Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Through babies' eyes: Practical and theoretical considerations of using wearable technology to measure parent-infant behaviour from the mothers' and infants' view points

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Ecologically valid measurement of mother–infant behaviour is difficult.

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Observations often rely on short snapshots with a researcher present.

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Wearable cameras can be worn by mothers and infants alone at home.

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Home interactions were compared with an observation with a researcher.

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More negative maternal behaviour was recorded using ‘headcams’ alone.

Aims

To explore the utility of first-person viewpoint cameras at home, for recording mother and infant behaviour, and for reducing problems associated with participant reactivity, which represent a fundamental bias in observational research.

Methods

We compared footage recording the same play interactions from a traditional third-person point of view (3rd PC) and using cameras worn on headbands (first-person cameras [1st PCs]) to record first-person points of view of mother and infant simultaneously. In addition, we left the dyads alone with the 1st PCs for a number of days to record natural mother–child behaviour at home. Fifteen mothers with infants (3–12 months of age) provided a total of 14 h of footage at home alone with the 1st PCs.

Results

Codings of maternal behaviour from footage of the same scenario captured from 1st PCs and 3rd PCs showed high concordance (kappa >0.8). Footage captured by the 1st PCs also showed strong inter-rater reliability (kappa = 0.9). Data from 1st PCs during sessions recorded alone at home captured more ‘negative’ maternal behaviours per min than observations using 1st PCs whilst a researcher was present (mean difference = 0.90 (95% CI 0.5–1.2, p < 0.001 representing 1.5 SDs).

Conclusion

1st PCs offer a number of practical advantages and can reliably record maternal and infant behaviour. This approach can also record a higher frequency of less socially desirable maternal behaviours. It is unclear whether this difference is due to lack of need of the presence of researcher or the increased duration of recordings. This finding is potentially important for research questions aiming to capture more ecologically valid behaviours and reduce demand characteristics.

Texture analysis of periventricular echogenicity on neonatal cranial ultrasound predicts periventricular leukomalacia

BACKGROUND

White matter periventricular echogenicity detected in neonatal cranial ultrasound (US) scans may be followed by cystic periventricular leukomalacia (PVL) or might resolve. Serial US are therefore needed to clarify the outcome. Texture analysis is a computerized method to analyze images and distinguish findings that are undetectable by the human eye.

OBJECTIVE

To test whether texture analysis can differentiate echogenicities that resolve from those that develop cystic PVL.

MATERIAL AND METHODS

Neonates with echogenicities on their initial US scan were studied; texture analysis was performed on the coronal and sagittal sections. Texture parameters were entered into a linear discriminant analysis (LDA) to classify the scans along two axes called most discriminant features (MDF) 1 and 2.

RESULTS

We studied twenty infants with periventricular echogenicities on initial scans; ten of them later resolved (group A), while the other ten infants developed cystic PVL (group B). The classification accuracy was 66% and 82% for group A and B on sagittal sections, and 75%, and 80% on coronal. In the coronal and sagittal plane respectively, a MDF1 value of 0.98 and 0.24 and an MDF2 value of 0.86 and 0.001 provided the best sensitivity, specificity, positive and negative likelihood ratio.

CONCLUSION

Texture analysis is a promising objective tool to early identify which cranial echogenicity that will develop into cystic PVL.

Breast cancer stem cells mutations: A new understanding of intratumoral heterogeneity

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Background: Breast cancer has long been recognized as a heterogeneous disease. This has profound implications for diagnosis, treatment and disease recurrence. Oncogenic mutations have been identified in breast cancer cells with stem-like and progenitor properties (BCSC). We have previously reported that BCSC mutations correlated with axillary lymph node metastases. This was even more significant when micrometastatic disease was included. Our hypothesis is that tumor heterogeneity extends to the genetics of BCSC, and that BCSC mutations are better predictors of lymph node status than whole tumor genetics. Methods: BCSC from fresh tissue specimens were matched to their whole tumor specimens. BCSC and whole tumor DNA were sent for PCR-based mutation analysis. Patient data was collected by chart review. Results: Twenty-eight matched BCSC and whole tumor samples were analyzed. PI3K/Akt signaling mutations in PIK3CA, AKT1, HRAS, and MET were identified in BCSC from 10 tumors. In 4 of these, mutations were also identified in the corresponding whole tumor specimens. In 4 patients, mutations were identified in whole tumor samples only. Fourteen tumors had no mutations. Tumor stage, grade, receptor status, and age did not correlate with tumor or BCSC mutation status. In contrast to BCSC mutations, mutation status of the whole tumor did not correlate with micro or macro metastatic disease in the lymph node (p = 0.92). Conclusions: Mutations in BCSC are more predictive of lymph node metastases than mutations identified in the tumors. Thus, PI3K/Akt pathway mutations in tumor precursor cells may have a stronger influence on tumor metastatic potential than mutations identified in whole tumor samples. Whole tumors and BCSC populations demonstrate significant heterogeneity, as mutations identified in BCSC and tumors were not always concordant. Rare BCSC populations must be tested separately as they provide crucial prognostic and treatment information in conjunction with whole tumor genetic analyses.

Electronic Health Record Adoption - Maybe It's not about the Money: Physician Super-Users, Electronic Health Records and Patient Care

OBJECTIVE

The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue.

METHODS

Two EHR systems were examined - the paperless VistA / Computerized Patient Record System used at the Veterans' Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity.

RESULTS

Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR's are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR's had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians' needs.

CONCLUSION

Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.

Overweight and obesity in pregnancy do not adversely affect neonatal outcomes: new evidence

We studied neonatal outcomes of infants of obese mothers in a cohort of 6,125 deliveries, using logistic multivariate analysis to remove the role of potential confounding variables. Although, as in previous reports, the crude unadjusted prevalence of several adverse neonatal outcomes was higher in these infants, the multivariable analysis revealed that only two outcomes remained significantly associated with maternal overweight and obesity: neonatal macrosomia (adjusted odds ratios aOR 1.4, p < 0.001) and meconium aspiration syndrome (aOR 1.6, p = 0.05), indicating that the unadjusted association with the other outcomes was caused by confounding factors. Nonetheless, as macrosomia is associated with increased health risks both to the mothers and their infants, and maternal obesity with considerable maternal morbidity during pregnancy, these results should not lead to complacency, but instead encourage better prevention of obesity in general and during pregnancy in particular.

Infants of diabetic mothers with abnormal fetal growth missed by standard growth charts

Diabetic pregnancies may result in fetal macrosomia when glycaemia is poorly controlled, and when associated with diabetic vasculopathy, with small for gestational age (SGA) neonates. Both groups of infants have high neonatal morbidity. As fetal growth depends on maternal genetic influences, ethnic group or parity, relying exclusively on population-based growth charts may wrongly categorise the growth pattern of these infants. We compared neonatal morbidity and mortality of a cohort of 214 infants of diabetic mothers (IDM), identified either by population standards or by customised birth weight percentiles (adjusted for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and sex). A total of 68 (31.8%) were diagnosed with macrosomia, 11 (16%) of whom were identified by the customised growth method alone, and 16 were diagnosed as SGA (7.5%), of whom the majority (13 or 81.2%) were identified by the customised growth method alone. None had increased mortality and morbidity.

CXCR4 but not CXCR7 is mainly implicated in ocular leukocyte trafficking during ovalbumin-induced acute uveitis

Uveitis is an inflammatory ocular disease characterized by the infiltration of T lymphocytes and other leukocytes into the eye. The recruitment of these inflammatory cells from systemic vasculature to ocular tissue is a well-coordinated multistep process including rolling, firm adhesion and transmigration. CXCL12 (SDF-1alpha) is an endothelial cell-derived cytokine interacting with CXCR4 and CXCR7, two chemokine receptors mainly expressed in T cells, neutrophils and monocytes. Recent studies have shown that CXCR4, CXCR7 and their ligand, CXCL12, are important for the regulation of leukocyte mobilization and trafficking. However, it is unclear whether these two chemokine receptors are implicated in the pathogenesis of uveitis. In this study, we used DO11.10 mice, whose CD4+ T cells are genetically engineered to react with ovalbumin (OVA), to investigate the role of CXCR4 and CXCR7 in an animal model of uveitis. Intravital microscopy revealed that intravitreal OVA challenge of DO11.10 mice caused the infiltration of both T cells and neutrophils. The invasion of these inflammatory cells coincided with the detection of transcriptional up-regulation of CXCR4 and CXCR7 in the eye. In addition, both real-time-PCR and immunohistochemistry revealed an enhanced expression of endothelial CXCL12. Furthermore, intraperitoneal injection of AMD3100 (a specific CXCR4 antagonist) significantly attenuated OVA-induced uveitis and CXCL12-mediated transwell migration. In contrast, intraperitoneal administration of CXCR7 neutralizing antibody did not significantly alter ocular infiltration of inflammatory cells caused by OVA challenge. Our data suggest that CXCR4 but not CXCR7 plays a critical role in antigen-induced ocular inflammation by facilitating leukocyte infiltration. This study not only enhances our knowledge of the immunopathological mechanism of uveitis but also provides a novel rationale to target CXCR4 as an anti-inflammatory strategy to treat uveitis.

Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK

This paper describes the development and validation of a 40-item inventory, the Postgraduate Hospital Educational Environment Measure (PHEEM), by researchers in Scotland and the West Midlands using a combination of grounded theory and Delphi process. The instrument has since returned an alpha reliability >0.91 in two administrations in England and may be a useful instrument in the quality assurance process for postgraduate medical education and training.

The 3rd international intercomparison on EPR tooth dosimetry: Part 1, general analysis

The objective of the 3rd International Intercomparison on Electron Paramagnetic Resonance (EPR) Tooth Dosimetry was the evaluation of laboratories performing tooth enamel dosimetry below 300 mGy. Participants had to reconstruct the absorbed dose in tooth enamel from 11 molars, which were cut into two halves. One half of each tooth was irradiated in a 60Co beam to doses in the ranges of 30-100 mGy (5 samples), 100-300 mGy (5 samples), and 300-900 mGy (1 sample). Fourteen international laboratories participated in this intercomparison programme. A first analysis of the results and an overview of the essential features of methods applied in different laboratories are presented. The relative standard deviation of results of all methods was better than 27% for applied doses in the range of 79-704 mGy. In the analysis of the unirradiated tooth halves 8% of the samples were identified as outliers with additional absorbed dose above background dose.

Neuregulin 1-alpha expression in locally advanced breast cancer

The human Neuregulin 1 (NRG1) gene encodes several alternatively spliced ligands that bind to both c-erbB-3 and c-erbB-4, members of the family of type 1 tyrosine kinase growth factor receptors. Antibodies raised to a synthetic peptide recognize selectively the alpha variant of NRG1. The NRG1-alpha isoforms' expression was studied in 115 locally advanced adenocarcinomas of the breast using immunohistochemistry. Absent or low levels of NRG1-alpha were found to be associated with poorer prognosis compared to tumours that had moderate to high levels of the protein.

Differences in conductance of M2 proton channels of two influenza viruses at low and high pH

The M2 protein of influenza A viruses forms a proton channel involved in modifying virion and trans Golgi pH during infection. Previous studies of the proton current using whole-cell patch clamp of mouse erythroleukaemia (MEL) cells expressing the M2 protein of the "Weybridge" strain provided evidence for two protonation sites, one involved in permeation, the other in activation by acid pH. The present report compares the M2 channels of two different strains of influenza virus, "Weybridge" (WM2) and "Rostock" (RM2). Whereas with external acid pH the current-voltage relations showed similar small degrees of inward rectification, a similar apparent K(d) of approximately 10 microM for proton permeation and a high selectivity for protons over Na(+), the two M2 proteins differed in whole-cell conductance at low and high pH. The proton conductance of unit membrane area was on average 7-fold greater in RM2- than WM2-expressing MEL cells. At high external pH WM2 was shown previously to have small conductance for outward current at positive driving potential. In contrast, RM2 shows high conductance for outward current with high external pH, but shows small conductance for inward current with high internal pH, conditions in which WM2 shows high conductance for inward current. The different properties of the conductances due to the two channels at high pH were determined by three amino acids in their transmembrane domains. All intermediate mutants possessed one or other property and transformation of the WM2 phenotype into that of RM2 required substitution in all three residues V27I, F38L and D44N; single substitutions in RM2 effected the opposite phenotypic change. The significance of this difference for virus replication is not clear and it may be that the higher proton flux associated with RM2 is the main factor determining its increased ability to dissipate pH gradients. It is apparent, however, from the specific differences in the sidedness of the pH-induced changes in voltage dependence of the whole-cell current that this is an intrinsic property of the virus proton channel which may have parallels with regulation of other proton channels.

Supervision of trainee anaesthetists: a survey of opinions and practices

This questionnaire survey investigated the different degrees of supervision of trainee anaesthetic senior house officers (SHOs) in hospitals across the United Kingdom, and compared it with past practices as well as with The Royal College of Anaesthetists' recommendations at that time. It is apparent that the duration of intensive supervision of new anaesthetic trainees has increased over the last 25 years. This study assesses these changes in order to evaluate whether or not these reforms have achieved their intended outcomes.

Social and demographic factors predictive of change over seven years in CHD-related behaviours in men aged 18-49 years

It is possible that the relationship of social status to coronary heart disease is partly mediated through health-related behaviours that have been found to relate to both social status and CHD. Changes in certain health-related behaviours are known to lead to changes in CHD incidence. What are the characteristics of men who change or do not change these behaviours and their subsequent chances of CHD? This study aims to relate changes in men's CHD-related behaviours over a seven-year period to their social and demographic characteristics.A survey was carried out on a random sample of adults in Great Britain in 1984-85 and the equivalent information was obtained again on those participants who were re-interviewed seven years later in 1991-92. Results are presented for the 582 men aged 18-34 and the 584 men aged 35-49 at the first interview who were re-interviewed seven years later. Changes over the seven years in smoking, saturated fat intake, alcohol consumption and exercise were related to social and demographic factors. The two age groups showed broadly similar patterns of behaviour. In both age groups, those who continued with or took up a low fat diet and/or exercise were more likely to be in a higher social class, in employment, to live in private housing and to have more educational qualifications. For the younger men only, those in private housing were more likely to reduce the amount they smoked. Other findings are also reported. The findings suggest that those people who are in less advantageous social and economic situations are less likely to change to a more healthy lifestyle and so should be a focus for health education.

Improved incidental memory with nicotine after semantic processing, but not after phonological processing

RATIONALE

A number of lines of evidence suggest that a nicotinic cholinergic system is mediating attentional processing. However, the evidence is less clear for a nicotinic system being involved in mnemonic processing.

OBJECTIVES

The present study investigated the effects of nicotine on memory using a depth of processing paradigm.

METHODS

A double-blind design was used with participants (n = 40) smoking either a nicotine containing cigarette (n = 20) and a denicotinized cigarette (n = 20). After smoking, each set of these participants was further subdivided into two groups (n = 10 for each). One group were presented with a series of trials each beginning with the presentation of a "decision word" which they had to say whether it represented something which was living or non-living (semantic-orienting). The second group had to say whether the word had one syllable or two syllables (phonological or non-semantic orienting condition). This decision was followed by a word in coloured ink whose colour participants were required to name as quickly as possible. On completion of the whole task the participants were given an unexpected free recall test.

RESULTS

The nicotine-containing cigarette reduced the latencies for decision-making and colour naming in comparison with the denicotinized cigarette. The free recall test showed that nicotine-containing cigarette increased the number of words remembered, but only for the semantic-orienting condition and not the non-semantic condition.

CONCLUSIONS

There is a nicotinic cholinergic system that mediates effortful processing. It can be deployed for attentional processing, including the associative processing required for memory encoding.

Levomepromazine for nausea and vomiting in advanced cancer

Levomepromazine (previously known as methotrimeprazine), despite virtually no high quality scientific data to support its use, has become a very popular antiemetic for use in patients with advanced cancer. This article considers the reasons for this.

Vital capacity and tidal volume preoxygenation with a mouthpiece

We have measured oxygen wash-in in 20 volunteers undergoing preoxygenation with a face mask, mouthpiece alone and a mouthpiece with a noseclip, in a crossover study. Tidal volume breathing and maximal deep breath techniques were studied with each type of equipment. When tidal volume breathing was used, the face mask and mouthpiece with noseclip were comparable, but the mouthpiece alone achieved a lower end-expiratory oxygen concentration than the two other methods after 3 min (P < 0.001 and P < 0.01), and after 5 min (P < 0.05 in each case). Conversely, during preoxygenation with vital capacity breaths, the mouthpiece and mouthpiece with noseclip were comparable, and both were more effective than the face mask (P < 0.001). In a second study, 20 patients who had undergone preoxygenation before induction of anaesthesia were asked later if they would have preferred the face mask or mouthpiece for this procedure. Significantly more patients (14 of 18 who expressed a preference) favoured the mouthpiece (P < 0.05; confidence limits 0.56-0.92).

Attitudes of consultant anaesthetists to the Calman proposals: a questionnaire survey

We undertook a postal survey to determine the views of all consultant anaesthetists within the North West (Mersey) Regional Health Authority on the Calman proposals for a consultant-based service; replies were received from 110 (84%). Fifty (45%) indicated that they would not resume emergency residential duties, 32 (29%) indicated that they would withdraw from the emergency duty rota, 12 (11%) said they would withdraw/retire from the NHS and 27 (25%) would change hospital under these circumstances. Most consultants had experience in the major anaesthetic sub-specialties within the preceding 5 years (obstetrics 67%, ITU 81%, major trauma 91%). Consequently the need for retraining amongst consultant anaesthetists prior to resuming residential emergency duties would be low. When questioned about the impact on anaesthetic services, 67 (61%) felt the proposals would be detrimental whilst 23 (21%) felt there would be beneficial effects. Most consultants remain antagonistic toward the Calman proposals, with a reluctance to return to residential duties.

Scar management of cultured epithelial autograft

Since the introduction of cultured epithelial autograft (CEA) for the treatment of burns wounds, the resulting scar has caused a great deal of concern. When CEA is applied to a deep wound the resulting scar is subject to breakdown with minimal trauma. It takes a considerable period of time, in some instances years, before the dermal-epidermal junction matures and the skin is able to endure the wear and tear of normal existence. Therefore it is understandable that the introduction of pressure garments for treating into these scars has been somewhat delayed. However, we believe that early aggressive pressure therapy is the treatment of choice in those cases where there is a strong chance of the scar becoming hypertrophic. This paper presents an approach to the problems of scar management with CEA, not only for the case of a major full-thickness burn, but also for a lesser burn injury. The concept of a hydrophobic fabric as a lining garment is introduced. The garment design has been changed, to pay particular attention to reduction of shearing forces and dissipation of pressure. The development of our hydrophobic pressure garment is beneficial as it both reduces surface maceration and shearing injury. Since it protects the fragile CEA, formal pressure management can be instituted early in the treatment programme.

Chromosomal mapping of the human and mouse homologues of two new members of the AP-2 family of transcription factors

The AP-2 transcription factor has been shown to play an important role in the development of tissues of ectodermal origin and has also been implicated in mammary oncogenesis. It has recently been found that AP-2 is encoded by a family of related genes, AP-2alpha, AP-2beta, and AP-2gamma. As a further step in understanding the role each of these genes has in development, we have used fluorescence in situ hybridization to map the chromosomal locations of the mouse and human homologues of the newly isolated AP-2beta and AP-2gamma genes. Tcfap2b and Tcfap2c map to mouse chromosomes 1A2-4 and 2H3-4, respectively, while TFAP2B and TFAP2C map to human chromosomes 6p12 and 20q13.2, the latter being a region that is frequently amplified in breast carcinoma.

Preoxygenation--the importance of a good face mask seal

We have studied 16 healthy volunteers whose lungs were preoxygenated six times each in order to assess the amount of room air entrained during tidal volume preoxygenation if a good seal is not maintained between the face mask and the face. With a fresh gas flow of 10 litre min-1, we found that using gravity alone to hold the face mask in position, more than 20% room air was entrained; if the face mask was held adjacent to the face, more than 40% room air was entrained.

The contribution of osteoarthritis to disability: preliminary data from the Women's Health and Aging Study

Our objective was to examine the relationship of a self-reported physician diagnosis of arthritis with disability in elderly community dwelling women. Data from a representative sample of 1541 women aged 65 and above were analyzed to determine the prevalence and associations of a self-reported physician diagnosis of arthritis with other chronic conditions and difficulty performing physical activities. A history of physician diagnosed arthritis was reported by 902 (58.5%) women. Women with arthritis were significantly more likely to report fair or poor perceived health, as well as a physician diagnosis of angina, myocardial infarction, hypertension, diabetes, stroke, lung disease, and hearing and vision problems. After adjustment for age, race, education, marital status, and comorbid/geriatric conditions, arthritis was significantly associated with difficulty in the following 13 activities: raising arms, lifting < or = 10 pounds, walking 2-3 blocks, bathing or showering, climbing 10 steps, grasping, getting in or out of a bed or chair, dressing, using the toilet, preparing meals, doing personal shopping, heavy and light housework. We conclude that physician diagnosed arthritis is a common problem among elderly community dwelling women and is associated with difficulties in physical activity.