Obstructive sleep apnea is associated with cancer mortality in younger patients

ObjectiveThe association between obstructive sleep apnea (OSA) and cancer mortality has scarcely been studied. The objective of this study was to investigate whether OSA is associated with increased cancer mortality in a large cohort of patients with OSA suspicion.MethodsThis was a multicenter study in consecutive patients investigated for suspected OSA. OSA severity was measured by the apnea–hypopnea index (AHI) and the hypoxemia index (% night-time spent with oxygen saturation <90%, TSat₉₀). The association between OSA severity and cancer mortality was assessed using Cox’s proportional regression analyses after adjusting for relevant confounders.ResultsIn all, 5427 patients with median follow-up of 4.5 years were included. Of these, 527 (9.7%) were diagnosed with cancer. Log-transformed TSat₉₀ was independently associated with increased cancer mortality in the entire cohort (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.03–1.42), as well as in the group of patients with cancer (HR, 1.19; 95% CI, 1.02–1.41). The closest association was shown in patients <65 years in both the AHI (continuous log-transformed AHI: HR, 1.87; 95% CI, 1.1–3.2; upper vs lower AHI tertile: HR, 3.98; 95% CI, 1.14–3.64) and the TSat₉₀ (continuous log-transformed TSat₉₀: HR, 1.73; 95% CI, 1.23–2.4; upper vs lower TSat₉₀ tertile: HR, 14.4; 95% CI, 1.85–111.6).ConclusionsOSA severity was associated with increased cancer mortality, particularly in patients aged <65 years.     

Causes of death in patients with multiple sclerosis and matched referent subjects: a population‐based cohort study

Background and purpose: Multiple sclerosis (MS) has been associated with increased mortality rates. However, influence of lifestyle parameters remains unknown, and inconsistencies exist regarding findings for causes of death. Methods: We conducted a population‐based cohort study using the General Practice Research Database, Hospital Episode Statistics, and national death certificates (January 2001 through March 2008). To each patient with MS (n = 1270), up to six referent subjects without MS were matched by age, gender, and practice. Cox proportional hazards models were used to estimate mortality rate ratios (HRs). Results: Patients with MS had a 3.5‐fold increased mortality rate for all‐cause mortality, compared with referent subjects (HR 3.51, 95% CI 2.63–4.69). The rate further increased amongst current smokers (HR 6.72, 95% CI 4.16–10.87) (but not in ex‐smokers) and subjects with a body mass index of <20 kg/m² (HR 6.67, 95% CI 3.50–12.73). The HR was highest for infectious/respiratory‐related deaths (HR 7.69, 95% CI 4.92–12.02) and was significantly increased for deaths related to cardiovascular diseases (2.4‐fold) and cancer (1.9‐fold), but not for accidents and suicide related deaths. Conclusion: British patients with MS have a 3.5‐fold increased mortality rate compared with the general population. Smoking and respiratory diseases are major (potentially preventable) factors related to increased mortality rate amongst patients with MS.     

Cancer risk in people with epilepsy using valproate-sodium

Singh G, Bell GS, Hernáiz‐Driever P, Sander JW. Cancer risk in people with epilepsy using valproate‐sodium.
Acta Neurol Scand: 2012: 125: 234–240.
© 2011 John Wiley & Sons A/S. Objectives – Based on reports of antitumour properties of sodium‐valproate, we hypothesised that valproate has a cancer‐protective effect in people with epilepsy. We aimed to determine cancer risk in people with epilepsy using sodium‐valproate. Materials and methods – Continuous data for 2997 people with epilepsy who had been prescribed valproate for at least two years, and for 11,988 unexposed people were provided by the UK General Practice Research Database. Hazard ratios (HRs) for all cancers and individual cancers between the exposed and unexposed groups, with smoking and alcohol consumption and age as covariates, were calculated using the Cox proportional hazards method. Results – Exposure to valproate had no influence on the incidence of the composite of all cancers [HR: 1.19, 95% CI: 0.97–1.47, P = 0.10]; there was, however, a significant excess of colon cancers [HR: 3.95, 95% CI: 1.97–7.92, P = 0.001] and a trend towards an excess of prostate neoplasms [HR: 2.15, 95% CI: 0.92–5.02, P = 0.08] and in addition, a trend towards reduced incidence of breast cancer [HR: 0.40, 95% CI: 0.14–1.30, P = 0.08] in the exposed group. Conclusions – The lack of an inverse association between valproate use and hazard ratios for all cancers and several individual cancer sites does not lend support for a cancer‐protective role for valproate.     

Nephrotic Syndrome is Associated with Increased Risk of Ischemic Stroke

Background: To determine if the nephrotic syndrome (NS) is an independent risk factor of ischemic stroke. Methods: This is a retrospective nationwide cohort study through an analysis of the National Health Insurance Research Database in Taiwan. To evaluate the risk of stroke, the corresponding controls were selected at a 4:1 ratio in the number of subjects, and they were matched with the study group in age, gender, Charlson comorbidity index (CCI), and index date. Results: From a total of 16,245 surveyed subjects, ischemic stroke occurred in 1235 (7.6%) and hemorrhagic stroke in 129 (.74%) of them. The incidence of ischemic stroke was significantly higher in patients with NS (n = 3496) compared to control patients without NS (n = 13,984) (9.92 versus 7.10, per 1000 person-year, P < .001). In the multivariate analysis, the overall adjusted hazard ratio (aHR) of stroke in NS patients was 1.37 (95% CI, 1.21-1.54, P < .001). The risk factors of ischemic stroke were NS (aHR, 1.38 [95% confidence interval {CI}, 1.21-1.57]; P < .001), age greater than 45 years (aHR, 7.98 [95% CI, 6.47-9.48]; P < .001), male gender (aHR, 1.23 [95% CI, 1.10-1.38]; P < .001), CCI greater than or equal to 1 (aHR ≥ 1.25 in different CCI score groups, all at P ≤ .003), ischemic heart disease (aHR, 1.95 [95% CI, 1.67-2.29]; P < .001), heart failure (HR, 1.77 [95% CI, 1.30-2.42]; P < .001). Risk factors of hemorrhagic stroke were those aged greater than 45 years, or with systemic lupus erythematosus, but not NS. Conclusions: We provided the first evidence that patients with NS had an increased risk of ischemic stroke.     

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10 ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study

Aim

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development after ICH.

Background and purpose

Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain.

Methods

We retrospectively included patients with spontaneous ICH treated in our hospital in 2006–2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation.

Results

Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7 months after ICH (range 1–132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14–2.37]; p = 0.008), ICH volume > 10 ml (multivariable HR 1.91 [95% CI 1.33–2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20–2.75]; p = 0.005). Patients with cortical ICH > 10 ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08–0.84]; p = 0.025).

Conclusions

Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.     

Oligoclonal bands predict multiple sclerosis in children with optic neuritis

We retrospectively evaluated predictors of conversion to multiple sclerosis (MS) in 357 children with isolated optic neuritis (ON) as a first demyelinating event who had a median follow‐up of 4.0 years. Multiple Cox proportional‐hazards regressions revealed abnormal cranial magnet resonance imaging (cMRI; hazard ratio [HR] = 5.94, 95% confidence interval [CI] = 3.39–10.39, p < 0.001), presence of cerebrospinal fluid immunoglobulin G oligoclonal bands (OCB; HR = 3.69, 95% CI = 2.32–5.86, p < 0.001), and age (HR = 1.08 per year of age, 95% CI = 1.02–1.13, p = 0.003) as independent predictors of conversion, whereas sex and laterality (unilateral vs bilateral) had no influence. Combined cMRI and OCB positivity indicated a 26.84‐fold higher HR for developing MS compared to double negativity (95% CI = 12.26−58.74, p < 0.001). Accordingly, cerebrospinal fluid analysis may supplement cMRI to determine the risk of MS in children with isolated ON. Ann Neurol 2015;77:1076–1082     

High mortality from Guillain‐Barré syndrome in Bangladesh

Although Guillain‐Barré syndrome (GBS) has higher incidence and poor outcome in Bangladesh, mortality from GBS in Bangladesh has never been explored before. We sought to explore the frequency, timing, and risk factors for deaths from GBS in Bangladesh. We conducted a prospective study on 407 GBS patients who were admitted to Dhaka Medical College Hospital, Dhaka, Bangladesh from 2010 to 2013. We compared deceased and alive patients to identify risk factors. Cox regression model was used to adjust for confounders. Of the 407 GBS patients, 50 (12%) died, with the median time interval between the onset of weakness and death of 18 days. Among the fatal cases, 24 (48%) were ≥40 years, 36 (72%) had a Medical Research Council sum score ≤20 at entry, 33 (66%) had a progressive phase <8 days, and 27 (54%) required ventilation support. Ten patients (20%) died due to unavailability of ventilator. The strongest risk factor for deaths was lack of ventilator support when it was required (HR: 11.9; 95% confidence interval [CI]: 4.6–30.7). Other risk factors for death included age ≥40 years (HR: 5.9; 95% CI: 2.1–16.7), mechanical ventilation (HR: 2.3; 95% CI: 1.02–5.2), longer progressive phase (>8 days) (HR: 2.06; 95% CI: 1.1–3.8), autonomic dysfunction (HR: 1.9; 95% CI: 1.05–3.6), and bulbar nerve involvement (HR: 5.4; 95% CI: 1.5–19.2). In Bangladesh, GBS is associated with higher mortality rates, which is related to lack of ventilator support, disease severity, longer progressive phase of the disease, autonomic dysfunction, and involvement of the bulbar nerves.     

Gastrointestinal biopsy of normal mucosa or nonspecific inflammation and risk of neurodegenerative disease: Nationwide matched cohort study

Background and purpose

Evidence has accumulated to support the early involvement of altered gastrointestinal (GI) function in neurodegenerative disease. However, risk of Alzheimer disease (AD) and Parkinson disease (PD) among individuals with a GI biopsy of normal mucosa or nonspecific inflammation is unknown.

Methods

This matched cohort study included all individuals in Sweden with a GI biopsy of normal mucosa (n = 480,346) or nonspecific inflammation (n = 655,937) during 1965–2016 (exposed group) as well as their individually matched population references and unexposed full siblings. A flexible parametric model and stratified Cox model were used to estimate hazard ratio (HR) and its 95% confidence interval (CI).

Results

Individuals with normal mucosa or nonspecific inflammation had a higher risk of AD and PD during the 20 years after biopsy. Compared with the population references, individuals with normal mucosa had an increased risk of AD (incidence rate [IR] difference = 13.53 per 100,000 person-years, HR [95% CI] = 1.15 [1.11–1.20]) and PD (IR difference = 6.72, HR [95% CI] = 1.16 [1.10–1.23]). Elevated risk was also observed for nonspecific inflammation regarding AD (IR difference = 13.28, HR [95% CI] = 1.11 [1.08–1.14]) and PD (IR difference = 6.83, HR [95% CI] = 1.10 [1.06–1.14]). Similar results were observed in subgroup and sensitivity analyses and when comparing with their unexposed siblings.

Conclusions

Individuals with a GI biopsy of normal mucosa or nonspecific inflammation had an increased risk of AD and PD. This adds new evidence of the early involvement of GI dysfunction in neurodegenerative disease.     

Effect of statin treatment on three-month outcomes in patients with stroke-associated infection: a prospective cohort study

Background and purpose: Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that statins reduce infection‐associated complications. The purpose of this study was to examine the influence of statin treatment on mortality and functional outcomes in patients with stroke‐associated infection. Methods: In this prospective observational cohort study, 514 patients with acute ischaemic stroke or transient ischaemic attack (mean age, 74 ± 11 years; men, 48%) with infection occurring in the first 7 days after admission were included. We examined the effect of in‐hospital statin treatment on mortality and favorable functional outcome (modified Rankin Scale score ≤2) at 3 months follow‐up. Results: Infection occurred at 0.93 ± 1.49 days after admission. All patients had not received statin treatment prior to admission, and 121 patients (24%) received statin at 1.71 ± 1.28 days after admission. Follow‐up at 3 months was completed for 511 patients (99%). National Institutes of Health Stroke Scale score and Charlson index were the most important independent predictors of mortality and functional outcome. Univariate [hazard ratio (HR), 0.82; 95% confidence intervals (CI), 0.47–1.42] and multivariate (HR, 1.68; 95% CI, 0.79–3.56) Cox regression analysis showed that statin did not significantly decrease the morality. In propensity analysis, statin treatment still had no significant association with mortality (HR, 1.54; 95% CI, 0.68–3.47) in the multivariate analyses after adjusting for age, sex, and propensity score. Conclusions: Statin use was not associated with a better functional outcome or survival in patients with stroke‐associated infection.     

Safety of sertindole versus risperidone in schizophrenia: principal results of the sertindole cohort prospective study (SCoP)

Thomas SHL, Drici MD, Hall GC, Crocq MA, Everitt B, Lader MH, Le Jeunne C, Naber D, Priori S, Sturkenboom M, Thibaut F, Peuskens J, Mittoux A, Tanghøj P, Toumi M, Moore ND, Mann RD. Safety of sertindole versus risperidone in schizophrenia: principal results of the sertindole cohort prospective study (SCoP) Objective: To explore whether sertindole increases all‐cause mortality or cardiac events requiring hospitalization, compared with risperidone. Method: Multinational randomized, open‐label, parallel‐group study, with blinded classification of outcomes, in 9858 patients with schizophrenia. Results: After 14147 person‐years, there was no effect of treatment on overall mortality (sertindole 64, risperidone 61 deaths, Hazard Ratio (HR) = 1.12 (90% CI: 0.83, 1.50)) or cardiac events requiring hospitalization [sertindole 10, risperidone 6, HR = 1.73 (95% CI: 0.63, 4.78)]: Of these, four were considered arrhythmia‐related (three sertindole, one risperidone). Cardiac mortality was higher with sertindole (Independent Safety Committee (ISC): 31 vs. 12, HR=2.84 (95% CI: 1.45, 5.55), P = 0.0022; Investigators 17 vs. 8, HR=2.13 (95% CI: 0.91, 4.98), P = 0.081). There was no significant difference in completed suicide, but fewer sertindole recipients attempted suicide (ISC: 68 vs. 78, HR=0.93 (95% CI: 0.66, 1.29), P = 0.65; Investigators: 43 vs. 65, HR=0.67 (95% CI: 0.45, 0.99), P = 0.044). Conclusion: Sertindole did not increase all‐cause mortality, but cardiac mortality was higher and suicide attempts may be lower with sertindole.     

Guideline-Concordant Antipsychotic Use and Mortality in Schizophrenia

Objective: To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality. Methods: We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality. Results: Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57–0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58–0.98) and 0.84 (95% CI 0.58–1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10–3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55–0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93–0.98). Conclusions: Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.Key words: schizophrenia, antipsychotic continuity, mortality     

Relationship of initial glucose level and all‐cause death in patients with ischaemic stroke: the roles of diabetes mellitus and glycated hemoglobin level

Background and purpose: Previous studies demonstrated that post‐stroke hyperglycemia was associated with poor outcome in non‐diabetic patients. However, evidence was inconclusive amongst patients with diabetes. The aim of this study was to evaluate the relationship between initial glucose levels and mortality amongst patients with acute ischaemic stroke, and further, to assess whether the association varied by diabetes mellitus and glycated hemoglobin (HbA_1c) levels. Methods: Data were collected from the medical records of 1277 first‐ever stroke patients admitted to the emergency room between January 1, 2008 and June 30, 2009. Cox regression analysis was performed to assess the relationship between initial glucose level and mortality. Results: Compared with the lowest quartile of initial glucose level, a significant association with all‐cause death [hazard ratio (HR), 2.18; 95% CI, 1.36–3.48] and cardiovascular death (HR, 1.91; 95% CI, 1.01–3.61) was seen in the highest quartile. In non‐diabetic subgroup, those patients within the highest quartile of initial glucose level had a 3.29‐fold relative risks (RR) [95% confidence interval (CI), 1.62–6.68] for all‐cause and a 2.54‐fold RR (95% CI, 1.43–8.77) for cardiovascular death compared with those within the lowest quartile. However, the association between initial glucose levels and the risk of death was not significant amongst those with diabetes (P for interaction = 0.01). In addition, the risk amongst patients with diabetes varied by the HbA_1c levels. Conclusions: A significant association was confirmed between initial glucose level and mortality in non‐diabetic ischaemic stroke patients. The possible relationship between initial glucose level, HbA_1c level, and mortality amongst ischaemic stroke patients with diabetes warrants further research.     

High‐Sensitivity C‐Reactive Protein is a Strong Risk Factor for Death after Acute Ischemic Stroke among Chinese

Background and purpose: Elevated plasma C‐reactive protein (CRP) has been suggested as a risk factor for ischemic stroke (IS) and coronary ischemic disease. Evidence has shown that high‐sensitivity CRP (hs‐CRP) is related to a worsening prognosis after IS, but hs‐CRP was rare in a large‐sample study in a Chinese population. We investigated the associations between hs‐CRP and outcome of Chinese patients after acute IS. Methods: Seven hundred and forty‐one consecutive acute IS patients (74.9% male, mean age 60.9 years), with baseline characteristics and hs‐CRP measured within 24 h after hospitalization, were admitted in this study. We also prospectively followed up for clinical outcome and death 3 months after disease onset. hs‐CRP was divided into two categories: hs‐CRP >3 mg/L and hs‐CRP ≤3 mg/L. Survival analysis using multivariable Cox regression was performed to analyze the association between hs‐CRP and stroke outcomes after adjusting for potential confounding factors. Results: Compared with low hs‐CRP, patients with high hs‐CRP (>3 mg/L) had a significantly higher rate of all‐cause death (0.71% vs. 10.00%; P < 0.001) at 3 months after stroke onset. High hs‐CRP was an independent risk factor for all‐cause death (HR, 6.48; 95% CI, 1.41 to 29.8; P= 0.016), as well as history of atrial fibrillation (HR, 5.24; 95% CI, 1.83 to 15.0; P= 0.002), no statin therapy during hospitalization (HR, 4.56; 95% CI, 2.18 to 9.55; P < 0.001), high homocysteine (>15.1 mmol/L) (HR, 2.66; 95% CI, 1.26 to 5.60; P= 0.01); fasting glucose (>6.1 mmol/L) (HR, 9.14; 95% CI, 3.34 to 25.0; P < 0.001), NIHSS at admission (HR, 2.35; 95% CI, 1.35 to 4.09; P= 0.003) and history of coronary heart disease (CHD) (HR, 2.34; 95% CI, 1.06 to 5.17; P= 0.035). Kaplan–Meier survival curves showed a higher risk of death for patients with hs‐CRP >3 mg/L (P= 0.016). Conclusion: Elevated plasma hs‐CRP independently predicted risk of all‐cause death within 3 months after acute IS in Chinese patients.     

Mortality by clinical characteristics in a tertiary care cohort of adult patients with chronic epilepsy

The authors evaluated the contribution of various clinical characteristics to mortality risk and underlying causes of death among all adult patients with epilepsy seen at the Department of Neurology, Oulu University Hospital in Finland during 1996 and 1997. Hazard ratios (HRs) for mortality in 1998–2006 relative to a population‐based reference cohort were estimated using Cox modeling, with adjustment for age and gender. The HR for total mortality was 2.66 (95% confidence interval [CI] 2.09–3.39). Infectious etiology of epilepsy (HR 5.77, 95% CI 2.52–13.2) and a seizure frequency of ≥1 per month (HR 4.42, 95% CI 3.00–6.52) related to high risks of death. Cancer (21%), ischemic heart disease (15%), and accidents (12%) caused most of the potential years of life lost. Despite recent advances in treatment of epilepsy and improved seizure control, chronic epilepsy still carries a substantially increased risk of death.     

Associations of sleep duration and quality with incident cardiovascular disease,cancer, and mortality: a prospective cohort study of 407,500 UK biobank participants

ObjectiveFew studies have investigated the associations of sleep duration and sleep quality with incident cardiovascular diseases (CVDs), cancer, and mortality in the same large population. This study aimed at estimating the independent risk factors of long or short sleep durations and several typical characteristics of poor sleep quality for incident CVDs, cancer, and mortality.MethodsIn this prospective cohort study, 407 500 individuals were enrolled. Cox proportional hazards models were used to calculate the adjusted hazard ratios and 95% confidence intervals (HR, 95%CI) of associations of sleep duration and quality with incident CVDs, cancer, and mortality.ResultsCompared with the sleep duration of 7 h, sleep duration of ≤5 h and ≥9 h were both associated with higher risk of all-cause mortality (HR = 1.25, 95% CI: 1.16–1.34 and HR = 1.30, 95% CI: 1.22–1.38, respectively), CVD mortality (HR = 1.27, 95% CI: 1.09–1.49 and HR = 1.32, 95% CI: 1.16–1.50, respectively), and CVD incidence (HR = 1.23, 95% CI: 1.16–1.31 and HR = 1.08, 95% CI: 1.02–1.15, respectively). Additionally, long sleep duration (≥9 h) was associated with a higher risk of cancer mortality (HR = 1.19, 95% CI: 1.10–1.30) and cancer incidence (HR = 1.08, 95% CI: 1.04–1.12). Moreover, CVD incidence was significantly associated with snoring, insomnia and narcolepsy, increasing the risk by 7%, 26%, and 20%, respectively.ConclusionLong sleep durations may substantially increase the risk of mortality and morbidity. Snoring, insomnia, and narcolepsy were independent risk factors for incident CVD.     

Does adherence to epilepsy quality measures correlate with reduced epilepsy‐related adverse hospitalizations? A retrospective experience

In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy‐related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD‐9 code 345.1‐9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176–0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016–1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377–4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721–9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258–3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332–5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.     

Alcohol consumption in the elderly and risk of dementia related death - a Norwegian prospective study with a 17-year follow-up

Purpose: The aim of this study was to determine the association between alcohol intake and risk of dementia related death, taking into account relevant confounding and mediating factors. Materials and Methods: Data was obtained from a Norwegian prospective study with a 17-year follow-up. The study population comprised 25,635 participants aged between 60 and 80 years at the time of examination from the Cohort of Norway (CONOR). Cox regression was used to investigate the association between alcohol use and dementia related death. Results: Nearly half (12,139) of the study population died during follow-up, of which 1,224 had a diagnosis of dementia on their death certificate. The risk of dementia related death was significantly higher among abstainers than among individuals that drank alcohol once per month (HR = 1.33, 95% CI = 1.14–1.56, p < 0.001, in a fully adjusted model). Respondents with missing information regarding alcohol consumption (representing 5% of the study population) had the highest risk of dementia related death (HR = 1.60, 95% CI = 1.28–2.00, p < 0.001) and also significantly higher mortality rates due to alcohol-related causes (HR = 1.41, 95% CI = 1.03–1.93, p = 0.031) and other causes (HR = 1.32, 95% CI = 1.21–1.43, p < 0.001), all compared to those drinking alcohol no more than once per month. Conclusion: These findings suggest that the risk of dementia related death is significantly higher among elderly abstainers than among those who drink alcohol, after adjusting for relevant confounders. However, care should be taken in interpretation of data due to missing information on drinking frequency, as this missing-group might have a large share of the heavy drinkers in the study cohort.     

Gender differences in bipolar disorder type I and II

Objective: We investigated gender differences in bipolar disorder (BD) type I and II in a representative cohort of secondary care psychiatric in‐ and out‐patients. Method: In the prospective, naturalistic Jorvi Bipolar Study of 191 secondary care psychiatric in‐ and out‐patients, 160 patients (85.1%) could be followed up for 18 months with a life chart. Results: After adjusting for confounders, no marked differences in illness‐related characteristics were found. However, female patients with BD had more lifetime comorbid eating disorders (P < 0.001, OR = 5.99, 95% CI 2.12–16.93) but less substance use disorders (P < 0.001, OR = 0.29, 95% CI 0.16–0.56) than males. Median time to recurrence after remission was 3.1 months longer among men than women, female gender carrying a higher hazard of recurrence (P = 0.006, HR = 2.00, 95% CI 1.22–3.27). Conclusion: Men and women with type I and II BD have fairly similar illness‐related clinical characteristics, but their profile of comorbid disorders may differ significantly, particularly regarding substance use and eating disorders. In medium‐term follow‐up, females appear to have a higher hazard of recurrence than males.     

10‐Year trends in the treatment and outcomes of patients with first‐episode schizophrenia

Nielsen J, le Quach P, Emborg C, Foldager L, Correll CU. 10‐Year trends in the treatment and outcomes of patients with first‐episode schizophrenia. Objective: The first episode of schizophrenia is a critical period for illness course and outcomes. We aimed to investigate treatments and outcomes during the first year after the diagnosis of schizophrenia. Method: Pharmacoepidemiologic inception cohort study of all newly diagnosed patients with schizophrenia in Denmark (n = 13 600) 1996–2005. Results: From 1996 to 2005, the mean age at first diagnosis decreased significantly (29.2–26.1 years), more patients received antipsychotics (67.2–80.7%, annual OR = 1.07, CI: 1.06–1.09, P < 0.001) and antipsychotic polypharmacy for >4 months (16.7–37.1%, OR = 1.14, CI: 1.12–1.57, P < 0.001). The antipsychotic defined daily dosage (DDD) doubled (150–332 DDD, P < 0.001), use of antidepressants (24.3–40.6%, P < 0.001). Bed days [89.9 days (CI: 81.8–98.8) to 71.8 days, CI: 63.7–80.8, P < 0.0001] decreased, whereas outpatient contacts [10.2 (CI: 9.5–11.0) to 21.4 (CI: 19.9–21.0), P < 0.0001] doubled. Conclusion: Between 1996 and 2005, there was an earlier recognition of schizophrenia, intensified outpatient treatment, increased use and dosing of antipsychotics and antidepressants, but also more antipsychotic polypharmacy.     

The role of routine echocardiography in unselected patients with cerebrovascular ischaemic events

Background: Cardiac embolism is an important etiology of cerebrovascular ischaemic events (CIE). Echocardiography is routinely performed in patients with CIE despite guidelines recommending restriction of echocardiography to patients with clinically suspected cardioembolism. Objective: The aim of this study was to examine the therapeutic impact and prognostic role of echocardiographic findings in an unselected population suffering from CIE. Methods: Between November 2006 and November 2007, 319 patients with CIE underwent evaluation by transthoracic echocardiography (TTE) and in addition by transesophageal echocardiography (TEE) if deemed mandatory (n = 49). The combined clinical end‐point included death or recurrent CIE, occurring during a follow‐up period of 3 and 12 months, respectively. Results: After 3 months of follow‐up, the combined end‐point was noted in 30 (9%) and after 12 months in 43 (13%) patients. In multivariate analysis, atrial fibrillation (AF) (HR 2.12, 95% CI 1.38–3.25; P < 0.001) and coronary artery disease (CAD: HR 1.85, 95% CI 1.21–2.81; P = 0.004) were predictors of events occurring during short‐term follow‐up. After 1 year of follow‐up, AF (HR 1.67, 95% CI 1.19–2.32; P = 0.003) and CAD (HR 1.5, 95% CI 1.09–2.06; P = 0.01) were associated with the combined end‐point. Echocardiographic parameters assessed at study entry were not independently related to an adverse outcome. Conclusion: Whereas AF and CAD appear to increase the risk of events after suffering from CIE, echocardiographic findings were not independently associated with the combined end‐point of recurrent CIE or death.