Risk of ischemic stroke associated with direct oral anticoagulants discontinuation on patients with non-valvular atrial fibrillation

INTRODUCTION

Although direct oral anticoagulants' (DOACs) prescriptions have experienced immense growth in the last decade, the proportion of discontinuers is still common yielding an increased risk of ischemic stroke (IS) onset.

AIMS

We aimed to estimate the association between DOACs discontinuation and risk of IS among patients with non-valvular atrial fibrillation (NVAF).

METHODS

We used data from a cohort of new DOACs users, followed patients from the first DOAC prescription date up to IS (index date) and conducted a nested case-control analysis using conditional logistic regression. Adjusted odds ratios, 95% confidence intervals were calculated for discontinuation of DOACs (current use compared with past use). The latter, subdivided among those stopping treatment 3 to 2 months and 6 and 3 months prior to index date. The effect of naïve current users against IS onset compared with non-naïve current users was also evaluated.

RESULTS

DOACs discontinuation showed an OR of IS of 1.47 (95% CI: 1.02-2.12); estimates were 2.51 (95% CI: 1.84-3.42) for whom discontinued treatment within months 3 and 2 and 1.43 (95% CI: 0.96-2.13) for those between months 6 and 3 prior to index date. Analyzing DOACs individually, risk of IS associated with past users compared with current users: 1.98 (95% CI: 1.25-3.12) for apixaban, 1.38 (95% CI: 0.40-4.72) for edoxaban, 1.98 (95% CI: 1.24-2.65) for dabigatran and 1.87 (95% CI: 1.26-2.76) for rivaroxaban. Similar results were found when stratified by naïve and non-naïve users.

CONCLUSIONS

DOACs' discontinuation is associated with higher risk of IS, especially in the second and third months following interruption.

Blockade Antibody Responses in Human Subjects Challenged with a New Snow Mountain Virus Inoculum

Background

Noroviruses (NoVs) are a leading cause of non-bacterial gastroenteritis in young children and adults worldwide. Snow Mountain Virus (SMV) is the prototype of NoV GII genotype 2 (GII.2) that has been developed as a viral model for human challenge studies, an important tool for studying pathogenesis and immune response of NoV infections and for evaluating NoV vaccine candidates. Previous studies have identified blockade antibodies that block the binding of NoV virus-like particles (VLPs) to histo-blood group antigens (HBGAs) as a surrogate for neutralization in human Norwalk virus and GII.4 infections but little is known about SMV blockade antibodies.

Methods

In this secondary data analysis study, blockade antibodies were characterized in pre-challenge and post-challenge serum samples from human subjects challenged with a new SMV inoculum. The correlation between blockade antibody geometric mean antibody titers (GMTs) and SMV-specific serum IgG/IgA GMTs were examined after stratifying the subjects by infection status. A linear mixed model was applied to test the association between HBGA blockade antibody concentrations and post-challenge days accounting for covariates and random effects.

Results

Laboratory results from 33 SMV inoculated individuals were analyzed and 75.7% (25/33) participants became infected. Serum SMV-specific blockade antibodies, IgA, and IgG were all significantly different between infected and uninfected individuals beginning day 15 post-challenge. Within infected individuals, a significant correlation was observed between both IgG and IgA and blockade antibody concentration as early as day 6 post-challenge. Analysis of blockade antibody using the linear mixed model showed that infected individuals, when compared to uninfected individuals, had a statistically significant increase in blockade antibody concentrations across the post-challenge days. Among the post-challenge days, blockade antibody concentrations on days 15, 30, and 45 were significantly higher than those observed pre-challenge. The intraclass correlation coefficient (ICC) analysis indicated that the variability of blockade antibody titers is more observed between individuals rather than within subjects.

Conclusions

These results indicate that HBGA-blockade antibody GMTs are generated after SMV challenge and the blockade antibodies were still detectable at day 45 post-challenge. These data indicate that the second-generation of SMV inoculum is highly effective.

Blockade Antibody Responses in Human Subjects Challenged with a New Snow Mountain Virus Inoculum

Background

Noroviruses (NoVs) are a leading cause of non-bacterial gastroenteritis in young children and adults worldwide. Snow Mountain Virus (SMV) is the prototype of NoV GII genotype 2 (GII.2) that has been developed as a viral model for human challenge models, an important tool for studying pathogenesis and immune response of NoV infections and for evaluating NoV vaccine candidates. Previous studies have identified blockade antibodies that block the binding of NoV virus-like particles (VLPs) to histo-blood group antigens (HBGAs) as a surrogate for neutralization in human Norwalk virus and GII.4 infections but little is known about SMV blockade antibodies.

Methods

In this secondary data analysis study, blockade antibodies were characterized in pre-challenge and post-challenge serum samples from human subjects challenged with a new SMV inoculum. The correlation between blockade antibody geometric mean antibody titers (GMTs) and SMV-specific serum IgG/IgA GMTs were examined after stratifying the subjects by infection status. A linear mixed model was applied to test the association between HBGA blockade antibody concentrations and post-challenge days accounting for covariates and random effects.

Results

Laboratory results from 33 SMV inoculated individuals were analyzed and 75.7% (25/33) participants became infected. Serum SMV-specific blockade antibodies, IgA, and IgG were all significantly different between infected and uninfected individuals beginning day 15 post-challenge. Within infected individuals, a significant correlation was observed between both IgG and IgA and blockade antibody concentration as early as day 6 post-challenge. Analysis of blockade antibody using the linear mixed model showed that infected individuals, when compared to uninfected individuals, had a statistically significant increase in blockade antibody concentrations across the post-challenge days. Among the post-challenge days, blockade antibody concentrations on days 15, 30, and 45 were significantly higher than those observed pre-challenge. The intraclass correlation coefficient (ICC) analysis indicated that the variability of blockade antibody titers is more observed between individuals rather than observations within subjects.

Conclusions

These results indicate that HBGA-blockade antibody GMTs are generated after SMV challenge and the blockade antibodies were still detectable at day 45 post-challenge. These data indicate that the second generation of SMV inoculum is highly effective.

Persistent SARS-CoV-2-specific immune defects in kidney transplant recipients following third mRNA vaccine dose

Kidney transplant recipients (KTRs) show poorer response to SARS-CoV-2 mRNA vaccination, yet response patterns and mechanistic drivers following third doses are ill-defined. We administered third monovalent mRNA vaccines to n = 81 KTRs with negative or low-titer anti-receptor binding domain (RBD) antibody (n = 39 anti-RBDNEG; n = 42 anti-RBDLO), compared with healthy controls (HCs, n = 19), measuring anti-RBD, Omicron neutralization, spike-specific CD8+%, and SARS-CoV-2-reactive T cell receptor (TCR) repertoires. By day 30, 44% anti-RBDNEG remained seronegative; 5% KTRs developed BA.5 neutralization (vs 68% HCs, P < .001). Day 30 spike-specific CD8+% was negative in 91% KTRs (vs 20% HCs; P = .07), without correlation to anti-RBD (rs = 0.17). Day 30 SARS-CoV-2-reactive TCR repertoires were detected in 52% KTRs vs 74% HCs (P = .11). Spike-specific CD4+ TCR expansion was similar between KTRs and HCs, yet KTR CD8+ TCR depth was 7.6-fold lower (P = .001). Global negative response was seen in 7% KTRs, associated with high-dose MMF (P = .037); 44% showed global positive response. Of the KTRs, 16% experienced breakthrough infections, with 2 hospitalizations; prebreakthrough variant neutralization was poor. Absent neutralizing and CD8+ responses in KTRs indicate vulnerability to COVID-19 despite 3-dose mRNA vaccination. Lack of neutralization despite CD4+ expansion suggests B cell dysfunction and/or ineffective T cell help. Development of more effective KTR vaccine strategies is critical. (NCT04969263).

Durability of immune responses to mRNA booster vaccination against COVID-19

BackgroundMaintaining durable immunity following vaccination represents a major challenge, but whether mRNA booster vaccination improves durability is unknown.MethodsWe measured antibody responses in 55 healthy adults, who received a booster dose of the Pfizer-BioNTech or Moderna vaccine against SARS-CoV-2 and calculated the half-life of the antibody titers. We also measured memory B and T cell responses in a subset of 28 participants. In 13 volunteers who received a second booster vaccine, we measured serum antibody titers and memory B and T cell responses.ResultsThe booster (third immunization) dose at 6 to 10 months increased the half-life of the serum-neutralizing antibody (nAb) titers to 76 days from 56 to 66 days after the primary 2-dose vaccination. A second booster dose (fourth immunization) a year after the primary vaccination further increased the half-life to 88 days. However, despite this modestly improved durability in nAb responses against the ancestral (WA.1) strain, there was a loss of neutralization capacity against the Omicron subvariants BA.2.75.2, BQ.1.1, and XBB.1.5 (48-, 71-, and 66-fold drop in titers, respectively, relative to the WA.1 strain). Although only 45% to 65% of participants demonstrated a detectable nAb titer against the newer variants after the booster (third dose), the response declined to below the detection limit in almost all individuals by 6 months. In contrast, booster vaccination induced antigen-specific memory B and T cells that persisted for at least 6 months.ConclusionThe durability of serum antibody responses improves only marginally following booster immunizations with the Pfizer-BioNTech or Moderna mRNA vaccines.

Background rates of 41 adverse events of special interest for COVID-19 vaccines in 10 European healthcare databases - an ACCESS cohort study

BACKGROUND

In May 2020, the ACCESS (The vACCine covid-19 monitoring readinESS) project was launched to prepare real-world monitoring of COVID-19 vaccines. Within this project, this study aimed to generate background incidence rates of 41 adverse events of special interest (AESI) to contextualize potential safety signals detected following administration of COVID-19 vaccines.

METHODS

A dynamic cohort study was conducted using a distributed data network of 10 healthcare databases from 7 European countries (Italy, Spain, Denmark, The Netherlands, Germany, France and United Kingdom) over the period 2017 to 2020. A common protocol (EUPAS37273), common data model, and common analytics programs were applied for syntactic, semantic and analytical harmonization. Incidence rates (IR) for each AESI and each database were calculated by age and sex by dividing the number of incident cases by the total person-time at risk. Age-standardized rates were pooled using random effect models according to the provenance of the events.

FINDINGS

A total number of 63,456,074 individuals were included in the study, contributing to 211.7 million person-years. A clear age pattern was observed for most AESIs, rates also varied by provenance of disease diagnosis (primary care, specialist care). Thrombosis with thrombocytopenia rates were extremely low ranging from 0.06 to 4.53/100,000 person-years for cerebral venous sinus thrombosis (CVST) with thrombocytopenia (TP) and mixed venous and arterial thrombosis with TP, respectively.

INTERPRETATION

Given the nature of the AESIs and the setting (general practitioners or hospital-based databases or both), background rates from databases that show the highest level of completeness (primary care and specialist care) should be preferred, others can be used for sensitivity. The study was designed to ensure representativeness to the European population and generalizability of the background incidence rates.

FUNDING

The project has received support from the European Medicines Agency under the Framework service contract nr EMA/2018/28/PE.

Durability of immune responses to the booster mRNA vaccination against COVID-19

Waning immunity to vaccination represents a major challenge in vaccinology. Whether booster vaccination improves the durability of immune responses is unknown. Here we show, using a cohort of 55 adult vaccinees who received the BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) vaccine against SARS-CoV-2, that a booster (i.e., 3 ^rd immunization) dose at 6 - 10 months increased the half-life of serum neutralizing antibody (nAb) titers to 76 days from 56 - 66 days estimated after the primary two-dose vaccination series. A second booster dose (i.e., 4 ^th immunization) more than a year after the primary vaccination increased the half-life further to 88 days. However, despite this modestly improved durability in nAb responses against the Wuhan strain, there was a loss in neutralization capacity against Omicron subvariants, especially the recently emerged variants, BA.2.75.2 and BQ.1.1 (35 and 50-fold drop in titers respectively, relative to the ancestral (WA.1) strain. While only 55 â€" 65% of participants demonstrated a detectable nAb titer against the newer variants after the booster (3 ^rd dose), the response declined to below the detection limit in almost all individuals by 6 months. Notably, even against BA.1 and BA.5, the titers declined rapidly in a third of the vaccinees and were below the detection limit at 6 months. In contrast, booster vaccination induced antigen-specific memory B and T cells that persisted for at least 6 months. Collectively, our data show that the durability of immune responses improves following subsequent booster immunizations; however, the emergence of immune evasive variants reduces the effectiveness of booster doses in preventing infection.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008-2015)

Aims: To describe and compare the adherence to different direct oral anticoagulants (DOACs) in eight European databases representing six countries. Methods: Longitudinal drug utilization study of new users (≥18 years) of DOACs (dabigatran, rivaroxaban, apixaban) with a diagnosis of non-valvular atrial fibrillation (2008-2015). Adherence was examined by estimating persistence, switching, and discontinuation rates at 12 months. Primary non-adherence was estimated in BIFAP and SIDIAP databases. Results: The highest persistence rate was seen for apixaban in the CPRD database (81%) and the lowest for dabigatran in the Mondriaan database (22%). The switching rate for all DOACs ranged from 2.4 to 13.1% (Mondriaan and EGB databases, respectively). Dabigatran had the highest switching rate from 5.0 to 20.0% (Mondriaan and EGB databases, respectively). The discontinuation rate for all DOACs ranged from 16.0 to 63.9% (CPRD and Bavarian CD databases, respectively). Dabigatran had the highest rate of discontinuers, except in the Bavarian CD and AOK NORDWEST databases, ranging from 23.2 to 64.6% (CPRD and Mondriaan databases, respectively). Combined primary non-adherence for examined DOACs was 11.1% in BIFAP and 14.0% in SIDIAP. There were differences in population coverage and in the type of drug data source among the databases. Conclusion: Despite the differences in the characteristics of the databases and in demographic and baseline characteristics of the included population that could explain some of the observed discrepancies, we can observe a similar pattern throughout the databases. Apixaban was the DOAC with the highest persistence. Dabigatran had the highest proportion of discontinuers and switchers at 12 months in most databases (EMA/2015/27/PH).

CRISPR-Cas9 Ribonucleoprotein-Mediated Genomic Editing in Mature Primary Innate Immune Cells

CRISPR genome engineering has become a powerful tool to functionally investigate the complex mechanisms of immune system regulation. While decades of work have aimed to genetically reprogram innate immunity, the utility of current approaches is restricted by poor knockout efficiencies or limited specificity for mature cell lineages in vivo. Here, we describe an optimized strategy for non-viral CRISPR-Cas9 ribonucleoprotein (cRNP) genomic editing of mature primary mouse innate lymphocyte cells (ILCs) and myeloid lineage cells that results in an almost complete loss of single or double target gene expression from a single electroporation. Furthermore, we describe in vivo adoptive transfer mouse models that can be utilized to screen for gene function during viral infection using cRNP-edited naive natural killer (NK) cells and bone-marrow-derived conventional dendritic cell precursors (cDCPs). This resource will enhance target gene discovery and offer a specific and simplified approach to gene editing in the mouse innate immune system.

Systems biological assessment of immunity to mild versus severe COVID-19 infection in humans

Coronavirus disease 2019 (COVID-19) represents a global crisis, yet major knowledge gaps remain about human immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We analyzed immune responses in 76 COVID-19 patients and 69 healthy individuals from Hong Kong and Atlanta, Georgia, United States. In the peripheral blood mononuclear cells (PBMCs) of COVID-19 patients, we observed reduced expression of human leukocyte antigen class DR (HLA-DR) and proinflammatory cytokines by myeloid cells as well as impaired mammalian target of rapamycin (mTOR) signaling and interferon-α (IFN-α) production by plasmacytoid dendritic cells. By contrast, we detected enhanced plasma levels of inflammatory mediators-including EN-RAGE, TNFSF14, and oncostatin M-which correlated with disease severity and increased bacterial products in plasma. Single-cell transcriptomics revealed a lack of type I IFNs, reduced HLA-DR in the myeloid cells of patients with severe COVID-19, and transient expression of IFN-stimulated genes. This was consistent with bulk PBMC transcriptomics and transient, low IFN-α levels in plasma during infection. These results reveal mechanisms and potential therapeutic targets for COVID-19.

Nesting biology and life history of the dung beetle Onthophagus lecontei (Coleoptera: Scarabaeinae)

Obtaining knowledge about a species’ life history and reproductive behaviour is fundamental for understanding its biology, ecology, and potential role in ecosystem services. Here, we focused on the dung beetle species Onthophagus lecontei. Adults were collected in the field and then confined to terrariums, where they were supplied with semi-fresh domestic goat dung (Capra aegagrus Erxleben, 1777). After being paired (26 pairs), the nesting behavior of beetles was observed under laboratory conditions and the preimaginal development of individuals obtained from mating (from the deposition of the egg until the emergence of the adult) was described. Their nesting behavior was found to be characteristic of what is known as pattern I, which comprises building of brood masses, oviposition of a single egg in each brood mass, development of three larval instars, construction of a pupation chamber, pupal stage and adult emergence. Both sexes were involved in the handling of dung, tunnel construction, and mass nest elaboration. Pairs built from one to seven brood masses. The pre-nesting period (feeding) lasted 16 days; the egg stage two days, the larval period 22 days; the pupal period 11 days and the imagoes four days, after which the adults emerged. Our results are discussed and compared with other species in the genus. However, our knowledge of this dung beetle is still limited, and further studies are required in all areas of its biology.

Effect of using different types of animal dung for feeding and nesting by the dung beetle Onthophagus lecontei (Coleoptera: Scarabaeinae)

Onthophagus lecontei Harold, 1871 is an American dung beetle that feeds on the dungs of a variety of species, perhaps owing to hitherto unknown differences in their effect on its development and survival. We tested whether using different types of dung (exotic and native) for feeding and nesting affects O. lecontei’s progeny. Adult beetles from the field were randomly paired and assigned to horse (Equus ferus Boddaert, 1785), goat (Capra hircus aegagrus Erxleben, 1777; domestic), or wild rabbit (Sylvilagus cunicularius (Waterhouse, 1848); native, endemic) dung under laboratory conditions. The number, mass, and volume of their brood masses, the number of emerged beetles, adult size, and duration of preimaginal stages (egg, larva, and pupa) were evaluated. There were differences for all variables: O. lecontei reared in wild rabbit dung produced more progeny, more brood masses, and larger adult beetles, and offspring remained in each preimaginal stage for a shorter period of time. Onthophagus lecontei is able to feed and nest using all three types of dung, but wild rabbit dung is the most favorable for its development. This suggests the existence of a long-standing association between O. lecontei and this native rabbit and the optional relationships with introduced herbivores; plasticity in reproductive behavior that may be useful when the optimal resource is not available.

Incidence rates and trends of hip/femur fractures in five European countries: comparison using e-healthcare records databases

Hip fractures represent a major public health challenge worldwide. Multinational studies using a common methodology are scarce. We aimed to estimate the incidence rates (IRs) and trends of hip/femur fractures over the period 2003-2009 in five European countries. The study was performed using seven electronic health-care records databases (DBs) from Denmark, The Netherlands, Germany, Spain, and the United Kingdom, based on the same protocol. Yearly IRs of hip/femur fractures were calculated for the general population and for those aged ≥50 years. Trends over time were evaluated using linear regression analysis for both crude and standardized IRs. Sex- and age-standardized IRs for the UK, Netherlands, and Spanish DBs varied from 9 to 11 per 10,000 person-years for the general population and from 22 to 26 for those ≥50 years old; the German DB showed slightly higher IRs (about 13 and 30, respectively), whereas the Danish DB yielded IRs twofold higher (19 and 52, respectively). IRs increased exponentially with age in both sexes. The ratio of females to males was ≥2 for patients aged ≥70-79 years in most DBs. Statistically significant trends over time were only shown for the UK DB (CPRD) (+0.7% per year, P < 0.01) and the Danish DB (-1.4% per year, P < 0.01). IRs of hip/femur fractures varied greatly across European countries. With the exception of Denmark, no decreasing trend was observed over the study period.

Risk factors for intestinal ischaemia among patients registered in a UK primary care database: a nested case-control study

BACKGROUND

Intestinal ischaemia, including ischaemic colitis and acute mesenteric ischaemia, causes significant morbidity and mortality. Few population-based studies have estimated incidence and potential risk factors for this disease.

AIMS

To estimate the incidence of intestinal ischaemia and identify the associated risk factors in cohorts: (i) patients with irritable bowel syndrome and/or chronic constipation (IBS/CC/both), (ii) individuals free of these conditions.

METHODS

Population-based case-control analysis nested in a cohort of patients with first ever recorded diagnosis of IBS/CC/both and a cohort free of these conditions from general population using the General Practice Research Database.

RESULTS

Of 78 cases of intestinal ischaemia, 71 were from general population, seven from the IBS/CC/both cohort. Incidence rate of intestinal ischaemia in IBS/CC/both patients vs. general population was 4.49:1.09 per 100,000 person-years; age- and gender-adjusted incidence rate ratio (95% CI) was 2.7 (1.2-5.9). Inflammatory bowel disease and heart failure showed an association with ischaemic colitis [OR (95% CI): 4.2 (0.5-38.4) and 5.6 (2.2-14.1)], but none with acute mesenteric ischaemia. Diabetes and prior cardiovascular surgery were associated with higher risk of acute mesenteric ischaemia, but showed no association with ischaemic colitis.

CONCLUSIONS

Results suggest that different risk factors are associated with acute mesenteric ischaemia and ischaemic colitis. However, due to small number of patients, associations should be carefully interpreted.

Non-steroidal anti-inflammatory drugs and risk of first hospital admission for heart failure in the general population

OBJECTIVES

To estimate the risk of a first hospital admission for heart failure (HF) associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Cohort study with a nested case-control analysis based on the UK General Practice Research Database. Overall, 1396 cases of first hospital admission for non-fatal HF were identified (January 1997 to December 2000) and compared with a random sample of 5000 controls.

RESULTS

The incidence rate was 2.7/1000 person years. Prior clinical diagnosis of HF was the main independent risk factor triggering a first HF hospitalisation (relative risk 7.3, 95% confidence interval (CI) 6.1 to 8.8). The risk of a first hospital admission for HF associated with current use of NSAIDs was 1.3 (95% CI 1.1 to 1.6) after controlling for major confounding factors. No effects of dose and duration were found. The relative risk in current users of NSAIDs with prior HF was 8.6 (95% CI 5.3 to 13.8) compared with patients who did not use NSAIDs and without prior clinical diagnosis of HF.

CONCLUSION

Use of NSAIDs was associated with a small increase in risk of a first hospitalisation for HF. In patients with prior clinical diagnosis of HF, the use of NSAIDs may lead to worsening of pre-existing HF that triggers their hospital admission. This increased risk, although small, may result in considerable public health impact, particularly among the elderly.

LRRK2 mutations are a common cause of Parkinson's disease in Spain

Pathogenic mutations in the leucine-rich repeat kinase 2 gene (LRRK2; PARK8) have been implicated in autosomal dominant, late-onset parkinsonism. The LRRK2 6055G > A (G2019S) mutation is the most common reported to date, and has been observed in a number of different European populations. So far, only the LRRK2 4321C > G (R1441G) mutation has been identified in the Spanish population. Herein we have assessed the frequency of G2019S in a referral-based series of 225 patients with Parkinson's disease (PD) from the region of Asturias, Northern Spain. The mutant allele was identified in five (2.7%) of the sporadic late-onset patients and was not present in control subjects. All carriers displayed genetic profiles consistent with the same haplotype, as previously reported for Lrrk2 G2019S-positive subjects. None of these patients presented with a family history of parkinsonism at the time of diagnosis. Thus, approximately 5% of sporadic patients with PD from the North of Spain have either Lrrk2 G2019S or R1441G substitutions.

Determinants of health system delay among confirmed tuberculosis cases in Spain

BACKGROUND

Health system delay (HSD) is an important issue in tuberculosis (TB) control. This report investigates HSD and associated factors in a cohort of Spanish culture-confirmed TB patients.

METHODS

Data were collected from clinical records. Using logistic regression with two different cut-off points to define HSD (median and 75th percentile), adjusted odds ratios were used to estimate the association between HSD and different variables.

RESULTS

A total of 5184 culture-confirmed TB cases were included. Median and 75th percentile HSD were 6 and 25 days respectively. HSD significantly greater than the median was associated with: age >44 years, past or present intravenous drug use, diagnosis at a primary-care centre, prior preventive therapy, positive histology, request for drug-sensitivity testing, presence of silicosis or neoplasia in addition to TB, presence of non-TB related symptoms, and gastrointestinal site. HSD greater than the 75th percentile was related to the same variables, with the exception of diagnosis at a primary-care centre, positive histology, silicosis, non-TB-related symptoms and gastrointestinal site, for which the association disappeared; in contrast, an association with female gender emerged.

CONCLUSION

Despite free health care being universally available in Spain, there are some groups of TB patients whose treatment is unduly delayed.

Determinants of patient delay among tuberculosis cases in Spain

BACKGROUND

Patient delay was investigated in a cohort of TB patients identified from May 1996 until April 1997 in 13 Autonomous Regions in Spain. The study covered almost 67% of the total Spanish population.

METHODS

Data were collected from clinical records. Using unconditional logistic regression with two different cut-off points to define 'patient delay' (the median and 75th percentile), the association between patient delay and different factors was estimated.

RESULTS

A total of 7,037 cases were included. Median and 75th percentile delays were 22 and 57 days respectively. Factors associated with patient delay greater than the median (p<0.05) were: non-respiratory symptoms of TB and age over 14 years, although the effect of age was not linear. Furthermore, an interaction was observed between intravenous drug user (IDU) and HIV status, in that, whereas patient delay was greater in IDUs than in non-IDUs among cases whose HIV status was either negative or unknown, among HIV-positive patients no such IDU-related differences were in evidence. Factors associated with extreme patient delay (greater than the 75th percentile) were essentially the same, but the above-described interaction disappeared, with IDU status showing no direct effect. In addition, likelihood of extreme patient delay increased in the case of alcoholism and female gender and decreased in the case of chronic renal failure, corticoid treatment, prison inmates and residents of old age homes.

CONCLUSION

Although there is a universally enjoyed right to health care in Spain, some groups of TB patients could nevertheless be experiencing problems in seeking medical attention.

Respiratory medications and risk of asthma death

BACKGROUND

The effect of respiratory medications on risk of asthma death in the UK was studied using the General Practice Research Database.

METHODS

A total of 96 258 individuals with a diagnosis of asthma were identified, 43 of whom had died as a result of their asthma. For each case 20 controls were selected. Relative risk (RR) estimates and 95% confidence intervals (CI) were computed for each respiratory drug category controlling for effects of age, sex, body mass index, smoking, frequency of visits to the GP, hospital admissions for asthma, and visits to a specialist.

RESULTS

The strongest associations were found for at least 13 prescriptions of short acting beta agonists during the previous year (RR=51.6, 95% CI 7.9 to 345) and 7-12 prescriptions of short acting beta agonists (RR=16.2, 95% CI 2.6 to 101). Short acting beta agonists and inhaled steroids tended to be prescribed most frequently to the same patients. In patients who received more than one prescription per month of short acting beta agonists during the previous year, regular use of inhaled steroids was associated with a 60% reduced risk of asthma death (RR=0.4, 95% CI 0.2 to 1.0).

CONCLUSIONS

Regular use of inhaled steroids is associated with a decreased risk of asthma death, and excessive use of short acting beta agonists is associated with a markedly increased risk of asthma death.

Tuberculosis in Spain: epidemiological pattern and clinical practice

SETTING

Thirteen Autonomous Regions in Spain.

OBJECTIVE

To study the incidence of all forms of tuberculosis (TB) and investigate clinical practice in TB.

DESIGN

Cases of all forms of tuberculosis diagnosed in the study setting from May 1986 to April 1997 were identified though active search of different databases. Clinical and epidemiological information on cases was collected from clinical records or by interview with physicians.

RESULTS

The overall incidence of all forms of tuberculosis was 38.5/100,000 and the incidence of smear-positive disease was 13.83/100,000. Most cases (97.1%) were Spanish nationals, with rates higher in men than in women (52.7/100,000 vs. 24.87/100,000) and in groups aged 25-34 and 75 years and over (61.35/100,000 and 59.35/100,000, respectively). Disseminated forms were frequent (6.6%), and the most common risk factor was human immunodeficiency virus (HIV) infection (17.7% of cases). Hospitalisation was common (71.6%). Microbiological confirmation of diagnosis was sought for 87.7% of the cases (91.8% of pulmonary vs. 75.5% of extra-pulmonary cases), and 65.2% were culture-positive (73.8% of pulmonary vs. 39.7% of extra-pulmonary cases). HIV-infected patients were treated in almost equal proportions with three or four drugs (49.7% and 48.2%, respectively), while HIV-negative cases or those whose HIV status was unknown were usually treated with three drugs.

CONCLUSION

The epidemiological pattern of TB in Spain is different to other industrialised countries in the age distribution of cases and the proportions of foreigners and cases with HIV infection. Microbiological confirmation of diagnosis is more common in pulmonary than in extra-pulmonary disease, and treatment with four drugs more frequent in HIV-positive cases.

Lipid-lowering drugs and risk of myopathy: a population-based follow-up study

We conducted a population-based cohort study to estimate the risk of myopathy associated with use of lipid-lowering drugs. Using data from general practices in the United Kingdom in 1991 through 1997, we identified three cohorts of individuals 40 to 74 years of age. One cohort comprised 17,219 persons who had received at least one prescription for lipid-lowering drugs in the period; a second cohort consisted of patients with a hyperlipidemia diagnosis who had not been prescribed lipid-lowering drugs (N = 28,974); and a third cohort comprised 50,000 individuals from the general population with no diagnosis of hyperlipidemia. The incidence rate of myopathy in the cohort of users of lipid-lowering drugs was 2.3 per 10,000 person-years [95% confidence interval (95% CI) = 1.2-4.4], which exceeded the incidence rates observed in the nontreated hyperlipidemia cohort [0 per 10,000 person-years (95% CI = 0.0-0.4)] and the general population [0.2 per 10,000 person-years (95% CI = 0.1-0.4)]. The relative risks of myopathy in current users of fibrates and statins compared with nonusers were 42.4 (95% CI = 11.6-170.5) and 7.6 (95% CI = 1.4-41.3), respectively. Potential risk factors other than drug use could not explain our findings in the nested case-control analysis. We conclude that use of lipid-lowering drugs is associated with a substantially greater risk of myopathy, which is most pronounced for fibrates. The absolute risk of myopathy in users of lipid-lowering drugs is, however, small.

The risk of obstructive airways disease in a glaucoma population

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD), defined as obstructive airways disease (OAD), are two common chronic conditions especially in the elderly. Glaucoma is also a common disease in the elderly with a prevalence close to 5% among those older than 75 years. Most medical therapy for glaucoma is given as eye drops. It has been described that small amounts of systemically absorbed beta-blockers can produce significant respiratory adverse events in predisposed patients.

METHODS

Population-based cohort study with nested case-control analysis using the UK General Practice Research Database (GPRD). We studied the prevalence of OAD in a cohort of patients 60 to 85 years old with a first ever diagnosis of glaucoma and compared it to the prevalence in an age- and sex-matched cohort sampled from the general population. We also calculated the RR and 95% CI of worsening asthma in non-severe asthma patients among the two cohorts. Incidence of OAD was studied in a cohort of glaucoma patients 60 to 85 years old and in an age- and sex-matched cohort from the general population.

RESULTS

The prevalence of OAD was the same between the glaucoma cohort and the general population (OR 1.1; 95% CI 0.9-1.4). The risk of worsening asthma associated with glaucoma was OR 1.2 (95% CI 0.5-2.8). The incidence of OAD was similar in both cohorts. Current users of ophthalmic drugs presented a RR of 1.2 (95% CI 0.8-1.9) of developing asthma compared to non-users in the glaucoma population. The risk in the first month of treatment with topical beta-blockers was 2.1 (95% CI 0.7-6.7).

DISCUSSION

We did not find an association between glaucoma and OAD. Use of topical glaucoma medication was not associated with a major increased risk of asthma.

Are users of lipid-lowering drugs at increased risk of peripheral neuropathy?

OBJECTIVE

To estimate the risk of peripheral neuropathy associated with use of lipid-lowering drugs.

METHODS

Population-based dynamic cohort study based on data from general practices in the United Kingdom from 1991 to 1997. Three cohorts of individuals aged 40-74 years were identified: a cohort of 17,219 persons who received at least one prescription for lipid-lowering drugs in the period; a second cohort of patients with a hyperlipidaemia diagnosis who had not been prescribed lipid-lowering drugs (n = 28,974) and a third cohort comprised of 50,000 individuals from the general population. The incidence rates of peripheral neuropathy in the three cohorts were calculated and the relative risk of peripheral neuropathy in users of lipid-lowering drugs was compared with non-users from the general population cohort.

RESULTS

The incidence rate of idiopathic peripheral neuropathy in users of lipid-lowering drugs was higher [0.73 per 10,000 person-years, 95% confidence interval (CI) 0.01-2.62] than in the hyperlipidaemia non-treated cohort (0.40 per 10,000 person-years, CI 0.05-1.46) and the general population cohort (0.46 per 10,000 person-years, CI 0.13-1.18). The raised risk of idiopathic peripheral neuropathy in users of lipid-lowering drugs was confined to current users of statins (relative risk 2.5, CI 0.3-14.2). These figures suggest one excess case of neuropathy for every 14,000 person-years of statin treatment.

CONCLUSIONS

Because of the wide CIs, these results are inconclusive and should be interpreted with caution. However, although peripheral neuropathy as an adverse effect of the use of lipid-lowering drugs cannot be excluded, the magnitude of this untoward effect appears to be small.

Cervical spine stabilization in pediatric patients: evaluation of current techniques

We evaluated the performance of commercially available infant and pediatric cervical collars, both alone and in combination with commonly used supplemental devices (eg, Kendrick Extrication Device, half-spine board). One infant and 11 pediatric-sized collars were tested on mannequins representing an infant and a 5-year old child. Maximum forces generated by cooperative children were measured, then applied to the mannequins to reproduce head and neck flexion, extension, rotation, and lateral motion. Limitation of motion was measured in each direction for each collar and combination method. In general, collars of rigid plastic construction performed better than did foam types. However, when used alone none of the collars provided acceptable immobilization, with even the best allowing 17 degrees flexion, 19 degrees extension, 4 degrees rotation, and 6 degrees lateral motion. When combined with supplemental devices, immobilization to 3 degrees or less in any direction could be achieved. Findings were verified using cooperative children and selected collars. Overall, combination methods were more effective than cervical collars alone (P less than .001) or supplemental devices alone (P less than .05). The modified half-spine board used with a rigid collar and tape was the most effective combination method. We conclude that prehospital cervical spine stabilization in pediatric patients is best accomplished using a rigid-type cervical collar in combination with supplemental devices as described.