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Vollert J, Kumar A, Coady EC, Cullinan P, Dyball D, Fear NT, Gan Z, Miller EF, Sprinckmoller S, Schofield S, Bennett A, Bull AMJ, Boos CJ, Rice ASC, Kemp HI. Pain after combat injury in male UK military personnel deployed to Afghanistan. Br J Anaesth 2024; 132:1285-1292. [PMID: 38521656 DOI: 10.1016/j.bja.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Chronic pain after injury poses a serious health burden. As a result of advances in medical technology, ever more military personnel survive severe combat injuries, but long-term pain outcomes are unknown. We aimed to assess rates of pain in a representative sample of UK military personnel with and without combat injuries. METHODS We used data from the ADVANCE cohort study (ISRCTN57285353). Individuals deployed as UK armed forces to Afghanistan were recruited to include those with physical combat injuries, and a frequency-matched uninjured comparison group. Participants completed self-reported questionnaires, including 'overall' pain intensity and self-assessment of post-traumatic stress disorder, anxiety, and depression. RESULTS A total of 579 participants with combat injury, including 161 with amputations, and 565 uninjured participants were included in the analysis (median 8 yr since injury/deployment). Frequency of moderate or severe pain was 18% (n=202), and was higher in the injured group (n=140, 24%) compared with the uninjured group (n=62, 11%, relative risk: 1.1, 95% confidence interval [CI]: 1.0-1.2, P<0.001), and lower in the amputation injury subgroup (n=31, 19%) compared with the non-amputation injury subgroup (n=109, 26%, relative risk: 0.9, 95% CI: 0.9-1.0, P=0.034). Presence of at least moderate pain was associated with higher rates of post-traumatic stress (RR: 3.7, 95% CI: 2.7-5.0), anxiety (RR: 3.2, 95% CI: 2.4-4.3), and depression (RR: 3.4, 95% CI: 2.7-4.5) after accounting for injury. CONCLUSION Combat injury, but not amputation, was associated with a higher frequency of moderate to severe pain intensity in this cohort, and pain was associated with adverse mental health outcomes.
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Affiliation(s)
- Jan Vollert
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK; Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
| | - Alexander Kumar
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Loughborough, UK
| | - Emma C Coady
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Daniel Dyball
- King's Centre for Military Health Research, King's College London, London, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, UK; Academic Department of Military Mental Health, King's College London, London, UK
| | - Zoe Gan
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Eleanor F Miller
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, UK
| | - Stefan Sprinckmoller
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, UK
| | - Suzie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Alexander Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Loughborough, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Christopher J Boos
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, UK
| | - Andrew S C Rice
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Harriet I Kemp
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
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Maqsood R, Schofield S, Bennett AN, Khattab A, Bull AMJ, Fear NT, Boos CJ. Exploratory analysis of spontaneous versus paced breathing on heart rate variability in veterans with combat-related traumatic injury. PM R 2024. [PMID: 38634349 DOI: 10.1002/pmrj.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Respiration is a crucial determinant of autonomic balance and heart rate variability (HRV). The comparative effect of spontaneous versus paced breathing on HRV has been almost exclusively explored in healthy adults and never been investigated in an injured military cohort. OBJECTIVE To examine the effect of spontaneous versus paced breathing on HRV in veterans with combat-related traumatic injury (CRTI). DESIGN Observational cohort study. SETTING ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study, Stanford Hall, UK. PARTICIPANTS The sample consisted of 100 randomly selected participants who sustained CRTI (eg, amputation) during their deployment (Afghanistan 2003-2014) and were recruited into the ongoing ADVANCE prospective cohort study. INTERVENTION Not applicable. MAIN OUTCOME MEASURE HRV was recorded using a single-lead ECG. HRV data were acquired during a sequential protocol of 5-minute spontaneous breathing followed immediately by 5 minutes of paced breathing (six cycles/minute) among fully rested and supine participants. HRV was reported using time domain (root mean square of successive differences), frequency domain (low frequency and high frequency) and nonlinear (sample entropy) measures. The agreement between HRV during spontaneous versus paced breathing was examined using the Bland-Altman analysis. RESULTS The mean age of participants was 36.5 ± 4.6 years. Resting respiratory rate was significantly higher with spontaneous versus paced breathing (13.4 ± 3.4 vs. 7.6 ± 2.0 breaths/minute; p < .001), respectively. Resting mean heart rate and root mean square of successive differences were significantly higher with paced breathing than spontaneous breathing (p < .001). Paced breathing significantly increased median low frequency power than spontaneous breathing (p < .001). No significant difference was found in the absolute power of high frequency between the two breathing protocols. The Bland-Altman analysis revealed poor agreement between HRV values during spontaneous and paced breathing conditions with wide limits of agreement. CONCLUSION Slow-paced breathing leads to higher HRV than spontaneous breathing and could overestimate resting "natural-state" HRV.
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Affiliation(s)
- Rabeea Maqsood
- Department of Medical Sciences and Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Alexander N Bennett
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Loughborough, UK
| | - Ahmed Khattab
- Department of Medical Sciences and Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Nicola T Fear
- The Academic Department of Military Mental Health, King's College London, London, UK
| | - Christopher J Boos
- Department of Medical Sciences and Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
- Department of Cardiology, University Hospitals Dorset, Poole Hospital, Poole, UK
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Dyball D, Bennett AN, Schofield S, Cullinan P, Boos CJ, Bull AM, Stevelink SA, Fear NT. The underlying mechanisms by which Post-Traumatic Growth is associated with cardiovascular health in male UK military personnel: The ADVANCE cohort study. J Health Psychol 2024:13591053241240196. [PMID: 38605584 DOI: 10.1177/13591053241240196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
Post-Traumatic Growth (PTG) is associated with good cardiovascular health, but the mechanisms of this are poorly understood. This cross-sectional analysis assessed whether factors of PTG (Appreciation of Life (AOL), New Possibilities (NP), Personal Strength (PS), Relating to Others (RTO) and Spiritual Change (SC)) are associated with cardiovascular health in a cohort of 1006 male UK military personnel (median age 34). The findings suggest AOL, PS and RTO are associated with better cardiovascular health through cardiometabolic effects (lower levels of triglycerides, and total cholesterol) and haemodynamic functioning (lower diastolic blood pressure), but not inflammation. However, NP and SC were associated with poorer cardiovascular health through cardiometabolic effects (lower levels of high-density lipoproteins and higher levels of total cholesterol) and AOL had a non-linear association with low-density lipoproteins. These findings suggest that the relationship between PTG and cardiovascular functioning is complex and in need of further scrutiny.
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Maqsood R, Schofield S, Bennett AN, Khattab A, Clark C, Bull AMJ, Fear NT, Boos CJ. The Influence of Physical and Mental Health Mediators on the Relationship Between Combat-Related Traumatic Injury and Ultra-Short-Term Heart Rate Variability in a U.K. Military Cohort: A Structural Equation Modeling Approach. Mil Med 2024; 189:e758-e765. [PMID: 37656495 PMCID: PMC10898941 DOI: 10.1093/milmed/usad341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/21/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated. MATERIALS AND METHODS A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS < 25 and NISS ≥ 25]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling. RESULTS Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9 ± 5.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS ≥ 25 vs. uninjured) and RMSSD was -0.06 (95% CI: -0.12, -0.00, P < .05). CONCLUSIONS The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.
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Affiliation(s)
- Rabeea Maqsood
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London SW3 6LR, UK
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London SW3 6LR, UK
| | - Alexander N Bennett
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London SW3 6LR, UK
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Nottinghamshire LE12 5QW, UK
| | - Ahmed Khattab
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
| | - Carol Clark
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
| | - Nicola T Fear
- Academic Department of Military Mental Health and King's Centre for Military Health Research, King's College London, London SE5 9RJ, UK
| | - Christopher J Boos
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
- Department of Cardiology, University Hospitals Dorset, Poole BH15 2JB, UK
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Boos CJ, Hein A, Khattab A. Ambulatory arterial stiffness index, mortality, and adverse cardiovascular outcomes; Systematic review and meta-analysis. J Clin Hypertens (Greenwich) 2024; 26:89-101. [PMID: 38234206 PMCID: PMC10857461 DOI: 10.1111/jch.14755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/30/2023] [Accepted: 11/19/2023] [Indexed: 01/19/2024]
Abstract
The ambulatory arterial stiffness index (AASI) is a novel measure of both blood pressure (BP) variability and arterial stiffness. This systematic review and meta-analysis was designed to evaluate the strength of the association between AASI and mortality and major adverse cardiovascular events (MACE). PubMed, Scopus, CINAHL, Google Scholar. and the Cochrane library were searched for relevant studies to July 31, 2023. Two investigators independently extracted data. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of all included articles. The relationship between baseline AASI and outcomes were examined using relative risk (RR) ratios with 95% confidence intervals (CI) with RevMan web. Thirteen studies were included and representing 28 855 adult patients who were followed up from 2.2 to 15.2 years. A 1-standard deviation (1-SD) increase in AASI was associated with a significant increase in all-cause death (RR 1.12; 95% CI: 0.95-1.32), stroke (RR 1.25; 95% CI: 1.09-1.44), and MACE (RR 1.07; 95% CI: 1.01-1.13; [I2 = 32%]). Higher dichotomized AASI (above vs. below researcher defined cut-offs) was associated with a significant increase in all-cause mortality (RR 1.19; 95% CI: 1.06-1.32), cardiovascular death (RR 1.29; 95% CI: 1.14-1.46), stroke (RR 1.57; 95% CI: 1.33-1.85), and MACE (RR1.29; 95% CI: 1.16-1.44). There was a significant risk of bias in more than 50% of studies with no evidence of significant publication bias. Higher AASI is associated with an increased risk of all-cause and cardiovascular death, stroke, and MACE. Further high-quality studies are warranted to determine reproducible AASI cut-offs to enhance its clinical risk precision.
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Affiliation(s)
| | - Aung Hein
- Faculty of Health & Social SciencesBournemouth UniversityBournemouthUK
| | - Ahmed Khattab
- Faculty of Health & Social SciencesBournemouth UniversityBournemouthUK
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Boos CJ, Haling U, Schofield S, Cullinan P, Bull AMJ, Fear NT, Bennett AN. Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study. BMC Cardiovasc Disord 2023; 23:581. [PMID: 38012542 PMCID: PMC10680223 DOI: 10.1186/s12872-023-03605-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND This study investigated the relationship between combat-related traumatic injury (CRTI) and its severity and predicted cardiovascular disease (CVD) risk. MATERIAL AND METHODS This was an analysis of comparative 10-year predicted CVD risk (myocardial infarction, stroke or CVD-death) using the QRISK®3 scoring-system among adults recruited into the Armed Services Trauma Rehabilitation Outcome (ADVANCE) cohort study. Participants with CRTI were compared to uninjured servicemen frequency-matched by age, sex, rank, deployment (Afghanistan 2003-2014) and role. Injury severity was quantified using the New Injury Severity Score (NISS). RESULTS One thousand one hundred forty four adult combat veterans were recruited, consisting of 579 injured (161 amputees) and 565 uninjured men of similar age ethnicity and time from deployment/injury. Significant mental illness (8.5% vs 4.4%; p = 0.006) and erectile dysfunction (11.6% vs 5.8%; p < 0.001) was more common, body mass index (28.1 ± 3.9 vs 27.4 ± 3.4 kg/m2; p = 0.001) higher and systolic blood pressure variability (median [IQR]) (1.7 [1.2-3.0] vs 2.1 [1.2-3.5] mmHg; p = 0.008) lower among the injured versus uninjured respectively. The relative risk (RR) of predicted CVD (versus the population expected risk) was higher (RR:1.67 [IQR 1.16-2.48]) among the injured amputees versus the injured non-amputees (RR:1.60 [1.13-2.43]) and uninjured groups (RR:1.52 [1.12-2.34]; overall p = 0.015). After adjustment for confounders CRTI, worsening injury severity (higher NISS, blast and traumatic amputation) were independently associated with QRISK®3 scores. CONCLUSION CRTI and its worsening severity were independently associated with increased predicted 10-year CVD risk.
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Affiliation(s)
- Christopher J Boos
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Near Loughborough, LE12 5QW, Nottinghamshire, UK.
- The Academic Department of Military Mental Health, King's College London, London, SE5 9RJ, UK.
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, BH1 3LT, UK.
- Department of Cardiology, University Hospitals Dorset, Poole Hospital, Longfleet Rd, Poole, BH15 2JB, Dorset, UK.
| | - Usamah Haling
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Susie Schofield
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Paul Cullinan
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, SW7 2AZ, UK
| | - Nicola T Fear
- The Academic Department of Military Mental Health, King's College London, London, SE5 9RJ, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Near Loughborough, LE12 5QW, Nottinghamshire, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
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Boos CJ, Schofield S, Bull AMJ, Fear NT, Cullinan P, Bennett AN. The relationship between combat-related traumatic amputation and subclinical cardiovascular risk. Int J Cardiol 2023; 390:131227. [PMID: 37527753 DOI: 10.1016/j.ijcard.2023.131227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/06/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study. METHODS AND RESULTS UK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003-14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94-0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91-0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury. CONCLUSION CRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.
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Affiliation(s)
- Christopher J Boos
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Near Loughborough, Nottinghamshire LE12 5QW, United Kingdom of Great Britain and Northern Ireland; The Academic Department of Military Mental Health, King's College London, SE5 9RJ, United Kingdom of Great Britain and Northern Ireland; Faculty of Health & Social Sciences, Bournemouth University, Bournemouth BH1 3LT, United Kingdom of Great Britain and Northern Ireland; Department of Cardiology, University Hospitals Dorset, Poole Hospital, Poole BH15 2JB, United Kingdom of Great Britain and Northern Ireland.
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, SW3 6LR, United Kingdom of Great Britain and Northern Ireland
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, SW7 2AZ, United Kingdom of Great Britain and Northern Ireland
| | - Nicola T Fear
- The Academic Department of Military Mental Health, King's College London, SE5 9RJ, United Kingdom of Great Britain and Northern Ireland
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, SW3 6LR, United Kingdom of Great Britain and Northern Ireland
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Near Loughborough, Nottinghamshire LE12 5QW, United Kingdom of Great Britain and Northern Ireland; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, SW3 6LR, United Kingdom of Great Britain and Northern Ireland
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McMenemy L, Behan FP, Kaufmann J, Cain D, Bennett AN, Boos CJ, Fear NT, Cullinan P, Bull AMJ, Phillips ATM, McGregor AH. Association Between Combat-Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study. J Bone Miner Res 2023; 38:1227-1233. [PMID: 37194399 DOI: 10.1002/jbmr.4794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 05/18/2023]
Abstract
The association between combat-related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross-sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK-Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency-matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role-in-theatre. BMD was assessed using dual-energy X-ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 versus -0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.
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Affiliation(s)
- Louise McMenemy
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Institute of Naval Medicine, Gosport, UK
| | - Fearghal P Behan
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Josh Kaufmann
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
- Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, London, UK
- Musculoskeletal Biodynamics, Imperial College London, London, UK
| | - David Cain
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Christopher J Boos
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
- Academic Department of Military Mental Health, King's College London, London, UK
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
- Cardiology, University Hospitals Dorset NHS Foundation Trust, Poole Hospital, Poole, UK
| | - Nicola T Fear
- Academic Department of Military Mental Health, King's College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Andrew T M Phillips
- Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, London, UK
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Maqsood R, Khattab A, Bennett AN, Boos CJ. Reliability of carotid-femoral arterial waveforms for the derivation of ultra-short term heart rate variability in injured British servicemen: An inter-rater reliability study. PLoS One 2023; 18:e0290618. [PMID: 37656708 PMCID: PMC10473479 DOI: 10.1371/journal.pone.0290618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/12/2023] [Indexed: 09/03/2023] Open
Abstract
In this study, the comparative precision of carotid versus femoral arterial waveforms to measure ultra-short term heart rate variability (HRVUST) following traumatic injury was investigated for the first time. This was an inter-rater reliability study of 50 British servicemen (aged 23-44 years) with non-acute combat-related traumatic injury (CRTI). Paired continuous arterial waveform data for HRVUST analysis, were simultaneously sampled at the carotid and femoral arterial sites (14-16 seconds) during pulse wave velocity (PWV) measurement. HRVUST was reported as the root mean square of the successive differences (RMSSD). Following the determination of the superior sampling site (carotid versus femoral), the blinded inter-rater agreement in RMSSD for the preferred site was quantified using the Intra-class Correlation Coefficient (ICC) and the Bland-Altman plot. The mean age of participants was 34.06±4.88 years. The femoral site was superior to the carotid site with a significantly higher number of reliable signals obtained (Fisher's Exact test; p<0.001). The inter-rater agreement in femoral-derived RMSSD was excellent [ICC 0.99 (95%CI: 0.994-0.997)] with a moderate level of agreement (mean difference [bias]: 0.55; 95% CI: -0.13-1.24 ms). In this study, we demonstrated that the femoral artery is a more reliable site than the carotid artery for HRVUST measurement and post-trauma risk stratification following CRTI.
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Affiliation(s)
- Rabeea Maqsood
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Ahmed Khattab
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Alexander N. Bennett
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom
| | - Christopher J. Boos
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, United Kingdom
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Dyball D, Bennett AN, Schofield S, Cullinan P, Boos CJ, Bull AMJ, Stevelink SAM, Fear NT. Post-traumatic growth amongst UK armed forces personnel who were deployed to Afghanistan and the role of combat injury, mental health and pain: the ADVANCE cohort study. Psychol Med 2023; 53:5322-5331. [PMID: 35993322 PMCID: PMC10476051 DOI: 10.1017/s0033291722002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Post-traumatic growth (PTG) is a positive psychological consequence of trauma. The aims of this study were to investigate whether combat injury was associated with deployment-related PTG in a cohort of UK military personnel who were deployed to Afghanistan, and whether post-traumatic stress disorder (PTSD), depression and pain mediate this relationship. METHODS 521 physically injured (n = 138 amputation; n = 383 non-amputation injury) and 514 frequency-matched uninjured personnel completed questionnaires including the deployment-related Post-Traumatic Growth Inventory (DPTGI). DPTGI scores were categorised into tertiles of: no/low (score 0-20), moderate (score 21-34) or a large (35-63) degree of deployment-related PTG. Analysis was completed using generalised structural equation modelling. RESULTS A large degree of PTG was reported by 28.0% (n = 140) of the uninjured group, 36.9% (n = 196) of the overall injured group, 45.4% (n = 62) of amputee and 34.1% (n = 134) of the non-amputee injured subgroups. Combat injury had a direct effect on reporting a large degree of PTG [Relative risk ratio (RRR) 1.59 (95% confidence interval (CI) 1.17-2.17)] compared to sustaining no injury. Amputation injuries also had a significant direct effect [RRR 2.18 (95% CI 1.24-3.75)], but non-amputation injuries did not [RRR 1.35 (95% CI 0.92-1.93)]. PTSD, depression and pain partially mediate this relationship, though mediation differed depending on the injury subtype. PTSD had a curvilinear relationship with PTG, whilst depression had a negative association and pain had a positive association. CONCLUSIONS Combat injury, in particular injury resulting in traumatic amputation, is associated with reporting a large degree of PTG.
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Affiliation(s)
- Daniel Dyball
- King's Centre for Military Health Research, King's College London, London, SE5 9RJ, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, near Loughborough, Nottinghamshire, LE12 5BL, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Susie Schofield
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Paul Cullinan
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, SW3 6LR, UK
| | - Christopher J. Boos
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, BH1 3LT, UK
| | - Anthony M. J. Bull
- Department of Bioengineering, Centre for Blast Injury Studies, Imperial College London, London, SW7 2AZ, UK
| | - Sharon A. M. Stevelink
- King's Centre for Military Health Research, King's College London, London, SE5 9RJ, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
| | - Nicola T. Fear
- King's Centre for Military Health Research, King's College London, London, SE5 9RJ, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
- Academic Department of Military Mental Health, King's College London, London, SE5 9RJ, UK
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Maqsood R, Schofield S, Bennett AN, Bull AM, Fear NT, Cullinan P, Khattab A, Boos CJ. Relationship between combat-related traumatic injury and ultrashort term heart rate variability in a UK military cohort: findings from the ADVANCE study. BMJ Mil Health 2023:military-2022-002316. [PMID: 36990509 DOI: 10.1136/military-2022-002316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/05/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Combat-related traumatic injury (CRTI) has been linked to an increased cardiovascular disease (CVD) risk. The long-term impact of CRTI on heart rate variability (HRV)-a robust CVD risk marker-has not been explored. This study investigated the relationship between CRTI, the mechanism of injury and injury severity on HRV. METHODS This was an analysis of baseline data from the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study. The sample consisted of UK servicemen with CRTI sustained during deployment (Afghanistan, 2003-2014) and an uninjured comparison group who were frequency matched to the injured group based on age, rank, deployment period and role in theatre. Root mean square of successive differences (RMSSD) was measured as a measure of ultrashort term HRV via <16 s continuous recording of the femoral arterial pulse waveform signal (Vicorder). Other measures included injury severity (New Injury Severity Scores (NISS)) and injury mechanism. RESULTS Overall, 862 participants aged 33.9±5.4 years were included, of whom 428 (49.6%) were injured and 434 (50.3%) were uninjured. The mean time from injury/deployment to assessment was 7.91±2.05 years. The median (IQR) NISS for those injured was 12 (6-27) with blast being the predominant injury mechanism (76.8%). The median (IQR) RMSSD was significantly lower in the injured versus the uninjured (39.47 ms (27.77-59.77) vs 46.22 ms (31.14-67.84), p<0.001). Using multiple linear regression (adjusting for age, rank, ethnicity and time from injury), geometric mean ratio (GMR) was reported. CRTI was associated with a 13% lower RMSSD versus the uninjured group (GMR 0.87, 95% CI 0.80-0.94, p<0.001). A higher injury severity (NISS ≥25) (GMR 0.78, 95% CI 0.69-0.89, p<0.001) and blast injury (GMR 0.86, 95% CI 0.79-0.93, p<0.001) were also independently associated with lower RMSSD. CONCLUSION These results suggest an inverse association between CRTI, higher severity and blast injury with HRV. Longitudinal studies and examination of potential mediating factors in this CRTI-HRV relationship are needed.
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Affiliation(s)
- Rabeea Maqsood
- Department of Medical Sciences and Public Health, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - S Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - A N Bennett
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
| | - A Mj Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - N T Fear
- Academic Department of Military Mental Health, King's College London, London, UK
| | - P Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - A Khattab
- Department of Medical Sciences and Public Health, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - C J Boos
- Department of Medical Sciences and Public Health, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
- Department of Cardiology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
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Dyball D, Bennett AN, Schofield S, Cullinan P, Boos CJ, Bull AMJ, Stevelink SA, Fear NT. The underlying mechanisms by which PTSD symptoms are associated with cardiovascular health in male UK military personnel: The ADVANCE cohort study. J Psychiatr Res 2023; 159:87-96. [PMID: 36696788 DOI: 10.1016/j.jpsychires.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
Post-Traumatic Stress Disorder (PTSD) has been identified as an independent risk factor for cardiovascular disease, but the mechanisms of this relationship are not well understood. This study investigates the associations between PTSD symptom clusters (hyperarousal, intrusive thoughts, avoidance behaviours and emotional numbing) and mechanisms of cardiovascular disease including cardiometabolic effects, inflammation, and haemodynamic functioning. In the ADVANCE study cohort of UK male military personnel, 1111 participants were assessed for PTSD via questionnaire and cardiovascular risk via venous blood sampling, pulse wave analysis and dual energy x-ray absorptiometry between 2015 and 2020. Variable selection procedures were conducted to assess which of the symptom clusters if any were associated with cardiovascular risk outcomes. Associations were confirmed via robust regression modelling. Avoidance behaviours were associated with greater systolic Blood Pressure (BP) (Adjusted Coefficient (AC) 0.640 (95% Confidence Interval (CI) 0.065, 1.149). Emotional numbing was associated with greater estimated glucose disposal rate (AC -0.021 (95%CI -0.036, -0.005). Hyperarousal was associated with greater levels of (log)triglycerides (exponentiated-AC 1.009 (95%CI 1.002, 1.017). Intrusive thoughts were associated with greater visceral adipose tissue (AC 0.574 (95%CI 0.020, 1.250). Nonlinear relationships were observed between emotional numbing with heart rate and intrusive thoughts with systolic BP. Limited evidence is present for symptom associations with lipoproteins and pulse wave velocity. No associations were observed between PTSD symptom clusters and high sensitivity c-reactive protein, diastolic BP, total cholesterol, or haemoglobin fasting glucose. In conclusion, symptom clusters of PTSD were associated with increased cardiovascular risk via cardiometabolic and haemodynamic functioning mechanisms, but not inflammation.
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Affiliation(s)
- Daniel Dyball
- King's Centre for Military Health Research, King's College London, SE5 9RJ, UK.
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Near Loughborough, Nottinghamshire, LE12 5BL, UK
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, SW3 6LR, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, SW3 6LR, UK
| | - Christopher J Boos
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, BH1 3LT, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, SW7 2AZ, UK
| | - Sharon Am Stevelink
- King's Centre for Military Health Research, King's College London, SE5 9RJ, UK; Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8AF, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, SE5 9RJ, UK; Academic Department of Military Mental Health, King's College London, SE5 9RJ, UK
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Maqsood R, Khattab A, Bennett AN, Boos CJ. Association between non-acute Traumatic Injury (TI) and Heart Rate Variability (HRV) in adults: A systematic review and meta-analysis. PLoS One 2023; 18:e0280718. [PMID: 36689421 PMCID: PMC9870143 DOI: 10.1371/journal.pone.0280718] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/07/2023] [Indexed: 01/24/2023] Open
Abstract
Heart rate variability (HRV) is a non-invasive measure of autonomic function. The relationship between unselected long-term traumatic injury (TI) and HRV has not been investigated. This systematic review examines the impact of non-acute TI (>7 days post-injury) on standard HRV indices in adults. Four electronic databases (CINAHL, Medline, Scopus, and Web of Science) were searched. The quality of studies, risk of bias (RoB), and quality of evidence (QoE) were assessed using Axis, RoBANS and GRADE, respectively. Using the random-effects model, mean difference (MD) for root mean square of successive differences (RMSSD) and standard deviation of NN-intervals (SDNN), and standardized mean difference (SMD) for Low-frequency (LF): High-Frequency (HF) were pooled in RevMan guided by the heterogeneity score (I2). 2152 records were screened followed by full-text retrieval of 72 studies. 31 studies were assessed on the inclusion and exclusion criteria. Only four studies met the inclusion criteria. Three studies demonstrated a high RoB (mean RoBANS score 14.5±3.31) with a low QoE. TI was associated with a significantly higher resting heart rate. Meta-analysis of three cross-sectional studies demonstrated a statistically significant reduction in RMSSD (MD -8.45ms, 95%CI-12.78, -4.12, p<0.0001) and SDNN (MD -9.93ms, 95%CI-14.82, -5.03, p<0.0001) (low QoE) in participants with TI relative to the uninjured control. The pooled analysis of four studies showed a higher LF: HF ratio among injured versus uninjured (SMD 0.20, 95%CI 0.01-0.39, p<0.04) (very low QoE). Albeit low QoE, non-acute TI is associated with attenuated HRV indicating autonomic imbalance. The findings might explain greater cardiovascular risk following TI. Trial registration PROSPERO registration number: CRD: CRD42021298530.
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Affiliation(s)
- Rabeea Maqsood
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Ahmed Khattab
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, United Kingdom
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Christopher J. Boos
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, United Kingdom
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Maqsood R, Khattab A, Bennett AN, Boos CJ. Association between non-acute traumatic injury (TI) and heart rate variability (HRV) in adults: A systematic review protocol. PLoS One 2022; 17:e0273688. [PMID: 36026501 PMCID: PMC9417186 DOI: 10.1371/journal.pone.0273688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/12/2022] [Indexed: 12/05/2022] Open
Abstract
Heart Rate Variability (HRV) is an indirect measure of autonomic function. Attenuated HRV is linked to worsening health outcomes including Major Adverse Cardiovascular Events (MACE). The relationship between traumatic injury (TI) and HRV has been limitedly studied. This research protocol has been designed to conduct a systematic review of the existing evidence on the association between non-acute TI and HRV in adults. Four electronic bibliographic databases (Web of Science, CINAHL, Medline, and Scopus) will be searched. The studies on non-acute (>7 days post injury) TI and HRV in adults will be included, followed by title-abstract screening by two reviewers independently. The quality and risk of bias of the included studies will be assessed using Axis and a six-item Risk of Bias Assessment tool for of Non-randomized Studies (RoBANS) respectively. Grading of Recommendations Assessment, Development and Evaluation (GRADE) will assess the quality of evidence. The extracted data will be synthesized using narrative syntheses and a Forest plot with or without meta-analysis- whichever permitted by the pooled data. This will be the first systematic review to examine the relationship between generalized TI and HRV in adults. Trial registration: (PROPSERO registration number: CRD: CRD42021298530) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021298530.
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Affiliation(s)
- Rabeea Maqsood
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
- * E-mail:
| | - Ahmed Khattab
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Christopher J. Boos
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, United Kingdom
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Dyball D, Bennett AN, Schofield S, Cullinan P, Boos CJ, Bull AMJ, Wessely S, Stevelink SAM, Fear NT. Mental health outcomes of male UK military personnel deployed to Afghanistan and the role of combat injury: analysis of baseline data from the ADVANCE cohort study. Lancet Psychiatry 2022; 9:547-554. [PMID: 35717965 DOI: 10.1016/s2215-0366(22)00112-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The long-term psychosocial outcomes of UK armed forces personnel who sustained serious combat injuries during deployment to Afghanistan are largely unknown. We aimed to assess rates of probable post-traumatic stress disorder (PTSD), depression, anxiety, and mental health-associated multimorbidity in a representative sample of serving and ex-serving UK military personnel with combat injuries, compared with rates in a matched sample of uninjured personnel. METHODS This analysis used baseline data from the ADVANCE cohort study, in which injured individuals were recruited from a sample of UK armed forces personnel who were deployed to Afghanistan and had physical combat injuries, according to records provided by the UK Ministry of Defence. Participants from the uninjured group were frequency-matched by age, rank, regiment, deployment, and role on deployment. Participants were recruited through postal, email, and telephone invitations. Participants completed a comprehensive health assessment, including physical health assessment and self-reported mental health measures (PTSD Checklist, Patient Health Questionnaire-9, and Generalised Anxiety Disorder-7). The mental health outcomes were rates of PTSD, depression, anxiety, and mental health-associated multimorbidity in the injured and uninjured groups. The ADVANCE study is ongoing and is registered with the ISRCTN registry, ISRCTN57285353. FINDINGS 579 combat-injured participants (161 with amputation injuries and 418 with non-amputation injuries) and 565 uninjured participants were included in the analysis. Participants had a median age of 33 years (IQR 30-37 years) at the time of assessment. 90·3% identified as White and 9·7% were from all other ethnic groups. The rates of PTSD (16·9% [n=89] vs 10·5% [n=53]; adjusted odds ratio [AOR] 1·67 [95% CI 1·16-2·41], depression (23·6% [n=129] vs 16·8% [n=87]; AOR 1·46 [1·08-2·03]), anxiety (20·8% [n=111] vs 13·5% [n=71]; AOR 1·56 [1·13-2·24]) and mental health-associated multimorbidity (15·3% [n=81] vs 9·8% [n=49]; AOR 1·62 [1·12-2·49]) were greater in the injured group than the uninjured group. Minimal differences in odds of reporting any poor mental health outcome were noted between the amputation injury subgroup and the uninjured group (AOR range 0·77-0·97), whereas up to double the odds were noted for the non-amputation injury subgroup compared with the uninjured group (AOR range 1·74-2·02). INTERPRETATION Serious physical combat injuries were associated with poor mental health outcomes. However, the type of injury sustained influenced this relationship. Regardless of injury, this cohort represents a group who present with greater rates of PTSD than the general population, as well as increased psychological burden from multimorbidity. FUNDING The ADVANCE Charity.
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Affiliation(s)
- Daniel Dyball
- King's Centre for Military Health Research, King's College London, London, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Christopher J Boos
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Simon Wessely
- King's Centre for Military Health Research, King's College London, London, UK
| | - Sharon A M Stevelink
- King's Centre for Military Health Research, King's College London, London, UK; Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, UK; Academic Department of Military Mental Health, King's College London, London, UK.
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Boos CJ, Schofield S, Cullinan P, Dyball D, Fear NT, Bull AMJ, Pernet D, Bennett AN. Association between combat-related traumatic injury and cardiovascular risk. Heart 2021; 108:367-374. [PMID: 34824088 PMCID: PMC8862100 DOI: 10.1136/heartjnl-2021-320296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness. Methods This was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003–2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP). Results Overall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, p<0.0001) and the mean cAIx (17.61%±8.79% vs 15.23%±8.19%, p<0.0001) were higher among the CRTI versus the uninjured group, respectively. Abdominal waist circumference, visceral fat area, triglycerides, estimated insulin resistance and hs-CRP levels were greater and physical activity and high-density lipoprotein-cholesterol lower with CRTI. There were no significant between-group differences in blood glucose, blood pressure or PWV. CRTI, injury severity (↑NISS), age, socioeconomic status (SEC) and physical activity were independently associated with both MetS and cAIx. Conclusions CRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.
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Affiliation(s)
- Christopher J Boos
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK .,Academic Department of Military Mental Health, King's College London, London, UK.,Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK.,Cardiology, University Hospitals Dorset NHS Foundation Trust, Poole Hospital, Poole, UK
| | - Susie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Daniel Dyball
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK.,Academic Department of Military Mental Health, King's College London, London, UK
| | - Nicola T Fear
- Academic Department of Military Mental Health, King's College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - David Pernet
- Academic Department of Military Mental Health, King's College London, London, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK.,National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
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Marshall AR, Rimmer JE, Shah N, Bye K, Kipps C, Woods DR, O'Hara J, Boos CJ, Barlow M. Marching to the Beet: The effect of dietary nitrate supplementation on high altitude exercise performance and adaptation during a military trekking expedition. Nitric Oxide 2021; 113-114:70-77. [PMID: 34051342 DOI: 10.1016/j.niox.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim was to investigate the effect of dietary nitrate supplementation (in the form of beetroot juice, BRJ) for 20 days on salivary nitrite (a potential precursor of bioactive nitric oxide), exercise performance and high altitude (HA) acclimatisation in field conditions (hypobaric hypoxia). METHODS This was a single-blinded randomised control study of 22 healthy adult participants (12 men, 10 women, mean age 28 ± 12 years) across a HA military expedition. Participants were randomised pre-ascent to receive two 70 ml dose per day of either BRJ (~12.5 mmol nitrate per day; n = 11) or non-nitrate calorie matched control (n = 11). Participants ingested supplement doses daily, beginning 3 days prior to departure and continued until the highest sleeping altitude (4800 m) reached on day 17 of the expedition. Data were collected at baseline (44 m altitude), at 2350 m (day 9), 3400 m (day 12) and 4800 m (day 17). RESULTS BRJ enhanced the salivary levels of nitrite (p = 0.007). There was a significant decrease in peripheral oxygen saturation and there were increases in heart rate, diastolic blood pressure, and rating of perceived exertion with increasing altitude (p=<0.001). Harvard Step Test fitness scores significantly declined at 4800 m in the control group (p = 0.003) compared with baseline. In contrast, there was no decline in fitness scores at 4800 m compared with baseline (p = 0.26) in the BRJ group. Heart rate recovery speed following exercise at 4800 m was significantly prolonged in the control group (p=<0.01) but was unchanged in the BRJ group (p = 0.61). BRJ did not affect the burden of HA illness (p = 1.00). CONCLUSIONS BRJ increases salivary nitrite levels and ameliorates the decline in fitness at altitude but does not affect the occurrence of HA illness.
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Affiliation(s)
- Anna R Marshall
- Department of Surgical and Interventional Sciences, Institute of Sport, Exercise & Health, UCL, London, WC1E 6B, UK.
| | | | - Nishma Shah
- Department of Surgical and Interventional Sciences, Institute of Sport, Exercise & Health, UCL, London, WC1E 6B, UK
| | - Kyo Bye
- Defence Medical Services, Lichfield, WS14 9PY, UK
| | - Courtney Kipps
- Department of Surgical and Interventional Sciences, Institute of Sport, Exercise & Health, UCL, London, WC1E 6B, UK
| | - David R Woods
- Defence Medical Services, Lichfield, WS14 9PY, UK; Carneige School of Sport, Leeds Beckett University, Leeds, LS16 5LF, UK; Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, NE66 2NS, UK
| | - John O'Hara
- Carneige School of Sport, Leeds Beckett University, Leeds, LS16 5LF, UK
| | - Christopher J Boos
- Carneige School of Sport, Leeds Beckett University, Leeds, LS16 5LF, UK; Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, BH15 2JB, UK; Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, BH1 3LT, UK
| | - Matthew Barlow
- Carneige School of Sport, Leeds Beckett University, Leeds, LS16 5LF, UK
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Boos CJ, Thiri-Toon L, Steadman CD, Khambekar S, Jordan A, Carpenter JP. The Relationship Between Ambulatory Arterial Stiffness Index and Cardiovascular Outcomes in Women. Cardiol Res 2021; 12:161-168. [PMID: 34046110 PMCID: PMC8139754 DOI: 10.14740/cr1189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 11/30/2022] Open
Abstract
Background The ambulatory arterial stiffness index (AASI) obtained during ambulatory blood pressure monitoring (ABPM) has been cited as an independent predictor of major adverse cardiovascular events (MACEs) including cardiovascular death, stroke and worsening chronic kidney disease (CKD) among mixed-sex adult populations. This study aimed to determine the relationship between AASI and MACE and its predictive precision in women. Methods This work follows the guidelines of the STROBE initiative for cohort studies. This was a retrospective single-center observational study of adult women (aged 18 - 75 years), who underwent 24-h ABPM for the diagnosis of hypertension or its control. The primary endpoint was a composite MACE of cardiovascular death, acute limb ischemia, stroke, acute coronary syndrome (ACS), or progression to stage V CKD. Results A total of 219 women aged 57.4 ± 13.3 years were followed up for a median (interquartile range (IQR)) of 25.5 (18.3 - 31.3) months. Overall, 16 (7.3%) patients suffered one or more MACE events. AASI was significantly higher in patients with known coronary artery disease (CAD), diabetes mellitus, peripheral vascular disease (PVD), heart failure, previous stroke, or transient ischemic attack (TIA). AASI was a significant predictor of MACE (area under the curve: 0.78; P < 0.001) with an optimal cut-off of ≥ 0.56. On Kaplan-Meier analysis AASI ≥ 0.56 was significantly associated with MACE (log-rank test, P < 0.001). The only independent predictors of MACE on Cox proportional hazard analysis were diabetes mellitus, low high-density lipoprotein (HDL) levels, cumulative AASI values, or AASI ≥ 0.56. Conclusions An AASI of ≥ 0.56 is an independent predictor of MACE in women. A further validation study in a larger cohort of women is recommended.
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Affiliation(s)
- Christopher J Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK.,Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, BH1 3LT, UK.,Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, LS16 5LF, UK
| | - Lin Thiri-Toon
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK
| | - Christopher D Steadman
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK
| | - Sujata Khambekar
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK
| | - Andrew Jordan
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK
| | - John Paul Carpenter
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Rd., Poole, Dorset, BH15 2JB, UK
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19
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Griffiths A, Deighton K, Boos CJ, Rowe J, Morrison DJ, Preston T, King R, O'Hara JP. Carbohydrate Supplementation and the Influence of Breakfast on Fuel Use in Hypoxia. Med Sci Sports Exerc 2021; 53:785-795. [PMID: 33044437 DOI: 10.1249/mss.0000000000002536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE This study investigated the effect of carbohydrate supplementation on substrate oxidation during exercise in hypoxia after preexercise breakfast consumption and omission. METHODS Eleven men walked in normobaric hypoxia (FiO2 ~11.7%) for 90 min at 50% of hypoxic V˙O2max. Participants were supplemented with a carbohydrate beverage (1.2 g·min-1 glucose) and a placebo beverage (both enriched with U-13C6 D-glucose) after breakfast consumption and after omission. Indirect calorimetry and isotope ratio mass spectrometry were used to calculate carbohydrate (exogenous and endogenous [muscle and liver]) and fat oxidation. RESULTS In the first 60 min of exercise, there was no significant change in relative substrate oxidation in the carbohydrate compared with placebo trial after breakfast consumption or omission (both P = 0.99). In the last 30 min of exercise, increased relative carbohydrate oxidation occurred in the carbohydrate compared with placebo trial after breakfast omission (44.0 ± 8.8 vs 28.0 ± 12.3, P < 0.01) but not consumption (51.7 ± 12.3 vs 44.2 ± 10.4, P = 0.38). In the same period, a reduction in relative liver (but not muscle) glucose oxidation was observed in the carbohydrate compared with placebo trials after breakfast consumption (liver, 7.7% ± 1.6% vs 14.8% ± 2.3%, P < 0.01; muscle, 25.4% ± 9.4% vs 29.4% ± 11.1%, P = 0.99) and omission (liver, 3.8% ± 0.8% vs 8.7% ± 2.8%, P < 0.01; muscle, 19.4% ± 7.5% vs 19.2% ± 12.2%, P = 0.99). No significant difference in relative exogenous carbohydrate oxidation was observed between breakfast consumption and omission trials (P = 0.14). CONCLUSION In acute normobaric hypoxia, carbohydrate supplementation increased relative carbohydrate oxidation during exercise (>60 min) after breakfast omission, but not consumption.
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Affiliation(s)
- Alex Griffiths
- Carnegie School of Sport, Leeds Beckett University, Leeds, UNITED KINGDOM
| | - Kevin Deighton
- Carnegie School of Sport, Leeds Beckett University, Leeds, UNITED KINGDOM
| | | | - Joshua Rowe
- Carnegie School of Sport, Leeds Beckett University, Leeds, UNITED KINGDOM
| | - Douglas J Morrison
- Stable Isotope Biochemistry Laboratory, SUERC, University of Glasgow. East Kilbride, Scotland, UNITED KINGDOM
| | - Tom Preston
- Stable Isotope Biochemistry Laboratory, SUERC, University of Glasgow. East Kilbride, Scotland, UNITED KINGDOM
| | - Roderick King
- Carnegie School of Sport, Leeds Beckett University, Leeds, UNITED KINGDOM
| | - John P O'Hara
- Carnegie School of Sport, Leeds Beckett University, Leeds, UNITED KINGDOM
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20
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Boos CJ, Toon LT, Almahdi H. The relationship between ambulatory arterial stiffness, inflammation, blood pressure dipping and cardiovascular outcomes. BMC Cardiovasc Disord 2021; 21:139. [PMID: 33726683 PMCID: PMC7968202 DOI: 10.1186/s12872-021-01946-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/02/2021] [Indexed: 12/30/2022] Open
Abstract
Background The ambulatory arterial stiffness index (AASI) is an indirect measure of arterial stiffness obtained during ambulatory blood pressuring monitoring (ABPM). Its relationship to nocturnal blood pressure dipping status and major adverse cardiovascular events (MACE) are controversial and its association with vascular inflammation has not been examined. We aimed to investigate the relationship between the AASI, inflammation and nocturnal blood pressure dipping status and its association with MACE. Methods Adults (aged 18–80 years) who underwent 24-h ABPM for the diagnosis of hypertension or its control were included. The inflammatory markers measured were the neutrophil–lymphocyte (NLR), platelet-lymphocyte (PLR) and monocyte-lymphocyte ratios (MLR). The primary MACE was a composite of cardiovascular death, acute limb ischaemia, stroke or transient ischaemic attack (TIA) or acute coronary syndrome. Results A total of 508 patients (51.2% female) aged 58.8 ± 14.0 years were included; 237 (46.7%) were normal-dippers (≥ 10% nocturnal systolic dip), 214 (42.1%) were non-dippers (0–10% dip) and 57 (11.2%) were reverse-dippers (< 0% dip). The AASI was significantly higher among reverse (0.56 ± 0.16) and non-dippers (0.48 ± 0.17) compared with normal dippers (0.39 ± 0.16; p < 0.0001) and correlated with the NLR (r = 0.20; 95% CI 0.11 to 0.29: < 0.0001) and systolic blood pressure dipping % (r = − 0.34; − 0.42 to − 0.26: p < 0.0001). Overall 39 (7.7%) patients had ≥ 1 MACE which included a total of seven cardiovascular deaths and 14 non-fatal strokes/TIAs. The mean follow up was 113.7 ± 64.0 weeks. Increasing NLR, but not AASI or systolic dipping, was independently linked to MACE (overall model Chi-square 60.67; p < 0.0001) and MLR to cardiovascular death or non-fatal stroke/TIA (overall model Chi-square 37.08; p < 0.0001). Conclusions In conclusion AASI was associated with blood pressure dipping and chronic inflammation but not independently to MACE. The MLR and NLR were independent predictors of MACE. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-01946-2.
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Affiliation(s)
- Christopher J Boos
- Department of Cardiology, University Hospital Dorset NHS Foundation Trust, Longfleet Rd., Poole, BH15 2JB, UK. .,Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, BH1 3LT, UK. .,Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, LS16 5LF, UK.
| | - Lin-Thiri Toon
- Department of Cardiology, University Hospital Dorset NHS Foundation Trust, Longfleet Rd., Poole, BH15 2JB, UK
| | - Halah Almahdi
- Department of Cardiology, University Hospital Dorset NHS Foundation Trust, Longfleet Rd., Poole, BH15 2JB, UK
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21
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Bennett AN, Dyball DM, Boos CJ, Fear NT, Schofield S, Bull AMJ, Cullinan P. Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study. BMJ Open 2020; 10:e037850. [PMID: 33127630 PMCID: PMC7604820 DOI: 10.1136/bmjopen-2020-037850] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/16/2020] [Accepted: 09/21/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma. METHODS AND ANALYSIS ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality. ETHICS AND DISSEMINATION The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications. TRIAL REGISTRATION NUMBER The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.
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Affiliation(s)
- Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Daniel Mark Dyball
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
- King's Centre for Military Health Research, King's College London, London, UK
| | - Christopher J Boos
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, UK
- Academic Department for Military Mental Health, King's College London, London, UK
| | - Susie Schofield
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Imperial College London, London, UK
| | - Paul Cullinan
- Occupational and Environmental Medicine, National Heart and Lung Institute, Imperial College, London, UK
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22
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Gifford RM, Boos CJ, Reynolds RM, Woods DR. Recovery time and heart rate variability following extreme endurance exercise in healthy women. Physiol Rep 2019; 6:e13905. [PMID: 30381902 PMCID: PMC6209688 DOI: 10.14814/phy2.13905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/30/2018] [Accepted: 10/01/2018] [Indexed: 11/24/2022] Open
Abstract
The relationship between autonomic function and recovery following prolonged arduous exercise in women has not been examined. We undertook an exploratory study that aimed to examine the temporal change in linear and nonlinear measures of heart rate variability (HRV) following prolonged arduous exercise in the form of first all‐female (mean age 32.7 ± 3.1 years) team to attempt an unassisted Antarctic traverse. HRV analysis was performed before and 1, 4, and 15 days postexpedition. The traverse was completed in 61 days. There was a significant paired reduction in heart rate, LnLF, LF:HF, DFAα1 between baseline and 15 days postexercise in the same environment. Conversely, RMSSD, LnHF and HFnu, SD1:SD2, and SampEn significantly increased. DFAα2 levels significantly fell from baseline to Day 1 postexercise. In conclusion, we observed a significant latent increase in relative parasympathetic dominance and RR interval irregularity at 15 days post prolonged arduous exercise, versus pre‐exercise baseline, in a group of very fit and healthy adult women.
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Affiliation(s)
- Robert M Gifford
- Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, Edinburgh.,Defence Medical Services, Lichfield, United Kingdom
| | - Christopher J Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, United Kingdom.,Centre for Postgraduate Medical Education, Bournemouth University, Bournemouth, United Kingdom.,Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - Rebecca M Reynolds
- Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, Edinburgh
| | - David R Woods
- Defence Medical Services, Lichfield, United Kingdom.,Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, United Kingdom.,Centre for Postgraduate Medical Education, Bournemouth University, Bournemouth, United Kingdom.,Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom.,Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, United Kingdom.,University of Newcastle, Newcastle Upon Tyne, United Kingdom
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23
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Dyball D, Evans S, Boos CJ, Stevelink SAM, Fear NT. The association between PTSD and cardiovascular disease and its risk factors in male veterans of the Iraq/Afghanistan conflicts: a systematic review. Int Rev Psychiatry 2019; 31:34-48. [PMID: 31041877 DOI: 10.1080/09540261.2019.1580686] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Military personnel with Post-Traumatic Stress Disorder (PTSD) can experience high levels of mental and physical health comorbidity, potentially indicating a high level of functional impairment that can impact on both military readiness and later ill-health. There is strong evidence to implicate PTSD as a contributory factor to Cardiovascular Disease (CVD) among serving personnel and veterans. This systematic review focusses on the association between PTSD and cardiovascular disease/risk factors in male, military serving and ex-serving personnel who served in the Iraq/Afghanistan conflicts. PUBMED, MEDLINE, PILOTS, EMBASE, PSYCINFO, and PSYCARTICLES were searched using PRISMA guidelines. Three hundred and forty-three records were identified, of which 20 articles were selected. PTSD was positively associated with the development of CVD, specifically circulatory diseases, including hypertension. PTSD was also positively associated with the following risk factors: elevated heart rate, tobacco use, dyslipidaemia, and obesity. Conflicting data is presented regarding heart rate variability and inflammatory markers. Future studies would benefit from a standardized methodological approach to investigating PTSD and physical health manifestations. It is suggested that clinicians offer health advice for CVD at an earlier age for ex-/serving personnel with PTSD.
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Affiliation(s)
- Daniel Dyball
- a King's Centre for Military Health Research, Psychological Medicine , King's College London , London , UK.,b ADVANCE study, Academic Department of Military Rehabilitation , Defence Medical Rehabilitation Centre Stanford Hall , Loughborough , UK
| | - Sarah Evans
- a King's Centre for Military Health Research, Psychological Medicine , King's College London , London , UK.,b ADVANCE study, Academic Department of Military Rehabilitation , Defence Medical Rehabilitation Centre Stanford Hall , Loughborough , UK
| | - Christopher J Boos
- b ADVANCE study, Academic Department of Military Rehabilitation , Defence Medical Rehabilitation Centre Stanford Hall , Loughborough , UK.,c Department of Postgraduate Medical Education , Bournemouth University , Poole , UK
| | - Sharon A M Stevelink
- a King's Centre for Military Health Research, Psychological Medicine , King's College London , London , UK.,d Department of Psychological Medicine , King's College London , London , UK
| | - Nicola T Fear
- a King's Centre for Military Health Research, Psychological Medicine , King's College London , London , UK.,b ADVANCE study, Academic Department of Military Rehabilitation , Defence Medical Rehabilitation Centre Stanford Hall , Loughborough , UK.,e Academic Department for Military Mental Health , King's College London , London , UK
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24
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Boos CJ, Bass M, O’Hara JP, Vincent E, Mellor A, Sevier L, Abdul-Razakq H, Cooke M, Barlow M, Woods DR. The relationship between anxiety and acute mountain sickness. PLoS One 2018; 13:e0197147. [PMID: 29927953 PMCID: PMC6013200 DOI: 10.1371/journal.pone.0197147] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/28/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction Whilst the link between physical factors and risk of high altitude (HA)-related illness and acute mountain sickness (AMS) have been extensively explored, the influence of psychological factors has been less well examined. In this study we aimed to investigate the relationship between ‘anxiety and AMS risk during a progressive ascent to very HA. Methods Eighty health adults were assessed at baseline (848m) and over 9 consecutive altitudes during a progressive trek to 5140m. HA-related symptoms (Lake Louise [LLS] and AMS-C Scores) and state anxiety (State-Trait-Anxiety-Score [STAI Y-1]) were examined at each altitude with trait anxiety (STAI Y-2) at baseline. Results The average age was 32.1 ± 8.3 years (67.5% men). STAI Y-1 scores fell from 848m to 3619m, before increasing to above baseline scores (848m) at ≥4072m (p = 0.01). STAI Y-1 scores correlated with LLS (r = 0.31; 0.24–0.3; P<0.0001) and AMS-C Scores (r = 0.29; 0.22–0.35; P<0.0001). There was significant main effect for sex (higher STAI Y-1 scores in women) and altitude with no sex-x-altitude interaction on STAI Y-1 Scores. Independent predictors of significant state anxiety included female sex, lower age, higher heart rate and increasing LLS and AMS-C scores (p<0.0001). A total of 38/80 subjects (47.5%) developed AMS which was mild in 20 (25%) and severe in 18 (22.5%). Baseline STAI Y-2 scores were an independent predictor of future severe AMS (B = 1.13; 1.009–1.28; p = 0.04; r2 = 0.23) and STAI Y-1 scores at HA independently predicted AMS and its severity. Conclusion Trait anxiety at low altitude was an independent predictor of future severe AMS development at HA. State anxiety at HA was independently associated with AMS and its severity.
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Affiliation(s)
- Christopher J. Boos
- Department of Cardiology, Poole Hospital NHS Foundation trust, Poole, United Kingdom
- Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, United Kingdom
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
- * E-mail:
| | - Malcolm Bass
- Consultant Clinical Psychologist, Tees Esk and Wear Valleys NHS Trust, Middlesbrough, United Kingdom
| | - John P. O’Hara
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - Emma Vincent
- Defence Medical Services, Lichfield, United Kingdom
| | - Adrian Mellor
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
- Consultant Clinical Psychologist, Tees Esk and Wear Valleys NHS Trust, Middlesbrough, United Kingdom
- Defence Medical Services, Lichfield, United Kingdom
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - Luke Sevier
- Department of Cardiology, Poole Hospital NHS Foundation trust, Poole, United Kingdom
| | - Humayra Abdul-Razakq
- Department of Cardiology, Poole Hospital NHS Foundation trust, Poole, United Kingdom
| | - Mark Cooke
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - Matt Barlow
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - David R. Woods
- Research Institute, for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
- Consultant Clinical Psychologist, Tees Esk and Wear Valleys NHS Trust, Middlesbrough, United Kingdom
- Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, United Kingdom
- University of Newcastle, Newcastle upon Tyne, United Kingdom
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25
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Boos CJ, Bye K, Sevier L, Bakker-Dyos J, Woods DR, Sullivan M, Quinlan T, Mellor A. High Altitude Affects Nocturnal Non-linear Heart Rate Variability: PATCH-HA Study. Front Physiol 2018; 9:390. [PMID: 29713290 PMCID: PMC5911497 DOI: 10.3389/fphys.2018.00390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/28/2018] [Indexed: 01/23/2023] Open
Abstract
Background: High altitude (HA) exposure can lead to changes in resting heart rate variability (HRV), which may be linked to acute mountain sickness (AMS) development. Compared with traditional HRV measures, non-linear HRV appears to offer incremental and prognostic data, yet its utility and relationship to AMS have been barely examined at HA. This study sought to examine this relationship at terrestrial HA. Methods: Sixteen healthy British military servicemen were studied at baseline (800 m, first night) and over eight consecutive nights, at a sleeping altitude of up to 3600 m. A disposable cardiac patch monitor was used, to record the nocturnal cardiac inter-beat interval data, over 1 h (0200-0300 h), for offline HRV assessment. Non-linear HRV measures included Sample entropy (SampEn), the short (α1, 4-12 beats) and long-term (α2, 13-64 beats) detrend fluctuation analysis slope and the correlation dimension (D2). The maximal rating of perceived exertion (RPE), during daily exercise, was assessed using the Borg 6-20 RPE scale. Results: All subjects completed the HA exposure. The average age of included subjects was 31.4 ± 8.1 years. HA led to a significant fall in SpO2 and increase in heart rate, LLS and RPE. There were no significant changes in the ECG-derived respiratory rate or in any of the time domain measures of HRV during sleep. The only notable changes in frequency domain measures of HRV were an increase in LF and fall in HFnu power at the highest altitude. Conversely, SampEn, SD1/SD2 and D2 all fell, whereas α1 and α2 increased (p < 0.05). RPE inversely correlated with SD1/SD2 (r = -0.31; p = 0.002), SampEn (r = -0.22; p = 0.03), HFnu (r = -0.27; p = 0.007) and positively correlated with LF (r = 0.24; p = 0.02), LF/HF (r = 0.24; p = 0.02), α1 (r = 0.32; p = 0.002) and α2 (r = 0.21; p = 0.04). AMS occurred in 7/16 subjects (43.8%) and was very mild in 85.7% of cases. HRV failed to predict AMS. Conclusion: Non-linear HRV is more sensitive to the effects of HA than time and frequency domain indices. HA leads to a compensatory decrease in nocturnal HRV and complexity, which is influenced by the RPE measured at the end of the previous day. HRV failed to predict AMS development.
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Affiliation(s)
- Christopher J Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, United Kingdom.,Centre of Postgraduate Medical Research and Education, Bournemouth University, Bournemouth, United Kingdom.,Research Institute for Sport Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - Kyo Bye
- The Defence Medical Services, Lichfield, United Kingdom
| | - Luke Sevier
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, United Kingdom
| | - Josh Bakker-Dyos
- Research Institute for Sport Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - David R Woods
- Research Institute for Sport Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom.,The Defence Medical Services, Lichfield, United Kingdom.,Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom.,Department of Academic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Adrian Mellor
- The Defence Medical Services, Lichfield, United Kingdom.,James Cook University Hospital, Middlesbrough, United Kingdom
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Goon PKY, Boos CJ, Stonelake PS, Blann AD, Lip GYH. Detection and quantification of mature circulating endothelial cells using flow cytometry and immunomagnetic beads: A methodological comparison. Thromb Haemost 2017; 96:45-52. [PMID: 16807650 DOI: 10.1160/th06-04-0185] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryMature circulating endothelial cells (CECs) are novel cellular markers of endothelial damage/dysfunction. The two main techniques of CEC enumeration are flow cytometry (FC) and immunomagnetic bead (IB) isolation. Both quantify CECs accurately, but a direct comparison of both methods has not been reported. We sought to assess the agreement between the two methods in two patient populations, and a group of healthy subjects, with emphasis given to methodological issues. We included 34 patients with acute coronary syndrome (ACS), 60 patients with primary breast cancer (PBC) and 30 healthy controls (HC). We quantified CECs using the IB method [CD146 and FITCUlex europaeus lectin-1] and FC [CD45, CD34 and CD146]. Bland-Altman plots suggested reasonable agreement (<5% of events >2 standard deviations from the mean) between FC and the IB methods for CEC quantification in whole blood in the two disease groups (ACS and PBC), but not among the HCs. There were no statistically significant differences in CEC levels by the two methods amongst all three patient groups. There is reasonable agreement between the FC and the IB methods for mature CEC quantification in whole blood, especially amongst disease groups. The agreement between the two methods appears to weaken in healthy controls, and at lower and higher absolute CEC counts.
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Affiliation(s)
- Patrick K Y Goon
- Haemostasis Thrombosis and Vascular Biology Unit, City Hospital, Dudley Road, Birmingham, B18 7QH, United Kingdom.
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Boos CJ, Holdsworth D, Woods DR, O'Hara JP, Brooks N, Macconnachie L, Bakker-Dyos J, Paisey JR, Mellor A. 18Assessment of cardiac arrhythmias at extreme high altitude using an implantable cardiac monitor: REVEAL HA Study. Europace 2017. [DOI: 10.1093/europace/eux283.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Boos CJ, Vincent E, Mellor A, Woods DR, New C, Cruttenden R, Barlow M, Cooke M, Deighton K, Scott P, Clarke S, O'Hara J. The effect of high altitude on central blood pressure and arterial stiffness. J Hum Hypertens 2017; 31:715-719. [PMID: 28540933 DOI: 10.1038/jhh.2017.40] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/05/2017] [Accepted: 01/17/2017] [Indexed: 12/31/2022]
Abstract
Central arterial systolic blood pressure (SBP) and arterial stiffness are known to be better predictors of adverse cardiovascular outcomes than brachial SBP. The effect of progressive high altitude (HA) on these parameters has not been examined. Ninety healthy adults were included. Central BP and the augmentation index (AI) were measured at the level of the brachial artery (Uscom BP+ device) at <200 m and at 3619, 4600 and 5140 m. The average age of the subjects (70% men) were 32.2±8.7 years. Compared with central arterial pressures, brachial SBP (+8.1±6.4 mm Hg; P<0.0001) and pulse pressure (+10.9±6.6 mm Hg; P<0.0001) were significantly higher and brachial diastolic BP was lower (-2.8±1.6 mm Hg; P<0.0001). Compared with <200 m, HA led to a significant increase in brachial and central SBP. Central SBP correlated with AI (r=0.50; 95% confidence interval (CI): 0.41-0.58; P<0.0001) and age (r=0.32; 95% CI: 21-0.41; P<0.001). AI positively correlated with age (r=0.39; P<0.001) and inversely with subject height (r=-0.22; P<0.0001), weight (r=-0.19; P=0.006) and heart rate (r=-0.49; P<0.0001). There was no relationship between acute mountain sickness scores (Lake Louis Scoring System (LLS)) and AI or central BP. The independent predictors of central SBP were male sex (coefficient, t=4.7; P<0.0001), age (t=3.6; P=0.004) and AI (t=7.5; P<0.0001; overall r2=0.40; P<0.0001). Subject height (t=2.4; P=0.02), age (7.4; P<0.0001) and heart rate (t=11.4; P<0.0001) were the only independent predictors of AI (overall r2=0.43; P<0.0001). Central BP and AI significantly increase at HA. This rise was influenced by subject-related factors and heart rate but not independently by altitude, LLS or SpO2.
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Affiliation(s)
- C J Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Leeds Beckett and Bournemouth Universities, Poole, UK.,Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, UK.,Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
| | - E Vincent
- Defence Medical Services, Lichfield, UK
| | - A Mellor
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK.,Defence Medical Services, Lichfield, UK.,James Cook University Hospital, Middlesbrough, UK
| | - D R Woods
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK.,Defence Medical Services, Lichfield, UK.,Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - C New
- Defence Medical Services, Lichfield, UK
| | | | - M Barlow
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
| | - M Cooke
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
| | - K Deighton
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
| | - P Scott
- Defence Medical Services, Lichfield, UK
| | - S Clarke
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
| | - J O'Hara
- Research Institute, For Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK
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Brown LAE, Boos CJ. Atrial fibrillation and heart failure: Factors influencing the choice of oral anticoagulant. Int J Cardiol 2016; 227:863-868. [PMID: 28029411 DOI: 10.1016/j.ijcard.2016.09.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) frequently coexist. AF is identified in approximately one third of patients with HF and is linked to increased morbidity and mortality than from either condition alone. AF is relatively more common in HF with preserved ejection fraction (HFpEF) than with reduced ejection fraction (HFrEF). Nevertheless, the risk of stroke and systemic embolism (SSE) is significantly increased with both HF types and the absolute risk is heavily influenced by the presence and severity of associated additional stroke risk factors. The European Society of Cardiology has very recently introduced a third HF subtype entitled HF with mid-range ejection fraction (HFmrEF). At present oral anticoagulation is recommended for all patients with AF and HF, independent of HF type. In addition to warfarin there are currently four non-vitamin K oral anticoagulants (NOACs, previously called novel oral anticoagulants) that have been approved for the prevention of SSE. They consist of one direct thrombin inhibitor, dabigatran and three factor Xa inhibitors: rivaroxaban, apixaban and, most recently, edoxaban. In this review article we present an overview of the evidence to support the use of NOACs for the prevention of SSE in patients with AF and HF and review the influence of HF subtype and co-morbidities on the potential choice of oral anticoagulant.
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Affiliation(s)
- Louise A E Brown
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, UK.
| | - Christopher J Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, UK; Dept of Postgraduate Medical Education, Bournemouth University, UK
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Cox AT, Ayalew Y, White S, Boos CJ, Haworth K, Ray S. Pericarditis and pericardial effusions in the military patient. J ROY ARMY MED CORPS 2015; 161:268-74. [PMID: 26251458 DOI: 10.1136/jramc-2015-000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/27/2015] [Indexed: 11/04/2022]
Abstract
The pericardium is the thin double-walled sac encapsulating the heart which has a number of important physiological roles including fixing the heart in the mediastinum, protecting it from cross-organ infection (eg, lung) and lubricating cardiac contraction. The pericardium is associated with several disease syndromes that occasionally affect the military population. These include acute and recurrent pericarditis, pericardial effusion and tamponade, which may result from a large number of different aetiological agents. Pericardial diseases have a wide range of clinical manifestations and the diagnosis of pericardial diseases can be a challenge. This article reviews the anatomy and pathophysiology of pericarditis and pericardial effusions before outlining their clinical features, recommended investigations and management options. Particular emphasis is placed on the impact of these diseases for patients in a military occupational environment.
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Affiliation(s)
- Andrew T Cox
- Royal Centre for Defence Medicine, Birmingham, UK St George's, University of London, London, UK
| | - Y Ayalew
- Royal Centre for Defence Medicine, Birmingham, UK
| | - S White
- Royal Centre for Defence Medicine, Birmingham, UK
| | - C J Boos
- Department of Cardiology, Poole Hospital NHS Trust, Dorset and Bournemouth University, Poole, UK
| | | | - S Ray
- University Hospital of South Manchester NHS Trust, Manchester, UK
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Abstract
Syncope is a relatively common occurrence in military populations. It is defined as a transient loss of consciousness due to global cerebral hypoperfusion, characterised by a rapid onset, short duration and a spontaneous and complete recovery. While the symptom of syncope is easily elicited, discovering the mechanism can be more problematic and may require a plethora of diagnostic tests. The aim of this paper is to review current evidence pertaining to the classification, investigation and management of syncope, from a military perspective. Emphasis is placed on assisting primary healthcare professionals in the assessment and management of syncope, in the UK and on operations, while providing explicit guidance on risk. The occupational limitations required in safely managing patients with syncope are stressed along with the potential long-term limitations.
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Affiliation(s)
- Iain T Parsons
- Department of Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK Defence Medical Services, Royal Centre for Defence Medicine, Lichfield, UK
| | - A T Cox
- Defence Medical Services, Royal Centre for Defence Medicine, Lichfield, UK Department of Cardiology, St George's Hospital NHS Trust, London, UK
| | - I A Mollan
- RAF Centre of Aviation Medicine, RAF Henlow, UK
| | - C J Boos
- Centre for Postgraduate Medical Education, Bournemouth University, Bournemouth, UK Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
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Cox AT, Boos CJ, Sharma S. The Hearts of Heroes: the epidemiology of cardiac disease in the UK Armed Forces. J ROY ARMY MED CORPS 2015; 161:169-72. [DOI: 10.1136/jramc-2015-000498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/27/2015] [Indexed: 01/16/2023]
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Lane DA, Boos CJ, Lip GYH. Atrial fibrillation (chronic). BMJ Clin Evid 2015; 2015:0217. [PMID: 25994013 PMCID: PMC4439734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Atrial fibrillation is a supraventricular tachyarrhythmia characterised by the presence of fast and uncoordinated atrial activation leading to reduced atrial mechanical function. Risk factors for atrial fibrillation include increasing age, male sex, co-existing cardiac and thyroid disease, pyrexial illness, electrolyte imbalance, cancer, and co-existing infection. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of oral medical treatments to control heart rate in people with chronic (defined as longer than 1 week for this review) non-valvular atrial fibrillation? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found four studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: beta-blockers (rate-limiting, with or without digoxin), calcium-channel blockers (with or without digoxin), and digoxin.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Mellor AJ, Boos CJ, Ball S, Burnett A, Pattman S, Redpath M, Woods DR. Copeptin and arginine vasopressin at high altitude: relationship to plasma osmolality and perceived exertion. Eur J Appl Physiol 2014; 115:91-8. [PMID: 25213006 DOI: 10.1007/s00421-014-2994-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/01/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE A diuresis is a key part of acclimatisation to high altitude (HA). Arginine vasopressin (AVP) is a hormone involved in salt and water balance and may potentially have a role in the development of altitude illness. ProAVP (copeptin) is more stable than AVP and is assayed by a straightforward, automated method. We investigated the relationship of AVP to copeptin and the copeptin response to exercise and altitude illness in a large cohort during a field study at HA. METHODS 48 subjects took part in a 10-day trek at HA. Venous blood samples were taken at 3,833, 4,450 and 5,129 m post-trek (exercise) and the following day at rest. Daily recordings of symptoms of altitude illness, oxygen saturations and perceived exertion were carried out. RESULTS AVP and copeptin levels increased with exercise and correlated closely (ρ 0.621 p < 0.001), this was strongest in the stressed state when AVP secretion was highest, at 5,129 m post-exercise (ρ 0.834 p < 0.001). On two-way ANOVA, both altitude (F = 3.5; p = 0.015) and exercise (F = 10.2; p = 0.002) influenced copeptin levels (interaction F = 2.2; p = 0.08). AVP levels were influenced by exercise (F = 14.4; p = 0.0002) but not altitude (F = 2.0; p = 0.12) with no overall group interactions (F = 1.92.6; p = 0.06). There was no association between copeptin or arginine vasopressin and altitude illness. Copeptin correlated with the Borg RPE score and was significantly higher in the group with a Borg score ≥15 (7.9 vs. 3.7 p < 0.001). CONCLUSION We have shown that arginine vasopressin and copeptin levels correlate and are suppressed below 5,129 m. Furthermore, we have demonstrated that exertion, rather than altitude illness or increasing osmolality, is the stimulus for increases in copeptin.
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Affiliation(s)
- A J Mellor
- Defence Medical Services, Lichfield, UK,
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and the most frequently encountered cause of embolic stroke. Vitamin K antagonists (such as warfarin) have represented the cornerstone of anticoagulation practice for the last 60 years. Although highly effective in preventing thromboembolic events among patients with atrial fibrillation, warfarin therapy is limited by a multitude of potential problems. Hence, warfarin is significantly underused in clinical practice, with only half of warfarin-treated patients actually achieving therapeutic anticoagulation in routine clinical practice. Consequently, there is an overwhelming need for an alternative oral anticoagulant for patients with atrial fibrillation that is safer, more practical and effective. Ximelagatran (Exanta, AstraZeneca) is a novel oral direct thrombin inhibitor that is rapidly converted to the active compound melagatran after oral absorption. It has a low potential for drug interactions, anticoagulation monitoring is not required, and it is administered at a fixed twice-daily dose. The Stroke Prevention using the ORal Thrombin Inhibitor in patients with nonvalvular atrial Fibrillation (SPORTIF) III and V trials have together demonstrated the noninferiority of ximelagatran relative to warfarin for the prevention of stroke and embolic events in atrial fibrillation. Unfortunately, initial optimism has been tempered by serious concerns over its safety data in view of its propensity to cause elevation in liver enzymes.
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Affiliation(s)
- Christopher J Boos
- City Hospital, Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, Birmingham B18 7QH, UK
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Claridge S, Chakrabarti A, Greaves K, Boos CJ. Successful use of Trastuzumab following cardiac resynchronisation therapy. Int J Cardiol 2013; 166:e33-4. [DOI: 10.1016/j.ijcard.2013.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
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Boos CJ, Hodkinson PD, Mellor A, Green NP, Bradley D, Greaves K, Woods DR. The Effects of Prolonged Acute Hypobaric Hypoxia on Novel Measures of Biventricular Performance. Echocardiography 2013; 30:534-41. [DOI: 10.1111/echo.12088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | - Adrian Mellor
- Consultant Anaesthetist; James Cook University Hospital; Middlesborough; United Kingdom
| | - Nick P. Green
- RAF Centre of Aviation Medicine; RAF Henlow; Beds; United Kingdom
| | - Daniel Bradley
- Cardiovascular Division; GE Healthcare; Herts; United Kingdom
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Boos CJ, Jamil Y, Park M, Moy W, Khanna V, Timperley AC, Sharma S. Electrocardiographic abnormalities in medically screened military aircrew. ACTA ACUST UNITED AC 2013; 83:1055-9. [PMID: 23156093 DOI: 10.3357/asem.3276.2012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) recently published its updated recommendations for electrocardiogram (ECG) interpretation in athletes. It distinguishes ECG changes related to physical training (group 1 abnormalities) from training-unrelated changes (group 2) which may represent underlying electrical and structural heart disorders implicated in exercise related sudden cardiac death. This study sought to prospectively apply the ESC screening criteria to a large cohort of screened military aircrew. METHODS This was a prospective observational study. The 12-lead ECGs of 868 consecutively evaluated healthy aircrew were analyzed for the presence of ESC-defined group 1 and 2 abnormalities. RESULTS The average age was 39.6 (11.2) yr (95.4% male). Overall, 402 (46.3%) of ECGs could be classified as entirely normal. However, 466 ECGs (53.7%) were abnormal. Group 1 abnormalities were identified in 400 (46.1%) persons with 66 (7.6%) persons classified as having group 2 abnormalities. The most commonly identified group 1 ECG changes were sinus bradycardia (32.5%), early repolarization (11.8%), and isolated voltage criteria of left ventricular hypertrophy (10.1%). The most commonly noted group 2 abnormalities were left-axis deviation/left anterior hemiblock (2.4%), T-wave inversion (1.6%), and ST-segment depression (1.3%). Prolongation of the QTC > 0.46 s was observed in 0.69% of ECGs. CONCLUSIONS The vast majority of ECGs performed in military aircrew could be classified as representing likely normal physiological changes. Training unrelated ECG changes, suggestive of possible genuine cardiac pathology, were observed in only a minority of persons who should be considered for further investigation.
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Affiliation(s)
- Christopher J Boos
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK.
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Lane DA, Apostolakis S, Boos CJ, Lip GYH. Atrial fibrillation (chronic). BMJ Clin Evid 2011; 2011:0217. [PMID: 22075545 PMCID: PMC3262479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Atrial fibrillation is a supraventricular tachyarrhythmia characterised by the presence of fast and uncoordinated atrial activation leading to reduced atrial mechanical function. Risk factors for atrial fibrillation include increasing age, male sex, co-existing cardiac and thyroid disease, pyrexial illness, electrolyte imbalance, cancer, and co-existing infection. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral medical treatments to control heart rate in people with chronic (defined as longer than 1 week for this review) non-valvular atrial fibrillation? What is the effect of different treatment strategies (rate versus rhythm) for people with persistent non-valvular atrial fibrillation? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: beta-blockers (with or without digoxin), calcium channel blockers (with or without digoxin), calcium channel blockers (rate-limiting), digoxin, and rate versus rhythm control strategies.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Boos CJ, Treveil I. Use of transoesophageal echocardiography during the peri-operative period for trauma patients: sprinting before we can walk or run! J ROY ARMY MED CORPS 2011; 157:255-256. [PMID: 21977719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Boos CJ, Sharma S. Commentary: Sudden cardiac death in the British military: should all service recruits undergo ECG screening? J ROY ARMY MED CORPS 2011; 157:187-190. [PMID: 21805773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- C J Boos
- MDHU Portsmouth, Cosham, Portsmouth, Hampshire.
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Abstract
Amiodarone is a highly effective and well-established antiarrrhythmic drug. It can be used to treat supraventricular and ventricular tachyarrhythmias and has the added advantage of being well tolerated in patients with impaired left ventricular systolic function with a low incidence of arrhythmic events, such as torsades de pointes. However, owing to its marked lipid affinity, it is highly concentrated in tissues and is linked to a number of adverse effects, including thyroid dysfunction. Amiodarone can lead to both hypothyroidism (amiodarone-induced hypothyroidism) and less commonly hyperthyroidism (amiodarone-induced thyrotoxicosis) and relates to high iodine content within the molecule as well as to several unique intrinsic properties of amiodarone. Dronedarone is a recently approved antiarrhythmic drug. It is structurally very similar to amiodarone, however the iodine moiety, present with amiodarone has been removed and replaced with a methylsulfonamide group to reduce fat solubility and adverse effects. We present an overview of the effects of amiodarone on thyroid function and the treatment options available, as well as a brief insight into dronedarone and its potential as an alternative to amiodarone.
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Affiliation(s)
| | - David R. Woods
- Northumbria and Newcastle NHS Trusts, Wansbeck General Hospital and Royal Victoria Infirmary, Honorary Clinical Senior Lecturer, University of Newcastle, UK
| | - Christopher J. Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB, UK
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Abstract
We describe the case of a 32-year-old soldier who presented with acute organic psychosis during an operational tour to Iraq. This was precipitated by excessive consumption of caffeine coupled with additional use of oral nutritional stimulants. Her biochemical profile was compounded by the additional use of exogenous creatine. We present a brief overview of the issue of exercise supplementation and highlight some of the potential problems and clinical issues surrounding their use. This has important implications for both serving soldiers and the wider medical community.
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Affiliation(s)
- C J Boos
- MDHU (Portsmouth), Queen Alexandra Hospital, Cosham PO6 3LY.
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Abstract
Pyogenic Spinal Infection (PSI) is an uncommon disorder encompassing a broad spectrum of diseases including septic spondylodiscitis, osteomyelitis, epidural and paravertebral abscess formation. Presentation can be vague and highly variable but usually includes back pain and fever. Whilst predisposing factors, such as trauma and diabetes can often be identified a pathogenic organism may not be identified in up to a half of all cases leading to significant delay in both accurate diagnosis and effective treatment. Precise spinal imaging is essential and includes plain X-ray, CT and preferably MRI. The treatment of PSI can be conservative (including antibiotics); however, spinal surgery may be required for the complications in up to 50% of cases, with varying degrees of success. We present a challenging case of PSI encountered in a locally-employed 42-year-old Bangladeshi civilian working in Iraq. Despite obvious resource limitations available within a Role 2 Field Hospital, clinical suspicion coupled with repeat spinal CT was pivotal in obtaining the diagnosis. The patient was repatriated to Bangladesh for MRI and definitive surgical treatment.
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Affiliation(s)
- S H White
- Royal Centre for Defence Medicine, Birmingham, and Hospital Squadron, UK Medical Group, Op Telic, BFPO 641
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Idriss NK, Lip GYH, Balakrishnan B, Jaumdally R, Boos CJ, Blann AD. Plasma haemoxygenase-1 in coronary artery disease. A comparison with angiogenin, matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1 and vascular endothelial growth factor. Thromb Haemost 2010; 104:1029-37. [PMID: 20838751 DOI: 10.1160/th09-11-0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 06/27/2010] [Indexed: 11/05/2022]
Abstract
It was the aim of this study to determine plasma haemoxygenase-1 (HO-1) across the spectrum of health, angina but normal coronary arteries (NCA), stable coronary artery disease (CAD), and acute coronary syndromes (ACS), and relationships with angiogenin, matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase-1, and vascular endothelial growth factor. Plasma markers were measured (ELISA) in peripheral venous citrated plasma from 50 healthy subjects, 30 with NCA, 70 with stable CAD and 24 with an ACS, and from patient's aortic root, coronary ostium, coronary sinus and femoral artery. Human umbilical vein endothelial cells (HUVECs) were cultured with or without tumour necrosis factor (TNF), and platelets were probed. HO-1 was raised in stable CAD (p<0.05) and increased further in ACS (p<0.01) compared to healthy controls and NCA. HO-1 correlated only with MMP-9, and then only in the healthy controls. There were no major differences from cardiac or peripheral sites. HO-1 was present in HUVECs and 24-hour HUVEC supernatants but release was abolished by TNF. Platelets had no HO-1. In conclusion, HO-1 is raised in stable CAD and ACS and may arise from the endothelium but not the platelet. This may have implications for our understanding of the pathophysiology of CAD and its acute presentation as ACS.
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Affiliation(s)
- Naglaa K Idriss
- Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre of Cardiovascular Sciences, City Hospital, Birmingham, UK
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Michaelides M, Kaines A, Hamilton RD, Fraser-Bell S, Rajendram R, Quhill F, Boos CJ, Xing W, Egan C, Peto T, Bunce C, Leslie RD, Hykin PG. A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study) 12-month data: report 2. Ophthalmology 2010; 117:1078-1086.e2. [PMID: 20416952 DOI: 10.1016/j.ophtha.2010.03.045] [Citation(s) in RCA: 358] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 03/15/2010] [Accepted: 03/18/2010] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To report the findings at 1 year of a study comparing repeated intravitreal bevacizumab (ivB) and modified Early Treatment of Diabetic Retinopathy Study (ETDRS) macular laser therapy (MLT) in patients with persistent clinically significant diabetic macular edema (CSME). DESIGN Prospective, randomized, masked, single-center, 2-year, 2-arm clinical trial. PARTICIPANTS A total of 80 eyes of 80 patients with center-involving CSME and at least 1 prior MLT. METHODS Subjects were randomized to either ivB (6 weekly; minimum of 3 injections and maximum of 9 injections in the first 12 months) or MLT (4 monthly; minimum of 1 treatment and maximum of 4 treatments in the first 12 months). MAIN OUTCOME MEASURES The primary end point was the difference in ETDRS best-corrected visual acuity (BCVA) at 12 months between the bevacizumab and laser arms. RESULTS The baseline mean ETDRS BCVA was 55.7+/-9.7 (range 34-69) in the bevacizumab group and 54.6+/-8.6 (range 36-68) in the laser arm. The mean ETDRS BCVA at 12 months was 61.3+/-10.4 (range 34-79) in the bevacizumab group and 50.0+/-16.6 (range 8-76) in the laser arm (P = 0.0006). Furthermore, the bevacizumab group gained a median of 8 ETDRS letters, whereas the laser group lost a median of 0.5 ETDRS letters (P = 0.0002). The odds of gaining > or =10 ETDRS letters over 12 months were 5.1 times greater in the bevacizumab group than in the laser group (adjusted odds ratio, 5.1; 95% confidence interval, 1.3-19.7; P = 0.019). At 12 months, central macular thickness decreased from 507+/-145 microm (range 281-900 microm) at baseline to 378+/-134 microm (range 167-699 microm) (P<0.001) in the ivB group, whereas it decreased to a lesser extent in the laser group, from 481+/-121 microm (range 279-844 microm) to 413+/-135 microm (range 170-708 microm) (P = 0.02). The median number of injections was 9 (interquartile range [IQR] 8-9) in the ivB group, and the median number of laser treatments was 3 (IQR 2-4) in the MLT group. CONCLUSIONS The study provides evidence to support the use of bevacizumab in patients with center-involving CSME without advanced macular ischemia.
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Affiliation(s)
- Michel Michaelides
- Department of Medical Retina, Moorfields Eye Hospital, London, United Kingdom.
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Boos CJ, Balakrishnan B, Blann AD, Lip GYH. The relationship of circulating endothelial cells to plasma indices of endothelial damage/dysfunction and apoptosis in acute coronary syndromes: implications for prognosis. J Thromb Haemost 2008; 6:1841-50. [PMID: 18761720 DOI: 10.1111/j.1538-7836.2008.03148.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND While coronary artery disease has been linked to both endothelial damage and cellular apoptosis, their inter-relationships and impact on cardiovascular (CV) outcomes has been barely explored. AIMS First, we investigated the inter-relationships between circulating endothelial cells (CECs, and index of endothelial damage) and circulating plasma markers of endothelial damage/dysfunction [von Willebrand factor (VWF), soluble E selectin (sEsel)] and apoptosis [soluble Fas (sFas), Fas ligand (sFasL) and their ratio, sFas/sFasL] in patients presenting with acute coronary syndrome (ACS). Second, we assessed their prognostic values for major adverse CV events (MACE) in ACS. METHODS We studied 211 patients with ACS, who were compared with 60 healthy controls (HC) and 45 'disease controls' (patients with stable coronary artery disease, CAD). Simultaneous blood samples for CECs (immunobead method), VWF, sESel, sFas and sFasL (ELISA) were taken within 24 h of presentation of ACS and at 48 h post admission. RESULTS CEC, sEsel and VWF levels were significantly higher among the ACS groups compared with the CAD and HC (P < 0.05) groups. sFas was higher (P = 0.016) and sFasL lower (P = 0.021) in ACS compared with controls (HC and CAD). There was a significant increase in sFas/sFasL ratio with increasing disease severity (P = 0.0004). There were significant correlations between CECs and both VWF and sEsel (both P < 0.01) but no correlations between CECs and either sFas or sFas ligand. On univariate survival analysis, CECs were associated with an increased risk of both MACE [hazard ratio (HR) 2.4 (95% CI 1.2-4.1); P = 0.009] and cardiovascular death [HR 2.95 (95% CI 1.01-8.81); P = 0.047]. On multivariate Cox regression analysis, only VWF (and not CECs) remained as an independent predictor of MACE [HR 1.02 (95% CI 1.005-1.040); P = 0.009]. CONCLUSION CECs were associated with abnormal plasma indices of endothelial damage/dysfunction and not apoptosis, despite abnormalities of all these markers being associated with ACS. VWF remained as an independent predictor of MACE, on multivariate analysis.
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Affiliation(s)
- C J Boos
- Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, UK
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Boos CJ, Lane DA, Lip GYH. Atrial fibrillation (chronic). BMJ Clin Evid 2008; 2008:0217. [PMID: 19450316 PMCID: PMC2907948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Atrial fibrillation is a supraventricular tachyarrhythmia, which is characterised by the presence of fast and uncoordinated atrial activation leading to reduced atrial mechanical function. Risk factors for atrial fibrillation include increasing age, coexisting cardiac and thyroid disease, pyrexial illness, electrolyte imbalance, cancer, and coexisting infection. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral medical treatments to control heart rate in people with chronic (defined as longer than 1 week for this review) non-valvular atrial fibrillation? What is the effect of different treatment strategies (rate vs. rhythm) for people with persistent non-valvular atrial fibrillation? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: beta-blockers (with or without digoxin), calcium channel blockers (with or without digoxin), calcium channel blockers (rate limiting), digoxin, and rate versus rhythm control strategies.
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