Millions of children live in Brazil's semi-arid region, one of the most socially-deprived areas of the country, where undernutrition co-exists with obesity as a consequence of the nutrition transition. There is evidence that childhood obesity predisposes adult obesity and, thus, that obesity should be prevented as early as possible. Some studies have shown that breastfeeding is a protective factor against overweight and obesity while other studies have not found this association. There have been few studies on this association in developing countries and of children below two years of age. The present study aimed to investigate whether children exposed to exclusive breastfeeding for ≥6 months showed a lower prevalence of overweight in the second year of life, based on a probability sample of 2,209 children (aged 12 to 24 months). The dependent variable was overweight, defined as weight-for-length z-scores of >2, based on the WHO 2006 standard while the independent variable was exclusive breastfeeding (≥6 months). The prevalence ratio (PR) and its 95% CI were estimated using Poisson regression with robust adjustment of variance. After adjusting for potential confounding factors , children on exclusive breastfeeding for ≥6 months showed a lower prevalence of overweight . It was found that exclusive breastfeeding for six months or more is a protective factor against overweight in children in the second year of life living in the Brazilian semi-arid region. Several studies have reported that overweight children are more likely to become obese adults ,2, reinfRegarding how to prevent childhood overweight, the potentially-protective effect of breastfeeding could make it a valuable strategy ,5. HowevQuilombola communities (descendants of fugitive African slaves) live in this region. Infant mortality is higher than the national average in 95% of the municipalities in this region and perinatal conditions, acute respiratory infections, and nutritional deficiencies account for 33.8% of deaths in children below one year of age. The population of this region is undergoing a nutrition transition, resulting in a reduced prevalence of stunting, alongside rising rates of obesity , and 30 municipalities were selected per state. In each municipality surveyed, two vaccination centres were randomly selected as secondary sampling units. At each centre, children queuing for vaccination were systematically selected. This method produced a strict probability sample of 16,934 randomly-selected children. The subsample of 2,581 children aged 12 to 24 months was the group of interest for this study. Information on breastfeeding duration was missing for 372 of the children (14.4%), reducing the studied population to 2,209 children in the second year of life.Data collection took place during National Immunization Day on 20 August 2005. It was conducted by local health professionals recruited and trained especially for the survey. After immunization, the children underwent an anthropometric examination and their parents/caregivers were interviewed. Information on demographic, socioeconomic, anthropometric and health-related variables was collected by the interviewers, using a pretested questionnaire.Recumbent length was assessed using wooden CARCI infantometers with a measuring range of 10 to 99 cm and graduations of 1 mm, and weight was assessed using a scale with 150 kg capacity and 100 g precision. Measurements of weight and length were taken twice for each child by two trained and supervised examiners.The sets of questionnaire were coded, and 30% of these were double-checked by supervisors. These were then scanned, and the data were entered into a database. Range and consistency checks were carried out during the coding stage and after data-entry.Body-weight, length, age, and sex were combined to build anthropometric indices, expressed as z-scores, using Anthro 3.2.2 software package, which includes the WHO 2006 anthropometric references . StuntinBirthweight was categorized as low , underweight , normal , and high  .Socioeconomic conditions were evaluated using the Brazilian Economic Classification Criteria . Using aExclusively-breastfed (exc-BF) children were those who received only breastmilk but no water, tea, juice, or any other type of milk or food .In the analysis, the dependent variable was overweight, and the independent variable was exclusive breastfeeding (categorized as ≥6 months or <6 months).t-test for independent samples was used for comparing means between groups.Means and standard deviations were calculated for the weight-for-length z-scores according to the breastfeeding categories. Levene's test was applied to verify the homogeneity of variances and when there was no significant difference (p>0.05). Student's In the crude analysis, we tested the association between overweight, exc-BF, and covariates  based on the prevalence ratio (PR) and 95% confidence intervals (95% CI). In order to control for potential confounding factors, the variables with p<0.2 in the crude analysis were included in the Poisson regression model with robust adjustment of variance to calculate adjusted PR and 95% CI . These vMultiple linear regressions were used for assessing the effect of exc-BF on weight-for-length z-scores, controlling for potential confounding factors. For adjustment, the same covariates as included in the final Poisson regression model were used. All statistical analyses were performed using Stata (version 12.0)  at a 5% significance level.The “Health and Nutrition Day” study protocol was approved by the Research Ethics Committee of the National School of Public Health at Fundação Oswaldo Cruz. The purposes of the study were explained to all parents/caregivers, and data were only collected after they had signed an informed consent form agreeing to their participation.A total of 2,209 children  were studied. The prevalence of stunting was 13.1% while the prevalence of overweight was 7.8%. Most families (85.8%) had a lower socioeconomic status (Class D and E), and more than half (51.4%) of the heads of household had low schooling.Among the 2,209 children studied, 38.1% were on exc-BF for ≥6 months. Even after adjusting for potential confounding factors, the risk of overweight was lower among these children than those who were exc-BF for <6 months .Mean weight-for-length z-scores were also lower in children who were exc-BF for ≥6 months , with a mean difference of 0.140 (95% CI 0.05-0.23).The multiple regression analysis showed that exc-BF for ≥6 months yielded 0.13 lower (95% CI 0.23-0.03) weight-for-length z-scores.In addition to exc-BF for ≥6 months, socioeconomic status and birthweight were also independently associated with overweight . There wet al. (The present study found that there is a protective effect of breastfeeding against overweight as early as the second year of life. However, this association was only evidenced following at least six months of exc-BF; von Kries et al.  found thet al. (et al. (Two meta-analyses have reported protective effects of breastfeeding. Arenz et al.  assessed (et al.  analyzedIn light of this evidence, it is important to explore the biological plausibility of this protective effect of breastfeeding, i.e. potential mechanisms that might interfere with the child's body composition. There is some evidence that it might be related to the adverse metabolic consequences of excessive protein intake –29.Some authors have argued that bioactive compounds, such as leptin, adiponectin, ghrelin, resistin, and obestatin may also play a role in the physiological action of human milk –32. OtheExposure to breastmilk components during the first months of life is the earliest nutritional experience of the newborn and is related to metabolic imprinting , a term In the assessment of the relationship between breastfeeding and overweight, it should be questioned whether the lower prevalence of overweight among breastfed children is due to breastmilk-related factors or to the fact that children who are not breastfed become more exposed to a diet of high energy density and proteins. In fact, in northeastern Brazil, where most of the Brazilian semi-arid region is located, the prevailing cultural practice is to introduce other foods at a very early age, such as food preparations based on cow's milk with a thickened mixture of complex carbohydrates sweetened with sucrose . UnfortuNational Breastfeeding Programme of the Brazilian Ministry of Health was launched in 1981 since when it has been implemented throughout the country, including the semi-arid region. With the support of all state and municipal departments of health and various civil society organizations, it has contributed greatly to the adoption of breastfeeding in Brazil. Its main actions include mass campaigns, training of health workers, individual and group counselling and health education, production and distribution of educational materials, establishment of support groups in the community, and approval of regulations to protect breastfeeding and for the marketing of formula milk . The WHOAs mentioned before, overweight children are more likely to become obese adults ,2. Thus,It can be concluded that exclusive breastfeeding for the first six months of life is a protective factor against overweight in children in the second year of life. More effective actions need to be taken to promote breastfeeding among mothers, especially for those living in areas of high social exclusion, such as the Brazilian semi-arid region.Conflict of interest: Authors declare no competing interests.


Sertraline (SERT) is a clinically effective Selective Serotonin Reuptake Inhibitor (SSRI) known to increase and stabilize serotonin levels. This neurotransmitter plays an important role in adolescent brain development in both rodents and humans, and its dysregulation has been correlated with deficits in behavior and emotional regulation. Since prenatal stress may disturb serotoninergic homeostasis, the aim of this study was to examine the long-lasting effects of exposure to SERT throughout adolescence on behavioral and physiological developmental parameters in prenatally stressed Wistar rats. SERT was administered (5 mg/kg/day p.o.) from the age of 1–3 months to half of the progeny, of both sexes, of gestating dams stressed by use of a restraint (PS) or not stressed. Our data reveal that long-term SERT treatment slightly reduced weight gain in both sexes, but reversed the developmental disturbed “catch-up” growth found in PS females. Neither prenatal stress nor SERT treatment induced remarkable alterations in behavior and had no effects on mean startle reflex values. However, a sex-dependent effects of PS was found: in males the PS paradigm slightly increased anxiety-like behavior in the open field, while in females, it impaired startle habituation. In both cases, SERT treatment reversed the phenomena. Additionally, the PS animals exhibited a disturbed leukocyte profile in both sexes, which was reversed by SERT. The present findings are evidence that continuous SERT administration from adolescence through adulthood is safe in rodents and lessens the impact of prenatal stress in rats. Sertraline (SERT) is a clinically effective Selective Serotonin Reuptake Inhibitor (SSRI) that increases serotonin  levels in the brain  and the variety of functions regulated by each receptor subtype  and its habituation, both considered good tools for the investigation of emotional status and the brain mechanisms involved in behavioral plasticity, are often used in pharmacological animal models Davis, . In viewThus, to evaluate the long-lasting effects induced by both early stress and exposure to antidepressants during youth, our main goal was to determine the neurobiological changes in previously stressed rats subjected to SERT treatment. Considering during this developmental period, in humans, antidepressant treatments could last for years  or previously disturbed (PS) subjects of both sexes are currently available. Thus, we hope present findings help to further our understanding of the long-term effects of antidepressants during this critical window of brain development.n = 12) weighting 250 g were obtained from outbred rats from our own animal facility at the University of Salamanca. Vaginal smears were collected daily for 8 days before mating to determine the stage of the estrus cycle and the day of conception. On the day of proestrus, sexually experienced male Wistar rats were introduced for mating. The day the spermatozoa were found in the smear was designated as day 1 of pregnancy.Virgin female Wistar rats CLS:WI(HAN) , the current Spanish legislation (RD 1201/05), and with those established by the Institutional Bioethics Committee. All efforts were made to minimize the number of animals used.The animals were housed randomly and maintained under a normal 12/12 h light/dark cycle (lights on at 08:00 h) in a temperature- and humidity-controlled environment. The rats were given n = 6 per group) and housed individually in plastic breeding cages. Stress consisted on placing the females in the third trimester of gestation (days 15–21) on transparent cylinder restrainers ; under a bright light directed onto the surface of the restrainer for 45 min three times a day  . To avoid the effect of the dams, care was taken so that groups included no more than two pups from the same litter, in agreement with the protocols and results of previous authors  or not . This resulted in equal number of animals in each condition  was administered orally at a dose of 5.0 mg/kg/day in the animals’ drinking water, starting on postnatal day 30 (P30) and continuing until the end of experiments (P90). The SERT solution was prepared using filtered water as a vehicle. Liquid consumption was controlled  and monitored every 2 days, and the dose of the drug was adjusted on the basis of the liquid consumption and animal’s weight. Freshly prepared solutions were then provided. Filtered water was given to control animals. During this period, the rats were kept in groups of four animals in polycarbonate boxes (45 cm × 30 cm × 20 cm), with unrestricted access to food. A dose of 5 mg/kg/day of SERT was chosen based on the pharmacokinetic and pharmacodynamic profiles of the drug , as described by Castellano et al. . The acoSpontaneous behavior was studied with the open-field (OF) test. The apparatus consisted of a round, white wooden arena , divided into an inner  and an outer zone . The OF apparatus was illuminated by an 80 W bulb, focused onto the field from a height of 100 cm above the floor. The behavior of each animal was studied for a period of 3 min over 3 consecutive days, and the occurrence of the following types of behavior was recorded: outer (OA) and inner (IA) exploratory activity  and rearings (Rear) .Between the introductions of each animal, the surfaces were cleaned with water and 70% ethanol. To minimize subjectivity, the behavior of the rats was recorded by two experimenters blind to the treatment conditions. All trials were performed between 11:00 and 14:00 h.n = 6 per group and sex) by cardiac puncture following intraperitoneal anesthesia with a mixture of ketamine (200 mg/kg) and xylazine (10 mg/kg). The blood was immediately transferred to EDTA (K3)-containing tubes and processed on an automatic cell counter .After the behavioral tests had been completed and after 60 days of SERT-treatment blood samples were taken between 09:00 and 11:00 h from a subset of animals from each group  was similar than the variability across litters, on all our dependent measures. Also, when data were analyzed using the effect of litter as a covariate, we found no significant effects. Thus, in the final analyses the litter as a variable was not considered and the data from each individual animal were used.® SPSS® software, version 20 . The differences between groups were analyzed by ANOVA , followed by the Fisher-PLSD-test for post hoc comparison if appropriate, and ANOVA mixed (or “SPLIT-PLOT”) with the Bonferroni-test. Mean differences were subjected pairwise to Student’s t-test, using the Levene Test for equality of variances. Pearson’s coefficient was used to determine correlations. Differences were regarded as statistically significant when p < 0.05.Statistical analysis were performed using the IBMF1,30 = 14.04, p < 0.01), since among the males the body weights of the pups were similar.As expected, as a main effect of prenatal stress, differences were observed in the neonates’ body weights the day after delivery P1), but only among the female pups  and weight by treatment by sex  interactions were found, indicating differences, in the effect of PS on growth rate, that were sex-dependent.Body weight gain was analyzed using a three-factor ANOVA  with repeated measures on the age factor . Analysis of these data revealed that the prenatal treatment affected body weight gain. As the animals’ age advanced, weight by treatment . Female pups from stressed mothers had lower birth weights (P1) than the controls, but these differences disappeared by the time of weaning (P21). However, this process changed at P28, and PS females exhibited a higher body weight than their controls (Table p = 0.03).weights P than theper se, did not influence weight gain, and no sex differences in the neonates’ body weights were found at any point.At this early stage of development, sex F4,73 = 1460, p < 0.001), with group, F16,304 = 1.69, p = 0.048; sex, F4,73 = 98.8, p < 0.001; and group by sex, F16,304= 1.81, p = 0.029 interactions affecting body weight, indicating the influence of the different treatments on weight gain in each sex. As expected, there was a clear difference between the growth of males and females throughout adolescence in all experimental groups , with males weighting more than females . During this period, a significant overall effect of age was observed  and males .At the beginning of this phase (P35) neither the prenatal manipulation nor the pharmacological treatment affected the animals’ body weights. However, at P90 , differences in body weight (g) were found, both in females , but not between treatments.F1,77 = 312.3, p < 0.001), with no group interaction, but with a strong sex interaction , marked by the differences between sexes seen at P90 , which were not seen at P30 . Although the difference did not reach statistical significance by sex, post hoc analysis revealed a marginal effect of prenatal stress, increasing startle amplitude in rats from both sexes regardless of SERT treatment. Additionally, SERT treatment did not induce changes in mean startle amplitude , probably given the deterioration of habituation found in PS females , sex differences were observed specifically in PS animals (p = 0.03).On using a block-to-block analysis to study startle amplitude, differences between the different experimental groups were observed. Startle habituation  was significantly different as effect of group, specifically in females . Whereas at P30 no differences between groups were found; at P90, the latency to startle of PS animals was shorter than in the controls . SERT has no effect on this parameter .Additionally, there was an overall increase in the latency to startle from P30 to P90 , such that the animals with higher latency responses were those with greater startle amplitudes.Interestingly, a strong correlation was seen between ASR amplitude and its latency . Females were more active than males in all the sessions, this difference being significant in both the Control  and PS animals . In the case of the SERT-treated animals, the differences between sexes lost significance .Upon analyzing the total exploratory activity  (ANOVA with session by group by gender as within factors), no group effect was observed, but a major effect of sex was observed  was observed, given the overall differences between PS males and females in their willingness to engage in exploratory activity. PS males exhibited significantly less outer-field activity  and inner-field activity  and also fewer rearings than the females from the same group .A comparison of the horizontal and vertical activity performed in the sessions did not reveal differences due to stress or SERT treatment in any case Figures , 6A. AgaWith the exception of the Control females, in all experimental groups of both sexes the horizontal activity remained unchanged over the 3 days. In response to repeated exposure to the test, exploration in the OF increased in Control females Figures , in maleF2,68 = 4.38, p = 0. 018), with no sex or group interactions , indicating an anxiogenic effect of prenatal stress . Sex differences were also found in the PS animals (p = 0.014), indicating that PS increases anxiety in males, specifically, and that SERT treatment reversed it.As an anxiolytic indicator, the ratio between inner-field and outer-field activity (IA/OA) was further analyzed, and no overall differences were found. However, when the analyses were split by day and sex, in males, a major effect of group was noted, specifically on the first day of the test  from adolescence until adulthood was safe and effective in reversing the harmful effects of prenatal stress.Perturbations, such as maternal stress, in the uterine environment during development can permanently alter metabolism and body weight in the offspring Pollard, . The latBy contrast, our results indicate that PS females increased more in weight during growth. Whereas in males no effects of early stress on weight gain were found, prenatally stressed females weighed less than their controls at birth. This difference rapidly disappeared, and was later counteracted, a trend that persisted into adulthood. Even though, this is in disagreement with earlier studies addressing prenatal stress in which PS delayed development Pollard, , recentlThe rapid weight gain, or “catch-up” growth, reported here in PS females, that follows low birth weight has already been described in humans . This initial increase reflects the influence of the novel, potentially aversive stimulus on the central nervous system, thus indicating PS males as being more sensitive  has already been reported in rodents  Archer, . An inteNonetheless, the lack of differences caused by PS observed here is in accordance with previous works  and hippocampal neurogenesis are stimulated (Anacker et al., SERT has been shown to have an immunomodulatory action once it has reversed the state of leukopenia found in prenatally stressed animals. As expected, prenatal stress induced alterations in the immune function of the offsprings; this could still be seen when the immune function was determined in adulthood. A decrease was found in both total leukocyte counts in blood and in all subpopulation types, lymphocytic cells being those most affected. This has been extensively described before by authors proposing that gestational stress compromises immune function in the offspring (Kay et al., The mechanisms underlying the effects of prenatal stress on the immune system of progeny, probably result from the action of maternal stress hormones (Barbazanges et al., Moreover, gestation is an ontogenic period during which some of the most critical events that allow normal functioning of the immune system are taking place, and, it is reasonable to assume that prenatal exposure to environmental protocols might also cause a temporary or permanent disruption in the genesis or functioning of the immune system itself (Sobrian et al., The long-term consequences of this early type of stress on immune function are less well known. Most of these studies reported effects in neonate or juvenile offspring. Sobrian et al.  describeFinally, we demonstrate the central role of SERT in restoring leukocyte levels to normality. The mechanisms underlying the effects of SSRIs on the immune system under normal and pathological situations remain to be clarified (Gobin et al., As far as we know this is the first work to study the impact of SERT in reversing the adverse effects of prenatal stress on immune competence. The low doses used here may have been crucial, since Sacre et al. , for insIn conclusion, our results contribute to the general knowledge about the beneficial effects of SERT, a drug known to exert anti-depressive effects, reversing early stress-associated impairments. Such beneficial effects are therefore of considerable interest in clinical practice. Also, the central role of sex susceptibility to maternal restriction stress is highlighted. The sex-dependent effects reported here could be due to the sex-specific timing of developmental processes during gestation (Roussel et al., 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.


Odocoileus hemionus hemionus) from a chronic wasting disease (CWD) endemic area in Saskatchewan, Canada, to better understand factors that may affect disease transmission. Using group size data collected on 365 radio-collared mule deer (2008–2013), we built a generalized linear mixed model (GLMM) to evaluate whether factors such as CWD status, season, habitat and time of day, predicted group occurrence. Then, we built another GLMM to determine factors associated with group size. Finally, we used 3 measures of group size  to quantify levels of sociality. We found that mule deer showing clinical signs of CWD were less likely to be reported in groups than clinically healthy deer after accounting for time of day, habitat, and month of observation. Mule deer groups were much more likely to occur in February and March than in July. Mixed-sex groups in early gestation were larger than any other group type in any season. Groups were largest and most likely to occur at dawn and dusk, and in open habitats, such as cropland. We discuss the implication of these results with respect to sociobiology and CWD transmission dynamics.Infectious disease dynamics are determined, to a great extent, by the social structure of the host. We evaluated sociality, or the tendency to form groups, in Rocky Mountain mule deer ( Odocoileus hemionus hemionus) population. We determine factors that predict group size and occurrence, and describe group size distribution to provide empirically derived parameters for CWD transmission models.The rate and pattern of information and pathogen spread within a population depends on its social structure , 2. GrouOdocoileus virginianus), elk (Cervus canadensis) and moose  in North America. CWD has a long incubation period (about 17 months) during which infectious prions are shed in saliva, urine and feces , and groups with >15 deer were rare (2.1%). Most observed groups were mixed-sex (20.1%), followed by groups of males (19.4%), solitary males (19.2%), groups of females (15.4%), solitary females (15.2%), and adult female-fawn/juvenile dyads (5.9%); we could not assign a sex and age class to every deer in the group in 4.8% of the observations.The best model predicting the occurrence of groups of at least 2 deer included these variables: month, clinical signs, time of day, habitat, and focal deer sex; the latter as a confounder for the effect of habitat. Eight percent of the unexplained variation in group occurrence was explained by the identity of the focal deer, while 6.6% was explained by the person doing the observation. The strength of the associations between these factors and group occurrence is described in The best model predicting group size included the factors season, time of the day, habitat, sex of focal deer, age of focal deer, group type, year, and the interaction terms of season*group type, and season*year. The sex of focal deer was included in the model to adjust for confounding of the effects of habitat and time of day on mean group size. Mean-count ratios were 1.08 for focal deer and 1.1 for observers, indicating a relatively small amount of variability in mean group size among both focal deer and observers. The overall Lin´s concordance correlation coefficient between predicted and observed group sizes was 0.8 (95% CI = 0.7–0.8). Predicted mean group sizes of main effects (except for those included in the interaction terms), with their 95% confidence intervals, are presented in Mixed-sex groups were significantly larger than both female and male groups in every season (P<0.001) . The onlWe further described the distribution of group sizes using TGS, mean and median . ResultsCWD, as well as other important infectious diseases in cervids such as tuberculosis and brucellosis, can be transmitted through direct contact between individual animals as well as through the environment. The importance of spatial aggregation of deer, and hence of environmental prions, has been recognized , and theBased on our study, we cannot identify the mechanisms behind a reduced occurrence of sick individuals in groups. However, there are probable explanations: 1) normal activities daily performed by healthy deer are challenging for sick deer, 2) healthy deer actively avoid grouping with sick deer, and 3) both strategies are occurring. Deer with CWD develop spongiform encephalopathy caused by the accumulation of disease-associated prion proteins . This leIt is likely that subtle behavioral changes are apparent to deer and predators, but not to humans, and we do not know at what point in the infectious period deer start showing changes in grouping behavior. Without applying our findings in a dynamic simulation model, it is not possible to fully appreciate the implications of our findings on CWD transmission dynamics. Although CWD models published to date have not included detailed aspects of deer sociality, they recognized the advantages this may have , 66. RemSimilarities of our findings to reports on mule deer in geographical areas free from CWD  include: 1) increase of mean group size with habitat openness , 2) compTwo trends are well-documented in cervids: group size increases with habitat openness –69, and Female groups were estimated to be larger than male groups in early gestation. One possible explanation is that the proportion of males in mixed-sex groups is greater than that of females, which is not the case in our study (data not shown). A complementary explanation would be that contrary to the way males group, adult females are also joined by their fawns, increasing the group size more rapidly than when males form their groups. Also, female groups are larger in early gestation than in any other season; at that age fawns are with their mother at all times, no longer needing to hide and isolate , and areBased on our field observations on mule deer, mother’s hostility towards young males is evident in late gestation. Males then start migrating to new territories , formingFrom our occurrence likelihood, and TGS, mean and median calculations, we found that the largest groups happened in February and March, and the smallest in July. This is not surprising, as similar trends have been previously reported in mule deer . Large wMule deer are known to move faster (m/min) and to use different habitats at dusk and dawn than at midday . This caIn summary, we demonstrated that the presentation of clinical signs of disease affect the probability of an individual to be seen in groups, found factors that influence group size, and described mule deer group size distribution. Our data can serve to complement future modeling and parameter estimation; we believe that well-informed spatially- and behaviorally-explicit epidemiological models can serve as important tools to inform and guide CWD management strategies.S1 File(DOCX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Background. Intravenous tissue plasminogen activator, a time dependent therapy, can reduce the morbidity and mortality of acute ischemic stroke. This study was designed to assess the effect of simple in-hospital interventions on reducing door-to-CT (DTC) time and reaching door-to-needle (DTN) time of less than 60 minutes. Methods. Before any intervention, DTC time was recorded for 213 patients over a one-year period at our center. Five simple quality-improvement interventions were implemented, namely, call notification, prioritizing patients for CT scan, prioritizing patients for lab analysis, specifying a bed for acute stroke patients, and staff education. After intervention, over a course of 44 months, DTC time was recorded for 276 patients with the stroke code. Furthermore DTN time was recorded for 106 patients who were treated with IV thrombolytic therapy. Results. The median DTC time significantly decreased in the postintervention period comparing to the preintervention period . At the postintervention period, the median (IQR) DTN time was 55 (40–73) minutes and proportion of patients with DTN time less than 60 minutes was 62.4% (P < 0.001). Conclusion. Our interventions significantly reduced DTC time and resulted in an acceptable DTN time. These interventions are feasible in most hospitals and should be considered. In the setting of acute ischemic stroke, intravenous tissue plasminogen activator (IV-tPA), if given within three hours of symptoms onset, has been proven to reduce the combined endpoint of death and disability after stroke , 2. HoweAs reported elsewhere, at our hospital, the most important barriers to implement thrombolytic therapy for acute ischemic stroke patients were in-hospital delays such as initial patient assessment, performing CT scan, and lab studies , 9. ThisThis study was set up as a before-versus-after study, divided into 2 periods: the preintervention period  for one year and the postintervention period  for 44 months. The study was performed at Tabriz Imam Reza Hospital, which is a tertiary referral university hospital in East Azerbaijan Province, Iran.We assessed the door-to-CT time  and the door-to-needle time .This was the pre-r-TPA stage in which thrombolysis was not available at our center for acute ischemic stroke patients. Any patient, who met the Cincinnati stroke scale, with sudden onset of at least one of the following symptoms (less than 3 hours of symptoms onset), was enrolled into the study: facial droop, motor arm weakness, or speech abnormalities. The demographic data and DTC time were recorded. However, not having r-TPA at the time, the DTN time could not be recorded. During this period, 213 patients were enrolled.This period is associated with the time when r-TPA was available in our center and some measures were already taken to improve in-hospital delays for treating stroke patients.Any patient, for whom stroke code was activated, enrolled. Based on the algorithm, the code should be activated for patients with the onset of symptoms in previous three hours . Overall, the stroke code was activated for 321 patients. Given that during the preintervention period none of the patients had prehospital notification, forty-five patients in the postintervention period were excluded because they had prehospital notification. Finally, 276 patients enrolled in the postintervention period, in which IV r-TPA was administered in 106 patients. In addition to the demographic data and DTC time, DTN time was also recorded for these patients.Based on the results of the preintervention period, evaluation process of patients with probable stroke was too slow, so a multidisciplinary team consisting of two stroke neurologist, two attending physicians of emergency department (ED), neurology and ED residents, a neuro-ICU, and an ED nurse analyzed the existing process of approach to a probable acute stroke patient. At last, five feasible simple interventions were implemented, with a goal of enhancing the flow of patients and reducing in-hospital delay as follows.The Quality-Improvement InterventionsSingle call notification.Prioritizing patient for CT scanning.Prioritizing patient for lab analysis.ICU bed.Staff education.For clarifying what should be done step by step when stroke code is being activated, an algorithm was made and explained during education sessions  and specified one bed as “TPA bed” which is allocated just for acute stroke patients who receive thrombolytic therapy. This was a major hurdle because, at times, we could not find empty bed for our patients and therefore losing the opportunity of treating the patient with IV r-TPA.“Time is brain”: The importance of time for early treatment of stroke patients was emphasized through multiple sessions for all medical staff involved in the process, including ED and neuro-ICU nurses and CT and lab technicians of all hospitals. This was done to create a sense of urgency for acute stroke patients.The primary outcome of the study was the median DTC time, during the two study periods described previously. Secondary outcomes were the percentage of patients with DTC time of less than 25 minutes and DTN time less than 60 and 30 minutes.U test was used to assess the mean difference between the two groups. A P value less than 0.05 was considered statistically significant.All statistical analyses were carried out using PASW statistics version 18. Due to nonnormal distribution of variables , data are presented as median and interquartile range. Mann-Whitney This study was approved by the Ethic Committee of Tabriz University of Medical Sciences. Informed consent was obtained from all individual participants included in the study.Overall, 489 patients with probable stroke according to Cincinnati stroke scale were admitted to the emergency department during the preintervention and postintervention periods. Of this total, 276 patients enlisted in the postintervention period, of which 106 were treated with IV r-TPA because of an acute ischemic stroke.P < 0.001). The proportion of patients with DTC time less than 25 minutes increased significantly, from 3.0% in the preintervention period to 66.7% in the postintervention period (P < 0.001).Demographic parameters and outcome measurements are shown in At the postintervention period, out of 276 patients with stroke code, 106 (38%) patients were treated with IV thrombolytic therapy. The median (IQR) DTN time was 55 (40–73) minutes. The proportion of patients with DTN time less than 60 and 30 minutes was 62.4% and 11.8%, respectively. In the postintervention period, the rate of intravenous thrombolysis was 6.1%.In this quality-improvement study, the DTC time in intravenous thrombolysis for acute stroke patients was reduced drastically and DTN time reached less than 60 minutes in 62% of patients, due to implementation of simple interventions. We had two major barriers with the interventions; firstly our hospital is located in Tabriz metropolitan city (serving for approximately 3.5 million people), which is the main referral hospital for the province and a trauma center as well; any intervention we were going to implement must not interfere with the treatment of other patients. Secondly, as being in a developing country, any expensive intervention would not be accepted. Multiple previous studies have shown the effect of different interventions on reducing in-hospital delay for patients with acute ischemic stroke –14. In sAt postintervention period, forty-five patients had prehospital notification (PHN) but none in the preintervention period. We excluded all, since PHN effectively reduces the DTC and DTN times and this has been shown well in multiple studies previously , 17–19.The achieved postintervention DTC and DTN time of 20 and 55 minutes are lower than the recommended 25 and 60 minutes by the National Institute of Neurological Disorders and Stroke (NINDS).At the preintervention period thrombolysis was not available at our center for acute stroke patients and we could not determine the DTN time. However, at the postintervention period median DTN was 55 (40–73) minutes, showing that, with the present algorithm, an acceptable time interval can be achieved.In the United States, in the Get With the Guidelines-Stroke Program with 1082 hospitals participating, only 26.6% of all treated patients had the DTN time of less than 30 minutes . In our Our study had limitations. Firstly, while our interventions were successful in reducing DTC time and reaching an acceptable DTN time, we do not know whether they actually could reduce DTN time in case we had r-TPA in preintervention period.Secondly, based on our experience, we know there were patients with acute stroke symptoms presented to ED within 3 hours of onset and stroke code was not activated for them. So we do not exactly know how much our education was effective in proper triage and code activation for these patients.Thirdly, there was a considerable delay between brain CT and IV thrombolysis in this study. We think the reason is that, based on our algorithm, after CT scan we needed to transfer patients to TPA bed which is located in two floors up and ask for written inform consent and the treating physician needed to wait for hard copy of brain CT scan. In future, for further shortening of the time between brain CT and IV thrombolysis we should change the algorithm so that we can start thrombolysis in the CT room.In summary, our study confirms the effect of multiple and simple inexpensive systemic improvements on reducing in-hospital delay for acute ischemic stroke patients and shows that acceptable DTC and DTN times can be achieved in a hospital with limited facilities. Nevertheless, further studies with emphasis on clinical outcomes are warranted.


There is a lack of information about fitness and other health indicators in women from countries such as Morocco. This study aims to explore the association of weight status with physical and mental health in Moroccan perimenopausal women.151 women (45-65 years) from the North of Morocco were analyzed by standardized field-based fitness tests to assess cardiorespiratory fitness, muscular strength, flexibility, agility and balance. Quality of life was assessed by means of the Short-Form-36 Health Survey. Resting heart rate, blood pressure and plasma fasting glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were also measured.Blood pressure (P=0.001), plasma triglycerides (P=0.041) and the prevalence of metabolic syndrome (P<0.001) increased as weight status increased. Levels of cardiorespiratory fitness, upper-body flexibility , static balance (P<0.05) and dynamic balance (P<0.01) decreased as weight status increased. Pairwise comparisons showed differences mainly between normal-weight and overweight vs. obese groups. No differences between groups were observed on quality of life.Cardiovascular and lipid profile and fitness, important indicators of cardiovascular disease risk, worsened as weight status increased, whereas quality of life appears to be independent of weight status. Exercise and nutritional programs focus on weight management may be advisable in this under studied population. A high BMI and a low physical fitness, particularly cardiorespiratory fitness, are powerful predictors of all-cause mortality, especially from cardiovascular disease (CVD) –3. MoreoConsequently, CVD is currently the first cause of mortality among women in Morocco, as well as in Africa , 18. TheA descriptive, cross-sectional design with convenience sampling was used to conduct this study. The recruitment of participants was performed by researchers from the Department of Physiology and Pathophysiology at the University Abdelmalek Essaadi, Tetouan (Morocco) via information panels, lectures, e-mails, letters or telephone. The sample was distributed between Tetouan and nearby cities like Martil. The inclusion criteria were: (a) women, (b) age ranged 45-65 years old, (c) not to have acute or terminal illness, (d) willingness to participate in the research. Most of the women belonged to two different women associations  at Tetouan and Martil (n=114), and the rest of participants sample was completed through theUniversity environment related to the present study (staff working at the Universityor their family). The final study sample comprised 151 midlife women aged 52.5±3.8 years old. A 10.6% of the women were single, 66.9% married, and 22.5% widow (any women was separated or divorced). Regarding educational level, 69.7% of the sample had no studies, 21.9% had completed the Primary school, 15.9% had finished the Secondary school, and 12.6% had a University degree. Finally, we have analyzed the socioeconomic status of the sample. The 50.3% of the sample presented a low socioeconomic level, 38.4% a medium level, and 11.3% a high socioeconomic level. Participants were informed about the study aims and procedures and signed a written informed consent to participate. All the measurements were performed by women, in a single day and by the same trained researchers to reduce inter-examiners error. The study was reviewed and approved by the Ethics Committee of the “Hospital Virgen de las Nieves” .2), normal-weight (18.5-24.99 kg/m2), overweight (25.0-29.99 kg/m2) and obese (≥30.0 kg/m2) [A portable eight-polar tactile-electrode impedanciometer  was used to measure weight (kg), body fat (%) and skeletal muscle mass (kg). Height (cm) was measured using a stadiometer . Body mass index (BMI) was calculated as weight (in kilograms) divided by height (in meters) squared and categorized following the World Health Organization criteria: underweight . The average value of two trials was selected for the analysis.Fasting glucose, triglycerides, total cholesterol, low density lipoprotein (LDL)-cholesterol and high density lipoprotein (HDL)-cholesterol were measured using commercials kits . Additionally, total cholesterol/HDL-cholesterol ratio was calculated.The criteria recommended by the American Heart Association/National Heart, Lung, and Blood Institute  was usedDue to the age range of the present sample, the “Functional Senior Fitness Test” battery was used because it is relatively easy to administer and requires minimal equipment, space and it is safe . AdditioThe “6-min walk test” was used to assess aerobic fitness. This test measures the maximum distance (in meters) that can be walked in 6 min along a 45.7 m rectangular course .The “30-s chair stand test” measures the number of times an individual can rise to a full stand, starting from a seated position, with the back straight and feet flat on the floor without pushing off with the arms within 30 seconds. The women performed one trial after familiarization. The handgrip strength was assessed using a digital dynamometer  as previously described . The womIn the “chair sit-and-reach” test, the women started in a sitting position with one leg extended, and slowly bended forward sliding the hands down the extended leg in an attempt to touch (or pass) the toes. The number of centimeters short of reaching the toe (minus score) or reaching beyond it (plus score) was recorded. The test was performed twice for every each leg, and the average of the best value from each of them was employed in the analyses. The “back scratch test” provides a measure of the overall shoulder range of motion, and involves measuring the distance between (or overlap of) the middle fingers behind the back with a ruler. They performed the test twice, alternately with both hands, and the best value was registered. The average of both hands was used in further analyses.In the “blind flamingo” test , the numThe “8-feet up-and-go” test involves standing up from a chair, walking 8 feet to and around a cone, and returning to the chair in the shortest period of time . The besQuality of life The Arabic version of the Short-Form-36 Health Survey (SF36) was applied to assess QoL [sess QoL . This qusess QoL .The association between weight status and the study outcomes was examined by one-way analysis of covariance (ANCOVA) after adjusting for age. The model was adjusted for age due to the fact that age is strongly positively associated to worse physical fitness and lower QoL . The oveAnthropometric and body composition characteristics of the study participants are shown in The prevalence of metabolic syndrome, overweight and obesity among Moroccan perimenopausal women was extremely high. Blood pressure and cardiorespiratory fitness, important indicators for CVD risk, were impaired as weight status increased. Weight loss and aerobic exercise programs focus on increasing cardiorespiratory fitness and decreasing blood pressure are mandatory to reduce CVD risk in this population. To note is that QoL did not differ across weight status categories, suggesting that obesity could be not linked to QoL in this population. Prescribing exercise and diet focus on weight loss as medicine becomes an essential component. In the present study, the percentage of overweight (33%) and obese women (48%) as well as the body fat percentage 42%) were extremely elevated, but only slightly higher to epidemiologic reference values found in Moroccan women of the same age-range , 16, 30.% were exThe “6-minutes walking test” is a good marker of cardiorespiratory fitness and has been suggested as a powerful predictor of survival in some diseases . The disPostmenopausal women are at a higher risk of hypertension, proatherogenic lipid changes, diabetes, and severe CVD as compared with their premenopausal counterparts . SmokingSome limitations need to be mentioned. i. The study lacked of a high sample size and was of convenience.ii. We have not information about the menopause's state of the women (e.g. we did not measure estradiol levels of the participants). iii. The present study was carried out only in women, and future studies should be replicated in Moroccan men. On the other hand, this is the first study examining physical fitness, fatness, cardiovascular and lipid profile and QoL across weight status in Moroccan perimenopausal women, and did it in a single report, which allowed us to draw a global picture of the physical and mental health status of the participants and the influence of obesity.Obesity is the new pandemic in Morocco. Indeed, in the present study, 81% of the perimenopausal women studied were overweight or obese (BMI > 30 kg/m2). Metabolic syndrome markers and fitness, important indicators of CVD risk, worsened as weight status increased whereas QoL appears to be independent of weight status. This study allows health professionals to understand how weight status affects health indicators such as physical fitness, MS and QoL. Since obesity and a low fitness are both associated to higher risk of CVD and all-cause of death, nutritional interventions for weight management and exercise programs focused on increasing cardiorespiratory fitness and decreasing blood pressure should be advisable in this population. Randomized intervention studies are needed to show whether nutritional and exercise interventions focus on this population induce a better cardiovascular and lipid profile. Further research is needed in African countries, in which data on health outcomes in women still scarce.There is a lack of information about fitness and other health indicators in adult women from African countries, especially among women.The high prevalence of overweight, obesity and metabolic syndrome among Moroccan perimenopausal women is worrisome.Cardiovascular disease is currently the first cause of mortality among women in Morocco, as well as in Africa.This study allows understanding how weight status affects health indicators such as physical fitness, cardiometabolic status and quality of life in perimenopausal Moroccan women.Metabolic syndrome markers and physical fitness, important indicators of cardiovascular disease risk, worsened as weight status increased, whereas quality of life appears to be independent of weight status in this population.Dietary interventions and aerobic exercise programs focus on increasing cardiorespiratory fitness and decreasing blood pressure are mandatory to reduce cardiovascular disease risk in this population.


Fibromyalgia (FM) is a syndrome primarily characterised by chronic, widespread musculoskeletal pain. In the aetiology of this syndrome a crucial role is played by complex interactions among biological, genetic, psychological, and socio-cultural factors. Recently, researchers have started to explore emotional functioning in FM, with their attention focused on alexithymia, a personality construct that affects the regulation of a person’s own emotions. On the other hand, the detection and experience of emotional signals from other people have only been sparsely investigated in FM syndrome and no studies have investigated the ability to represent other people’s mental states  in these patients. Here we present the first study investigating a large set of social-cognitive abilities, and the possible relationships between these abilities and the performance on executive-function tasks, in a homogenous sample of patients with FM.Forty women with FM and forty-one healthy women matched for education and age were involved in the study. Social cognition was assessed with a set of validated experimental tasks. Measures of executive function were used to test the correlations between this dimension and the social-cognitive profile of patients with FM. Relationships between social-cognitive abilities and demographic, clinical and psychological variables were also investigated.Patients with FM have impairments both in the regulation of their own affect and in the recognition of other’s emotions, as well as in representing other people’s mental states. No significant correlations were found between social cognition tasks and the subcomponents of the executive function that were analysed.The results show the presence of several impairments in social cognition skills in patients with FM, which are largely independent of both executive function deficits and symptoms of psychological distress. The impairments reported highlight the importance of adequately assessing ToM and emotional functioning in clinical practice. Fibromyalgia (FM) is a syndrome primarily characterised by chronic, widespread musculoskeletal pain –2. Its pcentral sensitisation syndrome, caused by increased sensitivity of the central nervous system to pain signals [The aetiology of this syndrome is not completely understood, but a crucial role seems to be played by complex interactions among biological, genetic, psychological, and socio-cultural factors, such as medical illness, neuroendocrine disturbances, stress, and psychiatric disorders. In particular, high levels of stress and psychiatric symptoms may negatively influence the perception of disease severity, functional ability, and the threshold and tolerance for pain –11. Some signals .Among psychological factors, the high prevalence of depression 20–80%) and anxiety disorders (13–64%) has been widely reported –15. Only–80% and On the other hand, the detection and experience of emotional signals from other people have only been sparsely investigated in FM syndrome. A link between alexithymic traits and deficits in the processing of other people’s emotions has been highlighted in both healthy individuals and specific clinical populations, e.g. affective disorders, eating disorders, borderline and psychopathic personality disorders, schizophrenia, somatoform disorders –26. To tsocial cognition domain, defined as the ability to construct mental representations of the relations that exist between oneself and others and to flexibly use these representations to function effectively in one’s social environment [The ability to decipher information about the intentions and affective states of social partners is crucial for the implementation of appropriate behaviour during social interactions. This complex process is part of the so-called ironment –29. Examironment –31, and ironment –33.From a neurological point of view, ToM and emotional processing abilities are associated with overlapping but distinct brain networks –36. CommThe social cognition domain includes a series of different abilities, which gradually evolve throughout the lifetime. An open issue concerns the relationship between these capacities, particularly ToM processes, and the higher-level cognitive skills known as executive functions (EF). Growing numbers of studies are trying to address this relationship in patients with different psychiatric and neurological conditions –57.Updating is related to working memory and requires monitoring and coding information as well as replacing old non-relevant information with new relevant information. Shifting implies the ability to shift attention between different sub-tasks or different elements of the same task. Inhibition is concerned with the individual’s ability to withhold dominant, automatic or prepotent responses when they are inappropriate, and is considered to be a key component in planning abilities. Fisk and Sharp [Access, refers to the processes involved in verbal fluency tasks, which are believed to mediate access to representations in long-term memory.EF refers to all of the skills that people use to control and coordinate their cognitive abilities and behavior. These are essential for independent everyday functioning in life, and for the establishment of adaptive social relations –59. In tnd Sharp  later adCurrently, there are two opposing views about the relationship between ToM abilities and EF. Some authors believe that ToM is a circumscribed cognitive process, independent of general intellectual functioning and other cognitive domains, included EF . Basing The present study is based on both clinical evidence, which has highlighted high levels of emotional distress  in patients with FM, and neuroimaging and neuropsychological data that has reported functional and structural alterations in brain areas crucial for ToM and emotional processing abilities  in these patients –70, as wThe study was approved by the San Giovanni Battista University Hospital’s ethics committee and was conducted in accordance with the Declaration of Helsinki. All the participants gave their written informed consent to participate in the study.Forty female participants with FM (51.75 ± 7.76 years of age) were consecutively recruited from the Fibromyalgia Integrated Outpatient Unit (FIOU), a multidisciplinary unit based on the collaboration between rheumatologists, psychologists, and psychiatrists at the San Giovanni Battista University Hospital of Turin. All patients had a main diagnosis of fibromyalgia, made by rheumatologists who are experts in the field. In addition, a psychiatric interview based on DSM IV-TR axis II criteria  [As an index of pain intensity, the item “Pain” of the Italian version of the Fibromyalgia Impact Questionnaire (FIQ) –77 was uThe presence of symptoms of depression and anxiety was assessed using the Italian version of the Hospital Anxiety and Depression Scale (HADS) –79. It cNeuropsychological assessment was performed, using tests for short-term memory (Digit Span-Forward—DS F) , learninTwenty-Item Toronto Alexithymia Scale (TAS-20). Alexithymia was assessed using the Italian version of the Toronto Alexithymia Scale (TAS-20) [difficulty identifying feelings (Factor 1), which measures the inability to distinguish specific emotions and between emotions and the bodily sensations of emotional arousal; difficulty describing feelings (Factor 2), which assesses the inability to verbalise one’s emotions to other people; and externally-oriented thinking (Factor 3), which evaluates the tendency of individuals to focus their attention externally and not on the inner emotional experience [(TAS-20) –88. Subjperience . The TASperience , and it Empathy Quotient (EQ). The EQ is a validated self-report questionnaire, employed to assess the capacity to empathise with another, i.e. to recognise another’s affective state and to respond to this with an appropriate emotion [ emotion –91. The Ekman 60 Faces. The Italian version of this test was used to assess the recognition of facial expressions pertaining to basic emotions [emotions . The Ekmemotions  series. Reading the Mind in the Eyes Test (RME). The RME was employed to assess the ability to represent other people’s affective mental states [l states . In the t-tests were used. In order to evaluate the possible relationships between variables, Spearman or Pearson correlations were computed, as appropriate.All the statistical analyses were conducted using IBM SPSS Statistics, version 20.0. Normal distribution was assessed using indices of asymmetry and kurtosis. Non-parametric equivalent tests were performed on data that violated this assumption. For normally distributed variables, independent Data on the demographic and psychological variables are presented in p< 0.001) and for each of the two subscales evaluating anxiety (p< 0.001) and depression (p< 0.001). According to the cut-off scores of the HADS, 67.5% (27/40) of the patients with FM showed a clinically relevant level of both anxiety and depression, compared with 34% (14/41) for anxiety (Χ2(1) = 9.011, p< 0.001) and 19.5% (8/41) for depression (Χ2(1) = 19.000, p< 0.001) in the HC group.For psychological assessment we used data from the HADS total score and the scores for subscales HADS-A and HADS-D. The results showed significantly higher scores in patients with FM both for the total score  years of duration of illness and a high rate of pain intensity (7 ± 2.55 to the item “Pain” of the FIQ).p values ranging from < 0.001–0.011). Furthermore, a poorer performance in the FM group also emerged in the DS F (p = 0.005), in the AVLT-Delayed recall (p = 0.006) and in the TMT B-A (p = 0.004). No statistically significant differences were found on the other neuropsychological measures.The comparisons between the neuropsychological scores of the two groups are shown in In order to bring out the individual differences that could be flattened by group analyses, the individual scores were analysed comparing for each test the number of subjects with impaired or borderline performance according to the age- and education-corrected scores . The results showed that a significantly higher number of patients with FM compared with HC had a deficient performance in the DS F (short-term memory) and B (working memory), and in the Delayed recall task of AVLT (episodic memory) see .Data from social cognition tasks are reported in Regulation of own emotions. Concerning alexithymia, statistical analyses revealed the presence of significant differences between FM and HC on the TAS-20 total score (p< 0.001), and on the F1 (p< 0.001) and F2 subscales (p = 0.011); in all these comparisons patients with FM scored higher than HC. According to the TAS-20 cut-off scores, 27.5% (11/40) of the patients with FM were alexithymic and 45% (18/40) were borderline, compared with 7% (3/41) and 19.5% (8/41), respectively, in the HC group.Empathic capacity. No significant difference between the two groups was found in the EQ score.Recognition of others emotions. Concerning the Ekman 60 Faces Test, independent t-tests revealed the presence of significant differences between the two groups on total score (p = 0.010), and on two of the six emotions investigated by means of the test, i.e. anger (p = 0.049) and disgust (p = 0.016). Once again, patients with FM showed significantly lower scores, indicating a reduced ability to recognise other people’s emotions, especially anger and disgust.Representation of other people’s affective mental states. No significant difference between FM and HC was found in the control task for RME. In the experimental condition, patients with FM evidenced a significantly lower performance on the mental states attribution task (p = 0.007).The second aim of this study was to investigate the possible relationships between social cognition tasks and EF measures in patients with FM. Moreover, we also evaluated the correlations between social cognition tasks and demographic, clinical and psychological data. To do that, we only considered the variables that showed a significant difference in the comparison between FM and HC, i.e. TAS-20 F1, F2, and total score; Ekman anger, disgust and total score; and RME experimental task.r = -0.276, p: ns; DI and DS B: r = -0.132, p: ns; DI and ToL: r = 0.196, p: ns; DI and TMT B: sr = 0.185, p: ns; DI and TAS-20 F1: r = 0.319, p: ns; DI and TAS-20 F2: r = 0.333, p: ns; DI and TAS-20 Total: r = 0.342, p: ns; DI and Ekman Anger: r = 0.087, p: ns; DI and Ekman Disgust: sr = -0.175, p: ns; DI and Ekman Total: r = -0.036, p: ns; DI and RME Experimental: r = -0.053, p: ns).Correlations between social cognition measures and EF tasks are listed in r = 0.359, p = 0.023). However, significant correlations were detected between demographic, clinical and psychological variables and the TAS-20 scores. In particular, positive correlations were found between the TAS-20 total score and the HADS-A , the HADS-D , and the FIQ-pain . Likewise, positive correlations were found between the TAS-20 F1 and the HADS-A , the HADS-D  and the FIQ-pain . Finally, the TAS-20 F2 was positively correlated only with the HADS-D  and the FIQ-Pain .Regarding the relationship between social cognition measures and demographic, clinical and psychological variables, no significant correlations were detected between age, HADS-A, HADS-D, FIQ-pain, and the RME experimental or the Ekman anger, disgust and total score; a positive correlation was only found between the RME experimental and the level of education  between the two groups both for the total score and for two of the six emotions investigated by means of the test, i.e. anger and disgust; no significant differences were found for other emotions. These data are in line with the only study that has investigated the ability to recognise another’s facial emotions in patients with FM . As mentThe only social cognition task, in which no differences between the two groups were found, was the EQ. In this case, the FM group didn’t report a lower capacity for empathy compared to the control group.Concerning the general cognitive profile, neuropsychological assessment revealed the presence of significant differences in most of the measures. In particular, the FM group displayed significantly lower performance on the verbal fluency (FAS), the DS B and F, the AVLT-Delayed recall, and the TMT B and B-A, compared to HC. These data are consistent with previous studies that have reported cognitive deficits in attention, memory, and EF domains in patients with FM –74. In pFinally, from a psychological standpoint, our group of patients with FM presented with significantly higher levels of depressive and anxiety symptoms (67.5% in both cases) compared with the HC group. These results corroborate, once again, the high prevalence of psychological distress reported in previous studies of patients with FM –15, 19.To the best of our knowledge, this is the first study to investigate social-cognitive abilities in a homogenous sample of patients with FM. The results show that patients with FM have impairments both in the regulation of their own affect and in the recognition of other’s emotions, as well as in representing other people’s affective mental states. There is evidence that appropriate behaviour in social interactions is determined by the ability to decipher information about the intentions and affective states of social partners. Thus, impairments in facial affect recognition and difficulties in accurately inferring other people’s affective mental states may lead to substantial difficulties in interpersonal contacts , which have been already reported in patients with FM . FurtherFrom a neurological standpoint, the brain networks relevant for pain and emotional processing partially overlap. The amygdala plays a crucial role in sharing emotional experiences and in recognising emotions in oneself and others , 36. In As far as the second goal of this study is concerned, we investigated whether EF measures in the FM group were related to the different social cognition tasks that were used. In addition, we also analysed the possible relationships between demographic, clinical and psychological variables, and measures of social cognition. Concerning EF tasks, no correlations were found between social cognition tasks and each of the four subcomponents of the EF domain that were analysed. The only exception was represented by a low positive correlation between the Ekman total score and the DS B. Regarding the demographic, clinical and psychological variables, correlation analyses showed no relationship between Ekman total score, anger and disgust, RME experimental, on the one hand, and anxiety, depression and pain intensity, on the other hand. Positive correlations were only detected between the latter measures  and the total score and scores for the F1 and F2 subscales of the TAS-20. This result is consistent with previous studies that have investigated the presence of alexithymia in FM patients , 20, 102Taken together, as far as the first aim of this study is concerned, the results show the presence of several impairments in social cognition skills in patients with FM. As for the second aim, i.e. to explore the possible relationships between the performance on executive-function tasks and the performance on social-cognition tasks in patients with FM, we found that the latter are largely independent of both EF deficits and symptoms of psychological distress. The only exception seems to be represented by alexithymia; in fact, psychological disorders, but not EF deficits, seem to play a role in explaining the high levels of alexithymia found in the FM sample. Concerning other measures of social cognition, no relationship was found with EF deficits or symptoms of psychological distress. In our sample, impairments in ToM and emotional processing ability appeared to be independent of the EF domain.This study also has some limitations. Firstly, even though we enrolled an adequate number of patients with FM, our study is still limited by a relatively small sample size. Secondly, the self-reported measures we used might have elicited a bias towards social desirability, masking the real profile of some individuals. Thirdly, although in patients with FM there is evidence of structural and functional alterations in brain areas crucial for ToM and emotional processing abilities  –70, we dIn spite of these limitations, the findings reported in the present study represent the first contribution towards understanding the complex social-cognitive profile of patients with FM. The impairments reported in tasks that evaluate ToM and emotional processing abilities highlight the importance of adequately assessing these abilities in clinical practice. In this way, it could be possible for clinicians to plan better pharmacological and/or psychological treatment based on each patient’s needs.


To explore gender differences and associations between metabolic syndrome (MetS) and its components, and diabetic retinopathy (DR) in Korean adults aged 40 years and older with diabetes.We analyzed data from the Korean National Health and Nutrition Examination Surveys (2008–2012). In total, 2,576 type 2 diabetic participants, aged 40 and older, were evaluated. Seven standard retinal fundus photographs were obtained after pupil dilation in both eyes. DR was graded using the modified Airlie House classification system. Vision-threatening diabetic retinopathy (VTDR) included proliferative diabetic retinopathy and clinically significant macular edema. MetS was defined according to the Joint Interim Statement, proposed in 2009, by the International Diabetes Federation and the American Heart Association/National Heart, Lung, and Blood Institute. Multivariate logistic regression analysis was used to assess the relationship between MetS and its individual components with DR and VTDR.After controlling for confounders, MetS was not associated with DR in men or women. Moreover, the risk for DR or VTDR did not increase with increasing MetS components. However, high waist circumference was significantly inversely associated with VTDR  only in men..MetS was not associated with DR or VTDR in a Korean diabetic population. However, among MetS components, it seems that abdominal obesity was inversely associated with VTDR in Korean diabetic men The term metabolic syndrome (MetS) was introduced in 1988 by Reaven, who suggested that insulin resistance and compensatory hyperinsulinemia are responsible for the clustering of cardiovascular risk factors, such as glucose intolerance, hypertension, abdominal obesity, and dyslipidemia , 3. In aHowever, in East Asian populations, such as Korean and Japanese, the situation is somewhat different from the Caucasian population. The prevalence of obesity differs markedly between Caucasians and East Asians in diabetics , 7, and per se, in a Chinese study [There are few data on the relationship between MetS and DR in East Asian countries, and they are controversial. Terauchi et al.  found thse study . HoweverThus, in the present population-based study, we first assessed the association of MetS and its individual components with DR. Then, we assessed vision-threatening diabetic retinopathy (VTDR) in a representative Korean population.The present study was based on data acquired in the Korean National Health and Nutrition Survey (KNHNS), 2008–2012. The KNHNS, conducted annually by the Division of Chronic Disease Surveillance, Korean Center for Disease Control and Prevention, uses a rolling sampling design involving a complex, stratified, multistage, probability-cluster survey of a representative sample of the noninstitutionalized civilian population in Korea . The surAnnually, 4000 households in 200 enumerated districts are selected by a panel to represent the civilian, noninstitutionalized South Korean population using a systematic stratified, multistage-clustered sampling method, based on National Census Data. All of the members of each selected household were asked to participate in the survey, and the participation rates between 2008 and 2012 ranged from 77.8% to 82.8%.All of the participants provided written informed consent. This study design followed the tenets of the Declaration of Helsinki for biomedical research and was approved by the Institutional Review Board of the Catholic University of Korea, Seoul, Korea.Those who were diagnosed by a self-reported history of a physician diagnosis or were receiving drug treatment for DM, including insulin and oral hypoglycemic agents, and those who had a fasting plasma glucose level > 126 mg/dL were defined as diabetics. In the present analysis, we limited the study population to type 2 diabetic patients aged 40 years or older. Participants were considered to have type 1 DM if they were aged < 30 years when diagnosed with DM and were receiving insulin therapy . Otherwitable tennis, tennis doubles, etc., a regular basis was defined more than five times per week for over 30 min each time.All of the participants were asked about their demographic and socioeconomic characteristics, including residential area, education, income, and occupation. Respondents who were exposed to sunlight for more than 5 h per day were categorized as the sun exposure group. Respondents were categorized into two groups: ever smokers (current smokers and ex-smokers) and non-smokers. High-risk drinking was defined as the consumption of at least five alcoholic drinks for men, or four or more alcoholic drinks for women, in a row, at least once in the past 2 weeks . The subThere was no item in the KNHNS that showed daily magnesium intake. However, the daily magnesium intake from foods was estimated using a magnesium content database reported by a previous study . The sub2) after height and weight were measured using standardized techniques and equipment. High BMI was defined as a BMI > 25 kg/m2. Blood pressure (BP) was measured three times on the right arm while the individual was in a seated position after at least 5 min of rest using a mercury sphygmomanometer . The final BP value was obtained by averaging the values of the second and third BP measurements. Blood samples were collected in the morning after fasting. If fasting time was less than 8 h, the fasting glucose of that patient was considered a missing value, and if it was less than 12 h, triglycerides were considered a missing value. Serum levels of glucose, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, and triglycerides were measured enzymatically using a Hitachi automatic analyzer 7600 . Glycated hemoglobin (HbA1c) was measured by the SLS hemoglobin (no cyanide) method using a XE-2100D .WC was measured to the nearest 0.1 cm in a horizontal plane at the level of the midpoint between the iliac crest and the costal margin at the end of a normal expiration. Body mass index (BMI) was calculated by dividing body weight by height squared  was performed in all of the KNHNS participants. Seven standard field photographs according to the Early Treatment for Diabetic Retinopathy Study (ETDRS) protocol were obtained from each eye after pharmacological pupil dilation . DR was A preliminary grading was done on-site by ophthalmologists trained by the National Epidemiologic Survey Committee of the Korean Ophthalmologic Society (KOS). The fundus photos were re-examined by 15 university hospital professors . The quality of the survey was verified by the Epidemiologic Survey Committee of the KOS.MetS was defined using the criteria proposed by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI), together with the IDF, in 2009 . MetS waAll of the data are presented as means ± SE for continuous variables or proportions (SE) for categorical variables. Statistical analyses were conducted using the SAS statistics software for Windows, version 9.2 ; the stratification and clustering of the design were included in the analyses of this study to ensure appropriate estimates and standard errors according to specific guidelines for analyses and reporting of sample weights that were provided by the KNHNS. To miniSimple logistic regression analyses were performed to estimate the magnitude of association of MetS, DR, and VTDR with the parameters of the participants. Multiple logistic regression analyses were performed to estimate the magnitude of the association of DR and VTDR with MetS and its components, and two statistical models based on the characteristics of the variables were used. One model included age and survey year. Subsequently, socioeconomic and lifestyle-related characteristics including income, education, residential area, smoking status, drinking alcohol, exercise, occupation (farmer or fisher), and sun exposure were included, based on the results from the univariate analysis. The Cochran–Armitage Trend Test was used to test the effects of clustering of MetS components on DR and VTDR. A P value < 0.05 was considered statistically significant.In total, numbers of type 2 diabetic subjects were 2576 : 1303  men and 1273  women. Of these, 2099 (82.7%) participants had non-mydriatic fundus photographs and 2046 (81.0%) participants had 7 gradable standard photographs. The prevalence of MetS in this population was 79.5%  = 77.4–81.4%; 71.1% for men and 89.3% for women). The prevalences of individual components of MetS were 55.8% for abdominal obesity, 58.2% for elevated triglycerides, 64.4% for low HDL-cholesterol, and 69.4% for high BP. The prevalence of DR in participants aged 40 years or older was 17.7% . After controlling for confounding factors, MetS was not significantly associated with DR or VTDR in either gender . One criMetS, defined according to the Joint Interim Statement proposed in 2009, was not associated with the presence of DR or VTDR complications in Korean patients with type 2 diabetes. Even a clustering of MetS components did not lead to an increase in the prevalence of DR or VTDR. In contrast, the Metascreen Writing Committee reported that the presence of MetS, as defined by the National Cholesterol Education Program (NCEP) and IDF guidelines, was a strong, independent predictor of DR in type 2 diabetics . FurtherData on the relationship between MetS and DR in East Asian populations are less consistent. One clinical cross-sectional study based on 130 Japanese patients reported the lack of an association between MetS and DR, similar to our results . In cont1c. DM duration and HbA1c are well-known risk factors for DR according to previous reports, and this was also shown in our study [1c, and socioeconomic factors, were not included in their model, and the robustness of their results is questionable. Shimajiri et al. [1c and socioeconomic factors, using a multiple logistic regression model.However, these two conflicting studies had some problems in their statistical analyses in controlling for compounding factors, such as DM duration and HbAur study –26. Thusur study  used muli et al.  subdividThe differences between our study and reports based on Caucasian populations may be explained, at least in part, by possible ethnicity-related differences in the role of the insulin resistance, represented by MetS in development of microvascular complications of DM. Both insulin deficiency and insulin resistance are involved in the pathogenesis of type 2 DM. Moreover, the relative balance of the factor may differ widely by ethnicity.Because insulin resistance is considered a key player in the pathophysiology of the MetS , 27, theSimilar non-obese characteristics and the relative importance of an insulin secretory defect in type 2 DM were shown in Japanese studies , 31. BecType 1 DM and type 2 DM patients of East Asian origin share the same feature, with an insulin secretory defect that is more dominant, although insulin resistance is also involved in the development of the disease. Due to this, MetS appears to have little predictive value in distinguishing type 1 diabetic patients who are most likely to develop DR, even in Caucasians. Kilpatrick et al.  showed tinverse relationship with VTDR in men. In women, there was a significant inverse relationship between high BMI and DR. In men, a high BMI had a negative relationship with VTDR, but it was not significant by a narrow margin (P = 0.071).In the analysis of MetS components, no component showed a positive association with DR or VTDR in our study. In particular, a high WC showed an These findings contrast with many previous reports in which obesity was a risk factor for DR –37. HoweHigh WC patients had short durations of diabetes in our study (P = 0.045), which may partly explain the inverse relationship between high WC and VTDR in our study. Significant weight loss was also observed in another study during the course of the development of diabetes in a Korean population, also consistent with our study . HoweverSeveral studies have suggested the so-called obesity paradox, which is an apparently protective effect of obesity against adverse clinical outcomes in patients with obstructive coronary artery disease –42. One Hypertension is the one of the most consistent risk factors of DR in many studies, although the details differ in studies. In the prospective Wisconsin study, systolic BP predicted progression of retinopathy in patients under 30 years of age at onset . The Uniper se not being a risk factor for DR in Koreans. If we revise the criteria for MetS, focusing on systolic BP and discarding diastolic BP, this criterion may have clinical significance as a risk factor for DR in Koreans.Although hypertension as a component of MetS did not show an association with DR or VTDR in our study, DR was associated with higher systolic BP in both genders after controlling for other significant factors. Thus, there may be a problem with the criteria for MetS rather than hypertension Associations of DR with hyperlipidemia are less consistent than with hypertension. Serum lipid profiles were associated with DR or VTDR in our study, consistent with some previous studies , 48, 49.Our study had some limitations. One was that a causal relationship could not be assessed because of the cross-sectional nature of study. We attributed the lack of influence of MetS on DR to the balance between insulin resistance and insulin secretory defects, but markers that can be used to evaluate insulin secretory ability, such as the insulinogenic index or C-peptide levels, were not measured in our study. Further prospective studies to measure these surrogate markers of insulin secretory ability in East Asians may confirm our hypothesis.Although our study used criteria to exclude type 1 diabetes, it is possible that type 1 diabetic patients could have been included. However, considering the extremely low incidence of type 1 diabetes in Korea , the probability is minimal .Zimmet introduced the term ‘‘latent autoimmune diabetes of adults” (LADA) to describe a subgroup of adult phenotypic Type 2 diabetic patients positive for glutamic acid decarboxylase (GADA) . SeveralDespite these limitations, this study used a nationally representative sample of adults in Korea with a high response rate, a crucial strength of our study. Moreover, we controlled other risk factors statistically, which can affect the results versus other previous studies dealing with the same issues in East Asians with fewer or less complete controls. Moreover, to our knowledge, this is the first reported large population-based study to examine the association between DR and VTDR with MetS and its components in East Asians.In conclusion, the presence of MetS, defined according to the Joint Interim Statement proposed in 2009, was not associated with the presence of DR or VTDR in a representative Korean population with type 2 diabetes. VTDR was inversely associated with a high WC in men. As a consequence, this study showed that classifying a patient with Type 2 diabetes with MetS may be of limited or no use in predicting DR or VTDR.


To assess the impact of respiratory tract infection in the postoperative period ofcardiac surgery in relation to mortality and to identify patients at higher riskof developing this complication.Cross-sectional observational study conducted at the Recovery of CardiothoracicSurgery, using information from a database consisting of a total of 900 patientsoperated on in this hospital during the period from 01/07/2008 to 1/07/2009. Weincluded patients whose medical records contained all the information required andundergoing elective surgery, totaling 109 patients with two excluded. Patientswere divided into two groups, WITH and WITHOUT respiratory tract infection, as thedevelopment or respiratory tract infection in hospital, with patients in the groupwithout respiratory tract infection, the result of randomization, using for thepairing of the groups the type of surgery performed. The outcome variablesassessed were mortality, length of hospital stay and length of stay in intensivecare unit. The means of quantitative variables were compared using the Wilcoxonand student t-test.P=0.17; sexP=0.94; surgery performed P=0.85-1.00)Mortality in the WITH respiratory tract infection group was significantly higher(P<0.0001). The times of hospitalization and intensive care unit weresignificantly higher in respiratory tract infection (P<0.0001). The presence ofrespiratory tract infection was associated with the development of othercomplications such as renal failure dialysis and strokeP<0.00001 and P=0.002 respectively.The groups were similar (average age The development of respiratory tract infection postoperative cardiac surgery isrelated to higher mortality, longer periods of hospitalization and intensive careunit stay. In Recife, at Real HospitalPortuguês de Beneficência in Pernambuco (RHP) only, 1,400 surgeries areperformed every year, demonstrating the significance of the procedure in our country.Many patients develop complications that affect the results, increasing morbidity andmortality at the individual level, and burdening the health care system. In heartsurgery, three major events, when present, increase the chances of death: thedevelopment of respiratory infection, perioperative stroke and renal failure dialysis(RFD),3, Besides associated with higher mortality, suchoccurrences are important causes of readmission to the intensive care unit, increasinghospital costs.In Brazil, more than 100,000 heart surgeries are performed each year,especially the respiratory infection, the most frequent in this type of procedure - itexceeds 50% of high mortality infections. It is also known that the early identification ofpatients at higher risk of developing this complication and the adoption of prophylacticmeasures can reduce the mortality rate significantly-9.An important determinant of bad results in cardiac surgery is theinfectionThe lack of local studies to determine the prevalence and the impact of renal tractinfection (RTI) justifies this study. The understanding of this problem in our regioncan help implement intervention strategies that change the current situation.The aim of this study is to assess the impact of respiratory tract infection incardiac surgery postoperative period in RHP, especially regarding the hospitalmortality, and to identify patients at higher risk of developing thiscomplication.We used a cross sectional observational study that was made by the Thoracic SurgeryRecuperation Unit (TSRU) of RHP.st 2008 to July31st 2009.Data were collected from existing database containing information of 900 patientsoperated and admitted to the TSRU of RHP, from July 1The sample was initially composed by 109 patients, being two later excluded because oflack of data. The 107 remaining patients were divided into 02 groups: one defined as RTIGroup, composed by 29 patients who developed respiratory tract infection, and ControlGroup, made up of 78 patients without RTI.The variable used to pair the two groups was the type of performed surgery. Thus thetype of surgery proportion performed on the RTI group was determined. Then there was arandomization among patients who did not develop RTI and were part of the database, thusforming the control group, with 78 patients.For the RTI diagnosis, we used clinical respiratory infection parameters associated withtracheal aspirate secretion culture, with colony counts equal to or greater than onemillion units.The sample size calculation was based on the RTI development prevalence in cardiacsurgery postoperative, existing in the literature.Demographic variables were assessed, such as gender and age, in addition to the type ofsurgery performed and the outcome variables, such as mortality, length of hospital stayand ICU length of stay. Categorical variables were expressed by their absolute andrelative frequencies and the quantitative variables were expressed by their average andstandard deviations.To compare the averages of different groups, we used the t-test when the variablesfollowed a normal distribution. For variables that did not follow this distribution, weused non-parametric tests (Wilcoxon). For association studies, we used the chi-squaretest or Fisher's exact when indicated.P<0.05 were consideredstatistically significant.When the alternative hypothesis was sought, BioStat 5.0 was used.The project was submitted to the Ethics Committee of RHP and to the Ethics ResearchCommittee of UFPE. We requested authorization for the use of the records in thisstudy.The sample was composed by 107 patients, divided into 2 groups: with and withoutRTI.P=0.17), gender distribution (P=0.94) and type ofperformed surgery (P=0.85-1.00), demonstrating the similarity of thepopulation of the two groups.After pairing the groups, it was observed that they had no difference in age average(P=0.07).A higher average value of the EuroSCORE was observed in the group WITH RTI, compared tothe control group, (WITHOUT RTI), with a tendency to statistical significance(vs.3.8%), as shown in We found a significantly higher mortality in the group with RTI (48%P<0.0001 andP=0.002 respectively), as The length of hospital stays and ICU length stay was significantly higher in the groupWITH RTI compared to the control group (P<0.0001 and P=0.002 respectively). Thisassociation was not observed in the control group  and stroke(ol group .P=0.01).Studying the RTI group specifically and analyzing the risk group by EuroSCORE separately, we found no statistically significant association between riskgroup and prevalence of RTI. However, dividing them in low and medium-high, we found ahigher prevalence of RTI on medium-high of patients, compared to low risk to the higher prevalence of complications-16.The RTI group had higher EuroSCORE,18.Mortality in patients with RTI was significantly higher than in the group without RTI,as demonstrated in the literature. Datafrom this study, in line with published data, show that the existence of complicationsafter heart surgery is directly related to a longer hospital stays and higher mortalityrate.The length of hospital stay and the time of ICU stay were significantly higher in thegroup with RTI compared to the control group. This fact implies probably a higher cost,as intensive care units (ICUs) make up about 20% of total hospitalcosts. This was observed in this study, and it is interesting tonote the fact that the RFD and stroke are most commonly associated with respiratoryinfection. That is, the RTI is strongly associated with such complications. Failure toobserve the presence of RFD and stroke in the group without RTI reinforces thisclaim.Cardiac surgery has as primarily non-cardiac complications the development of infection(most respiratory), IRA and strokeThe development of RTI in cardiac surgery postoperative is related to higher mortality,as well as to longer hospital and ICU stay. This complication has also been associatedwith the development of other co-morbidities such as renal failure dialysis andstroke.