The aim of this study was to evaluate breast arterial calcification (BAC)detected on routine mammography, analyzing its association with chronicdegenerative disease.This was a cross-sectional study involving women treated at a specializedoutpatient clinic for high-risk hypertension, diabetes, or chronic kidneydisease, as well as volunteers who participated in a study to validate amethod of screening for occult renal disease. A total of 312 patientsbetween 40 and 69 years of age, with no history of breast cancer, all ofwhom had undergone routine mammography in the last two years, were included.The mammograms were analyzed by researchers who were unaware of the riskfactors for BAC in each case.2. Seventy-one patients (22.8%) had BAC. We foundthat BAC was associated with advanced age, hypertension, diabetes, chronickidney disease, and low glomerular filtration rate. In the multivariateanalysis, advanced age and diabetes continued to be associated with BAC. Theodds ratio for BAC was higher for all chronic diseases.The mean age was 55.9 ± 7.4 years, and 64.3% of the patients werewhite. The mean glomerular filtration rate was 41.87 ± 6.23mL/min/1.73 mThe association of BAC with advanced age, hypertension, diabetes, chronickidney disease, and low glomerular filtration rate should call the attentionof radiologists. Therefore, the presence of BAC should be reported, andpatients with BAC should be screened for those diseases. Chronic degenerative diseases have a multifactorial etiology,with risk factors shared and associated with multiple conditions.Chronic degenerative diseases, which may currently be responsible for 85% of alldeaths, characterized by thickening andloss of elasticity of the muscle layer of the arterial walls, due to calcificationof the medial or intimal layer.Although this may happen with normal aging, the process is accelerated in certainpathological states, including diabetes mellitus (DM), specific genetic diseases,and chronic kidney disease (CKD). Arterial calcification or vascular calcification can lead tocardiovascular morbidity and mortality, which are highly prevalent in patients with CKD and usuallyfound in peripheral  arteries,9, with reports of increased cardiovascular risk in that patientpopulation.Vascular calcification is defined as inappropriate and pathological deposition ofmineral in the form of calcium phosphate salts in the vascular tissues recognizes the utility of thesemethods in screening for vascular calcification. However, none of these methodsdifferentiate the location of calcifications in the vessel .Plain radiography, echography of large vessels, and echocardiography are simple andinexpensive methods best suited to screening for vascular calcification in patientson dialysis. The Kidney Disease: Improving Global Outcomes initiative orMönckeberg's sclerosis.Such changes are unique to vascular calcifications of the medial layer,15, being easily detected on mammography, correlating witharterial calcification in extremities, and are typically benign. The mammographic featurerepresented by parallel or curvilinear lines is classically described as a "traintrack" pattern.Although mammography is primarily used for breast cancer detection, it canoccasionally reveal breast abnormalities related to extramammary disease, especiallyvascular diseases, the indication of which observed by mammography is the presenceof arterial calcifications hypothesized thatbreast arterial calcification (BAC) is a specific marker of calcification of themedial layer and that mammography could be used to determine the prevalence and riskfactors for calcification of that layer in CKD patients. That study, which was thefirst to establish the histopathological correlation, showed that BAC was a specificmarker of medial arterial calcification in CKD, and that its prevalence was markedlyincreased in advanced and final stages, correlating with the radiological findingsin the extremities (hands and feet). However, the authors listed some importantlimitations of their study, including the relatively small number of patients in thesample.Duhn et al.. BAC may be associated with other cardiovascular diseasessuch as arterial hypertension (AH) and coronary heart disease. An association between BAC and DM was alsoobserved by Fuster Selva et al..Although CKD is a known risk factor for medial arterial calcification, the stage ofCKD in which that risk arises remains unknownGiven the high prevalence of chronic degenerative diseases, the fact that vascularcalcification is a risk factor for cardiovascular disease (CVD) mortality, and thefact that routine mammography is not valued as a consistent risk factor, weconducted a study to evaluate the association between chronic degenerative diseasesand BACs detected through routine mammography, as well as to determine whether suchBACs correlate with CKD, DM, and CVD.. The HiperDia Program, run out ofthe Center for the Secondary Treatment of Arterial Hypertension, Diabetes Mellitus,and CKD, operates under the auspices of the Minas Gerais State Department of Health.The program is considered a reference in the treatment of hypertensive patients withhigh or very high cardiovascular risk, insulin-dependent diabetes, or CKD in stages3, 4, or 5. It is sanctioned by the Minas Gerais Institute for Teaching and Researchin Nephrology and by the Interdisciplinary Center for Study, Research, and Treatmentin Nephrology, both operated by the Federal University of Juiz de Fora. The SCOREDinstrument is a questionnaire, comprising nine items of different weights, aimed atidentifying CKD in its early stages and at allowing interventions with the potentialto alter the natural course of the disease, a score ≥ 4 being predictive of a20% chance of developing CKD. The goal of the SCORED project was to translate theSCORED questionnaire to Portuguese, to adapt it  for use in Brazil,and to validate it for such use. The confidentiality of personal information wasguaranteed, and all participants gave written informed consent. The study wasapproved by the Research Ethics Committee of the Universidade Federal de Juiz deFora , inaccordance with Brazilian National Health Council Resolution 196/96.This was a cross-sectional study involving 312 women in two groups: a high-riskgroup, comprising consecutive patients enrolled in the Arterial Hypertension andDiabetes Program ; and a grouprepresentative of the general population, comprising volunteers involved in theSCreening for Occult REnal Disease (SCORED) validation projectTo calculate the sample size for our study, we considered the prevalence of BAC(detected on routine mammography) in the 40- to 59-year age group and in the≥ 60-year age group, predicting that it would be approximately 29% in theformer group and higher (approximately 60%) in the latter, which is a high-riskgroup. The result was 104 subjects for the 40- to 59-year age group and 200 subjectsfor the ≥ 60-year age group.We included females between 40 and 69 years of age who had undergone mammography inthe last two years. Patients with a history of radiation therapy or breast surgery(including silicone implant surgery) were excluded, as were those who had previouslybeen diagnosed with breast cancer, those who were on dialysis, and those in whom themammography was not of adequate quality. Patients were allowed to opt out of thestudy at any time.Volunteers were contacted by phone or e-mail. Initially, they were asked if theyremembered the date and result of their most recent mammography. Data related to thefollowing sociodemographic variables were collected: race, sex, age, marital status,level of education, family income, and personal income. Anamnesis included thepersonal and family pathological history ; menstrual history ; pregnancy; hormone replacement therapy; breast radiotherapy;breast surgery ; and smoking history.2), blood pressure, andankle-arm index. In addition, the following biochemical data were collected from thelaboratory test results available in the patient charts or from new tests if no datawere available: serum creatinine; estimated glomerular filtration rate (GFR),determined with the CKD Epidemiology Collaboration formula; and abnormal elements andsediment in urine samples. All new tests were conducted at the same laboratory wherethe original patient tests had been performed. Mammograms, provided by the subjects,were reevaluated by two radiologists experienced in the abovementioned diagnosticmethod. The radiologists worked independently and were blinded to any data thatmight identity a given subject, as well as to the subject medical histories. Themammograms were evaluated after the presence or absence of arterial calcificationshad been confirmed, the location of any calcifications (in one or both breasts) hadbeen established, and the number of calcified vessels  had beendetermined.The following clinical data were obtained directly from the HiperDia database:weight, height, body mass index . In the logistic regression, odds ratios (OR) areaccompanied by their respective 95% confidence intervals (95% CI). Values ofp ≤ 0.05 were considered statisticallysignificant.We used descriptive statistics, including mean ± standard deviation,median (interquartile variation), or relative frequency, according to thecharacteristics of the variable in question. Subjects were divided into twogroups-with and without BAC. To compare the two groups, in terms of thesociodemographic, clinical, and biochemical variables, we used the chi-squaretest for categorical variables and the Student's Of the 431 eligible SCORED/HiperDia subjects, 119 (42 SCORED subjects and 77 HiperDiasubjects) were excluded because they had no mammogram available. Therefore, thefinal sample comprised 312 subjects.2, the mean waist circumference was 102.63 ± 12.4 cm, andfew of the subjects (only 8.7%) were smokers. The most prevalent comorbidity was AH,followed by DM. Approximately one third of subjects (66.7%) reported beingmenopausal. Laboratory testing showed that the mean serum level of creatinine was1.13 ± 0.7 mg/dL, and that the mean GFR was 41.87 ± 6.23 mL/min/1.73m2.Sociodemographic and clinical data related to the studied population are shown inp < 0.0001).Seventy-one subjects (22.8%) presented BAC, and the number of calcified vesselsranged from 1 to 6. Of the 312 women evaluated, 162 (52%) had BAC in both breasts.We conducted a receiver operating characteristic curve analysis with DM as theoutcome variable and the number of BACs as the predictor variable; the area underthe curve was 0.59, sensitivity and specificity improving when there were ≥ 3calcified vessels . When the outcome variablewas AH, the area under the curve was 0.60 and the sensitivity and specificity werealso better when there were ≥ 3 calcified vessels . In the case of CKD, the area under the curve was 0.60 and thesensitivity and specificity were again higher when there were ≥ 3 calcifiedvessels . There was a significant, inversecorrelation between GFR and the number of calcified vessels . The proportion of subjects earning only 1–3 times the minimum wage wassignificantly higher among the subjects with BAC than among those without . The proportion of subjects having graduated fromhigh school or college was significantly higher among the subjects without BAC thanamong those with BAC . Wefound that BAC correlated significantly with AH and DM (p <0.001 for both), as well as with CKD (p = 0.05). In addition, theproportion of menopausal women was higher in the BAC group (p <0.001). The GFR was significantly lower among the subjects with BAC than among thosewithout .We compared the subjects with and without BAC in terms of the sociodemographic andclinical characteristics . Onavern =58 and n = 131, respectively), we observed that the mean age washigher among those with BAC . In addition, family income was lower among the subjects with BAC(p = 0.05). As can also be seen in p = 0.09). There was also ahigher number of menopausal women in the BAC group (p < 0.0001).However, the GFR was significantly lower in the subjects with BAC .When we analyzed only the subjects with DM , stratifp = 0.001). Family income tended tobe lower among the subjects with BAC (p = 0:07). Among the subjectswith CKD, comorbid DM was more common in those with BAC than in those without(p = 0.01). In addition, the GFR was significantly lower inthose with BAC .The characteristics of the subjects with CKD are shown in n = 70); 50–59 years(n = 145); and ≥ 60 years (n = 93). Thereference for this variable was the 40- to 49-year age group. We observed thatpresenting with AH was a risk factor for BAC , as was presenting with DM  andbeing over 60 years of age . We constructedanother model, using the GFR as a continuous variable rather than CKD as acategorical variable. Nevertheless, there was no statistical significance (data notshown).In the logistic regression analysis ,variablAs can be seen in In the present study, we attempted to determine the incidence of BAC in women beingtreated at a secondary care center for AH, DM and CKD, as well as to look forcorrelations between this finding and those diseases. We found that the prevalenceof BAC correlated with advanced age, AH, DM, and CKD. However, after adjustment forconfounders, the variables that remained relevant were advanced age and DM.,the heterogeneity of the incidence of BAC, as documented in several studies, rangesfrom 9% to 41%. The incidenceof BAC in the present study was 22.8%.The prevalence of BAC in the literature is varied and controversial. According toFreitas-Júnior et al.-28. It is of note that, in our sample, there was apredominance of white individuals, individuals with a low level of education, andindividuals with a low income, all of which is in accordance with population datafrom the Brazilian Institute of Geography and Statistics. In addition, approximately half of the subjectsin our study sample had a body mass index consistent with obesity, as well aspresenting with an increased waist circumference. In the last 20 years, theBrazilian population has shown higher rates of obesity, which is in keeping with our data.The mean age of the subjects in our study sample was similar to that reported inother studiesThe high prevalence of comorbidities in our study is due to the fact that our samplecomprised a population of individuals with high cardiovascular risk (HiperDiapatients), together with a group representative of the general population (SCOREDvolunteers). Therefore, we could make a comparative analysis., which can exceed 50% amongindividuals over 65 years of age. Reddy et al. analyzed 1905 routine mammograms and detected BAC in 560(29.4%). The authors also found that the incidence of BAC was higher among Hispanicwomen than among those who were white, black, or Asian. In the present study, therewas no correlation between BAC and ethnicity; we believe that this is due to thegreat heterogeneity of the Brazilian population and, consequently, of oursample.Advanced age has been directly related to the extent and incidence of BAC have shown that poorer outcomes are associated with lowerlevels of literacy. For example, Iribarren et al. found an inverse correlation between BAC andlevel of education.The fact that, in the present study, the prevalence of BAC was higher among subjectswith a low level of education and a low income is probably related to healthliteracy, given that other studies, Zafar et al., and Akinola et al., we found no correlation between obesity and BAC in ourstudy sample. It is also noteworthy that we found no correlation between smoking andBAC, which is in line with the findings of Almeida et al. and Iribarren et al..In keeping with the findings of Bielak et al. and Yildiz etal. showed thatrecurrence of BAC is more common among women with AH and DM. In the study conductedby the former group of authors, the prevalence of AH was lower among the women with BAC thanamong those with DM (17.6% vs. 25.4%), and the presence of BAC would indicate thepossibility of AH, especially in patients without DM. Cetin et al. conducted another study,underscoring the idea that the prevalence of these conditions is higher when theyoccur together with BAC, which could indicate undiagnosed DM or AH, especially after59 years of age. In the study conducted by Yildiz et al., recurrence of DM and AH was also significantlymore common among individuals with BAC than among those without (p< 0.05). Data from thepresent study show that DM was the variable that correlated most strongly with thepresence of BAC, despite the fact that AH also correlated with BAC. In themultivariate analysis, the correlation between DM and BAC persisted.Cetin et al. and Marinelli et al., have involved patients in the later stages of CKD andhave included patients on renal replacement therapy. In the present study, weevaluated women in the early stages of CKD, most in stage 3B, and found that theprevalence of BAC was higher among those women. However, when we analyzed onlysubjects with CKD, excluding those with DM, we observed no such relationship.Nevertheless, in our study, there was a clear inverse correlation between GFR andthe number of calcified vessels. In addition, when found that, in the presence ofBAC, the GFR was lower in all subgroups . With the objective ofascertaining the risk of CKD in the presence of BAC, Hassan et al., studied women with CKD stage 3(n = 146); CKD stage 4 or 5 (n = 54); orend-stage renal disease (n = 92). The authors found that among thewomen with end-stage renal disease, estimated GFR and age were independentpredictors of BAC (p = 0.005 for both).Studies that address CKD and medial layer calcification of the arteries, such asthose conducted by O'Neill et al.. In patientswith DM, we can find metabolic and inflammatory alterations,43. Another study demonstrated that the presence of BAC,especially in women over 59 years of age, could be related to the duration ofdiabetes. In thepresent study, we evaluated patients with DM and CKD, with and without BAC, and weobserved an intersection between the two diseases. However, in our multivariateanalysis, CKD was no longer found to be an isolated risk factor for BAC, whereas DMand advanced age persisted as major risk factors. It is noteworthy that, in ourstudy, the OR for calcification of the medial layer of the arteries was higher amongthe subjects with AH, DM, or CKD.In patients with CKD, medial layer calcification of the arteries appears to beassociated with mineral and bone disorder, such as elevated serum levels of calciumand phosphateOne limitation of our study is that among the subjects with DM or AH in our sample,there was a large number who were at high cardiovascular risk and a small number whowere at low cardiovascular risk. Therefore, the risk of BAC might have beenunderestimated in the latter group. One strength of our study was that we evaluatedCKD patients in the pre-dialysis phase. However, although we found BAC to correlatewith CKD and with the GFR, those correlations did not retain their significance inthe multivariate analysis. Another limitation of our study is that, due to itscross-sectional design, we cannot make causal inferences. Therefore, we can stateonly that BAC might play a role in the pathophysiology of DM.In conclusion, we found that BAC correlated with advanced age and with chronicdegenerative diseases-AH, DM, and CKD-in our study sample. This should alertradiologists and other physicians to the fact that BACs should be reported and thatpatients with BAC should be screened for those associated diseases.


One Health issue.Lead (Pb) is toxic and is banned from gasoline, paints, and various household items in most developed countries. Lead ammunition, however, is still widely used for hunting and shooting, and is now likely the greatest, largely unregulated source of lead that is knowingly discharged into the environment in the USA  or in reference lists of published literature. Finally, we were left with 570 peer-reviewed papers published from 1975 through August 2016. The number of articles per year showed a strong increase over time during the period covered: 6.9 in 1975–1989, 9.3 in 1990–1999, 19.0 in 2000–2009, and 27.7 in 2010–2016. These papers were analyzed for relevance and conclusions, with special reference to topics such as health risks for humans consuming game hunted with lead-based ammunition  supported the bill, disregarding scientific evidence on health and environmental risks from lead-based ammunition. The Norwegian Association for Hunters and Anglers (NJFF The AFEMS  promotesDespite overwhelming scientific evidence and increasing policy imperatives, nationally regulated bans on the use of lead shotgun and rifle ammunition are few. North American and European arms industries have developed non-toxic shot and bullets that are as effective and comparably priced as their lead counterparts Thomas . Our und


Background: The evidence of increased mortality attributable to extreme temperatures is widely characterized in climate-health studies. However, few of these studies have examined the role of humidity on temperature-mortality association. We investigated the joint effect between temperature and humidity on cardiovascular disease (CVD) mortality in Zhejiang Province, China. Methods: We collected data on daily meteorological and CVD mortality from 11 cities in Zhejiang Province during 2010–2013. We first applied time-series Poisson regression analysis within the framework of distributed lag non-linear models to estimate the city-specific effect of temperature and humidity on CVD mortality, after controlling for temporal trends and potential confounding variables. We then applied a multivariate meta-analytical model to pool the effect estimates in the 11 cities to generate an overall provincial estimate. The joint effects between them were calculated by the attributable fraction (AF). The analyses were further stratified by gender, age group, education level, and location of cities. Results: In total, 120,544 CVD deaths were recorded in this study. The mean values of temperature and humidity were 17.6 °C and 72.3%. The joint effect between low temperature and high humidity had the greatest impact on the CVD death burden over a lag of 0–21 days with a significant AF of 31.36% (95% eCI: 14.79–38.41%), while in a condition of low temperature and low humidity with a significant AF of 16.74% . The AFs were higher at low temperature and high humidity in different subgroups. When considering the levels of humidity, the AFs were significant at low temperature and high humidity for males, youth, those with a low level of education, and coastal area people. Conclusions: The combination of low temperature and high humidity had the greatest impact on the CVD death burden in Zhejiang Province. This evidence has important implications for developing CVD interventions. Environmental risk factors have emerged as a major public health concern, with a growing literature investigating the effects of weather variations on human health. Previous literature has found cardiovascular disease (CVD) is most sensitive to weather across various climates throughout the world . Fueled The Intergovernmental Panel on Climate Change (IPCC) has stated that an increase in extreme weather is the result of climatic change, and one of the greatest challenges we face today worldwide . NumerouCurrently, most studies rely on summaries based on relative risk (RR), odds ratio (OR), and rate ratio, resulting in limited information on excess burden due to volatile weather exposure. The attributable fraction (AF) and attributable number (AN) may solve these problems and could provide the accumulative effect from a specified time period and present the fraction of cases or deaths from a disease . Those iIn this study, we aimed to fill gaps in current knowledge by identifying the effect of relative humidity on the relationship between temperature and CVD mortality. We also identified vulnerable groups and provided more evidence for policymakers to develop public health interventions to reduce the risk effect of CVD mortality.2 and a population size of 55.9 million in 2016. There are four distinct seasons and overall pleasant climate. The annual mean temperature ranges from 15.0 to 18.0 °C, and the average annual rainfall is 980 to 2000 mm across cities. We collected daily mortality and meteorological data from 11 cities in Zhejiang Province, China. In total, there were seven coastal cities  and four inland cities . Zhejiang Province is located in the southern part of the Yangtze River Delta on the east coast of China with a total land area of 105,500 kmThe daily count of death data was acquired from the Zhejiang Provincial Center for Disease Control and Prevention during the period 2010 to 2013. The original data included variables on age, sex, education, date of mortality, and cause of death. CVD was based on primary death cause and was categorized by the International Classification of Diseases, Tenth Revision (ICD-10): I00-I99. We conducted stratified analyses by sex, age group (0–74 years and 75+ years), education levels , location of cities , and levels of humidity . http://cdc.nmic.cn/home.do). The observation station in each city included daily maximum, minimum, and mean degrees of temperature, relative humidity, wind speed, and atmospheric pressure. The data did not contain any missing values during the study period. Previous studies have documented that atmospheric pressure and wind speed are important risk factors for death. In particular, these two variables may have an influence on humidity [We collected meteorological data from China Meteorological Data Sharing Service System  natural cubic smooth function with 7 degrees of freedom (df) per year to control long-term and seasonal trends; (2) 3 df was used for relative humidity, atmospheric pressure, and wind speed, respectively; (3) days of the week and public holidays were analyzed as categorical variables. Specifically, we modeled the exposure-response curve with a quadratic B-spline with three internal knots placed at the 10th, 75th, and 90th percentiles and the lag-response curve with a natural cubic B-spline with three internal knots placed at equally spaced values in the log scale with maximum lag of 21 days ,20. The For the modifying effect of humidity, we calculated the cold and hot effects on CVD mortality in the stratified analyses by low and high humidity. The minimum mortality temperature (MMT) was used as a reference for calculating the relative risk by re-centering the models. The city-specific cumulative relative risk over lag periods was used to compute the daily attributable death (AD) corresponding to each day’s temperature. The ADs of different levels of humidity were calculated by aggregating the humidity level contributions from the days of the series, and their ratio to the corresponding total number of deaths yielded low or high humidity attributable fraction (AF) . Low andQ test and I2 statistic to evaluate the heterogeneity of 11 cities. To identify vulnerable subpopulations, we conducted subgroup analyses based on gender, age, education level, and location of cities. In the second stage analysis, we used multivariate meta-analytical model to pool the city-specific effect estimates. We reported both Cochran The sensitivity analyses were performed to check the robustness of the results. We changed the knots of temperature-mortality dimension, the maximum lag days for mean temperature from 14 to 24, and different degrees of freedom per year for time trends from 6 to 10. The df of weather variables such as relative humidity, atmospheric pressure, and wind speed, is from 4 to 6, respectively. All the model choices were performed by Q-AIC. p-values < 0.05 were considered statistically significant.All analyses were performed using R software  by using DLNM and MVMETA packages to fit the two-stage model. All statistical tests were two-tailed, and Q = 48.72, I2 = 17.9%, p = 0.162). The daily mean temperature ranged from −2.7 to 35.7 °C and relative humidity ranged from 17 to 100% in the 11 cities. The median temperature and relative humidity were 18.4 °C and 73%.p < 0.05), and mean temperature and relative humidity . However, we found negative correlations between daily CVD death and daily mean temperature . Additionally, the correlations between daily CVD deaths and atmospheric pressure, as well as daily CVD deaths and wind speed, were both significant in this study.We conducted sensitivity analyses on modeling choices. The effect estimates for total AFs and QAIC were similar when changing the location of knots for the exposure-lag-response relationship and the degrees of freedom for time and meteorological factors . The tesTo the best of our knowledge, this is the first study to examine whether humidity modifies the association between temperature and CVD mortality in Zhejiang Province, China. The main finding on the joint effects was that low temperature and high humidity could account for majority of CVD death burden, with an AF of 31.36%, and with a significant AF of 16.74% in the condition of low temperature and low humidity. Recently, Gasparrini et al. reported a similar study estimate of 11.3% for all-cause mortality was attributed to ambient temperatures in China, which is smaller than our estimates . A studyp < 0.05), and a negative correlation between daily CVD death and daily mean temperature . Similarly, previous studies also found a positive relationship between relative humidity and CVD death, and a positive relationship between temperature and CVD death [Our study showed the impact of temperature on CVD death was higher at high humidity. High humidity may lead to increased thrombotic risk , exacerbVD death ,24. HoweVD death ,25. In gEpidemiological studies have verified that susceptibility to extreme weather varies by gender and age ,27,28. OOur study found youths and the elderly had higher risk at low temperatures and high humidity, with an AF of 32.50% and 27.86%. The CVD death burden was significant and higher among youth when compared to the elderly. Perhaps elderly people are more likely to remain at home and are therefore not exposed to cold temperatures frequently. Moreover, age-appropriate primary care and community-based measures have been targeted for the elderly. In recent years, the proportion of younger men of the total number of employees in industry, construction, and agriculture has been relatively stable in Zhejiang Province, China. Younger people often work outside, resulting in elevated exposure to cold temperatures ,31,32. SPoverty is associated with a greater risk of cardiovascular disease, as well as lower levels of education, a major determinant of disease and death in low-income countries . Low eduOur study revealed that specific location was associated with cold-related and humid-related deaths. In coastal areas, high temperature and high humidity were associated with higher and more significant risks, with an AF of 27.25% for CVD death. However, we did not observe significant association between joint effect of temperature and humidity on CVD mortality for inland areas. A possible explanation is the air in coastal areas often contains more moisture than inland areas. Majority of residents lived in coastal areas, which resulted in a greater impact on CVD mortality compared with those in inland areas. The frequently adverse weather conditions may cause larger accumulative harmful health impacts to local residents.Although the mechanism on how humidity affects health remains unclear, it is biologically plausible that the effects of extreme temperature on the cardiovascular system may be involved in the changes in vascular tone, autonomic nervous system response, arrhythmia, and oxidative stress. Cold exposure may raise a number of thrombogenic factors, such as blood cell counts, plasma cholesterol, C-reactive protein, fibrinogen concentrations, and platelet reactivity. It could also increase the frequency of heart rate and ventricular ectopic beats, and may contribute to morbidity and mortality in sympathetic nervous system and the hemodynamic system when responding to cold stress . MeanwhiThe present study makes a number of contributions, as follows: To the best of our knowledge, this is the first study to provide comprehensive evidence that the joint effect of temperature and humidity is an important factor in CVD mortality in China. Specifically, majority of previous studies were based on relative risk and other diseases, and did not consider the integrated effects of temperature and humidity on CVD mortality ,43. FurtOur present study also has limitations. First, data were only from 11 cities in Zhejiang province. For this reason, it is important to be cautious when extending our findings to other areas in China because of the unique weather conditions and other city-specific parameters. Second, measurement errors with temperature and humidity are inevitable and the collected data from monitoring stations may not best reflect real exposure level, especially for those persons who died far from the station. Third, we have only considered the deaths where CVD was the underlying cause. To provide greater knowledge, we would need to separately investigate people with and without preexisting CVD. Fourth, the data on air pollution were unavailable, and unmeasured residual factors such as smoking, family history of CVD, air condition use, and activity patterns may potentially confound the relationship.The significantly influential study should play an important role in public health policy implications. First, our findings suggest identified susceptible subpopulations that should be specifically targeted. Second, our analysis found that humidity is a modifier in southern areas on human health that can be extended to other areas in further studies. Third, this study could encourage health care institutions and governmental agencies to establish a fair policy on climate change adaptation. Our study found that humidity might be an important factor to modify the relationship between temperature and mortality in Zhejiang, China. This was also observable for the joint effect between low temperature and high humidity, having the greatest influence on CVD death burden, in which the effect was significant and stable at different lag periods. At different levels of humidity, the AFs were highest at low temperature and high humidity in stratified analyses by gender, age group, education level, and location of cities. In addition, the effects were significant for males, youth, those with a low level of education, and individuals in coastal areas. These identified, susceptible subpopulations should be specifically protected. Evidence from our study is complementary to the literature and has important public health implications for planning intervention measures to reduce CVD mortality risk. Further research needs to be verified and extended to other areas.


Our aim was to study the association between country of birth and incidence of gout in different immigrant groups in Sweden. The study population included the whole population of Sweden. Gout was defined as having at least one registered diagnosis in the National Patient Register. The association between incidence of gout and country of birth was assessed by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (95% CI), using Swedish-born individuals as referents. All models were conducted in both men and women, and the full model was adjusted for age, place of residence in Sweden, educational level, marital status, neighbourhood socio-economic status and co-morbidities. The risk of gout varied by country of origin, with highest estimates, compared to Swedish born, in fully adjusted models among men from Iraq , and Russia , and also high among men from Austria, Poland, Africa and Asian countries outside the Middle East; and among women from Africa , Hungary , Iraq  and Austria , and also high among women from Poland. The risk of gout was lower among men from Greece, Spain, Nordic countries (except Finland) and Latin America and among women from Southern Europe, compared to their Swedish counterparts. The increased risk of gout among several immigrant groups is likely explained by a high cardio-metabolic risk factor pattern needing attention.The online version of this article (doi:10.1007/s10067-016-3525-1) contains supplementary material, which is available to authorized users. Gout is the most common inflammatory arthritis where monosodium urate crystals are deposited in joints and soft tissues. Individuals with gout experience acute attacks of excruciating pain; and, if left untreated, gout may lead to debilitating complications such as chronic joint damage and renal insufficiency . All theIn addition, gout is also associated with different metabolic conditions, such as insulin resistance , the metAs a metabolic disorder, gout is associated with several established risk factors according to epidemiological studies : geneticRecent review of epidemiological evidence has indicated that gout has risen worldwide over the last few decades , tailingIn Sweden, almost one fifth of the population is foreign born, and immigration to Sweden increases with each year . DescribThe dataset used in this study was retrieved from governmental national registers such as the Total Population Register (TPR) and the National Patient Register (NPR) that contain longitudinal information on the entire population of Sweden for a period of 40 years. The TPR contains comprehensive nationwide individual-level data as well as data on neighbourhood socio-economic status (SES). The Swedish nationwide population and health care registers have exceptionally high completeness and validity . IndividThis study included the whole Swedish population. Country of birth was registered, and we included 10 regions  and 27 countries  for gout (M10) in the National Patient Register. Patients with gout diagnosed before 1998, i.e. during the years 1987–1997 (according to ICD-9 1987–1996 and ICD-10 1997) were excluded.We also identified co-morbidities according to ICD-10 for the following diagnoses: hypertension I10–I19, coronary heart disease (CHD) I20–I25, heart failure I50, stroke I60–I69, diabetes E10–E14, obesity E65–E68, alcoholism and related disorders F10 and K70 and chronic obstructive pulmonary disease (COPD) J40–J47.Gout ICD-10 code M10.Sex: men and women.Age was used as a continuous variable in the analysis.Educational attainment was categorized as ≤9 years , 10–12 years  and >12 years (attendance at college and/or university).Geographic region of residence was included in order to adjust for possible regional differences in hospital admissions and was categorized as (1) large cities, (2) southern Sweden and (3) northern Sweden. Large cities were defined as municipalities with a population of >200,000 and comprised the three largest cities in Sweden: Stockholm, Gothenburg and Malmö.The neighbourhoods were derived from small-area market statistics (SAMS), which were originally created for commercial purposes and pertain to small geographic areas with boundaries defined by homogenous types of buildings. The average population in each SAMS neighbourhood is approximately 2000 people for Stockholm and 1000 people for the rest of Sweden. A summary index was calculated to characterize neighbourhood-level deprivation. The neighbourhood index was based on information about female and male residents aged 20 to 64 years, because this age group represents those who are among the most socio-economically active in the population . The index was based on the following four variables: low educational status ; income from all sources, including interest and dividends, that is <50% of the median individual income; unemployment ; and receipt of social welfare. The index was categorized into three groups: more than one standard deviation (SD) below the mean (high SES or low deprivation level), more than one SD above the mean (low SES or high deprivation level) and within one SD of the mean (middle SES or deprivation level) , with neBaseline subject characteristics were presented for population samples when estimating incidence rates of gout among first-generation immigrants and among second-generation immigrants.Cox regression was used for estimating the risk for gout in different immigrant groups compared to Swedish born as referents. Time was from January 1, 1998, or immigration date until hospitalization/outpatient treatment of gout at diagnosis, death, emigration or the end of the study period on December 31, 2012.All analyses were stratified by sex. Four models were used: model 1 was adjusted for age and region of residence in Sweden; model 2 was adjusted for age, region of residence in Sweden, educational level and marital status; model 3 was as model 2 with the addition of neighbourhood SES; and model 4 was as model 3 with the addition of co-morbidities. As a sensitive analysis, we also analysed hazard ratios (HRs) for first-generation immigrants with exclusion of immigrants who moved to Sweden within 5 years of follow-up with full adjustment according to model 4.The study was approved by the local ethical vetting board at the Karolinska Institutet .Table Table Table Tables We explored the risk of being diagnosed with gout in first- and second-generation immigrant men and women than their Swedish-born counterparts, with a total prevalence of 0.5%. The most prominent differences in rates of gout were observed between first-generation immigrants and in Swedish-born people. Risk of being diagnosed with gout was higher not only among first-generation immigrants from several European countries but also among immigrants from Africa and some Asian countries, while the risk of being diagnosed with gout was lower among first-generation immigrants in some Southern European countries and among second-generation immigrant men from Greece. The differences in gout rates between the second-generation immigrant men and their Swedish-born counterparts were less apparent, while almost no difference was noted among women. The latter, however, may have been due to a low number of events.When looking at the risk of gout among immigrants from European countries and the estimated prevalence in these countries, some interesting differences could be noted. Prevalence of gout is reported to be highest in Greece, with slightly lower figures from the UK, the Netherlands and Spain, while the lowest prevalence is reported from Portugal and the Czech Republic, with also low figures from France and Italy . We founWe have no certain explanation for the disagreement between our study and earlier prevalence figures, e.g. the high gout prevalence in Greece and the low gout risk among Greek immigrants we found. However, emigrants from a specific country or region may differ from those staying in their country of origin, i.e. migrants often tend to be healthier , even if many immigrants retain many of their dietary habits. The low estimates in some groups could possibly be related to the healthy migrant effect, e.g. men from Denmark and Norway and women from Northern America. For second-generation immigrants, an adaptation to the mainstream dietary culture could be expected, which could explain the regression towards the reference population, i.e. individuals with indigenous parents. Besides, comparing prevalence figures between studies of diagnosed gout in published papers is difficult, as there is a large variation in the prevalence of gout depending on different factors, including the used definition of gout, the sampling methods, the studied age groups and the sex distribution, with a higher prevalence in men , 21. ForRegarding the situation among different immigrant groups, the higher gout prevalence in different ethnic groups, including Filipinos and African Americans, has been attributed to the high gout prevalence in North America . The higWhen trying to understand the risk pattern of gout among the immigrant groups found in our study, the pattern of risk factors for gout is of importance. Gout is strongly related to lifestyle and dietary habits , includiThe increased prevalence of gout and hyperuricemia in both Western and third-world societies has been linked not only to urbanization, western lifestyle and immigration to western countries  but alsoWhen looking at the specific immigrant groups and the risk of gout, among Turkish born women an increased risk of abdominal obesity and the metabolic syndrome  and alsop level < 0.05. Thus, the results should be interpreted with caution owing to the multiple testing. The statistical power to detect significant results also differed between the immigrant groups owing to varying sample size, and the power was lower among women, especially second-generation women. We used hospital diagnoses to identify individuals with gout, and it is possible that other groups would have been identified if we had access to diagnoses in other care forms, especially primary care. As diagnoses were taken from the National Patient Register, they are clinically based and we cannot check for the criteria for gout diagnosis being used. Furthermore, we had no access to prescription of allopurinol, but when this was actual, the diagnosis was probably set. We adjusted for co-morbidities which can be discussed as the association between gout and co-morbidities may go in both directions, i.e. may be a risk factor for gout or a consequence of gout. However, results when adjusted for co-morbidities were similar in most cases. Despite the limitations, this is one of rare studies in Europe providing insight in differences in gout among different immigrant groups. A strength of the study is that we used neighbourhood SES that is a proxy for lifestyle factors [There are some limitations in this study. As we divided into many different immigrant groups, there is a risk of mass significance when using the  factors , and it  factors , 45.In conclusion, the results of this study indicate significant differences in risks of gout between immigrants and Swedish-born groups, which are more prominent between first-generation immigrant men and women and their Swedish counterparts. As gout is a risk factor for cardio-vascular diseases, including an increased mortality risk , identifESM 1(DOCX 19.3 kb)ESM 2(DOCX 13.8 kb)ESM 3(DOCX 13.3 kb)


Escherichia coli is associated with the emergence of bacterial resistance, and not all countries have strict policies against the indiscriminate use of drugs in order to prevent resistance. This cross-sectional and retrospective study (2010–2015) aimed to evaluate the sensitivity and resistance of patient-derived E. coli to different drugs broadly used to treat urinary infections in Brazil: ampicillin + sulbactam, cephalothin, ciprofloxacin, norfloxacin, and nitrofurantoin. We obtained 1654 E. coli samples from ambulatory patients with disease symptoms of the urinary tract from a Brazilian public hospital. While all antibiotics were effective in killing E. coli to a large degree, nitrofurantoin was the most effective, with fewer samples exhibiting antibiotic resistance. We assessed the costs of generic and brand name versions of each antibiotic. Nitrofurantoin, the most effective antibiotic, was the cheapest, followed by the fluoroquinolones (ciprofloxacin and norfloxacin), ampicillin + sulbactam and, lastly, cephalothin. Finally, assessment of antibiotic resistance to fluoroquinolones over the study period and extrapolation of the data led to the conclusion that these antibiotics could no longer be effective against E. coli-based urinary infections in approximately 20 years if their indiscriminate use in empirical treatment continues.Empirical and prolonged antimicrobial treatment of urinary tract infections caused by  Escherichia coli, which is normally associated with acute cases [E. coli causes both intestinal and extra-intestinal infections. Antimicrobial treatment of infections caused by E. coli must be appropriately targeted; for this purpose, the medical community uses a wide variety of drugs both alone or in combination. Among the most widely used drugs or combinations in Brazil are ampicillin with sulbactam, cephalothin, ciprofloxacin, norfloxacin, and nitrofurantoin.Bacterial urinary infections are common in clinical practice, where approximately 80/1000 consultations lead to this diagnosis [te cases . E. coliMycobacterium tuberculosis [Klebsiella pneumoniae and E. coli strains producing extended-spectrum beta-lactamase (ESBL), which hydrolyses the beta-lactam ring of penicillin, cephalosporins, and other related antibiotics, contributing to treatment failure [While antibiotics are considered the most effective method of treatment for bacterial infections, their empirical, indiscriminate, prolonged, or incorrect usage contributes significantly to the emergence of new infections by leading to the selection of resistant strains ,4. For irculosis . In addi failure ,7. Drug- failure , drugs oE. coli. One such concern is the ability of bacteria to form micro-colonies (biofilms) on the mucosal lining of the bladder to resist the host’s immune response and conventional antibiotic treatment [The prevalence of antibiotic resistance stems primarily from the promiscuous nature of bacteria, as susceptible bacteria may acquire resistance genes from plasmids and other horizontally transferred genetic material, resulting in evolution by leaps ,10. In areatment . Two facreatment  and the reatment ,13,14. SE. coli that were obtained from outpatients of a public hospital in the Brazilian Health System. In addition, we also surveyed and compared the real costs to the community of the primary antibiotics used to treat these infections.Our study used a cross-sectional, retrospective study to determine the antibiotic susceptibility profiles of 1654 samples positive for This retrospective, cross-sectional study was conducted in a public hospital at the Federal University of Triângulo Mineiro belonging to the Brazilian Health System in Minas Gerais/Brazil. This hospital attends to approximately 1.17 million inhabitants belonging to more than 27 cities in the macroregion south of the Triângulo Mineiro. Data were collected from January 2010 to December 2015 from the clinical pathology services database of the hospital, including reports of technical procedures conducted and urine cultures performed in the laboratory. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Federal University of Triângulo Mineiro (protocol number: 914797).5 colony-forming units (CFU)/mL, and we excluded urine cultures that were not positive for Escherichia coli after identification.Adherence to trial criteria was assessed in a systematic fashion, as represented in Urine was sampled in a sterile container, and 0.001 mL was plated on cystine lactose electrolyte deficient (CLED) agar with a calibrated platinum loop. The culture was incubated for 18–24 h at 35 °C, and bacterial colonies were then counted, with results expressed in CFU/mL. Species identification was performed using standard biochemical tests. Antimicrobial susceptibility testing was conducted on Mueller Hinton agar  using a standard disc diffusion method with discs of standard potency as per the Clinical and Laboratory Standards Institute’s guidelines . The antJournal of the Brazilian Association of Pharmaceutical Commerce.To determine the costs of the investigated antibiotics for statistical comparison, we used standard prices from the t-test. Normality (Kolmogorov-Smirnov) and homogeneity of variance (Bartlett’s) tests were applied to all variables. When under normal distribution and homogeneous variance, parametric tests (ANOVA with post-hoc Tukey’s multiple comparison) were applied, and the results are expressed as the mean ± SEM. Otherwise, we used non-parametric tests , and the results are expressed as median, maximum, and minimum values. Differences were considered significant when p ≤ 0.05 [Statistical analysis was performed using the GraphPad Prism program . To analyze paired elements, we used the paired p ≤ 0.05 .E. coli was high (~79%) compared to the frequency of samples positive for other microorganisms. This frequency was also higher in female patients (83%) than in male patients (17%). Over the course of the six years of study, we obtained 1654 E. coli-positive urine samples, with an average of 275.70 ± 30.16 samples/year and a coefficient of variation of 26.80%  (For each ibiotics . Althoug < 0.05) .E. coli, we evaluated whether there were significant differences in the distribution in the ratio of the relative frequencies of susceptibility and resistance over the years to each antibiotic. In general, ratios higher than 1 (>1) in the relative frequencies demonstrate positive indices for antimicrobial susceptibility (p < 0.05). On the other hand, the antibiotics of the classes of fluoquinolones and cephalothin have ratios of the relative frequencies lower than 1, indicating less satisfactory indices for antimicrobial susceptibility .In addition to assessing the susceptibility of samples to different antibiotics, we also investigated temporal variation in antibiotic resistance . The perWe extrapolated this correlation into an estimation of future resistance to fluoroquinolones . Based oE. coli. Most of these drugs are available from community clinicians, with the exception of cephalothin, which is restricted to hospital use. Values take into account whether the medicine is generic or brand-name. The only exception was Sulbamox BD® , which was compared to another generic drug of the same class (β-lactamase inhibitor) because it is generally prescribed. The data revealed high variation in cost  based on antibiotic, brand, and tax rate of the state . Costs ranged from R$6.17 ± 0.11 to R$230.80 ± 4.17 for drugs used in the community and up to R$244 ± 4.41 for drugs used only in the hospital . Surprisingly, while nitrofurantoin was demonstrated to be the most effective by our susceptibility testing, it exhibited the lowest average cost (R$7.83 ± 1.66) among all evaluated antibiotics (p < 0.05).We calculated the average commercial value of brand-name and generic drugs for each antibiotic used for treatment of genitourinary tract infections caused by E. coli , revealiE. coli causing urinary tract infections. We also performed a comparison of the actual costs of the generic and brand-name antibiotics used for the treatment of urinary infections.In this study, we evaluated the efficacy of antibiotics against strains of E. coli, particularly in female patients. This is corroborated by data on E. coli infections worldwide [E. coli infection may be even more prevalent considering the large number of cases of urinary infection where the causative agent is never identified and/or the infection is treated empirically [E. coli-positive samples identified in our study was considerable , E. coli infection is likely to be even more prevalent, as these numbers do not include outpatients, in whom urinary tract infections may be common.After assessing the bacterial strains associated with urinary tract infection in ambulatory patients over six years, we noted a high frequency of infections caused by orldwide ,18. We birically . MoreoveSeveral studies have evaluated the microbicidal activity of the antibiotics used for urinary tract infections, as well as the mechanisms involved in drug resistance ,18,20,21E. coli isolated from the urine samples and presented the lowest resistance rate. Nitrofurantoin was followed by ampicillin + sulbactam, the fluoroquinolones and, lastly, cephalothin, in terms of efficacy. In assessing antibiotic efficacy over the period of the six years of the study, we observed a significant increase in resistance to fluoroquinolones (ciprofloxacin and norfloxacin) over time, which may be due to empirical treatment of urinary infections. This effect was also reported in Uruguay, a country with extensive use of fluoroquinolones as a form of empirical treatment for urinary infections [E. coli-based urinary infections in approximately 20 years if appropriate measures are not taken against the generalized misuse of antibiotics in empirical treatments.Thus, we evaluated the susceptibility and resistance profiles separately for each antibiotic. Nitrofurantoin was the most effective treatment against fections , as wellfections . The confections ,28. Evidfections . Our datOne of the major reasons for such increases in resistance is the misapplication of antibiotics due to economic and social issues in some countries ,13,14. WE. coli-based urinary infections. Clinicians must be careful regarding their choice of antibiotics considering costs and the occurrence of microbial resistance. Taken together these strategies may contribute to a more effective control of infections, thus reducing loss of life. Finally, new strategies aiming the treatment and control of bacterial infections are still needed. These approaches may include the discovery of new medicines, vaccines, the control of hospital infections, and the rational use of existing antibiotics.Indeed, in addition to the misapplication of antibiotics due to economic and social issues, the elevated number of mutations in bacteria is a natural and inseparable factor for the occurrence of resistance. Hence, it is crucial to discuss the best approaches to choose which antibiotic will be used in the future, especially because there is an inverse relationship between the necessity of new antibiotics and the amount of newly discovered drugs of this class. The results presented here are of major concern and a matter of debate for everyone involved in healthcare, especially considering the use of fluoroquinolones for the treatment of E. coli samples in order to obtain the best strategy for empirical treatment of urinary infections. We recommend that clinicians take into account not only the effectiveness of specific antibiotics but also the actual costs to the patient when determining the best course of treatment.In summary, our data reveal the importance of evaluating the antibiotic susceptibility profile of patient


Child welfare organizations are increasingly concerned with challenges emerging from the assessment of social workers' dissatisfaction. This type of service represents the work area where social workers are at greater risk of burnout. Although several studies account for high social workers' burnout scores, they do not systematically dwell upon its sources and roots. In addition, scholars point out that a considerable number of work related issues may be perceived both as a source of dissatisfaction and satisfaction. We assume that there is a need to deepen the understanding of how dissatisfaction's sources may exert an impact on both personal job satisfaction and professional self-efficacy, which are positively associated with well-being at work. The present mixed-method research has two aims: (1) the extensive exploration, applying qualitative methodology, of the perceived sources of dissatisfaction; (2) the attempt to identify the extent to which those sources predict job satisfaction and professional self-efficacy. It is our purpose to further explore which differences emerge by age. The research involved child welfare workers, that is, SWs employed in public child welfare agencies in the North East of Italy. Results show the predominant role of interpersonal trust and mutual respect, as main predictors of both professional self-efficacy and job satisfaction. Practical implications of findings are discussed. According to the OECD's (Organization for Economic Cooperation and Development) definition , the publden era  of the wDrastic cut in resources compromises sometimes the necessary generational turnover in the public administration and services. In addition, studies in child welfare account for the ageing of the SWs' population in Europe, and Associations of SWs worry about the insufficient following of subsequent generations of workers –6.Social work requires high social competencies and communication skills. This is even more important in child welfare. Since the late 1980s, the ambiguity of the SWs' professional and public role  has repr social recognition and the sense of “not being good enough” [The lack of enough”  make the enough” , 11. Def enough”  and shamPrevious studies  underlinRapidly changing work conditions accelerated the introduction of changes to the service delivery system, and the social pressure experienced by SWs in different domains leads us to underline the need to redirect the scientific attention on how workers perceive and organize each and every potential source of both dissatisfaction and satisfaction. According to scholars , the disCompassionate actions may be associated with feeling of comfort and relief and not necessarily to stress and emotional exhaustion. The urge to be compassionate and to meet users' need as to act respecting users' self-determination rights often develops in what scientists identify as compassion satisfaction that is in the positive and rewarding feeling about the personal ability to help and support others [t others . Compasst others . Howevert others  underlint others –23, and Relationships with users may be often fulfilling and rewarding, supporting workers' high intrinsic job satisfaction [sfaction , 25, andsfaction . These rsfaction . Despitesfaction  considerSupervisors and staff's support may be of great service to enhance SWs' awareness and coping strategies, but different supervisee may perceive the same supervisor [pervisor , 29 in qThe presence of coworkers and the relationship with them may be satisfying and supporting [pporting . Trust ipporting . Mutual pporting  and inflpporting . Supportpporting  and can pporting . Previoupporting  define spporting , 34. work type focused on child protection and their families, lack of resources, uncooperative social environment, and tenuous informal network enhance the worker's strain but can also be perceived as positive challenges, which enable workers to feel satisfied in applying their own skills, experience, and abilities [Last but not least,bilities , 35 to fbilities , 36 undebilities . Not achbilities . The absThe above-mentioned, rapidly changing work-contexts in social services and the ambivalence in SWs' perception lead us to accept Zyphur's suggestion . The autSelf-efficacy  is a critical element for successful coping with stressful conditions  , and SWsJob satisfaction is an emotional reaction to work and it is a function of the perceived relationship between what a SW seeks to gain from his/her job and what the SW perceives his/her job to be offering , 43. SWsIn order to investigate the perceived sources of dissatisfaction in child welfare and to clarify their relation to professional self-efficacy and job satisfaction, we applied a mixed-method research design. We conducted two studies. Study 1 explored what SWs perceive as dissatisfying and uncomfortable at work . Study 2 verified if and to which extent those sources predict professional self-efficacy and job satisfaction.An additional purpose is to deepen how age influences SWs' self-efficacy and job satisfaction. In fact, previous literature shows that child welfare SWs' age and length of service correlate positively with lower levels of burnout . In addiThe data for these two studies were collected from two online questionnaires. Ethical approval was obtained from the Ethics Committee at the researchers' institution. Questionnaires included a section that explained the nature and purpose of these studies and a consent form. Informed consent was obtained from each participant, who voluntarily participated in the studies. Participants were informed about their right to withdraw or refuse to give information at any time without incurring any penalties. We protected the privacy and anonymity of answers of individuals involved in our research. The research involved child welfare workers, that is, SWs employed in public child welfare agencies in the North East of Italy.Subjects and Data Collection. SWs reported narratives about sources of dissatisfaction at work. The qualitative analysis was carried out with NVivo 11. The latter allowed us to identify different risk factor categories and to determine relationships and hierarchies among them. This study was carried out between January and February 2017. This study was presented as research on child welfare workers' sources of dissatisfaction at work. We contacted by e-mail 120 SWs employed in public child welfare agencies in the North East of Italy. Their e-mail addresses were collected during a training course held by one of the authors. A total of 73 questionnaires were completed, with response rate of 60.83%. The gender distribution was 3 males (4.1%) and 70 females (95.9%). Most respondents were aged between 20 and 39 years (54.8%), 19.2% were aged between 40 and 49 years, and 26.0% were older than 50 years. About half of the sample (50.7%) had up to 10 years of service, 31.5% had between 11 and 20 years of service, and 17.8% had more than 20 years of service.Measurement and Data Analysis. The questionnaire included the following:Three open-ended questions about sources of dissatisfaction at work (“What is your first/second/third source of dissatisfaction at work?”)Some questions on demographic and occupational characteristics Qualitative analysis was performed with NVivo 11. We analyzed our data according to grounded theory –75 as a We identified four factors of dissatisfaction (parent nodes): lack of trust and mutual respect (49.62%), work-overload (34.21%), employment contractual concerns (8.27%), and difficult cases (7.90%).As shown in p < .040) and in lack of social recognition (p < .005); these are the major risk factors in the sample of younger SWs. By contrast, senior SWs assigned more importance than younger SWs to lack of trust (p < .010), lack of support, training and supervision (p < .015), insufficient resources and schedule problems (p < .050), and difficult cases (p < .015).We performed Mann–Whitney tests using SPSS 21.0 in order to explore possible differences regarding the category saturation between senior and younger subgroups see . We diviSubjects and Data Collection. Study 2 investigated the relationship between the two most important identified psychosocial risk factors at work, professional self-efficacy and job satisfaction within a larger sample of child welfare workers. Participants, employed in public child welfare agencies in the North East of Italy, completed a questionnaire including measures of work-overload, trust and mutual respect, self-efficacy, and job satisfaction. This study was carried out on April 2017. This study was presented as research on child welfare workers' well-being at work. We contacted by e-mail 400 SWs employed in child welfare agencies, selected on the basis of voluntary participation.The sample of study 2 is partly (21.95%) overlapping with the sample of Study 1. Both samples belong to the same geographical area and type of service.A total of 246 questionnaires were completed, with response rate of 61.50%. The gender distribution was 18 males (7.32%) and 224 females (91.06%); 4 participants have not indicated the gender (1.62%). The mean age was 38.77 years , and the mean length of service was 12.51 years .Measurement and Data Analysis. The questionnaire included work-overload, trust and mutual respect, self-efficacy, and job satisfaction. Responses were given on a 7-point Likert scale, ranging from 1 (completely disagree) to 7 (completely agree).Work-Overload. It was evaluated using a four-item measure [ measure  , two-items to measure trust and mutual respect in the relationships with different professionals employed in health, educational, and foster services , and two-items to measure trust and mutual respect in the relationship with the leadership . Cronbach alpha was .86.SESSW. The Self-Efficacy Scale for Social Workers [ Workers  consistsJob Satisfaction. In this study, job satisfaction was measured with one item (“I am satisfied with my job”).t-tests were applied. We divided participants into two groups on the basis of their age, using the quartile split method. We split the sample into two groups relating to the average of age (from 23 to 30 years and from 48 to 60 years). Finally, multiple linear regression analyses were conducted: emotional regulation, procedural self-efficacy, support request, and job satisfaction were dependent variables. We included in the regression models work-overload, trust and mutual respect, and age as predictors.Quantitative analysis was performed with SPSS statistical software package; Version 21.0. PRELIS (LISREL 8.7) was used for the imputation of missing data with the expectation-maximization (EM) algorithm, because it provides more accurate estimates of population parameters than list-wise deletion or mean substitution . Only 1.The means, standard deviations, and correlations of study variables are presented in F = 61.09, p < .001, R2 = .43, shows that trust and mutual respect (p < .005) facilitate and support satisfaction at work.The regression analysis with job satisfaction as dependent variable , F = 21.27, p < .001, R2 = .21, 21% of the variance in the score were predicted by trust and mutual respect (p < .005) and by age (p < .005). The regression analysis, with the procedural self-efficacy  = 19.82, p < .001, R2 = .20, shows that trust and mutual respect on the part of other professionals facilitate this type of self-efficacy (p < .005).For the emotional regulation self-efficacy , F = 40.80, p < .001, R2 = .34, shows that trust and mutual respect (p < .005) and work-overload (p < .020) facilitate and support this type of self-efficacy.Finally, the regression analysis with self-efficacy in requesting support as dependent variable , F and from 48 to 60 (N = 63). One difference emerged: younger subjects  perceived lower self-efficacy in emotion regulation than senior SWs .We divided SWs into two groups on the basis of their age, using the quartile split method. We split the sample into two groups: from 23 to 30 years  allowed us to intercept four main categories as sources of dissatisfaction and unease: lack of trust and mutual respect; work-overload; employment contractual concerns; and difficult cases. Relational issues mainly determine SWs' dissatisfaction: lack of trust and mutual respect are the core element and represent the root of dissatisfaction. We could account for differences in subgroups according to their age. Younger SWs' unease is mostly represented by professional isolation and lack of support that is by concerns related to the relational dimension, whereas senior SWs are more concerned with lack of resources, lack of trust, and lack of supporting supervision. In addition, they perceive as consistent source of strain the frequent occasions where they have to struggle with complicated cases. Literature underlines the fact that the resolution of complicated cases in child welfare requires the contribution of professionals working in different services: social, health, and foster services. In fact, SWs have to guide complex decision making processes, which may trigger interprofessional trust issues. While younger workers feel more isolated, senior ones seem to have developed communication skills over time, which enable them to cooperate effectively at the interservice level. Although the latter seem to have overcome the sense of isolation, senior SWs experience trust issues, which arise mainly when individuals are aware of both the need for cooperation and open communication and the associated risks.Study 2 allowed us to recognize the importance of relational issues within the workplace defined by its different contexts and actors within: the SW-user relationship, the coworkers' cooperation, supervision, and intra- and interprofessional relationships. The relational dimension, defined by subject's rates on trust and mutual respect, exerts the major effects on job satisfaction. Professional self-efficacy is predicted by the quality of the relationships at work and age. If we consider separately the three different dimensions of the Self-Efficacy Scale for Social Workers, we find that the relational dimension affects them all. Moreover, self-efficacy in emotion regulation is also affected by age, whereas self-efficacy in seeking support is also due to work-overload. Interestingly and in line with literature, we can underline that seniors feel more effective than younger SWs in emotion regulation and in general work self-efficacy.Scholars suggest that this may be due to the fact that seniors are more likely to be committed to their work because of a lack of alternatives, which in turn are available for younger workers and would explain the latter's proclivity to quit. In addition, scholars suggest that senior workers may have developed problem-focused coping skills which are much more effective than emotion-focused coping strategies in ensuring workers' well-being , 81. Pro the relational dimension  in predicting job satisfaction and self-efficacy. Our findings are in line with previous studies on the role of supervision in social work [Moreover, we highlight the significant role of social support and all concerns related to the development and management of relational/interpersonal issues above all among younger workers. The original contribution of this study is represented by the important role SWs attribute toial work . Superviial work , 83, 84.Future research could explore the relationship between attachment style and perceived stress in different work related relational domains such as relationship with user, with coworker, with supervisor, and with different professionals who are committed to cooperate in child protection, employed in health, educational, and foster services. In fact, attachment style is recognized to be the variable of individual difference, which determines the way individuals engage in, develop, and manage their interpersonal interactions. In addition, it shapes self-perception and the evaluation of others with specific reference to the value and relevance one accords to relationships in domestic, peer, and work relationships. Finally, different attachment styles are associated with congruent caregiving styles, shaping thereby up-down relationships, the way individuals take care of others, and the extent to which they feel engaged with needy others.Moreover, it is reasonable to assume that SWs who are provided with sociopsychological training should not experience a great deal of problems in the relational interpersonal domain at work. Furthermore, there is a considerable difference among European countries and worldwide, in terms of training opportunities to acquire relational skills for SWs: in European Northern countries attachment style can be assessed by SWs who are skilled to use this framework in order to assess children's attachment style and parental skills and to provide effective foster placement . In the According to literature , there iWe can enumerate some limitation of the present study. Firstly, no causal relationships can be drawn from the findings of our study because of its cross-sectional nature. In addition, our sample consists of a majority of female SWs accounting thereby for the still persisting stereotype that attributes to women the orientation to prefer helping professions, having low need for power, being sensitive to others, and having high needs for affiliation . Finally


To provide an empirical examination of patient–provider relationships (PPR) and its association with organizational and individual factors.A national cross-sectional survey was conducted by stratified cluster sampling in 77 hospitals across seven provinces in China between July 2014 and April 2015, involving 3621 doctors, 5561 nurses, and 8022 patients with response rates of 62.93%, 61.16%, and 33.08%, respectively. Self-perceived PPR was the outcome variable. Organizational factors included hospital type ; hospital level ; area of specialization ; ratio of doctors (nurses) to ward beds; doctors/nurses’ concerns about performance assessment; and patients’ perceptions of healthcare cost. Individual factors included consultation, listening to patients and socio-demographic factors.54.6% of doctors, 36.6% of nurses, and 10.2% of patients perceived PPR as poor. Organizational factors independently associated with providers’ perception of poor PPR included hospital type (WM vs TCM: OR = 1.25 [95% CI: 1.06–1.47]) and concerns about performance assessment (high vs low levels: OR = 1.40 [95% CI: 1.14–1.72]) for doctors, and concerns about performance assessment (average vs low levels: OR = 0.79 [95% CI: 0.67–0.93]) for nurses. Those associated with patients’ perception of poor PPR included hospital type (WM vs TCM: OR = 0.63 [95% CI: 0.53–0.74]) and hospital level (tertiary vs secondary: OR = 0.65 [95% CI: 0.51–0.82]). Doctors and nurses reporting listening to patients “frequently” had better perceptions of PPR , as did their patients .Although our findings require validation in different organizational settings given the likely variability of these associations across systems, our results suggest that implementing moderate levels promoting the level of medical treatment, and broadening doctors/nurses training regarding listening to patients, may benefit to enhance PPR. Over the past few decades, progress in medical science and technology has made treatments more effective. Despite this, patient–provider relationships (PPR) have increasingly deteriorated around the world –5. In ChExisting research suggests the decline of PPR in China may have three possible causes. The first is the emergence of the Internet with its myriad health-related websites, giving patients wide-ranging access to sources of medical information, and changing their attitudes towards health, healthcare and healthcare providers . In ChinTo more fully understand PPR perceived by doctors, nurses, and patients in China as well as its association with organizational and individual factors, we conducted a national survey in 77 general hospitals. The aim of the study is to provide evidence and recommendations to improve PPR combined the organizational and individual perspectives. Additionally, in this period of social transition from planned to market economy, healthcare in China, including the deterioration of PPR, is both complex and important. China’s experience may provide an important reference for both developing and developed countries.The study was a stratified cluster sampling survey across the whole of mainland China. Provinces were selected from each geographical area, with two from each of East and West China , and one each from South, Central and North China , which have a population of 427.15 million, accounted for 31.88% of the total population of China . With reIn each province, it selected one provincial hospital of Western medicine (WM) and one of Traditional Chinese Medicine (TCM), from the one or two in each area. In each provincial capital city, it selected two or three municipal people’s hospitals  from the three or four available, and one municipal TCM hospital, usually the only one. convenience sampling in each province was used to select two prefecture-level cities from the six to eight in the area. In each one, it selected two WM city hospitals out of around two or three and one TCM city hospital, usually the only one. The total number of eligible hospitals was 85, of which eight refused to participate, leaving a total of 77 hospitals (90.59%). In each hospital, convenience sampling was used to select four surgical departments and four internal medicine departments (excluding obstetrics and pediatrics). A total of 528 departments were selected .All full-time doctors , nurses  and inpatients  in the 528 departments from July 2014 to April 2015 were eligible and invited to participate. Trained survey interviewers sent copies of the questionnaire in an envelope to each department, with an explanation of the purpose and method of the survey, including that participation was voluntary and their contribution would be anonymous. The survey was a self-administered paper survey, and family members were allowed to help patients fill in questionnaires. After one or two days, the interviewer returned to the department to collect completed questionnaires.The crude response rate of doctors, nurses and patients was 74.40%, 73.32% and 50.99%. Questionnaires were given a manual check for handwriting using three trained survey interviewers, and a computer check for logical errors. The total rejected by these two tests were 634 from doctors (11.02%), 1,085 from nurses (11.93%) and 4,128 from patients (17.02%). We also excluded any participants missing the dependent variable . This left a total of 3,621 doctors (62.93%), 5,561 nurses (61.16%) and 8,022 patients (33.08%) .Participants provided oral informed consent for interviews. The institutional review board at the Tongji Medical College, Huazhong University of Science and Technology  approved the study protocol [No. IORG0003571].The survey included questions evaluating health services and health-related behaviors of doctors, nurses and inpatients. To ensure it was appropriate for our participants, we developed the questionnaire following 13 focus groups with 69 healthcare staff  and 73 inpatients and family members to gather information on their understanding of health services and health-related behaviors. Drawing on previous studies –32, we aIn the current study, we focused on PPR and influencing factors. PPR is an important but poorly defined topic, and research in the area has been somewhat fragmented ,33. AccoOur main independent variables included six organizational and two individual factors. The organizational-level variables were: hospital type (WM or TCM); hospital level (secondary or tertiary); area of specialization ; the ratio of doctors(nurses) to ward beds. The Ministry of Health of China specifies that the ratio should not be less than 0.3 for doctors and 0.6 for nurses . We diviThe individual-level variables were: consultation levels, consulting with patients assessed for doctors or nurses by the question: “How often do you consult with your patient about their medical treatment?” and patients being consulted for patients by the question: “How often did your doctor / nurse consult you about your medical treatment?”. In each case, there were three response categories: infrequently, sometimes, and frequently; listening to patients was assessed for doctors or nurses by the question: “How often do you listen attentively to your patients?”, with three response categories: infrequently, about the same as others, frequently; and for patients feeling they can ask question by: “How difficult is it to ask your doctor / nurse something when you need?”, with three response categories: difficult, fair, and easy.The socio-demographic variables were: gender, with the response options of female and male; age, with the response options of under 44 years old, 45–59 years old, and 60 years and over; education status, with categories of undergraduate and below, Masters and PhD for doctors; junior college and lower, undergraduate, Masters and above for nurses; and junior high school and lower, senior high school, undergraduate and above for patients; marital status, with options of married and single/divorced/widowed/other; and self-reported economic status, with options of poor, fair or good.The effects of the market-oriented reform of medical services and the use of the Internet are indirectly reflected in some organizational and individual factors. In particular, the main pressure in performance assessment for doctors is the assessment of income generation , and docWe used binary logistic regression to calculate odds ratios (ORs) to examine the association between PPR and the independent variables. OR>1 indicates increased likelihood and OR<1 indicates decreased likelihood of perceiving poor PPR. ORs were adjusted for socio-demographic factors such as gender, age, education status, marital status, and self-reported economic status (see supplementary data). Fair and good PPR were combined to form dichotomous dependent variables. Two-sided tests were used for all the analyses, and P-values of 0.05 or less were considered statistically significant. All analyses were performed using SPSS, version 12.0 .To the best of our knowledge, this study provides the first national evidence in China about PPR that assesses the views of doctors, nurses and patients. Our findings that doctors have the lowest perceptions of PPR, empirically verifying its severity in China –8. Of thThe effects of hospital type on doctors’ perception of PPR might be related to the severity of their patients’ illnesses. Over the past few decades, TCM has been in decline, and has had to learn from WM . NowadayPerformance assessment of doctors is a reaction of healthcare provider organizations to the market-oriented reform of medical services. In the past 20 to 30 years, government financial subsidies for public hospitals have been inadequate in China . More reChina’s secondary and tertiary hospitals are usually general hospitals, with higher overall levels of medical treatment in tertiary hospitals. Patients who attend tertiary hospitals usually suffer from more serious conditions, so there may be more potential for medical disputes. We found, however, that there was no difference in perceptions of PPR among doctors working in different levels of hospital. This may suggest that as the result of a chilling effect , doctor The effects of the type and level of hospitals on patients’ perception of PPR may be related to the core needs of the patients. The level of medical treatment in WM and tertiary hospitals is likely to be higher, with patients having more needs. These patients may therefore have a better perception of PPR, even with higher fees and more difficulty seeing doctors. There were no significant effects of medical fees on patients’ perception of PPR. This may be for two reasons. First, patients with higher levels of need recognize that they need to pay more. They also believe that life is more important than money. The second reason is the universal coverage of health insurance, which eases the financial burden on patients . Nearly The ratios of doctors(nurses) to ward beds is, in many cases, far below the level stipulated by the Ministry of Health of China . This suThe difference between doctors and nurses in effect of hospital type on perceptions of PPR is probably related to their different roles. The difference in the effects of performance assessment is probably related to the differences in content of performance assessment for nurses and doctors. Performance assessment for doctors is mainly focused on income generation. For nurses, however, performance assessment mainly focuses on quality of care . For nurImproved patient-provider communication should improve PPR ,14. We dThe effects of economic status on doctors and nurses’ perceptions of PPR is probably related to market-oriented reform of medical services. If doctors or nurses have better economic status, the pressure and psychological burden of income generation is less, so their perception of PPR is better . PatientContinuity of care was not involved as an individual influencing factor in this study mainly with the suggestion of the instrument selection of PPR in this study. In China, patients can select freely nationwide hospital or doctor, as buying clothes in mall. Sometimes they would see a few hospitals at the same time; even at the same time see a few doctors in a hospital, especially they are suffering from serious illness. Additional, China is almost universal medical insurance, and also can achieve national networking, the use of personal medical insurance card is not limited to hospitals or doctors, but to the proportion of reimbursement of medical expenses varied with hospital levels and areas. Therefore, continuity is very weak in China, especially for patients in general hospitals.Notably, organizational and management measures are considered important for promoting continuity of care and doctors’ communication skill training ; howeverAmong the social and demographic factors, the previous studies showed that patients with poor economic status report lower PPR , 58,59, p values should be regarded as exploratory rather than hypothesis testing, and moderate p values should be interpreted cautiously. Third, we excluded obstetrics and pediatrics in departments sample, which may bring some selection bias.Our study has several strengths. First, the study data are collected from a nationally representative sample in China. Second, we conducted an analysis with organizational and individual factors, extending the existing studies that focused primarily on individual factors. Third, the study examined perceptions of PPR among doctors, nurses, and patients simultaneously. Limitations include, first, the response rate was low. We did not use any incentives or persuasion to improve participation, as this would have increased potential information bias. Similarly, low response rates have been seen in other national surveys of doctors, and some have shown no significant differences between responding and non-responding doctors –63. We wIn a nationally representative sample, the deterioration of PPR were serious with doctors’ perceptions in China. Although our findings require validation in different organizational settings given the likely variability of these associations across systems, our results suggest that implementing moderate levels of performance assessment, promoting the level of medical treatment, and broadening doctors/nurses training contents with listening to patients, may benefit to promoting PPR.S1 File(XLSX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.


Background: Mechanical ventilation is an integral, but expensive, part of the intensive care unit (ICU). Optimal use of mechanical ventilation could save costs and improve patient outcomes. Here, the cost effectiveness of proportional assist ventilation (PAV™ ventilation by Medtronic) is estimated relative to pressure support ventilation (PSV).Methods: A cohort-level, clinical model was built using data from clinical trials. The model estimates patient-ventilator asynchrony >10%, tracheostomy, ventilator-associated pneumonia, other nosocomial infections, spontaneous breathing trial success, hypoxemia, and death. Cost and quality of life are associated with all events, with cost effectiveness defined as the cost per quality-adjusted life year (QALY) gained in the US and UK.Results: The mean cost of ICU care was lower with PAV™ than with PSV in the US and UK, but the total cost of care over 40 years was higher due to more patients surviving and incurring future care costs. Reduced time on mechanical ventilation, fewer nosocomial infections, and extended life expectancy with PAV™ drove QALY improvement. The cost per QALY gained with PAV™ was $8,628 and £2,985.Conclusion: PAV™ improves quality of life and reduces short-term costs. PAV™ is likely to be considered cost-effective over 40-years in the US and UK. Mechanical ventilation via an endotracheal tube, is life-saving for patients with acute respiratory failure in the intensive care unit (ICU). As the most widely used supportive technique in the ICU , its patThere are various modes of mechanical ventilation, which can be generally split into “controlled” and “assisted.” With controlled modes the respiratory system is a passive structure and all breath characteristics depend on ventilator settings as determined by the caregiver and respiratory system mechanics . During Proportional-assist ventilation with load-adjustable gain factors  is an assisted mode in which ventilator software measures, semi-continuously, elastance and resistance of the respiratory system and once triggered delivers pressure proportional to the instantaneous inspiratory flow and volume and, hence, to the inspiratory muscles' pressure . Severalin-silico approach taken complies with good practice guidelines and the requirements of health technology assessment agencies  and quality of life utility is applied Table , and likThe model outcome in the base case provides an estimate of the costs and QALYs associated with use of PSV and PAV™. There is, though, inherent uncertainty about the parameters used as model inputs, which is often described via the standard deviation or 95% confidence interval. To understand how the uncertainty in model inputs influences outcomes, 2,000 patient cohorts were simulated using sampled age and gender distributions and run through the model. In each case, all model parameters (such as incidence of VAP and the relative risk of a successful SBT with PAV™) were also sampled from underlying distributions. Incidence data used normal, and relative risks log-normal, distributions. The 2,000 analyses were also used to estimate the cost-effectiveness plane and the likelihood of PAV™ being considered cost effective. The willingness-to-pay threshold, the maximum level at which a payer would consider an intervention to be cost effective, was taken to be the commonly accepted values of USD 50,000 and GBP 30,000 per QALY gained in the US and UK, respectively .p-values are generally not appropriate measures of significance. As such, the 95% credible interval (CrI) for outcomes of the 2,000 simulations were also calculated. This is the outcome range, in which 95% of results fall . Although no direct relationship holds between the Bayesian CrI and the frequentist confidence interval, a 95% CrI that does not cross parity can be approximated to the same significance as a p-value of < 0.05.As model outcome data rarely follow a normal distribution, frequentist statistics and their calculated Over 40 years in the base case compared with PSV, PAV™ was associated with increased life expectancy and quality-adjusted life expectancy Table . In the In varying the time horizon of the model, it was evident that results are sensitive to the time frame of the analysis Figure . In bothIn assessing the impact of parameter uncertainty on model findings, 2,000 simulations were performed with random input values sampled from underlying distributions. In the majority of cases, results of these simulations were aligned with the base case. In the US setting, PAV™ increased life expectancy and QALYs in 89.40 and 89.25% of simulations, respectively, compared to PSV. The median QALY increase with PAV™ was 0.71 . Costs were increased in 73.20% of cases, the median being USD 8,457 . Overall, PAV™ would be considered cost-effective in 82.95% of simulations at a willingness-to-pay threshold of USD 50,000 per QALY gained  and Academy of Managed Care Pharmacy (AMCP) do not specify a time horizon to use , 37, butThe results of the analyses were robust to changes in input parameters. The model is, however, only a representation of real life and based on average patients and mean outcome data. Clinical practice and even guidelines vary by country and hospital, the model cannot account for all these variations but aims to account for varying rates of events and intervention and levels of efficacy through sensitivity and scenario analyses. Results in individual hospitals would likely vary from those presented here because care practices, patient populations, and costs vary by institution. Furthermore, there is likely a learning curve to become familiar with the operation of PAV+ that has not and cannot (due to a lack of data) be explored in the model. The randomized, controlled trials informing this model were run by groups familiar with PAV+ and this may bias results relative to users new to the technology. Still, over a set of hospitals we would expect that results would be in line with those presented here. Probabilistic sensitivity analyses have shown that a payer would have a 95% chance of seeing a cost difference of between USD −17,813 and USD 47,194 in the US and GBP −7,709  and GBP 18,985  in the UK, when a 40-year time horizon is used. The actual healthcare cost burden for a particular hospital using PAV™ will be dependent on local event rates and costs for devices, interventions, and personnel.To fully validate the results of a model would require an extended, prospective cost collection study. This is beyond the realms of feasibility, and so model outputs are compared with previously reported values. In 2015, Hjelmgren et al. considered the cost consequence of neutrally-adjusted ventilatory assist (NAVA) mechanical ventilation relative to PSV in the Swedish setting . Their mIn 2012, Kollef et al. indicated that the cost of uncomplicated mechanical ventilation was USD 59,770 per patient . ConvertOptimizing provision of mechanical ventilation is of high importance to healthcare providers. For payers, the costs of ICU care and mechanical ventilation in particular are a substantial burden on budgets. In general, an ICU accounts for fewer than 10% of hospital beds but over 20% of hospital costs . In a prFrom a provider perspective, use of PAV™ could result in lower resource use and improved patient comfort and quality of life. A key aspect of the PAV™ technology is the reduction in patient-ventilator asynchrony. Scenario analyses changing the relative level of asynchrony did not, however, have a large impact on cost-effectiveness outcomes. More pertinent were fewer days on mechanical ventilation and in the ICU, as reported by Bosma et al.  This wasThe published reductions in asynchrony and length of stay in the ICU with PAV™ , 17. ledDG provided information on the patient care pathway and clinical and economics outcomes to include. RS performed the literature search and review and created the initial model design. The model was finalized after review and updates from DG. RS ran analyses and sensitivity analyses and drafted the manuscript. Manuscript review and updates were performed by DG. Both authors met to approve the final manuscript for submission.RS is the owner of Coreva Scientific GmbH & Co KG, which received consultancy fees for performing, analysing, and communicating the work presented here. DG received an honorarium from Medtronic Inc. for identifying clinical data and helping to conceptualize the clinical model developed.