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Bayesian Inference of Pathogen Phylogeography using the Structured Coalescent Model.

Over the past decade, pathogen genome sequencing has become well established as a powerful approach to study infectious disease epidemiology. In particular, when multiple genomes are available from several geographical locations, comparing them is informative about the relative size of the local pathogen populations as well as past migration rates and events between locations. The structured coalescent model has a long history of being used as the underlying process for such phylogeographic analysis. However, the computational cost of using this model does not scale well to the large number of genomes frequently analysed in pathogen genomic epidemiology studies. Several approximations of the structured coalescent model have been proposed, but their effects are difficult to predict. Here we show how the exact structured coalescent model can be used to analyse a precomputed dated phylogeny, in order to perform Bayesian inference on the past migration history, the effective population sizes in each location, and the directed migration rates from any location to another. We describe an efficient reversible jump Markov Chain Monte Carlo scheme which is implemented in a new R package StructCoalescent. We use simulations to demonstrate the scalability and correctness of our method and to compare it with existing software. We also applied our new method to several state-of-the-art datasets on the population structure of real pathogens to showcase the relevance of our method to current data scales and research questions.

Bayes Theorem↗

Declining beta-HCG levels: an indicator for expectant approach in ectopic pregnancy.

Early surgical intervention in ectopic pregnancy is desirable. However, occasionally some patients do not benefit from this approach, as the natural history of ectopic pregnancy is not always tubal rupture or any other catastrophic event. A retrospective as well as a prospective analysis of 144 cases of suspected ectopic pregnancies was performed. The results of this study support expectant management in cases where serum beta-HCG levels are declining, provided the patient is stable and has no acute abdominal symptoms.

Chorionic Gonadotropin↗

Multiple implantation after oocyte donation: a frequent but inefficient event.

OBJECTIVE: To evaluate the natural history of multiple implantation in a donor oocyte program. DESIGN: Retrospective review of clinical pregnancies resulting from donor oocytes with analysis of serial vaginal ultrasound examinations beginning 21 days after embryo transfer. SETTING: University of Southern California IVF program (USC-IVF). MAIN OUTCOME MEASURES: Number of implantation sites lost during gestation, furthest development of the gestation, and clinical symptoms of those experiencing loss. RESULTS: Sixty-two of 101 patients (61%) who became pregnant had multiple implantations, 41 (41%) with two sacs, 12 (12%) with three sacs, 6 (6%) with four sacs, and 3 (3%) with five sacs. Overall 28% of implantations sites were lost spontaneously. Rates of loss were similar for multiple implantations. The majority (62%) of these nonviable sacs did not develop beyond a gestational sac. All patients with three or more implantation sites had ongoing pregnancies through the first trimester. The probability of pregnancy loss after visualization of fetal heart motion was 5.7%. Few patients who underwent a natural self reduction of sacs were symptomatic. CONCLUSIONS: There is a significant self-reduction in multiple implantation sites in a donor oocyte program. This may obviate the need for a selective reduction procedure. Patients should be followed for up to 10 weeks after ET before committing to a selective reductive procedure.

Abortion, Spontaneous↗

Nocturnal electrobioimpedance volumetric assessment of patients with erectile dysfunction.

OBJECTIVES: Electrobioimpedance volumetric assessment is a procedure that can measure penile length, cross-sectional area, and volume. From these variables, the number and duration of erectile events, volume change, and percentage of volume increase from baseline can be determined. This procedure was performed on patients with erectile dysfunction (ED) and findings were compared with patients with no history of ED. Examples of etiology are reported. METHODS: Two groups of patients with ED were evaluated by electrobioimpedance assessment. Group 1 patients (n = 23), ranging in age from 26 to 60 years (mean 50), were involved in simultaneous electrobioimpedance assessment and duplex Doppler ultrasound penile volume measurements. A tissue correction was derived. Group 2 patients (n = 10), ranging in age from 38 to 64 years (mean 50), used nocturnal electrobioimpedance volumetric assessment (NEVA) at home for 2 consecutive nights. RESULTS: After deriving an expression to correct for tissue volume, simultaneous measurement of penile blood volume by NEVA and duplex Doppler showed that the regression line for study participants and the identity line was not significantly different by analysis of variance. Using NEVA in comparing patients with ED to a reference population with no history of ED, and using a two-tailed Student's t test for means, the data demonstrated a statistically significant (P < or =0.05) difference in the number of erectile events and percentage of volume change over baseline. With NEVA data, it was possible to distinguish arterial insufficiency from veno-occlusive dysfunction. CONCLUSIONS: The present study demonstrates that electrobioimpedance volumetric assessment can be used in patients with ED. Compared with a reference population with no history of ED, the group with ED had fewer nocturnal erectile events that resulted in a smaller increase in penile blood volume change over baseline. Although the time dependence of the measured variables identifies the cause of ED, the application of NEVA to a larger population will allow further analysis of the dynamic information contained in the NEVA data.

Adult↗

Clinical predictors of 30-day cardiac events in patients with acute coronary syndrome at a community hospital.

OBJECTIVE: We sought to determine predictors of coronary events (cardiac death, acute myocardial infarction, and urgent revascularization) within 30 days after admission. METHODS: We prospectively collected data on 400 patients admitted through our emergency room for unstable angina and acute coronary syndromes. Patients with ST-segment elevation myocardial infarction and those who required thrombolysis were excluded. RESULTS: Of 383 patients who were eligible, 120 patients had coronary events within 30 days. Statistically significant variables associated with coronary events were advanced age, male sex, family history of premature coronary artery disease (CAD), diabetes mellitus, tobacco abuse, prior congestive heart failure, prior myocardial infarction, and history of CAD. Symptoms at presentation associated with cardiac events were typical angina and shortness of breath. Objective measures of ischemia associated with cardiac events were elevated troponin T, elevated creatine kinase MB, and ischemic electrocardiographic changes. Using forward stepwise regression analysis, we generated a model to predict 30-day major adverse cardiac events. The strongest predicting variable was serum troponin T (accounting for 33% of predicting r2, P < 0.001) followed by typical angina (r2 increasing to 37%), ischemic electrocardiographic changes (40%), prior CAD (42%), family history of premature CAD (44%), shortness of breath (46%), and positive creatine kinase MB (48%). The positive predictive power of the complete model was r2 = 48%, P < 0.001. CONCLUSION: Our model incorporating elements from the patient's demographic, medical history, presentation, and ischemic assessment identified 48% of patients presenting with unstable angina and acute coronary syndromes who will suffer a major adverse cardiac event within 30 days of admission. Although the strongest predictor was identified as serum troponin T, other clinical criteria offered improvement in our predictive abilities. Therefore, good initial clinical evaluation in addition to simple tests such as serum cardiac markers and electrocardiography are valuable in risk stratification of patients presenting with acute coronary syndromes and cardiac chest pain. Additional testing may be necessary to improve the positive predictive value of the model. Cardiac enzymes and electrocardiographic changes have the highest negative predictive value for occurrence of major adverse cardiac events. Identification of high-risk patients is essential to direct resources toward these patients and to avoid unnecessary costs and risk to the low-risk population.

Acute Disease↗

Women's voices reflecting changed expectations for pregnancy after perinatal loss.

PURPOSE: To describe women's experiences of pregnancy after loss and their long-term effects of perinatal loss. DESIGN: Phenomenology. METHODS: Three focus groups were conducted in fall 1996 with a total of 21 women. These women varied in their obstetrical and loss histories. The time since their losses ranged from 34 years ago to the previous year. Data analysis was guided by Colaizzi's procedural steps. FINDINGS: Women's stories portrayed perinatal loss as a life-altering event. Women did not feel emotionally safe in their pregnancies after loss and were afraid that those babies too would die. Despite the differences in their obstetrical and loss histories and time since loss, similarities in their responses to pregnancy far outweighed their differences. These commonalities contained in six themes: (a) dealing with uncertainty, (b) wondering if the baby is healthy, (c) waiting to lose the baby, (d) holding back their emotions, (e) acknowledging that loss happened and that it can happen again, and (f) changing self. CONCLUSIONS: This study indicated many common concerns and experiences among women in response to perinatal loss and subsequent pregnancies. Variations were not linked to the number or gestational age of the losses. Care providers should acknowledge women's past losses, address their concerns during a current pregnancy, and recognize the potentially life-long effect perinatal loss may have on these women.

Abortion, Spontaneous↗

[Management of patients after a first seizure].

Neuroimaging evaluation in patients after a first seizure could be easily determined on the basis of seizure history, neurological examination, blood sample analysis and electroencephalography. The main objectives of the initial work-up are to differentiate a true seizure event from seizure-like symptoms, to exclude a single seizure as a manifestation of non organic cause and finally to consider the seizure as a result of cerebral lesion or inaugurate epilepsy. When a new onset seizure is diagnosed, urgent neuroimaging is recommended only in patients with focal neurological deficit, persistent or worsening alteration in the level of consciousness and when clinical and biological data lead to a suspected vascular or infectious etiology. Brain CT scan is usually more available in emergency to identify the cause of seizure. It may have an important role for the therapeutic strategy and may defer MRI investigation. Nevertheless, brain MRI must be performed in emergency when CT scan is not conclusive despite a severe clinical condition or in case of cerebral venous thrombosis. Imaging modalities depend on clinical data, patient age and suspected epilepsy type.

Brain Diseases↗

Topical alprostadil cream for the treatment of erectile dysfunction: a combined analysis of the phase II program.

OBJECTIVES: To present a meta-analysis of the efficacy and safety data of two recently completed Phase II studies examining a novel alprostadil topical cream for the treatment of erectile dysfunction (ED). METHODS: Patients (n = 303) with ED of at least 3 months' duration were randomized to receive placebo or 50, 100, 200, or 300 microg alprostadil in two nearly identical 11-dose, multicenter, at-home studies of a novel topical cream containing alprostadil and a proprietary skin permeation enhancer. The primary efficacy endpoint was the change in erectile function domain score from baseline to the final visit. Secondary endpoints included changes in scores for questions 3 and 4 of the International Index of Erectile Function and standard diary analyses. Safety was assessed by analysis of adverse events, changes in laboratory test results, and physical examination findings. RESULTS: The mean baseline parameters for the erectile function score, ED history, and secondary diagnoses suggested no significant differences among the treatment groups. The changes from baseline to the final visit erectile function scores were 0.98 +/- 0.84, 3.4 +/- 1.3, 3.4 +/- 0.88 (P <0.05), 5.3 +/- 0.92 (P <0.001), and 9.4 +/- 1.43 (P <0.001) for the ascending dose groups. Most secondary efficacy endpoints were significant for the 200 and 300-microg dose groups. Dose-related trends in efficacy were observed. Adverse events were localized to the application site, were of mild or moderate intensity, and were of short duration. CONCLUSIONS: These results suggest topical alprostadil cream, when combined with a novel dermal permeation-enhancer, to be a potentially useful agent for the treatment of ED.

Administration, Topical↗

Systematic review of the prognostic effectiveness of SPECT myocardial perfusion scintigraphy in patients with suspected or known coronary artery disease and following myocardial infarction.

OBJECTIVES: In patients with suspected or known coronary artery disease (CAD), or following myocardial infarction (MI), assessing the degree of ischaemia is important from a prognostic and therapeutic point of view. Single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) is a non-invasive technique that allows the presence, location and extent of ischaemia to be determined. The aim of this systematic review was to assess the prognostic effectiveness of SPECT MPS. METHODS: We sought prognostic studies involving SPECT, exercise tolerance testing (ETT) and/or coronary angiography (CA) in people with suspected or known CAD, or following MI. Outcomes included cardiac death, non-fatal MI and revascularization. We searched the following databases: MEDLINE, PREMEDLINE, EMBASE, BIOSIS, Science Citation Index, the Cochrane Library, the Health Management Information Consortium and the Health Technology Assessment Database. RESULTS: Twenty-one observational studies enrolling 53,762 people reported the general prognostic value of SPECT MPS. In multivariate analysis, SPECT MPS variables yielded both independent and incremental value to combinations of clinical, ETT and angiographic variables in predicting cardiac death or non-fatal MI. Three comparative studies reported lower revascularization rates following a SPECT MPS-CA strategy (6-21%) compared with direct CA (16-44%). Four observational studies enrolling 2106 people reported the prognostic value of SPECT for patients following MI. In multivariate analysis including clinical history, ETT, SPECT MPS and angiographic variables, strategies involving SPECT MPS provided independent and incremental prognostic performance in predicting future cardiac events. CONCLUSIONS: SPECT MPS provides important additional information to that from ETT and/or CA that helps to risk-stratify patients with suspected or known CAD or following MI, enabling them to be managed more appropriately. Increasing the use of strategies involving SPECT MPS may identify lower risk patients for whom invasive CA might be avoided.

Aged↗

Apolipoprotein(a) phenotypes are reliable biomarkers for familial aggregation of coronary heart disease.

Lipoprotein(a) [Lp(a)] is an atherogenic and prothrombotic molecule formed by the covalent binding of the highly polymorphic apolipoprotein(a) [apo(a)] to apoprotein B-100 of LDL. High Lp(a) concentrations are a recognized genetic risk factor for coronary heart disease (CHD) and have been shown to be related with a familial clustering of ischemic cardiac events. Nevertheless, the association between apolipoprotein(a) isoforms and a positive familial history of CHD has received far less attention. In this report, we explored the distribution of apo(a) phenotypes in 127 CHD subjects with a family history of coronary events and in 92 CHD patients without such a history. Twenty-two apo(a) isoforms were detected by a high-resolution immunoblotting method. In univariate analysis, the percentage of subjects with at least one small sized apo(a) isoform was significantly higher in CHD patients with a positive family history than in those without (P<0.01). Multivariate analysis showed that apo(a) isoforms of low molecular weight were the best predictors of familial aggregation of cardiac ischemia. We conclude that apo(a) size polymorphism is strongly associated with a familial history of CHD and is more efficient than Lp(a) plasma concentrations in predicting the familial clustering of coronary disease. When detected by high-resolution techniques, apo(a) phenotypes are objective laboratory markers that can substitute for a knowledge of a positive family history of CHD and should be used, together with Lp(a) levels, to better assess the familial predisposition to coronary events.

Apolipoproteins↗

Long-term prognostic value of time domain analysis of signal-averaged electrocardiography in idiopathic dilated cardiomyopathy.

The aim of this study was to evaluate the long-term prognostic value of signal-averaged electrocardiography (SAECG) in idiopathic dilated cardiomyopathy (IDC). Time domain analysis of SAECG was assessed in 131 patients with angiographically confirmed IDC (age 52+/-12 years; 108 men; left ventricular ejection fraction 33+/-12%) using specific criteria in 44 patients with bundle branch block. Late potentials (LP) on SAECG were present in 27% of the patients. Patients with LP had a similar left ventricular ejection fraction and a similar left ventricular end-diastolic diameter than patients with a normal SAECG. With a follow-up of 54+/-41 months, 24 patients suffered cardiac death and 19 had major arrhythmic events (sudden death, resuscitated ventricular fibrillation, or sustained ventricular tachycardia). Patients with LP had an increased risk of all-cause cardiac death (RR 3.3, 95% confidence interval 1.5 to 7.5, p = 0.004) and of arrhythmic events (RR 7.2, 95% confidence interval 2.6 to 19.4, p = 0.0001). Using multivariate analysis, only LP on SAECG (p = 0.001), reduced SD of all normal-to-normal intervals (SDNN) (p = 0.002), increased pulmonary capillary wedge pressure (p = 0.005), and history of sustained ventricular tachyarrhythmia (p = 0.02) predicted cardiac death. A history of previous sustained ventricular tachyarrhythmia (p = 0.0001), reduced SDNN (p = 0.003), and LP on SAECG (p = 0.006) were the only independent predictors of major arrhythmic events. Results were not altered when considering separately patients with or without bundle branch block, or after exclusion of patients with a history of sustained ventricular tachyarrhythmia. This study is one of the first to suggest that LP on SAECG is an independent predictor of all-cause cardiac death and is of high interest for arrhythmia risk stratification in IDC.

Arrhythmias, Cardiac↗

Vascular events during follow-up in patients with aortic arch atherosclerosis.

BACKGROUND AND PURPOSE: An association between aortic arch atherosclerosis and vascular events has been demonstrated. However, few data exist regarding follow-up evaluation of this disease. METHODS: In this study, 183 patients with the diagnosis of aortic arch atherosclerosis were prospectively followed up. This diagnosis was made during an echocardiographic cross-sectional study. In 136 patients, raised plaques with thickness < 5 mm had been shown to exist, and in 47 patients complex plaques with thickness > or = 5 mm or plaques with mobile components had been demonstrated on the initial transesophageal echocardiography. RESULTS: During a mean follow-up period of 16 +/- 7 months, vascular events with a presumed embolic origin occurred in 15 patients. The incidence was 4.1 per 100 person-years in patients with raised plaques compared with 13.7 per 100 person-years in the group with complex plaques. The Kaplan-Meier survival analysis revealed a significantly higher rate of vascular events in patients who were found to have complex plaques (P < .01). In the Cox proportional hazards analysis, the finding of complex plaques (relative risk [RR], 4.3; 95% confidence interval [CI], 1.5 to 12.0; P = .006), coronary artery disease (RR, 4.0; 95% CI, 1.2 to 13.1; P = .02), and a history of previous embolism (RR, 4.0; 95% CI, 1.1 to 14.4; P = .03) were independent predictors of vascular events. CONCLUSIONS: Patients with the finding of protruding plaques or plaques with mobile components have a high risk of subsequent vascular events.

Adult↗

ST segment depression detected by continuous electrocardiography in patients with acute ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Forty percent of patients with a history of ischemic stroke or transient ischemic attack (TIA) have concomitant coronary artery disease. ST segment depression, detected by continuous electrocardiography, is associated with increased cardiac morbidity and mortality in patients with known coronary artery disease. While electrocardiographic changes have been associated with acute stroke, the etiology and significance of these changes remain unclear. In this pilot study we report the prevalence of ST segment depression and ventricular arrhythmias in patients with acute ischemic stroke or TIA monitored by continuous electrocardiography. Clinical predictors of ST segment depression and ventricular arrhythmia are also identified. METHODS: Consecutive patients presenting with acute ischemic stroke or TIA were enrolled within 72 hours of hospital admission and monitored by continuous electrocardiography for 48 hours. The electrocardiographic results were analyzed for periods of ST segment depression and ventricular arrhythmias. RESULTS: Of 51 patients with ischemic stroke or TIA, 15 (29%) had episodes of ST segment depression (95% confidence interval, 15% to 43%), and 18 (35%) had ventricular arrhythmias (95% confidence interval, 21% to 49%). In logistic regression analysis, increasing age (P < .02) and a left-sided neurological event (P < .01) were significant predictors of ST segment depression. Increasing numbers of atherosclerotic risk factors, a history of cardiac disease, and increasing or decreasing mean arterial pressure were not predictive of ST segment depression. CONCLUSIONS: Patients with acute ischemic stroke or TIA have a 29% prevalence of ST segment depression within the first 5 days after their event. In comparison, the prevalence of ST depression is 2.5% to 8% in asymptomatic adults and 43% to 60% in patients with symptomatic coronary artery disease. The association of ST segment depression with left-sided neurological events suggests that the electrocardiographic changes are in part neurologically mediated. Further study is necessary to better define the brain-heart interaction and to determine whether ST segment depression in patients with ischemic stroke or TIA reflects underlying coronary artery disease.

Acute Disease↗

Atrial flutter and the risk of thromboembolism: a systematic review and meta-analysis.

PURPOSE: We conducted a systematic review and meta-analysis of observational studies to assess the risk of thromboembolism associated with atrial flutter. METHODS: MEDLINE, EMBASE, bibliographies, and consultation with clinical experts were used to identify studies that report the risk of thromboembolism associated with attempted cardioversion and longer-term risk in chronic atrial flutter. The review process and data extraction were performed by two reviewers. Study event rates were assessed graphically, and a chi-squared test was used to assess heterogeneity across studies. Meta-regression with weighted logistic regression was used to assess the association between study-level clinical factors and reported thromboembolic event rates. RESULTS: We found 13 studies that reported the risk of thromboembolism associated with cardioversion of atrial flutter. Short-term event rates ranged from 0% to 7.3%. A chi-squared test for heterogeneity was significant (P < 0.001), so results were not pooled. Instead, a meta-regression analysis was performed, which partly explained the heterogeneity across studies. Studies were more likely to report high event rates when they included patients with a prior history of thromboembolism, and to report lower event rates when at least some patients were anticoagulated or if patients underwent echocardiography before cardioversion. Four studies reported the longer-term risk of thromboembolism, and these suggest a yearly event rate of approximately 3% with sustained atrial flutter. CONCLUSION: These findings suggest that atrial flutter is indeed associated with an increased risk of thromboembolism, and that clinical factors account for the low event rates reported in some studies.

Atrial Flutter↗

A multivariate study of predictors of repeat parasuicide.

OBJECTIVE: To identify variables which differentiate future repeaters of parasuicide from non-repeaters in a multivariate analysis. METHOD: Interviews were conducted with 507 parasuicide cases; data were collected on precipitating factors for the index parasuicide, psychiatric and medical history, stressful life events, prior history of parasuicide, hopelessness, anger, self-esteem and social adjustment. Individuals were followed for 1-2 years to determine if a repeat parasuicide occurred. RESULTS: A logistic regression model identified four significant predictors of repeat parasuicide: prior history of parasuicide, a history of depression, a history of schizophrenia and poor physical health. A risk factor scale constructed from these four variables showed that the risk of repeat parasuicide increases as the number of risk factors increases. CONCLUSION: This study identifies four key predictors of repeat parasuicide, and provides evidence that the risk of repeat parasuicide increases when multiple risk factors are present.

Adolescent↗

Phylogeography and introgressive hybridization: chipmunks (genus Tamias) in the northern Rocky Mountains.

If phylogeographic studies are to be broadly used for assessing population-level processes relevant to speciation and systematics, the ability to identify and incorporate instances of hybridization into the analytical framework is essential. Here, we examine the evolutionary history of two chipmunk species, Tamias ruficaudus and Tamias amoenus, in the northern Rocky Mountains by integrating multivariate morphometrics of bacular (os penis) variation, phylogenetic estimation, and nested clade analysis with regional biogeography. Our results indicate multiple examples of mitochondrial DNA introgression layered within the evolutionary history of these nonsister species. Three of these events are most consistent with recent and/or ongoing asymmetric introgression of mitochondrial DNA across morphologically defined secondary contact zones. In addition, we find preliminary evidence where a fourth instance of nonconcordant characters may represent complete fixation of introgressed mitochondrial DNA via a more ancient hybridization event, although alternative explanations of convergence or incomplete sorting of ancestral polymorphisms cannot be dismissed with these data. The demonstration of hybridization among chipmunks with strongly differentiated bacular morphology contradicts long-standing assumptions that variation within this character is diagnostic of complete reproductive isolation within Tamias. Our results illustrate the utility of phylogeographic analyses for detecting instances of reticulate evolution and for incorporating this and other information in the inference of the evolutionary history of species.

Animals↗

A cross-sectional study of clinical thrombotic risk factors and preventive treatments in antiphospholipid syndrome.

OBJECTIVE: Antiphospholipid antibodies (aPL) are major risk factors for thrombosis. Other clinical factors exist in antiphospholipid syndrome (APS) patients which may have an additive or preventive effect on thrombosis. We therefore performed a cross-sectional study to analyse additive clinical thrombotic risk factors and possible preventive treatments in APS patients, and to compare the results with those obtained in asymptomatic aPL-positive (no history of vascular thrombosis or pregnancy morbidity) patients. METHODS: We identified 77 APS patients with non-gravid thrombotic events (group A) and 56 asymptomatic aPL-positive patients (group B). The study periods were defined as 6 months prior to the time of first vascular event in group A and 6 months prior to the patient's last visit in group B. Medical records were reviewed to evaluate the incidence of hypertension, diabetes mellitus, hypercholesterolaemia, regular cigarette smoking, oral contraceptive use or hormone replacement therapy, surgical procedures, pregnancy with or without an APS-related event, malignancy and infections. In addition, any history of thrombocytopenia or the use of aspirin, hydroxychloroquine, corticosteroids or immunosuppressives during the study periods was recorded. Bivariate statistical analysis and logistic regression tests were performed to compare groups. RESULTS: In group A, 75% (n=58) of patients and in group B 48% (n=27) of patients had at least one of the additional risk factors during the study periods. In the bivariate analysis, pregnancy (P=0.005) and surgical procedures (P=0.04) were significantly more frequent in group A, while aspirin (P<0.001), hydroxychloroquine (P<0.001) and corticosteroids (P=0.002) were used significantly more frequently in group B. In logistic regression, the probability of an event was decreased by taking aspirin and/or hydroxychloroquine. In women only, the probability of an event was increased with thrombocytopenia and pregnancy or surgical procedures. The incidences of hypertension and smoking and the presence of more than one risk factor were significantly associated with arterial thrombosis but not venous thrombosis. CONCLUSION: While traditional risk factors were similar between groups, pregnancy and surgical procedures increased the risk of thrombosis. Hypertension and smoking were associated with arterial events. Possessing a combination of risk factors may increase the occurrence of arterial thrombosis but not venous thrombosis. Use of aspirin and/or hydroxychloroquine may be protective against thrombosis in asymptomatic aPL-positive individuals.

Antiphospholipid Syndrome↗

Cold periods and coronary events: an analysis of populations worldwide.

STUDY OBJECTIVE: To investigate the association between cold periods and coronary events, and the extent to which climate, sex, age, and previous cardiac history increase risk during cold weather. DESIGN: A hierarchical analyses of populations from the World Health Organisation's MONICA project. SETTING: Twenty four populations from the WHO's MONICA project, a 21 country register made between 1980 and 1995. PATIENTS: People aged 35-64 years who had a coronary event. MAIN RESULTS: Daily rates of coronary events were correlated with the average temperature over the current and previous three days. In cold periods, coronary event rates increased more in populations living in warm climates than in populations living in cold climates, where the increases were slight. The increase was greater in women than in men, especially in warm climates. On average, the odds for women having an event in the cold periods were 1.07 higher than the odds for men (95% posterior interval: 1.03 to 1.11). The effects of cold periods were similar in those with and without a history of a previous myocardial infarction. CONCLUSIONS: Rates of coronary events increased during comparatively cold periods, especially in warm climates. The smaller increases in colder climates suggest that some events in warmer climates are preventable. It is suggested that people living in warm climates, particularly women, should keep warm on cold days.

Adult↗