antibiotic treatment.All plants were harvested at the end of the test, and then, plant heights, root lengths, and fresh biomasses of 10 plants from each treatment were measured and recorded. The growth inhibition rate was calculated using following formula:Samples of the edible pakchoi portions (stem and leaf) were selected and freeze-dried for 24 h until moisture was no longer present . Then, t−3. Each 100 μL of diluted suspension was spread on meat-peptone agar and on corresponding antibiotic-containing agars  for cultivation at 28 °C for 3 days. Each sample was replicated three times. The colony-forming units (CFUs) of TCEB and AREB  were enumerated.To isolate endophytic bacteria, the edible portions of fresh pakchoi were immersed in 3% hydrogen peroxide for 30 min, followed by rinses with sterile deionized water (3 min × 3 times). Then, they were immersed in 70% ethanol for 1 min and rinsed as before . FinallyThe surface-sterilized edible pakchoi portions were cut into pieces and ground with liquid nitrogen before extraction under sterile conditions. Total DNA was extracted using PowerPlant DNA Isolation Kit  following the manufacturer’s instructions . The contetA, tetC, tetG, tetK, tetL, tetM, tetO, tetQ, tetT, tetW, tetB/P, and tetX), 5 sulfonamides-resistant genes , and 6 β-lactams-resistant genes . PCR detection assays were performed as previously described [PCR detection assays were used to screen for the presence or absence of 23 types of ARGs in the antibiotic-treated samples, including 12 tetracyclines-resistant genes (escribed . Primers2 > 0.99)  using a LightCycler real-time PCR system  with SYBR Green I. Details of the primers are listed in  > 0.99) . The 20 p < 0.05) between treatments.Ten plant samples from each treatment were used to test the effect of antibiotics on plant growth. For other analyses, three repetitions, each of which was the mixture of different plant parts from six plants, were performed. The mean values and standard deviations (SDs) of all data were calculated using Microsoft Office Excel 2016 . Statistical analyses were performed using the software SPSS 21.0 . Duncan’s multiple comparisons were used to determine the significant differences . When the exposure dose was increased to MIC levels, this growth-promoting effect was maintained in CPL-treated plants. However, the TC- and SMX-treated plants were significantly inhibited (p < 0.01), as indicated by the growth parameters being less than those of the controls. According to the detection of growth inhibition rates . These changes in AREB abundance resulted in dramatic increases in the ratios of AREB to TCEB from 0.23%, 3.77%, and 1.26% of TC, CPL, and SMX resistance, respectively, in the controls, to 0.79–1.23% , one β-lactamase gene (blaCTX-M), and two sul genes (sul1 and sul2) responsible for TC, CPL, and SMX resistance, respectively, were present in the corresponding antibiotic-treated samples. Thus, further quantification using qPCR was conducted to monitor their responses to different treatment doses. To minimize the differences in background bacterial abundances and DNA extraction efficiency, 16S rRNA gene was also quantified and the absolute numbers of the above four quantified ARGs were normalized to that of the ambient 16S rDNA  [tetX gene isolated from patients are still resistant to tigecycline [tetX gene in edible pakchoi should be highly concerning. The other ARGs, sul1, sul2, and blaCTX-M, are widely present in various environmental media [sul1 gene is normally found linked to other resistance genes in the Tn21 type integron, while sul2 is usually located on small plasmids of the IncQ family [Among the four detected ARGs, the presence of acteria) ,53,54. Hecycline . Therefoal media ,57,58, aQ family . qPCR shPrevious studies have demonstrated the antibiotic uptake  and the The present study investigated the growth of pakchoi and the antibiotic resistance in its endophytic system under TC, CPL, and SMX exposure. Pakchoi was shown to absorb antibiotics from the hydroponic culture environment. The absorption was selective toward different antibiotics, and the absorption amount was related to the antibiotic concentration. The accumulated antibiotics in the plant influenced the growth of the plant and increased the levels of AREB and ARGs, even at sub-inhibitory doses, which should be noted due to considerations surrounding the possible transfer of ARGs through the food chain.


Periprosthetic joint infection (PJI) is a catastrophic complication following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with difficulties, which is characterized by technical limitations. The question of whether sonication fluid PCR can provide high value in the diagnosis of PJI remains unanswered. This meta-analysis included 9 studies that evaluated PCR assays of sonication fluid for the diagnosis of PJI. The pooled sensitivity, specificity, Positive likelihood ratio (PLR), Negative likelihood ratio (NLR) and Diagnostic odds ratio (DOR) were 0.75 , 0.96 , 18.24 , 0.27  and 86.97 , respectively. The AUC value of the SROC was 0.9244 . Subgroup analyses showed that use of multiplex PCR and may improve sensitivity and specificity. The results of this meta-analysis showed that PCR of fluid after sonication is reliable and of great value in PJI diagnosis. The rise in the number of total joint arthroplasty performed worldwide could result in an increasing number of complications, the most catastrophe of these include periprosthetic joint infection (PJI), with an incidence of 1 to 12% .Several studies have assessed the diagnostic value of PJI, including PCR techniques of implant sonication samples –5. HowevThe methodological approach to evidence searching and synthesis described in this protocol was conducted according to the Cochrane Collaboration’s Diagnostic Test Accuracy methods . In our We searched electronic databases including PubMed, EMBASE, Cochrane Library, Web of Science, Science Direct and OVID for articles that were published from the time of database inception to June 2017, using the following medical subject headings (MeSH) or keywords: “periprosthetic joint infection OR prosthesis-related infections” “septic loosening”, “aseptic loosening”, “sonication OR sonicate OR ultrasound”, “PCR OR polymerase chain reaction”. We also manually searched the reference lists of eligible studies and review articles. Animal-only studies and studies that do not report data on the diagnostic performance of our target index were excluded.Our reviewers independently evaluated the selected studies according to the following inclusion criteria: (1) the study assessed the accuracy of sonication fluid PCR for the diagnosis of PJI compared with the presence of a sinus tract communicating with the prosthesis, the visible purulence of the synovial fluid or surgical site, simultaneously obtained microbiological cultures from at least two periprosthetic tissue samples or acute inflammation in the histopathological periprosthetic tissue sections; (2) sufficient data were reported to allow the calculation of true-positive (TP), true-negative (TN), false-positive (FP), and false-negative (FN) values; (3) the study reported at least 10 patients, from which data extraction using our standardized data collection form. Discrepancies were resolved by discussion with other reviewers and reanalysis of the original articles.Two reviewers independently screened the retrieved clinical studies for inclusion, extracted data from all included studies and conducted the quality assessment. The methodological quality of the selected studies was evaluated by using the quality assessment of diagnostic accuracy studies tool (QUADAS-2) , which wData were extracted independently by two reviewers with all outcomes and then verified by the other reviewers. The following information were abstracted: (1) study characteristics including author, year of publication, country, sample size, study design, sample site and diagnostic criteria; (2) intervention characteristics including ultrasonic conditions, sample conditions, type of PCR and target gene; (3) diagnostic outcomes including sensitivity and specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR).I2 statistic, which indicated the existence of significant heterogeneity when the value exceeded 50%. The value of I2 ranges from 0 to 100%, with 0 implying no observed heterogeneity, and larger values indicating increasing heterogeneity [χ2 test. If there was no significant heterogeneity between studies , the analysis was performed using a fixed-effects model; otherwise, the random effects model  was used [For the analysis of diagnostic value of sonication fluid PCR, all statistical analyses were conducted using Meta-Disc software . The specificity, sensitivity, PLR, NLR, diagnostic odds ratio (DOR), and area under the curve (AUC) of summary receiver operating characteristic (SROC) were estimated. Meta-regression and subgroup analyses were performed to assess potential heterogeneity. The percentage of the total variation across studies was described by the ogeneity . Analysiwas used .Of the yielded 287 primary articles, 162 of which were excluded with the reasons of duplicates. Among the left 125 articles, 114 were excluded after reviewing the title, abstract and full text of the articles. After reading the whole 11 articles included, 2 were unqualified due to insufficient data. Finally, a total of 9 studies were considered suitable for the diagnostic meta-analysis –17, the I2 = 68.2%), specificity (I2 = 87.4%), PLR (I2 = 90.2%), NLR (I2 = 55.6%) and DOR (I2 = 58.9%), respectively; thus, the random-effects model was used. No threshold effect existed  in the pooled data. The pooled sensitivity, specificity, PLR, NLR, DOR estimates for the detection of PJI using sonication fluid PCR were 0.75 , 0.96 , 18.24 , 0.27 , and 86.97, respectively . Compared to the article of USA, the article of Europe and Asia had a higher sensitivity of 0.83  (P<0.05). The sensitivity and specificity of the fresh samples were 0.82  and 0.95 , and those of the frozen samples were 0.70  and 0.96 , respectively.In subgroup analyses, the test performances varied by study design, vortexing, centrifugation, sample conditions, type of PCR, geographical location, and sample size , Fig 10.PJI is currently one of the most catastrophic complications associated with TJA. Since PJI diagnosis remains a challenge, many preoperative and intraoperative tests have been employed –4, 18. UIn fact, the true diagnostic ability of cultures depends on the accurate recovery of bacteria from samples. Dislodging bacteria from the prosthetic surface by sonication may be an appropriate option . In addiPCR techniques have demonstrated beneficial diagnostic value for diagnosing PJI in recent years. Compared to intraoperative tissue culture, PCR theoretically has higher sensitivity, a faster turnaround time, and is not as affected by antibiotic treatments . HoweverP<0.05). However, this type of PCR cannot satisfy both increased sensitivity and increased specificity concurrently.Our results showed that PCR is another diagnostic method that has an equivalent or better diagnostic value to that of intraoperative tissue culture and may add important insight into the diagnosis of PJI. However, the main problems in the diagnosis of PJI are recovery and identification of bacteria from the samples. Whether relying on intraoperative tissue culture or PCR, the bacterial recovery from the samples is always one of the most important aspects in the diagnosis of PJI. In this meta-analysis, sonication prosthetic fluid samples for PCR had an adequate diagnostic value for the detection of PJI. It was estimated that, in current practice, the sensitivity and specificity of PCR are approximately 75% and 96%, respectively. Our subgroup analyses showed that compared with non-multiplex PCR, use of multiplex PCR had a higher specificity Click here for additional data file.


Third, the differences between groups were tested and relationships between health effects and environmental pollution studied using multiple regression analysis. Compared to the control groups from non-industrial areas in Tartu or Lääne-Viru, residents of Ida-Viru more frequently (p < 0.05) reported wheezing, chest tightness, shortness of breath, asthma attacks, a long-term cough, hypertension, heart diseases, myocardial infarction, stroke, and diabetes. All health effects except asthma were reported more frequently among non-Estonians. People living in regions with higher levels of PM2.5, had significantly higher odds (p < 0.05) of experiencing chest tightness , shortness of breath  or an asthma attack  during the previous year. People living in regions with higher levels of benzene had higher odds of experiencing myocardial infarction  and with higher levels of phenol chest tightness , long-term cough  and myocardial infarction . The prevalence of adverse health effects was also higher among those who had been working in the oil shale sector. Next to direct health effects, up to a quarter of the residents of Ida-Viru County were highly annoyed about air pollution. Perceived health risk from air pollution increased the odds of being annoyed. Annoyed people in Ida-Viru had significantly higher odds of experiencing respiratory symptoms during the last 12 months, e.g., wheezing , chest tightness .Eastern Estonia has large oil shale mines and industrial facilities mainly focused on electricity generation from oil shale and shale oil extraction, which produce high air pollution emissions. The “Study of the health impact of the oil shale sector—SOHOS” was aimed at identifying the impacts on residents’ health and annoyance due to the industrial processing. First, a population-wide survey about health effects and annoyance was carried out. Second, the total and oil shale sectors’ emitted concentrations of benzene, phenol, and PM Eastern Estonia or Ida-Viru is a north-eastern county in Estonia bordered by the Finnish Gulf to the north, the Narva River and Russia to the east, and Peipsi Lake to the south. The county has a long tradition of industries focused on oil shale . The extraction of oil shale began in Estonia in 1916. The annual output peaked in 1980 with 29.7 million tons, after which it started to decrease due to the construction of a nuclear power station in Sosnovyj Bor and decreasing electricity exportation to Russia [2), particulate matter (PM10), and nitrogen oxides (NOX), as well as various other industrial pollutants, such as benzene and phenols released in oil extraction, and trace elements [The oil shale industry employed 6400 people in 2016 and is one of the Estonia’s largest employers . Howeverelements . Health elements ,10,11,122S, PM10, and SOX exposure [In industrially contaminated areas, many different human health effects have been documented, such as increased mortality and morbidity rates, hospital admissions, and reproductive outcomes ,14,15. Iexposure . Even though the Estonian oil shale industry is relatively unique, refining shale oil is considered to have health effects similar to other refining operations  and thusApart from the direct health effects caused by exposure, the mere perception of pollution may cause annoyance. The concept of annoyance is complex and can be considered a perception, an emotion, an attitude or a mixture of these . Annoyan10 concentrations were also high in Kohtla-Järve and Narva (NO2 concentrations were lower in the towns of Ida-Viru County because of lower traffic intensity). The decrease in life expectancy was highest in larger towns, such as Tallinn, Tartu, Narva, Pärnu, and Kohtla-Järve, and somewhat higher in Ida-Viru County in general [When it comes to specific sources of pollution, industrial facilities and large boiler houses significantly contribute to ambient air pollution concentrations, however traffic remains the largest contributor of pollution in general in Europe ,46. In E general . Epidemi general , and a h general . A time- general . Based on earlier studies, the effect of different air pollutants on health conditions in cities are clear; however, information on the health effects of air pollution in the industrial areas of Estonia is limited. Therefore, the current study aimed to identify the air quality situation in Ida-Viru County (the region with the largest air polluting industry in Estonia) and people’s annoyance regarding air pollution, in order to study the relationships between industrial pollutants and the health of local residents. The epidemiological investigation “Study of the health impact of oil shale sector—SOHOS” was a cross-sectional survey, consisting of a health questionnaire for residents, and air quality monitoring and modelling data. The study was part of the material for National Development Plan for the Use of Oil Shale 2016–2030. The cross-sectional study of the people living in three different counties was approved by the Research Ethics Committee of the University of Tartu (231/T-10).First, a postal questionnaire was sent in 2014 and 2015 to 2097 residents aged 18–70 years old living in Ida-Viru (Eastern Estonia) County. Second, questionnaires were sent to a reference group of 403 individuals aged 18–70 years living in neighbouring Lääne-Viru (west) County and to 2750 individuals aged 18–40 years old living in Tartu . All participants were randomly selected by the Estonian Population Registry according the age and ethnic structure of the area. Third, the information collected during a similar earlier survey entitled “Respiratory Health in Northern Europe—RHINE III”, carried out in 2011 and 2012 in Tartu , was incAll participants received a postal questionnaire about their socio-economic situation, general health, respiratory symptoms, chronic diseases, indoor and outdoor environment, working history, and health behaviour , see the detailed description in the Airviro Documentation [Annual mean concentrations of phenol, benzene, and PMentation . Airviroentation . The indAccording to their home address, the respondents were divided into three groups: residents of Ida-Viru County, Lääne-Viru County, or Tartu. According to the home address, respondents’ prevalence of respiratory symptoms, chronic diseases, risk perception, and socio-economic indicators were calculated. The differences between the three groups were tested with a chi-square test. Furthermore, the differences between genders, ethnicities, and employed/un-employed in the oil shale sector, were tested.The relationships between self-reported health effects and modelled pollutant concentrations at the respondents’ home addresses were studied using logistic regression analysis in Stata 12.1 . The regression models were adjusted for possible confounders such as gender, age, body mass index (BMI), environmental tobacco smoke (ETS), smoking history, and income per family member.Altogether 2127 people responded to the SOHOS questionnaire (a response rate of 40.7%). The response rate was highest in Lääne-Viru County (45.4%), followed by Ida-Viru County (40.8%), and Tartu (39.8%). Among the Ida-Viru respondents, 9.8% used the possibility to fill in the questionnaire online. In Lääne-Viru County, this proportion was 6.0% and in Tartu 13.6%. The socio-demographic characteristics of the respondents in SOHOS and RHINE III are given in p < 0.05) about wheezing, chest tightness, shortness of breath, asthma attack, long-term cough, hypertension, heart disease, myocardial infarction, stroke, and diabetes compared to residents of Tartu and even compared to residents from neighbouring Lääne-Viru County when it came to wheezing (p < 0.05) from chronic obstructive pulmonary disease, wheezing, and heart attacks than women, and men in reference areas (data not shown). The analysis also identified significant differences between ethnic groups, with non-Estonians suffering more from most of the health complaints and chronic diseases , compared to those not been working (n = 540), had significantly more frequently (p < 0.05) experienced wheezing (32.8% vs. 30.0%), chest tightness (33.3% vs. 27.4%), hypertension (37.3% vs. 29.8%), heart disease (17.4% vs. 12.6%), cardiac infarction (8.7% vs. 5.9%), stroke (5.0% vs. 2.2%), and diabetes (10.4% vs. 8.3%).Besides the living environment, as the working environment also influences the development of diseases, the prevalence of diseases were compared between individuals who had and had not worked in the oil shale sector. It appeared that those who had worked in the oil shale sector (3) had decreased from 122 in 2004 to 43 in 2013 at the three measuring stations in Ida-Viru County. The annual average phenol concentration in 2013 was 1.12 μg/m3 at Järveküla Road, 1.12 μg/m3 at Kalevi Street, and 1.3 μg/m3 in Narva (2S concentration in Kohtla-Järve were exceeded most often in 2007 (230 times); over the following years such occasions remained in the range of 40–50 times, and had decreased to 16 occasions by 2013. The temporal variation of some pollutants can be seen in According to urban ambient air surveillance, the highest number of exceedances of Estonian limit values was related to phenol as a product of the thermal processing of oil shale. The number of exceedances  had 1.13 (95% CI 1.02–1.26), 1.16 (95% CI 1.03–1.31) and 1.22 (95% CI 1.04–1.42) higher odds of reporting chest tightness, shortness of breath, and asthma attacks respectively, compared to residents in the quartile with the lowest levels  to very high annoyance (10)) significantly differed between the regions . RespondAs for the effects of education, compared to the other regions, in Ida-Viru County there were significantly more respondents annoyed by air pollution among people with a secondary or higher education . As for Regarding health, people with good health were more frequently annoyed by air pollution in Ida-Viru County, compared to the other regions . When itWe clarified factors explaining the annoyance with air pollution in Ida-Viru County and reference regions using logistic regression. In base models predicting annoyance, we included gender, age, education, income, smoking history and self-assessed health status. When considering all regions together, compared to being a representative of Tartu, being a representative of Ida-Viru County significantly increased the odds 1.66 (1.18–2.31) of being annoyed, but being from Lääne-Viru did not increase the odds for annoyance. In all regions, the odds of being annoyed significantly increased when a person had chest tightness. In Ida-Viru region, the odds of being annoyed significantly increased when a person had symptoms such as wheezing without a cold, attacks of coughing and diagnosed wheezing. In Tartu, the odds of being annoyed increased when a person had shortness of breath, attacks of coughing, wheezing and a long-term cough. The odds of being annoyed did not significantly increase when a person had cardiovascular diseases.2.5, benzene, or phenol had higher odds of experiencing chest tightness, shortness of breath, or an asthma attack during the previous year and a long-term cough or myocardial infarction in the past. The prevalence of adverse health effects was also higher among those who had been working in the oil shale sector.The current study was carried out to identify the air quality situation in Ida-Viru County and people’s annoyance regarding air pollution, as well as to study the relationships between industrial pollutants and the health of local residents. Our cross-sectional study based on a large sample, shows that compared to the control groups from non-industrial areas in Tartu or Lääne-Viru County, Ida-Viru County residents more frequently reported wheezing, chest tightness, shortness of breath, asthma attacks, a long-term cough, hypertension, heart diseases, myocardial infarction, stroke, and diabetes. People living in regions with higher levels of PM2.5, benzene, or phenol, had significantly higher odds of reporting several respiratory diseases and myocardial infarction, but no other cardiovascular disease or diabetes. Similar relationships were documented in the same region more than 25 years ago by Etlin [An increased prevalence of almost all cardio-respiratory diseases (except asthma) and diabetes in Ida-Viru County reflects trends from earlier studies made approximately 15 years earlier, where they observed an increase in respiratory symptoms, such as wheezing and crackling in Narva compared to Tallinn and the Western islands ; whereasby Etlin .2.5 on the cardio-respiratory system [The increased risk of respiratory diseases has been shown in industrial areas in China, if residents were living close to a factory or chimney , as welly system ,64 and ay system ,66; thery system ,68 and py system ,70, espeThe study shows that up to a quarter of the residents of Ida-Viru County in eastern Estonia are highly annoyed about air quality. Compared to Tartu and Lääne-Viru regions, the annoyance in Ida-Viru was higher even after controlling for the effects of socio-economic status and subjective health assessment. The mere perception of pollution may cause annoyance and health symptoms as a protective mechanism. However, at the current relatively low concentrations, benzene, phenol and particulate matter may not evoke strong enough odour sensations to activate the chemosomatosensory system, leading to eye irritation and a pungent nasal sensation that could lead to feelings of annoyance in the Ida-Viru region. Worry due to health risk perceptions, i.e., the belief that the exposure is hazardous, may lead to annoyance and health symptoms ,38,41. PAnnoyance from environmental exposure has been suggested to serve as an early warning signal of illness . AnalysiAs for the other factors mediating the relationship between air pollution and annoyance, women have higher odds to be annoyed by air pollution, as also noted in earlier research . Ethnic 2, H2S, SO2, dust, Pb, benzene, formaldehyde etc., have been observed [The analysis showed a clear problem of industrial pollutants including benzene, phenol, and hydrogen sulphide. The main source of industrial emissions of benzene and phenol are oil shale processing and energy production. Thanks to the toughening of environmental protection requirements and investment in new technologies and treatment facilities, the number of exceedances has decreased. Also, the concentrations of benzene, polycyclic aromatic hydrocarbons, and heavy metals in the ambient air have considerably decreased compared to previous studies . Howeverobserved . Phenolsobserved ,75. 2005 329–1053 billion in Europe between 2008 and 2012, although only a small number of industries are responsible for causing the majority of the costs to people’s health and the environment [The problem of industrial activities causing local and diffuse contamination, to an extent considerably hazardous to human health, is not unique to Estonia. The effects of industry are large Europe-wide, with the European Environmental Agency reporting industrial emissions as being responsible for damage at a cost of EURironment . Episodeironment . 3 [In addition to the direct health effects of industrial air pollution, the annoyance caused by, for example, benzene and the unpleasant odour of hydrogen sulphide needs further attention in the Ida-Viru region. According to the WHO, people can start to smell the (‘rotten egg’) odour from a hydrogen sulphide concentration of 11 µg/m3 . As peop3 .To elimi3 ,56. This3 . Howeverp < 0.05) difference between many health indicators among the people living in the area of oil shale chemical and energy enterprises, compared to those living in control areas . In their study, special attention was paid to the homogeneity of the population groups observed in these areas, to reduce the effect of confounding factors. Therefore, the different quality of the ambient air was regarded as the main reason for the differences in the health indicators between the groups [Often health, the environment, and social aspects are strongly interconnected, which make it difficult to separate the effects of environmental pollution from other risk factors. Besides environmental concerns, Ida-Viru County has multiple problems, with rapid population decline, a smaller proportion of young people than average, and the lowest birth rate and life expectancy in Estonia ,78. In ae groups . One of The study indicated that working in the oil shale industry poses a significant occupational hazard. Respondents who had been working in the oil shale sector had a significantly higher prevalence of respiratory and cardiovascular diseases. One reason could be high benzene concentrations, which have been found to be twice as high in mines compared to other production units. As the ventilation systems in the mines are weak and raw material is handled with machines using diesel fuel, mine workers had a much higher exposure to benzene than those who worked on the ground . ExposurAs shale oil production has been modernised in several plants in Estonia, the levels of pollutants in Estonia could be lower now than 15–20 years ago. For instance, the B(a)P levels of a modern Finnish coke oven are nearly five times lower compared to older types and also better personal protective equipment is now used . HoweverThe main limitations of the study include the cross-sectional nature of the investigation, using only current exposure and self-reporting of health-related symptoms and illnesses. In addition, in questionnaire studies indigenous residents, females and older people tend to answer more frequently. The study could be further developed to address the earlier exposures that may have influenced the occurrence of chronic diseases. In addition to exposure assessment in the current study, we would foresee a population-based cohort study of the same exposures, allowing for the analysis of the duration of exposure on the health outcomes. Furthermore, in 10 years the SOHOS study respondents could be included in the follow-up as was the case in the RHINE study . This wo2.5, benzene and phenol exposure. Perceived health risk from air pollution significantly contributes to annoyance from air pollution. Annoyed people have higher odds of experiencing respiratory symptoms and lower self-assessed health.A very large proportion of residents of Ida-Viru County have been exposed to oil shale industries and more than one quarter have worked in the sector. Residents of Ida-Viru County reported higher rates of four respiratory symptoms  and five serious chronic health states including hypertension and heart disease than Estonian reference populations. Several of these self-reported health data were statistically significantly associated with PMThe results of this study show that we need to pay more attention to the state of the environment and the health of residents and industry workers in the region, and to carry out even more comprehensive health surveys, also including children. The long-term improvement of the health of people living in Ida-Viru County depends on cooperation between decision-makers, scientists, local government, businesses, health systems and local residents.