Predictors of the quality of cardiovascular prevention �C a multilevel cross-sectional study

Aim

To attempt to develop a model of predictors for quality of the process of cardiovascular prevention in patients at high risk of cardiovascular disease (CVD).

Methods

We formed a random sample of patients from a stratified sample of 36 family practice registers of patients at high risk of CVD without diabetes and without established CVD. Data were gathered by chart audit and questionnaires about patient and practice characteristics. We defined the process of care as a dependent variable by principle component analysis and tested the relationship of the process with several independent variables (family physicians’, patients’, and practice characteristics). To study the effects of independent variables (predictors) on the process of care we carried out multilevel regression analysis with the patients constituting the lower level and nested within the family physician/practice (the second level).

Results

Multilevel regression analysis included 645 patients from 36 practices (74.1% from the final sample). Patients’ characteristics that predicted the higher-quality process of CVD prevention were younger age (t = -4.94, 95% confidence interval [CI] -0.018 to -0.008) and lower socioeconomic status (t = -2.18, 95%CI -0.195 to -0.010). Practice characteristics that predicted the higher-quality process of CVD prevention were smaller practice size (t = 2.83, 95% CI 0.063 to 1.166), a good information system for CVD prevention (t = 3.15, 95% CI 0.030 to 0.282), and the organization of education on CVD prevention (t = 3.19, 95%CI 0.043 to 0.380).

Conclusion

This study shows that the quality of cardiovascular prevention could be measured as a composite outcome and future studies should further develop this approach and test the impact of several practice/patient characteristics on the quality of CVD prevention with the international data.Prevention of cardiovascular diseases (CVD) is an important task for family physicians. While patients with a low risk of CVD profit mostly from public health activities, high risk patients also need preventive activities provided by their family physicians (1,2). In the countries with a national program of CVD prevention (Slovenia is one of them), these activities and procedures can be highly standardized (3) and, therefore, should be easily measurable. The Slovenian national preventive program for CVD was launched in 2001 and requires preventive check-ups for the defined age groups of patients (women from 45 to 70 years and men from 35 to 65 years). Eighty percent of the target group in every practice needs to go through the program in 5 years, and a register of high risk patients is created in each practice and collected on the national level. The preventive activities consist of two parts: the first part includes a health check-up with determination of risk factors (information on life-style, clinical exam, laboratory tests of lipids and fasting blood glucose) and the second part includes the referral of patients at high risk to preventive workshops, for example for healthy weight reduction, smoking cessation, etc.Although there is some evidence on several isolated aspects of CVD prevention in Slovenia (4-6), a comprehensive and systematic approach for measuring its quality and actual outcomes is still not available. Therefore, we aimed to develop an integral statistically evaluated presentation of the process of cardiovascular prevention and determine the variables that influence it. Post-hoc analyses were performed on patients at a high risk for coronary diseases using Slovenian data from the international EPA-Cardio study, a cross-sectional study conducted in 9 European countries that had developed quality indicators for cardiovascular prevention on the international level (7) and evaluated the quality of cardiovascular prevention for high-risk patients (8).     

Can rhBMP-2 Containing Collagen Sponges Enhance Bone Repair in Ovariectomized Rats?: A Preliminary Study

With an aging population the frequency of postmenopausal fractures is increasing. Methods to enhance the repair of osteoporotic bone repair therefore become more important to reduce the society burden of care. We asked if absorbable collagen sponges containing recombinant human bone morphogenetic protein-2 (rhBMP-2) have the potential to enhance bone repair. We randomly assigned 40 rats into the ovariectomy and sham operation groups. A segmental defect was created in the right tibia 12 weeks after ovariectomy. rhBMP-2-containing absorbable collagen sponges were implanted into the defect in half of the animals in each group. We analyzed radiographs and histological sections and performed three-point bending tests to assess repair. Radiological scores in the rhBMP-2 applied rats were higher than those in controls at the end of 8 weeks after tibial osteotomy. The specimens failed under higher loads in the rhBMP-2-applied groups and histology revealed a higher fracture healing score, including callus formation, bone union, marrow changes, and cortex remodeling. We observed no adverse tissue responses such as fibrous connective tissue formation and inflammatory cellular infiltration. rhBMP-2 in absorbable collagen sponges enhanced bone repair in segmental tibial defects of ovariectomized rats. The sponges with rhBMP-2 appeared to enhance bone repair.     

In vivo performance of simvastatin-loaded electrospun spiral-wound polycaprolactone scaffolds in reconstruction of cranial bone defects in the rat model

Reconstruction of large bone defects is still a major problem. Tissue-engineering approaches have become a focus in regeneration of bone. In particular, critical-sized defects do not ossify spontaneously. The use of electrospinning is attracting increasing attention in the preparation of tissue-engineering scaffolds. Recently, acellular scaffolds carrying bioactive agents have been used as scaffolds in "in situ" tissue engineering for soft and hard tissue repair. Poly(epsilon-caprolactone) (PCL) with two different molecular weights were synthesized, and the blends of these two were electrospun into nonwoven membranes composed of nanofibers/micropores. To stimulate bone formation, an active drug, "simvastatin" was loaded either after the membranes were formed or during electrospinning. The matrices were then spiral-wound to produce scaffolds with 3D-structures having both macro- and microchannels. Eight-millimeter diameter critical size cranial defects were created in rats. Scaffolds with or without simvastatin were then implanted into these defects. Samples from the implant sites were removed after 1, 3, and 6 months postimplantation. Bone regeneration and tissue response were followed by X-ray microcomputed tomography and histological analysis. These in vivo results exhibited osseous tissue integration within the implant and mineralized bone restoration of the calvarium. Both microCT and histological data clearly demonstrated that the more successful results were observed with the "simvastatin-containing PCL scaffolds," in which simvastatin was incorporated into the PCL scaffolds during electrospinning. For these samples, bone mineralization was quite significant when compared with the other groups.     

Matrix metalloproteinase-9 expression correlated with tumor response in patients with locally advanced rectal cancer undergoing preoperative chemoradiotherapy

PURPOSE: To analyze whether the expression of matrix metalloproteinases (MMPs) and their tissue inhibitors are associated with tumor response to preoperative chemoradiotherapy in rectal cancer patients. METHODS AND MATERIALS: Forty-four patients who had undergone preoperative chemoradiotherapy were evaluated retrospectively. Treatment consisted of pelvic radiotherapy and two cycles of 5-fluorouracil plus leucovorin. Surgery was performed 6-8 weeks later. MMP-2, MMP-9, and tissue inhibitors of metalloproteinase-1 and -2 expression was analyzed by immunohistochemistry of the preradiation biopsy and surgical specimens. The intensity and extent of staining were evaluated separately, and a final score was calculated by multiplying the two scores. The primary endpoint was the correlation of expression with tumor response, with the secondary endpoint the effect of chemoradiotherapy on the expression. RESULTS: Preoperative treatment resulted in downstaging in 20 patients (45%) and no clinical response in 24 (55%). The pathologic tumor response was complete in 11 patients (25%), partial in 23 (52%), and none in 10 (23%). Positive MMP-9 staining was observed in 20 tumors (45%) and was associated with the clinical nodal stage (p = 0.035) and the pathologic and clinical response (p < 0.0001). The staining status of the other markers was associated with neither stage nor response. The overall pathologic response rate was 25% in MMP-9-positive patients vs. 52% in MMP-9-negative patients (p = 0.001). None of the 11 patients with pathologic complete remission was MMP-9 positive. CONCLUSIONS: Matrix metalloproteinase-9 expression correlated with a poor tumor response to preoperative chemoradiotherapy in rectal carcinoma patients.     

Depression in dermatology: an integrative perspective

An example which confirmes the adequacy of the integrative perspective in medicine is depression in dermatology because of the sufficient number of arguments linking depression and some chronic skin conditions in depth more than simply comorbidity. In recent literature, the authors found, how depression in dermatology occurs significantly more frequently than in the general population. In dermatological patients the prevalence of depression is around 30% which is more in comparison to patients in general practice where prevalence of depression is 22%. The authors found a considerable similarity in the various characteristics between depression and psoriasis, based upon recent research findings in immunity disorder and elevated concentrations of proinflammatory cytokines as well as acute phase proteins in both disorders, indicating that both disorders can be considered as immunologicaly mediated, inflammatory states with repetitive chronic progress and similar comorbidity. The afore mentioned theoretical settings evoke the integrative aspect and the integrative interdisciplinary approach placing in the center of attention not only the diseased person with his fears, needs, preocupations and expectations during treatment, but the person who is at risk of becoming burdened with these disorders.     

Fluid resuscitation of acute hemorrhage in uninephrectomized rabbits--effects on the early function of the remnant kidney

The aim of this study was to determine the effects of fluid resuscitation of acute hemorrhage on the early function and histopathology of the remnant kidney in uninephrectomized rabbits. Thirty-nine adult rabbits were studied in four groups. Group 1 (n = 8) included healthy controls; Group 2 (n = 10) healthy, bled animals; Group 3 (n = 10) uninephrectomized, non-bled animals; and Group 4 (n = 11) uninephrectomized, bled animals. In the hemorrhage groups, 8 mL kg(-1) of blood was drawn, and replaced with lactated Ringer's solution three times the volume of shed blood. Urine and blood samples were collected after 120-minutes of observation. None of the animals experienced hypotension during the study period. Serum and urinary electrolytes were similar between the Groups (p > 0.05). Urine output was lower in Groups 3 and 4 than in Group 1 (p = 0.001, both). Urinary microalbumin, NAG, fractional sodium excretion and creatinine clearance were similar in all four Groups. Light microscopic evaluation revealed only slight enlargement of the proximal tubule lumen in the renal medulla of the rabbits that were both uninephrectomized and bled. We observed no deleterious effects of well resuscitated hemorrhage on early function and histopathology of the remnant kidney in uninephrectomized rabbits.     

Early weight bearing of porous HA/TCP (60/40) ceramics in vivo: a longitudinal study in a segmental bone defect model of rabbit

Porous interconnected hydroxyapatite (HA) and HA/tricalcium phosphate (TCP) (60/40) ceramics are promising materials for hard tissue repair. However, the mechanical properties of these materials have not been accurately determined under weight-bearing conditions. In this study, newly developed HA and HA/TCP (60/40) ceramics were used with intramedullary fixation in segmental bone defects of rabbits. Early radiological, histological, densitometric and biomechanical changes were evaluated. The mean radiological grade of healing and bonding to bone was higher in HA/TCP (60/40) ceramics than that of pure HA ceramics but the difference was not statistically significant. The densities of both implanted ceramics improved with time, supported by the histological evaluation of bone matrix ingrowth into ceramic pores, whereas the densities at the bone–ceramic interface decreased gradually. Flexural resonant frequencies and three-point bending strength increased, revealing an increase in mechanical stability during this early critical time interval where implant and/or bone–implant interface failures occur frequently. It can be concluded that both HA and HA/TCP (60/40) ceramics have a limited application in the treatment of load-bearing segmental bone defects but did not fail at the early stages of implantation.     

Effects of Angiotensin-converting enzyme inhibition and statin treatment on inflammatory markers and endothelial functions in patients with longterm rheumatoid arthritis

OBJECTIVE: To investigate the effects of angiotensin-converting enzyme (ACE) inhibitors and statins (hydroxy-methyl-glutaryl-CoA reductase inhibitors) on inflammatory markers and endothelial functions in patients with rheumatoid arthritis (RA). METHODS: A total of 45 patients with longterm RA were randomized into 3 groups to receive 8 weeks of treatment with placebo (n = 15), simvastatin (20 mg/day, n = 15), or quinapril (10 mg/day, n = 15) as an adjunct to existing antirheumatic drug treatment. Factors with a role in the development of endothelial dysfunction, such as C-reactive protein (CRP), fibrinogen, nitric oxide (NO), and serum cytokine concentrations including interleukin 1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha (TNF-alpha) were measured at baseline and in the posttreatment period. Brachial artery vasodilator responses were assessed by high resolution ultrasound to evaluate endothelial functions. RESULTS: Simvastatin treatment significantly decreased serum CRP and TNF-a [from 14 +/- 6 to 7 +/- 3 mg/l (p = 0.025) and 30 +/- 5 to 16 +/- 4 pg/ml (p = 0.012), respectively], while quinapril had no significant changes in these 2 measures. IL-1beta and IL-6 showed insignificant changes in patients in the 2 drug groups. Endothelium-dependent vasodilatation was improved significantly in the simvastatin group [from 5.3 +/- 1.1% to 8.9 +/- 1.4% (p = 0.025)], while there was no difference in endothelium-independent vasodilatation [9.0 +/- 1.8% to 11.2 +/- 2.5% (p = 0.17)]. The quinapril group showed no significant changes in both types of vasodilation although there was a tendency to an increase in endothelium-dependent vasodilatation [from 6.1 +/- 0.8% to 7.8 +/- 0.7% (p = 0.06)]. Treatment with the 2 drugs had no significant effects on resting arterial diameter. CONCLUSION: We show that simvastatin 20 mg daily improves endothelial function in patients with RA. Its beneficial effect may be attributed to lowering CRP and TNF-alpha concentrations. ACE inhibition with daily 10 mg quinapril was found to have no significant effects on inflammatory markers and endothelial vasodilator response.     

Pulmonary exchange of solutes during experimental lung lavage in pigs

Unilateral continuous lung lavage in a nonregenerating system (3,000 ml isotonic cristalloid) was done in 12 pigs for 270 min. The concentration of substances in serum and fluid was measured. Half-time (t1/2) of exchange and permeability constants (P) were determined. In the fluid Na+ decreased significantly (t1/2 = 107 min, P = 7.8 x 10(-7]. Urea increased significantly, reaching serum level after 270 min (t1/2 = 109.1 min, P = 6.18 x 10(-6]. Ca2+ (t1/2 = 36.7 min, P = 4.1 x 10(-7] PO4 = (t1/2 = 173.3 min, P = 1.1 x 10(-7], and creatinine (t1/2 = 55.2 min, P = 6.2 x 10(-7] also increased markedly but did not reach serum level. The adjustment to serum concentration may be prevented by interaction between diffusion, active transport or Donnan's equilibria. K+ increased almost linearly, documented by the long half-time (t1/2 = 7,835.2 min, P = 7.7 x 10(-7] and did not reach serum level. The calculated limit value was higher than the serum level. Active transport systems or influx of K+ from cellular compartments rather than from the serum might be involved in its linear kinetics. Total protein (t1/2 = 61.5 min, P = 2.06 x 10(-9] and albumin (t1/2 = 58.8 min, P = 1.7 x 10(-9] increased initially but levelled far below the serum value. The low P indicates a lack of significant permeation. Initial increase may be due to washout of the epithelial lining fluid compartment. There was minimal transfer of lavage fluid into the organism (10-20 ml/30 min). Serum concentrations were not affected by the lavage.