Survival and trends of occurrence of left ventricular hypertrophy,gender differences, 1967-92: The Reykjavik Study

OBJECTIVE: We estimated the prevalence, incidence and risk factors of left ventricular hypertrophy (LVH) in a prospective cohort study of 26 489 participants. MATERIAL AND METHODS: The LVH was defined as Minnesota Code 310 on electrocardiogram (ECG). Everyone with this code at first visit was defined as a prevalence case and those who developed it between subsequent visits were incidence cases. The comparison cohort were all other participants in the Reykjavik Study stages I-V. RESULTS: A total of 297 men and 49 women were found to have LVH of 3.2% and 0.5%, respectively. The incidence was 25 per 1000 per year amongst men and six per 1000 per year amongst women. Prevalence in both genders increased with increasing age. Risk factors at the time of diagnosis were systolic blood pressure [odds ratio (OR) per mmHg 1.02; 95% confidence interval (CI): 1.01-1.03], age (OR per year 1.04; 95% CI: 1.02-1.05), silent myocardial infarction (MI) (OR 3.18; 95% CI: 1.39-7.27) and ST-T changes (OR 3.06; 95% CI: 2.14-4.38) amongst men and systolic blood pressure and age for women with similar odds ratio. Predictive factors for acquiring LVH were systolic blood pressure [incidence ratio (IR) 1.01; 95% CI: 1.01-1.02] and angina with ECG changes (IR 2.33; 95% CI: 1.08-5.02) amongst men and systolic blood pressure amongst women (IR 1.03; 95% CI: 1.01-1.04). The risk for coronary mortality was significantly increased amongst women with hypertrophy [hazard ratio (HR) 3.07; 95% CI: 1.5-6.31] and their total survival was poorer with increasing time from diagnosis of LVH (HR 2.17; 95% CI: 1.36-3.48). CONCLUSIONS: We conclude that the presence of LVH and its appearance is associated with age and increased blood pressure amongst both genders. Women with LVH have poorer survival than other women and they are at threefold risk of dying of ischaemic heart disease.     

Higher dietary salt intake is associated with microalbuminuria,but not with retinopathy in individuals with type 1 diabetes: the EURODIAB Prospective Complications Study

Aims/hypothesis

High dietary salt intake has been associated with elevated BP and may also have a deleterious effect on microvascular complications. We studied the cross-sectional associations between dietary salt intake (estimated from 24 h urinary sodium excretion) and urinary potassium excretion on the one hand, and the prevalence of microvascular complications on the other, in individuals with type 1 diabetes.

Methods

We measured sodium and potassium concentrations in two 24 h urine samples in 1,212 individuals with type 1 diabetes (40?±?10 years old, 51% men) who participated in the EURODIAB Prospective Complications Study. We used multiple logistic regression analyses to investigate associations between dietary salt intake and microvascular complications adjusted for age and sex, and additionally for BMI, smoking, urinary potassium excretion, antihypertensive medication and physical activity, and total energy, protein, alcohol, saturated fat and fibre intake.

Results

After full adjustment, 1 g/day higher dietary salt intake was positively associated with the presence of microalbuminuria (OR 1.06 [95% CI 1.01, 1.10]), but not macroalbuminuria (OR 0.99 [95% CI 0.94, 1.05]), non-proliferative retinopathy (OR 1.00 (95% CI 0.96, 1.04]) or proliferative retinopathy (OR 1.02 (95% CI 0.95, 1.08]). After excluding individuals with cardiovascular disease and/or antihypertensive medication (n?=?418), we found a non-significant association with microalbuminuria (OR 1.04 [95% CI 0.99, 1.10]) and macroalbuminuria (OR 1.05 [95% CI 0.96, 1.16]). The association between dietary salt intake and microalbuminuria was stronger in individuals with a BMI above 25 kg/m² (OR 1.11 [95% CI 1.04, 1.18]) than in those with BMI below 25 kg/m² (OR 1.03 [95% CI 0.97, 1.09]). No significant associations were found between urinary potassium excretion and microvascular complications.

Conclusions/interpretation

In individuals with type 1 diabetes, higher dietary salt intake, as determined by 24 h urinary sodium excretion, may be positively associated with microalbuminuria, particularly in overweight individuals.     

Association between nutrient intake and peripheral artery disease: results from the InCHIANTI study

BACKGROUND: Little is known about the relationship between dietary patterns and peripheral arterial disease (PAD). Our aim was to estimate the association between nutrient intake and diagnosis of PAD. METHODS AND RESULTS: We assessed the nutrient intake of 1251 home-dwelling subjects enrolled in the InCHIANTI study, mean age 68 years (S.D.: 15). We explored the relationship between nutrient intake, obtained through the European Prospective Investigation into Cancer and Nutrition (EPIC) questionnaire, and PAD, defined as an ankle-brachial index (ABI)<0.90. After adjustment for potential confounders, we found a reduction of the risk of having an ABI<0.90 associated with vegetable lipid intake>or=34.4 g/day (OR: 0.39; 95% CI: 0.16-0.97), Vitamin E intake>or=7.726 mg/day (OR: 0.37; 95% CI 0.16-0.84) and higher serum HDL cholesterol concentration (OR: 0.76; 95% CI: 0.63-0.92 for 10mg/dl increase). Age (OR: 1.11; 95% CI 1.07-1.14 for 1 year increase), smoking (OR: 1.03; 95% CI: 1.01-1.04 for 10 packs/year increase) and pulse pressure (OR: 1.11; 95% CI: 1.03-1.19 for 5 mmHg increase) were associated with an increased risk of PAD. CONCLUSIONS: A higher intake of vegetable lipids, Vitamin E and higher concentrations of serum HDL cholesterol characterize subjects free from PAD. Prospective studies are needed to verify whether this dietary pattern and/or interventions aimed at increasing HDL cholesterol exert some protective effect against PAD.     

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients’ demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima’s classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02–1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04–3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01–1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03–0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08–1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r ² = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.     

The relationship between sexual activity and urinary incontinence in older women

OBJECTIVES: To determine whether continence status is associated with sexual activity in older women. DESIGN: Cross-sectional postal survey. SETTING: Random selection from a list of respondents to a Canada Post survey. PARTICIPANTS: Community-dwelling women aged 55 to 95. MEASUREMENTS: The International Consultation on Incontinence Questionnaire Short Form measured the presence, severity, and type of incontinence. Sexual activity and marital status were assessed using single close-ended questions. The Medical Outcomes Study 12-item Short-Form Health Survey was used to query physical and mental health status. RESULTS: Data from 2,361 women (mean age 71) were available for analysis. Thirty-nine percent reported urinary incontinence (UI), and 27% were sexually active. UI was associated with sexual activity in crude logistic analyses (odds ratio (OR)=0.82, 95% confidence interval (CI)=0.68-0.98) but not in multivariate models adjusted for physical and mental health. Marital status and age were the strongest predictors of sexual activity (OR 8.94, 95% CI=6.89-11.60 for married women; OR=3.09, 95% CI=2.57-3.73 for age 相似文献   

Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: a role for insulin resistance and diabetes

It is uncertain whether patients with nonalcoholic fatty liver disease (NAFLD) and normal alanine aminotransferase (ALT) have a milder disease and should undergo liver biopsy. We reviewed the histological data of 458 Italian patients with NAFLD in whom liver biopsy was indicated by altered liver enzymes (395 cases, 86%), or persistently elevated ferritin or long-lasting severe steatosis (63 cases). Factors associated with nonalcoholic steatohepatitis (NASH) and fibrosis >/= 2 were identified by multivariate analysis. Patients with normal ALT were significantly older, had lower body mass index, fasting triglycerides, insulin resistance according to homeostasis model assessment (HOMA-IR), ALT, and gamma-glutamyltransferase, but a higher prevalence of hypertension. NASH was diagnosed in 59% and 74% of the patients with normal and increased ALT, respectively (P = 0.01). In the overall series of patients, NASH was independently predicted by ALT (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.04-1.19 per 10-IU/mL increase) and diabetes (OR, 1.5; 95% CI, 1.1-2.0). The same variables were selected in patients with increased ALT, whereas in those with normal ALT, HOMA-IR and ALT were independent predictors. Severe fibrosis was independently predicted by serum ferritin (OR, 1.04; 95% CI, 1.001-1.08 per 50-ng/mL increase), ALT (OR, 1.07; 95% CI, 1.02-1.14), and diabetes (OR, 1.8; 95% CI, 1.4-2.3) in the overall series, serum ferritin and diabetes in those with increased ALT, and only HOMA-IR (OR, 1.97; 95% CI, 1.2-3.7) in patients with normal ALT. CONCLUSION: Normal ALT is not a valuable criterion to exclude patients from liver biopsy. Alterations in glucose metabolism and insulin resistance in subjects with normal ALT should also be considered in the selection of NAFLD cases for histological assessment of disease severity and progression.     

Disparities in the use of immunomodulators and biologics for the treatment of inflammatory bowel disease: a retrospective cohort study

BACKGROUND: Treatment disparities between African Americans (AA) and Caucasians exist in multiple diseases. There are limited studies in inflammatory bowel disease (IBD). Our objectives were to assess differences in IBD therapies between AA and Caucasians, controlling for disease severity. METHODS: We identified outpatients with ulcerative colitis (UC) or Crohn's disease (CD) evaluated at the University of Maryland and the Baltimore Veterans Affairs Medical Center from 1997-2005. We assessed medications used and the presence of covariates by race. RESULTS: We identified 406 patients; 102 were AA (25%). AA were less likely to receive steroids (56% versus 68%; P = 0.02), mercaptopurine/azathioprine (6-MP/AZA) (28% versus 40%; P = 0.03), infliximab (IFX) (10% versus 20%; P = 0.03), or either 6-MP/AZA or IFX (28% versus 44%; P = 0.005). Age at diagnosis <40 (odds ratio [OR] 2.22, 95% confidence interval [CI] 1.06-4.54), steroid use (OR 4.75, 95% CI 1.93-11.7), and CD (OR 6.25, 95% CI 3.22-12.5) were positively associated with IFX use, while AA (OR 0.50, 95% CI 0.23-1.08) was negatively associated with IFX use. Age at diagnosis <40 (OR 1.84, 95% CI 1.12-3.23), steroid use (OR 10.2, 95% CI 5.37-19.2), and CD (OR 2.32, 95% CI 1.43-3.20) were positively associated with either 6-MP/AZA or IFX use, while AA (OR 0.57, 95% CI 0.32-1.01) was negatively associated with 6-MP/AZA or IFX use. CONCLUSIONS: There were trends toward lower odds of treatment with IFX or either 6-MP/AZA or IFX in AA when compared with Caucasians. Further studies are needed to determine if these differences are due to less severe disease in AA patients or due to disparities in care.     

Impact of patatin-like phospholipase-3 (rs738409 C>G) polymorphism on fibrosis progression and steatosis in chronic hepatitis C

Only 20% of patients with chronic hepatitis C (CHC) will develop cirrhosis, and fibrosis progression remains highly unpredictable. A recent genome-wide association study identified a genetic variant in the patatin-like phospholipase-3 (PNPLA3) gene (rs738409 C>G) associated with steatosis that was further demonstrated to influence severity of fibrosis in nonalcoholic fatty liver disease. The aim of this study was to assess the impact of this polymorphism on histological liver damage and response to antiviral therapy in CHC. We recruited 537 Caucasian CHC patients from three European centers (Brussels, Belgium [n = 229]; Hannover, Germany [n = 171]; Lyon, France [n = 137]); these patients were centrally genotyped for the PNPLA3 (rs738409 C>G) polymorphism. We studied the influence of rs738409 and other variants in the PNPLA3 region on steatosis and fibrosis assessed both in a cross-sectional and longitudinal manner. Seven other variants previously associated with fibrosis progression were included. Finally, we explored the impact of rs738409 on response to standard antiviral therapy using the interferon lambda 3 (IL28B) [rs12979860 C>T] variant both as a comparator and as a positive control. After adjustment for age, sex, body mass index, alcohol consumption, and diabetes, rs738409 mutant G allele homozygote carriers remained at higher risk for steatosis (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.08-6.03, P = 0.034), fibrosis (OR 3.13, 95% CI 1.50-6.51, P = 0.002), and fibrosis progression (OR 2.64, 95% CI 1.22-5.67, P = 0.013). Conversely, rs738409 was not independently associated with treatment failure (OR 1.07, 95% CI 0.46-2.49, P = 0.875) and did not influence clinical or biological variables. CONCLUSION: The PNPLA3 (rs738409 C>G) polymorphism favors steatosis and fibrosis progression in CHC. This polymorphism may represent a valuable genetic predictor and a potential therapeutic target in CHC liver damage.     

The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease

BACKGROUND: The prevalence of erectile dysfunction (ED) and associated risk factors has been described in many clinical settings, but there is little information regarding men seen by primary care physicians. We sought to identify independent factors associated with ED in a primary care setting. METHODS: We surveyed a cross-sectional sample of 3921 Canadian men, aged 40 to 88 years, seen by primary care physicians. Participants completed a full medical history, physical examination, and measurement of fasting blood glucose and lipid levels. We used the International Index of Erectile Function to define ED as a score of less than 26 on the erectile function domain. RESULTS: The overall prevalence of ED was 49.4%. The presence of cardiovascular disease (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.16-1.81; P<.01) or diabetes (OR, 3.13; 95% CI, 2.35-4.16; P<.001) increased the probability of ED after adjustment for other confounders. Among those individuals without cardiovascular disease or diabetes, the calculated 10-year Framingham coronary risk (OR, 1.03 per 1% increase; 95% CI, 1.02-1.05; P<.001) and fasting blood glucose levels (OR, 1.14 per 18-mg/dL [1-mmol/L] increase; 95% CI, 1.04-1.24; P<.01) were independently associated with ED. Erectile dysfunction was also independently associated with undiagnosed hyperglycemia (OR, 1.46; 95% CI, 1.02-2.10; P = .04), impaired fasting glucose (OR, 1.26; 95% CI, 1.08-1.46; P = .004), and the metabolic syndrome (OR, 1.45; 95% CI, 1.24-1.69; P<.001). CONCLUSIONS: Cardiovascular disease, diabetes, future coronary risk, and increasing fasting glucose levels are independently associated with ED. It remains to be determined if ED precedes the development of these conditions.     

Telomere length and cardiovascular risk in hypertensive patients with left ventricular hypertrophy: the LIFE study

Short telomeres are associated with aging and age-related diseases. Our aim was to determine whether short leukocyte telomere length is associated with risk factors and cardiovascular diseases in a high-risk hypertensive population. We measured leukocyte telomere lengths at recruitment in 1271 subjects with hypertension and left ventricular hypertrophy (LVH) participating in the Lifestyle Interventions and Independence for Elders (LIFE) study. At baseline, short mean telomere length was associated with coronary artery disease in males (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39-0.95), and transient ischemic attack in females (OR 0.62 95% CI 0.39-0.99). Proportion of short telomeres (shorter than 5?kb) was associated with Framingham risk score (r=0.07, P<0.05), cerebrovascular disease (OR 1.18, 95% CI 1.01-1.15) and type 2 diabetes in men (OR 1.07, 95% CI 1.02-1.11). During follow-up, proportion of short telomeres was associated with combined cardiovascular mortality, stroke or angina pectoris (hazard ratio 1.04, 95% CI 1.01-1.07). Telomere length was not associated with smoking, body mass index, pulse pressure or self-reported use of alcohol. Our data suggest that reduced leukocyte telomere length is associated with cardiovascular risk factors and diseases as well as type 2 diabetes, and is a predictor of cardiovascular disease in elderly patients with hypertension and LVH.     

Sociodemographic and socioeconomic characteristics of elder self-neglect in an US Chinese aging population

This study aimed to examine the socio-demographic and socioeconomic characteristics associated with prevalence and severity of elder self-neglect in an U.S. Chinese older population. The PINE study is a population-based epidemiological study in the greater Chicago area. In total, 3159 Chinese older adults were interviewed from 2011 to 2013. Elder self-neglect was assessed with systematic observations of a participant’s personal and home environment across five domains: hoarding, personal hygiene, house in need of repair, unsanitary conditions, and inadequate utility. Elder self-neglect was prevalent among older adults aged 80 years or over (mild self-neglect: 34.6% 95% CI 30.9–38.4; moderate/severe: 15.6% 95% CI 12.8–18.6), men (mild: 28.6% 95% CI 26.1–31.3; moderate/severe: 13.1% 95% CI 11.2–15.1), those with 0–6 years of education (mild: 32.2% 95% CI 29.7–34.9; moderate/severe: 12.6% 95% CI 10.8–14.5), and those with an annual personal income between $5000 and $10,000 (mild: 30.8% 95% CI 28.4–33.2; moderate/severe: 11.8% 95% CI 10.2–13.5). Older age (mild self-neglect: OR 1.02, 95% CI 1.01–1.03; moderate/severe self-neglect: OR 1.02, 95% CI 1.00–1.03) and lower education levels (mild self-neglect: OR 1.06, 95% CI 1.03–1.08; moderate/severe self-neglect: OR 1.07, 95% CI 1.04–1.09) were associated with significantly increased odds of elder self-neglect. Women (moderate/severe self-neglect: OR 0.73, 95% CI 0.58–0.93) had significantly decreased odds of moderate/severe elder self-neglect. No significant association was found between levels of income and overall elder-self-neglect of all severities. Future research is needed to examine risk/protective factors associated with elder self-neglect in U.S. Chinese older populations.     

Heart failure after acute coronary syndrome: identify to treat better!

INTRODUCTION: The development of heart failure (HF) following acute coronary syndromes (ACS) significantly worsens short- and long-term prognosis. The present study aimed to identify clinical characteristics, detectable at admission for ACS, that could predict HF development during hospitalization, and to evaluate its impact on in-hospital mortality. METHODS: This was a retrospective cohort study that included 601 patients consecutively admitted with ACS. Demographic, clinical and laboratory data at admission were collected and HF was defined as maximum Killip class II or III. Logistic regression analysis was performed to identify independent predictors of HF and, additionally, in-hospital death. RESULTS: 29.3% of the population developed HF, mostly older patients (69.52+/-11.9 years vs. 61.81+/-12.4 years, p<0.0001), women, hypertensive, diabetic and non-smokers. On admission, this subgroup of patients presented with higher heart rate and glycemia, and lower glomerular filtration rate (eGFR) and hemoglobin. The percentage of patients with left ventricular systolic dysfunction (LVSD) was significantly higher in the group of patients with HF (74.4% versus 48.7%, p<0.0001); however, no significant differences were found in the type of ACS or its location. In the present study, we found that patients with HF were stratified less invasively (less likely to undergo cardiac catheterization or percutaneous coronary intervention). The development of HF was associated with longer hospitalization and higher in-hospital mortality (7.4% versus 2.1%, p=0.004) on univariate analysis, but not on multivariate analysis. On multivariate analysis, only age (OR=1.04; 95% CI 1.02-1.06), diabetes mellitus (OR=1.77; 95% CI 1.05-2.96), glycemia (OR=1.05; 95% CI 1.01-1.08), eGFR <60 ml/min/1.73m2 (OR=2.90, 95% CI 1.73- 4.84), heart rate (OR=1.03, 95% CI 1.02-1.04) and LVSD (OR=2.48, 95% CI 1.59-3.85) were independent predictors of HF. CONCLUSIONS: HF is a frequent complication in ACS and is associated with higher in-hospital mortality. Identifying risk of HF development on admission, through easily acquired clinical characteristics (older age, diabetes and/or elevated glycemia, renal failure and higher heart rate), will certainly influence immediate therapeutic choices and permit an individualized approach to each patient.     

Contemporary clinical outcomes of primary percutaneous coronary intervention in elderly versus younger patients presenting with acute ST-segment elevation myocardial infarction

Background: Primary percutaneous coronary intervention (PPCI) is the choice reperfusion strategy for acute ST‐segment elevation myocardial infarction (STEMI). However, data on PPCI in elderly patients are sparse. This study determined clinical outcome post‐PPCI in elderly versus younger patients with STEMI. Methods and Results: A cohort of 790 consecutive STEMI patients was studied for survival and major adverse cardiovascular events (MACE) after PPCI using a precise cardiac catheterization protocol. Patients were divided into two groups: those ≥75 years (elderly) and those <75 years. Median door‐to‐balloon time (DBT) was 82 minutes in the elderly versus 66 minutes in the younger group (P = 0.002). In‐hospital all‐cause mortality was higher in the elderly group (15.5% vs. 2.7%, P < 0.001). In elderly patients, MACE were found to be higher (32.3% vs. 16.1%, P < 0.001). Using a multivariate logistic regression analysis, age (odds ratio [OR]= 1.04, 95% confidence interval [CI]= 1.02–1.05, P < 0.001), diabetes (OR = 2.17, 95% CI = 1.33–3.53, P = 0.002), renal failure (OR = 3.75, 95% CI = 1.30–10.79, P = 0.014) and coronary artery disease (OR = 1.61, 95% CI = 1.00–2.59, P = 0.050) were associated with higher in‐hospital MACE, while age (OR = 1.05, 95% CI = 1.02–1.08, P = 0.001), diabetes (OR = 2.18, 95% CI = 1.06–4.47, P = 0.034) and renal failure (OR = 6.65, 95% CI = 2.01–22.09, P = 0.002) were associated with higher in‐hospital mortality. Kaplan–Meier 1‐year survival rate was lower in the elderly. Conclusions: In a contemporary population of STEMI patients treated with PPCI, overall in‐hospital MACE and mortality remain higher in elderly compared to younger patients. Although partly due to higher burden of preexisting comorbidities, a higher DBT may also be responsible. (J Interven Cardiol 2011;24:357–365)     

Treatment choices and outcomes of patients with manometrically diagnosed achalasia

This prospective population‐based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre‐diagnosis and Medical Outcomes Study 36‐item Short‐Form (SF‐36) survey. Treatment decisions were made by the referring physician and the patient. Follow‐up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1‐year follow‐up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty‐four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/? 12.2, 17 +/? 10.9, and 9 +/? 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of ?3.5 +/? 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF‐36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment.     

Effectiveness of thrombolytic therapy for acute myocardial infarction in the elderly: cause for concern in the old-old

BACKGROUND: National guidelines have encouraged increased use of thrombolytic therapy for elderly patients with acute myocardial infarction (AMI). However, evidence supporting thrombolytic therapy in patients 75 years and older is lacking. In a retrospective cohort study of 2659 elderly AMI patients, we determined the association between thrombolytic use and in-hospital mortality by age and among patients with or without absolute or relative contraindications to thrombolytic treatment. METHODS: We abstracted the medical records of 2659 elderly patients admitted with AMI at 37 Minnesota community hospitals between 1992 and 1996. The main outcome measure was in-hospital mortality, controlling for demographic, clinical, comorbidity, and severity-of-illness variables. RESULTS: Sixty-three percent of 719 eligible patients received thrombolytic therapy. Twenty-seven percent of thrombolytic recipients had absolute contraindications to treatment. Patients receiving thrombolytic agents had fewer and less severe comorbidities than those not receiving thrombolytic therapy. There was a 4% increase in the odds of death for every 1-year increase in age for all thrombolytic recipients vs nonrecipients (odds ratio [OR], 1.04 per year; 95% confidence interval [CI], 1.01-1.08; P =.03). Among patients with 1 or more contraindication, the OR for death associated with thrombolytic use was 1.57 (95% CI, 1.03-2.40; P =.04). The adjusted odds of death among eligible thrombolytic recipients (vs nonrecipients) increased significantly with age (OR, 1.08 per year; 95% CI, 1.02-1.14; P =.008). Among eligible patients aged 80 to 90 years, the predicted odds of death among thrombolytic recipients vs nonrecipients was 1.4. Among eligible patients younger than 80 years, thrombolytic use was associated with reduced mortality. CONCLUSIONS: Our findings suggest the need for more research on the effectiveness of thrombolytic therapy for AMI patients 75 years and older and for more careful selection of elderly patients for this treatment.     

A multicenter cross sectional study on bone mineral density in rheumatoid arthritis. Italian Study Group on Bone Mass in Rheumatoid Arthritis

OBJECTIVE: To determine the frequency of osteoporosis in a large cohort of women with rheumatoid arthritis (RA) and to investigate the main determinants of bone mineral density (BMD) and risk factors for vertebral fractures in this population. METHODS: We recruited 925 consecutive female patients with RA at 21 Rheumatology Centers in Italy. For each patient pre-registered demographic, disease, and treatment-related variables were collected. BMD was measured at lumbar spine and proximal femur by dual x-ray absorptiometry technique. Collected variables underwent a univariate and multivariate statistical procedure. Osteoporosis was defined as BMD > -2.5 T score. RESULTS: The frequency of osteoporosis in the whole sample was 28.8% at lumbar spine and 36.2% at femoral neck and increased linearly from Steinbrocker's functional stage I to IV (p = 0.0001). Patients with spinal or femoral osteoporosis were significantly older (p = 0.0001), had a lower body mass index (BMI) (p < 0.02), a significantly longer disease duration (p < 0.02) and a significantly higher Health Assessment Questionnaire (HAQ) score (p = 0.0001). These differences were significant, even after adjusting for age. Steroid use was associated with significantly lower lumbar and femoral BMD (p = 0.0001) even after adjusting for the main confounding covariates. Analysis of lateral spine radiographs revealed 74 women with at least one vertebral fracture. These women had a significantly lower lumbar and femoral BMD (p = 0.0001). The generalized linear model showed that steroid use, menopause, BMI, age, and HAQ were all significant independent predictors of lumbar and femoral BMD. The logistic procedure showed that age (OR 1.05, 95% CI 1.03-1.07), HAQ (OR 1.3, 95% CI 1.07-1.7), menopause (OR 1.9, 95% CI 1.1-3.2), use of steroids (OR 1.5, 95% CI 1.07-2.1), and BMI (OR 0.8, 95% CI 0.8-0.9) were significantly associated with the risk for osteoporosis. The only variables associated with an increased risk for vertebral fracture were age (OR 1.04, 95% CI 1.01-1.08), HAQ (OR 1.7, 95% CI 1.08-2.09), and cumulative steroid intake (OR for 1 g of prednisone 1.03, 95% CI 1.006-1.07). CONCLUSION: To prevent osteoporosis and its dramatic complications in RA the therapeutic challenge is to preserve functional capacity using the lowest possible dosage of corticosteroids.     

Willingness to participate in HIV/STD prevention activities among Chinese rural-to-urban migrants.

Data from 4,208 migrants aged 18-30 years old in Beijing and Nanjing, China, were analyzed to examine the correlates of willingness to participate (WTP) in HIV/STD prevention intervention activities among Chinese rural-to-urban migrants. Overall, 83.3% of the respondents would be willing to participate. Increased WTP was associated with employment in the industrial sector (OR=1.59, 95% CI: 1.11-2.29), migrating to cities to learn more about the outside world (OR=1.31, 95% CI: 1.08-1.59), prior experience with health maintenance (OR=1.36, 95% CI: 1.11-1.66), higher level of HIV/AIDS awareness (OR=1.16, 95% CI: 1.02-1.31), and perceived severity of risk behaviors (OR=1.32, 95% CI: 1.04-1.68). Decreased WTP was associated with increased involvement in health risk behaviors (OR=0.50, 95% CI: 0.35-0.73), increased perceptions of peer risk involvement (OR=0.81, 95% CI: 0.68-0.98), perceived intrinsic rewards for risk behaviors (OR=0.81, 95% CI: 0.68-0.96) and perceptions of HIV-related stigma (OR=0.68, 95% CI: 0.53-0.89). The high level of WTP suggests that HIV/STD prevention activities are acceptable among rural-to-urban migrants. Their awareness of HIV/AIDS should be increased and HIV-related stigma should be reduced to increase the level of WTP. Recruitment and retention of individuals with high-risk behavior in prevention activities will be critical and challenging.     

Hepatic steatosis and insulin resistance are associated with severe fibrosis in patients with chronic hepatitis caused by HBV or HCV infection

Background and aims: Steatosis and insulin resistance (IR) are the major disease modifying in patients with chronic hepatitis C (CHC). Only few studies evaluated these features in patients with chronic hepatitis B (CHB). We aimed to assess the prevalence and the factors related to steatosis and IR in CHB patients, compared with CHC subjects, and to evaluate the potential association between these features and fibrosis severity. Material and methods: One hundred and seventy consecutive patients with CHB (28 HBeAg positive, 142 HBeAg negative), were evaluated using liver biopsy and metabolic measurements and matched for sex, age and body mass index with 170 genotype 1 CHC patients. IR was defined if HOMA‐IR>2.7. All biopsies were scored for grading and staging by Scheuer's score, and the steatosis was considered significant if ≥10%. Results: The prevalence of significant steatosis was similar in both CHB and CHC patients (31 vs. 38%; P=0.14). IR rate was significantly higher in CHC than in CHB patients (42 vs. 26%; P=0.002). Severe fibrosis (F3–F4), at multivariate analysis, was independently associated with older age (OR 1.050, 95% CI 1.009–1.093), steatosis >10% (OR 4.375, 95% CI 1.749–10.943), and moderate–severe necroinflammatory activity (OR 8.187, 95% CI 2.103–31.875), regardless of HBeAg status, in CHB patients, and with older age (OR 1.080, 95% CI 1.028–1.136), IR (OR 2.640, 95% CI 1.110–6.281), steatosis >10% (OR 3.375, 95% CI 1.394–8.171), and moderate–severe necroinflammatory activity (OR 8.988, 95% CI 1.853–43.593) in CHC patients. Conclusions: CHB patients had high steatosis prevalence, similar to CHC controls, but lower IR rate. Both steatosis and IR in CHC, and only steatosis in CHB, are independently associated with fibrosis severity.     

高血浆高半胱氨酸和脂蛋白相关磷脂酶A2水平与痴呆的相关性

目的 探讨血浆高半胱氨酸(homocysteine, Hcy)和脂蛋白相关磷脂酶A2(lipoprotein-associated phospholipase A2, Lp-PLA2)水平与痴呆的相关性.方法 回顾性纳入住院的痴呆患者,根据Hachinski缺血量表分为血管性痴呆(vascular dementia, VaD)组、混合性痴呆(mixed dementia, MD)组和阿尔茨海默病(Alzheimer''s disease, AD)组,同时根据简易精神状态检查量表将痴呆严重程度分为轻度、中度和重度.另选同时期住院的非痴呆患者作为对照组.比较各组人口统计学、血管危险因素以及血浆Hcy和Lp-PLA2水平.应用logistic回归分析确定血浆Hcy和Lp-PLA2水平与痴呆风险和严重程度的独立相关性.结果 共纳入125例痴呆患者,VaD组52例(41.6%),MD组21例(16.8%),AD组52例(41.6%);轻度组49例(39.2%),中度组51例(40.8%),重度组25例(20%).40例非痴呆患者被纳入作为对照组.VaD组、MD组和AD组血浆Hcy及Lp-PLA2水平均显著高于对照组(P均<0.001).多变量logistic回归分析显示,高龄[优势比(odds ratio, OR)1.12,95%可信区间(confidence interval, CI)1.03~1.21;P=0.010]、高血浆Hcy水平(OR 1.44,95% CI 1.21~1.71;P<0.001)、高Lp-PLA2水平(OR 1.01,95% CI 1.00~1.02;P=0.006)和既往卒中史(OR 4.29,95% CI 1.50~12.36;P=0.007)是痴呆的独立危险因素;高Hcy水平(OR 1.48,95% CI 1.21~1.82;P<0.001)、高Lp-PLA2水平(OR 1.01,95% CI 1.00~1.03;P=0.002)和既往卒中史(OR 152.78,95% CI 20.41~999.97;P<0.001)是VaD的独立危险因素;高龄(OR 1.10,95% CI 1.02~1.17;P=0.008)和高Hcy水平(OR 1.41,95% CI 1.25~1.58;P<0.001)是重度痴呆的独立危险因素.结论 血浆Hcy和Lp-PLA2水平升高与痴呆相关,降低血浆Hcy和Lp-PLA2水平可能对治疗和预防痴呆有益.     

Metabolic biomarkers and gallstone disease – a population-based study

Objectives: The objectives for this study were to examine the associations between metabolic biomarkers of obesity including insulin resistance, vascular dysfunction, systemic inflammation, genetic susceptibility and ultrasound proven gallstone disease or cholecystectomy in a population-based cross-sectional study.

Material and methods: A total of 2650 participants were included, of whom 422 had gallstone disease. Associations between selected metabolic biomarkers and gallstone disease were estimated by multivariable logistic regression models and expressed as odds ratio (OR) and 95% confidence interval (CI).

Results: Gallstone disease was associated with fasting glucose (OR 1.14, 95% CI [1.05;1.24]), fasting insulin (OR 1.03, 95% CI [1.01;1.05]), homeostasis model assessment insulin resistance (OR 1.18, 95% CI [1.02;1.36]), the metabolic syndrome (OR 1.51, 95% CI [1.16;1.96]), white blood cell count (OR 1.07, 95% CI [1.00;1.15]) and C-reactive protein (OR 1.03, 95% CI [1.01;1.05]). A tendency towards an association for soluble urokinase plasminogen activator receptor was also found (OR 1.08, 95% CI [0.99;1.18]). The MC4R(rs17782313) (OR 1.27, 95% CI [1.02;1.58]), MAP2K5(rs2241423) (OR 1.80, 95% CI [1.04;3.41]), NRXN3(rs10146997) (OR 1.26, 95% CI [1.01;1.57]), HHEX(rs1111875) (OR 1.29, 95% CI [1.03;1.62]), FAIM2(rs7138803) (OR 0.66, 95% CI [0.48;0.91]), and apolipoprotein E4 allele (OR 0.76, 95% CI [0.59;0.98]) were associated with gallstone disease. Urinary albumin was not associated with gallstone disease. The association between BMI and gallstone disease was explained by insulin resistance.

Conclusions: Biomarkers of insulin resistance, systemic inflammation and genetic obesity or type 2 diabetes risk alleles seem to be associated with gallstone disease. Future studies should explore temporal associations and genetic associations in other populations in order to clarify targets for prevention or intervention.