Objectives. To review epidemiologic studies on the prevalence, incidence, and risk factors of dementia in sub-Saharan Africa (SSA). Methods. A MEDLINE search (from January 1992 to December 31, 2013) of epidemiologic studies, with no language restriction, was conducted using the keywords “dementia” or “Alzheimer's” and “Africa.” We selected for review population and hospital-based studies that reported the prevalence, incidence, or risk factors of dementia in SSA in people aged 60 years and above. References of selected articles were reviewed to identify additional relevant articles that met our selection criteria. Results. Of a total of 522 articles, 41 were selected and reviewed. The reported prevalence of dementia in SSA varied widely (range: 2.29%–21.60%); Alzheimer's disease was the most prevalent type of dementia. Only two studies conducted in Nigeria reported incidence data. Major risk factors identified include older age, female gender, cardiovascular disease, and illiteracy. Conclusion. Data on the epidemiology of dementia in SSA is limited. While earlier studies reported a lower prevalence of dementia in older persons, recent studies have put these findings into question suggesting that dementia prevalence rates in SSA in fact parallel data from Western countries.
Objective. Acute gout is among the most painful inflammatory arthritides and a frequent cause of emergency department (ED) visits. Prescription opioids are the leading contributor to the ongoing opioid epidemic; EDs are often the source of the index prescription. Our aim was to assess the burden of opioid use and factors associated with its use among gout patients discharged from the ED.Methods. In the electronic health records system of Lifespan Healthcare System (currently contains 2.2 million records), adult gout patients discharged from the ED or hospital were identified using International Classification of Diseases, Ninth Revision or Tenth Revision diagnostic codes. The study period was March 2015 to September 2017, and only patients with a primary diagnosis of gout were included. If a patient was seen multiple times, only the first encounter was included. For these patients, we estimated the frequency, dose, and duration of opioids prescribed. Using multivariable logistic regression, we ascertained the factors associated with increased odds of opioid prescription at discharge among patients with acute gout.Results. Of the 456 patients, 129 (28.3%) received opioids at discharge (~80% were new patients). The average dose of prescription was mean ± SD 37.9 ± 17.2 mg of morphine equivalent for a median duration of 8 days (interquartile range 5-14). We noted that patients with polyarticular gout attack and diabetes mellitus and those taking opioids prior to admission had higher odds of receiving opioids at discharge. Conclusion.Despite the availability of effective treatments, opioids are commonly used for the management of acute gout. This study highlights an opportunity to curb the opioid epidemic among gout patients.
Gout is the most common inflammatory arthritis in the US, affecting 3.9% of the population. Although many effective gout therapies are available for acute flares and chronic management, it is suboptimally treated worldwide, and recurrent gout flares can cause significant pain and irreversible joint damage.
Background:Emergency department (ED) visits for acute gout increased by approximately 20% between 2006 and 2014 in the United States. (1) Reducing ED length of stay (LOS) can help improve health outcomes, and reduce ED crowding and cost of care for patients with gout.Objectives:The aim of our study was to assess ED LOS and to identify factors associated with prolonged ED LOS in patients with acute gout.Methods:In this retrospective analysis, we included the first ED visit of adult patients (>18years) with acute gout who presented to the 3 EDs affiliated with Lifespan Health Systems, the largest healthcare provider in Rhode Island. Our study period was 3/30/2015 to 9/30/2017.We calculated ED LOS as the time spent by patients in the ED until they were discharged. Patients presenting to the ED and subsequently admitted to the hospital were excluded given the differential effect of systems factors in these patients. We assessed the following factors’ association with being in the upper quartile of ED LOS: (a) Patient factors – demographics, comorbidities and clinical presentation of gout (number of joints involved, severity as gauged by an ED triage nurse on a scale of 1 to 5; 1 being the worst) and (b) systems factors – time of day, day of the week, and time of year at presentation to the ED, teaching versus non-teaching hospital setting, and performing an arthrocentesis. We performed univariate and multivariable analyses to identify factors associated with prolonged ED LOS in patients with acute gout.Results:A total of 355 patients (mean age 56.6 ± 16.03 years, 81.3% males) were included. The median ED LOS was 2.65 hours (1.75, 4.3 hours). A quarter of the patients spent more than 4.3 hours in the ED; the national average across all medical illnesses being 3.7 hours (2). In the univariate analysis, older age (> 65 years), comorbidities (hypertension, congestive heart failure), worse ED severity score, procedural delays, and teaching hospital setting were associated with being in the upper quartile of ED LOS. In a multivariable analysis, age >65 years, procedural delays, and worse ED acuity score continued to be associated with longer ED LOS.Conclusion:In our study settings, patients with acute gout spent a longer time in the ED than the national median of 120-150 minutes. (2) We noted that older age and higher acuity score in addition to procedural delays led to longer length of stay in the ED. The results of our study should guide future interventions to reduce ED LOS for patients with acute gout.References:[1] Mithal, A., & Singh, G. (2018). OP0185 Emergency department visits for gout: a dramatic increase in the past decade[2]Centers for Disease Control and Prevention. (2014). QuickStats: median emergency department (ED) wait and treatment times, by triage level–National Hospital Ambulatory Medical Care Survey, United States, 2010-2011. Morb Mortal Wkly Rep, 63,439. (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6319a8.htm)Disclosure of Interests:None declared
B lymphocyte induced maturation protein-1 (Blimp-1) is a transcriptional repressor involved in B-lymphocyte differentiation and reported to be relatively plasma cell specific. The mechanisms that control its gene expression remain unknown although internal regulatory sequences have been postulated as required for B cell specificity. Aimed at directing therapeutic proteins into myeloma cells, we employed a transgenic strategy in studying the Blimp-1 promoter. We first cloned 5kb, 2.5kb and 1.6kb Blimp-1 promoter fragments from a BAC clone that contains the entire mouse Blimp-1 gene and fused the promoters to the luciferase reporter gene. As compared to a basal promoter PGL3, the Blimp-1 promoter fragments all demonstrated high and similar transcriptional activity (>7 fold over baseline) when transfected into BHK, Raji, OCIMy5 cells and R1 ES cells but weak activity (<2 fold) in murine preB leukemia cells. To further dissect Blimp-1 promoter function in vivo, the 5 kb promoter fragment (−4700 to +72bp) was fused to EGFP and used to generate transgenic mice. Northern blot and RT-PCR demonstrated that EGFP was expressed in the spleen, bone marrow (BM) and peripheral blood (PB) lymphocytes but not in the other tissue types examined. By FACS analysis, however, the EGFP positive population proved to be low (0.5–1%) in the spleen, PB or BM. To achieve higher Blimp-1 promoter-driven EGFP expression, we electroporated the 5kb Blimp-1/EGFP construct into ES cells and screened for higher EGFP expression clones. One clone with strong EGFP expression was used in blastocyst injection and generating chimeric mice. In this way, we have generated transgenic lines with higher EGFP expression in the spleen, BM and PB (3.2–4.7%, 2.2-3.4% and 3.8- 7.5%, respectively). After stimulation of cultured spleen and BM cells with 20 ug/ml LPS for 72 hrs, the EGFP population increased 2–3 fold in spleen cells and 3–4 fold in BM cells. Further FACS analyses of EGFP expression in LPS stimulated spleen cells demonstrated that EGFP was expressed in 14% of plasma cells (CD138+), 6.7% of mature B cells (CD19+), 4.6% of pre-B and B-cells (B220+) and 9.3% of CD8+ T cells. In BM culture after LPS plus IL-3 and IL-7 stimulation for 72 hr., EGFP is expressed in 8.7% of CD138+ cells, 5.9% of CD19+ cells, 6.9% of B220+ cells, 10% of TER119+ cells (erythropoietic cells), 11.3% of Sca-1+ cells and 12.8% cKit+ cells (progenitor cells). Furthermore, intravenous delivery of LPS resulted in upregulated EGFP expression in B cells, T cells and macrophages. The number of circulating B220-positive and EGFP-positive B cells doubled within 48hrs after LPS i.v. injection. Given EGFP expression in ES cells as well as Sca-1 and c-Kit+ve cells we examined emryos by fluorescent microscopy and observed strong EGFP expression in 9.5 dpc to 19.5 dpc mouse embryos. The precise localization of expression is now being analyzed. In summary: (1). The 5kb, 2.5kb and 1.6 kb Blimp-1 promoter fragments have similar transcriptional activity; (2). The 5kb Blimp-1 promoter is functional in vivo and specifically directs gene expression in all hematopoietic lineages. (3). The 5kb promoter is sufficient for LPS regulation. (4). The 5kb promoter is active in mouse embryonic development. As B cells were not specifically targeted we conclude that Blimp-1 has wider expression potential than previously recognized or that elements which control B cell specificity lie outside of the promoter fragments studied.
A 48-year-old White woman was hospitalized for evaluation of worsening painful ulcerated breast lesions in the setting of newly diagnosed untreated hepatitis C viral infection and successful gastric bypass surgery for morbid obesity a year ago.
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