Stroke Rehabilitation Clinical Practice Guidelines in Low- and Middle-Income Countries: A Systematic Review of Quality and Unique Features.

INTRODUCTION: Efforts toward reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in low- and middle-income countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs. METHODS: Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, Embase, CINAHL, and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using "Appraisal of Guidelines REsearch and Evaluation" (AGREE) tools: version II & Recommendations Excellence (REX) version. Features of contextualizations/adaptations of non-de novo CPGs were narratively summarized. RESULTS: Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services poststroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development and applicability. CONCLUSION: Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice.

Residential greenspace and major depression among older adults living in urban and suburban areas with different climates across the United States.

BACKGROUND AND AIM: Residential greenspace could alleviate depression - a leading cause of disability. Fewer studies of depression and greenspace have considered major depression, and, to our knowledge, none have considered how climate, which determines vegetation abundance and type, may change the impacts of greenspace. Our aim was to investigate whether residential greenspace is associated with major depression among older adults and explore effect modification by climate. METHODS: We used biennial interviews between 2008 and 2016 from the Health and Retirement Study. We calculated greenness within walking distance of home addresses as the maximum NDVI for the year of each participant interview averaged within a 1 km buffer. Reflecting clinical criteria, a score of ≥5 on the CIDI-SF indicated major depression in the preceding 12-months. We characterized climate using Köppen-Geiger classifications. To estimate prevalence ratios, we used Poisson regression. Our models adjusted for sociodemographic characteristics, geography, annual sunshine, and bluespace. RESULTS: The 21,611 eligible participants were 65 ± 10 years old on average, 55% female, 81% White, 12% Black, 10% Hispanic/Latino, and 31% had at least a 4-year college degree. The 12-month prevalence of a major depression was 8%. In adjusted models, more residential greenspace was associated with a lower prevalence of major depression (prevalence ratio per IQR, 0.91; 95% CI, 0.84 to 0.98). There was evidence of effect modification by climate (P forinteraction, 0.062). We observed stronger associations in tropical (prevalence ratio per IQR 0.69; 95% CI, 0.47 to 1.01) and cold (prevalence ratio per IQR, 0.83; 95% CI, 0.74 to 0.93) climates compared to arid (prevalence ratio per IQR 0.99; 95% CI, 0.90 to 1.09) and temperate (prevalence ratio per IQR 0.98; 95% CI, 0.86 to 1.11) climates. CONCLUSIONS: Residential greenspace may help reduce major depression. However, climate may influence how people benefit from greenspace.

Long-term community noise exposure in relation to dementia, cognition, and cognitive decline in older adults.

INTRODUCTION: Exposure to noise might influence risk of Alzheimer's disease (AD) dementia. METHODS: Participants of the Chicago Health and Aging Project (≥65 years) underwent triennial cognitive assessments. For the 5 years preceding each assessment, we estimated 5227 participants' residential level of noise from the community using a spatial prediction model, and estimated associations of noise level with prevalent mild cognitive impairment (MCI) and AD, cognitive performance, and rate of cognitive decline. RESULTS: Among these participants, an increment of 10 A-weighted decibels (dBA) in noise corresponded to 36% and 29% higher odds of prevalent MCI (odds ratio [OR] = 1.36; 95% confidence interval [CI], 1.15 to 1.62) and AD (OR = 1.29, 95% CI, 1.08 to 1.55). Noise level was associated with worse global cognitive performance, principally in perceptual speed (-0.09 standard deviation per 10 dBA, 95% CI: -0.16 to -0.03), but not consistently associated with cognitive decline. DISCUSSION: These results join emerging evidence suggesting that noise may influence late-life cognition and risk of dementia.

Does the Environment Cause Changes in Hemiparetic Lower Limb Muscle Activity and Gait Velocity During Walking in Stroke Survivors?

Stroke survivors often face difficulty in community ambulation though they attain steady-state walking in clinical setups. Compliance and unpredictability of the environment may alter the muscle activity and challenge the individual's gait. Successful reintegration into the community requires gait assessment and training in a real-life challenging environment. Little is known about the assessment and training of gait in the community environment under challenging mobility dimensions. Hence, we aimed to study the changes that real-life environmental dimensions have on the activity of selected muscles in hemiparetic lower limb and gait velocity in stroke survivors. METHODS: An observational cross-sectional study was conducted on 16 ambulatory stroke survivors to assess the hemiparetic lower limb muscle activity during walking in real-life environmental dimensions. Participants were made to walk in the community on a walkway consisting of even surface, ramp, stairs, uneven terrain and obstacles. They were also made to manoeuvre through traffic and pick a load while walking for a distance in the walkway. Muscle activity of Rectus Femoris, Biceps Femoris, Gastrocnemius Medialis and Tibialis Anterior of the paretic lower limb were continuously recorded while walking using wireless surface electromyography. Gait velocity for the entire walkway and level of perceived difficulty while walking in different dimensions were also measured. Paired t-test was used to compare the percentage Maximum Voluntary Contraction (%MVC) of lower limb muscles between even surface and real-life environment dimensions while walking. One sample t-test was used to compare the gait velocity in real-life dimensions versus gait velocity in even surface measured in an earlier study. RESULTS: There was a significant reduction (p < 0.01) in the activity of all four hemiparetic lower limb muscles while walking under the influence of real-life environmental dimensions compared to even surface. Gait velocity (0.33 ± 0.17 m/s) was significantly lower than that is essential to be a community ambulator. The level of perceived difficulty across all dimensions was reported qualitatively with the highest difficulty reported during stair and obstacle clearance. CONCLUSION: Real-life environmental dimensions lead to the reduction of paretic lower limb muscle activities and gait velocity during walking in community-dwelling stroke survivors. Stroke survivors perceived more difficulty while walking in real-life environment dimensions particularly while negotiating stairs and obstacles. SIGNIFICANCE: Knowledge about the influence of real-life environmental dimensions will help the clinicians to target rehabilitation methods to improve walking adaptability.

Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes.

BACKGROUND: Pregnant women with epilepsy frequently experience seizures related to pregnancy complications and are often prescribed anti-epileptic drugs (AEDs) to manage their symptoms. However, less is known about the comparative safety of AED exposure in utero. We aimed to compare the risk of congenital malformations (CMs) and prenatal outcomes of AEDs in infants/children who were exposed to AEDs in utero through a systematic review and Bayesian random-effects network meta-analysis. METHODS: MEDLINE, EMBASE, and Cochrane CENTRAL were searched from inception to December 15, 2015. Two reviewers independently screened titles/abstracts and full-text papers for experimental and observational studies comparing mono- or poly-therapy AEDs versus control (no AED exposure) or other AEDs, then abstracted data and appraised the risk of bias. The primary outcome was incidence of major CMs, overall and by specific type (cardiac malformations, hypospadias, cleft lip and/or palate, club foot, inguinal hernia, and undescended testes). RESULTS: After screening 5305 titles and abstracts, 642 potentially relevant full-text articles, and 17 studies from scanning reference lists, 96 studies were eligible (n = 58,461 patients). Across all major CMs, many AEDs were associated with higher risk compared to control. For major CMs, ethosuximide (OR, 3.04; 95% CrI, 1.23-7.07), valproate (OR, 2.93; 95% CrI, 2.36-3.69), topiramate (OR, 1.90; 95% CrI, 1.17-2.97), phenobarbital (OR, 1.83; 95% CrI, 1.35-2.47), phenytoin (OR, 1.67; 95% CrI, 1.30-2.17), carbamazepine (OR, 1.37; 95% CrI, 1.10-1.71), and 11 polytherapies were significantly more harmful than control, but lamotrigine (OR, 0.96; 95% CrI, 0.72-1.25) and levetiracetam (OR, 0.72; 95% CrI, 0.43-1.16) were not. CONCLUSION: The newer generation AEDs, lamotrigine and levetiracetam, were not associated with significant increased risks of CMs compared to control, and were significantly less likely to be associated with children experiencing cardiac malformations than control. However, this does not mean that these agents are not harmful to infants/children exposed in utero. Counselling is advised concerning teratogenic risks when the prescription is written for a woman of childbearing age and before women continue with these agents when considering pregnancy, such as switching from polytherapy to monotherapy with evidence of lower risk and avoiding AEDs, such as valproate, that are consistently associated with CMs. These decisions must be balanced against the need for seizure control. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014008925.

Long-term Coarse Particulate Matter Exposure and Heart Rate Variability in the Multi-ethnic Study of Atherosclerosis.

BACKGROUND: Reduced heart rate variability, a marker of impaired cardiac autonomic function, has been linked to short-term exposure to airborne particles. This research adds to the literature by examining associations with long-term exposures to coarse particles (PM10-2.5). METHODS: Using electrocardiogram recordings from 2,780 participants (45-84 years) from three Multi-ethnic Study of Atherosclerosis sites, we assessed the standard deviation of normal to normal intervals and root-mean square differences of successive normal to normal intervals at a baseline (2000-2002) and follow-up (2010-2012) examination (mean visits/person = 1.5). Annual average concentrations of PM10-2.5 mass, copper, zinc, phosphorus, silicon, and endotoxin were estimated using site-specific spatial prediction models. We assessed associations for baseline heart rate variability and rate of change in heart rate variability over time using multivariable mixed models adjusted for time, sociodemographic, lifestyle, health, and neighborhood confounders, including copollutants. RESULTS: In our primary models adjusted for demographic and lifestyle factors and site, PM10-2.5 mass was associated with 1.0% (95% confidence interval [CI]: -4.1, 2.1%) lower standard deviation of normal to normal interval levels per interquartile range of 2 µg/m. Stronger associations, however, were observed before site adjustment and with increasing residential stability. Similar patterns were found for root-mean square differences of successive normal to normal intervals. We found little evidence for associations with other chemical species and with the rate of change in heart rate variability, though endotoxin was associated with increasing heart rate variability over time. CONCLUSION: We found only weak evidence that long-term PM10-2.5 exposures are associated with lowered heart rate variability. Stronger associations among residentially stable individuals suggest that confirmatory studies are needed.

Adopting Clean Fuels and Technologies on School Buses. Pollution and Health Impacts in Children.

RATIONALE: More than 25 million American children breathe polluted air on diesel school buses. Emission reduction policies exist, but the health impacts to individual children have not been evaluated. METHODS: Using a natural experiment, we characterized the exposures and health of 275 school bus riders before, during, and after the adoption of clean technologies and fuels between 2005 and 2009. Air pollution was measured during 597 trips on 188 school buses. Repeated measures of exhaled nitric oxide (FeNO), lung function (FEV1, FVC), and absenteeism were also collected monthly (1,768 visits). Mixed-effects models longitudinally related the adoption of diesel oxidation catalysts (DOCs), closed crankcase ventilation systems (CCVs), ultralow-sulfur diesel (ULSD), or biodiesel with exposures and health. MEASUREMENTS AND MAIN RESULTS: Fine and ultrafine particle concentrations were 10-50% lower on buses using ULSD, DOCs, and/or CCVs. ULSD adoption was also associated with reduced FeNO (-16% [95% confidence interval (CI), -21 to -10%]), greater changes in FVC and FEV1 (0.02 [95% CI, 0.003 to 0.05] and 0.01 [95% CI, -0.006 to 0.03] L/yr, respectively), and lower absenteeism (-8% [95% CI, -16.0 to -0.7%]), with stronger associations among patients with asthma. DOCs, and to a lesser extent CCVs, also were associated with improved FeNO, FVC growth, and absenteeism, but these findings were primarily restricted to patients with persistent asthma and were often sensitive to control for ULSD. No health benefits were noted for biodiesel. Extrapolating to the U.S. population, changed fuel/technologies likely reduced absenteeism by more than 14 million/yr. CONCLUSIONS: National and local diesel policies appear to have reduced children's exposures and improved health.

Coarse Particulate Matter and Markers of Inflammation and Coagulation in the Multi-Ethnic Study of Atherosclerosis (MESA) Population: A Repeat Measures Analysis.

BACKGROUND: In contrast to fine particles, less is known of the inflammatory and coagulation impacts of coarse particulate matter (PM10-2.5, particulate matter with aerodynamic diameter ≤10µm and>2.5µm). Toxicological research suggests that these pathways might be important processes by which PM10-2.5 impacts health, but there are relatively few epidemiological studies due to a lack of a national PM10-2.5 monitoring network. OBJECTIVES: We used new spatiotemporal exposure models to examine associations of both 1-y and 1-month average PM10-2.5 concentrations with markers of inflammation and coagulation. METHODS: We leveraged data from 7,071 Multi-Ethnic Study of Atherosclerosis and ancillary study participants 45-84 y of age who had repeated plasma measures of inflammatory and coagulation biomarkers. We estimated PM10-2.5 at participant addresses 1 y and 1 month before each of up to four exams (2000-2012) using spatiotemporal models that incorporated satellite, regulatory monitoring, and local geographic data and accounted for spatial correlation. We used random effects models to estimate associations with interleukin-6 (IL-6), C-reactive protein (CRP), fibrinogen, and D-dimer, controlling for potential confounders. RESULTS: Increases in PM10-2.5 were not associated with greater levels of inflammation or coagulation. A 10-µg/m3 increase in annual average PM10-2.5 was associated with a 2.5% decrease in CRP [95% confidence interval (CI): -5.5, 0.6]. We saw no association between annual average PM10-2.5 and the other markers (IL-6: -0.7%, 95% CI: -2.6, 1.2; fibrinogen: -0.3%, 95% CI: -0.9, 0.3; D-dimer: -0.2%, 95% CI: -2.6, 2.4). Associations consistently showed that a 10-µg/m3 increase in 1-month average PM10-2.5 was associated with reduced inflammation and coagulation, though none were distinguishable from no association (IL-6: -1.2%, 95% CI: -3.0 , 0.5; CRP: -2.5%, 95% CI: -5.3, 0.4; fibrinogen: -0.4%, 95% CI: -1.0, 0.1; D-dimer: -2.0%, 95% CI: -4.3, 0.3). DISCUSSION: We found no evidence that PM10-2.5 is associated with higher inflammation or coagulation levels. More research is needed to determine whether the inflammation and coagulation pathways are as important in explaining observed PM10-2.5 health impacts in humans as they have been shown to be in toxicology studies or whether PM10-2.5 might impact human health through alternative biological mechanisms. https://doi.org/10.1289/EHP12972.

Elevated Exposure to Air Pollutants Accelerates Primary Glomerular Disease Progression.

Introduction: Environmental contributors to kidney disease progression remain elusive. We explored how residential air pollution affects disease progression in patients with primary glomerulopathies. Methods: Nephrotic Syndrome Study Network (NEPTUNE) and CureGlomerulonephropathy (CureGN) participants with residential census tract data and ≥2 years of follow-up were included. Using Cox proportional hazards models, the associations per doubling in annual average baseline concentrations of total particulate matter with diameter ≤2.5 µm (PM2.5) and its components, black carbon (BC), and sulfate, with time to ≥40% decline in estimated glomerular filtration rate (eGFR) or kidney failure were estimated. Serum tumour necrosis factor levels and kidney tissue transcriptomic inflammatory pathway activation scores were used as molecular markers of disease progression. Results: PM2.5, BC, and sulfate exposures were comparable in NEPTUNE (n = 228) and CureGN (n = 697). In both cohorts, participants from areas with higher levels of pollutants had lower eGFR, were older and more likely self-reported racial and ethnic minorities. In a fully adjusted model combining both cohorts, kidney disease progression was associated with PM2.5 (adjusted hazard ratio 1.55 [95% confidence interval: 1.00-2.38], P = 0.0489) and BC (adjusted hazard ratio 1.43 [95% confidence interval: 0.98-2.07], P = 0.0608) exposure. Sulfate and PM2.5 exposure were positively correlated with serum tumour necrosis factor (TNF) (P = 0.003) and interleukin-1ß levels (P = 0.03), respectively. Sulfate exposure was also directly associated with transcriptional activation of the TNF and JAK-STAT signaling pathways in kidneys (r = 0.55-0.67, P-value <0.01). Conclusion: Elevated exposure to select air pollutants is associated with increased risk of disease progression and systemic inflammation in patients with primary.

Source-Specific Air Pollution and Loss of Independence in Older Adults Across the US.

Importance: Air pollution is a recognized risk factor associated with chronic diseases, including respiratory and cardiovascular conditions, which can lead to physical and cognitive impairments in later life. Although these losses of function, individually or in combination, reduce individuals' likelihood of living independently, little is known about the association of air pollution with this critical outcome. Objective: To investigate associations between air pollution and loss of independence in later life. Design, Setting, and Participants: This cohort study was conducted as part of the Environmental Predictors Of Cognitive Health and Aging study and used 1998 to 2016 data from the Health and Retirement Study. Participants included respondents from this nationally representative, population-based cohort who were older than 50 years and had not previously reported a loss of independence. Analyses were performed from August 31 to October 15, 2023. Exposures: Mean 10-year pollutant concentrations (particulate matter less than 2.5 µm in diameter [PM2.5] or ranging from 2.5 µm to 10 µm in diameter [PM10-2.5], nitrogen dioxide [NO2], and ozone [O3]) were estimated at respondent addresses using spatiotemporal models along with PM2.5 levels from 9 emission sources. Main Outcomes and Measures: Loss of independence was defined as newly receiving care for at least 1 activity of daily living or instrumental activity of daily living due to health and memory problems or moving to a nursing home. Associations were estimated with generalized estimating equation regression adjusting for potential confounders. Results: Among 25 314 respondents older than 50 years (mean [SD] baseline age, 61.1 [9.4] years; 11 208 male [44.3%]), 9985 individuals (39.4%) experienced lost independence during a mean (SD) follow-up of 10.2 (5.5) years. Higher exposure levels of mean concentration were associated with increased risks of lost independence for total PM2.5 levels (risk ratio [RR] per 1-IQR of 10-year mean, 1.05; 95% CI, 1.01-1.10), PM2.5 levels from road traffic (RR per 1-IQR of 10-year mean, 1.09; 95% CI, 1.03-1.16) and nonroad traffic (RR per 1-IQR of 10-year mean, 1.13; 95% CI, 1.03-1.24), and NO2 levels (RR per 1-IQR of 10-year mean, 1.05; 95% CI, 1.01-1.08). Compared with other sources, traffic-generated pollutants were most consistently and robustly associated with loss of independence; only road traffic-related PM2.5 levels remained associated with increased risk after adjustment for PM2.5 from other sources (RR per 1-IQR increase in 10-year mean concentration, 1.10; 95% CI, 1.00-1.21). Other pollutant-outcome associations were null, except for O3 levels, which were associated with lower risks of lost independence (RR per 1-IQR increase in 10-year mean concentration, 0.94; 95% CI, 0.92-0.97). Conclusions and Relevance: This study found that long-term exposure to air pollution was associated with the need for help for lost independence in later life, with especially large and consistent increases in risk for pollution generated by traffic-related sources. These findings suggest that controlling air pollution could be associated with diversion or delay of the need for care and prolonged ability to live independently.

Classifying temporal relations in clinical data: a hybrid, knowledge-rich approach.

We address the TLINK track of the 2012 i2b2 challenge on temporal relations. Unlike other approaches to this task, we (1) employ sophisticated linguistic knowledge derived from semantic and discourse relations, rather than focus on morpho-syntactic knowledge; and (2) leverage a novel combination of rule-based and learning-based approaches, rather than rely solely on one or the other. Experiments show that our knowledge-rich, hybrid approach yields an F-score of 69.3, which is the best result reported to date on this dataset.

In-utero exposure to multiple air pollutants and childhood undernutrition in India.

BACKGROUND: Several studies have been conducted to understand the impact of socioeconomic and maternal factors on child undernutrition. However, the past literature has not directly examined the joint impacts of fuel use and ambient pollution and have primarily focused on PM2.5. OBJECTIVE: This study explored the individual and community-level associations of both indoor (cooking fuel type) and ambient air pollution (PM2.5, NO2 and SO2) during maternal gestation on child undernutrition. METHODS: This study analysed stunting, being underweight, and anaemia of children aged 0-59 months (n = 259,627) using the National Family Health Survey. In-utero exposures to ambient PM2.5, NO2, and SO2 were measured using satellite data and self-reported fuel type was a marker of indoor pollution exposure. The study used univariate and bivariate Moran's I, spatial lag model and multivariable logistic regression models after adjusting for other covariates to understand the effect of pollution on in-utero exposure and child health status at the individual and community-levels. RESULTS: Higher concentration of indoor and ambient air pollution was found in the Northern and parts of Central regions of India. Estimates of spatial modelling show that each 1 µg/m-3 increase in maternal exposure to ambient PM2.5 across the clusters of India was associated with a 0.11, 9 and 19 percentage points increase in the prevalence of stunting, underweight and anaemia, respectively. The results of multi-pollutant model show that a higher ambient PM2.5 exposure during pregnancy was linked to higher odds of stunting (AOR:1.38; 95% CI:1.32-1.44), underweight (AOR:1.59; 95% CI:1.51-1.67) and anaemia (AOR:1.61; 95% CI:1.52-1.69) in children. Weaker but similar associations were observed for NO2, but not with SO2. Indoor pollution exposure during in-utero periods was also significantly associated with childhood undernutrition and this association was modified by ambient PM2.5 levels, where exposure to both indoor and ambient air pollution had even greater odds of being undernourished. IMPACT STATEMENT: Our research on multi-pollutant models has revealed the initial proof of the individual impacts of indoor and outdoor pollution (PM2.5, NO2, and SO2) exposure during fetal development on children's nutrition.

Impact of COVID-19 research: a study on predicting influential scholarly documents using machine learning and a domain-independent knowledge graph.

Multiple studies have investigated bibliometric features and uncategorized scholarly documents for the influential scholarly document prediction task. In this paper, we describe our work that attempts to go beyond bibliometric metadata to predict influential scholarly documents. Furthermore, this work also examines the influential scholarly document prediction task over categorized scholarly documents. We also introduce a new approach to enhance the document representation method with a domain-independent knowledge graph to find the influential scholarly document using categorized scholarly content. As the input collection, we use the WHO corpus with scholarly documents on the theme of COVID-19. This study examines different document representation methods for machine learning, including TF-IDF, BOW, and embedding-based language models (BERT). The TF-IDF document representation method works better than others. From various machine learning methods tested, logistic regression outperformed the other for scholarly document category classification, and the random forest algorithm obtained the best results for influential scholarly document prediction, with the help of a domain-independent knowledge graph, specifically DBpedia, to enhance the document representation method for predicting influential scholarly documents with categorical scholarly content. In this case, our study combines state-of-the-art machine learning methods with the BOW document representation method. We also enhance the BOW document representation with the direct type (RDF type) and unqualified relation from DBpedia. From this experiment, we did not find any impact of the enhanced document representation for the scholarly document category classification. We found an effect in the influential scholarly document prediction with categorical data.

Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs): Protocol for systematic review.

INTRODUCTION: Stroke rehabilitation guidelines promoteclinical decision making, enhance quality of healthcare delivery, minimize healthcare costs, and identify gaps in current knowledge to guide future research. However, there are no published reviews that have exclusively evaluated the quality of existing Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs) or provided any insights into the cultural variation, adaptations, or gaps in implementation specific to LMICs. OBJECTIVES: To identify CPGs developed by LMICs for stroke rehabilitation and evaluate their quality using AGREE-II and AGREE-REX tool. METHODS: The review protocol is prepared in accordance with the PRISMA-P guidelines and the review was registered in PROSPERO (CRD42022382486). The search was run in Medline, EMBASE, CINHAL, PEDro for guidelines published between 2000 till July 2022. Additionally, SUMSearch, Google, and other guideline portals and gray literature were searched. The included studies were then subjected to data extraction for the following details: Study ID, title of the CPG, country of origin, characteristics of CPG (Scope-national/regional, level of care, multidisciplinary/uni-disciplinary), and information on stroke rehabilitation relevant recommendations. The quality of the included CPGs will be subsequently evaluated using AGREE-II and AGREE-REX tool. RESULTS & CONCLUSION: This systematic review aims to explore the gaps in existing CPGs specific to LMICs and will aid in development/adaptation/contextualization of CPGs for implementation in LMICs.

Hypertension and Stroke as Mediators of Air Pollution Exposure and Incident Dementia.

Importance: Fine particulate matter air pollution (PM2.5) has been consistently associated with cardiovascular disease, which, in turn, is associated with an increased risk of dementia. As such, vascular dysfunction might be a mechanism by which PM2.5 mediates dementia risk, yet few prior epidemiological studies have examined this potential mechanism. Objective: To investigate whether hypertension and stroke serve as mediators and modifiers of the association of PM2.5 with incident dementia. Design, Setting, and Participants: As part of the Environmental Predictors of Cognitive Health and Aging (EPOCH) Project, this cohort study used biennial survey data collected between 1998 and 2016 from respondents of the Health and Retirement Study (HRS), a nationally representative, population-based, cohort in the US. Eligible participants were those over 50 years of age who were free of dementia at baseline and had complete exposure, mediator, outcome, and demographic data from the HRS. Data analysis was conducted from August to November 2022. Exposures: Exposure to PM2.5, calculated for the 10 years preceding each person's baseline examination according to residential histories and spatiotemporal models. Main Outcomes and Measures: Incident dementia was identified using a validated algorithm based on cognitive testing and informant reports. The 4-way decomposition causal mediation analysis method was used to quantify the degree to which hypertension and stroke mediated or modified the association of PM2.5 with incident dementia after adjustment for individual-level and area-level covariates. Results: Among 27 857 participants (mean [SD] age at baseline, 61 [10] years; 15 747 female participants [56.5%]; 19 249 non-Hispanic White participants [69.1%]), 4105 (14.7%) developed dementia during the follow-up period (mean [SD], 10.2 [5.6] years). Among participants with dementia, 2204 (53.7%) had a history of hypertension at baseline and 386 (9.4%) received a diagnosis of hypertension during the follow up. A total of 378 participants (9.2%) had a history of stroke at baseline and 673 (16.4%) developed stroke over the follow-up period. The IQR of baseline PM2.5 concentrations was 10.9 to 14.9 µg/m3. In fully adjusted models, higher levels of PM2.5 (per IQR) were not associated with increased risk of incident dementia (HR, 1.04; 95% CI, 0.98 to 1.11). Although there were positive associations of prevalent stroke (HR, 1.67; 95% CI, 1.48 to 1.88) and hypertension (HR, 1.15; 95% CI, 1.08 to 1.23) with incident dementia compared with those free of stroke and hypertension during follow-up, there was no statistically significant association of PM2.5 with stroke (odds ratio per IQR increment in PM2.5, 1.08; 95%CI, 0.91 to 1.29) and no evidence of an association of PM2.5 with hypertension (odds ratio per IQR increment in PM2.5, 0.99; 95%CI, 0.92 to 1.07). Concordantly, there was no evidence that hypertension or stroke acted as mediators or modifiers of the association of PM2.5 with incident dementia. Although the nonmediated interaction between PM2.5 and hypertension accounted for 39.2% of the total excess association (95% CI, -138.5% to 216.9%), the findings were not statistically significant. Conclusions and Relevance: These findings suggest that although hypertension may enhance the susceptibility of individuals to air pollution, hypertension and stroke do not significantly mediate or modify the association of PM2.5 with dementia, indicating the need to investigate other pathways and potential mediators of risk.

Comparison of Particulate Air Pollution From Different Emission Sources and Incident Dementia in the US.

Importance: Emerging evidence indicates that exposure to fine particulate matter (PM2.5) air pollution may increase dementia risk in older adults. Although this evidence suggests opportunities for intervention, little is known about the relative importance of PM2.5 from different emission sources. Objective: To examine associations of long-term exposure of total and source-specific PM2.5 with incident dementia in older adults. Design, Setting, and Participants: The Environmental Predictors of Cognitive Health and Aging study used biennial survey data from January 1, 1998, to December 31, 2016, for participants in the Health and Retirement Study, which is a nationally representative, population-based cohort study in the US. The present cohort study included all participants older than 50 years who were without dementia at baseline and had available exposure, outcome, and demographic data between 1998 and 2016 (N = 27 857). Analyses were performed from January 31 to May 1, 2022. Exposures: The 10-year mean total PM2.5 and PM2.5 from 9 emission sources at participant residences for each month during follow-up using spatiotemporal and chemical transport models. Main Outcomes and Measures: The main outcome was incident dementia as classified by a validated algorithm incorporating respondent-based cognitive testing and proxy respondent reports. Adjusted hazard ratios (HRs) were estimated for incident dementia per IQR of residential PM2.5 concentrations using time-varying, weighted Cox proportional hazards regression models with adjustment for the individual- and area-level risk factors. Results: Among 27 857 participants (mean [SD] age, 61 [10] years; 15 747 [56.5%] female), 4105 (15%) developed dementia during a mean (SD) follow-up of 10.2 [5.6] years. Higher concentrations of total PM2.5 were associated with greater rates of incident dementia (HR, 1.08 per IQR; 95% CI, 1.01-1.17). In single pollutant models, PM2.5 from all sources, except dust, were associated with increased rates of dementia, with the strongest associations for agriculture, traffic, coal combustion, and wildfires. After control for PM2.5 from all other sources and copollutants, only PM2.5 from agriculture (HR, 1.13; 95% CI, 1.01-1.27) and wildfires (HR, 1.05; 95% CI, 1.02-1.08) were robustly associated with greater rates of dementia. Conclusion and Relevance: In this cohort study, higher residential PM2.5 levels, especially from agriculture and wildfires, were associated with higher rates of incident dementia, providing further evidence supporting PM2.5 reduction as a population-based approach to promote healthy cognitive aging. These findings also indicate that intervening on key emission sources might have value, although more research is needed to confirm these findings.

Diabetes: how to manage overweight and obesity in type 2 diabetes mellitus.

The prevalence of obesity worldwide continues to increase substantially. Obesity is a chronic disease that can lead to other health conditions, including type 2 diabetes mellitus (T2DM). A variety of treatment options are available to treat T2DM. With its prevalence increasing, it is essential that healthcare professionals assess how their patients' current diabetes treatment is being managed to avoid further weight gain in those with overweight or obesity.