Physical and mental health status of older long-term cancer survivors

OBJECTIVES: To assess the physical and mental health status of older long-term cancer survivors. DESIGN: Cohort study using propensity score methods to control for baseline differences between cancer survivors and controls. SETTING: General community population in the United States. PARTICIPANTS: Nine hundred sixty-four cancer patients who had survived for more than 4 years and 14,333 control patients who had never had cancer from a population-based sample of Americans aged 55 and older responding to the 2002 Health and Retirement Study. MEASUREMENTS: Medical conditions, symptoms, health behaviors, health status, mobility, activities of daily living, mental health diagnoses, self-rated memory, depressive symptoms, cognitive function, and self-reported life expectancy. RESULTS: Cancer survivors reported higher rates of lung disease (13.9% vs 9.6%; P=.001), heart condition (29.3% vs 22.9%; P<.001), arthritis (69.4% vs 59.4%; P<.001), incontinence (26.6% vs 19.7%; P=.001), frequent pain (36.4% vs 29.4%; P=.005), and obesity (27.0% vs 24.2%; P=.001) than individuals without cancer but lower rates of smoking (12.0% vs 14.8%; P=.03). Cancer survivors were less likely than persons without cancer to report excellent or very good health status (37.2% vs 44.6%; P<.001) and had more mobility (P<.001) and activity of daily living (P=.01) limitations. Cancer survivors did not differ from persons without cancer in rates of depression or cognitive function (both P>.2) but were less optimistic about their life expectancy (P=.004). CONCLUSION: The physical health status of older long-term cancer survivors is somewhat worse than that of comparable persons who have never had cancer, but they have surprisingly similar mental health status. Future research is needed to understand factors contributing to poorer health status and identify patients at highest risk of long-term cancer-related problems.     

Risk of cognitive decline in older patients after carotid endarterectomy: an observational study

OBJECTIVES: To determine whether patients undergoing carotid endarterectomy (CE) for symptomatic left internal carotid artery (LICA) stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right internal carotid artery (RICA) disease. DESIGN: Observational. SETTING: Vascular surgery day hospital. PARTICIPANTS: The analysis included 103 patients (mean age 72.6+/-7.0, 73 men), of whom 50 had LICA disease (29 symptomatic). MEASUREMENTS: Cognitive function was evaluated (age- and education-adjusted Mini-Mental State Examination (MMSE), and Clock tests (CLOX1 and 2)) at baseline and at the end of the study period (average follow-up+/-standard deviation 44.4+/-14.3 months) in a sample of patients aged 65 and older, free from cognitive impairment, consecutively undergoing CE. RESULTS: At the end of the study period, MMSE, CLOX1, and CLOX2 scores were significantly lower in patients with symptomatic LICA disease (P<.001, P<.001, and P=.002, respectively) and not in the other groups of patients. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals according to MMSE score (F=5.18, P=.002) or CLOX1 and 2 scores (F=5.66, P=.001, and F=4.33, P=.006, respectively). CONCLUSION: Patients undergoing CE for symptomatic LICA disease appear to be at greater risk of cognitive decline than other subjects. These findings suggest that future studies should evaluate the effects on cognitive function of different timing for CE in patients with LICA and RICA disease.     

Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study

BACKGROUND: The incidence of congestive heart failure (CHF) has been increasing steadily in the United States during the past 2 decades. We studied risk factors for CHF and their corresponding attributable risk in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. PARTICIPANTS AND METHODS: A total of 13 643 men and women without a history of CHF at baseline examination were included in this prospective cohort study. Risk factors were measured using standard methods between 1971 and 1975. Incidence of CHF was assessed using medical records and death certificates obtained between 1982 and 1984 and in 1986, 1987, and 1992. RESULTS: During average follow-up of 19 years, 1382 CHF cases were documented. Incidence of CHF was positively and significantly associated with male sex (relative risk [RR], 1.24; 95% confidence interval [CI], 1.10-1.39; P<.001; population attributable risk [PAR], 8.9%), less than a high school education (RR, 1.22; 95% CI, 1.04-1.42; P =.01; PAR, 8.9%), low physical activity (RR, 1.23; 95% CI, 1.09-1.38; P<.001; PAR, 9.2%), cigarette smoking (RR, 1.59; 95% CI, 1.39-1.83; P<.001; PAR, 17.1%), overweight (RR, 1.30; 95% CI, 1.12-1.52; P =.001; PAR, 8.0%), hypertension (RR, 1.40; 95% CI, 1.24-1.59; P<.001; PAR, 10.1%), diabetes (RR, 1.85; 95% CI, 1.51-2.28; P<.001; PAR, 3.1%), valvular heart disease (RR, 1.46; 95% CI, 1.17-1.82; P =.001; PAR, 2.2%), and coronary heart disease (RR, 8.11; 95% CI, 6.95-9.46; P<.001; PAR, 61.6%). CONCLUSIONS: Male sex, less education, physical inactivity, cigarette smoking, overweight, diabetes, hypertension, valvular heart disease, and coronary heart disease are all independent risk factors for CHF. More than 60% of the CHF that occurs in the US general population might be attributable to coronary heart disease.     

An 18-year follow-up of overweight and risk of Alzheimer disease

BACKGROUND: Overweight and obesity are epidemic in Western societies and constitute a major public health problem because of adverse effects on vascular health. Vascular factors may play a role in the development of a rapidly growing disease of late life, Alzheimer disease (AD). Using body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), we examined whether overweight is a risk factor for dementia and AD. METHODS: The relationship between BMI and dementia risk was investigated in a representative cohort of 392 nondemented Swedish adults who were followed up from age 70 to 88 years, with the use of neuropsychiatric, anthropometric, and other measurements. Multivariate Cox proportional hazards regression analyses included BMI, blood pressure, cardiovascular disease, cigarette smoking, socioeconomic status, and treatment for hypertension. RESULTS: During the 18-year follow-up (4184.8 risk-years), 93 participants were diagnosed as having dementia. Women who developed dementia between ages 79 and 88 years were overweight, with a higher average BMI at age 70 years (27.7 vs 25.7; P =.007), 75 years (27.9 vs 25.0; P<.001), and 79 years (26.9 vs 25.1; P =.02) compared with nondemented women. A higher degree of overweight was observed in women who developed AD at 70 years (29.3; P =.009), 75 years (29.6; P<.001), and 79 years (28.2; P =.003) compared with nondemented women. For every 1.0 increase in BMI at age 70 years, AD risk increased by 36%. These associations were not found in men. CONCLUSIONS: Overweight is epidemic in Western societies. Our data suggest that overweight at high ages is a risk factor for dementia, particularly AD, in women. This may have profound implications for dementia prevention.     

Sex hormones and cognitive function in older men

OBJECTIVES: Recent studies have suggested that estrogen may improve cognitive function or prevent cognitive decline in older women. Little research has been conducted on exogenous or endogenous sex hormones and cognition in older men, yet it has been hypothesized that testosterone, either directly or by conversion to estrogens, may improve cognitive function. We investigated whether serum level of testosterone and estradiol is associated with cognition in older community-dwelling men. DESIGN: A cross-sectional study. SETTING: Population-based listings in the Monongahela Valley near Pittsburgh, Pennsylvania. PARTICIPANTS: Three hundred ten men (mean age +/- standard deviation = 73.0 +/- 7.1) who were part of a cohort study. MEASUREMENTS: We measured cognitive function using the Mini-Mental State Examination (MMSE), Trails B, and Digit Symbol. Sex hormone levels were determined by radioimmunoassay from serum obtained at the time of cognitive testing and analyzed by tertile. RESULTS: No consistent association between total testosterone level and cognitive test scores was observed. However, men with high bioavailable (loosely protein-bound) testosterone had better cognitive test scores on all three tests (P < or =.001). Total estradiol levels were associated with worse cognitive scores on Digit Symbol (P <.001) and Trails B (P =.002), but bioavailable estradiol levels were not associated with cognitive function. Level of sex hormone binding globulin (SHBG) was negatively associated with cognitive scores on all three tests (P < or =.001). After adjusting for age and education, the statistical significance lessened for bioavailable testosterone (MMSE, P =.086; Digit Symbol, P =.047; Trails B, P =.076) and became nonsignificant for SHBG (all cognitive tests P>.10). CONCLUSIONS: Our findings support the hypothesis that higher levels of bioavailable testosterone, but not of bioavailable estradiol, are associated with better cognitive function in older men. In addition, bioavailable measures of testosterone may better reflect hormone levels available to the brain and thus be more closely associated with central nervous system outcomes such as cognition. Future studies, especially randomized trials, should be undertaken to determine whether testosterone may protect against cognitive decline in older men.     

Metabolic syndrome and cognitive decline in elderly Latinos: findings from the Sacramento Area Latino Study of Aging study

OBJECTIVES: To investigate the effect of metabolic syndrome on cognitive function in an elderly Latino population and to determine whether inflammation modifies this association. DESIGN: A longitudinal cohort study. SETTING: Sacramento area and the surrounding California counties from 1998 to 1999. PARTICIPANTS: One thousand six hundred twenty-four Latinos aged 60 and older who participated in the Sacramento Area Latino Study of Aging. MEASUREMENTS: Baseline metabolic syndrome was calculated using the Third Adult Treatment Panel of the National Cholesterol Education Program. Cognitive function was measured using the Modified Mini-Mental State Examination (3MS) and the Delayed Word-List Recall (DelRec), a verbal memory test. The effect of metabolic syndrome on cognitive change scores was examined using random effects models; in addition, the effect of the individual components of the syndrome on cognitive change was examined. RESULTS: Of the 1,624 participants, 718 (44%) had metabolic syndrome at baseline. Those with metabolic syndrome had worse 3-year change scores on 3MS (P=.04) and DelRec (P=.03). Multivariate adjustment attenuated the results for DelRec but not for 3MS. This association was especially pronounced in participants with a high serum level of inflammation, resulting in an average 3MS score 0.64 points lower per year (P=.03) for those with metabolic syndrome. Individual components of metabolic syndrome were not associated with cognitive decline except for elevated glucose on the DelRec (P=.02) and high blood pressure on 3MS (P=.05). CONCLUSION: Metabolic syndrome and inflammation may both contribute to cognitive decline in older people of diverse backgrounds. The results also suggest that, in elderly Latinos, the composite measure of metabolic syndrome is a greater risk for cognitive decline than its individual components.     

Mild cognitive deterioration with subcortical features: prevalence,clinical characteristics,and association with cardiovascular risk factors in community-dwelling older persons (The InCHIANTI Study)

OBJECTIVES: To identify subjects with minimal or mild nonamnestic cognitive impairment with parkinsonian stance and gait and investigate vascular correlates of this condition. DESIGN: First wave of an epidemiological longitudinal study (InCHIANTI) on factors predicting loss of mobility in older persons. SETTING: The Chianti geographic area (Tuscany, Italy). PARTICIPANTS: Five hundred fifty-six subjects aged 70 to 90 with Mini-Mental State Examination (MMSE) scores greater than 23 of 30, of the 1,260 persons aged 65 and older randomly selected from the population registry of Greve in Chianti and Bagno a Ripoli, two small towns near Florence. METHODS: Low cognitive performance (LCP) was defined as an age- and education-adjusted MMSE below the 50th percentile for the InCHIANTI population. Subcortical features were plastic rigidity on neurological examination (parkinsonism), gait disturbance (small-step gait or parkinsonian gait), and dysexecutive features. Two hundred forty-three participants had high cognitive performance, 166 had LCP without subcortical features, and 75 had LCP with subcortical features. Vascular risk factors were hypertension, atrial fibrillation or pathological findings on electrocardiogram (ECG), low serum high-density lipoprotein (HDL) or high low-density lipoprotein cholesterol, diabetes mellitus, obesity, and heavy smoking. RESULTS: Three main vascular risk factors were significantly more prevalent in LCP with subcortical features: hypertension (P =.02), atrial fibrillation or ECG changes (P =.04), and low HDL cholesterol (P =.001). LCP with subcortical features was significantly associated with cerebrovascular risk factors (P =.001). CONCLUSION: Gait disturbance and nonamnestic cognitive symptoms might be the consequence of subcortical vascular damage.     

Prevalence of diabetic complications in fibrocalculous pancreatic diabetic patients and type 2 diabetic patients: a cross-sectional comparative study

OBJECTIVE: To determine the prevalence of diabetes-related complications in subjects with fibrocalculous pancreatic diabetes (FCPD) and compare them with subjects with type 2 diabetes mellitus matched for age, sex, and duration of diabetes. METHODS: The study group comprised of 277 FCPD patients and 277 age, sex, and duration of diabetes-matched type 2 diabetic patients. All the study subjects underwent a detailed clinical examination, and fasting blood samples were obtained for biochemical studies. Peripheral Doppler was used for diagnosis of peripheral vascular disease (PVD). Vibratory perception threshold (VPT) was determined using biothesiometry for diagnosis of neuropathy. Diagnosis of coronary artery disease (CAD) was based on medical history and 12-lead resting ECG. Retinal photographs were used for diagnosis of retinopathy using a modified version of Early Treatment Diabetic Retinopathy Study (ETDRS) grading system. RESULTS: FCPD patients had lower body mass index (BMI) (P<.001), systolic blood pressure (P<.0001), diastolic blood pressure (P<.001), serum cholesterol (P<.001), serum triglyceride (P<.001), and serum creatinine (P<.01) but higher glycosylated hemoglobin (P<.001) levels compared to patients with type 2 diabetes. Prevalence of CAD was significantly higher among type 2 diabetic patients (11.9%) compared to FCPD patients (5.1%), P<.003. There was no significant difference in the prevalence of other diabetic complications between the two study groups (type 2 diabetes vs. FCPD: retinopathy-37.2% vs. 30.1%, PVD-4.3% vs. 4.7%, Neuropathy-25.3% vs. 20.9%, Nephropathy-15.0% vs. 10.1%). Multiple logistic regression analysis revealed the following risk factors for diabetes complications among type 2 diabetic subjects-retinopathy: BMI (P=.028), duration of diabetes (P<.001), and glycosylated hemoglobin (P=.026); nephropathy: diastolic blood pressure (P=.016) and glycosylated hemoglobin (P=.040); neuropathy: age (P<.001), duration of diabetes (P=.003), and glycosylated hemoglobin (P=.001). Among subjects with FCPD, systolic blood pressure (P=.013), glycosylated hemoglobin (P=.021), and duration of diabetes (P<.001) were associated with retinopathy; BMI (P=.057), glycosylated hemoglobin (P=.010), and duration of diabetes (P=.024) with nephropathy and age (P=.011) and BMI (P=.010) with neuropathy. Conclusion: The prevalence of retinopathy, nephropathy, neuropathy, and PVD was similar among FCPD patients and type 2 diabetic patients, but the prevalence of CAD was lower among FCPD patients.     

Insulinlike Growth Factor-1, Insulinlike Growth Factor Binding Protein-1, and Cognitive Function in Older Men and Women

OBJECTIVES: To assess the association between insulinlike growth factor (IGF)-1 and IGF binding protein (IGFBP)-1 with three cognitive function tests in a healthy elderly population.
DESIGN: Cross-sectional analyses from the Rancho Bernardo Cohort Study.
SETTING: Southern California community of Rancho Bernardo.
PARTICIPANTS: Men (n=636) and women (n=899) from the Rancho Bernardo study (median age 74) were assessed between 1988 and 1992 for cognitive function using the Mini-Mental State Examination (MMSE), Verbal Fluency (VF) test, and Trail-Making Test Part B (Trails B). Blood samples were obtained at the same time for IGF-1 and IGFBP-1 levels. The association between biomarkers and cognitive function tests was assessed by dichotomizing tests at the clinically relevant cutoff using logistic regression and according to tertiles and continuous IGF-1 and IGFBP-1 levels using multivariate linear regression analyses.
RESULTS: The mean MMSE, VF and Trails B scores indicated better cognitive function with higher IGF-1 tertile. Multivariate analyses showed that VF and MMSE were each significantly associated with IGF-1 in a dose-response manner for men ( P for trend=.001), but no cognitive function tests were related to IGF-1 in women. For men, the highest IGFBP-1 tertile was inversely and significantly different from the lowest tertile for the MMSE test only ( P for trend=.02).
CONCLUSION: IGF-1 was independently and positively related to MMSE and VF in men, and IGFBP-1 was inversely associated with MMSE in men. Sex differences in the association should be further investigated.     

Use of medications and dietary supplements in later years among male former top-level athletes

BACKGROUND: The association between sports participation and later need of medications and dietary supplements is unknown. SUBJECTS AND METHODS: Male athletes (N = 2026) who had represented Finland in international events from 1920 through 1965 and 1401 control subjects who had been classified healthy at the age of 20 years participated in this population-based cohort study. MAIN OUTCOME MEASURES: The main outcome measures were reimbursable medications for hypertension, cardiac insufficiency, coronary heart disease, diabetes, and asthma identified from the national registry from 1970 through 1998 as well as the use of nonsteroidal anti-inflammatory drugs, antacids, and specific vitamin and mineral supplements for at least 60 days during the past year reported by questionnaire in 1985. RESULTS: Among former top-level athletes compared with controls, the probability of initiating medication was decreased for cardiac insufficiency (age-adjusted hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.50-0.74; P<.001), coronary heart disease (age-adjusted HR, 0.72; 95% CI, 0.58-0.89; P=.002), and asthma (age-adjusted HR, 0.47; 95% CI, 0.36-0.66; P<.001). Furthermore, the risk of initiation of treatment with regular medication for hypertension (age-adjusted HR, 0.73; 95% CI, 0.54-1.00; P=.046) and diabetes (age-adjusted HR, 0.38; 95% CI, 0.20-0.73; P=.004) was reduced for endurance athletes but not for power athletes. In 1985, compared with control subjects, athletes used fewer nonsteroidal anti-inflammatory drugs (age-adjusted odds ratio [OR], 0.48; 95% CI, 0.35-0.67; P<.001) and antacids (age-adjusted OR, 0.49; 95% CI, 0.31-0.77; P=.002) but more vitamin A (age-adjusted OR, 1.87; 95% CI, 1.24-2.82; P=.003), vitamin B (age-adjusted OR, 2.26; 95% CI, 1.64-3.12, P<.001), vitamin C (age-adjusted OR, 1.96; 95% CI, 1.45-2.63; P<.001), selenium (age-adjusted OR, 1.62; 95% CI, 1.15-2.28; P=.006), and iron (age-adjusted OR, 2.35; 95% CI, 1.33-4.15; P=.003) supplements. CONCLUSION: The need for long-term therapy for cardiac disease and asthma as well as for treatment with nonsteroidal anti-inflammatory drugs and antacids is reduced among former top-level athletes, but the use of dietary supplements is increased.     

Tissue velocity echocardiography shows early improvement in diastolic function with irbesartan and atenolol therapy in patients with hypertensive left ventricular hypertrophy. Results form the Swedish Irbesartan Left Ventricular Hypertrophy Investigation vs Atenolol (SILVHIA)

BACKGROUND: Abnormal diastolic function is common in hypertensive left ventricular hypertrophy (LVH). Early identification and treatment may prevent future cardiovascular events. METHODS: We examined 58 hypertensive patients with LVH, 38 with hypertension but no LVH, and 38 normotensive subjects. The effects of the AT1 receptor blocker irbesartan and the beta1 blocker atenolol on diastolic function during 48 weeks of treatment were evaluated in the LVH group by tissue velocity echocardiography (TVE). We measured basal septal and lateral wall velocities of early (Em) and late (Am) diastolic myocardial wall motion, Em velocity deceleration time (E-decm), and isovolumic relaxation time (IVRTm). For comparison, diastolic function was assessed by conventional mitral pulse wave Doppler echocardiography. RESULTS: Diastolic function was impaired in both hypertensive groups. Irbesartan and atenolol (week 48, septal wall) improved IVRTm (-44%, P<.001, and -19%, P<.001; P相似文献   

Characteristics associated with physician discipline: a case-control study

BACKGROUND: There has been increasing attention devoted to patient safety. However, the focus has been on system improvements rather than individual physician performance issues. The purpose of this study was to determine if there is an association between certain physician characteristics and the likelihood of medical board-imposed discipline. METHODS: Unmatched, case-control study of 890 physicians disciplined by the Medical Board of California between July 1, 1998, and June 30, 2001, compared with 2981 randomly selected, nondisciplined controls. Odds ratios (ORs) were calculated for physician discipline with respect to age, sex, board certification, international medical school education, and specialty. RESULTS: Male sex (OR, 2.76; P<.001), lack of board certification (OR, 2.22; P<.001), increasing age (OR, 1.64; P<.001), and international medical school education (OR, 1.36; P<.001) were associated with an elevated risk for disciplinary action that included license revocation, practice suspension, probation, and public reprimand. The following specialties had an increased risk for discipline compared with internal medicine: family practice (OR, 1.68; P =.002); general practice (OR, 1.97, P =.001); obstetrics and gynecology (OR, 2.25; P<.001); and psychiatry (OR, 1.87; P<.001). Physicians in pediatrics (OR, 0.62; P =.001) and radiology (OR, 0.36; P<.001) were less likely to receive discipline compared with those in internal medicine. CONCLUSION: Certain physician characteristics and medical specialties are associated with an increased likelihood of discipline.     

Dementia undiagnosed in poor older adults with functional impairment

OBJECTIVES: To identify variables associated with diagnosing dementia in poor older adults by comparing older people with dementia who were diagnosed by their primary care physicians (PCPs) with those not diagnosed by their PCP.
DESIGN: Observational study.
SETTING: Community-based, in-home cognitive assessment program.
PARTICIPANTS: Four hundred eleven adults aged 55 and older with cognitive impairment.
MEASUREMENTS: Instrumental activities of daily living (IADLs), activities of daily living (ADLs), Mini-Mental State Examination, Short Blessed Memory Orientation and Concentration Test, and Clinical Dementia Rating.
RESULTS: Alzheimer's disease was the most common diagnosis in this group of primarily African-American (73%) older people. Of the 411 participants, 232 (56%) were not diagnosed by their PCP. Participants without a previous diagnosis were older (mean age 81.7 vs 78.7, P =.01), more independent in IADLs ( P <.001), and more likely to live alone ( P =.001) than persons diagnosed by their PCP. Of the 201 who lived alone, 66% were not diagnosed with dementia by their PCP. Variables associated with PCP diagnosis were more severe cognitive impairment ( P <.001), spouse caregiver ( P =.009), younger age ( P =.02) and care from a university-based PCP ( P =.04).
CONCLUSION: Persons with dementia who were older and lived alone were less likely to be diagnosed by their PCP. Although persons not diagnosed by their PCP had less cognitive impairment, they had substantial impairment in activities, including handling finances, cooking, and managing medications.     

Use of the Minnesota Living With Heart Failure Quality of Life Questionnaire in Spain

INTRODUCTION AND OBJECTIVES: Quality of life is an important end-point in heart failure studies, as well as mortality and hospitalization rates. The Minnesota Living With Heart Failure Questionnaire is the instrument used most widely to evaluate quality of life in research studies. We used this questionnaire to evaluate quality of life in a general population attended by a heart failure unit in Spain. PATIENTS AND METHOD: 326 patients seen for the first time at the unit were evaluated. We analyzed the relationship between the questionnaire score and different clinical and demographic factors. RESULTS: The median global score on the Minnesota Living With Heart Failure Questionnaire was relatively low (28). We found a strong correlation (P<.001) between the score and functional class, sex (women had higher scores), and diabetes. We also found a correlation between the score and number of hospital admissions in the previous year (P<.001), anemia (P<.001) and etiology (P=.01), and a weak trend toward higher scores with increasing age (P=.04). The highest scores were observed in patients with valve disease disorders (43), and the lowest were seen in patients with alcoholic cardiomyopathy (20) and ischemic heart disease (24). We found no correlation with time of evolution of heart failure or with left ventricular ejection fraction. CONCLUSIONS: The scores on the Minnesota Living With Heart Failure Questionnaire in a general population attended by a heart failure unit in Spain were relatively low. However, we found a strong correlation between this score and functional class, and also between this score and number of admissions in the previous year. These results suggest that the questionnaire adequately reflects the severity of the disease.     

The relation between coronary flow rate, plasma endothelin-1 concentrations, and clinical characteristics in patients with normal coronary arteries

BACKGROUND: Coronary slow flow (CSF) is characterized by delayed opacification of epicardial arteries in the absence of occlusive disease. In the present study, we aimed to investigate the relation between coronary flow rate, plasma endothelin-1 (ET-1) concentrations, and clinical characteristics in patients with normal coronary arteries. METHODS: The study population included 77 patients with angiographically normal coronary arteries who underwent coronary angiography on suspicion of ischemic heart disease due to typical chest pain or ischemic findings on treadmill exercise test or myocardial scintigraphy. Based on the Thrombolysis In Myocardial Infarction frame count (TFC), patients were grouped into those with normal coronary flow and those with slow coronary flow. RESULTS: Forty-eight (61.5%) patients were found to have CSF. Plasma ET-1 concentrations were significantly higher with the presence of CSF (P=.03). There were significant differences between plasma ET-1 concentrations, and mean TFC, TFC for left anterior descending coronary artery (LAD), TFC for left circumflex coronary artery (CX), and TFC for right coronary artery separately in patients with and without CSF (P=.033, P<.001, P<.001, P<.001, and P<.001, respectively). Mean TFC, TFC for LAD, and TFC for CX, and ET-1 concentrations were significantly higher in smokers than in nonsmokers (P<.001, P<.001, P=.004, and P=.033, respectively). However, logistic regression analysis suggested that ET-1 concentration was not an independent determinant of CSF. CONCLUSIONS: Although there is a significant relation between ET-1 concentrations and coronary flow rate, ET-1 concentrations are not sufficient to determine the presence of CSF. Smoking is strongly associated with CSF, TFC, and increased ET-1 concentrations.     

The interplay between uric acid and antioxidants in relation to physical function in older persons

OBJECTIVES: To investigate the relationship between circulating uric acid (UA) levels and plasma antioxidants and whether antioxidant levels modulate the association between UA and physical function. DESIGN: Cross-sectional. SETTING: Community-based. PARTICIPANTS: Nine hundred sixty-six elderly persons participating in the baseline assessment of the Invecchiare in Chianti Study. MEASUREMENTS: UA, carotenoid, tocopherol, and selenium concentrations were assayed. Physical function was measured using the Short Physical Performance Battery (SPPB) and difficulties in instrumental activities of daily living (IADLs). Potential confounders were assessed using standardized methods. RESULTS: Total carotenoids (P=.008), in particular alpha-carotene (P=.02), lutein (P<.001), zeaxanthin (P<.001), lycopene (P=.07), cryptoxanthin (P=.29), and selenium (P=.04) were inversely associated with UA levels. Total tocopherols (P=.06) and alpha-tocopherol (P=.10) had a positive trend across UA levels. SPPB (P=.01) and IADL disability (P=.002) were nonlinearly distributed across the UA quintiles. Participants within the middle UA quintile (4.8-5.3 mg/dL) were less disabled in IADLs and had better SPPB scores than those in the extreme UA quintiles. There was a significant interaction between UA and selenium in the model predicting SPPB score (P=.02). CONCLUSION: UA levels are inversely associated with circulating carotenoids and selenium. Participants with intermediate UA levels had a higher prevalence of good physical functions, higher SPPB scores, and lower IADL disability. This study suggests that older subjects with intermediate UA levels may have an optimum balance between proinflammatory and antioxidant compounds that may contribute to better physical performance.     

Lower Glomerular Filtration Rate Is Associated With Higher Systemic Vascular Resistance in Patients Without Prevalent Kidney Disease

The authors examined the association between estimated glomerular filtration rate (eGFR), calculated using the Chronic Kidney Disease Epidemiology Collaboration creatinine‐cystatin C equation, and hemodynamics in 556 normotensive or never‐treated hypertensive patients without kidney disease (mean age, 46 years). Hemodynamic variables were recorded using pulse wave analysis and whole‐body impedance cardiography. The mean eGFR was 98 mL/min/1.73 m² (range, 64–145 mL/min/1.73 m² and one third of the patients had values below 92, while none had proteinuria. In linear regression analyses adjusted for differences in age, weight:height ratio, low‐density lipoprotein cholesterol, and sex, significant associations were found between lower eGFR and higher systolic (P=.001) and diastolic blood pressure (P<.001) and higher systemic vascular resistance (P=.001). There was no association between eGFR and cardiac output or extracellular volume. In the absence of clinical kidney disease, lower eGFR was associated with higher blood pressure and systemic vascular resistance. Therefore, early impairment in kidney function may be involved in the pathogenesis of essential hypertension.     

Cardiovascular disease risk factors in chronic kidney disease: overall burden and rates of treatment and control

BACKGROUND: Mild to moderate chronic kidney disease (CKD) is associated with increased risk for cardiovascular disease. The burden of cardiovascular disease risk factors in this setting is not well described. METHODS: We compared the age- and sex-adjusted prevalence of cardiovascular disease risk factors and their treatment and control among persons with and without CKD in 3258 Framingham offspring cohort members who attended the seventh examination cycle (1998-2001). Glomerular filtration rate (GFR) was estimated using the simplified Modification of Diet in Renal Disease Study equation. We defined CKD as a GFR of less than 59 mL/min per 1.73 m(2) in women and less than 64 mL/min per 1.73 m(2) in men. RESULTS: Those with CKD were older, more likely to be obese (33.5% vs 29.3%; P=.02), and more likely to have low levels of high-density lipoprotein cholesterol (45.2% vs 29.4%; P<.001) and high triglyceride levels (39.9% vs 29.8%; P<.001). Those with CKD had a higher prevalence of hypertension (71.2% vs 42.7%; P<.001) and hypertension treatment (86.0% vs 72.5%; P<.001), but were less likely to achieve optimal blood pressure control (27.0% vs 45.5%; P<.001). Participants with CKD had a higher prevalence of elevated low-density lipoprotein cholesterol levels (60.5% vs 44.7%; P=.06) and lipid-lowering therapy (57.1% vs 42.6%; P=.09), although this was not statistically significant. A greater proportion of individuals with CKD than those without had diabetes (23.5% vs 11.9%; P=.02) and were receiving diabetes treatment (63.6% vs 46.9%; P=.05), but were less likely to achieve a hemoglobin A(1c) level of less than 7% (43.8% vs 59.4%; P=.03). CONCLUSIONS: Chronic kidney disease is associated with a significant burden of cardiovascular disease risk factors in the community. The diagnosis of CKD should alert the practitioner to look for potentially modifiable cardiovascular risk factors.     

Gallstone disease and related risk factors in patients with Crohn disease: analysis of 330 consecutive cases

BACKGROUND: The reported prevalence of gallstone disease (GD), defined as current gallstones or previous cholecystectomy for gallstones, in patients with Crohn disease ranges from 13% to 34%. The aim of this study was to characterize the still undefined risk factors of this complication. METHODS: A total of 330 consecutive patients with Crohn disease (189 males and 141 females aged 17-82 years, mean +/- SD age, 41 +/- 14 years) underwent liver ultrasonography. RESULTS: A diagnosis of GD was made in 78 patients (24%), 54 with current gallstones and 24 who had undergone previous cholecystectomy. Its frequency was comparable in males and females (23% vs 25%), but was significantly associated with age (P =.001), being 13%, 36%, and 51% in patients aged 44 years and younger, 45 to 59 years, and 60 years and older, respectively (P =.001). Its prevalence significantly differed according to the site of the disease at diagnosis (P =.02) and was unrelated to disease duration. Gallstone disease was more frequent in patients who had undergone surgery (34% vs 14%; P =.001) and was significantly associated with the number (P =.001) and site of bowel resections (P =.001), increasing from 28% in the patients who had undergone 1 resection to 53% in those having had 2 or more resections (P =.005) and being significantly higher in patients with a resection involving the ileocecal region. Multivariate analysis showed that age; site of disease at diagnosis; and the presence, number, and site of bowel resections were significantly related to GD. CONCLUSIONS: In patients with Crohn disease, the frequency of GD is significantly higher than that reported in the general population with comparable characteristics (z = 5.04, P<.001). Age; site of disease at diagnosis; and the history, number, and site of bowel resections are independently associated with GD.     

Predictive value of clinic and ambulatory heart rate for mortality in elderly subjects with systolic hypertension

OBJECTIVE: To examine the association of clinic and ambulatory heart rate with total, cardiovascular, and noncardiovascular death in a cohort of elderly subjects with isolated systolic hypertension from the Systolic Hypertension in Europe Trial. METHODS: A total of 4682 patients participated, whose untreated blood pressure on conventional measurement at baseline was 160 to 219 mm Hg systolic and lower than 95 mm Hg diastolic. Clinic heart rate was the mean of 6 readings during 3 visits. Ambulatory heart rate was recorded with a portable intermittent technique in 807 subjects. RESULTS: Raised baseline clinic heart rate was positively associated with a worse prognosis for total, cardiovascular, and noncardiovascular mortality among the 2293 men and women taking placebo. Subjects with heart rates higher than 79 beats/min (bpm) (top quintile) had a 1.89 times greater risk of mortality than subjects with heart rate lower than or equal to 79 bpm (95% confidence interval, 1.33-2.68 bpm). In a Cox regression analysis, predictors of time to death were heart rate (P<.001), age (P<.001), serum creatinine level (P =.001), presence of diabetes (P =.002), previous cardiovascular disease (P =.01), triglyceride readings (P =.02), smoking (P =.04), and elevated systolic blood pressure (P =.05), while total cholesterol level was found to be nonsignificant in the model. In the ambulatory monitoring subgroup, clinic and ambulatory heart rates predicted noncardiovascular but not cardiovascular mortality. However, in a Cox regression analysis in which clinic and ambulatory heart rates were included, a significant association with noncardiovascular mortality was found only for clinic heart rate (P =.004). In the active treatment group, the weak predictive power of clinic heart rate for mortality disappeared after adjustment for confounders. CONCLUSIONS: In untreated older patients with isolated systolic hypertension, a clinic heart rate greater than 79 bpm was a significant predictor of all-cause, cardiovascular, and noncardiovascular mortality. Ambulatory heart rate did not add prognostic information to that provided by clinic heart rate.