Anemia is a major public health concern among children aged <5 years in the Lao People’s Democratic Republic. Thus far, no study has determined the factors associated with anemia among children aged <5 years in the Lao People’s Democratic Republic using a nationwide representative sample. Therefore, this study aimed to evaluate the prevalence of anemia and its associated factors with multilevel variations among children aged 6–59 months. This quantitative, cross-sectional study used a nationally representative sample from the Lao Social Indicator Survey II, 2017. Children aged 6–59 months tested for anemia were included in this study through multistage sampling approaches. Anemia was defined as a hemoglobin level of <11.0 g/dL. Multilevel binary logistic regression analyses were used to determine the adjusted effect of the factors associated with anemia. Among the 5,087 children included, the overall prevalence of anemia was 43.0%. Three factors were associated with higher odds of developing anemia—male sex , underweight , and residence in central provinces  and southern provinces . However, the other three factors—age, educational level of the household head, and Hmong-Mien ethnicity—were inversely associated with anemia. To resolve the problem regarding the severity of the anemia among children aged <5 years in the Lao People’s Democratic Republic. Our findings highlight the need for designing an effective approach to address each factor associated with childhood anemia. Interventions should focus on the prevention of childhood anemia, which is considered a major priority of public health intervention in the Lao People’s Democratic Republic. Anemia (low blood hemoglobin [Hb] levels) is a global public health problem affecting low-, middle-, and high-income countries that has major human health consequences and an adverse impact on social and economic development . In 2011Similar to many developing countries, anemia is a major public health problem among children aged <5 years in the Lao People’s Democratic Republic (Lao PDR), where the prevalence of anemia was slightly increased from 40.9% to 42.0% between 2006 and 2011 . HoweverThis study used the Lao Social Indicator Survey (LSIS) II, 2017 dataset from the Lao Statistics Bureau, Ministry of Planning, and Investment in collaboration with the Ministry of Health and Ministry of Education and Sport. This cross-sectional survey provides national figures on social indicators. It combined the Multiple Indicator Cluster Survey (MICS) and the Demographic and Health Survey modules to maximize government resources, which aim to provide up-to-date information with the selection of data on key social development indicators to support monitoring of the Sustainable Development Goals.Details of the questionnaires, procedures, and methodology used in this survey can be found elsewhere . LSIS IIThe outcome of the present study was anemia, defined as Hb level <11.0 g/dL based on the WHO classification . The indIndividual-level factors included the sex of children, age in months , health insurance status, and health status in the last 2 weeks before the survey, including diarrhea, fever, and illness with a cough. The anthropometric indicators weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) were used to determine nutritional status, which included underweight, stunting, and wasting. Children with a WAZ Z-score of <-2 standard deviation (SD) are considered underweight . StuntinHousehold-level factors included age , sex of the household head, education level of the household head and mother , and ethnicities . In addition, the household wealth index was determined using the scores derived from the principal component analysis of almost all household assets, and utility services. This variable was already included in the dataset as five quintiles ranked from the poorest to the richest. Moreover, the size of the family was based on the number of household members . The main sources of drinking water were categorized as improved  and unimproved  sources. The type of toilet facilities were categorized as improved  and unimproved  toilets, and the availability of mosquito bed nets were also included.Community-level factors, including the area of residence, were categorized based on sampling stratification as urban areas and rural areas with and without roads, and the regions of residence were categorized based on three geographic regions of the Lao PDR: northern , central , and southern  provinces.Data analysis was performed using SPSS software, version 25 . Children’s sampling weights were provided in the dataset and included in all analyses to adjust for the effects of the stratification and cluster sampling approaches. Descriptive statistics were used to summarize the anemia status according to each independent variable. Pearson’s chi-squared test was used to determine the factors associated with anemia among children. To provide valid estimates of exposure effects, only variables with a p-value of <0.20 in the bivariate analysis were considered for entry into multivariate analyses [The survey protocol was approved by the Lao Statistics Bureau, Ministry of Planning and Investment. Moreover, for the protection of using the secondary data in this study, the research proposal was reviewed and provided ethical approval (ID: 2020.33.NW) by the National Ethics Committee for Health Research, Ministry of Health of the Lao PDR. Interviewers explained the objective of the survey to parents/guardians, and informed verbal consent was obtained from parents/guardians before data collection. The interviewers drew a cycle on the questionnaire if permission was given.A total of 5,087 children aged 6–59 months  were included in this study. Approximately 24.5% children were aged 36–47 months, and most of them (85.9%) were uninsured . Most chThe mean Hb level in the study population was 11.09 ± 1.28 g/dL. The overall prevalence of anemia among children aged 6–59 months was 43.0% . The prevalence of anemia was significantly higher among patients aged 6–11 months (72.6%) who had diarrhea (49.2%), and fever (49.4%) in the last 2 weeks prior to the survey in comparison to an older aged patients who had non-diarrhea and non-fever . MoreoveThis study identified various factors associated with anemia among children aged 6–59 months in the Lao PDR. After controlling for covariates, multilevel logistic regression analysis showed that at the individual-level, male  and underweight children  were more likely to be anemic than female and non-underweight children . HoweverAt the household level, many factors were inversely associated with anemia, including education level of the household head .At the community level, the odds of developing anemia increased among children living in central provinces  or southern provinces  compared to that those children living in the northern provinces.To the best of our knowledge, this is the first study to estimate the factors associated with anemia among children aged 6–59 months using multilevel analysis, which was conducted using a nationally representative sample of children aged <5 years. In this nationally representative survey of 5,087 children aged 6–59 months in the Lao PDR, 43.0% children had of anemia. The prevalence of anemia has slightly increased from the previous national prevalence in 2006 (40.9%)  and 2011In this study, after controlling for individual-, household-, and community-level factors, several factors were associated with an increase and decrease odds of developing childhood anemia. At the individual level, our study found an increased odds of developing anemia among male than female children. Previous studies in India , Brazil At the household level, there was a reduced odds of developing anemia among children of Hmong–Mien ethnicity. Geographic differences may be responsible for this association because as the Hb level increases with the increasing altitude, particularly at altitudes >1,000 m . The HmoAscaris lumbricoides, and Trichuris trichiura, which cause anemia among children [At the community level, we demonstrated that children living in central or southern provinces were more likely to be anemic than those living in the northern provinces of the country. The central or southern provinces are considered to be higher malaria-endemic regions than the northern provinces . A previchildren , 44, waschildren , 46. Furchildren .The LSIS II is a nationally representative survey and provides a large health database that could be used to determine factors associated with anemia among children aged 6–59 months throughout the country. However, this study has some limitations. First, the cross-sectional study design does not make it possible to establish a cause–effect relationship. Second, several known risk factors for anemia, including parasitic infections such as malaria, and dietary information were not including in this study. Third, due to a lack of data on the altitudes of areas of residence of the participants, it is plausible that anemia in these children could have been overestimated.To the best of our knowledge, this is the first study to use a large sample of children aged 6–59 months in the Lao PDR to identify factors associated with anemia using multilevel analysis. The prevalence of anemia among children in the Lao PDR is a major public health concern. In this multilevel analysis, we found that childhood anemia was associated with various factors, including sex, age, underweight, ethnicity, educational level of the household head, and region of residence. These factors were identified as having significant random effects at the community and household levels. Therefore, to resolve the problem of anemia in the Lao PDR, an effective approach is needed to address each factor associated with childhood anemia. Interventions should consider three factors—male sex, underweight, and region of residence—that increase the odds of developing anemia. Moreover, to improve the health and well-being of anemic children aged <5 years in the Lao PDR, it is necessary to focus strongly on improving the nutritional status of the children, and prevention of childhood anemia should be considered as a major priority of public health interventions.S1 Fig(PDF)Click here for additional data file.


Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by difficulty to control the own behavior. Neuroimaging studies have related ADHD with the interplay of fronto-parietal attention systems with the default mode network DMN; . However Topological data analysis (TDA) investigates the topology of interacting nodes. It may model the connectomes as a topological process instead of a static graph, exploring the transition of all nodes being isolated to binding together, as a function of the connectivity threshold. Here, we explored three parameters to characterize the algebraic topology of individual connectomes using four different brain atlases, further exploring the subnetwork levels. Our findings showed that the area under the curve (AUC) robustly differentiates children with attention-deficit/hyperactivity disorder (ADHD) and typically developing children (TDC), suggesting decreased functional segregation, with the greatest effects on the frontal lobe and the default-mode network. Overall, these results support the use of the proposed methods to robustly explore topological differences in the brain connectome.Current neuroimaging technology allows the exploration of the human brain as a network of structurally and/or functionally connected constituents, i.e., voxels or regions of interest. In particular, functional connectivity is defined as the synchrony of neuronal activity patterns of anatomically separated brain regions  and manyOne of the most commonly used frameworks to explore the functional brain network is graph theory, which provides a theoretical basis to describe and characterize complex networks . In thisRecently, topological data analysis (TDA), has been adopted in neuroimaging as a tool to quantify and visualize the evolution of the brain network at different thresholds . The maiIn this work, TDA was applied to explore individual brain networks based on the resting state functional MRI (rsfMRI) of children diagnosed with ADHD and typically developing children (TDC), obtained from the publicly available ADHD-200 database . First, https://fcon_1000.projects.nitrc.org/indi/adhd200/). Subjects reported with a secondary diagnosis and/or not medication-naive status were discarded. Only those with good imaging quality and complete phenotypic information were used for subsequent analysis, resulting in a total of 182 children. Study protocols were approved by the New York University Institutional Review Boards, and after an explanation of study procedures a written informed consent from parents and assent from children were required.Imaging and phenotypic data from 263 participants corresponding to the New York University Child Study Center dataset were obtained from the ADHD-200 database  and 96 TDC  and the Conners’ Parent Rating Scale-Revised, Long version (CPRS-LV). Moreover, IQ was measured with the Wechsler Abbreviated Scale of Intelligence (WASI). Inclusion in the ADHD group was based on the parent and child responses to KSADS-PL and obtaining a t-score greater or equal than 65 in any of the ADHD related indices of the CPRS-LV. TDC had ADHD summarized t-scores below 60, and lack of any DSM-IV axis-I disorders. Exclusion criteria were an IQ below 80 or any chronic medical conditions. However, phenotypic data of three ADHD datasets showed full intelligence scores below 80, while two TDC showed *-weighted echo planar imaging interleaved sequence  with a scan duration of 6 min. Participants were instructed to remain still, close their eyes, think of nothing systematically and not fall asleep. In order to obtain an anatomic reference, high-resolution structural T1-weighted magnetization prepared rapid acquisition gradient echo (MPRAGE) images were acquired .Magnetic resonance images were acquired with a Siemens Magnetom Allegra 3T scanner . Whole-brain fMRI volume images were obtained using a T23 children-specific template, the 4.5–18.5 years old NIHPD atlas  were computed based on different brain atlases: AAL , P264 P, CC200, For each subject and atlas, the average fMRI signal of every defined region was extracted and then the functional connectome was computed as the Pearson’s cross-correlation between all possible pairs of regions. The reliability of the explored TDA variables along the atlases was assessed by the Kendall’s concordance coefficient (KCC).0) accounts for the number of components, i.e., the number of isolated nodes or sets of nodes connected by a sequence of edges; Betti-1 number refers to the number of cavities in the two-dimensional space between nodes, and so on , which is a collection of nodes (V) and edges (E). Nodes usually represent regions of interest, while edges represent structural or functional connections between those nodes. Nevertheless, this graph can be represented as a topological space as well, in particular, the Rips complex, denoted by Rips, where F represent the nodes (same as V) and ε, the filtration value, which is a positive number that states if two nodes in F are connected (if their distance is lower than ε). Algebraic properties extracted from this topological space are called Betti numbers, particularly, the Betti-0 number (BB0 curve .j) = 1 − r, where r is the Pearson’s correlation between the pair of nodes ξ and xj. The B0 curves are computed with the TDA package in R (https://cran.r-project.org/web/packages/TDA/index.html), and characterized in terms of the area under the curve (AUC), slope, and kurtosis. The AUC accounts for the overall transition from all nodes being isolated to being connected into a single component, with smaller areas suggesting that B0 decreases with smaller filtration values. The slope accounts for the rate of change, being all negative, lower values mean a faster transition to a single component. Finally, the kurtosis accounts for how “tailed” the distribution is with respect to the average value, with higher values meaning faster transition to a single component.Here, the distance between nodes is defined as in 0 curves are features of the brain topology, observed values were compared with those generated from a random distribution. A weighted null distribution was calculated based on the rewiring of the original connectivity matrices  approach based on clusters of edges  was set for individual edges, and a null distribution of clusters was computed with 10,000 permutations.In addition, the same logistic regression model  was implhttps://github.com/BrainMapINB/TDA_ADHD. Also, the code is available as The code/software described in the paper is freely available online at 10.1523/ENEURO.0543-19.2020.ed1Extended Data 1Extended Data 1, ZIP file.Code applied in the present article. Download 0 curves showed a generalized sample agreement along the four brain parcellations. Significant agreement was found considering every atlas and each feature: area , slope , and kurtosis . Moreover, pairwise concordance coefficient was significant for every pair of atlases and every TDA metric .When comparing observed results against those generated from the null model, Bnal data . Regardi0 curves showed significantly lower odds for the ADHD group, no matter the brain atlas , which means that the ADHD group has smaller AUC compared with the TDC group  or the nodes of two networks (internetwork), according to the lobular and the functional parcellation of the AAL and P264 atlases, respectively. Resulting patterns of the AUC were significant after FWE correction,  the TDC . These r the TDC .0 curves were characterized in terms of three parameters: AUC, slope, and kurtosis; and compared between ADHD and TDC. The application of this model to a pediatric sample showed that the AUC was significantly lower for the ADHD group, both at the whole-brain and at the subnetwork level. These results showed decreased functional segregation in the ADHD group, mainly involving the frontal lobe and the DMN.In this work, methods from TDA were applied to explore the topology of the brain network as a function of the filtration value . Resulting B0 curves were characterized in terms of three parameters, the AUC, slope, and kurtosis. Pairwise agreement between brain parcellations was high for the AUC (KCC range: 0.84–0.97) and the slope (KCC range: 0.69–0.9), and medium to low for the kurtosis (KCC range: 0.59–0.66). These results suggest that this methodology is consistent among different parcellation schemes, especially for the area under the B0 curve. In addition, considering that the B0 features do not depend on a particular connectivity threshold, but instead explore all the filtration values with a change in the topology of the network, this methodology contributes to provide a complete picture of the brain network, overcoming one of the main limitations of other approaches. Taken together, these are potentially important advantages that may complement other methods applied to brain networks, such as graph theory, which has been shown to be highly dependent on the brain parcellation scheme (The Bn scheme , and on n scheme .0 curve was significantly lower for the ADHD group, both at the whole-brain network and at the subnetwork level, being strikingly significant for the interactions involving the frontal lobe and the DMN. As mentioned above, the AUC accounts for the overall transition from all nodes being isolated to being connected into a single component, with smaller areas suggesting that B0, the number of components, decreases faster as the filtration value increases. Such differences in B0 for a given filtration value are mediated by edges that bind together previously split components, which results from increased connectivity in some edges mediating the integration into larger components. Taken together, the results here presented can be interpreted as higher functional connectivity within the connectome and specific subnetworks in the ADHD group, especially those involving the frontal lobe and the DMN. Previous evidence has also suggested increased functional connectivity in a variety of regions of the frontal lobe in ADHD (The area under the B in ADHD , as well in ADHD  and fron in ADHD , particu in ADHD . Our res in ADHD . These r in ADHD , particu in ADHD .0 curves could be interpreted as higher integration and lower segregation of isolated components, our results seem to be contradictory to the aforementioned ones. Nevertheless, the previous studies explored connectivity costs higher than 10%, which according to 0 curves consider a wider range of connectivity thresholds, rarely explored with graph theory. Indeed, when exploring the edge-wise proportions between groups at different connectivity thresholds (Previous studies have reported a myriad of differences in network properties between ADHD and TDC participants. At the whole-brain level, higher functional segregation and lower functional integration in ADHD subjects compared with controls have been reported , althougresholds , the ADHresholds . These r0 in ADHD brain networks (As far as we are concerned, only two previous studies have explored Bnetworks , 2012, uIn summary, the present study showed a robust and informative implementation of TDA in functional connectomics. The results exhibited significant differences for the brain topology of children with ADHD, both at the whole-brain network and at the functional subnetwork level, particularly involving the frontal lobe and the DMN. Therefore, this approach may contribute to identifying the physio-pathology of neurodevelopmental disorders, complementing other connectomics methods by exploring a larger connectivity range and reducing the bias of selecting a fixed threshold.


Background and objectives: Inflammatory bowel disease (IBD) is associated with an increased risk of developing colorectal cancer as well as some extra-intestinal tumors, but there are still limited data about the risk of prostate cancer (PC). To analyze if there is an increased risk of PC in patients affected by IBD, we performed a systematic review with meta-analysis. Materials and Methods: A Pubmed search of all studies comparing standardized incidence ratio (SIR) or odds ratio (OR) or relative risks (RR) of PC between IBD and non IBD groups, published until March 2020 was conducted. The study protocol was registered on PROSPERO. Twelve studies, mostly population studies, were included. The quality score of these studies, evaluated by the Newcastle–Ottawa Scale, was 7. The heterogeneity was high among the studies in which ulcerative colitis (UC) was considered separate from Crohn’s disease (CD) and in the studies that considered UC and CD together (“IBD-studies”), while it was low in the studies which considered CD separate from UC. Results: The relative risk of developing PC was 1.71  in IBD, 1.10  in CD, and 1.22  in UC. Conclusions: Patients with IBD appear to have a slightly increased risk of PC compared to the general population. Inflammatory bowel disease (IBD) is characterized by a chronic idiopathic gastrointestinal inflammation due to a dysregulated immune response. Based on clinical, histopathological, and endoscopic features, IBD can be differentiated in Crohn’s Disease (CD) and Ulcerative Colitis (UC) . AlthougChronic inflammation is a well-known risk factor for cancer development, and in the literature, it is widely acknowledged that IBD is associated with a higher risk of intestinal cancers, such as colorectal cancer or small bowel adenocarcinoma ,8. SeverProstate cancer (PC) is the second most frequent malignancy in men worldwide, but only limited and controversial data on the risk of PC in IBD patients are available . Indeed,In the present study, we conducted a systematic review with meta-analysis aimed at analyzing the association between IBD and PC.This systematic review with meta-analysis was conducted according to the PRISMA  guidelines . The stuArticles published in English about risks of PC in patients with IBD were identified through PubMed (“All databases”) searches using the terms “(inflammatory bowel disease [Title] OR Crohn’s Disease [Title] OR Ulcerative Colitis [Title]) AND prostate [Title] AND cancer [Title]”. The final date of the search was March 30, 2020.Reference lists from published articles were also employed, such as citing articles on PubMed Central. Titles of these publications and their abstracts were scanned in order to eliminate duplicates and irrelevant articles. The inclusion criteria were: (1) studies comparing the incidence of PC between a group of IBD patients and those without IBD or subjects belonging to the general population; (2) studies reporting standardized incidence ratio (SIR) or odds ratio (OR) or relative risks (RR) and the corresponding 95% confidence intervals (CI); (3) whatever the sample was. The exclusion criteria were: (1) studies which did not estimate the association between IBD and PC risk; (2) studies which did not report the number of PC in the two cohorts; (3) reviews; (4) case reports; (5) meta-analyses.Two authors (D.G.R. and E.C.) independently reviewed titles and abstracts of references retrieved from the literature search and selected potentially relevant studies. The full-text versions of selected studies were then assessed by the two authors to determine whether the inclusion criteria were satisfied. Differences in opinion were solved by discussion until consensus was reached. If an agreement failed to be reached, a third author (G.M.S.) was consulted.The following information was collected: first author, country, publication year, number of patients included, numbers of cancers observed in the cohort, expected numbers in a matched background population, SIRs or OR or RRs, and 95%CI.Q-test’s p < 0.05, I2 > 50%), a random-effect model was used , otherwise a fixed-effect model was employed.Cochran’s Q and I2 statistics were used to estimate heterogeneity across studies. When assessing heterogeneity .The Newcastle–Ottawa Scale (NOS) was used to evaluate the quality of the included studies. The NOS is based on a “star system” and judges study quality according to three perspectives: selection of the study groups, comparability of the groups, and ascertainment of the outcome of interest. The average of quality score was 7 for all the included studies .To identify publication bias, funnel plots were created and visually evaluated. In the absence of publication bias, the distribution of effect estimates in the funnel plot resembles a symmetrical inverted funnel, whereas heterogeneity, publication bias, or chance lead to an asymmetrical funnel plot .We identified 150 studies satisfying the search terms. After screening titles and abstracts, 12 of these underwent full-text review. During this process, four papers were excluded as one study was a case-report, one study did not report the exact number of patients with PC, and two studies did not have a comparison with a non-IBD population. By reviewing the lists of references from the retrieved articles, four other articles were included. Twelve studies were finally included, 10 of them were cohort studies, while two had a case-control design. Among these studies, six evaluated the risk of PC in both CD and UC, three evaluated only the correlation between UC and PC, one explored only the correlation between CD and PC, and two referred to IBD patients, without differentiating between the two types ,21,22,23The flow diagram about the studies’ identification, screening, eligibility, and the number of included studies is reported in Among the eight studies evaluating PC risk in IBD , three dFive studies, instead, evidenced an opposite scenario, pointing out an increased risk of PC in patients with IBD. Kappelman et al., in a Danish population-based study, reported an SIR for PC of 1.21 (IC 1.08–1.35) . The samp = 0.007). As a high heterogeneity was detected , a random effects model was used . As a low heterogeneity was detected , a fixed effects model was used . High heterogeneity was present ; thus, a random effects model was used , we did not evidence a statistically significant increased risk of PC in both UC  and CD . The difference can be explained by the fact that we included the highest number of studies in our analysis. For instance, five studies included in our meta-analysis were absent from the meta-analyses performed by Chen et al. [Our meta-analysis showed a slightly different result: in fact, while we confirmed an increased risk of PC in IBD patients , or the fact that the IBD patients could have an increased ascertainment of PC because they are more frequently subjected to rectal examinations due to the characteristics of the disease. Furthermore, we did not consider concomitant medications, such as immunosuppressive drugs, that could increase the risk of developing cancer, decrease ability to eradicate infections, and induce direct DNA impairment. Furthermore, there was a high heterogeneity among the studies, probably due to the different age of the participants and follow-up periods. Another possible bias could be the age of the patients of the included studies. Generally, the majority of those affected by PC are older men, whereas UC and CD affect a younger population. Despite that, the included studies matched case and control for age and showed also an SIR (standardized incidence ratio): hence, this possible confounder was eliminated.Importantly, our meta-analysis included the highest number of studies published on this subject; we enrolled not only cohort studies, but even case-control ones, and we did a sub-analysis, excluding studies with lower quality, thus confirming the obtained results.Our study found that men with IBD have an increased risk of PC, but larger studies are needed to evaluate the risk in the IBD subgroups, especially in patients with UC. Further research should aim at evaluating the impact of concomitant medications on the risk of developing PC. These results could be useful in evaluating the possibility of implementing tailored screening programs for PC in patients with IBD.


Both IBD and HCs have an intermediate adherence to MD. The comparison between Crohn’s disease (CD) and Ulcerative colitis (UC) patients showed significant difference in protein intake in CD patients (p = 0.047), as well as for vitamin D (p = 0.044) and iron intake (p = 0.023). Interestingly; in IBD patients we found a significant association between adherence to MD and a low level of fecal calprotectin (p = 0.027). Conclusion: Children with IBD in remission have a sub-optimal food intake compared to HCs. MD seems to correlate to decreased intestinal inflammation.Background: Nutritional support is very important in the treatment of Paediatric Inflammatory Bowel Disease (IBD). The role of the Mediterranean Diet (MD) has been understudied in children with IBD. The aims of this study were to assess the dietary intakes of IBD children in comparison with healthy controls (HCs), their adherence to MD; and the relationship between inflammation and dietary behaviors. Methods: Paediatric IBD patients in clinical remission and HCs were enrolled. The nutritional status and adherence to the Mediterranean Diet was evaluated through a 3-day food diary and the Mediterranean Diet Quality Index for Children and Adolescents (KIDMED). Results: The analysis of food diaries showed a significantly higher kilocalorie intake in IBD patients compared to HCs ( In Inflammatory Bowel Disease (IBD), nutritional problems are common and depend on the location, disease activity, surgery and associated complications. Between 20 and 85% of IBD patients have nutritional deficiencies, and especially protein-caloric malnutrition ,2. Some Therefore, a growing body of evidence supports the need for special attention to nutrition and diet in children with IBD, although data on the diet of children with IBD is scarce. There are only few studies evaluating dietary intake in pediatric IBD, which report a limited number of patients ,11 or laIndeed, some evidence supports dietary behaviors as a mechanism in the relationship between active disease and nutritional status, specifically that active disease is associated with inadequate or lower caloric and micronutrient intake, whereas the relationship between chronic inflammation and altered dietary intake has not been consistent ,11,15. FTherefore, the aims of the present study were to assess the dietary intakes and anthropometrics parameters of IBD children in remission in comparison to healthy controls subjects, their adherence to MD and the relationship between biomedical factors  and dietary behaviors. A single center cross sectional study was undertaken at the Department of Translational and Medical Science, Section of Paediatrics, University of Naples “Federico II” from September 2018 to October 2019. Our study population included subjects aged less than 18 years with a diagnosis of Crohn’s Disease (CD) or ulcerative colitis (UC) according to the revised Porto criteria .To be eligible for the study, patients were required to: (a) have a documented diagnosis of UC or CD based on clinical, radiological and endoscopic criteria; (b) be in clinical remission within three months of recruitment; (c) be in steroid-free remission for three months prior to study entry. Patients were excluded if: (a) they used corticosteroids within the preceding three months, (b) they had bowel resection or a stomy was present, (c) they used prebiotic or probiotic fiber supplements in the past three months, (d) comorbidities known to affected the nutritional status and/or bone metabolism, growth, or pubertal development, (e) they were on special diets. The baseline patients’ characteristics were extracted from patients’ medical records: age, sex, time since diagnosis, IBD phenotype according to the Paris classification , currentHealthy children (HCs), matched with patients for age and gender, were enrolled as control group. To obtain healthy controls, we surveyed subjects aged 4 to 18 years enrolled in schools (primary schools and secondary schools) in the same period. For each city, the schools were selected randomly from a list of all the schools available in the region.The Principal Investigator contacted the directors of the selected schools to obtain permission to conduct the study. From each school, randomly selected classes were surveyed. Informed consent was obtained by parents/legal guardians of the involved children. Control subjects were excluded if they had any gastrointestinal disease or a medical condition requiring a specialized or restricted diet.Physical examination was performed at the time of recruitment in IBD children. All measurements were performed by a single investigator on the same scale and stadiometer. Weight, height and BMI, were expressed as z-scores  calculated considering the general Italian population as a reference, in order to compare parameters from subjects with different age and gender, weight, height, BMI, and growth velocity z-scores. Weight was measured to the nearest 0.1 kg using a platform beam scale and height to the nearest 0.5 cm using a stadiometer. BMI was calculated as weight (in kilograms) divided by height (in meters squared) and expressed as a z-score.® PRO 3.9.x . The nutrients intake of patients with IBD was compared with recommended daily allowances (RDA) for energy, macro, and micronutrients. Moreover, dietary intake of children with IBD was compared with the control group. Adherence to the Mediterranean Diet was evaluated using a specific questionnaire, the KIDMED based on a test of 16 questions with scores ranging from 0 to 12 .The dietary intake was assessed using a 3-day food diary record. The patients were asked to record everything they ate and drank immediately after consumption, including the amounts consumed (in household measures), the method of cooking, and the brand names of any product used. We evaluated 2 days of the week and one day of the weekend to analyze any changes in the diet. Data from the diaries were analyzed for energy and macro and micronutrients intake, using nutrient analysis software WinfoodThe Institutional Review Board of the University of Naples “Federico II” approved the study protocol with the registration number 127/19. Written informed consent was obtained from parents, and patients older than 13 years signed a statement of assent.2 test or Fisher’s Exact test for categorical variables, while Student’s t test or Mann-Whitney test, were used for quantitative variables, as appropriate. All comparisons between CD and UC were adjusted for sex using classical multiple linear regression. Data were presented as the number of patients (%) for categorical variables and as mean ± standard error of mean (SEM) or median (range), as appropriate, for quantitative variables. Comparison between groups were performed using χt-test was used when the reference value was a mean.As for the tests for differences between patients with IBD and the reference intakes from RDA of several dietary components, the one sample Wilcoxon test was used when the reference value was a median, while the one sample Student’s p-value of <0.05. All statistical analyses were performed with the R statistical software (version 3.4.4). Statistical significance was set as a One hundred twenty five children with IBD were enrolled between September 2018 and October 2019. In the same period, we enrolled 125 healthy control subjects. Fifty three (42.4%) subjects with CD, while 72/125 (57.6%) with UC. Sixty eight (54.4%) were male and 57 (45.6%) female.There were no significant differences in z-scores for weight and height between the IBD and HC group. Baseline clinical details of patients enrolled are summarized in p = 0.012), and a significant increase in carbohydrate intake  and in protein intake . .  Patients 0.024).  Moreover 0.024). .p = 0.0037), whereas there were no significant differences in z-scores for weight and height. The analysis of food diaries adjusted for sex showed no differences in kilocalories, carbohydrates and lipids intake in patients with CD compared to UC, but a significant increase in protein intake in CD children . We also found significant differences in Vitamin D  and iron intake  between the two groups  in the UC group and 16/52 (30.2%) in the CD group (o groups .p = 0.027)  and high levels (>70 mcg/g) of calprotectin. In particular, IBD patients with low values of calprotectin showed a significant higher KIDMED score mean  . We did p < 0.001). Regarding vitamin intake, we found in IBD patients a significant lower intake in Vitamin D (p < 0.001), Vitamin A ; Vitamin C , Vitamin E .  and some micronutrients . On the contrary it was significantly higher in protein (0.0028). The present single-center study describes the dietary patterns and food intake at one-time point in pediatric IBD patients in remission, compared to a representative sample of healthy children. Moreover, we assess for the first time in IBD children adherence to the Mediterranean Diet and its correlation with inflammation.As previously reported, our study confirms that children and adolescents with IBD compared to the RDA have significant lower intake of kilocalories and carbohydrates, as well as a deficiency of several micronutrients and fibers. Instead, the protein intake exceeded the RDA in accordance with a previous study from Hartman et al. . InteresTraditionally, children with IBD have been described as malnourished and underweight. However, in two recent pediatric studies, it has been demonstrated that a significant proportion of IBD patients had a BMI consistent with being overweight or were at risk for being overweight ,20. SincThere is only one study  analyzinSimilar to Dierden et al., our study found that despite the lower energy intake in our patients, the BMI Z-scores were not impaired overall. Finally, in the study from Dierden et al. dietary intake was assessed by using the food frequency questionnaire (FFQ), which tends to overestimate intakes in adult validation studies ,27,28. OThe 3-day food record is the most time-consuming method for dietary assessment to administer: children and their parents had to be instructed in its use and then debriefed. Nonetheless, it offers the highest degree of accuracy of reporting with the lowest proportion of missing foods and phantom foods .Interestingly, when we stratified patients according to disease subtype, we found that in CD patients there was a higher protein intake, as well as better intake of some micronutrients such as vitamin D and zinc. It could be speculated that CD patients manifest a more pronounced trust in healthy nutrition and greater engagement in controlling their diet given the importance of nutrition, in particular enteral nutrition, as a treatment for the disease.Finally, despite a low consumption in fibers, as previously reported ,22,23,24There is a large body of evidence proving that Mediterranean dietary patterns regulate inflammation in chronic disease ,34,35 anThe strength of this study is that we assessed the diet in a large cohort of pediatric IBD patients under medical guidance with a reliable tool and compared this to a matched cohort of children from the general population. Furthermore, to avoid bias, we excluded patients who had active disease or a had different diet related to therapy or bowel resection.In conclusion, our study provides data on the nutritional status and dietary intake of pediatric patients with IBD in remission; however, it reveals the complexity of the relationship between nutrient intake and disease activity in children with IBD. Furthermore, our study suggests the need for evaluating the intake of IBD children compared to the healthy population, as it provides different information compared toRDA.Finally, our patients reported food choices with restricted nutrient intake compared to a Mediterranean dietary pattern. Given the anti-inflammatory properties shown by MD, our results suggest that children with IBD should be screened for nutrient deficiencies and inadequacy of dietary patterns. However, further investigation is needed to test the efficacy of clinical outcomes of nutrition interventions promoting the MD pattern.


Methylene blue (MB) is used in human therapy in various pathological conditions. Its effects in neurodegenerative disease models are promising. MB acts on multiple cellular targets and mechanisms, but many of its potential beneficial effects are ascribed to be mitochondrial. According to the “alternative electron transport” hypothesis, MB is capable of donating electrons to cytochrome c bypassing complex I and III. As a consequence of this, the deleterious effects of the inhibitors of complex I and III can be ameliorated by MB. Recently, the beneficial effects of MB exerted on complex III-inhibited mitochondria were debated. In the present contribution, several pieces of evidence are provided towards that MB is able to reduce cytochrome c and improve bioenergetic parameters, like respiration and membrane potential, in mitochondria treated with complex III inhibitors, either antimycin or myxothiazol. These conclusions were drawn from measurements for mitochondrial oxygen consumption, membrane potential, NAD(P)H steady state, MB uptake and MB-cytochrome c oxidoreduction. In the presence of MB and complex III inhibitors, unusual respiratory reactions, like decreased oxygen consumption as a response to ADP addition as well as stimulation of respiration upon administration of inhibitors of ATP synthase or ANT, were observed. Qualitatively identical results were obtained in three rodent species. The actual metabolic status of mitochondria is well reflected in the distribution of MB amongst various compartments of this organelle. The synthetic drug methylene blue (MB) has been used in human therapy since the last decade of the nineteenth century . Its indComplex III is at the crossroad of the respiratory complexes, accepting electrons from α-glycerophosphate dehydrogenase, fatty acid oxidation, complex I and complex II . The ele+ and/or from the FMN functional group of complex I and can reduce cytochrome c bypassing CI and CIII. The mitochondrion is a target for MB: the mitochondrial connection has been explored in 255 recent scientific articles. The beneficial effects of MB exerted on respiratory chain-inhibited mitochondria are summarized in the “alternative electron transport” theory ,22. AccoEarlier, it was published by our group that MB can beneficially affect the bioenergetic parameters of mitochondria after inhibiting complex I or complex III . More re+ steady state, and the CAT-induced increase in oxygen consumption rate (OCR) and decrease in the NADH/NAD+ ratio are also species-independent and can potentially all be attributed to the oxidation-reduction dependent shuttling of MB between the mitochondria and the extramitochondrial space.The aim of this study was to reinvestigate whether inhibition of the mitochondrial respiratory complex III (at various sites) could perhaps be overcome or bypassed by MB. In order to assess potential species-specific characteristics, experiments were performed on three different rodent species . It has also been investigated in model systems and in mitochondria as well, whether MB could donate electrons directly to cytochrome c. Besides corroborating our earlier results, i.e., proving the beneficial effects of MB on isolated brain mitochondria treated with CIII inhibitors; antimycin A or myxothiazol, unusual bioenergetic reactions to ADP and the adenine nucleotide translocase (ANT) inhibitor carboxy-atractylate (CAT) are described and analyzed in the presence of complex III inhibitors and MB. It is concluded that (i) MB can partially overcome the inhibition of CIII mediated by either antimycin or myxothiazol, (ii) MB can directly transfer electrons to cytochrome c, (iii) the unusual bioenergetic reactions in the presence of MB and CIII inhibitors namely an ADP-mediated inhibition of respiration, increase in NADH/NADMitochondria of synaptic and nonsynaptic origin were isolated from three different rodent species  brain. Animals were decapitated via a procedure that is in accord with the International Guiding Principles for Biomedical Research Involving Animals and Guidelines for Animal Experiments at Semmelweis University. According to the EU Directive “ Directive 2010/63/eu of the European Parliament and of the Council of 22 September 2010 on the protection of animals used for scientific purposes” , the applied procedure above does not require any further specific permission. A discontinuous Percoll gradient was used for isolation of mitochondria, as was detailed earlier ,26. At t2HPO4, 1 MgCl2, 0.1 EGTA, pH 7.0 (KOH)), supplemented with 0.025% fatty-acid-free bovine serum albumin (BSA).All laboratory chemicals, except for ADP, were purchased from Sigma . ADP was purchased from Merck . Experiments were carried out in a standard assay medium containing (in mM): 125 KCl, 20 Hepes, 2 Kplus malate (5 mM each) or glutamate plus malate (5 mM each).Mitochondrial oxygen consumption assays were performed using the high-resolution respirometry system Oxygraph-2K   at 37 °Cm was determined with two different methods. The first uses the cationic dye safranin O, which is accumulated and quenched in energized mitochondria /[reduced] ratio of MB towards the more oxidized state (The addition of MB (2 µM) to substrate-free mitochondria leveled up the absorbance of the solution at 660 nm. Energization of mitochondria with the respiratory substrate pyruvate ed state a. Aliquoed state b. The loed state d. ResultThe aim of the following experiments was to give support to the hypothesis that MB could stimulate the transfer of electrons from NADH to cytochrome c (cyt. c).plus malate. Exogenous acetyl-cytochrome c (ac-cyt. c) was present in the reaction medium from the beginning of the experiments. In the absence of MB and in either the presence or absence of CIII inhibitors, reduction of ac-cyt. c could not be observed . The results presented above, however, provided indirect proof for the participation of cyt. c in the oxidation of NADH.A question to be answered was whether the reduced MB is able to reduce cyt. c. In order to elucidate this, an NADH solution in the standard medium was examined with a high-resolution oxygen electrode to determine the actual oxygen concentration. The oxygen consumption of this solution was moderate. Upon administering MB, the oxygen consumption rate was immediately increased. The rate of oxygen consumption was gradually decreased as NADH was oxidized by MB . When acIn order to detect directly the electron transfer between MB and cyt. c, the reduction of cyt. c by MB was measured . In the m, which was depolarized earlier by either inhibitor of complex III. In order to eliminate as much as possible the potential optical artifacts, two fluorescent dyes were utilized for detecting alterations in Δψm. The two applied dyes both produced concordant results in all the three investigated species  since MB is also a well-known photosensitizer and hence ROS producer  were in quite good agreement (~10% difference). Energization of mitochondria by PM decreased the concentration of oxidized MB both in the presence of mitochondria and in the supernatant; absorbance of the supernatant decreased by 34%. Calculating the uptake of MB from these results, using 1 µL/mg protein for mitochondrial volume (as a rough estimation), we could conclude that in the hyperpolarized mitochondria the MB concentration was more than two orders of magnitude higher than in the extramitochondrial space. The untaken MB remained oxidized or became oxidized during centrifugation, since saturating the mitochondrial supernatant solution with oxygen did not increase the absorbance at 660 nm. Based on the conclusion that mitochondria can take up MB in its oxidized form and partially release it in its reduced form, we could attempt to interpret the unconventional results of our experiments. By detecting the absorbance changes of MB in the presence of CIII inhibitors, we could monitor the oxidoreduction state of MB.Usually, the addition of ADP to mitochondria supported by respiratory substrates initiates an increased rate of respiration as a consequence of the OXPHOS-induced decrease in the membrane potential, lower NADH/NAD lowered  and the  lowered . The addTo summarize our explanation: In the absence of inhibitors and MB, ADP attenuated the membrane potential, increased the oxygen consumption and decreased the NAD(P)H fluorescence, whereas CAT hyperpolarized the membrane, decreased the oxygen consumption and increased the NAD(P)H level.+/2e− to 2H+/2e−. In the absence of inhibitors, but in the presence of MB, MB in itself (in the dosage applied here at least) did not alter the membrane potential , but stiWith CIII inhibitors, but no MB present, ADP and CAT did not considerably affect the oxygen consumption, membrane potential and NAD(P)H steady state. + ratio and the decrease in the OCR. The decreased OCR could be attributed to the phenomenon that less reduced MB was available to bypass the inhibition of CIII and reduce cyt c. The entry of ADP through ANT assumes an exchange with ATP, therefore ATP production is a necessary prerequisite for the function of ANT. There are two possible ways for ATP production in mitochondria with compromised OXPHOS machinery. One of them is the function of the adenylate kinase isoenzymes [In the presence of CIII inhibitors and MB, the addition of ADP decreased the OCR. We may explain this phenomenon by the depolarizing effect of ADP. MB added before the ADP partially repolarized the mitochondria . The entoenzymes ,40,41, wThis work is concerned with the bioenergetic effects of methylene blue (MB) in respiratory complex III-inhibited mitochondria. Evidence is provided in favor of the hypothesis that MB is indeed capable of transferring electrons from the respiratory chain and/or reducing equivalents directly to cyt. c, bypassing the complex III. Experiments were performed in three different rodent species in order to avoid individual species-specific characteristics. Unexpected bioenergetic phenomena are presented in terms of mitochondrial oxygen consumption, membrane potential and NADH steady state in the presence of MB and complex III inhibitors. These phenomena might be accounted for by the dynamic charge- and membrane potential-dependent changes of MB’s extra and intramitochondrial localization .We have already entered the era of genome sequencing, where the molecular background of diseases associated with non-characteristic symptoms, with ill health, can be identified. Selected so-called rare diseases, like some mitochondrial diseases, are apparently not as rare as we earlier thought, and a relatively well tolerable drug like MB  is at times indeed capable of ameliorating the clinical pictures. On the other hand, unusual or rarely described bioenergetic features, like those described in this study, might stimulate thinking and dispute, and give rise to a better understanding of the true effects of selected redox compounds.


The aim of this study was to explore the beliefs of rheumatologists and patients about treatment-related factors, long-term adherence, and their communication with regard to rheumatic diseases.In a multicentre, observational study conducted in Greece, a structured questionnaire was administered to 75 rheumatologists and 398 rheumatic patients from different regions. Five domains were investigated: i) effectiveness of treatment, ii) choice of treatment, iii) change of ineffective treatment, iv) long-term adherence, and v) the quality of communication between doctors and patients. Descriptive data, confidence intervals, t-tests and factor analysis were employed.Examining the patients’ and rheumatologists’ beliefs and attitudes about treatment profiles and long-term adherence, a statistically significant convergence in their views on effectiveness and safety as the predominant factors concerning choice of treatment and long-term adherence was found. Although patients reported high trust to their doctors, a divergence of views is recorded regarding communication of the two parts. Statistically significant differences in the views between patients and rheumatologists were found with regards to access (p<0.001), time per visit (p<0.001), mutual understanding (p<0.001), and overall communication (p<0.001).Our study shows a great rate of agreement between patients and rheumatologists regarding the factors determining the efficacy, choice, switching and adherence to treatment while there was significant divergence in the views regarding the quality of communication between the two parts. Co-ordinated efforts are needed in order to improve the communication level between rheumatic patients and rheumatologists. For the purposes of this study, we mainly focus on patients with rheumatoid arthritis. Rheumatoid arthritis (RA) is a chronic, incapacitating,1 inflammatory arthritis that results, without appropriate therapy, in joint destruction and reduced quality of life and working ability.8 It has often been argued that RA treatment choice should be based on what is often referred to as “shared decision-making”10 between the patient and the rheumatologist. Szasz and Hollender11 suggested that the most appropriate type of doctor-patient relationship is the “mutual participation” model. This implies that both parties share responsibility for planning and implementing treatment. Hendrikx et al.12 proposed an “asking and listening to the patient” model, emphasizing patient’s satisfaction with RA therapy leading to pain relief and less anxiety.Chronic rheumatic conditions comprise over 150 diseases and syndromes, which are usually progressive and associated with pain.14 Doctors are more knowledgeable about the factors contributing to health, the clinical effectiveness, and the potential risks associated with a treatment profile compared to their patients.However, there is a discrepancy in the doctors-patients views in physical functioning and health in general.17 ii) adverse effects,22 iii) poor communication on doctors’ part,25 iv) lack of trust of the doctor,27 v) cost or lack of insurance coverage,31 and vi) changes to the medication that affect patients’ routine.28The literature has indicated that, the most commonly cited barriers in the doctors-patients relationship are i) health literacy,32 saying that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”.33 According to the same report, adherence rates in developed countries rates averaged around only about 50%. It should be noted that adherence is strongly associated with the effectiveness of all therapies.In its 2003 report on medication adherence, the World Health Organisation (WHO) quoted the statement by Haynes et al.34 ii) fear of side effects,35 and iii) limited communication between patients and doctors.35Medication adherence is related to three major groups of factors: i) patient characteristics and health status, ii) disease features, and iii) treatment effectiveness. A great part of the literature focuses on the patients’ barriers to adherence. It has often been argued that patients’ non-adherence is related to several factors, such as: i) lack of information concerning the clinical effectiveness of alternative treatment profiles,37 and providing both verbal and non-verbal guidance38 in order to achieve the desired results.39Doctors have a substantial role to play in improving the communication with their patients by sharing information on biological, psychological, behavioural and social aspect of their patients’ healthThe purpose of this paper is to investigate patients’ and rheumatologists’ beliefs about treatment related factors, long-term adherence, and the communication between them concerning rheumatic diseases.A structured questionnaire was designed based on international literature to investigate beliefs and attitudes of rheumatologists and patients concerning the treatment-related factors, patients’ adherence, and the communication between the two parties. This questionnaire was administered to 75 rheumatologists and 398 rheumatic patients from different regions of Greece. A convenient quota sampling procedure was adopted, ensuring the representativeness in both samples with respect to sex, age, and other socio-demographic characteristics. In the patient group, adults were enrolled if they were above 18 years old, reporting suffering from an inflammatory rheumatic disease . The PanHellenic Federation of patients, parents, caregivers, and friends of children with rheumatic diseases associations (REUMAZEIN) organised the selection of patients’ data. The Web-Rating Health electronic tool was used to collect information on rheumatologists’ views in collaboration with the Greek (Hellenic) Society of Rheumatology. Given that disease management is a multifactorial procedure, five major dimensions have been selected to examine the attitudes and beliefs of rheumatologists and rheumatic patients about the treatment of the disease. The first dimension focuses on the effectiveness of the treatment in relation to pain relief, swelling, mobility, fatigue, lab tests, and manifestation of the disease. The second domain examines the choice of treatment with reference to the safety profile of drugs, access to and experience in clinical use of drugs. The third dimension investigates the changes of an ineffective treatment. The fourth dimension analyses the aspects of long-term adherence. Finally, the fifth domain concentrates on the doctor-patient communication. A series of five-level Likert items were used to examine subjects’ preferences, with the following possible responses: 1. Not at all, 2. A little, 3. Moderate, 4. Very, 5. Too much.α = 0.05.The Cronbach’s alpha test was applied to analyse the internal consistency in doctors and patients’ responses. The convergence or divergence in the views of these groups was examined and presented diagrammatically. T-tests were applied to examine the differences between the mean preferences of doctors and patients. Significance level was set at Factor analysis was performed for patients and rheumatologists to investigate the interrelationship between adherence and a set of constructs. The specified models are presented below:“a priori” assumptions about the interrelationship of different constructs. Data analysis was conducted with the package SPSS v.26.Factor analysis does not make Table 1. The patient group consisted of 398 patients with inflammatory rheumatic diseases of which 72.1% were women. Around 51.6% of them suffered from RA, 27% from AS, and 21% from PsA. The mean age of patients was 53.74 years with a standard deviation of 14.72 years. The rheumatologists group includes 75 doctors of which 56% were females, with a mean age of 51 years (SD: 9 years).The demographic and socio-economic characteristics of the rheumatologists and patients’ groups are presented in 40 The Cronbach’s alpha test revealed a high level of internal consistency for both the rheumatic patients (Cronbach’s α = 0.918) and the rheumatologists (Cronbach’s α = 0.927).The accepted Cronbach’s values for internal consistency is Cronbach’s alpha > 0.70.Figure 1. Rheumatologists assigned greater values on average in comparison with patients for all items. All differences were statistically significant except for the laboratory results item: pain relief (p = 0.004), swelling and mobility improvement (p = 0.048), controlling stiffness (p = 0.001), fatigue (p < 0.001), laboratory results improvement (p = p= 0.0162), and treating all manifestations of the disease including functionality (p < 0.001). The largest differences in the mean responses between the rheumatologists and patient groups were observed in the items of: treating all the manifestations of the disease (mean difference = 0.69), general fatigue improvement (mean difference = 0.54) and morning stiffness (mean difference = 0.36). Interestingly, the lowest ratings for both groups were found in the laboratory results improvement factor.The results about the mean perceived importance of each investigated factor in determining the effectiveness of treatment in rheumatic diseases, are displayed in 41 while doctors’ views are usually affected by biomedical factors such as swelling, mobility, stiffness, fatigue, and the overall functionality of the patient.42It is well known that patients; views are influenced by subjective information such as pain relief,Figure 2. Apart from the safety profile of, and the ease of access to, the drug, where responses were similar on average between the two groups, rheumatologists’ ascribed importance was higher on average for all other dimensions explored. The differences which were found to be statistically significant were: route of administration (p < 0.001), effectiveness in all of the manifestations of the drug (p = 0.013), frequency of administration of the treatment (p < 0.001), and experience in the clinical usage of drugs (p < 0.001). The route of administration (mean difference = 0.85) and the frequency of administration (mean difference = 0.71) were the items associated with the highest mean rating differences between the doctor and the patient groups. Patients seem to pay little attention to the route of their treatment’s administration as well as its frequency, while rheumatologists also rate these factors as the least important .The results concerning the factors affecting the choice of treatment are displayed in Figure 3). In most of the factors explored, a statistically significant difference was not found, except for the better effectiveness in quality of life  and whether the next treatment would be even less effective . Also, both rheumatologists and patients agree that the least important factor in this case is the possibility that the next drug would be even less effective.The change of an ineffective treatment is the third dimension that was explored . Rheumatologists recorded a statistically significant higher interest in maintaining the therapeutic regimen that achieved the desired effect, compared with patients . This was followed by the factors of patient cost reduction , and informing patients and agreement between the two parties about any treatment change .Figure 5 presents the results concerning the factors that influence the quality of communication between rheumatologists and patients in rheumatic diseases. Overall, there seems to be a high rate of disagreement between patients and rheumatologists regarding the quality of their communication. On average, patients assigned lower values in all dimensions compared with rheumatologists, and the differences in the mean ratings were all statistically significant. Specifically, statistically significant differences in the views between the groups were found regarding access (p<0.001), duration of visit (p<0.001), understanding (p<0.001), and overall communication (p<0.001).Figure 6 presents the relationship between the average time per patient’s visit to the doctor, and the patient views on a successful communication with his/her doctor. It appears to be a positive exponential relationship between time and satisfactory communication with the doctor.An important factor influencing the doctor-patient relationship is the time devoted to patient. Supplemental Table 2 and Supplemental Table 3) represent the amount of variance in the constructs under investigation.43 Factors with EVs >1 were selected, according to the Kaiser-Guttman rule,45 in order to satisfy the following criteria: i) the matrix has to be positive, ii) definite, and iii) factorable.46 The cumulative percentage is 66.9% variance for the patients (Table 2) and 75.98% variance for the physicians (Table 3). For both parties, the most important factors contributing to long-term adherence are stable efficacy and safety of the therapeutic regimen.Factor analysis was performed to investigate the interrelationship between long-term adherence and several construct for patients and doctors. The estimated Eigenvalues (EVs)  assign great values in safety and efficacy and much less to the rest of the factors. Rheumatologists  have great interest for safety and efficacy but they also take into account other factors like the maintenance of a successful therapeutic regimen, adjustment of the treatment to their needs and the cost of therapy.Our current study indicates that medication-taking behaviour is extremely complex, requiring multifactorial strategies examining the different dimensions of doctor-patient relationship. The right choice of treatment contributes substantially to clinical outcomes and long-term adherence. Given the existence of alternative clinical scenarios, the right choice of treatment, would lead to a more or less adequate and successful adherence, and would eventually have an impact on the desired clinical outcome. Disease management and efficient utilization of resources contributes to improvements in patients’ quality of life and better health outcomes.Rheumatologists in our study assigned high scores in attaining effectiveness, and, in particular, pain relief, joint swelling, mobility, and controlling stiffness. Ensuring safety and access were the major factors for both groups when it comes to the choice of treatment. It is obvious that an ineffective treatment needs to be changed. In this case, it imprints the fear of a less effective future treatment. In addition, we can see the need of motivation that both parties have, in order to remain adherent or to continue good communication. Interestingly, the route and frequency of treatment administration were the less important factors both for patients and rheumatologists regarding the choice of therapy.Regarding long-term adherence, both groups indicated high level of convergence in their views in safety and efficacy. Factor analysis confirmed this finding. Rheumatologists emphasised the need to maintain the therapeutic regimen that contributes most to the achievement of desired clinical effects. Tapering of medication and cost were the less important factors both for patients and rheumatologists. Among all factors examined, the greatest discrepancy between patients and their treating physicians regarded to the quality of communication between them. Overall patients seem to be less satisfied in their communication with doctors. Patients reported the need for more time per visit, better access to medical services, and more qualitative channels of communication with their doctor.31 that patients’ concern about side effects of the therapeutic regimen, cost imposed to patient, changes of treatment, and barriers to communication contribute to sub-optimal levels in the doctor-patient relationship. In addition, they have an impact on health outcome, quality of life, and long-term adherence.48The findings of our study are in agreement with previous studies,12 barriers are raised because of the existing asymmetry in information. Lack of full understanding of the disease,49 lack of involvement in the treatment decision-making process,16 and suboptimal medical literacy15 are some factors that set patients in a disadvantageous position. Also, beliefs and attitudes concerning their previous medical experiences can affect the degree of medication adherence.51Although various models have been suggested considering a closer collaboration between the two parts,25 by prescribing complex, difficult to read drug regimens,17 and inadequately considering the financial burden to the patients.31Concerning the doctors’ side, they may unwittingly contribute to patient’s nonadherence due to lack of understanding between the two parts,30 and feels encouraged to participate in the decision-making process53Another factor affecting the whole procedure is the quality of communication between the two parts and the trust that patients show to their doctor. We must keep in mind that the doctor-patient relationship must count on both verbal and non-verbal communication, so the patient is capable of understanding illness, risks and benefits of the chosen treatment54 and improve substantially the doctor-patient relationship.55. Rheumatologists should also be trained by specialists  about the possible factors affecting short or long-term adherence, as well as by communication professionals in order to improve their communication skills. Additionally, safer and more reliable measures of adherence should be tested and implemented accordingly such as a pill-reminder system, regular blood tests or a Real Time System.Taking under consideration the above factors, the implementation of patient educational programs would minimize the existing discrepancies56 a better doctor-patient relationship would lead to improvements in health outcome, better adherence, and more cost -effective therapies.In a country like Greece that is characterized by limited resources and, in many cases, health need has turned to be catastrophic,


Background: Brucellosis is one of the most significant zoonosis over the world, threatening both veterinary and human public health. However, few studies were focused on nationwide animal brucellosis and made association with human brucellosis.Methodology and Principal Findings: We conducted a bilingual literature search on Brucella or brucellosis in China on the two largest databases  and conducted a systematic review. A total of 1,383 Chinese and 81 English publications, published between 1958 and 2018 were identified. From them, 357 publications presenting 692 datasets were subjected to the meta-analysis. The overall prevalence rate is 1.70% (95% CI: 1.66–1.74), with a declining (until the late 1990s) and rising trend (starting the early 2000s). Interestingly, the animal with highest prevalence rate is canine , and lowest in cattle . The prevalence of Brucella in animals was unequally distributed among the 24 examined regions in China.Conclusions: Brucellosis is a reemerging disease for both humans and animals in China. The observed data suggests that dogs and yaks are the leading reservoirs for Brucella, and the provinces with highest prevalence rates in animals are Hubei, Sichuan, Inner Mongolia, Fujian, and Guizhou. Accordingly targeted intervention policy should be implemented to break the Brucella transmission chain between animals and humans in China. Brucella, is a textbook example of zoonotic disease prevalent all over the world. Brucellosis, recognized as the leading neglected zoonotic diseases by World Health Organization (WHO), remains a major epidemic, particularly in low- and middle-income countries, including China  and English papers were from PubMed with the same search string composed using keywords “Brucella or Brucellosis” and “China.”This review and systematic analysis included studies published in Chinese or English languages, between 1958 and 2018. The Chinese Publications were retrieved from China National Knowledge Infrastructure, CNKI , sampling year, type of samples, number of total samples, number of positive samples and number of Brucella in humans and some common animals including cattle, dog, pig, sheep & goat, and pointed out potentially high-risk infectious sources toward the human.Descriptive analysis was undertaken to calculate an approximately accurate epidemiologic picture of the disease and its causative agent. We analyzed the spatiotemporal relationship between human and animal brucellosis, where possible. We identified dominant species of A second step quality control screening of each record used for the descriptive analysis was applied using the exclusion criteria . This waThe data extracted from hence selected publications were meta-analyzed in a binary random-effects model by DerSimonian-Laird method at 95% confidence level using OpenMeta-analysis, as described previously . The metA total of 1,464 bilingual publications, which included 1,383 in Chinese and 81 in English, were used for the descriptive analysis after a full-text screening of primary eligible studies. Only 357 publications, 350 in Chinese, and 7 in English, among the total of 692 eligible records, were deemed suitable for meta-analysis. A flow chart of literature research and data extraction is shown .n = 431), while there were only a few records from Tianjin (n = 11). Rose-Bengal Plate Agglutination Test (RBPT), Standard Tube Agglutination Test (SAT), Polymerase Chain Reaction (PCR), and Enzyme-Linked Immunosorbent Assay (ELISA) were the most common assays used for the detection of positive samples which were mostly blood. A total of 70,035,273 samples were tested in all these eligible studies, while 2,339,773 samples turned out to be positive, considered as the confirmed brucellosis cases or separated strains in these studies. There were more records on Brucella and brucellosis in northern China than in southern China. The number of samples tested in northern China was also much higher. The details are shown in All provinces or municipality cities in China except Macao had reported positively for the prevalence of brucellosis. In mainland China, the largest number of records were from Inner Mongolia , whereas the smallest was for 1961–1965 (n = 6). There was an insufficient number of records (less than five) for the years 1951–1955, 1956–1960, 1966–1970, and 1971–1975 so these time frames were not shown. The result of subgroup analysis on the sampling year showed declining followed by a rising trend. Period with the lowest prevalence rate, irrespective of the host was 0.24% during 1996–2000 , while the one with the highest prevalence was 12.44% during 1961–1965 . In recent years, 2016–2018 the prevalence rate was 2.91% , ~10 times higher than the lowest one.The overall prevalence rate among all animals in China from 1951 to 2018 was estimated to be 1.70% (95% CI: 1.66–1.74) . As a faThere were only 24 provinces/autonomous regions which had no less than five qualified datasets for meta-analysis . Five prBrucella transmission in China. The detailed results of subgroup analysis are shown as forest plots in Among the five different types of host groups analyzed , dog posBrucella in multiple kinds of hosts and prevalence within other animals is ambiguous. To a general extension, our unique One Health approach, combined with evidence-based meta-analysis, could be readily scaled to other zoonotic agents with significant public health importance.Brucellosis is one of the most common zoonotic diseases worldwide, with a bioweapon potential, posing a significant public health concern . It not Brucella seroprevalence from animal and human sero-surveys conducted in China during 1950–2014 , even though numerous studies reported significant accumulation of human brucellosis in China, only scattered and unintegrated animal brucellosis datasets are available, leaving huge knowledge gap for the zoonotic control and measurement.After over 100 years in discovery of the agent of Malta fever by David Bruce, brucellosis remains one of the important zoonotic infections causing huge reproductive failure in livestock, and economic losses of the dairy industry in low and middle-income countries. Brucellosis is also a serious public health problem for humans, due to food-chain, and/or occupational exposure. It is estimated that over one-fifth of the 1.4 billion worldwide cattle population is currently infected by We used the evidence-based studies, a meta-analysis, to build the most updated and comprehensive picture of brucellosis in China, including humans, livestock, and companion animals. The One Health approach indicates that the trend of human and animal brucellosis are closely associated with each other in China, with significant expansion from traditional northern farming areas to southern China. Importantly, we found that canine and yak could serve as the emerging reservoirs for human infections in China.The surveillance measurement for human brucellosis should be shifted from traditional northern China to southern regions. Policymakers should consider regional epidemiological data and risk factors to mitigate the zoonotic transmission from animals to humans. Our unique One Health approach, combined with evidence-based meta-analysis, could be readily scaled to other zoonotic agents with significant public health importance.All datasets generated for this study are included in the article/MY: conceptualization. KZ and BW: data curation. KZ and NP: formal analysis and visualization. MY, NP, and HP: methodology. MY and YL: project administration, and writing—review and editing. NP, HP, and JJ: software. MY, YL, and LZ: supervision. KZ: writing—original draft. All authors contributed to the article and approved the submitted version.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.


Background and objectives: In kidney transplant recipients (KTR), hyperuricemia (HU) is a commonly-observed phenomenon, due to calcineurin inhibitors and reduced kidney graft function. Factors predicting HU, and its association with graft function, remains equivocal. Materials and Methods: We conducted a retrospective longitudinal study to assess factors associated with HU in KTR, and to determine risk factors associated with graft function, measured as glomerular filtration rate (GFR). Moreover, GFR > 60 mL/min/1.73 m2 was considered normal. HU was defined as a serum uric acid level of > 416 μmol/L (4.70 mg/dL) in men and >357 μmol/L (4.04 mg/dL) in women, or xanthine-oxidase inhibitor use. We built multiple logistic regression models to assess predictors of HU in KTR, as well as the association of demographic, clinical, and biochemical parameters of patients with normal GFR after a three-year follow-up. We investigated the effect modification of this association with HU. Results: There were 144 patients (mean age 46.6 ± 13.9), with 42.4% of them having HU. Predictors of HU in KTR were the presence of cystic diseases ), the use of diuretics ), and the male gender ). Being a younger age, of female gender, with a normal BMI, and the absence of diuretic medications increased the possibility of normal GFR. HU was the effect modifier of the association between demographic, clinical, and biochemical factors and a normal GFR. Conclusions: Factors associated with HU in KTR: Presence of cystic diseases, diuretic use, and male gender. HU was the effect modifier of the association of demographic, clinical, and biochemical factors to GFR. Traditionally, hyperuricemia (HU) is associated with clinical consequences when saturating concentrations result in symptomatic urate or uric acid crystal deposition—gout, acute or chronic uric acid nephropathy, and urolithiasis , which mRecent experimental studies demonstrate many deleterious effects of UA on vascular cells, resulting in smooth muscle cell proliferation and inflammation: this occurs through increased production of growth factors , vasoconstrictive substances (cyclooxygenase-2 induced thromboxane and angiotensin II) and proinflammatory molecules (C-reactive protein and monocyte chemoattractant protein) ,8,9. HU HU has a particularly high prevalence in the KTR population, or 30% to 84% . In addiHowever, studies investigating the association of HU with kidney transplant function and the effect of UA-lowering therapy on kidney transplant function are scarce. Very few studies investigated factors related to HU itself. In this study, there were two specific aims: (1) To investigate demographic, clinical, and biochemical factors that could be associated with HU, and (2) to assess the role of HU as an effect measure modifier in the association between these factors and as a function of kidney transplant.2 for normal weight, and ≥30 kg/m2 as overweight), clinical parameters , biochemical parameters , and use of medications that could affect HU after kidney transplantation  inhibitors/angiotensin receptor blocker, xanthine oxidase inhibitors, and/or diuretics). Hypertension was defined as systolic blood pressure > 140 mmHg and diastolic blood pressure > 90 mmHg, or regular use of blood pressure lowering medications. Presence of diabetes mellitus was defined as the presence of diagnosis in patient records, or a glucose level of ≥126 mg/dl, or use of antidiabetic medications. HU was defined as the level of uric acid in blood >416 μmol/l (4.70 mg/dL) for men or 357 μmol/L (4.04 mg/dL) for women, or the use of xanthine oxidase inhibitors. Dyslipidemia was defined as the level of total serum cholesterol >200 mg/dl or the regular use of antilipidemic medications. All patients received triple immunosuppressive therapy—calcineurin inhibitors (cyclosporine A or tacrolimus), antiproliferative agents (mycofenolate mofetil or azathioprine), and prednisone. Data were collected about the use of ACE inhibitors/angiotensin receptor blockers, diuretics, and xanthine oxidase inhibitors  as well.We performed a longitudinal retrospective study, using patient records with kidney transplantation from 01.01.2009 until 31.12.2011 in the Latvian Transplantation Centre. Only patients with data available for more than 12 months were included in the analysis, patients with a gout diagnosis were excluded. This study was approved by the Ethical Committee for Scientific Research of the University of Latvia . We also assessed demographic parameters of patients , according to the Cockroft-Gault equation:For the subsequent analysis, we calculated the function of the kidney transplant after the third year follow-up, with GFR . A p-value of less than 0.05 was considered statistically significant. Differences between patients both with and without HU in their demographic, clinical, and biochemical parameters, and with the use of medications were assessed using Chi-square/Exact Fisher tests for group variables or the t-test for continuous variables, as all continuous variables in this study were normally distributed. Statistical analysis was performed using the Statistical Program for the Social Sciences (SPSS) software, 23We performed two-stage multivariate analysis: Stage 1. Multiple logistic regression model was built to assess demographic, clinical, and biochemical factors associated with HU. Stage 2: The multiple logistic regression model investigated the association of demographic, clinical, and biochemical factors with GFR after a three-year follow-up. The adjustment set for the main model was based on variables univariately associated with GFR, with a significance level at 0.1, and other clinically meaningful variables. The full adjustment set consisted of age, gender, BMI (<30 or ≥30), hypertension, dyslipidemia, diabetes mellitus, use of ACE inhibitors/angiotensin receptor blockers, and diuretics. Effect modification: We investigated the possible effect measure modification by HU for the association between predictors and GFR. Sensitivity analysis: We performed a sensitivity analysis to evaluate the possible role of HU as a predictor of GFR, using the model built for Stage 2. As such, we also adjusted the main model for HU. 2) BMI (79.9%). We found the same proportion of men and women in the study sample . Groups with and without HU differed on dyslipidemia and the presence of cystic diseases, use of ACE inhibitors/angiotensin receptor blockers, and use of diuretics  were younger than 60 years, with a normal ) followed by use of diuretics (and a four-fold higher risk of HU in those who used diuretics), or those of the male gender  were a younger age ), the female gender ), BMI less than 30 kg/m2 ), and the absence of diuretic medications ) ) . The proEffect modification: We observed an effect modification from HU for the association observed in the main model. For patients without HU, factors associated with normal GFR were female gender ) and normal BMI ), although for patients with HU, the only factor significantly associated with normal GFR was younger age ) ) . For patSensitivity analysis: We did not observe HU to be predictive of normal GFR ) ) .In this study, we observed that three major factors associated with HU in KTR included: presence of cystic diseases, use of diuretics and male gender. HU was the effect modifier of the association of demographic, clinical, and biochemical factors with GFR, as a better explanation of variation in GFR for those with HU. According to our research, the presence of cystic diseases was a significant predictor of HU after kidney transplantation. To our knowledge, there are no studies that analysed cystic kidney disease as a risk factor for HU in KTR. Future studies must be performed to confirm this finding. According to many epidemiological studies, the main diseases considered to be associated with a risk of HU are diabetes, metabolic syndrome, hypertension, and cardiovascular diseases ,15,16,17+, K+, and 2Cl- cotransporter; this results from decreased levels of uromodulin in the UMOD genetic form, or renin deficiency that leads to aldosterone deficiency in the REN genetic form, which subsequently decreases sodium and chloride reabsorption, in turn leading to a volume depletion which may promote proximal reabsorption of UA [The physiological mechanisms of HU in these two diseases are completely different. ADTKD is a group of genetic kidney diseases that cause progressive loss of kidney function, thereby resulting in end stage renal disease (ESRD) in the third through seventh decade of life . HU and on of UA ,22. Also, ADPKD is the most common inherited kidney disorder, known to affect all ethnic groups at a prevalence of 1:400–1:1000 live births . This isAccording to the results of our study, we would like to emphasize that regular testing of HU in patients with an underlying diagnosis of cystic kidney disease is especially important after kidney transplantation in order to prevent symptomatic HU. It should be noted that with haemodialysis, patients often have normal or even lower uric acid levels , but aftOur study also found that the use of diuretics was independently associated with higher risk for HU. In the general population, diuretics are one of the most important causes of secondary HU. Loop diuretics and thiazide diuretics interact with renal organic anion transporters (OAT), entering the proximal tubular cell from the blood side via OAT1 and OAT3 transporters may be considered as competitive substrates of uric acid . MoreoveIn the current study, we observed that the male gender to be a significant predictor of HU. Gender is a common nonmodifiable risk factor for HU and gout, which is the most severe complication of HU in the general adult population. Men have a greater risk of developing gout than women in all age groups, although the sex ratio tends to equalize with advancing age . In a maOur study confirmed that the male gender is an independent risk factor for post-transplant HU. Thus, this could be the group of patients who need more intensive monitoring of UA concentration and as such, initiation of UA-lowering treatment is necessary to protect the kidney graft function.The results of our study did not indicate HU as an independent risk factor for graft function. We demonstrated that in certain clinical situations HU may affect renal transplant function along with some other risk factors. Controversial to our results, some studies revealed possible association between increased serum uric acid concentration and transplant failure. For example, in FAVORIT study with 3512 patients followed up for 3.9 years  uric aciThis study had several limitations. First, a small number of patients can reduce the power of a study, so more studies are needed to assess possible predictors of HU, as well as its role in KTR. In addition, a possibility of human mistakes whilst using electronic data bases should be taken into account. A second and major limitation of this study was the absence of electronic registers in Latvia, which makes more human mistakes possible. As one of the limitations of this study should be mentioned a lack of possibility to assess the number of patients with HU, that did not undergo KTR. In that case, we cannot be fully sure that some of observed associations will remain correct for patients without KTR. For example, lack of association with cyclosporine that was observed in this study may be not proved by studies that include participants with and without KTR. Finally, 24 patients who had been lost to follow-up could be those with an abnormal GFR, and this loss would be meaningful for such a small sample size.To our knowledge, this is the first study that investigates sociodemographic factors that predict HU, as well as the role of HU in KTR. Without a doubt, this study adds to the global evidence about KTR patients and provides understanding about the necessity for therapy in cases of asymptomatic HU. The novelty of the study is the fact that hyperuricemia after kidney transplantation is an effect modifying factor. Up to date, there is a broad discussion in literature in the effect of hyperuricemia on graft function. We demonstrated that in certain clinical situations , hyperuricemia may affect graft function. We also identified cystic kidney disease as a significant risk factor for hyperuricemia after kidney transplantation. Our study is in line with studies that exist in the field. The fact that we can reproduce results of studies performed in completely different conditions and in completely different populations provides additional validation of results of studies by other authors affirming previously observed results.In this study, factors associated with HU in KTR were presence of cystic diseases, use of diuretics, and male gender. HU might be seen as the effect modifier of the association of demographic, clinical, and biochemical factors with GFR. According to this study, it can be proposed for patients with abnormal GFR to have special care even in the case of asymptomatic HU.