Reactive arthritis and other musculoskeletal symptoms associated with acquisition of diarrhoeagenic Escherichia coli (DEC)

ObjectivesUsing a prospective research design, we evaluated the association between acquisition of diarrhoeagenic Escherichia coli (DEC) and development of reactive arthritis (ReA) and other reactive musculoskeletal (MSK) symptoms among international travellers.MethodsA total of 526 study participants were asked to provide pretravel and post-travel stool samples and fill in questionnaires (pretravel, post-travel and 3-week follow-up). A multiplex quantitative PCR assay was deployed to detect five DEC comprising enteroaggregative E. coli, enteropathogenic E. coli, enterotoxigenic E. coli, enterohaemorrhagic E. coli and enteroinvasive E. coli and Salmonella, Shigella, Campylobacter, Yersinia, and Vibrio cholerae. Multivariate analysis was employed to identify factors predisposing to MSK symptoms. New post-travel MSK symptoms reported by participants with DEC were assessed by phone interviews and, if needed, clinically confirmed.ResultsFrom among the total of 224 volunteers who returned all questionnaires and stool specimens, 38 (17.0%) reported MSK symptoms. Multivariate analysis revealed that acquisition of DEC was associated with MSK symptoms (OR 3.9; 95% CI 1.2 to 13.3). Of the 151 with only-DEC, four (2.6%) had ReA, two (1.3%) reactive tendinitis and three (2.0%) reactive arthralgia. ReA was mostly mild, and all patients with ReA were negative for human leucocyte antigen B27. Antibiotic treatment of travellers’ diarrhoea did not prevent development of MSK symptoms.ConclusionA total of 17% of volunteers reported post-travel MSK symptoms. DEC acquisition was associated with an increased risk of developing them, yet the ReA incidence remained low and the clinical picture mild. Antibiotic treatment did not protect against development of MSK symptoms.

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Diarrheagenic Escherichia coli and Acute and Persistent Diarrhea in Returned Travelers

Journal of Clinical Microbiology ◽

10.1128/jcm.38.10.3550-3554.2000 ◽

2000 ◽

Vol 38 (10) ◽

pp. 3550-3554 ◽

Cited By ~ 34

Author(s):

C. Schultsz ◽

J. van den Ende ◽

F. Cobelens ◽

T. Vervoort ◽

A. van Gompel ◽

...

Keyword(s):

Escherichia Coli ◽

Multivariate Analysis ◽

Acute Diarrhea ◽

Case Control Study ◽

Persistent Diarrhea ◽

E Coli ◽

Diarrheagenic Escherichia Coli ◽

Stool Samples ◽

Control Study

To determine the role of diarrheagenic Escherichia coliin acute and persistent diarrhea in returned travelers, a case control study was performed. Enterotoxigenic E. coli (ETEC) was detected in stool samples from 18 (10.7%) of 169 patients and 4 (3.7%) of 108 controls. Enteroaggregative E. coli (EAggEC) was detected in 16 (9.5%) patients and 7 (6.5%) controls. Diffuse adherent E. coli strains were commonly present in both patients (13%) and controls (13.9). Campylobacter andShigella species were the other bacterial enteropathogens most commonly isolated (10% of patients, 2% of controls). Multivariate analysis showed that the presence of ETEC was associated with acute diarrhea (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.5 to 29.1; P = 0.005), but not with persistent diarrhea (OR, 1.6; 95% CI, 0.4 to 7.4). EAggEC was significantly more often present in patients with acute diarrhea than in controls (P = 0.009), but no significant association remained after multivariate analysis. ETEC and EAggEC are frequently detected in returned travelers with diarrhea. The presence of ETEC strains is associated with acute but not with persistent diarrhea.

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Respiratory Complications in Outpatient Endoscopy with Endoscopist-Directed Sedation

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.233.kf1 ◽

2014 ◽

Vol 23 (3) ◽

pp. 255-259 ◽

Cited By ~ 11

Author(s):

Kilian Friedrich ◽

Sabine G. Scholl ◽

Sebastian Beck ◽

Daniel Gotthardt ◽

Wolfgang Stremmel ◽

...

Keyword(s):

Antibiotic Treatment ◽

Respiratory Infection ◽

Endoscopic Procedure ◽

Shortness Of Breath ◽

Respiratory Complications ◽

Endoscopic Procedures ◽

Increased Risk ◽

High Incidence ◽

Respiratory Complaints

Background & Aims: Respiratory complications represent an important adverse event of endoscopic procedures. We screened for respiratory complications after endoscopic procedures using a questionnaire and followed-up patients suggestive of respiratory infection.Method: In this prospective observational, multicenter study performed in Outpatient practices of gastroenterology we investigated 15,690 patients by questionnaires administered 24 hours after the endoscopic procedure.Results: 832 of the 15,690 patients stated at least one respiratory symptom after the endoscopic procedure: 829 patients reported coughing (5.28%), 23 fever (0.15%) and 116 shortness of breath (SOB, 0.74%); 130 of the 832 patients showed at least two concomitant respiratory symptoms (107 coughing + SOB, 17 coughing + fever, 6 coughing + coexisting fever + SOB) and 126 patients were followed-up to assess their respiratory complaints. Twenty-nine patients (follow-up: 22.31%, whole sample: 0.18%) reported signs of clinically evident respiratory infection and 15 patients (follow-up: 11.54%; whole sample: 0.1%) received therefore antibiotic treatment. Coughing or vomiting during the endoscopic procedure resulted in a 156.12-fold increased risk of respiratory complications (95% CI: 67.44 - 361.40) and 520.87-fold increased risk of requiring antibiotic treatment (95% CI: 178.01 - 1524.05). All patients of the follow-up sample who coughed or vomited during endoscopy developed clinically evident signs of respiratory infection and required antibiotic treatment while this occurred in a significantly lower proportion of patients without these symptoms (17.1% and 5.1%, respectively).Conclusions: We demonstrated that respiratory complications following endoscopic sedation are of comparably high incidence and we identified major predictors of aspiration pneumonia which could influence future surveillance strategies after endoscopic procedures.

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1671. Diagnosis and management of Escherichia coli bacteriuria at a Veterans Affairs hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1849 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S821-S821

Author(s):

Niyati H Shah ◽

Brooke K Decker ◽

Gaetan Sgro ◽

Monique Y Boudreaux-Kelly ◽

...

Keyword(s):

Escherichia Coli ◽

Antibiotic Treatment ◽

High Yield ◽

Comorbid Conditions ◽

Provider Education ◽

Transmitted Infection ◽

Physician Practices ◽

E Coli ◽

Diagnosis And Management ◽

Tract Infections

Abstract Background The IDSA recommends against screening for and treating ASB in all patients except for those pregnant or undergoing urologic procedures. Nevertheless, antibiotic treatment of ASB is widespread. We conducted a retrospective analysis of physician practices in diagnosis and management of Escherichia coli (E. coli) ASB in a male Veteran population, and compared outcomes in ASB patients treated or not treated with antibiotics. Methods Patients with an E. coli positive urine culture during an ED visit or inpatient admission from 01/2017 to 12/2017 were screened. Patients admitted to the intensive care unit or diagnosed with a sexually transmitted infection, pyelonephritis, prostatitis, or epididymitis/orchitis were excluded. A total of 163 patients were included. Demographics, clinical comorbidities and severity of illness, and outcomes were compared in ASB patients managed with or without antibiotics. ANOVA and Chi-square or Fisher’s exact tests were utilized for comparing measurements. Results ASB was present in 92/163 patients. The majority (74%) of these patients were given antibiotics. Regardless of qSOFA score or alternate infection, there were no significant differences in outcomes between ASB patients treated or not treated with antibiotics: 3-month mortality (15% vs 21%; p = 0.53), emergence of newly resistant bacterial pathogens (7% vs 13%; p = 0.43), recurrent urinary tract infections (61% vs 50%; p = 0.72), clearance of urinary pathogens (75% vs 58%; p = 0.45), length of hospital stay (7 vs 6 days, p = 0.67). Factors that were predictive of physician treatment of ASB included patient comorbid conditions such as benign prostatic hyperplasia, pyuria, and the absence of hematuria. The incidence of adverse events with antibiotic treatment of ASB was low. Conclusion The rate of antibiotic treatment of E. coli ASB in male veterans is high. Outcomes do not differ among ASB patients managed with or without antibiotics. Future studies examining outcomes in patients prescribed antibiotics for multiple episodes of ASB may yield differences, particularly in emergence of resistant pathogens. Focusing on patients with comorbid conditions who are not critically ill would be a high yield target for provider education to reduce ASB treatment. Disclosures All Authors: No reported disclosures

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The Association of Sensory Impairment With Incident Disability-Related Cessation of Employment in Older Adults

Innovation in Aging ◽

10.1093/geroni/igaa057.697 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 216-216

Author(s):

Ahmed Shakarchi ◽

Emmanuel Garcia Morales ◽

Nicholas Reed ◽

Bonnielin Swenor

Keyword(s):

Older Adults ◽

Hearing Aids ◽

Population Based ◽

Sensory Impairment ◽

Loss To Follow Up ◽

Increased Risk ◽

Cox Proportional Hazard Regression ◽

Study Participants ◽

Adjusted Model

Abstract Sensory impairment (SI) is common among older adults, and it is an increasingly important public health challenge as the population ages. We evaluated the association between SI and incident disability-related cessation of employment in older adults using the population-based Health and Retirement Study. Participants employed in 2006 completed biennial interviews until self-reported incident disability-related cessation of employment. Participants were censored at loss to follow-up, retirement, or 2018. Participants rated their vision and hearing, using eyeglasses or hearing aids if applicable, on a Likert scale (poor, fair, good, very good, excellent). SI was defined as poor or fair ability, and SI was categorized as neither SI (NSI), vision impairment alone (VI), hearing impairment alone (HI), and dual SI (DSI). Cox proportional hazard regression assessed the association between SI and incident disability-related cessation of employment, adjusting for demographic and health covariates. Overall, 4726 participants were included: 421 (8.9%) were with VI, 487 (10.3) with HI, and 203 (4.3%) with DSI. Mean age was 61.0 ± 6.8 years, 2488 (52.6%) were women, and 918 (19.4) were non-White. In the fully adjusted model, incident disability-related cessation of employment over the 12-year follow-up period was higher in VI (Hazard Ratio (HR)=1.30, 95% confidence interval (CI)=0.92, 1.85), HI (HR=1.60, CI=1.16, 2.22), and DSI (HR=2.02, CI=1.38, 2.96). These findings indicate that employed older adults with SI are at increased risk of incident disability-related cessation of employment, and that older adults with DSI are particularly vulnerable. Addressing SI in older adults may lengthen their contribution to the workforce.

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Impact of Mobile Health Devices for the Detection of Atrial Fibrillation: Systematic Review

JMIR mhealth and uhealth ◽

10.2196/26161 ◽

2021 ◽

Vol 9 (4) ◽

pp. e26161

Author(s):

Tom E Biersteker ◽

Martin J Schalij ◽

Roderick W Treskes

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Mobile Health ◽

Standard Care ◽

Detection Rate ◽

Increased Risk ◽

Study Results ◽

Statistical Heterogeneity ◽

Study Participants

Background Atrial fibrillation (AF) is the most common arrhythmia, and its prevalence is increasing. Early diagnosis is important to reduce the risk of stroke. Mobile health (mHealth) devices, such as single-lead electrocardiogram (ECG) devices, have been introduced to the worldwide consumer market over the past decade. Recent studies have assessed the usability of these devices for detection of AF, but it remains unclear if the use of mHealth devices leads to a higher AF detection rate. Objective The goal of the research was to conduct a systematic review of the diagnostic detection rate of AF by mHealth devices compared with traditional outpatient follow-up. Study participants were aged 16 years or older and had an increased risk for an arrhythmia and an indication for ECG follow-up—for instance, after catheter ablation or presentation to the emergency department with palpitations or (near) syncope. The intervention was the use of an mHealth device, defined as a novel device for the diagnosis of rhythm disturbances, either a handheld electronic device or a patch-like device worn on the patient’s chest. Control was standard (traditional) outpatient care, defined as follow-up via general practitioner or regular outpatient clinic visits with a standard 12-lead ECG or Holter monitoring. The main outcome measures were the odds ratio (OR) of AF detection rates. Methods Two reviewers screened the search results, extracted data, and performed a risk of bias assessment. A heterogeneity analysis was performed, forest plot made to summarize the results of the individual studies, and albatross plot made to allow the P values to be interpreted in the context of the study sample size. Results A total of 3384 articles were identified after a database search, and 14 studies with a 4617 study participants were selected. All studies but one showed a higher AF detection rate in the mHealth group compared with the control group (OR 1.00-35.71), with all RCTs showing statistically significant increases of AF detection (OR 1.54-19.16). Statistical heterogeneity between studies was considerable, with a Q of 34.1 and an I2 of 61.9, and therefore it was decided to not pool the results into a meta-analysis. Conclusions Although the results of 13 of 14 studies support the effectiveness of mHealth interventions compared with standard care, study results could not be pooled due to considerable clinical and statistical heterogeneity. However, smartphone-connectable ECG devices provide patients with the ability to document a rhythm disturbance more easily than with standard care, which may increase empowerment and engagement with regard to their illness. Clinicians must beware of overdiagnosis of AF, as it is not yet clear when an mHealth-detected episode of AF must be deemed significant.

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Supper Timing and Cardiovascular Mortality: The Japan Collaborative Cohort Study

Nutrients ◽

10.3390/nu13103389 ◽

2021 ◽

Vol 13 (10) ◽

pp. 3389

Author(s):

Jingyun Tang ◽

Jia-Yi Dong ◽

Ehab S. Eshak ◽

Renzhe Cui ◽

Kokoro Shirai ◽

...

Keyword(s):

Hemorrhagic Stroke ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Stroke Mortality ◽

Hazard Ratios ◽

Risk Of Mortality ◽

Increased Risk ◽

Study Participants

Evidence on the role of supper timing in the development of cardiovascular disease (CVD) is limited. In this study, we examined the associations between supper timing and risks of mortality from stroke, coronary heart disease (CHD), and total CVD. A total of 28,625 males and 43,213 females, aged 40 to 79 years, free from CVD and cancers at baseline were involved in this study. Participants were divided into three groups: the early supper group (before 8:00 p.m.), the irregular supper group (time irregular), and the late supper group (after 8:00 p.m.). Cox proportional hazards regression models were used to calculate hazard ratios (HRs) for stroke, CHD, and total CVD according to the supper time groups. During the 19-year follow-up, we identified 4706 deaths from total CVD. Compared with the early supper group, the multivariable HR of hemorrhagic stroke mortality for the irregular supper group was 1.44 (95% confidence interval [CI]: 1.05–1.97). There was no significant association between supper timing and the risk of mortality from other types of stroke, CHD, and CVD. We found that adopting an irregular supper timing compared with having dinner before 8:00 p.m. was associated with an increased risk of hemorrhagic stroke mortality.

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Prevalence, seasonality and severity of disease caused by pathogenic Escherichia coli in children with diarrhoea in Bolivia

Journal of Medical Microbiology ◽

10.1099/jmm.0.060798-0 ◽

2013 ◽

Vol 62 (11) ◽

pp. 1697-1706 ◽

Cited By ~ 15

Author(s):

Lucia Gonzales ◽

Enrique Joffre ◽

Rosario Rivera ◽

Åsa Sjöling ◽

Ann-Mari Svennerholm ◽

...

Keyword(s):

Escherichia Coli ◽

Antibiotic Resistance ◽

Severe Disease ◽

Severe Diarrhoea ◽

E Coli ◽

Number Of Children ◽

Severity Of Disease ◽

Positive Stool ◽

Pathogenic Escherichia Coli ◽

Stool Samples

The prevalence of infection caused by different categories of diarrhoeagenic E. coli (DEC) strains, including enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC) and enterohaemorrhagic (EHEC) E. coli, in children who suffered from diarrhoea (n = 3943) or did not have diarrhoea (n = 1026) were analysed in two areas in Bolivia over a period of 4 years. We also analysed the seasonality of DEC infections and severity of diarrhoea in children with DEC infection and compared antibiotic resistance in DEC strains isolated from children with and without diarrhoea. Stool samples were analysed for the presence of DEC by culturing followed by PCR. The most prevalent DEC categories in samples from the children were: EAEC (11.2 %); ETEC (6.6 %); EPEC (5.8 %); and EIEC and EHEC (<1 %). DEC strains were isolated significantly more often from diarrhoea cases (21.6 %) than from controls (17.6 %; P = 0.002). The number of children with diarrhoea associated with EAEC, EPEC and ETEC infections peaked in the Bolivian winter (April–September), although the proportion of DEC-positive stool samples was higher during the warm rainy season (October–March). High levels of antibiotic resistance were detected among the DEC strains. In particular, resistance to tetracycline and sulfamethoxazole–trimethoprim was significantly higher in strains isolated from individuals with diarrhoea than in samples from controls. The severity of disease in children infected with EAEC, EPEC and ETEC varied from mild to severe diarrhoea, although disease severity did not differ significantly between the different DEC categories. ETEC, EPEC and EAEC are commonly found in Bolivia and may cause severe disease in children.

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Detection of Enterotoxigenic Escherichia coli in Rotavirus-Infected Ghanaian Children Diagnosed with Acute Gastroenteritis

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.21-0717 ◽

2021 ◽

Author(s):

Bartholomew Dzudzor ◽

Albert Amenyedor ◽

Vincent Amarh ◽

George E. Armah

Keyword(s):

Escherichia Coli ◽

Developing Countries ◽

Enterotoxigenic Escherichia Coli ◽

Surveillance Study ◽

Vaccination Program ◽

E Coli ◽

Rotavirus Vaccination ◽

Stool Samples ◽

Global Health Problem ◽

Vaccine Surveillance

Diarrhea is a notable global health problem in several developing countries, especially in children. Prior to the introduction of the rotavirus vaccination program in Ghana, a surveillance study was conducted to investigate the prevalence of the disease caused by rotavirus in children. In this report, we re-used archival stool samples from the pre-vaccine surveillance study to provide information on prevalence of enterotoxigenic Escherichia coli in Ghanaian children. Re-analysis of the stool samples revealed co-infection of enterotoxigenic E. coli and rotavirus in 2% of the children whose samples were selected for this study. As Ghana is approaching 10 years post-implementation of the rotavirus vaccination program, the preliminary data presented in this report are a vital reference for subsequent studies aimed at ascertaining the effect of the vaccine on both rotavirus and enterotoxigenic E. coli.

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2609. Escherichia coli Clonal Lineages and Virulence Factors Predict Fecal Colonization within Households

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2287 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S907-S907

Author(s):

Teresa C Fox ◽

Paul Thuras ◽

Connie Clabots ◽

Stephen Porter ◽

James R Johnson

Keyword(s):

Escherichia Coli ◽

Clinical Isolate ◽

Virulence Factors ◽

Outcome Variable ◽

E Coli ◽

Wilcoxon Rank Sum Test ◽

Colonization Patterns ◽

Stool Samples ◽

Colonization Factors ◽

Colonization Behavior

Abstract Background Extraintestinal Escherichia coli infections are an ever-growing threat, to which specific clonal lineages and virulence factors contribute disproportionately. Despite the gut being the main reservoir for such E. coli strains, relationships between clonal lineages, virulence factors, and fecal colonization patterns are poorly understood. Accordingly, we defined E. coli fecal colonization patterns within households (HHs) and assessed specific lineages and virulence genes (VGs) as predictors of colonization behaviors. Methods Veterans with an E. coli clinical isolate (n = 22: 11 fluoroquinoline [FQ]-resistant, 11 FQ-susceptible) and their HH members provided stool samples on 2–6 occasions each. Stools were screened for total and FQ-resistant E. coli. Distinct E. coli strains were resolved by genomic profiling of 10 colonies/sample. Strains underwent molecular lineage identification, VG detection, and comparison with the veteran’s clinical isolate. Clonal lineages and VGs were assessed (Wilcoxon rank-sum test) as predictors of strains’ (i) predominance within the fecal sample, (ii) persistence across serial fecal samples, (iii) within-HH strain sharing, and (iv) overall within-HH colonization prevalence. Results From the 22 veterans and 46 HH members (27 humans, 19 pets) we recovered 139 unique-by-household fecal E. coli strains. Sixty-four traits were evaluated (16 clonal lineages, 48 VGs). Of these, 44 exhibited n ≥ 5, so could be analyzed statistically. Among these 44 traits, the proportion significantly associated with ≥ 1 outcome variable was 5/6 (83%) for clonal lineages and 18/38 (47%) for VGs. Additionally, fecal strains that matched the veteran’s clinical isolate exhibited significantly greater sharing, persistence, and overall colonization. Conclusion The studied E. coli traits – known for their associations with clinical infections –here were significantly associated with within-HH colonization behavior. These findings support that “virulence factors” may be regarded also (or perhaps best) as “colonization factors,” and “virulent lineages” as “colonizing lineages.” This suggests the possibility that future interventions that disrupt colonization behavior also could prevent E. coli infections. Disclosures All authors: No reported disclosures.

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The impact of triglyceride-glucose index on incident cardiovascular events during 16 years of follow-up: Tehran Lipid and Glucose Study

Cardiovascular Diabetology ◽

10.1186/s12933-020-01121-5 ◽

2020 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Niloofar Barzegar ◽

Maryam Tohidi ◽

Mitra Hasheminia ◽

Fereidoun Azizi ◽

Farzad Hadaegh

Keyword(s):

Multivariate Analysis ◽

Risk Score ◽

Framingham Risk Score ◽

Significant Trend ◽

Lipid Lowering ◽

Tyg Index ◽

Framingham Risk ◽

Triglyceride Glucose Index ◽

Increased Risk

Abstract Background To investigate whether the Triglyceride-Glucose index (TyG-index) is associated with increased risk of cardiovascular diseases (CVD)/coronary heart disease (CHD). Methods A total of 7521 Iranians aged ≥ 30 years (male = 3367) were included in the study. Multivariate Cox regression analyses (adjusted for age, gender, waist circumference, body mass index, educational level, smoking status, physical activity, family history of CVD, type 2 diabetes, hypertension, low and high density lipoprotein cholesterol, and lipid lowering drugs) were used to assess the risk of incident CVD/CHD across quintiles and for 1-standard deviation (SD) increase in the TyG-index. The cut off point for TyG-index was assessed by the minimum value of $$\sqrt {\left( {1 - sensitivity} \right)^{2} + \left( {1 - specificity} \right)^{2} }$$ 1 - s e n s i t i v i t y 2 + 1 - s p e c i f i c i t y 2 . We also examined the added value of the TyG-index in addition to the Framingham risk score when predicting CVD. Results During follow-up, 1084 cases of CVD (male = 634) were recorded. We found a significant trend of TyG-index for incident CVD/CHD in multivariate analysis (both Ps for tend ≤ 0.002). Moreover, a 1-SD increase in TyG-index was associated with significant risk of CVD/CHD in multivariate analysis [1.16 (1.07–1.25) and 1.19 (1.10–1.29), respectively]. The cut-off value of TyG-index for incident CVD was 9.03 (59.2% sensitivity and 63.2% specificity); the corresponding value of TyG-index for incident CHD was 9.03 (60.0% sensitivity and 62.8% specificity), respectively. Although no interaction was found between gender and TyG-index for CVD/CHD in multivariate analysis (both Ps for interaction > 0.085), the significant trend of TyG-index was observed only among females for incident CVD (P = 0.035). A significant interaction was found between age groups (i.e. ≥ 60 vs < 60 years) and TyG-index for CVD outcomes in the multivariate model (P-value for interaction = 0.046). Accordingly, a significant association between the TyG-index and outcomes was found only among the younger age group. Among the population aged < 60 the addition of TyG-index to the Framingham risk score (FRS) did not show improvement in the predictive ability of the FRS, using integrated discrimination improvement. Conclusion The TyG-index is significantly associated with increased risk of CVD/CHD incidence; this issue was more prominent among the younger population. However, adding TyG-index to FRS does not provide better risk prediction for CVD.

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