Black race is associated with digital artery endothelial dysfunction: results from the Heart SCORE study

AIMS

We evaluated whether black race is independently associated with arterial endothelial dysfunction. The pathophysiological basis for race-related differences in cardiovascular disease (CVD) risk has not been established. Endothelial dysfunction, which precedes obstructive atherosclerotic disease, may contribute to CVD disparities. Accordingly, we evaluated race-related differences in digital pulse amplitude tonometry (PAT) response to an endothelium-dependent vasodilatory stimulus.

METHODS AND RESULTS

A total of 1377 subjects (41% black; mean age 58.5 ± 7.5 years; 67% female) enrolled in the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study underwent assessment of digital pulse amplitude response to forearm occlusion-induced hyperaemia. The response was measured as a PAT ratio of hyperaemia:baseline pulse amplitude in a finger that was subject to hyperaemic stimulus divided by this same ratio in a control finger on the contralateral arm which did not undergo forearm occlusion, expressed as the natural logarithm. The average PAT ratio was significantly lower in blacks compared with whites (0.67 ± 0.44 vs. 0.80 ± 0.46, P < 0.001), signifying greater endothelial dysfunction in blacks. Black race was independently correlated with lower PAT ratio. This finding was consistent across all Framingham risk strata. Adjusted analyses showed significant gender-race interactions. With white women serving as the referent group, parameter estimates for lower PAT ratio in ascending order were as follows: black males (t = -6.93, P < 0.0001); white males (t = -3.31, P = 0.001); and black females (t = -1.12, P = 0.26).

CONCLUSION

Our findings indicate that black race is independently associated with arterial endothelial dysfunction. Racial differences in CVD risk may be related, in part, to race-related differences in endothelial dysfunction.

Acute physiologic effects of secondhand smoke exposure in children

INTRODUCTION

We investigated the hypothesis that exhaled carbon monoxide (eCO), heart rate (HR), and blood pressure (BP) would increase acutely in exposed but not in unexposed children.

METHODS

In a nonrandomized controlled design, parent-child dyads were assigned to groups based on exposure: child subjects, 7-18 years of age, exposed to smoking daily in the home (exposed) or with no household exposure (unexposed control). HR, BP, and eCO were measured before and after exposure to a parent smoking 1 cigarette (exposed) or a time-lapse equivalent (control). The primary analysis compared mean acute changes in physiological measures following intervention or control procedure.

RESULTS

Forty-one dyads were enrolled. At baseline, no differences in child gender, race, ethnicity, HR, BP, lipids, or fasting glucose were noted between exposure groups. Following experimental or control procedures, the median change in eCO was similar between groups (-0.1 ppm exposed vs. 0.0 ppm unexposed, p = .27). Acute hemodynamic changes were also similar between exposed and unexposed children, respectively: (HR change 4.2 vs. 2.6 beats per minute, p = .62; systolic blood pressure change 0.08 vs. 0.41 mm Hg, p = .91; diastolic blood pressure 0.08 vs. 2.27 mm Hg, p = .37).

DISCUSSION

This is the first study to report on acute physiologic changes of secondhand smoke exposure in children in a naturalistic setting. A single acute dose of passive smoke exposure in children did not alter the physiologic variables of HR or BP. Further in-home study using continuous monitoring is needed. Demonstration of acute effects may serve as clinical feedback to motivate parents to quit smoking.

Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center

BACKGROUND

Our primary aim was to determine if the rate of small bowel resection (SBR) has declined over time among Crohn's disease (CD) patients seen at a single academic institution. A secondary aim was to establish whether the indication for surgery has changed.

METHODS

Patients with a primary or secondary ICD-9 code for CD (555.0-555.9) who underwent SBR at the University of Pittsburgh were included. Patients were divided into 4 separate time periods based on when they had surgery: 1995-1998 (Period 1), 1999-2001 (Period 2), 2002-2004 (Period 3), and 2005-2007 (Period 4). Medical records were reviewed for the 6 months preceding surgery. Use of 5-ASAs, immunomodulators (IMs), tumor necrosis factor (TNF) antagonists, and corticosteroids were noted. Disease behavior was defined as nonstricturing, nonpenetrating (B1), stricturing (B2), and penetrating (B3). Proportions of patients undergoing SBR were calculated according to calendar cohort and these rates were examined for time trends.

RESULTS

In all, 227 unique patients were analyzed for a total of 236 surgeries. The rates of 5-ASA, IM, and corticosteroid use were similar across the 4 time periods. By contrast, TNF antagonist usage progressively increased over time (0%, 18%, 34%, 35%; P = 0.0002). The annual rate of SBR per period did not change (1.6%, 1.9%, 1.6%, 1.9%; P = 0.93). Similarly, the disease behavior did not change over time.

CONCLUSIONS

While the frequency of TNF antagonist use in CD at the University of Pittsburgh has increased over time, the rate of SBR and indication for surgery has remained unchanged. These findings may be explained by long-standing, complicated disease refractory to medical therapy.

Poor 1-year outcomes after percutaneous coronary interventions in systemic lupus erythematosus: report from the National Heart, Lung, and Blood Institute Dynamic Registry

BACKGROUND

Women with systemic lupus erythematosus (SLE) have premature and accelerated atherosclerosis. Although percutaneous coronary intervention (PCI) is used frequently to treat coronary artery disease in SLE, little is known regarding PCI outcomes immediately after PCI and after discharge.

METHODS AND RESULTS

Baseline demographic, procedure-related, and adverse outcome data on consecutive patients undergoing PCI during 5 recruitment "waves" of the National Heart, Lung, and Blood Institute Dynamic Registry across 23 clinical centers were collected. SLE patients (n=28) were compared with non-SLE patients (n=3385). SLE patients were younger and more often female in comparison with non-SLE patients undergoing PCI. SLE patients were less likely than non-SLE patients to have hyperlipidemia but had a similar prevalence of hypertension, diabetes mellitus, and tobacco use. The prevalence of multivessel disease was similar between groups. Initial intervention success (by angiographic definition) was not significantly different between groups. At 1 year, SLE patients were more likely to experience a myocardial infarction (15.6% versus 4.8%, P=0.01) and more often required repeat PCI (31.3% versus 11.8%, P=0.009) than non-SLE patients, even after adjustment for important covariates.

CONCLUSIONS

SLE patients had significantly worse cardiovascular outcomes at 1 year than non-SLE patients. Even considering the small number of SLE patients, these differences were striking. Further study is warranted to explore other factors potentially accounting for this disparity, including SLE disease activity and duration, presence of hypercoagulable state, and immunosuppressive therapy.

Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer

OBJECTIVES

Considerable morbidity persists among survivors of breast cancer (BC) including high levels of psychological stress, anxiety, depression, fear of recurrence, and physical symptoms including pain, fatigue, and sleep disturbances, and impaired quality of life. Effective interventions are needed during this difficult transitional period.

METHODS

We conducted a randomized controlled trial of 84 female BC survivors (Stages 0-III) recruited from the H. Lee Moffitt Cancer and Research Institute. All subjects were within 18 months of treatment completion with surgery and adjuvant radiation and/or chemotherapy. Subjects were randomly assigned to a 6-week Mindfulness-Based Stress Reduction (MBSR) program designed to self-regulate arousal to stressful circumstances or symptoms (n=41) or to usual care (n=43). Outcome measures compared at 6 weeks by random assignment included validated measures of psychological status (depression, anxiety, perceived stress, fear of recurrence, optimism, social support) and psychological and physical subscales of quality of life (SF-36).

RESULTS

Compared with usual care, subjects assigned to MBSR(BC) had significantly lower (two-sided p<0.05) adjusted mean levels of depression (6.3 vs 9.6), anxiety (28.3 vs 33.0), and fear of recurrence (9.3 vs 11.6) at 6 weeks, along with higher energy (53.5 vs 49.2), physical functioning (50.1 vs 47.0), and physical role functioning (49.1 vs 42.8). In stratified analyses, subjects more compliant with MBSR tended to experience greater improvements in measures of energy and physical functioning.

CONCLUSIONS

Among BC survivors within 18 months of treatment completion, a 6-week MBSR(BC) program resulted in significant improvements in psychological status and quality of life compared with usual care.

Paclitaxel-eluting versus sirolimus-eluting stents in diabetes mellitus: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

BACKGROUND

Diabetes is a powerful predictor of adverse events in patients undergoing percutaneous coronary intervention. Drug-eluting stents reduce restenosis rates compared with bare metal stents; however, controversy remains regarding which drug-eluting stents provides greater benefit in patients with diabetes. Accordingly, we compared the safety and efficacy of sirolimus-eluting stents (SES) with paclitaxel-eluting stents (PES) among diabetic patients in a contemporary registry.

METHODS AND RESULTS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 2-year outcomes of diabetic patients undergoing percutaneous coronary interventions with SES (n=677) and PES (n=328). Clinical and demographic characteristics, including age, body mass index, insulin use, left ventricular function, and aspirin/clopidogrel use postprocedure, did not differ significantly between the groups except that PES-treated patients had a greater frequency of hypertension and hyperlipidemia. At the 2-year follow-up, no significant differences were observed between PES and SES with regard to safety or efficacy end points. PES- and SES-treated patients had similar rates of death (10.7% versus 8.2%, P=0.20), death and myocardial infarction (14.9% versus 13.6%, P=0.55), repeat revascularization (14.8% versus 17.8%, P=0.36), and stent thrombosis (1.3% versus 1.3%, P=0.95). After adjustment, no significant differences between the 2 stent types in any outcome were observed.

CONCLUSIONS

PES and SES are equally efficacious and have similar safety profiles in diabetic patients undergoing percutaneous coronary interventions in clinical practice.

Temporal trends in patient-reported angina at 1 year after percutaneous coronary revascularization in the stent era: a report from the National Heart, Lung, and Blood Institute-sponsored 1997-2006 dynamic registry

BACKGROUND

Percutaneous coronary intervention (PCI) has witnessed rapid technological advancements, resulting in improved safety and effectiveness over time. Little, however, is known about the temporal impact on patient-reported symptoms and quality of life after PCI.

METHODS AND RESULTS

Temporal trends in post-PCI symptoms were analyzed using 8879 consecutive patients enrolled in the National Heart, Lung, and Blood Institute-sponsored Dynamic Registry (wave 1: 1997 [bare metal stents], wave 2: 1999 [uniform use of stents], wave 3: 2001 [brachytherapy], wave 4, 5: 2004, 2006 [drug eluting stents]). Patients undergoing PCI in the recent waves were older and more often reported comorbidities. However, fewer patients across the waves reported post-PCI angina at one year (wave 1 to 5: 24%, 23%, 18%, 20%, 20%; P(trend)<0.001). The lower risk of angina in recent waves was explained by patient characteristics including use of antianginal medications at discharge (relative risk [95% CI] for waves 2, 3, 4 versus 1: 1.0 [0.9 to 1.2], 0.9 [0.7 to 1.1], 1.0 [0.8 to 1.3], 0.9 [0.7 to 1.1]). Similar trend was seen in the average quality of life scores over time (adjusted mean score for waves 1 to 5: 6.2, 6.5, 6.6 and 6.6; P(trend)=0.01). Other factors associated with angina at 1 year included younger age, female gender, prior revascularization, need for repeat PCI, and hospitalization for myocardial infarction over 1 year.

CONCLUSIONS

Favorable temporal trends are seen in patient-reported symptoms after PCI in routine clinical practice. Specific subgroups, however, remain at risk for symptoms at 1 year and thus warrant closer attention.

Impact of drug-eluting stents among insulin-treated diabetic patients: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

OBJECTIVES

This study sought to evaluate the safety and efficacy of drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with insulin- and noninsulin-treated diabetes.

BACKGROUND

Diabetes is a powerful predictor of adverse events after percutaneous coronary interventions (PCI), and insulin-treated diabetic patients have worse outcomes. The DES are efficacious among patients with diabetes; however, their safety and efficacy, compared with BMS, among insulin-treated versus noninsulin-treated diabetic patients is not well established.

METHODS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 1-year outcomes of insulin-treated (n = 817) and noninsulin-treated (n = 1,749) patients with diabetes who underwent PCI with DES versus BMS.

RESULTS

The use of DES, compared with BMS, was associated with a lower risk for repeat revascularization for both noninsulin-treated patients (adjusted hazard ratio [HR] = 0.59, 95% confidence interval [CI] 0.45 to 0.76) and insulin-treated subjects (adjusted HR = 0.63, 95% CI 0.44 to 0.90). With respect to safety in the overall diabetic population, DES use was associated with a reduction of death or myocardial infarction (adjusted HR = 0.75, 95% CI 0.58 to 0.96). However, this benefit was confined to the population of noninsulin-treated patients (adjusted HR = 0.57, 95% CI 0.41 to 0.81). Among insulin-treated patients, there was no difference in death or myocardial infarction risk between DES- and BMS-treated patients (adjusted HR = 0.95, 95% CI 0.65 to 1.39).

CONCLUSIONS

Drug-eluting stents are associated with lower risk for repeat revascularization compared with BMS in treating coronary artery disease among patients with either insulin- or noninsulin-treated diabetes. In addition, DES use is not associated with any significant increased safety risk compared with BMS. These findings suggest that DES should be the preferred strategy for diabetic patients.

Baseline coronary angiographic findings in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial (BARI 2D)

This report describes the baseline angiographic findings in the Bypass Angioplasty Revascularization Investigation (BARI) 2 Diabetes (BARI 2D) trial, a randomized study that was initiated after the original BARI trial (BARI 1). Unlike BARI 1, which compared coronary artery bypass graft surgery with coronary angioplasty (percutaneous coronary intervention) in patients with and without diabetes, BARI 2D is investigating early versus deferred revascularization as needed in selected patients with type 2 diabetes mellitus and significant stable coronary artery disease (CAD). This analysis included 1,773 patients without previous procedures. The intended mode of revascularization, percutaneous coronary intervention or coronary artery bypass graft surgery, was specified before randomization. Angiographic findings in those randomized to revascularization versus medical treatment were similar. Overall, the mean number of lesions >or=20% diameter stenosis was 4.6 +/- 2.3, and the myocardial jeopardy index was 46 +/- 24%. Patients selected for the coronary artery bypass graft stratum had a higher mean number of lesions >or=20% diameter stenosis (5.7 vs 4.0, p <0.0001) and a higher myocardial jeopardy index (61% vs 38%, p <0.0001) than those selected for the percutaneous coronary intervention stratum. Female gender, black race, and higher body mass index were associated with less extensive CAD, whereas a history of hypertension, age at entry, low-density lipoprotein cholesterol, and ankle-brachial index <or=0.9 were associated with more extensive CAD. In conclusion, BARI 2D patients, who by design have mild or no symptoms, demonstrate considerable variation in the extent of CAD and amount of jeopardized myocardium. Coronary arteriographic findings are consistent with the intent of the design of BARI 2D. Certain baseline and clinical features were associated with the extent of disease and myocardial jeopardy.

Infliximab prevents Crohn's disease recurrence after ileal resection

BACKGROUND & AIMS

Crohn's disease commonly recurs after intestinal resection. We evaluated whether the administration of infliximab after resective intestinal surgery for Crohn's disease reduces postoperative recurrence.

METHODS

We randomly assigned 24 patients with Crohn's disease who had undergone ileocolonic resection to receive intravenous infliximab (5 mg/kg), administered within 4 weeks of surgery and continued for 1 year, or placebo. The primary end point was the proportion of patients with endoscopic recurrence at 1 year. Secondary end points were clinical recurrence and remission and histologic recurrence.

RESULTS

The rate of endoscopic recurrence at 1 year was significantly lower in the infliximab group (1 of 11 patients; 9.1%) compared with the placebo group (11 of 13 patients; 84.6%) (P = .0006). There was a nonsignificant higher proportion of patients in clinical remission in the infliximab group (8 of 10; 80.0%) compared with the placebo group (7 of 13; 53.8%) (P = .38). The histologic recurrence rate at 1 year was significantly lower in the infliximab group (3 of 11 patients; 27.3%) compared with the placebo group (11 of 13 patients; 84.6%) (P = .01). The occurrence of adverse events was similar between the placebo and infliximab groups, and none occurred in the immediate postoperative period.

CONCLUSIONS

Administration of infliximab after intestinal resective surgery was effective at preventing endoscopic and histologic recurrence of Crohn's disease.

Twenty-year evolution of percutaneous coronary intervention and its impact on clinical outcomes: a report from the National Heart, Lung, and Blood Institute-sponsored, multicenter 1985-1986 PTCA and 1997-2006 Dynamic Registries

BACKGROUND

Percutaneous coronary intervention (PCI) has undergone rapid progress, both in technology and adjunct therapy. However, documentation of long-term temporal trends in relation to contemporary practice is lacking.

METHODS AND RESULTS

We analyzed PCI use and outcomes in 8976 consecutive patients in the multicenter, National Heart, Lung, and Blood Institute-sponsored 1985-1986 percutaneous transluminal coronary angioplasty (PTCA) and 1997-2006 Dynamic Registries waves (wave 1: 1997-1998, bare-metal stents; wave 2: 1999, uniform use of stents; wave 3: 2001-2002, brachytherapy; waves 4 and 5: 2004-2006, drug-eluting stents). Patients undergoing PCI in the recent waves were older and more often reported comorbidities than those in the balloon era. PCI was more often performed for acute coronary syndromes and, in spite of the greater disease burden, was more often selective. Procedural success was achieved and maintained more often in the stent era. Significant reductions were observed in in-hospital rates (%) of myocardial infarction (PTCA Registry: 4.9; wave 1, 2.7; wave 2, 2.8; wave 3, 1.9; wave 4, 2.6; wave 5, 2; P(trend)<0.001) and emergency coronary artery bypass surgery (PTCA Registry: 3.7; wave 1, 0.4; wave 2, 0.4; wave 3, 0.3; wave 4, 0.4; wave 5, 0; P(trend)<0.001). Compared with the PTCA Registry, risk for repeat revascularization (31 to 365 days after index PCI) was significantly lower in the dynamic waves (adjusted hazard ratio: wave 1, 0.72; wave 2, 0.51; wave 3, 0.51; wave 4, 0.30; wave 5, 0.36; P<0.05 for all).

CONCLUSIONS

Percutaneous interventions, in the last 2 decades, have evolved to include more urgent, comorbid cases, despite achieving high success rates with significantly reduced need for repeat revascularization.

Population variations in atherogenic dyslipidemia: A report from the HeartSCORE and IndiaSCORE Studies

BACKGROUND

Asian Indians and blacks have a higher risk for cardiovascular disease (CVD) events compared to whites. Atherogenic dyslipidemia, comprised of small-dense low-density lipoprotein (LDL), low high-density lipoprotein (HDL) levels, and high triglyceride (TG) levels, constitutes an important risk factor for CVD often seen in the presence of obesity. The contribution of atherogenic dyslipidemia to CVD risk across diverse racial populations is not well established.

OBJECTIVE

Our primary aim was to investigate the relationship between race and atherogenic dyslipidemia among whites, blacks, and Asian Indians. A secondary aim was to evaluate the association between obesity and atherogenic dyslipidemia across populations.

METHODS

From community-based sampling, 720 whites and 373 blacks underwent evaluation of CVD risk factors, including fasting lipoproteins. An identical protocol was administered to 205 Asian Indians from Chennai, India. Lipid profiles, including those comprising atherogenic dyslipidemia, were compared among populations.

RESULTS

The prevalence of small-dense LDL (pattern B) and of TG/HDL ratio >3 was greatest among Asian Indians and smallest among blacks. Compared to whites, the adjusted odds for Indians having a LDL pattern B was 2.06 (P < .001) and TG/HDL ratio >3 was 9.42 (P < .001). The adjusted odds of having LDL pattern B (odds ratio 0.39, P < 0.001) or TG/HDL ratio >3 (odds ratio 0.41, P < .001) was lower in blacks compared to whites. Among Indians, obesity had a weak association with atherogenic dyslipidemia, in contrast to the strong association among whites.

CONCLUSIONS

Significant population variations in atherogenic dyslipidemia exist. This may be an important component to explain population differences in cardiovascular risk.

Postmenopausal women with a history of irregular menses and elevated androgen measurements at high risk for worsening cardiovascular event-free survival: results from the National Institutes of Health--National Heart, Lung, and Blood Institute sponsored Women's Ischemia Syndrome Evaluation

BACKGROUND

Women with polycystic ovary syndrome (PCOS) have a greater clustering of cardiac risk factors. However, the link between PCOS and cardiovascular (CV) disease is incompletely described.

OBJECTIVE

The aim of this analysis was to evaluate the risk of CV events in 390 postmenopausal women enrolled in the National Institutes of Health-National Heart, Lung, and Blood Institute (NIH-NHLBI) sponsored Women's Ischemia Syndrome Evaluation (WISE) study according to clinical features of PCOS.

METHODS

A total of 104 women had clinical features of PCOS defined by a premenopausal history of irregular menses and current biochemical evidence of hyperandrogenemia. Hyperandrogenemia was defined as the top quartile of androstenedione (> or = 701 pg/ml), testosterone (> or = 30.9 ng/dl), or free testosterone (> or = 4.5 pg/ml). Cox proportional hazard model was fit to estimate CV death or myocardial infarction (n = 55).

RESULTS

Women with clinical features of PCOS were more often diabetic (P < 0.0001), obese (P = 0.005), had the metabolic syndrome (P < 0.0001), and had more angiographic coronary artery disease (CAD) (P = 0.04) compared to women without clinical features of PCOS. Cumulative 5-yr CV event-free survival was 78.9% for women with clinical features of PCOS (n = 104) vs. 88.7% for women without clinical features of PCOS (n = 286) (P = 0.006). PCOS remained a significant predictor (P < 0.01) in prognostic models including diabetes, waist circumference, hypertension, and angiographic CAD as covariates.

CONCLUSION

Among postmenopausal women evaluated for suspected ischemia, clinical features of PCOS are associated with more angiographic CAD and worsening CV event-free survival. Identification of postmenopausal women with clinical features of PCOS may provide an opportunity for risk factor intervention for the prevention of CAD and CV events.

A comparison of bare-metal and drug-eluting stents for off-label indications

BACKGROUND

Recent reports suggest that off-label use of drug-eluting stents is associated with an increased incidence of adverse events. Whether the use of bare-metal stents would yield different results is unknown.

METHODS

We analyzed data from 6551 patients in the National Heart, Lung, and Blood Institute Dynamic Registry according to whether they were treated with drug-eluting stents or bare-metal stents and whether use was standard or off-label. Patients were followed for 1 year for the occurrence of cardiovascular events and death. Off-label use was defined as use in restenotic lesions, lesions in a bypass graft, left main coronary artery disease, or ostial, bifurcated, or totally occluded lesions, as well as use in patients with a reference-vessel diameter of less than 2.5 mm or greater than 3.75 mm or a lesion length of more than 30 mm.

RESULTS

Off-label use occurred in 54.7% of all patients with bare-metal stents and 48.7% of patients with drug-eluting stents. As compared with patients with bare-metal stents, patients with drug-eluting stents had a higher prevalence of diabetes, hypertension, renal disease, previous percutaneous coronary intervention and coronary-artery bypass grafting, and multivessel coronary artery disease. One year after intervention, however, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug-eluting stents as compared with those with bare-metal stents, whereas the risk of repeat revascularization was significantly lower among patients with drug-eluting stents.

CONCLUSIONS

Among patients with off-label indications, the use of drug-eluting stents was not associated with an increased risk of death or myocardial infarction but was associated with a lower rate of repeat revascularization at 1 year, as compared with bare-metal stents. These findings support the use of drug-eluting stents for off-label indications.

Do short-term markers of treatment efficacy predict long-term sequelae of pelvic inflammatory disease?

OBJECTIVE

This study was undertaken to assess whether short-term markers, often used to measure clinical cure after treatment for pelvic inflammatory disease, predict sequelae of lack of pregnancy, recurrent pelvic inflammatory disease, and chronic pelvic pain.

STUDY DESIGN

Women with mild-to-moderate pelvic inflammatory disease were assessed after treatment initiation at 5 days for tenderness (n = 713) and at 30 days for tenderness, cervical infections and endometritis (n = 298). Pregnancy, recurrent pelvic inflammatory disease, and chronic pelvic pain were evaluated after 84 months, on average.

RESULTS

Pelvic tenderness at 5 and at 30 days significantly elevated the risk for developing chronic pelvic pain; tenderness at 30 days was also significantly associated with recurrent pelvic inflammatory disease. However, pelvic tenderness at 5 and at 30 days was only modestly clinically predictive of chronic pelvic pain or recurrent pelvic inflammatory disease (positive predictive values 22.1-66.9%). No short-term marker significantly influenced the likelihood of achieving a pregnancy.

CONCLUSION

Tenderness at 5 or 30 days did not accurately predict the occurrence of pelvic inflammatory disease-related reproductive morbidities.

Early pregnancy lipid concentrations and spontaneous preterm birth

OBJECTIVE

Women who deliver preterm infants may be at increased risk for cardiovascular disease, perhaps related to dyslipidemia.

STUDY DESIGN

In a nested case control study of women with spontaneous preterm birth, cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were evaluated. Lipid concentrations and gestational changes, as well as risk for preterm birth, were evaluated in women who delivered <34 (n = 23), >or=34-<37 (n = 67), and >or=37 weeks (n = 199).

RESULTS

High cholesterol or triglycerides <or=15 weeks were associated with a 2.8-fold (1.0-7.9) and 2.0-fold (1.0-3.9) increased risk for preterm birth <34 weeks and >or=34-<37 weeks, respectively. Overweight women who delivered <34 weeks had particularly elevated early pregnancy concentrations of cholesterol and low-density lipoprotein; lean women with moderate preterm birth had elevated triglycerides. There was a reduced triglyceride response in the first half of pregnancy among women who delivered <34 weeks.

CONCLUSION

Our results indicate the presence of dyslipidemia in women with spontaneous preterm birth.

Predictors of significant short-term increases in blood pressure in a community-based population

BACKGROUND

Blood pressure predicts the risk of cardiovascular disease events in a linear, graded manner. Factors associated with significant short-term increases in blood pressure are not well established. We aimed to identify predictors of a significant increase in blood pressure over a 1-year period among nonhypertensive, community-dwelling adults.

METHODS

From the community-based Heart Strategies Concentrating on Risk Evaluation study, 509 nonhypertensive adults (mean age 58 years; 68% were female; 24% were black) had baseline and 1-year assessments of blood pressure. Demographics, medical history, anthropometrics, lipids/lipoproteins, physical activity, and psychologic status were measured at both intervals. A "significant" increase in blood pressure was defined as an increase in systolic blood pressure of greater than 20 mm Hg, diastolic blood pressure of greater than 10 mm Hg, or initiation of antihypertensive medication.

RESULTS

At 1 year, 22% of participants had a significant increase in blood pressure. In multivariable analysis, baseline body mass index (BMI) and a greater than 5% increase in weight or waist circumference were associated with a significant increase in blood pressure (adjusted relative risk 2.09; 95% confidence interval, 1.35-3.21). The adverse effect of an increase in weight and waist circumference on blood pressure was evident in subgroup analyses by age, race, baseline BMI, and regular exercise.

CONCLUSIONS

Baseline BMI and a greater than 5% increase in weight or waist circumference over 1 year are associated with a significant increase in blood pressure. These data emphasize the need for weight maintenance. They also serve to stratify individuals who may benefit from close clinical observation and preventive intervention.

Vaginal douching and development of bacterial vaginosis among women with normal and abnormal vaginal microflora

OBJECTIVES

To evaluate the relationship between douching and bacterial vaginosis (BV) among women with and without prior abnormal vaginal flora.

STUDY DESIGNS

1193 women had vaginal swabs obtained for Gram stain for BV, culture for vaginal microflora, and DNA amplification for Neisseria gonorrhoeae and Chlamydia trachomatis at baseline and 6, 12, 24, and 36 months. Self-reported douching was queried every 6 months.

RESULTS

In cross-sectional analyses, douching at least once per month was associated with BV among women who had BV at the immediately preceding visit but not among women with normal or intermediate flora. In prospective analyses, douching increased the risk of acquisition for BV among women with intermediate flora (adj. HR 1.5, 95% CI 1.1-2.4) but not among women with normal flora.

CONCLUSIONS

Douching appeared to be associated with BV among women with already imbalanced flora but not among women with normal flora.

Completeness of Revascularization for Multivessel Coronary Artery Disease and Its Effect on One-Year Outcome: A Report from the NHLBI Dynamic Registry

When percutaneous coronary intervention (PCI) is performed in patients with multivessel coronary disease, a targeted revascularization (TR) of diseased vessels is performed more often than complete revascularization (CR). We compared baseline characteristics and 1-year outcomes of patients undergoing TR by operator choice (n = 1,091), TR because CR was unachievable (n = 375), and CR (n = 315) in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry. Patients receiving TR because CR was unachievable were older, had more comorbidities, worse ejection fraction, less often received 2b/3a inhibitors and stents, and less frequently achieved complete angiographic success than either patients receiving TR by choice or CR. Despite these considerable differences, cumulative rates of 1-year mortality, the need for repeat PCI, or coronary bypass surgery were similar in patients who received CR, TR by choice, or TR because CR was unachievable. In multivariable models, after adjustment for clinical characteristics and propensity to receive CR, the hazard ratio for CR versus TR was 1.10 (95% CI: 0.58-2.10) for 1-year mortality; 0.89 (0.60-1.32) for repeat PCI, and 0.92 (0.66-1.29) for repeat PCI or coronary bypass surgery. In conclusion, despite the presence of more unfavorable characteristics, patients undergoing TR demonstrate 1-year outcomes equivalent to those having CR, supporting its continued use in selected patients.

Infliximab dose intensification in Crohn's disease

BACKGROUND

Crohn's disease (CD) patients who lose response to infliximab may benefit from an increase in dose or decrease in interval between infusions. The aims of this study were to determine the proportion of CD patients who require dose intensification and factors associated with dose intensification.

METHODS

All CD patients who received at least 8 doses of infliximab at the University of Pittsburgh infusion center were included in an analysis to determine the need for dose intensification. Dose intensification was defined as either an increase in infliximab dose, a decrease in interval, or both. Factors were analyzed for association with dose intensification during follow-up.

RESULTS

Between 2002 and 2005 there were 108 CD patients who received at least 8 infliximab doses. At 30 months from initial infusion, 69.1% were event-free from an interval decrease, 48.5% from a dose increase, and 45.7% from any dose intensification. Of the 54 patients who received dose intensification, 75.9% were able to regain response and remained on infliximab. The 30-month event-free rates did not differ by whether the patient had received prior infliximab therapy (P=0.49), had a lapse of more than 6 months between infusions (P=0.75), or were on concomitant immunomodulators (P=0.82).

CONCLUSIONS

A significant proportion of CD patients on long-term infliximab treatment lose response and require an increase in dose and/or decrease in infusion interval. The majority of these patients regain response with dose intensification. Every-8-week maintenance infusions and concomitant immunomodulators did not alter the rate of infliximab dose intensification.

The effect of coronary artery bypass grafting on specific causes of long-term mortality in the Bypass Angioplasty Revascularization Investigation

OBJECTIVES

We sought to examine the effect of revascularization with coronary artery bypass grafting on specific causes of death in the Bypass Angioplasty Revascularization Investigation cohort. Although the effect of coronary revascularization on long-term mortality has been previously described, there are limited data describing its effect on specific causes of death in patients with coronary artery disease. Evaluation of cause of death might help elucidate disease mechanisms and be useful for developing treatment strategies.

METHODS

In the Bypass Angioplasty Revascularization Investigation randomized trial and registry, 3610 patients underwent initial revascularization with coronary artery bypass grafting or balloon angioplasty and were followed for an average of 7.7 years. Causes of all deaths were classified by an independent committee.

RESULTS

Among 3610 revascularized patients, 2239 underwent coronary artery bypass grafting as an initial or subsequent procedure. Over 7.7 years of follow-up, 3% of all patients died of sudden cardiac death, 3% died of myocardial infarction-related death, 2% died of congestive heart failure and other cardiac causes, and 9% died of noncardiac causes. Coronary artery bypass grafting (vs no coronary artery bypass grafting) was associated with a significantly lower risk of sudden cardiac death (relative risk, 0.60; P = .01) but was not significantly associated with any other causes of long-term mortality.

CONCLUSIONS

In the Bypass Angioplasty Revascularization Investigation coronary artery bypass grafting significantly decreased the risk of sudden cardiac death but not any other cause of long-term mortality. Because major risk factors for sudden cardiac death have historically favored a revascularization strategy of coronary artery bypass grafting over angioplasty, evaluation of the current practice of extending angioplasty as an alternative to coronary artery bypass grafting in similar high-risk subgroups is paramount.

Polycystic ovarian syndrome (PCOS): a significant contributor to the overall burden of type 2 diabetes in women

BACKGROUND

Given the high prevalence of polycystic ovarian syndrome (PCOS) in the population, the increased risk for the development of type 2 diabetes in these women, and the role of type 2 diabetes in mediating adverse long-term sequelae, the objective of this analysis was to quantify the contribution of this early-life exposure (e.g., PCOS) to the burden of type 2 diabetes in the total population of middle-aged women.

METHODS

The cumulative incidence and relative risk (RR) of type 2 diabetes were examined in a group of women with PCOS (n = 149) and unaffected women (n = 166), aged 35-64, who were part of an ongoing investigation of cardiovascular risk factors in women with PCOS. The population attributable risk percent (PAR%) was calculated using Levin's formula to estimate the percentage of type 2 diabetes in the total population among middle-aged women that can be attributed to the presence of PCOS at young adulthood.

RESULTS

When the RR of type 2 diabetes among women with PCOS observed in our current study and others (4.0-6.0) was applied to an estimated 6%-10% prevalence of PCOS in the female population, 15.0%-35.6% of all incident cases of type 2 diabetes in white women were estimated to be attributable to PCOS. Moreover, other investigators have noted this proportion of undiagnosed PCOS in populations of women with type 2 diabetes.

CONCLUSIONS

These results support the recommendation that all women with PCOS should be periodically rescreened for diabetes and underscores the importance of the early identification of young women with PCOS and the need for early lifestyle intervention.

Outcomes and complications associated with off-label and untested use of drug-eluting stents

CONTEXT

Limited data exist regarding use of drug-eluting stents outside of approved indications in real-world settings.

OBJECTIVES

To determine the frequency, safety, and effectiveness of drug-eluting stents for off-label (restenosis, bypass graft lesion, long lesions, vessel size outside of information for use recommendation) and untested (left main, ostial, bifurcation, or total occlusion lesions) indications in percutaneous coronary intervention (PCI).

DESIGN, SETTING, AND PATIENTS

Observational, prospective, multicenter registry to evaluate in-hospital, 30-day, and 1-year outcomes among patients undergoing PCI between January and June 2005 in 140 US academic and community medical centers. Of 7752 PCI-treated patients, 6993 (90%) received drug-eluting stents; of these, 5851 (84%) received no other devices. Standard, off-label, and untested use was determined in 5541 (95%) of these 5851 patients, constituting the study cohort.

MAIN OUTCOME MEASURES

Frequency of off-label and untested use, 1-year repeat target vessel revascularization, and composite of death, myocardial infarction (MI), or stent thrombosis at in-hospital follow-up and during 1 year of follow-up.

RESULTS

Of 5541 patients receiving drug-eluting stents, 2588 (47%) received stents for off-label or untested indications. Adjusted in-hospital risk of death, MI, or stent thrombosis was not statistically different with off-label or untested vs standard use. At 30 days, the risk of this composite end point was significantly higher with off-label use (adjusted hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.24-3.48; P = .005) but not untested use (adjusted HR, 1.45; 95% CI, 0.79-2.67; P = .23). Excluding early events, this end point was not different at 1 year with off-label use (adjusted HR, 1.10; 95% CI, 0.79-1.54; P = .57) or untested use (adjusted HR, 0.91; 95% CI, 0.60-1.38; P = .66). At 1 year, compared with standard use, significantly higher rates of target vessel revascularization were associated with off-label use (adjusted HR, 1.49; 95% CI, 1.13-1.98; P = .005) and untested use (adjusted HR, 1.49; 95% CI, 1.10-2.02; P = .01), although absolute rates were low (standard, 4.4% [n = 113]; off-label, 7.6% [n = 95]; untested, 6.7% [n = 72]).

CONCLUSIONS

In contemporary US practice, off-label and untested use of drug-eluting stents is common. Compared with standard use, relative early safety is lower with off-label use, and the long-term effectiveness is lower with both off-label and untested use. However, the absolute event rates remain low.

Racial differences in coronary artery calcification are not attributed to differences in lipoprotein particle sizes: the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study

BACKGROUND

Lipoprotein particle levels and size distributions differ by race. As a group, blacks have less coronary artery calcification (CAC) than whites. We evaluated whether racial differences in CAC are explained by differences in lipoprotein levels and particle sizes.

METHODS

A total of 721 blacks and 988 whites underwent measurement of fasting lipoprotein levels and particle sizes. There were 608 subjects who had CAC quantified by electron beam computed tomography. Distributions and interrelationships among lipoprotein levels, particle sizes, and CAC were evaluated by race and sex.

RESULTS

Blacks had nominally higher adjusted high-density lipoprotein cholesterol levels (men, 51 vs 50 mg/dL; women, 63 vs 61 mg/dL; P = .05), lower intermediate-density lipoprotein cholesterol levels (women only, 17 vs 18 mg/dL; P = .02), and significantly lower triglyceride levels (men, 116 vs 138 mg/dL; women, 103 vs 136 mg/dL; P < .0001) than whites. Adjusted small dense low-density lipoprotein 3 particle levels were significantly lower (P < .0001) in black men (47 vs 53 mg/dL) and black women (43 vs 48 mg/dL) compared with white men and women, respectively. Black race was associated with a 48% lower adjusted odds of moderate or significant CAC (odds ratio, 0.52; 95% confidence interval, 0.34-0.80). However, this strong association between race and CAC was independent of lipoprotein levels and particle sizes.

CONCLUSIONS

Blacks have less CAC and more favorable lipoprotein profiles than whites. Racial differences in CAC are not attributable to differences in lipoprotein particle sizes. Future studies of mechanisms of race-related differences in CAC may enhance understanding of the pathophysiology of racial differences in cardiovascular disease.

Risk of early or severe preeclampsia related to pre-existing conditions

BACKGROUND

Preeclampsia (PE), especially severe or early PE, is a leading cause of morbidity and mortality among mothers and infants. We estimated the population attributable fractions of severe or early PE associated with pre-existing conditions among nulliparous and multiparous women.

METHODS

Among 70 924 women in the Danish National Birth Cohort, we used hospital discharge data to identify 2117 cases of PE, of which 449 were early (<37 weeks), 426 were severe (clinically diagnosed) and 228 were both early and severe. Prospective interview data were supplemented with hospital registry data to identify women with pre-existing conditions. Generalized estimating equations were utilized to estimate adjusted relative risks, and population attributable fractions were calculated with 95% CI.

RESULTS

Pre-existing hypertension, diabetes, obesity or multiple gestation were associated with 22.3% (19.8-24.9) of all PE cases among nulliparous women. These conditions, or a prior preeclamptic pregnancy, were associated with 52.2% (46.4-57.9) of PE among multiparous women. Early PE was preceded by these pre-existing conditions among 34% (28.3-40.0) of affected nulliparous women and among 50% (37.5-63.4) of multiparous women. The fraction of severe PE associated with these conditions was 23% among nulliparas and 59% among multiparas. Being obese or overweight was associated with 15-17% of the population risk of early PE among nulliparous and multiparous women.

CONCLUSIONS

Pre-existing maternal and obstetric conditions are associated with a high proportion of severe or early cases of PE. Obesity and overweight contributed independently to the risk of pre-term PE, a finding with potentially profound public health implications.

Relief of Symptoms, Side Effects, and Psychological Distress Through Use of Complementary and Alternative Medicine in Women With Breast Cancer

PURPOSE/OBJECTIVES

To identify use of complementary and alternative medicine (CAM) for relief of symptoms and side effects among women diagnosed with breast cancer and to identify demographic and clinical factors associated with the use of CAM in these patients.

DESIGN

A descriptive, cross-sectional survey.

SETTING

Clinics and community groups in the Tampa Bay area and community groups in a rural midwestern area.

SAMPLE

A convenience sample of 105 predominantly Caucasian women (mean age = 59 years) with a diagnosis of breast cancer was recruited from the Tampa Bay area and a rural midwestern area.

METHODS

The instrument used to gather the data was the Use of Complementary Therapies Survey. The reasons for choosing 33 individual CAM treatments were tabulated. The frequency of use was calculated according to four reasons: (a) to reduce physical symptoms or side effects, (b) to reduce psychological distress, (c) to gain a feeling of control over treatment, or (d) because of dissatisfaction with traditional medical care. Least-squares regression models were fit to identify independent demographic and clinical predictors of CAM therapy use.

MAIN RESEARCH VARIABLES

Use of CAM for relief of physical and psychological distress.

FINDINGS

Patients used all categories of CAM therapies to reduce physical symptoms and side effects. The most frequently cited reason for use of CAM was to reduce the symptom of psychological distress, whereas the lowest frequency of CAM use was because of dissatisfaction with traditional medical care. Traditional and ethnic medicines frequently were used to reduce physical symptoms and side effects, followed by diet and nutritional supplements. The most frequently used CAM therapy category cited for gaining a feeling of control over treatment was use of diet and nutritional supplements. Previous chemotherapy and having more than a high school education were associated with more frequent use of diet and nutritional supplements and stress-reducing techniques.

CONCLUSIONS

Frequency of specific use according to type of CAM was higher and more specific than reported in other studies. Patients who had undergone chemotherapy were most likely to use CAM.

IMPLICATIONS FOR NURSING

Oncology nurses are in a key position to identify which symptoms or side effects patients are experiencing and which CAM therapies may be helpful to relieve patients' symptoms related to treatment and psychological distress related to their cancer.

Screening children to identify families at increased risk for cardiovascular disease

OBJECTIVES

Atherosclerotic cardiovascular disease is the leading cause of death in the United States. Atherosclerosis begins early in life; however, children and young and middle-aged adults are not universally screened for the presence of modifiable cardiovascular disease risk factors. The purpose of this study was to investigate whether cardiovascular disease risk-factor assessment in children can identify families who are at increased risk for cardiovascular disease.

PARTICIPANTS AND METHODS

Family Strategies Concentrating on Risk Evaluation is a community-based participatory research study designed to stratify cardiovascular disease risk in a cohort of children and their parents. Eligible families, consisting of > or = 1 child and > or = 1 biological parent, are recruited through community and faith-based educational and screening programs. In a single, fasted study visit, participants undergo assessment of cardiovascular disease risk factors: obesity, hypertension, dyslipidemia, and metabolic syndrome. Associations of cardiovascular disease risk factors between children and their parents were assessed.

RESULTS

Data were analyzed from 94 families: 108 parents (mean age: 38.5 +/- 7.5 years), 141 children (mean age: 10.5 +/- 3.4 years), and 170 child-parent pairs. Child-parent association was strong for many risk factors: BMI, waist circumference, systolic blood pressure, triglycerides, and total cholesterol. Several discrete-defined risk factors in children were found to be significant predictors of the presence of the same risk factors in their parents. Parents of children with hypertension, obesity, or hypertriglyceridemia had 15 times, 6 times, or 5 times increased odds, respectively, of having the same risk factors.

CONCLUSIONS

Identification of several clinically apparent and silent cardiovascular disease risk factors in children predicts elevated cardiovascular disease risk in their parents. Because children access primary care more frequently than adults, children can potentially serve as the index case to identify families at increased risk for cardiovascular disease.

Outcomes of 6906 patients undergoing percutaneous coronary intervention in the era of drug-eluting stents: report of the DEScover Registry

BACKGROUND

The DEScover Registry was designed to characterize patients selected for drug-eluting stents (DES) in routine clinical practice and their outcomes in the United States.

METHODS AND RESULTS

From January to June 2005, data were collected on 6906 patients who underwent percutaneous coronary intervention at 140 medical centers. Baseline characteristics and outcomes were compared on the basis of treatment with > or =1 bare-metal (BMS; n=397), sirolimus-eluting (SES; n=3873), or paclitaxel-eluting (PES; n=2636) stent. Clinical characteristics and the types of lesion treated for BMS patients differed substantially from those treated with DES, but minimal differences were noted between DES patients receiving SES or PES. At 1 year, the unadjusted cumulative incidence of death/myocardial infarction was higher in BMS than in DES patients (9.0% versus 5.2%; P=0.002) but similar in SES and PES patients (5.2% versus 5.3%; P=0.64). After adjustment, risk of death/MI was not significantly lower in DES- compared with BMS-treated patients (adjusted hazard ratio, 0.74; 95% confidence interval, 0.52 to 1.07). Although target vessel revascularization occurred less often in DES patients (9.5% versus 6.0%; P=0.007), rates were similar between SES and PES patients (6.3% versus 5.5%; P=0.20). Rates of stent thrombosis were similar among BMS (0.8%), SES (0.5%), and PES (0.8%) patients.

CONCLUSIONS

In DEScover, differences in patient selection were observed between BMS and DES patients but not between SES and PES patients. DES use resulted in lower rates of clinically driven repeat revascularization with similar rates of stent thrombosis. These observations confirm the effectiveness and safety of both SES and PES in unselected patients.

Development and psychometric properties of the Vertebral Compression Fracture Pain and Functional Disability Questionnaire

Object

Vertebral compression fractures (VCFs) result in severe and disabling pain, diminished quality of life, and substantial medical costs. There exists no standard instrument with which to measure pain and functional status before and after treatment of VCFs.

Methods

A questionnaire was specifically developed to assess pain and disability in patients with VCFs before and after undergoing percutaneous polymethylmethacrylate–augmented vertebroplasty. The first section of the baseline questionnaire (before treatment) contains 11 items that address the patient’s previous and current levels of back pain and distress. The second section of the baseline questionnaire lists 24 activities of daily living (ADLs), each measured on a four-point scale ranging from “able to do without pain” to “cannot do because of pain.” The follow-up questionnaire (after treatment) is similar in format.

Among 72 vertebroplasty-treated patients, the internal consistency reliability of the 24 ADLs ranged from 0.87 to 0.98, with similar results observed before and after treatment. Correlations of 0.29 to 0.72 were observed among the 24 ADLs and the internal measures of pain and distress measured on both visual analog and adjectival scales. Similar correlations (range 0.35–0.63) were observed between the questionnaire and 10 dimensions of the Oswestry Disability Index’s low-back pain questionnaire, an external instrument used to assess criterion-referenced validity. Evidence in support of the validity of the questionnaire was present before and after treatment.

Conclusions

The Vertebral Compression Fracture Pain and Functional Disability Questionnaire appears to be a reliable and valid instrument for assessing back pain and functional ability in patients before and after treatment for VCFs.

Accessing adult smokers in the pediatric setting: What do parents think?

The anticipation of negative parental reaction is cited by pediatricians as a common barrier to intervening with parents who smoke. In an effort to clarify perceived versus actual parent reaction, the present study investigated the reactions of a diverse parent sample toward pediatricians addressing parental smoking in the outpatient setting. This study represents a descriptive cross-sectional in-person survey of 906 parents interviewed exiting four geographically diverse pediatric practices. Only 3% of the sample felt their smoking status was not the pediatrician's business, 89% stated they believe it is an important part of a pediatrician's job to ask about their smoking status, and 8% stated it wouldn't matter if the pediatrician asked. Demographic characteristics were associated with a positive attitude about being asked. Compared with nonsmokers, fewer smokers had positive attitudes (81% vs. 91%, p = .0002); and more highly educated parents were more strongly positive about being asked (91% vs. 83%, p = .006). Among 187 smokers, 177 (95%) would appreciate or feel okay about the physician's concern if advised to quit and 57% reported wanting some kind of smoking cessation help from the pediatrician's office. In a heterogeneous sample of parents, strong support exists for pediatricians addressing parental smoking at pediatric office visits. This finding is encouraging for pediatricians who are concerned about negative parental reaction.

Associations of increases in serum creatinine with mortality and length of hospital stay after coronary angiography

The absence of a universally accepted definition of radiocontrast nephropathy (RCN) has hampered efforts to characterize effectively the incidence and the clinical significance of this condition. The objective of this study was to identify a clinically relevant definition of RCN by assessment of the relationships between increases in serum creatinine (Scr) of varying magnitude after coronary angiography and clinical outcomes. An electronic medical database was used to identify all patients who underwent coronary angiography at the University of Pittsburgh Medical Center during a 12-yr period and abstract Scr levels before and after angiography, as well as demographic characteristics and comorbid conditions. Changes in Scr after angiography were categorized into mutually exclusive categories on the basis of absolute and relative changes from baseline levels, with a separate category denoting "unknown" change. Discrete proportional odds models were used to examine the association between increases in Scr and 30-d in-hospital mortality and length of stay. A total of 27,608 patients who underwent coronary angiography were evaluated. Small absolute (0.25 to 0.5 mg/dl) and relative (25 to 50%) increases in Scr were associated with risk-adjusted odds ratios for in-hospital mortality of 1.83 and 1.39, respectively. Larger increases in Scr generally were associated with greater risks for these clinical outcomes. Small increases in Scr after the administration of intravascular radiocontrast are associated with adverse patient outcomes. This observation will help guide the post-procedure care of patients who undergo coronary angiography and has important implications for future studies that investigate RCN.

The economic burden of angina in women with suspected ischemic heart disease: results from the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation

BACKGROUND

Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, < 50% stenosis) coronary artery disease (CAD) is frequently reported. Few data exist regarding the type and intensity of resource consumption in women with chest pain after coronary angiography.

METHODS AND RESULTS

A total of 883 women referred for coronary angiography were prospectively enrolled in the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation (WISE). Cardiovascular prognosis and cost data were collected. Direct (hospitalizations, office visits, procedures, and drug utilization) and indirect (out-of-pocket, lost productivity, and travel) costs were estimated through 5 years of follow-up. Among 883 women, 62%, 17%, 11%, and 10% had nonobstructive and 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Five-year cardiovascular death or myocardial infarction rates ranged from 4% to 38% for women with nonobstructive to 3-vessel CAD (P < 0.0001). Five-year rates of hospitalization for chest pain occurred in 20% of women with nonobstructive CAD, increasing to 38% to 55% for women with 1-vessel to 3-vessel CAD (P < 0.0001). The volume of repeat catheterizations or angina hospitalizations was 1.8-fold higher in women with nonobstructive versus 1-vessel CAD after 1 year of follow-up (P < 0.0001). Drug treatment was highest for those with nonobstructive or 1-vessel CAD (P < 0.0001). The proportion of costs for anti-ischemic therapy was higher for women with nonobstructive CAD (15% versus 12% for 1-vessel to 3-vessel CAD; P = 0.001). For women with nonobstructive CAD, average lifetime cost estimates were $767,288 (95% CI, $708,480 to $826,097) and ranged from $1,001,493 to $1,051,302 for women with 1-vessel to 3-vessel CAD (P = 0.0003).

CONCLUSIONS

Symptom-driven care is costly even for women with nonobstructive CAD. Our lifetime estimates for costs of cardiovascular care identify a significant subset of women who are unaccounted for within current estimates of the economic burden of coronary heart disease.

Recent trends in the percutaneous treatment of chronic total coronary occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has a lower success rate than PCI for non-CTO lesions. We sought to determine trends in the treatment of CTOs within the current interventional era. Using 4 sequential recruitment waves of the National Heart, Lung, and Blood Institute Dynamic Registry, we assessed the relative prevalence and success rates in treating CTO (n=371) versus non-CTO (n=4,802) lesions over a 7-year period (1997 to 2004). Characteristics of attempted lesions and factors associated with PCI outcome were evaluated. CTO lesion attempts decreased by 41% over time, from 9.6% (1997 to 1998) to 5.7% (2004, p<0.0001 for trend). More contemporary CTO lesions were longer (22.4 vs 17.0 mm, p=0.006 for trend), had thrombus less often (21.3% vs 35.4%, p=0.03 for trend), and were more often treated with stents (69.8% vs 45.4% p=0.02). The rate of successful intervention for CTO lesions decreased nonsignificantly during this time, from 79.7% to 71.4% (p=0.18). Using multivariable analysis, female gender (adjusted odds ratio 0.42, 95% confidence interval 0.20 to 0.88, p=0.02), and thrombus (adjusted odds ratio 0.31, 95% confidence interval 0.15 to 0.61, p=0.0008) were associated with higher success rates, whereas the presence of severe noncardiac disease (adjusted odds ratio 1.91, 95% confidence interval 1.05 to 3.45, p=0.03) was associated with a higher risk for PCI failure. Recruitment wave and patient age were not independently related to lesion success. In conclusion, during the PCI period of 1997 to 2004, CTO lesions were attempted less frequently and success rates did not increase, indicating a need for new operator techniques or device technologies to treat this important lesion subset by a percutaneous approach.

Variability of Bacterial Vaginosis Over 6- to 12-Month Intervals

OBJECTIVES

To examine variability in bacterial vaginosis (BV) over 6- to 12-month intervals.

STUDY DESIGN

One thousand one hundred ninety-three women were followed for a median of 3 years with serial vaginal swab Gram stains for BV. Discrete time hazard models were fit to identify independent risk factors for BV.

RESULTS

Women with BV at study entry were categorized as having normal flora at the next visit 20% of the time, and women with normal flora at study entry were categorized as having BV at the next visit 20% of the time. Among women with initially normal flora, factors associated with BV were black race, lower education, a history of BV, a history of chlamydial/gonococcal cervicitis, and lack of monogamy.

CONCLUSION

About one fifth of women with normal flora develop BV over a given 6- to 12-month interval, and the modifiable risk factors of cervicitis and lack of monogamy contribute to the development of BV.

Obesity, hormone therapy, estrogen metabolism and risk of postmenopausal breast cancer

Hormone therapy (HT) and body mass index (BMI) have been associated with postmenopausal breast cancer. Because estrogen metabolism may affect breast cancer risk and can be altered by weight and HT, it might play a role in the HT-BMI-breast cancer associations. We undertook a nested case-control study within the Observational Study of the Women's Health Initiative. Baseline levels of 2- and 16alpha-hydroxy estrone (2-OHE1 and 16alpha-OHE1) were measured in 200 women who developed breast cancer during follow-up and 200 healthy controls matched to cases by ethnicity, enrollment date, clinic site, type of HT and years since menopause. Wilcoxon nonparametric tests were used to compare estrogen metabolite levels between cases and controls. Conditional logistic regression was used to assess the relationship between BMI, estrogen metabolites and breast cancer risk. 16alpha-OHE1 levels were modestly but significantly higher in HT users among cases (median 356 pg/ml vs. 315 pg/ml) and controls (354 pg/ml vs. 298 pg/ml). 2-OHE1 levels were substantially and significantly higher in HT users among cases (369 pg/ml vs. 125 pg/ml) and controls (347 pg/ml vs. 134 pg/ml). For non-HT users only, greater BMI and higher 16alpha-OHE1 levels were individually and jointly associated with increased breast cancer risk (OR for women with high BMI and high 16alpha-OHE1 compared to those with low BMI and low 16alpha-OHE1 = 3.51, 95% CI = 1.34-9.16). No associations between BMI, estrogen metabolism and breast cancer risk were found for HT users. Estrogen metabolism differs according to both BMI and HT use, potentially explaining the interaction between BMI and HT in relation to breast cancer risk.

Risk of T2DM and impaired fasting glucose among PCOS subjects: results of an 8-year follow-up

Women with polycystic ovary syndrome (PCOS) often develop type 2 diabetes mellitus (T2DM). To determine the magnitude of risk of developing T2DM among women with PCOS, development of T2DM was prospectively assessed among women who had T2DM (n = 97) and controls (n = 95) using Kaplan-Meier survival analysis and Cox proportional hazards modeling. The women with T2DM had higher baseline weight (body mass index, P < 0.01) and lower insulin sensitivity (homeostasis assessment model of insulin resistance, P < 0.01). The 8-year incidence rate among cases and controls was 13.4% and 5.8%, respectively (relative risk = 2.3). Obese cases had a fivefold risk of T2DM developing (P < 0.01) compared with age-adjusted obese controls, indicating significant interaction between PCOS and obesity to effect T2DM risk.

Global inflammation predicts cardiovascular risk in women: a report from the Women's Ischemia Syndrome Evaluation (WISE) study

BACKGROUND

Measurement of C-reactive protein (CRP), a marker of inflammation, is recommended to improve cardiovascular disease (CVD) risk stratification. However, no studies have collectively evaluated how inflammatory markers cluster empirically and relate to angiographic coronary artery disease and CVD events.

METHODS

From the WISE study, 580 women with fasting plasma samples of inflammatory markers (interleukin [IL]-6, IL-18, tumor necrosis factor alpha, transforming growth factor beta, CRP, serum amyloid A [SAA], and intercellular adhesion molecules) were analyzed over a median of 4.7 years follow-up. All women were referred for coronary angiography (1996-2000) to evaluate suspected myocardial ischemia.

RESULTS

In factor analysis, a "proinflammation" factor (cluster) loaded on IL-6, CRP, and SAA (r = 0.63-0.87); a "proinflammation and anti-inflammation" cluster loaded on IL-18 and tumor necrosis factor alpha (r = 0.72, 0.77); and an "immunosuppressive" factor loaded singly on transforming growth factor beta (r = 0.96). No cluster was independently associated with angiographic coronary artery disease. However, quartile increases of the "proinflammation" cluster (IL-6, CRP, and SAA) yielded death rates of 2.6%, 7.2%, 13.1%, 26.6%, respectively (P < .0001). Women with > or = 2 of 3 proinflammation markers in the upper quartile had an adjusted relative risk of death of 4.21 (95% CI 1.91-9.25), a higher conferred risk than any single marker alone, all of which were roughly equally predictive.

CONCLUSIONS

Although IL-6, CRP, and SAA all predict CVD risk in women, development of global measures of inflammation and simply counting the number of markers with high levels improve CVD risk stratification. In addition, results indicate that the adverse impact of inflammation may be largely through other mechanisms than promotion of atherogenesis (ie, destabilization of vulnerable plaques).

A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease

Controversy surrounds the association between bacterial vaginosis (BV) and pelvic inflammatory disease (PID). Women (N = 1,140) were ascertained at five US centers, enrolled (1999-2001), and followed up for a median of 3 years. Serial vaginal swabs were obtained for Gram's stain and cultures. PID was defined as 1) histologic endometritis or 2) pelvic pain and tenderness plus oral temperature >38.8 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital infection. Exploratory factor analysis identified two discrete clusters of genital microorganisms. The first correlated with BV by Gram's stain and consisted of the absence of hydrogen peroxide-producing lactobacillus, Gardnerella vaginalis, Mycoplasma hominis, anaerobic gram-negative rods, and, to a lesser degree, Ureaplasma urealyticum. The second, unrelated to BV by Gram's stain, consisted of Enterococcus species and Escherichia coli. Being in the highest tertile in terms of growth of BV-associated microorganisms increased PID risk (adjusted rate ratio = 2.03, 95% confidence interval: 1.16, 3.53). Carriage of non-BV-associated microorganisms did not increase PID risk. Women with heavy growth of BV-associated microorganisms and a new sexual partner appeared to be at particularly high risk (adjusted rate ratio = 8.77, 95% confidence interval: 1.11, 69.2). When identified by microbial culture, a combination of BV-related microorganisms significantly elevated the risk of acquiring PID.

Temporal variation in inhospital mortality with percutaneous coronary intervention: a report from the National Heart, Lung and Blood Institute Dynamic Registry

BACKGROUND

Cardiovascular morbidity and mortality display a distinct time dependence also known as circadian variation. Whether such time dependence extends to the risk of procedural-related mortality after percutaneous coronary intervention (PCI) is presently unknown.

METHODS

Inhospital mortality was analyzed in 6,347 patients with PCI start times from 8:00 am to 6:59 pm ("usual" workday). The sample was divided into 3 evenly populated groups (morning start 8:00-10:59 AM, midday start 11:00 AM-1:59 PM, afternoon start 2:00-6:59 PM). The association between procedural start time and mortality was assessed using multivariable analysis including a propensity score accounting for factors associated with procedural start time.

RESULTS

There was a significant, nonlinear relationship between procedural-related mortality and start time (P = .03). Afternoon start patients were at higher adjusted risk of mortality compared with midday start patients (OR 2.03, 95% CI 1.07-3.83, P = .03 ). Morning start patients were also at higher risk compared with midday start patients although the association was not statistically significant (OR 1.73, 95% CI 0.89-3.39, P = .11).

CONCLUSIONS

There is a significant time-dependent variation in the risk of inhospital PCI-related mortality during usual working hours. The highest risk period, taking into account numerous factors that confound this association, is the latter part of the workday. A second period of apparent greater risk occurs during the early part of the workday and is consistent with our present understanding of circadian variation in cardiovascular disease processes.

Bacterial vaginosis (BV) and the risk of incident gonococcal or chlamydial genital infection in a predominantly black population

OBJECTIVE

The objective of this study was to assess in prospective data whether bacterial vaginosis (BV) is associated with gonococcal/chlamydial cervicitis.

STUDY

A total of 1179 women at high risk for sexually transmitted infections was followed for a median of 3 years. Every 6 to 12 months, vaginal swabs were obtained for Gram stain, culture of microflora, and Neisseria gonorrhoeae and Chlamydia trachomatis. A Gram stain score of 7 to 10 based on the Nugent criteria categorized BV.

RESULTS

Baseline BV was associated with concurrent gonococcal/chlamydial infection (adjusted odds ratio, 2.83; 95% confidence interval [CI], 1.81-4.42). However, the association between BV and subsequent, incident gonococcal/chlamydial genital infection was not significant (adjusted relative risk [RR], 1.52; 95% CI, 0.74-3.13). Dense growth of pigmented, anaerobic Gram-negative rods (adjusted RR, 1.93; 95% CI, 0.97-3.83) appeared to elevate the risk for newly acquired gonococcal/chlamydial genital infection.

CONCLUSIONS

BV was common among a predominantly black group of women with concurrent gonococcal/chlamydial infection but did not elevate the risk for incident infection.

Inflammation, endothelial cell activation, and coronary microvascular dysfunction in women with chest pain and no obstructive coronary artery disease

BACKGROUND

Coronary artery microvascular dysfunction is prevalent in women with chest pain in the absence of obstructive coronary artery disease (CAD) and is manifested by attenuated coronary flow reserve (CFR). Markers of inflammation and endothelial cell activation have been found to be elevated in patients with chest pain but without CAD. The relationship between inflammation, endothelial activation, and CFR is not known.

METHODS

Ninety-four women with chest pain in the absence of obstructive angiographic CAD underwent catheterization-based assessment of CFR and measurement of levels of inflammatory markers (n = 78) and endothelial cell activation in the NHLBI WISE study.

RESULTS

Coronary flow reserve did not correlate with levels of C-reactive protein (high-sensitivity C-reactive protein) (rs = -0.07, P = .53), interleukin (IL)-6 (rs = -0.12, P = .31), IL-18 (rs = 0.14, P = .23), tumor necrosis factor alpha (rs = -0.09, P = .43), transforming growth factor beta1 (rs = 0.02, P = .84), and soluble intracellular adhesion molecule-1 (rs = 0.04, P = .68). Median levels of markers of inflammation and endothelial cell activation did not differ between the 57 women with abnormal CFR (< 2.5) and the 37 women with normal coronary microvascular function (high-sensitivity C-reactive protein 0.32 vs 0.25 mg/dL, P = .80; IL-6 2.89 vs 2.39 pg/mL, P = .63; IL-18 218 vs 227 pg/mL, P = .59; tumor necrosis factor alpha 2.7 vs 2.4 pg/mL, P = .43; transforming growth factor beta1 9928 vs 12436 pg/mL, P = .76; soluble intracellular adhesion molecule-1 286 vs 287 pg/mL, P = .95). Multivariable models demonstrated no evidence of associations between markers of inflammation and of endothelial cell activation and CFR.

CONCLUSIONS

Coronary microvascular dysfunction is not associated with markers of inflammation and endothelial cell activation in women with chest pain in the absence of obstructive CAD. These results suggest that inflammation and endothelial cell activation may not play a pathophysiological role in coronary microvascular dysfunction.

Douching, pelvic inflammatory disease, and incident gonococcal and chlamydial genital infection in a cohort of high-risk women

Douching has been linked to gonococcal or chlamydial cervicitis and pelvic inflammatory disease (PID) in retrospective studies. The authors conducted a 1999-2004 prospective observational study of 1,199 US women who were at high risk of acquiring chlamydia and were followed for up to 4 years. Cervical Neisseria gonorrhoeae and Chlamydia trachomatis were detected from vaginal swabs by nucleic acid amplification. PID was characterized by histologic endometritis or pelvic pain and tenderness plus one of the following: oral temperature >38.3 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital tract infection. Associations between douching and PID or gonococcal/chlamydial genital infections were assessed by proportional hazards models. The 4-year incidence rate of PID was 10.9% and of gonococcal and/or chlamydial cervicitis was 21.9%. After adjustment for confounding factors, douching two or more times per month at baseline was associated with neither PID (adjusted hazard ratio = 0.76, 95% confidence interval: 0.42, 1.38) nor gonococcal/chlamydial genital infection (adjusted hazard ratio = 1.16, 95% confidence interval: 0.76, 1.78). Frequency of douching immediately preceding PID or gonococcal/chlamydial genital infection was not different between women who developed versus did not develop outcomes. These data do not support an association between douching and development of PID or gonococcal/chlamydial genital infection among predominantly young, African-American women.

Cigarette smoking and age at diagnosis of inflammatory bowel disease

OBJECTIVES

The incidence and age of onset of inflammatory bowel disease (IBD) appear to be changing. The aim of this study was to determine whether the prevalence of cigarette smoking differs among patients with Crohn's disease (CD) or ulcerative colitis (UC) at the time of diagnosis compared with the general population and whether smoking history is related to the type and age of IBD onset.

METHODS

Prevalence rates of smoking at the time of IBD diagnosis were compared between patients with CD and UC from the IBD Center at the University of Pittsburgh Medical Center versus age-, gender-, and time period-adjusted rates in the Pennsylvania general population. Analyses also were stratified by gender and diagnoses before and after 40 years of age, i.e., early and late onset.

RESULTS

There were 263 IBD patients (144 UC patients and 119 CD patients) seen in the IBD center between August 2000 and December 2002. The prevalence of active smoking was significantly higher at diagnosis in CD patients compared with the Pennsylvania general population (33% versus 24%, P = 0.04), particularly in those with CD onset at 40 years of age or later (47% versus 27%, P = 0.005). In contrast, smoking prevalence was significantly lower in UC patients than the general population (9% versus 28%, P < 0.0001), particularly among those with UC onset before the age of 40 years (6% versus 27%, P < 0.0001). Smoking cessation was associated with an approximate, but nonsignificant, 3-fold higher likelihood of late-onset UC compared with CD.

CONCLUSIONS

Cigarette smoking is associated with the development of late-onset CD and is protective against developing UC at any age, particularly early onset. Former smoking is associated with a high likelihood of developing late-onset UC, but not CD.

Bacterial Vaginosis and Risk of Pelvic Inflammatory Disease

BACKGROUND

Bacterial vaginosis commonly is found in women with pelvic inflammatory disease (PID), but it is unclear whether bacterial vaginosis leads to incident PID.

METHODS

Women (n = 1,179) from 5 U.S. centers were evaluated for a median of 3 years. Every 6-12 months, vaginal swabs were obtained for gram stain and culture of microflora. A vaginal microflora gram stain score of 7-10 was categorized as bacterial vaginosis. Pelvic inflammatory disease was diagnosed by presence of either histologic endometritis or pelvic pain and tenderness plus one of the following: oral temperature greater than 38.3 degrees C; sedimentation rate greater than 15 mm/hour; white blood count greater than 10,000; or lower genital tract detection of leukorrhea, mucopus, or Neisseria gonorrhoeae or Chlamydia trachomatis.

RESULTS

After adjustment for relevant demographic and lifestyle factors, baseline bacterial vaginosis was not associated with the development of PID (adjusted hazard ratio 0.89, 95% confidence interval 0.55-1.45). Carriage of bacterial vaginosis in the previous 6 months before a diagnosis (adjusted risk ratio 1.31, 95% confidence interval 0.71-2.42) also was not significantly associated with PID. Similarly, neither absence of hydrogen peroxide-producing Lactobacillus nor high levels of Gardnerella vaginalis significantly increased the risk of PID. Dense growth of pigmented, anaerobic gram-negative rods in the 6 months before diagnosis did significantly increase a woman's risk of PID (P =.04). One subgroup of women, women with 2 or more recent sexual partners, demonstrated associations among bacterial vaginosis, Gardnerella vaginalis, anaerobic gram-negative rods, and PID.

CONCLUSION

In this cohort of high-risk women, after adjustment for confounding factors, we found no overall increased risk of developing incident PID among women with bacterial vaginosis.

LEVEL OF EVIDENCE

II-2

Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease

Among 684 sexually active women with pelvic inflammatory disease (PID) followed up for a mean of 35 months, we related contraceptive use to self-reported PID recurrence, chronic pelvic pain, and infertility. Persistent use of condoms during the study reduced the risk of recurrent PID, chronic pelvic pain, and infertility. Consistent condom use (about 60% of encounters) at baseline also reduced these risks, after adjustment for confounders, by 30% to 60%. Self-reported persistent and consistent condom use was associated with lower rates of PID sequelae.