The impact of COVID-19 lockdown measures on symptoms control in children with asthma: A systematic review and meta-analysis of observational cohort studies

OBJECTIVES

Reported reductions in emergency department visits and hospitalizations for asthma in previous studies have suggested a beneficial effect of the coronavirus disease of 2019 (COVID-19) lockdown measures on asthma morbidity. Nevertheless, studies relying on administrative data may overestimate the true impact of lockdowns due to changes in health-seeking behavior and reduced availability of pediatric asthma services during the pandemic. In this study, we systematically reviewed the literature and identified observational cohort studies that focused on nonadministrative data to assess the true impact of COVID-19 lockdowns on symptom control in children with asthma.

METHODS

A systematic literature search was conducted between January 2020 and August 2022 (International Prospective Register of Systematic Reviews ID: CRD42022354369). The impact of COVID-19 lockdowns across studies was expressed as a standardized mean difference (SMD) for continuous outcomes and as a summary relative risk (RR) for binary outcomes.

RESULTS

During the lockdown periods, the pooled asthma symptoms control test score (SMD: 1.99, 95% confidence interval [CI]: 0.75, 3.24, I2 : 98.4%) and the proportion of children with well-controlled asthma (RR: 1.35, 95% CI: 1.06, 1.71, I2 : 77.6%) were significantly increased. On the other hand, the pooled proportion of children with poorly controlled asthma (RR: 0.47, 95% CI: 0.38, 0.57, I2 : 0.0%) was significantly decreased.

CONCLUSIONS

During COVID-19 lockdowns, asthma symptoms and breakthrough disease exacerbations were significantly reduced in children with asthma. Further research is warranted on potential interventions aiming to enhance asthma control after the pandemic while taking into consideration their acceptability and potential tradeoffs.

Impact of the MEDEA exposure-reduction strategies on indoor air quality during desert dust storms

Background

Desert dust storms (DDS) impact the Mediterranean basin heavily, particularly in the context of climate change, reduced precipitation and increasing desertification. There is a pressing need to develop policies protecting EU citizens’ health from DDS. While Public Health authorities in affected regions commonly issue warnings, the effectiveness of recommendations to reduce exposure has not been documented.

Methods

This work is part of the wider “MEDEA” intervention studies, co-funded by LIFE 2016 Programme. Among other outcomes, the studies examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation and use of air cleaners) across homes of asthmatic schoolchildren and individuals with atrial fibrillation in Cyprus. Participants were randomized to either a control or indoor intervention group. The assessment took place in a sample of participants’ homes, during 2019 and 2021, with the collection of indoor and outdoor PM10 and PM2.5 samples, which were analyzed for mass and elemental concentrations.

Results

Indoor PM2.5 and PM10 mass and elements concentrations were significantly lower in the indoor intervention group compared to the control group, both during days with no dust (e.g., 55% and 48% reduction for PM2.5 and PM10, respectively) and days with desert dust (PM2.5: 47% and PM10: 40% reduction). In addition, the infiltration of PM2.5 and PM10 particles from the outdoor to the indoor air was significantly lower in the intervention vs. the control group (PM2.5: -55%, 95% CI: -42%, -65%; PM10: -41%, 95% CI: -61%, -12%).

Conclusions

The study assessed a realistic exposure-reduction strategy and provided first-time evidence that closing doors and windows along with air cleaners can reduce indoor exposure to DDS particles. This evidence can further inform decision-making and strategic planning for population-level mitigation of DDS health effects in Mediterranean Europe.

Key messages

Mitigating effects of desert dust storms in asthmatic children: health visitors’ perceptions, Cyprus

Background

Countries of the Mediterranean basin such as Cyprus are experiencing frequent desert dust storm (DDS) events that adversely impact children with asthma. As school health visitors (SHVs) have important role in asthma management, we examined SHVs practices and perceptions on asthma management and their level of engagement in school-based interventions to mitigate DDS- health effects.

Methods

A descriptive cross-sectional survey was conducted among SHVs across state schools in Cyprus via an anonymous questionnaire, which rated the importance of asthma management measures (10-point scale), current implementation of these practices (1=never - 5=always), and regulatory authorities’ preparedness to respond to DDS events (1-5 Likert scale).

Results

Responses from 78 of the 93 SHVs (84%), with an average work experience of 13.5 years (SD 7.3), revealed discordance between high perception of the importance of asthma management measures and their actual implementation, with poor scoring especially in assessment of asthma control (M = 2.4, SD = 1.5), tracking school absenteeism (M = 2.1, SD = 1.0) and monitoring of asthma triggers (M = 1.9, SD = 1.4). Any DDS-related measures (e.g. air quality real-time monitoring, warnings, recommendations, awareness campaigns, etc) were implemented very infrequently. Ratings of authorities’ preparedness were moderate (<3.5), and only slightly higher in the health versus the educational or other government services. SHVs who recognized the severity of DDS and potential impact on asthmatic children were more likely to support school-based interventions for DDS events (OR = 7.3, 95% CI: 2.1-25.3).

Conclusions

Asthma management practices in school settings in Cyprus are suboptimal and responses during DDS are fragmented. While SHV’s awareness and support for interventions is high, this is not reflected in current practices. A concerted effort is needed for adoption of policies and implementation of action plans for DDS within school settings.

Key messages

• Suboptimal asthma management policies and practices were found to be implemented in schools in Cyprus, a country highly exposed to dust events.

• School health visitors recognize the health impact of desert dust on asthmatic children and support the plan for dust-mitigation programmes in schools, despite authorities’ low preparedness.

Profiling the variability and inequity in the residential environment in Cyprus according to citizens' ratings: a cross-sectional internet-based "Place Standard" survey

Background

The “Place Standard Tool” (PST) offers a practical framework for structuring conversations about physical and social dimensions of Place which impact on health and well-being. The aim of this study was to survey citizens’ perceptions of Place across diverse settings in Cyprus. While the PST has been extensively used in the context of community engagement, its properties as a measurement tool haven’t been explored.

Methods

An open call was addressed to citizens to rate their neighbourhood environment across the 14 PST items (1: large to 7: little room for improvement). Exploratory factor, cluster and regression analyses were used to explore the dimensionality of the scale, depict neighbourhood profiles and explore differences in ratings according to socio-demographic characteristics, area-level census indicators and residents’ assessment of neighbourhood social position (10-step ladder).

Results

With the exception of safety (M = 4.4, SD = 1.7), 492 participants (mean age 42, 50% residents for > 10 years) from 254 postcodes (21.7% islandwide) did not rate other features favourably, with lowest scores for “influence and sense of control” and “public transport”. A stepwise pattern of dissatisfaction was observed along the social position continuum both for features rated less as well as more favourably (e.g. social contact). For instance, among participants who placed their neighbourhood at the three top steps of the ladder, 48.8% gave a low rating for “influence and sense of control”, while the equivalent figure was 81.0% at the bottom three steps (OR = 4.5, 95% CI 2.3, 8.6). A clear dimensionality of Built (6 items, Cronbach’s α = 0.798), Physical (3 items, α = 0.765), Social (2 items, α = 0.749) and Service (3 items, α = 0.58) environment was identified. A social gradient was evident according to census measures of socio-economic disadvantage (e.g. pre-1980 housing, single-parent households) with larger differences in terms of the built than the social environment.

Conclusions

The study profiled the variability and documented the inequity in the health-related neighbourhood environment across Cypriot communities. The readily interpretable dimensionality of the scale supports its construct validity, allowing calculation of composite scores. The PST can be used as measurement tool in research as well as public health practice to advocate for neighbourhood initiatives which support and enhance citizens’ participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12706-y.

The Effect of Fibrates on Kidney Function and Chronic Kidney Disease Progression: A Systematic Review and Meta-Analysis of Randomised Studies

Aim: Fibrates have proven efficacy in cardiovascular risk reduction and are commonly used, in addition to statins, to control hypertriglyceridaemia. Their use is often limited due to reduction in glomerular filtration rate at treatment initiation. However, recent studies suggest benign changes in kidney function and improvement of proteinuria, an established early marker of microvascular disease and kidney disease progression. We summarize the evidence from existing trials and provide a summary of effects of fibrates, alone or in combination, on kidney disease progression and proteinuria. Methods and Results: Systematic review and meta-analysis of randomized, controlled trials (PROSPERO CRD42020187764). Out of 12,243 potentially eligible studies, 29 were included in qualitative and quantitative analysis, with a total of 20,176 patients. Mean creatinine increased by 1.05 (95% CI (0.63 to 1.46)) units in patients receiving fibrates vs. comparator, and this was similar in all other subgroups. eGFR showed a bigger decrease in the fibrates arm (SMD −1.99; 95% CI (−3.49 to −0.48)) when all studies were pooled together. Notably, short-term serum creatinine and eGFR changes remained constant in the long-term. Pooled estimates show that fibrates improve albuminuria progression, RR 0.86; 95% CI (0.76 to 0.98); albuminuria regression, RR 1.19; 95% CI (1.08 to 1.310). Conclusions: Fibrates improve albuminuria in patients with and without diabetes when used to treat hyperlipidaemia. The modest creatinine increase should not be a limiting factor for fibrate initiation in people with preserved renal function or mild CKD. The long-term effects on kidney disease progression warrant further study.

CT of transposition of the great arteries in adults

Transposition of the great arteries is one of the most common cyanotic congenital heart diseases. It is characterised by an abnormal connection of the ventricles and great arteries, so that the aorta arises from the morphological right ventricle and the pulmonary artery arises from the morphological left ventricle. Historically, as with many congenital heart diseases, patients with transposition of the great arteries had poor life expectancy. Advances in surgical and medical management have resulted in patients surviving into adulthood. As these patients are living longer, they will be encountered more frequently in practice. The purpose of this article is to familiarise the general radiologist with the expected postoperative anatomy, and the appearance on cross-sectional imaging as well as the long-term complications in this group of patients.

Depicting socioeconomic disadvantage and social gradient in quality of life in Limassol, Cyprus

Background

The lack of validated and accepted area-level indices of socioeconomic disadvantage at national or regional level in Cyprus poses a barrier to “spatial thinking” among Public Health policy-makers and researchers.

Methods

A composite index of socioeconomic disadvantage was constructed by exploring the factor structure of 28 commonly used census indicators at city quarter (N = 38, median population 3894, IQR 2570-6169) and postcode level (N = 124, median 1320, IQR 798-2014). Predictive validity was explored in mixed random-effect regression models in term of associations with SF-36 health-related quality of life among a stratified random sample aged 45-64 (N = 450, 45 neighbourhoods).

Results

There was wide variability across communities in all indicators, for instance, 0.4%-25.9% unemployment, 41.1%-90.7% at most secondary level education, 3.6%-95.9% residences built prior to 1980. Two factors were identified: “socioeconomic disadvantage” (SED), with the same set of 11-12 indicators at the two levels of geographical aggregation, and “built environment”, reflecting proximity to the city centre, with nevertheless no meaningful associations with the outcome of interest. The SED index captured a stepwise decrease in physical (-1.39 95%CI -2.06, -0.72) and mental health (-1.26 95% -1.98, -0.54) scores across quartiles of postcodes with increasing disadvantage, of similar clinically significant effect size by gender. Associations attenuated slightly but remained significant after adjusting for person-based indicators of social position, with some weak evidence of cross-level interactions for physical, but not mental, health.

Conclusions

The composite index, tapping on educational, economic, material, occupational and social disadvantage, allowed the exploration of socioeconomic disadvantage patterning at a small-area level in the city of Limassol and documented the social gradient in health-related quality of life among a late working-life sample of residents.

Key messages

First-time depiction of the geographical patterning of socioeconomic disadvantage across the small geographical level of postcodes in the city of Limassol, Cyprus. Social gradient in physical and mental health in men and women across the continuum of socioeconomic disadvantage over and above person-based indicators of social position.

Objective and subjective assessment of the neighborhood health environment, Limassol, Cyprus

Background

While neighborhood audit tools are commonly assessed for inter- and intra-rater reliability, validity and relevance are not always demonstrated.

Methods

A stratified random sample of 45 neighbourhoods in Limassol were audited with the 150-item Cyprus Neighborhood Observational Tool for urban environments (CyNOTes). Ratings were correlated with census indicators of socioeconomic disadvantage. The extent to which residents' neighborhood assessment (Place Standard, N = 444) and self-rated quality of life (SF-36 in second sample N = 450) differed across neighborhoods classified according to domain were explored in mixed random effect models.

Results

CyNOTes items are organized in 9 domains (internal consistency=0.5-0.9) with a 3-factor higher structure. In seven, a stepwise pattern of lower mean ratings was observed across increasing socioeconomic disadvantage, for domains rated generally high across neighborhoods (e.g. lack of physical disorder) and low (e.g. outdoor spaces). Though not always statistically significant, a systematic pattern of higher self-rated health was observed in better-off neighborhoods across most domains. “Pedestrian environment” captured the largest difference for both physical (1.34 95%CI 0.42,2.26), p = 0.005 per tertile increase) and mental health (1.46 95% 0.54,2.40; p = 0.003). “Social contact” and “Safety: lack of security-related features” were more likely to be rated favorably in disadvantaged neighborhoods, however no associations with quality of life were observed. While the residents' assessment was often in the expected direction, more for built environment features, this was not always the case.

Conclusions

The study demonstrated the content, construct, criterion and predictive validity of an audit tool for supplementary profiling the built, physical and social health-related neighbourhood environment. Concurrent validity against residents' perceptions was not always supported, raising questions about differential expectations.

Key messages

Neighbourhood audits can provide useful supplementary information not captured by other community assessment methods and independent of residents’ perceptions. Depicting the social gradient in the neighborhood microenvironment can trigger and contextualize the conversation about place effects on health among Public Health research and policy community.

337Systematic social observation tool for auditing the physical, built and social health-related urban neighboourhood environment

Background

Several generic or feature-specific neighborhood audit tools have been developed. While inter/intra-observer reliability if commonly assessed, validity is not always considered.

Methods

A two-phase mixed-methods process was used to develop the Cyprus Neighborhood Observational Tool for urban environments (CyNOTes). Phase I: draft based on literature review, culturally adapted and content validated in focus groups with community professionals and social media ethnographic study of citizens’ experience and feasibility tested across 15 neighbourhoods. Phase II: variability in features across 45 neighbourhoods along the social disadvantage continuum and associations with census area indicators, citizens’ perceptions and health-related quality of life were assessed.

Results

Content validity was supported by residents’ and professionals’ descriptions of neighbourhood problems, giving rise to a 17-domain, 151-item inventory, 126 from the literature and 25 arising via Nominal Group Technique consensus and content analysis of social media posts. With good inter- and intra-observer agreement, neighborhoods with lower educational attainment scored lower in over half domains. Social gradient and clustering of adverse features observed while in neighbourhoods with adverse features residents reported lower physical and mental health-related quality of life. The social gradient was not always reflected in the perception survey. With the exception of social aspects, residents did not rate the built and physical environment favorably. “Influence and sense of control” was rated lowest while “Citizens’ voice” emerged in the inductive content analysis of residents’ lived experience.

Conclusions

A culturally relevant audit tool of the health-related neighborhood microenvironment was developed by assessing its content, concurrent, criterion and predictive validity.

Key messages

There is need for valid audit tools, independent of residents’ perceptions, for supplementary profiling of the health-related neighbourhood microenvironment

Neighborhoods audits can trigger and widen conversation among local research community and policy-makers about health and place.

112Neighbourhood environment and health-related quality of life, Limassol, Cyprus

Background

The extent and magnitude of socio-geographical inequalities in health in Cyprus is not clear as neither “place” nor “health inequalities” feature on the public health agenda.

Methods

In the context of a wider Neighbourhood Environment and Health programme, the magnitude of inequality in health-related quality of life (HRQoL) among Limassol citizens was explored in a door-to-door SF-36 survey of residents aged 45-64 (N = 450, 50:50 gender quota) across 45 randomly selected neighbourhoods stratified by socio-economic disadvantage and profiled using a culturally-adapted Systematic Social Observation neighbourhood audit tool.

Results

The social gradient was steeper for physical than mental component scores of HRQoL irrespective of the indicator of social position. Education and income captured the gradient better in women, and occupational-based social class in men, with large effect (0.7-1 SD) on the SF-36 scale at opposite ends of the continuum. Lower HRQoL and more adverse health behaviours observed in disadvantaged neighborhoods according to census area-level measures and neighbourhood audit profiles, with generally larger differences in women.

Conclusions

This study profiled the variability in the urban neighbourhood environment,and documented the magnitude of social gradient in health and health-related quality of life in a representative sample of late working-life population in Cyprus.

Key messages

Social gradient in health behaviours and quality of life in late working-life Cypriot population.

Gradient apparent in both men and women across individual and neighborhood measures of social position.

111“Place standard” depicts the social gradient in the neighbourhood environment in Cyprus

Background

Census data, GIS, surveys and audits are used to profile “place”, each with shortcomings. There are several “neighbourhood environment” tools, including the “Place Standard” a policy and advocacy tool developed in Scotland. “Place” is not a strong feature in the public health agenda in Cyprus.

Methods

In an internet survey, participants rated 14 features of their neighborhood environment. Exploratory factor, cluster and regression analysis were used to explore the dimensionality of the concept, neighborhood profiles and differences according to individual and area-level characteristics.

Results

With the exception of safety (M = 4.4, SD = 1.7 on a 1: large to 7: little improvement), 492 participants (mean age 42, 50% residents for >10 years) from 266 postcodes (33% islandwide) did not rate other features favourably. A clear dimensionality of Built, Physical, Social and Service environment supports the construct validity of the tool. People who rated their neighbourhood lower on a social position ladder were consistently more likely to rate all contextual neighrbourhood features less favourably. The social gradient was evident according to individual and area measures of socio-economic disadvantage and appeared stronger in terms of the built than the social environment.

Conclusions

The “place standard” shows good metric properties and captures the variability ad inequity in the neighbourhood environment.

Key messages

The “Place Standard” can be used to profile the context of health inequalities.

Evidence of a social gradient across all features with larger differences in terms of the built environment.

447Decoding the effect of neighbourhood on arterial health (DEpICT): Preliminary results on neighbourhood self-evaluation

Background

DEpICT is an ongoing exploratory, observational, cross-sectional study in community-dwelling individuals in Limassol, Cyprus aiming to combine individual-level and community-level risk factors to decode their effect on arterial health (stiffness) as measured with pulse wave velocity (PWV).

Methods

Participants are >40 years and living in the same address for ≥5 years. They provide personal information on quality of life and mental health (SF-12 and GHQ-12), physical activity (IPAQ), adherence to Mediterranean diet (MedDiet) and sociodemographic. Arterial stiffness is measured as PWV. Neighborhood is self-assessed using the “Place Standard” Tool, as well as independent neighborhood audit with the newly-developed CyNoTes tool.

Results

Mean age of the first 176 participants (53%male) was 55.2 (±8.6). All participants rated their health between excellent/very good (50.5%) and good/modest (49.5%), however participants with a higher net family income reported significantly better health (p for trend=0.02), with 61.4% reporting very good/excellent health in those earning >2000E Vs 40.2% in those earning ≤ 2000E/m (p = 0.005). Out of 14 constructs in “Place”, “Public transport” and “Participation and sense of control” were rated lowest (3.1 ± 1.9 and 3.1 ± 1.8) and “Identity and sense of belonging” and “Safety” highest (4.1 ± 1.9 and 4.5 ± 1.8). Out of these, family income was associated with “Safety” (p = 0.005) and self-health with “Participation and sense of control”.

Conclusions

Participants rate social and safety aspects of their neighborhood higher than build aspects.

Key messages

Participants express the need for more public engagement in community decision-making; sense of lacking control may affect individual health.

Cardiovascular Risk Assessment Using Ultrasonographic Surrogate Markers of Atherosclerosis and Arterial Stiffness in Patients With Chronic Renal Impairment: A Narrative Review of the Evidence and a Critical View of Their Utility in Clinical Practice

PURPOSE OF THE REVIEW

Validated tools to improve cardiovascular disease (CVD) risk assessment and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. Noninvasive measures of arteriosclerosis and subclinical atherosclerosis such as pulse wave velocity (PWV) and carotid intima-media thickness (cIMT), respectively, have emerged as promising risk stratification tools and potential modifiable biomarkers. Their wide use as surrogate markers in clinical research studies is based on the strong pathophysiological links with CVD. However, whether their effect as risk stratification or intervention targets is superior to established clinical approaches is uncertain. In this review, we examine the evidence on the utility of PWV, cIMT, and plaque assessment in routine practice and highlight unanswered questions from the clinician's perspective.

SOURCES OF INFORMATION

Electronic databases PubMed and Google Scholar were searched until February 2020.

METHODS

This narrative review is based on peer-reviewed meta-analyses, national and international societies' guidelines, and on focused critical review of recent original studies and landmark studies in the field.

KEY FINDINGS

Although patients with CKD are considered in the high-risk CVD groups, there is still need for tools to improve risk stratification and individualized management strategies within this group of patients. Carotid intima-media thickness is associated with all-cause mortality, CVD mortality, and events in CKD and hemodialysis cohorts. However, the evidence that measurement of cIMT has a clinically meaningful role over and above existing risk scores and management strategies is limited. Plaque assessment is a better predictor than cIMT in non-CKD populations and it has been incorporated in recent nonrenal-specific guidelines. In the CKD population, one large observational study provided evidence for a potential role of plaque assessment in CKD similar to the non-CKD studies; however, whether it improves prediction and outcomes in CKD is largely understudied. Pulse wave velocity as a marker of arterial stiffness has a strong pathophysiological link with CVD in CKD and numerous observational studies demonstrated associations with increased cardiovascular risk. However, PWV did not improve CVD reclassification of dialysis patients when added to common risk factors in a reanalysis of ESRD cohorts with available PWV data. Therapeutic strategies to regress PWV, independently from blood pressure reduction, have not been studied in well-conducted randomized trials.

LIMITATIONS

This study provides a comprehensive review based on extensive literature search and critical appraisal of included studies. Nevertheless, formal systematic literature review and quality assessment were not performed and the possibility of selection bias cannot be excluded.

IMPLICATIONS

Larger, prospective, randomized studies with homogeneous approach, designed to answer specific clinical questions and taking into consideration special characteristics of CKD and dialysis, are needed to study the potentially beneficial role of cIMT/plaque assessment and PWV in routine practice.

Association between education and self-assessment of the neighborhood environment

Background

DEpICT is an ongoing observational, cross-sectional study in community-dwellers in Limassol, Cyprus aiming to combine individual-level and community-level risk factors to decode their effect on arterial health (stiffness) as measured with pulse wave velocity (PWV).

Methods

Participants are >40 years who have been living in the same address for ≥5 years. They provide personal information on quality of life and mental health (SF-12 and GHQ-12), physical activity (IPAQ), adherence to Mediterranean diet (MedDiet) and sociodemographic. Anthropometric characteristics are measured on site, as well as arterial stiffness (carotid-femoral PWV) and central blood pressure. Neighborhood is self-assessed using the “Place Standard” Tool, as well as with an independent neighborhood audit using the newly-developed CyNoTes tool.

Results

Out of the first 176 participants (53% male), 45% had a college/university degree with a further 19% having graduate degrees, while the vast majority (92%) reported home ownership. Education was not associated with net family income (p = 0.3) nor home-ownership (p = 0.28). Out of the 14 constructs in Place standard, “Public transport” and “Participation and sense of control” were rated lowest (3.1 ± 1.9 and 3.1 ± 1.8) and “Identity and sense of belonging” and “Safety” highest (4.1 ± 1.9 and 4.5 ± 1.8). Education was not associated with any construct in “Place” or with total neighbourhood score.

Conclusions

Participants rate the social and safety aspects of their neighbourhood higher than the build aspects. Educational attainment may not be a good proxy for neighbourhood socioeconomic assessment in Cyprus, given the high rates of university graduates.

Key messages

Participants express the need for more public engagement in community decision-making; sense of lacking control may affect individual health. Educational attainment is not a good proxy for neighborhood socioeconomic assessment in the cultural context of Cyprus.

Spatio-temporal variability of desert dust storms in Eastern Mediterranean (Crete, Cyprus, Israel) between 2006 and 2017 using a uniform methodology

The characteristics of desert dust storms (DDS) have been shown to change in response to climate change and land use. There is limited information on the frequency and intensity of DDS over the last decade at a regional scale in the Eastern Mediterranean. An algorithm based on daily ground measurements (PM₁₀, particulate matter ≤10 μm), satellite products (dust aerosol optical depth) and meteorological parameters, was used to identify dust intrusions for three Eastern Mediterranean locations (Crete-Greece, Cyprus, and Israel) between 2006 and 2017. Days with 24-hr average PM₁₀ concentration above ~30 μg/m³ were found to be a significant indicator of DDS for the background sites of Cyprus and Crete. Higher thresholds were found for Israel depending on the season (fall and spring: PM₁₀ > 70 μg/m³, winter and summer: PM₁₀ > 90 μg/m³). We observed a high variability in the frequency and intensity of DDS during the last decade, characterized by a steady trend with sporadic peaks. The years with the highest DDS frequency were not necessarily the years with the most intense episodes. Specifically, the highest dust frequency was observed in 2010 at all three locations, but the highest annual median dust-PM₁₀ level was observed in 2012 in Crete (55.8 μg/m³) and Israel (137.4 μg/m³), and in 2010 in Cyprus (45.3 μg/m³). Crete and Cyprus experienced the same most intense event in 2006, with 24 h-PM₁₀ average of 705.7 μg/m³ and 1254.6 μg/m³, respectively, which originated from Sahara desert. The highest 24 h-PM10 average concentration for Israel was observed in 2010 (3210.9 μg/m³) during a three-day Saharan dust episode. However, a sub-analysis for Cyprus (years 2000-2017) suggests a change in DDS seasonality pattern, intensity, and desert of origin. For more robust conclusions on DDS trends in relation to climate change, future work needs to study data over several decades from different locations.

“Is anyone walking in our neighborhoods?”: Citizens’ experience of the neighbourhood environment

Background

Several generic or feature-specific neighbourhood audit tools have been developed in recent years. In the context of developing the Cyprus Neighbourhood Observation Tool for auditing urban environments (CyNOTes), a virtual ethnographic study of citizens’ perceptions of their neighbourhood environment was performed.

Methods

The municipality and mayor’s Facebook were reviewed for posts related to neighbourhood environment over a 12-month period (e.g. regeneration projects). Comments were content analysed using a deductive as well as an inductive approach to gain an in-depth understanding of citizens’ perceptions of neighbourhood environment.

Results

348 comments to 27 relevant posts were identified. The unit of analysis was sentences or short phrases and 289 CMU were identified. The central theme was “Citizens’ voice”. Six themes and several sub-themes emerged. “Comparisons” to contrast the differing conditions between high-profile locations versus “left out” residential neighbourhoods (“Yes, the city centre, the waterfront is a jewel, what about the neighborhoods?”) or to compare their experience to “another place-another time”. They express “Mixed feelings” ranging from “hope” to “disbelief” about proposed actions. Citizens are referring to “Consequences” of neighbourhood adverse environment on “Quality of Life” or “Local ecomomy and housing” and identify “Causes” in “Money and Power” or “Lack of vision and planning”. They are placing “Responsibility” in both “Authorities’ inaction” as well as “Everyone’s role”. “Suggestions” included measures related to “Law and Order” as well as “Citizens’ participation”.

Conclusions

Citizens voice their experiences of the neighbourhood environment lack of influence and control and demand for more involvement in decision-making. They blame authorities for neighbourhood problems but also recognize the lack of individual responsibility, suggesting policing and punitive measures and stronger collective action.

Key messages

A virtual ethnographic study of citizens’ comments on social media offers an in-depth understanding of the neighbourhood experience. Citizens want to have a “voice” to express their concerns about neighbourhood problems as well as to participate in decision-making.

Citizens’ perceptions of the health-related neighbourhood environment in Limassol, Cyprus

Background

“Place” can impact on health and quality of life. There is a growing interest in neighbourhood audits. In the context of developing the CyNOTes audit tool, a residents’ perception of the neighbourhood environment survey was performed.

Methods

A systematic random sample of ten adult residents (N = 150) across a stratified sample of fifteen neighbourhoods according to educational attainment as per census data responded to the “Place Standard” tool which assesses 14 aspects of the physical, built and social neighbourhood environment. Neighbourhoods were also audited using the 126-item CyNOTes.

Results

Three in four participants were home owners and lived in the neighbourhood for over 10 years. With the exception of “identity and sense of belonging” (M = 5.8, SD = 2.0) and “opportunities for social interaction” (M = 5.3, SD = 2.1), physical and built aspects of the environment were rated close to the middle point on a scale 1: large to 7: little room for improvement. “Parks, playgrounds and green space” and “garbage, animal droppings and other physical disorder” were the most commonly mentioned priorities for action in the free text by one in three participants. The lowest score was recorded for “influence and sense of control” (M = 3.4, SD = 2.4). While on a 1-10 subjective perception of neighbourhood position, residents in lower education neighbourhoods gave a rating of 6.6 on average compared to 8.1 in the higher group, they tended to rate aspects of their neighbourhood more favourably. Even though the audit revealed a systematic pattern of less favourable conditions along the socio-economic continuum, the perception survey revealed a U-pattern with residents in the middle category more likely to give less favourable ratings.

Conclusions

The extent to which perceptions surveys may be affected by differential expectations across social groups is not clear. Neighborhood audits provide supplementary profiles of “place” independent of the perceptions of residents.

Key messages

Based on the Place Standard tool, Limassol residents’ rate social aspects of their neighbourhood environment more favourably than aspects of the built and physical environment. Neighbourhood observed-based audits, independent of residents’ perceptions surveys can supplement each other in city health profiling.

Deterioration of visuospatial associative memory following a first psychotic episode: a long-term follow-up study

BACKGROUND

Cognitive deficits are a core feature of schizophrenia, and impairments in most domains are thought to be stable over the course of the illness. However, cross-sectional evidence indicates that some areas of cognition, such as visuospatial associative memory, may be preserved in the early stages of psychosis, but become impaired in later established illness stages. This longitudinal study investigated change in visuospatial and verbal associative memory following psychosis onset.

METHODS

In total 95 first-episode psychosis (FEP) patients and 63 healthy controls (HC) were assessed on neuropsychological tests at baseline, with 38 FEP and 22 HCs returning for follow-up assessment at 5-11 years. Visuospatial associative memory was assessed using the Cambridge Neuropsychological Test Automated Battery Visuospatial Paired-Associate Learning task, and verbal associative memory was assessed using Verbal Paired Associates subtest of the Wechsler Memory Scale - Revised.

RESULTS

Visuospatial and verbal associative memory at baseline did not differ significantly between FEP patients and HCs. However, over follow-up, visuospatial associative memory deteriorated significantly for the FEP group, relative to healthy individuals. Conversely, verbal associative memory improved to a similar degree observed in HCs. In the FEP cohort, visuospatial (but not verbal) associative memory ability at baseline was associated with functional outcome at follow-up.

CONCLUSIONS

Areas of cognition that develop prior to psychosis onset, such as visuospatial and verbal associative memory, may be preserved early in the illness. Later deterioration in visuospatial memory ability may relate to progressive structural and functional brain abnormalities that occurs following psychosis onset.

Plaque area at carotid and common femoral bifurcations and prevalence of clinical cardiovascular disease

AIM

Different ultrasonic arterial wall measurements have been used as predictors of future myocardial infarction or stroke. The aim of the present study was to determine the relationship of total plaque area (TPA) (the sum of the atherosclerotic plaque area measurements from both carotid and both common femoral arteries) with prevalence of cardiovascular disease in a population-based cross-sectional study and compare it with intima-media thickness (IMT).

METHODS

Seven hundred sixty-two individuals (47% male) over the age of 40 were screened for cardiovascular risk factors.

RESULTS

Evidence of clinical cardiovascular disease was present in 113 (14.8%). Both carotid and both common femoral bifurcations were scanned with ultrasound. After adjustment for conventional risk factors the association of IMT with prevalence of clinical cardiovascular disease was low (P=0.84, OR of upper IMT quintile 1.36; 95% CI 0.56 to 3.26) and of TPA high (P<0.001, OR of upper TPA quintile 8.38; 95% CI 2.57 to 27.32). TPA greater than 42 mm2 (cut-point derived from ROC curve analysis) identified 266 (34.9%) of the population that contained 87/113 (76.9%) of the clinical events (sensitivity: 77%; specificity: 73%; positive predictive value: 33%; negative predictive value: 94%; positive likelihood ratio of 2.79). In contrast, IMT greater than 0.07 mm had a sensitivity, specificity, positive and negative predictive value and positive likelihood ratio of 68%, 60%, 23%, 91% and 1.69 respectively.

CONCLUSION

Total plaque area appears to be more strongly associated with the prevalence of cardiovascular disease than IMT. This finding warrants further prospective studies.

Carotid and femoral arterial wall changes and the prevalence of clinical cardiovascular disease

Abstract

The Cyprus Study is a prospective cohort study of cardiovascular disease (CVD). Its aim is to determine the relationship of intima–media thickness (IMT) of the common carotid (IMTcc), maximum thickness of IMT in the carotid bifurcation (IMTmax), number of carotid and femoral bifurcations with plaque and total plaque thickness (TPT) (sum of the maximum plaque measurements taken from the four bifurcations scanned) with the prevalence of clinical CVD. A total of 767 individuals (46% male) over the age of 40 years were recruited from a mountain village and a town outside the capital Nicosia. In addition to clinical examination, carotid and common femoral bifurcations were scanned with ultrasound. After controlling for conventional risk factors, there was little evidence of an association of IMTcc with CVD prevalence. However, IMTmax and TPT were associated with 2.9-fold (1.22 to 7.07) and 6.87-fold (2.42 to 19.43) increased odds of CVD prevalence, respectively. In conclusion, the TPT and number of bifurcations with plaque are more strongly associated with the prevalence of CVD. These findings warrant investigation in prospective studies to document associations with incident CVD events.

Serum total homocysteine, folate, 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C-->T genotype and subclinical atherosclerosis

OBJECTIVE

To determine the relationship of serum total homocysteine (tHcy), serum folate and 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C-->T genotype with ultrasonic arterial wall measurements associated with subclinical atherosclerosis.

STUDY DESIGN

Cross-sectional analysis of 767 participants in an ongoing prospective study. Intima-media thickness (IMT) of the common carotid (IMTcc), IMT of the internal carotid including plaque when present (IMT(max)) and the sum of the thickest plaques present in both carotid and both common femoral bifurcations (total plaque thickness (TPT)) were measured using ultrasound.

RESULTS

People in the upper homocysteine quartile were more likely to have clinical cardiovascular disease (CVD) than those in the lowest three quartiles. They were also more likely to have plaques. The MTHFR 677C-->T genotype was not associated with any of the measures of subclinical atherosclerosis in either men or women but was the most important determinant of total homocysteine levels in men under 60 years of age.

CONCLUSIONS

Increased homocysteine levels but not MTHFR 677C-->T genotype, are associated with subclinical atherosclerosis and the presence of plaques. Our results indicate that measurements of blood levels of homocysteine and folate in people at intermediate risk for atherosclerotic CVD before symptoms occur, might improve risk stratification and facilitate the decision to provide folate/B vitamin intervention in primary prevention.

ApoB/ApoA1 ratio and subclinical atherosclerosis

AIM

It has been demonstrated that an increased apolipoprotein B (ApoB)/apolipoprotein A-I (ApoA1) ratio is associated with atherogenic low density lipoprotein (LDL) particles and the development of clinical cardiovascular disease. The aim of this study was to test the hypothesis that ApoB/ApoA1 ratio is associated with early subclinical atherosclerosis as demonstrated by ultrasonic measurements.

METHODS

Both common carotid and common femoral bifurcations have been scanned with high-resolution ultrasound in 767 volunteers over the age of 40. The latter consisted of 95% of the population of two randomly selected areas. IMTcc, IMTmax (including plaques), total plaque thickness (TPT) (the sum of the thickest plaques present at each bifurcation in cm) and black plaque burden (BPB) (TPT means plaque type) using the Widder classification with type 1 being the most hyperechoic and calcified and type 5 the most hypoechoic plaque were recorded. A medical history was taken with emphasis on risk factors present and a fasting lipid profile including ApoB and ApoA1 was determined.

RESULTS

In the total population (N.=767) the mean (+/-SD) ApoB/ApoA1 ratio was 0.85 (+/-0.22). In linear regression analysis, the Apob/ApoA1 ratio was significantly associated with all the ultrasonic measurements of early atherosclerosis (intima media thickness, IMTcc, IMTmax, TPT and BPB). These findings remained significant after correcting for age, gender, smoking, hypertension and diabetes (P<0.001 for all).

CONCLUSION

The results indicate that a high ApoB/ApoA1 ratio is associated not only with early atherosclerosis but also with hypoechoic (BPB) and by inference unstable plaques.

Lipid fractions with aggregatory and antiaggregatory activity toward platelets in fresh and fried cod (Gadus morhua): correlation with platelet-activating factor and atherogenesis

Cod (Gadus morhua) is a popular part of the diet in many countries on both sides of the North Atlantic; in most cases it is consumed fried. In this study, total lipids of cod muscle were separated into neutral and polar lipids, which were further fractionated by HPLC. The lipid fractions were tested in vitro, against washed rabbit platelets, for the probable existence of lipid compounds that either exhibit an action similar to that of platelet-activating factor (PAF) or inhibit the action of PAF. The platelet bioassay was used to evaluate total lipids, total polar lipids, and total neutral lipids, before any further separation. Detection of these compounds in fresh and fried cod could be used to evaluate the nutritional value of this important fish. The in vitro biological study of lipids showed that in fresh cod lipid fractions, ranges of PAF-like and anti-PAF-like activities were present, whereas in fried cod lipid fractions, both neutral and polar, anti-PAF activities were mainly observed. Because it has already been reported that PAF is involved in atheromatosis generation, the existence of PAF inhibitors in cod may contribute to the possible protective role of fish, in this case cod, against atherosclerosis.

Identification of candidate endothelial cell autoantigens in systemic lupus erythematosus using a molecular cloning strategy: a role for ribosomal P protein P0 as an endothelial cell autoantigen

OBJECTIVE

To attempt to characterize the diversity and nature of antigens recognized by anti-endothelial cell antibodies (AECA) in patients with systemic lupus erythematosus (SLE) using a molecular cloning strategy.

METHODS

AECA in sera of 15 SLE patients were measured by ELISA and Western blot analysis was used to examine the diversity of autoantigen targets in two clinically active patients. A human umbilical vein endothelial cell cDNA expression library was immunoscreened with sera from these two patients to identify their autoantigen targets. An anti-ribosomal P peptide antibody ELISA was used to assess the clinical significance of anti-ribosomal P protein antibodies in the sera of one patient.

RESULTS

Significantly higher AECA levels were found in five patients with active disease and nephritis than in five patients with clinically inactive disease. Sera from two clinically active patients were found to recognize distinct spectra of autoantigens. The candidate autoantigens that were identified included (1) endothelial cell-specific plasminogen activator inhibitor; (2) the classical lupus antigen, i.e. ribosomal P protein P0; and (3) proteins never before described as putative autoantigens in SLE, including ribosomal protein L6, elongation factor 1alpha, adenyl cyclase-associated protein, DNA replication licensing factor, profilin II and the novel proteins HEAPLA 1 and HEAPLA 2 (human endothelial associated putative lupus autoantigens 1 and 2). In one patient, antibodies against ribosomal P protein P0 were predominant and levels of these antibodies correlated with total AECA levels, anti-DNA antibody titres, overall clinical score and renal disease in a longitudinal study.

CONCLUSIONS

A panel of candidate endothelial autoantigens in SLE, which includes previously described autoantigens and novel targets, has been identified by a molecular cloning strategy. This novel molecular approach could also be applied to the identification of autoantigens in other autoimmune vascular diseases.