Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study.

Funder: Action Bladder Cancer UKFunder: Rosetrees Trust; Id: http://dx.doi.org/10.13039/501100000833Funder: Urology Care Foundation; Id: http://dx.doi.org/10.13039/100006280OBJECTIVE: To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. PATIENTS AND METHODS: This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. RESULTS: Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001). CONCLUSIONS: A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study

Objective To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. Patients and Methods This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. Results Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3–34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1–30.2), UTUC (n = 128) 1.14% (95% CI 0.77–1.52), renal cancer (n = 107) 1.05% (95% CI 0.80–1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32–2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03–1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90–4.15; P < 0.001), male sex 1.30 (95% CI 1.14–1.50; P < 0.001), and smoking 2.70 (95% CI 2.30–3.18; P < 0.001). Conclusions A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

BACKGROUND: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. METHODS: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). FINDINGS: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29-146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0- 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25-1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39-1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65-1·60]; p=0·92). INTERPRETATION: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. FUNDING: British Heart Foundation

The epidemiology of Campylobacter jejuni in commercial broiler flocks in New Zealand : a thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Massey University, Palmerston North, New Zealand

Irregular pagination: jumps from xix to 21New Zealand maintains the highest incidence rate of human campylobacteriosis of the industrialized countries (334.2 cases per 100,000 in 2002), it accounts for more than 56% of all disease notifications in the country. New Zealand is unique globally, with a 'notification-based surveillance system for notifiable diseases that is complemented by laboratory reporting. In other countries (Australia, US, UK), the notification system is entirely laboratory based. Thus, the high incidence of Campylobacteriosis in humans may be related to the methods of reporting rather than the reality of the disease situation. However, the reason for such high incidence has not yet been fully elucidated, and several studies conducted in New Zealand and overseas have implicated the consumption of poultry meat as the main cause of human infections. The reduction or elimination of Campylobacter jejuni in the food chain, particularly from poultry meat products, is a major strategy in efforts to control campylobacteriosis. One approach to this is to prevent C. jejuni colonization of broiler chickens, This approach has been used to control Salmonella contamination of poultry, but the measures put in place for control of Salmonella have not controlled C jejuni. It is generally unknown how frequently C. jejuni colonizes commercial broiler chickens in New Zealand, or what could be done to prevent these infections from occurring. The present study was undertaken in order to describe some of the basic epidemiology of C. jejuni in commercial broiler flocks in New Zealand. The thesis is intended to further describe the epidemiology of colonisation of commercial broiler chickens by C. jejuni in NZ, and present possible risk factors that could be controlled in future to decrease the number of positive flocks of birds that are processed. The thesis set out to elucidate first the extent of C. jejuni colonisation of birds, flocks and farms while the birds were on the farm, having had minimal risk of exposure to Campylobacter spp., by sampling 15 birds in 80 flocks belonging to two companies prior to the first partial depopulation, an event during which the flock are exposed to potentially contaminated fomites and biosecurity levels are dropped, doors opened and personnel movements are extensive. The resulting prevalence estimates are 25.6% of farms, and 12.5% of sheds, are likely to be used to rear broiler chickens colonised with C. jejuni. When a positive flock is discovered, 76.9% of the birds are likely to be colonised with C. jejuni. These figures are results across the whole study population of farms and sheds, as there were no significant differences between prevalence estimates between companies. Following this prevalence estimation, a longitudinal study was conducted involving 12 sheds, to determine whether the environment or the birds were colonised with C. jejuni first. Although 12 sheds were observed every other day from day 14 to the end of the rearing period, it was determined that the birds were positive either first, or at the same time as the environment. Having said that, the sensitivity of the testing method for the environment was dubious, as there were instances where a shed that had positive samples collected on one occasion appeared negative the next, before returning a positive result on the third consecutive sampling occasion. A cross-sectional study of 810 flocks was undertaken to determine the most relevant risk factors for colonisation of the broiler chickens with C. jejuni. Because of the vertically integrated structure of the poultry industry, these 810 flocks corresponded to data collected from 77 farmers about their farms and the 219 sheds on those farms. The caeca from ten birds from each flock processed were pooled and examined for the presence of C. jejuni. These results were used to create a case definition, such that the flocks could be analysed with the questionnaire data, and different risk factors were seen in each season. More flocks reared for Company One were colonised by C. jejuni than for Company Two. Protective factors included having hard (i.e. gravel, asphalt or concrete) pathways to the growout houses, being near to another broiler farm, using the reticulated town water supply for the birds drinking water, using tunnel or crossflow shaped growout houses, using a Chore-TimeTM feed delivery system within the growout house and chlorinating the water supply to the birds (only in winter). The odds of raising flocks colonised with C jejuni increased if rodents were seen on the farm, if the growout houses were constructed with a concrete nib wall, if gas heaters were used during brooding, if cattle were farmed on the property, or if workers were employed on the farm. Sanitising the annex at least as frequently as once per run decreased the odds during summer, and tended to have a similar effect in other seasons. Chlorinating the water supply appeared to have a protective effect in only one season, though the trend appeared towards protection in the other seasons. The risk factor was validated by sampling the drinking water that broilers chickens had access to for the FAC to sec whether the levels that were present in the drinking water could have an effect on C. jejuni 11 sheds that were known to chlorinate the water were sampled to determine whether they met the drinking water standards for humans in NZ, or met the requirements presented by one of the companies involved. Only three sheds met the human drinking water standards for FAC, and two of these (one from each company) met Company Two's requirements. This thesis is for both regulatory and industry stakeholders to assist with developing risk management approaches to diminishing the number of C. jejuni positive flocks. Where management practices are altered, it is hoped that the efficacy of such practices be measured by examining the changes in the rates of C jejuni colonization within the industr

Urban mining of lithium-ion batteries in Australia : Current state and future trends

With declining ore grades and increasing waste volumes, lithium-ion battery (LIB) wastes are increasingly considered valuable for urban mining for metal recovery and re-use. In Australia, LIB is not classified as hazardous, despite having significant human and environmental health risks if handled and disposed of improperly. Unlike in Europe and Asia, regulations or policies to enforce or encourage product stewardship are lacking, with small recycling schemes targeting only consumer behaviour, and voluntary actions of manufacturers and distributors. Although manual sorting and dismantling of LIB waste occur onshore, the valuable components are shipped overseas for processing due to limited onshore capacity to recover the inherent metal values. In this paper, LIB recycling in Australia is reviewed, considering the projections of LIB waste generation, identification of future trends, opportunities and potential for innovation for LIB recycling in Australia. Key gaps surrounding materials tracking, waste generation and fate and technology design need to be addressed to support the development of the industry and to support the use of primary minerals and materials in Australia.</p

In a quest for engineering acidophiles for biomining applications : Challenges and opportunities

Biomining with acidophilic microorganisms has been used at commercial scale for the extraction of metals from various sulfide ores. With metal demand and energy prices on the rise and the concurrent decline in quality and availability of mineral resources, there is an increasing interest in applying biomining technology, in particular for leaching metals from low grade minerals and wastes. However, bioprocessing is often hampered by the presence of inhibitory compounds that originate from complex ores. Synthetic biology could provide tools to improve the tolerance of biomining microbes to various stress factors that are present in biomining environments, which would ultimately increase bioleaching efficiency. This paper reviews the state-of-the-art tools to genetically modify acidophilic biomining microorganisms and the limitations of these tools. The first part of this review discusses resilience pathways that can be engineered in acidophiles to enhance their robustness and tolerance in harsh environments that prevail in bioleaching. The second part of the paper reviews the efforts that have been carried out towards engineering robust microorganisms and developing metabolic modelling tools. Novel synthetic biology tools have the potential to transform the biomining industry and facilitate the extraction of value from ores and wastes that cannot be processed with existing biomining microorganisms.publishedVersionPeer reviewe

Poliomyelitis Outbreak,Pointe-Noire, Republic of the Congo, September 2010–February 2011

On November 4, 2010, the Republic of the Congo declared a poliomyelitis outbreak. A cross-sectional survey in Pointe-Noire showed poor sanitary conditions and low vaccination coverage (55.5%), particularly among young adults. Supplementary vaccination should focus on older age groups in countries with evidence of immunity gaps