Cycle-ergometry stress testing and use of chronotropic reserve adjustment of ST depression for identification of significant coronary artery disease in clinical practice

Diagnostic reliability of indexations of peak exercise ST segment depression (DeltaST) for heart rate reserve (HRi) or chronotropic reserve (CR) to identify significant coronary artery disease (CAD) by cycle-ergometer exercise testing has not been evaluated previously. Exercise testing by upright cycle-ergometer (25 W/3 min) were performed in consecutive patients in primary prevention with history of exercise-related chest discomfort and cardiovascular risk factors, or with overt peripheral artery disease, with or type-2 diabetes associated with two or more additional cardiovascular risk factors. Coronary angiography was performed after the test to assess significant CAD. Three different criteria for definition of inducible myocardial ischemia were tested versus significant CAD: peak DeltaST>or=100 microV, ST/HRi>1.69 microV/bpm or ST/CR>1.76 microV/%. Diagnostic accuracy vs. CAD of DeltaST>or=100 microV, of ST/HRi>1.69 microV/bpm, and of ST/CR>1.76 microV/% were 78%, 72%, and 89% respectively; sensitivity and specificity of the three criteria were 91% and 50%, 84% and 43%, 88% and 93%, respectively. Abnormal ST/CR predicted CAD independent of risk factors, pre-test probability, and more strongly than DeltaST. Combination of ST/HRi and ST/CR criteria did not improve CAD prediction. In conclusions, in clinical setting in patients in primary prevention but with moderate-to-high pre-test probability of CAD, exercise testing by cycle-ergometry and use of ST/CR>1.76 microV/% showed elevated sensitivity and specificity, and the best accuracy for diagnosis of significant CAD.     

Bleeding risk and outcomes of Bivalirudin versus Glycoprotein IIb/IIIa inhibitors with targeted low-dose unfractionated Heparin in patients having percutaneous coronary intervention for either stable or unstable angina pectoris

For patients undergoing elective percutaneous coronary intervention (PCI), procedural anticoagulation with bivalirudin was previously shown to significantly reduce bleeding complications at the cost of a modest increase in ischemic events compared with unfractionated heparin (UFH) and glycoprotein IIb/IIIa inhibitors (GPIs). However, the excess bleeding in patients treated with UFH and GPIs may have been caused by excessively high UFH doses and increased activated clotting times. This study sought to determine the bleeding risk of targeted low-dose UFH with GPIs compared with bivalirudin in patients undergoing elective PCI. Of 1,205 patients undergoing elective PCI, 602 underwent PCI with adjunctive UFH and GPIs with the UFH dose targeted to an activated clotting time of approximately 250 seconds, and 603 patients matched for baseline characteristics underwent PCI with bivalirudin. Outcomes were analyzed for major bleeding (hematocrit decrease >15%, gastrointestinal bleed, or major hematoma) and 6-month major adverse cardiac events (death, myocardial infarction, and target-lesion revascularization). The maximum activated clotting time achieved was 261.7 +/- 61.6 seconds in the UFH/GPI group and 355.4 +/- 66.6 in the bivalirudin group (p <0.001). In-hospital major bleeding rates were similar between groups (1.8% UFH/GPI vs 1.7% bivalirudin; p = 0.83), as were transfusion requirements (1.2% UFH/GPI vs 0.5% bivalirudin; p = 0.61). The 6-month major adverse cardiac event rate was also similar between groups (9.5% UFH/GPI vs 9.0% bivalirudin; p = 0.81). In conclusion, there were no significant differences in major bleeding and 6-month major adverse cardiac events for patients undergoing elective PCI treated with targeted low-dose UFH and GPIs compared with those treated with bivalirudin.     

Mucosal Integrity Testing Can Detect Differences in the Rectums of Patients with Inflammatory Bowel Disease Compared to Controls: A Pilot Study

Digestive Diseases and Sciences - While the pathogenesis of inflammatory bowel disease (IBD) is incompletely understood, disruption of epithelial integrity is suspected to play a prominent role in...     

Plasma and urinary GH following a standardized exercise protocol to assess GH production in short children

Plasma and urinary GH responses following acute physical exercise were evaluated in 19 short-statured children (12 males, 7 females, median age: 11.4 yr, age range: 6.1-14.5 yr, Tanner stage I-III, height < or = 3rd centile for age; 7 with familial short stature, FSS; 8 with constitutional growth delay, CGD; 4 with GH deficiency, GHD) and 7 normally growing, age- and sex-matched control children (4 males, 3 females, median age 11.0 yr, range: 7.2-13.1 yr, Tanner stage I-III). All patients and controls underwent a standardized exercise protocol (consisting of jogging up and down a corridor for 15 min, strongly encouraged to produce the maximum possible effort, corresponding to 70-80% of the maximal heart rate) after an overnight fasting. Samples for plasma GH determinations were drawn at 0 time (baseline), at 20 min (5 min after the end of exercise) and at 35 min (after 20 min of rest); urine samples were collected before (0 time) and at 40, 80 and 120 min after exercise. The distance covered by children with GHD during the test was significantly lower (p<0.05) than in the other groups of patients and controls. No differences in the pattern of plasma GH responses after physical exercise were found between children with FSS, CGD and healthy controls, the maximum percent increase (vs baseline) being evident at 20 min (median, FSS: +1125%; CGD: +1271%; controls: +571%). Children with GHD showed a smaller percent increase (+94%) of plasma GH, significantly lower (p<0.01) than those recorded in the other groups. A significant percent increase (p<0.01) of baseline urinary GH following exercise was found in children with FSS (median: +34%), CGD (+18%) and controls (+44%). Children with FSS and CGD showed a gradual increase of urinary GH, reaching the maximum at 80 min, while healthy controls had a more evident and precocious increase (maximum at 40 min). Urinary median GH levels did not change following physical exercise in children with GHD (-5%, not significant). A significant correlation was found between the maximal percent increase (vs baseline) of plasma and urinary GH following physical exercise (r=0.7, p<0.001). In conclusion, our results show that: 1) plasma and urinary GH responses (as well as the distance covered and the number of steps, i.e. the physical performance) to a standardized exercise protocol are similar in children with FSS, CGD and in normal-statured controls, being unable to differentiate among the "normal variants" of growth; 2) children with GHD, unable to accomplish the same performance of the other three groups, show significantly reduced plasma and urinary GH responses following physical exercise. Although the determination of GH responses to pharmacological stimuli remains the definitive tool for the diagnosis of GHD, these preliminary results seem to suggest a potential role of urinary (and plasma) GH response to a standardized exercise protocol as a safe, acceptable first screening test for GH sufficiency also in children, as previously reported in adults.     

Statin use is not associated with improved 30-day survival in patients undergoing surgery for colorectal cancer

Purpose

Besides the lipid-lowering properties, statins are thought to have anti-inflammatory effects and it has been shown that statins directly attenuate the inflammatory stress response after surgical trauma. The aim of the study was to examine the association between preoperative statin use and 30-day mortality as well as postoperative complications after curative-intended surgery for colorectal cancer.

Methods

The study was a Danish nationwide register-based observational study. A total of 29,352 patients undergoing surgery for colorectal cancer between January 1, 2003, and December 31, 2012, were included in the study. At the time of surgery, 5961 were registered as statin users. The outcomes were 30-day mortality and risk of postoperative complications.

Results

The adjusted hazard ratio of 30-day mortality was 0.91 (95 CI 0.80–1.04, P?=?0.16) among statin users compared with the non-statin group. There was no difference between the two groups regarding the risk of infectious complications (sepsis, anastomotic leakage, pneumonia) (odds ratio 0.95, 95% CI 0.86–1.05, P?=?0.31). For other postoperative complications (cardiovascular events, stroke, renal failure, respiratory insufficiency, and thromboembolic events), there was no significant difference between the two groups (odds ratio 0.89, 95% CI 0.78–1.01, P?=?0.06).

Conclusion

The study did not show an improved 30-day survival after surgery for colorectal cancer in patients treated with statins in the year preceding surgery. No overall association with the risk of postoperative complications was shown.

     

Group Cognitive Rehabilitation and Exposure/Sorting Therapy: A Pilot Program

While cognitive-behavioral therapy for hoarding disorder (HD) has resulted in significant reductions in symptoms, most individuals continue to have significant hoarding symptoms following treatment. This investigation sought to extend the literature on the behavioral treatments for hoarding by examining (1) group cognitive rehabilitation and exposure/sorting therapy (CREST) and (2) group exposure therapy (ET) for hoarding. Participants in both studies reported significant decreases in hoarding symptom severity from baseline to post-treatment on all primary outcome measures using mixed-effects linear regression models with the intent to treat sample. Participants who received group CREST reported statistically significant reductions in anxiety, depression, and overall severity at post-treatment, while participants who received group ET did not. Results provide preliminary evidence for both group CREST and group ET as effective treatments for hoarding disorder.