Medical Care as Flea Market Bargaining? An International Interdisciplinary Study of Varieties of Shared Decision Making in Physician-Patient Interactions

Phenomenon: Shared decision making (SDM) is a core ideal in the interaction between healthcare providers and patients, but the implementation of the SDM ideal in clinical routines has been a relatively slow process. Approach: In a sociological study, 71 interactions between physicians and simulated patients enacting chronic heart failure were video-recorded in China, Germany, the Netherlands, and Turkey as part of a quasi-experimental research design. Participating physicians varied in specialty and level of experience. The secondary analysis presented in this article used content analysis to study core components of SDM in all of the 71 interactions and a grounded theory approach to observe how physicians responded actively to patients even though they did not actively employ the SDM ideal. Findings: Full realization of the SDM ideal remains an exception, but various aspects of SDM in physician-patient interaction were observed in all four locations. Analyses of longer interactions show dynamic processes of interaction that sometimes surprised both patient and physician. We observed varieties of SDM that differ from the SDM ideal but arguably achieve what the SDM ideal is intended to achieve. Our analysis suggests a need to revisit the SDM ideal-to consider whether varieties of SDM may be acceptable, even valuable, in their own right. Insights: The gap between the SDM ideal and SDM as implemented in clinical practice may in part be explained by the tendency of medicine to define and teach SDM through a narrow lens of checklist evaluations. The authors support the argument that SDM defies a checklist approach. SDM is not uniform, but nuanced, dependent on circumstances and setting. As SDM is co-produced by patients and physicians in a dynamic process of interaction, medical researchers should consider and medical learners should be exposed to varieties of SDM-related practice rather than a single idealized model. Observing and discussing worked examples contributes to the physician's development of realistic expectations and personal professional growth.

Associations of systemic oxidative stress with functional outcomes after ST-segment elevation myocardial infarction

BACKGROUND

Ischemia-reperfusion is accompanied by oxidative stress. Serum free thiols (FTs; sulfhydryl groups) reliably reflect systemic oxidative stress. This study evaluates longitudinal changes in FTs and their associations with outcomes after ST-segment elevation myocardial infarction (STEMI).

METHODS

FTs were detected in archived serum samples from 378 participants of a neutral randomized trial on metformin therapy after STEMI. FT levels were determined at presentation with STEMI and at 24 h, 2 weeks, 4 months and 1 year thereafter. Outcomes included infarct size and left ventricular ejection fraction (LVEF), both determined with cardiac magnetic resonance imaging after 4 months, and 5-year major adverse cardiovascular events (MACE).

RESULTS

Serum FT concentrations at presentation and at 24 h were 356 ± 91 and 353 ± 76 μmol/L, respectively. The change in FTs between presentation and 24 h (ΔFTs) was associated with outcomes in age- and sex-adjusted analysis (per 100 μmol/L FT increase, β = -0.87 for infarct size, 95% confidence interval (CI): -1.75 to -0.001, P = 0.050; β = 1.31, 95% CI: 0.37 to 2.25 for LVEF, P = 0.007). Associations between ΔFTs and LVEF were markedly stronger in patients with Thrombolysis in Myocardial Infarction flow of 0 or 1 before percutaneous coronary intervention (PCI)(β = 2.73, 95% CI: 0.68 to 4.77, P = 0.009). Declining FTs during the first 24 h might be associated with higher incidence of 5-year MACE (P = 0.09).

CONCLUSIONS

Changes in oxidative stress early post-PCI may predict functional outcomes after STEMI. Our findings warrant validation in larger cohorts, and then may be used as rationale for development of thiol-targeted therapy in ischemic heart disease.

Differences in shuntflow (Qa), cardiac function and mortality between hemodialysis patients with a lower-arm fistula, an upper-arm fistula, and an arteriovenous graft

BACKGROUND

High-flow vascular accesses may contribute to cardiovascular morbidity and mortality in hemodialysis patients. Since shuntflow (Qa) varies between vascular access types, the current study aims to investigate differences in left ventricular hypertrophy (LVH), systolic and diastolic function parameters, and all-cause mortality between patients with a lower-arm arteriovenous fistula (AVF), an upper-arm AVF, and an arteriovenous graft (AVG).

METHODS

A post hoc analysis of 100 patients was performed in a single-center, prospective observational study. Echocardiography examinations were performed prior to the dialysis session. Qa measurements were performed using ultrasound dilution. Patient groups were categorized by vascular access type. Cox proportional hazards models were used to investigate the association of shunt type with all-cause mortality with adjustment for potential confounders including, amongst others, age, sex, diabetes, the duration of hemodialysis treatment, shunt vintage, and Qa.

RESULTS

Patients with an upper-arm AVF had significantly (p < 0.001) higher Qa (median 1902, IQR 1223-2508 ml/min) compared to patients with a lower-arm AVF (median 891, IQR 696-1414 ml/min) and patients with an AVG (median 881, IQR 580-1157 ml/min). The proportion of patients with LVH and systolic and diastolic echocardiographic parameters did not differ significantly between groups. Survival analysis showed that an upper-arm AVF was associated with a significantly lower all-cause mortality (p = 0.04) compared to a lower-arm AVF.

CONCLUSIONS

Patients with an upper-arm fistula had a higher Qa but similar systolic and diastolic cardiac function. Patients with an upper-arm fistula had a significantly lower risk of all-cause mortality compared with patients with a lower-arm fistula.

Systemic oxidative stress associates with disease severity and outcome in patients with new-onset or worsening heart failure

BACKGROUND

Oxidative stress may be a key pathophysiological mediator in the development and progression of heart failure (HF). The role of serum-free thiol concentrations, as a marker of systemic oxidative stress, in HF remains largely unknown.

OBJECTIVE

The purpose of this study was to investigate associations between serum-free thiol concentrations and disease severity and clinical outcome in patients with new-onset or worsening HF.

METHODS

Serum-free thiol concentrations were determined by colorimetric detection in 3802 patients from the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF). Associations between free thiol concentrations and clinical characteristics and outcomes, including all-cause mortality, cardiovascular mortality, and a composite of HF hospitalization and all-cause mortality during a 2-years follow-up, were reported.

RESULTS

Lower serum-free thiol concentrations were associated with more advanced HF, as indicated by worse NYHA class, higher plasma NT-proBNP (P < 0.001 for both) and with higher rates of all-cause mortality (hazard ratio (HR) per standard deviation (SD) decrease in free thiols: 1.253, 95% confidence interval (CI): 1.171-1.341, P < 0.001), cardiovascular mortality (HR per SD: 1.182, 95% CI: 1.086-1.288, P < 0.001), and the composite outcome (HR per SD: 1.058, 95% CI: 1.001-1.118, P = 0.046).

CONCLUSIONS

In patients with new-onset or worsening HF, a lower serum-free thiol concentration, indicative of higher oxidative stress, is associated with increased HF severity and poorer prognosis. Our results do not prove causality, but our findings may be used as rationale for future (mechanistic) studies on serum-free thiol modulation in heart failure. Associations of serum-free thiol concentrations with heart failure severity and outcomes.

Cardiovascular Implantable Electronic Devices Enabled Remote Heart Failure Monitoring; What We Have Learned and Where to Go Next

Despite recent developments, heart failure (HF) remains to be a great burden to the individual patient, entailing major morbidity and mortality. Moreover, HF is a great burden to overall healthcare, mainly because of frequent hospitalizations. Timely diagnosis of HF deterioration and implementation of appropriate therapy may prevent hospitalization and eventually improve a patient’s prognosis; however, depending on the patient’s presentation, the signs and symptoms of HF often offer too little therapeutic window to prevent hospitalizations. Cardiovascular implantable electronic devices (CIEDs) can provide real-time physiologic parameters and remote monitoring of these parameters can potentially help to identify patients at high risk. However, routine implementation of remote monitoring of CIEDs has still not been widely used in daily patient care. This review gives a detailed description of available metrics for remote HF monitoring, the studies that provide evidence of their efficacy, ways to implement them in clinical HF practice, as well as lessons learned on where to go on from where we currently are.

Hearts in their hands-Physicians' gestures embodying shared professional knowledge around the world

The biomedical approach to medical knowledge is widely accepted around the world. This article considers whether the incorporated aspects of physician-patient interaction have become similarly common across the globe by comparing the gestures that physicians use in their interactions with patients. Up to this point, there has been little research on physicians' use of gestures in health-care settings. We explore how-in four university hospitals in Turkey, the People's Republic of China, The Netherlands and Germany-physicians use gesture in their discussions with simulated patients about the condition of heart failure. Our analysis confirms the importance of gestures for organising both the personal interaction and the knowledge transfer between physician and patient. From the perspective of global comparison, it is notable that physicians in all four hospitals used similar gestures. This demonstrates the globality of biomedical knowledge in an embodied mode. Physicians used gestures for a range of purposes, including to convey the idea of an 'anatomical map' and for constructing visual models of (patho-)physiological processes. Since biomedical language is rife with metaphor, it was not surprising that we also identified an accompanying metaphorical gesture which has a similar form in the various locations that were part of the study.

Predictors of adverse diastolic remodeling in non-diabetic patients presenting with ST-elevation myocardial infarction

BACKGROUND

Adverse systolic remodeling after ST-elevation myocardial infarction (STEMI) is associated with poor clinical outcomes. However, little is known about diastolic remodeling. The purpose of this study was to identify the factors leading to diastolic remodeling.

METHODS

Echocardiography was performed during hospitalization and at 4 months follow-up in 267 non-diabetic STEMI patients from the GIPS-III trial. As parameters of diastolic remodeling we used (1.) the E/e' at 4 months adjusted for the E/e' at hospitalization and (2.) the change in E/e' between hospitalization and 4 months. Multivariable regression models correcting for age and sex were constructed to identify possible association of clinical and angiographic variables as well as biomarkers with diastolic remodeling.

RESULTS

Older age, female gender, hypertension, multi vessel disease, higher glucose and higher peak CK were independent predictors of higher E/e' at 4 months in a multivariable model (R2:0.20). After adjustment for E/e' during hospitalization only female gender, multivessel disease and higher glucose remained predictors of E/e' at four months (R2:0.40). Lower myocardial blush grade, AST and NT-proBNP were independent predictors of a higher increase of E/e' between hospitalization and at 4 months in a multivariable model (R2:0.08).

CONCLUSIONS

Our data supports the hypothesis that female gender, multivessel coronary artery disease, and microvascular damage are important predictors of adverse diastolic remodeling after STEMI. In addition, our data suggests that older age and hypertension prior to STEMI may have contributed to worse pre-existing diastolic function.

TRIAL REGISTRATION

NIH, NCT01217307. Prospectively registered on October 8th 2010, https://clinicaltrials.gov/ct2/show/NCT01217307 .

Rationale and Design of the Groningen Intervention Study for the Preservation of Cardiac Function with Sodium Thiosulfate after St-segment Elevation Myocardial Infarction (GIPS-IV) trial

BACKGROUND

Ischemia and subsequent reperfusion cause myocardial injury in patients presenting with ST-segment elevation myocardial infarction (STEMI). Hydrogen sulfide (H₂S) reduces "ischemia-reperfusion injury" in various experimental animal models, but has not been evaluated in humans. This trial will examine the efficacy and safety of the H₂S-donor sodium thiosulfate (STS) in patients presenting with a STEMI.

STUDY DESIGN

The Groningen Intervention study for the Preservation of cardiac function with STS after STEMI (GIPS-IV) trial (NCT02899364) is a double-blind, randomized, placebo-controlled, multicenter trial, which will enroll 380 patients with a first STEMI. Patients receive STS 12.5 grams intravenously or matching placebo in addition to standard care immediately at arrival at the catheterization laboratory after providing consent. A second dose is administered 6 hours later at the coronary care unit. The primary endpoint is myocardial infarct size as quantified by cardiac magnetic resonance imaging 4 months after randomization. Secondary endpoints include the effect of STS on peak CK-MB during admission and left ventricular ejection fraction and NT-proBNP levels at 4 months follow-up. Patients will be followed-up for 2 years to assess clinical endpoints.

CONCLUSIONS

The GIPS-IV trial is the first study to determine the effect of a H₂S-donor on myocardial infarct size in patients presenting with STEMI.

Association of Circulating Ketone Bodies With Functional Outcomes After ST-Segment Elevation Myocardial Infarction

BACKGROUND

Circulating ketone bodies (KBs) are increased in patients with heart failure (HF), corresponding with increased cardiac KB metabolism and HF severity. However, the role of circulating KBs in ischemia/reperfusion remains unknown.

OBJECTIVES

This study sought to investigate longitudinal changes of KBs and their associations with functional outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI).

METHODS

KBs were measured in 369 participants from a randomized trial on early metformin therapy after STEMI. Nonfasting plasma concentrations of KBs (β-hydroxybutyrate, acetoacetate, and acetone) were measured by nuclear magnetic resonance spectroscopy at presentation, at 24 hours, and after 4 months. Myocardial infarct size and left ventricular ejection fraction (LVEF) were determined by cardiac magnetic resonance imaging at 4 months. Associations of circulating KBs with infarct size and LVEF were determined using multivariable linear regression analyses.

RESULTS

Circulating KBs were high at presentation with STEMI (median total KBs: 520 μmol/L; interquartile range [IQR]: 315-997 μmol/L). At 24 hours after reperfusion, KBs were still high compared with levels at 4-month follow-up (206 μmol/L [IQR: 174-246] vs 166 μmol/L [IQR: 143-201], respectively; P < 0.001). Increased KB concentrations at 24 hours were independently associated with larger myocardial infarct size (total KBs, per 100 μmol/L: β = 1.56; 95% confidence interval: 0.29-2.83; P = 0.016) and lower LVEF (β = -1.78; 95% CI: (-3.17 to -0.39; P = 0.012).

CONCLUSIONS

Circulating KBs are increased in patients presenting with STEMI. Higher KBs at 24 hours are associated with functional outcomes after STEMI, which suggests a potential role for ketone metabolism in response to myocardial ischemia. (Metabolic Modulation With Metformin to Reduce Heart Failure After Acute Myocardial Infarction: Glycometabolic Intervention as Adjunct to Primary Coronary Intervention in ST Elevation Myocardial Infarction (GIPS-III): a Randomized Controlled Trial; NCT01217307).

2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation : Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups

Recently, the European Society of Cardiology (ESC) has updated its guidelines for the management of patients with acute coronary syndrome (ACS) without ST-segment elevation. The current consensus document of the Dutch ACS working group and the Working Group of Interventional Cardiology of the Netherlands Society of Cardiology aims to put the 2020 ESC Guidelines into the Dutch perspective and to provide practical recommendations for Dutch cardiologists, focusing on antiplatelet therapy, risk assessment and criteria for invasive strategy.

Multi-ancestry GWAS of the electrocardiographic PR interval identifies 202 loci underlying cardiac conduction

The electrocardiographic PR interval reflects atrioventricular conduction, and is associated with conduction abnormalities, pacemaker implantation, atrial fibrillation (AF), and cardiovascular mortality. Here we report a multi-ancestry (N = 293,051) genome-wide association meta-analysis for the PR interval, discovering 202 loci of which 141 have not previously been reported. Variants at identified loci increase the percentage of heritability explained, from 33.5% to 62.6%. We observe enrichment for cardiac muscle developmental/contractile and cytoskeletal genes, highlighting key regulation processes for atrioventricular conduction. Additionally, 8 loci not previously reported harbor genes underlying inherited arrhythmic syndromes and/or cardiomyopathies suggesting a role for these genes in cardiovascular pathology in the general population. We show that polygenic predisposition to PR interval duration is an endophenotype for cardiovascular disease, including distal conduction disease, AF, and atrioventricular pre-excitation. These findings advance our understanding of the polygenic basis of cardiac conduction, and the genetic relationship between PR interval duration and cardiovascular disease.

KCND3 potassium channel gene variant confers susceptibility to electrocardiographic early repolarization pattern

BACKGROUNDThe presence of an early repolarization pattern (ERP) on the surface ECG is associated with risk of ventricular fibrillation and sudden cardiac death. Family studies have shown that ERP is a highly heritable trait, but molecular genetic determinants are unknown.METHODSTo identify genetic susceptibility loci for ERP, we performed a GWAS and meta-analysis in 2,181 cases and 23,641 controls of European ancestry.RESULTSWe identified a genome-wide significant (P < 5 × 10-8) locus in the potassium voltage-gated channel subfamily D member 3 (KCND3) gene that was successfully replicated in additional 1,124 cases and 12,510 controls. A subsequent joint meta-analysis of the discovery and replication cohorts identified rs1545300 as the lead SNP at the KCND3 locus (OR 0.82 per minor T allele, P = 7.7 × 10-12) but did not reveal additional loci. Colocalization analyses indicate causal effects of KCND3 gene expression levels on ERP in both cardiac left ventricle and tibial artery.CONCLUSIONSIn this study, we identified for the first time to our knowledge a genome-wide significant association of a genetic variant with ERP. Our findings of a locus in the KCND3 gene provide insights not only into the genetic determinants but also into the pathophysiological mechanism of ERP, discovering a promising candidate for functional studies.FUNDINGThis project was funded by the German Center for Cardiovascular Research (DZHK Shared Expertise SE081 - STATS). For detailed funding information per study, see the Supplemental Acknowledgments.

Plasma syndecan-1 in hemodialysis patients associates with survival and lower markers of volume status

Syndecan-1, a transmembrane heparan sulfate proteoglycan, associates with renal and cardiovascular functioning. We earlier reported syndecan-1 to be involved in renal tubular regeneration. We now examined plasma values of syndecan-1 in a hemodialysis cohort and its association with volume and inflammatory and endothelial markers in addition to outcome. Eighty-four prevalent hemodialysis patients were evaluated for their plasma syndecan-1 levels by ELISA before the start of hemodialysis, as well as 60, 180, and 240 min after start of dialysis. Patients were divided into sex-stratified tertiles based on predialysis plasma syndecan-1 levels. We studied the association between plasma levels of syndecan-1 and volume, inflammation, and endothelial markers and its association with cardiovascular events and all-cause mortality using Kaplan-Meier curves and Cox regression analyses with adjustments for gender, age, diabetes, and dialysis vintage. Predialysis syndecan-1 levels were twofold higher in men compared with women ( P = 0.0003). Patients in the highest predialysis plasma syndecan-1 tertile had a significantly higher ultrafiltration rate ( P = 0.034) and lower plasma values of BNP ( P = 0.019), pro-ANP ( P = 0.024), and endothelin ( P < 0.0001) compared with the two lower predialysis syndecan-1 tertiles. No significant associations with inflammatory markers were found. Cox regression analysis showed that patients in the highest syndecan-1 tertile had significantly less cardiovascular events and better survival compared with the lowest syndecan-1 tertile ( P = 0.02 and P = 0.005, respectively). In hemodialysis patients, higher plasma syndecan-1 levels were associated with lower concentrations of BNP, pro-ANP, and endothelin and with better patient survival. This may suggest that control of volume status in hemodialysis patients allows an adaptive tissue regenerative response as reflected by higher plasma syndecan-1 levels.

Intradialytic Complement Activation Precedes the Development of Cardiovascular Events in Hemodialysis Patients

Background: Hemodialysis (HD) is a life-saving treatment for patients with end stage renal disease. However, HD patients have markedly increased rates of cardiovascular morbidity and mortality. Previously, a link between the complement system and cardiovascular events (CV-events) has been reported. In HD, systemic complement activation occurs due to blood-to-membrane interaction. We hypothesize that HD-induced complement activation together with inflammation and thrombosis are involved in the development of CV-events in these patients. Methods: HD patients were followed for the occurrence of CV-events during a maximum follow-up of 45 months. Plasma samples were collected from 55 patients at different time points during one HD session prior to follow-up. Plasma levels of mannose-binding lectin, properdin and C3d/C3 ratios were assessed by ELISA. In addition, levels of von Willebrand factor, TNF-α and IL-6/IL-10 ratios were determined. An ex-vivo model of HD was used to assess the effect of complement inhibition. Results: During median follow-up of 32 months, 17 participants developed CV-events. In the CV-event group, the C3d/C3-ratio sharply increased 30 min after the start of the HD session, while in the event-free group the ratio did not increase. In accordance, HD patients that developed a CV-event also had a sustained higher IL-6/IL-10-ratio during the first 60 min of the HD session, followed by a greater rise in TNF-α levels and von Willebrand factor at the end of the session. In the ex-vivo HD model, we found that complement activation contributed to the induction of TNF-α levels, IL-6/IL-10-ratio and levels of von Willebrand factor. Conclusions: In conclusion, these findings suggest that early intradialytic complement activation predominantly occurred in HD patients who develop a CV-event during follow-up. In addition, in these patients complement activation was accompanied by a pro-inflammatory and pro-thrombotic response. Experimental complement inhibition revealed that this reaction is secondary to complement activation. Therefore, our data suggests that HD-induced complement, inflammation and coagulation are involved in the increased CV risk of HD patients.

Effect of isolated ultrafiltration and isovolemic dialysis on myocardial perfusion and left ventricular function assessed with 13N-NH3 positron emission tomography and echocardiography

Hemodialysis is associated with a fall in myocardial perfusion and may induce regional left ventricular (LV) systolic dysfunction. The pathophysiology of this entity is incompletely understood, and the contribution of ultrafiltration and diffusive dialysis has not been studied. We investigated the effect of isolated ultrafiltration and isovolemic dialysis on myocardial perfusion and LV function. Eight patients (7 male, aged 55 ± 18 yr) underwent 60 min of isolated ultrafiltration and 60 min of isovolemic dialysis in randomized order. Myocardial perfusion was assessed by ¹³N-NH₃ positron emission tomography before and at the end of treatment. LV systolic function was assessed by echocardiography. Regional LV systolic dysfunction was defined as an increase in wall motion score in ≥2 segments. Isolated ultrafiltration (ultrafiltration rate 13.6 ± 3.9 ml·kg^-1·h^-1) induced hypovolemia, whereas isovolemic dialysis did not (blood volume change -6.4 ± 2.2 vs. +1.3 ± 3.6%). Courses of blood pressure, heart rate, and tympanic temperature were comparable for both treatments. Global and regional myocardial perfusion did not change significantly during either isolated ultrafiltration or isovolemic dialysis and did not differ between treatments. LV ejection fraction and the wall motion score index did not change significantly during either treatment. Regional LV systolic dysfunction developed in one patient during isolated ultrafiltration and in three patients during isovolemic dialysis. In conclusion, global and regional myocardial perfusion was not compromised by 60 min of isolated ultrafiltration or isovolemic dialysis. Regional LV systolic dysfunction developed during isolated ultrafiltration and isovolemic dialysis, suggesting that, besides hypovolemia, dialysis-associated factors may be involved in the pathogenesis of hemodialysis-induced regional LV dysfunction.

Strong predictive value of mannose-binding lectin levels for cardiovascular risk of hemodialysis patients

Background

Hemodialysis patients have higher rates of cardiovascular morbidity and mortality compared to the general population. Mannose-binding lectin (MBL) plays an important role in the development of cardiovascular disease. In addition, hemodialysis alters MBL concentration and functional activity. The present study determines the predictive value of MBL levels for future cardiac events (C-event), cardiovascular events (CV-event) and all-cause mortality in HD patients.

Methods

We conducted a prospective study of 107 patients on maintenance hemodialysis. Plasma MBL, properdin, C3d and sC5b-9 was measured before and after one dialysis session. The association with future C-events, CV-events, and all-cause mortality was evaluated using Cox regression models.

Results

During median follow-up of 27 months, 36 participants developed 21 C-events and 36 CV-events, whereas 37 patients died. The incidence of C-events and CV-events was significantly higher in patients with low MBL levels (<319 ng/mL, lower quartile). In fully adjusted models, low MBL level was independently associated with increased CV-events (hazard ratio 3.98; 95 % CI 1.88–8.24; P < 0.001) and C-events (hazard ratio 3.96; 95 % CI 1.49–10.54; P = 0.006). No association was found between low MBL levels and all-cause mortality. Furthermore, MBL substantially improved risk prediction for CV-events beyond currently used clinical markers.

Conclusions

Low MBL levels are associated with a higher risk for future C-events and CV-events. Therefore, MBL levels may help to identify hemodialysis patients who are at risk to develop cardiovascular disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0995-5) contains supplementary material, which is available to authorized users.

Fibroblast growth factor 23 correlates with volume status in haemodialysis patients and is not reduced by haemodialysis

BACKGROUND

Recent data suggest a role for fibroblast growth factor 23 (FGF-23) in volume regulation. In haemodialysis patients, a large ultrafiltration volume (UFV) reflects poor volume control, and both FGF-23 and a large UFV are risk factors for mortality in this population. We studied the association between FGF-23 and markers of volume status including UFV, as well as the intradialytic course of FGF-23, in a cohort of haemodialysis patients.

METHODS

We carried out observational, post hoc analysis of 109 prevalent haemodialysis patients who underwent a standardized, low-flux, haemodialysis session with constant ultrafiltration rate. We measured UFV, plasma copeptin and echocardiographic parameters including cardiac output, end-diastolic volume and left ventricular mass index at the onset of the haemodialysis session. We measured the intradialytic course of plasma C-terminal FGF-23 (corrected for haemoconcentration) and serum phosphate levels at 0, 1, 3 and 4 h after onset of haemodialysis and analysed changes with linear mixed effect model.

RESULTS

Median age was 66 (interquartile range: 51-75) years, 65% were male with a weekly Kt/V 4.3 ± 0.7 and dialysis vintage of 25.4 (8.5-52.5) months. In univariable analysis, pre-dialysis plasma FGF-23 was associated with UFV, end-diastolic volume, cardiac output, early diastolic velocity e' and plasma copeptin. In multivariable regression analysis, UFV correlated with FGF-23 (standardized β: 0.373, P < 0.001, model R(2): 57%), independent of serum calcium and phosphate. The association between FGF-23 and echocardiographic volume markers was lost for all but cardiac output upon adjustment for UFV. Overall, FGF-23 levels did not change during dialysis [7627 (3300-13 514) to 7503 (3109-14 433) RU/mL; P = 0.98], whereas phosphate decreased (1.71 ± 0.50 to 0.88 ± 0.26 mmol/L; P < 0.001).

CONCLUSIONS

FGF-23 was associated with volume status in haemodialysis patients. The strong association with UFV suggests that optimization of volume status, for example by more intensive haemodialysis regimens, may also benefit mineral homeostasis. A single dialysis session did not lower FGF-23 levels.

Changes in Plasma Copeptin Levels during Hemodialysis: Are the Physiological Stimuli Active in Hemodialysis Patients?

OBJECTIVES

Plasma levels of copeptin, a surrogate marker for the vasoconstrictor hormone arginine vasopressin (AVP), are increased in hemodialysis patients. Presently, it is unknown what drives copeptin levels in hemodialysis patients. We investigated whether the established physiological stimuli for copeptin release, i.e. plasma osmolality, blood volume and mean arterial pressure (MAP), are operational in hemodialysis patients.

METHODS

One hundred and eight prevalent, stable hemodialysis patients on a thrice-weekly dialysis schedule were studied during hemodialysis with constant ultrafiltration rate and dialysate conductivity in this observational study. Plasma levels of copeptin, sodium, MAP, and blood volume were measured before, during and after hemodialysis. Multivariate analysis was used to determine the association between copeptin (dependent variable) and the physiological stimuli plasma sodium, MAP, excess weight as well as NT-pro-BNP immediately prior to dialysis and between copeptin and changes of plasma sodium, MAP and blood volume with correction for age, sex and diabetes during dialysis treatment.

RESULTS

Patients were 63 ± 15.6 years old and 65% were male. Median dialysis vintage was 1.6 years (IQR 0.7-4.0). Twenty-three percent of the patients had diabetes and 82% had hypertension. Median predialysis copeptin levels were 141.5 pmol/L (IQR 91.0-244.8 pmol/L). Neither predialysis plasma sodium levels, nor NT-proBNP levels, nor MAP were associated with predialysis copeptin levels. During hemodialysis, copeptin levels rose significantly (p<0.01) to 163.0 pmol/L (96.0-296.0 pmol/L). Decreases in blood volume and MAP were associated with increases in copeptin levels during dialysis, whereas there was no significant association between the change in plasma sodium levels and the change in copeptin levels.

CONCLUSIONS

Plasma copeptin levels are elevated predialysis and increase further during hemodialysis. Volume stimuli, i.e. decreases in MAP and blood volume, rather than osmotic stimuli, are associated with change in copeptin levels during hemodialysis.

Follow-up of patients with interventional closure of ventricular septal defects with Amplatzer Duct Occluder II

Nonsurgical closure of congenital ventricular septal defects (VSD) has become increasingly acceptable with the availability of different occlusion systems. Transcatheter device treatment is used for perimembranous and muscular defects. Atrio-ventricular block remains the most troublesome complication of device closure. The aim of this study was to describe our experience with closure of VSD using the Amplatzer Duct Occluder II (ADO II) as an "off-label" approach in children and adults. Between 2004 and 2012 transcatheter closure of 31 VSD (20 perimembranous, 10 muscular VSD and 1 ruptured sinus valsalva) with ADO II was undertaken in patients between 3 months and 55 years of age and with a body weight ranging from 4 to 105 kg in our institution. In 29 of 31 procedures, the defect was successfully closed (93.5%) without any significant complications. No increase of aortic or tricuspid valve regurgitation was found in any after procedure. Small residual shunts were observed immediately after the device implantation, but disappeared during a median follow-up period of 38 months (0.4-63) in 27 of 31 patients. There was no incidence of AV block or other conductance abnormalities during implantation or follow-up. The ADO II device is safe and effective for transcatheter VSD closure, but this is still an "off-label" use. After long-term follow-up in a large number of patients this device may be approved for VSD closure in the future.

Renal handling of galectin-3 in the general population, chronic heart failure, and hemodialysis

Background

Galectin‐3 is a biomarker for prognostication and risk stratification of patients with heart failure (HF). It has been suggested that renal function strongly relates to galectin‐3 levels. We aimed to describe galectin‐3 renal handling in HF.

Methods and Results

In Sprague–Dawley rats, we infused galectin‐3 and studied distribution and renal clearance. Furthermore, galectin‐3 was measured in urine and plasma of healthy controls, HF patients and hemodialysis patients. To mimic the human situation, we measured galectin‐3 before and after the artificial kidney. Infusion in rats resulted in a clear increase in plasma and urine galectin‐3. Plasma galectin‐3 in HF patients (n=101; mean age 64 years; 93% male) was significantly higher compared to control subjects (n=20; mean age 58 years; 75% male) (16.6 ng/mL versus 9.7 ng/mL, P<0.001), while urinary galectin‐3 in HF patients was comparable (28.1 ng/mL versus 35.1 ng/mL, P=0.830). The calculated galectin‐3 excretion rate was lower in HF patient (2.3 mL/min [1.5 to 3.4] versus 3.9 mL/min [2.3 to 6.4] in control subjects; P=0.005). This corresponded with a significantly lower fractional excretion of galectin‐3 in HF patients (2.4% [1.7 to 3.7] versus 3.0% [1.9 to 5.5]; P=0.018). These differences, however, were no longer significant after correction for age, gender, diabetes, and smoking. HF patients who received diuretics (49%) showed significantly higher aldosterone and galectin‐3 levels. Hemodialysis patients (n=105; mean age 63 years; 65% male), without urinary galectin‐3 excretion, had strongly increased median plasma galectin‐3 levels (70.6 ng/mL).

Conclusions

In this small cross‐sectional study, we report that urine levels of galectin‐3 are not increased in HF patients, despite substantially increased plasma galectin‐3 levels. The impaired renal handling of galectin‐3 in patients with HF may explain the described relation between renal function and galectin‐3 and may account for the elevated plasma galectin‐3 in HF.

Hemodialysis-induced regional left ventricular systolic dysfunction: prevalence, patient and dialysis treatment-related factors, and prognostic significance

BACKGROUND AND OBJECTIVES

The hemodialysis procedure may acutely induce regional left ventricular systolic dysfunction. This study evaluated the prevalence, time course, and associated patient- and dialysis-related factors of this entity and its association with outcome.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Hemodialysis patients (105) on a three times per week dialysis schedule were studied between March of 2009 and March of 2010. Echocardiography was performed before dialysis, at 60 and 180 minutes intradialysis, and at 30 minutes postdialysis. Hemodialysis-induced regional left ventricular systolic dysfunction was defined as an increase in wall motion score in more than or equal to two segments.

RESULTS

Hemodialysis-induced regional left ventricular systolic dysfunction occurred in 29 (27%) patients; 17 patients developed regional left ventricular systolic dysfunction 60 minutes after onset of dialysis. Patients with hemodialysis-induced left ventricular systolic dysfunction were more often male, had higher left ventricular mass index, and had worse predialysis left ventricular systolic function (left ventricular ejection fraction). The course of blood volume, BP, heart rate, electrolytes, and acid-base parameters during dialysis did not differ significantly between the two groups. Patients with hemodialysis-induced regional left ventricular systolic dysfunction had a significantly higher mortality after correction for age, sex, dialysis vintage, diabetes, cardiovascular history, ultrafiltration volume, left ventricular mass index, and predialysis wall motion score index.

CONCLUSIONS

Hemodialysis induces regional wall motion abnormalities in a significant proportion of patients, and these changes are independently associated with increased mortality. Hemodialysis-induced regional left ventricular systolic dysfunction occurs early during hemodialysis and is not related to changes in blood volume, electrolytes, and acid-base parameters.

Comparison of cardiac positron emission tomography perfusion defects during stress induced by hemodialysis versus adenosine

The cardiac stress imposed by hemodialysis may differ from that induced by pharmacologic agents used for myocardial perfusion imaging-based stress testing. With repetitive intradialytic [(13)N]ammonia positron emission tomography, we showed that standard hemodialysis had an acute adverse effect on cardiac perfusion and left ventricular function that was not detected by standard diagnostic adenosine stress testing.

Chronic lithium treatment protects the rat kidney against ischemia/reperfusion injury: the role of nitric oxide and cyclooxygenase pathways

Ischemia/reperfusion injury is a major problem in renal transplantation. Several evidences represent lithium preconditioning effect against ischemia/reperfusion injury in various tissues. In this study our aim was to investigate the protective effect of chronic lithium administration on renal ischemia/reperfusion injury in rats. Ischemia/reperfusion injury was induced by clamping left renal pedicle for 60 min, 2 weeks after right nephrectomy. Lithium-treated animals received lithium-chloride in drinking water for 30days. In order to investigate the role of nitric oxide (NO) and cyclooxygenase (COX) pathways in renoprotective effect of lithium, N(ω)-nitro-L-arginine methyl ester hydrochloride (L-NAME, NO synthase inhibitor) and indomethacin (COX inhibitor) were used, respectively. Serum creatinine, blood urea nitrogen and renal histology were assessed 24h after inducing ischemia/reperfusion injury. Dimercaptosuccinic acid scan was also performed 48 h following operation. Chronic lithium treatment in ischemia/reperfusion injury groups significantly decreased creatinine (1.09±0.16 mg/dl), blood urea nitrogen (59.0±13.38 mg/dl), histological damage (7.83%±4.02%) and improved cortical function compared with non-lithium treated animals (4.45±0.44, 176.66±12.24 mg/dl and 83.5%±3.5%, respectively) (P<0.001). Either L-NAME or indomethacin administration partially reversed the protective effect of lithium, while simultaneous blockade of NO and COX pathways completely abolished lithium renoprotective effect. Our results indicate that lithium ameliorates renal ischemia/reperfusion injury through NO and/or COX pathways. We propose that lithium pre-treatment as a simple and practical intervention to boost the renal viability and function after ischemia/reperfusion injury may be promising in the setting of transplantation.

Rectal administration of d-alpha tocopherol for active ulcerative colitis: A preliminary report

AIM: To investigate the anti-oxidant and anti-neutrophil recruitment effects of rectal d-alpha (d-α) tocopherol administration on mild and moderately active ulcerative colitis (UC).

METHODS: Fifteen patients with mild and moderately active ulcerative colitis were enrolled in an open-label study of d-α tocopherol enema (8000 U/d) for 12 wk. All patients were receiving concomitant therapy with 5-aminosalicylic acid derivatives (5-ASA) and/or immunomodulator medications. Endoscopic evaluation was performed at baseline and after 4th and 12th weeks. Disease activity was measured with the Mayo disease activity index (DAI) and remission was defined as DAI of ≤ 2 with no blood in stool. Clinical response was defined as a DAI reduction of ≥ 2.

RESULTS: At the end of 12th week, the average DAI score significantly decreased compared to the beginning of the study (2.3 ± 0.37 vs 8 ± 0.48, P < 0.0001). One patient was withdrawn after 3 wk for being unavailable to follow-up. On the 4th week of therapy, 12 patients showed clinical response, 3 of whom (21.4%) achieving remission. After 12 wk, all 14 patients responded clinically to the therapy and remission was induced in 9 of them (64%). No patient reported adverse events or was hospitalized due to worsened disease activity.

CONCLUSION: This preliminary report suggests that rectal d-α tocopherol may represent a novel therapy for mild and moderately active UC. The observed results might be due to the anti-inflammatory and anti-oxidative properties of vitamin E.

Sacrococcygeal pilonidal sinus treated by a new fascio-cutaneous flap

PURPOSE

This study reported the technical details and preliminary clinical outcomes of a new fascio-cutaneous transposition flap for the surgical treatment of pilonidal sinus.

METHODS

Fifty-two patients with pilonidal sinus were surgically treated. During the surgical procedure, an inferiorly pedicled, fascio-cutaneous flap with specific geometric characteristics was prepared and transposed. Postoperative pain, complications, duration of hospital stay, and time off worked were assessed. Patients were followed for eighteen months after surgery.

RESULTS

The mean hospital stay was 2 days. Drains and sutures were removed after 3 and 12 days, respectively. No flap ischemia, wound dehiscence or major complications were observed. Tension on suture lines and pain after surgery were negligible. Wound infections occurred in 4 patients (7.7 percent) and were managed by removing a few sutures. Seroma was detected in 6 patients (11.5 percent). The mean time patients missed work was 7 days. No recurrence was observed during the follow-up period of 18 months.

CONCLUSIONS

With no disease recurrence, minimal complication rate, time off work, and acceptable aesthetic outcome, this fascio-cutaneous transposition flap technique is a safe and effective method for surgically treating pilonidal sinus.

Testosterone stimulates growth of tibial epiphyseal growth plate and insulin-like growth factor-1 receptor abundance in hypophysectomized and castrated rats

Puberty is associated with an increase in the plasma concentration of sex steroids, growth hormone (GH), and insulin-like growth factor-1 (IGF-1). Gonadal steroid hormones are important for the normal pubertal growth spurt and skeletal growth. The mechanism by which gonadal steroids induces skeletal growth is still not fully understood. To study the GH-independent effect of testosterone on growth, we investigated the effect of testosterone injections on the tibial epiphyseal growth plate (EGP) in an in vivo model of hypophysectomized and castrated male rats. Four groups (six animals each) of 28-d-old male rats were studied. Groups A, B, and C were hypophysectomized and castrated and received 500 microg/(kg x d) of hydrocortisone and 15 microg/(kg x d) of levothyroxine sodium. Groups A and B were also treated with daily sc injections of 10 microg of testosterone/100 g of body wt and 100 microg of testosterone/100 g of body wt, respectively, for 7 d. Group C was injected with vehicle alone. Group D were intact animals injected with saline (controls). Animals were sacrificed on 8 d. As expected, serum GH levels were found to be very low (1.13+/-0.1 ng/mL) in the hypophysectomized animals (group C, hypopit), and testosterone treatment did not change them significantly. Serum IGF-1 decreased from 502.9+/-13 ng/mL in group D to 167+/-41.4 ng/mL in group C (p < 0.001). Testosterone therapy had no stimulatory effect on serum IGF-1 levels in the hypopit + low-dose group (A) (220+/-94.8 ng/mL) and had an inhibitory effect in the hypopit + high-dose group (B) (39.3+/-17.5). Histomorphometric determinations demonstrated an EGP width of 472.3+/-39 microm in the intact animals but only 336.9+/-1.6 microm in the hypopit group (C) (p < 0.01). High-dose testosterone treatment (group B) significantly increased the EGP width (to 438.8+/-27.8), (p < 0.001), whereas low-dose testosterone (group A) did not. Immunohistochemistry studies revealed that the levels of IGF-1 in the EGP of the control animals were almost negligible and that testosterone did not change them. However, testosterone increased in a dose-dependent manner the abundance of IGF-1 receptor EGP. We conclude that testosterone has a direct, local, GH-independent effect on the EGP growth and IGF-1 receptor abundance.

Neonatal pig islets induce a lower T-cell response than adult pig islets in IDDM patients

BACKGROUND

Pancreatic pig islets may provide a substitute in the future for difficult to obtain human islets for transplantation in insulin-dependent diabetes millitus (IDDM) patients. However, the immune response to xenografts may significantly hamper this approach. Because neonatal tissue is believed to be less immunogenic, we examined whether the T-cell response to neonatal pig islets differs from the response to adult islets.

METHODS

The T-cell proliferative response to different concentrations of sonicated neonatal and adult pig islets, as well as to insulin and mitogens, was tested in 21 recent onset IDDM patients and 21 healthy controls. We determined the presence of various circulating islet autoantibodies and their association with the T-cell response in IDDM patients.

RESULTS

In the IDDM patients, sonicated adult pig islets (at 1 microg protein/ml) induced a significantly higher frequency (12 of 21 vs. 1 of 21, p<0.001) and magnitude (2.58+/-0.44 vs. 1.38+/-0.13, p<0.02) of positive T-cell responses than neonatal islets at the same concentration. Similar results were obtained with a 10-fold higher concentration of islet sonicate. There was no significant association between the individual T-cell responses and the presence of circulating autoantibodies in IDDM patients.

CONCLUSION

These results indicate that neonatal pig islets induce a lower T-cell reactivity than adult islets, suggesting that the neonatal tissue may be immunologically more suitable for future islet xenotransplantation.

D-penicillamine-induced pancreatic islet autoantibody production is independent of the immunogenetic background: a lesson from patients with Wilson's disease

D-penicillamine (d-PA) was reported to induce various immunological abnormalities including production of autoantibodies to insulin. These abnormalities were mainly described in patients with primary immunological disorders such as rheumatoid arthritis. In order to clarify whether d-PA-induced immune disorders are restricted to patients genetically prone to develop autoimmune diseases or to a direct drug effect, we tested for the presence of various autoantibodies and for molecular HLA typing in 17 patients with Wilson's disease treated with this drug. In 2/17 patients, low-titer (10 JDFU) circulating islet cell autoantibodies (ICA) were detected, while another patient was positive for the presence of insulin autoantibodies. None of the sera tested showed reactivity for glutamic acid decarboxylase or ICA512. Five of twelve patients were positive for anti-single-stranded DNA autoantibody. Molecular HLA typing of the autoantibody-positive subjects showed that they carry HLA haplotypes not associated with insulin-dependent diabetes. The insulin response to intravenous glucose tolerance test in two patients with autoantibodies was found to be normal. A second blood testing of the autoantibody-positive patients 5 months following initial evaluation revealed conversion to negativity in all three. Our results suggest that d-PA-induced autoantibodies in patients with Wilson's disease are independent of the immunogenetic background characteristics of diabetes.

HLA class II immunogenetics of IDDM in Yemenite Jews

The association between HLA-DR and DQ and insulin dependent diabetes mellitus (IDDM) was analyzed in 47 patients and 76 controls of Yemenite Jewish origin. The IDDM susceptibility alleles DRB1*03011, DQA1*0501, DQB1*02 and DRB1*0402, DQA1*0301, DQB1*0302 found in Caucasians had a very strong predisposing effect also in the Yemenite IDDM group. The DRB1*07, DQA1*0201 and DQB1*02 alleles were found to have a strong negative association with IDDM. None of the patients carried DRB1*07 and DQA1*0201 compared with healthy controls (43.7%). Our analysis revealed that the DRB1*03011 DQA1*0501 DQB1*02/DRB1*04 DQA1*03 DQB1*0302 heterozygous genotype confers the highest susceptibility (59.6% in patients vs. 0% in controls). The homozygous DRB1*03 and DRB1*04 genotypes were also found to be positively associated with the disease. 81% of the patients compared to 1.3% of controls carried the susceptibility alleles on both haplotypes. In conclusion, the development of IDDM in Yemenite Jews is strongly dependent on the presence of the susceptibility HLA alleles and on the absence of the DRB1*07 haplotype. The Yemenite Jewish group is uniquely homogenous with regard to genetic susceptibility factors involved in the process of IDDM, and may thus be an ideal model for further genetic studies.

[Islet autoantibody assays in type I diabetes: superiority of passage from use of ICA to traditional tests]

Islet cell antibodies (ICA) continue to serve as the basis of the principal serological test for definition of active autoimmunity of beta-cells. Its disadvantages are the need for human pancreatic tissue and difficulty in obtaining quantitative results. In the past decade biochemically-defined beta-cell antigens were described, leading to the development of sensitive and specific autoantibody assays, to predict insulin-dependent diabetes mellitus (IDDM). We examined the value of combined biochemically-based serological assays, such as autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and ICA512 (ICA512A) to replace the traditional ICA assay. Blood samples of 114 newly diagnosed IDDM patients, aged 12 +/- 5 yrs (range 2 months-29 years) were tested for ICA (indirect immunofluorescence), IAA, GADA and ICA512A (radiobinding assay). The latter 2 assays were performed using recombinant human [35S]-labeled antigen produced by in vitro transcription/translation. We found that fewer sera scored positive for ICA and/or IAA (80.7%, 92/114) than for 1 or more of IAA, GAD, or ICA512 (88.6%, 101/114). We conclude that combined testing for IAA, GAD and ICA512 can replace the traditional ICA/IAA test to predict IDDM and is helpful in the differential diagnosis of insulin-dependent and noninsulin-dependent diabetes.

Mathematical formulae for the prediction of the residual beta cell function during the first two years of disease in children and adolescents with insulin-dependent diabetes mellitus

On the basis of a retrospective study of 71 children followed for 24 months after diagnosis of type I insulin dependent diabetes a fitted mathematical model was constructed for the prediction of the course of beta cell function from the time of diagnosis. Two equations were derived, one for the maximal basal (B-max) and the other for the maximal i.v. glucagon stimulated peak C-peptide (P-max) levels reached during the remission period. The prognostic variables selected for analysis were: peak C-peptide levels at diagnosis (Po), age sex, degree of obesity, pubertal rating, the presence of islet cell antibodies (ICA) and levels of GHb. Multivariate analysis of the data showed that Po (p = 0.0006), puberty (p = 0.041). obesity (p = 0.0021), sex (p = 0.031), ICA (p = 0.0045) and GHb(p = 0.0066) significantly contributed to the prediction formula obtained for B-max whereas the contribution of the above variables for P-max were: Po (p = 0.0019), puberty (p = 0.0187), obesity (p = 0.0058), sex (p = 0.0598), ICA (p = 0.0187) and GHb (p = 0.0027). The residuals of the observed values from the values fitted by the predicted equations served to define two separate groups demonstrating distinct differences in the natural course of beta cell function in type I diabetes. This fitted model may thus be useful in distinguishing between newly diagnosed young patients who will undergo remission, requiring lower insulin doses, and those who have little chance for remission. It might also be helpful in the selection of patients most likely to benefit from immunosuppression or modulation, to maximize the benefit to risk ratio for such patients.

Insulin antibody assay: a statistical evaluation of sensitivity, precision and reproducibility in healthy subjects

Eighty-seven sera from healthy non-diabetic subjects, negative for islet cell antibodies, were analysed for 125I-insulin serum binding capacity by a commercial radioimmunoassay. In order to define the detection limit of the assay for insulin antibodies we used the corrected binding capacity to 125I-insulin of the normal sera obtained by competitive inhibition with excess of unlabelled insulin. To test the reproducibility of the results as a function of the tracer decay the sera were re-examined after intervals of 17 and 37 days, when a drift of more than 1% was found in the period investigated. Using the corrected bindings improved reproducibility considerably. The extra variation between the three assays, taking into account the decay of the tracer, was negligible. The main component of error contributing to these variations among individuals was found to be the precision, defined as the mean standard deviation among the replicates, which is SD(c) = 0.325%. We conclude that this assay is suitable for the screening of positive insulin autoantibodies in pre-diabetic subjects, and recommend that the estimate of precision from the replicates with excess insulin be used and that the detection limit be set at three times the estimated SD(c).

Elevated serum placental isoferritin in newly diagnosed type 1 (insulin-dependent) diabetes mellitus. A possible marker for identification of high risk subjects

Placental isoferritin is produced by activated T lymphocytes and may, therefore, be considered as a manifestation of T cell involvement. Placental isoferritin is measured using CM-H-9 monoclonal antibody which binds exclusively to placental isoferritin. Placental isoferritin has been determined in the serum of 80 patients with Type I (insulin-dependent) diabetes mellitus, 100 healthy first degree relatives and 81 healthy children. Serum levels which were measured in Type 1 diabetic patients, (24.0-140 U/ml; median and range) were significantly higher than those of family members (0,0-73; median and range; p less than 0.0001) and normal control subjects (0,0-48; median and range; p less than 0.0001). Using 0-10 U/ml as the upper limit of normal, it was found that 31 of 50 (62%) of Type 1 diabetic patients, 25 of 100 (25%) family members and 7 of 81 (8.6%) healthy control subjects had abnormal placental isoferritin levels. Islet cell antibodies were positive in 31 of 44 tested diabetic patients and, in 8 of 71 tested family members, and among them 54.8% and 50% respectively also had elevated placental isoferritin levels. However, no statistically significant correlation was found between islet cell antibodies and placental isoferritin levels. Treatment of Type 1 diabetic patients with insulin was accompanied by a significant decrease (p less than 0.002) of serum placental isoferritin within 2-4 weeks of treatment. It is noteworthy that placental isoferritin was below detection in 34 of 35 Type 2 (non-insulin-dependent) diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of short-term estrogen replacement therapy (ERT) on the blood pressure and daily urinary catecholamine excretion in a small group of post-menopausal women

The blood pressure and daily urinary catecholamine excretion were examined in nineteen non-smoking post-menopausal women, receiving estrogen replacement therapy for a period of 4 months. The estrogens administered consisted of 17 beta-estradiol combined with estriol and norethisterone acetate administered sequentially (Trisequens, Novo, Denmark). Before the institution of treatment, the blood pressure and urinary catecholamine excretion were normal. After a period of 4 months, no change in blood pressure was observed. However, a marked and significant increase in daily urinary catecholamine excretion was noticed (72.3 +/- 18.96 micrograms/day to 102.0 +/- 26.0 micrograms: p less than 0.01). The pathogenetic implications of this increase are discussed.

Trends in urolithiasis in various ethnic groups and by age, in Israel

A survey of upper urinary tract stone composition was carried out over 8 years (1974-1982) in 1147 patients, following a previous survey (1966-1974). Trends in the development of stone formation were found. The most obvious differences were fewer pure calcium oxalate (0.75 versus 5.50%) and uric acid stones (6.11 versus 13.30%) and more mixed stones than in our previous study. In most ethnic groups urinary stones were composed of calcium oxalate/calcium phosphate. A higher prevalence of stones in Israeli-born Jews was noted, in comparison with our previous survey. Age group analysis showed this increase to be limited to the 21-50-year-old group, in contradistinction to a clear decrease in stone formation in Israeli-born Arabs and Jews under the age of 20 years.