Absolute cardiovascular disease risk score and pharmacotherapy at the time of admission in patients presenting with acute coronary syndrome due to coronary artery disease in a single Australian tertiary centre: a cross-sectional study.

OBJECTIVES: To describe (1) absolute cardiovascular disease risk (ACVDR) scores in patients presenting to hospital with acute coronary syndrome (ACS) and (2) proportions of these patients on guideline-recommended pharmacotherapy according to their ACVDR score. DESIGN: Cross-sectional study. SETTING: Single-site tertiary centre hospital, Queensland, Australia over a 12-month period. PARTICIPANTS: Patients >18 years of age presenting to hospital with ACS due to coronary artery disease (CAD) confirmed by angiography. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients without prior history of CVD with a high ACVDR score, and of patients with a prior history of CVD, who are on guideline-recommended pharmacotherapy. RESULTS: 527 ACS patients were included of whom the mean age was 63 years and 75% were male. Overall, 66% (350) had no prior CVD and 34% (177) patients had prior CVD.In patients with no prior CVD, the proportions of patients with low, intermediate and high CVD risk scores were 41%, 24% and 36%. In the no prior CVD, high-risk patient group, 48% were on no preventative pharmacotherapy, 32% on single pharmacotherapy and 20% patients on complete guideline-recommended pharmacotherapy. In the prior CVD group, 7% patients were on no pharmacotherapy, 40% on incomplete pharmacotherapy and 53% were on complete guideline-recommended pharmacotherapy. CONCLUSION: This study adds to the evidence on implementation gaps in guideline-recommended management of ACVDR, showing that a large proportion of patients presenting with ACS due to CAD were at high risk of developing CVD prior to the event and most were not on guideline-recommended treatment. A significant proportion of these events are likely to have been preventable, and therefore, increased assessment and appropriate treatment of ACVDR in primary care is needed to reduce the incidence of CVD events in the population.

Power modulation contrast enhanced ultrasound for postoperative perfusion monitoring following free tissue transfer in head and neck surgery.

This feasibility study evaluated whether contrast enhanced ultrasound (CEU) was able to assess free flap perfusion following free tissue transfer in the head and neck region. Thirty-six patients underwent standard clinical monitoring (SCM) and CEU postoperatively. The time taken for each technique to detect flap failure was recorded. Qualitative CEU analysis by visual assessment predicted survival in 30/30 (100%) and failure in 5/6 (83%) flaps with sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of 100, 86, 97 and 100%, respectively. Quantitative CEU measurement of blood volume (α) values within healthy perfused flaps was over 60 times higher than in failing flaps (8.25±2.82dB vs. 0.12±0.17dB, respectively, P<0.0001). If a cut-off α value of <1.5dB was used to predict future flap failure, the accuracy of the test was 100% (sensitivity, specificity, PPV, NPV). If a cut-off α value of >1.9dB indicated flap success, the PPV and NPV are 100%. Following surgery, SCM took 76 (±15) h to detect flap failure compared with 18 (±38) h with CEU (P<0.05). CEU is highly accurate in its ability to distinguish between perfused and failing flaps. The technique is quick (<10min) and capable of imaging all flap types.

The cardiorenal syndrome: a review.

Cardiorenal syndrome (CRS) is the umbrella term used to describe clinical conditions in which cardiac and renal dysfunctions coexist. Much has been written on this subject, but underlying pathophysiological mechanisms continue to be unravelled and implications for management continue to be debated. A classification system-incorporating five subtypes-has recently been proposed though it has yet to permeate into day-to-day clinical practice. CRS has garnered much attention from both the cardiological and nephrological communities since the condition is associated with significant morbidity and mortality. Renal dysfunction is highly prevalent amongst patients with heart failure and has been shown to be as powerful and independent a marker of adverse prognosis as ejection fraction. Similarly, patients with renal failure are considerably more likely to suffer cardiovascular disease than matched subjects from the general population. This paper begins by reviewing the epidemiology and classification of CRS before going on to consider the different pathological mechanisms underlying cardiorenal dysfunction. We then focus on management strategies and conclude by discussing future directions in the diagnosis and management of patients suffering with CRS.

BMI from 3-6 y of age is predicted by TV viewing and physical activity, not diet.

OBJECTIVE: To investigate whether, diet, physical activity, sedentary behavior or television (TV) viewing predicted body mass index (BMI) among 3-7-y-old children. DESIGN: A triethnic cohort of 3-4-y-old children was followed for 3 y from 1986 to 1989. MEASUREMENTS: BMI was assessed at the beginning and end of each measurement year. Heart rate monitoring and observation were used to assess physical activity. Diet (calories, % calories from fat and carbohydrate), sedentary behavior and TV viewing were assessed by direct observation in each year. A repeated measures regression analysis with year as a factor and BMI at the end of each year as dependent variables was run. Nonsignificant variables were removed in a stepwise backward deletion process and significant interactions graphed. RESULTS: The interactions between minutes of TV viewing per hour and study year and minutes of physical activity per hour and study year were significant (P<0.05). There were also significant main effects for TV viewing, physical activity and BMI from the beginning of the study. The model accounted for 65% of the variance in BMI across the three study years. Plotting the significant interactions demonstrated that physical activity was positively associated with BMI in year 1, and negatively associated in years 2 and 3 with a stronger negative relationship in year 3 than 2. TV viewing became positively associated with BMI during the third study year. CONCLUSION: Physical activity and TV viewing were the only significant predictors (other than baseline BMI) of BMI among a triethnic cohort of 3-4-y-old children followed for 3 y with both physical activity (negatively associated) and TV viewing (positively associated) becoming stronger predictors as the children aged. It appears that 6 or 7 y is a critical age when TV viewing and physical activity may affect BMI. Therefore, focusing on reducing time spent watching television and increasing time spent in physical activity may be successful means of preventing obesity among this age group.

Clinical criteria and the appropriate use of transthoracic echocardiography for the exclusion of infective endocarditis.

BACKGROUND: Clinical guidelines currently suggest that transthoracic echocardiography (TTE) be carried out in all patients with suspected endocarditis, but the use of TTE where there is a low probability of infective endocarditis has a poor diagnostic yield. This screening approach may no longer be appropriate. OBJECTIVE: To examine whether clinical criteria might aid decision making with respect to the use of TTE in possible endocarditis. DESIGN: A retrospective review of patient records. SETTING: Cardiology department of a tertiary referral centre. PATIENTS: 500 consecutive hospital inpatients referred for TTE to exclude endocarditis. MAIN OUTCOME MEASURES: Evidence of endocardial vegetations on TTE and the presence of predetermined clinical criteria that may predispose to, or be suggestive of, endocarditis. RESULTS: Evidence of infective endocarditis was detected on echocardiography in 43 of the 500 patients (8.6%). In 239 patients (48%), vegetations and certain prespecified clinical criteria were both absent. These criteria were: vasculitic/embolic phenomena; the presence of central venous access; a recent history of injected drug use; presence of a prosthetic valve; and positive blood cultures. The collective absence of these five criteria indicated a zero probability of TTE showing evidence of endocarditis. CONCLUSIONS: The use of simple clinical criteria during the decision making process may avoid many unnecessary TTE examinations in hospital inpatients with a low probability of endocarditis.

Myocardial contrast echocardiography is superior to other known modalities for assessing myocardial reperfusion after acute myocardial infarction.

BACKGROUND: Angiographic flow measurements do not define perfusion accurately at a microvascular level, so other techniques which assess flow at a tissue level are to be preferred. OBJECTIVES: To compare intravenous myocardial contrast echocardiography (MCE) with other methods of assessing microvascular reperfusion for their ability to predict left ventricular function at one month after acute myocardial infarction. DESIGN: 15 patients underwent primary percutaneous coronary angioplasty for acute myocardial infarction, with restoration of TIMI grade 3 flow. Corrected TIMI frame count (cTFC), myocardial blush grade (MBG), and percentage ST segment resolution at 90 and 180 minutes were recorded. Baseline regional wall motion score index (WMSI) and regional contrast score index (RCSI) were obtained 12-24 hours after the procedure, with a final regional WMSI assessment at one month. RESULTS: Mean (SD) cTFC was 27 (9.4), and ST segment resolution was 69 (22)% at 90 minutes and 77 (20)% at 180 minutes. MBG values were 0 in six patients, 2 in two, and 3 in seven. Baseline regional WMSI, RCSI, and follow up WMSI were 2.7 (0.71), 1.5 (0.71), and 1.6 (0.73), respectively. The correlation coefficient between RCSI and follow up WMSI was 0.82 (p = 0.0012). Peak CK correlated with follow up WMSI (R = 0.80). None of the other reperfusion assessment techniques correlated significantly with follow up WMSI. Multiple regression analysis showed that a perfused hypokinetic or akinetic segment was 50 times more likely to recover function than a non-perfused segment. MCE predicted segmental myocardial recovery with a sensitivity of 88%, a specificity of 74%, and positive and negative predictive values of 83% and 81%, respectively. CONCLUSIONS: MCE is currently the best and most accurate measure of reperfusion at a microvascular level and an excellent predictor of left ventricular function at one month following acute myocardial infarction.

Survivors of coarctation repair: fixed but not cured.

While often considered to be cured, patients with repaired coarctation of the aorta frequently have premature morbidity and even mortality.

Chlamydial co-infection among patients with gonorrhoea.

The objective was to determine how often gonococcal (GC) infection is accompanied by chlamydial co-infection and to determine risk factors for dual infection. All GC-positive cultures were identified between 24 April and 9 September 1998, among patients seen at the three genitourinary medicine (GUM) clinics across the Chelsea and Westminster Directorate. Chlamydia trachomatis was diagnosed using an enzyme-linked immunosorbent assay (ELISA) (Dade-Behring). One hundred and fifty-three episodes of gonorrhoea were identified. Information on chlamydial infection was available for 149 cases of GC of whom 16 (10.7%) were found to be co-infected with C. trachomatis. In univariate analysis, chlamydial co-infection was exclusively diagnosed in heterosexuals, and was more likely to be diagnosed among females, in younger individuals and in individuals of black Caribbean ethnic group. In multivariable analyses, however, only the sex and age of the individual were independently associated with chlamydial co-infection. The rate of co-infection was 10.7%. Independent risk factors were being less than 20 years old and being female.

Validity of self-reported energy intake in lean and obese young women, using two nutrient databases, compared with total energy expenditure assessed by doubly labeled water.

OBJECTIVE: To compare self-reported total energy intake (TEI) estimated using two databases with total energy expenditure (TEE) measured by doubly labeled water in physically active lean and sedentary obese young women, and to compare reporting accuracy between the two subject groups. DESIGN: A cross-sectional study in which dietary intakes of women trained in diet-recording procedures were analyzed using the Minnesota Nutrition Data System (NDS; versions 2.4/6A/21, 2.6/6A/23 and 2.6/8.A/23) and Nutritionist III (N3; version 7.0) software. Reporting accuracy was determined by comparison of average TEI assessed by an 8 day estimated diet record with average TEE for the same period. RESULTS: Reported TEI differed from TEE for both groups irrespective of nutrient database (P<0.01). Measured TEE was 11.10+/-2.54 and 11.96+/-1.21 MJ for lean and obese subjects, respectively. Reported TEI, using either database, did not differ between groups. For lean women, TEI calculated by NDS was 7.66+/-1.73 MJ and by N3 was 8.44+/-1.59 MJ. Corresponding TEI for obese women were 7.46+/-2.17 MJ from NDS and 7.34+/-2.27 MJ from N3. Lean women under-reported by 23% (N3) and 30% (NDS), and obese women under-reported by 39% (N3) and 38% (NDS). Regardless of database, lean women reported higher carbohydrate intakes, and obese women reported higher total fat and individual fatty acid intakes. Higher energy intakes from mono- and polyunsaturated fatty acids were estimated by NDS than by N3 in both groups of women (P< or =0.05). CONCLUSIONS: Both physically active lean and sedentary obese women under-reported TEI regardless of database, although the magnitude of under-reporting may be influenced by the database for the lean women. SPONSORSHIP: USDA Hatch Project award (ARZT-136528-H-23-111) to LB Houtkooper and WH Howell.

Soy protein reduces the arterial low-density lipoprotein (LDL) concentration and delivery of LDL cholesterol to the arteries of diabetic and nondiabetic male cynomolgus monkeys.

We have previously shown that soy protein consumption improves lipoprotein concentrations and reduces the progression of atherosclerosis in cynomolgus monkeys. The mechanism for these beneficial effects is unclear. The purpose of this study was to determine potential mechanisms for the atheroprotective effects of soy and to determine if these effects extend to diabetic monkeys. We designed an experiment with a 2 x 2 factorial design in which adult male monkeys (N = 23) were fed an atherogenic diet with a protein source of either soy isolate or casein and lactalbumin, and the monkeys were either control or streptozotocin-induced diabetic. Diabetics had significantly increased fasting glucose and glycated hemoglobin (GHb) levels; this relationship was not affected by the type of dietary protein. Diabetics also had increased total (TC) and low-density lipoprotein cholesterol (LDLC) concentrations. However, soy consumption significantly reduced TC and LDLC concentrations in both control and diabetic monkeys. Plasma and arterial LDL metabolism was determined by injecting 125I-LDL at 48 hours and 131I-tyramine cellobiose LDL at 1 hour prior to necropsy. This allowed a determination of the arterial LDL concentration, permeability, and arterial LDL delivery. An increase in the whole-body plasma LDL fractional catabolic rate (FCR) was found with soy. Soy significantly reduced the arterial LDL concentration across all arterial sites by an average of 50%. Soy also significantly reduced the delivery of LDLC to all arterial sites by an average of 40%. While this was primarily due to the lower plasma LDLC concentration, LDL permeability in the carotid bifurcation and internal carotid arteries was also reduced. There was no additional effect of diabetes. These beneficial effects on plasma and arterial LDL metabolism would be expected to reduce atherosclerosis and were found in both control and diabetic monkeys.

Consumption of soy protein reduces cholesterol absorption compared to casein protein alone or supplemented with an isoflavone extract or conjugated equine estrogen in ovariectomized cynomolgus monkeys.

Dietary intake of soy protein is associated with reductions in plasma cholesterol. Isoflavones are thought to be active components of soy and responsible for the beneficial effects because of their structural similarities to estrogen. The purposes of this study were to determine if i) soy protein or a semipurified soy extract, rich in isoflavones, is responsible for improving the lipid profile and ii) altered intestinal cholesterol metabolism is one mechanism for hypocholesterolemic effects. Ovariectomized adult female cynomolgus monkeys (40) were assigned to groups fed diets containing i) casein-lactalbumin (CAS) ii) intact soy protein (SOY), iii) CAS plus an isoflavone-rich semipurified soy extract similar in isoflavone content as SOY (ISO) or iv) CAS plus conjugated equine estrogen (CEE) for 20 wk. Cholesterol absorption was determined using the fecal isotope ratio method. Bile acid excretion was measured using the 3alpha-hydroxysteroid dehydrogenase assay. The SOY group had significantly lower total- and VLDL + LDL-cholesterol compared to the other three groups and significantly higher HDL-cholesterol compared to the CAS and CEE groups. Cholesterol absorption was significantly lower in the SOY group compared to the other groups, but bile acid excretion was not significantly affected. The hypocholesterolemic effect of soy protein appears to be mediated in part by decreased cholesterol absorption. The semipurified soy extract, rich in isoflavones, added to casein protein did not have lipid-lowering effects. Other components of soy such as saponins, phytic acid or the amino acid composition may be involved in the hypocholesterolemic effects seen in this study.

Intact dietary soy protein, but not adding an isoflavone-rich soy extract to casein, improves plasma lipids in ovariectomized cynomolgus monkeys.

The dietary consumption of soy protein has been linked to a reduction in coronary heart disease and improvements in a number of related risk factors. Recent investigations have focused on isoflavone components of soy protein. The purpose of this study was to examine plasma lipids and lipoproteins, particularly LDL, with the intake of intact soy protein or casein-lactalbumin diets with and without a semipurified extract of soy, rich in isoflavones. Sixty ovariectomized cynomolgus monkeys were assigned to one of three groups fed diets containing the following: 1) casein-lactalbumin as the protein source (CAS; n = 20); 2) CAS plus a semipurified extract of soy, rich in isoflavones (ISO; n = 20); or 3) intact soy protein (SOY; n = 20) for 12 wk. Lipoproteins were fractionated by combined ultracentrifugation and HPLC. Isolated LDL particles were further subfractionated by dividing the LDL peak into three fractions for compositional analyses. The SOY group had significantly lower plasma total cholesterol, VLDL plus IDL cholesterol and LDL cholesterol, and significantly less HDL cholesterol than the CAS group. LDL particles from the SOY group had a significantly less cholesteryl ester than the CAS group. The semipurified extract of soy, rich in isoflavones, added to casein-lactalbumin protein did not have the same effects as intact soy protein on plasma lipids and lipoproteins. Other components of soy protein, either alone or in combination with isoflavones, may be involved in the effects seen in this study.

Carbon dioxide laser ablation with immediate autografting in a full-thickness porcine burn model.

OBJECTIVE: To compare the long-term clinical and histologic outcome of immediate autografting of full-thickness burn wounds ablated with a high-power continuous-wave CO2 laser to sharply débrided wounds in a porcine model. SUMMARY BACKGROUND DATA: Continuous-wave CO2 lasers have performed poorly as tools for burn excision because the large amount of thermal damage to viable subeschar tissues precluded successful autografting. However, a new technique, in which a high-power laser is rapidly scanned over the eschar, results in eschar vaporization without significant damage to underlying viable tissues, allowing successful immediate autografting. METHODS: Full-thickness paravertebral burn wounds measuring 36 cm2 were created on 11 farm swine. Wounds were ablated to adipose tissue 48 hours later using either a surgical blade or a 150-Watt continuous-wave CO2 laser deflected by an x-y galvanometric scanner that translated the beam over the tissue surface, removing 200 microm of tissue per scan. Both sites were immediately autografted and serially evaluated clinically and histologically for 180 days. RESULTS: The laser-treated sites were nearly bloodless. The mean residual thermal damage was 0.18+/-0.05 mm. The mean graft take was 96+/-11% in manual sites and 93+/-8% in laser sites. On postoperative day 7, the thickness of granulation tissue at the graft-wound bed interface was greater in laser-debrided sites. By postoperative day 180, the manual and laser sites were histologically identical. Vancouver scar assessment revealed no differences in scarring at postoperative day 180. CONCLUSIONS: Long-term scarring, based on Vancouver scar assessments and histologic evaluation, was equivalent at 6 months in laser-ablated and sharply excised sites. Should this technology become practical, the potential clinical implications include a reduction in surgical blood loss without sacrifice of immediate engraftment rates or long-term outcome.

Insulin sensitivity and cardiovascular risk factors in ovariectomized monkeys with estradiol alone or combined with nomegestrol acetate.

We have previously shown that medroxyprogesterone acetate (MPA), either alone or combined with conjugated equine estrogens (CEE), significantly decreased insulin sensitivity (SI), compared with both untreated controls and those treated with CEE alone. The purpose of this study was to determine the effects of estradiol (E2), with and without nomegestrol acetate (NA; a potent progestin that lacks androgenic activity), on SI and arterial antioxidant activity, as determined by F2-isoprostanes. Thirty-six adult female cynomolgus monkeys (Macaca fascicularis) were ovariectomized and fed a moderately atherogenic diet, with one of the following three treatments added to the diet, for 12 weeks: 1) no treatment (control); 2) E2; or 3) continuous combined E2 + NA (E2+NA). SI and glucose effectiveness were assessed by the frequently sampled i.v. glucose tolerance test using a third-phase insulin infusion after 10 weeks of treatment. Cholesterol content and F2-isoprostanes were measured in the thoracic aorta after 12 weeks of treatment. E2 treatment resulted in a significantly greater SI, compared with control or E2+NA-treated monkeys (10.03 +/- 0.91 vs. 6.35 and 6.49 x 10(-4) min(-1) microU(-1) mL; P < 0.05). In contrast to our studies of CEE and MPA, E2+NA treatment, though reducing the SI below that of the E2 group, did not reduce the SI below that of control monkeys. As expected, the short period of treatment resulted in no significant differences in aortic cholesterol content. There was no treatment effect on total F2-isoprostanes (representing F2-isoprostane formation caused primarily by autooxidation), suggesting minimal antioxidant activity. However, there was a treatment difference in the prostaglandin F2alpha (PGF2alpha) isomer (a prostaglandin (PG) isomer formed by both autooxidation of arachidonate and cyclooxygenase activity). PGF2alpha concentrations were 32% lower with E2 treatment, compared with controls, and 36% lower, compared with E2+NA treatment (0.48 +/- 0.08 vs. 0.71 +/- 0.12 and 0.75 +/- 0.06; P < 0.05), suggesting differences in PG synthesis between hormone treatments. In conclusion, NA, a progestin without androgenic activity, may still affect some cardiovascular risk factors differently than estrogen-only therapy. However, it seems to be less detrimental than MPA.

Cardiac troponin T does not increase after electrical cardioversion for atrial fibrillation or atrial flutter.

OBJECTIVE: To determine whether cardiac troponin T increases after electrical cardioversion in patients with atrial fibrillation or atrial flutter. DESIGN: Serum creatine kinase (CK), creatine kinase-MB (CKMB), and cardiac troponin T were measured before, 24 hours, and 48 hours after cardioversion in 15 patients with atrial fibrillation or atrial flutter. RESULTS: 12 of the 15 patients (80%) were successfully cardioverted to sinus rhythm. The median number of shocks was three (range one to six), the median cumulative energy 710 J (50 to 1430 J), and the median peak energy 300 J (50 to 360 J). Total CK increased from a baseline median concentration of 92 (45 to 259) to 1324 (96 to 6660) U/l at 24 hours and 1529 (120 to 4774) U/l at 48 hours after cardioversion. There was a small increase in CKMB but the ratio of CKMB to CK did not increase. There was no increase in cardiac troponin T in any patient. CONCLUSIONS: Following electrical cardioversion of atrial fibrillation or atrial flutter, cardiac troponin T remains unchanged despite a large rise in total CK, indicating that the CK is derived from skeletal muscle and that myocardial injury does not occur. If cardiac troponin T is increased after cardioversion for atrial arrhythmias then other causes of myocardial damage should be sought.

Burn depth estimation by use of indocyanine green fluorescence: initial human trial.

Indocyanine green dye (ICG) fluoresces when illuminated by infrared light. After successful trials in a porcine model and with approval of the Massachusetts General Hospital's human studies committee, 10 adult patients with burn injuries were given 0.2 mg/kg ICG intravenously, and 825 nm fluorescence images were obtained with 780 nm excitation at 5 minutes after injection in the initial five patients and at 1, 2, 3, 4, 5, and 10 minutes in the subsequent five patients. Fluorescence intensities at burned and unburned sites were determined and images were correlated with burn depth as determined by healing or intraoperative assessment. In the latter five patients, seven sites were imaged (six that were of partial thickness and one that was of full thickness). The burn/normal skin fluorescence ratio was greater than 1 for superficial burns and less than 1 for deep burns. Imaging within 5 minutes of injection resulted in optimal contrast between injured and uninjured tissue. In this initial pilot trial it is apparent that ICG fluorescence has potential value as an aid in the early estimation of burn depth. In subsequent trials we will attempt to refine our ability to correlate ICG fluorescence images with burn depth.

Nutrients, body composition and exercise are related to change in bone mineral density in premenopausal women.

This study determined relationships among total energy intake, nutrient intake, body composition, exercise group status, and annual rates of change (slopes) in bone mineral density in 66 Caucasian premenopausal women (mean age, 34.4 +/- 2.7) taking calcium supplements. Body composition components measured by dual-energy X-ray absorptiometry included fat mass, soft tissue lean mass, and bone mineral density (g/cm2) of total body, spine (lumbar vertebrae 2-4), and three femur sites measured at baseline, 5, 12, and 18 mo. Nutrients were not significant variables in regression models predicting bone mineral density slopes (rates of change) at any femur site. The only significant variable in models predicting Ward's triangle bone mineral density slope was the initial fat mass and, for trochanter, exercise. Significant variables (P < 0.05) in models predicting total body bone mineral density slope included the initial fat mass and fat mass slope plus either vitamin A, carotene, fiber, magnesium, or phosphorus (R2 from 0.31 to 0.25) and fat mass slope plus sodium (R2 = 0.24). The significant variable in the model predicting L2-4 slope was energy intake (R2 = 0.17, P < 0.05). We conclude that nutrient intake, exercise, and body composition are related to bone mineral density rate of change and that relations among these variables vary by bone site.