Association between dietary inflammatory index and risk of endometriosis: A population-based analysis

Background and aimsChronic inflammation plays a significant role in the etiology of endometriosis, which might be affected by dietary intake. This study aimed to investigate the association between dietary inflammatory index (DII) and the risk of endometriosis.MethodsA cross-sectional analysis using data from the National Health and Nutrition Examination Survey (1999–2006) was conducted on 3,410 American participants, among whom 265 reported a diagnosis of endometriosis. DII scores were calculated based on the dietary questionnaire. The association of DII scores with endometriosis was evaluated by adjusted multivariate logistic regression analyzes, which were further investigated in the subgroups.ResultsIn the fully adjusted models, the odds ratio (OR) for endometriosis participants in the highest and middle tertiles of DII scores were 1.57 [95% confidence interval (CI): 1.14–2.17] and 1.18 (95% CI: 0.84–1.65), compared to the lowest tertile (Ptrend = 0.007). In subgroup analyzes, the significant positive association between DII scores and the endometriosis risk was also observed in non-obese women (ORtertile3vs1: 1.69, 95% CI: 1.12–2.55; Ptrend = 0.012), women without diabetes (ORtertile3vs1: 1.62, 95% CI: 1.16–2.27; Ptrend = 0.005), women with hypertension (ORtertile3vs1: 2.25, 95% CI: 1.31–3.87; Ptrend = 0.003), parous women (ORtertile3vs1: 1.55, 95% CI: 1.11–2.17; Ptrend = 0.011), and women using oral contraceptives (ORtertile3vs1: 1.63, 95% CI: 1.15–2.30; Ptrend = 0.006).ConclusionThis nationally representative study found that increased intake of the pro-inflammatory diet, as a higher DII score, was positively associated with endometriosis risk among American adults. Our results suggested anti-inflammatory dietary interventions may be promising in the prevention of endometriosis. Further prospective studies are necessary to confirm these findings

Speciated online PM1 from South Asian combustion sources-Part 1: Fuel-based emission factors and size distributions

Combustion of biomass, garbage, and fossil fuels in South Asia has led to poor air quality in the region and has uncertain climate forcing impacts. Online measurements of submicron aerosol (PM1) emissions were conducted as part of the Nepal Ambient Monitoring and Source Testing Experiment (NAMaSTE) to investigate and report emission factors (EFs) and vacuum aerodynamic diameter (dva) size distributions from prevalent but poorly characterized combustion sources. The online aerosol instrumentation included a qmini aerosol mass spectrometer (mAMS) and a dual-spot eight-channel aethalometer (AE33). The mAMS measured non-refractory PM1 mass, composition, and size. The AE33-measured black carbon (BC) mass and estimated light absorption at 370 nm due to organic aerosol or brown carbon. Complementary gas-phase measurements of carbon dioxide (CO2), carbon monoxide (CO), and methane (CH4) were collected using a Picarro Inc. cavity ring-down spectrometer (CRDS) to calculate fuel-based EFs using the carbon mass balance approach. The investigated emission sources include open garbage burning, diesel-powered irrigation pumps, idling motorcycles, traditional cookstoves fueled with dung and wood, agricultural residue fires, and coal-fired brick-making kilns, all of which were tested in the field. Open-garbage-burning emissions, which included mixed refuse and segregated plastics, were found to have some of the largest PM1 EFs (3.77-19.8 g k-1) and the highest variability of the investigated emission sources. Non-refractory organic aerosol (OA) size distributions measured by the mAMS from garbage-burning emissions were observed to have lognormal mode dva values ranging from 145 to 380 nm. Particle-phase hydrogen chloride (HCl) was observed from open garbage burning and was attributed to the burning of chlorinated plastics. Emissions from two diesel-powered irrigation pumps with different operational ages were tested during NAMaSTE. Organic aerosol and BC were the primary components of the emissions and the OA size distributions were centered at ∼ 80 nm dva. The older pump was observed to have significantly larger EFOA than the newer pump (5.18 g k-1 compared to 0.45 g k-1) and similar EFBC. Emissions from two distinct types of coal-fired brick-making kilns were investigated. The less advanced, intermittently fired clamp kiln was observed to have relatively large EFs of inorganic aerosol, including sulfate (0.48 g k-1) and ammonium (0.17 g k-1), compared to the other investigated emission sources. The clamp kiln was also observed to have the largest absorption Ångström exponent (AAE Combining double low line 4) and organic carbon (OC) to BC ratio (OC: BC Combining double low line 52). The continuously fired zigzag kiln was observed to have the largest fraction of sulfate emissions with an EFSO4 of 0.96 g k-1. Non-refractory aerosol size distributions for the brick kilns were centered at ∼ 400 nm dva. The biomass burning samples were all observed to have significant fractions of OA and non-refractory chloride; based on the size distribution results, the chloride was mostly externally mixed from the OA. The dung-fueled traditional cookstoves were observed to emit ammonium, suggesting that the chloride emissions were partially neutralized. In addition to reporting EFs and size distributions, aerosol optical properties and mass ratios of OC to BC were investigated to make comparisons with other NAMaSTE results (i.e., online photoacoustic extinctiometer (PAX) and off-line filter based) and the existing literature. This work provides critical field measurements of aerosol emissions from important yet under-characterized combustion sources common to South Asia and the developing world

Nepal Ambient Monitoring and Source Testing Experiment (NAMaSTE): Emissions of trace gases and light-absorbing carbon from wood and dung cooking fires, garbage and crop residue burning, brick kilns, and other sources

The Nepal Ambient Monitoring and Source Testing Experiment (NAMaSTE) campaign took place in and around the Kathmandu Valley and in the Indo-Gangetic Plain (IGP) of southern Nepal during April 2015. The source characterization phase targeted numerous important but undersampled (and often inefficient) combustion sources that are widespread in the developing world such as cooking with a variety of stoves and solid fuels, brick kilns, open burning of municipal solid waste (a.k.a. trash or garbage burning), crop residue burning, generators, irrigation pumps, and motorcycles. NAMaSTE produced the first, or rare, measurements of aerosol optical properties, aerosol mass, and detailed trace gas chemistry for the emissions from many of the sources. This paper reports the trace gas and aerosol measurements obtained by Fourier transform infrared (FTIR) spectroscopy, whole-air sampling (WAS), and photoacoustic extinctiometers (PAX; 405 and 870nm) based on field work with a moveable lab sampling authentic sources. The primary aerosol optical properties reported include emission factors (EFs) for scattering and absorption coefficients (EF Bscat, EF Babs, inm2kg-1 fuel burned), single scattering albedos (SSAs), and absorption Ångström exponents (AAEs). From these data we estimate black and brown carbon (BC, BrC) emission factors (gkg-1 fuel burned). The trace gas measurements provide EFs (gkg-1) for CO2, CO, CH4, selected non-methane hydrocarbons up to C10, a large suite of oxygenated organic compounds, NH3, HCN, NOx, SO2, HCl, HF, etc. (up to ∼ 80 gases in all). The emissions varied significantly by source, and light absorption by both BrC and BC was important for many sources. The AAE for dung-fuel cooking fires (4.63±0.68) was significantly higher than for wood-fuel cooking fires (3.01±0.10). Dung-fuel cooking fires also emitted high levels of NH3 (3.00±1.33gkg-1), organic acids (7.66±6.90gkg-1), and HCN (2.01±1.25gkg-1), where the latter could contribute to satellite observations of high levels of HCN in the lower stratosphere above the Asian monsoon. HCN was also emitted in significant quantities by several non-biomass burning sources. BTEX compounds (benzene, toluene, ethylbenzene, xylenes) were major emissions from both dung- (∼4.5gkg-1) and wood-fuel (∼1.5gkg-1) cooking fires, and a simple method to estimate indoor exposure to the many measured important air toxics is described. Biogas emerged as the cleanest cooking technology of approximately a dozen stove-fuel combinations measured. Crop residue burning produced relatively high emissions of oxygenated organic compounds (∼12gkg-1) and SO2 (2.54±1.09gkg-1). Two brick kilns co-firing different amounts of biomass with coal as the primary fuel produced contrasting results. A zigzag kiln burning mostly coal at high efficiency produced larger amounts of BC, HF, HCl, and NOx, with the halogenated emissions likely coming from the clay. The clamp kiln (with relatively more biomass fuel) produced much greater quantities of most individual organic gases, about twice as much BrC, and significantly more known and likely organic aerosol precursors. Both kilns were significant SO2 sources with their emission factors averaging 12.8±0.2gkg-1. Mixed-garbage burning produced significantly more BC (3.3±3.88gkg-1) and BTEX (∼4.5gkg-1) emissions than in previous measurements. For all fossil fuel sources, diesel burned more efficiently than gasoline but produced larger NOx and aerosol emission factors. Among the least efficient sources sampled were gasoline-fueled motorcycles during start-up and idling for which the CO EF was on the order of ∼700gkg-1 - or about 10 times that of a typical biomass fire. Minor motorcycle servicing led to minimal if any reduction in gaseous pollutants but reduced particulate emissions, as detailed in a companion paper (Jayarathne et al., 2016). A small gasoline-powered generator and an insect repellent fire were also among the sources with the highest emission factors for pollutants. These measurements begin to address the critical data gap for these important, undersampled sources, but due to their diversity and abundance, more work is needed

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Ecthyma gangrenosum aggravated by systemic antibiotics: A case report and literature review

Ecthyma gangrenosum is a cutaneous manifestation of systemic infection caused predominantly by Pseudomonas aeruginosa. We report a case of ecthyma gangrenosum in a child caused by P. aeruginosa who had been previously unsuccessfully treated with systemic antibiotics. A four years old boy presented with the complaints of fever and ulcers on the trunk and extremities. He had been initiated on systemic antibiotics without sending or awaiting reports of blood and skin swab culture and sensitivity. The swab samples taken from the ulcers revealed growth of P. aeruginosa. He was then started on antipseudomonal intravenous antibiotics which eventually led to full recovery. Injudicious use of systemic antibiotics can lead to colonization and infection by opportunistic organisms such as P. aeruginosa. The use of antibiotics has to be based on reports of culture and sensitivity

this happen or why is it mistaken?

A second gravida with normal antenatal period delivered a baby within an hour of admission and also expelled placenta which appeared at vagina. This placenta was adhererent to the fundus of uterus which was inverted but was persistently pulled out as uterine inversion was unrecognized. This case report will be of help to many of us who may mistake such condition. A habit to palpate the fundus of uterus and make sure it is contracted before controlled cord traction will help making the diagnosis in time

Challenges in Effective Referral of Cardiovascular Diseases in Nepal: A Qualitative Study from Health Workers’ and Patients’ Perspective

Background. Nepal, currently facing a high burden of noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), which poses the highest mortality rate in the country, does not seem to have a proper referral strategy. This study explored the wide range of factors and challenges that affect the referral system of CVD cases in Nepal. Methods. In this qualitative study, we conducted face-to-face and telephone interviews with purposely selected 57 key participants which included 35 healthcare professionals from tertiary, secondary, and primary levels from Bagmati Province and 22 CVD patients (myocardial infarction and stroke) from Bagmati and Madhesh Provinces. We interviewed them using an interview guide with open-ended questions for in-depth information in a local language and in a private space. The interviews were audio-recorded, transcribed verbatim, coded, and analyzed using the thematic approach. Results. The findings indicated that the referral system for CVD cases from primary- to secondary- to tertiary-level care is inadequate and malfunctioning. The major factors affecting referral of CVD cases are centralization of CVD-specific services in few urban areas, inadequate systematic communication between the centers, self-referential, lack of human resources for CVD care, and obstacles to patient transfer due to geographical and financial reasons. Conclusion. A referral system for CVD patients is absent in the context of Nepal. Understanding and addressing key factors that affect the referral system of CVD patients may help to improve cardiac outcomes and ultimately save lives

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal

International audienceBackgroundThere is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established.ObjectivesThis paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal.MethodsWe used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process.ResultsWe engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement.ConclusionsThe stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal

Health system gaps in cardiovascular disease prevention and management in Nepal

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.</p

The Kathmandu Declaration on Global CVD/Hypertension Research and Implementation Science: A Framework to Advance Implementation Research for Cardiovascular and Other Noncommunicable Diseases in Low- and Middle-Income Countries

Highlights NCD represent a serious challenge globally, particularly in LMIC.Implementation research capacity building are critical to inform the prevention and control of NCD in LMIC.Sustainable evidence-based strategies can reduce mortality and prevent avoidable illness from NCD.Strategic change agents (i.e., key stakeholders, institutions, communities, health systems, patients, and families) should work collaboratively to make the necessary advancements to reducing the burden of NCD in LMIC.Fil: Aifah, Angela. No especifíca;Fil: Iwelunmor, Juliet. No especifíca;Fil: Akwanalo, Constantine. No especifíca;Fil: Allison, Jeroan. Massachusetts Institute of Technology; Estados UnidosFil: Amberbir, Alemayehu. No especifíca;Fil: Asante, Kwaku P.. No especifíca;Fil: Baumann, Ana. Washington University in St. Louis; Estados UnidosFil: Brown, Angela. Washington University in St. Louis; Estados UnidosFil: Butler, Mark. No especifíca;Fil: Dalton, Milena. No especifíca;Fil: Davila Roman, Victor. Washington University in St. Louis; Estados UnidosFil: Fitzpatrick, Annette L.. No especifíca;Fil: Fort, Meredith. State University of Colorado at Boulder; Estados UnidosFil: Goldberg, Robert. No especifíca;Fil: Gondwe, Austrida. No especifíca;Fil: Ha, Duc. No especifíca;Fil: He, Jiang. University of Tulane; Estados UnidosFil: Hosseinipour, Mina. No especifíca;Fil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Kamano, Jemima. No especifíca;Fil: Karengera, Stephen. Washington University in St. Louis; Estados UnidosFil: Karmacharya, Biraj M.. No especifíca;Fil: Koju, Rajendra. No especifíca;Fil: Maharjan, Rashmi. No especifíca;Fil: Mohan, Sailesh. No especifíca;Fil: Mutabazi, Vincent. No especifíca;Fil: Mutimura, Eugene. No especifíca;Fil: Muula, Adamson. No especifíca;Fil: Narayan, K.M.V.. University of Emory; Estados UnidosFil: Nguyen, Hoa. No especifíca;Fil: Njuguna, Benson. No especifíca;Fil: Nyirenda, Moffat. No especifíca;Fil: Ogedegbe, Gbenga. No especifíca;Fil: van Oosterhout, Joep. No especifíca;Fil: Onakomaiya, Deborah. No especifíca;Fil: Patel, Shivani. University of Emory; Estados UnidosFil: Paniagua-Ávila, Alejandra. No especifíca;Fil: Ramirez zea, Manuel. No especifíca;Fil: Plange Rhule, Jacob. No especifíca;Fil: Roche, Dina. No especifíca;Fil: Shrestha, Archana. No especifíca;Fil: Sharma, Hanspria. No especifíca;Fil: Tandon, Nikhil. No especifíca;Fil: Thu Cuc, Nguyen. No especifíca;Fil: Vaidya, Abhinav. No especifíca;Fil: Vedanthan, Rajesh. No especifíca;Fil: Weber, Mary Beth. University of Emory; Estados Unido