Vietnam is experiencing an unprecedented demographic transition. Its proportion of elderly people is growing rapidly. This study explored the health status and health-related quality of life (HRQoL) of rural elderly Vietnamese and assessed their needs for healthcare services. This study used a survey with stratified proportion sampling and quota assignment. In 2016, data was collected from 713 people in the rural Quoc-Oai district of Hanoi aged 60 or older. The mean age of the respondents was 70.9. Both self-rated health status and functional status decreased with age. Women reported more functional limitations than men. Musculoskeletal disorders were the most frequently reported chronic diseases, followed by hypertension, gastrointestinal diseases, and cardiovascular diseases. Age, self-rated health status, BMIs, and the number of noncommunicable diseases (NCDs) were found to be significant determinants of HRQoL, after controlling for socioeconomic effects. More than half the respondents requested more healthcare information, particularly on disease management. Vietnam's healthcare system is being challenged to make health services easily accessible and meet the growing needs for chronic illness management, risk reduction, promoting healthy lifestyles, and improving the aging population's quality of life. The world's population is aging, and this trend is also evident in Vietnam, where the proportion of people over 60 years of age has increased rapidly in recent decades, from 6.7% in 1979 to 10% in 2013. Further influencing this trend is confirmation that life expectancy at birth increased from 66 years in 1990 to 76 years by 2012 [These data highlight elderly people's need to adopt lifestyle modifications for their health. However, lifestyle changes are not made easily. Systematic education, motivation, and continuous monitoring by health professionals might be very helpful for encouraging lifestyle changes. In addition, functional status and health status are both highly related to the quality of life, and especially so for the elderly . In one With rapid industrialization, young people moved to urban areas for employment, and, over time, the family structure in rural areas has changed significantly. In 1998, the proportion of families comprised only of elderly spouses was 12.7%, and the proportion of elderly people aged 60 and over living alone was 4.93%. However, these proportions increased to 21.47% and 6.14%, respectively, in 2008 . The comWhile elderly people in urban areas can benefit directly from facilities for the elderly , more thTo date, studies on the health status of elderly populations in Vietnam's rural areas have been very limited. Conducting these studies requires that the targeted population's functional status (ADL) and health-related quality of life (HRQoL) be evaluated and the factors that influence these measures be identified. Furthermore, their needs for healthcare services should be assessed, and strategies and policies for improving their health should be developed.This study of elderly people in Vietnam's rural areas has two main objectives. The first is to explore this population's health status and HRQoL and to confirm the significant determinants. The second objective is to assess their needs for healthcare services.This study was conducted in 2016 as part of a joint cohort study for a Health System Strengthening project led by collaborators from two universities in Vietnam and one in Korea. The project team selected the Quoc-Oai district of Hanoi—located 30 km from Western Hanoi—as the research area and conducted a community-based survey to generate baseline data. The area is divided into two strata, namely, lowland and mountainous areas. All clusters and corresponding population numbers were listed using a probability-proportional-to-size (PPS) technique  that is The sample size selected for this survey was based on the formula suggested by the WHO , and a pThe number of households that responded to the survey was 2,399, and the response rate was 99.9%. Individual interviewees were chosen using the Kish Method , and, inFace-to-face interviews were conducted with participants using structured questionnaires. The questionnaires were divided into sections for households and individuals. After the survey had been completed, the data collected from the two surveys were consolidated. Double data-entry using Epidata 3.1 was performed, to evaluate inconsistent values for any variables. To ensure the study's accuracy, any responses with missing or irrelevant values were deleted.We used age, gender, ethnicity, location, marital status, educational level, religion, working status, and household size as demographic variables. Self-rated health status was measured using a 5-point Likert scale, which was reclassified into three categories: good, normal, and bad. BMIs were calculated using self-reported heights and weights and categorized on the basis of Asian-specific BMI cut-offs . ChronicSocial capital encompasses different characteristics, such as social networks, social participation, social support, social cohesion, attitudes, and trust . For thiThe participants' functioning assessment was measured using a modified version of a generic assessment instrument for health and disability developed as part of a WHO Disability Assessment Schedule (WHODAS) . This inThe Vietnamese version of the EQ-5D-3L questionnaire  was usedParticipants' needs for health information and home healthcare services were confirmed during interviews conducted using open-ended questions. Participants who responded by saying that they needed information with regard to their health status described what types of health information they wanted to receive. If they had any needs for home healthcare services—including rehabilitation—participants were asked to describe the health problems for which would they like to receive services. Interviewers summarized participants' answers and coded the responses using short words.t-test and a one-way ANOVA were used to compare the differences between these characteristics in a functioning assessment and the HRQoL. For the post hoc test, Fisher's least significant difference (LSD) was applied. Multiple regression analysis was performed to detect the effects of factors on the HRQoL index. The significance level was set at p < 0.05.SPSS Statistics 23 software was used for the statistical analysis. Descriptive statistical analyses were used to describe the socioeconomic characteristics, health status, prevalence of NCDs, social capital, functioning assessment, and health-related quality of life. Student's The responses to open-ended questions for healthcare needs were analyzed using NVivo 11 software. The responses most frequently in all the subjective texts were selected and a weighted percentage was calculated, after which the authors created domains and categorized the texts into these domains.The Institutional Review Board of the Hanoi School of Public Health approved this study in 2016. After they had been informed of the purpose of the study and their rights, informed consent was obtained from all participants. They were told that they could refuse to participate, or choose to withdraw from an interview, at any time. Confidentiality was assured, by coding participants' responses.An overview of the distribution of study participants is provided in 2), 5.0% were moderately underweight (16.0–16.9 kg/m2), and 7.9% of participants were severely underweight (<16 kg/m2). The total mean score for social capital in this study was 3.52 (0.487) on a 5-point scale. The average score for the first domain (trust in daily life), which was asking about one's generalized trust in everyday life, was 4.17 (0.490). The other domain, which asked questions concerning how one felt about neighbors' attitudes toward helping them when they were in an emergency situation, scored 3.00 (0.628). There are no statistically significant relationships between social capital and other variables such as age, gender, and wealth quintile. Musculoskeletal disorders were the most frequently reported chronic disease among all age groups (50.8%), followed by hypertension (31.6%), gastrointestinal diseases (17.3%), and cardiovascular diseases (7.9%). Very few cases of cancer or diabetes were reported.Self-rated health status, body mass indexes (BMIs), and the prevalence of a chronic disease diagnosis by a doctor within 12 months are summarized in The distribution of participants on the basis of the functional status of different groups is presented in The mean indices of the health-related quality of life (HRQoL) as measured by EQ-5D-3L are presented in Multiple regression analyses were performed to identify the determining factors of elderly participants' HRQoL . Model 1The number of respondents who expressed a need for health-related information was 387 (54.3%). These needs were categorized into seven areas: disease management, diet, pain management, exercise, general health, disease prevention, the health system, and others . The infThe number of participants who needed home healthcare services including rehabilitation was 154 (21.6%). The health problems for which respondents want home healthcare services or rehabilitation were categorized and summarized in The results of this study are consistent with previous studies that found epidemiological patterns shifting from a predominance of communicable diseases to noncommunicable diseases in Vietnam , 20. Of The study's findings are not consistent with those of a previous systematic literature review that found a significant relationship between recent smoking behaviors, alcohol consumption, and the level of functioning. We suspect that this is because the systematic literature review primarily included research studies that had been conducted in highly developed countries .The results of this study were similar to those of Hoi et al.'s study , which rMeanwhile, even though more people recognize the importance of healthy lifestyles in modern society, older people's smoking and drinking habits are not easily changed. An et al.  reportedThe results of this study documented the various needs for healthcare and rehabilitation services among Vietnam's elderly population. Physical disabilities and functional limitations are common among older people  and leadAlong with the increase in the proportion of the population that is aging, and the increasing prevalence of non-communicable diseases, readily accessible community-based primary care is critical. A Vietnamese commune health center is located in a community which covers 25,000 people. The roles of these centers should be strengthened to address effectively the elderly population's needs for health care services, particularly in rural areas. The WHO has emphasized the importance of community-based primary health services. Community health centers may become critical healthcare service providers for managing chronic illnesses, promoting healthy lifestyles and behaviors, reducing health risks, preventing diseases, promoting health, and improving the elderly population's quality of life.The study's findings are limited by certain factors. First, the study's participants were limited to the elderly living in the rural Quoc-Oai district of Hanoi, using stratified proportion sampling, and quota assignment. Thus, to validate the generalizability of the results for the rural elderly in Vietnam, the study should have involved more participants from different regions and districts. Second, the data was collected through a survey questionnaire, and the information obtained from the study participants was assumed to be accurate. Further research is required to examine the correlates and predictors of health outcomes, and to investigate the effectiveness and feasibility of community health center-based, nurse-led, chronic illness management programs for the rural elderly in Vietnam.The aging proportion of Vietnam's population is growing rapidly. The burden of providing healthcare for non-communicable diseases continues to increase as a consequence. It is vital that health challenges and the healthcare needs of older adults be assessed. Furthermore, it is important that healthcare services be easily accessible and address the elderly population's increasing needs for chronic illness management, risk reduction, help adopting healthy lifestyles, and improving their quality of life.


The existence of non-excitable cells in the myocardium leads to the increasing conduction non-uniformity and decreasing myocardial electrical conductivity. Slowed myocardial conduction velocity (MCV) believed to enhance the probability of cardiac arryhthmia and alter the cardiac mechanical pumping efficacy, even in sinus rhythm. Though several studies on the correlation between MCV and cardiac electrical instabilities exist, there has been no study concerning correlation or causality between MCV and cardiac mechanical pumping efficacy, due to the limitation in clinical methods to document and evaluate cardiac mechanical responses directly. The goal of this study was to examine quantitatively the cardiac pumping efficacy under various MCV conditions using three-dimensional (3D) electromechanical model of canine’s failing ventricle. The electromechanical model used in this study composed of the electrical model coupled with the mechanical contraction model along with a lumped model of the circulatory system. The electrical model consisted of 241,725 nodes and 1,298,751 elements of tetrahedral mesh, whereas the mechanical model consisted of 356 nodes and 172 elements of hexahedral mesh with Hermite basis. First, we performed the electrical simulation for five different MCV conditions, from 30 to 70 cm/s with 10 cm/s interval during sinus pacing. Then, we compared the cardiac electrical and mechanical responses of each MCV condition, such as the electrical activation time (EAT), pressure, volume, and energy consumption of the myocardium. The energy consumption of the myocardium was calculated by integrating ATP consumption rate of each node in myofilament model.The result showed that under higher MCV conditions, the EAT, energy consumption, end diastolic and systolic volume are gradually decreased. Meanwhile, the systolic pressure, stroke volume, stroke work, and stroke work to ATP are increased as the MCV values increased. The cardiac functions and performances are more efficient under higher MCV conditions by consuming smaller energy (ATP) while carrying more works.In conclusion, this study reveals that MCV has strong correlation with the cardiac pumping efficacy. The obtained results provide useful information to estimate the effect of MCV on the electro-physiology and hemodynamic responses of the ventricle and can be used for further study about arrhythmogeneis and heart failure. Action potential (AP) propagates from one myocyte to the next myocyte through gap junctions. However, there are not only myocytes exist in the myocardium but also non-excitable cells such as collagenous strands, blood vessels, and fibroblasts. Those non-excitable cells affect electrical properties by increasing conduction non-uniformity and decreasing myocardial electrical conductivity. Myocardial conduction velocity (MCV) varies from 30 to 70 cm/s depending on the level of non-uniformity. Slowed MCV is associated with an increased risk of re-entrant excitation, predisposing to cardiac arrhythmia  and willQuantitative analysis of the effect of MCV on cardiac electrophysiology and mechanical pumping function is highly important for further research of cardiac arrhythmia and heart failure. Though several studies on the correlation between MCV and cardiac electrical instabilities exist –5, thereWe have previously developed a three-dimensional (3D) electromechanical model of failing canine ventricles along with a lumped model of the circulatory system –8. The gTo construct the computational model for this study, we employed the existing 3D electromechanical model, combined with a lumped model of cardiovascular system –8. The eV (mV) is the membrane potential of one cell, t (ms) is time, pA/pF) is the total transmembrane ionic current, pA/pF) is the total external stimulus current, and 2) is cell capacitance per unit surface area. A negative value represents a transmembrane at rest.The 3D electrical model was constructed through finite element of tetrahedral mesh, consists of 241,725 nodes and 1,298,751 elements. The mesh has the characteristic of realistic heart compartments including the endocardium, mid-myocardium, and epicardium, as well as purkinje fibers. The model mimics the propagation of AP in cardiac tissue using an electrical conduction equation, derived from continuum mechanics. The equation describes the continuum characteristic of the current flow through cardiomyocytes which are connected electrically via conductive gap junction. The current flow in the ventricular tissue was driven by active ion exchange across the cell membrane. Many researchers have made a great contribution in developing mathematical models of these ionic properties in the cardiac myocyte . In thisx, y, and z directions, and x, y, and z directions. The total transmembrane ionic current, + current, 2+ current, +–Ca2+ exchanger current, +-2+ pump current, 2+ current, and + current. The more details of model parameters can be found in ten Tusscher et al. [While the equation for electrical behavior in 3D cardiac tissue is represented by:mentclasspt{minima2+) from the sarcoplasmic reticulum (SR), which causes the Ca2+ concentration in the cytoplasm to increase. The Ca2+ then binds to troponin C, inducing a deformation of troponin and subsequently moves the tropomyosin away from the actin-binding sites. This removal of tropomyosin allows the myosin head to pull the actin filament toward the center of sarcomere, forming the cross-bridge cycles and triggering contraction.The cardiac muscle contracts via excitation–contraction (EC) coupling. EC coupling can be described as the process of converting an electrical excitation into a force generation, resulting in the occurrence of contraction of the heart. EC coupling occurs, as the AP depolarized through the heart, activating the release of calcium  is the cytoplasmic volume, 3) is the SR volume, pA/pF) is the leakage current from SR to cytoplasm, pA/pF) is the pumping current required to return the calcium to the SR, and pA/pF) is the calcium-induced calcium released current. For details, see Ten Tusscher et al. [To remodel EC coupling in our study, we incorporated the electrical model as described in the previous section, with the mechanical model of myocyte filament from Rice et al.  using thmentclasspt{minimaThe mechanical model illustrates the active contraction and deformation of ventricles in the form of myofilament dynamics, including descriptions of attachment and detachment of cross-bridges and their elastic properties. The active contraction of the ventricles is a result of the active tension generated by the myofilament dynamics model of Rice et al. . The actTo simulate the ventricular hemodynamics, we coupled the finite element electromechanical model with a lumped model of the systemic and pulmonic circulations based on Kerckhoffs et al. . Both ofMCV (cm/s) values used for this study were determined by measuring the distance d(cm) between two points in the ventricle and dividing by the time t(s) taken to complete the activation of ventricle, as given by:2+ cycling, which served as the inputs for mechanical contraction model, as the instances when the myofilament model is activated. Next, we ran the mechanical contraction simulation for 32 cycles to obtain steady responses. Lastly, we took the end of the cycle data of the cardiac mechanical responses to analyze the cardiac pumping efficacy. These responses included pressure, volume, energy consumption in the form of ATP, and contractility of ventricle. The energy consumption of the myocardium in this study was calculated by integrating the ATP consumption of each node of the ventricles with time for one cycle (600 ms). The ATP consumption is derived from the contractile ATP consumption rate in the myofilament model of Rice et al. [To achieve the goals of this study, first, we performed the electrical simulation for 3 s using sinus pacing with one cycle length of 600 ms. We simulated several MCV cases: 30, 40, 50, 60, and 70 cm/s for this study. This variation are chosen first, by setting the normal MCV as 70 cm/s, according to the previous study from ten Tusscher et al. , where tmentclasspt{minimar et al.  by implee et al. , as follFigure Figure As shown in Fig. −1, followed by the 40 cm/s MCV with 96 s−1, 50 cm/s MCV with 94 s−1, 60 cm/s MCV with 93 s−1, and 70 cm/s MCV with 92 s−1, respectively. The ATP consumption decreased by approximately 6% between these cases. Finally, SW over ventricular ATP consumption, which indicates energetic pumping efficiency of the ventricle, was smaller under higher MCV conditions  and ejection fraction (EF) were the greatest  under the 70 cm/s MCV condition, were lowest  under 30 cm/s MCV condition  .The ventricle depolarization timing is shorter with the higher MCV. According to equation  in the mThe cardiac systole occurs in response to the spontaneous electrical conduction of the whole ventricles. Rapid and organized conduction is necessary to generate efficient pressure during systole to pump blood out of ventricles. Our results showed that the pressure of left ventricle (LV) during systole is higher under faster MCV see Fig. a. It des SV is calculated by subtracting the end systolic volume (ESV) from end diastolic volume (EDV) in the PV curves. Both ESV and EDV of the LV are reduced under higher MCV. The ESV reduced by approximately 1.5%, whereas the EDV reduced by approximately 0.5%. The reduction in the ESV is higher than in the EDV, thereby forming a horizontally extended PV curves, generating larger SV values. Subsequently, EF is calculated by dividing the SV by the EDV of the LV in one cycle contraction. EF also increased under higher MCV conditions. Increasing in SV and EF Fig. c indicatIn conclusion, this study reveals that MCV has strong correlation with the cardiac pumping efficacy. The alteration of MCV affects to the electrical and mechanical behavior of the heart. The obtained results provide useful information to estimate the effect of MCV on the electro-physiology and hemodynamic responses of the ventricle and can be used for further study about arrhythmogeneis and heart failure.There are several limitations of the present study. First, we did not conduct experimental or clinical data in the study. Instead, we used the validated cell model and methodologies from previous studies , 12, 13.Over the past 3 decades, the clinical, experimental, and theoretical studies have validated that slow conduction, plays important role in the pathogenesis of cardiac arrhythmias. Slowed myocardial conduction can increase the probability of the occurrence of cardiac arrhythmia through the formation of slow conducting re-entry circuits . HoweverBased on these findings, we conclude that the cardiac pumping efficacy is better under higher MCV conditions due to an increasing in the force generation during systole and cardiac output while consuming less energy.


He reports that, six months ago, after discreet exercise (having run about 500meters) he felt tiredness and dizziness, malaise and skin paleness. Repeatedmigraines accompany the clinical status. Recent bi-Doppler echocardiography revealedthe high origin of the right coronary artery at the sinotubular junction. There wasno morbid past of importance.Physical examination: eupneic, acyanotic, normal pulses. Weight: 66 Kgs, Height: 169cm, BP: 110/65 mm Hg, HR: 57 bpm, O2 saturation = 96%. The aorta was not palpated atthe suprasternal notch.ictus cordis wasnot palpated. Cardiac sounds were normal and heart murmur was not heard. The liverwas not palpated.In the precordium, without systolic impulses, the Electrocardiogram showed sinus rhythm and signs of electricalnormality. The duration of the QRS complex was 0.092` with morphology rS in V1and qRs in V6, with negative T wave in V1. AP: + 40°, AQRS: + 75°, AT: +25°.Chest X-ray shows normal cardiac area and pulmonary vascularmarkings  and heart rate (from 77 to 94 bpm).Dynamic 24-hour electrocardiogram (Holter): showed no changes inheart rhythm and / or waves, complex and electrical segments.Angiotomography of the coronary arteries revealed normal and usualorigin of them in the different sinuses of Valsalva and both at the same height, aswell as in hypoplastic coronary arteries, in stenosis in the coronaryostium-As the findings of the echocardiogram did not find any correspondence with thenormal images revealed by angiotomography and consolidated by the functionalstudy of myocardial scintigraphy, there was the recommendation of periodicfollow-up without limitation of the usual activities. It was difficult toexplain the echocardiographic finding that was characterized by a diagnosticerror of this coronary anomaly. Hence, the need for an ever more accurateassessment in order to confirm the diagnosis, having as support the analysis ofall the elements that were exhaustively pursued in the case in question.1 and intramuralaortic. Thus, in findings of high origin of the coronary artery we shouldimmediately eliminate the presence of myocardial ischemia due to decreased ostium(50% of the diameter), interarterial pathway or presence of anotherabnormality.However, there are authors who believe in the hypothesis of myocardialischemia only because of the high coronary origin due to the reduction of thediastolic filling of the coronary, being able in addition to theoretically causechronic myocardial damage with consequences in adulthood. Thus, the question is ifthe high origin of the coronary artery constitutes a benign or malignantanomaly.3High origin of the coronary artery is very rare  and in the reported cases,associated ischemia is systematically correlated with the presence of otheradditional abnormalities. Therefore, it is difficult to implicate high coronaryorigin as a cause of ischemic event and hence as being definitely pathological. Itmay predispose to myocardial ischemic alterations in the presence of associatedabnormalities, such as in a single coronary artery, in a vertical and oblique pathbetween the aorta and the pulmonary artery, allowing obstruction by compression andwith consequent reduction of coronary flow, as well as a narrow coronaryostium


Studies investigating different medical conditions and settings have demonstrated mixed results regarding the weekend effect. However, data on the outcome of elderly patients hospitalised on weekends is scarce. The objective was to compare in-hospital and two-day mortality rates between elderly emergency department (ED) patients (≥65 years) admitted on weekends versus weekdays.. The weekend was defined as the period from midnight on Friday to midnight on Sunday.A retrospective cohort study of emergency department visits of internal medicine patients ≥65 years presenting to the emergency department between 01 and 09-2010 and 31–08-2012 was conductedData on 3697 emergency department visits by elderly internal medicine patients (mean age 78.6 years old) were included. In total, 2743 emergency department visits (74.2%) resulted in hospitalisation, of which 22.9% occurred on weekends. Comorbidity and urgency levels were higher in patients admitted on weekends. In-hospital mortality was 11.4% for patients admitted on weekends compared with 8.9% on weekdays . Two-day mortality was 3.2% in patients hospitalised on weekends versus 1.9% on weekdays . Multivariable adjustment for age, comorbidity and triage level demonstrated comparable in-hospital and two-day mortality for weekend and week admission .A small weekend effect was observed in elderly internal medicine patients, which was not statistically significant. This effect was partly explained by a higher comorbidity and urgency level in elderly patients hospitalised on weekends than during weekdays. Emergency care for the elderly is not compromised by adjusted logistics during the weekend. Emergency departments (EDs) offer acute care for critically ill patients 24 h a day. However, numerous studies have identified a shortfall in the quality of care at EDs during the weekend and demonstrated an association between weekend admission and adverse outcomes, such as increased in-hospital mortality, which has been labelled as “the weekend effect” –5.Several explanations for the weekend effect have been proposed, such as the different organisation of the health care system at the weekend, including a decreased staffing level, less experienced personnel and reduced availability of diagnostic resources , 6, 7. IIt is well-established that ED visits and hospitalisation of elderly patients are associated with poor outcome, such as morbidity, institutionalisation and mortality , 12. To A retrospective cohort study was performed in a 550-bed teaching hospital, the Máxima Medical Centre, in the Netherlands . Around All elderly patients, aged ≥65 years old, visiting the ED for internal medicine, and being admitted between 1st September 2010 and 31st August 2012 were included. The unit of analysis was hospital admission following an ED visit, allowing multiple admissions per patient. One abstractor extracted the administrative data of all patients. This person was blinded to the study hypothesis, and information bias was minimised by using standard data collection forms. No informed consent of the patients deemed to be necessary because of the retrospective design, and therefor exemption of ethical approval was acquired by the Ethics Committee of MMC.For each ED visit, the following data were obtained from electronic patient and hospital records: age, gender, medical history (past diagnoses), and current medication use. Organisational factors pertaining to the ED visits were: day and time of ED visit, mode of referral, seniority of the first treating physician on the ED, and number of diagnostic procedures . Information on the triage level, vital parameters , laboratory assessments (C-reactive protein (CRP) and leukocyte count), and ED diagnosis was retrieved to estimate the severity of the illness at the ED. The date of admission and discharge were gathered. Follow-up lasted from the date of the ED visit until 1 year of follow-up was reached, the date of death or the date of last available information whichever was earliest.N = 53). Mode of referral was categorised into referral by a GP, ambulance or medical specialist, and self-referral. The triage level was based on the five-level Manchester Triage System (MTS) [Visits were categorised into weekend and weekday visit based on the date and time of admission from the ED visit. In accordance with previous studies investigating the weekend effect, the weekend was defined as the period from midnight on Friday until midnight on Sunday . Daytimeem (MTS) , and wasem (MTS) . The diaThe primary outcome of this study was the mortality rate of elderly ED patients admitted during the weekend as compared with admissions on weekdays. The in-hospital mortality rate, the two-day mortality rate, and the 30-day mortality rate were calculated from the day of admission.p-value < 0.05 was considered significant.All statistical analyses were performed using SPSS . Differences in characteristics between patients admitted on weekends or on weekdays were compared using the Chi-square test for categorical variables. Numerical variables were tested using the Mann-Whitney U test, and unpaired T-test, depending on the number of groups and the distribution pattern of the variable. Missing data were categorised as “unknown” and included in the analysis of categorical parameters in order to explore the influence of missing values. Logistic regression analysis was performed to test differences in mortality rates and to estimate the effect of covariates on patient outcomes. The odds ratios (OR) and the corresponding 95% confidence interval (CI) were calculated as indicated. Admission on weekdays served as the reference category for weekends. Multivariable analysis was performed in order to estimate the effect of age, CCI and severity of illness (triage level) on mortality and to calculate adjusted OR (ORadj). To evaluate the effect of readmissions on the results, we performed a sensitivity analysis including only the first admission following an ED visit in the analysis. In addition, a second sensitivity analysis was performed in order to evaluate the effect of daytime admission on weekdays versus on weekends on mortality rate. A two-sided A total of 3697 ED visits for internal medicine by 2798 elderly patients were registered, of which 2743 (74.2%) ED visits resulted in a hospital admission. The mean age at admission was 78.2 years old (SD 7.7). A total of 2114 (77.1%) admissions were during weekdays, and 629 (22.9%) were during the weekend . The seniority of the first physician on the ED differed significantly between weekends and weekdays, mainly due to the absence of medical students and more trainee residents during the weekend (Table p = 0.009). The ED-LOS was comparable between weekend and weekday presentation to the ED . Hospital length of stay (LOS) among patients admitted during weekends  was shorter than on weekdays .Patient characteristics, such as mean age, gender, and medication use of elderly patients admitted from the ED on weekdays and weekends were comparable Table . Week adp < 0.001) (Table Elderly patients admitted during weekends more often had a high urgency level 20.0%) in the ED compared with patients admitted on weekdays . Weekend admission following the ED visit was not associated with a higher 30-day mortality rate than weekday admission . Additionally, the adjusted two-day mortality was similar for weekend and weekday admission .The sensitivity analysis, performed to evaluate the effect of readmissions on in-hospital mortality outcome, revealed similar results  for the in-hospital mortality rate. Moreover, the outcome was not different for 2-day and 30-day mortality after sensitivity analysis. The second sensitivity analysis demonstrated a higher in-hospital mortality rate among elderly patients hospitalised during daytime on weekdays compared with on weekends . After multivariable adjustment for age, CCI, urgency level and the number of diagnostic tests, the in-hospital mortality for daytime admission on weekdays and on weekends was similar . The 2-day and 30-day mortality was comparable among elderly patients hospitalised during daytime on weekdays and weekends.In this study, we observed a small weekend effect in elderly internal medicine patients (≥ 65 years old), which was not statistically significant. This effect was partly explained by a generally higher comorbidity level and a higher urgency level in elderly patients hospitalised on weekends than during weekdays. Additionally, the 2-day and 30-day mortality demonstrated no difference between weekend admissions and week admissions.Our results offer insight into the outcome of elderly internal medicine patients admitted from the ED on the weekends, for which existing literature is scarce. The in-hospital mortality rate of elderly patients hospitalised during weekends was 11.4%, which is higher than the 4.2–5.2% found in other studies examining a general population , becauseOur study is one of the first studies to examine the weekend effect among elderly patients. Only one earlier study demonstrated the existence of a weekend effect in an elderly population, focusing on patients with substantial head trauma, and found a mortality rate of 9.3% . In contOther studies reported conflicting results on the existence of a weekend effect –6, 10. WThe discrepancy with other studies might be due to the difference in health care organisation of various countries. It is plausible that certain health care systems, or even individual health centres, create a weekend effect , 19, 20.Since the main supposed causes of the weekend effect are of an organisational nature, such as decreased availability of diagnostic resources, and less experienced ED personnel , 5, 7, wA strength of our study was the assessment of confounders, such as the severity of illness of elderly ED patients hospitalised on weekends or weekdays, which contributes important information to existing evidence , 3, 8. WOur results may have several limitations being retrospective and observational by nature. Firstly, there is a potential for bias, because of the use of administrative data with the possibility of coding errors. Due to missing values, we were unable to apply a standardised tool, such as the Acute Physiology and Chronic Health Evaluation Score, to assess the severity of illness. Instead, we analysed surrogate markers for the severity of illness, such as triage level, vital parameters, and laboratory measurements. The effect of incomplete data was assessed by including this information in the analyses. A second limitation is the single centre setting, which may compromise the generalisability of the results. However, to the best of our knowledge, so far no similar study has been done yet regarding the weekend effect in the Netherlands. Furthermore, the organisation of acute care system in other centres and countries should be considered in interpreting our results, although we can also learn from the differences in this respect. Third, the relatively small number of patients may have led to reduced reliability of our results. It is possible that the sample size of the study was too small to exclude the presence of a weekend effect with sufficient statistical power. Fourth, although we corrected for confounders, such as severity of illness, residual confounding may still be present.Our results demonstrate a slightly higher in-hospital mortality rate in elderly internal medicine patients hospitalised on weekends compared with weekdays. However, adjustment for a higher comorbidity and higher urgency level showed there is no independent causal association between weekend effect and in-hospital mortality. This suggests that emergency care in the Netherlands is not compromised by different logistics during the weekend, and appears to provide adequate emergency care to elderly patients.


Foodborne outbreaks are a serious public health and food safety concern worldwide. There is a great demand for rapid, sensitive, specific, and accurate methods to detect microbial pathogens in foods. Conventional methods based on cultivation of pathogens have been the gold standard protocols; however, they take up to a week to complete. Molecular assays such as polymerase chain reaction (PCR), sequencing, microarray technologies have been widely used in detection of foodborne pathogens. Among molecular assays, PCR technology [conventional and real-time PCR (qPCR)] is most commonly used in the foodborne pathogen detection because of its high sensitivity and specificity. However, a major drawback of PCR is its inability to differentiate the DNA from dead and viable cells, and this is a critical factor for the food industry, regulatory agencies and the consumer. To remedy this shortcoming, researchers have used biological dyes such as ethidium monoazide and propidium monoazide (PMA) to pretreat samples before DNA extraction to intercalate the DNA of dead cells in food samples, and then proceed with regular DNA preparation and qPCR. By combining PMA treatment with qPCR (PMA-qPCR), scientists have applied this technology to detect viable cells of various bacterial pathogens in foods. The incorporation of PMA into PCR-based assays for viability detection of pathogens in foods has increased significantly in the last decade. On the other hand, some downsides with this approach have been noted, particularly to achieve complete suppression of signal of DNA from the dead cells present in some particular food matrix. Nowadays, there is a tendency of more and more researchers adapting this approach for viability detection; and a few commercial kits based on PMA are available in the market. As time goes on, more scientists apply this approach to a broader range of pathogen detections, this viability approach  may eventually become a common methodology for the rapid, sensitive, and accurate detection of foodborne pathogens. In this review, we summarize the development in the field including progress and challenges and give our perspective in this area. Escherichia coli O157:H7, Salmonella spp., Staphylococcus aureus, Listeria monocytogenes, Campylobacter spp., and Vibrio parahaemolyticus have been a public health concern and there is a growing demand for rapid, sensitive, and accurate methods to detect these pathogens  physiological state, in which they are living but cannot be grown outside of their natural habitat . It is based on that bacterial transcripts are sensitive to degradation by intra- and extracellular RNases; and mRNA levels should rapidly decline after cell death. Hence, mRNA would only be limited to the viable cells within the population. The development of RT-PCR assays to detect foodborne pathogens such as  O157:H7  utilized O157:H7 . Third,  O157:H7 .The other technique for viable cell detection is an approach that uses PCR method in conjunction with biological dyes, ethidium monoazide (EMA) and propidium monoazide . The approach can specifically detect DNA from cells with intact cell/wall membranes and the viability discrimination is based on the characteristics of EMA and PMA. These biological dyes are positively charged molecules and thus are excluded by intact, negatively charged, bacterial cell-walls, but can enter bacteria with compromised cell-wall/membranes .Figure 1.The mechanism of action of EMA/PMA has not been fully elucidated yet, but it could be as the result of a combination of following factors, (i) when a EMA or PMA solution is added to a mixture of intact and membrane-compromised cells, the chemical can selectively enter only the compromised cells; (ii) once inside the cell, the dye intercalates into nucleic acids and the presence of an azide group allows for a cross-linking between the dye and the DNA after exposure to strong visible light; (iii) the light leads to the formation of a highly reactive nitrene radical, which can react with any organic molecule in its proximity including the bound DNA; (iv) this modification strongly inhibits the sequential DNA amplification in PCR; and (v) at the same time, when the cross-linking occurs, the light reacts with unbound excess dye with water molecules and the resulting hydroxylamine is no longer reactive, so the DNA from cells with intact membranes is not modified in the DNA extraction . TherefoE. coli O157:H7, Salmonella, S. aureus, L. monocytogenes, Campylobacter, and V. parahaemolyticus in foodborne pathogens and summarize the developments in this area.EMA/PMA-PCR assays have been applied to the detection of a variety of microbes, including bacterial cells and spores, fungi, viruses, and yeast in food and the environment . RecentlE. coli O157:H7, Salmonella, S. aureus, L. monocytogenes, Campylobacter, and V. parahaemolyticus; and we also discussed the challenges in using this approach and proposed strategies to remedy the drawbacks of this approach.Although EMA/PMA behaves nearly identically as intercalating stains, the two dyes differ in regard to their permeation through cell membranes. EMA, due to its chemical composition, is slightly more efficient in signal suppression than PMA, however, PMA is more effective than EMA in terms of live and dead discrimination. Numerous studies have used the EMA/PMA approach to detect viable cells of foodborne pathogens, and such work has yielded valuable data on the EMA/PMA efficiency and influence factors. The factors associated with efficiency of the viability detection includes the type and concentration of dye, concentration of organisms, type of food matrices, ratio between viable and dead cells, length of the PCR amplicon, physical condition of the sample, and light exposure conditions. In the study, we reviewed the development in application of the biological dyes, PMA/EMA, in differentiation of viable cells of foodborne pathogens including Escherichia coli O157:H7 is one of the most notorious foodborne pathogens, with an infectious dose of as low as a few hundred cells . In addition, the light exposure time was optimized at 2 min (Table 2). Subsequently, they optimized the PMA treatment conditions as the following: live/dead cell mixtures were added to PMA to a final concentration of 50 μM and incubated at room temperature in the dark for 5 min; the PMA-treated samples were exposed to a 650-W halogen light source, 20 cm from the samples for 2 min for the photo-induced cross-linking. After that the samples were subjected to regular DNA purification procedures and qPCR as illustrated in Figure 2. They demonstrated that this PMA-qPCR assay could detect 8 × 101 CFU/g mixed with 8 × 107 dead cells/g E. coli O157:H7 cells in spiked beef samples with an 8-h enrichment and that PMA treatment did not significantly affect the amplification of DNA from viable cells. In comparison, an EMA-qPCR assay could only detect at the 103 CFU/g E. coli O157:H7 cells in spiked beef samples after 8-h enrichment but failed to detect at 101 or 102 CFU/g E. coli O157:H7 cells in spiked beef samples with an 8-h enrichment  between the PMA-treated and untreated viable cells; and third, PMA is more selective than EMA in inhibiting DNA amplification from dead cells. It is worth noting that the PMA-qPCR assay developed by E. coli O157:H71.ed cells . Beef, dutbreaks . Recentlrichment . In compSalmonella in produce and E. coli O157:H7 by slightly acidic electrolyzed water. 2 CFU of E. coli O157:H7 per reaction by using rfbE gene as target gene and 3 μg/ml PMA as final concentration to treat the samples. Compared with PMA-qPCR, this PMA-LAMP assay had lower sensitivity, but it was more economical to run; it is particularly suitable for resource-limited labs to conduct large-scale detection.Besides qPCR, researchers have also applied PMA/EMA to loop-mediated isothermal amplification LAMP; . Chen etE. coli O157:H7. They used 25 μM PMA to treat the cell mixtures with 10-min intensive light exposure. In the qPCR, the uidA gene and TaqMan were used. This PMA-qPCR assay could detect as low as 102 CFU/ml viable E. coli O157:H7 in pure culture and 105 CFU/g in ground beef in the presence of 106/g of dead cells. With an 8-h enrichment, 1 CFU/g viable E. coli O157:H7 in ground beef was detectable without interference from 106 dead cells/g  with a TC value of 21.19. These data clearly demonstrated that the Amplicon D (130-bp) was the optimized amplicon in the PMA-qPCR assay. With the Amplicon D, the authors not only attained superior qPCR amplification efficiency with a TC value of 18.34, but also achieved high signal suppression of dead cells in qPCR with a TC value of 13.18 as shown in Table 3. Furthermore, this PMA-qPCR assay was capable of detecting live Salmonella cells in live/dead cell mixtures. In addition, the level of sensitivity achieved was 30 CFU/g live Salmonella cells from enriched spiked spinach samples as early as 4 h. produce . There i produce . Recentl in food . In thatE. coli O157:H7, they found that PMA cannot efficiently exclude the DNA of the dead cells when the sizes of amplicons smaller than 190 bp were targeted by PCR. This is a significant size difference in designing amplicons for qPCR because the amplification efficiency of qPCR is affected by the sizes of amplicons and most of the qPCR instruments work best with amplicons under 150-bp. Therefore, selecting the right-sized amplicons for qPCR is a key factor to successfully detect viable foodborne pathogens  in the qPCR is quite different to that previously reported . In thatathogens . Additio in food .Legionella pneumophila, S. Typhimurium, and S. aureus in environmental waters  to the PMA solution and found that 0.2% sarkosyl increased PMA’s penetration to the dead cells with little effect on the viable cells . Recentll waters . The autSalmonella in food. Salmonella. They found that the concentration EMA is critical in effecting the DNA amplification of viable cells, i.e., if the EMA concentration used was <8.0 μg/ml, the DNA amplification of viable cell was not affected, otherwise, it would be significantly affected  and found the PMA-qPCR quantification compared favorably with direct culture-based detection of Campylobacter in their study. The limit of detection of PMA-qPCR reached 102 CFU/g in the presence of dead cells. The specificity of the PMA-qPCR method was 100%, and it was shown to be more sensitive compared to the culture-based method. Eight chicken samples in that study were found to be Campylobacter positive by PMA-qPCR but not by culture  or OD600nm greater than 0.8. Although the authors believed the PMA-qPCR was an effective tool for producing reliable quantitative data on viable V. parahaemolyticus in raw seafood  for direct enumeration or the recovery of isolates after enrichment in selective broth for 24–48 h at 37°C. Subsequently, the suspected colonies that are positive for DNase, and then coagulase production should be tested. This conventional method takes from 5 to 6 days and has low sensitivity and specificity  EMA to treat viable and dead cells and concluded that EMA influences not only dead but also viable cells of C. jejuni and L. monocytogenes. Thus, EMA/real-time PCR is a poor indicator of cell viability  (nd beef) . In a stEnterobacter sakazakii cells. It was concluded that EMA was less effective than PMA in selective amplification of DNA from viable cells and PMA was a useful alternative  adapted , and may adapted . Additio adapted .With the downsides in using the PMA approach being recognized by scientists, the remedies have been proposed to address these issues. For example, “activity-labile compounds” as a possible alternative for PMA treatment was suggested . SoejimaE. coli O157:H7, Salmonella, S. aureus, V. parahaemolyticus, L. monocytogenes, and Campylobacter, and achieved various degree of success in surpassing the signals of DNA of the dead cells in the detection assay. In general, this PMA approach is the most practical means for detection of viable cells of foodborne pathogens.Obviously, culture-based methods cannot match the challenges that the foodborne pathogens pose to the food safety and public health. There is a great demand for rapid, sensitive, specific, and accurate methodologies for pathogen detection in foods. Molecular assays such as PCR and LAMP methods have been demonstrated huge advantages in sensitivity, specificity, and speed. However, a major drawback of these assays is that their inability to differentiate viable and dead cells may overestimate risk of contamination of foodborne pathogens. To circumvent this shortcoming, recently, scientists have combined EMA/PMA to PCR or LAMP for accurate detection of viable cells of foodborne pathogens in foods. Numerous studies have used this approach for detection of viable cells of various foodborne pathogens, including As pathogen detection method, PCR, qPCR, or LAMP method each shows its advantages and shortcomings. PMA-qPCR is the most commonly used technique in foodborne detection because it is rapid, specific, sensitive, and quantitative. Although the sensitivity of PMA-LAMP is slightly lower than that of PMA-qPCR, it is simpler, more economic, and particularly suitable for the need of pathogen detection of resource-limited institutions.PMA is more preferably used dye in viable cells detection of foodborne pathogens compared with EMA, which has been shown not only penetrates compromised membranes of dead cells but also penetrate membranes of viable cells, leading false negative results by numerous studies. While PMA-qPCR assays have been successfully applied to various foodborne pathogens, the drawbacks of this approach have been noted by researchers. For instance, the removal efficiency of DNA of dead cells is incomplete when small-sized amplicons (<130 bp) and/or high concentration of dead cells are used ; and fooBL conceived and contributed largely for the review, and DZ and FX contributed in writing, while all other authors contributed in organizing.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.


Brucella melitensis infection has been recently identified in a French population of Alpine ibex (Capra ibex), after the emergence of brucellosis was confirmed in a dairy cattle farm and two human cases. This situation raised the need to identify the factors driving the persistence of Brucella infection at high prevalence levels in this ibex population. In the present paper, we studied the shedding pattern of B. melitensis in ibex from Bargy Massif, French Alps. Bacteriological examinations  were performed on 88 seropositive, supposedly infected and euthanized individuals. Among them, 51 (58%) showed at least one positive culture, including 45 ibex with at least one Brucella isolation from a urogenital sample or a lymph node in the pelvic area (active infection in organs in the pelvic area). Among these 45 ibex, 26  showed at least one positive culture for a urogenital organ and were considered as being at risk of shedding the bacteria at the time of capture. We observed significant heterogeneity between sex-and-age classes: seropositive females were most at risk to excrete Brucella before the age of 5 years, possibly corresponding to abortion during the first pregnancy following infection such as reported in the domestic ruminants. The high shedding potential observed in young females may have contributed to the self-sustained maintenance of infection in this population, whereas males are supposed to play a role of transmission between spatial units through venereal transmission during mating. This heterogeneity in the shedding potential of seropositive individuals should be considered in the future to better evaluate management scenarios in this system as well as in others.Wildlife reservoirs of infectious diseases raise major management issues. In Europe, brucellosis has been eradicated in domestic ruminants from most countries and wild ruminants have not been considered important reservoirs so far. However, a high prevalence of  Escherichia coli O157 in cattle  population of the Bargy area (French Alps) , some pathogenesis characteristics of B. abortus were similar between bison (Bison bison) and cattle, but specificities such as increased bison susceptibility were also demonstrated  analyze the distribution of Brucella in different organs and estimate the frequency of bacterial carriage in seropositive individuals, (ii) identify the different transmission routes, and (iii) study the potential variation of excretion with sex and age. We provide here the first description of B. melitensis carriage and shedding in Alpine ibex and discuss the potential consequences of individual heterogeneity in terms of transmission, persistence and disease management in this population.In the present study, we have addressed the distribution of B. abortus or B. melitensis) by 2005  . Most captures occurred between April and June, corresponding to the last third of pregnancy, on mature animals (≥2 years old). During captures, test-and-cull was implemented on the basis of serological tests  as part of management measures decided by the French Authorities , autumn 2013 (n = 233), and spring 2014 (n = 18). Non-selective culling on unmarked individuals, considered as having a higher risk of being seropositive than marked individuals , was also performed in autumn 2015 (n = 70). The serological status of these animals was tested using the same assays as for captured animals, when a blood sample of good quality was available.In addition to CMR monitoring and test-and-cull measures, the French Authorities implemented selective culling of animals with observed clinical signs  or individuals older than 5 years, based on the observation that seroprevalence was significantly higher for this age class   and the Complement Fixation Test (CFT), according to requirements of the European Union (EU) for diagnosis of brucellosis in small ruminants and following standards of the World Organization for Animal Health (OIE). For CFT, a cut-off titer of 20 IU/mL was applied according to EU and OIE requirements EU, .- The indirect Enzyme-Linked ImmunoSorbent Assay iELISA  and the blocking cELISA .All captured animals were blood-sampled by trained technical staff. Four tests were performed in parallel on serum samples:In 2012–2013, individuals considered as seropositive on the basis of at least two of the four above-mentioned tests were shot after laboratory testing. In 2014, a rapid Laminar Flow Immune-chromatographic Assay (LFIA)  had been validated on ibex samples by the EU/OIE/FAO and National reference laboratory .Brucella distribution. Finally, genital swabs  were performed in the field (before necropsy) and were used for bacterial cultures in some individuals in 2013–2015.This list comprised organs that may have shedding potential , organs with lesions compatible with brucellosis  and fetuses. Fetuses were analyzed independently from their mother on heart, kidneys, spleen, abomasum, liver, and testes. Other organs  had been sampled on some ibex necropsied by 2013–2015, to better characterize Brucella strains were further bio-typed by the National Reference Laboratory for animal brucellosis (ANSES). All methods were performed according to OIE standards as described previously : the veterinary laboratory of the Savoie department (LDAV 73). Isolated - Urogenital organs  can directly excrete the bacteria in the environment;- Lymph nodes from the pelvic area , that drain the udder and the reproductive organs and can reflect a latent infection with potential further urogenital or milk excretion following recirculation of the bacteria;- Other “entry” or “closed” organs, such as retropharyngeal lymph nodes, joints, visceral abscesses, which reflect the presence of the bacteria but with a much lower risk of excretion.We separated the analyzed organs into three categories in relation to their shedding potential:Since the risk of bacterial shedding varied according to the category of organ infected, we considered four infection statuses in ibex according to the previous organ categories and positive results from culture Table . Individlme4 R package, with the spatial unit and the year fitted as random effects , and six animals on which CFT was not performed. We also tested for the period of sampling as a fixed effect (before/after the mass culling performed in autumn 2013: PERIOD). Indeed sampling biases were likely in 2012–2013 . We also tested for the effect of first-order interactions between sex, age, and CFT because the course of Brucella infection may differ between males and females  any organ, (ii) organs in the pelvic area, or (iii) urogenital organs. According to its capture or culling location, each individual was assigned to one of the five socio-spatial units structuring the population previously identified by Marchand et al. . To contBrucella carriage among organs, to test whether Brucella preferentially infected specific organs and whether this preference varied with age or sex. This expected heterogeneity would have direct implications on the shedding potential, as we assume that the higher the bacteria load in organs, the higher the shedding probability in associated regions  or fluids . After examining the variable distribution, we used a GLMM with a negative binomial distribution . We also tested the first order interactions between sex, age, CFT titer and organ category in order to assess the variation over time of Brucella distribution in each sex.The semi-quantitative assessment of bacterial load also allowed us to analyze the variations in MuMIn R package, Kamil, c), keeping models for which the difference between their AICc value and the lowest AICc value (ΔAICc) was <2  and 32 males aged from 2 to 15. The sampling was heterogeneous among spatial units  and over time . Among the 88 individuals, 81 were necropsied at the LDAV73, whereas only genital swab and blood sampling was performed on the seven remaining animals. Most individuals were captured or culled in spring during the last third of gestation , and a few were culled or captured in autumn before the mating period .Among the 88 seropositive ibex, one was negative with RBT and CFT (<20 UI/mL) but was positive on LFIA, iELISA and cELISA; one was negative in RBT but positive on LFIA, CFT, iELISA, and cELISA; one was negative in iELISA but positive on LFIA, RBT, CFT, and cELISA; and six individuals culled in 2015 were only tested by LFIA because of small blood samples; all six LFIA tests were positive. The 79 remaining ibex were positive to all tests performed and did not show inconsistency between tests. Overall, CFT titer decreased with age in both males and females (data not shown).n = 6), udder (5), other lymph nodes (5), lungs (4), nuchal ligament (2), C3/C4 cervical vertebrae (1), cotyledons (1), and mesentery (1).A total of 516 bacteriological results were obtained from these 88 animals. The number of analyzed organs per individual ranged from 1 to 15  and 0.8 in males . Similarly, when gross lesions of the testes were present, bacterial culture was positive in six cases and negative in three. In the absence of gross lesions, six bacterial cultures were positive and 15 were negative. To conclude, cultures of testes in the presence of gross lesions were not significantly more often positive than in the absence of gross lesions .When gross lesions of the joints were present, associated bacterial culture of the joint fluid was positive in 17 cases, negative in 15 cases. On the other hand, six bacterial cultures were positive and two negative for joints without gross lesions. Bacterial cultures of joints with gross lesions were not significantly more often positive than those of joints without gross lesions , kidneys (n = 3), liver (n = 3), spleen (n = 2), abomasum (n = 3), and testes (n = 2). One of these fetuses was positive for all analyzed organs . Its mother was also positive for 8 out of 9 of the analyzed organs, including cotyledons , 37 42%) were negative for all analyzed samples and thus infection was not bacteriologically confirmed. The remaining 51 (58%), which were positive for at least one sample, were considered as having active infection. Among them, 45 were positive for at least one lymph node from the pelvic area , including 26 positives for at least one urogenital sample  had more than one positive sample  = 2.71 [1.84–3.97]) but not for males (ORper 1 unit in log(TITER) = 0.83 [0.45–1.52]—Table males vs. females = 1.55 [0.97–2.47]). It is important to note that, infection being generally active in young individuals, the CFT titer decreased with age . Consequently, a confounding effect was possible between the effects of AGE and TITER, however both variables still appeared in the selected model.The model best fitting the probability of a bacterial culture being positive in any organ included the variables AGE, SEX, TITER and the interaction SEX:TITER. These variables were present in all models with ΔAICc<2 Table . The profresh vs. frozen = 1.37 [0.76–2.47]) and the PERIOD variable (OR2012–2013 vs. 2014–2017 = 1.79 [0.43–7.51]) were also present in some of the selected models based on the AICc, but they did not significantly improve the model-data fit and were thus not retained in the most parsimonious model (Table The AGE:TITER interaction (OR = 1.07 [0.97–1.17]), the TREATMENT variable (OR9 0.43–7.1) were aRegarding the probabilities of positive culture in pelvic area organs and of positive culture in urogenital organs, both models retained the variables AGE, SEX, TITER, and the interaction SEX:TITER, and the results were qualitatively and quantitatively the same as before Tables . Unlike Regarding bacteria carriage on the organ level, the final model included the SEX, ORGAN, TITER variables, and the SEX:ORGAN and SEX:TITER interactions. These variables were present in all models with ΔAICc<2 Table . The aveper year = 0.90 [0.79–1.02]), TREATMENT (ORfresh vs. frozen = 1.23 [0.58–2.63]), PERIOD (OR2012−2013 vs. 2014−2017 = 1.38 [0.59–3.25]) variables and the AGE:SEX (OR = 0.89 [0.67–1.17]) and AGE:TITER (OR = 1.09 [0.96–1.24]) interactions were also present in models with low AICc values, but not in the most parsimonious model.The AGE , (ii) a broad bacterial dissemination and high Brucella carriage both at individual and tissue/sample levels , and (iii) a strong variation in the bacteriological carriage and shedding capacity according to ibex sex, age, and serological status. In the following sections, we will discuss each of these results, each time highlighting their limitations and inferring on the epidemiology of the infection in Alpine ibex.Overall, our results revealed (i) a high probability of detecting We selected supposedly infected ibex based on serological test results. The diagnostic sensitivity of serological tests are good in domestic animals, i.e., up to 97% in cattle  assay have been developed . Proportion of animals with active infection in naturally-infected seropositive cattle was under 50% in several studies [e.g., 46% of 355 cattle in Harrington and Brown  would be interesting.Our data supports a high shedding potential in ibex infected by in utero or during birth, pseudo-vertical transmission through the consumption of colostrum or milk, and venereal transmission  from infected mothers, vertical transmission Here, our data supported possible horizontal transmission through urogenital secretions, as we found positive bacterial cultures in genital swabs, genital tracts, and urine/bladders of seropositive Alpine ibex of both sexes.Bison bison), low amounts of bacteria in the semen outside the mating period did not support this transmission route, but it cannot be excluded that the amount of bacteria could increase during the mating period  males with more than 100 CFU per plate for five individuals support the ability of males to transmit the infection through venereal transmission. In seropositive naturally-infected bulls, Hill  found poB. melitensis in Alpine ibex, with one positive fetus out of the three fetuses analyzed. Besides, our results support a possible transmission from females to newborns through the consumption of colostrum or milk. B. melitensis was isolated from the udder of five females, and from 35% of supramammary lymph nodes , whose infection is related to the presence of brucellae in milk in livestock  and then decreased with age, as described in wild bison . However, one cannot exclude that young ibex individuals may play an unrecognized role in brucellosis dynamics since they might get infected early in life, either through transmission from infected females to viable fetus or through the colostrum or the infected environment after birth, and become shedders once sexually mature. In the future, depending on the management measures implemented to control this outbreak, analyzing young ibex might allow us to confirm that sexually immature animals may experience latent (undetected) infection, showing no or mild serological response until their sexual maturity or first gestation, as demonstrated in cattle with  Renoux, .B. melitensis in primiparous females often leads to abortion and subsequent Brucella shedding during the last third of the pregnancy  remains unknown. Active shedding with high titers of antibodies might happen then, in a similar way as females around abortion or birth. Season of sampling (April-June vs. October-November) could also have influenced the bacterial load; unfortunately, too few animals were sampled in autumn to allow us to explore the effect of season on our results.Interestingly, the probability of bacterial shedding and the bacterial load did not vary with CFT titers in males, i.e., males with low CFT titers could carry high amounts of Males generally had higher probability of positive culture and higher bacterial load than females Figure . HoweverFinally, we failed to detect any change in this shedding pattern before and after a mass culling had been performed in this ibex population, thus the selective captures performed before 2013 did not result in any obvious change in the bacterial shedding pattern.Our results on shedding and previous results on the spatial behavior and contact patterns of Alpine ibex in the study population . Therefore, further studies are needed to better understand the infection dynamics in the whole population. However, our results provide a new insight in the infection epidemiology, which is critical for future development of control strategies. Indeed, heterogeneity due to age and sex can impact the efficacy of management methods such as culling based on the serological status of individuals or groups, for example by skewing population age structure in favor of highly susceptible juveniles (Bolzoni et al., BG-B, YG, JH, SR, CP, and MJ designed the study. PF, EP, and CT collected the data during the field work, and YG, GR, and M-NB performed laboratory analyses. SL and PF filtered, entered and prepared the data for the analysis. SL, PF, and EG-F performed the analysis. SL, PF, SR, AT, EG-F, and CT interpreted the data. SL wrote the manuscript. SR and JH supervised the monitoring program conducted by the French Hunting and Wildlife Agency. All authors participated in drafting the manuscript or revising it critically for important intellectual content. All the authors approved the submitted version of the manuscript.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.


The Dutch painter Sir Peter Paul Rubens , the most famous artist of the Flemish Baroque art school, studied anatomy and medicine to understand the human body and devoted his life to sharing views common among his contemporaries. Rubens believed that physical weakness could lead to spiritual weakness. He painted nudes and highlighted their physical beauty, goodness, temptation, desire, and fertility. His full-figured women were later called “Rubenesque” or “Rubensian”  or intramuscular fat   accounts for as much as 20% of the body weight in men and 25% in women. The brown adipose tissue (BAT) contains multiple lipid droplets, high density vasculature, and mitochondrial cytochromes . WAT and muscle) . BAT is  muscle) ,9. AdipoAccumulation of adipose tissue in individuals with obesity is associated with a state of persistent low-grade inflammation that seems to play a pivotal role in the pathogenesis of obesity-linked insulin resistance, diabetes, and cardiovascular and neurodegenerative diseases . In thisYersinia pestis), nevertheless, it is a public health crisis. The Black Death was one of the most devastating pandemics in Eurasia; in the period between 1346 and 1353, an estimated 75 to 200 million people died  reported that the number of people with diabetes mellitus increased 4-fold from 1980 to 2014. In 2012, 1.5 million deaths were caused directly by diabetes and 2.2 million deaths were attributable to high blood glucose. Ten years from now, the 7th leading cause of death will be diabetes. The WHO estimated 108 million people lived with diabetes in 1980 and reported 422 million diabetic people in 2014. Diabetes has become a global issue and, although the number of “Rubensians” is rapidly increasing in high-income countries, we can also observe the same trend in middle- and low-income countries . One of The major complications of diabetes are heart attack, stroke, kidney failure, blindness, and neurodegenerative diseases. In 2012, an estimated 17.5 million people died from cardiovascular diseases (CVD), 7.4 million from coronary heart disease, and 6.7 million from stroke. Globally, more people die annually from CVD than from any other cause; CVD is responsible for 31% of global deaths. Three quarters of CVD deaths occurred in low- and middle-income countries .The coming epidemic is neurodegenerative diseases. By 2025, the percentage of people in the EU population aged over 65 years is predicted to increase from 15.4% to 22.4%, which is likely to correlate with a rise in Alzheimer disease (AD), accounting for one-half to three-quarters of all dementia cases . MidlifeOne of the most commonly used oral antidiabetic medicines for the treatment of insulin-resistant diabetes is metformin. Metformin stimulates AMP-activated protein kinase (AMPK) that inhibits lipid synthesis through phosphorylation and inactivation of key lipogenic enzymes . It coulLiraglutide, another widely used antidiabetic drug in type 2 diabetes, is an incretin mimetic and helps the pancreas to release the right amount of insulin after consumption of carbohydrates. Liraglutide is also successfully used in non-diabetic obesity for weight loss . Its mecThe “Rubensian beauty” is not merely an individual problem. It has become epidemic! New approaches are required to investigate the complex origin of obesity and related diseases, as obesity rates continue to rise in both the developed and the developing world.


There are two treatment modalities for early gastric cancer (EGC)—surgery and endoscopic submucosal dissection (ESD). We aimed to compare the safety and efficacy of ESD with surgery. P value.  The article was performed by searching PubMed databases. Data were extracted using predefined form and odds ratios (OR) with 95% confidence intervals (CI) calculated and P = 0.02]. The prevalences of synchronous and metachronous cancer in the ESD group were higher than those in the surgery group . The recurrence and complete resection rates were different . Compared with the surgery group, the hospital stay was shorter , the adverse event rate was lower, and the quality of life (QOL) was better in the ESD group. The difference of bleeding was not found.  13 studies were identified. The incidence of perforation in two groups was different [OR = 6.18 (95% CI: 1.37–27.98),  ESD appears to be preferable for EGC, due to a lower rate of adverse events, shorter hospital stay, cheaper cost, and higher QOL. Gastric cancer is the fourth most common malignancy and the second leading cause of cancer mortality worldwide . The proThere are several treatment options for EGC, such as the endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and gastrectomy plus D1 or D2 lymphadenectomy through laparoscopic or open operation. Among these treatment methods, radical surgery can achieve adequate oncological clearance with wide resection margins, nodal dissection, and low rate of recurrence. However, the perioperative mortality, compromised long-term gastrointestinal function, long operation time, and lower quality of life after surgical resection could not be ignored . In receBased on these investigations, we could find that both ESD and surgery have advantages and disadvantages. It is still uncertain which therapy could be better for EGC. Therefore, we performed this systematic review and meta-analysis to compare the safety and efficacy of ESD with surgery for early gastric cancer.The present systematic review and meta-analysis was performed according to a protocol determined before the study, including search strategy, selection of article, and statistical analysis.A PubMed search was carried out using terms )) AND ))) AND ). The search was performed on November 4, 2016. When the same data was reported in more than one published paper, only the studies, with more complete data and a more extensive interval of enrolment, were included in our review and meta-analysis.Only adults were included in the study.Only patients diagnosed with EGC were included regardless of lymph node metastasis.The studies definitely included two groups, the endoscopic submucosal dissection and surgery groups, and there were no limitations in gastrectomy or laparoscopic resection.Articles published in English were included.Article selection was determined by four inclusion criteria:We excluded the following: editorials; comments; letters to the editor; review articles; case reports; guidelines articles; animal studies; number of patents in any included studies less than ten; studies including patients with other malignancies, such as esophageal carcinoma, colorectal cancer, and polyps; articles without explicit data on the ESD group, but rather endoscopic resection (ER); and the articles with insufficient data.All data were extracted independently by two reviewers (Hu J. and Zhao Y.). In case of disagreement between the two reviewers, a consensus was achieved through discussion among the two reviewers. The primary outcome was complication which refers to perforation and bleeding in our study. The secondary outcome was synchronous cancer, metachronous cancer, complete resection, adverse events, hospital stay, hospital cost, quality of life, 5-year disease-free survival (DFS) rate, and 3-year survival rate. The quality of included studies was assessed by the Newcastle–Ottawa Scale (NOS) , 8.The surgery group included traditional gastrectomy and laparoscopic gastrectomy. Complications in our study refer to bleeding and perforation. Bleeding can be subdivided into immediate (intraoperative) bleeding and delayed bleeding. The significant immediate bleeding is defined as the hemoglobin (Hb) reduced more than 2 g/dL comparing preprocedure and next-day levels .Metachronous cancer refers to a newly developed cancer after at least 1 year after ESD or surgery. Synchronous cancer refers to the malignant lesions distinctly separated by a microscopically normal gastric wall and ruled out from local extension or metastasis . CompletP < 0.10 was considered to represent significant statistical heterogeneity) and 2I statistic   , without a significant heterogeneity . The fixed effects model was applied , without a significant heterogeneity . Thus, fixed effects model was applied , and then, the fixed effects model was applied. The prevalence of metachronous cancer in the ESD group (6.1%) was significantly higher than that in the surgery group (0.7%). The OR for metachronous cancer was 7.15   .P < 0.001), without a significant heterogeneity . Thus, the fixed effects model was applied (The data of complete resection among 3 studies were identified –21. The  applied .P < 0.001), without a significant heterogeneity . The fixed effects model was applied. The other 4 studies used the approach “mean range” describing the data, and one study used the “mean” as the approach. All these studies suggested that there were significant statistic differences of hospital stay time between the ESD and the surgery groups. Compared with the surgery group, the hospital stay time in the ESD group was much shorter.In 7 studies, the hospital stay time was reported , 18–21. There were eight studies describing the survival rate of patients treated with ESD and surgery, and the results are shown in P ≤ 0.0001), respectively.The hospital cost in ESD and surgery showed significant differences among 3 studies. In general, ESD has lower medical costs than conventional surgeries for EGC when it is done in conservative indication . In a stAmong 13 studies, two studies reported the status of adverse events with ESD and gastric cancer treatment , 22. In There are two articles comparing the differences of the quality of life between the ESD and the surgery groups , 13. TheThe purpose of this study is to compare the efficacy between the ESD and surgery. After retrospectively analyzing enrolled researches, we could find that ESD would be preferable to surgery in terms of lower occurrence rate of adverse events, shorter hospital stay, cheaper cost, and higher QOL for the treatment of EGC, while surgery is advanced in higher complete resection rate, higher 5-year DFS rate, and 3-year survival rate.According to our analysis, compared to those in the ESD group, the 5-year DFS rate and 3-year survival rate in the surgery group are higher, which may be affected by the interval of endoscopic surveillance and the follow-up periods. The interval of endoscopic surveillance was not definitely established, and the median follow-up periods in the ESD group and surgery group were relatively short. What is worse, the follow-up period was shorter in the ESD group than in the surgery group . Thus, t2 insufflation [Bleeding, one of the most serious complications of ESD, is subdivided into immediate (intraoperative) bleeding and delayed bleeding. In our study, there was no statistically significant difference between the ESD group and surgery group. It was reported that the rate of delayed bleeding after ESD ranged from 0% to 15.6% . Endoscofflation , 27.Tumor recurrence is an unignorable problem in the treatment for EGC, which can recur as synchronous cancer or metachronous cancer. There was a study reporting that the incidence of metachronous or synchronous tumor was 4.8% and 1.2% per person-year in the differentiated and undifferentiated cancer groups . In our It was known that the complete resection is one of the advantages of ESD compared to endoscopic mucosal resection (EMR) . In our This systematic review and meta-analysis had several limitations. Firstly, there was no randomized controlled trial published. Most of the studies failed to provide detailed information about the survival outcomes. Thus, the meta-analysis about the survival results, hospital cost, and the quality of life between these two groups were not performed. Secondly, in the current systemic review, 12 articles were conducted in Asian countries, and most of them were from Korea. On this side, the data of our study was lacking of representative in the worldwide range.In conclusion, the present systematic review and meta-analysis suggested that, compared with surgery, ESD would be preferable for patients with EGC, due to lower rate of adverse events, shorter hospital stay, lower cost, and higher QOL. Further randomized controlled and multicentral clinical studies with large samples from additional countries are needed to confirm these findings and compare the efficacy of ESD with surgery.


To investigate whether patients with normal-tension glaucoma (NTG) have a higher incidence of stroke.A population-based retrospective cohort study based on data from the Taiwan National Health Insurance Research Database (NHIRD) from January 1, 2001, to December 31, 2010.Data were retrospectively collected from the NHIRD. A total of 245 (20.1%) patients with a history of stroke at the time of glaucoma diagnosis were excluded, and 1,218 patients with NTG who were 20 years of age and older were identified. Patients’ age, gender and pre-existing comorbidities, including hypertension, diabetes, congestive heart failure, ischemic heart disease, atrial fibrillation and disorders of lipid metabolism, were recorded. The propensity score method with a 1:5 matching ratio was used to minimize selection bias. Cox regression with robust variance estimation was used to estimate the hazard ratio (HR) of developing stroke between the NTG and control groups.After adjusting for patient age, gender, and pre-existing comorbidities, the HR was 6.34, indicating that the incidence of stroke was significantly higher in patients with NTG than in controls. Furthermore, a higher risk of stroke was also found in most subgroups with the above-mentioned comorbidities.NTG is a significant risk factor for subsequent stroke in most of the described comorbidity subgroups. Early interventions for stroke prevention should be provided to newly diagnosed patients with NTG. Glaucoma refers to a group of eye diseases characterized by optic neuropathy that is often accompanied by elevated intraocular pressure (IOP), which may result in irreversible optic nerve damage and blindness if not treated adequately. Glaucoma is one of the leading causes of blindness following cataracts –5. PrimaLike most chronic forms of glaucoma, symptoms do not manifest early in NTG. In particular, NTG cannot be diagnosed simply by IOP measurement. NTG is considered a multifactorial disease, and vascular risk factors may play an important role in its etiology . PatientThe pathophysiology of NTG remains poorly understood. Ocular and systemic circulation abnormalities have been linked to the cause and progression of both POAG –24 and NWhile there is scattered evidence in the literature suggesting a correlation between NTG and vascular diseases, particularly stroke, there is a lack of large-scale studies attempting to directly elucidate a causal relationship between NTG and stroke. The aim of this study was to compare the incidence of stroke between patients with NTG and individuals in a matched comparison group using population-based claims data. Patients diagnosed with NTG were hypothesized to possess a greater risk of developing stroke.Data were collected from the National Health Insurance Research Database (NHIRD), which was released by the Taiwan National Health Research Institute. The National Health Insurance (NHI), a single-payer covering more than 99% of Taiwan’s 23 million residents, was implemented in 1995. In the NHIRD, all of the identification information is scrambled. It is a longitudinal, individual-based database containing all medical claims data for one million enrollees who are randomly sampled from the NHI registry. The NHI enrollees included in the NHIRD do not differ significantly in age, gender, or overall healthcare costs from the overall population of NHI enrollees. Therefore, the NHIRD provides a unique resource with which to examine the relationship between NTG and stroke. The data used in this study were obtained from the NHI claims data of one million enrollees collected between 2001 and 2010.A retrospective cohort study was then conducted using the NHIRD. In this study, patients with NTG were identified from the NHIRD between January 1, 2001, and December 31, 2010. Patients diagnosed with NTG (ICD-9-CM: 365.12) on three or more ambulatory care claims or in an inpatient setting were eligible to ensure the validity and reliability of the diagnosis. Because NTG and stroke occur less commonly in children and adolescents, the age range was restricted to patients over 20 years old. Using these methods, 1,218 NTG patients greater than 20 years old were identified. A total of 245 patients who had a history of stroke (20.1%) were excluded.Patient age, gender and pre-exiting comorbidities, including HTN (ICD-9-CM: 401–405), diabetes (ICD-9-CM: 250), congestive heart failure (CHF) (ICD-9-CM: 428), ischemic heart disease (IHD) (ICD-9-CM: 410–414), atrial fibrillation (AF) (ICD-9-CM: 427) and disorders of lipid metabolism (ICD-9-CM: 272), were gathered from the NHI claims data.The comparison group was extracted from the remaining patients in the NHIRD. We excluded patients who were diagnosed with any other type of glaucoma or who were diagnosed with stroke. Each patient with NTG was assigned an index date of diagnosis, which was defined as the date of the first recording of NTG, and a matched control was assigned with an identical mock index date of diagnosis ,37.This study was approved by the ethics board of Taipei City Hospital . All participants’ identifying information was scrambled in the NHIRD.The primary outcome of the study was the occurrence of an episode of stroke (ICD-9-CM: 430–438), which was defined as the occurrence of a visit to an emergency department or admission to a hospital for stroke after the index date.The propensity score method (PSM) was employed to minimize selection bias and avoid problems of endogeneity . The proAfter propensity matching, a total of 5,658 cohort participants were included in the study, 943 in the NTG group and 4,715 in the comparison group. Thirty patients with NTG were excluded due to incomplete matching to 5 controls. There was no significant difference in age, gender, HTN, diabetes, CHF, IHD, AF, or disorders of lipid metabolism between the two groups. All subsequent analyses were performed in the matched samples by methods appropriate for the analysis of matched data in estimating the treatment effect and the statistical significance. Kaplan-Meier survival analyses were performed in both groups with an end point of the first stroke event, and we compared the time to outcome using a stratified log-rank test . The hazAnalyses of the six subgroups stratified by different comorbidities were performed. All the above-mentioned statistical analyses were performed using SAS version 9.3 for Windows .P<0.0001). The stratified log-rank test also indicated that patients with NTG had significantly lower stroke-free survival rates (P<0.0001) (The distribution of demographic characteristics and selected comorbidities for these two cohorts are presented in <0.0001) .P<0.0001), as shown in After adjustment for patient age, gender, HTN, diabetes, CHF, IHD, AF, and disorders of lipid metabolism, the HR was 6.34-fold greater in patients with NTG  in patients with NTG. After adjustment for diabetes, the HR for stroke was 6.88  in patients with NTG. After adjustment for CHF, the HR for stroke was 5.32  in patients with NTG. After adjustment for IHD, the HR for stroke was 5.29  in patients with NTG. After adjustment for AF, the HR for stroke was 4.64  in patients with NTG. After adjustment for disorders of lipid metabolism, the HR for stroke was 4.38  in patients with NTG.The results of the subgroup analysis stratified by different comorbidities are shown in In this retrospective cohort study, we demonstrated that NTG significantly increases the risk of stroke after adjustment for age, gender and medical comorbidities related to cerebrovascular diseases. This is, to the best of our knowledge, the first study to report a correlation between NTG and the subsequent development of stroke.By traditional definition, an IOP of 21 mmHg was used as a cut-off diagnosis value for glaucoma. Glaucoma can actually develop at any IOP level, with typical glaucomatous optic nerve head damage and visual field changes ,43, but Vascular insufficiency in the central nervous system has been related to the pathogenesis of NTG . CerebroThe incidence of a glaucomatous optic disk appearance is significantly higher in patients with symptomatic atherosclerotic cerebrovascular diseases, and it leads to NTG . In addiIn this study, we used a population-based dataset that covers more than 99% of Taiwan’s 23 million residents. Within the dataset, PSM was used to match all the variables to minimize selection bias while preserving an adequate sample size. The diagnosis of NTG was made by board-certified ophthalmologists once the patients experienced glaucomatous disc atrophy, occasional disc hemorrhage, and the typical visual field defects without documented IOP elevation. Compared with the comparison group, the adjusted HR of stroke occurrence among the NTG group (ICD-9-CM: 365.12) was 6.34, which is much higher than the value reported in a previous study regarding the risk of stroke associated with open-angle glaucoma (OAG) (ICD-9-CM: 365.1 to 365.11) [In addition, we found that NTG is a strong indicator of future stroke after adjustment for the diagnosis of comorbidities, including HTN, diabetes, IHD, AF, and disorders of lipid metabolism. There was no significant difference in the subgroup of NTG with CHF due to a small sample size (n = 74).As a “silent vision killer,” glaucoma is not well understood in the general population. IOP is not always evaluated in adult wellness examinations even though it is known that high IOP is an important risk factor for blindness. In addition, the possibility of NTG cannot be ruled out simply by IOP screening tests. Complete fundus and visual field examinations are needed for the definitive diagnosis of NTG. We recommend a good referral system and cooperation between physicians and ophthalmologists for patients with any systemic cardiovascular diseases and other comorbidities as described.The limitations of the study are as follows. The prevalence of NTG may have been underestimated due to the use of a secondary claims database. Nevertheless, the NHI program covers almost 99% of the residents in Taiwan and requires ophthalmologists to present evidence of their diagnosis, including visual field defects and fundus exams, to obtain approval for medications to treat patients with NTG. Thus, those who were diagnosed with NTG were bona fide patients. Another limitation is that the claims data did not include details on the severity of NTG, and thus we could not correlate the incidence of stroke with the severity of NTG. For the same reason, although low systolic blood pressure is a risk factor for NTG , we coulIn summary, patients with NTG, which is more difficult to diagnose than OAG, harbor a significantly higher risk of developing stroke based on this case-control longitudinal study, and the result was unchanged after adjustment for most chronic comorbidities. For patients with NTG, we recommend education regarding chronic comorbidities. Referral of patients with NTG to physicians to identify possible causes or chronic comorbidities, such as HTN, diabetes, disorders of lipid metabolism, and cardiovascular diseases, including carotid artery lesions, should be performed. Early intervention, such as the administration of antihypertensive agents, oral hypoglycemic agents, insulin, lipid-lowering agents, or even prophylactic antiplatelet agents, should also be provided to prevent the development of atherosclerotic stenosis and thrombosis and to reduce the risk of stroke. Most importantly, physicians should pay close attention to patients with the above-described chronic comorbidities and refer them to an ophthalmologist for NTG screening to prevent loss of vision and life-threatening stroke.