Targeted temperature management in cardiovascular disease complicated by cardiac arrest

PURPOSE

The majority of cardiac arrests occur due to cardiovascular etiology. Targeted temperature management (TTM) (32-34 °C) is a part of the standard post arrest care. We hypothesized that lower body temperature may lead to reduced cardiac metabolic demand and potentially have a beneficial effect on myocardial function.

METHODS

We performed a retrospective study on patients admitted to the intensive care unit following cardiac arrest secondary to cardiovascular etiology over a 9 year period. We assessed the impact of TTM on neurological and cardiac outcomes.

RESULTS

There were 57 patients in the cohort; 21 patients in the TTM group and 36 in the non-TTM group. Demographic characteristics were similar in both groups-the majority of patients (86 vs 80 %, respectively) were males in their 60s. Neurological outcomes were similar; 24 % of patients died during the ICU admission in the TTM group vs 18 % in the non-TTM group. Mean GCS on admission to the ICU was 4 vs 7, respectively, and 11 at discharge in both groups. Majority of patients recovered good neurological function (GCS ≥ 13)-57 % in the TTM group vs 64 % in the non-TTM group. The change in left ventricular function over a 6 month follow up period was significantly better in patients who received targeted temperature management-mean change of +4.4 vs -3.3 %, respectively. This proved to be statistically significant (p = 0.02).

CONCLUSIONS

The study demonstrates a possible beneficial effect of TTM on long-term cardiac function, when instituted following cardiac arrest.

Effect of maternal gestational diabetes on the cardiovascular risk factor profile of infants at 1 year of age

BACKGROUND AND AIM

Offspring of women with gestational diabetes (GDM) exhibit an adverse cardiovascular risk factor profile by as early as age 5 years. Recently, maternal glycemia has been associated with epigenetic modification of genes on the fetal side of the placenta, including those encoding emerging risk factors (adiponectin, leptin), suggesting that vascular differences may emerge even earlier in life. Thus, we sought to evaluate cardiovascular risk factors and determinants thereof in 1-year-old infants of women with and without GDM.

METHODS AND RESULTS

Traditional (glucose, lipids) and emerging (C-reactive protein (CRP), adiponectin, leptin) risk factors were assessed in pregnancy in 104 women with (n = 36) and without GDM (n = 68), and at age 1-year in their offspring. In pregnancy, women with GDM had higher triglycerides (2.49 vs 2.10 mmol/L, p = 0.04) and CRP (5.3 vs 3.6 mg/L, p = 0.03), and lower adiponectin (7.3 vs 8.5 μg/mL, p = 0.04) than did their peers. At age 1-year, however, there were no differences in cardiovascular risk factors (including adiponectin) between the infants of women with and without GDM. Of note, maternal and infant adiponectin levels were associated in the non-GDM group (r = 0.39, p = 0.001) but not in the GDM group (r = 0.07, p = 0.67). Furthermore, on multiple linear regression analyses, maternal adiponectin emerged as an independent predictor of infant adiponectin in the non-GDM group only (beta = 776.1, p = 0.0065).

CONCLUSION

Infants of women with and without GDM have a similar cardiovascular risk factor profile at age 1-year. However, there are differences in their early-life determinants of adiponectin that may be relevant to the subsequent vascular risk of GDM offspring.

Fish consumption, insulin sensitivity and beta-cell function in the Insulin Resistance Atherosclerosis Study (IRAS)

BACKGROUND AND AIMS

Previous research on the association between fish consumption and incident type 2 diabetes has been inconclusive. In addition, few studies have investigated how fish consumption may be related to the metabolic abnormalities underlying diabetes. Therefore, we examined the association of fish consumption with measures of insulin sensitivity and beta-cell function in a multi-ethnic population.

METHODS AND RESULTS

We examined the cross-sectional association between fish consumption and measures of insulin sensitivity and secretion in 951 non-diabetic participants in the Insulin Resistance Atherosclerosis Study (IRAS). Fish consumption, categorized as <2 vs. ≥2 portions/week, was measured using a validated food frequency questionnaire. Insulin sensitivity (S(I)) and acute insulin response (AIR) were determined from frequently sampled intravenous glucose tolerance tests. Higher fish consumption was independently associated with lower S(I)-adjusted AIR (β = -0.13 [-0.25, -0.016], p = 0.03, comparing ≥2 vs. <2 portions/week). Fish consumption was positively associated with intact and split proinsulin/C-peptide ratios, however, these associations were confounded by ethnicity (multivariable-adjusted β = 0.073 [-0.014, 0.16] for intact proinsulin/C-peptide ratio, β = 0.031 [-0.065, 0.13] for split proinsulin/C-peptide ratio). We also observed a significant positive association between fish consumption and fasting blood glucose (multivariable-adjusted β = 2.27 [0.68, 3.86], p = 0.005). We found no association between fish consumption and S(I) (multivariable-adjusted β = -0.015 [-0.083, 0.053]) or fasting insulin (multivariable-adjusted β = 0.016 [-0.066, 0.10]).

CONCLUSIONS

Fish consumption was not associated with measures of insulin sensitivity in the multi-ethnic IRAS cohort. However, higher fish consumption may be associated with pancreatic beta-cell dysfunction.

Independent and conjoint associations of gout and hyperuricaemia with total and cardiovascular mortality

BACKGROUND

Gout and serum uric acid are associated with mortality but their simultaneous contributions have not been fully evaluated in the general population.

PURPOSE

To explore the independent and conjoint relationships of gout and uric acid with mortality in the US population.

METHODS

Mortality risks of gout and serum uric acid were determined for 15 773 participants, aged 20 years or older, in the Third National Health and Nutrition Examination Survey by linking baseline information collected during 1988-1994 with mortality data up to 2006. Multivariable Cox proportional hazards regression determined adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for each exposure and all analyses were conducted in 2011 and 2012.

RESULTS

Compared with subjects without a history of gout, the multivariable HR for subjects with gout were 1.42 (CI 1.12-1.82) for total and 1.58 (CI 1.13-2.19) for cardiovascular mortality. Adjusted HRs per 59.5 µmol/l (1 mg/dl) increase in uric acid were 1.16 (CI 1.10-1.22) for total and cardiovascular mortality and this pattern was consistent across disease categories. In the conjoint analysis, the adjusted HRs for mortality in the highest two uric acid quartiles were 1.64 (CI 1.08-2.51) and 1.77 (CI 1.23-2.55), respectively, for subjects with gout, and were 1.09 (CI 0.87-1.37) and 1.37 (CI (1.11-1.70), respectively, for subjects without gout, compared with those without gout in the lowest quartile. A similar pattern emerged for cardiovascular mortality.

CONCLUSION

Gout and serum uric acid independently associate with total and cardiovascular mortality. These risks increase with rising uric acid concentrations.

Quality of colonoscopy performance among gastroenterology and surgical trainees: a need for common training standards for all trainees?

BACKGROUND AND STUDY AIM

Cecal intubation and polyp detection rates are objective measures of colonoscopy performance. Minimum cecal intubation rates greater than 90% have been endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) and the Joint Advisory Group (JAG) UK. Performance data for medical and surgical trainee endoscopists are limited, and we used endoscopy quality parameters to compare these two groups.

METHODS

Retrospective review of all single-endoscopist colonoscopies done by gastroenterology and surgical trainees ("registrars," equivalent to fellows, postgraduate year 5) with more than two years' endoscopy experience, in 2006 and 2007 at a single academic medical center. Completion rates and polyp detection rates for endoscopists performing more than 50 colonoscopies during the study period were audited. Colonoscopy withdrawal time was prospectively observed in a representative subset of 140 patients.

RESULTS

Among 3079 audited single-endoscopist colonoscopies, seven gastroenterology trainees performed 1998 procedures and six surgery trainees performed 1081. The crude completion rate was 82%, 84% for gastroenterology trainees and 78% for surgery trainees (P < 0.0001). Adjusted for poor bowel preparation quality and obstructing lesions, the completion rate was 89%; 93% for gastroenterology trainees, and 84% for surgical trainees (P < 0.0001). The polyp detection rate was 19% overall, with 21% and 14% for gastroenterology and surgical trainees, respectively (P < 0.0001). The adenoma detection rate in patients over 50 was 12%; gastroenterology trainees 14% and surgical trainees 9% (P = 0.0065). In the prospectively audited procedures, median withdrawal time was greater in the gastroenterology trainee group and polyp detection rates correlated closely with withdrawal time (r = 0.99).

CONCLUSION

The observed disparity in endoscopic performance between surgical and gastroenterology trainees suggests the need for a combined or unitary approach to endoscopy training for specialist medical and surgical trainees.

An assessment of the long-term health outcome of renal transplant recipients in Ireland

BACKGROUND

Renal transplantation remains the preferred method of renal replacement therapy in terms of patient survival, quality of life and cost. However, patients have a high risk of complications ranging from rejection episodes, infection and cancer, amongst others.

AIMS AND METHODS

In this study, we sought to determine the long-term health outcomes and preventive health measures undertaken for the 1,536 living renal transplant patients in Ireland using a self-reported questionnaire. Outcomes were divided into categories, namely, general health information, allograft-related information, immunosuppression-related complications and preventive health measures.

RESULTS

The results demonstrate a high rate of cardiovascular, neoplastic and infectious complications in our transplant patients. Moreover, preventive health measures are often not undertaken by patients and lifestyle choices can be poor.

CONCLUSIONS

This study highlights the work needed by the transplantation community to improve patient education, adjust immunosuppression where necessary and aggressively manage patient risk factors.

The impact of exercise consultation on activity levels and metabolic markers in obese adolescents: a pilot study

Objective. To assess the impact of exercise consultation on physical activity (PA) levels, anthropometric measures, and metabolic markers in obese adolescents. Methods. Obese adolescents (14-18 years) were randomized to either an exercise consultation (intervention group) or to review "Canada's Physical Activity Guide for Youth" (control group). Outcomes, including accelerometry, anthropometrics, blood pressure, stage of exercise behavior change, fasting glucose, insulin, and lipids, were measured at baseline and 3 months later. Results. Thirty adolescents (mean BMI = 36.1 kg/m(2); SD = 6.9) completed the study. At follow-up, the intervention group had significantly greater PA compared with controls (P < .05). Similarly, the intervention group weighed an average 2.6 kg less than the control group (P < .05), with a mean BMI z-score of 2.15 compared to 2.21 for controls (P = .054). No other differences were noted. Conclusion. Exercise consultation may be a simple approach to increase PA levels, reduce weight, and lower BMI in obese adolescents.

Prospective association between fasting NEFA and type 2 diabetes: impact of post-load glucose

AIMS/HYPOTHESIS

Elevated fasting NEFAs are thought to promote type 2 diabetes. Three prospective studies support this concept, showing increased diabetes risk associated with fasting NEFA. However, these prospective associations may be confounded by strong cross-sectional correlations between fasting NEFA and metabolic predictors of diabetes. To examine this assumption, we used cohort data from the Insulin Resistance Atherosclerosis Study (IRAS).

METHODS

Within the IRAS cohort (n = 902, 145 incident cases), we examined nine metabolic variables for their confounding effect on the fasting NEFA-diabetes association: 2 h glucose; fasting plasma glucose; body mass index; waist circumference; waist-to-hip ratio; weight; insulin sensitivity (S (I)); fasting insulin; and acute insulin response. We compared odds ratios for fasting NEFA (log( e ) transformed and adjusted for age, sex, ethnicity and clinic) before and after inclusion of each metabolic variable into a logistic regression model.

RESULTS

Three variables (2 h glucose, BMI and S (I)) cross-sectionally correlated with fasting NEFA (r > or = 0.1, p < 0.05). Unadjusted for metabolic predictors, fasting NEFA levels were positively associated with diabetes risk: OR 1.37 (95% CI 0.87-2.15) per unit on a log scale. All metabolic variables except AIR showed confounding. Inclusion of 2 h glucose reversed the positive association (OR 0.50 [95% CI 0.30-0.82]), whereas other predictors reduced the association to the null. The final model included the variables correlated with baseline fasting NEFA (2 h glucose, BMI and S (I)) and the demographic variables resulting in OR 0.47 (95% CI 0.27-0.81).

CONCLUSIONS/INTERPRETATION

Our results indicate that 2 h glucose strongly confounds the prospective association between fasting NEFA and diabetes; carefully adjusted fasting NEFA levels are inversely associated with diabetes risk.

Friedreich's ataxia cardiomyopathy: case based discussion and management issues

Cardiac involvement is common in Friedreich's Ataxia and is a common cause of premature death. Evidence regarding treatment of congestive heart failure in patients with Friedreich's Ataxia is lacking. The case of a 31-year-old male with advanced Friedreich's Ataxia who presented with an acute diarrhoeal illness and features of acute heart failure is discussed. We then review the reported cardiac manifestations of Friedreich's Ataxia and discuss management options.

Population fluctuations of the New Holland mouse Pseudomys novaehollandiae at Wilson?s Promontory National Park, Victoria

The New Holland mouse (Pseudomys novaehollandiae) was first recorded at Wilson?s Promontory in 1972 in heathland vegetation, but has not been located in this habitat subsequently. The species was not trapped again until 1993 when it was found in calcarenite dune woodland on the Yanakie Isthmus. The aims of this study were to assess the population dynamics and habitat use of the species in this dune habitat. Mark-recapture trapping was conducted at three sites from 1999 to 2002. One site was located on low (0 - 5 m), flat sand dunes and open swales, another on medium (5 ? 10 m) vegetated dunes, and the third on high (20 m) steep vegetated dunes. The three sites had not been burnt for 30 to 50 years. The abundance of P. novaehollandiae was related to understorey vegetation density and differences in population densities on the sites are likely to be related to the primary succession stages on the sand dunes, rather than fire history. The maximum density (24 ha-1) recorded at one site was very high compared to other Victorian populations, however this was followed by a substantial decline in numbers within the year. At another site a small population declined to extinction. Populations on the isthmus are thus capable of achieving high densities but may decline quickly. Rainfall patterns may have affected the population fluctuations, but further research is required to elucidate fully the factors involved in the long-term dynamics of this species.

The prevalence of NIDDM and associated risk factors in native Canadians

OBJECTIVE

To determine the true prevalence of impaired glucose tolerance (IGT), NIDDM, and associated risk factors by age and sex in an isolated native community.

RESEARCH DESIGN AND METHODS

A community-wide prevalence survey using a 75-g oral glucose tolerance test (OGTT) was undertaken in the remote native reserve of Sandy Lake, Ontario, Canada. Measurements for obesity included waist-to-hip circumference, BMI, and percentage body fat.

RESULTS

A total of 728 individuals were enrolled, representing a community participation rate of 72%. The overall crude prevalence of NIDDM was 17.2% (18.1% females and 16.0% males) and increased to 26.1% overall (28.0% females and 24.2% males) when age-standardized. The prevalence of IGT was higher in females compared with males (age-standardized prevalence of 19.8 vs. 7.1%, respectively). Females had a higher prevalence of obesity, IGT, and NIDDM occurring at younger ages. Measures of obesity and fasting insulin levels were significantly associated with NIDDM in the 18-49 age-group.

CONCLUSIONS

The prevalence rates of NIDDM in this study population are the highest reported to date in a Canadian native population and among the highest reported in the world. Females appear to be at much higher risk of developing obesity, IGT, and NIDDM and at a younger age. Due to the high prevalence rates of IGT and NIDDM in this young population, there is urgent need to develop culturally appropriate community-based public health intervention programs before the long-term complications of diabetes have a devastating effect on the residents.

DNA demethylation in erythroleukaemia cells

Despite a fall in the proportion of CGs methylated, evidence has not been obtained for significant demethylation of prelabelled DNA when mouse erythroleukaemia cells are induced to differentiate. There is, however, a delay in the methylation of the DNA that is synthesised in the early period of induction, leading to its undermethylation by 30-50% and this may be a contributory cause of the observed fall in CG methylation.