Acute alterations in glucose homeostasis impact coronary microvascular function in patients presenting with ST-segment elevation myocardial infarction.

BACKGROUND: Microvascular dysfunction in the setting of ST-segment myocardial infarction (STEMI) is thought to be related to stress-related metabolic changes, including acute glucose intolerance. The aim of this study was to assess the relationship between admission glucose levels and microvascular function in non-diabetic STEMI patients. METHODS: 92 consecutive patients with a first anterior-wall STEMI treated with primary percutaneous coronary intervention (PPCI) were enrolled. Blood glucose levels were determined immediately prior to PPCI. After successful PPCI, at 1­week and 6­month follow-up, Doppler flow was measured in culprit and reference coronary arteries to calculate coronary flow velocity reserve (CFVR), baseline (BMR) and hyperaemic (HMR) microvascular resistance. RESULTS: The median admission glucose was 8.3 (7.2-9.6) mmol/l respectively 149.4 mg/dl [129.6-172.8] and was significantly associated with peak troponin T (standardised beta coefficient [std beta] = 0.281; p = 0.043). Multivariate analysis revealed that increasing glucose levels were significantly associated with a decrease in reference vessel CFVR (std beta = -0.313; p = 0.002), dictated by an increase in rest average peak velocity (APV) (std beta = 0.216; p = 0.033), due to a decreasing BMR (std beta = -0.225; p = 0.038) in the acute setting after PPCI. These associations disappeared at follow-up. These associations were not found for the infarct-related artery. CONCLUSION: Elevated admission glucose levels are associated with impaired microvascular function assessed directly after PPCI in first anterior-wall STEMI. This influence of glucose levels is an acute phenomenon and contributes to microvascular dysfunction through alterations in resting flow and baseline microvascular resistance.

Sex differences in characteristics and outcome in acute coronary syndrome patients in the Netherlands.

BACKGROUND: Sex differences in acute coronary syndrome (ACS) have been reported, but little is known about the situation in the Netherlands. METHODS: This registry is a merge of available data on ACS patients in the electronic data capture systems of 11 centres with 24/7 interventional cardiology services. We included patients >18 years undergoing a cardiac catheterisation between 2010-2012. We evaluated sex differences in clinical and procedural characteristics and 1­year mortality. RESULTS: A total of 29,265 ACS patients (8,720 women and 20,545 men) were registered. Women were on average 4.5 years older (68.5 vs 63.0 years, p < 0.001) and had a higher prevalence of hypertension (62.7 vs 49.8%, p < 0.001) and insulin-dependent diabetes mellitus (9.6 vs 6.8%, p < 0.001) than men. Women less often presented with ST-elevation myocardial infarction (43.7% vs 47.6%, p < 0.001) and appeared to have less extensive coronary artery disease than men. Women less often underwent coronary angiography by radial access (52.5 vs 55.9%, p < 0.001). One-year mortality was higher in women than in men (7.3% and 5.6%, p < 0.001). More specific, the relationship between sex and mortality was age-dependent and showed higher mortality in women ≤71 years, but lower mortality in older women compared with men (p-interaction <0.001). CONCLUSION: We found differences in clinical and procedural characteristics and outcome between women and men admitted for ACS, which are in line with other Western countries. The limitations of our registry, based on existing local databases, can be overcome by the use of the prospective Netherlands Heart Registry that is currently in development.

Safety and long-term effects of renal denervation: Rationale and design of the Dutch registry.

BACKGROUND: Percutaneous renal denervation (RDN) has recently been introduced as a treatment for therapy-resistant hypertension. Also, it has been suggested that RDN may be beneficial for other conditions characterised by increased sympathetic nerve activity. There are still many uncertainties with regard to efficacy, safety, predictors for success and long-term effects. To answer these important questions, we initiated a Dutch RDN registry aiming to collect data from all RDN procedures performed in the Netherlands. METHODS: The Dutch RDN registry is an ongoing investigator-initiated, prospective, multicentre cohort study. Twenty-six Dutch hospitals agreed to participate in this registry. All patients who undergo RDN, regardless of the clinical indication or device that is used, will be included. Data are currently being collected on eligibility and screening, treatment and follow-up. RESULTS: Procedures have been performed since August 2010. At present, data from 306 patients have been entered into the database. The main indication for RDN was hypertension (n = 302, 99%). Patients had a mean office blood pressure of 177/100 (±29/16) mmHg with a median use of three (range 0-8) blood pressure lowering drugs. Mean 24-hour blood pressure before RDN was 157/93 (±18/13) mmHg. RDN was performed with different devices, with the Simplicity™ catheter currently used most frequently. CONCLUSION: Here we report on the rationale and design of the Dutch RDN registry. Enrolment in this investigator-initiated study is ongoing. We present baseline characteristics of the first 306 participants.

The impact of gender on long-term mortality in patients with multivessel disease after primary percutaneous coronary intervention.

BACKGROUND: Gender and complete revascularisation are known to affect mortality. The objective of this study was to analyse a gender difference in mortality with respect to complete revascularisation for multivessel disease after primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients. METHOD: In a prospective consecutive cohort of 1472 patients presenting with STEMI for PPCI, between January 2006 and January 2010, 832 patients with multivessel disease were analysed. The primary outcome was long-term mortality. RESULTS: Median follow-up was 3.3 ± 1.2 years. Complete revascularisation was performed less in females than in males (30 vs. 38 %; p = 0.04). At PPCI, women (27 %, n = 221) were ± 10 years older (p = 0.001), had more hypertension, renal failure and symptoms of heart failure (all p < 0.01). Cumulative long-term mortality with incomplete revascularisation was higher in females (F: 30 vs. M: 15 %, p = 0.01). After adjustment for baseline characteristics, complete revascularisation (0.84; 95 % CI 0.54-1.32) and gender (1.11; 95 % CI 0.73-1.69) lost significance. Also the gender-by-complete revascularisation interaction was not significant at long term. In women, age under 60 years independently predicted higher mortality (HR 10.09; 95 % CI 3.08-33.08; p < 0.001). CONCLUSION: In STEMI patients with multivessel disease at PPCI, women under the age of 60 years had higher mortality, but in women older than 60 years comorbidity impacted the outcome of revascularisation strategy in the long term.

How Dutch medical specialists perceive the competencies and training needs of medical residents in healthcare management.

BACKGROUND: The Dutch postgraduate medical training has been revised to focus on seven competencies. The role as manager is one of these competencies. Recent studies show that this competency receives little attention during the residency training. In an earlier study, we discovered that residents perceived their competency as managers to be moderate. AIM: In this study, we investigated how medical specialists perceived the managerial competencies of medical residents and their need for management education. METHODS: In September 2010, a 46-item questionnaire was designed which examined medical specialists' perceptions of the competency and needs of residents in the field of medical management. Two hundred ninety-eight specialists were invited via email to participate. RESULTS: Hundred twenty-nine specialists (43.3%) responded to our survey. They rated the residents' competencies in contract negotiating skills, knowledge of the healthcare system, and specialist department poorly. They felt that residents were competent in updating their medical knowledge. Ninety-four percent reported a need for training in management among residents. Preferred topics were time management and healthcare organization. The preferred training method was a workshop given during residency by an extramural expert. CONCLUSION: Dutch medical specialists perceive the management competencies of residents in some areas to be inadequate. They feel that training in medical management during residency is necessary.

Muscle composition slightly affects in vitro digestion of aged and cooked meat: identification of associated proteomic markers.

Meat is an appropriate source of proteins and minerals for human nutrition. Technological treatments modify the physical-chemical properties of proteins, making them liable to decrease the nutritional potential of meat. To counteract this damage, antioxidants and chaperone proteins in muscle cells can prevent oxidation, restore the function of denatured proteins, and thus prevent aggregation. This study aimed to explore the impact of indoor vs outdoor-reared meat protein composition on digestion and to associate protein markers to in vitro digestion parameters. Indoor-reared meat tended to show less oxidation and denaturation than outdoor-reared meat and was characterised by an overexpression of contractile and chaperone proteins. Outdoor-reared meat showed amplification of antioxidant and detoxification metabolism defending against oxidised compounds. Impacts on digestion remained minor. Several protein markers of in vitro digestion parameters were found for aged and cooked meat, linked to the detoxification process and to muscle contraction.

Proteomic profile evolution during steatosis development in ducks.

We investigated a protein profile evolution during steatosis in ducks using 2-dimensional electrophoresis gels to better understand the mechanisms underlying liver steatosis at the level of hepatic proteins in waterfowl. Two-dimensional electrophoresis gels were performed in the liver at different stages of steatosis in the duck. Mule ducks were slaughtered after 0, 14, or 23 meals of overfeeding, according to commercial conditions. Thirty-one proteic spots were differentially expressed between 3 or 2 durations of overfeeding: 3 spots were differentially expressed between the 3 times and 28 spots were differentially expressed between 2 times. The identified proteins (14) could be regrouped into 5 categories: enzymes, translation factors, proteins involved in cell structure, proteins with antioxidant properties, and proteins that can link calcium. This study opens new research areas in the understanding of steatosis in waterfowl, such as cell structure and oxidative stress.

Dealing with the archetypes development process for a regional EHR system.

OBJECTIVES: This paper aims to present the archetype modelling process used for the Health Department of Minas Gerais State, Brazil (SES/MG), to support building its regional EHR system, and the lessons learned during this process. METHODS: This study was undertaken within the Minas Gerais project. The EHR system architecture was built assuming the reference model from the ISO 13606 norm. The whole archetype development process took about ten months, coordinated by a clinical team co-ordinated by three health professionals and one systems analyst from the SES/MG. They were supported by around 30 health professionals from the internal SES/MG areas, and 5 systems analysts from the PRODEMGE. Based on a bottom-up approach, the project team used technical interviews and brainstorming sessions to conduct the modelling process. RESULTS: The main steps of the archetype modelling process were identified and described, and 20 archetypes were created. LESSONS LEARNED: -The set of principles established during the selection of PCS elements helped the clinical team to keep the focus in their objectives;-The initial focus on the archetype structural organization aspects was important;-The data elements identified were subjected to a rigorous analysis aimed at determining the most suitable clinical domain;-Levelling the concepts to accommodate them within the hierarchical levels in the reference model was definitely no easy task, and the use of a mind mapping tool facilitated the modelling process;-Part of the difficulty experienced by the clinical team was related to a view focused on the original forms previously used;-The use of worksheets facilitated the modelling process by health professionals;-It was important to have a health professional that knew about the domain tables and health classifications from the Brazilian Federal Government as member in the clinical team. CONCLUSION: The archetypes (referencing terminology, domain tables and term lists) provided a favorable condition for the use of a controlled vocabulary between the central repository and the EMR systems and, probably, will increase the chances of preserving the semantics from the knowledge domain. Finally, the reference model from the ISO 13606 norm, along with the archetypes, proved sufficient to meet the specificities for the creation of an EHR system for basic healthcare in a Brazilian state.

Changed dynamics in myofibrillar protein aggregation as a consequence of heating time and temperature.

The kinetics of protein aggregation induced by cooking were investigated in pig M. Longissimus dorsi. The 4 day aged muscles were cooked either in water or under dry heat conditions for 30 min. Four temperatures from 50 to 100 degrees C were tested for the "in water" cooking mode and an additional temperature of 140 degrees C was tested in the dry condition. Raw and cooked meat specimens were ground in a KCl solution. After delipidation of the meat extract, protein aggregation was evaluated with a laser granulometer (Sysmex FPIA-3000) which enabled reliable and reproducible characterization of particle number, size, and shape distribution using automated imaging techniques. The cooking mode (dry/"in water") did not affect the granulometry measurements. But, increasing cooking time and temperature affected the number, the size, and the shape of particles. An important decrease in particle number was observed during cooking in parallel with a reduction in particle size and a change in circularity. From these data a model with intermediary fibrillar aggregates and final amorphous aggregates was proposed.

Evaluation of a new electromagnetic tracking system using a standardized assessment protocol.

This note uses a published protocol to evaluate a newly released 6 degrees of freedom electromagnetic tracking system (Aurora, Northern Digital Inc.). A practice for performance monitoring over time is also proposed. The protocol uses a machined base plate to measure relative error in position and orientation as well as the influence of metallic objects in the operating volume. Positional jitter (E(RMS)) was found to be 0.17 mm +/- 0.19 mm. A relative positional error of 0.25 mm +/- 0.22 mm at 50 mm offsets and 0.97 mm +/- 1.01 mm at 300 mm offsets was found. The mean of the relative rotation error was found to be 0.20 degrees +/- 0.14 degrees with respect to the axial and 0.91 degrees +/- 0.68 degrees for the longitudinal rotation. The most significant distortion caused by metallic objects is caused by 400-series stainless steel. A 9.4 mm maximum error occurred when the rod was closest to the emitter, 10 mm away. The improvement compared to older generations of the Aurora with respect to accuracy is substantial.

The prognostic value of pre-procedural plasma C-reactive protein in patients undergoing elective coronary angioplasty.

AIMS: The acute phase reactant C-reactive protein is an important prognostic risk factor in patients with both stable and unstable coronary artery disease. The potential prognostic implications of an abnormal pre-procedural C-reactive protein concentration in patients undergoing elective coronary angioplasty may be relevant for subsequent treatment. METHODS AND RESULTS: Pre-procedural plasma levels of C-reactive protein were measured in 501 patients with stable coronary artery disease undergoing elective coronary angioplasty. The incidence of death or myocardial infarction during a 2-year follow-up was 10.6% (24/227) in patients with an increased C-reactive protein level (>3 mg. l(-1)) and 2.9% (8/274) in patients with a normal C-reactive protein level (RR 3.9, 95% CI 1.7-8.9). Survival without death, myocardial infarction, urgent revascularization or hospital admission for unstable angina was significantly lower in patients with an increased C-reactive protein vs patients with a normal C-reactive protein (log-rank 14.62, P<0.0001). Logistic regression analysis identified an increased C-reactive protein level as a strong independent predictor of event-free survival (RR 2.54, 95% CI: 1.44-4.47, P=0.001). CONCLUSION: Pre-procedural C-reactive protein levels are increased in 45% of patients undergoing elective coronary angioplasty. An increased C-reactive protein level is a powerful independent prognostic indicator for subsequent cardiac events, suggesting that late clinical outcome is markedly influenced by pre-procedural systemic activation of inflammation.

Fractional flow reserve, absolute and relative coronary blood flow velocity reserve in relation to the results of technetium-99m sestamibi single-photon emission computed tomography in patients with two-vessel coronary artery disease.

OBJECTIVES: We sought to perform a direct comparison between perfusion scintigraphic results and intracoronary-derived hemodynamic variables (fractional flow reserve [FFR]; absolute and relative coronary flow velocity reserve [CFVR and rCFVR, respectively]) in patients with two-vessel disease. BACKGROUND: There is limited information on the diagnostic accuracy of intracoronary-derived variables (CFVR, FFR and rCFVR) in patients with multivessel disease. METHODS: Dipyridamole technetium-99m sestamibi (MIBI) single-photon emission computed tomography (SPECT) was performed in 127 patients. The presence of reversible perfusion defects in the region of interest was determined. Within one week, angiography was performed; CFVR, rCFVR and FFR were determined in 161 coronary lesions after intracoronary administration of adenosine. The predictive value for the presence of reversible perfusion defects on MIBI SPECT of CFVR, rCFVR and FFR was evaluated by the area under the curve (AUC) of the receiver operating characteristics curves. RESULTS: The mean percentage diameter stenosis was 57% (range 35% to 85%), as measured by quantitative coronary angiography. Using per-patient analysis, the AUCs for CFVR (0.70 +/- 0.052), rCFVR (0.72 +/- 0.051) and FFR (0.76 +/- 0.050) were not significantly different (p = NS). The percentages of agreement with the results of MIBI SPECT were 76%, 78% and 77% for CFVR, rCFVR and FFR, respectively. Per-lesion analysis, using all 161 measured lesions, yielded similar results. CONCLUSIONS: The diagnostic accuracy of three intracoronary-derived hemodynamic variables, as compared with the results of perfusion scintigraphy, is similar in patients with two-vessel coronary artery disease. Cut-offvalues of 2.0 for CFVR, 0.65 for rCFVR and 0.75 for FFR can be used for clinical decision-making in this patient cohort. Discordant results were obtained in 23% of the cases that require prospective evaluation for appropriate patient management.

Role of variability in microvascular resistance on fractional flow reserve and coronary blood flow velocity reserve in intermediate coronary lesions.

BACKGROUND: Fractional flow reserve (FFR) and coronary blood flow velocity reserve (CFR) represent physiological quantities used to evaluate coronary lesion severity and to make clinical decisions. A comparison between the outcomes of both diagnostic techniques has not been performed in a large cohort of patients with intermediate coronary lesions. METHODS AND RESULTS: FFR and CFR were assessed in 126 consecutive patients with 150 intermediate coronary lesions (between 40% and 70% diameter stenosis by visual assessment). Agreement between outcomes of FFR and CFR, categorized at cut-off values of 0.75 and 2.0, respectively, was observed in 109 coronary lesions (73%), whereas discordant outcomes were present in 41 lesions (27%). In 26 of these 41 lesions, FFR was <0.75 and CFR>or=2.0 (group A); in the remaining 15 lesions, FFR was >or=0.75 and CFR<2.0 (group B). Minimum microvascular resistance, defined as the ratio of mean distal pressure to average peak blood flow velocity during maximum hyperemia, showed a large variability (overall range, 0.65 to 4.64 mm Hg x cm(-1) x s(-1)) and was significantly higher in group B than in group A (2.42+/-0.77 versus 1.91+/-0.70 mm Hg x cm(-1) x s(-1); P:=0.034). CONCLUSIONS: Our findings demonstrate the prominent role of microvascular resistance in modulating the relationship between FFR and CFR and emphasize the importance of combined pressure and flow velocity measurements to evaluate coronary lesion severity and microvascular involvement.