Lipid-related markers and cardiovascular disease prediction.

CONTEXT: The value of assessing various emerging lipid-related markers for prediction of first cardiovascular events is debated. OBJECTIVE: To determine whether adding information on apolipoprotein B and apolipoprotein A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 to total cholesterol and high-density lipoprotein cholesterol (HDL-C) improves cardiovascular disease (CVD) risk prediction. DESIGN, SETTING, AND PARTICIPANTS: Individual records were available for 165,544 participants without baseline CVD in 37 prospective cohorts (calendar years of recruitment: 1968-2007) with up to 15,126 incident fatal or nonfatal CVD outcomes (10,132 CHD and 4994 stroke outcomes) during a median follow-up of 10.4 years (interquartile range, 7.6-14 years). MAIN OUTCOME MEASURES: Discrimination of CVD outcomes and reclassification of participants across predicted 10-year risk categories of low (<10%), intermediate (10%-<20%), and high (≥20%) risk. RESULTS: The addition of information on various lipid-related markers to total cholesterol, HDL-C, and other conventional risk factors yielded improvement in the model's discrimination: C-index change, 0.0006 (95% CI, 0.0002-0.0009) for the combination of apolipoprotein B and A-I; 0.0016 (95% CI, 0.0009-0.0023) for lipoprotein(a); and 0.0018 (95% CI, 0.0010-0.0026) for lipoprotein-associated phospholipase A2 mass. Net reclassification improvements were less than 1% with the addition of each of these markers to risk scores containing conventional risk factors. We estimated that for 100,000 adults aged 40 years or older, 15,436 would be initially classified at intermediate risk using conventional risk factors alone. Additional testing with a combination of apolipoprotein B and A-I would reclassify 1.1%; lipoprotein(a), 4.1%; and lipoprotein-associated phospholipase A2 mass, 2.7% of people to a 20% or higher predicted CVD risk category and, therefore, in need of statin treatment under Adult Treatment Panel III guidelines. CONCLUSION: In a study of individuals without known CVD, the addition of information on the combination of apolipoprotein B and A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 mass to risk scores containing total cholesterol and HDL-C led to slight improvement in CVD prediction.

Process of care for battle casualties at Walter Reed Army Medical Center: Part IV. Occupational therapy service.

Occupational therapy addresses deficits in activities of daily living, upper-extremity motor performance deficits secondary to injury or disease, and occupational or role performance deficits attributable to mental and behavioral health conditions. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned.

Differences in risk factors for coronary heart disease among diabetic and nondiabetic individuals from a population with high rates of diabetes: the Strong Heart Study.

CONTEXT: Coronary heart disease (CHD) is the leading cause of death in the United States. OBJECTIVE: This study compares differences in risk factors for CHD in diabetic vs. nondiabetic Strong Heart Study participants. DESIGN: This was an observational study. SETTING: The study was conducted at three centers in Arizona, Oklahoma, and North and South Dakota. PARTICIPANTS: Data were obtained from 3563 of 4549 American Indians free of cardiovascular disease at baseline. INTERVENTION(S): CHD events were ascertained during follow-up. MAIN OUTCOME MEASURE: CHD events were classified using standardized criteria. RESULTS: In diabetic and nondiabetic participants, 545 and 216 CHD events, respectively, were ascertained during follow-up (21,194 and 22,990 person-years); age- and sex-adjusted incidence rates of CHD were higher for the diabetic group (27.5 vs. 12.1 per 1,000 person-years). Risk factors for incident CHD common to both groups included older age, male sex, prehypertension or hypertension, and elevated low-density lipoprotein cholesterol. Risk factors specific to the diabetic group were lower high-density lipoprotein cholesterol, current smoking, macroalbuminuria, lower estimated glomerular filtration rate, use of diabetes medication, and longer duration of diabetes. Higher body mass index was a risk factor only for the nondiabetic group. The association of male sex and CHD was greater in those without diabetes than in those with diabetes. CONCLUSIONS: In addition to higher incidence rates of CHD events in persons with diabetes compared with those without, the two groups differed in CHD risk factors. These differences must be recognized in estimating CHD risk and managing risk factors.

Heart rate is associated with markers of fatty acid desaturation: the GOCADAN study.

OBJECTIVES: To determine if heart rate (HR) is associated with desaturation indexes as HR is associated with arrhythmia and sudden death. STUDY DESIGN: A community based cross-sectional study of 1214 Alaskan Inuit. METHODS: Data of FA concentrations from plasma and red blood cell membranes from those ≥35 years of age (n = 819) were compared to basal HR at the time of examination. Multiple linear regression with backward stepwise selection was employed to analyze the effect of the desaturase indexes on HR, after adjustment for relevant covariates. RESULTS: The Δ(5) desaturase index (Δ(5)-DI) measured in serum has recently been associated with a protective role for cardiovascular disease. This index measured here in plasma and red blood cells showed a negative correlation with HR. The plasma stearoyl-CoA-desaturase (SCD) index, previously determined to be related to cardiovascular disease (CVD) mortality, on the other hand, was positively associated with HR, while the Δ(6) desaturase index (Δ(6)-DI) had no significant effect on HR. CONCLUSION: Endogenous FA desaturation is associated with HR and thereby, in the case of SCD, possibly with arrhythmia and sudden death, which would at least partially explain the previously observed association between cardiovascular mortality and desaturase activity.

Safety and feasibility of achieving lower systolic blood pressure goals in persons with type 2 diabetes: the SANDS trial.

The Stop Atherosclerosis in Native Diabetics Study (SANDS) was a randomized open-label clinical trial in type 2 diabetics designed to examine the effects of intensive reduction of blood pressure, aggressive vs standard goals (< or =115/75 mm Hg vs < or =130/80 mm Hg), and low-density lipoprotein (LDL) cholesterol on the composite outcome of change in carotid intimal-medial thickness and cardiovascular events. The study demonstrated that in conjunction with a lower LDL cholesterol target of 70 mg/dL, aggressive systolic blood pressure-lowering resulted in a reduction in carotid intimal-medial thickness and left ventricular mass without measurable differences in cardiovascular events. The blood pressure treatment algorithm included renin-angiotensin system blockade, with other agents added if necessary. The authors conclude that both standard and more aggressive systolic blood pressure reduction can be achieved with excellent safety and good tolerability in patients with type 2 diabetes mellitus.

Carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists.

OBJECTIVE: This report describes work-related upper extremity musculoskeletal disorders in four radiologists and identifies risk factors and preventive measures for these syndromes. SUBJECTS AND METHODS: Four radiologists with complaints of upper extremity pain, numbness, and weakness or a combination of symptoms were examined by an occupational therapist. The work activities and duties of all 12 staff radiologists in our filmless department were subsequently evaluated. Time working as staff, workday hours, and academic activities were recorded. Nonoccupational activities were also noted. An industrial hygienist evaluated the department work areas and staff offices. RESULTS: One radiologist had bilateral carpal tunnel syndrome, and all four radiologists had cubital tunnel syndrome (two [50%] unilateral, two [50%] bilateral). The four spent 3.4 +/- 0.3 years (mean +/- standard error of the mean) as staff radiologists in our filmless department, performing computer keyboard and mouse or trackball image manipulation and work list navigation, typing preliminary reports and telephone notifications, and editing electronically and approving dictated final reports. All four are academically active and had significantly greater workday hours (p < 0.05) and performed more research (p < 0.003) than the asymptomatic radiologists. Three (75%) of four radiologists routinely performed sonography. The industrial hygienist identified hazardous working conditions, especially related to ergonomics, in the reviewing areas and staff offices. CONCLUSION: Current technology renders staff radiologists at risk for work-related, upper extremity musculoskeletal disorders, including carpal and cubital tunnel syndromes. Proper equipment, ergonomics, and professional consultation should be used in all radiology departments.