Increasing rates of inflammatory bowel disease (IBD) are now seen in populations where it was once uncommon. The pattern of IBD in children of Middle Eastern descent in Australia has never been reported. This study aimed to investigate the burden of IBD in children of Middle Eastern descent at the Sydney Children's Hospital, Randwick (SCHR). The SCHR IBD database was used to identify patients of self-reported Middle Eastern ethnicity diagnosed between 1987 and 2011. Demographic, diagnosis, and management data was collected for all Middle Eastern children and an age and gender matched non-Middle Eastern IBD control group. Twenty-four patients of Middle Eastern descent were identified. Middle Eastern Crohn's disease patients had higher disease activity at diagnosis, higher use of thiopurines, and less restricted colonic disease than controls. Although there were limitations with this dataset, we estimated a higher prevalence of IBD in Middle Eastern children and they had a different disease phenotype and behavior compared to the control group, with less disease restricted to the colon and likely a more active disease course. Inflammatory bowel disease (IBD) is a chronic, relapsing, idiopathic inflammation of the gastrointestinal tract. Subtypes of IBD include Crohn's disease (CD), ulcerative colitis (UC), and inflammatory bowel disease unclassified (IBD-U). The majority of epidemiological studies on the incidence and prevalence of IBD relate to the adult population . HistoriThe emergence of chronic inflammatory diseases such as IBD has been closely linked to social and economic development  and it hRecent studies have found the overall incidence rate of IBD in Australia to be among the highest reported . In addiA retrospective chart review was undertaken on all patients identified as being of Middle Eastern ethnicity on the SCHR IBD database. IBD specific data collection began at SCHR in 1987 and data was complete up to the year 2011 at the time of review. At diagnosis, parents were requested to provide a familial history including familial ethnicity. Children were considered to be of Middle Eastern ethnicity if one or both parents self-identified as being of Middle Eastern ethnicity or from any of the following countries: Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, United Arab Emirates, West Bank and Gaza, and Yemen. Children with Israeli ancestry and Jewish ethnicity were not included in this study due to the well-defined predisposition to IBD in this population. A control group of patients of non-Middle Eastern descent was also identified from the SCHR IBD database: these were matched to patients of Middle Eastern descent according to age at diagnosis, gender, and disease type. The project was approved by the South Eastern Sydney and Illawarra Area Health Service Research Ethics Committee.Information collected at diagnosis for the study and control groups included family history of IBD in first degree relatives, smoking exposure history, residential postal code, age at diagnosis, symptoms at presentation, duration of symptoms at presentation, specific blood tests (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelets, albumin, haematocrit, alanine transaminase (ALT), aspartate transaminase (AST)), disease location, extraintestinal manifestations, pediatric Crohn's disease activity index (PCDAI) or pediatric ulcerative colitis activity index (PUCAI) score, height, and weight. Disease management information was also collected including whether they received the following treatments: exclusive enteral nutrition (EEN), corticosteroids, aminosalicylates, thiopurines, methotrexate, biological, tacrolimus, or surgical intervention.z-scores and weight for age z-scores using the Centre for Disease Control application EpiInfo, based on the CDC-2000 charts.Disease location was classified according to the Montreal classification of L1 , L2 (colon), L3 (ileocolonic), and L4 ) for CD . SymptomPoint incidence and point prevalence were calculated for both the Middle Eastern study group and the control group for the SCHR catchment area. For this purpose the catchment of the SCHR was defined as the Local Government Areas (LGA) of the South Eastern Sydney and Illawarra Area Health Service, which includes Botany, Hurstville, Kogarah, Randwick, Rockdale, Sutherland, Sydney, Waverley, Wollongong, and Woollahra. Population information for the LGAs was obtained from the Australian Bureau of Statistics 2006 census data. Ancestry information in the 2006 census data was collected by similar means to data in the SCHR database, where ancestry was defined by self-reporting of familial ancestry and birthplace. The census data was sorted by ancestry, LGA, and age (0–16 years). The SCHR IBD database was used to identify patients who resided in the defined catchment area and had active inflammatory bowel disease in 2006 to calculate point prevalence. The database was also used to identify those patients within the catchment area who were diagnosed in 2006 to calculate the point incidence.The remoteness area category was calculated for each patient from residential postal codes based on the Australian Standard Geographical Classification-Remoteness Area (ASGC-RA). The ASGC-RA is a hierarchical classification system of geographical areas developed by the Australian Bureau of Statistics (ABS) that provides a common framework of statistical geography. The categories used were RA1 , RA2 , RA3 , RA4 , and RA5 .t-test was used to compare platelets, albumin, haematocrit, PCDAI, height for age z-scores, and weight for age z-scores between the two groups. The Mann-Whitney test was used to compare the groups for ESR, CRP, ALT, and AST. Results were considered significant if P < 0.05. The relative risk (RR) was calculated for incidence and prevalence; a result was considered significant if the confidence intervals (CI) did not embrace a relative risk of one.Statistical analysis was carried out using Graph Pad Prism 5. A Fisher's exact test was used to compare the two groups with regard to smoking exposure history, family history, symptoms at presentation, extraintestinal manifestations, and disease location. The management of IBD was analysed by Fisher's exact tests, with UC and CD being analysed separately. A chi-squared test was used to compare ASGC-RA scores. An unpaired Of the 441 patients on the SCHR IBD database, 35 (7.9%) were identified as being of Middle Eastern ethnicity. However, 11 of the 35 were excluded from this retrospective study as files for these patients were unavailable. Therefore a final cohort of 24 patients of Middle Eastern ethnicity (both parents of Middle Eastern ethnicity) and 24 non-Middle Eastern controls were included in this study.Of the 24 patients of Middle Eastern ethnicity, 14 (58.3%) had CD, 7 (29.2%) had UC, and the remainder had IBD-U . FifteenP = 0.017).In those children identified as Middle Eastern ethnicity, 16 had parents identified as Lebanese, 3 Egyptian, 2 Turkish, and 1 Algerian, and 2 parents did not provide a country of birth but self-identified as Middle Eastern ethnicity. Of the controls, 18 had parents identified as Caucasian, 2 Indian, and 1 Caucasian-Jewish, and 3 did not provide a country of birth but self-identified as non-Middle Eastern ethnicity. There was no difference in family history of IBD in first-degree relatives of Middle Eastern  and control  patients. There was no difference in smoking exposure history between the two groups, Middle Eastern  and control patients . All Middle Eastern patients  were living in RA1 (major city), while the controls had fewer patients  in RA1 and a greater distribution over RA2  and RA3  areas (P = 0.37). Abdominal pain and diarrhoea were the most common symptoms at presentation for both groups (P = 0.02); however, all other standard blood results were similar in both groups   and control groups   .P = 0.033) (z-score and weight for age z-scores at diagnosis were similar between the groups. Two (8.3%) of the Middle Eastern patients and one (4.2%) control had height for age z-score indicating stunted growth (< −2 SD). There was a lower incidence of colonic disease (L2) (P = 0.01) in the Middle Eastern group with CD compared with the control group  compared to the control group  . There wol group . Upper Gol group . There wThe incidence of IBD in the SCHR catchment area in 2006 for the Middle Eastern pediatrics population (aged 0–16 years) was higher (33.1 per 100 000 children per year) compared to the control group (4.3 per 100 000 children per year). The relative risk analysis, although indicating a high risk of IBD with Middle Eastern ethnicity, does not reach significance  . HoweverP > 0.05 for all). In addition, there was no difference in surgical management between the two groups (P > 0.05). However, considering the children with CD separately, the use of thiopurines was significantly higher in the Middle Eastern group for the management of CD (P = 0.002)  . There w= 0.002) . There wThis is the first study comparing the incidence, presentation, and management of IBD in a Middle Eastern pediatric population now residing in a “Western” country. The estimated incidence rate for IBD in this population in 2006 was among the highest reported in the pediatric literature and was almost 8 times higher than that observed for the non-Middle Eastern population in the same location. There is great variation in the literature on the difference in incidence between different populations. However our findings are consistent with those of other studies that have identified higher risk of IBD in specific groups such as South Asians and Ashkenazi Jews , 9.Accurate prevalence and incidence rates of pediatric IBD for many Middle Eastern countries have not been reported in the literature . It has We have presented point incidence and point prevalence; however, there are a number of limitations that must be considered when assessing this data. The cohort was limited to the geographical catchment area of one pediatric centre in Sydney, Australia. Taking into consideration the limitations of this dataset, the small sample size and potential confounders due to immigration, emigration, and referrals outside of the catchment area, the results presented here may have either overestimated or underestimated the incidence of IBD in this population. Ahuja and Tandon  suggesteThe gender preponderance (higher number of boys) observed among these Middle Eastern children contrasts with studies of the adult IBD population where there are a slightly greater proportion of females with CD , althougMiddle Eastern children with CD had significantly less disease restricted to the colon (L2) than the controls while there were similar levels of terminal ileal disease, ileocolonic disease, and upper gastrointestinal involvement between the groups. In contrast to this, studies in other ethnic populations have found more extensive colonic disease than the general IBD population . HoweverThe comparatively high use of thiopurines in the treatment of CD in the Middle Eastern patients is suggestive of a more severe disease requiring immunosuppressive treatment. The efficacy of thiopurines in maintaining clinical remission in CD is well established with trial data supporting the introduction of thiopurines in children with moderately severe disease at diagnosis . InteresThe mean age at diagnosis for this cohort of patients was 9.8 years, which was slightly lower than reported in the literature . Family z-scores indicative of stunted growth. This inconsistency may be due to the small sample size or may represent shorter symptom duration prior to diagnosis and therefore less impact upon linear growth. Active IBD may also impact adversely upon pubertal development, especially in boys [Altered linear growth is commonly present in children at the time of presentation with IBD , 30. A p in boys . AlthougIn conclusion, the present study indicated that Middle Eastern patients were less likely to have disease restricted to the colon than the control children. Further the Middle Eastern children had higher CD activity at diagnosis and also required a higher incidence of immunosuppressive treatment. This data is consistent with a more severe phenotype of CD in Middle Eastern children. Although there were limitations with the dataset used to calculate point incidence and prevalence, the calculated values indicated that there is a higher point incidence and prevalence of IBD in Middle Eastern children attending the SCHR. Likely these patterns of disease in an ethnic group now resident in Australia reflect the interactions between environmental and genetic factors. Further epidemiological and genetic investigations of such populations with high incidence of disease are required to better understand the aetiology of pediatric IBD.


Objective: describe the nutritional status of patients with tuberculosis. Methods: an observational follow-up study over a 180-day period of tuberculosis therapy in adults was conducted. Subjects were assessed for body composition , serum biomarkers and offered dietary counseling. The data obtained at each visit  were analyzed, showing trajectories over time and central tendencies each time. Results: at baseline, the mean age was 41.1 (±13.4) years; they were predominantly male, with income lower than a local minimum wage and at least six years of schooling. Patients showed predominantly pulmonary tuberculosis. At baseline, all patients suffered from malnutrition. The overall energy malnutrition prevalence was of 70.6%. Anemia at baseline was observed in both groups (63.2%), however, it was significantly more pronounced in the HIV+. At the end, energy malnutrition was reduced to 57.1% (42.9% of HIV- and 71.4% of the HIV+). Micronutrients malnutrition was evident in 71.4% of the HIV- patients and 85.7% of HIV+ patients at the end of tuberculosis therapy. Using BMI (≤18.5 kg/m2cutoff) as an index of malnutrition, it was detected in 23.9% of the HIV- and 27.3% of the HIV+ patients at baseline, with no evident improvement over time; using TSF (≤11.4mm as cutoff) or MUAC (≤28.5cm as cutoff), malnutrition was detected in 70.1% and 85.3% of all patients, respectively. Nevertheless, combining all biomarkers, at the end of follow-up, all patients suffered from malnutrition. Conclusion: Although with a limited number of patients, the evidence does not support that dietary counseling is effective to recover from malnutrition in our population.The Brazilian Ministry of Health and the World Health Organization recommend dietary counseling for patients with malnutrition during tuberculosis treatment. Patients under tuberculosis therapy (infected and not infected with HIV) were followed-up to evaluate the effectiveness of dietary counseling.  Tuberculosis and the human immunodeficiency virus (HIV) are historically associated with malnutrition, reduced appetite, low dietary intake, malabsorption and increased caloric demand –4.The Brazilian Ministry of Health (BMH)  and the Studies conducted with patients being treated for tuberculosis, who followed dietary advice exclusively or received supplemental food donation –11, showThere is an extensive discussion on the nutritional status of patients with tuberculosis, including the occurrence of anemia, reduced food consumption and adherence to treatment when food is donated , but notThis study aims to describe the nutritional status of patients with tuberculosis, including those infected with HIV, who received dietary counseling exclusively during tuberculosis treatment in Rio de Janeiro, and to evaluate if this strategy is enough to enhance recovery from their nutritional impairment observed at the beginning of tuberculosis treatment.This is an observational prospective follow-up study that was conducted in patients who received tuberculosis diagnosis from July 2008 to September 2013.Patients were eligible if they had tuberculosis, whether infected or not with HIV, and if they were between 18 and 65 years old and agreed to participate in the study. HIV positive patients were naïve of antiretrovirals (ARV). Patients were urged to refrain from using nutritional supplements during the entire study period. Exclusion criteria were: those who had hypermetabolism, digestive diseases or who used any nutritional supplementation up to six months before tuberculosis treatment. Only the supplementation of pyridoxine (vitamin B6) was allowed, in conformity with the protocol of the Brazilian Ministry of Health , which rMycobacterium tuberculosis in culture. In cases where the Mycobacterium tuberculosis was not isolated, the diagnosis of tuberculosis was made using therapeutic response [The diagnosis of tuberculosis was established by assessing clinical signs and symptoms, compatible radiological findings and the identification of response . The strresponse ,5,21, whPatients underwent nutritional evaluation and received dietary counseling after tuberculosis diagnosis and during their tuberculosis treatment. The steps and procedures used in this study are presented in 2), mid–upper-arm circumference (MUAC– 28.5–29.3cm), triceps skinfold (TSF– 11.4–18.2mm) and mid-arm muscle circumference (MAMC– 21.0–27.8cm), according to Lohman [Anthropometric and biochemical biomarkers, including the analysis of serum micronutrients, were used to assess nutritional status. Anthropometric evaluation was conducted using the body mass index  for hemoglobin and 34–54 (%) for hematocrit. Chromatic measurement with a reference value of 3.4–5.0 for albumin; 6.4–8.2 (g/dl) for total protein; 2.5–4.0 (g/dl) for globulin; 250–450 (mcg/dl) for iron fixation capacity. High-performance liquid chromatography with a reference value of >0.7 (mcg/dl) for retinol and >0.5 (mg/l) for tocopherol. Atomic absorption with reference value of >70 (mg/dl) for zinc, 70–90 (mcg/l) for selenium and 50–170 (mcg/dl) for iron .Serum samples were frozen (-20°C to -10°C) for analysis of vitamins A, E and zinc; and plasma was refrigerated from 2 to 8°C for selenium analysis. All tubes were transported to the laboratory for analysis, with a maximum of 7 days of storage. The analyses for the remaining biomarkers were done immediately after blood collection.The study endpoint was the recovery from malnutrition. Individuals were considered to be without malnutrition, at any time, if all the biomarkers  were within the reference values, as established by FAO . And thePatients were classified within the following malnutrition statuses, at every moment: (a) global, using BMI, TSF, MUAC, serum protein, albumin, transferrin and iron fixation; (b) energy, using the parameters BMI and TSF; (c) protein, using the somatic parameter MAMC, and visceral parameters serum protein, albumin, transferrin and iron fixation; (d) micronutrients, using serum biomarkers .The dietary counseling proposed by BMH  was deliThis study was conducted in accordance with the ethical standards outlined for research in humans in the declaration of Helsinki, and approved by the Research Ethics Committee of the National Institute of Infectious Diseases Evandro Chagas, under identification number CAE 0008.0.009.000–08. All patients who agreed to participate in the study signed an informed consent form.The data were analyzed using the R-project software, version 3.0.2. The results were obtained by dividing the data into a baseline time point and follow-up . For basSixty-eight patients were included in the study. 22 were HIV positive and 46 were HIV negative. Exclusions and their reasons were: 5 patients needed nutritional supplementation, 3 patients died and 24 patients were lost to follow-up. Thirty four patients remained until the end of the study .At baseline the mean (standard deviation) age was 41.1 (±13.4) years old and there was a predominance of males, with income below a local minimum wage, average of six years of education, and pulmonary clinical form of tuberculosis . In addiAt the beginning of the study, all of the patients exhibited malnutrition . In bothIt is noteworthy that BMI measurements were less sensitive than TSF to detect energy malnutrition. BMI detected a quarter of patients with energy malnutrition at baseline and TSF detected more than two-thirds at baseline .A pattern of progressive increase over time was not observed for BMI, retinol and selenium. However, there was an apparent linear increase over time of the following parameters: weight, hemoglobin, hematocrit, iron fixation, transferrin, iron and tocopherol . The iroThe average transferrin and retinol levels were below the reference range and remained low until the end of the follow-up. In addition, patients exhibited a reduced ability to fix iron, and had low hematocrit and albumin levels . The remThe nutritional status did not show any apparent trend over time, except for the energy nutritional status. The energy nutritional status had an apparent increment after the second month of follow-up. However, a visually perceptible linear trend was not evident . Energy The main results of this study were: (a) all tuberculosis patients had malnutrition at baseline and, despite the provision of dietary counseling (following BMH’s and WHO’s recommendation), none of the patients recovered nutritional status during the six months of tuberculosis treatment; (b) the nutritional impairment was more intense at baseline in patients infected with HIV than in non-infected ones, regarding total protein and parameters related to iron metabolism.Studies conducted in other countries showed impairment of nutritional status only in HIV-infected patients ,26. In tThe choice of a malnutrition concept that uses different nutritional parameters, besides the anthropometric, is a consequence of the fact that these additional parameters are considered important in the clinical progression of organic changes . The conBMI is an anthropometric parameter for the monitoring of nutritional status. It has been used in clinical practice and at research settings to describe the nutritional status of study volunteers, and was adopted by the Brazilian Ministry of Health ,20 and tThe lack of sensitivity of BMI for the monitoring of nutritional status has already been described by other authors ,29, who TSF is an anthropometric measure which is extremely sensitive to energy malnutrition ,32. TherRegardless of whether the possibility that malnutrition had occurred prior to tuberculosis or HIV infection or not, there are several factors that may have influenced the patients’ food choices, or their access to more nutritionally complete foods, including: food taboos and beliefs , stigma Energy malnutrition, and specially protein, iron and retinol deficiencies, could be the result of social issues, which were intensified by illness, and they remained after tuberculosis treatment was over. Since we did not have information on the nutritional status of the patients prior to tuberculosis and HIV infection, we are unable to confirm that the nutritional deficiencies were due to the illness or to their social condition prior to treatment. This assumption can be supported by published reports, which indicate that the brazilian population has moderate prevalence of malnutrition even without consumptive-associated diseases . ConsequAnother important point to be discussed is how long dietary counseling should be offered to be effective. This is a very challenging point, because if dietary counselling should be offered for a longer period than tuberculosis therapy, it would be necessary to retain patients for more than 6 months (in non-infected with HIV patients). Hospitals are not an adequate environment for healthy people and a more effective strategy is desired.Surprisingly, vitamin A deficiency was identified in all of the volunteers throughout the treatment period, regardless of their HIV status. Studies conducted outside of Brazil showed a persistent vitamin A deficiency only in HIV-infected patients ,44. It iOn the other hand, serum zinc and serum selenium deficiencies in these patients with this degree of malnutrition are not as intense as retinol deficiency, as expected in high oxidative stress conditions ,46. SeleMycobacterium tuberculosis [We expected to find anemia in TB-HIV patients because both diseases are involved in different mechanisms that lead to anemia: the disease itself, antiretroviral therapy or blocked iron entry into the cell caused by rculosis . Anemia As serum iron mean values did not change during tuberculosis treatment, the anemia and the impairment on the iron-related metabolism observation were possible because, besides total iron, other iron-related biomarkers were measured. In clinical practice, iron supplementation is neither used nor recommended in any guidelines, perhaps because iron deficiency and iron-related metabolism alterations are not so easily identified.The main limitations of the study were the sample size and subject retention, both for the nutritional follow-up and for tuberculosis treatment. This lack of data, due to loss in follow-up, raises an uncertainty about the conclusions, as many outcomes are unknown. However, the prevalence of malnutrition observed at the end of follow-up was high, and selective loss in follow-up would be a problem only if this loss in follow-up is somehow related to full recovery of nutritional status. It is unlikely that this has happened as it would be necessary to observe a pattern in which preferably the subjects with the less impaired nutritional status are lost during follow-up. However, this pattern was not observed (data not shown). Some patients were discontinued because of severe malnutrition, to receive dietary supplement and others died. Also, this information could be interpreted as an absence of recovery of their nutritional status increasing the amount of patients with unfavorable outcomes. At the end, the lack of compliance with the follow-up could also be interpreted as a lack of effectiveness of the current recommendation. Another point is the lack of interventions to make patients feel “treated”, and the lack of financial support to allow them to choose the food they would like to eat.Patients infected with HIV had a worse condition at baseline, indicated by parameters related to protein and iron biomarkers. The nutritional status of all patients remained below the desired levels until the end of tuberculosis treatment. Adherence was a main challenge for medical treatment and nutritional counselling. Therefore, the evidence presented here does not support nutritional counselling as an effective recommendation.S1 Dataset(ZIP)Click here for additional data file.


Background: Diabetes mellitus (DM) and Impaired Fasting Glucose (IFG) represent serious threats to human health, and as a result, this study was aimed at understanding the blood glucose distribution characteristics and the risk factors among a large health examination population in China. Methods: An investigation with physical and biochemical examinations and questionnaires was conducted in the physical examination center from 2011 to 2014 and as a result 175,122 physical examination attendees were enrolled in this study. Multivariate logistic regression was used to explore the factors influencing blood sugar levels. Results: The rates of IFG and DM were 6.0% and 3.8%. Prevalence were 7.6%/5.1% in males and 5.1%/2.8% in females for IFG and DM, respectively. The prevalence of IFG and DM were thus higher in males than in females. In the normal group, except high density lipoprotein (HDL) that was significantly higher than in the IFG and DM group, the other indexes , glucose (Glu), total cholesterol (TC) and total glycerides (TG) were lower than those in the IFG and DM group. The proportion of IFG and DM also increased with the increases in proportion of abnormal blood pressure, smoking and alcohol consumption. Multivariate logistic regression analysis showed that increasing age, high BMI, high TC, high TG and low HDL increased the risk of diabetes, while in males, in addition to the above factors, the smoking and drinking factors also increased the risk of diabetes. After the age of 65, the blood glucose level reached a peak in males, while in females, the increasing trends was on the rise. The inflexion age of the fast rise was younger in males than in females. Conclusion: The study population showed a high prevalence of DM and IFG among the adults. Regular physical examination for the early detection of diabetes is recommended in the high-risk population. Diabetes mellitus (DM) is a chronic systemic metabolic disease, which not only seriously harms human health, but causes a great socioeconomic burden ,2. The eThis study was performed by a cross-sectional physical examination method at Yijishan Hospital of Wannan Medical College, which is located in Wuhu City in China. The total sample, which included 175,122 cases ≥18 years old examined during 2011–2014, included 102,261 males (mean age 42.8 ± 13.0) and 72,861 females (age 40.4 ± 13.6).This study was conducted in accordance with the Declaration of Helsinki and was approved by Ethics Committee of Wannan Medical College (2010wy038). Verbal informed consent was obtained from each subject before the investigation, all participants (volunteers aged 18 years or more) were identified. All the participants were requested to complete the questionnaire, physical examination and laboratory test. Participants’ demographic characteristics such as age and sex, and lifestyle habits such as smoking, and alcohol consumption were assessed by trained investigators. On the day of the survey, investigators explained the purpose of the study, the elements of informed consent, and distributed the survey. After that, participants were asked to complete questionnaires by themselves or with the help of the investigators. The completed questionnaires were checked by reviewers.The questionnaires were followed by a general physical examination, which included a fasting blood collection, liver and kidney ultrasonography, and anthropometric assessment. The anthropometric assessments included height, weight and blood pressure. The weight was collected using a calibrated electronic digital scale, accurate to 100 g with subjects wearing only light underwear. Heights were measured to the nearest 0.1 cm using a secure portable stadiometer while wearing no shoes. The blood pressure was recorded twice by an experienced nurse in both arms with a mercury sphygmomanometer in the sitting position after a 5 min rest.Also, blood samples were withdrawn from the antecubital vein of subjects in fasting status. High density lipoprotein (HDL), low density lipoprotein (LDL), triglyceride (TG), and total cholesterol (TC) were assessed by the clinical laboratory of the hospital. All laboratory values were assayed by an automated biochemical analysis instrument , using commercially available assays.In our study, glucose intolerance, DM and hypertension were considered. Diabetes mellitus was diagnosed according to the 1999 World Health Organization diagnostic criteria or previously diagnosed diabetes : impaireThe diagnosis of hypertension was based on standard criteria according to the Guidelines for Prevention and Treatment of Hypertension in China : Normal t-test or Chi squared, accordingly. Multivariate logistic regression analysis was used to estimate the risk factors for hyperglycemia . The odds ratio (OR) and its 95% confidence interval (CI) were presented to show the risks. The trend in glucose with age for the different sexes was shown with a graphic. A p-value < 0.05 was considered as significant.All participant information and laboratory results were entered into a customized database, and then analyzed by the R 3.0 statistical software . Descriptive analysis and chi-square tests were conducted to analyze the general characteristics of participants regarding lifestyle habits and glucose levels. The differences between laboratory results and lifestyle habits among different glucose level groups were compared using p < 0.001)  .p < 0.001). The HDL of the normal group was higher than that of the IFG and DM groups, other variables were lower. An increasing rate of IFG and DM was associated with the increasing rate of abnormal BP, smoking and alcohol consumption.As The level of blood glucose data was assigned to two groups: hyperglycemia (includes IFG and DM) and control. In a multivariate logistics analysis, using an enter method, a significant positive correlation was observed between blood glucose and participants’ age, BMI, BP, TG and TC as well as inverse correlations with HDL . ConcomiAs This study was conducted among a 175,122 person physical examination population aged 18–95 from Wuhu City and the surrounding areas during 2011–2014. This large sample data only reflected the level of FPG and incidence of DM in the local population. However, a diagnosis of diabetes should not be excluded merely on the basis of glucose levels because this study included only one FPG result in this physical examination population, therefore the rate of undiagnosed diabetes was an outcome measured in our study.Compared with the global prevalence of DM (2.8%), the local DM rate was higher 3.8%). Previous studies showed that the prevalence of DM was 2.8% in 2000, which would be expected to rise to 4.4% by 2030, and the number of DM cases would reach 5 million .8%. Prev,7,12. HoThe current study showed that the prevalence of IFG was positively correlated with age, which was similar to previous studies ,16,17. TAs One of the major advantages of this study is that it was a large sample investigation, with subjects from the same area, which support the accuracy and stability of the result. Of course, the present study has some limitations. First, FPG but not has oral glucose tolerance test (OGTT) been used as an indicator of blood glucose because of the specificity and acceptability in physical examination groups. In general, OGTT shows higher sensitivity and specificity for diagnosis of diabetes. More studies are needed to confirm these findings in the future. Second, some questions in the questionnaire are mainly subjective and the fact the results were self-reported may lead to bias. Finally, our study failed to explore the causality relationship between blood glucose and related factors because of inherent limitations of the cross-sectional study. Despite these limitations, the results of this study are noteworthy for DM education and intervention.In summary, high prevalence of DM and IFG was observed in a large population of adults. Various factors such as age, sex and other disorders contribute to hyperglycemia, especially lifestyle habits. It is particularly important to strengthen community care of DM, screen high-risk groups and adopt appropriate preventive measures.


The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD).Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity.Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality .Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort. Recent epidemiology data have shown that the Roma minority represents the largest ethnic group in Central and South-East European countries (up to7-9% of the population) .Several studies showed a higher prevalence of chronic diseases  in the Roma minority in comparison to the general population , 3, 4. Tst of November 2010 (332 men and 268 women) in 7 Romanian centers. The cohort was followed-up until 31st of December 2013, or until death. No patient was lost to follow-up.In this prospective observational study we included all 600 ESRD patients under chronic HD therapy on 1At inclusion, patient’s data were obtained from their medical records. Dialysis vintage was defined as the time between the first day of dialysis treatment and the study entry date. A routine, complete hematologic and biochemical panel of analysis was performed according to the protocols of the Romanian Ministry of Health . Patients were treated with high flux, high surface, polysulfone (Xevonta) filters (not reused) and ready-to-use dialysis fluid (B. Braun acidic bicarbonate HD concentrate). Anemia and CKD-MBD were treated according to the KDIGO guidelines , 7.Ethnicity was established based on patient’s self-identification and the appraisal of the nephrologist.st November 2010) to the date of death or the administrative end of the study (31st of December 2013). We assessed the association between ethnicity and all-cause mortality using Cox-proportional hazard models in which patients remained at risk until death or the end of the study. In the adjusted analysis of survival differences, the following covariates were included: ethnicity (Roma vs. Caucasian), patient’s age, HD duration, body mass index (BMI), hemoglobin, vitamin D levels, history of coronary artery disease, peripheral vascular disease, stroke, hepatitis virus infection and type 2 diabetes mellitus (DM).Survival time was calculated from the study entry date  and are presented as mean ± standard deviations for continuous variables with Gaussian distribution, median (interquartile range) for continuous variables without Gaussian distribution, or percentages for categorical variables. Survival was analyzed with Hazard Ratio (HR) method and presented using Kaplan-Meier diagrams.To assess the significance of the differences between groups, the Student t-test , Mann-Whitney-U test , Chi-square (proportions) and log-rank test  were used. Continuous variable distributions were tested for normality using the Shapiro-Wilk test, and the Levene’s test for equality of variances. For evaluating the involvement of more confounding factors in time-related risk, Cox proportional-hazards models were constructed. The acceptance of a predictor in the equation was performed according to a backward Wald principle, having an entry probability threshold of 0.05 respectively removal probability threshold at 0.10. A p value of <0.05 was considered as the threshold for statistical significance.The baseline characteristics of the cohort are presented in The study was approved by the Ethical Committee of BBraun Avitum Ltd Romania and the Ethical Committee for Human Research of the University of Medicine and Pharmacy Timisoara. Every patient provided written informed consent before enrollment. The study have been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.The studied group was divided in two subgroups in respect to their ethnicity: Caucasian patients (n = 549) respectively Roma patients (n = 51) and compared accordingly. Tables  and 3The Roma group had a significantly lower median age  having at the same time a similar duration of chronic HD . Also, Roma patients initiated maintenance HD at a significantly younger age , leading to the conclusion that Roma ethnicity is associated with an earlier onset of end-stage renal disease.Compared to the control group, in the Roma ethnicity group there were significantly higher mean PO4 levels , alkaline phosphatase  and serum albumin . There were no other significant differences between the two groups. .Although the Roma ethnicity group included significantly younger patients than those included in the control group, there were no differences regarding the prevalence of comorbidities between the two groups. Treatment prescriptions with iron, erythropoietin, vitamin D, vitamin D receptor activator, and phosphate binders did not significantly differ in the two groups (data not shown).During the 3 years of follow-up, 153 deaths were recorded, representing 25.5% of the enrolled patients. In the Roma group the overall mortality was higher compared to Caucasians (33.3% vs. 24.8%). The difference in the median of ages between the two groups, (the Roma group being younger by 3 years), suggests that Roma dialysis patients have a poorer outcome during dialysis therapy and are dying at a younger age compared to Caucasians.th day of follow-up, with a more pronounced mortality in the Roma ethnic group after this moment. , patient’s age, HD duration, BMI, hemoglobin, vitamin D levels, PO4, albumin, history of coronary artery disease, peripheral vascular disease, stroke, hepatic virus infections and type 2 diabetes. According to the backward Wald method and by defining an entry probability threshold of 0.05, respectively removal probability threshold at 0.10, the final equation was obtained after 7 removal steps. The final predictors accepted in the hazard equation were ethnicity, age, BMI, vitamin D levels, coronary artery disease and peripheral vascular disease. The excluded co-variates proved to be neither significant, nor marginally significant, having a p value for hazard ratio higher than 0.10.According to our model Roma ethnicity , higher age  and the presence of coronary artery disease  were associated with an increase in the risk of mortality in dialysis patients, while a higher value of vitamin D levels at baseline proved to have a significant protective impact . In our model a higher body mass index also proved to have a protective action; however, it was only marginally significant . The details of the multivariate Cox regression analysis are presented in Our results suggest that after adjusting for the studied confounding factors, Roma ethnicity represents an important and significant risk factor for mortality in dialysis patients.Since the survival curves were crossed at the middle of the studied period and thus the proportional hazards hypothesis may be biased , 9, we cAccording to these new models, the significant predictors for the short-term survival (424 days of follow-up) were age  and peripheral vascular disease  while BMI  and the presence of coronary artery disease  were only marginally significant .For the long-term survival, as defined the survival from day 425 to the end of the follow-up period (day 1125), we observed that Roma ethnicity , age  and cholecalciferol  were significant predictors for mortality .Data regarding the survival of Roma people with ESRD on maintenance HD are lacking. For the first time, we assessed the 3 year survival rate of Roma ethnicity from a large cohort of HD patients. Our data showed that the prevalence of Roma ethnics among HD patients is high. Roma peoples are initiating chronic HD at a younger age than Caucasians and are presenting more frequently higher phosphate levels. They are at a higher risk of dying at a younger age. Furthermore, in the long-term survival analysis, Roma ethnicity represents per se, a significant, independent risk factor for mortality in HD patients.In our cohort the prevalence of Roma patients is high 8.5%), though, according to the 2011 Census, in our country, Roma ethnic minority represents only 3.3% of the population . Similar%, thoughAccording to our data, Roma patients with CKD initiated HD therapy at a significantly younger age compared to Caucasians, as the African-Americans in the USA . Racial/The racial disparity in CKD could be related to the hereditary gene polymorphisms, to the variances in mineral bone disorder, nutritional status, dietary intake, inflammatory and oxidative status profile or in body composition . Some psThe data focusing on CKD in the Roma ethnicity are limited to few studies. Thus, scarce reports have shown a higher prevalence of primary renal diseases among Roma children, a higher frequency of nephropathies with a lower eGFR in Roma women, and a higher relative risk of ESRD (RR = 1.34) for Roma people as compared to Caucasian counterparts , 24, 5. The higher risk of CKD in Roma minority and the faster progression to ESRD seem to be associated with the similar disparities reported in African-Americans and/or Hispanics, but with some particularities. Giving the Indian origin of this population, specific genetic factors could be associated with the higher risk of CKD . RecentlIn the last decade racial differences have been described in the regulation of bone and mineral metabolism in patients with ESRD , 33, 34.According to the results of the Global Burden of Disease 2013 study, CKD is a non-communicable cause of premature death, with a 90% increase over the last years . The lifThe survival paradox does not apply to the Roma minority. Data regarding the mortality of Roma patients treated with HD are scarce and we are not aware of any other similar research. In our cohort of HD patients, Roma ethnicity represents an independent risk factor for mortality in long term survival analysis . Moreover, Roma dialysis patients are dying at a younger age compared to Caucasians. In our study, the survival analysis revealed an interesting fact: Roma people presented a similar survival rate in the first 424 days of the study period, and a higher mortality rate after this date, as compared to Caucasian patients. It is possible that, at the initiation of HD therapy, Roma patients, being younger and healthier, had an initial better survival. Later on, they developed more severe complications at a higher rate which increased their mortality.In the Roma minority from the general population or with kidney transplants the results seem to be similar. Jackson et al reported a life expectancy gap of 5–15 years in Roma people compared with the general population . FurtherThe lower socio-economic status with subsequent limited access to health care system, lower adherence to medical treatment prescriptions and specific genetic background related to their North-Indian origin could be considered potential causes of the poorer outcome of the Roma population , 26, 48.In Romania some of those explanations are not valid. Our country has a long-standing universal access to health care with a single, state managed financing system, generating a higher degree of homogeneity of quality of care and higher equity. Even under these conditions, the Roma population continues to experience a higher mortality rate.Our study has several strengths: the large size of the studied cohort, recruited from one of the East European countries where Roma people represent the second-largest ethnic minority; a follow-up period of 3 years and the fact that it is the first study investigating Roma patients survival on HD therapy.In our opinion the study has some limitations also. Firstly, we analyzed the risk of mortality by performing an extensive multivariate Cox regression analysis, but, as with all observational studies, we cannot exclude the possibility of residual confounding factors. Secondly, the severity of comorbidities could not be assessed. Finally some variables, such as education, income or hospitalization rate were not available in the patient’s medical records though they could have influenced the outcome.In conclusion, this study demonstrates that Roma people experience a higher prevalence of ESRD requiring dialysis. In the Roma minority group, patients initiate HD at a younger age, suggesting that CKD progression rate in the pre-dialysis period is higher in this ethnicity. No survival paradox could be evidenced in the Roma minority. According to our study, Roma patients with CKD treated with HD are at an increased risk of death and are dying at a younger age compared to their Caucasians counterparts. Further research is required to establish the causes of these findings.


Women's malnutrition, particularly undernutrition, remains an important public health challenge in Ethiopia. Although various studies examined the levels and determinants of women's nutritional status, the influence of living close to an international border on women's nutrition has not been investigated. Yet, Ethiopian borders are regularly affected by conflict and refugee flows, which might ultimately impact health.To investigate the impact of living close to borders in the nutritional status of women in Ethiopia, while considering other important covariates.Our analysis was based on the body mass index (BMI) of 6,334 adult women aged 20–49 years, obtained from the 2011 Ethiopian Demographic and Health Survey (EDHS). A Bayesian multilevel multinomial logistic regression analysis was used to capture the clustered structure of the data and the possible correlation that may exist within and between clusters.After controlling for potential confounders, women living close to borders (i.e. ≤100 km) in Ethiopia were 59% more likely to be underweight  than their counterparts living far from the borders. This result was robust to different choices of border delineation . Women from poor families, those who have no access to improved toilets, reside in lowland areas, and are Muslim, were independently associated with underweight. In contrast, more wealth, higher education, older age, access to improved toilets, being married, and living in urban or lowlands were independently associated with overweight.The problem of undernutrition among women in Ethiopia is most worrisome in the border areas. Targeted interventions to improve nutritional status in these areas, such as improved access to sanitation, economic and livelihood support, are recommended. The nutritional status of women has important implications both for their own health and that of their children. Malnutrition increases women's susceptibility to diseases and slow recovery from illnesses, and puts them at higher risk of pregnancy-related mortality. The children of undernourished women are more likely to be undernourished, which can lead to poorer cognitive development, shorter stature, and higher risk of morbidity and mortality. Malnutrition also hampers women's productivity and that of the society at large –3.Women's undernutrition particularly remains a public health challenge in Ethiopia . ComparaAlthough health outcomes heavily depend on contextual factors such as community-based services and norms operating at community level , studiesOur analysis was based on the third comprehensive Ethiopian Demographic and Health Surveys (EDHS) 2011 dataset. The survey was conducted to provide information mainly on fertility, family planning, HIV/AIDS, maternal and child health, and nutrition indicators at the national and regional levels. A stratified two-stage cluster sampling design was used to select the sample households. The sample initially included 624 enumeration areas (clusters) – 437 rural and 187 urban areas. However, in the Somali region, 28 of the 65 clusters were not interviewed due to drought and security concerns. Overall, 16,515 women of reproductive age (15–49 years) were selected from 596 clusters to form a representative sample of this age group. The data was collected using a questionnaire, which was adapted from the MEASURE DHS project  divided by height (in meters) squared was used to assess the nutritional status of women. The use of BMI cut-offs is not recommended for adolescents (15–19 years) due to the remarkable growth during this period .kg/m2), normal weight (18.5–24.9 kg/m2), and overweight (≥25.0 kg/m2).The outcome variable is the women's nutritional status measured in BMI. We adopted the WHO BMI cut-offs , distingThe exposure variable of the study is the residence status (border resident or not), measured by the nearest distance, in kilometers (km), from the borders to the sampled clusters. We used the GPS coordinates of the sampled clusters to measure the nearest distance to the border. Then, we dichotomized the distance into border (≤100 km) and non-border (>100 km), based on a previous study . We alsoThe selection of confounding variables was guided by previous studies , 6, 8–10The EDHS data has a hierarchical structure, as women are grouped within clusters. This structure often yields data that are correlated and thus cannot be assumed independent. A multilevel approach adequately represents the unexplained variability of the nested structure, which is often difficult to represent in the single-level approach . Taking 6) for regression parameters and inverse gamma  for precision parameters. We then run the chain for 50,000 iterations with a burn-in length of 25,000 iterations to ensure convergence of the Markov chains. The convergence of Markov chain was assessed by a visual inspection of the trace- and autocorrelation-plots. Further, Bayesian deviance information criterion (DIC) was used to evaluate the goodness-of-fit of the models  method was used as recommended by Browne . For thee models .Three models were fitted. Model 1 does not include any covariate; Model 2 include cluster level covariates ; and Model 3 include variables in Model 2 and individual level covariates. We also conducted a sensitivity analysis to assess whether the different choice of distance from the border might have impacted the results. We used survey weight as provided in the EDHS, to ensure the representativeness of the sample characteristics.runmlwin command, a program to run the MLwiN multilevel modeling software from within Stata  and 95% Bayesian credible intervals (CrI) for each of the variables in the full model (Model 3). The statistical significance was based on the non-inclusion of 1.0 in the 95% CrI. The statistical analysis was performed in STATA/IC 12.1 using in Stata . The mapin Stata .kg/m2); nearly 25% of the women were underweight and 8% were overweight. The average distance between a border and a cluster was 184.4 km (ranging from 0.2 to 449 km). About 10% of the women lived close to the borders (i.e. ≤100 km) (≤100 km) . The med≤100 km) .In addition, the odds of underweight were significantly higher among women from poor families  compared to those from rich families; among lowland women  compared to midland women; among Muslim women  compared to protestant; and among women who had no access to improved toilet facilities  .On the other hand, women who had no education  or primary education  were less likely to be overweight than women with secondary education or above. Similarly, women from poor families  and middle class families ; who had no access to improved toilet facilities ; and who were never married  were less likely to be overweight. The odds of being overweight were much higher among urban women ; and women who lived in lowland areas . Finally, 1 year increase in age was associated to 7% higher odds of being overweight (95% CrI: 5–8%) .Var(u1) and Var(u3)) and covariance (Cov(u13)) estimates of the random effects parameters in Model 1 suggest that there is a large variation in women's nutritional status between clusters. The inclusion of all covariates (Model 3) reduced the between-cluster variances substantially. Moreover, the reduction of Bayesian DIC from Model 1 to Model 3 suggests that the full model best fit the data  adult women in Ethiopia were underweight while 8% were overweight. Such underweight prevalence is classified as serious according to the WHO Expert committee on physical status . MoreoveMany factors can explain the border differentials. For example, the Afar, Gambella, Somali and Benishangul-Gumz regions in general and their peripheries in particular are poorly developed , 22. RecFurthermore, the border areas themselves have been struggling with their own internal and cross-border violent conflicts: for example, instability has affected the regions of Afar , Somali Ethiopia has also hosted a large number of refugees escaping conflict, political instability, inter-ethnic clashes, and droughts in neighboring countries . The majOur results further depicted that lowland women were more likely to be underweight. In the lowland areas of Ethiopia, the communities are mainly pastoralist and semi-pastoralist . PopulatIt is well recognized that poverty affects an individual's health status by various channels, be it through household food security, health care utilization, access to sanitation facilities, or gender inequality . Our stuWe found that the odds of overweight increased with age, education, family wealth, having access to improved toilet facilities, and living in urban settings or lowlands. Studies conducted in Ethiopia and other developing countries corroborate our findings , 40, 44,Our study presents some limitations. First, BMI is influenced by the body shapes found in a population with heterogeneous body proportions (the ratio of leg-length to torso-length) . As the Women's malnutrition, particularly undernutrition, remains an important public health challenge in Ethiopia, which is not tackled adequately to date. The burden is particularly heavy among women who live close to the borders. Targeted interventions that are recommended to improve nutritional status in borders zones include improved access to sanitation, and programs to enhance household wealth and livelihood support. Our results also acknowledge pockets of overweight particularly in urban and affluent families, which should not be overlooked. Finally, our study aims to foster the debate on the health of communities living at the borders by investigating both internal and external factors. In view of the growing trends in internal and cross-border insecurity both in Ethiopia and elsewhere in the region, this type of study provides important insights into identifying vulnerable population groups and zones.


Premature birth is one of the most important unresolved reproductive health problems. Premature birth is often traumatic and a source of distress for parents. Increased parental stress during the first year of their infant's life is a risk factor for later behavioral problems in infants.This study was designed to compare anxiety, post-traumatic stress, and social supports in parents of premature and mature infants.This was a comparative descriptive study conducted at healthcare centers of Qom city, in 2012. In this study, 82 couples (164 parents) divided into two groups including parents who have preterm and term infants. Questionnaires including items such as demographic characteristics, obstetric and post-traumatic stress disorders, Spielberger anxiety and Multidimensional Scale of Perceived Social Support were completed two months after childbirth. Data were analyzed using χ2 test, Fisher’s exact test, Mann-Whitney test, independent t-test, and regression logistic using SPSS18 software.The levels of anxiety was not significantly different in mothers and fathers in the two groups, but the trait anxiety level of mothers (P < 0.001) and fathers who had preterm infants (P = 0.01) was significantly greater than the parents of full-term infants. Post-traumatic stress disorder was significantly greater in mothers of preterm infants than those of term infants (P = 0.03), but this amount was not significantly different between the two groups of fathers. Mothers' social support did not differ significantly (P = 0.08), however, it was significantly different in fathers (P = 0.01).Premature infants' parents are more at risk of mental disorders than term infants' parents. This result shows the need of interventions, so these parents can better deal with the problems of premature infants. Premature birth is one of the most important unresolved reproductive health problems. Preterm birth is defined as birth after 20 and before 37 weeks of gestational age . The preSocial support is an intermediate factor that affects the mental status of people based on World Health Organization framework . PerceivWe aimed to compare the anxiety, post-traumatic stress disorder and social support status of parents of premature infants with those parents with term infants.This comparative descriptive study was conducted on 164 parents of premature and mature infants who had referred to health centers in Qom city to receive postnatal care from December to March 2012. The inclusion criteria included: no mental illness, no history of any mental disorders, no mental medications usage such as antidepressants, or psychotropic substances, and no neurological or congenital defects in newborns. Based on statistics, each group was comprised of 41 couples , multistThe questionnaires for this study include:Part I:Questionnaire including father’s information comprised of two parts. The first part includes questions about demographic characteristics, history of psychiatric illness in their first-degree relatives (six questions). The second part comprised of information about the unpleasant events that the father may have experienced during the pregnancy of his spouse (27 questions).Questionnaire including mother’s information comprised of four parts. The first part includes questions about demographic characteristics, socioeconomic status of the family including housing, family income, and family size (12 items). The second part contained information about the mother's pregnancy such as questions about: previous pregnancies, methods of contraception, prenatal care, the rate of satisfaction of midwife’s care during childbirth, history of diseases during pregnancy, insurance type, delivery type, and hospitalization after delivery (38 questions). The third part included neonatal factors including questions about the baby's gender, type of pregnancy, baby’s disease(s) after birth, infant's history of admission to hospital, parent’s satisfaction with the baby's gender, baby’s gestational age at birth, baby’s weight at birth, baby’s nutrition, problems while caring the newborn, ability to pay baby’s hospitalization costs (15 questions). The fourth part included questions related to unpleasant events in pregnancy (27 questions).In this study, content validity was used to determine the validity of demographic and obstetric questionnaire. To determine reliability of this questionnaire, test retest analysis was used. The reliability coefficient was calculated as 0.98.Part II:Post-traumatic stress disorder symptoms scale:To diagnose post-traumatic stress disorder (PTSD), the severity of symptoms was evaluated based on DSMIV containing 17 questions with Likert scale. Each question contained a short question and the person’s answers were graded from zero  to 3 (5 or more times a week). In this scale, the frequency and severity of symptoms have been incorporated because some PTSD symptoms can be evaluated based on their frequencies (such as trauma-related nightmares) and others can be described based on their severity . Four questions were related to re-experiencing, seven questions were related to avoidance, and six questions were related to motivational responses. In case of one or more re-experiencing related symptoms, three or more symptoms of avoidance, two or more symptoms related to motivational reactions, PTSD was diagnosed , 17.From Iran, Mirzamani et al. studied the validity of this scale using concurrent validity method in 2006 . Its test-retest reliability was 0.74 in various studies and 0.88 in Cronbach's alpha method .Part III:Spielberger Anxiety Questionnaire:Spielberger Anxiety Questionnaire was performed in order to the study anxiety level. The questionnaire consists of two parts measuring the trait and state anxieties separately. Each section comprised of 20 questions and each question has been scored form 1 to 4. The total score for each individual will be between 20 and 80. Based on this questionnaire, people were classified into three groups of mild (20-40 points), moderate (40-60), and severe anxiety (60-80). This scale has a 0.73 to 0.85 concurrent validity with other anxiety questionnaires . ReliabiPart IV:Multidimensional scale of perceived social support (MSPSS) was used to measure social support in this research. This scale consisted of 12 items which measured three issues: support perceived by the family members (four items), support perceived by important persons (four items), and support perceived by friends (four items). Based on 7-point Likert scale, all items of this scale ranged from very strongly agree to very strongly disagree. The total score ranged from 12 to 84.In 2013 Mirabzadeh et al. reported the reliability of this instrument with Cronbach's alpha of 0.89 . SararouIn this study, chi-square test and Fisher's exact test were used to compare the qualitative variables, t-test was used to compare the relationship between quantitative variables, Mann-Whitney test was used for ordinal variables and logistic regression was also used. Data analysis was performed using SPSS version 18. Missing data was replaced by the mean of variables. Confidence coefficient of the study was 0.95.The means age of mothers in full-term baby group was 28.22 ± 4.54 and those in preterm infants group was 27.6 ± 6.25, the results showed no significant statistical differences in terms of age between fathers and mothers of term and preterm infants. However, Mann-Whitney test showed that fathers of term infants had higher levels of education compared to preterm infants. This difference was significant (P < 0.001).In 41.5%, the average monthly salary of fathers in term group was 120 to 240 USD and 46.3 % of preterm group was 240 to 300 USD. As for housing, 37.7 % of the participants owned their place of residence and others had rental housing, governmental housing or lived with their families. The statistical analysis showed no significant difference between the two groups of mothers and fathers in terms of jobs, income and housing type. Most parents in both groups experienced their first childbirth. There were no significant differences between the two groups in terms of labor type, number of childbirths, number of live births, number of sons, number of daughters, abortion history, stillbirth history and infant gender. According to the results, there is a statistically significant difference between infants of two groups in terms of need for hospitalization (P < 0.001) and admission to the neonatal intensive care units (P < 0.001) . No significant relationship was found between disorders such as diabetes, pregnancy hypertension, urinary tract infections, vaginal infections, bleeding or spotting, oligohydramnios, polyhydramnios and other diseases in pregnancy. Overall, there was no significant difference between the two groups in terms of occurrence of unpleasant life events for parents during the last year.The results showed that in terms of state anxiety, there was no significant difference between the mothers and fathers. However, in the appearance of trait anxiety, the results showed significant differences between the two groups of parents, (P > 0.001). Parents of premature infants significantly suffered from higher trait anxiety than parents of term infants . The results showed significant statistical differences between the two groups of mothers in terms of PTSD (P = 0.03). The rate of PTSD in mothers of preterm infants is significantly higher than mothers of term infants. The Fisher’s exact test showed no significant difference between the two groups of fathers . The mean perceived social support was 59.49 ± 14.47 and 63.43 ± 14.5 in mothers of term infants, and those of preterm infants, respectively, which shows no significant difference in the perceived social support between two groups of mothers. That for fathers of term babies was 60.6 ± 13.64 and for those of premature infants was 66.43 ± 14.85. Based on the t-test, there were significant differences (P = 0.01) between two groups of fathers in terms of social support. The results of mixed model analysis or GEE analysis are shown in The estimate for the marginal modeling parameter of term variable of -4.88 can be interpreted that mean social support score in the term group had been almost five points less than those in preterm group (P = 0.006). However, in terms of social support scores, no significant difference was found between mothers and fathers (P = 0.127).Results revealed no significant difference in the state anxiety between term and preterm groups (P = 0.817). However, the mean level of state anxiety in mothers was 6.41 points less than that in fathers, and this difference was statistically significant (P < 0.001).Results showed that there was no significant difference between preterm and term groups (P = 0.796). The difference between fathers and mothers in terms of trait anxiety was also not significant (P = 0.469).Post-traumatic stress disorder was measured using ranking scale, thus, after finding exp (B), the resulting value expressed in the form of OR, could be interpreted as the odds ratio index of 3.66 for variable of parent, which means that the fathers’ chance of post-traumatic stress disorder is almost 3.5 times higher than the mothers. However, no significant difference was found in scores of post-traumatic stress between preterm and term groups (P = 0.313).Few studies have examined the psychological disorders of parents with preterm babies in early infancy. Most of such studies have mainly focused on the psychological status of mothers while the fathers have been neglected. According to the current study, there was no significant difference between the state anxiety level of mothers in preterm and term groups. Mothers of premature infants experienced significantly higher trait anxiety compared to mothers of term infants. However by using GEE analysis, the state anxiety of mothers was on average 6.41 points lower compared to the fathers, and this difference was statistically significant and the trait anxiety level between fathers and mothers was also similar. In terms of anxiety, the results of this research are not in line with those reported by Gambina et al. in 2011, in terms of stress, anxiety and depression levels in mothers of preterm and term infants . GambinaThe difference between Gray’s research and the present one is that in the current study the questionnaires mentioned above were handed out to parents to evaluate their mental disorders two months after the birth of their baby. However, in Gray et al. research, the data were collected four months after the delivery. They used PSI-SF scale to study mothers’ stress. This is different from the scale used in the present study which is post-traumatic stress disorder scale. Furthermore, Gary et al. only studied the psychological status of the mothers and the fathers’ mental state was ignored. Participants in Gray et al.’s study included mothers who had babies at 24-30 weeks of pregnancy, and their infants were admitted to NICU. In the present study, mothers of infants born between 32-36 weeks entered into the study as preterm group and only 52.4 % of them required hospitalization in intensive care unit.The findings of the current study are also inconsistent with the those by Yurdakul et al. in 2009 to determine the symptoms of depression, anxiety and mother-infant relationship in neonatal intensive care units . AccordiBased on the results of the current study, the level of PTSD after childbirth was significantly higher in mothers of preterm infants than mothers of term infants. No difference in PTSD level in fathers of preterm and term babies were detected. Thus, these results are in agreement with those of Pierrehumbert et al. in 2003, which studied the effect of post-traumatic reactions of parents on children’s nutrition and sleep problems, and those of Kersting et al. research that compared the symptoms of PTSD in mothers of preterm and term infants , 25. BasSeverity of parents’ post-traumatic reactions is a strong predictor of the infants’ sleep and behavioral problems. Kersting et al. also found that mothers of preterm infants showed significantly higher rates of PTSD compared to mothers of term group  . No reduDifference between the present study and Kersting study was in data collection and the used tools. They used impact of event scale to measure the signs, and followed mothers up for PTSD symptoms. The difference in the current research with Pierrehumbert research was the time spent on gathering information and the age range of preterm babies. Parents were interviewed about their baby 18 months after delivery, and they were asked to complete prenatal post-traumatic stress disorder questionnaire (PPQ). In their study the premature infant age was between 25-33 weeks; however, in our study the age of preterm infants was 32 to 36 weeks in the present study.In 2009, Shaw et al. conducted a study to investigate the prevalence of PTSD in parents of premature or sick babies, four months after childbirth to find the relationship between the symptoms of acute stress disorder immediately after birth and PTSD (33.22 % of fathers and 9% of mothers suffered from PTSD). Signs of acute stress disorder were significantly correlated with PTSD and depression. PTSD symptoms appeared in fathers much later than mothers; however, in the fourth month they were at greater risk than mothers and 54.4 % of mothers showed all signs of acute stress disorder while none of the fathers showed such signs .Mean social support score in the term group had been almost five points less than that in preterm group. However, in terms of social support scores, no significant difference was found between mothers and fathers. Social support is an emotional, psychological, informational, and instrumental help provided by others, and directly or indirectly affects the recipient’s behavior. It seems social support for mothers of premature infants compared to those of mature infants is of higher importance because it has been observed that lack of general social support and spouse support is a predictor of maternal distress in mothers with preterm infants . Weiss aThe findings of this study suggest that trait anxiety in mothers and fathers of preterm babies was significantly higher than those in term group. PTSD in mothers of preterm group was significantly higher than mothers of term babies. Regarding the social support of mothers, no significant difference was observed. However, this difference was significant among fathers. Thus, it appears that mothers of preterm infants are at greater risk of mental disorders compared to the fathers. These results show the need for intervention for these parents to better deal with problems of premature infants. The results reveal the existence of mental disorders during this time, and the need of parents’ consultation.When a baby is born prematurely, most of the attention is focused on baby, or at least, mother receives less attention. As is observed in most previous studies in this area, only few studies have focused on the mental status of fathers of these infants, whereas if both parents are considered, it may lead to an improved care of the preterm infant. The main focus of this study was in consideration for fathers’ mental status. Due to the large extent of factors that are associated with mental disorders, all of those could not be covered in this study.


This work presents a learning method, weighted DeepCNF , to improve the accuracy of order/disorder prediction by exploiting the long-range sequential information and the interdependency between adjacent order/disorder labels and by assigning different weights for each label during training and prediction to solve the label imbalance issue. Evaluated by the CASP9 and CASP10 targets, our method obtains 0.855 and 0.898 AUC values, which are higher than the state-of-the-art single ab initio predictors.Intrinsically disordered proteins or protein regions are involved in key biological processes including regulation of transcription, signal transduction, and alternative splicing. Accurately predicting order/disorder regions  Protein sequence determining structure and therefore function is a long-standing paradigm in biology. However, this paradigm has been challenged ever since the discovery of the first functional protein featuring no stable structure over 50 years ago . Since tab initio methods that require only the protein sequence as input, and results are predicted based on a single method, such as IUpred [et al. and Deng et al. [Since the late 1990s, more interest has been focused on IDP and IDR due to additional evidence from experimental approaches such as NMR . Due to s IUpred , DISOPREs IUpred , SPINE-Ds IUpred , and DNds IUpred , PONDR [s IUpred , POODLE s IUpred , and Mets IUpred . For a mg et al. ,14.ab initio method is still valuable since the improved results may contribute to other consensus methods, and then in turn to increase overall prediction accuracy. However, there are three challenges that block the advancement of single methods: (a) How to exploit the interdependency of adjacent order/disorder states (or labels), as well as the long-range sequential information that determines the order/disorder state at a certain position. In fact, adjacent order/disorder states are interdependent. In other words, the order/disorder state in one position influences adjacent states, as shown by the occurrence of long consecutively disordered regions. PrDOS-CNF [Despite the good performance of currently available hybrid and consensus methods for order/disorder prediction , an accurDOS-CNF  and OnD-rDOS-CNF  exploit rDOS-CNF , but therDOS-CNF . It has rDOS-CNF . BesidesThis paper presents a machine learning model, called weighted DeepCNF , for order/disorder region prediction to overcome the three challenges described above. (a) Weighted DeepCNF combines the advantages of both conditional neural fields (CNF)  and deepIn this section we describe our experimental verification on the prediction for disordered regions. The first part describes the datasets we use, the programs to be compared with and the evaluation measures. The second part shows how we train and validate our DeepCNF model using a small Disorder723 dataset , and evaet al. [Our weighted DeepCNF model for order/disorder prediction is trained and validated using Disorder723 dataset. This dataset, built by Cheng A ten-fold cross-validation on this Disorder723 dataset was performed to determine the model parameter. In particular, the original dataset was randomly partitioned into 10 equal-sized subsamples. Among the 10 subsamples, a single subsample is retained as the validation data for testing the model, while the remaining nine are used as training data. The list of all these training/validating proteins, as well as the corresponding features for our model, could be found in i.e., CASP9 [et al. [We further trained our weighted DeepCNF model using UniProt90 dataset for release purpose and evaluated it with two publicly available CASP datasets, ., CASP9  and CASP., CASP9 . CASP9 d., CASP9 , followe [et al.  for Disoi.e., CASP9 and CASP10) used in this study are dominated by proteins with short disordered regions, the two training datasets  are relatively equally distributed in disordered region length, especially the UniProt90 dataset which is used to train our model for release.We also analyzed the overall properties of the non-terminal disordered regions with different lengths on the four datasets used in this work. As shown in ab initio methods and are downloadable. Since our method is also an ab initio method, it might be unfair to compare ours with those clustering, template-based, and meta or consensus methods as defined in Deng et al. [We compared our method with the following programs: IUpred , SPINE-Dg et al. . All resFor evaluation of disorder predictors as binary classifiers we used the precision defined asectively .i.e., disordered) if its predicted probability is equal to or greater than the threshold value. The area under the curve (AUC) is used as an aggregate measure of the overall quality of a prediction method. An area of 1.0 corresponds to a perfect predictor while an area of 0.5 means purely random.As the problem of order/disorder region prediction is strongly imbalanced (only ~7% of residues are disordered), using the conventional accuracy and precision measurement might inflate performance estimates and is therefore not appropriate . AnotherThere are three components of tunable parameters in the weighted DeepCNF model, (a) number of hidden layers; (b) weight of labels; and (c) combination of input features. It should be noted that in order to simplify the following analysis, we fix some of the other tunable model parameters such as the window size (fixed to 11) and the number of neurons at each layer (fixed to 50). Thus, by default, our weighted DeepCNF model contains two hidden layers, applies 0.7:9.3 for the weight ratio between order and disorder labels, and includes all 129 features from the three classes.To show the relationship between the performance and the number of layers, we trained three different weighted DeepCNF models with one, two, and three layers, respectively. As shown in It is well known that the label imbalance issue occurs in many real-world prediction tasks . A simplAs mentioned in the previous section, the features used in the training process consist of three classes: evolution related, structure related, and amino acid related, respectively. In order to estimate the impact of each class on order/disorder prediction, we applied each one and several combinations of them to train the model and perform the prediction. i.e., 0.5) for the other predictors while choosing 0.2 for our method DeepCNF-D. The reason to choose 0.2 for our method is based on the optimal performance of MCC value on the training data. The results show that DeepCNF-D archives 0.486 MCC value on CASP9 and 0.474 on CASP10, which are higher than the other predictors. If only amino acid related features are used, DeepCNF-D (ami_only) reaches 0.4 MCC on CASP9 and 0.433 on CASP10, which are significantly higher than IUpred.We also compare our method with other predictors using precision, balanced accuracy (bacc), and Mattehews correlation coefficient (MCC), respectively. Since these measurements are based on a user-defined threshold for order/disorder classification, we use default value , for protein order/disorder prediction has been presented. This model not only captures long-range sequence information by a deep hierarchical architecture and exploits interdependency between adjacent order/disorder labels, but also assigns different weights for each label during training and prediction to solve the label imbalance issue that was known as a long-standing problem in order/disorder prediction. The source code of our method DeepCNF-D is available at 0.tar.gz . The oveIt should also be noted that if amino acid related features are used, our method outperforms the best sequence-based method IUpred, while still keeps the same extremely fast running speed. This pure sequence version of our method  can be applied to large-scale proteome analysis for disordered regions . From a The observation of the deterioration with three layers compared to two layers may due to over-fitting because the regularization factor is the same for all trained models. If we specifically fine-tune the regularization factor for the three layer model, then the results could be comparable to the two layer model. We also tried different numbers of neurons per hidden layer (from 10 to 100) for the one to three layers models. The improvements in terms of AUC saturated at 50 neurons and did not largely increase after 50. However, instead of using these ad-hoc fine-tune procedures, we could try to use the following general strategies to prevent over-fitting and to further improve the performance of the deep network architecture: (a) a dropout framework ,34,35,36ab initio order/disorder prediction methods are still possible in the following three approaches: (a) Since the area under the curve (AUC) is a proper measurement for the performance of order/disorder prediction and was applied in the CASP assessment [Further developments for single sessment , a methosessment ,34,35,36sessment , and it sessment . In the In this section we describe the definition of order/disorder states, our proposed prediction methods, as well as the related features for prediction. The first part is the definition for order/disorder regions on a given protein. The second part shows the major contribution of our work, a machine learning model called weighted DeepCNF , for order/disorder region prediction. DeepCNF is a Deep Learning extension of a probabilistic graphical model Conditional Markov Neural Fields (CNF), which can capture medium- or even long-range information in a protein chain by a deep hierarchical architecture, and also model interdependency between adjacent order/disorder labels. In order to solve the label imbalance issue, we assign a relatively larger weight to disorder label, which is sparsely represented in the dataset. Then more cost would be given to errors in these disorder labels during training process to unbias the DeepCNF model. In the third part we introduce the related protein features that could be categorized into classes of amino acid, evolution, and structural properties.et al. [We use the same definition of order/disorder states as Cheng et al.  and the et al. . In partet al. [As shown in et al. . Given ai at layer k. Wheni.e.,i.e.,i.e., the disorder state) is of prime importance but this class might be completely ignored by traditional classifiers. For example, with an imbalance ratio of 0.93 to 0.07 for order/disorder states, a classifier that classifies everything to be ordered state will be 93% accurate, but it will be completely useless as a suitable classifier.Traditional algorithms choose an approximation of the accuracy  algorithm  as the oet al. [A variety of protein features have been studied by Becker et al.  to prediet al. [et al. [et al. [et al. [et al. [Four types of amino acid related features are considered, including: (a) amino acid indicator vector; (b) physico-chemical property; (c) specific propensity of being endpoints of a secondary structure segment; and (d) correlated contact potential. Specifically, the amino acid indicator vector is a 20 dimensional vector with value 1 for the specific amino acid occurring at positionn et al. ); specif [et al. ); correl [et al. ). All th [et al.  for seco [et al.  for solv [et al.  for homoThe order/disorder state of a residue has a strong relationship with the residue’s substitution and evolution ,47,48. RLocal structural features, such as secondary structure and/or solvent accessibility, are also very useful for predicting order/disorder state, as indicated in . Here we