Presence Of Established Risk Factors Research Articles

Atherosclerotic cardiovascular disease events among adults with high predicted risk without established risk factors

ObjectiveAge is the strongest contributor to 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk. Some older adults have a predicted ASCVD risk ≥7.5 %, without established risk factors. We sought to compare ASCVD incidence among adults with predicted ASCVD risk ≥7.5 %, with and without established ASCVD risk factors, to adults with predicted risk <7.5 %. MethodsWe analyzed data from REasons for Geographic and Racial Differences in Stroke study participants, 45–79 years old, without ASCVD or diabetes, not taking statins and with low-density lipoprotein cholesterol 70–189 mg/dL. Participants were categorized into 3 groups based on their 10-year predicted ASCVD risk and presence of established risk factors: <7.5 %, ≥7.5 % with established risk factors and ≥7.5 % without established risk factors. Established risk factors included smoking, systolic blood pressure ≥130 mmHg or antihypertensive medication use, total cholesterol ≥200 mg/dL, or high-density lipoprotein cholesterol <50 mg/dL for women (<40 mg/dL for men). Participants were followed for ASCVD events. ResultsAmong 11,115 participants, 911 incident ASCVD events occurred over a median of 11.1 years. ASCVD incidence rates were 3.6, 12.8, and 9.8 per 1,000 person-years for participants with predicted risk <7.5 %, predicted risk ≥7.5 % with established risk factors and predicted risk ≥7.5 % without established risk factors, respectively. Compared to adults with predicted risk <7.5 %, hazard ratios for incident ASCVD in participants with risk ≥7.5 % with and without established risk factors were 3.58 (95 %CI 3.03 – 4.21) and 2.72 (95 %CI 1.91–3.88), respectively. ConclusionsAdults with a 10-year predicted ASCVD risk ≥7.5 % but without established risk factors had a high ASCVD incidence.

Surgical resection based on ontogenetic cancer field theory for cervical cancer: 10-year updated results of the MMR study.

5539 Background: Previously published findings from our center suggest that carcinoma of the cervix propagates within ontogenetic cancer fields, tissue compartments defined by staged morphogenesis. In the MMR study we aimed to determine whether surgical treatment that accounts for stage-associated, ontogenetic cancer fields and their associated lymphoid tissues results in locoregional tumor control without the need for adjuvant radiotherapy. Methods: The Leipzig School Mesometrial Resection Study (MMR study) is an ongoing, prospective, single-center, observational cohort study including patients with primary cervical cancer. All study participants undergo either total or extended mesometrial resection (TMMR or EMMR) and therapeutic lymph node dissection. Because this treatment strategy enables surgical removal of all locoregional at-risk tissues, no adjuvant radiotherapy is necessary, even in the presence of established risk factors. The trial is registered at the German Clinical Trials Register, number DRKS00015171. For this updated analysis, we identified patients in our institutional study database with primary cervical cancer staged IB1 – IIA2 according to the 2009 International Federation of Gynecology and Obstetrics staging system. Using the Kaplan-Meier estimator, we calculated recurrence free and overall survival. Results: Between October 16, 1999, and December 16, 2020, 420 patients were treated per protocol and followed up for a median of 136 months (IQR 77-190). The median age was 42 years (IQR 36-51). 329 patients (78.3%) had stage IB1, 58 (13.8%) stage IB2, 24 (5.7%) stage IIA1 and 9 (2.1%) stage IIA2 disease. Patients had either squamous cell (n = 297, 70.7%), adenocarcinoma (n = 104, 24.8%), adenosquamous (n = 18, 4.3%) or other (n = 1, 0.24%) histology. The nodal status was pN0 in 349 (83.1%) patients and pN1 in 71 (16.9%) of the cases. Clinically occult parametrial involvement was present in 47 (11.2%) patients. 10-year overall survival was 90.2% (95% confidence interval [CI] 87.1-93.4) and recurrence-free survival was 90.6% (95% CI 87.8-93.6). Stratified for lymph node status 10-year overall survival was 91.7% (95% confidence interval [CI] 88.5-95) for pN0 and 83.2% (95% confidence interval [CI] 74.6-92.9) for pN1. Recurrence-free survival was 93.8% (95% CI 91.2-96.5) for pN0 and 75.4% (95% CI 65.9-86.3) for pN1. Conclusions: Despite dispense of adjuvant radiotherapy, patients treated with total or extended mesometrial resection with therapeutic lymph node dissection have excellent survival outcomes. Additional multicenter studies are needed to further investigate and confirm our results. Clinical trial information: DRKS00015171 .

Lameness prevalence and management practices on Irish pasture-based dairy farms

BackgroundLameness is a painful disease, which negatively impacts dairy cow production and welfare. The aim of this observational study was to determine herd lameness prevalence, describe current lameness management practices and identify the presence of established risk factors for lameness on Irish pasture-based dairy farms. Farms were visited once during grazing (99 farms) and again during housing (85 farms). Lameness scoring was carried out at each visit (AHDB 0–3 scale); cows were classified as lame if they scored two or three. Farm management practices and infrastructure characteristics were evaluated via farmer questionnaires and direct measurements of farm infrastructure.ResultsMedian herd-level lameness prevalence was 7.9% (interquartile range = 5.6 – 13.0) during grazing and 9.1% (interquartile range = 4.9 – 12.0) during housing; 10.9% of cows were lame at a single visit and 3.5% were lame at both visits (chronically lame or had a repeat episode of lameness). Fifty-seven percent of farmers were not familiar with lameness scoring and only one farm carried out lameness scoring. Only 22% of farmers kept records of lame cows detected, and 15% had a lameness herd health plan. Twenty-eight percent of farmers waited more than 48 h to treat a lame cow, and 21% waited for more than one cow to be identified as lame before treating. Six percent of farmers carried out routine trimming and 31% regularly footbathed (> 12 times per year). Twelve percent put severely lame cows in a closer paddock and 8% stated that they used pain relief to treat severely lame cows. Over 50% of farms had at least one cow track measurement that was classified as rough or very rough, and cow tracks were commonly narrow for the herd size. On 6% of farms, all cubicle beds were bare concrete (no matting or bedding) and on a further 6% of farms, there was a combination of cubicles with and without matting or bedding. On 56% of farms, all pens contained less than 1.1 cubicles per cow and on 28% of farms, a proportion of pens contained less than 1.1 cubicles per cow.ConclusionsOverall, this study identified infrastructure and management practices which could be improved upon. The comparatively low lameness prevalence demonstrated, compared to fully housed systems, also highlights the benefits of a pasture-based system for animal welfare; however, there remains scope for improvement.

Evaluation of Risk Factors and Approach to Screening for Asymptomatic Neonatal Hypoglycemia

Introduction: Protocols to identify asymptomatic neonatal hypoglycemia (NH) rely on the presence of established risk factors (late preterm gestation, large or small for gestational age, and infant of a diabetic mother) for inclusion. We analyzed the performance of these risk factors in identifying hypoglycemia in modern practice, and additionally evaluated the optimal duration of screening blood glucose measurements. Methods: We analyzed a retrospective cohort of 830 infants with 1 or more known risk factor(s) for NH admitted to the mother-baby unit of a single tertiary-care center from May 2017 to April 2018. Manual chart review was performed for data extraction and confirmation of risk factor(s). Infants were excluded if glucose measurements were obtained for any reason other than screening for asymptomatic NH. Results: Of the 830 included infants, 31 (3.7%) ultimately received intravenous dextrose (IVD). Most screened infants (n = 510, 61.4%) did not develop hypoglycemia. None of the established risk factors showed strong association with hypoglycemia. Cesarean delivery was associated with hypoglycemia, although not strongly. All infants who received IVD for feeding-refractory hypoglycemia were identified by the first 2 measurements with nearly all (30/31, 97%) identified at the initial measurement. Conclusions: Currently accepted risk factors are limited in their ability to identify infants who subsequently develop hypoglycemia, and as a result, most screened infants do not develop hypoglycemia. The majority of infants in our cohort who did develop hypoglycemia achieved normoglycemia with feeding-based interventions and did not require IVD. Those that received IVD were more likely to develop hypoglycemia early and to a more severe degree. Together, our data suggest further refinement of protocol duration and risk factors utilized for screening as potential areas of screening protocol optimization.

Features of management and vaccination of comorbid patients with rheumatic diseases in a pandemic of a new coronavirus infection

The review presents the results of scientific studies devoted to the features of the course and outcomes of a new coronavirus infection COVID-19 in patients with immuno-inflammatory rheumatic diseases (IIRD). It was noted that the risk of developing COVID-19 for patients with IVR, apparently, is similar to the population or slightly increased and mostly depends on the presence of established risk factors for its severe course (old age, obesity, diabetes mellitus, cardiovascular diseases). Patients receiving long-term immunosuppressive therapy and high doses of glucocorticoids may have a long period of positive viral replication and isolation of a viable virus, which requires dynamic monitoring of such patients and correction of anti-rheumatic therapy. The issues of post-COVID-19 joint syndrome, which can occur within the framework of post-viral arthritis or be the debut of an immuno-inflammatory rheumatic disease, are highlighted. The draft recommendations of the All-Russian Public Organization Association of Rheumatologists of Russia on the management and temporary recommendations of V.A. Nasonova Research Institute of Rheumatology for vaccination of patients with rheumatic diseases in the conditions of the COVID-19 pandemic are presented.

Testosterone and estradiol in men with acute ischemic stroke: A North Indian case control

Background: One intriguing aspect of stroke is its higher incidence in men as compared to women. Endogenous sex hormones, testosterone and estradiol, may be responsible for this difference. This research aims to study serum testosterone and estradiol levels in men with acute ischemic stroke (AIS) and to correlate these levels with National Institutes of Health Stroke Scale (NIHSS) score and infarct size in computed tomography (CT). Methods: 100 male patients with AIS and 100 age-matched controls were included in this case-control study. Patients with hemorrhagic stroke, taking hormonal preparations, or suffering from chronic illnesses like tuberculosis (TB), cancer, etc. were excluded. Complete history was obtained including presence of established risk factors and physical examination was done in cases and controls with informed written consent. Severity of stroke in cases was assessed by the NIHSS. CT scan of brain was performed within 72 hours of patient’s admission to hospital. The infarct size was measured in centimeters as the largest visible diameter of the infarct on CT scan. Fasting blood samples were obtained for routine investigations and estimating estradiol and testosterone levels. Results: Mean total testosterone level in cases (223.30 ± 143.44 ng/dl) was significantly lower than that of controls (515.34 ± 172.11 ng/dl) (P < 0.001), while estradiol levels had no significant statistical difference (P = 0.260). A significant inverse correlation was found between total testosterone levels and stroke severity (r = -0.581, P < 0.001) and also, total testosterone levels and infarct size (r = -0.557, P < 0.001). Estradiol levels in patients had no significant correlation with stroke severity (P = 0.618) or infarct size (P = 0.463). Conclusion: Low testosterone levels are associated with increased stroke severity and infarct size in men. Further studies are required to establish whether low testosterone is a cause or effect of ischemic stroke and also to explore the potential benefits of testosterone supplementation in men with AIS.

Effectiveness of intravenous high-dose methotrexate for prevention of relapse in patients with DLBCL.

e19562 Background: Central nervous system (CNS) relapse develops in 2-10% of patients with diffuse large B cell lymphoma (DLBCL) and has an adverse prognosis. Tools like IPI and CNS-IPI scores identify patients at high risk of systemic or CNS relapse based on the presence of established risk factors ( Schmitz et al. JCO 2016). International guidelines propose prophylactic intravenous high-dose methotrexate (HD-MTX) for patients at high risk of CNS relapse; however, limited data is backing this approach. Methods: We conducted a retrospective review of newly diagnosed DLBCL patients aged 18-75 years treated with curative intent at large academic medical centers in Riyadh, Saudi Arabia, between 2015-2018. Patients who were planned for CNS HD-MTX after cycles 2, 4, and 6 of R-CHOP and received at least one HD-MTX cycle were included. Results: We identified 35 DLBCL patients who received at least one R-CHOP cycle with one cycle of HD-MTX. The median IPI and CNS-IPI score were 3, (range = 0-4) and 3, (range = 0-5), respectively. The median number of R-CHOP cycles received was 6 (range 3-6) and HD-MTX 3 (range 1-6). The overall response rate was 91%, with 3 (9%) primary refractory patients per interim evaluation on cycle 3 of R-CHOP. Achieving complete remission after six cycles of RCHOP was noted in 80%, with four additional patients showed residual disease at the end of treatment evaluation. The entire cohort's overall survival was not reached, and five years estimated survival is 75%. With a median follow-up duration of 37.3 months, none of the patients relapsed after achieving CR at the end of treatment evaluation. The risk of systemic or CNS relapse in our cohort was 0%. In restricting the analysis to CNS-IPI of ≥ 4, a total of 13 patients with a median follow-up of 42 months were included; four patients did not achieve CR by the end of treatment, while nine patients continue to be in CR without any evidence of relapsed disease. Conclusions: High-dose methotrexate with high-intensity chemoimmunotherapy (R-CHOP) seems to be associated with an improvement in the expected rate of CNS relapse. Our data set is small, and a more extensive study evaluating HD-MTX's effectiveness in high-risk DLBCL is warranted.[Table: see text]

A comprehensive, contemporary assessment of the association between hepatosteatosis and coronary artery calcium scoring

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf Liverpool Multiparametric Imaging Collaboration Background Coronary artery calcium (CAC) score is a well-established technique for stratifying an individual’s cardiovascular disease (CVD) risk. Several well-established registries have incorporated CAC scoring into CVD risk prediction models to enhance accuracy. Hepatosteatosis (HS) has been shown to be an independent predictor of CVD events and can be measured on non-contrast computed tomography (CT). We sought to undertake a contemporary, comprehensive assessment of the influence of HS on CAC score alongside traditional CVD risk factors. In patients with HS it may be beneficial to offer routine CAC screening to evaluate CVD risk to enhance opportunities for earlier primary prevention strategies. Methods We performed a retrospective, observational analysis at a high-volume cardiac CT centre analysing consecutive CT coronary angiography (CTCA) studies. All patients referred for investigation of chest pain over a 28-month period (June 2014 to November 2016) were included. Patients with established CVD were excluded. The cardiac findings were reported by a cardiologist and retrospectively analysed by two independent radiologists for the presence of HS. Those with CAC of zero and those with CAC greater than zero were compared for demographic and cardiac risks. A multivariate analysis comparing the risk factors was performed to adjust for the presence of established risk factors. A binomial logistic regression model was developed to assess the association between the presence of HS and increasing strata of CAC. Results In total there were 1499 patients referred for CTCA without prior evidence of CVD. The assessment of HS was completed in 1195 (79.7%) and CAC score was performed in 1103 (92.3%). There were 466 with CVD and 637 without CVD. The prevalence of HS was significantly higher in those with CVD versus those without CVD on CTCA (51.3% versus 39.9%, p = 0.007). Male sex (50.7% versus 36.1% p= &amp;lt;0.001), age (59.4 ± 13.7 versus 48.1 ± 13.6, p= &amp;lt;0.001) and diabetes (12.4% versus 6.9%, p = 0.04) were also significantly higher in the CAC group compared to the CAC score of zero. HS was associated with increasing strata of CAC score compared with CAC of zero (CAC score 1-100 OR1.47, p = 0.01, CAC score 101-400 OR:1.68, p = 0.02, CAC score &amp;gt;400 OR 1.42, p = 0.14). This association became non-significant in the highest strata of CAC score. Conclusion We found a significant association between the increasing age, male sex, diabetes and HS with the presence of CAC. HS was also associated with a more severe phenotype of CVD based on the multinomial logistic regression model. Although the association reduced for the highest strata of CAC (CAC score &amp;gt;400) this likely reflects the overall low numbers of patients within this group and is likely a type II error. Based on these findings it may be appropriate to offer routine CVD risk stratification techniques in all those diagnosed with HS.

Glucocorticoid‐induced diabetes among people without diabetes: a literature review

AbstractThe effect of glucocorticoid on glycaemic control in people with diabetes has been studied extensively in the literature. However, data regarding its effect on glucose homeostasis in those without diabetes are sparse. This review aims to investigate the incidence of glucocorticoid‐induced diabetes among people without diabetes subjected to high‐dose glucocorticoid, to determine its associated risk factors and to examine the effect of high‐dose glucocorticoid on glucose homeostasis.Four databases (Ovid Medline, Scopus, Embase, and PubMed) were searched until August 2017 using the following MeSH terms: ‘glucocorticoid*’, ‘dexamethasone’, ‘diabetes mellitus’ and ‘incidence’. Only studies that included the use of high‐dose glucocorticoid (equivalent to 4 mg dexamethasone per day) for at least seven days in their methodology were included.Nine out of 302 identified studies were included in this review. The incidence of glucocorticoid‐induced diabetes ranged from 1–50%. Pre‐diabetes, age, cumulative dose of glucocorticoid and family history of diabetes were predictors of glucocorticoid‐induced diabetes. The use of high‐dose glucocorticoid aggravated insulin resistance.Most of the studies were retrospective, and used low‐dose glucocorticoid with a short follow‐up period. The incidence of glucocorticoid‐induced diabetes reported varies widely depending on the type, dose and duration of glucocorticoid, the underlying condition and the presence of established risk factors for diabetes. Further prospective studies testing the effect of glucocorticoid in those without pre‐existing risk factors are required to accurately estimate the incidence of glucocorticoid‐induced diabetes. Copyright © 2018 John Wiley &amp; Sons.

Fibrous Dysplasia and Medication-Related Osteonecrosis of the Jaw

Osteonecrosis of the jaw (ONJ) is an established side effect of intravenous bisphosphonates and other antiresorptive medications. Although bisphosphonates are frequently prescribed for patients with the skeletal disorder fibrous dysplasia (FD), there are no reports of ONJ in this population. This has led some to conclude that patients with FD are at low risk for the development of bisphosphonate-related ONJ. Patients were evaluated as part of a longstanding FD natural history study at the National Institutes of Health. Of 76 patients with FD who were treated with bisphosphonates, 4 developed ONJ (5.4%). Three patients developed ONJ in areas of FD-affected bone and 1 in an area of normal bone. All 4 patients had features known to be associated with ONJ in the general population, including long-term high-dose intravenous bisphosphonate treatment, periodontal and endodontic infections, and dentoalveolar surgical procedures. These cases establish ONJ as a potential complication of bisphosphonate treatment in patients with FD. The presence of established risk factors for ONJ in this group of patients with FD suggests that high-risk patients could be identified before the development of ONJ. Clinicians should use caution in prescribing bisphosphonates to patients with FD and should do so only for established indications.

Riesgos y beneficios a largo plazo de la terapia mediante substitución de hormonas

Existe un consenso en cuanto a que las consecuencias a largo plazo de la deprivación ovárica pueden ser prevenidas o reducidas mediante una terapia del hueso trabecular que en uno de cada dos casos resulta en riesgos de por vida de fracturas osteoporósicas. La terapia de substitución hormonal (TSH) previene esta pérdida del hueso y disminuye la incidencia de fracturas. Se recomienda un mínimo de 5 años de tratamiento para lograr beneficios significativos. La evidencia epidemiológica viene acumulándose en cuanto a que la terapia de estrógenos postmenopausia reduce el riesgo de enfermedades cardiovasculares y de apoplejías en cerca de 30% y 70%, aún en presencia de factores de riesgo establecidos. Dada la frecuencia de enfermedades cardiovasculares, ésta viene a ser probablemente una de las ventajas originales de la terapia mediante substitución de hormonas en la próxima década. Las inquietudes acerca de la seguridad a largo plazo de la TSH se han concentrado en el cáncer endometrial y de mama. El incremento del riesgo de cáncer de endometrio asociado con la terapia única con estrógenos es disminuida con la adición secuencia de progesterona por 10 a 12 días de cada ciclo. El posible efecto de la terapia (TSH) en cuanto a riesgos de cáncer de mama debe ser considerada frente a experiencias que indican que uno de cada 12 desarrollan esta enfermedad. Los estudios epidemiológicos que investigan esta relación son revisados en este trabajo. Existe un gran consenso en que la terapia mediante substitución de hormonas (TSH) con una duración de 5 a 6 años no incrementa los riesgos de cáncer de mama. Terapias de mayor duración (10-15 años) se han reportado, que incrementan este riesgo, pese a que no toda la información es conforme. Otros factores, tales como la historia familiar y las enfermedades benignas de mama, también podrían influir en los riesgos de cáncer. Los beneficios potenciales de la terapia de substitución de hormonas frente a la mortalidad y morbilidad son enormes. Frente a esto existe un posible pequeño incremento del riesgo de cáncer de mama con un tratamiento a largo plazo. Debe buscarse un mayor conocimiento de las consecuencias a largo plazo de la menopausia y de beneficios potenciales de la TSH, de manera que las mujeres puedan tomar decisiones informadas acerca de la necesidad de la terapia mediante substitución de hormonas.

1,25-Dihydroxyvitamin D Levels in Pediatric Intensive Care Units: Risk Factors and Association With Clinical Course

Multiple adult and some pediatric critical care studies have suggested that poor vitamin D status is associated with illness severity and outcome. The majority have evaluated vitamin D status through serum 25-hydroxyvitamin D [25(OH)D]. Critical illness-related organ dysfunction may result in impaired conversion of 25(OH)D to the active hormone 1,25-dihydroxyvitamin D [1,25(OH)2D]. Consequently 1,25(OH)2D levels could be an independent additive prognostic marker in the intensive care unit. The distribution of 1,25(OH)2D levels, prevalence of low levels, investigation of risk factors, and tests for associations with markers of illness severity and outcome are reported. This was a secondary analysis of data and samples collected as part of a prospective cohort study in six Canadian pediatric intensive care units (PICUs). Admission blood 1,25(OH)2D concentrations were measured. The median cohort 1,25(OH)2D level was 93.3 pmol/L (interquartile range, 53.0-121.9) with 13% (95% confidence interval, 9-17) and 21% (95% confidence interval, 17-27) of patients having levels of <40 and <50 pmol/L, respectively. Low 1,25(OH)2D levels occurred more often in patients with low 25(OH)D and hepatic, renal, and parathyroid organ dysfunction. After adjustment for 25(OH)D, low 1,25(OH)2D levels were not associated with catecholamine or fluid administration, ventilation, PICU length of stay, or mortality. Critically ill children are at risk for low 1,25(OH)2D levels, particularly in the presence of established risk factors. However, the lack of association between the 1,25(OH)2D level and selected outcome measures, after controlling for 25(OH)D, does not suggest value in measuring this metabolite at the time of PICU admission.

Sudden Cardiac Arrest in a Young Patient with Hypertrophic Cardiomyopathy and Zero Canonical Risk Factors: The Inherent Limitations of Risk Stratification in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is the most common heritable cardiovascular disease and a common cause of sudden cardiac death (SCD) in young adolescents and athletes. Clinical risk stratification for SCD is predicated on the presence of established risk factors; however, this assessment is far from perfect. Herein, we present a 16-year-old male who was resuscitated successfully from his sentinel event of out-of-hospital cardiac arrest. Prior to this event, he was asymptomatic and lacked all traditional SCD-predisposing risk factors for hypertrophic cardiomyopathy.

Rural–urban disparities in the prevalence of diabetes and coronary heart disease

To examine the rural-urban differences in the prevalence of diabetes and coronary heart disease, and the extent to which they are explained by the presence of established risk factors including poverty. Cross-sectional study of more than 214,000 respondents using data from the US Centers for Disease Control and Prevention's (CDC's) 2008 Behavioral Risk Factor Surveillance System. Logistic regression models were utilized; prevalence odds ratios with corresponding confidence intervals and P-values are provided. The crude prevalence rates of diabetes and coronary heart disease were 8.6% (P=0.001) and 38.8% (P<0.001) higher among respondents living in rural areas compared with urban areas, respectively. The higher prevalence in rural areas of many of the common risk factors for these conditions, including poverty (P<0.001), obesity (P<0.001) and tobacco use (P<0.001), may contribute to these findings. After controlling for these and other risk factors, the prevalence of diabetes was lower among respondents living in rural areas [prevalence odds ratio (POR)=0.94, P=0.032], but the prevalence of coronary heart disease was higher (POR=1.09, P=0.011). The higher prevalence of diabetes and coronary heart disease in rural populations in the USA presents a formidable public health challenge. It exacerbates many of the pre-existing rural health disparities, including a lack of access to financial resources and primary care providers.

Prolonged Rhythm Monitoring for the Detection of Occult Paroxysmal Atrial Fibrillation in Ischemic Stroke of Unknown Cause

Atrial fibrillation (AF), commonly encountered in patients with ischemic stroke and transient ischemic attack (TIA), confers a 5-fold increased risk of ischemic stroke.1,2 AF-related strokes are associated with an ≈50% increased risk of disability and 60% increased risk of death at 3 months compared with strokes of other etiologies.3 Paroxysmal AF (PAF), a self-terminating recurrent form of cardiac arrhythmia that comprises between 25% and 62% of AF cases, may present as a brief single episode of arrhythmia or as clusters of abnormal rhythm of variable duration, sometimes evolving into a more persistent or permanent form.4 The self-terminating nature of PAF may lead to its underdiagnosis and consequent use of less effective treatment strategies (aspirin instead of oral anticoagulation) in poststroke patients. To address the underdiagnosis of PAF in patients with ischemic stroke and TIAs, several treatment guidelines have singled out the identification of PAF as an important goal after a stroke/TIA.5–8 The diagnosis of PAF, however, poses a challenge. Several features of AF (such as its brief duration, episodic frequency, and asymptomatic presentations) make its detection difficult and elusive to bedside screening measures, such as pulse monitoring and routine ECGs. To date, several studies have explored the use of prolonged noninvasive and invasive cardiac monitoring devices to identify AF but with variable success. After detection of AF, a cardioembolic mechanism is often inferred and anticoagulation occasionally prescribed for secondary stroke prevention. The routine use of cardiac monitoring to identify patients with PAF who will benefit from anticoagulation has been reported to be cost-effective.9 In this review, we provide an overview of the different methods of cardiac monitoring, summarize studies that investigated the incidence of PAF after stroke, and highlight gaps in our understanding of the pathogenic and prognostic significance of AF …

Risk Perception and Preference for Prevention of Alzheimer's Disease

ObjectivesTo understand how older adults perceive their risk of Alzheimer's Disease (AD) and how this may shape their medical care decisions, we examined whether presence of established risk factors of AD is associated with individuals' perceived risk of AD, and with preference for preventing AD. MethodsParticipants: Data came from the US Health and Retirement Study participants who were asked questions on AD risk perception (N = 778). Measurements: Perceived risk of AD was measured by respondents' estimate of their percent chance (0–100) developing AD in the next 10 years. Preference for AD prevention was measured with questions eliciting willingness to pay for a drug to prevent AD. Analysis: Multivariate linear regressions were used to estimate correlates of perceived risk and preference for prevention. ResultsBetter cognitive functioning and physical activity are associated with decreased perceived risk. Neither age nor cardiovascular disease is associated with perceived risk. African Americans have lower perceived risk than non-Latino whites; the difference is wider among people age 65 and above. Only 4% to 7% of the variation in perceived risk was explained by the model. Preference for prevention is stronger with increased perceived risk, but not with the presence of risk factors. Persons with better cognitive functioning, physical functioning, or wealth status have a stronger preference for prevention. ConclusionSome known risk factors appear to inform, but only modestly, individuals' perceived risk of AD. Furthermore, decisions about AD prevention may not be determined by objective needs alone, suggesting a potential discrepancy between need and demand for AD preventive care.

Non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence

Background and AimsNon-operative management (NOM) of blunt liver trauma is currently, if possible, the preferred treatment of choice. The present study evaluates the experience of blunt liver injury in adults in a Swedish university hospital. Material and MethodsForty-six patients with blunt liver trauma were treated from January 1994 through to December 2004. Patient charts were reviewed retrospectively to examine injury severity score (ISS), liver injury grade, diagnostics, treatment and outcome. ResultsThirty-five patients (76%) were initially treated non-operatively and 11 (24%) patients had immediate surgery. In four (11%) patients, NOM failed and the patients required surgery 8–72h after admission. Patients failing non-operative care had a significantly lower systolic blood pressure on admission as compared with patients with successful NOM (P= 0.001). Patients immediately operated upon had higher ISS (P < 0.001) and were haemodynamically unstable to a greater extent (P < 0.001) as compared with patients initially considered for NOM. Operated patients had increased transfusion requirements (P < 0.001), longer total hospital stay (P= 0.011) and stay in the intensive care unit (ICU) unit (P < 0.001) as compared with NOM. One immediately operated and one failed NOM died (total mortality 4%). Seventeen patients in the NOM group were successfully treated without surgery despite the presence of at least one described risk factor. ConclusionsMost patients with blunt liver trauma can be treated without surgery, and non-operative management may be performed even in the presence of established risk factors.

Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors.

Treatment of blunt splenic trauma has undergone dramatic changes over the last few decades. Nonoperative management (NOM) is now the preferred treatment of choice, when possible. The outcome of NOM has been evaluated. This study evaluates the results following the management of blunt splenic injury in adults in a Swedish university hospital with a low blunt abdominal trauma incidence. Fifty patients with blunt splenic trauma were treated at the Department of Surgery, Lund University Hospital from January 1994 to December 2003. One patient was excluded due to a diagnostic delay of > 24 h. Charts were reviewed retrospectively to examine demographics, injury severity score (ISS), splenic injury grade, diagnostics, treatment and outcome measures. Thirty-nine patients (80%) were initially treated nonoperatively (NOM), and ten (20%) patients underwent immediate surgery (operative management, OM). Only one (3%) patient failed NOM and required surgery nine days after admission (failure of NOM, FNOM). The patients in the OM group had higher ISS (p < 0.001), higher grade of splenic injury (p < 0.001), and were hemodynamically unstable to a greater extent (p < 0.001). This was accompanied by increased transfusion requirements (p < 0.001), longer stay in the ICU unit (p < 0.001) and higher costs (p = 0.001). Twenty-seven patients were successfully treated without surgery. No serious complication was found on routine radiological follow-up. Most patients in this study were managed conservatively with a low failure rate of NOM. NOM of blunt splenic trauma could thus be performed in a seemingly safe and effective manner, even in the presence of established risk factors. Routine follow-up with CT scan did not appear to add clinically relevant information affecting patient management.

Methylphenidate use in children and risk of cancer at 18 sites: results of surveillance analyses

A recent report linked methylphenidate (MPH) use in children to cytologic abnormalities in plasma lymphocytes, a possible cancer biomarker. The purpose of this study was to investigate the association of MPH use and childhood cancer risk. Using automated pharmacy databases and the SEER-affiliated cancer registry of the Kaiser Permanente Medical Care Program (KPMCP), we compared cancer rates at 18 sites among 35,400 MPH users who received it before age 20 to rates among KPMCP membership (age, sex, and calendar year standardized). Medical records of MPH exposed cancer cases were reviewed to identify the presence of established risk factors. There were 23 cancers among MPH users, versus 20.4 expected (standardized morbidity ratio, SMR = 1.13, 95% confidence interval (0.72, 1.70)). Given the small number of cancers, site-specific SMR estimates were imprecise. Only one SMR was statistically significant at the p < 0.05 level, which given the number of comparisons is consistent with the absence of a true association at any site. MPH use was associated with increased risk of lymphocytic leukemia (SMR = 2.64 (1.14, 5.20)), based on eight observed cases). The medical records of these exposed cases did not reveal any lymphocytic leukemia risk factors (prior cancer, radiotherapy or chemotherapy, or Down syndrome). Our results are consistent with no moderate or strong association between MPH use and cancer risk in children, although our ability to examine dose and duration of use or risk at specific sites was limited by small numbers. Further study of MPH use and lymphocytic leukemia risk is needed to determine whether our results are due to chance alone.

Health behaviors, body composition, and coronary heart disease risk in women with multiple sclerosis

Slawta JN, Wilcox AR, McCubbin JA, Nalle DJ, Fox SD, Anderson G. Health behaviors, body composition, and coronary heart disease risk in women with multiple sclerosis. Arch Phys Med Rehabil 2003;84:1823–30. Objectives To explore coronary heart disease risk in a sample of women with multiple sclerosis (MS) by identifying the presence of established risk factors for coronary heart disease and to determine the relationship between disease severity and level of participation in health-related behaviors. Design Survey study. Setting Five general community settings in Oregon. Participants Women with physician-diagnosed MS (N=123) recruited from MS chapters, physician referrals, and newspaper announcements. Interventions Not applicable. Main outcome measures Modified Yale Physical Activity Survey, Block Food Frequency Questionnaire, blood analysis, skinfolds, and waist and hip circumferences. Results The majority of women met current physical activity guidelines. The frequencies of unfavorable levels of metabolic variables and obesity were similar to those reported in the general population. Significant associations were observed between mobility and physical activity, total and abdominal fat, and several dietary habits. Conclusion Coronary heart disease risk in this sample was comparable to that of the general population of women without MS. Physical inactivity, body composition, and perhaps nutritional habits decline with decreasing mobility, emphasizing the need for families and health care providers to work together to find solutions that increase health-promoting behaviors in women with more advanced MS.