Does better than expected life expectancy in areas of disadvantage indicate health resilience? Stakeholder perspectives and possible explanations

Some places have better than expected health trends despite being disadvantaged in other ways. Thematic analysis of qualitative data from stakeholders (N = 25) in two case studies of disadvantaged local authorities the North West and South East of England assessed explanations for the localities' apparent health resilience. Participants identified ways of working that might contribute to improved life expectancy, such as partnering with third sector, targeting and outcome driven action. Stakeholders were reluctant to assume credit for better-than-expected health outcomes. External factors such as population change, national politics and finances were considered crucial. Local public health stakeholders regard their work as important but unlikely to cause place-centred health resilience.

Validation of a Simple Clinical Tool for Screening of Acute Lacunar Stroke - a substudy of the WAKE-UP trial

INTRODUCTION

Lacunar stroke represents around a quarter of all ischemic strokes, however, their identification with Computed Tomography in the hyperacute setting is challenging. We aimed to validate a clinical score to identify lacunar stroke in the acute setting, independently, with data from the WAKE-UP trial using magnetic resonance imaging.

METHODS

We analysed data from the WAKE-UP trial and extracted Oxfordshire Community Stroke Project (OCSP) classification. Lacunar score was defined by NIHSS<7 and OCSP lacunar syndrome. Assessment of lacunar infarct by two independent investigators was blinded to clinical data. We calculated sensitivity, specificity, negative and positive predictive value (NPV and PPV, respectively) of lacunar score.

RESULTS

We included 503 patients in the analysis, mean (±SD) age 65.2 (±11.6), 325 (65%) males, median (IQR) NIHSS=6 (4-9); 108 (22%) lacunar infarcts were identified on MR, patients fulfilling lacunar score criteria were 120 (24%), of which 47 (44%) had a lacunar infarct. Lacunar score correctly identified 322 (82%) of patients without lacunar infarct. Patients with lacunar score had lower NIHSS (4 vs 7,p<0.001), higher systolic (157 mmHg vs 151 mmHg,p=0.001) and diastolic (86 mmHg vs 83 mmHg,p=0.013) blood pressure and smaller infarct volume (2.4 ml vs 9.5 ml,p<0.001). Performance of lacunar score was: sensitivity 0.44; specificity 0.82; PPV 0.39; NPV 0.84; accuracy 0.73. Assuming a prevalence of lacunar stroke of 13%, PPV lowered to 0.30 but NPV was 0.90. Lacunar score performed better for supratentorial lacunar infarcts.

CONCLUSIONS

Lacunar score had a very good specificity and NPV for screening of lacunar stroke. Implementation of this simple tool into clinical practice may help hyperacute management and guide patient selection in clinical trials.

Improving Strength and Fatigue Resistance in Post-Polio Syndrome Individuals with REAC Neurobiological Treatments

Post-Polio Syndrome (PPS) is a chronic condition characterized by the emergence of new symptoms and functional decline in individuals who previously had polio. Despite advances in medical understanding, management of PPS remains challenging. This study aimed to evaluate the use of neurobiological modulation treatments using Radio Electric Asymmetric Conveyer (REAC) technology on fatigue and muscle strength. An open-label study was conducted with 17 patients submitted to four neuromodulation protocols: Neuro Postural Optimization (NPO), Neuro Psycho Physical Optimization (NPPO), Neuro Psycho Physical Optimization-Cervico Brachial (NPPO-CB), and Neuromuscular Optimization (NMO). The Time Up and Go (TUG) test, Handgrip Strength Test, and Revised Piper Fatigue Scale (RPFS) were used to assess participants' fatigue and muscle strength, being applied at the beginning and end of each protocol. The results obtained from the improvement in strength, physical endurance, and particularly the RPFS behavioral dimension, affective dimension, and psychological sensory dimension, through the utilization of REAC neurobiological modulation treatments, highlight this correlation. These results suggest that these treatments could be considered as a potential therapeutic approach for PPS.

Intersectionality and public understandings of health inequity in England: learning from the views and experiences of young adults

OBJECTIVES

Attempts to reduce health inequities in England frequently prioritise some equity dimensions over others. Intersectionality highlights how different dimensions of inequity interconnect and are underpinned by historic and institutionalised power imbalances. We aimed to explore whether intersectionality could help us shed light on young adults' understanding of health inequities.

STUDY DESIGN

The study incorporatedqualitative thematic analysis of primary data.

METHODS

Online focus groups with young adults (n = 25) aged 18-30 living in three English regions (Greater London; South Yorkshire/Midlands; North-East England) between July 2020 and March 2021. Online semistructured interviews (n = 2) and text-based communication was conducted for participants unable to attend online groups.

RESULTS

Young adults described experiencing discrimination, privilege, and power imbalances driving health inequity and suggested ways to address this. Forms of inequity included cumulative, within group, interacting, and the experience of privilege alongside marginalisation. Young adults described discrimination occurring in settings relevant to social determinants of health and said it adversely affected health and well-being.

CONCLUSION

Intersectionality, with its focus on discrimination and identity, can help public health stakeholders engage with young adults on health equity. An upstream approach to improving health equity should consider multiple and intersecting forms of discrimination along with their cultural and institutional drivers.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review

Introduction

Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption.

Methods

A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each.

Results

366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences.

Conclusion

NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Improving Functional Capacity and Quality of Life in Parkinson's Disease Patients through REAC Neuromodulation Treatments for Mood and Behavioral Disorders

Parkinson's disease is a neurological disorder that affects both motor and non-motor functions, including depression, anxiety, and cognitive decline. Currently, it remains a challenge to distinguish the correlation between these aspects and their impact on one another. To try to clarify these reciprocal influences, in this study we have used specific radio electric asymmetric conveyer (REAC) technology neuromodulation treatments for behavioral mood disorders and adjustment disorders. In particular, we employed the neuro-postural optimization (NPO) and neuro-psycho-physical optimization (NPPOs) treatments. The study enrolled randomly 50 subjects of both genders previously diagnosed with Parkinson's disease for at least six months. Prior to and following REAC NPO and NPPOs treatments, we assessed the subjects using functional dysmetria (FD) evaluation, five times sit to stand test (FTSST) for postural stability, and the 12-item Short-Form Health Survey (SF-12) for quality of life (QLF) evaluation. The positive results produced by the REAC NPO and NPPOs neuromodulation treatments, specific for mood and adaptation disorders, on dysfunctional motor disorders, and quality of life confirm how the non-motor components can condition the symptomatology of Parkinsonian motor symptoms. These results also highlight the usefulness of REAC NPO and NPPOs treatments in improving the overall quality of life of these patients.

Regenerative Radio Electric Asymmetric Conveyer Treatment in Generalized Cerebral and Cerebellar Atrophy to Improve Motor Control: A Case Report

This report presents a case with a diagnosis rarely described in the literature, that is generalized cerebral-cerebellar atrophy. The patient showed a rapid decline with general cognitive deterioration, memory loss, temporal and spatial disorientation, and ataxic manifestations in voluntary movements. The loss of neurons and synaptic connections can be explained by an alteration of the correct endogenous bioelectrical activity (EBA), the phenomenon which allows all the processes of cellular life, such as differentiation, proliferation, migration, morphogenesis, apoptosis, and neurotransmission. The patient was treated with a specific regenerative neurobiological stimulation treatment applied with the radio electric asymmetric conveyer (REAC) technology, which was designed to recover the correct EBA. The tissue optimization regenerative (TO RGN) treatments used in this case report have already demonstrated the ability to induce neuroregenerative processes. At the follow-up, the patient showed a reduction in ataxia both in walking and running. This case report allows us to learn that the manipulation of the EBA can induce improvements even in clinical cases in which the scientific literature leaves no room for improvement.

Radio Electric Asymmetric Conveyer (REAC) Neurobiological Stimulation Treatments in Dysfunctional Motor Behavior in Flail Arm Syndrome: A Case Report

Flail arm syndrome (FAS) is a variant of amyotrophic lateral sclerosis (ALS) that manifests itself with the progressive loss of motor control of the upper limbs starting from the proximal part. Both electrophysiological and magnetic resonance studies have shown that functional alterations in the subcortical structures, cerebellum, and cortex are present in this pathology. These alterations appear to play a significant component in determining cognitive, motor, and behavioral effects.

To try to modulate these alterations, in this case report, we used three noninvasive and specific neuromodulation treatments of the Radio Electric Asymmetric Conveyer (REAC) technology. The Neuro Postural Optimization (NPO), the Neuro Psycho Physical Optimization (NPPO), and the Neuro Psycho Physical Optimization Cervico-Brachial (NPPO-CB) with the aim of improving motor control, depression, anxiety, and stress. At the end of the treatment cycle that lasted five consecutive days, the patient regained the ability to raise his arms, a capacity he had lost for several months. This case demonstrates that REAC neurobiological modulation treatments aimed at improving dysfunctional neuropsychomotor behavior (DNPMB) can be useful in highlighting and reducing these components, allowing for better evaluation of the real neurodegenerative damage and determination of a better quality of life for these patients.

A Framing Analysis of Consultation Submissions on the WHO Global Strategy to Reduce the Harmful Use of Alcohol: Values and Interests

BACKGROUND

In response to the magnitude of harms caused by alcohol, the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol (GAS) was endorsed in 2010. We analysed submissions to the 2019 WHO consultation on the implementation of the GAS to identify how different stakeholders frame alcohol use and control; and to assess how stakeholders engage with the consultation process, with possibly harmful consequences for public health policy.

METHODS

All submissions from WHO Member States, international organisations, non-governmental organisations (NGOs), academic institutions and private sector entities were identified and used as data for an inductive framing analysis. This involved close reading and data familiarisation, thematic coding and identifying emergent framings. Through the analysis of texts, framing analysis can give insights into the values and interests of stakeholders. Because framing influences how issues are conceptualised and addressed, framing analysis is a useful tool to study policy-making processes.

RESULTS

We identified 161 unique submissions and seven attachments. Emerging frames were grouped according to their function: defining the problem, assigning causation, proposing solutions, or justifying and persuading. Submissions varied in terms of the framing they deployed and how this was presented, eg, how the problem was defined. Proposed policy solutions also varied. Targeted solutions emphasising individual responsibility tended to be supported by industry and some Member States. Calls for universal regulation and global mobilisation often came from NGOs and academia. Stakeholders drew on evidence and specific value systems to support the adoption of certain problem and solution ideas and to oppose competing framing.

CONCLUSION

Alcohol control is a contested policy field in which different stakeholders use framing to set the agenda and influence what policy solutions are considered legitimate. WHO should consider which interests are served by these different framings and how to weigh different stakeholders in the consultation process.

Public-Private Partnerships With Unhealthy Commodity Industries: Are They Undermining Real Progress in Non-communicable Disease Prevention? Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

Public-private partnerships (PPPs) and whole-of-society approaches are increasingly common in public health promotion and non-communicable disease (NCD) prevention, despite a lack of evidence in favour of their effectiveness in improving health outcomes. While PPPs may have advantages, they also give industry actors more influence over the design and implementation of public health strategies and interventions. Partnering with unhealthy commodity industries in particular - including the alcohol and ultra-processed food and beverages industries - can pose significant risks to public health due to these industries' deep-rooted conflicts of interest. In this commentary, I reiterate Suzuki and colleagues' message about the importance of assessing and managing conflicts of interest before engaging with non-state actors through PPPs or other forms of engagement.

Long-Lasting Efficacy of Radio Electric Asymmetric Conveyer Neuromodulation Treatment on Functional Dysmetria, an Adaptive Motor Behavior

Background

Fluctuating asymmetry (FA) is widely defined as the deviation from perfect bilateral symmetry and is considered an epigenetic measure of environmental stress. Rinaldi and Fontani hypothesized that the FA morpho-functional changes originate from an adaptive motor behavior determined by functional alterations in the cerebellum and neural circuits, not caused by a lesion, but induced by environmental stress. They called this phenomenon functional dysmetria (FD). On this premise, they developed the radio electric asymmetric conveyer (REAC) technology, a neuromodulation technology aimed at optimizing the best neuro-psycho-motor strategies in relation to environmental interaction.

Aims

Previous studies showed that specific REAC neuro postural optimization (NPO) treatment can induce stable FD recovery. This study aimed to verify the duration of the NPO effect in inducing the stable FD recovery over time.

Materials and methods

Data were retrospectively collected from a population of 29,794 subjects who underwent a specific semiological FD assessment and received the NPO treatment, regardless of the pathology referred.

Results

The analysis of the data collected by the various participants in the study led us to ascertain the disappearance of FD in 100% of the cases treated, with a stability of the result detected up to 18 years after the single administration of the REAC NPO treatment.

Conclusions

The REAC NPO neurobiological modulation treatment consisting of a single administration surprisingly maintains a very long efficacy in the correction of FD. This effect can be explained as the long-lasting capacity of the NPO treatment to induce greater functional efficiency of the brain dynamics as proven in previous studies.

An automated algorithm minimising ATP failure: re-initiation to enhance anti-tachycardia pacing efficacy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

Re-initiation is an important mechanism of anti-tachycardia pacing (ATP) failure, whereby VT is first terminated by the initial ATP application, before being re-initiated by successive pulses. Current ICD designs are able to measure and store electrograms (EGMs) for detecting and classifying arrhythmias, which contain information that may also be used during ATP application. Developing an algorithm that automatically processes EGMs during ATP, with the goal of detecting the initial VT termination and truncating subsequent ATP pulses (which has the potential to re-initiate), may thus increase ATP efficacy.

Purpose

To develop a proof-of-concept ATP detection algorithm: Early Termination Detection Algorithm (ETDA), to automatically sense the signs of early VT termination and cease further ATP pulses based on real-time sensed EGMs from implanted devices.

Methods

A cohort of 7 porcine infarcted ventricular computational models were subject to virtual induction protocols to induce sustained VTs. Functional model properties were adjusted to provide 73 unique VT episodes (260≤VT cycle length (CL)≤480ms). For each episode, burst ATP was delivered from typical pacing sites near the right ventricle (RV) septum to evaluate its efficacy. The ATP failures and their failure mechanisms were identified, accordingly. During ATP application, five common sensing EGM vectors from implanted devices were recovered from simulations including can-to-Superior vena cava (SVC) coil, can-to-RV ring, SVC coil-to-RV coil ring, RV coil tip-to-RV coil ring and LV coil at the lateral base-to-RV tip. Our proposed ETDA utilises those EGMs for VT termination detection. Specifically, correlation coefficients (CCs) of the EGMs between two successive ATP pulses were calculated and averaged to identify sudden changes in EGM morphology that indicate VT termination (Fig A). A discriminating threshold on the CCs was chosen by comparing all re-initiation cases with detailed analysis of the actual VT termination time observed from simulation results. ETDA was then applied to all cases to identify initial termination and improvement in efficacy.

Results

Before ETDA application, ATP terminated 42 cases (58%, Fig C), with re-initiation attributing to 11 (35%) of ATP failures. Application of ETDA accurately detected VT termination in 91% of re-initiated cases, 90% of terminated cases and 81% of not-terminated cases (Fig B), which enhanced the overall ATP efficacy to 71% (P=0.08) (Fig C).

Conclusions

The real-time EGMs measured from standard ICD/CRT-D devices may be used to improve ATP efficacy through an approach such as ETDA. ETDA detects signs of early termination automatically in real time which enables identification of successful VT termination, truncating subsequent pulses that may re-initiate the VT, which enhances overall ATP efficacy.

In silico study of anti-tachycardia pacing efficacy optimisation through scar-targeted stimulation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

Anti-tachycardia pacing (ATP) is a reliable electrotherapy to painlessly terminate ventricular tachycardia (VT). However, ATP is often ineffective, particularly for fast VTs, which is often due to the inability of paced wavefronts to reach the re-entrant circuit, because of functional or anatomical barriers. It is thought that efficacy may be enhanced by optimised delivery closer to the re-entrant circuit driving the VT.

Purpose

To quantitatively assess the dependence of ATP efficacy upon different delivery locations with respect to the re-entrant circuit.

Methods

A cohort of 7 porcine ventricular infarct computational models were generated based on in vivo magnetic resonance imaging. Rapid-pacing protocols were applied to the cohort to induce VTs. Functional model parameters were adjusted to produce 73 episodes of sustained monomorphic VT, including 32 fast VTs (cycle length (CL)≤320ms) and 41 slow VTs (320ms-&lt;VTCL≤&lt;VTCL≤&gt;480ms). Burst ATP (2 sequences of 8 pulses at 88% of VTCL) was separately delivered from 3 locations proximal to the re-entrant circuit (along the RV septum), specifically within the critical isthmus (CI), and at the Exit and Entrance sites, along with 3 locations distal to the circuit (lateral/posterior LV), based on multipolar implanted devices with LV epicardial leads, constituting 438 virtual scenarios and efficacy compared (Fig A).

Results

ATP efficacy was significantly higher for slow VTs than for fast VTs (65% vs 46%, P=0.00004) (Fig B). Separate analysis of slow VT cases revealed that delivering from distal locations to the re-entrant circuit was significantly more effective than delivering from proximal locations (72% vs 59%, P=0.04). However, for fast VT cases, the trend was reversed with proximal application (41%) being more effective than distal application (51%, P=0.15) (Fig B). Moreover, individual analysis on specific proximal locations revealed that in slow VT cases, delivering at the Exit site of VT was significantly less efficient than delivering at the Entrance site (46% vs 73%, P=0.01), with a similar (although non-significant) trend also being seen for fast VTs (44% vs 53%, P=0.5) (Fig C). Moreover, for fast VT cases, ATP delivery within the CI was overall the most effective (56%) than all other locations while this trend was not seen in slow VT cases.

Conclusions

ATP delivery proximal to the re-entrant circuit improves efficacy in fast VTs, but less so in slow VTs, where delivering from distal sites is superior. Specifically, for fast VTs, ATP delivery within the CI is the most effective. This work suggests that real-time alteration in applied ATP delivery site choice in a multipolar device (guided by the sensed VT rate by the device prior to therapy delivery) may be beneficial. Combined with the state-of-art leadless pacing technology, this also provides a clinical opportunity for patient-specific ATP delivery configuration and programming.

In-silico optimisation of ICD defibrillation efficacy by modifying lead/can configurations using a cohort of high-resolution whole-torso heart models

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

ICD is an effective direct therapy against VT/VF by applying a strong electrical shock across the heart between the shocking coil and can. Conventionally, patients will have a shocking coil inside the right ventricle (RV) and a can at the upper left chest. However, due to infections or other conditions, the can may need to place towards the right chest. The placement of the RV coil may also vary in different cases, for example avoiding scar. However, it is unclear how defibrillation efficacy may be altered by these unavoidable modifications to conventional lead/can configurations and whether optimisation may be possible.

Purpose

To compare defibrillation efficacy of modifications of ICD configurations in a cohort of whole-torso models.

Methods

A cohort of 15 whole torso models was generated from high resolution CT data and contrast CT cardiac scans, including 5 dilated cardiomyopathy (DCM), 5 hypertrophic cardiomyopathy (HCM) and 5 structurally normal patients (Fig A). Transvenous ICDs were represented by a shocking coil inside the RV (near apex) and a (ground) can at the upper left chest as default settings. Configurations were then varied by moving the can to the right chest, moving the RV coil up the mid-septum or adding extra grounds (Superior Vena Cava (SVC) coil, coronary sinus (CS) coil (Fig A)). Defibrillation-strength shocks were applied to all models (Fig B). DFTs and mean electrical field were evaluated across the whole heart as well as specific LV, RV, RV insertion regions, along with overall impedance.

Results

Shifting the can from left to right significantly increased DFT for the whole heart (23 J vs 15 J, P=0.03) and LV (25 J vs 17 J, P=0.03) (Fig C) and reduced the mean electrical field. Moving the RV coil further up the septum did not significantly alter DFT (Fig D), but did reduce mean electrical field for all regions and reduce impedance significantly. Additional separate coils significantly reduced DFT for all regions (Fig D) by increasing mean electrical field, whilst adding both coils significantly reduced DFT the most (whole heart: 15 J vs 6 J, P=0.03) (Fig E). Impedance was increased significantly by adding SVC coil, but reduced significantly by adding CS coil. Adding both coils increased impedance slightly.

Conclusions

Although a right-sided can increases DFT by over 50%, additional leads (grounds) may mitigate this increase by increasing mean electrical field. Moving the RV coil closer to the mid-septum reduces DFT slightly, but also reduces mean electrical field and impedance significantly.

Understanding the Online Environment for the Delivery of Food, Alcohol and Tobacco: An Exploratory Analysis of 'Dark Kitchens' and Rapid Grocery Delivery Services

Online spaces are increasingly important in the sale of food, alcohol and tobacco. This analysis focuses on two developments in online food delivery: delivery-only 'dark kitchens' and rapid grocery delivery services (RGDS), with the aim to understand and assess the availability of health harming and health promoting products through these services. Data was collected for one metropolitan local authority in London, UK, using publicly available online sources. Being explorative in nature, the analysis includes descriptive statistics and qualitative assessment. Three dark kitchens (renting kitchens to 116 food businesses), three grocery delivery apps, and 76 grocery businesses available through online delivery platforms were identified. Most businesses renting dark kitchen space were 'virtual restaurants' (52%) selling fast food (47%) or dessert (21%) through online delivery platforms. RGDS sold a variety of items, with a focus on pre-packaged foods high in fat, salt and sugar, alcoholic beverages and tobacco. These items were also most likely to be promoted through offers and promotional language. Fruits and vegetables were less commonly available and mainly on grocery delivery apps. Online delivery services increase the temporal and geographic availability and promotion of many unhealthy products. Research expanding on the geographic area of interest is needed.

Noncontrast Computed Tomography Markers of Cerebral Hemorrhage Expansion: Diagnostic Accuracy Meta-Analysis

BACKGROUND AND PURPOSE

Assess the diagnostic accuracy of noncontrast computed tomography (NCCT) markers of hematoma expansion in patients with primary intracerebral hemorrhage.

METHODS

We performed a meta-analysis of observational studies and randomized controlled trials with available data for calculation of sensitivity and specificity of NCCT markers for hematoma expansion (absolute growth >6 or 12.5 mL and/or relative growth >33%). The following NCCT markers were analyzed: irregular shape, island sign (shape-related features); hypodensity, heterogeneous density, blend sign, black hole sign, and swirl sign (density-related features). Pooled accuracy values for each marker were derived from hierarchical logistic regression models.

RESULTS

A total of 10,363 subjects from 23 eligible studies were included. Significant risk of bias of included studies was noted. Hematoma expansion frequency ranged from 7% to 40%, mean intracerebral hemorrhage volume from 9 to 27.8 ml, presence of NCCT markers from 9% (island sign) to 82% (irregular shape). Among shape features, sensitivity ranged from 0.32 (95%CI = 0.20-0.47) for island sign to 0.68 (95%CI = 0.57-0.77) for irregular shape, specificity ranged from 0.47 (95%CI = 0.36-0.59) for irregular shape to 0.92 (95%CI = 0.85-0.96) for island sign; among density features sensitivity ranged from 0.28 (95%CI = 0.21-0.35) for black hole sign to 0.63 (95%CI = 0.44-0.78) for hypodensity, specificity ranged from 0.65 (95%CI = 0.56-0.73) for heterogeneous density to 0.89 (95%CI = 0.85-0.92) for blend sign.

CONCLUSION

Diagnostic accuracy of NCCT markers remains suboptimal for implementation in clinical trials although density features performed better than shape-related features. This analysis may help in better tailoring patients' selection for hematoma expansion targeted trials.

Applying a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in the 21st century: a scoping review

BACKGROUND AND AIMS

A complex systems perspective has been advocated to explore multi-faceted factors influencing public health issues, including alcohol consumption and associated harms. This scoping review aimed to identify studies that applied a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in order to summarize their characteristics and identify evidence gaps.

METHODS

Studies published between January 2000 and September 2020 in English were located by searching for terms synonymous with 'complex systems' and 'alcohol' in the Scopus, MEDLINE, Web of Science and Embase databases, and through handsearching and reference screening of included studies. Data were extracted on each study's aim, country, population, alcohol topic, system levels, funding, theory, methods, data sources, time-frames, system modifications and type of findings produced.

RESULTS

Eighty-seven individual studies and three systematic reviews were identified, the majority of which were conducted in the United States or Australia in the general population, university students or adolescents. Studies explored types and patterns of consumption behaviour and the local environments in which alcohol is consumed. Most studies focused on individual and local interactions and influences, with fewer examples exploring the relationships between these and regional, national and international subsystems. The body of literature is methodologically diverse and includes theory-led approaches, dynamic simulation models and social network analyses. The systematic reviews focused on primary network studies.

CONCLUSIONS

The use of a complex systems perspective has provided a variety of ways of conceptualizing and analyzing alcohol use and harm prevention efforts, but its focus ultimately has remained on predominantly individual- and/or local-level systems. A complex systems perspective represents an opportunity to address this gap by also considering the vertical dimensions that constrain, shape and influence alcohol consumption and related harms, but the literature to date has not fully captured this potential.

Perpendicularly magnetized Co/Pd-based magneto-resistive heterostructures on flexible substrates

Flexible magneto-resistive heterostructures have received a great deal of attention over the past few years as they allow for new product paradigms that are not possible with conventional rigid substrates. While the progress and development of systems with longitudinal magnetic anisotropy on non-planar substrates has been remarkable, flexible magneto-resistive heterostructures with perpendicular magnetic anisotropy (PMA) have never been studied despite the possibility to obtain additional functionality and improved performance. To fill this gap, flexible PMA Co/Pd-based giant magneto-resistive (GMR) spin-valve stacks were prepared by using an innovative transfer-and-bonding strategy exploiting the low adhesion of a gold underlayer to SiO _x /Si(100) substrates. The approach allows overcoming the limits of the direct deposition on commonly used polymer substrates, whose high surface roughness and low melting temperature could hinder the growth of complex heterostructures with perpendicular magnetic anisotropy. The obtained PMA flexible spin-valves show a sizeable GMR ratio (∼1.5%), which is not affected by the transfer process, and a high robustness against bending as indicated by the slight change of the magneto-resistive properties upon bending, thus allowing for their integration on curved surfaces and the development of a novel class of advanced devices based on flexible magneto-resistive structures with perpendicular magnetic anisotropy. Besides endowing the family of flexible electronics with PMA magneto-resistive heterostructures, the exploitation of the results might apply to high temperature growth processes and to the fabrication of other functional and flexible multilayer materials engineered at the nanoscale.

A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe

BACKGROUND

In light of worrying public health developments such as declining life expectancy gains and increasing health inequalities, there is a heightened interest in the relationship between politics and health. This scoping review explores the possible welfare policy consequences of populist radical right (PRR) parties in Europe and the implications for population health. The aim is to map the available empirical evidence regarding the influence of PRR parties on welfare policy reforms and to understand how this relationship is mediated by political system characteristics in different countries.

METHODS AND ANALYSIS

A scoping review of peer-reviewed empirical literature addressing the relationship between PRR parties, political systems and welfare policy in Europe was performed using the methodology by the Joanna Briggs Institute. Data was charted on main study characteristics, concepts and relevant results, after which a qualitative content analysis was performed. The data was categorised according to the political system characteristics: constitution, political economy, interest representation and partisanship. Five expert interviews were conducted for validation purposes. Early evidence from 15 peer-reviewed articles suggests that exclusionary welfare chauvinistic positions of PRR parties are likely to have negative effects on the access to welfare provisions and health of vulnerable population groups. Differences in implementation of welfare chauvinistic policy reforms are partly explained by mediation of the constitutional order (judicial institutions at national and European Union [EU] level), political economy (healthcare system funding and European single market) and partisanship (vote-seeking strategies by PRR and mainstream parties). No clear evidence was found regarding the influence of interest representation on welfare chauvinistic policies.

DISCUSSION

While early evidence suggests that the welfare chauvinistic ideology of PRR parties is harmful for public health, the possible mediating role of political system characteristics on PRR welfare policy influence offers risk and protective factors explaining why the PRR ideology plays out differently across Europe.

Blood-Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis

Introduction: Hemorrhagic transformation (HT) is a complication of reperfusion therapy for acute ischemic stroke. Blood–brain barrier (BBB) disruption is a crucial step toward HT; however, in clinical studies, there is still uncertainty about this relation. Hence, we conducted a systematic review and meta-analysis to summarize the current evidence.

Methods: We performed systematic review and meta-analysis of observational studies from January 1990 to March 2020 about the relation between BBB disruption and HT in patients with acute ischemic stroke with both computed tomography (CT) and magnetic resonance (MR) assessment of BBB. The outcome of interest was HT at follow-up imaging evaluation (within 48 h from symptom onset). We pooled data from available univariate odds ratios (ORs) in random-effects models with DerSimonian–Laird weights and extracted cumulative ORs.

Results: We included 30 eligible studies (14 with CT and 16 with MR), N = 2,609 patients, with 88% and 70% of patients included in CT and MR studies treated with acute stroke therapy, respectively. The majority of studies were retrospective and had high or unclear risk of bias. BBB disruption was measured with consistent methodology in CT studies, whereas in MR studies, there was more variability. All CT studies provided a BBB disruption cutoff predictive of HT. Four CT and 10 MR studies were included in the quantitative analysis. We found that BBB disruption was associated with HT with both CT (OR = 3.42; 95%CI = 1.62–7.23) and MR (OR = 9.34; 95%CI = 3.16–27.59). There was a likely publication bias particularly for MR studies.

Conclusion: Our results confirm that BBB disruption is associated with HT in both CT and MR studies. Compared with MR, CT has been more uniformly applied in the literature and has resulted in more consistent results. However, more efforts are needed for harmonization of protocols and methodology for implementation of BBB disruption as a neuroradiological marker in clinical practice.

Epilepsy with auditory features: Contribution of known genes in 112 patients

Epilepsy with Auditory Features (EAF) is a focal epilepsy syndrome mainly of unknown aetiology. LGI1 and RELN have been identified as the main cause of Autosomal Dominant EAF and anecdotally reported in non-familial cases. Pathogenic variants in SCN1A and DEPDC5 have also been described in a few EAF probands belonging to families with heterogeneous phenotypes and incomplete penetrance. We aimed to estimate the contribution of these genes to the disorder by evaluating the largest cohort of EAF. We included 112 unrelated EAF cases (male/female: 52/60) who underwent genetic analysis by next-generation sequencing (NGS) techniques. Thirty-three (29.5%) were familial cases. We identified a genetic diagnosis for 8% of our cohort, including pathogenic/likely pathogenic variants (4/8 novel) in LGI1 (2.7%, CI: 0.6-7.6); RELN (1.8%; CI: 0.2-6.3); SCN1A (2.7%; CI: 0.6-7.6) and DEPDC5 (0.9%; CI 0-4.9).This study shows that the contribution of each of the known genes to the overall disorder is limited and that the genetic background of EAF is still largely unknown. Our data emphasize the genetic heterogeneity of EAF and will inform the diagnosis and management of individuals with this disorder.

First-phase ejection fraction predicts response to cardiac resynchronization therapy and adverse outcomes

Background

Cardiac Resynchronization Therapy (CRT) is an important therapeutic treatment for chronic heart failure. However, even in carefully selected cases up to 40% of patient fail to respond. First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction, is a novel and more sensitive echocardiographic measure of early systolic function.

Purpose

We examined the value of EF1, to predict response to CRT and clinical outcomes after CRT.

Methods

We analysed echocardiograms from 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes.

Results

Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% vs. 12.1%, for those with EF1 in the highest vs. lowest tertiles (p&lt;0.001). A cut-off value of 11.9% for EF1 had &gt;85% sensitivity and specificity for prediction of response to CRT; on multivariate logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (OR: 1.563, 95% CI: 1.371–1.782, p&lt;0.001) (table 1). EF1 was also the strongest predictor of a clinical composite score (OR: 1.115, 95% CI: 1.044–1.191, p=0.001). Improvement in EF1 at 6 months after CRT implantation (6.5±5.8% vs 1.8±4.3% in responders vs. non-responders, p&lt;0.001) was the best predictor of heart failure re-hospitalization and death after median follow-up of 29.2 months (HR: 0.819, 95% CI:0.765–0.876, p&lt;0.001).

Conclusion

EF1 is a promising marker to identify patients likely to respond to CRT and most likely provides a measure of myocardial viability that determines response.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Wellcome/EPSRC Centre for Medical Engineering

Stress levels among workers: an observational study

Introduction

While some stress is a common part of everyday work for most people, higher or prolonged levels of stress might be harmful. Work-related stress is becoming a study subject because of its important implications: it is related to coronary heart disease and health in general and it also influences employee satisfaction and productivity. Because of this, workers should be aware of their stress levels in order to prevent disease and increase performance levels. Therefore, the aim of our study was to evaluate stress levels among employees.

Methods

We conducted an observational study in collaboration with Anteo, an onlus society based in Biella which employs more than 1000 workers. The first step of our study ran from December 2019 to February 2020, and included 300 workers. Informed consent was gathered trough structure chiefs prior to the intervention. We administered an online questionnaire based on the Kessler Psychological Distress Scale (K10) for screening than, subjects with a high perceived stress level were invited for a personal interview with our medical and psychological staff.

Results

The response rate was 31% with 94 questionnaires completed by the end of February 2020. 80% of respondents were women (75 out of 94). 17% of the employees presented a moderate to high level of stress (16 total, 72% women). Only 5% of workers presented a high level of stress (4 total, 50% women). All Patients presenting a high level of perceived stress went through medical and psychological evaluation, which confirmed the results in 88% cases (14 out of 16).

Conclusions

Our study evidenced that workers are often exposed to high levels of stress, which can influence health, everyday life as well as productivity. The introduction of stress management programs in companies could improve workers health and productivity having a positive impact on one's health, company productivity and society in general.

Key messages

The introduction of stress management programs might improve workers health and productivity. The introduction of stress management programs might have a positive impact on one’s health, company productivity and society in general.

The Netherlands

Background

While the literature on the relationship between populist radical right (PRR) parties and public health is still relatively scarce, early evidence suggests that PRR parties and their exclusionary policy agenda could be a threat to population health and health equity. The aim of this case study is to take a closer look at the standpoints and influence of the Dutch Party for Freedom (PVV) on national health and healthcare policies. The PVV is considered the main PRR party in the Netherlands and has been part of the 2010-2012 center-right coalition government.

Methods

This case study was informed by various information sources including academic literature, publicly available data, party manifestos and other statements issued by the PVV, coalition agreements, newspaper articles and interviews.

Results

Two key characteristics of PRR parties can be identified in relation to the PVV's standpoints on health and healthcare: authoritarianism (believing in the value of obeying and valuing authority) and nativism (believing that there is an ethnically united people with a territory). This is, for example, exemplified through strong support for the expansion of home and elderly care, while simultaneously opposing free, non-acute healthcare for refugees and asylum seekers who have not (yet) financially contributed to the healthcare system.

Conclusions

Health and healthcare are generally not priority issues for the PVV, whose political agenda tends to focus on immigration and law and order. While the party takes a leftist position on some aspects of the healthcare system, a nativist rhetoric remains present.

Defensive practices among non-medical health professionals: An overview of the scientific literature

INTRODUCTION

Defensive medicine (DM) is used when a doctor deviates from good practices to prevent complaints from patients or caregivers. This is a structured phenomenon that may not only affect the physician, but all healthcare personnel. The aim of this review was to determine whether DM is also performed by Non-Medical Health Professionals (NMHP), and the reasons, features, and effects of NMHP-DM.

MATERIALS AND METHODS

The review was conducted according to PRISMA guidelines, and specific inclusion criteria were used to search for relevant documents published up to 12 April 2018 in the main biomedical databases.

RESULTS

A total of 91 potentially relevant studies were identified. After the removal of duplicates, 72 studies were screened for eligibility, separately by two of the authors. Finally, 14 qualitative and quantitative studies were considered relevant for the purpose of the present review. These last studies were assessed for their methodological quality.

CONCLUSIONS

NMHP-DM is quite similar to DM practiced by doctors, and is mainly caused by fear of litigation. Midwives and nursing personnel practiced both active and passive DM, such as over-investigation, over-treatment, and avoidance of high-risk patients. NMHP-DM could increase risks for patient health, costs, risk of burnout for healthcare employees. Further studies are needed to better understand prevalence and features of NMHP-DM in all health professional fields, in order to apply appropriate preventive strategies to contrast DM among health care personnel.

Radio electric asymmetric conveyer neuromodulation in depression, anxiety, and stress

BACKGROUND

The purpose of this study was to assess the efficacy of specific neuromodulation treatments performed with radio electric asymmetric conveyer (REAC) technology in the treatment of the symptomatic triad depression, anxiety, and stress by the use of a specific psychometric test such as the Depression Anxiety Stress Scale-42 items (DASS-42) version, which assesses simultaneously the severity of expression of this triad.

PATIENTS AND METHODS

The design of this study was planned to compare two populations that performed DASS-42 test twice within a similar period of time. The first population performed the first DASS test before the treatment and the second test about 3 months later, at the end of two specific REAC neuromodulation treatments, neuropostural optimization (NPO) and neuropsychophysical optimization (NPPO), that have previously shown an efficacy in the treatment of depression, anxiety and stress. The second population (untreated), used as the randomized control group, consisted of a similar group by gender and age, who performed the DASS-42 test in an online platform twice, with an interval of about 3 months between the first and second tests, similar to the interval between the two tests in the treated group.

RESULTS

The comparison between the treated group and the control group points out the REAC treatment efficacy in improving the quality of life. At the second DASS-42 test, self-administered about 3 months after the treatments, treated patients were positioned on average values of much milder severity in all the three clusters, depression, anxiety, and stress, while in untreated patients there was no significant difference between the mean values of the first and second DASS tests.

CONCLUSION

The results obtained in this study, evaluated with the DASS-42 test, confirm that REAC-NPO and REAC-NPPO neuromodulation treatments can be useful tools for the clinical treatment of depression, anxiety, and stress, as already proven by previous results evaluated with different psychometric tests.

Macrophages escape Klotho gene silencing in the mdx mouse model of Duchenne muscular dystrophy and promote muscle growth and increase satellite cell numbers through a Klotho-mediated pathway

Duchenne muscular dystrophy (DMD) is a muscle wasting disease in which inflammation influences the severity of pathology. We found that the onset of muscle inflammation in the mdx mouse model of DMD coincides with large increases in expression of pro-inflammatory cytokines [tumor necrosis factor-α (TNFα); interferon gamma (IFNγ)] and dramatic reductions of the pro-myogenic protein Klotho in muscle cells and large increases of Klotho in pro-regenerative, CD206+ macrophages. Furthermore, TNFα and IFNγ treatments reduced Klotho in muscle cells and increased Klotho in macrophages. Because CD206+/Klotho+ macrophages were concentrated at sites of muscle regeneration, we tested whether macrophage-derived Klotho promotes myogenesis. Klotho transgenic macrophages had a pro-proliferative influence on muscle cells that was ablated by neutralizing antibodies to Klotho and conditioned media from Klotho mutant macrophages did not increase muscle cell proliferation in vitro. In addition, transplantation of bone marrow cells from Klotho transgenic mice into mdx recipients increased numbers of myogenic cells and increased the size of muscle fibers. Klotho also acted directly on macrophages, stimulating their secretion of TNFα. Because TNFα is a muscle mitogen, we tested whether the pro-proliferative effects of Klotho on muscle cells were mediated by TNFα and found that increased proliferation caused by Klotho was reduced by anti-TNFα. Collectively, these data show that pro-inflammatory cytokines contribute to silencing of Klotho in dystrophic muscle, but increase Klotho expression by macrophages. Our findings also show that macrophage-derived Klotho can promote muscle regeneration by expanding populations of muscle stem cells and increasing muscle fiber growth in dystrophic muscle.

Finite magnetic relaxation in x-space magnetic particle imaging: Comparison of measurements and ferrohydrodynamic models

Magnetic Particle Imaging (MPI) is an emerging tomographic imaging technology that detects magnetic nanoparticle tracers by exploiting their non-linear magnetization properties. In order to predict the behavior of nanoparticles in an imager, it is possible to use a non-imaging MPI relaxometer or spectrometer to characterize the behavior of nanoparticles in a controlled setting. In this paper we explore the use of ferrohydrodynamic magnetization equations for predicting the response of particles in an MPI relaxometer. These include a magnetization equation developed by Shliomis (Sh) which has a constant relaxation time and a magnetization equation which uses a field-dependent relaxation time developed by Martsenyuk, Raikher and Shliomis (MRSh). We compare the predictions from these models with measurements and with the predictions based on the Langevin function that assumes instantaneous magnetization response of the nanoparticles. The results show good qualitative and quantitative agreement between the ferrohydrodynamic models and the measurements without the use of fitting parameters and provide further evidence of the potential of ferrohydrodynamic modeling in MPI.

The determinants of defensive medicine in Italian hospitals: The impact of being a second victim

BACKGROUND

Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear.

OBJECTIVE

To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event.

RESULTS

A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians' experience of being a second victim after an adverse event (OR=1.88; 95%CI, 1.38-2.57). Other determinants included age, years of experience, activity volume and risk of specialty.

CONCLUSIONS

Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine.

Electric field control of magnetic properties and electron transport in BaTiO₃-based multiferroic heterostructures

In this paper, we report on a purely electric mechanism for achieving the electric control of the interfacial spin polarization and magnetoresistance in multiferroic tunneling junctions. We investigate micrometric devices based on the Co/Fe/BaTiO3/La0.7Sr0.3MnO3 heterostructure, where Co/Fe and La0.7Sr0.3MnO3 are the magnetic electrodes and BaTiO3 acts both as a ferroelectric element and tunneling barrier. We show that, at 20 K, devices with a 2 nm thick BaTiO3 barrier present both tunneling electroresistance (TER = 12   ±   0.1%) and tunneling magnetoresistance (TMR). The latter depends on the direction of the BaTiO3 polarization, displaying a sizable change of the TMR from  -0.32   ±   0.05% for the polarization pointing towards Fe, to  -0.12   ±   0.05% for the opposite direction. This is consistent with the on-off switching of the Fe magnetization at the Fe/BaTiO3 interface, driven by the BaTiO3 polarization, we have previously demonstrated in x-ray magnetic circular dichroism experiments.

GLYOXALASE I A111E, PARAOXONASE 1 Q192R AND L55M POLYMORPHISMS IN ITALIAN PATIENTS WITH SPORADIC CEREBRAL CAVERNOUS MALFORMATIONS: A PILOT STUDY

It is already known that the conditions of increased oxidative stress are associated to a greater susceptibility to vascular malformations including cerebral cavernous malformations (CCMs). These are vascular lesions of the CNS characterized by abnormally enlarged capillary cavities that can occur sporadically or as a familial autosomal dominant condition with incomplete penetrance and variable clinical expression attributable to mutations in three different genes: CCM1(Krit1), CCM2 (MGC4607) and CCM3 (PDCD10). Polymorphisms in the genes encoding for enzymes involved in the antioxidant systems such as glyoxalase I (GLO I) and paraoxonase I (PON I) could influence individual susceptibility to the vascular malformations. A single nucleotide polymorphism was identified in the exon 4 of GLO 1 gene that causes an amino acid substitution of Ala for Glu (Ala111Glu). Two common polymorphisms have been described in the coding region of PON1, which lead to glutamine → arginine substitution at 192 (Q192R) and a leucine → methionine substitution at 55 (L55M). The polymorphisms were characterized in 59 patients without mutations in the CCM genes versus 213 healthy controls by PCR/RFLP methods using DNA from lymphocytes. We found that the frequency of patients carrying the GLO1 A/E genotype among the case group (56%) was four-fold higher than among the controls (14.1%). In the cohort of CCM patients, an increase in the frequency of PON192 Q/R genotype was observed (39% in the CCM group versus 3.7% in the healthy controls). Similarly, an increase was observed in the proportion of individuals with the genotype R/R in the disease group (5%) in respect to the normal healthy cohort (0.5%). Finally, the frequency of the PON55 heterozygotes L/M genotype was 29% in patients with CCMs and 4% in the healthy controls. The same trend was observed in PON55 homozygous M/M genotype frequency (CCMs 20% vs controls 10%). The present study aimed to investigate the possible association of GLO1 A111E, PON1 Q192R and L55M polymorphisms with the risk of CCMs. We found that individuals with the GLO1 A /E genotype, PON192/QR-RR genotypes and PON55/LM-MM genotypes had a significantly higher risk of CCMs compared with the other genotypes. However, because CCM is a heterogeneous disease, other additional factors might be involved in the initiation and progression of CCM disease.

Recent progress in ferrofluids research: novel applications of magnetically controllable and tunable fluids

Ferrofluids are suspensions of magnetic nanoparticles that have the attractive feature of being controlled by applied magnetic fields. Ferrofluids have been studied for decades in an ever growing number of applications that take advantage of their response to applied magnetic fields. Here, we provide a summary of recent advances in established and emerging applications of ferrofluids, including applications in optics, sensors, actuators, seals, lubrication, and static/dynamic magnetically driven assembly of structures.