Predictors of Obstructive Sleep Apnea Risk among Blacks with Metabolic Syndrome.

INTRODUCTION: Identification of risk factors for obstructive sleep apnea (OSA) is important to enable comprehensive intervention to reduce OSA-related cardiovascular disease (CVD). The metabolic syndrome outcome study (MetSO) provides a unique opportunity to address these factors. This study investigated risk of OSA among blacks with metabolic syndrome. METHODS: The present study utilized data from MetSO, an NIH-funded cohort study of blacks with metabolic syndrome. A total of 1,035 patients provided data for the analysis. These included sociodemographic factors, health risks, and medical history. Physician-diagnosed conditions were obtained using an electronic medical record system (Allscripts, Sunrise Enterprise). Patients were diagnosed with metabolic syndrome using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. Patients with a score ≥6 on the Apnea Risk Evaluation System (ARES) questionnaire were considered at risk for OSA. Obesity is defined by body mass index (BMI ≥ 30 kg/m2). RESULTS: Of the 1,035 patients screened in the MetSO cohort, 48.9% were at high risk for OSA. Using multivariate-adjusted logistic regression analysis, we observed that obesity was the strongest predictor of OSA risk (OR=1.59, 95%CI=1.24-2.04, p<0.0001). This finding remained significant even after adjustment for known covariates including blood pressure, low-density lipoprotein, high-density lipoprotein, and glucose levels (OR=1.44, 95%CI=1.11-1.86, p<0.001). CONCLUSION: Blacks in the MetSO cohort are at greater OSA risk, relative to the adult population in developed countries. Consistent with previous observations, obesity proved the strongest independent predictor of OSA risk among blacks with metabolic syndrome.

METABOLIC EFFECTS OF MARIJUANA USE AMONG BLACKS.

BACKGROUND: Increased legalization of marijuana has resulted in renewed interest in its effects on body weight and cardiometabolic risk. Conflicting data exist regarding marijuana effects on body weight, waist circumference as well as lipid profiles, blood pressure and cardiovascular disease. Furthermore, there is a dearth of data available on this effect in the black population. OBJECTIVE: To assess the metabolic profile and cardiovascular risk factors as well as body weight and waist circumference among urban black marijuana users. METHODS: A cross sectional study design involving 100 patients seen in a Family Practice clinic at University hospital of Brooklyn, NY, USA, over a period of 3 months from January 2014 to March 2014. Participants were administered a questionnaire regarding marijuana use, and other associated behaviors. Socio-demographic, laboratory, and clinical data were collected. We report measures of central tendencies, and dispersion for continuous variables and the frequency of distribution for categorical variables. RESULTS: Of the 100 patients surveyed, 57% were females. The mean (±SEM) age of the entire cohort was 46.3 years±1.5; range, 19-78 years. The mean body mass index (BMI) was 29.6 kg/m2±0.73; SBP=128.0 mmHg±1.69; DBP=76.1 mmHg±1.17. Current marijuana users had the lowest waist circumference compared to former or never users respectively (32.9±0.66 vs. 35.9±0.88 vs. 33.4±0.74), p<0.01. Diastolic blood pressure in mmHg was significantly higher among former marijuana users compared to current or never users, (80.0±2.1 vs. 73.3±2.3 vs. 73.4±1.6), p<0.01. Current marijuana users showed a tendency (not statistically significant) towards lower total cholesterol, Triglycerides (TG), High Density Lipoprotein (HDL)-cholesterol, Low Density Lipoprotein (LDL)-cholesterol, body mass index (BMI) and systolic blood pressure, compared to former users or never users. CONCLUSION: Current marijuana use is associated with significantly lower waist circumference, compared to former users and never users. Except for diastolic BP that was significantly lower among current users, other metabolic parameters showed tendency towards favorable profile. Further studies are needed to characterize the metabolic effects and to elucidate mechanisms of actions of marijuana in view of its rapid rate of utilization in the USA and around the world.

Linking sleep to hypertension: greater risk for blacks.

Background. Evidence suggests that insufficient sleep duration is associated with an increased likelihood for hypertension. Both short (<6 hours) and long (>8 hour) sleep durations as well as hypertension are more prevalent among blacks than among whites. This study examined associations between sleep duration and hypertension, considering differential effects of race and ethnicity among black and white Americans. Methods. Data came from a cross-sectional household interview with 25,352 Americans (age range: 18-85 years). Results. Both white and black short sleepers had a greater likelihood of reporting hypertension than those who reported sleeping 6 to 8 hours. Unadjusted logistic regression analysis exploring the race/ethnicity interactions between insufficient sleep and hypertension indicated that black short (<6 hours) and long (>8 hours) sleepers were more likely to report hypertension than their white counterparts (OR = 1.34 and 1.37, resp.; P < 0.01). Significant interactions of insufficient sleep with race/ethnicity were observed even after adjusting to effects of age, sex, income, education, body mass index, alcohol use, smoking, emotional distress, diabetes, coronary heart disease, and stroke. Conclusion. Results suggest that the race/ethnicity interaction is a significant mediator in the relationship between insufficient sleep and likelihood of having a diagnosis of hypertension.

Excessive Daytime Sleepiness among Hypertensive US-Born Blacks and Foreign-Born Blacks: Analysis of the CAATCH Data.

Background. Evidence shows that blacks exhibit greater daytime sleepiness compared with whites, based on the Epworth Sleepiness Scale. In addition, sleep complaints might differ based on individuals' country of origin. However, it is not clear whether individuals' country of origin has any influence on excessive daytime sleepiness (EDS). Study Objectives. We tested the hypothesis that US-born blacks would show a greater level of EDS compared with foreign-born blacks. The potential effects of sociodemographic and medical risk were also determined. Design. We used the Counseling African-Americans to Control Hypertension (CAATCH) data. CAATCH is a group randomized clinical trial that was conducted among 30 community healthcare centers in New York, yielding baseline data for 1,058 hypertensive black patients. Results. Results of univariate logistic regression analysis indicated that US-born blacks were nearly twice as likely as their foreign-born black counterparts to exhibit EDS (OR = 1.87, 95% CI: 1.30-2.68, P < 0.001). After adjusting for effects of age, sex, education, employment, body mass index, alcohol consumption, and smoking habit, US-born blacks were 69% more likely than their counterparts to exhibit EDS (OR = 1.69, 95% CI: 1.11-2.57, P < 0.01). Conclusion. Findings demonstrate the importance of considering individuals' country of origin, in addition to their race and ethnicity, when analyzing epidemiologic sleep data.

Diabetes mellitus and the risk of cancer.

Although diabetes has been known to increase the risk of cancer for over a century, it was not until recently when this area gained momentum and generated a lot of interest. That is in- part because of the rising global diabetes epidemic and the wide spread use of insulin analogues, metformin and other anti-diabetic agents, providing hypothesis generating data on the cancer risk in the diabetic population. Type 2 diabetes is associated with increased risk of breast, colon, pancreatic and other types of cancer, while type 1 diabetes is associated with increase in stomach, pancreatic, endometrial and cervical cancer. Mechanisms postulated for increased cancer risk in diabetes include hyperglycemia, hyperinsulinemia with stimulation of IGF-1 axis, obesity that serves as a common soil hypothesis for both cancer and diabetes as well as other factors such as increased cytokine production. More recently some antidiabetic agents have been thought to increase cancer risk such as insulin glargine, while metformin appears to lower cancer risk. In this review, we present the evidence for the link between diabetes and cancer highlighting the general mechanisms proposed for such a link as well as specific hypotheses for individual cancer. We will also discuss the role of insulin, metformin and other antidiabetic agents in cancer risk.

Resistant hypertension and obstructive sleep apnea in the primary-care setting.

We ascertained the prevalence of resistant hypertension (RH) among blacks and determined whether RH patients are at greater risk for obstructive sleep apnea (OSA) than hypertensives. Method. Data emanated from Metabolic Syndrome Outcome Study (MetSO), a study investigating metabolic syndrome among blacks in the primary-care setting. Sample of 200 patients (mean age = 63 ± 13 years; female = 61%) with a diagnosis of hypertension provided subjective and clinical data. RH was defined using the JNC 7and European Society guidelines. We assessed OSA risk using the Apnea Risk Evaluation System ARES), defining high risk as a total ARES score ≥6. Results. Overall, 26% met criteria for RH and 40% were at high OSA risk. Logistic regression analysis, adjusting for effects of age, gender, and medical co morbidities, showed that patients with RH were nearly 2.5 times more likely to be at high OSA risk, relative to those with hypertension (OR = 2.46, 95% CI: 1.03-5.88, P < .05). Conclusion. Our findings show that the prevalence of RH among blacks fell within the range of RH for the general hypertensive population (3-29%). However, patients with RH were at significantly greater risk of OSA compared to patients with hypertension.

Management of hypertension in high-risk ethnic minority with heart failure.

Hypertension (HTN) is the most common co-morbidity in the world, and its sequelae, heart failure (HF) is one of most common causes of mortality and morbidity in the world. Current understanding of pathophysiology and management of HTN in HF is mainly based on studies, which have mainly included whites. Among racial groups, African-American adults have the highest rates (44%) of hypertension in the world and are more resistant to treatment. There is an emerging consensus on the significance of racial disparities in the pathophysiology and treatment options of hypertension and heart failure. However, African Americans had been underrepresented in all the trials until the initiation of the A-HEFT trial. Since the recognition of obstructive sleep apnea (OSA) as an important medical condition, large clinical trials have shown benefits of OSA treatment among patients with HTN and HF. This paper focuses on the pathophysiology, causes of secondary hypertension, and treatment of hypertension among African-American patients with heart failure. There is increasing need for randomized clinical trials testing innovative treatment options for African-American patients.

Evaluating the appropriateness of thromboprophylaxis in an acute care setting using a computerised reminder, through order-entry system.

AIMS: Evidence suggests that thromboprophylaxis is still significantly underutilised across the United States despite its relationship with morbidity, mortality and resource expenditure. Previous randomised trials that have incorporated computerised reminders, through order-entry systems, have resulted in increased rates of thromboprophylaxis and lower incidences of clinically diagnosed deep-vein thrombosis or pulmonary embolism. The primary purpose of this prospective, observational study is to evaluate the use and appropriateness of preset computerized thromboprophylaxis regimens for patients in a major county metropolitan hospital over a 1-month period by evaluating the proportion of patients actually receiving recommended thromboprophylaxis according to established hospital guidelines. METHODS: This prospective, observational study was conducted in a large county hospital that recently established an evidence-based routine computerised policy to decrease risk of venous thromboembolism. Physicians, residents, medical interns, medical students, pharmacy students, and nurses were the targets of the investigation. Data were randomly collected between 10 internal medicine teams from 10 October 2006 to 10 November 2006. Investigators completed one DVT/PE risk assessment form for each patient reviewed and compared this to actual prescribed therapy to determine appropriateness of therapy. RESULTS: Pharmacological or non-pharmacological thromboprophylaxis was administered to 100% of patients evaluated. Eighty-six patients received recommended DVT/PE prophylaxis based on established hospital guidelines. DISCUSSION: Reported values seem to indicate that computerized reminders are capable of providing venous thromboprophylaxis for medically ill (non-surgical) patients relative to published norms. CONCLUSION: Results of this observational study reinforces the evidence that computerized, reminders, through order-entry systems might increase the delivery of thromboprophylaxis for hospitalized patients.

Medical management of obesity: an update.

Obesity is rapidly growing global epidemic with monumental impact on health and economics. It is associated with multiple adverse health consequences including hypertension, diabetes, dyslipidemia, coronary heart disease, heart failure and stroke to name a few. It is also associated with premature death. The economic impact of obesity is also striking and represents up to 6% of the total healthcare expenditure worldwide. Therefore, effective therapeutic strategies are desperately needed to curb the rising epidemic of obesity. In this review, we present the underlying cause of obesity, together with pathophysologic insights necessary for the practicing physician as basis for the medical therapeutic options available, that are presented in more details. We also discuss promising therapeutic agents that are under different stages of development.

Role of oral anti-diabetic agents in modifying cardiovascular risk factors.

Patients with type 2 diabetes have an increased risk for cardiovascular disease (CVD) and it accounts for up to 80% of excess deaths in these patients. It has been recognized that type 2 diabetes is associated with an increased prevalence of CVD risk factors, including hypertension, dyslipidemia, microalbuminuria, and altered hemostasis. The benefit of cardiovascular protection can only be partially explained by controlling hyperglycemia. Some of the oral agents used to treat hyperglycemia significantly modify other cardiovascular risk factors. This article will review oral agents used to treat type 2 diabetes and their effects on modifying CVD risk factors.

Intussusception in an adult patient with severe hyperglycaemia--a case report.

AIMS: To report a case of adult intussusception associated with and possibly induced by acute hyperglycaemia. METHODS: We present the first case report of adult intussusception with severe hyperglycaemia. Clinical and laboratory data together with radiological findings are presented with a brief review of the literature. RESULTS: A 20-year-old man with no past medical history presented with abdominal pain for 2 days. The patient was severely hyperglycaemic with blood glucose of 72.7 mmol/l (normal 3.3-6.1 mmol/l), a pH of 7.2 and serum potassium of 6.5 mmol/l (normal 3.5-5.0 mmol/l). He had a computed tomography (CT) scan of the abdomen that revealed small bowel intussusception. Upon treatment of his hyperglycaemia, the patient's abdominal pain completely resolved. Follow up abdominal CT revealed complete resolution of the previously detected intussusception. CONCLUSION: Clinicians should be aware of the potential for the occurrence of intussusception in severely hyperglycaemic patients. Correction of hyperglycaemia could lead to resolution of the intussusception without surgical intervention. Possible effects of hyperkalaemia and/or acidosis on gastrointestinal motility should also be considered.

Clinical review 145: Pleiotropic effects of statins: lipid reduction and beyond.

There is accumulating evidence that statins have beneficial effects that are independent of their classical actions on lipoproteins. These effects include reductions in inflammation in the vasculature, kidney, and bone. Potential beneficial effects of these agents include enhancement of nitric oxide production in vasculature and the kidney. These agents appear to reduce bone fractures and may improve insulin sensitivity and reduce the likelihood of persons progressing from impaired glucose tolerance to type II diabetes. Potential beneficial pleiotropic effects of statins are covered in this review.

Near-normoglycaemic remission in African-Americans with Type 2 diabetes mellitus is associated with recovery of beta cell function.

AIMS: To prospectively determine the frequency of remission and possible mechanism of beta cell recovery in non-Whites with Type 2 diabetes mellitus in the setting of intensive glycaemic regulation using pharmacological agents. METHODS: Twenty-six consecutive, newly diagnosed African-American, Type 2 diabetic patients presenting primarily for severe hyperglycaemia (31.0+/-12.8 mmol/l) were followed for at least 1 year. Initial hospitalization included treatment with insulin, fluids and electrolytes. Outpatient intensive glycaemic regulation included insulin or glibenclamide, diabetes education and diet that altered nutrient content. Plasma glucose and C-peptide responses to an oral glucose tolerance test and HbA1c were measured at < 14, 15-56 and 57-112 days after presentation. Remission was defined as a HbA1c < or = 6.3% and fasting plasma glucose < 6.9 mmol/l, 3 months after discontinuing all pharmacological agents. RESULTS: Eleven of 26 patients (42.3%) developed remission after a mean of 83 days of pharmacological treatment and remained in remission during follow-up for 248-479 days; one relapsed after 294 days. Fifteen patients who did not develop a remission and were followed for 168-468 days, required continuing pharmacological therapy to be well-controlled. (mean HbA1c = 7.1%). There was no significant difference in age, sex, plasma glucose at presentation, initial glycaemic regulation, final body mass index, magnitude of weight change or pharmacological agents used for treatment between the two groups. Plasma C-peptide response to oral glucose was initially (< 14 days) suppressed in all subjects and subsequently increased. The increase was significantly greater in those who underwent a remission than those who did not. Neither significant weight loss nor severe hypoglycaemia was observed in either group during intensive treatment. CONCLUSIONS: Forty-two per cent of newly diagnosed, unselected African-Americans with Type 2 diabetes, treated intensively using pharmacological agents, education and diet developed near-normoglycaemic remission. Remission was associated with a greater recovery of glucose-stimulated insulin secretion suggesting that therapies directed at promoting beta cell recovery and preservation are potentially useful approaches to the treatment of Type 2 diabetes mellitus.

Vascular complications in diabetes and their prevention.

Diabetes mellitus is increasing throughout the world. Cardiovascular disease (CVD) accounts for up to 80% of excess mortality in this high-risk population. Patients with diabetes have the same CVD risk factors as those people without diabetes. However, these risk factors are much more powerful in diabetic patients. CVD risk is especially high for diabetic women, and premenopausal diabetic women lose all the protection normally afforded to them by female sex hormones. Controlled clinical trials have clearly demonstrated that rigorous treatment of blood pressure, dyslipidemia and platelet hyperaggrebility strikingly reduces CVD risk in diabetic patients. Strategies directed at interrupting the renin-angiotensin system (both tissue and systemic systems) and the use of 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors have proven to be especially beneficial for this high-risk population.

Medical-resource use for suspected tuberculosis in a New York City hospital.

OBJECTIVE: To compare resource use by diagnostic outcome among hospital admissions during which tuberculosis (TB) was suspected. DESIGN: Retrospective study based on chart review and microbiology laboratory data. SETTING: The department of medicine in a municipal hospital serving central Brooklyn, New York. PARTICIPANTS: We identified all adult admissions in 1993 during which TB was suspected. We assigned each admission to one of four mutually exclusive groups defined by the results of microbiological tests (acid-fast bacilli [AFB] smear and culture): culture-positive and smear-positive (C+S+); culture-positive and smear-negative (C+S-); culture-negative and smear-positive (C-S+); or culture-negative and smear-negative (C-S-). Each admission was divided into two separate periods to which the utilization of medical resources was assigned: the diagnostic and the postdiagnostic periods, which were separated by the date of receipt of the first definitive culture report. RESULTS: Data on 519 admissions (93 C+S+; 57 C+S-; 30 C-S+; and 339 C-S-) were analyzed. Although C+S+ were more likely than other groups to have an admitting diagnosis of TB, approximately one quarter of the admissions without TB (C-S+, C-S-) were admitted with the principal diagnosis of TB. For the four groups, C+S+, C+S-, C-S+, and C-S-, the respective rates of TB isolation and anti-TB treatment, and median lengths of isolation were 98%, 87%, and 34 days; 74%, 74%, and 7 days; 83%, 83%, and 15 days; and 44%, 29%, and 0 days. During the diagnostic period, the rate and length of isolation were similar in the AFB-smear-positive groups (C+S+ and C-S+). We estimated that admissions without culture-proven TB (C-S+ and C-S-) accounted for 3,174 (36%) of the 8,712 days of TB isolation expended and for 65% of the 16,671 days of anti-TB treatment. The vast majority of this resource consumption (2,737 [86%] of 3,174 days of isolation) occurred during the diagnostic period before a definitive culture result was known. CONCLUSIONS: Our results suggest that prolonged diagnostic uncertainty and misclassification of cases due to false-positive and false-negative smears are associated with substantial medical-resource consumption. New diagnostic modalities that reduce the period of diagnostic uncertainty could reduce the utilization of resources later found to be unnecessary.