Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis

BACKGROUND

Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown.

METHODS

In a randomized, noninferiority, multicenter trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed.

RESULTS

After randomization, antibiotic treatment was completed after a median of 19 days (interquartile range, 14 to 25) in the intravenously treated group and 17 days (interquartile range, 14 to 25) in the orally treated group (P=0.48). The primary composite outcome occurred in 24 patients (12.1%) in the intravenously treated group and in 18 (9.0%) in the orally treated group (between-group difference, 3.1 percentage points; 95% confidence interval, -3.4 to 9.6; P=0.40), which met noninferiority criteria.

CONCLUSIONS

In patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continued intravenous antibiotic treatment. (Funded by the Danish Heart Foundation and others; POET ClinicalTrials.gov number, NCT01375257 .).

Association Between Traumatic Brain Injury and Risk of Suicide

IMPORTANCE

Traumatic brain injuries (TBIs) can have serious long-term consequences, including psychiatric disorders. However, few studies have assessed the association between TBI and risk of suicide.

OBJECTIVE

To examine the association between TBI and subsequent suicide.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using nationwide registers covering 7 418 391 individuals (≥10 years) living in Denmark (1980-2014) with 164 265 624 person-years' follow-up; 567 823 (7.6%) had a medical contact for TBI. Data were analyzed using Poisson regression adjusted for relevant covariates, including fractures not involving the skull, psychiatric diagnoses, and deliberate self-harm.

EXPOSURE

Medical contacts for TBI recorded in the National Patient Register (1977-2014) as mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injuries with evidence of structural brain injury).

MAIN OUTCOMES AND MEASURES

Suicide recorded in the Danish Cause of Death register until December 31, 2014.

RESULTS

Of 34 529 individuals who died by suicide (mean age, 52 years [SD, 18 years]; 32.7% women; absolute rate 21 per 100 000 person-years [95% CI, 20.8-21.2]), 3536 (10.2%) had medical contact: 2701 with mild TBI, 174 with skull fracture without documented TBI, and 661 with severe TBI. The absolute suicide rate was 41 per 100 000 person-years (95% CI, 39.2-41.9) among those with TBI vs 20 per 100 000 person-years (95% CI, 19.7-20.1) among those with no diagnosis of TBI. The adjusted incidence rate ratio (IRR) was 1.90 (95% CI, 1.83-1.97). Compared with those without TBI, severe TBI (absolute rate, 50.8 per 100 000 person-years; 95% CI, 46.9-54.6) was associated with an IRR of 2.38 (95% CI, 2.20-2.58), whereas mild TBI (absolute rate, 38.6 per 100 000 person-years; 95% CI, 37.1-40.0), and skull fracture without documented TBI (absolute rate, 42.4 per 100 000 person-years; 95% CI, 36.1-48.7) had an IRR of 1.81 (95% CI, 1.74-1.88) and an IRR of 2.01 (95% CI, 1.73-2.34), respectively. Suicide risk was associated with number of medical contacts for TBI compared with those with no TBI contacts: 1 TBI contact, absolute rate, 34.3 per 100 000 person-years (95% CI, 33.0-35.7; IRR, 1.75; 95% CI, 1.68-1.83); 2 TBI contacts, absolute rate, 59.8 per 100 000 person-years (95% CI, 55.1-64.6; IRR, 2.31; 95% CI, 2.13-2.51); and 3 or more TBI contacts, absolute rate, 90.6 per 100 000 person-years (95% CI, 82.3-98.9; IRR, 2.59; 95% CI, 2.35-2.85; all P < .001 for the IRR's). Compared with the general population, temporal proximity since the last medical contact for TBI was associated with risk of suicide (P<.001), with an IRR of 3.67 (95% CI, 3.33-4.04) within the first 6 months and an incidence IRR of 1.76 (95% CI, 1.67-1.86) after 7 years.

CONCLUSIONS AND RELEVANCE

In this nationwide registry-based retrospective cohort study individuals with medical contact for TBI, compared with the general population without TBI, had increased suicide risk.

C-reactive protein, dietary n-3 fatty acids, and the extent of coronary artery disease

The acute-phase reactant C-reactive protein (CRP) has emerged as an independent risk factor for coronary artery disease. Experimental and clinical studies provide evidence of anti-inflammatory effects of n-3 polyunsaturated fatty acids (PUFA) derived from fish. We have studied the effect of marine n-3 PUFA on CRP levels in 269 patients referred for coronary angiography because of clinical suspicion of coronary artery disease. All patients filled out a food questionnaire regarding fish intake. The n-3 PUFA content of granulocyte membranes was determined and the concentration of CRP in serum was measured using a highly sensitive assay. The results were related to angiographic findings. CRP was significantly higher in patients with significant coronary stenoses than in those with no significant angiographic changes (p <0.001), but the CRP levels were not associated with the number of diseased vessels. Subjects with CRP levels in the lower quartile had a significantly higher content of docosahexaenoic acid (DHA) in granulocytes than subjects with CRP levels in the upper quartile (p = 0.02), and in a multivariate linear regression analysis, DHA was independently correlated to CRP (R(2) = 0.179; p = 0.003). The inverse correlation between CRP and DHA may reflect an anti-inflammatory effect of DHA in patients with stable coronary artery disease and suggest a novel mechanism by which fish consumption may decrease the risk of coronary artery disease.

Testosterone, ticks and travels: a test of the immunocompetence-handicap hypothesis in free-ranging male sand lizards

The immunocompetence-handicap hypothesis suggests that androgen-dependent male characters constitute honest signals of mate and/or rival quality because of the imposed costs through immune suppression associated with elevated testosterone levels. We demonstrate in a field experiment that male sand lizards (Lacerta agilis) exposed to elevated testosterone suffered from increased mass loss and tick load compared to control males. Although the first of these two results could be due to an elevated basal metabolic rate from increased plasma testosterone levels, the increased parasite load was statistically independent of the loss in body condition and is likely to be due to compromised immune function. Testosterone-treated males showed greater mobility than control males, and greater mobility resulted in higher mating success. Our experiment thus lends support to the immunocompetence-handicap hypothesis, suggesting that male testosterone levels have been moderated by balancing selection for reproductive success and sustained immune function.

Isolation and characterization of an anaerobic chlorophenol-transforming bacterium

An obligately anaerobic bacterium which transforms several chlorinated phenols was isolated. Dechlorination of the substituents ortho to the phenolic OH group was preferred, while removal of a meta-substituted chlorine was observed only with 3,5-dichlorophenol. The bacterium was a gram-positive, endospore-forming, motile, slightly curved rod. Sulfate was not reduced. Nitrate was reduced via nitrite to ammonium. The bacterium is related to the genus Clostridium. The highest growth rate was obtained in a medium containing pyruvate and yeast extract. Pyruvate supported growth as the sole source of carbon, and the fermentation of pyruvate produced almost equimolar amounts of acetate.

Natural killer cell activity and lymphocyte function during and after coronary artery bypass grafting in relation to the endocrine stress response

The effects of elective coronary artery bypass grafting (CABG) and the associated endocrine stress response on natural killer (NK) cell activity in peripheral blood, the distribution of lymphocyte subpopulations, and the phytohemagglutinin (PHA)-induced lymphocyte transformation were studied in 20 patients anesthetized with either etomidate-high dose fentanyl (75-125 micrograms . kg-1) or midazolam-low dose fentanyl (less than 20 micrograms . kg-1). The endocrine response to surgery was measured as changes in serum cortisol, plasma epinephrine, and norepinephrine. Compared with control values, a significant increase of NK cell activity was found in both groups prior to induction of anesthesia, followed by a decrease after induction until initiation of cardiopulmonary bypass (CPB) and a gradual increase to levels exceeding controls during CPB. Postoperatively, NK cell activity and the lymphocyte transformation to PHA stimulation were significantly depressed for at least 1-3 days. These changes were accompanied by severe lymphopenia affecting the T-lymphocytes (T3, T4, and T8) and the NK cells (Leu 11). Apart from a delayed cortisol increase in the etomidate group, the endocrine response showed a similar pattern in the two groups. Compared with control values, a significant decrease in the serum cortisol until CPB could be demonstrated, followed by a significant increase persisting for at least 6 days postoperatively. The plasma catecholamines showed a steep rise and, consequently, a significant increase during CPB, followed by a gradual return to control values in the postoperative period. The results indicate that, in patients undergoing CABG, immune surveillance is impaired prior to CPB and during the early postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

An LI and ML motif in the cytoplasmic tail of the MHC-associated invariant chain mediate rapid internalization

Invariant chain (Ii) is a transmembrane protein that associates with the MHC class II molecules in the endoplasmic reticulum. Two regions of the 30 residue cytoplasmic tail of Ii contain sorting information able to direct Ii to the endocytic pathway. The full-length cytoplasmic tail of Ii and the two tail regions were fused to neuraminidase (NA) forming chimeric proteins (INA). Ii is known to form trimers and when INA was transfected into COS cells it assembled as a tetramer like NA. The INA molecules were targeted to the endosomal pathway and cotransfection with Ii showed that both molecules appeared in the same vesicles. By labelling the INA fusion proteins with iodinated antibody it was found that molecules with either endocytosis signal were expressed at the plasma membrane and internalized rapidly. Point mutations revealed that an LI motif within the first region of the cytoplasmic tail and an ML motif in the second region were essential for efficient internalization. The region containing the LI motif is required for Ii to induce large endosomes but a functional LI internalization motif was not fundamental for this property. The cytoplasmic tail of Ii is essential for efficient targeting of the class II molecules to endosomes and the dual LI and ML motif may thus be responsible for directing these molecules to the endosomal pathway, possibly via the plasma membrane.

The effect of dietary n-3 fatty acids on serum concentrations of C-reactive protein: a dose-response study

C-reactive protein (CRP) is a sensitive marker for low-grade inflammation. Long-chain n-3 polyunsaturated fatty acids (PUFA) have anti-inflammatory effects. The objective of the present study was to investigate the effect on serum levels of CRP of n-3 PUFA at two different doses. We also investigated correlations between CRP and the cellular contents of PUFA. Sixty healthy volunteers (twenty-five women and thirty-five men) were randomly assigned to three treatment groups in a double-blind design. The subjects received a supplement of either 6.6 g n-3 PUFA/d, 2.0 g n-3 PUFA/d or placebo (olive oil) for 12 weeks. CRP was measured using a highly sensitive assay. The median serum CRP concentration was 0.78 mg/l. No significant correlations were found between CRP and the content of n-3 PUFA in granulocytes or platelets. Subjects receiving n-3 PUFA had a significant (P<0.01) increase in the cellular contents of 20 : 5n-3, 22 : 5n-3 and 22 : 6n-3, with the largest increase occurring in the group receiving 6.6 g PUFA/d. A significant (P<0.01) decrease in cellular content of 18 : 2n-6 and 20 : 4n-6 was observed simultaneously. Serum CRP concentrations, however, were unaffected by the PUFA-containing supplements. The present study shows that dietary supplementation with PUFA-containing supplements has no effect on serum concentrations of CRP, measured with a highly sensitive assay, in healthy subjects.

A Nationwide Cohort Study of the Association Between Hospitalization With Infection and Risk of Death by Suicide

IMPORTANCE

Findings suggest that infections might be linked to the development of psychiatric disorders and suicidal behavior. Large-scale studies are needed to investigate the effect of infection on the risk of suicide.

OBJECTIVE

To estimate the association between hospitalization with infection and the risk of death by suicide.

DESIGN, SETTING, AND PARTICIPANTS

Nationwide, population-based, prospective cohort study with more than 149 million person-years of follow-up. Data were analyzed with survival analysis techniques and were adjusted for sex, age, calendar period, cohabitation status, socioeconomic status, and the Charlson Comorbidity Index. Individual data were drawn from Danish longitudinal registers. A total of 7.22 million individuals 15 years or older living in Denmark between January 1, 1980, and December 31, 2011, were observed during a 32-year follow-up period.

MAIN OUTCOMES AND MEASURES

The risk of death by suicide was identified in the Danish Cause of Death Register. Incidence rate ratios (IRRs) and accompanying 95% CIs were used as measures of relative risk.

RESULTS

In 7 221 578 individuals (3 601 653 men and 3 619 925 women) observed for a total of 149 061 786 person-years, 32 683 suicides were observed during the follow-up period. Among the suicides, 7892 (24.1%) individuals had previously been diagnosed as having an infection during a hospitalization. Hospitalization with infection was linked to an elevated risk of suicide, with an IRR of 1.42 (95% CI, 1.38-1.46) compared with those without prior infection. Dose-response relationships were observed with respect to the number of hospital contacts for different infections. For example, having 7 or more infections was linked to an IRR of 2.90 (95% CI, 2.14-3.93). The number of days of treatment for infections was associated with an elevated risk of suicide in a dose-response relationship. More than 3 months of hospital treatment was linked to an IRR of 2.38 (95% CI, 2.05-2.76). The population-attributable risk associated with hospitalization with infection accounted for 10.1% of suicides.

CONCLUSIONS AND RELEVANCE

An increased risk of death by suicide was found among individuals hospitalized with infection in prospective and dose-response relationships. These findings indicate that infections may have a relevant role in the pathophysiological mechanisms of suicidal behavior.

Effects of sulfuroxy anions on degradation of pentachlorophenol by a methanogenic enrichment culture

We studied the degradation of pentachlorophenol (PCP) under methanogenic and sulfate-reducing conditions with an anaerobic mixed culture derived from sewage sludge. The consortium degraded PCP via 2,3,4,5-tetrachlorophenol, 3,4,5-trichlorophenol, and 3,5-dichlorophenol and eventually accumulated 3-chlorophenol. Dechlorination of PCP and metabolites was inhibited in the presence of sulfate, thiosulfate, and sulfite. A decrease in the rate of PCP transformation was noted when the endogenous dissolved H(2) was depleted below 0.11 muM in sulfate-reducing cultures. The effect on dechlorination observed with sulfate could be relieved by addition of molybdate, a competitive inhibitor of sulfate reduction. Addition of H(2) reduced the inhibition observed with sulfuroxy anions. The inhibitory effect of sulfuroxy anions may be due to a competition for H(2) between sulfate reduction and dechlorination. When cultured under methanogenic conditions, the consortium degraded several chlorinated and brominated phenols.

Predictors of psychiatric inpatient suicide: a national prospective register-based study

OBJECTIVE

To study the incidence and risk factors of psychiatric inpatient suicide within a national cohort representing all psychiatric hospital admissions.

METHOD

This national prospective register-based study followed all psychiatric hospital admissions in Denmark from the date of patient admission until patient discharge or inpatient suicide over a 10-year study period from 1997 through 2006. By using survival analysis techniques, this study was the first to take the inpatient time at risk into account in the estimation of the suicide rate and the predictors of suicide among hospital-admitted psychiatric patients.

RESULTS

Among 126,382 psychiatric inpatients aged 14 years or older, 279 suicides occurred. The risk of inpatient suicide was high: 860 suicides per 100,000 inpatient years. Of those individuals who completed suicide, 50% died within 18 days of admission. The inpatient suicide rate significantly decreased, about 6% each year (HR = 0.94; 95% CI, 0.90-0.99), over this 10-year period. Several significant predictors of suicide were found, including the following: Patients with a bachelor's degree had a significantly higher hazard ratio (HR) of suicide compared with those with a primary school education (HR = 0.41; 95% CI, 0.29-0.60) or those with vocational training (HR = 0.54; 95% CI, 0.39-0.77). Having a personality disorder as a secondary diagnosis (all psychiatric diagnoses were made according to ICD-10) raised the risk of suicide (HR = 1.60; 95% CI, 1.01-2.53), as did having recent contact (within the last year) with a private psychologist (HR = 1.85; 95% CI, 1.05-3.28). Recent suicide attempt before admission to the hospital was associated with the highest risk of inpatient suicide (HR = 4.99; 95% CI, 3.57-6.96).

CONCLUSIONS

This study demonstrated a high risk of psychiatric inpatient suicide in Denmark of 860 per 100,000 inpatient years and also revealed several significant predictors of psychiatric inpatient suicide. Furthermore, the inpatient suicide rate decreased from 1997 through 2006 in Denmark.

Anaerobic transformation and toxicity of trichlorophenols in a stable enrichment culture

The transformation and toxicity of trichlorophenols (TCPs) were studied with a methanogenic enrichment culture derived from sewage sludge. Transformation of TCPs rapidly resumed after heating of the culture at *) degrees C for 1 h, suggesting that the dechlorinating bacteria are spore-forming anaerobes. 2,4,6-TCP was rapidly dechlorinated via 2,4-dichlorophenol to 4-chlorophenol. During the transformation of 2,4,6-TCP, the most probable number of dechlorinating bacteria increased by 4 orders of magnitude. The most extensive dechlorination was observed in media with complex carbon sources such as yeast extract, peptone, and Casamino Acids, but glucose, galactose, and lactose were also used by the consortium. Experiments using chloramphenicol indicated that the reductive dechlorination of 2,4,6-TCP was regulated by an inducible enzyme system. The highest initial concentration at which dechlorination of 2,4,6-TCP was observed was 400 microM. 2,4,5-TCP and 3,4,5-TCP were dechlorinated to, respectively, 3,4-dichlorophenol and 3-chlorophenol at initial concentrations of less than or equal to 40 microM. Toxicity for the acid-producing and methanogenic bacteria in the consortium was a function of chemical structure, as the inhibition of these activities increased from 2,4,6-TCP, via 2,4,5-TCP, to 3,4,5,-TCP.

Risk of suicide according to level of psychiatric treatment: a nationwide nested case-control study

PURPOSE

Knowledge of the epidemiology of suicide is a necessary prerequisite of suicide prevention. We aimed to conduct a nationwide study investigating suicide risk in relation to level of psychiatric treatment.

METHODS

Nationwide nested case-control study comparing individuals who died from suicide between 1996 and 2009 to age-, sex-, and year-matched controls. Psychiatric treatment in the previous year was graded as "no treatment," "medicated," "outpatient contact," "psychiatric emergency room contact," or "admitted to psychiatric hospital."

RESULTS

There were 2,429 cases and 50,323 controls. Compared with people who had not received any psychiatric treatment in the preceding year, the adjusted rate ratio (95 % confidence interval) for suicide was 5.8 (5.2-6.6) for people receiving only psychiatric medication, 8.2 (6.1-11.0) for people with at most psychiatric outpatient contact, 27.9 (19.5-40.0) for people with at most psychiatric emergency room contacts, and 44.3 (36.1-54.4) for people who had been admitted to a psychiatric hospital. The gradient was steeper for married or cohabiting people, those with higher socioeconomic position, and possibly those without a history of attempted suicide.

CONCLUSIONS

Psychiatric admission in the preceding year was highly associated with risk of dying from suicide. Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.

MHC class I variation associates with parasite resistance and longevity in tropical pythons

Using restriction fragment length polymorphism (RFLP) we identified 26 unique major histocompatibility complex (MHC) genotypes in 104 water pythons. We observed a significant independent association between reduced blood parasite load (Hepatozoon sp.) and python body length/age, presence of a specific RFLP fragment (C-fragment) and the overall number of fragments. The parasite has a negative impact on several python life-history traits such as growth, nutritional status and longevity. Thus, the C-fragment could be considered a 'good gene' (a fitness-enhancing genetic element). However, while the number of fragments affected parasite load, the association between level of parasitaemia and fragment number was not linear, and, hence, minimum parasite infection level was achieved at an intermediate number of fragments. Intermediate MHC fragment numbers were also observed among the largest/oldest pythons, suggesting that both a specific fragment and intermediate levels of MHC polymorphism enhanced python longevity. Thus, our results suggest python MHC is subject to both frequency-dependent and balancing selection.

Promiscuity in sand lizards (Lacerta agilis) and adder snakes (Vipera berus): causes and consequences

We review postcopulatory phenomena in the Swedish sand lizard (Lacerta agilis) and adder (Vipera berus), and in particular, links between female promiscuity, determinants of paternity, and offspring viability. In both species, females mate multiply and exhibit a positive relationship between the number of partners and offspring viability. We conclude that this relationship is most likely the result of variable genetic compatibility between mates arising from postcopulatory phenomena, predominantly assortative fertilization with respect to parental genotypes. However, males who were more successful at mate acquisition were also more successful in situations of sperm competition, suggesting a possible link between male (diploid and haploid) genetic quality per se and probability of fertilization. Neither the number of partners nor the number of matings influenced the risk of infertility in sand lizards, suggesting that selection for reduced risk of infertility is not a sufficient explanation for maintaining female promiscuity in this population. Finally, we conclude that the relatively low genetic variability exhibited by our study populations may have facilitated detection of genetic benefits compared to more outbred ones. However, recent work derived from outbred populations in other taxa suggest a greater generality of the principles we discuss than previously may have been appreciated.

Repeated Suicide Attempts and Suicide Among Individuals With a First Emergency Department Contact for Attempted Suicide: A Prospective, Nationwide, Danish Register-Based Study

OBJECTIVE

Emergency departments are important, albeit underutilized, sites for suicide prevention. Preventive strategies and interventions could benefit from a greater understanding of factors influencing the course of suicide risk after emergency department contact due to attempted suicide. The aim of our study was 2-fold: to identify predictors of repeated suicide attempts and suicide and to investigate the timing of these events.

METHODS

Data from Danish nationwide, longitudinal registers were used in this prospective, population-based study of all individuals first presenting to an emergency department after attempted suicide (index attempt) between January 1, 1996, and December 31, 2011 (N = 11,802). Cox regression analysis identified predictors, and Kaplan-Meier survival analysis modeled the time to repeated suicide attempts and suicide.

RESULTS

Sixteen percent of the sample repeated suicide attempt, and 1.4% died by suicide. Repetition was less likely among men than women (adjusted hazard ratio [AHR] = 0.70; 95% CI, 0.63-0.79), whereas those most prone to repeated attempts were individuals with recent psychiatric treatment (AHR = 2.19; 95% CI, 1.97-2.43) and those with recent psychiatric treatment (AHR = 2.19; 95% CI, 1.97-2.43). Predictors of suicide included age over 35 years (AHR = 5.56; 95% CI, 2.89-10.69); hanging, strangling, or suffocation as the method of the index attempt (AHR = 2.55; 95% CI, 1.29-5.01); and receiving psychiatric hospitalization for the index attempt (AHR = 1.74; 95% CI, 1.22-2.49). The cumulative rates of repeated attempts and suicide deaths in the total sample were particularly high within the first week of the index attempt, reaching 3.6% and 0.1%, respectively.

CONCLUSIONS

Preventive efforts need to target the period close to discharge from emergency departments.

Heart rate variability and n-3 polyunsaturated fatty acids in patients with diabetes mellitus

OBJECTIVES

Dietary n-3 polyunsaturated fatty acids (PUFA) derived from fish may reduce the incidence of sudden cardiac death (SCD). The aim of the present study was to examine associations between n-3 PUFA and 24-h heart rate variability in patients with type 1 and type 2 diabetes mellitus (DM).

DESIGN

Observational study.

SETTING

The out-patient's diabetic clinic at Hjørring Hospital, Hjørring, Denmark.

SUBJECTS

Forty-three patients with type 1 DM and 38 patients with type 2 DM.

MAIN OUTCOME MEASURES

The patients fulfilled a food-questionnaire regarding fish consumption, whilst the content of n-3 PUFA in platelets was measured and 24-h heart rate variability (HRV) was obtained.

RESULTS

The patients fish consumption was strongly related to their content of n-3 PUFA in platelets. Furthermore, in patients with type 1 DM a close positive association was found between the content of n-3 PUFA in platelets and 24-h HRV. This association was not significant in patients with type 2 DM.

CONCLUSIONS

The positive association between n-3 PUFA in platelets and HRV may indicate a beneficial effect of n-3 PUFA on HRV in patients with type 1 DM. Further studies are warranted to clarify whether supplementation with n-3 PUFA reduce the risk of SCD amongst patients with DM.

Latent trajectories of trauma symptoms and resilience: the 3-year longitudinal prospective USPER study of Danish veterans deployed in Afghanistan

OBJECTIVE

To identify trajectories of posttraumatic stress disorder (PTSD) symptoms from before to 2.5 years after deployment and to assess risk factors for symptom fluctuations and late-onset PTSD.

METHOD

743 soldiers deployed to Afghanistan in 2009 were assessed for PTSD symptoms using the PTSD Checklist (PCL) at 6 occasions from predeployment to 2.5 years postdeployment (study sample = 561). Predeployment vulnerabilities and deployment and postdeployment stressors were also assessed.

RESULTS

Six trajectories were identified: a resilient trajectory with low symptom levels across all assessments (78.1%) and 5 trajectories showing symptom fluctuations. These included a trajectory of late onset (5.7%), independently predicted by earlier emotional problems (OR = 5.59; 95% CI, 1.57-19.89) and predeployment and postdeployment traumas (OR = 1.10; 95% CI, 1.04-1.17 and OR = 1.13; 95% CI, 1.00-1.26). Two trajectories of symptom fluctuations in the low-to-moderate range (7.5% and 4.1%); a trajectory of symptom relief during deployment, but with a drastic increase at the final assessments (2.0%); and a trajectory with mild symptom increase during deployment followed by relief at return (2.7%) were also found. Symptom fluctuation was predicted independently by predeployment risk factors (depression [OR = 1.27; 95% CI, 1.16-1.39], neuroticism [OR = 1.10; 95% CI, 1.00-1.21], and earlier traumas [OR = 1.09; 95% CI, 1.03-1.16]) and deployment-related stressors (danger/injury exposure [OR = 1.20; 95% CI, 1.04-1.40]), but not by postdeployment stressors.

DISCUSSION

The results confirm earlier findings of stress response heterogeneity following military deployment and highlight the impact of predeployment, perideployment, and postdeployment risk factors in predicting PTSD symptomatology and late-onset PTSD symptoms.

Pathogenic RBM20-Variants Are Associated With a Severe Disease Expression in Male Patients With Dilated Cardiomyopathy

Background As pathogenic variants in the gene for RBM20 appear with a frequency of 6% among Danish patients with dilated cardiomyopathy (DCM), it was the aim to investigate the associated disease expression in affected families. Methods and Results Clinical investigations were routinely performed in DCM index-patients and their relatives. In addition, ≥76 recognized and likely DCM-genes were investigated. DNA-sequence-variants within RBM20 were considered suitable for genetic testing when they fulfilled the criteria of (1) being pathogenic according to the American College of Medical Genetics and Genomics-classification, (2) appeared with an allele frequency of <1:10.000, and (3) segregated with DCM in ≥7 affected individuals. A total of 80 individuals from 15 families carried 5 different pathogenic RBM20-variants considered suitable for genetic testing. The penetrance was 66% (53/80) and age-dependent. Males were both significantly younger and had lower ejection fraction at diagnosis than females (age, 29±11 versus 48±12 years; P<0.01; ejection fraction, 29±13% versus 38±9%; P<0.01). Furthermore, 11 of 31 affected males needed a cardiac transplant while none of 22 affected females required this treatment ( P<0.001). Thirty percent of RBM20-carriers with DCM died suddenly or experienced severe ventricular arrhythmias although no adverse events were identified among healthy RBM20-carriers with a normal cardiac investigation. The event-free survival of male RBM20-carriers was significantly shorter compared with female carriers ( P<0.001). Conclusions The disease expression associated with pathogenic RBM20-variants was severe especially in males. The findings of the current study suggested that close clinical follow-up of RBM20-carriers is important which may ensure early detection of disease development and thereby improve management.

Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis

It has been shown that 12 weeks of eccentric heavy resistance training can reduce pain in runners suffering from chronic Achilles tendinosis, but the mechanism behind the effectiveness of this treatment is unknown. The present study investigates the local effect of an eccentric training regime on elite soccer players suffering from chronic Achilles tendinosis on the turnover of the peritendinous connective tissue. Twelve elite male soccer players, of whom six suffered from unilateral tendinosis and six were healthy controls, participated in this study. All participants performed 12 weeks of heavy-resistance eccentric training apart from their regular training and soccer activity. Before and after the training period the tissue concentration of indicators of collagen turnover was measured by the use of the microdialysis technique. After training, collagen synthesis was increased in the initially injured tendon (n=6; carboxyterminal propeptide of type I collagen (PICP): pre 3.9+/-2.5 microg/L to post 19.7+/-5.4 microg/L, P<0.05). The collagen synthesis was unchanged in healthy tendons in response to training (n=6; PICP: pre 8.3+/-5.2 microg/L to post 11.5+/-5.0 microg/L, P>0.05). Collagen degradation, measured as carboxyterminal telopeptide region of type I collagen (ICTP), was not affected by training neither in the injured nor in the healthy tendons. The clinical effect of the 12 weeks of eccentric training was determined by using a standardized loading procedure of the Achilles tendons showing a decrease in pain in all the chronic injured tendons (VAS before 44+/-9, after 13+/-9; P<0.05), and all subjects were back playing soccer following the eccentric training regime. The present study demonstrates that chronically injured Achilles tendons respond to 12 weeks of eccentric training by increasing collagen synthesis rate. In contrast, the collagen metabolism in healthy control tendons seems not to be affected by eccentric training. These findings could indicate a relation between collagen metabolism and recovery from injury in human tendons.

The effect of HCl infusion in the lower part of the oesophagus on the pharyngo-oesophageal sphincter pressure in normal subjects

A measuring unit combined with a perfused catheter has been developed for measurement of the pharyngo-oesophageal sphincter pressure. The system is able to register pressure measurements using either intermittent or continuous withdrawal of the catheter, at the same flow rate (0.5 ml/min). Repeated measurements of pharyngo-oesophageal sphincter pressure have been made on eight healthy volunteers. No differences were found in the sphincter pressures measured by the continuous and the intermittent withdrawal techniques (p greater than 0.10); the coefficient of variation was 0.18 for both techniques. The pharyngo-oesophageal sphincter pressure was measured during infusion of 0.1 N HCl (5 ml/min) 5 cm proximally to the gastro-oesophageal sphincter. There was an increase in the pharyngo-oesophageal sphincter pressure after 1 min of infusion (p less than 0.05). Measurements after 5 min and 10 min were no different from the initial value; thus a fall was observed between the first and the fifth minute (p less than 0.05). The observed rise in sphincter pressure may be explained as a response acting to prevent gastro-oesophageal reflux from entering the pharynx.

12-Hour simultaneous registration of acid reflex and peristaltic activity in the oesophagus. A study in normal subjects

Twelve-hour simultaneous registration of acid gastro-oesophageal reflux and peristaltic activity in the oesophagus was carried out on 30 healthy subjects. The intensity of the acid gastro-oesophageal reflux was determined by automatic integration of the pH variation. Acid gastro-oesophageal reflux to pH less than or equal to 4 occurs in normal subjects within a range of 0--2.4% of the total registration period. The intravariation was measured in 10 investigations on 1 subject, and lay within the intervariation. To maintain the pressure-measuring system intact, 3 ml H2O/h were fed to the proximal and distal pressure catheters, respectively; it has been shown that this small quantity of water has no influence on the pH variation. Peristaltic activity for the entire measuring period was recorded and related to the individual reflex episodes. The total activity was found to be dependent on the level of consciousness, with little activity occurring during sleep. A positive correlation was found between the lowest pH during a reflux episode and the peristaltic activity in the oesophagus (p less than 0.001), between the lowest pH during a reflux episode and the duration of the reflux episode (p less than 0.001), and between the peristaltic activity and the duration of the reflux episode (p less than 0.001). During long-term registration of oesophageal pH it appears that pH less than or equal to 4 is a usable parameter for distinguishing between pathological and non-pathological acid gastro-oesophageal reflux. Sudden falls in pH to below 4 release increased peristalsis in the oesophagus.