Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Repeatability of High Resolution Laser Doppler Images of the hands in patients with systemic sclerosis and secondary Raynaud's phenomenon

OBJECTIVES

The objective of the study was to establish the repeatability of baseline diagnostic images of the dorsum of the hands acquired using a high resolution Laser Doppler imager in patients with Raynaud's phenomenon secondary to Systemic Sclerosis (SSc).

METHODS

The dorsal side of the hands of 22 patients (8 male 14 female) , age range 29-73, median 62, with SSc and secondary Raynaud's phenomenon were imaged over two consecutive days at approximately the same time using a Moor Instruments High Resolution Laser Doppler imaging unit. The images were analysed by taking regions of interest at discrete locations in the images to calculate dimensionless values of flux(PU). Repeatability of the diagnostic investigation was assessed by using methods described by Bland and Altman and by also plotting the results from visit 1 against visit 2 and calculating the line of best fit.

RESULTS AND CONCLUSIONS

Based on the criteria that 95% of all measurement differences should be within a factor of 1.96 of the standard deviations of the mean values, then high resolution Laser Doppler Imaging technique is probably repeatable when acquiring and analysing baseline images of patients with Raynaud's phenomenon secondary to SSc. However a larger study with more patients is required to prove this conclusively - as only data from 19 patients was analysed [3 patients were not included due to technical issues] - and was therefore susceptible to marked clinical variations in patients presenting on different days for the investigations.

Validity and sensitivity to change of laser Doppler imaging as a novel objective outcome measure for cutaneous lupus erythematosus

OBJECTIVES

The objectives of this study were to assess the reliability of a novel objective outcome measure, laser Doppler imaging (LDI), its validity against skin biopsy histology and other clinical instruments, including localized cutaneous lupus disease area and severity index (L-CLASI) and visual analogue scale (VAS) score of photographs, and its responsiveness to clinical change with therapy.

METHODS

A prospective observational cohort study was conducted in 30 patients with active cutaneous lupus erythematosus (CLE). At baseline and 3 months, disease activity was assessed using L-CLASI and a high resolution LDI system by two assessors. Skin biopsy was scored as 0 = non-active, 1 = mild activity and 2 = active. Photographs were assessed by two clinicians using 100 mm VAS. Inter-rater reliability was analyzed using Bland-Altman limits of agreement. Correlation between histology and LDI, L-CLASI and VAS and sensitivity to change of LDI with physician subjective assessment of change (PSAC) at 3 months were analyzed using Kendall's tau-a.

RESULTS

Of 30 patients with CLE, 28 (93%) were female, mean (SD) age 48.4 (11.5) y, 25 (83%) were Caucasians, 25 (83%) had concurrent systemic lupus erythematosus and 16 (53%) were smokers. CLE subtypes were acute = 9, subacute = 8 and chronic = 13. Inter-rater agreement for LDI was fair but for VAS score of photographs was poor. In 20 patients with biopsy, correlation with histology was better for LDI (tau-a = 0.53) than L-CLASI (tau-a = 0.26) (difference = 0.27; 90% CI 0.05-0.49) or VAS score of photographs (tau-a = 0.17) (difference = 0.36; 90% CI 0.04-0.68). There was a moderate correlation between PSAC score and change in LDI (tau-a = 0.56; 90% CI 0.38-0.74; p < 0.001, n = 15).

CONCLUSION

LDI provides a reliable, valid and responsive quantitative measure of inflammation in CLE. It has a better correlation with histology compared to clinical instruments. LDI provides an objective outcome measure for clinical trials.

Alcohol consumption and risk of tuberculosis: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of the association between alcohol consumption and risk of tuberculosis (TB).

METHODS

Medline, EMBASE and Web of Science were searched for observational studies from 2005 to April 2018. Reference lists of included studies were screened.

RESULTS

Forty-nine studies were included. Compared with people with low or no alcohol intake, the risk of TB in people with high or any alcohol consumption was increased by relative odds of 1.90 (95%CI 1.63-2.23). Substantial levels of heterogeneity were seen (I² = 82%); however, there was no evidence of publication bias (P = 0.54). Sensitivity analysis restricted to studies using no alcohol drinking as a reference group found a slightly lower but still increased risk (OR 1.60, 95%CI 1.39-1.84). Subgroup analyses revealed no significant differences in relation to study design and quality, geographic location, publication year or adjustment for confounders. A pooled analysis of a further four studies reporting hazard ratios (HRs) found a nearly three-fold increase in risk of TB in relation to alcohol consumption during follow-up (HR 2.81, 95%CI 2.12-3.74). An exposure-response analysis showed that for every 10-20 g daily alcohol intake, there was a 12% increase in TB risk.

CONCLUSION

Alcohol consumption is an important risk factor for the development of TB.

What is the association between price and economic activity with cigarette consumption in Cuba from 1980 to 2014?

OBJECTIVES

Cuba is a tobacco-producing country that has been economically isolated as a consequence of an embargo imposed by the USA. It has also experienced a severe economic depression in the 1990s after the withdrawal of support by the former Soviet Union. These characteristics provide a unique opportunity to study the relation between large changes in economic activity, cigarette price and demand for cigarettes in a relatively isolated socialist economy.

STUDY DESIGN

This is an observational epidemiological study.

METHODS

Data were obtained on the annual price of a packet of cigarettes and the mean number of cigarettes consumed per adult living in Cuba from 1980 to 2014. Descriptive and regression analysis were used to explore the relationship between cigarette consumption and price in Cuba.

RESULTS

In 1980, the mean price of a packet of cigarettes was 1.53 Cuban peso (CUP) in 1997 prices and the mean annual per capita consumption was 2237 cigarettes. In 2014, the mean price had increased to 5.57 CUP (1997 prices) per packet of cigarettes, and consumption had fallen to 1527 cigarettes per capita. There were significant negative associations between annual cigarette consumption and both price and living through an economic depression. The elasticity was approximately -0.31 with price, and living through an economic depression was also associated with lower consumption of cigarettes (a reduction of 9%, 95% confidence intervals -0.18 to -0.001).

CONCLUSIONS

Higher cigarette pricing, along with other public health interventions, are required to protect the national population from the adverse effects of tobacco smoke exposure.

Prevalence and risk factors for initiating tobacco and alcohol consumption in adolescents living in urban and rural Ethiopia

Objectives

African countries are potential high growth markets for the alcohol and tobacco industries. This study aimed to identify exposures that are associated with initiating use of alcohol and tobacco products in young people living in Ethiopia. As televised football and Internet viewing are media through which products can be promoted to this population efficiently, these risk factors were of particular interest.

Study design

This is a cross-sectional study.

Methods

Data were collected using a self-administered questionnaire of 3967 children aged 13–19 years in 20 high schools in urban and rural Ethiopia on consumption and risk factors for alcohol and tobacco use in 2016, as well as exposure to potential sources of advertising.

Results

Eight percent of respondents reported having ever smoked and 3% were current smokers. Twenty-nine percent reported ever having used alcohol, and 14% were current users. Risk factors for ever smoking included father smoking (odds ratio [OR] 1.95; 95% confidence interval [CI]: 1.21 to 3.15), mother smoking (OR 3.90; 95% CI: 1.63 to 9.33), best friend smoking (OR 5.86; 95% CI: 4.31 to 7.96) and home Internet access (OR 1.75; 95% CI: 1.35 to 2.27). There was a very strong positive association between ever having smoked cigarettes and ever having tried alcohol (P < 0.001). Risk factors for currently drinking alcohol included father drinking (OR 1.45; 95% CI: 1.05 to 2.01), mother drinking (OR 2.00; 95% CI: 1.44 to 2.77), home Internet access (OR 1.53; 95% CI: 1.24 to 1.90) and regular watching of televised football (OR 2.44 compared to those who do not; 95% CI: 1.58 to 3.78).

Conclusions

As in rich countries, tobacco and alcohol use among Ethiopian teenagers increases among those exposed to family and peer use but are also more common among those accessing the Internet and, for alcohol, those watching televised football. The effect of watching televised football on alcohol use, at least, is likely to be due to exposure to advertising.

•

Rapid economic development is changing the environment in developing countries rapidly, generating a new potential market for the alcohol and tobacco industries.

•

Fourteen percent of adolescents living in Ethiopia are regular consumers of alcohol, and 3% regularly smoke cigarettes.

•

Regular watching of international football on television is associated with being a current consumer of alcohol.

•

Public health strategies to modify alcohol and tobacco usage in adolescents living in Ethiopia need to consider that the Internet and televised football matches are potential sources of exposure to advertising aiming to promote consumption.

Effect of Inhaled Alpha-Blocker on Airflow Obstruction in Asthma1

A controlled study of the effect on airflow obstruction of 30 mg of the alpha-blocker thymoxamine given by inhalation is reported in 10 patients with chronic stable asthma. No significant change in peak expiratory flow rate was seen with either thymoxamine or placebo in any patient. Alpha-adrenergic receptors are therefore unlikely to contribute significantly to resting bronchomotor tone in chronic stable asthma.

The effect of the cobalt and manganese central metal ions on the nonlinear optical properties of tetra(4-propargyloxyphenoxy)phthalocyanines

The phthalocyanines were investigated as optical limiters. The paramagnetic complexes were not effective owing to quenching of the excited states.

Direct Measurement of the Surface Energy of Graphene

Graphene produced by chemical vapor deposition (CVD) is a promising candidate for implementing graphene in a range of technologies. In most device configurations, one side of the graphene is supported by a solid substrate, wheras the other side is in contact with a medium of interest, such as a liquid or other two-dimensional material within a van der Waals stack. In such devices, graphene interacts on both faces via noncovalent interactions and therefore surface energies are key parameters for device fabrication and operation. In this work, we directly measured adhesive forces and surface energies of CVD-grown graphene in dry nitrogen, water, and sodium cholate using a modified surface force balance. For this, we fabricated large (∼1 cm²) and clean graphene-coated surfaces with smooth topography at both macro- and nanoscales. By bringing two such surfaces into contact and measuring the force required to separate them, we measured the surface energy of single-layer graphene in dry nitrogen to be 115 ± 4 mJ/m², which was similar to that of few-layer graphene (119 ± 3 mJ/m²). In water and sodium cholate, we measured interfacial energies of 83 ± 7 and 29 ± 6 mJ/m², respectively. Our work provides the first direct measurement of graphene surface energy and is expected to have an impact both on the development of graphene-based devices and contribute to the fundamental understanding of surface interactions.

Ultra-stiff large-area carpets of carbon nanotubes

Herewith, we report the influence of post-synthesis heat treatment (≤2350 °C and plasma temperatures) on the crystal structure, defect density, purity, alignment and dispersibility of free-standing large-area (several cm(2)) carpets of ultra-long (several mm) vertically aligned multi-wall carbon nanotubes (VA-MWCNTs). VA-MWCNTs were produced in large quantities (20-30 g per batch) using a semi-scaled-up aerosol-assisted chemical vapour deposition (AACVD) setup. Electron and X-ray diffraction showed that the heat treatment at 2350 °C under inert atmosphere purifies, removes residual catalyst particles, and partially aligns adjacent single crystals (crystallites) in polycrystalline MWCNTs. The purification and improvement in the crystallites alignment within the MWCNTs resulted in reduced dispersibility of the VA-MWCNTs in liquid media. High-resolution microscopy revealed that the crystallinity is improved in scales of few tens of nanometres while the point defects remain largely unaffected. The heat treatment also had a marked benefit on the mechanical properties of the carpets. For the first time, we report compression moduli as high as 120 MPa for VA-MWCNT carpets, i.e. an order of magnitude higher than previously reported figures. The application of higher temperatures (arc-discharge plasma, ≥4000 °C) resulted in the formation of a novel graphite-matrix composite reinforced with CVD and arc-discharge-like carbon nanotubes.

Exposure to Helicobacter pylori infection in early childhood and the risk of allergic disease and atopic sensitization: a longitudinal birth cohort study

Background

An inverse relation between Helicobacter pylori infection and allergic disease has been reported by a range of independent epidemiological studies, but evidence from longitudinal studies is scarce.

Objective

We have investigated the effects of H. pylori infection on the incidence and prevalence of allergic diseases and sensitization in a low-income birth cohort.

Methods

In 2005/2006, a population-based birth cohort was established in Butajira, Ethiopia, and the 1006 singleton babies born were followed up at ages 1, 3, and 5. Symptoms of allergic disease were collected using the ISAAC questionnaire, allergen skin tests performed, and stool samples analysed for H. pylori antigen and geohelminths. Multiple logistic regression was used to determine the independent effects of H. pylori measured at age 3 on the incidence of each outcome between ages 3 and 5 years (in those without the outcome at age 3), controlling for potential confounders, and to additionally assess cross-sectional associations.

Results

A total of 863 children were followed up to age 5. H. pylori infection was found in 25% of the children at both ages 3 and 5, in 21% at age 5 but not 3, and in 17% at age 3 but not at age 5. H. pylori infection at age 3 was significantly associated with a decreased risk of incident eczema between ages 3 and 5 (adjusted OR, 95% CI, 0.31; 0.10–0.94, P = 0.02). Cross-sectionally at age 5, H. pylori infection was inversely associated with skin sensitization (adjusted OR, 95% CI, 0.26; 0.07–0.92, P = 0.02).

Conclusion and clinical relevance

These findings provide further evidence to suggest that early-life exposure to H. pylori may play a protective role in the development of allergy.

A graphene surface force balance

We report a method for transferring graphene, grown by chemical vapor deposition, which produces ultraflat graphene surfaces (root-mean-square roughness of 0.19 nm) free from polymer residues over macroscopic areas (>1 cm(2)). The critical step in preparing such surfaces involves the use of an intermediate mica template, which itself is atomically smooth. We demonstrate the compatibility of these model surfaces with the surface force balance, opening up the possibility of measuring normal and lateral forces, including friction and adhesion, between two graphene sheets either in contact or across a liquid medium. The conductivity of the graphene surfaces allows forces to be measured while controlling the surface potential. This new apparatus, the graphene surface force balance, is expected to be of importance to the future understanding of graphene in applications from lubrication to electrochemical energy storage systems.

WS2 2D nanosheets in 3D nanoflowers

WS₂ nanoflower (false colour).

Large-aperture wide-bandwidth antireflection-coated silicon lenses for millimeter wavelengths

The increasing scale of cryogenic detector arrays for submillimeter and millimeter wavelength astrophysics has led to the need for large aperture, high index of refraction, low loss, cryogenic refracting optics. Silicon with n=3.4, low loss, and high thermal conductivity is a nearly optimal material for these purposes but requires an antireflection (AR) coating with broad bandwidth, low loss, low reflectance, and a matched coefficient of thermal expansion. We present an AR coating for curved silicon optics comprised of subwavelength features cut into the lens surface with a custom three-axis silicon dicing saw. These features constitute a metamaterial that behaves as a simple dielectric coating. We have fabricated silicon lenses as large as 33.4 cm in diameter with micromachined layers optimized for use between 125 and 165 GHz. Our design reduces average reflections to a few tenths of a percent for angles of incidence up to 30° with low cross polarization. We describe the design, tolerance, manufacture, and measurements of these coatings and present measurements of the optical properties of silicon at millimeter wavelengths at cryogenic and room temperatures. This coating and lens fabrication approach is applicable from centimeter to submillimeter wavelengths and can be used to fabricate coatings with greater than octave bandwidth.

Risk factors for wheezing in infants born in Cuba

BACKGROUND

Cuba is a unique country, and despite limited economic development, has an excellent health system. However, the prevalence of asthma symptoms in children in Havana, Cuba, is unusually high.

AIM

As early life exposures are critical to the aetiology of asthma, we have studied environmental influences on the risk of wheezing in Cuban infants.

DESIGN

Cross-sectional study.

METHODS

A random sample of 2032 children aged 12-15 months living in Havana was selected for inclusion in the cohort. Data were collected using questionnaires administered by researchers.

RESULTS

Of 2032 infants invited to participate, 1956 (96%) infants provided data. The prevalence of any wheeze was 45%, severe wheeze requiring use of emergency services was 30% and recurrent wheeze on three or more occasions was 20%. The largest adjusted risk factors for any wheeze were presence of eczema [odds ratio (OR) 2.09; 95% confidence interval (CI) 1.48-2.94], family history of asthma (OR 2.05; 95% CI 1.60-2.62), poor ventilation in the house (OR 1.99; 95% CI 1.48-2.67), attendance at nursery (OR 1.78; 95% CI 1.24-2.57), male sex (OR1.52; 95% CI 1.19-1.96) and the number of smokers in the house (P < 0.03 for trend), OR 1.64 (95% CI 1.17-2.31) for three or more smokers in the house compared to no smokers in the household.

CONCLUSION

We have identified several risk factors for any wheeze in young infants living in modern day Cuba. As the prevalence of smoking in the house is high (51%), intervention studies are required to determine effective strategies to improve infant health.

Probing the bonding in nitrogen-doped graphene using electron energy loss spectroscopy

Precise control of graphene properties is an essential step toward the realization of future graphene devices. Defects, such as individual nitrogen atoms, can strongly influence the electronic structure of graphene. Therefore, state-of-the-art characterization techniques, in conjunction with modern modeling tools, are necessary to identify these defects and fully understand the synthesized material. We have directly visualized individual substitutional nitrogen dopant atoms in graphene using scanning transmission electron microscopy and conducted complementary electron energy loss spectroscopy experiments and modeling which demonstrates the influence of the nitrogen atom on the carbon K-edge.

Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.

DESIGN

Open, cluster randomised controlled trial.

SETTING

Acute medical wards in one large teaching hospital in the United Kingdom.

PARTICIPANTS

264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study.

INTERVENTIONS

The intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment.

MAIN OUTCOME MEASURES

Smoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.

RESULTS

All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).

CONCLUSIONS

Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN25441641.

Investigation of the relationship between transcranial impedance and intracranial pressure

Studies on piglets have shown that cranial bioimpedance (Z) measurements correlate well with invasively measured intracranial pressure (ICP). We have tested the feasibility of collecting transcranial impedance from a clinical device for measuring whole-body water content (ImpediMed SFB7). In the clinical study, 50 normal healthy volunteers had transcranial impedance measured using nine different head montages (forehead to mastoid (left/right), temporal to mastoid (left/right), forehead to temporal (left/right), forehead to occipital (left/right) and temporal to temporal). Impedance was measured 20 times over a frequency range per montage and ANOVA used to test for effects of electrode position upon recorded value. For the experimental study, five sedated and ventilated Marino sheep were instrumented for intraventricular ICP and transcranial impedance measurement. Measures of ICP were recorded while ICP was increased from baseline to greater than 50 mmHg in five steps using an intraventricular infusion of mock CSF. There is a significant effect of electrode position and gender upon transcranial impedance (p < 0.001). The temporal-mastoid electrode position had significantly lower impedance values in keeping with its shorter path length. ICP correlated with craniospinal compliance measurements and Impedance vs Freq by ICP step shows a clear ICP dependence (p = 0.007) across the sheep.

Smoking status ascertainment and interventions in acute medical patients

Hospital admission provides an opportunity to promote smoking cessation. Clinical guidelines recommend ascertainment of smoking status and delivery of cessation interventions in all consultations. In this article, smoking ascertainment and intervention among all patients admitted to medical wards in a UK hospital over a four-week period in 2010 were audited. Medical records of 767 patients were screened; 96 (13%) were current smokers, 243 (32%) ex-smokers and 233 (30%) non-smokers. There was no record of smoking status in 243 (25%) individuals and this proportion varied between specialties. Of the 96 current smokers, only 23 received documented cessation advice or pharmacological support. Four weeks after discharge, 31% reported that they were abstinent from smoking, representing 50% of those who received support and 20% of those who did not. Ascertainment of smoking status and delivery of cessation support to patients admitted to medical wards was low, suggesting that there is room for improvement in the management of smoking among inpatients.

Pneumonectomy for congenital isolated unilateral pulmonary artery agenesis

Unilateral pulmonary artery agenesis (UPAA) is a rare congenital anomaly usually diagnosed in infancy due to associated cardiovascular malformations. We report a rare case of isolated right UPAA that presented atypically in adulthood with massive haemoptysis requiring a pneumonectomy. This case highlights the importance of maintaining a high clinical suspicion, the role of CT angiography and a multi disciplinary approach. Optimal management is often surgical however bronchial artery embolization (BAE) remains a useful adjunct.

Effects of Helicobacter pylori, geohelminth infection and selected commensal bacteria on the risk of allergic disease and sensitization in 3-year-old Ethiopian children

BACKGROUND

Epidemiological studies have suggested that gastro-intestinal infections including Helicobacter pylori, intestinal microflora (commensal bacteria) and geohelminths may influence the risk of asthma and allergy but data from early life are lacking.

OBJECTIVE

We aimed to determine the independent effects of these infections on allergic disease symptoms and sensitization in an Ethiopian birth cohort.

METHODS

In 2008/09, 878 children (87% of the 1006 original singletons in a population-based birth cohort) were followed up at age 3 and interview data obtained on allergic symptoms and potential confounders. Allergen skin tests to Dermatophagoides pteronyssinus and cockroach were performed, levels of Der p 1 and Bla g 1 in the child's bedding measured and stool samples analysed for geohelminths and, in a random subsample, enterococci, lactobacilli, bifidobacteria and H. pylori antigen. The independent effects of each exposure on wheeze, eczema, hayfever and sensitization were determined using multiple logistic regression.

RESULTS

Children were commonly infected with H. pylori (41%; 253/616), enterococci (38.1%; 207/544), lactobacilli (31.1%; 169/544) and bifidobacteria (18.9%; 103/544) whereas geohelminths were only found in 8.5% (75/866). H. pylori infection was associated with a borderline significant reduced risk of eczema (adjusted OR 0.49, 95% CI 0.24-1.01, P=0.05) and D. pteronyssinus sensitization (adjusted OR 0.42, 95% CI 0.17-1.08, P=0.07). Geohelminths and intestinal microflora were not significantly associated with any of the outcomes measured.

CONCLUSION AND CLINICAL RELEVANCE

Among young children in a developing country, we found evidence to support the hypothesis of a protective effect of H. pylori infection on the risk of allergic disease. Further investigation of the mechanism of this effect is therefore of potential therapeutic and preventive value.

Atopy and current intestinal parasite infection: a systematic review and meta-analysis

BACKGROUND

The rate of increase in prevalence of allergic disease in some countries implies environmental exposures may be important etiological factors. Our aim was to undertake a systematic review and meta-analysis of epidemiological studies to quantify the association between current intestinal parasite infection and the presence of atopy and to determine whether this relation is species specific.

METHODS

We searched MEDLINE, EMBASE, LILIACS and CAB Abstracts (to March 2009); reviews; and reference lists from publications. No language restrictions were applied. We included studies that measured current parasite infection using direct fecal microscopy and defined atopy as allergen skin sensitization or presence of specific IgE. We estimated pooled odds ratios (OR) and 95% confidence intervals (95% CI) using data extracted from published papers using random-effects model.

RESULTS

Twenty-one studies met our inclusion criteria. Current parasite infection was associated with a reduced risk of allergen skin sensitization OR 0.69 (95% CI 0.60-0.79; P < 0.01). When we restricted our analyses to current geohelminth infection, the size of effect remained similar OR 0.68 (95% CI 0.60-0.76; P < 0.01). In species-specific analysis, a consistent protective effect was found for infection with Ascaris lumbricoides, Tricuris trichuria, hookworm and Schistosomiasis. There were insufficient data to pool results for atopy defined by the presence of specific IgE.

CONCLUSION

Intestinal parasite infection appears to protect against allergic sensitization. Work should continue to identify the mechanisms of this effect and means of harnessing these to reduce the global burden of allergic disease.

Prevalence and risk factors of wheeze and eczema in 1-year-old children: the Butajira birth cohort, Ethiopia

BACKGROUND

The rising global prevalence of asthma and other allergic conditions has been linked to potential aetiological factors influencing the developing immune system.

OBJECTIVE

To investigate the prevalence and associated risk factors for wheeze and eczema in 1-year-old children in a birth cohort from Butajira, Ethiopia.

METHODS

In 2005/6, a population-based cohort of 1065 pregnant women was established. At 1 year of age, data on wheeze and eczema in the children were collected from the mother via an interview-administered questionnaire, along with numerous demographic and lifestyle factors. A stool sample was also obtained from the child for geohelminth analysis.

RESULTS

The prevalence of wheeze was 11.5% (103/899) and eczema 8.6% (77/899). Independent predictors of wheeze were maternal allergic history [adjusted OR (AOR)=3.00, 95% CI 1.23-7.36], paternal allergic history (AOR=2.59, 95% CI 1.08-6.25), increasing household size (P for trend=0.023; AOR=3.54, 95% CI 1.31-9.56 for 7+ vs. 1-3 individuals) and paracetamol use by the child (overall P<0.001; AOR 11.04, 95% CI 4.30-28.31 for 4+ tablets in past month vs. never). Factors independently associated with eczema were maternal allergic history (AOR=3.68, 95% CI 1.54-8.77), household size (overall P=0.035; AOR=0.45, 95% CI 0.23-0.87 for 4-6 individuals relative to 1-3) and place of sleeping (overall P<0.001; AOR=0.29, 95% CI 0.10-0.82 for floor vs. bed/platform).

CONCLUSION

These findings support the hypothesis that eczema in early life in these children is a manifestation of allergy, while wheezing is probably due to infection as well as allergy.

Effect of living close to a main road on asthma, allergy, lung function and chronic obstructive pulmonary disease

BACKGROUND

A number of epidemiological studies suggest that the risk of asthma is increased among those living in close proximity to major roads. However, the evidence is inconsistent, and effects on asthma and related respiratory and allergic conditions using objective measures such as lung function and allergic sensitisation have not been widely investigated.

METHODS

In 1995, 1996 and 2001 data on respiratory and allergic disease, along with demographic and lifestyle factors, were collected in 59 285 children (aged 2-16 years) and adults as part of the Health Survey for England, a nationally representative annual survey. Using Geographical Information System software, we mapped the location of each participant's home and computed distance to the nearest major road. We estimated the effect of distance on self-reported wheezing in the past year, asthma, eczema and hay fever in 50 994 participants, and on 1-second forced expiratory volume (FEV(1)), immunoglobulin E and spirometry-defined chronic obstructive pulmonary disease (COPD) in subgroups of those aged 7+, 11+ and 16+ years, respectively.

RESULTS

Living within 150 m from a major road was not significantly associated with an increased risk of any of the outcome variables in any age group (adjusted odds ratios ranged from 0.85 to 1.05). Furthermore there was little evidence that risk increased with increasing proximity across the 0-150 m range where contrasts in traffic-related pollutant concentrations are greatest.

CONCLUSION

Our analysis of a large and nationally representative population sample did not provide evidence of an adverse effect of living in close proximity to main roads on the risk of asthma, COPD or allergic disease in England.

Smoking uptake and prevalence in Ghana

BACKGROUND

Developing countries are at high risk of epidemic increases in tobacco smoking, but the extent of this problem is not clearly defined because few collect detailed smoking data. We have surveyed tobacco smoking in the Ashanti region of Ghana, a rapidly developing African country with a long-established tobacco industry.

METHODS

We took a random sample of 30 regional census enumeration areas, each comprising about 100 households, and a systematic sample of 20 households from each. These were visited, a complete listing of residents obtained and questionnaire interviews on current and past smoking, age at smoking uptake, sources of cigarettes and other variables carried out in all consenting residents aged 14 or over.

RESULTS

Of 7096 eligible individuals resident in the sampled households, 6258 (88%; median age 31 (range 14-105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%) and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking was more common in older people, those of Traditionalist belief, those of low educational level, the unemployed and the less affluent. Smokers were more likely to drink alcohol and to have friends who smoke. About 10% of cigarettes were smuggled brands. About a third of smokers were highly or very highly dependent.

CONCLUSIONS

Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence in Ghana is low, particularly among younger people. This suggests that progression of an epidemic increase in smoking has to date been avoided.

Reduced helminth burden increases allergen skin sensitization but not clinical allergy: a randomized, double-blind, placebo-controlled trial in Vietnam

BACKGROUND

Observational evidence suggests that infection with helminths protects against allergic disease and allergen skin sensitization. It is postulated that such effects are mediated by helminth-induced cytokine responses, in particular IL-10.

OBJECTIVE

We tested this hypothesis in a rural area of central Vietnam where hookworm infection is endemic.

METHODS

One thousand five hundred and sixty-six schoolchildren aged 6-17 were randomly allocated to receive either anti-helminthic therapy or a placebo at 0, 3, 6, and 9 months. We compared changes in the prevalence of exercise-induced bronchoconstriction, allergen skin sensitization, flexural eczema on skin examination, questionnaire-reported allergic disease (wheeze and rhinitis symptoms), and immunological parameters (hookworm-induced IFN-gamma, IL-5, IL-10) between 0 and 12 months.

RESULTS

One thousand four hundred and eighty-seven children (95% of these randomized) completed the study. The most common helminth infections were hookworm (65%) and Ascaris lumbricoides (7%). There was no effect of the therapy on the primary outcome, exercise-induced bronchoconstriction (within-participant mean percent fall in peak flow from baseline after anti-helminthic treatment 2.25 (SD 7.3) vs. placebo 2.19 (SD 7.8, P=0.9), or on the prevalence of questionnaire-reported wheeze [adjusted odds ratio (OR)=1.16, 95% confidence interval (CI) 0.35-3.82, P=0.8] and rhinitis (adjusted OR=1.39, 0.89-2.15, P=0.1), or flexural dermatitis on skin examination (adjusted OR=1.15, 0.39-3.45, P=0.8). However, anti-helminthic therapy was associated with a significantly higher allergen skin sensitization risk (adjusted OR=1.31, 1.02-1.67, P=0.03). This effect was particularly strong for children infected with A. lumbricoides at baseline (adjusted OR=4.90, 1.48-16.19, P=0.009). Allergen skin sensitization was inversely related to hookworm-specific IL-10 at baseline (adjusted OR=0.76, 0.59-0.99, P=0.04). No cytokine tested, including IL-10, changed significantly after the anti-helminthic therapy compared with the placebo.

CONCLUSION

A significant reduction in worm burden over a 12-month period in helminth-infected children increases the risk of allergen skin sensitization but not of clinical allergic disease. The effect on skin sensitization could not be fully explained by any of the immunological parameters tested.

Repeatability and validity of IUATLD Respiratory Questionnaire responses as a measure of asthma in an Ethiopian population

OBJECTIVE

To assess the repeatability and validity of the IUATLD respiratory symptoms questionnaire in relation to exercise-induced bronchoconstriction or bronchodilator responses in a community in southern Ethiopia.

DESIGN

A case-control study.

SETTING

Rural and small town setting in southern Ethiopia, April to May 2006.

SUBJECTS

Two hundred and forty seven adults and children who previously reported wheeze in the past year, and 174 who did not.

INTERVENTIONS

Administered IUATLD bronchial symptoms questionnaire; standardised free-running exercise test or (for those with airflow obstruction) assessment of bronchodilator response to inhaled salbutamol.

RESULTS

Kappa values for four-week repeatability for the wheeze and asthma questions were 0.61 (95% CI 0.52 to 0.70) and 0.75 (0.63 to 0.87), respectively. Of the 58 people who reported wheeze in 2003 and in April 2006, only five had a positive exercise test or bronchodilator challenge (Positive Predictive Value (PPV) 0.09, 95% CI 0.01 to 0.22). Of the 12 who reported asthma in 2003 and April 2006, three had a positive result to either to exercise test or bronchodilator challenge test (PPV 0.25, 95% CI 0.05 to 0.50).

CONCLUSION

Our findings suggest that self-reported wheeze and asthma have good short-term repeatability, but do not closely reflect exercise-induced bronchospasm or bronchodilator responsiveness. The validity of questionnaire methods of studying asthma epidemiology in developing countries needs further investigation.