The effect of vitamin d on aldosterone and health status in patients with heart failure.

BACKGROUND: Vitamin D deficiency is associated with heart failure (HF) events, and in animal models vitamin D down-regulates renin-angiotensin-aldosterone system hormones. METHODS: Patients with New York Heart Association (NYHA) functional class II-IV HF and a 25OH-D level ≤37.5 ng/mL received 50,000 IU vitamin D3 weekly (n = 31) or placebo (n = 33) for 6 months. Serum aldosterone, renin, echocardiography, and health status were determined at baseline and 6 months. RESULTS: Mean age of participants was 65.9 ± 10.4 years, 48% were women, 64% were African American, mean ejection fraction was 37.6 ± 13.9%, 36% were in NYHA functional class III, and 64% were in class II. The vitamin D group increased serum 25OH-D (19.1 ± 9.3 to 61.7 ± 20.3 ng/mL) and the placebo group did not (17.8 ± 9.0 to 17.4 ± 9.8 ng/mL). Aldosterone decreased in the vitamin D group (10.0 ± 11.9 to 6.2 ± 11.6 ng/dL) and not in the placebo group (8.9 ± 8.6 to 9.0 ± 12.4 ng/dL; P = .02). There was no difference between groups in renin, echocardiographic measures, or health status from baseline to 6 months. Modeling indicated that variables which predicted change in aldosterone included receiving vitamin D, increasing age, African American race, and lower glomerular filtration rate. CONCLUSIONS: Vitamin D3 repletion decreases aldosterone in patients with HF and low serum vitamin D. Vitamin D may be an important adjunct to standard HF therapy. Further study will assess if vitamin D provides long-term benefit for patients with HF.

Age, stress, and isolation in older adults living with HIV.

People living with HIV (PLWH) have increasingly longer life spans. This age group faces different challenges than younger PLWH, which may include increased stress and social isolation. The purpose of this study was to determine whether the age and sex of PLWH are associated with measures of physiologic stress, perceived stress, and social isolation. In this cross-sectional study, we enrolled 102 PLWH equally into four groups divided by age (younger or older than 50 years) and gender. Participants completed well-validated survey measurements of stress and isolation, and their heart rate variability over 60 minutes was measured by Holter monitor. The mean (SD) Perceived Stress Scale score was 17.4 (6.94), mean Visual Analog Stress Scale score was 3.51 (2.79), and mean Hawthorne Friendship Scale score, a measure of social isolation, was 17.03 (4.84). Mean heart rate variability expressed as the SD of successive N-N intervals was 65.47 (31.16) msec. In multivariable regression models that controlled for selected demographic variables, there was no relationship between the Perceived Stress Scale and age (coefficient = -0.09, p =-0.23) or female gender (coefficient = -0.12, p = 0.93); however, there was a modest relationship between female gender and stress using the Visual Analog Stress Scale (coefficient = 1.24, p = 0.05). Perceived Stress was negatively associated with the Hawthorne Friendship score (coefficient = -0.34, p = 0.05). Hawthorne Friendship score was positively associated with younger age (coefficient = 0.11, p = 0.02). Age was the only independent predictor of physiologic stress as measured by heart rate variability (coefficient = -1.3, p < 0.01). Our findings suggest that younger PLWH may experience more social isolation; however, age-related changes in heart rate variability do not appear to be related to perceived stress or social isolation. Future longitudinal research is required to more thoroughly understand this relationship and its impact on the health of PLWH.

Home health care with telemonitoring improves health status for older adults with heart failure.

Home telemonitoring can augment home health care services during a patient's transition from hospital to home. Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations. This randomized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring. Patients were followed up to 180 days post-discharge from home health care services. Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care. Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care. Therefore, for older adults with heart failure, telemonitoring may be an important adjunct to home health care services to improve health status.

A randomized controlled trial of high dose vitamin D3 in patients with heart failure.

OBJECTIVE: To investigate the effect of Vitamin D3 on physical performance in patients with HF. BACKGROUND: HF is associated with functional decline and frailty. Vitamin D deficiency is associated with loss of muscle strength and poor outcomes in patients with HF. METHODS: Sixty-four patients participated in a 6-month parallel design double blind RCT to test the hypothesis that oral vitamin D3 would improve physical performance. Vitamin D3 50,000 IU or placebo was given weekly; all received daily calcium. Patients were included regardless of EF and 25OHD ≤ 37.5 ng/ml. The primary outcome was peak VO2, and secondary outcomes were the 6MW, TGUG and knee isokinetic muscle strength. Between group comparisons were made using ANCOVA models that adjust for baseline measures. RESULTS: Patients were age 65.9 ± 10.4 years old, 48% women, 64% African American, EF 37.6±13.9, 36% NYHA III, the remainder NYHA II. At baseline the vitamin D group 25OHD was 19.1 ± 9.3 ng/ml and increased to 61.7 ± 20.3 ng/ml; in the placebo group baseline 25OHD was 17.8 ± 9.0 ng/ml and decreased to 17.4 ± 9.8 ng/ml at 6 months (between groups p<0.001). There was no significant change from baseline to 6 months in peak VO2, 6MW, TGUG or isokinetic muscle strength. CONCLUSIONS: Vitamin D3 did not improve physical performance for patients with HF despite a robust increase in serum 25OHD. Vitamin D repletion in patients with HF should conform to standard adult guidelines for vitamin D supplementation.

Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function.

BACKGROUND: Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical intervention's effect on a patient's quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on abdominal wall function, evaluate its measurement properties, and assess the impact of VHR on QofL using this new instrument. STUDY DESIGN: A 16-question QofL survey tool, HerQLes, was constructed. Patients presenting for elective VHR completed the survey. Rasch modeling was used to evaluate the items; fit statistics, person-item mapping, separation index, and reliability were examined. Associations between baseline characteristics and QofL were assessed. RESULTS: Eighty-eight patients completed the survey before assessment for VHR. Mean age was 57.2 years (±12.4 years), mean American Society of Anesthesiologists score was 2.8 (±0.5), and mean body mass index was 34.9 kg/m(2) (±9.3 kg/m(2)). Based on Rasch modeling, 12 of 16 items met model fit criteria. The 4 poorly fitting items were eliminated from further analysis. The 12 items retained have good internal consistency reliability (0.86). On a 0- to 100-point scale, mean QofL score was 47.2 (±15.6). Patients with higher grade hernias had lower HerQLes scores (p = 0.06). Patients showed significant improvement in abdominal wall function and QofL 6 months after VHR (p < 0.01). CONCLUSIONS: Quality-of-life is an important component of surgical management of ventral hernias. The 12-question QofL survey, HerQLes, is reliable and valid. At baseline, patients with more complex hernias tended to have a decreased abdominal wall function and QofL. Six months after surgical repair, HerQLes scores change in the predicted direction. We believe HerQLes is potentially a valuable tool to assess patient-centered abdominal wall functional improvements after VHR.

Predictive equations underestimate resting energy expenditure in female adolescents with phenylketonuria.

Resting energy expenditure (REE) is often used to estimate total energy needs. The Schofield equation based on weight and height has been reported to underestimate REE in female children with phenylketonuria (PKU). The objective of this observational, cross-sectional study was to evaluate the agreement of measured REE with predicted REE for female adolescents with PKU. A total of 36 females (aged 11.5 to 18.7 years) with PKU attending Emory University's Metabolic Camp (June 2002 to June 2008) underwent indirect calorimetry. Measured REE was compared to six predictive equations using paired Student's t tests, regression-based analysis, and assessment of clinical accuracy. The differences between measured and predicted REE were modeled against clinical parameters to determine whether a relationship existed. All six selected equations significantly under predicted measured REE (P<0.005). The Schofield equation based on weight had the greatest level of agreement, with the lowest mean prediction bias (144 kcal) and highest concordance correlation coefficient (0.626). However, the Schofield equation based on weight lacked clinical accuracy, predicting measured REE within +/-10% in only 14 of 36 participants. Clinical parameters were not associated with bias for any of the equations. Predictive equations underestimated measured REE in this group of female adolescents with PKU. Currently, there is no accurate and precise alternative for indirect calorimetry in this population.

Off-pump coronary artery bypass disproportionately benefits high-risk patients.

BACKGROUND: It is not known which patient subgroups may benefit most from off-pump coronary artery bypass grafting (OPCAB) rather than coronary artery bypass grafting on cardiopulmonary bypass (CPB). METHODS: The Society of Thoracic Surgeons database was queried for all isolated, primary coronary artery bypass graft cases between January 1, 1997, and December 31, 2007, at a US academic center. The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) was calculated by a formula based on 30 preoperative risk factors. It was used in three ways to compare 30-day operative mortality between patients treated with OPCAB versus CPB. First, patients were divided into quartiles based on their PROM, and mortality rates were compared between OPCAB and CPB patients within each PROM quartile. Second, a logistic regression model tested for an interaction between surgery type and PROM; a significant interaction would indicate that the relative mortality risk of OPCAB versus CPB varied with different PROM levels. Finally, locally smoothed kernel regression curves were used to visually estimate a threshold PROM point at which mortality rates diverge for the surgery types. RESULTS: There were 14,766 consecutive patients, 7,083 OPCAB (48.0%) and 7,683 CPB (52.0%). There was no difference in operative mortality between OPCAB and CPB for patients in the lower two risk quartiles. In the higher risk quartiles there was a mortality benefit for OPCAB (odds ratio, 0.62 and 0.45 for OPCAB in the third and fourth risk quartiles). Logistic regression analysis confirmed a significant interaction between surgery type and PROM (p = 0.005) meaning that OPCAB is especially beneficial to patients with higher PROM. This benefit is most significant for patients with PROM values above 2.5% to 3%, where mortality curves sharply diverge. CONCLUSIONS: Off-pump coronary artery bypass grafting is associated with lower operative mortality than coronary artery bypass grafting on CPB for higher risk patients. This mortality benefit increases with increasing PROM.

Evaluation of physiological measures for correcting variation in urinary output: Implications for assessing environmental chemical exposure in children.

Urinary contaminant concentrations are commonly adjusted by creatinine to account for the variability in urinary output. This approach may not be optimal among children due to developmental growth of muscle mass and the associated increase in creatinine formation. An alternative approach is to measure the specific gravity of the urine sample, which reflects the solute concentration of the urine. We compare the appropriateness of urinary creatinine and urinary-specific gravity as factors for correcting morning and evening spot urine samples collected from 23 children (3-11 years) for a total of 41 days in four different seasons. Two linear mixed-effects models were fit using age, sex, season, and sample collection time (morning/evening) as predictors with specific gravity and creatinine as dependent variables. Specific gravity was significantly associated with the sample collection time (P<0.001) with morning samples higher than evening samples. Creatinine was significantly associated with season (P<0.05), sample collection time (P<0.0001), and age (P<0.0001). Creatinine levels were higher during the summer compared to the other seasons, higher in the morning compared to the evening, and higher with increases in children's age. Normalizing the children's spot urine samples using creatinine would introduce bias to the data analysis. Whereas using specific gravity to correct for variable urinary output would be more robust. In addition, measuring specific gravity is relatively easy, does not require the use of chemicals, and the results are available instantaneously.

Proteomic identification of biomarkers in the cerebrospinal fluid (CSF) of astrocytoma patients.

The monitoring of changes in the protein composition of the cerebrospinal fluid (CSF) can be used as a sensitive indicator of central nervous system (CNS) pathology, yet its systematic application to analysis of CNS neoplasia has been limited. There is a pressing need for both a better understanding of gliomagenesis and the development of reliable biomarkers of the disease. In this report, we used two proteomic techniques, two-dimensional gel electrophoresis (2-DE), and cleavable Isotope-Coded Affinity Tag (cICAT) to compare CSF proteomes to identify tumor- and grade-specific biomarkers in patients bearing brain tumors of differing histologies and grades. Retrospective analyses were performed on 60 samples derived from astrocytomas WHO grade II, III, and IV, schwannomas, metastastic brain tumors, inflammatory samples, and non-neoplastic controls. We identified 103 potential tumor-specific markers of which 20 were high-grade astrocytoma-specific. These investigations allowed us to identify a spectrum of signature proteins that could be used to distinguish CSF derived from control patients versus those with low- (AII) or high-grade (AIV) astrocytoma. These proteins may represent new diagnostic, prognostic, and disease follow-up markers when used alone or in combination. These candidate biomarkers may also have functional properties that play a critical role in the development and malignant progression of human astrocytomas, thus possibly representing novel therapeutic targets for this highly lethal disease.