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Background The COVID-19 pandemic fundamentally changed the way services are delivered. Self-care, including good hygiene practices and avoidance of risk was emphasised as the key measure to tackle the pandemic in the early stages. Objective To understand how self-reported professional attitudes, perceptions and practices of self-care have changed as a result of the COVID-19 pandemic. Design Cross-sectional online survey and semi-structured qualitative interview. Setting Health and social care. Participants 304 health and social care professionals. Methods A wide range of health and social care professionals took part in a 27-item anonymous online survey. Semi-structured qualitative interviews with nine health & social care professionals explored attitudes to and practices of self-care before and during the pandemic. Views were sought on the permanence and implications of changes. Data were analysed using routine statistics and thematic analysis to identify major themes. Results A total of 304 health and social care professionals responded to the survey fully. Nine participated in a semi-structured interview. There was agreement that the importance of self-care has increased markedly during the pandemic. The percentage of respondents who felt that self-care was 'extremely' important to their clients increased from 54.3% to 86.6% since the pandemic. Personal empowerment and capacity of service users to self-care increased significantly during the pandemic. Willingness of patients to engage (74%) and poor understanding of self-care (71%) were cited as the two main barriers to self-care. A close third was digital exclusion (71%), though 86% of respondents recommending online resources and 77% the use of smartphone apps. Survey respondents believed the changes to be permanent and positive. Interviewees reported a major, and positive move to self-care with the pandemic seen as an opportunity to be grasped, but professional education would have to be aligned to make the most of it. They raised concerns as to whether the shift to self-care was perceived by users as 'abandonment' rather than 'empowerment' and whether problems had been stored rather than dealt with through self-care and therefore whether the positive changes would continue after the pandemic. Conclusion Reporting their views before the pandemic, barely more than half of the professionals surveyed saw self-care as fundamentally important to the individuals they served. This changed to 86% as a result of the pandemic. Patient/client engagement with and understanding of self-care were reported as major barriers, as was digital exclusion, though, increased technological solutions were used by all respondents. Concerns were raised that the permanence of the changes depended upon continued encouragement and empowerment of individuals to self-care and on its inclusion in professional education as a substantive subject.

Background Domestic violence and abuse (DVA) is a rising societal concern with increased prevalence since the national lockdowns and remains largely under-detected by the medical community. Although screening increases early detection of abuse, current NICE guidelines which were produced before the advent of COVID-19 do not recommend routine DVA screening in primary care. Little is known about patient views regarding DVA screening in UK primary care. This exploratory survey assesses the public’s experiences and their views on routine DVA screening. Methods An open, easily accessible anonymous 27-item eSurvey made available on the Imperial College London Qualtrics platform between 8 March and 27 September 2021 was used to collect data from community dwelling adults. Potentially eligible participants were contacted via email through community groups in Northwest London catchment area, and using adverts on social media. The survey targeted a wider population in the community, including those who were 18 years and over, living in the UK and spoke English. The eSurvey also included information on accessible support services. Data were summarised using frequencies and percentages. Regression analysis explored the association between WAST-short questions and previous exposure to abuse. Results Data from 298 community-dwelling adults was analysed. A third of respondents confirmed having experienced DVA, and another 6.4% declined disclosure. The univariable analysis suggested that those with a history of abuse compared to those with no history were 11 times more likely to have tension in the relationship and nine times more likely to have difficulty working out arguments. After adjusting for a-priori confounders (age, gender and ethnicity), those who answered ‘would rather not say’ appeared to be 34 times more likely to have tension in the relationship, and 17 times more likely to have difficulty working out arguments. Nearly two-thirds of the study population recommended routine screening in general practice using a short-validated tool. Conclusion The routine use of the already established screening tool such as WAST-short in primary care could help identify and potentially tackle DVA in our society. Training health and social care professionals in administering the brief, non-threatening DVA screening questionnaire would help raise awareness, identify and support victims.

Context Dysnatremia is an independent predictor of mortality in patients with bacterial pneumonia. There is paucity of data about the incidence and prognostic impact of abnormal sodium concentration in patients with coronavirus disease 2019 (COVID-19). Objective This work aimed to examine the association of serum sodium during hospitalization with key clinical outcomes, including mortality, need for advanced respiratory support and acute kidney injury (AKI), and to explore the role of serum sodium as a marker of inflammatory response in COVID-19. Methods This retrospective longitudinal cohort study, including all adult patients who presented with COVID-19 to 2 hospitals in London over an 8-week period, evaluated the association of dysnatremia (serum sodium 145 mmol/L, hyponatremia, and hypernatremia, respectively) at several time points with inpatient mortality, need for advanced ventilatory support, and AKI. Results The study included 488 patients (median age, 68 years). At presentation, 24.6% of patients were hyponatremic, mainly due to hypovolemia, and 5.3% hypernatremic. Hypernatremia 2 days after admission and exposure to hypernatremia at any time point during hospitalization were associated with a 2.34-fold (95% CI, 1.08-5.05; P = .0014) and 3.05-fold (95% CI, 1.69-5.49; P Conclusion Abnormal sodium levels during hospitalization are risk factors for poor prognosis, with hypernatremia and hyponatremia being associated with a greater risk of death and respiratory failure, respectively. Serum sodium values could be used for risk stratification in patients with COVID-19.

Impairment in mental functions attributed to the effects of indoor air quality and thermal conditions has received considerable attention in the past decade, particularly for educational buildings where students’ cognitive performance is essential to foster learning. This study explores the combined effects of indoor temperatures and CO2 levels as markers for ventilation rates on cognitive performance among female students (16– 23 years old) in Saudi Arabia. The longitudinal experiments involved nine conditions combining three CO2 concentration levels (achieved via changes in ventilation) and three temperature levels involving 499 participants, all exposed to the nine conditions. The study implemented a computer- based cognitive performance battery with “9Button” keyboards. Univariable and multivariable multilevel regression models explored the association of indoor temperature and CO2 levels (as markers for ventilation rates) with cognitive performance after adjusting for potential confound-ers. Potential benefits were found on speed and accuracy of tasks of cognitive perfor-mance when indoor temperature was set between 20 and 23ºC and at CO2 levels of 600 ppm compared to higher temperatures and poorer ventilation rates and that both ventilation and thermal environmental control are important and need to be improved for achieving optimum learning conditions. Nevertheless, the results are relevant for short-term exposures lasting no more than 2 h.

Objective: To investigate the prevalence of widespread pain among people with HIV (PWH) and describe associations with antiretroviral therapy (ART) and markers of HIV disease stage. Design: Cross-sectional analysis of cohort study in the United Kingdom and Ireland. Methods: Pain information was collected during the baseline visit (conducted from 2013 to 2015) through a self-completed manikin identifying pain at 15 sites from five body regions. Pain was classified as widespread if reported at at least four regions and at least seven sites, or regional otherwise. Chi-squared tests, Kruskal–Wallis tests and ordinal logistic regression were used to consider associations between pain extent and sociodemographic and HIV-related factors. Results: Among the 1207 participants (614 PWH ≥ 50 years, 330 PWH < 50 years, 263 HIV-negative controls ≥50 years), pain was most commonly reported at the upper (left: 28.9%, right: 28.0%) and lower (left: 25.7%; right: 24.5%) leg, upper (18.6%) and lower (29.7%) back and shoulders (left: 16.0%; right: 16.8%). Widespread pain was more commonly reported in PWH than in HIV-negative controls (PWH ≥ 50 years: 18.7%; PWH < 50 years: 12.7%; HIV-negative ≥50 years: 9.5%) with regional pain reported in 47.6, 44.8 and 49.8%, respectively (global P = 0.001). In multivariable analyses, pain extent was greater in those with lower educational attainment, those exposed to more ART drugs, and those with a higher current CD4+ cell count but longer exposure to immunosuppression. Conclusion: Widespread pain is commonly reported in PWH and is associated with longer duration of exposure to HIV, immunosuppression and ART. Our findings call for greater awareness, and interventions to support the management, of pain in PWH.

The aims of the study were to describe the prevalence of obesity in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) cohort, to identify demographic, clinical and HIV-specific factors associated with obesity, and to characterize the association between obesity and sociodemographic, clinical and HIV-specific factors and quality of life (QoL).A cross-sectional analysis was carried out of baseline data from the three groups ["older" people with HIV infection (PWH) aged ≥ 50 years, "younger" PWH aged50 years and HIV-negative controls aged ≥ 50 years] within the POPPY cohort. Obesity was defined as a body mass index (BMI) 30 kg/mA total of 1361 subjects were included in the study, of whom 335 (24.6%) were obese. The prevalence of obesity was higher in controls (22.3%) than in older (16.8%) and younger (14.2%) PWH, with no differences between the two groups of PWH. Factors associated with obesity were older age, female gender, black African ethnicity and alcohol consumption. Recreational drug use and a higher current CD4 T-cell count (in PWH) were associated with lower and higher odds of being obese, respectively. The presence of obesity was associated with worse physical health QoL scores, higher odds of having cardiovascular disease, type 2 diabetes and hypertension, but lower odds of having osteopenia/osteoporosis, irrespective of HIV status.Despite a lower prevalence of obesity in PWH, specific subgroups (women, people of black African origin and older people) were more likely to be obese, and negative health consequences of obesity were evident, regardless of HIV status. Whether targeted preventive strategies can reduce the burden of obesity and its complications in PWH remains to be determined.

Associations between markers of liver and renal dysfunction and nucleotide reverse transcriptase inhibitor plasma exposure are ill-defined. As part of a large cohort study (Pharmacokinetic and Clinical Observations in People over Fifty), we analysed associations between alanine aminotransferase and estimated glomerular filtration rate results in people living with HIV on tenofovir disoproxil fumarate, emtricitabine, abacavir and lamivudine. While we found no associations between nucleotide reverse transcriptase inhibitor concentrations and alanine aminotransferase, lower estimated glomerular filtration rate values were associated with greater tenofovir, emtricitabine and lamivudine exposure, whereas abacavir showed no associations.

In the hot climate of Saudi Arabia, people living year-round in air-conditioned spaces are likely to develop high expectations for homogeneity and cool temperatures, becoming potentially more sensitive if thermal conditions deviate from the comfort zone they expect. This paper presents the results from a field intervention investigating the association between participants’ thermal sensations with cognitive performance in a female university in Saudi Arabia. The climatic context plays a key role in choosing Saudi Arabia, whereas the total reliance on air-conditioners (AC) for cooling is believed to have significant effects on occupants’ perceptions of the comfort temperature. Results reveal discrepancies in the actual thermal sensations between the Saudi and non-Saudi participants which affected their performances. “Cool” and “Slightly Cool” sensations versus neutral were associated with significant lower percentage of errors and significant higher speed for all participants independently of any association with ethnicity and acclimatization. The estimates remained significant even after adjusting for ethnicity and the number of years spent in the country and the set temperature of AC at home. Implications of the study suggest a preference for staying cool when working independently of acclimatization status.

Objectives To investigate the associations of plasma lamivudine (3TC), abacavir (ABC), emtricitabine (FTC) and tenofovir (TFV) concentrations with cognitive function in a cohort of treated people with HIV (PWH). Methods Pharmacokinetics (PK) and cognitive function (Cogstate, six domains) data were obtained from PWH recruited in the POPPY study on either 3TC/ABC or FTC/tenofovir disoproxil fumarate (TDF)-containing regimens. Association between PK parameters (AUC0-24: area under the concentration-time curve over 24 hours, Cmax: maximum concentration and Ctrough: trough concentration) and cognitive scores (standardized into z-scores) were evaluated using rank regression adjusting for potential confounders. Results Median (IQR) global cognitive z-scores in the 83 PWH on 3TC/ABC and 471 PWH on FTC/TDF were 0.14 (-0.27, 0.38) and 0.09 (-0.28, 0.42), respectively. Higher 3TC AUC0-24 and Ctrough were associated with better global z-scores [rho = 0.29 (p = 0.02) and 0.27 (p = 0.04), respectively], whereas higher 3TC Cmax was associated with poorer z-scores [rho = -0.31 (p0.05). None of the FTC and TFV PK parameters were associated with global or domain cognitive scores. Conclusions Whilst we found no evidence of either detrimental or beneficial effects of ABC, FTC and TFV plasma exposure on cognitive function of PWH, higher plasma 3TC exposures were generally associated with better cognitive performance although higher peak concentrations were associated with poorer performance.

Objectives Despite the proven efficacy of several smoking cessation medications that have been shown to improve long-term abstinence rates, approximately two-thirds of smokers report not having used medication in their most recent quit attempt. A main barrier could be delayed access to pharmacological interventions. This study investigated the utility of a primary care linked online portal to streamline timely access to pharmacological support to patients who want to quit smoking by making an asynchronous request for treatment to their general practitioner. Study design Prospective cohort study. Methods An online portal with added functionality was developed, which allowed patients with a unique link to make an asynchronous request for treatment. Two GP practices identified a total of 4337 eligible patients who received an SMS or email invite to engage with an online portal including an electronic survey to capture information about smoking behaviours and to request treatment. Portal informatics and patient level data were analysed to measure the efficacy of the online system in reducing the time between making a formal request to treatment and access to pharmacological support. The primary outcome measure was the time between making a formal request for treatment and access to pharmacological support from a designated community pharmacy. Results 323 patients (7.4%) initiated the survey, but only 56 patients completed the survey and made a formal request for treatment. 94% of participants did not return to use the portal to make a second or follow-up request for treatment. Only 3 participants completed the 12-week pathway. A total of 75 medication items were prescribed and collected by 56 patients. The time difference between the formal request to treatment and GP review ranged between 20 h and 1 week. The time difference between approval of prescription by the GP and access to medication was 5 days ± 2.1 days (range = 1.9–7.0 days). Conclusion The widespread adoption and diffusion of an IT enabled and asynchronous primary care led remote consultation pathway can streamline timely access to smoking cessation support without the need for the patient to see a GP or an independent prescriber in the first instance.

Background Self-reported sleep quality is poor in persons with human immunodeficiency virus (PWH), but prior studies commonly used nonspecific questionnaires, investigated only single sleep disorders, or lacked human immunodeficiency virus (HIV)-negative controls. We addressed these limitations in the Pharmacokinetics and Clinical Observations in People Over Fifty (POPPY) Sleep Substudy by assessing PWH and HIV-negative controls for insomnia, restless legs syndrome (RLS), and sleep apnea (SA). Methods Previously enrolled POPPY participants coenrolled in this substudy without regard to sleep symptoms. Participants completed validated sleep assessments including the Insomnia Severity Index questionnaire, International Restless Legs Syndrome Study Group questionnaire, and in-home, wrist-worn overnight oximetry. They also completed health-related quality of life questionnaires including 36-item Short Form (SF-36) and Patient-Reported Outcomes Measurement Information System (PROMIS) sleep questionnaires. Results We enrolled 357 PWH (246 >50 years of age; 111 between 18 and 50 years) and 126 HIV-negative controls >50 years of age. Among PWH, criteria were met by 21% for insomnia, 13% for RLS, and 6% for SA. Compared with HIV-negative controls, PWH had a higher risk of insomnia (adjusted odds ratio, 5.3; 95% confidence interval, 2.2–12.9) but not RLS or SA. Compared with PWH without insomnia, those with insomnia reported significantly worse scores on all SF-36 and PROMIS components; fewer than 30% reported previous diagnosis or treatment for insomnia. Conclusions Insomnia was more common in PWH, associated with worse health-related quality of life, and frequently undiagnosed. Further research should focus on the pathogenesis of insomnia in PWH and the development of effective screening and intervention strategies for this unique population.

ObjectiveTo assess the suitability of primary care vignettes in benchmarking the performance of online symptom checkersDesignObservational study using publicly available, free online symptom checkersParticipantsThree symptom checkers (Healthily, Ada and Babylon) that provided consultations in English. 139 standardized patient vignettes were compiled by RCGP. Three independent GPs interpreted the vignettes to arrive at a “Gold Standard” consisting of 3 dispositions and divided into one of three categories of triage urgency: (1) emergency care required, (2) primary care required and (3) self-care.Main outcome measuresSix professional non-medical and lay inputters simulated 2774 standardized patient evaluations using 3 online symptom checkers (OSC). We recorded when OSC provided a triage recommendation and whether it correctly recommended the appropriate triage recommendation across three categories of triage urgency (emergency care, primary care or self-care). We collected data on whether the solution appeared within the first 3 dispositions in each of the standards across 2774 standardized patient evaluations.ResultsWhen benchmarked against the Gold Standard, Healthily provided an appropriate triage recommendation 61.9% of the time compared to 45.3% and 42.4% of the time for Babylon and Ada respectively. There was poor agreement between OSC consultation outcome and Gold Standard dispositions. When compared to the Gold Standard, Healthily gave an unsafe “under-triage” recommendation 28.6% of the time overall across the three categories compared to 43.3% for Ada and 47.5% for Babylon (PConclusionsOSCs recommended ‘very unsafe’ triages only Strengths and limitations of this study139 independently created primary care vignettes covering 18 subcategories of primary care were used to benchmark the performance of three online symptom checkers using 2774 unique patient simulationsA gold standard for each primary care vignette was derived using GP roundtables and single blinded testingWe investigated the extent that different inputters using the same vignette and online symptom checker received differing consultation outcomes and triage recommendationsWe developed an accuracy matrix to objectively monitor online symptom checker consultation outcome and the safety of the triage recommendationLimitations included a different number of inputters to simulate patients across the three online symptom checkers tested

Background: Hypernatremia and hyponatremia (serum sodium > 145 mmol/L and < 135 mmol/L, respectively) are independent risk factors for excess mortality in patients with bacterial pneumonia. We sought, for the first time, an association of sodium [Na] abnormalities with mortality, need for advanced respiratory support and Acute Kidney Injury (AKI) in hospitalized patients with coronavirus disease 19 (COVID-19). Methods: This retrospective, longitudinal, cohort study included 488 adults, 277 males and 211 females, with a median age of 68 years, who were hospitalized with COVID-19 to two hospitals in London over an 8-week period (February to May 2020). Results: The in-hospital mortality rate was 31.1% with a medial length of stay of 8 days. High [Na] levels at any timepoint during hospital stay were associated with significantly increased mortality rate (56.6% vs 21.1% in patients who remained constantly normonatremic; odds ratio 3.05, 95% CI 1.69-5.49; p death. AKI affected 37.1% of patients (21.3%, 7.4% and 8.4% stages 1, 2 and 3 respectively) but was not related to serum sodium values. Conclusions: In hospitalized COVD-19 patients, hypernatremia at any timepoint was associated with excess mortality, suggesting that [Na] concentration may facilitate risk stratification. In addition, whilst our data cannot prove causality, these findings highlight the significance of judicious rehydration in such patients.

Objectives\ud High rates of respiratory symptoms and chronic bronchitis (CB) are reported in people with HIV infection (PWH). We investigated the prevalence of respiratory symptoms and CB in PWH and HIV‐negative people in the Pharmacokinetic and clinical Observations in PeoPle over fiftY (POPPY) study.\ud \ud Methods\ud Assessment of respiratory symptoms and CB was undertaken using the modified form of the St. George’s Respiratory Questionnaire for chronic obstructive pulmonary disease (COPD). Univariate (χ2 tests, Mann–Whitney U tests and Spearman’s rank correlation) and multivariable (linear and logistic regression) analyses were performed to consider associations of respiratory symptoms with demographic, lifestyle and HIV‐related parameters, and with depressive symptoms and quality of life.\ud \ud Results\ud Among the 619 participants, respiratory Symptom scores were higher in older and younger PWH compared to older HIV‐negative people, with median (interquartile range) scores of 17.7 (6.2, 39.5), 17.5 (0.9, 30.0) and 9.0 (0.9, 17.5), respectively (P = 0.0001); these differences remained significant after confounder adjustment. Sixty‐three participants (10.2%) met the criteria for CB [44 (14.0%) older PWH, 14 (9.2%) younger PWH, and five (3.3%) older HIV‐negative people; P = 0.002], with these differences also remaining after adjustment for confounding variables, particularly smoking status [older vs. younger PWH: odds ratio (OR) 4.48 (95% confidence interval (CI) 1.64, 12.30); P = 0.004; older PWH vs. HIV‐negative people: OR 4.53 (95% CI 1.12, 18.28); P = 0.03]. Respiratory symptoms and CB were both associated with greater depressive symptom scores and poorer quality of life. No strong associations were reported between CB and immune function, HIV RNA or previous diagnosis of any AIDS event.\ud \ud Conclusions\ud Respiratory symptoms and CB are more common in PWH than in demographically and lifestyle‐similar HIV‐negative people and are associated with poorer mental health and quality of life.

We evaluated associations between history of syphilis infection and both cognitive function and depressive symptoms in people living with HIV (PLHIV) and comparable HIV-negative controls. Syphilis serological tests, cognitive function and depression were assessed in PLHIV and controls participating in the Pharmacokinetic and Clinical Observations in People Over Fifty study. Cognitive test scores were converted to demographically adjusted T-scores (mean = 50, SD = 10) and then averaged to obtain a global T-score. Severity of depressive symptoms was assessed via the Patient Health Questionnaire-9. Associations of syphilis with global T-scores and depression were assessed using median regression. The 623 PLHIV and 246 HIV-negative controls were predominantly male (89.3% and 66.5%) with median age (interquartile range [IQR]) of 57 (53–63) and 58 (53–63) years, respectively. PLHIV had lower global cognitive T-scores (median [IQR] 48.7 [45.1, 52.1] versus 50.5 [47.0, 53.9], p

Aims To evaluate the effectiveness of a workplace digital health promotion programme with monthly telecoaching on various lifestyle and clinical outcome measures. Methods We recruited 103 participants from an occupational setting in the UK. Participants were assessed at baseline, and 3 and 6 months following intervention to determine the effect of an employer sponsored digital telecoaching intervention on various lifestyle and clinical outcome measures. Results A pragmatic sample size of 103 participants from a wide demographic background was recruited at baseline, with 95 participants (92%) completing the programme by 6 months. Almost all participants showed a significant improvement in the health score and 24 secondary outcome measures including HbA1c, blood pressure and reduction in smoking. Linear regression model showed that after adjusting for age and gender, the LiveSmart health score appeared to significantly improve by 6.22 units at 3 months (95% confidence interval (CI) 4.38 to 8.06) and by 7.73 units at 6 months (95% CI 5.75 to 9.71), compared with baseline visit, p

Background Polypharmacy (use of ≥ five medications) increases the risk of drug-drug interactions and can lead to negative health outcomes. This study aimed to review the medications of people living with HIV (PLWH) and HIV-negative controls in the POPPY study and evaluate the frequency of polypharmacy and potential drug-drug interactions (PDDIs). Methods PDDIs between non-antiretroviral (ARV) drugs were analysed using the Lexicomp® database, and PDDIs between non-ARV and ARV drugs using the Liverpool drug interaction database. Between-group differences were assessed using χ2, Mann-Whitney U and Kruskal-Wallis tests. Results This analysis included 698 PLWH ≥50 years, 374 PLWH Conclusions Polypharmacy and PDDIs involving non-ARV/ARV drugs and non-ARV/non-ARV drugs were common among older PLWH, highlighting the need for increased awareness and additional research on all types of PDDI.

OBJECTIVE: We describe the prevalence of pain and its associations with healthcare resource utilization and quality-of-life. DESIGN: The POPPY Study recruited three cohorts: older people living with HIV (PLWH; ≥50 years, n = 699), younger demographically/lifestyle similar PLWH (less than 50 years, n = 374) and older demographically/lifestyle similar HIV-negative (≥50 years, n = 304) people from April 2013 to February 2016. METHODS: Current pain and pain-related healthcare use was collected via a self-reported questionnaire. Logistic regression assessed between-group differences in the prevalence of pain in the past month and current pain after controlling for potential confounders. Associations between current pain and healthcare resource use, reported joint problems, depressive symptoms, quality-of-life and functional status were assessed in PLWH using Mann-Whitney U and chi-squared tests. RESULTS: Pain in the past month was reported by 473 out of 676 (70.0%) older PLWH, 224 out of 357 (62.7%) younger PLWH and 188 out of 295 (63.7%) older HIV-negative controls (P = 0.03), with current pain reported in 330 (48.8%), 134 (37.5%) and 116 (39.3%), respectively (P = 0.0007). Older PLWH were more likely to experience current pain, even after adjustment for confounders. Of those with pain in the past month, 56 out of 412 (13.6%) had missed days of work or study due to pain, and 520 (59%) had seen a doctor about their pain. PLWH experiencing current pain had more depressive symptoms, poorer quality-of-life on all domains and greater functional impairment, regardless of age group. CONCLUSION: Even in the effective antiretroviral therapy era, pain remains common in PLWH and has a major impact on quality-of-life and associated healthcare and societal costs. Interventions are required to assist clinicians and PLWH to proactively manage pain.

Aim Review a series of children with posterior circulation arterial ischaemic stroke (PCAIS) to identify diagnostic modality and associations in cases of vertebral artery dissection (VAD). Method Retrospective analysis of 30 cases of childhood PCAIS identified from two tertiary centres over 11 years. Clinical and demographic details were recorded. Brain and cerebrovascular imaging were reviewed. Aetiology was classified using the Childhood Arterial Ischaemic Stroke Standardized Classification and Diagnostic Evaluation criteria. Outcome was evaluated using standardized paediatric stroke outcome scores. Logistic regression was used to explore variables associated with diagnosis. Results Twenty-three patients were male (77%) and 7 were female (23%). VAD was the most commonly identified aetiology, in 15 cases (50%). Aetiology was undetermined in 12 (40%), probable cardioembolism in two, and reversible cerebral vasoconstriction syndrome in one. In those with VAD, diagnosis was made on initial magnetic resonance angiography (MRA) in six (40%). Further cases of VAD were diagnosed with catheter angiography (n=6), computed tomographic angiography (n=1), or follow-up MRA (n=2). Presence of multiple infarcts was associated with a diagnosis of VAD. Interpretation Endoluminal cerebrovascular imaging increases the rate of diagnosis of VAD in childhood PCAIS and should especially be considered if there are multiple infarcts.

Summary Background Women living with HIV are potentially at increased risk of adverse pregnancy outcomes, due to a range of factors, including immunosuppression, use of combination antiretroviral therapy (ART), and injecting drug use. Rates of mother-to-child transmission of HIV in Ukraine have declined to around 2–4%, but little is known about other pregnancy outcomes in this setting. We used data from an observational prospective cohort study to assess pregnancy outcomes among HIV-positive women in Ukraine. Methods The European Collaborative Study (ECS) in EuroCoord is a continuing cohort study, established in Ukraine in 2000. Eligible women are those with a diagnosis of HIV infection before or during pregnancy (including intrapartum) who deliver liveborn babies at seven sites. Maternal sociodemographic, HIV-related, and delivery (mother and infant) data were collected with study-specific questionnaires. We used Poisson regression models to identify factors associated with preterm delivery (before 37 weeks' gestation) and small weight for gestational age (less than the tenth percentile of weight for gestational age), based on complete cases. Findings Between January, 2000, and July, 2012, data were collected on 8884 HIV-positive mother and liveborn infant pairs. Median maternal age was 26·5 years (IQR 23·1–30·3). 832 (11%) women had WHO stage 3 or 4 HIV and 1474 (17%) had a history of injecting drug use. 7348 (83%) had received antenatal ART. Among 7435 for whom ART type was available, 4396 (50%) had received zidovudine monotherapy and 2949 (33%) combination ART. Preterm delivery was seen in 780 (9%, 95% CI 8–9) of 8860 births overall and in 77 (9%, 7–11) of 889 babies with small size for gestational age. Factors associated with preterm delivery were history of injecting drug use (adjusted risk ratio 1·64, 95% CI 1·38–1·95), no ART (2·94, 2·43–3·57 vs zidovudine monotherapy), antenatal combination ART (1·40, 1·14–1·73 vs zidovudine monotherapy), WHO stage 4 HIV (2·42, 1·71–3·41 vs WHO stage 1), and being in the most socially deprived group (1·38, 1·11–1·71). Small size for gestational age was associated with history of injecting drug use (adjusted RR 1·39, 95% CI 1·16–1·65), most socially deprived (1·32, 1·09–1·61), no ART (1·60, 1·32–1·94 vs zidovudine monotherapy), and antenatal combination ART (1·33, 1·12–1·60 vs zidovudine monotherapy). Interpretation Some risk factors for adverse pregnancy outcomes were directly associated with HIV and treatment and others were shared with the general antenatal population. Monitoring of pregnancy outcomes in Ukraine will be important as use of antenatal combination ART increases. Funding European Union Seventh Framework Programme, Wellcome Trust.

Background Intravenous aminoglycoside (IV AG) antibiotics, widely used in patients with cystic fibrosis (CF), are known to have ototoxic complications. Despite this, audiological monitoring is not commonly performed and if performed, uses only standard pure-tone audiometry (PTA). The aim of this study was to investigate ototoxicity in CF children, to determine the most appropriate audiological tests and to identify possible risk factors. Methods Auditory assessment was performed in CF children using standard pure tone audiometry (PTA), extended high-frequency (EHF) audiometry and distortion-product otoacoustic emissions (DPOAE). Results 70 CF children, mean (SD) age 10.7 (3.5) years, were recruited. Of the 63 children who received IV AG, 15 (24%) children had ototoxicity detected by EHF audiometry and DPOAE. Standard PTA only detected ototoxicity in 13 children. Eleven of these children had received at least 10 courses of IV AG courses. A 25 to 85dBHL hearing loss (mean±SD: 57.5±25.7dBHL) across all EHF frequencies and a significant drop in DPOAE amplitudes at frequencies 4 to 8kHz were detected. However, standard PTA detected a significant hearing loss (>20dBHL) only at 8kHz in 5 of these 15 children and none in 2 subjects who had significantly elevated EHF thresholds. The number of courses of IV AG received, age and lower lung function were shown to be risk factors for ototoxicity. Conclusions CF children who had received at least 10 courses of IV AG had a higher risk of ototoxicity. EHF audiometry identified 2 more children with ototoxicity than standard PTA and depending on facilities available, should be the test of choice for detecting ototoxicity in children with CF receiving IV AG.

Objectives Hyponatraemia is strongly associated with increased inpatient mortality, but it is unknown whether hyponatraemia per se contributes to excess mortality. Our hypothesis was that if hyponatraemic patients had significantly greater mortality compared with controls despite no difference with regard to gender, age, comorbidities and type of primary pathology, this would incriminate hyponatraemia as an independent predictor of mortality. Design Single-centre, case-control study. Patients Cases (N = 139) were hospitalized patients with serum Na ≤ 128 mmol/l over 3 months. Controls were 254 age- and gender-matched patients residing in the same hospital ward with serum Na > 128 mmol/l. Measurements Data were collected about age, gender, comorbidities, drug history, serum creatinine, intensive care unit (ICU) admission and length of hospitalization. The main outcome measure was inpatient mortality. Results Hyponatraemic patients had an inpatient mortality rate of 17·3% and were more than three times more likely to die during their hospital stay compared with controls (OR 3·33, 95% CI 1·68-6·58, P < 0·01) despite no statistically significant difference with respect to age, gender, comorbidities, use of common drugs, serum creatinine, ICU admission rate and length of hospitalization. Comparison of cases with the normonatraemic subgroup of controls demonstrated that cases were almost 12 times more likely to die during admission than normonatraemic controls (OR 11·89, 95% CI 2·75-51·51, P < 0·01). Conclusions This study showed that hyponatraemia is an independent predictor of mortality, and hyponatraemia per se is likely to contribute to excess mortality. Further studies are needed to examine whether correction of hyponatraemia can reduce mortality. © 2014 John Wiley & Sons Ltd.

Our aim was to assess second-hand smoke (SHS) exposure in hospitality venues after the smoke-free legislation implemented in September 2010 in Greece and to compare with when a partial ban was in place and in 2006 when no ban was in place.Hospitality venues were prospectively assessed for their indoor concentrations of particulate matter (PM(2.5)) during the partial ban phase (n=149) and the complete ban phase (n=120, 80% followed up), while overall and matched by venue comparisons were also performed (no ban vs. partial ban vs. complete ban). Comparisons with previously collected data in 2006 when no ban was in place also was performed.Indoor air levels of PM(2.5) attributable to SHS dropped following the transition from a partial to a complete ban by 34% (137 μg/m(3) vs. 90 μg/m(3), p=0.003). This drop was larger in bars (from 195 μg/m(3) to 121 μg/m(3)), than in cafes (124 μg/m(3) vs. 87 μg/m(3)) or restaurants (42 μg/m(3) vs. 39 μg/m(3)). PM(2.5) concentrations between 2006 (no ban) and the partial ban of 2010 were also found to decrease by 94 μg/m(3); however, among matched venues, the levels of indoor air pollution were not found to change significantly (218 μg/m(3) vs. 178 μg/m(3), p=0.58). Comparing the 2010 complete ban results (n=120) with previously collected data from 2006 when no ban was in place (n=43), overall PM(2.5) concentrations were found to fall from 268 μg/m(3) to 89 μg/m(3), while a matched analysis found a significant reduction in PM(2.5) concentrations (249 μg/m(3) vs. 46 μg/m(3), p=0.011).The complete ban of smoking in hospitality venues in Greece led to a reduction in SHS exposure, in comparison to when the partial ban or no ban was in place; however, exposure to SHS was not eliminated indicating the need for stronger enforcement.

Objective To determine the effect of visual feedback on rate of chest compressions, secondarily relating the forces used. Design Randomised crossover trial. Setting Tertiary teaching hospital. Subjects Fifty trained hospital staff. Interventions A thin sensor-mat placed over the manikin's chest measured rate and force. Rescuers applied compressions to the same paediatric manikin for two sessions. During one session they received visual feedback comparing their real-time rate with published guidelines. Outcome measures Primary: compression rate. Secondary: compression and residual forces. Results Rate of chest compressions (compressions per minute (compressions per minute; cpm)) varied widely (mean (SD) 111 (13), range 89–168), with a fourfold difference in variation during session 1 between those receiving and not receiving feedback (108 (5) vs 120 (20)). The interaction of session by feedback order was highly significant, indicating that this difference in mean rate between sessions was 14 cpm less (95% CI −22 to −5, p=0.002) in those given feedback first compared with those given it second. Compression force (N) varied widely (mean (SD) 306 (94); range 142–769). Those receiving feedback second (as opposed to first) used significantly lower force (adjusted mean difference −80 (95% CI −128 to −32), p=0.002). Mean residual force (18 N, SD 12, range 0–49) was unaffected by the intervention. Conclusions While visual feedback restricted excessive compression rates to within the prescribed range, applied force remained widely variable. The forces required may differ with growth, but such variation treating one manikin is alarming. Feedback technologies additionally measuring force (effort) could help to standardise and define effective treatments throughout childhood.

Although benefits of breastfeeding have been widely promoted and accepted, exclusive breastfeeding for the first 6 months of life is far from the norm in many countries. In a prospective mother-child cohort study in Crete, Greece ('Rhea' study), we assessed the frequency of breastfeeding and its socio-demographic predictors. Information on breastfeeding was available for a period of 18 months post-partum for a cohort of 1181 mothers and their 1208 infants. The frequency of exclusive and predominant breastfeeding in the first month post-partum was 17.8% and 3.4%, respectively, with almost three-quarters of women (73.6%) ceasing any breastfeeding after 4 months post-partum. Women were less likely to initiate breastfeeding if they had a caesarean delivery (CD), whereas they were more likely to initiate breastfeeding if they had a higher education or gave birth to a private clinic. Among women breastfeeding, those who had a CD, were ex-smokers or smokers during pregnancy had a statistically significant shorter duration of breastfeeding, whereas higher education and being on leave from work were associated with a longer duration of breastfeeding. Study findings suggest suboptimal levels of exclusive and any breastfeeding and difficulty maintaining longer breastfeeding duration. CD and smoking are common in Greece and are strong negative predictors for breastfeeding initiation and/or duration, necessitating targeting women at risk early in the prenatal period so as to have a meaningful increase of breastfeeding practices in future cohorts of mothers.

Estimation and interpretation of thyroid function tests in pregnant women is of utmost importance for maternal, fetal and neonatal health. Our objective was to calculate laboratory- and geography-specific reference intervals for thyroid hormones during pregnancy in an iodine-sufficient area of the Mediterranean, Crete, Greece. This project was performed in the context of “Rhea” mother-child cohort. Fulfillment of extensive questionnaires and estimation of free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), and antithyroid antibodies were performed. The reference population was defined using inclusion criteria regarding thyroidal, obstetric, and general medical status of women. Reference interval for TSH was 0.05–2.53 μIU/mL for the first and 0.18–2.73 μIU/mL for the second trimester. 6,8% and 5,9% of women in the first and second trimester, respectively, had TSH higher than the upper reference limit. These trimester-specific population-based reference ranges are essential in everyday clinical practice for the correct interpretation of thyroid hormone values and accurate classification of thyroid disorders.

SummaryObjective European guidelines do not recommend tolvaptan for treatment of syndrome of inappropriate antidiuretic hormone secretion (SIADH), principally owing to concerns about risk of overly rapid correction of hyponatraemia. This study evaluated the real-life effectiveness and safety of tolvaptan. Design Consecutive case series. Patients Inpatients treated with tolvaptan for SIADH in 2 UK hospitals over a 3-year period. Measurements The primary outcome measures were serum sodium (sNa) correction at 24 and 48 h after tolvaptan therapy. Results This case series included 61 patients aged 74·4 ± 15·3 years with (mean ± SD) sNa 119·9 ± 5·5 mmol/l. The mean sNa increase 24 h after tolvaptan initiation was 9 ± 3·9 mmol/l. Excessive correction of hyponatraemia was observed in 23% of patients with all these patients having baseline sNa

Although benefits of breastfeeding have been widely promoted and accepted, exclusive breastfeeding for the first 6 months of life is far from the norm in many countries. In a prospective mother–child cohort study in Crete, Greece (‘Rhea’ study), we assessed the frequency of breastfeeding and its socio‐demographic predictors. Information on breastfeeding was available for a period of 18 months post‐partum for a cohort of 1181 mothers and their 1208 infants. The frequency of exclusive and predominant breastfeeding in the first month post‐partum was 17.8% and 3.4%, respectively, with almost three‐quarters of women (73.6%) ceasing any breastfeeding after 4 months post‐partum. Women were less likely to initiate breastfeeding if they had a caesarean delivery (CD), whereas they were more likely to initiate breastfeeding if they had a higher education or gave birth to a private clinic. Among women breastfeeding, those who had a CD, were ex‐smokers or smokers during pregnancy had a statistically significant shorter duration of breastfeeding, whereas higher education and being on leave from work were associated with a longer duration of breastfeeding. Study findings suggest suboptimal levels of exclusive and any breastfeeding and difficulty maintaining longer breastfeeding duration. CD and smoking are common in Greece and are strong negative predictors for breastfeeding initiation and/or duration, necessitating targeting women at risk early in the prenatal period so as to have a meaningful increase of breastfeeding practices in future cohorts of mothers.

Background To date, no research exists on the role that different sources of exposure to second-hand smoke (SHS) have on 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and nicotine uptake, assessed via urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and cotinine concentrations of non-smoking pregnant women, nor the differences in NNAL concentrations among pregnant women who quit smoking in comparison to those who do not. Methods As part of the ‘Rhea’ mother childbirth cohort in Crete, Greece, 1317 mother–child pairs were followed-up until delivery, while among a subsample, maternal urine was assessed for its NNAL (n=117) and cotinine concentrations (n=377). Results Pregnant women who continued to smoke during pregnancy were found to have geometric mean urinary NNAL concentrations of 0.612 pmol/ml, in comparison to the 0.100 pmol/ml of ex-smokers and 0.0795 pmol/ml of non-smokers exposed to SHS. Exposure to SHS in the home was associated with a 4.40 ng/ml increase in urinary cotinine levels, while reported exposure to SHS in cars was associated with an even higher (8.73 ng/ml) increase in cotinine concentrations and was strongly related to NNAL concentrations. Exposure to SHS in the workplace and in public places was also shown to increase cotinine and NNAL concentrations. The NNAL:cotinine ratio was found to be higher among pregnant women who were exposed to SHS but did not smoke (p Conclusions Using cotinine levels as an indicator of NNK, exposure due to SHS during pregnancy leads to an underestimation of exposure to NNK uptake. Moreover, each source of exposure contributed to the increase in cotinine levels, indicating the importance of avoiding SHS exposure from any source.

The syndrome of inappropriate antidiuresis is often undertreated with most patients discharged with persistent hyponatraemia. This study tested the hypothesis that an endocrine input is superior to routine care in correcting hyponatraemia and can improve patient outcomes. This single-centre prospective-controlled intervention study included inpatients admitted at a UK teaching hospital, with serum sodium ≤ 127 mmol/l, due to syndrome of inappropriate antidiuresis over a 6-month period. The prospective intervention group (18 subjects with mean serum sodium 120.7 mmol/l) received prompt endocrine input, while the historical control group (23 patients with mean serum sodium 124.1 mmol/l) received routine care. The time needed for serum sodium increase ≥ 5 mmol/l was the primary endpoint. The intervention group achieved serum sodium rise by ≥5 mmol/l in 3.5 vs. 7.1 days in the control group (P = 0.005). In the intervention group, the mean total serum sodium increase was 12 mmol/l with only 5.8 % of patients discharged with serum sodium