Efficacy and Safety of Pulsed Field Ablation in Atrial Fibrillation: A Systematic Review.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient-provider risk-benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA. METHODS: The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly. RESULTS: A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%). CONCLUSIONS: The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.

Association between diabetes mellitus and poor patient outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Diabetes mellitus (DM) serves as an important prognostic indicator in patients with cardiac-related illness. Our objective is to compare survival and neurological outcomes among diabetic and non-diabetic patients who were admitted to the hospital after an out-of-hospital cardiac arrest (OHCA). We searched MEDLINE and EMBASE for relevant articles from database inception to July 2018 without any language restriction. Studies were included if they evaluated patients who presented with OHCA, included mortality and neurological outcome data separately for DM patients and Non-DM patients and reported crude data, odds ratio (OR), relative risk (RR) or hazard ratio (HR). Two investigators independently reviewed the retrieved citations and assessed eligibility. The quality of included studies was evaluated using Newcastle-Ottawa quality assessment scale for cohort studies. Random-effect models using the generic variance method were used to create pooled odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 value. Survival and neurological outcomes (using modified rankin scale and cerebral performance category scale) after OHCA in hospitalized patients with DM compared with patients without DM. Out of 57 studies identified, six cohort studies met the inclusion criteria. In an analysis of unadjusted data, patients with DM had lower odds of survival, pooled OR 0.64; 95% CI, 0.52-0.78, [I2 = 90%]. When adjusted ORs were pooled, the association between DM and survival after OHCA was still significantly reduced, pooled OR 0.78, 95% CI, 0.68-0.89 [I2 = 55%]. Unadjusted pooled OR revealed poor neurological outcomes in patients with DM, pooled OR 0.55, 95% CI, 0.38-0.80 [I2 = 90%]. The result demonstrates significant poor outcomes of in-hospital survival and neurological outcomes among DM patients after OHCA.

Comparison of Radial Artery Occlusion Following Transradial Access for Percutaneous Coronary Intervention Using Sheath-based versus Sheathless Technique.

We compared the risk of radial artery occlusion (RAO) in patients undergoing coronary intervention with introducer sheath (SG) or without introducer sheath (SLG). 1251 consecutive patients, from 2 tertiary care center in Pennsylvania, USA, undergoing percutaneous coronary interventions (PCI) between 2008-2013 formed the study cohort (SLG: 161 patients, SG: 1090 patients). Radial artery patency was assessed using plethysmography. The association between sheath use and RAO was assessed using unadjusted, adjusted and propensity macthed logistic regression analyses. Mean age: 65 years, men: 63%, diabetics: 37%. SG was associated with lower RAO at band removal [unadjusted (OR: 0.31, 95% CI: 0.21-0.46), adjusted (OR: 0.10, 95% CI: 0.05-0.20) and propensity matched (OR: 0.20, 95% CI: 0.13-0.32)], at 24 hours [unadjusted (OR: 0.20, 95% CI: 0.12-0.34), adjusted (OR: 0.12, 95% CI: 0.06-0.24) and propensity matched (OR: 0.13, 95% CI: 0.07-0.25)] and 30 days [unadjusted (OR: 0.28, 95% CI: 0.14-0.54), adjusted (OR: 0.22, 95% CI: 0.10-0.50) and propensity matched (OR: 0.18, 95% CI: 0.10-0.40)], compared to SLG. Sheath use during radial access for PCI is associated with less RAO. It is unclear if use of introducer sheath during radial access for PCI reduces incidence of RAO. In this prospective cohort study involving 1251 concecutive patients undergoing PCI via radial access between 2008-2013, we assessed the difference in incidence of RAO between the SG (n = 1090) and the SLG (n = 161 patients) groups. SG group experienced lower incidence of RAO at band removal, 24 hours and 30 days post PCI in the unadjusted, adjusted, and propensity matched analyses compared to the SLG group. In conclusion sheath use during radial access for PCI is associated with less RAO.

Hospital Complications and Causes of 90-Day Readmissions After Implantation of Left Ventricular Assist Devices.

Left ventricular assist devices (LVADs) have emerged as an attractive option in patients with advance heart failure. Nationwide readmission database 2013 to 2014 was utilized to identify LVAD recipients using ICD-9 procedure code 37.66. The primary outcome was 90-day readmission. Readmission causes were identified using ICD-9 codes in primary diagnosis field. The secondary outcomes were LVAD associated with hospital complications. Hierarchic 2-level logistic models were used to evaluate study outcomes. We identified 4,693 LVAD recipients (mean age 57 years, 76.2% males). Of which 53.9% were readmitted in first 90 days of discharge. Cardiac causes (33.3%), bleeding (21.3%), and infections (12.4%) were leading etiologies of 90-day readmissions. Significant predictors (odds ratio, 95% confidence interval, p value) of readmission were disposition to nursing facilities (1.33, 1.09 to 1.63, p = 0.01) and longer length of stay (1.01, 1.00 to 1.01, p <0.01). Although private insurance (0.75, 0.66 to 0.86, p <0.01), and self-pay (0.58, 0.42 to 0.81, p <0.01) predicted lower readmissions. Cardiac complications (36.3%), major bleeding (29.8%), and postoperative infections (10.4%) were most common LVAD-related complications. In conclusion, high early readmission rate was observed among LVAD recipients with Cardiac complications, bleeding complications, and infections were driving force for major complications and most of readmissions.

Temporal trends of in-hospital complications associated with catheter ablation of atrial fibrillation in the United States: An update from Nationwide Inpatient Sample database (2011-2014).

BACKGROUND: Catheter ablation is widely accepted intervention for atrial fibrillation (AF) refractory to antiarrhythmic drugs, but limited data are available regarding contemporary trends in major complications and in-hospital mortality due to the procedure. This study was aimed at exploring the temporal trends of in-hospital mortality, major complications, and impact of hospital volume on frequency of AF ablation-related outcomes. METHODS: The Nationwide Inpatient Sample database was utilized to identify the AF patients treated with catheter ablation. In-hospital death and common complications including vascular access complications, cardiac perforation and/or tamponade, pneumothorax, stroke, and transient ischemic attack, were identified using International Classification of Disease (ICD-9-CM) codes. RESULT: In-hospital mortality rate of 0.15% and overall complication rate of 5.46% were noted among AF ablation recipients (n = 50,969). Significant increase in complications during study period (relative increase 56.37%, P-trend < 0.001) was observed. Cardiac (2.65%), vascular (1.33%), and neurological (1.05%) complications were most common. On multivariate analysis (odds ratio [OR]; 95% confidence interval [95% CI]; P value), significant predictors of complications were female sex (OR = 1.40; CI = 1.17-1.68; P value < 0.001), high burden of comorbidity as indicated by Charlson Comorbidity Index ≥2 (OR = 2.84; CI = 2.29-3.52; P value < 0.001), and low hospital volume (< 50 procedures). CONCLUSION: Our study noted a decline in AF ablation-related hospitalizations and complications associated with the procedure. These findings largely reflect shifting trends of outpatient performance of the procedure and increasing safety profile due to improved institutional expertise and catheter techniques.

Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis.

PURPOSE: In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. MATERIALS AND METHODS: We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. RESULTS: Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. CONCLUSIONS: Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

Gender Differences in the Trends of Hospitalizations for Acute Stroke Among Patients With Atrial Fibrillation in the United States: 2005 to 2014.

Female gender was included in stroke prediction algorithms in an attempt to improve anticoagulation rates in women with atrial fibrillation (AF). It is unclear if these efforts reduced stroke burden in women with AF. To bridge this literature gap, using the Nationwide Inpatient Sample, we assessed gender differences in the trends of hospitalizations for stroke among patients with AF in the United States in 2005 to 2014. International classification of diseases, 9th revision, clinical modification codes were used to abstract AF and stroke diagnoses. From 2005 to 2014, 18,413,291 hospitalizations of women with AF and 18,035,866 hospitalizations of men with AF were reported. Of these, 740,635 hospitalizations in women and 595,730 hospitalizations in men had stroke as the primary diagnosis. Age-adjusted stroke hospitalizations increased in women (443 per million in 2005 to 495 per million in 2014) as well as in men (351 per million in 2005 to 453 per million in 2014) (p trend < 0.001). Further, anticoagulation rates increased in women (11.5% in 2005 to 24.0% in 2014) as well as in men (11.7% in 2005 to 24.9% in 2014). Stroke hospitalizations involving anticoagulated patients with AF decreased in women (411 per million in 2005 to 347 per million in 2014) as well as in men (402 per million in 2005 to 311 per million in 2014) (p trend < 0.001). In conclusion, although we noted an increasing trend of stroke hospitalizations in both genders, it is reassuring to note that stroke hospitalizations involving anticoagulated patients with AF is decreasing in both genders and in particular among women.

A clinical score to predict dose reductions of antidiabetes medications with intentional weight loss: A retrospective cohort study.

BACKGROUND: We assessed the predictive accuracy of an empirically-derived score (weight loss, insulin resistance, and glycemic control: "WIG") to predict patients who will be successful in reducing diabetes mellitus (DM) medication use with weight loss. METHODS: Case records of 121 overweight and obese patients with DM at two outpatient weight management centers were analyzed. RESULTS: Mean period of follow-up was 12.5 ± 3.5 months. To derive the "WIG" scoring algorithm, one point each was assigned to "W" (loss of 5% of initial body weight within the first 3 months of attempting weight loss), "I" (triglyceride [TGL]/highdensity lipoprotein ratio >3 [marker of insulin resistance] at baseline), and "G" (glycosylated hemoglobin [A1c%] >8.5 at baseline). WIG score showed moderate accuracy in discriminating anti-DM dose reductions at baseline, and after 3 months of weight loss efforts (likelihood ratios [LR] + >1, LR- <1, and area under the curve >0.7), and demonstrated good reproducibility. CONCLUSIONS: WIG score shows promise as a tool to predict success with dose reductions of antidiabetes medications.

Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis.

BACKGROUND: The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVES: We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. METHODS AND RESULTS: Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76). CONCLUSION: Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.

Effect of renal sympathetic denervation on apnea-hypopnea index in patients with obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: Recent evidence associates sympathetic tone with severity of obstructive sleep apnea (OSA). Renal sympathetic denervation (RDN), by decreasing sympathetic tone, has the potential to decrease OSA severity. Small observational studies that assessed this hypothesis lacked precision. Hence, in this meta-analysis, we have attempted to pool available data from studies that have assessed the effect of RDN on OSA severity in patients with OSA. METHODS: Medline, Embase, Cochrane central, Ovid, Cinahl, web of science, and conference abstracts were searched for eligible citations by two independent reviewers using key words "renal denervation," "hypertension," and "obstructive sleep apnea." From a total of 2,863 identified citations, using meta-analysis of observational studies in epidemiology method, five studies were assessed eligible and included in the meta-analysis. RESULTS: All five studies followed an observational study design, involved patients with OSA and HTN, and reported an apnea-hypopnea index (AHI) 6 months post-RDN. Four were "before and after" studies and one compared continuous positive airway pressure with RDN. In the pooled analysis, involving 49 patients, RDN was associated with a significant reduction in mean AHI [weighted mean difference -9.61 (95 % CI -15.43 to -3.79, P = 0.001)] 6 months post-RDN. One study also reported improvement in oxygen desaturation index and Epworth sleepiness scale score 6 months post-RDN. CONCLUSIONS: RDN is associated with significant improvement in OSA severity. However, our results need validation in RCTs that assess effect of RDN in patients with OSA, which can potentially broaden the clinical applicability of RDN.

Sex differences in short-term and long-term all-cause mortality among patients with ST-segment elevation myocardial infarction treated by primary percutaneous intervention: a meta-analysis.

IMPORTANCE: Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) have improved in the past 2 decades, a sex disparity exists in survival, with women having higher mortality than men. OBJECTIVE: To conduct a meta-analysis of observational studies that examined differences in mortality by sex in patients with STEMI treated with primary percutaneous coronary intervention (PPCI). DATA SOURCES: MEDLINE, EMBASE, Cochrane central, and electronic databases were searched for relevant studies in all languages and without time restriction. STUDY SELECTION: Studies were included if (1) they studied patients who presented with STEMI, (2) primary percutaneous coronary intervention (PPCI) was the treatment for STEMI, (3) PPCI was performed within 12 hours of symptom onset, and (4) sex-specific in-hospital and/or 1-year mortality were reported. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed retrieved citations and assessed eligibility. Discrepancies were resolved by consensus. Quality of included studies was assessed using Newcastle-Ottawa Quality Assessment Scale for cohort studies. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES: Sex-specific in-hospital and 1-year all-cause mortality. Risk ratios (RRs) of mortality were used for these 2 time points, if reported. RESULTS: Of the 149 studies identified, 35 met inclusion criteria, representing 18 555 women and 49 981 men. In the unadjusted analyses, women were at a higher risk for in-hospital (RR, 1.93; 95% CI, 1.75-2.14 [P < .001, I2 = 14%]) and 1-year all-cause mortality (RR, 1.58; 95% CI, 1.36-1.84 [P < .001, I2 = 51%]) compared with men. However, when adjusted RRs were used, the association between women and higher risk of all-cause mortality was attenuated but still significantly elevated for in-hospital mortality (RR, 1.48; 95% CI, 1.07-2.05 [P = .02, I2 = 56%]), but the higher risk for 1-year mortality in women was no longer significant (RR, 0.90; 95% CI, 0.69-1.17 [P = .42, I2 = 58%]). CONCLUSIONS AND RELEVANCE: An increased mortality in women with STEMI treated with PPCI was detected in this large meta-analysis but is likely confounded by baseline cardiovascular risk factors and the differences in clinical profile of male and female patients with STEMI. Intensive cardiovascular risk modification efforts in women may help to reduce this sex disparity.

Meta-analysis of the effect of renal denervation on blood pressure and pulse pressure in patients with resistant systemic hypertension.

Data comparing the effect of renal denervation (RD) with those of maximal medical therapy (MMT) have shown conflicting results. Also, effect of RD on pulse pressure (PP) has not been evaluated. The aim of this meta-analysis was to compare the effect of RD with that of MMT on blood pressure (BP) and PP at 6-month follow-up in patients with resistant hypertension. Randomized controlled trials and nonrandomized controlled trials reporting systolic BP, diastolic BP, and PP results in RD and MMT groups at 6-month follow-up in patients with resistant hypertension were systematically reviewed, and eligible citations were pooled using a random-effects model. Five studies (3 randomized controlled trials, 2 nonrandomized controlled trials, n = 800) met the inclusion criteria. In the pooled analysis, RD was associated with a significant decrease in systolic BP (weighted mean difference -19.4 mm Hg, 95% confidence interval -32.8 to -5.9, p = 0.005), diastolic BP (weighted mean difference -6.4 mm Hg, 95% confidence interval -10.7 to -2.0 mm Hg, p = 0.004), and PP (weighted mean difference -12.7 mm Hg, 95% confidence interval -22.3 to -3.1 mm Hg, p = 0.009) compared with MMT at 6-month follow-up. Sensitivity analysis limited to randomized controlled trials showed a borderline significant difference in lowering systolic BP, a significant difference in lowering diastolic BP, and a nonsignificant difference in lowering PP when RD was compared with MMT. In conclusion, this meta-analysis shows that RD is superior to MMT in lowering BP, but heterogeneity among study populations in this pooled sample is high, and further data are needed to better compare these treatment strategies.

Prevalence and causes of blindness and visual impairment and their associated risk factors, in three tribal areas of Andhra Pradesh, India.

OBJECTIVE: To assess the prevalence of blindness and visual impairment (VI), their associated causes and underlying risk factors in three tribal areas of Andhra Pradesh, India and compare this data in conjunction with data from other countries with low and middle income settings. METHODS: Using a validated Rapid Assessment of Avoidable Blindness methodology, a two stage sampling survey was performed in these areas involving probability proportionate to size sampling and compact segment sampling methods. Blindness, VI and severe visual impairment (SVI) were defined as per the WHO guidelines and Indian definitions. RESULTS: Based on a prior enumeration, 7281 (97.1%) subjects were enrolled (mean age = 61.0+/-7.9 years). Based on the presenting visual acuity (PVA), the prevalences of VI, SVI and blindness were 16.9% (95% CI: 15.7-18.1), 2.9% (95% CI: 2.5-3.4), and 2.3% (95% CI: 1.9-2.7), respectively. When based on the Pinhole corrected visual acuity (PCVA), the prevalences were lower in VI (6.2%, 95% CI: 5.4-6.9), SVI (1.5%, 95% CI: 1.2-1.9) and blindness (2.1%, 95% CI: 1.7-2.5). Refractive error was the major cause of VI (71.4%), whereas, cataract was the major cause of SVI and blindness (70.3%). Based on the PVA, the odds ratio (OR) of blindness increased in the age groups of 60-69 years (OR = 3.8, 95% CI: 2.8, 5.1), 70-79 years (OR = 10.6, 95% CI: 7.2, 15.5) and 80 years and above (OR = 30.7, 95% CI: 19.2, 49). The ORs were relatively higher in females (OR = 1.3, 95% CI: 1.0, 1.6) and illiterate subjects (OR = 4.3, 95% CI: 2.2, 8.5), but lower in those wearing glasses (OR = 0.2, 95% CI: 0.1, 0.4). CONCLUSIONS: This is perhaps the first study to assess the prevalence of blindness and VI in these tribal regions and the majority of the causes of blindness and SVI were avoidable (88.5%). These findings may be useful for planning eye care services in these underserved regions.

Serum vitamin D levels may not reflect tissue-level vitamin D in sarcoidosis.

Hypercalcemia in sarcoidosis is due to three mechanistic reasons: (1) systemic conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by the enzyme 1-α hydroxylase produced by activated monocyte/macrophage system, (2) production of parathormone-related peptide (PTHrP) by the sarcoid granuloma, (3) tissue-level conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by 1-αhydroxylase produced by local monocyte/macrophage system in the sarcoid granuloma. We report two cases of one proposed mechanism of hypercalcaemia in sarcoidosis (mechanism 3). Both individuals presented with sarcoidosis and 25-hydroxyvitamin D deficiency and developed symptomatic hypercalcaemia with vitamin D replacement. Given their low serum parathormone and parathormone-related peptide levels, low serum 25-hydroxy vitamin D and normal serum 1,25-dihydroxyvitamin D, the systemic 25-hydroxy vitamin D deficiency may not have reflected an increased activity of vitamin D at the local granulomatous tissue level.

Intentional weight loss and dose reductions of antihypertensive medications: a retrospective cohort study.

BACKGROUND: Though it is well known that weight loss tends to decrease blood pressure, the quantitative association between the magnitude of weight loss and the effect on the need for antihypertensive medications is not well studied. We analyzed this association among overweight and obese attendees at two outpatient weight management centers. METHODS: Case records of patients with a body mass index >25 at baseline were analyzed. The weight loss intervention consisted of a calorie-restricted diet (~1,000 kcal/day deficit), a behavior modification plan, and a plan for increasing physical activity. RESULTS: The study cohort consisted of 100 participants, and the mean follow-up period was 15 ± 3.5 months. Significant weight loss (12.2 ± 3.4 kg) and systolic/diastolic blood pressure reductions (9.1/6.3 mm Hg) were observed by study exit. For 5, 10, and 15% weight loss, respectively, 3, 39, and 39% of the patients achieved at least 1 discontinuation of any antihypertensive medication, and 8, 42, and 21 dose reductions were achieved. Dose reductions or discontinuations occurred in all classes of antihypertensive medications with similar magnitudes of weight loss. CONCLUSIONS: Intentional weight loss can potentially result in dose reductions/discontinuations of antihypertensive medications. Our results should be validated with data from larger randomized controlled studies and may help to inform the conduct of a systematic review of prior randomized controlled trials that contain data on medication changes accompanying weight loss.

Association of blood lactate with carotid atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Carotid MRI Study.

OBJECTIVES: Cardiovascular risk factors such as aging, smoking, and insulin resistance may lead to atherosclerosis through various mechanisms of which their association with mitochondrial dysfunction may be one of them. In order to examine this hypothesis, we assessed the association between elevated blood lactate, a marker of mitochondrial dysfunction, and carotid atherosclerosis. METHODS: From a total of 2066 participants from the Atherosclerosis Risk In Communities Carotid MRI study, 1496 were included for this analysis. Wall Thickness and Lipid core presence were measured using gadolinium-enhanced MRI. Blood lactate was categorized into quartiles (Q1: <5.9 mg/dl, Q2: 5.9-7.2 mg/dl, Q3: 7.3-9.2 mg/dl, and Q4: >9.2 mg/dl). RESULTS: Of the 1496 study participants, 763 (51%) were females, 296 (19.8%) African American, 539 (36%) obese and 308 (20.6%) had diabetes. There was a strong and graded association between lactate and wall thickness [Q1: 1.08 mm (95% CI: 1.01 mm-1.15 mm), Q2: 1.33 mm (95% CI: 1.19 mm-1.47 mm), Q3: 1.44 (95% CI: 1.34 mm-1.54 mm) and Q4: 1.62 (95% CI: 1.53 mm-1.71 mm); p for trend <0.001] after adjusting for age, gender, ethnicity, stature, body mass index (BMI), waist circumference, LDL, High sensitivity C reactive protein (HsCRP), statin use, thiazolidinedione use, hypertension, and diabetes. This association was attenuated, but still significant, after adjusting for a marker of insulin resistance, the triglyceride/HDL ratio, [Q1: 0.96 mm (95% CI: 0.82 mm-1.10 mm), Q2: 1.17 mm (95% CI: 1.08 mm-1.26 mm), Q3: 1.18 mm (95% CI: 1.07 mm-1.29 mm), Q4: 1.22 mm (95% CI: 1.13 mm-1.31 mm), p for linear trend 0.039]. There was no association of lactate with lipid core presence after adjustment for wall thickness. CONCLUSIONS: Blood lactate is associated with carotid atherosclerosis. Attenuation of the association with adjustment for triglyceride/HDL ratio, a marker of insulin resistance, suggests that lactate's association with carotid atherosclerosis may be related to insulin resistance.

Lactate and risk of incident diabetes in a case-cohort of the atherosclerosis risk in communities (ARIC) study.

BACKGROUND: Oxidative capacity is decreased in type 2 diabetes. Whether decreased oxidative capacity is a cause or consequence of diabetes is unknown. Our purpose is to evaluate whether lactate, a marker of oxidative capacity, is associated with incident diabetes. METHODS AND FINDINGS: We conducted a case-cohort study in the Atherosclerosis Risk in Communities (ARIC) study at year 9 of follow-up. We evaluated lactate's association with diabetes risk factors at baseline and estimated the hazard ratio for incident diabetes by quartiles of plasma lactate in 544 incident diabetic cases and 533 non-cases. Plasma lactate showed a graded positive relationship with fasting glucose and insulin (P<0.001). The relative hazard for incident diabetes increased across lactate quartiles (P-trend ≤0.001). Following adjustment for demographic factors, medical history, physical activity, adiposity, and serum lipids, the hazard ratio in the highest quartile was 2.05 times the hazard in the lowest quartile (95% CI: 1.28, 3.28). After including fasting glucose and insulin the association became non-significant. CONCLUSIONS: Lactate, an indicator of oxidative capacity, predicts incident diabetes independent of many other risk factors and is strongly related to markers of insulin resistance. Future studies should evaluate the temporal relationship between elevated lactate and impaired fasting glucose and insulin resistance.

Population based outcomes of cataract surgery in three tribal areas of Andhra Pradesh, India: risk factors for poor outcomes.

PURPOSE: To report visual outcomes and risk factors for poor outcomes of cataract surgery in three Integrated Tribal Development Agency (ITDA) areas of Andhra Pradesh, India. METHODS AND RESULTS: Using validated Rapid Assessment of Avoidable Blindness (RAAB) methodology, a population based cross-sectional study, was conducted in three ITDA areas. A two-stage sampling procedure was used to select 7281 participants aged 50 years and above. Vision assessment using a tumbling E chart and standard ocular examinations were completed. Visual outcomes and risk factors for poor outcomes were assessed among subjects undergoing cataract surgery (1548 eyes of 1124 subjects). Mean age at surgery was 67±8 years; Among the operated eyes, presenting visual acuity (PVA) and best corrected visual acuity (BCVA) worse than 6/18 was seen in 492 (31.8%; 95% CI, 29.5-34.2%) and 298 eyes (19.3%; 95% CI, 17.3-21.3%), respectively. Similarly, PVA and BCVA worse than 6/60 was seen in 219 (14.1%; 95% CI, 12.4-16%) and 147 eyes (9.5%; 95% CI, 8.1-11.1%), respectively. When either eye was taken into consideration, the PVA and BCVA worse than 6/18 was seen in 323 (20.1%; 95% CI, 18.9-23%) and 144 subjects (9.3%; 95% CI, 7.9-10.9%), respectively. PVA and BCVA worse than 6/60 was seen in 74 (4.8%; 95% CI, 3.8-6%) and 49 subjects (3.2%; 95% CI, 2.4-4.2%), respectively. Posterior capsular opacification was seen in 51 of 1316 pseudophakic eyes (3.9%; 95% CI, 2.9-5.1%). In multivariable analysis among pseudophakic subjects with PVA worse than 6/18, increasing age (p = 0.002) and undergoing free surgery (p = 0.05) were independent risk factors. Undergoing surgery before 2005 (p = 0.05) and being illiterate (p = 0.05) were independent risk factors for BCVA worse than 6/18. CONCLUSIONS: There are changing trends with improved outcomes in cataract surgery among these tribal populations of India. However, post-operative refractive error correction remains an issue, especially for those undergoing free surgeries.

Association between glycosylated hemoglobin and intentional weight loss in overweight and obese patients with type 2 diabetes mellitus: a retrospective cohort study.

PURPOSE: The purpose of this study is to assess the relationship between magnitude of weight loss and improvement in percentage A1C (A1C%) among overweight and obese patients with type 2 diabetes mellitus (DM) undergoing weight reduction. METHODS: Case records of patients enrolled in 2 university-based weight management programs were reviewed. Patients were sampled if they had a diagnosis of DM and had at least 1 documented A1C% reduction from their baseline value. Weight loss treatment was individualized and consisted of a calorie-restricted diet, a behavior modification plan, and a plan for increasing physical activity. Patient weights were measured at bimonthly visits. A1C% was measured every 3 months. RESULTS: Seventy-two patients formed the study cohort. Mean baseline body mass index was 35.1 kg/m(2), mean age was 52.6 years, and 59% were males. Mean starting A1C% was 8.6. Patients achieved significant mean weight loss (10.7 kg) at study exit. Weight loss of 6.5 kg (4.5% of baseline body weight), 12.2 kg (8.7%), and 15.9 kg (10.3%) was required to reduce A1C% by 0.5, 1, and 1.5, respectively, and it took a mean of 5.6, 8.7, and 10.1 months, respectively, to achieve this. After adjustment for antidiabetic medication intake, for every 10% weight loss, the predicted reduction in A1C% was 0.81. CONCLUSIONS: Intentional weight loss of 10% can potentially decrease A1C% by 0.81 among patients with type 2 DM. This finding may be clinically useful in encouraging and counseling a patient attempting weight loss.

Screening for latent tuberculosis in refugees with renal failure.

Refugee camps are prone for easy spread of infections of various kinds and tuberculosis (TB) is no exception. Refugees with renal failure are often a vulnerable group because they are immunocompromised due to reasons such as poor nutrition, overcrowding and immune suppression due to renal failure. Latent pulmonary TB is a particular problem in this patient population as it is not easily diagnosed and has immense potential for spread. Tuberculin Skin Test (TST), although easy to perform and is cost-effective, suffers from the limitations of giving false positive results due to cross-reaction with the vaccination. Chest radiography though cheap, has not yet been validated in refugee populations for this purpose. Sputum analysis shows promise due to ease of performing but again has not been validated in refugees. Newer assays such as IF-γ show great promise but needs large scale studies for validation and cheaper assays need to be developed for use in resource poor refugee setting. In short, an ideal tool for effective screening of latent TB in refugees with renal failure is lacking. Future studies are required to identify this ideal tool.