Preadmission oral anticoagulant treatment and clinical outcome among patients hospitalized with acute stroke and atrial fibrillation:a nationwide study

Background and Purpose— Preadmission oral anticoagulant treatment (OAT) has been linked with less severe stroke and a better outcome in patients with atrial fibrillation. However, the existing studies have methodological limitations and have, with one exception, not included hemorrhagic strokes. We performed a nationwide historic follow-up study using data from population-based healthcare registries to assess the effect of preadmission OAT on stroke outcomes further. Methods— We identified 11 356 patients with atrial fibrillation admitted to hospital with acute stroke (including ischemic stroke and intracerebral hemorrhage) between 2003 and 2009. Propensity score–matched analyses were used to compare stroke severity (Scandinavian Stroke Scale score) and mortality among 2175 patients with preadmission OAT and 2175 patients without preadmission OAT. Results— A total of 2492 (21.9%) patients received OAT at the time of their stroke. Preadmission OAT was associated with a lower risk of severe stroke (Scandinavian Stroke Scale score at time of admission, &lt;30 point; propensity score–matched odds ratio, 0.74; 95% confidence interval, 0.63–0.86) and lower 30-day mortality rate (propensity score–matched adjusted odds ratio, 0.83; 95% confidence interval, 0.71–0.98). Conclusions— Only a minority of hospitalized patients with acute stroke with atrial fibrillation received OAT at the time of stroke. Preadmission OAT was associated with less severe stroke and lower 30-day mortality rate in a propensity score–matched analysis. </jats:sec

Structure, Function, and Immunogenic Applications of AB\u3csub\u3e5\u3c/sub\u3e-type ADP-Ribosylating Bacterial Toxins

Bacterial mono-ADP-ribosyltransferases (ARTs) catalyze the singular transfer of an ADP-ribose moiety from an NAD+ molecule onto a target molecule. ARTs contain an ancient and highly conserved tertiary structure and have a wide variety of intracellular targets and effects. Some, but not all, bacterial ARTs have an AB5-type multimeric structure consisting of an enzymatically active subunit non-covalently situated atop of a non-toxic pentamer. The active, or A, subunit of AB5-type toxins has a catalytic action that contributes to bacterial pathogenicity, and it is sometimes, but not always, an ART. ArtAB is an ART with AB5-type structure from the virulent and highly antibiotic resistant Salmonella Typhimurium DT104. In the studies described here, we tested the hypothesis that the active subunit of ArtAB is structurally and enzymatically homologous to that of the well-characterized AB5-type ART pertussis toxin. ArtAB was purified from E. coli and was used to characterize ArtAB’s cellular effects, predicted structure, and biophysical properties. In addition, a set of single-residue mutants was constructed and purified to probe ArtAB’s active site. AB5-type toxins have long been studied for their immunogenic properties, and some of these bacterial munitions have been harnessed and repurposed as vaccines or vaccine adjuvants to prevent infectious disease. Their receptor-binding pentamer, abbreviated as B5, binds to, and facilitates entry into, host cells. In additional work presented here, we tested the hypothesis that the B5 subunit of cholera toxin (CTB) from Vibrio cholerae could be used to construct a safe and effective mucosal vaccine against Staphylococcus aureus-caused mastitis. We constructed a bovine vaccine by conjugating Staphylococcus aureus antigens to the CTB-based adjuvant platform, and the immunogenicity of the vaccine was characterized in a bovine clinical trial. Finally, clinical isolates of caprine S. aureus were screened for the presence of surface antigens that could be use in a caprine version of the vaccine against mastitis. The work on bacterial AB5-type ARTs presented here contributes to a growing global understanding of the bacterial ART family, lays a foundation for the potential incorporation of ArtAB in a vaccine against Salmonella, and advances the development of bovine and caprine vaccines against S. aureus-caused mastitis

Trends in quality of care among patients with incident heart failure in Denmark 2003-2010:a nationwide cohort study

BACKGROUND: The treatment of heart failure (HF) is complex and the prognosis remains serious. A range of strategies is used across health care systems to improve the quality of care for HF patients. We present results from a nationwide multidisciplinary initiative to monitor and improve the quality of care and clinical outcome of HF patients using indicator monitoring combined with systematic auditing. METHODS: We conducted a nationwide, population-based prospective study using data from the Danish Heart Failure Registry. The registry systematically monitors and audits the use of guideline recommended processes of care at Danish hospital departments treating incident HF patients. We identified patients registered between 2003 and 2010 (n = 24504) and examined changes in use of recommended processes of care and 1-year mortality. RESULTS: The use of the majority of the recommended processes of care increased substantially from 2003 to 2010: echocardiography (from 62.7% to 90.5%; Relative Risk (RR) 1.45 (95% CI, 1.39-1.50)), New York Heart Association classification (from 29.4% to 85.5%; RR 2.91 (95% CI, 2.69-3.14)), betablockers (from 72.6% to 88.3%; RR 1.23 (95% CI, 1.15-1.29)), physical training (from 5.6% to 22.8%; RR 4.04 (95% CI, 2.96-4.52)), and patient education (from 49.3% to 81.4%; RR 1.65 (95% CI, 1.52-1.80)). Use of ACE/ATII inhibitors remained stable (from 92.0% to 93.2%; RR 1.01 (95% CI, 0.99-1.04)). During the same period, 1-year mortality dropped from 20.5% to 12.8% (adjusted Hazard Ratio 0.79 (95% CI, 0.65-0.96). CONCLUSIONS: Use of guideline recommended processes of care has improved among patients with incident HF included in the Danish Heart Failure Registry between 2003 and 2010. During the same period, a decrease in mortality was observed

Patients’ initial steps to cancer diagnosis in Denmark, England and Sweden : what can a qualitative, cross-country comparison of narrative interviews tell us about potentially modifiable factors?

Objectives: To illuminate patterns observed in International Cancer Benchmarking Programme studies by extending understanding of the various influences on presentation and referral with cancer symptoms. Design: Cross-country comparison of Denmark, England and Sweden with qualitative analysis of in-depth interview accounts of the prediagnostic process in lung or bowel cancer. Participants: 155 women and men, aged between 35 and 86 years old, diagnosed with lung or bowel cancer in 6 months before interview. Setting: Participants recruited through primary and secondary care, social media and word of mouth. Interviews collected by social scientists or nurse researchers during 2015, mainly in participants’ homes. Results: Participants reported difficulties in interpreting diffuse bodily sensations and symptoms and deciding when to consult. There were examples of swift referrals by primary care professionals in all three countries. In all countries, participants described difficulty deciding if and when to consult, highlighting concerns about access to general practitioner appointments and overstretched primary care services, although this appears less prominent in the Swedish data. It was not unusual for there to be more than one consultation before referral and we noted two distinct patterns of repeated consultation: (1) situations where the participant left the primary care consultation with a plan of action about what should happen next; (2) participants were unclear about under which conditions to return to the doctors. This second pattern sometimes extended over many weeks during which patients described uncertainty, and sometimes frustration, about if and when they should return and whether there were any other feasible investigations. The latter pattern appeared more evident in the interviews in England and Denmark than Sweden. Conclusion: We suggest that if clear action plans, as part of safety netting, were routinely used in primary care consultations then uncertainty, false reassurance and the inefficiency and distress of multiple consultations could be reduced

Countrywise results of total hip replacement. An analysis of 438,733 hips based on the Nordic Arthroplasty Register Association database

Background and purpose: An earlier Nordic Arthroplasty Register Association (NARA) report on 280,201 total hip replacements (THRs) based on data from 1995–2006, from Sweden, Norway, and Denmark, was published in 2009. The present study assessed THR survival according to country, based on the NARA database with the Finnish data included. Material and methods: 438,733 THRs performed during the period 1995–2011 in Sweden, Denmark, Norway, and Finland were included. Kaplan-Meier survival analysis was used to calculate survival probabilities with 95% confidence interval (CI). Cox multiple regression, with adjustment for age, sex, and diagnosis, was used to analyze implant survival with revision for any reason as endpoint. Results: The 15-year survival, with any revision as an endpoint, for all THRs was 86% (CI: 85.7–86.9) in Denmark, 88% (CI: 87.6–88.3) in Sweden, 87% (CI: 86.4–87.4) in Norway, and 84% (CI: 82.9–84.1) in Finland. Revision risk for all THRs was less in Sweden than in the 3 other countries during the first 5 years. However, revision risk for uncemented THR was less in Denmark than in Sweden during the sixth (HR = 0.53, CI: 0.34–0.82), seventh (HR = 0.60, CI: 0.37–0.97), and ninth (HR = 0.59, CI: 0.36–0.98) year of follow-up. Interpretation: The differences in THR survival rates were considerable, with inferior results in Finland. Brand-level comparison of THRs in Nordic countries will be required