Stability and bifurcation analysis of a discrete predator-prey system of Ricker type with refuge effect.

The refuge effect is critical in ecosystems for stabilizing predator-prey interactions. The purpose of this research was to investigate the complexities of a discrete-time predator-prey system with a refuge effect. The analysis investigated the presence and stability of fixed points, as well as period-doubling and Neimark-Sacker (NS) bifurcations. The bifurcating and fluctuating behavior of the system was controlled via feedback and hybrid control methods. In addition, numerical simulations were performed as evidence to back up our theoretical findings. According to our findings, maintaining an optimal level of refuge availability was critical for predator and prey population cohabitation and stability.

Impact of Ablation during Index Hospitalization on All-Cause Mortality in Patients with Typical Atrial Flutter: Insights from National Multicenter Database.

Background We sought to assess the impact of ablation during index hospitalization (IH) on all-cause mortality (ACM) in patients presenting with newly diagnosed typical atrial flutter (tAFL) as compared with patients without ablation, irrespective of optimal rate or rhythm control medications. Methods We identified patients with newly diagnosed tAFL in the TriNetX Research Network between January 20, 2010, and January 20, 2021. Using International Classification of Diseases, 10th revision (ICD-10) codes, patients were stratified into those who had undergone ablation during IH and those who did not undergo the procedure. Results were assessed using propensity score matching (PSM) analysis as well as Kaplan-Meier curves. Results A total of 12,986 (N) patients (aged 35-85 years) met our inclusion criteria. Of those, 3,665 had undergone ablation during IH compared with 9,321 patients who did not. Patients in the ablation group (mean age 64.3 ± 10.1 years) had a higher prevalence of hypertension (80 vs. 78.3%, p = 0.02), respectively. PSM created two well-matched groups of 3,652/3,652 patients each with an ACM of ablation of 4.5 versus 7.8% ( p = 0.01) at 6 months, 6.6 versus 11.4% ( p = 0.01) at 12 months, and 14.5 versus 20.9% ( p < 0.001) at 36 months of follow-up. Survival data were confirmed through Kaplan-Meier analysis using a log-rank test. Conclusion From a large, federated, multicenter population database, we report significant survival benefit of ablation during IH in patients presenting with new tAFL diagnosis. Kaplan-Meier mortality curves confirmed survival advantage with ablation at 6, 12, and 36 months of follow-up in this cohort.

Stigma, Social Support, Illicit Drug Use, and Other Predictors of Anxiety and Depression Among HIV/AIDS Patients in Pakistan: A Cross-Sectional Study.

Introduction: Anxiety and depression in people living with HIV/AIDS (PLWHA) can lead to non-adherence to antiretroviral therapy (ART), morbidity, and mortality. Therefore, assessing the stigma, social support, and other determinants of anxiety and depression in PLWHA are important for developing further interventions. Methods: An institution-based cross-sectional study was conducted in 505 PLWHA, approached through systematic sampling, who paid routine visits to the ART center, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Data was collected by pretested validated hospital anxiety and depression scale (HADS). Version 26 of the SPSS was used to apply Logistic regression analysis to identify determinants, and the 95% confidence interval (CI) adjusted odds ratio (AOR) was calculated to assess the magnitude of the relationships. Results: In PLWHA, the prevalence of co-morbid depression and anxiety was 80%. Separately, 89.9% had depression, and 80.3% had anxiety. Use of illicit drugs [AOR = 1.87, 95% CI (1.01, 3.27)], low social support [AOR = 1.21, 95% CI (1.02, 2.25)], being male [AOR = 2.21, 95% CI (1.11, 5.49)], and HIV related stigma [AOR = 2.48, 95% CI (1.25, 6.02)] were significant predictors of depression. Having detectable viral load [AOR = 3.04, 95% CI (1.04, 8.86)], young age [AOR = 5.31, 95% CI (1.19, 29.39)], no formal education [AOR = 21.78, 95% CI (4.03, 117.62)], low [AOR = 1.70, 95% CI (1.12, 6.93)] or moderate [AOR = 2.20, 95% CI (1.79, 6.09)] social support, illicit drugs addiction [AOR = 1.17, 95% CI (1.03, 2.55)], and HIV stigma [AOR = 54.3, 95% CI (21.20, 139.32)] had a remarkable association with anxiety. Conclusions: Given the high prevalence of anxiety and depression among PLWHA, the Pakistan Ministry of Health should focus more on monitoring mental health, expanding mental health services, and developing interventions based on identified factors to treat depression and anxiety among PLWHA.

Evaluation of Disease Related Knowledge in Patients of Osteoporosis: An Observational Study.

OBJECTIVE: Osteoporosis is a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue which results in consequent increase in bone fragility and susceptibility to fracture and more common in post-menopausal women and elderly people. This study was aimed to assess the knowledge of osteoporosis among patients in tertiary healthcare systems, as well as their knowledge of associated lifestyle, risk factors, and preventive measures. METHODS: A cross-sectional study design was used to determine the knowledge of outpatients towards osteoporosis. The survey was carried out in a tertiary care hospital Federal Government Polyclinic Hospital, Islamabad. This study included patients visiting various outpatient departments of Federal Government Polyclinic Hospital, Islamabad. A structured questionnaire was used as a tool to collect the data from the participants. The compiled data was analyzed by using the Statistical Package for Social Sciences (SPSS) software version 21.0. Chi-square test was performed to determine association level among study variables. Multiple regression was used to predict the impact of two or more independent variables on dependent variable. p-value of < .05 was considered to be significant. RESULTS: The mean score of knowledge was 8.73 ± 3.72. 159 (63.6%) respondents had poor knowledge, 78 (31.2%) had moderate knowledge and 13 (5.2%) had good knowledge. The results showed that most respondents had poor knowledge. Differences were statistically significant when age, gender, marital status and education were analyzed (P < .001). CONCLUSION: According to the results of all aspects of current study, it was concluded that mostly patients had inadequate knowledge regarding their disease which leads to an increased risk and progression of osteoporosis.

Devoid Knowledge and Low Adherence Precipitate Uncontrolled Blood Pressure: A Depiction From Cross-Sectional Study.

OBJECTIVE: The present study was aimed to assess knowledge regarding disease, adherence to medication and blood pressure control among hypertensive patients. METHODS: A cross-sectional study involving 384 hypertensive patients attending a tertiary care, public sector hospital in Islamabad, Pakistan, was conducted. Data was collected by using Urdu versions of pre-validated hypertension knowledge questionnaire and Medication Adherence Scale by Morisky. Each patient's blood pressure was measured through a calibrated mercury sphygmomanometer. Data was analyzed statistically by using SPSS software version 21.0. Chi-square test was performed to determine association level among study variables. Mann-Whitney and Kruskal-Wallis tests were performed to assess for statistically significant differences of demographic variables with systolic BP and diastolic BP. Multiple regression was used to predict the impact of two or more independent variables on dependent variable. P value of <.05 was considered to be significant. RESULTS: Mean (SD) systolic and diastolic blood pressures of 384 patients were 140.39 ± 15.485 and 88.74 ± 10.683 in mmHg respectively. The mean knowledge score was (13.26 ± 5.16 out of 22) and median score was 13. 103 (26.8%) of the patients had poor knowledge, whereas, 191 (49.7%) had moderate knowledge regarding hypertension with most of them at bottom line in the scale of moderate knowledge. The mean medication adherence score was (4.66 ± 2.743 out of 8), while 204 (53.1%) were categorized as poor adherent. CONCLUSION: The current study concluded that knowledge regarding hypertension, adherence to treatment and blood pressure control among hypertensive patients was found poor.

sessment Of Blood Pressure and Health-Related Quality of Life Among Hypertensive Patients: An Observational Study.

OBJECTIVES: Objective • Health-related quality of life (HRQoL) is an important tool in the assessment of treatment outcomes. Healthcare professionals use the concept of HRQoL to measure factors other than illness which affect human health and its status. Patient's everyday activities are adversely affected by hypertension (HTN) and results in decreased self-confidence. The present study was aimed to assess blood pressure and health-related quality of life (HRQoL) of hypertensive patients in Pakistan. METHODS: A questionnaire-based cross-sectional study was undertaken with 384 hypertensive patients attending a tertiary care public sector hospital in Islamabad, Pakistan. The assessment of HRQoL was done by using an EuroQol EQ-5D scale. Values derived from the UK general population survey were used to score HRQoL. The blood pressure of each patient was measured by using a calibrated sphygmomanometer. Data analysis was performed by using SPSS version 21 (SPSS Inc., Chicago, IL, USA). P ≤ .05 was taken as significant. RESULTS: Two hundred and fifteen (56%) patients were male with 3.31 ± 2.13 years of history of hypertension. The majority (n = 138, 35.9%) was categorized in the age group of 41 to 50 years with mean age of 50.21 ± 9.51. Mean (SD) systolic BP and mean (SD) diastolic BP was measured as 140.39 ± 15.485 and 88.74 ± 10.683 in mmHg respectively. Poor HRQoL was measured among the study participants (0.6456 ± 0.2317). Age, gender, education, occupation and monthly income had a significant relation with HRQoL score. CONCLUSION: Hypertension imposes an adverse effect on patient's HRQoL. Results from this study could be useful in clinical practice. Attention is required to highlight determinants of HRQoL and policies should be implemented for better management of HTN, particularly in early treatment phases where it is still possible to improve HRQoL.

Impact of pharmacist's intervention on disease related knowledge, medication adherence, HRQoL and control of blood pressure among hypertensive patients.

The present study was aimed to evaluate the effect of educational intervention provided to the patients of hypertension through pharmacist with the goal to improve knowledge about hypertension, adherence to prescribed medicines, blood pressure control and HRQoL(Health Related Quality of Life).A total of 384 patients were assigned randomly into 2 groups including intervention and control groups each having 192 patients. Urdu versions of knowledge questionnaire regarding hypertension, medication adherence scale (MMAS-U) by Morisky and EuroQol scale (EQ-5D) were utilized. Each patient's blood pressure was measured. After educational intervention, an increase was found in mean knowledge score about hypertension (18.18 ± 4.00), adherence score (5.89 ± 1.90), HRQoL score (0.73 ± 0.12) and Visual Analogue Scale (VAS) score (69.39 ± 5.90) among the IG. The blood pressure control also improved and lower systolic (131.81 ± 10.98 mmHg) and diastolic blood pressures (83.75 ± 6.21 mmHg) were observed among the patients of IG. This study showed that educational programs are useful for patients in increasing patient's levels of knowledge about hypertension, improving adherence to prescribed medication and enhancing blood pressure control. This increase is in turn accountable to improve HRQoL.

Probiotics and Their Use in Inflammatory Bowel Disease.

Context • Crohn's disease and ulcerative colitis result in similar gastrointestinal (GI) symptoms, including pain, diarrhea, stools with mucus or blood, and ulceration or tissue damage within the alimentary canal. Gut microbiota play a crucial role in triggering, maintaining, and exacerbating inflammatory bowel disease (IBD). Probiotics might help to rebalance the gut flora in a positive way, shifting from pro- to anti-inflammatory. Objectives • The study intended to investigate the safety and use of probiotics and the biological effects of probiotic bacteria on IBD. Design • The research team performed a literature review. The team conducted a database search in April 2015 using Google Scholar and PubMed to find studies relevant to probiotics and their use in IBD. Only papers that were published in English were considered, and all available years in each database were searched. The initial search identified 38 published articles, for which the research team obtained full texts and independently read them in full to identify those papers suitable for inclusion in the review. Setting • The study took place in the main library of the University of Lahore (Islamabad, Pakistan). Results • Many strains of probiotics exist, but the most common strains available today are (1) the Bifidobacterium species, (2) Enterococcus faecium, (4) the Lactobacillus strains, (4) Saccharomyces boulardii, (5) the Bacillus species, and (6) Pediococcus, all used to produce beneficial health effects. These species showed their beneficial effects on the host using different mechanisms involving (1) production of proteins, quorum sensing signaling inhibitors, butyrate, immunoglobulin A, and short-chain fatty acids; (2) decreased production of tumor necrosis factor alpha and interleukin 8; (3) increased expression of mucin 2; and (4) increased upregulation of defensin. Conclusions • Studies on probiotics in animal models of IBD are promising, and clinical results in IBD patients are encouraging; however, the data are limited, and few studies are placebo controlled. Additional placebo-controlled, double-blind studies in IBD are required before recommendations can be offered for routine use of probiotics in IBD. Additional organisms may eventually be developed through genetic engineering. The current evidence also indicates that probiotic effects are strain specific; they do not act through the same mechanisms nor are all probiotics indicated for the same health conditions. More research is needed to determine what strains and at what dose probiotics become more useful as part of a clinical intervention.

Pregnancy of unknown location: Outcome in a tertiary care hospital.

OBJECTIVE: To find out the outcome of a cohort of women with pregnancy of unknown location presenting to a tertiary care hospital. METHODS: The prospective study was conducted from January to December, 2011, at Early Pregnancy Assessment Unit, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia. Data was collected for women with early pregnancy or with history of amenorrhoea, bleeding or pain. These women were investigated with serum beta-human chorionic gonadotrophin levels twice weekly and transvaginal ultrasonography weekly. Expectant management was done for failing pregnancy of unknown location while medical or surgical management was considered for persistent pregnancy of unknown location and ectopic pregnancy. RESULTS: During study period, 7215 patients were admitted, and, of them, 2212(30.6%) were patients with early pregnancy. Meeting the inclusion criteria were 183(2.53%) patients who formed the study sample. There were 131(71.6%) patients presenting with amenorrhoea, 90(49.2%) had bleeding and 93(50.8%) presented with pain. Outcome of 100(54.6%) patients was failing pregnancy of unknown location, 58(31.7%) had intrauterine pregnancy, 14(7.7%) converted to ectopic pregnancy, while 11(6%) had persistent pregnancy of unknown location. All patients with persistent pregnancy of unknown location and 5(36%) patients with ectopic pregnancy were medically treated. Five (36%) patients having ectopic pregnancy were managed surgically. CONCLUSIONS: Management of choice for asymptomatic patients having pregnancy of unknown location is expectant management. Most of the patients suspected to have Most of the patients with persistent pregnancy of unknown location and ectopic pregnancy can be managed medically.

Effects of dietary sodium and the DASH diet on the occurrence of headaches: results from randomised multicentre DASH-Sodium clinical trial.

OBJECTIVES: Headaches are a common medical problem, yet few studies, particularly trials, have evaluated therapies that might prevent or control headaches. We, thus, investigated the effects on the occurrence of headaches of three levels of dietary sodium intake and two diet patterns (the Dietary Approaches to Stop Hypertension (DASH) diet (rich in fruits, vegetables and low-fat dairy products with reduced saturated and total fat) and a control diet (typical of Western consumption patterns)). DESIGN: Randomised multicentre clinical trial. SETTING: Post hoc analyses of the DASH-Sodium trial in the USA. PARTICIPANTS: In a multicentre feeding study with three 30 day periods, 390 participants were randomised to the DASH or control diet. On their assigned diet, participants ate food with high sodium during one period, intermediate sodium during another period and low sodium during another period, in random order. OUTCOME MEASURES: Occurrence and severity of headache were ascertained from self-administered questionnaires, completed at the end of each feeding period. RESULTS: The occurrence of headaches was similar in DASH versus control, at high (OR (95% CI)=0.65 (0.37 to 1.12); p=0.12), intermediate (0.57 (0.29 to 1.12); p=0.10) and low (0.64 (0.36 to 1.13); p=0.12) sodium levels. By contrast, there was a lower risk of headache on the low, compared with high, sodium level, both on the control (0.69 (0.49 to 0.99); p=0.05) and DASH (0.69 (0.49 to 0.98); p=0.04) diets. CONCLUSIONS: A reduced sodium intake was associated with a significantly lower risk of headache, while dietary patterns had no effect on the risk of headaches in adults. Reduced dietary sodium intake offers a novel approach to prevent headaches. TRIAL REGISTRATION NUMBER: NCT00000608.

25-Hydroxyvitamin D and ankle-brachial blood pressure index in adults without peripheral artery disease.

BACKGROUND: Inverse association between lower level of 25-hydroxyvitamin D [25(OH)D] and higher prevalence of peripheral arterial disease (PAD) among individuals with cardiovascular diseases (CVD) is known. Less is known about the relationship between 25(OH)D and ankle-brachial blood pressure index (ABPI) in asymptomatic adults. We hypothesized a nonlinear relationship between 25(OH)D and ABPI in asymptomatic adults without PAD. METHODS: Data from the continuous NHANES (2001-2004) was used. Minimum of the two reported ABPI value was chosen for each individual (>18 years). Linear regression models with spline adjusted for demographic and traditional risk factors for CVD were used to examine nonlinear relationship between 25(OH)D and ABPI. Mean changes in ABPI per 10 ng/mL change in 25(OH)D were reported. RESULTS: Mean (SD) age and 25(OH)D levels of 4979 participants (48% females) were 60.4 (13.22) years and 22.1 (8.68) ng/mL, respectively, while mean (SD) ABPI was 1.07 (0.15). We observed positive association between 25(OH)D and ABPI both in the univariable and multivariable regression models (all p < 0.05). In univariable regression with spline, a significant increase in ABPI (ß = 0.03, 95% CI: 0.02-0.04) was observed until 25(OH)D reached but not above 27 ng/mL. Similarly, in multivariable spline models, 25(OH)D was positively associated with ABPI (ß = 0.02, 95% CI: 0.01-0.03) only up to 27 ng/mL. CONCLUSIONS: In asymptomatic adults without PAD, rising serum 25(OH)D concentration but not above 27 ng/mL was associated with statistically significant increase in ABPI.

The relationship between 25-hydroxyvitamin D and homocysteine in asymptomatic adults.

CONTEXT: Hyperhomocysteinemia is an independent risk factor for premature atherosclerosis and thromboembolism. 25-Hydroxyvitamin D [25(OH)D] may modulate the expression of genes involved in homocysteine metabolism. OBJECTIVE: Little is known about the relationship between homocysteine and 25(OH)D. We hypothesized an inverse and nonlinear association between 25(OH)D and homocysteine. DESIGN: We analyzed data from the continuous National Health and Nutrition Examination Survey 2001-2006 for asymptomatic adults (≥18 y). SETTING: Linear regression models with spline adjusted for cardiovascular disease risk factors were used to explore nonlinearity. MAIN OUTCOMES MEASURE: Mean change (ß-coefficients with 95% confidence intervals) in homocysteine was reported per 10 ng/mL change in 25(OH)D. RESULTS: Mean (SD) age and homocysteine levels of 14 630 participants were 47.2 (20) years and 8.8 (4.7) µmol/L, respectively, whereas the median (interquartile range) of 25(OH)D was 21 (15-27) ng/mL. Without using spline, we observed an inverse relation between homocysteine and 25(OH)D both in simple [-0.25 (-0.34 to -0.02) µmol/L] and multivariable [-0.13 (-0.18 to -0.01) µmol/L] regression. With spline, in a univariate model, an increase in 25(OH)D was associated with a significant decrease in homocysteine [-0.56 (-0.75 to -0.37) µmol/L] until 25(OH)D reaches but not if above its median (21 ng/mL). Similarly, in multivariable spline models, the inverse relationship between homocysteine and 25(OH)D remain significant [-0.49 (-0.67 to -0.31) µmol/L] only below the population median of 25(OH)D. CONCLUSIONS: From a large community-based cohort of asymptomatic adults, we found an inverse relation between 25(OH)D and homocysteine among those with 25(OH)D concentration of 21 ng/mL or less. We did not observe any statistical decrease in homocysteine once 25(OH)D concentration rose above 21 ng/mL.

Foetal central nervous system anomalies: frequency and foeto-maternal outcome.

OBJECTIVE: To assess the frequency and outcome in pregnant females suspected to have foetal central nervous system anomalies on the basis of ultrasonography. METHODS: The retrospective study was conducted at the Department of Obstetrics and Gynaecology, Armed Forces Hospital, Southern Region, Khamis Mushait, Saudi Arabia, and comprised all women who were diagnosed by ultrasound to have foetal central nervous system abnormalities during anomaly scan at 18-20 weeks between January 2009 and December 2012. Data was retrieved from patient files and reviewed for foetal and maternal outcome. RESULTS: Of the 31,754 live births at the hospital during the study period, 22,880(72%) pregnant women were sent for ultrasonography to have foetal central nervous system anomalies checked. Of them, 181(0.57%) women had positive scans. Mean maternal age was 29.8±7 years and the mean gestational age at diagnosis was 24.4±7 weeks. There were 35(19%) primigravida, 108(60%) Para 2 to 5, and 38(21%) more than Para 5. Overall, 102(56.4%) women delivered vaginally, while 50(27.6%) delivered by caesarean section. Mean gestational age at delivery was 37.5±4.2 weeks. Major anomalies included ventriculomegaly 95(52.2%) neural tube defect 31(17.03%), cisterna magna 17(9.34%), and acrania 12(6.6%). No termination of pregnancy was done due to legal and religious reasons. CONCLUSION: Antenatal detection of central nervous system anomalies by screening with ultrasonography helps make multidisciplinary management plans.

Relationship between 25-hydroxyvitamin D and all-cause and cardiovascular disease mortality.

BACKGROUND: Observational studies have suggested a strong relationship between 25(OH)D and all-cause and cardiovascular disease mortality. A few studies also have described a nonlinear trend for this relationship in population subgroups, but less is known about this relationship in healthy adults. We examined the presence of a nonlinear relationship between 25(OH)D and all-cause and cardiovascular disease mortality among healthy adults. METHODS: We examined 10,170 participants (≥18 years of age) using National Health and Nutrition Examination Survey data (2001-2004) combined with National Death Index for vital status information through December 2006. Cox proportional hazard models with spline (single knot at population median of 25[OH]D) were fit to estimate hazard ratios (HRs) for all-cause and cardiovascular disease mortality for each 10-unit increase in serum 25(OH)D. Models were adjusted for demographic and conventional cardiovascular disease risk factors. RESULTS: Mean age of study participants was 46.6 (20.5) years, while median (interquartile range) 25(OH)D was 21 (15-27) ng/mL. After a median follow-up of 3.8 years (range 2.8-4.9), 509 all-cause and 184 cardiovascular diseases-related deaths were observed. In univariate analysis, 25(OH)D decreased hazards of all-cause (HR 0.59; 95% confidence interval [CI], 0.45-0.77) and cardiovascular disease (HR 0.56; 95% CI, 0.38-0.82) mortality below but not above its population median. In adjusted models, 25(OH)D retained the inverse association for all-cause (HR 0.54; 95% CI, 0.35-0.84) and cardiovascular disease (HR 0.50; 95% CI, 0.26-0.98) mortality below but not above its population median. CONCLUSIONS: We found an inverse association between 25(OH)D and all-cause and cardiovascular disease mortality in healthy adults with serum 25(OH)D levels of ≤21 ng/mL. Clinical trials for the primary prevention of cardiovascular disease with 25(OH)D supplementation may target healthy adults with serum 25(OH)D levels of ≤21 ng/mL to validate these findings.

Retinopathy of prematurity: are we missing any infant with retinopathy of prematurity?

AIMS: To evaluate incidence of retinopathy of prematurity (ROP) and validity of current ROP screening criteria adopted in the Armed Forces Hospitals. METHODS: A retrospective study of ROP indices was carried out in infants admitted to the neonatal intensive care unit in Khamis Mushait, Saudi Arabia, from January 2009 to December 2011. All infants who had birth weight (BW) of 1500 g or less and/or gestational age (GA) of 32 weeks or less had their data reviewed for ROP diagnosis and related indices. Some heavier or older infants were also included in the study. RESULTS: 386 infants were screened and ROP was diagnosed in 90 infants (23.31%). 25 infants (6.47%) had type 1 or worse ROP and were treated with cryopexy or laser. For patients having ROP, the mean GA was 27.8 ± 2 weeks and mean BW was 961.8 ± 237.4 g. Infants who needed treatment for ROP had a mean BW of 828.8 ± 192.8 g and mean GA of 27 ± 1.8 weeks. All infants who developed ROP fulfilled both or one criterion of ROP screening. No infant greater than 1350 g BW or more than 31 weeks GA was treated for ROP. CONCLUSIONS: Current ROP screening criteria of BW of 1500 g or less and/or GA of 32 weeks or less seems reasonable in our set up as no infant having ROP was missed by using these criteria. We do not recommend lowering or using only one index for ROP screening.

Relation between serum 25-hydroxyvitamin D and C-reactive protein in asymptomatic adults (from the continuous National Health and Nutrition Examination Survey 2001 to 2006).

The inverse relation between vitamin D supplementation and inflammatory biomarkers among asymptomatic adults is not settled. We hypothesized that the inverse relation is present only at lower levels and disappears at higher serum levels of vitamin D. We examined the relation between 25-hydroxyvitamin D [25(OH)D] and C-reactive protein (CRP) using the continuous National Health and Nutrition Examination Survey data from 2001 to 2006. Linear spline [single knot at median serum levels of 25(OH)D] regression models were used. The median serum 25(OH)D and CRP level was 21 ng/ml (interquartile range 15 to 27) and 0.21 mg/dl (interquartile range 0.08 to 0.5), respectively. On univariate linear regression analysis, CRP decreased [geometric mean CRP change 0.285 mg/dl for each 10-ng/ml change in 25(OH)D, 95% confidence interval [CI] -0.33 to -0.23] as 25(OH)D increased ≤21 ng/ml. However, an increase in 25(OH)D to >21 ng/ml was not associated with any significant decrease [geometric mean CRP change 0.05 mg/dl for each 10-ng/ml change in 25(OH)D, 95% CI -0.11 to 0.005) in CRP. The inverse relation between 25(OH)D below its median and CRP remained significant [geometric mean CRP change 0.11 mg/dl for each 10-ng/ml change in 25(OH)D, 95% CI 0.16 to -0.04] on multivariate linear regression analysis. Additionally, we observed a positive relation between 25(OH)D above its median and CRP [geometric mean CRP change 0.06 mg/dl for each 10-ng/ml change in 25(OH)D, 95% CI 0.02 to 0.11) after adjusting for traditional cardiovascular risk factors. In conclusion, from this cohort of asymptomatic adults, independent of traditional cardiovascular risk factors, we observed a statistically significant inverse relation between 25(OH)D at levels <21 ng/ml and CRP. We found that 25(OH)D at a level ≥21 ng/ml is associated with an increase in serum CRP. It is possible that the role of vitamin D supplementation to reduce inflammation is beneficial only among those with a lower serum 25(OH)D.

Continuous infusion versus intermittent bolus furosemide in ADHF: an updated meta-analysis of randomized control trials.

OBJECTIVE: Administering intermittent boluses of furosemide to patients with acute decompensated heart failure (ADHF) often leads to unfavorable hemodynamic changes. Continuous infusion may induce similar or greater diuresis without adverse hemodynamic consequences. We conducted a systemic review and meta-analysis of randomized clinical trials that compared the effects of continuous infusion and intermittent bolus of furosemide in patients hospitalized with ADHF. METHODS: We searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials databases from their inception until March 2011. Two investigators independently abstracted data on study characteristics, quality, and selected outcomes. Differences between investigators were resolved by mutual consensus. Comparisons were reported as the weighted mean difference (WMDs). RESULTS: Ten trials involving a total of 564 patients were included. When administered as a continuous infusion, furosemide resulted in greater diuresis (WMD, -240.54 mL/24 hours/100 mg furosemide; 95% confidence interval [CI], -462.42 to -18.66) and reduction in total body weight (WMD, -0.78 kg; 95% CI, -1.54 to -0.03), than when administered in intermittent boluses. Urinary sodium excretion (WMD, -20.26 mmol/24 hours; 95% CI, -60.48 to 19.96) and duration of hospital stay (WMD, 0.99 days; 95% CI, -2.08 to 4.06) were not different between the 2 groups. CONCLUSION: This meta-analysis showed statistical support for administering furosemide as a continuous infusion for greater diuresis and reduction in total body weight in patients hospitalized with ADHF. With the exception of greater diuresis, available data are homogenous for the reported outcomes but lack information on clinical endpoints. Larger studies are needed to provide robust recommendations for clinical practice.