Orthopaedic surgeons' knowledge and practice of radiation safety when using fluoroscopy during procedures: A narrative review.

OBJECTIVES: The fluoroscopy environment poses a potential occupational radiation exposure risk to theatre personnel. Risks can be mitigated with effective application of radiation protection knowledge and methods. This review aimed to determine the link between orthopaedic surgeon's knowledge and the use of appropriate safety methods when using fluoroscopy. KEY FINDINGS: A keyword search of three databases discovered six articles, totalling 2209 orthopaedic surgeons, who completed surveys to assess knowledge on various aspects of radiation safety and training. Participants had varying levels of experience. Moreover 1981 participants always wore a lead gown (89 %), while only 1052 participants wore thyroid protection (47 %). 449 participants (20 %) received some form of training. CONCLUSION: Although surveys asked a range of questions it appeared that there was low knowledge of the ALARP principles. Usage of protective equipment is a legal requirement and thus was observed throughout, however, there were a number of incidences of disregarding some protective measures. Although there appeared to be limited knowledge surrounding radiation protection measures and lack of training provided, no clear link was demonstrated between compliance with protective methods and knowledge of the risks. IMPLICATIONS FOR PRACTICE: Formal and continuous training should be provided for the enhancement of knowledge to ensure the safety of all staff and help prevent the long-term effects of ionising radiation when using fluoroscopy.

The relationship of apparent diffusion coefficient values of renal cell carcinoma before and after cryotherapy ablation.

INTRODUCTION: The diagnosis of renal cell carcinoma (RCC) is increasing due to incidental findings with more frequent use of cross-sectional imaging. Therefore improvements to diagnostic and follow up imaging techniques is necessary. MRI diffusion weighted imaging (DWI) is a recognised method of measuring the diffusion of water within lesions using the apparent diffusion coefficient (ADC), and may have a role in monitoring the efficacy of cryotherapy ablation of RCC. METHODS: A retrospective cohort study of 50 patients was approved to investigate if the ADC value can determine the success of cryotherapy ablation treatment for RCC. DWI was performed at a single centre using 1.5 T MRI before and after cryotherapy ablation to the RCC. The control group was considered as the unaffected kidney. The ADC value of the RCC tumour and normal kidney tissue prior to and after cryotherapy ablation was measured, and compared to the result of the MRI. RESULTS: A statistically significant change in the ADC values was observed, pre ablation (1.562 × 10¯mm2/sec) to the post ablation (1.126 × 10¯³mm2/sec), p < 0.0005. There was no statistical significance in any of the other outcomes measured. CONCLUSION: Although a change of ADC value occurred this is likely due to cryotherapy ablation causing coagulative necrosis at the site, and does not determine the success of the cryotherapy ablation. This can be considered a feasibility study for future research. IMPLICATIONS FOR PRACTICE: DWI is a quick addition to routine protocols, does not require intravenous gadolinium based contrast agent, and provides qualitative and quantitative data. Further research is required to establish the role of ADC for treatment monitoring.

Persistent Orofacial Pain Attendances at General Medical Practitioners.

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

Sleep Quality and the Importance Women Place on Healthy Eating Interact to Influence Psychological Resilience.

Objectives: The impact women's daily habits may have on psychological resilience is not well understood. This cross-sectional analysis examined: (1) the impact of sleep quality on resilience, and (2) whether this association was modified by the importance women place on healthy eating. Methods: We collected data from 64 women (aged 18-67 years). The Pittsburgh Sleep Quality Index and Connor-Davidson Resilience Scale-10 assessed sleep quality and resilience, respectively, with lower scores indicating reduced resilience. One item assessed attitudes towards healthy eating. Linear regression models and 95% confidence intervals examined associations adjusted for age and income. Results: Reduced sleep quality was associated with a decreased resilience score (B=0.55, 95% CI: -1.06, -0.04, p=.04) when adjusted for age and income. After stratification, sleep quality and resilience were not associated among women who indicated healthy eating was very important. Among women who indicated healthy eating was less than very important, reduced sleep quality was associated with decreased psychological resilience (B=0.85, 95% CI: -1.55, -0.15, p=.02). Conclusions: Poor sleep quality was associated with reduced resilience among women. Placing a strong emphasis on healthy eating helped buffer the impact of poor sleep quality on women's psychological resilience.

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis.

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients' reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Artificial Intelligence: Guidance for clinical imaging and therapeutic radiography professionals, a summary by the Society of Radiographers AI working group.

INTRODUCTION: Artificial intelligence (AI) has started to be increasingly adopted in medical imaging and radiotherapy clinical practice, however research, education and partnerships have not really caught up yet to facilitate a safe and effective transition. The aim of the document is to provide baseline guidance for radiographers working in the field of AI in education, research, clinical practice and stakeholder partnerships. The guideline is intended for use by the multi-professional clinical imaging and radiotherapy teams, including all staff, volunteers, students and learners. METHODS: The format mirrored similar publications from other SCoR working groups in the past. The recommendations have been subject to a rapid period of peer, professional and patient assessment and review. Feedback was sought from a range of SoR members and advisory groups, as well as from the SoR director of professional policy, as well as from external experts. Amendments were then made in line with feedback received and a final consensus was reached. RESULTS: AI is an innovative tool radiographers will need to engage with to ensure a safe and efficient clinical service in imaging and radiotherapy. Educational provisions will need to be proportionately adjusted by Higher Education Institutions (HEIs) to offer the necessary knowledge, skills and competences for diagnostic and therapeutic radiographers, to enable them to navigate a future where AI will be central to patient diagnosis and treatment pathways. Radiography-led research in AI should address key clinical challenges and enable radiographers co-design, implement and validate AI solutions. Partnerships are key in ensuring the contribution of radiographers is integrated into healthcare AI ecosystems for the benefit of the patients and service users. CONCLUSION: Radiography is starting to work towards a future with AI-enabled healthcare. This guidance offers some recommendations for different areas of radiography practice. There is a need to update our educational curricula, rethink our research priorities, forge new strong clinical-academic-industry partnerships to optimise clinical practice. Specific recommendations in relation to clinical practice, education, research and the forging of partnerships with key stakeholders are discussed, with potential impact on policy and practice in all these domains. These recommendations aim to serve as baseline guidance for UK radiographers. IMPLICATIONS FOR PRACTICE: This review offers the most up-to-date recommendations for clinical practitioners, researchers, academics and service users of clinical imaging and therapeutic radiography services. Radiography practice, education and research must gradually adjust to AI-enabled healthcare systems to ensure gains of AI technologies are maximised and challenges and risks are minimised. This guidance will need to be updated regularly given the fast-changing pace of AI development and innovation.

Factors Influencing the Prevalence of Animal Cruelty During Adolescence.

Adolescents' interactions with animals are of increasing interest and their beneficial developmental outcomes are well known. However, negative interactions such as perpetrating cruelty toward animals during childhood and adolescence have been related with child abuse, domestic violence, and later interpersonal violence. Cruelty toward animals by adolescents has been reported predominately in criminal and clinical samples, and links have been made between animal cruelty and interpersonal violence. However, studies often lack a clear definition of animal cruelty and the animal involved. The present study addresses methodological shortcomings by providing a clear definition of the cruelty acts and the animals involved and the time frame within which cruelty acts have been taken place. Therefore, we investigated the prevalence of animal cruelty of 979 British adolescents (419 male, 497 female, Mage = 15.1 ± 1.57 years) by means of a survey questionnaire administered in school. Animal cruelty was investigated encompassing deliberate and nondeliberate cruelty acts, a clear definition of the target animals was included and a time frame was provided. Furthermore, acceptability of animal cruelty, engaging in antisocial behavior, and family affluence were investigated. Results show high reliabilities for the measures applied. Exploratory factor analysis reveals different types of animal cruelty. Gender differences were observed for deliberate and accidental cruelty acts, with boys reporting higher levels than girls. Younger adolescents reported higher accidental cruelty acts than older ones. Acceptance of animal cruelty played a significant role in predicting animal cruelty, together with antisocial behaviors and place of living. The present study shows for the first time the importance of distinguishing between different types of animal cruelty and defining the animals involved.

Comparison of public health specialty training in Australia and England.

OBJECTIVES: The objective of the study is to explore common challenges and distinct features of specialty public health training in Australia and England, given similarities in public health issues faced, shared histories and common political structures. STUDY DESIGN: The study design used in the study is a document review. METHODS: Using current curricula, along with other publicly available documents, we reviewed organisational, selection and content elements of public health specialty training in these two countries. RESULTS: In both countries, specialist public health training is coordinated and accredited through Faculties of Public Health housed within Royal Colleges of Physicians. However, eligibility, recruitment to training and funding routes differ. In England, entrants are accepted from a range of backgrounds including medicine, whereas only medical doctors are eligible in Australia. England has a national, annual recruitment process; Australia does not and has a less structured training path. In Australia, specialty advanced training is three years (excluding a Master's in Public Health [MPH]), whereas in England, training is generally five years (including an MPH). Curricula cover broadly common domains of public health practice although there are differences. Methods to assess readiness for consultant practice differ. CONCLUSIONS: Fostering an understanding of the specialist role of public health professionals in different countries establishes routes to share learning, encourage greater collaboration and creates opportunities for benchmarking.

Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries.

Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization. INTRODUCTION: Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports. METHOD: Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes. RESULTS: Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits. CONCLUSIONS: National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other's practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.

Racially-motivated housing discrimination experienced by Indigenous postsecondary students in Canada: impacts on PTSD symptomology and perceptions of university stress.

OBJECTIVES: To examine the impacts of housing discrimination experienced by Indigenous postsecondary students on post-traumatic stress disorder (PTSD) symptomology and perceptions of university stress. STUDY DESIGN: Cross-sectional study. METHODS: Data were gathered via in-person surveys completed by 142 Indigenous students between 2015 and 2017. Associations were analyzed using phi coefficients and linear regression models adjusted for confounders. Qualitative data were examined using thematic analyses. RESULTS: Indigenous students who had children (almost 50% of the sample), were living with a romantic partner, and/or were between the ages of 25-44 years experienced significantly more racially-motivated housing discrimination than other Indigenous students in the sample. The frequency of housing discrimination in the past 12 months was significantly associated with increased PTSD symptoms; particularly, intrusive recollection and more perceived stress at university in linear regression models adjusted for confounders. Every 1-point increase in the frequency of housing discrimination on a 4-point scale resulted in a 5.4-point increase in PTSD score. Although living with a romantic partner resulted in more housing discrimination, it also served as a resilience factor, buffering the impact of housing discrimination on PTSD symptomology. Qualitative data indicated students faced Racially-motivated housing discrimination that was blunt and deliberate and highlighted the resourceful ways students sought to resist it. CONCLUSIONS: Racially-motivated housing discrimination exacerbated PTSD symptomology among Indigenous students and adversely impacted perceptions of their university experience. Efforts are needed to address housing discrimination directly, as well as provide greater family-focused housing and mental wellness supports to Indigenous students to reduce potential impacts of this public health problem on postsecondary success and degree completion.

The risk of cardiac failure following metal-on-metal hip arthroplasty.

AIMS: The aim of this study was to determine whether patients with metal-on-metal (MoM) arthroplasties of the hip have an increased risk of cardiac failure compared with those with alternative types of arthroplasties (non-MoM). PATIENTS AND METHODS: A linkage study between the National Joint Registry, Hospital Episodes Statistics and records of the Office for National Statistics on deaths was undertaken. Patients who underwent elective total hip arthroplasty between January 2003 and December 2014 with no past history of cardiac failure were included and stratified as having either a MoM (n = 53 529) or a non-MoM (n = 482 247) arthroplasty. The primary outcome measure was the time to an admission to hospital for cardiac failure or death. Analysis was carried out using data from all patients and from those matched by propensity score. RESULTS: The risk of cardiac failure was lower in the MoM cohort compared with the non-MoM cohort (adjusted hazard ratio (aHR) 0.901; 95% confidence interval (CI) 0.853 to 0.953). The risk of cardiac failure was similar following matching (aHR 0.909; 95% CI 0.838 to 0.987) and the findings were consistent in subgroup analysis. CONCLUSION: The risk of cardiac failure following total hip arthroplasty was not increased in those in whom MoM implants were used, compared with those in whom other types of prostheses were used, in the first seven years after surgery. Cite this article: Bone Joint J 2018;100-B:20-7.

Prevalence, glucose control and relative survival of people with Type 2 diabetes in the UK from 1991 to 2013.

AIMS: To characterize the prevalence of Type 2 diabetes between 1991 and 2013 in the UK and to determine whether corresponding glucose control and survival had changed in the diabetic population during this period. METHODS: For this retrospective cohort study, people diagnosed with Type 2 diabetes between 1991 and 2013 were identified from the Clinical Practice Research Datalink (CPRD) and the annual point prevalence calculated. Mean HbA1c by year was estimated. The Cox proportional hazards model was used to calculate the risk of all-cause mortality by year for incident cases of Type 2 diabetes treated with glucose-lowering therapy. RESULTS: Crude prevalence of diagnosed Type 2 diabetes increased from 1.32% [95% confidence interval (95% CI) 1.30% to 1.34%] in 1991 to 4.54% (4.52% to 4.56%) in 2013. Mean HbA1c for people with diagnosed Type 2 diabetes was 71 mmol/mol (8.6%) in 1991, 59 mmol/mol (7.5%) in 2003 and 58 mmol/mol (7.5%) in 2013. For diagnosed Type 2 diabetes treated with glucose-lowering therapy, when compared with 1991, the hazard ratio for all-cause mortality was 0.33 (0.27-0.41) in 2013. CONCLUSION: The prevalence of diagnosed Type 2 diabetes trebled in the UK between 1991 and 2013. Improved survival in people with diagnosed Type 2 diabetes is likely to account, at least in part, for the increase in prevalence observed.

Dental pain in the medical emergency department: a cross-sectional study.

The aim of this study was to examine the number of patients attending a medical emergency department (MED) with dental problems over a three-year period. This cross-sectional study was carried out as part of a service evaluation. Data were collected via a database search of patient attendances at the MED using free text and the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) for oral and dental diagnoses. Data were analysed using descriptive statistics, t-test and chi-squared tests. Over the three-year period, there were 2504 visits to the MED for dental-related complaints, accounting for 0·7% of all attendances. The majority of patients were male (53·9%), with a mean age of 29 (s.d. 19·4) years for men, and 32 (s.d. 19·7) years for females. The mean index of multiple deprivation per cent rank was 35·0%. The most common diagnosis was unspecified dental disorder. Ten per cent of dental attendances to MED were repeat attendances by the same patients. In conclusion, patient attendances at MED for dental problems account for 0.7% of all attendances. MED may not be the most appropriate place for these patients to attend, in terms of care pathways, and also for economic reasons. The reasons why patients attend MED for dental problems clearly warrant further research.

Antimicrobial Activity of Actinobacteria Isolated From the Guts of Subterranean Termites.

Subterranean termites need to minimize potentially pathogenic and competitive fungi in their environment in order to maintain colony health. We examined the ability of Actinobacteria isolated from termite guts in suppressing microorganisms commonly encountered in a subterranean environment. Guts from two subterranean termite species, Reticulitermes flavipes (Kollar) and Reticulitermes tibialis Banks, were extracted and plated on selective chitin media. A total of 38 Actinobacteria isolates were selected for in vitro growth inhibition assays. Target microbes included three strains of Serratia marcescens Bizio, two mold fungi (Trichoderma sp. and Metarhizium sp.), a yeast fungus (Candida albicans (C.P. Robin) Berkhout), and four basidiomycete fungi (Gloeophyllum trabeum (Persoon) Murrill, Tyromyces palustris (Berkeley & M.A. Curtis) Murrill, Irpex lacteus (Fries) Fries, and Trametes versicolor (L.) Lloyd). Results showed both broad and narrow ranges of antimicrobial activity against the mold fungi, yeast fungus, and S. marcescens isolates by the Actinobacteria selected. This suggests that termite gut-associated Actinobacteria produce secondary antimicrobial compounds that may be important for pathogen inhibition in termites. Basidiomycete fungi were strongly inhibited by the selected Actinobacteria isolates, with G. trabeum and T. versicolor being most inhibited, followed by I. lacteus and T. palustris The degree of inhibition was correlated with shifts in pH caused by the Actinobacteria. Nearly all Actinobacteria isolates raised pH of the growth medium to basic levels (i.e. pH ∼8.0-9.5). We summarize antimicrobial activity of these termite gut-associated Actinobacteria and examine the implications of these pH shifts.

Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2).

We re-analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP-1) to describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%) 30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without peripheral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within five days after surgery was 0.983 (0.973-0.994) for each 5 mmHg intra-operative increment in systolic blood pressure, p = 0.0016, and 0.980 (0.967-0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent odds ratios (95% CI) for 30-day mortality were 0.968 (0.951-0.985), p = 0.0003 and 0.976 (0.964-0.988), p = 0.0001, respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was weakly correlated with a higher volume of subarachnoid bupivacaine: r(2) -0.10 and -0.16 for hyperbaric and isobaric bupivacaine, respectively. A mean 20% relative fall in systolic blood pressure correlated with an administered volume of 1.44 ml hyperbaric bupivacaine. Future research should focus on refining standardised anaesthesia towards administering lower doses of spinal (and general) anaesthesia and maintaining normotension.

Pain and problems: a prospective cross-sectional study of the impact of dental emergencies.

One-third of the population will only attend the dentist for an acute problem, often waiting a period of time before presenting. The objective of this study was to investigate the levels of pain in patients presenting for a dental emergency and the impact this had on their quality of life. Questionnaires were provided to adult patients attending dental emergency services over 1 week. Demographic and clinical details were collected. Quality of life was measured using EQ-5D-5L. Pain and the interference it caused were examined using the graded chronic pain scale. Data were analysed in STATA using descriptive statistics, Mann-Whitney and chi-squared tests. Results showed that majority of patients (64%) seen were male; the mean age was 36 (±14) years. Forty six per cent of patients reported having a general dental practitioner. One-third of the patients had attended this service previously for emergency care, and 13% consulted for the same problem. The mean duration of pain was 17·7 (±52·3) days prior to seeking care. The mean characteristic pain intensity was 53·6 (±23·6). The mean disability score was 43·4 (±33·6). The mean EQ-5D-5L score was 0·57 (±0·27). In conclusion, a large number of patients attend the emergency dental services despite being 'registered' with a general dental practitioner. A proportion of these individuals will re-attend for the same condition. Patients will often be in pain for over 2 weeks before attending, which may have a significant impact on their quality of life. Further research is warranted to investigate these care-seeking behaviours and patterns.

High daily insulin exposure in patients with type 2 diabetes is associated with increased risk of cardiovascular events.

AIMS: Intensive glucose control, often involving insulin treatment, failed to improve cardiovascular outcomes in several clinical trials. Observational studies reported an association between insulin use and cardiovascular disease (CVD) risk. It has therefore been suggested that insulin adversely affects CVD risk. To investigate the feasibility of this hypothesis, we studied the association between insulin dose and CVD risk in type 2 diabetes. METHODS: A case-control study was conducted of new users of oral antidiabetics who were prescribed insulin, using the Dutch Pharmo database. Cases were hospitalized for a cardiovascular event (CVE) and matched 1:2 to patients who were not hospitalized for a CVE, by sex, age, duration of diabetes and type of oral antidiabetic. Patients were divided into tertiles according to mean daily insulin dose. Conditional logistic regression analyses were used to explore the association between insulin exposure and CVE risk. RESULTS: We included 836 patients (517 (62%) male, mean age 66 years). After adjusting for available potential confounders, including HbA1c and triglycerides, insulin exposure was positively related to CVE risk (odds ratios for high (≥53.0 U/day) and intermediate (24.3-52.9 U/day) vs. low exposure (≤24.2 U/day): 3.00 [95% confidence interval (CI) 1.70 to 5.28] and 2.03 [95% CI 1.17 to 3.52]. CONCLUSION: Our findings are in line with the suggestion that high-dose insulin therapy adversely affects CVD risk, but need to be interpreted with caution due to the observational nature of the study. The role of particularly high-dose insulin in the progression of CVD warrants further investigation.