Heavy clinical and economic burden of osteoporotic fracture among elderly female Medicare beneficiaries

We comprehensively described elderly Medicare women with an outpatient visit in 2011 and fracture within 2 years before. These women were at very high risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low.

INTRODUCTION

Postmenopausal women with osteoporosis are stratified to high and very-high fracture risk categories, and this categorization drives algorithms for osteoporosis management in osteoporosis treatment guidelines. This study comprehensively describes a very-high-risk cohort.

METHODS

This retrospective cohort study used the Medicare 20% database; elderly women with an outpatient visit in 2011 and fracture within 2 years before the visit were included. Outcomes included fracture risk, all-cause and fracture-related healthcare resource utilization and cost, and osteoporosis medication use in the 5 years after the visit.

RESULTS

Overall, 43,193 patients were included. The 5-year probability was 0.36 for major fracture and 0.11 and 0.17 for hip fracture and vertebral fracture, respectively, much higher than the guidelines' 10-year probability thresholds for very-high-risk (0.3 for major fracture, 0.045 for hip fracture). Rates of hospitalizations, emergency department visits or observation stays, and skilled nursing facility stays in year 1 were 53.7, 57.0, and 18.8 per 100 patient-years, respectively, decreasing slightly in subsequent years. Mean healthcare cost was $23,700 in year 1, decreasing to $18,500 in year 5. About 29.1% of patients received osteoporosis medications in year 1, decreasing to 16.9% by year 5. Rates for all outcomes, especially fractures, were much higher among vertebral and multiple fracture cohorts.

CONCLUSION

Elderly women with a fracture within last 2 years were at very-high-risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low. More effort is needed to identify and treat patients at very-high-risk for fracture.

3294Frequency, management and outcomes of patients with stable coronary artery disease eligible for COMPASS. An analysis of the CLARIFY registry

Background

The COMPASS trial demonstrated that a combination of rivaroxaban and aspirin improved cardiovascular (CV) outcomes in high-risk patients with either peripheral artery disease (PAD) or stable coronary artery disease (CAD) compared with aspirin alone, at the price of increased bleeding. A previous analysis of the REACH Registry reported an eligibility rate of 52.9% within a population with stable vascular disease. However, most of cardiologists actually treat patients with stable CAD, rather than PAD. Data regarding eligibility to COMPASS in CAD patients from real life practice are scarce.

Purpose

We aimed to describe the proportion of patients eligible to COMPASS within the CLARIFY Registry. Additionally, we aimed to describe their management and outcomes, comparing patients excluded from the trial (COMPASS Excluded), patients eligible for the trial (COMPASS Eligible), and patients who did not meet the “enrichment criteria” for enrolment (COMPASS Not Included).

Methods

We used the CLARIFY Registry, an international observational registry of more than 30.000 patients with stable CAD. In accordance with COMPASS exclusion criteria, patients with a REACH bleeding risk score >10, heart failure (HF), severe renal insufficiency, need for dual antiplatelet therapy (DAPT), or anticoagulant (AC) therapy were excluded. Then, COMPASS inclusion criteria were applied: CAD patients had to be 65 years or more, or, if younger, have documented atherosclerosis (PAD or revascularization involving at least two vascular beds) or at least two enrichment criteria (current smoker, diabetes mellitus, GFR <60 mL/min, or non lacunar ischemic stroke).The ischemic outcome was a composite of CV death, MI, or stroke and bleeding outcome was a composite of bleeding leading to either admission or transfusion, or haemorrhagic stroke.

Results

Among 15.185 patients with comprehensive data allowing precise assessment of eligibility, 43.1% (n=6.540) had at least one exclusion criteria (COMPASS-Excluded), 23.1% (n=3.503) did not have enrichment criteria (COMPASS-Not Included) and 33.9% (n=5.142) were eligible. The vast majority of excluded patients were excluded due to high bleeding risk (62.7% needing DAPT, and 52.7% for high REACH bleeding risk score). The rates (100 patients/year) of ischemic and bleeding outcome were 2.3 [2.1–2.5] and 0.5 [0.4–0.6] respectively for COMPASS-Eligible, 3.0 [2.8–3.2] and 0.6 [0.5–0.7] for COMPASS-Excluded and 1.2 [1.0–1.4] and 0.2 [0.2–0.3] for COMPASS-Not Included.

Ischemic and bleeding events

Conclusion

In a large contemporary registry of stable CAD patients, approximately one of three patients was potentially eligible for adjunction of low-dose rivaroxaban to aspirin. This group is at particularly high risk of ischemic outcome. Patients with exclusion criteria for COMPASS had the worse ischemic and bleeding outcomes and represent a group in need of improved therapy.

Acknowledgement/Funding

None

P5010Use of risk score to identify lower and higher risk subsets among COMPASS-Eligible patients with stable CAD. Insights from the CLARIFY Registry

Background

The COMPASS trial showed that a combination of rivaroxaban and aspirin improved cardiovascular (CV) outcomes in patients with stable coronary artery disease (CAD) compared with aspirin alone, at the expense of increased bleeding. An important issue is to identify in this broad population, patients who are likely to derive the greatest benefit without too great a bleeding risk.

Purpose

To evaluate the performance of the CHA2DS2VaSc (range from 0 to 9), the REACH Recurrent Ischemic Score (RIS) (range from 0 to ≥29) and the REACH Bleeding Risk Score (BRS) (range from 0 to 22) to identify patients with the most favourable trade-off between ischemic and bleeding events, among CAD patients eligible to COMPASS

Methods

We used the CLARIFY Registry, an international registry of >30.000 patients with stable CAD. COMPASS inclusion and exclusion criteria were applied to the CLARIFY population with complete data (n=15.185) to define the “COMPASS eligible population”. Patients at high bleeding risk (REACH BRS >10), were excluded in accordance to COMPASS exclusion criteria. Patients were categorized as low-intermediate (0–1) or high (≥2) CHA2DS2VaSc; low (0–12) or intermediate (13–19) REACH RIS, and low (0–6) or intermediate (7–10) REACH BRS. The ischemic outcome was a composite of CV death, MI or stroke, and the bleeding outcome was a composite of bleeding leading to either admission or transfusion, or haemorrhagic stroke.

Results

The COMPASS-eligible population comprised 5.142 patients (33.9%). Ischemic and bleeding outcome for this group were 2.3 [2.1–2.5] and 0.5 [0.4–0.6] events/100 patient-years, respectively. Patients with high CHA2DS2VaSc score, intermediate REACH BRS and RIS represented 95.5% (n=4.913), 83.8% (n=4.309) and 37.6% (n=1.934) of the population. Regarding ischemic risk, patients with intermediate REACH RIS had the higher ischemic risk (3.0 [2.6–3.4] vs 1.9 [1.7–2.1] for patients with low REACH RIS, p<0.001), followed by intermediate REACH BRS (2.5 [2.2–2.7] vs 1.5 [1.2–2.0] for patients with low REACH BRS, p=0.0003) and high CHA2DS2VaSc score (2.4 [2.2–2.6]), compared to the overall population. Patients with low CHA2DS2VaSc had the lowest ischemic risk (0.6 [0.3–1.3]) compared to the overall population. Regarding bleeding risk, there were no differences between patients categorized according to CHA2DS2VaSc (0.5 [0.2–1.15] vs 0.5 [0.4–0.6], p=0.95) REACH BRS (0.4 [0.3–0.7] vs 0.5 [0.4–0.6], p=0.80) or REACH RIS (0.4 [0.3–0.5] vs 0.5 [0.4–0.7], p=0.26).

Ischemic (blue) and bleeding (red) event

Conclusions

Among a broad population of CAD patients eligible to COMPASS, low CHA2DS2VaSc score identify a small subset of patients with very low ischemic risk which is unlikely to benefit from the adjunction of low dose rivaroxaban to standard therapy. Patients with intermediate REACH Recurrent Ischemic Score had higher ischemic risk, without increased bleeding risk and may be optimal candidates from adjunction of low dose rivaroxaban.

Acknowledgement/Funding

None

2211Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. an analysis from the CLARIFY registry

Background

The prevalence, and prognostic implication of left bundle branch block (LBBB) in general population and patients admitted for acute myocardial infarction (MI) as been extensively studied. However, data are scarce about patients with stable coronary artery disease (CAD) and it remains unclear whether LBBB is only a marker of a severe cardiomyopathy or an independent predictor of events in these patients.

Purpose

We aimed to describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. Additionally, we aimed to describe the incidence of newly diagnosed LBBB that occurred without recent myocardial infarction.

Methods

CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was collected at baseline and at each follow-up visit, and patients were considered to have LBBB if the length of the QRS complex was of more than 120 milliseconds. Patients with previous pacemaker implantation of internal cardiac defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation.

Results

From the 23.457 patients with available data regarding LBBB status, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) had at least one LBBB assessed during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2±10.1 versus 63.6±10.4 years, p<0.0001), history of coronary artery bypass grafting (29.2% vs 23.7%, p<0.0001), diabetes (35.1% vs 28.4%, p<0.0001), and HF (25.2% vs 16.8%, p<0.0001) (Table). In unadjusted analysis, patients with LBBB had a higher risk of primary outcome (13.4% vs 8.7%, p<0.0001) and each secondary outcome. In multivariate analysis taking into account several possible confounders, there was no difference in the rate of CV death, MI or stroke between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). However, patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, p<0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, p<0.0001) (Figure).

Outcomes according to LBBB status

Conclusion

The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The overwhelming majority of newly diagnosed LBBB were not contemporary of documented myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, including all cause mortality but with a higher risk of pacemaker implantation and hospitalization for heart failure. To our knowledge this is the first study reporting such results in a broad population of stable CAD patients.

Acknowledgement/Funding

None

Work productivity loss and indirect costs associated with new cardiovascular events in high-risk patients with hyperlipidemia: estimates from population-based register data in Sweden

OBJECTIVES

To estimate productivity loss and associated indirect costs in high-risk patients treated for hyperlipidemia who experience cardiovascular (CV) events.

METHODS

Retrospective population-based cohort study conducted using Swedish medical records linked to national registers. Patients were included based on prescriptions of lipid-lowering therapy between 1 January 2006 and 31 December 2011 and followed until 31 December 2012 for identification of CV events and estimation of work productivity loss (sick leave and disability pension) and indirect costs. Patients were stratified into two cohorts based on CV risk level: history of major cardiovascular disease (CVD) and coronary heart disease (CHD) risk equivalent. Propensity score matching was applied to compare patients with new events (cases) to patients without new events (controls). The incremental effect of CV events was estimated using a difference-in-differences design, comparing productivity loss among cases and controls during the year before and the year after the cases' event.

RESULTS

The incremental effect on indirect costs was largest in the CHD risk equivalent cohort (n = 2946) at €3119 (P value <0.01). The corresponding figure in the major CVD history cohort (n = 4508) was €2210 (P value <0.01). There was substantial variation in productivity loss depending on the type of event. Transient ischemic attack and revascularization had no significant effect on indirect costs. Myocardial infarction (€3465), unstable angina (€2733) and, most notably, ischemic stroke (€6784) yielded substantial incremental cost estimates (P values <0.01).

CONCLUSIONS

Indirect costs related to work productivity losses of CV events are substantial in Swedish high-risk patients treated for hyperlipidemia and vary considerably by type of event.

Healthcare costs associated with cardiovascular events in patients with hyperlipidemia or prior cardiovascular events: estimates from Swedish population-based register data

OBJECTIVES

To estimate healthcare costs of new cardiovascular (CV) events (myocardial infarction, unstable angina, revascularization, ischemic stroke, transient ischemic attack, heart failure) in patients with hyperlipidemia or prior CV events.

METHODS

A retrospective population-based cohort study was conducted using Swedish national registers and electronic medical records. Patients with hyperlipidemia or prior CV events were stratified into three cohorts based on CV risk level: history of major cardiovascular disease (CVD), coronary heart disease (CHD) risk-equivalent, and low/unknown risk. Propensity score matching was applied to compare patients with new events to patients without new events for estimation of incremental costs of any event and by event type.

RESULTS

A CV event resulted in increased costs over 3 years of follow-up, with the majority of costs occurring in the 1st year following the event. The mean incremental cost of patients with a history of major CVD (n = 6881) was €8588 during the 1st year following the event. This was similar to that of CHD risk-equivalent patients (n = 3226; €6663) and patients at low/unknown risk (n = 2497; €8346). Ischemic stroke resulted in the highest 1st-year cost for patients with a history of major CVD and CHD risk-equivalent patients (€10,194 and €9823, respectively); transient ischemic attack in the lowest (€3917 and €4140). Incremental costs remained elevated in all cohorts during all three follow-up years, with costs being highest in the major CVD history cohort.

CONCLUSIONS

Healthcare costs of CV events are substantial and vary considerably by event type. Incremental costs remain elevated for several years after an event.

Lipid-lowering treatment patterns in patients with new cardiovascular events - estimates from population-based register data in Sweden

OBJECTIVES

The aim of this study was to assess treatment patterns of lipid-lowering therapy (LLT) in patients with hyperlipidaemia or prior cardiovascular (CV) events who experience new CV events.

METHODS

A retrospective population-based cohort study was conducted using Swedish medical records and registers. Patients were included in the study based on a prescription of LLT or CV event history and followed up for up to 7 years for identification of new CV events and assessment of LLT treatment patterns. Patients were stratified into three cohorts based on CV risk level. All outcomes were assessed during the year following index (the date of first new CV event). Adherence was defined as medication possession ratio (MPR) > 0.80. Persistence was defined as no gaps > 60 days in supply of drug used at index.

RESULTS

Of patients with major cardiovascular disease (CVD) history (n = 6881), 49% were not on LLT at index. Corresponding data for CV risk equivalent and low/unknown CV risk patients were 37% (n = 3226) and 38% (n = 2497) respectively. MPR for patients on LLT at index was similar across cohorts (0.74-0.75). The proportions of adherent (60-63%) and persistent patients (56-57%) were also similar across cohorts. Dose escalation from dose at index was seen within all cohorts and 2-3% of patients switched to a different LLT after index while 5-6% of patients augmented treatment by adding another LLT.

CONCLUSIONS

Almost 50% of patients with major CVD history were not on any LLT, indicating a potential therapeutic gap. Medication adherence and persistence among patients on LLT were suboptimal.

Cardiovascular event rates and healthcare resource utilisation among high-risk adults with type 2 diabetes mellitus in a large population-based study

OBJECTIVE

This study ascertained the incidence and resource utilisation of non-fatal myocardial infarction (MI), stroke, coronary bypass surgery or angioplasty among adults with type 2 diabetes mellitus (T2DM) at high risk for cardiovascular disease (CVD) over 3 and 5 years.

METHODS

Respondents from the US, population-based SHIELD study with T2DM and at cardiovascular risk were stratified into an established CVD cohort and a risk factors cohort. Proportion of respondents self-reporting a new MI, stroke or revascularisation was calculated. Multivariate discrete logistic hazards models were utilised.

RESULTS

Incidence rate in the established CVD cohort (n = 1198) was 26.3% over 3 years (31.2%, 5 years) and in the risk factors cohort (n = 924) 18.8% over 3 years (26.0%, 5 years). Healthcare resource use was significantly greater among respondents who had a new CV event than among those not experiencing an event (p < 0.001).

CONCLUSIONS

Individuals with T2DM at risk for CVD had a high incidence of CV events in this large US study, which represents a significant burden on the healthcare system.

Ischaemic cardiac events and use of strontium ranelate in postmenopausal osteoporosis: a nested case-control study in the CPRD

We explored the cardiac safety of the osteoporosis treatment strontium ranelate in the UK Clinical Practice Research Datalink. While known cardiovascular risk factors like obesity and smoking were associated with increased cardiac risk, use of strontium ranelate was not associated with any increase in myocardial infarction or cardiovascular death.

INTRODUCTION

It has been suggested that strontium ranelate may increase risk for cardiac events in postmenopausal osteoporosis. We set out to explore the cardiac safety of strontium ranelate in the Clinical Practice Research Datalink (CPRD) and linked datasets.

METHODS

We performed a nested case-control study. Primary outcomes were first definite myocardial infarction, hospitalisation with myocardial infarction, and cardiovascular death. Cases and matched controls were nested in a cohort of women treated for osteoporosis. The association with exposure to strontium ranelate was analysed by multivariate conditional logistic regression.

RESULTS

Of the 112,445 women with treated postmenopausal osteoporosis, 6,487 received strontium ranelate. Annual incidence rates for first definite myocardial infarction (1,352 cases), myocardial infarction with hospitalisation (1,465 cases), and cardiovascular death (3,619 cases) were 3.24, 6.13, and 14.66 per 1,000 patient-years, respectively. Obesity, smoking, and cardiovascular treatments were associated with significant increases in risk for cardiac events. Current or past use of strontium ranelate was not associated with increased risk for first definite myocardial infarction (odds ratio [OR] 1.05, 95 % confidence interval [CI] 0.68-1.61 and OR 1.12, 95 % CI 0.79-1.58, respectively), hospitalisation with myocardial infarction (OR 0.84, 95 % CI 0.54-1.30 and OR 1.17, 95 % CI 0.83-1.66), or cardiovascular death (OR 0.96, 95 % CI 0.76-1.21 and OR 1.16, 95 % CI 0.94-1.43) versus patients who had never used strontium ranelate.

CONCLUSIONS

Analysis in the CPRD did not find evidence for a higher risk for cardiac events associated with the use of strontium ranelate in postmenopausal osteoporosis.

Health-related quality of life association with weight change in type 2 diabetes mellitus: perception vs. reality

AIMS

This study compared health-related quality of life (HRQOL) in adults with type 2 diabetes mellitus (T2DM) who reported their perception of weight change vs. actual weight change.

METHODS

Respondents to the US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) 2008 survey were asked if they had lost, maintained or gained weight compared with 1 year earlier (perception). Respondents also provided their actual weight and completed the SHIELD WQ-9 questionnaire to report how weight change affected 9 aspects of daily life. Perceived weight loss or gain was compared with measured weight change reported (2007 weight - 2008 weight) in those with T2DM.

RESULTS

In respondents reporting weight loss (n = 762), 75.4% lost weight and 15.9% gained weight. For respondents reporting weight gain (n = 392), 70.2% gained weight and 19.6% lost weight. HRQOL did not differ between those who reported weight loss and actually lost weight vs. those who reported weight loss and actually gained weight (p > 0.05), except for self-esteem (p = 0.004). HRQOL was similar for those who reported weight gain and actually gained weight vs. those who reported weight gain, but actually lost weight (p > 0.20). Respondents who had perceived weight loss had significantly better HRQOL than those who perceived that they had gained weight.

CONCLUSIONS

Perception of weight loss/gain may be as powerful as actual weight loss/gain in impacting HRQOL among adults with T2DM. Interventions that help individuals lose weight or perceive weight loss in addition to lowering glucose will assist in improving HRQOL.

Influence of heating and acidification on the flavor of whey protein isolate

Previous studies have established that whey protein manufacture unit operations influence the flavor of dried whey proteins. Additionally, manufacturers generally instantize whey protein isolate (WPI; ≥ 90% protein) by agglomeration with lecithin to increase solubility and wettability. Whey protein isolate is often subjected to additional postprocessing steps in beverage manufacturing, including acidification and heat treatment. These postprocessing treatments may further influence formation or release of flavors. The objective of the first study was to characterize the effect of 2 processing steps inherent to manufacturing of acidic protein beverages (acidification and heat treatment) on the flavor of non-instant WPI. The second study sought to determine the effect of lecithin agglomeration, a common form of instantized (INST) WPI used in beverage manufacturing, on the flavor of WPI after acidification and heat treatment. In the first experiment, commercial non-instantized (NI) WPI were rehydrated and evaluated as is (control); acidified to pH 3.2; heated to 85°C for 5 min in a benchtop high temperature, short time (HTST) pasteurizer; or acidified to 3.2 and heated to 85°C for 30s (AH-HTST). In the second experiment, INST and NI commercial WPI were subsequently evaluated as control, acidified, heated, or AH-HTST. All samples were evaluated by descriptive sensory analysis, solid-phase microextraction (SPME), and gas chromatography-mass spectrometry. Acidification of NI WPI produced higher concentrations of dimethyl disulfide (DMDS) and sensory detection of potato/brothy flavors, whereas heating increased cooked/sulfur flavors. Acidification and heating increased cardboard, potato/brothy, and malty flavors and produced higher concentrations of aldehydes, ketones, and sulfur compounds. Differences between INST and NI WPI existed before treatment; INST WPI displayed cucumber flavors not present in NI WPI. After acidification, INST WPI were distinguished by higher intensity of cucumber flavor and higher concentrations of E-2-nonenal. No perceivable differences were observed between INST and NI WPI after heating; sulfur and eggy flavors increased in both types of WPI. After treatment, AH-INST-HTST samples were differentiated from AH-NI-HTST by grassy/hay and grainy flavor and increased lipid oxidation products. Further processing of WPI in food applications has negative effects on the flavor contributions of WPI.

Rate and risk predictors for development of self-reported type-2 diabetes mellitus over a 5-year period: the SHIELD study

AIMS

This investigation determined the proportion of adults newly diagnosed as having type-2 diabetes mellitus (T2DM), and ascertained risk predictors for development of self-reported T2DM.

METHODS

The US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) survey was a 5-year longitudinal study of adults with and without diabetes mellitus. Adults completed a baseline health questionnaire in 2004 and ≥1 annual follow-up survey through 2009. Respondents with no self-reported diagnosis of diabetes at baseline were followed to measure rate of and assess risk factors for development of T2DM over 5 years.

RESULTS

Among 8582 respondents without diabetes at baseline, 622 (7.2%) reported a diagnosis of T2DM over the subsequent 5 years. Increasing age, family history of T2DM, body mass index ≥30 kg/m(2), abdominal obesity, excessive thirst, asthma, gestational diabetes and 'high blood sugar without diabetes' significantly increased the risk of developing T2DM (p < 0.05 for each). Good to excellent health status and self-reported circulatory problems decreased the risk (p < 0.05 for each).

CONCLUSIONS

Among this representative US adult population, the rate of developing T2DM was 7.2% over 5 years. Predictors of T2DM diagnosis identified in this analysis were readily obtainable via self-report.

Long-term follow-up of the first patients to undergo transcatheter alcohol septal ablation

We describe the 10-year outcome of the first-in-human series of 12 patients with hypertrophic cardiomyopathy treated with alcohol septal ablation. There was no 30-day mortality. Survival free of death, internal cardiac defibrillator discharge for treatment of ventricular fibrillation or tachycardia, severe New York Heart Association (NYHA) class III/IV and/or Canadian Cardiovascular Society class III/IV symptoms and the need for surgical myectomy in this cohort was 91% at 1 year and 73% at 10 years. The reduction in outflow tract gradient was maintained over the 10 years, from a mean preoperative gradient of 70 mm Hg to a median of 3 mm Hg at 126 months of follow-up (p < 0.01). Two patients (16%) underwent a further ablation procedure. Two patients (16%) suffered sudden cardiac death, 91 and 102 months after the procedure. Long-term symptom benefit was experienced by all patients, with a reduction in mean NYHA class from 2.7 +/- 0.6 before the procedure to 1 after the procedure at the last follow-up (p < 0.01). This historic small cohort study demonstrates that septal ablation can provide long-term haemodynamic and symptomatic benefit.

Underutilisation of cardiovascular medications among at-risk individuals

AIMS

Guidelines recommend antihypertensive, lipid-lowering and/or antiplatelet therapy for prevention of cardiovascular disease (CVD). This study examined the utilisation of cardiovascular therapies among individuals at CVD risk to assess adherence to guidelines.

METHODS

Respondents to the SHIELD study were classified based on National Cholesterol Education Program Adult Treatment Panel III risk categories. High coronary heart disease (CHD) risk (n = 7510) was defined as self-reported diagnosis of heart disease/heart attack, narrow or blocked arteries, stroke or diabetes; moderate risk (n = 4823) included respondents with > or = 2 risk factors (i.e., men > 45 years, women > 55 years, hypertension, low high-density lipoprotein cholesterol, smoking and family history of CHD); and low risk (n = 5307) was 0-1 risk factor. Respondents reporting a myocardial infarction, stroke or revascularisation at baseline (prior CVD event) (n = 3777), those reporting a new CVD event during 2 years of follow up (n = 953), and those with type 2 diabetes mellitus (n = 3937) were evaluated. The proportion of respondents reporting treatment with lipid-lowering, antiplatelet or antihypertensive agents was calculated.

RESULTS

Utilisation of lipid-lowering therapy was low (< or = 25%) in each group. Prescription antithrombotic therapy was minimal among respondents with prior CVD events, but 47% received antihypertensive medication. No use before or after a new CVD event was reported by 36% of respondents for lipid-lowering, 32% for antithrombotic and > 50% for antihypertensive medications.

CONCLUSIONS

More than 50% of at-risk respondents and > 33% of respondents with new CVD events were not taking CVD therapy as recommended by guidelines.

Self-reported diagnosis of heart disease: results from the SHIELD study

OBJECTIVE

This study evaluated the self-reported method of diagnosis of heart disease (HD) to elucidate whether diagnosis is occurring at early, presymptomatic stages as recommended by the prevention guidelines.

METHODS

Respondents to the 2006 survey in the US population-based Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) reported whether a physician told them that they had HD, including heart attack, angina, heart failure, angioplasty or heart bypass surgery. Self-report of age at diagnosis, specialty of physician who made the diagnosis and whether the diagnosis was made after having symptoms, during routine screening or while being treated for another health problem were assessed. Year of diagnosis was categorised into 3-year intervals from 1985 to 2006. Individuals with HD diagnosis with and without type 2 diabetes mellitus (T2DM) were compared using chi-square tests.

RESULTS

Of 1573 respondents reporting a diagnosis of HD, > 87% were white, > 49% were men and 38% had T2DM. Approximately 19% of respondents reported that their HD diagnosis was made during routine screening. A significantly greater percentage of HD respondents with T2DM reported the diagnosis being made based on symptoms (54%) and while being treated for another health problem (22%) compared with respondents without diabetes (48% symptoms and 15% other health problem, p > 0.05). HD was diagnosed primarily by cardiologists (> 60%) and family doctors (> 25%).

CONCLUSION

There remains a missed opportunity to diagnose HD at earlier stages through routine screening or during treatment of other health conditions such as diabetes, as many individuals were not diagnosed until they were symptomatic.

Vibrio cholerae non-O1 infection in cirrhotics: case report and literature review

Vibrio species are ubiquitous in the marine environment and can cause severe infections in cirrhotic patients. Patients with liver disease should be warned about the potential dangers of consuming raw or undercooked seafood, and avoiding exposure of wounds to seawater. We report a case of severe sepsis from Vibrio cholerae non-O1 in a patient with cirrhosis awaiting orthotopic liver transplant. This case is aimed to advise clinicians about the importance of V. cholerae subtypes, and non-cholera Vibrio species infections in cirrhotic patients, highlighting the need to educate these patients to stay away from undercooked seafood.

Self-reported prevalence and awareness of metabolic syndrome: findings from SHIELD

PURPOSE

This study assessed awareness of metabolic syndrome and evaluated health knowledge, attitudes and behaviours of respondents at risk.

METHODS

Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD), a longitudinal US population-based survey initiated in 2004, included respondents, > or = 18 years of age, reporting a diagnosis of metabolic syndrome. Prevalence of metabolic syndrome was compared in SHIELD and National Health and Nutrition Examination Survey (NHANES) 1999-2002 survey. The proportion of SHIELD respondents who had heard of and/or understood metabolic syndrome was estimated. Respondents at high risk for metabolic syndrome were stratified into attitude-behaviour categories of 'Already Doing It', 'I Know I Should' and 'Don't Bother Me' and differences in attitudes and behaviours were evaluated with chi-square tests.

RESULTS

Prevalence of reported metabolic syndrome was 0.6% in SHIELD screening questionnaire respondents (n = 211,097) vs. 25.9% in NHANES (n = 10,780). Less than 15% of SHIELD baseline questionnaire respondents (n = 22,001) had heard of or understood metabolic syndrome. Attitudes toward health status were more favourable in the 'Doing' group (27% reported fair/poor health) compared with those in the 'Should' (38%) and 'Don't' (54%) groups (p < 0.0001). The 'Don't' group was most likely to prefer medications to lifestyle change (13% vs. 2-4%) compared with 'Should' and 'Doing' groups (p < 0.0001). More 'Doing' respondents (79%) than 'Should' (59%) and 'Don't' (48%) respondents reported exercising regularly (p < 0.0001).

CONCLUSIONS

The lack of knowledge about metabolic syndrome reported in SHIELD indicates limited penetration of this concept into public awareness. With behaviour categories, respondents who report healthy attitudes are more likely to embrace lifestyle changes, while respondents who do not care may be more difficult to treat.

Quality of life and depression of people living with type 2 diabetes mellitus and those at low and high risk for type 2 diabetes: findings from the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD)

OBJECTIVES

This study compared health-related quality of life (HRQoL) and depression among individuals with type 2 diabetes mellitus (T2D) and those at low or high risk for T2D.

METHODS

Respondents in a population-based US 2004 survey reported whether they had T2D (n = 3530) or risk factors for T2D [abdominal obesity, body mass index (BMI) >/= 28 kg/m(2), dyslipidaemia, hypertension and history of cardiovascular disease]. Respondents without T2D were stratified into low risk (0-2 risk factors, n = 5335) and high risk (3-5 risk factors, n = 5051). SF-12 version 2 (SF-12) and Patient Health Questionnaire (PHQ)-9 were used to measure HRQoL and depression. Mean scores were compared across the three groups using analysis of variance. Linear regression identified factors associated with SF-12 Physical and Mental Component Summary scores (PCS and MCS), adjusting for age, gender, race, income, geographic region, household size, BMI and group.

RESULTS

Respondents were mostly women (60%) with mean age of 54 years. Mean PCS scores for T2D and high risk (39.5 and 41.7, respectively) were significantly lower than for low risk (50.6, p < 0.001). After adjustment, high-risk and T2D groups were associated with lower PCS and MCS scores compared with low risk group (p < 0.05). Mean PHQ-9 scores and per cent with moderate-to-severe depression were significantly higher for T2D and high risk than for low risk (p < 0.01).

CONCLUSIONS

Health-related quality of life and depression scores in T2D were similar to those at high risk, and indicated significant decrements in physical health and greater depression compared with low-risk respondents.

ACE inhibition and endothelial function: main findings of PERFECT, a sub-study of the EUROPA trial

Background

ACE inhibition results in secondary prevention of coronary artery disease (CAD) through different mechanisms including improvement of endothelial dysfunction. The Perindopril-Function of the Endothelium in Coronary artery disease Trial (PERFECT) evaluated whether long-term administration of perindopril improves endothelial dysfunction.

Methods

PERFECT is a 3-year double blind randomised placebo controlled trial to determine the effect of perindopril 8 mg once daily on brachial artery endothelial function in patients with stable CAD without clinical heart failure. Endothelial function in response to ischaemia was assessed using ultrasound. Primary endpoint was difference in flow-mediated vasodilatation (FMD) assessed at 36 months.

Results

In 20 centers, 333 patients randomly received perindopril or matching placebo. Ischemia-induced FMD was 2.7% (SD 2.6). In the perindopril group FMD went from 2.6% at baseline to 3.3% at 36 months and in the placebo group from 2.8 to 3.0%. Change in FMD after 36 month treatment was 0.55% (95% confidence interval −0.36, 1.47; p = 0.23) higher in perindopril than in placebo group. The rate of change in FMD per 6 months was 0.14% (SE 0.05, p = 0.02) in perindopril and 0.02% (SE 0.05, p = 0.74) in placebo group (0.12% difference in rate of change p = 0.07).

Conclusion

Perindopril resulted in a modest, albeit not statistically significant, improvement in FMD.

Health-related behaviours of people with diabetes and those with cardiometabolic risk factors: results from SHIELD

OBJECTIVES

The study assessed knowledge, attitudes and behaviours towards health, diabetes, diet and exercise among respondents with type 2 diabetes mellitus and those with cardiometabolic risk factors.

METHODS

Respondents in the SHIELD study reported their health conditions, exercise, diet and weight loss. Three groups were assessed: (i) type 2 diabetes, (ii) high risk (HR) defined as 3-5 of the following factors: abdominal obesity, BMI > or = 28 kg/m(2), reported diagnosis of dyslipidaemia, hypertension, coronary heart disease or stroke and (iii) low risk (LR) defined as < or = 2 factors. Comparisons across groups were made using analysis of variance.

RESULTS

More type 2 diabetes and HR respondents (> 46%) received recommendations to change their lifestyle habits (increase exercise and change eating habits), compared with < 29% of LR respondents, p < 0.0001. Less than 25% of respondents agreed that type 2 diabetes is not as serious as type 1 diabetes and > 85% agreed that obesity can aggravate or contribute to onset of chronic conditions. Mean number of healthcare visits was highest in type 2 diabetes (11.0) than HR (9.4) and LR (6.1) groups, p < 0.05. Type 2 diabetes and HR respondents were least likely to report exercising regularly (26%), compared with LR (37%), p < 0.05. More type 2 diabetes (70%) and HR (72%) respondents reported trying to lose weight vs. LR respondents (55%), p < 0.05.

CONCLUSIONS

Type 2 diabetes and HR respondents reported attitudes and knowledge conducive to good health, but the majority of respondents did not translate these positive traits into healthy behaviour with respect to diet, exercise and weight loss.

Effectiveness of statins in Medicare-eligible patients and patients < 65 years using clinical practice data

OBJECTIVE

This study compared effectiveness of rosuvastatin (RSV) with other statins on lowering LDL-C and LDL-C goal attainment among Medicare-eligible patients (age >or= 65 years) and patients with age < 65 years treated in usual clinical practice to provide evidence of real-world effectiveness of statins.

METHODS

Retrospective cohort study was conducted in patients, newly prescribed statin therapy during August 2003 to May 2005. Patient inclusion criteria: no prior prescription for dyslipidaemic medication in the preceding 12 months, continuously enrolled for >or= 15 months and >or= 90-day supply of statin. Effectiveness of RSV in reducing LDL-C and attaining LDL-C goal when compared with other statins was evaluated using multivariate regression, adjusting for baseline LDL-C, age, gender, smoking, hypertension, coronary heart disease (CHD), systolic blood pressure and therapy duration.

RESULTS

Adjusted per cent LDL-C reduction was significantly greater (p < 0.05) with RSV (24.3% for >or= 65 and 28.5% for < 65) compared with ATV (17.5%, 21.3%), SMV (14.8%, 18.4%), PRV (11.3%, 15.8%), FLV (10.7%, 20.6%) and LOV (13.3%, 14.4%). Among patients in both age groups at high or moderate CHD risk, a greater proportion of RSV patients attained LDL-C goal (76.0% for age group >or= 65 years and 78.4% for age group < 65 years) vs. 50.5-73.0% for >or= 65 and 51.3-71.5% for < 65 years of age on other statins (p < 0.0001).

CONCLUSIONS

Rosuvastatin is more effective in lowering LDL-C in Medicare-eligible patients and patients < 65 years of age when compared with other statins in usual clinical practice. Moreover, RSV patients had higher LDL-C goal attainment rates when compared with other statins in high- and moderate-risk patients. The study results have implications for clinicians in selecting the optimal statin to meet individual patient care needs.

Adverse prognosis associated with the metabolic syndrome in established coronary artery disease: data from the EUROPA trial

OBJECTIVE

To assess the prevalence of metabolic syndrome, and its effect on cardiovascular morbidity and mortality in patients with established coronary disease and to explore the inter-relationships between metabolic syndrome, diabetes, obesity and cardiovascular risk.

METHODS

The presence of metabolic syndrome was determined in 8397 patients with stable coronary disease from the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease, with mean follow-up of 4.2 years. Metabolic syndrome was defined using a modified version of the National Cholesterol Education Programme criteria.

RESULTS

Metabolic syndrome was present in 1964/8397 (23.4%) of the population and significantly predicted outcome; relative risk (RR) of cardiovascular mortality = 1.82 (95% CI 1.40 to 2.39); and fatal and non-fatal myocardial infarction RR = 1.50 (95% CI 1.24 to 1.80). The association with adverse outcomes remained significant after adjustment, RR of cardiovascular mortality after adjustment for conventional risks and diabetes = 1.39 (95% CI 1.03 to 1.86). In comparison with normal weight subjects without diabetes or metabolic syndrome, normal weight dysmetabolic subjects (with either diabetes or metabolic syndrome) were at substantially increased risk of cardiovascular death (RR = 4.05 (95% CI 2.38 to 6.89)). The relative risks of cardiovascular death for overweight and obese patients with dysmetabolic status were nominally lower (RR = 3.01 (95% CI 1.94 to 4.69) and RR = 2.35 (95% CI 1.50 to 3.68), respectively).

CONCLUSIONS

Metabolic syndrome is associated with adverse cardiovascular outcome, independently of its associations with diabetes and obesity. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Minimising cold damage during reproductive development among temperate rice genotypes. II. Genotypic variation and flowering traits related to cold tolerance screening

Low temperature during microspore development increases spikelet sterility and reduces grain yield in rice (Oryza sativa L.). The objectives of this study were to determine genotypic variation in spikelet sterility in the field in response to low temperature and then to examine the use of physio-morphological traits at flowering to screen for cold tolerance. Multiple-sown field experiments were conducted over 4 consecutive years in the rice-growing region of Australia to increase the likelihood of encountering low temperature during microspore development. More than 50 cultivars of various origins were evaluated, with 7 cultivars common to all 4 years. The average minimum temperature for 9 days during microspore development was used as a covariate in the analysis to compare cultivars at a similar temperature. The low-temperature conditions in Year 4 identified cold-tolerant cultivars such as Hayayuki and HSC55 and susceptible cultivars such as Sasanishiki and Doongara. After low temperature conditions, spikelet sterility was negatively correlated with the number of engorged pollen grains, anther length, anther area, anther width, and stigma area. The number of engorged pollen grains and anther length were found to be facultative traits as their relationships with spikelet sterility were identified only after cold water exposure and did not exist under non-stressed conditions.

Vasculitis masquerading as aortic valve endocarditis

Small vessel vasculitis and endocarditis can both present with multisystem involvement and may present a diagnostic dilemma. Renal and cardiac involvement is common in small vessel vasculitis and rarely small vessel vasculitis may cause heart block. When a patient presents with diffuse symptoms, deteriorating renal function, and heart block, endocarditis and vasculitis should be included in the differential diagnosis. The case is discussed of a man with a history of aortic valve endocarditis who presented again with similar symptoms, deteriorating renal function, and heart block. There was no evidence of aortic valve endocarditis with abscess formation. A renal biopsy confirmed small vessel vasculitis and the patient responded promptly to immunosuppressive treatment. Correct diagnosis is essential in such cases, as immunosuppression in true endocarditis can be catastrophic. In this case, with the correct diagnosis, immunosuppression proved life saving and prevented erroneous aortic valve surgery.

Preprocedural inflammatory markers do not predict restenosis after successful coronary stenting

BACKGROUND

Levels of C-reactive protein (CRP), serum amyloid A protein (SAA), and interleukin-6 (IL-6) can predict coronary restenosis following angioplasty and stent deployment in patients with unstable angina. We investigated whether measurement of periprocedural inflammatory markers predicted the angiographic outcome at 6 months in stable angina patients undergoing coronary stenting.

METHODS

We prospectively studied 182 patients; 152 patients underwent elective and successful stenting procedure for de novo lesions in native and nongrafted coronary arteries and 30 individuals in the control group underwent diagnostic angiography alone. CRP, SAA, and IL-6 were determined by high-sensitivity immunoassays.

RESULTS

At 6 months, quantitative computer-assisted angiographic analysis in 133 patients with stents showed a binary restenosis rate of 33.8%. Statins were being taken by 80% of the patients. There were no significant differences between the pre- or postprocedure values of CRP, SAA, or IL-6 in patients with or without in-stent restenosis.

CONCLUSIONS

Preprocedural inflammatory markers in stable angina subjects undergoing coronary artery stent deployment did not correlate with the development of in-stent restenosis. Differences in pathobiology between stable and unstable coronary syndromes, the widespread use of statins with anti-inflammatory activity in our cohort of patients, along with different mechanisms underlying the early angiographic appearances of restenosis as compared to clinical end points, most likely explain our findings.

Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study)

BACKGROUND

Treatment with angiotensin-converting-enzyme (ACE) inhibitors reduces the rate of cardiovascular events among patients with left-ventricular dysfunction and those at high risk of such events. We assessed whether the ACE inhibitor perindopril reduced cardiovascular risk in a low-risk population with stable coronary heart disease and no apparent heart failure.

METHODS

We recruited patients from October, 1997, to June, 2000. 13655 patients were registered with previous myocardial infarction (64%), angiographic evidence of coronary artery disease (61%), coronary revascularisation (55%), or a positive stress test only (5%). After a run-in period of 4 weeks, in which all patients received perindopril, 12218 patients were randomly assigned perindopril 8 mg once daily (n=6110), or matching placebo (n=6108). The mean follow-up was 4.2 years, and the primary endpoint was cardiovascular death, myocardial infarction, or cardiac arrest. Analysis was by intention to treat.

FINDINGS

Mean age of patients was 60 years (SD 9), 85% were male, 92% were taking platelet inhibitors, 62% beta blockers, and 58% lipid-lowering therapy. 603 (10%) placebo and 488 (8%) perindopril patients experienced the primary endpoint, which yields a 20% relative risk reduction (95% CI 9-29, p=0.0003) with perindopril. These benefits were consistent in all predefined subgroups and secondary endpoints. Perindopril was well tolerated.

INTERPRETATION

Among patients with stable coronary heart disease without apparent heart failure, perindopril can significantly improve outcome. About 50 patients need to be treated for a period of 4 years to prevent one major cardiovascular event. Treatment with perindopril, on top of other preventive medications, should be considered in all patients with coronary heart disease.

The surgical treatment of morbid obesity

Obesity is the second leading cause of preventable death in the United States according to C. Everett Koop, M.D., former Surgeon General of the United States. The use of tobacco is the leading cause, but in the near future, obesity will become the first. Estimates of the percentage of adult Americans who are overweight range from 35% to 50%. Those who are morbidly obese (100 pounds or more overweight), number approximately 8 million. There is no doubt that obesity is a significant public health problem, particularly when its comorbidities are considered: diabetes, hyperlipidemia, hypertension, gastroesophageal reflux, cardiovascular disease, degenerative arthritis, cholelithiasis, respiratory insufficiency, cancer, sleep apnea, and many others. Serious medical problems are usually present in patients with morbid obesity. When significant long-term weight loss is accomplished for these patients, the comorbidities almost always improve or disappear entirely.

The endothelial nitric oxide synthase (Glu298Asp and -786T>C) gene polymorphisms are associated with coronary in-stent restenosis

AIMS

Coronary stent deployment is a major advance in percutaneous treatment of ischaemic heart disease, but 10-40% of patients still develop angiographic restenosis by 6 months due to neointimal hyperplasia. Patient-specific factors, including genetic factors, can contribute to this process. We have conducted a prospective study to examine the involvement of genetic risk factors (eNOS, ACE, MMP-3, IL-6, and PECAM-1) in restenosis following coronary stent deployment.

METHODS AND RESULTS

A total of 226 patients who underwent elective and successful coronary artery stenting to de novo lesions in native coronary arteries were studied. Two hundred and five (90.7%) patients were restudied by coronary angiogram at 6 months and the stented lesions were assessed using an automated quantitative angiography system. Genotype was determined by polymerase chain reaction (PCR) and restriction enzyme digestion. Restenosis rate, defined as >or=50% diameter stenosis, was 29.3%. The overall genotype frequency distributions were in Hardy-Weinberg equilibrium for all variants. Carriers of the 298Asp allele of the eNOS Glu298Asp polymorphism showed a higher frequency of restenosis with an odds ratio of 1.88 (95%CI: 1.01-3.51, P=0.043) compared to 298Glu homozygotes. Carriers of the -786C allele of the eNOS -786T>C polymorphism also showed a higher frequency of restenosis with odds ratio of 2.06 (95%CI: 1.08-3.94, P=0.028). These effects were essentially additive and were independent of other classical risk factors. Other studied genes did not show significant association with coronary in-stent restenosis.

CONCLUSION

In patients with coronary artery disease, the possession of the 298Asp and -786C variants of the eNOS gene are a risk factor for coronary in-stent restenosis, demonstrating the importance of the nitric oxide system in restenosis.

Potassium channel openers in myocardial ischaemia: therapeutic potential of nicorandil

Potassium channel openers or agonists represent a novel new class of compounds in the treatment of a range of cardiovascular disorders, particularly angina pectoris and hypertension. Nicorandil is the only clinically available potassium channel opener with antianginal effects, and with comparable efficacy and tolerability to existing antianginal therapy. It confers benefits through a dual action: opening the mitochondrial KATP channels leading to preconditioning of the myocardium and a nitrate-like effect. Myocardial preconditioning is important in reducing infarct size, severity of stunning and cardiac arrhythmias. These effects make nicorandil a unique antianginal compound that reduces both pre- and after-load and improves coronary blood flow. Comparative and noncomparative studies support the use of nicorandil as monotherapy or in combination with other antianginal therapy for stable angina pectoris. However, large studies are required to confirm its role in the treatment of acute coronary syndromes despite the favourable results from small studies.

Why is recurrent myocardial ischaemia a predictor of adverse outcome in unstable angina? An observational study of myocardial ischaemia and its relation to coronary anatomy

OBJECTIVE

To establish why recurrent myocardial ischaemia predicts adverse outcome in patients with refractory unstable angina on maximal medical treatment.

DESIGN

Prospective observational study in 101 patients with refractory unstable angina who underwent continuous ST-segment monitoring and kept detailed pain charts prior to cardiac catheterization. Setting Tertiary referral centre.

RESULTS

Significant coronary disease was identified in 90 subjects with 74 (82%) having multivessel disease, 41 (46%) complex lesion morphology, and 10 (11%) subjects with definite features of intra-coronary thrombus. The frequency of complex lesions or intra-coronary thrombus did not differ in relation to the extent of coronary disease. Recurrent chest pain was present in 72 of the 90 (80%) subjects, while transient ischaemia was detected in 26 (29%). The presence of transient ischaemia was a powerful predictor of complex lesions or thrombus (odds ratio 7.1;P<0.001). Subjects with severe recurrent chest pain had a greater frequency of intracoronary thrombus (odds ratio 9.5;P<0.05).

CONCLUSIONS

In unstable angina once the normal mechanisms causing myocardial ischaemia (i.e. increased myocardial demand and coronary vasoconstriction) have been treated using maximal antianginal treatment, the continued development of transient myocardial ischaemia is strongly associated with complex coronary lesion morphology and intracoronary thrombus. It is already known that patients with complex lesion morphology and intracoronary thrombus have an adverse outcome in unstable angina and therefore it is this association that explains why transient ischaemia is a predictor of poor outcome in unstable angina.

Circadian variation of the total ischemic burden and influence by beta-blocking agents

We investigated 150 unselected patients with proven coronary artery disease. All patients were off all routine antianginal treatments and there were 598 ischemic episodes, of which 75% were silent. It was found that episodes of ischemia, both silent and painful, occurred predominantly during the daytime hours from 0730 to 1930 h. This pattern is similar to that described by others. There was a significant excess of episodes of ischemia in the morning hours (0730-1330 h), with a secondary peak occurring in the evening hours. We further investigated a subgroup of 41 patients who were monitored for 1,581 h while being treated with atenolol. These patients were investigated in a double-blind fashion, and during the off treatment phase the circadian pattern of ischemic episodes was similar to that described for the group as a whole. However, on treatment with atenolol, there was a significant reduction in the frequency and total duration of ischemic episodes throughout the day. Atenolol significantly altered the circadian distribution of ischemic episodes with elimination of the morning peak; there was some preservation of the evening peak although this was smaller than that described when the patients were off therapy. The circadian distribution of ischemic episodes and the observed changes with beta-blocking treatment resemble the reported circadian variation of acute myocardial infarction and sudden death. Although these studies do not in any way prove that myocardial ischemic episodes and their alteration by treatment are related to the development of acute myocardial infarction and death, the relationship between ischemic episodes and the end points of coronary disease require further investigation.

Serum and urine markers of bone metabolism during the year after hip fracture

OBJECTIVE

As part of a larger study to describe indices of recovery during the year after hip fracture, the current prospective study investigated longitudinal changes in serum and urine markers of bone metabolism for the year after hip fracture and related them to bone mineral density (BMD).

DESIGN

A representative subset of participants provided serum and urine samples and had bone density measured at 3, 10, 60, 180, and 365 days postfracture.

SETTING

Two Baltimore hospitals.

PARTICIPANTS

The subjects were 205 community-dwelling, white women age 65 and older with fresh proximal femur fractures.

MEASUREMENTS

Samples were assayed for specific bone-related proteins and bone turnover markers, including serum osteocalcin (OC), procollagen type 1 carboxy-terminal extension peptide (PICP), bone-specific alkaline phosphatase (BAP), and urinary deoxypyridinoline (DPD) cross-links. Selected hormonal regulators of bone metabolism, including parathyroid hormone (PTH), calcitonin (CT), 1,25-dihydroxy vitamin D(3) (1,25 (OH)(2)D), and estrone (E(1)) were measured from serum samples. Repeated measures analyses were used to evaluate postfracture changes in each of the markers.

RESULTS

BAP, OC, and PICP were most active during the early postfracture period (3-60 days). BAP and OC remained elevated at 365 days compared with 3 days. DPD rose 48% from 3 days to 60 days, but this difference was not statistically significant. PTH and 1,25 (OH)(2)D increased steadily and significantly from 3 to 365 days. E(1) was highest at baseline and decreased at each time point, whereas CT showed no significant changes. When subjects were stratified into high-, medium-, and low-BMD groups based on their measurement at 3 days, both osteoclastic and osteoblastic markers in the low-BMD group displayed exaggerated and different patterns over time compared with the other groups.

CONCLUSION

Currently, the standard treatment of care for hip fractures still results in high morbidity and mortality and failure to regain prefracture quality of life. Gaining an understanding of bone cell activity in these patients after hip fracture, derived by measuring markers longitudinally during recovery, provides a baseline by which to measure the effectiveness of new interventions to improve recovery from hip fracture.

The EUROPA trial: design, baseline demography and status of the substudies

BACKGROUND

Angiotensin-converting enzyme inhibitors do reduce both mortality and morbidity in patients with left ventricular dysfunction, recent myocardial infarction and hypertension. However, the long-term effects in patients with coronary artery disease have not been established. The EUROPA study is designed to assess the long-term (3-4 years) effects of perindopril on the reduction of cardiac events in patients with proven stable coronary artery disease but with no evidence of heart failure.

STUDY DESIGN AND METHODS

EUROPA is a 12236 patient, randomised, double-blind, placebo-controlled and multicentre trial. EUROPA had an initial run-in period of 4 weeks during which patients received 4 and then 8 mg of perindopril daily to assess tolerance to maximum dose. This was followed by a double-blind randomisation to either perindopril or placebo. Patients were followed-up at 3 and 6 months and then 6 monthly until the last patient included in the main study completes the 3-year follow-up. EUROPA includes five sub-studies. Each of these sub-studies investigates the effects of perindopril on a different aspect of coronary artery disease: endothelial dysfunction, atherosclerosis progression regression, diabetes mellitus, inflammation, thrombosis, neurohormonal activation. Patients are characterised genetically to assess characteristics associated with improved or unfavourable outcome. The final results of EUROPA will be available in 2002.

Three-dimensional structure of human follicle-stimulating hormone

The crystal structure of a betaThr26Ala mutant of human follicle-stimulating hormone (hFSH) has been determined to 3.0 A resolution. The hFSH mutant was expressed in baculovirus-infected Hi5 insect cells and purified by affinity chromatography, using a betahFSH-specific monoclonal antibody. The betaThr26Ala mutation results in elimination of the betaAsn24 glycosylation site, yielding protein more suitable for crystallization without affecting the receptor binding and signal transduction activity of the glycohormone. The crystal structure has two independent hFSH molecules in the asymmetric unit and a solvent content of about 80%. The alpha- and betasubunits of hFSH have similar folds, consisting of central cystine-knot motifs from which three beta-hairpins extend. The two subunits associate very tightly in a head-to-tail arrangement, forming an elongated, slightly curved structure, similar to that of human chorionic gonadotropin (hCG). The hFSH heterodimers differ only in the conformations of the amino and carboxy termini and the second loop of the beta-subunit (L2beta). Detailed comparison of the structures of hFSH and hCG reveals several differences in the beta-subunits that may be important with respect to receptor binding specificity or signal transduction. These differences include conformational changes and/or differential distributions of polar or charged residues in loops L3beta (hFSH residues 62-73), the cystine noose, or determinant loop (residues 87-94), and the carboxy-terminal loop (residues 94-104). An additional interesting feature of the hFSH structure is an extensive hydrophobic patch in the area formed by loops alphaL1, alphaL3, and betaL2. Glycosylation at alphaAsn52 is well known to be required for full signal transduction activity and heterodimer stability. The structure reveals an intersubunit hydrogen bonding interaction between this carbohydrate and betaTyr58, an indication of a mechanism by which the carbohydrate may stabilize the heterodimer.

Understanding the bariatric surgical patient: a demographic, lifestyle and psychological profile

BACKGROUND

Although improved recently, the public is generally unaware of current scientific knowledge in bariatrics and the availability of surgery for massive obesity. As bariatric professionals we recognize the need for this education. Understanding the patientís socio-economic, demographic and psychological make-up and lifestyle preferences is a crucial element.

METHODS

1200 obesity surgery patients were sent questionnaires to assess a variety of personal parameters. 395 (33%) were returned and tabulated. A literature review of the obese person's psychological profile was also summarized.

RESULTS

An overview of these patients' height, weight, age, ethnicity, marital, educational and employment status, number of children, residential population, and income are presented. Their television and movie viewing, radio listening, social event participation, print media and Internet habits are described. The psychological profile is outlined so that the whole person is understood.

CONCLUSION

Understanding the obese person is primary to effectively educating the public. There are many appropriate and much-needed applications of this information to the public, the obese population, other health-care providers, legislators, and insurers.

A national Survey of Acute Myocardial Infarction and Ischaemia (SAMII) in the U.K.: characteristics, management and in-hospital outcome in women compared to men in patients under 70 years

AIMS

To assess the clinical characteristics, management and outcome of women compared to men with acute myocardial infarction or ischaemia.

DESIGN

A prospective clinical survey was made in a random sample of 94 District General Hospitals in the U.K. 1064 patients, <70 years of age, comprising six consecutive females and six consecutive males from each hospital, diagnosed on admission as acute coronary syndromes (myocardial infarction or myocardial ischaemia) were studied. Outcome measures included: admission and final diagnosis, time to delivery of care, inpatient management, complications and clinical outcome.

RESULTS

Five hundred and three women and 561 men were admitted with a diagnosis of acute myocardial infarction or myocardial ischaemia. Women were older, waited longer between seeking and receiving advice, and much less likely to have infarction than men. After adjustment for age, diagnosis and past medical history there were no gender differences in initial and subsequent hospital management, in complications (recurrent ischaemia, arrhythmias, temporary pacing, heart failure), any routine procedure or outcome. Of all patients, 3.4% died in a District General Hospital, 12.2% were transferred to Specialist Cardiac Centres and 84.4% discharged home. Prophylactic medication on discharge was similar for men and women.

CONCLUSION

After adjustment for age, diagnosis and past medical history, although women waited longer between seeking and receiving medical advice, in hospital their assessment, management, complications, outcome and follow-up arrangements were the same as for men. In hospital, management and outcomes were mainly influenced by age, diagnosis (infarction or ischaemia), a past history of coronary disease, but not by gender. This large, nationally representative, survey has found no evidence of important gender difference in the hospital management of acute ischaemic syndromes.