Spontaneous coronary artery dissection: etiology and recurrence

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly appreciated cause of acute myocardial infarction (AMI) and sudden cardiac death most often affecting young to middle-aged women with few conventional cardiovascular risk factors.

Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 04/30/2019). Authors review the key clinical features of SCAD and highlight what is known regarding its pathophysiology and associated factors. The relationship between SCAD and other systemic vasculopathies, notably fibromuscular dysplasia (FMD) is also discussed. Authors also mention the management of acute SCAD along with considerations for long term follow-up such as chest pain syndrome, extracoronary vasculopathy screening, and recurrent SCAD.

Expert opinion: Our understanding regarding the association of SCAD and other arteriopathies such as FMD is anticipated to grow. In addition, progress is likely to be made in our efforts to predict recurrent SCAD risk and define potential preventative strategies, possibly through the incorporation of adjunctive imaging.     

The clinical toxicology of sodium hypochlorite

Introduction: Sodium hypochlorite is used as a bleaching and disinfecting agent and is commonly found in household bleach.

Objective: The objective is to review critically the epidemiology, mechanisms of toxicity, clinical features, diagnosis, and management of hypochlorite poisoning.

Methods: PubMed was searched from January 1950 to June 2018 using the terms “Hypochlorite”, “Sodium Hypochlorite”, “Sodium Oxychloride”, “Hypochlorous Acid”, “Bleach”, “Chlorine Bleach”, in combination with the keywords “poisoning”, “poison”, “toxicity”, “ingestion”, “adverse effects”, “overdose”, and “intoxication”. In addition, bibliographies of identified articles were screened for additional relevant studies including non-indexed reports. Non-peer-reviewed sources were also included. These searches produced 110 citations which were considered relevant.

Epidemiology: There is limited information regarding statistical trends on world-wide poisoning from sodium hypochlorite. In the United States of America, poison control center data have shown that enquiries regarding hypochlorite bleaches have ranged from 43,000 to 46,000 per year over the period 2012–2016.

Mechanisms of toxicity: Hypochlorite’s potential to cause toxicity is related to its oxidizing capacity and the pH of the solution. Toxicity arises from its corrosive activity upon contact with mucous membranes and skin.

Features following ingestion: While small accidental ingestions are very unlikely to cause clinically significant toxicity, large ingestions may cause corrosive gastrointestinal injury and systemic effects, including metabolic acidosis, hypernatremia, and hyperchloremia.

Features following dental exposure: Hypochlorite is used extensively by dentists for cleaning root canals and is safe if the solution remains within the root canal. Extrusions into the periapical area can result in severe pain with localized large and diffuse swelling and hemorrhage.

Features following skin exposure: Prolonged or extensive exposure may cause skin irritation and damage to the skin or dermal hypersensitivity. Such exposures can result in either immediate or delayed-type skin reactions. High concentration solutions have caused severe chemical skin burns.

Features following inhalation: Although there are only limited data, inhalation of hypochlorite alone is likely to lead to no more than mild irritation of the upper airways.

Features following ocular exposure: Corneal injuries from ocular exposure are generally mild with burning discomfort and superficial disturbance of the corneal epithelium with recovery within 1 or 2 days. With higher concentration solutions, severe eye irritation can occur.

Diagnosis: The diagnosis can typically be made on the basis of a careful history, including details of the specific product used, its hypochlorite concentration, and the amount involved. As hypochlorite bleach produces a characteristic smell of chlorine, this may provide a diagnostic clue. In severe cases, corrosive injury is suggested on presentation because of hypersalivation, difficulty swallowing, retrosternal pain or hematemesis.

Management: Symptom-directed supportive care is the mainstay of management. Gastrointestinal decontamination is not beneficial. Local corrosive injury is the major focus of treatment in severe cases. Fiberoptic endoscopy and CT thorax/abdomen are complimentary and have been shown to be useful in corrosive injuries in assessing the severity of injury, risk of mortality and risk of subsequent stricture formation and should be performed as soon as possible after ingestion. Dental periapical extrusion injuries should be left open for some minutes to allow bleeding through the tooth and to limit hematoma development in tissue spaces. Once the bleeding has ceased, the canal can be dressed with non-setting calcium hydroxide and sealed coronally.

Conclusions: Accidental ingestion of household bleach is not normally of clinical significance. However, those who ingest a large amount of a dilute formulation or a high concentration preparation can develop severe, and rarely fatal, corrosive injury so prompt supportive care is essential as there is no specific antidote. Treatment primarily consists of symptom-directed supportive care.     

Mechanisms of toxic cardiomyopathy

Background: Dilated cardiomyopathy is a frequent disease responsible for 40–50% of cases of heart failure. Idiopathic cardiomyopathy is a primary disorder often related to familial/genetic predisposition. Before the diagnosis of idiopathic cardiomyopathy is made, clinicians must not only rule out viral and immune causes, but also toxic causes such as drugs, environmental agents, illicit substances and natural toxins.

Objective: The objective of this review is to present recent data on the mechanisms underlying toxic cardiomyopathy.

Methods: The US National Library of Medicine Pubmed database was searched from 1980 to December 2017 utilizing the combinations of the search terms “toxic cardiomyopathy”, “drugs”, “anticancer drugs”, “azidothymidine”, “rosiglitazone”, “carbon monoxide”, “alcohol”, “illicit drugs”, “cocaine”, “metamfetamine”, “metals”, “venom”. A total of 339 articles were screened and papers that dealt with the pathophysiology of toxic cardiomyopathy, either in animal models or in clinical practice were selected, with preference being given to more recently published papers, which left 92 articles.

Anticancer drugs: The mechanisms of anthracycline-induced cardiotoxicity are primarily related to their mechanisms of action as anticancer drugs, mainly the inhibition of topoisomerase II β and DNA cleavage. Additional metabolic or oxidative stress factors may play a part, together with interference with iron metabolism. The more recent drugs, trastuzumab and imatinib, also influence stress pathways.

Antiretroviral agents: Azidothymidine is cardiotoxic as a result of mitochondrial toxicity. In addition to energy depletion, azidothymidine also increases the production of mitochondrial reactive oxygen species (ROS).

Antidiabetic drugs: The cardiotoxicity of thiazolidinedione antidiabetic drugs is still under investigation, though interference with mitochondrial respiration or oxidative stress is suspected.

Cocaine: Among the multiple mechanisms involved in cocaine-related cardiotoxicity, excessive sympathetic stimulation with increased myocardial oxygen consumption is well documented in the acute form of left ventricular dysfunction. As for cocaine-related cardiomyopathy, the role of apoptosis and ROS is under investigation.

Ethanol: The aetiology of ethanol-related cardiotoxicity is multifactorial, with individual susceptibility being important. It involves apoptosis, alterations of the excitation–contraction coupling in cardiac myocytes, structural and functional alterations of the mitochondria and sarcoplasmic reticulum, changes in cytosolic calcium flows, changes in calcium sensitivity of myofilaments, alterations of mitochondrial oxidation, deregulation of protein synthesis, decrease of contractile proteins and disproportion between the different types of myofibrils, changes in the regulation of myosin ATPase, up-regulation of the L-type calcium channels, increase of oxidative stress, and induction of ANP and p21 mRNA expression in ventricular myocardium.

Metamfetamines: Catecholamine-mediated toxicity is the probable cause, with a possible role for genetic susceptibility.

Carbon monoxide: In addition to hypoxic injury, carbon monoxide is also directly toxic to the mitochondria, with impairment of mitochondrial respiratory chain at the cytochrome c oxidase level, decrease of glutathione concentrations and of ATP production. There is no evidence for a delayed dilated cardiomyopathy in survivors of an acute exposure.

Metals: Cobalt-related cardiomyopathy probably results from interference with energy production and contractile mechanisms, but additional factors (nutrition, hypothyroidism) are often required. Antimony may cause lethal oxidative stress and cell death mediated by elevation in intra-cellular calcium. Proposed mechanisms for mercury toxicity include glutathione depletion, production of ROS, and interruption in selenium-dependent endogenous enzymatic reactions. The existence of a lithium-induced cardiomyopathy is still debated.

Scorpion venom: Catecholamine release is the probable cause of acute cardiomyopathy following scorpion envenomation.

Conclusions: The mechanisms behind toxic cardiomyopathy are complex and multifactorial but include interference with myocardial cell bioenergetics and intracellular calcium handling, the generation of ROS, neurohormonal stress, and induction of apoptosis.     

Transradial access versus transfemoral access: a comparison of outcomes and efficacy in reducing hemorrhagic events

Introduction: The radial artery is currently the most widely used access site for PCI procedures both acute and stable patient settings. Thanks to advantages in pharmacological therapy as well as in interventional devices, the rate of ischemic complications following PCI has significantly decreased. Nevertheless, this has been counterbalanced by an increased risk of periprocedural and late bleeding event, that can occur both at access and non-access sites. Choice of access site for PCI is of paramount importance to reduce the risk of access-related bleeding events.

Areas covered: The aim of this review is to provide an overview of the actual available evidence comparing the transradial versus transfemoral approach to reduce hemorrhagic events.

The most robust evidence comes from large randomized trials, partly also from observational registries, which compared the transradial and transfemoral approach.

Expert opinion: Results show that radial access has proved to be decisive in reducing the incidence of hemorrhagic events. Furthermore, it showed a significant reduction in mortality and AKI compared to transfemoral access. However, increased experience in the use of the radial approach has led to less practice in the use of the femoral approach, which may be useful in cases of emergency, complications or inability to use the radial artery.     

Nursing Consultation in a Public Bathhouse: A Community Resource for the Vulnerable Population in a European Capital

Background: In Portugal’s capital, Lisbon, there are 19 public showers (PS) attended by a vulnerable population.

Aim: To describe the assessment and interventions performed during nursing consultations.

Method: This is a quantitative, observational, and cross-sectional study.

Findings: In a convenience sample of 77 users, 52% are females, 43% are single, 52% do not possess any economic resources, 87% have mental health issues, and 32% are homeless. The main nursing focuses found were: arterial hypertension, disease management skills, and emotional suffering. The most used nursing intervention is listening, followed by the expression of feelings, valuing the individual and his/her story, analyzing causes, providing support, and comforting.

Conclusions: This study shows that the main focus of the nursing care in these facilities is the human being. The respect for individuality and dignity was the primary concern, in an attempt to empower the individual to better manage his/her health and illness processes.     

Visit patterns at primary care centres and individual blood pressure level – a cross-sectional study

Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control.

Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region.

Patients: A total of 88,945 patients with uncomplicated hypertension age 40–79.

Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90?mmHg.

Results: Overall, 63% of patients had BP?≤?140/90?mmHg (48% BP?<?140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32).

Conclusions: In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care.     

Medication adherence,biological and lifestyle risk factors in patients with myocardial infarction: a ten-year follow-up on socially differentiated cardiac rehabilitation

Objective: There is strong evidence that medication adherence and lifestyle changes are essential in patients undergoing secondary cardiovascular disease prevention. Cardiac rehabilitation (CR) increases medication adherence and improves lifestyle changes. Patients with cardiac diseases and a low educational level and patients with little social support are less responsive to improve medication adherence and to adapt lifestyle changes. The aim of the present study was to investigate the long-term effects of a socially differentiated CR intervention on medication adherence as well as changes in biological and lifestyle risk factors at two- five- and ten-year follow-up.

Design: A prospective cohort study.

Setting: The cardiac ward at Aarhus University Hospital, Denmark.

Intervention: A socially differentiated CR intervention in addition to the standard CR program.

Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N?=?379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network.

Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status.

Results: No significant long-term effect of the intervention was found.

Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

• Key points

• The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors.

• Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking.

• General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

     

The link between anemia and adverse outcomes in patients with acute coronary syndrome

Introduction: Anemia is one of the most frequent comorbidities in acute coronary syndrome (ACS) patients and is associated with a significant impact on clinical outcomes. This review summarizes the knowledge and updated management of anemia in the setting of ACS.

Areas covered: We provide a review on the prevalence, pathophysiology, prognosis, impact, and updated management of anemia.

Expert opinion: Patients with anemia represent a therapeutic challenge in the setting of acute coronary syndrome and require specific acute and chronic management. Despite the high prevalence of anemia and the large amount of data confirming its strong impact on short- and long-term outcomes, a commonly used and accurate definition in the context of patients undergoing percutaneous coronary intervention and stent implantation for ACS is still lacking. Furthermore, therapeutic options to address anemia remain limited. The combined use of risk scores to identify high-risk characteristics for adverse bleeding or thrombotic events may guide individualized treatment of anemic patients, for example, by selecting an antiplatelet regimen aimed at minimizing bleeding or thrombotic risk. The optimal strategy for blood transfusion is currently being evaluated by an ongoing randomized trial.     

The effectiveness of stretching for infants with congenital muscular torticollis

Introduction: Congenital muscular torticollis (CMT) is a neck deformity that involves unilateral shortening of the sternocleidomastoid (SCM). Conservative physiotherapy management of CMT is primarily focused on stretching the affected SCM. However, there is limited research evidence on the use of stretching to improve the extensibility of SCM in infants with CMT.

Aim: To investigate the effectiveness of stretching for infants with CMT.

Method: A systematic search of AMED, CINAHL, MEDLINE, EMBASE, Physiotherapy Evidence Database (PEDro) and Cochrane Library was conducted during the period 2011–2018.

Results: Seven articles that met eligibility criteria were reviewed out of a total number of 415 articles that were screened; two articles were randomised control trials and five were cohort studies. The studies typically reported statistically significant benefits of stretching for the restoration of cervical range of movement and SCM thickness (p < 0.05). Appraisal of the studies revealed varied quality.

Conclusion: The results suggest that stretching is an effective treatment intervention for the management of infants with CMT and early physiotherapy referral can lead to decreased treatment duration. However, due to a variation in study quality; additional high-quality research is needed to help formulate more robust conclusions.     

Laparoscopic anterior and posterior native tissue repair: a new pelvic floor approach

Introduction: Traditionally, a cystocele caused by a midline defect of the pelvic fascia is treated by vaginal fascia duplication, also known as anterior colporraphy. The rectocele is managed by suturing the posterior fascia and, frequently, the levator ani muscles. We developed the approach of laparoscopic anterior and posterior fascia repair by native tissue.

Material and methods: The methods were based on anterior and posterior exposure of pelvic fascia similar to the preparation of an extended sacral colpopexy. The fascia was compressed and narrowed by absorbable woven sutures, size 1. Twenty-seven patients were followed up for 6–13?months. All patients received additional apical fixation by pectopexy.

Results: In the examination group, 13 patients underwent anterior laparoscopic fascia repair and 23 had posterior repair. We detected one apical and one posterior relapse, and also one in the anterior repair group. The patient with the apical relapse reported pain and de novo urgency. Anatomical reconstruction was achieved in all other patients.

Summary: Laparoscopic anterior and posterior native tissue repair appears to be a feasible method for the treatment of midline cystocele and rectocele. No new risks were observed. The technique leaves no scar in the vagina and is well accepted.

Abbreviations: POPQ: Pelvic Organ Prolapse Quantification System; FDA: Food and Drug Association; US: United States; Fig: Figure; ICIQ: International Consultation on Incontinence Questionnaire     

The lived experience of Joint Hypermobility and Ehlers-Danlos Syndromes: a systematic review and thematic synthesis

Background: Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome (EDS) are heritable connective tissue disorders characterised by joint instability, pain, anxiety, depression and poor quality of life. However, peoples’ lived experiences are not well understood.

Objective: To understand the lived experiences of people with JHS and EDS.

Methods: A systematic review was conducted using PRISMA guidelines. Critical appraisal and a thematic synthesis of participants’ lived experiences were conducted. Eight online databases were searched from 1990 to February 2018: AMED, CINAHL, EMBASE, MEDLINE, PubMed, PsychINFO, SPORTDiscus and the Cochrane Library. Eligibility criteria were: (1) People with either JHS or EDS, clearly distinguished from generalised joint laxity; (2) Qualitative studies, or mixed qualitative and quantitative studies with qualitative data reported independently and (3) Published in English.

Results: A total of nine studies were included. Five main themes were identified: (1) Lack of professional understanding; (2) Restricted life; (3) Social stigma; (4) Trying to ‘keep up’ and (5) Gaining control. The implications of these results are explored.

Conclusions: Further qualitative research is required to examine the impact of JHS/EDS on a wider range of participants and in greater depth.     

Noise Levels in an Acute Psychiatric Unit: An Exploratory Observational Study

Background: Noise is an important aspect of the ward atmosphere climate – the combination of the architectural solutions, organizational features, the psychological traits of the operators and their interactions, and the patients’ characteristics. Despite its importance noise levels have been less analyzed than other aspects of the ward atmosphere climate.

Aim: In this study the aim is to identify the sources of noise and the sound pressure level in an acute psychiatric ward, and secondly to ascertain whether this is perceived by inpatients as disturbing.

Method: The sound pressure levels were measured during three nonconsecutive mornings, three afternoons, and three nights. A questionnaire was administered to ascertain patients’ opinions about the noise in the ward.

Results: The average noise level in the ward was 62.5?dB(A)eq in the morning, 55.8 in the afternoon, and 51.5 at night. A total of 23 patients took part in the study: 65.2% of this sample did not perceive the noise in the ward as disturbing.

Conclusion: In a psychiatric ward, the main source of noise is the verbal communication, and acoustic pressure also derived from care activities based around relationships. Other sources of noise perceived as disturbing came from the opening and closing of doors and the entry doorbell. Adopting relational and architectural-structural measures could reduce the sound pressure, with a view to further improving the ambience in the ward.     

Quantitative real-time PCR for differential diagnostics of parvovirus B19 infection in acute liver failure patients

Background: Human Parvovirus B19 (B19V) is a common pathogen worldwide. After primary infection, B19V-DNA may permanently persist in non-erythroid tissues, including the liver of patients with acute liver failure (ALF).

Objective: To validate a real-time PCR (qPCR) for the quantification of B19V-DNA, in order to establish a differential diagnosis for B19V infection in ALF patients.

Methods: The qPCR techniques were based on Sybr Green® and TaqMan® methodologies. To evaluate the quality parameters of both methods, samples from patients with or without B19V infection were tested. The diagnostic utility of qPCR in the detection B19V-DNA in patients with ALF was evaluated by testing archived serum and hepatic tissue explants from 10 patients.

Results: The Sybr Green® methodology showed 97% efficiency, the limits of detection and quantification were 62.6 and 53,200 copies/mL, respectively. The TaqMan® methodology showed 95% efficiency, the limits of detection and quantification were 4.48 and 310 copies/mL, respectively. A false positive result was found only with the Sybr Green® methodology. Among ALF patients without defined etiology, three (30%) were positive for B19V DNA in serum and liver.

Conclusion: The qPCR methods validated here were effective in clarifying uncommon cases of B19V-related ALF and are fit for differential diagnosis of ALF causes.     

Prevalence of recent fentanyl use among treated users of illicit opioids in England: based on piloted urine drug screens

Objective: To use a pilot of national fentanyl screening to establish the current prevalence of recent fentanyl use among treated users of illicit opioids in the English treatment system and inform the design of a full study.

Design: Cross-sectional fentanyl metabolite urine screening in randomly-selected study sites, stratified to cover all nine geographical regions of England, supplemented with self-report subsequent to a positive fentanyl test.

Patients: 468 adult (18 years of age and above) patients receiving treatment for opioid use disorder, screened December 2017 to May 2018.

Results: The fentanyl-positive rate in patients receiving treatment for opioid use disorder in the English treatment system was 3% (15/468, 95% CI 1.8% to 5.2%) with a per-site range (for the 10 sites in 9 regions where fentanyl was detected) of between 2% (1/57) and 15% (4/27). Self-report data indicated that the majority of fentanyl-positives (12/15, 80%) was unaware of having purchased fentanyl.

Conclusions: Despite alerts already in place, patients receiving treatment for opioid use disorder, who were fentanyl-positive, were unwittingly purchasing and consuming fentanyl.     

Diagnosis and treatment of pediatric pulmonary arterial hypertension

Introduction: Pediatric pulmonary arterial hypertension (PAH) remains a rare and severe disease with a poor prognosis. PAH may be idiopathic, heritable or associated with systemic conditions in particular associated with congenital heart disease.

Areas covered: A thorough and extensive diagnostic approach is required for a correct diagnosis. The outcome has improved over the last decade with a better diagnostic approach and with the initiation of new targeted therapies. However, there is still significant progress to achieve as there is still no cure for this devastating disease.

Expert opinion: Adapted clinical studies to define the best therapeutic approach are needed. Even if the treatment approach is still mainly derived from adult data and expert consensus, several studies and registries are currently underway and should deliver important information in the next future.

This review aims to give an overview of the current diagnosis and treatment strategies of PAH.     

Burn care and rehabilitation in Australia: health professionals’ perspectives

Objective: To understand health professionals’ perspectives of burn care and rehabilitation.

Design: Qualitative and semi-structured interviews.

Setting: Australian burn and rehabilitation units.

Participants: Twenty-two clinicians working in burns units across disciplines and healthcare settings.

Results: The data portrayed the health professionals’ perspectives of burn care and rehabilitation in Australia. Three themes were identified: (1) interprofessional collaboration; (2) integrated community care, and (3) empowering patients to self-care.

Conclusion: Burn care and rehabilitation remains a complex and a challenging area of care with limited access to burn services especially in rural and remote areas. Interprofessional training and education of health professionals involved with the complex care of burn injury remains a key element to support and sustain the long-term rehabilitation requirements for patients and their families. Empowering patients to develop independence early in their rehabilitation is fundamental to their ongoing recovery. A burns model of care that embraces a multidisciplinary collaboration and integrated care across the continuum has the potential to positively impact recovery and improve health outcomes.

• Implications for rehabilitation

• Burn care and rehabilitation remains a complex and challenging area of care.

• Managing the rehabilitation phase after burn injury can be as complex as managing the acute phase.

• Interprofessional collaboration, integrated community care, and empowering patients to self-care are key elements for sustaining the rehabilitation of adults with burn injuries.

     

A cross-sectional study evaluating the knowledge and beliefs about,and the use of antibiotics amongst Malaysian university students

Background: The introduction of antibiotics into modern medicine has changed clinical care by saving millions of lives. However, misuse of antibiotics has led to their benefits being overshadowed by the development of antimicrobial resistance.

Aims of Study: This study aimed to assess university students’ knowledge and beliefs about and their use of antibiotics.

Methods: This cross-sectional study was conducted among 674 medical and non-medical students of the National Defence University of Malaysia, using universal and convenience sampling methods. The data was collected using a validated questionnaire and analyzed using IBM SPSS 24, and the MANOVA test and Logistic Regression were used to explore the associated factors.

Results: More than half of the respondents’ knowledge was low and their health beliefs outdated. Age, race and program were significantly associated with up-to-date knowledge and beliefs about antibiotic use, factors associated with finishing a course of antibiotics were studying medicine, personal health, and ethnicity. The significant factors associated with antibiotic self-prescribing were beliefs having been prescribed antibiotics during the last one year, and trusting the doctors who did not prescribe antibiotics.

Conclusion: This study has identified a concerning low knowledge about antibiotics amongst some Malaysian university students, reflected in use of un-prescribed antibiotics and a lack of adherence to treatment. There is a need for educational interventions for students regarding antibiotic usage and resistance issues.     

Gender differences in the clinical features and outcomes of patients with coronary artery disease

Introduction: Women have been at a higher risk for adverse cardiac events following percutaneous coronary intervention (PCI), compared with men.

Areas covered: In this review, authors discuss the gender differences that can affect the clinical outcomes after PCI and the important points that can be improved on.

Expert commentary: Various factors, such as old age and higher prevalence of comorbidities, have been considered to account for the worse clinical outcomes of PCI in women than in men. In addition, men and women have different presentations of angina or acute coronary syndrome (ACS); atypical symptoms are more frequent in women. This variation of the clinical presentation in women likely contributes to the misdiagnosis or delayed recognition of ischemia, which may explain the worse clinical outcomes. In addition, compared with men, women are less likely to be referred for revascularization for coronary artery disease (CAD) and receive less of these guideline-recommended therapies. Recently, sex differences in cardiovascular events have decreased, especially among stable CAD patients, but sex differences in the clinical outcomes of ACS remain. Further evolution of treatment is expected to narrow these sex differences among patients with CAD and improve the clinical outcomes of both men and women.     

Healthcare-seeking with bothersome lower urinary tract symptoms among men in the Danish population: the impact of lifestyle and socioeconomic status

Objective: (1) To identify possible factors of importance for reporting lower urinary tract symptoms (LUTS) among men and (2) to examine possible associations between socioeconomic status (SES), lifestyle factors, and likelihood of men contacting a general pracitioner (GP) regarding LUTS reported to be of concern or influencing daily activities (bothersome LUTS).

Design: Nationwide population-based, cross-sectional survey. Data was collected in 2012.

Setting: The general Danish population.

Subjects: A total of 48,910 randomly selected men aged 20+.

Main Outcome Measures: (1) Odds ratios for reporting LUTS by lifestyle and SES, and (2) Odds ratios for GP contact with bothersome LUTS by lifestyle and SES.

Results: 23,240 men participated (49.8%). Nocturia was the most commonly experienced LUTS (49.8%). Incontinence was most often reported as bothersome (64.1%) and nocturia less often reported as bothersome (34.2%). Only about one third of the men reporting a bothersome LUTS contacted their GP. Odds for reporting LUTS significantly increased with increasing age, obesity, and lack of labor market affiliation. Increasing age and symptom burden significantly increased the odds for GP contact regarding bothersome LUTS. No overall associations were found between lifestyle, SES, and GP contact.

Conclusion: Bothersome LUTS are common among Danish men. Concern and influence of LUTS on daily activities are important determinants of GP contact, yet only one in three bothersome LUTS are discussed with a GP. Advanced age and symptom burden were significantly associated with GP contact.

Implications: Information on treatment options for LUTS might be desirable among Danish men regardless of SES and lifestyle.

• Key points

• Urological symptoms are common among men in the Danish population and are often managed without contacting healthcare professionals.

• Increasing age and symptom burden significantly increase the likelihood of consulting a general practitioner regarding bothersome urological symptoms

• Healthcare-seeking behavior with bothersome urological symptoms is not influenced by lifestyle or socioeconomic status among Danish men;

• Information about available, effective treatment options for urological symptoms might be desirable among men regardless of socioeconomic status and lifestyle