The LH/FSH ratio was not significantly different among the PCOS group  compared to the control group  (p = 0.308). Among women with PCOS, the most common phenotype was type I (50.3%), with type III (29.6%), type II (14.5%) and type IV (5.7%). Type I had the highest values of fasting insulin (median = 12.98 mU/mL) and HOMA IR values  and is associated with severity of the disease. There was no difference in glucose levels.Polycystic ovary syndrome (PCOS) is a common problem among Arab women and is the main cause of infertility due to anovulation. This study investigates insulin resistance (IR) and obesity in different PCOS phenotypes among infertile women (n = 213), of whom 159 had PCOS and 54 women without PCOS, recruited as a control group. Biometric, hormonal and clinical parameters were studied. IR was observed in 133 (83.6%) women with PCOS and in 25 (46.3%) women without PCOS (p < 0.001). IR was significantly associated with PCOS only among women with central obesity (χ The prevalence of PCOS varies with ethnicity2, appearing in 6.6% in the population of the south-eastern United States3, 6.8% in Greece4, 6.5% in Spain5, 13% among Mexican American women6, and 52% among South Asian female immigrants of Britain7.Polycystic ovary syndrome (PCOS) is a heterogeneous condition, the pathophysiology of which appears to be a multifactorial, polygenic and multisystem endocrine disorder affecting 5–10% of women of reproductive age, characterised by hyperandrogenism and chronic anovulation8 menstrual irregularity, usually from the time of menarche9; acne10; hyperinsulinemia11; insulin resistance (IR); early onset of type 2 diabetes mellitus12; and dyslipidemia13. According to the 1990 NICHD definition, women with PCOS may present three phenotypes: (i) oligo-ovulation, hyperandrogenemia and hirsutism (Oligo+ HA+ Hirsutism); (ii) oligo-ovulation and hyperandrogenemia, without frank hirsutism (Oligo+ HA); and (iii) oligo-ovulation and hirsutism, without measurable hyperandrogenemia (Oligo+ Hirsutism)14. According to ESHRE guidelines15, women with PCOS present with four phenotypes: type I: hyperandrogenism, chronic anovulation, and polycystic ovaries; type II: hyperandrogenism and chronic anovulation but with normal ovaries; type III: hyperandrogenism and polycystic ovaries but ovulatory cycles; and type IV: chronic anovulation and polycystic ovaries but no clinical or biochemical hyperandrogenism.Clinical features of PCOS include hirsutism; androgenic alopeciaet al.16, as it became clear that women with the syndrome have major metabolic as well as reproductive morbidities. Recently, more attention was focused on the degree of IR (insulin resistance) in women with PCOS. One report even considered all women with PCOS to have some degree of IR17. Recent evidence suggests that obesity appears to exert an additive synergistic impact on the manifestations of PCOS, including a modifying effect on insulin sensitivity and gonadotrophin secretion and independently and negatively affecting insulin sensitivity, risk of diabetes, and cardiovascular impact18.The association between PCOS and hyperinsulinemia was first reported by Burghen This study aimed to examine the prevalence of different PCOS phenotypes among infertile women with PCOS and to investigate the prevalence of insulin resistance and obesity in different PCOS phenotypes compared with infertile women without PCOS.n = 59, 27.7%) had been infertile for more than 4 years, with no significant difference by duration of infertility , followed by type III  29.6% (n = 47/159). Twenty-three women had chronic anovulation and hyperandrogenism but normal ovarian morphology, type II (H/O), 14.5% (n = 23/159) and, finally, only 5.7% (n = 9/159) of patients had type IV . Type III and IV phenotypes represent the newer phenotypes according to the Rotterdam criteria.The most common phenotype in our study was type I (full-blown PCOS) 50.3% . However, there were significant differences in the waist-circumference categories ; mainly, the obese status n = 40 (25.2%) compared to the obese of the control group n = 4 (7.4%), p-value = 0.018 ; for women with PCOS, BMI was 28 (SD = 4.51) and for controls 27.6 (SD = 5.4) with no statistically significant difference (P = 0.644). However, waist circumference mean values were for all women 79.5 cm (SD = 9.46), women with PCOS 80.49 cm (SD = 9.47), controls 76.6 cm (SD = 8.9), with a n = 59 (37.1%) was more common among the PCOS group compared to the control group n = 3 (5.6%) . Acanthosis nigricans was not statistically significant . The modified Ferriman-Gallwey (mFG) score > 8, n = 85 (53.5%) was significantly higher in the PCOS group compared to the control group . Hirsutism and/or acne were the highest among all hyperandrogenism categories  and were significantly associated with hyperandrogenism in comparison to the control group . The total number of women with oligomenorrhea or amenorrhea was 107 (67.3%) and was significantly higher in women with PCOS compared to the control group . Ovarian volume of more than 10 mm3 was n = 124 (78.0%) in the PCOS group, which was significant compared to the control group  with p-value < 0.001. Insulin resistance (IR > 2.5)  was also more common among the cases of PCOS compared to the control group . However, when we compared the luteinising hormone/ follicle-stimulating hormone (LH/FSH) ratio (cut-off > 2), we found that it was higher among the PCOS group  than in the control group , but this difference was not statistically significant  . However, fasting glucose, sex hormone binding globulin (SHBG) and FSH values were not statistically significant   and  for BMI and waist circumference, respectively . Obesity was associated with IR in all cases and controls  for IR (>2.5 vs. <2.5) and the clinical status (cases vs. controls) while controlling for BMI status  showed that IR > 2.5 was significantly associated with PCOS for normal BMI , whereas for the obese category, it was also significant . Mantel-Haenszel statistics were significant with χ2 = 29.08 and p < 0.001. IR > 2.5 was significantly associated with the PCOS only among the obese category of waist circumference . For the normal category, it was not significant . Mantel-Haenszel statistics were significant with χ2 = 26.48 and p < 0.001 . Fasting glucose did not differ between the groups. HOMA-IR, FSH, LH and FSH/LH ratio were statistically different between the groups. Phenotype IV had the highest LH and LH/FSH ratio, whereas type I had the highest HOMA-IR values. When we compared FSH levels, using post hoc Bonferroni comparisons between different phenotypes, there were statistically significant differences in FSH levels between phenotypes I and II and between I and III (p < 0.01)  Table .Table 5Mp-value < 0.001  with 2) = 48 women (30.2), overweight (>25 < 30 Kg/m2) = 61 women (38.4%) and obese (>30 Kg/m2) = 50 women (31.4%). When exploring the percentages of BMI and WC categories in relation to HOMA-IR (>2.5) . Moreover, Table The distribution of patients among weight categories shows women with PCOS with waist circumference categories Normal (<79.9 cm) = 67 women 42.1%), overweight (80.0 to 87.9 cm) = 53 women (33.3%) and obese (>88 cm) = 39 women (24.5%), whereas according to WHO BMI categories, Normal , overweight: 41.0% (n = 25), obese: 68.0% (n = 34) with p-value < 0.001.Concerning clinical hyperandrogenism features, our results showed that androgenic alopecia was associated with only obesity among all PCOS subjects: normal weight 0%  in the obese compared with lean women with PCOS25. Although polycystic ovary syndrome is believed to be one of the most common endocrine disorders in women worldwide, reports are very rare regarding the clinical and biochemical features of Arabic (including Jordanian) women with PCOS26. The hormonal profile of PCOS among Saudi women was similar to that published in the literature, with the exception of the prevalence of metabolic syndrome, which was less than in global reports27. As shown above, HOMA-IR was significantly correlated with BMI. In addition, our advanced statistical analysis showed that IR is highly associated with the presence of PCOS, although the additive synergistic effect of obesity could not be excluded. The results also show that obesity would worsen the severity of insulin resistance. The prevalence of insulin resistance was not significantly different between various PCOS phenotypes and type I, the most severe phenotype had the highest values of IR, in agreement with other reports28. Obese women with PCOS have more severe hyperandrogenism and its related clinical features  than normal-weight women with PCOS. This picture tends to be more profound29 particularly in obese women with PCOS and central obesity.Obesity is a common problem among Jordanian females33. Actually, insulin possesses true gonadotrophic function and an increase in insulin availability within ovarian tissue may enhance excess androgen synthesis. Obesity, particularly the abdominal type, may be partly responsible for insulin resistance and associated hyperinsulinemia in women with PCOS. Therefore, obesity-related hyperinsulinemia may play a key role in favouring hyperandrogenism34. Moreover, obesity is associated with IR35. IR is also affected by ethnicity36 and age37. When we used the HOMA-IR calculation to estimate insulin sensitivity, adjusted for confounders, we observed that 133 (83.6%) of 159 PCOS patients were insulin-resistant. This is consistent with the recent findings of other reports39. Furthermore, insulin resistance is present in both obese and non-obese women with PCOS40. Legro et al.41 reported a higher prevalence of insulin resistance in obese (64%) than in non-obese (20%) women with PCOS. In our study, the prevalence of insulin resistance was significantly higher in overweight patients than in patients of normal weight.Many patients with PCOS demonstrate other metabolic abnormalities. Especially notable is the presence of insulin resistance (IR), accompanied by compensatory hyperinsulinemia42. The overproduction of LH and, consequently, an incorrect LH/FSH ratio is presently not considered to be a characteristic attributed to all PCOS patients. In our study, we found that LH/FSH changes were attribute of 23.3% of cases with PCOS and in 16.7% of controls, which differs from the findings of other studies, in which higher incidence was reported29. Moreover, our results show that obesity was not a risk factor for an abnormal LH/FSH ratio, disproving the traditional concept of the disease that the heavier the patient is, the higher the LH/FSH ratio, and our results agree with a recent report43.As shown above, there was no difference in FSH levels between cases and controls and, in fact, there was a relative deficit in FSH levels in women with PCOS. Some reports indicate that altered secretion of inhibin B may lead to a relative deficit of FSH in PCOS22 as a marker for IR.This study has a number of strengths, including the relatively good number of patients and the richness of data, which paves the way for more studies to address this problem. In addition, our study population is homogeneous in racial and ethnic variations, which gives more credibility to the results and conclusions. Furthermore, this study included subjects with infertility with or without PCOS, in whom, unfortunately, the main focus of doctors and patients was on infertility problems; our data will encourage doctors and patients to be aware of the high prevalence and role of obesity and insulin resistance first and, second, to correct the endocrine dysfunction in those women with PCOS by reducing their weight and improving their insulin levels. The use of mFG score for the assessment of hirsutism may be considered a limitation in the study because it is a subjective issue. The other probable limitation is the use of the HOMA-IR threshold value for diagnosis of IR resistance, which may have affected the true prevalence of IR among our study subjects. However, the gold standard for establishing IR is the euglycemic hyperinsulinemic clamp, which is not suitable for large-scale clinical use; therefore, we used the HOMA-IR calculation, which correlates with the euglycemic hyperinsulinemic clamp and is often used in other reportsThe full-blown phenotype of PCOS was the most common phenotype in this cohort of Jordanian women with PCOS. The prevalence of hyperandrogenism , obesity and insulin resistance were higher in this cohort than in women from other ethnicities. This fact will encourage doctors to focus on resolving obesity and IR problems in addition to infertility problems. A focus on central adiposity evaluation by waist circumference measurement instead of BMI is more valid. LH/FSH ratio should not be part of PCOS assessment. Owing to Arabic women, including Jordanians, being at high risk developing abnormal glucose metabolism and type II diabetes, further research is required to investigate the value of the recommendation for initial and periodic screening for hyperglycemia and IR in women with PCOS, including annual evaluation for diabetes.Incorporating information from our study, we can now characterise the phenotype of Arabic women with PCOS as being similar to other women with PCOS with regard to insulin resistance and obesity, but the key differences are that our women have more of types I and III and less of type IV phenotypes.15. Patients’ median age was 24 (IQR: 22–29) years. Due to infertility problems, none had used oral contraceptives for at least 3 months preceding the study. Women with persistent elevations of prolactin (PRL) (>24 μg/L) or abnormal thyrotropin (TSH) values (>5.5 mIU/L or <0.35 mIU/L) were excluded. Six cases were excluded, leaving a total final number of 213 study subjects. Of them, 159 had infertility problems due to PCOS; 54 women had infertility problems due to other reasons, including tubal factor, endometriosis and pelvic inflammatory disease, and these women served as a control group. The causes of infertility were determined by clinical evaluation, laboratory investigations, hysterosalpingogram and hysteroscopy or laparoscopy.This cross sectional observational study was carried out in Karak City in the southern part of Jordan from January 2012 to April 2015. A total of 219 consecutive, untreated women presenting with initial diagnosis and treatment of infertility due to different causes, including PCOS, were recruited. The diagnosis of PCOS was determined according to the Rotterdam’s criteriaThis study was based in two gynaecological clinics, one at the Ministry of Health in Al-Karak Hospital, affiliated with the Mutah University Obstetrics & Gynaecology Department in the south of Jordan, and the other at the main author’s (MA) private practice. Institutional review board approval was obtained from Mutah University Ethics Committee (N0-201217), and informed written consent was obtained from all study participants. We confirm that all methods were performed in accordance with the relevant guidelines and regulations of the ethics in Human research and all research data can be available.A standardised form was used to take medical history and physical examination, with emphasis on menstrual dating and regularity, the presence of hirsutism, acne and acanthosis nigricans. Full records of medications and gynaecological and family histories were obtained. Menstrual cycles were identified as (1) regular menses: a cycle with an inter-menstrual interval of 21 to 35 days; (2) oligomenorrhea: an inter-menstrual interval of 36 days or longer; and (3) amenorrhea: an inter-menstrual interval of 6 months or longer in previously regularly menstruating women and more than 3 months in women with oligomenorrhea.2 in kg/m2) with normal range between 17 and 25, overweight between 25 and 30 and obese >30. Central obesity was assessed by waist circumference (WC) measurements according to the WHO protocol44, measured at the mid-point between the highest point of the iliac crest and the last palpable rib, using a flexible, inelastic measuring tape with a tension meter attached. Then all measures were classified into three categories: normal (WC 79.9 cm or less), overweight (WC 80.0 to 87.9 cm) and obese (WC 88.0 cm or more), according to age- and sex-specific cut-offs45.Women diagnosed with infertility were grouped into two groups: those with PCOS and those without PCOS. The diagnosis of PCOS was based on clinical, laboratory and ultrasound scan data (see ovarian assessment). All women underwent physical examination. Obesity was assessed by estimating body mass index , with the examiner assessing terminal hair growth in each area and rating it from 0 (no hair) to 4 (extensive hair growth)48. Biochemical hyperandrogenism was identified as a total T level >83.6 ng/dL (SI Unit: 2.96 nmol/L), free T level >0.81 ng/dL (0.026 nmol/L), free androgen index FAI = [total testosterone/sex hormone binding globulin (SHBG) × 100] > 549 or a DHEAS level >1,580 ng/mL (6.64 mol/L)50. We defined clinical hyperandrogenism (HA) as the presence of hirsutism and/or acne; because there is no agreement regarding the best way to assess acne51, we elected to record its presence without scores in our study subjects.On physical examination, the presence of terminal hair growth was scored using a modification of the Ferriman-Gallwey (mFG) method with a score of 8 or greater (mFG ≥ 8) was considered hirsutism52), biochemical or clinical hyperandrogenism (HA) and polycystic ovaries (PCO). Participants with PCOS were grouped according to their PCOS features in four possible groups53 as follows:PCOS is heterogeneous endocrine disease that can present by oligo- or anovulation (O) (progesterone <5.0 ng/mL (1 ng/mL = 3.2 nmol/L) on at least one luteal phase sample dayType I: hyperandrogenism, chronic anovulation and polycystic ovaries (O + HA + PCO).Type II: hyperandrogenism and chronic anovulation (O + HA).Type III: hyperandrogenism and polycystic ovaries (HA + PCO).Type IV: chronic anovulation and polycystic ovaries (O + PCO).54. HOMA−IR was calculated using the equation HOMA−IR = Fasting insulin (μU/mL) × fasting glucose (mg/dL)/40555 with HOMA-IR > 2.5 mol μU/mL as cut-off of abnormal value56.Blood samples were collected from all participants after having been instructed not to eat, drink or smoke. All patients reported no consumption of alcohol ever. A 10-cc sample of blood was drawn during days 2–6 of the menstrual cycles  in plain-top tubes for subsequent hormonal analysis. If amenorrhoea was present, this was performed after excluding a dominant follicle with ultrasound. Blood was analysed for free and total testosterone (FT and TT) , sex hormone-binding globulin , LH (units per L), FSH (units per L) and fasting blood glucose (mg/dL); fasting insulin (micro-units per mL) was detected by the glucose oxidase method , sex hormone binding globulin (SHBG), luteinising hormone (LH) and follicle-stimulating hormone (FSH). LH/FSH ratio was calculated for each subject; LH/FSH ratio >2 was considered abnormal. The LH and FSH were measured by electrochemiluminescence technique in a COBAS AutoAnalyzer using reagents manufactured by Roche Diagnostics; quality control was done by PreciControl 1 and 2, and then the mean LH/FSH ratio was obtained. Free androgen index (FAI) was calculated by [total testosterone] X 100 divided by [SHBG]. Normal insulin sensitivity was defined by fasting insulin levels <12 mU/mL. We also calculated indices of the homeostasis model assessment (HOMA-IR)57. In addition, blood samples of dehydroepiandrosterone sulfate (DHEAS) ug/dL and 17-hydroxyprogesterone (OHP) were also obtained with, normal values = 380 ug/dL. If values of DHEAS were <380 ug/dL, patients with apparent adrenal problems causing hyperandrogenism were excluded.In cases of fasting glucose consistent with impaired glucose tolerance (fasting glucose [FG] 110–125 mg/dL), a 75-g oral glucose tolerance test was performed; subjects with overt diabetes mellitus and impaired glucose tolerance were referred to a diabetes specialist. In addition, serum PRL (nomograms per mL), TSH (micro-units per mL) and 17α-hydroxyprogesterone  levels were examined in blood samples of women with oligomenorrhea. Normal values of 20–100 ng/dL  were accepted to exclude other causes of menstrual disorders58, i.e., either an ovary with ≥12 follicles measuring 2–9 mm in diameter or an ovary with increased volume (>10 cm3 without concomitant cysts). Ultrasound examination was performed by one investigator (MA) during the first 5 days of the menstrual cycle (the early follicular phase). The ultrasound assessments were undertaken trans-vaginally using a computed sonography system with a 7.0-MHz transducer. After identification of the ovaries, the size of the ovary was measured in three orthogonal planes. Ovarian volume was calculated using the formula for a prolate ellipsoid. The total number of follicles in each ovary was counted. Measurements of the largest and smallest follicles were taken in their maximum diameters and recorded in mm. Follicles were counted on the frozen images of two non-overlapping planes in the longitudinal section of each ovary.The revised Rotterdam criteria were used for the diagnosis of PCO on ultrasoundt-test was used for the comparison of continuous variables. Group means were compared using analysis of variance (ANOVA) with post hoc least squares means pair-wise comparisons . Statistical significance was considered when two-tailed P was ≤ 0.05.Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 20.0, for Windows . Data are presented as mean ± SD. When variables were significantly skewed, median and interquartile ranges were used. Categorical variables were analysed using Chi-square tests, normally distributed continuous variables using analysis of variance (ANOVA) and significantly skewed continuous variables were analysed using the Kruskal-Wallis test. Student’s


Tuberculosis/Human immunodeficiency virus (TB/HIV) co-infection is bidirectional and synergistic which mainly affects interventions that have been taken on the area. Tb patients co-infected with HIV have poorer treatment outcome as compared to non-co-infected patients. There is limited information regarding successful TB treatment outcomes and its associated factors; a reason that this study was planned to investigate.p < 0.05.An institution based cross sectional study was carried out from July 2010 to January 2016. Data were abstracted from patients’ medical chart using data abstraction format. The completeness of the data was checked and cleaned manually. Then, it was entered and analyzed by using SPSS version 20.0. Bi-variable and Multi-variable logistic regression model was fitted to identify factors associated with successful Tb treatment outcome. Significance was obtained through adjusted odds ratio with its 95% CI and a Successful TB treatment outcome among TB/HIV co-infected patients in Gondar University Hospital was 77.3% [95%CI 72.6–81.9]. Being residing in outside the Gondar town , having less than the mean baseline weight (<43.7 kg) at initiation of TB treatment , being in the bedridden condition , and experiencing anti-TB treatment side effect  were the factors that resulted the patient in treatment failure.Successful Tb treatment outcome among TB/HIV co-infected patients was lower than the target set by Global Plan to Stop TB 2011–2015. Strengthening collaborative TB/HIV management activities that would trace the identified factors shall be recommended to increase successful treatment outcome of TB. Despite various efforts made to prevent and/or control the disease, many countries have not yet achieved the TB control targets. Rather, it remains a major public health problem leading to mortality in high HIV- burden countries , 2. HIV Tuberculosis/HIV co-infection constitutes several problems including diagnostic and therapeutic challenges in the healthcare settings –7. It isth with an incidence rate of 379 cases of all forms of TB per 100,000 populations. Continuous tracing of TB treatment outcome, mainly in those TB/HIV co-infected patients, is essential in the area /d2]) assuming 95% confidence level of Z a/2 = 1.96, 5% margin of error, and proportion (p) of 70.9% according to the previous similar study from Tigray region [The study population was all TB/HIV co-infected patients who attended at the Gondar University Hospital. TB/HIV co-infected patients who were transferred out to other health institution during the study period were excluded. The necessary sample size (n) was computed by single population proportion formula   and WHO Unsuccessful/unfavorable/poor outcome was considered for TB patients resulted in treatment failure, default or death . PatientPatients with clinical and/or bacteriological signs of continued active disease or deterioration requiring a treatment change were considered as failed patients. Died patient is a patient who died for any reason during the course of treatment. A patient whose treatment outcome is unknown (including former “transfer out”) was considered as not evaluated patients. A Patient who smoked at time of TB diagnosis or had history of cigarette smoking were taken as smokers and a patient who had never smoked in his/her life , 16 wereFunctional status was determined based on WHO guideline as follows; (a) Working = able to perform usual work in or out of the house, harvest, go to school or, for children, normal activities or playing (b) Ambulatory = able to perform activities of daily living but not able to work or play, and (c) Bedridden = not able to perform activities of daily living. Tb treatment side effect was ascertained by assessing and/or following of the patients’ complain, and a comprehensive clinical history and additional medical exams along with different laboratory investigations including chemistry and hematocrit analysis.Socio-demography of the patient , concomitant condition , Biological factor (CD4+ Count), Patient Behavior (Smoking history), and medication related factor  were collected as an independent variables of the study.Data abstraction checklist was pre-tested at Felege Hiwot Referral Hospital, which provides similar services to the TB/HIV co-infected patients prior to the commencement of the actual data collection. Data were collected by the trained data collectors with close supervision and assistant of the investigators. Completeness of the data was checked, coded and entered into the computer using SPSS version 20 statistical software on a daily basis. Each entry was cross checked independently to ensure the quality of data.A total of 324 TB/HIV co-infected patients were primarily enrolled in the study. Of this figure, 308 patients fulfilled the inclusion criteria and were analyzed. Descriptive statistics (mean (SD), proportion) aimed to summarize patients’ characteristics across the outcome variables was used. Findings were described using words and tables. Association between successful TB treatment outcomes and each independent variable was analyzed using Bi-variable and Multi-variable logistic regression model.p-value less than 0.2 in the bi-variable binary logistic regression were entered to multivariable logistic regression model to identify the predictors of successful Tb treatment outcome. Association between outcome and predictor variables was calculated using Adjusted odds ratio at p-value <0.05 and 95% confidence interval. Assumption of goodness of the model was checked by Hosmer-lemeshow test (p = 0.828).The outcome was categorized as successful (cure + treatment completed) and unsuccessful  treatment outcomes , 17. AllEthical approval was obtained from the Ethical Clearance Committee of the School of Medicine, College of Medicine and Health Sciences, University of Gondar prior to the commencement of the study. Confidentiality of the participants’ information was maintained by giving participant’s code number and the data locked in the cupboard and computer with password.th), 97(31.5%) were daily laborer, and 264(85.7%) had no history of cigarette smoking  were male. The mean age of the respondents was 31.7 (SD ± 13.4) year. Two hundred and twenty nine (74.4%) study participants were residing in the Gondar town, and 206(66.9%) were ever married  during their visits of the health institution. One hundred thirty three (43.2%) had primary educational level (Grade 1 to 83 at initiation of their TB treatment. The mean baseline weight at entry of TB treatment was 43.7 kg. Six hundred sixty three (52.9%) of the study participants have been found to be on working functional status. Two hundred seventy four patients (88.9%) were on Co-trimoxazole Prophylactic Treatment (CPT), 188(61.0%) on ART, and 188(61.0%) were categorized as WHO clinical stage III during the initiation of their TB treatment. In addition, 231(75.0%) respondents had not history of TB treatment, 219(71.1%) had Pulmonary tuberculosis (PTB), and 290(94.2%) had no TB treatment side effects (Table One hundred and ninety five (63.3%) respondents had <200 CD4 cell/mmAs shown in Table P < 0.05).In the Multi-variable logistic regression analysis; residence, mean baseline weight (kg), functional status, and TB treatment side effect of the respondents were significantly associated with the successful TB treatment outcome . Being residing in the Gondar town, having baseline body weight above the mean, able to perform usual work in or out of the house, and being free of treatment side effects were found to be factors associated with successful TB treatment outcome. Thus, we recommended that strengthening the integration of TB/HIV collaborative activities could improve the treatment outcome. In addition, improvise means of TB patients’ follow up and tracing to keep them in contact with health professionals at service delivery point during treatment could increase the successfulness of TB treatment outcome.


Recent GWAS-associated studies reported that single nucleotide polymorphisms (SNPs) in ABCB1, TGFβ1, XRCC1 genes were associated with hepatitis A virus (HAV) infection, and variants of APOA4 and APOE genes were associated with and hepatitis E virus (HEV) infection in US population. However, the associations of these loci with HAV or HEV infection in Chinese Han population remain unclear.A total of 3082 Chinese Han persons were included in this study. Anti-HAV IgG and anti-HEV IgG were detected by enzyme-linked immunosorbent assay (ELISA). Genotypes in ABCB1, TGFβ1, XRCC1, APOA4 and APOE SNPs were determined by TaqMan MGB technology.P < 0.05). However, the effect direction was different with the previous US study. Rs1001581 A to G variation in XRCC1, which was not identified in US population, was significantly associated with the protection against HAV infection in our samples (P < 0.05). In addition, our results suggested that rs7412 C to T variation in APOE was significantly associated with lower risk of HEV infection in males  but not in females.In Chinese Han population, rs1045642 C to T variation in ABCB1 was significantly associated with the decreased risk of HAV infection  contains supplementary material, which is available to authorized users. Hepatitis A and E virus (HAV and HEV) infections are heavy public health problems in developed and developing countries. It is estimated that over ten millions people have been infected by these two viruses every year worldwide , 2. BothIn the past decade, Genome-wide association studies (GWAS) have been carried out rapidly and contributed to identify susceptible loci for many kinds of infectious diseases, such as malaria, tuberculosis, hepatitis B and C –7. In a In another study, Zhang et al. further reported that rs5110-C/A in APOA4 and rs7412-C/T in APOE were significantly associated with protection against HEV infection in non-Hispanic blacks in United States . Both APHowever, the associations of these loci with HAV or HEV infections have not been evaluated in other populations. Owing to its long history, large population, environmental pollution, and poor hygiene, both hepatitis A and E outbreaks and sporadic incidents are the major public health problems in China , 17. AddThis study was performed with 3082 Chinese Han persons from the Huai’an-09 Study, which is established in 2009 and is designed to investigate the health conditions of general populations in Huaian, China. Between April 2009 and September 2009, 3166 individuals (aged 30–75 yrs) were randomly selected from Huai’an city. All participants underwent questionnaire assessment, physical examination, and routine blood, urine, and biochemical tests at baseline without charge. All the doctors and nurses had rigorous unified training before they measured the anthropometric indices. Blood samples were obtained by venipuncture and stored at − 80 °C until further analysis.In the current study, we excluded 84 persons including 83 individuals with HBsAg positive, one person with anti-HCV IgG positive. None of participants tested for antibodies to human immunodeficiency virus. In addition, people with hepatic fibrosis, diabetes, renal inadequacy and cancer were excluded. Eventually, 3082 persons were finally included in this study.Both anti-HAV IgG and anti-HEV IgG were detected by enzyme-linked immunosorbent assay (ELISA) with commercial reagents purchased from Wantai Bio, Beijing, China. According to the manufacturer’s instructions, the sensitivity and specificity is 98% and 97% for the anti-HAV IgG detection, and 99% and 97% for anti-HEV IgG detection, respectively.2 > 0.8 with rs1799782 in Caucasian population) with HAV infections in the present study. Additionally, the genotypes of rs1045642 in ABCB1, rs1800469 in TGFB1, and two SNPs marginally associated with anti-HAV (rs2031920 in CYP2E1 and rs769214 in CAT) were selected to evaluation according to the findings of Zhang’s study [There were five SNPs have been reported to be associated with HAV infection in US GWAS studies . Because2 < 0.1) with rs405509 or rs769450 in Caucasian population, rs7412, rs405509 (MAF: 0.31) and rs769450 (MAF: 0.20) were selected to analysis in our present study.Rs5110 in APOA4 and rs7412 in APOE gene were reported to be associated with HEV infection in Zhang’s study. However, MAF of rs5110 in Chinese population (HapMap) was much lower (MAF = 0 for CHB and MAF = 0.023 for HCB). We selected rs1268354 in the present study because rs1268354 is the only polymorphism with MAF > 0.05 in APOA4 in Chinese population (MAF = 0.45). In addition, Zhang et al. suggested that there was a significant joint effect of rs7412 and rs429358 on HEV infection . ConsideProteinase K digestion and phenol-chloroform extraction were used to isolate genomic DNA from EDTA-treated blood samples. Genotyping was performed using TaqMan MGB technology and 7900HT Fast Real-Time PCR System . The commercial reagents including primers and probes were ordred from Applied BioSystems and Biosteed Biotechnologies , respectively  tests. The odds ratio (OR) and 95% confidence intervals (CI) were calculated by logistic regression (adjusted for age and gender) and used to test for the risk of associations. All of the statistical analyses were performed with SPSS version 17.0 . A two-tailed P < 0.05 was considered statistically significant.Fisher’s exact test was used to test for Hardy-Weinberg equilibrium (HWE). The genotype and allele distribution were analyzed using chi-squared . Among of them, 1299 males (78.49%) were anti-HAV IgG positive, which was significantly higher than those in the females  and 399 females (27.96%) were positive for anti-HEV IgG, respectively. There was not significant deference between males and females  and four major genotypes (1–4), respectively , 19. BotTo our knowledge, this is the first replication study to explore the associations between GWAS-associated SNPs and HAV or HEV infection in China. However, there are several general limitations should be considered. First, although the number of study participants met the requirement for analysis, independent replications in larger population should be conducted in future. Second, our study only sought to replicate the limited SNPs in a Chinese Han population because we felt such a replication would be a critical first step to understanding these results. Greater genome coverage and more informative markers including APOE isoforms are required in order to realize true genetic determinants of hepatitis A and E infections. Last, it is well known that HAV or HEV infections are significantly associated with environmental and social factors. Thus, gene-gene and gene-environment interaction on the risks of virus infection should be further discussed.Summary, our present study suggested that ABCB1 and XRCC1 genes variants were significantly associated with the lower risk of HAV infection. Additionally, Chinese Han males with rs7412 C to T variation in APOE are less prone to be infected by HEV. In order to further understand the effects of host genetic factors on HAV or HEV infection in different ethnic populations, more studies using a large-scale association analysis should be warranted in future.Additional file 1:Table S1. Information about primers and probes of selected SNPs. (XLSX 10 kb)Additional file 2:Table S2. Characteristics of selected SNPs. (DOCX 16 kb)Additional file 3:Table S3. Allele frequencies of selected SNPs in Chinese and US populations. (XLSX 13 kb)


This study aimed to establish an effective predictive nomogram for non-small cell lung cancer (NSCLC) patients with chronic hepatitis B viral (HBV) infection.The nomogram was based on a retrospective study of 230 NSCLC patients with chronic HBV infection. The predictive accuracy and discriminative ability of the nomogram were determined by a concordance index (C-index), calibration plot and decision curve analysis and were compared with the current tumor, node, and metastasis (TNM) staging system.P < 0.01], and the decision curve analyses showed that the nomogram model had a higher overall net benefit than did the TNM stage. Based on the total prognostic scores (TPS) of the nomogram, we further subdivided the study cohort into three groups: low risk (TPS ≤ 13.5), intermediate risk (13.5 < TPS ≤ 20.0) and high risk (TPS > 20.0).Independent factors derived from Kaplan–Meier analysis of the primary cohort to predict overall survival (OS) were all assembled into a Cox proportional hazards regression model to build the nomogram model. The final model included age, tumor size, TNM stage, treatment, apolipoprotein A-I, apolipoprotein B, glutamyl transpeptidase and lactate dehydrogenase. The calibration curve for the probability of OS showed that the nomogram-based predictions were in good agreement with the actual observations. The C-index of the model for predicting OS had a superior discrimination power compared with the TNM staging system [0.780 (95% CI 0.733–0.827) vs. 0.693 (95% CI 0.640–0.746), The proposed nomogram model resulted in more accurate prognostic prediction for NSCLC patients with chronic HBV infection. Lung cancer remains the most common cause of cancer deaths worldwide. The recent literature reported that 5-year survival rate of lung cancer was 18% . The lowChronic hepatitis B viral (HBV) infection is also a serious global public problem. Two billion people are estimated to be infected with HBV worldwide . In partNumerous studies have reported that many prognostic factors are correlated with the prognosis of NSCLC patients. The prognostic factors include liver function indicators (LFIs), such as aspartate aminotransferase (AST) , lactateThe risk of liver injury may increase when HBV infects patients. Most studies suggest that liver injury in viral hepatitis is not caused by the direct cytopathic effects of viruses but by the host immune response to viral proteins expressed by infected hepatocytes , which cNomogram is currently widely applied as graphical representations of complex mathematical formulas. They can integrate essential factors to build a statistical prognostic model for estimating prognosis in the outcomes of many cancers , 13. FurA retrospective observational study was performed including a total of 230 NSCLC patients with chronic HBV infection, and the patients first visited Sun Yat-sen University Cancer Center  between January 2008 and December 2010. The inclusion criteria were as follows: (1) patients with a confirmed pathological diagnosis of NSCLC; (2) patients who were positive for the hepatitis B surface antigen (HBsAg), excluding acute hepatitis; (3) patients without co-infection of other types of hepatitis viruses; (4) patients with complete clinical data; (5) patients without secondary carcinomas as assessed by clinical history, computed tomography (CT), ultrasonographic examination and routine laboratory tests; and (6) patients without liver fibrosis, steatosis, and cirrhosis as detected by CT or ultrasonographic examination.All the samples were collected at the time of diagnosis before any treatment. We obtained the patients’ clinicopathologic parameters including gender, age, family history, smoking history, body mass index (BMI), pathologic TNM stage , tumor shttp://www.researchdata.org.cn), with the approval RDD Number as RDDA2018000554.We randomly divided the patients into a primary cohort and a validation cohort. Computer-generated random numbers were used to assign 141 of the patients to the primary cohort and 89 patients to the validation cohort. The overall survival (OS) of the patients was recorded based on a follow-up clinical visit or a telephone call. The OS was calculated from the time of initial diagnosis until the time of death from any cause, or until the last follow-up. All the patients were followed up until death or January 2016, if still alive. The authenticity of this article has been validated by uploading the key raw data onto the Research Data Deposit public platform . HBsAg, HbsAb, HbeAg, HbeAB, and HbcAb were detected by enzyme-linked immunosorbent assay (ELISA) technology. The values of all the variables tested a few days before pretreatment were recorded. The SLR was defined as the serum AST level divided by the serum ALT level. The coefficient of variation for these methods over the range of measurements was < 5% as established by routine quality control procedures.http://www.r-project.org/). P values less than 0.05 were considered statistically significant.Categorical variables were classified based on clinical findings, and continuous variables were transformed into categorical variables based on cutoff points, which were determined by the minimum P value from log-rank ×2 statistics using the X-tile program . SurvivaThe study enrolled a total of 230 patients. We randomly divided the patients into a primary cohort and a validation cohort. The patients’ demographic and clinical characteristics are listed in Table P < 0.001), TNM stage (P < 0.001), tumor size (P = 0.001), treatment (P < 0.001), SLR (P = 0.044), APOAI (P < 0.001), APOB (P = 0.024), ALP (P = 0.018), GGT (P = 0.003) and LDH (P < 0.001) were significantly associated with OS in NSCLC patients with HBV infection.In the univariate analysis Table , Kaplan–The variables age, TNM stage, tumor size, treatment, SLR, APOAI, APOB, ALP, GGT and LDH were identified as predictors of OS in the univariate analysis and were entered into the Cox’s proportional hazards regression. The selection of the final model was performed using a backward step-down selection process with the Akaike information criterion (AIC). We selected the optimal model based on the smallest AIC. The factors in our final model included age, TNM stage, tumor size, treatment, APOAI, APOB, GGT and LDH, and the AIC of the final model was 559.41. The nomogram model was constructed based on the selected factors, and Fig. P < 0.01). This result was also confirmed in the validation cohort, where the C-index of the nomogram model  was higher than the C-index of the TNM staging system . Calibration curves at 1, 3 and 5 years were then used to assess the agreement between the predicted and actual outcomes .Next, we determined the cutoff values using the X-tile program by grouping the patients in the primary cohort evenly into the following 3 groups based on the predictions of the nomogram model: low-risk prognosis , intermediate-risk prognosis  and high-risk prognosis . The low-risk group had the highest probability of survival , followed by the intermediate-risk group with survival probabilities of 76.7, 37.2 and 14.0% for 1, 3 and 5 years, respectively. The high-risk group had survival probabilities of 45.8, 8.3 and 0% for 1, 3 and 5 years, respectively. The differences in survival could be used to discriminate these three groups   and oncoIn summary, we developed and validated an effective nomogram model predicting the 1-, 3- and 5-year OS in NSCLC patients with HBV infection. The proposed nomogram in this study showed a better level of discrimination and accuracy than the current AJCC TNM classification system. Furthermore, it could be useful for patient counseling and individualized prediction of survival for NSCLC patients with HBV infection.


Saudi women depend on food sources to maintain their serum 25(OH) D concentrations because covering by traditional clothing and time spent indoors limit their sun exposure. Little is known about vitamin D intake and its main food sources in Saudi Arabia. In addition, the association between vitamin D and calcium intake and bone mineral density (BMD) in young women is not well researched.  To assess the adequacy of vitamin D intake among Saudi women as compared to the estimated average requirements (EARs), to identify dietary vitamin D sources, to examine potential determinants of vitamin D intake, and to assess bone health and the association of calcium and vitamin D intake with BMD. n=102) at the lumbar spine and femur neck.  This cross-sectional study was conducted in 257 premenopausal women aged 20–50 years in Jeddah, Saudi Arabia. Dietary vitamin D and calcium were assessed by the Semiquantitative Food Frequency Questionnaire. BMD was measured using dual-energy X-ray absorptiometry (DXA) in a subset of women (p < 0.001). The prevalence of osteopenia was 33% in the lumbar spine and 30% in the femur neck. There was a significant positive association between calcium intake and BMD at the lumbar spine (p=0.043) after controlling for body mass index and energy intake. Vitamin D intake was not significantly different between women with low and normal bone mass.  Sixty-five percent of women were below the EAR for vitamin D, and 61% fell below the EAR for calcium. Dairy products, supplements, and fish contributed most to vitamin D intake. Increased age was an independent determinant of sufficient vitamin D intake ( Premenopausal women in Jeddah have insufficient vitamin D and calcium intakes. Public health strategies to improve nutrition in young women are needed, and expanding fortification programs to include all dairy products would be useful. Vitamin D is obtained through synthesis in the epidermis with exposure to ultraviolet (UVB) sunlight which converts 7-dehydrocholesterol to previtamin D3. It is naturally present in very few foods, mainly vitamin D3  from animal sources including oily fish, egg yolks, veal, beef, and liver –3. VitamSunlight exposure, rather than diet, has been reported as the main source of vitamin D for the majority of the population , 2. HoweFortification measures in Saudi Arabia are limited. Many Saudi dairy companies fortify milk and Laban (buttermilk) with vitamin D (400 IU/L). Fortification of other foods, such as cheese, cereal, and vegetable oils, is fairly low and variable in Saudi Arabia. Yet, even a national fortification program may not guarantee adequate vitamin D intake, particularly for at-risk populations with certain dietary patterns, such as low milk consumption . In addiOn the other hand, vitamin D and calcium are essential nutrients for maximizing peak bone and preventing bone loss, thus decreasing osteoporosis and the risk of fractures over the long term , both ofThus, the aim of this study was to assess the adequacy of vitamin D intake from food and supplements among premenopausal women in Jeddah as compared to the estimated average requirement (EAR) of 400 IU/day, to investigate the sources of vitamin D in their diet, and to examine potential determinants of vitamin D intake, including demographic factors. In addition, we evaluated the association between calcium intake from food and supplements, vitamin D intake from food and supplements, serum vitamin D levels, and serum parathyroid hormone levels with BMD in a subgroup of premenopausal women in Jeddah.n=257) was reached. Women were eligible for the study if they were citizens of Saudi aged 20 to 50 years. Women were excluded from the study if they were pregnant or lactating or postmenopausal (defined as amenorrhea for at least six months). Women with cancer, diabetes, hyperthyroidism or hypothyroidism, metabolic bone disease, malabsorption, and renal diseases, or those taking medications known to effect bone metabolism were also excluded from the study. To select participants for the DXA scan, each woman, chosen through the systematic sampling method described above, was asked to participate in this portion of the study until completion of the required sample for this subgroup (n=102) was achieved. Upon completion of the first visit, each woman was asked to return for a second visit, during which bone mineral density (BMD) measurements were taken via DXA scan.A cross-sectional study of premenopausal Saudi women aged 20 to 50 years was conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Saudi Arabia. Two hundred fifty-seven participants were selected from attendees of the primary care clinic at KAMC using systematic sampling. The sampling frame was derived from daily listing sheets, which include walk-in females who were seeking general outpatient services. A systematic sampling method was applied to the list of eligible women who were seen in the primary care clinic during the study period between December 2014 and April 2015. To implement the systematic sampling, a random number between one and three was generated each day. The random number determined which woman was chosen first from the list. Starting with the first woman chosen, then every third woman on the list was selected for potential inclusion in the sample. The exact process was repeated daily until the targeted sample size (2), normal (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). Waist circumference (centimeters) was measured. According to the International Diabetes Federation abdominal obesity cut points for people in the Middle East (≥80 cm in women), waist circumference was dichotomized into normal (<80 cm) and abdominal obesity (≥80 cm) [Weight and height were measured. Body Mass Index (BMI) was calculated by dividing the weight (kilograms) by the square of the height (meters). Standard BMI cut points according to the World Health Organization (WHO) criteria  were use(≥80 cm) .Demographic variables included age, marital status, occupation status, monthly household income divided into categories ):  , and resr=0.82, p < 0.001 and r=0.74, p < 0.001 for calcium and vitamin D, respectively) [Dietary intake of vitamin D per day was estimated using the Semiquantitative Food Frequency Questionnaire (SFFQ). The SFFQ used was a modified version of a previously validated questionnaire , which wctively) . The modctively)  and Arabctively)  that arectively)  were useThe selection of food items in the SFFQ was obtained and reviewed with the investigator using visual estimates (photographs) to help subjects estimate the average portion size. On the SFFQ, respondents were asked to record how often they consumed a single serving of each food listed during the previous month, with possible responses ranging from less than once per month to 2 or more per day. Vitamin D and calcium intakes were computed by multiplying the intake frequency by the nutrient content of the portion size of specific items. Intake of vitamin D and calcium was calculated by summing nutrient intake from diet and supplemental sources. Vitamin D and calcium intakes were examined in terms of absolute and energy-adjusted nutrients . Energy-adjusted values, termed “nutrient densities,” were computed as daily intake from diet and supplements divided by calories per day and multiplied by 1,000 , 23.The sun exposure recall questionnaire included details of the time of the day of sunlight exposure and length of exposure to sunlight during the previous month on weekdays and weekends. Cover status when they were outside in the public area was used to determine the area exposed to direct sunlight. Women were classified as either (1) covering the whole body including the face, (2) face covered but hands exposed, or (3) face and hands exposed. From the amount of clothing worn outside, the percentage of body surface area (BSA) exposed to sunlight was determined using an adjusted “rule of nines”  used in clinical practice to estimate the burnt area of the skin . A Sun ENonfasting venous blood samples were drawn for serum 25-hydroxyvitamin D 25(OH) D, parathyroid hormone (PTH), adjusted serum calcium (adCa), phosphate (P04), and alkaline phosphates (ALPs). Serum calcium was measured by Arsenazo III dye . PTH was measured by a two-step sandwich immunoassay for the quantitative determination of intact PTH in human serum using CMIA technology . The PTH assay showed a detection sensitivity of ≤3.0 pg/mL, intra-assay CV was 12.9–6.1%, and interassay CV was 3.0–6.4%. The reference range for PTH in the study laboratory is 24–114 pg/mL. 25(OH) D in serum was determined by using a delayed one-step chemiluminescent microparticle immunoassay (CMIA) . The laboratory undertaking the testing is a participant in the proficiency accuracy-based vitamin D since 2012. Intra-assay 25(OH) D coefficient of variation (CV) from daily quality control was 1.4–3.7%, and interassay CV was 2.6–4.6%. The fully automated architect assay is designed to have an imprecision of ≤10%.The serum samples were taken in the laboratory in the primary care clinic; after blood collections, the samples were left for 10 min for clotting and then immediately centrifuged at 3000 rpm for 10 min. Then, the samples were aliquoted and frozen at −20°C until further analysis. All analyses were performed in the Pathology Laboratory at KAMC. Baseline serum 25(OH) D levels were classified into two categories according to the Institute of Medicine and WHO , 26: vitBone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DXA)  in a subgroup of 102 women at the lumbar spine (L1 to L4) and the neck of the femur. The precision of the measurements was 1.0–1.2% and 1.1–2.2% in the lumbar spine and the neck of the femur, respectively. DXA scans were performed in the Department of Radiology at KAMC. The BMD values at the hip were compared with peak bone mass for Caucasian female normative database from the National Health and Nutrition Examination Survey NHANES III data, as recommended by the International Society for Clinical Densitometry . In addiThe research protocol and the consent documents were approved by the Ethics Committee of the Institutional Review Board (IRB) at the University of Maryland, College Park (no. 539327-3), and IRB at King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia (no. RJ14/015/J). Participants were informed about the aim of the study, the clinical tests, and the type of interview.f2 = 0.10) with power = 0.80, given the following testing parameters: a multiple forward stepwise regression with 16 predictors and conducted at α = 0.05. The analysis indicated that a sample size of 207 would detect a small effect given these parameters. The power analysis was conducted with G∗Power 3.1 software package [An a priori power analysis was conducted to determine the number of participants required to detect a small effect  of 400 IU/day and 800 mg/day, respectively. Percentages values between groups were compared using the chi-square tests. Kruskal–Wallis tests were performed to test for differences in intakes of vitamin D and calcium among age groups. Spearman rank correlations were used to assess the strength of the relationship of BMD at the lumbar spine and the femur neck with variables such as BMI, parity, and smoking, variables that were thought to influence BMD. Statistical significance was considered at p value < 0.05.Data were analyzed using the Statistical Package for Social Science (SPSS) software version 22.0 . The characteristics of the study population were described through frequencies and percentages for categorical variables. For continuous variables, medians and interquartile ranges (IQRs) were used to summarize nonnormal data, and means ± standard deviations (SDs) were used to summarize data with normal distribution. The 257 women were divided into two groups: 167 women with insufficient vitamin D intake from food and supplement (ISVDI) (<400 IU/day) and 90 women with sufficient vitamin D intake from food and supplement (SVDI) (≥400 IU/day). Median anthropometric, dietary, and biochemical values between groups were compared using nonparametric Mann–Whitney α = 0.05, and the condition for predictor removal at each iteration was α = 0.10. In these analyses, the dependent variable vitamin D intake was log transformed since it was not normally distributed. The following independent variables were considered for entry in the stepwise regression: age, years of formal education, the number of children, income level, occupation, type of residence, marital status, and taken vitamin D supplement during the breastfeeding period. Note that age, years of formal education, and the number of children were continuous variables, and the remaining variables were categorical variables. Additionally, in order to keep the sample size as balanced as possible for each level of the categorical variables, some regrouping was implemented. The new categories for each categorical variable are as follows: household income level (less than 15000 versus 15000 and above), occupation (employed versus not employed), type of residence (owned versus not owned), marital status (married versus unmarried (single/separated/divorced)), and taken vitamin D supplement during the breastfeeding period (yes versus no). The assumptions for the regression model were evaluated using normal quantile-quantile (QQ) plots of the standardized residuals  and scatter plots with standardized residuals versus standardized predicted values (the assumption of homogeneous error variance). The assumptions of the regression model were satisfied.The forward stepwise multiple linear regression was conducted in order to investigate the relationship between the dependent variable, vitamin D intake (from food and supplement), and the independent variables, the sociodemographic and parity variables. The condition for entry at each iteration was p value < 0.05. The Hosmer–Lemeshow goodness-of-fit test was used to determine the model adequacy, and p value > 0.05 indicates good model fit. In this analysis, 88 subjects were used for logistic regression, after excluding subjects with missing values in the study variables.Multiple logistic regressions were implemented to identify and analyze factors that influence BMD markers. Hence, the two dependent variables were BMD at the lumbar spine and BMD at the femur neck, both being binary response variables . The independent variables being considered included vitamin D intake, calcium intake, serum 25(OH) D levels, and serum PTH level. The following variables served as possible confounding variables: BMI and energy intake. The Wald test was used to determine if an effect was statistically significant. Statistical significance was considered at p < 0.001).Demographic, anthropometric, dietary intake, and biochemical characteristics of the 257 premenopausal Saudi women aged 20–50 years, who were divided into two groups—insufficient vitamin D intake (ISVDI) (<400 IU/day) and sufficient vitamin D intake (SVDI) (≥400 IU/day)—are presented in p=0.52) (p=0.029) or 41–50 years (p < 0.001). Additionally, a higher proportion of young women aged 20–30 years ate less than the EAR for vitamin D . For calcium intake, median daily intake from diet and supplement was significantly lower (p=0.005) than the EAR (p < 0.015). The median intake of calcium was significantly higher in women aged 41–50 years when compared to the other two younger age groups. A higher proportion of young women aged 20–30 and 31–40 years ate less than the EAR for calcium . The intakes of vitamin D and calcium were found to be strongly correlated  in this study population.The median daily intakes of vitamin D and calcium from all sources are presented in p=0.52) . Approxip=0.52) . Thirty- the EAR . ApproxiThe sources of vitamin D  in 20- to 50-year-old women are presented in r2=0.27, p < 0.001), marital status , gravidity , parity , and BMI . The results of the forward stepwise regression suggest that there was a statistically significant relationship between log-transformed vitamin D intake (diet and supplement) and age   . The R2 Out of 257 premenopausal women, 102 women agreed to undergo DXA scan. Median serum 25(OH) D levels were low (median 40 nmol/L). Of the women in this analysis, there was a high proportion, 77.5% of the women, with vitamin D deficiency (25(OH) D < 50 nmol/L), and of these, approximately 14% had severe vitamin D deficiency (25(OH) D < 25 nmol/L). Elevated PTH was seen in 16% (14/88) of the women ; among those with elevated PTH, 78.6% (11/14) women had vitamin D deficiency (25(OH) D < 50 nmol/L). The prevalence of osteopenia was 33% and 30% in the lumbar spine and the neck of the femur, respectively. Of the 102 women, 55 (54%) women did not suffer from osteopenia in both sites, whereas 18 (17.6%) women had osteopenia in both sites. The remaining 29 women (28.4%) had osteopenia in one of the sites. Approximately 45.5% (5/11) of our participants who experienced vitamin D deficiency and elevated PTH had lower BMD at either site.r2=0.27, p=0.006 at the lumbar spine and r2=0.34, p < 0.001 at the femoral neck). Similarly, there was a significant positive correlation between BMD at the lumbar spine and at the femoral neck and weight, and BMI, . No significant association was found between BMD and age, sun exposure, physical activity, parity, and smoking. χ2=4.100, p=0.043). The odds ratio was 1.002 with 95% confidence = . There was a statistically significant relationship between BMD at the lumbar spine and BMI =6.06, p=0.014). The odds ratio was 1.117 with 95% confidence = . There was a statistically significant relationship between BMD classification at the lumbar spine and energy intake =7.362, p=0.007). The odds ratio was 0.997 with 95% confidence = . There was no statistically significant relationship between BMD classification at the lumbar spine and serum 25(OH) D, serum PTH, and vitamin D intake. At the femur neck, there was no statistically significant relationship between BMD classification and calcium intake, serum 25(OH) D, serum PTH, and vitamin D intake.In univariate analysis (Spearman correlation), the measures of BMD at the lumbar spine and the femoral neck showed significant positive relationship with anthropometric measurements. There was a significant positive correlation between height and BMD , Alhaddad et al. reported a mean dietary intake of 187 IU/day of vitamin D, which was insufficient to meet bodily requirements [n=214, aged 20–50 years) was 89.0 IU/day from food sources [The results of the current study showed that this sample of premenopausal women (aged 20–50 years) in Jeddah did not consume sufficient amounts of dietary vitamin D and calcium to meet the EAR for this age group. The low vitamin D intake observed in the present study is consistent with that which has been previously reported in the Middle East. In a study of Bahraini women (irements . Productn=96) of the women took vitamin D supplements during the last 30 days; of these, 52% (n=50) took single or multiple high doses, ranging from 15,000 to 50,000 IU. Approximately 30% (n=29) of the women took high-dose vitamin D2 and 22% (n=21) took high-dose vitamin D3, while the remaining 48% (n=46) of the women took vitamin D3 alone or in combination with calcium or other multivitamins that contained 400–4000 IU vitamin D3 per daily dose.In analyzing the various vitamin D sources, we found that women have a high consumption rate of fortified dairy products, which explains the importance of dairy products, particularly Laban and yogurt, as major sources of vitamin D. In addition, vitamin D supplements and canned fish, such as tuna, are considered to be good sources of this vitamin among women in Jeddah. An international comparison of vitamin D intake and its main sources of published information with regard to Australia, Japan, Norway, Lebanon, Taiwan, the US, and the UK, along with the results of the current study, are summarized in p < 0.001). Some studies have reported that participants' vitamin D intake is highly correlated with their serum 25(OH) D concentrations, and that this relationship may become stronger as the influence of solar ultraviolet B radiation weakens, particularly among people with limited sun exposure [r2=0.60, p < 0.001). Furthermore, Saudi women are dependent on food sources, rather than sun exposure, to maintain their serum 25(OH) D concentrations. This is partly because their fully covering traditional clothing limits exposure to the sun and partly due to the fact that they tend to spend more time indoors than outdoors because of the hot climatic conditions that prevail for most of the year.Vitamin D intake from food and supplements was associated with improved vitamin D status among women in the present study. Women whose vitamin D intake was below the EAR had a significantly higher percentage (95%) of vitamin D deficiency than those whose intake was above the EAR . In addition, 51% of the women who took a vitamin D supplement achieved a sufficient serum vitamin D level (25(OH) D ≥ 50 nmol/L), compared to 4.5% of the women who did not take a supplement (p < 0.001). Therefore, it is important to consider supplementation as an effective approach in helping to ensure sufficient vitamin D intake and to address vitamin D deficiency among women in Jeddah.Sufficient vitamin D intake among premenopausal women in Jeddah is unlikely to be achieved through dietary sources alone. Although vitamin D-fortified food may help to maintain vitamin D status in the general population, it may not be effective in correcting vitamin D deficiency in at-risk groups . In 2014p=0.04), and a higher consumption of vitamin D-containing supplements . A high prevalence of vitamin D deficiency was also observed in young women, compared to middle-aged women . The results of the present study suggest that young women at greatest risk of vitamin D deficiency were consuming the lowest amount of vitamin D from dietary and supplementary sources, which confirms the results of previous reports. In a study conducted in healthy young Canadian women , Gozdzik et al. underlined the fact that vitamin D intake was low among those who were at greatest risk of vitamin D insufficiency (25(OH) D < 75 nmol/L) [Multiple linear regression analysis showed that only age was an independent predictor of vitamin D intake in premenopausal women in Jeddah. Previous studies on this topic are limited; none have investigated the demographic determinants of vitamin D intake, particularly among nonpregnant women. A recent study conducted in 68,447 pregnant Danish women found a lower level of sufficient vitamin D intake from diet and supplements, suggesting that young women may be less conscious of health matters compared to older women . In the  nmol/L) . In the p=0.02), which may explain the higher serum 25(OH) D concentrations that were found in women with high household income compared to those with low household income (median 25(OH) D: 38.1 nmol/L versus 33.2 nmol/L, p=0.035). This relationship has also been previously found. McCormack et al. investigated the prevalence of vitamin D supplement use in Canadians aged 45 years and over who participated in the Healthy Aging module of the Canadian Community Health Survey from 2008 to 2009 [In the bivariate analyses, being married and multiparty was positively associated with vitamin D intake. Our finding is inconsistent with the results of a previous study conducted in a Danish birth cohort , which sn=267) in Makkah [n=267, aged 17–25 years) in Makkah was 559.3 ± 32.2, with approximately 86.1% of the sample consuming less than 800 mg/day of calcium. Different types of dietary assessment methods may explain the observed differences between our study and the one conducted in Makkah [The prevalence of osteopenia found in the present study is in accordance with the findings of other studies that were conducted in Saudi Arabia. For example, Youssef found that the prevalence of osteopenia was 39.7% in female students . The association between PTH and BMD has not been consistently observed. Some studies have shown that elevated serum PTH levels are significantly associated with lower BMD [A low serum 25(OH) D concentration is considered to be an important risk factor for low BMD, and previous studies have shown positive correlations between serum 25(OH) D and BMD at the lumbar spine and at the neck of femur in premenopausal women . Howeverower BMD , while oower BMD . In the ower BMD . PTH maiower BMD . Body weower BMD , 43, 48.The present study provides new insights regarding daily vitamin D intake and examined the food sources that make the biggest contribution among premenopausal women in Jeddah and the subgroup most vulnerable to insufficient vitamin D intake. In addition, this study is the first assessment of dietary intake of vitamin D and calcium among premenopausal women in Jeddah and its association with the bone health parameter, BMD. However, we must consider its limitations. First, SFFQ may not be the most accurate tool for use in the assessment of dietary sufficiency; thus, dietary vitamin D and calcium intake may be subject to measurement error. However, we attempted to minimize this error by using an interviewer to administer the questionnaire to help participants to accurately estimate portion sizes, rather than using a self-reported questionnaire. Second, the use of Caucasian normative data for peak adult bone mass may have led to overdiagnosis of the prevalence of osteopenia. Standardization of BMD by DXA to a database that is culturally specific for Saudi Arabia is necessary and recommended to ensure reliable interpretation of the individual DXA data and to capture those women at risk. Third, although the participants included in the present study were young and healthy, our results are limited to premenopausal women attending the primary health center at King Abdulaziz Medical City in Jeddah and not to all women residing in Jeddah or in other regions of Saudi Arabia.Insufficient intake of vitamin D and calcium is a growing concern for premenopausal women in Jeddah. Our data indicated that vitamin D intake was particularly low among young women who were at greatest risk of vitamin D deficiency. This study supports the call for intense public health strategies to improve nutrition among young women. Such strategies should start in adolescence, before peak bone mass is reached, to help provide diets rich in calcium and vitamin D and promote physical activity. Dairy products provide the most calcium and vitamin D in the average diet; it is important for girls to meet the recommended intake of dairy products during peak height velocity . We sugg


Group Dex: received dexmedetomidine loading dose 1 mcg/kg IV over 10 min followed by infusion of 0.2–0.7 mcg/kg/hr; Group KFL: received ketofol as an initial bolus dose 500 mcg/kg IV (ketamine/propofol 1 : 1) and maintenance dose of 5–10 mcg/kg/min. Sedation level (Ramsay sedation score), bispectral index (BIS), duration of mechanical ventilation, surgical intensive care unit (SICU) stay, and mean time to extubation were evaluated. Complications  and number of patients requiring reintubation were recorded. There was a statistically significant difference between the two groups in BIS at the third hour only . Duration of mechanical ventilation, SICU stay, and extubation time showed no statistically significant differences. No complications were recorded in both groups. Thus, dexmedetomidine was associated with lesser duration of mechanical ventilation and time to extubation than ketofol, but these differences were not statistically significant.Patients with sleep apnea are prone to postoperative respiratory complications, requiring restriction of sedatives during perioperative care. We performed a prospective randomized study on 24 patients with obstructive sleep apnea (OSA) who underwent elective surgery under general anesthesia. The patients were equally divided into two groups:  Obstructive sleep apnea (OSA) is a common condition  and is cα2-adrenoreceptor agonist; it has analgesic and sedative properties and is associated with limited respiratory depression [Patients with OSA have increased incidence of perioperative complications ; they arpression –9. Propopression . Ketaminpression , amnesiapression . Its usepression .Ketofol, which is a mixture of ketamine and propofol in a single syringe, has been shown to be effective in the operating theater and in day surgeries , 15. It No previous reports have compared the efficacy of dexmedetomidine and ketofol for postoperative sedation of mechanically ventilated patients with OSA. In this study, we compare the efficacy of dexmedetomidine and ketofol for postoperative sedation of mechanically ventilated patients with OSA in terms of sedation level, duration of mechanical ventilation, time of extubation, duration of surgical intensive care unit (SICU) stay, and occurrence of complications.ISRCTN56992547).This single-center randomized study was conducted in the SICU of Benisuef University Hospital. We obtained approval from the ethics committee of the institution (The FM-BSU REC). The study was registered at ISRCTN  with OSA requiring postoperative short-term sedation and mechanical ventilation (less than 12 hours).Requirement for prolonged sedation and mechanical ventilation (more than 12 hours)EpilepsyKnown allergies to the drugs being studiedSevere hepatic, renal, or central nervous system involvement, significant cardiac diseases, or arrhythmiasPregnancyIntake of other sedatives and anticonvulsant drugsIntraoperative analgesia was maintained in all patients with fentanyl 1 mcg/kg, followed by infusion of 1-2 mcg/kg/h; the administration was ceased at the end of the operation.On arrival to the SICU, the patients were connected to the mechanical ventilator; complete monitoring was performed using ECG, pulse oximetry, noninvasive and invasive arterial blood pressure measurement, and capnography. Bispectral index (BIS) electrodes were applied on the forehead. A baseline 12-lead ECG, chest radiograph, ABGs, and CBC were obtained, and biochemical tests were performed.Group Dex comprised twelve patients receiving a loading dose infusion of dexmedetomidine  1 mcg/kg IV over 10 min, followed by infusion of 0.2–0.7 mcg/kg/hr [Group KFL comprised twelve patients receiving ketofol as an initial bolus dose 500 mcg/kg IV ) with 8 ml ketamine (50 mg/ml) and 2 ml dextrose 5% , followed by infusion of 5–10 mcg/kg/min [Patients were randomly allocated into two groups by a sealed opaque envelop technique: cg/kg/hr . Group Kg/kg/min .The degree of sedation was measured hourly using the Ramsay sedation score (RSS). In both groups, the target was to achieve and maintain RSS of 4 or 5.Patient is anxious and agitated or restless, or both.Patient is cooperative, oriented, and tranquil.Patient responds to commands only.Patient exhibits brisk response to light glabellar tap or loud auditory stimulus.Patient exhibits a sluggish response.Patient exhibits no response .Sedation level description is as follows:2, and end-tidal CO2, which were continuously monitored and recorded at baseline (after admission to the SICU), at 1 hour and 3 hours after the start of sedation, and then every 3 hours; (3) sedation level: RSS was recorded at baseline, at 1 hour and 3 hours after the start of sedation, and then every three hours; (4) BIS was recorded at baseline, at 1 hour and three hours after the start of sedation, and then every three hours; (5) duration of mechanical ventilation, and stay in the SICU (hours) (secondary outcome); (6) mean time to extubation (the time of discontinuation of sedative to extubation in minutes) (primary outcome); (7) behavioral pain scale for pain assessment recorded at baseline, at 1 hour, and 3 hours after the start of sedation, and then every 3 hours  release 22 for Microsoft Windows. Data were statistically described in terms of mean ± standard deviation (±SD), median and range, or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using the Mann–Whitney U test for independent samples. For comparing categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency is less than 5. p values less than 0.05 were considered statistically significant.After a pilot study with three patients in each group, the mean ± SD of extubation time in dexmedetomidine treated group was 32.3 ± 2.1 minutes, while in ketofol group was 39 ± 2.2 minutes. Accordingly, we calculated that the minimum proper sample size was 10 participants in each arm to be able to detect a real difference of 13.2 minutes with 95% power at Group DEX than Group KFL at 1, 3, 6, 9, 12, and 18 hours   . No stat= 0.036) . The dur= 0.036) , and len= 0.036)  was lowefference . No hypoThe results of the present study showed that both dexmedetomidine and ketofol were effective for sedation of postoperative mechanically ventilated patients with obstructive sleep apnea and provided hemodynamic stability without complications.Obstructive sleep apnea is characterized by periodic, partial, or complete obstruction of the upper airway, resulting in the disruption of sleep and hypoxemia .Patients with OSA are prone to postoperative respiratory problems after general anesthesia , 25.Sedation and analgesia used in critical care units provide patients with comfort and safety .Dexmedetomidine, an alpha-2 agonist, may reduce the duration of mechanical ventilation ; it is aPropofol and ketamine, when used in combination, provided effective sedation for spinal anesthesia and cardiovascular procedures ; it has Xu et al.  in theirEremenko and Chemova  comparedPaliwal et al.  showed aA study by Srivastava et al.  reportedElbaradei et al.  showed tIn our study, ketofol was used for short-term sedation with no complications reported; similarly, Hamimy et al. . concludDexmedetomidine was associated with lower duration of mechanical ventilation and less time for extubation than ketofol for sedation of postoperative mechanically ventilated patients with obstructive sleep apnea, but these differences were not statistically significant. Both provided hemodynamic stability without complications.


However, presentation of regulation values showed a weak but significantly positive correlation with excessive intake of tuna-type fish (odds ratio: 2.95 (0.93–9.32), p < 0.10). Presenting the information on regulation values increases sense of safety; however, it may also lead to excessive intake.Risk communication aims to promote health and understanding through information exchange; however, explanations regarding the basis of regulation values for the public are insufficient. Moreover, it is unclear how information presentation affects the public’s sense of safety and their consumption intentions. We first investigated the relationship between perception of mercury-risk in fish and shellfish and individual attributes and knowledge. We then examined how presenting information on regulation values and primary factors regarding perception affected sense of safety toward regulations and food-consumption intentions. An online survey was conducted with Japanese individuals (N = 1148). Respondents were randomly assigned to one of three groups based on the presentation level of regulation values. People who frequently consumed tuna had a high perception of dread risk of mercury. This suggests that the dread risk perception of mercury does not determine tuna-type consumption behavior; rather, individuals’ consumption behavior determines dread risk perception of mercury. Among those with high tuna-type consumption, those receiving information that a safety factor of 10 times had been considered showed a significantly greater sense of safety than did the group that was not presented with information on regulation values : 2.04 (1.18–3.53),  When food risks are obvious, individuals decide to consume or avoid high-risk foods based on society’s regulation values. However, in general, since various experts’ judgments can determine food regulation values, the public finds this decision-making process confusing . In partThe U.S. National Research Council defines risk communication as “an interactive process of exchange of information and opinion among individuals, groups, and institutions” and states that “risk communication is successful to the extent that it raises the level of understanding of relevant issues or actions and satisfies those involved that they are adequately informed within the limits of available knowledge” . The FooRisk acceptance is governed by perceptions of risk, benefit, and trust , and risThis study addressed the risk of mercury in fish and shellfish. Exposure to methylmercury affects the central nervous system and has an adverse impact on developing fetuses ,15; therSince 2003 (revised in 2010), the Japanese government has provided advice for pregnant women on the number of times they could consume specific types of fish and shellfish  . The U.SFirst, we examined the association between risk perception of mercury and knowledge and individual attributes including sex, age, beliefs regarding fish and shellfish, and consumption frequency, and identified these perceptions’ primary underlying factors. Subsequently, we quantitatively examined how presentation of information on regulation values and these perception factors affected sense of safety regarding regulation values for fish and shellfish and food-consumption intention. This novel study, using mercury in fish and shellfish as an example, is the first to examine the impact of presenting evidence for regulation values on people’s sense of safety and food-consumption intentions.Ethical approval for the study was granted by the Fukushima Medical University Ethics Committee .An online survey was conducted from December 2–4, 2015. Participants were individuals aged 20–69, from across Japan who had registered with the Intage Research Inc., one of the largest survey companies in Japan with 1.32 million panelists. In the online survey, the company set up target number of participants, grouped according to sex, age, and residential area. They then asked registered members to respond to the questionnaires until this target number of participants was achieved. The targets were selected for consistency with actual composition ratios for age , sex, and residential area (10 areas). Elderly individuals aged 70 years or older, who may have been unfamiliar with online surveys, were excluded. The company also adjusted response time to “within a day” to collect well-balanced data from participants throughout the collection period to reduce selection bias. Based on information on regulation values, the company assigned one of three conditions to participants before the questionnaire  to avoid potential self-selection bias.There were no missing data in the surveys. Responses were excluded in the case of inconsistencies in sex and age in Intage Research Inc.’s registration information and responses (± 1-year age difference was accepted), short response time, and multiple responses from the same IP address. Intage Research Inc. managed panelist information such as confirming participants’ location by sending a postcard to the registered address and eliminating inappropriate panelists. Respondents were encouraged to answer the survey by awarding points that could be exchanged for cash, Internet points, or gift certificates. The characteristics and advantages of the online survey are described in previous reports ,21.In total, data of 1148 participants were collected: 367 did not receive information on regulation values (A1), 387 were presented evidence based on epidemiological study findings (A2), and 394 were presented evidence stating that, as per epidemiological studies, health impacts are 10 times less than LOAEL (A3).science course, science course chosen from between science course and humanities course, neither, humanities course chosen from between science course and humanities course, or humanities course); frequency of fish and shellfish consumption ; how often they currently eat tuna-type fish ; and general beliefs regarding fish and shellfish , delicious (taste-view), and reasonably priced (availability-view)), scored on a 5-point Likert scale ranging from 5 (strongly agree) to 1   . These qstrongly agree to 1: do not agree at all  may adversely affect the fetus. In Japan, guidelines are given to pregnant women to limit the number of times they consume some specific types of fish and shellfish.”We asked participants whether they knew this information, since an association between knowledge and risk perception has been previously reported –26. Subs“In Japan, regulation values are set for mercury in fish and shellfish. Mercury exists not only from artificial origin but also naturally, and regulation values are determined without distinction between artificial and natural mercury. Some specific types of fish and shellfish contain trace amounts of naturally derived mercury that is higher than regulation values. These types of fish and shellfish are excluded from these regulations. As stated previously, the government gives guidelines for pregnant women to limit the number of times they eat some of these types of fish and shellfish.”Scombrops gilberti.We also presented current Japanese guidelines for pregnant women on limiting the consumption amount of fish and shellfish : ≤ once very safe to 1: not safe at all). Women who were not currently pregnant were asked, “If you were pregnant, how often could you eat tuna-type fish in total  without concern?” . The data of each participant are shown in In addition, we manipulated the presentation of information on regulation values . For theOccupation, educational background, and science- and humanities-courses were grouped following a previous study . Occupatnearly every day, 5.5 for 5–6 times per week, 4 for 4 times per week, 3 for 3 times per week, 2 for twice per week, 1 for once per week, 0.5 for less than once per week, and 0 for do not eat.Current consumption frequency for fish and shellfish and tuna-type fish were classified as follows: 7 for GFI = 0.921, AGFI = 0.830, CFI = 0.720, RMSEA = 0.157. Therefore, we performed an exploratory factor analysis based on Niiyama’s question items using the maximum-likelihood method and Promax rotation. We extracted two factors based on a parallel analysis [p < 0.01. Cronbach’s α for three and four representative items in Factor 1 and Factor 2 was 0.733 and 0.608, respectively. Therefore, the result of the factor analysis was considered reliable.To evaluate risk perception of mercury in fish and shellfish, we separately conducted confirmatory factor analyses using Slovic’s  and Niiyanalysis , scree tt-test for 2 groups and an analysis of variance using Tukey-Kramer as a post-hoc test for 3 or more. To demonstrate a causal relationship between risk perception and consumption frequency or general beliefs regarding fish and shellfish, Pearson’s correlation coefficients were first estimated among factor scores and between factor scores and current consumption frequency for fish and shellfish and tuna-type fish and beliefs regarding fish and shellfish. After we confirmed the causal relationship between them based on the results (see details in “p < 0.05) were added and insignificant variables (p > 0.10) were removed.The difference in factor scores for risk perception among individual attributes were determined by a A logistic regression analysis was performed to evaluate the impact of information on regulation values and primary risk perception factors on the sense of safety regarding regulation values for fish and shellfish and food-consumption intention. The analysis of sense of safety involved a multivariate ordered logistic regression analysis. For the analysis on food-consumption intention , a binomial logistic regression analysis was used. Considering consumption guidelines for pregnant women in Japan, we used response results for tuna-type consumption frequency if the participant were pregnant, and set excessive avoidance at < once per week and excessive intake at ≥ 3 times per week. Regarding explanatory variables, in addition to Model 1 , the Model 2 analysis was performed using information on regulation values and variables that showed significant association in the multiple regression analysis described above.Since the group with high tuna-type consumption frequency (≥ once per week) is assumed to have a high risk of mercury exposure, the above analysis targeted not only all respondents , but also the group with current high tuna-type consumption frequency. In the multiple regression and logistic regression analyses, we created dummy variables for each individual attribute (except current consumption frequency for fish and shellfish and tuna-type fish and beliefs regarding fish and shellfish), knowledge of consumption guidelines, and information on regulation values. All variance inflation factors of explanatory variables used in the multiple regression and logistic regression analyses were 2.71 or less. Since they were less than 10, multicollinearity was not a concern. IBM SPSS Version 22, 24 and Amos version 24 were used for the analysis.2 = 428.68, df = 43, p < 0.01; GFI = 0.932, AGFI = 0.895, CFI = 0.875, RMSEA = 0.088. The arithmetic mean ± standard deviation (SD) of factors scores in dread and unknown risk were 0 ± 0.92 and 0 ± 0.79, respectively. Two factors were extracted for risk perception using Niiyama’s [In this study, the confirmatory factor analysis for Slocvic’s  model waiiyama’s  items  out of 565 participants (who were currently not pregnant women) demonstrated excessive avoidance. Similarly, the percentage of excessive intake was 4.2%.Women who believed that they would eat tuna-type fish ≥ 3 times per week without concern if they were pregnant were minor.We evaluated the effect of information presentation of the basis of regulation values and the primary factors of risk perception (as mentioned in “Factors of Risk Perception of Mercury”) on sense of safety regarding mercury regulations for fish and shellfish as well as tuna-type consumption intentions using a logistic regression analysis . When wep < 0.10, where adjusted OR (95% CI) was 2.95 (0.93–9.32)). Although no significant association was seen in Model 2, positive directivities were observed for excessive intake with presenting information on regulation values: adjusted ORs (95% CI) were 1.77 (0.48–6.60) for A2 and 2.69 (0.78–9.22) for A3.For excessive avoidance, significant negative associations were observed with tuna-type consumption frequency: adjusted OR (95% CI) was 0.51 (0.39–0.66) (Model 2). Availability-view also showed a weak but significant association: 0.83 (0.67–1.04). For excessive avoidance, no significant association was seen with presenting information on regulation values in either model. For excessive intake, significant positive associations were seen for tuna-type consumption frequency and availability-view: adjusted OR (95% CI) was 2.06 (1.54–2.76) and 2.08 (1.21–3.55), respectively (Model 2). In Model 1, a weak but significant positive association was found when presenting the basis of regulatory values (A3 group) : 0.63 (0.39–1.01) for Model 2). Regarding excessive avoidance, a significant positive association with presence of spouse was observed in terms of adjusted OR (95% CI): 2.34 (1.03–5.34) for Model 2. No significant association was observed in either model for presentation of information on regulation values. For excessive intake, a significant positive association was observed with tuna-type consumption frequency and availability-view (adjusted ORs (95% CI): 1.68 (1.16–2.43) and 2.50 (1.18–5.29), respectively; Model 2). Information on regulation values was not significantly associated with these consumption behaviors in either model.When targeting groups that ingest tuna at a high frequency, in both models, significant positive associations were seen between sense of safety and information presentation based on regulation values (A3) in terms of adjusted ORs (95% CI): 2.04 (1.18–3.53) for Model 1 and 2.04 (1.16–3.57) for Model 2. In Model 2, health-view showed a significantly positive association: 1.56 (1.09–2.23). People with a spouse had a weak but significantly lower sense of safety : 2.04 (1.18–3.53)). This suggests that presenting information on regulation values increases the sense of safety among those with high tuna-type consumption. Since the group with high tuna-type consumption is equivalent to a mercury high-risk group and has strong interest in their own mercury risks, it is inferred that this knowledge regarding a “10 times” safety factor makes them perceive regulatory measures as safe. Those with knowledge of consumption guidelines had a significantly and strongly higher sense of safety : 1.64 (1.27–2.11)), suggesting that acquiring knowledge has a potential positive impact on developing a sense of safety.However, information on regulation values showed a weak but significant positive association with excessive intake. Although this information enhances sense of safety, there is also danger of causing excessive intake.In this study, the authors did not intend to determine the appropriateness of the types of presentation methods or information. People’s perceptions and decision-making are influenced by a framing effect . TherefoA lacking of a sense of safety  may positively affect risk avoidance; however, it also has negative impacts such as decreased well-being, risk tradeoff , and psychological distress –4,32,33.This study had some limitations. First, there were potential participant biases. We conducted an online survey through which biases may have been introduced. However, since respondents acquired points through online surveys, respondents with no interest in this survey’s topic may have been motivated to participate; this is potentially more effective for reducing bias than central-location testing or mailing methods. To reduce bias in this study, factors such as individual attributes were categorized and the strength of their associations was examined. The three presentation conditions for information on regulation values, which is this study’s focus, were randomly assigned to participants. Second, this study dealt with mercury risks in fish and shellfish and presenting information on regulation values; however, we did not discuss generalizations regarding other risks and regulations. In particular, with the spread of Minamata disease, Japan has historically experienced pollution-related problems; therefore, it is possible that mercury risk perception and sense of safety differs in Japan and other countries.Despite these limitations, this study revealed that dread risk perception of mercury did not govern tuna-type consumption behavior; rather, individuals’ consumption behavior governed dread risk perception of mercury. Although presenting information on regulation values increases the high-risk group’s sense of safety, there is a danger of promoting increased risk associated with excessive intake. Future research can deepen our understanding on presenting other information on regulation values. This can help information providers and authorities support individuals’ decision-making and reduce societal risks, ultimately leading to ethical, justifiable, and appropriate information presentation and risk communication methods.S1 FigScree plots in parallel analysis are also shown.(DOCX)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.