Prospective study of exposure to smoking imagery in films and changes in susceptibility to smoking in a cohort of school students in Southern India.

INTRODUCTION: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India. METHODS: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery. RESULTS: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, ptrend<0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility. CONCLUSIONS: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films.

Prevalence, regional patterns and socio-demographic factors associated with poly-tobacco use in India: A secondary data analysis.

BACKGROUND: Tobacco use is associated with early, intermediate and long-term complications throughout the life course. With an influx of newer products containing nicotine, poly-tobacco use is slowly emerging as a public health concern, that is defined as existing tobacco users currently using two or more tobacco or nicotine products. While many studies have investigated single use tobacco, there is a paucity of research on regional patterns and socio-demographic factors associated with poly-tobacco use in India. OBJECTIVES: To assess prevalence of poly-tobacco use and determine the socio-demographic factors associated with poly-tobacco use in India. METHODS: Data from the Global Adult Tobacco Survey 2 (GATS, 2016-17) was analysed, which included information on tobacco use among people aged >15 years. The pattern of current tobacco status was described using descriptive statistics. Multiple logistic regression models were estimated to determine factors associated with poly-tobacco use. RESULTS: The prevalence of poly-tobacco use in India was found to be 9.8%. Among the current tobacco users, the prevalence was 33%. Significant socio-demographic factors associated with poly-tobacco use included younger age, male gender, religion and backward caste. North-eastern region reported highest prevalence of poly-tobacco use in the country, followed by the central region. CONCLUSION: The number of poly-tobacco users in India is considerably high and a matter of concern, more so in north east and central regions of the country. There is a need to create awareness about dangerous effects of all types of tobacco products and strengthen implementation of tobacco control policies with special focus on regions with high burden.

The association between living alone, loneliness and suicide mortality and effect modification by age: A case:control study.

BACKGROUND: Social isolation is a potentially reversible risk factor for suicide. METHODS: A matched case control study design was used. The study population was from England and identified from an electronic primary case database with linkage to a secondary care database and Office for National Statistics mortality data. Cases were individuals who had been recorded as dying by suicide. Controls were randomly selected, matched by primary care centre and date of suicide mortality. RESULTS: Data were available from 14,515 cases who died from suicide and 580,159 controls. After adjustment for age and sex, the risk of suicide in individuals who had previously been reported to be either living alone or suffering loneliness was increased (Odds ratio OR 4.9; 95 % confidence intervals CI: 4.4 to 5.5). Age affected the level of this risk, with individuals aged 15 to 34 years who were lonely or lived alone having a much higher risk of suicide (OR 16.4; 95 % CI: 8.7 to 31.1). LIMITATIONS: We can demonstrate an association between loneliness and living alone, but this may not be a causal effect. The conclusions may not be generalisable to societies outside the UK. CONCLUSIONS: Loneliness and social isolation are associated with an approximately five-fold increase in risk of mortality from suicide, which was substantially higher in younger adults. These represent potentially reversible risk factors for suicide mortality and may also help identify individuals who are at a higher risk of suicide.

Primary care consultation patterns prior to suicide: a nationally representative case-control study.

BACKGROUND: Consultation with primary health care may provide an opportunity to identify patients at higher suicide risk. AIMS: To explore primary care consultation patterns in the 5 years before suicide to identify suicide high-risk groups and common reasons for consulting. DESIGN: A case-control study in England from 2001 to 2019 using electronic health records. METHOD: Analysis of 14515 patients aged ≥15 who died by suicide and up to 40 matched live controls per case (N=594674). RESULTS: Frequent consultations (>once per month in the final year) were associated with increased suicide risk (age and sex adjusted odds ratio (OR) 5.88; 95% CI: 5.47-6.32). The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation (>once per month in the final year) demonstrating higher suicide risk compared to their counterparts who consulted once: females (adjusted OR 9.50; 95% CI: 7.82-11.54); patients aged 15 to 45 (adjusted OR 8.08; 95% CI: 7.29-8.96); patients experiencing less socioeconomic deprivation (adjusted OR 6.56; 95% CI: 5.77-7.46); and those with psychiatric conditions (adjusted OR 4.57;95% CI: 4.12 to 5.06). Medication review, depression and pain were the commonest reasons for which suicide decedents consulted in the year before death. CONCLUSION: Escalating, or more than monthly consultations are associated with increased suicide risk regardless of patients' sociodemographic characteristics and regardless of the presence (or absence) of known psychiatric illnesses.

Evaluation of common prescription analgesics and adjuvant analgesics as markers of suicide risk: a longitudinal population-based study in England.

Background: Analgesics prescriptions may provide a marker for identifying individuals at higher risk of suicide. In particular, awareness of which analgesics are implicated may help clinicians assess and modify risk. Method: A case-control study in England using the Clinical Practice Research Datalink (for primary care records) linked with hospital and national mortality electronic registries. We included patients aged ≥15 who died by suicide between 2001 and 2019 (N = 14,515), to whom we individually matched 580,159 controls by suicide date and general practice (N = 594,674). Odds ratios (ORs) for suicide, controlled for age and sex, were assessed using conditional logistic regression. Findings: Suicide risks were highest in those prescribed adjuvant analgesics (pregabalin, gabapentin and carbamazepine) (adjusted OR 4.07; 95% confidence intervals CI: 3.62-4.57), followed by those prescribed opioids (adjusted OR 2.01; 95% CI: 1.88-2.15) and those prescribed non-opioid analgesics (adjusted OR 1.48; 95% CI: 1.39-1.58) compared to those not prescribed these medications. By individual analgesic, the highest suicide risks were seen in patients prescribed oxycodone (adjusted OR 6.70; 95% CI: 4.49-9.37); pregabalin (adjusted OR 6.50; 95% CI: 5.41-7.81); morphine (adjusted OR 4.54; 95% CI: 3.73-5.52); and gabapentin (adjusted OR 3.12; 95% CI: 2.59-3.75). Suicide risk increased linearly with the number of analgesic prescriptions in the final year (p < 0.01 based on the likelihood ratio test), and the more different analgesics categories were prescribed in the final year (p < 0.01 based on the likelihood ratio test). Interpretation: Analgesic prescribing was associated with higher suicide risk. This is a particular issue with regard to adjuvant non-opiate analgesics. Funding: There was no funding for this study.

Respiratory rate responses to both hypercapnia and acidaemia are modified by age in patients with acidosis.

OBJECTIVE: To explore the associations between arterial pO2, pCO2 and pH and how these are modified by age. METHODS: An analysis of 2598 patients admitted with a diagnosis of Covid-19 infection to a large UK teaching hospital. RESULTS: There were inverse associations for arterial pO2, pCO2 and pH with respiratory rate. The effects of pCO2 and pH on respiratory rate were modified by age; older patients had higher respiratory rates at higher pCO2 (p = 0.004) and lower pH (p = 0.007) values. CONCLUSIONS: This suggests that ageing is associated with complex changes in the physiological feedback loops that control respiratory rate. As well as having clinical relevance, this may also impact on the use of respiratory rate in early warning scores across the age range.

Anaemia of acute inflammation: a higher acute systemic inflammatory response is associated with a larger decrease in blood haemoglobin levels in patients with COVID-19 infection.

AIMS: The study tests the hypothesis that a higher acute systemic inflammatory response was associated with a larger decrease in blood hemoglobin levels in patients with Coronavirus 2019 (COVID-19) infection. METHODS: All patients with either suspected or confirmed COVID-19 infection admitted to a busy UK hospital from February 2020 to December 2021 provided data for analysis. The exposure of interest was maximal serum C-reactive protein (CRP) level after COVID-19 during the same admission. RESULTS: A maximal serum CRP >175mg/L was associated with a decrease in blood haemoglobin (-5.0 g/L, 95% confidence interval: -5.9 to -4.2) after adjustment for covariates, including the number of times blood was drawn for analysis.Clinically, for a 55-year-old male patient with a maximum haemoglobin of 150 g/L who was admitted for a 28-day admission, a peak CRP >175 mg/L would be associated with an 11 g/L decrease in blood haemoglobin, compared with only 6 g/L if the maximal CRP was <4 mg/L. CONCLUSIONS: A higher acute systemic inflammatory response is associated with larger decreases in blood haemoglobin levels in patients with COVID-19. This represents an example of anaemia of acute inflammation, and a potential mechanism by which severe disease can increase morbidity and mortality.

Prevalence and risk factors for tobacco, khat, and alcohol consumption among high school students in Ethiopia.

BACKGROUND: Tobacco, khat, alcohol, and marijuana are the main risk factors for non-communicable diseases. There are limited studies on substance use in Ethiopia, especially among secondary school students. This study aims to determine the epidemiology of substance use among secondary school students in Ethiopia. METHODS: This cross-sectional study was conducted in March 2020 in four large regions of Ethiopia and the capital Addis Ababa. We collected data from 3,355 grade 9 and grade 10 students in 36 randomly selected high schools. Data were collected on tobacco, khat, alcohol and other substances. Mixed effect logistic regression models were fitted to determine the predictors of cigarette smoking. RESULTS: 157 (4.7%) of the participants ever smoked cigarettes and 81 (2.4%) were current smokers. 106 (3.2%) ever used smokeless tobacco, 1,342 (41.8%) had ever drunk alcohol, 290 (8.7%) ever used khat, 137 (4.8%) chewed khat regularly and 76 (2.3%) ever used marijuana. There was a significant regional variation in substance use patterns; cigarette and khat use was the highest in southern regions, whereas alcohol use was highest in the northern areas. Availability of cigarette and khat shops within a 100-meter radius of the school compound was reported by 1,229 (37.5%) and 816 (25%) students, respectively. Three hundred fifty-four (10.9%) students had ever seen someone smoking a cigarette in the school compound. Ever use of smokeless tobacco (Adjusted Odds Ratio (AOR) = 9.4, 95%CI: 4.9-17.9), ever use of shisha (AOR = 8, 95% CI: 3.9-16.3), ever use of khat (AOR = 4.1, 95%CI: 2.5-6.8), ever use of alcohol (AOR = 2.3, 95%CI: 1.4-3.7), having a friend who smoked a cigarette (AOR = 2, 95%CI: 1.2-3.5), and ever seen someone smoking a cigarette in the school compound (AOR = 1.9, 95%CI: 1.1-3.4) were associated with ever use of cigarettes. CONCLUSION: Substance use prevalence in Ethiopia has regional variations and prevention strategies should be tailored to the needs of the regions. Although this study reported a lower prevalence of cigarette smoking, students could access cigarettes and khat in nearby school areas. The existing tobacco control laws that prohibit selling tobacco products to children and adolescents under 21 years of age and ban establishing tobacco shops close to school compounds should be enforced.

Inverse association between blood pressure and pulse oximetry accuracy: an observational study in patients with suspected or confirmed COVID-19 infection.

BACKGROUND: Pulse oximeters are a standard non-invasive tool to measure blood oxygen levels, and are used in multiple healthcare settings. It is important to understand the factors affecting their accuracy to be able to use them optimally and safely. This analysis aimed to explore the association of the measurement error of pulse oximeters with systolic BP, diastolic BP and heart rate (HR) within ranges of values commonly observed in clinical practice. METHODS: The study design was a retrospective observational study of all patients admitted to a large teaching hospital with suspected or confirmed COVID-19 infection from February 2020 to December 2021. Data on systolic and diastolic BPs and HR levels were available from the same time period as the pulse oximetry measurements. RESULTS: Data were available for 3420 patients with 5927 observations of blood oxygen saturations as measured by pulse oximetry and ABG sampling within 30 min. The difference in oxygen saturation using the paired pulse oximetry and arterial oxygen saturation difference measurements was inversely associated with systolic BP, increasing by 0.02% with each mm Hg decrease in systolic BP (95% CI 0.00% to 0.03%) over a range of 80-180 mm Hg. Inverse associations were also observed between the error for oxygen saturation as measured by pulse oximetry and with both diastolic BP (+0.03%; 95% CI 0.00% to 0.05%) and HR (+0.04%; 95% CI 0.02% to 0.06% for each unit decrease in the HR). CONCLUSIONS: Care needs to be taken in interpreting pulse oximetry measurements in patients with lower systolic and diastolic BPs, and HRs, as oxygen saturation is overestimated as BP and HR decrease. Confirmation of the oxygen saturation with an ABG may be appropriate in some clinical scenarios.

Risk of Suicide After Dementia Diagnosis.

Importance: Patients with dementia may be at an increased suicide risk. Identifying groups at greatest risk of suicide would support targeted risk reduction efforts by clinical dementia services. Objectives: To examine the association between a dementia diagnosis and suicide risk in the general population and to identify high-risk subgroups. Design, Setting, and Participants: This was a population-based case-control study in England conducted from January 1, 2001, through December 31, 2019. Data were obtained from multiple linked electronic records from primary care, secondary care, and the Office for National Statistics. Included participants were all patients 15 years or older and registered in the Office for National Statistics in England with a death coded as suicide or open verdict from 2001 to 2019. Up to 40 live control participants per suicide case were randomly matched on primary care practice and suicide date. Exposures: Patients with codes referring to a dementia diagnosis were identified in primary care and secondary care databases. Main Outcomes and Measures: Odds ratios (ORs) were estimated using conditional logistic regression and adjusted for sex and age at suicide/index date. Results: From the total sample of 594 674 patients, 580 159 (97.6%) were controls (median [IQR] age at death, 81.6[72.0-88.4] years; 289 769 male patients [50.0%]), and 14 515 (2.4%) died by suicide (median [IQR] age at death, 47.4 [36.0-59.7] years; 10 850 male patients [74.8%]). Among those who died by suicide, 95 patients (1.9%) had a recorded dementia diagnosis (median [IQR] age at death, 79.5 [67.1-85.5] years; median [IQR] duration of follow-up, 2.3 [1.0-4.4] years). There was no overall significant association between a dementia diagnosis and suicide risk (adjusted OR, 1.05; 95% CI, 0.85-1.29). However, suicide risk was significantly increased in patients diagnosed with dementia before age 65 years (adjusted OR, 2.82; 95% CI, 1.84-4.33), in the first 3 months after diagnosis (adjusted OR, 2.47; 95% CI, 1.49-4.09), and in patients with dementia and psychiatric comorbidity (adjusted OR, 1.52; 95% CI, 1.21-1.93). In patients younger than 65 years and within 3 months of diagnosis, suicide risk was 6.69 times (95% CI, 1.49-30.12) higher than in patients without dementia. Conclusions and Relevance: Diagnostic and management services for dementia, in both primary and secondary care settings, should target suicide risk assessment to the identified high-risk groups.

Predicting Need for Escalation of Care or Death From Repeated Daily Clinical Observations and Laboratory Results in Patients With Severe Acute Respiratory Syndrome Coronavirus 2.

We compared the performance of prognostic tools for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using parameters fitted either at the time of hospital admission or across all time points of an admission. This cohort study used clinical data to model the dynamic change in prognosis of SARS-CoV-2 at a single hospital center in the United Kingdom, including all patients admitted from February 1, 2020, to December 31, 2020, and then followed up for 60 days for intensive care unit (ICU) admission, death, or discharge from the hospital. We incorporated clinical observations and blood tests into 2 time-varying Cox proportional hazards models predicting daily 24- to 48-hour risk of admission to the ICU for those eligible for escalation of care or death for those ineligible for escalation. In developing the model, 491 patients were eligible for ICU escalation and 769 were ineligible for escalation. Our model had good discrimination of daily risk of ICU admission in the validation cohort (n = 1,141; C statistic: C = 0.91, 95% confidence interval: 0.89, 0.94) and our score performed better than other scores (National Early Warning Score 2, International Severe Acute Respiratory and Emerging Infection Comprehensive Clinical Characterisation Collaboration score) calculated using only parameters measured on admission, but it overestimated the risk of escalation (calibration slope = 0.7). A bespoke daily SARS-CoV-2 escalation risk prediction score can predict the need for clinical escalation better than a generic early warning score or a single estimation of risk calculated at admission.

Silent hypoxia is not an identifiable characteristic in patients with COVID-19 infection.

BACKGROUND: We aimed to assess whether asymptomatic ("happy") hypoxia was an identifiable physiological phenotype of COVID-19 acute respiratory distress syndrome (ARDS), and associated with need for ICU admission. METHODS: We performed an observational cohort study of all adult patients admitted with hypoxaemic respiratory failure to a large acute hospital Trust serving the East Midlands, UK. Patients with confirmed COVID-19 were compared to those without. Physiological response to hypoxaemia was modelled using a linear mixed effects model. RESULTS: Of 1,586 patients included, 75% tested positive for SARS-CoV-2. The ROX index was 2.08 min-1 lower (1.56-2.61, p < 0.001) in the COVID-19 cohort when adjusted for age and ethnicity, suggesting an enhanced respiratory response to hypoxia compared to the non-Covid-19 patients. There was substantial residual inter- and intra-patient variability in the respiratory response to hypoxaemia. 33% of the infected cohort required ICU, and of these 31% died within 60 days. ICU admission and mortality were both associated with an enhanced respiratory response for all degrees of hypoxaemia. CONCLUSIONS: Patients with COVID-19 display a more symptomatic phenotype in response to hypoxaemia than those with other causes of hypoxaemic respiratory failure, however individual patients exhibit a wide range of responses. As such although asymptomatic hypoxaemia may be a phenomenon in any individual patient with hypoxaemic respiratory failure, it is no more frequently observed in those with SARS-CoV-2 infection than without.

Age modifies both the maximal temperature and inflammatory response in patients with SARS-CoV-2 infection.

OBJECTIVE: To determine the maximal response of the temperature and inflammatory response to SARS-CoV-2 infection and how these are modified by age. METHODS: Participants were patients admitted to hospital with SARS-CoV-2 infection. For each participant, the maximal temperature and serum C-reactive protein (CRP) were identified and stratified by age. In a secondary analysis, these were compared in patients treated before and after dexamethasone. RESULTS: Mean maximal temperature varied by age (p<0.001; ANOVA) with the highest mean maximal temperature of 37.3°C observed in patients aged 30-49 years and decreasing maximal mean temperatures in the older age groups, with the lowest measure of 36.8°C observed in individuals aged 90-99 years. The mean maximal serum CRP also varied across age groups (p<0.001; ANOVA) and increased with age across all age categories from 34.5 mg/dL (95% confidence interval (CI) 22.0-47.0) for individuals aged 20-29 years to 77.6 mg/dL (95% CI 72.0-83.2) in those aged 80-89 years. After dexamethasone became standard treatment for COVID-19 pneumonia, mean maximal CRP decreased by 17 mg/dL (95% CI -22 to -11). CONCLUSION: Age modifies both maximal temperature and systemic inflammatory response in patients with SARS-CoV-2 infection.

"If I don't smoke shisha, I won't be able to sleep": lived experiences of high school students in Ethiopia.

Background: Shisha smoking predisposes the users to cardiovascular diseases, cancer, and infections, such as tuberculosis, hepatitis, and herpes. In Ethiopia, there is little data on the adolescents' shisha smoking experience. This study aimed to explore the lived experience of high school students and inform ongoing and future prevention and control interventions. Methods: This study was conducted in Addis Ababa and Adama cities in Ethiopia. Twenty-five secondary school students aged 15-22 years who had shisha smoking experience participated in this study. A topic guide was used to facilitate the in-depth interviews (IDIs) and a digital audio recorder recorded the interviews. Interviews varied between 40-90 minutes and were conducted in private open-air spaces where only the interviewee and researcher were present. Each transcript was coded using Atlas.ti version 8 software. The analytical approach was iterative, with interview transcripts analyzed at the time of coding and re-analyzed after a preliminary result was drafted to search for additional themes. Results: Students described two key factors that influenced their decision to initiate shisha smoking: peer influence and perceiving it as a means to release stress. After initiating shisha use students maintained the behaviour because of: peer influence, khat chewing, enjoyment of shisha smoking, having prolonged leisure time, and accessibility to shisha. Students regretted the impact shisha use had on their lives, such as conflict with their families, poor academic performance, and spending money on shisha smoking. Female students were also concerned about reproductive health risks related to shisha use. Conclusions: Peer influence played a major role both in initiating and maintaining shisha use. However, students admitted concern over the impact of shisha smoking on academic performance and their relationship with their families. Since shisha use is associated with khat chewing; shisha smoking control programs cannot be successful without controlling khat. Especially young girls had worries about their reproductive health risks associated with shisha use. This suggests that targeted awareness raising programs highlighting the dangers of shisha use for both health and safety; especially for young women is required.