Standardization of lipoprotein reporting

We wanted to ascertain whether the current format of lipid laboratory reports seemed adequate to promote identification and treatment of patients with dyslipidemia. In a random survey of lipid laboratory reports from 25 laboratories, we found great inconsistencies among reporting formats and contents. Fewer than half the laboratories correctly reported the ranges for cholesterol, only 4 correctly reported ranges for high-density lipoprotein cholesterol, only 2 correctly reported ranges for triglycerides, and none presented low-density lipoprotein cholesterol ranges in terms of risk factors for coronary heart disease. Reports typically were disjointed and difficult to read. The current practice of reporting results for lipid panels is confusing and does not follow the National Cholesterol Education Program (NCEP) guidelines. We recommend that reporting of results be standardized, and a "model" standardized report is presented herein, based on consensus from a team of experts. The standardized report uses current recommendations for ranges, follows the flowcharts of the NCEP guidelines, and takes the patient's clinical condition (the number of risk factors and the presence of coronary heart disease) into consideration. Standardizing lipid reports should decrease confusion and perhaps increase application of the guidelines and patient compliance with treatment.     

Intrafamilial relations of cardiovascular disease risk factors in African-Americans: longitudinal results from DC SCAN

BACKGROUND: Few studies have examined intrafamilial patterns of cardiovascular disease (CVD) risk factors in African-American families or identified potential influences on these patterns. This study examines the effects of age and sex of child on correlations between siblings during childhood as well as between mothers and their offspring in African-American families at two points in time. METHODS: CVD risk factors were assessed in a sample of 267 pairs of African-American siblings and their mothers. One hundred nine of these families were selected for a second assessment of CVD risk factors approximately 28 months later. RESULTS: Older siblings had significantly greater correlations than younger siblings with mothers' low-density lipoproteins (r = 0.61 versus r = 0.43 for older and younger siblings, respectively), apolipoprotein A-I (r = 0. 46 versus r = 0.16), and lipoprotein (a) (r = 0.71 versus r = 0.34). Correlations between female siblings were significantly higher than between male siblings for total cholesterol (r = 0.74 versus r = 0. 18 for female versus male siblings), triglycerides (r = 0.56 versus r = 0.05), and apolipoprotein B (r = 0.72 versus r = 0.31); they were also higher between female siblings than between mixed-sex siblings for measures of adiposity (r = 0.46 versus r = 0.19) and total cholesterol (r = 0.74 versus r = 0.27). CONCLUSIONS: Significant intrafamilial correlations for African-American children were influenced by both age and sex of siblings, reflecting potential genetic and environmental influences. Assessing family patterns of CVD risk factors in high-risk populations may assist in the early identification of children who can benefit most from intervention.     

C-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus

CONTEXT: Inflammation is hypothesized to play a role in development of type 2 diabetes mellitus (DM); however, clinical data addressing this issue are limited. OBJECTIVE: To determine whether elevated levels of the inflammatory markers interleukin 6 (IL-6) and C-reactive protein (CRP) are associated with development of type 2 DM in healthy middle-aged women. DESIGN: Prospective, nested case-control study. SETTING: The Women's Health Study, an ongoing US primary prevention, randomized clinical trial initiated in 1992. PARTICIPANTS: From a nationwide cohort of 27 628 women free of diagnosed DM, cardiovascular disease, and cancer at baseline, 188 women who developed diagnosed DM over a 4-year follow-up period were defined as cases and matched by age and fasting status with 362 disease-free controls. MAIN OUTCOME MEASURES: Incidence of confirmed clinically diagnosed type 2 DM by baseline levels of IL-6 and CRP. RESULTS: Baseline levels of IL-6 (P<.001) and CRP (P<.001) were significantly higher among cases than among controls. The relative risks of future DM for women in the highest vs lowest quartile of these inflammatory markers were 7.5 for IL-6 (95% confidence interval [CI], 3.7-15.4) and 15.7 for CRP (95% CI, 6.5-37.9). Positive associations persisted after adjustment for body mass index, family history of diabetes, smoking, exercise, use of alcohol, and hormone replacement therapy; multivariate relative risks for the highest vs lowest quartiles were 2.3 for IL-6 (95% CI, 0.9-5.6; P for trend =.07) and 4.2 for CRP (95% CI, 1.5-12.0; P for trend =.001). Similar results were observed in analyses limited to women with a baseline hemoglobin A(1c) of 6.0% or less and after adjustment for fasting insulin level. CONCLUSIONS: Elevated levels of CRP and IL-6 predict the development of type 2 DM. These data support a possible role for inflammation in diabetogenesis.     

Biomarkers of endothelial dysfunction and risk of type 2 diabetes mellitus

Context  Endothelial dysfunction occurs in diagnosed type 2 diabetes mellitus but may also precede development of diabetes. Objective  To determine whether elevated plasma levels of biomarkers reflecting endothelial dysfunction (E-selectin; intercellular adhesion molecule 1 [ICAM-1]; and vascular cell adhesion molecule 1 [VCAM-1]) predict development of type 2 diabetes in initially nondiabetic women. Design and Setting  Prospective, nested case-control study within the Nurses' Health Study, an ongoing US study initiated in 1976. Participants  Of 121 700 women initially enrolled, 32 826 provided blood samples in 1989-1990; of those free of diabetes, cardiovascular disease, or cancer at baseline, 737 developed incident diabetes by 2000. Controls (n = 785) were selected according to matched age, fasting status, and race. Main Outcome Measure  Risk of confirmed clinically diagnosed type 2 diabetes by baseline levels of E-selectin, ICAM-1, and VCAM-1. Results  Baseline median levels of the biomarkers were significantly higher among cases than among controls (E-selectin, 61.2 vs 45.4 ng/mL; ICAM-1, 264.9 vs 247.0 ng/mL; VCAM-1, 545.4 vs 526.0 ng/mL [all P values .004]). Elevated E-selectin and ICAM-1 levels predicted incident diabetes in logistic regression models conditioned on matching criteria and adjusted for body mass index (BMI), family history of diabetes, smoking, diet score, alcohol intake, activity index, and postmenopausal hormone use. The adjusted relative risks for incident diabetes in the top quintile vs the bottom quintiles were 5.43 for E-selectin (95% confidence interval [CI], 3.47-8.50), 3.56 for ICAM-1 (95% CI, 2.28-5.58), and 1.12 for VCAM-1 (95% CI, 0.76-1.66). Adjustment for waist circumference instead of BMI or further adjustment for baseline levels of C-reactive protein, fasting insulin, and hemoglobin A_1c or exclusion of cases diagnosed during the first 4 years of follow-up did not alter these associations. Conclusion  Endothelial dysfunction predicts type 2 diabetes in women independent of other known risk factors, including obesity and subclinical inflammation.      

Akutes Leberversagen

Acute liver failure is a rare dynamic disease with a high spontaneous mortality. It is defined as acute (<26 weeks) severe liver insufficiency (INR?>1.5) with hepatic encephalopathy in the absence of chronic liver disease. The most important prognostic parameters in acute liver failure are the etiology as well as the stage of hepatic encephalopathy. Multiorgan failure, infections as well as advanced cerebral edema are the most frequent causes of death in patients with acute liver failure. Management of acute liver failure always requires intensive care surveillance with close monitoring. In case of complications an early and aggressive therapy is recommended. This includes a fluid and blood glucose monitoring, tracheal intubation and mannitol in cases of cerebral edema, a substitution of coagulation factors only in case of hemorrhage, early antibiotics for infections, early renal replacement therapy, N-acetyl cysteine for stage I/II hepatic encephalopathy as well as etiology-specific therapeutic measures. Liver transplantation is the last step therapy.     

ST Segment Elevation in One Lead: A Case Report

Background: We describe an unusual finding in an electrocardiogram showing ST‐segment elevation not related to coronary artery stenosis, pericarditis, bundle branch block, or other well known disorders. Case Presentation: A 60‐year‐old African American woman admitted for elective coronary artery bypass graft surgery. A temporary pacemaker with pacing wires was placed intraoperatively for prevention and treatment of postoperative bradyarrhythmia. One day following uneventful surgery, her electrocardiogram demonstrated marked ST segment elevation confined to lead V₆. These changes were comparable to tracings obtained from direct epicardial electrocardiogram, due to contact between the V₆ electrode and the temporary pacemaker ventricular lead wire. Conclusion: Current‐of‐injury patterns are represented on surface electrocardiogram by deviations of the ST segment from the isoelectric baseline. The pacing wire causes direct localized epicardial current‐of‐injury, affecting the action potential and the resting membrane potentials of cardiomyocytes. Our case report demonstrates epicardial current‐of‐injury pattern obtained via surface rather than epicardial electrocardiogram, with surface leads as surrogates of epicardial tracing. Measurement of ST‐segment shifts from the epicardial electrocardiogram has been shown to provide a more sensitive measurement of ischemia when compared to surface precordial ECG.