Optimizing risk stratification in cardiac rehabilitation with inclusion of a comorbidity index

PURPOSE: The risk stratification criteria of the American Association of Cardiovascular and Pulmonary Rehabilitation include guidelines to be used in stratifying cardiac rehabilitation (CR) patients for risk of disease progression (long term) and clinical events (short term). Noncardiac comorbidities are not included as indicators in these criteria. This study was designed to ascertain the prevalence of noncardiac comorbidities among CR patients, and to assess their relation to the current risk stratification algorithm for clinical events. METHODS: Patients were stratified into high-, intermediate-, and low-risk groups according to the American Association of Cardiovascular and Pulmonary Rehabilitation risk stratification criteria for clinical events (ARSE) at program entry. Within each risk group, age, gender, race, and noncardiac comorbidities were ascertained. Comorbidities were summarized in a comorbidity index (CMI). The relation between clinical events and risk status by ARSE and CMI was evaluated by logistic regression. RESULTS: Among 490 patients (age, 60 +/- 12 years; 35% women; 30% nonwhite) enrolled in CR with ischemic heart disease, the number of comorbidities ranged from 0 to 7 (median, 2; 75th percentile, 3). The patients categorized in the three ARSE groups differed significantly in age and comorbidities. Although ARSE tended to identify patients with a greater comorbidity burden, 38% of the patients with a comorbidity index exceeding the 75th percentile were not classified in the highest ARSE group. Clinical events increased across ARSE and CMI risk strata. Both ARSE and CMI were independent predictors of events in an age-, gender-, and race-adjusted logistic regression analysis (ARSE odds ratio [OR], 1.56; 95% confidence interval [CI], 1.14-2.12; CMI OR, 1.23, 95% CI, 1.03a-1.47). Events were predicted best when both classifications were combined. Exploratory gender-specific analyses suggested that ARSE performed better among men than among women, whereas CMI was a more important predictor among women. CONCLUSIONS: To appreciate more fully the overall complexity of disease among CR patients, ARSE should be supplemented not only with the inclusion of cardiac risk factors, as suggested in the current guidelines, but also with an assessment of noncardiac comorbidities.     

Morphosyntax, prosody, and linking elements: the auditory processing of German nominal compounds

The morphosyntactic decomposition of German compound words and a proposed function of linking elements were examined during auditory processing using event-related brain potentials. In Experiment 1, the syntactic gender agreement was manipulated between a determiner and the initial compound constituent (the 'nonhead' constituent), and between a determiner and the last constituent ('head'). Although only the head is (morpho)syntactically relevant in German, both constituents elicited a left-anterior negativity if its gender was incongruent. This strongly suggests that compounds are morphosyntactically decomposed. Experiment 2 tested the function of those linking elements which are homophonous to plural morphemes. It has been previously suggested that these indicate the number of nonhead constituents. The number agreement was manipulated for both constituents analogous to Experiment 1. Number-incongruent heads, but not nonhead constituents, elicited an N400 and a subsequent broad negativity, suggesting that linking elements are not processed as plural morphemes. Experiment 3 showed that prosodic cues (duration and fundamental frequency) are employed to differentiate between compounds and single nouns and, thereby, between linking elements and plural morphemes. Number-incongruent words elicited a broad negativity if they were produced with a single noun prosody; the same words elicited no event-related potential effect if produced with a compound prosody. A dual-route model can account for the influence of prosody on morphosyntactic processing.     

Results of psychodynamic inpatient psychotherapy in relation to diagnosis

Therapy outcome is analysed according to the main diagnoses in a 5 years' sample of psychodynamic inpatient psychotherapy (n=461) and controlled in a 6-9 months follow-up (n=312). Therapy effects, as measured in a pre-post comparison of the patients' self-rating, are generally good and especially noticeable for affective and anxiety disorders, whereas the effects for somatoform disorders are relatively low. The opposite tendencies are seen in follow-up, i.e. relapses in anxiety and affective disorders, and further improvement in somatoform disorders. A surprisingly positive outcome is shown for personality disorders and especially for severe personality disorders (e.g. Borderline). Regardless of the diagnoses, 80% of the patients show a high degree of satisfaction with their treatment and its outcome.     

Recognition of pneumococcal peptidoglycan: an expanded,pivotal role for LPS binding protein

Lipopolysaccharide binding protein (LBP) has a well-established role in LPS-induced immune responses. Here, we report that LBP also plays an essential role in the innate immune response to Gram-positive pneumococci, specifically to their major inflammatory component, pneumococcal cell wall (PCW). LBP was present in the CSF of patients with meningitis, and LBP-deficient mice failed to develop meningeal inflammation. LBP enhanced PCW-induced cell signaling and TNF-alpha release. LBP bound specifically to PCW multimers, indicating novel lipid-independent binding capability for LBP. We propose the iterative anionic groups along the glycan backbone of the cell wall are a crucial structure for recognition by LBP. Such a function for LBP expands its role to Gram-positive infections.     

Chronic pelvic pain: an integrated approach to diagnosis and treatment

Chronic pelvic pain affects upward of 15% of women and is a frustrating condition for both patients and physicians. Chronic pelvic pain is not a disease, but a syndrome that results from a complex interaction between neurologic, musculoskeletal, and endocrine systems that is further influenced by behavioral and psychologic factors. Traditional approaches to this disorder have been surgical, although long-term success rates have been disappointing. Placebo response to surgery is common, and many conditions that contribute to the pain cannot be identified or treated with a surgical approach. Many patients will require a combination of both pharmacologic and nonpharmacologic treatments in addition to various types of invasive procedures. It is now recognized that many disorders contribute to the chronic pelvic pain symptom complex; thus, an integrated multidisciplinary approach to diagnosis and treatment is essential to achieve the greatest success. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the pathophysiology of chronic pelvic pain, to outline the evaluation of a patient with chronic pelvic pain, and to explain the treatment options for patients with chronic pelvic pain.     

Hearts late after fontan operation have normal mass,normal volume,and reduced systolic function: a magnetic resonance imaging study

OBJECTIVES: The purpose of this study was to assess ventricular mass, volume, and systolic function in patients late after Fontan operation by cardiac magnetic resonance imaging. BACKGROUND: An assessment of determinants for ventricular function in post-Fontan patients was intended. METHODS: Twenty-three unselected patients (9 female, 14 male) at a median age of 19.4 years (range, 7.8 to 31.3 years), at a median time of 10.5 years (range, 4.1 to 18 years) after Fontan operation were studied. A standard 1.5-T scanner was used, and analysis was performed using dedicated software. Ten healthy volunteers (median age 26.4, range 18 to 39.3 years) served as the control group. RESULTS: Median end-systolic mass index was 72.2 g/m(2) (range, 43 to 138 g/m(2)) and 86.6 g/m(2) (range, 52 to 123 g/m(2)) in the control group (p = NS). Median end-diastolic ventricular volume was 64 ml/m(2) (range, 32 to 117 ml/m(2)) compared with 67.7 ml/m(2) (range, 59 to 75 ml/m(2)) in the control group (p = NS). Median ejection fraction was 49.3% (range, 20% to 63%) compared with 64.8% (range, 57% to 79%) in normals (p = 0.00001). CONCLUSIONS: We conclude that long-term survivors of a Fontan operation have normal ventricular mass, normal volume, but reduced systolic ventricular function.