Editor's Choice - Prevalence of Smoking and Impact on Peri-Operative Outcomes After Elective Abdominal Aortic Aneurysm Repair.

OBJECTIVE: The contemporary burden of smoking in patients undergoing elective abdominal aortic aneurysm (AAA) repair in the UK is unknown. This study aimed to quantify the prevalence of smoking in patients undergoing AAA repair in the UK and determine the association between smoking and peri-operative outcomes. METHODS: This was an observational cohort study. The National Vascular Registry was interrogated for adults undergoing elective infrarenal AAA repair from 2014 to 2021 for prevalence of current smokers, former smokers, and non-smokers over time. The primary outcomes were post-operative complications by smoking status. Secondary outcomes were variation in smoking rates over time and by hospital, in hospital mortality, and length of stay by smoking status. All analyses were adjusted using the validated British Aneurysm Repair score. RESULTS: Overall, 26 916 patients undergoing elective AAA repair were included (21.9% smokers, 62.2% former smokers, 15.9% non-smokers). The prevalence of smoking did not change over time, with a 2.4 fold variation between UK hospitals (range 13.0 - 31.8% excluding outliers). In hospital mortality was not significantly different between smokers, former smokers, and non-smokers (p > .050 for all comparisons). Compared with non-smokers, smoking was associated with increased overall (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.24 - 1.57) and respiratory complications (OR 1.98, 95% CI 1.63 - 2.39), limb ischaemia (OR 1.63, 95% CI 1.19 - 2.23), bowel ischaemia (OR 1.64, 95% CI 1.06 - 2.54), return to theatre (OR 1.38, 95% CI 1.11 - 1.71), and intensive care admission (OR 1.43, 95% CI 1.31 - 1.56). Compared with former smokers, smoking was associated with increased overall (OR 1.24, 95% CI 1.14 - 1.36), respiratory (OR 1.44, 95% CI 1.27 - 1.63) and limb ischaemia complications (OR 1.48, 95% CI 1.19 - 1.84), and intensive care admission (OR 1.37, 95% CI 1.28 - 1.46). On analysis of the endovascular aneurysm repair subgroup, active smoking was associated with significantly higher rates of limb ischaemia compared with former and non-smokers (OR 2.12, 95% CI 1.49 - 3.01 and OR 1.94, 95% CI 1.19 - 3.16 respectively). CONCLUSION: The prevalence of smoking remains high in patients undergoing elective AAA repair with no evidence of a decline in active smokers from 2014 to 2021 compared with the general UK population. Smoking is associated with increased peri-operative complication rates.

Analytical sensitivity of the Rapid Antigen Test kits for detection of SARS-CoV-2 Omicron variant BA.2 sublineage.

The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) Omicron was classified as a variant of concern in November 2021. The sublineage BA.2 spreads rapidly worldwide. Currently, there is a lack of data for the parallel comparison of Rapid Antigen Test (RAT) Kits to detect SARS-CoV-2 Omicron BA.2. We evaluated the analytical sensitivity of 12 RAT kits to detect Omicron BA.2 in the present study. Analytical sensitivity was determined by means of the limit of detection (LOD). We prepared a dilution set using a respiratory specimen collected from a COVID-19 patient infected by Omicron BA.2. The reverse transcription-polymerase chain reaction was used as a reference method. The LOD results showed that all 12 RAT kits had comparable analytical sensitivity to detect Omicron BA.2. The RAT kits selected in the current study may be used for the first-line screening of the rapid spreading Omicron BA.2.

Systematic review and narrative synthesis of surveillance practices after endovascular intervention for lower limb peripheral arterial disease.

OBJECTIVE: The optimal timing and modality of surveillance after endovascular intervention for peripheral arterial disease is controversial, and no randomized trial to assess the value of peripheral endovascular intervention has ever been performed. The aim of this systematic review was to examine the practice of surveillance after peripheral endovascular intervention in randomized trials. METHODS: We used the Medline, Embase, Cochrane Library, and WHO trial registry databases in this systematic review of the literature to capture surveillance strategies used in randomized trials comparing endovascular interventions. Surveillance protocols were assessed for completeness, modalities used, duration, and intensity. RESULTS: Ninety-six different surveillance protocols were reported in 103 trials comparing endovascular interventions. Protocol specification was incomplete in 32% of trials. The majority of trials used multiple surveillance modalities (mean of 3.46 modalities), most commonly clinical examination (96%), ankle-brachial index (80%), duplex ultrasound examination (75%), and digital subtraction angiography (51%). Trials involving infrapopliteal lesions used more angiographic surveillance than trials with femoropopliteal lesions (P = .006). The median number of surveillance visits in the first 12 months after intervention was three and the mean surveillance duration was 21 months. Trials treating infrapopliteal vessels had a higher surveillance intensity compared with those treating femoropopliteal lesions in the first 12 months after endovascular intervention (mean 5 vs 3 surveillance visits; P = .017). Trials with drug-eluting devices had longer surveillance duration compared with those without (mean 26 vs 19 months; P = .020). CONCLUSIONS: There is a high level of variation in the modality, duration, and intensity of surveillance protocols used in randomized trials comparing different types of peripheral endovascular arterial intervention. Further research is required to determine the value and impact of postprocedural surveillance on patient outcomes.

A Systematic Review and Meta-Analysis on the Impact of High On-Treatment Platelet Reactivity on Clinical Outcomes for Patients Taking ADP Receptor Inhibitors Following Lower Limb Arterial Endovascular Intervention.

OBJECTIVE: Adenosine diphosphate (ADP) receptor inhibitors such as clopidogrel are known to be less effective at reducing platelet function for some patients because of a phenomenon called high on-treatment platelet reactivity (HTPR). However, the clinical effect of this for patients undergoing endovascular intervention for peripheral arterial disease is unclear. The aim of this study was to assess the impact of ADP receptor inhibitor HTPR on clinical outcomes following lower limb arterial endovascular intervention for peripheral arterial disease. METHODS: A systematic review and meta-analysis was performed. Primary outcomes included all cause mortality and major bleeding. Secondary outcomes were major adverse cardiovascular events, major adverse limb events, restenosis, and target lesion revascularisation. Outcome quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. RESULTS: There were 10 eligible studies including 1 444 patients included in the meta-analysis. The most commonly tested ADP receptor inhibitor was clopidogrel (seven studies). The pooled rate of ADP receptor inhibitor HTPR was 29% (95% CI 27 - 32). The meta-analysis showed that ADP receptor inhibitor HTPR was associated with a greater risk of major adverse limb events (OR 6.25, 95% CI 2.09 - 18.68, p = .001) and a trend towards a higher all cause mortality (OR 1.71, 95% CI 0.99 - 2.94, p = .050) and more major adverse cardiovascular events (OR 4.23, 95% CI 0.46 - 38.92, p = .20) after endovascular intervention. Overall strength of evidence was very low for all outcomes. CONCLUSION: ADP receptor inhibitor HTPR was associated with worse clinical outcomes after lower limb endovascular intervention for peripheral arterial disease. Prospective studies are required to determine the impact of modifying the antithrombotic regimen on clinical outcomes.

Antithrombotic Therapy for Aortic Aneurysms: A Systematic Review and Meta-Analysis.

OBJECTIVES: The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact of antithrombotics on clinical outcomes for aortic and peripheral aneurysms. METHODS: Medline, Embase, and CENTRAL databases were searched. Randomised controlled trials and observational studies investigating the effect of antithrombotic therapy on clinical outcomes for patients with any aortic or peripheral artery aneurysm were included. RESULTS: Fifty-nine studies (28 with antiplatelet agents, 12 anticoagulants, two intra-operative heparin, and 16 any antithrombotic agent) involving 122 102 patients were included. Abdominal aortic aneurysm (AAA) growth rate was not significantly associated with the use of antiplatelet therapy (SMD -0.36 mm/year; 95% CI -0.75 - 0.02; p = .060; GRADE certainty: very low). Antithrombotics were associated with increased 30 day mortality for patients with AAAs undergoing intervention (OR 2.30; 95% CI 1.51 - 3.51; p < .001; GRADE certainty: low). Following intervention, antiplatelet therapy was associated with reduced long term all cause mortality (HR 0.84; 95% CI 0.76 - 0.92; p < .001; GRADE certainty: moderate), whilst anticoagulants were associated with increased all cause mortality (HR 1.64; 95% CI 1.14 - 2.37; p = .008; GRADE certainty: very low), endoleak within three years (OR 1.99; 95% CI 1.10 - 3.60; p = .020; I2 = 60%; GRADE certainty: very low), and an increased re-intervention rate at one year (OR 3.25; 95% CI 1.82 - 5.82; p < .001; I2 = 35%; GRADE certainty: moderate). Five studies examined antithrombotic therapy for popliteal aneurysms. Meta-analysis was not possible due to heterogeneity. CONCLUSIONS: There was a lack of high quality data examining antithrombotic therapy for patients with aneurysms. Antiplatelet therapy was associated with a reduction in post-intervention all cause mortality for AAA, whilst anticoagulants were associated with an increased risk of all cause mortality, endoleak, and re-intervention. Large, well designed trials are still required to determine the therapeutic benefits of antithrombotic agents in this setting.

A webinar series to educate applicants about the UK academic foundation programme: a longitudinal cross-sectional study.

BACKGROUND: The UK academic foundation programme (AFP) is a competitive programme for medical graduates and forms the initial stage of the integrated clinical academic pathway. The application is complex and targeted education is beneficial. As online technologies improve, virtual medical education is becoming more common. Currently, webinar education, particularly that of webinar series, are poorly evidenced. An online course was created to investigate the acceptability and effectiveness of webinars for medical education. METHODS: A six-part, one-hour sessional webinar course was developed following a focus group with academic foundation doctors. A pre- and post-course cross-sectional questionnaire study evaluated participant demographics, webinar opinion and self-rated understanding of the AFP via Google Form (Google, USA). Where applicable a five-point Likert scale (1-Strongly disagree to 5-strongly agree) was utilised and analysis using non-parametric paired statistical analysis. RESULTS: Medical students (n=303) from 35 UK universities completed the pre-course questionnaire. Most students had not received targeted education on the AFP. They rated webinars useful for education (mean=4.2 s.d. 0.7). After the course, participants (n=66) expressed it was significantly convenient (mean=4.7), effective (mean=4.7) and suitably interactive (mean=4.4) (p<0.001 compared to neutral). Participants preferred short sessions over multiple days to the concept of a full-day event (mean=4.6 vs 3.1, p<0.001). Paired analysis of participants completing both forms (n=47) demonstrates a significant increase in self-rated understanding of AFP content, portfolio building, application process, acute clinical scenarios, interview technique and overall confidence in acquiring an AFP post (p<0.001). Follow-up identified 43 participants who completed the course were successful in their AFP application. This represents 7.8% of all successful AFP applicants in 2021. CONCLUSIONS: This study evidences an accessible and effective webinar series for AFP education. Comprehensive webinar courses for similar topics and demographics may provide valuable utility in the provision of future medical education. TRIAL REGISTRATION: Ethics requirements were waived for this study by Bristol University Ethics Committee. All participants in this study consented for anonymous use of their data. As such the trial is not registered.

Antiplatelet and Anticoagulant Use in Randomised Trials of Patients Undergoing Endovascular Intervention for Peripheral Arterial Disease: Systematic Review and Narrative Synthesis.

OBJECTIVE: Randomised trials of new devices for peripheral arterial endovascular intervention are published regularly. The evidence for which antiplatelet and/or anticoagulant (antithrombotic) therapy to use after an intervention is lacking. The aim of this systematic review was to examine the antithrombotic regimens in randomised trials for peripheral arterial endovascular intervention to understand choices made and trends with time or type of device. METHODS: Data sources were the Medline, Embase, and Cochrane Library databases. Randomised trials including participants with peripheral arterial disease undergoing any endovascular arterial intervention were included. Trial methods were assessed to determine whether an antithrombotic protocol had been specified, its completeness, and the agent(s) prescribed. Antithrombotic therapy protocols were classed as peri-procedural (preceding and during intervention), immediate post-procedural (up to 30 days following intervention), and maintenance post-procedural (therapy continuing beyond 30 days). RESULTS: Ninety-four trials were included in narrative synthesis. Study quality was low. None of the trials justified their antithrombotic therapy protocol. Only 29% of trials had complete peri-procedural antithrombotic protocols, and 34% had complete post-procedural protocols. In total, 64 different peri-procedural protocols, and 51 separate post-procedural protocols were specified. Antiplatelet monotherapy and unfractionated heparin were the most common regimen choices in the peri-procedural setting, and dual antiplatelet therapy (55%) was most commonly utilised post procedure. Over time there has been an increasing tendency to use dual therapy (p < .001). This corresponds with the introduction of newer technologies and trials focussed on below knee intervention. CONCLUSION: Randomised trials comparing different types of peripheral endovascular arterial intervention have a high level of heterogeneity in their antithrombotic regimens. Antiplatelet therapy needs to be standardised in trials comparing endovascular technologies to reduce potential confounding. To do this, an independent randomised trial specifically examining antiplatelet therapy following peripheral arterial endovascular intervention is needed.

Interdisciplinary collaboration in the use of a music-with-movement intervention to promote the wellbeing of people with dementia and their families: Development of an evidence-based intervention protocol.

The music-with-movement intervention is particularly suitable for people with dementia because their gross motor ability is preserved until the later stage of dementia. This study examines the effect of music-with-movement on reducing anxiety, sleep disturbances, and improving the wellbeing of people with dementia. This paper reports the first stage of the study - developing the intervention protocol that staff can use to teach family caregivers. A registered music therapist developed a music-with-movement protocol and taught staff of two social service centers over five weekly 1.5 h sessions, with center-in-charges (social workers and occupational therapists) and our research team joining these sessions to provide comments from their professional perspective. Each discipline had different expectations about the content; therefore, numerous meetings and discussions were held to bridge these differences and fine-tune the protocol. Few healthcare professionals doubt the merits of interdisciplinary collaboration at all levels of health promotion. In practice, interdisciplinary collaboration is complex and requires commitment. Openness and persistence is required from all stakeholders to achieve a successful intervention for consumers.

Optimizing heat inactivation for SARS-CoV-2 at 95 °C and its implications: A standardized approach.

Background: Standardized and validated heat inactivation procedure for Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are not available. For heat inactivation, various protocols were reported to prepare External Quality Assessment Programme (EQAP) samples without direct comparison between different durations. Objective: To assess the heat inactivation procedures against SARS-CoV-2. The efficacy of the optimized condition was reflected by the results from laboratories testing the EQAP samples. Study design: The SARS-CoV-2 strain was exposed to 95 °C in a water bath for three different time intervals, 5 min, 10 min and 15 min, respectively. The efficacy of inactivation was confirmed by the absence of cytopathic effects and decreasing viral load in 3 successive cell line passages. The viral stock inactivated by the optimal time interval was dispatched to EQAP participants and the result returned were analyzed. Results: All of the three conditions were capable of inactivating the SARS-CoV-2 of viral load at around cycle threshold value of 10. When the 95 °C 10 min condition was chosen to prepare SARS-CoV-2 EQAP samples, they showed sufficient homogeneity and stability. High degree of consensus was observed among EQAP participants in all samples dispatched. Conclusions: The conditions evaluated in the present study could be helpful for laboratories in preparing SARS-CoV-2 EQAP samples.

The relationships between communication, care and time are intertwined: a narrative inquiry exploring the impact of time on registered nurses' work.

AIM: To report a qualitative study which explores registered nurses' views on the issue of time in the workplace. BACKGROUND: There is a worldwide shortage of healthcare workers, subsequently time as a healthcare resource is both finite and scarce. As a result, increased attention is being paid to the restructuring of nursing work. However, the experience of time passing is a subjective one and there exists little research which, over a prolonged period of time, describes nurses' experiences of working in time-pressurized environments. DESIGN: A narrative inquiry. METHOD: Five registered nurses were individually interviewed a total of three times over a period of 12 months, amounting to a total of 15 interviews and 30 hours of data. Data were collected and analysed following a narrative enquiry approach during the period 2008-2010. FINDINGS: Participants describe how attempts to work more effectively sometimes resulted in unintended negative consequences for patient care and how time pressure encourages collegiality amongst nurses. Furthermore, the registered nurses' account of how they opportunistically create time for communication with patients compels us to re-evaluate the nature of communication during procedural nursing care. CONCLUSION: Increasingly nursing work is translated into quantitative data or metrics. This is an inescapable development which seeks to enhance understanding of nursing work. However, qualitative research may also offer a useful approach which captures the otherwise hidden, subjective experiences associated with time and work. Such data can exist alongside nursing metrics, and together these can build a better and more nuanced consideration of nursing practice.

Mineralocorticoid receptor antagonism in diabetes reduces albuminuria by preserving the glomerular endothelial glycocalyx.

The glomerular endothelial glycocalyx (GEnGlx) forms the first part of the glomerular filtration barrier. Previously, we showed that mineralocorticoid receptor (MR) activation caused GEnGlx damage and albuminuria. In this study, we investigated whether MR antagonism could limit albuminuria in diabetes and studied the site of action. Streptozotocin-induced diabetic Wistar rats developed albuminuria, increased glomerular albumin permeability (Ps'alb), and increased glomerular matrix metalloproteinase (MMP) activity with corresponding GEnGlx loss. MR antagonism prevented albuminuria progression, restored Ps'alb, preserved GEnGlx, and reduced MMP activity. Enzymatic degradation of the GEnGlx negated the benefits of MR antagonism, confirming their dependence on GEnGlx integrity. Exposing human glomerular endothelial cells (GEnC) to diabetic conditions in vitro increased MMPs and caused glycocalyx damage. Amelioration of these effects confirmed a direct effect of MR antagonism on GEnC. To confirm relevance to human disease, we used a potentially novel confocal imaging method to show loss of GEnGlx in renal biopsy specimens from patients with diabetic nephropathy (DN). In addition, patients with DN randomized to receive an MR antagonist had reduced urinary MMP2 activity and albuminuria compared with placebo and baseline levels. Taken together, our work suggests that MR antagonists reduce MMP activity and thereby preserve GEnGlx, resulting in reduced glomerular permeability and albuminuria in diabetes.

Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care.

BACKGROUND AND PURPOSE: Controversy surrounds the need for routine hospital admission for transient ischemic attack. The Monash Transient Ischemic Attack Triaging Treatment (M3T) model adopts rapid management in the emergency department followed by outpatient management prioritized by stroke mechanism. We compared safety and processes of care between M3T and the previous model of routine admission. METHODS: Study cohorts consisted of patients managed with M3T (2004-2007) and the previous model (2003-2004). We determined 90-day stroke outcome using clinical and medical record review and data linkage to the population level state-wide hospital discharge morbidity database. We compared models of care using risk difference analysis, followed by logistic regression to adjust for previous indicators of risk. Secondary outcomes were proportions admitted, proportions undergoing carotid ultrasound, times to ultrasound and revascularization, and medication prescription. RESULTS: In M3T (mean age, 64.7±14.7) 85/488 (17.4%) patients were admitted compared with 117/169 (62.9%) in the previous model (mean age, 72.5±13.9). With near-complete follow-up, 90-day stroke outcome was 1.50% (95% confidence interval, 0.73%-3.05%) in M3T and 4.67% (95% confidence interval, 2.28%-9.32%) in the previous model (P=0.03). Compared with the previous model, the adjusted odds ratio of stroke for M3T was 0.46 (95% confidence interval, 0.12-1.68; P=0.24). M3T was associated with greater proportions undergoing carotid ultrasound (P<0.001) and receiving antiplatelet therapy (P=0.005). CONCLUSIONS: The M3T system was associated with low 90-day stroke outcome in transient ischemic attack patients, providing proof of concept that these patients may be managed safely without routine hospital admission using a closely supervised protocol in the emergency department.

Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease.

BACKGROUND AND PURPOSE: Traditional vascular risk factors do not completely explain the asymmetry, racial, and sex differences in carotid artery disease. Carotid anatomy and geometry may play a role in the pathogenesis of internal carotid artery (ICA) stenosis, but their effects are unknown. We hypothesized that carotid artery anatomy and geometry would be independently associated with ICA stenosis. METHOD: This is a retrospective study of patients with CT angiography at Monash Medical Centre, 2006 to 2007. Carotid arteries were segmented using semiautomated methods to estimate measures of carotid anatomy and geometry. Measurements of carotid artery geometry were performed according to the recent article by Thomas and colleagues. ICA stenosis was dichotomized as <30% or ≥ 30% stenosis. Cluster logistic regression was used to examine the associations of anatomy and geometry with stenosis accounting for the paired arteries within subjects, adjusting for age, sex, and vascular risk factors. RESULTS: Mean age of the sample (n=178) was 68.4 years (SD, 14 years). The following were independently associated with ICA stenosis: ICA radius at the bifurcation (OR, 0.20; 95% CI, 0.14-0.29), ICA angle (OR, 1.05 per degree increment; 95% CI, 1.04-1.07), age (OR, 1.05 per year increment; 95% CI, 1.03-1.07), male sex (OR, 1.72; 95% CI, 1.08-2.8), and ever-smoker (OR, 1.85; 95% CI, 1.15-2.96). CONCLUSIONS: Carotid anatomy and geometry may enhance the risk of stenosis independent of traditional vascular risk factors and may be of help in very early identification of patients at high risk of developing carotid artery atherosclerosis for aggressive intervention.

Virulence potential of fusogenic orthoreoviruses.

Several severe respiratory virus infections that have emerged during the past decade originated in animals, including bats. In Indonesia, exposure to bats has been associated with increased risk of acquiring orthoreovirus infection. Although orthoreovirus infections are mild and self-limiting, we explored their potential for evolution into a more virulent form. We used conventional virus culture, electron microscopy, and molecular sequencing to isolate and identify orthoreoviruses from 3 patients in whom respiratory tract infection developed after travel to Indonesia. Virus characterization by plaque-reduction neutralization testing showed antigenic similarity, but sequencing of the small segment genes suggested virus reassortment, which could lead to increased virulence. Bats as a reservoir might contribute to virus evolution and genetic diversity, giving orthoreoviruses the potential to become more virulent. Evolution of this virus should be closely monitored so that prevention and control measures can be taken should it become more virulent.

Evaluation of rapid antigen detection kits for detection of SARS-CoV-2 B.1.617.2 virus.

Aim: Currently, there is lack of data regarding rapid antigen detection (RAD) kits to detect SARS-CoV-2 B.1.617.2 virus. Objective: The purpose of this evaluation is to assess analytical sensitivity of 12 RAD kits against SARS-CoV-2 B.1.617.2. Study design: Analytical sensitivity was determined by limit of detection (LOD). A serial tenfold dilution set from a respiratory specimen collected from a COVID-19 patient infected by SARS-CoV-2 B.1.617.2 was used. RT-PCR was used as a reference method. Results: The LOD results showed that 11 and one RAD kits were 100- and 1000-fold less sensitive than RT-PCR respectively. Conclusion: The results showed that the RAD kits evaluated in this study may be used for first-line screening of the SARS-CoV-2 B.1.617.2 variant.

A randomized, double-blind, placebo-controlled trial of levetiracetam for dyskinesia in Parkinson's disease.

BACKGROUND: This randomized double blind, placebo-controlled crossover study investigated the antidyskinetic effects of levetiracetam in Parkinson's disease. METHODS: Sixteen participants with levodopa-induced dyskinesia were enrolled. Hourly videotaped dyskinesia assessments scored by the Goetz method and hourly Unified Parkinson's Disease Rating Scale motor subscale scoring were conducted on 1 day at the end of each treatment period. RESULTS: Dyskinesia was slightly less on placebo (P = .26). Patient diary records also showed less dyskinesia on placebo (P = .10). Parkinsonism was a little worse on levetiracetam, at borderline statistical significance (P = .05). CONCLUSIONS: Levetiracetam was well tolerated at doses up to 2000 mg per day, but we did not detect any antidyskinetic properties.

Clinical predictive value of the ABCD2 score for early risk of stroke in patients who have had transient ischaemic attack and who present to an Australian tertiary hospital.

OBJECTIVE: To determine the predictive value of the ABCD(2) score for early risk of stroke in Australian patients who have had transient ischaemic attack (TIA). DESIGN, PARTICIPANTS AND SETTING: Cohort study of 512 consecutive patients with suspected TIA referred by the emergency department to the acute stroke unit (in accordance with the TIA pathway) of an urban tertiary hospital in Melbourne, Victoria, between 1 June 2004 and 30 November 2007. MAIN OUTCOME MEASURES: Overall accuracy, estimated by the area under the curve (AUC) of receiver operating characteristic plots (of true positive rate v false positive rate), and sensitivity, specificity, predictive values and likelihood ratios at prespecified cut-off ABCD(2) scores for stroke within 2, 7 and 90 days. RESULTS: 24 patients were excluded because their symptoms lasted more than 24 hours. All included patients were reviewed by a stroke physician; TIA was confirmed in 301/488 (61.7%). Most (289/301; 96.0%) had complete follow-up. Stroke occurred in 4/292 patients (1.37%; 95% CI, 0.37%-3.47%) within 2 days and 7/289 (2.42%; 95% CI, 0.98%-4.93%) within 90 days; no patient had a stroke between 2 and 7 days. The AUCs for stroke in patients with confirmed TIA were 0.80 (95% CI, 0.68-0.91) and 0.62 (95% CI, 0.40-0.83) for stroke within 2 days and 90 days, respectively. At a cut-off of ≥ 5, the ABCD(2) score had modest specificity for stroke within 2 days (0.58) and 90 days (0.58), but positive predictive values (2 days, 0.03; 90 days, 0.04) and positive likelihood ratios (2 days, 2.40; 90 days, 1.71) were both poor. The score performed similarly poorly at other prespecified cut-off scores. CONCLUSIONS: Given its poor predictive value, the use of the ABCD(2) score alone may not be dependable for guiding clinical treatment decisions or service organisation in an Australian tertiary setting. Validation in other Australian settings is recommended before it can be applied with confidence.

Differences in Levodopa Response for Progressive and Non-Progressive Micrographia in Parkinson's Disease.

Background: Micrographia, one element of the dysgraphia of Parkinson's disease (PD), may be classified according to the presence or absence of a decremental pattern. The decremental form, progressive micrographia, is an expression of the sequence effect seen generally in bradykinesia. Its responsiveness to levodopa has not been evaluated kinematically. Objectives: Aim of this study is to investigate the difference in levodopa response for progressive and non-progressive micrographia. Methods: Twenty-four PD patients and 24 age-matched repeatedly wrote the letter e on a computerized digital tablet. PD patients performed the task two times, in a defined off state and again after levodopa. Scripts were classified as progressive micrographia (PDPM) or non-progressive micrographia (PDNPM) depending on whether a 10% decrement was seen between the first and final characters of a line of lettering. Results: While levodopa produced a similar response on the MDS-UPDRS motor scale for the two groups, the effect on the two types of micrographia was different. While writing speed improved significantly in both groups after levodopa, the responses were over twofold greater for PDNPM. Moreover, the decremental features of PDPM-in size, speed, and pen-pressure-were largely unaltered by a levodopa dose. Conclusions: Progressive micrographia is less responsive to levodopa. Our findings agree with research showing that the sequence effect of bradykinesia is relatively resistant to medication. Yet we did not find a weaker overall levodopa motor benefit. Caution is needed in the interpretation of such micrographia measurements for estimating drug responses.