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ABSTRACTThis commentary is about how a paper published in the Cities & Healthwas used in the Hon’ble Delhi High Court in an ongoing suo-motopetition to prevent mosquito infestation in the capital of India. The Court took cognisance of the rising density of mosquitoes and the rise in cases of mosquito-borne illness and instructed the various local government agencies to take action. One of the authors of this commentary intervened in this matter and brought the Court’s attention to the built environment interventions, especially screening of doors and windows and integrating the same in Unified Building Bye-laws, 2016.

Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated. The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) Post-Marketing Surveillance Program (PMS) has prospectively followed patient status and outcomes, drug side effects, and the economic impact of illness for [is greater than] 11,000 arthritis patients at 8 participating institutions in the United States and Canada. Analysis of these data indicates that: (1) osteoarthritis (OA) and rheumatoid arthritis (RA) patients are 2.5-5.5 times more likely than the general population to be hospitalized for NSAID-related GI events; (2) the absolute risk for serious NSAID-related GI toxicity remains constant and the cumulative risk increases over time; (3) there are no reliable warning signals-[is greater than] 80% of patients with serious GI complications had no prior GI symptoms; (4) independent risk factors for serious GI events were age, prednisone use, NSAID dose, disability level, and previous NSAID-induced GI symptoms; and (5) antacids and [H.sub.2] antagonists do not prevent NSAID-induced gastric ulcers, and high-risk NSAID users who take gastro-protective drugs are more likely to have serious GI complications than patients not taking such medications. Currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events. Ongoing ARAMIS research is aimed at developing a simple point-score system for estimating individual risks of developing serious NSAID-related GI complications. Am J Med. 1998;105(1B):31S-38S. [C] 1998 by Excerpta Medica, Inc.

We performed a randomized controlled trial to evaluate the effectiveness of a patient education and health promotion program in the treatment of Parkinson's disease. The health promotion program (PROPATH) was designed to improve health confidence, provide information and support, improve physical function through exercise, and work with the physician to optimize medical treatment and compliance. The intervention was delivered by mail, with disease assessment questionnaires completed by patient or caregiver at 0, 2, 4, and 6 months, with computer-generated reports and individualized recommendation letters returned to patients and reports to physicians. Two hundred ninety patients completed the 6-month trial, 140 patients in the intervention group and 150 in a control group of patients who received only questionnaires. The intervention group had significantly increased exercise, decreased 'time off' and percentage of time off, reduced side effects, and decreased summary Parkinson's scores by approximately 10% (P >0.05). Twelve of 13 variables showed differences favoring the intervention group. The rate of progression of summary scores became essentially flat during the program for the intervention group and continued to rise sharply for controls (P >0.01). Levodopa dose rose for controls and slightly decreased for the intervention group. Doctor visits, hospital days, and sick days were reduced in the intervention group. The quality-of-life assessment demonstrated improvement in patient global, self-efficacy scores, and spouse or caregiver assessments. We conclude that a low-cost patient education program provides a useful adjunct to medical therapy of Parkinson's disease, may reduce costs, and can improve intermediate term outcomes.

* Objective: To determine, by longitudinal study, whether regular vigorous running activity is associated with accelerated, unchanged, or postponed development of disability with increasing age. * Study Design: 8-year prospective, longitudinal study with yearly assessments. * Participants: 451 members of a runners' club and 330 community controls who were initially 50 to 72 years old (also characterized as 'ever-runners' [n = 534] and 'never-runners' [n = 247], respectively). * Measurements: The dependent variable was disability as assessed by the Health Assessment Questionnaire and separately validated in these participant cohorts. Covariates included age, sex, body mass index, comorbid conditions, education level, smoking history, alcohol intake, mean blood pressure, initial disability level, family history of arthritis, and radiologic evidence of osteoarthritis of the knee in a subsample. * Results: initially, the runners were leaner, reported joint symptoms less frequently, took fewer medications, had fewer medical problems, and had fewer instances of and less severity of disability, suggesting either that the average previous 12 years of running had improved health or that self-selection bias was present. After 8 years of longitudinal study, the differences in initial disability levels (0.026 compared with 0.079; P < 0.001) had steadily increased to 0.071 for runners compared with 0.242 for controls (P < 0.001). The difference was consistent for men and women. The rate of development of disability was several times lower in the runners' club members than in community controls; this difference persisted after adjusting for age, sex, body mass, baseline disability, smoking history, history of arthritis, or other comorbid conditions slopes of progression of disability for the years 1984 to 1992, after adjusting for covariates: men in the runners' club, 0.004 [SE, 0.002]; community controls, 0.012 [SE, 0.0021; women in the runners' club, 0.009 [SE, 0.005]; community controls, 0.027 [SE, 0.004]; P < 0.002 for both sets of comparisons). In addition to differences in disability, there were significant differences in mortality between the runners' club members (1.49%) and community controls (7.09%) (P < 0.001). These differences remained significant after adjusting for age, sex, body mass, comorbid conditions, education level, smoking history, alcohol intake, and mean blood pressure (P < 0.002, conditional risk ratio for community controls compared with the runners, 4.27; 95% Cl, 1.78 to 10.26). * Conclusions: Older persons who engage in vigorous running and other aerobic activities have lower mortality and slower development of disability than do members of the general population. This association is probably related to increased aerobic activity, strength, fitness, and increased organ reserve rather than to an effect of postponed osteoarthritis development., Running for exercise may delay musculoskeletal disability in older persons. Among 781 people between 50 and 72 years old at the beginning of an eight-year study, 451 were members of a runners' club and 330 were selected from the community for a comparison group. Researchers also classified the study participants as ever-runners (534) and never-runners (247). Functional disability was assessed annually by means of a questionnaire. Runners' club members and ever-runners showed little increase in disability over the eight years, while nonrunners had a significant increase. These differences remained even when researchers adjusted the data for age, gender, body mass, initial disability, smoking history, and history of arthritis or other illnesses. Both runners and nonrunners had x-ray evidence of similar increases in osteoarthritis. Therefore, the lower disability rate among runners is probably due to improved conditioning and cardiovascular health.

Background: Aspirin therapy has been largely superseded by prescription nonsteroidal anti-inflammatory drug (NSAID) therapy in rheumatoid arthritis, in part because of premarketing studies suggesting lesser toxic effects for NSAIDs than for aspirin. This study evaluates these toxic effects in a postmarketing population of patients with rheumatoid arthritis. Methods: We studied 1521 consecutive courses of aspirin and 4860 courses of NSAIDs in patients with rheumatoid arthritis from eight Arthritis, Rheumatism, and Aging Medical Information System Post-marketing Surveillance Centers. Toxicity index scores were generated from symptoms, laboratory abnormalities, and hospitalizations, weighted for variable severity and severity of side effect. Results: The toxicity index was only 1.37 (SE=0.10) for aspirin and 1.87 to 2.90 for selected nonsalicylate NSAIDs. These differences were consistent across centers and remained after statistical adjustment for differing patient characteristics. There was a different toxicity with different aspirin preparations, with a score for plain aspirin of 1.36 (SE=0.23), for buffered aspirin of 1.10 (0.20), and for enteric-coated aspirin preparations of 0.92 (0.14). Most important, there were strong dose effects, with a score of 0.73 (0.09) for 651 to 2600 mg daily, 1.08 (0.17) for 2601 to 3900 mg, and 1.91 (0.38) for more than 3900 mg. The average aspirin dose taken was only 2665 mg/d, approximately eight 'tablets,' compared with 3600 to 4800 mg/d used in the 16 pivotal premarketing studies reviewed. Average NSAID doses were, on the other hand, lower in premarketing trials (eg, naproxen 500 mg/d vs 773 mg/d in the Arthritis, Rheumatism, and Aging Medical System clinical practices). Conclusions: Aspirin therapy, in doses commonly employed in practice, has an excellent safety profile in rheumatoid arthritis, and it is the least costly NSAID. The safety advantage is explained primarily by a dose effect and secondarily by possible differences between formulations. Newer management strategies for rheumatoid arthritis emphasize NSAID use as symptomatic therapy and use of disease-modifying anti-rheumatic drug therapy for anti-inflammatory objectives. Thus, the original recommendation for 'anti-inflammatory' doses of aspirin now is less easily justified. Aspirin therapy merits reconsideration as adjunctive therapy for the management of rheumatoid arthritis.

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In today's world, electric vehicles (EVs) are becoming increasingly popular. A significant power outage occurs in the system when EVs are charged from grid-connected charging stations. This manuscript proposes a hybrid approach for charging station electricity generation by integrating solar PV and biomass. The proposed hybrid technique is a combination of both the Dandelion Optimizer (DO) and Deep Attention Dilated Residual Convolutional Neural Network (DADRCNN). It is hence called DO-DADRCNN. The proposed approach DO is used to optimize the control parameter of the converter. And DADRCNN model used to predict the control parameter of the converter. This paper's main goal is the minimization of levelized cost of energy (LCOE), initial cost and net present cost (NPC). The most ecologically friendly system is the Photo Voltaic (PV)/battery hybrid since it emits no pollutants. The new uses for hybrid renewable energy power systems that combine solar photovoltaics and biogas, as well as an examination of the system's economic and environmental performance. The DAO-DADRCNN approach and the environmental economic evaluation of hybrid sustainable energy systems are intended to be investigated. Biogas and solar PV-based EV charging solutions provide techno economic and environmental feasibility. The proposed strategy is implemented in the MATLAB platform and the emission of carbon-di-oxide (CO2) emission is compared with various existing techniques like Wild horse optimizer, Salp Swarm Algorithm, and Particle Swarm Optimization. The proposed approach DO-DADRCNN obtains lower carbon dioxide (CO2) emission than the existing techniques. The CO2emissions of the proposed technique is 5 kg/h which is lower and the cost for energy is 0.8$ which is lower than the existing methods.

A study is conducted to investigate that whether the increased risk of serious gastrointestinal (GI), which is associated to exposure to non-steroidal anti-inflammatory drugs (NSAIDs), is sustained over time. Result shows small decrease in risk over time, which are of negligible clinical importance, while also suggesting that for patients who need long-term treatment, precautionary measures are to be considered to reduce the net probability of serious GI events over the anticipated treatment duration.

John B Wong, MD(*); Jared D Schettler, MS; Dena Ramey, BA and Gurkirpal Singh, MD. Clinical Decision Making, Tufts-New England Medical Center, Boston, MA and Medicine and Biostatistics, Stanford University [...]

The majority of diabetes care is delivered in the primary care setting. Studies reveal large gaps between recommended standards of diabetes care and current practices in these settings. We have [...]

OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAID) not only cause damage to the upper gastrointestinal (GI) tract but also affect the lower GI tract. To date, there is no endpoint that evaluates serious GI events in the entire GI tract. The objective of this report is to introduce a novel composite endpoint that measures damage to the entire GI tract — clinically significant upper and lower GI events (CSULGIE) — in patients with NSAID-induced GI damage. METHODS: We reviewed the data from largescale, multicenter, randomized, clinical trials on lower GI toxicity associated with NSAID use. The rationale for using CSULGIE as a primary endpoint in 2 ongoing trials — the Celecoxib vs Omeprazole and Diclofenac for At-risk Osteoarthritis (OA) and Rheumatoid Arthritis (RA) Patients (CONDOR) trial and the Gastrointestinal Randomized Events and Safety Open-Label NSAID Study (GI-REASONS) — is also discussed. RESULTS: Previous randomized trials focused primarily on damage to the upper GI tract and often neglected the lower GI tract. The CSULGIE endpoint extends the traditional "perforation, obstruction, and bleeding" assessment of upper GI complications by including events in the lower GI tract (small/large bowel) such as perforation, bleeding, and clinically significant anemia. CONCLUSION: By providing clinicians with a new, descriptive language for adverse events through the entire GI tract, the CSULGIE endpoint has the potential to become a standard tool for evaluating the GI effects of a range of therapies.

In the last 2 years, there have been numerous publications on the safety of nonsteroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors. An evaluation of the potential risks and benefits of other analgesics has also followed. In this time of greater analysis of analgesic use, this review seeks to present the most recent evidence.

OBJECTIVE: Patient dropout (attrition) can bias and threaten validity of databank-based studies. Although there are several databanks of rheumatoid arthritis (RA) in operation, this phenomenon has not been well studied. METHODS: We studied the attrition patterns of patients with RA in 11 long-running databanks where patients were followed using semiannual Health Assessment Questionnaires. Attrition rates were calculated as the proportion of living patients who were in active followup at the cutoff date. Mantel-Haenszel methods and Weibull regression were used to model the relationship between attrition and age, sex, race, education, disease duration, functional disability, and other characteristics. RESULTS: Overall, 6346 patients with RA were recruited into the study cohorts and followed for 32,823 person-years with 65,649 observations. The crude attrition rate was 3.8% per cycle. Rates were lowest in community-based databanks. Smaller size of the centers, inner-city location, and university clinic settings were associated with worse attrition. In multivariable analyses, younger age, lower levels of education, and non-Caucasian race predicted attrition. Level of disability and disease duration were not associated with attrition. Conclusion. In terms of person-years of followup and observation-points, this may be the largest study on attrition to date. While it is possible to have very high overall retention rates, certain types of databanks (smaller, inner-city-based, and university-based) are more likely to be biased due to selective retention of older, more educated Caucasian patients.

To develop and validate a self-administered instrument for measuring functional status in Japanese-speaking rheumatoid arthritis patients. We translated the Stanford Health Assessment Questionnaire (HAQ) into Japanese (original HAQ), and then made a tentative Japanese version of the HAQ (J-HAQ) with culturally appropriate modifications of the arising, eating, and reach category questions. The questionnaire was then administered to 3,763 RA patients (82.6% female; mean age 58.0 years; mean onset age 47.4 years; mean disease duration 10.5 years). This instrument showed excellent internal reliability (Cronbach's α = 0.927), with a mean interitem correlation of 0.60. For the arising category question, the J-HAQ asks about arising from a futon in addition to a bed because futons are still common in Japanese culture. Arising from a futon is generally more difficult for disabled individuals than is arising from a bed, so the arising score was higher in the J-HAQ (mean score 0.82) than in the original HAQ (0.48). The average scores for the eating and reach categories were virtually identical for the original HAQ and the J-HAQ, with correlation coefficients of 0.979 and 0.926, respectively. Thus, the overall disability index (average of the scores for all functional areas) was higher in the J-HAQ (0.81) than in the original HAQ (0.76), although the correlation coefficient was high (0.993). The test-retest reliability value (0.92), studied at a 1-week interval, revealed identical disability index scores measured on the 2 occasions. The final version of the J-HAQ is a valid and reliable instrument for measuring functional status in Japanese-speaking RA patients.

OBJECTIVE: To estimate the potential effect on cardiovascular event occurrence and treatment costs associated with increases in systolic blood pressure (SBP) among patients with osteoarthritis (OA) and rheumatoid arthritis (RA). METHODS: We used cardiovascular risk prediction models from the Framingham Heart Study and data on risk factors from the Third National Health and Nutrition Examination Survey (NHANES III) to estimate occurrences of ischemic heart disease and stroke over one year among US adults with OA/RA. Separate analyses were conducted for treated hypertensive patients, and untreated hypertensive and normotensive patients, respectively. Published estimates were used to assign costs to these events and to follow care. The effect of incremental increases in SBP on events and costs was then assessed. Monte Carlo simulation was undertaken to assess the range of event occurrence and costs associated with alternative assumptions regarding the distribution of increased SBP in the at-risk population. RESULTS: Of the estimated 30 million adults in the US aged ≥ 35 years with OA and RA, roughly 11.8 million (39%) receive pharmacologic treatment for hypertension. Increases in SBP of 1-5 mm Hg were associated with 7,100-35,700 additional ischemic heart disease and stroke events over one year, with corresponding costs (year 2000 USD) of $114-569 million. A 20 mm Hg increase in SBP experienced by 15% of the at-risk population (equivalent to a population-average 3 mm Hg increase) is associated with about 21,700 additional events (95% CI 19,120, 24,221) and $346 million (95% CI $305, 387 million) in associated costs. CONCLUSION: Relatively small changes in SBP associated with use of common arthritis medications can have a significant effect on the cardiovascular risk profile. It is important that clinicians who treat patients with OA/RA accurately weigh the potential risks of these medications against their benefits.

To estimate the morbidity, mortality, and lifetime costs of care for rheumatoid arthritis (RA). We developed a Markov model based on the Arthritis, Rheumatism, and Aging Medical Information System Post-Marketing Surveillance Program cohort, involving 4,258 consecutively enrolled RA patients who were followed up for 17,085 patient-years. Markov states of health were based on drug treatment and Health Assessment Questionnaire scores. Costs were based on resource utilization, and utilities were based on visual analog scale–based general health scores. The cohort had a mean age of 57 years, 76.4% were women, and the mean duration of disease was 11.8 years. Compared with a life expectancy of 22.0 years for the general population, this cohort had a life expectancy of 18.6 years and 11.3 quality-adjusted life years. Lifetime direct medical care costs were estimated to be $93,296. Higher costs were associated with higher disability scores. A Markov model can be used to estimate lifelong morbidity, mortality, and costs associated with RA, providing a context in which to consider the potential value of new therapies for the disease.

Incident cases of lymphoma and leukemia in a cohort of 3824 rheumatoid arthritis (RA) patients from the Arthritis, Rheumatism and Aging Medical Information System (ARAMIS) database were identified, and the use of azathioprine, cyclophosphamide, and methotrexate was compared in a matched case-control study. Controls were matched on age, sex, year of study entry, disease duration, center, and years of follow-up. Twenty-four cases of lymphoma and 10 cases of leukemia were identified: 21 of patients with cancer versus 9 of controls had taken azathioprine [McNemar statistic 1.50 (p= 0.22), odds ratio 5.0 (95 confidence interval 0.6,236.5)]. Equal numbers of cases and controls (6 each) had taken cyclophosphamide and 18 of cases and 12 of controls had taken methotrexate [McNemar statistic 0.13 (p= 0.72), odds ratio 1.7 (0.3, 10.7)]. Results suggest but do not prove that RA patients taking azathioprine and methotrexate may have an increased risk of developing lymphoma. However, even if this increased risk can be confirmed, it accounts for only a small proportion of the greatly increased incidence of these malignancies in RA.

Concerns about the short‐term and long‐term toxic effects of azathioprine (AZA) have limited its use. Accordingly, we surveyed 393 AZA‐treated rheumatoid arthritis (RA) patients, who were recruited and enrolled through a nationwide call to rheumatologists. Findings in these patients were compared with the findings, retrieved from the databank of the American Rheumatism Association Medical Information System, on 153 similarly treated RA patients. All 546 patients were surveyed prospectively, using the Health Assessment Questionnaire and information abstracted from hospital records. The 2 groups were closely similar in clinical characteristics. The most frequently reported side effects of AZA treatment were nausea, vomiting, and leukopenia. Gastrointestinal intolerance accounted for nearly 60% of therapy interruptions in 95 patients. Of 81 hospitalizations for all causes, only 8 may have been related in part to AZA, and no deaths were attributed to AZA therapy. No lymphomas or leukemias were encountered, and the overall frequency of neoplasms was not significantly different from that seen in RA patients receiving conventional therapy. As used in the treatment of RA, AZA has a surprisingly benign profile with relatively few serious therapeutic mishaps.

Summary: A dot-immunobinding (DIB) assay was used to detect rinderpest antibodies in cattle vaccinated with Kabete ‘O’ strain vaccine, using purified rinderpest virus. Of 120 serum samples from vaccinated and non-vaccinated animals, rinderpest antibodies were detected in 80%, 88·4% and 91·6% of samples at 2, 3 and 4 weeks postvaccination respectively. All the serum samples from non-vaccinated animals were negative. The DIB results had a good correlation with those of the micro neutralisation test. The technique is simple, easy to perform and suitable for routine use in detecting rinderpest antibodies following vaccination.