The BDNF Val66Met polymorphism and health-related quality of life in youth with obesity.

The brain derived-neurotrophic factor (BDNF) Val66Met polymorphism causes functional changes in BDNF, and is associated with obesity and some psychiatric disorders, but its relationship to health-related quality of life (HRQoL) remains unknown. This study examined, in youth with obesity, whether carriers of the BDNF Val66met polymorphism Met-alleles (A/A or G/A) differed from noncarriers (G/G) on HRQoL. The participants were 187 adolescents with obesity. Ninety-nine youth were carriers of the homozygous Val/Val (G/G) alleles, and 88 were carriers of the Val/Met (G/A) or Met/Met (A/A) alleles. Blood samples were drawn in the morning after an overnight fast for genotyping. HRQoL was measured using the Pediatric-Quality of Life core version. Compared to carriers of the Val66Met Val (G/G) alleles, carriers of the Met-Alleles reported significantly higher physical -HRQoL (p = 0.02), school-related HRQoL, (p = 0.05), social-related HRQoL (p = 0.05), and total HRQoL (p = 0.03), and a trend for Psychosocial-HRQoL. Research is needed to confirm our findings and determine whether carriers of the BDNF Val66Met homozygous Val (G/G) alleles may be at risk of diminished HRQoL, information that can influence interventions in a high-risk population of inactive youth with obesity.

Effects of the HEARTY exercise randomized controlled trial on eating behaviors in adolescents with obesity.

Background: There are well-recognized benefits of behavioral interventions that include exercise for children and adolescents with obesity. However, such behavioral weight management programs may precipitate unintended consequences. It is unclear if different exercise modalities impact eating behaviors differently in youth with obesity. Objectives: The purpose of this study was to examine the effects of aerobic, resistance, and combined aerobic and resistance exercise training on eating attitudes and behaviors (uncontrolled eating, restrained eating, emotional eating, external eating and food craving) among adolescents with overweight and obesity. Methods: N = 304 (70% female) adolescents with overweight and obesity participated in the 6-month Healthy Eating Aerobic and Resistance Training in Youth (HEARTY) randomized controlled trial. All participants were inactive post-pubertal adolescents (15.6 ± 1.4 years) with a mean BMI = 34.6 ± 4.5 kg/m2. The Food Craving Inventory (food cravings), Dutch Eating Behavior Questionnaire (restrained eating, emotional eating, external eating), and the Three-Factor Eating Questionnaire (uncontrolled eating) were used to assess eating attitudes and behaviors. Results: All exercise groups showed within-group decreases in external eating and food cravings. Participants randomized to the Combined training group and were more adherent showed the greatest improvements in eating behaviors and cravings. Conclusions: A 6-month exercise intervention produced improvements in disordered eating behaviors and food cravings, but effects may be gender and modality-specific. Findings highlight the need to tailor exercise intervention to participant characteristics for the promotion of healthier eating and weight management outcomes in youth with obesity.Clinical Trial Registration # and Date: ClinicalTrials.Gov NCT00195858, September 12, 2005.

The Resistance Exercise in Already Active Diabetic Individuals (READI) Randomized Clinical Trial.

CONTEXT: Resistance exercise training (strength training) and aerobic exercise training are both recommended for people with type 1 diabetes, but it is unknown whether adding resistance exercise provides incremental benefits in people with this condition who already perform aerobic exercise regularly. OBJECTIVE: This work aimed to evaluate the incremental effect of resistance training on glycated hemoglobin A1c (HbA1c), fitness, body composition, and cardiometabolic risk factors in aerobically active people with type 1 diabetes. METHODS: The Resistance Exercise in Already-active Diabetic Individuals (READI) trial (NCT00410436) was a 4-center, randomized, parallel-group trial. After a 5-week run-in period with diabetes management optimization, 131 aerobically active individuals with type 1 diabetes were randomly assigned to resistance exercise (n = 71, intervention-INT) or control (n = 60, CON) for 22 additional weeks. Both groups maintained their aerobic activities and were provided dietary counseling throughout. Exercise training was 3 times per week at community-based facilities. The primary outcome was HbA1c, and secondary outcomes included fitness (peak oxygen consumption, muscle strength), body composition (anthropometrics, dual-energy x-ray absorptiometry, computed tomography), and cardiometabolic risk markers (lipids, apolipoproteins). Assessors were blinded to group allocation. RESULTS: There were no significant differences in HbA1c change between INT and CON. Declines in HbA1c (INT: 7.75 ± 0.10% [61.2 ± 1.1 mmol/mol] to 7.55 ± 0.10% [59 ± 1.1 mmol/mol]; CON: 7.70 ± 0.11% [60.7 ± 1.2 mmol/mol] to 7.57 ± 0.11% [59.6 ± 1.3 mmol/mol]; intergroup difference in change -0.07 [95% CI, -0.31 to 0.18]). Waist circumference decreased more in INT than CON after 6 months (P = .02). Muscular strength increased more in INT than in CON (P < .001). There were no intergroup differences in hypoglycemia or any other variables. CONCLUSION: Adding resistance training did not affect glycemia, but it increased strength and reduced waist circumference, in aerobically active individuals with type 1 diabetes.

White blood cell count trajectory and mortality in septic shock: a historical cohort study.

PURPOSE: Septic shock is associated with a mortality of 20-40%. The white blood cell count (WBC) at hospital admission correlates with prognosis in septic shock. Here, we explore whether the trajectory of WBC after admission provides further information about outcomes. We aimed to identify groups of patients with different WBC trajectories and the association of WBC trajectory with mortality. METHODS: We included adult patients with septic shock in two academic intensive care units (ICU) in Winnipeg, MB, Canada between 2006 and 2012. We used group-based trajectory analysis to group patients according to their WBC patterns over the first seven days in the ICU. Our primary analysis was the association of WBC trajectory group on 30-day mortality using multivariable Cox proportional hazards regression. RESULTS: We included 917 patients with septic shock. The final model identified seven distinct WBC trajectories. The rising WBC trajectory was independently associated with increased mortality (hazard ratio, 3.41; 95% confidence interval, 1.86 to 6.26; P < 0.001) compared with the stable WBC trajectory. CONCLUSION: In patients with septic shock, distinct and clinically relevant groups can be identified by analyzing WBC trajectories. A rising WBC trajectory was associated with higher mortality.

RéSUMé: OBJECTIF: Le choc septique est associé à une mortalité de 20 à 40 %. La numération leucocytaire à l'admission à l'hôpital est corrélée au pronostic en cas de choc septique. Dans ce manuscrit, nous tentons de déterminer si l'évolution de la numération leucocytaire après l'admission fournit plus d'informations sur les devenirs. Nous avons cherché à identifier des groupes de patients présentant différentes trajectoires d'évolution de numération leucocytaire et l'association entre l'évolution de la numération et la mortalité. MéTHODE: Nous avons inclus des patients adultes atteints d'un choc septique dans deux unités de soins intensifs (USI) universitaires à Winnipeg, Manitoba, Canada entre 2006 et 2012. Nous avons utilisé une analyse de l'évolution basée sur le groupe pour regrouper les patients en fonction du type d'évolution de la numération leucocytaire au cours des sept premiers jours à l'USI. Notre analyse principale consistait à déterminer l'association entre le groupe d'évolution de numération leucocytaire et la mortalité à 30 jours en utilisant une régression multivariable à risque proportionnel de Cox. RéSULTATS: Nous avons inclus 917 patients atteints de choc septique. Le modèle final a identifié sept types de trajectoire d'évolution de numération leucocytaire distincts. Une évolution ascendante de la numération leucocytaire était indépendamment associée à une augmentation de la mortalité (rapport de risque, 3,41; intervalle de confiance à 95 %, 1,86 à 6,26; P < 0,001) par rapport à une évolution de numération leucocytaire stable. CONCLUSION: Chez les patients atteints de choc septique, des groupes distincts et cliniquement pertinents peuvent être identifiés en analysant les trajectoires d'évolution de la numération leucocytaire. Une évolution ascendante de la numération leucocytaire était associée à une mortalité plus élevée.

Rhythm Control Vs Rate Control in a Contemporary Ambulatory Atrial Fibrillation Cohort: Post Hoc Analysis of the IMPACT-AF Trial.

Background: We examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control. Methods: This is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months. Results: A total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS2 scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group. Conclusions: Both rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Contexte: Nous avons examiné les caractéristiques et le devenir de patients ambulatoires contemporains atteints de fibrillation auriculaire (FA) dans le cadre d'une comparaison entre la maîtrise de la fréquence cardiaque et la maîtrise du rythme cardiaque. Méthodologie: Nous avons effectué une analyse a posteriori d'un essai à répartition aléatoire par grappes ( I ntegrated M anagement P rogram A dvancing C ommunity T reatment of A trial F ibrillation [IMPACT-AF]) mené de 2016 à 2018 chez des patients ambulatoires atteints de FA en vue de comparer un outil d'aide à la décision clinique destiné aux omnipraticiens avec les soins habituels. Notre analyse a permis d'établir une comparaison entre les patients pris en charge par une maîtrise de la fréquence cardiaque et ceux pris en charge par une maîtrise du rythme cardiaque lors de leur inscription à l'essai. Les paramètres d'évaluation comprenaient les consultations aux urgences liées à la FA, les hospitalisations imprévues ayant des causes cardiovasculaires et les épisodes hémorragiques à 12 mois. Résultats: Au total, 870 patients ont été inclus dans cette analyse; 99 (11,4 %) faisaient partie du groupe pris en charge par une maîtrise du rythme cardiaque, et 40 % étaient de femmes. Dans le groupe pris en charge par une maîtrise du rythme cardiaque, l'âge moyen était moindre (70 ± 11,4 ans vs 72,7 ± 9,5 ans, P = 0,03), un plus grand nombre de patients présentaient une FA paroxystique (80 % vs 43 %, P < 0,001) et les scores CHADS2 étaient moins élevés. Le taux de consultations aux urgences liées à la FA était plus élevé dans le groupe pris en charge par une maîtrise du rythme cardiaque (17,2 vs 7,3 %, P = 0,003) tout comme le taux de consultations répétées aux urgences (rapport des taux de 3,03, intervalle de confiance à 95 % de 1,99 à 4,52, P < 0,001). Le nombre de consultations répétées aux urgences était indépendamment associé au sexe féminin et à l'inclusion dans le groupe pris en charge par une maîtrise du rythme cardiaque. Conclusions: Des consultations répétées aux urgences ont été notées tant chez les patients pris en charge par une maîtrise de la fréquence cardiaque que chez ceux pris en charge par une maîtrise du rythme cardiaque quoique plus fréquemment chez ces derniers. Nos constats sont de type observationnel. Néanmoins, dans le contexte des lignes directrices actuelles, ils pourraient contribuer à la mise au point d'autres traitements visant à atténuer le fardeau des symptômes tant chez les patients pris en charge par une maîtrise du rythme cardiaque que chez ceux pris en charge par une maîtrise de la fréquence cardiaque et ainsi permettre globalement une meilleure utilisation des soins de santé chez les patients atteints de FA.

Urban-Rural Differences in Cardiac Arrest Outcomes: A Retrospective Population-Based Cohort Study.

Background: Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas. Methods: This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms. Results: A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3). Conclusions: Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

Contexte: Environ 10 % des personnes qui subissent un arrêt cardiaque en milieu extrahospitalier (ACEH), traité par des intervenants paramédicaux, survivent jusqu'à leur congé de l'hôpital. Le taux de survie peut différer de 19,2 % entre les centres urbains et les régions rurales. Notre étude visait à étudier les différences en matière de survie après un ACEH entre les centres urbains et les régions rurales. Méthodologie: Il s'agissait d'une étude de cohorte rétrospective portant sur des patients ayant subi un ACEH traité par les services médicaux d'urgence de la Nouvelle-Écosse en 2017. Les cas d'ACEH traumatique, prévu et non cardiaque ont été exclus. Les données ont été recueillies à partir du système de dossiers électroniques de soins aux patients des services médicaux d'urgence et de la Base de données sur les congés des patients. L'analyse du système d'information géographique a classé les cas selon qu'ils sont survenus dans un centre urbain (population de plus de 1 000 personnes) ou dans une région rurale, en utilisant les limites du recensement canadien de 2016. Le principal paramètre d'évaluation était la survie à la sortie de l'hôpital. Les covariables utilisées dans la régression logistique multivariée étaient l'âge, le sexe, la réanimation effectuée par des témoins si présents lors de l'arrêt cardiaque, l'emplacement public et les symptômes précédents. Résultats: Au total, 510 ACEH traités par les services médicaux d'urgence de la Nouvelle-Écosse ont été inclus aux fins de l'analyse. En tout, 12 % (n = 62) des sujets ont survécu jusqu'à leur congé hospitalier. Les patients ayant subi un ACEH dans un centre urbain étaient 107 % plus susceptibles de survivre que ceux ayant subi un ACEH dans une région rurale (rapport de cotes ajusté : 2,1; intervalle de confiance à 95 % : 1,1 ­ 3,8; p = 0,028). Le temps moyen de délivrance d'un choc lors d'un ACEH avec rythme défibrillable est significativement plus court (11,2 ± 6,2 minutes) dans un centre urbain que dans une région rurale (17,5 ± 17,3 minutes). Conclusions: La Nouvelle-Écosse fait état d'une disparité dans les soins de l'ACEH entre les régions urbaines et les régions rurales, que l'on observe également dans les villes densément peuplées. La survie est plus longue dans les centres urbains. Il est possible de prolonger davantage la survie globale, en particulier dans les régions rurales, en sensibilisant la communauté à l'ACEH et en optimisant la prestation des soins de santé.

Ventricular tachycardia characteristics and outcomes with catheter ablation vs. antiarrhythmic therapy: insights from the VANISH trial.

AIMS: Catheter ablation is superior to escalated antiarrhythmic drugs among patients with ventricular tachycardia (VT) and prior myocardial infarction (MI). However, it is uncertain whether clinical VT characteristics, should influence choice of therapy. The purpose of this study was to evaluate whether presentation with electrical storm and the clinical VT cycle length predicted response to ablation vs. escalated antiarrhythmic therapy. METHODS AND RESULTS: All patients enrolled in the Ventricular Tachycardia Ablation vs. Escalated Antiarrhythmic Drug Therapy in Ischaemic Heart Disease (VANISH) trial were included. The association between VT cycle length and presentation with electrical storm and the primary outcome of death, subsequent VT storm or appropriate ICD shock was evaluated. Among the study population of 259 patients, escalated antiarrhythmic drug therapy had worse outcomes for those presenting with a VT cycle length >400 ms [<150 b.p.m., 89/259, hazard ratio (HR) 1.7 (1.02-3.13)]. This effect was more pronounced among those taking amiodarone at baseline [HR of 2.22 (1.19-4.16)]. Presentation with VT storm (32/259) did not affect the primary outcome between groups. However, those presenting with VT storm on amiodarone had a trend towards worse outcomes with escalated antiarrhythmic therapy [HR 4.31 (0.55-33.93)]. CONCLUSION: The VT cycle length can influence response to either ablation or escalated drug therapy in patients with VT and prior MI. Those with slow VT had improved outcomes with ablation. Patients presenting with electrical storm demonstrated similar outcomes to the overall trial population, with a trend to benefit of catheter ablation, particularly in those on amiodarone.

Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery.

BACKGROUND: Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events. METHODS: Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes. RESULTS: A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery. CONCLUSION: A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications.

INTRODUCTION: Les grandes lignes directrices sociétales recommandent une interruption de cinq jours avant l'intervention chirurgicale du cœur des patients atteints d'un syndrome coronarien aigu qui prennent du clopidogrel. Toutefois, comme il s'agit pour plusieurs d'entre eux de patients de haute acuité, le chirurgien penche vers l'utilisation d'une interruption plus courte. Par conséquent, la présente étude avait pour objectif de déterminer les conséquences de la durée et du moment de la cessation du clopidogrel sur les événements hémorragiques indésirables. MÉTHODES: La présente étude de cohorte rétrospective portait sur les patients qui avaient subi une intervention chirurgicale au cœur entre 2009 et 2016 dans un centre de soins tertiaires. Nous avons utilisé les modèles multivariés de régression logistique ajustés à l'interruption du clopidogrel, à l'âge, à l'urgence de l'intervention chirurgicale et au type d'intervention chirurgicale pour quantifier les effets des caractéristiques démographiques initiales cliniquement pertinentes sur la fréquence des transfusions massives ainsi que sur les issues des complications hémorragiques. RÉSULTATS: Un total de 5 748 patients ont subi une intervention chirurgicale au cœur. Dans cette cohorte, parmi les 1 743 patients (30,3 %) qui avaient reçu du clopidogrel avant l'opération, 884 (50,7 %) avaient cessé le clopidogrel cinq jours avant leur admission à la salle d'opération. L'administration du clopidogrel un à deux jours avant l'intervention chirurgicale (ratio d'incidence approché 1,97; intervalle de confiance [IC] à 95 % : de 1,18 à 3,29) était un prédicteur indépendant des transfusions massives et des complications hémorragiques (ratio d'incidence approché 1,85; [IC] à 95 % : de 1,01 à 3,37). Le groupe de l'interruption de trois à quatre jours n'a pas montré de risque accru de complications hémorragiques graves. Le risque de transfusions massives et de complications hémorragiques a aussi contribué à l'augmentation de l'urgence et de la complexité de l'intervention chirurgicale. CONCLUSION: Une interruption du clopidogrel de trois à quatre jours avant l'opération n'a pas été associée à un risque accru de complications hémorragiques graves.

Effect of seat height on manual wheelchair foot propulsion, a repeated-measures crossover study: part 2 - wheeling backward on a soft surface.

PURPOSE: The aim of this study was to test the hypotheses that, during manual-wheelchair foot propulsion backward on a soft surface, lowering the seat height increases speed, push frequency and push effectiveness, and decreases perceived difficulty. MATERIALS AND METHODS: In a repeated-measures crossover study, 50 able-bodied participants used one foot to propel a manual wheelchair 5 m backward on a soft surface at 5 seat heights, ranging from 5.08 cm below to about 5.08 cm above lower-leg length, in random order. We recorded Wheelchair Skills Test (WST) capacity scores and used the Wheelchair Propulsion Test (WPT) to calculate speed (m/s), push frequency (cycles/s) and push effectiveness (m/cycle). We also recorded the participants' perceived difficulty (0-4) and video-recorded each trial. RESULTS: WST capacity scores were reduced at the higher seat heights. Using repeated-measures models (adjusted for age, sex and order), there were negative relationships between seat height and speed (p < 0.0001) and push effectiveness (p < 0.0001). Lowering the seat height by 5.08 cm below lower-leg length corresponded to improvements in speed of 0.097 m/s and in push effectiveness of 0.101 m/cycle. The trend for push frequency was also significant (p = 0.035) but the effect size was smaller. Perceived difficulty increased with seat height (p < 0.0001). The video-recordings provided qualitative kinematic data regarding the seated "gait cycles". CONCLUSIONS: During manual-wheelchair foot propulsion backward on a soft surface, lowering the seat height increases speed and push effectiveness, and decreases perceived difficulty.IMPLICATIONS FOR REHABILITATIONBackward wheelchair foot propulsion on soft surfaces is affected by seat height.Speed (m/s) is improved if the seat height is lowered.Push effectiveness (m/gait cycle) is improved if the seat height is lowered.Perceived difficulty of propulsion is lower if the seat height is lowered.

Associations of the BDNF Val66Met Polymorphism With Body Composition, Cardiometabolic Risk Factors, and Energy Intake in Youth With Obesity: Findings From the HEARTY Study.

The brain-derived neurotrophic factor (BDNF) Val66Met polymorphism is functionally related to BDNF, and is associated with obesity and metabolic complications in adults, but limited research exists among adolescents. This study comparatively examined carriers and non-carriers of the BDNF Val66Met polymorphism on body composition, energy intake, and cardiometabolic profile among adolescents with obesity. The sample consisted of 187 adolescents with obesity; 99 were carriers of the homozygous Val (G/G) alleles and 88 were carriers of the Val/Met (G/A) or Met (A/A) alleles. Cardiometabolic profile and DNA were quantified from fasted blood samples. Body composition was assessed by magnetic resonance imaging (MRI). Compared to carriers of the homozygous Val (G/G) allele, carriers of the Val/Met (G/A) or Met/Met (A/A) variants exhibited significantly higher protein (p = 0.01) and fat (p = 0.05) intake, C-Reactive protein (p = 0.05), and a trend toward higher overall energy intake (p = 0.07), fat-free mass (p = 0.07), and lower HDL-C (p = 0.07) Results showed for the first time that among youth with obesity, carriers of the Val66Met BDNF Met-alleles exhibited significantly higher C-reactive protein and energy intake in the form of fat and protein compared to Val-allele carriers, thereby providing support for the possible role of BDNF in appetite, weight, and metabolic regulation during adolescence. Clinical Trial Registration: http://clinicaltrials.gov/, identifier NCT00195858.

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study.

AIMS: Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. METHODS: We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. RESULTS: Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. CONCLUSION: Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850-857.

Remote Monitoring of Cardiovascular Implantable Electronic Devices in Canada: Survey of Patients and Device Health Care Professionals.

BACKGROUND: Remote monitoring is used to supplement in-clinic follow-up for patients with cardiac implantable electronic devices (CIEDs) every 6-12 months. There is a need to optimize remote management for CIEDs because of the consistent increases in CIED implants over the past decade. The objective of this study was to investigate real and perceived barriers to the use of remote patient management strategies in Canada and to better understand how remote models of care can be optimized. METHODS: We surveyed 512 CIED patients and practitioners in 22 device clinics in Canada. RESULTS: Device clinic surveys highlighted significant variation and inconsistency in follow-up care for in-clinic and remote visits across and within clinics. This survey showed that funding policies and management of additional workflow are barriers to optimal use and uptake. Despite this, device clinics perceive remote follow-up as a valuable resource and an efficient way to manage patient follow-up. Patients were broadly satisfied with their CIED follow-up care but identified barriers related to coordination of care, visit logistics, and information needs. Views varied as a function of clinical or sociodemographic characteristics. Most patients (n = 228; 91%) expressed a desire to receive a phone call from their device clinic after a remote transmission has been received. CONCLUSIONS: Lack of a unified, guideline-supported approach to follow-up after CIED implant, and discrepant funding policies across jurisdictions, are significant barriers to the use of remote patient management strategies in Canada. Efforts to increase or expand use of remote follow-up must recognize these barriers and the needs of specific subgroups of patients.

INTRODUCTION: La télésurveillance sert de complément à la consultation en clinique des patients porteurs d'un dispositif cardiaque électronique implantable (DCEI) tous les 6 à 12 mois. Il est nécessaire d'optimiser la prise en charge à distance des patients porteurs de DCEI en raison de la constante augmentation des implantations de DCEI au cours de la dernière décennie. L'objectif de la présente étude était d'examiner les obstacles réels et perçus à l'utilisation des stratégies de prise en charge à distance des patients du Canada et de mieux comprendre la façon d'optimiser les modèles de soins à distance. MÉTHODES: Nous avons interrogé 512 patients porteurs de DCEI et praticiens de 22 cliniques spécialisées en DCEI du Canada. RÉSULTATS: Les enquêtes des cliniques spécialisées en DCEI ont fait ressortir la variation importante et le manque d'uniformité dans les soins de suivi lors des consultations en clinique et à distance au sein de toutes les cliniques et entre elles. Cette enquête a montré que les politiques de financement et la gestion du flux de travail supplémentaire sont les obstacles qui empêchent l'utilisation optimale et l'adoption. Malgré cela, les cliniques spécialisées en DCEI perçoivent le suivi à distance comme une ressource très utile et un moyen efficace de prendre en charge le suivi du patient. Les patients étaient dans l'ensemble satisfaits de leurs soins de suivi relatifs à leur DCEI, mais relevaient des obstacles liés à la coordination des soins, à la logistique des consultations et à leurs besoins d'information. Les points de vue variaient en fonction des caractéristiques cliniques et sociodémographiques. La plupart des patients (n = 228 ; 91 %) ont fait part de leur souhait de recevoir un appel téléphonique de leur clinique spécialisée en DCEI après la réception de la transmission à distance. CONCLUSIONS: L'absence d'une approche unifiée et fondée sur les lignes directrices qui porte sur le suivi après l'implantation de DCEI, et la divergence des politiques de financement des provinces et territoires sont des obstacles importants à l'utilisation de stratégies de prise en charge à distance des patients au Canada. Les efforts visant à accroître ou à étendre l'utilisation du suivi à distance doivent tenir compte de ces obstacles et des besoins des sous-groupes particuliers de patients.

Predicting acute kidney injury following nonemergent cardiac surgery: A preoperative scorecard.

OBJECTIVE: To determine the predictors of postoperative acute kidney injury (AKI) following nonemergent cardiac surgery among patients with variable preoperative estimated glomerular filtration rate (eGFR) levels. METHODS: A retrospective study of patients who underwent elective or in-hospital cardiac surgical procedures was performed between January 2006 and November 2015. The procedures included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), or combined CABG and AVR. The primary outcome AKI (any stage) following nonemergent cardiac surgery utilizing the 2012 Kidney Disease-Improving Global Outcomes (KDIGO) criteria. Patients were categorized based on the following renal outcomes: mild AKI, severe AKI (KDIGO stage 2 or 3), and postoperative dialysis. Patients with G5 preoperative kidney function (including dialysis patients) were excluded. RESULTS: A total of 6675 patients were included in our study. The mean age was 66.8 years (SD ± 10.4), with 76.3% being males. A total of 4487 patients had normal or mildly decreased eGFR (G1 or G2) preoperatively (67.2%), while 1960 patients were in the G3 category (29.4%). Only 228 patients (3.4%) had G4 renal function. A total of 1453 (21.7%) patients experienced postoperative AKI. The need for postoperative dialysis occurred in 3.2% of the AKI subgroup. In-hospital mortality was higher among the AKI subgroup (7.2% vs. 0.5%; p < .0001). In an adjusted model, a lower preoperative eGFR category was the strongest predictor of AKI. A practical scorecard for the preoperative estimation of severe AKI for nonemergent cardiac procedures incorporating these parameters was developed. CONCLUSIONS: Preoperative eGFR is the strongest predictor of postoperative AKI in individuals undergoing nonemergent cardiac surgery. A practical scorecard incorporating preoperative predictors of AKI may allow informed decision-making and predict AKI following nonemergent cardiac surgery.

No association between dopaminergic polymorphisms and response to treatment of binge-eating disorder.

BACKGROUND: The genetics of binge-eating disorder (BED) is an emerging topic, with dopaminergic genes being implicated in its etiology due to the role that dopamine (DA) plays in food reward sensitivity and self-regulation of eating behavior. However, no study to date has examined if DA genes influence response to behavioral treatment of BED. OBJECTIVE: The primary objective of this study was to examine the ability of DA-associated polymorphisms to predict BED treatment response measured using binge frequency over 12 months. As secondary objectives, this study examined cross-sectional relationships between these polymorphisms and anthropometrics in women living with and without BED and obesity. METHODS: Women aged 18-64 years old were genotyped for the DA-related SNPs DRD2/ANKK1 Taq1A (rs1800497) and COMT (rs4680), as well as the DA-related uVNTRs DAT-1 (SLC6A3) and MAO-A. A multi-locus DA composite score was formed from these 4 polymorphisms using genotypes known to have a functional impact resulting in modified DA signaling. Binge frequency (Eating Disorder Examination - Interview) and body composition (Tanita BC-418) were assessed in a pre-post analysis to examine genetic predictors of treatment response in women living with obesity and BED. Secondary data analysis was conducted on a cross-sectional comparison of three groups of women enrolled in trial group treatment for BED: women living with obesity and BED (n = 72), obesity without BED (n = 27), and normal-weight without BED (n = 45). RESULTS: There were no significant genotype × time interactions related to anthropometrics or binge frequency for any individual DA genotypes, or to the composite score reflecting DA availability. At baseline, there were no significant between-group differences in frequencies of DA-related alleles, nor were there associations between genotypes and anthropometrics. CONCLUSIONS: Our study found no evidence to suggest that the DRD2/ANKK1 Taq1A, COMT, MAO-A, or DAT-1 polymorphisms are associated with response to behavioral intervention for BED as measured by changes in binge frequency. Future studies should examine a greater variety of dopaminergic polymorphisms, other candidate genes that target other neurotransmitter systems, as well as examine their impact on both behavioral and pharmacological-based treatment for BED.

Exercise training and reproductive outcomes in women with polycystic ovary syndrome: A pilot randomized controlled trial.

OBJECTIVE: Exercise is recommended for polycystic ovary syndrome (PCOS), but the most effective exercise prescription is unclear. This trial compared effects of high-intensity interval training (HIIT), continuous aerobic exercise training (CAET) and no-exercise control on reproductive, anthropometric and cardiometabolic outcomes in PCOS. DESIGN: Pilot randomized controlled trial. PARTICIPANTS: Previously inactive women aged 18-40 years with PCOS. MEASUREMENTS: Feasibility outcomes included recruitment, retention, adherence to exercise and daily ovulation prediction kit (OPK) testing. Preliminary efficacy outcomes included reproductive, anthropometric and cardiometabolic health markers. RESULTS: Forty-seven women were randomized to no-exercise control (n = 17), HIIT (n = 16), or CAET (n = 14). Forty (85%) participants completed the trial. Median exercise adherence was 68% (IQR 53%, 86%). Median daily OPK-testing adherence in the first half of the intervention was 87% (IQR 61%, 97%) compared with 65% (IQR 0%, 96%) in the second half. Body mass index decreased significantly in CAET compared with control (-1.0 kg/m2 , p = .01) and HIIT (-0.9 kg/m2 , p = .04). Mean waist circumference decreased in all groups (-7.3 cm, -6.9 cm, -4.5 cm in HIIT, CAET and control) with no significant between-group differences. Mean LDL-C was significantly reduced for HIIT compared to CAET (-0.33 mmol/L, p = .03). HDL-C increased in HIIT compared with control (0.18 mmol/L, p = .04). CONCLUSIONS: There were feasibility challenges with adherence to daily ovulation assessment limiting the ability to analyse the effect of the exercise interventions on ovulation. CAET and HIIT were both effective at improving anthropometrics and some cardiometabolic health markers. Further studies need to determine optimal and acceptable exercise prescriptions for this population.

Prevalence of Frailty in Patients Referred to the Kidney Transplant Waitlist.

Background: Comparisons between frailty assessment tools for waitlist candidates are a recognized priority area for kidney transplantation. We compared the prevalence of frailty using three established tools in a cohort of waitlist candidates. Methods: Waitlist candidates were prospectively enrolled from 2016 to 2020 across five centers. Frailty was measured using the Frailty Phenotype (FP), a 37-variable frailty index (FI), and the Clinical Frailty Scale (CFS). The FI and CFS were dichotomized using established cutoffs. Agreement was compared using κ coefficients. Area under the receiver operating characteristic (ROC) curves were generated to compare the FI and CFS (treated as continuous measures) with the FP. Unadjusted associations between each frailty measure and time to death or waitlist withdrawal were determined using an unadjusted Cox proportional hazards model. Results: Of 542 enrolled patients, 64% were male, 80% were White, and the mean age was 54±14 years. The prevalence of frailty by the FP was 16%. The mean FI score was 0.23±0.14, and the prevalence of frailty was 38% (score of ≥0.25). The median CFS score was three (IQR, 2-3), and the prevalence was 15% (score of ≥4). The κ values comparing the FP with the FI (0.44) and CFS (0.27) showed fair to moderate agreement. The area under the ROC curves for the FP and FI/CFS were 0.86 (good) and 0.69 (poor), respectively. Frailty by the CFS (HR, 2.10; 95% CI, 1.04 to 4.24) and FI (HR, 1.79; 95% CI, 1.00 to 3.21) was associated with death or permanent withdrawal. The association between frailty by the FP and death/withdrawal was not statistically significant (HR, 1.78; 95% CI, 0.79 to 3.71). Conclusion: Frailty prevalence varies by the measurement tool used, and agreement between these measurements is fair to moderate. This has implications for determining the optimal frailty screening tool for use in those being evaluated for kidney transplant.

Effect of seat height on manual wheelchair foot propulsion, a repeated-measures crossover study: part 1 - wheeling forward on a smooth level surface.

PURPOSE: To test the hypotheses that, during manual wheelchair foot propulsion forward on smooth level surfaces, lowering the seat height increases speed, push frequency and push effectiveness, and decreases perceived difficulty. MATERIALS AND METHODS: In a repeated-measures crossover study, 50 able-bodied participants used one foot to propel a manual wheelchair 10 m on a smooth level surface at 5 seat heights in random order, ranging from 5.08 cm below to about 5.08 cm above lower-leg length. We recorded Wheelchair Skills Test (WST) capacity scores and used the Wheelchair Propulsion Test (WPT) to calculate speed (m/s), push frequency (cycles/s) and push effectiveness (m/cycle). We also recorded the participants' perceived difficulty (0-4) and video-recorded each trial. RESULTS: WST capacity scores were reduced at the higher seat heights. Using repeated-measures models (adjusted for age, sex and order), there were negative relationships between seat height and speed (p < 0.0001) and push effectiveness (p < 0.0001). Lowering the seat height by 5.08 cm below lower-leg length corresponded to improvements in speed of 0.20 m/s and in push effectiveness of 0.20 m/cycle. The trend for push frequency was also significant (p = 0.003) but the effect size was smaller. Perceived difficulty increased with seat height (p < 0.001). The video-recordings provided qualitative kinematic data regarding the seated "gait cycles". CONCLUSIONS: During manual wheelchair foot propulsion forward on smooth level surfaces, lowering the seat height increases speed and push effectiveness, and decreases perceived difficulty. CLINICAL TRIAL REGISTRATION NUMBER: NCT03330912.Implications for RehabilitationGenerally, wheelchairs used for forward foot propulsion should have a seat height that is 2.54-5.08 cm less than the sitting lower-leg length.Clinicians should, however, take into consideration other functions that may be adversely affected by lowering the seat height.

The effect of revascularization on mortality and risk of ventricular arrhythmia in patients with ischemic cardiomyopathy.

BACKGROUND: There is clear evidence that patients with prior myocardial infarction and a reduced ejection fraction benefit from implantation of a cardioverter-defibrillator (ICD). It is unclear whether this benefit is altered by whether or not revascularization is performed prior to ICD implantation. METHODS: This was a retrospective cohort study following patients who underwent ICD implantation from 2002 to 2014. Patients with ischemic cardiomyopathy and either primary or secondary prevention ICDs were selected for inclusion. Using the electronic medical record, cardiac catheterization data, revascularization status (percutaneous coronary intervention or coronary bypass surgery) were recorded. The outcomes were mortality and ventricular arrhythmia. RESULTS: There were 606 patients included in the analysis. The mean age was 66.3 ± 10.1 years, 11.9% were women, and the mean LVEF was 30.5 ± 12.0, 58.9% had a primary indication for ICD, 82.0% of the cohort had undergone coronary catheterization prior to ICD implantation. In the overall cohort, there were fewer mortality and ventricular arrhythmia events in patients who had undergone prior revascularization. In patients who had an ICD for secondary prevention, revascularization was associated with a decrease in mortality (HR 0.46, 95% CI (0.24, 0.85) p = 0.015), and a trend towards fewer ventricular arrhythmia (HR 0.62, 95% CI (0.38, 1.00) p = 0.051). There was no association between death or ventricular arrhythmia with revascularization in patients with primary prevention ICDs. CONCLUSION: Revascularization may be beneficial in preventing recurrent ventricular arrhythmia, and should be considered as adjunctive therapy to ICD implantation to improve cardiovascular outcomes.

Six-year follow-up of aortic valve reoperation rates: Carpentier-Edwards Perimount versus St. Jude Medical Trifecta.

BACKGROUND: The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and low rates of valve-related complications and prosthesis-patient mismatch. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable with Perimount valves, with a few recent studies bringing into focus early structural valve deterioration (SVD), and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared with Perimount. METHODS: The Maritime Heart Centre Database was searched for AVR between 2011 and 2016, inclusive. The primary endpoint of the study was all-cause reoperation rate. RESULTS: In total, 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99; p = .02), female (vs. male): 0.35 (0.08-1.53; p = .16), smoker (vs. nonsmoker): 2.44 (0.85-7.02; p = .1), and Trifecta (vs. Perimount): 2.68 (0.97-7.39; p = .06). Kaplan-Meier survival analysis in subgroups-age <60, age ≥60, male, female, smoker, and nonsmoker-showed Perimount having lower reoperation rates than Trifecta in patients younger than 60 (p = .02) and current smokers (p < .01). CONCLUSIONS: The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow-up, are needed to confirm these findings.