Inclisiran for the treatment of cardiovascular disease: the ORION clinical development program

Inclisiran is a novel drug that inhibits PCSK9 synthesis specifically in the liver, harnessing the natural mechanism of RNAi. Phase I and II data show that inclisiran lowers low-density lipoprotein cholesterol levels on average by >50% with a duration of effect that enables twice-yearly dosing. Phases I, II and emerging Phase III data support inclisiran's safety, tolerability and risk-benefit profile. The ongoing ORION program includes Phase III trials that will provide robust evidence of inclisiran's safety and efficacy in individuals at high risk of atherosclerotic cardiovascular disease (ASCVD), including established ASCVD and familial hypercholesterolemia. In addition, the ORION-4 trial will assess the impact of inclisiran on cardiovascular outcomes in approximately 15,000 ASCVD subjects.

Effectiveness of telephone-based interventions for managing osteoarthritis and spinal pain: a systematic review and meta-analysis

BACKGROUND

Osteoarthritis and spinal pain are common and burdensome conditions; however, the majority of patients with these conditions do not receive care that is consistent with clinical practice guidelines. Telehealth models of care have the potential to improve care for osteoarthritis and spinal pain patients. The aim of this review was to assess the effectiveness of verbal real-time telehealth interventions, including telephone-based and videoconferencing interventions to reduce pain intensity and disability in patients with osteoarthritis of the knee or hip and spinal pain (back or neck pain).

METHODS

We searched seven electronic databases from inception to May 2018. Randomised controlled trials (RCTs), cluster-RCTs, and non-randomised controlled trials were included. Two review authors independently extracted data for each included study. Primary outcomes were pain intensity and disability. We conducted primary meta-analyses combining all conditions with similar interventions and comparators. Standardised mean difference (SMD) and 95% confidence intervals (CIs) were calculated using random effects models. We used the Cochrane Risk of Bias tool to assess risk of bias, and GRADE to evaluate the quality of evidence.

RESULTS

We included 23 studies with 56 trial arms and 4,994 participants. All studies utilised telephone-based interventions. Only two studies used a telephone only approach and the remainder included educational materials and/or face-to-face components. We found no studies utilising videoconferencing. Meta-analysis showed telephone-based interventions (with educational materials) for osteoarthritis and spinal pain improved pain intensity (n = 5 trials, n = 1,357 participants, SMD -0.27, 95% CI [-0.53, -0.01], Tau2 = 0.06, I 2 = 74%; moderate-quality evidence) and disability (n = 7 trials, n = 1,537 participants, SMD -0.21, 95% CI [-0.40, -0.02], Tau2 = 0.03, I 2 = 56%; moderate-quality evidence) compared to usual care. Meta-analyses found telephone with face-to-face interventions does not improve pain and disability compared to usual care or face-to-face care alone.

DISCUSSION

We are moderately confident that telephone-based interventions reduce pain intensity and disability in patients with osteoarthritis and spinal pain compared to usual care, but telephone plus face-to-face interventions are no more effective than usual care or face-to-face interventions alone.

In-depth echocardiographic analysis of left atrial function in healthy adults using speckle tracking echocardiography and volumetric analysis

Purpose

Left atrial (LA) dilatation is predictive for complications in a multitude of cardiac diseases; therefore, adequate assessment is essential. Technological advances have made it possible to quantify LA function with Speckle Tracking Echocardiography (STE); however, there are currently no recommendations for normal values with regard to LA function. We aimed to assess LA myocardial and volumetric function in a healthy cohort and investigate correlations with baseline characteristics.

Methods

This prospective cohort study included 147 (aged 20–72) healthy individuals and assessed LA volumetric function using maximum, minimum and pre‐a‐wave volumes and myocardial function using reservoir function using peak strain in LA relaxation (LA‐strain), conduit function using peak strain rate in early LA contraction (LA‐SRe) and pump function using peak strain rate in late LA contraction (LA‐SRa).

Results

Mean LA‐strain was 39.7 ± 6.2%, LA‐SRe −2.78 ± 0.62 s⁻¹ and LA‐SRa −2.56 ± 0.62 s⁻¹. Subjects were divided into 5 age decades (each 50% female). LA‐strain and LA‐SRe were lower in the oldest groups, whereas LA‐SRa was higher. LA‐SRa was higher in males(−2.69 ± 0.68 s⁻¹ vs −2.42 ± 0.52 s⁻¹). Age‐specific values are provided. Age proved to be an independent predictor for LA‐SRa after correction for blood pressure and heart rate. LA expansion index and passive emptying fraction decreased with age, while active emptying fraction increased with age. LA maximum volume did not increase with age.

Conclusion

This study provides normal values for the three phasic functions of the LA, assessed with STE and volumetric function. Our results suggest the need for age‐specific reference ranges, and normal values for this cohort have been calculated.

Distinct Expression Pattern of Epigenetic Machinery Genes in Blood Leucocytes and Brain Cortex of Depressive Patients

In major depressive disorder (MDD), altered gene expression in brain cortex and blood leucocytes may be due to aberrant expression of epigenetic machinery coding genes. Here, we explore the expression of these genes both at the central and peripheral levels. Using real-time quantitative PCR technique, we first measured expression levels of genes encoding DNA and histone modifying enzymes in the dorsolateral prefrontal cortex (DLPFC) and cingulate cortex (CC) of MDD patients (n = 24) and healthy controls (n = 12). For each brain structure, transcripts levels were compared between subject groups. In an exploratory analysis, we then compared the candidate gene expressions between a subgroup of MDD patients with psychotic characteristics (n = 13) and the group of healthy subjects (n = 12). Finally, we compared transcript levels of the candidate genes in blood leucocytes between separate samples of MDD patients (n = 17) and healthy controls (n = 16). In brain and blood leucocytes of MDD patients, we identified an overexpression of genes encoding enzymes which transfer repressive transcriptional marks: HDAC4-5-6-8 and DNMT3B in the DLPFC, HDAC2 in the CC and blood leucocytes. In the DLPFC of patients with psychotic characteristics, two genes (KAT2A and UBE2A) were additionally overexpressed suggesting a shift to a more transcriptionally permissive conformation of chromatin. Aberrant activation of epigenetic repressive systems may be involved in MDD pathogenesis both in brain tissue and blood leucocytes.

Exosomes derived from rAAV/AFP-transfected dendritic cells elicit specific T cell-mediated immune responses against hepatocellular carcinoma

Background

Dendritic cell (DC)-derived exosomes (Dexs) have been proved to induce and enhance antigen-specific T cell responses in vivo, and previous clinical trials have shown the feasibility and safety of Dexs in multiple human cancers. However, there is little knowledge on the efficacy of Dexs against hepatocellular carcinoma (HCC) until now.

Methods

In this study, human peripheral blood-derived DCs were loaded with recombinant adeno-associated viral vector (rAAV)-carrying alpha-fetoprotein (AFP) gene (rAAV/AFP), and high-purity Dexs were generated. Then naive T cells were stimulated with Dexs to investigate the specific T cell-mediated immune responses against HCC.

Results

Our findings showed that Dexs were effective to stimulate naive T cell proliferation and induce T cell activation to become antigen-specific cytotoxic T lymphocytes (CTLs), thereby exhibiting antitumor immune responses against HCC. In addition, Dex-sensitized DC precursors seemed more effective to trigger major histocompatibility complex class I (MHC I)-restricted CTL response and allow DCs to make full use of the minor antigen peptides, thereby maximally activating specific immune responses against HCC.

Conclusion

It is concluded that Dexs, which combine the advantages of DCs and cell-free vectors, are promising to completely, or at least in part, replace mature DCs (mDCs) to function as cancer vaccines or natural antitumor adjuvant.

The interrater reliability of a pain mechanisms-based classification for patients with nonspecific neck pain

OBJECTIVE

To examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP).

METHODS

Design - Observational, cross-sectional reliability study with a simultaneous examiner design.

SETTING

University hospital-based outpatient physical therapy clinic.

PARTICIPANTS

A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included.

INTERVENTIONS

Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants' NSNP on 3 main outcome measures.

MAIN OUTCOME MEASURES

The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP).

RESULTS

There was almost perfect agreement between the 2 physical therapists' judgements on the predominant pain mechanism, kappa=.84 (95% CI, .65-1.00), p<.001. There was substantial agreement between the raters' judgements on the predominant pain pattern and predominant DP with respectively kappa=.61 (95% CI, .42-.80); and kappa=.62 (95% CI, .44-.79), p<.001.

CONCLUSION(S)

The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).

Novel Urinary Biomarkers For Improved Prediction Of Progressive Egfr Loss In Early Chronic Kidney Disease Stages And In High Risk Individuals Without Chronic Kidney Disease

Chronic kidney disease is associated with increased risk of CKD progression and death. Therapeutic approaches to limit progression are limited. Developing tools for the early identification of those individuals most likely to progress will allow enriching clinical trials in high risk early CKD patients. The CKD273 classifier is a panel of 273 urinary peptides that enables early detection of CKD and prognosis of progression. We have generated urine capillary electrophoresis-mass spectrometry-based peptidomics CKD273 subclassifiers specific for CKD stages to allow the early identification of patients at high risk of CKD progression. In the validation cohort, the CKD273 subclassifiers outperformed albuminuria and CKD273 classifier for predicting rapid loss of eGFR in individuals with baseline eGFR > 60 ml/min/1.73 m². In individuals with eGFR > 60 ml/min/1.73 m² and albuminuria <30 mg/day, the CKD273 subclassifiers predicted rapid eGFR loss with AUC ranging from 0.797 (0.743-0.844) to 0.736 (0.689-0.780). The association between CKD273 subclassifiers and rapid progression remained significant after adjustment for age, sex, albuminuria, DM, baseline eGFR, and systolic blood pressure. Urinary peptidomics CKD273 subclassifiers outperformed albuminuria and CKD273 classifier for predicting the risk of rapid CKD progression in individuals with eGFR > 60 ml/min/1.73 m². These CKD273 subclassifiers represented the earliest evidence of rapidly progressive CKD in non-albuminuric individuals with preserved renal function.

Disability Weights for Pediatric Surgical Procedures: A Systematic Review and Analysis

BACKGROUND

Metrics to measure the burden of surgical conditions, such as disability weights (DWs), are poorly defined, particularly for pediatric conditions. To summarize the literature on DWs of children's surgical conditions, we performed a systematic review of disability weights of pediatric surgical conditions in low- and middle-income countries (LMICs).

METHOD

For this systematic review, we searched MEDLINE for pediatric surgery cost-effectiveness studies in LMICs, published between January 1, 1996, and April 1, 2017. We also included DWs found in the Global Burden of Disease studies, bibliographies of studies identified in PubMed, or through expert opinion of authors (ES and HR).

RESULTS

Out of 1427 publications, 199 were selected for full-text analysis, and 30 met all eligibility criteria. We identified 194 discrete DWs published for 66 different pediatric surgical conditions. The DWs were primarily derived from the Global Burden of Disease studies (72%). Of the 194 conditions with reported DWs, only 12 reflected pre-surgical severity, and 12 included postsurgical severity. The methodological quality of included studies and DWs for specific conditions varied greatly.

INTERPRETATION

It is essential to accurately measure the burden, cost-effectiveness, and impact of pediatric surgical disease in order to make informed policy decisions. Our results indicate that the existing DWs are inadequate to accurately quantify the burden of pediatric surgical conditions. A wider set of DWs for pediatric surgical conditions needs to be developed, taking into account factors specific to the range and severity of surgical conditions.

Caloric restriction improves the redox homeostasis in the aging male rat heart even when started in middle-adulthood and when the body weight is stable

Evidence indicates that maintenance of redox homeostasis is fundamental for cellular longevity. Caloric-restriction (CR) is said to decrease the formation of oxidatively modified cellular macromolecules and improve health. On the other hand, some studies indicate that many CR studies are flawed, because ad libitum fed rats are not well-controlled. Thus, it is claimed that purported beneficial effects of CR could be not due to real CR effect, but due to control animals going obese. Also, it remains to be elucidated whether effects of CR could be observed even when CR is started in mid-adulthood. Male Sprague-Dawley rats were grouped as: non-CR 6-month-old rats (n = 7), 24-month-old rats subjected to 40% CR for 6 months between 18th and 24th months (n = 8), and non-CR 24-month-old animals (n = 8). We investigated 16 previously validated biomarkers of macromolecular redox homeostasis, ranging from protein and lipid oxidation to glycation and antioxidative capacity. In the present study, the protein, lipid and antioxidant capacity redox homeostasis biomarkers overwhelmingly indicate that, CR, even though not started very early in adulthood, could still offer potential therapeutic effects and it could significantly improve various redox homeostasis biomarkers associated with disease reliably in the heart tissue of aging male Sprague-Dawley rats. Therefore, the effects of CR likely operate through similar mechanisms throughout adulthood and CR seems to have real ameliorative effects on organisms that are not due to confounding factors that come from ad libitum fed rats.

The One step-No prep technique: A straightforward and minimally invasive approach for full-mouth rehabilitation of worn dentition using polymer-infiltrated ceramic network (PICN) CAD-CAM prostheses

OBJECTIVES

To introduce a novel approach for full-mouth rehabilitation of severely worn dentition using polymer-infiltrated ceramic network (PICN) computer-aided-design and manufacturing (CAD-CAM) restorations, without tooth tissue preparation and provisional phase.

CLINICAL CONSIDERATIONS

Three patients with generalized tooth wear, suffering from dental pain, masticatory dysfunction, bruxism and neck and back pain, were selected and treated in collaboration with physiotherapists. Occlusal analyses were performed and full-mouth diagnostic wax-ups were designed on the basis of estimated tissue loss. Deficient direct restorations were replaced and low-thickness PICN (Vita Enamic) restorations (up to 0.2 mm) were CAD-CAM designed from wax-ups, milled, tried-in and then bonded within two consecutive days. To mask palatal veneers, either buccal direct composites or glass-ceramic veneers were later performed. An occlusal splint was realized. Clinical results were shown to be successful after a follow-up of 22, 18, and 13 months, respectively. The absence of provisional phase did not engender any inconveniences. Patient reported outcomes were very positive, showing a reduction in neck and back pain and a well-being increase.

CONCLUSION

The proposed protocol is particularly minimally invasive and straightforward compared to classical techniques. PICNs exhibit several advantages compared to other materials. Preliminary results of this multidisciplinary approach are promising but deserve further clinical research.

CLINICAL SIGNIFICANCE

The development of CAD-CAM technologies offers the possibility of improving treatment of severe worn dentition, reducing chairtime and need of tooth tissue preparation, and introducing a new class of composite materials (hybrid ceramics), which exhibit interesting properties for this indication. The influence of the proposed multidisciplinary approach, particularly the collaboration with physiotherapists, needs to be further explored with respect to treatment of associated symptoms, such as masticatory muscles hypertrophy and neck pain.

Preventing Lethal Prostate Cancer with Diet, Supplements, and Rx: Heart Healthy Continues to Be Prostate Healthy and "First Do No Harm" Part I

PURPOSE OF REVIEW

To discuss the overall and latest observations of the effect of diet, lifestyle, supplements, and some prescription heart healthy medications for prostate cancer prevention.

RECENT FINDINGS

The concept of maximizing heart health to prevent aggressive prostate cancer continues to be solidified with the addition of more prospective observational and randomized controlled trial data. Heart healthy is prostate healthy, but heart unhealthy is prostate unhealthy. The primary goal of reducing the risk of all-cause and cardiovascular disease (CVD) morbidity and mortality also allows for maximizing prostate cancer prevention. The obesity epidemic in children and adults along with recent diverse research has only strengthened the nexus between heart and prostate health. Greater dietary adherence toward a variety of healthy foods is associated with a graded improved probability of CVD and potentially aggressive cancer risk reduction. Preventing prostate cancer via dietary supplements should encourage a "first do no harm", or less is more approach until future evidence can reverse the concerning trend that more supplementation has resulted in either no impact or an increased risk of prostate cancer. Supplements to reduce side effects of some cancer treatments appear to have more encouraging data. Medications that improve heart health including statins, aspirin, and metformin (S.A.M.), and specific beta-blocker medications are primarily generic or low-cost and should continue to garner research interest. A watershed moment in medical education has arrived where the past perception of a diverse number of trees seemingly separated by vast distances, in reality, now appear to exist within the same forest.

Resilience to Climate-Induced Disasters and Its Overall Relationship to Well-Being in Southern Africa: A Mixed-Methods Systematic Review

The available literature suggests that natural disasters, especially droughts and floods, were occurring in southern Africa in the early 1900s. However, their frequency and intensity increased during the 1980s. The aim of this systematic review was to assess the relationship between resilience to droughts and people's well-being in southern Africa. A combination of keywords was used to search the following 13 electronic bibliographic databases: Africa Journal Online (AJOL), MEDLINE, Academic Search Complete, Environment Complete, Humanities International Complete, Psychology and Behavioral Sciences Collection, PsycINFO, Embase, Scopus, Web of Science, Applied Social Science Index and Abstracts, ProQuest Central, and CINAHL. Relevant websites were also searched and potential studies for inclusion were downloaded in an EndNote database and screened for eligibility using pre-determined criteria. Quality assessment of the studies was undertaken using the Joana Briggs Qualitative Assessment and Review Instrument, the National Institutes of Health (NIH) checklist, and the Authority, Accuracy, Coverage, Objectivity, Date, Significance (AACODS) checklist. Resilience and well-being scales used in the studies for inclusion were also assessed using pre-defined criteria. Nineteen studies met the inclusion criteria. Poverty alleviation policies were important in strengthening resilience and well-being outcomes. Resilience and well-being were connected by old age, gender, race, adaptive farming and livelihoods diversification, security, and knowledgeability. Resilience and well-being outcomes were advanced by the synergistic effect of household, community and governance level capacities encapsulated in knowledgeability. This systematic review is critical to improving southern Africa context-specific resilience, and well-being policies and interventions.

Interventions to Reduce Future Cancer Incidence from Diesel Engine Exhaust: What Might Work?

Exposure to diesel engine exhaust (DEE) contributes appreciably to the burden of occupational cancer. This study aims to estimate the potential impact of a range of interventions on the future burden of cancer from occupational exposure to DEE in Australia. The future excess fraction method, a novel method based on the lifetime risk approach, was used to model changes in the future burden of cancer among the Australian working age population exposed to DEE at work in 2012 under various intervention strategies. The interventions modeled were based on the widely accepted hierarchy of control model. At baseline, 600 (0.4%) future bladder and 4,450 (0.6%) future lung cancer cases over the lifetime of the cohort were estimated to be attributable to occupational exposure to DEE in those exposed in 2012. Up to 2,000 of these cases were estimated to be avoidable through the use of various interventions. Exhaust hoses (engineering controls) were estimated to be particularly effective. This study provides an indication of which intervention strategies may be most useful in reducing the future burden of cancer associated with occupational DEE exposure. These results show the potential effect of changing current exposure, rather than focusing on past exposures, and thus provide relevant information for policy planning.

Outcomes for symptomatic non-obstructed individuals and individuals with mild (GOLD stage 1) COPD in a population based cohort

BACKGROUND

We aimed to study the adverse outcomes of symptomatic and asymptomatic non-obstructed individuals and those with mild COPD longitudinally in participants from three Latin-American cities.

METHODS

Two population-based surveys of adults with spirometry were conducted for these same individuals with a 5- to 9-year interval. We evaluated the impact of respiratory symptoms (cough, phlegm, wheezing or dyspnea) in non-obstructed individuals, and among those classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 1, COPD on exacerbation frequency, mortality and FEV1 decline, compared with asymptomatic individuals without airflow obstruction or restriction.

RESULTS

Non-obstructed symptomatic individuals had a marginal increased risk of mortality (HR 1.3; 95% CI 0.9-1.94), increased FEV1 decline (-4.5 mL/year; 95% CI -8.6, -0.4) and increased risk of 2+ exacerbations in the previous year (OR 2.6; 95% CI 1.2-6.5). Individuals with GOLD stage 1 had a marginal increase in mortality (HR 1.5; 95% CI 0.93-2.3) but a non-significant impact on FEV1 decline or exacerbations compared with non-obstructed individuals.

CONCLUSIONS

The presence of respiratory symptoms in non-obstructed individuals was a predictor of mortality, lung-function decline and exacerbations, whereas the impact of GOLD stage 1 was mild and inconsistent. Respiratory symptoms were associated with asthma, current smoking, and the report of heart disease. Spirometric case-finding and treatment should target individuals with moderate-to-severe airflow obstruction and those with restriction, the groups with consistent increased mortality.

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review

Background

With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems.

Objective

We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature.

Methods

A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools.

Results

The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease–focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories.

Conclusions

In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

OBJECTIVE

We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters.

METHODS

Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air.

RESULTS

Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p < .001) and to attend (81% vs. 75%, p < .01) a cardiac rehabilitation programme.

CONCLUSION

Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

BMI1 promotes cardiac fibrosis in ischemia-induced heart failure via the PTEN-PI3K/Akt-mTOR signaling pathway

Cardiac fibrosis has been known to play an important role in the etiology of heart failure after myocardial infarction (MI). B lymphoma Mo-MLV insertion region 1 homolog (BMI1), a transcriptional repressor, is important for fibrogenesis in the kidneys. However, the effect of BMI1 on ischemia-induced cardiac fibrosis remains unclear. BMI1 was strongly expressed in the infarct region 1 wk post-MI in mice and was detected by Western blot and histological analyses. Lentivirus-mediated overexpression of BMI1 significantly promoted cardiac fibrosis, worsened cardiac function 4 wk after the intervention in vivo, and enhanced the proliferation and migration capabilities of fibroblasts in vitro , whereas downregulation of BMI1 decreased cardiac fibrosis and prevented cardiac dysfunction in mice 4 wk post-MI in vivo. Furthermore, upregulated BMI1 inhibited phosphatase and tensin homolog (PTEN) expression, enhanced phosphatidylinositol 3-kinase (PI3K) expression, and increased the phosphorylation level of Akt and mammalian target of rapamycin (mTOR) in mice 4 wk after lentiviral infection, which was in accordance with the changes seen in their infarcted myocardial tissues. At the same time, the effects of BMI1 on cardiac fibroblasts were reversed in vitro when these cells were exposed to NVP-BEZ235, a dual-kinase (PI3K/mTOR) inhibitor. In conclusion, BMI1 is associated with cardiac fibrosis and dysfunction after MI by regulating cardiac fibroblast proliferation and migration, and these effects could be partially explained by the regulation of the PTEN-PI3K/Akt-mTOR pathway. NEW & NOTEWORTHY Ischemia-induced B lymphoma Mo-MLV insertion region 1 homolog (BMI1) significantly promoted cardiac fibrosis and worsened cardiac function in vivo, whereas downregulation of BMI1 decreased cardiac fibrosis and prevented cardiac dysfunction in myocardial infarcted mice. BMI1 also enhanced proliferation and migration capabilities of fibroblasts in vitro; these effects were reversed by NVP-BEZ235. Effects of BMI1 on cardiac fibrosis could be partially explained by regulation of the phosphatase and tensin homolog-phosphatidylinositol 3-kinase/Akt-mammalian target of rapamycin pathway.

Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Background

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease.

Methods

We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016.

Findings

The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016.

Interpretation

Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary.

Funding

Bill & Melinda Gates Foundation.

'The only chance of a normal weight life': A qualitative analysis of online forum discussions about bariatric surgery

Background

The only effective weight loss treatment for severe obesity is bariatric surgery, with Roux-en-Y gastric bypass being the most common method. Patients often have unrealistic expectations of surgery and expect a “miracle cure” even though the procedure requires major lifelong lifestyle changes. Most patients access information about the procedure online, and come into contact with others who have had the surgery.

Objective

The objective of this study was to describe shared values, feelings, and thoughts among visitors to a web-based forum for those undergoing bariatric surgery.

Methods

In this cross-sectional observation study using qualitative contents analysis, the material consisted of an online discussion forum thread about bariatric surgery, with 498 posts. These were saved in a document, read and re-read. Through coding of meaningful units of text, themes were established.

Results

Four themes were constructed during data analysis: a) A new life—anticipating dramatic changes of body and mind; b) Negotiating the system and playing the waiting game; c) A means to an end—managing the pre-operative diet; and d) Managing the attitudes of others. Posters described the process of bariatric surgery as a journey, riddled with roadblocks, setbacks and trials, but also with joy and expectations of a new life.

Conclusion

Professionals who encounter this group should be aware of their need for support throughout the process, and investigate the possibility of both pre- and postoperative support groups, either online or face-to-face. The results also show that the posters on the forum had very high, and often unrealistic, expectations on how the surgery would change their lives. It is important for those who encounter this group before surgery to be aware of this tendency and to take measures to ensure that patients undergo the surgery with realistic expectations.

Trends in smoking prevalence and implication for chronic diseases in China: serial national cross-sectional surveys from 2003 to 2013

BACKGROUND

China is the world's largest consumer of tobacco and has a large smoking-related chronic disease burden. In this nationwide study, we aimed to evaluate smoking prevalence and its implication on chronic diseases in the Chinese population.

METHODS

We collected data from serial cross-sectional National Health Service Surveys done in China in 2003, 2008, and 2013. These surveys cover all 31 provinces, autonomous regions, and municipalities in mainland China, and use multistage stratified cluster sampling. We divided mainland China into east, central, and west regions and then sampled counties from each region stratified by urban and rural areas. All respondents aged 15 years or older in the selected households were eligible. We analysed the variation in smoking prevalence from 2003 to 2013, further identified risk factors for smoking, and assessed the association between smoking and chronic diseases by using multiple logistic regression.

FINDINGS

The number of individuals interviewed and involved in the study was 153 450 in 2003, 145 223 in 2008, and 229 676 in 2013. The standardised smoking prevalence in China was consistently high, with a proportion of current smokers of 26·0% (95% CI 25·8-26·2) in 2003, 24·9% (24·8-25·1) in 2008, and 25·2% (25·1-25·4) in 2013 (p value for trend 0·5062). For men, prevalence was 48·4% (48·1-48·7) in 2003, 47·0% (46·6-47·4) in 2008, and 47·2% (46·9-47·5) in 2013. For women, prevalence was 3·1% (3·0-3·2) in 2003, 2·3% (2·2-2·5) in 2008, and 2·7% (2·6-2·8) in 2013. Smoking prevalence varied in different regions, and we identified four major patterns. While a consistently high proportion of Chinese men smoked, the standardised smoking prevalence in women younger than 40 years increased from 1·0% in 2003 to 1·6% in 2013. Moreover, the smoking prevalence among adolescent smokers aged 15-24 years increased from 8·3% in 2003 to 12·5% in 2013. Alcohol consumption was closely linked to smoking in adolescents (odds ratio 7·5, 95% CI 6·9-8·1). Risk factors for adolescent smoking were having older family members who smoke (1·9, 1·8-1·9) and low level education (1·3, 1·2-1·4). Increased risks of chronic diseases were related to smoking (1·1, 1·0-1·1), with higher risks related to early smoking initiation (1·1, 1·0-1·1) and long-term smoking (1·2, 1·2-1·3).

INTERPRETATION

The implementation of tobacco control policies in China since the signing of the WHO Framework Convention on Tobacco Control in 2003 has not been effective in reducing smoking prevalence. Smoking prevalence among adolescents of both genders has increased substantially and there has been a steady increase among young women. More practical and effective policies targeting adolescents and women are urgently needed. Action is needed to prevent the large and growing smoking-related chronic disease burden further increasing as China's population ages.

FUNDING

National Health Commission of the People's Republic of China.

A stroke gene panel for whole-exome sequencing

Extensive analyses of known monogenic causes of stroke by whole-exome/genome sequencing are technically possible today. We here aimed to compile a comprehensive panel of genes associated with monogenic causes of stroke for use in clinical and research situations. We systematically searched the publically available database Online Mendelian Inheritance in Man, and validated the entries against original peer-reviewed publications in PubMed. First, we selected known pathogenic or putatively pathogenic stroke genes reported in at least one person with stroke, and classified the stroke phenotype for each gene into eight subgroups: (1) large artery atherosclerotic, (2) large artery non-atherosclerotic (tortuosity, dolichoectasia, aneurysm, non-atherosclerotic dissection, occlusion), (3) cerebral small-vessel diseases, (4) cardioembolic (arrhythmia, heart defect, cardiomyopathy), (5) coagulation dysfunctions (venous thrombosis, arterial thrombosis, bleeding tendency), (6) intracerebral hemorrhage, (7) vascular malformations (cavernoma, arteriovenous malformations), and (8) metabolism disorders. Second, we selected other genes that may plausibly cause stroke through diseases related to stroke, but without any documented stroke patient description. A third section comprised SNPs associated with stroke in genome-wide association studies (GWAS). We identified in total 214 genes: 120 associated with stroke, 62 associated with diseases that may cause stroke, and 32 stroke-related genes from recent GWAS. We describe these 214 genes and the clinical stroke subtype(s) associated with each of them. The resulting gene panel can be used to interpret exome sequencing results regarding monogenic stroke. Based on the panel's clinical phenotype description, the pathogenicity of novel variants in these genes may be evaluated in specific situations.

Recent advances in magnetic fluid hyperthermia for cancer therapy

Recently, magnetic fluid hyperthermia using biocompatible magnetic nanoparticles as heat mediators for cancer therapy has been extensively investigated due to its high efficiency and limited side effects. However, the development of more efficient heat nanomediators that exhibit very high specific absorption rate (SAR) value is essential for clinical application to overcome the several restrictions previously encountered due to the large quantity of nanomaterial required for effective treatment. In this review, we focus on the current progress in the development of magnetic nanoparticles based hyperthermia therapy as well as combined therapy harnessing hyperthermia with heat-mediated drug delivery for cancer treatment. We also address the fundamental principles of magnetic hyperthermia, basics of magnetism including the effect of several parameters on heating capacity, synthetic methods and nanoparticle surface chemistry needed to design and develop an ideal magnetic nanoparticle heat mediator suitable for clinical translation in cancer therapy.

Responsiveness, Reliability, and Minimally Important and Minimal Detectable Changes of 3 Electronic Patient-Reported Outcome Measures for Low Back Pain: Validation Study

Background

The Roland Morris Disability Questionnaire (RMDQ), visual analog scale (VAS) of pain intensity, and numerical rating scale (NRS) are among the most commonly used outcome measures in trials of interventions for low back pain. Their use in paper form is well established. Few data are available on the metric properties of electronic counterparts.

Objective

The goal of our research was to establish responsiveness, minimally important change (MIC) thresholds, reliability, and minimal detectable change at a 95% level (MDC₉₅) for electronic versions of the RMDQ, VAS, and NRS as delivered via iOS and Android apps and Web browser.

Methods

We recruited adults with low back pain who visited osteopaths. We invited participants to complete the eRMDQ, eVAS, and eNRS at baseline, 1 week, and 6 weeks along with a health transition question at 1 and 6 weeks. Data from participants reporting recovery were used in MIC and responsiveness analyses using receiver operator characteristic (ROC) curves and areas under the ROC curves (AUCs). Data from participants reporting stability were used for analyses of reliability (intraclass correlation coefficient [ICC] agreement) and MDC₉₅.

Results

We included 442 participants. At 1 and 6 weeks, ROC AUCs were 0.69 (95% CI 0.59 to 0.80) and 0.67 (95% CI 0.46 to 0.87) for the eRMDQ, 0.69 (95% CI 0.58 to 0.80) and 0.74 (95% CI 0.53 to 0.95) for the eVAS, and 0.73 (95% CI 0.66 to 0.80) and 0.81 (95% CI 0.69 to 0.92) for the eNRS, respectively. Associated MIC thresholds were estimated as 1 (0 to 2) and 2 (–1 to 5), 13 (9 to 17) and 7 (–12 to 26), and 2 (1 to 3) and 1 (0 to 2) points, respectively. Over a 1-week period in participants categorized as “stable” and “about the same” using the transition question, ICCs were 0.87 (95% CI 0.66 to 0.95) and 0.84 (95% CI 0.73 to 0.91) for the eRMDQ with MDC₉₅ of 4 and 5, 0.31 (95% CI –0.25 to 0.71) and 0.61 (95% CI 0.36 to 0.77) for the eVAS with MDC₉₅ of 39 and 34, and 0.52 (95% CI 0.14 to 0.77) to 0.67 (95% CI 0.51 to 0.78) with MDC₉₅ of 4 and 3 for the eNRS.

Conclusions

The eRMDQ was reliable with borderline adequate responsiveness. The eNRS was responsive with borderline reliability. While the eVAS had adequate responsiveness, it did not have an attractive reliability profile. Thus, the eNRS might be preferred over the eVAS for measuring pain intensity. The observed electronic outcome measures’ metric properties are within the ranges of values reported in the literature for their paper counterparts and are adequate for measuring changes in a low back pain population.

Capitalizing on Insights from Human Genetics to Identify Novel Therapeutic Targets for Coronary Artery Disease

Coronary artery disease (CAD) is a major cause of morbidity and mortality. Unfortunately, despite decades of research focused on disease pathogenesis, we still lack a sufficient pharmacopeia for preventing CAD. The failure of many novel cardiovascular drugs to improve clinical outcomes reflects the major substantial challenge of drug development: identifying causal mechanisms that can be therapeutically manipulated to lower disease risk. Identifying genetic variants that are associated with risk of CAD has emerged as a clear path toward improving our understanding of the underlying mechanisms that lead to disease and to the development of new therapies. Here, we review the potential utility and limitations of using human genetics to guide the identification of therapeutic targets for CAD.

Combined surgical treatment of esophageal cancer and coronary heart diseases in elderly patients

OBJECTIVE

The co-incidence of esophageal cancer and coronary heart disease (CHD) is increasing in elderly patients. This study was carried out to analyze the efficiency and safety of simultaneous esophagectomy and cardiac surgery in a selected group of elderly patients.

METHODS

Prospective database for coexistency of severe CHD and esophageal or esophageal-gastric junction cancer was firstly reviewed. Twenty-two patients undergoing combined surgical interventions, including first beating-heart coronary artery bypass grafting (off-pump CABG) and then esophagectomy, were involved as group A. Then, 44 patients undergoing isolated esophagectomy were selected as group B using the propensity score matching method. Data including clinic pathological characteristics and postoperative outcomes were investigated. Kaplan-Meier analysis was used.

RESULTS

The surgical procedure was performed through left lateral thoracotomy in all patients, except one patient in group A who received median sternotomy and left lateral thoracotomy. The operation time and blood loss were both more in group A, as a result of two operations performed at one session. Patients in both groups were followed up from 1.3 to 78.3 months. No significant between-group was found in overall survival or relapse-free survival.

CONCLUSION

The risk of simultaneous esophagectomy and cardiac surgery is not high. Despite certain differences in clinical indicators between groups, the safety of simultaneous procedures in group A is evident.

TRIAL REGISTRATION

ChiCTR 1800014498 . Registered 17 January 2018.

Plasma exosome levels in non-small-cell lung cancer: Correlation with clinicopathological features and prognostic implications

BACKGROUND

Biomarker studies revealed important clinical significance of exosome for cancer patients. However, there is currently no consensus on exosome quantification methods.

METHODS

Bicinchoninic acid (BCA) method, acetylcholinesterase (AChE) method and nanoparticle tracking analysis (NTA) were utilized to quantify 20 plasma exosome samples, and interrelations between these three methods were explored. Associations of plasma exosome levels with characteristics and prognosis of 208 non-small-cell lung cancer (NSCLC) patients were investigated.

RESULTS

Results of the three methods for exosome quantification were significantly correlated with each other. Correlation coefficient between AChE and NTA (r= 0.79, P< 0.001) was greater than that between BCA and NTA (r= 0.64, P= 0.003). Plasma exosome levels of 208 NSCLC patients were then quantified with AChE method. Exosome level was significantly associated with tumour stage (P< 0.001) and the history of chronic obstructive pulmonary disease (P= 0.023). Cox proportional hazard analysis demonstrated that higher exosome level was independently associated with poorer overall survival (P= 0.033; hazard ratio = 1.72, 95% confidence interval: 1.05-2.83).

CONCLUSIONS

Plasma exosome level correlates with tumor stage and the history of chronic obstructive pulmonary disease, and may serve as a prognostic factor for NSCLC.

Anionic 1,2-distearoyl-sn-glycero-3-phosphoglycerol (DSPG) liposomes induce antigen-specific regulatory T cells and prevent atherosclerosis in mice

Atherosclerosis is the predominant underlying pathology of many types of cardiovascular disease and is one of the leading causes of death worldwide. It is characterized by the retention of oxidized low-density lipoprotein (ox-LDL) in lipid-rich macrophages (foam cells) in the intima of arteries. Autoantigens derived from oxLDL can be used to vaccinate against atherosclerosis. However, a major challenge is the induction of antigen-specific Tregs in a safe and effective way. Here we report that liposomes containing the anionic phospholipid 1,2-distearoyl-sn-glycero-3-phosphoglycerol (DSPG) induce Tregs that are specific for the liposomes' cargo. Mechanistically, we show a crucial role for the protein corona that forms on the liposomes in the circulation, as uptake of DSPG-liposomes by antigen-presenting cells is mediated via complement component 1q (C1q) and scavenger receptors (SRs). Vaccination of atherosclerotic mice on a western-type diet with DSPG-liposomes encapsulating an LDL-derived peptide antigen significantly reduced plaque formation by 50% and stabilized the plaques, and reduced serum cholesterol concentrations. These results indicate that DSPG-liposomes have potential as a delivery system in vaccination against atherosclerosis.

Morphometric changes over the whole brain in caffeine-containing combination-analgesic-overuse headache

Objective

To investigate brain morphometric changes in medication-overuse headache with excessive intake of caffeine-containing combination analgesics.

Materials and methods

We recruited 32 medication-overuse headache patients overusing caffeine-containing combination analgesics and 26 normal controls with matched sex and age. Magnetic resonance T1-weighted images were processed by automatic volume algorithm of brain regions over the whole brain according to the neuromorphometrics template. We explored the volume differences between groups and correlation with clinical variables.

Results

Medication-overuse headache patients demonstrated decreased volume in cerebellum, optic chiasm, and increased volume in right lateral orbital gyrus, left calcarine, bilateral middle occipital gyrus, right superior parietal lobe, and right temporal transverse gyrus compared with normal controls. The increased volume was primarily contributed by patients of lower headache frequency (10–20 days/month) and with no psychological comorbidities. In regression analyses, the volume of bilateral middle occipital gyrus had negative association with migraine duration, and the volume of right lateral orbital gyrus and right superior parietal lobe was negatively correlated with number of medications per month.

Conclusions

Volume changes of brain regions involved in affective and cognitive processing, visual and auditory perception, and pain sensory/discrimination suggested a particular role of those regions in the pathogenesis of medication-overuse headache overusing caffeine-containing combination analgesics. Morphometric changes in multiple visual processing areas and volume gain in lower headache frequency and less anxiety and depression may be specific features related to overusing caffeine-containing combination analgesics.

Trend of vaccine preventable diseases in Iraq in time of conflict

Introduction

Iraq has passed through a series of successive conflicts, economic sanction and violence. The overall health sector in Iraq has been plunged and the services are facing a continuous shortage in vaccines, medicines and other supplies, and access of people to the basic health services being more impaired. The objective of this study was to portray the trend of vaccine preventable diseases in Iraq during the past 17 years to provide baseline information for disease burden estimation.

Methods

This study was built on collection and treatment of morbidity data related to vaccine preventable diseases (tuberculosis, poliomyelitis, measles, mumps, rubella, diphtheria, tetanus, pertussis, and hepatitis B) that were registered by the Department of Health Statistics during the years (2000-2016). The incidence rates were plotted on a timeline to define the trend of each disease. Data were also categorized by gender and age groups (less than five years, 5 to 15 years and 15 years and more).

Results

Diphtheria, rubella, and tuberculosis showed a slowly down going trend of incidence while mumps demonstrated a peak at 2016. Hepatitis B showed an up going trend of incidence while measles showed a secular trend every 4-5 years.

Conclusion

Vaccine preventable diseases are still causing outbreaks; precipitated by fluctuation of vaccine coverage. Tuberculosis has been reemerged after a relatively long period of control.

HIV related hypochlorhydria does not appear to respond to anti-retroviral therapy in Zambian adults: a case control study

INTRODUCTION

Human Immunodeficiency Virus (HIV) infection is associated with hypochlorhydria but the mechanism is unknown. The objective of this study was to determine effects of anti-retroviral therapy (ART) on gastric physiology as measured by validated markers.

METHODS

We studied HIV infected individuals who were either ART-naïve or on treatment with undetectable viral loads. We measured H.pylori IgG antibodies, pepsinogen (PG) 1 and 2 levels and fasting gastrin-17 using Biohit GastroPanel®. Gastric antral biopsies and juice were obtained for histology and pH respectively. Also included were historical data from HIV negative participants (n = 72) in a previous study, for reference.

RESULTS

We enrolled 84 HIV positive individuals with a median age 42 years (IQR 37-40 years). 55(66%) were female, 32(38%) were ART naïve, and 52(62%) were on ART. Hypochlorhydria (pH>4) was present in 48(57%) of the HIV positive and 18(25%) of the HIV negative individuals (OR 4: 95% CI 1.9-8.5, P<0.001) with no significant effect of ART (OR 0.9: 95% CI 0.3-2.3, P = 0.82). Hypochlorhydria was not associated with the serological detection of corpus atrophy using low PG 1:2 ratio (OR 2.1: 95% CI 0.5-10.2, P = 0.37) or GastroPanel® algorithm, (OR 0.7: 95% CI 0.01-60.1, P = 1.0). ART reduced the frequency of low PG 1:2 ratio (P = 0.001), but not the histological detection in the antrum of atrophy or non-atrophic gastritis.

CONCLUSION

ART use is associated with reduced serological evidence of corpus atrophy but has no effect on fasting pH, supporting earlier data that suggest that the mechanism of HIV-associated hypochlorhydria is multifactorial.

Exposure of remote organs and associated cancer risks from tangential and multi-field breast cancer radiotherapy

PURPOSE

With the ever-increasing cure rates in breast cancer, radiotherapy-induced cancers have become an important issue. This study aimed to estimate secondary cancer risks for different treatment techniques, taking into account organs throughout the body.

MATERIAL AND METHODS

Organ doses were evaluated for a tangential three-dimensional conformal (3D-CRT) and a multi-field intensity-modulated radiotherapy (IMRT) plan using a validated, Monte Carlo-based treatment planning system. Effects of wedges and of forward versus inverse planning were systematically investigated on the basis of phantom measurements. Organ-specific cancer risks were estimated using risk coefficients derived from radiotherapy patients or from the atomic bomb survivors.

RESULTS

In the 3D-CRT plan, mean organ doses could be kept below 1 Gy for more remote organs than the lung, heart, and contralateral breast, and decreased to a few cGy for organs in the lower torso. Multi-field IMRT led to considerably higher mean doses in organs at risk, the difference being higher than 50% for many organs. Likewise, the peripheral radiation burden was increased by external wedges. No difference was observed for forward versus inverse planning. Despite the lower doses, the total estimated secondary cancer risk in more remote organs was comparable to that in the lung or the contralateral breast. For multi-field IMRT it was 75% higher than for 3D-CRT without external wedges.

CONCLUSION

Remote organs are important for assessment of radiation-induced cancer risk. Remote doses can be reduced effectively by application of a tangential field configuration and a linear accelerator set-up with low head scatter radiation.

Mobile Phone Devices and Handheld Microscopes as Diagnostic Platforms for Malaria and Neglected Tropical Diseases (NTDs) in Low-Resource Settings: A Systematic Review, Historical Perspective and Future Outlook

The accurate, rapid, and cost-effective diagnosis of malaria and neglected tropical diseases (NTDs) in low-resource settings may benefit by significant technological advances in handheld and mobile phone microscopy. We systematically review the available literature in this field and discuss the future directions in which these technologies may be applied. English-language studies from the PubMed, Embase, and Web of Sciences were searched through April 2018 for observational and interventional studies reporting diagnostic characteristics of handheld and mobile phone microscopy devices as compared to field-established gold standard reference tests. Seventeen studies were included in the analysis. Findings included the high performance of the Newton Nm1 microscope in the diagnosis of Plasmodium species, Schistosoma mansoni, and soil-transmitted helminths (STHs), exhibiting sensitivity and specificity values often greater than 90%. Similarly, the CellScope was shown to have excellent diagnostic characteristics in the detection of Loa loa and Schistosoma species. Fluorescent microscopy was found to have high specificity and sensitivity in the diagnosis of Plasmodium species. Mobile phone technologies and handheld microscopes hold significant promise in the rapid and effective diagnosis of malaria and NTDs in areas where accurate diagnosis is vital. Although many of these technologies have yet to be securely embedded within the health system and studied directly in this context, the foundations for significant healthcare advances and impact have already been laid by several studies conducted within the last decade.

Frequency of post-stroke pneumonia: Systematic review and meta-analysis of observational studies

Background

Post-stroke pneumonia and other infectious complications are serious conditions whose frequency varies widely across studies.

Aims

We conducted a systematic review to estimate the frequency of post-stroke pneumonia and other types of major infection.

Summary of review

MEDLINE, EMBASE, CINAHL, and PsycINFO databases were searched for prospective studies with consecutive recruitment of stroke patients. The primary outcome was post-stroke pneumonia. Secondary outcomes were any infection and urinary tract infection. Quality assessment was done using Newcastle Ottawa scale. Heterogeneity of estimates across study populations was calculated using Cochran's Q (heterogeneity χ2) and I2 statistics. A total of 47 studies (139,432 patients) with 48 sample populations were eligible for inclusion. Mean age of patients was 68.3 years and their mean National Institute of Health Stroke Scale score was 8.2. The pooled frequency of post-stroke pneumonia was 12.3% (95% confidence interval [CI] 11%–13.6%; I2 = 98%). The pooled frequency from 2011 to 2017 was 13.5% (95% CI 11.8%–15.3%; I2 = 98%) and comparable with earlier periods (P interaction = 0.31). The pooled frequency in studies in stroke units was 8% (95% CI 7.1%–9%; I2 = 78%) and significantly lower than other locations (P interaction = 0.001). The pooled frequency of post-stroke infection was 21% (95% CI 13%–29.3%; I2 = 99%) and of post-stroke urinary tract infection was 7.9% (95% CI 6.7%–9.3%; I2 = 96%).

Conclusion

Approximately 1 in 10 stroke patients experience pneumonia during the acute period of hospital care. The frequency of post-stroke pneumonia has remained stable in recent decades but is lower in patients receiving stroke unit care compared to management in other ward settings.

SEEDi1.0-3.0 strategies for major noncommunicable diseases in China

The purpose of this article is to briefly introduce the status and challenges of major noncommunicable diseases (mNCDs), which include cardiovascular disease, diabetes and cancer, as well as related risk factors, such as environmental pollution, smoking, obesity and sleep disorders. "S-E-E-D" rules or the strategies of "S-E-E-D" intervention (SEEDi) consist of four core healthy elements: sleep, emotion, exercise and diet. The history of SEEDi^1.0-3.0 is also introduced, which includes versions 1.0, 1.5, 2.0 and 3.0 of the program. These guidelines are suitable for prevention and control of mNCDs. Not only the "Healthy China" initiated in China's "13th Five-year Plan," but also the "Healthy World" philosophy needs SEEDi^1.0-3.0 strategies for control of mNCDs.

Determinants of hypertension among adults in Bangladesh as per the Joint National Committee 7 and 2017 American College of Cardiology/American Hypertension Association hypertension guidelines

We investigated determinants of hypertension in Bangladesh using both Joint National Committee 7 (JNC7) and 2017 American College of Cardiology/American Hypertension Association (2017 ACC/AHA) guidelines. After reporting background characteristics, odds ratios (ORs) were obtained by multilevel logistic regression. Among 7839 respondents aged ≥35 years, 25.7% (n = 2016) and 48.0% (n = 3767) respondents had hypertension as per the JNC7 and 2017 ACC/AHA guidelines, respectively. The following factors were significant according to the 2017 ACC/AHA guideline: ≥65 years (adjusted OR [AOR]: 2.4, 95% confidence interval [CI]: 2.2-3.0), 55-64 years (AOR: 1.6, 95% CI: 1.4-1.9), and 45-54 years (AOR: 1.4, 95% CI: 1.3-1.6) age groups, females (AOR: 2.0, 95% CI: 1.7-2.2), overweight/obesity (AOR: 2.4, 95% CI: 2.0-2.8), diabetes (AOR: 1.4, 95% CI: 1.2-1.6), secondary (AOR: 1.2, 95% CI: 1.1-1.4), or college education level (AOR: 1.8, 95% CI: 1.4-2.3), middle (AOR: 1.3, 95% CI: 1.1-1.6), richer (AOR: 1.5, 95% CI: 1.2-1.8) or richest (AOR: 2.0, 95% CI: 1.6-2.4) wealth quintiles, residence in Khulna (AOR: 1.5, 95% CI: 1.2-1.9), and Rangpur (AOR: 1.7, 95% CI: 1.3-2.2) divisions. All factors were significant as per the JNC7 guideline too. Both guidelines found similar determinants. Prevention and control programs should prioritize increasing awareness among people with higher likelihood of hypertension.

Arrhythmogenic Substrates for Atrial Fibrillation in Obesity

Global obesity rates have nearly tripled since 1975. This obesity rate increase is mirrored by increases in atrial fibrillation (AF) that now impacts nearly 10% of Americans over the age of 65. Numerous epidemiologic studies have linked incidence of AF and obesity and other obesity-related diseases, including hypertension and diabetes. Due to the wealth of epidemiologic data linking AF with obesity-related disease, mechanisms of AF pathogenesis in the context of obesity are an area of ongoing investigation. However, progress has been somewhat slowed by the complex phenotype of obesity; separating the effects of obesity from those of related sequelae is problematic. While the initiation of pathogenic pathways leading to AF varies with disease (including increased glycosylation in diabetes, increased renin angiotensin aldosterone system activation in hypertension, atrial ischemia in coronary artery disease, and sleep apnea) the pathogenesis of AF is united by shared mediators of altered conduction in the atria. We suggest focusing on these downstream mediators of AF in obesity is likely to yield more broadly applicable data. In the context of obesity, AF is driven by the interrelated processes of inflammation, atrial remodeling, and oxidative stress. Obesity is characterized by a constant low-grade inflammation that leads to increased expression of pro-inflammatory cytokines. These cytokines contribute to changes in cardiomyocyte excitability. Atrial structural remodeling, including fibrosis, enlargement, and fatty infiltration is a prominent feature of AF and contributes to the altered conduction. Finally, obesity impacts oxidative stress. Within the cardiomyocyte, oxidative stress is increased through both increased production of reactive oxygen species and by downregulation of scavenging enzymes. This increased oxidative stress modulates of cardiomyocyte excitability, increasing susceptibility to AF. Although the initiating insults vary, inflammation, atrial remodeling, and oxidative stress are conserved mechanisms in the pathophysiology of AF in the obese patients. In this review, we highlight mechanisms that have been shown to be relevant in the pathogenesis of AF across obesity-related disease.

Moderation of alcohol consumption as a recommendation in European hypertension management guidelines: a survey on awareness, screening and implementation among European physicians

OBJECTIVES

Moderation of alcohol consumption is included as a class I, level of evidence A recommendation in the current European guidelines for the management of hypertension. We investigated its awareness and self-reported implementation among European physicians across different specialties and workplaces.

DESIGN AND SETTING

A cross-sectional survey study conducted in two annual German meetings (German Society of Cardiology and the German Society of Internal Medicine) and two annual European meetings (European Society of Hypertension and European Society Cardiology) in 2015.

PARTICIPANTS

1064 physicians attending the European meetings were interviewed including 52.1% cardiologists, 29.2% internists and 8.8% general practitioners.

MAIN OUTCOME MEASURES

Physician screening of alcohol consumption, awareness and self-implementation of the recommendation of the current European guidelines about moderation of alcohol consumption for the management of hypertension.

RESULTS

Overall, 81.9% of physicians reported to generally quantify alcohol consumption in patients with hypertension. However, only 28.6% and 14.5% of participants reported screening alcohol consumption in their patients with newly detected or treatment-resistant hypertension. Physicians recommended a maximum alcohol intake of 13.1±11.7 g/day for women (95% CI 12.3 to 13.8) and 19.9±15.6 g/day for men (95% CI 18.8 to 20.9). In case of moderate to high alcohol consumption, 10.3% would manage only hypertension without addressing alcohol consumption, while 3.7% of the physicians would do so in case of alcohol dependence (p<0.001).

CONCLUSIONS

The average amount of alcohol intake per day recommended by European physicians in this survey was in agreement with the guidelines. The low number of physicians that screen for alcohol consumption in patients with newly detected and with treatment-resistant hypertension indicates an important deficit in the management of hypertension.

Blood pressure goals: A moving target

Clinical guidelines on hypertension have evolved over the past several decades. Each recommends varying blood pressure (BP) cut-offs which define hypertension, determine the thresholds to initiate pharmacotherapy, and guide treatment targets. In addition, different techniques of measuring BP in clinical trials may further contribute to the discrepancies in the achieved BP targets. Physicians find it difficult to navigate through different recommendations for hypertension management based on studies among different age groups and patients with a variety of co-morbidities and target organ involvement. In 2003, JNC 7 recommended a BP goal of < 140/90 mmHg in the general population and < 130/80 mmHg in those with diabetes mellitus or renal disease. JNC 8 re-set the BP target at < 140/90 mmHg for all adults under the age of 60 regardless of co-morbidities, and an even higher target of < 150/90 mmHg for those 60 years or older without diabetes or chronic kidney disease. The more recent results of the Systolic BP Intervention Trial (SPRINT) have a significant influence on the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) guideline which redefines hypertension as BP ≥ 130/80 mmHg. It emphasizes individualized cardiovascular risk assessment and recommends a more aggressive BP target of < 130/80 mmHg and a treatment threshold based on the age, co-morbidities, and cardiovascular risk. The 2017 ACC/AHA guideline also advocates proper BP measurement and provides the estimates of corresponding BP values for clinic, home, and ambulatory BP monitoring measurements. A higher prevalence of hypertension is expected based on the ACC/AHA 2017 guideline. Its implementation may potentially lead to better BP control through enhanced awareness, improved adherence, and more timely initiation and intensification of pharmacologic therapy. Although there is no one-size-fits-all BP target, the ACC/AHA 2017 guideline is simple, inclusive and practical. Nonetheless, more studies are warranted to help further individualize BP goals for elderly patients and those with certain co-morbidities or multiple cardiovascular risk factors.