Meta-analysis : subclinical thyroid dysfunction and the risk for coronary heart disease and mortality

Rapport de synthèse : Description : ce travail de thèse évalue de façon systématique les études sur l'association entre les dysfonctions thyroïdiennes infracliniques d'une part, et la maladie coronarienne et la mortalité d'autre part. Les hypothyroïdies infracliniques affectent environ 4-5% de la population adulte alors que la prévalence de l'hyperthyroïdie infraclinique est inférieure (environ 1%). L'éventuelle association entre elles pourrait justifier un dépistage systématique des dysfonctions thyroïdiennes infracliniques. Les précédentes études sur l'association entre l'hypothyroïdie infraclinique et la maladie coronarienne ont donné des résultats conflictuels. La parution de nouveaux articles récents basés sur de grandes cohortes prospectives nous a permis d'effectuer une méta-analyse basée uniquement sur des études de cohorte prospectives, augmentant ainsi la validité des résultats. Résultats: 10 des 12 études identifiées pour notre revue systématique sont basées sur des cohortes issues de la population générale («population-based »), regroupant en tout 14 449 participants. Ces 10 études examinent toutes le risque associé à l'hypothyroïdie infraclinique (avec 2134 événements coronariens et 2822 décès), alors que 5 étudient également le risque associé à l'hyperthyroïdie infraclinique (avec 1392 événements coronariens et 1993 décès). En utilisant un modèle statistique de type random-effect model, le risque relatif [RR] lié à l'hypothyroïdie infraclinique pour la maladie coronarienne est de 1.20 (intervalle de confiance [IC] de 95%, 0.97 à 1.49). Le risque diminue lorsque l'on regroupe uniquement les études de meilleure qualité (RR compris entre 1.02 et 1.08). Il est plus élevé parmi les participants de moins de 65 ans (RR, 1.51 [IC, 1.09 à 2.09] et 1.05 [IC, 0.90 à 1.22] pour les études dont l'âge moyen des participants est >_ 65 ans). Le RR de la mortalité cardiovasculaire est de 1.18 (IC, 0.98 à 1.42) et de 1.12 (IC, 0.99 à 1.26) pour la mortalité totale. En cas d'hyperthyroïdie infraclinique, les RR de la maladie coronarienne sont de 1.21 (IC, 0.88 à 1.68), de 1.19 (IC, 0.81 à 1.76) pour la mortalité cardiovasculaire, et de 1.12 (IC, 0.89 à 1.42) pour la mortalité totale. Conclusions et perspectives : nos résultats montrent que les dysfonctions thyroïdiennes infracliniques (hypothyroïdie et hyperthyroïdie infracliniques) représentent un facteur de risque modifiable, bien que modéré, de la maladie coronarienne et de la mortalité. L'efficacité du traitement de ces dysfonctions thyroïdiennes infracliniques doit encore être prouvée du point de vue cardiovasculaire et de la mortalité. Il est nécessaire d'effectuer des études contrôlées contre placebo avec le risque cardiovasculaire et la mortalité comme critères d'efficacité, avant de pouvoir proposer des recommandations sur le dépistage des ces dysfonctions thyroïdiennes dans la population adulte.

Is screening for fetal anomalies reliable in HIV-infected pregnant women? A multicentre study.

OBJECTIVE: To assess the impact of HIV infection on the reliability of the first-trimester screening for Down syndrome, using free beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A and fetal nuchal translucency, and of the second-trimester screening for neural tube defects, using alpha-fetoprotein. PATIENTS AND METHODS: Multicentre study comparing the multiples of the median of markers for Down syndrome and neural tube defect screening among 214 HIV-infected pregnant women and 856 HIV-negative controls undergoing a first-trimester Down syndrome screening test, and 209 HIV-positive women and 836 HIV-negative controls with a risk evaluation for neural tube defect. The influence of treatment, chronic hepatitis and HIV disease characteristics were also evaluated. RESULTS: Multiples of the median medians for pregnancy-associated plasma protein-A and beta-human chorionic gonadotrophin were lower in HIV-positive women than controls (0.88 vs. 1.05 and 0.84 vs. 1.09, respectively; P < 0.005), but these differences had no impact on risk estimation; no differences were observed for the other markers. No association was found between HIV disease characteristics, antiretroviral treatment use at the time of screening or chronic hepatitis and marker levels. CONCLUSION: Screening for Down syndrome during the first trimester and for neural tube defect during the second trimester is accurate for HIV-infected women and should be offered, similar to HIV-negative women.

Continuous assessment of electrical epileptic activity in acute stroke.

OBJECTIVE: To determine the incidence and risk factors of electrical seizures and other electrical epileptic activity using continuous EEG (cEEG) in patients with acute stroke. METHODS: One hundred consecutive patients with acute stroke admitted to our stroke unit underwent cEEG using 10 electrodes. In addition to electrical seizures, repetitive focal sharp waves (RSHWs), repetitive focal spikes (RSPs), and periodic lateralized epileptic discharges (PLEDs) were recorded. RESULTS: In the 100 patients, cEEG was recorded for a mean duration of 17 hours 34 minutes (range 1 hour 12 minutes to 37 hours 10 minutes). Epileptic activity occurred in 17 patients and consisted of RSHWs in seven, RSPs in seven, and PLEDs in three. Electrical seizures occurred in two patients. On univariate Cox regression analysis, predictors for electrical epileptic activity were stroke severity (high score on the National Institutes of Health Stroke Scale) (hazard ratio [HR] 1.12; p = 0.002), cortical involvement (HR 5.71; p = 0.021), and thrombolysis (HR 3.27; p = 0.040). Age, sex, stroke type, use of EEG-modifying medication, and cardiovascular risk factors were not predictors of electrical epileptic activity. On multivariate analysis, stroke severity was the only independent predictor (HR 1.09; p = 0.016). CONCLUSION: In patients with acute stroke, electrical epileptic activity occurs more frequently than previously suspected.

Perfil de ácidos graxos da carne de novilhos europeus e zebuínos alimentados com milheto

O objetivo deste trabalho foi avaliar o perfil de ácidos graxos da carne de novilhos mestiços alimentados, em confinamento, com dietas contendo níveis crescentes de grão de milheto moído em substituição ao grão de milho moído. Foram utilizados 24 tourinhos mestiços europeus e 24 mestiços zebuínos, abatidos aos 24 meses de idade, após 96 dias de confinamento. Utilizou-se o delineamento experimental inteiramente casualizado, com os tratamentos em arranjo fatorial 4x2 (quatro dietas com 0, 33, 66 e 100% de milheto no concetrado e dois grupos genéticos) com seis repetições. O aumento dos níveis de grão de milheto na dieta elevou linearmente a participação dos ácidos graxos, araquídico (C20:0), heneicosanoico (C21:0), α-linolênico (C18:3 n-3) e dihomo-γ-linolênico (C20:3 n-6). Tourinhos europeus apresentaram carne com menor teor dos ácidos graxos, mirístico (C14:0), heneicosanoico (C21:0) e γ-linolênico (C18:3 n-6) do que tourinhos zebuínos. A concentração total de ácidos graxos saturados (45,2%), monoinsaturados (41,2%) e poli-insaturados (8,7%), e a relação monoinsaturados/saturados (1,09) e poli-insaturados/saturados (0,18) não foi alterada pelos grupos genéticos e pelas dietas. O aumento da percentagem de grão de milheto na dieta de tourinhos europeus ou zebuínos melhora a relação entre os ácidos graxos ω-6/ω-3.

Canakinumab Relieves Symptoms of Acute Flares and Improves Health-Related Quality Of Life (HRQoL) in Difficult-To-Treat Gouty Arthritis Patients by Suppressing Inflammation: Results of a Randomized, Dose-Ranging Study

RATIONALE:We investigated the impact of canakinumab, a fully human anti-interleukin-1b monoclonal antibody on inflammation and HRQoL in gouty arthritis patients.METHODS: In this 8-week, single-blind, dose-ranging study, patients with acute gouty arthritis flares, unresponsive/intolerant or contraindicated to NSAIDs and/or colchicine were randomized to single subcutaneous canakinumab (10, 25, 50, 90, or 150mg, N5143) or single intramuscular triamcinolone acetonide (TA, 40mg, N557). Patients assessed pain (Likert scale), physicians assessed clinical signs of joint inflammation, and HRQoL was recorded using SF-36.RESULTS: At baseline, 98% patients had moderate-to-extreme pain, 85% had moderate/severe joint swelling, 64-79% had elevated inflammatory markers and HRQoL scores indicated impaired physical function. Percentage of patients with no/mild pain was numerically greater in most canakinumab groups vs. TA, 24-72h post-dose; difference significant for 150mg group at these time-points (P<0.05). Canakinumab 150mg was associated with significantly lower Likert scores for tenderness [OR, 3.2; 95% CI, 1.27-7.89; P50.014] and swelling (OR, 2.7; 95% CI, 1.09-6.50, P50.032) at 72h vs. TA; erythema was not different. Median CRP and SAA levels normalized by 7 days post-dose in most canakinumab groups, but remained elevated in TA. Physical function improved at 7 days postdose in all groups, highest improvement for canakinumab 150mg. SF-36 scores for physical functioning and bodily pain with canakinumab 150mg approached US general population scores by 7 days post-dose and exceeded normal values by 8 weeks post-dose.CONCLUSION: Canakinumab 150mg produced significantly greater and rapid pain-relief and improvements in HRQoL vs. TAin acute gouty arthritis patients.

Efeito da omissão de macronutrientes no crescimento, nos sintomas de deficiências nutricionais e na composição mineral em gravioleiras (Annona muricata)

Com o objetivo de avaliar o efeito da omissão de macronutrientes no crescimento, nos sintomas de deficiências nutricionais e na composição mineral em gravioleiras, conduziu-se experimento em casa de vegetação, mediante a técnica do elemento faltante. O delineamento foi o inteiramente casualizado, com quatro repetições e sete tratamentos, sendo completo (N, P, K, Ca, Mg, S e micronutrientes) e com omissão individual de N, P, K, Ca, Mg e S. As omissões dos macronutrientes afetaram o crescimento em altura, diâmetro das plantas e produção de matéria seca, quando comparados ao tratamento completo. Com base nos teores em g/kg dos macronutrientes nas folhas, encontraram-se os seguintes valores adequados nos tratamento completo e com omissão: N = 14,70 e 8,82; P = 0,92 e 0,47; K = 12,35 e 2,62; Ca = 14,11 e 3,44; Mg = 3,59 e 1,09; S = 5,32 e 2,30.

Logging residues from regeneration fellings for biofuel production - a GIS-based availability and supply cost analysis

Finland has large forest fuel resources. However, the use of forest fuels for energy production has been low, except for small-scale use in heating. According to national action plans and programs related to wood energy promotion, the utilization of such resources will be multiplied over the next few years. The most significant part of this growth will be based on the utilization of forest fuels, produced from logging residues of regeneration fellings, in industrial and municipal power and heating plants. Availability of logging residues was analyzed by means of resource and demand approaches in order to identify the most suitable regions with focus on increasing the forest fuel usage. The analysis included availability and supply cost comparisons between power plant sites and resource allocation in a least cost manner, and between a predefined power plant structure under demand and supply constraints. Spatial analysis of worksite factors and regional geographies were carried out using the GIS-model environment via geoprocessing and cartographic modeling tools. According to the results of analyses, the cost competitiveness of forest fuel supply should be improved in order to achieve the designed objectives in the near future. Availability and supply costs of forest fuels varied spatially and were very sensitive to worksite factors and transport distances. According to the site-specific analysis the supply potential between differentlocations can be multifold. However, due to technical and economical reasons ofthe fuel supply and dense power plant infrastructure, the supply potential is limited at plant level. Therefore, the potential and supply cost calculations aredepending on site-specific matters, where regional characteristics of resourcesand infrastructure should be taken into consideration, for example by using a GIS-modeling approach constructed in this study.

Floração da variedade Tobias (Citrus sinensis Osbeck.) sobre três porta-enxertos no Vale do Taquari-RS

O objetivo do trabalho foi determinar a plena floração (70% de flores abertas) de uma variedade cítrica no Vale do Taquari - RS, no ano de 2003. O trabalho foi realizado no Centro de Pesquisa de Fruticultura de Taquari, em um pomar de laranjeira Tobias, com 16 anos de idade, e enxertado sobre os seguintes porta-enxertos: C13, Poncirus trifoliata e Laranjeira Caipira, denominadas de Tobias 1, Tobias 2 e Tobias 3, respectivamente. A data utilizada como início da floração foi 1º/09/2003. A plena floração foi estimada em 16-07 para a variedade Tobias enxertada sobre C13 e Poncirus trifoliata e 19-07 sobre Laranjeira Caipira; a combinação Tobias 2 apresentou a data de plena floração antes da Tobias 3; o quadrante Sul reduz a média da plena floração da Laranjeira Tobias sobre a Laranjeira Caipira (Tobias 3).

Inmigración y formación continuada en el colectivo de enfermería de la región sanitaria de Lleida

El aumento significativo de la inmigración en los últimos años supone un nuevo reto para la enfermería. Objetivos: conocer la situación actual de la formación de enfermería respecto a la inmigración, su interés por formarse y las dificultades y necesidades que tienen en materia de inmigración. Metodología: estudio descriptivo y transversal analizando una muestra representativa de todos los profesionales de enfermería colegiados en la provincia de Lleida. Para la recogida de datos se utilizó un cuestionario y el análisis estadístico se realizó con el programa informático SPSS versión 13.0. Resultados: más del 90% de los profesionales de enfermería de la provincia de Lleida son mujeres menores de 50 años y que mayoritariamente trabajan en atención hospitalaria. No obstante el interés expresado por temas relacionados con la inmigración, sólo el 24% ha realizado algún tipo de formación al respecto. La mayoría también reconoce tener problemas de comunicación con los inmigrantes. Las sugerencias recogidas en el cuestionario se categorizaron en modelos de integración y en formación. Conclusión: la formación de enfermería en inmigración es baja y se debe a su elevado coste y a que no se realiza en horario laboral. En términos generales, los profesionales de enfermería que se dedican a la Atención Primaria de salud, muestran mayor interés por formarse y mayor flexibilidad para modificar los protocolos y cuidados que sus homónimos hospitalarios.

Caracterização fenológica e requerimento térmico para a videira niagara rosada em diferentes épocas de poda no sudoeste Goiano

O experimento foi instalado no município de Aparecida do Rio Doce-GO, no sudoeste Goiano, durante os anos de 2007 e 2008, com o objetivo de avaliar o comportamento fenológico, bem como o requerimento térmico em diferentes épocas de poda: (1) 09-07-07, (2) 28-09-07, (3) 03-03-08 e (4) 19-04-08. Avaliou-se a duração, em dias, dos estádios fenológicos: poda até gemas inchadas; gemas inchadas (gema algodão) a início de brotação (ponta verde); brotação a 5 - 6 folhas separadas; 5 - 6 folhas separadas ao início do florescimento; início do florescimento ao pleno florescimento, pleno florescimento a "chumbinho"; "chumbinho" a "ervilha"; "ervilha" a ½ baga; ½ baga à início da maturação e início da maturação até plena maturação. Os requerimentos térmicos foram obtidos em termos de graus-dia (GD) necessários para atingir os seguintes subperíodos: poda a brotação, brotação a floração e floração a colheita. A duração do ciclo foi de 127; 130; 163 e 161 dias para as épocas de podas 1; 2; 3 e 4, respectivamente, sendo que, nas épocas 1 e 2, a colheita foi antecipada em 32 dias em relação às demais. Os períodos compreendidos entre início e final de maturação, ½ baga a início da maturação; "ervilha" a ½ baga apresentaram a maior duração nas 4 épocas de poda. O maior e o menor requerimento térmico, considerando temperaturas-base de 10 e 12 °C, foram registrados para as podas de julho (menor ciclo) e de abril (segundo maior ciclo) com 2.214,5 e 1.911,5 GD e 1.960,3 e 1.638,3 GD, respectivamente.

Produção e qualidade da videira cv. Niágara Rosada em diferentes épocas de poda no sudoeste goiano

O experimento foi realizado no município de Aparecida do Rio Doce-GO, no sudoeste Goiano, durante os anos de 2007 e 2008, visando a caracterizar a produção da videira 'Niágara Rosada', em diferentes épocas de poda: (1) 09-07-07; (2) 28-09-07; (3) 03-03-08 e (4) 19-04-08. Variáveis associadas à produção por planta, avaliação de cachos e bagas, folhas remanescentes na colheita, posição de brotos na gema e quantidade de cachos/broto, pH, sólidos solúveis (SS), acidez titulável (AT) e relação SS/AT foram analisadas nas produções obtidas nas quatro épocas de poda. A maior massa de cachos foi encontrada nas podas de julho e de abril. As podas realizadas em março e abril permitiram maior número de cachos e maior produtividade. A poda de setembro apresentou maior comprimento, largura e massa de bagas. A qualidade dos frutos foi semelhante entre as safras, mostrando apenas diferenças significativas para pH, AT e para a relação SS/AT nas quatro épocas. A época de poda 3 apresentou o menor valor de folhas remanescentes em relação às demais (6,15 folhas), não sendo considerado como grande desfolha nem causando quedas de produtividade. Para a avaliação da posição do broto na gema, a maior média foi observada na época de poda 1, sendo que as gemas de maior frequência de emissão de ramos com frutos foram aquelas onde se aplicou a cianamida hidrogenada (3ª a 6ª gema), indispensável na estimulação das brotações em videiras. Então, conclui-se que a videira Niágara Rosada pode ser podada nas quatro épocas do ano estudadas no Sudoeste Goiano, já que as avaliações dos cachos e bagas mostraram-se satisfatórias em relação a outras regiões, e as precipitações não afetaram a qualidade final dos frutos em nenhum dos períodos.

Adjusting fracture probability by trabecular bone score.

The aim of the present study was to determine the impact of trabecular bone score on the probability of fracture above that provided by the clinical risk factors utilized in FRAX. We performed a retrospective cohort study of 33,352 women aged 40-99 years from the province of Manitoba, Canada, with baseline measurements of lumbar spine trabecular bone score (TBS) and FRAX risk variables. The analysis was cohort-specific rather than based on the Canadian version of FRAX. The associations between trabecular bone score, the FRAX risk factors and the risk of fracture or death were examined using an extension of the Poisson regression model and used to calculate 10-year probabilities of fracture with and without TBS and to derive an algorithm to adjust fracture probability to take account of the independent contribution of TBS to fracture and mortality risk. During a mean follow-up of 4.7 years, 1754 women died and 1639 sustained one or more major osteoporotic fractures excluding hip fracture and 306 women sustained one or more hip fracture. When fully adjusted for FRAX risk variables, TBS remained a statistically significant predictor of major osteoporotic fractures excluding hip fracture (HR/SD 1.18, 95 % CI 1.12-1.24), death (HR/SD 1.20, 95 % CI 1.14-1.26) and hip fracture (HR/SD 1.23, 95 % CI 1.09-1.38). Models adjusting major osteoporotic fracture and hip fracture probability were derived, accounting for age and trabecular bone score with death considered as a competing event. Lumbar spine texture analysis using TBS is a risk factor for osteoporotic fracture and a risk factor for death. The predictive ability of TBS is independent of FRAX clinical risk factors and femoral neck BMD. Adjustment of fracture probability to take account of the independent contribution of TBS to fracture and mortality risk requires validation in independent cohorts.

Colorectal Cancer Screening in Switzerland: Cross-Sectional Trends (2007-2012) in Socioeconomic Disparities.

BACKGROUND: Despite universal health care coverage, disparities in colorectal cancer (CRC) screening by income in Switzerland have been reported. However, it is not known if these disparities have changed over time. This study examines the association between socioeconomic position and CRC screening in Switzerland between 2007 and 2012. METHODS: Data from the 2007 (n = 5,946) and 2012 (n = 7,224) population-based Swiss Health Interview Survey data (SHIS) were used to evaluate the association between monthly household income, education, and employment with CRC screening, defined as endoscopy in the past 10 years or fecal occult blood test (FOBT) in the past 2 years. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and health utilization. RESULTS: CRC screening increased from 18.9% in 2007 to 22.2% in 2012 (padjusted: = 0.036). During the corresponding time period, endoscopy increased (8.2% vs. 15.0%, padjusted:<0.001) and FOBT decreased (13.0% vs. 9.8%, padjusted:0.002). CRC screening prevalence was greater in the highest income (>$6,000) vs. lowest income (≤$2,000) group in 2007 (24.5% vs. 10.5%, PR:1.37, 95%CI: 0.96-1.96) and in 2012 (28.6% vs. 16.0%, PR:1.45, 95%CI: 1.09-1.92); this disparity did not significantly change over time. CONCLUSIONS: While CRC screening prevalence in Switzerland increased from 2007 to 2012, CRC screening coverage remains low and disparities in CRC screening by income persisted over time. These findings highlight the need for increased access to CRC screening as well as enhanced awareness of the benefits of CRC screening in the Swiss population, particularly among low-income residents.

Serum Vitamin D Concentrations Are Not Associated with Insulin Resistance in Swiss Adults.

BACKGROUND: Low vitamin D status has been associated with an increased risk of developing type 2 diabetes and insulin resistance (IR), although this has been recently questioned. OBJECTIVE: We examined the association between serum vitamin D metabolites and incident IR. METHODS: This was a prospective, population-based study derived from the CoLaus (Cohorte Lausannoise) study including 3856 participants (aged 51.2 ± 10.4 y; 2217 women) free from diabetes or IR at baseline. IR was defined as a homeostasis model assessment (HOMA) index >2.6. Fasting plasma insulin and glucose were measured at baseline and at follow-up to calculate the HOMA index. The association of vitamin D metabolites with incident IR was analyzed by logistic regression, and the results were expressed for each independent variable as ORs and 95% CIs. RESULTS: During the 5.5-y follow-up, 649 (16.9%) incident cases of IR were identified. Participants who developed IR had lower baseline serum concentrations of 25-hydroxyvitamin D3 [25(OH)D3 (25-hydroxycholecalciferol); 45.9 ± 22.8 vs. 49.9 ± 22.6 nmol/L; P < 0.001], total 25(OH)D3 (25(OH)D3 + epi-25-hydroxyvitamin D3 [3-epi-25(OH)D3]; 49.1 ± 24.3 vs. 53.3 ± 24.1 nmol/L; P < 0.001), and 3-epi-25(OH)D3 (4.2 ± 2.9 vs. 4.3 ± 2.5 nmol/L; P = 0.01) but a higher 3-epi- to total 25(OH)D3 ratio (0.09 ± 0.05 vs. 0.08 ± 0.04; P = 0.007). Multivariable analysis adjusting for month of sampling, age, and sex showed an inverse association between 25(OH)D3 and the likelihood of developing IR [ORs (95% CIs): 0.86 (0.68, 1.09), 0.60 (0.46, 0.78), and 0.57 (0.43, 0.75) for the second, third, and fourth quartiles compared with the first 25(OH)D3 quartile; P-trend < 0.001]. Similar associations were found between total 25(OH)D3 and incident IR. There was no significant association between 3-epi-25(OH)D3 and IR, yet a positive association was observed between the 3-epi- to total 25(OH)D3 ratio and incident IR. Further adjustment for body mass index, sedentary status, and smoking attenuated the association between 25(OH)D3, total 25(OH)D3, and the 3-epi- to total 25(OH)D3 ratio and the likelihood of developing IR. CONCLUSION: In the CoLaus study in healthy adults, the risk of incident IR is not associated with serum concentrations of 25(OH)D3 and total 25(OH)D3.

Transient detectable viremia and the risk of viral rebound in patients from the Swiss HIV Cohort Study.

BACKGROUND: Temporary increases in plasma HIV RNA ('blips') are common in HIV patients on combination antiretroviral therapy (cART). Blips above 500 copies/mL have been associated with subsequent viral rebound. It is not clear if this relationship still holds when measurements are made using newer more sensitive assays. METHODS: We selected antiretroviral-naive patients that then recorded one or more episodes of viral suppression on cART with HIV RNA measurements made using more sensitive assays (lower limit of detection below 50 copies/ml). We estimated the association in these episodes between blip magnitude and the time to viral rebound. RESULTS: Four thousand ninety-four patients recorded a first episode of viral suppression on cART using more sensitive assays; 1672 patients recorded at least one subsequent suppression episode. Most suppression episodes (87 %) were recorded with TaqMan version 1 or 2 assays. Of the 2035 blips recorded, 84 %, 12 % and 4 % were of low (50-199 copies/mL), medium (200-499 copies/mL) and high (500-999 copies/mL) magnitude respectively. The risk of viral rebound increased as blip magnitude increased with hazard ratios of 1.20 (95 % CI 0.89-1.61), 1.42 (95 % CI 0.96-2.19) and 1.93 (95 % CI 1.24-3.01) for low, medium and high magnitude blips respectively; an increase of hazard ratio 1.09 (95 % CI 1.03 to 1.15) per 100 copies/mL of HIV RNA. CONCLUSIONS: With the more sensitive assays now commonly used for monitoring patients, blips above 200 copies/mL are increasingly likely to lead to viral rebound and should prompt a discussion about adherence.