Myocardial infarction classification and its implications on measures of cardiovascular outcomes,quality, and racial/ethnic disparities

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high-sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan-do-check-adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular-related health disparities, and ultimately improve and save lives.     

Efficacy of treatment of insomnia in migraineurs with eszopiclone (Lunesta®) and its effect on total sleep time,headache frequency,and daytime functioning: A randomized,double-blind,placebo-controlled,parallel-group,pilot study

Aims:

A review on headache and insomnia revealed that insomnia is a risk factor for increased headache frequency and headache intensity in migraineurs. The authors designed a randomized, double blind, placebo-controlled, parallel-group, pilot study in which migraineurs who also had insomnia were enrolled, to test this observation.

Methodology:

In the study, the authors treated 79 subjects with IHS-II migraine with and/or without aura and with DSM-IV primary insomnia for 6 weeks with 3 mg eszopiclone (Lunesta^®) or placebo at bedtime. The treatment was preceded by a 2-week baseline period and followed by a 2-week run-out period.

Results:

Of the 79 subjects treated, 75 were evaluable, 35 in the eszopiclone group, and 40 in the placebo group. At baseline, the groups were comparable except for sleep latency. Of the three remaining sleep variables, total sleep time, nighttime awakenings, and sleep quality, the number of nighttime awakenings during the 6-week treatment period was significantly lower in the eszopiclone group than in the placebo group (P?=?0·03). Of the three daytime variables, alertness, fatigue, and functioning, this was also the case for fatigue (P?=?005). The headache variables, frequency, duration, and intensity, did not show a difference from placebo during the 6-week treatment period.

Conclusions:

The study did not meet primary endpoint, that is, the difference in total sleep time during the 6-week treatment period between eszopiclone and placebo was less than 40 minutes. Therefore, it failed to answer the question as to whether insomnia is, indeed, a risk factor for increased headache frequency and headache intensity in migraineurs.     

Psychosocial predictors of long-term mortality among women with suspected myocardial ischemia: the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation

This paper evaluated long-term associations between psychosocial factors and premature mortality among women with suspected coronary artery disease (CAD). We tracked total mortality events over a median 9.3 years in a cohort of 517 women [baseline mean age = 58.3 (11.4) years]. Baseline evaluations included coronary angiography, psychosocial testing, and CAD risk factors. Measures included the Spielberger Trait Anxiety Scale, Beck Depression Inventory, self-rated health, and Social Network Index. Cox regression analysis was used to assess relationships. Covariates included age, CAD risk factors, and CAD severity. BDI scores (HR 1.09, 95 % CI 1.02–1.15), STAI scores (HR .86, 95 % CI .78–.93), and very good self-rated health (relative to the poor self-rated health group; HR .33, 95 % CI .12–.96) each independently predicted time to mortality outcomes in the combined model. SNI scores (HR .91, 95 % CI .81–1.06) and other self-rated health categories (i.e., fair, good, and excellent categories) were not significant mortality predictors after adjusting for other psychosocial factors. These results reinforce and extend prior psychosocial research in CAD populations.     

Evaluation of renal markers of T1D in Sprague‐Dawley exposed to 2‐aminoanthracene

The incidence of type 1 diabetes (T1D) and its associated risks of chronic kidney disease or end‐stage renal disease development are on the rise. T1D is an autoimmune disease in which insulin‐producing beta cells are destroyed. Increased incidence of T1D has been suggested to be a result of environmental factors such as exposure to polycyclic aromatic hydrocarbons (PAHs). 2‐aminoanthracene (2AA) is a PAH that has been associated with the onset of early diabetic symptoms. This study was conducted to assess if 2AA dietary ingestion would induce T1D renal injuries. To accomplish study goals, Sprague‐Dawley rats were assigned into three 2AA dietary (0, 50, and 100 mg/kg‐2AA) ingestion groups for 12 weeks. Animals were evaluated for various morphometric indices, clinical markers, and gene expression. The rats in the 100 mg/kg group lost 5% less weight than the other treatment groups and converted roughly 3% more of their food intake into body mass. Renal histopathology indicated no significant difference between groups. The kidney weight per bodyweight of the 100 mg/kg treatment group was 30.1% greater than the control group. Creatinine concentration of the 100 mg/kg group was 46.2% greater than the control group. Serum glucose levels were significantly elevated in rats exposed to 2AA. On the contrary, serum albumin concentration was significantly reduced in 2AA‐treated rats. T1D and genetic markers of renal injury such as FABP1, SPP1, IL‐1B, and IL‐7 were elevated in treated groups. These results suggest that 2AA may induce the early diabetic renal injuries.     

Advance Care Planning in Patients With Chronic Kidney Disease

Poor communication and failure to establish goals of care result in unnecessary admissions to hospital, invasive procedures, suffering, and prolongation of the dying process for many CKD patients. Comprehensive CKD care requires systematic integration of advance care planning (ACP). This report describes an approach to ACP for patients with CKD, discusses essential aspects of how to facilitate these conversations, and briefly reviews the empirical evidence supporting the value of ACP.