Neck circumference (NC), is an emerging marker of obesity and associated disease risk, but is challenging to use as a screening tool in children, as age and sex standardized cutoffs have not been determined. A population-based sample of NC in Canadian children was collected, and age- and sex-specific reference curves for NC were developed.th percentile) and overweight/obese (BMI > 85th percentile) subjects.NC, waist circumference (WC), weight and height were measured on participants aged 6–17 years in cycle 2 of the Canadian Health Measures Survey. Quantile regression of NC versus age in males and females was used to obtain NC percentiles. Linear regression was used to examine association between NC, body mass index (BMI) and WC. NC was compared in healthy weight (BMI < 85p < 0.0001). For each additional unit of BMI, average NC in males was 0.49 cm higher and in females, 0.43 cm higher. For each additional cm of WC, average NC in males was 0.18 cm higher and in females, 0.17 cm higher.The sample included 936 females and 977 males. For all age and sex groups, NC was larger in overweight/obese children (This study presents the first reference data on Canadian children’s NC. The reference curves may have future clinical applicability in identifying children at risk of central obesity-associated conditions and thresholds associated with disease risk. Neck Circumference (NC) is an emerging marker of pediatric obesity, a rising epidemic and a major public health issue, with prevalence in Canada of 10% . There iIt is difficult, however, to establish thresholds of NC associated with disease risk in children, as normal neck size changes with age, sex and development. Age and sex-standardized NC values for children are therefore needed to better assist translation of this measurement into clinical practice.To our knowledge, there are no reference data on neck circumference measurements in a large population-based sample of children in Canada. Some reference data is available from Germany  and TurkThe Canadian Health Measures Survey (CHMS) is a large, nationally-representative survey which collected direct measures of NC in Canadian children and youth. Use of a healthy-weight, nationally representative sample of children to develop pediatric reference curves for NC is a strategy recommended by the World Health Organization in the development of growth curves, where a population with ideal health circumstances should be selected as the reference population . This apCycle 2 of the Canadian Health Measures Survey (CHMS) covers the Canadian population aged 3 to 79 living in private dwellings. Residents of Indian Reserves or Crown lands, institutions, certain remote regions, and full-time members of the Canadian Forces are excluded. Approximately 96% of the Canadian population is represented.Ethics approval for the survey was obtained from Health Canada’s Research Ethics Board ,20. InfoData for Cycle 2 of the CHMS were collected from 18 sites across Canada from September 2009 through December 2011. The survey consisted of two parts: 1) an in-home interview that collected information on socio-demographic characteristics and health behaviours; and 2) a subsequent visit to a mobile examination centre for a series of direct physical measurements, including various anthropometric and fitness tests, in addition to the collection of blood and urine samples [Of the households selected, 75.9% agreed to participate. Within each responding household, one or two members were then selected to participate. Of those, 90.5% completed the household questionnaire, and 81.7% attended the mobile examination centre. The final response rate, after adjusting for the sampling strategy, was 55.5% . The sam2). Age- and sex-specific cut-points from the Centres for Disease Control (CDC) were used to classify children and youth into two groups based on BMI: healthy-weight (BMI ≤85th percentile), and overweight/obese  [NC and other anthropometric measurements such as height, weight, and WC were taken during the mobile examination centre visit, according to a detailed data collection protocol (CHMS Data User Guide) . NC was centile) .http://www.csep.ca) and followed validated and standardized measurement techniques [All anthropometric measurements were taken by trained CHMS staff with a degree in Kinesiology and certification as Certified Exercise Physiologists®  and BMI group for height, weight, WC, and NC. The distribution of continuous variables was examined using percentile plots. Mean NC by age, sex and BMI category were also calculated, along with 95% confidence intervals. T-tests by sex, age and BMI group were used to compare mean anthropometric values between healthy-weight and overweight/obese individuals.To examine the association between NC and other markers of overweight/obesity, linear regression was used to model (a) NC versus BMI, adjusted for age and (b) NC versus WC, adjusted for age. This was done for males and females separately, and also using an interaction by sex. P-values and adjusted r-square statistics were used to determine the significance and explanatory power of the model. Two-sided significance was set at p < 0.05.th-order polynomial in age was ultimately fitted to NCs. Reference curves were constructed for the 95th, 90th, 75th, 50th, 25th and 5th percentage points, chosen as they correspond to percentage points on the CDC growth charts, [In order to create a reference dataset for NC, only the healthy-weight sample was considered. This classification of healthy weight or overweight/obese was chosen to ensure that the sample used to develop the reference growth curves represented an “ideal healthy population”, as recommended by the World Health Organization . For malth percentile) were determined from the quantile regression model fit. A receiver operator characteristic (ROC) curve was plotted in order to determine the most appropriate cut-off point for NC in a clinical setting. Note that since NC percentiles were obtained from a sample with BMI < 85th percentile, the specificity is almost the same as the NC threshold.Finally, the sensitivity and specificity of various NC percentile cut-off values for predicting a BMI of overweight or obese  in males was higher than in females, particularly for those approximately age 10 years and older. Curves of NC percentile estimates from the model by age and sex are displayed graphically in Figure Table th percentile for this sample yields a sensitivity of 97% and specificity of 50% for predicting BMI above the 85th percentile.Results of the sensitivity and specificity analysis of NC percentile and BMI are presented as a receiver operator characteristic curve in Figure th percentile is a sensitive predictor of overweight/obesity (BMI > 85th percentile).The purpose of this study was to create a reference dataset of NC by age and sex using quantile regression analysis in a sub-sample of healthy-weight children. Using the reference dataset, we found that a NC above the 50The results of this study provide age and sex-standardized reference values of NC that can be used in future studies to examine the predictive ability of a NC threshold for overweight and obesity-associated co-morbidities. This may be of particular interest for prediction of obstructive sleep apnea in older children, since its etiology is specifically linked to fat distribution in the neck in adults and is likely similar in older youth ,27. FurtFor both males and females, NC increases with age. In both sexes, variability in NC increases with increasing age and there is divergence of the quantile regression curves, as seen in Figure The NC values reported in this study differ from most of the existing literature, which relied on raw NC, which is not standardized for age and sex. This study also included only healthy weight individuals, an ideal reference population , unlike th percentile provides high sensitivity for predicting those with BMI above the 85th percentile (Figure th percentile, which yields a sensitivity of 86% and specificity of 74%, may be more useful. Further research about how enlarged NC is related to co-morbidities of obesity, will allow refinement of this model.The reference values determined in this study will enable clinicians to identify children with NCs that are different from healthy-weight Canadian children of the same age and sex. Further studies are needed to determine whether elevated NC is a predictor of other co-morbid health conditions. Thresholds of NC percentiles used to identify those at higher risk of other health conditions may vary, however, according to the setting in which they are used. NC percentile above the 50e Figure  and may Although we have a high degree of confidence in the data quality of this analysis, as the CHMS uses rigorous standards for measurement and analysis, this study does have some limitations. First, the overall response rate of the CHMS was 55.5%. Adjustments were made to the sampling weights to compensate for this. Despite the response rate, the sample size obtained was still large and representative enough for the creation of reference curves. Second, a well-known issue in growth curve modelling concerns “edge effects”: estimates are least precise at the oldest and youngest ages, and flexible curves may exhibit undesirable behaviour near these boundaries . The conIn conclusion, this study demonstrates that NC increases with age, BMI and WC in children and youth aged 6 to 17. Furthermore, reference values of NC for healthy-weight children and youth in a Canadian population have been determined. Elevated NC percentile may ultimately prove to be a useful adjunct to BMI or WC in identifying children and youth who are at risk for overweight and obesity-related conditions such as obstructive sleep apnea, although future work is needed to determine NC cut-offs or percentiles that correspond to increased health risk in children. The work presented here represents the first step towards achieving that goal.BMI: Body mass index; CDC: Centres for Disease Control; CHMS: Canadian Health Measures Survey; CI: Confidence interval; NC: Neck circumference.The authors declare that they have no competing interests.Drs. SLK, J-PV and RCC were responsible for the study conception and design, as well as the interpretation of the data and manuscript preparation. Dr. NJB and Ms. JC were responsible for the data analysis and assisted with both study design and data interpretation. Ms. LH was responsible for data collection and oversaw the training of data collectors, as well as contributing to the study design and manuscript preparation. All authors have had input into the manuscript and have approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/14/159/prepub


Objectives: To analyze the impact of caesarean section (CS) on mode of delivery, pregnancy-induced and pregnancy-associated disorders, as well as complications in the subsequent pregnancy within German gynecological practices.Methods: 1,801 women with CS and 1,801 matched women with vaginal delivery (VD) from the IMS Disease Analyzer database were included. The impact of previous CS on the mode of delivery and pregnancy-associated disorders as well as complications prior to or during birth in the subsequent pregnancy were analyzed. Cox regressions were used to determine the influence of CS with regard to these outcomes.Results: Medical abortion and single spontaneous delivery were significantly less frequent in women with a history of CS compared to VD , whereas CS after CS was the significantly more common mode of delivery . Gestational hypertension without significant proteinuria, gestational hypertension with significant proteinuria, and polyhydramnios were more frequent in women with CS than in women with VD . Hemorrhage and maternal care for known or suspected disproportion were more common in the CS group than in the VD group . Prolonged pregnancy, preterm labor, abnormalities arising from forces of labor, and perineal laceration during delivery were significantly less frequent in women with CS than in women with VD (OR between 0.32 and 0.75), whereas long labor was more common (OR=2.09).Conclusion: Women with CS were more likely to undergo further CS and to develop major pregnancy-associated diseases in the following pregnancy compared to women with VD.  Caesarean section (CS), also known as C-section, is a surgical procedure which has been increasingly used in the past decades , 2], , . In 2014CS has been at the center of an intensive debate in recent years. Some authors have suggested that CS may be deleterious to both mother and baby , 6]. In. In6]. IAlthough Germany has a high CS rate, there is a lack of comprehensive epidemiological studies on the effect of CS on the mother and the baby in this country. Thus, our goal was to analyze the impact of CS on mode of delivery, pregnancy-induced and pregnancy-associated disorders, and complications arising during the subsequent pregnancy in Germany. The Disease Analyzer database  compiles drug prescriptions, diagnoses, basic medical and demographic data obtained directly and in anonymous format from computer systems used in the practices of gynecological practitioners . DiagnosIn Germany, the sampling methods used for the selection of physicians’ practices were consistent with a representative database of gynecological practices . PrescriBetween January 2000 and December 2013, 10,195 women gave birth by CS and 16,132 gave birth by VD for the first time in the German gynecological practices identified in the IMS Health database. We selected women who were pregnant a second time. After matching (1:1) women with CS and women with VD using age and diagnosis of obesity (ICD 10: E66) as criteria, 1,801 subjects were included in each group (see data publication . T. T15]. TIndeed, although women believe that VD is more natural than CS, it is associated with considerable side effects (i.e. urinary incontinence and neuropathy) , 21]. I. I21]. IMoreover, it was shown that CS was associated with a reduction in the rates of medical abortion, prolonged pregnancy, preterm labor, abnormalities of forces of labor, and perineal laceration during delivery. Nonetheless, another important result of this work is that CS is associated with elevated risk of several adverse outcomes involving short- and long-term effects on both the mother and the baby. It was discovered that CS was associated with a 7-fold increase in the risk of developing gestational hypertension without significant proteinuria as well as with a 2-fold increase in the probability of developing gestational hypertension with significant proteinuria. It was shown that CS had a major impact on polyhydramnios . These findings correspond with the existing literature, as several studies have already demonstrated that CS has a negative effect on morbidity and mortality. In a study including 120,633 singleton second births, Smith and colleagues have found that the odds of unexplained stillbirth was significantly higher with prior CS than with prior VD . In 2006, Silver et al. further showed in 30,132 women examined between 1999 and 2002 in 19 American academic medical centers that the risk for placenta accreta increased with the number of CS  [Retrospective primary care database analyses are generally limited by the validity and completeness of the data on which they are based. The present study includes several limitations, such as the assessment of abortion and the definition of CS use and co-morbidities, which relied solely on ICD codes entered by gynecologists in gynecological practices, not by the obstetrician. Another important limitation of this work is that only two variables (age and diagnosis of obesity) were used for matching women with CS and women with VD, resulting in potential bias factors. Furthermore, age, and data pertaining to socioeconomic status  and lifestyle-related risk factors , were also lacking due to legal restrictions for data privacy protection. Finally, Disease Analyzer database did not allow us to separate elective Caesarean for breech, Caesarean for other indications, and emergency Caesarean.Overall, the present study indicates that women with CS in German gynecological practices were less likely to have a single spontaneous delivery and more likely to undergo CS in a subsequent pregnancy compared to women with VD. Interestingly, CS was associated with both the increase and decrease of the risk of major diseases and disorders associated with pregnancy. Congruent with the literature, these data underscore the need for intensive management and follow-up of women with CS. Furthermore, new studies are required to reevaluate the CS-related risk-benefit balance, and to gain a better understanding of the association between prior and subsequent CS. http://dx.doi.org/10.5061/dryad.g7t04 [Data for this article are available from the Dryad Repository: ad.g7t04 .The authors declare that they have no competing interests.


Obesity is an important risk factor for cardiovascular and metabolic diseases and could affect mortality rates. Body mass index (BMI) and waist circumference (WC) have been used to classify obesity, and waist-to-hip ratio (WHR) has recently emerged as a discriminator of cardiovascular disease. Sasang constitution (SC) is a kind of well-known traditional Korean medicine: Tae-eumin (TE), Soeumin (SE), Taeyangin (TY) and Soyangin (SY) carrying a different level of susceptibility to chronic diseases. We aimed to examine the prevalence in general and abdominal obesity (AO) using BMI, WC and WHR according to SC in the Korean population.p < .05).A total of 3,348 subjects were recruited from 24 Korean medicine clinics. Obesity was divided into three categories: general obesity by BMI, abdominal obesity by waist circumference (WC AO) and abdominal obesity by waist-to-hip ratio (WHR AO). A Chi-square test was performed to compare prevalence, and logistic regression was conducted to generate odds ratios (ORs) according to SC , of WC AO , and of WHR AO  compared with the SE type. In addition, after controlling for age, social status and eating habits, the ORs were similar to the crude model according to gender and SC.This study shows that the prevalence of obesity varies according to SC in the Korean population. In particular, the TE type was highly associated with increased ORs for general obesity, WC AO and WHR AO in both genders. Obesity increases the likelihood of various diseases, particularly heart disease, type 2 diabetes, obstructive sleep apnea, certain types of cancers and osteoarthritis , 2. ManyObesity is classified as overweight, general obesity, abdominal obesity (AO), visceral fat obesity and other types to estimate body fatness, which in turn is defined by body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), skin fold thickness and bio-impedance . Among tThe cause of obesity is well known to be a combination of environmental factors, including excessive food energy intake, lack of physical activity and genetic susceptibility , 11. RecAccording to SCM, the requisite energy, or the preservative energy related to the most hypoactive viscera or the weakness of each SC type, is considered to be the essential energy necessary to maintain homeostasis. The clearing Yin energy, the warming Yang energy, the dispersive energy and the accumulative energy are the requisite energies for SC types, respectively. Diseases and illnesses are caused by the aggravation of hypoactive visceral functions .Each constitution has different body shape, psychological and physiological characteristics , 16. TheRecently, an experimental study revealed that the TE type is more susceptible to obesity than are the other types, from a genetic perspective , 22. SevTherefore, the purpose of this research was to identify the prevalence of general and abdominal obesity in the Korean population using BMI, WC and WHR according to SC.This was a cross sectional study based on data from the Korean Constitutional Multicenter Study (KCMS) collected between November 2006 and August 2012. The KCMS collected data from 24 Korean medical clinics (KMCs), the details of which have been published in previous studies , 24, 25.We used a sample size of at least 600 subjects of the SE type, which is known to occur in 20% of individuals in Korea population . We alsoThe inclusion criteria for the subjects in this study were over 20 years old. The exclusion criteria were as follows: inability to understand and follow the researcher’s indications and inability to stand up or sit down for measurement. Details regarding the researcher’s instructions and the subjects’ measurement postures were described in former reliability study . SubjectThis study was approved by the Korea Institute of Oriental Medicine (KIOM) Institutional Review Board (I-0910/02-001), and signed informed consent was obtained from all subjects. Data collectors were trained rigorously to ensure quality of data acquisition according to the standard operating procedure (SOP) developed by KIOM , 27.The subjects’ SC was diagnosed by SCM specialists at each hospital. To ensure highly accurate SC diagnoses, we applied strict criteria for the SCM specialists and study subjects. SCM specialists had more than 5 years of clinical experience in a medical institution, and the subjects had been administered SC-specific pharmaceuticals before recruitment additionally .The general information obtained included gender, age, education status (under high school graduates and university graduates), occupation type (white collar and others), and eating habits (amount and speed of eating), which potentially contributed to the SC-obesity association , 29.Anthropometric measurements, including WC, hip circumference, height and weight, which are necessary for the diagnosis of obesity were measured following the SOP . Height 2, in accordance with the Asia-Pacific criteria of the WHO guidelines [Obesity was divided into three categories: general obesity, abdominal obesity by waist circumference (WC AO) and abdominal obesity by waist-to-hip ratio (WHR AO). General obesity was defined as BMI ≥25 kg/midelines . WC AO widelines . WHR AO idelines .p < .05.Continuous variables were reported as the mean ± SD, while categorical variables were expressed as percentages. A T test and One-way ANOVA were used to the compare continuous variables  according to gender and SC. A Chi-square test was performed to compare the prevalence of obesity as defined by BMI, WC and WHR according to gender and SC, as well as by 20-year age groups. Logistic regression was used to calculate odds ratios (ORs) for general obesity, WC AO and WHR AO, setting the reference SE type. We conducted all of the analyses using SPSS 17.0 software . The level of statistical significance was considered to be p < .05).Table p < .001). In females, the prevalence of general obesity, WC and WHR AO was also highest in the TE type at 50.3%, 62.9% and 83.3%, respectively (p < .001). The overall prevalence of general obesity was 39.2% and 26.3% for males and females, respectively (p < .001), whereas the overall prevalence of WC AO was 40.4% and 38.4% (p = .259), and that of WHR AO was 68.5% and 70.7% for males and females (p = .206), respectively.Figure p < .001). Most prevalence rates for general obesity, WC AO and WHR AO increased following age increases in each gender and SC. The TE type had the highest prevalence, and the SE type had the lowest prevalence of general and abdominal obesity among all SC types for all age groups and both genders.Figure Table The aim of the present study was not only to reveal a clinical association between Sasang constitution and the prevalence of general and abdominal obesity, but also to determine whether a SC (TE type) is associated with greater risk compared to reference SC (SE type).This study revealed some different prevalence trends in general obesity between males and females. The prevalence of general obesity as determined by BMI was higher in males than in females, whereas the prevalence of AO by WC and WHR was similar in males and females. Furthermore, the prevalence of general obesity was similar to that of WC AO in males, although it was relatively lower than that of WC AO in females. This reconfirmed that obesity type could differ according to gender. This finding corresponds well with reports from the Korea National Health and Nutrition Examination Surveys . These fOur results also clarify the assumption that the TE type might be much more associated with overweight and obese than the SE and SY types, which has been implied in previous published studies –19, 23. Because age is associated with obesity  and was Among the SC types, the TE type had the highest prevalence rates of general and abdominal obesity in all age groups. The age-specific obesity prevalence trends according to SC type were similar to those of metabolic syndrome . This reThis study suggests the TE type is associated with higher rates of general obesity , WC AO , and WHR AO  than are the SE and SY types in both males and females. The findings indicate that the TE type may be most susceptible to all types of obesity, including general obesity, WC AO and WHR AO, ranked from highest to lowest prevalence.This study is meaningful by suggesting that SC may be associated with various obesities. In particular, the TE type was the highest risk factor for obesity, which many previous studies did not show, even though they hinted that TE types might gain much more weight than other types. Second, we applied WHR AO as an AO index following the WHO guidelines and proposed trends according to age increases.However, this study had some limitations. This study has a cross-sectional design, which cannot demonstrate causal effects and time trends. Therefore, the evidence may be slightly weak. We did not exclude body shape influences from the SC diagnoses conducted by specialists. As such, the SC diagnoses by the SCM specialists may have been dependent on or at least affected by the patient’s body shape.We tried to adjust for confounders such as social status and eating habits, but we did not control for other environmental factors that can influence obesity, such as lifestyle, exercise habits, smoking, physical activity and psychosocial factors, all of which are known to affect body shape. Finally, it is controversial that a pure SC effect, excluding the effect of weight gain, may exist or influence specific diseases that have already been known to result from obesity. We think further research is warranted to identify a pure SC effect by controlling for environmental factors and BMI.This study showed that the prevalence of obesity varies according to SC. In particular, the TE type was highly associated with increased ORs of general and abdominal obesity in both genders and in all age groups.


Background: Prehypertension is a category between normotension and hypertension that is becoming increasingly common in China. However, limited data are available on the prevalence and correlates of prehypertension in northeastern China. Methods: A cross-sectional study using stratified, clustered multistage, and random sampling methods was performed on 17,584 participants. Results: The prevalence of prehypertension and hypertension was 36.0% and 30.8% in northeastern China, respectively. As age increased, the prevalence of prehypertension in males declined (p-trend < 0.001), in parallel to an increase in the prevalence of hypertension (p-trend < 0.001). The prevalence of hypertension for females increased as age increased (p-trend < 0.001). Logistic regression analysis showed that age, gender, location, drinking, Body Mass Index (BMI), abdominal obesity, hypertriglyceridemia, and hypercholesterolemia correlated with prehypertension and hypertension (p-trend < 0.05). Conclusions: This study revealed a high prevalence of prehypertension and hypertension in an adult population of northeastern China and some correlates of prehypertension and hypertension. To drawet al. , prehypeWith the recent rapid economic growth and urbanization of China, the prevalence of hypertension and prehypertension has increased significantly. Although numerous studies have focused on prehypertension, epidemiological data on the prevalence and correlates of prehypertension and hypertension in northeastern China are limited. The aims of the present study were: (1) to estimate the prevalence of prehypertension and hypertension in the Jilin Province in northeastern China; (2) to examine the correlates of prehypertension and hypertension from a population-based study of Chinese adults; and (3) to provide scientific references on the primary prevention, early detection, and intervention strategies for treating prehypertension and hypertension.Data were obtained from a large-scale, cross-sectional epidemiological study in Jilin Province in 2012. Community residents who were aged 18–79 years old and had lived in Jilin Province for 6 months were recruited. A sample of 1‰ of the total population was used to obtain a representative sample of the population. A face-to-face questionnaire interview was performed by the investigators who had been uniformly trained, and participants then underwent the anthropometric checks including height and weight.This process included five steps. First, nine regions were sampled according to the proportion of the population; second, 32 districts or counties were sampled according to rural and urban locations; third, three neighborhood committees were sampled in each counties; fourth, one resident group was sampled in each neighborhood committee; finally, one adult resident was randomly selected from each household of the selected resident groups .We contacted 23,050 people to participate in the survey. Only 17,584 individuals completed both the questionnaire and the anthropometric measurements in the present study, yielding a response rate of 76.3%. This study was conducted in a national comprehensive university located in Jilin Province in northeastern China. Approval from the Ethics Committee of Jilin University School of Public Health  was obtained before the study commenced.The data collection period was from July to August 2012. Participants were asked to complete a questionnaire designed by our project team through face-to-face interviews; trained observers made anthropometric examinations using standardized procedures. Information obtained from the questionnaire included socio-demographic characteristics, lifestyle, and family history. The anthropometric examinations included body weight, height, waist circumference, and hip circumference.In addition, specially assigned people managed quality control. Before the official investigation, a pre-investigation was conducted to explore the design of the questionnaire. All of the investigators were medical students who were systematically trained. To ensure that the data collected were high-quality and representative, standard protocols and instruments were used, the certification requirements for data collection were strict, and a quality assurance program was conducted.Blood pressure was measured using an electric sphygmomanometer . Two measurements were taken after the participants had rested for at least 5 min. SBP or DBP was defined as the average of the two SBP or DBP readings.per capita. Lifestyle included drinking and dietary intake. Dietary intake assessment was done under two headings: (1) Salt intake and (2) Frequency of fruit, egg and meat intakes. “Salt intake” was divided into three levels: light, moderate, and salty. The participants made their own choices based on life experience. Frequencies of eating fruits, eggs or meat were divided into two: Frequently/sometimes and seldom/never. Frequently/sometimes fruits, eggs or meat intake was defined as eating these food ≥2 times/week; while seldom/never was defined as eating <2 times/week. Body weight, height, waist circumference, and hip circumference were measured using a standardized method. Body mass index (BMI) was calculated as weight(kg)/height(m2). Waist circumference was measured at the level of the umbilicus. Hip circumference was measured at the level of the greater trochanter. A fasting blood specimen was collected for lipid analysis. Dyslipidemia, including triglycerides and total cholesterol, was based on the cut-off points of 150 mg/dL (1.70 mmol/L) and 200 mg/dL (5.18 mmol/L), respectively [Information on socio-demographic characteristics, lifestyle, and family history was self-reported. Socio-demographic characteristics included age, gender, ethnicity, educational status, marital status, occupation and family income ectively .2 test was used to assess differences in categorical variables based on the complex sampling model. Univariate and multivariate logistic regression analyses were used to test the significant determinants of prehypertension vs. normotension and hypertension vs. prehypertension. Complex weighted computation was used to analyze all of the statistics.Data were entered into a computer using EpiData  and were analyzed using SPSS . Continuous variables were expressed using mean and standard deviation. Categorical variables were presented as frequencies. The prevalence (PR) and 95% confidence interval (CI) of prehypertension and hypertension were adjusted by complex weighted computation with the gender, age, and location distribution, according to the Sixth Chinese National Population Census, 2010, and were calculated using the Taylor Series approach. The Rao-Scott χp-trend < 0.001). There was no difference in the prevalence between prehypertension and hypertension for different locations and ethnicity.There were 8096 males and 9488 females in the survey. The mean age was 47.81 ± 13.20 years . The prevalence of prehypertension and hypertension in the socio-demographic characteristics in the study is reported in p-trend < 0.001), although the prevalence of hypertension increased (p-trend < 0.001). The prevalence of prehypertension in females remained constant across younger age groups (<45 years) and decreased in older age groups. The prevalence of hypertension in females increased as age increased (p-trend < 0.001). The prevalence of prehypertension was 43.5% in men and 27.9% in women. The prevalence of hypertension was 34.9% in men and 26.4% in women.The age-specific prevalence of prehypertension and hypertension is listed in per capita was significantly lower in rural areas than it was in urban areas, whereas the rate of marriage in rural areas was higher than that in urban areas. The proportions of drinking and fruit, egg and meat intake ≥2 times/week were slightly higher in urban areas. The distribution of family history and hypercholesterolemia varied in rural and urban regions, but the amount was greater in urban areas.Univariate and multivariate logistic regression were performed using SPSS to assess significant determinants of prehypertension and hypertension. Prehypertension or hypertension served as the dichotomous outcome variable. Socio-demographic characteristics, lifestyle, family history, obesity, abdominal obesity, triglyceride, and total cholesterol were the independent predictor variables. Age, gender, and location were corrected based on complex weighted computation. The results of the univariate logistic regression are presented in Multivariate logistic regression analysis showed that age, gender, location, drinking, eggs intake ≥2 times/week, BMI, abdominal obesity, hypertriglyceridemia, and hypercholesterolemia are significantly associated with prehypertension . Comparevs. normotension) via multivariable logistic regression analysis were shown in Determinants of hypertension  of adults in the Jilin Province in northeastern China. This is generally consistent with published studies, such as the figures of 36.1% in Brazilian adults  and 33.7Prehypertension and hypertension, which accounted for two thirds of the total population, appeared to be quite common in northeastern China. Furthermore, in the present study, we found that the prevalence of prehypertension decreased in males as age increased; and decreased in females in those aged ≥35 years, which was concordant with Liaoning Province adults . In the Another finding of the present study was that the prevalence of hypertension increased with age in both genders and that this increase was more rapid in females than males. Consistent with previous reports, the rates of hypertension were higher in men than in women at younger ages, whereas the reverse was true in older participants . The speIn this study, living in an urban area led to a reduced correlation of prehypertension (OR = 0.828) . The infIn our study, drinking was associated not only with hypertension but also with prehypertension . The patIn particular, high egg intake (≥2 times/week) was an important factor associated with prehypertension but not for hypertension. Interestingly, we found a high prevalence of prehypertension in individuals with a high egg intake. However, this result was not comparable with other studies because the standard of egg intake was not the same . HyperteHowever, a low fruit intake (<2 times/week) and a family history of circulatory system disease were significantly associated with hypertension but not prehypertension . In thisIn this study, obesity was identified as being more associated with prehypertension (OR = 2.960) than with hypertension (OR = 5.716). It is worth noting that obesity had the highest correlation with hypertension among the normotensive individuals apart from age . When obIn another study , there wThis study has several limitations. The first limitation was the low response rate, which often exists in cross-sectional epidemiological studies. Second, our data were obtained from a cross-sectional study in the Jilin Province and were not representative of adults throughout China. Third, because this is a cross-sectional study, the interpretation of causal relationships between risk factors and the development of prehypertension and hypertension is limited. Fourth, during our survey, we created analogous “clinic environments” by assembling participants for anthropometric examinations. The higher blood pressures as observed in our study participants might be explained in part as a result of the white-coat effect that might be associated with the clinic environments in which these blood pressures were measured ,22. FurtDespite the above limitations, the results of this study as community-based data could be important in providing relevant epidemiological information to help promote health for the primary prevention of hypertension. We used the complex weighted computation by adjusting for age, gender, and location to approximate the actual population composition of the Jilin Province in northeastern China. This study reinforced the need to urgently address the problem of prehypertension and hypertension in China by establishing an effective health security system for the public.Prehypertension and hypertension are highly prevalent in northeastern China. Prevention and treatment are urgently needed to address the public health problem of prehypertension and hypertension and to prevent prehypertensive people from developing hypertension or cardiovascular disease. For individuals with normotension, these common correlates of both prehypertension and hypertension  should be controlled as the most important factors. In addition, our results are the first to suggest that living in an urban environment is associated with a lower prevalence of prehypertension. These factors are probably important in decreasing the risk of developing hypertension among prehypertensive and normotensive people.


These data are opposite to findings in students entering Western universities, in whom increasing stress and a deteriorating cardiometabolic profile have been repeatedly noted. Perceived stress and morning cortisol levels among students of the Preparatory Year in KSU remained constant for both genders over time, yet an improved cardiometabolic profile was observed, suggesting good adaptation among our pre-college students in their first year of university life.In this prospective study we wanted to determine whether perceived stress over time among students in the Preparatory Year of King Saud University (KSU) predisposes them to cardiometabolic abnormalities. A total of 110 apparently healthy Saudi students (35 men and 75 women enrolled during the 2010−2011 academic year) were included. Perceived stress was determined at baseline and 1 year later. Anthropometrics were obtained and morning fasting serum glucose, lipid profile and cortisol were measured at both times. Perceived stress was noted among 48.2% of subjects at baseline and was not significantly different after follow-up, with 45.4% scoring high. In men, the prevalence of perceived stress was 48.6% at baseline (13 out of 35) and 37.1% at follow-up (13 out of 35), while in women it was 48% at baseline and 49.3% at follow-up. Interestingly, significant improvements in the blood pressure and lipid profiles, with the exception of HDL-cholesterol, were observed in both men and women, while fasting glucose also improved in women. Serum cortisol was inversely associated to fasting glucose, and total- and LDL-cholesterol ( There is accumulating evidence that college students have alarming rates of psychological distress ,2. ImproThere have been several studies indicating that adolescents who are about to begin their university lives are at high risk for abnormal weight gain secondary to tangible environmental stimuli and disordered eating in men, but more so, in women ,8. SeverIn this prospective study, our aim was to monitor the perceived stress of incoming students entering and completing their Preparatory Year of KSU, using a well-known tool in assessing global measure of perceived stress that has been used and validated in several studies ,14,15,16In this prospective study, a total of 110 apparently healthy young adult Saudi students (35 men and 75 women during the 2010−2011 academic year) were included. The study was conducted in the Preparatory Year (PY) Building of King Saud University, Riyadh, Saudi Arabia, and was done in collaboration with the PY dean and with the support of PY faculty members, most notably the physical education instructors who helped recruit students in their respective classes. The study is part of a larger cross-sectional research project of the PY involving 1,878 Saudi students . Participating students were rewarded with minor items (shirts and snacks) as a token of appreciation, and those who consented to participate in the follow-up study were rewarded with additional credits both for course and extra-curricular activities, as deemed appropriate by the assigned faculty member.Students answered a pre-designed questionnaire that was developed, pre-tested and validated in a pilot study. The questionnaire was based on a previously published article and has an internal consistency of 0.85 (Cronbach α co-efficient) and test-retest reliability during a short retest interval  of 0.85 . For theOnly consenting students with unremarkable medical history from the Preparatory Year were included in the study. Out of the original 1,878 students who participated on the cross-sectional survey, only 110 consented to be followed-up for one year. The large drop-out was secondary to the non-mandatory nature of participation in the present study, which was not the case in the cross-sectional survey where all students were required by school administration to participate. Students with underlying acute and chronic medical conditions that warrant immediate attention , and students who were disabled were excluded from the follow-up study.2, and classified as lean or obese, depending on BMI for age and gender for subjects below 18 years old. Waist and hip circumferences were measured by non-stretchable tape measure, and recorded to the nearest 0.1cm. Body fat composition was also assessed by Body Fat Analyzer . All measurements were administered by well-trained BRP research assistants. All measurements were repeated after 1 year.Participating students had their anthropometrics assessed wearing light clothing in an isolated room by the assigned school nurse. Weight was recorded to the nearest 0.2 kg using an international standard scale ; height to the nearest 0.5 cm using the same scale. BMI was calculated as kg/mBlood was collected at baseline and one year later. Blood was withdrawn in the morning after an overnight fast (>10 h) and collected in non-heparinized test tubes by an assigned physician. Fasting serum glucose and lipid profile  were measured using routine laboratory procedures . Levels of cortisol in serum was measured by electrochemiluminescence immunoassay (ECLIA) on a Roche Elecsys 411 system . This method can measure the concentrations of cortisol in the range of 0.5−1,750 nmol/L and has analytical sensitivity of 0.5 nmol/L. The intra- and inter-assay variation for cortisol were 3.8% and 4.2%, respectively. All biochemical estimations and storage of samples were carried out in the Biomarker Research Program (BRP) of King Saud University, Riyadh, Kingdom of Saudi Arabia.N = 72 has an actual power of 0.80 with α = 0.05 and an effect size of 0.34 . The present sample size of N = 110 has a power of 0.90 to detect difference at α = 0.03.Sample size calculation was done based on the mean cortisol differences across follow-up which is the variable of interest . Continuous variables were presented as mean ± standard deviation. Cortisol values were log transformed prior to analysis because it was not normally distributed as compared to other variables. Paired Student t-test was done to compare baseline and follow-up visits. Spearman correlation was done to assess significant associations with variables of interest at baseline and follow-up. Significance was set at p-values < 0.001, <0.001, <0.001, and <0.001, respectively. There was a significant decrease in LDL-cholesterol (<0.001), as well as HDL-cholesterol levels (<0.001). No further significant associations were identified among women.p-values 0.03 and 0.02, respectively). Overall, there was a significant decrease in the levels of total, LDL- and HDL-cholesterol levels  in the follow-up as compared to baseline. In women, there was a significant improvement in the blood pressure, glucose and lipid profile, with the exception of HDL-cholesterol , triglycerides  and LDL-cholesterol   see . No furtThe main findings in this prospective study is that students entering the preparatory year were able to “adapt” to the stressful environment of pre-college, as evidenced by the favorable metabolic profile at the completion of their first year, and the non-significant change of stress levels despite being exposed to added stress of university life. It has been consistently documented that the environment provided by universities and other academic institutions can be stressful to students and this can contribute to altered metabolic and behavioral patterns ,18,19. FThe significant associations of fasting cortisol between glucose and the select lipid profile are worthy of mention as they confirm previous findings. Indeed, long-term, even mildly elevated cortisol levels can have detrimental effects on the beta cells of the pancreas and may significantly increase fat accumulation, diminish skeletal muscle mass and alter carbohydrate and lipid metabolism ,20,21,22The presence of stress and the activation of the stress system in both adults and children is known to affect a variety of endocrine, metabolic, behavioral and cardiovascular functions, which, if persistent, can lead to a variety of diseases later on in life . ChildreIn the present study, our young adult subjects were subjected to stress secondary to a change in environment and social life in the year of pre-college education. Despite this exposure, there were no significant differences in the perceived stress score one year after baseline collection in both men and women, as well as no significant changes in the cortisol levels, suggesting that probably the incoming students were able to adapt positively with the change in environment. Another plausible explanation might be the social environment of our students is not as stressful as that of Western academic institutions. The Preparatory Year has only 4 programs that include English, computer, basic sciences and self-development skills, and each student is to develop these skills on different tracks, depending on the career they wish to pursue  . ReligioThe study has several limitations. The small sample size of the students followed up might contribute to type 2 errors in associations that would have been avoided had the size been bigger. Stress was not measured before college entry, which may explain the high % percentage of perceived stress at baseline which remained the same after follow-up. Furthermore, several variables that include physical activity, diet and changes in sleep patterns have not been taken into consideration in the analysis.In summary, perceived stress and cortisol levels among students of the Preparatory Year over time remained constant in both genders. Yet an improved cardiometabolic profile was observed during this time period, suggesting an increase in coping or adaptation regardless of the stress level among our students. This is different from data in Western institutions of higher learning, in which perceived stress and cardiometabolic risk indices are noted to increase in the first college year. Further studies are required to evaluate whether this observed reduction in cardiometabolic risk continues in Saudi students during their subsequent years in the university.


Interactions between species, particularly where one is likely to be a pathogen of the other, as well as the geographical distribution of species, have been systematically extracted from various web-based, free-access sources, and assembled with the accompanying evidence into a single database. The database attempts to answer questions such as what are all the pathogens of a host, and what are all the hosts of a pathogen, what are all the countries where a pathogen was found, and what are all the pathogens found in a country. Two datasets were extracted from the database, focussing on species interactions and species distribution, based on evidence published between 1950–2012. The quality of their evidence was checked and verified against well-known, alternative, datasets of pathogens infecting humans, domestic animals and wild mammals. The presented datasets provide a valuable resource for researchers of infectious diseases of humans and animals, including zoonoses. Communicable diseases were estimated to have caused nearly 565 million disability-adjusted life years (DALYs) in 2010, about 23% of the total2. DALYs are a measure that combines years of life lost (from premature death) and years lived with disability, and therefore takes account of both mortality and morbidity.Communicable diseases continue to impose a tremendous burden of mortality and morbidity on humans. The most recent assessment of the global burden of disease3–5. Effort is underway to estimate the global burden of human disease that is food-borne ; (iv) communicable diseases may limit or cause extreme fluctuations in population size of wild animals7 and reduce the chances of survival of endangered or threatened species8. Indeed, disease can be the primary cause of extinction in animals or be a significant contributory factor towards it.The global burden of communicable diseases of animals, including livestock, has not been quantified, but is undoubtedly high. Such diseases are important for four major reasons: (i) animal welfare; (ii) livestock provide income, food and clothing and, particularly in low income countries, building materials and draught power; as such, livestock diseases may affect human mortality and morbidity indirectly, affecting food security and contributing to malnutrition; (iii) animal diseases are a source of human disease. About three-fifths of human diseases are believed to have arisen from animal pathogens, especially those of livestock5 found 1415 pathogens of humans. The data were compiled from fourteen textbooks of human and zoonotic disease and twenty-five reviews of emerging diseases. These sources were not systematically selected or exhaustive and may themselves have had biases and gaps in the diseases listed. The final dataset is also time-limited and does not reference communicable diseases that have emerged since publication. There is no comprehensive dataset of animal diseases.Despite the importance of communicable diseases, there have been few attempts to construct datasets of the full set of infectious agents of humans or animals. Such datasets have many uses, for example facilitating the estimation of comprehensive infectious disease burdens, quantifying important characteristics of diseases, such as type of agent, whether they are zoonotic etc.; and providing a baseline for studying the rate of emergence of new diseases. The most notable attempt that has been madeHere we provide a full description of the development of a database of the interactions of species with (i) other species and (ii) locations. A large subset of the database is interactions where one species causes disease in another, i.e., pathogen-host relationships. However, a number of other interactions are also included such as commensal/mutualistic and vector-host. The database has been populated using automated procedures from freely-available, web-based sources. The database stores information on species (including hosts and pathogens) and where they have been found in the world . Sources of supporting evidence are linked to each entry. Importantly, the database can be regularly updated and is free to access.We finish by describing the validation of three subsets of the database  with lists of pathogens of these hosts produced by other workers.http://www.ncbi.nlm.nih.gov/taxonomy), NCBI Nucleotide database (http://www.ncbi.nlm.nih.gov/nuccore), PubMed citation and index (http://www.ncbi.nlm.nih.gov/pubmed) provide a source of valuable information that may not have been their primary focus. For instance, the descriptive metadata uploaded with genetic sequence submissions can be mined for the purposes of identifying interactions among species, including host-pathogen interactions, or the geographical distribution of the sequenced organism. Below we describe the processes by which raw data were obtained from these sources, and the methods by which interactions between organisms, or organisms and their geographical locations were extracted from these data. Open access, freely available web-based sources, such as the NCBI Taxonomy database (http://www.ncbi.nlm.nih.gov/Taxonomy/). This dataset was manually supplemented with an additional 2,171 organisms of interest that were not found in the NCBI Taxonomy database.856,031 organism scientific names, their unique identifiers (TaxID), taxonomic ranks and classifications were obtained from the NCBI Taxonomy database =>No rank.Where organism name contained any of the following words , was subsequently altered according to the following rules:The application of the above rules resulted in the following changes: Species count decreased from 579,175 to 224,751. Subspecies count increased from 12,289 to 14,821. No rank count increased from 80,692 to 432,584. The remaining organisms were classified at or above genus level and were therefore excluded from the datasets described in this paper.A is a parent of Organism B were also obtained from NCBI to replicate the hierarchical phylogenetic structure for the species, subspecies and no ranks listed above so that outputs can be obtained for species and higher taxonomic groups . The 2,171 additional organisms were forced into the resulting tree, assigned to the most suitable parent nodes; where the correct parent was not found already in the tree, new nodes were added.Taxonomic lineage relationships of the form Organism 9. Where needed, the organisms were linked to sets of inclusion (AND) and exclusion (NOT) terms. These sets  were utilised in disambiguating organism names and in retrieving publication metadata from PubMed as described in subsequent sections.Some organisms were then linked to a collection of alternative names  that were collected from a variety of sources including textbooks. Additional care was given to humans and their domestic animals. Here, we focussed on 46 species of common domestic animals in Europehttp://www.geonames.org), and subsequently supplemented with the list of countries available in the Medical Subject Headings (MeSH) library (http://www.ncbi.nlm.nih.gov/mesh). For each country (particularly for larger countries), information about the country's administrative divisions was collected; State codes and acronyms for countries such as the United States, Brazil, and China were also added . For the purposes of the datasets described here only the first level administrative divisions (hereafter regions), were required; for these regions , extensive lists of major cities, natural features and unique place names were also obtained from GeoNames and other sources.To enable the discovery of the geographical distribution of species a comprehensive dictionary of geographical names was built. First a list of countries and their alternative names was obtained from the GeoNames geographical database  the host tag indicated the possibility of the sequenced organism being found Country: where available (17.5%) the country tag indicated the possibility of the organism being found in a certain geographical location that can be associated with a single country (and/or water body). 59.9% of sequences with country tag contained additional location information, such as the name or code of a state, a river, or a national park in which the organism was found.The total of 39,238,061 nucleotide sequences' metadata files covering the period 1993–2012, were retrieved in XML format from NCBI Nucleotide Sequences database. The following data items were extracted (where available) from each metadata file (And (All of the inclusion terms)) NOT (any of the exclusion terms). Below is the search term generated for classical swine fever virus:Comprehensible search terms were automatically built using the three sets of names associated with each organism adhering to the following rule:   NOT ‘african swine fever’ [Text Word]6,473,167 citation metadata files were downloaded in XML format from the PubMed database. 6,028,487 of these files cited 7,463 species, 323,483 cited 208 subspecies and 674,836 cited 1,482 no rank organisms. Note that one paper may cite more than one organism.Using the data and evidence obtained and processed as discussed above, two types of interactions were identified: species-species interactions and species-geographic location interactions.Cargo G) being found in or on another species (Carrier A). Many of these interactions are of the type: Pathogen P was found in Host H, however due to the nature of the underlying evidence we cannot assume all interactions to be of this type. Interactions can also be commensal  or mutualistic , or vector-host. Additionally, an organism that is pathogenic to one host may be non-pathogenic in another so it is inappropriate to label the organism itself a pathogen; rather, it is interactions between species that are pathogenic or non-pathogenic. We therefore use a more generic terminology: Cargoes are found in/on Carriers. Cargoes are often pathogens and carriers are often hosts, but this is not always the case.Species-species interactions indicate the possibility of one species  where information is provided for the host tag. Where the metadata for an organism includes an entry for the host tag, we infer a cargo-carrier interaction. These files were processed as follows:Cargo species identification: sequenced organisms ranked above species-level were discarded from this dataset. Subspecies and no ranks were used to recursively identify their parent species in conjunction with the taxonomic tree. In other words, if the cargo is a subspecies, we store the interaction of the parent species with the carrier, not the subspecies itself.Carrier species identification: the host tag was used to directly identify 73.6% of carriers to species level. For the remaining sequences a simple disambiguation algorithm was applied resulting in the identification of 94.5% of carriers. As with cargoes, sequenced organisms ranked above species level were discarded, and sequenced organisms ranked below species level (sub-species and no rank) were assigned to their parent speciesEvidence extraction from publications: Having used the nucleotide database to define organisms as cargoes and carriers, we used this information to interrogate the publication metadata files obtained from PubMed. First, we retrieved all publication metadata files from PubMed for all cargoes and carriers identified above. Then, we intersected the two sets for common PubMed identifiers . This enabled us to identify new combinations of carrier and cargo that were not apparent from the nucleotide evidence. Following a validation exercise9 a threshold of at least 5 papers was applied in including a publication-only interaction that was not backed up by sequence-based evidence.The identification of carrier-cargo interactions is a two steps process:22,515 unique species interactions were thus generated between 6,314 carrier species and 8,905 cargo species. Species identification: sequenced organisms were processed in a similar way to cargoes in the previous subsection.Country identification: the country part of the extracted strings was matched against our collection of geographical identifiers. Where the country was found to be a historical one  region information (if available) were used to identify the country (and where possible region), otherwise data were discarded. Water bodies , were also discarded where no region substring was provided, or where the region substring was also a water body.‘Italy: Milan’: C=Italy and R=Regione Lombardia.‘USA: MA’: C=United States and R=Massachusetts.‘China: Shantou’: C=China and R=Quangdong sheng.‘United Kingdom: Yorkshire, Old Peak’: C=United Kingdom and R=England.Region identification: countries without administrative divisions and small countries  were excluded from this step. A region identification algorithm was applied. The algorithm splits the location string into substrings, each of which is matched against the collected location names from higher to lower ranked places , and selecting the highest ranked match. Below are some examples:Location identification: The string within the country tag was assumed to adhere to the following format ‘Country: Location’, the typical format of items within the nucleotide database.Evidence extraction from nucleotide sequences metadata: 6,714,520 metadata files where location information was provided , were processed as follows:C.A MeSH-based search term was generated to retrieve PubMed paper identifiers (PMIDs) for publications about C. We refer to this set of PMIDs as PMID‘Scotland’ [title or abstract] or ‘Glasgow’ [title or abstract] or ‘Edinburgh’ [title or abstract]) or …...). We refer to this set of PMIDs as PMIDR.For each region R of C, a title and abstract only search term was generated using the region name, major cities and landmarks within the region. For instance, the following search term was used to retrieve publications about Scotland (RC.Only the PMIDs appearing in both sets were included when extracting information about regions within a country. We refer to this set as PMIDC and PMIDRC.The set of PMIDs retrieved for each species was then intersected with PMIDWhere the results of the intersection contained five or more publications the interaction of species-country or species-region (in a country) was added to the database.The country C is in the MeSH library:The country C is not in the MeSH library: an altered search term was used to look for the country in the title or abstract of the papers using the country's official name and the set of alternative names. Steps (a).ii-(a).v were then executed as described above.Evidence extraction from publications: Suitable PubMed search terms were generated for countries and their regions, taking into account whether the country is in the MeSH library, and including the main geographical locations  in the search terms, as per the following steps:Location interactions indicate the possibility of a species being found in a certain location. Locations were interpreted at two levels: country C and region R. Regions correspond to first administrative divisions rather than geographical or natural regions , departments (France), home nations (UK), etc.). Similarly to above, these interactions were extracted in two steps.In this way, 157,204 locations for 72,533 species were identified.The raw data curated in the above steps, and the identified interactions are stored in a web-fronted relational-database, the Enhanced Infectious Disease Database (EID2) (www. zoonosis. ac. uk/ EID2/). The database is continuously updated with new organisms, evidence and interactions. EID2 uses a 4-tier modular architecture separating the web front from the business logic and the database services following the S#arp Architecture model. EID2 is a web-based system, its user-interface UI is accessible via multiple web-browsers, and is supported by ASP.NET MVC framework from Microsoft Corporation. EID2 utilises and integrates various technologies such as Fluent Nhibernate for conversion-based, strongly typed mapping, and a number of technologies for visualisation and data-display. EID2 is freely accessible via a free of charge and simple registration procedure and subsequent login. In addition to the datasets presented in this paper, EID2 UI enables the user to access each of the evidence pieces on which the interactions were based; generate maps of the distribution of all organisms at both country level and region level, as well as access climate and other useful data.9. A summary of the species-species interactions is shown in Cargo: name of cargo species.Cargo classification: the taxonomic classification of the cargo .Carrier: name of carrier species.Carrier classification: the taxonomic classification of the carrier .Sequences count: Total number of nucleotide sequences supporting the interaction.Publication count: Total number of PubMed publications supporting the interaction.Sequences: semi colon separated list of the nucleotide sequence identifiers (GIs) that can be used to retrieve these sequences from the NCBI Nucleotide database. For readability purposes this list was restricted to a maximum of 100 identifiers.Publications: semi colon separated list of the PubMed citation identifiers (PMIDs) that can be used to retrieve these publications from the NCBI PubMed database. For readability purposes this list was restricted to a maximum of 100 identifiers.The full species-species interactions dataset was uploaded, in csv format, to FigShare Data Citation 1. This dataset comprises the following fields:Species: name of species.Species classification: the taxonomic classification of the species.Country: official name of the countryRegion: where available the official name of the region (sub-country) part of the location is provided.Sequences count: similar to previous dataset.Publication count: similar to previous dataset.Sequences: similar to previous dataset.Publications: similar to previous dataset.The generated species-location interactions dataset was uploaded, in csv format, to FigShare (Data Citation 2). This dataset comprises the following fields:et al.9 provides an in-depth validation of PubMed based interactions, particularly for location interactions in Europe.We focus on validating the quality of the information extracted from the nucleotide sequences metadata, as this evidence base provide support to 94.36% of species interactions and 94.95% of location interactions. McIntyre host (carrier) species and sub-species were extracted from 24,656 unique strings in 1,074,943 nucleotide sequence metadata files. In 82.21% of the cases (in 74.47% of the files) no disambiguation was needed as the host tag contained the Latin name of the host. The remaining 4,412 host strings were manually checked against the collection of alternative names in the EID2 database. Following these two steps, a total of 99.44% host strings were correctly matched to a host (carrier) species. (99.63% when taking the number of sequence in which each string occurred into the equation).Here we differentiate between country-only disambiguation and country and region disambiguation. Country level information was extracted from 2,216,652 nucleotide sequence metadata files . Here, the verification was straightforwardly achieved by comparing the ‘country’ part of the string extracted from the sequence with the country names in the EID2 database. 99.99% of strings were correctly matched at country level .USA: Japan and where the region and country belonged to two different countries. At regional level, we have found that 99.65% of the regions were correctly identified. Sample sizes for these validation exercises were estimated for accepted error of 1%, confidence level of 99%, and a conservative estimate of 50% failure.Country and region disambiguation were performed on 80,441 unique location strings extracted from 2,302,691 nucleotide sequence metadata files. In order to estimate the accuracy of our methods, we examined a sample of 13,150 unique country tags. The sample was randomly selected and the results manually checked. We found that 99.99% of the countries were correctly matched. Mismatched countries included ambiguous country tags such as Homo sapiens as the carrier (host) was compared against the 1,415 pathogens of humans listed in Taylor et al.5 64.95% of human pathogens in Taylor et al.5 were included in our list, whereas 57.05% of human cargoes in our list were included in Taylor et al.5 Combining both sources resulted in 2,107 possible cargoes of humans. The species interaction data Data Citation 1 with et al.3 was obtained. Where the pathogen-host interactions were implicit, only the exclusive terms were selected . As the number of hosts in Cleaveland et al.3 is limited, we have focused on comparing the pathogens rather than the interactions. In other words, we have assumed that Data Citation 1 and Cleaveland et al.3 share a pathogen P if both datasets included an interaction between P and any of the hosts listed in Cleaveland et al.3 The percentages of shared cargoes were then calculated as follows: 67.10% of pathogens listed in Cleaveland et al.3 were found to be associated with the same species in Data Citation 1, and 59.15% of the cargoes extracted from Data Citation 1 for the mammals identified in Cleaveland et al.3 were also found in Cleaveland et al.3 Combining both sources resulted in 1,339 possible cargoes for the domesticated mammals listed in Cleaveland et al.3A list of the pathogens infecting the domesticated mammal species as investigated in Cleaveland http://www.mammalparasites.org/)10. The list was then processed to identify unique interactions between wild mammals and their parasites, and only those with non-negative prevalence were taken into consideration. This is because the EID2 database is a presence only database, as the nature of the underlying evidence-base makes it hard to identify negative interactions of the type pathogen P is not prevalent in host H without further development of the algorithms used in extracting interactions from this evidence base. Following this step, 304 positive prevalence interactions between wild mammals and their parasites were identified from the GMPD database, and provided a basis for comparison with the species-interaction dataset discussed here.A list of 5,142 interactions at species or sub-species level between wild mammals and their parasites was obtained from the Global Mammal Parasite Database (GMPD) .


A European web-based registry for refractive surgery was established in 2008; The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO). The aim of the registry was to improve treatment and standards of care for refractive surgery. Further aims were to offer a tool for benchmarking by establishing a reference database and for surgeons to enter and analyze their own outcomes. The purpose of this study was to characterize the registry and analyze the data collected during its first decade.th 2004 until June 30th 2014 are included in the analysis. The database is analyzed in terms of surgical technique, indications for surgery, complications, and refractive and visual outcomes.The characteristics of the web-based registry are described. Data collected from February 4Data have been reported from 47 centers in 14 countries until mid-2014. About 4,000 procedures were reported annually. The most frequent procedure was laser-assisted in-situ keratomileusis (LASIK) with 11697 reported surgeries. Over time in the database, LASIK declined (p < 0.001) while photorefractive keratectomy (PRK) and refractive lens exchange (RLE) increased (p < 0.001 for both procedures). The indications for surgery, in terms of preoperative refraction and age, were stable over time, for all types of procedures. Surgical complications were reported infrequently and with a well-known relationship to the type of surgical procedure. The reported refractive outcomes were good. The visual outcomes indicate a significant increase of visual acuity after high myopia treatment by phakic intraocular lens in the anterior (phakic IOL AC) and the posterior (phakic IOL PC) chamber and a poorer visual outcome, after both myopia and hyperopia treatment, by epithelial LASIK (Epi-LASIK).We describe the establishment of a European registry for refractive surgery. The database increases at a rate of approximately 4000 refractive procedures per year. The most frequent procedure is LASIK, but both PRK and RLE are an increasing part of the reported procedures. The indications for surgery have been stable over time. Surgical complications and visual outcome vary, depending on the type of surgery. In 2004, the European Society of Cataract & Refractive Surgeons (ESCRS) took the initiative to establish a registry for refractive surgery outcomes: the Refractive Surgery Outcomes Information System (RSOIS). The purpose of this web-based system was to record outcomes of refractive surgery and improve quality of care for these procedures. Reasons behind the initiative were the growing health tourism within the field and increasing patient complaints after refractive surgery reported in the press, in some countries ,2. PatieThe aims of the project were to improve treatment and standards of care for cataract and refractive surgery, and to develop evidence-based guidelines for cataract and refractive surgery across Europe. Further aims were to offer a tool for benchmarking by establishing a reference database and to provide a system for surgeons to record and analyze their own outcomes. Finally, the project also served to continue the RSOIS initiative and merge data into the new database. Details about technical, clinical, and legal issues have been published earlier .The purpose of this report is to describe the establishment of a European refractive surgery database and to describe the achievements, in terms of participating countries, surgeons, and trends within refractive surgery, as reflected by the growing database.http://eurequo.org) for manual input of data , and no complications. Quality indicators reflecting these three important outcomes were decided on, and dictated the choice of variables. Demographic and case-mix variables were also included for accurate benchmarking. The output reports were designed on the basis of earlier experience (RSOIS). Each participating center/surgeon can obtain output statistics from the database via the web, in the form of frequency tables or graphs Figure . The systh 2004 (in the RSOIS database during 2004-2007 and in the EUREQUO database from 2008 onwards). Data entered until June 30th 2014 are included in the analysis. All statistical calculations were performed using IBM SPSS Statistics software package, version 22, IBM Ltd, Chicago, Ill. Changes over time for surgical techniques were tested with logistic regression analysis. A p-value of <0.05 was considered significant.The data presented here have been derived from the EUREQUO database. Data have been entered into the system from February 4th, 2004 and June 30th, 2014 was 27,339. Data were entered by 47 centers/surgeons from 14 countries. The contributing countries are Denmark, Austria, Germany, Greece, Great Britain, Ireland, Spain, Iceland, Belgium, The Netherlands, Slovakia, Slovenia, Sweden and Turkey.The number of refractive procedures reported into the system between February 4The number of refractive procedures reported to the database, per annum, from 2010 onwards, was, approximately, 4000.The most frequently reported procedure in the database was Laser-assisted in-situ keratomileusis (LASIK) Table .Table 1The majority (95.2%) of reported refractive procedures were primary procedures. The remaining procedures were enhancements or additional procedures to a primary procedure. The frequency of reported surgical techniques, changed over time Figure . The proThe indication for surgery in terms of preoperative spherical refraction and age, differed among surgical techniques and between myopia and hyperopia. Table In the refractive correction of myopia, LASIK was mainly used for low myopic corrections, with 86% of the treated eyes in the database having preoperative spherical equivalent of less than -6.0 D. For laser-assisted subepithelial keratectomy (LASEK) and PRK, the corresponding numbers were 87.6% and 89.7%, respectively. Phakic IOL AC were used for higher myopic corrections; 31.3% of reported phakic IOL AC cases had preoperative spherical equivalent of -10.0 D or more, and 83.3% had -6.0 D or more. The corresponding numbers for RLE were 13% and 47.1%, respectively.Trends over time, in the level of preoperative myopia, as an indication for specific refractive procedures, are shown in Table The mean preoperative refraction for different reported refractive procedures, was stable over time, in the database Table .Table 4The mean age of patients undergoing RLE increased  over time, but the mean age of patients undergoing other refractive procedures, remained stable.Surgical and postoperative complications are listed in Table Table The mean postoperative refraction , achieved with different refractive procedures, is shown in Table As shown in Table Table In this study, LASIK is the most frequently reported refractive surgery. LASIK technique and outcome has indeed been reported in numerous studies since the development of this surgical technique ,8. HowevThe majority of refractive procedures in the database were aimed at treating myopia. Low and medium myopia was reported for LASIK, LASEK, Epi-LASIK and PRK. These techniques were used for eyes with an average myopia between -3.2 to -3.6 D. For higher myopia, Phakic IOL (average -8.5 D) or RLE (average -5.8 D) were used. Trends in the database do not show significant changes in indications for treating myopia or hyperopia over time .The database was meant to offer an opportunity for comparison and bench-marking to the benefit of participating surgeons, clinics, and their patients. The low inflow of data indicates that European refractive surgeons have not detected or appreciated this opportunity. This is in contrast to a number of other ophthalmic databases, which have generated much more interest from ophthalmologists. The quality registry databases for cataract ,15, cornOne weakness of this study is that all data are self-reported by self-selected surgeons interested in reporting to a clinical database. We do not know whether these clinics are a selection of well-performing clinics or just clinics interested in quality control. If the majority of data come from well-performing clinics there may be a bias towards a very good outcome. However, the selection of surgical technique, indications, and trends over time should not be affected. Other weaknesses include the use of different visual acuity test charts and that we do not have data on the use of mitomycin C for surface laser treatments. A strength of this study is the large amount of data from different clinics and countries reflecting outcomes in real life. We hope that the increasing interest in quality improvement among refractive surgeons will result in more reporting to the database in future. Furthermore, with a larger database, more detailed analyses can be performed. The fields for data collection, included in the web form, are currently being reviewed.A European registry for refractive surgery has been established. The purpose of the registry is to improve quality of care and serve as a reference database for benchmarking. The number of reported surgical procedures increases with around 4,000 cases added annually. The registry shows changing trends in reported types of surgical procedure but stable indications and good refractive outcomes. The frequency of surgical complications and visual outcomes varies between the surgical procedures.