13 research outputs found
Associations between exhaust and non-exhaust particulate matter and stroke incidence by stroke subtype in South London
Background: Airborne particulate matter (PM) consists of particles from diverse sources, including vehicle exhausts.
Associations between short-term PM changes and stroke incidence have been shown. Cumulative exposures over several months, or years, are less well studied; few studies examined ischaemic subtypes or PM
source.
Aims: This study combines a high resolution urban air quality model with a population-based stroke register to
explore associations between long-term exposure to PM and stroke incidence.
Method: Data from the South London Stroke Register from 2005â2012 were included. Poisson regression explored
association between stroke incidence and long-term (averaged across the study period) exposure to
PM2.5(PM b 2.5 ÎŒm diameter) and PM10(PM b 10 ÎŒm), nitric oxide, nitrogen dioxide, nitrogen oxides and
ozone, at the output area level (average population=309). Estimates were standardised for age and sex and adjusted
for socio-economic deprivation. Models were stratified for ischaemic and haemorrhagic strokes and further
broken down by Oxford Community Stroke Project classification and Trial of ORG 10172 in Acute Stroke
Treatment (TOAST) classification.
Results: 1800 strokes were recorded (incidence= 42.6/100,000 person-years). No associations were observed between PM and overall ischaemic or haemorrhagic incidence. For an interquartile range increase in PM2.5, there was a 23% increase in incidence (Incidence rate ratio=1.23 (95%CI: 1.03â1.44)) of total anterior circulation infarcts (TACI) and 20% increase for PM2.5 from exhausts (1.20(1.01â1.41)). Therewere similar associations with PM10, overall (1.21(1.01â1.44)) and from exhausts (1.20(1.01â1.41)). TACI incidence was not associated with non-exhaust sources. There were no associations with other stroke subtypes or pollutants.
Conclusion: Outdoor air pollution, particularly that arising from vehicle exhausts, may increase risk of TACI but
not other stroke subtypes
Extracranial and Intracranial Vasculopathy With âMoyamoya Phenomenonâ in Association With Alagille Syndrome
Background: Alagille syndrome (AGS) is an autosomal-dominant, multisystem disorder caused by mutations in the JAG1 gene.Case Description: A 34-year-old man was referred to our service 10 years ago with focal seizures with impaired awareness and transient slurred speech. He had a 5-year history of intermittent left monocular low-flow retinopathy. He has a family history of AGS. General examination revealed mild hypertension, aortic regurgitation, and livedo reticularis. Neurological examination was normal.Investigations: He had mild hyperlipidaemia and persistently-positive lupus anticoagulant consistent with primary anti-phospholipid syndrome. Color Doppler ultrasound revealed low velocity flow in a narrowed extracranial left internal carotid artery (ICA). MR and CT angiography revealed a diffusely narrowed extracranial and intracranial left ICA. Formal cerebral angiography confirmed severe left ICA narrowing consistent with a left ICA âvasculopathyâ and moyamoya phenomenon. Transthoracic echocardiogram revealed a bicuspid aortic valve and aortic incompetence. Molecular genetic analysis identified a missense mutation (A211P) in exon 4 of the JAG1 gene, consistent with AGS.Discussion: AGS should be considered in young adults with TIAs/stroke and unexplained extracranial or intracranial vascular abnormalities, and/or moyamoya phenomenon, even in the absence of other typical phenotypic features. Gene panels should include JAG1 gene testing in similar patients
First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa
BACKGROUND : There is a paucity of data on the national
population-level effectiveness of preventing mother-tochild
transmission (PMTCT) programmes in high-HIVprevalence,
resource-limited settings. We assessed
national PMTCT impact in South Africa (SA), 2010.
METHODS : A facility-based survey was conducted using
a stratified multistage, cluster sampling design. A
nationally representative sample of 10 178 infants aged
4â8 weeks was recruited from 565 clinics. Data
collection included caregiver interviews, record reviews
and infant dried blood spots to identify HIV-exposed
infants (HEI) and HIV-infected infants. During analysis,
self-reported antiretroviral (ARV) use was categorised:
1a: triple ARV treatment; 1b: azidothymidine
>10 weeks; 2a: azidothymidine â€10 weeks; 2b:
incomplete ARV prophylaxis; 3a: no antenatal ARV and
3b: missing ARV information. Findings were adjusted for
non-response, survey design and weighted for live-birth
distributions.
RESULTS : Nationally, 32% of live infants were HEI; early
mother-to-child transmission (MTCT) was 3.5% (95% CI
2.9% to 4.1%). In total 29.4% HEI were born to
mothers on triple ARV treatment (category 1a) 55.6%
on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal
ARV (3a) and 5.5% had missing ARV information (3b).
Controlling for other factors groups, 1b and 2a had
similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b,
0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT
was higher in group 2b (AOR 3.68, 1.69 to 7.97).
Within group 3a, early MTCT was highest among
breastfeeding mothers 11.50% (4.67% to 18.33%) for
exclusive breast feeding, 11.90% (7.45% to 16.35%)
for mixed breast feeding, and 3.45% (0.53% to 6.35%)
for no breast feeding). Antiretroviral therapy or
>10 weeks prophylaxis negated this difference (MTCT
3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60%
and 2.11%, 1.28% to 2.95%, respectively).
CONCLUSIONS : SA, a high-HIV-prevalence middle income
country achieved <5% MTCT by 4â8 weeks post
partum. The long-term impact on PMTCT on HIV-free
survival needs urgent assessment.South African National Research Foundationhttp://jech.bmj.comhb201
Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.
BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden
Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19.
Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19.
DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 nonâcritically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022).
INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (nâ=â257), ARB (nâ=â248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; nâ=â10), or no RAS inhibitor (control; nâ=â264) for up to 10 days.
MAIN OUTCOMES AND MEASURES The primary outcome was organ supportâfree days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes.
RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ supportâfree days among critically ill patients was 10 (â1 to 16) in the ACE inhibitor group (nâ=â231), 8 (â1 to 17) in the ARB group (nâ=â217), and 12 (0 to 17) in the control group (nâ=â231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ supportâfree days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively).
CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes.
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570
Are consent workshops sustainable and feasible in third level institutions? Evidence from implementing and extending the SMART consent workshop.
Health Promoting School Indicators: schematic models from students
Purpose â The purpose of this paper is to outline a threeâstage process for engaging with students to develop school level indicators of health; in sequential class groups students first generated, then categorised indicators and finally developed schematic representations of their analyses. There is a political and practical need to develop appropriate indicators for healthâpromoting schools. As key stakeholders in education, students have the right to be fully engaged in this process. Design/methodology/approach â The sample in this paper comprised 164 students aged 16â17 years in three mediumâsized Dublin schools. In the first classroom, students answered the question âIf you moved to a new school, what would it need to have to be a healthy place?â on individual flashcards. In the second classroom students classified the flashcards into groups using a variation of the card game âsnapâ. In the third classroom, students discussed the relationships between the developed categories and determined how the categories should be presented. These procedures were repeated twice in three schools, resulting in six developed schemata. Findings â The paper finds that the six sets of categories showed remarkable similarity â physical aspects of the school predominated but emotional and social health issues also emerged as potential indicators. The schema demonstrated the holistic perspectives of students. They illustrate the importance of relationships and the physical and psychoâsocial environment within schools. Originality/value â The paper illustrates that students can productively engage in the process of indicator development and have the potential to act as full stakeholders in healthâpromoting schools. The methods enabled student control over the data generation, analysis and presentation phases of the research, and provided a positive, fun experience for both students and researchers
Extracranial and Intracranial Vasculopathy With "Moyamoya Phenomenon" in Association With Alagille Syndrome.
Background: Alagille syndrome (AGS) is an autosomal-dominant, multisystem disorder caused by mutations in the JAG1 gene.
Case Description: A 34-year-old man was referred to our service 10 years ago with focal seizures with impaired awareness and transient slurred speech. He had a 5-year history of intermittent left monocular low-flow retinopathy. He has a family history of AGS. General examination revealed mild hypertension, aortic regurgitation, and livedo reticularis. Neurological examination was normal.
Investigations: He had mild hyperlipidaemia and persistently-positive lupus anticoagulant consistent with primary anti-phospholipid syndrome. Color Doppler ultrasound revealed low velocity flow in a narrowed extracranial left internal carotid artery (ICA). MR and CT angiography revealed a diffusely narrowed extracranial and intracranial left ICA. Formal cerebral angiography confirmed severe left ICA narrowing consistent with a left ICA ?vasculopathy? and moyamoya phenomenon. Transthoracic echocardiogram revealed a bicuspid aortic valve and aortic incompetence. Molecular genetic analysis identified a missense mutation (A211P) in exon 4 of the JAG1 gene, consistent with AGS.
Discussion: AGS should be considered in young adults with TIAs/stroke and unexplained extracranial or intracranial vascular abnormalities, and/or moyamoya phenomenon, even in the absence of other typical phenotypic features. Gene panels should include JAG1 gene testing in similar patients