Use of primary health care services and mortality in older patients with type 2 diabetes with or without comorbidities

OBJECTIVE

This study aimed to examine primary health care (PHC) service utilization and mortality in older patients with type 2 diabetes (T2D) with or without comorbidities.

DESIGN AND SETTING

A cohort study in PHC in the city of Vantaa, Finland. Follow-up period was set between the years 2011 and 2018.

SUBJECTS

PHC patients aged 60 years or more with a T2D were included.

MAIN OUTCOME MEASURES

Service utilization was defined as the number of face-to-face appointments and telephone contacts between a patient and general practitioner (GP) or nurse. The presence of comorbidities was defined using the Charlson Comorbidity Index (CCI). Mortality was assessed using hazard ratio (HR) and standardized mortality ratio (SMR).

RESULTS

In total, 11,020 patients were included and followed for 71,596 person years. Mean age of the women and men in the beginning of follow-up were 71 and 69 years, respectively. The patients in the study cohort had a mean of eight appointments per person year to the GPs or nurses. Patients with T2D with comorbidities had more appointments than patients with T2D without comorbidities (incidence rate ratio (IRR) 1.44 [95% CI 1.39-1.49]). Increase in the number of all appointments reduced mortality in patients with T2D with and without comorbidities. Between patients with T2D with comorbidities and patients with T2D without comorbidities, the age and sex adjusted HR for death was 1.50 (95% CI 1.39-1.62). The SMR was higher in patients with T2D with comorbidities (1.83 [95% CI 1.74-1.92]) than in patients with T2D without comorbidities (0.91 [95% CI 0.86-0.96]).

CONCLUSIONS

In older patients with T2D, the presence of comorbidities was associated with increased use of PHC services and increased mortality. Increase in the number of appointments was associated with reduced mortality in patients with T2D with or without comorbidities.Key PointsIn older patients with T2D, it has not been studied whether and to what extend multimorbidity affects use of PHC services and mortality.The presence of comorbidities according to the Charlson Comorbidity Index (CCI) was associated with increased use of PHC services.The number of appointments to GPs or nurses was associated with reduced mortality in patients with T2D with or without comorbidities according to the CCI.

Prevalence of atrial fibrillation – a comprehensive nationwide analysis in Finland

Introduction

Prevalence of atrial fibrillation (AF) is strongly associated with age, and with longer life-time expectancy number of AF patients is worldwide strongly increasing. However, nationwide prevalence of AF is not known when primary care data as well is accessible.

Purpose

The FinACAF-study is a nationwide registry study including of all AF patients searched from all available national health care registers. To our knowledge, this is the first nationwide AF study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the prevalence of AF in unselected nationwide population in Finland.

Methods

In the FinACAF study we gathered data of all AF patients (hospitalizations and outpatient specialist visits and primary health care, and National Reimbursement Register) from all national health care registers from 01st January 2004 to 31st December 2018. The annual prevalence on December 31st of each year 2007–2018 was calculated as the cumulative number of patients alive with AF divided by the number of Finnish population on the last day of that year. The prevalence is presented for population ≥20 years, and with the entire population as the background population, as well as for populations ≥65 years, and ≥75 years.

Results

In total, 411,387 patients with the diagnosis of AF were documented during 2004–2018 in Finland. The number of adult patients with AF at the end of the study period in 2018 was 226,847, corresponding to an AF prevalence of 5.2% in the age group ≥20 years. The prevalence in the total Finnish population was 4.1%. The prevalence rates increased remarkably with increasing age and were higher in men compared to women (5.9% vs. 4.6%, p<0.001) in all age groups (Figure 1). The prevalence of AF in the adult population increased remarkably from 2.5% in 2007 to 5.2% in 2018 (p<0.001) (Figure 2). Among the population ≥65 years the prevalence in 2018 was 15.3%, and in the elderly, ≥75 years the prevalence of AF was 23.4%.

Conclusions

Based on comprehensive, nationwide data – also including the primary care – we observed extremely increasing prevalence of AF in the older population, as well as remarkably increasing prevalence of AF over time.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Characteristics of incident atrial fibrillation patients – a nationwide register-based study with information from primary-, secondary- and tertiary care

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a current prevalence of 4.1% in Finland. Many of the comorbidities associated with AF are known risk factors for the arrhythmia and vice versa, as well as contributors to the risk of stroke and other AF related adverse events. A generally used evaluation method for the risk of stroke is the clinical risk factor -based CHA2DS2-VASc score, but other thromboembolic risk factors also exist.

Purpose

To better understand current AF population, this study describes characteristics, comorbidities, medication, and laboratory values of Finnish AF patients at the time of first AF diagnosis.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide register-based cohort study in which AF patient data has been linked from several Finnish health care- and national registers, with information from primary-, secondary-, and tertiary care. This substudy consists of patients over 20 years old with available laboratory data and an incident AF diagnosis (ICD-10 I48) between 1/1/2010–31/12/2018 in any of the used registers.

Results

Within the study period 143,455 patients with a new AF were registered. The mean age at time of diagnosis was 69.1 years for men and 76.3 years for women. The mean CHA2DS2-VASc score when entering the cohort was 3.48 (SD 1.88), and 84.9% of the cohort had at least one of the comorbidities included in the CHA2DS2-VASc score. The most prevalent comorbidities and medications of the cohort are shown in the figure, and a more comprehensive look is presented in the table. The medications listed have been in use during the year before cohort entry.

Conclusion

Atrial fibrillation does not come alone. Almost all patients diagnosed with AF have previous comorbidities and medications. Future analysis will provide information on how these evolve after AF diagnosis and elucidate their association with different endpoints.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland

Background

Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC).

Purpose

The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC.

Methods

This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC.

Results

The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value <2.0 before ECV and at the time of stroke and one patient had INR value <2.0 before ECV.

Conclusion

In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Sex differences in the use of rhythm control strategies in patients with atrial fibrillation in FinACAF study

Aim

Women with atrial fibrillation (AF) have been reported to receive less antiarrhythmic therapies (AAT) than men. We assessed sex differences in AAT use in Finland.

Methods

The FinACAF registry linked data from several nationwide registries covering all levels of care in addition to drug purchases and included records on all patients diagnosed with incident AF in Finland during 2007–2018. The outcomes of interest (use of antiarrhythmic drugs (AAD), cardioversions (CV), catheter ablation procedures and any AAT including all aforementioned rhythm control modalities) were identified based on procedure-specific codes and drug purchases. Sex differences in AAT use were analyzed in the entire cohort and separately in three age groups: <65 years, 65–74 years and ≥75 years using Fine-Gray subdistribution hazard regression with death as a competing risk and adjustments made for comorbidities, age and levels of income and education.

Results

Altogether, 229565 patients (50.0% female; mean age 68.90±13.44 in men and 76.57±11.79 in women) with incident AF were identified. In the entire patient population, female sex was associated a higher incidence of AAD use and lower incidence of CVs and ablation procedures contributing to an overall slightly lower incidence of any AAT compared to men (Table 1). In the age group specific analyses, the lower incidence of CVs and higher incidence of AAD use in females were observed only in patients <65 years and <75 years, respectively, whereas the association of female sex with lower incidence of catheter ablation procedures was observed only in the age group ≥75 years.

Conclusion

Our nationwide data showed no considerable sex difference in overall use of AAT in Finland. Despite a lower number of CVs in women, ablation procedures were performed almost equally and AADs were used more frequently in women compared to men.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Sydäntutkimussäätiö

Gastrointestinal bleeding preceding new-onset atrial fibrillation - results from the nationwide FinACAF study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation of Cardiovascular Research

Introduction

Initiation of oral anticoagulation (OAC) in case of a new-onset atrial fibrillation (AF) requires assessment of bleeding history. Gastrointestinal (GI) bleedings are among the most common bleeding events.

Purpose

We aimed to assess clinical characteristics and initiation of OAC in patients with new-onset AF and a history of previous GI bleeding.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. The study population consists of all patients diagnosed with AF between the years 2010-2018 and with laboratory data available. Patients were identified from nationwide primary care and reimbursement registries and hospitalization records. OAC purchases at 90 days from cohort entry were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.

Results

134 242 patients from the initial FinACAF cohort were included in this substudy. Of these, 6543 (4.9%) patients had a history of GI bleeding. Those with GI bleeding were more often male (52.6%), older (mean age 76.6 ± 11.4 vs 72.4 ± 13.1 years), and had more comorbidities. They also had lower blood hemoglobin (mean 124.9 ± 21.3 vs 135.8 ± 18.4 g/l) and higher serum creatinine (mean 99.7 ± 75.8 vs 87.5 ± 52.7 µmol/l) levels than patiens without preceding GI bleeding. Furthermore, initiation of OAC medication was less frequent in the GI bleeding group (46.9% vs 58.6%).

Patient characteristics of the study population including age, sex, comorbidities, OAC medication and laboratory findings are shown in Figures 1 and 2.

Conclusions

Patients with AF and preceding GI bleeding are vulnerable to rebleeding events. This may affect decision-making of clinicians, leading to more infrequent initiation of OAC medications.

CHA2DS2-VASc score and the risk of death in atrial fibrillation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation

Background

Atrial fibrillation (AF) is recognized as a major public health problem due to increased mortality, morbidity and risk of stroke. Advanced age and burden of other comorbidities are potential contributors to AF development and adverse outcomes. Clinical risk factor based CHA2DS2-VASc score is widely used to assess thromboembolic risk in AF, but mortality risk associated with different CHA2DS2-VASc scores is not established.

Purpose

Using data from a nationwide AF registry study including comorbidities and outcomes of unselected AF patients, we wanted to study whether CHA2DS2-VASc score could be useful in estimating prognosis in newly diagnosed AF patients.

Methods

New-onset AF patients in Finland 2007-2017 were identified from comprehensive national registries. Comorbidities were gathered from individualized registry data on drug reimbursements and from ICD-10 diagnoses during hospitalizations and outpatient visits in primary and specialist care. These were used to create CHA2DS2-VASc risk score for each AF patient at cohort entry, including data on heart failure, hypertension, age, diabetes, stroke, vascular disease and sex. Patients were followed until the end of 2018 from the causes of death registry, which records every death in the country. All-cause mortality in each CHA2DS2-VASc category per 1000 person-years was determined, and relative risk (RR) of death according to the CHA2DS2-VASc category was calculated.

Results

A total of 229 357 patients with new-onset AF (mean age 73.2 ± 13.2 years, 50.0% female) were identified. Distribution of CHA2DS2-VASc score among these individuals is shown in Table. Mortality increased significantly with rising CHA2DS2-VASc risk score points, as demonstrated in Table. Compared to CHA2DS2-VASc 0, those with 2 points had a RR 2.9 (95%CI 2.7-3.1), 3 points RR 5.0 (4.7-5.3), 4 points RR 8.0 (7.5-8.4), 5 points RR 11.0 (10.4-11.7) and >5 points RR 14.8 (14.0-15.7) for all-cause mortality.

Conclusions

In new-onset AF, mortality increased drastically with increasing age and comorbidities as depicted in the CHA2DS2-VASc score. Besides assessing thromboembolic risk, CHA2DS2-VASc score seems to be useful in estimating survival of AF patients.

Mortality and causes of death after new-onset atrial fibrillation: a nationwide study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is increasing with aging population. AF is associated with increased cardiovascular morbidity and mortality, but the prognosis of newly detected AF in the general population is not well established.

Purpose

Using data from the large FinACAF-study, a comprehensive nationwide retrospective cohort study including all diagnosed Finnish AF patients, we studied one-year mortality after new-onset AF in the general population and determined the causes of death of deceased AF patients.

Methods

All patients with new-onset AF in Finland 2007-17 were identified from nationwide primary care and reimbursements registries and hospitalization records. Baseline characteristics of these patients were determined, and their survival was followed from registries for one year. Principal cause of death was determined from death certificate’s International Classification of Diseases (ICD-10) Codes.

Results

A total of 229 321 patients with first-diagnosed AF were identified (50.0% female). Mean age of men and women with new-onset AF was 69.4 ± 13.4 and 77.1 ± 11.8 years, respectively (p<0.001 for difference). In men and women, hypertension had been diagnosed in 68.0% vs 80.4% (p<0.001), congestive heart failure in 15.4% vs 19.3% (p<0.001), diabetes in 22.5% vs 20.7% (p<0.001) and vascular disease in 27.2% vs 24.8% (p<0.001), respectively. Prior stroke or transient ischemic attack had occurred in 14.0% of men and 16.8% of women (p<0.001).

During the one-year follow-up, 11.6% of men and 13.7% of women died (Figure). Most common cause of death in these patients was ischaemic heart disease (26.2% of all deaths), followed by malignancies (17.4%) and dementia (12.4%). Cerebrovascular diseases were responsible for 10.8% of mortality.

Conclusion

In this population-based nationwide study, we demonstrated that one-eight of patients with new AF died within one year of the diagnosis. Ischaemic heart disease was most frequent cause of death.

Use of antihypertensive medication before diagnosis of atrial fibrillation in Finland – results from the nationwide FinACAF -study

Background and aims

Long-standing arterial hypertension increases the risk of cardiovascular morbidity including atrial fibrillation (AF), coronary heart disease and renal failure. Arterial hypertension is the most common aetiologic factor associated with the development of AF and is also the most prevalent co-morbid cardiovascular disease in patients with AF. Coexisting arterial hypertension together with AF increases further the risk of stroke, heart failure and overall mortality.

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) -study is a nationwide retrospective register-based AF study that combines data from several Finnish health care registers. In this sub-study, we characterized the use of antihypertensive medications in patients with new-onset AF.

Methods

This sub-study included all adult new-onset AF patients of the FinACAF study from January 2007 to December 2018. Patients were excluded if they were under 18 years of age, had any oral anticoagulant purchase in the year prior to AF diagnosis, or had diagnosis of AF or warfarin purchases between the years 2004–2006.

Appropriate data such as anonymized study ID's, ICD-10 diagnoses, and drug purchases (dates, ATC-codes, amounts) were obtained from the National Prescription Register as well as the Finnish Hospital and Primary care registers. The antihypertensive medication purchases from the year preceding the AF diagnosis were analysed and identified by appropriate ATC-codes. Purchases one-month prior to the new-onset AF diagnosis were excluded from in order to avoid confounding by any medication changes due to AF diagnosis.

Results

Of 229,282 patients with new-onset AF 164,527 (71.8%) had purchased antihypertensive medication during the year prior to the AF diagnosis. The most common antihypertensive drugs used were beta blockers (n=108,510; 47.3%), ACE-inhibitors or angiotensin receptor blockers (n=104,840; 45.7%), diuretics (n=79,270; 34.6%) and selective calcium channel blockers (n=61,610; 26.9%). Diltiazem was purchased by 2,001 patients (0.9%) and verapamil by 1,508 patients (0.7%). At the beginning of the study period, beta-blockers were the most widely used antihypertensive agents, but between 2007 and 2018, RAAS-inhibitors (ACE inhibitors and ARB blockers) became the most widely used group of antihypertensive drugs (Figure 1).

Conclusion

Most Finnish new-onset AF patients had at least one pre-existing antihypertensive medication in use before the diagnosis of AF. Beta blockers were the most common antihypertensives until the latest years when RAAS-inhibitors became the most prescribed antihypertensive agents, whereas the use of diltiazem and verapamil was marginal in the treatment of hypertension before the AF diagnosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research Figure 1. Annual use of antihypertensive medication among Finnish new-onset AF patients prior to diagnosis. Annual number of new-onset AF patients plotted for reference.

Incidence of atrial fibrillation. A comprehensive nationwide analysis in Finland

Introduction

Atrial fibrillation (AF) is a chronic condition, and once diagnosed, most of the patients need life-long treatment for AF; rate and rhythm control for symptom relief and oral anticoagulation to mitigate the associated risk of stroke. Incidence of AF is strongly associated with age, and with longer life-expectancy the number of AF patients is worldwide rapidly increasing.

Purpose

The FinACAF study is a nationwide registry study including all AF patients searched from comprehensive national health care registers. To our knowledge, FinACAF is the first nationwide study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the incidence of new-onset AF in unselected nationwide population in Finland.

Methods

In the FinACAF study we gathered data (hospitalizations, outpatient specialist and primary health care visits, and drug reimbursement) from all national health care registers to identify new-onset AF patients from 01st January 2004 to 31st December 2018.

To minimize the risk of misclassification, we considered a patient to have incident AF only if the new-onset AF diagnosis emerged after 1st January 2007 allowing at least three years of registration in Finnish health care registers without diagnosis of AF. Furthermore, patients with warfarin prescriptions during 2004–2006 were excluded. Raw incidence rates (1/100 000) were calculated using the total number of incident AF cases during a given year as numerator, and the total number of Finnish population free of AF on the last day of that year as denominator. The age-standardized incidence rates (1/100 000) were calculated using the total number of new-onset AF cases per year compared to the Nordic population free of AF age distribution.

Results

In total, 411 080 patients with the diagnosis of AF were documented during 2004–2018 in Finland, and the number of new-onset AF patients during 2007–2018 was 256 323. The incidence of AF in relation to age is shown in the Figure 1, and the increasing incidence with advancing age is outstandingly seen. Incidence of AF was more than 2000/100 000 in the population 80 years or older. The incidence of new-onset AF in the whole Finnish population increased during the study period from 330/100 000 and peaked to 456/100 000 in 2018. However, after adjustment for age, the age-adjusted AF incidence remained unchanged during 2007–2018 (Figure 2), but an obvious leap in the incidence emerged during 2011–2013 when the national primary care register was established.

Conclusions

In 2018 the incidence of AF per the whole population was 456/100 000. Based on very novel data and including all the known, diagnosed AF patients in Finland, this is the highest reported incidence rate of AF. Incidence of AF is strongly age-dependent, but the age-standardized incidence was not significantly changed from 2007 to 2018.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research The incidence of AF in relation to ageAge-adjusted annual incidence of AF

Renal function and use of medication preceding new-onset atrial fibrillation – results from the nationwide FinACAF study

Background and aims

Chronic kidney disease (CKD) is a global public health problem with an increasing number of patients due to obesity, hypertension, diabetes, and aging. CKD is an independent risk factor for atrial fibrillation (AF) and the incidence of AF in patients with CKD is two- to threefold higher compared to the general population. The relationship between CKD and AF is bidirectional, and the incidence of renal insufficiency is higher in patients with AF. Both AF and CKD are associated with increased risk of stroke and systemic thromboembolism, as well as an increased bleeding risk. The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. We aimed to characterize demographics and medications of patients with new-onset AF included FinACAF according to stages of renal function.

Method

The FinACAF study includes data from 411000 patients covering all Finnish AF patients from 1 January 2004 to 31 December 2018. Using national unique personal identification numbers, individual patients' data from ten nationwide population registries and six regional laboratory databases were linked together. The inclusion criteria of this substudy were all patients 20 years or older with a new-onset AF diagnosis between January 2010 and December 2018 and a measured estimated glomerular filtration rate (eGFR) within the proximity of the AF diagnosis. Drug purchases (date, Anatomical Therapeutic Chemical (ATC) codes, and amount) were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.

Results

147001 patients from the initial FinACAF cohort were included in this substudy. The mean age at the time of AF diagnosis was 73 years (range 20 to 107 years), 48.9% of the patients were female. The mean age of AF patients increased in various stages of glomerular filtration at the cohort entry during 2010–2018. Baseline medications are shown in Table. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) at the cohort entry decreased from 27.4% to 22.1% during 2010–2018 (p<0.001).

Conclusions

Medications were used increasingly with worsening renal function, except for NSAIDs.

NSAIDs use remained remarkably high in all stages of renal function, albeit much less with the lowest eGFRs. The number of patients with lipid-lowering medication was unexpectedly low considering the high cardiovascular risk in patients with impaired renal function.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This work was supported by Aarne Koskelo Foundation, Yrjö Jahnsson Foundation, The Finnish Foundation for Cardiovascular Research, and Helsinki and Uusimaa Hospital District research fund (TYH2019309).

All you want to know about the arrhythmia: A comprehensive, nationwide registry study of atrial fibrillation in Finland

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation for Cardiovascular Research

OnBehalf

FinACAF

Introduction

The number of atrial fibrillation (AF) patients is increasing, and thus, the socio-medico-economic impact of AF is exploding.  Up-to-date, multifaceted data about the characteristics of AF patients, their treatments, and outcomes are urgently needed.

Purpose

The aim of the Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is to evaluate the incidence and prevalence of AF, risk of stroke, thromboembolic complications, myocardial infarction, major bleeding events, and mortality in AF patients using comprehensive nationwide registries regulated by law. Assessment of the socio-medico-economic aspects of AF and the effect of socio-economic factors on the AF treatment play a central role in this study.

Methods

The FinACAF study collects data from 411 000 patients covering all Finnish AF patients from 1st January 2004 to 31st December 2018. Using national unique personal identification number, individual patient data from ten nationwide population registries and six regional laboratory databases (∼282000, 77 % of the patients) are linked together. All the register data were obtained during Q1-Q2/2020. The main results will be expected during Q1-2/2021.

Results

Since the introduction of the national primary care register in 2012, 9% of all AF patients were identified outside hospital care registers. The total number of AF patients on 31st December 2018 was 227 114, which translates to an AF prevalence of 4.1% in Finland (population of 5 517 900).

The Table represents the registries used in the FinACAF study.

Conclusions

The FinACAF study records all patient contacts with the health care institutions and organizations, as well as incomes and places of domicile. Thus, the database allows a unique possibility to investigate the epidemiology and socio-medico-economic impact of AF as well as the cost effectiveness of different AF management strategies in a completely unselected, nationwide population. This data will markedly help "leading with data" when the increasing number of AF patients are treated. The registries used in the FinACAF study Register Registry Information obtained Finnish Care Register for Health Care: Primary, Hospital and Social care registries National Institute for Health and Welfare Diagnosis (ICD-10), procedure codes and date; non-hospital institutionalizations National Prescription Register, National Reimbursement Register The Social Insurance Institution of Finland Drug purchases (date, ATC codes, amount), Reimbursement decisions for chronic diseases (date, ICD-10) National Causes of Death Register, The Register of Completed Education and Degrees Statistics Finland Deaths and causes of deaths (ICD-10), Education and socio-economic status National Cancer Registry (1st Jan 1950 to 31st Dec 2018) Finnish Cancer Registry National registry of all cancer cases (e.g. date, ICD-O-3, TNM) Population Register, Tax register Population Register Center, Tax Administration Places of domicile, Income and taxes Laboratory databases (1st Jan 2010 to 31st Dec 2018) Six largest regional laboratory databases INR and other relevant laboratory measurements

Scraping up CHA2DS2-VASc - defining components of the acronym in a nationwide registry study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital district Finnish foundation for cardiovascular research

Introduction

Atrial fibrillation (AF) is a major cause of ischemic stroke. The risk of stroke is strongly associated with age, sex and comorbidities of the patients. Therefore, it is crucial that the comorbidities are consistently recorded in medical records as well as health care registries.

Purpose

This study aims to evaluate the prevalence of the comorbidities related to AF stroke risk in Finnish nationwide population registries, and assess how the use and combination of these registries affect the calculated CHA2DS2-VASc risk score. The comorbidities evaluated were Hypertension, Diabetes, Stroke or TIA, Heart Failure, and Vascular Disease.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study collected data on all Finnish AF patients from 1st January 2004 to 31st December 2018. Due to the initiation of the national primary care register in 2012, this substudy uses the data of patients with a new AF diagnosis during 2012-2018 (n = 168 353). Using a unique personal identification code, individual patient data were linked from the Finnish national health care registries "AvoHILMO" (primary care) and "HILMO" (secondary and tertiary care), National Prescription Register (ATC codes of purchased medication) and the National Reimbursement Register for reimbursed medication upheld by the Social Insurance Institute (KELA).

Results

The average CHA2DS2-VASc risk score when entering the cohort, and including information from all registries, equaled 2.91 for men (mean age 70.0 years) and 4.42 for women (mean age 76.9 years). The highest prevalence of diabetes and hypertension were found based on the National Reimbursement Register (ATC codes). Stroke or TIA and heart failure were identified almost exclusively based on secondary and tertiary hospital records.

The table represents our results. 

Conclusion

Comprehensive registry analysis of AF patients requires the inclusion of both hospital and medication data. The role of primary care information was limited. Comorbidity and CHA2DS2-VASc weight Total Prevalence Primary care ICD-10 codes Primary care ICPC-2 codes Secondary and tertiary care ICD-10 codes ATCcodes Medication reimbursement codes Hypertension 1 82%137 317 28%47 337 13%21 427 39%66 252 77%130 400 7%10 957 Diabetes 1 24%41 017 13%22 666 13%22 547 14%23 793 21%35 942 12%20 295 Stroke or TIA 2 17%28 653 4%6 254 1%1 968 16%27 379 - - Heart Failure 1 18%29 827 5%7 630 1%1 398 16%26 366 - 1%1 908 Vascular Disease1 28%47 420 12%19 581 2%3 265 25%41 647 - 7%11 802 Average CHA2DS2-VASc contribution 1.86 0.65 0.31 1.26 0.99 0.26 The prevalence of the comorbidities and average CHA2DS2-VASc risk score contribution by registry and combined.

The association between bacterial infections and the risk of coronary heart disease in type 1 diabetes

BACKGROUND

Diabetes increases the risk of infections and coronary heart disease (CHD). Whether infections increase the risk of CHD and how this applies to individuals with diabetes is unclear.

OBJECTIVES

To investigate the association between bacterial infections and the risk of CHD in type 1 diabetes.

METHODS

Individuals with type 1 diabetes (n = 3781) were recruited from the Finnish Diabetic Nephropathy Study (FinnDiane), a prospective follow-up study. CHD was defined as incident events: fatal or nonfatal myocardial infarction, coronary artery bypass surgery or percutaneous coronary intervention, identified through national hospital discharge register data. Infections were identified through national register data on all antibiotic purchases from outpatient care. Register data were available from 1 January 1995 to 31 December 2015. Bacterial lipopolysaccharide (LPS) activity was measured from serum samples at baseline. Data on traditional risk factors for CHD were collected during baseline and consecutive visits.

RESULTS

Individuals with an incident CHD event (n = 370) had a higher mean number of antibiotic purchases per follow-up year compared to those without incident CHD (1.34 [95% CI: 1.16-1.52], versus 0.79 [0.76-0.82], P < 0.001), as well as higher levels of LPS activity (0.64 [0.60-0.67], versus 0.58 EU mL^-1 [0.57-0.59], P < 0.001). In multivariable-adjusted Cox proportional hazards models, the mean number of antibiotic purchases per follow-up year was an independent risk factor for incident CHD (HR 1.21, 95% CI: 1.14-1.29, P < 0.0001). High LPS activity was a risk factor for incident CHD (HR 1.93 [1.34-2.78], P < 0.001) after adjusting for static confounders.

CONCLUSION

Bacterial infections are associated with an increased risk of incident CHD in individuals with type 1 diabetes.

P1904Oral anticoagulation in patients undergoing elective cardioversion of atrial fibrillation. Real-life experience from Finland

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used in patients with atrial fibrillation (AF) undergoing elective cardioversion (ECV). The real-life data evaluating the safety and efficacy of ECV in patients receiving NOACs is sparse.

Purpose

The aim was to investigate the use of NOACs and warfarin in ECV in a real-life setting and to assess how the chosen regimen affected the delay to ECV and rate of complications.

Methods

Consecutive AF patients undergoing ECVs in a large city in Finland between January 2015 and December 2016 were studied. Data on patient characteristics, delays to cardioversion, anticoagulation treatment, acute (<30 days) complications and regimen changes within one year were evaluated.

Results

Nine hundred patients (59.2% men; mean age, 68.0±10.0) underwent 992 ECVs, of which 596 (60.0%) were performed using NOACs and 396 (40.0%) using warfarin. The mean CHA2DS2-VASc score was 2.5 (±1.6). In patients without previous anticoagulation treatment, NOACs were associated with a shorter mean time to cardioversion than warfarin (51 vs. 68 days, respectively; P<0.001). Furthermore, patients receiving NOAC had fewer postponements of scheduled elective cardioversion compared with warfarin (12.6% vs. 37.4%, respectively, P<0.001). The most common reason for visit cancellation was an imbalance of warfarin therapy and labile INR values. Six thromboembolic events (0.6%) occurred: 4 (0.7%) in NOAC-treated patients and 2 (0.5%) in warfarin-treated patients. All patients who experienced a stroke or TIA had adequate anticoagulation therapy for at least 3 weeks preceding the cardioversion, and both patients in the warfarin group had an INR value >2 when thromboembolic complications occurred. Clinically relevant bleeding events occurred in 3 patients (0.5%) receiving NOACs and 7 patients (1.8%) receiving warfarin. Anticoagulation treatment was altered for 99 patients (11.0%) during the study period, with the majority (88.2%) of changes from warfarin to NOACs.

Conclusion

In this real-life study, the rates of thromboembolic and bleeding complications were low in AF patients undergoing ECV. Patients receiving NOAC therapy had a shorter time to cardioversion and fewer postponements of scheduled elective cardioversion compared with warfarin. Furthermore, patients receiving NOAC therapy had less anticoagulation treatment changes than patients on warfarin.

Acknowledgement/Funding

Finnish Foundation for Cardiovascular Research, Helsinki University Hospital District research fund, Boehringer-Ingelhem, Finnish Medical Foundation

A novel glycocluster molecule prevents timothy-induced allergic airway inflammation in mice

BACKGROUND

Allergen-specific immunotherapy (SIT) effectively alleviates type I allergic diseases characterized by T helper (Th)2-type immunity. Our recent studies have shown that a synthetic trivalent glycocluster, triacedimannose (TADM), suppresses the Th2-type allergic inflammation. The aim of this study was to compare TADM with two well-known adjuvants, unmethylated cytosine-phosphate-guanine oligodeoxynucleotide (CpG) and monophosphoryl lipid A (MPLA) in a grass allergen-induced chronic allergic inflammation model in mice.

METHODS

Female BALB/c mice were intranasally sensitized with 50 μL of timothy grass pollen extract (TE) twice a week for a period of 15 weeks. Therapeutic intranasal treatments were then performed once a week after the tenth intranasal TE instillation using TADM (10 or 25 μg/50 μL), CpG-ODN (20 μg/50 μL) or MPLA (2 μg/50 μL). Groups of 9-10 animals per treatment were killed 24 hours after the last timothy dosage. Blood, bronchoalveolar lavage (BAL) fluids and lung biopsies were taken for subsequent analysis.

RESULTS

When mice were repeatedly exposed to TE for 15 weeks, the number of eosinophils and lymphocytes increased in the BAL fluids. The eosinophil and lymphocyte counts decreased dose-dependently and were practically abolished in the mice treated with TADM. Treatments with MPLA or CpG significantly increased the numbers of neutrophils, while CpG nonsignificantly decreased eosinophilia compared to timothy exposure.

CONCLUSIONS

A novel synthetic glycocluster molecule inhibited the development of grass-induced eosinophilic pulmonary inflammation in mice when administrated in the airways. This compound could be a candidate to be used either as an adjuvant in SIT or as a topical anti-inflammatory treatment.

Nasal mucosa and blood cell transcriptome profiles do not reflect respiratory symptoms associated with moisture damage

Upper and lower respiratory symptoms and asthma are adverse health effects associated with moisture-damaged buildings. Quantitative measures to detect adverse health effects related to exposure to dampness and mold are needed. Here, we investigate differences in gene expression between occupants of moisture-damaged and reference buildings. Moisture-damaged (N = 11) and control (N = 5) buildings were evaluated for dampness and mold by trained inspectors. The transcriptomics cohort consisted of nasal brushings and peripheral blood mononuclear cells (PBMCs) from 86 teachers, with/without self-perceived respiratory symptoms. Subject categories comprised reference (R) and damaged (D) buildings with (S) or without (NS) symptoms, that is, R-S, R-NS, DS, and D-NS. Component analyses and k-means clustering of transcriptome profiles did not distinguish building status (R/D) or presence of respiratory symptoms (S/NS). Only one nasal mucosa gene (YBX3P1) exhibited a significant change in expression between D-S and D-NS. Nine other nasal mucosa genes were differentially expressed between R-S and D-S teachers. No differentially expressed genes were identified in PBMCs. We conclude that the observed mRNA differences provide very weak biological evidence for adverse health effects associated with subject occupancy of the specified moisture-damaged buildings. This emphasizes the need to evaluate all potential factors (including those not related to toxicity) influencing perceived/self-reported ill health in moisture-damaged buildings.

Intestinal alkaline phosphatase at the crossroad of intestinal health and disease - a putative role in type 1 diabetes

BACKGROUND

Patients with type 1 diabetes have shown an increase in circulating cytokines, altered lipoprotein metabolism and signs of vascular dysfunction in response to high-fat meals. Intestinal alkaline phosphatase (IAP) regulates lipid transport and inflammatory responses in the gastrointestinal tract. We therefore hypothesized that changes in IAP activity could have profound effects on gut metabolic homeostasis in patients with type 1 diabetes.

METHODS

Faecal samples of 41 nondiabetic controls and 46 patients with type 1 diabetes were analysed for IAP activity, calprotectin, immunoglobulins and short-chain fatty acids (SCFAs). The impact of oral IAP supplementation on intestinal immunoglobulin levels was evaluated in C57BL/6 mice exposed to high-fat diet for 11 weeks.

RESULTS

Patients with type 1 diabetes exhibited signs of intestinal inflammation. Compared to controls, patients with diabetes had higher faecal calprotectin levels, lower faecal IAP activities accompanied by lower propionate and butyrate concentrations. Moreover, the amount of faecal IgA and the level of antibodies binding to oxidized LDL were decreased in patients with type 1 diabetes. In mice, oral IAP supplementation increased intestinal IgA levels markedly.

CONCLUSION

Deprivation of protective intestinal factors may increase the risk of inflammation in the gut - a phenomenon that seems to be present already in patients with uncomplicated type 1 diabetes. Low levels of intestinal IgA and antibodies to oxidized lipid epitopes may predispose such patients to inflammation-driven complications such as cardiovascular disease and diabetic nephropathy. Importantly, oral IAP supplementation could have beneficial therapeutic effects on gut metabolic homeostasis, possibly through stimulation of intestinal IgA secretion.

Is longer waiting time associated with health and social services utilization before treatment? A randomized study

Objective: To determine whether longer waiting time for major joint replacement is associated with health and social services utilization before treatment.

Methods: When placed on the waiting list, patients were randomized to short (≤3 months) or a non-fixed waiting time. Utilization measures were the use of home health care, rehabilitation and social services before treatment.

Results: A total of 833 patients with osteoarthritis of the hip or knee joint were recruited into the study. Six hundred and twenty-two patients were included in the analysis. The majority of patients were not using any services before hospital admission for joint replacement surgery. The most commonly used service was unpaid home help provided by relatives, neighbours, friends and volunteers (informal care). In both groups, private support services were utilized more often than public ones. Patients with a short waiting time were more likely than those with a non-fixed waiting time to use rehabilitation (13.5% versus 8.2%, P = 0.032) and visiting care services (7.5% versus 3.9%, P = 0.054).

Conclusions: Only a few patients used professional care. They were more likely to require informal care during the waiting time. A longer waiting time did not result in a higher utilization rate before admission for treatment.

A novel mannoside-glycocluster adjuvant: Compared in vitro to CpG ODN and MPL and tested in vivo in mouse asthma model

BACKGROUND

Allergen-specific immunotherapy balances the Th2-biased immunity towards Th1 and Treg responses. Adjuvants are used in allergen preparations to intensify the immune responses. The increased prevalence of allergies in developed societies has been associated with decreased microbial load during childhood. This has initiated a search for microbial structures to be used as adjuvants. Our study has shown that a synthetic triacedimannose (TADM) may suppress the Th2-type allergic inflammatory response. The aim of this study was to compare the properties of TADM with capacities of other adjuvants, CpG ODN and MPL, to modulate cytokine production in PBMC and regulate sensitisation in an OVA-sensitised mouse asthma model.

METHODS

The effects of TADM were studied in vitro on birch stimulated PBMC cultures of birch allergic rhinitis patients with other known adjuvants. Cytokines in supernatants were measured by Luminex. Effects of TADM were analysed in vivo in a mouse model of OVA-induced allergic asthma by analysing BAL, cytokine mRNA and serum antibodies.

RESULTS

TADM was the only adjuvant that significantly suppressed the production of all birch induced Th2-type cytokines. In a murine model, TADM significantly suppressed the specific IgE production and enhanced IFN-γ production.

CONCLUSIONS

TADM suppresses the birch allergen induced Th2-type cytokine responses in allergic subjects more efficiently than the two other adjuvants, MPL and CpG ODN. TADM is immunomodulatory also in vivo and decreases the IgE levels and increases the IFN-γ responses in a murine model. These results suggest that TADM may be a promising candidate for novel adjuvants in immunotherapy.

Podocyte apoptosis is prevented by blocking the Toll-like receptor pathway

High serum lipopolysaccharide (LPS) activity in normoalbuminuric patients with type 1 diabetes (T1D) predicts the progression of diabetic nephropathy (DN), but the mechanisms behind this remain unclear. We observed that treatment of cultured human podocytes with sera from normoalbuminuric T1D patients with high LPS activity downregulated 3-phosphoinositide-dependent kinase-1 (PDK1), an activator of the Akt cell survival pathway, and induced apoptosis. Knockdown of PDK1 in cultured human podocytes inhibited antiapoptotic Akt pathway, stimulated proapoptotic p38 MAPK pathway, and increased apoptosis demonstrating an antiapoptotic role for PDK1 in podocytes. Interestingly, PDK1 was downregulated in the glomeruli of diabetic rats and patients with type 2 diabetes before the onset of proteinuria, further suggesting that reduced expression of PDK1 associates with podocyte injury and development of DN. Treatment of podocytes in vitro and mice in vivo with LPS reduced PDK1 expression and induced apoptosis, which were prevented by inhibiting the Toll-like receptor (TLR) signaling pathway with the immunomodulatory agent GIT27. Our data show that LPS downregulates the cell survival factor PDK1 and induces podocyte apoptosis, and that blocking the TLR pathway with GIT27 may provide a non-nephrotoxic means to prevent the progression of DN.

In-Hospital Cardiac Complications after Intracerebral Hemorrhage

Background and purpose

Data on cardiac complications and their precipitants after intracerebral hemorrhage are scarce. We examined the frequency and risk factors for serious in-hospital cardiac events in a large cohort of consecutive intracerebral hemorrhage patients.

Methods

A retrospective chart review of 1013 consecutive patients with nontraumatic intracerebral hemorrhage treated at the Helsinki University Central Hospital (2005–2010). We excluded patients with intraparenchymal hematoma related to sub-arachnoid hemorrhage or intracerebral hemorrhage because of fibrinolytic therapies for acute ischemic stroke or myocardial infarction. Serious in-hospital cardiac event was defined as any of in-hospital poststroke acute myocardial infarction, ventricular fibrillation or tachycardia, moderate to serious acute heart failure, or cardiac death.

Results

Among the 948 patients included, ≥1 serious in-hospital cardiac event occurred in 39 (4·1%) patients after a median delay of two-days from stroke onset (acute myocardial infarction in three patients, ventricular fibrillation or tachycardia in three patients, acute heart failure in 36 patients, and cardiac death in three patients). Hospital stay was longer in patients with serious in-hospital cardiac event than in those without (median 12, interquartile range 7–19 vs. 8, 3–14; P = 0·001), with no difference in in-hospital mortality (23·1% vs. 24·3%; P = 0·86). In multivariable logistic regression analysis adjusted for age, gender, and diabetes, atrial fibrillation during hospitalization (odds ratio 6·68 for new-onset atrial fibrillation, 95% confidence interval 2·11–21·18; 4·46 for old atrial fibrillation, 2·08–9·56), and history of myocardial infarction (3·20, 1·18–8·66) were independently associated with serious in-hospital cardiac events.

Conclusions

After intracerebral hemorrhage, 4% of patients suffer an acute serious cardiac complication. Those with history of myocardial infarction or in-hospital atrial fibrillation are at greater risk for such events.

Ammonia in breath and emitted from skin

Ammonia concentrations in exhaled breath (eNH3) and skin gas of 20 healthy subjects were measured on-line with a commercial cavity ring-down spectrometer and compared to saliva pH and plasma ammonium ion (NH(+)4), urea and creatinine concentrations. Special attention was given to mouth, nose and skin sampling procedures and the accurate quantification of ammonia in humid gas samples. The obtained median concentrations were 688 parts per billion by volume (ppbv) for mouth-eNH3, 34 ppbv for nose-eNH3, and 21 ppbv for both mouth- and nose-eNH3 after an acidic mouth wash (MW). The median ammonia emission rate from the lower forearm was 0.3 ng cm(-2) min(-1). Statistically significant (p < 0.05) correlations between the breath, skin and plasma ammonia/ammonium concentrations were not found. However, mouth-eNH3 strongly (p < 0.001) correlated with saliva pH. This dependence was also observed in detailed measurements of the diurnal variation and the response of eNH3 to the acidic MW. It is concluded that eNH3 as such does not reflect plasma but saliva and airway mucus NH(+)4 concentrations and is affected by saliva and airway mucus pH. After normalization with saliva pH using the Henderson-Hasselbalch equation, mouth-eNH3 correlated with plasma NH(+)4, which points to saliva and plasma NH(+)4 being linked via hydrolysis of salivary urea.

IRAK-M in macrophages around septically and aseptically loosened hip implants

The most common long-term complication of joint arthroplasty is loosening, which is mediated by chronic inflammatory cytokines produced by macrophages stimulated by implant-derived debris and eventually bacterial components adherent to such debris. In this study, antiinflammatory interleukin-1 receptor-associated kinase-M (IRAK-M) was studied in macrophages in interface membranes in vivo using immunohistochemical staining and in titanium particle-stimulated macrophages in vitro using reverse transcriptase-polymerase chain reaction. Results show that the interface membranes of septically and aseptically loosened prosthesis express more IRAK-M protein than control membranes from osteoarthritic patient and that IRAK-M mRNA-levels increase upon particle stimulation. These findings suggest that, the upregulation of IRAK-M in macrophages is involved in the local immunosuppression around implants, and may contribute to septic and aseptic implant loosening.

Soluble receptor for AGE (RAGE) is a novel independent predictor of all-cause and cardiovascular mortality in type 1 diabetes

AIMS/HYPOTHESIS

Activation of the receptor for AGE (RAGE) is implicated in the development and progression of vascular complications of diabetes. In this study, we explore factors and mortality outcomes associated with soluble RAGE (sRAGE) in a multicentre nationwide cohort of Finnish adults with type 1 diabetes.

METHODS

Baseline sRAGE concentrations were estimated in 3,100 adults with type 1 diabetes. Clinical and biological variables independently associated with sRAGE were identified using multivariate regression analysis. Independent predictors of mortality were determined using Cox and Fine-Gray proportional-hazards models.

RESULTS

The main independent determinants of sRAGE concentrations were estimated glomerular filtration rate, albuminuria, body mass index, age, duration of diabetes, HbA(1c) and insulin dose (all p < 0.05). During a median of 9.1 years of follow-up there were 202 deaths (7.4 per 1,000 patient years). sRAGE was independently associated with all-cause (Cox model: HR 1.03) and cardiovascular mortality (Fine-Gray competing risks model: HR 1.06) such that patients with the highest sRAGE concentrations had the greatest risk of mortality, after adjusting for age, sex, macrovascular disease, HDL-cholesterol, HbA(1c), triacylglycerol, high-sensitivity C-reactive protein (hsCRP) and the presence and severity of chronic kidney disease. Although polymorphisms in the gene coding for RAGE were significantly associated with sRAGE concentrations, none were associated with mortality outcomes.

CONCLUSIONS/INTERPRETATION

Increased concentrations of sRAGE are associated with increased all-cause and cardiovascular mortality in type 1 diabetes, potentially reflecting the activation and production of RAGE in the context of accelerated vascular disease. These novel findings highlight the importance of the RAGE activation in the prevention and management of diabetic complications.

A combined Fuzzy and Naive Bayesian strategy can be used to assign event codes to injury narratives

BACKGROUND

Bayesian methods show promise for classifying injury narratives from large administrative datasets into cause groups. This study examined a combined approach where two Bayesian models (Fuzzy and Naïve) were used to either classify a narrative or select it for manual review.

METHODS

Injury narratives were extracted from claims filed with a worker's compensation insurance provider between January 2002 and December 2004. Narratives were separated into a training set (n=11,000) and prediction set (n=3,000). Expert coders assigned two-digit Bureau of Labor Statistics Occupational Injury and Illness Classification event codes to each narrative. Fuzzy and Naïve Bayesian models were developed using manually classified cases in the training set. Two semi-automatic machine coding strategies were evaluated. The first strategy assigned cases for manual review if the Fuzzy and Naïve models disagreed on the classification. The second strategy selected additional cases for manual review from the Agree dataset using prediction strength to reach a level of 50% computer coding and 50% manual coding.

RESULTS

When agreement alone was used as the filtering strategy, the majority were coded by the computer (n=1,928, 64%) leaving 36% for manual review. The overall combined (human plus computer) sensitivity was 0.90 and positive predictive value (PPV) was >0.90 for 11 of 18 2-digit event categories. Implementing the 2nd strategy improved results with an overall sensitivity of 0.95 and PPV >0.90 for 17 of 18 categories.

CONCLUSIONS

A combined Naïve-Fuzzy Bayesian approach can classify some narratives with high accuracy and identify others most beneficial for manual review, reducing the burden on human coders.

Is longer waiting time for total knee replacement associated with health outcomes and medication costs? Randomized clinical trial

BACKGROUND

The aim of this prospective randomized study was to evaluate the effect of waiting time (WT) on health-related quality of life (HRQoL), knee pain and physical function, and the use and costs of medication of patients awaiting total knee replacement.

METHODS

When placed on the waiting list, 438 patients were randomized into a short waiting time (SWT ≤ 3 months) or a nonfixed waiting time (NFWT > 3 months) group. HRQoL was measured by the 15D, and pain and physical function by modified Knee Society Clinical Rating System at baseline, admission, and 3 and 12 months postoperatively. The costs of medication due to osteoarthritis were calculated at the same measurement points. All analyses were performed using the intention-to-treat principle.

RESULTS

The mean WT was 94 and 239 days in the SWT and NFWT groups, respectively. Apart from higher weekly cost of medication in the SWT group at admission and better HRQoL in the NFWT group 1 year postoperatively, there were no statistically significant differences between the groups in other outcomes during the follow-up.

CONCLUSION

Those in the SWT group had higher weekly costs of medication at admission, and reached better HRQoL 3 months earlier than those in the NFWT group, but the latter had better HRQoL after operation. Otherwise, the length of WT was not associated with different health and HRQoL outcomes in the groups.

Bayesian methods: a useful tool for classifying injury narratives into cause groups

To compare two Bayesian methods (Fuzzy and Naïve) for classifying injury narratives in large administrative databases into event cause groups, a dataset of 14 000 narratives was randomly extracted from claims filed with a worker's compensation insurance provider. Two expert coders assigned one-digit and two-digit Bureau of Labor Statistics (BLS) Occupational Injury and Illness Classification event codes to each narrative. The narratives were separated into a training set of 11 000 cases and a prediction set of 3000 cases. The training set was used to develop two Bayesian classifiers that assigned BLS codes to narratives. Each model was then evaluated for the prediction set. Both models performed well and tended to predict one-digit BLS codes more accurately than two-digit codes. The overall sensitivity of the Fuzzy method was, respectively, 78% and 64% for one-digit and two-digit codes, specificity was 93% and 95%, and positive predictive value (PPV) was 78% and 65%. The Naïve method showed similar accuracy: a sensitivity of 80% and 70%, specificity of 96% and 97%, and PPV of 80% and 70%. For large administrative databases, Bayesian methods show significant promise as a means of classifying injury narratives into cause groups. Overall, Naïve Bayes provided slightly more accurate predictions than Fuzzy Bayes.

The effect of waiting time on health and quality of life outcomes and costs of medication in hip replacement patients: a randomized clinical trial

OBJECTIVE

To evaluate the effect of waiting time on health and quality of life outcomes and costs of medication in total hip replacement (THR) patients in a randomized clinical trial.

METHODS

395 THR patients were recruited into the study. When placed on the waiting list, patients were randomized into a short (< or =3 months) or a non-fixed waiting time (NFWT) (>3 months) group. In the final analyses 309 patients (179 women) with a mean age of 65 years were included. Health-related quality of life (HRQoL) (generic 15D), and pain and function (modified Harris Hip Score (HHS)) were calculated when placed on the waiting list, at hospital admission, and at 3 and 12 months postoperatively. The costs of disease-specific medication were calculated at the same measurement points. All analyses were performed using the intention-to-treat (ITT) principal.

RESULTS

Of the recruited patients, 309 (78%) completed the follow-up (short group 140 and non-fixed group 169 patients). The mean waiting time was 74 days in the short and 194 days in the NFWT groups. In the ITT analyses there were no statistically significant differences between the groups in the weekly use and costs of medication, HRQoL or HHS at baseline, at admission, or 3 or 12 months after surgery. The only difference was in total medication costs during the waiting time period, at EUR 83 and 171, respectively.

CONCLUSIONS

The length of the waiting time did not generate different effects on the studied health and quality of life outcomes of the randomized groups. However, those in short waiting time group reached earlier better HRQoL.

The effect of waiting time on health-related quality of life, pain, and physical function in patients awaiting primary total hip replacement: a randomized controlled trial

OBJECTIVE

This prospective randomized study assessed the effect of waiting time (WT) on health outcomes in Finnish patients admitted to hospital for primary total hip replacement (THR).

METHODS

A total of 395 consecutive patients with a need for a primary THR because of osteoarthritis and who were placed on the waiting list between August 2002 and November 2003. After placement on the waiting list, the patients were randomly assigned to a short WT (<or=3 months) group (n = 174) or a nonfixed WT group (n = 221). The patients completed self-administered questionnaires at the time of placing on the waiting list and at hospital admission. Health-related quality of life was measured by the generic 15D instrument. Hip pain and function were measured by the patient self-report Harris hip score (HHS).

RESULTS

Of the 395 patients, 312 (79%) completed the follow-up (140 patients with short and 172 with nonfixed WT). At admission, the mean 15D scores for patients with short and nonfixed WT were 0.784 and 0.783, respectively. In the intention-to-treatment analysis, the difference between the groups (Delta 0.001, 95% confidence interval [CI]: -0.019 to 0.021) was not statistically significant or clinically important. The mean self-report HHS in patients with short WT was 43.5, and among those with nonfixed WT was 41.9. The difference (Delta 1.6, 95% CI: -1.77 to 4.87) was not statistically significant.

CONCLUSIONS

Both generic and disease-specific measures revealed that longer WTs did not result in poorer health status at admission.

Total hip replacement in patients eighty years of age and older

BACKGROUND

The number of people eighty years of age and older in developed countries is increasing, with a concomitant increased demand for total hip replacement. We analyzed the outcomes of total hip arthroplasty for patients in this age group using data from the Finnish National Arthroplasty Registry.

METHODS

Data from the Finnish Arthroplasty Registry on 6540 patients (6989 hips) who were eighty years of age or older at the time of a total hip arthroplasty, performed between 1980 and 2004, were evaluated with use of survival analyses. Factors affecting survivorship rates were sought, and the reasons for revision were identified.

RESULTS

The mean age of the patients undergoing a primary total hip arthroplasty was 82.7 years. The mean longevity of 3065 patients who died following total hip arthroplasty was 5.1 years. With revision total hip arthroplasty for any reason as the end point, Kaplan Meier survivorship was 97% (95% confidence interval, 96% to 97%) at five years (2617 hips) and 94% (95% confidence interval, 93% to 95%) at ten years (532 hips). Of the 195 hip replacements that required revision, 183 had information on the reason for revision. Eighty-four (46%) were revised for aseptic loosening; thirty-six (20%), for recurrent dislocation; twenty-four (13%), for a periprosthetic fracture; and twenty-three (13%), for infection. Seven hundred and twenty-nine patients had undergone hybrid fixation (a cemented stem and a cementless cup). The survivorship of these replacements was significantly better than that for replacements with cementless fixation in 399 patients (p < 0.05).

CONCLUSIONS

In patients who had a total hip arthroplasty when they were more than eighty years old, the prevalence of aseptic loosening was less than that encountered in younger patients, but recurrent dislocation, periprosthetic fracture, and infection were more common in this age group. Cementation of the femoral stem demonstrated better long-term results than cementless fixation, indicating that it may provide better initial fixation and, therefore, longer life-in-service.

Evaluating waiting time effect on health outcomes at admission: a prospective randomized study on patients with osteoarthritis of the knee joint

AIMS

To evaluate the effect of waiting on health-related quality of life (HRQoL), pain and physical function in patients awaiting primary total knee replacement (TKR) due to osteoarthritis.

METHODS

Some 438 patients awaiting TKR were randomized to a short waiting time (WT) group (< or =3 months) or a non-fixed WT group. In the final assessment, 310 patients (213 women) with a mean age of 68 years were included. HRQoL was measured on being placed on the waiting list and again at hospital admission using the generic 15D. Patients' self-report pain and physical function were evaluated using a scale modified from the Knee Society Clinical Rating System.

RESULTS

The median WTs for patients with short and non-fixed WT were 73 days (range 8-600 days) and 266 days (range 28-818 days), respectively. At admission, as assessed by the intention-to-treat analysis, there were no statistically significant differences between the groups in the 15D total score and disease-specific pain and function.

CONCLUSIONS

Our study showed that longer WT did not result in worse pre-operative HRQoL.

Hev b 6.01 and Hev b 5 induce pro-inflammatory cytokines and chemokines from peripheral blood mononuclear cells in latex allergy

BACKGROUND

Hev b 6.01 (prohevein) and Hev b 5 [acidic natural rubber latex (NRL) protein] are major IgE-binding allergens in NRL allergy.

OBJECTIVE

To examine allergen-specific cytokine and chemokine responses in NRL-allergic patients.

METHODS

Fourteen NRL-allergic patients and 10 healthy controls participated in the study. Hev b 6.01 and Hev b 5 were purified under non-denaturating conditions by chromatographic methods. Specific IgE antibodies were measured by ELISA and proliferation of peripheral blood mononuclear cells (PBMC) by (3)H-thymidine incorporation assay. Allergen-specific induction of cytokine and chemokine mRNA in PBMC was measured by real-time PCR and protein levels by ELISA. Surface expression of chemokine receptors was analysed by flow cytometry.

RESULTS

Twelve (86%) NRL-allergic patients had positive skin prick test reactions and IgE antibodies against Hev b 6.01, but less than 30% responded to Hev b 5. Cell proliferation against Hev b 6.01, but not against Hev b 5, was significantly increased. Both allergens elicited significantly higher expression of pro-inflammatory and T-helper type 2 cytokines (TNF, IL-12p40, IL-13) and chemokines (CCL3, CCL4, CCL20) in the NRL-allergic patients than in controls. Interestingly, mRNA expression of the regulatory cytokine TGF-beta1 was reduced, whereas IL-10 expression was enhanced after allergen stimulations in patients with NRL allergy. Finally, the NRL-allergic patients showed increased CCR4 expression on CD3(+)CD8(-) T cells and decreased CXCR3 expression on CD3(+)CD8(+) T cells.

CONCLUSION

Allergen-specific induction of cytokines and chemokines in PBMC and chemokine receptor expression on circulating T cells may contribute to the pathogenesis of NRL allergy.

Latex allergy: low prevalence of immunoglobulin E to highly purified proteins Hev b 2 and Hev b 13

BACKGROUND

Hevea brasiliensis (Hev b) 2 and Hev b 13 have recently been identified as major latex allergens by detecting specific IgE antibodies in >50% of sera from Hev b latex-allergic individuals.

OBJECTIVE

We assessed the prevalence rates for sensitization to extensively purified latex allergens in patients from three diverse geographical areas.

METHODS

Native Hev b 2, Hev b 5, Hev b 6.01 and Hev b 13 were purified by non-denaturating chromatography and were used in ELISAs to assess sera from 215 latex-allergic patients and 172 atopic non-sensitized controls from Finland, Spain and the United States to detect allergen-specific IgE antibodies.

RESULTS

Unexpectedly, even highly purified Hev b 13 contained epitope(s) to which Hev b 6-specific human IgE antibodies bound effectively. Further purification, however, reduced the prevalence of IgE antibody reactivity to low levels: 15%, 5% and 11% for Hev b 2, and 18%, 30% and 27% for Hev b 13 among latex-allergic Finnish, Spanish and American patients, respectively. Interestingly, Finnish patients had a lower prevalence of Hev b 5-specific IgE antibody (28%) as compared with Spanish (49%) and American (71%) patients. The prevalence of Hev b 6.01-specific IgE reactivity was uniformly >50% in all three populations.

CONCLUSION

Neither Hev b 2 nor Hev b 13 appear to be major latex allergens when evaluated in serological assays using highly purified allergens. The reason(s) for the observed differences in published sensitization rates in various geographic regions requires further study. The purity of the allergen preparations has a marked impact on the accuracy of latex-specific IgE antibody detection in epidemiological studies and in the serological diagnosis of latex allergy.

The effect of co-morbidities on health-related quality of life in patients placed on the waiting list for total joint replacement

Background

Co-morbidity is a powerful predictor of health care outcomes and costs, as well as an important cofounder in epidemiologic studies. The effect of co-morbidities is generally related to mortality or complications. This study evaluated the association between co-morbidity and health-related quality of life (HRQoL) in patients awaiting total joint replacement.

Methods

A total of 893 patients were recruited to the study between August 2002 and November 2003 in four Finnish hospitals. The effect of co-morbidity on HRQoL was measured by the generic 15D instrument and by a Visual Analog Scale (VAS). Comparative variance analysis of socio-demographic and clinical characteristics was described by using either an independent samples t-test or the Chi-square test. The differences in each of the 15D dimensions and the overall 15D single index score for patients were calculated. Two-sided p-values were calculated with the Levene Test for Equality of Variances.

Results

Patients with co-morbidity totaled 649; the incidence of co-morbidity was 73%. The mean number of co-morbidities among the patients was two. At baseline the 15D score in patients with and without co-morbidity was 0.778 vs 0.816, respectively. The difference of the score (0.038) was clinically and statistically significant (P < 0.001). The patients' scores with and without co-morbidity on the different 15D dimensions related to osteoarthritis-moving, sleeping, usual activities, discomfort and symptoms, vitality and sexual activity–were low in both groups. Patients with co-morbidity scored lower on the dimensions of moving, vitality and sexual activity compared to the patients without co-morbidity. Co-morbidity was significantly associated with a reduced HRQoL. Patients without co-morbidity had poorer VAS, arthritis had strong effect to their quality of life compared to the patients with co-morbidity.

Conclusion

Assessing co-morbidity in patients placed on the waiting list for joint replacement may be useful method to prioritization in medical decision-making for healthcare delivery. The assessment of co-morbidities during waiting time is important as well as evaluating how the co-morbidity may affect the final outcomes of the total joint replacement.

The OSBP-related proteins (ORPs): global sterol sensors for co-ordination of cellular lipid metabolism, membrane trafficking and signalling processes?

Protein families related to OSBP (oxysterol-binding protein) are present in eukaryotes from yeast to human. The functions of the ORPs (OSBP-related proteins) have remained largely enigmatic. Even though they have been implicated in the function of ERJs (endoplasmic reticulum junctions), it is evident that any single model for their mechanism of action is insufficient. The existing evidence points in many different directions, such as integration of sterol and sphingomyelin metabolism, regulation of neutral lipid metabolism, control of signalling cascades, regulation of secretory vesicle generation, and function in the microtubule-based motility of endo/lysosomes. Some of these functions could involve ERJ and non-vesicular transport of lipids, but this is unlikely to be the unifying feature. We believe, rather, that the common denominator for ORP function is acting as sterol sensors that relay information to a spectrum of cellular processes.

Revision total knee arthroplasty: 1990 through 2002. A review of the Finnish arthroplasty registry

BACKGROUND

National and regional arthroplasty registries have been used to study the results of primary total knee arthroplasties. The purpose of this paper was to present the results of revision total knee replacements and describe predictors of survival of those replacements, with repeat revision as the end point.

METHODS

The nationwide Finnish Arthroplasty Registry included 2637 revision total knee arthroplasties from 1990 through 2002. Survivorship of the revision total knee arthroplasties was analyzed, with repeat revision as the end point. The survivorship analyses comprised evaluations of the proportional hazards assumption followed by calculations of univariate and multivariate statistics and model diagnostics as appropriate.

RESULTS

The survival rate following the revision total knee arthroplasties was 95% (95% confidence interval, 94% to 96%) at two years (1874 knees), 89% (95% confidence interval, 88% to 90%) at five years (944 knees), and 79% (95% confidence interval, 78% to 81%) at ten years (141 knees). Multivariate regression analysis showed the most significant predictors of prosthetic survival to be the age of the patient and the life in service of the primary total knee replacement (that is, the time between the primary total knee replacement and the revision). Survivorship was also significantly predicted by the year of the first revision total knee arthroplasty and the reason for the revision.

CONCLUSIONS

An age greater than seventy years, revision five years or more after the primary arthroplasty, and absence of patellar subluxation are positive indicators of survival of a revision total knee replacement. We believe that normal aging as well as the deconditioning effect of disease (osteoarthritis and rheumatoid arthritis) and its treatment (primary total knee replacement) may lead to a reduced activity level, which, together with a presumed reluctance to operate on elderly patients, protects against repeat revisions.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Revision total knee arthroplasty with the total condylar III system: a comparative analysis of 71 consecutive cases of osteoarthritis or inflammatory arthritis

BACKGROUND

As revision total knee arthroplasty surgery is becoming more common, it is necessary to evaluate how individual revision prosthesis systems perform in degenerative and inflammatory arthritides. In this study, results of the use of the Total Condylar III (TC III) system in osteoarthritis (55 knees) were compared to results of its use in inflammatory arthritis (16).

METHODS

Patients were followed radiographically for 5.9 (3.0-10.2) years and clinically for 3.0 (0.2-6.8) years, using re-revision as the endpoint.

RESULTS

At 1 year after revision and at final follow-up, the total Knee Society knee score, function score and range of motion had improved (p < 0.001) with no differences between osteoarthritis and inflammatory arthritis. No knee had definite component loosening, although 23 knees had asymptomatic radiolucent lines. Complications comprised 4 infections, 1 patellar pain syndrome and 1 rupture of the patellar tendon. Using any re-revision of the prosthesis as the endpoint, 5-year survival was 95% and 8-year survival was 94%.

INTERPRETATION

Concentration of demanding revision knee arthroplasties to a few hands led to good or excellent knee joint knee score results in four-fifths of the patients, and showed good outcome with the TCIII system. In spite of ligamentous laxity, propensity to develop infections, bone destruction and poor general health, patients with inflammatory arthritis had results similar to those with osteoarthritis.

Health-related quality of life in patients waiting for major joint replacement. A comparison between patients and population controls

Background

Several quality-of-life studies in patients awaiting major joint replacement have focused on the outcomes of surgery. Interest in examining patients on the elective waiting list has increased since the beginning of 2000. We assessed health-related quality of life (HRQoL) in patients waiting for total hip (THR) or knee (TKR) replacement in three Finnish hospitals, and compared patients' HRQoL with that of population controls.

Methods

A total of 133 patients awaiting major joint replacement due to osteoarthritis (OA) of the hip or knee joint were prospectively followed from the time the patient was placed on the waiting list to hospital admission. A sample of controls matched by age, gender, housing and home municipality was drawn from the computerised population register. HRQoL was measured by the generic 15D instrument. Differences between patients and the population controls were tested by the independent samples t-test and between the measurement points by the paired samples t-test. A linear regression model was used to explain the variance in the 15D score at admission.

Results

At baseline, 15D scores were significantly different between patients and the population controls. Compared with the population controls, patients were worse off on the dimensions of moving (P < 0.001), sleeping (P < 0.001), sexual activity (P < 0.001), vitality (P < 0.001), usual activities (P < 0.001) and discomfort and symptoms (P < 0.001). Further, psychological factors – depression (P < 0.001) and distress (P = 0.004) – were worse among patients than population controls. The patients showed statistically significantly improved average scores at admission on the dimensions of moving (P = 0.026), sleeping (P = 0.004) and discomfort and symptoms (P = 0.041), but not in the overall 15D score compared with the baseline. In patients, 15D score at baseline (P < 0.001) and body mass index (BMI) (P = 0.020) had an independent effect on patients' 15D score at hospital admission.

Conclusion

Although patients' HRQoL did not deteriorate while waiting, a consistently worse HRQoL was observed in patients waiting for major joint replacement compared with population controls.