Hoover's sign is a predictor of airflow obstruction severity and is not related to hyperinflation in chronic obstructive pulmonary disease

Background

Several phenotypes are described in COPD.

Objectives

To assess if COPD patients with Hoover's sign (HS) belong to a particular phenotype.

Methods

All consecutive COPD patients with varying degree of airflow obstruction that came for lung function testing in one university hospital were prospectively assessed, using clinical and magnetometer detection of HS, body mass index (BMI), St. George's Respiratory Questionnaire for health-related quality of life, six-minute-walk test (6MWT) with inspiratory capacity (IC) measurements and expiratory flow limitation (EFL) detection. Previous exacerbations were also reported.

Results

82 patients were studied. Magnetometers confirmed HS in 56 of them, of which 79% (44/56) were detected by clinical assessment. HS (+) patients were older (64 ± 10 vs 59 ± 10 years, p = 0.03), had a higher BMI (26 ± 5 vs 23 ± 4, p = 0.04), a lower FEV1 (53% ± 18% vs 63% ± 18% pred, p = 0.02) and a higher IC decrease at the end of 6MWT, (− 19 ± 2 vs − 7 ± 4% pred, p = 0.003). A larger proportion of HS (+) patients also reported severe exacerbations during the past 2 years (39% vs 12% p = 0.01). There was no statistical evidence that HS was related to hyperinflation and/or EFL.

Conclusion

The very simple clinical HS allows identifying a particular population of COPD patients of older age and higher BMI with a more severe airflow obstruction, increased dynamic hyperinflation during exercise and higher exacerbation frequency. These characteristics were not linked to hyperinflation or EFL.     

Impaired carbon monoxide diffusing capacity as a marker of limited systemic sclerosis

Background

As impairment of diffusing capacity for carbon monoxide (DLCO) likely reflects underlying pulmonary vasculopathy in limited systemic sclerosis (lSSc), we examined whether DLCO could help to distinguish secondary from idiopathic Raynaud's phenomenon (iRP).

Methods

We compared pulmonary function test (PFT) results in 145 lSSc patients and 24 age- and sex-matched iRP patients. RP duration at time of PFT was similar in the two groups.

Results

DLCO values were low (< 80% of predicted) in 106 (73%) of the 145 lSSc patients, and in 69 (71%) of the 97 patients with early lSSc. Interstitial lung disease (ILD) was found in 10% of lSSc patients. DLCO was significantly lower in lSSc than in iRP (72 ± 15% versus 89 ± 9%, p < 0.0001). When evaluated, alveolar capillary membrane conductance (Dm) was markedly lower in lSSc patients without ILD than in iRP patients (45 ± 12% versus 71 ± 2.5%, p = 0.003), although capillary blood volume was not different. DLCO was low in 3 iRP patients (12.5%). The sensitivity and specificity of low DLCO values for early lSSc diagnosis in patients with Raynaud's phenomenon were 71% and 87.5%, respectively. Sensitivity was similar to that of anti-centromere-antibodies (75%) and nailfold capillary abnormalities (81%). A DLCO cutoff of < 70% had a sensitivity and specificity of 41% and 100%, respectively.In multivariable analysis, age and low DLCO were the only independent predictors of death; the hazard ratio for DLCO ≤ 50% was 7.9 (95% CI 2.3-26, p = 0.0007).

Conclusion

Isolated DLCO impairment is significantly more frequent in patients with lSSc than in patients with idiopathic iRP. DLCO measurement could be a useful diagnostic tool for lSSc.     

Effects of arm-cranking exercise in cutaneous microcirculation in older, sedentary people

Objectives

Microvascular integrity is compromised by several diseases and conditions as well as age. Exercise can reverse these effects but it is unclear whether these are systemic or localised, or which mechanisms are responsible for observed improvements Therefore, the primary objective of this study was to assess whether arm-cranking exercise had a systemic or localised cutaneous, microcirculatory effect in an older, healthy population and compare these findings with our previous work on patients with chronic venous disease. A secondary objective was to see if improvements were greater in the lower- or in the upper-limb.

Methods

Endothelial-dependent- and independent-vasodilation were assessed on the forearm and the perimalleolar region in 14 older (59 ± 4.5 years), sedentary, healthy participants using LDF and incremental doses of acetylcholine (ACh) and sodium nitroprusside (SNP), before and after a session of arm-cranking exercise. Cutaneous blood flux data were expressed as cutaneous vascular conductance (CVC).

Results

Endothelial-dependent vasodilation increased both in the upper- (p = 0.04, d = 0.59) and lower-limb (p = 0.03, d = 0.52), after exercise. Endothelial-independent vasodilation did not change either in the lower- and upper-limb (p > 0.05 on both occasions). “Between-limbs” comparison showed that pre-exercise differences between the forearm and the lower-leg (p = 0.04, d = 0.47) disappeared after ACh-induced vasodilation, following arm-cranking exercise (p > 0.05). Conversely, SNP-induced did not change.

Conclusion

Our results suggest that in a healthy, sedentary population (and in contrast to post-surgical varicose vein patients), acute arm-cranking exercise leads to an improvement of microvascular endothelial function in the extremities.     

Monosensitization and polysensitization in allergic rhinitis

Background

Polysensitization is common in patients with allergic rhinitis (AR) and may affect clinical feature. However, there are patients who remain monosensitized.

Objective

This cross-sectional study aimed at evaluating a large cohort of AR patients to define the percentage and the features of mono- and poly-sensitized subjects.

Methods

This observational cross-sectional study included a large group of AR patients: 2415 subjects (1958 males, mean age 24.6 ± 5 years) were consecutively evaluated. Symptom severity, type and number of sensitizations, and AR duration were considered.

Results

621 patients (25.7%) were monosensitized: 377 to Parietaria, 194 to house dust mites, 19 to birch, 17 to grasses, 12 to molds, 2 to olive, and 1 to cypress. There was no difference between mono- and polysensitized patients concerning the duration of rhinitis (6 ± 2.14 years vs 6 ± 3.7).Severity of symptoms was higher in polysensitized patients than in monosensitized (p < 0.05); in addition, there was a difference among monosensitized patients: Parietaria-allergy induces the most severe symptoms.

Conclusion

This study conducted in a large AR population might suggest that monosensitized and polysensitized AR patients could constitute two different categories. In addition, the specific type of allergy may condition the clinical feature.     

Hyperleptinaemia positively correlated with metabolic syndrome in hemodialysis patients

Objective

To evaluate the relationship between metabolic syndrome (MetS) and the fasting serum leptin concentration in hemodialysis (HD) patients.

Patients and methods

Fasting blood samples were obtained from 101 HD patients. MetS and its components were defined using the diagnostic criteria of the International Diabetes Federation.

Results

Forty-eight patients (47.5%) had MetS. Serum leptin concentrations were positively correlated with MetS (p < 0.001). Serum leptin levels correlated with increasing numbers of MetS criteria in HD patients (p = 0.001). Univariate linear regression analysis showed that the pre-HD body weight (p < 0.001), waist circumference (p < 0.001), body mass index (p = 0.001), triglycerides (p = 0.003), insulin level (p = 0.043), and homeostasis model assessment of insulin resistance (p = 0.003) positively correlated with serum leptin levels in HD patients and high-density lipoprotein-cholesterol (p = 0.016) negatively correlated with serum leptin levels in HD patients. Multivariate forward stepwise linear regression analysis of the significant variables revealed that pre-HD body weight (R² = 0.175; p < 0.001) was the independent predictor of the fasting serum leptin concentration.

Conclusion

Fasting serum leptin levels positively correlated with MetS and the pre-HD body weight could influence serum leptin in HD patients.     

The predictive value of mean platelet volume in differential diagnosis of non-functional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas

Objective

The aim of the present study is to evaluate in a retrospective manner the diagnostic value of mean platelet volume (MPV) in pancreatic adenocarcinomas and pancreatic neuroendocrine tumors (PNETs).

Patients and methods

A total of 92 patients, who were admitted for pancreatic adenocarcinoma (n = 76) and PNET (n = 16) between March 2007 and December 2009, were analyzed retrospectively for demographics and clinical information.

Results

Thirty-nine patients (51.3%) had a resectable, whereas 37 patients (48.7%) had an unresectable pancreatic adenocarcinoma. Nine patients (56.3%) had a non-functional PNET, 6 patients (37.5%) had an insulinoma, and the remaining one patient had a gastrinoma. The mean age was 59.3 ± 10.5 for pancreatic adenocarcinomas and 45.1 ± 10.6 for PNETs. The mean age at diagnosis was significantly higher in patients with pancreatic adenocarcinomas than the patients with PNET (p < 0.001). Preoperative mean hemoglobin levels were significantly lower in patients with pancreatic adenocarcinoma than those with PNET (12.4 ± 1.8 g/dl vs 13.7 ± 2.2 g/dl), (p < 0.013). The preoperative median MPV levels were significantly lower in patients with PNET 7.8 fL (7.2-9.4) than in patients with pancreatic adenocarcinomas 8.6 fL (6.6-13.5), (p < 0.014). In subgroup analysis, a significant difference in MPV levels was mainly caused by the difference between pancreatic adenocarcinomas and non-functional PNETs (p = 0.017). The cut-off value of MPV level for detection of PNETs was calculated as ≤ 7.8 fL using ROC analysis [Sensitivity: 66.7%, specificity: 75.9%, AUC: 0.734 (0.587-0.880) p = 0.022]. In logistic regression analysis, independent predictive factors for determining PNETs in the differential diagnosis of pancreatic adenocarcinomas were calculated as age (OR = 0.068, 95% CI: 0.012-0.398), Ca 19-9 (OR = 0.039, 95% CI: 0.006-0.263), MPV (OR = 0.595, 95% CI: 0.243-1.458), and hemoglobin (OR = 1.317, 95% CI: 0.831-2.086).

Conclusion

Age, Ca 19-9, MPV, and hemoglobin levels have diagnostic value for distinguishing PNETs from pancreatic adenocarcinomas.     

Renin-angiotensin system inhibitors reduce the progression of mesangioproliferative glomerulonephritis: 10 year follow-up

Background

Proteinuria is a common presentation of mesangioproliferative glomerulonephritis (MsPGN). No studies are available on the long-term effect of treatment by renin-angiotensin system (RAS) inhibitors on renal outcome in MsPGN patients. This study prospectively evaluates the effects of RAS inhibitors on renal outcome in patients with low risk MsPGN followed up for 10 years using historical patients with similar features at the time of presentation as untreated controls.

Methods

Endpoints: decrease of basal proteinuria > 20% and loss > 20% of basal glomerular filtrate rate (GFR) at the end of first year of observation. The patients were re-evaluated bimonthly during the first year and every 6 months thereafter.

Results

Twenty-five patients fulfilled the selection criteria. After one year follow-up 19 patients reached the endpoint of proteinuria and no patient reached the endpoint of GFR. No significant change in blood pressure levels (BP) and GFR was registered, by contrast daily proteinuria decreased significantly (p < 0.001), falling by 29% at sixth month and 47% at the end of the follow-up. The historical control group consisted of 15 untreated patients seen between 1987 and 1992. The two-way analysis of variance for repeated measures showed greater values of GFR (p < 0.001) and lower levels of daily proteinuria (p < 0.001) in treated patients as compared to untreated controls.

Conclusions

This 10-year follow-up study indicates that the early treatment with RAS inhibitors at low doses favourably influences the long-term renal outcome in proteinuric patients with MsPGN. Limitations were the small sample size and lack of randomization.     

Phosphorus levels are associated with subclinical atherosclerosis in the general population

Objective

To evaluate the effect of large unilamellar vesicles (LUVs) infusion on endothelial function. Low-density lipoprotein (LDL) lowering, particularly with statins, results in rapid attenuation of endothelial dysfunction and decreases cardiovascular events. Unique methods of removing cholesterol from the vessel wall are being developed. The effect of LUVs on endothelial function has not been evaluated in humans.

Method

75 subjects (mean age 61 ± 10 years) with established vascular disease were randomized to receive either 2 g, 8 g or matching placebo of LUVs as a weekly intravenous bolus infusion for 4 consecutive weeks. Brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation was measured at baseline and 1 week after the last infusion. The primary study outcome was the change from baseline in FMD in the active therapy groups combined. Predefined secondary end-points included nitroglycerin-mediated dilation and safety.

Results

Active therapy (combined 2 g + 8 g treatment groups, n = 49) did not result in a change in FMD, but did improve nitroglycerin dilation (p < 0.05). However, a beneficial effect on both FMD (10.2 ± 5.7% vs. 11.8 ± 5.5%) and nitroglycerin-mediated dilation (18.1 ± 9.3% vs. 21.2 ± 8.7%, both p < 0.05) was seen in the 2-g group. Infusion of the 8-g dose resulted in significantly higher levels of unesterified cholesterol compared with the other groups during the study period (p < 0.01).

Conclusion

The current study demonstrated no overall effect of LUVs on FMD, however nitroglycerin-mediated dilation was improved. Further studies are required to clarify if there is a dose-dependent effect of this therapy and what its role is in subjects with atherosclerosis.     

Valvular and thoracic aortic calcium as a marker of the extent and severity of angiographic coronary artery disease

Background

The presence of calcified extracoronary structures as a useful indicator of underlying coronary artery disease (CAD) has not yet been established. The purpose of this study was to evaluate whether valvular and thoracic aortic calcification is associated with obstructive CAD.

Methods

We evaluated 99 patients who underwent both coronary angiography and electron beam tomography (EBT) coronary scanning. We identified the presence, absence, and amount of calcification in the aortic valve (AVC), mitral annulus (MAC), descending aorta (DAC), and ascending aorta (AAC). The extent of CAD was graded according to the number of vessels diseased (VD).

Results

Patients with multivessel disease (MVD) had a higher proportion of DAC. The presence of DAC significantly increased the specificity of EBT to detect CAD (58% with a calcium score >0 to 88% for calcium score>0 and DAC >0, P < .001). Both AAC and DAC were associated with a significantly higher rate of MVD in women (DAC, 63% in MVD vs 19% without, P < .01.; AAC, 65% vs 22%, P < .05). MAC had no relationship to either stenosis severity or the presence of obstructive CAD. AVC was the strongest predictor of the severity of CAD and predicted the presence of 3-vessel disease.

Conclusion

AVC and thoracic aortic calcification as detected with EBT are associated with the angiographic extent and severity of CAD and add incremental diagnostic value to the coronary artery calcium score. MAC does not add incremental value. (Am Heart J 2003;145:xxx-xxx.)     

Is serum cystatin-C a reliable marker for metabolic syndrome?

Purpose

Chronic kidney disease and metabolic syndrome are recognized as major cardiovascular risk factors. It has been shown that cystatin C has a stronger association with mortality risk than creatinine-based estimations of glomerular filtration rate. We measured cystatin values in dyslipidemic patients and looked for correlations between renal function, cystatin, and metabolic syndrome.

Methods

There were 925 dyslipidemic patients prospectively included in this cross-sectional study and evaluated over 10 months. Each visit included clinical and biological assessment.

Results

Most patients exhibited cardiovascular risk factors other than dyslipidemia: hypertension in 34%, diabetes in 11%, and smoking in 18%. Mean triglycerides were 149 ± 136 mg/dL, mean high-density lipoprotein cholesterol 54 ± 14 mg/dL, and low-density lipoprotein 167 ± 48 mg/dL. Metabolic syndrome was present in 238 (26%) patients. Plasma creatinine did not differ between control group and metabolic syndrome patients (80 ± 26 vs 82 ± 20 μmol/L, respectively, P = .2), but creatinine clearance evaluated by abbreviated Modification of Diet in Renal Disease Study formula was lower in the metabolic syndrome group than in the non-metabolic-syndrome group (83.3 ± 18.8 mL/min/1.73m² vs 86.8 ± 16.9 mL/min/1.73m², respectively, P <.007). Cystatin value was significantly higher in metabolic syndrome patients than in others (0.86 ± 0.23 vs 0.79 ± 0.20 mg/L, respectively, P <.0001), independently of serum creatinine level and creatinine clearance. Furthermore, there was a progressive increase in cystatin, as a function of the number of metabolic syndrome components.

Conclusions

Our study shows that cystatin is associated with metabolic syndrome in dyslipidemic patients. Cystatin may be an interesting marker of metabolic syndrome and of increased cardiovascular and renal risk.     

Mucosal healing for predicting clinical outcome in patients with ulcerative colitis using thiopurines in monotherapy

Background

Mucosal healing (MH) has emerged as a desirable treatment goal for patients with ulcerative colitis (UC). Currently little is known about the efficacy of using thiopurine immunosuppressants in monotherapy to achieve and maintain long-term MH in UC. This study analyzes the efficacy and the clinical impact of MH in patients with UC responded to thiopurine immunosuppressants in the long term.

Methods

An open, observational, cohort study in 20 patients with UC had been in clinical remission in monotherapy with thiopurine immunosuppressants for at least 1 year. MH was assessed by endoscopy. The patients according to the Mayo Endoscopic Score (0 vs 1 and 2), were followed until the end of the study or patient relapse. (according to Truelove and Witts criteria).

Results

Mean treatment time was 5.4 years. Twelve (60%) patients presented a Mayo Endoscopic Score of 0. A total of 18 patients were followed up for a median of 27.1 months. After endoscopy, 4 patients (22.2%) presented relapse, with a mean time of 27.5 months for a score ≥ 1 (95% CI; 18.2-36.8) versus 54.3 months for a score = 0 (95% CI 47.2-61.3) (p = 0.032).

Conclusions

This study shows the efficacy of thiopurine immunosuppressants in achieving mucosal healing in patients who respond to thiopurine immunosuppressants in the long term. We also observe the presence of endoscopy activity is not a rare event in this group of patients and is a predictor of early relapse.     

Prognostic utility of NT-proBNP in acute exacerbations of chronic pulmonary diseases

Background

The prognostic value of NT-proBNP levels in patients admitted to hospital due to acute exacerbations of chronic pulmonary diseases (CPDs) is unknown.

Setting

Internal Medicine units at two general hospitals.

Methods

NT-proBNP levels were obtained within 72 h after admission in 192 consecutive patients with acute exacerbations of CPDs and no history of heart failure or diuretic treatment. Clinical characteristics and main outcomes were assessed over a 12-month follow-up. NT-proBNP cut-points for outcomes were obtained by ROC (receiver operating characteristics) curve analysis.

Results

Chronic obstructive lung disease (69.3%) and chronic asthma (22.4%) were the most prevalent CPDs, and non-pneumonic acute respiratory infection (72.4%) and pneumonia (22.9%) were the most frequent causes of exacerbation. Atrial flutter or fibrillation rate was 11%. During the one-year follow-up period, 22 patients died, 42 were re-admitted, 46 received new long-term oxygen therapy, and 39 received new diuretic treatment.NT-proBNP values correlated with hospitalisation days. NT-proBNP values over 587.9 pg/ml were associated with significantly raised one-year mortality (OR = 3.90; 95% IC 1.46-10.47; p = 0.006) and over 782.2 pg/ml with cardio-pulmonary deaths (OR = 6.38; 95% IC 1.91-21.3; p = 0.002). That association persisted after adjustment for age, gender, creatinine levels and cardiac rhythm. NT-proBNP values over 628.7 pg/ml were associated with significantly higher probability of new diuretic treatment (OR = 4.38; IC 95% 2.07-9.25; p < 0.001). The negative predictive values for these cut-points ranged from 89% to 97%.

Conclusion

NT-proBNP levels below 587.9 pg/ml in patients with acute exacerbations of CPD were associated with favourable one-year outcomes.     

Biochemical and ultrasound parameters may help predict the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with a firm clinical and biochemical suspicion for choledocholithiasis

Background

Prediction of the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected choledocholithiasis (CDL) remains a challenging task.

Aims

We aimed to evaluate the predictive value of biochemical and ultrasound parameters and to create a corresponding model for prediction of the need for therapeutic ERCP.

Methods

203 consecutive patients referred to our center due to a firm clinical and/or biochemical suspicion for CDL. All patients underwent ERCP. Biochemical and ultrasound variables were analyzed.

Results

The sample was divided into testing group (103; 50.7%) and validation group (100; 49.3%) which did not differ in their baseline characteristics. Elevated gamma glutamil transaminase (GGT), common bile duct (CBD) diameter and presence of hyperechoic structures in CBD were found to be significant predictors for presence of CBD stones on ERCP (p < 0.05) in the testing group. We used these variables to construct a predictive model for the presence of CBD stones on ERCP. The model was tested on a second, validation group of patients using ROC analysis with the area under the ROC curve of 0.81 (%95 CI = 0.75-0.86; p < 0.001). We identified a threshold (0.86) above which, patients had a high probability (93.1%) for the need for interventional ERCP.

Conclusion

Our predictive model may help predict the need for therapeutic ERCP in patients with a suspicion for choledocholithiasis.     

冠心病患者血清可溶性E-选择素检测的意义

目的　探讨血清可溶性E 选择素在监测冠心病病情及与冠状动脉病变程度的关系。方法　 81例冠心病患者 ,按临床诊断分为 4组 :急性心肌梗死 (AMI) 17例、不稳定性心绞痛 (UAP) 2 4例、稳定性心绞痛 (SAP) 2 0例和对照组患者 2 0例。检测各组患者血清可溶性E 选择素的水平 ,并比较各组间的差异。对冠心病患者的冠状动脉损害行Gensini评分 ,并与其血清可溶性E 选择素水平进行直线相关分析。结果　 (1)AMI组、UAP组及SAP组的血清可溶性E 选择素水平比对照组高 ;(2 )AMI组、UAP组可溶性E 选择素水平和SAP组相比 ,其值增加明显 ;AMI组和UAP组结果相似 ;(3)急性冠脉综合征 (AMI组 +UAP组 )血清可溶性E 选择素水平与冠状动脉Gensini评分呈正相关。结论　血清可溶性 E选择素可能是冠状动脉粥样硬化的标志 ,参与了冠心病的发病过程 ,在急性冠脉综合征中 ,其值与冠状动脉病变程度密切相关。     

Association of serum uric acid with body mass index among long-lived Chinese

Objectives

To examine the individual association between BMI and level of serum uric acid (SUA) among the very elderly Chinese population.

Methods

A survey was conducted on 870 long-lived subjects (aged ≥ 90 years). Subjects were divided into four groups according to quartile of BMI (< 16.6, 16.6–18.9, 18.9–21.1, ≥ 21.1 kg/m²) and to classification criteria of underweight, normal weight, overweight and obesity in BMI (< 18.5, 18.5–23.0, 23.0–27.5, ≥ 27.5 kg/m², respectively). Subjects were also divided into hyperuricemia and normal SUA groups.

Results

The sample included 661 unrelated Chinese. The mean age was 93.52 ± 3.29 years (range 90–108 years). The mean level of BMI was 19.16 ± 3.47 kg/m² and mean SUA was 318.72 ± 87.01. Compared to individuals without hyperuricemia, high level of SUA was associated with a higher level of BMI in both genders (p < 0.001). According to the both BMI classification criteria, the group with higher BMI had higher level of SUA (p < 0.001). Pearson correlation showed that SUA was significantly correlated with BMI (with coefficients r = 0.235, 0.140, in men and women, respectively). Unadjusted and adjusted multiple logistic regressions showed that odds ratios for hyperuricemia were associated with BMI according to quartile of BMI.

Conclusions

We found that among long-lived Chinese subjects, higher levels of SUA may be associated with higher BMI.     

Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients

Purpose

To evaluate the effectiveness of home temperature monitoring to reduce the incidence of foot ulcers in high-risk patients with diabetes.

Methods

In this physician-blinded, 18-month randomized controlled trial, 225 subjects with diabetes at high risk for ulceration were assigned to standard therapy (Standard Therapy Group) or dermal thermometry (Dermal Thermometry Group) groups. Both groups received therapeutic footwear, diabetic foot education, regular foot care, and performed a structured foot inspection daily. Dermal Thermometry Group subjects used an infrared skin thermometer to measure temperatures on 6 foot sites twice daily. Temperature differences >4°F between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized.

Results

A total of 8.4% (n = 19) subjects ulcerated over the study period. Subjects were one third as likely to ulcerate in the Dermal Thermometry Group compared with the Standard Therapy Group (12.2% vs 4.7%, odds ratio 3.0, 95% confidence interval, 1.0 to 8.5, P = .038). Proportional hazards regression analysis suggested that thermometry intervention was associated with a significantly longer time to ulceration (P = .04), adjusted for elevated foot ulcer classification (International Working Group Risk Factor 3), age, and minority status. Patients that ulcerated had a temperature difference that was 4.8 times greater at the site of ulceration in the week before ulceration than did a random 7 consecutive-day sample of 50 other subjects that did not ulcerate (3.50 ± 1.0 vs 0.74 ± 0.05, P = .001).

Conclusions

High temperature gradients between feet may predict the onset of neuropathic ulceration and self-monitoring may reduce the risk of ulceration.     

Change of multiple complex coronary plaques in patients with acute myocardial infarction: a study with coronary angiography

Background

Patients with acute myocardial infarction (AMI) may have multiple complex coronary plaques that are not limited to the culprit lesions. However, it is unknown whether they tend to progress in severity, regress, or remain stable. The aim of this angiographic study is to evaluate the natural history of these lesions.

Methods

We consecutively enrolled 229 patients who underwent coronary angiography at the time of their hospitalization to treat AMI with primary angioplasty. Baseline and follow-up (mean follow-up duration, 192 ± 33 days) coronary angiographic data in patients with multiple complex coronary plaques characterized by thrombus, ulceration, plaque irregularity, and impaired flow were compared.

Results

Single complex coronary plaques were identified in 167 patients (73%), and multiple complex plaques were identified in the other 62 patients (27%). Among the patients with multiple complex plaques (62 patients, 83 non-culprit complex plaques), the angiographic examinations were reviewed simultaneously in 43.5% (27 patients, 35 non-culprit complex plaques). Of 35 non-culprit complex lesions, 29 lesions (82%) remained complex without changing into smooth lesions, 1 lesion became totally occluded, and 4 lesions regressed. The severity of non-culprit complex lesions between baseline and follow-up angiography is equal (maximal diameter stenosis, 74% ± 15% vs 72% ± 15%, P = .4). Long-term cardiac events after discharge were more likely to develop in patients with multiple complex plaques than in patients with single complex plaques (24% vs 10%, respectively; P <.01).

Conclusions

In patients with AMI, little angiographic change occurred during 6 months of follow-up in the non-culprit complex plaques.     

Oxidized low-density lipoprotein levels circulating in plasma and deposited in the tissues: comparison between Helicobacter pylori-associated gastritis and acute myocardial infarction

Background

Oxidized low-density lipoprotein (ox-LDL) is a key factor in the progression of atherosclerosis. We developed a sensitive method for measuring plasma ox-LDL levels using a novel anti-ox-LDL antibody. Recently, several studies have shown positive associations between Helicobacter pylori (H pylori) infection and coronary heart disease. Thus the question arises whether an increase in the plasma levels of ox-LDL occurs in patients with H pylori gastritis.

Methods

We measured plasma ox-LDL levels in patients with H pylori gastritis (n = 27) and compared them with those in patients with acute myocardial infarction (AMI) (n = 62) and stable angina pectoris (SAP; n = 63) and those in control subjects (n = 64). In addition, ox-LDL localization and the presence of macrophages and neutrophils were studied immunohistochemically in gastritis specimens and in coronary culprit lesions obtained from patients with AMI.

Results

Plasma ox-LDL levels in patients with AMI were significantly higher than those in patients with SAP (P <.0001), patients with H pylori gastritis (P <.0001), or in control subjects (P <.0001; AMI, 1.34 ± 0.95; SAP, 0.61 ± 0.29; Gastritis, 0.53 ± 0.17; control, 0.57 ± 0.23 ng/5μg LDL protein). Immunohistochemically, H pylori gastritis specimens showed distinct infiltration of macrophages and myeloperoxidase-positive neutrophils; however, ox-LDL localization was not detected. In contrast, coronary culprit plaques revealed strong positivity for ox-LDL in ruptured lipid cores with abundant macrophage-derived foam cells, and these plaques also contained myeloperoxidase-positive neutrophils.

Conclusion

Our results suggest that plasma ox-LDL levels do not seem to be associated with H pylori infection, but do relate to coronary plaque instability in AMI.     

Pericardial fat is associated with carotid stiffness in the Multi-Ethnic Study of Atherosclerosis

Background and aims

Arterial stiffness is a prominent feature of vascular aging and a risk factor for cardiovascular disease (CVD). Fat around the heart and blood vessels (i.e. pericardial fat, Pfat) may contribute to arterial stiffness via a local paracrine effect of adipose tissue on the surrounding vasculature. Thus, we determined the association between Pfat and carotid stiffness in 5770 participants (mean age 62 years, 53% female, 25% African American, 24% Hispanic, and 13% Chinese) from the Multi-Ethnic Study of Atherosclerosis.

Methods and results

Pfat was measured by computed tomography, and ultrasonography of the common carotid artery was used to calculate the distensibility coefficient (DC) and Young's modulus (YM). Lower DC and higher YM values indicate stiffer arteries. Pfat quartile was highly associated with demographic, behavioral, anthropometric, hemodynamic, metabolic, and disease variables in both men and women. After adjusting for height, clinical site, CVD risk factors, and medications, a 1 standard deviation (41.91 cm³) increment in Pfat was associated with a 0.00007 ± 0.00002 1/mmHg lower DC (p = 0.0002) in men and a 48.1 ± 15.1 mmHg/mm higher YM in women (p = 0.002). Additional adjustment for C-reactive protein, coronary artery calcification, and carotid intima-media thickness had only modest effects. More importantly, adjusting for body mass index and waist circumference did not significantly change the overall results.

Conclusion

Higher Pfat is associated with higher carotid stiffness, independent of traditional CVD risk factors and obesity.     

Role of occult hepatitis B virus in chronic hepatitis C patients with flare of liver enzymes

Background

Occult HBV infection is defined by detection of HBV DNA in the serum or liver tissue of patients who test negative for HBsAg. The prevalence of occult HBV is higher in hepatitis C virus (HCV) positive patients than HCV negative patients and may have an impact on their clinical outcome. In this study, we evaluated the role of occult hepatitis B virus infection in chronic hepatitis C patients with ALT flare.

Methods

Sixty HBsAg negative patients with chronic hepatitis C virus infection were included. Patients were divided into 2 groups according to their ALT level: 30 patients with normal or slightly high ALT and 30 patients with ALT flare (≥ 5 times normal values). Patients in both groups were examined for the detection of anti-HBs, anti-HBc IgM, and anti-HBc IgG. HBV DNA was detected using semi-nested PCR technique.

Results

In patients with normal or slightly high ALT, HBV DNA was detected in 4 (13.3%) patients, while in those with ALT flare, HBV DNA was detected in 19 (63.3%) patients (p < 0.001). No association was found between the presence of HBV DNA and various serology markers of HBV infection.

Conclusion

Presence of occult hepatitis B, with its added deleterious effect, must always be considered in chronic hepatitis C patients especially those with flare in liver enzymes; HBsAg should not be used alone for the diagnosis of HBV infection.