Subclinical Hypothyroidism and the Risk of Stroke Events and Fatal Stroke: An Individual Participant Data Analysis

OBJECTIVE The objective was to determine the risk of stroke associated with subclinical hypothyroidism. DATA SOURCES AND STUDY SELECTION Published prospective cohort studies were identified through a systematic search through November 2013 without restrictions in several databases. Unpublished studies were identified through the Thyroid Studies Collaboration. We collected individual participant data on thyroid function and stroke outcome. Euthyroidism was defined as TSH levels of 0.45-4.49 mIU/L, and subclinical hypothyroidism was defined as TSH levels of 4.5-19.9 mIU/L with normal T4 levels. DATA EXTRACTION AND SYNTHESIS We collected individual participant data on 47 573 adults (3451 subclinical hypothyroidism) from 17 cohorts and followed up from 1972-2014 (489 192 person-years). Age- and sex-adjusted pooled hazard ratios (HRs) for participants with subclinical hypothyroidism compared to euthyroidism were 1.05 (95% confidence interval [CI], 0.91-1.21) for stroke events (combined fatal and nonfatal stroke) and 1.07 (95% CI, 0.80-1.42) for fatal stroke. Stratified by age, the HR for stroke events was 3.32 (95% CI, 1.25-8.80) for individuals aged 18-49 years. There was an increased risk of fatal stroke in the age groups 18-49 and 50-64 years, with a HR of 4.22 (95% CI, 1.08-16.55) and 2.86 (95% CI, 1.31-6.26), respectively (p trend 0.04). We found no increased risk for those 65-79 years old (HR, 1.00; 95% CI, 0.86-1.18) or ≥ 80 years old (HR, 1.31; 95% CI, 0.79-2.18). There was a pattern of increased risk of fatal stroke with higher TSH concentrations. CONCLUSIONS Although no overall effect of subclinical hypothyroidism on stroke could be demonstrated, an increased risk in subjects younger than 65 years and those with higher TSH concentrations was observed.

Effect of the REG1 anticoagulation system versus bivalirudin on outcomes after percutaneous coronary intervention (REGULATE-PCI): a randomised clinical trial.

BACKGROUND REG1 is a novel anticoagulation system consisting of pegnivacogin, an RNA aptamer inhibitor of coagulation factor IXa, and anivamersen, a complementary sequence reversal oligonucleotide. We tested the hypothesis that near complete inhibition of factor IXa with pegnivacogin during percutaneous coronary intervention, followed by partial reversal with anivamersen, would reduce ischaemic events compared with bivalirudin, without increasing bleeding. METHODS We did a randomised, open-label, active-controlled, multicentre, superiority trial to compare REG1 with bivalirudin at 225 hospitals in North America and Europe. We planned to randomly allocate 13,200 patients undergoing percutaneous coronary intervention in a 1:1 ratio to either REG1 (pegnivacogin 1 mg/kg bolus [>99% factor IXa inhibition] followed by 80% reversal with anivamersen after percutaneous coronary intervention) or bivalirudin. Exclusion criteria included ST segment elevation myocardial infarction within 48 h. The primary efficacy endpoint was the composite of all-cause death, myocardial infarction, stroke, and unplanned target lesion revascularisation by day 3 after randomisation. The principal safety endpoint was major bleeding. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, identifier NCT01848106. The trial was terminated early after enrolment of 3232 patients due to severe allergic reactions. FINDINGS 1616 patients were allocated REG1 and 1616 were assigned bivalirudin, of whom 1605 and 1601 patients, respectively, received the assigned treatment. Severe allergic reactions were reported in ten (1%) of 1605 patients receiving REG1 versus one (<1%) of 1601 patients treated with bivalirudin. The composite primary endpoint did not differ between groups, with 108 (7%) of 1616 patients assigned REG1 and 103 (6%) of 1616 allocated bivalirudin reporting a primary endpoint event (odds ratio [OR] 1·05, 95% CI 0·80-1·39; p=0·72). Major bleeding was similar between treatment groups (seven [<1%] of 1605 receiving REG1 vs two [<1%] of 1601 treated with bivalirudin; OR 3·49, 95% CI 0·73-16·82; p=0·10), but major or minor bleeding was increased with REG1 (104 [6%] vs 65 [4%]; 1·64, 1·19-2·25; p=0·002). INTERPRETATION The reversible factor IXa inhibitor REG1, as currently formulated, is associated with severe allergic reactions. Although statistical power was limited because of early termination, there was no evidence that REG1 reduced ischaemic events or bleeding compared with bivalirudin. FUNDING Regado Biosciences Inc.

The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus.

OBJECTIVE We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in UIA management and research. METHODS An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39 panel members involved in identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr*) (vr* = 0 indicating excellent agreement and vr* = 1 indicating poor agreement). RESULTS The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (vr*) for both cohorts was 0.026 (95% CI 0.019-0.033). CONCLUSIONS This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA.

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

CONTEXT Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. OBJECTIVE To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. EVIDENCE ACQUISITION A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery." EVIDENCE SYNTHESIS We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. CONCLUSIONS ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. PATIENT SUMMARY This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.

Discrimination in Metropolitan Housing Markets: National Results from Phase 1 of the Housing Discrimination Study (HDS)

The Housing Discrimination Study 2000 (HDS 2000) is the third nationwide effort sponsored by HUD to measure the amount of discrimination faced by minority home seekers. This report provides national estimates of discrimination faced by African Americans and Hispanics in 2000 as they searched for housing in the sales and rental markets. It also provides an accurate measure of how housing discrimination has changed since 1989. The report shows large decreases between 1989 and 2000 in the level of discrimination experienced by Hispanics and African Americans seeking to a buy a home. There are, however, worrisome upward trends of discrimination in the areas of geographic steering in home sales for African Americans and the amount of help agents provide to Hispanics with obtaining financing. There has also been a modest decrease in discrimination toward African Americans seeking to rent a unit. This downward trend, however, has not been seen for Hispanic renters. Hispanic renters now are more likely to experience discrimination in their housing search than do African American renters.

Sechs Predigten, gehalten in der Synagoge zu Hohenems

Abraham Kohn

Geochemistry and minerals at DSDP Leg 81 Holes

Three phases of volcanism have been recognized in the lower Paleogene sequence of the southwest Rockall Plateau which are related to the onset of seafloor spreading in the NE Atlantic. The earliest, Phase 1, is marked by a sequence of tholeiitic basalts and hyaloclastites which form the dipping reflector sequence in Edoras Basin. Phase 2 is characterized by tuffs and lapilli tuffs of air-fall origin, ranging in composition from basic to intermediate. They were generated by highly explosive igneous activity due to magma-water interaction, and terminate at the level of a major transgression. Subsequently, volcanism reverted to tholeiitic basalt type, producing the thin tuffs and minor basalt flows of Phase 3. Alteration of the volcanic glass and diagenesis of the tuffs and lapilli tuffs has been considerable in many cases, with a large number of diagenetic mineral phases observed, including smectite, celadonite, analcime, phillipsite, clinoptilolite, mordenite, and calcite. Although calcite is the latest observed diagenetic cement, it nevertheless occurred relatively early, in one case totally preserving basaltic glass from alteration.

Seal census raw data during POLARSTERN expedition ANT-XV/3 (PS48)

The density, species composition, and possible change in the status of pack ice seals within the Weddell Sea were investigated during the 1997/1998 summer cruise of the RV "Polarstern" (ANT-XV/3, PS48). Comparisons were made with previous surveys in the Weddell Sea where it was assumed that all seals were counted in a narrow strip on either side oft he ship or aircraft. A total of 15 aerial censuses were flown during the period 23 January - 7 March 1998 in the area bounded by 07°08' and 45°33' West longitude. The censused area in the eastern Weddell Sea was largely devoid of pack ice while a well circumscribed pack ice field remained in the western Weddell Sea. A total of 3,636 (95.4 %) crabeater seals, 21 (0.5 %) Ross seals, 45 (1.2 %) leopard seals and 111 (2.9 %) Weddell seals were observed on the pack ice during a total of 1,356.57 linear nautical miles (244.2 nm) of transect line censused. At a mean density of 21.16 1/nm**2 over an area of 244.2 nm, it is the highest densities on record for crabeater seals, density of up to 411.7 1/nm**2 being found in small areas. The overall high densities of seals (30.18 1/nm**2) recorded for the eastern Weddell Sea (27.46 1/nm**2, 0.27 1/nm**2, and 0.66 1/nm**2 for crabeater, leopard and Weddell seals respectively) is a consequence of the drastically reduced ice cover and the inverse relationship that exists between cover and seal densities. Ross seal densities (0.08 1/nm**2) were the lowest on record fort the area. It is suggested that seals largely remain within the confines of the pack ice despite seasonal and annual changes in its distribution. Indications are that in 1998 the El Niño has manifested itself in the Weddell Sea, markedly influencing the density and distribution of pack ice seals.

Organic carbon, age, lithology, and CPI-alkenes at DSDP Sites 57-440 and 56-436

"Bound" and "free" solvent-extractable lipids have been examined from Sections 440A-7-6, 440B-3-5, 440B-8-4, 440B-68-2, and 436-11-4. The compound classes studied include aliphatic and aromatic hydrocarbons, ketones, alcohols, and carboxylic acids. Carotenoids and humic acids have also been examined. The quantitative results are considered in terms of input indicators, diagenesis parameters, and structural classes. A difference in input is deduced across the Japan Trench, with a higher proportion of autochthonous components on the western inner trench slope compared with the more easterly, outer trench, wall and greater input in the early Pleistocene than in the Miocene. A variety of diagenetic transformations is observed at Site 440 as sample depth increases. Results are compared with those of samples from Atlantic Cretaceous sediments and from the Walvis Bay high productivity area.

Carbonate minerals, uranium and thorium concentration and U-Th ages of sediments from ODP Leg 166 sites

We have performed U-Th isotope analyses on pure aragonite samples from the upper sections of Leg 166 cores to assign each aragonite-rich sediment package to the correct sea-level highstand. The uppermost sediment package from each of the four sites investigated (Sites 1003, 1005, 1006, and 1007) yielded a Holocene U-Th age. Sediment packages from deeper in the cores have suffered diagenesis. This diagenesis consists of significant U loss (up to 40%) in the site nearest the platform (Site 1005), slight U gain in sites further from the platform, and continuous loss of pure 234U caused by alpha recoil at all sites. The difference in diagenesis between the sites can be explained by the different fluid-flow histories they have experienced. Site 1005 is sufficiently close to the platform to have probably experienced a change in flow direction whenever the banks have flooded or become exposed. Other sites have probably experienced continuous flow into the sediment. Although diagenesis prevents assignment of accurate ages, it is sufficiently systematic that it can be corrected for and each aragonite-rich package assigned to a unique highstand interval. Site 1005 has sediment packages from highstands associated with marine isotope Stages 1, 5, 7, 9, and 11. Site 1006 is similar, except that the Stage 7 highstand is missing, at least in Hole 1006A. Site 1003 has sediment only from Stage 1 and 11 highstands within the U-Th age range. And Site 1007 has sediment only from the stage 1 highstand. This information will allow the construction of better age models for these sites. No high-aragonite sediments are seen for Stage 3 or Substages 5a and 5c. Unless rather unusual erosion has occurred, this indicates that the banks did not flood during these periods. If true, this would require the sea level for Substages 5a and 5c to have remained at least ~10 m lower than today.