Enoxaparin Versus Direct Oral Anticoagulants for Venous Thromboembolism in Asians Undergoing Total Knee Arthroplasty: A Meta-Analysis and Systematic Review

BackgroundThe introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study.MethodsThe review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included.ResultsFive studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33).ConclusionDOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist.     

Insights on home blood pressure monitoring in Asia: Expert perspectives from 10 countries/regions

Hypertension is one of the most powerful modifiable risk factors for cardiovascular disease. It is usually asymptomatic and therefore essential to measure blood pressure regularly for the detection of hypertension. Home blood pressure monitoring (HBPM) is recognized as a valuable tool to monitor blood pressure and facilitate effective diagnosis of hypertension. It is useful to identify the masked or white‐coat hypertension. There is also increasing evidence that supports the role of HBPM in guiding antihypertensive treatment, and improving treatment compliance and hypertension control. In addition, HBPM has also shown prognostic value in predicting cardiovascular events. Despite these benefits, the use of HBPM in many parts of Asia has been reported to be low. An expert panel comprising 12 leading experts from 10 Asian countries/regions convened to share their perspectives on the realities of HBPM. This article provides an expert summary of the current status of HBPM and the key factors hindering its use. It also describes HBPM‐related initiatives in the respective countries/regions and presents strategies that could be implemented to better support the use of HBPM in the management of hypertension.     

From the Cover: Ancient DNA and multimethod dating confirm the late arrival of anatomically modern humans in southern China

The expansion of anatomically modern humans (AMHs) from Africa around 65,000 to 45,000 y ago (ca. 65 to 45 ka) led to the establishment of present-day non-African populations. Some paleoanthropologists have argued that fossil discoveries from Huanglong, Zhiren, Luna, and Fuyan caves in southern China indicate one or more prior dispersals, perhaps as early as ca. 120 ka. We investigated the age of the human remains from three of these localities and two additional early AMH sites (Yangjiapo and Sanyou caves, Hubei) by combining ancient DNA (aDNA) analysis with a multimethod geological dating strategy. Although U–Th dating of capping flowstones suggested they lie within the range ca. 168 to 70 ka, analyses of aDNA and direct AMS ¹⁴C dating on human teeth from Fuyan and Yangjiapo caves showed they derive from the Holocene. OSL dating of sediments and AMS ¹⁴C analysis of mammal teeth and charcoal also demonstrated major discrepancies from the flowstone ages; the difference between them being an order of magnitude or more at most of these localities. Our work highlights the surprisingly complex depositional history recorded at these subtropical caves which involved one or more episodes of erosion and redeposition or intrusion as recently as the late Holocene. In light of our findings, the first appearance datum for AMHs in southern China should probably lie within the timeframe set by molecular data of ca. 50 to 45 ka.

The fossil record suggests that Homo sapiens had evolved in Africa by 315,000 y ago (315 ka) (1), spread into West Asia before 177 ka (2), but disappeared and were seemingly replaced by Homo neanderthalensis until ca. 75 to 55 ka (3, 4). A second and final excursion from Africa by so-called anatomically modern humans (AMHs) occurred soon after and broadly coincides with the extinction of the last archaic hominins, ca. 40 to 30 ka (5, 6). This dispersal involved the ancestors of all present-day non-Africans and according to molecular data occurred ca. 65 to 45 ka (7, 8). Additional support for this “late dispersal” theory is provided by the geographical structure of contemporary DNA lineages with all non-Africans closely related to present-day and ancient eastern African populations (9, 10), as well as a clinal pattern of decreasing diversity from Africa to Eurasia, the signature of serial founder effect (10–12). Corroboration has also been provided by the estimated split time between western and eastern Eurasians of ca. 47 to 42 ka as determined by ancient DNA (aDNA) from the 46,880 to 43,210 cal y B.P. (calendar year before present, i.e., before AD1950) Ust’-Ishim femur (western Siberia, Russian Federation) and the 42,000 to 39,000 cal B.P. Tianyuan skeleton (Northeast China) (13–15). Finally, the upper age boundary for this dispersal is set by interbreeding between early AMHs and the Neanderthals estimated to have occurred ca. 65 to 47 ka and the ancestors of New Guineans with the Denisovans ca. 46 ka and again ca. 30 ka (13, 16–19).In contrast, some paleoanthropologists have suggested that AMHs settled mainland East Asia much earlier, within the period of ca. 120 to 70 ka, in accordance with the “early dispersal” theory. This model is based largely upon the dating of isolated human teeth recovered at Huanglong, Luna, and Fuyan caves and a partial mandible from Zhirendong in southern China (20–24). Yet several researchers have raised questions about these and other sites on the basis of uncertainties surrounding the identification of some of them as AMHs, relationships between human remains and dated materials, or limited information available about their depositional context and dating (25–27).Here, we describe the results of an investigation of the arrival time of AMHs in southern China at five apparent early AMH cave localities involving aDNA analyses of human teeth and the dating of flowstones, sediments, fossil remains, and charcoal. The five localities we studied are the following:

• 1)Huanglong cave, located about 25 km from the town of Yunxi, northern Hubei Province (Fig. 1). Excavations by the Hubei Provincial Institute of Cultural Relics and Archaeology during three field seasons from 2004 to 2006 provided a rich mammal record, comprising 91 taxa and representing a Middle to Late Pleistocene Ailuropoda-Stegodon fauna, stone artifacts, and seven AMH teeth dated indirectly with U–Th dating on thin flowstone formations ca. 101 to 81 ka (20).Open in a separate windowFig. 1.(A) Geographical location of Huanglong Cave (1), Luna Cave (2), Fuyan Cave (3), Yangjiapo Cave (4), and Sanyou Cave (5). (B) Human remains from three localities: Yangjiapo Cave (i), Sanyou Cave (ii), and Fuyan Cave (iii). b = buccal, d = distal, l = lingual, m = mesial, and o = occlusal).
• 2)Luna cave, situated in the karst mountains of the southeastern part of the Bubing basin, Guangxi Zhuang Autonomous Region (Fig. 1). A small sample of mammal fossils (Ailuropoda-Stegodon assemblage), stone artifacts, and two AMH teeth were recovered during excavations by the Natural History Museum of Guangxi Autonomous Region in 2004 and 2008. They have since been dated indirectly through U–Th dating of flowstone in the range ca. 127 to 70 ka (21).
• 3)Fuyan cave, located in Daoxian County, Hunan Province (Fig. 1). Excavations from 2011 to 2013 resulted in a large sample of mammal fossils (Ailuropoda-Stegodon faunal group) and 47 AMH teeth but no associated artifacts (22). They have been dated indirectly using U–Th dating of flowstone within the range ca. 120 to 80 ka (22). Two additional (in situ) AMH teeth, stratigraphically associated with the original finds, were recovered by us during field investigations at the site during early 2019.
• 4)Yangjiapo Cave is a large karstic chamber located in Jianshi County (Fig. 1). It was excavated during 2004 by the Hubei Provincial Institute of Cultural Relics and Archeology and yielded 11 AMH teeth found in association with the fragmentary bones of 80 species belonging to an Ailuropoda-Stegodon fauna, implying it should be of similar age to Huanglong, Luna, and Fuyan caves. No stone artifacts or other cultural remains were found.
• 5)Sanyou Cave is a small chamber within a limestone hill at the confluence of the Yangtze River and Xiling Gorge, close to Yichang city, Hubei Province (Fig. 1). A small excavation was undertaken in 1986 by the Yichang Museum and led to the recovery of a possible Late Pleistocene age partial AMH cranial vault (Fig. 1).

     

Identification of Possible Virulence Marker from Campylobacter jejuni Isolates

A novel protein translocation system, the type-6 secretion system (T6SS), may play a role in virulence of Campylobacter jejuni. We investigated 181 C. jejuni isolates from humans, chickens, and environmental sources in Vietnam, Thailand, Pakistan, and the United Kingdom for T6SS. The marker was most prevalent in human and chicken isolates from Vietnam.     

A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: Limited evidence from India and Pakistan

Cardiovascular diseases (CVD) are major contributors to mortality and morbidity in South Asia. Chronic exposure to air pollution is an important risk factor for cardiovascular diseases, although the majority of studies to date have been conducted in developed countries. Both indoor and outdoor air pollution are growing problems in developing countries in South Asia yet the impact on rising rates of CVD in these regions has largely been ignored. We aimed to assess the evidence available regarding air pollution effects on CVD and CVD risk factors in lower income countries in South Asia. A literature search was conducted in PubMed and Web of Science. Our inclusion criteria included peer-reviewed, original, empirical articles published in English between the years 1990 and 2012, conducted in the World Bank South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka). This resulted in 30 articles. Nine articles met our inclusion criteria and were assessed for this systematic review. Most of the studies were cross-sectional and examined measured particulate matter effects on CVD outcomes and indicators. We observed a bias as nearly all of the studies were from India. Hypertension and CVD deaths were positively associated with higher particulate matter levels. Biomarkers of oxidative stress such as increased levels of P-selection expressing platelets, depleted superoxide dismutase and reactive oxygen species generation as well as elevated levels of inflammatory-related C-reactive protein, interleukin-6 and interleukin-8 were also positively associated with biomass use or elevated particulate matter levels. An important outcome of this investigation was the evidence suggesting important air pollution effects regarding CVD risk in South Asia. However, too few studies have been conducted. There is as an urgent need for longer term investigations using robust measures of air pollution with different population groups that include a wider range of air pollutants and outcomes, including early indicators of CVD. These regions are facing burdens from increasing urbanization, air pollution and populations, generally weaker health infrastructure, aging populations and increased incidence of non-communicable diseases, included CVD. The extent to which the problem of air pollution and CVD will impact these countries will depend largely on the information available to inform policy and programs, which are still lacking, political will as well as social and economic development.     

财务管理促进非政府组织成长结果分析

目的:通过财务管理有效方法提高非政府组织(NGO)综合能力,促进NGO成长。方法:以云南省中澳艾滋病亚洲区域项目支持所有19个县中的31家NGO为研究对象,收集2008—2012年以来NGO资金投入、财务培训、经费使用领域、财务报账管理能力及后期获得其他资金支持等信息。综合分析财务管理在NGO成长中所起作用。结果:投入159万元,新增非政府组织26家及成员254名。从初期3万元增至18万元用于NGO财务能力建设,逐年递增干预活动经费,后期在NGO专项调查、对外宣传及对外参与或提供技术支持方面提供经费支持,分别为10万元、15万元和15万元。小组独立报账金额从无到43万元、到当地资金托管机构报账的NGO报账金额从1.5万元增至30万元。财务管理促进31家NGO在熟悉财务标准要求、活动经费预算、经费活动匹配、独立报销及争取其他资金支持等方面能力有较大改变。最后一年23家NGO获得本项目外其他资金来源。结论:以财务管理为核心推动NGO成长方法可行,确保了NGO可持续发展。     

Older person behavioral and psychological symptoms (BPS) and functional limitations mediate the association between older person cognitive impairment and depressive symptoms in the caregiver

We assess for the mediation of the association between older person cognitive impairment and caregiver depressive symptoms through older person BPS and functional limitations, and whether the mediation varies by caregiver–older person relationship (spouse/adult child). Data for 1111 older person (aged 75+ with activity of daily living (ADL) limitation)–caregiver dyads from Singapore were used. The outcome variable was dichotomous (caregiver clinically significant depressive symptoms [CSDS]: yes/no) in the primary analysis and continuous (caregiver depressive symptoms score) in the sensitivity analysis. The causal steps approach assessed for the mediation of the association between older person cognitive impairment (yes/no) and the outcome variable through the two potential mediators. A bootstrapping approach calculated point estimates and confidence intervals (CIs) of the indirect (∼mediated) effects. Variation of the indirect effects by caregiver–older person relationship was also assessed. In the primary analysis, the causal steps approach supported older person BPS and functional limitations as mediators. The bootstrapping approach confirmed both as significant mediators, though BPS (indirect effect odds ratio (OR) 1.32 [95% bootstrap CI 1.19,1.48]; %mediation: 70.6%) was a stronger mediator than functional limitations (1.04 [1.01,1.11]; %mediation: 11.5%). Variation of the indirect effects by caregiver–older person relationship was not supported. Results of the sensitivity analysis confirmed these results. We conclude that while caring for an older person with cognitive impairment is detrimental for the caregiver's mood, management of associated BPS and functional limitations, especially the former, among such older persons may reduce depressive symptoms among their caregivers. Spouse as well as adult child caregivers benefit.