Effectiveness of a Physical Activity and Weight Loss Intervention for Middle-Aged Women: Healthy Bodies,Healthy Hearts Randomized Trial

BACKGROUND

Physical inactivity is a significant risk factor for cardiovascular disease and remains highly prevalent in middle-aged women.

OBJECTIVE

We hypothesized that an interventionist-led (IL), primary-care–based physical activity (PA) and weight loss intervention would increase PA levels and decrease weight to a greater degree than a self-guided (SG) program.

DESIGN

We conducted a randomized trial.

PARTICIPANTS

Ninety-nine inactive women aged 45–65 years and with BMI ≥ 25 kg/m² were recruited from three primary care clinics.

INTERVENTIONS

The interventionist-led (IL) group (n = 49) had 12 weekly sessions of 30 min discussions with 30 min of moderate-intensity PA. The self-guided (SG) group (n = 50) received a manual for independent use.

MAIN MEASURES

Assessments were conducted at 0, 3, and 12 months; PA and weight were primary outcomes. Weight was measured with a standardized protocol. Leisure PA levels were assessed using the Modifiable Activity Questionnaire. Differences in changes by group were analyzed with a t-test or Wilcoxon rank-sum test. Mixed models were used to analyze differences in changes of outcomes by group, using an intention-to-treat principle.

KEY RESULTS

Data from 98 women were available for analysis. At baseline, mean (SD) age was 53.9 (5.4) years and 37 % were black. Mean weight was 92.3 (17.7) kg and mean BMI was 34.7 (5.9) kg/m². Median PA level was 2.8 metabolic equivalent hours per week (MET-hour/week) (IQR 0.0, 12.0). At 3 months, IL women had a significantly greater increase in PA levels (7.5 vs. 1.9 MET-hour/week; p = 0.02) than SG women; there was no significant difference in weight change. At 12 months, the difference between groups was no longer significant (4.7 vs. 0.7 MET-hour/week; p = 0.38). Mixed model analysis showed a significant (p = 0.048) difference in PA change between groups at 3 months only.

CONCLUSIONS

The IL intervention was successful in increasing the physical activity levels of obese, inactive middle-aged women in the short-term. No significant changes in weight were observed.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3077-5) contains supplementary material, which is available to authorized users.KEY WORDS: physical activity, exercise, clinical trial, intervention     

Predictors of acute myocardial infarct size in STEMI patients receiving thrombolytic therapy: A delayed contrast enhanced cardiac MRI study

Introduction

Delayed contrast enhanced Cardiac MRI has been accepted as a standard tool worldwide for determination of infarcted myocardium and viability. Infarct size as determined by cardiac MRI has important therapeutic and prognostic information.

Methods

Twenty six STEMI patients who had received thrombolytic therapy were subjected to cardiac MRI assessment at 5–7 day of admission. Base line variables of the study population were compared with the acute infarct size as determined by the Cardiac MRI.

Results

The mean acute infarct size in our study population was 27.2 ± 17.4% of LV. We found through univariate analysis that final infarct size was dependent on time to thrombolysis (p = 0.04), Status of Thrombolysis (p = 0.01), smoking status (p = 0.02), location of infarct (p < 0.00001), presence of microvascular obstruction (p = 0.01) and viability status (p = 0.0004). Thus, larger acute infarct size was seen in delayed time to thrombolysis, failed status of thrombolysis, smokers, anterior location of the infarct, presence of microvascular obstruction and non viable myocardial status.

Conclusion

Infarct size as determined by Cardiac MRI has been shown to carry important therapeutic and prognostic information. We have tried to evaluate predictors of acute infarct on cardiac MRI in STEMI patients during their initial hospital stay. Knowing the predictors of acute infarct size can help in early intervention and provide prognostic information for future cardiac events.     

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

Background

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

Methods

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

Results

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC– 20, IGBC – 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T_1b (n = 1), T₂ (n = 11) and T₃ (n = 8), respectively. The median lymph node yield was 10 (4–31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6–34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

Conclusion

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.     

Yoga based cardiac rehabilitation after coronary artery bypass surgery: One-year results on LVEF,lipid profile and psychological states – A randomized controlled study

Objective

To compare the long term effects of yoga based cardiac rehabilitation program with only physiotherapy based program as an add-on to conventional rehabilitation after coronary artery bypass grafting (CABG) on risk factors.

Methods

In this single blind prospective randomized parallel two armed active control study, 1026 patients posted for CABG at Narayana Hrudayalaya Institute of Cardiac Sciences, Bengaluru (India) were screened. Of these, 250 male participants (35–65 years) who satisfied the selection criteria and consented were randomized into two groups.Within and between group comparisons were done at three points of follow up (i.e. 6th week, 6th month, and 12th month) by using Wilcoxon''s signed ranks test and Mann Whitney U test respectively.

Results

Yoga group had significantly (p = 0.001, Mann Whitney) better improvement in LVEF than control group in those with abnormal baseline EF (<53%) after 1 year. There was a better reduction in BMI in the yoga group (p = 0.038, between groups) in those with high baseline BMI (≥23) after 12 months. Yoga group showed significant (p = 0.008, Wilcoxon''s) reduction in blood glucose at one year in those with high baseline FBS ≥110 mg/dl. There was significantly better improvement in yoga than the control group in HDL (p = 0.003), LDL (p = 0.01) and VLDL (p = 0.03) in those with abnormal baseline values. There was significantly better improvement (p = 0.02, between groups) in positive affect in yoga group. Within Yoga group, there was significant decrease in perceived stress (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), and negative affect (p = 0.03) while in the control group there was reduction (p = 0.003) only in scores on anxiety.

Conclusion

Addition of yoga based relaxation to conventional post-CABG cardiac rehabilitation helps in better management of risk factors in those with abnormal baseline values and may help in preventing recurrence.     

Do circulating blood cell types correlate with modifiable risk factors and outcomes in patients with acute coronary syndrome (ACS)?

Aims

Atherosclerosis is an inflammatory process with different cardiovascular risk factors (CVRFs) contributing to its pathogenesis. We aimed to evaluate the specific relationship between circulating blood leukocytes, troponin I and CVRFs.

Methods

We prospectively enrolled 959 patients with evidence of acute coronary syndrome either in form of unstable angina or STEMI or NSTEMI. Details demographic characteristics, CVRF and biochemical parameters such as total white blood cells (WBC), neutrophil, lymphocytes, platelet, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and troponin I were collected.

Results

The results indicated that patients having either hypertension, diabetes or smoking habit had significantly higher levels of total WBC (p = 0.013), neutrophil (p = 0.029), NLR (p = 0.029) and PLR (p = 0.009). The level of troponin I was unaffected by these risk factors. Significant association of hypertension was found with total WBC (p = 0.0392), lymphocytes (p = 0.0384) and PLR (p = 0.0027), whereas in diabetes and females all other leukocyte subtypes were significantly altered except for platelet and troponin I. Smokers had higher level of total WBC count (p = 0.0033) and PLR (p = 0.0464). No relationship between CVRFs and leukocytes was observed in males. The age independent effect was observed with PLR, whereas association with total WBC, lymphocytes, NLR, platelet was specific in older population. In younger patients NLR (p = 0.0453) is more likely to be elevated. Mortality was significantly associated with changes in the leukocytes but not with the CVRF presence.

Conclusion

We demonstrate that the neutrophils, lymphocytes and total WBC along with its ratios predict mortality and are more likely to be elevated in presence of CVRFs.     

Sudden cardiac death early after ST elevation myocardial infarction with and without severe left ventricular dysfunction

Introduction

There is high incidence of SCD in the early period following STEMI. We compared the temporal patterns and predictors of SCD amongst patients with LVEF ≤35% and LVEF >35%.

Methods

Data from STEMI patients was prospectively collected. SCD cases formed the study cohort and were categorized into 2 groups based on their LV function.

Results

There were 929 patients (mean age 55 ± 17 years) with a follow up of 41 ± 16 months. 154 pts (16.6%) had LVEF ≤35% (Group A, LVEF-29.9% ± 6%) and 775 pts had LVEF >35% (Group B, LVEF – 49% ± 14%). The two groups were similar with respect to sex distribution, age, prevalence of hypertension, and mean period of presentation. They differed in incidence of anterior wall MI (77.2% vs 55%), reperfusion (69% vs. 75%), prevalence of diabetes (50.6% vs 42%), and medication non-compliance (34% vs. 13%). The total SCD was 78 [Gp A, 25 (16.2%); Gp B, 53 (6.8%); p < 0.001]. The temporal cumulative SCD related mortality in the 2 groups was 1st month (8% vs. 4% p = 0.075), 3 months (14% vs. 5%, p < 0.001), 6 months (17% vs. 5%, p < 0.001), 1 year (18% vs. 6%, p < 0.001), at end of follow up (27% vs. 8%, p < 0.001). Multivariate predictors of SCD were medication compliance in the first month, and severe LV dysfunction with medication compliance beyond 1st month.

Conclusion

The incidence of SCD is high in first month after STEMI, irrespective of LV function. The number of SCD is higher in Group B patients. Algorithms to assess risk of SCD in early post STEMI period are urgently needed.     

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Background

Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.

Objective

To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.

Design

The study was designed as a patient-level randomized controlled trial.

Participants

Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.

Interventions

All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).

Main Outcomes and Measures

Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.

Results

Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.

Conclusions

In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation     

Role of angiotensin II type I (AT1 A1166C) receptor polymorphism in susceptibility of left ventricular dysfunction

Background

Left ventricular dysfunction (LVD) with subsequent congestive heart failure (CHF) constitutes the final common pathway for a host of cardiac disorders. The impaired LV function develops in response to an ischemic insult followed by a fall in cardiac output that leads to activation of renin-angiotensin-system (RAS). Angiotensin II type I receptor (AT1), which mediate the vasoconstrictive and salt-conserving actions of the RAS, represent interesting candidate genes for cardiovascular diseases. Therefore, we conducted an association study between single nucleotide polymorphism (SNP) in AT1 gene and LVD in CAD patients.

Methods and results

The present study recruited a total of 950 subjects including 720 angiography confirmed CAD patients and 230 healthy controls. Among 720 CAD patients, 229 with reduced left ventricle ejection fraction (LVEF ≤ 45%) were categorized as LVD. The AT1 (A1166C, rs5186) polymorphism was determined by ARMS-PCR. Our results showed that the frequency of AT1 1166AC and CC genotypes were significantly higher in LVD patients in comparison to non-LVD (LVEF >45%) patients (p value = 0.003; OR = 1.81 and p value <0.001; OR = 4.33). Further analysis showed that AT1 A1166C polymorphism was significantly associated with LV end diastole (p-value = 0.031), end systole (p-value = 0.038) dimensions, and mean LVEF (p-value = 0.035). Moreover, on comparing the AT1 A1166C polymorphism in CAD patients with healthy controls, we did not find any association both at genotypic and allelic level (p value = 0.927; OR = 1.04 and p value = 0.219; OR = 0.83) respectively.

Conclusions

Our study suggests that AT1 A1166C polymorphism may play significant role in conferring genetic susceptibility of LVD.     

Comparison of cardiac magnetic resonance with gated SPECT for evaluation of left ventricular function and volumes in patients with severe and multiple myocardial perfusion defects

Objectives

Gated SPECT is an accurate technique for assessment of myocardial perfusion (MP), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV). However recent studies have concluded that there are large discrepancies in assessment of LVEF and volumes by gated SPECT in patients with multiple severe myocardial perfusion defects. We sought to investigate the correlation between LVEF and volumes calculated by gated SPECT and cardiac magnetic resonance (CMR) in patients with severe multiple perfusion defects who are referred for CMR.

Methods

Twenty-nine patients (20 male and 9 female, mean age: 63 years ± 11) with multiple severe fixed perfusion defects (mean 5 ± 3 segments) were referred to undergo CMR. The average time between CMR and SPECT was 4 weeks. LVEF, EDV, and ESV were derived automatically from gated SPECT. In the CMR studies, the endocardial and epicardial borders were delineated manually in the short axis planes to calculate the LVEF and volumes.

Results

The different parameters were compared using linear regression, and correlation coefficients were calculated. Substantial correlation was found between CMR and gated SPECT for EDV: r = 0.7, p < 0.001. Moderate correlation between CMR and gated SPECT for LVEF: r = 0.5, p < 0.007 and ESV r =0 .53, p < 0.003.

Conclusion

Our data showed that the gated SPECT correlates substantially with MRI for measurement of EDV and moderately for ESV and LVEF in patients with multiple and severe perfusion defects. Thus, when accurate measurement is required, cardiac MRI is recommended.     

Association of ST elevation with apical aneurysm in hypertrophic cardiomyopathy

Objectives

Apical aneurysms in patients with hypertrophic cardiomyopathy (HCM) represent an underrecognized but clinically important subset of HCM patients. However it may be frequently missed by echocardiography because of poor image quality of left ventricular apex. We aimed to compare electrocardiographic STE in HCM patients with and without apical aneurysm.

Methods

We developed this clinical review using an extensive MEDLINE review of the literature and data from our laboratories; and some electrocardiographic parameters including STE were analysed in HCM patients with and without apical aneurysm.

Results

There were 29 HCM patients without apical aneurysm (Group 1; 52.6 ± 17.7years, 69% male) and 28 HCM patients with apical aneurysm (Group 2; 59.6 ± 13.2years, 57% male). The STE in V4-6 derivations were statistically more frequent in patients with apical aneurysm compared to those without aneurysm (93% vs 7%, p < 0.001). There was a positive correlation between the presence of the STE in V4-6 derivations and the presence of the apical aneurysm (Spearman''s ρ = 0.895, p < 0.001).

Conclusions

Clinicians and specifically echocardiographers must pay special attention on the electrocardiography to correctly detect the frequently overlooked apical aneurysm in HCM patients, and should be careful for apical aneurysm particularly in the presence of STE in V4-6 derivations.     

Pre-ejection mitral annular motion velocity responses to dobutamine infusion: A quantitative approach for assessment of myocardial viability

Background

Dobutamine stress echocardiography (DSE) is widely used for detection of myocardial viability. The main limitation of DSE is its subjective interpretation. Assessment of mitral annular motion velocities with tissue Doppler imaging is a simple and quantitative measurement.

Objective

To determine the relationship between myocardial viability and regional systolic mitral annular motion tissue Doppler velocities responses to dobutamine stress.

Methods

Our study group included 42 patients with previous myocardial infarction referred for coronary angiography and revascularization. We did dobutamine stress tissue Doppler echocardiography (DSTDE) measuring velocities of pre-ejection wave (pre-Ej) and peak ejection wave (Ej) at rest and during low-dose dobutamine infusion. We did follow up echocardiography after 1 month.

Results

After exclusion of the normokinetic walls, we analyzed 196 walls. Using receiver operator characteristic ROC curves, the optimal cut-off value for viability assessment was an increase of 1.75 cm/s in pre-ejection velocity during DSTDE (area under the curve 0.70, p < 0.001). On the other hand, the optimal cut-off value for viability assessment was an increase of 1.75 cm/s in ejection velocity during DSTDE (area under the curve 0.613, p = 0.01). The sensitivity, specificity, and total accuracy of the DSTSE (pre-Ej) versus the gold standard for detection of myocardial viability were 66.15%, 67.94%, and 67.35%, respectively. The sensitivity, specificity, and total accuracy of the DTSE (Ej) were 56.92%, 64.12%, and 61.43%, respectively. There was a good correlation between the pre-Ej at 5 ug/kg/min dobutamine infusion and the pre-Ej after revascularization (r = 0.64, p = 0.01) while the correlation with the Ej was moderate (r = 0.50, p = 0.01).

Conclusion

Viable left ventricular myocardium could be identified easily and quantitatively with pre-ejection mitral annular velocity during dobutamine infusion. The pre-ejection wave during DSTDE showed greater sensitivity and specificity for the prediction of myocardial viability than the ejection wave.     

Atrial synchronous left ventricular only pacing with VDD pacemaker system – A cost effective alternative to conventional cardiac resynchronization therapy

Introduction

Atrial synchronous left ventricular (LV) only pacing using two leads and VDD pacemaker could be a cost effective alternative to conventional cardiac resynchronization therapy (CRT).

Methods

We implanted right atrial (RA) and LV leads with VDD pulse generator (LV only pacing) in five carefully screened heart failure patients who could not afford conventional CRT. All had NYHA class III/IV symptoms despite maximal guideline directed medical therapy. The sensed atrioventricular delay was programmed to pre-excite the LV and achieve fusion beat. Response to treatment was assessed at 6 months.

Results

Four patients were males. The mean age was 58 ± 12 years. At follow up, there was improvement in electrocardiographic, and echocardiographic parameters: Mean QRS duration decreased from 174 ± 17 msec to 128 ± 10.9 msec (p = 0.009), LV end-diastolic diameter decreased from 73.2 ± 12 mm to 65.8 ± 9.6 mm (p = 0.026), LV end-systolic diameter decreased from 65 ± 12 mm to 54 ± 10 mm (p = 0.020). There was a trend towards reduction of LV end-systolic and end-diastolic volumes. LV ejection fraction improved from 25 ± 6% to 34 ± 6% (p = 0.013) and left atrial dimension reduced from 44 ± 4 mm to 39 ± 5 mm (p = 0.045). All patients improved clinically.

Conclusion

RA-LV pacing using VDD pacemaker is a safe and effective technique of CRT. This may be a cost effective alternative to conventional CRT for patients in developing countries.     

Outcomes of recurrent laryngeal nerve injury following congenital heart surgery: A contemporary experience

Objective

Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition.

Design

A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus.

Results

The incidence of post-operative vocal cord paralysis was 1.1% (32 out of 3036 patients; 95% confidence interval: 0.7–1.5%). The majority were left-sided injuries (71%). Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation (median 10 vs. 5 days, p = 0.03), ICU length of stay (50 vs. 8 days, p = 0.002), and hospital length of stay (92 vs. 41 days, p = 0.01). No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement.

Conclusion

Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery.     

Gender differences in the surgical management and early clinical outcome of coronary artery disease: Single centre experience

Objective

To investigate the gender disparity in the distribution of patient-related risk factors and their effect on the surgical management and clinical outcome of coronary artery disease in Saudi population.

Materials and methods

We carried out a retrospective analysis of prospectively collected data of 971 patients undergoing isolated coronary artery bypass grafting (CABG) at our institution between January 2005 and December 2008. Seven hundred and eighty seven patients (81%) were males and 184 patients (19%) were females. We analyzed gender-based difference in clinical presentation and patient-related pre-operative risk factors and studied their impact on surgical management and clinical outcome.

Results

The mean age was 59.5 years in males and 63.4 years in females (p = <0.0001). Associated co-morbidities were higher in females. Prevalence of diabetes mellitus was 61.2% in males and 78.8% in females (p-value = <0.0001); hypertension 61.9% in males and 79.9% in females (p-value <0.0001); hyperlipidemia 66.7% in males and 77.7% in females (p-value 0.0035); morbid obesity 24.7% in males and 45.1% in females (p-value <0.0001); and Hypothyroidism 2.5% in males and 13.6% in females (p-value <0.0001). Smoking was the only risk factor with higher prevalence in males compared to females (44.2% v/s 2.2%; p-value <0.0001). The mean logistic euroSCORE was 3.94 in males and 5.51 in females (p < 0.0003). On-pump and off-pump CABG was carried out in equal numbers in two groups. Females required urgent surgery and less than 3 grafts more frequently while males underwent elective surgery and more than 3 grafts in greater numbers. No significant difference was present between the two gender groups in aortic occlusion times and bypass times. Univariant analysis revealed females gender as an independent risk factor for higher in-hospital mortality (1.1% versus 4.9% p = 0.0026) and higher incidence of post-operative complications like surgical wound infection, need for prolonged ventilation, low cardiac output state and multi-organ failure (p-values 0.01 or less).

Conclusion

Female gender is an independent predictor of adverse outcome after isolated CABG due to significantly higher co-morbidities and acute presentation and independent of their peri-operative management. Therefore, major socioeconomic education and preventive measures are needed to reduce the burden of major co-morbidities in females and to seek early cardiac advice and care.     

Epidemiological and evolutionary characteristics of heart failure in patients with left bundle branch block – A Moroccan center-based study

Background

In patients with heart failure, left bundle branch block (LBBB) seems to be associated with an increased risk of cardiovascular mortality.

Purpose

The purpose of this study is to determine the in-hospital outcome of congestive heart failure patients with LBBB versus those without.

Methods

We conducted a prospective observational study at the Department of Intensive Care and Rhythmology at the Mohammed V Military Hospital of Rabat, where 330 patients were admitted for heart failure between January 2008 and September 2012. Screening out patients with missing data yielded a cohort of 274 patients. Among the 274 patients, only 110 had LBBB and a left ventricular ejection fraction lower than 50%. We randomly selected a subset of 110 patients diagnosed as non-LBBB to ensure a significant statistical comparison between LBBB and non-LBBB patients. We therefore considered two groups in our analysis: 110 heart failure (HF) patients with LBBB and 110 HF patients without LBBB. Patients with incomplete records were excluded.

Results

Male gender was dominant in both groups (82.7% vs. 66.7%, p = 0.005). Patients with LBBB had a higher prevalence of idiopathic dilated cardiomyopathy (39.1% vs. 4.8%, p < 0.001); and a higher prevalence of previous hospitalization for heart failure (64.5% vs. 23.3%, p < 0.001). The left ventricular ejection fraction was significantly lower in the group with LBBB (25.49% vs. 39.53%, p < 0.001). Age, cardiovascular risk factors, rhythmic and thromboembolic complications did not significantly differ. In patients with LBBB, 61.8% received cardiac resynchronization therapy performed both during the index hospital stay (50.9%) and previously (10.9%). Hospital outcome was marked by 20 in-hospital deaths in the group with LBBB and eight deaths in the group without LBBB (p = 0.008).

Conclusion

Our analysis emphasizes increased in-hospital mortality and higher disease severity, over a short period of stay, in heart failure patients with left bundle branch block.     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Comparison of the effects of 52 weeks weight loss with either a high-protein or high-carbohydrate diet on body composition and cardiometabolic risk factors in overweight and obese males

Background:

A high-protein (HP), low-fat weight-loss diet may be advantageous for improving cardiometabolic health outcomes and body composition. To date, only limited research has been conducted in male participants.

Objective:

To evaluate the medium to long-term effects of two, low-fat, hypocaloric diets differing in carbohydrate:protein ratio on body composition and cardiometabolic health outcomes in overweight and obese males.

Design:

One hundred and twenty males (age 50.8±9.3 (s.d.) years, body mass index 33.0±3.9 kg m⁻²) were randomly assigned and consumed a low-fat, isocaloric, energy-restricted diet (7 MJ per day) with either HP (protein:carbohydrate:fat %energy, 35:40:25) or high carbohydrate (HC; 17:58:25). Body weight, body composition and cardiometabolic risk factors were assessed at baseline and after 12 and 52 weeks.

Results:

Sixty-eight participants completed the study (HP, n=33; HC, n=35). At 1 year both the groups experienced similar reductions in body weight (HP, −12.3±8.0 kg (−12%); HC, −10.9±8.6 kg (−11%); P=0.83 time × group interaction) and fat mass (−9.9±6.0 kg (−27%) vs −7.3±5.8 kg (−22%); P=0.11). Participants who consumed the HP diet lost less fat-free mass (−2.6±3.7 kg (−4%) vs −3.8±4.7 kg (−6%); P<0.01). Both groups experienced similar increases in high-density lipoprotein cholesterol (8%) and reductions in total cholesterol (−7%), low-density lipoprotein cholesterol (−9%), triglycerides (−24%), glucose (−3%), insulin (−38%), blood pressure (−7/−12%) and C-reactive protein (−29%), (P⩾0.14).

Conclusion:

In overweight and obese men, both a HP and HC diet reduced body weight and improved cardiometabolic risk factors. Consumption of a HP diet was more effective for improving body composition compared with an HC diet.     

Association Between Study Quality and Publication Rates of Medical Education Abstracts Presented at the Society of General Internal Medicine Annual Meeting

Background

Studies reveal that 44.5 % of abstracts presented at national meetings are subsequently published in indexed journals, with lower rates for abstracts of medical education scholarship.

Objective

We sought to determine whether the quality of medical education abstracts is associated with subsequent publication in indexed journals, and to compare the quality of medical education abstracts presented as scientific abstracts versus innovations in medical education (IME).

Design

Retrospective cohort study.

Participants

Medical education abstracts presented at the Society of General Internal Medicine (SGIM) 2009 annual meeting.

Main Measures

Publication rates were measured using database searches for full-text publications through December 2013. Quality was assessed using the validated Medical Education Research Study Quality Instrument (MERSQI).

Key Results

Overall, 64 (44 %) medical education abstracts presented at the 2009 SGIM annual meeting were subsequently published in indexed medical journals. The MERSQI demonstrated good inter-rater reliability (intraclass correlation range, 0.77–1.00) for grading the quality of medical education abstracts. MERSQI scores were higher for published versus unpublished abstracts (9.59 vs. 8.81, p = 0.03). Abstracts with a MERSQI score of 10 or greater were more likely to be published (OR 3.18, 95 % CI 1.47–6.89, p = 0.003). ). MERSQI scores were higher for scientific versus IME abstracts (9.88 vs. 8.31, p < 0.001). Publication rates were higher for scientific abstracts (42 [66 %] vs. 37 [46 %], p = 0.02) and oral presentations (15 [23 %] vs. 6 [8 %], p = 0.01).

Conclusions

The publication rate of medical education abstracts presented at the 2009 SGIM annual meeting was similar to reported publication rates for biomedical research abstracts, but higher than publication rates reported for medical education abstracts. MERSQI scores were associated with higher abstract publication rates, suggesting that attention to measures of quality—such as sampling, instrument validity, and data analysis—may improve the likelihood that medical education abstracts will be published.KEY WORDS: medical education, medical education research, quality, publication     

B-Type natriuretic peptide levels predict extent and severity of coronary artery disease in non-ST elevation acute coronary syndrome and normal left ventricular function

Background

B-type natriuretic peptide has been used as a biological marker for prognosis in patients with acute coronary syndrome (ACS). However, a relation between the quantity of BNP levels and the severity of coronary artery disease has not been systematically evaluated.

Methods

197 patients with ACS without ST elevation with normal LV systolic function were enrolled. BNP was measured in all recruited patients within 12 h of hospitalization. All patients underwent coronary angiography. We correlated BNP levels in patients with unstable angina (USAP) and non ST-elevation myocardial infarction (NSTEMI) with angiographic disease severity including Gensini Score.

Results

BNP levels were significantly higher in the NSTEMI group in comparison to the USAP Group (161 ± 149.3 vs 79.6 ± 94.2 pg/mL; p < 0.001). BNP levels rose significantly with increasing number of vessels involved (1-vessel = 51.4 ± 31.6; 2-vessels = 114.0 ± 67.8; 3 vessels = 265.4 ± 188.8 pg/mL, p < 0.001). Most importantly, BNP> 80 pg/ml was found to strongly predict the presence of Triple vessel disease (odds ratio 18.87; 95% confidence intervals 5.36–66.36), and Double vessel disease (odds ratio 3.62; 95% confidence intervals 1.75–7.47). In single vessel group, BNP was significantly higher when LAD was involved vessel (64.78 vs 49.76 pg/mL, p < 0.05).Gensini Score showed a strong correlation with BNP levels (r = 0.675, p < 0.01), and Gensini Score was significantly higher in those with BNP> 80 pg/ml (40.9 ± 29.7 vs 13.4 ± 16.5 p < 0.001).

Conclusion

Circulating BNP levels appear elevated in Non ST Elevation ACS, even in the absence of LV systolic dysfunction. High BNP levels are associated with multi-vessel disease and diffuse coronary atherosclerosis.     

N-terminal-pro-brain natriuretic peptide,a surrogate biomarker of combined clinical and hemodynamic outcomes following percutaneous transvenous mitral commissurotomy

Aim

To examine the relationship between plasma levels of N-terminal-proB type natriuretic peptide (NT-proBNP) and various echocardiographic and hemodynamic parameters in patients with mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC).

Materials and methods

The study population consisted of 100 patients with rheumatic mitral stenosis who underwent PTMC. NT-proBNP levels in these patients were measured before PTMC and 48 hours after PTMC. These levels were then correlated with various echocardiographic and hemodynamic parameters measured before and after PTMC.

Results

Eighty-one percent of the study population were women, and the most common presenting symptom was dyspnea which was present in 94% of the patients. Dyspnea New York Heart Association class correlated significantly with baseline NT-proBNP levels (r = 0.63; p < 0.01). The plasma NT-proBNP levels in these patients increased as echocardiogram signs of left atrial enlargement and right ventricular hypertrophy developed (r = 0.59, p < 0.01). Patients in atrial fibrillation had significantly higher NT-proBNP levels than patients in sinus rhythm. Baseline NT-proBNP levels correlated significantly with left atrial volume (r = 0.38; p < 0.01), left atrial volume index (r = 0.45; p < 0.01), systolic pulmonary artery pressures (r = 0.42; p < 0.01), and mean pulmonary artery pressures (r = 0.41; p < 0.01). All patients who underwent successful PTMC showed a significant decrease in NT-proBNP (decreased from a mean 763.8 pg/mL to 348.6 pg/mL) along with a significant improvement in all echocardiographic and hemodynamic parameters (p < 0.01). The percent change in NT-proBNP correlated significantly with the percent improvement noted with left atrial volume (r = 0.39; p < 0.01), left atrial volume index (r = 0.41; p < 0.01), systolic (r = 0.32, p < 0.01), and mean pulmonary artery pressures (r = 0.31, p < 0.01).

Conclusions

The decrease in NT-proBNP levels following PTMC reflects an improvement in clinical and hemodynamic status; hence, it is reasonable to suggest that NT-proBNP is helpful in evaluating the response to PTMC.