Detection of atrial fibrillation in patients with cryptogenic stroke: The Nordic Atrial Fibrillation and Stroke (NOR-FIB) study - topline results

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): NOR-FIB is an investigator driven academic study. 100 of 259 devices are supported by Medtronic.

BRT and ATL are recipients of a PhD grants from the South-Eastern Norway Regional Health Authority.

The study is supported by the research infrastructure of the European Cerebrovascular Research Infrastructure (ECRI).

Background

Cardioembolism due to occult atrial fibrillation (AF) is one of the common causes often identified by additional investigations in patients with cryptogenic stroke (CS). A large proportion of recurrent cerebral infarctions caused by AF can probably be prevented if more patients receive optimal cardiac monitoring after CS and TIA.

Purpose

The aim of the prospective observational multi-center NOR-FIB study was to detect and quantify AF in patients with cryptogenic stroke or TIA under continuous 12 months cardiac rhythm monitoring with an implantable cardiac monitor (ICM) and to possibly identify biomarkers predicting incident AF.

Methods

Patients with cryptogenic stroke and TIA diagnosed after state-of-the-art work-up had their ICM implanted by a stroke physician within 14 days after symptom onset. All patients were followed clinically and by rhythm monitoring for 12 months. AF was defined by detected atrial arrhythmia episodes ≥ 2 min, and these patients were considered for a change of their secondary prevention from antiplatelet drugs to oral anticoagulants (OAC).

Results

A total of 259 patients with cryptogenic stroke or TIA from 18 hospitals in Norway, Sweden and Denmark were included. After 12 months follow-up 74 (28.6 %) patients were diagnosed with paroxysmal AF, of which 91.9% were asymptomatic. Patients with AF had significantly higher mean age (72.6 vs 62.2, p<0.001), more severe stroke (median National Institute Stroke Scale Score on admission 2 vs 1, p 0.002) and higher pre-stroke median CHA2DS2-VASc score (3 vs 2, p<0.001) than patients without AF. Both hypertension and hyperlipidemia was more common in patients with AF. In 64 (86.5%) cases AF was detected early after index stroke, i.e., within the first two months of monitoring (mean 47.7 days + 52,1). Recurrent AF episodes were detected in 68 (91.9%) cases. Of the 74 AF patients, 72 (97.3%) were switched to OAC. Recurrent strokes during follow-up occurred in 2 AF patients (2.7 %) and in 9 non-AF patients (4.9 %).

Conclusion

AF was detected in 29% of all cryptogenic stroke/TIA patients. Most of the patients were asymptomatic for their arrhythmia, and would have gone undiagnosed without a continuous monitoring approach. Since most of the patients with detected AF were switched to OAC, the 12 months risk of recurrent stroke in this group was low. Prolonged cardiac rhythm monitoring with ICMs is an effective tool for diagnosing underlying asymptomatic AF in a patient population typically confined to a stroke unit.

652 Fate of The Contralateral Limb Following Major Lower Limb Amputation in Patients with Peripheral Arterial Disease And/Or Diabetes: Case Series from Two Regional Vascular Centres

Introduction

This is the first clinical case series to report time to ulceration, minor and major amputation of the contralateral limb (CLL) in the first 12 months following major lower limb amputation (LLA) in patients with peripheral arterial disease (PAD) and/or diabetes.

Method

Consecutive patient samples at two regional UK vascular centres were included; from 2010 to 2017 (site 1) and 2014 to 2016 (site 2). Data were extracted from electronic records for 12 months following index major LLA. Survival analyses are presented for the event of mortality in the total study population, plus major amputation-free survival, and complication-free survival in site 1 only; results are stratified by diabetes status.

Results

Of 381 patients reviewed (n = 197 site 1; n = 184 site 2), 208 (54.6%) were diagnosed with diabetes at the time of their index major LLA. The mean survival time of patients was lower in those without diabetes (HR: 0.64 [95% CI, 0.43 to 0.95], p=.03). The mean time to major amputation of the CLL or death in patients was lower in those without diabetes (HR: 0.65 [95% CI, 224 0.40 to 1.06]; p=.08). The median time to any complication of the CLL or death was greater in those without diabetes (HR: 1.25 [95% CI, 227 0.88 to 1.78]; p=.21).

Conclusions

Death rates were higher in patients without diabetes, whilst those with diabetes had high levels of CLL complications. Optimisation of care to protect the CLL following major LLA and guidance for carers, patients, and clinicians is required.

Marine mammal conservation: over the horizon

Marine mammals can play important ecological roles in aquatic ecosystems, and their presence can be key to community structure and function. Consequently, marine mammals are often considered indicators of ecosystem health and flagship species. Yet, historical population declines caused by exploitation, and additional current threats, such as climate change, fisheries bycatch, pollution and maritime development, continue to impact many marine mammal species, and at least 25% are classified as threatened (Critically Endangered, Endangered or Vulnerable) on the IUCN Red List. Conversely, some species have experienced population increases/recoveries in recent decades, reflecting management interventions, and are heralded as conservation successes. To continue these successes and reverse the downward trajectories of at-risk species, it is necessary to evaluate the threats faced by marine mammals and the conservation mechanisms available to address them. Additionally, there is a need to identify evidence-based priorities of both research and conservation needs across a range of settings and taxa. To that effect we: (1) outline the key threats to marine mammals and their impacts, identify the associated knowledge gaps and recommend actions needed; (2) discuss the merits and downfalls of established and emerging conservation mechanisms; (3) outline the application of research and monitoring techniques; and (4) highlight particular taxa/populations that are in urgent need of focus.

Preventing child sexual abuse: A systematic review of interventions and their efficacy in developing countries

BACKGROUND

Research on prevalence, risk factors, and prevention interventions for child sexual abuse has continued to focus on western and developed countries. Where country-level prevalence data or large-scale research exists, rates of child sexual abuse are consistently higher in developing and non-western countries than their western and developed counterparts.

OBJECTIVE

We systematically reviewed research on the nature of child sexual abuse interventions in developing countries, the settings and populations included to identify types of child sexual abuse prevention initiatives being implemented in developing countries and their effectiveness.

METHODS

Following PRISMA guidelines, we conducted a systematic search of six databases and identified eight studies to include in our analysis.

RESULTS

Most empirically evaluated interventions in developing countries have focused on preschool and primary school-aged children. Most have focused on interventions delivered in educational settings, with a lack of focus on population-level interventions to prevent child sexual abuse. Researchers have used outcomes measuring knowledge or skills for young people in self-protection and help-seeking, not deployment of those skills, actual reduction in prevalence of CSA, or improvements in conditions of safety in organizational contexts.

CONCLUSIONS

If the focus on school-based strategies to prevent child sexual abuse continues in developing countries, a significant gap in knowledge of the efficacy of population-level interventions outside of school contexts, and consistency across the application of interventions will remain. Evaluations are needed that address the efficacy of broader government-led or whole-of-community prevention interventions to reduce actual prevalence of child sexual abuse, or that can link increased knowledge and skill with reduced victimization.

USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair

PURPOSE

Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons.

METHODS

An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR).

RESULTS

110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively.

CONCLUSION

The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Advanced ultrasound methods in assessment of carotid plaque instability: a prospective multimodal study

Background

A significant proportion of ischemic strokes are caused by emboli from atherosclerotic, unstable carotid artery plaques. The selection of patients for endarterectomy in current clinical practice is primarily based on the degree of carotid artery stenosis and clinical symptoms. However, the content of the plaque is known to be more important for stroke risk. Intraplaque neovascularization (IPN) has recently emerged as a possible surrogate marker for plaque instability. Neo-microvessels from the adventitial vasa vasorum grow into the full thickness of the vessel wall in an adaptive response to hypoxia, causing subsequent intraplaque haemorrhage and plaque rupture. Conventional ultrasound cannot detect IPN. Contrast-enhanced ultrasound and Superb Microvascular Imaging (SMI), have, however, shown promise in IPN assessment. Recent research using Shear Wave Elastography (SWE) has also reported reduced tissue stiffness in the artery wall (reduced mean Young’s modulus) in unstable compared to stable plaques. The purpose of this study is to identify unstable carotid artery plaques at risk of rupture and future ischemic stroke risk using multimodal assessments.

Methods

Forty five symptomatic and 45 asymptomatic patients > 18 years, with > 50% carotid stenosis referred to Oslo University Hospital ultrasound lab will be included in this on-going project. Patients will undergo contrast enhanced ultrasound, SMI, carotid-MRI and PET-(¹⁸F-FDG). Contrast enhanced ultrasound will be analyzed semi-quantitatively (5-levels visual classification) and quantitatively by plotting time-intensity curve analyses to obtain plaque peak contrast enhancement intensity. Plaques removed at carotid endarterectomy will be assessed histologically and the number of microvessels, areas of inflammation, granulation, calcification, lipid and fibrosis will be measured.

Discussion

This multimodality study will primarily provide information on the clinical value of advanced ultrasound methods (SMI, SWE) for the detection of unstable carotid artery plaque in comparison with other methods including contrast-enhanced ultrasound, carotid-MRI and PET-(¹⁸F-FDG) using histology as the gold standard. Secondly, findings from the methods mentioned above will be related to cerebrovascular symptoms, blood tests (leukocytes, CRP, ESR, lipoproteins and inflammatory markers) and cardiovascular risk factors at inclusion and at 1-year follow-up. The overall aim is to optimize detection of plaque instability which can lead to better preventive decisions and reduced stroke rate.

Health experiences of asylum seekers and refugees in Wales

Key messages

Improving health equity is key to realising Wales’ ambition to become a Nation of Sanctuary. Peer Researchers enabled participation by sanctuary seekers and revealed useful findings to steer future policy and practice.

Multi-pathogen serological survey of migratory caribou herds: A snapshot in time

Pathogens can impact host survival, fecundity, and population dynamics even when no obvious disease is observed. Few baseline data on pathogen prevalence and diversity of caribou are available, which hampers our ability to track changes over time and evaluate impacts on caribou health. Archived blood samples collected from ten migratory caribou herds in Canada and two in Greenland were used to test for exposure to pathogens that have the potential to effect population productivity, are zoonotic or are emerging. Relationships between seroprevalence and individual, population, and other health parameters were also examined. For adult caribou, the highest overall seroprevalence was for alphaherpesvirus (49%, n = 722), pestivirus (49%, n = 572) and Neospora caninum (27%, n = 452). Lower seroprevalence was found for parainfluenza virus type 3 (9%, n = 708), Brucella suis (2%, n = 758), and Toxoplasma gondii (2%, n = 706). No animal tested positive for antibodies against West Nile virus (n = 418) or bovine respiratory syncytial virus (n = 417). This extensive multi-pathogen survey of migratory caribou herds provides evidence that caribou are exposed to pathogens that may have impacts on herd health and revealed potential interactions between pathogens as well as geographical differences in pathogen exposure that could be linked to the bio-geographical history of caribou. Caribou are a keystone species and the socio-economic cornerstone of many indigenous cultures across the North. The results from this study highlight the urgent need for a better understanding of pathogen diversity and the impact of pathogens on caribou health.

The barriers to linkage and retention in care for women living with HIV in an high income setting where they comprise a minority group

Women comprise a minority population of individuals living with HIV in Australia, and are often poorly represented in research and clinical trials so their needs remain largely unknown. Data suggests that they are diagnosed later than men and start antiretroviral therapy at a lower CD4 cell count. This raises the question whether there are sex specific barriers to linkage and retention in care. This study analyzed 484 surveys received from clinicians collecting demographic, virological, and reproductive health data along with perceived barriers to linkage and retention in care. Most women (67%) were estimated to have been linked into care within 28 days of diagnosis. For women who were not linked into care for more than 28 days, the most commonly reason cited was fear of disclosure to others, followed by fear of disclosure to their partner. The main reasons given for non-retention in care were related to transport, carer responsibilities, financial pressure, health beliefs and concern about stigma or disclosure.

Cardiovascular disease and diabetes in HIV-positive and HIV-negative gay and bisexual men over the age of 55 years in Australia: insights from the Australian Positive & Peers Longevity Evaluation Study

OBJECTIVES

As HIV-positive people age, diagnosis and management of comorbidities associated with ageing are of increasing concern. In this study, we aimed to compare the self-reported prevalences of heart disease, stroke, thrombosis and diabetes in older Australian HIV-positive and HIV-negative gay and bisexual men (GBM).

METHODS

We analysed data from the Australian Positive & Peers Longevity Evaluation Study (APPLES), a study of a prospectively recruited cross-sectional sample of 228 (51.1%) HIV-positive and 218 (48.9%) HIV-negative GBM, aged ≥ 55 years. Regression methods were used to assess the association of HIV status with self-reported comorbidities.

RESULTS

Of 446 patients, 389 [200 (51.4%) HIV-positive] reported their disease history. The reported prevalence of comorbidities was higher in the HIV-positive group than in the HIV-negative group: heart disease, 19.5 versus 12.2%; stroke, 7.5 versus 4.2%; thrombosis, 10.5 versus 4.2%; and diabetes, 15.0 versus 9.0%, respectively. In adjusted analyses, HIV-positive GBM had significantly increased odds of reporting heart disease [adjusted odds ratio (aOR) 1.99; P = 0.03] and thrombosis (aOR 2.87; P = 0.01). In our analysis, HIV status was not significantly associated with either age at diagnosis of heart disease (median 53 years for HIV-positive GBM versus 55 years for HIV-negative GBM; P = 0.64) or 5-year cardiovascular disease (CVD) risk estimated using the Framingham risk score.

CONCLUSIONS

HIV-positive GBM more commonly reported heart disease and thrombosis compared with their HIV-negative peers. These results further highlight the need to understand the impact of HIV on age-related comorbidities in GBM, to guide optimal screening and treatment strategies to reduce the risk of these comorbidities among the HIV-positive population.

Acquired Bilateral Superior Oblique Palsy: A Localising Sign in the Dorsal Midbrain

Bilateral superior oblique palsy is an uncommon ocular motility problem, the commonest cause being closed head trauma. Two cases, both adults, are presented in whom bilateral superior oblique palsy occurred as a result of neoplastic infiltration of the dorsal midbrain in the region of the anterior medullary velum. In the absence of a history of head trauma, the presence of an acquired bilateral superior oblique palsy is a definite sign of a single lesion in the region of the decussation of the trochlear nerves and appropriate imaging is indicated.

European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke

BACKGROUND AND PURPOSE

The reduction of delay between onset and hospital arrival and adequate pre-hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence-based practices for the management of patients with suspected stroke in the pre-hospital setting.

METHODS

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations.

RESULTS

Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre-hospital 'code stroke' including highest priority dispatch, pre-hospital notification and rapid transfer to the closest 'stroke-ready' centre. Insufficient evidence was found to recommend a pre-hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre-hospital telemedicine during ambulance transport.

CONCLUSIONS

These guidelines inform on the contemporary approach to patients with suspected stroke in the pre-hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Outcomes of exertional rhabdomyolysis following high-intensity resistance training

BACKGROUND

High-intensity resistance training (HIRT) programmes are increasingly popular amongst personal trainers and those attending gymnasiums. We report the experience of exertional rhabdomyolysis (ER) at two tertiary hospitals in Melbourne, Australia.

AIMS

To compare the clinical outcomes of ER with other causes of rhabdomyolysis.

METHODS

Retrospective cross-sectional study of patients presenting with a serum creatine kinase (CK) of greater than 25 000 units/L from 1 September 2013 to 31 August 2014 at two tertiary referral hospitals in Melbourne, Australia. Records were examined to identify care measures implemented during hospital stay, clinical outcomes during admission and on subsequent follow up.

RESULTS

Thirty four cases of rhabdomyolysis with a CK of greater than 25 000 units/L (normal range: 20-180 units/L) were identified during the 12-month study period. Twelve of the 34 cases (35%) had ER with 10 of 12 related to HIRT. No acute kidney injury, intensive care admission or death were seen among those with ER. All cases were managed conservatively, with 11 admitted and 9 receiving intravenous fluids only. In contrast, patients with rhabdomyolysis from other causes experienced significantly higher rates of intensive care admission (64%, P = 0.0002), acute kidney injury (82%, P = 0.0001) and death (27%, P = 0.069).

CONCLUSION

ER resulting from HIRT appears to have a benign course compared with rhabdomyolysis of other aetiologies in patients with a serum CK greater than 25 000 units/L. Conservative management of ER appears to be adequate, although this requires confirmation in future prospective studies.

Shipping noise in a dynamic sea: a case study of grey seals in the Celtic Sea

Shipping noise is a threat to marine wildlife. Grey seals are benthic foragers, and thus experience acoustic noise throughout the water column, which makes them a good model species for a case study of the potential impacts of shipping noise. We used ship track data from the Celtic Sea, seal track data and a coupled ocean-acoustic modelling system to assess the noise exposure of grey seals along their tracks. It was found that the animals experience step changes in sound levels up to ~20dB at a frequency of 125Hz, and ~10dB on average over 10-1000Hz when they dive through the thermocline, particularly during summer. Our results showed large seasonal differences in the noise level experienced by the seals. These results reveal the actual noise exposure by the animals and could help in marine spatial planning.

Reduced Global Cerebral Blood Flow in Non-Demented HIV Positive Patients

Twelve non-demented HIV positive men with different degrees of immunodeficiency were examined with single photon emission computed tomography (SPECT). Reduction in relative global cerebral blood flow was found in HIV positive patients compared to healthy HIV negative controls (p = 0.014). In the patients there was also a change in cerebral flow distribution, with lower global flow compared to central flow (p = 0.01), most pronounced in patients with early disease. In the patients with advanced HIV disease the relative cerebral blood flow was lower than in the controls in 108 of 116 (93%) regions investigated.

Insulin-like growth factor 1 prevents diastolic and systolic dysfunction associated with cardiomyopathy and preserves adrenergic sensitivity

AIMS

Insulin-like growth factor 1 (IGF-1)-dependent signalling promotes exercise-induced physiological cardiac hypertrophy. However, the in vivo therapeutic potential of IGF-1 for heart disease is not well established. Here, we test the potential therapeutic benefits of IGF-1 on cardiac function using an in vivo model of chronic catecholamine-induced cardiomyopathy.

METHODS

Rats were perfused with isoproterenol via osmotic pump (1 mg kg(-1) per day) and treated with 2 mg kg(-1) IGF-1 (2 mg kg(-1) per day, 6 days a week) for 2 or 4 weeks. Echocardiography, ECG, and blood pressure were assessed. In vivo pressure-volume loop studies were conducted at 4 weeks. Heart sections were analysed for fibrosis and apoptosis, and relevant biochemical signalling cascades were assessed.

RESULTS

After 4 weeks, diastolic function (EDPVR, EDP, tau, E/A ratio), systolic function (PRSW, ESPVR, dP/dtmax) and structural remodelling (LV chamber diameter, wall thickness) were all adversely affected in isoproterenol-treated rats. All these detrimental effects were attenuated in rats treated with Iso+IGF-1. Isoproterenol-dependent effects on BP were attenuated by IGF-1 treatment. Adrenergic sensitivity was blunted in isoproterenol-treated rats but was preserved by IGF-1 treatment. Immunoblots indicate that cardioprotective p110α signalling and activated Akt are selectively upregulated in Iso+IGF-1-treated hearts. Expression of iNOS was significantly increased in both the Iso and Iso+IGF-1 groups; however, tetrahydrobiopterin (BH4) levels were decreased in the Iso group and maintained by IGF-1 treatment.

CONCLUSION

IGF-1 treatment attenuates diastolic and systolic dysfunction associated with chronic catecholamine-induced cardiomyopathy while preserving adrenergic sensitivity and promoting BH4 production. These data support the potential use of IGF-1 therapy for clinical applications for cardiomyopathies.

Risk factors associated with incident sexually transmitted infections in HIV-positive patients in the Australian HIV Observational Database: a prospective cohort study

OBJECTIVES

We established a subcohort of HIV-positive individuals from 10 sexual health clinics within the Australian HIV Observational Database (AHOD). The aim of this study was to assess demographic and other factors that might be associated with an incident sexually transmitted infection (STI).

METHODS

The cohort follow-up was from March 2010 to March 2013, and included patients screened at least once for an STI. We used survival methods to determine time to first new and confirmed incident STI infection (chlamydia, gonorrhoea, syphilis or genital warts). Factors evaluated included sex, age, mode of HIV exposure, year of AHOD enrolment, hepatitis B or C coinfection, time-updated CD4 cell count, time-updated HIV RNA viral load, and prior STI diagnosis.

RESULTS

There were 110 first incident STI diagnoses observed over 1015 person-years of follow-up, a crude rate of 10.8 [95% confidence interval (CI) 9.0-13.0] per 100 person-years. Factors independently associated with increased risk of incident STI included younger age [≥ 50 vs. 30-39 years old, adjusted hazards ratio (aHR) 0.4; 95% CI 0.2-0.8; P < 0.0001]; prior STI infection (aHR 2.5; 95% CI 1.6-3.8; P < 0.001), and heterosexual vs. men who have sex with men (MSM) as the likely route of exposure (aHR 0.2; 95% CI 0.1-0.6; P < 0.001).

CONCLUSIONS

In this cohort of individualsbeing treated with antiretroviral drugs, those who were MSM, who were 30-39 years old, and who had a prior history of STI, were at highest risk of a further STI diagnosis.

Overview of shorthand medical glossary (OMG) study

BACKGROUND

Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable.

AIM

We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries.

METHODS

Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff.

RESULTS

The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary.

CONCLUSION

Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

Potential benefits of diagnosis and treatment on health outcomes among elderly people with symptoms of overactive bladder

OBJECTIVES

This study examined potential benefits of diagnosing and treating elderly adults with overactive bladder (OAB) symptoms.

METHODS

Data were analysed from the OAB Re-Contact Study (N = 2750), a cross-sectional, self-reported Internet survey. Elderly respondents (65+ years old) with OAB were identified according to current medication use to control OAB symptoms or by scores > 14 (men) or > 16 (women) on the OAB Awareness Tool. Treated were those currently using prescription medication and never treated were those who never used prescription medication for OAB. Outcome measures included health-related quality of life, activity impairment, OAB-related severity and symptoms, and healthcare resource use (e.g. hospitalisations). Generalised linear models predicted health outcomes as a function of diagnosis or treatment, adjusting for covariates.

RESULTS

Diagnosed vs. not diagnosed elderly respondents had higher mental component summary (MCS) scores and SF-6D health utilities, and less activity impairment. Treated vs. never treated elderly respondents had higher MCS and SF-6D health utilities, less activity impairment, fewer OAB symptoms, lower OAB Awareness Tool scores, and lower odds of having bladder problems or incontinence. There were no significant differences in healthcare resource use. Further analysis by age group (middle-aged vs. elderly respondents) revealed significantly greater diagnosis- and treatment-related benefits on MCS (2.93 and 4.49 points more, respectively) and activity impairment (1.24 and 1.37 times as much, respectively) among elderly respondents.

CONCLUSIONS

Diagnosis and treatment were each associated with a lower health burden for elderly adults with OAB symptoms. These findings highlighted the importance of diagnosis and treatment in alleviating OAB symptoms and their impact on health outcomes.

Assessment of acute stroke cerebral CT examinations by anaesthesiologists

Background and purpose

It is essential to diagnose ischaemic stroke as soon as possible after symptom onset, so that thrombolytic treatment can be initiated as quickly as possible. This might be greatly facilitated if cerebral CT could be carried out in a pre‐hospital setting. The aim of this study was to evaluate if anaesthesiologists, who in Norway provide pre‐hospital medical care, could be trained to assess cerebral CT scans to exclude radiological contraindications for thrombolytic stroke treatment.

Methods

Thirteen anaesthesiologists attended an 8‐h course in acute stroke assessment, including a 2‐h introduction to the neuroradiology of acute stroke. Each participant then assessed 12 non‐contrast cerebral CT examinations of acute stroke patients with specific regard to radiological contraindications for thrombolytic therapy. Test results were compared with those of three experienced neuroradiologists. Inter‐rater agreement between anaesthesiologists and neuroradiologists was calculated using Cohen's Kappa statistics. Robustness of the results was assessed using the non‐parametric bootstrap.

Results

Among the neuroradiologists, Kappa was 1 for detecting radiological contraindications for thrombolytic therapy. Twelve of the 13 anaesthesiologists showed good or excellent agreement (Kappa > 0.60) with the neuroradiologists. The anaesthesiologists spent a median time of 2 min and 18 s on each CT scan.

Conclusions

This study suggests that anaesthesiologists who are experienced in pre‐hospital care may be quickly trained to assess cerebral CT examinations in acute stroke patients with regard to radiological contraindications for thrombolytic therapy.

Development of a risk-based prioritisation methodology to inform public health emergency planning and preparedness in case of accidental spill at sea of hazardous and noxious substances (HNS)

Hazardous and noxious chemicals are increasingly being transported by sea. Current estimates indicate some 2000 hazardous and noxious substances (HNS) are carried regularly by sea with bulk trade of 165milliontonnes per year worldwide. Over 100 incidents involving HNS have been reported in EU waters. Incidents occurring in a port or coastal area can have potential and actual public health implications. A methodology has been developed for prioritisation of HNS, based upon potential public health risks. The work, undertaken for the Atlantic Region Pollution Response programme (ARCOPOL), aims to provide information for incident planning and preparedness. HNS were assessed using conventional methodology based upon acute toxicity, behaviour and reactivity. Tonnage was used as a proxy for likelihood, although other factors such as shipping frequency and local navigation may also contribute. Analysis of 350 individual HNS identified the highest priority HNS as being those that present an inhalation risk. Limitations were identified around obtaining accurate data on HNS handled on a local and regional level due to a lack of port records and also political and commercial confidentiality issues. To account for this the project also developed a software tool capable of combining chemical data from the study with user defined shipping data to be used by operators to produce area-specific prioritisations. In conclusion a risk prioritisation matrix has been developed to assess the acute risks to public health from the transportation of HNS. Its potential use in emergency planning and preparedness is discussed.

Diabetes and CVD risk during angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker treatment in hypertension: a study of 15,990 patients

Differences in clinical effectiveness between angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in the primary treatment of hypertension are unknown. The aim of this retrospective cohort study was to assess the prevention of type 2 diabetes and cardiovascular disease (CVD) in patients treated with ARBs or ACEis. Patients initiated on enalapril or candesartan treatment in 71 Swedish primary care centers between 1999 and 2007 were included. Medical records data were extracted and linked with nationwide hospital discharge and cause of death registers. The 11 725 patients initiated on enalapril and 4265 on candesartan had similar baseline characteristics. During a mean follow-up of 1.84 years, 36 482 patient-years, the risk of new diabetes onset was lower in the candesartan group (hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69–0.96, P=0.01) compared with the enalapril group. No difference between the groups was observed in CVD risk (HR 0.99, 95% CI 0.87–1.13, P=0.86). More patients discontinued treatment in the enalapril group (38.1%) vs the candesartan group (27.2%). In a clinical setting, patients initiated on candesartan treatment had a lower risk of new-onset type 2 diabetes and lower rates of drug discontinuation compared with patients initiated on enalapril. No differences in CVD risk were observed.