Influence of education and income on atherogenic risk factor profiles among patients hospitalized with acute myocardial infarction

BACKGROUND: Survival after acute myocardial infarction (AMI) varies with socioeconomic status. It is unknown whether these differences can be attributed, in part, to variations in the prevalence of atherogenic risk factors preceding the index AMI event. OBJECTIVES: To examine how cardiovascular risk factors varied according to person-level indicators of income and education among a cohort of younger patients (younger than 65 years of age) hospitalized with AMI in Ontario. METHODS: The Socio-Economic and Acute Myocardial Infarction study (SESAMI) prospectively assembled a cohort of 3335 patients hospitalized with AMI who consented to participate (75% consent rate) from 53 of 57 large-volume institutions (100 AMI cases per year or more) throughout Ontario between December 1, 1999, and June 1, 2002. Given the known challenges inherent in characterizing the socioeconomic status in elderly patients and the ubiquity of atherosclerosis in elderly persons, the study focused on 1635 nonelderly participants. The relationship between income or education and cardiovascular risk factors, after adjustment for age, sex, ethnoracial factors and geography (urban-rural status) was examined. RESULTS: The prevalence of diabetes, hypertension, smoking and pre-existing heart disease was higher among poorer, less educated patients, as were the total number of cardiovascular risk factors. After adjusting for baseline factors, both income (adjusted OR 0.50, 95% CI 0.31 to 0.82, P=0.006) and education (adjusted OR 0.52, 95% CI 0.31 to 0.87, P=0.01) were independently associated with cardiovascular risk factors or pre-existing heart disease. There were no significant interactions between income, education and baseline cardiovascular risk. CONCLUSIONS: Outcome differences across socioeconomic strata following AMI may reflect major income- and education-related differences in atherogenic risk profile.     

Impact of a Standardized Titration Protocol with Carvedilol in Heart Failure: Safety,Tolerability, and Efficacy—A Report from the GESICA Registry

Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA) studied whether a standardized protocol for the initiation and titration of the β-blocker carvedilol in a multicenter, open-label program would optimize β-blocker use in heart failure (HF) patients. The program included: (1) the carvedilol initiation and titration period, and (2) long-term follow-up at 6 and 12 months. Of 1299 patients in the registry, 504 were excluded due to current therapy; of the remaining 795 eligible patients, 293 were excluded due to contraindications. Of the included patients with follow-up data (n = 316), 93.3% tolerated carvedilol initiation and 47.7% of the patients reached the target dose of 50 mg/day for a mean dose of 39 mg/day. Rates were comparable in the elderly (n = 83), of which 53% achieved a target dose for a mean dose of 43.08 mg/day. This protocol improved therapy rates and achieved target doses quickly (average of 4 visits). Concomitant medications did not have to be adjusted and there were low withdrawal rates (10%) and hospital admissions (7.2%) for HF. Patients were able to maintain carvedilol therapy at 6 and 12 months. These results indicate that a standardized titration protocol, as used in GESICA, for the initiation and titration of β-blockers is well tolerated and may improve β-blocker use in carefully selected heart failure patients.The study authors are members of the GESICA Steering Committee and Subcommittees     

Different normalizations for body size and population attributable risk of left ventricular hypertrophy: the MAVI study

BACKGROUND: Different methods of normalizing left ventricular (LV) mass for body size identify generally similar relative risks of adverse cardiovascular outcome but with variable prevalences of LV hypertrophy (H). Preliminary results from a population with high prevalence of obesity suggest that the population attributable-risk percent (PAR%) of LVH is substantially higher when LV mass is normalized for allometric power of height. METHODS: We calculated the PAR% of LVH by different definitions in the cohort of the MAssa Ventricolare sinistra nell' Ipertensione (MAVI) study (n = 1019, 62% women), a population with low prevalence of obesity (22%, with only 3% and 0.1% in class II and class III obesity, respectively). Composite fatal and nonfatal cardiovascular events occurred in 53 participants (5.2%). RESULTS: Prevalence of LVH was between 28% and 56%, with slight greater values for height-based normalization. Age- and sex-adjusted hazard ratios were comprised between 1.37 and 1.44 for different measures of LV mass index. The PAR% was not meaningfully different among the different methods of normalization (between 47% and 56%), and height-based methods showed in general a performance similar to body surface area-based normalizations. CONCLUSIONS: In a large clinical population of hypertensive subjects with low prevalence of obesity, population risk attributable to LV hypertrophy was not meaningfully different in relation to the type of normalization of LV mass for body size. Height-based methods perform as well as body surface area-based ones. We suggest that the prevalence of obesity in hypertensive populations might substantially influence differences in population risk attributable to LVH identified by different methods of normalizing LV mass.     

Beneficial effect of a novel pentadecapeptide BPC 157 on gastric lesions induced by restraint stress,ethanol, indomethacin,and capsaicin neurotoxicity

Very recently, the integrity of capsaicin somatosensory neurons and their protection were suggested to be related to the activity in nociception of a newly discovered 15-amino acid peptide, BPC 157, shown to have strong beneficial effect on intestinal and liver lesions. Therefore, from this viewpoint, we have studied the gastroprotective effect of the pentadecapeptide BPC 157, on gastric lesions produced in rats by 96% ethanol, restraint stress, and indomethacin. The possible involvement of sensory neurons in the salutary actions of BPC 157 (10µg/kg, 10 ng/kg intraperitoneally) was studied with capsaicin, which has differential effects on sensory neurons: a high dose in adult (125 mg/kg subcutaneously, 3 months old) or administration (50 mg/kg subcutaneously) to neonatal animals (age of the 7 days) destroys sensory fibers, whereas a low dose (500µg/kg intraperitoneally) activates neurotransmitter release and protective effects on the mucosa. In the absence of capsaicin, BPC 157 protected gastric mucosa against ethanol, restraint, and indomethacin application. In the presence of neurotoxic doses of capsaicin, the negative influence of capsaicin on restraint, ethanol, or indomethacin lesions consistently affected salutary activity of BPC 157. However, BPC 157 protection was still evident in the capsaicin-treated rats (either treated as adults or as newborns) in all of these assays. Interestingly, after neonatal capsaicin treatment, a complete abolition of BPC gastroprotection was noted if BPC 157 was applied as a single nanogram-regimen, but the mucosal protection was fully reversed when the same dose was used daily. In line with the excitatory dose of capsaicin the beneficial effectiveness of BPC 157 appears to be increased as well. Taken together, these data provide evidence for complex synergistic interaction between the beneficial effectiveness of BPC 157 and peptidergic sensory afferent neuron activity.     

Early benefit from structured care with atorvastatin in patients with coronary heart disease and diabetes mellitus

This is a prospective evaluation of the effect of structured care of dyslipidemia with atorvastatin (strict implementation of guidelines) versus usual care (physician's standard of care) on morbidity and mortality of patients with coronary heart disease (CHD) and diabetes mellitus (DM). From 1600 consecutive CHD patients randomized to either form of care in the GREek Atorvastatin and CHD Evaluation Study (GREACE), 313 had DM: 161 in the structured care arm and 152 in the usual care arm. All patients were followed up for a mean of 3 years. In the structured care group, patients were treated with atorvastatin to achieve the National Cholesterol Education Program (NCEP) low-density lipoprotein cholesterol (LDL-C) treatment goal of <2.6 mmol/L (100 mg/dL). Primary endpoints were all-cause and coronary mortality, coronary morbidity, and stroke. In the structured care group, 156 patients (97%) were taking atorvastatin (10-80 mg/day; mean, 23.7 mg/day) throughout the study; the NCEP LDL-C treatment goal was reached by 150 patients (93%). Only 17% (n=26) of the usual care patients were on long-term hypolipidemic drug treatment and 4% (n=6) reached the NCEP LDL-C treatment goal. During the study, 46 of 152 (30.3%) CHD patients with DM on usual care experienced a major vascular event or died versus 20 of 161 (12.5%) patients on structured care; relative risk reduction (RRR) 58%, p<0.0001. RRR for all-cause mortality was 52%, p=0.049; coronary mortality 62%, p=0.042; coronary morbidity 59%, p<0.002; and stroke 68%, p=0.046. Event rate curves started deviating from the sixth treatment month and the RRR was almost 60% by the 12th month. RRRs remained at that level until the end of the study, when they became statistically significant. The cost/life-year gained with structured care was estimated at 6200 US dollars. In CHD patients with DM, structured care of dyslipidemia with atorvastatin to achieve the NCEP LDL-C treatment goal, reduces all-cause and coronary mortality, coronary morbidity, and stroke by more than one half within a 3-year period, in comparison to usual care. Clinical benefit is manifested as early as the sixth month of treatment.     

Early Breastfeeding Cessation Among HIV-Infected and HIV-Uninfected Women in Western Cape Province,South Africa

As part of the Mother-Infant Health Study, we describe infant feeding practices among HIV-infected and HIV-uninfected mothers over a 12-month period when the Western Cape Province prevention of mother-to-child transmission (PMTCT) program was transitioning from a policy of exclusive formula feeding to one of exclusive breastfeeding. Two hundred pairs of mother and HIV-uninfected infant were included in the analysis, among whom 81 women were HIV uninfected and breastfeeding. Of the 119 HIV-infected mothers, 50 (42%) were breastfeeding and 69 (58%) were formula feeding. HIV-infected mothers predominantly breastfed for 8.14 (7.71–15.86) weeks; HIV-uninfected mothers predominantly breastfed for 8.29 (8.0–16.0) weeks; and HIV-infected mothers predominantly formula fed for 50.29 (36.43–51.43) weeks. A woman’s HIV status had no influence on the time to stopping predominant breastfeeding (P?=?0.20). Our findings suggest suboptimal duration of breastfeeding among both HIV-infected and HIV-uninfected mothers. Providing support for all mothers postdelivery, regardless of their HIV status, may improve breastfeeding practices.     

Emergency Department influenza vaccination campaign allows increasing influenza vaccination coverage without disrupting time interval quality indicators

To evaluate the impact of an influenza vaccination (IV) coverage (IVC) in a vaccination campaign of an Emergency Department (EDVC) and its impact on ED time interval quality indicators. We conducted a 4 year observational study, with an intervention during the 4th year. IVC was calculated during pre-and early-epidemic periods. During the final period, a 12 weeks EDVC was implemented. Physicians and nurses were trained and sensitized in the importance of vaccination, and their role in the prevention of severe forms of influenza was reinforced. The vaccine was proposed by physicians and nurses, and delivered by them. Repeated measures ANOVA is a validated method for related not independent groups (https://statistics.laerd.com/statistical-guides/repeated-measures-anova-statistical-guide.php). Overall, IVC was 987/3191 (30.9%) with an increasing trend from 28.8 to 33.2%. In the fourth period, out of 868 patients identified with IV indication, 288 had already been vaccinated (IVC?33.2%). After excluding patients presenting criteria of exclusion, IV was proposed to 475 patients: 317 (66.7%) accepted. The vaccination rate after patient’s acceptance was 89.6% (288/317). At the end of the EDVC, influenza vaccination coverage was 572 (284?+?288)/868 (65.9%). The delay between arrival at the ED and seeing the triage nurse and physician as well as the overall ED length of stay were not modified during the study period and before and during EDVC. EDVC effectively doubled the influenza vaccination coverage, without modifying ED time interval quality indicators.     

Dose-escalation, phase I/II study of azithromycin and pyrimethamine for the treatment of toxoplasmic encephalitis in AIDS

OBJECTIVE: To assess the safety, tolerance and activity of increasing doses of azithromycin in combination with pyrimethamine for the treatment of toxoplasmic encephalitis (TE) in patients with AIDS. DESIGN: A phase I/II dose-escalation study of oral azithromycin in combination with pyrimethamine. SETTING: Eight clinical sites in the United States. PATIENTS: Forty-two adult HIV-infected patients with confirmed or presumed acute TE. METHODS: Patients were enrolled into three successive cohorts receiving azithromycin 900, 1200 and 1500 mg a day with pyrimethamine as induction therapy. The induction period was 6 weeks followed by 24 weeks of maintenance therapy. MAIN OUTCOME MEASURES: Patient response was evaluated clinically and radiologically. RESULTS: Of the 30 evaluable patients, 20 (67%) responded to therapy during the induction period. Ten experienced disease progression. Of the 15 patients who received maintenance therapy, seven (47%) relapsed. Six patients discontinued treatment during the induction period as a result of reversible toxicities. Treatment-terminating adverse events occurred most frequently among the patients receiving the 1500 mg dose. CONCLUSION: The combination of azithromycin (900-1200 mg a day) and pyrimethamine may be useful as an alternative therapy for TE among patients intolerant of sulfonamides and clindamycin, but maintenance therapy with this combination was associated with a high relapse rate. The combination was safe, but low-grade adverse events were common.