Effect of empagliflozin in hfref patients treated with angiotensin receptor neprilysin inhibitor an analysis of EMPIRE HF

Introduction

Inhibition of neprilysin/valsartan (ARNi) or sodium glucose cotransporter 2 (SGLT2) in patients with heart failure (HF) and reduced ejection fraction (HFrEF) has been shown to reduce the risk of Cardiovascular death and hospitalization for HF. Recent trails suggested that SGLT2 reduces the risk for cardiovascular death or hospitalization for HF, regardless of underlying ARNi treatment and that the effect may even be greater in those receiving the combination. Whether there exist an interaction between effect of ARNi and SGLT2 on functional endpoints related to mechanism of action is unknown.

Purpose

This post-hoc analysis of the randomized double-blinded Empire HF trial evaluated the influence of ARNi on the effect of the SGLT2 Empagliflozin on N-terminal prohormone B-type natriuretic peptide (NT-proBNP), pulmonary capillary wedge pressure (PCWP), Left ventricular end-systolic and end-diastolic volumes index; (LVESVI) (LVEDVI), left atrial volume index (LAVI), Left ventricular ejection fraction (LVEF), and Kansas City Cardiomyopathy Questionnaire (KCCQ) HFrEF patients.

Methods

Empire HF trial randomized 190 patients with HFrEF (LVEF ≤40%) to placebo or empagliflozin (10 mg/day), on top of recommended treatment for HFrEF, for 12 weeks of treatment. A total of 58 (31%) received ARNi at baseline and no patients initiated ARNi during study period.

Results

Patients on ARNi were well-treated with a similar baseline characteristic as those who were not treated with ARNi (Table 1). Patients with ARNi had a lower systolic blood pressure (P=0.01), with a higher NT-proBNP (P<0.001) when compared with those not receiving ARNi. When compared to placebo, empagliflozin did not reduce the ratio of change of NT-proBNP with or without ARNi (0.94 [95% CI, 0.75 to 1.19] pg/ml; P=0.62) and (1.02 [95% CI, 0.86 to 1.22] pg/ml; P=0.78), respectively, adjusted (age, atrial fibrillation) interaction P=0.57. Empagliflozin reduced PCWP regardless of ARNi treatment (with ARNi; −4.9 [95% CI, −9.1 to −0.6] mmHg; P=0.02) and (without ARNi; −2.1 [95% CI, −3.8 to −0.4] mmHg; P=0.01), adjusted interaction P=0.20. Overall, empagliflozin was associated with a reduction in LVESVI, LVEDVI, and LAVI volumes, but no effect on LVEF. However, Empagliflozin combined with ARNi at baseline, significantly reduced LVEDVI (−11.2 [95% CI, −21.2 to −1.2] ml/m2; P=0.03), but not without ARNI (−2.9 [95% CI, −8.7 to 2.9] ml/m2; P=0.32), adjusted interaction P=0.13. Treatment-by-subgroup interaction P-values for LVESVI, LAVI, and LVEF analysis were >0.05 (Figure 1). KCCQ total symptom score were significantly increased in those not receiving ARNi (5.4 [95% CI, 1.1 to 9.6]; P=0.013), but not with ARNi (−4.0 [95% CI, −10.3 to 2.3]; P=0.22), adjusted P=0.02.

Conclusion

In this post hoc analysis the effects on empagliflozin to reduce PCWP and LV volumes were not diminished in patients receiving ARNi, however KCCQ change were diminished in patients receiving ARNi.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline characteristicsFigure 1. Change in echo variables +/− ARNi

A Comparison of Demographic and Psychosocial Characteristics Between Transgender Youth Enrolling Versus Not Enrolling in a Multisite Study

Purpose: To characterize demographics, psychosocial functioning, and gender-related experiences in transgender youth enrolling versus declining participation in a multisite research study. Methods: Clinical data were abstracted from patient charts at two study sites. Continuous variables were compared using t-tests, and categorical variables were compared using χ ² tests based on study enrollment status. Results: Few significant differences were observed between enrolled and nonenrolled youth. None of these differences (i.e., designated sex at birth/gender identity; parent-reported separation anxiety; and youth-reported attention deficit/hyperactivity disorder) was replicated across sites. Conclusion: Trans Youth Care findings are likely generalizable to transgender youth initiating hormone treatment at pediatric academic centers.

There's nothing plain about projection radiography! A discussion paper

OBJECTIVES

Unlike the technological advances in cross-sectional imaging, the adoption of CR and DR has been relatively overlooked in terms of the additional radiographer skills and competences required for optimal practice. Furthermore, projection radiography is often referred to as basic, plain or other words suggesting simplicity or entry-level skill requirements. Radiographers' professional identity is connected with the discourse expressed via the language used in daily practice and consequently, if the perception of projection radiography is regarded as simple practice not requiring much reflection or complex decision-making, apathy and carelessness may arise. The purpose of this narrative review was to raise projection radiography from its longstanding lowly place and re-position it as a specialist imaging field.

KEY FINDINGS

Danish pre-registration radiography curricula contain little mention of projection radiography and a low proportion (n = 17/144; 11.8%) of Danish radiography students chose to focus on projection radiography within publicly available BSc. theses between 2016 and 2020 as compared to topics related to CT and MRI (n = 60/144; 41.7%).

CONCLUSION

By changing how we as the profession perceive the role and position of projection radiography, we can start to rebuild its lost prestige and demand a greater, more detailed and clinically relevant educational offering from academic partners. For this to commence, the language and terminology we use to describe ourselves and tasks undertaken must reflect the complexity of the profession.

IMPLICATIONS FOR PRACTICE

Regardless of imaging modality, every patient should be assured that a radiographer with expertise in acquiring images of diagnostic quality undertakes their examination. Reclaiming the prestige of projection radiography may lead students and radiographers to recognize projection radiography as a demanding specialist field for the benefit of the patients.

Group therapy for mood disorders: A meta-analysis

The addition of group psychotherapy as a specialty by the APA in 2018 creates a need for rigorous empirical reviews of group treatments for specific disorders. We conducted a meta-analysis of randomized controlled trials (RCTs) that tested the effect of group psychotherapy for mood disorders, including depression and bipolar disorder, at posttreatment and follow-up time-points, as well as rates of recovery and attrition. Major databases were searched for RCTs of group treatment for depression and bipolar disorder published from 1990 to 2018, which identified 42 studies across both disorders. Random effects meta-analyses indicated that group therapy for depression produced superior outcomes compared to waitlist control (WLC) and treatment as usual (TAU) and equivalent outcomes to medication. Similarly, group therapy for bipolar disorder produced superior outcomes to TAU. Analyses of recovery rates were conducted for depression, producing similar results to the main outcome analyses. Rates of attrition did not differ between group and comparison conditions for either disorder. These findings support group therapy for treating depression and bipolar disorder, although further research is needed comparing group treatment for bipolar disorder to medication.

Rare variants in HCN4 identified in the general population are associated with complete atrioventricular (AV) block, 1. degree AV block and bundle branch block, results from 50.000 exomes

Background/Introduction

Cardiac conduction disorders cover disorders such as atrioventricular (AV) block and bundle branch block. Genome-wide association studies have identified more than 100 genetic loci for atrial fibrillation, including HCN4 loci associated with duration of the PR interval, a proxy for AV dysfunction. Recent candidate studies suggest an association between HCN4 variants and AV-block.

Purpose

We seek to determine the contribution of rare genetic variants in HCN4 to complete AV-block, 1. degree AV-block and bundle branch block (BBB) in the general population.

Methods

The UK Biobank is a population-based study of 500 000 individuals including a subset with genome-wide genotyping and exome sequencing (n=45,596). In this case-control study, we included persons of genetically determined white-European ancestry and analyzed their exome data. Analyses were performed using a logistic mixed-effects model. A gene-based burden analysis and single variant test were performed to examine the relationship between HCN4 variants and complete AV-block, 1. degree AV-block and BBB in the general population.

Results

The study included 43,371 persons. In an analysis of the HCN4 genes a significant association between rare variants (MAF<0.01) in HCN4 gene was found (complete AV-block, P=2.5x10–5, 1. degree AV-block, P=1.3x10–3 and BBB, P=0.01) (Figure 1A). The association to complete AV block was mostly driven by the variants Ser835Phe (P=2.7e-3), Glu153Gly (P=3.5e-3) and Arg378Cys (P=6.3e-3) (Figure 1B).

Conclusions

Rare HCN4 variants contribute to the risk of complete AV-block, 1. degree AV-block and BBB in the general population. These HCN4 variants seem to confer a substantial penetrance. Clinical screening for some of these variants seems appropriate.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Hallas Møller - Novo nordisk

Utilization and outcomes of rotational atherectomy in Sweden

Aim

To evaluate utilization and outcomes of rotational atherectomy (RA) using data from the Swedish Coronary and Angioplasty Registry (SCAAR)

Methods

We included 1476 patients with 2218 lesions who underwent RA from 2005 to 2016. To study temporal changes, the study period was divided into three equal time-periods, period A, B and C.

Results

Although the number of RA procedures increased 3-fold from 2005 to 2016, the rate of RA (of all PCI procedures) remained low (0.5% vs 1.2% in 2005 vs 2016). RA patients consisted a high-risk group, with advanced age and clustering of comorbidities. Over time, included patients were older and had a higher risk profile. Trans-radial access, drug eluting stent (DES) use and use of intravascular imaging significantly increased from period A to C whereas positioning of a temporary pacemaker or intra-aortic balloon pump declined. Unfractionated heparin became the main anticoagulant (52 vs 87%) and use of glycoprotein IIb/IIIa inhibitors declined (31 vs 12%, in period A vs C). Following RA, 11% of lesions were treated without stent (15 vs 15 vs 8%, in period A, B and C) (Rota-only). In lesions treated with a stent, a bare metal stent (BMS) was implanted in 39% vs 12% vs 2% and a new generation DES (N-DES) in 5 vs 75 vs 97% (period A vs B vs C) of lesions.

The 3-year cumulative rate of restenosis was 6.7% (122 events), (11.1 vs 7.1 vs 4.1% in period A vs B vs C). As compared to DES, rota-only (adjusted HR 2.71; 95% CI 1.69- 4.36) and BMS (adjusted HR 3.63; 95% CI 2.27- 5.81) were associated with significantly higher risk for restenosis. First generation DES were associated with numerically higher but not significantly different risk for restenosis as compared to N-DES (adjusted HR 1.31; 95% CI 0.74- 2.31).

The 3 year cumulative rate of major adverse cardiac events (MACE), including death, myocardial infarction (MI) or any restenosis was 30.6% (34.2 vs 31.4 vs 28.2%, in period A vs B vs C) and the corresponding numbers for all-cause mortality were 18.1% (18.9 vs 18.4 vs 17.0%). After adjustment for baseline characteristics and angiographic findings, RA in period A was associated with higher risk for MACE as compared to period C (adjusted HR 1.40; 95% CI 1.09- 1.79), due to higher risk for MI and restenosis. The difference disappeared when procedural characteristics, including DES use, were added to the model.

The rate of major in-hospital complications was 7.0%, including in-hospital death 1.3%, periprocedural MI 2.8%, perforation 1.1%, cardiac tamponade 0.7%, stroke 0.2% and major bleedings 2.1%. We found no significant differences over time.

Conclusion

During the studied period, RA remained a rare procedure, utilised in a highly selected population. Over time a declining rate of restenosis and MI after RA was observed, a finding that appeared to be mainly driven by an increased use of DES. The rate of major in-hospital complication remained low.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific International

Bayesian estimation of genetic variance and response to selection on linear or ratio traits of feed efficiency in dairy cattle

This study aimed to estimate genetic parameters of the linear trait genetic residual feed intake (RFI) and the ratio traits feed conversion ratio (FCR) and feed conversion efficiency (FCE) along with dry matter intake (DMI) and energy sink traits such as energy-corrected milk (ECM), body weight (BW), body condition score (BCS), and BW change (BWC) across different weeks in the first lactation of Danish Holstein cows. A second objective was to conduct a Bayesian analysis of direct and correlated superiority of the selected group when selecting on genetic RFI, FCR, or FCE. Feed intake and energy sink traits were recorded during wk 1 to 44 of lactation on 847 primiparous Danish Holstein cows. A Bayesian multivariate random regression animal model was used to analyze DMI, ECM, BW, and BCS in different weeks of lactation. Genetic RFI was obtained by conditioning DMI on ECM, BW, BCS, and BWC using genetic partial regression coefficients. The posterior distribution of the breeding values for FCR and FCE was derived from the posterior distribution of functions of "fixed" environmental effects and random additive genetic effects on DMI and ECM. Genetic superiority of the selected group was defined as the difference in additive genetic mean of the selected top individuals expected to be potential parents, and the total population after integrating genetic trends out of the posterior distribution of selection responses. Posterior means of heritability of genetic RFI ranged from 0.10 to 0.15, genetic variance of FCR and FCE ranged from 2.13 × 10^-3 to 3.2 × 10^-3 (kg² DMI/kg² ECM) and 6.11 × 10^-3 to 2.4 × 10^-2 (kg² ECM/kg² DMI), respectively. Selection against RFI showed a direct response of -1.01 to -2.23 kg/d RFI and correlated responses of -0.031 to -0.056 kg/kg for FCR, 0.104 to 0.160 kg/kg for FCE, and -0.316 to -1.057 kg/d for DMI in different weeks of lactation. Selection against RFI had no significant effect on production traits but selection for ratio traits reduced BW and BCS. Posterior means of genetic correlation between DMI and ratio traits were low. In conclusion, the Bayesian procedure allowed us to estimate genetic RFI without the need for separate multiple regression analysis and considered the non-normal posterior distribution of ratio traits. Selection against genetic RFI might be an effective means to improve feed efficiency compared with ratio traits for feed efficiency in dairy cattle.

Plasma oxylipins and unesterified precursor fatty acids are altered by DHA supplementation in pregnancy: Can they help predict risk of preterm birth?

Oxidized lipids derived from omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids, collectively known as oxylipins, are bioactive signaling molecules that play diverse roles in human health and disease. Supplementation with n-3 docosahexaenoic acid (DHA) during pregnancy has been reported to decrease the risk of preterm birth in singleton pregnancies, which may be due to effects of DHA supplementation on oxylipins or their precursor n-6 and n-3 fatty acids. There is only limited understanding of the levels and trajectory of changes in plasma oxylipins during pregnancy, effects of DHA supplementation on oxylipins and unesterified fatty acids, and whether and how oxylipins and their unesterified precursor fatty acids influence preterm birth. In the present study we used liquid chromatography-tandem mass spectrometry to profile oxylipins and their precursor fatty acids in the unesterified pool using plasma samples collected from a subset of pregnant Australian women who participated in the ORIP (Omega-3 fats to Reduce the Incidence of Prematurity) study. ORIP is a large randomized controlled trial testing whether daily supplementation with n-3 DHA can reduce the incidence of early preterm birth compared to control. Plasma was collected at study entry (≈pregnancy week 14) and again at ≈week 24, in a subgroup of 48 ORIP participants-12 cases with spontaneous preterm (<37 weeks) birth and 36 matched controls with spontaneous term (≥40 weeks) birth. In the combined preterm and term pregnancies, we observed that in the control group without DHA supplementation unesterified AA and AA-derived oxylipins 12-HETE, 15-HETE and TXB2 declined between weeks 14-24 of pregnancy. Compared to control, DHA supplementation increased unesterified DHA, EPA, and AA, DHA-derived 4-HDHA, 10-HDHA and 19,20-EpDPA, and AA-derived 12-HETE at 24 weeks. In exploratory analysis independent of DHA supplementation, participants with concentrations above the median for 5-lipoxygenase derivatives of AA (5-HETE, Odds Ratio (OR) 8.2; p = 0.014) or DHA (4-HDHA, OR 8.0; p = 0.015) at 14 weeks, or unesterified AA (OR 5.1; p = 0.038) at 24 weeks had higher risk of spontaneous preterm birth. The hypothesis that 5-lipoxygenase-derived oxylipins and unesterified AA could serve as mechanism-based biomarkers predicting spontaneous preterm birth should be evaluated in larger, adequately powered studies.

Modeling urban socio-ecological drivers of human– carnivore coexistence

Achieving human–carnivore coexistence is a growing challenge in an increasingly crowded world. In many cases, humans are already sharing landscapes with carnivores, but conditions promoting coexistence are not well understood. Coyotes (Canis latrans) are adaptable meso carnivores and their activities increasingly overlap with those of humans in urban environments. Does this overlap constitute coexistence? How do social variables situated within their rightful ecological contexts influence the potential for conflict? In this study, we explore aggregated social and land cover variables contributing to coexistence between humans and coyotes. We surveyed residents in four North Carolina cities on their perceptions, interactions and preferred management actions related to coyotes. We then modeled spatial patterns in urbanite interactions with and perceptions regarding coyotes and investigated how land cover characteristics may correlate with those perceptions. Our results suggest prior interactions and select land cover types may drive human coexistence with coyotes and contribute contextual understanding of urban socio-ecological systems to prevent conflict and effectively promote coexistence. Additional research that expands upon this study and explores spatial as well as temporal dimensions of human–wildlife coexistence is needed in diverse contexts.

P2238Prognostic value and incremental benefit of ischaemic myocardial burden subtended by non-invasive CT-derived fractional flow reserve (FFRCT) significant stenoses

Background

Fractional flow reserve derived from CT-coronary angiography (FFRCT) accurately identifies ischaemic vessels which may be associated with clinical outcomes. Its predictive value in grey zone FFRCT values between 0.7–0.8 is not defined. The technique permits estimation of burden of ischaemic myocardium subtended by FFRCT significant vessels.

Purpose

To evaluate the prognostic value and incremental benefit of FFRCT defined ischaemic myocardial burden when compared to FFRCT alone.

Methods

This is a subanalysis of NXT (Analysis of Coronary Blood-Flow Using CTA:Next-Steps), a prospective study of stable coronary artery disease (CAD) patients referred for invasive angiography (ICA) undergoing invasive FFR, CTA and FFRCT in whom treating physicians had been blinded to FFRCT results. Primary endpoint, defined as a composite of non-fatal myocardial infarction and any revascularisation, was determined in 206 patients (age 64±9.5 years, 64% male) and 618 vessels. Burden of ischaemic myocardium was defined as percentage of myocardium subtended beyond the point at which a vessel's FFRCT becomes ≤0.8 as estimated by APPROACH score (FFRCT-APPROACH). In significant FFRCT vessels, the predictive value and incremental benefit of FFRCT-APPROACH was compared with significant FFRCT (≤0.8) for primary endpoint as measured by area under the receiver operator characteristic curve (AUC). Significant ischaemic myocardial burden was defined as >10%. The incidence and relationship between the primary endpoint with each 10% increase in FFRCT-APPROACH and 0.05-unit decrease in FFRCT values ≤0.8 was determined.

Results

Significant FFRCT was identified in 52.9% of patients (109/206) and 29.3% of vessels (181/618). At 4.7 years median follow-up the incidence of the primary endpoint in vessels with significant FFRCT-APPROACH was 58.9% (96/163) which was comparable with vessels with significant FFRCT (55.2%,100/181; P=0.50). The predictive value of FFRCT-APPROACH for the primary endpoint was comparable with FFRCT (AUC 0.72 [95% CI 0.65–0.79] vs 0.71 [0.63–0.78], P=0.79). When combined, there was significant predictive improvement compared with FFRCT alone (AUC 0.77 [0.70–0.84]; P=0.01). The largest incremental benefit upon FFRCT was observed in vessels with FFRCT values in the grey zone between 0.70–0.80 (AUC 0.76 [0.65–0.86] vs 0.62 [0.48–0.74]; P<0.01). Each 10% increase in FFRCT-APPROACH (Adjusted-HR 1.36; 95% CI 1.16–1.60; P<0.001) and each 0.05-unit FFRCT decrease (Adjusted-HR 1.42; 1.19–1.70; P<0.001) were independently associated with significant increase in the incidence of the primary-endpoint.

Conclusion

In patients with stable CAD referred for ICA, the burden of ischaemic myocardium subtended by FFRCT significant vessels predicted non-fatal myocardial infarction and future revascularisation. This provided significant incremental benefit when used in combination with FFRCT particularly at FFRCT values in the grey zone between 0.7 to 0.8.

P4449Incident cardiovascular disease in patients with type 2 diabetes: Established cardiovascular disease versus traditional risk markers

Background/Introduction

It is well established that patients with both T2D and established cardiovascular disease (CVD) are at high-risk of a re-event and should be treated with either a glucagon-like peptide-1 (GLP-1) analogue or a sodium-glucose transporter-2 (SGLT-2) inhibitor. Other high-risk patients with T2D may also benefit from these treatments. Whether traditional risk markers can identify patients with T2D without CVD with a similar incidence of CVD events as patients with T2D with established CVD is unknown.

Purpose

To compare the CVD incidence in patients with T2D with and without established CVD, stratified according to mid-regional pro-atrial natriuretic peptide (MR-proANP), albuminuria, electrogardiogram (ECG), echocardiography and age, to identify patients without established CVD who are at high risk of a CVD event.

Methods

In this prospective cohort study, patients with T2D (n=921) from a specialized diabetes clinic were examined at baseline regarding the different risk markers. Increasing cut-offs for MR-proANP were analysed to identify high-risk patients. Albuminuria included both micro- and macroalbuminuria. An abnormal ECG was defined as the presence of ST-/T-changes, bundle branch block or atrial fibrillation, and an abnormal echocardiography was defined as either heart failure with preserved (HFpEF) or reduced (HFrEF) ejection fraction. Established CVD was reported at baseline as prior myocardial infarction, coronary revascularization, cerebrovascular disease or peripheral artery disease. Information regarding CVD events was retrieved through national registers and a CVD event was similarly defined as established CVD, but in addition also included hospitalisation for heart failure and CVD death.

Results

In total, 224 (24%) patients had established CVD at baseline. Median [interquartile range] of follow-up was 4.7 [4.0–5.3] years. The incidence of CVD events among patients with established CVD was 95.7 per 1000-person years. Using a cut-off for MR-proANP of 190 pmol/l revealed that patients with a value above had similar incidence (93.9 per 1000-person years) and was found in 47 of 697 (6.7%) patients without CVD. In contrast, patients without CVD and with albuminuria (146 of 685 (21.3%) patients) or abnormal ECG (147 of 679 (21.6%)) or abnormal echocardiography (221 of 618 (35.7%)) or an age>65 years (335 of 697 (35.7%)) had substantial lower incidence (47.1, 35.1, 32.7 and 33.7 per 1000-person years, respectively).

Kaplan-Meier curves

Conclusion(s)

In patients with T2D without established CVD, using a range of traditional risk markers, we were only able to identify a subgroup of patients with MR-proANP values above 190 pmol/l who had a similar high incidence of CVD as T2D patients with established CVD. This subgroup may benefit from treatment with a GLP-1 analog or a SGLT-2 inhibitor. In contrast, the presence of other traditional risk markers in T2D was not associated with risk of incident CVD similar to patients with established CVD.

Acknowledgement/Funding

Thermo Fisher Scientific (Germany) funded the MR-proANP kits

Central Amygdala Prepronociceptin-Expressing Neurons Mediate Palatable Food Consumption and Reward

Food palatability is one of many factors that drives food consumption, and the hedonic drive to feed is a key contributor to obesity and binge eating. In this study, we identified a population of prepronociceptin-expressing cells in the central amygdala (Pnoc^CeA) that are activated by palatable food consumption. Ablation or chemogenetic inhibition of these cells reduces palatable food consumption. Additionally, ablation of Pnoc^CeA cells reduces high-fat-diet-driven increases in bodyweight and adiposity. Pnoc^CeA neurons project to the ventral bed nucleus of the stria terminalis (vBNST), parabrachial nucleus (PBN), and nucleus of the solitary tract (NTS), and activation of cell bodies in the central amygdala (CeA) or axons in the vBNST, PBN, and NTS produces reward behavior but did not promote feeding of palatable food. These data suggest that the Pnoc^CeA network is necessary for promoting the reinforcing and rewarding properties of palatable food, but activation of this network itself is not sufficient to promote feeding.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection

OBJECTIVES

We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed.

METHODS

We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin.

RESULTS

We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed.

CONCLUSIONS

For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

An item reduction analysis of the Group Questionnaire

There is a constant tension between having measures short enough for daily practice and long enough to provide useful information. Although shorter measures are more convenient for clients, fewer items necessarily mean less information, a loss of psychometrics, and possible floor and ceiling effects. This study examined the effects of shortening the Group Questionnaire (GQ) on its clinical utility and psychometric integrity. Creation of a 12-item GQ (GQ-12) was done using archival data with 1,087 participants gathered from counseling centers, nonclinical process groups, outpatient psychiatric hospitals, and an inpatient state hospital. Testing of the loss of clinical utility was conducted using archival data from 432 group counseling center patients. Analysis for creation of the GQ-12 was done using multilevel structural equation modeling. Items were selected using clinical judgment and statistical judgment considering interitem correlation and factor loading. Model fit was analyzed in comparison with the standards in the literature and with the full-length GQ. Loss of clinical utility was analyzed by comparing alerts generated by the GQ-30 with alerts generated by the GQ-12. The GQ-12 has good model fit and acceptable reliability. A significant number of alerts were lost by reducing the items (status alerts: sensitivity 82-93%, specificity 97-99%; change alerts: sensitivity 52-67%, specificity 99-100%). This study suggests that although it is possible to create a psychometrically sound, shortened version of a feedback measure, clinicians should be aware that helpful information is lost. (PsycINFO Database Record

Short communication: Multivariate outlier detection for routine Nordic dairy cattle genetic evaluation in the Nordic Holstein and Red population

It is of practical importance to ensure the data quality from a milk-recording system before use for genetic evaluation. A procedure was developed for detection of multivariate outliers based on an approximation for Mahalanobis distance and was implemented in the Nordic Holstein and Red population. The general target of this procedure is based on the Nordic Cattle Genetic Evaluation yield model, which is a 9-trait model for milk, protein, and fat in the first 3 lactations. The procedure is based on the phenotypic correlation structure as a function of days in milk (DIM) and on computation of trait means and standard deviations within a production year, lactation, and DIM. For each record in the data, a Mahalanobis distance value was computed based on the trait mean and the covariance matrix for the actual production year, lactation, and DIM. A set of cutoff values, ranging from 10 to 100 with steps of 10, for discarding multivariate outliers was investigated. Prediction accuracy was calculated as the Pearson correlations between estimated breeding values predicted by full data set and estimated breeding values predicted by reduced data set for cows without records in the reduced data set and with 1 or more records deleted due to the editing rules on Mahalanobis distance. The results showed that, averaged over all scenarios, gains of 0.005 to 0.048 on prediction accuracy have been obtained by deleting the multivariate outliers. The improvements were more profound for progeny of young bulls compared with progeny of proven bulls. It is easy to implement this multivariate outlier-detection procedure in the routine genetic evaluation for different dairy cattle breeds; however, an optimal cutoff value for Mahalanobis distance needs to be defined to achieve an acceptable compromise between genetic evaluation accuracy and data deletion.

Vorkommen von Ehrlichia canis bei Hunden in Deutschland?

Gegenstand und Ziel: Retrospektive Untersuchung von Hunden auf eine autochthone Infektion mit E. canis in Deutschland. Material und Methode: In die Studie gingen 111 Hunde ein, die sich in eine symptomatische (n = 49) und eine asymptomatische (n = 62) Gruppe unterteilten. Bei allen Hunden erfolgten eine Antikörperbestimmung gegen Ehrlichia canis mittels Immunfluoreszenztest im Serum und ein Direktnachweis von Ehrlichia und Anaplasma spp. mittels PCR aus EDTA-Vollblut. Ausschlusskriterien waren ein Auslandsaufenthalt sowie die Vorbehandlung mit Tetrazyklinen, Chloramphenicol oder Imidocarb. Ergebnisse: Niedrige IFT-Antikörpertiter gegen E. canis konnten bei sieben Hunden (6,3%) festgestellt werden. Sechs Hunde gehörten der symptomatischen und ein Hund der asymptomatischen Gruppe an. Gleichzeitig wurden bei vier dieser Hunde sehr hohe und bei einem ein moderater Antikörpertiter gegen Anaplasma phagocytophilum gefunden. Das PCR-Screening für Ehrlichia und Anaplasma war lediglich in zwei Fällen positiv. Beide Male ließ sich A. phagocytophilum nachweisen. Schlussfolgerungen: Nur bei zwei für E. canis seropositiven Hunden konnten keine Kreuzreaktionen mit A. phagocytophilum nachgewiesen werden. Da ein Direktnachweis bei diesen zwei Hunden nicht möglich war, ist eine tatsächliche Infektion mit E. canis fraglich. Die Gefahr der autochthonen Infektion von Hunden mit E. canis in Deutschland scheint somit gering zu sein, ist aber nicht ausgeschlossen. Klinische Relevanz: Bei unspezifischen Symptomen wie Apathie, Fieber und Inappetenz sowie Laborveränderungen in Form von Anämie und/oder Thrombozytopenie sollte deshalb auch bei Hunden, die Deutschland nicht verlassen haben, an eine Infektion mit E. canis gedacht werden.