Intraoral Ultrasound versus MRI for Depth of Invasion Measurement in Oral Tongue Squamous Cell Carcinoma: A Prospective Diagnostic Accuracy Study

Oral squamous cell carcinoma (OSCC) of the tongue is the most common type of oral cavity cancer, and tumor depth of invasion (DOI) is an important prognostic factor. In this study, we investigated the accuracy of intraoral ultrasound and magnetic resonance imaging (MRI) for assessing DOI in patients with OSCC. Histopathological measurement of DOI was used as a reference standard. We conducted a prospective study including patients planned for surgical treatment of OSCC in the tongue. The DOI was measured in an outpatient setting by intraoral ultrasound and MRI, and was compared to the histopathological DOI measurements. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for ultrasound and MRI, and the Wilcoxon signed-rank test was used to test for significance. The correlation was evaluated using Pearson's correlation coefficient. We included 30 patients: 26 with T1 or T2 tumors, and 4 with T3 tumors. The mean difference from histopathology DOI was significantly lower for ultrasound compared to MRI (0.95 mm [95% LOA -4.15 mm to 6.06 mm] vs. 1.90 mm [95% LOA -9.02 mm and 12.81 mm], p = 0.023). Ultrasound also led to significantly more correct T-stage classifications in 86.7% (26) of patients compared to 56.7% (17) for MRI, p = 0.015. The Pearson correlation between MRI and histopathology was 0.57 (p < 0.001) and the correlation between ultrasound and histopathology was 0.86 (p < 0.001). This prospective study found that intraoral ultrasound is more accurate than MRI in assessing DOI and for the T-staging of oral tongue cancers. Clinical practice and guidelines should implement intraoral ultrasound accordingly.

Oral fluoroquinolones and risk of aortic dissection and aortic aneurysm: a nationwide nested case-control study

Background

Oral fluoroquinolones are commonly prescribed antibiotics. Observational studies have shown an association between fluoroquinolone-use and subsequent risk of aortic aneurysm (AA) and aortic dissection (AD) due to a potential collagen degrading effect of fluoroquinolones.

Purpose

To investigate if fluoroquinolone-use was associated with increased rates of AA or AD in patients without known aortic disease. Secondly, to investigate if fluoroquinolone-use was associated with increased all-cause mortality and aortic interventions in high-risk patients with known aortic disease.

Methods

We used a nested case-control study design in which individuals aged 30–100 years from 2003 to 2018 were included from Danish nationwide registers. Exclusion criteria were bicuspid aortic valve, coarctation of the aorta, and connective tissue disease. A main cohort and a secondary high-risk cohort were defined. The main cohort comprised patients without history of AA/AD in which two case definitions were used: 1) A broad case definition of first-time AA/AD. 2) A severe case definition of ruptured AA/AD. The high-risk cohort comprised patients surviving index AA/AD admission in which cases were defined as all-cause mortality and aortic interventions.

Cases were matched on age, sex, and year of inclusion in a 1:30 ratio with controls. For the main cohort, a potential dose-response effect was investigated using groups of cumulative defined daily doses (cDDD) of fluoroquinolones. Hazard ratios (HR) with 95% confidence intervals (CI) for fluoroquinolone-use compared with amoxicillin as an active comparator were obtained from time-dependent Cox regression models using multiple exposure windows.

Results

The main cohort comprised 4.81 million individuals with 43,280 cases. Short-term 30-day, intermediate-term 90-day, and long-term 1-year fluoroquinolone use were all not associated with AA/AD (30-day HR 1.18 [95% CI: 0.84 to 1.66]; 90-day HR 1.12 [95% CI 0.96 to 1.30]; 1-year HR 1.00 [95% CI 0.93 to 1.07]). Using a severe case definition of ruptured AA/AD yielded comparable results. For the dose-response analysis, increasing cDDD did not confer increased rates of AA/AD (1–5 cDDD: Reference group; 6–10 cDDD: HR 1.03 [95% CI: 0.87 to 1.23]; &gt;10 cDDD: HR 1.00 [95% CI 0.83 to 1.29]) (Figure 1).

The secondary high-risk cohort included 20,195 patients surviving index admission with 9,183 cases of all-cause mortality and 1,768 cases of aortic interventions. The 30-day HR for all-cause mortality was 1.21 (95% CI 0.92 to 1.60) and the 60-day HR 1.06 (95% CI 0.89 to 1.26). No association with aortic interventions was found either (Figure 2).

Conclusion

Fluroquinolone-use was not associated with AA/AD. Furthermore, fluoroquinolone-use was not associated with all-cause mortality or aortic interventions in potentially susceptible patients with known aortic disease. These findings do not support an increased risk of AA/AD with fluoroquinolone-use.

Funding Acknowledgement

Type of funding sources: None.

Risk of heart failure following short-term non-steroidal anti-inflammatory drug use in patients with type 2 diabetes mellitus

Background

Fluid retention is a known but underappreciated side-effect of non-steroidal anti-inflammatory drug (NSAID) use. As type 2 diabetes mellitus (T2DM) has been linked to both subclinical cardiomyopathy and a decline in kidney function, short-term NSAID use could lead to subsequently development of heart failure (HF) due to aberrations in fluid balances.

Purpose

We investigated associations between short-term NSAID use and the risk of HF in a nationwide cohort of patients with T2DM.

Methods

Using nationwide Danish registers, we identified patients diagnosed with T2DM during 1998–2018. Follow-up began 120 days after first-time T2DM diagnosis among patients without prior heart failure or a rheumatological diagnosis indicating long-term NSAID use.

To describe use of NSAID among patients with T2DM, we reported proportions of patients claiming at least 1, 2, 3 or 4 prescriptions of NSAID within one year of start of follow-up. We investigated associations between use of NSAIDs (celecoxib, diclofenac, ibuprofen and naproxen) and new-onset HF hospitalizations using a case-crossover design with 28-day exposure windows and reported odds ratios (OR) with 95% confidence intervals (CI). The case-crossover design uses each individual as his or her own control making it suitable to study the effect of short-term exposure on immediate events while mitigating unmeasured confounding. Sensitivity analyses using exposure windows of 14 and 42 days were performed as well.

Results

A total of 334,950 patients with T2DM was included (47.7% female, median age of 61 [interquartile range 50–70]). Celecoxib and naproxen were rarely used; on the contrary, prescriptions of diclofenac and ibuprofen were claimed at least once within one year from the beginning of follow-up by 4.9% and 15.5% of patients, respectively–0.9% and 2.7% claimed at least four prescriptions (Figure 1).

The risk of new-onset HF hospitalization was increased following use of diclofenac or ibuprofen with corresponding ORs of 1.3 (95% CI 1.0 to 1.7) and 1.3 (95% CI 1.1 to 1.5) using 28-day exposure windows. An increased risk following use of celecoxib or naproxen was not found (Figure 2).

Conclusion

NSAIDs diclofenac and ibuprofen were both widely used and associated with an increased risk of new-onset HF hospitalization in patients with T2DM. This suggests a previously unknown and serious, clinically relevant concern of NSAID use in patients with T2DM.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondHelsefonden

Cardiovascular risk following cannabinoid treatment for patients with chronic pain

Background

Treatment with medical cannabis for chronic pain is in popular demand, and a rising number of countries allow physicians to prescribe medical cannabis for pain management. However, data on drug-safety is scarce. Studies have showed a risk of cardiovascular side effects following use of recreational cannabis warranting further investigations into the safety of prescribing medical cannabis.

Purpose

We investigated risk of new-onset arrhythmias (tachy- or bradyarrhythmia and conduction disorders), acute coronary syndrome (ACS) and heart failure (HF) following use of prescribed medical cannabis compared with no use in a nationwide cohort of patients with chronic pain.

Methods

Using nationwide Danish registers, a cohort of patients with chronic pain and without prior history of arrhythmias, ACS, HF or prescribed medical cannabis (cannabinoid, cannabidiol or dronabinol) use were followed from 2018–2021. Any patient from the cohort initiating first-time treatment with medical cannabis was identified and matched 1:10 to corresponding controls within the cohort using incidence density sampling. Matching parameters were age group, sex, and chronic pain diagnosis. Follow-up was initiated at the date of the first claimed prescription of medical cannabis or the corresponding date among controls. We reported 180-day standardized absolute risks (AR) with 95% confidence intervals (CI) and risk ratios (RR) from fitted multivariable logistic regression models comparing patients exposed to medical cannabis with patients not exposed. Separate analyses for each chronic pain group were conducted as well.

Results

Among 1.6 million patients with chronic pain, 4,562 patients claimed at least one prescription of medical cannabis (exposed) and were each matched to 10 controls (non-exposed). Exposed and non-exposed patients were identical in relation to matching parameters; however, exposed patients were slightly more comorbid, and a larger proportion was concomitantly treated with other pain medication (Table). The risk of new-onset arrhythmia was elevated among exposed patients with 180-day AR of 0.71% (95% CI 0.47%–0.94%) compared with 0.43% (95% CI 0.37%–0.49%) yielding a RR of 1.64 (95% CI 1.04–2.23). The risk of new-onset ACS and HF was not increased comparing exposed to non-exposed with corresponding 180-day ARs of 0.13% (95% CI 0.03%-0.23%) vs 0.11% (95% CI 0.08%–0.14% and 0.13% (95% CI 0.03%–0.24%) vs 0.14% (95% CI 0.11%–0.17% (corresponding RRs of 1.2 [95% CI 0.3–2.1] and 0.9 [95% CI 0.2–1.7]) (Figure). Subgroup analyses of each chronic pain group yielded similar results.

Conclusion

In a nationwide cohort of patients with chronic pain, use of medical cannabis was associated with a 64% risk increase of arrhythmias compared with no use. This poses a potential health concern and is vital knowledge for any physician prescribing medical cannabis. Use of medical cannabis was not associated with an elevated risk of ACS or HF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondHelsefonden

Temporal trends, characteristics and comorbidities of patients with hypertrophic cardiomyopathy in Denmark from 2005 to 2018: a nationwide cohort study

Background

The majority of patients with Hypertrophic cardiomyopathy (HCM) are mildly symptomatic or unaware of their condition, but some develop serious complications such as heart failure, atrial fibrillation (AF) as well as sudden cardiac death. Previous studies have suggested that HCM detection-rates in women are significantly lower than in men. This leads to diagnosis often being delayed to later stages of the disease in women, where symptoms are more severe. Further characterization of HCM patients to improve early detection of adverse outcomes and warning signs might improve long-term outcomes.

Purpose

To describe the characteristics of Danish patients diagnosed with HCM between 2005–2018 and determine trends and changes in these factors over time.

Methods

All patients aged 16 years or older with a diagnosis of HCM between the 1st of January 2005 and the 31st of December 2018 were identified in Danish nationwide administrative registers and included in the study.

Time trends were calculated, and differences analyzed using the Cochran-Armitage trend test and linear regression.

Results

A total of 3856 patients were diagnosed with HCM in the study period and included in the study. The median age at diagnosis was 68 years (IQR 56 and 78 years), 53% were male, and 44% were diagnosed with obstructive HCM, while the number of patients diagnosed with HCM each year overall increased. At the time of diagnosis, 22,3% patients were previously diagnosed with ischemic heart disease, 17% with AF, 7,5% with ischemic stroke, 13,6% with heart failure. Median age and gender distribution remained stable over time, while the proportion of obstructive HCM among the newly diagnosed decreased (p = &lt;0.001) (Figure1). During the study period, there was a significant decrease in the prevalence of heart failure (p = &lt;0.001), ischemic heart disease (p = &lt;0.001), and chronic obstructive pulmonary syndrome (p = &lt;0.001), while the prevalence of AF, hypertension and ischemic stroke remained stable (Figure 2).

Conclusion

Despite previous studies describing a gender gap in patients diagnosed with HCM, gender distribution was near equal in this cohort. The number of patients diagnosed with non-obstructive HCM is increasing and the prevalence of comorbidities such as heart failure, ischemic heart disease, and COPD decreased over time.

Whether these findings are the result of improved early detection of HCM warrants further research and examination.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Herlev-Gentofte Hospital, Denmark

Atrial fibrillation and stroke risk of patients with hypertrophic cardiomyopathy in denmark from 2005-2018: a nationwide cohort study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Internal funding: Herlev-Gentofte Cardiovascular Research Department.

Background

Hypertrophic cardiomyopathy (HCM) can be associated with serious complications such as heart failure, atrial fibrillation (AF) and sudden cardiac death. The treatment of AF in HCM patients can be challenging since AF often aggravates symptoms. Previous studies have suggested that HCM patients with AF have an elevated risk of thromboembolism and stroke compared to AF patients without HCM regardless of their CHA2DS2VASc score.

Purpose

To determine the risk of AF and stroke in HCM patients.

Methods

Through the Danish National Registers all patients aged 16 or older diagnosed with HCM between the 1st of January 2005, and the 31st of December 2018 were included in the analysis. The association between HCM, AF, and stroke was investigated using multivariable Cox proportional-hazard analysis adjusted for gender, age, atrial fibrillation, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease and hypertension. Cumulative incidence of AF and stroke was calculated using the Aalen-Johansen estimator, taking death as a competing risk into account.

Results

A total of 3856 patients were included, 2060 (53,4%) were male and median age of 67,8 (IQR 56 and 77,8) years. During the study period, 384 (10%) patients were diagnosed with AF. The risk of AF was significantly lower in males (HR 0,72 (0,59–0,90), p-value = 0.003) and for patients below 60 years (HR 0,18 (0,12–0,27), p-value = &lt;0.001). (Figure 1)

157 (4,1%) of the HCM patients developed stroke. The risk of developing stroke was significantly decreased for patients aged under 60 (HR 0,32 (0,2–0,52), p-value = &lt;0.001). There was no increased risk of stroke comparing genders.

Stroke risk was further analyzed in patients with known AF at time of inclusion, 656 (17%) in total. Compared to patients without AF and adjusted for age, gender and co-morbidities, there was no significant difference in stroke risk between these groups (HR 1.2 (0,81-1,76), p-value = 0.36). (Figure 2)

Conclusion

AF and stroke are common complications in HCM. Women are more susceptible to developing AF than men, and age over 60 at the time of diagnosis was associated with significantly higher risk of AF and stroke. HCM patients with previously known AF did not have a significantly elevated risk of stroke. More research will be needed to further explore these connections.

Recurrence rates of atrial fibrillation ablation according to body mass Index, a nationwide, registry-based danish study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk supported the project.

Background

The proportion of people with obesity is rapidly rising, and the number of overweight patients undergoing ablation for atrial fibrillation (AF) is also increasing. The link between body mass index (BMI), and AF prevalence is well-established but the impact of BMI on the risk of recurrent AF after ablation is less elucidated. Therefore, data pertaining to recurrence rates of ablations according to BMI in large, unselected cohorts of patients is still warranted.

Purpose

To examine the risk of recurrent AF after AF ablation by BMI.

Method

Using Danish nationwide registries, all Danish patients above 18 years who underwent first-time AF ablation from January 1st 2010 to December 31st 2018 were identified and included at the date of ablation. The patients were categorized by BMI; underweight: &lt; 18.5 kg/m2; normal weight: 18.5-24 kg/m2; overweight 25-29 kg/m2; obese 30-34 kg/m2; morbidly obese &gt; 34 kg/m2. Recurrent AF was defined using a composite endpoint comprising claimed prescriptions of anti-arrhythmic drugs, hospital admissions due to AF, re-ablation, or electrical cardioversions. The cumulative incidence of recurrent AF by BMI at 1- and 5-year follow-up after a blanking period of 90 days, was estimated using the Aalen-Johansen estimator, takin death as competing risk in to account. The relative rates of recurrent AF by BMI were examined using Cox models adjusted for sex, age, procedure-year, heart failure, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, and diabetes.

Results

The study cohort consisted of 9,229 patients. Median age [IQR] decreased from 64 [60, 75] in the normal weight group to 60 [53, 66] in the morbidly obese. The number of patients with a CHA2DS2-VASc score of 2 or more increased from 48% in normal-weight to 65% in morbidly obese. Use of amiodarone increased by BMI category, while the use of Class 1C anti-arrhythmic medication remained stable.

Figures 1 and 2 show the 1- and 5-year cumulative incidence of recurrent AF, Hazard Ratios (HR), and 95% Confidence Intervals (CI 95%) stratified by BMI categories and depict that the risk of recurrent AF increased incrementally and significantly in overweight groups compared to normal weight patients, both in 1- and 5-year follow-up. Underweight patients demonstrated non-significantly increased risk of recurrent AF, both in 1- and 5-year follow-up.

Conclusion

In this large nationwide study examining recurrent AF post AF ablation, we found that recurrence rates of AF increased incrementally according to BMI, both in short- and long-term follow-up. Therefore, aggressive weight management in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

Oral anticoagulants in older patients with atrial fibrillation: insights from a nationwide study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Bayer

Background

Atrial fibrillation (AF) is a predominant risk factor of ischemic stroke and prophylactic treatment with oral anticoagulants (OACs) is recommended in older patients. Advancing age increases the risk of stroke, however, ageing simultaneously increases the prevalence of bleeding risk factors such as multimorbidity, polypharmacy, frail vessels as well as the tendency to fall. As such, treatment with OACs in older frail patients is often associated with complex risk-benefit considerations.

Purpose

To examine treatment patterns with OACs in older patients with AF.

Methods

Using nationwide registries and databases, Danish patients &gt; 75 years of age with a primary diagnosis of AF between 2010 and 2018 were identified. The primary event of interest was claimed prescriptions for OACs in a period of 180 days after hospital contact due to AF. Proportions of patients treated with OACs were estimated and depicted graphically. Clinical factors associated with the probability of receiving OAC treatment were identified using adjusted logistic regression models with estimates presented as Odds Ratios (OR) with 95% Confidence Intervals (95% CI).

Results

A total of 40,027 patients were included with a slight majority of women (54%). The median age was 81 years (IQR 78-86). We found that an overall 32,235 patients (81%) were prescribed an OAC after hospital contact due to AF. Increasing age was associated with a clear tendency toward a decreased probability of receiving OAC treatment. As such, among patients aged 75 years, 85 % received OAC treatment decreasing to 68 % in patients aged 90 years. (Figure 1)

Collectively during the study period, a substantial increase in the proportion of patients treated with OACs was observed. Hence, in 2011, 63 % claimed OAC prescriptions whereas this proportion increased to 92 % in 2018. (Figure 2)

Factors related to a low probability of OAC treatment were bleeding risk factors such as a history of bleeding (OR 0.58, 95% CI 0.53-0.82), hemorrhagic stroke (OR 0.21, 95% CI 0.16-0.27), treatment with dual antiplatelet therapy (OR 0.52, 95% CI 0.47-0.59) as well as markers of frailty such as osteoporosis (OR 0.78, 95% CI 0.71-0.85) and previous falling (OR 0.56, 95 % CI 0.51-0.62).

Conclusions

In this large nationwide study, we found that in older patients with AF, the overall rates of OAC prescription were relatively high (~ 80%) but decreased notably with age. Factors associated with not receiving guideline directed OAC treatment were generally related to bleeding risk factors or frailty. These data highlight a clinical conundrum as older patients potentially benefit the most from treatment with OACs.

Figure legend

Figure 1

Combined plot depicting the absolute number of patients by age (red bars) as well as the proportion of patients treated with oral anticoagulants by age (blue curve).

Figure 2

Plot depicting the proportion of patients receiving treatment with oral anticoagulants by calendar year.

Beta-blocker treatment in atrial fibrillation with chronic obstructive pulmonary disease: a Danish nationwide study from 1995 to 2015

Background

Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) often coexist. Beta-blockers are a mainstay of treatment in AF and are considered safe in COPD patients after myocardial infarction, though real-life studies have demonstrated significant under-use. Little is known on the utilization patterns in patients with AF and COPD.

Purpose

To investigate the temporal trends of beta-blocker utilization in patients following first diagnosis of AF in a hospital setting, with and without concomitant COPD, and determine clinical factors associated with beta-blocker use.

Methods

A nationwide study from 1995 to 2015 using data from the comprehensive Danish health registers. All patients with first registered AF diagnosis in a hospital setting were included. Beta-blocker use was identified by claimed prescriptions within 90 days following AF diagnosis. Factors associated with beta-blocker use or non-use in COPD patients during the most recent period (2010–2015) was examined using multivariable logistic regression and presented as odds ratios (OR) with 95% confidence intervals (95% CI).

Results

A total of 264 180 patients were included, of these 31 981 (12.1%) had COPD. Patients with concurrent COPD were older than those without COPD (median age 76 vs. 74 years), the proportion of males was similar (54%) and patients with COPD had more comorbidities, particularly cardiovascular disease. Across the 21-year study period, fewer patients with COPD used beta-blockers after AF diagnosis, than those without COPD (38.8% vs. 53.2%, p&lt;0.001). Beta-blocker use increased in both groups during the study period (Figure 1). Nevertheless, the proportion of users was consistently lower among patients with COPD, although the difference was smaller during the most contemporary year (2015: 55.5% vs. 61.6% in COPD vs. non-COPD respectively).

Predictors for decreased beta-blocker use included high age, COPD severity represented by use of triple inhaled therapy (OR 0.84 [95% CI 0.77–0.92]), and a history of frequent COPD exacerbations (OR 0.80 [95% CI 0.74–0.86]) (Figure 2).

In a subgroup of COPD patients with complete clinical data from the Danish Register of COPD, severe airflow limitation (Forced Expiratory Volume in 1 second &lt;30% of predicted) and high grade of dyspnoea (Modified Medical Research Council Dyspnoea scale 3–4) were associated with decreased odds for beta-blocker use (OR 0.48 [95% CI 0.38–0.59] and OR 0.67 [95% CI 0.55–0.80], respectively).

Conclusions

Beta-blocker use in patients with AF and concurrent COPD have increased considerably over a 21-year period yet remained less used than in patients without COPD. The severity of COPD was a strong negative predictor for beta-blocker use following AF diagnosis, suggesting a fear for adverse effects. The lower use of beta-blocker treatment in patients with severe COPD and AF might suggest underuse and warrants further evaluation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Naestved - Slagelse - Ringsted Hospitals, Region Sjaelland, Denmark Figure 1. Temporal trends of beta-blocker useFigure 2. Factors associated with beta-blocker use

No effects of a 6-week intervention with a glucagon-like peptide-1 receptor agonist on pancreatic volume and oedema in obese men without diabetes

AIM

To investigate the effect of a glucagon-like peptide-1 receptor agonist (GLP-1RA), liraglutide, on pancreatic volume, oedema, cellularity and DNA synthesis in humans.

MATERIALS AND METHODS

We performed an open-label study in 14 obese men (age 38 ± 11 years, body mass index 32 ± 4 kg/m² ) without diabetes. Subjects were examined at baseline, during titration (week 4) of liraglutide towards 3.0 mg/day, and 2 weeks after steady-state treatment (week 6) of a final dose of liraglutide. The primary endpoint was pancreatic volume determined by magnetic resonance imaging. Secondary endpoints included pancreatic oedema and cellularity, positron emission tomography-based [¹⁸ F]fluorothymidine (FLT) uptake (DNA synthesis) and plasma pancreatic enzymes.

RESULTS

Plasma amylase (+7 U/L [95% confidence intervals 3-11], P < .01) and lipase (+19 U/L [7-30], P < .01) increased during liraglutide treatment. Pancreatic volume did not change from baseline to steady state of treatment (+0.2 cm³ [-8-8], P = .96) and no change in pancreatic cellular infiltration was found (P = .22). During titration of liraglutide, FLT uptake in pancreatic tissue increased numerically (+0.08 [0.00-0.17], P = .0507).

CONCLUSIONS

Six weeks of treatment with liraglutide did not affect pancreatic volume, oedema or cellularity in obese men without diabetes.

Time trends and patient selection in the use of continuous electrocardiography for detecting atrial fibrillation after stroke: a nationwide cohort study

BACKGROUND AND PURPOSE

Clinical use of continuous electrocardiography (cECG) for detecting atrial fibrillation (AF) after stroke is unclear. In a Danish nationwide cohort, we described post-stroke time trends in outpatient cECG usage and AF incidence and characterized factors associated with cECG use.

METHODS

Patients without AF discharged after their first ischaemic stroke between 2010 and 2016 were identified from Danish nationwide registries. cECG included Holter or event recording within 120 days from discharge. Cumulative incidence analysis and multivariable adjusted logistic regression were used to assess time trends and factors associated with cECG usage and AF.

RESULTS

The study population comprised 39 641 patients. Cumulative use of cECG increased threefold from 3.3% [95% confidence intervals (CI), 2.8-3.8] in 2010 to 10.5% (95% CI, 9.7-11.3) in 2016. Correspondingly, cumulative incidence of post-stroke AF increased from 1.9% (95% CI, 1.5-2.3) to 2.8% (95% CI, 2.4-3.2). Of all cECG-evaluated patients, 6.3% received an AF diagnosis versus 2.2% of the unevaluated. Receiving cECG was associated with increased odds of AF (odds ratio, 3.4; 95% CI, 2.8-4.0). Lower age, milder strokes and less comorbidity were associated with increased odds of receiving cECG. In contrast, risk factors for AF were increasing age and more comorbidity.

CONCLUSIONS

Post-stroke outpatient cECG use and AF incidence have increased over time, but screening rates were low. cECG use was associated with tripled odds of detecting AF. There was a disparity between factors associated with cECG use and risk factors of AF. This raise questions as to the appropriateness of the current clinical approach to post-stoke AF detection.

Families' Adherence to a Family-Based Childhood Obesity Intervention: A Qualitative Study on Perceptions of Communicative Authenticity

Childhood obesity is associated with severe physical and psychological health problems. Interventions are often directed at the whole family, but the literature provides no clear indication of the characteristics of an effective family-based intervention. The objective of the present paper is to study whether and how an analytical framework focusing on communicative authenticity can be used to observe and elaborate upon aspects of adherence in relation to health behavior change in a concrete family-based intervention. We do this by focusing on the families' experiences with a Shared-care health education intervention and thus explore the association between families' self-reported experience and their adherence to the intervention. The dataset consists of 21 in-depth semi-structured family interviews. The study shows that the Shared-care model has potential, but that this potential is rarely fulfilled in the intervention form under study. The sharing of care adds potential for several kinds of communicative authenticity because families are met by both the medical knowledge authority at the hospital and the local nurses in their municipality. It is, however, a significant finding that the families rarely benefit from this potential authenticity. Using theories of authenticity in this context adds theoretical and analytical potential and manages to incorporate elements of participation in tasks and practices of value, a sense of who we are and what we know, negotiation of meaning, emphatic caring, consistency between values and actions, and horizons of significance. The article brings new perspectives on how family-based interventions could be tailored to communicatively suit individual families.

[Christmas article: The best bubbles - radiology as sommelier]

INTRODUCTION

The aim of the study was to assess bubble characteristics in three different sparkling wines, two different sparkling waters, one standard beer and one demineralised water for ironing with CT, MRI and ultrasound (US). Furthermore, the correlation between personal taste and the measured bubble intensity should be assessed.

METHODS

The study was carried out as a prospective study. All liquid samples were scanned in three rounds, and the outcomes were measured blinded. Afterwards four healthy volunteers from a department of radiology tasted all samples: three sparkling wines with different ages, two tiers of sparkling waters, one pilsner beer and demineralised water for ironing. The main outcome measures were: bubble size, intensity and decay, evaluated with MRI and US and Hounsfield units (HU) from CT. Foam, bubble intensity, smell and colour were evaluated from a custom-made questionnaire.

RESULTS

The decay of bubbles in sparkling wine and beer was slower than in sparkling water as seen on US and MRI, and the intensity as well as the bubble size diminished over time. CT was unable to assess bubble characteristics but showed increasing HU values with increasing sugar content. Measurements on US and MRI were correlated with more factors from the taste evaluation than CT was. No signs of intoxication were observed in the assessors.

CONCLUSIONS

US and MRI could be useful tools for evaluating sparkling wine objectively in blaseology. CT was of insufficient spatial resolution to assess individual bubbles.

Gastrointestinal sequelae and growth impairment at school age following necrotising enterocolitis in the newborn period

AIM

To evaluate gastrointestinal sequelae and growth impairment at school age in children who suffered from necrotising enterocolitis (NEC).

METHODS

This historic cohort study compared all surviving children born in Denmark between 1 January 2002 and 31 December 2011 with NEC in the newborn period, to surviving children without NEC, but same gestational age, birthweight and year of birth. Outcomes were investigated through a parental questionnaire, including gastrointestinal and growth-related outcomes. We performed exploratory ad hoc analysis, by adjusting for possible confounding and by dividing NEC children into surgical and medical.

RESULTS

In total, 163 children with NEC (50%) and 237 (36%) without NEC completed the parental questionnaire. Episodes of diarrhoea were more often reported in the NEC group (p = 0.0002). The increased risk seemed to be limited to those who underwent surgery for NEC. The absence from school (1.67 versus 1.31 days), rate of low height for age (17.9 versus 12.1%) and weight (29.9 versus 31.6 kg) did not differ significantly between children with NEC and children without NEC.

CONCLUSION

Our findings suggest that long-term gastrointestinal complications following NEC appeared to be of little clinical importance at the population level and therefore do not encourage specific routine follow-up.

P4774Older patients with atrial fibrillation and comorbidities are less likely to be treated with oral anticoagulation: insights from a nationwide study

Background

Older patients with atrial fibrillation (AF) often have multiple chronic conditions adding complexity to treatment decisions. However, regarding older AF patients, the association between multimorbidity and quality of care has not been explored previously in a non-selected nationwide cohort.

Purpose

To investigate the association between morbidity burden and the treatment with oral anticoagulation therapy (OAC) and rhythm-control strategies in patients >65 years of age with incident AF in Denmark.

Methods

Using Danish nationwide registers, we identified all Danish AF patients >65 years of age hospitalized for incident AF between 2010 and 2016. Using logistic regression models, we estimated the association between morbidity burden (<2, 2–3, 4–5, and >5 comorbidities) and the likelihood of receiving AF specific treatments. Estimates were reported as odds ratios with 95% confidence intervals (OR, 95% CI) with <2 comorbidities as reference. The primary outcome of interest was OAC therapy initiation. Secondary outcomes were initiation of anti-arrhythmic drugs (Class IC and Class III) and AF related procedures (electrical cardioversion and radiofrequency ablation). All models were adjusted for age, sex and calendar year.

Results

A total of 49,802 AF patients were eligible for inclusion, with a median age of 77.5 years (Interquartile range [IQR] 71.8–83.8) and 24,983 (50.2%) were male. A total of 25,181 (50.6%) patients had <2 comorbidities, 18,714 (37.6%) had 2–3 comorbidities, 4,891 (9.8%) had 4–5 comorbidities, and 1,016 (2.0%) patients had >5 comorbidities. The median CHA2DS2-VASc score ranged from 3 (IQR 2–3) to 5 (IQR 4–5) in patients with <2 comorbidities and >5 comorbidities, respectively.

Increasing morbidity burden was associated with decreasing odds of being treated with OAC therapy with the lowest odds in patients with >5 comorbidities (OR 0.39, 95% CI 0.34–0.45) compared with AF patients with <2 comorbidities. (Figure 1) Using morbidity burden as a continuous variable, an increment of one comorbidity was associated with decreasing odds of initiating OAC therapy (OR 0.85, 95% CI 0.84–0.86).

Morbidity burden was associated with increased odds of being prescribed anti-arrhythmic medication with the highest odds in patients with >5 comorbidities (OR 2.50 95% CI 2.08–2.99). In contrast, having >5 comorbidities was associated with decreased odds of AF related procedures (OR 0.32, 95% CI 0.23–0.43) compared to patients with <2 comorbidities.

Forest plot of OAC initiation factors

Conclusion

Morbidity burden is strongly associated with OAC initiation and rhythm-control strategies in older patients with incident AF. Older AF patients with multimorbidity are less likely to be treated with OAC although these are the patients who benefit most from treatment. Therefore, initiatives and quality improvement programs should be done to close this important gap between clinical trials and clinical practice.

5036Increased 1-year mortality among patients discharged following hospitalization for pericarditis - a nationwide cohort study

Background

Pericarditis accounts for 5% of all chest pain referrals to the emergency department and is generally considered a benign condition. However, recent studies suggested that pericarditis can be an early predictor of malignant disease, but data on mortality and other morbidity after incident pericarditis is lacking.

Purpose

To assess mortality risk and hospitalization patterns in patients with incident pericarditis.

Methods

In nationwide Danish registries we identified patients discharged from hospital with a first-time diagnosis of pericarditis from 1996 to 2016. Patients with prior myocarditis, heart failure, myocardial infarction and recent thoracic surgery were excluded.

The patients were risk set matched with 8 controls each from the general population on sex and year of birth. We assessed 1-year mortality risk using Kaplan Meier and logistic regression adjusted for baseline comorbidities; cerebrovascular disease, chronic obstructive lung disease, cardiac dysrhythmias, ischaemic heart disease and malignancy. We identified subsequent hospital admissions due to new onset cardiovascular-, respiratory- or malignant disease. Differences in frequencies between the pericarditis group and controls were calculated with Chi squared test.

Results

We identified 8,077 patients with pericarditis, median age 45 years (IQR: 32–59) and 75.6% were men. The absolute 1-year mortality was 2.9% in patients with pericarditis compared to 0.8% in the control group (p<0.001) (Figure 1).

The adjusted odds ratio (OR) of 1-year mortality was 2.79 (95%-CI: 2.14–3.65, p<0.001). Within the first year after incident pericarditis, hospital admission due to recurrent pericarditis was observed in 10.6% of the patients. Further, we observed significantly higher frequencies of other hospital admissions compared to the matched controls; cardiovascular disease: 4.6% vs, 1.2%, p>0.001, respiratory disease: 3.4% vs. 0.7%, p>0.001) and malignant disease: 1.4% vs. 0.5%, p>0.001).

Figure 1

Conclusion

In a nationwide cohort of patients discharged from hospital with incident pericarditis, we observed more than a triple 1-year mortality compared to age- and sex matched controls. Further, we observed a higher frequency of both cardiovascular and non-cardiovascular hospital admissions, highlighting the need for more focus on underlying morbidity in patients presenting with pericarditis.

[Christmas article. MRI assessment of the optimal type of traditional pork roast and preparation method - a randomised blinded trial]

INTRODUCTION

Pork roast is part of the traditional Danish Christmas meal and has been so for several hundreds of years. A novel cooking method is sous vide, in which the meat under vacuum is cooked for a long time at low temperature. Can MRI predict the optimal type of traditional pork roast and the optimal preparation method: oven or sous vide preparation?

METHODS

Two different pork roasts, one from an ordinary pig and one from a pig from an organic farm, were divided in two and randomised to oven cooking or sous vide. All four roasts underwent MRI at 1.5 tesla before and after preparation for evaluation of the fat content, as fat has an influence on taste. A test panel blinded to type of roast evaluated taste, juiciness and texture.

RESULTS

Eleven persons participated in the tasting (three men, eight women). Median age group was 30-39 years, and the median consumption of pork roast was once every half year. All roasts lost weight during the preparation. The favourite roast among participants was the one from an organic farm cooked sous vide.

CONCLUSION

Pork roast cooked sous vide instead of oven-cooked was preferred among different healthcare professionals blinded to the type of preparation.

Dynamic Contrast-Enhanced Ultrasound of Colorectal Liver Metastases as an Imaging Modality for Early Response Prediction to Chemotherapy

Our aim was to investigate whether dynamic contrast-enhanced ultrasound (DCE-US) can detect early changes in perfusion of colorectal liver metastases after initiation of chemotherapy. Newly diagnosed patients with colorectal cancer with liver metastases were enrolled in this explorative prospective study. Patients were treated with capecitabine or 5-fluorouracil-based chemotherapy with or without bevacizumab. DCE-US was performed before therapy (baseline) and again 10 days after initiation of treatment. Change in contrast-enhancement in one liver metastasis (indicator lesion) was measured. Treatment response was evaluated with a computed tomography (CT) scan after three cycles of treatment and the initially observed DCE-US change of the indicator lesion was related to the observed CT response. Eighteen patients were included. Six did not complete three series of chemotherapy and the evaluation CT scan, leaving twelve patients for analysis. Early changes in perfusion parameters using DCE-US did not correlate well with subsequent CT changes. A subgroup analysis of eight patients receiving bevacizumab, however, demonstrated a statistically significant correlation (p = 0.045) between early changes in perfusion measures of peak enhancement at DCE-US and tumor shrinkage at CT scan. The study indicates that early changes in DCE-US perfusion measures may predict subsequent treatment response of colorectal liver metastases in patients receiving bevacizumab.

Surgical findings during exploratory laparotomy are closely related to mortality in premature infants with necrotising enterocolitis

AIM

This study investigated whether a correlation existed between surgical findings during the first laparotomy for necrotising enterocolitis (NEC) and death and, or, disease progression.

METHODS

We included infants admitted within one day of birth to our tertiary neonatal department at Rigshospitalet, Denmark, from 2006 to 2015, who underwent a laparotomy for acute NEC. They were classified according to the locality and extent of intestinal necrosis by a paediatric surgeon, based on the surgical findings. We correlated the surgical findings with postoperative outcomes, namely death and, or, progression of NEC.

RESULTS

The first laparotomy showed that 48 infants had NEC, including 21 who demonstrated postoperative progression. Of these, six died before undergoing another laparotomy and 14 of the 15 infants who underwent relaparotomy also died. There was a significant association between surgical findings and NEC-related mortality (p = 0.03). The association between surgical findings and the progression of NEC was also significant (p < 0.0001).

CONCLUSION

Surgical findings during laparotomy for NEC were strongly correlated with mortality, which was close to 100% after relaparotomy. Considering the discouraging outcome, further studies should focus on alternative surgical approaches, such as proximal diverting jejunostomy and the clip and drop technique for the treatment of severe NEC.

Poor validity of the routine diagnosis of necrotising enterocolitis in preterm infants at discharge

AIM

Necrotising enterocolitis contributes considerably to the mortality of preterm infants, but most questions remain unsolved after decades of extensive research. This Danish study investigated the validity of necrotising enterocolitis diagnoses at discharge according to Bell's staging system.

METHODS

We conducted a retrospective single-centre cohort study of 714 preterm infants with a gestational age of less than 30 weeks born in 2006-2013. The infants were diagnosed with necrotising enterocolitis according to Bell's stages 2-3 at discharge and in retrospect by an expert panel, which served as our gold standard.

RESULTS

The sensitivity of necrotising enterocolitis diagnosed at discharge was 0.72-0.75 depending on whether spontaneous intestinal perforation was included as necrotising enterocolitis or not. The positive predictive value of the diagnosis was 0.49-0.61. The incidence was significantly higher when diagnosed at discharge than when diagnosed by the expert panel (11.1 versus 9.0%, p = 0.03). The mortality rate for infants who were underdiagnosed at discharge was 50.0%, and it was 25.8% for infants who were overdiagnosed (p = 0.10).

CONCLUSION

We found poor validity for the discharge diagnosis of necrotising enterocolitis. In future, a better way of defining the disease is needed for large-scale epidemiologic research.

Interobserver and Intraobserver Reproducibility with Volume Dynamic Contrast Enhanced Computed Tomography (DCE-CT) in Gastroesophageal Junction Cancer

The purpose of this study was to assess inter- and intra-observer reproducibility of three different analytic methods to evaluate quantitative dynamic contrast-enhanced computed tomography (DCE-CT) measures from gastroesophageal junctional cancer. Twenty-five DCE-CT studies with gastroesophageal junction cancer were selected from a previous longitudinal study. Three radiologists independently reviewed all scans, and one repeated the analysis eight months later for intraobserver analysis. Review of the scans consisted of three analysis methods: (I) Four, fixed small sized regions of interest (2-dimensional (2D) fixed ROIs) placed in the tumor periphery, (II) 2-dimensional regions of interest (2D-ROI) along the tumor border in the tumor center, and (III) 3-dimensional volumes of interest (3D-VOI) containing the entire tumor volume. Arterial flow, blood volume and permeability (k^trans) were recorded for each observation. Inter- and intra-observer variability were assessed by Intraclass Correlation Coefficient (ICC) and Bland-Altman statistics. Interobserver ICC was excellent for arterial flow (0.88), for blood volume (0.89) and for permeability (0.91) with 3D-VOI analysis. The 95% limits of agreement were narrower for 3D analysis compared to 2D analysis. Three-dimensional volume DCE-CT analysis of gastroesophageal junction cancer provides higher inter- and intra-observer reproducibility with narrower limits of agreement between readers compared to 2D analysis.

Cardiovascular risk in patients with sleep apnoea with or without continuous positive airway pressure therapy: follow-up of 4.5 million Danish adults

BACKGROUND

The prognostic significance of age and continuous positive airway pressure (CPAP) therapy on cardiovascular disease in patients with sleep apnoea has not been assessed previously.

METHODS

Using nationwide databases, the entire Danish population was followed from 2000 until 2011. First-time sleep apnoea diagnoses and use of CPAP therapy were determined. Incidence rate ratios (IRRs) of ischaemic stroke and myocardial infarction (MI) were analysed using Poisson regression models.

RESULTS

Amongst 4.5 million individuals included in the study, 33 274 developed sleep apnoea (mean age 53, 79% men) of whom 44% received persistent CPAP therapy. Median time to initiation of CPAP therapy was 88 days (interquartile range 34-346). Patients with sleep apnoea had more comorbidities compared to the general population. Crude rates of MI and ischaemic stroke were increased for sleep apnoea patients (5.4 and 3.6 events per 1000 person-years compared to 4.0 and 3.0 in the general population, respectively). Relative to the general population, risk of MI [IRR 1.71, 95% confidence interval (CI) 1.57-1.86] and ischaemic stroke (IRR 1.50, 95% CI 1.35-1.66) was significantly increased in patients with sleep apnoea, in particular in patients younger than 50 years (IRR 2.12, 95% CI 1.64-2.74 and IRR 2.34, 95% CI 1.77-3.10, respectively). Subsequent CPAP therapy was not associated with altered prognosis.

CONCLUSIONS

Sleep apnoea is associated with increased risk of ischaemic stroke and MI, particularly in patients younger than 50 years of age. CPAP therapy was not associated with a reduced rate of stroke or MI.

Post-endoscopic retrograde cholangiopancreaticography complications in liver transplanted patients, a single-center experience

BACKGROUND

Complications in the biliary tract occur in 5%-30% after liver transplantation and the main part of the complications is successfully managed with endoscopic retrograde cholangiopancreaticography (ERCP). The incidence and risk factors for post-ERCP complications in liver transplantation patients are not well described. Our objective was to define the frequency of post-ERCP complications in liver transplantation patients at the Abdominal Center, Rigshospitalet, the only Liver Transplantation Center in Denmark.

METHODS

Retrospective study of all ERCPs performed in liver transplantation patients during a 9-year period.

RESULTS

A total of 292 ERCPs were included. Overall post-ERCP complications occurred in 24 procedures (8.2%): pancreatitis in 8 (2.7%), bleeding in 5 (1.7%), and cholangitis in 13 (4.5%) procedures. Simultaneous pancreatitis and cholangitis, and simultaneous bleeding and cholangitis occurred after two procedures, respectively. Multivariate analysis concerning overall complications identified biliary sphincterotomy (p = 0.006) and time since liver transplantation within 90 days postoperatively (p = 0.044) as risk factors for post-ERCP complications. Specifically concerning post-ERCP pancreatitis (PEP), it was found that pre-ERCP cholangitis was another independent risk factor for PEP (p = 0.026). Stent in the biliary tract prior to ERCP seemed to be protective (p = 0.041).

CONCLUSIONS

Complications were of surprisingly mild degree. The rates of post-ERCP complications in our study were in line with previous studies with liver transplantation patients. Cholangitis prior to ERCP may be another risk factor for post-ERCP pancreatitis.

Does last week's alcohol intake affect semen quality or reproductive hormones? A cross-sectional study among healthy young Danish men

The association between last 5 days of alcohol intake, semen quality and reproductive hormones was estimated in this cross-sectional study among 347 men. Conventional semen characteristics, DNA fragmentation index and reproductive hormones (testosterone, estradiol, sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and inhibin B) were determined. There was a tendency towards lower semen characteristics at higher intake of alcohol past 5 days, albeit with no statistically significant dose-response association. The ratio between free estradiol and free testosterone was higher at higher alcohol intake during the 5 days preceding semen sampling. In conclusion, alcohol intake was associated with impairment of most semen characteristics but without a coherent dose-response pattern. The study indicates an association between recent alcohol intake and a hormonal shift towards higher estradiol/testosterone ratio. The hormonal changes observed may over time, lead to adverse effects on semen quality, but longitudinal studies are needed to study this.

Bleeding risk in 'real world' patients with atrial fibrillation: comparison of two established bleeding prediction schemes in a nationwide cohort

BACKGROUND

Oral anticoagulation (OAC) in patients with atrial fibrillation (AF) is a double-edged sword, because it decreases the risk of stroke at the cost of an increased risk of bleeding. We compared the performance of a new bleeding prediction scheme, HAS-BLED, with an older bleeding prediction scheme, HEMORR(2)HAGES, in a cohort of 'real-world' AF patients.

METHODS

By individual-level-linkage of nationwide registers, we identified all patients (n = 118,584) discharged with non-valvular AF in Denmark during the period 1997-2006, with and without OAC. Major bleeding rates during 1 year of follow-up were determined, and the predictive capabilities of the two schemes were compared by c-statistics. The risk of bleeding associated with individual risk factors composing HAS-BLED was estimated using Cox proportional-hazard analyses.

RESULTS

Of AF patients receiving OAC (n = 44,771), 34.8% and 47.3% were categorized as 'low bleeding risk' by HAS-BLED and HEMORR(2)HAGES, respectively, and the bleeding rates per 100 person-years were 2.66 (95% confidence interval [CI], 2.40-2.94) and 3.06 (2.83-3.32), respectively. C-statistics for the two schemes were 0.795 (0.759-0.829) and 0.771 (0.733-0.806), respectively. The risk factors composing HAS-BLED were associated with varying risks, with a history of bleeding (hazard ratio [HR] 2.98; 95% CI 2.68-3.31) and being elderly (HR 1.93; 95% CI 1.71-2.18) being associated with the highest risks. Comparable results were found in AF patients not receiving OAC (n = 77,813).

CONCLUSIONS

In an unselected nationwide cohort of hospitalized patients with atrial fibrillation, the HAS-BLED score performs similarly to HEMORR(2)HAGES in predicting bleeding risk but HAS-BLED is much simpler and easier to use in everyday clinical practise.

Changes in short- and long-term cardiovascular risk of incident diabetes and incident myocardial infarction--a nationwide study

AIMS/HYPOTHESIS

We assessed secular trends of cardiovascular outcomes following first diagnosis of myocardial infarction (MI) or diabetes in an unselected population.

METHODS

All Danish residents aged > or = 30 years without prior diabetes or MI were identified by individual-level linkage of nationwide registers. Individuals hospitalised with MI or claiming a first-time prescription for a glucose-lowering medication (GLM) during the period from 1997 to 2006 were included. Analyses were by Poisson regression models. Primary endpoints were death by all causes, cardiovascular death and MI.

RESULTS

The study included 3,092,580 individuals, of whom 77,147 had incident MI and 118,247 new-onset diabetes. MI patients had an increased short-term risk of all endpoints compared with the general population. The rate ratio (RR) for cardiovascular death within the first year after MI was 11.1 (95% CI 10.8-11.5) in men and 14.8 (14.3-15.3) in women, respectively. The risk rapidly declined and 1 year after the index MI, RR was 2.11 (2.00-2.23) and 2.8 (2.64-2.97) in men and women, respectively. Patients with diabetes carried a constantly elevated risk of all endpoints compared with the general population. The cardiovascular death RR was 1.90 (1.77-2.04) and 1.92 (1.78-2.07) in men and women, respectively during the first year after GLM initiation.

CONCLUSIONS/INTERPRETATION

Incident MI is associated with high short-term risk, which decreases rapidly over time. Incident diabetes is associated with a persistent excessive cardiovascular risk after initiation of GLM therapy. This further strengthens the necessity of early multi-factorial intervention in diabetes patients for long-term benefit.

Maternal alcohol consumption during pregnancy and semen quality in the male offspring: two decades of follow-up

BACKGROUND

Concurrent alcohol exposure has been associated with reduced fecundity, but no studies have estimated the effect of prenatal alcohol exposure on male fecundity. The aim of this study was to investigate the association between maternal alcohol consumption during pregnancy, semen quality and levels of reproductive hormones in young, adult men.

METHODS

From a Danish pregnancy cohort established in 1984-1987, 347 sons were selected for a follow-up study conducted in 2005-2006. Semen and blood samples were analyzed for conventional semen characteristics and reproductive hormones, respectively, and results were related to prospectively self-reported information on maternal alcohol consumption during pregnancy.

RESULTS

The sperm concentration decreased with increasing prenatal alcohol exposure. The adjusted mean sperm concentration among sons of mothers drinking >or=4.5 drinks per week during pregnancy was 40 (95% CI: 25-60) millions/ml. This concentration was approximately 32% lower compared with men exposed to <1.0 drink per week, who had a sperm concentration of 59 (95% CI: 44-77) millions/ml. The semen volume and the total sperm count were also associated with prenatal alcohol exposure; sons prenatally exposed to 1.0-1.5 drinks per week had the highest values. No associations were found for sperm motility, sperm morphology or any of the reproductive hormones, including testosterone.

CONCLUSIONS

These results indicate that prenatal exposure to alcohol may have a persisting adverse effect on Sertoli cells, and thereby sperm concentration. If these associations are causal they could explain some of the reported differences between populations and long-term changes in semen quality.

Clinical consequences of hospital variation in use of oral anticoagulant therapy after first-time admission for atrial fibrillation

OBJECTIVE

To analyse how hospital factors influence the use of oral anticoagulants (OAC) in atrial fibrillation (AF) patients and address the clinical consequences of hospital variation in OAC use.

DESIGN AND SUBJECTS

By linkage of nationwide Danish administrative registers we conducted an observational study including all patients with a first-time hospitalization for AF between 1995 and 2004 as well as prescription claims for OAC. Multivariable logistic regression analysis was used to evaluate hospital factors associated with prescription of OAC therapy. Cox proportional-hazard models were used to estimate the risk of re-hospitalization for thromboembolism and haemorrhagic stroke with respect to discharge from a low, intermediate, or high OAC use hospital.

RESULTS

Overall 40,133 (37%) out of 108,504 patients received OAC; ranging from 17% to 50% between the hospitals with the lowest and highest OAC use, respectively. Cardiology departments had the highest use of OAC, but neither tertiary university hospitals nor high volume hospitals had higher OAC use than local community hospitals and low volume hospitals. Risk of a thromboembolic event was significantly increased amongst patients from hospitals with a low OAC use (hazard ratio 1.16, confidence interval 1.10-1.22). Notably, higher OAC use was not associated with a higher risk of haemorrhagic stroke.

CONCLUSION

In Denmark between 1995 and 2004, there was a major hospital variation in AF patients receiving OAC, and consequently, more thromboembolic events were observed amongst patients from low OAC use hospitals. Our study emphasizes the need for a continued vigilance on implementation of international AF management guidelines.

Resistance to an herbivore through engineered cyanogenic glucoside synthesis

The entire pathway for synthesis of the tyrosine-derived cyanogenic glucoside dhurrin has been transferred from Sorghum bicolor to Arabidopsis thaliana. Here, we document that genetically engineered plants are able to synthesize and store large amounts of new natural products. The presence of dhurrin in the transgenic A. thaliana plants confers resistance to the flea beetle Phyllotreta nemorum, which is a natural pest of other members of the crucifer group, demonstrating the potential utility of cyanogenic glucosides in plant defense.

A closed-loop cadaveric foot and ankle loading model

Investigations of human foot and ankle biomechanics rely chiefly on cadaver experiments. The application of proper force magnitudes to the cadaver foot and ankle is essential to obtain valid biomechanical data. Data for external ground reaction forces are readily available from human motion analysis. However, determining appropriate forces for extrinsic foot and ankle muscles is more problematic. A common approach is the estimation of forces from muscle physiological cross-sectional areas and electromyographic data. We have developed a novel approach for loading the Achilles and posterior tibialis tendons that does not prescribe predetermined muscle forces. For our loading model, these muscle forces are determined experimentally using independent plantarflexion and inversion angle feedback control. The independent (input) parameters -- calcaneus plantarflexion, calcaneus inversion, ground reaction forces, and peroneus forces -- are specified. The dependent (output) parameters -- Achilles force, posterior tibialis force, joint motion, and spring ligament strain -- are functions of the independent parameters and the kinematics of the foot and ankle. We have investigated the performance of our model for a single, clinically relevant event during the gait cycle. The instantaneous external forces and foot orientation determined from human subjects in a motion analysis laboratory were simulated in vitro using closed-loop feedback control. Compared to muscle force estimates based on physiological cross-sectional area data and EMG activity at 40% of the gait cycle, the posterior tibialis force and Achilles force required when using position feedback control were greater.

Comparison of EEG, MRI and PET in reading epilepsy: a case report

The pathophysiological and neuroanatomical bases of reading epilepsy (RE) are unclear. We performed video-EEG, high quality MRI and [11C]diprenorphine PET in a patient with RE to detect structural and functional abnormalities. EEG showed multifocal seizure onset bilaterally in temporal and fronto-central regions. MRI was normal, whereas [11C]diprenorphine PET revealed peri-ictal opioid binding decreases in both temporal lobes and the left frontal lobe. These findings confirm that RE is due to abnormal activity in the network subserving reading.

Occupational arsenic exposure and glycosylated haemoglobin

In a group of 40 workers occupationally exposed to arsenic (As workers) biological markers for cardiovascular diseases were studied. The median arsenic concentration in urine samples from the exposed group was 22.3 nmol of As per mmol of creatinine, while the individual maximum level was 294.5 nmol of As per mmol of creatinine. That of the reference group was 12 nmol of As per mmol of creatinine and significantly below the level of the exposed group (p < 0.001). The arsenic concentration in urine samples from colleagues of the persons working with arsenic containing products was similar to the arsenic concentration in urine samples from the As workers. The concentration of glycosylated haemoglobin (Hgb A1C) was increased in whole blood from the As workers. The level of the As workers was 5.4% (median), similar to that of colleagues (5.5%), while that of the reference group was 4.4%. The differences were significant (p < 0.001). Multiple regression analysis showed a significant connection (p = 0.034) between the concentration of Hgb A1C in whole blood and the arsenic level in urine from the As workers. The systolic blood pressure was 125 mm Hg in the As workers and 117 mm Hg in the control group. The difference was significant (p = 0.023). It is concluded that arsenic exposure has an influence on carbohydrate metabolism, increases the systolic blood pressure and finally may result in increased risk of development of cardiovascular diseases.

Spectral power and coherence analysis of sleep EEG in AIDS patients: decrease in interhemispheric coherence

Fifteen patients aged between 26 and 55 years with the acquired immunodeficiency syndrome (AIDS) and various cerebral manifestations of the disease underwent an all-night sleep electroencephalogram (EEG) registration. The recordings of 15 age-matched volunteers were examined as controls. Sleep stages were determined visually and the following spectral analysis was based on corresponding artifact-free 40-second periods. The sampling rate was 64 second-1, the spectral resolution was 0.25 Hz and the frequency ranged from 0.25-24 Hz. The power density spectra of eight EEG derivations (left and right frontopolar, frontal, central and occipital; reference montage to the ipsilateral Cb electrodes) and the coherence spectra of interhemispheric (interfrontal, interoccipital) and intrahemispheric (frontooccipital, left and right) channel pairs were computed. The power density of the patients in the 11.5-13-Hz frequency range of nonrapid eye movement (NREM) sleep was considerably lower than that of the controls (p < 0.05 and p < 0.01 at left and right frontal derivations, two-tailed Mann-Whitney U test). The power density of rapid eye movement (REM) sleep showed no consistent differences between the two groups. The interfrontal coherence of the whole frequency range below 12 Hz was markedly lower in the patient group. This applied to NREM sleep and also to REM sleep (p < 0.01 and p < 0.001 for different frequency bands between 1 and 12 Hz in NREM and REM sleep). Possible relations to clinical features are discussed.

Career Ladder Program

In June 1990, Santa Rosa Children's Hospital instituted a multitrack career ladder program for registered nurses, in response to the issues of retention of expert nursing staff and development of professional nursing practice. The program incorporates clinical, education, and management tracks, providing vertical and lateral mobility to the registered nurse. Performance evaluation criteria complement the promotional process, and the registered nurse has a menu of requirements to fulfill each year upon promotion to or maintenance of career ladder level. Through incorporation of a graduated salary system, the program has been a retention bonus for registered nurses at Santa Rosa Children's Hospital. In addition, the career ladder program has been very successful in promoting professional nursing practice within the hospital.

Increased rCBF in gray matter heterotopias detected by SPECT using 99mTc hexamethyl-propylenamine oxime

Imaging findings of morphology and regional cerebral blood flow in two patients suffering from epileptic seizures are presented. CT and MRI revealed heterotopic gray matter as a probable structural correlate, causing the seizure disorder. 99mTc hexamethyl-propylenamine oxime (HM-PAO) SPECT demonstrated focally increased regional cerebral blood flow in both patients in the areas of their heterotopic lesions. Heterotopic and orthotopic gray matter seem to have similar features in terms of regional perfusion. A focally increased brain perfusion in interictal epileptic patients may indicate an underlying migration anomaly.

[Condoms and adolescents. A prospective study of a new method of teaching]

A prospective investigation was carried out with the object of assessing the effect of supplementary sex education for 1.3 hours in addition to the compulsory sex education in Danish elementary schools. One doctor did the teaching and practice with a condom was introduced as a new method of teaching. On an average, seven weeks before and seven weeks after this teaching session, these pupils completed a questionnaire. Altogether 451 pupils from the eighth and ninth classes participated. Great changes had occurred in the methods of contraception employed by the adolescents and in their attitudes to these from 1982 to date. Many more of the adolescents consider today that condoms provide the best form of contraception as compared with oral contraception. Nevertheless, only 9% of the adolescents were able to use a condom correctly. After the teaching session, knowledge about the correct use of a condom was significantly better and more had a positive attitude to condoms. A balance in information about methods of contraception is recommended and the young people should be sent to their own general practitioners for individual advice. On the basis of the results of this investigation, this teaching should be given already to pupils in the eighth classes.

Focal-unilateral accentuation of changes observed in the early stage of Creutzfeldt-Jakob disease

We report on a 67-year-old male patient with progressive right-sided hemiparesis predominating in the arm and right-sided myoclonias. The EEG showed periodic delta activity in the left hemisphere. The patient died of pulmonary embolism 10 weeks after the onset of the symptoms. The neuropathological examination was indicative of Creutzfeldt-Jakob disease: distinct spongiform changes, nerve cell loss and proliferation of astroglia in the left hemisphere were found; in the right hemisphere, however, only a few circumscribed spongiform foci were seen. There was a clear correlation between the unilateral predominance of the EEG abnormality and neuropathological changes. The hypothesized spread of infection along commissural projection pathways is supported by this pattern of lesions.

[EEG and SPECT in cerebral manifestations of AIDS]

The purpose of the presented study was to determine the diagnostic value of correlated EEG and SPECT findings in patients with CNS-manifestations of AIDS. Ten HIV 1 infected patients had been examined. Diagnoses: meningitis (2 x), lymphoma (2 x), necrotizing encephalitis (1 x), toxoplasmosis (7 x) (Some patients had more than one diagnosis). Unenhanced and Gd-DTPA enhanced MR, 99mTc-HM-PAO SPECT and clinical EEG were compared. In 9/10 patients MR demonstrated intracranial lesions. In one patient with necrotizing encephalitis (not detected by MR), SPECT revealed an inhomogeneous cerebral perfusion. Only lymphoma was hyperperfused. Toxoplasmic lesions-when detectable by SPECT-were hypoperfused. Reduced rCBF was also seen in brain regions not affected directly, but functionally associated to altered areas. EEG revealed diffuse signs such as slowing in patients with brain atrophy, but also in those patients with lesions of basal ganglia and thalamus. Focal signs in the EEG were in concordance with imaging findings in only 2/10 patients. In 4/10 patients foci even adjacent to the cortex - as shown by MR - remained undetected by EEG. One patient with an active toxoplasmosis had sharp waves over the affected region. The parallel application of the three methods as suggested in this paper appears useful not only for scientific purposes. In most cases, this procedure provides relevant diagnostic information. It is recommended for AIDS-patients with CNS manifestations of unknown etiology.

[Effects of flurazepam on disturbed sleep in patients with AIDS]

Polysomnograms were recorded of twelve patients with acquired immune deficiency syndrome (AIDS) during different stages in an open design. During the first night no hypnotics were administered, during the second night 30 mg flurazepam per os were given. Flurazepam affected mainly the NREM parameters. The times "awake" during the night were reduced, sleep stage 2 showed an increase, and the effective sleep time was also increased. The increase in sleep spindle density was remarkable, however, delta sleep and generation of K-complexes were not affected. Flurazepam did not affect REM sleep at all. The amount of REM sleep showed a slight increase. REM distribution during the night did not show the "bell shaped" increase and the decrease in the morning; the degree of the illness correlated with a flattening of REM distribution.

[Visual motor coordination of AIDS patients, HIV-positive asymptomatic probands and healthy persons during video-tracking]

Here we investigated the applicability of a computer-aided video-tracking as a method for evaluating potential deficits of neural information processing in patients with AIDS and those showing only positive HIV-seroreactivity. Video-tracking was accompanied with a simultaneous recording of EEG. Eight HIV-positive asymptomatic volunteers and eight AIDS-patients with cerebral manifestation of the disease participated in the pilot study. Two groups of eight normals each served as a control. Video-tracking performance of the HIV-positive volunteers and AIDS-patients significantly differed (p less than 0.05) from those of the healthy volunteers. Although the AIDS-patients' performance tended to be worse than that of the HIV-group, this difference was not significant. Power spectrum analysis of the EEG-data indicated that the diminished performance of the two test groups (AIDS and HIV-positives), accompanied by an increased spectral power across the entire frequency range measured in the study, could be an expression of an enhanced synchronization in cortical neuronal networks. The synchronization in turn could be a sign of possible organic brain damage resulting from HIV-infection. In conclusion, we suppose that video-tracking measures parameters which may indicate early deficits of information processing in CNS.

[Spectral power density and coherence in sleep EEG in patients with acquired immunodeficiency syndrome]

15 male AIDS-patients from 26 to 55 years (mean 41.8 +/- 8.5) with various cerebral manifestations had a whole-night-sleep-EEG registration. As control the recordings of 15 age-matched volunteers (26-55 years, mean 41.8 +/- 9.8) were examined. Spectral characteristics of elementary EEG-epochs of 40 s length were computed, and sleep staging was performed visually for these intervals. The spectral power density of eight EEG-derivations (left and right frontopolar, frontal, central and occipital electrodes, reference montage to the ipsilateral Cb) were measured (sampling rate 64(-1) s, spectral resolution .25 Hz, frequency range from .25 to 24 Hz). Interhemispherical coherences of the frontal and occipital derivation pairs, and intrahemispherical fronto-occipital coherences of the left and right hemisphere, were computed. In the patients the frontal power density of NREM sleep showed lower values in the frequency range of 10 to 14 Hz. In central and in occipital derivations the power density between 12.5 and 15 Hz was lower in the patients, but the difference was less accentuated. The spectral power density of REM sleep showed similar characteristics in both groups. The interhemispherical frontal coherence of the whole frequency range below 13 Hz was markedly lower in the patient group. This was true for the NREM sleep, and, slightly less, for the REM sleep, too. The interoccipital spectral coherence was generally slightly lower in the patient group; the difference was most clearly in the 12.5 to 15 Hz range of NREM sleep.