Background The association between substance use including marijuana use and attempted suicide has been well documented.However,little is known about marijuana use and its association with attempted suicide repetition...Background The association between substance use including marijuana use and attempted suicide has been well documented.However,little is known about marijuana use and its association with attempted suicide repetition among young people in low-income and middle-income contexts.Aims This analysis was conducted to assess the factors associated with marijuana use and ascertain marijuana use as a determinant of repeated attempted suicide among senior high school(SHS)students in Ghana.Methods Data from the 2012 Global School-Based Student Health Survey in Ghana was used for this study.Modified Poisson,Logistic and Probit models weighted with Mahalanobis distance matching within propensity calliper were employed separately to determine the hypothetical association between marijuana use and repeated attempted suicide.All analysis was performed using Stata 16 and p<0.05 was deemed statistically significant.Results The prevalence estimates of marijuana use and repeated attempted suicide among SHS students in Ghana were 3.4%(95%Cl:2.3 to 5.1)and 11.5%(95%Cl:9.1 to 14.4),respectively.The prevalence of marijuana use was significantly associated with school grade,smoking exposure,parent smoker,alcohol intake and truancy.Marijuana use was positively associated with repeated attempted suicide among SHS in Ghana correlation=0.23,p<0.001.Repeated attempted suicide among students who use marijuana was approximately threefold and fivefold significant compared with nonmarijuana use students,based on the Poisson(adjusted prevalence ratio:3.02;95%Cl:1.67 to 5.43,p<0.001)and Logistic(adjusted OR:5.06;95%Cl:3.19 to 11.64,p<0.001)estimates respectively.Also,the Probit model showed that marijuana use significantly increased the log count of repeated attempted suicide by 95%(ap:0.95;95%CI:0.49 to 1.41,p<0.001).Conclusion Marijuana use does not only influence the onset of suicidal attempts but also repeated attempted suicide among SHS students in Ghana.Special attention is required for suicide attempters with a history of repeated attempts and current marijuana use among SHS students in Ghana.Early identification of the potential risk and protective factors is recommended to inform school-based interventions.National level structured school-based substance abuse interventions and health promotion programmes would be useful.展开更多
We present a case of a patient who presented with chest pain,and on diagnostic coronary angiography appeared to have a grossly angulated yet significant coronary stenosis.This was proven to be an artefactual appearanc...We present a case of a patient who presented with chest pain,and on diagnostic coronary angiography appeared to have a grossly angulated yet significant coronary stenosis.This was proven to be an artefactual appearance on further assessment with intravascular ultrasound imaging.We describe the causes and associations of coronary tortuosity with other arteriopathy,and highlight challenges in the interpretation of tortuous vessels to accurately assess luminal narrowing and suitability for coronary intervention.We describe a case of artefactual coronary stenosis,and its thorough assessment with intravascular ultrasound.A literature review describes the pathogenesis of coronary tortuosity,and links with other cardiovascular disease.Readers will gain an understanding of the challenge in determining the severity of luminal stenosis based on coronary angiography alone in tortuous coronary anatomy,the use of intravascular ultrasound in this setting,and the allied vasculopathies of interest.展开更多
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated w...BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.展开更多
Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering ther...Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.展开更多
Background Marijuana use among adolescents,including high school students,has been consistently reported to be associated with a high incidence of suicidal behaviours.Little empirical research has been conducted on th...Background Marijuana use among adolescents,including high school students,has been consistently reported to be associated with a high incidence of suicidal behaviours.Little empirical research has been conducted on the propensity impact of marijuana use on suicidal behaviours in Africa.Aims To assess factors associated with marijuana use and further quantify marijuana use as an associated factor of suicidal behaviours,including repeated attempted suicide,suicidal ideation and suicide planning,among high school students in Africa.Methods A cross-sectional study was conducted among 32802 school-going adolescents using the Global School-Based Student Health Survey data from 10 African countries grouped into West Africa,North Africa,South-East Africa,South Africa and East Africa subregions.Marijuana use and repeated attempted suicide were the main outcome variables.We employed double selection least absolute shrinkage and selection operator poisson regression model to assess risk factors associated with marijuana use and dominance analysis to establish ranked important and common risk factors.Inverse probability weighting poisson regression adjustment was applied to assess impact.Results The prevalence of marijuana use and repeated attempted suicide were 3.7%(95%CI:3.1 to 4.3)and 6.6%(95%CI:5.9 to 7.4),respectively.The most important risk factor for marijuana use generally across the countries and specifically in three subregions was alcohol consumption,which constituted approximately 40%of the impact.The average treatment effect on the treated(ATT)indicated that marijuana use significantly increased the risk of suicidal ideation,suicide planning and repeated attempted suicide by 12%(ATT=0.12(95%CI:0.02 to 0.22)),18%(ATT=0.18(95%CI:0.13 to 0.22))and 31%(ATT=0.31(95%CI:0.20 to 0.41)),respectively.Conclusions Marijuana use was significantly associated with suicidal behaviours(suicidal ideation,planning and repeated attempted suicide)among the students.To achieve Sustainable Development Goal 3.5(to strengthen prevention and treatment of substance abuse),school-based-based psychosocial interventions should be streamlined to adequately assess and manage marijuana use.Targeting the most dominant risk factors in this population could translate into the reduction of suicidal behaviours in countries within Africa.展开更多
Inferior vena cava (IVC) filters have since been implanted in the 1970s. The aim of implantation is to prevent the occurrence of fatal pulmonary embolism (PE). However, fatal pulmonary embolisms have been occurring af...Inferior vena cava (IVC) filters have since been implanted in the 1970s. The aim of implantation is to prevent the occurrence of fatal pulmonary embolism (PE). However, fatal pulmonary embolisms have been occurring after filter insertion. The mechanism is that either a thrombus or an embolus was already located cranial to the site of deployment of the filter within the inferior vena cava. And so after the filter implantation significant embolism can still occur. We present the case of a 62-year-old woman who had an IVC filter but died two weeks later from pulmonary embolism, through an unusual mechanism. The patient had a fracture of the left tibia, had open reduction and internal fixation developed pulmonary embolism secondary to deep vein thrombosis of the left lower limb. Anticoagulation was started, an IVC filter was inserted and she was discharged home with a therapeutic INR. However, she passed away two weeks later from pulmonary embolism, through the unusual mechanism of thrombus propagation across the IVC filter. The clinical significance of this article is to draw clinicians’ attention to the existence of another mechanism of fatal pulmonary embolism after an IVC filter insertion. The thrombus can propagate across the IVC filter leading to fatal pulmonary embolism.展开更多
We performed a pilot study to assess the significance of modest, asymptomatic, elevated serum cardiac markers- troponin T(TnT) and creatinine kinase- MB(CK- MB)- 18- 24 h following successful elective percutaneous cor...We performed a pilot study to assess the significance of modest, asymptomatic, elevated serum cardiac markers- troponin T(TnT) and creatinine kinase- MB(CK- MB)- 18- 24 h following successful elective percutaneous coronary intervention(PCI) and to explore their relationship with changes in aerobic exercise capacity, as measured by peak oxygen consumption(VO2), 6 weeks following the procedure. Twenty-three patients with single-vessel disease and chronic angina performed an incremental cardiopulmonary exercise test before and 6 weeks after successful uncomplicated PCI. A venous blood sample was taken at rest before PCI and 18-24 h after the procedure. Successful PCI resulted in a trend towards an increased peak VO2 [21. 62 ±0. 64(pre) vs. 23. 03±0. 75 ml/kg/min(post), p = 0. 07; mean ± SEM] . There was a significant increase [median(IQR) ] in TnT, from 0. 00(0. 00) μg/l at baseline increasing to 0.02(0.03) μg/l at 18-24 h, p = 0. 002. CK-MB levels showed no significant difference. In the group of 15/23(65%) patients with an elevation in serum TnT( FF>> 0. 01 μg/l), 18-24 h after successful PCI, there was no significant increase in peak VO2 [23. 31 ±0. 96(pre)vs. 23. 89 ± 1. 09 ml/kg/min(post), p=0. 57] . In 8(35% ) patients with no rise in TnT at 18 - 24 h, a significant increase in peak VO2 was observed following successful PCI[23. 10 ±0. 91 (pre) vs. 25. 09 ± 0. 75 ml/ kg/min(post), p =0. 02]. Although 7 of these 8 patients increased their peak VO2, the absence of a TnT rise at 18-24 h was not significantly associated with an increase in peak VO2 following successful PCI(p =0. 18). To confirm these interesting initial results and investigate the relationship of serum cardiac markers following successful PCI and subsequent exercise capacity, further studies are required.展开更多
Background: A stentless valve is expected to be hemodynamically superior to a stented valve. The aim of this study was to compare early postoperative hemodyna mic function and clinical events in a randomized, prospect...Background: A stentless valve is expected to be hemodynamically superior to a stented valve. The aim of this study was to compare early postoperative hemodyna mic function and clinical events in a randomized, prospective series of 160 sten tless and stented biological replacement aortic valves. Methods: We randomized 1 60 consecutive patients on 1 surgeon’s list to receive either a Toronto stentle ss porcine valve (St Jude Medical, Inc, St Paul, Minn) or a Perimount stented bo vine pericardial valve (Edwards Lifesciences, Irvine, Calif). Echocardiography w as performed at discharge, between 3 and 6 months, and at 1 year after surgery. Statistical analysis was performed by both intention to treat and act ual valves implanted. Results: The mean labeled size of both designs of valve wa s 24.7. There were no statistically significant differences in results at any ti me interval or whether analysis was performed by actual valves implanted or inte ntion to treat. At 3 to 6 months for the Toronto versus the Perimount valve, the effective orifice area was 1.58 versus 1.66 cm2, the mean pressure difference w as 7.54 versus 7.42 mm Hg, and the peak velocity was 2.07 versus 2.01 m/s. There was no difference in mortality, regression of left ventricular hypertrophy, or complications other than paraprosthetic regurgitation at 12 months or on follow -up for a proportion of the sample to 8 years. The incidence of regurgitation t hrough the valves was similar for Toronto (10%) and Perimount (13.8%) at 1 yea r, but mild paraprosthetic regurgitation was found in 5 patients with the Perimo unt valve and none with Toronto valves. Conclusions: There were no significant d ifferences in hemodynamic function or clinical events between the stented and st entless biological valves chosen for comparison in the early postoperative perio d or in preliminary follow-up to 5 years.展开更多
文摘Background The association between substance use including marijuana use and attempted suicide has been well documented.However,little is known about marijuana use and its association with attempted suicide repetition among young people in low-income and middle-income contexts.Aims This analysis was conducted to assess the factors associated with marijuana use and ascertain marijuana use as a determinant of repeated attempted suicide among senior high school(SHS)students in Ghana.Methods Data from the 2012 Global School-Based Student Health Survey in Ghana was used for this study.Modified Poisson,Logistic and Probit models weighted with Mahalanobis distance matching within propensity calliper were employed separately to determine the hypothetical association between marijuana use and repeated attempted suicide.All analysis was performed using Stata 16 and p<0.05 was deemed statistically significant.Results The prevalence estimates of marijuana use and repeated attempted suicide among SHS students in Ghana were 3.4%(95%Cl:2.3 to 5.1)and 11.5%(95%Cl:9.1 to 14.4),respectively.The prevalence of marijuana use was significantly associated with school grade,smoking exposure,parent smoker,alcohol intake and truancy.Marijuana use was positively associated with repeated attempted suicide among SHS in Ghana correlation=0.23,p<0.001.Repeated attempted suicide among students who use marijuana was approximately threefold and fivefold significant compared with nonmarijuana use students,based on the Poisson(adjusted prevalence ratio:3.02;95%Cl:1.67 to 5.43,p<0.001)and Logistic(adjusted OR:5.06;95%Cl:3.19 to 11.64,p<0.001)estimates respectively.Also,the Probit model showed that marijuana use significantly increased the log count of repeated attempted suicide by 95%(ap:0.95;95%CI:0.49 to 1.41,p<0.001).Conclusion Marijuana use does not only influence the onset of suicidal attempts but also repeated attempted suicide among SHS students in Ghana.Special attention is required for suicide attempters with a history of repeated attempts and current marijuana use among SHS students in Ghana.Early identification of the potential risk and protective factors is recommended to inform school-based interventions.National level structured school-based substance abuse interventions and health promotion programmes would be useful.
文摘We present a case of a patient who presented with chest pain,and on diagnostic coronary angiography appeared to have a grossly angulated yet significant coronary stenosis.This was proven to be an artefactual appearance on further assessment with intravascular ultrasound imaging.We describe the causes and associations of coronary tortuosity with other arteriopathy,and highlight challenges in the interpretation of tortuous vessels to accurately assess luminal narrowing and suitability for coronary intervention.We describe a case of artefactual coronary stenosis,and its thorough assessment with intravascular ultrasound.A literature review describes the pathogenesis of coronary tortuosity,and links with other cardiovascular disease.Readers will gain an understanding of the challenge in determining the severity of luminal stenosis based on coronary angiography alone in tortuous coronary anatomy,the use of intravascular ultrasound in this setting,and the allied vasculopathies of interest.
文摘BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.
文摘Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.
文摘Background Marijuana use among adolescents,including high school students,has been consistently reported to be associated with a high incidence of suicidal behaviours.Little empirical research has been conducted on the propensity impact of marijuana use on suicidal behaviours in Africa.Aims To assess factors associated with marijuana use and further quantify marijuana use as an associated factor of suicidal behaviours,including repeated attempted suicide,suicidal ideation and suicide planning,among high school students in Africa.Methods A cross-sectional study was conducted among 32802 school-going adolescents using the Global School-Based Student Health Survey data from 10 African countries grouped into West Africa,North Africa,South-East Africa,South Africa and East Africa subregions.Marijuana use and repeated attempted suicide were the main outcome variables.We employed double selection least absolute shrinkage and selection operator poisson regression model to assess risk factors associated with marijuana use and dominance analysis to establish ranked important and common risk factors.Inverse probability weighting poisson regression adjustment was applied to assess impact.Results The prevalence of marijuana use and repeated attempted suicide were 3.7%(95%CI:3.1 to 4.3)and 6.6%(95%CI:5.9 to 7.4),respectively.The most important risk factor for marijuana use generally across the countries and specifically in three subregions was alcohol consumption,which constituted approximately 40%of the impact.The average treatment effect on the treated(ATT)indicated that marijuana use significantly increased the risk of suicidal ideation,suicide planning and repeated attempted suicide by 12%(ATT=0.12(95%CI:0.02 to 0.22)),18%(ATT=0.18(95%CI:0.13 to 0.22))and 31%(ATT=0.31(95%CI:0.20 to 0.41)),respectively.Conclusions Marijuana use was significantly associated with suicidal behaviours(suicidal ideation,planning and repeated attempted suicide)among the students.To achieve Sustainable Development Goal 3.5(to strengthen prevention and treatment of substance abuse),school-based-based psychosocial interventions should be streamlined to adequately assess and manage marijuana use.Targeting the most dominant risk factors in this population could translate into the reduction of suicidal behaviours in countries within Africa.
文摘Inferior vena cava (IVC) filters have since been implanted in the 1970s. The aim of implantation is to prevent the occurrence of fatal pulmonary embolism (PE). However, fatal pulmonary embolisms have been occurring after filter insertion. The mechanism is that either a thrombus or an embolus was already located cranial to the site of deployment of the filter within the inferior vena cava. And so after the filter implantation significant embolism can still occur. We present the case of a 62-year-old woman who had an IVC filter but died two weeks later from pulmonary embolism, through an unusual mechanism. The patient had a fracture of the left tibia, had open reduction and internal fixation developed pulmonary embolism secondary to deep vein thrombosis of the left lower limb. Anticoagulation was started, an IVC filter was inserted and she was discharged home with a therapeutic INR. However, she passed away two weeks later from pulmonary embolism, through the unusual mechanism of thrombus propagation across the IVC filter. The clinical significance of this article is to draw clinicians’ attention to the existence of another mechanism of fatal pulmonary embolism after an IVC filter insertion. The thrombus can propagate across the IVC filter leading to fatal pulmonary embolism.
文摘We performed a pilot study to assess the significance of modest, asymptomatic, elevated serum cardiac markers- troponin T(TnT) and creatinine kinase- MB(CK- MB)- 18- 24 h following successful elective percutaneous coronary intervention(PCI) and to explore their relationship with changes in aerobic exercise capacity, as measured by peak oxygen consumption(VO2), 6 weeks following the procedure. Twenty-three patients with single-vessel disease and chronic angina performed an incremental cardiopulmonary exercise test before and 6 weeks after successful uncomplicated PCI. A venous blood sample was taken at rest before PCI and 18-24 h after the procedure. Successful PCI resulted in a trend towards an increased peak VO2 [21. 62 ±0. 64(pre) vs. 23. 03±0. 75 ml/kg/min(post), p = 0. 07; mean ± SEM] . There was a significant increase [median(IQR) ] in TnT, from 0. 00(0. 00) μg/l at baseline increasing to 0.02(0.03) μg/l at 18-24 h, p = 0. 002. CK-MB levels showed no significant difference. In the group of 15/23(65%) patients with an elevation in serum TnT( FF>> 0. 01 μg/l), 18-24 h after successful PCI, there was no significant increase in peak VO2 [23. 31 ±0. 96(pre)vs. 23. 89 ± 1. 09 ml/kg/min(post), p=0. 57] . In 8(35% ) patients with no rise in TnT at 18 - 24 h, a significant increase in peak VO2 was observed following successful PCI[23. 10 ±0. 91 (pre) vs. 25. 09 ± 0. 75 ml/ kg/min(post), p =0. 02]. Although 7 of these 8 patients increased their peak VO2, the absence of a TnT rise at 18-24 h was not significantly associated with an increase in peak VO2 following successful PCI(p =0. 18). To confirm these interesting initial results and investigate the relationship of serum cardiac markers following successful PCI and subsequent exercise capacity, further studies are required.
文摘Background: A stentless valve is expected to be hemodynamically superior to a stented valve. The aim of this study was to compare early postoperative hemodyna mic function and clinical events in a randomized, prospective series of 160 sten tless and stented biological replacement aortic valves. Methods: We randomized 1 60 consecutive patients on 1 surgeon’s list to receive either a Toronto stentle ss porcine valve (St Jude Medical, Inc, St Paul, Minn) or a Perimount stented bo vine pericardial valve (Edwards Lifesciences, Irvine, Calif). Echocardiography w as performed at discharge, between 3 and 6 months, and at 1 year after surgery. Statistical analysis was performed by both intention to treat and act ual valves implanted. Results: The mean labeled size of both designs of valve wa s 24.7. There were no statistically significant differences in results at any ti me interval or whether analysis was performed by actual valves implanted or inte ntion to treat. At 3 to 6 months for the Toronto versus the Perimount valve, the effective orifice area was 1.58 versus 1.66 cm2, the mean pressure difference w as 7.54 versus 7.42 mm Hg, and the peak velocity was 2.07 versus 2.01 m/s. There was no difference in mortality, regression of left ventricular hypertrophy, or complications other than paraprosthetic regurgitation at 12 months or on follow -up for a proportion of the sample to 8 years. The incidence of regurgitation t hrough the valves was similar for Toronto (10%) and Perimount (13.8%) at 1 yea r, but mild paraprosthetic regurgitation was found in 5 patients with the Perimo unt valve and none with Toronto valves. Conclusions: There were no significant d ifferences in hemodynamic function or clinical events between the stented and st entless biological valves chosen for comparison in the early postoperative perio d or in preliminary follow-up to 5 years.
