To determine the optimal cut-off points of handgrip strength (HGS) to identify the undernutrition risk among individuals older than 65 years of age in Bosnia and Herzegovina.  Cross-sectional study.  Towns of Sarajevo, Foca, Rogatica, and Pale in Bosnia and Herzegovina.  300 community-dwelling older adults and 146 nursing home residents. Comprehensive Geriatric multidimensional assessment (CGA) was carried out to evaluate general health, functional, and cognitive capabilities. Nutritional status and undernutrition risk were assessed by Mini Nutritional Assessment (MNA) and Seniors in the Community: risk evaluation for eating and nutrition, version II (SCREEN II). HGS was measured with a Smedley dynamometer. p < 0.001). When nutritional status was assessed by SCREEN II, 100% on nursing home residents, 86% of community-dwelling men and 80% of women were identified as having a high risk for undernutrition. Per MNA, HGS cut-off thresholds were 23.50 kgF (65–74 years) and 19.50 kgF (≥75 years) for men; 15.50 kgF (65–74 years) and 13.50 kgF (≥75 years) for women. Per SCREEN II, cut-points were 28.50 kgF (65–74 years) and 24.50 kgF (≥75 years) for men; 24.50 kgF (65–74 years), 19.50 kgF (≥75 years for women).  According to the classification of nutritional status by MNA, 42% of community-dwelling men and 39% of community-dwelling women were at undernutrition risk. The undernutrition risk was significantly higher among nursing home residing men (89%) and women (78%) ( HGS can be a useful instrument to identify undernutrition risk among the elderly patients. This study provides threshold for men and women older than 65 years of age in Bosnia and Herzegovina. Undernutrition among the elderly population is a prevalent public health problem that may ultimately lead to the progression of underlying chronic diseases and the development of acute conditions  . UndernoAccording to Bedogni, an ideal screening instrument should include the analysis of risk factors, energy/nutrients balance, and anthropometric, functional, and biochemical indicators of undernutrition risk . AlthougAlthough anthropometric parameters, such as body mass index (BMI) and circumferences, have been used widely as standard indicators of nutritional status, they often mask sarcopenia or other weight changes needed to evaluate undernutrition risk . Recent The aim of this study was to determine the optimal cut-off values of HGS to identify the undernutrition risk among individuals older than 65 years of age in Bosnia and Herzegovina.The cross-sectional study was carried out in four municipalities of Bosnia and Herzegovina  between April and September 2018. Study participants were individuals older than 65 years of age, living in the community (community-dwelling) or nursing homes. Sample size calculation was conducted to assess the minimum number of prospective subjects. The calculation was based on the previous study, which showed that the prevalence of undernutrition in community-dwelling elderly is 15% and in the nursing home residents is 30% . With a All clinical measurements were performed by the principal investigator, with the same instruments. To test reliability, the pilot study was carried out on the separate sample of 25 elderly individuals . Reproducibility of tests was analyzed by the interclass correlation coefficient (ICC). The rater performed all clinical measurements on 5 patients per day during five consecutive days. The measurements were repeated seven days later, by the same rater and on the same individuals. ICC estimates were between 0.798 and 0.886, so the level of intrarater reliability could be regarded as good. Research assistants and trained nursing students administered questionnaires. To maintain anonymity and confidentiality, no identifying information about participants was collected. The principal investigator explained the aims of the study and asked each participant to sign an informed consent form. This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Ethics Committee of Faculty of Medicine Foca (No: 01-2-1). Written informed consent was obtained from all subjects/patients.α = 0.874) and excellent (α = 0.952).To meet the expert recommendations, clinical assessment of undernutrition risk included the evaluation of dietary, anthropometric, functional, and biochemical indicators , 23. TheTo assess memory, calculation, and orientation, the Six-Item Cognitive Impairment test (6-CIT) was used. Scoring was inverse and included the following categories: <10 ; 10–19 (mild cognitive impairment); ≥20 (significant cognitive impairment) . AccordiTimed Up and Go Test was performed to assess mobility. A standard chair with support for the spine was used. The participants were required to rise from the chair, walk at a normal pace 3 m to a line on the floor, turn, walk back to the chair, and sit down, without any encouragement from the investigator. In one-minute intervals, three tests were completed and measured in seconds (stopwatch). The best time recorded was considered as the performance score for mobility. The thresholds were categorized as follows: <10 s ; 11–20 s (good mobility); and >21 s (impaired mobility) .The functional reach test was carried out with the participants standing with their dominant arm next to the wall, placed at 90 degrees of shoulder flexion, with elbows and hands extended. Fingers were closed into a fist. The starting position was recorded at the tip of the middle finger on the measuring tape. The participants were instructed to reach as far as they could without taking a step or lowering their arm. The test was repeated three times with a pause of 30 sec in between. The difference between the starting and reached point was calculated in centimeters, and the mean value was recorded. The threshold for impaired mobility was <15 .α coefficient of 0.726 indicated adequate reliability of MNA.Likelihood of undernutrition was assessed by Mini Nutritional Assessment (MNA). MNA included 18 items grouped into screening  and assessment scales . Total indicator scores were categorized as undernutrition (<17); a risk of undernutrition (17–23.9); and normal nutritional status (≥24) . Internaα = 0.610). The SCREEN II questionnaire is the copyright of Dr. Heather Keller.Likelihood of undernutrition risk was evaluated using seniors in the community: risk evaluation for eating and nutrition, version II [SCREEN II). SCREEN II consisted of 14 items (each with five possible score from 0–4), providing information on weight change (1 item), meal frequency (2 items), appetite (1 item), food intake (4 items), and risk factors (6 items), such as difficulties with chewing, swallowing, meal preparation or groceries shopping, eating alone, and meal replacement. The total number of points ranged from 0 to 64, with the score lower than 50 indicating high, 50–54 moderate, >54 low nutritional risk . Interna2), weight was divided by the square height. With a standard nonelastic tape measure, calf circumference (CC) was measured at the level of the maximum gastrocnemius muscle's bulk when in a standing position on both legs. Compression of subcutaneous tissue was avoided. Midupper arm circumference measurements were taken on both arms while relaxed at the side with palms facing inwards , and following the contour of the tissue without compressing it. Measurement of waist circumference was performed in the horizontal plane midway between the lowest rib and the iliac crest, at the end of expiration. To assess reproducibility, anthropometric measurements were repeated three times, and the average values were recorded in centimeters [Duplicate measurement of weight (to the nearest 0.1 kg) and height (to the nearest 0.5 cm) were taken by a standard weighbridge and stadiometer, respectively. To obtain a body mass index (BMI) value  between the thumb and middle finger and pulled it away from the muscle tissue. The edges of a GIMA code 27320 Caliper were placed 1 cm below the investigator's fingers. The caliper (readings were executed 3 seconds after full pressure was applied to the nearest 1 mm). The procedure included four sites: triceps , biceps , subscapular , and suprailiac . All measurements were done in triplicate, and the mean value was recorded as a score of skinfold thickness. The scores were converted into a total fat percentage (% BF) .Blood markers included albumin, hemoglobin, total cholesterol, and ferritin. All parameters were measured according to the protocols of Laboratory for hematological, immunological, and biochemical analyses.HGS was measured using calibrated Smedley dynamometer. The participants were seated with elbows by their sides flexed at a 90° angle, supported in a neutral wrist position. The investigator asked participants to squeeze the dynamometer as hard as they could for 3 sec. Measurements were carried out three times at intervals of 1 minute on the right and left arm. The maximal value was recorded in kilograms. HGS of the dominant hand was used for analysis. For Smedley dynamometer, the force range was 1–100 kilograms, and the resolution was 0.5 kgF . As bodyT-test or Analysis of variance (ANOVA) for numerical variables were applied. Pearson's correlation coefficients were used to measure the extent to which HGS is related to other variables. The ROC curves were generated to determine sensitivity and specificity of optimal cut-off values for handgrips of the dominant arm in relation to MNA (<17) and SCREEN II (<50) as the criterion. Univariate linear regression analysis was carried out to explore associations between HGS as a key variable and undernutrition indicators. Statistically significant independent variables were included in the multivariate linear regression model. p value less than 0.05 was considered to be significant.Statistical analyses were performed using the Statistical Package for Social Science version 25 . Categorical variables were presented as numbers and percentages; numerical variables, as means and SD, medians and percentiles. Percentiles were stratified by age, gender, and body height. To test the difference between the variables, Chi-square, or Kruskal–Wallis test for nonparametric and The study included 300 (67%) community-dwellers and 146 nursing home residents (33%), with the mean age of 75.96 ± 7.41 years (age range from 66 to 99). Most of the participants were married (47%); had primary education (67%), specific hobbies (56%), and pensions (87%); and lived in their own homes (67%).p < 0.001).Clinical characteristics of the study sample are presented in r = 0.684, p < 0.001).When nutritional status was assessed by SCREEN II, 86% of community-dwelling men and 80% of women were identified as having a high risk for undernutrition. All nursing home residents were at high risk for undernutrition (100%). SCREEN II score was significantly correlated with the MNA score (2 in men and 25.47 ± 4.93 kg/m2 in women) in comparison with community-dwellers (26.92 ± 3.85 kg/m2 in men and 28.84 ± 5.25 kg/m2 in women). Nursing home residents also had significantly lower other anthropometric measurements compared to community-dwelling study participants (p < 0.001). Majority of participants had memory difficulties  (p < 0.001). The risk for falls per Timed Up and Go Test was lower in the group of community-dwellers  than in nursing home residents . Independence level in performing basic ADL was higher in community-dwellers  compared to nursing home residents  (p < 0.001). Among community-dwelling elderly, average Lawton score for men was 7.98 ± 0.16 and for women was 7.95 ± 0.39.An average BMI was lower in nursing home residents (26.07 ± 4.91 kg/mp < 0.001). Statistical difference between two groups was also found in the value of left HGS (p < 0.001). Gender and age-specific percentiles of height were generated to describe HGS values of community-dwellers and nursing home residents in Bosnia and Herzegovina  compared to the community-dwellers  (zegovina .p=0.127), area under the curve (AUC) was >0.5 and statistically significant for all ROC curves (HGS cut-off thresholds for undernutrition were 23.50 kgF (65–74 years) and 19.50 kgF (≥75 years) for men and 15.50 kgF (65–74 years) and 13.50 kgF (≥75 years) for women. For nutritional risk likelihood, cut-points were 28.50 kgF (65–74 years) and 24.50 kgF (≥75 years) for men; 24.50 kgF (65–74 years), 19.50 kgF (≥75 years for women). Except for the women older than 75 years of age in the relation to SCREEN II , functional reach test score <15 cm (p < 0.001), and BMI value (p=0.002) were associated with low HGS in community-dwelling elderly. Individual practicing some hobbies had higher HGS values (p=0.015). Independent determinants on HGS value among nursing home residents were functional reach test score <15 cm (p=0.027), number of medical visits <3 (p < 0.001), and number of meals >2 (p=0.040).The results of the multivariable linear regression analysis are listed in The current study found that low HGS is associated with undernutrition risk among the community-dwelling and nursing home-residing individuals in Bosnia and Herzegovina. The findings corroborate the results of international studies analyzing the role of HGS in nutritional status assessment , 13, 32.Bosnian community-dwelling men had lower average HGS compared to their coevals in other countries, whose values ranged from 50 kgF in USA to 30.00 kgF in Portugal –40. The High prevalence of risk for undernutrition among elderly in Bosnia and Herzegovina may be attributed to numerous underlying factors. The Community-based Framingham offspring cohort study described the favorable effects of high animal protein intake, but not plant protein on the preservation of HGS . IncreasRecently published meta-analysis found that cut-off points for HGS were higher in developed regions  compared to developing regions  , 48–50. All participants in our study were right-handed. In accordance with other research, dominant hands were significantly stronger compared to nondominant hands due to more frequent use in the performance of tasks and heavier workloads .According to MNA, nursing home residents were at higher risk of undernutrition, while the nutritional status assessment by SCREEN II showed that both groups were at high risk for being undernourished. The correlation between the scores was high, statistically significant, and positive. Notwithstanding, validation studies showed good (MNA) and satisfactory (SCREEN II) reliability and validity of these instruments , 30, 52,As frailty leads to numerous adverse outcomes, measuring HGS in the context of comprehensive geriatric assessment might improve early detection of sarcopenia and the resultant time-effective introduction of therapeutic interventions to prevent disability . In the This is the first study describing HGS values among older adults in Bosnia and Herzegovina. The sample represents the average Bosnian elderly population, including community-dwelling individuals, as well as institutionalized persons. Different variables were collected from participants simultaneously and consistently by the same trained rater. Undernutrition risk, previously undiagnosed, was identified as high, indicating the need for improvement in the care of elderly populations in primary health care. In regards to practice implications, the study highlighted the utility of measuring muscle strength across the elderly population. Although HGS cannot be used as a solemn indicator of undernutrition, it could provide valuable information on undernutrition risk. The HGS cut-off points for undernutrition risk should be considered within age, gender, and height. Measuring HGS may help family physicians or other primary care workers (frequently only providers included in the care for older adults) identify older adults who would benefit from more comprehensive nutritional assessment and nutritional therapy programs. The results also propose that it is necessary to improve the quality of care for nursing home residents, who are often marginalized in the healthcare system of Bosnia and Herzegovina . To imprHowever, several limitations need to be considered. This study design was cross-sectional, exploring the association between variables, but not the cause-effect or direction of the relationship. Although we measured the HGS using the recommended protocols, the method might be different compared to the methods other researchers used, what might have influenced the results. Using HGS as a marker of undernutrition risk is difficult in cognitively impaired people and individuals with severe musculoskeletal disorders. High prevalence of high undernutrition risk might have had impact on cut-off values for HGS.There may also be other variables influencing HGS or undernutrition status that were not explored in the current study. Further studies are required to analyze and validate if internationally acceptable cut-off points of HGS could be used as a diagnostic criterium for undernutrition risk in clinical practice. It should also be investigated whether HGS could replace robust assessment tools as an undernutrition screening instrument. To minimize variation in HGS measuring and facilitate comparison of international data, research exploring standardized measurement protocol needs to be explored in the future.According to MNA and SCREEN II, elderly individuals in Bosnia and Herzegovina are at high risk of undernutrition. HGS could be the useful clinical indicator of nutritional status within the routine comprehensive geriatric assessment. A region-specific definition of cut-off values, stratified by age and gender, is necessary to identify the population at undernutrition risk. The results of the current study contribute to data on HGS values of older Bosnian adults; however, further validation studies need to be conducted.


During 13 months of follow-up (median 9 months), clinical deterioration occurred in 14 patients (including 2 deaths). On the Cox regression analysis, MDA, TAC, and CAT were associated with clinical deterioration . There was no significant difference in SOD . The cut-off value derived from ROC curve analysis was 3.79 μM  for MDA, 0.49 mM  for TAC, and 1.34 U/L  for CAT. MDA in the group with deterioration was higher (p = 0.0041), while TAC as well as CAT were lower  when compared to stable patients. Survival without clinical deterioration was significantly longer in patients with lower MDA , higher TAC , and higher CAT . Markers of oxidative stress such as MDA, TAC, and CAT were associated with adverse clinical outcomes in patients with PAH and inoperable or residual CTEPH.Oxidative stress is regarded to play a crucial role in the pathophysiology of pulmonary arterial hypertension (PAH) and inoperable chronic thromboembolic pulmonary hypertension (CTEPH). This study evaluated the prognostic value of serum oxidative stress markers , total antioxidant capacity (TAC), catalase activity (CAT), and superoxide activity (SOD)) in patients with PAH and CTEPH ( Pulmonary arterial hypertension (PAH) is a progressive disease characterized by the proliferation and vasoconstriction of pulmonary arterioles resulting in an increase of pulmonary pressure and pulmonary vascular resistance that might lead to right ventricle failure and eventually death . Similarin vitro and in vivo experimental models and clinical data, oxidative stress, an imbalance between the generation of reactive oxygen species (ROS) and the biological system's ability to detoxify the reactive intermediates or to repair the resulting damage, appears as a significant mediator in the pathophysiology of PAH. Chronically increased ROS levels can uncouple endogenous nitric oxide (NO), which otherwise has a protective role, via the oxidation of its cofactors or direct oxidation which results in the production of superoxide (O2•-), further scavenged by NO to form peroxynitrite (ONOO−). Elevated levels of this product can in turn diminish endothelial nitric oxide synthase and prostacyclin synthase [κB and activator protein-1 [Chronic upregulated inflammatory response has been widely acknowledged as a crucial pathogenic element of PAH and inoperable CTEPH , 10. As synthase –15. Thissynthase , 17. Allsynthase , 18, 19.rotein-1 . Such inrotein-1 , 22. Therotein-1 . Patientrotein-1 . The othrotein-1 . ConsideThe present study assessed the prognostic value of the following serum markers of oxidative stress in patients with PAH and inoperable or residual CTEPH: MDA concentration, total antioxidant capacity (TAC), and activities of superoxide dismutase (SOD) and catalase (CAT). All of these parameters are broadly employed to evaluate redox balance in various clinical conditions –29. MDA n = 28, and CTEPH, n = 17) were studied. The PAH group included patients with IPAH  and PAH associated with congenital heart disease  and connective tissue disease . Most patients had WHO FC II and were predominantly female. The CTEPH group included patients with inoperable lesions in pulmonary arteries  as well as patients after pulmonary artery thromboendarterectomy (PEA) with residual pulmonary hypertension after operation . Detailed baseline characteristics are shown in Forty five patients . All patients signed a written consent form. The total antioxidant capacity (TAC), malondialdehyde (MDA) content, and activity of catalase (CAT) and superoxide dismutase (SOD) were analyzed in the collected serum.μM ABTS with the ferrylmyoglobin radical species, generated by the activation of 2.5 μM metmyoglobin with 75 μM H2O2. Antioxidant agents suppress the formation of the ABTS radical cation. The assay was performed with the use of the Antioxidant Assay Kit . Briefly, ABST, myoglobin, and 10 μL of serum were mixed, and the reaction was initiated by the addition of H2O2. Following the incubation for 5 min at 21°C, the absorbance of the product was read at 735 nm and compared to a calibration curve prepared using Trolox , a water soluble analogue of vitamin E commonly used in antioxidant assays as a standard antioxidant [r2 = 0.98) and given as mM Trolox equivalents. Three technical replicates were performed for each serum sample.TAC was assessed by a method adapted from Rice-Evans and Miller  which isioxidant ) (0.0–2.μL) were supplemented with butylated hydroxytoluene to prevent artificial lipid peroxidation. The samples were then centrifuged  to remove insoluble material, and 100 μL of supernatants were transferred to a microcentrifuge tube and supplemented with 800 μL of thiobarbituric acid (TBA) to generate an MDA-TBA adduct. To accelerate the process, samples were incubated at 95°C for 60 min, placed on an ice bath for 10 min to inhibit the reaction, and centrifuged . The final product was measured colorimetrically at 532 nm), and the absorbance values were compared to a calibration curve prepared using the MDA standard  . Three technical replicates were performed for each serum sample.Lipid peroxidation was evaluated by means of serum levels of thiobarbituric acid-reactive substances (TBARs) that include malondialdehyde (MDA), one of the most commonly reported biomarkers of lipid peroxidation in clinical studies . Here, t2O2 by xanthine oxidase, converts the tetrazolium salt WST-1 to water-soluble WST-1 formazan. The SOD reduces concentrations of the superoxide anion radical and thereby lowers the rate of formation of WST-1 formazan. The absorbance of this final product was measured at 450 nm, and SOD activity was calculated as a percent of inhibition of WST-1 formazan formation.SOD (EC 1.15.1.1.) activity in serum was measured using the SOD Determination Kit . Briefly, in this assay, a superoxide radical, generated from the conversion of xanthine to uric acid and H2O2 to produce water and oxygen while its unconverted pool reacts with the OxiRed™ Probe to produce a product which is measured at 570 nm. For each sample, a High Control in which the CAT activity was inhibited at the beginning of the procedure, was prepared. The final amount of degraded H2O2 was calculated by subtracting the absorbance measured and a sample from that measured in the High Control. These values were compared to a calibration curve (r2 = 0.99) prepared using an H2O2 standard .Catalase  activity in serum was assayed with the Catalase Assay Activity Kit . Briefly, in this assay, CAT reacts with HU test for continuous data. We assessed the impact of the level of MDA, TAC, and CAT as well as specific therapy on clinical deterioration by creating a Cox proportional hazard model. Receiver operating characteristic (ROC) curve was used to determine a cut-off point associated with a higher probability of clinical deterioration. A survival curve was plotted as estimated by the Kaplan-Meier method and compared with others using the log-rank test. p values < 0.05 were considered statistically significant. Statistical analysis was performed using the PQStat version 1.6.8 and Statistica version 12.The distribution of all variables was verified with the Shapiro-Wilk test for normality. Data is shown as mean ± SD or median values with interquartile range (IQR) as appropriate. We compared group with deterioration vs. stable group using the Fisher exact test for categorical data and the Mann-Whitney p = 0.0068, HR = 1.42, 95% CI: 1.10-1.82; p = 0.0038, HR = 0.033, 95% CI: 0.0032-0.33; and p = 0.046, HR = 0.20, 95% CI: 0.04-0.98, respectively). There was no significant difference in SOD . The cut-off value derived from ROC curve analysis was 3.79 μM  for MDA, 0.49 mM  for TAC, and 1.34 U/L  for CAT. Survival without clinical deterioration was significantly longer in patients with lower MDA , clinical deterioration occurred in 14 patients (including 2 deaths). On the Cox regression analysis, MDA, TAC, and CAT were associated with clinical deterioration . There was, however, no difference in TAC, MDA, CAT, and SOD between patients receiving prostacyclines and those without their use , had lower peakVO2 derived from pulmonary exercise test (p = 0.039), had more frequent fluid in the pericardium (p = 0.023), and had higher concentrations of troponin I (p = 0.017) and MDA (p = 0.0041), while activities of TAC (p = 0.027) and CAT (p = 0.028) were significantly lower compared to stable patients , significantly increased endothelial NO synthase expression and superoxide dismutase activity, and downregulated nicotinamide adenine dinucleotide phosphate oxidase expression in rat lung tissue [There is a large body of evidence that increased oxidative stress contributes to PAH pathogenesis. Elevated levels of urinary F2-isoprostanes, a biomarker of lipid peroxidation, was documented in patients with PAH and correlated inversely with vasoreactivity . Moreoveg tissue . Oxidizeg tissue .Recently, we have documented that neopterin concentration which increases the cytotoxic potential of activated macrophages and dendritic cells through promoting oxidative stress was elevated compared to the control group and predicted adverse outcomes in patients with PAH and inoperable CTEPH . The resAn increasing number of studies focus on the evaluation of oxidative stress markers in various human diseases and treatment outcomes , 41. For2O2, while CAT further converts it into water. As shown in vivo, SOD and CAT mimetics can reverse pulmonary vascular remodeling and PAH [2O2. No effect was identified for SOD which is an interesting finding if one considers that patients with chronic obstructive pulmonary disease (COPD) combined with PAH were previously demonstrated to reveal significantly higher serum SOD levels than subjects with pure COPD [2O2 resulting from CAT inhibition can finally suppress SOD activity [In the present study, a set of four oxidative stress biomarkers in serum has been taken into account: CAT and SOD activity, MDA concentration, and TAC. The former two represent the core of an enzymatic antioxidant system: the general function of SODs is to catalyze the conversion of superoxide radical to H and PAH . It is ture COPD . Howeverure COPD . This maactivity , 51. Lasactivity .The prognostic value was also demonstrated for the serum concentration of MDA, which along with 4-hydroxy-2-nonenal, is a major genotoxic product of lipid peroxidation . This isIn the study group, 14 patients were treated with prostacyclines (treprostinil or iloprost). This may in turn potentially affect a systemic redox imbalance as these pharmaceuticals are regarded to reduce oxidative stress , 37. How2 derived from pulmonary exercise test and fluid in the pericardium significantly distinguished stable patients from patients with clinical worsening. These results suggest that a pulmonary exercise test has a higher value than 6MWT in disease prognostication. Interestingly, among the laboratory parameters, higher concentrations of troponin I  and MDA and lower activities of TAC as well as CAT were observed in patients with clinical deterioration compared to stable patients, which indicate that studied oxidative stress biomarkers and troponin I may precede the change in NT-pro-BNP and measured simultaneously can be a better prognostic tool than NT-pro-BNP alone.As shown in Although the study provided new insights into the prognostic value of oxidative stress markers in PAH and CTEPH, one should acknowledge its limitations. Firstly, this research encompassed a small cohort size and the observations would require confirmation from a larger population. Therefore, the reported findings should be considered as preliminary. Secondly, due to the small group of studied patients, we were unable to perform multivariable analysis. Although the selected markers and complimentary markers of oxidative stress were selected, there are number of other relevant antioxidant agents  or In summary, serum markers of oxidative stress such as MDA concentration and TAC and CAT activities were associated with adverse clinical outcomes in patients with PAH and inoperable or residual CTEPH. MDA and TAC appeared to have the superior prognostic value.


Klebsiella pneumoniae poses a therapeutic challenge when implicated in urinary tract infections, pyelonephritis, pneumonia, skin infections, osteomyelitis, and respiratory infections. The mutant prevention concentration (MPC) represents a concentration threshold above which increase of resistant mutants occurs rarely. The aim of the present study is to determine the MPC among ciprofloxacin-resistant K. pneumoniae clinical isolates.  Fluoroquinolone-resistantK. pneumoniae were collected from a tertiary care hospital. The MPCs were determined for 24 selected strains using an inoculum of 1010 CFU/ml in Müller–Hinton agar plates with serial/various concentrations (0.003–100 μg) of ciprofloxacin. In addition to the MPC, phenotypic screening for ESBL, AmpC, and carbapenemase was performed. The detection of qnr genes for 24 isolates and DNA sequencing for six isolates were performed.  A total of 240 clinical isolates of K. pneumoniae clinical isolates. Among the ciprofloxacin-resistant isolates, 14 isolates showed an MPC value of more than 100 μg. The MPC ranged between 100 μg and 20 μg for ciprofloxacin-resistant isolates. ESBL producers and qnr gene-producing strains had a high MPC. 11 isolates showed the presence of either qnrB or qnrS genes. None of the samples showed the presence of the qnrA gene.  Ciprofloxacin resistance was observed in 19.6% of the qnr gene-possessing strains are frequently resistant to ciprofloxacin. Estimation of the MPC in the case of multidrug-resistant isolates in the clinical setup may help in treating these drug-resistant strains. From our study, we infer that ESBL producers and  Enterobacteriaceae including Klebsiella. However, the recurrence of ciprofloxacin-resistant Klebsiella pneumoniae has expanded worldwide lately [Fluoroquinolones have phenomenal clinical effect against e lately , 2. The e lately –5. Antibe lately –8. The oe lately . Ciprofle lately –12.The mechanism by which quinolones affect bacterial DNA synthesis is by inhibiting DNA gyrase and type IV topoisomerase in Gram-negative bacteria and Gram-positive bacteria, respectively. Both DNA gyrase and type IV topoisomerase are essential for relaxing DNA supercoils during DNA replication –15.The resistance of Gram-negative bacteria to fluoroquinolones is reported concomitant with their use –18. BactEnterobacteriaceae species, Staphylococcus aureus, and P. aeruginosa [The development of very high minimum inhibitory concentrations to ciprofloxacin in isolates of ruginosa  is due truginosa . Such a ruginosa , 22.qnr, was found on plasmids varying in size from 54–≥180 kb in clinical isolates of K. pneumoniae and Escherichia coli from which low-level quinolone resistance could be transferred to a sensitive recipient by conjugation [qnr) encoding for proteins that belong to the pentapeptide repeat family and protect DNA gyrase and topoisomerase IV against quinolone compounds [qnr determinants are qnrA, qnrB, and qnrS [Although chromosomal mutations commonly result in quinolone resistance, plasmid-mediated resistance has been discovered recently. The gene responsible for plasmid-mediated resistance, jugation , 24. Plaompounds . The thrand qnrS , 27.The mutant prevention concentration (MPC) is a novel concept coined by Dong and colleagues following the recognition of a two-stage decline in colony forming units when high-density bacterial inocula were exposed to varying antimicrobial drug concentrations .Dong et al. have defined the mutant prevention concentration (MPC) as a parameter which prevents or interferes with the emergence and development of resistant mutants. Such resistant mutants may be associated with treatment failures and surfacing of resistance . MPC repK. pneumoniae. Recently, plasmid-mediated resistance to quinolones was identified for the first time in clinical strains of K. pneumoniae [β-lactamase- (ESBL-) producing isolates [Currently, the drug resistance among Gram-negative bacilli is on the rise with regard to ESBL-producing eumoniae . Quinoloisolates –33. FluoK. pneumoniae clinical isolates.Hence, the aim of the present study is to determine the MPC among ciprofloxacin-resistant K. pneumoniae were collected from a tertiary care hospital between October 2015 and December 2018. The source of the clinical isolates included blood (n=7), pus (n=8), sputum (n=10), urine (n=170), vaginal swab (n=28), and wound swab (n=7). Out of the 240 isolates, 47 were resistant to ciprofloxacin. The ciprofloxacin-resistant (n=20) and ciprofloxacin-susceptible (n=4) isolates were subjected to an MPC assay.A total of 240 clinical isolates of μg) alone and with 400 μg of phenyl boronic acid and 292 μg of EDTA were used [To consider the strains positive for ESBL, a modified CLSI-ESBL confirmatory test  was perfere used . Phenotyere used .10 CFU/ml was prepared in peptone water and compared with McFarland's standard 1. For MPC determination, 100 μl of the bacterial suspension was inoculated onto MHA plates containing ciprofloxacin. The concentration of ciprofloxacin ranged between 200 and 0.003 μg. These plates were incubated at 37°C and observed for colonies every 24 hours over 2 days to confirm the stabilization of the colony number.The ciprofloxacin MIC was determined for all clinical isolates using VITEK 2 systems version 7.0 as per CLSI guidelines. MPC was analyzed for 24 clinical isolates as per the study of Blondeau et al. . Fresh cqnrA, qnrB, and qnrS genes. The PCR master mix (25 μl) contained sterile Milli Q water (18.4 μl), 10x PCR buffer (2.5 μl), dNTP mix (1 μl), 16S forward primer (1 μl), 16S reverse primer (1 μl), Taq polymerase enzyme (0.1 μl), and DNA template (1 μl). The primers used for screening qnr genes are mentioned in qnrA and 60°C for qnrB and qnrS and extended for 45 seconds at 72°C. The final extension was at 72°C for 5 minutes. The amplified products were detected by electrophoresis on 1% agarose gel with ethidium bromide and visualized under a UV transilluminator.DNA was extracted by the boiling lysis method. The supernatant was transferred to a sterile tube and stored at 20°C until assaying. Conventional PCR was used to detect the presence of qnr genes were sequenced using the specific primer as described above. Sequencing was carried out at Macrogen Inc.  using an ABI PRISM® BigDye™ Terminator and ABI 3730XL sequencer . The qnr gene sequences of representative isolates were compared with known sequences in the NCBI Database by using BLAST analysis (http://www.ncbi.nlm.nih.gov/blast/). The sequences were submitted to GenBank under accession numbers MK 414320, MK414318, MK414319, MK414320, MK414321, and MK414322.PCR amplicons of the K. pneumoniae, 47 isolates showed resistance to ciprofloxacin. The source of the resistant isolates were blood (n=2), Pus (n=1), sputum (n=3), urine (n=31), vaginal swab (n=6), and wound swab (n=4). All ciprofloxacin-resistant isolates showed similar MIC values (≥4). There were nine multidrug-resistant strains. None of the isolates were resistant to the last-resort drug colistin.Among the 240 clinical isolates of K. pneumoniae which showed resistance to ciprofloxacin (n=47) were randomly chosen (n=20) for the determination of the MPC. Four susceptible isolates were used as the control. Among the ciprofloxacin-resistant isolates, 14 isolates showed an MPC value of more than 100 μg  or qnrS (n=4) genes. Only one isolate was positive for both qnrB and qnrS genes (qnrA gene was not detected in any of the 24 isolates (n=20) which were phenotypically positive for ESBL (n=6), AmpC (n=8), and carbapenemases (n=5) showed the presence of either qnrB or qnrS genes.The MIC and MPC results of ciprofloxacin for the 24 isolates are shown in n 100 μg . Rest ofrS genes . The qnrisolates . The cipKlebsiella pneumoniae strains producing ESBL and AmpC are a major health problem because of the difficulty in treating severe infections caused by these microorganisms. Furthermore, they may show resistance to other groups of antimicrobial agents [qnr genes were detected with high frequency among ciprofloxacin-resistant Klebsiella isolates and these strains also exhibited a high MIC and MPC. Some of the ciprofloxacin-resistant isolates which did not show the presence of qnr genes also showed an elevated MPC. Such an elevated MPC among isolates that were positive for qnr may lead to resistant mutants. This was well in line with our results shown by resistant strains of K. pneumoniae [qnr genes and a high MPC among resistant isolates. The strains which did not show the presence of any of the genes might harbour other variants of qnr genes. Treatment with higher doses of fluoroquinolones above the MPC value in the case of multidrug-resistant strains can be provided to eradicate these isolates at the site of infection. The MPC values may be considered to plan the dosage for treating patients infected with isolates showing coresistance to ciprofloxacin and ESBL [l agents . As thesl agents . In our l agents , while tl agents . Fluoroql agents . Daoud el agents . The plaeumoniae . Studiesand ESBL , 42. Theand ESBL .Enterobacteriaceae family. Our study also emphasizes the frequent finding of resistance to fluoroquinolones in ESBL-producing K. pneumoniae strains. The determination of MPCs in the case of multidrug-resistant isolates in the clinical setup may be significant in therapeutic planning.The concept of the MPC can be considered to make therapeutic decisions about the choice and dosage of antibiotics to control the development of resistant mutants in the


This study examines socio-economic determinants of food consumption patterns amongst women of reproductive age and children aged 6–59 months from urban poor settlements of Lusaka and their implications for nutritional status. Particular emphasis was placed on the role of fish in their diets and nutritional status.A cross-sectional survey design was applied, in which 714 mother-child dyads, with children aged 6–59 months were enrolled. A three-stage randomized cluster sampling approach was applied.2 = 10.979, df = 2, p = 0.004). Children from poorer households consumed mostly small fish (Kapenta). The quantity of fish consumed by children was significantly associated with stunting in both age groups, odds ratio = 0.947  for children aged 6–23 months and odds ratio = 1.038  for children aged 24–59 months old. Other significant risk factors for stunting in children aged 6–23 months were the child’s age, mother’s body mass index, access to treated water and child morbidity. Child’s age, mother’s educational level and wealth status were determinants of dietary diversity in children aged 6–59 months as shown by the Poisson regression.The mean dietary diversity score among children aged 6–23 and 24–59 months was 2.98 (±1.27) and 3.478 (±1.07), respectively. In children aged 6–23 months, there was a significant difference in their nutritional status, based on fish consumption (χKapenta) is an animal-source food that is particularly important in the diet of children in urban poor households in Zambia and contributes to better nutritional outcomes. As all small fish stem from capture fisheries, sustainable one health environmental integration, monitoring and management strategies are desirable.Nutritional status of children aged 6–23 months is associated with fish consumption, with children consuming fish less likely to be stunted. Small fish ( The Worsegments  and acutsegments .Numerous studies indicate that inadequate food/nutrient intake is one of the major factors responsible for undernutrition. Inadequacies in complementary feeding are common, with foods of low nutrient density and with little consumption of animal-source foods in low-income households –10. AnimSocial factors have also been found to be associated with nutritional status in developing countries, for example, Kenya and Ghana ,20, and The presented findings examine food consumption patterns amongst women and children aged 6–59 months in households from urban poor settlements of Lusaka, Zambia and their implications for nutritional status. Research questions addressed are: (1) whether socio-economic factors influence food consumptions patterns of women and under-five children from urban poor households; (2) to what extent fish and fish products contribute to diets in urban poor households; and (3) whether any associations exist between dietary intake, fish consumption and nutrition status of women and children aged 6–59 months.Lusaka district in Lusaka Province was purposively selected as the study area for the following reasons: it is an urban area within Lusaka Province with the highest number of high density settlement townships where the majority of the urban poor live in Zambia. The study targeted low-income settlement localities as the people living in these areas are most vulnerable to food and nutrition insecurity. Three constituencies: Kanyama, Matero and Munali, from Lusaka district were purposively selected. According to the Zambia Living Condition Monitoring Survey ,28, a hiUsing a cross-sectional study design, a household survey was conducted to establish the food consumption patterns and nutritional status among women of reproductive age (WRA) (15–49 years old) and having children aged 6–59 months. Thus, households with mother-child dyads were targeted.α = 0.05), π is the population proportion of interest estimated to be 11%, the prevalence of stunted growth among children in Lusaka [d is the margin of error (assumed to be 5%). The calculated sample size was further adjusted for the design effect and non-response rate (predicted to be 5%), to obtain the optimal sample size of 714 households. A sampling frame was developed from the 2010 Population Census and Housing report, in consultation with the local authorities and the Central Statistics Office (CSO). The sampling process involved, firstly, purposively selecting the three constituencies  from Lusaka district. From each constituency, one ward was randomly selected to participate in the study. In each reporting domain, study households were selected using a three-stage randomized cluster approach, with the first two stages using the Ward and Standard Enumeration Area (SEA) sampling frame from the 2010 CSO. A total of 36 SEAs (clusters) were identified and from each, 20 households were selected. Using a determined sampling interval, systematic random sampling was used in the final sampling stage. The first household that met the inclusion criteria (i.e. with mother-child dyad and with children aged 6–23 months and/or 24–59 months) was randomly picked. Using the sampling interval, the next households were picked and this procedure was followed until the required number of households was obtained. In households with more than one woman and/or child in each age group, one woman and one child in each age group were randomly selected.To derive the sample size,n Lusaka ,28 and dPreceding data collection, enumerators with prior experience on household surveys were trained on how to conduct the survey, take anthropometric measures and collect dietary data. The data collection tools were pre-tested and amendments made.A standard questionnaire specific to the scope of the study objectives was applied. The sub-sections included in the questionnaire are described below.Data on the demographic characteristics of household members, income-earning activities, household assets, water and sanitary living conditions of the household were collected. Data on household assets were used to determine relative household wealth through a computed asset-based indicator, using Principal Component Analysis (PCA) .Food frequency questionnaire (FFQ) gathered dietary data on foods consumed and frequency of their consumption by women and children. The children’s FFQ had seven food groups, following guidelines from WHO and UNICEF . The fooWeight and length/height measurement were taken for all study children and women. Weight was taken using the SECA (S-876) electronic scale. Participants were weighed with minimal clothing to the nearest 0.1 kg. SECA length boards (Seca 417) and Stadiometer (Seca 217) were used to take the length and height to the nearest 0.1 cm, respectively. Measurements for each child and mother were taken twice and the average determined and recorded. Children’s age was verified using the under-five clinic card.jXj + jμ where, y is the independent variable , jX is a vector of control and explanatory variables that include (i) characteristics of child j including age, gender of child, morbidity  and infant feeding practices , (ii) characteristics of child j’s mother including age, height, BMI, education (iii) household characteristics: household size, access to clean water and toilet and (iv) βj are coefficients that were estimated. Stunting was selected as the dependent variable as it is a measure of long-term chronic undernutrition, a cumulative indicator of growth failure due to inadequate dietary intake, frequent infection, and sustained inappropriate feeding practices. Values of p < 0.05 were considered statistically significant.Statistical Package for Social Sciences  and STATA were used to analyze the data. WHO classification  was applThe research protocol was approved by the University of Zambia Research Ethics Committee (UNZAREC). As data were collected electronically, a written informed consent was read out to potential study participants and signed by those who agreed to participate in the study. Participants who could not read and write gave a thumb-print on the consent form. Prior to starting the data collection exercise, the study objectives were explained to the respondents by the enumerators, who then proceeded to collect data, only from those who agreed to participate in the study.The analyses were based on data from 714 households. Demographic and socio-economic characteristics are presented in Consumption of food items from various food groups in the preceding 24 hours was determined for children in both age groups (6–23 and 24–59 months). Foods from the starchy staples  were consumed by almost all children in both age categories. In children aged 6–23 months, the second most consumed foods were pulses, legumes and nuts , followed by flesh foods  . Least consumed foods by children in this age group were eggs, vitamin A-rich fruit and vegetables (yellow and orange in colour), vitamin A-rich fruit and vegetables (dark green in colour) and other fruit and vegetables such as cucumber, eggplant and cabbage. A high proportion of children in the two age groups (6–23 and 24–59 months) consumed sugary foods (64.7 and 63.2%) and fatty foods (70.8% and 87.2%), respectively . These fThe DDS for children aged 6–23 months and those aged 24–59 months was determined (as described above). A child aged 6–23 months met the criterion for minimum dietary diversity if she/he had received food from four or more food groups . The mea2 = 5.440, p = 0.142, df = 3). Chi square statistics showed a significant difference in dietary diversity by wealth groups among children aged 24–59 months .Evaluating dietary diversity of children by wealth group, the proportions of children not meeting the minimum dietary diversity in SES-G1 and SES-G3 were higher compared to children in SES-G2 and SES-G4, for both age groups . There wStarchy staples were the most consumed food group by almost all women (99.4%). More than half of the women (59.9%) reported to have consumed flesh foods  in the preceding 24 hours, with a similar proportion (59.9%) having consumed dark green vegetables, whereas, only a small proportion of mothers had consumed dairy products, eggs, and nuts . The maj2 = 7.69; df = 3; p = 0.053). About one quarter of women from each wealth group consumed food items from 5 or more food groups  achieved minimum dietary diversity. The mean MDD-W was 5.8, with a range of 2.0 to 10.0. The proportion of women meeting the MDD-W was more likely to achieve adequate micronutrient intakes. Dietary diversity by wealth groups revealed no major differences in the proportions of women consuming food items from 5 or more food groups (χd groups .Milonge (Clarias theodorae); 36.4% (n = 36) did not consume Kababa ; 11.1% (n = 11) did not eat Daaga (Rastrineobola argentea), and 9.1% (n = 9) did not eat other small fish species, such as Kapenta and Chisense (Limnothrissa miodan and Stolothrissa miodon). Of the 360 children aged 6–23 months, the majority  consumed fish. In this age category, 12.2% made up the largest proportion among those who did not eat fish, whereas, with increase in age, the proportion of children who did not eat fish decreased  of households reported having consumed fish in the preceding 24 hours. Among fish products consumed, fresh fish and dried fish were the most frequently consumed, compared to smoked or salted fish products. In 36.8% (n = 263) of the households, certain household members did not consume fish at all or did not consume specific fish species. Among those household members who did not consume or did not consume specific fish species, a small proportion of children  did not consume fish, and 50.5% (n = 50) did not consume ecreased .With regards to fish consumption among pregnant and lactating mothers, respondents were asked to report whether pregnant and lactating women in their community were allowed to consume fish. Most , reported that pregnant and lactating women consumed fish, with no significant differences between wealth groups. Respondents gave various reasons that hinder fish consumption by pregnant and lactating women, including: fish gives rashes; unpleasant smell; health concerns due to unhealthy preservatives used; risk of swallowing bones; some fish species are associated with evil spirits; negative effects on the unborn child (e.g. baby being born with ringworm), and fish causes some women to feel sick (e.g. vomiting and nausea).Analysis of fish consumption by wealth group indicated that more households in SES-G4,  reported consumption of fish in the preceding 24 hours compared to those from SES-G1 (poorest). Chi square test indicated a significant difference in fish consumption by wealth group (p = 0.003). Differences in patterns of fish consumption between wealth groups were with respect to the size of fish. Households belonging to SES-G3 and SES-G4 tended to eat significantly more fresh large fish (p = 0.001) or dried large fish (p = 0.016) compared to the lower wealth groups. Significant differences were noted in the frequency of consumption by wealth group of fresh large fish (p = 0.000) and dried large fish (p = 0.043). A high proportion of households in SES-G4 (52.3%) consumed fresh large fish as well as dried large fish (33.1%) more frequently compared to households in the lower wealth groups . There wRegardless of the fish species and fish product consumed, the mean intake of fish consumed was 91.4 g/d in women; 36.9 g/d in children aged 6–23 months; 49.0 g/d in children aged 24–59 months; and 110.3 g/d in men. There were differences regarding the quantity of fish consumed among the various wealth groups, but these were not significant. Given that about 80% of the households surveyed consumed fish at least once per week, conservative estimates of annual fish consumption  are: 4.8 kg/y in women; 1.9 kg/y in children aged 6–23 months; 2.5 kg/y in children aged 24–59 months; and 5.7 kg/y in men.The length/height for age Z-scores (HAZ), weight for age Z scores (WAZ) and weight for length/height (WHZ) indices were used to determine the nutritional status of children. The HAZ scores were determined for 359 children aged 6–23 months and 397 children aged 24–59 months. Prevalence of stunting was 37.4% in children aged 6–23 months and 43.3% in children aged 24–59 months; higher than those reported in the Zambia DHS 2013–2014 (35.7% stunting in Lusaka Province) ,28. AbouPrevalence of wasting was 7% in children aged 6–23 months and 3.3% in children aged 24–59 months. A higher proportion of children (14.5%) aged 6–23 months was overweight compared to those aged 24–59 months (8.1%), as well as those who suffered from moderate and severe wasting. The prevalence of underweight was 9.7% in children aged 6–23 months and 13.9% in children aged 24–59 months. A t-test showed a significance difference in underweight in the two age groups of children . There were no significant differences in the proportions of children aged 6–23 months who were stunted, wasted and underweight by wealth category. A higher proportion of children aged 24–59 months in the SES-G4 wealth group , were within the normal range for HAZ, WHZ and WAZ scores. More children from the poorest wealth group, SES-G1 wealth group (poorest) were severely stunted, followed by those in SES-G3 wealth group. There were significant differences in HAZ scores for children aged 24–59 months by different wealth categories .p = 0.000).There were no significant differences in WHZ and WAZ scores by wealth groups in this age group. A t-test showed significant differences in HAZ (mean = -1.130 (±2.520), t = -8.499, p = 0.000), WAZ (mean = -0.390 (±1.34), t = -5.505, p = 0.000) and WHZ (mean = 0.264 (±1.653), t = 3.304) between girls and boys aged 6–23 months. The same trend was observed in children aged 24–59 months, with statistical values for HAZ (mean = -1.737 (±1.673), t = -20.69; p = 0.000), WHZ (mean = -0.720 (±4.98), t = 2.261, p = 0.024) and WAZ (mean = -0.720 (±2.609); t = -5.502, 2 = 10.979, df = 2, p = 0.004). A higher proportion of children who consumed fish  were within the normal range of HAZ score compared to those who did not consume fish. Spearman rank order correlation coefficient indicated a significant correlation between fish consumption and HAZ score . There was no statistically significant association between fish consumption and WAZ or WHZ scores.There was a statistically significant difference in nutritional status (as measured by HAZ) in children aged 6–23 months, in relation to fish consumption  were within the normal BMI range (BMI 18.5–25); 22.3% (n = 159) were overweight (BMI ≥25.00–29.9); and 5.5% (n = 39) were underweight (BMI <18.50). Few women  were found to be obese (BMI ≥30.00), and 1% (n = 7) were found to be morbidly obese (BMI ≥40.00). Mothers’ nutritional status by wealth group showed no significant differences. Spearman rank order correlation coefficient indicated no significant correlation between fish consumption and women’s BMI .A Poisson regression was conducted to determine factors that influence dietary diversity in children. Mothers’ education and child’s age were significant determinants of dietary diversity in children aged 6–23 months. In children aged 24–59 months, wealth status of the household had a significant influence on the child’s dietary diversity . Other factors  were not significant at p = 0.05.This study examined socio-economic determinants of food consumption amongst WRA and children under five years of age from households in urban poor settlements of Lusaka, Zambia and the contribution of fish consumption to their nutritional status. Starchy staples were the most consumed food group by almost all women and children. Among animal-source foods, fish was the most consumed by a high proportion of women and children, whereas, eggs and dairy products were seldom consumed. In recent findings on dietary diversity and animal-source foods consumption at household level in Ethiopia, it was observed that the most commonly consumed food group was cereals, whereas, fish, eggs and fruit were the least consumed . DietaryConsumption of a diverse diet and animal-source foods are associated with reduced risk of stunting, wasting and underweight in children under five years of age, as reported in studies conducted in Ethiopia, Vietnam and Cambodia ,39. The Fish consumption in women and men was below the estimated annual per capita consumption of 18.8 kg/capita/y in developing countries, in 2013 . In 2016A high prevalence of stunting in children aged 24–59 months was found in this study in comparison to that reported for the Lusaka Province in the Zambia DHS 2013–2014 ,46 and cKapenta). Small fish species found in developing countries have been shown to have high levels of vitamin A, iron and zinc [Notable differences were also found in HAZ and WAZ by sex, in both age groups of children. Despite the overall low dietary diversity of the child’s diet across wealth groups that could have contributed to the poor child nutritional status, fish consumption by children in the relatively wealthy households had a bearing on the children’s better nutritional status. The findings of this study indicated that children from the third and fourth wealth quartiles (SES-G3 and SES-G4) had higher mean intakes of fish. HAZ was associated with fish consumption. A high proportion of children who consumed fish were found to be within the normal range of HAZ scores. From the results of the logistic regression, the quantity of fish consumed by children pointed to a better nutritional outcome . Children consumed mainly whole small fish  as earlier reported. Among all provinces in Zambia, the highest proportion of overweight/ obesity among women is found in Lusaka Province 35%), and the lowest in Western Province (10%); and is correlated with educational level and wealth status %, and th. AlthougThe study had some limitations. The cross-sectional nature of the data does not allow examining causality in the relationships between dietary diversity and socio-economic factors, as well as causality of fish consumption and nutritional status.Kapenta) is particularly important in the diets of children in poor urban households in Zambia and contributes to better nutritional outcomes. As all small fish stem from capture fisheries, sustainable one health environmental integration, monitoring and management strategies are desirable. Older children aged 24–59 months had a higher prevalence of stunting than those aged 6–23 months. This is attributed to inadequate nutrient adequacy of diets as observed in the low dietary diversity. Furthermore, there are factors that affect stunting that are age-related (e.g. feeding practices and other child care practices). Among the urban poor, both undernutrition, overweight and obesity among children and women are major problems that need a more focused attention by policy makers. The government and development partners should not only channel efforts to solving the stunting problem, but should also implement prevention programmes for overweight/ obesity which is on the increase, especially among children. Utilization of locally produced food in complementary feeding and ensuring that diets are diversified, combined with caring practices, education of mothers and proper sanitary environments are paramount to ensure optimal child nutrition.Wealth status, mother’s educational level and child’s age had an influence on the dietary diversity of children. Fish was the most consumed animal-source food by both women and children and can therefore contribute towards the much-needed nutrients from animal-source foods; especially in children aged 6–59 months. Small fish (S1 File(PDF)Click here for additional data file.


Acute kidney injury (AKI) is a major postoperative morbidity of patients undergoing cardiac surgery and has a negative effect on prognosis. The kidney outcomes after pulmonary endarterectomy (PEA) have not yet been reported; However, several perioperative characteristics of PEA may induce postoperative AKI. The objective of our study was to identify the incidence and risk factors for postoperative AKI and its association with short-term outcomes.This was a single-center, retrospective, observational, cohort study. Assessments of AKI diagnosis was executed based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria.A total of 123 consecutive patients who underwent PEA between 2014 and 2018 were included.p < 0.001, p = 0.002, respectively). The independent predictors of postoperative AKI were the preoperative platelet count , preoperative hemoglobin concentration  and deep hypothermic circulatory arrest (DHCA) time  in the multivariate analysis.The incidence of postoperative AKI was 45% in the study population. Stage 3 AKI was associated with worse short-term outcomes and 90-day mortality (The incidence of postoperative AKI was relatively high after PEA compared with other types of cardiothoracic surgeries. The preoperative platelet count, preoperative hemoglobin concentration and DHCA duration were modifiable predictors of AKI, and patients may benefit from some low-risk, low-cost perioperative measures. Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare chronic form of pulmonary hypertension (PH) characterized by pathological changes in the pulmonary arteries and the presence of an occlusive tissue thromboembolism in the arterial lumen. CTEPH may lead to a gradual deterioration of PH, followed by right ventricular failure and eventually death –4. The iPulmonary endarterectomy (PEA) is recommended as the gold standard therapy by current guidelines , 7–10. IAcute kidney injury (AKI) is a common postoperative complication in patients undergoing cardiothoracic surgery and is associated with increased mortality and major adverse outcomes –16. Due The PEA procedure has the similar characteristics to thoracic aortic surgery. However, numerous studies have reported on the PEA-related complications –21, suchn = 3) and whose pre- or postoperative serum creatinine (SCr) data were missing (n = 1). The final study population was 123 patients.This study was approved by the Ethics Committees of the authors’ center. We included consecutive patients with CTEPH undergoing PEA between January 1, 2014 and August 31, 2018 in this retrospective observational study. We excluded patients whose final diagnosis at discharge was something other than CTEPH criteria , which aContinuous variables are presented as the mean (± standard deviation (SD)) for normally distributed variables or the median and interquartile range (IQR) and 25 – 75th percentiles for non-normally distributed variables, and categorical variables are presented as frequencies with percentages. Student’s t-test or the Mann-Whitney U-test were used to compare continuous variables, and the chi-square test or Fisher’s exact test were used to compare categorical variables among different groups. Logistic regression models were used to identify univariate and multivariate risk factors for AKI. All significant univariates were included in the multivariate model. A stepwise backward method was chosen for regression analysis. The Hosmer-Lemeshow goodness-of-fit statistic was performed to evaluate the fitness of the logistic regression model, and receiver operating characteristic (ROC) curve analysis was used to assess its discrimination. For all analyses, a probability value of less than 0.05 was considered statistically significant. Data were analyzed using SPSS 20.0.There were 127 CTEPH patients who received PEA at Fuwai Hospital during the last 5 years. We excluded 3 patients with a final diagnosis of something other than CTEPH at discharge and 1 patients with missing preoperative SCr data. Ultimately, 123 patients were included in the study  were male, with a mean age of 46.5 ± 12.8 years . All patients were diagnosed with CTEPH. Other comorbidities included hypertension (16.2%), diabetes (3.3%), and coronary artery disease (8.9%). Concerning risk factors for CTEPH, 26 (21.1%) patients had acute pulmonary embolism, 49 (39.8%) patients were diagnosed with deep venous embolism, 9 (7.3%) patients were diagnosed with anti-phospholipid syndrome, and 17 (13.8%) patients had a history of acute thrombolysis. All study participants underwent PEA at the authors’ center. The mean CPB time in this study cohort was 243 ± 170 min, and the mean duration of DHCA was 35 ± 17 min.Concerning preoperative renal function, the SCr levels of 12 (9.8%) patients were greater than 1.2 mg/dL, but none of them had SCr levels greater than 2 mg/dL. There was no difference between the AKI and non-AKI groups in preoperative renal function.n = 54); 37 (31%) patients were in stage 1, 10 (8%) patients were in stage 2, and 7 (6%) patients were in stage 3 AKI. Demographic and perioperative variables of the 4 groups are compared in the Table The overall incidence of postoperative AKI diagnosed according to the KDIGO criteria was 45% (p = 0.505). The area under the curve of ROC for AKI was 0.737   and 95% confidence intervals (CIs) for these predictors of AKI are as follows: preoperative platelet count of 0.992 (0.984–0.999); preoperative hemoglobin concentration of 0.969 (0.946–0.993); and DHCA duration of 1.197 (1.052–1.362) (Table p = 0.948) between AKI patients and non-AKI patients. Table p < 0.01).The primary outcome analysis demonstrated no difference in 90-day mortality  and LOIS  between the AKI and non-AKI groups, while the p-LOHS  showed no difference. However, in the sub-group analysis, patients both with AKI stage2 and stage3 AKI also had a significantly prolonged p-LOHS  compared with the non-AKI group. In addition, the MVT, LOIS and p-LOHS showed no difference between the stage 1 AKI and non-AKI groups (p > 0.05).In terms of secondary outcomes, significant differences were detected in the MVT  after PEA. We identified that a lower preoperative platelet count, lower preoperative hemoglobin concentration and prolonged DHCA duration were independent risk factors through multivariate logistic regression analysis. The MVT, LOIS and p-LOHS increased with increasing AKI severity. There was a significant difference in 90-day mortality between patients reaching stage 3 AKI and patients without AKI.As a result of the different diagnostic criteria for AKI and varied inclusion criteria among different previous studies, the incidence of AKI after cardiothoracic surgery under DHCA ranges from 11 to 55%, and the renal replacement therapy (RRT) rate is approximately 1.2 to 11% –28. InitThis study demonstrated a significant increase in the MVT, LOIS and p-LOHS in patients with stage 3 and stage 2 AKI, with an additional significant influence of stage 3 AKI on increased 90-day mortality. However, no difference was detected between patients with non-AKI and stage 1 AKI in any of the primary outcomes. In addition, we observed no significant difference in mortality between the AKI and non-AKI groups in the present study, as a result of the relatively lower intrinsic mortality rate and insufficient sample size to detect a difference.In this study, the logistic regression model identified that a lower preoperative platelet count, lower preoperative hemoglobin concentration and prolonged DHCA duration were independent risk factors for AKI. Previous literatures , 30consiTo achieve improved visualization, PEA is performed under CPB with DHCA, which not only provides a bloodless operative field for surgeons to perform a thorough distal-endarterectomy , but alsThe association of postoperative AKI with a prolonged DHCA duration has been discussed. On one hand, Mori et al.  reportedSimilar to previous studies , 34–40, In the present study, we found a significant association between the preoperative platelet count and postoperative AKI, indicating that the magnitude of the decreased platelet count was significantly correlated with the severity of postoperative AKI. This finding is consistent with those from studies by Miklos D et al.  and WailReduction in the preoperative platelet count may be related to platelet consumption caused by microthrombosis. Therefore, a decrease in the preoperative platelet count may indicate not only macroembolism, such as pulmonary embolism and deep venous thrombosis, but also microthrombosis formed with a similar pathophysiologic mechanism in CTEPH patients before surgery. This hypothesis may account for both the severity of and susceptibility to AKI in CTEPH patients.Since PEA is the most effective therapy for CTEPH, reducing AKI after PEA will greatly improve surgical outcomes. In this study, all independent variables associated with AKI after PEA were modifiable. If the observed association between these 3 factors— preoperative platelet count, preoperative hemoglobin concentration and duration of DHCA—and AKI after PEA is causal, then treating or avoiding these factors would reduce the incidence of AKI after PEA. There are some feasible measures with better risk-benefit profiles, such as preoperative iron and vitamin supplementation or administration of erythropoietin, cessation of drugs that affect blood clotting before surgery, minimization of hemodilution, management of antifibrinolytic drugs, and positive treatment of excessive bleeding . SimultaThis study has several limitations. First, because this was a retrospective study, missing data and inaccurate record keeping were inevitable. The rate of AKI and the short-term outcomes of patients may have been estimated improperly in this study. As a result, only an association between the three risk factors and AKI can be demonstrated, and a cause effect relationship cannot be assumed. Furthermore, we only focused on short-term outcomes, and the long-term outcomes were not analyzed. Second, the effects of unknown or unmeasured confounders on the observed associations between the risk factors and AKI  cannot be ruled out. Third, although we are one of the largest centers in Asia, the sample size is still small due to the low incidence of CTEPH and the late implementation of surgical techniques.This retrospective study first reported the incidence (45%) of postoperative AKI after PEA using the KDIGO criteria, and confirmed that AKI has a negative impact on short-term outcomes, including the MVT, LOIS and p-LOHS. Only stage 3 AKI was associated with a significant increase in 90-day morbidity. In the multivariate analysis, lower preoperative platelet count, lower preoperative hemoglobin concentration and prolonged DHCA duration were independent risk factors for postoperative AKI. We recommend that the preoperative platelet count, preoperative hemoglobin concentration and DHCA duration be used as predictors so that postoperative AKI after PEA can be identified earlier and treated promptly.


This paper combined GWAS, meta-analysis and sequence homology comparison with common bean to identify regions associated with seed size variation in domesticated cowpea.Vigun05g036000, Vigun05g039600, Vigun05g204200, Vigun08g217000, Vigun11g187000, and Vigun11g191300) which are implicated in multiple functional categories related to seed size such as endosperm development, embryo development, and cell elongation were identified. These results suggest that a combination of GWAS meta-analysis with synteny comparison in a related plant is an efficient approach to identify candidate gene (s) for complex traits in cowpea. The identified loci and candidate genes provide useful information for improving cowpea varieties and for molecular investigation of seed size.Seed size is an important trait for yield and commercial value in dry-grain cowpea. Seed size varies widely among different cowpea accessions, and the genetic basis of such variation is not yet well understood. To better decipher the genetic basis of seed size, a genome-wide association study (GWAS) and meta-analysis were conducted on a panel of 368 cowpea diverse accessions from 51 countries. Four traits, including seed weight, length, width and density were evaluated across three locations. Using 51,128 single nucleotide polymorphisms covering the cowpea genome, 17 loci were identified for these traits. One locus was common to weight, width and length, suggesting pleiotropy. By integrating synteny-based analysis with common bean, six candidate genes (The online version of this article (10.1007/s00122-019-03407-z) contains supplementary material, which is available to authorized users. Vigna unguiculata (L.) Walp] is a multipurpose crop and a major source of dietary protein, fiber, vitamins, and minerals for millions of people and livestock in sub-Saharan Africa. Eaten in the form of fresh seeds, dry seeds, and fresh pods and as forage, cowpea is also an important crop in some parts of Asia, Latin America, and the USA , SHB1 and IKU1  have been reported as seed weight candidate genes.A few GWA studies have been reported in cowpea for root architecture . The 368 lines were classified into six subgroups based on population structure . All accessions were grown under favorable conditions in the greenhouse and field in 2016 and 2017. Greenhouse growth was carried out at the University of California Riverside campus  as follows: Seeds from each accession were grown in 3.8 L pots filled with UCmix3 with temperatures at 35 °C day and 23 °C night. Mature, dried pods were harvested from each plant. For field experiments, each accession was planted in a single-row plot at the UCR Citrus Experiment Station, California, USA  and at the Coachella Valley Agricultural Research Station, California, USA . In field trials, mature, dried pods were harvested randomly as to minimize bias.A mini-core collection consisting of 368 accessions  was used for association mapping. The 368 accessions included landraces and breeding materials from 51 countries . It also included members of both the subspecies 3) in greenhouse and field experiments. The phenotyping for seed length and width was based on the average length and width of 10 seeds of each accession measured using a digital caliper. Seed density was calculated for each accession based on seed mass and its volume following the formula:Seed size-related traits were evaluated as 100-seed weight (g), seed length (mm), seed width (mm), and seed density . Total DNA was quantified using a Quant-IT dsDNA Assay Kit . The 368 accessions were genotyped using the Cowpea iSelect Consortium Array containing 51,128 SNPs . Principal component analysis (PCA) and a kinship coefficient matrix (K) were generated in TASSEL. PCA was used to account for population structure (Q), and K was used to correct for relatedness of accessions. The percentage contribution of each SNP to the total phenotypic variation was calculated using marker R2 values (computed by TASSEL) multiplied by 100.GWAS was conducted on 100-seed weight (measured in three locations), length, width, and density . GWAS was performed using the mixed linear model . Using functions of cowpeamine and legumemine (https://mines.legumeinfo.org), syntelogs were further intersected with a list of genes associated with seed weight as reported in Schmutz et al. . Seed size-related traits were evaluated based on seed weight, length, width and density. Mean and standard deviation were determined for each trait Table . Broad sA total of 42,711 polymorphic SNPs were used for GWAS. A total of 17 loci were identified for the seed size-related traits Fig. . A hot sR2 values of significant SNPs were calculated for each single environment and are reported in Supplemental Table 1. We also used Fisher’s meta-analysis to combine results of the three replications for seed weight. The results are almost indistinguishable from the Probit method developed here  identified six syntelogs from the intersection with seed weight candidate genes reported by Schmutz et al. , one for Sw5.2 (Vigun05g204200), one for Sw8.2 (Vigun08g217000), and two for Sw11 . The gene Vigun05g036000 is annotated as cell wall protein while Vigun05g039600 encodes a phosphate transporter PHO1. Vigun05g204200 is annotated as encoding a polycomb group protein FERTILIZATION-INDEPENDENT ENDOSPERM and Vigun08g217000 codes for a histidine kinase 2. The genes Vigun11g187000 and Vigun11g191300 are annotated as WD repeat-containing protein 61-like isoform 1 and delta (24)-sterol reductase-like protein, respectively. As comparative genomics is an efficient approach, we draw attention to these six interesting candidate genes.All identified loci were aligned to the cowpea reference genome . This result also revealed a presence of a significant G × E interaction with some loci being location specific. The presence of G × E interaction loci noted here confirms the complexity of seed weight. Overlap between our meta-analysis result and previous studies was found. BLAST searches of RLFP probe sequences from Fatokun et al. (Vigna radiata), suggesting that the genomic region has remained conserved through evolution. Also, Pan et al.  was in the same region as Sw3.2. Also, a clear peak for seed length was noted on the same genomic region. We note also that this region overlapped with a region identified for grain weight by Pan et al. . Taken tVigun05g036000 and Vigun05g039600. The former encodes a cell wall protein, which was reportedly associated with seed size . FIE genes are involved in endosperm development -sterol reductase protein and is an ortholog of the Arabidopsis DIMINUTO gene which has been shown to regulate cell elongation  using the annotated cowpea reference genome Frequency distribution of seed weight in the diversity panel (PPTX 60 kb)Supplementary material 3 (XLSX 36 kb)Supplementary material 4 (XLSX 2250 kb)Supplementary material 5 (XLSX 151 kb)Supplementary material 6 (XLSX 10 kb)Below is the link to the electronic supplementary material.


This study investigated the sex-specific incidence of asthma and the effects of modifiable risk factors, particularly obesity, on asthma incidence among middle-aged and older individuals in Korea.We used data from the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), which includes health examinees aged 40–79 years in 2002–2003. In total, 459,529 participants with baseline anthropometric measurements were followed-up for 10 years and the development of asthma was evaluated (2004–2013). For subgroup analysis, 246,019 participants who had body mass index (BMI) and waist circumference (WC) measurements taken in 2008–2009 were included in the analysis of the asthma incidence for 2010–2013. Factors associated with asthma were analysed using Cox proportional hazard models.The cohort comprised 4,248,813  person-years of follow-up for 2004–2013. The asthma incidence was 10.58 and 15.03 per 1000 person-years for men and women, respectively. Asthma incidence increased with age, notably so in men. Obesity based on the baseline BMI was significantly associated with asthma development in both sexes  = 1.13–1.34; women, HR = 1.40 95% CI = 1.32–1.48). High WC was also related to asthma incidence in both sexes with statistical significance . Analysis of the combined effects of BMI and WC showed that men had a higher asthma risk in the group with both general obesity and abdominal obesity than in the group with non-abdominal obesity and normal BMI. However, obese women had a higher risk of asthma regardless of abdominal obesity. Similarly, smoking was associated with asthma in both sexes but drinking and physical activity showed different associations between the sexes.Our results revealed that asthma incidence was substantially high at old age and lifestyle factors were associated with asthma development. Practical strategies including weight control and healthy lifestyle modification are required to prevent asthma in older people. Asthma in older adults is a serious health problem, particularly in conjunction with the rapid aging of society . The preLifestyle factors such as smoking, drinking and physical activity are reportedly modifiable risk factors for adult asthma. However, there are inconsistencies in their associations according to sex . Two preObesity is another well-known modifiable risk factor for asthma –27; howeBMI is a commonly employed tool for measuring obesity in adults. However, it cannot reflect the distributions of lean mass and fat in body compartments, which are significantly influenced by age and sex , 29. AltTherefore, this study aimed to assess the asthma incidence according to both age and sex while also investigating the sex-specific associations between modifiable risk factors and asthma incidence in Korean middle-aged and older adults. In particular, the association between obesity and asthma using individual and combined measurements of BMI and WC was explored.n = 514,866) from all health-screened participants aged 40–79 years from 2002 to 2003 [The National Health Insurance Service–Health Screening Cohort (NHIS-HEALS) is a cohort comprising a 10% random sample (n = 516), the number of participants who had their BMIs measured from 2002 to 2003 was 514,350. Among them, participants who had extreme BMI values (n = 17) and those who had a diagnosis of asthma  or had died (n = 1025) in 2002–2003 were excluded. Finally, 459,529 participants in total were analysed as the baseline study sample.Except for participants without BMI measurements  and those who had an asthma diagnosis  or had died  before the follow-up period , 2) 18.5 to < 23 kg/m2 , 3) 23 to < 25 kg/m2 (overweight), 4) 25 to < 30 kg/m2 (obesity) and 5) ≥30 kg/m2 (severe obesity) [Anthropometric indexes including height, weight and WC were measured in a standardised manner by trained nurses at each examination . Generalobesity) . The meaobesity) . The comHousehold income was divided into three groups , based on 11 levels of insurance fees in the NHIS insurance eligibility data. Information on health behaviours such as smoking, drinking and physical activity was collected via questionnaires. Smoking status was categorised as current smoker, past smoker and non-smoker using the question “Do you smoke cigarettes now?” with three levels of responses: 1) never smoked, 2) smoked in the past, but not now and 3) currently smoke. The questionnaires regarding drinking and physical activity were assessed based on the frequency of behaviours and consisted of five levels: 1) none, 2) 2–3 times per month, 3) 1–2 times per week, 4) 3–4 times per week and 5) almost every day. Using these levels, the variables were categorised into none, < 2 times per week and > 3 times per week. The insurance types were: self-employed insured, employed insured and medical aid beneficiary.The development of asthma was monitored from 1 January 2004 to 31 December 2013 for the analysis of baseline BMI and health behaviours. For subgroup analysis on both BMI and WC, the follow-up for asthma incidence started on 1 January 2010 and ended on 31 December 2013. The participants who had medical records with an asthma diagnosis code (J45 or J46) before starting the follow-up  were excluded in the analysis to confirm the pre-existence of asthma. Asthma incidence was the end-point for all analyses and participants who were dead or did not have an asthma diagnosis by 31 December 2013 were censored.First, the sample size and proportion of each category were calculated to check the distribution of the baseline population. We analysed the asthma incidence rates according to sex and age groups, which were calculated by dividing the number of new cases of asthma by the summing person-years of observation in each category during the follow-up period. Uni- and multi-variable hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated using Cox proportional hazard models to evaluate the effects of baseline BMI on asthma incidence. In the subgroup analysis, HRs were estimated to explore the effects of BMI and WC both separately and in combination in 2008/2009 on the development of asthma. Multivariable models were adjusted for age, insurance type, household income, smoking, drinking and physical activity at the baseline. To reduce data loss, missing values for smoking, drinking and physical activity were included in the analysis as a separate category named ‘unknown’.Sensitivity analysis with various follow-up times was conducted to evaluate the induction period for obesity-induced asthma. We compared the effects of the baseline characteristics on the asthma incidence using two and four years of induction time before the asthma follow-up.All analyses of men and women were conducted separately to explore the association between BMI and asthma incidence in terms of sex. Statistical analyses were performed using SAS version 9.4 .2: men, 35.5%; women, 33.6%) were higher in men than in women.The cohort comprised 459,529 participants  with 9.2 years of mean follow-up time. The study period counted as 4,248,813 person-years . During the observation period, 24,959 men and 28,412 women developed asthma. The distributions of the characteristics at the baseline are presented according to sex in Table Figure 2, men HR = 1.23, 95% CI: 1.13–1.34; women, HR = 1.40, 95% CI: 1.32–1.48). In women, BMI-based underweight status was associated with a lower risk of asthma compared to normal weight, whereas underweight men had an increased risk of asthma .Table Current smoking was a significant risk factor for asthma development in both sexes . Men who drank had a lower HR for asthma than those who did not . However, a non-significant effect was observed in women. Physical activity had a preventive effect on the development of asthma in men , whereas it was a risk factor for women .2, men HR = 1.23, 95% CI: 1.05–1.45; women, HR = 1.28, 95% CI: 1.12–1.47). High WC was significantly associated with asthma incidence in both sexes. In the results for the combined variable of BMI and WC, women showed similar associations for general obesity measured by BMI and asthma regardless of abdominal obesity. However, an increased risk for asthma was observed in for overweight/obesity as measured by BMI only in men with abdominal obesity. Men without abdominal obesity did not show an increased risk of asthma even in obesity based on BMI.Table Sensitivity analysis was conducted using two- and four-year lag times before the follow-up for asthma development. The association patterns between BMI and asthma were similar, although HRs were slightly decreased  regardless of drug prescription in the selection process for the study sample, whereas newly diagnosed asthma was defined using both asthma diagnosis and drug prescription during the follow-up period for asthma incidence. A previous study by Dombkowski et al. explored the accuracy of several case definitions for asthma based on the claims database . They coAsthma incidence increased with age in both sexes and the increasing trend in terms of age was more prominent among men than among women. In addition, earlier studies revealed a higher asthma incidence among older individuals than among middle-aged individuals, particularly among men. For example, the asthma incidence in a Canadian population was 3.7 (2.8) and 4.2 (3.2) per 1000 person-years in individuals aged 40–69 and ≥ 70 years for 2000–2001 (2004–2005), respectively. The increment of the asthma incidence between middle-aged and elderly individuals was higher among men than among women  . The rap2) on asthma was slightly lower (20–40% increased risk) compared to the results of previous studies (OR or RR 1.5–3.0) [Although our results showed that the asthma incidence differed between men and women, the deleterious effects of obesity according to BMI on asthma were similar for both sexes. Several prospective studies have shown sex-specific associations between obesity in terms of BMI and asthma , 21, 22.1.5–3.0) , 27, 50,i) systemic inflammation modulated by adipokines and adipose tissues, ii) mechanical changes in the respiratory system and iii) comorbidities. Adipose tissue secretes various pro- and anti-inflammatory adipokines that modulate inflammation [The underlying mechanism responsible for the association between obesity and asthma has not been fully elucidated. However, the following are several plausible relationships: ammation . An exceammation , 53. Thuammation . In addiammation . Finallyammation .We observed a sex difference in the association between underweight status and asthma incidence. In our results, underweight men based on BMI had a higher risk of asthma development than men in normal BMI ranges but the association was non-significant in women. Although the association between underweight status and asthma is still unclear, several empirical studies have shown a higher incidence of asthma in underweight subjects compared to the normal group , 22, 27.It was found that the combined effect of abdominal obesity and BMI was also different between the sexes. Our results showed that only ‘obese men with abdominal obesity’ had a higher risk for asthma. ‘Obese men without abdominal obesity’ did not have an increased risk of asthma compared to those with ‘normal weight without abdominal obesity’. Meanwhile, the risk for asthma in women was elevated in general obesity based on BMI regardless of waist size. These results might be because VAT distribution showed age and sex differences. Abdominal obesity is characterised as increased adipose tissue surrounding the intra-abdominal organs, which is known as VAT . The incOur study showed that health-related behaviours such as smoking, drinking and physical activity were associated with asthma risk. Similar to previous results , 61, smoThis study has several limitations. First, there was uncertainty regarding the accuracy of the definition of asthma using ICD-10 codes in the NHIS claims database. The differential diagnosis of chronic obstructive pulmonary disease (COPD) and asthma in primary care is challenging . Thus, tThis study showed an association between modifiable risk factors and asthma incidence in later life. Lifestyle factors including obesity, smoking, drinking and physical activity had independent effects on asthma incidence. Our results suggest that weight control and a healthy lifestyle can help prevent asthma.Additional file 1: Table S1. Sensitivity analysis for association between baseline BMI (2002–2003) and asthma incidence according to various lag time by sex. This analysis was performed to confirm the similarity of the associations between the risk factors and asthma when using different start dates.