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This column describes a pilot study of a fully automated, Internet-based program that provides a key element of interpersonal and social rhythm therapy, a form of psychotherapy shown to be effective in the treatment of bipolar disorder when combined with mood-stabilizing medication. Participants (N=64) recorded the time they completed activities of daily living and their mood at the time of each entry. After 90 days they demonstrated a 31% increase in social rhythm stability and a small, though statistically significant, decrease in symptoms of abnormal mood. Internet-based programs can enhance access to a best practice in the management of bipolar disorder. [ABSTRACT FROM AUTHOR]

Background: Data on mRNA-1273 (Moderna) vaccine effectiveness (VE) in children aged 6 months to 5 years are limited. The objectives of this study were to assess mRNA-1273 vaccine effectiveness against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19)-related hospitalization among children aged 6 months to 5 years during the initial 5 months of the vaccination campaign rollout, as well as to determine whether VE varied by age group (6 months to <2 years vs 2 to 5 years)., Methods: We used a test-negative study with linked health administrative data in Ontario, Canada, to evaluate vaccine effectiveness of mRNA-1273 against symptomatic SARS-CoV-2 infection and COVID-19-related hospitalization from July 28 to December 31, 2022. Participants included symptomatic children aged 6 months to 5 years who were tested by real-time polymerase chain reaction. The primary outcome was symptomatic infection, and the secondary outcome was COVID-19-related hospitalization., Results: We included 572 test-positive cases and 3467 test-negative controls. Receipt of mRNA-1273 was associated with reduced symptomatic SARS-CoV-2 infection (VE, 90%; 95% CI, 53%-99%) and COVID-19-related hospitalization (VE, 82%; 95% CI, 4%-99%) ≥7 days after the second dose. We were unable to detect heterogeneity in VE across age groups., Conclusions: Our findings suggest that mRNA-1273 vaccine effectiveness was initially strong against symptomatic SARS-CoV-2 infection and hospitalization in children aged 6 months to 5 years. Further research is needed to understand long-term effectiveness., Competing Interests: Potential conflicts of interest. The authors declare no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: To investigate the prevalence of concomitant bacterial infection across common viral infections., Methods: This population-based cohort study included patients infected with influenza A and B (FLUA, FLUB) and respiratory syncytial virus (RSV) in Ontario between 2017 and 2019 and patients with SARS-CoV-2 between 2020 and 2021. Specific bacteria present in concomitant infections were identified. Concomitant infections were further classified into different categories (eg, coinfection -2 to +2 days from viral infection and secondary infection >2 days after viral infection). We used logistic regression models to estimate the odds of bacterial infections for FLUA, FLUB, and RSV relative to SARS-CoV-2 while adjusting for confounders., Results: A total of 4230 (0.5%, 885 004) viral cases had concomitant bacterial infections, encompassing 422 of FLUB (4.7%, 8891), 861 of FLUA (3.9%, 22 313), 428 of RSV (3.4%, 12 774), and 2519 of COVID-19 (0.3%, 841 026). The most prevalent species causing concomitant bacterial infection were Staphylococcus aureus , Streptococcus pyogenes , and Pseudomonas aeruginosa . When compared with SARS-CoV-2, the adjusted odds ratio for bacterial infection was 1.69 (95% CI, 1.48-1.93) for FLUA, 2.30 (95% CI, 1.97-2.69) for FLUB, and 1.56 (95% CI, 1.33-1.82) for RSV. The adjusted odds of coinfection in patients with SARS-CoV-2 were lower but higher for secondary infection as compared with the other viruses., Conclusions: A higher prevalence and risk of concomitant bacterial infection were found in FLUA, FLUB, and RSV as compared with SARS-CoV-2, although this is largely driven by coinfections. Ongoing surveillance efforts are needed to compare the risk of concomitant infections during periods when these viruses are cocirculating., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Randomized trials conducted in low- and middle-income settings demonstrated efficacy of influenza vaccination during pregnancy against influenza infection among infants <6 months of age. However, vaccine effectiveness (VE) estimates from settings with different population characteristics and influenza seasonality remain limited., Methods: We conducted a test-negative study in Ontario, Canada. All influenza virus tests among infants <6 months from 2010 to 2019 were identified and linked with health databases to ascertain information on maternal-infant dyads. VE was estimated from the odds ratio for influenza vaccination during pregnancy among cases versus controls, computed using logistic regression with adjustment for potential confounders., Results: Among 23 806 infants tested for influenza, 1783 (7.5%) were positive and 1708 (7.2%) were born to mothers vaccinated against influenza during pregnancy. VE against laboratory-confirmed infant influenza infection was 64% (95% confidence interval [CI], 50%-74%). VE was similar by trimester of vaccination (first/second, 66% [95% CI, 40%-80%]; third, 63% [95% CI, 46%-74%]), infant age at testing (0 to <2 months, 63% [95% CI, 46%-75%]; 2 to <6 months, 64% [95% CI, 36%-79%]), and gestational age at birth (≥37 weeks, 64% [95% CI, 50%-75%]; < 37 weeks, 61% [95% CI, 4%-86%]). VE against influenza hospitalization was 67% (95% CI, 50%-78%)., Conclusions: Influenza vaccination during pregnancy offers effective protection to infants <6 months, for whom vaccines are not currently available., Competing Interests: Potential conflicts of interest . During the conduct of this work, D. B. F. worked for the University of Ottawa and had academic appointments at the Children's Hospital of Eastern Ontario Research Institute and ICES; she is currently employed by Pfizer. K. W. is a cofounder and Chief Scientific Officer of CANImmunize, Inc; he served on the Independent Data Monitoring Committee for Medicago; and is a member of the Moderna Global Advisory Core Consultancy Group. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Introduction: Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology., Objective: To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits., Design: Retrospective cohort study using population-level administrative data., Setting: Ontario, Canada., Population: Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018., Interventions: Not applicable., Main Outcome Measures: Acute care hospitalizations and ED visits within one year post-initial discharge., Results: A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting., Conclusion: Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Guilcher et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: We previously identified specific immigrant groups (West African and Caribbean) with increased incidence of prostate cancer in Ontario, Canada. In this population-level retrospective cohort study, we used administrative databases to compare stage of diagnosis, 5-year overall survival and prostate cancer-specific survival for immigrants versus long-term residents of Ontario., Methods: We linked several provincial-level databases available at ICES, an independent, non-profit research institute. We included all male Ontario residents 20-105 years of age who had an incident prostate cancer diagnosis date between March 31, 2008 and March 31, 2017, stratified into immigrants vs. long-term residents. We used multivariable logistic regression to determine the odds of early (stage I-II) vs. late (III-IV) stage of diagnosis, adjusting for age, co-morbidities, neighbourhood income and continuity of care. We produced Kaplan-Meier curves for 5-year overall survival and for 5-year prostate cancer-specific survival., Results: Compared to long-term residents, men from West Africa (adjusted odds ratio 1.66 [95% CI 1.16-2.38], East Africa (AOR 1.54 [95% CI 1.02-2.33]) and the Caribbean (AOR 1.22 [95% CI 1.01-1.47]) had a diagnostic stage advantage, and men from South Asia were most likely to be diagnosed at a late stage. In both unadjusted and adjusted analyses, overall and prostate cancer-specific survival were higher for immigrants than long-term residents. The highest five-year overall survival was seen for men from Sub-Saharan Africa and the Caribbean, and the lowest was seen for South Asian men, where 11.7% died within five years of diagnosis., Conclusion: Immigrant men in Ontario with prostate cancer are more likely to be diagnosed at an early stage and to survive for 5 years than long-term residents. Among immigrant men, men from the Caribbean and Sub-Saharan Africa have the greatest stage and survival advantage and South Asian men the least. Differences in awareness, diagnostic suspicion, genetic predisposition, and social factors may play a role in these findings., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits., Methods: We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk., Results: Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines., Conclusions: History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Objective: To examine the association between Muslim religious affiliation and suicide and self-harm presentations among first- and second-generation immigrant youth., Methods: We performed a population-based cohort study involving individuals aged 12 to 24 years, living in Ontario, who immigrated to Canada between 1 January 2003 and 31 May 2017 (first generation) and those born to immigrant mothers (second generation). Health administrative and demographic data were used to analyze suicide and self-harm presentations. Sex-stratified logistic regression models generated odds ratios (OR) for suicide and negative binomial regression models generated rate ratios (aRR) for self-harm presentations, adjusting for refugee status and time since migration., Results: Of 1,070,248 immigrant youth (50.1% female), there were 129,919 (23.8%) females and 129,446 (24.2%) males from Muslim-majority countries. Males from Muslim-majority countries had lower suicide rates (3.8/100,000 person years [PY]) compared to males from Muslim-minority countries (5.9/100,000 PY) (OR: 0.62, 95% CI, 0.42-0.92). Rates of suicide between female Muslim-majority and Muslim-minority groups were not different (Muslim-majority 1.8/100,000 PY; Muslim-minority 2.2/100,000 PY) (OR: 0.82, 95% CI, 0.46-1.47). Males from Muslim-majority countries had lower rates of self-harm presentations than males from Muslim-minority (<10%) countries (Muslim majority: 12.2/10,000 PY, Muslim-minority: 14.1/10,000 PY) (aRR: 0.82, 95% CI, 0.75, 0.90). Among female immigrants, rates of self-harm presentations were not different among Muslim-majority (30.1/10,000 PY) compared to Muslim-minority (<10%) (32.9/10,000 PY) (aRR: 0.93, 95% CI, 0.87-1.00) countries. For females, older age at immigration conferred a lower risk of self-harm presentations., Conclusion: Being a male from a Muslim-majority country may confer protection from suicide and self-harm presentations but the same was not observed for females. Approaches to understanding the observed sex-based differences are warranted.

Importance: Patients with cancer are at increased risk of SARS-CoV-2-associated adverse outcomes., Objective: To determine the associations of tumor type with SARS-CoV-2 infection, hospitalization, intensive care unit (ICU) admission, and death., Design, Setting, and Participants: This retrospective, population-based cohort study included community-dwelling adults aged at least 18 years in Ontario, Canada, ICES-linked provincial health databases from January 1, 2020, to November 30, 2021. Data were analyzed from December 1, 2021, to November 1, 2022., Exposures: Cancer diagnosis., Main Outcomes and Measures: The primary outcome was SARS-CoV-2 infection, and secondary outcomes included all-cause 14-day hospitalization, 21-day ICU admission, and 28-day death following SARS-CoV-2 infection. Cox proportional hazards models were used to obtain adjusted hazard ratios (aHRs) and 95% CIs., Results: Of 11 732 108 people in the ICES-linked health databases, 279 287 had cancer (57.2% female; mean [SD] age, 65.9 [16.1] years) and 11 452 821 people did not have cancer (45.7% female; mean [SD] age, 65.9 [16.0] years). Overall, 464 574 individuals (4.1%) developed SARS-CoV-2 infection. Individuals with hematologic malignant neoplasms (33 901 individuals) were at increased risk of SARS-CoV-2 infection (aHR, 1.19; 95% CI, 1.13-1.25), 14-day hospitalization (aHR, 1.75; 95% CI, 1.57-1.96), and 28-day mortality (aHR, 2.03; 95% CI, 1.74-2.38) compared with the overall population, while individuals with solid tumors (245 386 individuals) were at lower risk of SARS-CoV-2 infection (aHR, 0.93; 95% CI, 0.91-0.95) but increased risk of 14-day hospitalization (aHR, 1.11; 95% CI, 1.05-1.18) and 28-day mortality (aHR, 1.31; 95% CI, 1.19-1.44). The 28-day mortality rate was high in hospitalized patients with hematologic malignant neoplasms (163 of 321 hospitalized patients [50.7%]) or solid tumors (486 of 1060 hospitalized patients [45.8%]). However, the risk of 21-day ICU admission in patients with hematologic malignant neoplasms (aHR, 1.14; 95% CI, 0.93-1.40) or solid tumors (aHR, 0.93; 95% CI, 0.82-1.05) was not significantly different from that among individuals without cancer. The SARS-CoV-2 infection risk decreased stepwise with increasing numbers of COVID-19 vaccine doses received (1 dose: aHR, 0.63; 95% CI, 0.62-0.63; 2 doses: aHR, 0.16; 95% CI, 0.16-0.16; 3 doses: aHR, 0.05; 95% CI, 0.04-0.06)., Conclusions and Relevance: These findings highlight the importance of prioritization strategies regarding ICU access to reduce the mortality risk in increased-risk populations, such as patients with cancer.

Objectives: This study aimed to provide real-world evidence on coronavirus disease 2019 vaccine effectiveness (VE) against symptomatic infection and severe outcomes caused by Omicron in children aged 5 to 11 years., Methods: We used the test-negative study design and linked provincial databases to estimate BNT162b2 vaccine effectiveness against symptomatic infection and severe outcomes caused by Omicron in children aged 5 to 11 years between January 2 and August 27, 2022 in Ontario. We used multivariable logistic regression to estimate VE by time since the latest dose, compared with unvaccinated children, and we evaluated VE by dosing interval., Results: We included 6284 test-positive cases and 8389 test-negative controls. VE against symptomatic infection declined from 24% (95% confidence interval [CI], 8% to 36%) 14 to 29 days after a first dose and 66% (95% CI, 60% to 71%) 7 to 29 days after 2 doses. VE was higher for children with dosing intervals of ≥56 days (57% [95% CI, 51% to 62%]) than 15 to 27 days (12% [95% CI, -11% to 30%]) and 28 to 41 days (38% [95% CI, 28% to 47%]), but appeared to wane over time for all dosing interval groups. VE against severe outcomes was 94% (95% CI, 57% to 99%) 7 to 29 days after 2 doses and declined to 57% (95%CI, -20% to 85%) after ≥120 days., Conclusions: In children aged 5 to 11 years, 2 doses of BNT162b2 provide moderate protection against symptomatic Omicron infection within 4 months of vaccination and good protection against severe outcomes. Protection wanes more rapidly for infection than severe outcomes. Overall, longer dosing intervals confer higher protection against symptomatic infection, however protection decreases and becomes similar to shorter dosing interval starting 90 days after vaccination.

Background: When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization., Methods: We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori., Key Results: One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications., Conclusions and Inferences: Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas., (© 2022 John Wiley & Sons Ltd.)

Background: Prostate cancer incidence has been associated with various sociodemographic factors, such as race, income and age, but the association with immigrant status in Canada is unclear. In this population-based study in Ontario, Canada, we compared age-standardized incidence rates for immigrant males from various regions of origin with the rates of long-term residents., Methods: In this retrospective cohort study, we linked several provincial-level databases available at ICES, an independent, non-profit research institute. We included all males aged 20 years and older in the province of Ontario eligible for health care for each fiscal year (Apr. 1 to Mar. 31) in 2008-2016. We determined age-standardized prostate cancer incidence rates, stratifying by immigrant status (a binary variable) and region of origin. We used a log-binomial model to estimate adjusted incidence rate ratios, with long-term residents (Canadian-born Ontarians as well as those who immigrated before 1985, when available data on immigration starts) as the reference group. We included age, neighbourhood income and time since landing in the models. Additional models limited to immigrant males in the cohort included immigration admission category (economic class, family class, refugee, other) and time since landing in Canada., Results: There were 74594 incident cases of prostate cancer in the study period, 6742 of which were among immigrant males. Males who had immigrated from West Africa and the Caribbean had significantly higher incidence of prostate cancer than other immigrants and long-term residents: adjusted rate ratios of 2.71 (95% confidence interval [CI] 2.41-3.05) and 1.91 (95% CI 1.78-2.04), respectively. Immigrants from other regions, including East Africa and Middle-Southern Africa, had lower or similar incidence rates to long-term residents. Males from South Asia had the lowest adjusted rate ratio (0.47, 95% CI 0.45-0.50)., Interpretation: The age-standardized incidence rate of prostate cancer from 2008 to 2016 was consistently and significantly higher among immigrants from West African and Caribbean countries than among other immigrants and long-term residents of the province. Future research in Canada should focus on further understanding heterogeneity in prostate cancer risk and epidemiology, including stage of diagnosis and mortality, for immigrants., Competing Interests: Competing interests: Aisha Lofters declares an operating grant paid to her institution from the Canadian Institutes of Health Research (grant no. 162506) and a paid role as provincial primary care lead, cancer screening with Ontario Health (Cancer Care Ontario). Anthony Henry is first vice president of The Walnut Foundation. Ken Noel is president of The Walnut Foundation. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Community-dwelling older adults living with dementia visit the emergency department (ED) more frequently than other older adults, but research on the reasons for repeated visits is lacking. We examined the rate of repeated ED visits and reasons for visits in a cohort of individuals with dementia., Methods: We conducted a population-based retrospective cohort study of community-dwelling older adults (≥66 years) living with dementia in Ontario, Canada, who visited the ED and were discharged home between April 1, 2010, and March 31, 2019. We calculated the proportion of the population with one, two, and three or more repeat ED visits within 1 year of the baseline visit and the categorized the reason for the visits., Results: Our cohort contained 175,863 individuals with dementia who visited the ED at least once. Overall, 66.1% returned at least once to the ED within 1 year, 39.4% returned twice, and 23.5% returned 3 or more times. Visit reasons were heterogenous and were most frequently related to general signs and symptoms (25.3%) while being infrequently due to cognitive or behavioral reasons (5.9%). Individuals typically visited for different reasons across successive visits., Conclusions: Community-dwelling older adults with dementia who visited an ED were very likely to return to the ED within a year, with a substantial proportion visiting multiple times. The high frequency of repeated visits for different reasons highlights the complexity of caring for this population and indicates greater need for comprehensive community and primary care as well as timely communication between the ED and the community., (© 2022 The American Geriatrics Society.)

Background: Heavy metals are well known to be associated with cancer outcomes, but its association with obesity and cardiometabolic risk outcomes requires further study., Methods: Adult data from the National Health and Examination Survey (NHANES Continuous 1999-2016, n  = 12,636 to 32,012) with data for blood or urinary metals concentrations and body mass index were used. The study aim was twofold: (1) to determine the association between heavy metals and obesity and (2) to examine the influence of heavy metals on the relationship between obesity and hypertension, type 2 diabetes, and dyslipidemia. Logistic regression was used to examine the main effects and interaction effects of metals and obesity for the odds of prevalent hypertension, type 2 diabetes, and dyslipidemia. Models were adjusted for age, gender, ethnicity, smoking status, physical active status, and poverty-income ratio, with additional adjustment for creatinine in models with the urinary measures of heavy metals. High-low concentration categories were defined by grouping metal quintiles with the most similar associations with obesity., Results: Blood lead had a negative linear association with obesity (odds ratio (OR)  = 0.42, 95% confidence interval (CI) = 0.37-0.47). In those with obesity, high blood lead was associated with lower risk of prevalent dyslipidemia, while no association was found in those without obesity. The study observed a curvilinear relationship between urinary antimony and obesity with the moderate group having the highest odds of obesity (OR = 1.36, 1.16-1.59). However, the relationship between urinary antimony and prevalent hypertension and dyslipidemia risk was linear, positive, and independent of obesity. While not associated with prevalent obesity risk, high urinary uranium was associated with 30% ( P =0.01) higher odds for prevalent type 2 diabetes., Conclusions: The impact of environmental factors on obesity and health may be complex, and this study reinforces the heterogeneous relationship between various metals, obesity, and obesity-related metabolic diseases even at levels observed in the general population., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Sarah Swayze et al.)

Objective: To examine the combined association between metformin use and physical activity on HbA1c in adults with type 2 diabetes., Research Design and Methods: Adults with type 2 diabetes from NHANES continuous survey (1999-2018, n = 6447) were classified as active and inactive based on self-reported engagement in moderate-to-vigorous or vigorous physical activity (MVPA or VigPA) and metformin use over the last month., Results: There was a significant negative main effect of metformin usage on HbA1c levels, independent of whether individuals engaged in modest levels of MVPA or VigPA. Moreover, there was a higher prevalence of metformin users with a HbA1c < 6.5% than non-metformin users with no differences by activity status (36.1%-39.5% versus 24.9%-29.7%, respectively). There was a significantly lower HbA1c level ( P  = .007) and trend for a higher odds of having a HbA1c that achieved the clinical target of <7% (OR, 95% CI = 1.2, 1.0-1.4, P  = .06) in the MVPA than non-MVPA group for only those not using metformin. For those using metformin, there was no difference in HbA1c levels by either MVPA or VigPA (both P  > .05)., Conclusions: There appears to be independent benefits of metformin and regular physical activity on glucose control, but the impact of these two treatments are not necessarily additive. Based on this analyses, the benefit of physical activity on HbA1c levels in type 2 diabetes is likely more apparent in those not taking metformin, as compared to those who are., Competing Interests: All authors have no related conflicts of interest to declare., (© 2020 The Authors. Endocrinology, Diabetes & Metabolism published by John Wiley & Sons Ltd.)

1. Self-help groups for individuals with sarcoidosis (a noncontagious multisystem disorder characterized by granulomas in many organs) are rare despite the physical and emotional problems associated with this disease. 2. The stimulus for the development of the group arose when staff in a pulmonary clinic identified that sarcoidosis patients were helping each other cope with problems and concerns related to their disease and feelings of isolation. 3. Nurses play a significant role in creating vehicles of help and service to facilitate and support patients experiencing fear and anxiety about their disease. Nurses must recognize the role self-help groups play in assisting individuals to maintain their quality of life as they adapt to the psychosocial, physiological, and medical aspects of their illness.

In patients with alpha 1-antitrypsin deficiency, the development of emphysema is believed to be caused by the unchecked action of proteases on lung tissue. We evaluated the feasibility, safety, and biochemical efficacy of intermittent infusions of alpha 1-antitrypsin in the treatment of patients with alpha 1-antitrypsin deficiency. Twenty-one patients were given 60 mg of active plasma-derived alpha 1-antitrypsin per kilogram of body weight, once a week for up to six months. After a steady state had been reached, the group had trough serum levels of alpha 1-antitrypsin of 126 +/- 1 mg per deciliter as compared with 30 +/- 1 mg per deciliter before treatment, and serum anti-neutrophil elastase capacities of 13.3 +/- 0.1 microM as compared with 5.4 +/- 0.1 microM. The alpha 1-antitrypsin level in the epithelial-lining fluid of the lungs was 0.46 +/- 0.16 microM before treatment, and the anti-neutrophil elastase capacity was 0.81 +/- 0.13 microM. Six days after infusion, alpha 1-antitrypsin levels (1.89 +/- 0.17 microM) and anti-neutrophil elastase capacities (1.65 +/- 0.13 microM) in the lining fluid were significantly increased (P less than 0.0001). Because of the chronicity of the disorder and the lack of sensitive measures of lung destruction, the clinical efficacy of this therapy could not be studied rigorously. No changes in lung function were observed in our patients over six months of treatment. The only important adverse reactions to the 507 infusions were four episodes of self-limited fever. This study demonstrates that infusions of alpha 1-antitrypsin derived from plasma are safe and can reverse the biochemical abnormalities in serum and lung fluid that characterize this disorder. Together with lifetime avoidance of cigarette smoking, replacement therapy with alpha 1-antitrypsin may be a logical approach to long-term medical treatment.