Clinical profile of early-onset and late-onset idiopathic chronic pancreatitis in South India

Background and Aim

Idiopathic chronic pancreatitis (ICP) is the most common form of chronic pancreatitis reported in India. There is paucity of literature on the prevalence and profiles of early- and late-onset forms of ICP in India.

Material and Methods

We compared the profile of early- and late-onset ICP in a patient population attending a tertiary care hospital in South India.

Results

Pain was the characteristic feature as more than 90 % with both early-onset and late-onset ICP had pain as the most significant symptom. Onset of pain was at age 14.9?±?7.7 years in early-onset and at 38.1?±?9.9 in late-onset ICP (p?<?0.001). There was considerable delay between onset of pain in early onset as compared to late-onset ICP. Diabetes was seen in 41.4 % in early-onset as compared to 69.1 % in late-onset ICP (p?<?0.001). Pancreatic exocrine insufficiency was seen in 34.4 % in early-onset as compared to 53.2 % in late-onset ICP (p?<?0.001). Increased prevalence of exocrine insufficiency and diabetes was observed in late-onset as compared to early-onset ICP. Univariate analysis showed that alcohol use, smoking, age, and family history of diabetes were significantly associated with diabetes. Multivariate analysis showed strong associations for diabetes with smoking (odds ratio (OR)?=?4.2), calcification (OR?=?7.7), as well as family history and age >40 years.

Conclusions

There were differences between early-onset and late-onset ICP in southern Indian patients. Diabetes was strongly associated with smoking and pancreatic calcification.     

Prevalence of irritable bowel syndrome and functional dyspepsia,overlapping symptoms,and associated factors in a general population of Bangladesh

Background

This community-based survey aimed to find out the prevalence of irritable bowel syndrome (IBS), functional dyspepsia (FD), overlapping symptoms, and associated factors for overlap.

Method

By cluster sampling method, 3,000 (1,523 male) randomly selected adult subjects in the Sylhet district of Bangladesh were interviewed by a questionnaire based on ROME III criteria. Multivariate logistic regression analyses were done to find out the factors for overlap with significance level set at ≤0.05.

Results

The mean age of the study population was 33.9?±?16.4 years. Prevalence of IBS and FD and IBS-FD were 12.9 % (n?=?387), 8.3 % (n?=?249), and 3.5 % (n?=?105), respectively. Approximately 27.1 % of IBS patients and 42.1 % of FD patients had overlapping IBS-FD. The odds ratio for IBS-FD overlap was 6.3 (95 % CI, 4.8–8.4). Mean age (p?=?0.011) and epigastric pain (p?=?0.002) were more in overlap patients than FD alone, whereas epigastric pain syndrome subtype (p?<?0.009) was more prevalent in lone FD subjects. In the multivariate logistic analysis, early satiety (OR, 3.0; 95 % CI, 1.2–7.5; p?=?0.018) and epigastric pain (OR, 14.5; 95 % CI, 5.0–42.1; p?=?0.000) in FD patients appeared as independent risk factors for overlap. Bloating (p?=?0.026), <3 stools per week (p?=?0.050), abdominal pain reduced by defecation (p?=?0.002), abdominal pain severity score (p?=?0.004), and overall symptom frequency score (p?=?0.000) were more in overlap patients than IBS-alone patients. In IBS patients, bloating (OR, 3.6; CI, 2.0–6.5; p?=?0.000) was found as potential symptom associated with IBS-FD overlap.

Conclusion

FD was a less prevalent disorder than IBS in our community, and significant overlap existed between the two disorders. Early satiety, epigastric pain, and bloating were important factors associated with overlap.     

Assessment of shoulder pain and shoulder disability in patients with implantable cardioverter–defibrillator

Purpose

Shoulder pain and disability is a common but overlooked disorder in patients with implantable cardioverter–defibrillators (ICD). We aimed to assess chronic shoulder pain and disability in patients with ICD.

Methods

Two hundred fifty-four patients (mean age, 66?±?12 years; 156 men) with ICD were included in the study. The Shoulder Pain and Disability Index (SPADI) was used for assessment of shoulder pain and disability.

Results

Of the patients, 131 (52 %) have shoulder pain and disability. The total mean SPADI score in patients with shoulder pain and disability was 33?±?18 and was significantly higher than in patients without shoulder pain and disability (11?±?2; p?<?0.001). Patients with three-lead ICD have significantly higher SPADI scores than patients with single-lead ICD (p?<?0.001). Number of leads correlated with pain score (p?=?0.001, r?=?0.253), disability score (p?=?0.006, r?=?0.174) and total SPADI score (p?=?0.001, r?=?0.213). In multivariate analysis, significant associates of shoulder pain and disability were evaluated, adjusting for age, sex, body mass index, procedure time, implantation time interval, limitation of shoulder activity and number of leads. Number of leads was the only predictor of shoulder pain and disability (OR 0.518, 95 % CI, 0.372–0.721; p?<?0.001).

Conclusions

Patients with ICD implantation frequently have chronic shoulder pain and disability. Patients with three leads suffer more shoulder pain and disability.     

Fragmented QRS as a predictor of arrhythmic events in patients with hypertrophic obstructive cardiomyopathy

Objectives

This study aims to determine whether fragmented QRS (fQRS) in the surface electrocardiogram (ECG) at implantable cardioverter defibrillator (ICD) implant can predict arrhythmic events using appropriate therapy delivered by the ICD as a surrogate.

Background

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder associated with life-threatening arrhythmias frequently requiring an ICD. Seeking a noninvasive method of risk stratification remains a challenge.

Methods

This paper is a retrospective, multicenter study of patients with HOCM and ICD. Surface 12-lead ECGs were analyzed. Appropriate therapy was validated by a blinded Core Lab. Univariate and multivariate analyses were performed. A p value of <0.05 was considered significant.

Results

We included 102 patients from 13 centers. Mean age at implant was 41.16?±?18.25 years, 52 % were male. Mean left ventricular ejection fraction was 61.56?±?9.46 % and two thirds had heart failure according to the New York Heart Association class I. Secondary prophylaxis ICD implantation was the indication for implant in 40.2 % of cases. About half received a single-chamber ICD. fQRS was present at the time of diagnosis in 21 and in 54 % at ICD implant. At a mean follow-up of 47.8?±?39.3 months, 41 patients (40.2 %) presented with appropriate therapy. In a multivariate logistic regression, predictors of appropriate therapy included fQRS at implant (odds ratio [OR], 16.4; 95 % confidence interval [CI], 3.6–74.0; p?=?0.0003), history of combined ventricular tachycardia/fibrillation/sudden death (OR, 14.3; 95 % CI, 3.2–69.3; p?=?0.001) and history of syncope (OR, 5.5; 95 % CI, 1.5–20.4; p?=?0.009). Ten deaths (9.8 %) occurred during the follow-up. fQRS in the lateral location increased the risk of appropriate therapy (p?<?0.0001).

Conclusions

fQRS predicts arrhythmic events in patients with HOCM and should be considered in a model of risk stratification.     

Clinical implications of left ventricular assist device implantation in patients with an implantable cardioverter-defibrillator

Purpose

This study aims to study the clinical implications of the concomitant use of a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD).

Methods

In this retrospective study, all patients who underwent LVAD (Heart Mate II) implantation with concomitant ICD therapy at our institution between June 2007 and August 2012 were included. We sought to investigate (1) the electromagnetic interference between LVAD and ICD telemetry, (2) the effect of LVAD implantation on right ventricular (RV) lead parameters and (3) the ventricular tachyarrhythmias (VAs) that occur post-LVAD implantation.

Results

Of the 23 patients (53?±?9 years, 73 % male, LVEF 19?±?9 %) included, ICD telemetry was lost in four patients post-LVAD implantation (Saint-Jude-Medical Atlas V-193, V-240, V-243, and Sorin CRT-8750), prompting either use of a metal shield (n?=?1), a change in position of the programmer head (n?=?1) or ICD replacement (n?=?2). LVAD implantation was associated with a decrease in both RV signal amplitude (p?=?0.04) and RV impedance (p?<?0.01), and a trend towards an increased RV pacing threshold (p?=?0.08), without affecting clinical outcome. Eleven patients (47.8 %) experienced VAs after LVAD implantation, which on the whole were well tolerated. Their occurrence was strongly linked to a history of VAs before device implantation (p?<?0.01).

Conclusions

Electromagnetic interference between LVADs and ICD telemetry may necessitate ICD replacement. LVAD placement is associated with significant changes in RV lead parameters that have minimal clinical significance. VAs occur in approximately half of LVAD patients seen and their occurrence is strongly related to a history of VAs prior to LVAD implantation.     

Incidence of very high defibrillation thresholds (DFT) and efficacy of subcutaneous (SQ) array insertion during implantable cardioverter defibrillator (ICD) implantation

Background

The incidence, risk factors, and management of very high defibrillation thresholds (DFTs) during present-day implantable cardioverter defibrillator (ICD) testing are not well known.

Objectives

The purpose of this study was to assess (1) the incidence of very high DFTs and (2) the efficacy/safety of routinely adding a subcutaneous (SQ) array for these patients.

Methods

The study evaluated patients undergoing first-time ICD implantation at Southlake Regional Healthcare Centre from January 2006 to December 2007. All implanted ICDs had a maximal output of 35 J. Patients with DFTs greater than a 10-J safety margin from maximum output were considered to have very high readings and underwent SQ array insertion after other attempts at lowering DFT (group I). These patients were compared with the rest of the patients who had acceptable DFTs (group II) using both univariate and multivariate logistic regression analysis. Outcomes of array insertion were also assessed.

Results

A total of 313 patients underwent first-time ICD implantation during the analysis period. Of those, 16 (5.1%) had very high DFTs (group I). By univariate analysis, advanced New York Heart Association class (3 or 4), congestive heart failure hospitalization, non-ischemic cardiomyopathy, amiodarone use, implant of a biventricular device, and highest quartile of left ventricular (LV) chamber enlargement were all significant predictors of very high DFTs (p?<?0.05). By multivariate analysis, only amiodarone use [odds ratio (OR)?=?10.3, 95% confidence interval (95% CI)?=?3.7–32.6] and being in the highest quartile for LV diastolic diameter [OR?=?5.4, 95% CI?=?1.4–20.8] predicted very high DFT. In all 16 cases, other methods to lower DFT prior to array insertion were attempted but failed for all patients: reversing shock polarity (n?=?15), removing the superior vena cava coil (n?=?14), reprogramming shock waveform (n?=?9), and repositioning right ventricular lead (n?=?9). Addition of the array successfully decreased DFT to within safety margin for all patients (33?±?2 vs 21?±?5 J, p?=?0.02). Complication due to array insertion occurred in one patient (pneumothorax).

Conclusions

Very high DFTs occur in about 5% of patients undergoing ICD implantation and may be predicted by LV dilation and amiodarone use. SQ array insertion reliably corrects this problem over other interventions with a low rate of procedural complication.     

Common genetic variants in selected Ca2+ signaling genes and the risk of appropriate ICD interventions in patients with heart failure

Purpose

Defective Ca²⁺ handling in failing cardiomyocites predisposes patients with heart failure (HF) to ventricular arrhythmia. We investigated whether gene variants of Ca²⁺ handling proteins are associated with the occurrence of ventricular tachycardia/fibrillation (VT/VF) in HF patients implanted with a primary prevention implantable cardioverter-defibrillator (ICD).

Methods

One hundred thirty-six patients with HF were followed from ICD implantation to the time of first appropriate ICD intervention for VT?>?170 bpm. The following polymorphisms were genotyped: ATP2A2 rs1860561 and rs56243033; RYR2 rs4142933; CASQ2 rs4074536; SLC8A1 g.-23449C?>?A; PLN rs12198461; FKBP1B rs7568163. Hazard ratios (HR) were derived from Cox proportional-hazards regression analysis.

Results

After a mean follow-up of 879 days (IQ range, 327 to 1,459), 34 patients (25 %) had appropriate ICD intervention. Non-sustained VT (HR, 2.12; 95 %CI, 0.87–5.19; p?=?0.09) and atrial fibrillation (AF) at ICD implantation (HR, 2.33; 95 %CI, 0.89–6.10; p?=?0.08) predicted appropriate ICD interventions with borderline statistical significance. Prevalence of ATP2A2 rs1860561 variant was 17 % in patients without VT/VF and 4 % in those with ventricular arrhythmia (p?=?0.009). After adjustment for AF and NSVT, the rs1860561 A mutant allele independently predicted lower incidence of VT/VF (HR, 0.29; 95 %CI, 0.09–0.98; p?=?0.04).

Conclusions

The observation that ATP2A2 rs1860561 gene variant associated with lower risk of life-threatening arrhythmia in HF patients suggests that selected calcium gene variants may modify the risk of SD even within the complex and polygenic pathological condition of HF. Combining traditional risk factors and genetic profiling could reveal helpful to identify HF patients who will benefit most from ICD implantation.     

Angiotensin-converting enzyme gene polymorphism in north Indian population with obstructive sleep apnea

Background

A deletion of 287-bp Alu repeat of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene is associated with hypertension.

Purpose

The aim of this study is to determine the frequency of ACE (I/D) polymorphism in patients with obstructive sleep apnea (OSA).

Methods

Genotyping of ACE (I/D) gene polymorphism and estimation of serum angiotensin-converting enzyme (SACE) activity were done in 813 subjects who underwent polysomnography. Of these, 395 were apneics and 418 were non-apneics.

Results

The frequencies of II genotype (OR = 1.8, 95 % CI 1.26–2.60, p?=?0.001) and I allele (OR = 1.4, 95 % CI 1.13–1.69, p?=?0.001) of ACE gene were found to be significantly increased in patients with OSA as compared to patients without OSA. Frequency of II genotype was significantly decreased (OR = 0.46, 95 % CI 0.28–0.77, p?=?0.003) in OSA patients with hypertension. In contrast, the frequencies of ID (OR?=?1.80, 95 % CI 1.08–2.99, p?=?0.024) and DD genotypes (OR?=?2.15, 95 % CI 1.30–3.57, p?=?0.003) were significantly increased in this group. The activity of SACE was significantly decreased in the apneic group as compared to the non-apneic group (OR?=?0.99, 95 % CI 0.98–1.00, p?=?0.04).

Conclusions

The findings suggest that II genotype confers susceptibility towards development of OSA whereas DD genotype confers susceptibility towards hypertension irrespective of OSA.     

The relationship between defibrillation threshold and total mortality

Background

The relationship between the defibrillation threshold (DFT) and total mortality is unclear.

Methods

A university hospital prospectively maintained implantable defibrillator (ICD) database identified 508 patients who underwent ICD implantation and had DFT testing performed at implant. Patients were placed in one of three groups based on the implant DFT (high (≥20 J), moderate (19–11 J), or low DFT (≤10 J)).

Results

Sixty-seven patients had a high DFT, 216 had a moderate DFT, and 225 had a low DFT. The mean left ventricular ejection fraction (LVEF) was 0.25, 0.28, and 0.30 in the high, moderate, and low DFT groups, respectively, (p?=?0.04). There were significantly more patients with a subcutaneous electrode in the high DFT group (p?<?0.001), more patients taking amiodarone (p?<?0.001), and more patients on oral anticoagulation (p?=?0.04). There were a total of 140 deaths during the follow-up period (mean 3.2?±?1.7 years). There were 24 deaths in the high DFT group (35.8 %), 62 in the moderate DFT group (28.7 %), and 54 in the low DFT group (24.0 %) (p?=?0.05). Implant DFT was a significant predictor of mortality (p?=?0.01), as was age, LVEF (p?<?0.001), CAD (p?=?0.01), amiodarone use (p?=?0.02), and hematoma at implant (p?=?0.01). An elevated DFT was an independent predictor of mortality after controlling for all significant univariate variables (p?=?0.004).

Conclusions

A high-implant DFT predicts an adverse prognosis, even when an adequate ICD safety margin is present.     

Unique features and risk factors of Helicobacter pylori infection at the main children’s intermediate school in Rabigh,Saudi Arabia

Background

This study was conducted to determine characters and risk factors of Helicobacter pylori infection and its relationship with recurrent abdominal pain and other gastrointestinal symptoms at the main children’s intermediate school in Rabigh, Saudi Arabia.

Methods

A cross-sectional study was conducted at a boys’ intermediate school. A questionnaire for the gastrointestinal (GI) symptoms and relevant personal and socioeconomic risk factors related to H. pylori infection was distributed followed by H. pylori IgG antibody assay and 14C urea breath test to detect active infection.

Results

H. pylori was diagnosed by positive urea breath test in 51.5 % of students. H. pylori infection was symptomatic with at least one upper GI symptom in 89.7 % of infected students which was higher than symptomatic cases reported in any other study. H. pylori-infected students had significantly more association with the presence of any upper GI symptom (p?<?0.001), recurrent abdominal pain (p?<?0.001), anorexia (p?<?0.001), nausea (p?<?0.026), family history of peptic disease (p?<?0.001), drinking desalinated municipal water (p?<?0.001), lower income (p?=?0.02), and eating outside home (p?=?0.003) than uninfected students. Logistic regression analysis showed that the most significant predictors of H. pylori infection were presence of any upper GI symptom (OR 5.3, 95 % CI 2.32–15.71), family history of peptic disease (OR 2.2, 95 % CI 1.11–3.9), and drinking desalinated municipal water (OR 2.1, 95 % CI 1.09–3.2).

Conclusions

This study presented unique features and risk factors of H. pylori infection in 12–15-year-old Saudi boys in Rabigh, and mainly supported the role of H. pylori in causing recurrent abdominal pain.     

Risk factors and early signs of pancreatic cancer in diabetes: screening strategy based on diabetes onset age

Background

Diabetes mellitus (DM) has long been recognized as a risk factor for pancreatic cancer (PaC) and recently has attracted attention as a manifestation of PaC. Diabetes is expected to be a clue for the early detection of PaC; however, no effective screening strategy has been established.

Methods

Forty diabetic patients with PaC were identified and compared with 120 diabetic patients without any malignancies. We analyzed risk factors for and early signs of PaC, focusing on the DM-onset age.

Results

As there were peaks at 40–45 years and 60–65 years in the distribution of DM-onset age, we analyzed the clinical characteristics of and risk factors for PaC according to DM-onset age: i.e., early-onset (<55 years) and late-onset (≥55 years). PaC was diagnosed within 2 years of DM onset (new-onset) in 0 % of the patients with early-onset DM, and in 33 % of those with late-onset DM. The mean duration of DM in patients with early-onset DM with PaC was longer than that in the late-onset patients (26 vs. 9 years; P < 0.01). A family history of DM (odds ratio [OR] 3.60) and use of insulin (OR 3.52) were significant risk factors in patients with early-onset DM, while the onset age of DM (OR 1.12) and multiple diabetic patients in the family (OR 6.13) were risk factors in those with late-onset DM. Body weight loss and exacerbation of DM were seen 12 months prior to PaC diagnosis in both groups.

Conclusions

Our study revealed specific risk factors for and similar early signs of PaC in early-onset and late-onset DM. Thus, we could develop a screening strategy, combining these risk factors specific for DM-onset age with early signs of disease.     

Effects of obstructive sleep apnea severity on serum lipid levels in Greek children with snoring

Background

Although obstructive sleep apnea (OSA) is related to dyslipidemia in adults, limited data are available regarding its effects on serum lipids during childhood. Aim of this study was to assess the potential relationships between severity of OSA and cholesterol or triglyceride levels in a cohort of Greek children.

Methods

Data from children with snoring who underwent polysomnography and complete serum lipids measurements during a specified study period were analyzed retrospectively.

Results

Overall, obese children (n?=?261) had lower HDL cholesterol levels than non-obese subjects (n?=?113) (49.6?±?10.5 vs. 53.9?±?11.4 mg/dL; p?=?0.001) and higher triglyceride concentrations (69.8?±?32.2 vs. 63.2?±?27 mg/dL; p?=?0.041). Non-obese subjects with moderate-to-severe OSA did not differ in triglycerides, total, and LDL cholesterol concentrations but had lower HDL cholesterol, when compared to non-obese children with primary snoring/mild OSA (50.4?±?13.1 vs. 54.9?±?10.7 mg/dL; p?=?0.008). The risk for having low HDL cholesterol (??40 mg/dL) was threefold higher in non-obese subjects with moderate-to-severe OSA than in those with primary snoring/mild OSA, even after adjustment for age and gender [OR?=?3.44 (95% CI 1.44 to 8.24; p?=?0.006)]. Concentrations of serum lipids in obese children were not associated with severity of OSA. HDL cholesterol was 48.5?±?8.7 mg/dL in subjects with moderate-to-severe OSA and 50.0?±?11.1 mg/dL in children with primary snoring/mild OSA (p?=?0.519).

Conclusions

HDL cholesterol levels are inversely related to severity of OSA in non-obese children with snoring.     

Sleepiness and sleep-disordered breathing in truck drivers

Background

Portugal has one of the highest road traffic fatality rates in Europe. A clear association between sleep-disordered breathing (SDB) and traffic accidents has been previously demonstrated. This study aimed to determine prevalence of excessive daytime sleepiness (EDS) and other sleep disorder symptoms among truck drivers and to identify which individual traits and work habits are associated to increased sleepiness and accident risk.

Methods

We evaluated a sample of 714 truck drivers using a questionnaire (244 face-to-face interviews, 470 self-administered) that included sociodemographic data, personal habits, previous accidents, Epworth Sleepiness Scale (ESS), and the Berlin questionnaire (BQ).

Results

Twenty percent of drivers had EDS and 29 % were at high risk for having obstructive sleep apnea syndrome (OSAS). Two hundred sixty-one drivers (36.6 %) reported near-miss accidents (42.5 % sleep related) and 264 (37.0 %), a driving accident (16.3 % sleep related). ESS score ≥11 was a risk factor for both near-miss accidents (odds ratio (OR)?=?3.84, p?<?0.01) and accidents (OR?=?2.25, p?<?0.01). Antidepressant use was related to accidents (OR?=?3.30, p?=?0.03). We found an association between high Mallampati score (III–IV) and near misses (OR?=?1.89, p?=?0.04).

Conclusion

In this sample of Portuguese truck drivers, we observed a high prevalence of EDS and other sleep disorder symptoms. Accident risk was related to sleepiness and antidepressant use. Identifying drivers at risk for OSAS should be a major priority of medical assessment centers, as a public safety policy.     

Key Barriers to Medication Adherence in Survivors of Strokes and Transient Ischemic Attacks

BACKGROUND

Even though medications can greatly reduce the risk of recurrent stroke, medication adherence is suboptimal in stroke survivors.

OBJECTIVE

To identify key barriers to medication adherence in a predominantly low-income, minority group of stroke and transient ischemic attack (TIA) survivors.

DESIGN

Cross-sectional study.

PARTICIPANTS

Six hundred stroke or TIA survivors, age ≥ 40 years old, recruited from underserved communities in New York City.

MAIN MEASURES

Medication adherence was measured using the 8-item Morisky Medication Adherence Questionnaire. Potential barriers to adherence were assessed using validated instruments. Logistic regression was used to test which barriers were independently associated with adherence. Models were additionally controlled for age, race/ethnicity, income, and comorbidity.

KEY RESULTS

Forty percent of participants had poor self-reported medication adherence. In unadjusted analyses, compared to adherent participants, non-adherent participants had increased concerns about medications (26 % versus 7 %, p?<?0.001), low trust in their personal doctor (42 % versus 29 %, p?=?0.001), problems communicating with their doctor due to language (19 % versus 12 %, p?=?0.02), perceived discrimination from the health system (42 % versus 22 %, p?<?0.001), difficulty accessing health care (16 % versus 8 %, p?=?0.002), and inadequate continuity of care (27 % versus 20 %, p?=?0.05). In the fully adjusted model, only increased concerns about medications [OR 5.02 (95 % CI 2.76, 9.11); p?<?0.001] and perceived discrimination [OR 1.85 (95 % CI 1.18, 2.90); p?=?0.008] remained significant barriers.

CONCLUSIONS

Increased concerns about medications (related to worry, disruption, long-term effects, and medication dependence) and perceived discrimination were the most important barriers to medication adherence in this group. Interventions that reduce medication concerns have the greatest potential to improve medication adherence in low-income stroke/TIA survivors.     

Economic impact of remote monitoring on ordinary follow-up of implantable cardioverter defibrillators as compared with conventional in-hospital visits. A single-center prospective and randomized study

Introduction

Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups.

Methods and results

Patients (N?=?233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly in-hospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p?=?0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103?±?27 and 154?±?21 per patient/year, respectively (p?=?0.01). RM was cost-saving for the patients: USD 97?±?121 per patient/year in the RM group versus 287?±?160 per patient/year (p?=?0.0001).

Conclusion

The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year.     

A variant in the G6PC2/ABCB11 locus is associated with increased fasting plasma glucose, increased basal hepatic glucose production and increased insulin release after oral and intravenous glucose loads

Aims/hypothesis

An association between elevated fasting plasma glucose and the common rs560887 G allele in the G6PC2/ABCB11 locus has been reported. In Danes we aimed to examine rs560887 in relation to plasma glucose and serum insulin responses following oral and i.v. glucose loads and in relation to hepatic glucose production during a hyperinsulinaemic–euglycaemic clamp. Furthermore, we examined rs560887 for association with impaired fasting glycaemia (IFG), impaired glucose tolerance (IGT), type 2 diabetes and components of the metabolic syndrome.

Methods

rs560887 was genotyped in the Inter99 cohort (n?=?5,899), in 366 young, healthy Danes, in non-diabetic relatives of type 2 diabetic patients (n?=?196), and in young and elderly twins (n?=?159). Participants underwent an OGTT, an IVGTT or a 2 h hyperinsulinaemic–euglycaemic clamp.

Results

The rs560887 G allele associated with elevated fasting plasma glucose (p?=?2?×?10^?14) but not with plasma glucose levels at 30 min (p?=?0.9) or 120 min (p?=?0.9) during an OGTT. G allele carriers had elevated levels of serum insulin at 30 min during an OGTT (p?=?1?×?10^?4) and relatives of type 2 diabetes patients carrying the G allele had an increased acute insulin response (p?=?4?×?10^?4) during an IVGTT. Among elderly twins, G allele carriers had higher basal hepatic glucose production (p?=?0.04). Finally, the G allele associated with the risk of having IFG (OR 1.26, 95% CI 1.08–1.47, p?=?0.002), but not with IGT (OR 0.94, 95% CI 0.82–1.08, p?=?0.4) or type 2 diabetes (OR 0.93, 95% CI 0.84–1.04, p?=?0.2).

Conclusions/interpretation

The common rs560887 G allele in the G6PC2/ABCB11 locus is associated with increased fasting glycaemia and increased risk of IFG, associations that may be partly related to an increased basal hepatic glucose production rate.     

Beta-blocker therapy is associated with a lower incidence of syncope due to fast ventricular tachycardias among implantable cardioverter-defibrillator patients with left ventricular dysfunction: results from a multicenter study

Introduction

Among implantable cardioverter-defibrillator (ICD) patients, a substantial proportion of syncopes are due to fast ventricular tachycardias (FVTs). In the experimental models of ventricular tachycardias, the arterial vasoconstriction plays an important role in recovering the arterial pressure. Since beta-blockers increase vascular resistance, we hypothesized that beta-blockers could reduce the occurrence of syncope due to FVTs. Our objective was to determine the relationship between the beta-blocker therapy and the incidence of syncope in FVT (cycle length [CL] 250–320 ms) occurring in ICD patients. Slow VTs were excluded because of the lack of symptoms and VF episodes because of the small number.

Methods and results

In this multicenter study, 226 patients (LVEF 31?±?10%) with single-chamber ICDs were followed. FVT programming was standardized, including antitachycardia pacing (ATP) as initial therapy. Symptoms were correlated with ICD-stored episode data of FVTs. The beta-blocker therapy was determined at each FVT presentation. We analyzed 289 FVTs (CL 291?±?21 ms; 77% under beta-blockers; median of the duration:8 s) occurring consecutively in 52 ICD patients. The frequency of FVT-related syncope was 22 (7.6%). Beta-blockers were associated with a lower heart rate preceding FVT (85?±?22 vs. 94?±?23 bpm; p?=?0.009), a higher ATP effectiveness (86 vs. 57%; p?<?0.001), a lower duration of episodes (8 [2] vs. 10 [14] s; p?<?0.001), and a lower incidence of FVT-related syncope (4.5 vs. 18%; p?<?0.001). By logistic regression, a FVT >?8 s (OR?=?21; p?=?0.003) and the beta-blocker therapy (OR?=?0.3; p?=?0.012) were found as independent predictors of syncope.

Conclusion

Among ICD patients with left ventricular dysfunction, beta-blockers are associated with a lower incidence of FVT-related syncope.

     

Common genetic variation in the glucokinase gene (GCK) is associated with type 2 diabetes and rates of carbohydrate oxidation and energy expenditure

Aims/hypothesis

Glucokinase (GCK) plays a role in glucose metabolism and glucose-stimulated insulin secretion. Rare mutations in GCK cause MODY. We investigated whether common variation (minor allele frequency ≥0.01) in GCK is associated with metabolic traits and type 2 diabetes.

Methods

Four exonic single-nucleotide polymorphisms (SNPs) and three SNPs predicted to cause loss of promoter function were identified in whole-genome sequence data from 234 Pima Indians. These seven tag SNPs and rs4607517, a type 2 diabetes variant established in other studies, were analysed in 415 full-heritage non-diabetic Pima Indians characterised for metabolic traits, and 7,667 American Indians who had data on type 2 diabetes and BMI.

Results

A novel 3′ untranslated region (3′UTR) SNP, chr7:44184184-G/A, was associated with the rate of carbohydrate oxidation post-absorptively (β?=?0.22 mg [kg estimated metabolic body size (EMBS)]^?1?min^?1, p?=?0.005) and during a hyperinsulinaemic–euglycaemic clamp (β?=?0.24 mg [kg EMBS]^?1?min^?1, p?=?0.0002), the rate of carbohydrate oxidation in a respiratory chamber (β?=?311 kJ/day, p?=?0.03) and 24 h energy expenditure, which was attributable to the thermic effect of food (β?=?520 kJ/day, p?=?3.39?×?10^?6). This 3′UTR SNP was also associated with diabetes (OR 1.36, 95% CI 1.11, 1.65, p?=?0.002), where the A allele (allele frequency 0.05) was associated with a lower rate of carbohydrate oxidation, lower 24 h energy expenditure and higher risk for diabetes. In a Cox proportional hazards model, a rate of insulin-stimulated carbohydrate oxidation lower than the mean rate at baseline predicted a higher risk for developing diabetes than for those above the mean (hazard rate ratio 2.2, 95% CI 1.3, 3.6, p?=?0.002).

Conclusions/interpretation

Common variation in GCK influences the rate of carbohydrate oxidation, 24 h energy expenditure and diabetes risk in Pima Indians.     

Incidence of nonphysiologic short VV intervals detected by the sensing integrity counter with integrated bipolar compared with true bipolar leads: clinically inconsequential or cause for concern?

Introduction

The need to detect impending implantable cardiac defibrillator (ICD) lead failure has grown. Automated sensing diagnostics have been developed for this reason. The sensing integrity counter (SIC) is one such oversensing diagnostic, which forms an integral part of the Medtronic? lead integrity alert (LIA) feature on implantable defibrillators. It records nonphysiologic short VV intervals (NPSVVIs). It is unclear whether SIC data derived from integrated bipolar (IBP) leads need to be interpreted differently when compared to true bipolar (TBP) leads. We hypothesized that IBP ICD leads by virtue of a larger “antennae” may generate more NPSVVIs on than TBP leads, leading to more false-positive SIC counts.

Methods

Equal durations of remote monitoring records of 44 patients (mean age of 65.9?±?2.2 years, 52 % female) with IBP ICD leads and Medtronic (MDT) generators (IBP group) were compared with those of 44 randomly selected patients (64.0?±?2.2 years, 24 % female) who had TBP ICD leads and MDT generators (TBP group). Mean surveillance time, defined as the time over which the cumulative SIC count was acquired, was 614?±?44 days (TBP group) vs. 620?±?49 days (IBP group, p?=?ns). The mean time of follow-up following the first documented short VV interval was 115.2 months in the integrated bipolar group and 66.9 months in the true bipolar group. Leads on advisory were excluded from the study.

Results

A total of 26/44 patients in the IBP group displayed NPSVVI compared to 11/44 patients in the TBP group (59 vs. 25 %; p?=?0.002, Fisher exact test). When adjusted for gender and lead age, the difference was still significant (p?=?0.008). When evaluating the clinical consequence of NPSVVI in this cohort, 3/11 TBP leads with NPSVVI of >0 were eventually extracted due to additional abnormalities vs. 0/26 IBP leads with NPSVVI (p?=?0.02, Fisher exact test). None of the IBP group patients with NPSVVI have developed inappropriate therapy from lead noise or a need for abandonment or extraction.

Conclusion

Integrated bipolar ICD leads are more likely to have elevated SIC counts than true bipolar leads despite revealing no other evidence of lead failure. There does not appear to be a need for heightened surveillance in IBP leads with observed elevated SIC counts that have no other findings to suggest lead malfunction.     

Negative association between self-reported jaw symptoms and apnea–hypopnea index in patients with symptoms of obstructive sleep apnea syndrome: a pilot study

Objectives

Prior to oral appliance therapy for snoring and obstructive sleep apnea syndrome (OSAS), patients are screened for jaw symptoms (e.g., pain). However, the presence of jaw symptoms in a large spectrum of OSAS patients remains unknown. This study aimed to assess the distribution of subjective jaw symptoms in patients with symptoms of OSAS.

Methods

Five hundred and eleven consecutive patients (66 female, 445 male; mean age 49.6?±?12.6 years) with clinical symptoms of OSAS were enrolled for cardiorespiratory evaluation. Self-administered questionnaires were used to assess jaw symptoms, tooth grinding and clenching during sleep, morning oral dryness, morning heartburn sensation, and pain in the neck and back.

Results

The mean apnea–hypopnea (AHI) index was 32.5?±?30.6 per hour of sleep. Nineteen percent of patients (n?=?96) reported at least one jaw symptom. The presence of jaw symptoms was more frequently reported by patients with AHI less than 15 (25 %) than those with AHI of 15 and more (15 %, p?=?0.012). In the crude analyses, jaw symptoms were associated with tooth grinding, tooth clenching, morning oral dryness, morning heartburn sensation, and neck/back pain. Multiple logistic regression analysis confirmed that jaw symptoms were associated with AHI less than 15 (odds ratio (OR) 1.99, p?=?0.009), tooth clenching (OR 1.79, p?=?0.006), morning oral dryness (OR 2.17, p?=?0.02), and neck/back pain (OR 1.99, p?=?0.005).

Conclusions

Jaw symptoms can be found in 19 % of patients with symptoms of OSAS and are more frequently reported in patients with lower AHI, a patient population for whom oral appliances are often prescribed.