20 research outputs found
1115 Undertreatment of vascular risk factors in patients presenting with ischaemic ocular events: results from 395 patients in a tertiary centre
No full textFlexible and Optimized IDL Compilation for Distributed Applications
No full text. The author of a distributed system is often faced with a dilemma when writing the system's communication code. If the code is written by hand (e.g., using Active Messages) or partly by hand (e.g., using mpi) then the speed of the application may be maximized, but the human effort required to implement and maintain the system is greatly increased. On the other hand, if the code is generated using a high-level tool (e.g., a corba idl compiler) then programmer effort will be reduced, but the performance of the application may be intolerably poor. The tradeoff between system performance and development effort arises because existing communication middleware is inefficient, imposes excessive presentation layer overhead, and therefore fails to expose much of the underlying network performance to application code. Moreover, there is often a mismatch between the desired communication style of the application (e.g., asynchronous message passing) and the communication style of the code produce..
Hypertension and small vessel disease: do the drugs work?
No full textAssociations of hypertension with ischaemic stroke and intracerebral haemorrhage, particularly when attributed to cerebral small vessel disease, are well established. While it seems plausible that treating hypertension should prevent small vessel disease from developing or progressing, there is limited evidence demonstrating this. This article critically appraises the evidence answering this clinical question. Hypertension is also closely associated with chronic kidney disease, with anatomical and functional similarities between the vasculature of the brain and kidneys leading to the hypothesis that shared multi-system pathophysiological processes may be involved. Therefore, the article also summarises data on prevention of progression of chronic kidney disease. Evidence supports a target blood pressure of <130/80 mmHg to optimally prevent progression of both small vessel disease and chronic kidney disease. However, future studies are needed to determine long-term effects of more intensive blood pressure treatment targets on small vessel disease progression and incident dementia
Income diversification in Zimbabwe : welfare implications from urban and rural areas
No full textThe author examines, taking into account the urban-rural divides, the changes and welfare implications of income diversification in Zimbabwe following macroeconomic policy changes and droughts of the early 1990s. Data from two comparable national income, consumption and expenditure surveys in 1990-91 and 1995-96, which straddled a period of economic volatility and natural disasters, show that the percentage of households earning income from private and informal sources grew considerably, while that from government and formal sources declined in the aftermath of the drought and policy changes. The author finds that, in general, rural households tend to have a more diversified portfolio of income compared with their urban counterparts, and the degree of diversification decreases with the level of urbanization. However, there are important differences in the level of diversification within the rural and urban areas depending on wealth: While the relatively better-off households have a more diversified income base in rural areas, it is the poor who pursue multiple income sources in urban areas. A decomposition of changes in welfare indicates that the total contribution of income diversification is large and increased between 1990-91 and 1995-96 in both urban and rural areas. On the other hand, there were significant declines in returns to human and physical capital assets during the same period. The findings suggest that households with a more diversified income base are better able to withstand the unfavorable impacts of the policy and weather shocks. The fact that relatively better-off households have a more diversified income base following the shocks implies that the poor are more vulnerable to economic changes unaccompanied by well-designed safety nets.Rural Poverty Reduction,Inequality,Poverty Diagnostics,Economic Theory&Research
Comparison of mothership versus drip-and-ship models for endovascular treatment of basilar artery occlusion in the London metropolitan area
No full textBACKGROUND
To date it is uncertain whether the drip‐and‐ship (DS) model (transport to the nearest primary stroke centers) or the mothership (MS) model (direct transportation to the comprehensive stroke center) is the best prehospital stroke system of care to deliver endovascular thrombectomy in patients with basilar artery occlusion. In the present analysis, we aim to investigate the impact of MS versus DS model in patients with basilar artery occlusion treated with endovascular thrombectomy in the London metropolitan area.
METHODS
This is a multicenter observational, investigator‐initiated, retrospective study comparing outcomes (functional independence, defined as modified Rankin scale scores of 0 through 2, the rate of successful reperfusion, and the rate of complications postprocedure) in DS versus MS stroke patients with basilar artery occlusion admitted in 5 thrombectomy capable centers in London (United Kingdom).
RESULTS
Of 113 patients, 38 (33.6%) patients were MS and 75 (66.4%) were DS. Between the 2 groups we did not observe statistically significant differences for most of the clinical characteristics. There was a significant difference regarding the rate of functional independence at 3 months between the MS and DS groups, respectively 47.4% versus 36% (P = 0.047). Rates of complications postprocedure and successful recanalization did not differ between the 2 groups. Multivariable regression analysis demonstrated that MS model was an independent predictor of functional independence at 90 days (odds ratio [OR] 1.17; [95% CI, 1.11–1.26]; P = 0.003 and independent negative predictor of postoperative complications (OR, 0.39; [95% CI, 0.16–0.98]; P = 0.045).
CONCLUSION
Our study showed that MS model was a predictor of functional independence at 3 months and reduced risk of postoperative complications post‐endovascular thrombectomy in patients with basilar artery occlusion in a metropolitan area
Doctors and nurses subjective predictions of 6-month outcome compared to actual 6-month outcome for adult patients with spontaneous intracerebral haemorrhage (ICH) in neurocritical care: An observational study
No full textBackground:
Acute spontaneous intracerebral haemorrhage is a devastating form of stroke. Prognostication after ICH may be influenced by clinicians' subjective opinions.//
Purpose:
To evaluate subjective predictions of 6-month outcome by clinicians' for ICH patients in a neurocritical care using the modified Rankin Scale (mRS) and compare these to actual 6-month outcome.
Method:
We included clinicians' predictions of 6-month outcome in the first 48 h for 52 adults with ICH and compared to actual 6-month outcome using descriptive statistics and multilevel binomial logistic regression.//
Results:
35/52 patients (66%) had a poor 6-month outcome (mRS 4–6); 19/52 (36%) had died. 324 predictions were included. For good (mRS 0–3) versus poor (mRS 4–6), outcome, accuracy of predictions was 68% and exact agreement 29%. mRS 6 and mRS 4 received the most correct predictions. Comparing job roles, predictions of death were underestimated, by doctors (12%) and nurses (13%) compared with actual mortality (36%). Predictions of vital status showed no significant difference between doctors and nurses: OR = 1.24 {CI; 0.50–3.05}; (p = 0.64) or good versus poor outcome: OR = 1.65 {CI; 0.98–2.79}; (p = 0.06). When predicted and actual 6-month outcome were compared, job role did not significantly relate to correct predictions of good versus poor outcome: OR = 1.13 {CI;0.67–1.90}; (p = 0.65) or for vital status: OR = 1.11 {CI; 0.47–2.61}; p = 0.81).//
Conclusions:
Early prognostication is challenging. Doctors and nurses were most likely to correctly predict poor outcome but tended to err on the side of optimism for mortality, suggesting an absence of clinical nihilism in relation to ICH
The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review
No full textSevere acute malnutrition (SAM) arises as a consequence of a sudden period of food shortage and is associated with loss of a person’s body fat and wasting of their skeletal muscle. Many of those affected are already undernourished and are often susceptible to disease. Infants and young children are the most vulnerable as they require extra nutrition for growth and development, have comparatively limited energy reserves and depend on others. Undernutrition can have drastic and wide-ranging consequences for the child’s development and survival in the short and long term. Despite efforts made to treat SAM through different interventions and programmes, it continues to cause unacceptably high levels of mortality and morbidity. Uncertainty remains as to the most effective methods to treat severe acute malnutrition in young children.ObjectivesTo evaluate the effectiveness of interventions to treat infants and children aged < 5 years who have SAM.Data sourcesEight databases (MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CAB Abstracts Ovid, Bioline, Centre for Reviews and Dissemination, EconLit EBSCO and The Cochrane Library) were searched to 2010. Bibliographies of included articles and grey literature sources were also searched. The project expert advisory group was asked to identify additional published and unpublished references.Review methodsPrior to the systematic review, a Delphi process involving international experts prioritised the research questions. Searches were conducted and two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full texts of retrieved papers by one reviewer and checked independently by a second. Included studies were mapped to the research questions. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Differences in opinion were resolved through discussion at each stage. Studies were synthesised through a narrative review with tabulation of the results.ResultsA total of 8954 records were screened, 224 full-text articles were retrieved, and 74 articles (describing 68 studies) met the inclusion criteria and were mapped. No evidence focused on treatment of children with SAM who were human immunodeficiency virus sero-positive, and no good-quality or adequately reported studies assessed treatments for SAM among infants < 6 months old. One randomised controlled trial investigated fluid resuscitation solutions for shock, with none adequately treating shock. Children with acute diarrhoea benefited from the use of hypo-osmolar oral rehydration solution (H-ORS) compared with the standard World Health Organization-oral rehydration solution (WHO-ORS). WHO-ORS was not significantly different from rehydration solution for malnutrition (ReSoMal), but the safety of ReSoMal was uncertain. A rice-based ORS was more beneficial than glucose-based ORSs, and provision of zinc plus a WHO-ORS had a favourable impact on diarrhoea and need for ORS. Comparisons of different diets in children with persistent diarrhoea produced conflicting findings. For treating infection, comparison of amoxicillin with ceftriaxone during inpatient therapy, and routine provision of antibiotics for 7 days versus no antibiotics during outpatient therapy of uncomplicated SAM, found that neither had a significant effect on recovery at the end of follow-up. No evidence mapped to the next three questions on factors that affect sustainability of programmes, long-term survival and readmission rates, the clinical effectiveness of management strategies for treating children with comorbidities such as tuberculosis and Helicobacter pylori infection and the factors that limit the full implementation of treatment programmes. Comparison of treatment for SAM in different settings showed that children receiving inpatient care appear to do as well as those in ambulatory or home settings on anthropometric measures and response time to treatment. Longer-term follow-up showed limited differences between the different settings. The majority of evidence on methods for correcting micronutrient deficiencies considered zinc supplements; however, trials were heterogeneous and a firm conclusion about zinc was not reached. There was limited evidence on either supplementary potassium or nicotinic acid (each produced some benefits), and nucleotides (not associated with benefits). Evidence was identified for four of the five remaining questions, but not assessed because of resource limitation.LimitationsThe systematic review focused on key questions prioritised through a Delphi study and, as a consequence, did not encompass all elements in the management of SAM. In focusing on evidence from controlled studies with the most rigorous designs that were published in the English language, the systematic review may have excluded other forms of evidence. The systematic review identified several limitations in the evidence base for assessing the effectiveness of interventions for treating young children with severe acute malnutrition, including a lack of studies assessing the different interventions; limited details of study methods used; short follow-up post intervention or discharge; and heterogeneity in participants, interventions, settings, and outcome measures affecting generalisability.ConclusionsFor many of the most highly ranked questions evidence was lacking or inconclusive. More research is needed on a range of topic areas concerning the treatment of infants and children with SAM. Further research is required on most aspects of the management of SAM in children < 5 years, including intravenous resuscitation regimens for shock, management of subgroups (e.g. infants < 6 months old, infants and children with SAM who are human immunodeficiency virus sero-positive) and on the use of antibiotics.FundingThe National Institute for Health Research Technology Assessment programme.<br/
Evaluation of stroke thrombectomy including patients where IV thrombolysis is contraindicated or has failed: A randomized trial of two novel thrombectomy devices
No full text\ua9 Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. Background: Study was a PROBE design phase II randomized controlled trial (RCT). We assessed trial feasibility and technical efficacy and safety of two novel thrombectomy devices - ERIC (a retriever device) and SOFIA (a distal access catheter) - used alone or in combination depending on operator preference. Methods: Four UK neuroscience centers enrolled adults with proximal large artery occlusion (LAO) stroke on imaging where arterial puncture was achievable within 5.5 hours (8.5 hours for posterior circulation) of symptom onset; National Institutes of Health Stroke Scale (NIHSS) ≥6 with limited ischemic change on CT imaging. Randomization was 2:1 into intervention arm (ERIC and/or SOFIA). Patients and core lab were blinded to allocation. Primary outcome was independent core lab adjudication of reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) scale). Secondary outcomes were modified Rankin score (mRS) at 90 and 365 days (independence and shift analysis), 30-day mortality, symptomatic intracranial hemorrhage (sICH), procedural complications and NIHSS change. Results: Sixty-six patients were enrolled. TICI 2B/3 reperfusion was achieved in 72% in intervention compared with 90% in control arm on intention to treat (ITT) analysis (P=0.2) and 78% compared with 86% on per protocol analysis (P=0.7). Functional independence at 90 days was 40% (intervention) compared with 43% (control) on ITT analysis (P=1.0). sICH rates were low at 0% and 5%, respectively (P=0.3). The 30-day mortality was 9% intervention compared with 14% control (P=0.7). Conclusions: Study indicated feasibility of a phase II RCT trial approach for assessing new thrombectomy devices. In a broad LAO stroke population ERIC and SOFIA were not statistically different from control devices. Larger trials are needed
Trust and Formal Control in interorganizational Relationships
No full textThere is a tendency to see trust and control by formal agreements as substitutes. According to transaction cost economics trust is unreliable, and some form of control is needed to reduce hazards of opportunism. According to others, high trust allows for a limited extent of formal control. Formal control signals distrust and thereby evokes reciprocal distrust and formal control. This paper studies all combinations of high/low trust and high/low formal control in four longitudinal case studies. We find that trust and formal control are at least as much complements as they are substitutes. We find that like trust contracts can be both the basis and the outcome of relations.governance;inter-organizational relations;trust;contract
Challenges of stroke management in resource-limited settings: A case-based reflection
No full textA 19-year-old man presented with a 1-year history of headache, generalised body weakness, progressive memory loss, and disorientation. One month prior to admission, there was aggravation of the weakness of the right upper limb, with new-onset difficulty with mastication, speech impairment, apathy, and urinary incontinence. On clinical examination, the patient had a motor aphasia and a right-sided hemiparesis with increased muscle tone and hyperreflexia. A noncontrast computed tomography (CT) scan of the brain revealed large ischaemic strokes extending beyond the classical vascular territories. Cerebrospinal fluid analysis showed a mildly increased protein level. The electrocardiogram revealed an irregular sinus bradycardia. The remainder of the cardiovascular and laboratory workup was unremarkable. Considering a working diagnosis of central nervous system vasculitis, the patient was treated with aspirin, prednisolone, and physiotherapy. However, he died suddenly a few weeks later. Based on this case, we discuss the challenges of stroke management in resource-limited settings, provide practical tips for general practitioners, reflect on the potential avenues for short- and long-term action, and introduce the budding collaboration platform between the University College London, the University of Liverpool, the Queen Elizabeth Central Hospital, and the Malawi-Liverpool-Wellcome Trust Clinical Research Programme
