Tag Archives: Peter Chilton

Lead Exposure and DALYs

It is well known that exposure to lead can cause a number of health problems, such as cognitive impairment, cardiovascular problems, low birth weight, etc. Exposure is also associated with a decreased life expectancy and economic output. While many countries have banned the use of lead in products such as petrol and paints, leading to significant declines in the levels of lead recorded in a person’s blood (termed blood lead levels – BLLs) there are still numerous other sources of exposure. In India, for example, studies found elevated BLLs in the population more than ten years after leaded petrol was phased out; sources include from lead smelting sites, some ayurvedic medicines, cosmetics, contaminated food, and contaminated tube wells, rivers and soil. In order to assess the extent of elevated BLLs in India, Ericson and colleagues conducted a meta-analysis of 31 studies totalling 67 samples.[1] Overall, they found a mean BLL of 6.86 μg/dL (95% CI: 4.38-9.35) in children, and 7.52 μg/dL (95% CI: 5.28-9.76) in adults (who did not work with lead). As a reference, the CDC deem a BLL of 5 μg/dL as requiring prompt medical investigation, “based on the 97.5% of BLL distribution among children… in the United States”.[2] From these figures the authors estimated that such high levels of exposure resulted in a DALY loss of 4.9 million (95% CI 3.9-5.6) in 2012. Further, data from other studies suggest that a BLL of 0.1-1.0 μg/dl contributes to loss of a single IQ point, meaning the levels of lead seen in these children would result in an average loss of four IQ points (95% CI 2.5-4.7).

The authors fear that a significant amount of the lead exposure stems from used lead batteries used in motor vehicles, which are often processed informally, and thus call for better regulations and larger studies.

Peter Chilton, Research Fellow

References:

  1. Ericson B, Dowling R, Dey S, et al. A meta-analysis of blood lead levels in India and the attributable burden of disease. Environ Int. 2018; 121(1): 461-70.
  2. Centers for Disease Control and Prevention. CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in “Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention”. 2012.
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Food Allergies and Childbirth

In a previous News Blog we looked at the practice of swabbing babies delivered via Caesarean section with vaginal fluid in an attempt to reduce the incidence of allergies in the child.[1] Another study has now been reported that could potentially strengthen this argument.[2] This was a nationwide cohort study conducted in Sweden that looked at over 1 million children, their route of delivery and the incidence of food allergies. Overall 2.5% of children were diagnosed with a food allergy, and this was positively associated with those who were delivered via C-section (hazard ratio 1.21, 95% CI 1.18-1.25) – both elective and emergency. Analysis of the data suggests that an extra 5 in 1,000 children delivered via C-section would develop a food allergy (compared to the reference group).

Interestingly there was also a negative association with those who were born prematurely (earlier than 32 weeks) (HR 0.74, 95% CI 0.56-0.98). The authors suggest this may be due to the postnatal care preterm infants receive, or is due to an immature gastrointestinal tract.

— Peter Chilton, Research Fellow

References:

  1. Lilford RJ. Exposure of the Baby to a Rich Mixture of Coliform Organisms from the Birth Canal. NIHR CLAHRC West Midlands News Blog. 22 April 2016.
  2. Mitselou N, Hallberg J, Stephansson O, Almqvist C, Melén E, Ludvigsson JF. Cesarean delivery, preterm birth, and risk of food allergy: Nationwide Swedish cohort study of more than 1 million children. J Allerg Clin Immunol. 2018.

Low-Tech Solution to a Devastating Infection

What do you do when you finish your bottle of shampoo? Throw it straight in the recycling bin? Turn it into a child’s space rocket? Well, Dr Mohamad Chisti became inspired to invent a treatment for pneumonia.

Globally more than 920,000 children died from pneumonia in 2015, accounting for around 16% of all deaths in under-fives.[1] However, this rate is far higher in low-income countries, such as Bangladesh where the figure is 28%.[2] This is partially due to the greater amount of malnourishment – pneumonia results in inflammation of the alveoli in the lungs, resulting in breathlessness and difficulty breathing – malnourished children do not have the energy required to breath in enough oxygen. The standard treatment listed in World Health Organization guidelines is to deliver ‘low-flow’ oxygen through a face mask or tubes near the nostrils, but this still requires a lot of effort to breathe. Whilst visiting Australia Dr Chisti was shown a bubble-CPAP ventilator for premature babies. This type of ventilator passes exhaled breath through water, which forms bubbles that push fresh air into the lungs and thus makes breathing easier. However, the device is prohibitively expensive for many hospitals in low-income countries. When Dr Chisti spotted a discarded shampoo bottle he realised it could be possible to recreate such a ventilator at a fraction of the cost.[3] Results of a trial to assess the efficacy of bubble-CPAP for children with pneumonia were published in the Lancet in 2015, with positive results,[4] and since then the mortality rate at Dhaka Hospital where the device is used routinely has significantly decreased, as have associated costs.[5] Further trials are starting to be carried out in other hospitals.

— Peter Chilton, Research Fellow

References:

  1. UNICEF. Pneumonia. 2018.
  2. International Centre for Diarrhoeal Disease Research, Bangladesh. Pneumonia and other respiratory diseases. 2018.
  3. Duke T. CPAP: a guide for clinicians in developing countries. Paediatr Int Child Health. 2013; 34(1): 3-11.
  4. Chisti MJ, Salam MA, Smith JH, et al. Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial. Lancet. 2015; 386: 1057-65.
  5. The Economist. How a shampoo bottle is saving young lives. The Economist. 6 September 2018.

Electronic Health Records and Mortality Rate

In a number of our previous blogs we have looked at the impact of electronic health records,[1-3] and now we add another.[4] In a paper recently published in Health Affairs the authors found that adoption of electronic health records was associated with an improvement in thirty-day mortality rates. Although the mortality rates increased when hospitals initially introduced the system (0.11 percentage points per function [such as radiology reports, laboratory reports, radiology images, medication prescribing, etc.] that was adopted), this improved over time (presumably as staff become more familiar, and were able to integrate the system into their work), and eventually mortality rates had decreased by 0.09% per year, per function adopted. Adding new functions during the study period saw further improvements with a decrease of 0.21% per year, per function. These improvements were greatest in smaller hospitals and those that were not teaching hospitals – perhaps because such hospitals have more opportunity for improvement as they are less likely to have engaged other initiatives; or they may have lacked resources to implement other improvement initiatives.

— Peter Chilton, Research Fellow

References:

  1. Lilford RJ. Going Digital – The Electronic Patient Record. NIHR CLAHRC West Midlands News Blog. 6 May 2016.
  2. Lilford RJ. Electronic Health Record System and Adverse Outcomes. NIHR CLAHRC West Midlands News Blog. 28 October 2016.
  3. Lilford RJ. If You Have Time for Only One Article. NIHR CLAHRC West Midlands News Blog. 24 August 2018.
  4. Lin SC, Jha AK, Adler-Milstein J. Electronic Health Records Associated With Lower Hospital Mortality After Systems Ha­ve Time To Mature. Health Aff. 2018;37(7).

Changes in Mealtimes Leading to Eating Less

People have long looked for a method of dieting that is effective and easy to undertake. A recent pilot study in the Journal of Nutritional Sciences may offer a new alternative.[1] For ten weeks participants were required to both delay their usual breakfast time and bring forward their evening meal time by an hour and a half – there were no other restrictions on what food they could consume, or what exercises they needed to do. When compared to a control group they found that the participants in the intervention group reduced their daily energy intake (p=0.019), with an associated reduction in adipose levels (p=0.047). Further, there was also a significant difference in fasting glucose levels, though the authors note that this was mainly due to an increase in control participants compared to baseline. Questionnaire results suggest that the reduction in energy intake may have been due to less time for snacking, and/or still feeling full from the previous meal. Unfortunately the majority of participants found that the restrictions were too severe, impacting on their social and family life, and did not believe they could continue past the end of the study.

Although this was only a very small study of 13 participants it shows a potential opportunity for future research.

— Peter Chilton, Research Fellow

Reference:

  1. Antoni R, Robertson TM, Robertson MD, Johnston JD. A pilot feasibility study exploring the effects of a moderate time-restricted feeding intervention on energy intake, adiposity and metabolic physiology in free-living human subjects. J Nutri Sci. 2018;7:e22.

The Effect Moving Has on Young People

A number of years ago researchers from CLAHRC WM Theme 2, Youth Mental Health, worked on a prospective birth cohort study of ~6,500 children, which found a significant association between how often children moved schools and the incidence of psychotic-like symptoms.[1] Now, a similar study has been conducted with 1.4 million young Swedish people followed up until their 29th birthday.[2] In this study the authors focused on how often and how far participants moved house, and at what age, and any associations with non-affective psychosis. They found that frequent moves were associated with a significant increase in the risk of non-affective psychosis (p<0.001), and that adolescents who moved regularly between the ages of 16-19 had the strongest association with an increased adjusted hazard ratio for psychosis risk of 1.99 (95% CI, 1.30-3.05) when compared to those who did not move. Those who moved in adulthood (older than 20 years) showed little variation in risk, with only those who moved at least four times showing a significantly increased risk. The authors found that moves that resulted in changes in schools and/or friendship groups were most strongly associated with a future risk of psychosis.

For another interesting study that looked at the effect moving to areas of higher income had on mental health, you may like to look at our previous News Blog.[3]

— Peter Chilton, Research Fellow

References:

  1. Singh SP, Winsper C, Wolke D, Bryson A. School Mobility and Prospective Pathways to Psychotic-like Symptoms in Early Adolescence: A Prospective Birth Cohort Study. J Am Acad Child Adolesc Psych. 2014; 53(5): 518-27.
  2. Price C, Dalman C, Zammit S, Kirkbridge JB. Association of Residential Mobility Over the Life Course With Nonaffective Psychosis in 1.4 Million Young People in Sweden. JAMA Psychiatry. 2018.
  3. Lilford RJ. Neighbourhood Effect and Child Development – Long-term Results of a RCT. NIHR CLAHRC West Midlands News Blog. 17 June 2016.

A Real-Life Trolley Problem

News blog readers may be familiar with some form of the trolley problem, an ethical thought experiment positing a runaway tram heading towards five people tied on to the track – you can pull a lever to redirect the tram but there is a single person tied to that track – what do you do? Researchers at Ghent University (Belgium) decided to see what people would do in a real-life trolley problem, and whether their responses to a hypothetical dilemma were an accurate reflection of how they would react in reality.[1] Around 200 student participants were tasked with choosing to either administer a non-lethal electroshock to a single mouse or to do nothing and let five other mice to be shocked (all shocks were, of course, simulated). The results showed that earlier responses to hypothetical dilemmas were not predictive of real-life behaviour (p=0.406). Further, a separate group of 83 students were given a hypothetical version of the same dilemma and, when results were compared, the authors found that participants were approximately twice as likely to state that they would not press the button in the hypothetical experiment (34%) (leaving the five mice to be ‘shocked’), than actually did not press it in the real-life experiment (16%) (p=0.017). This goes against previous wisdom that people would feel guiltier about intervening (pulling the lever, pressing the button) the more ‘real’ the situation gets. The authors believe such findings could have implications in programming self-driving cars that may have to decide between colliding with an oncoming vehicle or swerving into pedestrians.

Readers may also want to read our previous News Blog on revisiting the Milgram experiments, where participants were encouraged to administer (simulated) electrical shocks.[2]

— Peter Chilton, Research Fellow

References:

  1. Bostyn DH, Sevenhant S, Roets A. Of Mice, Men, and Trolleys: Hypothetical Judgment Versus Real-Life Behavior in Trolley-Style Moral Dilemmas. Psychol Sci. 2018; 29(7): 1084-93.
  2. Lilford RJ. Revisiting the Milgram Experiment. NIHR CLAHRC West Midlands News Blog. 4 May 2018.

Reducing Risk of Postpartum Haemorrhage in LMICs

­Worldwide around 127,000 women die each year due to postpartum haemorrhage (the loss of 500ml of blood within the first 24 hours after giving birth), making it the most common cause of maternal death.[1] It is especially prevalent in low- or middle-income countries (LMICs). The standard treatment is administration of oxytocin – however, the drug needs to be kept at 20-25°C, which can be difficult in some countries where refrigeration isn’t reliable in either the hospital or whilst being transported. Thus, there is a need for an alternative option. Widmer and colleagues conducted a double-blind RCT of nearly 30,000 women across ten countries comparing postpartum administration of oxytocin with carbetocin, a heat-stable oxytocin analogue that can be stored at room temperature.[2] Both groups of women showed similar frequencies of blood loss – 14.4% of those given oxytocin lost >500ml of blood, compared to 14.5% given carbetocin (relative risk 1.01, 95% CI 0.95-1.06); while, respectively, 1.45% and 1.51% lost >1000ml of blood (relative risk 1.04, 95% CI 0.87-1.25). There were also no significant differences in necessary interventions or adverse events.

Carbetocin could even perform better than oxytocin in LMICs as the oxytocin was stored in optimum conditions, which may not accurately reflect real-life settings. It will be interesting to track the implementation to uptake of this new finding – any takers?

— Peter Chilton, Research Fellow

References:

  1. World Health Organization. Making Pregnancy Safer. Issue 4. Geneva, CHE: World Health Organization; 2007.
  2. Widmer M, Piaggio G, Nguyen TMH, et al. Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth. New Engl J Med. 2018.

Using Polio to Treat Cancer

Up until the mid-1950s polio was epidemic across many countries with an estimated 500,000 people paralysed or killed each year. Two vaccines were developed (one by Jonas Salk launched in 1957, the other by Albert Sabin in 1962), which lead to a dramatic decline in cases, and eventually eradication in many high-income countries. Following this the World Health Organization, UNICEF and the Rotary Foundation began an eradication campaign in 1988, and as a result there were only 22 reported polio cases worldwide in 2017. However, recent research has suggested that polio may be able to help patients with grade IV malignant gliomas.[1] Such patients have low survival rates – less than 20 months following diagnosis, and less than 12 months for recurrent gliomas. Current therapies are ineffective, inconsistent in improving survival and have many toxic effects. The trial was conducted using PVSRIPO, a modified live attenuated poliovirus type 1 vaccine. This is able to recognise CD155, a poliovirus receptor that is widely expressed in tumour cells. In total 61 patients were given a dose of PVSRIPO and followed up. Although 19% of patients had moderate-severe (grade 3 or higher) adverse events attributed to PVSRIPO, the overall survival of patients reached a plateau of 21% (95% CI 11-33) at 24 months, which was sustained at 36 months. This was higher than the rate among historical controls.

References:

  1. Desjardins A, Gromeier M, Herndon JE, et al. Recurrent Glioblastoma Treated with Recombinant Poliovirus. New Engl J Med. 2018.

More on Body-Worn Cameras for the Police

In our previous News Blog we talked about a study that looked at the effect body cameras had on the behaviour of police officers.[1] The study found there was no significant differences seen for those who did and did not wear a body camera, and there was no improvement in behaviours. However, as we pointed out the results may have been context-specific as the study was conducted in only one district. Now, News Blog reader Peter Lilford has directed us to a similar study based in the UK and the USA.[2] This study, by researchers at Cambridge University, looked at over 4,000 shifts across seven sites where police officers were randomised to either wear a camera or not. All officers taking part wore a camera at some point over the year-long study. They found that by the end of the study period complaints against police officers had fallen by 93% (p<0.001). However, there was no significant difference in the number of complaints received by those wearing or not wearing a camera. The authors believe that this could be due to ‘contiguous accountability’ from repeated surveillance that even affected departments not taking part in the study. Another factor that the authors believe to be important is that police officers issued a warning at the beginning of any encounter that there was a camera present, perhaps serving to influence the resulting behaviours.

— Peter Chilton, Research Fellow

References:

  1. Lilford RJ. What are the Effects of Body-Worn Cameras on Police and Citizen Behaviour? NIHR CLAHRC West Midlands News Blog. 1 June 2018.
  2. Ariel B, Sutherland A, Henstock D, et al. Contiguous Accountability: Global Multisite Randomized Controlled Trial on the Effect of Police Body-Worn Cameras on Citizens’ Complaints Against the Police. Crim Just Behav. 2016.