Background: Emerging evidence points to potential roles of the humoral immune responses in the development of pancreatic cancer. Epidemiological studies have suggested involvement of viral and bacterial infections in pancreatic carcinogenesis. Experimental studies have reported high expression levels of antigens in pancreatic cancer cells. Therefore, we aimed to investigate the role of different components of humoral immunity in the context of pancreatic cancer. We evaluated associations between pre-diagnostic serum markers of the overall humoral immune system , and the risk of pancreatic cancer in the Swedish Apolipoprotein-related MORtality RISk (AMORIS) study.Methods: We selected all participants (≥20 years old) with baseline measurements of IgA, IgG or IgM . Participants were excluded if they had a history of chronic pancreatitis and individuals were free from pancreatic cancer at baseline. Multivariate Cox proportional hazards regression was used to estimate risk of pancreatic cancer for medical cut-offs of IgA, IgG, and IgM.Results: Compared to the reference level of 6.10–14.99 g/L, risk of pancreatic cancer was elevated among those with IgG levels <6.10 g/L [HR: 1.69 (95% CI 0.99–2.87)], and an inverse association was observed among those with IgG levels ≥15.00 g/L . The association appeared to be stronger for women than men . No associations were observed with IgA or IgM.Conclusion: An inverse association was observed between pre-diagnostic serum levels of IgG and risk of pancreatic cancer. Our findings highlight the need to further investigate the role of immune response in pancreatic cancer etiology. Pancreatic cancer is predicted to be the second leading cause of cancer-related death by 2030 , and is Helicobacter pylori and found contradicting results  in relation to pancreatic cancer.The Swedish Apolipoprotein-related MORtality RISk (AMORIS) cohort includes information from blood and urine samples for 812,073 subjects obtained and analyzed between 1985 and 1996. All laboratory analyses were conducted at the Central Automation Laboratory (CALAB), Stockholm. The subjects were residents of Sweden and were predominantly living in the Stockholm county, ranging in age from less than 20 to over 80 years old. All participants were either healthy individuals referred for clinical laboratory testing as part of health check-ups or outpatients referred for laboratory testing . A more The AMORIS cohort has been followed via record linkage using the Swedish 10-digit personal identity number in Swedish national health registers, registers of quality of care, and surveys including socio-economic data as well as a questionnaire and biomedical data from number of research cohorts . For theThis study included all individuals aged 20 years or older who were free from pancreatic cancer at baseline, as registered in the National Cancer Register dating back to 1958. Furthermore, participants were excluded if they had a history of chronic pancreatitis, as defined in the National Patient Register going back nationally to 1987 and regionally to 1964. All subjects were required to have a baseline measurement of IgA or IgG or IgM measured at a health examination between 1985 and 1996. If a participant had multiple measurements of an immunoglobulin, the first measurement was included in the study to allow for consistency across the entire cohort. Follow-up time was defined as time from baseline measurement until date of cancer diagnosis, death, emigration, or end of the study (31st of December 2011), whichever occurred first.The main outcome variable was a diagnosis of pancreatic cancer , Revision 7 (1955) code 157). We also included the following information from the AMORIS study: serum IgA (g/L), serum IgG (g/L), serum IgM (g/L), serum glucose (mmol/L), age at baseline measurement and gender. From the other registries, we collected information regarding education, Charlson Comorbidity Index (CCI) and socioeconomic status (SES).The quantitative determination of IgA, IgG, and IgM was performed using turbidimetry with reagents  using a HITACHI 911 automatic analyser  with a coefficient of variation <5% (IgA), ≤ 5% (IgG), and ≤ 7% (IgM) –42.We estimated the risk of pancreatic cancer with multivariate Cox proportional hazards regression for medical cut-offs used in the CALAB laboratory of IgG  . IgA wasMultivariate Cox proportional hazards regression models were adjusted for age, gender, education, CCI and serum glucose level (continuous variable). A test for trend was conducted by using assignment to medical cut-offs as an ordinal scale for IgG. To assess reverse causation, a sensitivity analysis was conducted in which those who had a follow-up time <1 year and <3 years, respectively, were removed.P-value for interaction was calculated.With regards to IgG, we performed stratified analyses for age (<55 and ≥55), gender  and serum glucose levels (<7.00 and ≥7.00 mmol/L). A Finally, restrictive Cubic Spline (RCS) function was used to graphically display the hazard ratios representing the dose-response association between IgG and the risk of pancreatic cancer. We used knots located at the 5, 50, and 95th percentiles. This analysis was performed using the RCS_RegSAS Macro created by Desquibet and Mariotti . All staCharacteristics of study participants with a measurement of IgG are shown in Ptrend = 0.027]  for the association between immunoglobulin G and the risk of pancreatic cancer showed that, compared to the IgG reference level of 6.10–14.99 g/L, there was a positive association for those with IgG levels <6.10 g/L [HR: 1.69 (95% CI 0.99–2.87)]. We also found an inverse association for those with IgG levels ≥15.00 g/L  . A sensiStratified analysis by gender showed a similar inverse association between categories of IgG and the risk of developing pancreatic cancer. However, the strength of the association was more pronounced for women P = 0.003) . No effe . No effCharacteristics of study participants with a measurement of IgA are shown in We found no association between immunoglobulin A or immunoglobulin M and the risk of pancreatic cancer , 7.In this project, we indicate the presence of an inverse association between serum IgG levels and the risk of developing pancreatic cancer in the Swedish AMORIS cohort. The inverse association was stronger in females compared with males. Pre-diagnostic serum levels of IgA or IgM did not show any association with the risk of pancreatic cancer.The immune system has been thought to modulate the development and evolution of pancreatic cancer . TobaccoHelicobacter Pylori is suggested as a risk factor for pancreatic cancer , a serum biomarker of allergies studied previously in relation with pancreatic cancer , was onlTo our knowledge, this study is the first prospective cohort study evaluating the association between pre-diagnostic serum markers of the overall humoral immune response and the risk of pancreatic cancer. We observed an inverse association between pre-diagnostic serum levels of IgG and the risk of pancreatic cancer. Our findings highlight the need to investigate the roles of different components of humoral immunity and agents that may cause a humoral immune response related to pancreatic cancer. Future studies could provide further insight into potential biological mechanisms by exploring longitudinal data such as repeated measurements of pre-diagnostic serum markers of the humoral immune system. Moreover, molecular pathological epidemiological studies, exploring tumor tissues, can potentially untangle the interlink between lifestyle factors, microbiome, carcinogenesis and the immune system –66.http://amoriscohort.imm.ki.se.Access to data for collaboration is provided by the Steering group members of the AMORIS study by request in email under the heading AMORIS Cohort Collaboration. This can be found at the AMORIS homepage This study complied with the Declaration of Helsinki and was approved by the Ethics Review Board of the Karolinska Institute who waived the need for consent.SS, AS, NH, GW, and HG: data collection. SS, AS, DM, NH, GW, HG, LH, IJ, and MV: data analysis and interpretation. SS and AS: draft of manuscript. SS, DM, AS, DS, SK, DJ, NH, GW, HG, LH, IJ, and MV: final editing of manuscript. We can confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Depression is one of the most common disorders in psychiatric and primary care settings, and is associated with disability, loss in quality of life, and economic costs. Internet-based psychological interventions have been shown to be effective in depression treatment but present problems with a low degree of adherence. The main aim of this study is to analyze the adherence predictors in three low-intensity interventions programs applied by Information and Communication Technologies (ICTs) for depression. A multi-center, randomized, controlled clinical trial was conducted with 164 participants with depression, who were allocated to: Healthy Lifestyle Program, Positive Affect Promotion Program or Mindfulness Program. Sociodemographic characteristics, Patient Health Questionnaire-9, Visual Analog Scale, Short Form Health Survey, Positive and Negative Affect Schedule, Five Facets Mindfulness Questionnaire, Pemberton Happiness Index and Treatment Expectancy Questionnaire were used to study adherence. Results showed that positive affect resulted in a predictor variable for Healthy Lifestyle Program and Positive Affect Promotion Program. Perceived health was also a negative adherence predictor for the Positive Affect Promotion Program. Our findings demonstrate that there are differences in clinical variables between treatment completers and non-completers and we provide adherence predictors in two intervention groups. Although new additional predictors have been examined, further research is essential in order to improve tailored interventions and increase adherence treatment. About 30 million Europeans are estimated to suffer from depression . In SpaiA large body of research has reported that Internet-based intervention programs have been shown as an efficacious therapeutic option for the treatment of many mental health problems including depression ,17,18,19A large body of research has focused on the study of adherence predictors in the past years ,29,30,31In reference to clinical predictors, baseline depression severity is one of the most commonly explored characteristics. Many studies have reported that lower levels of baseline depression predicted adherence ,25,28 whOther psychological characteristics were also studied, such as pre-treatment expectations, perceived credibility of the treatment, and/or attitudes toward Internet-interventions. Nevertheless, results showed that these variables were not related with treatment completion ,34. It iFor all these reasons, it is crucial to examine new additional characteristics such as factors of mindfulness, positive and negative affect, and well-being, in order to have new knowledge of which variables are associated and predict treatment adherence.The aim of the present study is to examine the differences in sociodemographic and clinical characteristics between treatment completers and non-completers and to analyze the adherence predictors in three low-intensity intervention programs applied by ICTs: Healthy Lifestyle Program; Positive Affect Promotion Program and Mindfulness Program, for depression treatment in Spanish Primary Care.The current study is a secondary analysis of a multi-center, controlled, randomized clinical trial conducted with patients with depression recruited in the primary care. They were randomized to receive one of four intervention groups: (a) improved primary care usual treatment (iTAU), (b) Healthy Lifestyle Program + iTAU, (c) Positive Affect Promotion Program + iTAU or (d) Mindfulness Program + iTAU.Trial Number Registration from the original study is ISRCTN82388279. The aim of the original study was to assess the effectiveness of three low-intensity intervention programs applied by ICTs  compared with a control condition. The research protocol and main results have been reported elsewhere ,36.In the original study, a total of 221 patients with depression were recruited in primary care settings, between March 2015 and March 2016 in the Spanish regions of Aragon, Andalucía and Baleares. Inclusion criteria were: older than 18 years old; DSM-5 diagnose of Major Depression or Dysthymia, with mild or moderate severity depression assessed as score lower than 14 according to the Patient Health Questionnaire (PHQ-9) , with syn = 164) led to a lack of statistical power, resulting in our major limitation.For the present study, a total of 164 participants were selected and included, those who were allocated to one of the intervention groups . Those allocated to iTAU were excluded from the analysis because they were control group, with no access to online treatment. Our small sample size .The Healthy Lifestyle Program provides information to understand the relationship between physical and mental health and physical activity, diet and sleep control. Modules are: (1) Beginning of a lifestyle change, focused on the importance of healthy lifestyle to improve emotional health and general well-being; (2) physical activity—learning to move, to give information about exercises to improve mood, to increase motivation, to start being more active, and to maintain this physical activity; (3) diet—learning to eat, focused on the importance of diet to achieve a good physical and mental health, and the role of the Mediterranean diet in the prevention and treatment of depression; and (4) sleep—the importance of good sleep, to understand the relationship between sleep, and general health.The Positive Affect Promotion Program aims to decrease depressive symptomatology and to prevent relapses using the promotion of well-being and positive affect. The modules are: (1) Learning to live, focused on the importance of establishing and maintaining an adequate activity level and the relevance of choosing activities that are significant for the individual; (2) learning to enjoy, to give education about the effect of positive emotions and to train the patient in learning procedures to increase the likelihood of experiencing positive emotions; (3) accepting to life, focused on the training to the patient in concentrating on positive emotions related with the past or the future; and (4) living and learning, to train the patient in understanding life as a continuous process of learning and personal growth, emphasizing the training in strategies to promote psychological strengths, resilience, and meaningful goals linked to important values.The Mindfulness Program has the objective to decrease depressive symptomatology using mindfulness, emphasizing the benefits of its therapy. The modules are: (1) Getting to know mindfulness, to explain what mindfulness is, prejudices about it, the inattention problem, and some of its main benefits and recommendations to practice it; (2) establishing formal and informal practices, focused on the importance of the establishment of formal and informal practice; (3) through management, body scan practice and values, to help people to see the importance of values to keep a regular mindfulness practice; and (4) Self-compassion. Integrating mindfulness in everyday life, to establish a regular practice of mindfulness to be indefinitely kept.Full details of the interventions are described in Castro et al.  and GiliIn the context of this analysis, adherence refers to the extent to which individuals complete the whole intervention in the post-test evaluation. Therefore, a participant was considered to be part of the adherence group (completer participant) if they completed the whole intervention (1 face-to-face session plus 4 self-guided online therapeutic modules) at the post-test assessment. A participant who did not complete the whole intervention at the post-test was considered non-completer participant.Case report form (CRF). The patient’s sociodemographic and clinical characteristics were gathered using a CRF: gender, date of birth and age, place of residence, family status, if they live alone or accompanied, level of education, work status and income level. Psychopharmacologic medication (yes vs. no) and the number of physician visits in the last 12 months were also collected.The Mini International Neuropsychiatric Interview 5.0 (M.I.N.I. 5.0) . This diPatient Health Questionnaire-9 (PHQ-9) . This inThe Visual Analog Scale of the EuroQol (VAS); . This scThe Short Form Health survey (SF-12v1) . This scPositive and Negative Affect Schedule (PANAS) . This scFive Facets Mindfulness Questionnaire (FFMQ) . This quThe Pemberton Happiness Index (PHI) . This inTreatment Expectancy Questionnaire . This quhttps://psicologiaytecnologia.labpsitec.es/). Included participants were randomized to 1 of the 4 groups by an independent researcher using a computer-generated random number. The Ethical Review Board of the regional health authority approved the study (Ref: IB 2144/13 PI). More details about the study design, recruitment, randomization and data collection procedure are described elsewhere [Patients were recruited in Spanish Primary Care settings. When the general practitioner (GP) identified a potential participant during a visit, he or she explained to the participant the characteristics of the study. If the participant was interested on it, he or she signed an informed consent form and the GP filled a referral form describing the sociodemographic characteristics of the patient and a checklist for inclusion and exclusion criteria. GP also gave him or her the patient’s information sheet and a handout describing the study. Then, the GP sent these documents to the local researcher. Participants were interviewed after a few days by the researcher, which administered psychological assessment instruments related with inclusion and exclusion criteria by phone. All participants fulfilled their assessments through a web . Descriptive analysis examined the differences between groups of adherence (treatment completer vs. non-completer) for each intervention group and was computed in terms of mean and standard deviation for continuous variables, and frequency with percentage for ordinal and nominal variables. Discrete variables were compared using the chi-square test and Student t tests were used for continuous variables comparisons. A post-hoc analysis was conducted in order to explore the intervention group differences regarding adherence considering adherence as a dichotomous variable (completers vs. non-completers) through chi-square homogeneity test, and as a continuous variable (number of modules completed) by ANOVA test. Logistic regression models using adherence as a dependent variable were constructed using independent predictor variables. Subsequent binary logistic regression analyses for each intervention group were conducted to build parsimonious models. Significance associated probability for analyzed contrasts were fit to 0.05, while significance analyses for b coefficients in logistic regressions and for Odd Ratios were calculated based on 95% CI. The effects of b coefficients of final logistic regressions were bootstrapped with 1000 replications. The analyses were performed using IBM SPSS v22 .Final analyses were undertaken on 164 subjects, those who were allocated in one of the three intervention groups, with 32.9% receiving Healthy Lifestyle Program, 32.9% receiving Mindfulness Program, and 34.1% receiving Positive Affect Promotion Program. The sample was predominantly female (79.9%) and the mean age was 45.03 (SD = 11.16) years. Most were married (58%), lived accompanied (83.4%), had primary/secondary educational level (68%) and had no paid employment (51.6%), and had an income level predominantly more than 2 NMW (35.6%). With respect to clinical variables, the PHQ-9 mean of the total sample was 12.62 (SD = 2.34) and 70.9% used psychopharmacologic treatment.p = 0.000), baseline scores from “Describing” FFMQ Subscale  and baseline global average PHI . In the Positive Affect Promotion Program, statistically significant differences between treatment completers and non-completers were found in baseline perceived health, self-measured by the VAS  and baseline scores from “Not reacting to inner experience” FFMQ Subscale . In the Mindfulness Program, statistically significant differences between treatment completers and non-completers were not found in sociodemographic and clinical variables.Regarding differences in sociodemographic and clinical characteristics between treatment completers and non-completers in each intervention groups, analysis found that the Healthy Lifestyle Program group had statistically significant differences in Positive Affect baseline scores, self-measured by the Positive Affect dimension from PANAS Schedule (PA-PANAS)  = 4.417; p = 0.110), nor in terms of modules completed .Results of the post-hoc analysis found neither statistically significant differences in the proportions of completers and non-completers between intervention groups (χp < 0.10). After a literature review, models were also adjusted by the following variables: age, sex, educational level, depression symptomatology (PHQ-9), perceived health (VAS), and treatment expectations.A logistic regression was carried out to test if there were interactions between the predictors variables. Because of an effect of interaction between some predictor variables and intervention variable, models were analyzed separately. After that, a bivariate analysis was performed between independent baseline demographic and clinical variables and adherence (completers vs. non-completers) as a dependent variable in order to identify the potential predictors. No reactivity to inner experience FFMQ subscale and positive affect (PA-PANAS) variables were significantly associated (p = 0.005) for Healthy Lifestyle Program and perceived health (self-measured by the VAS) for Positive Affect Promotion Program (p = 0.012). Models were significant fit of data for Healthy Lifestyle Program (X2(8) = 23, p = 0.003) and for Positive Affect Promotion Program (X2(8) = 21.628, p = 0.006) but not for Mindfulness Program (X2(8) = 2.479, p = 0.963).Odds ratio (OR) and 95% confidence intervals for each adherence predictor in each intervention group are shown in 2(1) = 16.11, p < 0.001, for Healthy Lifestyle Program; χ2(2) = 16.358, p < 0.001 for the Positive Affect Promotion Program  = 3.422, p = 0.181).For Mindfulness Program, the most parsimonious model was found, although it was not significant fit of data  for depression in primary care.Our completion treatment rates were relatively low in the whole sample (41.5%) and in each intervention groups with no differences between them . Our results were comparable to previous research that showed that only about half of the participants of unguided interventions complete all modules . HoweverContrary to prior findings, sociodemographic characteristics were not associated to adherence condition in our sample. This is inconsistent with the findings of earlier researches on this subject which found that participant’s characteristics, such as age, gender, or educational level are associated with adherence ,29. In tWhen logistic regression analyses were performed, some of our findings were attenuated. According to adherence predictors, a consistent finding was found: for patients in Healthy Lifestyle Program and Positive Affect Promotion Program, positive affect, self-measured by the PA-PANAS, predicted adherence. Hence, those participants that presented high positive affect scores at baseline tend to adhere more than those with low positive affect levels. A possible explanation of this finding could be that positive affect assesses personal traits such as interest, excitement, enthusiasm, among others. These traits could be related to the motivation to start and use a non-conventional psychotherapy such as an intervention program applied by ICTs, as the Healthy Lifestyle Program or the Positive Affect Promotion Program are. Also, it is important to note that Positive Affect Promotion Program is mainly designed to decrease depressive symptomatology through the promotion of positive affect and subjective-well-being, and this could maybe explain why people with higher basal levels of positive affect persist in this program. Nevertheless, our finding cannot be compared with the previous literature. To the best of our knowledge, this predictor has not been explored before. Therefore, more research is required to determine the impact of this predictor on adherence in other intervention programs applied by ICTs for depression.Perceived health, self-measured with the EuroQoL VAS, also predicted adherence but just in Positive Affect Promotion Program. Therefore, those participants that perceived their health to be worse at baseline assessment are more likely to adhere to the treatment. As we reported before, Positive Affect Promotion Program is also designed to promote well-being, and well-being could be related with perceived health. Participants with worse perceived health could feel the treatment useful for their health and maybe they are more like to keep on this program.The result that perceived health is related to adherence is partially in line with the findings of an earlier study on this subject, where Castro et al.  found thIn fact, a growing body of research found that low depression severity at baseline predicted higher adherence ,25,26,28No adherence predictors were found for Mindfulness program. Possible explanations of this fact could be that the percentage of treatment completers and non-completers are almost equal. Another potential explanation could be that this study examined a specific number of predictors of adherence, and perhaps other possible variables that could predict adherence treatment have not been included in this study.There are several limitations associated with this research. First, our sample size is smaller than the previous studies ,27 and cAlthough the adherence rates found in this research are low in the three intervention groups, it is surprising that only about 30% of the participants completed the Positive Affect Promotion Program. More specific research is needed to understand and improve the adherence in this type of intervention in particular, and Internet interventions in general. It is well-known that adherence is an important measure of acceptability, appropriateness, and effect of psychological treatment . The ideOur research found that there are some clinical variables associated with adherence in two low-intensity intervention programs applied by ICTs. In particular, treatment completers present higher basal levels of positive affect, higher basal scores in the FFMQ Subscale Describing and higher basal levels of well-being compared to treatment non-completers in Healthy Lifestyle Program. In Positive Affect Promotion Program, treatment completers present lower basal levels of perceived health and higher basal scores in the FFMQ Subscale Not reacting to inner experience. With regard to adherence predictors, for patients in Healthy Lifestyle Program and Positive Affect Promotion Program, positive affect predicts adherence. That is, those participants that present high positive affect scores at baseline tend to adhere more than those with low positive affect level. Finally, perceived health, is a negative predictor of adherence but just in Positive Affect Promotion Program; those participants that perceived their health to be worse at baseline assessment are more likely to adhere to the treatment. Significant differences in sociodemographic and clinical characteristics between treatment completers and non-completers were not found nor adherence predictors in Mindfulness Program.


They also scored higher in the MLHFQ, denoting worse QoL . Regarding iron metabolism biomarkers, serum soluble transferrin receptor (sTfR) was the strongest independent predictor of functional capacity  and QoL  in multivariate models. This study postulates that ID is associated with worse functional capacity and QoL in HFpEF as well, and that sTfR is the best iron-related biomarker to predict both. Our study also suggests that the effects of ID could differ among HFpEF patients by left ventricular ejection fraction.The effects of iron deficiency (ID) have been widely studied in heart failure (HF) with reduced ejection fraction. On the other hand, studies in HF with preserved ejection fraction (HFpEF) are few and have included small numbers of participants. The aim of this study was to assess the role that ID plays in functional capacity and quality of life (QoL) in HFpEF while comparing several iron-related biomarkers to be used as potential predictors. ID was defined as ferritin <100 ng/mL or transferrin saturation <20%. Submaximal exercise capacity, measured by the 6-min walking test (6MWT), and QoL, assessed by the Minnesotta Living with Heart Failure Questionnaire (MLHFQ), were compared between iron deficient patients and patients with normal iron status. A total of 447 HFpEF patients were included in the present cross-sectional study, and ID prevalence was 73%. Patients with ID performed worse in the 6MWT compared to patients with normal iron status (ID 271 ± 94 m vs. non-ID 310 ± 108 m,  Heart failure with preserved ejection fraction (HFpEF), accounts for more than 50% of chronic heart failure (HF) patients , with inIron deficiency (ID) is a widespread comorbidity among HF patients, with prevalence ranging from 50% in HFrEF to 64% in HFpEF ,11, and Therefore, it is necessary to outline exhaustively this highly prevalent ID in HFpEF in order to characterize its clinical repercussion. It could also be useful to explore whether this potential effect behaves similarly across the LVEF spectrum within HFpEF.The aim of this study was to assess the association of ID in functional capacity and quality of life among HFpEF patients while comparing several iron-related parameters to be used as potential predictors and, finally, to explore possible differences according to LVEF.The DAMOCLES study  was a single-center, observational, prospective cohort study of 1236 consecutive patients diagnosed with chronic HF from 2004 to 2013. For the present secondary analysis, only baseline data from the study was used, acquiring a cross-sectional design. The methodology of the study has been previously published by our group . BrieflyIron deficiency was assessed using the Kidney Disease Outcomes Quality Initiative (KDOQI) criteria , which cp values were obtained using the t-test or Mann-Whitney U test. For qualitative variables, number and percentages within specified groups were calculated using the χ2 test for the p values.Using the baseline data from the DAMOCLES cohort, a cross-sectional analysis was performed. Demographic and clinical characteristics, as well as laboratory test results, were summarized using basic descriptive statistics, both overall and categorized by iron deficiency. For quantitative variables, arithmetic mean and standard deviation or median and interquartile ranges were reported, and 2). Auto-adjusted generalized additive models (GAMs) were used to assess nonlinear associations between (sTfR) and exercise capacity and quality of life depending on LVEF. Finally, to explore possible differences in ID effect according to LVEF in HFpEF patients, we repeated the different analyses based on whether the LVEF was >60% or ≤60%.Univariate and multivariate linear regression models were performed with several iron-related parameters in order to predict 6MWT results and MLHFQ scores, which formed a normal distribution. Logarithmic transformation was used to fit skewed continuous variables, such as ferritin, serum iron, and sTfR, into normal distributions when necessary. Unadjusted models were used in order to clarify the effect of each independent parameter, whereas multivariate ones increased relevance and clinical context, as well as significance and determination coefficient .All N = 447). Patients were subdivided in two groups according to the presence of ID (N = 325) or not (N = 122). The baseline characteristics of the study sample, both overall and according to ID, are shown in From the total 1236 chronic HF patients included in the DAMOCLES study, only those with EF ≥ 50% and with iron-related parameters tested were selected . Furthermore, the number of patients who had to discontinue the test before its completion was greater in the ID group compared to patients without ID. Interestingly, this worse functional capacity present in patients with HFpEF and ID was also observed in those patients without anemia (p < 0.03).A total of 282 patients were able to undergo the 6MWT, 202 in the ID group and 80 in the non-ID group, whereas 107 and 36 were not, respectively. As summarized in p = 0.01), reflecting worse quality of life.Using the MLHFQ to assess quality of life, statistically significant differences were found between ID and non-ID patients. As seen in p = 0.025; social and personal: 8.5 ± 6.7 vs. 6.9 ± 6.3, p = 0.018), although the remaining two dimensions were close to the significance threshold. Results subdivided by items are available in When we analyzed these results according to the different dimensions evaluated in the MLHFQ, physical, as well as social and personal dimensions, were the most affected  and higher scores in MLHFQ, denoting worse quality of life  in patients with HFpEF. On the other hand, the association of the classic definition of the FAIR-HF study [2 = 0.35; p < 0.03) and was not significantly associated with worse quality of life (p = 0.21). This worse predictive capacity of the FAIR-HF definition is consistent with biomarkers univariate results that we obtained, since ferritin was not associated with functional capacity or quality of life, whereas TSAT did in both.The definition of ID we used (ferritin <100 ng/mL or TSAT <20%) was independently associated with worse results in 6MWT  and poorer quality of life  in multivariate models. Detailed results are shown in Our results showed that sTfR was the best iron-related biomarker since it was the only laboratory parameter that was significantly associated with both worse functional capacity  and LVEF ≤60% (N = 227). Baseline characteristics according to these two groups are shown in p < 0.01) and had more ischemic heart disease . We found no differences regarding age, comorbidities, or functional class.Additionally, in order to elucidate possible differences along EF range within HFpEF, our study population was further subdivided in two groups, LVEF >60% . However, we did not find a significant association in the group of patients with LVEF >60% (p = 0.20). In contrast, the association of ID with worse quality of life was found in the group of patients with LVEF > 60%  but not in patients with LVEF 50–60% (p = 0.41).Interestingly, we found differences regarding the association of ID in HFpEF with both functional capacity and quality of life according to the two groups of LVEF . The assp < 0.02) and worse quality of life (p < 0.001). In LVEF >60%, however, we found nonlinear associations with functional capacity (p nonlinear < 0.005) and quality of life (p nonlinear < 0.03).Finally, sTfR, which showed to be the best biomarker of iron status to predict worse exercise capacity and quality of life in the whole cohort of HFpEF, did not show a significant association with either in the subgroup of patients with LVEF >60% in multivariate linear regression models. Again, we found a different response in the association of ID depending on the LVEF in HFpEF patients. We explored these different associations performing generalized additive models (GAM) models, as seen in This study has shown an association between ID and both worse functional capacity and quality of life in HFpEF patients. To the best of our knowledge, this is the largest study on this field, highlighting sTfR as the best predictor biomarker for both in HFpEF for the first time. Furthermore, our study postulates that the effects of ID in patients with HFpEF may be different according to their LVEF. This could support recent studies suggesting patients with HFpEF are a heterogeneous group. Another aspect to highlight is the high prevalence of ID in HFpEF (73%), based on the KDOQI definition of ID, which was superior to the current ID definition based on the FAIR-HF study for the prediction of worse functional capacity and quality of life in patients with HFpEF.Iron is an essential component for the proper function of the mitochondria and, therefore, ID leads to an energy metabolism alteration that is not limited to cardiomyocytes, where it causes cardiac enlargement, ventricular hypertrophy, diastolic dysfunction, and progressive cardiac fibrosis, but also has effects on the striated muscle cells of the musculoskeletal system . Thus, t2 was observed among ID patients. Additionally, the role of TSAT and serum ferritin as predictors were highlighted in the former, although no information was provided about sTfR. As summarized recently by Beale et al. , severalRegarding quality of life, in a 110 HFpEF patients cohort, Bekfani et al.  suggesteRecently, the use of sacubitril/valsartan was evaluated in patients with HFpEF in the PARAGON-HF study . No signOnce the association of ID to worse exercise capacity and poorer quality of life was assessed in HFpEF patients, the next step would be a randomized clinical trial testing iron-depletive treatments to mitigate the differences.As we explained before, HFrEF studies have shown a benefit receiving intravenous (IV) ferric carboxymaltose, with current guidelines supporting its consideration in symptomatic patients with ID and HFrEF, leaving oral iron therapy as ineffective for replenishment of iron stores and improvement of clinical status ,11,17. H2 may have masked the maximal exertion performance. Additionally, existing comorbidities in our study population could condition 6MWT results. However, excluding anemia, which has been analyzed and reported subsequently, the remaining comorbidities affected both groups equally, thus outshining its effects.Some limitations must be taken into account. First, given its single center cross-sectional design, the single determinations of iron profile, functional capacity, and quality of life did not allow us to provide information about their evolution. Second, the inclusion criteria required an exacerbation in the last 12 months, and this could have therefore favored advanced-stage HFpEF patients, as well as diminished the number of 6MWT-eligible patients. Third, the use of 6MWT to measure functional capacity instead of peak VOIn this cohort, we determined that ID was highly prevalent and was associated with worse functional capacity and quality of life in HFpEF patients. After the assessment of several iron-related biomarkers, sTfR showed the best performance to be used as a potential predictor of both. Exploratory analyses suggest possible differences in the association of ID according to LVEF in HFpEF patients, although further research is needed to confirm and explain these findings.


Salmonella). The presence of antimicrobial-resistant microorganisms was investigated for a period of three years and the differences between chicks in the nest (n = 81) and adult and immature birds (n = 61) were analyzed. Gram negative bacteria were isolated in all the samples. Escherichia coli was obtained in 80.28% of the samples, where the prevalence of Salmonella in our study was 6.3%. The results of our study support the idea that raptors could act as reservoirs of Salmonella and antimicrobial-resistant bacteria, posing a risk not only to wildlife but also to livestock and the human population.Antibiotics are used to prevent and treat bacterial infections in both animals and humans. If bacteria become resistant to them, in particular as the result of the misuse and overuse of antibiotics, the infections that they cause are harder to treat. Therefore, the detection of microorganisms resistant to antimicrobial drugs is an important issue, considering the interaction among domestic animals, human, the ecosystem and wild animals. Wild birds, and particularly birds-of-prey, are sentinels, reservoirs, spreaders and a source of infection for human beings and other animals. Wildlife can also act as an asymptomatic reservoir for zoonotic bacteria , an endemic bird of prey. One hundred and forty-two cloacal swabs were obtained; Escherichia coli was isolated from 80.28% and Salmonella from 6.3% of these samples. Low levels of susceptibility to ampicillin, tetracycline and trimethoprim/sulfamethoxazole were found. About 20% of the isolates were resistant or presented intermediate susceptibility to fluoroquinolones. Surprisingly, we found isolates resistant to imipenem (6.96%). Isolates from chicks were more susceptible to antimicrobial drugs than adult and immature birds. About 50% of E. coli isolates were resistant to ampicillin, tetracycline and trimethoprim/sulfamethoxazole, and about 20% to piperacillin, enrofloxacin and marbofloxacin. High percentages of isolates of Salmonella were found to be resistant to cephalexin (88%) and aminoglycosides (greater than 77%). Our results support the idea that raptors could act as reservoirs of Salmonella and antimicrobial-resistant bacteria, posing a risk not only to wildlife but also to livestock and the human population, thus reinforcing the need to minimize the exposure of wildlife to antimicrobial agent through human and livestock waste.Due to their predatory habits, raptors may serve as indicators of the presence of antimicrobial-resistant bacteria in the environment, but they also represent a public health risk for livestock and humans because they can act as reservoirs, sources and spreaders of these bacteria. Our objective was to determine the presence of antimicrobial-resistant bacteria in cloacal samples of Canarian Egyptian vultures ( Neophron percnopterus majorensis) is an endemic bird-of-prey in the Canary Islands, known locally as the “guirre”. Based on its morphological and genetic characteristics, this vulture is a subspecies of the Egyptian vulture (Neophron percnopterus) [Neophron percnopterus majorensis  is included under the category of “In Danger of Extinction” in the Spanish Catalogue of Endangered Species [Neophron percnopterus is included under the category of “Endangered” in the International Union for Conservation of Nature’s (IUCN) Red List of Threatened Species.The Canarian Egyptian vulture (opterus) . It is aopterus) . In addiopterus) ,3. The N Species . NeophroAntimicrobial resistance is a “One Health” issue . “One HeRegarding to antimicrobial resistance, wild birds can be important as sentinels, reservoirs, spreaders and sources of infection for human beings and other animals ,11. The Escherichia coli has been detected in humans, pets, food-producing animals and derived meat products [Escherichia coli, especially in the case of storks (Ciconia spp.), kites (Milvus spp.) and vultures. This research showed that birds could contribute to the global spread of ESBL/pAmpC producing E. coli in natural ecosystems [Microorganisms present in the vulture may exhibit resistance to antibiotics, which could constitute a threat to global health, food security and development, as defined by the WHO . Over thproducts ,14. In Sosystems .Salmonella, and this bacterium can also be a cause of disease [Gyps fulvus), as well as a high percentage of multiresistant Salmonella isolates. Vidal et al. [E. coli was the most common microorganism recovered from necropsies of raptors with clinical signs of septicemia or respiratory disorders. In this research, 50% of all the isolates, and 71% of E. coli, showed multidrug resistance. Fecal contamination of the environment by wild birds could play a role in the transmission of pathogens to humans, via livestock or water supplies. Some important mechanisms of resistance are encoded by genes located on mobile elements and this allows the transference of resistance genes from commensal or opportunistic bacteria like E. coli to pathogenic ones [Salmonella in birds-of-prey could help us to understand the role of birds-of-prey in its epidemiology in terms of the wildlife–human interface [Wildlife can act as an asymptomatic reservoir for zoonotic bacteria, such as  disease . A study disease , showed l et al.  found thnic ones . Investinterface .E. coli and Salmonella. We also compared the resistance throughout the three years of the study and analyzed the differences among chicks in the nest and adult or immature birds.Information on antimicrobial resistance pertaining to Gram-negative bacteria from wild raptors has been obtained mainly from birds at rescue centers, but only a few studies have investigated this topic in raptors living in their natural ecosystems. This knowledge is needed to assess the importance of wild raptors as reservoirs and transmitters of antimicrobial-resistant bacteria, to determine their potential impact on public health and their role as a potential health threat to workers involved in the protection of this animal species . TherefoCloacal samples of vultures were collected during the years 2015 (30 samples), 2016 (62 samples) and 2017 (50 samples), as part of a long-term monitoring program of this population .The birds were classified by age as chicks, immature birds—which include juveniles (less than 2 years of age) and sub-adults (between 2 and 5 years of age)—and adults (over 5 years of age). The age of the animals was determined according to the plumage characteristics and the color of the beak and the eye . Adult aTM, Darmstadt, Germany)) and conserved at 4 °C until they reached to the Microbiology Laboratory (within 24 h).A total of 142 cloacal swabs were obtained, of which 81 were from chicks on the nests and 61 were from wild adult or immature birds. Cloacal swabs were placed in Amies blue plastic/viscose gel transport medium  was also inoculated and incubated overnight at 42 °C, and was later streaked onto Hektoen agar .®2 automated system , with VITEK® 2 GN ID Cards, following the manufacturer’s instructions. These cards allow for the identification of more than 150 species of clinically relevant Gram-negative bacilli.Bacteria were identified using the VitekAntimicrobial susceptibility tests were performed using the disk diffusion method in accordance with the Clinical and Laboratory Standards Institute (CLSI 2015) guidelines . The inoThe following 16 antibiotics were tested: ampicillin (10 µg), amoxicillin/clavulanic acid (20 µg + 10 µg), cephalexin (30 µg), cefpodoxime (10 µg), piperacillin (100 µg), imipenem (10 µg), gentamicin (10 µg), tobramycin (10 µg), amikacin (30 µg), enrofloxacin (5 µg), marbofloxacin (5 µg), tetracycline (30 µg), nitrofurantoin (300 µg), chloramphenicol (30 µg), polymyxin B (300 U) and trimethoprim/sulfamethoxazole (23.75 µg + 1.25 µg).p < 0.05. Additionally, statistical differences in the antimicrobial resistances of Salmonella compared with the rest of the isolated species were studied.For the comparison of the results of the antimicrobial resistance related to the age of the animals, the chi-square with the Yates’s correction for continuity was calculated. SPSS v.22.0  was used to compare datasets. Statistical significance was set at The results of this study identify antimicrobial resistance in Gram-negative bacteria isolated from cloacal samples of vultures on the Canary Island Archipelago (Spain).E. coli, and nine isolates (6.3%) were determined to be Salmonella spp., while the remaining 19 isolates (13.42%) included Proteus mirabilis, Providencia rettgeri, P. stuartii, Klebsiella pneumoniae, K. oxytoca, Raoultella ornithinolytica and Citrobacter braakii.Gram-negative bacteria were isolated in all the samples. Biochemical identification was carried out for one colony per plate. One hundred and fourteen (80.28%) isolates were identified as In order to present our results from different perspectives, the percentages of resistant bacteria were analyzed in relation to the global susceptibility , the yeaVariations in susceptibility percentages during the three years of the study are shown in E. coli, Salmonella and the rest of species are summarized in E. coli isolates were resistant to ampicillin, tetracycline and trimethoprim/sulfamethoxazole and about 20% were resistant to piperacillin, enrofloxacin and marbofloxacin. High percentages of isolates of Salmonella resistant to cephalexin and aminoglycosides were also found. We did not find any statistically significant differences in the presence of Salmonella between animals of different ages .Lastly, the differences in susceptibility found among The increase in multidrug-resistant bacteria in wildlife is a global threat, because it can lead to increased morbidity and mortality, and can also lead to increase healthcare costs . In ordeAbout 20% of isolates were resistant or presented intermediate susceptibility to fluoroquinolones (enrofloxacin and marbofloxacin). The use of veterinary antimicrobials is clearly regulated and withdrawal periods or residue levels are established only for animal by-products intended for human consumption. However, carcasses and other remains, frequently from diseased animals, can be consumed by raptors, which implies the ingestion of antimicrobial residues or resistant bacteria. Blanco et al.  evaluateE. coli, Proteus and Providencia. As pointed out by Wang et al. [Surprisingly, we also found isolates resistant to imipenem, an antibiotic restricted exclusively to hospital use. High levels of resistance to carbapenems by bacteria isolated from migratory birds have been described by other authors ,28. Imipg et al. .Enterobacterales from silver gulls  in Australia . The blaIMP-4 gene was found in 116 isolates, and it was also the most commonly detected gene among carbapenemase-producing Enterobacterales isolates in humans in that country. As described below, this high prevalence is probably due to the feeding habits of gulls. Prevalence in Canarian vultures was low, probably because they usually feed on the remains of dead animals, but it is possible that in some cases they might eat rubbish and acquire carbapenem-resistant bacteria. Since vultures can also hunt small prey, it would also be possible for the prey to harbor imipenem-resistant bacteria, due to their close contact with human habitats. Therefore, the feeding habits of gulls, which usually forage in rubbish dumps, could explain this difference.Dolejska et al.  describeResistance to amikacin, which has been withdrawn from community use, is also relevant. It has been demonstrated than the use of aminoglycosides in human and veterinary medicine is associated with an increase in resistance to this group of antimicrobials . AminoglWhen we focused on the variations in susceptibility percentages , there wEnterococcus in raptors, differences has been observed in the transmission of different antimicrobial-resistant enteric bacteria from cattle and the environment to wild birds, in particular between E. coli and Enterococcus [In our study, the bacteria isolated from chicks were more susceptible to several antibiotics  than thorococcus . To our E. coli was obtained in 80.28% of the samples. This high prevalence is in agreement with the results of Sharma et al. [Neophron percnopterus) in India and the results found by Radhouani et al. [Buteo buteo) in Portugal. However, other authors describe a lower prevalence of E. coli, and it seems that the differences in prevalence do not depend on whether the samples come from birds of prey from countries with different human and livestock populations, and it does not matter if they are in the wild or housed at a rescue center [With regard to the prevalence of different bacterial species, a et al.  for Egypi et al.  in sample center ,38. SomeSalmonella in vultures is important for public health reasons, but also because this bacterium can play an important role in wildlife disease [Salmonella when eating contaminated livestock carcasses or in rubbish dumps. The prevalence of Salmonella in our study was 6.3%, which is lower than the level described by other authors for griffon vultures [Salmonella in raptors similar to ours [Salmonella between animals of different ages.The presence of  disease . Outbrea disease . Vulturevultures ,39 and Evultures . It shou to ours ,43,44. G to ours  reported to ours , we did Raoultella ornithinolytica has been described as an emerging pathogen, associated with hospital-acquired human infections [R. ornithinolytica lives in an aquatic environment and can be isolated from fish [fections . Its potfections . R. ornirom fish . Until nE. coli obtained from common buzzards, with the exception of the percentage of resistance to ampicillin, which is similar. Sharma et al. [E. coli obtained from Egyptian vultures. Their data showed a temporal variation in resistance, so it is possible that our results would be different, depending on the sampling periods.Our results show lower percentages of isolates resistant to the antimicrobials tested than those reported by Radhouani et al.  for E. ca et al.  found a E. coli. Szmolka et al. [E. coli that could transfer those resistance genes in vivo to pathogenic strains of E. coli or to Salmonella.Alcalá et al.  proposeda et al.  call attIn the case of our study, vultures are sedentary, so the dissemination of antimicrobial-resistant bacteria through migration is not feasible. Therefore, the effects should be limited to the local level of the islands. To avoid these potential negative effects and others affecting the populations of this threatened subspecies, it is necessary to prevent the vultures from feeding on the remains of intensive livestock farming, particularly pigs , and on The excessive use of antibiotics in the recent decades, in both human and veterinary medicine, has created what is currently one of the biggest public health problems: the rise and spread of large quantities of antibiotic-resistant bacteria. Action must be taken to avoid the set of factors that promote the increase and evolution of antibiotic resistance in wildlife, which can be easily be transferred to humans, domestic animals and the environment. However, for this to occur, a more accurate picture of the situation is needed.Salmonella and other antimicrobial-resistant bacteria, posing a risk not only to wildlife but also to livestock and the human population. These data highlight the need to minimize the exposure of wildlife to antimicrobials through human and livestock waste and to take into account a “One Health” approach to manage the problem of antimicrobial resistance.The results of our study support the idea that raptors could act as a reservoir for


Background: Emergency treatments determined by emergency physicians may affect mortality and patient satisfaction. This paper attempts to examine the impact of patient characteristics, health status, the accredited level of hospitals, and triaged levels on the following emergency treatments: immediate life-saving interventions (LSIs), computed tomography (CT) scans, and specialist consultations (SCs). Methods: A multivariate logistic regression model was employed to analyze the impact of patient characteristics, including sex, age, income and the urbanization degree of the patient’s residence; patient health status, including records of hospitalization and the number of instances of ambulatory care in the previous year; the Charlson Comorbidity Index (CCI) score; the accredited level of hospitals; and the triaged level of emergency treatments. Results: All the patient characteristics were found to impact receiving LSI, CT and SC, except for income. Furthermore, a better health status was associated with a decreased probability of receiving LSI, CT and SC, but the number of instances of ambulatory care was not found to have a significant impact on receiving CT or SC. This study also found no evidence to support impact of CCI on SC. Hospitals with higher accredited levels were associated with a greater chance of patients receiving emergency treatments of LSI, CT and SC. A higher assigned severity (lower triaged level) led to an increased probability of receiving CT and SC. In terms of LSI, patients assigned to level 4 were found to have a lower chance of treatment than those assigned to level 5. Conclusions: This study found that several patient characteristics, patient health status, the accredited level of medical institutions and the triaged level, were associated with a higher likelihood of receiving emergency treatments. This study suggests that the inequality of medical resources among medical institutions with different accredited levels may yield a crowding-out effect. The emergency departments (EDs) of medical institutions represent a unique way for the public to enter the health care system. EDs provide 24-h medical services throughout the year ,2. As soThe determination of emergency treatments may affect outcomes such as patient mortality, the cost and quality of care for hospitals and the effective use of medical resources by medical administration authorities . A delayThis study was based on a cross-sectional study to examine the factors affecting emergency treatments for ED patients. A multivariate logistic regression model was employed to analyze the factors affecting ED treatments. In this study, ED treatments included immediate LSIs, CT scans, and SCs.Immediate LSI has been widely performed in the ED and includes cardiopulmonary resuscitation (CPR), endotracheal tube insertion, noninvasive positive pressure, electrical defibrillation or cardioversion, transcutaneous pacemakers, electrocardiograms monitoring, thoracocentesis, pericardial puncture, chest intubation, central venous pressure catheter intubation, peripheral arterial line insertion, and general blood transfusions. For example, rapid sequence intubation is widely used for airway control in EDs . The useThe determination of emergency treatments may depend on a complex interplay of the care providers  and the acuity of the claimed disease as well as patient characteristics . Thus, eIn general, patient characteristics such as sex, age, income, and the urbanization degree of residence play important roles in the utilization of emergency services ,18. Age  in 2012 . Thus, hThe variables of patient health status included hospitalization in the previous year, records of ambulatory care in the previous year, and the CCI. As the average number of instances of ambulatory care was 14 times per year in recent years , a patieIn Taiwan, medical institutions are categorized into four levels: academic medical centers, regional hospitals, district hospitals, and clinics based on accreditation standards. Clinics are only responsible for ambulatory care and referral to hospitals for in-need patients. Thus, no data in association with clinics were available in this study.All patients presenting to the ED at first were triaged upon arrival, based on the vital signs and their chief complaint. The senior medical staff in the emergency department was responsible for the triage. incorporated with a computer-aided decision-making system according to the classification criteria of the Taiwan Triage and Acuity Scale (TTAS). The degree of urgency based on the TTAS consists of five levels: resuscitation (level 1), emergent (level 2), urgent (level 3), less urgent (level 4) and nonurgent (level 5).In this paper, we conducted a population-based study using data obtained from the National Health Insurance Research Database (NHIRD). Since 1995, Taiwan has started to implement a National Health Insurance (NHI) program that focuses on reducing the financial barrier for all people, in order to obtain sufficient medical services in Taiwan. Until now, the NHI program covers 99.5% of the population ,25,26. TThe subjects of this study were emergency medical users in 2012 who were recorded in the same year. Thus, the data excluded patients who visited the emergency department but were determined to remain outside the triage scale and those with an unknown triaged scale. To conduct this study, institutional ethical approval was obtained from the research ethics committee of Taipei City Hospital (TCHIRB-10512105-W). The sample screening process is shown in The patient characteristics and health statuses are listed in Approximately 52.89% of subjects came from regional hospitals, followed by academic medical centers (28.99%) and district hospitals (18.12%). Most patients were classified as level 3, accounting for 64.28%, followed by level 4 (21.21%) and level 2 (10.45%). Only a small portion of patients were assigned to level 1 (2.43%) and level 5 (1.63%).P < 0.0001), CT  and SC  services. This result coincides with the finding of [nding of .P < 0.0001), CT  and SC . Patients categorized into low-income households were found to have a significantly higher AOR of 1.29 (P = 0.0069) for LSI, but there was no significant association for CT or SC. The AOR of receiving LSI (P = 0.0301), CT (P = 0.0068) and SC (P = 0.0002) for patients living in satellite cities/towns was significantly slightly higher than that for patients living in municipal cities.Patients aged P < 0.0001) but more likely to receive CT (P = 0.0010) and SC (P = 0.0213). The number of instances of ambulatory care in the previous year was not found to have an impact on receiving LSI, CT and SC. The CCI score was found to have a high impact on receiving LSI and CT but no impact on SC. Patients with higher CCI scores  were significantly more likely to receive LSI and CT. Hospitals with higher levels were associated with a greater probability for patients to receive LSI (P < 0.0001), CT (P < 0.0001) and SC (P < 0.0001).Patients without a record of hospitalization in the previous year were significantly less likely to receive LSI (P < 0.0001), CT , and SC , followed by level 2 for LSI , CT , and SC .Eventually, the triaged level was also found to have significant impacts on receiving LSI, CT and SC. Level 1 (resuscitation) of the triaged level (assigned acuity) had the highest AOR for LSI  are associated with higher rates of LSI, CI, and SC treatment. Currently, rural regions have aged populations in Taiwan, as younger generations leave villages for municipal cities in order to work. Previous studies have found that the aged tend to have multiple comorbidities and high mortality ,32,33; tThe measurement of health status was found to have a significant impact on the treatment of LSI, CT and SC, except for records of ambulatory care. It is intuitively accepted that a worse health status results in a greater need for the emergency treatments of LSI, CT and SC. Higher CCI scores represent a worse status that is associated with worse outcomes due to more comorbidity and increased risks of organ failure. Thus, more aggressive treatment with LSI and CT is recommended.Patients who received in-patient care in the previous year were found to have a greater chance of receiving LSI but a lower probability for receiving CT and SC. This implies that patients with worse health status are seen as more emergent cases and more often require LSI, including intubation for airway obstruction, needle thoracocentesis, thoracostomy, tourniquets, application of a chest seal, positive-pressure ventilation for ventilatory inadequacy, etc. Since patients had been hospitalized in the previous year, the previous diagnosis had already been recorded. Thus, the use of CT and SC was not required. In this study, the number of visits for ambulatory care was not found to have a significant impact on these treatments. This implies that visits for ambulatory care in the previous year are independent of patient presentation to the ED.Hospitals with higher accredited levels provided a greater chance for patients to receive emergency treatments of LSI, CT and SC. This suggests that ED patients highly trust the assigned levels of hospitals. District hospitals provided less of a chance for the use of LSI, CT, and SC than regional hospitals and academic medical centers. This may be explained by the limited medical resources in district hospitals, including the availability of CT scanners and quality physicians with sufficient experience in complicated diseases. Academic medical centers in general have higher budgets provided by the government or funds to install expensive equipment such as CT scanners. Basically, patients with more severe triaged level have more chance of receiving the treatments of LSI, CT and SC. However, the AOR of Level 4 and 5 for LSI is 0.35 and 0.48, respectively. A patient assigned to lower severity (Level 5) has more chance to receive the treatment of LSI. This may be explained by the fact that patients with thalassemia may receive blood transfusion at emergency departments and the blood transfusion for these patients is probably treated as one of the LSIs in this study. These patients are in general triaged as Level 5 of the triaged level. Thus, the AOR of Level 5 for LSIs indicated in This study was based on the database extracted from National Health Insurance (NHI); thus, the accuracy of the data used may have affected the results. Furthermore, the database was not tailored for this study. The format of the data field was given and thus limits the depth and scope of the study. The data regarding patient wait times for triage and physicians and the total length of stay in the emergency department were not available in the National Health Insurance database. Thus, the analysis of the relationship between patient wait times and the prescribed time for each triaged level was neglected in this study.This study found that several patient characteristics, patient health status, the accredited level of medical institutions and the triaged level were associated with a higher likelihood of receiving emergency treatments. The probability of receiving the emergency treatments of LSI, CT and SC was found to be associated with the accredited level of hospitals. Hospitals with higher accredited levels were more likely to provide the emergency treatments of LSI, CT and SC. This study highlights that the inequality of medical resources among medical institutions with different accredited levels may yield a crowding-out effect. Academic medical centers with more capabilities (including physicians and equipment) may attract an increasing number of visiting patients, despite the emergency and severity of diseases.To avoid the crowding-out effect, administration units should motivate the public to seek general care for nonurgent disease or to access clinics first that conduct a preliminary diagnosis and make a referral to hospitals for in-need patients. These ED treatments  may reduce mortality and increase patient satisfaction, but the increase in cost is accompanied by overuse. Some strategies are needed to decrease the overuse of medical resources.A lack of or delay in the performance of LSI may have a very serious negative effect on mortality. However, clinical judgment regarding the need for immediate LSI in EDs is very difficult to determine, as it is uncertain with regard to the expected outcome . The use


Numerous studies confirmed the main role of the inner blood-retinal barrier in the development of Diabetic Macular Oedema (DMO). Lately, the focus of research shifted towards the external retinal barrier with potential involvement in the pathogenesis of DMO. Materials and method. We set up retrospectively 3 groups of patients diagnosed with nonproliferative diabetic retinopathy (NPDR) and DMO, proliferative diabetic retinopathy (PDR) and DMO, and controls. We compared the RPE thickness in every quadrant between groups and performed correlations between best-corrected visual acuity (BCVA) and the thickness of the retinal layers. The Social Science Statistics platform was used for statistical tests.  We aim to identify the OCT changes of the external blood-retinal barrier in patients with DMO and to define them as biomarkers with predictive value. p < 0.001); in the NPDR-DMO group, only the central minimum and central maximum values of the RPE thickness were significantly different from the control group. We did not find any strong correlation between BCVA and the thickness of the retinal layers.  The NPDR-DMO group consisted of 18 eyes, the PDR-DMO group consisted of 19 eyes, and the control group included 36 eyes. In the PDR-DMO group, RPE thickness was decreased in almost all quadrants ( The thickness of the RPE layer is an OCT biomarker able to predict the functioning of the outer BRB. Eyes with PDR-DMO exhibited decreased thickness of the RPE layer in almost all quadrants, highlighting the degenerative changes occurring in a hypoxic environment. The thickness of a specific layer could not be identified as a biomarker to correlate significantly with BCVA, most likely because we did not analyze specific morphologic features, such as continuity and reflectivity. The analysis of the RPE thickness could clarify the unexplained decrease of BCVA and predict early the evolution of DR. Diabetic macular oedema (DMO) is the main cause of visual impairment within the group of working-age population in developed countries . DMO aff− and K+ [α and of vascular endothelial growth factor (VEGF). VEGF is also responsible for the depletion of the occludin in RPE, with subsequent disruption of the tight junction's integrity in the outer BRB [The retina is one of the most metabolically active tissues in the organism, requiring important amounts of glucose and lactose . The nee− and K+ , thus fi− and K+ . Further− and K+ . The diauter BRB .α− and ZO-1α+ mRNA and proteins, causing an increased TER  which is an indicator of RPE's barrier function. In addition, when soluble VEGF was neutralized with an antibody, it led to partial recovery of the RPE barrier's function [Electronic microscopy demonstrated the degeneration of RPE in DMO induced in animal models: shrank nuclei, reduced endoplasmic reticulum, in-folding of the cell membrane, altered melanosome, and even loss of RPE cells . When elfunction . Exposurfunction , which dfunction .The aim of the present study was to investigate whether the thickness of RPE is modified in patients with DMO associated with nonproliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR), using Spectral Domain-Optical Coherence Tomography (SD-OCT). The novelty of our approach comes from the observation that even if there is evidence in the literature that RPE thickness decreases in patients with DMO , there iThe primary outcome of this research is to find out whether there was a difference between groups in RPE thickness. The secondary outcomes are to identify the differences between DMO with NPDR and DMO with PDR versus control. Furthermore, we aimed to investigate if there is a correlation between RPE and inner retinal thickness, photoreceptors, and central macular thickness (CMT). Finally, we intended to identify the OCT biomarkers that correlate best with BCVA: central macular thickness (CMT), inner retinal thickness, photoreceptor layer thickness, or RPE thickness.A retrospective, single-centre, observational, and comparative study was carried out. The study was approved by the Ethics Committee belonging to “Iuliu Hatieganu” University of Medicine and Pharmacy (IHUMP), Cluj-Napoca, Romania, and the study protocol adhered to the rules of the Declaration of Helsinki.We included in the study the patients diagnosed with type 1 or type 2 DM and with NPDR or PDR associated with DMO. The patients were examined in the Department of Ophthalmology belonging to IHUMP, between January 2017 and September 2019. Patients with an ophthalmological examination in the same setting between July and September 2019, with no history of DM, were selected for the control group. Thus, we set up 3 groups of patients: NPDR with DMO, PDR with DMO, and control. The algorithm according to which the 3 groups were created is presented in An eye was eligible for diabetic retinopathy (DR) group if the following criteria were met: NPDR (level 20-53E of the Early Treatment Diabetic Retinopathy Study (ETDRS) classification) or PDR (61-65 of the ETDRS classification). All the recruitments were performed by an ophthalmologist with experience in medical retina, and they were validated by OCT  examination. Patients with a history of vitreoretinal surgery, laser or anti-VEGF injections, AMD or other macular diseases, ocular trauma, lens or corneal opacification, vitreous hemorrhage, tractional retinal detachment, segmentation errors on OCT examination, OCT segmentation quality less than 20 db, or subretinal fluid were excluded. If a patient was confirmed with bilateral DR meeting the selection criteria, but different ETDRS stages, both eyes were included in the study.Every eye included in the study had BCVA equal or above 20/40, refraction with spherical equivalent less than ±5 dpt and had undergone macular OCT imaging. Patients who were confirmed with DM, macular diseases, ocular trauma, glaucoma, significant opacification of the lens or cornea, segmentation errors on OCT examination, OCT segmentation quality less than 20 db were excluded. One eye was randomly selected for the final analysis for each patient within this group.All participants underwent VA testing measured with the Snellen acuity chart, slit lamp biomicroscopy, dilated eye fundus examination.The following baseline clinical characteristics were recorded: age, gender, BCVA, DR, and DMO classification.Demographic data and ophthalmic examination were collected from the hospital's informatic system. OCT data were collected from the OCT database.μm, with a 20 × 20° scan and an automatic real mean value  set at 9. All scans were performed by the same experienced technician. Segmentation was automatically performed using the Spectralis software version 6.0. Only images with more than 20 db signal strength and with individual retinal layers that could be identified were used for the analysis. ETDRS macular maps were used to report macular thickness: 1, 3, and 6 mm concentric rings. The central 1 mm ring was defined as central thickness. The 3 mm ring, known as the intermediate, was divided into four quadrants: inner superior, inner inferior, inner nasal, and inner temporal, and the 6 mm ring, known as the outer ring, was divided into outer superior, outer inferior, outer nasal, and outer temporal. The numerical values such as thickness and volume recorded for each quadrant were used in the analysis.OCT was performed using Spectralis OCT . The fast macular protocol was used: 25 raster lines per eye separated by 240 The boundaries between the retinal layers are illustrated in In order to check out the relationship between RPE and the photoreceptors, we approximated the thickness of the photoreceptor layer as follows: from the outer retina, we subtracted the RPE thickness to get the thickness of photoreceptors' inner and outer segments (PR 1/2); then, we added to PR 1/2 the thickness of ONL (rod and cone cell bodies). As a result, the boundaries of the photoreceptor layer are the inner limit of the RPE band and the outer limit of the OPL.We further detailed the segmentation of the outer retina. Thus, we defined the inner segments of the photoreceptors (IS), the outer segments of the photoreceptors (OS), and the interdigitation zone (IZ). IS are divided into two parts: myoid zone (MZ) and ellipsoid zone (EZ). MZ is a hyporeflective region located between ELM and EZ. It corresponds to the myoid portion of the inner photoreceptors' segments. EZ is a hyperreflective band between MZ and OS, previously known as the junction between photoreceptors' inner and outer segments; it represents the ellipsoid layer of the outer portion of the inner photoreceptors' segments. The OS layer is a hyporeflective band between EZ and IZ. IZ is a hyperreflective band representing the contact between the apices of the RPE cells and the outer segments of the photoreceptors; it was previously called the cone outer segment tips (COST) and rod outer segment tips (ROST).We defined the thickness of the inner quadrant as the average thickness from all the four inner sectors and the thickness of the external quadrant as the average thickness from all the four outer sectors.The images were reviewed by the investigator before data analysis, and manual adjustments to retinal layer segmentation were made if necessary.In order to perform statistical analysis, the Snellen Visual Acuity fraction was converted into an approximate ETDRS letter score. Numerical variables are summarized with means and standard deviations, whereas the nominal variables are expressed in frequencies and percentages. The nonparametric Kruskal-Wallis test was applied to assess the differences between the thickness of retinal layers among groups followed by post hoc analysis with the Mann-Whitney test if an overall significance was found. We corrected for the effect of multiple comparisons by conducting a posteriori Bonferroni adjustment. The gender difference between the groups was compared using the chi-squared test.The Spearman correlation coefficient was used for the detection of correlations between quantitative variables such as the different thickness of layers and VA or age.p values ≤0.05 were considered statistically significant. The platform Social Science Statistics (https://www.socscistatistics.com/) was used to perform the tests.p < 0.00001), PDR-DMO and control (p < 0.00001), but not significantly different between NPDR-DMO and PDR-DMO (p = 0.3125). The baseline characteristics of these patients are presented in A total of 73 eyes were included in the analysis, as follows: 18 eyes within the NPDR-DMO group, 19 eyes within the PDR-DMO group, and 36 eyes within the control group. We used the Kruskal-Wallis test for age and BCVA and the chi-squared test for gender. No statistically significant difference emerged regarding the age and gender distribution between the groups. BCVA was significantly different between NPDR-DMO and control (p < 0.00001), central subfield (p = 0.026), central minimum (p < 0.00001), central maximum (p < 0.00001), inner nasal (p = 0.0005), inner superior (p = 0.0002), inner inferior (p = 0.0017), outer nasal (p = 0.02), and outer superior (p = 0.009) were further analysed with the Mann-Whitney test.The RPE thickness and volume in every quadrant see  were comThe mean RPE thickness in the eyes with PDR-DMO compared to controls was decreased in most quadrants: central minimum (-33.8%), temporal inner (-2.09%), nasal inner (-11.1%), superior inner (-12.5%), nasal outer (-6.76%), superior outer (-8.69%), inferior outer (-3.1%), average RPE (-6.33%), inner quadrant (-7.04%), and outer quadrant (-4.58%). In contrast, in the eyes with NPDR-DMO, the RPE thickness was decreased as compared to controls, for central minimum (-33%), superior inner (-3.97%), and superior outer (-3.62%), but increased for the remaining quadrants see .p < 0.00001) and central maximum (p < 0.00001) thickness values. Regarding PDR-DMO and controls, differences between central thickness (p = 0.00008), central minimum (p < 0.00001), central maximum (p < 0.00001), inner nasal quadrant (p = 0.00044), inner superior (p < 0.00001), inner inferior (p = 0.00058), and internal quadrant (p = 0.0014) were statistically significant. Between NPDR-DMO and PDR-DMO, only the thickness of the inner nasal quadrant (p = 0.009) was statistically different  (see r = 0.735) (see r = 0.383) (see r = −0.3686) (see r = 0.451). The remaining correlations were negligible  see , inner r735) see , a low p383) see , and a l383) see , CMT and686) see . In the ible see . We compSince 1995, when the first study regarding the status of OCT in the diagnosis of macular diseases was published, this new technology has provided important insights into the pathophysiology and treatment of retinal diseases . OCT hasFor a long time, CMT has been the only biomarker according to which macular oedema was analyzed. However, progress in OCT technology revealed other structural changes, like intraretinal cysts, the disintegration of the retinal structure, flattening of the central fovea, haemorrhages, hard exudates, and subretinal fluid .Since age was similar within our groups, the differences in the thickness between layers cannot be assigned to an age-related diffuse loss of neural tissue, nor to an accumulation of excessive metabolic strain causing an increased thickness  or an opIn the context of increased retinal thickness, especially on the account of INL and OPL , the extμm and ± 8 μm, respectively. Constant oxidative stress which is a feature of DR impairs autophagy  and heterophagy (phagocytosis of exogenous photoreceptor outer segments in RPE cells), as proved by Kaarniranta et al. [In the PDR-DMO group, apart from CMT, the RPE thickness was decreased in all quadrants. The reason for this finding seems to be a disruption of the RPE-photoreceptors complex , possibla et al. . In contHowever, higher than the normal values were found occasionally when measuring RPE thickness, as proved within the groups of CMT in PDR-DMO and NPDR-DMO. One possible explanation is that over the RPE cells, new cells grow in order to compensate and to minimise the fluid leakage within the retina . AnotherWhen we examined the RPE volume, in the PDR-DMO group in all quadrants, the values were decreased as compared to controls, but the differences were not statistically significant. In the NPDR-DMO group, in some quadrants, the volume was increased, whereas in other quadrants, it was decreased. This is probably due to the oedema within the layers and the lower ischemic status.Besides its leading role in the diagnosis and monitoring of the response to treatment, OCT delivers biomarkers able to predict BCVA. Over time, multiple hypotheses were tested. The most frequently used OCT biomarker was CMT, but scenarios in which the normalization of CMT was not paralleled by the improvement of BCVA or with a modest correlation between the two variables were described . FurtherTaking into account the multiple roles played by the RPE for the normal functioning of the photoreceptors, the search for a correlation with BCVA is mandatory. In the PDR-DMO group, we found only a low positive correlation between the outer retina and BCVA. In the NPDR-DMO group, a low negative correlation was identified between CMT, central RPE thickness, inner retina thickness, and BCVA. Our results are limited by the analysis of cell thickness, not morphology. Therefore, thickness within the normal range is compatible with altered cellular anatomy. IS/OS and ELM are useful hallmarks to evaluate the integrity of the foveal photoreceptor layer, being closely associated with the final BCVA . BCVA beFurther on, we intended to find out if there is any correlation between the CMT and the central thickness of the RPE, namely, whether the RPE thickness will influence the CMT. In the NPDR-DMO group, the correlation was highly positive, whereas in the PDR-DMO group, it was negative, but negligible. This finding could be explained by a higher level of oedema within the retinal layers in the NPDR-DMO group, as compared to the PDR-DMO one.We also set out to identify if there was any correlation between the internal and external retinal barriers, by approximating an overlap with the OCT layers: inner retina = internal BRB and RPE = external BRB. As Das et al.  have fouIt is well known that RPE is a monolayer of pigmented cells that are vital for the photoreceptors' functioning, survival, and maintenance. After having proved the role of RPE damage in the pathogenesis of DMO, we aimed to quantify its effect on the photoreceptor layer. RPE and photoreceptor layers are regarded as a functional unit due to their interdependence. Structural and functional changes of this complex were found also in patients with DR without DMO . When anFerreira et al.  have repWhen comparing the results between studies, we must pay attention to the type of OCT machine and to the segmentation algorithm of the outer retina because different results could emerge . Xia et Our study has several limitations: the small sample size, the quantitative assessment of the RPE layer, and the selection bias. The strength of our study comes from the different approach of making the distinction between the NPDR and PDR within the group of patients with DMO. Our results add to previous research serving as evidence for the key part played by the changes in the RPE layer during the evolution of DR.In the PDR-DMO group, apart from CMT, RPE thickness was significantly decreased in almost all quadrants in our series. In the NPDR-DMO group, the number of quadrants with significantly decreased RPE thickness was lower as compared to the PDR-DMO group, proving the key impact of DR staging on DMO.In the PDR-DMO group, we found only a low positive correlation between the outer retina and BCVA. In the NPDR-DMO group, a low negative correlation was identified between the central RPE thickness and BCVA.In the NPDR-DMO group, the correlation between the CMT and the central RPE thickness was highly positive, whereas in the PDR-DMO group, it was negative, but negligible.The photoreceptors' thickness was significantly lower in both groups, PDR-DMO and NPDR-DMO.Further and more refined studies are needed to provide definite OCT biomarkers by analyzing the outer BRB in patients with DMO.