Psychological Development during Medical School Clerkship: Relationship to Resilience.

OBJECTIVE: The authors investigated changes in medical students' defenses during clerkship and examined the effects of these changes on students' resilience. METHODS: Between 2012 and 2014, all year-2 preclinical students (N = 249) at Gyeongsang National University Medical School were asked to participate. Those who agreed to participate (N = 237) completed the Korean version of the Defense Style Questionnaire (K-DSQ) and the Connor-Davidson resilience scale-10 (CD-RISC-10). After clerkship, students who proceeded to year 4 in 2 years (n = 187 (93 females), aged 24-38 years (mean, 28.9 ± 2.8 years)) completed the K-DSQ, CD-RISC-10, and the Korean version of the Hospital Anxiety and Depression Scale (K-HADS) in September 2014, 2015, and 2016. RESULTS: The use of adaptive (W = 11,603.5, p < 0.001, r = 0.39) and self-inhibiting (W = 10,901.5, p < 0.001, r = 0.32) styles increased significantly after clerkship. A multiple linear regression analysis showed that changes in adaptive defense styles (B = 1.336, SE = 0.386, ß = 0.218, p = 0.001) during clerkship were significantly related to resilience after adjusting for age, sex, depression, and anxiety. CONCLUSIONS: Both positive personality development and maladaptive changes in defenses were evident. An increase in the adaptive defense style score was related to resilience.

Influence of physicochemical characteristics of flour on pancake quality attributes.

This study was conducted to identify the influence of flour characteristics of 13 Korean wheat cultivars on quality attributes of pancake. Pancake diameter showed negative correlation with SRC with distilled water and pancake height and positive correlation with springiness of cooked pancake. Springiness of baked pancake was under negative correlation with protein content, SDSS, dry gluten content, and positive correlation with final viscosity and setback in pasting properties of flour. Springiness and cohesiveness of baked pancake were under negative correlation with mixing time of Mixograph. Hardness of baked pancake was correlated with amylose content and breakdown of flour. Regression and principal component analysis indicated that pancake diameter, and springiness and cohesiveness of baked pancake can be explained by protein quantity and quality parameters, protein content, SDSS, mixing time of Mixograph, and SRCs related to protein content. Hardness of baked pancake can be predicted from amylose content and breakdown of flour. Batter viscosity as well as texture of cooked pancake could be influenced by protein quality and quantity according to grain hardness.

Hovenia Dulcis Extract Reduces Lipid Accumulation in Oleic Acid-Induced Steatosis of Hep G2 Cells via Activation of AMPK and PPARα/CPT-1 Pathway and in Acute Hyperlipidemia Mouse Model.

Hovenia dulcis Thunb. (HDT) was known to have anti-fatigue, anti-diabetes, neuroprotective, and hepatoprotective effects. In the present study, the anti-fatty liver mechanism of HDT was elucidated in oleic acid (OA)-treated Hep G2 cells and acute hyperlipidemia mouse model using Triton WR-1339. Here, HDT activated p-AMP-activated protein kinase (p-AMPK), proliferator activated receptor-α, carnitine palmitoyltransferase and also inhibited the expression of lipogenesis and cholesterol synthesis proteins, such as 3-hydroxy-3-methylglutaryl-CoA reductase, sterol regulatory element binding protein-1c, SREBP-2, and fatty acid synthase in OA-treated Hep G2 cells. Conversely, AMPK inhibitor compound C blocked the anti-fatty liver effect of HDT to induce AMPK phosphorylation and decrease 3-hydroxy-3-methylglutaryl-CoA reductase and lipid accumulation by oil red O staining in OA-treated Hep G2 cells. Additionally, HDT pretreatment protected against the increase of serum total cholesterol, triglyceride, low-density lipoprotein cholesterol and phospholipid in an acute hyperlipidemia mouse model with enhancement of glutathione reductase, glutathione peroxidase, superoxide dismutase, and catalase activities. Taken together, HDT inhibits OA-induced hepatic lipid accumulation via activation of AMPK and proliferator activated receptor-α/carnitine palmitoyltransferase signaling and enhancement of antioxidant activity as a potent candidate for nonalcoholic fatty liver disease and hyperlipidemia. Copyright © 2016 John Wiley & Sons, Ltd.

A wheat R2R3-MYB protein PURPLE PLANT1 (TaPL1) functions as a positive regulator of anthocyanin biosynthesis.

Transcriptional activation of anthocyanin biosynthesis genes in vegetative tissues of monocotyledonous plants is mediated by cooperative activity of one component from each of the following two transcription factor families: MYB encoded by PURPLE PLANT1/COLORED ALEURONE1 (PL1/C1), and basic helix-loop-helix (bHLH) encoded by RED/BOOSTER (R1/B1). In the present study, putative PL cDNA was cloned from the wheat (Triticum aestivum) cultivar Iksan370, which preferentially expresses anthocyanins in coleoptiles. Phylogenetic tree analysis of deduced amino acid sequences showed that a putative TaPL1 is highly homologous to barley (Hordeum vulgare) HvPL1, but is distinct from wheat TaC1. Transgenic Arabidopsis thaliana stably expressing putative TaPL1 accumulated anthocyanin pigments in leaves and up-regulated structural genes involved in both early and late anthocyanin biosynthesis steps. TaPL1 transcript levels in Iksan370 were more prominent in vegetative tissues such as young coleoptiles than in reproductive tissues such as spikelets. TaPL1 expression was significantly up-regulated by environmental stresses including cold, salt, and light, which are known to induce anthocyanin accumulation. These combined results suggest that TaPL1 is an active positive regulator of anthocyanin biosynthesis in wheat coleoptiles.

Evaluation of the incremental prognostic value of the combination of CYP2C19 poor metabolizer status and ABCB1 3435 TT polymorphism over conventional risk factors for cardiovascular events after drug-eluting stent implantation in East Asians.

PURPOSE: We evaluated the incremental prognostic value of combining the CYP2C19 poor metabolizer (PM) and ABCB1 3435 TT for adverse clinical outcomes over conventional risk factors in a percutaneous coronary intervention (PCI) cohort. METHODS: We enrolled 2,188 patients. The primary end point was a composite of death from any cause, nonfatal myocardial infarction (MI), and stroke during 1-year follow-up. The population was stratified into the following four groups: CYP2C19 EM/IM+ABCB1 3435 CC/CT, CYP2C19 EM/IM+ABCB1 3435 TT, CYP2C19 PM+ABCB1 3435 CC/CT, and CYP2C19 PM+ABCB1 3435 TT. RESULTS: A total of 87 (3.97%) primary end-point events occurred (64 deaths, 8 non-fatal MIs and 15 strokes). Multivariate Cox analysis indicated that CYP2C19 PM+ABCB1 3435 TT status was a significant predictor of the primary end point (hazard ratio = 4.51, 95% confidence interval (CI) = 1.92-10.58). However, addition of combined genetic status to the clinical risk model did not improve the model discrimination (C-statistic = 0.786 (95% CI = 0.734-0.837) to 0.785 (95% CI = 0.733-0.838)) or risk reclassification (categorical net reclassification improvement (0.040, P = 0.32), integrated discrimination improvement (0.021, P = 0.026)). CONCLUSIONS: In a real-world East Asian PCI population taking clopidogrel, although the concurrent presence of CYP2C19 PM and ABCB1 TT is a strong independent predictor of adverse outcomes, the combined status of two at-risk variants does not have an incremental prognostic value beyond that of the conventional clinical risk factors.Genet Med 18 8, 833-841.

Allergic diseases, excessive Internet use and suicidal ideation in Korean adolescents.

OBJECTIVE: The aim of this study is to evaluate the relation between suicidal ideation, allergic diseases, and excessive Internet use in Korean youth using a national representative dataset. METHODS: Data from the Korean Youth Risk Behavior Web-Based Survey (KYRBWS), conducted by the Korean Centers for Disease Control and Prevention, were used in this study. Complex sample logistic regression and structural equation modeling were performed to define the relation between suicidal ideation, allergic disease and excessive Internet use. RESULTS: A total of 73,238 students participated in this survey. In Korea, 19.3% of adolescents had suicidal ideation in the previous year. Asthma (OR=1.23, 95% CI=1.15-1.32, p<0.01) and allergic rhinitis (OR=1.17, 95% CI=1.11-1.22, p<0.01) were identified as risk factors for suicidal ideation after adjusting for school and family factors. Structural equation modeling showed that excessive Internet use interacted with the association between allergic diseases and suicidal ideation. CONCLUSION: Allergy problems could positively affect suicidal ideation in Korean adolescents. Excessive Internet use could be a mediating factor between allergic disease and suicidal ideation.

Development and validation of a high-performance liquid chromatography-tandem mass spectrometric method for simultaneous determination of bupropion, quetiapine and escitalopram in human plasma.

In the present study, an effective high performance liquid chromatography-tandem mass spectrometric (HPLC/MS/MS) method was developed and validated to simultaneously determine bupropion (BUP), quetiapine (QUE) and escitalopram (ESC) in human plasma using carbidopa as the internal standard. Chromatographic separation was achieved on a Waters Sun Fire C18 column using reversed-phase chromatography. The MS/MS experiment was performed in positive ion multiple reaction monitoring mode to produce product ions of m/z 240.3 → 184.2 for BUP, 384.2 → 253.1 for QUE, 325.3 → 109.3 for ESC and 227.2 → 181.2 for the internal standard. The method showed good linearity (R(2) ≥ 0.997), precision (relative standard deviation ≤7.5%), satisfactory intra- and interday accuracy (88.4-113.0%) and acceptable extraction recovery (87.2-115.0%), matrix effect (84.5.5-108.7%) and stability (92.3-103.5%). The method was successfully applied to determine the concentrations of BUP, QUE and ESC in human plasma samples.

Clinical significance of chronic kidney disease and atrial fibrillation on morbidity and mortality in patients with acute myocardial infarction.

BACKGROUND/AIMS: Atrial fibrillation (AF) often coexists with acute myocardial infarction (AMI), and chronic kidney disease (CKD) is a major risk for AMI. However, the combined impact of CKD and AF on the mortality and morbidity in AMI population has not been determined. METHODS: Between January 2004 and December 2009, a total of 4,738 AMI patients were enrolled prospectively. Patients were divided into four groups according to the combined status of CKD and AF. The primary endpoint was a combination of 5-year major adverse cardiac and cerebrovascular events (MACCE). RESULTS: The prevalence of AF was significantly higher in CKD patients than in non-CKD patients (6.76 vs. 3.31%, p < 0.001). The highest cumulative event rate of MACCE and death was observed in patients with both CKD and AF (68.5 and 64.0%), respectively. In multivariable analyses, compared with patients with neither AF nor CKD, hazard ratios (HR) for composite of MACCE were 1.66 (95% CI, 1.14-2.41), 1.24 (95% CI, 1.06-1.46), and 2.10 (95% CI, 1.42-3.13) for patients with AF only, those with CKD only, and those with both CKD and AF, respectively (p for interaction = 0.935). Patients with both CKD and AF had a greatest risk for all-cause mortality (HR 2.54; 95% CI, 1.60-4.53), and the significant synergistic interaction was observed between CKD and AF (p for interaction = 0.015). CONCLUSION: The combined effect of AF and CKD on the risk of MACCE after an AMI is stronger than any separate condition, and it confers a synergistic effect on the all-cause mortality risk.

Profiling of mitochondrial proteome in wheat roots.

Mitochondria are important organelles for cellular respiration within the eukaryotic cell and have many important functions including vitamin synthesis, amino acid metabolism and photorespiration. To investigate the mitochondrial proteome of the roots of wheat seedlings, a systematic and targeted analysis were carried out on the mitochondrial proteome from 15 day-old wheat seedling root material. Mitochondria were isolated by Percoll gradient centrifugation; and extracted proteins were disassociated and analyzed by Tricine SDS-PAGE couple to LTQ-FTICR mass spectrometry. From the isolated the sample, 184 proteins were identified which is composed of 140 proteins as mitochondria and 44 proteins as other subcellular proteins that are predicted by the freeware sub-cellular predictor. The identified proteins in mitochondria were functionally classified into 12 classes using the ProtFun 2.2 servers based on biological processes. Proteins were shown to be involved in amino acid biosynthesis (17.1%), biosynthesis of cofactors (6.4%), cell envelope (11.4%), central intermediary metabolism (10%), energy metabolism (20%), fatty acid metabolism (0.7%), purines and pyrimidines (5.7%), regulatory functions (0.7%), replication and transcription (1.4%), translation (22.1%), transport and binding (1.4%), and unknown (2.8%). These results indicate that many of the protein components present and functions of identifying proteins are common to other profiles of mitochondrial proteins performed to date. These results are provided the extensive and noble clues, to our knowledge, of mitochondrial proteins from wheat roots.

Proteome analysis of roots of wheat seedlings under aluminum stress.

The root apex is considered the first sites of aluminum (Al) toxicity and the reduction in root biomass leads to poor uptake of water and nutrients. Aluminum is considered the most limiting factor for plant productivity in acidic soils. Aluminum is a light metal that makes up 7 % of the earth's scab dissolving ionic forms. The inhibition of root growth is recognized as the primary effect of Al toxicity. Seeds of wheat cv. Keumkang were germinated on petridish for 5 days and then transferred hydroponic apparatus which was treated without or with 100 and 150 µM AlCl3 for 5 days. The length of roots, shoots and fresh weight of wheat seedlings were decreased under aluminum stress. The concentration of K(+), Mg(2+) and Ca(2+) were decreased, whereas Al(3+) and P2O5 (-) concentration was increased under aluminum stress. Using confocal microscopy, the fluorescence intensity of aluminum increased with morin staining. A proteome analysis was performed to identify proteins, which are responsible to aluminum stress in wheat roots. Proteins were extracted from roots and separated by 2-DE. A total of 47 protein spots were changed under Al stress. Nineteen proteins were significantly increased such as sadenosylmethionine, oxalate oxidase, malate dehydrogenase, cysteine synthase, ascorbate peroxidase and/or, 28 protein spots were significantly decreased such as heat shock protein 70, O-methytransferase 4, enolase, and amylogenin. Our results highlight the importance and identification of stress and defense responsive proteins with morphological and physiological state under Al stress.

Inhibitory effect of corn silk on skin pigmentation.

In this study, the inhibitory effect of corn silk on melanin production was evaluated. This study was performed to investigate the inhibitory effect of corn silk on melanin production in Melan-A cells by measuring melanin production and protein expression. The corn silk extract applied on Melan-A cells at a concentration of 100 ppm decreased melanin production by 37.2% without cytotoxicity. This was a better result than arbutin, a positive whitening agent, which exhibited a 26.8% melanin production inhibitory effect at the same concentration. The corn silk extract did not suppress tyrosinase activity but greatly reduced the expression of tyrosinase in Melan-A cells. In addition, corn silk extract was applied to the human face with hyperpigmentation, and skin color was measured to examine the degree of skin pigment reduction. The application of corn silk extract on faces with hyperpigmentation significantly reduced skin pigmentation without abnormal reactions. Based on the results above, corn silk has good prospects for use as a material for suppressing skin pigmentation.

Impact of the CYP2C19*17 polymorphism on the clinical outcome of clopidogrel therapy in Asian patients undergoing percutaneous coronary intervention.

The impact of the CYP2C19*17 polymorphism on the clinical outcome in Asians undergoing percutaneous coronary intervention (PCI) is unknown. We sought to assess the long-term impact of CYP2C19*17 on the risk for adverse clinical events in 2188 Korean patients taking clopidogrel after PCI. The prevalence of the CYP2C19*17 allele [*wt/*17: 2.4% (n = 53), *17/*17: 0%] was very low. The 2-year cumulative event rates for bleeding [*wt/*17 vs. *wt/*wt: 2 vs. 2.3%; adjusted hazard ratio (HR), 1.23; 95% confidence interval (CI), 0.16-9.45], stent thrombosis (2 vs. 1.1%; HR, 3.98; 95% CI, 0.49-31.6) or composite of any death, and myocardial infarction or stroke (5.4 vs. 7.1%; HR, 1.37; 95% CI, 0.32-5.73) did not differ on the basis of the presence of CYP2C19*17. In conclusion, in our study population of Asian patients, the CYP2C19*17 polymorphism was not associated with adverse clinical outcomes after PCI because of its low prevalence, the rarity of homozygotes, and the relatively low rate of adverse clinical events.

Usefulness of the combined application of the Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale in screening for bipolar disorder.

OBJECTIVE: This study aimed to examine whether combined application of the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) is more effective than exclusive application of either tool in screening for bipolar disorder (BD). METHOD: The MDQ and BSDS were completed by a total of 113 patients diagnosed with BD and major depressive disorder who were experiencing a current major depressive episode. The initial diagnosis of the subject was confirmed during a 1-year follow-up period. When each MDQ and BSDS optimal cutoff score was calculated, a modified scoring method for the MDQ that considered only one item was used to increase its performance in this population. The following three combinations of the cutoff scores for the two tools were used to screen for BD: (A) The score on either the MDQ or BSDS was greater than or equal to the cutoff score; (B) the scores on both the MDQ and BSDS were greater than or equal to the cutoff score; and (C) Reducing either cutoff score by 1 point resulted in the MDQ and BSDS scores being greater than or equal to the cutoff score. The sensitivity, specificity, positive predictive value, and negative predictive value of the three methods, the MDQ, and the BSDS were compared for screening BD. RESULTS: The sensitivity and specificity of the MDQ were 0.741 and 0.844, respectively, and those for the BSDS were 0.731 and 0.742, respectively. These indicators for the combined application of the MDQ and BSDS were as follows, respectively: method A 0.901 and 0.688, method B 0.580 and 0.875, and method C 0.691 and 0.844. Method A was superior to using one measure alone as well as to methods B and C with regard to sensitivity and negative predictive values. Method A also showed a higher sensitivity for BD subtypes than did the individual tools. Compared with the use of individual instruments, method A showed a similar positive predictive value. CONCLUSION: This study suggests that combined use of the MDQ and BSDS is more effective than the individual use of either of these measures in screening for BD. The data also showed that when both tools were used, the most effective interpretation of the results in terms of screening for BD was achieved when positive scores were defined as those that were equal to or greater than the cutoff for the MDQ or BSDS.

Randomized comparison of the efficacy and safety of zotarolimus-eluting stents vs. sirolimus-eluting stents for percutaneous coronary intervention in chronic total occlusion--CAtholic Total Occlusion Study (CATOS) trial.

BACKGROUND: Limited data are available regarding the direct comparison of angiographic and clinical outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for chronic total occlusion (CTO). METHODS AND RESULTS: A prospective, randomized, multicenter trial was conducted to evaluate the non-inferiority of a zotarolimus-eluting stent (ZES; Endeavor Sprint®, n=80) to a sirolimus-eluting stent (SES; Cypher®, n=80) in patients with CTO lesion with a reference vessel diameter ≥ 2.5mm. The primary endpoint was in-segment binary restenosis rate at 9-month angiographic follow-up. Key secondary endpoints included target vessel failure (TVF; including cardiac death, myocardial infarction, and target vessel revascularization) and Academic Research Consortium-defined definite/probable stent thrombosis (ST) within 12 months. The ZES was non-inferior to the SES with respect to the primary endpoint, which occurred in 14.1% (95% confidence interval [CI]: 6.0-22.2) and in 13.7% (95%CI: 5.8-21.6) of patients, respectively (non-inferiority margin, 15.0%; P for non-inferiority <0.001). There were no significant between-group differences in the rate of TVF (10.0% vs. 17.5%; P=0.168) nor in the rate of ST (0.0% vs. 1.3%; P=0.316) during the 12-month clinical follow-up. CONCLUSIONS: The effectiveness and safety of ZES are similar to those of SES and therefore it is a good treatment option in patients undergoing PCI for CTO with DESs.

Analgesic effects of dexmedetomidine in vincristine-evoked painful neuropathic rats.

Dexmedetomidine, which is a selective α2-adrenoceptor agonist, was recently introduced into clinical practice for its analgesic properties. The purpose of this study was to evaluate the effects of dexmedetomidine in a vincristine-evoked neuropathic rat models. Sprague-Dawley rats were injected intraperitoneally with vincristine or saline (0.1 mg/kg/day) using a 5-day-on, 2-day-off schedule for 2 weeks. Saline and dexmedetomidine (12.5, 25, 50, and 100 µg/kg) were injected to rats developed allodynia 14 days after vincristine injection, respectively. We evaluated allodynia at before, 15, 30, 60, 90, 120, 180, and 240 min, and 24 hr after intraperitoneal drug (normal saline or dexmedetomidine) injection. Saline treatment did not show any differences for all the allodynia. Maximal paw withdrawal thresholds to mechanical stimuli were 3.0 ± 0.4, 9.1 ± 1.9, 13.0 ± 3.6, 16.6 ± 2.4, and 24.4 ± 1.6 g at saline, 12.5, 25, 50, and 100 µg/kg dexmedetomidine injection, respectively. Minimal withdrawal frequency to cold stimuli were 73.3 ± 4.2, 57.1 ± 6.8, 34.3 ± 5.7, 20.0 ± 6.2, and 14.3 ± 9.5 g at saline, 12.5, 25, 50, and 100 µg/kg dexmedetomidine injection, respectively. Dexmedetomidine shows a dose-dependent antiallodynic effect on mechanical and cold stimuli in vincristine-evoked neuropathic rat models (P < 0.05).

Uptake of F-18 FDG and ultrasound analysis of carotid plaque.

OBJECTIVES: To elucidate the relation between the echolucent plaque on carotid ultrasound and acute inflammation on F-18 FDG carotid PET/CT. METHODS: Thirty nine patients (M:F ratio = 23:16, mean age = 63 ± 11 years) that underwent coronary angiography and carotid ultrasound were divided into three groups-echolucent plaque (n = 22), calcified (n = 10), and no plaque(n = 7). All the patients underwent F-18 FDG carotid PET/CT. The mean standardized uptake values (SUV), namely target to background ratio (TBR) on 180 minutes delayed F-18 FDG carotid PET/CT images were compared with levels of serum inflammatory markers and lipid profiles, and in terms of the presence of carotid plaque on carotid US. RESULTS: 180 minutes TBR of carotid arterial wall at echolucent plaque, calcified plaque, and no plaque were 1.40 ± 0.05, 1.23 ± 0.03, 1.17 ± 0.03 in both carotid artery. TBR of carotid arterial walls for echolucent plaque were significantly larger than TBR for calcified, and no plaque respectively at the both side of carotid artery (P < .05). Serum HDL levels were found to be inversely correlated with F-18 FDG uptake at both carotid arteries (r = -0.43, P = .005) on 180 minutes delayed phase images. Also serum hs-CRP levels were found to be correlated with F-18 FDG TBR values of right carotid arteries (r = 0.41, P = .04). CONCLUSIONS: Our results show that F-18 FDG carotid PET/CT can depict metabolically active atherosclerotic plaques, and suggest that F-18 FDG carotid PET/CT can be used as a noninvasive imaging modality for functional evaluation of atherosclerosis.

A prospective, multicentre, randomised, open-label trial to compare the efficacy and safety of clopidogrel versus ticagrelor in stabilised patients with acute myocardial infarction after percutaneous coronary intervention: rationale and design of the TALOS-AMI trial.

AIMS: In patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), the risk of ischaemic complications is highest in the early phase (during the first 30 days), while most bleeding events occur predominantly during the maintenance phase of treatment (after the first 30 days). Data on the de-escalation of dual antiplatelet therapy by switching from ticagrelor to clopidogrel in stabilised AMI patients are limited. The aim of this study is to investigate the efficacy and safety of switching from ticagrelor to clopidogrel in AMI patients with no adverse event during the first month after the index PCI with newer-generation DES. METHODS AND RESULTS: TALOS-AMI is a multicentre, randomised, open-label study enrolling 2,590 AMI patients with no adverse events during the first month after the index PCI. One month after the index PCI, eligible patients are randomly assigned either to 1) aspirin 100 mg plus clopidogrel 75 mg daily, or to 2) aspirin 100 mg plus ticagrelor 90 mg twice daily, in a 1:1 ratio. The primary endpoint is a composite of cardiovascular death, MI, stroke, and bleeding type 2, 3 or 5 according to the Bleeding Academic Research Consortium (BARC) criteria from 1 to 12 months after the index PCI. CONCLUSIONS: The TALOS-AMI trial is the first large-scale, multicentre, randomised study exploring the efficacy and safety of the de-escalation of antiplatelet therapy by switching from ticagrelor to clopidogrel in stabilised AMI patients undergoing PCI.

Gender Differences in the Impact of New-Onset Atrial Fibrillation on Long-Term Risk of Ischemic Stroke after Acute Myocardial Infarction.

BACKGROUND: Atrial fibrillation (AF) has been identified as a major risk factor for mortality after acute coronary syndrome (ACS). However, the long-term risk of ischemic stroke associated with new-onset atrial fibrillation (NOAF) in ACS remains controversial, and its gender-specific association is unknown. METHODS: We analyzed the data of 10,137 ACS survivors included in a multicenter, prospective registry for Korean patients with acute myocardial infarction (AMI) between January 2004 and August 2014. Subjects were categorized into three groups (non-AF vs. NOAF vs. previous AF) based on medical history and electrocardiographic evidence of AF, either at admission or during hospitalization. RESULTS: Among the total study population (72.3% men), 370 patients (3.6%) had NOAF and 130 (1.3%) had previous AF. During a median follow-up of 61 months (interquartile range, 38.8 to 89.3 months), 245 (2.4%) patients (218 (2.3%) non-AF vs. 15 (4.1%) NOAF vs. 12 (9.2%) previous AF, p < 0.001) experienced ischemic stroke. After adjustment for confounding variables, both NOAF (adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09-3.24, p = 0.024) and previous AF (adjusted HR 4.00, 95% CI 2.03-7.87, p < 0.001), along with older age, diabetes, current smoker, and previous stroke were independent risk factors of ischemic stroke. In the gender-stratified analysis, men with previous AF but not NOAF had a significantly higher risk of ischemic stroke (adjusted HR 4.14, 95% CI 1.79-9.55, p = 0.001) than those without AF. In women, NOAF (adjusted HR 2.54, 95% CI 1.21-5.35, p = 0.014) as well as previous AF (adjusted HR 3.72, 95% CI 1.16-11.96, p = 0.028) was a strong predictor of ischemic stroke, and the predictive value was comparable to that of previous AF among patients with a CHA2DS2-VASc score ≥ 2. CONCLUSIONS: Both NOAF and previous AF were associated with ischemic stroke after AMI, but the impact of NOAF as a risk factor of ischemic stroke was significant only in women.

Coronary flow reserve is a comprehensive indicator of cardiovascular risk factors in subjects with chest pain and normal coronary angiogram.

BACKGROUND: The aim of the present study was to analyze the parameters related to baseline coronary flow velocity (CFV) and coronary flow reserve (CFR) using Doppler transthoracic echocardiography (TTE), and to assess their associations with components of the Framingham risk score (FRS), which estimates 10-year risk of coronary heart disease, in subjects with chest pain and a normal coronary angiogram. METHODS AND RESULTS: A total of 354 individuals (mean age: 55+/-11 years, M:F ratio =186:168) with angina or angina-like chest pain and a normal coronary arteriogram were enrolled. CFR, using TTE and adenosine or dipyridamole, was measured within 2 weeks after coronary angiogram. The clinical, electrocardiographic, echocardiographic and laboratory parameters related to baseline CVF and CFR were analyzed, and CFR was compared with FRS. There was an inverse correlation between baseline CFV and CFR (r=-0.374, P<0.001). On multivariate analysis the fulfilling of left ventricular hypertrophy criteria on electrocardiography was an independent predictor of baseline CFV for the upper 75% quartile (23.2> or =cm/s; odds ratio (OR) = 2.840, 95% confidence interval (CI) =1.155-6.983, P=0.023). On multivariate analysis hemoglobin A(1c) level was independently related to a CFR <2.0 (OR = 2.195, 95%CI = 0.920-1.005, P=0.013). CFR had an inverse correlation with FRS (r=-0.222, P<0.001). On multiple regression analysis among the components of the FRS system (FRSS), independent factors related to a CFR <2.0 included age (OR =1.033, 95%CI =1.000-1.067, P=0.041), high-density lipoprotein-cholesterol level (OR = 0.961, 95%CI = 0.933-0.991, P=0.012) and smoking status (OR = 2.461, 95%CI =1.078-5.618, P=0.033), respectively. CONCLUSIONS: CFR can be a comprehensive indicator of cardiovascular risk factors, including parameters of the FRSS, in subjects with chest pain and a normal coronary angiogram.

Insulin therapy in divided doses coupled with blood transfusion versus large bolus doses in patients at high risk for hyperkalemia during liver transplantation.

OBJECTIVE: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation. DESIGN: Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation. SETTING: University-based, academic, tertiary center. PARTICIPANTS: Adult patients whose baseline potassium levels were >/=4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007. INTERVENTIONS: Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation. MEASUREMENTS AND MAIN RESULTS: Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001). CONCLUSIONS: The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.