The relationship between complaints of night‐time heartburn and sleep‐related gastroesophageal reflux

This study investigated whether the complaint of night‐time heartburn (NHB) as opposed to daytime heartburn (DHB) is a reliable reflection of actual sleep‐related reflux events. Three groups of individuals were studied: individuals with complaints of NHB at least twice per week (n = 24), individuals with complaints of DHB (n = 23), and normal participants without any complaints of regular heartburn during the day or night (n = 25). All three groups were studied on one occasion with combined pH monitoring and polysomnography, and subjective questionnaires about sleep disturbance and sleep quality were given to all participants. The NHB group had significantly more sleep‐related reflux events compared with both DHB and control groups (P < 0.01). DHB subjects had significantly (P < 0.05) more sleep‐related reflux events than normal controls. Total acid contact time (ACT) was significantly (P < 0.05) elevated in the NHB group compared with both the DHB and control group. Sleep‐related ACT was also significantly (P < 0.05) elevated in the NHB group compared with the other two groups, while upright (daytime) ACT was not significantly different. The NHB group was significantly (P < 0.05) worse regarding measures of both objective and subjective sleep quality. Subjects with exclusively DHB do have sleep‐related reflux that is greater than normal controls. Subjects with NHB have significantly more sleep‐related reflux, and both objective and subjective sleep abnormalities compared with normal controls. Complaints of NHB reflect sleep‐related reflux events and may be indicative of a more clinically significant condition.     

A review of methotrexate‐associated hepatotoxicity

Methotrexate is effective not only in treating psoriasis and rheumatoid arthritis but also various other disorders. The use of methotrexate has been somewhat limited by concerns regarding its adverse effects, including its potential for hepatotoxicity. The purpose of this article is to provide an overview of methotrexate‐associated hepatotoxicity, including risk factors, pathogenesis and recommendations for monitoring it by US, UK and European guidelines, as well as providing a brief overview of its mechanism of action and of high‐dose methotrexate.     

Accuracy of flash glucose monitoring in insulin‐treated patients with type 2 diabetes

The present study evaluated the accuracy of interstitial glucose measurements by flash glucose monitoring (FGM) and continuous glucose monitoring (CGM). Five diabetes patients simultaneously underwent FGM (FreeStyle Libre Pro) and CGM (iPro?2), and their glucose levels were compared with venous blood and capillary blood glucose levels. The range of daily venous blood glucose levels (30 measurements) was 70–245 mg/dL, with a median of 138 mg/dL. There were good correlations of glucose levels measured by FGM (r² = 0.90, mean absolute relative difference 8.2 ± 5.6%), CGM (r² = 0.86, mean absolute relative difference 9.2 ± 9.1%) and capillary blood (r² = 0.87, mean absolute relative difference 7.2 ± 7.2%) with venous blood glucose levels. The accuracy of FGM measurements was also shown against CGM, with 99.9% of the FGM values (1,279 measurements) being within the Parkes error grid zones A and B. The results suggest that the accuracy of FGM is similar to that of CGM, and that FGM is a useful tool for determining daily glucose profile.     

Prognostic Value of Continuous ST‐Segment Monitoring in Patients with Non‐ST‐Segment Elevation Acute Coronary Syndromes

Background: Patients with non‐ST‐segment elevation acute coronary syndromes constitute a heterogeneous group concerning prognosis. The 12‐lead ECG at rest is recommended for early risk stratification but is unable to reflect the dynamic nature of myocardial ischemia and coronary thrombosis. This study investigated whether continuous ST‐segment monitoring provides early prognostic information in such patients. Methods: We prospectively studied 183 patients admitted due to chest pain at rest suggestive of an acute coronary syndrome. ST‐segment monitoring was performed continuously for 24 hours from admission. Cardiac‐specific troponin I levels were determined on admission and every 6 hours for the first 24 hours. The endpoint was defined as death or nonfatal myocardial infarction, whichever occurred first by 30 days follow‐up. Results: ST episodes, defined as transient ST deviations of at least 0.1 mV, were detected in 50 patients 27.3%) and associated with worse 30‐day outcome: 22.0% endpoint rate compared to 6.8% for patients without ST episodes (P = 0.003). In a multivariate analysis, the presence of ST episodes hazard ratio, 3.07; 95% Cl, 1.26 to 7.46; P = 0.014) and peak troponin I levels > 0.2 μg/L (hazard ratio, 2.65; 95% Cl, 1.01 to 6.95; P = 0.048) were independent predictors of prognosis. The combination of ST‐segment monitoring and peak troponin I identified patients at low (2.5%, n = 79), intermediate (14.5%, n = 76), and high (25.0%, n = 28) risk for the 30‐day endpoint. Conclusions: In patients with non‐ST‐segment elevation acute coronary syndromes, continuous ST‐segment monitoring provides on‐line early prognostic information, in addition to troponin I levels. A.N.E. 2002;7(1):29–39     

Severity in Myocardial Dysfunction Contributed to Long‐term Fluctuation of Heart Rate,Rather than Short‐Term Fluctuations

Background: It is known that heart rate shows complex behavior, long‐term fluctuation of heart rate, and short‐term fluctuations in heart failure. Analyzing these properties and examining the relationship to the disease, severity may increase the understanding of the background of heart rate variability (HRV). Methods: In 61 patients (mean age 65 ± 9 years , 32 ischemic heart disease, 29 cardiomyopathy), with myocardial dysfunction, 24‐hour ambulatory electrocardiography was performed. After the construction of the time series of R‐R intervals, 15 HRV parameters were measured, including mean heart rate, standard deviation of N‐N intervals (SDNN), ratio of low frequency/high frequency power (LF/HF), HRV triangular index (TI), and ratio of length/width at the 90% level of all scattered points. Results: By using the multiple regression analysis, we tested which HRV parameter (HR, SDNN, LF/HF, TI, or length/width) independently correlated with left ventricular ejection fraction (EF) or left ventricular diastolic dimension (EDD). The results demonstrated that TI and SDNN independently correlated with EF (multiple R = 0.59). Moreover, TI and SDNN independently correlated with EDD (multiple R = 0.45). Conclusion: TI and SDNN were indicators of the disease severity in myocardial dysfunction, while LF/HF, indicators of autonomic tone, did not have such an ability. It was of interest that the disease severity contributed to long‐term fluctuations (TI, SDNN) of heart rate, rather than short‐term fluctuations (LF/HF).     

Self‐monitoring of blood glucose changed non‐insulin‐treated Type 2 diabetes patients’ beliefs about diabetes and self‐monitoring in a randomized trial

Aims To determine whether differences in beliefs about diabetes and its treatment resulted from different intensities of self‐monitoring of blood glucose (SMBG) in non‐insulin treated patients with Type 2 diabetes in the Diabetes Glycaemic Education and Monitoring (DiGEM) trial. Methods Patients (n = 453) were randomized to usual care, less‐intensive SMBG and more intensive SMBG. Beliefs about diabetes were measured with a standard questionnaire (the revised Illness Perceptions Questionnaire; IPQ‐R). Changes in beliefs were analysed using analysis of covariance (ancova) with adjustment for baseline values. Mediation analyses assessed whether differences in behavioural outcomes between groups could be attributed to differences in beliefs. Results Completed questionnaires were returned by 339 patients (74.8%). Respondents were mean (± sd ) age 65.9 ± 10 years and with diabetes duration of 4.8 ± 4.7 years (median 36, range 1–384 months). Concerns about the consequences of diabetes increased in both self‐monitoring groups, relative to control subjects [P = 0.004; Cohen's d standardized effect size = 0.19 less intensive and d = 0.36 more intensive monitoring]. No other beliefs about diabetes differed between groups. Beliefs about the importance of self‐testing increased in both self‐monitoring groups relative to the usual‐care group (P < 0.001; d = 0.57 less intensive and d = 0.63 more intensive monitoring). Changes in psychological well‐being did not differ between groups, but control patients reported greater increases in general (P = 0.014) and specific (P < 0.001) dietary adherence than did patients in the self‐monitoring groups. These outcomes were not mediated by intervention‐related changes in beliefs. Conclusions Despite changes in some beliefs about diabetes differing between groups there were no corresponding changes in self‐reported health behaviours. This suggests that changes in illness beliefs resulting from SMBG do not cause changes in diabetes‐related health behaviours.     

Heart Rate Variability Fraction—A New Reportable Measure of 24‐Hour R‐R Interval Variation

Background: The scatterplot of R‐R intervals has several unique features. Its numerical evaluation may produce a new useful index of global heart rate variability (HRV) from Holter recordings. Methods: Two‐hundred and ten middle‐aged healthy subjects were enrolled in this study. The study was repeated the next day in 165 subjects. Each subject had a 24‐hour ECG recording taken. Preprocessed data were transferred into a personal computer and the standard HRV time‐domain indices: standard deviation of total normal R‐R intervals (SDNN), standard deviation of averaged means of normal R‐R intervals over 5‐minute periods (SDANN), triangular index (TI), and pNN50 were determined. The scatterplot area (0.2–1.8 second) was divided into 256 boxes, each of 0.1‐second interval, and the number of paired R‐R intervals was counted. The heart rate variability fraction (HRVF) was calculated as the two highest counts divided by the number of total beats differing from the consecutive beat by <50 ms. The HRVF was obtained by subtracting this fraction from 1, and converting the result to a percentage. Results: The normal value of the HRVF was 52.7 ± 8.6%. The 2–98% range calculated from the normal probability plot was 35.1–70.3%. The HRVF varied significantly with gender (female 48.7 ± 8.4% vs male 53.6 ± 8.6%, P = 0.002). The HRVF correlated with RRI (r = 0.525) and showed a similar or better relationship with SDNN (0.851), SDANN (0.653), and TI (0.845) than did the standard HRV measures with each other. Bland‐Altman plot showed a good day‐by‐day reproducibility of the HRVF, with the intraclass correlation coefficient of 0.839 and a low relative standard error difference (1.8%). Conclusion: We introduced a new index of HRV, which is easy for computation, robust, reproducible, easy to understand, and may overcome the limitations that belong to the standard HRV measures. This index, named HRV fraction, by combining magnitude, distribution, and heart‐rate influences, might become a clinically useful index of global HRV.     

Structured self‐monitoring of blood glucose reduces glycated hemoglobin in insulin‐treated diabetes

The aim of the preset study was to investigate the effectiveness of structured self‐monitoring of blood glucose (SMBG) in insufficiently controlled insulin‐treated diabetes. A total of 86 insulin‐treated patients were randomized to a routine testing group (RTG; n = 43) and a structured testing group (STG; n = 43). The STG used a chart to record seven‐point blood glucose (BG) profile on three consecutive days per month. The primary end‐point was the glycated hemoglobin (HbA1c) at 3 months and 6 months. There were no significant differences of HbA1c between the RTG and STG at 3 months. However, the STG had significantly improved HbA1c at 6‐month follow‐up compared with the RTG (P = 0.002). In the STG, HbA1c decreased by 0.5% from 7.9 (SD 0.5) to 7.4 (0.7)%, whereas it decreased by 0.1% in the RTG from 7.9 (0.5) to 7.8 (0.7)%. In the STG, 55% of the patients were willing to continue structured SMBG and they achieved a 0.7% decrease of HbA1c. The present findings suggest that structured SMBG significantly improves glycemic control.     

The first study comparing a wearable watch‐type blood pressure monitor with a conventional ambulatory blood pressure monitor on in‐office and out‐of‐office settings

Wearable blood pressure (BP) monitoring devices which measure BP levels accurately both in and out of the office are valuable for hypertension management using digital technology. The authors have conducted the first comparison study of BPs measured by a recently developed wrist‐worn watch‐type oscillometric BP monitoring (WBPM) device, the “HeartGuide,” versus BPs measured by an ambulatory BP monitoring (ABPM) device, A&D TM‐2441, in the office (total of 4 readings alternately measured in the sitting position) and outside the office (30‐minutes interval measurements during daytime) in 50 consecutive patients (mean age 66.1 ± 10.8 years). The 2 BP monitoring devices were simultaneously worn on the same non‐dominant arm throughout the monitoring period. The mean difference (±SD) in systolic BPs (average of 2 readings) between WBPM and ABPM was 0.8 ± 12.8 mm Hg (P = .564) in the office and 3.2 ± 17.0 mm Hg (P < .001) outside the office. The proportion of differences that were within ±10 mm Hg was 58.7% in the office and 47.2% outside the office. In a mixed‐effects model analysis, the temporal trend in the difference between the out‐of‐office BPs measured by the two devices was not statistically significant. In conclusion, the difference between the WBPM and ABPM device was acceptable both in and out of the office.