The occurrence of asthma in hospitalized patients with type 2 diabetes mellitus.

Diabetes mellitus (DM) has been found to be associated with cardiovascular disease. The goal of this study is to evaluate the prevalence of asthma in patients with type II DM after adjusting for other comorbid conditions. We used patient treatment files of inpatients' admissions containing discharge diagnosis (Classification of Mental and Behavioural Disorders (ICD)-9 codes) from Veterans Health Administration Hospitals. The patients were divided into two groups: ICD-9 code for DM and a control group with hypertension but no DM. ICD-9 codes for asthma were used to study the prevalence of asthma in DM patients versus the control. We performed uni- and multi-variable analysis adjusting for comorbid conditions. Asthma was present in 13 242 (4.5%) of DM patients versus 16 038 (2.9%) in the control group. Using multi-variable analysis, DM remained independently associated with asthma (odds ratio: 2.99; confidence interval: 2.92-3.06; P < 0.0001). The prevalence of asthma is significantly higher in hospitalized patients with type II DM independent of other comorbid conditions. The pathogenesis of this association is not known warranting further investigation.

Significant increase in the prevalence of non-rheumatic aortic valve disease in patients with type 2 diabetes mellitus.

BACKGROUND: Diabetes mellitus (DM) is a major risk for coronary artery disease and hyperlipidemia. The role of Diabetes as an independent risk factor for aortic stenosis or regurgitation has been controversial. The goal of this study was to evaluate any association between DM and non-rheumatic aortic valve disease using a very large database. METHOD: We used PTF documents containing discharge diagnosis using ICD-9 codes of inpatient treatment from all Veterans Health Administration Hospitals (VA). The data were stratified using ICD-9 code for DM (n=293,124), a control group with hypertension (HTN) but no DM (n=552,623). The occurrence of non-rheumatic aortic valve disease in DM patients was studied in comparison with the control. We performed multivariate analysis adjusting for coronary artery disease (CAD), congestive heart failure (CHF) , smoking, renal failure, and hyperlipidemia. RESULTS: Non-rheumatic aortic valve disease diagnosis was present in 7,322 (2.5%) of DM patients vs. 10,906 (2.0%) in the control group. (25% relative increase) Using multivariate analysis, DM remained strongly associated with non-rheumatic aortic valve disease: (odds ratio (OR): 2.23, 95%; confidential interval (CI): 2.16 to 2.30 p<0. 0001). CONCLUSION: Type II diabetes mellitus is independently associated with non-rheumatic aortic valve disease. Since women were underrepresented in our study, our results apply only to diabetic men. The cause of this association is not known. CONDENSE ABSTRACT:The role of Diabetes as an independent risk factor for aortic stenosis or regurgitation has been controversial. We used PTF documents containing discharge diagnosis using ICD-9 codes of inpatient treatment from Veterans Health Administration Hospitals (VA) were analysed.( DM (n=293,124), a control group with hypertension (HTN) but no DM (n=552,623)). The occurrence of non-rheumatic aortic valve disease in DM patients was studied in comparison with the control. Non-rheumatic aortic valve disease diagnosis was present in 7,322 (2.5%) of DM patients vs. 10,906 (2.0%) in the control group. Using multivariate analysis, DM remained strongly associated with non-rheumatic aortic valve disease: (odds ratio (OR): 2.23, 95%; confidential interval (CI): 2.16 to 2.30 p<0. 0001). Since women were underrepresented in our study, our results apply only to diabetic men.

Vancomycin use in a large teaching hospital in Shiraz, Islamic Republic of Iran, 2003.

We investigated adherence to the Hospital Infection Control Practice Advisory Committee (HICPAC) guidelines on vancomycin prescription in a large university-affiliated hospital in Shiraz. From August to December 2003, 200 hospitalized patients received vancomycin. For only 12 (6%) of these patients was vancomycin prescribed appropriately according to HICPAC guidelines. The main reasons why vancomycin use did not comply with HICPAC recommendations were: surgical prophylaxis in patients with negative cultures for resistant Gram-positive organisms, no investigation of vancomycin serum levels in patients receiving > 48 hours of vancomycin, vancomycin serum levels not repeated in patients receiving > 1 week of vancomycin, no appropriate adjustment of dosage with respect to serum levels in patients receiving vancomycin.

Strong independent association between obesity and essential hypertension.

Obesity and hypertension (HTN) are major risk factors for cardiovascular disease. Association between obesity and HTN has not been studied in a large populations following adjustment for comorbidities. The goal of this study was to evaluate any association between obesity and HTN after adjusting for baseline characteristics. We used ICD-9 codes for obesity and HTN from the Nationwide Inpatient Sample (NIS) databases. Two randomly selected years, 1992 and 2002, were chosen from the databases as two independent samples. We used uni- and multivariable analysis to study any correlation between obesity and HTN. The 1992 database contained a total of 6,195,744 patients. HTN was present in 37.2 % of patients with obesity versus 12% of the control group (OR: 4.36, CI 4.30-4.42, P < 0.001). The 2002 database contained a total of 7,153,982 patients. HTN was present in 50.7% of patients with obesity versus 25.6% of the control group (OR: 2.98, CI 2.96-3.00, P < 0.001). Using multivariable analysis adjusting for gender, hyperlipidaemia, age, smoking, type 2 diabetes and chronic renal failure, obesity remained correlated with HTN in both years (1992: OR 2.69, CI 2.67-2.72, P < 0.001; 2002: OR 2.98, CI 2.96-3.00, P < 0.001). The presence of obesity was found to be strongly and independently associated with HTN. The cause of this correlation is not known warranting further investigation.

The effect of chronic digitalization on pump function in systolic heart failure.

BACKGROUND: Short- and intermediate-term use of cardiac glycosides promotes inotropy and improves the ejection fraction in systolic heart failure. AIM: To determine whether chronic digitalization alters left ventricular function and performance. METHODS: Eighty patients with mild-to-moderate systolic heart failure (baseline ejection fraction < or =45%) participated from our institution in a multi-center, chronic, randomized, double-blind study of digitalis vs. placebo. Of the 40 survivors, 38 (20 allocated to the digitalis arm and 18 to the placebo arm) were evaluated at the end of follow-up (mean, 48.4 months). Left ventricular systolic function was assessed by both nuclear ventriculography and echocardiography. The ejection fraction was measured scintigraphically, while the ventricular volumes were computed echocardiographically. RESULTS: The groups did not differ, at baseline or end-of-study, with respect to the ejection fraction and the loading conditions (arterial pressure, ventricular volumes and heart rate) by either intention-to-treat or actual-treatment-received analysis. Over the course of the trial, the digitalis arm exhibited no significant increase in the use of diuretics (18%, P=0.33), in distinction from the placebo group (78%, P=0.004), and a longer stay on study drug among those patients who withdrew from double-blind treatment (28.6 vs. 11.4 months, P=0.01). CONCLUSION: Following chronic use of digitalis for mild-to-moderate heart failure, cross-sectional comparison with a control group from the same inception cohort showed no appreciable difference in systolic function or performance. Thus, the suggested clinical benefit cannot be explained by an inotropic effect.

The optimal treatment of STEMI: new pharmacological and device approaches.

Cardiovascular disease remains the leading cause of mortality worldwide. Many deaths are contributed to acute ST elevation myocardial infarction (STEMI). Recently, epidemiological studies have been shown reduction in STEMI related mortality over the last decade. This reduction has partially been attributed to new pharmacological and device advances that were utilized during STEMI treatment. The goal of this manuscript is to review new pharmacological and device approaches available in the treatment of STEMI patients.

Poor correlation of estimated pulmonary artery systolic pressure between echocardiography and right heart catheterization in patients awaiting cardiac transplantation: results from the clinical arena.

BACKGROUND: Pulmonary arterial pressure measurement is an integral part of the pre-heart transplant evaluation. In the clinical arena, the correlation and agreement between pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography versus catheterization in pre-heart transplant patients has not been studied. METHODS: Data on all patients evaluated for heart transplantation at our program between 2003 and 2005 (n = 176) were retrospectively reviewed. Patients with both transthoracic echocardiography (with interpretable images) and right heart catheterization performed were included (n = 108; mean time difference, 2.2 days; median, 2 days). The tricuspid valve regurgitant jet was identified by color flow Doppler and jet maximum velocity was measured by continuous wave Doppler. The PASP was estimated by using the modified Bernoulli equation and adding right atrial pressure. We correlated echocardiographically estimated PASP with that measured by right heart catheterization. RESULTS: Mean estimated PASP by echocardiography was 46.6 +/- 13.7 mmHg versus 44.8 +/- 17.9 mmHg by right heart catheterization (P = NS). However, the correlation between echocardiographic and measured PASP was poor (r = 0.49, P < .001). The correlation was poor in both ischemic and nonischemic cardiomyopathy. CONCLUSION: Among patients referred for heart transplant evaluation, there is poor agreement and correlation between echocardiographically estimated PASP and values obtained by right heart catheterization. Furthermore, echocardiographically obtained estimates of PASP should not be exclusively relied upon to exclude heart transplant recipient candidates.

Infection with Chlamydia pneumoniae and atherosclerosis: a review.

There are numerous studies that were able to find C. pneumoniae infections as a contributing factor in atherosclerosis pathogenesis. Positive serology for C. pneumoniae was found in most studies in patients with atherosclerosis (IgG, IgA, IgM). Most studies were able to correlate an elevated IgA antibody titer rather than the IgG titer to the risk for atherosclerosis. C. pneumoniae and its components (DNA, antigens) were detected in atherosclerotic plaques using immunohistochemistry, PCR, electron microscopy and cell cultures. C. pneumoniae has been located in endothelium, smooth muscle cells and macrophages of arterial wall with atherosclerosis but not in normal arteries. Cellular models have shown that C. pneumoniae is able to replicate in endothelium, macrophages and smooth muscle cells. A high C. pneumoniae antibody titer was found to correlate with high level of LDL and triglycerides and low level of HDL. C. pneumoniae infection increases platelet adhesion and adhesion molecules at the surface of endothelium. C. pneumoniae could be a cofactor for atherosclerosis combined with high level of lipids as shown in an animal model but not alone. Strong cellular and humoral immunity have been found in men with atherosclerosis and positive C. pneumoniae titers. This organism could be found in diverse arteries with atherosclerosis. One particular C. pneumoniae strain (AR 39) appears to be more frequently involved in atherosclerosis. Antibiotic treatment with azithromycin appears to be protective against atherosclerosis complications. However, there is as yet no conclusive evidence that C. pneumoniae causes atherosclerosis, but most likely it may enhance this process. Two large randomized clinical trials are currently underway evaluating azithromycin treatment in patients with atherosclerosis which will hopefully give us answers about the role of antibiotic treatment.

Prediction of non-occurrence of syncope during a tilt-table test by early heart rate variations.

A recent study showed that, in a select patient population with no drug use and no cardiac or other illness, an increase in heart rate equal to or less than 18 beats per minute from baseline in the first 6 minutes of a tilt-table test at 60 degrees identifies patients who will not develop syncope during prolonged tilting, with specificity and positive predictive value nearing 100 percent. We retrospectively reviewed 110 consecutive tilt-table tests at an angle of 70 degrees or more, performed at our institutions between 1994 and 1999 in patients with and without cardiac disease or drug use. Excluded were 320 additional patients due to either incomplete heart rate documentation or development of syncope in the first ten minutes of tilting. The difference between maximal heart rate in the first ten minutes during tilting and the average of at least two baseline heart rate measurements was used to assess correlation with the non-occurrence of syncope during the same test. The tilt-table angle used varied from 70 degrees to 90 degrees (80 degrees in 89 percent of patients). There was a strongly significant (p < 0.0001) correlation between a sustained rise in heart rate equal to or less than 18 beats per minute in the first ten minutes of tilting and the non-occurrence of subsequent syncope during the test. The sensitivity, specificity, positive and negative predictive values were 75.7 percent, 65.0 percent, 79.1 percent and 60.47 percent, respectively. These data indicate that even in the routine setting, that is, a non-select population and at a higher tilt-table angle, an increase in heart rate equal to or less than 18 beats per minute in the first ten minutes of tilting constitutes a good predictor of a negative test. However, the specificity and positive predictive value of this criterion were not high enough to justify an early termination of the test.

Diastolic effects of chronic digitalization in systolic heart failure.

BACKGROUND: The efficacy of short-term digitalization on exercise tolerance may, in part, reflect enhanced diastolic performance. However, cardiac glycosides can impair ventricular relaxation from cytosolic Ca++ overload. To detect any time-dependent adverse effect, we assessed the diastolic function after long-term use of digitalis in patients with mild to moderate systolic left ventricular failure. METHODS AND RESULTS: From a cohort of 80 patients who received long-term, randomized, double-blind treatment with digitalis versus placebo at the WJB Dorn Veterans Affairs Medical Center, 38 survivors were evaluated at the end of follow-up (mean 48.4 months) with evaluators blinded to treatment used. Each survivor underwent equilibrium scintigraphic and echocardiographic assessment of diastolic function. Peak and mean filling rates normalized with filling volume (FV), diastolic phase durations normalized with duration of diastole, and filling fractions were measured from the time-activity curve. The isovolumic relaxation period and ventricular dimensions were computed echocardiographically. By actual-treatment-received analysis, treated versus untreated patients manifested a trend toward longer isovolumic relaxation (80.76 ms vs 61.54 ms, P = .06) but a markedly lower peak rapid filling rate (6.39 FV/sec vs 10.56 FV/sec, P = .02) despite comparable loading conditions. In addition, treated patients exhibited a lower mean rate of rapid filling (2.75 FV/sec vs 3.78 FV/sec, P = .05) in the absence of a longer rapid filling duration. However, the end-diastolic ventricular dimension did not differ between the 2 groups. Similar results were obtained by intention-to-treat analysis. Importantly, the mortality rate from worsening heart failure in the inception cohort was lower in the digitalis group versus the placebo group (P = .05) with no difference in total cardiac or all-cause mortality. CONCLUSIONS: After long-term digitalization for systolic left ventricular failure, cross-sectional comparison with a control group from the same inception cohort shows a decrease in the rate and degree of ventricular relaxation. This effect did not interfere with the overall ventricular filling or with a favorable impact on outcome from worsening heart failure.