Accuracy of proband reported family history: the NHLBI Family Heart Study (FHS)

Proband-reported family histories are widely used in research and counseling, yet little is known about the validity of family history reporting. The Family Heart Study (FHS), a population-based study of familial cardiovascular disease, gathered family history information from 3,020 middle-aged probands in four U.S. communities. Probands reported on the history of coronary heart disease (CHD), diabetes, hypertension, and asthma among a total of 10,316 living relatives (9,186 siblings, 1,130 parents) and 2,685 spouses. Questionnaires were returned by 6,672 siblings, 901 parents, and 2,347 spouses, yielding response rates of 73, 79, and 87%, respectively. Utilizing the relatives' self-report as the standard, sensitivity of the proband report on their spouse, parent, and sibling was 87, 85, and 81% for CHD, 83, 87, and 72% for diabetes, 77, 76, and 56% for hypertension, and 66, 53, and 39% for asthma, respectively. Most specificity values were above 90%. Analyses using generalized estimating equations (GEE) were performed to evaluate differences in proband accuracy based on the proband's age, gender, disease state, center, and ethnicity. In multivariate models, age, gender, and disease status were significantly associated with the accuracy of proband's report of sibling disease history, but had little effect on the accuracy of their report on spouses or parents. In general, older probands were significantly less accurate reporters of disease than younger probands. These results demonstrate that CHD family history can be captured effectively based on proband reports, but suggest that additional family contacts may be helpful when working with older probands or with chronic diseases that have few recognized medical events or procedures.

Is there a 'weekend effect' in elective lower limb arthroplasty?

INTRODUCTION

The weekend effect has been defined as a real or perceived decline in patient care provided on weekends and that provided on weekdays. The primary aim of this study was to investigate the association between day of surgery and length of stay for patients receiving elective lower limb joint arthroplasty in a large NHS teaching hospital.

MATERIALS AND METHODS

Data were obtained from a prospectively collected database of consecutive patients undergoing elective primary total knee and hip arthroplasty. Patient and clinical variables were collected alongside length of hospital stay. Data were anonymised and analysed using a multiple linear regression model.

RESULTS

A total of 3,544 knee and 3,277 hip replacements were included. No association was found between length of stay and day of surgery for either procedure. A significant association was noted between longer length of stay and increasing age, higher American Society of Anesthesiologists grade and male compared with female gender.

DISCUSSION

No evidence of a weekend effect was identified. Certain patient factors predicted longer hospital stay and focussing additional resources on these patient groups may prove a useful strategy in reducing overall length of stay.

CONCLUSIONS

Length of stay reduced across the time period included in this review while maintaining equality between the days of the week, which represents the successful management of weekend services.

161 CLEAR DISCHARGE PRESCRIBING IN STROKE PATIENTS: A RETROSPECTIVE AUDIT OF DUAL ANTIPLATELET DURATION AT FIRST FOLLOW-UP APPOINTMENT

Background

The risk of further ischaemic events post stroke and TIA is high in the following weeks. Short term treatment with Dual Anti-Platelet Therapy (DAPT) in appropriate patients has been shown to decrease the incidence of recurrent ischaemic events. However continuing DAPT longer than six weeks increases the risk of haemorrhagic complications.

Methods

Retrospective analysis of patients admitted to the Acute Stroke Unit over 4 months in a tertiary referral centre, reviewing discharge summaries and follow-up Outpatient Department (OPD) clinic letters on the online hospital computer system.

Results

We analysed data from 205 patients. 57 patients were discharged on DAPT. Of those, 18(31.6%) did not have a recommended duration of DAPT documented in their discharge summary. 40 patients returned to OPD for review, 16 patients had no documented follow-up, 11 were repatriated to a referring hospital for follow-up locally. The average time of OPD review was 4 months post discharge. Of those 40 patients who attended OPD follow up appointment, 33(82.5%) had documented evidence of a medication review in clinic. 9 of those patients (27.3%) were still inappropriately on DAPT, 5 of whom (55.6%) had no DAPT duration instructions documented in the discharge summary.

Conclusion

Treatment with DAPT puts patients at risk of haemorrhagic complications with longer term use. Clear documentation of treatment duration and communication with the patient and the patient’s GP is vital to ensure medication errors and unnecessary complications for the patient are avoided. Intervention: Following these results, we organised an education session for the Stroke Department staff and re-designed the stroke discharge summary template to highlight instructions on DAPT duration. We also emphasised the importance of communication with the patient’s GP and medication counselling with patients.

A randomized evaluation of a computer-based physician's workstation: design considerations and baseline results

We are performing a randomized, controlled trial of a Physician's Workstation (PWS), an ambulatory care information system, developed for use in the General Medical Clinic (GMC) of the Palo Alto VA. Goals for the project include selecting appropriate outcome variables and developing a statistically powerful experimental design with a limited number of subjects. As PWS provides real-time drug-ordering advice, we retrospectively examined drug costs and drug-drug interactions in order to select outcome variables sensitive to our short-term intervention as well as to estimate the statistical efficiency of alternative design possibilities. Drug cost data revealed the mean daily cost per physician per patient was 99.3 cents +/- 13.4 cents, with a range from 0.77 cent to 1.37 cents. The rate of major interactions per prescription for each physician was 2.9% +/- 1%, with a range from 1.5% to 4.8%. Based on these baseline analyses, we selected a two-period parallel design for the evaluation, which maximized statistical power while minimizing sources of bias.

The role of ionotropic AMPA receptors in T cell tolerance

The ability of T cells to mount effective immune responses to pathogens and cancer while remaining tolerant to self-tissue is critical for maintaining immune homeostasis. Previously, our group identified neuritin, a neuronal protein, as a highly differentially expressed gene in anergic and regulatory T cells. Furthermore, our results indicate neuritin deficient mice exhibit enhanced autoimmunity due, in part, to dysfunctional regulatory T cells. Neuritin was recently identified as an accessory component of the ionotropic AMPA receptor (AMPAR) complex in neurons. AMPAR complexes are typically found on the post-synaptic neuronal cell and mediate glutamate dependent cation flux. Given our previous findings involving neuritin in autoimmunity and this newly identified interaction between neuritin and AMPAR, we sought to evaluate whether there is a role for the AMPAR in T cell tolerance. Here, we show that the AMPAR is expressed in CD4+ T cells and that the specific deletion of the AMPAR in T cells (AMPAR KO) leads to significantly reduced disease pathogenesis in an experimental autoimmune encephalomyelitis (EAE) model. The spinal cord inflammatory immune infiltrates from AMPAR KO mice are markedly reduced in cell number, proliferative state, and expression of proinflammatory cytokines compared to wild type (WT) mice. In addition, we have observed an increase in the CD4+FoxP3+ regulatory cell population among spinal cord infiltrates from AMPAR KO EAE mice. Consistent with the EAE model, AMPAR KO T cells also exhibit increased induced regulatory T cell development during in vitro differentiation. Taken together our results support a previously unappreciated role for ionotropic AMPA receptors in regulating T cell tolerance.

Alfentanil mediated activation of epileptiform activity in the electrocorticogram during resection of epileptogenic foci

PURPOSE

Alfentanil is a potent, short-acting opioid agent which has been used during balanced anaesthesia in children undergoing the surgical excision of epileptic foci. After the observation that this agent had the potential to induce epileptic seizures, we questioned the frequency of this occurrence in this group of patients.

METHOD

Twelve patients (6 males, 6 females) undergoing surgical excision of an epileptic foci were prospectively followed. For each patient an electrocorticogram was recorded for 30 minutes before and after receiving alfentanil 20 micrograms/kg intravenously. The frequency of epileptiform abnormalities before and after drug administration was evaluated. When the electrocorticogram no longer showed the effects of alfentanil administration, methohexital 0.5 microgram/kg was given intravenously.

RESULTS

Alfentanil induced significant activation of epileptiform discharges among 83% of these patients. Twenty-five per cent had an electrographic seizure. In comparison, methohexital induced significant activation of epileptiform discharges in 50% of these patients. None experienced electrographic seizures.

CONCLUSIONS

As alfentanil can induce electrographic seizures in patients known to have epilepsy, caution is advised in its use in this group of patients.

Body mass index and mortality among nonsmoking older persons. The Framingham Heart Study

The relationship of weight at age 65 years and subsequent mortality was examined in a population of 1723 nonsmokers who were followed up from one to 23 years (mean, 9.5 years) during the Framingham Heart Study. In sex-specific proportional hazards analyses, risks of mortality were increased for men and women at the high and low extremes of body mass index, even when accounting for potential effects of excess weight on serum cholesterol level, blood glucose level, and systolic blood pressure. For those at the lower extreme of body mass index, the relative risk of death was almost twice as high in the years immediately after age 65 years as in later follow-up, suggesting that the increased early death rate was due to disease that was already present. At the upper extreme, risk of death was twofold over the entire follow-up period for persons with body mass indexes at or above the 70th percentile at both 55 and 65 years of age. We conclude that, even when accounting for cardiovascular risk factors, being overweight is a serious health problem for older people, especially for those with long-standing weight problems.

[Demographic trends and the burden of cardiovascular diseases]

The current burden of cardiovascular disease in the U.S. population and recent trends in morbidity, mortality and risk factors provide a perspective on heart disease in the 21st century. Projections of demographic trends for populations and predictions of the frequency, distribution and characteristics of cardiovascular disease in the future are offered with numerous reservations and subject to revision. Nonetheless, we can expect to see more patients with cardiovascular disease in the next few decades and these patients are likely to be older and to be from the less well-educated and poorer socioeconomic segments of society. Improvements in treatment for the initial cardiovascular event may result in increased survival of women and men suffering permanent damage or disability. There will also be better opportunities to prevent cardiovascular diseases through modifying risk factors in the general population and in high risk individuals. Non-invasive procedures will also increase opportunities for detecting and reversing preclinical atherosclerosis through hygienic and therapeutic measures.

313 STREAMLINING A ZOLEDRONIC ACID SERVICE TO A LEVEL TWO HOSPITAL

Background

Approximately, 350-400 patients are admitted to a level 4 hospital for hip-fractures yearly (2019). According to the Irish Hip Fracture Database (2020) the average age for a hip-fracture is 81 years old. Patients post-hip fractures are commenced on Zoledronic acid; a bisphosphonate which is given intravenously 10 days post-surgery and then annually in year two and three. Zoledronic acid is a first line choice of bisphosphonate for the ≥65 population with a fragility fracture.

Methods

274 patients were transferred from the level 4 Hospital waiting list to a level 2 hospital waiting list to streamline the service. Meetings occurred to establish a pathway for the transition of services. A rapid improvement of the level 2 Day Hospital (DH) was commenced. Essential resources, training and information leaflets were developed in order to begin the service. A policy review, procedure guidelines and referral pathway were implemented. An excel database of patient information was transferred between organisations. The 274 patients were triaged by the DH. Pre-assessment phone calls were conducted determining if patients were still eligible for Zoledronic acid.

Results

Of the 274 referrals; 24 had died; 30 refused; 37 were on other bone treatments and another 7 patients haven’t made creatinine clearance, leaving 176. All 176 patients were allocated an appointment for 2022. Of the 176 patients; currently 57 patients have received their Zoledronic acid infusion in the DH. 69 of these referrals had an indicative date for their next Zoledronic acid infusion for dates after April 2022. There are 50 patients yet to receive their treatment which is overdue.

Conclusion

With the prospect of service demands increasing due to Irelands aging population inevitably placing extra pressures on infusion suites in a level 4 hospital. The level 2 hospital has effectively managed to focus on tackling the backlog, streamlining referrals to the bone health service and thus reducing the risk of subsequent hip fractures.

Modeling disease incidence rates in families

We apply an extended Cox model to study latent genes and measured environmental exposures simultaneously as risk factors for disease. Using this method, we assume Mendelian transmission of the genes and either dominant or recessive gene action. We compared the results from this model with those obtained under a model that includes the environmental variables and a family risk score. We demonstrate the method in samples of 1,433 Caucasian families (N = 6,791) and 206 African-American families (N = 771) from the National Heart, Lung, and Blood Institute Family Heart Study. In Caucasians, we found evidence suggesting that having ever smoked increased the risk of coronary heart disease only in individuals who carry a genetic susceptibility. We also noted that in both Caucasian and African-American families, the relative risk of coronary heart disease for ever-treated vs never-treated for high serum total cholesterol increased after including an unobserved susceptibility genotype in the model. This finding implied that there may be genes influencing coronary heart disease independent of those that influence total cholesterol. Such findings were not evident when genetic risk was summarized by the family history score. We also discuss the extension of the model to address the etiology of complex diseases.

Neurotrophic factor Neuritin modulates T cell electrical and metabolic state for the balance of tolerance and immunity

The adaptive T cell response is accompanied by continuous rewiring of the T cell's electric and metabolic state. Ion channels and nutrient transporters integrate bioelectric and biochemical signals from the environment, setting cellular electric and metabolic states. Divergent electric and metabolic states contribute to T cell immunity or tolerance. Here, we report that neuritin (Nrn1) contributes to tolerance development by modulating regulatory and effector T cell function. Nrn1 expression in regulatory T cells promotes its expansion and suppression function, while expression in the T effector cell dampens its inflammatory response. Nrn1 deficiency causes dysregulation of ion channel and nutrient transporter expression in Treg and effector T cells, resulting in divergent metabolic outcomes and impacting autoimmune disease progression and recovery. These findings identify a novel immune function of the neurotrophic factor Nrn1 in regulating the T cell metabolic state in a cell context-dependent manner and modulating the outcome of an immune response.