Optimal Prevention Strategies Research Articles

Medication-related osteonecrosis of the jaw: A literature review and update.

Since the initial description of medication-related osteonecrosis of the jaw (MRONJ) almost two decades ago, the potential pathophysiology and risk factors have been elaborated on in many investigations and guidelines. However, the definitive pathophysiology based on scientific evidence remains lacking. Consequently, the optimal clinical treatment and prevention strategies for MRONJ have not been established. Despite their different mechanisms of action, many drugs, including bisphosphonates, denosumab, angiogenesis inhibitors, and other medications, have been reported to be associated with MRONJ lesions in cancer and osteoporosis patients. Importantly, MRONJ occurs predominantly in the jawbones and other craniofacial regions, but not in the appendicular skeleton. In this up-to-date review, the currently available information and theories regarding MRONJ are presented from both clinical and basic science perspectives. The definition and epidemiology of MRONJ, triggering medication, and histopathology are comprehensively summarized. The immunopathology and the potential pathophysiology based on immune cells such as neutrophils, T and B cells, macrophages, dendritic cells, and natural killer cells are also discussed. In addition, antiangiogenesis, soft tissue toxicity, necrotic bone, osteocyte death, and single-nucleotide polymorphisms are examined. Moreover, other possible mechanisms of MRONJ development are considered based on the unique embryological characteristics, different cell behaviors between jawbones and appendicular skeleton, unique anatomical structures, and sustained bacterial exposure in the oral cavity as a basis for MRONJ site specificity. Based on the literature review, it was concluded that multiple factors may contribute to the development of MRONJ, although which one is the key player triggering MRONJ in the craniofacial region remains unknown.

August 2022 Stroke Highlights

August 2022 Stroke Highlights

Automated risk assessment of newly detected atrial fibrillation poststroke from electronic health record data using machine learning and natural language processing.

BackgroundTimely detection of atrial fibrillation (AF) after stroke is highly clinically relevant, aiding decisions on the optimal strategies for secondary prevention of stroke. In the context of limited medical resources, it is crucial to set the right priorities of extended heart rhythm monitoring by stratifying patients into different risk groups likely to have newly detected AF (NDAF). This study aimed to develop an electronic health record (EHR)-based machine learning model to assess the risk of NDAF in an early stage after stroke.MethodsLinked data between a hospital stroke registry and a deidentified research-based database including EHRs and administrative claims data was used. Demographic features, physiological measurements, routine laboratory results, and clinical free text were extracted from EHRs. The extreme gradient boosting algorithm was used to build the prediction model. The prediction performance was evaluated by the C-index and was compared to that of the AS5F and CHASE-LESS scores.ResultsThe study population consisted of a training set of 4,064 and a temporal test set of 1,492 patients. During a median follow-up of 10.2 months, the incidence rate of NDAF was 87.0 per 1,000 person-year in the test set. On the test set, the model based on both structured and unstructured data achieved a C-index of 0.840, which was significantly higher than those of the AS5F (0.779, p = 0.023) and CHASE-LESS (0.768, p = 0.005) scores.ConclusionsIt is feasible to build a machine learning model to assess the risk of NDAF based on EHR data available at the time of hospital admission. Inclusion of information derived from clinical free text can significantly improve the model performance and may outperform risk scores developed using traditional statistical methods. Further studies are needed to assess the clinical usefulness of the prediction model.

Outcomes of COVID-19 in a Large Cohort of Lung Transplant Recipients: A Retrospective Study

Background: Early reports of COVID-19 in lung transplant recipients (LTRs) showed high hospitalization and mortality rates. However, the outcomes of COVID-19 in LTRs since the advent of newer therapies and vaccines have been poorly defined. Methods: We evaluated the risks for SARS-CoV-2-related hospitalization and mortality in a cohort of LTRs at the Henry Ford Lung Transplant Program in Detroit, Michigan during the study period March 2020–March 2022. Univariate logistic regression, followed by multivariable modeling were performed to estimate the odds ratio (OR) with 95% confident intervals (CI). Results: Sixty-four laboratory-confirmed SARS-CoV-2 infections were identified in 59 patients. For the primary analysis of the hospitalization and mortality risks, we included these 59 patients with symptomatic COVID-19. SARS-CoV-2 infections were confirmed with real-time polymerase chain reaction (RT-PCR) from a nasopharynx swab. The mean age (±STD) was 61 (±12), 63% were males, 27% were African Americans, and the time from lung transplant to COVID-19 was 5.5 (±4.8) years. Thirty-four (57.6%) patients were hospitalized, and the inpatient mortality rate was 24% (8/34). A multivariable analysis showed that patients with a higher baseline forced expiratory volume (FEV1) were less likely to be hospitalized (OR = 0.91 and 95% CI 0.87–0.98, p = 0.02). Seventy-five percent (75%; 6/8) of patients on invasive mechanical ventilation died, compared with only 8% mortality rate in those without mechanical ventilation (OR = 36.0 and 95% CI 4.2–310.4, p < 0.01). Although a trend toward a higher risk of death was observed in those infected during the Alpha (p = 0.17) and Delta (p = 0.22) waves, no significant risk was detected after adjusting for other covariates. Five LTRs were diagnosed with COVID-19 twice. Thirty of the sixty-four COVID-19 cases (46.8%) occurred in LTRs that had received at least two doses of any of the available mRNA vaccines at a median of 123 days (IQR 98–164 days) after vaccination. Twelve of the thirty (40%) were hospitalized, and four patients (33%) died during their hospitalizations. Conclusions: In our LTR population, the hospitalization and mortality rates associated with COVID-19 were high despite the increased use of new therapies. Vaccine-breakthrough infections were common and were associated with poor outcomes. Studies are needed to determine optimal prevention and therapeutic strategies to improve COVID-19 outcomes in LTRs.

Postoperative anaemia and patient-centred outcomes after major abdominal surgery: a retrospective cohort study

BackgroundCompared with anaemia before surgery, the underlying pathogenesis and implications of postoperative anaemia are largely unknown. MethodsThis retrospective cohort study analysed prospective data obtained from 2983 adult patients across 47 centres enrolled in a clinical trial evaluating restrictive and liberal intravenous fluids. The primary endpoint was persistent disability or death up to 90 days after surgery. Secondary endpoints included major septic complications, hospital stay, and patient quality of recovery using a 15-item quality of recovery (QoR-15) score, hospital re-admissions, and disability-free survival up to 12 months after surgery. Anaemia and disability were defined according to the WHO definitions. Multivariable regression was used to adjust for baseline risk and surgery. ResultsA total of 2983 patients met inclusion criteria for this study, of which 78.5% (95% confidence interval [CI], 76.7–80.1%) had postoperative anaemia. Patients with postoperative anaemia had a higher adjusted risk of death or disability up to 90 days after surgery when compared with those without anaemia: 18.2% vs 9.2% (risk ratio [RR]=1.51; 95% CI, 1.10–2.07, P=0.011); lower QoR-15 scores on Day 3 and Day 30, 105 (95% CI, 87–119) vs 114 (95% CI, 99–128; P<0.001), and 130 (95% CI, 112–140) vs 139 (95% CI, 121–144; P<0.011), respectively; higher adjusted risk of a composite of mortality/septic complications, 2.01 (95% CI, 1.55–42.67; P<0.001); unplanned admission to ICU (RR=2.65; 95% CI, 1.65–4.23; P<0.001); and longer median (inter-quartile range [IQR]) hospital stays, 6.6 (4.4–12.4) vs 3.7 (2.5–6.5) days (P<0.001). ConclusionsPostoperative anaemia is common and is independently associated with poor outcomes after surgery. Optimal prevention and treatment strategies need to be investigated. Clinical trial registrationNCT04978285 (ClinicalTrials.gov).

Functions of Breast Cancer Predisposition Genes: Implications for Clinical Management.

Approximately 5–10% of all breast cancer (BC) cases are caused by germline pathogenic variants (GPVs) in various cancer predisposition genes (CPGs). The most common contributors to hereditary BC are BRCA1 and BRCA2, which are associated with hereditary breast and ovarian cancer (HBOC). ATM, BARD1, CHEK2, PALB2, RAD51C, and RAD51D have also been recognized as CPGs with a high to moderate risk of BC. Primary and secondary cancer prevention strategies have been established for HBOC patients; however, optimal preventive strategies for most hereditary BCs have not yet been established. Most BC-associated CPGs participate in DNA damage repair pathways and cell cycle checkpoint mechanisms, and function jointly in such cascades; therefore, a fundamental understanding of the disease drivers in such cascades can facilitate the accurate estimation of the genetic risk of developing BC and the selection of appropriate preventive and therapeutic strategies to manage hereditary BCs. Herein, we review the functions of key BC-associated CPGs and strategies for the clinical management in individuals harboring the GPVs of such genes.

Masks trigger facial seborrheic dermatitis and psoriasis: evidence from a multicenter, case-control study during COVID-19 pandemic.

Wearing masks is an optimal preventive strategy during COVID-19 pandemic, but it may increase facial sebum production. However, few case reports have described seborrheic dermatitis (SeBD) and psoriasis (PsO) flares due to masks. Hence, we conducted a multicenter study to clarify the possibility of increased SeBD and PsO flares in association with mask wearing during the COVID-19 pandemic. This multicenter study enrolled patients with a diagnosis of facial SeBD and PsO. All dermatological consultations were conducted in teledermatology at baseline (T0) and after 1 month (T1) Of >6 hours/day wearing mask. PsO patients were assessed using PsO Area and Severity Index (PASI) and self-administered PASI (SAPASI), whilst SeBD patients with symptom scale of seborrheic dermatitis' (SSSD) and seborrheic dermatitis area and severity index (SEDASI). A total of 33 (20 males, 13 females, average age 43.61±9.86) patients with PsO and 33 (20 males, 13 females, average age 44.00±8.58) with SeBD were enrolled. After 1 month, PsO patients displayed higher values of both PASI and SAPASI (P<0.0001), while SeBD patients experienced a flare, as testified by the increment of both SSSD and SEDASI (P<0.0001). Mask type did not seem to influence the flare severity. Masks remain an optimal preventive strategy during COVID-19 pandemic, but patients with PsO and SeBD may experience facial flares. Thus, therapeutic approach should be more aggressive in these groups of patients to counteract the triggering effect of masks.

Factors Influencing Men's Attitudes toward HPV Vaccination in Males Included in the Chinese National Immunization Program.

Background: Human papillomavirus (HPV) infection is the most common sexually transmitted disease, and it is associated with anogenital warts and oropharyngeal and anogenital cancers. Among female malignant tumors in China, the incidence of cervical cancer ranks second, with only breast cancer being more prevalent. HPV infection and related diseases affects both women and men. HPV vaccination is an optimal prevention strategy in preventing HPV infection and related diseases. The inclusion of the HPV vaccine in the national immunization program is an effective way to increase immunization coverage, reduce the burden of HPV related diseases, and increase national life expectancy. Objective: This study aimed to explore the factors influencing the attitudes of Chinese men toward the inclusion of the HPV vaccine in males included in the national immunization program, thus providing reference for launching the national immunization program policy. Methods: We invited men aged 20 to 45 to participate in an online survey. The participants were requested to complete a questionnaire, including sociodemographic characteristics, sexual behavior characteristics, knowledge of HPV and the HPV vaccine, and attitudes toward the HPV vaccine. A logistic regression model was constructed to analyze the influencing factors of attitudes. Results: A total of 660 males in China participated in this survey, and 80.45% supported the inclusion of HPV vaccines in national immunization programs. Participants earning CNY 100,000–200,000 (dds ratio (OR): 0.63, 95% confidence interval (CI): 0.39–1.00) or ≥200,000 (OR: 0.34, 95% CI: 0.17–0.68) were more likely to disapprove this strategy. Compared with people without a history of HPV infection, those with a history of HPV infection (OR: 1.84, 95% CI: 1.17–2.90) were more likely to approve. Men who had better knowledge of HPV were more likely to approve than men with less knowledge about HPV (OR: 1.44, 95% CI: 1.17–1.79). Compared with participants who did not know when the HPV vaccine should be given, those who knew that the ideal time of vaccination is before an individual becomes sexually active (OR: 1.75, 95% CI: 1.04–2.95) were more likely to approve. Conclusion: One in five men did not support the inclusion of HPV vaccines in national immunization programs, and they are likely to be from higher socioeconomic background and have poor knowledge of HPV. In order to implement comprehensive immunity, targeted actions need to be taken at national and public levels. In addition, when implementing measures, more attention needs to be paid to lower income men, men without a history of HPV infection and with poor knowledge of HPV, as well as young men.

Candidemia in cancer patients: phenotypical and molecular-genetic characteristics of antifungal drug resistance, pathogenic factor genes of Candida spp.

Relevance. The global trend of rapid increase in resistance to antifungal drugs due to multiple factors, dictates the need for continuous monitoring of taxonomic structure and susceptibility of nosocomial pathogens, causing invasive fungal infections, for permanent correction of the optimal prevention and treatment strategies. Purpose: to determine antifungal susceptibility of the main yeast pathogens in candidemia in cancer patients, as well as to determine resistance genes and pathogenic factor genes. Material and Methods. Eighty-two strains of Candida spp. isolated from blood of cancer patients from 2015 to 2021 were analyzed. Minimum inhibitory concentrations of fuconazole, voriconazole, posaconazole, anidulafungin and micafungin were determined by a gradient method (E-test, BioMerieux, France). The EUCAST and CLSI criteria were used for MIC value assessment. The genes, associated with pathogenicity factors, and resistance to antifungal drugs were identifed. Results. Our study results based on EUCAST 2020, v.10.0 criteria showed that triazoles, especially fuconazole, were the least effective drugs in empirical therapy for invasive candidiasis (including candidemia). Resistance of Candida spp. fuconazole was superior to that of voriconazole (47.2 % vs 23.2 %, respectively, p&lt;0.01) and posaconazole (47.2 % vs 30.4 %, respectively, p&gt;&lt;0.05). The highest in vitro activity was observed in echinocandins, and anidulafungin was 2 times more active than micafungin (4.1 % of resistant strains vs 11.4 %, respectively), with no statistically signifcant difference (p&gt;0.05). The ERG11 and FKS1 genes associated with resistance to antifungal drugs were detected in 28.6 % of Candida spp. strains. The ERG11 gene was detected in 8.6 % of cases, exclusively in Candida albicans strains. The FKS1 gene was identifed in 20.0 % of strains (85.7 % of them were C. parapsilosis, 7.1 % each were C. tropicalis and C. glabrata). Pathogenic factor genes were identifed in 78.6 % of C. albicans and in 79.1 % of C. parapsilosis strains. Conclusion. Molecular genetic methods for the detection of Candida spp strains carrying resistance genes to antifungal drugs, and the determination of pathogenicity factors are promising trends in searching for biomarkers. They facilitate interpretation of results of microbiological study to assess the ability of Candida spp. strains to develop invasive mycoses.

Cerebral small vessel disease and intracranial bleeding risk: Prognostic and practical significance.

Balancing the risks of recurrent ischemia and antithrombotic-associated bleeding, particularly intracranial hemorrhage (ICH), is a key challenge in the secondary prevention of ischemic stroke and transient ischemic attack. In hyperacute ischemic stroke, the use of acute reperfusion therapies is determined by the balance of anticipated benefit and the risk of ICH. Cerebral small vessel disease (CSVD) causes most spontaneous ICH. Here, we review the evidence linking neuroimaging markers of CSVD to antithrombotic and thrombolytic-associated ICH, with emphasis on cerebral microbleeds (CMB). We discuss their role in the prediction of ICH, and practical implications for clinical decision making. Although current observational data suggest CMB presence should not preclude antithrombotic therapy in patients with ischemic stroke or TIA, they are useful for improving ICH risk prediction with potential relevance for determining the optimal secondary prevention strategy, including the use of left atrial appendage occlusion. Following ICH, recommencing antiplatelets is probably safe in most patients, while the inconclusive results of recent randomized controlled trials of anticoagulant use makes recruitment to ongoing trials (including those testing left atrial appendage occlusion) in this area a high priority. Concern regarding CSVD and ICH risk after hyperacute stroke treatment appears to be unjustified in most patients, though some uncertainty remains regarding patients with very high CMB burden and other risk factors for ICH. We encourage careful phenotyping for underlying CSVD in future trials, with the potential to enhance precision medicine in stroke.

Determination of optimal prevention strategy for COVID-19 based on multi-agent simulation.

This study proposes a direction for the utilization of multi-agent simulation (MAS) to consider an optimal prevention strategy for the spread of the coronavirus disease of 2019 (COVID-19) through a pandemic modeling example in Japan. MAS can flexibly express macroscopic phenomena formed through the interaction of micro-agents modeled to act autonomously. The use of MAS can provide a variety of recommendations for bringing a pandemic under control, even in the case of the COVID-19 pandemic, which has become more intense as of 2021. However, models that do not consider individual heterogeneity, such as analytical Susceptible–Exposed–Infectious–Recovered (SEIR) models, are often used as predictive models for infectious diseases and the main reference for decision-making. In this study, we show that by constructing a MAS that simulates a metropolitan city in Japan in a simple manner while considering the heterogeneity of age and other background information, we can capture the effects of various measures such as vaccinations on the spread of infections in a more realistic setting. Moreover, it is possible to offer various recommendations for optimal strategies to suppress a pandemic by combining reinforcement learning with MAS. This study explicates the potential of MAS in the development of strategies to prevent the spread of infection.

1058-P: Diabetic Ketoacidosis during Pregnancy: Maternal Characteristics and Pregnancy Outcomes

Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with morbidity and mortality. As this condition is rare (affecting 1-3% pregnant women with preexisting diabetes) , available data are limited. The aim of this retrospective cohort study is to present comprehensive data on maternal characteristics and pregnancy outcomes for women with DKA who attended our center for prenatal care from 2001-21. In total 71 DKA episodes were identified in 58 women, of whom 86% (n=50) had type 1 diabetes mellitus and 83% (n=48) were White. The mean (±SD) maternal age was 28 (±7) years and diabetes duration was (±7) years. Pregnancy loss during or within 1 week of the DKA episode occurred in 17% (6 miscarriages and 4 stillbirths) . There were no maternal deaths. Women were poorly prepared for pregnancy [mean 1st trimester HbA1c 9.3 (±2.5) %]. Social stressors were present in 52% (n=30) and 24% (n=14) reported smoking. The mean gestational age at DKA was 25.4 weeks (16.3 weeks for pregnancies with fetal demise vs. 27.5 weeks for livebirths, p&amp;lt;0.001) . Insulin non-adherence was the most common precipitating factor (40%) , followed by infection (23%) , and a new diagnosis of type 1 diabetes (10%) . Pre-existing hyperemesis was associated with fetal demise (31%, n=4 vs. 3%, n=2 among livebirths; p=0.004) . The mean plasma glucose at presentation was 362 mg/dL and the β-hydroxybutyrate was 4.2 mmol/L, with 28 (39%) women requiring intensive care unit (ICU) admission. Among livebirths, the mean gestational age at delivery was 32.7 weeks with 41% (n=21) requiring emergency cesarean. Large for gestational age occurred in 29% (n=17) and 8% (n=4) had shoulder dystocia. Congenital anomaly was present in 10% (n=5) . Neonatal hypoglycemia occurred in 60% (n=29) and neonatal ICU admission was required in 52% (n=25) . In summary, pregnancies affected by DKA continue to be associated with numerous adverse pregnancy outcomes. Future work should focus on optimizing prevention strategies in high-risk women. Disclosure M.Dhanasekaran: None. S.Mohan: None. D.Erickson: None. P.Shah: None. L.M.Szymanski: None. A.Vella: Advisory Panel; Crinetics Pharmaceuticals, Inc., Rezolute, Inc., vTv Therapeutics, Zealand Pharma A/S, Other Relationship; Novo Nordisk. A.M.Egan: None. Funding National Institutes of Health (K12 HD065987/HD/NICHD)

Central venous catheter-associated deep vein thrombosis in critically ill pediatric patients: risk factors, prevention, and treatment

Central venous catheter (CVC) placement and ICU admission are the two most important risk factors for pediatric deep vein thrombosis. The optimal prevention and treatment strategies for CVC-associated deep vein thrombosis (CADVT) are unclear, but recently, seminal studies have been published. This review aims to summarize the recent literature on CADVT in critically ill children. Recent publications focused on three themes: risk factors, prevention, and treatment of CADVT. Newly identified risk factors for CADVT relate to Virchow's triad of hemostasis, blood vessel injury, and hypercoagulability. New risk prediction models have moderately good accuracy in predicting CADVT. Though previous data on pharmacologic CADVT prophylaxis was equivocal, recent studies indicate that low-molecular-weight heparin may be effective in preventing CADVT, particularly in critically ill children. Finally, new studies suggest that direct oral anticoagulants and shorter treatment times are noninferior to traditional agents and treatment durations in the treatment of CADVT. Recent research suggests new ways to accurately identify children at high risk of CADVT, effectively prevent CADVT, and optimize CADVT treatment. Future research should focus on understanding the pathobiology of CADVT formation, prevention, and treatment in critically ill children.

Occupational respiratory diseases: risk assessment, laboratory markers, quality of life

The article is devoted to the definition and assessment of occupational risk, laboratory markers and quality of life in occupational diseases of the respiratory system and in industrial workers who come into contact with high concentrations of industrial fibrogenic aerosols. The conducted research allows assessing the personalized risk, laboratory markers and quality of life in chronic dust bronchitis, silicosis and pneumoconiosis from exposure to highly dispersed welding aerosols, and optimize prevention strategies for this patho

Multimodal strategy to rescue the brain in mild cognitive impairment: Ketogenic oral nutrition supplementation with B vitamins and aerobic exercise

Mild cognitive impairment (MCI) is characterized by a decline in cognition and is associated with a higher risk of progression to dementia and Alzheimer's disease (AD). Considering the complexity and multifactorial etiology of MCI, dementia, and AD, there is a growing understanding that optimal preventive strategies are likely to require targeting several risk factors and mechanisms simultaneously. Recent evidence shows that interventions such as exercise, in particular aerobic exercise (AE), exogenous sources of ketones (namely ketogenic medium-chain triglyceride [kMCT]), and supplementation with vitamins B12 , B6 and folic acid may positively impact cognitive performance in MCI and AD. Although further studies might be necessary to understand the exact pathways through which this occurs, there are reasons to suspect that, in combination, these interventions could have a synergetic effect. In this paper, we hypothesize that a multicomponent cognitive therapy with ketogenic oral nutritional supplementation with vitamins B12 , B6 , and folic acid, and AE could have a synergistic effect and help delay cognitive decline in patients with MCI. Further studies that include objective measurements of cognitive function are needed to confirm this hypothesis.

Wound-Related Complication in Growth-Friendly Spinal Surgeries for Early-Onset Scoliosis-Literature Review.

Background: The treatment for early-onset scoliosis (EOS) is one of the most challenging for pediatric orthopedics. Surgical treatment is often necessary, and wound problems and surgical site infections (SSIs) are common, with potentially severe complications in these patients. The aim of the study was to review current literature according to this complication. Methods: PubMed, Cochrane Library, and Embase were systematically searched for relevant articles by two independent reviewers in January 2022. Every step of the review was done according to PRISMA guidelines. Results: A total of 3579 articles were found. Twenty four articles were included in this systematic review after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of wound-related problems (on average, 15.5%). Conclusion: The literature concerning the definitions, collection, and interpretation of data regarding EOS wound-related complications is often difficult to interpret. This causes problems in the comparison and analysis. Additionally, this observation indicates that data on the incidence of SSI may be underestimated. Awareness of the high rate of SSI of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Validation of Risk Scores for Predicting Atrial Fibrillation Detected After Stroke Based on an Electronic Medical Record Algorithm: A Registry-Claims-Electronic Medical Record Linked Data Study.

BackgroundPoststroke atrial fibrillation (AF) screening aids decisions regarding the optimal secondary prevention strategies in patients with acute ischemic stroke (AIS). We used an electronic medical record (EMR) algorithm to identify AF in a cohort of AIS patients, which were used to validate eight risk scores for predicting AF detected after stroke (AFDAS).MethodsWe used linked data between a hospital stroke registry and a deidentified database including EMRs and administrative claims data. EMR algorithms were constructed to identify AF using diagnostic and medication codes as well as free clinical text. Based on the optimal EMR algorithm, the incidence rate of AFDAS was estimated. The predictive performance of 8 risk scores including AS5F, C2HEST, CHADS2, CHA2DS2-VASc, CHASE-LESS, HATCH, HAVOC, and Re-CHARGE-AF scores, were compared using the C-index, net reclassification improvement, integrated discrimination improvement, calibration curve, and decision curve analysis.ResultsThe algorithm that defines AF as any positive mention of AF-related keywords in electrocardiography or echocardiography reports, or presence of diagnostic codes of AF was used to identify AF. Among the 5,412 AIS patients without known AF at stroke admission, the incidence rate of AFDAS was 84.5 per 1,000 person-year. The CHASE-LESS and AS5F scores were well calibrated and showed comparable C-indices (0.741 versus 0.730, p = 0.223), which were significantly higher than the other risk scores.ConclusionThe CHASE-LESS and AS5F scores demonstrated adequate discrimination and calibration for predicting AFDAS. Both simple risk scores may help select patients for intensive AF monitoring.

Low-dose unfractionated heparin prophylaxis is a safe strategy for the prevention of hepatic sinusoidal obstruction syndrome after myeloablative adult allogenic stem cell transplant.

Hepatic sinusoidal obstruction syndrome (SOS) is a serious complication after allogeneic stem cell transplantation (allo-HCT). However, there is no uniform consensus on the optimal strategy for SOS prevention. Ursodeoxycholic acid is the most used regimen, even though its administration is challenging in recipients unable to tolerate oral medication. Defibrotide was recently studied in a phase 3 trial, but enrollment was stopped early due to futility. Low dose unfractionated heparin (UFH) is an alternative strategy. However, its efficacy is reputed but unproven increased risk of bleeding has not been fully established. We evaluated 514 adult allo-HCT recipients who received SOS prophylaxis with low dose UFH. Bleeding complications occurred in 12 patients 2.3% of patients of which only 2 (0.4%) had significant grade 3 bleeding. Only 14 patients were diagnosed with hepatic SOS. Univariate analysis showed that day 100 SOS was higher in recipients of unmodified grafts when compared to CD34+ selected ex vivo T-cell depleted grafts (p ≤ 0.001), and patients with hepatitis B and/or C exposure pre-HCT (p = 0.028). Overall, UFH was well tolerated and associated with a low incidence of subsequent hepatic SOS. Low dose UFH prophylaxis can be considered in select patients who cannot tolerate oral ursodiol.

Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study.

Background:In patients with intracerebral hemorrhage (ICH) and prevalent atrial fibrillation (AF), the optimal stroke prevention strategy is unclear. We sought to estimate the risk of cerebrovascular events among ICH survivors with AF.Methods:We used the Danish Stroke Registry to identify patients with incident ICH and prevalent AF between 2003 and 2018. Key inclusion/exclusion criteria of the PRESTIGE-AF (Prevention of Stroke in Intracerebral hemorrhage Survivors With Atrial Fibrillation) trial were applied. Cumulative incidence of recurrent ICH, cerebrovascular ischemic event, and all-cause death were investigated after one year.Results:A total of 1885 patients (median age 80.0 years; 47.6% females) were included in the study. We observed 191 cerebrovascular events and 650 all-cause deaths, and more cerebrovascular ischemic events (N=63) than recurrent ICH events (N=40). Risks of recurrent ICH, cerebrovascular ischemic event, and all-cause death were 1.5%, 3.2%, and 30.3%, respectively, among patients not exposed to OAC during follow-up. The cumulative incidences were 2.8% for recurrent ICH, 3.2% for cerebrovascular ischemic events, and 22.0% for all-cause death among patients initiating/resuming OAC during follow-up.Conclusions:We observed a high risk of cerebrovascular ischemic events and a very high risk of all-cause death at one year after the incident ICH. The results of ongoing clinical trials are warranted to determine optimal stroke prevention treatment among ICH survivors with concomitant AF.

Network analysis of Standardbred horse movements between racetracks in Canada and the United States in 2019: Implications for disease spread and control

Horse movements are one of the most important factors for the spread of equine diseases, and past epidemics indicate that contact networks play an important role. Network analysis was used to describe the spatial and temporal characteristics of horse movements between Standardbred racetracks in Canada and the United States during 2019, and to characterize the network to provide a better understanding of the potential racetrack-to-racetrack spread of infectious disease within the network. Networks were constructed and analyzed as an overall network (the entire study period) and monthly networks. There were 254 active Standardbred racetracks in 2019, organized in 24 geographically clustered communities. Movements and subsequent network measures of cohesiveness and centrality exhibited strong seasonal variation. Networks were more highly connected during the summer and early autumn, coinciding with peak racing activities. Monthly networks showed evidence of small-world properties, whereby disease introduction into a racetrack within a local cluster could result in the rapid spread to other racetracks within that cluster, and to other topologically distant clusters through few additional movements. Using centrality measures, a small subset of racetracks were identified as highly influential in the network and could be considered high-risk for disease introduction and disease spread to other racetracks. Enhancement of disease prevention strategies might be most appropriate if targeted to the months associated with peak racing season, and particularly to influential racetracks. The networks produced in this study were not a true representation of the entire contact network as the information contained within the race records only allowed for the consideration of between-racetrack movements. Other non-recorded movements represent further contacts in the network that can have a substantial effect on the spread of disease within a network, and the exclusion of this information can result in incorrect network measure estimates. While likely not an easy task, given the initial findings of this study and experiences from past horse industry infectious disease outbreaks, it could be beneficial for the Standardbred industry to put a movement recording strategy in place. One benefit would be enhanced ability to respond rapidly and efficiently in the event of an outbreak, thereby limiting potential animal health and economic impacts. Additional movement data could also enable further characterization of the network to inform optimal disease prevention and control strategies.