The prevalence of GERD increased gradually with weight gain . With regard to lifestyle, the prevalence of GERD in the subjects who smoked , consumed alcohol excessively, lacked physical activity , and had an excessive intake of oil, meat, fish, and eggs showed an ascending trend . In contrast, an adequate intake of vegetables (≥300 g/d) and fruit (≥200 g/d) was associated with a significantly lower incidence of GERD. Suspected GERD is very common in individuals undergoing health examinations. Unhealthy lifestyles are closely related to the high incidence of suspected GERD. GerdQ scores can play a role in screening for GERD.The aim of this study was to investigate the distribution characteristics of GerdQ results in a Chinese population and the association between lifestyle and GerdQ scores. Among the 37 442 individuals enrolled from September 2009 to March 2016, 7 449 (19.89%) had a GerdQ score of ≥8 points and 29 993 (80.11%) had a GerdQ score of <8 points. The percentage of men with suspected GERD was significantly higher than the percentage of women with suspected GERD ( Gastroesophageal reflux disease (GERD) refers to the symptoms and complications caused by the backflow of gastric content into the oesophagus, mouth (including the throat), or lungs . Reflux At present, GERD is often diagnosed by the following five methods: (a) a questionnaire to learn the frequency and severity of symptoms; (b) upper gastrointestinal endoscopy; (c) proton pump inhibitor (PPI) treatment as a diagnostic test; (d) 24-h oesophageal pH monitoring; and (e) combined 24-h and impedance-pH monitoring , and theMany studies have focused on the association between GERD and established risk factors, such as age, gender, body mass index (BMI) , obesityTherefore, in the present study, we first analysed the incidence of GERD. Second, we explored the potential association between daily lifestyles and the incidence of GERD in an attempt to further investigate the application of the GerdQ in diagnosing GERD in physical examination populations.Individuals who had undergone a routine physical examination in the Health Medical Center of the PLA General Hospital from September 2009 to March 2016 were enrolled as the subjects of this study. Patients with stroke, heart failure, renal insufficiency, malignant tumour, and/or gastric surgery were excluded. Individuals with incomplete examination and test records were also excluded. For patients who had received multiple physical examinations, the results of the latest physical health checkup were used. A total of 37 442 subjects were enrolled, including 27 274 men (72.84%) and 10 168 women (27.16%).The survey content included general demographic information, smoking and drinking histories, diet and exercise habits, and physical examination and laboratory findings. Physical examinations included the measurement of height, weight, and blood pressure, whereas laboratory tests included routine items such as blood lipids and blood glucose. Smoking is defined as consuming ≥10 cigarettes per day for at least 1 year, and smoking cessation is defined as the continuous quitting of smoking for more than one year, which was consistent with the World Health Organization (WHO) definition for smoking .Alcohol consumption is classified as limited alcohol consumption  and excessive alcohol consumption . It was based on the WHO Global Status Report on Alcohol and Health 2014 and the Dietary Guidelines for Chinese Residents 2016 .Blood pressure was measured in accordance with the Chinese Hypertension Prevention and Treatment Guidelines 2005, which is defined as a systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg .2 (m2), according to WHO standards [2 to 28 kg/m2 and obesity as a BMI of ≥28 kg/m2, according to the 2016 “Expert consensus on medico-nutritional treatment of overweight and obesity in China” [A body composition analyser was used to measure body weight and height, and the BMI was calculated as weight (kg)/heighttandards . Values All subjects fasted overnight and wore a hospital gown during the measurements. This study was approved by the Ethics Committee of the PLA General Hospital, Beijing, China. All subjects were informed that their health checkup data might be used anonymously in scientific research and signed informed consent.During the GerdQ-based survey, the subjects were asked to recall their symptoms and the frequency of their occurrence over the past 7 days. The symptom frequencies were scored as follows: (a) the frequency of positive symptoms (heartburn and reflux): 0, 1, 2, and 3 points for 0 day, 1 day, 2-3 days, and 4-7 days, respectively, with the highest possible score being 6 points; (b) the frequency of negative symptoms : 3, 2, 1, and 0 points for 0 day, 1 day, 2-3 days, and 4-7 days, respectively, with the highest possible score being 6 points; and (c) the frequency of heartburn and reflux affecting sleep at night and the need for additional medications: 0, 1, 2, and 3 points for 0 day, 1 day, 2-3 days, and 4-7 days, respectively. The sum of the points for the abovementioned frequencies served as a subject's GerdQ scores, and a diagnosis of GERD could be made if the sum was ≥8 points [The judgement criteria for dietary factors were as follows: (a) standard daily intake of cereals : 250 g-400 g; nonstandard if <250 g or >400 g; (b) standard daily vegetable (≥300 g) and fruit (≥200 g) consumption; (c) standard daily intake of fish and shrimp (50 g-100 g), livestock and poultry meat (50 g-75 g), and eggs (25 g-75 g); inadequate if <125 g and excessive if >225 g; (d) standard daily edible oil consumption: <30 g; (e) standard alcohol consumption: ≤25 g for men and ≤15 g for women or never drinking; and (f) standard daily intake of dairy products: 250 g-350 g; inadequate if <250 g and excessive if >350 g. These classifications are derived from the general recommendations of the WHO panel on diet, nutrition, and chronic disease prevention and the Dietary Guidelines for Chinese Residents 2016 , 21, 22.The judgement criteria for physical activity were as follows: (a) adequate physical activity: engaging in vigorous activity for at least 3 days per week  min per week) or 7 days a week ; (b) moderate physical activity: engaging in at least 20 minutes of vigorous physical activity per day for a minimum of 3 days per week or at least 30 minutes of nonvigorous physical activity per day for a minimum of 5 days per week, or at least 5 days of physical activity per week, achieving a minimum of 600 MET-min per week but not exceeding 3000 MET-min; (c) inadequate physical activity: if the abovementioned criteria  are not met .http://www.stata.com/stata11/). The normality was tested by the Kolmogorov-Smirnov method. The measurement data are expressed as the means ± standard deviations, and the categorical data are expressed as percentages. Chi-squared tests and logistic regression analyses were performed, and a P value of <0.05 was considered statistically significant.The survey data were encoded, quantified, and entered into a computer. Statistical analysis was performed using Stata 11.0 software  had a GerdQ score of ≥8 points and 29 993 (80.11%) had a GerdQ score of <8 points.χ2 = 111.571, P ≤ 0.001)  but was significantly higher in young and middle-aged subjects than in elderly subjects , which shows a positive association between GERD and younger age  (P ≤ 0.001). Fasting blood glucose (P = 0.039) and LDL-C were also slightly higher (P = 0.002), while HDL-C was significantly lower (P ≤ 0.001)  . The age≤ 0.001) . The difnger age . The bodnger age . The pre≤ 0.001) . Associa≤ 0.001) .χ2 = 119.361, P ≤ 0.001). The proportion of suspected GERD was significantly higher in the excessive alcohol consumption group than in the nonexcessive alcohol consumption group. The rate of suspected GERD was the lowest in subjects with adequate physical activity, followed by subjects with moderate and inadequate levels of physical activity . In terms of dietary factors, subjects with excessive daily oil intake had a significantly higher incidence of GERD than did those with standard oil intake. The prevalence of GERD was significantly lower in subjects with standard vegetable (≥300 g/day) and fruit (≥200 g/day) intake than in those who did not meet the standards. The intake of dairy products showed no significant effect on GERD incidence. The prevalence of GERD was not significantly different between the low-cereal-intake group and the moderate-cereal-intake group (P = 0.317) but was significantly lower than in the high-cereal-intake group. The prevalence of GERD gradually increased in subjects with inadequate, adequate, and excessive consumption of meat, fish, and eggs   , Table 2Based on the results of univariate analysis, a stepwise multivariate regression analysis was performed with suspected GERD as the dependent variable and the following as independent variables: gender; smoking; alcohol consumption; salt intake; physical activity; age stratification; BMI stratification; waist circumference; systolic blood pressure; diastolic blood pressure; TC; TG; uric acid; fasting blood glucose; LDL-C; HDL-C; and daily intake of oil, dairy products, vegetables, fruits, cereals, milk, and meat/fish/eggs. The results are shown in This was the first large-scale study exploring the prevalence of GERD-related symptoms using GerdQ scores in a sample of individuals receiving health checkups in China. Our data showed a prevalence rate of weekly symptoms in 19.89% of the total subjects. The GerdQ is a simple, rapid, noninvasive, and effective tool that can reliably reflect changes in symptoms and quality of life. It is easy to operate, with minor memory bias and good patient compliance; furthermore, it has a sensitivity of 60%-90% with a specificity of 45%-86%, which is the diagnostic accuracy of a gastroenterologist .The prevalence of GERD is geographically and racially related in GERD epidemiology –26. The χ2 = 111.571, P ≤ 0.001), and the proportion of GERD was high in younger and middle-aged subjects.In the present study, the proportion of suspected GERD was significantly higher in men than in women (Differences in the proportion of suspected GERD between men and women may have emerged simply because the population screened was ~70% men and ~30% women. It is worthwhile to investigate the percentage of men and women who had suspected GERD.Further dietary analysis suggested that excessive alcohol consumption, excessive daily salt and fat intake, inadequate intake of vegetables and fruits, excessive intake of cereals, and excessive intake of meat, fish, and eggs were associated with a high incidence of GERD. It has been reported that the incidence of GERD was high among the residents in north-western China, who have a preferred diet of beef and mutton . SimilarRecent studies have also shown that smoking is an independent factor in predicting the progression of GERD , 34. HowThe present study had several strengths. It was based on a large sample size, and the results were highly representative of the Chinese population. All questionnaires were completed by the subjects themselves, and the data acquired were highly reliable. We found that 19.89% of the subjects receiving health checkups had a GerdQ score of ≥8 points. Although GERD cannot be diagnosed by GerdQ scores alone, this method is cost-effective and of great practical significance in preliminary screenings for GERD in individuals receiving health checkups to identify suspicious or risky cases and offer appropriate lifestyle interventions.Our study had several limitations. First, the GerdQ provides a symptom-based diagnosis; some patients with GERD may present with atypical symptoms, such as cough, asthma, laryngitis, and the absence of typical oesophageal symptoms, while other patients with GERD experience no symptoms at all , 38. In In conclusion, suspected GERD or a high risk of GERD is very common in the population of individuals undergoing health examinations. Unhealthy lifestyles are closely related to a high incidence of suspected GERD. GerdQ scores can play a role in screening for GERD. Larger prospective controlled trials are required to conclusively modify the recommended dietary guidelines in the treatment of GERD.


Few literatures have evaluated the exact role of metabolomics in the identification process of potential biomarkers for acute kidney injury among the patients receiving renal transplantation. On top of this, the success of metabolomics in biomarker translation seems to lie in the robust quantitative method. As such, a single-center retrospective observational study was conducted enrolling 42 patients underwent renal transplantation with/without acute kidney injury, as well as 24 healthy volunteers, in Shanghai Changzheng Hospital. Plasma amino acid metabolic patterns for the participants were investigated by targeted UHPLC-MS/MS metabolic profiling. The most significant changes of the explored metabolites were related to the disturbance of tryptophan metabolism and arginine metabolism. Abnormal circulating tryptophan and symmetric dimethylarginine were identified to be potential biomarkers of acute kidney injury, combination of which showed a higher area under receiver-operator curve value (AUC = 0.901), improved sensitivity (0.889) and specificity (0.831) compared with creatinine only. Overall, these results revealed that targeted metabolomics analysis would be a potent and promising strategy for identification and pre-validation of biomarkers of acute kidney injury in renal transplantation patients. Early detection has proved to be the key to limit the potential damage to transplanted organs and improve long-term prognosis of these receiving kidney transplantation. In addition to kidney biopsy, serum creatinine (SCr) is widely applied as the indicator to monitor the renal function, which is of significant heterogeneity and observed only after substantial kidney injury. While kidney biopsy, an invasive option, could be costly and impractical in multiple sampling. Failure to early diagnosis of AKI often leads to disastrous or even life-threatening episodes of renal dysfunction, thus it is desirable to discover ideal biomarkers, which should be non-invasive and identify AKI in renal transplantation patients.Acute kidney injury (AKI) is increasingly common and associated with transplant failure and death in renal transplantation patients. Its causes are multiple and include rejection, infections, ischemia-reperfusion injury, and drug toxicity and etc2. Of note, the success of metabolomics in biomarker translation seems to lie in the fact that the underlying instrumentation is robust, quantitative, easily adapted to new assays and already located in many clinical testing laboratories3, and the clinical merit of potential biomarkers needs to be validated in a well-planned separate targeted study4. As a result, the targeted metabolomics approach is reckoned to be preferable for assessment of specific pathways with focus of interest recently, for instance, the newborn screening of inborn errors of metabolism would facilitate doctors to prevent or reduce significant morbidity and mortality in the early stage, by analyzing metabolic patterns of vitamins, amino acids, acylcarnitines, and so on7.Metabolomics, an approach for precision medicine, has been yielding important insights into the underlying reasons for acute kidney injury, as well as the biomarker identification. Nevertheless, few metabolomics studies have been conducted in the renal transplantation patients8. Data from previous researches had shown promising evidence of AA analytics in monitoring the progress of kidney diseases9. AA profile in patients’ plasma and urine were of relevance with their clinical evaluation not only in different stages of chronic kidney disease10, but also in the AKIs12. In spite of the established association between plasma AA concentrations with estimated glomerular filtration rate (eGFR) in transplantation patients13, little information was available about the value of AA profile in prediction of AKI among patients receiving the renal transplantation. Furthermore, our previous research revealed that concentrations of total AAs and many AAs, such as alanine, lysine, aspartic acid, serine, and methionine, were significantly altered in renal transplantation patients when compared to the healthy volunteers14. This finding shed light on the meaning of the AA profile in renal transplantation patients, characterization of which would be necessary for understanding AKI process and identifying potential biomarkers for kidney dysfunction.Plasma free amino acids (PFAAs) played a fundamental role in the metabolism realm as the direct response of metabolic flux, and kidney was shown to play a central role in modulation of AA metabolism. Abnormal plasma AA concentrations had been confirmed to be associated with renal diseases. Once renal dysfunction occurs, both the lost control of AA metabolism by kidney as well as the impact of renal failure and acidosis on whole-body nitrogen metabolism would contribute to the disturbed plasma AA levels14, which was based on modification of our previously published method. Furthermore, the targeted metabolomics study was conducted in 42 patients underwent renal transplantation with/without acute kidney injury and 24 healthy volunteers, in a single-center retrospective observational study. In this pre-validation study, the diagnostic accuracy of potential AA biomarkers was investigated using receiver operating characteristic (ROC) analysis.Therefore, we herein present a quantitative method of 25 AAs in plasma samples by ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC–MS/MS)0/C0 (ng/ng/mL), SCr (μmol/L), BUN (mmol/L), UA (μmol/L) and LDH (U/L). However, eGFR (mL/min/1.73 m2), HGB (g/L), RBC (10^12/L), LYM (10^9/L), T-BIL (μmol/L) and ALT (U/L) were significantly lower in the NB group. There were no significant differences in other characteristics.Characteristics of the recruited participants were summarized Table , enrolli15  indicated a different metabolic pattern for most studied AA. To be specific, NA and NB patients had a lower level of AA profile, such as Cys, HA, Arg, His, Trp, Gln/Glug, Arg/Phe, Ser/Gly, Val/Gly, compared with those from HV subjects (p < 0.05)  or Spearman (ρ) Rank test, and displayed in a heat-map Fig. . Detaile21  compared with NA group, supported its potential role as an early marker for kidney injury, which was in agreement with a previous report24. Although both SDMA and ADMA could affect the endogenous deficiency of NO, ADMA was often recognized as an indicator of cardiovascular events and death in different populations. In contrast to ADMA, SDMA was barely catabolized, but excreted exclusively by the kidney, implying that its accumulation could only occur due to the decreased excretion in patients with renal diseases. SDMA was therefore identified as a promising marker of renal function25 . Furthermore, its plasma level was elevated in patients with AKI (0.37 ± 0.08 μg/mL) in comparison to those without (0.22 ± 0.07 μg/mL). These findings were in accordance with the results derived from much larger populations28. Convincingly, both SDMA level and SDMA/SCr ratio showed strong correlations with plasma levels of SCr, eGFR, BUN and UA. However, SDMA level showed little correlation with levels of SCr, eGFR, BUN and UA in both HV and NB groups. Similar correlation coefficients were also uncovered by many reports, including meta-analysis and metabolomics studies32. Additionally, SDMA was reported to be independently associated with graft loss and mortality after adjusting for eGFR in human as well as in rodents33. To this end, our data firstly presented the promising value of SDMA or SDMA/SCr for prediction of AKI in patients receiving renal transplantation, and revealed that plasma SDMA levels increased in parallel with the rise of SCr, BUN and UA when such patients developed renal injury.AA profile analysis revealed the perturbed Arg cycle in both NA and NB groups. Arg was degraded to Cit by nitric oxide synthase (NOS), but Arg could be synthesized from Cit via the urea cycle enzymes argininosuccinate synthetase (ASS) and argininosuccinatelyase (ASL), which were mainly located in the proximal tubular cells34. In our study, NB group was elucidated with a marked decrease of Trp (P < 0.01) and slight rise of Kyn, indicating a disturbed Trp metabolism. Enzyme indoleamine 2,3 dioxygenase 1 (IDO1) was the key and rate-limiting enzyme of Trp metabolism, therefore plasma Kyn/Trp ratio was applied as an indicator of the enzymatic function of IDO1 40. Likewise, our experiment demonstrated that Trp level significantly decreased from 12.28 ± 2.36 μg/mL in NA group to 9.94 ± 2.30 μg/mL in NB group (0.8 fold-change), accompanied by a rise trend of Kyn level, from 0.50 ± 0.27 μg/mL to 0.59 ± 0.22 μg/mL. In parallel of this, Kyn/Trp ratio was significantly increased from 0.04 ± 0.03 to 0.06 ± 0.02 during episodes of kidney injury.Trp metabolism was highlighted in recent metabolomics researches in patients with kidney cancerDO1 Fig. 35,36. InSome limitations of this analysis demanded further discussion. Firstly, the observed perturbed AA biomarkers could not be substantiated to be associated with the donor and recipient pharmacogenetic factors for AKI in current study. In view of this, further interpretation of the metabolomics, with pharmacogenetic and demographic characters, was still needed for a robust integrated biomarker system. Secondly, only some preselected AAs had been investigated and tested in our study. Because it was becoming increasingly clear that the signs of AA profile disorders would entail and/or accompany with a suite of altered metabolites, which could be analyzed in the future LC-MS/MS based targeted metabolomics method that covered more predefined metabolites. Besides, our results reinforced the concept that AA metabolism were important for the AKI episode. Thirdly, the diagnostic value of the potential AAs or the AA profile should be validated with larger sample volume in clinical practice, and whether the alteration in the plasma AA preceded changes in the classically used biomarkers or other established ones needs to be confirmed. Importantly, future researches should attempt to differentiate the causes of AKI, which was not identified in this study, because it was our preliminary research to correlate the diagnostic performance of targeted AA metabolic profiling analysis with kidney injury.In summary, we investigated the perturbed AA metabolic pattern in plasma from renal transplantation patients by using targeted metabolomics study, based on a validated UHPLC-MS/MS method. This strategy resulted in the discovery of Arg and Trp cycle disturbances in AKI, with SDMA and Trp as potential risk predictors. Furthermore, SDMA and Trp combination revealed a larger AUC over SCr and any other single AA biomarker. To our knowledge, this was the first study to report that SDMA and/or Trp may function as potential biomarkers for prediction of AKI in renal transplantation patients.A retrospective review of a prospectively collected database of kidney transplants at Shanghai Changzheng Hospital from Nov. 2013 to Aug. 2014 revealed 42 hospitalized kidney transplantation patients suitable for the study. Each patient enrolled in this study received a kidney transplantation from a living donor at our institution . Recipients of a deceased donor kidney were not included in this study and no organs were procured from (executed) prisoners. Patients who suffered from diabetes, hypoglycemia, inherited metabolic diseases, and other metabolic disorders were excluded. All the clinical and research activities reported here were in accordance with the Declaration of Helsinki as well as other relevant guidelines and regulations, and approved by the ethical board of Shanghai Changzheng Hospital. Informed consent was retrieved from all the participants. They were treated with tacrolimus , mycophenolate mofetil (1.0 g/d). Corticosteroids were given intravenously during the operation and over the next 2 days. From day 3 post-transplantation, prednisone (0.15 mg/kg) was prescribed with a dose reduced to 10 mg/d at the end of 4 months. Besides, patients were forbidden from any drug or food that could influence the FK506 concentrations. Blood samples for the determination of trough FK506 concentrations (C0) were taken immediately prior to the morning dose for therapeutic drug monitoring (TDM), with C0 maintained at 10–12 ng/mL within the first three post-operative months, 8–10 ng/mL in the post-operative 3–6 months, 6–8 ng/mL in the post-operative 6–12 months, and 4–6 ng/mL thereafter. As a retrospective study, the plasma from the enrolled patients were from the sample after TDM.42, 12 patients were diagnosed with AKI, as there was an increase in SCr of more than 0.3 mg/dL (26.5 μmol/L) or at least a 50% increase of SCr over baseline values. As at least three independent groups were suggested for metabolite biomarkers identification study, healthy control (HV), disease group (NB), and an additional related-disease control group (NA) were investigated in our targeted metabolomics study43.Based on KDIGO  criteria44.All patients were enrolled following the inclusion criteria: subjects were followed up in Shanghai Changzheng Hospital and were clinically stable at the time of the study. Subjects were excluded when any of the following exclusion criteria was met: age under 18 or above 65, being a recipient of a multi-organ transplant, cancer patients, residing abroad, being pregnant, presence of obstructive uropathy which was ruled out by performing a renal ultrasound, and inability to give informed consent. Demographics and clinical data of subjects investigated were listed in Table g for 10 min at 4 °C. Plasma samples were stored at −80 °C before analysis.Blood samples were taken in the morning after an overnight fasting in EDTA-3K tubes, and centrifuged at 4000 × g for 15 min at 4 °C. The supernatant was transferred to chromatography vials, prior to UHPLC–MS/MS analysis.Thawed plasma sample (100 μl) was treated with acetonitrile  in 1.5 ml Eppendorf tubes for sample preparation. The mixture was vortexed and then centrifuged at 12,000 × Targeted AA metabolic profiling was obtained by a non-derivatization UHPLC–MS/MS method, applying heptafluorobutyric acid as ion-pair reagent. Analysis was performed on a UHPLC system  coupled with a 6460 triple-quadrupole mass spectrometer , by an established method with an expanded assay ability. In brief, assay was studied on a Zorbax SB-C18 column  maintaining at 50 °C. A binary solvent system consisting of methanol (A) and water  was used for gradient elution. The following gradient program was used: 0 min, 2% elute A; 1−4 min, 15% elute A; 4−5 min, 20% elute A; 9.5 min, 80% elute A; post time, 3.5 min. Flow rate was set at 0.4 mL/min and 2 μL of samples was injected. Data acquisition was carried out in the multiple reaction monitoring (MRM) mode SI, Figs  and S5. The raw metabolomics data files were conducted on Agilent Quantitative Analysis version B.06.00 analyst data processing software . Data were expressed as mean ± SD in normal distribution variables. Differential metabolites among three groups were identified by the use of ANOVA analysis with a threshold of p < 0.05. Multi-group comparisons were achieved by a strict Tukey’s post-hoc test in the SPSS 11.0 software . Correlation analyses were performed using the Pearson or Spearman Rank test from the R package, illustrated by heat-map. Receiver operating characteristic (ROC) analyses were performed to obtain the area under the ROC curve (AUC). Youden index was used to identify the best biomarkers cut-off level to distinguish between NA and NB patients.Supplementary Information


Uncontrolled asthma poses substantial negative personal and health system impacts. Web-based technologies, including smartphones, are novel means to enable evidence-based care and improve patient outcomes.breathe) using content based on international evidence-based clinical guidelines.The aim of this study was to design, develop, and assess the utilization of an asthma collaborative self-management (CSM) platform  platform accessible on smartphones, tablets, or desktop with user-centered design methods and International Organization for Standardization–certified quality development processes. Moreover, breathe was envisioned as a multifunctional, CSM mHealth platform, with content based on international clinical practice guidelines and compliant with national privacy and security specifications. The system enabled CSM  and self-monitoring of asthma patients through (1) assessment of asthma control, (2) real-time access to a dynamic asthma action plan, (3) access to real-time environmental conditions, and (4) risk-reduction messaging. The data collection protocol collected user data for 12 months, with clinic visits at baseline and 6 and 12 months. Utilization outcomes included user interactions with the platform, user impressions, self-reported medication use, asthma symptom profile, reported peak flow measurement, and the delivery and impact of email reminders.We designed and developed breathe intervention. Majority were female , had a smartphone , and had a mean Asthma Control Test score of 18.3 (SD 4.9). A majority reported that breathe helped in the management of their asthma. Moreover, breathe scored 71.1 (SD 18.9) on the System Usability Scale. Overall, 123 patients had complete usage analytics datasets. The platform sent 7.96 reminder emails per patient per week (pppw), patients accessed breathe 3.08 times, journaled symptoms 2.56 times, reported medication usage 0.30 times, and reported peak flow measurements 0.92 times pppw. Furthermore, breathe calculated patients’ action plan zone of control 2.72 times pppw, with patients being in the green (well-controlled) zone in 47.71%  of the total calculations. Usage analysis showed that 67.5% (83/123) of the participants used the app at week 4 and only 57.7% (71/123) by week 45. Physician visits, email reminders, and aged 50 years and above were associated with higher utilization.We enrolled 138 patients with a mean age of 45.3 years to receive the breathe notifications, and had confidence in the platform’s assessment of asthma control. Strong utilization was seen at the intervention’s initiation, followed by a rapid reduction in use. Patient reminders, physician visits, and being aged 50 years and above were associated with higher utilization.Individuals with asthma reported good usability and high satisfaction levels, reacted to ClinicalTrials.gov NCT01964469; https://clinicaltrials.gov/ct2/show/NCT01964469 Asthma is a common chronic disease that poses a serious global health problem. In Canada alone, asthma affects 10.8% of Canadians ,3. HowevCollaborative self-management (CSM) is defined as “a system of coordinated healthcare interventions and communications for populations with conditions in which self-care efforts are significant” . NationaSmartphones have become ubiquitous, and mHealth apps have the potential to transform elements of chronic disease management ,19. mHeaWe sought to design and develop a multifunctional, CSM mHealth platform for patients with Asthma, based on clinical content from international evidence-based guidelines, following a UCD process and then evaluate its utilization to inform iterative product improvement.breathe development program was structured in 2 main phases: (1) the design and development process for building the breathe mHealth platform including architecture, design, platform content, functional elements, user experience, and utilization  and (2) an evaluation of the patient outcomes by randomized controlled trial  and by a population-based cohort study. The utilization data reported in this manuscript are derived from the intervention (breathe) arm of the RCT. The RCT comparing conventional best practice plus the breathe platform with conventional best practice has been completed, and the main results are published in abstract form [breathe platform, breathe utilization, and the user experience. The results of the RCT will be published in an upcoming manuscript.The act form . The focSpecifications were developed collaboratively with Canada Health Infoway and included (1) a user-centered Web-based asthma self-management platform available on any Web-enabled device including mobile phone browsers and standard Web browsers on laptop, desktop, and tablet to ensure equitable access of the app; (2) patient access to their personal health information and electronic health  records through connectivity with TELUS health space, which was a localized version of Microsoft HealthVault ; (3) alignment with national and provincial clinical and eHealth priorities, as per the Canadian Thoracic Society (CTS), Ontario Lung Association (OLA), eHealth Ontario , and the Ontario Ministry of Health and Long-Term Care; and (4) scalability to the provincial level and ability to be leveraged by other jurisdictions within Canada. Evidence-based best practices from the CTS Asthma guidelines  and the breathe was developed by the Centre for Global eHealth Innovation at the University Health Network in collaboration with clinicians; researchers; and scientists from Western University, Queen’s University, Hospital for Sick Children, and the University of Toronto. The Centre is certified under International Organization for Standardization 13485, an international quality management system, to ensure the safety and quality of innovations. The mHealth platform development was guided by a 16-member interdisciplinary steering committee including asthma expert respirologists, certified asthma educators, population health scientists, knowledge translation experts, and eHealth experts. These experts were informed by 4 working groups: benefits evaluation, technical, consumer engagement (patients with asthma), and clinical. Working groups comprised a few members of the steering committee, along with additional individuals who contributed specific expertise such as consumers (patients with asthma), information technology professionals, and clinicians.breathe  arm of the RCT designed to evaluate patient outcomes [breathe had a baseline onboarding clinic visit where they were provided with breathe accounts, received a brief orientation, and completed a 6- and 12-month follow-up visit.The utilization data reported in this manuscript are derived from the intervention   were admbreathe was designed to collect usage data  to enable data-driven design and evaluation. Information flowing through the breathe data server was logged and used as a part of this evaluation. The breathe server tracked medications prescribed to patients, self-reported medication use, actual peak flow compared with personal best or normal, action plan zone of control, general access, and email notifications sent by the system. Each entry to the database was identified with a unique user ID and time stamped to enable further analysis.The statistics reported in this manuscript are primarily descriptive. We reported counts and percentages for categorical variables as well as means and SDs for continuous variables or pseudocontinuous variables derived as means of multiple ordinal questionnaire items. We used the Wilcoxon rank-sum Test to compare the number of weeks with at least one login during the 52 weeks between groups defined by age, college education, smartphone use, and baseline Asthma Control Test (ACT) score. Age groups were defined as less than 50 years versus aged 50 years and above because it approximately divided the population in half.breathe is a Web-based mHealth platform that utilizes HTML5 and responsive design allowing a single version of the platform to be accessible on any device . Furthermore, breathe retrieves real-time environmental conditions directly from Environment Canada, which include current and forecasted weather conditions, in addition to the Air Quality Health Index (AQHI) with relevant risk-reduction health messaging from Health Canada. The AQHI is a simple 1 to 10 scale designed to help individuals understand air quality, the impact of poor air quality on their health, and what actions to take to minimize health risks [th risks .asthma app prescription in a collaborative triad of patient, provider, and app. The health care provider determined the patient’s asthma medications, their individualized action plan by zone, and peak flow ranges for control zone calculations (if applicable). The breathe platform did not advise on the selection of medications and did not create the action plan. This remained a physician responsibility. Integrating with TELUS health space offered patients the option to share breathe data with family members and other health care providers, which could be accomplished through the health space Web-based profile. The breathe features can be seen in The health care provider developed an The Journal feature allows patients to track daily symptoms, record reliever and controller medication usage, and log peak flow measurements. The historical review feature allows users to look back at previous journal entries and peak flow values entered.breathe server, based on the CTS Asthma Guidelines [The journal entries feed an integrated asthma control algorithm at the idelines ,12 that idelines . PatientData visualization and analysis of several trends, including identified triggers, control zone, and peak flow values, were available to users. An example of the usefulness of this feature is that trigger frequency reported back to patients may enable patient insights into which triggers to avoid in the future.This feature provides real-time current and forecast of location-specific (based on users’ input about their location) environmental conditions including temperature, humidity index, weather forecast, and the AQHI with specific poor air quality risk-reduction health messaging.check-in emails for users not accessing the platform within 7 days, and daily adherence reminders for controller medications. There was no limit to the daily reminder emails; however, we designed the system to try to mitigate fatigue by creating approximately 30 different body messages that were randomly emailed to the user. A demonstration of how the breathe platform works can be found in the Canada Health Infoway website, with a detailed description of functionalities and platform capabilities.This feature includes a variety of options including changing default (7:00 pm EST) time and email address to receive emailed medication adherence reminders and setting a location for location-specific environmental information. Email adherence reminders were automatically generated based on predefined rule-based logic including a welcome email, breathe intervention arm. Consent was withdrawn (n=10) or we were unable to find the patient to consent for data transfer (n=23) in 33 patients, leaving 138 patient that could be used in this analysis. Complete platform utilization data were available in 89.1% (123/138) participants, and 12-month usability and satisfaction questionnaires were available for 86.2% (119/138) participants. The majority of the 138 patients were women 72.5% (100/138), mean age 45.3 (SD 15.8) years, and 97.1% (134/138) were Caucasian. Of these participants, 66.7% (92/138) had a smartphone, and the majority 83% (76/92) reported being comfortable or very comfortable using it. Patients recruited had a mean ACT score of 18.3 (SD 4.9), suggesting well- to somewhat-well-controlled baseline asthma [A total of 344 patients were recruited into the RCT between October 31, 2012, and March 31, 2014, of whom 171 were allocated to the e asthma .breathe system scored 71.1 (SD 19.9) at 12 months indicating good usability, as defined by Bangor et al [breathe components useful and were satisfied with the design.  of patients were confident that the breathe app was correct when it presented the patient’s asthma action plan zone of control. Furthermore, 49.6% (58/117) of participants agreed or strongly agreed that they would continue to use the app after the study if it remained available  of patients agreed or strongly agreed that the vailable .breathe 19,678 times , reported symptoms in their diary 16,357 times (2.56 times pppw), reported medication use 1922 times , and reported peak flow measurements 5864 times (0.92 times pppw). Total counts can include patients accessing the platform multiple times in the same day.The 123 patients in the intervention arm with utilization data accessed breathe calculated patients’ action plan zone of control 17,396 times (2.72 times pppw). Patients were most often in the green zone of control , followed by yellow zone  and red zone . In 22.00%  of the calculations, breathe did not have enough information to return a zone of control back to the patient based on the programmed algorithm in the breathe platform  to remind participants to take their controller medications or to return to the platform after 7 days of no usage. breathe did not log email responses potentially generated by the users.Tracking patient log-ins to the platform demonstrated a fall in use within the first 4 weeks of initiation and thereafter a standard decay in usage , wherebybreathe functionality, or the interaction of both.Further utilization analysis demonstrated patterns of use that related to patient behavior, Time of day: Analyzing log-ins by time of day revealed 2 periods of increased utilization  compared with days with symptoms .We considered that decreased utilization (attrition) in this study might have been related to population and design characteristics, including technology savviness, patients with relatively good disease control, infrequent physician monitoring, or because patients achieved their expected outcomes  of our population had a smartphone and reported being comfortable or very comfortable with its use, one-third did not have a smartphone and therefore accessed the platform by laptop, desktop, or tablet. We considered that the nonsmartphone subset may have been less technology savvy, contributing to the decline in utilization and particularly may have contributed to the sharp decline in the first 4 weeks. However, our post hoc analysis did not find an association between utilization and having a smartphone.We considered that younger age and higher education level might have an impact on utilization. We did not find an association between utilization and education level. In a post hoc analysis, we were able to demonstrate that being aged 50 years and above was significantly associated with higher utilization. Although general app use is normally greater in a younger population, we speculate that our participants over the age of 50 with a chronic disease may have had a higher level of concern about their chronic disease and potentially find more value in health-related apps than a younger population. We observed that increased utilization was associated with time of day, anticipated physician visits, and email reminders.Patients in this study had relatively well controlled asthma as indicated by high baseline ACTs and a high percentage of good days when compared with episode days. We did not have a specific engagement strategy to motivate patients to return to the platform when they were feeling well. Failure to engage the users in moments of disease stability has been described by other authors as a critical factor affecting attrition across diseases -41. Howebreathe platform utilization was associated with upcoming 6- and 12-month clinic appointments. An increase in eHealth utilization in response to anticipated clinical review has been described by Mohr et al as supportive accountability [breathe.In this study, patients were evaluated by a physician only twice after enrollment. Infrequent monitoring may have increased the attrition rate. Increased tability  and by otability ,44 as a tability . The neetability . The fintability . New Blutability  will be breathe, and 63.8% (74/116) agreed or strongly agreed that “the breathe application is helpful in the management of my asthma.” Thus, it is possible that after an interval, having achieved their personal goals, patients no longer felt a need to use the platform.Patients were satisfied with breathe platform utilization was associated in time with email adherence reminders. Others have identified reminders as powerful design features to increase adherence and engagement with eHealth platforms [Increased latforms , to alerlatforms ,49, or tlatforms . Althouglatforms ,51, we dPatterns of usage analysis identified physician visits and email reminders as strongly associated with utilization. A post hoc analysis identified being aged 50 years and above as significantly associated with higher utilization.breathe. The improved performance of native app platforms may positively impact utilization and reduce attrition.The population studied was a convenience sample from primary and specialty clinics with a dedicated asthma program, and at the time of enrollment, patients had relatively good asthma control. As such, patients’ evaluation of the app and their utilization patterns may not be representative of the general asthma population. Since this project was completed, native apps have largely supplanted Web browser–based apps such as breathe, a multifunctional asthma CSM platform with content based on international clinical practice guidelines, compliant with national privacy and security specifications, to support patients as active participants in chronic disease management at home, work, and in the community. breathe enabled self-management and self-monitoring of asthma patients through assessment of asthma control, real-time access to a dynamic action plan, environmental conditions display, and air quality risk-reduction messaging. Individuals with asthma reported good usability and high satisfaction levels and had confidence in the platform’s assessment of asthma control. We embedded in-platform analytics, evaluated utilization, and examined the utilization patterns in the context of known patient characteristics. We related increased utilization to physician monitoring, email reminders, and age 50 years and above. Looking to the future, embedded app analytics combined with data-driven design will enable real-time evaluation of mHealth platforms, enabling innovators to execute design improvements during the deployment of the technology.We followed UCD methods to develop breathe platform based on lessons learned, we will seek to (1) leverage the surveillance effect of in-platform or in-person patient-physician contact to support utilization, (2) create a specific strategy to engage patients when they are feeling well and to reengage as they become unwell, (3) create a strategy to support adherence specifically for asthma patients aged less than 50 years, (4) integrate automated logging technology  to capture actual medication utilization, (5) leverage the sustained impact of patient reminders on utilization, (6) create a more interactive experience to enhance platform use, (7) utilize embedded app analytics that provide continuous evaluation of usage to enable the execution of design improvements during platform deployment, and (8) develop the next version of the breathe platform with a native iOS or Android app.As we iterate development of the


Introduction: The study objective was to assess the impact of pharmacist-led education on the patient’s knowledge and skills on SBPM (self-blood pressure monitoring). Methods: Patient knowledge was assessed using tests and patients’ skills were based on a checklist (20 parameters) completed by the researcher based on the SBPM video records. Patients taking pressure measurements were filmed for 20 days and after 6 months. After the first 10 days, patients were educated about the correct SBPM procedure. Knowledge tests were repeated three times (before/after/6 months after education). Results: All patients’ knowledge and skills in the field of SBPM were improved after education. After the education, patients scored an average of 9 out of 10 points in the knowledge test (increasing an average of five points after education), six months later—an average increase of 7.36 points. Patient skills after training were rated at 17.4 out of 20 points on average (increase by an average of 5.14 points after education), six months later, there was an average of 16.23 points. Conclusions: The study showed an increase in patients' knowledge and skills in the field of SBPM after training.  Scientific publications and guidelines of scientific associations indicate the significant role of self-blood pressure measurements (SBPM) in the process of arterial hypertension therapy monitoring and for the therapeutic decision-making ,3,4,5,6.SBPM constitutes an indispensable assistance in the control of the health state of a patient only when the measurement is correctly conducted and it complies with the recommendations/guidelines of scientific associations, since only then the obtained results are reliable ,15,16,17Unfortunately, the knowledge as well as skills of patients in this field are insufficient ,18,19,20The study objective was to assess the impact of training process on the change of the knowledge and skills levels of patients with arterial hypertension in the field of self-blood pressure measurement using semi-automatic pressure gauge. Moreover, the usability of the used methods and education tools was also assessed. The study was performed in the facilities  described in the article of Dymek et al. . The metWithin the study, patients performed self-blood pressure measurements using the provided, individually to each patient, arm monitors, which were semi-automatic with built-in memory. The choice of a semi-automatic device, instead of a fully automatic device, allowed patients to master the ability to independently select the pressure value to which the cuff should be pumped. This type of pressure device is cheaper than fully automatic ones and therefore more often used among Polish patients.The measurements were performed twice a day for 20 consecutive work days in the presence of a researcher. The measurement was recorded using audiovisual means. After the first 10 days, each patient had individual educational meeting with researcher concerning the principles of proper blood pressure measurement . The topPrior to the process of education, patients were assigned at random to two groups , in accordance with the simple randomization principles using dependent randomization. During training, patients in group 1 were provided with individualized leaflets containing information provided in the course of the meeting. Patients were able to use the leaflet during subsequent measurements. Patient education in group 2 was not supported with written information during an educational meeting. Patients in this group received an educational leaflet after completing TEST 2 . After 1Assessment of the patient knowledge in the field of self-blood pressure measurement (SBPM) was performed based on the results of knowledge test results. The test contained 10 questions, and was identical for all study participants at any stage of the study . Over a half of the participants (57.14%) consisted of persons with secondary education, those with university and primary education made up 21.43% of the total. The study included two men. Patients suffered from arterial hypertension for the period of 6 months to 32 years (6).Patient knowledge was assessed based on a three repetitions of test containing 10 questions. After the training, the knowledge on SBPM increased in all patients by a mean of 5 points (TEST 2 vs TEST 1 p < 0.0001). In this test, patients scored a mean of 9 points out of 10. In TEST 3, the results were reduced relative to TEST 2 (p < 0.02), by an average of 1 point. Finally, the TEST 3 results remained significantly higher relative to those obtained in TEST 1 (p < 001). In TEST 3, patients scored an average of 7.36 points. The difference in the percentage of persons responding correctly to individual test questions is presented in The greatest increase (by over 70%) of the percentage of correct answers in TEST 2 as compared with TEST 1 concerns the question on the time interval between a hearty meal and the SBPM and on the cuff inflation value .In TEST 3, as compared with TEST 2, a decrease in the percentage of correct answers to seven test questions occurred. The greatest decrease of the percentage of correct answers concerns questions on the selection of arm for the measurement, time lapse between administration of medicines before the measurement and the time interval between measurements (decrease by over 20%).The final increase in the knowledge, i.e., comparison of TEST 3 and TEST 1, concerns all questions and it amounts to 4.4% in the case of question on the time interval between medicine administration and measurement to 64.3% in the question on the factors influencing result reliability. Details on the increase of knowledge on the individual test questions are presented in The results failed to reject normality with the Ryan-Joiner test at a 0.01 significance level. Assuming normality of distribution, the t-Student test (paired t-test) for the dependent samples has demonstrated that differences in the percentage of correct answers between TEST 2/TEST 1; TEST 3/TEST 2; TEST 3/TEST 1 are statistically significant (p = 0.05). Results were verified with a non-parametric Kruskal-Wallis test, which demonstrated that medians of differences between the percentage of correct answers in the appropriate combinations are significantly different (p = 0.05).By comparing the increase of knowledge in SBPM in both analyzed groups , differeAssessment of patients’ skills during self-blood pressure measurement was performed on the basis of analysis of 1064 video recordings of measurements performed by 14 patients. In all patients, an increase of skill in SBPM performance was observed after the training, both in the second as well as in the third study stage. Measurements performed by patients after training were rated at 17.34 points on average (max. 20). This means an average increase of 5.14 points relative to measurements prior to training (in group 1 patients by 5.46 and in group 2 patients by 4.81). In both groups, a decrease in the skill level was observed after 6 months from training. Results of skill analysis after this period demonstrated that patients scored a lower number of points on average than after the training. However, this result was still higher than the result obtained prior to training (average increase by 4.29 points in group 1 and by 3.89 points in group 2). Based on the ANOVA with repeatable measurements it can be stated that patients of group 1 and group 2 do not differ statistically (p = 0.65) within the range of results determining the ability to perform self-blood pressure measurement prior and after training and after a 6-month period after training. The increase in skills of both patient groups is presented in After the training, the greatest increase of skills expressed by the number of points scored per measurement concerned assuming the correct body posture during measurement, patients sat facing the table more frequently (increase by 63%), they kept back upright (increase by over 58%) and rested the back against the chair’s backrest (increase by over 83%) . Results presenting increase of skills were verified with non-parametric Kruskal-Wallis test, which has demonstrated that medians of differences between the percentage of correct answers in the appropriate combinations  are significantly different (p = 0.05). Mean pressure values were compared before and after the training for each patient individually. For comparison of pressure values, results obtained by patients within 10 days before and 10 days after education were used. This analysis does not take into account the results of measurements made after 6 months, because their value, apart from the method of pressure measurement itself, could have been influenced by changes in lifestyle and pharmacotherapy during the next 6 months.In two patients, mean systolic pressure and diastolic received during 10 days of measurements after education was higher than before education  and Diastolic Blood Pressure (DBP) on average). In 10 patients, there was a decrease in mean systolic and or diastolic pressure in the measurements performed after the educational meeting. The most significant reduction of the pressure values is a 10% decrease relative to the initial SBP and 17% compared to the initial DBP.In the presented study, a pharmacist was the educator, which is part of the role of a modern pharmacist ,22,23,24Education of all patients was performed by one educator. Thus, the issue arising in scientific publications was eliminated, consisting in the influence of differences in the level of substantive knowledge, communication competences or styles of providing information by various educators ,34. In aEducation of each patient was expanded with analysis of knowledge test results as well as analysis of video recordings of SBPM performance. This enabled adjustment of educational  content to the individual needs of each patient. The available literature data indicate that individualized provision of information during training greatly impacts the efficiency of an education process ,39,40,41Following the procedure described in the literature, in order to assess the efficiency of the educational activities undertaken, tools used by the educator to assess the knowledge and skills of patients prior to the training were also used after the education ,43,44.An undisputed advantage of the conducted education was the use of semi-automatic devices, provided to each patient. Blood pressure measuring devices, according to the guidelines, were validated according to internationally accepted protocols . The devAs presented by the study, verbal education conducted in all patients covered by the study constitutes an efficient training method. This remains in line with the study results of Axtell et al., which confirmed the high efficiency of direct trainings; furthermore, it indicated a considerably higher knowledge level and patient skills using this educational technique as compared with other education forms . HoweverFollowing the data analysis from the present study and the mentioned publications, we can assume that the influence of educational leaflet on the increase of knowledge level is significant in the situation when the educator uses only this educational tool, completely replacing verbal education. This is confirmed by the study by Axtell et al. as well as in the study by Dawes et al. ,44. The Patients’ education increased the ability to perform self-blood pressure measurement by the patients, which became apparent by the reduction of the frequency of errors made during measurement. As a result of education, the percentage of correctly performed parameters increased from 61% to 86.7%. It appears that the presented study is the first one providing such a complex analysis of the impact of education on the ability to correctly perform 20 different elements of SBPM. The analyzed, available studies typically analyze the pressure measurement method, including errors during the performance of such a measurement and regularity at which it is performed. Those studies typically assess in detail one selected aspect, without examining the influence of education on the change of behavior and patient skills ,46,47. Following the assumptions of studies on health education of patients with chronic diseases, the present study also examined the durability of effects of the conducted education after 6 months ,48. As sThe study has demonstrated an increase of knowledge under the impact of education conducted by the pharmacist in all patients who participated in the study. Moreover, the conducted training caused an increase in the skills of self-blood pressure measurement, which translates into the reduced frequency of errors made by patients during the measurement. The knowledge and skills levels acquired during educational meetings decrease over time. It is necessary to repeat the education process. According to our results, it could be valuable to re-educate patients at least every six months.


Endothelial dysfunction is one of the most important early indicators of atherosclerosis in obstructive sleep apnea (OSA) patients. Endothelial cell specific molecules-1 (ESM-1), which is a novel endothelial dysfunction marker that may be linked to cardiovascular disease. We investigated to assess whether circulating ESM-1 levels are correlated with the presence of coronary artery disease (CAD) in patients with OSA.We performed a cross-sectional study in 228 Chinese OSA subjects, including 185 patients with OSA and 43 controls. The Gensini stenosis scoring system was used to assess the severity of CAD. Circulating ESM-1 levels were measured by Human Magnetic Luminex Screening Assay. The associations between circulating ESM-1 levels and CAD were determined by multivariate logistic regression analysis. The association between ESM-1 levels and Gensini scores was determined by multivariate linear regression analysis.P < 0.001). After adjusting for confounding factors, we found that circulating ESM-1 levels were an independent risk factor for CAD , while circulating ESM-1 levels have no significant correlation with the Gensini score. Furthermore, circulating ESM-1 showed higher discriminatory accuracy in predicting the presence of OSA (AUC:0.910).CAD patients had significantly higher circulating ESM-1 levels compared with non-CAD patients  contains supplementary material, which is available to authorized users. Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder caused by recurrent collapse of the upper airway during sleep leading to intermittent airway obstruction and absence of airflow despite respiratory efforts of the diaphragm against the occluded pharynx. These respiratory disturbances are associated with an increased risk for cardiovascular disease, including coronary artery disease, hypertension, and stokes, atherosclerosis –4. The cESM-1, previously named endothelial cell-specific molecule-1, is a new biomarker of endothelial dysfunction . LassallThis study was cross-sectional study done in the sleep center . The study was approved by the ethics committee of Beijing Anzhen Hospital . All patients gave written informed consent to the ethically approved protocols.All consecutive patients who underwent overnight full polysomnography study due to snoring, apnea, and excessive daytime sleepiness in the sleep center of Beijing Anzhen Hospital between March 2017 and March 2018 were included in this study. A total of 476 patients were eligible for the study. Subjects younger than 18 years, with central sleep apnea syndrome, heart failure, arrhythmias, stroke, chronic kidney disease, chronic obstructive pulmonary diseases (COPD), pulmonary hypertension, active infections and malignancy were excluded from the study. CAD was defined as present if any of the following characteristics was observed: history of physician-diagnosed CAD, use of medications for CAD; the presence of ≥50% luminal stenosis in at least one major coronary artery in coronary angiography . While in = 117) and CAD (n = 68).A final total of 228 participants were consecutively enrolled, including 185 patients with OSA and 43 healthy controls . Blood pressure (BP) was measured at the nondominant arm in the morning of the procedure after a 5 min resting interval. Sleepiness was evaluated using the Epworth sleepiness scale (ESS) [Data on patient characteristics, including clinical/biochemical factors, were collected. Body mass index (BMI) was calculated by dividing weight in kilograms by squared height in meters (kg/mle (ESS) . We alsoConventional invasive coronary angiography was performed according to standard protocols by interventional cardiologists blinded to the study protocol. The Gensini stenosis scoring system was used to assess the severity of CAD  by two iAll blood samples were collected after the participants had fasted overnight. Blood samples were then centrifuged for 10 min at 3000 rpm and 4 °C. Plasma samples were subsequently stored in a freezer at − 80 °C before analysis. Serum triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) levels and fasting blood glucose (FBG), and other routine serum biochemical parameters were measured in a biochemical analyzer  using blinded quality control specimens in the Department of the Biochemical Laboratory at Beijing Anzhen Hospital.Magnetic Luminex® Assay is a magnetic bead-based antibody microarray founded upon the sandwich immunoassay principle, which can be used to assess the levels of multiple biomarkers with high sensitivity , 16. PlaP = 0.9, alpha = 0.05, P0 = 0.5, and odds ratio (OR) = 1.633. The sample size of 228 according to the calculation could satisfy the meet of this study. Continuous variables are expressed as mean ± standard deviation or median (interquartile range) and categorical variables as numerals (percentages). The independent Student’s t test for normal distribution and the Wilcoxon rank sum test for asymmetric distribution were used to analyze the differences in continuous variables. The Chi square test was used to analyze categorical variables. The association between circulating ESM-1 and OSA was determined by multivariate logistic regression analysis. The association between circulating ESM-1 levels and other inflammatory factors were also evaluated using multivariable liner regression analysis. To evaluate the predictive power of the identified predictors of CAD, we used receiver operating characteristic (ROC) curves and in particular the associated area under the curve (AUC). The ROC curves were made with maternal factors alone and combined with different factors to find the best performing model. A P value of < 0.05 was considered statistically significant. Statistical analysis was performed with SPSS 19.0 .The study was designed as a cross-sectional study. The sample size was calculated by PASS 11.0  using logistic regression models, with P = 0.184), TG (P = 0.132), FBG (P = 0.088), ALT (P = 0.144), AST (P = 0.053), SBP (P = 0.115) between the two groups. Compared with the non-CAD patients, CAD Patients had a significantly difference in HDL-C levels (P = 0.029), ODI(P < 0.001), Longest apnea time(P < 0.001), CT90%(P < 0.001) and arousal index (P < 0.001) than those without CAD. As shown in Fig. P < 0.001).The baseline clinical characteristics of the study groups are shown in Table P < 0.001), LSaO2 , and ESM-1 levels  were risk factors for CAD. However, HDL-C levels were a protective factor for CAD .We used ordinal logistic regression analysis to estimate associations between CAD and clinical or biochemical variables. As shown in Table P < 0.001, Table P < 0.001). We also adjusted AHI and LSaO2, we found that elevated circulating ESM-1 levels were associated with higher risk of CAD .The association between CAD and circulating ESM-1 levels were tested in different models of logistic regression. Patients with CAD who had higher circulating ESM-1 levels had a higher OR   is a marker of subclinical atherosclerosis . This reOur study showed that circulating ESM-1 levels were positively correlated with age, BMI, SBP, DBP Additional file 2:Table S1. List of medications for participants. (DOCX 15 kb)Additional file 3:Table S2. Correlations between clinical variables and circulating ESM-1 levels. (DOCX 16 kb)


Thestudy included hypertensive patients at different stages and evaluated variousbiomarkers, such as adipokines, as well as cardiovascular properties. The first notablefinding was the high prevalence of MS in patients with AH in both RH and control groups,and the prevalence was slightly higher in the former. This result is in accordance withwhat has been observed in the clinical practice in the last years - a high prevalence ofobesity and metabolic abnormalities associated with hypertension and itsconsequences.2 This should be considered intherapeutic approaches of these patients, and changes in life style should be encouragedaiming at better controlling blood pressure and preventing related cardiovasculardiseases.5 The study also reported anassociation of MS with early kidney injury , the leptin/adiponectinratio (L/A) and RH. No association was found between MS and increased arterial stiffnessor left ventricular hypertrophy. The authors draw attention to the early detection ofrenal injuries in MS, regardless of the hypertension stage, emphasizing the role ofmetabolic changes on the development of microalbuminuria in hypertensive patients,6 and the need for controlling these changes toprevent kidney injury prevention. On the other hand, the lack of differences in vascularand cardiac lesions according to the presence of MS suggests that blood pressure is thecomponent of greatest impact on these target-organ lesions, and that an adequate bloodpressure control is essential for their prevention, as previously described.8As the authors pointed out, the main finding of the study was the association betweenthe L/A ratio and MS in hypertensive patients, reinforcing the role of increased leptinand reduced adiponectines in the pathophysiology of MS, showing as a potentialtherapeutic target in these patients. Besides, the L/A ratio, as suggested by theauthors, may be a key tool for the screening of patients at higher risk for MS andprovide them with early intervention. This, in turn, would delay the development ofrenal lesions and increase the likelihood of better control of blood pressure.Nevertheless, further prospective, long-term studies involving a higher number ofpatients are needed, as the study by Catharina et al.5 shows the association of the L/A ratio and MS in hypertensive patients ina cross-sectional design only. In summary, metabolic changes and obesity negativelyaffect blood pressure control and its repercussions in hypertensive patients and shouldbe the target of therapeutic interventions in these individuals.Recent definitions of systemic arterial hypertension (AH) include metabolic changes andsustained hypertension, based on the association of AH with dyslipidemia, glucoseintolerance and obesity.


Minority populations, including Asian Americans, face disparities in hypertension compared with non-Hispanic whites. This underscores the need for culturally adapted programs in settings that reach Asian American communities, such as faith-based organizations. We worked collaboratively with community partners to culturally adapt and implement an evidence-based community blood pressure monitoring program for Asian Americans  in metropolitan New York during 2015 and 2016. The program included regularly scheduled volunteer-led screening and counseling events with congregants at faith-based organizations. Among participants with complete 6-month data (n = 348), health-related self-efficacy significantly improved after 6 months, and systolic and diastolic blood pressure was significantly reduced in some subgroups; reductions were highest in participants who self-reported a previous diagnosis of hypertension. Among Asian Americans, faith-based programs may be a replicable, low-cost, sustainable way to increase health-related self-efficacy and decrease blood pressure, specifically among individuals with self-reported hypertension. Minority populations, including Asian Americans, face disparities in hypertension compared with non-Hispanic whites, underscoring the need for culturally adapted programs in settings that reach Asian American communities.We collaborated with our community partners to culturally adapt and implement an evidence-based community blood pressure monitoring program for Asian Americans  in metropolitan New York and New Jersey in 2015 and 2016 across 12 faith-based organizations.Faith-based programs targeting Asian Americans may be a replicable, low-cost, sustainable way to increase health-related self-efficacy and for decreasing blood pressure among Asian Americans with diagnosed hypertension.Preventing Chronic Disease. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.Release date: August 8, 2019; Expiration date: August 8, 2020Upon completion of this activity, participants will be able to:Distinguish elements of the current community-based interventionAssess the effects of the current intervention on blood pressure variablesAnalyze particular groups who benefited from the current community-based interventionEvaluate the current intervention among individuals with elevated blood pressure at baselineEDITORCamille MartinPreventing Chronic DiseaseEditor, Disclosure: Camille Martin has disclosed no relevant financial relationships.CME AUTHORCharles P. Vega, MDHealth Sciences Clinical Professor of Family MedicineUniversity of California, Irvine School of MedicineIrvine, CaliforniaDisclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKlineServed as a speaker or a member of a speakers bureau for: ShireAUTHORSStella S. Yi, PhDDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Stella S. Yi, PhD, has disclosed no relevant financial relationships.Laura C. Wyatt, MPHDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Laura C. Wyatt, MPH, has disclosed no relevant financial relationships.Shilpa Patel, PhDDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Shilpa Patel, PhD, has disclosed no relevant financial relationships.†Catherine Choy, MPHDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Catherine Choy, MPH, has disclosed no relevant financial relationships.†Deceased.Ritu Dhar, BSDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Ritu Dhar, BS, has disclosed no relevant financial relationships.Jennifer M. Zanowiak, MADepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Jennifer M. Zanowiak, MA, has disclosed no relevant financial relationships.Harmanpreet Chauhan, MPHCalifornia State University, Fullerton, CADisclosure: Harmanpreet Chauhan, MPH, has disclosed no relevant financial relationships.M.D. Taher, MPHDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: M.D. Taher, MPH, has disclosed no relevant financial relationships.Maryjoy Garcia, DNP, RNKalusugan Coalition Woodside, Queens, NYDisclosure: Maryjoy Garcia, DNP, RN, has disclosed no relevant financial relationships.Rucha Kavathe, PhDUNITED SIKHS, New York, NYDisclosure: Rucha Kavathe, PhD, has disclosed no relevant financial relationships.Sara Kim, MPHKorean Community Services of Metropolitan New York, Inc., New York, NYDisclosure: Sara Kim, MPH, has disclosed no relevant financial relationships.Simona C. Kwon, DrPHDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Simona C. Kwon, DrPH, has disclosed no relevant financial relationships.Nadia S. Islam, PhDDepartment of Population Health, NYU School of Medicine, New York, NYDisclosure: Nadia S. Islam, PhD, has disclosed no relevant financial relationships.Nearly one-third of the US adult population has hypertension . MinoritKeep on Track (KOT), a program developed by the New York City Department of Health and Mental Hygiene (NYC DOHMH), is a volunteer-run, community-based blood pressure monitoring program that aims to lower blood pressure in community-dwelling adults. KOT was first successfully implemented and evaluated through senior center programming in New York City. The involvement of peer volunteers was central to the program .Faith-based organizations (FBOs) may be effective settings for implementing health promotion and prevention strategies in Asian American communities. A 2012 Pew Research Center survey found that Asian Americans report a high level of FBO engagement but also report substantial differences in religious affiliation within and across subgroups . ResearcThe Racial and Ethnic Approaches to Community Health For Asian Americans (REACH FAR) project, led by a coalition composed of academic, government, and community-based organizations, culturally adapted and implemented the KOT program for 4 Asian American faith-based communities in metropolitan New York City and New Jersey during 2015 and 2016 . We presThe REACH FAR KOT program approach was informed by prior work in senior centers  and drewVolunteers advertised the REACH FAR KOT program launch through FBO communication channels, including fliers, newsletters, listservs, and congregation leadership announcements. At each launch event, volunteers conducted a free blood pressure screening for all interested congregation members aged 18 to 85 years and recorded blood pressure measurements on a tracking card. After the screening, volunteers provided in-language, culturally tailored lifestyle counseling on maintaining healthy blood pressure and weight management, which included reviewing healthy eating tips and examples of healthy plates using common cultural foods . KOT volAll KOT program participants were invited to enroll in the KOT program evaluation through recruitment events held before or after regular FBO services. Pregnant women were not eligible to participate. People who consented to participate completed surveys at baseline and 6 months post-launch administered by program evaluation staff and received a gift card incentive. All activities were approved by the New York University School of Medicine institutional review board.Outcomes, assessed at baseline and 6-month follow-up, were 1) systolic and diastolic blood pressure (SBP and DBP), 2) a blood pressure screening in the last 6 months, 3) a doctor’s visit in the last 6 months, and 4) health-related self-efficacy.Blood pressure measurements were taken by trained volunteers at the initial KOT event and each subsequent screening event by using the Omron Model BP785 (Omron Corporation). Because multiple blood pressure readings were not consistently taken, the first blood pressure measurements were used for all analyses.Baseline and 6-month surveys assessed blood pressure outcomes ; demographics ; physiologic measures (self-reported height and weight); and health-related self-efficacy. A health-related self-efficacy scale was adapted from Bandura to measure health-related decision-making behaviors . Eight qt tests; differences in proportions (blood pressure screening or doctor’s visit within 6 months) were assessed using χ2 tests. Analyses were conducted for all participants and stratified by Asian American subgroups as well as self-reported hypertension at baseline. Self-reported hypertension was determined by asking the question, “Has a doctor or other health professional ever told you that you have high blood pressure?” We also stratified by elevated blood pressure at baseline (SBP ≥160 mm Hg and/or DBP ≥100 mm Hg) as a conservative proxy for including those with uncontrolled hypertension. Changes in SBP and DBP were assessed longitudinally by examining the slope of blood pressure change over time across multiple readings and using generalized estimating equations among all participants (with readings at points in addition to baseline and follow-up). Finally, we descriptively analyzed program data to determine program feasibility, including average number of screening events and number of people screened per event.Differences in means  were assessed using A total of 1,653 congregants were screened across all sites and screening events. A subset of participants were enrolled, consented, and completed a baseline survey (n = 719). A total of 348 participants (48.4%) completed follow-up surveys . Participants were predominantly aged 55 years or more, female, and foreign-born . ObesityOn average, 10.5% of congregants participated across the 12 sites, varying from 4.6% of congregants at Bangladeshi sites to 54.7% of congregants at Filipino sites. Sites held an average of 9 screenings across the 6-month period . Across sites, an average of 25 congregants were screened per event, and each screening event lasted 4 hours. Since the launch, the KOT program has been maintained at 11 of 12 sites. When comparing individuals who completed 6-month follow-up with those who did not complete follow-up, Korean Americans were significantly more likely to complete than other subgroups, as were women  and older participants .P = .03); blood pressure screening increased significantly , as did mean health-related self-efficacy  (P = .007) and mean DBP . Filipino American participants had a significant increase in doctor’s visits in the last 6 months , and health-related self-efficacy significantly improved among Korean American participants .Between baseline and 6 months, mean SBP decreased significantly  . ResultsP = .005; −2.4 mm Hg, P = .01, respectively); and mean health-related self-efficacy increased significantly . Participants without self-reported hypertension also had significant changes in health-related self-efficacy and blood pressure screening.The REACH FAR KOT program appeared to be effective among participants with self-reported hypertension. Among these participants, mean SBP and DBP decreased significantly from baseline to 6 months among participants . No significant changes in blood pressure were observed over time when using longitudinal data collected from all program participants and across all screening events (results not shown).Finally, among 24 participants with elevated blood pressure at baseline (SBP ≥160 and/or DBP ≥100), mean SBP and DBP significantly decreased (−16.7 mm Hg, Our analysis demonstrates that faith-based programs may be an effective way to increase health-related self-efficacy among Asian Americans and improve blood pressure among certain Asian American subgroups or among those with self-reported hypertension. Blood pressure significantly improved for Bangladeshis after KOT program implementation. This result may be due to the high blood pressure at baseline for this group, but it may also result from their unique sociodemographic profile in New York City. Bangladeshis have lower rates of English proficiency and income compared with other racial/ethnic subgroups in New York City, which may affect use of health care resources related to hypertension and CVD . CommuniOur study has limitations. Caution should be used in interpreting the large changes in blood pressure that were observed, because regression to the mean may have occurred without a control group. The findings, however, provide a promising avenue for addressing undiagnosed elevated blood pressure, particularly for Asian American communities who may not have access to regular care and who may be more likely to be reached in trusted community settings such as FBOs. Additionally, because this evaluation used a pre–post design, our internal validity is limited.However, our results indicate high program feasibility and sustainability, which is in large part due to the integration of sustainability planning throughout each KOT program site using a capacity-building approach. For example, training FBO volunteers who were known and trusted to deliver the blood pressure screening program built the FBO’s capacity to engage in and sustain broader health promotion activities. Given the change in recent guidelines stating that high blood pressure should be treated earlier with lifestyle changes and/or medication at blood pressure readings of 130/80 mm Hg rather than 140/90 mm Hg, at-risk populations will increasingly need to be linked to blood pressure monitoring and health promotion resources at the community level. Programs such as KOT, which provide community-based health counseling and blood pressure screening, may offer easily replicable, low-cost, sustainable programs for underserved communities.


Anemia is a common finding in patients with diabetes, even in the absence of kidney disease and is a risk factor for adverse outcomes, including all-cause and cardiovascular mortality. Despite this, relatively little is known about the burden of anemia among adults with diabetes in sub-Saharan Africa. The aim of this study was to determine the prevalence of anemia and its association with renal disease among diabetic adult outpatients attending a hospital in Northeast Ethiopia.A cross-sectional study was conducted among 412 diabetic adults at the diabetes clinic of Dessie Referral hospital in Northeast Ethiopia, from January to April 2018. Each patient provided a blood sample for hemoglobin and serum creatinine levels and urine for albuminuria. Anemia was defined by World Health Organization criteria (<13 g/dl for men and <12 g/dl for women). Glomerular filtration rate (GFR) was estimated using the 4-variable Modification of Diet in Renal Disease (MDRD) equation. Chronic kidney disease (CKD) was classified into 5 stages based on the eGFR and albuminuria.P < 0.001). The prevalence of anemia increased with stage of CKD, from 22.6% at stage 1 to 100% at stage 4. Fifteen percent of the patients had anemia below the treatment threshold of 11 g ⁄dl. In multivariate analysis, older age ; type 2 diabetes ; presence of hypertension ; high systolic BP ; serum creatinine  and low GFR  were independently associated with greater odds for the presence of anemiaAnemia was present in 26.7% of the participants, and CKD in 43.0%. Anemia was more prevalent in patients with CKD (39.5%) than those without CKD (17.0%; Anemia is commonly present among diabetic adults attending our diabetes outpatient clinic in Northeast Ethiopia, including those without kidney disease. Our findings highlight the need for incorporating anemia screening into routine diabetes care to enable early detection and treatment of anemia and hence improve the overall care of patients with diabetes. Anemia is a common and often unrecognized complication of diabetes associated with all-cause and cardiovascular disease mortality ,2. Anemi12), autoimmune diseases, drugs and advanced glycation [The risk of anemia in patients with diabetes is estimated to be two- to three fold higher than that of patients without diabetes ,10. Evidlycation ,18.Despite the high prevalence of anemia in patients with diabetes, even in the absence of renal disease and its significant adverse effect on disease outcomes ,19, veryWe conducted a cross-sectional study at the out-patient diabetic clinic of Dessie Referral Hospital (DRH) in Northeast Ethiopia, from January to April 2018. DRH is found in Dessie town of Amhara regional state, which is located 401 km northeast of the capital Addis Ababa, Ethiopia, and it serves as a referral center for the Wollo and surrounding zones. The hospital registers and treats all diagnosed diabetic patients and provides tertiary diabetes patient care in the region. Patients with diabetes receive chronic care at the out-patient section of the diabetes clinic of the hospital. Patients with diabetes receiving care in the unit undergo an annual evaluation that includes amongst others: a clinical evaluation, an assessment of diabetes control (fasting blood glucose), chronic complications and cardiovascular risk factors assessment. Adult patients (≥ 18 years) attending the outpatient diabetes clinic of the hospital for routine follow up during the study period were included. All patients with a known hematologic disease, any acute condition within the last 2 weeks, or those who received a blood transfusion in the preceding 3 months were excluded. Patients were also excluded if they were pregnant (women) or hospitalized.The required sample size of the study was determined using single population proportion formula by considering: 50% prevalence rate of anemia, Z = the level of statistical significance with a 95% confidence interval (CI) of 1.96, and a precision level of 0.05. Then the minimum sample size obtained was 384. After adding 10% to account for non-respondents, a total of 422 diabetic patients were included in the study. A systematic random sampling technique  was employed to select the study participants. Ten patients with missing clinical data were excluded, leaving 412 patients for the final analysis.2). Blood pressure (BP) was taken using a manual sphygmomanometer in a sitting position, after 5 minutes of rest and three measurements were averaged to be recorded. Hypertension was defined as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or a self-reported presence of hypertension/use of antihypertensive medication.Eligible patients were approached and invited to participate while they were attending the clinic for their regular follow-up. Consenting patients were interviewed by the study investigators to collect information on demographic , medical history (presence of hypertension/use of antihypertensive medication) and behavioral factors  using a structured questionnaire. Anthropometric data such as weight (kg), height (m), and blood pressure (mm Hg) also were collected by the attending nurse or doctor. The body mass index (BMI) was calculated as weight divided by the square of height  values were determined using the hematology analyzer Cell-Dyn 1800 . Five ml of venous blood was obtained by using the serum separation tube (SST) and centrifuged within 1 hour for serum separation for creatinine measurement. Serum creatinine was measured using Jaffe kinetic method as mg/dl. Urine samples were also collected from the participating patients to detect albuminuria using dipsticks .2 with albuminuria; and stage 2, eGFR = 60–89.9 ml/min/1.73 m2 with albuminuria; and stages 3, 4 and 5 as an eGFR of 30–59.9, 15–29.9 and < 15 ml/min/1.73 m2, respectively. CKD was defined as K/DOQI CKD stages 1–5  [Anemia was defined according to the World Health Organization (WHO) criteria: Hgb concentration <13 g/dl for males and < 12 g/dl for females . A seconminuria) .2) test was used for comparison of categorical variables while the Student t-test  was used to compare continuous variables. Because only 32 patients had both eGFR < 60 ml/min/1.73 m2 and albuminuria, we examined the association between eGFR and albuminuria with anemia prevalence using chi-square test. For this, patients with eGFR< 60 ml/min/1.73 m2 were combined and compared with those eGFR ≥ 60 ml/min/1.73 m2. We also evaluated the associations of anemia with level of renal function (eGFR) using logistic regression. We repeated the analyses using mildly reduced eGFR (eGFR 60–89.9 ml/min/1.73 m2) in place of eGFR ≥ 90 ml/min/1.73 m2, as the reference group. Multivariate logistic regression analysis (backwards stepwise) was conducted and the corresponding adjusted odds ratios (AOR) and 95% confidence intervals (CI) were used to identify factors independently associated with anemia. P < 0.05 was used to indicate statistical significance.The data was entered in to “EpiData version 3.1” and was exported to SPSS version 20.0 statistical software for analysis. Normally distributed and continuous variables were expressed as mean (± SD), and non-normally distributed variables were presented as medians (quartiles 25 and 75%). Chi squared . Mean BMI was 22.23 ± 3.2 Kg/m2. Mean systolic and diastolic BP was 120 ± 19 and 79 ± 32 mmHg, respectively and 117 (28.4%) patients were hypertensive. The mean eGFR was 100.1 ± 39.8 ml/min/1.73 m2, and 59 patients (14.3%) had eGFR < 60 ml/min/1.73 m2. One hundred and fifty patients (36.4%) had albuminuria. On the other hand, about 79% of patients with albuminuria had eGFR ≥60 ml/min/1.73 m2. CKD was present in 43.0% of patients; of these, 35.0% had stage 1, 31.6% had stage 2, 32.2% had stage 3 and only one patient (0.6%) had stage 4 CKD  and anemia prevalence progressively increased with age: 18.3% for age 18–30 years, 14.6% for 31–45 years, 31.4% for 46–60 years and 52.4% for >60 years (P < 0.001). Interestingly, males were more likely to be anemic than females (P < 0.001), but this may be related to the higher threshold of hemoglobin for males in the definition used. Patients with anemia were more likely to have type 2 diabetes, longer duration of diabetes, alcohol consumers, hypertension, high current systolic BP, fasting blood glucose, serum creatinine and low eGFR . There was no significant difference in the educational status, smoking, BMI and diastolic BP of patients with and without anemia.Of the 412 study patients, 110 (26.7%) had anemia according to the WHO criteria. Characteristics of patients with or without anemia are summarized in P < 0.001). The prevalence of anemia increased with stage of CKD, from 20.6% at stage 1 to 100.0% at stage 4 (P < 0.001). The prevalence of anemia at a Hgb level <11 g/dl increased significantly with worsening of CKD stages as expected. stage 4 . Sixty-t2 had WHO-defined anemia compared with 21.2% of those with eGFR ≥ 60 ml/min/1.73 m2 (P < 0.001). In addition, logistic regression revealed that patients with moderate renal impairment (eGFR = 30–59.9 ml/min/1.73 m2) were 6.3 times  as likely to have anemia as patients with normal renal function (eGFR ≥ 90 ml/min/1.73 m2). Patients with moderate renal impairment were also 4.2 times  as likely to have anemia as patients with mild renal impairment (eGFR = 60–89.9 ml/min/1.73 m2) (data not shown). When stratified by albuminuria status, 38.7% of those with albuminuria had anemia, about 2.5 times higher than the 19.8% in those without albuminuria (P < 0.001).More than half (59.3%) of the patients with eGFR < 60 ml/min/1.73 mP = 0.026); type 2 diabetes ; presence of hypertension ; current high systolic BP ; high serum creatinine  and low eGFR  were independently associated with greater odds for the presence of anemia . This prevalence of anemia is comparable to 14.3% prevalence reported from sub-Saharan African study in Cameroon . Our preP < 0.001). This finding is significant given that anemia has previously been shown to be associated with cardiovascular disease and all-cause mortality and higher cost of managing diabetic patients with CKD [Our findings of increased rates of anemia among diabetic patients with CKD compared to those without CKD is consistent with findings from previous studies evaluating the relationship of diabetes to anemia ,14,32. Iwith CKD ,17. The with CKD –35, whicwith CKD .2 had anemia compared with 21.2% of those with eGFR ≥ 60 ml/min/1.73 m2. Renal function as measured by GFR equations was the strongest risk factor for prevalent anemia and may help to identify diabetic patients at greater risk [2). This is in accordance with previous findings [Similar to previous reports, anemia in our study was more common among diabetic patients with impaired renal function (low eGFR) ,24,25,37ter risk . It has ter risk . Howeverfindings ,19,25,37The multivariate analysis of this study showed that older age is independently associated with greater odds for the presence of anemia and this is consistent with other related studies ,34,37. TThis study also showed a significant association between anemia and the presence of hypertension and current high systolic blood pressure. This association is of concern considering that hypertension in diabetic patients’ increases the risk of renal impairment and thus increasing the subsequent development of anemia. In the above study by Thomas et al, a weak association between systolic blood pressure and hemoglobin level was detected in diabetic patients with renal disease after adjusting for differences in renal function . HoweverThe present study has some limitations: the study lacks control groups and did not assess the causes of anemia in diabetic patients. Renal disease was assessed based on a one-time GFR and proteinuria measurements, possibly leading to overestimation of the actual prevalence of CKD. The cross-sectional nature of the study, where better relationship between anemia and different potential factors affecting it progressively cannot be well established, so a longitudinal study is needed to assess the relationship over time. However, the study has provided some data to inform decision-makers to improve current care and management of diabetic persons.In conclusion, anemia is commonly present among diabetic adults attending our outpatient diabetes clinic in Northeast Ethiopia, including those without kidney disease. More than a quarter (26.7%) of our diabetic outpatients had anemia and 15.3% had anemia below the recommended treatment threshold of 11 g ⁄ dl. Our findings highlight the need for incorporating anemia screening into the routine assessment of diabetic complications particularly for those with significant risk factors to enable early detection and treatment of anemia and hence improve the overall care of patients with diabetes.S1 File(XLS)Click here for additional data file.