[Prevention and management of COVID-19 outbreaks on merchant ships]. / Prävention und Management von COVID-19-Ausbrüchen auf Handelsschiffen: Technische, organisatorische und persönliche Schutzmaßnahmen zur Risikominimierung in einem besonderen Arbeitsumfeld.

BACKGROUND: A pandemic is a particular medical challenge for seafarers traveling without a physician on board. At the same time the global fight against the coronavirus disease 2019 (COVID-19) pandemic has to rely on resilient merchant shipping in order to maintain the flow of goods. For infection prevention and management on board, those responsible need a portfolio of protective measures that can be used on ships. RESEARCH QUESTIONS: The overview examines the question of which technical, organizational and personal protective measures can be used on a merchant ship in order to prevent or cope with COVID-19 outbreaks on board. MATERIAL AND METHODS: Guidelines, information and occupational health and safety standards from the maritime setting, but also from many other work areas, were examined in order to facilitate a variable use by those responsible (e.g. according to ship size, equipment, weather, operating status, work requirements, contact with external persons, medical problems). RESULTS: A handout was compiled that contains specific technical, organizational and personal protective measures for crews, explaining their use in a maritime context. Possible safety barriers, options to combine them and an appropriate timing are explained in a target group-oriented manner. CONCLUSION: A great variety of protective measures derived from occupational medical literature and the experience of the port medical service in Hamburg can also be implemented on the high seas. In pandemic times, merchant ships should be equipped with foresight (e.g. with rapid diagnostic tests) and those responsible should be authorized to use effective infection control measures adapted to the situation on board. Seafarers should receive priority vaccination offers regardless of their national origin.

Incidence of advanced-stage breast cancer in regular participants of a mammography screening program: a prospective register-based study.

BACKGROUND: The European Guidelines for breast cancer screening suggest that the impact of population-based mammography screening programmes (MSP) may be assessed using the relative reduction in the incidence of advanced breast cancer (ABC, that is, stage UICC II and higher) as a surrogate indicator of screening effectiveness. METHODS: This prospective, population register-based study contained individual data of 1,200,246 women (aged 50-69 years) who attended the initial prevalence screening between 2005 and 2009. Of them, 498,029 women returned for the regular (i.e., within 24 months) first subsequent, and 208,561 for the regular second subsequent incidence screenings. The incidence rate of ABC was calculated for the 24-months period following, but not including, the initial screening by incorporating all interval ABCs and all ABCs detected at the regular first incidence screening; the ABC rate for the second 24-months period was determined in the same way, including ABCs detected in the interval after the first and, respectively, at the second incidence screening. The relative reduction in the ABC incidence was derived by comparing the age-standardized rates in these two periods with an age-standardized reference incidence rate, observed in the target population before the MSP implementation. The strengths and weaknesses of this particular study design were contrasted with a recently published checklist of main methodological problems affecting studies of the effect of MSP on ABC incidence. RESULTS: The age-standardized ABC incidence rate was 291.6 per 100,000 women for the 24-months period subsequent to the initial screening, and 275.0/100,000 for the 24-months period following the first subsequent screening. Compared to the 2-year incidence of 349.4/100,000 before the start of the MSP, this amounted to a relative reduction of 16.5 and 21.3%, respectively, in the incidence of ABC among regular MSP participants. CONCLUSIONS: The design employed in this study avoids some of the substantial methodological limitations that compromised previous observational studies. Nevertheless, specific limitations prevail that demand a cautious interpretation of the results. Therefore, the study findings, indicating a reduction in ABC for regular MSP participants, need to be followed with respect to potential impacts on breast cancer mortality rates.

Detection Rates of Ductal Carcinoma in Situ with Biennial Digital Mammography Screening: Radiologic Findings Support Pathologic Model of Tumor Progression.

Purpose To compare detection rates of ductal carcinoma in situ (DCIS), classified according to nuclear grade, between the prevalence round (baseline screening) and two subsequent screening rounds of a population-based digital mammography screening program, to assess differences over time. Materials and Methods The cancer registry provided data for 1970 graded pure DCIS cases from 16 screening regions of the prevalence round (baseline screening, from 2005 to 2008), first subsequent round, and second subsequent round; the interval between all screening rounds was 22-30 months. Age-adjusted logistic regression analysis was performed to compare the grade-specific detection rates between the prevalence round (reference) and subsequent screening rounds. Results Over all screening rounds, cancer detection rates were lowest for low-grade DCIS (range, 0.11 [58 of 508 817 patients] to 0.25 [178 of 713 867 patients] per 1000 women screened) and highest for high-grade DCIS (range, 0.53[271 of 508 817 patients] to 0.59 [237 of 398 944 patients] per 1000 women screened). Detection rates for low-grade DCIS were significantly lower in the first (odds ratio [OR] = 0.45, P < .001) and second (OR = 0.57, P < .001) subsequent screening rounds compared with that in the prevalence round; the relative reduction of detection rates of intermediate-grade DCIS was less pronounced (OR = 0.79, P = .006 and OR = 0.76, P = .003, respectively). Conversely, the detection rate of high-grade DCIS remained at the high level found in the prevalence screening (OR = 0.89, P = .143 and OR = 0.97, P = .700, respectively). Conclusion The findings demonstrate persistently high detection rates of high-grade DCIS in two consecutive subsequent screening rounds compared with the prevalence round; conversely, rates of low-grade DCIS and, less markedly, intermediate-grade DCIS decreased in subsequent rounds. Grade-related changes of DCIS detection are suggestive of distinct dynamics of lesion progression. © RSNA, 2017 An earlier incorrect version of this article appeared online. This article was corrected on November 10, 2017.

Digital Mammography Screening: Does Age Influence the Detection Rates of Low-, Intermediate-, and High-Grade Ductal Carcinoma in Situ?

PURPOSE: To investigate the association between age at screening and detection rates for ductal carcinoma in situ (DCIS) separately for different nuclear grades after introduction of a population-based digital mammography screening program. MATERIALS AND METHODS: The retrospective study was approved by the ethics board and did not require informed consent. In 733 905 women aged 50-69 years who participated in a screening program for the first time in 2005-2008 (baseline examinations were performed with digital mammography), DCIS detection rates were determined for 5-year age groups (detection rates per 1000 women screened) to distinguish high-, intermediate-, and low-grade DCIS. Multivariable logistic regression was used to compare detection rates between age groups by adjusting for screening units (P < .05). RESULTS: There were 989 graded DCIS diagnoses among 733 905 women (detection rate, 1.35‰): 419 diagnoses of high-grade DCIS (detection rate, 0.57‰), 388 diagnoses of intermediate-grade DCIS (detection rate, 0.53‰), and 182 diagnoses of low-grade DCIS (detection rate, 0.25‰). Detection rate for types of DCIS combined increased significantly across age groups (50-54 years, detection rate of 1.15‰ [254 of 220 985 women]; 55-59 years, detection rate of 1.23‰ [218 of 177 782 women]; 60-64 years, detection rate of 1.34‰ [201 of 150 415 women]; and 65-69 years, detection rate of 1.71‰ [316 of 184 723 women]; P < .001). Of note, the detection rate for high-grade DCIS showed a significant increase with age (odds ratio, 1.18 per 5-year age group; P < .0001). The increase was lower for intermediate-grade DCIS (odds ratio, 1.11; P = .016) and not significant for low-grade DCIS (P = .10). CONCLUSION: Total DCIS detection rates increase with age, mostly because of an increase in high- and intermediate-grade DCIS, which are precursor lesions that carry a higher risk for transition to more aggressive invasive breast cancer than low-grade DCIS.

Passive smoking and smoking cessation among patients with coronary heart disease across Europe: results from the EUROASPIRE III survey.

AIMS: Passive smoking is the inhalation of environmental tobacco smoke (ETS) and is a risk factor for coronary heart disease (CHD). We aimed to describe the frequency of passive smoking among patients with CHD and to investigate the association between ETS exposure and smoking cessation. METHODS AND RESULTS: The EUROASPIRE III survey was conducted in 2006-07 among CHD patients up to 80 years of age from 22 European regions. Patients were interviewed and examined on average 15 months after hospital admission for CHD. Information was obtained on smoking prior to hospital admission, smoking at interview, and ETS exposure at home, at work, and at other locations. Breath carbon monoxide was measured to validate self-reported non-smoking. Among 8729 patients, 6060 (69.4%) were non-smokers prior to hospital admission, of whom 10.3% reported ETS exposure at home, 7.2% at work, and 13.8% at other locations. Overall, 24.2% of non-smokers were exposed to ETS at any place. Among the 2669 patients who were smoking prior to hospital admission, the likelihood of cessation at interview was lower in those with ETS exposure at home than in those without [25.3 vs. 58.1%; adjusted odds ratio (OR) 0.26, 95% confidence interval (CI) 0.20-0.33]. This finding applied also to ETS exposure at work (32.2 vs. 52.7%; adjusted OR 0.56, 95% CI 0.42-0.76) and at other locations (38.0 vs. 52.8%; adjusted OR 0.63, 95% CI 0.48-0.84). CONCLUSION: A noteworthy proportion of non-smokers with CHD are exposed to ETS. Passive smoking may jeopardize smoking cessation among CHD patients.

Workplace-related inhalation test - Specific inhalation challenge: S2k Guideline of the German Society for Occupational and Environmental Medicine e.V. (DGAUM), the German Society for Pneumology and Respiratory Medicine e.V. (DGP) and the German Society for Allergology and Clinical Immunology e.V. (DGAKI).

Not available.

A mass casualty incident of infectious diseases at the port of Hamburg: an analysis of organizational structures and emergency concepts.

BACKGROUND: The project "ARMIHN" (Adaptive Resiliency Management in Port) focuses on strengthening the capability to act in a mass casualty incident (MCI) due to an outbreak of infectious diseases (MCI-ID). In addition to the current threat from the COVID-19 pandemic and associated outbreaks on cruise ships, previous MCI-ID were especially caused by pathogens such as Influenza virus or Norovirus. The first step was, to get an overview of processes and resources using the example of the Port of Hamburg, and to show the associated interaction of involved parties. This will serve as a basis for developing an operational strategy and offers the opportunity to optimize current work processes. METHODS: A selective literature research using specified key words was performed and existing MCI concepts were received from local authorities. Identified structures and processes were analyzed in a multiple step process and also brought together through discussions in workshops with involved organizations and other experts. Additionally, the distances between the nearest rescue stations and selected hospitals from the Port of Hamburg were analyzed. RESULTS: The current available concepts are proven, but an adaptation to an MCI-ID shows opportunities for a further cross-organizational development. The organizational structure of an MCI-ID in the Port of Hamburg was described, including a large number of involved organizations (n = 18). There are 17 involved fire and rescue stations and the port can be reached from these locations within 6 to 35 min. Based on their specialist expertise, 14 of the 31 listed clinics were selected. CONCLUSION: The purpose of the study was to provide an analysis of the current situation and show how involved parties would cope an MCI. A description of processes and resources at the Port of Hamburg will be used when designing a management plan for responding to an MCI-ID.

Systematic Review on Outbreaks of SARS-CoV-2 on Cruise, Navy and Cargo Ships.

The confined environment of a ship promotes the transmission of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) due to close contact among the population on board. The study aims to provide an overview of outbreaks of SARS-CoV-2 on board of cruise, navy or cargo ships, to identify relevant outbreak management techniques, related problems and to derive recommendations for prevention. Four databases were searched. The study selection included reports about seroprevalences or clinically/laboratory confirmed infections of SARS-CoV-2 on board ships between the first of January, 2020 and the end of July, 2020. A total of 37 studies were included of whom 33 reported outbreaks of SARS-CoV-2 on cruise ships (27 studies referred to the Diamond Princess). Two studies considered outbreaks on the Grand Princess, three studies informed about Nile River cruises and one study about the MS Westerdam (mention of multiple outbreaks possible in one study). Additionally, three studies reported outbreaks of SARS-CoV-2 on navy vessels and one study referred to a cargo ship. Problems in handling outbreaks resulted from a high number of asymptomatic infections, transportation issues, challenges in communication or limited access to health care. Responsible operators need to implement infection control measures which should be described in outbreak management plans for ships to prevent transmission risks, including, e.g., education, testing strategies, communication lines, social distancing and hygiene regulations.

Management of overweight and obese patients with coronary heart disease across Europe.

AIMS: Several studies have reported increasing obesity rates in the general population. Using data from the EUROASPIRE III survey, we investigated as to what extent the obesity epidemic affects the high priority group of coronary heart disease patients. METHODS AND RESULTS: Data from 8924 patients, who had experienced a recent coronary acute event, from 22 countries in Europe participating in the EUROASPIRE III study were gathered in 2006-2007. Eight centres had also participated in the earlier two EUROASPIRE surveys carried out in 1994-1995 and 1999-2000. In these eight centres, obesity prevalence in coronary patients had increased from 25 to 38% during the past decade. The most recent survey shows that obesity is more prevalent in women (45 vs. 32% in men) and is a major health problem across all the 22 countries. Only 18% of all the patients were found to reach a body mass index below 25 kg/m whereas 53% were diagnosed with central obesity. Since their hospital discharge, only half of the obese patients reported to have followed the dietary recommendations and 48% reported engagement in more physical activity. Only 13% of the patients who were overweight at the time of the coronary event reached the target of >or=5% weight loss whereas 21% of them presented with a weight gain of 5% or more. CONCLUSION: The prevalence of obesity is still increasing and reaching epidemic proportions in the high priority group of coronary patients all over Europe. Patients' awareness and current management of obesity seems inadequate. More intensive programs focusing on diet and especially physical activity are urgently required.

The efficacy of erythropoietin and its analogues in animal stroke models: a meta-analysis.

BACKGROUND AND PURPOSE: Erythropoietin (EPO) was explored regarding its suitability as a candidate stroke drug in animal experimental studies. We performed a meta-analysis to obtain an overall impression of the efficacy of EPO in published animal experimental stroke studies and for potential guidance of future clinical studies. METHODS: By electronic and manual searches of the literature, we identified studies describing the efficacy of EPO in experimental focal cerebral ischemia. Data on study quality, EPO dose, time of administration, and outcome measured as infarct volume or functional deficit were extracted. Data from all studies were pooled by means of a meta-analysis. RESULTS: Sixteen studies were included in the meta-analysis. When administered after the onset of ischemia, EPO and its analogues reduced infarct size by 32% and improved neurobehavioral deficits significantly. A meta-regression suggests higher doses of EPO to be associated with smaller infarct volumes. When administered earlier than 6 hours EPO was more effective compared to a later treatment initiation. Both hematopoietic and nonhematopoietic EPO analogues showed efficacy in experimental stroke. CONCLUSIONS: In conclusion, this analysis further strengthens confidence in the efficacy of EPO and its analogues in stroke therapy. Nonhematopoietic EPO analogues which are known to have less systemic adverse effects compared to EPO are also promising candidate stroke drugs. Further experimental studies are required that evaluate the safety of a combination of EPO with thrombolysis and whether EPO is also effective in animals with comorbidity.

Meta-analysis of the efficacy of granulocyte-colony stimulating factor in animal models of focal cerebral ischemia.

BACKGROUND AND PURPOSE: Recent reports have described the efficacy of the hematopoietic growth factor granulocyte-colony stimulating factor (G-CSF) in animal stroke models. Early clinical multicenter trials evaluating the effect of G-CSF in acute stroke and pilot clinical trials for the subacute phase are ongoing. To guide further development, a meta-analysis was performed to assess the effects of G-CSF on infarct size and sensorimotor deficits. METHODS: Using electronic and manual searches of the literature, we identified studies describing the efficacy of G-CSF in animal models of focal cerebral ischemia. Two reviewers independently selected studies and extracted data on study quality, G-CSF doses, time of administration, and outcome measured as infarct volume and/or sensorimotor deficit. Data from all studies were pooled by meta-regression analyses. RESULTS: Thirteen studies including 277 animals for infarct size calculation and 258 animals for assessment of sensorimotor deficit met the criteria for inclusion. Overall efficacy of G-CSF regarding infarct size reduction was 42%. Meta-regression analysis revealed a 0.8% (P<0.0001) decrease in infarct size per 1-mug/kg increase in G-CSF dose when applied within the first 6 hours and a 2.1% (P<0.0001) decrease when applied later than 6 hours after induction of ischemia with a significant (P=0.0004) greater infarct size reduction after delayed treatment. Sensorimotor deficits categorized into 3 subgroups improved between 24% and 40%. CONCLUSIONS: Our findings consolidate G-CSF as a drug that both reduces infarct size and enhances functional recovery. These effects are presumably dose dependent. In contrast to most other neuroprotectants, a beneficial outcome may also be achieved when treatment is delayed.

Stroke risk perception among participants of a stroke awareness campaign.

BACKGROUND: Subjective risk factor perception is an important component of the motivation to change unhealthy life styles. While prior studies assessed cardiovascular risk factor knowledge, little is known about determinants of the individual perception of stroke risk. METHODS: Survey by mailed questionnaire among 1483 participants of a prior public stroke campaign in Germany. Participants had been informed about their individual stroke risk based on the Framingham stroke risk score. Stroke risk factor knowledge, perception of lifetime stroke risk and risk factor status were included in the questionnaire, and the determinants of good risk factor knowledge and high stroke risk perception were identified using logistic regression models. RESULTS: Overall stroke risk factor knowledge was good with 67-96% of the participants recognizing established risk factors. The two exceptions were diabetes (recognized by 49%) and myocardial infarction (57%). Knowledge of a specific factor was superior among those affected by it. 13% of all participants considered themselves of having a high stroke risk, 55% indicated a moderate risk. All major risk factors contributed significantly to the perception of being at high stroke risk, but the effects of age, sex and education were non-significant. Poor self-rated health was additionally associated with high individual stroke risk perception. CONCLUSION: Stroke risk factor knowledge was high in this study. The self perception of an increased stroke risk was associated with established risk factors as well as low perception of general health.

Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.

BACKGROUND: Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe. DESIGN: This study was based on a multicentre cross-sectional survey. METHODS: In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries. RESULTS: Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8-26.8 vs 36.7%, 95% CI 29.8-44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46-0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity. CONCLUSIONS: Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.

Trends in advanced breast cancer incidence rates after implementation of a mammography screening program in a German population.

BACKGROUND: Mammography screening programs (MSPs) aim to detect early-stage breast cancers in order to decrease the incidence of advanced-stage breast cancers and to reduce breast cancer mortality. We analyzed the time trends of advanced-stage breast cancer incidence rates in the target population before and after implementation of the MSP in a region of northwestern Germany. METHODS: The MSP in the Münster district started in October 2005. A total of 13,874 women with an incident invasive breast cancer (BC) was identified by the population-based epidemiological cancer registry between 2000 and 2013 in the target group 50-69 years. Multiple imputation methods were used to replace missing data on tumor stages (10.4%). The incidence rates for early-stage (UICC I) and advanced-stage (UICC II+) BC were determined, and Poisson regression analyses were performed to assess trends over time. RESULTS: The incidence rates for UICC I breast cancers increased during the step-up introduction of the MSP and remained elevated thereafter. By contrast, after increasing from 2006 to 2008, the incidence rates of UICC II+ breast cancers decreased to levels below the pre-screening period. Significantly decreasing UICC II+ incidence rates were limited to the age group 55-69 years and reached levels that were significantly lower than incidence rates in the pre-screening period. DISCUSSION: The incidence rates of advanced-stage breast cancers decreased in the age groups from 55 years to the upper age limit for screening eligibility, but not in the adjacent age groups. The findings are consistent with MSP lead time effects and seem to indicate that the MSP lowers advanced-stage breast cancer rates in the target population.

Digital mammography screening in Germany: Impact of age and histological subtype on program sensitivity.

INTRODUCTION: Program sensitivity (PS), i.e., the ratio of screen-detected cancers divided by the sum of screen-detected plus interval cancers, is a major outcome in population-based mammography screening programs (MSP). This study evaluated PS within the digital MSP in Germany focussing on the impact of age and histological subtype. METHODS: Data of 838,579 first-time participants aged 50-69 years who were screened in 2005-2008 were linked with cancer registry data from Germany's most populous state, North Rhine-Westphalia. Invasive breast cancers and ductal carcinomas in situ (DCIS) were detected either at screening or during the 24 month post-screening interval. PS was evaluated with respect to age at screening, in-situ or invasive cancer and histological characteristics. RESULTS: In total, 6767 cancers were detected at screening and 1884 cancers were diagnosed during the post-screening interval. The overall PS amounted to 78.2% and increased from 72.1% at age 50-54 years to 82.4% at age 65-69 years (p for trend <0.0001). PS was higher for non-lobular (79.1%) than lobular carcinomas (72.1%, p < 0.0001). The highest PS was observed in DCIS across all ages (>90%), while PS was lowest among participants aged 50-54 years with invasive breast cancer (67.7%), particularly among those with lobular subtype (62.8%). Interval cancers showed generally more advanced tumour stages. CONCLUSIONS: While overall PS was high, differences across subgroups indicated that youngest screening participants are at higher risk of interval cancer. Age-adapted recall and assessment strategies in younger participants may need to be considered to improve PS in younger women.

Readiness for smoking cessation in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.

BACKGROUND: Readiness for smoking cessation is an important predictor of quit attempts and cessation success. We aimed to investigate the prevalence and correlates of readiness for smoking cessation in coronary heart disease (CHD) patients. DESIGN: The EUROpean Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey is a cross-sectional study conducted in 2006-2007 among CHD patients <80 years of age from 22 European regions. METHODS: Patients were interviewed on average 15 months after hospital admission for an acute coronary event or procedure. Readiness for smoking cessation was assessed using the smoking stages of change (SSC) short form questionnaire. Breath carbon monoxide was measured to validate self-reported non-smoking. RESULTS: Among 2585 patients who were smoking prior to hospital admission, 25.6%, 16.8%, 8.1%, 5.6% and 44.0% were in the precontemplation (no intention to quit), contemplation (thinking of quitting), preparation (planning to quit), action (having quit within six months) and maintenance (having quit more than six months ago) stages, respectively. Significant multivariable correlates of advancement in SSC showed positive associations of older age and attended cardiac rehabilitation and negative associations of severe depressive symptoms, longer smoking duration and environmental tobacco smoke (ETS) exposure. CONCLUSIONS: One-quarter of CHD patients across Europe who were smoking prior to hospitalisation have no intention to quit, and an additional quarter is thinking of quitting or planning to quit. Patients who are younger, do not attend cardiac rehabilitation, have severe depressive symptoms, have been smoking for longer periods of time and are exposed to ETS may need to be specifically targeted in cessation interventions.

Control of main risk factors after ischaemic stroke across Europe: data from the stroke-specific module of the EUROASPIRE III survey.

BACKGROUND: Previous cross-sectional surveys in different European countries within the EUROASPIRE programme demonstrated a high prevalence of modifiable risk factors, unhealthy lifestyles and inadequate drug treatment in coronary heart disease patients. Comparable data for ischaemic stroke patients is lacking. METHODS: A stroke-specific study module was added to the EUROASPIRE III core survey. This cross-sectional multicentre survey included consecutive patients with first-ever ischaemic stroke from four European countries. Data were obtained from medical records, patient interviews and patient examinations within 6-36 months after the stroke event. Control of modifiable risk factors after stroke was evaluated against contemporary European guidelines. RESULTS: A total of 881 patients was recruited. Median age was 66 years, 37.5% were female; average time from the stroke event to interview was 550 days. At the time of the interview, 17.6% of stroke patients smoked cigarettes, 35.5% had a body mass index ≥30 kg/m(2), 62.4% showed elevated blood pressure and 75.7% exhibited elevated LDL cholesterol levels. Antiplatelet drugs or oral anticoagulants were used by 87.2%, antihypertensive medication by 84.4% and statins by 56.8% of stroke patients. Among patients using antihypertensive drugs and lipid-lowering medication at the time of the interview, 34.3% and 34.4%, respectively, achieved target blood pressure and total cholesterol values according to current European guidelines. CONCLUSION: The EUROASPIRE III stroke-specific module shows that secondary prevention and risk factor control in patients after ischaemic stroke need to be improved in four European centres at the time of the study since about half of patients are not achieving risk factor targets defined in European guidelines.

Blood pressure is insufficiently controlled in European patients with established coronary heart disease.

BACKGROUND: Elevated blood pressure is associated with an impaired prognosis in patients with established coronary heart disease. Adequate blood pressure control is therefore of utmost importance. We report on two successive European surveys that evaluated whether the goals given in recommendations on secondary prevention are achieved. METHODS: The first European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE I) survey was conducted during 1995-1996 in 21 hospitals in nine European countries. The second survey (EUROASPIRE II) was conducted during 1999-2000 in 47 hospitals (including 20 hospitals that participated in EUROASPIRE I) in 15 Europeans countries. Consecutive patients (aged < 71 years) were identified from hospital records after coronary artery bypass grafting, percutaneous coronary intervention, myocardial infarction, or myocardial ischaemia. Patients were invited for an interview and examination at least 6 months after hospitalization. During the interview, blood pressure was measured in a standardized fashion. Systolic blood pressure >/= 140 mmHg and/or a diastolic blood pressure >/= 90 mmHg were considered as elevated blood pressure. EUROASPIRE II provides a more comprehensive view on the actual management of patients with established coronary disease. Therefore, we decided to concentrate mainly on the EUROASPIRE II data, and to use EUROASPIRE I for the evaluation of time trends. RESULTS: In EUROASPIRE II, 5556 patients were interviewed, and 51% were diagnosed with elevated blood pressure. Large regional variations in the prevalence of elevated blood pressure were observed, with values ranging from 37 to 64%. Twenty-five per cent (1401) of patients were on a diet to reduce blood pressure, and among these 61% had elevated blood pressure. The prevalence of elevated blood pressure among the 4827 (87%) patients taking blood pressure-lowering medication (which was not necessarily taken as an antihypertensive treatment) was 51%. Patients with elevated blood pressure were more likely to be diabetic, hypercholesterolemic, and obese than normotensive patients. The proportion of patients who reported being aware of their hypertensive status was somewhat higher in EUROASPIRE II than in EUROASPIRE I (71 versus 67%), and the use of blood pressure-lowering medication was intensified (91 versus 85%). However, these changes were not accompanied by a decrease in the prevalence of elevated blood pressure (54 versus 55% in centres that participated in both surveys). CONCLUSION: During 1995-2000 the prevalence of elevated blood pressure in patients with established coronary heart disease remained at an unacceptably high level. Throughout Europe, still about half of coronary patients require more intensive blood pressure management.

Self-rated health and its relation to all-cause and cardiovascular mortality in southern Germany. Results from the MONICA Augsburg cohort study 1984-1995.

PURPOSE: Studies worldwide show that self-rated health (SRH) is a robust predictor of mortality among the elderly. Only few studies have focussed on a middle-aged population and no such study has been reported from Germany. This study examined the association between SRH and mortality in a middle-aged, population based cohort from Germany, using data from the MONICA (Monitoring Trends and Determinants in Cardiovascular Diseases) Augsburg project. METHODS: The cohort comprises 1521 men and 1498 women aged 35-64; they were followed over 11 years from 1984-1995. Participants provided extensive data on medical conditions and cardiovascular risk factors through interviews and examinations. SRH was assessed globally and in comparison to those of the same age. We estimated relative hazards for mortality from all-causes and cardiovascular disease according to self-ratings of health. RESULTS: Among males the adjusted hazards rate ratio (HRR) of mortality from all-causes was 1.5 (95% CI 1.1-2.2) for combined fair/poor perceived health compared with good/excellent health. Women with fair/poor ratings had no increased risk of dying (HRR = 1.1, 95% CI 0.7-1.9). Men who perceived worse health than persons of the same age showed an adjusted HRR of 1.7 (95% CI 1.0-2.9) as compared to those perceiving better health; in women the adjusted HRR was 1.9 (95% CI 1.0-3.7). The adjusted hazards for dying from cardiovascular diseases in men were 1.3 (95% CI 0.8-2.1) for those perceiving fair/poor and 1.7 (95% CI 0.7-3.7) for those perceiving worse health. CONCLUSIONS: Self-rated health was a predictor of mortality in a middle-aged German population and contains information that is not entirely reflected in underlying medical conditions and risk factors. Self-assessments of health in comparison to individuals of the same age were stronger and more consistently associated with mortality. Global self-ratings of health and self-ratings in comparison to those of the same age may measure slightly different dimensions and the effect of self-rated health may differ among men and women.

Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy.

CONTEXT: Data are limited regarding the risks and benefits of thrombolytic therapy for acute ischemic stroke outside of clinical trials. OBJECTIVE: To investigate predictors of in-hospital mortality in patients with ischemic stroke treated with intravenous tissue plasminogen activator (tPA) within a pooled analysis of large German stroke registers. DESIGN AND SETTING: Prospective, observational cohort study conducted at 225 community and academic hospitals throughout Germany cooperating within the German Stroke Registers Study Group. PATIENTS: A total of 1658 patients with acute ischemic stroke who were admitted to study hospitals between 2000 and 2002 and were treated with tPA. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: One hundred sixty-six patients (10%) who received tPA died during hospitalization, with 67.5% of these deaths occurring within 7 days. Factors predicting in-hospital death after tPA use were older age (for each 10-year increment in age, adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.9) and altered level of consciousness (adjusted OR, 3.4; 95% CI, 2.4-4.7). The overall rate of symptomatic intracranial hemorrhage was 7.1% and increased with age. One or more serious complications was observed in 27.2% of all patients and in 83.9% of patients who died after tPA treatment. An inverse relation between the number of patients treated with tPA in the respective hospital and the risk of in-hospital death was observed (adjusted OR, 0.97; 95% CI, 0.96-0.99 for each additional patient treated with tPA per year). CONCLUSION: In patients with ischemic stroke who are treated with tPA, disturbances of consciousness and increasing age are associated with increased in-hospital mortality.