Anthracycline-Induced Cardiotoxicity in Breast Cancer Patients: A Five-Year Retrospective Study in 10 Centers.

Background: Cardiotoxicity as a result of anthracycline chemotherapy has been linked to increased morbidity and mortality in breast cancer patients. There is a need for early detection through risk factor identification. To date, no large multicenter study has been conducted to describe the incidence, risk factors and clinical and demographic profiles of breast cancer patients with anthracycline-induced cardiotoxicity (AIC) in the Philippines. Methods: This was a nationwide multicenter retrospective cohort study among adult breast cancer patients who underwent anthracycline chemotherapy from 2015 to 2020 in 10 sites in the Philippines. Baseline characteristics and possible risk factors for AIC were retrieved from medical records and cancer registries. AIC was defined as a reduction of left ventricular ejection fraction (LVEF) by > 10% from baseline to a value of < 53% or the development of overt left ventricular systolic dysfunction or heart failure (HF). Odds ratios from logistic regression were computed to determine risk factors associated with AIC using STATA-15.0 software. Results: Out of 341 patients included, 33 had AIC, accounting for an incidence of 9.68%. Nine patients (2.6%) had clinical HF. AIC patients had a mean age of 53.91 ± 10.84 years. Breast cancer AIC patients were significantly older and had lower body mass index (BMI) than those without AIC. AIC patients had significantly more comorbidities, especially hypertension and atrial fibrillation. Multivariate analysis showed that patients with any preexisting comorbidity are approximately 12.37 times as likely to have AIC, while those with concurrent chemotherapy are 0.07 times or 93% less likely to have AIC. Conclusion: Among adult breast cancer patients undergoing anthracycline chemotherapy, we determined a high incidence of cardiotoxicity at 9.68%. Having preexisting comorbidities gave patients 12 times increased odds of developing anthracycline cardiotoxicity. The presence of concurrent non-anthracycline chemotherapy showed an inverse association with the development of AIC which we attribute largely to patient selection in a retrospective study. The significantly higher propensity for AIC development in patients with preexisting comorbidities may warrant closer monitoring and control of patient comorbidities such as hypertension among patients undergoing anthracycline chemotherapy.

Association of lipoprotein lipase gene polymorphisms with coronary artery disease among Filipinos.

Studies have shown association of lipoprotein lipase (LPL) polymorphisms with coronary artery disease (CAD); however, limited studies on the genetics of CAD have been done in the Philippines. Because of their effects on high-density lipoprotein and triglyceride metabolism, the G-allele of the Ser447X variant of LPL gene has been shown to be atheroprotective, while HindIII polymorphism has been shown to be pro-atherogenic. We assessed 1301 patients undergoing coronary angiography to determine the prevalence of HindIII and Ser447X polymorphisms and their association with angiographically significant CAD. Genotyping for HindIII and Ser447X variants were analyzed by real-time PCR. Multivariate analyses were performed to determine the interaction between LPL polymorphisms and risk factors of CAD. CAD+ group (72%) was predominantly male (76%) with a mean age of 60.17 ± 11.01 with hypertension (89%), dyslipidemia (84%) and smoking (54%) as the most common risk factors. HindIII carriage frequency among the CAD+ group was 20.3% with a genotypic distribution of 78.71% (T/T), 19.83% (T/G) and 1.46% (G/G). Ser447X carriage frequency among the CAD+ group was 8.0% with a genotypic distribution of 91.39% (C/C), 8.38% (C/G) and 0.23% (G/G). HindIII and Ser447X polymorphisms were both not significantly associated with CAD. LPL polymorphic allele HindIII was common, while Ser447X was rare. Present study did not show association of LPL polymorphisms with the development of CAD. However, among patients with dyslipidemia, presence of Ser447X allele is associated with an increased risk (OR 2.6; 95% CI 2.1-3.7; p value < 0.001) of developing CAD than those without LPL polymorphisms.

Status of the SPIRAL2 injector commissioning.

The SPIRAL2 injector, installed in its tunnel, is currently under commissioning at GANIL, Caen, France. The injector is composed of two low energy beam transport lines: one is dedicated to the light ion beam production, the other to the heavy ions. The first light ion beam, created by a 2.45 GHz electron cyclotron resonance ion source, has been successfully produced in December 2014. The first beam of the PHOENIX V2 18 GHz heavy ion source was analyzed on 10 July 2015. A status of the SPIRAL2 injector commissioning is given. An upgrade of the heavy ion source, named PHOENIX V3 aimed to replace the V2, is presented. The new version features a doubled plasma chamber volume and the high charge state beam intensity is expected to increase by a factor of 1.5 to 2 up to the mass ∼50. A status of its assembly is proposed.

All-cause mortality by age and gender based on coronary artery calcium scores.

AIMS: Although coronary artery calcium (CAC) has been established as a robust tool for predicting total mortality during intermediate follow-up, less is known about the long-term predictive value of CAC. METHODS AND RESULTS: This study included 13 092 asymptomatic patients without known cardiovascular disease who underwent a clinically indicated CAC scan. CAC was categorized as an Agatson score of 0, 1-99, 100-399, and ≥400. We used multivariable Cox proportional hazards to calculate adjusted hazard ratios (HRs) for mortality stratified by age (younger, intermediate, or older) and gender. The mean age of participants was 58 ± 11 years and 67% were men. During a median follow-up of 11.0 ± 3.2 years, there were 522 deaths (4.0%). Compared with CAC = 0, increasing CAC was associated with higher mortality rate: 1-99 [HR: 1.5, 95% confidence interval (95% CI): 1.1-2.1]; 100-399 (HR: 1.8, 95% CI: 1.3-2.5); ≥400 (HR: 2.6, 95% CI: 1.9-3.6). Relative risk according to CAC category did not differ between genders. The strongest associations between CAC and mortality were observed for young and intermediate age participants. Nonetheless, the mortality rate of the older patients with CAC = 0 was far lower than that of the general US population. CAC was more predictive of long-term (15 years) than intermediate-term (5 years) mortality for men [receiver operator characteristics (ROC): 0.723 vs. 0.702] and women (ROC: 0.69 vs. 0.65). CONCLUSION: CAC is strongly associated with the long-term risk of mortality in young- and middle-aged men and women. In older patients, the long-term risk stratification of CAC is lower, due principally to increased mortality rate in patients with low calcium scores; however, even in the older patients, those with absent or low CAC are at a significantly lower risk of mortality compared with the general population.

High-degree atrioventricular block in patients with preexisting bundle branch block or bundle branch block occurring during transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become the standard therapy for high-risk and non-operable patients with severe aortic stenosis. However, the procedure involves several adverse effects, such as rhythm and conduction disturbances. Patients with postprocedural left bundle branch block may have an increased mortality risk, whereas patients with preprocedural right bundle branch block display a higher rate of postinterventional bradyarrhythmias. OBJECTIVE: The purpose of this study was to investigate the occurrence of high-degree atrioventricular block (AVB) in patients with preexisting bundle branch block (BBB) or BBB occurring during TAVI. METHODS: In this prospective single-center study, 50 consecutive patients undergoing TAVI with the Medtronic CoreValve Revalving System were included. Of these patients, 17 with preexisting BBB or BBB occurring during TAVI received a primary prophylactic permanent DDD pacemaker, programmed to the SafeR-mode and featuring dual-channel event counters as well as stored intracardiac electrograms. Pacemaker readouts and intracardiac electrograms were analyzed for the occurrence of high-degree AVB. RESULTS: Ten of 17 patients (58.8%) with preexisting BBB or BBB occurring during TAVI developed episodes of high-degree AVB that were immediately terminated due to switch into DDD backup pacing. In 5 of the cases (29.4%), the first documented episode of high-degree AVB occurred after hospital discharge. Mean follow-up period was 578.1 ± 294.9 days. CONCLUSION: Development of high-degree AVB is a common complication in patients with preexisting BBB or BBB occurring during TAVI. Accordingly, intensified monitoring might be reasonable, especially in patients treated with the self-expandable Medtronic CoreValve Revalving System.

Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis.

Anthrax is extremely rare in the western world but is endemic to areas of south and central Asia. In early 2010 an outbreak was identified in heroin-injecting intravenous drug users in the United Kingdom and Europe. Afghanistan is currently the principal source of heroin which reaches the United Kingdom. When anthrax occurs, cutaneous disease accounts for over 95% of cases. At least 47 cases with 13 deaths have been confirmed so far. We present three cases presenting during this time with marked swelling, one resulting in compartment syndrome but all with an absence of the expected cutaneous appearances. We suggest that rather than cutaneous anthrax, these patients represent a new subcutaneous presentation of anthrax.

Measurement of thoracic bone mineral density with quantitative CT.

PURPOSE: To create standard thoracic bone mineral density (BMD) values for patients undergoing cardiac computed tomography (CT) by using thoracic quantitative CT and to compare these BMDs (in a subpopulation) with those obtained by using lumbar spine quantitative CT. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study. A total of 9585 asymptomatic subjects (mean age, 56 years; age range, 30-90 years) who underwent coronary artery calcium scanning, including 4131 women, were examined. Patients with vertebral deformities or fractures were excluded. Six hundred forty-four subjects (322 of whom were female) also underwent lumbar quantitative CT. The mean thoracic vertebral BMDs for both sexes were reported separately in a subgroup of subjects aged 30 years and in 29 age-based subgroups in 2-year intervals from ages 30 to 90 years. The formulas used to calculate the female T score (T(f)) and the male T score (T(m)) on the basis of thoracic quantitative CT measurements were as follows: T(f) = (BMD(im) - 222)/36, and T(m) = (BMD(im) - 215)/33, where BMD(im) is the individual mean BMD. Comparisons between thoracic quantitative CT and lumbar quantitative CT measurements, as well as analyses of intraobserver, interobserver, and interscan variability, were performed. RESULTS: The young-subgroup mean BMD was 221.9 mg/mL ± 36.2 (standard deviation) for the female subjects and 215.2 mg/mL ± 33.2 for the male subjects. The mean thoracic BMDs for the female and male subjects were found to be 20.7% higher and 17.0% higher, respectively, than the values measured with lumbar quantitative CT (P < .001 for both comparisons). A significant positive association between the thoracic and lumbar quantitative CT measurements (r > 0.85, P < .001) was found. Intraobserver, interobserver, and interscan variabilities in thoracic quantitative CT measurements were 2.5%, 2.6%, and 2.8%, respectively. CONCLUSION: There was a significant association between the mean thoracic and lumbar BMDs. Therefore, standard derived measurements (young-subgroup BMD ± standard deviation) based on these data can be used with thoracic CT images to estimate the bone mineral status.

Cost-effectiveness of multidetector computed tomography compared with myocardial perfusion imaging as gatekeeper to invasive coronary angiography in asymptomatic firefighters with positive treadmill tests.

BACKGROUND: In a prospective evaluation of 3950 Los Angeles County firefighters who underwent wellness/fitness examinations, 495 firefighters had abnormal treadmill tests and were referred for cardiology evaluation. Cost of the traditional myocardial perfusion imaging (MPI) followed by invasive coronary angiography (ICA) was compared with a method incorporating 64-slice multidetector computed tomography (MDCT) with coronary calcium score (CCS) followed by computed tomographic angiography (CTA) and ICA as indicated. OBJECTIVE: We compared the costs of 2 methods of predicting coronary artery disease (CAD) by ICA among asymptomatic patients with positive treadmill tests. METHODS: A decision-analytic framework was used to compare the net direct costs of CAD diagnosis associated with MDCT versus MPI. In the MDCT arm, all received CCS followed by CTA for those with calcium scores>10 and ICA for those with > or =50% stenosis on CTA. For the MPI arm, results were estimated from prior years' experience, in which firefighters with abnormal treadmill results were referred to ICA. RESULTS: Of 495 firefighters, 131 (26.9%) had abnormal CCS and went to CTA; 40 (8.1%) had > or =50% stenosis on CTA and went to ICA. According to prior years' experience with MPI, 146 (29.5%) would have shown abnormalities requiring ICA. Average cost was $1376/person for MPI versus $503/person for CCS with or without CTA as gatekeeper. All sensitivity analyses showed lower costs for the MDCT pathway compared with MPI. CONCLUSION: In this firefighter population, the cost of ICA-confirmed diagnosis of CAD is substantially lower with MDCT as gatekeeper than with MPI.

Aged garlic extract supplemented with B vitamins, folic acid and L-arginine retards the progression of subclinical atherosclerosis: a randomized clinical trial.

OBJECTIVES: Previous studies demonstrated that aged garlic extract reduces multiple cardiovascular risk factors. This study was designed to assess whether aged garlic extract therapy with supplements (AGE+S) favorably affects inflammatory and oxidation biomarkers, vascular function and progression of atherosclerosis as compared to placebo. METHODS: In this placebo-controlled, double-blind, randomized trial (conducted 2005-2007), 65 intermediate risk patients (age 60+/-9 years, 79% male) were treated with a placebo capsule or a capsule containing aged garlic extract (250 mg) plus Vitamin B12 (100 microg), folic acid (300 microg), Vitamin B6 (12.5 mg) and l-arginine (100 mg) given daily for a 1 year. All patients underwent coronary artery calcium scanning (CAC), temperature rebound (TR) as an index of vascular reactivity using Digital Thermal Monitoring (DTM), and measurement of lipid profile, autoantibodies to malondialdehyde (MDA)-LDL, apoB-immune complexes, oxidized phospholipids (OxPL) on apolipoprotein B-100 (OxPL/apoB), lipoprotein (a) [Lp (a)], C-reactive protein (CRP), homocysteine were measured at baseline and 12 months. CAC progression was defined as an increase in CAC>15% per year and an increase in TR above baseline was considered a favorable response. RESULTS: At 1 year, CAC progression was significantly lower and TR significantly higher in the AGE+S compared to the placebo group after adjustment of cardiovascular risk factors (p<0.05). Total cholesterol, LDL-C, homocysteine, IgG and IgM autoantibodies to MDA-LDL and apoB-immune complexes were decreased, whereas HDL, OxPL/apoB, and Lp (a) were significantly increased in AGE+S to placebo. CONCLUSION: AGE+S is associated with a favorable improvement in oxidative biomarkers, vascular function, and reduced progression of atherosclerosis.

Baseline cortisol measures and developmental pathways of anxiety in early adolescence.

OBJECTIVE: This study investigated whether baseline cortisol measures predicted future anxiety, and compared cortisol values of groups with different developmental pathways of anxiety. METHOD: Cortisol levels were assessed in 1768 individuals (10-12 years). Anxiety levels were assessed at the same age and 2 years later. RESULTS: Cortisol measures did not predict future anxiety levels. Individuals with persistent anxiety problems did not show higher morning cortisol levels than those with persistently low, decreasing, or increasing anxiety levels. Instead, individuals with persistently high anxiety levels showed significantly lower evening cortisol levels than all other individuals. Further, participants with increasing anxiety levels showed higher morning cortisol levels (area under the curve; AUC) than individuals with persistently low anxiety levels. CONCLUSION: The extent to which the HPA-axis - by itself - plays a role in the aetiology of anxiety is questionable. Interactions of the HPA-axis with other biological or environmental factors may be more important.

The role of perceived parenting in familial aggregation of anxiety disorders in children.

This study was designed to explore the role of perceived parenting style in the familial aggregation of anxiety disorders. We examined the association between parental and child anxiety diagnoses, and tested whether this association was partly due to a perceived parenting style. The study was conducted in a clinical sample as well as in a control sample. Parental lifetime and current anxiety diagnoses were significantly associated with child anxiety diagnoses. When maternal and paternal lifetime and current anxiety diagnoses were entered as separate predictors, only maternal current anxiety diagnoses appeared to be significant. Perceived parenting style was assessed with the dimensions "overprotection," "emotional warmth," "rejection," and "anxious rearing." Results indicated that only maternal and paternal 'overprotection' was significantly but negatively associated with child anxiety. However, further analyses showed that 'overprotection' did not have a significant mediating role in the familial aggregation of anxiety disorders.

Transvenous, intracardial cardioversion for the treatment of postoperative atrial fibrillation.

Atrial fibrillation (AF) following cardiac surgery is an important factor contributing to postoperative morbidity. Transvenous, intracardial cardioversion (TIC) has been shown to be effective in the treatment of chronic AF, but is an invasive and cost-intensive procedure. However, TIC would definitely be a beneficial approach if recurrence of AF following TIC is low and pharmacological treatment could be avoided. Thus, we hypothesised that TIC would be superior to conventional treatment with amiodarone with respect to the conversion rate and recurrence of AF. We compared TIC and conventional amiodarone therapy in a prospective, randomised and controlled trial in patients who developed AF following cardiac surgery. Twenty-three patients developed AF out of a total of 76 patients who gave written informed consent. Eighteen of these AF patients could be randomised into two equally sized groups to receive either an ALERT pulmonary artery catheter and TIC, or a standard pulmonary artery catheter and treatment with amiodarone. Haemodynamic parameters were registered before intervention to exclude pulmonary hypertension or fluid overload. Rates of cardioversion were compared by a Likelyhood ratio test. Out of the nine ALERT patients, AF in five cases converted to sinus rhythm (SR) with a median of two shocks (6 J). After 24 hours however, only two patients remained in sinus rhythm. On the other hand, six of the nine patients treated with amiodarone were still in SR after 24 hours. Whereas no difference was detectable in the conversion rate, persistence of SR following TIC was low. Thus, TIC without antiarrhythmic treatment is not recommendable for the treatment of postoperative AF.

Normal thoracic aorta diameter on cardiac computed tomography in healthy asymptomatic adults: impact of age and gender.

RATIONALE AND OBJECTIVES: To establish the normal criterion of ascending aortic diameter (AAOD) measured by 64 multidetector computed tomography (MDCT) and electron beam computed tomography (EBT) based on gender and age. MATERIALS AND METHODS: A total of 1442 consecutive subjects who were referred for evaluation of possible coronary artery disease underwent coronary computed tomographic (CT) angiography (CTA) and coronary artery calcium scanning (CACS) (55 + 11 years, 65% male) without known coronary heart disease, hypertension, chronic pulmonary and renal disease, diabetes, and severe aortic calcification. The AAOD aortic diameter, descending aortic diameter (DAOD), pulmonary artery (PAD), and chest anteroposterior diameter (CAPD), posterior border of the sternal bone to the anterior border of the spine, were measured at the slice level of mid-right pulmonary artery using end systolic trigger imaging. The volume of four chambers, ejection fraction of left ventricle, and cardiac output were measured in 56% of the patients. Patients' demographic information, age, gender, weight, height, and body surface area were recorded. The mean value and age-specific and gender-adjusted upper normal limits (mean +/- 2 standard deviation) were calculated. The linear correlation analysis was done between AAOD and all parameters. The reproducibility, wall thickness, and difference between end-systole and end-diastole were calculated. RESULTS: AAOD has significant linear association with age, gender, DAOD, and pulmonary artery diameter (P < .05). There is no significant correlation between AAOD and body surface area, four-chamber volume, left ventricular ejection fraction, cardiac output, and CAPD. The mean intraluminal AAOD was 31.1 +/- 3.9 and 33.6 +/- 4.1 mm in females and males, respectively. The upper normal limits (mean +/- 2 standard deviations) of intraluminal AAOD, were 35.6, 38.3, and 40 mm for females and 37.8, 40.5, and 42.6 mm for males in age groups 20-40, 41-60, and older than 60 years, respectively. Intraluminal aortic diameters should parallel echocardiography and invasive angiography. Traditional cross-sectional imaging (with CT and magnetic resonance imaging) includes the vessel wall. The mean total AAOD was 33.5 and 36.0 mm in females and males, respectively. The upper normal limits (mean +/- 2 standard deviations) of intraluminal AAOD were 38.0, 40.7 and 42.4 mm for females and 40.2, 42.9, and 45.0 mm for males in age group 20 to 40, 41 to 60, and older than 60 years, respectively. The inter- and intraobserver, scanner, and repeated measurement variabilities were low (r value >0.91, P < .001, coefficient variation <3.2%). AAOD was 1.7 mm smaller in end-diastole than end-systole (P < .001). CONCLUSIONS: The AAOD increases with age and male gender. Gender-specific and age-adjusted normal values for aortic diameters are necessary to differentiate pathologic atherosclerotic changes in the ascending aorta. Use of intraluminal or total aortic diameter values depends on the comparison study employed.

[Pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children and adolescents: an overview]. / Farmacotherapie bij sociale fobie, gegeneraliseerde angststoornis en separatieangststoornis bij kinderen en adolescenten: Een literatuuroverzicht.

BACKGROUND: Anxiety disorders are among the most prevalent psychiatric disorders during childhood. They are often persistent and are associated with a number of negative outcomes. Therefore, effective treatment is required. AIM: To present an overview of placebo-controlled studies of pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children an adolescents and to determine which medication is the most effective. METHOD: The literature was reviewed using Pubmed. RESULTS: Nine randomised double-blind studies on the efficacy of pharmacotherapy for generalised anxiety disorder, separation anxiety disorder and social phobia were found. Tricyclic antidepressants were not more effective than placebo. Studies on benzodiazepines showed that the effect of these drugs was not superior to that of placebo either. Studies of the efficacy of ssris, however, proved that they were superior to placebo. CONCLUSION: SSRIS are the drugs of first choice for the treatment of social phobias, separation anxiety disorder and generalised anxiety disorder in children and adolescents. There is strong evidence that ssris are effective for the treatment of these anxiety disorders; the standardised effect size varies between medium and large.

Prognostic value of number and site of calcified coronary lesions compared with the total score.

OBJECTIVES: This study sought to evaluate the long-term prognostic value of the number and sites of calcified coronary lesions and to compare the accuracy of number of calcified lesions with the extent of total calcium score. BACKGROUND: There is a strong relationship between mortality and total coronary artery calcium (CAC) score. It is not known whether the number of calcified lesions or their location influences outcome. METHODS: A total of 14,759 asymptomatic patients were referred for evaluation of CAC scanning using electron beam tomography. Univariable and multivariable Cox proportional hazards models were developed to estimate time to all-cause mortality at, on average, 6.8 years (n = 281). RESULTS: Risk-adjusted annual mortality was 0.19% (95% confidence interval 0.18% to 0.21%) for patients without any calcified lesions. For patients with >20 lesions, annual risk-adjusted mortality exceeded 2% per year. Mortality rates were significantly higher for left main lesions as compared to other coronary arteries with annual mortality rates of 1.3%, 2.1%, 9.2%, and 13.6% for 1 to 2, 3 to 5, and > or =6 lesions, respectively (p < 0.0001). For left main CAC scores of 0 to 10, 11 to 100, 101 to 399, and 400 to 999, annual risk-adjusted mortality was 0.33%, 0.81%, 1.73%, and 7.71%, respectively (p < 0.0001). All 4 patients with a CAC score of > or =1,000 in the left main died during follow-up. However, patients with more frequent calcified lesions also had higher CAC scores. Specifically, > or =81% of patients with >10 calcified lesions also had a CAC score > or =100. With exception, for patients with CAC scores > or =1,000, annual mortality was dramatically higher at 3.0% to 4.5% for those with 1 to 5 calcified lesions as compared with 1.1% to 2.0% for those with 6 or more lesions (p < 0.0001). CONCLUSIONS: We report that mortality rates increased proportionally with the number of calcified lesions. Although predictive information is contained in the number of calcified lesions, its added statistical value is minimal. With exception, patients with frequent lesions in the left main or those with a few large calcified lesions have a particularly high mortality risk.

Associations between HPA axis functioning and level of anxiety in children and adolescents with an anxiety disorder.

The hypothalamus-pituitary-adrenal (HPA) axis becomes active in response to stress. Hence, increased levels of anxiety in children and adolescents may be associated with changes in HPA-axis functioning. The aim of this study was to test if level of anxiety or specific anxiety disorders were associated with basal HPA axis activity in children and adolescents with an anxiety disorder. In 99 8- to 16-year-olds with an anxiety disorder, basal cortisol levels were assessed. It was tested if (1) cortisol levels correlated with the level of self-reported anxiety and (2) if cortisol levels were different for individuals with different anxiety disorders. In girls, low levels of anxiety were associated with a stronger rise in early morning cortisol concentrations. In both boys and girls, harm avoidance predicted low cortisol concentrations after awakening. Separation anxiety and physical anxiety symptoms predicted cortisol concentrations at noon. Differences between individuals with different anxiety disorders were not found. More research is needed regarding mechanisms that explain the associations that were found, and to investigate if treatment may influence HPA axis functioning in children and adolescents with an anxiety disorder.

Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality.

OBJECTIVES: The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large, ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality. BACKGROUND: Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than non-Hispanic whites (NHW). Some of this variability may be due to differing pathophysiological mechanisms and effects of underlying atherosclerosis. METHODS: Ten-year death rates from all causes (total deaths = 505) were compared using risk-adjusted Cox proportional hazards models in AA (n = 637), Hispanic (HS, n = 1,334), Asian (AS, n = 1,065), and NHW (n = 11,776) populations. RESULTS: Ethnic minority patients were generally younger (0.3 to 4 years), more often persons with diabetes (p < 0.0001), hypertensive (p < 0.0001), and female (p < 0.0001). The prevalence of CAC scores > or =100 was highest in NHW (31%) and lowest for HS (18%) (p < 0.0001). Overall survival was 96%, 93%, and 92% for AS, NHW, and HS, respectively, as compared with 83% for AA (p < 0.0001). When comparing prognosis by CAC scores in ethnic minorities as compared with NHW, relative risk ratios were highest for AA with CAC scores > or =400 exceeding 16.1 (p < 0.0001). Hispanics with CAC scores > or =400 had relative risk ratios from 7.9 to 9.0, whereas AS with CAC scores > or =1,000 had relative risk ratios 6.6-fold higher than NHW (p < 0.0001). CONCLUSIONS: Consistent with population evidence, AA with increasing burden of subclinical coronary artery disease were the highest-risk ethnic minority population. These data support a growing body of evidence noting substantial differences in cardiovascular risk by ethnicity.

[Child and adolescent psychiatry: a profession and its identity II]. / Kinder- en jeugdpsychiatrie: een vak en een identiteit II.

BACKGROUND: Up till the 1970s child and adolescent psychiatry had no distinctive diagnostic system of its own. From the 1980s onwards qualitative information-gathering (e.g. via discussion or play-situations) was no longer regarded as adequate and the standardised gathering of (quantitative) information became the cornerstone of the diagnostic process. This development fundamentally changed the child psychiatrist's profession and its identity. AIM: To investigate the specific features that are required in current child and adolescent psychiatry. METHOD: In this article we will clarify the change in the child psychiatrist's profession and identity by outlining how child an adolescent psychiatry evolved as from the early 1980s. We will do this by concentrating on the diagnostic process. The treatment aspect will be discussed only briefly. RESULTS: Over the last 25 years the role of the child psychiatrist has undoubtedly changed. From being mainly a diagnostician and/or being personally responsible for treating the child or adolescent the child psychiatrist has become increasingly the person who controls the diagnostic process and plans treatment. CONCLUSION: Over the last two decades the diagnostic technique of the child psychiatrist has developed in a new direction. The child psychiatrist has chosen instead to elucidate a patient's referral and to discuss the reasons for a request for assistance and/or care. The psychiatrist uses many types of information and a multitude of informants and methods. This development has led to a fundamental change in the child psychiatrist's profession and its identity.

Higher cortisol awakening response in young adolescents with persistent anxiety problems.

OBJECTIVE: The aims of the present study were to test the association between current anxiety problems and basal cortisol levels in a large population sample of young preadolescents, and to test if HPA-axis activity differs between individuals with no, only current, or persistent anxiety problems. METHOD: Cortisol levels of 10- to 12-year olds (n = 1,768) from the general population were measured on three time points during the day. A self-report questionnaire (RCADS) was used to assess current anxiety, a parent-report questionnaire (TPBQ) to assess anxiety problems at age 4. RESULTS: Associations between cortisol levels and current anxiety problems were not found. However, individuals with persistent anxiety problems had higher morning cortisol levels and a higher cortisol awakening response. CONCLUSION: Apparently, only persistent, and not current, anxiety problems are associated with higher HPA-axis activity. Alterations in HPA-axis activity might underlie persistent anxiety problems, or result from the stress accompanied by persistent anxiety problems.