Use of diagnostic tests and the appropriateness of the treatment decision in patients with suspected urinary tract infection in primary care in Denmark - observational study.

BACKGROUND: Inappropriate prescription of antibiotics is the leading driver of antimicrobial resistance (AMR). The majority of antibiotics are prescribed in primary care. Understanding how general practitioners (GPs) use diagnostic tests and the effect on treatment decision under daily practice conditions is important to reduce inappropriate prescription of antibiotics. The aim of the study was to investigate the use of diagnostic tests in primary care patients with suspected urinary tract infection (UTI) and to assess the appropriateness of the treatment decision (TD) under daily practice conditions in Denmark. METHODS: Prospective observational study. Symptomatic adult patients consulting general practice with suspected UTI recruited over 12 months. The diagnostic workup was registered in a standardized form. The appropriateness of the TD was assessed based on the results of a culture performed at a reference microbiological laboratory. TD was considered appropriate if a patient had a positive culture and was prescribed antibiotics or had a negative culture and was not prescribed antibiotics. TD was considered inappropriate if a patient had a negative culture and was prescribed antibiotics (overtreatment) or had a positive culture and was not prescribed antibiotics (undertreatment). RESULTS: Four hundred and eighty-eight patients were included. Dipstick was used in 98% of the patients and urine culture was used in 89% of the patients; 317 had the culture performed in practice and 117 had the culture performed at the hospital. The appropriateness of the final TD was significantly (p = 0.04) lower in patients without culture (55%) than in patients with culture performed in practice (71%) or at hospital (69%). CONCLUSION: In a context with wide availability of diagnostic tests, GPs use diagnostic tests for the decision-making process in all patients with suspected UTI. Urine culture is used in the majority of the patients and is associated with a higher proportion of appropriate treatment decisions. Performance of urine culture is therefore important in reducing inappropriate antibiotic prescribing in patients with suspected UTI seeking care in general practice in Denmark. TRIAL REGISTRATION: ClinicalTrials.gov NCT02249273 .

Substance use among Danish psychiatric patients: a cross-sectional study.

BACKGROUND: Patients with psychiatric disorders have a greater risk of mortality than the general population. Use or abuse of substances, including alcohol, play a crucial part in this context. Moreover, it is well known that drug use can worsen psychopathology and reduce treatment compliance. However, the magnitude of these problems among Danish psychiatric patients has not been studied previously. AIMS: The aim of this study is to investigate substance use among psychiatric patients in the Capital Region of Denmark. METHODS: Outpatients from five psychiatric units were asked to complete a questionnaire regarding their use of alcohol and other drugs of abuse. The questionnaire was based on the Alcohol Use Disorder Identification Test (AUDIT), supplemented by questions regarding use of tobacco and illicit drugs. The results were compared with those uses in the general population. RESULTS: In total, 412 psychiatric patients participated in the study, and 33% had an AUDIT-score ≥8, indicating problematic alcohol use according to the AUDIT guidelines. The mean weekly alcohol intake was 9.7 ± 28.3 standard drinks, and 47% were current smokers with a mean daily use of 19.9 ± 13.8 cigarette equivalents. Compared to the general population, the psychiatric patients had higher odds of being current smokers and having used illicit drugs within the past month. Women with psychiatric disorders were twice as likely to binge drink on a monthly basis. No significant difference was found in the patients' AUDIT scores compared to the general population. CONCLUSIONS: Our findings demonstrate a substantial and problematic use of tobacco and illicit drugs among Danish psychiatric patients, greater than in the general population.

Clinical accuracy of point-of-care urine culture in general practice.

OBJECTIVE: To assess the clinical accuracy (sensitivity (SEN), specificity (SPE), positive predictive value and negative predictive value) of two point-of-care (POC) urine culture tests for the identification of urinary tract infection (UTI) in general practice. DESIGN: Prospective diagnostic accuracy study comparing two index tests (Flexicult™ SSI-Urinary Kit or ID Flexicult™) with a reference standard (urine culture performed in the microbiological department). SETTING: General practice in the Copenhagen area patients. Adult female patients consulting their general practitioner with suspected uncomplicated, symptomatic UTI. MAIN OUTCOME MEASURES: (1) Overall accuracy of POC urine culture in general practice. (2) Individual accuracy of each of the two POC tests in this study. (3) Accuracy of POC urine culture in general practice with enterococci excluded, since enterococci are known to multiply in boric acid used for transportation for the reference standard. (4) Accuracy based on expert reading of photographs of POC urine cultures performed in general practice. Standard culture performed in the microbiological department was used as reference standard for all four measures. RESULTS: Twenty general practices recruited 341 patients with suspected uncomplicated UTI. The overall agreement between index test and reference was 0.76 (CI: 0.71-0.80), SEN 0.88 (CI: 0.83-0.92) and SPE 0.55 (CI: 0.46-0.64). The two POC tests produced similar results individually. Overall agreement with enterococci excluded was 0.82 (0.77-0.86) and agreement between expert readings of photographs and reference results was 0.81 (CI: 0.76-0.85). CONCLUSIONS: POC culture used in general practice has high SEN but low SPE. Low SPE could be due to both misinterpretation in general practice and an imperfect reference standard. Registration number: ClinicalTrials.gov NCT02323087.

Point of care susceptibility testing in primary care - does it lead to a more appropriate prescription of antibiotics in patients with uncomplicated urinary tract infections? Protocol for a randomized controlled trial.

BACKGROUND: Urinary tract infection (UTI) is a common infection in primary care and is the second leading reason for prescription of antibiotics in Denmark. The diagnosis is often based on symptoms and urine dip-stick, which has limited validity, causing the risk of unnecessary antibiotic prescription. Additionally, with increasing antibiotic resistance, the risk of choosing an antibiotic to which an infecting pathogen is resistant is rising. Combined point-of-care-tests (POCT) for urine culture and susceptibility testing have been developed and validated for primary care, and performing such a test in all patients with suspected UTI in primary care seems rational in order to reduce the use of inappropriate antibiotics. However, the clinical effect of the culture and susceptibility test has not yet been investigated. This study aims to investigate whether POCT urine culture and susceptibility testing decreases the inappropriate use of antibiotics and leads to faster patient recovery. METHODS/DESIGN: Randomized controlled open label trial of two diagnostic approaches. 750 patients with symptoms of uncomplicated UTI, consecutively contacting their general practitioner (GP), randomized to either POCT urine culture and susceptibility testing and targeted treatment or POCT urine culture without susceptibility testing and empirical treatment. Treatment is started when the POCT is read. The two groups are compared with regard to appropriate choice of antibiotics, clinical remission, and microbiological cure rates. DISCUSSION: The results of this study may provide important evidence to recommend POCT culture and susceptibility testing in all patients with suspected uncomplicated UTI. This could become an additional strategy to fight antibiotic resistance. TRIAL REGISTRATION: ClinicalTrials.gov NCT02323087 .

Renal effects of NO-inhibition in patients with cirrhosis vs. healthy controls: a randomized placebo-controlled crossover study.

BACKGROUND: Nitric oxide (NO) is an important regulator of renal hemodynamics and sodium excretion. Systemic and splanchnic NO-synthesis is increased in liver cirrhosis contributing to the characteristic hyperdynamic circulation. The significance of renal NO in human cirrhosis is not clear. AIMS: In order to clarify the role of NO in the regulation of renal hemodynamics and sodium excretion in human cirrhosis, we studied the effects of N(G)-monomethyl-L-arginine (L-NMMA) - a nonselective NO-inhibitor - on blood pressure (MAP), heart rate (HR), GFR, RPF, UNa × V, FENa, FELi and plasma levels of renin, angII, aldo, ANP, BNP and cGMP in 13 patients with cirrhosis (Child gr.A: 8; Child gr.B+C: 5) and 13 healthy controls. METHODS: The study was randomized and placebo-controlled. Renal hemodynamics were assessed by measuring renal clearance of (51) Cr-EDTA and (125) I-Hippuran for GFR and RPF, respectively. RESULTS: L-NMMA induced a similar, significant increase in MAP in both groups and a more pronounced relative decrease in HR in the CIR group (P = 0.0209, anova). L-NMMA did not change GFR in any group, but RPF decreased significantly in both groups, but most pronouncedly in CIR (P = 0.0478, anova). FENa decreased significantly in both groups after l-NMMA, but the response was again most pronounced in the CIR group (P = 0.0270, anova). All parameters remained stable after placebo. No significant differences were observed between the effects of L-NMMA in Child gr.A vs. Child gr. B+C patients. CONCLUSION: The data supports the hypothesis that renal NO is enhanced in human cirrhosis.

COVID-19 vaccination coverage for half a million non-EU migrants and refugees in England.

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants' COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55-1.79) and third dose (1.55; 1.43-1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23-2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Influencing attitudes towards antimicrobial use and resistance in companion animals-the impact on pet owners of a short animation in a randomized controlled trial.

Objectives: Antimicrobial resistance (AMR) is a vital One Health issue; the rational use of antimicrobials is essential to preserve their efficacy. Veterinarians cite pressure from pet owners as a contributor to antimicrobial prescription. Engaging pet owners in antimicrobial stewardship could reduce this pressure. A short educational animation could facilitate communication of this message. The impact of the animation on participant's opinions relating to antimicrobial prescribing and awareness of AMR was assessed via a randomized controlled trial. Methods: A survey was created based on the health belief model. Owners attending six UK veterinary centres were randomized to the intervention or control group (ratio 1:1). All owners completed an agreement level survey of two questions followed by 18 statements scored using a Likert agreement scale. The control group responded without interruption, whereas the animation group was shown the animation after answering the first two questions and five statements. Results: In total, 647 owners participated in the study; 350 complete responses were analysed. Responses to 10 of 13 statements asked after the animation were significantly different (all P < 0.050) between groups, whereas there was no significant difference between groups in response to any of the statements asked before the animation. The animation group were more likely to agree that lower antimicrobial use would help maintain future efficacy (P < 0.001) and that requesting antimicrobials from their vet could increase unnecessary use (P < 0.001). The animation group were more likely to disagree that they would expect antimicrobials if their pet had diarrhoea (P = 0.048). Conclusions: Pet owners that watched a short AMR engagement animation displayed greater awareness of the impact of AMR and were more likely to support measures in line with antimicrobial stewardship. This behavioural-nudge resource could support owners towards contributing to a multi-faceted approach to AMR.

Adherence to COPD guidelines in general practice: impact of an educational programme delivered on location in Danish general practices.

BACKGROUND: The general practitioner (GP) is often the first healthcare contact for patients with chronic obstructive pulmonary disease (COPD). AIMS: To determine whether participating in a standardised educational programme delivered in the GP's own practice is associated with adherence to COPD guidelines. METHODS: A nationwide register-based observational before and after study was undertaken with a control group of propensity-matched practices (follow-up period 6 months). COPD was defined as age 40+ years and at least two prescriptions for inhaled medication. The educational programme consisted of a 3-hr teaching lesson with a respiratory specialist and five visits by a representative from the sponsoring pharmaceutical company focusing on assessment and management of patients including written algorithms. A one-to-one propensity-matched control group of practices was selected. Register data were used to compare the rate of spirometry testing, preventive consultations, and influenza vaccinations provided to COPD patients and the rate of spirometry testing in non-COPD individuals, assumed to reflect diagnostic activity. RESULTS: Data for 102 participating GP practices were analysed. Participating clinics had a significant increase in preventive consultations and influenza vaccinations (p<0.05). For the control group, a significant change was observed only for influenza vaccinations. No significant change was found when comparing participating and control clinics in the difference-in-difference estimator. However, a significant improvement was observed for the subgroup of 48 clinics with the lowest starting point of spirometry testing. CONCLUSIONS: Focused education of GPs and their staff delivered in the GPs' own practices may improve adherence to COPD guidelines, not least for clinics with a high potential for improvement.

Understanding the child mortality decline in Guinea-Bissau: the role of population-level nutritional status measured by mid-upper arm circumference.

BACKGROUND: Malnutrition is considered an important contributing factor to child mortality, and the mid-upper arm circumference (MUAC) is regarded as one of the better anthropometric predictors of child mortality. We explored whether the decline in child mortality over recent decades could be explained by changes in children's MUAC. METHODS: This prospective study analysed individual-level data from 47 731 children from the capital of Guinea-Bissau followed from 3 months until 36 months of age over 2003 to 2016. We used standardization to compare the mortality rate as if only the MUAC distribution had changed between an early period (2003-05) and a late period (2014-16). We adjusted the analyses for age, sex, socioeconomic-related possessions and maternal education. RESULTS: A total of 949 deaths were included in the analysis. The adjusted mortality rate was 18.9 [95% confidence interval (CI) 14.3-23.3] deaths per 1000 person-years (pyrs) in the early period and declined to 4.4 (95% CI 2.9-6.0) deaths per 1000 pyrs in the late period, a 77% (95% CI 71-83%) reduction in the mortality rate. At all calendar years, the MUAC distribution in the population was close to the WHO reference population. MUAC below -1 z-score was associated with increased child mortality. The change in MUAC distribution from the early period to the late period (in the early period mortality standardization) corresponded to 1.5 (95% CI 1.0-2.2) fewer deaths per 1000 pyrs, equivalent to 11% (95% CI 7-14%) of the observed change in child mortality. CONCLUSIONS: From 2003 to 2016, child mortality in urban Guinea-Bissau declined considerably but, though a low MUAC was associated with increased mortality, changes in the MUAC distribution in the population explained little of the decline. Understanding the driving factors of child mortality decline can help scope tomorrow's interventions.

Daily use of lateral flow devices by contacts of confirmed COVID-19 cases to enable exemption from isolation compared with standard self-isolation to reduce onward transmission of SARS-CoV-2 in England: a randomised, controlled, non-inferiority trial.

BACKGROUND: In the UK, during the study period (April to July, 2021), all contacts of people with COVID-19 were required to self-isolate for 10 days, which had adverse impacts on individuals and society. Avoiding the need to self-isolate for those who remain uninfected would be beneficial. We investigated whether daily use of lateral flow devices (LFDs) to test for SARS-CoV-2, with removal of self-isolation for 24 h if negative, could be a safe alternative to self-isolation as a means to minimise onward transmission of the virus. METHODS: We conducted a randomised, controlled, non-inferiority trial in adult contacts identified by COVID-19 contact tracing in England. Consenting participants were randomly assigned to self-isolation (single PCR test, 10-day isolation) or daily contact testing (DCT; seven LFD tests, two PCR tests, no isolation if negative on LFD); participants from a single household were assigned to the same group. Participants were prospectively followed up, with the effect of each intervention on onward transmission established from routinely collected NHS Test and Trace contact tracing data for participants who tested PCR-positive for SARS-CoV-2 during the study period and tertiary cases arising from their contacts (ie, secondary contacts). The primary outcome of the study was the attack rate, the percentage of secondary contacts (close contacts of SARS-CoV-2-positive study participants) who became COVID-19 cases (tertiary cases) in each group. Attack rates were derived from Bernoulli regression models using Huber-White (robust) sandwich estimator clustered standard errors. Attack rates were adjusted for household exposure, vaccination status, and ability to work from home. The non-inferiority margin was 1·9%. The primary analysis was a modified intention-to-treat analysis excluding those who actively withdrew from the study as data from these participants were no longer held. This study is registered with the Research Registry (number 6809). Data collection is complete; analysis is ongoing. FINDINGS: Between April 29 and July 28, 2021, 54 923 eligible individuals were enrolled in the study, with final group allocations (following withdrawals) of 26 123 (52·6%) participants in the DCT group and 23 500 (47·4%) in the self-isolation group. Overall, 4694 participants tested positive for SARS-CoV-2 by PCR (secondary cases), 2364 (10·1%) in the self-isolation group and 2330 (8·9%) in the DCT group. Adjusted attack rates (among secondary contacts) were 7·5% in the self-isolation group and 6·3% in the DCT group (difference of -1·2% [95% CI -2·3 to -0·2]; significantly lower than the non-inferiority margin of 1·9%). INTERPRETATION: DCT with 24 h exemption from self-isolation for essential activities appears to be non-inferior to self-isolation. This study, which provided evidence for the UK Government's daily lateral flow testing policy for vaccinated contacts of COVID-19 cases, indicated that daily testing with LFDs could allow individuals to reduce the risk of onward transmission while minimising the adverse effects of self-isolation. Although contacts in England are no longer required to isolate, the findings will be relevant for future policy decisions around COVID-19 or other communicable infections. FUNDING: UK Government Department of Health and Social Care.

Nurses' experiences of delirium and how to identify delirium-A qualitative study.

AIM: Delirium is a serious, acute medical condition which places a heavy burden on the patient, his or her family and healthcare professionals. There have been only a limited number of studies to explore nurses' experiences of delirium and how delirium is identified in community care. The research questions of the study are as follows: "How do community care nurses' experience delirium?" and "How is delirium identified?". DESIGN: This study has been designed as an explorative and descriptive study. METHODS: A topic-based interview guide was developed containing questions associated with the Registered Nurses' experiences of their meetings with people with delirium and their identification of delirium. RESULTS: Nurses working in the community care need to know more about delirium as they play a key role in treatment. Our results also show that the participants have difficulty in establishing whether a patient is suffering from acute confusion/delirium, depression or dementia.

Is night-time light intensity associated with cardiovascular disease risk factors among adults in early-stage urbanisation in South India? A cross-sectional study of the Andhra Pradesh Children and Parents Study.

OBJECTIVES: To explore associations of night-time light intensity (NTLI), a novel proxy for continuous urbanisation levels, with mean systolic blood pressure (SBP), body mass index (BMI), fasting serum low-density lipoprotein (LDL) and fasting plasma glucose (FPG), among adults in early-stage urbanisation in Telangana, South India. DESIGN: Cross-sectional analysis of the third wave of the Andhra Pradesh Children and Parents Study cohort. SETTING: 28 villages representing a continuum of urbanisation levels, ranging from rural settlement to medium-sized town in Telangana, South India. PARTICIPANTS: Data were available from 6944 participants, 6236 of whom were eligible after excluding pregnant women, participants younger than 18 years of age and participants missing data for age. Participants were excluded if they did not provide fasting blood samples, had implausible or missing outcome values, were medicated for hypertension or diabetes or had triglyceride levels invalidating derived LDL. The analysis included 5924 participants for BMI, 5752 participants for SBP, 5287 participants for LDL and 5328 participants for FPG. RESULTS: Increasing NTLI was positively associated with mean BMI, SBP and LDL but not FPG. Adjusted mean differences across the range of village-level NTLI were 1.0 kg/m2 (95% CI 0.01 to 1.9) for BMI; 4.2 mm Hg (95% CI 1.0 to 7.4) for SBP; 0.3 mmol/L (95% CI -0.01 to 0.7) for LDL; and -0.01 mmol/L (95% CI -0.4 to 0.4) for FPG. Associations of NTLI with BMI and SBP were stronger in older age groups. CONCLUSION: The association of NTLI with cardiovascular disease (CVD) risk factors identify NTLI as a potentially important tool for exploring urbanisation-related health. Consistent associations of moderate increases in urbanisation levels with important CVD risk factors warrant prevention strategies to curb expected large public health impacts from continued and rapid urbanisation in India.

Is agricultural engagement associated with lower incidence or prevalence of cardiovascular diseases and cardiovascular disease risk factors? A systematic review of observational studies from low- and middle-income countries.

Non-communicable diseases, such as cardiovascular diseases (CVDs), diabetes and cancer account for more than half of the global disease burden, and 75% of related deaths occur in low- and middle-income countries (LMICs). Despite large regional variations in CVD incidence and prevalence, CVDs remain the leading causes of death worldwide. With urbanisation, developing nations are undergoing unprecedented labour-force transitions out of agriculture and into types of non-agricultural employment, mainly in the industry and service sectors. There are few studies on the effect of these transitions on CVDs and CVD risk factors in LMICs. We systematically searched MEDLINE, PubMed, EMBASE and the Cochrane Library from January 1950 to January 2017 to assess the association of engaging in agriculture compared to types of non-agricultural employment (e.g. services and manufacturing) with CVD incidence, prevalence and risk factors. Studies were included if they: included participants who engaged in agriculture and participants who did not engage in agriculture; measured atherosclerotic CVDs or their modifiable risk factors; and involved adults from LMICs. We assessed the quality of evidence in seven domains of each study. Prevalence ratios with 95% confidence intervals were calculated and compared in forest plots across studies. Study heterogeneity did not permit formal meta-analyses with pooled results. There was a lack of publications on the primary outcomes, atherosclerotic CVDs (n = 2). Limited evidence of varying consistency from 13 studies in five countries reported that compared with non-agricultural workers, mainly living in urban areas, rural agriculture workers had a lower prevalence of hypertension, overweight and obesity; and a higher prevalence of underweight and smoking. High quality evidence is lacking on the associations of engaging in and transitioning out of agriculture with atherosclerotic CVDs and their modifiable risk factors in LMICs. There is a need for interdisciplinary longitudinal studies to understand associations of types of employment and labour-force transitions with CVD burdens in LMICs.

Subclinical bacteriuria in a mixed population of 179 middle-aged and elderly cats: a prospective cross-sectional study.

OBJECTIVES: Subclinical bacteriuria (SBU) is the presence of bacteria in urine with no clinical evidence of lower urinary tract disease. The aims of this study were to investigate if being overweight and/or obesity predispose cats to SBU, to investigate previously reported risk factors and to determine the prevalence of SBU in a prospectively sampled cohort of middle-aged and elderly cats. METHODS: Cats aged ⩾6 years presenting to the University Hospital for Companion Animals in Copenhagen from 2015-2019 for causes unrelated to the lower urinary tract were eligible for enrolment. Body condition scoring was performed on a 9-point scale. Overweight was defined as a body condition score (BCS) ⩾6 and obese as a BCS ⩾8. The correlation between SBU and the variables of sex, healthy/diseased, age, BCS and comorbidities (chronic kidney disease, diabetes mellitus, hyperthyroidism, hepatic disorders and gastrointestinal disease) were analysed by binominal logistic regression. RESULTS: In total, 179 cats ranging from 6-20 (median 10) years of age were included. SBU was identified in 11/179 cats (6.1%). Being overweight was not a significant risk factor (overweight/obese odds ratio [OR] 0.3, 95% confidence interval [CI] 0.06-1.6, relative risk [RR] 0.3 [95% CI 0.05-1.3] vs lean; P = 0.2) and neither was obesity compared with lean and overweight cats (P = 0.99). Female sex (OR 6.2 [95% CI 1.3-30], RR 4.7 [95% CI 1.5-12] vs male; P = 0.02) and the presence of hepatic disease (OR 7.5 [95% CI 1.4-39], RR 5.3 [95% CI 1.3-12]; P = 0.02) were significant risk factors. CONCLUSIONS AND RELEVANCE: The prevalence of SBU in cats is low, and being overweight/obese was not identified as a predisposing factor. The increased risk associated with hepatic disease has not been previously reported, and further studies are needed to confirm this finding.

Thromboelastography-guided transfusion in dogs with hypocoagulable disorders: a case series.

BACKGROUND: Thromboelastography (TEG) is a global whole blood hemostasis assay which includes plasma as well as cellular components of hemostasis in the analysis and follows the quality and dynamics of clot development, stabilization, and lysis. In human medicine TEG is also a valuable asset in the therapeutic setting, allowing evaluation of the effect of transfusion therapy in vitro. This case series describes the use of TEG as a guiding tool for transfusion therapy in four dogs with hypocoagulable hemostatic disorders. CASE PRESENTATION: Four dogs presented with hypocoagulable disorders of hemostasis, diagnosed as rodenticide intoxication, angiostrongylosis, disseminated intravascular coagulation following severe systemic inflammation, and immune-mediated thrombocytopenia, respectively. TEG was used as a diagnostic tool as well as a guiding tool in the decision of whether or not, and in what dose, fresh frozen plasma would be of benefit in the treatment protocol for each dog. CONCLUSIONS: TEG may be applied in the therapeutic setting as a means to tailor individual patient transfusion therapy in critically ill dogs with hypocoagulable states.

Effects of community-based pulmonary rehabilitation in 33 municipalities in Denmark - results from the KOALA project.

BACKGROUND: The positive impact of pulmonary rehabilitation (PR) in patients with COPD is well documented. However, little is known regarding the effect of this treatment in community-based settings. Since 2007, all Danish municipalities have been offering PR to patients with moderate to severe COPD, whereas patients with very severe disease or those suffering from many comorbidities were referred to outpatient hospital-based PR. OBJECTIVE: To analyze the effect of a standardized PR program conducted in a community-based setting on exercise capacity and health-related quality of life (HRQoL). METHODS: This is a real-life study including data from patients attending PR at one of the 33 healthcare centers in Denmark during the period 2011-2012. For the purpose of registration and for quality assurance, the KOALA database was established and this web-based registration instrument was offered free of charge to every municipality. Measures included sociodemographic and health-related variables and outcomes were exercise capacity and HRQoL assessed by 6-minute walking distance (6MWD) and the 15D questionnaire, respectively, at the beginning (baseline) and after completion of PR. Relative improvements in 6MWD and 15D were analyzed with multivariable linear models in patients who attended >50% of the sessions. RESULTS: A total of 581 patients completed the PR (72% of those included). We found statistically significant and clinically meaningful differences between baseline and end of rehabilitation values for both main outcomes with a mean change in 6MWD of 45 m, and the magnitude of improvement corresponds to other findings. Furthermore, relative improvements in 6MWD and 15D were correlated, as was the relative change in 15D and baseline Medical Research Council scores. CONCLUSION: Standardized, multidisciplinary PR conducted in a community-based setting showed good adherence to the program and produced effects on exercise capacity and HRQoL that were clinically meaningful and comparable in size to hospital-based PR.

Toxoplasma gondii as a risk factor for early-onset schizophrenia: analysis of filter paper blood samples obtained at birth.

BACKGROUND: Infections during fetal life or neonatal period, including infections with Toxoplasma gondii, may be associated with a risk for schizophrenia and other mental disorders. The objectives of this study were to study the association between serological markers for maternal and neonatal infection and the risk for schizophrenia, related psychoses, and affective disorders in a national cohort of newborns. METHODS: This study was a cohort-based, case-control study combining data from national population registers and patient registers and a national neonatal screening biobank in Denmark. Patients included persons born in Denmark in 1981 or later followed up through 1999 with respect to inpatient or outpatient treatment for schizophrenia or related disorders (ICD-10 F2) or affective disorders (ICD-10 F3). RESULTS: Toxoplasma gondii immunoglobulin G (IgG) levels corresponding to the upper quartile among control subjects were significantly associated with schizophrenia risk (odds ratio [OR] = 1.79, p = .045) after adjustment for urbanicity of place of birth, year of birth, gender, and psychiatric diagnoses among first-degree relatives. There was no significant association between any marker of infection and other schizophrenia-like disorders or affective disorders. CONCLUSIONS: Our study supports an association between Toxoplasma gondii and early-onset schizophrenia. Further studies are needed to establish if the association is causal and if it generalizes to cases with onset after age 18.

Early infections of Toxoplasma gondii and the later development of schizophrenia.

Early exposure to several infectious agents has been associated with the later development of schizophrenia. Two recent studies assessed in utero or early postnatal exposure to Toxoplasma gondii. In one study of 63 individuals, who developed schizophrenia spectrum disorders, maternal sera obtained during pregnancy showed an increased risk (OR 2.61) of having IgG antibodies to T. gondii. In the other study of 71 individuals who developed schizophrenia, sera obtained shortly after birth also showed an increased risk (OR 1.79) of having IgG antibodies to T. gondii. Causal linking mechanisms are at present speculative but include possible direct effects of maternal IgG on the developing central nervous system (CNS) of the offspring. Additional studies are underway.