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related macular degeneration
Smoking and age related macular degeneration: a review of association
J Thornton1, R Edwards1, P Mitchell2, R A Harrison3, I Buchan1 and S P Kelly4
1Evidence for Population Health Unit, Division of Epidemiology and Health Sciences, University of Manchester, Manchester, UK2University of Sydney Department of Ophthalmology, Centre for Vision Research, Westmead Hospital, Westmead, Australia3Bolton Primary Care Trust, St Peter's House, Bolton, UK4Bolton Eye Unit. Bolton Hospitals NHS Trust, Bolton, UKCorrespondence: SP Kelly, Bolton Hospitals NHS Trust, Minerva Road, Bolton BL4 0JR, UK. Tel: +44 1204 390694; Fax: +44 1204 390554.
Top of pageAbstractPurpose Age related macular degeneration (AMD) is the leading cause of severe and irreversible vision loss in the Western world. As there is no effective treatment for all types of AMD, identifying modifiable risk factors is of great importance. This review evaluates the epidemiological evidence associating smoking with AMD.
Methods Systematic review of published epidemiological studies evaluated against established criteria for evidence of a causal relationship.
Results In total, 17 studies (cross sectional studies, prospective cohort studies, and case studies) were included in the review. A total of 13 studies found a statistically significant association between smoking and AMD with increased risk of AMD of two to three fold in current smokers compared with never smokers. Five studies found no association between smoking and AMD. There was also evidence of dose response, a temporal relationship and reversibility of effect.
Conclusion The literature review confirmed a strong association between current smoking and AMD, which fulfilled established causality criteria. Cigarette smoking is likely to have toxic effects on the retina. This paper evaluates the evidence for a causal association between smoking and AMD.
Top of pageMethodsSearching and review of studiesMEDLINE (1966 to July 2003) and EMBASE (1980 to July 2003) were searched using combinations of the key words of 'smoking', 'macular degeneration', and 'age related maculopathy'. Bibliographies were checked for further relevant studies.
Studies were included if they were epidemiological studies (case cohort or cross sectional studies) published in English, assessed the relationship between tobacco smoking and AMD or ARM, and included an estimate of the degree of association (odds ratio (OR) or relative risk (RR)). The outcome measure was the presence of ARM or AMD fake van cleef bracelet as defined by the investigators of each study. The evidence was reviewed against a framework for assessing the evidence for causality derived from Hill10 and subsequently modified by Susser11 (see box).
Top of pageResultsDesign of studiesIn total, 23 studies examined the link between smoking and AMD. Two studies were excluded from the review as they were not published in the English language.12, 13 One study was excluded because it was a case series.14 Three studies did not report an OR or RR.15, 16, 17 We attempted to calculate crude ORs for these studies using the available data. Pauleikhoff et al15 did not contain sufficient data to allow calculation of an OR. In the study by Hirvela et al,16 there were very large differences in smoking between men and women but there were insufficient data to calculate a sex specific OR. The fourth study was a very small (30 cases) individually matched case study. For the cross sectional and prospective cohort studies, subjects were recruited from the general population or through selected occupations such as watermen,18 physicians19 and nurses.20 For the case studies, cases were recruited through knock off van cleef & arpels bangle eye clinics, and hospital controls were recruited through eye clinics21, 22, 23, 24 or general medicine clinics.25
The age range for subjects in most studies was 40 years. The sex of subjects was not always reported, but approximately equal numbers of males and females were included in studies where data were available. In total, 10 studies evaluated neovascular AMD and six of these found a positive association;22, 24, 25, 28, 29, 30 five studies evaluated atrophic AMD and four found a positive association.24, 30, 33, 34 In van cleef bracelets knock off addition, some studies found the association was different for men or women. These variations could have been caused by random fluctuation because of relatively small numbers after stratifying by lesion type.
The results were not completely consistent and five studies found no association or only a very weak link between smoking and AMD.18, 23, 35, 36, 37 Of these, West et al18 found a nonsignificant decreased risk of AMD in ever smokers in a small cross sectional study, and Blumenkranz et al35 found a small nonsignificant increase among current smokers in a small case study. More importantly, a generally well conducted large French case study found only a weak and nonsignificant association between previous and current smoking with AMD after adjustment for confounding factors.23 Finally, although the Beaver Dam Eye Study found a strong association between smoking and neovascular AMD at baseline,28 the association at the 5 and 10 year follow up examinations was weaker.36, 37
Findings from the three large well executed cross sectional studies from Europe, Australia, and the USA demonstrate a consistent association between smoking and AMD.28, 29, 30 The populations from these three key studies were combined giving a pooled population of 12 468 subjects.26 Apart from age, smoking was the only factor that retained a clear (three fold) association with AMD (Table 4). The association with current smoking was stronger for neovascular AMD compared with atrophic AMD.
Is there a temporal relationship? The prospective cohort study design is best for demonstrating that smoking preceded the development of AMD. The three key cross sectional studies (the Beaver Dam Eye Study, the Rotterdam Study, and the Blue Mountains Eye Study) were subsequently extended into longitudinal studies; two studies reported results from further analysis of smoking and the risk of AMD after 533, 36 and 10 years37 follow up. In the Blue Mountains Eye Study, the association between all ARM and atrophic AMD (but not neovascular AMD) was still present 5 years from baseline.33 A further pooled analysis of the 5 year results from these three studies found a continued three fold association of current smoking with development of AMD (Table 4).27 The Physicians' Health Study19 and the Nurses' Health Study20 also observed positive associations between smoking and AMD after 7 years of follow up.
Is there a dose effect? Eight studies investigated a dose by comparing different levels of smoking, classified using pack years (Table 5).19, 20, 25, 29, 31, 32, 36, 37 All except the 10 year follow up of the Beaver Dam cohort study identified a dose effect. In the 5 year follow up results from the Beaver Dam study, the relative risk of early ARM increased as the amount smoked (measured in cigarette pack years) increased.36 However, there appeared to be a negative association between the incidence of late ARM and the amount smoked in the 10 year follow up.37 In female current smokers and ex smokers, an increasing number of cigarettes smoked was associated with an increased risk of developing AMD.20 In men, current smokers of 20 cigarettes per day.19 When the length and duration of smoking were combined as pack years, compared with never smokers, there was an increasing risk of AMD as the number of pack years increased from 0.25 to >40 (P for trend 19
Smoking and age related macular degeneration: a review of association
J Thornton1, R Edwards1, P Mitchell2, R A Harrison3, I Buchan1 and S P Kelly4
1Evidence for Population Health Unit, Division of Epidemiology and Health Sciences, University of Manchester, Manchester, UK2University of Sydney Department of Ophthalmology, Centre for Vision Research, Westmead Hospital, Westmead, Australia3Bolton Primary Care Trust, St Peter's House, Bolton, UK4Bolton Eye Unit. Bolton Hospitals NHS Trust, Bolton, UKCorrespondence: SP Kelly, Bolton Hospitals NHS Trust, Minerva Road, Bolton BL4 0JR, UK. Tel: +44 1204 390694; Fax: +44 1204 390554.
Top of pageAbstractPurpose Age related macular degeneration (AMD) is the leading cause of severe and irreversible vision loss in the Western world. As there is no effective treatment for all types of AMD, identifying modifiable risk factors is of great importance. This review evaluates the epidemiological evidence associating smoking with AMD.
Methods Systematic review of published epidemiological studies evaluated against established criteria for evidence of a causal relationship.
Results In total, 17 studies (cross sectional studies, prospective cohort studies, and case studies) were included in the review. A total of 13 studies found a statistically significant association between smoking and AMD with increased risk of AMD of two to three fold in current smokers compared with never smokers. Five studies found no association between smoking and AMD. There was also evidence of dose response, a temporal relationship and reversibility of effect.
Conclusion The literature review confirmed a strong association between current smoking and AMD, which fulfilled established causality criteria. Cigarette smoking is likely to have toxic effects on the retina. This paper evaluates the evidence for a causal association between smoking and AMD.
Top of pageMethodsSearching and review of studiesMEDLINE (1966 to July 2003) and EMBASE (1980 to July 2003) were searched using combinations of the key words of 'smoking', 'macular degeneration', and 'age related maculopathy'. Bibliographies were checked for further relevant studies.
Studies were included if they were epidemiological studies (case cohort or cross sectional studies) published in English, assessed the relationship between tobacco smoking and AMD or ARM, and included an estimate of the degree of association (odds ratio (OR) or relative risk (RR)). The outcome measure was the presence of ARM or AMD fake van cleef bracelet as defined by the investigators of each study. The evidence was reviewed against a framework for assessing the evidence for causality derived from Hill10 and subsequently modified by Susser11 (see box).
Top of pageResultsDesign of studiesIn total, 23 studies examined the link between smoking and AMD. Two studies were excluded from the review as they were not published in the English language.12, 13 One study was excluded because it was a case series.14 Three studies did not report an OR or RR.15, 16, 17 We attempted to calculate crude ORs for these studies using the available data. Pauleikhoff et al15 did not contain sufficient data to allow calculation of an OR. In the study by Hirvela et al,16 there were very large differences in smoking between men and women but there were insufficient data to calculate a sex specific OR. The fourth study was a very small (30 cases) individually matched case study. For the cross sectional and prospective cohort studies, subjects were recruited from the general population or through selected occupations such as watermen,18 physicians19 and nurses.20 For the case studies, cases were recruited through knock off van cleef & arpels bangle eye clinics, and hospital controls were recruited through eye clinics21, 22, 23, 24 or general medicine clinics.25
The age range for subjects in most studies was 40 years. The sex of subjects was not always reported, but approximately equal numbers of males and females were included in studies where data were available. In total, 10 studies evaluated neovascular AMD and six of these found a positive association;22, 24, 25, 28, 29, 30 five studies evaluated atrophic AMD and four found a positive association.24, 30, 33, 34 In van cleef bracelets knock off addition, some studies found the association was different for men or women. These variations could have been caused by random fluctuation because of relatively small numbers after stratifying by lesion type.
The results were not completely consistent and five studies found no association or only a very weak link between smoking and AMD.18, 23, 35, 36, 37 Of these, West et al18 found a nonsignificant decreased risk of AMD in ever smokers in a small cross sectional study, and Blumenkranz et al35 found a small nonsignificant increase among current smokers in a small case study. More importantly, a generally well conducted large French case study found only a weak and nonsignificant association between previous and current smoking with AMD after adjustment for confounding factors.23 Finally, although the Beaver Dam Eye Study found a strong association between smoking and neovascular AMD at baseline,28 the association at the 5 and 10 year follow up examinations was weaker.36, 37
Findings from the three large well executed cross sectional studies from Europe, Australia, and the USA demonstrate a consistent association between smoking and AMD.28, 29, 30 The populations from these three key studies were combined giving a pooled population of 12 468 subjects.26 Apart from age, smoking was the only factor that retained a clear (three fold) association with AMD (Table 4). The association with current smoking was stronger for neovascular AMD compared with atrophic AMD.
Is there a temporal relationship? The prospective cohort study design is best for demonstrating that smoking preceded the development of AMD. The three key cross sectional studies (the Beaver Dam Eye Study, the Rotterdam Study, and the Blue Mountains Eye Study) were subsequently extended into longitudinal studies; two studies reported results from further analysis of smoking and the risk of AMD after 533, 36 and 10 years37 follow up. In the Blue Mountains Eye Study, the association between all ARM and atrophic AMD (but not neovascular AMD) was still present 5 years from baseline.33 A further pooled analysis of the 5 year results from these three studies found a continued three fold association of current smoking with development of AMD (Table 4).27 The Physicians' Health Study19 and the Nurses' Health Study20 also observed positive associations between smoking and AMD after 7 years of follow up.
Is there a dose effect? Eight studies investigated a dose by comparing different levels of smoking, classified using pack years (Table 5).19, 20, 25, 29, 31, 32, 36, 37 All except the 10 year follow up of the Beaver Dam cohort study identified a dose effect. In the 5 year follow up results from the Beaver Dam study, the relative risk of early ARM increased as the amount smoked (measured in cigarette pack years) increased.36 However, there appeared to be a negative association between the incidence of late ARM and the amount smoked in the 10 year follow up.37 In female current smokers and ex smokers, an increasing number of cigarettes smoked was associated with an increased risk of developing AMD.20 In men, current smokers of 20 cigarettes per day.19 When the length and duration of smoking were combined as pack years, compared with never smokers, there was an increasing risk of AMD as the number of pack years increased from 0.25 to >40 (P for trend 19
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Suspect In Philadelphia Hospital Shooting Had History Of Gun Arrests
Dr. Lee Silverman emptied his gun's chamber, striking patient Richard Plotts several times, Delaware County District Attorney Jack Whelan said. Plotts by then had shot the caseworker in the face and fired several shots at Silverman, including one that grazed his temple and another that struck his thumb, he said.Plotts had 39 unspent bullets on him when he was wrestled to the ground at Mercy van cleef and arpels bangle fake Fitzgerald Hospital in Darby, just southwest of Philadelphia, and police believe he had planned to use them.Pa. Hospital Sees Gun Fight Between Psychiatrist And Patient July 25, 2014"If the doctor did not have a firearm, (and) the doctor did not utilize the firearm, he'd be dead today, and I believe that other people in that facility would also be dead," Whelan said.Police in Upper Darby, where Plotts lived, were aware of at least three mental health commitments including once after he cut his wrists and once when he threatened suicide but said such stays can last just one to three days.Whelan said Plotts had spent time in a mental health facility, but he did not discuss any potential diagnosis.Plotts also had at least four gun arrests, along with assault and drug charges, according to police and court records. And he has been barred from at least one residential shelter because of his violent history, Upper Darby police Superintendent Michael Chitwood said."The caseworkers and the doctors and the catchment centers they know who violent individuals are, because they're frequent fliers," Chitwood said. bracelet van cleef replica "And the system is not geared toward keeping these people housed somewhere until they start van cleef and arpels bracelet knock off to be better. So you put whole communities at risk."Cathy Nickel, a neighbor at Plotts' last known address, an apartment complex in Upper Darby, saw a caseworker move him out of the building about a year ago. As he was taken away in a van, she said, he yelled, "You haven't heard the end of me!"Plotts was sedated but in stable condition after surgery Thursday for his gunshot wounds, police said. They expected to arraign him at his Philadelphia hospital bedside, charging him with murder in the death of caseworker Barbara Hunt and other crimes.Plotts doesn't have a listed home number, and it was unclear if he has relatives in the area.Hospital policy bars anyone except on duty law enforcement officers from carrying weapons on campus, said a Mercy Health System spokeswoman.The hospital said Friday it was thankful for the "brave and difficult action" taken by Silverman and his colleagues. It said he remains a full member of the medical staff and "we look forward to Dr. Silverman's return to serving patients at our hospital."Plotts had complained to Silverman previously about the gun policy.Whelan said he believes Silverman, not Hunt, was Plotts' target. He said that when the caseworker was shot, Silverman crouched down behind a desk to avoid being shot also."He was able to reach for his weapon, and realizing it was a life or death situation, was able to engage the defendant in the exchange of gunfire," Whelan said.The struggle spilled into the hallway, where another doctor and a caseworker jumped in to help Silverman and secure Plotts' weapon, Whelan said.Silverman told police he was at his desk, behind a computer screen, when Plotts pulled a gun from his waistband and killed Hunt.
Dr. Lee Silverman emptied his gun's chamber, striking patient Richard Plotts several times, Delaware County District Attorney Jack Whelan said. Plotts by then had shot the caseworker in the face and fired several shots at Silverman, including one that grazed his temple and another that struck his thumb, he said.Plotts had 39 unspent bullets on him when he was wrestled to the ground at Mercy van cleef and arpels bangle fake Fitzgerald Hospital in Darby, just southwest of Philadelphia, and police believe he had planned to use them.Pa. Hospital Sees Gun Fight Between Psychiatrist And Patient July 25, 2014"If the doctor did not have a firearm, (and) the doctor did not utilize the firearm, he'd be dead today, and I believe that other people in that facility would also be dead," Whelan said.Police in Upper Darby, where Plotts lived, were aware of at least three mental health commitments including once after he cut his wrists and once when he threatened suicide but said such stays can last just one to three days.Whelan said Plotts had spent time in a mental health facility, but he did not discuss any potential diagnosis.Plotts also had at least four gun arrests, along with assault and drug charges, according to police and court records. And he has been barred from at least one residential shelter because of his violent history, Upper Darby police Superintendent Michael Chitwood said."The caseworkers and the doctors and the catchment centers they know who violent individuals are, because they're frequent fliers," Chitwood said. bracelet van cleef replica "And the system is not geared toward keeping these people housed somewhere until they start van cleef and arpels bracelet knock off to be better. So you put whole communities at risk."Cathy Nickel, a neighbor at Plotts' last known address, an apartment complex in Upper Darby, saw a caseworker move him out of the building about a year ago. As he was taken away in a van, she said, he yelled, "You haven't heard the end of me!"Plotts was sedated but in stable condition after surgery Thursday for his gunshot wounds, police said. They expected to arraign him at his Philadelphia hospital bedside, charging him with murder in the death of caseworker Barbara Hunt and other crimes.Plotts doesn't have a listed home number, and it was unclear if he has relatives in the area.Hospital policy bars anyone except on duty law enforcement officers from carrying weapons on campus, said a Mercy Health System spokeswoman.The hospital said Friday it was thankful for the "brave and difficult action" taken by Silverman and his colleagues. It said he remains a full member of the medical staff and "we look forward to Dr. Silverman's return to serving patients at our hospital."Plotts had complained to Silverman previously about the gun policy.Whelan said he believes Silverman, not Hunt, was Plotts' target. He said that when the caseworker was shot, Silverman crouched down behind a desk to avoid being shot also."He was able to reach for his weapon, and realizing it was a life or death situation, was able to engage the defendant in the exchange of gunfire," Whelan said.The struggle spilled into the hallway, where another doctor and a caseworker jumped in to help Silverman and secure Plotts' weapon, Whelan said.Silverman told police he was at his desk, behind a computer screen, when Plotts pulled a gun from his waistband and killed Hunt.
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Poverty does not breed extremism
By Fareed Zakaria, CNN
Since 9/11, a decade ago, Washington has given the government of Pakistan more than $20 billion in aid. Two thirds of that has gone to the military to fight the war on terror. The other third, about $6 billion, has gone for development of Pakistan civilian economy and society.
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The study points out that this goes against most of the existing policy literature on the subject. State Department and the UK Department for International Development as saying poverty motivates people to extreme violence.
Now, giving aid to poor people is good in and of itself. But if we been doing that to prevent them from becoming Islamic fundamentalists, then this study suggests we been aiming at the wrong target. Perhaps our focus should be on the middle classes or on secular education.
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A CNN poll from last week shows that nearly half of all Americans think all aid to Pakistan should be stopped. Another quarter thinks it should be reduced.
It seems like 10 years and $20 billion later, the American people understand basic lessons in accounting that Washington has been learning the hard way. Pentagon documents now show that we are rejecting nearly half of Islamabad claims for expenses over the last two years.
But the more important question is: Will the Pakistani military in return for all this money, finally move against the terror organizations like the Haqqani Network and Lashkar e Taiba that they claim to be willing to battle?
It long delayed, but it is the right message that we should be sending.
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As usual, Western scholars understand nothing about extremism. Poverty and exposure to violence are at the very root of the fomentation of extremist ideologies. The fact that IRA extremists (or other groups) come from affluent backgrounds does not directly speak to the issue of poverty as a catalyst in extremist movements. Consider the American Civil War. The extremist KKK arose just after the end of the war when the economy of the southern states was in shambles. In the Middle East, extreme poverty is a common rose gold cartier love ring knock off problem as is exposure to violence. Both of these variables operate to provide a scapegoat for extremists as a recruitment tool. One should not confuse the socioeconomic level of the extremists themselves with the general perception of poverty in a given area. Where the perception exists that a person economic opportunities and social mobility are limited, there will be extremist elements eager to exploit such perceptions to cartier friendship ring fake their advantage. The anti immigrant rhetoric rose sharply after the economic downturn in as people used immigration as the scapegoat for economic problems that were, in reality, caused by many factors that had nothing at all to do with immigration. This is completely off base. Even a cursory reading of history will show that co option is one of the best methods for dealing with extremism (ie, by eliminating the perceived perceived being the key word here problems which give rise to extremist sentiments). AliExpress currently hosts more than 5,900 different types of products from over 4
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By Fareed Zakaria, CNN
Since 9/11, a decade ago, Washington has given the government of Pakistan more than $20 billion in aid. Two thirds of that has gone to the military to fight the war on terror. The other third, about $6 billion, has gone for development of Pakistan civilian economy and society.
The theory behind many of those billions of dollars is that by bringing Pakistan poorest out of poverty and despair, fewer young men will be seduced by radical Islam.
As President Obama said, must stand with those who want to build Pakistan. And Secretary Clinton adds, this assistance is not only the right thing to do, but we believe it is essential to global security and the security of the United States. uses all over the world, from Baghdad to Bali and back.
But what if you discover that aid money does not necessarily make Pakistanis less likely to turn to terror? What if you learn that there actually no correlation between being poor and supporting Islamic extremism?
Well, that what a new serious academic study seems to prove. It a robust survey by four academics from Princeton, Georgetown and the University of Pennsylvania that conducted extensive field research in Pakistan, interviewing 6,000 people across a broad spectrum of income groups and geography. Their findings could challenge the way we copy cartier friendship ring approach fighting terror, not just in Pakistan but around the world.
First, they find that in general Pakistanis don like militant groups. Not just al Qaeda, but the other ones like the Pakistani or Afghan Taliban.
Second, contrary to conventional wisdom, poor Pakistanis dislike militant groups more than the middle classes.
Third, the people who hate militants the most are the urban poor, probably because more than any other group they the ones who are affected by terror attacks bombs in subways or cafes or whatever.
It an interesting conclusion. The people we long considered the likeliest candidates for extremism are actually the ones most against it.
The study points out that this goes against most of the existing policy literature on the subject. State Department and the UK Department for International Development as saying poverty motivates people to extreme violence.
Now, giving aid to poor people is good in and of itself. But if we been doing that to prevent them from becoming Islamic fundamentalists, then this study suggests we been aiming at the wrong target. Perhaps our focus should be on the middle classes or on secular education.
Research shows that members of the IRA in Northern Ireland or Hezbollah militant ring fake rose gold cartier love ring are more likely to come from economically advantaged families and with a relatively high level of schooling.
These are important issues for Washington to consider. Who does it want to give economic aid to? What exactly is the best way to create a climate less conducive to extremism? Those are long term issues.
For now, what I want to say in the short term is: Let at least focus on accountability for this aid for both hard and soft aid. We need to demand results. What is the money achieving?
A CNN poll from last week shows that nearly half of all Americans think all aid to Pakistan should be stopped. Another quarter thinks it should be reduced.
It seems like 10 years and $20 billion later, the American people understand basic lessons in accounting that Washington has been learning the hard way. Pentagon documents now show that we are rejecting nearly half of Islamabad claims for expenses over the last two years.
But the more important question is: Will the Pakistani military in return for all this money, finally move against the terror organizations like the Haqqani Network and Lashkar e Taiba that they claim to be willing to battle?
It long delayed, but it is the right message that we should be sending.
American purse strings are important and necessary from Afghanistan to Zimbabwe, but they don have to remain open at all costs.
As usual, Western scholars understand nothing about extremism. Poverty and exposure to violence are at the very root of the fomentation of extremist ideologies. The fact that IRA extremists (or other groups) come from affluent backgrounds does not directly speak to the issue of poverty as a catalyst in extremist movements. Consider the American Civil War. The extremist KKK arose just after the end of the war when the economy of the southern states was in shambles. In the Middle East, extreme poverty is a common rose gold cartier love ring knock off problem as is exposure to violence. Both of these variables operate to provide a scapegoat for extremists as a recruitment tool. One should not confuse the socioeconomic level of the extremists themselves with the general perception of poverty in a given area. Where the perception exists that a person economic opportunities and social mobility are limited, there will be extremist elements eager to exploit such perceptions to cartier friendship ring fake their advantage. The anti immigrant rhetoric rose sharply after the economic downturn in as people used immigration as the scapegoat for economic problems that were, in reality, caused by many factors that had nothing at all to do with immigration. This is completely off base. Even a cursory reading of history will show that co option is one of the best methods for dealing with extremism (ie, by eliminating the perceived perceived being the key word here problems which give rise to extremist sentiments). AliExpress currently hosts more than 5,900 different types of products from over 4
March 27, 2015 at 11:57 am Reply
Fareed Zakaria GPS TVEvery week we bring you in depth interviews with world leaders, newsmakers and analysts who break down the world's toughest problems.
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