Burden of lipoprotein(a) for patients with atherosclerotic cardiovascular disease: A retrospective analysis from the United States

BACKGROUND: Lipoprotein(a) (Lp(a)) is an inherited, independent, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE: To assess the burden of elevated Lp(a) for patients with ASCVD in a real-world setting in the United States. METHODS: This retrospective cohort study assessed US patients with available Lp(a) measurement and established ASCVD using Optum's Clinformatics Data Mart database (2007-2020). Index date was defined as the first diagnosis of an ASCVD event. Patient demographics, medications, health care resource utilization (HCRU), and occurrence of cardiovascular events were assessed for patients with elevated (≥150 nmol/L) vs normal (≥65 nmol/L) Lp(a) levels, within the first year of index date. HCRU was characterized by inpatient hospitalization, inpatient length of stay (LOS), outpatient visits, and emergency department (ED) visits. All comparative analyses of patients with elevated (≥150 nmol/L) vs normal (≥65 nmol/L) Lp(a) levels within the first year of index date were adjusted for age, sex, baseline statin use, and diabetes. RESULTS: 8,372 patients with ASCVD and Lp(a) measurement in nmol/L were included in this study. Patient demographics and baseline clinical characteristics were similar among those with normal and elevated Lp(a). However, the proportion of patients receiving statins and β-blockers at baseline were significantly higher in the elevated vs normal Lp(a) group (54.76% vs 42.91%, P < 0.0001, and 30.92% vs 27.32%, P = 0.0183, respectively). At 1 year of follow-up, the rates per 100 person-years for ASCVD-related inpatient hospitalizations, outpatient hospitalizations, and ED visits were higher among patients with elevated Lp(a) compared with normal Lp(a) (13.33 vs 9.46, 89.08 vs 85.10, and 2.89 vs 2.29, respectively). The mean LOS per ASCVD-related hospitalization was 7.21 days in the elevated and 6.26 days in the normal Lp(a) group (P = 0.3462). During the 1-year post-index follow-up period, 15% of patients in the elevated Lp(a) group required revascularization compared with 10% of patients in the normal Lp(a) group (P = 0.0002). The odds of composite myocardial infarction, ischemic stroke, and revascularization occurrence of events within the first year of index was significantly higher in the elevated Lp(a) group compared with the normal Lp(a) group (1.46; 95% CI = 1.20-1.77; P < 0.05). CONCLUSIONS: HCRU within the first year of ASCVD diagnosis is substantial among patients with ASCVD and elevated Lp(a). Relatively higher rates of inpatient hospitalizations, increased LOS per hospitalization, and requirement of revascularization procedures within the first year of ASCVD index diagnosis were observed in patients with elevated Lp(a) compared with normal Lp(a) levels. Lp(a) testing in routine clinical practice could help in identification of high-risk patients with ASCVD and play an important role in the overall cardiovascular risk management, aiming to reduce the HCRU associated with ASCVD. DISCLOSURES: Ms Fonseca, Dr Laguna, Dr Itani, Dr Rachel Studer, and Dr Ferber are employees of Novartis Pharma AG, Basel, Switzerland. Ms Byrne is an employee of Novartis AG, Dublin, Ireland. Dr Costa-Scharplatz is an employee of Novartis Sweden AB, Stockholm, Sweden. Dr Heo and Ms Dillon are employees of Genesis Research. Genesis Research was commissioned to conduct the study (data extraction and analysis) on behalf of Novartis Pharma AG.

Burden of illness in metastatic colorectal cancer

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Background: Current treatment options for patients with metastatic colorectal cancer (mCRC) have limited efficacy and are associated with substantial toxicity, especially for patients with mCRC refractory to standard therapies. Targeted agents may improve outcomes, compared with traditional chemotherapeutic approaches, in those patients with mCRC expressing actionable biomarkers. The objective of this study was to evaluate clinical outcomes and associated health care costs by line of therapy among patients with mCRC. Methods: A retrospective analysis of Merative MarketScan Commercial and Medicare Supplemental Administrative health claims databases was conducted. Adult patients with mCRC initiating systemic therapy between January 1, 2017 and September 30, 2021 were identified. Patient characteristics, time to discontinuation (TTD), time to next treatment (TTNT), and per-patient-per-month (PPPM) healthcare resource utilization and costs were evaluated for each line of therapy. Results: 3,455 patients with mCRC initiated systemic therapy during the study period and met all patient selection criteria. The median age at index was 56 years and median follow-up was 14 months. 1082 (31%), 372 (11%), and 185 (5%) patients went on to receive 2L, 3L, and 4L+ treatment, respectively. The most common regimens in 1-3L were as follows: 1L – FOLFOX; capecitabine, oxaliplatin; 2L - FOLFIRI+Bev; tipiracil/trifluridine; 3L – tipiracil/trifluridine; regorafenib. Median TTD in 1L through 3L was 22.0, 16.6, and 14.4 weeks, respectively. Median TTNT was 47, 26, and 21 weeks, in 1-3L, respectively. 184 (17%) and 265 (25%) of 2L patients experienced ≥1 inpatient and ≥1 emergency department (ED) visit during 2L treatment, respectively. During 2L treatment, patients had an average of 3.7±7.3 mCRC treatment-related outpatient visits per month. PPPM inpatient, ED, outpatient, and pharmacy costs are displayed. Conclusions: There is an unmet need for effective therapies in 2L+ mCRC, where clinical outcomes are poor. Later lines of therapy are associated with substantial HCRU and costs. [Table: see text]

82 THE IMPACT OF THE COVID-19 PANDEMIC ON THE ACTIVITY OF A RAPID-ACCESS GERIATRIC DAY HOSPITAL SERVICE

Background

In the 1970s, Jack Flanagan developed the first Geriatric Day Hospital (GDH) in Ireland. Since, the GDH model of care has evolved to accommodate for the growing demands of our ageing population. Before the COVID-19 pandemic, the operational scope of our GDH was extended to allow for the rapid medical and multidisciplinary assessment and follow-up of older patients. During the pandemic, the GDH did not suspend operations and remained open as a COVID-negative ambulatory pathway. We evaluated the activity of this GDH service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office (Reference: 7419). Pseudonymised data corresponding to all GDH attendances between January 2017 and December 2021 were retrieved from the hospital electronic records. Yearly trends in proportions were tested with the Chi-square for trend statistic. Trends in monthly attendances were assessed via Statistical Process Control (SPC) charts with three-sigma limits. Statistical significance was set at p<0.05.

Results

There were 27,278 attendances of patients aged 65 and over to the GDH over the 5-year period (6,362, 5,978, 6,115, 4,306, and 4,517, respectively). Mean age was 82 every year. Of the 7,813 new episodes, yearly proportions referred directly by primary care teams were 10.4%, 29.5%, 38.6%, 24.5%, and 16.3% (p<0.001). SPC charts showed that Apr-May 2020 and Jan-Feb 2021 had significantly lower numbers of review attendances (50-59 and 146-142, respectively, average 324 p/m). However, new appointments did not significantly decline (average 130 p/m). Of the 7,813 new episodes, 2,595 (33.2%) were seen by Physiotherapy, and 1,860 (23.8%) by Occupational Therapy.

Conclusion

Our GDH saw a sustained number of new attendances and demonstrated increased community availability during the unprecedented COVID-19 crisis, especially during the first wave of the pandemic when hospital access was most affected. A rapid access GDH model can facilitate integrated care at times of crisis to promote ageing in place.

351 PRIDE IN AGEING - DEVELOPING LGBTQ+ EDUCATION TO DRIVE INCLUSION IN OLDER PERSONS CARE

Background

Older LGBTQ+ people are more likely to have diminished support networks and increased health risk factors, creating a greater reliance on healthcare. Within the literature concerns are voiced that fear of discrimination leads to mistrust and therefore underutilisation of health and social services among older LGBTQ+ people, leading to a lack of understanding of the specific needs and experiences of this cohort of patients. This mistrust of healthcare professionals and systems can negatively impact upon quality of life as older LGBTQ+ people do not avail of the health and social services they need to age well.

Methods

The author attended an international workshop to hear first-hand the lived experiences of older LGBTQ+ people from five European countries. A systematic literature review was completed to gain greater understanding of the challenges and discrimination faced by older LGBTQ+ people while accessing health and social care services. The author then received training with a leading LGBTQ+ organisation in order to gain insights into the experiences and concerns of older LGBTQ+ people in Ireland. Practical learning was gained on how to foster inclusion, provide education and create change within older persons services. Staff and patient engagement, feedback and evaluation was used to establish requirements for education, training and service development.

Results

LGBTQ+ education and training was developed for all disciplines working across acute, rehabilitation and residential older persons services in a large academic teaching hospital. This education is now delivered monthly to drive inclusion in older persons care. Staff feel more equipped and confident to provide inclusive care. There has been improved staff well-being and pride as the hospital moves towards being an inclusive and safe space for all.

Conclusion

There is a need for sustained education and training to equip staff with the skills and confidence to provide inclusive care to older LGBTQ+ patients accessing health and social care services.

New Indication for an Established Procedure: Cervical Cerclage for Prevention of Umbilical Cord Prolapse

Objective:

Funic presentation is a risk factor for umbilical cord prolapse. In the majority of cases, umbilical cord prolapse is an obstetric emergency. Currently there is no strategy to prevent umbilical cord prolapse in patients with funic presentation. Placing a third trimester cervical cerclage was proposed, as a mechanical barrier of prolapse, in women with funic presentation.

Materials and Methods:

Twelve patients with funic presentation, detected between 23 and 34 weeks of gestation, were included in the study. Patients were informed that although cervical cerclage have been widely used in obstetrics, it had not been offered in patients with funic presentation. Gestational age at delivery, mode of delivery, location of umbilical cord at birth, presence or absence of umbilical cord prolapsed, and neonatal condition at birth were recorded in all cases.

Results:

Patients’ age varied from 21 to 40 years, mean of 28 ± 6.2 years, and gestational age at the time of diagnosis of funic presentation varied from 26 to 34 weeks of pregnancy. All patients were seen weekly after the cervical cerclage placement to assess the umbilical cord location. Seven patients had vertex presentation, four had breech presentation, and one had transverse lie presentation. A follow-up sonogram of the umbilical cord revealed the following: funic presentation was persistent throughout the entire pregnancy in five patients, disappeared in four, and became intermittent in three. The delivery mode was as follows: cesarean section was performed in eight patients (five with persistent funic presentation, two with intermittent, and one with resolved funic presentation because of failure to progress in labor). There were five patients who delivered vaginally. Funic presentation was confirmed in all patients who underwent cesarean sections. None of the patients had had an umbilical cord prolapse.

Conclusion:

In view of high perinatal mortality of umbilical cord prolapses, placement of cervical cerclage could be added to obstetric armamentarium in patients with funic presentation, after proper counseling.

142 FRAILTY IDENTIFICATION AND INTERDISCIPLINARY ASSESSMENT OF OLDER PEOPLE IN THE EMERGENCY DEPARTMENT

Background

Older People are attending Emergency Departments (EDs) in increasing numbers but the optimal assessment measures to use have yet to be established. This study examined the clinical utility of different assessments of strength, functional mobility, sarcopenia, cognition and frailty used by the physiotherapist in an interdisciplinary team (IDT) in the ED and determined any associations with clinical outcomes.

Methods

This observational cross-sectional study recruited adults ≥70 years who were assessed by an IDT on weekdays during working hours. Demographic variables such as age, gender, social situation, baseline mobility, falls and clinical measures such as Clinical Frailty Scale (CFS), 4AT, hand-held dynamometry, calf circumference and functional mobility in ED were recorded. Clinical outcomes were admission to hospital, discharge from ED with onward referral (ambulatory care or community) and discharge from ED with no referral. Ethical approval was obtained and SPSS was used for statistical analysis.

Results

Two hundred and fifty four participants were recruited, 58.3% female, mean age 80.23 (SD 6.56). Median CFS was 4 (IRQ 2.0), range 1–7 with 32.7% (n = 83) considered frail. Sarcopenia prevalence was 89.3% using grip strength and 7.1% using calf circumference. Grip strength predicted frailty even after adjusting for age (p &lt; 0.0001), gender (p &lt; 0.0001) and falls (p = 0.043). Admission to hospital was predicted by major diagnostic category (p = 0.016) and inability to sit to stand independently in ED (p &lt; 0.0001). Seventy percent (n = 179) of participants were discharged from ED, with 27.6% referred to ambulatory care or community services. Onward referral was predicted by frailty (p = 0.016) and falls in the last six months (p = 0.028).

Conclusion

Grip strength in addition to a validated tool such as CFS may assist an experienced IDT in identifying frailty, which can in turn inform decision-making regarding ED disposition and pathways of care for older people. Functional assessment in the ED is also important to determine the need for hospital admission.

Can Cervical Cerclage Prevent Umbilical Cord Prolapse in Patients with Funic Presentation?

Objective:

Umbilical cord prolapse is a rare event complicating 0.17%–0.62% of all pregnancies. Funic presentation is a known risk factor for umbilical cord prolapse. Currently, there is no strategy to prevent umbilical cord prolapse in patients with funic presentation. The novel technique used is placement of late cervical cerclage to create a mechanical barrier and prevent an umbilical cord prolapse.

Methods:

Six patients with a sonographically detected funic presentation were included in the study. Funic presentation was defined as the sonographic presence of the umbilical cord below the presenting part using both transabdominal and transvaginal sonography. Cord prolapse was defined as an umbilical cord seen or palpated below the presenting part. Cervical cerclage was placed in patients with persistent funic presentations, which is the detection of the umbilical cord below the presenting part, on two or more sonograms at least a week apart.

Results:

Cervical cerclages were placed in six patients with funic presentation between 28 and 34 weeks of gestation without immediate complications. All patients were delivered by a cesarean section between 35 and 38 weeks of pregnancy. None experienced umbilical cord prolapse. Funic presentation was confirmed at birth in all cases. Apgar scores varied between 7 and 10.

Conclusion:

It appears that cervical cerclage may be an effective measure to prevent umbilical cord prolapse in cases of known persistent funic presentation.

Reducing nihilism in metastatic pancreatic ductal adenocarcinoma: Treatment, sequencing, and effects on survival outcomes

BACKGROUND

Real-world practice patterns, treatment sequencing, and outcomes in patients with metastatic pancreatic cancer remain unclear. Previous research indicates that the likelihood of patients with metastatic pancreatic cancer receiving or continuing cancer-directed therapy is low-a phenomenon called nihilism. This retrospective, descriptive analysis examined clinical characteristics, treatment patterns, and outcomes for patients with metastatic pancreatic ductal adenocarcinoma (mPDAC).

METHODS

Treatment patterns were examined using electronic health records from the Flatiron Health database covering the period from January 1, 2014, to June 30, 2019. Real-world overall survival [rwOS]) was compared for a subgroup of patients receiving treatment and a matched subgroup not receiving treatment.

RESULTS

Of 7666 patients, 5687 (74.2%) received at least one line of systemic therapy. A greater proportion of patients receiving treatment than not receiving treatment had an initial diagnosis of stage IV disease (68.8% vs 61.2%, respectively). Among patients receiving an initial therapy, fewer than half (38.2%; 2174/5687) received second-line treatment, mostly because they died, and only 34.3% (745/2174) of those receiving second-line treatment advanced to third-line treatment. The rwOS for patients receiving at least one line of systemic therapy was 8.1 months versus 2.6 months for matched patients not receiving treatment (hazard ratio, 0.41; 95% confidence interval, 0.38-0.45; 1470 patients per group).

CONCLUSIONS

Systemic therapy provided significant clinical benefit for patients who were eligible and chose to receive it, particularly when treatment was consistent with guideline recommendations. The large proportion of patients initiating treatment suggests that nihilism with mPDAC is diminishing.

Financial impact of delayed graft function in kidney transplantation

Increased utilization of suboptimal organs in response to organ shortage has resulted in increased incidence of delayed graft function (DGF) after transplantation. Although presumed increased costs associated with DGF are a deterrent to the utilization of these organs, the financial burden of DGF has not been established. We used the Premier Healthcare Database to conduct a retrospective analysis of healthcare resource utilization and costs in kidney transplant patients (n = 12 097) between 1/1/2014 and 12/31/2018. We compared cost and hospital resource utilization for transplants in high-volume (n = 8715) vs low-volume hospitals (n = 3382), DGF (n = 3087) vs non-DGF (n = 9010), and recipients receiving 1 dialysis (n = 1485) vs multiple dialysis (n = 1602). High-volume hospitals costs were lower than low-volume hospitals ($103 946 vs $123 571, P < .0001). DGF was associated with approximately $18 000 (10%) increase in mean costs ($130 492 vs $112 598, P < .0001), 6 additional days of hospitalization (14.7 vs 8.7, P < .0001), and 2 additional ICU days (4.3 vs 2.1, P < .0001). Multiple dialysis sessions were associated with an additional $10 000 compared to those with only 1. In conclusion, DGF is associated with increased costs and length of stay for index kidney transplant hospitalizations and payment schemes taking this into account may reduce clinicians' reluctance to utilize less-than-ideal kidneys.

Impact of prior irinotecan exposure on outcomes of metastatic pancreatic cancer (mPC) patients

667

Background: Published data suggests prior exposure to irinotecan infers a lower likelihood of benefit to liposomal irinotecan. This analysis seeks to expand this hypothesis by evaluating U.S. patterns of care to understand how prior irinotecan therapy impacts outcomes in mPC. Methods: Using the Flatiron Health database, data were extracted and analyzed for treated mPC patients (pts) in the 2L+ setting between Jan 1, 2014 and Jun 30,2019. Therapies of interest included: gemcitabine/ nab-paclitaxel (GnP), FOLFOX, FOLFIRI, FOLFIRINOX (FFX), and liposomal irinotecan/5-FU/LV (nal-IRI). The reference date for each treatment group was the date of treatment initiation. Prior irinotecan was defined as any irinotecan given in a prior regimen in mPC diagnosis. Cox proportional hazard (PH) methods were used to calculate mortality hazard ratios (HRs). HRs were adjusted to account for demographics and relevant covariates. Pts with prior exposure to irinotecan were used as the reference population for the Cox PH model (an HR < 1 represents worse survival for exposed pts relative to the unexposed). Results: N = 1,978 were included in this analysis. The median age at treatment initiation, and the proportion of pts previously treated with irinotecan are reported in table. Crude mortality was: GnP pts, HR 0.93 [95% CI: 0.77 – 1.11, adjusted HR, 0.94, 0.76 – 1.15]; nal-IRI pts, HR 0.81 [0.64 – 1.02, adjusted HR: 0.89, 0.67 – 1.19]; HR for FOLFOX was 0.55 [0.38 – 0.78, adjusted HR: 0.51, 0.33 – 0.79]. HRs are not reported for FFX and FOLFIRI due to the small numbers with prior irinotecan exposure. Conclusions: In mPC, prior irinotecan treatment may not preclude benefit from later treatment with nal-IRI or GnP as can be seen from the adjusted and unadjusted HRs. These findings are hypothesis-generating and need to be considered in the context of wide CI’s, retrospective nature and the limitations of such data. Further study is required to understand the less-favorable signal observed with FOLFOX and prior irinotecan.[Table: see text]

A Cluster of Hepatitis A Viral Infection in HSE South

Hepatitis A is an acute viral infection of the liver that produces clinical features ranging from asymptomatic infection to fulminant hepatitis¹. The authors report a cluster of 5 serologically-confirmed cases of acute Hepatitis A Virus (HAV), all serum IgM positive for HAV Genotype 1A. This is on a background of only 2 other cases notified to HSE-South in 2016 to date, both travel related. There was a considerable delay in notification in two out of 5 cases. This case report highlights the importance of prompt notification of Hepatitis A, as timely notification would have facilitated prompt contact vaccination and might well have prevented illness in two subsequent household contacts.

High uptake of hepatitis C virus treatment in HIV/hepatitis C virus co-infected patients attending an integrated HIV/hepatitis C virus clinic

Hepatitis C virus (HCV) is a major cause of liver disease in HIV-infected patients. The HCV treatment outcomes and barriers to HCV referral were examined in a centre with a HIV/HCV co-infection clinic. Patients who were antibody positive for both HIV and HCV between 1987 and January 2009 were identified. A retrospective chart review was undertaken. Multivariate analysis was performed to assess predictors of HCV clinic referral. Data were collected on 386 HIV/HCV patients; 202/386 had been referred to the co-infection clinic and 107/202 had HCV treatment. In addition, 29/202 were undergoing pretreatment work-up. Overall sustained virologic response (SVR) was 44%; SVR was equivalent in those who acquired HIV/HCV infection from intravenous drug use (IDU) and others. On multivariate analysis, patients who missed appointments, were younger, with active IDU and advanced HIV and who were not offered HCV treatment were less likely to be referred to the clinic. Patients attending the clinic were more likely to have been screened for hepatocellular carcinoma than those attending the general HIV service. Two-thirds of patients referred to the clinic had engaged with the HCV treatment programme. Dedicated co-infection clinics lower the threshold for treatment and improve management of liver disease in co-infected patients.

UNC5A promotes neuronal apoptosis during spinal cord development independent of netrin-1

In addition to their role as chemorepellent netrin-1 receptors, UNC5 proteins may mediate cell death because they induce apoptosis in cultured cells. To test this in vivo, we generated Unc5a (formerly Unc5h1) knockout mice and found that this deletion decreased apoptosis and increased the number of neurons in the spinal cord. In contrast, loss of netrin-1 (Ntn1) did not affect the amount of apoptosis, suggesting that NTN1 is not required for neuronal apoptosis in vivo.

The effectiveness of parenting programmes facilitated by health visitors

AIM OF THE STUDY

This study was designed to evaluate the effectiveness of parenting programmes that are facilitated by health visitors and offer practical and emotional support to parents in the Down Lisburn Trust, Northern Ireland.

METHODS

All parents (n=78) taking part were given a self-administered questionnaire both before and after attending a 'Positive Parenting' programme. The questionnaire contained items gathering demographic information, standardized measures of clinical anxiety/depression, personality states and coping styles and participants' experience of being a parent and what they wanted from the parenting group. Two items adapted from the Parent Stress Index looked at participants' ratings of themselves as parents, and if they enjoyed this role.

STATISTICAL ANALYSIS

All statistics were computed using the SPSS for Windows (version 7) statistical package. The parametric paired-samples t-test was used with the ratio data generated by the Hospital Anxiety and Depression Scale (HADS) questionnaire. It is used to test the difference between the means of the pre and postsets of scores for significance. The nonparametric Wilcoxon test was used to find if there was a significant difference between the pre and postprogramme related samples by ranking the means. The Wilcoxon was chosen firstly because the data were ordinal in nature, hence it cannot be assumed that the findings follow the normal curve of distribution and secondly because it cannot be assumed that the data have homogeneity of variance.

FINDINGS

At the end of the 8-week parenting programme, findings demonstrated significant statistically reduced levels of clinical anxiety and depression. Parents demonstrated an increase in more positive ratings of personality states such as not shouting at their children and being more calm and energetic at the end of the programme. Adaptive problem focused coping strategies were reported as being used more often subsequent to the programme, although some of the less adaptive emotion focused strategies had also increased in use. However, no change was evident in their ratings of how good a parent they were or if they enjoyed being a parent.

CONCLUSIONS

Health visitors have the skills and are in the position to be preventative agents of inadequate parenting, and advocates of positive parenting. Factors relevant to the realm of positive parenting are highlighted as possible avenues for future research.

Risk of chronic arthropathy among women after rubella vaccination. Vaccine Safety Datalink Team

CONTEXT

A review by the Institute of Medicine found a possible relationship between rubella vaccination and chronic arthritis among women.

OBJECTIVE

To evaluate the risk of persistent joint and neurologic symptoms in rubella seronegative women subsequently vaccinated with RA 27/3 rubella vaccine.

DESIGN

Retrospective cohort study based on computerized laboratory data and medical record review. Records were reviewed for symptoms occurring within 2 years before and after the date of serological testing and to identify vaccinees. Possible cases were evaluated by a rheumatologist blinded to serological findings and vaccination status.

SETTING

Large health maintenance organization in northern California.

PATIENTS

Women aged 15 to 59 years serotested for rubella during 1990 with continuous health plan membership for 2 years before and after the date of their serological test. Seronegative women immunized within 1 year of serotesting (n=971) were defined as exposed. Primary comparison groups included all unvaccinated, seronegative women (n=924) and randomly selected seropositive, unvaccinated women (n=2421) matched to exposed subjects on serological test date and age (+/-3 years).

MAIN OUTCOME MEASURES

Prevalence and incidence of chronic joint and neurologic symptoms during 1-year follow-up period stratified by age and serological findings, immunization, and postpartum status.

RESULTS

No significantly increased risk was associated with receipt of rubella vaccine for any outcome except for prevalence of carpal tunnel syndrome in vaccinated women at least 30 years old compared with seropositive, unvaccinated women (2.9% vs 1.4%; P=.03). A total of 34 women had onset of conditions within the 1-year follow-up period; 9 of these were in the group of seronegative, immunized women, of whom 6 had onset of symptoms within 6 weeks of vaccination. Among these 6 women, symptoms included transient arthritis or arthralgias (<6 weeks duration) in 4 women, arthralgia of indeterminate chronicity in 1 woman, and carpal tunnel syndrome in 1 woman. Postpartum women across all groups were less likely to be seen for nontraumatic arthropathies than nonpostpartum women (4.5% vs 7.2%, P=.08 in vaccinated women; 4.8% vs 8.1%, P=.09 in seronegative controls; and 4.8% vs 10.0%, P=.01 in seropositive controls).

CONCLUSIONS

In this large retrospective cohort analysis there was no evidence of any increased risk of new onset chronic arthropathies or neurologic conditions in women receiving the RA 27/3 rubella vaccine. These data support the continued vaccination of rubella-susceptible women to reduce the risk of congenital rubella syndrome.

Advanced neonatal nurse practitioners in the United Kingdom: where are they and what do they do?

The former Wessex region was the first in England to institute an advanced neonatal nurse practitioner (ANNP) course within the United Kingdom (UK), and at the time of this survey three cohorts had completed the course. The role has been developed over several years in the North American health care system, where it has been shown that ANNPs have the ability to perform as competently and efficiently as junior doctors. It is a major development both in neonatal care and nursing. Following a review of the literature on ANNPs, this paper details the distribution of ANNPs in the UK, and reports on a survey undertaken by the authors, which examined the function, clinical grading and source of funding of ANNPs, as well as examining the ANNPs' view of their role and challenges they have encountered.

Hemodynamic comparison of mild and severe preeclampsia: concept of stroke systemic vascular resistance index

Our purpose was to compare baseline hemodynamic parameters of mild and severe preeclampsia. Patients admitted to the Medical University Labor and Delivery Unit with the diagnosis of preeclampsia who had not received prior antihypertensive or magnesium sulfate therapy were recruited for noninvasive hemodynamic monitoring with thoracic electrical bioimpedance. After stabilization in the lateral recumbent position, hemodynamic monitoring was begun. Baseline hemodynamic parameters, mean arterial pressure (MAP), heart rate (HR), systemic vascular resistance index (SVRI), cardiac index (CI), and stroke index (SI) were recorded. Stroke systemic vascular resistance index (SSVRI), the resistance imposed by vasculature on each beat of the heart, was calculated for each patient by multiplying SVRI by HR. For statistical analysis, unpaired Student's t-tests (two-tailed) were utilized (P < 0.01). Forty-one preeclamptic patients (20 mild, 21 severe) were enrolled. Mean gestational age of severe patients was 32.2 +/- 4.0 and of mild patients was 37.0 +/- 3.5. MAP, SBP, diastolic blood pressure, HR, and SSVRI were higher in the severe group. SVRI, CI, cardiac output, and SI did not differ significantly between groups. Severe preclampsia appears to be a more intensely vasoconstricted state than mild preeclampsia. Although CI is inversely proportional to SVRI, increased HR in severe preeclampsia prevents this expected decrease in cardiac output.

Requirements for hypertext applications: the why, what and how approach

The present paper presents a simple task description procedure for the use of text, aimed at supporting human factors input to the specification stage of hypertext and electronic document design. The need for such a technique is outlined and the approach is described in the context of designing hypertext versions of software manuals. Applications and limitations of the procedure are discussed.

Nursing Curricula in the 80s- The Impact of Nursing Diagnosis

Both theory in nursing diagnosis and practice in diagnostic reasoning are imperative to prepare graduates to utilize nursing diagnosis at a level consistent with established standards. As nurses and students speak "the language of nursing diagnosis," they do so because they have learned to think "nursing diagnosis" and it becomes increasingly difficult to remember what nursing was like without it and to communicate with those who do not use it.

Systemic lupus erythematosus--a medical and social profile

The social functioning of 120 patients (114 women) with systemic lupus erythematosus (SLE) was studied. The proportion of Chinese, Japanese and Native Indians was greater than expected. Familial incidences of SLE (12.5%) and rheumatoid arthritis (17.5%) were high. Sixty-one women had 76 pregnancies after the onset of SLE; although fetal wastage was common, outcomes were otherwise satisfactory. Social difficulties worsened with disease exacerbations, drug reactions and delay in diagnosis. Thirty-three percent completed their education after the onset of SLE. Sixty-three percent with a work history were employed and 52% were totally or partially self-supporting. Patients experienced problems with self-image (20%), sexual functioning (4%) and lifestyle (17%). SLE was not a barrier to marriage or a primary cause of divorce: 40% married after the onset of SLE and 12.5% had a history of divorce. In summary, SLE patients can function well socially; it is imperative to recognize the difficulties and provide support.