Changes in anticoagulant prescription in Dutch patients with recent-onset atrial fibrillation: observations from the GARFIELD-AF registry.

BACKGROUND: For the improvement of AF care, it is important to gain insight into current anticoagulation prescription practices and guideline adherence. This report focuses on the largest Dutch subset of AF-patients, derived from the GARFIELD-AF registry. METHODS: Across 35 countries worldwide, patients with newly diagnosed 'non-valvular' atrial fibrillation (AF) with at least one additional risk factor for stroke were included. Dutch patients were enrolled in five, independent, consecutive cohorts from 2010 until 2016. RESULTS: In the Netherlands, 1189 AF-patients were enrolled. The prescription of non-vitamin K antagonist oral anticoagulants (NOAC) has increased sharply, and as per 2016, more patients were initiated on NOACs instead of vitamin K antagonists (VKA). In patients with a class I recommendation for anticoagulation, only 7.5% compared to 30.0% globally received no anticoagulation. Reasons for withholding anticoagulation in these patients were unfortunately often unclear. CONCLUSIONS: The data from the GARFIELD-AF registry shows the rapidly changing anticoagulation preference of Dutch physicians in newly diagnosed AF. Adherence to European AF guidelines in terms of anticoagulant regimen would appear to be appropriate. In absence of structured follow up of AF patients on NOAC, the impact of these rapid practice changes in anticoagulation prescription in the Netherlands remains to be established.

Legionella pneumophila occurrence in drinking water supplied by private wells.

Unregulated private wells are understudied potential sources of community-acquired Legionnaires' disease. Here we conducted a comprehensive survey of 44 homes supplied by private wells in Wake County, North Carolina, quantifying Legionella spp. DNA, Legionella pneumophila DNA, and total bacterial 16S rRNA genes via real-time polymerase chain reaction in hot and cold drinking water samples, along with culturable L. pneumophila via IDEXX Legiolert in cold drinking water samples. Legionella spp. DNA, L. pneumophila DNA and culturable L. pneumophila were detected in 100, 65·5 and 15·9% of the 44 homes, respectively, and culturable levels were comparable to some municipal surveys applying the same methods. Total coliforms and Escherichia coli were monitored as representative faecal indicators and were found in 20·4 and 0·0% of homes. Within certain sample types, Legionella spp. and L. pneumophila gene copy numbers were positively associated with total bacteria (i.e. total 16S rRNA genes) and water softener use, but were not associated with faecal indicator bacteria, inorganic water parameters or other well characteristics. These findings confirm that occurrence of Legionella and L. pneumophila is highly variable in private wells. SIGNIFICANCE AND IMPACT OF THE STUDY: Legionella is the leading identified cause of waterborne disease outbreaks associated with US municipal water systems. While Legionella is known to occur naturally in groundwater, prior efforts to characterize its occurrence in unregulated private wells are limited to sampling at the wellhead and not in the home plumbing where Legionella can thrive. This work documents much higher levels of Legionella in home plumbing versus water directly from private wells and examines factors associated with higher Legionella occurrence.

IL-23, IFN-α, and IFN-ß in the vaginal fluid of patients suffering from vulvovaginal candidosis.

Purpose of the investigation: Vulvovaginal candidosis (VVC) is a common vaginal infection affecting almost 75% of all women once per lifetime. Vaginal associated immunity is important in the protection against VVC. The purpose of this study was to evaluate a potential role of IL-23, IFN-α, and IFN-ß in the local immune response against VVC. MATERIALS AND METHODS: The study included 202 non-pregnant women; 71 patients with clinical symptoms of VVC and 131 asymptomatic patients served as control. IL-23, IFN-α, and IFN-ß were measured in the vaginal fluid by ELISA. Microbiological cultures were used for Candida detection. RESULTS: C. albicans was detected in 67.6% of patients, C. glabrata in 2 1.1% of patients, and 5.6% were infected with C. krusei or coinfected with C. albicans and C. krusei. Levels of IL-23 (p < 0.001) and IFN-ß (p < 0.017) were significantly lower in the VVC group. IFN-α was elevated in the VVC group compared to the asymptomatic patients (p < 0.001). CONCLUSION: IL-23 and IEFN-ß seem to play a protective role against VVC. Decreased levels in VVC patients suggest a compromised local immune response at the time of occurrence of symptoms. In contrast, IFN-α seems to be released once the infection has occurred. These cytokines may be prospective targets in the treatment and prevention of primary and recurrent vaginal infections with Candida species.

Occasional recombination of a selfish X-chromosome may permit its persistence at high frequencies in the wild.

The sex-ratio X-chromosome (SR) is a selfish chromosome that promotes its own transmission to the next generation by destroying Y-bearing sperm in the testes of carrier males. In some natural populations of the fly Drosophila neotestacea, up to 30% of the X-chromosomes are SR chromosomes. To investigate the molecular evolutionary history and consequences of SR, we sequenced SR and standard (ST) males at 11 X-linked loci that span the ST X-chromosome and at seven arbitrarily chosen autosomal loci from a sample of D. neotestacea males from throughout the species range. We found that the evolutionary relationship between ST and SR varies among individual markers, but genetic differentiation between SR and ST is chromosome-wide and likely due to large chromosomal inversions that suppress recombination. However, SR does not consist of a single multilocus haplotype: we find evidence for gene flow between ST and SR at every locus assayed. Furthermore, we do not find long-distance linkage disequilibrium within SR chromosomes, suggesting that recombination occurs in females homozygous for SR. Finally, polymorphism on SR is reduced compared to that on ST, and loci displaying signatures of selection on ST do not show similar patterns on SR. Thus, even if selection is less effective on SR, our results suggest that gene flow with ST and recombination between SR chromosomes may prevent the accumulation of deleterious mutations and allow its long-term persistence at relatively high frequencies.

Variation in methods used to determine national mean DMFT scores for 12-year-old children in European countries.

AIM: The aim of this study was to investigate the methods used to identify national mean DMFT scores for 12-year-old children in all the Member States of the European Union and European Economic Area, and in 11 other European countries. METHODS: The most recent national mean DMFT scores were accessed from the World Health Organisation Oral Health CAPP and the Council of European Chief Dental Officers databanks. A literature search was then performed to access the reports of the studies that had produced these DMFT scores, cited on these databanks. The reports were then analysed to determine: the year in which the survey/study that produced the score took place, the year the results were published, the geographical area (national, regional or local) covered, the number of children examined, how many examiners took part, how they were trained and calibrated, and the criteria used for the detection of caries. RESULTS: Data and information from 43 European countries were accessed. The years when the studies were performed ranged from 1990 to 2014. There were doubts over the representativeness of some samples. A wide range of different methods were used. Examiner training and calibration were very variable both in terms of duration and reported inter and intra-examiner consistency. There were important variations in the criteria employed for the detection of caries. CONCLUSIONS: These findings support the view that most of current national caries data for DMFT levels in 12-year-old children are not comparable across Europe.

[Evaluation of an Intensified Dental Preventive Programme Aimed at Children with Increased Caries Risk]. / Evaluation eines zahnmedizinischen Präventionsprogramms für Kinder mit erhöhtem Kariesrisiko.

Our study investigated the effect of a selective intensive prevention (SIP) programme on dental health of pupils in comparison to a control group. While no differences were observed in respect to dental health of first graders, the DMF-T values of fourth and 6 graders participating in SIP were significantly lower. Concerning the psychometric variables only few differences were found. The fourth and 6 graders in the test group reported less dental fear than the pupils in the control group.

[Dental health in 12-year-old children including initial lesions and dentine caries]. / Zahngesundheit bei 12-Jährigen unter Einbeziehung von Initialläsionen und Dentinkaries.

AIM: The aim of this study was to assess caries prevalence among 12-year-olds, including initial lesions and dentine caries (ICDAS-II criteria, Codes 0-6). METHODS: The study was conducted in 2 regions of Hesse with different group prevention programmes (in region 1 children receive regular school-based prophylaxis using fluoride varnish twice a year from 1(st)-6(th) grade, in region 2 there is no use of fluoride varnish in schools. The samples were selected by a random sampling procedure using a list of all public schools. Dental caries was recorded on surface base and the presence of sealants was recorded. Additionally, a school-based analysis was performed. Statistical analysis was performed using SPSS 17.0. To compare the mean caries scores of the subgroups, non-parametric tests were performed (α=0.05). RESULTS: 270 12-year-olds were examined in each region. Mean DF-S values were: Region 1: D1-6FS=1.61; D1+2FS=1.5; D3-6FS=0.84; D5+6FS=0.74. Region 2: D1-6FS=2.8; D1+2FS=2.3; D3-6FS=1.1; D5+6FS=0.72. In region 2 significantly more initial lesions were assessed (p=0.01, D1+2FS). The difference between the regions was not statistically significant at the level of dentine caries (p=0.531, D3-6FS and p=0.113, D5+6FS). In region 1 mean DFS values differ significantly between children with and without fissure sealants at all levels (p<0.05). The analysis for region 1 based on the type of school visited showed a significant difference of mean D1+2F-S and D1-6F-S values (p=0.01 and p=0.012, respectively). CONCLUSION: In total, the caries prevalence in both regions was low. Differences between mean DFS values were clearer when initial lesions were included. The results point out the impact of assessing initial lesions for evaluation of prevention programs.

Caries prevalence in 12-year-old children from Germany: results of the 2009 national survey.

OBJECTIVE: In 2009, complementary epidemiological studies were conducted in 16 German states. DESIGN: A 2009 cross-sectional oral health survey of children aged 12 years with 5% samples selected using a two-stage random sampling procedure. SUBJECTS: A random selection of 30,943 12-year-olds were examined in schools. METHOD: DMFT and fissure sealants were recorded following WHO criteria. Caries was diagnosed at the caries into dentine threshold (D3) using the visual method without radiography or fibre-optic transillumination. Statistical evaluation was performed using the software SPSS (v12.0). RESULTS: The proportion of children across Germany with caries experience was 31%. The mean DMFT score was 0.72 and the average Significant Caries Index (SiC) was 2.29. The results showed a wide variation among the different federal states, with mean regional DMFT values ranging from 0.56 to 1.06. Compared to the results obtained in 2004, caries prevalence and caries experience decreased distinctly in this age group. The mean DMFT score for 12-year-olds dropped from 2.44 to 0.72 between 1994 and 2009. The mean DMFT scores were 72.7% lower at the end of the observation period than a few years after the introduction of extensive caries prevention measures in Germany. The mean number of fissure sealed teeth ranged between 2.24 and 3.04. CONCLUSION: The decrease in caries prevalence observed between 1994 and 2004 continued between 2004 and 2009, although once again inequalities in oral health between federal states were observed.

Toothbrushing Performance and Oral Cleanliness after Brushing in 12-Year-Old Children.

OBJECTIVES: Nationwide prevention programs in Germany aim to promote oral health. The group prevention program starts in kindergarten and ends when the children are about 12 y old. While in a recent study, toothbrushing behavior of 12-y-old children was analyzed, the present study's objective was to examine the children's ability to achieve oral cleanliness and to analyze how toothbrushing behavior and compliance with the toothbrushing recommendations taught in the group prevention programs predict oral cleanliness. METHODS: Twelve-year-old randomly selected children (N = 174) were asked to brush their teeth to the best of their abilities, and simultaneously a video was recorded for behavioral analyses. Plaque levels were measured before and immediately after toothbrushing. In addition, dental status and gingival bleeding were assessed. RESULTS: After brushing to the best of their abilities, there was plaque on 50% (±24.72%) of all measured sites at the gingival margin (Marginal Plaque Index). Regression analyses revealed approximately 22% of the variance of marginal plaque on the outer surfaces to be explained by the time brushed by circular movements (ß = -0.41;P < 0.001) and the number of sextants brushed for at least 7.5 s (ß = -0.171; P < 0.05). Circular movements explained most additional variance (ΔR2 = 0.113; P < 0.001). With respect to inner surfaces, none of the behavioral aspects explained any variance of oral cleanliness. CONCLUSION: Despite regular group prevention measures, 12-y-old children show limited skills to clean their teeth adequately. Furthermore, none of the recommended behaviors relates to oral cleanliness after toothbrushing at inner surfaces. As a consequence, it is necessary to explore further which behavioral sequences effectively improve oral cleanliness. KNOWLEDGE TRANSFER STATEMENT: This study illustrates that children's compliance to toothbrushing recommendations is not necessarily related to toothbrushing effectiveness. Clinicians should therefore assess the effectivity of recommendations individually and provide individual guidance for improvement.

Effect of different time intervals between examinations on the reproducibility of ICDAS-II for occlusal caries.

AIM: To evaluate intra- and interexaminer reproducibility of ICDAS-II on occlusal caries diagnosis when different time intervals were allowed to elapse between examinations. A subsidiary aim was to determine whether collapsing the codes would influence this reproducibility. METHODS: The occlusal surfaces of 50 permanent posterior teeth were investigated by 3 trained examiners using ICDAS-II at baseline, 1 day, 1 week and 4 weeks after baseline. RESULTS: Weighted kappa values for intra- and interexaminer reproducibility were 0.76-0.93. CONCLUSION: The time span did not have a major impact on assessing intra- and interexaminer reproducibility. Collapsing ICDAS-II codes had no impact on examiner reproducibility.

Semiparametric estimation of structural failure time models in continuous-time processes.

Structural failure time models are causal models for estimating the effect of time-varying treatments on a survival outcome. G-estimation and artificial censoring have been proposed for estimating the model parameters in the presence of time-dependent confounding and administrative censoring. However, most existing methods require manually pre-processing data into regularly spaced data, which may invalidate the subsequent causal analysis. Moreover, the computation and inference are challenging due to the nonsmoothness of artificial censoring. We propose a class of continuous-time structural failure time models that respects the continuous-time nature of the underlying data processes. Under a martingale condition of no unmeasured confounding, we show that the model parameters are identifiable from a potentially infinite number of estimating equations. Using the semiparametric efficiency theory, we derive the first semiparametric doubly robust estimators, which are consistent if the model for the treatment process or the failure time model, but not necessarily both, is correctly specified. Moreover, we propose using inverse probability of censoring weighting to deal with dependent censoring. In contrast to artificial censoring, our weighting strategy does not introduce nonsmoothness in estimation and ensures that resampling methods can be used for inference.

Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro.

AIM: The aim of this study was to assess inter- and intra-examiner reproducibility and accuracy in the detection and assessment of occlusal caries in extracted human teeth using a newly developed visual method for caries diagnosis (International Caries Detection and Assessment System, ICDAS-II). Serial sectioning and microscopy were used as the 'gold standard'. METHODS: The occlusal surfaces of 100 teeth were examined by 4 dentists using the ICDAS-II graded scores 0-6. Thereafter the teeth were serially sectioned and assessed for depth of the lesion with two histological classification systems. RESULTS: The weighted kappa values for inter- and intra-examiner reproducibility for the ICDAS-II examination were 0.62-0.83. There was a moderate relationship between the visual and both histological examinations (r(s) = 0.43-0.72). At the D1 diagnostic threshold (enamel and dentine lesions) specificity was 0.74-0.91 and sensitivity was 0.59-0.73. At the D3 diagnostic threshold (dentine lesions) specificity was 0.82-0.94 and sensitivity was 0.48-0.83 for the 4 examiners. CONCLUSION: The ICDAS-II system has demonstrated reproducibility and diagnostic accuracy for the detection of occlusal caries at varying stages of the disease process which are comparable to previously reported data using similar visual classification systems.

Prevalence of dental fluorosis in German schoolchildren in areas with different preventive programmes.

In a retrospective study in two different regions of Germany, 1,041 fifteen-year-old pupils were examined for dental fluorosis. The adolescents had taken part in different caries prevention programmes. There were 746 subjects in the study group and 295 subjects in the control group. For each participant, specific aspects of early development, diet and fluoride exposure in group prevention programmes and at home were determined by means of questionnaires. The Thylstrup-Fejerskov index was used to classify the fluorosis scores on the buccal surfaces of teeth 11, 12, 13, 14, 15 and 16 after compressed air drying of the teeth. Binary logistic stepwise regression analyses were conducted to identify associations between fluorosis and potential influence factors. A distinction was made between early and late developing tooth parts. The significance level was set at alpha = 0.05. Fluorosis prevalence in the regions studied was 7.1 and 11.3%, respectively. The difference was not statistically significant (p = 0.052; chi square). Binary logistic stepwise regression analysis revealed that 'early start of toothbrushing' was a statistically significant predictor of dental fluorosis in the early-mineralizing enamel (OR = 1.99, p = 0.027). For the late-mineralizing enamel no single independent variable was identified as a significant predictor of dental fluorosis.

Survival of inlays and partial crowns made of IPS empress after a 10-year observation period and in relation to various treatment parameters.

UNLABELLED: This study evaluated the long-term survival of inlays and partial crowns made of IPS Empress. For this purpose, the patient data of a prospective study were examined in retrospect and statistically evaluated. MATERIALS AND METHODS: All of the inlays and partial crowns fabricated of IPS-Empress within the Department of Operative Dentistry at the School of Dental Medicine of Philipps University, Marburg, Germany were systematically recorded in a database between 1991 and 2001. The corresponding patient files were revised at the end of 2001. The information gathered in this way was used to evaluate the survival of the restorations using the method described by Kaplan and Meyer. RESULTS: A total of n = 1624 restorations were fabricated of IPS-Empress within the observation period. During this time, n = 53 failures were recorded. The remaining restorations were observed for a mean period of 18.77 months. The failures were mainly attributed to fractures, endodontic problems and cementation errors. The last failure was established after 82 months. At this stage, a cumulative survival probability of p = 0.81 was registered with a standard error of 0.04. At this time, n = 30 restorations were still being observed. Restorations on vital teeth (n = 1588) showed 46 failures, with a cumulative survival probability of p = 0.82. Restorations performed on non-vital teeth (n = 36) showed seven failures, with a cumulative survival probability of p = 0.53. Highly significant differences were found between the two groups (p < 0.0001) in a log-rank test. No significant difference (p = 0.41) was found between the patients treated by students (n = 909) and those treated by qualified dentists (n = 715). Likewise, no difference (p = 0.13) was established between the restorations seated with a high viscosity cement (n = 295) and those placed with a low viscosity cement (n = 1329).

Prediction of 1-year survival after thrombolysis for acute myocardial infarction in the global utilization of streptokinase and TPA for occluded coronary arteries trial.

BACKGROUND: When a patient survives thrombolysis for acute myocardial infarction, little information from large studies exists from which to estimate prognosis during follow-up visits. METHODS AND RESULTS: Baseline, in-hospital, and later survival data were collected from 41 021 patients enrolled in Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries, a randomized trial of 4 thrombolytic-heparin regimens with standard aspirin and beta-blockade. Cox proportional hazards models were developed to predict 1-year survival in 30-day survivors (n=37 869) from baseline clinical and ECG factors and in-hospital factors; a combined model then was developed (C-index 0.800). The model was simplified into a nomogram to predict individual outcomes (C-index 0.754). Factors reflecting demographics (advanced age, lighter weight), larger infarctions (higher Killip class, lower blood pressure, faster heart rate, longer QRS duration), cardiac risk (smoking, hypertension, prior cerebrovascular disease), and arrhythmia were important predictors of death between 30 days and 1 year. Black race was associated with a substantial increase in risk after considering other factors. Revascularization was associated with reduced risk between 30 days and 1 year. CONCLUSIONS: When evaluating a patient who has survived acute infarction treated with thrombolysis, clinicians can estimate the likelihood of survival from factors easily measured during admission. Although many risk factors clearly relate to age, left ventricular dysfunction, or clinical instability, black race is an unexplained risk factor requiring further examination.

Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report.

BACKGROUND: The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer neurological complications than men and whether these complications could explain, at least in part, their higher perioperative mortality. METHODS AND RESULTS: The Society of Thoracic Surgery National Cardiac Surgery Database was examined for the years 1996 and 1997 to determine the frequency of new neurological events (stroke, transient ischemic attack, or coma) occurring after cardiac surgery. We reviewed clinical information on 416 347 patients (32% women) for whom complete neurological outcome data were available. New neurological events after surgery were higher for women than for men (3.8% versus 2.4%, P=0.001). For the whole group, the 30-day mortality was higher for women than for men (5.7% versus 3.5%, P=0.001), and among those patients who suffered a perioperative neurological event, mortality was also significantly higher for women than men (32% versus 28%, P=0.001). After adjustment for other risk factors (eg, age, history of hypertension and/or diabetes, duration of cardiopulmonary bypass, and other comorbid conditions) by multivariable logistic regression, female sex was independently associated with significantly higher risk of suffering new neurological events after cardiac surgery (OR 1.21, 95% CI 1.14 to 1.28, P=0.001). CONCLUSIONS: Women undergoing cardiac surgery are more likely than men to suffer new perioperative neurological events, and they have higher 30-day mortality when these complications occur. The higher incidence of perioperative neurological complications in women cannot be explained by currently known risk factors.

Treatment of reinfarction after thrombolytic therapy for acute myocardial infarction: an analysis of outcome and treatment choices in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (gusto I) and assessment of the safety of a new thrombolytic (assent 2) studies.

BACKGROUND: Early reinfarction after thrombolytic therapy is associated with adverse outcomes and increased mortality. Among patients with reinfarction in the 1992 Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) and the 1998 Assessment of the Safety of a New Thrombolytic (ASSENT 2) trials, we investigated temporal and regional differences in the use of repeat thrombolysis, revascularization (angioplasty and/or bypass surgery), or conservative measures and the outcomes of each management strategy. METHODS AND RESULTS: Data from the 4% of patients (n=2301) who experienced reinfarction after thrombolytic therapy were studied. Baseline characteristics, 30-day mortality, and incidence of total and hemorrhagic strokes were compared among the 3 treatment groups. The 30-day mortality did not differ between the repeat thrombolysis and revascularization groups (P=0.72), and it was significantly lower among patients treated by these 2 strategies than in those treated conservatively (11% and 11% versus 28%, respectively; P<0.001). Stroke rates did not differ significantly between the 3 treatment strategies (P=0.49). From 1992 to 1998, the percentage of reinfarction patients treated with repeat thrombolysis decreased from 29.3% to 18.5% in US centers and from 51.4% to 41.9% in all other centers (P<0.001). In contrast, use of revascularization procedures increased from 33.5% to 47.9% in US centers and from 8.1% to 23.0% in all other centers (P<0.001). CONCLUSIONS: Repeat thrombolysis and revascularization are associated with significantly lower mortality among reinfarction patients. Randomized trials are necessary to assess the exact risks and benefits of rethrombolysis versus interventional revascularization in this subset of high-risk patients presenting with reinfarction after thrombolytic therapy.

Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials.

BACKGROUND: Trials report a 2% to 6% incidence of reinfarction after fibrinolysis for acute myocardial infarction (MI). We combined the Global Utilization of Streptokinase and Tissue plasminogen activator (alteplase) for Occluded coronary arteries (GUSTO I) and Global Use of Strategies To Open occluded coronary arteries (GUSTO III) populations to better define frequency, timing, and clinical predictors of in-hospital reinfarction. METHODS AND RESULTS: In 55 911 patients with ST-segment elevation myocardial infarction (MI) who were receiving fibrinolysis, we compared baseline characteristics and mortality rate by reinfarction incidence and developed multivariable logistic regression models to predict in-hospital reinfarction and composite of death or reinfarction. Reinfarction occurred in 2258 patients (4.3%) a median of 3.8 days after fibrinolysis; rates did not differ between GUSTO I (4.0%) and GUSTO III (4.2%) or by fibrinolytic assignment (streptokinase, 4.1%; alteplase, 4.3%; reteplase, 4.5%; combined streptokinase and alteplase, 4.4%; P=0.55). Advanced age, shorter time to fibrinolysis, non-US enrollment, nonsmoking status, prior MI or angina, female sex, anterior MI, and lower systolic blood pressure were associated significantly with reinfarction. Patients with reinfarction had higher mortality at 30 days (11.3% versus 3.5% without reinfarction; odds ratio, 3.5; P<0.001) and from 30 days to 1 year (4.7% versus 3.2%; hazard ratio, 1.5; P<0.001). Significant multivariate predictors of in-hospital death or reinfarction included age, Killip class, systolic and diastolic blood pressures, heart rate, anterior MI, smoking status, prior MI, sex, and country of enrollment (all P<0.001). CONCLUSIONS: Reinfarction occurs infrequently after fibrinolysis but confers increased risk of 30-day and 1-year mortality. Some predictors of reinfarction differ from known predictors of death after MI. Improved treatment and prevention strategies for reinfarction deserve study.

Early percutaneous coronary intervention, platelet inhibition with eptifibatide, and clinical outcomes in patients with acute coronary syndromes. PURSUIT Investigators.

BACKGROUND: Platelet glycoprotein (GP) IIb/IIIa antagonists prevent the composite end point of death or myocardial infarction (MI) in patients with acute coronary syndromes. There is uncertainty about whether this effect is confined to patients who have percutaneous coronary interventions (PCIs) and whether PCIs further prevent death or MI in patients already treated with GP IIb/IIIa antagonists. METHODS AND RESULTS: PURSUIT patients were treated with the GP IIb/IIIa antagonist eptifibatide or placebo; PCIs were performed according to physician practices. In 2253 of 9641 patients (23.4%), PCI was performed by 30 days. Early (<72 hours) PCI was performed in 1228 (12.7%). In 34 placebo patients (5.5%) and 10 treated with eptifibatide (1.7%) (P=0.001), MI preceded early PCI. In patients censored for PCI across the 30-day period, there was a significant reduction in the primary composite end point in eptifibatide patients (P=0.035). Eptifibatide reduced 30-day events in patients who had early PCI (11.6% versus 16.7%, P=0.01) and in patients who did not (14.6% versus 15.6%, P=0.23). After adjustment for PCI propensity, there was no evidence that eptifibatide treatment effect differed between patients with or without early PCI (P for interaction=0.634). PCI was not associated with a reduction of the primary composite end point but was associated with a reduced (nonspecified) composite of death or Q-wave MI. This association disappeared after adjustment for propensity for early PCI. CONCLUSIONS: Eptifibatide reduced the composite rates of death or MI in PCI patients and those managed conservatively.

Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators.

BACKGROUND: Appropriate treatment policies should include an accurate estimate of a patient's baseline risk. Risk modeling to date has been underutilized in patients with acute coronary syndromes without persistent ST-segment elevation. METHODS AND RESULTS: We analyzed the relation between baseline characteristics and the 30-day incidence of death and the composite of death or myocardial (re)infarction in 9461 patients with acute coronary syndromes without persistent ST-segment elevation enrolled in the PURSUIT trial [Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy]. Variables examined included demographics, history, hemodynamic condition, and symptom duration. Risk models were created with multivariable logistic regression and validated by bootstrapping techniques. There was a 3.6% mortality rate and 11.4% infarction rate by 30 days. More than 20 significant predictors for mortality and for the composite end point were identified. The most important baseline determinants of death were age (adjusted chi(2)=95), heart rate (chi(2)=32), systolic blood pressure (chi(2)=20), ST-segment depression (chi(2)=20), signs of heart failure (chi(2)=18), and cardiac enzymes (chi(2)=15). Determinants of mortality were generally also predictive of death or myocardial (re)infarction. Differences were observed, however, in the relative prognostic importance of predictive variables for mortality alone or the composite end point; for example, sex was a more important determinant of the composite end point (chi(2)=21) than of death alone (chi(2)=10). The accuracy of the prediction of the composite end point was less than that of mortality (C-index 0.67 versus 0.81). CONCLUSIONS: The occurrence of adverse events after presentation with acute coronary syndromes is affected by multiple factors. These factors should be considered in the clinical decision-making process.