Effects of intravenous single-bolus lidocaine infusion versus intravenous single-bolus magnesium sulfate infusion on postoperative pain, emotional status, and quality of life in patients undergoing spine fusion surgery: a randomized study

BACKGROUND

We assessed the efficiency of intravenous adjuvants in decreasing opioid intake and pain scores after spine fusion surgery.

METHODS

This study included 120 patients aged 18-60 listed for spine fusion surgery under general anesthesia. Patients were randomly assigned to four groups: Group (Lidocaine): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min. Group (Magnesium): received IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (combined Lidocaine and Magnesium): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min.+IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (Control): received IV saline 50 mL. The time to the first request analgesia, the postoperative pain score, total analgesic use, patient satisfaction, anxiety, depression, mental state, quality of life, and side effects were measured.

RESULTS

The combined group had more extended time for the first analgesic request and fewer rescue analgesia doses than the other groups. NRS scores at rest or movement were statistically significantly lower in the lidocaine group and the combined group compared to the control group (P1, P3<0.05) at almost all times. This combination reduces anxiety and depression and improves overall health up to three months after a single infusion. The combined group had higher patient satisfaction.

CONCLUSIONS

A synergistic effect of a combination of lidocaine and magnesium sulfate on perioperative pain was found. It reduces analgesic consumption, depression, and anxiety and improves overall health up to three months after a single infusion dose.

Familial hypercholesterolemia: Detect, treat, and ask about family

Familial hypercholesterolemia is an autosomal dominant disorder that affects the metabolism of low-density lipo-protein cholesterol (LDL-C) through mutations in the gene for LDL receptor (LDLR), and less commonly in those for apolipoprotein B (APOB), proprotein convertase subtili-sin-kexin type 9 (PCSK9), and others. Patients with these mutations have elevated plasma levels of LDL-C and, as a result, an increased risk of atherosclerotic cardiovascular disease beginning in childhood, leading to significant risk of illness and death.

Visit-to-Visit Blood Pressure Variability, Coronary Atheroma Progression, and Clinical Outcomes

Importance

Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events, but mechanisms and therapeutic implications underlying this association are not well understood.

Objective

To examine the association of intraindividual BPV, coronary atheroma progression, and clinical outcomes using serial intravascular ultrasonography.

Design, Setting, and Participants

Post hoc patient-level analysis of 7 randomized clinical trials conducted from 2004 to 2016 involving 3912 patients in multicenter, international, clinic-based primary and tertiary care centers. Adult patients with coronary artery disease who underwent serial intravascular ultrasonography in the setting of a range of medical therapies were included. Data were analyzed between November 2017 and March 2019.

Exposures

Visit-to-visit BPV measured using intraindividual standard deviation over 3, 6, 12, 18, and 24 months.

Main Outcomes and Measures

Percent atheroma volume (PAV) progression and major adverse cardiovascular events (defined as death, myocardial infarction, stroke, urgent revascularization for acute coronary syndrome, and hospitalization for unstable angina).

Results

Of 3912 patients, the mean (SD) age was 58 (9) years, 1093 (28%) were women, and 3633 (93%) were white . Continuous change in PAV was significantly associated with systolic BPV (β, .049; 95% CI, 0.021-0.078; P = .001), diastolic BPV (β, .031; 95% CI, 0.002-0.059; P = .03), and pulse pressure variability (β, .036; 95% CI, 0.006-0.067; P = .02), without a signal for differential effect greater than or less than a mean BP of 140/90 mm Hg. The PAV progression as a binary outcome was significantly associated with systolic BPV (odds ratio, 1.09; 95% CI, 1.01-1.17; P = .02) but not diastolic BPV (odds ratio, 1.04; 95% CI, 0.97-1.11; P = .30) or pulse pressure variability (odds ratio, 1.03; 95% CI, 0.96-1.10; P = .47). Survival curves revealed a significant stepwise association between cumulative major adverse cardiovascular events and increasing quartiles of systolic BPV (Kaplan-Meier estimates for quartiles 1-4: 6.1% vs 8.5% vs 10.1% vs 12.0%, respectively; log-rank P <.001). These distinct stepwise associations were not seen with diastolic BPV or pulse pressure variability.

Conclusions and Relevance

Greater BPV, particularly systolic BPV, is significantly associated with coronary atheroma progression and adverse clinical outcomes. These data suggest maintaining stable blood pressure levels may be important to further improve outcomes in patients with coronary disease.

Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity, mortality, and healthcare use. Great strides have been made in stroke prevention and rhythm control strategies, yet reducing the incidence of AF has been slowed by the increasing incidence and prevalence of AF risk factors, including obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, and other modifiable lifestyle-related factors. Fortunately, many of these AF drivers are potentially reversible, and emerging evidence supports that addressing these modifiable risks may be effective for primary and secondary AF prevention. A structured, protocol-driven multidisciplinary approach to integrate lifestyle and risk factor management as an integral part of AF management may help in the prevention and treatment of AF. However, this aspect of AF management is currently underrecognized, underused, and understudied. The purpose of this American Heart Association scientific statement is to review the association of modifiable risk factors with AF and the effects of risk factor intervention. Implementation strategies, care pathways, and educational links for achieving impactful weight reduction, increased physical activity, and risk factor modification are included. Implications for clinical practice, gaps in knowledge, and future directions for the research community are highlighted.

Cardioprotective anti-hyperglycaemic medications: a review of clinical trials

Despite extensive clinical efforts to achieve stricter glycaemic control over the past few decades, cardiovascular (CV) disease remains the leading cause of death among diabetic patients. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor (GLP-1-R) agonists have gained attention due to their apparent effects in reducing CV mortality. Four CV randomized controlled trials: EMPA-REG, CANVAS, LEADER, and SUSTAIN-6, found a decrease in CV events among patients with type 2 diabetes on empagliflozin, canagliflozin, liraglutide, and semaglutide, respectively. In light of this data, the US Food and Drug Administration has recently approved empagliflozin for CV mortality reduction in type 2 diabetic patients, making it the first diabetes medication approved for such an indication. The purpose of this review is to summarize the results of novel anti-hyperglycaemic medication trials, and shed light on their mode of action and cardioprotective pathways.

Association of Maternal Lactation With Diabetes and Hypertension: A Systematic Review and Meta-analysis

IMPORTANCE

Lactation has been shown to be associated with lower rates of diabetes and hypertension in mothers. However, the strength of association has varied between studies, and sample sizes are relatively small.

OBJECTIVE

To conduct a systematic review and meta-analysis to determine whether lactation is associated with a lower risk of diabetes and hypertension.

DATA SOURCES

Ovid MEDLINE, Ovid Embase, Cochrane CENTRAL, and CINAHL databases were searched from inception to July 2018 with manual search of the references.

STUDY SELECTION

Studies of adult women that specified duration of breastfeeding for at least 12 months, evaluated primary hypertension and diabetes as outcomes, were full-text articles in English, and reported statistical outcomes as odds ratios were included.

DATA EXTRACTION AND SYNTHESIS

Study characteristics were independently extracted using a standard spreadsheet template and the data were pooled using the random-effects model. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline for reporting was followed.

MAIN OUTCOMES AND MEASURES

Diabetes and hypertension.

RESULTS

The search yielded 1558 articles, from which a total of 6 studies met inclusion criteria for association between breastfeeding and diabetes and/or hypertension. The 4 studies included in the meta-analysis for the association between lactation and diabetes had a total of 206 204 participants, and the 5 studies included in the meta-analysis for the association between lactation and hypertension had a total of 255 271 participants. Breastfeeding for more than 12 months was associated with a relative risk reduction of 30% for diabetes (pooled odds ratio, 0.70 [95% CI, 0.62-0.78]; P < .001) and a relative risk reduction of 13% for hypertension (pooled odds ratio, 0.87 [95% CI, 0.78-0.97]; P = .01).

CONCLUSIONS AND RELEVANCE

This study suggests that education about the benefits of breastfeeding for prevention of diabetes and hypertension in women is a low-risk intervention that can be easily included in daily practice and may have a positive impact on cardiovascular outcomes in mothers.

ST-segment changes during tilt table testing for postural tachycardia syndrome: correlation with exercise stress test results

BACKGROUND

Prior studies have reported ECG (Electrocardiogram) changes during tilt table testing (TTT), specifically during repolarization with ST-segment and T-wave changes. The correlation with ischemic evaluation remains unclear. The purpose of this study was to analyze the prevalence of ST-segment changes during TTT in a young, otherwise healthy population of patients with postural tachycardia syndrome (POTS), and correlate them with exercise stress test results.

METHODS

Two hundred and fifty-five patients with POTS who underwent TTT and an exercise treadmill test (ETT) were analyzed.

RESULTS

Forty-five had ST-segment changes/depressions during TTT (91% female, average age 36 years). Of the 45, three had ST-segment depression during ETT; all three had negative exercise stress echocardiograms (ESEs). Two others had ST-segment depressions on ETT (but not TTT), with negative ESEs.

CONCLUSION

In a cohort of young, female, otherwise healthy patients with POTS, ST-segment changes occurred in a significant portion (18%) of patients during TTT. When evaluated with exercise stress testing, these patients had no evidence of underlying ischemia on ETT or ESE.

Temporal trends, ethnic determinants, and short-term and long-term risk of cardiac death in cancer patients: a cohort study

BACKGROUND

We evaluated the risk of cardiac death in patients with prior cancer diagnoses and compared risk by cancer type and ethnicity in a large US population.

METHOD

Utilizing the Surveillance, Epidemiology, and End Results database, data on patients with a cancer diagnosis between 2000 and 2014 were obtained. We calculated the standardized mortality ratio (SMR) of cardiac death after a cancer diagnosis and the excess risk per 10,000 person-years. We stratified the analysis according to the time interval between cancer and cardiac events, cancer site, cancer stage, and race.

RESULTS

A total of 4,671,989 patients with a cancer diagnosis were included, of which 163,255 died due to cardiac causes within 10 years of diagnosis. We found a significantly higher rate of cardiac death for cancer patients [SMR=1.16, 95% confidence interval (CI) 1.15-1.16] compared to the general population. When observed for each cancer site, the highest SMR was after a diagnosis of hepatocellular carcinoma (SMR=2.58, 95% CI 2.45-2.72), pancreatic cancer (SMR=2.36, 95% CI 2.25-2.47), and lung cancer (SMR=2.30, 95% CI 2.27-2.34). Patients with metastatic disease had a higher rate of cardiac death (SMR=2.16, 95% CI 2.13-2.19). When stratified by ethnicity, SMR for cardiac death was 1.76, 2.28, 3.68, 2.65, and 1.84 for whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics, respectively.

CONCLUSIONS

Cancer patients are more vulnerable to cardiac death than the general population, especially those with nonwhite ethnicity; liver, lung, and pancreatic cancers; and history of metastasis. Healthcare providers should be aware of this risk and pay particular attention to the highest-risk groups.

Use of Sex-Specific Clinical and Exercise Risk Scores to Identify Patients at Increased Risk for All-Cause Mortality

Importance

Risk assessment tools for exercise treadmill testing may have limited external validity. Cardiovascular mortality has decreased in recent decades, and women have been underrepresented in prior cohorts.

Objectives

To determine whether exercise and clinical variables are associated with differential mortality outcomes in men and women and to assess whether sex-specific risk scores better estimate all-cause mortality.

Design, Setting, and Participants

This retrospective cohort study included 59 877 patients seen at the Cleveland Clinic Foundation (CCF cohort) from January 1, 2000, through December 31, 2010, and 49 278 patients seen at the Henry Ford Hospital (FIT cohort) from January 1, 1991, through December 31, 2009. All patients were 18 years or older and underwent exercise treadmill testing. Data were analyzed from January 1, 2000, to October 27, 2011, in the CCF cohort and from January 1, 1991, to April 1, 2013, in the FIT cohort.

Main Outcomes and Measurements

The CCF cohort was divided randomly into derivation and validation samples, and separate risk scores were developed for men and women. Net reclassification, C statistics, and integrated discrimination improvement were used to compare the sex-specific risk scores with other tools that have all-cause mortality as the outcome. Discrimination and calibration were also evaluated with these sex-specific risk scores in the FIT cohort.

Results

The CCF cohort included 59 877 patients (59.4% men; 40.5% women) with a median (interquartile range [IQR]) age of 54 (45-63) years and 2521 deaths (4.2%) during a median follow-up of 7 (IQR, 4.1-9.6) years. The FIT cohort included 49 278 patients (52.5% men; 47.4% women) with a median (IQR) age of 54 (46-64) years and 6643 deaths (13.5%) during a median (IQR) follow-up of 10.2 (7-13.4) years. C statistics for the sex-specific risk scores in the CCF validation sample were higher (0.79 in women and 0.81 in men) than C statistics using other tools in women (0.70 for Duke Treadmill Score; 0.74 for Lauer nomogram) and men (0.72 for Duke Treadmill Score; 0.75 for Lauer nomogram). Net reclassification and integrated discrimination improvement were superior with the sex-specific risk scores, mostly owing to correct reclassification of events. The sex-specific risk scores in the FIT cohort demonstrated similar discrimination (C statistic, 0.78 for women and 0.79 for men), and calibration was reasonable.

Conclusions and Relevance

Sex-specific risk scores better estimate mortality in patients undergoing exercise treadmill testing. In particular, these sex-specific risk scores help to identify patients at the highest residual risk in the present era.

Correction: Hypertension guidelines

In Aleyadeh W, Hutt-Centeno E, Ahmed HM, Shah NP. Hypertension guidelines: treat patients, not numbers. Cleve Clin J Med 2019; 86(1):47-56. doi:10.3949/ccjm.86a.18027, on page 50, the following statement was incorrect: "In 2017, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) recommended a relaxed systolic blood pressure target, ie, below 150 mm Hg, for adults over age 60, but a tighter goal of less than 130 mm Hg for the same age group if they have transient ischemic attack, stroke, or high cardiovascular risk.⁹" In fact, the ACP and AAFP recommended a tighter goal of less than 140 mm Hg for this higher-risk group. This has been corrected online.

Hypertension guidelines: Treat patients, not numbers

The updated 2017 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for managing hypertension advocate tighter blood pressure control than previous guidelines. This review summarizes the evidence behind the guidelines, discusses the risks and benefits of stricter blood pressure control, and provides our insights on blood pressure management in clinical practice.

Predictors of cardiorespiratory fitness improvement in phase II cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) improves cardiorespiratory fitness (CRF) and has been shown to reduce cardiovascular events and death. However, data about predictors of fitness improvement during CR are limited and conflicting. The objective of this study was to determine predictors of improvement in metabolic equivalents of task (METs) based on formal exercise testing throughout phase II CR.

METHODS

We retrospectively reviewed 20 671 patients enrolled in phase II CR at our center from 2006 to 2016. Patients who completed 36 sessions and had entry and exit exercise stress tests were included for study. The short form-36 (SF-36) questionnaire was used to assess quality-of-life. Univariate and multivariate regression analyses were performed to determine independent predictors of METs improvement.

RESULTS

Of the full cohort, 827 patients completed 36 sessions and had entry/exit stress test data. The majority of patients (N = 647, 78.2%) had improvement in METs (mean Δ 2.0 ± 1.2 METs), including patients ≥65 and < 65 years old (77% vs 79%, P = 0.46 for difference). METs improvement was negatively associated with body mass index, diabetes, left ventricular dysfunction, and poor baseline fitness; and positively associated with SF-36 score (P < 0.05 for all). After multivariable adjustment, improvement was no longer affected by age, ejection fraction, or baseline fitness. Patients with poor fitness (≤5 METS) and adequate fitness (> 5 METS) both had improvement, with no statistical difference between the groups (P = 0.36).

CONCLUSIONS

In a large cohort of phase II CR patients, improvement in CRF was seen in the majority of patients across all ages, genders, and levels of baseline fitness.

Abstract 4242: Ethnic disparities in the risk of cardiac death following cancer diagnosis: A population-based study

Background: Cancer-related cardiac complications and mortality have been well studied. However, the disparities among racial and ethnic groups have not been addressed on a large scale. In this study, we aimed to investigate the racial and ethnic disparities associated with cardiac death in cancer patients.

Methods: Data were collected from The Surveillance, Epidemiology and End-Results program of the National Cancer Institute. We defined an "event" as death due to a cardiac cause within ten years after cancer diagnosis, and observed patients who experienced the event during that period. Then, we calculated the Observed/Expected (O/E) ratio and the excess risk per 10,000 person-years to estimate the change of risk following the diagnosis in different ethnicities, when compared to the general population.

Results: We reviewed 4,671,989 cancer patients, of whom 163,255 died due to a cardiac cause within the ten years following cancer diagnosis. The overall risk of cardiac death increased significantly in this period with an O/E ratio of 1.16 and an excess risk of 11.66 per 10,000. The sample was divided into 2 groups: Whites with a total O/E ratio of 1.11, and non-Whites with a total O/E ratio of 1.38. When examined for the risk in the first 5 years after diagnosis, Whites and non-Whites demonstrated significant increase in the risk with O/E of 1.12 and 1.39, respectively. However, when examined for the long-term risk more than 5 years after diagnosis, only non-Whites had a significant increase with an O/E of 1.21, while Whites with a cancer diagnosis had the same risk of cardiac death as Whites without cancer diagnosis with an O/E of 1.00. The sample was then further subdivided according to ethnicity into non-Hispanic Whites, Blacks, American Indians (or Alaska natives), Asians (or Pacific islanders), and Hispanics. All groups showed a significantly increased risk of cardiac death following a cancer diagnosis (O/E=1.13, 1.36, 2.33, 1.44, and 1.05, respectively).

Conclusion: Non-White patients with a prior cancer diagnosis had a significantly higher long-term risk of cardiac death compared to noncancer patients. Accordingly, careful attention should be paid to the cardiovascular status assessment of those patients to mitigate the added risk of cardiac mortality due to cancer-related morbidities. Further studies are warranted to determine why cardiac event risk increases at a discrepantly higher rate in minority patients with a cancer diagnosis.

Citation Format: Mohamed M. Gad, Anas M. Saad, Muneer J. Al-Husseini, Abdelrahman I. Abushouk, Haitham M. Ahmed. Ethnic disparities in the risk of cardiac death following cancer diagnosis: A population-based study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4242.

Six-Year Changes in Physical Activity and the Risk of Incident Heart Failure: ARIC Study

BACKGROUND

Higher physical activity (PA) is associated with lower heart failure (HF) risk; however, the effect of changes in PA on HF risk is unknown.

METHODS

We evaluated 11 351 ARIC study (Atherosclerosis Risk in Communities) participants (mean age 60 years) who attended visit 3 (1993-1995) and did not have a history of cardiovascular disease. Exercise PA was assessed using a modified Baecke questionnaire and categorized according to American Heart Association guidelines as recommended, intermediate, or poor. We used Cox regression models to characterize the association of 6-year changes in PA between the first (1987-1989) and third ARIC visits and HF risk.

RESULTS

During a median of 19 years of follow-up, 1750 HF events occurred. Compared with those with poor activity at both visits, the lowest HF risk was seen for those with persistently recommended activity (hazard ratio, 0.69; 95% confidence interval, 0.60-0.80). However, those whose PA increased from poor to recommended also had reduced HF risk (hazard ratio, 0.77; 95% confidence interval 0.63-0.93). Among participants with poor baseline activity, each 1 SD higher PA at 6 years (512.5 METS*minutes/week, corresponding to ≈30 minutes of brisk walking 4 times per week) was associated with significantly lower future HF risk (hazard ratio, 0.89, 95% confidence interval, 0.82-0.96).

CONCLUSIONS

Although maintaining recommended activity levels is associated with the lowest HF risk, initiating and increasing PA, even in late middle age, are also linked to lower HF risk. Augmenting PA may be an important component of strategies to prevent HF.

Using Machine Learning to Define the Association between Cardiorespiratory Fitness and All-Cause Mortality (from the Henry Ford Exercise Testing Project)

Previous studies have demonstrated that cardiorespiratory fitness is a strong marker of cardiovascular health. Machine learning (ML) can enhance the prediction of outcomes through classification techniques that classify the data into predetermined categories. The aim of the analysis is to compare the prediction of 10 years of all-cause mortality (ACM) using statistical logistic regression (LR) and ML approaches in a cohort of patients who underwent exercise stress testing. We included 34,212 patients (55% males, mean age 54 ± 13 years) free of coronary artery disease or heart failure who underwent exercise treadmill stress testing between 1991 and 2009 and had complete 10-year follow-up. The primary outcome of this analysis was ACM at 10 years. The probability of 10-years ACM was calculated using statistical LR and ML, and the accuracy of these methods was calculated and compared. A total of 3,921 patients died at 10 years. Using statistical LR, the sensitivity to predict ACM was 44.9% (95% confidence interval [CI] 43.3% to 46.5%), whereas the specificity was 93.4% (95% CI 93.1% to 93.7%). The sensitivity of ML to predict ACM was 87.4% (95% CI 86.3% to 88.4%), whereas the specificity was 97.2% (95% CI 97.0% to 97.4%). The ML approach was associated with improved model discrimination (area under the curve for ML [0.923 (95% CI 0.917 to 0.928)]) compared with statistical LR (0.836 [95% CI 0.829 to 0.846], p<0.0001). In conclusion, our analysis demonstrates that ML provides better accuracy and discrimination of the prediction of ACM among patients undergoing stress testing.

Usefulness of Coronary Artery Calcium to Predict Heart Failure With Preserved Ejection Fraction in Men Versus Women (from the Multi-Ethnic Study of Atherosclerosis)

We studied the association of coronary artery calcium (CAC) and risk of heart failure with preserved ejection fraction (HFpEF) among men and women in a multiethnic cohort. Coronary artery disease is a risk factor for development of HFpEF and assessment of subclinical atherosclerosis using CAC may allow for the early identification of patients at risk for HFpEF. We used data from the Multi-Ethnic Study of Atherosclerosis. CAC was measured at baseline in all participants. Incident HFpEF was defined as heart failure hospitalization with left ventricular ejection fraction ≥50%. Multivariable-adjusted Cox proportional hazards models were used to calculate HFpEF risk by CAC categories (0, 1 to 100, 101 to 300, and >300) and by CAC (continuous), stratified by gender and race/ethnicity. Of 6809 total participants, 127 incident HFpEF cases (1.8%) were ascertained. Mean age was 62 years (±10 years), and the participants were 53% female, 38% White, and 12% Black. In adjusted analysis, CAC >300 was associated with increased risk of HFpEF (hazard ratio [HR] 1.68, 95% confidence interval [95 CI] 1.00, 1.83); however, this was significant only in women (HR 2.82, 95% CI 1.32, 6.00 vs HR 0.91, 95% CI 0.46, 1.82 for men, interaction p = 0.03). Similarly, CAC modeled as a continuous variable was strongly predictive in women but not in men. In conclusion, measurement of CAC, a marker of coronary atherosclerosis, may stratify risk of HFpEF beyond traditional risk factors for women. Further investigation is needed to better understand potential gender differences in pathophysiology and presentation of HFpEF.

Feasibility of a Facebook Intervention for Exercise Motivation and Cardiac Rehabilitation Adherence: Study Protocol

Background

While cardiac rehabilitation has been shown to be effective at improving coronary heart disease (CHD), participation is generally poor. Attempts to increase uptake and adherence often fail. Use of a Facebook intervention for this population may be a unique opportunity to support self-determined motivation and affect adherence.

Objective

To evaluate the impact of a Facebook intervention on motivation for exercise and adherence to cardiac rehabilitation in patients with CHD during a 12-week, Phase II cardiac rehabilitation program.

Methods

A prospective, randomized controlled pilot study, grounded in Self-Determination Theory, will be conducted. Participants will be recruited from inpatient, or the intake visit to outpatient, cardiac rehabilitation, and then randomly assigned to the intervention or comparison group. Participants in the intervention group will take part in a private Facebook group. Weekly posts will be designed to support self-determined motivation, measured at baseline and postcardiac rehabilitation by the Behavioral Regulation in Exercise Questionnaire-3 (BREQ-3). The Psychological Need Satisfaction for Exercise (PNSE) scale will measure fulfillment of needs that affect motivation. Participants in the comparison group will be given the same materials, but these will be supplied via handouts and email. The number of sessions attended will be tallied and analyzed using t tests. Overall motivation will be evaluated using analysis of covariance (ANCOVA) models. Multivariate analysis of variance models will be used to evaluate differences in the change across motivation subtypes. If significant, ANCOVA models for each subtype will be fit. ANCOVA models will be used to compare changes in needs satisfaction, overall and separately among the three subscales, between groups. Engagement in the Facebook group will be measured by number of “likes” and self-report of weekly visits to the group.

Results

This project was funded in July 2017 and recruitment is currently underway. The recruitment goal is 60 cardiac rehabilitation patients. Data collection is anticipated to be complete by July 2018.

Conclusions

This pilot study will be the first to examine the effect of a Facebook intervention on patient adherence and motivation for exercise in a cardiac rehabilitation setting. Engagement in the Facebook group and participation in the study will help to determine the feasibility of using Facebook to affect adherence and motivation in cardiac rehabilitation patients, potentially improving outcomes through the use of a unique intervention.

Trial Registration

ClinicalTrials.gov NCT02971813; https://clinicaltrials.gov/ct2/show/NCT02971813 (Archived by WebCite at http://www.webcitation.org/6sRsz8Zpa)

Novel Risk Stratification Assays for Acute Coronary Syndrome

PURPOSE OF REVIEW

Since identification of aspartate aminotransferase as the first cardiac biomarker in the 1950s, there have been a number of new markers used for myocardial damage detection over the decades. There have also been several generations of troponin assays, each with progressively increasing sensitivity for troponin detection. Accordingly, the "standard of care" for myocardial damage detection continues to change. The purpose of this paper is to review the clinical utility, biological mechanisms, and predictive value of these various biomarkers in contemporary clinical studies.

RECENT FINDINGS

As of this writing, a fifth "next" generation troponin assay has now been cleared by the US Food and Drug Administration for clinical use in the USA for subjects presenting with suspected acute coronary syndromes. Use of these high-sensitivity assays has allowed for earlier detection of myocardial damage as well as greater negative predictive value for infarction after only one or two serial measurements. Recent algorithms utilizing these assays have allowed for more rapid rule-out of myocardial infarction in emergency department settings. In this review, we discuss novel assays available for the risk assessment of subjects presenting with chest pain, including both the "next generation" cardiac troponin assays as well as other novel biomarkers. We review the biological mechanisms for these markers, and explore the positive and negative predictive value of the assays in clinical studies, where reported. We also discuss the potential use of these new markers within the context of future clinical care in the modern era of higher sensitivity troponin testing. Finally, we discuss advances in new platforms (e.g., mass spectrometry) that historically have not been considered for rapid in vitro diagnostic capabilities, but that are taking a larger role in clinical diagnostics, and whose prognostic value and power promise to usher in new markers with potential for future clinical utility in acute coronary syndrome.

Joint effects of objectively-measured sedentary time and physical activity on all-cause mortality

OBJECTIVE

Examine the joint effects of objectively-measured sedentary time and moderate-to-vigorous physical activity (MVPA) on all-cause mortality.

METHODS

The present study included data from the 2003-2006 National Health & Nutrition Examination Survey, with mortality follow-up data (via National Death Index) through 2011 (N=5575U.S. adults). Sedentary time (activity counts/min between 0 and 99) and MVPA (activity counts/min ≥2020) were objectively measured using the ActiGraph 7164 accelerometer.

RESULTS

The median age of the participants was 50yrs; proportion of men was 50.2%; proportion of whites was 53.8%, 18.7% for blacks; median follow-up was 81months; and 511 deaths occurred over the follow-up period. After adjusting for age, gender, race-ethnicity, cotinine, weight status, poverty level, C-reactive protein and comorbid illness (summed score of 0-8 chronic diseases), and for a 1min increase in MVPA and sedentary time, both MVPA (HRadjusted=0.98; 95% CI: 0.96-0.99; P=0.04) and sedentary time (HRadjusted=1.001; 95% CI: 1.0003-1.002; P=0.008) were independently associated with all-cause mortality. Further, MVPA was associated with all-cause mortality among those with greater (above median) sedentary time (HRadjusted=0.95; 95% CI: 0.93-0.97; P<.001). Sedentary time was not associated with all-cause mortality among those engaging in above median levels of MVPA (HRadjusted=0.998; 95% CI: 0.996-1.001; P=.32), but sedentary time was associated with increased mortality risk among those below median levels of MVPA (HR=1.002; 95% CI: 1.001-1.003; P<0.001).

CONCLUSIONS

Sedentary time and MVPA are independently associated with all-cause mortality. Above median sedentary time levels did not negate the beneficial effects of MVPA on all-cause mortality risk.

Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure

BACKGROUND

About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy.

METHODS

We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined.

RESULTS

Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007).

CONCLUSIONS

Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

The association of ideal cardiovascular health with incident type 2 diabetes mellitus: the Multi-Ethnic Study of Atherosclerosis

AIMS/HYPOTHESIS

Levels of ideal cardiovascular health (ICH) and incident type 2 diabetes mellitus have not been examined in a multiethnic population. We assessed the total and race/ethnicity-specific incidence of diabetes based on American Heart Association (AHA) ICH components.

METHODS

Incident diabetes was assessed among 5341 participants in the Multi-Ethnic Study of Atherosclerosis without prevalent diabetes between 2002 and 2012. ICH components (total cholesterol, BP, dietary intake, tobacco use, physical activity and BMI) were assessed at baseline and participants were categorised as having ideal, intermediate or poor cardiovascular health, as defined by the AHA 2020 impact goals. We developed a scoring system based on the number of ICH components (0-1 'poor', 2-3 'intermediate', and ≥4 'ideal'). HRs were calculated using Cox models.

RESULTS

During a median follow-up of 11.1 years, we identified 587 cases of incident diabetes. After multivariable adjustment, participants with 2-3 and ≥4 ICH components vs 0-1 components had a 34% lower (HR 0.66; 95% CI 0.54, 0.80) and a 75% lower (HR 0.25; 95% CI 0.18, 0.35) diabetes incidence, respectively. There were significant differences by race/ethnicity: African-American and Hispanic-American participants with ≥4 ICH components had diabetes incidence rates per 1000 person-years of 5.6 (95% CI 3.1, 10.1) and 10.5 (95% CI 6.7, 16.4), respectively, compared with 2.2 (95% CI 1.3, 3.7) among non-Hispanic white Americans.

CONCLUSIONS/INTERPRETATION

Meeting an increasing number of AHA 2020 impact goals for dietary intake, physical activity, smoking, BP, cholesterol and BMI was associated with a dose-dependent lower risk of diabetes with significant variation by race/ethnicity.

Primary Low Level of High-Density Lipoprotein Cholesterol and Risks of Coronary Heart Disease, Cardiovascular Disease, and Death: Results From the Multi-Ethnic Study of Atherosclerosis

Prior studies observing associations between low levels of high-density lipoprotein (HDL) cholesterol and cardiovascular disease (CVD) have often been conducted among persons with metabolic or other lipid abnormalities. In this study, we investigated the association between primary low HDL cholesterol and coronary heart disease (CHD), CVD, and all-cause death after adjustment for confounders in the Multi-Ethnic Study of Atherosclerosis (MESA). Participants who were free of clinical CVD were recruited from 6 US research centers from 2000 to 2002 and followed for a median duration of 10.2 years. We defined "primary low HDL cholesterol" as HDL cholesterol level <40 mg/dL (men) or <50 mg/dL (women), triglyceride level <100 mg/dL, and low-density lipoprotein cholesterol level <100 mg/dL (n = 158). We defined an "optimal" lipid profile as HDL cholesterol ≥40 mg/dL (men) or ≥50 mg/dL (women) and triglycerides and low-density lipoprotein cholesterol <100 mg/dL (n = 780). For participants with primary low HDL cholesterol versus those with an optimal lipid profile, adjusted hazard ratios for total CHD, CVD, and death were 2.25 (95% confidence interval (CI): 1.20, 4.21; P = 0.011), 1.93 (95% CI: 1.11, 3.34; P = 0.020), and 1.11 (95% CI: 0.67, 1.84; P = 0.69), respectively. Participants with primary low HDL cholesterol had higher risks of CHD and CVD than participants with optimal lipid profiles but no difference in survival after a median 10.2 years of follow-up.

Sex and Race-Ethnicity Secular Trends in Mean and Elevated Red Blood Cell Distribution Width Among Adults in the United States, 1999-2012

OBJECTIVE

Red blood cell distribution width (RDW) has been shown to associate with increased risk of cardiovascular and non-cardiovascular death. To our knowledge, no study has examined secular trends in RDW over the last decade.

DESIGN

Serial cross-sectional design.

SETTING

Data from the National Health and Nutrition Examination Survey (NHANES), 1999-2012, were used.

PATIENTS

34,171 adults.

MAIN OUTCOME MEASURES

RDW was assessed from a blood sample derived from the coefficient of variation of the red cell volume distribution histogram and reported as a percent. Elevated RDW was defined as an RDW > 14.6%.

RESULTS

The overall age-adjusted mean RDW increased progressively and significantly (P<.05) from 12.59% in 1999-2000 to 12.89% in 2011-2012. The overall age-adjusted prevalence of elevated RDW increased progressively and significantly (P<.05) from 4.01% in 1999-2000 to 6.25% in 2011-2012. Statistically significant increases over this time period also occurred among non-Hispanic White women, non-Hispanic Black men and women, and Mexican American men and women. Across all sex and race-ethnicity combinations, women, compared with men, had higher RDW and larger increases over time in mean and elevated RDW.

CONCLUSIONS

Mean and elevated RDW has progressively increased from 1999-2012 among adults in the United States, with increases observed among non-Hispanic Whites, Blacks, and Mexican Americans. Future research is needed to describe the determinants and implications of this RDW rise, as well as explanations for why a greater RDW change has occurred among women.

Maximal exercise testing variables and 10-year survival: fitness risk score derivation from the FIT Project

OBJECTIVE

To determine which routinely collected exercise test variables most strongly correlate with survival and to derive a fitness risk score that can be used to predict 10-year survival.

PATIENTS AND METHODS

This was a retrospective cohort study of 58,020 adults aged 18 to 96 years who were free of established heart disease and were referred for an exercise stress test from January 1, 1991, through May 31, 2009. Demographic, clinical, exercise, and mortality data were collected on all patients as part of the Henry Ford ExercIse Testing (FIT) Project. Cox proportional hazards models were used to identify exercise test variables most predictive of survival. A "FIT Treadmill Score" was then derived from the β coefficients of the model with the highest survival discrimination.

RESULTS

The median age of the 58,020 participants was 53 years (interquartile range, 45-62 years), and 28,201 (49%) were female. Over a median of 10 years (interquartile range, 8-14 years), 6456 patients (11%) died. After age and sex, peak metabolic equivalents of task and percentage of maximum predicted heart rate achieved were most highly predictive of survival (P<.001). Subsequent addition of baseline blood pressure and heart rate, change in vital signs, double product, and risk factor data did not further improve survival discrimination. The FIT Treadmill Score, calculated as [percentage of maximum predicted heart rate + 12(metabolic equivalents of task) - 4(age) + 43 if female], ranged from -200 to 200 across the cohort, was near normally distributed, and was found to be highly predictive of 10-year survival (Harrell C statistic, 0.811).

CONCLUSION

The FIT Treadmill Score is easily attainable from any standard exercise test and translates basic treadmill performance measures into a fitness-related mortality risk score. The FIT Treadmill Score should be validated in external populations.

Structural, molecular orbital and optical characterizations of binuclear mixed ligand copper (II) complex of phthalate with N,N,N',N'-tetramethylethylenediamine and its applications

A new binuclear mixed ligand complex, [Cu2(Phth)(Me4en)2(H2O)2(NO3)2]·H2O (where, Phth=phthalate, and (Me4en)=N,N,N',N'tetramethylethylenediamine) was synthesized and characterized using analytical, spectral, magnetic, molar conductance, thermal gravimetric analysis (TGA), X-ray diffraction (XRD) and transmission electron microscope (TEM) measurements. The XRD data of Cu(II)-complex was analyzed on the basis of Williamson-Hall (W-H) and compared with TEM results. The results indicate that the complex is well crystalline and correspond to hexagonal crystal structure. Analysis of the absorption coefficient near the absorption edge reveals that the optical band gaps are indirect allowed transition with values of 1.17 and 1.78 eV. The d-d absorption bands of the complex (dissolved in various solvents) exhibit a color changes (solvatochromic). Specific and non-specific interactions of solvent molecules with the complex were investigated using Multiple Linear Regression Analysis (MLRA). Transient photocurrent characteristics of Cu(II)-complex/n-Si heterojunctions indicate that photocurrent under illumination increase with increasing of light intensity and explained by continuous distribution of traps. Structural parameters of the free ligands and their Cu(II)-complex were calculated on the basis of semi-empirical PM3 level and compared with the experimental data. The present copper (II) complex was screened for its antimicrobial activity against some Gram-positive and Gram-negative bacteria and fungus strain.

Structural, molecular orbital and optical characterizations of solvatochromic mixed ligand copper(II) complex of 5,5-Dimethyl cyclohexanate 1,3-dione and N,N,N',N'N″-pentamethyldiethylenetriamine

In this work, a new solvatochromic mononuclear mixed ligand complex with the formula, Cu(DMCHD)(Me5dien)NO3 (where, DMCHD=5,5-Dimethyl cyclohexanate 1,3-dione and (Me5dien)=N,N,N',N'N″-pentamethyldiethylenetriamine was synthesized and characterized by analytical, spectral, magnetic, molar conductance, thermal gravimetric analysis (TGA), X-ray diffraction (XRD) and transmission electron microscope (TEM) measurements. The formation constant-value for copper (II)-DMCHD was found to be much lower than the expected for similar β-diketones, revealing monobasic unidentate nature of this ligand. The d-d absorption bands of the prepared complex exhibit a color changes in various solvent (solvatochromic). Specific and non-specific interactions of solvent molecules with the complex were investigated using Multi Parametric Linear Regression Analysis (MLRA). Structural parameters of the free ligands and their Cu (II) - complex were calculated on the basis of semi-empirical PM3 level and compared with the experimental data. The crystallite size and morphology of Cu(DMCHD)(Me5dien)NO3 were examined using XRD analysis and TEM, revealing that the complex is well crystalline and correspond to the monoclinic crystal structure. The lattice strain and mean crystallite size were estimated by Williamson-Hall (W-H) plot using X-ray diffraction data. The main important absorption parameters such as extinction molar coefficient, oscillator strength and electric dipole strength of the principal optical transitions in the UV-Vis region were calculated. The analysis of absorption coefficient near the fundamental absorption edge reveals that the optical band gaps are direct allowed transitions with values of 2.78 eV and 3.59 eV. The present copper (II) complex was screened for its antimicrobial activity against Staphylococcus Aureus and Bacillus Subtilis as Gram-positive bacteria, Escherichia Coli and Salmonella Typhimurium as Gram-negative bacteria and Candida Albicans as fungus strain.

Very large database of lipids: rationale and design

Blood lipids have major cardiovascular and public health implications. Lipid-lowering drugs are prescribed based in part on categorization of patients into normal or abnormal lipid metabolism, yet relatively little emphasis has been placed on: (1) the accuracy of current lipid measures used in clinical practice, (2) the reliability of current categorizations of dyslipidemia states, and (3) the relationship of advanced lipid characterization to other cardiovascular disease biomarkers. To these ends, we developed the Very Large Database of Lipids (NCT01698489), an ongoing database protocol that harnesses deidentified data from the daily operations of a commercial lipid laboratory. The database includes individuals who were referred for clinical purposes for a Vertical Auto Profile (Atherotech Inc., Birmingham, AL), which directly measures cholesterol concentrations of low-density lipoprotein, very low-density lipoprotein, intermediate-density lipoprotein, high-density lipoprotein, their subclasses, and lipoprotein(a). Individual Very Large Database of Lipids studies, ranging from studies of measurement accuracy, to dyslipidemia categorization, to biomarker associations, to characterization of rare lipid disorders, are investigator-initiated and utilize peer-reviewed statistical analysis plans to address a priori hypotheses/aims. In the first database harvest (Very Large Database of Lipids 1.0) from 2009 to 2011, there were 1 340 614 adult and 10 294 pediatric patients; the adult sample had a median age of 59 years (interquartile range, 49-70 years) with even representation by sex. Lipid distributions closely matched those from the population-representative National Health and Nutrition Examination Survey. The second harvest of the database (Very Large Database of Lipids 2.0) is underway. Overall, the Very Large Database of Lipids database provides an opportunity for collaboration and new knowledge generation through careful examination of granular lipid data on a large scale.

Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: results from MESA

Unhealthy lifestyle habits are a major contributor to coronary artery disease. The purpose of the present study was to investigate the associations of smoking, weight maintenance, physical activity, and diet with coronary calcium, cardiovascular events, and mortality. US participants who were 44-84 years of age (n = 6,229) were followed in the Multi-Ethnic Study of Atherosclerosis from 2000 to 2010. A lifestyle score ranging from 0 to 4 was created using diet, exercise, body mass index, and smoking status. Coronary calcium was measured at baseline and a mean of 3.1 (standard deviation, 1.3) years later to assess calcium progression. Participants who experienced coronary events or died were followed for a median of 7.6 (standard deviation, 1.5) years. Participants with lifestyle scores of 1, 2, 3, and 4 were found to have mean adjusted annual calcium progressions that were 3.5 (95% confidence interval (CI): 0.0, 7.0), 4.2 (95% CI: 0.6, 7.9), 6.8 (95% CI: 2.0, 11.5), and 11.1 (95% CI: 2.2, 20.1) points per year slower, respectively, relative to the reference group (P = 0.003). Unadjusted hazard ratios for death by lifestyle score were as follows: for a score of 1, the hazard ratio was 0.79 (95% CI: 0.61, 1.03); for a score of 2, the hazard ratio was 0.61 (95% CI: 0.46, 0.81); for a score of 3, the hazard ratio was 0.49 (95% CI: 0.32, 0.75); and for a score of 4, the hazard ratio was 0.19 (95% CI: 0.05, 0.75) (P < 0.001 by log-rank test). In conclusion, a combination of regular exercise, healthy diet, smoking avoidance, and weight maintenance was associated with lower coronary calcium incidence, slower calcium progression, and lower all-cause mortality over 7.6 years.

[Serum and synovial adiponectin, resistin, and visfatin levels in rheumatoid arthritis patients. Relation to disease activity]

BACKGROUND

Recent data provided evidence on the implication of the adipocytokines adiponectin, visfatin, and resistin in inflammation, immune response, and tissue destruction and revealed several links between them and arthritis.

AIM OF THE STUDY

The purpose of this study was to assess the levels of adiponectin, visfatin, and resistin in serum and synovial fluid of patients with rheumatoid arthritis (RA) and their relationship with disease activity.

SUBJECTS AND METHODS

A total of 70 female patients with RA and 30 age- and sex-matched healthy controls were enrolled. The clinical activity of RA patients was assessed according to the 28 joint count Disease Activity Score and patients were classified into two groups: 39 patients with active disease (group A) and 31 patients in remission (group B). Synovial fluid was obtained by arthrocentesis of the affected knee joints from 39 patients with active disease. Serum adiponectin, visfatin, and resistin concentrations were measured in RA patients and controls, while a specific enzyme-linked immunosorbent assay was used to measure the synovial concentrations of adiponectin, visfatin, and resistin in the group of patients with active RA.

RESULTS

Serum levels of adiponectin and visfatin were significantly higher in all RA patients and patients with active disease compared to the control group and patients in remission. No significant difference was observed in the resistin level between patients and controls. Serum and synovial adiponectin and visfatin were positively correlated with DAS28-ESR in RA patients with active disease.

CONCLUSION

Our data demonstrated that adiponectin and visfatin are related to disease activity in RA patients and might be involved in the progression of RA. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Effects of physical activity on cardiovascular disease

Much attention has been directed toward lifestyle modifications as effective means of reducing cardiovascular disease risk. In particular, physical activity has been heavily studied because of its well-known effects on metabolic syndrome, insulin sensitivity, cardiovascular disease risk, and all-cause mortality. However, data regarding the effects of exercise on various stages of the atherosclerosis pathway remain conflicting. The investigators review previously published reports for recent observational and interventional trials investigating the effects of physical activity on markers of (or causal factors for) atherosclerotic burden and vascular disease, including serum lipoproteins, systemic inflammation, thrombosis, coronary artery calcium, and carotid intima-media thickness. In conclusion, the data show a correlation between physical activity and triglyceride reduction, apolipoprotein B reduction, high-density lipoprotein increase, change in low-density lipoprotein particle size, increase in tissue plasminogen activator activity, and decrease in coronary artery calcium. Further research is needed to elucidate the effect of physical activity on inflammatory markers and intima-media thickness.

Obesity, fast food manufacture, and regulation: revisiting opportunities for reform

Regulations have historically been able to shape public behavior in various ways. As poor dietary practices and obesity continue to pose major health and economic threats to society, attention will continue to be directed towards the ethical and legal responsibilities of fast food manufacturers as potential contributors to these problems. In light of these considerations, several opportunities emerge that may impact dietary behavior and obesity through regulation of the fast food industry. This article addresses the health consequences of fast food consumption, as well as the historical and legal contexts of fast food regulation in the United States.

Quinine therapy in severe Plasmodium falciparum malaria during pregnancy in Sudan

A prospective study was carried out in an area of unstable malaria transmission in central Sudan to determine the efficacy and toxicity of quinine in pregnancy. Thirty-three pregnant women with severe Plasmodium falciparum malaria at mean 28.8 weeks gestational age were treated with quinine for 7 days. The mean body temperature on presentation for 3 patients who delivered prematurely was significantly higher than for those who delivered at term (39.2 +/- 0.7 degrees C versus 38.7 +/- 1.3 degrees C). There were no significant difference between the 2 groups in other clinical or biochemical parameters. There were no clinically detectable congenital malformations and no auditory, visual or other neurological deficits in the babies at birth or 6 months later. Quinine may be safe in the treatment of severe falciparum malaria during pregnancy.

Analysis of the gene expression profile of Schistosoma mansoni cercariae using the expressed sequence tag approach

ESTs constitute rapid and informative tools with which to study gene-expression profiles of the diverse stages of the schistosome life cycle. Following a comprehensive EST study of adult worms, analysis has now targeted the cercaria, the parasite larval form responsible for infection of the vertebrate host. Two Schistosoma mansoni cercarial cDNA libraries were examined and partial sequence obtained from 957 randomly selected clones. On the basis of database searches, 551 (57.6%) ESTs generated had no homologs in the public databases whilst 308 (32.2%) were putatively identified, totaling 859 informative ESTs. The remaining 98 (10.2%) were uninformative ESTs (ribosomal RNA and non-coding mitochondrial sequences). By clustering analysis we have identified 453 different genes. The most common sequences in both libraries represented Sm8 calcium binding protein (8% of ESTs), fructose-1,6-bisphosphate aldolase, glyceraldehyde-3-phosphate dehydrogenase, cytochrome oxidase subunit 1, ATP guanidine kinase and triose phosphate isomerase. One hundred and nineteen identified genes were sorted into 11 functional categories, with genes associated with energy metabolism being the most abundant (13%) and diverse. The diversity and abundance of genes associated with the transcription/translation machinery and with regulatory/signaling functions were also marked. A paramyosin transcript was identified, indicating that this gene is not exclusively expressed in adult worms and sporocysts (as had been suggested previously). The possible physiological relevance to cercariae of the presence of transcripts with homology to calcium binding proteins of the EF-hand superfamily, Gq-coupled rhodopsin photoreceptor, rod phosphodiesterase 8 subunit and peripheral-type benzodiazepine receptor is discussed.

Toombak dipping and cancer of the oral cavity in the Sudan: a case-control study

To investigate the possible causal association between squamous-cell carcinomas of the oral cavity and use of toombak, we retrospectively compared the history of use of this substance in 375 patients with squamous-cell carcinomas of the lip, buccal cavity and floor of mouth, and 271 patients with squamous carcinomas of the tongue, palate and maxillary sinus, with 204 patients exhibiting non-squamous oral and non-oral malignant neoplasms and 2,820 individuals who had no malignancy, selected from the general population. The study revealed that the high prevalence of oral cancer in the Sudan is largely due to chronic use of toombak. The adjusted ORs associated with toombak dipping for the first case group, cancer of the lip, buccal cavity and floor of mouth in comparison with the hospital and population control groups, were 7.3 and 3.9 (95% confidence limits, 4.3-12.4 and 2.9-5.3) respectively and among long-term users the adjusted ORs were 11.0 and 4.3 (95% confidence limits, 4.8-25.1 and 2.9-6.3) respectively. The elevated risk found when investigating intra-oral cancers of sites in direct contact with toombak quid compared to those with little or no contact, confirms the hypothesis that direct contact with tissues is an important factor in tobacco carcinogenesis in the mouth. The increased risk associated with the use of toombak is of particular concern in view of its wide consumption in the Sudan.

Fatty acid composition of the milk of well-nourished Sudanese women

The fatty acid (FA) composition of samples of breast milk obtained from well-nourished Sudanese women was determined by capillary gas chromatography. Saturated fatty acids (SFA) constituted 46%, monoenoic acids (MONOENE) 33% and polyunsaturated fatty acids (PUFA) accounted for 21% of total fatty acids. The mean value (18.28%) of the essential fatty acid linoleic acid was comparable to the levels reported for well-nourished mothers from industrialised countries. The proportions of fatty acids synthesised de novo in the mammary gland (10:0, 12:0, 14:0) were less than expected from published studies of mothers consuming low fat diet averaging 17.4%. The amount of 22:6 n-3 which is synthesised from 18:3 n-3 and also taken up by consumption of fish were found to be low. The possible nutritional implications of the low n-3 fatty acids for the infants should therefore be investigated.