Association between depressive symptoms and sleep disturbances in community-dwelling older men

OBJECTIVES: To examine the association between depressive symptoms and subjective and objective measures of sleep in community-dwelling older men.
DESIGN: Cross-sectional.
SETTING: Six U.S. clinical centers.
PARTICIPANTS: Three thousand fifty-one men aged 67 and older.
MEASUREMENTS: Depressive symptoms assessed using the 15-item Geriatric Depression Scale and categorized as 0 to 2 (normal, referent group), 3 to 5 (some depressive symptoms), and 6 to 15 (depressed); objective sleep measures ascertained using wrist actigraphy (mean duration 5.2 nights); and subjective sleep measures assessed using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale.
RESULTS: There was a strong multivariable-adjusted association between level of depressive symptoms and subjective sleep disturbances ( P -trend <.001). For example, the odds of reporting poor sleep quality were 3.7 times (95% confidence interval (CI)=2.5–5.3) higher for depressed men as for normal men, and 2.1 times (95% CI=1.7–2.6) higher for men with some depressive symptoms. For objectively measured sleep disturbances, men with more depressive symptoms had greater odds of sleep latency of 1 hour or more ( P -trend=.006). There was no association between level of depressive symptoms and sleep efficiency, awakening after sleep onset, multiple long-wake episodes, or total sleep time. Excluding 384 men taking antidepressants, benzodiazepines, or other anxiolytic or hypnotics did not alter the results.
CONCLUSION: Depressive symptoms have a strong, graded association with subjective sleep disturbances and are moderately associated with objectively measured prolonged sleep latency. Future studies should address temporality of depression and sleep disturbances.     

Do gender disparities persist in gastroenterology after 10 years of practice?

BACKGROUND: Cross-sectional studies confirm gender disparity in many aspects of the practice of medicine and surgery. Some data suggest the disparities diminish after 10 yr of practice. This study aims to examine gender discrepancies in income, social, and professional status of gastroenterologists after 10 yr of practice.
METHODS: Prospective, observational, cohort study of gastroenterologists incepted upon graduation from a U.S. GI fellowship program in 1993 and 1995. A 36-item questionnaire was sent to the cohort at 3, 5, and 10 yr after graduation from GI fellowship training. The following are the results of the final, 10th year survey.
RESULTS: A total of 168 men and 25 women (mean age 45.5 yr) responded. Men and women were equally likely to be board certified and married, however, women had fewer children. Men earned a mean annual gross income of $375,000 versus $245,000 for women ( P = 0.001). After adjusting for practice setting, work hours, practice-ownership, free endoscopy center practice, and vacation time, female gastroenterologists earned $82,000 (22%) less per year than their male colleagues (95% CI $34,000–130,000, P = 0.001). Women were more frequently in academic practice (38% vs 17%), but were less likely to hold the most advanced academic positions.
CONCLUSIONS: After 10 yr of practice, significant economic, professional, and social disparities persist between male and female gastroenterologists in this cohort. Women were more likely to practice in a setting with flexible work hours, a family leave provision, and in a practice with other women. Initiatives to equalize pay and ensure opportunities for professional advancement for women may diminish the significant practice disparities incurred by women in gastroenterology.     

高龄患者非ST段抬高急性冠状动脉综合征介入治疗的差异

目的 比较非ST段抬高急性冠状动脉(冠脉)综合征不同年龄患者介入治疗的疗效和安全性.方法 非ST段抬高的急性冠脉综合征患者随机分配至早期介入组(24 h内接受冠脉造影)和延迟介入组(36 h后接受冠脉造影).主要研究终点为180 d随访时死亡、心肌梗死(MI)、卒中的复合终点.结果 共有815例患者入选,其中≥75岁患者198例,＜75岁患者617例.≥75岁患者主要终点事件发生率明显高于＜75岁患者(18.7%比9.2%,P=0.00).＜75岁患者早期介入组主要终点事件发生率明显低于延迟介入组(6.5%比12.5%,P=0.01).≥75岁患者早期介入组和延迟介入组间主要终点事件发生率差异无统计学意义(16.5%比21.3%,P=0.39).结论 非ST段抬高急性冠脉综合征介入治疗中≥75岁患者病死率和新发MI发生率高于＜75岁患者;＜75岁患者早期介入治疗可减少MI的发生率,≥75岁患者早期和延迟介入治疗差异无统计学意义.

Abstract：

Objective To investigate the effect and safety of early intervention and delayed intervention therapy on elderly patients and younger patients with non-ST segment elevation acute coronary syndrome. Methods The patients with non-ST segment elevation acute coronary syndrome were randomly divided into early intervention group (coronary angiography taken within 24 hours after grouping) and delayed intervention group ( coronary angiography taken after 36 hours after grouping). The primary endpoint was a composite endpoint of death, myocardial infarction and stroke during 180 days follow-up. Results A total of 815 patients were enrolled, including 198 elderly patients aged 75 years and above, and 617 younger patients aged below 75 years. The elderly patients had a greater incidence of the primary endpoint than that of younger patients ( P = 0. 00). The primary endpoint of early intervention group were obviously lower than that of delayed intervention group of younger patients ( P = 0. 01 ). There was no significant difference in primary endpoint incidence of early intervention group and delayed intervention group of the elderly patients (P =0. 39). Conclusions The elderly patients with non-ST segment elevation acute coronary syndrome who underwent intervention had greater incidence of death and myocardial infarction. Early intervention reduced the rate of myocardial infarction for the younger patients. There was no significant difference in primary endpoint incidence between early intervention and delayed intervention among elderly patients.     

2011年第1期中文目录

睡眠障碍性疾患如睡眠呼吸紊乱、失眠、睡眠运动障碍及异态睡眠在老年人中十分常见,避免延误诊疗的关键在于提高对其了解和认识。     

Antiretroviral therapy in prevention of HIV and TB: update on current research efforts

There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV- and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.     

Clustering of target organ damage increases mortality after acute coronary syndromes in patients with arterial hypertension

The impact of target organ damage (TOD) clustering in hypertensive patients with established cardiovascular disease has not been clearly defined. Multicentre, observational and prospective study of 1054 consecutive patients with acute coronary syndromes (ACSs). The objective was describing the impact of TOD on first-year mortality. Ankle-brachial index (ABI), left ventricular hypertrophy and renal dysfunction were assessed during hospital stay. Hypertensive patients accounted for 80% of the cohort and had slightly higher mean age, higher prevalence of risk factors, previous cardiovascular disease and TOD. During follow-up, mean time 387.9 (7.2) days and median 382 (364.0-430.0) days, mortality rate tended to be higher in hypertensive patients (6.1 versus 3.5%; P=0.16). Cox regression survival analysis identified pathological ABI as the only TOD independently associated with mortality. When assessed globally, the presence of at least one TOD predicted mortality only in patients with hypertension and differences in mortality rate appeared very early in the follow-up. A linear increase in mortality rate was observed with the clustering of TOD: 2.0%, if no TOD was present, 7.6% in one TOD, 11.1% in two TODs and 20.0%, if three TODs were present. An increased risk in the combined end point of ischaemic events was observed in hypertensive patients without TOD (odds ratio (OR): 3.18; 95% confidence interval (CI): 1.31-7.70; P=0.01) and was still higher in patients with hypertension and TOD (OR: 4.61; 95% CI: 1.90-11.80; P<0.01). TOD predicts mortality and ischaemic events of hypertensive patients after ACS.     

A prospective multicentre study of mycophenolate mofetil combined with prednisolone as induction therapy in 213 patients with active lupus nephritis

Mycophenolate mofetil (MMF) with prednisolone has been associated with high remission rates when used as induction treatment for lupus nephritis. This prospective, multicentre, cohort study investigates the efficacy and safety of this regimen over 24 weeks in 213 Chinese patients with active lupus nephritis (Classes III, IV, V or combination). Baseline activity index (AI) was 6.91+/-3.33 and chronicity index (CI) was 1.9+/-1.2. The remission rate was 82.6% at 24 weeks (complete remission, 34.3%; partial remission, 48.4%). There were significant (P<0.01) improvements in kidney function shown by reductions in proteinuria, serum albumin, serum creatinine and creatinine clearance, as well as in systemic lupus erythematosus disease activity index (SLEDAI) scores. Independent risk factors influencing remission were pathological classification (including Class V and III or Class V and IV nephritis) and elevated serum creatinine at baseline (OR 2.967, 95% CI: 1.479-6.332, P=0.001 and OR 1.007, 95% CI: 1.002-1.011, P=0.001, respectively). Patients with concomitant membranous features on biopsy had a lower remission rate than those with Class III and IV nephritis (66.7% vs 87.3%, P=0.002). Renal biopsy was repeated in 25 patients following treatment. There was a transition to less severe pathological morphologies in majority of subjects. Infections were monitored throughout treatment: eight patients (3.8%) experienced bacterial infections, whereas herpes zoster occurred in seven patients. Nine patients (4.2%) suffered from gastrointestinal upset, which resolved without discontinuation of MMF. One patient became leucopenic, whereas another died from active disease unrelated to kidney symptoms. MMF combined with prednisolone is an effective and well-tolerated induction treatment for patients with active lupus nephritis and for controlling SLE systemic activity.     

生脉注射液盐酸曲美他嗪联用治疗缺血性心肌病的临床观察

目的观察生脉注射液盐酸曲美他嗪（万爽力）联用治疗缺血性心肌病的临床疗效。方法入选48例缺血性心肌病患者，全部为心功能不全Ⅳ级，超声心动左室射血分数（LVEF）〈55％。随机分为两组，治疗组26例，在强心利尿基础上给予生脉注射液盐酸曲美他嗪联用，对照组22例，给予强心利尿治疗，疗程14d。结果治疗组心功能不全分级提高明显改善（治疗组改善21例，对照组改善12例）。超声心动LVEF升高与对照组相比明显改善[治疗组治疗前（46．7±7．2）％，治疗后（60．6±5．3）％，对照组治疗前（47．1±6．6）％，治疗后（51．0±4．7）％，P〈0．05]。结论生脉注射液盐酸曲美他嗪联用治疗缺血性心肌病疗效确切，值得推广应用。     

Decreased slow wave sleep increases risk of developing hypertension in elderly men

The importance of sleep to health and cardiovascular disease has become increasingly apparent. Sleep-disordered breathing, sleep duration, and sleep architecture may all influence metabolism and neurohormonal systems, yet no previous study has evaluated these sleep characteristics concurrently in relation to incident hypertension. Our objective was to determine whether incident hypertension is associated with polysomnography measures of sleep-disordered breathing, sleep duration, and sleep architecture in older men. Participants were 784 community-dwelling, ambulatory men ≥65 years of age (mean age: 75.1±4.9 years) from the Outcomes of Sleep Disorders in Older Men Study who did not have hypertension at the time of their in-home polysomnography sleep studies (2003-2005) and who returned for follow-up (2007-2009). Of 784 older men included in this report, 243 met criteria for incident hypertension after a mean follow-up of 3.4 years. In unadjusted analyses, incident hypertension was associated with increased hypoxemia, increased sleep stages N1 and N2, and decreased stage N3 (slow wave sleep [SWS]). After adjustment for age, nonwhite race, study site, and body mass index, the only sleep index to remain significantly associated with incident hypertension was SWS percentage (odds ratio for lowest to highest quartile of SWS: 1.83 [95% CI: 1.18 to 2.85]). No attenuation of this association was seen after accounting for sleep duration, sleep fragmentation, and indices of sleep-disordered breathing. Percentage time in SWS was inversely associated with incident hypertension, independent of sleep duration and fragmentation, and sleep-disordered breathing. Selective deprivation of SWS may contribute to adverse blood pressure in older men.