Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: do mitral valve leaflet length, septal thickness, or sex affect the outcome?

This retrospective cohort study aimed to assess whether basal septal wall thickness (BSWT), anterior (AML) and posterior (PML) mitral leaflet length, or sex were associated with remaining left ventricular outflow tract obstruction (LVOTO) in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA). One hundred fifty-four patients who underwent ASA at the Karolinska University Hospital in Stockholm, Sweden, between 2009 and 2021, were included retrospectively. Anatomical and hemodynamic parameters were collected from invasive catheterization before and during ASA, and from echocardiography (ECHO) examinations before, during, and at 1-year follow-up after ASA. Linear and logistic regression models were used to assess the association between sex, BSWT, AML, PML, and outcome, which was defined as the remaining LVOTO (≥ 30 mmHg) after ASA. The median follow-up was 364 days (interquartile range 334-385 days). BSWT ≥ 23 mm (n = 13, 12%) was associated with remaining LVOTO at follow-up (p = 0.004). Elongated mitral valve leaflet length (either AML or PML) was present in 125 (90%) patients. Elongated AML (> 24 mm) was present in 67 (44%) patients, although AML length was not associated with remaining LVOTO at follow-up. Elongated PML (> 14 mm) was present in 114 (74%) patients and was not associated with remaining LVOTO at follow-up. No significant sex differences were observed regarding the remaining LVOTO. ECHO measurement of BSWT can be effectively used to select patients for successful ASA and identify those patients with a risk of incomplete resolution of LVOTO after ASA.

Risk assessment in patients with symptomatic and asymptomatic pre-excitation.

AIMS: Controversy remains as to whether the exercise stress test (EST) is sufficient for risk evaluation in patients with pre-excitation. This study aims to clarify the usefulness of EST in risk stratification in both asymptomatic and symptomatic patients presenting with pre-excitation. METHODS AND RESULTS: This prospective study includes consecutive asymptomatic and symptomatic patients with pre-excitation referred for risk assessment. All participants performed an incremental EST (bicycle) prior to an electrophysiology study (EPS). Primary data from the EST included loss of pre-excitation during exercise, and primary data from the EPS included the measurement of accessory pathway effective refractory period (APERP), shortest pre-excited RR interval (SPERRI), and inducible arrhythmia with the use of a beta-adrenergic receptor agonist if deemed necessary. One hundred and sixty-four patients (59 asymptomatic, 105 symptomatic) completed an EST and EPS. Forty-five patients (27%) demonstrated low-risk findings on EST, of which 19 were asymptomatic and 26 were symptomatic. Six patients with low-risk EST findings had SPERRI/APERP ≤ 250 ms at EPS, and two of them were asymptomatic. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of low-risk EST for excluding patients with SPERRI/APERP ≤ 250 ms were 40, 91, 87, 51, and 60%, respectively. The number of patients with inducible arrhythmia at EPS was similar in the asymptomatic (36, 69%) and symptomatic (73, 61%) groups. CONCLUSION: Sudden loss of pre-excitation during EST has a low NPV in excluding high-risk APs. The EPS with the use of isoproterenol should be considered to accurately assess the risk of patients with pre-excitation regardless of symptoms (ClinicalTrials.gov Identifier: NCT03301935).

[Cosmetic breast implants can influence cardiac imaging]. / Bröstimplantat kan försvåra diagnostik av hjärtsjukdomar.

Cosmetic breast implants are increasing in popularity. The presence of foreign material overlying the anterior wall of the heart can influence cardiac imaging and lead to misdiagnosis of cardiac disease.  Echocardiography is commonly used in patients for evaluation of cardiac structure and function. Breast implants can cause impaired quality of the echocardiographic images because of an interaction between the implant material and the ultrasound beam, and as a consequence this can lead to a decreased diagnostic accuracy. In myocardial perfusion imaging breast implant can induce attenuation artifacts, which can be mistaken for myocardial infarction. The number of indications for cardiac MRI examinations are increasing, but also with this technique the presence of breast implants can induce artefacts that impair the possibilities to optimal quality. Women considering breast augmentation should be informed of the risk that the procedure can result in impaired quality of different cardiac imaging modalities.

Aerobic exercise capacity is maintained over a 5-year period in mild-to-moderate chronic kidney disease: a longitudinal study.

BACKGROUND: Aerobic exercise capacity is reduced in non-dialysis chronic kidney disease (CKD), but the magnitude of changes in exercise capacity over time is less known. Our main hypothesis was that aerobic ExCap would decline over 5 years in individuals with mild-to-moderate CKD along with a decline in renal function. A secondary hypothesis was that such a decline in ExCap would be associated with a decline in muscle strength, cardiovascular function and physical activity. METHODS: We performed a 5-year-prospective study on individuals with mild-to-moderate CKD, who were closely monitored at a nephrology clinic. Fiftytwo individuals with CKD stage 2-3 and 54 age- and sex-matched healthy controls were included. Peak workload was assessed through a maximal cycle exercise test. Muscle strength and lean body mass, cardiac function, vascular stiffness, self-reported physical activity level, renal function and haemoglobin level were evaluated. Tests were repeated after 5 years. Statistical analysis of longitudinal data was performed using linear mixed models. RESULTS: Exercise capacity did not change significantly over time in either the CKD group or controls, although the absolute workloads were significantly lower in the CKD group. Only in a CKD subgroup reporting low physical activity at baseline, exercise capacity declined. Renal function decreased in both groups, with a larger decline in CKD (p = 0.05 between groups). Peak heart rate, haemoglobin level, handgrip strength, lean body mass and cardiovascular function did not decrease significantly over time in CKD individuals. CONCLUSIONS: On a group level, aerobic exercise capacity and peak heart rate were maintained over 5 years in patients with well-controlled mild-to-moderate CKD, despite a slight reduction in glomerular filtration rate. In line with the maintained exercise capacity, cardiovascular and muscular function were also preserved. In individuals with mild-to-moderate CKD, physical activity level at baseline seems to have a predictive value for exercise capacity at follow-up.

Cardiovascular changes in patients with mild-to-moderate chronic kidney disease compared with healthy subjects: a 5-year follow-up study.

BACKGROUND: There is limited knowledge about how cardiovascular parameters change over time in patients with mild-to-moderate chronic kidney disease (CKD). We studied several cardiovascular biomarkers over a 5-year period in patients with mild-to-moderate CKD and in healthy controls. METHODS: Fifty-four patients with CKD stages 2-3 and 54 controls were included. The CKD patients were closely monitored and well controlled for hypertension and other cardiovascular risk factors. Ambulatory blood pressure (BP) monitoring, ankle-brachial index (ABI), carotid and cardiac ultrasound (including measurement of the left ventricular mass index (LVMI)), and biochemical analyses were evaluated. RESULTS: Renal function decreased in both groups, with no significant difference in the change over time. In the CKD patients, none of the BP variables increased over time, but in the controls, average 24-h and daytime systolic BP increased significantly. ABI increased slightly in the CKD patients (P<0·001), but not in the controls (P = 0·963), and phosphate had a significant positive effect on ABI. Although in the CKD patients, there was no significant increase over time in common carotid artery diameter (P = 0·274), there was a small but significant increase in the controls (P = 0·001). LVMI increased significantly over time in both groups. CONCLUSIONS: In our study of patients with mild-to-moderate CKD, the progression of cardiovascular changes over time was relatively slow. Good BP control and treatment of other risk factors may have contributed to slow the progress of cardiovascular involvement, which emphasizes the importance of dedicated care in this population.

Changes in Vitamin D Status in Overweight Middle-Aged Adults with or without Impaired Glucose Metabolism in Two Consecutive Nordic Summers.

BACKGROUND: Sun exposure is the main driver of vitamin D synthesis. High latitude, obesity, and type 2 diabetes mellitus (T2DM) are all risk factors for vitamin D deficiency. However, the seasonal variation in vitamin D concentrations (25[OH]D) in such populations before and after sun exposure during the summer is unknown. Therefore, we investigated 25[OH]D status before and after two consecutive summers in high latitude and its associations with body fat, sex, and glucose metabolism. METHODS: 158 participants from Sweden (87 women, 71 men; mean age, 60 ± 5 y; body mass index ≥ 25 kg/m2) and 25[OH]D were measured and evaluated in relation to normal or impaired glucose tolerance, body composition, and dietary habits during summer season. RESULTS: Eighty-four percent of the participants were categorized with low to deficient 25[OH]D values before summer (55.1 ± 21.7 nmol·L-1), with a significant increase after the summer season (66.3 ± 21.0 nmol·L-1; P < 0.001). However, the values remained below the recommended range (76-250 nmol·L-1) in 66% of the participants. These findings were verified in a subgroup of the study population during the subsequent summer. Participants who reported use of vitamin D supplements had higher initial concentrations (64.2 ± 20.1 nmol·L-1) compared to nonusers (53.7 ± 21.7 nmol·L-1; P=0.04). Further, 25[OH]D values correlated negatively with fat mass (kg) prior to summer only in the female population (r=-0.29, P=0.008). CONCLUSIONS: In the present study, sun exposure had a beneficial but insufficient effect on 25[OH]D levels, and the same levels were documented in two consecutive summer seasons, confirming that vitamin D supplementation in both summer and winter should be considered in this population.

Gradual reduction in exercise capacity in chronic kidney disease is associated with systemic oxygen delivery factors.

BACKGROUND: The cause of reduced exercise capacity (ExCap) in chronic kidney disease (CKD) is multifactorial. The aim of this study was to investigate determinants of aerobic ExCap in patients with mild to severe CKD not undergoing dialysis. METHODS: We included 52 individuals with CKD stage 2-3, 47 with stage 4-5, and 54 healthy controls. Peak workload and peak heart rate (HR) were assessed by a maximal cycle exercise test. Cardiac function including stroke volume (SV) and vascular stiffness were evaluated by ultrasound at rest. Handgrip strength, body composition, haemoglobin level and self-reported physical activity were assessed. RESULTS: Peak workload (221±60, 185±59, 150±54 W for controls, CKD 2-3 and CKD 4-5 respectively), peak HR (177±11, 161±24, 144±31 beats/min) and haemoglobin level (14.2±1.2, 13.5±1.4, 12.2±1.3 g/dL) were all three significantly lower in CKD 2-3 than in controls, (p = 0.001, 0.001 and 0.03 respectively) and were even lower in stages 4-5 CKD than in CKD 2-3 (p = 0.01, 0.001 and <0.001 respectively). Resting SV and lean body mass did not differ between groups and handgrip strength was significantly lower only in CKD 4-5 compared to controls (p = 0.02). Peak workload was strongly associated with the systemic oxygen delivery factors: SV, peak HR and haemoglobin level. These three factors along with age, sex and height2 explained 82% of variation in peak workload. Peak HR contributed most to the variation; the peripheral variables handgrip strength and vascular stiffness did not improve the explanatory value in regression analysis. CONCLUSIONS: In this cross-sectional study of CKD patients not on dialysis, aerobic ExCap decreased gradually with disease severity. ExCap was associated mainly with systemic oxygen delivery factors, in particular peak HR. Neither muscle function and mass, nor vascular stiffness were independent determinants of aerobic ExCap in this group of CKD patients.

Aspects of carotid structure and function in health and different stages of chronic kidney disease.

INTRODUCTION: Arterial remodelling and stiffening have been demonstrated in end-stage renal disease (ESRD). The presence of vascular alterations in earlier-stage chronic kidney disease (CKD) is less studied. We evaluated vascular structure and function in mild-to-moderate CKD (stages 2-3) compared with healthy subjects and advanced CKD (stages 4-5). METHODS: Carotid ultrasound was performed in 103 non-dialysis CKD patients and 54 healthy controls. Carotid intima-media thickness (CIMT) and common carotid artery (CCA) diameter were measured. Strain, stiffness and the pressure-strain elastic modulus (Ep ) of the right CCA were calculated. RESULTS: There was no significant difference in CCA diameter between CKD 2-3 and controls. The CCA diameter was larger in CKD 4-5 compared with CKD 2-3 and controls (CKD 4-5, 6·50 ± 0·79 mm versus CKD 2-3, 6·08 ± 0·56 mm, P = 0·003; and versus controls 5·97 ± 0·53 mm, P<0·001). However, after adjustments, the difference in CCA diameter was valid only for older ages and also dependent on systolic blood pressure (SBP). There were no significant differences in CIMT, strain or stiffness between the groups, but Ep was higher in CKD 4-5 compared with controls (P = 0·006). CONCLUSION: In mild-to-moderate CKD, there were no significant differences in carotid artery structure or function compared with healthy subjects. Only patients with advanced CKD and older ages showed signs of arterial remodelling. Our study indicates that vascular alterations occur in advanced CKD, with SBP and age as important contributing factors.

Intima-media thickness of the descending aorta in patients with bicuspid aortic valve.

OBJECTIVE: A bicuspid aortic valve (BAV) is associated with accelerated aortic valve disease (AVD) and abnormalities in aortic elasticity. We investigated the intima-media thickness of the descending aorta (AoIMT) in patients with AVD with or without an ascending aortic aneurysm (AscAA), in relation to BAV versus tricuspid aortic valve (TAV) phenotype, type of valve disease, cardiovascular risk factors, and single-nucleotide polymorphisms (SNPs) with a known association with carotid IMT. METHODS AND RESULTS: 368 patients (210 with BAV, 158 with TAV,); mean age 64 ± 13 years) were examined using transesophageal echocardiography (TEE) before valvular and/or aortic surgery. No patient had a coronary disease (CAD). The AoIMT was measured on short-axis TEE images of the descending aorta using a semi-automated edge-detection technique. AoIMT was univariately (P < 0.05) related to age, blood pressure, smoking, creatinine, highly sensitive C-reactive protein, HDL, valve hemodynamics and BAV. In the TAV subgroup it was also associated with the rs200991 SNP. Using multivariate regression analysis, age was the main determinant for AoIMT (P < 0.001), followed by male gender (P = 0.02), BAV was no longer a significant predictor of AoIMT. AoIMT was still related to the rs200991 SNP in TAV (P = 0.034), and to creatinine in BAV (P = 0.019), when other variables were accounted for. CONCLUSIONS: Intima-media thickness of the descending aorta is not affected by aortic valve morphology (BAV/TAV); age is the main determinant of AoIMT. Genetic markers (SNPs) known to influence IMT in the carotid artery seem to correlate to IMT in the descending aorta only in patients with TAV.

Aortic valve type and calcification as assessed by transthoracic and transoesophageal echocardiography.

INTRODUCTION: Aortic valve calcification (AVC) may predict poor outcome. Bicuspid aortic valve (BAV) leads to several haemodynamic changes accelerating the progress of aortic valve (AV) disease. AIMS: To compare the diagnostic accuracy of transoesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) in the assessment of aortic valve phenotype and degree of AVC, with intra-operative evaluation as a reference. METHODS: We examined 169 patients (median age 65 years, 51 women) without significant coronary artery disease undergoing AV and/or aortic root surgery. TTE was performed within a week prior to surgery and TEE at the time of surgery. RESULTS: Compared with surgical AVC assessment, visual evaluation using a 5-grade scoring system and real-time images showed a higher correlation (TTE r = 0·83 and TEE r = 0·82) than visual (TTE r = 0·64 and TEE 0·63) or grey scale mean (GSMn) (TTE r = 0·63 and TEE r = 0·52) assessment of end-diastolic still frames. AVC assessment using real-time images showed high intraclass correlation coefficients (TTE 0·94 and TEE 0·93). With regard to BAV, TEE was superior to TTE with a higher interobserver agreement, sensitivity and specificity (0·86, 92% and 94% versus 0·57, 77% and 82%, respectively). CONCLUSION: Semi-quantitative AVC assessment of real-time cine loops from both TEE and TTE correlated well with intra-operative evaluation of AVC. Applying a predefined scoring system for AVC evaluation assures a high interobserver correlation. TEE was superior to TTE for evaluation of valve phenotype and should be considered when a diagnosis of BAV is clinically important.

Cardiac remodelling and functional alterations in mild-to-moderate renal dysfunction: comparison with healthy subjects.

INTRODUCTION: Left ventricular (LV) hypertrophy (LVH) and reduced LV function correlate with poor prognosis in patients with chronic kidney disease (CKD). Our aim is to investigate whether mild-to-moderate CKD is associated with cardiac abnormalities. METHODS: Echocardiography, including tissue Doppler imaging, was performed in 103 patients with CKD at stages 2-3 and 4-5, and in 53 healthy controls. The systolic (s') and diastolic myocardial velocity (e'), and the transmitral diastolic flow velocity (E) were measured, and E/e' was calculated. RESULTS: Patients with chronic kidney disease had higher mean E/e' than controls (mean E/e': controls 5·00 ± 1·23 versus CKD 4-5 6·36 ± 1·71, P<0·001 and versus CKD 2-3 5·69 ± 1·47, P = 0·05), indicating altered diastolic function in the patients. The CKD groups showed lower longitudinal systolic function than controls, as assessed by atrio-ventricular plane displacement and s' (mean s': controls 11·5 ± 1·9 cm s(-1) versus CKD 4-5 10·4 ± 2·1 cm s(-1) , P = 0·03 and versus CKD 2-3 10·4 ± 2·1 cm s(-1) , P = 0·02). The prevalence of LVH was higher in patients with CKD than in controls (controls 13% versus CKD 4-5 37%, P = 0·006 and versus CKD 2-3 30%, P = 0·03). CONCLUSION: Alterations in systolic and diastolic myocardial function can be seen in mild-to-moderate CKD compared with controls, indicating that cardiac involvement starts early in CKD, which may be a precursor of premature cardiac morbidity.

Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial.

BACKGROUND AND AIMS: High-repetitive resistance training (RT) is recommended to increase peripheral muscular endurance in healthy adults; however, the effects of RT with this design on exercise capacity and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) is unknown. The study aimed to investigate if low-load/high-repetition elastic band RT could improve functional capacity, muscular function, endurance cycle capacity or HRQOL in patients with COPD. METHODS: A prospective, randomized, controlled, multicentre trial was constructed with concealed allocation, blinded outcome assessment and intention-to-treat analysis. A total of 44 patients with moderate-to-very-severe COPD (forced expiratory volume during the first second, 44.6% predicted) were included. Patients were randomized to either the experimental group receiving 8 weeks of RT (three sessions/week) in combination with patient education (four occasions) or the control group receiving the patient education alone. RESULTS: At post-tests, the between-group differences were in favor of the experimental group on the 6-min walk test [mean difference (95% confidence interval)]: 34 m (14-54) and the 6-min pegboard and ring test [20 rings (3-37)]. No difference between groups was found on the chronic respiratory disease questionnaire [0.1 (-0.2 to 0.4)]. On secondary outcomes, results were in favor of the experimental group regarding upper extremity endurance capacity, muscular function and depression, but no difference was seen between groups on endurance cycle capacity and HRQOL. CONCLUSION: RT can increase functional capacity and muscular function but not cycle endurance capacity and HRQOL in patients with moderate-to-severe COPD.

Criterion validation of two submaximal aerobic fitness tests, the self-monitoring Fox-walk test and the Åstrand cycle test in people with rheumatoid arthritis.

BACKGROUND: Aerobic capacity tests are important to evaluate exercise programs and to encourage individuals to have a physically active lifestyle. Submaximal tests, if proven valid and reliable could be used for estimation of maximal oxygen uptake (VO2max). The purpose of the study was to examine the criterion-validity of the submaximal self-monitoring Fox-walk test and the submaximal Åstrand cycle test against a maximal cycle test in people with rheumatoid arthritis (RA). A secondary aim was to study the influence of different formulas for age predicted maximal heart rate when estimating VO2max by the Åstrand test. METHODS: Twenty seven subjects (81% female), mean (SD) age 62 (8.1) years, diagnosed with RA since 17.9 (11.7) years, participated in the study. They performed the Fox-walk test (775 meters), the Åstrand test and the maximal cycle test (measured VO2max test). Pearson's correlation coefficients were calculated to determine the direction and strength of the association between the tests, and paired t-tests were used to test potential differences between the tests. Bland and Altman methods were used to assess whether there was any systematic disagreement between the submaximal tests and the maximal test. RESULTS: The correlation between the estimated and measured VO2max values were strong and ranged between r = 0.52 and r = 0.82 including the use of different formulas for age predicted maximal heart rate, when estimating VO2max by the Åstrand test. VO2max was overestimated by 30% by the Fox-walk test and underestimated by 10% by the Åstrand test corrected for age. When the different formulas for age predicted maximal heart rate were used, the results showed that two formulas better predicted maximal heart rate and consequently a more precise estimation of VO2max. CONCLUSIONS: Despite the fact that the Fox-walk test overestimated VO2max substantially, the test is a promising method for self-monitoring VO2max and further development of the test is encouraged. The Åstrand test should be considered as highly valid and feasible and the two newly developed formulas for predicting maximal heart rate according to age are preferable to use when estimating VO2max by the Åstrand test.

Elastic properties of the descending aorta in patients with a bicuspid or tricuspid aortic valve and aortic valvular disease.

BACKGROUND: The aim of this study was to explore possible differences in aortic strain, distensibility, and stiffness in the descending thoracic aorta between patients with bicuspid aortic valves (BAVs) and those with tricuspid aortic valves (TAVs) in relation to type of aortic valve disease and known cardiovascular risk factors. METHODS: Transesophageal echocardiography was used to examine 288 patients (mean age, 64 ± 13 years) in the operating room before surgery. The transesophageal echocardiographic images were analyzed offline using Velocity Vector Imaging software. One hundred forty patients had isolated severe aortic stenosis (AS) (89 of those with BAVs, 51 of those with TAVs), and 52 patients had isolated severe aortic regurgitation (AR) (24 of those with BAVs, 28 of those with TAVs). RESULTS: In patients with AS, stiffness in the descending aorta was 10 (range, 7.3-16) in those with BAVs and 13 (range, 11-18) in those with TAVs (P < .001). Distensibility was 19 kPa(-1) 10(-3) (range, 13-27 kPa(-1) 10(-3)) in patients with BAVs and 15 kPa(-1) 10(-3) (range, 11-19 kPa(-1) 10(-3)) in those with TAVs (P < .01). In patients with AR, stiffness was 6.9 (range, 5.5-7.8) in those with BAVs and 8.0 (range, 6.6-11) in those with TAVs (P < .05). After correction for age, dimension of the ascending aorta, cholesterol, and stroke volume in a multivariate regression model, BAV was associated with lower strain and distensibility of the descending aorta in the AR group and higher distensibility in the AS group, whereas stiffness was no longer related to aortic valve morphology in either of the two groups. CONCLUSIONS: The presence of BAVs in patients with severe AR is associated with lower strain and distensibility, suggesting that impairment of the elastic aortic properties may extend to the descending aorta. In patients with AS, BAVs correlate weakly with higher distensibility.

Real-time imaging required for optimal echocardiographic assessment of aortic valve calcification.

INTRODUCTION: Aortic valve calcification (AVC), even without haemodynamic significance, may be prognostically import as an expression of generalized atherosclerosis, but techniques for echocardiographic assessment are essentially unexplored. METHODS: Two-dimensional (2D) echocardiographic recordings (Philips IE33) of the aortic valve in short-axis and long-axis views were performed in 185 consecutive patients within 1 week before surgery for aortic stenosis (n = 109, AS), aortic regurgitation (n = 61, AR), their combination (n = 8) or dilation of the ascending aorta (n = 7). The grey scale mean (GSMn) of the aortic valve in an end-diastolic short-axis still frame was measured. The same frame was scored visually 1-5 as indicating that the aortic valve was normal, thick, or had mild, moderate or severe calcification. The visual echodensity of each leaflet was determined real time applying the same 5-grade scoring system for each leaflet, and the average for the whole valve was calculated. Finally, a similar calcification score for the whole valve based on inspection and palpation by the surgeon was noted. RESULTS: Visual assessment of real-time images using the proposed scoring system showed better correlation with the surgical evaluation of the degree of valve calcification (r = 0·83, P<0·001) compared to evaluation of stop frames by visual assessment (r = 0·66, P< 0·001) or the GSMn score (r = 0·64, P< 0·001). High inter- and intra-observer correlations were observed for real-time visual score (both intraclass correlation coefficient = 0·93). CONCLUSION: Real-time evaluation of the level of AVC is superior to using stop frames assessed either visually or by dedicated computer grey scale measurement software.

Does individual learning styles influence the choice to use a web-based ECG learning programme in a blended learning setting?

BACKGROUND: The compressed curriculum in modern knowledge-intensive medicine demands useful tools to achieve approved learning aims in a limited space of time. Web-based learning can be used in different ways to enhance learning. Little is however known regarding its optimal utilisation. Our aim was to investigate if the individual learning styles of medical students influence the choice to use a web-based ECG learning programme in a blended learning setting. METHODS: The programme, with three types of modules (learning content, self-assessment questions and interactive ECG interpretation training), was offered on a voluntary basis during a face to face ECG learning course for undergraduate medical students. The Index of Learning Styles (ILS) and a general questionnaire including questions about computer and Internet usage, preferred future speciality and prior experience of E-learning were used to explore different factors related to the choice of using the programme or not. RESULTS: 93 (76%) out of 123 students answered the ILS instrument and 91 the general questionnaire. 55 students (59%) were defined as users of the web-based ECG-interpretation programme. Cronbach's alpha was analysed with coefficients above 0.7 in all of the four dimensions of ILS. There were no significant differences with regard to learning styles, as assessed by ILS, between the user and non-user groups; Active/Reflective; Visual/Verbal; Sensing/Intuitive; and Sequential/Global (p = 0.56-0.96). Neither did gender, prior experience of E-learning or preference for future speciality differ between groups. CONCLUSION: Among medical students, neither learning styles according to ILS, nor a number of other characteristics seem to influence the choice to use a web-based ECG programme. This finding was consistent also when the usage of the different modules in the programme were considered. Thus, the findings suggest that web-based learning may attract a broad variety of medical students.

Strenuous physical exercise adversely affects monocyte chemotaxis.

Physical exercise is important for proper cardiovascular function and disease prevention, but it may influence the immune system. We evaluated the effect of strenuous exercise on monocyte chemotaxis. Monocytes were isolated from blood of 13 young, healthy, sedentary individuals participating in a three-week training program which consisted of repeated exercise bouts. Monocyte chemotaxis and serological biomarkers were investigated at baseline, after three weeks training and after four weeks recovery. Chemotaxis towards vascular endothelial growth factor-A (VEGF-A) and transforming growth factor-ß1 (TGF-ß1) was completely inhibited immediately after training (p<0.01), and remained so after four weeks recovery. Likewise, monocyte chemoattractant protein-1 (MCP-1)-induced migration declined after training (p<0.01) and improved only partially during the recovery period. MCP-1 serum levels were significantly reduced after four weeks recovery compared to baseline (p<0.01). Total blood antioxidant capacity was enhanced at this time point (p<0.01). Monocyte chemokinesis, TGF-ß1 and nitric oxide serum levels remained unchanged during the study. Strenuous three-week training consisting of repeated exercise bouts in healthy, sedentary individuals reduces monocyte chemotaxis. It remains to be established, whether this is a sound adaptation to increased stimuli or an untoward reaction to overtraining. Nevertheless, the effect remains for several weeks with no exercise.

The feasibility of velocity vector imaging by transesophageal echocardiography for assessment of elastic properties of the descending aorta in aortic valve disease.

BACKGROUND: Velocity vector imaging (VVI) is a novel two-dimensional speckle-based imaging technique for evaluation of tissue deformation. The aim of this study was to determine the feasibility and variability of VVI for the assessment of aortic strain, distensibility, and stiffness in patients with aortic valve disease. METHOD: Eighty-five patients (mean age 66 +/- 11 years) with aortic stenosis (AS) or aortic regurgitation (AR) were examined in the operating room before the operation using transesophageal echocardiography (TEE). The two-dimensional short-axis images and M-mode recordings of the descending aorta were acquired simultaneously with the invasive blood pressure measurement in the radial artery. The TEE images were analyzed off-line using VVI software. RESULTS: In comparison with patients with AS, patients with AR displayed significantly higher circumferential strain (7.6% +/- 4.5% vs. 3.7% +/- 1.9%, P < .001) and distensibility (27.1 +/- 12.8 kPa(-1)10(-3) vs. 17.2 +/- 7.2 kPa(-1)10(-3), P < .001) by VVI and distensibility (32.8 +/- 16.7 kPa(-1)10(-3) vs. 21.7 +/- 10.6 kPa(-1)10(-3), P < .004) by M-mode. Stiffness was higher in AS than AR, as measured by VVI (13.3 +/- 6.0 vs. 10.5 +/- 6.0, P < .01) and M-mode (11.2 +/- 6.1 vs. 10.4 +/- 9.1, P < .048). The correlations between VVI and M-mode distensibility (r = 0.84) and stiffness (r = 0.84) were both highly significant (P < .0001). The VVI strain measurements showed low inter- and intraobserver variability with intraclass correlations greater than 0.95 and coefficients of variation less than 10%. CONCLUSION: VVI-derived strain, distensibility, and stiffness differ significantly between AR and AS and correlate strongly with the corresponding M-mode-derived parameters. VVI is a feasible method for the assessment of the elastic properties of the descending aorta with low variability and has the advantage of incorporating the entire aortic wall circumference in the analysis, consequently accounting for local variations in the elastic properties of the aorta.

Oral contraceptives improve endothelial function in amenorrheic athletes.

Athletic amenorrhea has been associated with endothelial dysfunction and unfavorable lipid profile. Estrogen substitution may reverse these metabolic consequences. The aim of this study was to evaluate the effects of oral contraceptives (OCs) on endothelial function measured as flow-mediated dilatation (FMD) of the brachial artery, the lipid profile, and blood markers of endothelial activation (inflammation) in amenorrheic athletes. Age- and body mass index-matched groups of young endurance athletes with amenorrhea (n = 11), regularly cycling athletes (n = 13), and sedentary controls (n = 12) were examined before and after 9 months of treatment with a low dose, monophasic, combined OC (30 mug ethinyl estradiol and 150 mug levonorgestrel). The amenorrheic athletes displayed the lowest FMD at baseline and the largest increase after OC treatment. FMD also increased in the control group, but not in the regularly menstruating athletes, who had the highest values of FMD before treatment. All three groups, particularly the controls, showed moderate unfavorable changes in the lipid profile in accordance with previous known effects of a second generation OC. Furthermore, there was an overall increase in some inflammatory markers (high sensitive C-reactive protein and TNF-alpha) and a decrease in one of the markers (vascular cell adhesion molecule-1). We conclude that amenorrheic athletes benefit from treatment with OC with respect to endothelial function. OC treatment is also associated with some modest alterations in the lipid profile and in markers of inflammation.

Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile.

The aim of this study was to evaluate endothelial function measured as flow-mediated dilatation (FMD) of the brachial artery and blood markers of cardiovascular disease in young female endurance athletes with menstrual disturbance. Age- and body mass index-matched groups of young endurance athletes with amenorrhea (n = 14), oligomenorrhea (n = 9), and regular cycles (n = 12) and sedentary controls (n = 12) were compared with respect to endothelial function, lipid profile, markers of inflammation, and endocrine status. We found a significantly decreased FMD in the amenorrheic athletes, compared with all other groups. Amenorrheic athletes also had the most unfavorable lipid profile with significantly higher total cholesterol and low-density lipoprotein, compared with the other athlete groups. The oligomenorrheic athletes had the lowest levels of total cholesterol, low-density lipoprotein, and apolipoprotein B of all groups and significantly lower in comparison with the amenorrheic group. However, with respect to FMD, the oligomenorrheic group represented an intermediate between amenorrheic and regularly cycling subjects. There was a gradual impairment of FMD and the lipid profile to the degree of menstrual disturbance supporting an association with estrogen status. We conclude that amenorrhea in young endurance athletes is associated with endothelial dysfunction and unfavorable lipid profile. Additional studies are needed to elucidate the clinical implications of these results with regard to long-term risk for cardiovascular disease.