Associations between maternal overweight/obesity during pregnancy and body composition in young adult offspring.

Background: Maternal obesity is associated with an increased risk of large-for-gestational-age births and childhood obesity. However, evidence on its potential associations with long-term offspring body composition remains limited. This prospective cohort study examined associations between maternal body mass index (BMI) during pregnancy and body composition in the young adult offspring. Methods: Participants were the offspring from a birth cohort in Chiang Mai (Thailand). Maternal BMI was assessed at the first antenatal clinic visit (≤24 weeks of gestation) in 1989-1990. In 2010-2011, we followed up the offspring at approximately 20 years of age, assessing their body composition using whole-body dual-energy X-ray absorptiometry (DXA) scans. Associations between maternal BMI and offspring body composition were explored using unadjusted and adjusted analyses. Results: We assessed 391 young adults (55% were females). Higher maternal BMI was associated with increased offspring fat mass and lean mass. In adjusted analyses, offspring of mothers with overweight/obesity exhibited total body fat percentages 1.5 (95% CI 0.1, 2.9; p = 0.032) and 2.3 (95% CI 0.2, 4.5; p = 0.036) percentage points higher than offspring of normal-weight and underweight mothers, respectively. Fat mass index was similarly higher: 0.9 kg/m2 (95% CI 0.3, 1.5 kg/m2; p = 0.002) and 1.4 kg/m2 (95% CI 0.5, 2.3 kg/m2; p = 0.002), respectively. However, no differences in visceral adiposity were detected. Conclusion: Higher maternal BMI during pregnancy was associated with increased adiposity in young adult offspring. Our findings suggest that the cross-generational transmission of maternal obesity-related traits is associated with increased offspring adiposity in the long term.

Chronic Kidney Disease Predicts Adverse Major Cardiovascular Events and Adverse Limb Events in Patients With Diabetes and Peripheral Arterial Disease.

This study aims to explore the effect in each stage of chronic kidney disease (CKD) on the major adverse cardiovascular events (MACE) in diabetes mellitus (DM) patients with peripheral arterial disease (PAD). A total of 246 DM patients with diagnosed PAD were enrolled in this study. Of these, 86 patients (35%) died and 34 patients had non-fatal cardiovascular events occurred at the last 7 years follow-up. The baseline eGFR obtained from the first quantified eGFR value within 6 months from the date of enrollment estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Then, based on eGFR at entry, we defined CKD as an eGFR < 60 mL/min/1.73 m2, and stratified all patients into four groups: eGFR-1, normal eGFR (≥90 mL/min/1.73 m2); eGFR-2, mildly decreased eGFR (60-89 mL/min/1.73 m2); eGFR-3, moderately decreased eGFR (30-59 mL/min/1.73 m2); and eGFR-4, severely decreased eGFR (<30 mL/min/1.73 m2). The mean eGFR was 54.4 ± 28.9 mL/min/1.73m2, and more than 30% of all patients had CKD (eGFR <60 mL/min/1.73m2). The seven-year cumulative incidence of MACE was 29.8% (95% confident interval [95% CI] 15.5-35.7) for eGFR-1 group, 40.4% (95% CI 27.4-45.2) for eGFR-2group, 66.2% (95% CI 47.6-71.4) for eGFR-3 group, and 94% (95% CI 75.0-99.0) for eGFR-4 group. In addition, after adjustment, hazard ratio (HR) for MACE was 2.36 (95% CI 1.26-4.40) in the eGFR-3 group and 7.62 (95% CI 3.71-15.66) in the eGFR-4 group. Restricted mean survival time (RMST) for survival analysis was consistent with HR in this study. After adjusting confounders, relative to eGFR-1 group, an association between the eGFR group and MACE outcome was found only in eGFR-3 group and eGFR-4 group. The moderate to severe reduction in eGFR, was an independent risk factor for MACE among DM patients with PAD throughout a 7-year follow-up duration. Thus, early CKD screening might be essential in the management of diabetic patients with PAD.

Chronic Kidney Disease and Accelerated Decline of Renal Function in Older Adults with HIV in Northern Thailand.

Kidney disease remains prevalent in people living with HIV even in the antiretroviral treatment era. We determine the frequency of chronic kidney disease (CKD), rate of renal function decline, and associated factors in older adults with HIV (OAHIV) aged ≥50 years in northern Thailand. We used data from the medical records and calculated the estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation. Of the 269 participants (58% women, 61.8 years median age), 7.1% had CKD (eGFR <60 mL/min per 1.73 m2). There were 21 OAHIV (7.8%) with >25% decline in eGFR in the past year, 90 (33%) with accelerated (>5 mL/min per 1.73 m2 per year), and 44 (16%) with rapid (>10 mL/min per 1.73 m2 per year) declining eGFR. Female gender was the only factor associated with an accelerated decline in eGFR (odds ratio, 2.307; 95% confidence interval, 1.331-3.998; p = .003). Continuous monitoring of renal function is recommended for OAHIV to guide treatment modification and intervention.

Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis.

OBJECTIVES: This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN: A systematic review and meta-analysis. METHODS: Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS: 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS: This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.

The Effect of Standard Compression Adjuvant with a Tailored Exercise Training Program on Health-Related Quality of Life Outcomes in Treating Adults with Venous Leg Ulcer: A Randomized Controlled Trial.

Exercise training adjuvant to standard compression is considered to improve calf muscle pump dysfunction in venous leg ulcer (VLU) and subsequent healing. The objectives of this trial were to assess the effectiveness of a tailored exercise training intervention in addition to standard compression therapy on health-related quality of life and anticipating wound healing. Twenty-four VLU participants were recruited and randomly divided into 2 groups. The control group was prescribed conventional compression, and the intervention group received compression plus progressive tailored exercise training. The 14-item chronic venous disease quality of life questionnaire (CIVIQ-14) was used to assess improvement after treatment over time (0, 6, and 12 weeks). Intervention and control groups achieved wound closure for 11 (92%) and 7 (58%) patients. After adjusting for age, sex, and wound size at baseline, the exercise intervention group had 2 times the probability of complete wound healing in 12 weeks than those in the control group (risk ratio = 1.98, 95% CI= 1.01-3.72, P = .047). The primary outcome was the difference in CIVIQ-14 score in 3 dimensions and global index score per visit. The outcomes were evaluated by independent assessors. Demographic, comorbidities, and wound assessments were collected on enrollment. The overall adherence to exercise protocol was 71%. After adjusting age, sex, size of VLU, and CIVIQ score at baseline, the participants in the intervention group had the average global index scores and psychological scores increase at week 12 than those in the control group (21.2; 95% CI= 7.1-35.2, P = .005, and 13.5; 95% CI = 2.9-24.2, P = .044, respectively). Both groups showed similar improvement in the mean change in physical and pain scores within-group over time. Patients with combined conventional compression therapy with exercise training appeared to have a higher quality of life score in psychological and global scores than those with compression therapy alone.

Trends in the Incidence of Kaposi's Sarcoma and Non-Hodgkin Lymphoma in Northern Thailand during the Time Period of Universal Access to Antiretroviral Treatment, 1998-2017.

PURPOSE: We evaluated the trends in incidence of Kaposi's sarcoma (KS) and Non-Hodgkin's lymphoma (NHL)  over the two decades in northern Thailand during which access to antiretroviral treatments (ART) in Thailand was scaled up. METHODS: This is retrospective observational study. Data from 1998 to 2017 of patients diagnosed with KS and NHL from three long-standing, population-based cancer registries in northern Thailand (Chiang Mai, Lampang and Lamphun) were used to describe trends in age-adjusted incidence rate (ASR) of these cancers. The annual percent change (APC) of incidence rates were evaluated over this timeframe. RESULTS: The incidence of KS significantly increased from 1998 to 2017 in males (APC of 6.9%) and very low incidence for evaluating change in female. NHL incidence significantly increased from 1998 to 2017, 2.2% and 1.8% per year in males and females, respectively (p<0.001). CONCLUSION: In the last two decades, the incidence of KS in male and NHL in both sexes have increased in northern Thailand, while the incidence of KS in female remained low. The change in incidences in opposite to the decline in HIV prevalence and increase ART coverage rate supported that other associated factors attributable to the development of KS and NHL should be looked for i.e., environmental, occupational exposures and other infections.

Characteristics, clinical outcomes, and mortality of older adults living with HIV receiving antiretroviral treatment in the sub-urban and rural areas of northern Thailand.

Since the introduction of antiretroviral treatment (ART), people living with HIV worldwide live into older age. This observational study described the characteristics, clinical outcomes, and mortality of older adults living with HIV (OALHIV) receiving ART from the National AIDS program in northern Thailand. Participants aged ≥ 50 years were recruited from the HIV clinics in 12 community hospitals. Data were obtained from medical records and face-to-face interviews. In 2015, 362 OALHIV were enrolled; their median (interquartile range) age and ART duration were 57 years (54-61), and 8.8 years (6.4-11.2), respectively. At study entry, 174 (48.1%) had CD4 counts ≥ 500 cells/mm3; 357 of 358 (99.6%) with available HIV RNA results were virologic-suppressed. At the year 5 follow-up, 39 died, 11 were transferred to other hospitals, 3 were lost to follow-up, and 40 did not contribute data for this analysis, but remained in care. Among the 269 who appeared, 149 (55%) had CD4 counts ≥ 500 cells/mm3, and 227/229 tested (99%) were virologic-suppressed. The probability of 5-year overall survival was 89.2% (95% confidence interval, CI 85.4-92.1%). A significantly low 5-year overall survival (66%) was observed in OALHIV with CD4 counts < 200 cells/mm3 at study entry. The most common cause of death was organ failure in 11 (28%), followed by malignancies in 8 (21%), infections in 5 (13%), mental health-related conditions in 2 (5%), and unknown in 13 (33%). In OALHIV with stable HIV treatment outcomes, mortality from non-infectious causes was observed. Monitoring of organ function, cancer surveillance, and mental health screening are warranted.

The Prevalence and Risk Factors for Peripheral Arterial Disease in Adults Living With Human Immunodeficiency Virus.

Adult patients with human immunodeficiency virus (HIV) appear to be at high risk of cardiovascular disease (CVD). Peripheral arterial disease (PAD) is particularly concerning as it is associated with myocardial infarction and stroke. Nevertheless, the incidence of PAD is still unknown. The authors prospectively recruited HIV-infected patients from the outpatient clinic of the Department of Internal Medicine in our center. We assessed ankle-brachial index (ABI) using the VaSera system™ (Fukuda Denshi Co., Ltd). Patients were grouped into 3 ABI levels: an ABI ≤0.90 was considered abnormal and evidence of PAD, an ABI 1.0 to 1.40 was considered normal, and 0.91 to 0.99 was considered borderline. Cardiovascular risk factors were compared across all 3 levels of ABI and were analyzed using multivariate ordinal logistic regression. Eight hundred ninety-two patients were recruited. The mean age was 42.9 ± 10.0 years and 458 (51.4%) were males. There were 704, 149, and 39 patients in the normal, borderline, and abnormal ABI groups, respectively. The latter group of 39 patients was considered to have PAD, yielding a prevalence of 4.37% (95% confidence interval [CI] 3.21-5.93). Sex ratio, age, education levels, smoking rate, body mass index (BMI), blood pressure, prevalence of comorbidities with hypertension and coronary heart disease, median triglyceride level, reduced kidney function and HIV-1 RNA undetectable ratio, duration of HIV diagnosis, and duration on antiretroviral treatment were significantly different among 3 ABI subgroups. Independent risk factors associated with PAD were being female (odds ratio [OR]: 2.86; 95% CI: 1.94-4.22), being <30 years of age (OR: 4.66; 95% CI: 2.78-7.81), being overweight (BMI 25-25.9; OR: 0.39; 95% CI: 0.20-0.76), being obese (BMI: 30; OR: 3.53; 95% CI: 1.51-8.22), having a diastolic blood pressure ≥80 mmHg (OR: 0.50; 95% CI: 0.35-0.71), and having detectable HIV-1 RNA ≥20 copies/mL (OR: 1.85; 95% CI: 1.13-3.03). In conclusion, the prevalence of PAD in HIV-infected Thais was 4.37% in infected patients on therapy attending outpatient clinics. For this population, PAD appears to be relatively poorly correlated with traditional risk factors of CVD.

Association of cardio-ankle vascular index and future major adverse cardiovascular events in older adults living with HIV.

ABSTRACTIncreased arterial stiffness is an indicator of cardiovascular disease (CVD) and death in the general population. The cardio-ankle vascular index (CAVI) is a novel method for measuring arterial stiffness. This study investigated the utility of CAVI as a prognostic indicator of CVD and death in older adults living with HIV(OALHIV). Patients aged ≥50 taking antiretroviral treatment with no history of cardiovascular events enrolled from multiple centers in Chiang Mai, Thailand. Participants (N = 347) who underwent CAVI were followed up for five years. The primary endpoint was major adverse cardiovascular events (MACE): a composite of total deaths and hospitalizations due to myocardial infarction, coronary revascularization, stroke, and heart failure. Cox regression analysis determined between normal (<8) and high (≥8) CAVI against the incidence of MACE. Forty-five participants (13.0%) were diagnosed with MACE. The risk of MACE was more significant in high CAVI than normal CAVI (adjusted HR = 2.11, 95% confidence interval 1.06-4.20, p = 0.033). In OALHIV, CAVI was an independent prognosis of MACE, in addition to conventional CVD risk factors. CAVI-assisted to help identify high-risk patients showed the benefit of further evaluation and more intensive therapy to prevent CVD and death.

A COVID-19 Silver Lining-Decline in Antibiotic Resistance in Ischemic Leg Ulcers during the Pandemic: A 6-Year Retrospective Study from a Regional Tertiary Hospital (2017-2022).

Antibiotic resistance (AR) associated with chronic limb-threatening ischemia (CLTI) poses additional challenges for the management of ischemic leg ulcers, increasing the likelihood of severe outcomes. This study assessed AR prevalence in bacteria isolated from CLTI-associated leg ulcers before (1 January 2017-10 March 2020; n = 69) and during (11 March 2020-31 December 2022; n = 59) the COVID-19 pandemic from patients admitted with positive wound cultures to a regional hospital in Chiang Mai (Thailand). There was a marked reduction in AR rates from 78% pre-pandemic to 42% during the pandemic (p < 0.0001), with rates of polymicrobial infections 22 percentage points lower (from 61% to 39%, respectively; p = 0.014). There were reduced AR rates to amoxicillin/clavulanate (from 42% to 4%; p < 0.0001) and ampicillin (from 16% to 2%; p = 0.017), as well as multidrug resistance (19% to 8%; p = 0.026). Factors associated with increased AR odds were polymicrobial infections (adjusted odds ratio (aOR) 5.6 (95% CI 2.1, 15.0); p = 0.001), gram-negative bacteria (aOR 7.0 (95% CI 2.4, 20.5); p < 0.001), and prior use of antibiotics (aOR 11.9 (95% CI 1.1, 128.2); p = 0.041). Improvements in infection control measures and hygiene practices in the community during the pandemic were likely key factors contributing to lower AR rates. Thus, strategic public health interventions, including community education on hygiene and the informed use of antibiotics, may be crucial in mitigating the challenges posed by AR in CLTI. Further, advocating for more judicious use of empirical antibiotics in clinical settings can balance effective treatment against AR development, thereby improving patient outcomes.

Associations between maternal plasma zinc concentrations in late pregnancy and LINE-1 and Alu methylation loci in the young adult offspring.

BACKGROUND: In animal models, prenatal zinc deficiency induced epigenetic changes in the fetus, but data in humans are lacking. We aimed to examine associations between maternal zinc levels during pregnancy and DNA methylation in LINE-1 and Alu repetitive sequences in young adult offspring, as well as anthropometry and cardiometabolic parameters. METHODS: Participants were 74 pregnant women from the Chiang Mai Low Birth Weight cohort, and their offspring followed up at 20 years of age. Maternal plasma zinc concentrations were measured at approximately 36 weeks of gestation. DNA methylation levels in LINE-1 and Alu repetitive sequences were measured in the offspring, as well as anthropometry and cardiometabolic parameters (lipid profile, blood pressure, and glucose metabolism). RESULTS: Over half of mothers (39/74; 53%) were zinc deficient (<50 µg/dL) during their third trimester of pregnancy. Maternal zinc concentrations during pregnancy were associated with LINE-1 DNA methylation levels in adult offspring. Specifically, lower prenatal zinc concentrations were associated with: 1) lower levels of total LINE-1 methylation; 2) lower levels of LINE-1 hypermethylation loci; and 3) higher levels of LINE-1 partial methylation loci. Prenatal zinc concentrations were not associated with Alu methylation levels, nor with any anthropometric or cardiometabolic parameters in adult offspring. However, we observed associations between Alu and LINE-1 methylation patterns and cardiometabolic outcomes in offspring, namely total cholesterol levels and diastolic blood pressure, respectively. CONCLUSIONS: Lower maternal zinc concentrations late in gestation were associated with changes in DNA methylation in later life. Thus, zinc deficiency during pregnancy may induce alterations in total LINE-1 methylation and LINE-1 hypermethylation loci. These results suggest a possible epigenetic link between zinc deficiency during pregnancy and long-term outcomes in the offspring.

Long-Term Health Associated with Small and Large for Gestational Age Births among Young Thai Adults.

We examined the long-term health outcomes associated with being born small for gestational age (SGA) or large for gestational age (LGA). A total of 632 young adults aged ≈20.6 years were recruited from a longitudinal study (Chiang Mai, Thailand) in 2010: 473 born appropriate for gestational age (AGA), 142 SGA, and 17 LGA. The clinical assessments included anthropometry, blood pressure (BP), lipid profile, and an oral glucose tolerance test (OGTT). Young adults born SGA were 1.8 and 3.2 cm shorter than AGA (p = 0.0006) and LGA (p = 0.019) participants, respectively. The incidence of short stature was 8% among SGA compared with 3% in AGA and no cases among LGA participants, with the adjusted relative risk (aRR) of short stature among SGA 2.70 times higher than that of AGA counterparts (p = 0.013). SGA participants also had a 2 h glucose 7% higher than that of the AGA group (105 vs. 99 mg/dL; p = 0.006). Young adults born LGA had a BMI greater by 2.42 kg/m2 (p = 0.025) and 2.11 kg/m2 (p = 0.040) than those of SGA and AGA, respectively. Thus, the rate of overweight/obesity was 35% in the LGA group compared with 14.2% and 16.6% of SGA and AGA groups, respectively, with corresponding aRR of overweight/obesity of 2.95 (p = 0.011) and 2.50 (p = 0.017), respectively. LGA participants had markedly higher rates of BP abnormalities (prehypertension and/or hypertension) with an aRR of systolic BP abnormalities of 2.30 (p = 0.023) and 2.79 (p = 0.003) compared with SGA and AGA groups, respectively. Thai young adults born SGA had an increased risk of short stature and displayed some impairment in glucose metabolism. In contrast, those born LGA were at an increased risk of overweight/obesity and elevated blood pressure. The long-term follow-up of this cohort is important to ascertain whether these early abnormalities accentuate over time, leading to overt cardiometabolic conditions.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).

BACKGROUND: Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014. OBJECTIVES: To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists. SELECTION CRITERIA: Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS: Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE. MAIN RESULTS: No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS: This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

The Ability of Clinical Decision Rules to Detect Peripheral Arterial Disease: A Narrative Review.

Peripheral arterial disease (PAD) is a common cause of lower extremity wound. Consequently, PAD leads to a cause of leg amputation nowadays, especially in diabetic patients. In general practice (GP), confrontation with PAD prevention is a challenge. In general, ankle-brachial index (ABI) measurement can be used as a PAD diagnostic tool, but this takes some time. The tool is not generally available and this need to train healthcare workers to perform. Multiple independent predictors developed the diagnostic prediction model known as clinical decision rules (CDRs) to identify patients with high-risk PAD. This might therefore limit the number of patients (only high-risk patients) to refer for ABI evaluation. This narrative review summarized existing CDRs for PAD.

Cardio-ankle vascular index of increased arterial wall stiffness is associated with neurocognitive impairment in well-controlled HIV.

OBJECTIVES: HIV-associated neurocognitive disorders (HAND) remain prevalent in people living with HIV (PLWH) despite widespread use of combined antiretroviral therapy (ART). Vascular disease contributes to the pathogenesis of HAND, but traditional vascular risk factors do not fully explain the relation between vascular disease and HAND. A more direct measure of vascular dysfunction is needed. This cross-sectional study tested whether the cardio-ankle vascular index (CAVI), a novel method to assess arterial stiffness, is associated with HAND among PLWH. METHODS: Participants included 75 non-diabetic adults with well-controlled HIV from an outpatient HIV clinic. We assessed the relation between CAVI and neurocognitive impairment (NCI). The latter was primarily characterized by the Frascati criteria and secondarily (post hoc) using the Global Deficit Score (GDS). Logistic regression models tested whether high CAVI (≥ 8) was independently associated with NCI when controlling for potential confounders. RESULTS: Participants (Mage  = 45.6 ± 8.3 years; 30.1% male) had few traditional cardiovascular disease (CVD) risk factors (hypertension, n = 7; dyslipidaemia, n = 34; body mass index ≥ 25 kg/m2 , n = 12; smoking history, n = 13; 2.2% mean 10-year risk of CVD or stroke). Twelve (16%) participants had high CAVI, which was independently associated with meeting Frascati criteria for NCI [n = 39, odds ratio (OR) = 7.6, p = 0.04], accounting for age, education, gender, income, CD4 nadir, recent CD4 and traditional CVD risk factors. High CAVI was also associated with NCI as reflected by higher GDS (OR = 17.4, p = 0.02). CONCLUSIONS: Cardio-ankle vascular index is a promising measure of vascular dysfunction that may be independently associated with NCI in relatively healthy PLWH. Larger studies should test the utility of CAVI in predicting NCI/decline in PLWH.

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice.

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

Local versus general anaesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013. OBJECTIVES: To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted. MAIN RESULTS: We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants). AUTHORS' CONCLUSIONS: The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

Psychometric utility of the international HIV dementia scale and Montreal Cognitive Assessment in HIV-associated asymptomatic neurocognitive impairment.

There is a growing need for brief screening measures for HIV Associated Neurocognitive Disorders (HAND). We compared two commonly used measures (the Montreal Cognitive Assessment [MoCA] and the International HIV Dementia Scale [IHDS]) in their ability to identify asymptomatic HAND (i.e., asymptomatic neurocognitive impairment [ANI]). Participants included 74 Thai PLWH: 38 met Frascati criteria for ANI and 36 were cognitively normal (CN). Participants completed Thai language versions of the MoCA (MoCA-T) and IHDS, and a validated neurocognitive battery. We examined between-group differences for MoCA-T and IHDS total scores, and scale subcomponents. We also conducted receiver operating characteristic (ROC) analyses to determine the ability of the MoCA-T and IHDS to discriminate between CN and ANI groups, and compared their area under the curve (AUC) values. Results revealed lower MoCA-T total score, as well as the Visuospatial/Executive and Delayed Recall subtask scores, in the ANI relative to CN group. Groups did not differ on the IHDS. For ROC analyses, the MoCA-T, but not the IHDS, significantly differentiated the ANI from CN group, and there was a significant difference in AUC values between the MoCA-T (AUC = .71) and IHDS (AUC = .56). Sensitivity and specificity statistics were poor for both screening measures. These data indicate while the MoCA-T functions better than the IHDS in detecting Thai PLWH with ANI, the mildest form of HAND, neither cognitive screener, showed strong utility. Our findings reflect the limited efficacy of common screening measures in detecting subtler cognitive deficits among Thai PLWH, and highlight the need for better screening tools.

Time trends in the risk of HIV infection among men who have sex with men in Chiang Mai, Thailand: an observational study.

A cross-sectional study on men who have sex with men (MSM) for the HIV prevention project was conducted to assess the prevalence of HIV infection-related behaviors among 551 MSM recruited in 2008-2009 and 1910 MSM in 2014-2018 for voluntary counseling and testing at a HIV clinic in Chiang Mai. Overall, the study found that the prevalence of HIV infection was significantly decreased from 12.9% (71/551) in the earlier study (2008-2009) to 8.2% (157/1910) in the recent study (2014-2018) (p = 0.001). By comparison, in 2008-2009 and 2014-2018, there was no statistically significant difference in consistent condom use (39.0% [186/477] vs. 38.9% [591/1512], p = 0.969), while unprotected anal sex with casual partners significantly increased (44.5% [159/357] vs. 51.9% [645/1242], p = 0.014) and receptive anal sex significantly increased (37.7% [180/477] vs. 45.1% [860/1905], p = 0.004). However, previous HIV testing within 1 year increased significantly from 64.6% (197/305) to 74.7% (677/906, p = 0.001). In exploratory multivariate analysis, the factors associated with HIV infection included gay men, age below 20 years, being self-employed, being an employee, having only receptive anal sex, having both receptive/insertive anal sex, being a former substance user, using online dating, having a history of sexually transmitted infection symptoms, self-perception as being at high risk for HIV, last HIV testing >1 year, and never previously testing for HIV. The data represent the trend of health-seeking behavior improvements. The findings demonstrated the need for a novel sexual health service in an endemic setting and health promotion for online partner-seeking.

Caesarean delivery is associated with increased blood pressure in young adult offspring.

We examined the associations between caesarean section (CS) delivery and cardiovascular risk factors in young adults in Thailand. Participants were 632 offspring from a birth cohort in Chiang Mai (Northern Thailand), born in 1989-1990 and assessed in 2010 at a mean age of 20.6 years, including 57 individuals (9.0%) born by CS and 575 born vaginally. Clinical assessments included anthropometry, blood pressure (BP), carotid intima-media thickness, and fasting blood glucose, insulin, and lipid profile. Young adults born by CS had systolic BP (SBP) 6.2 mmHg higher (p < 0.001), diastolic BP 3.2 mmHg higher (p = 0.029), and mean arterial pressure (MAP) 4.1 mmHg higher (p = 0.003) than those born vaginally. After covariate adjustments, SBP and MAP remained 4.1 mmHg (p = 0.006) and 2.9 mmHg (p = 0.021) higher, respectively, in the CS group. The prevalence of abnormal SBP (i.e., pre-hypertension or hypertension) in the CS group was 2.5 times that of those born vaginally (25.0% vs 10.3%; p = 0.003), with an adjusted relative risk of abnormal SBP 1.9 times higher (95% CI 1.15, 2.98; p = 0.011). There were no differences in anthropometry (including obesity risk) or other metabolic parameters. In this birth cohort in Thailand, CS delivery was associated with increased blood pressure in young adulthood.