Cardiovascular prevention, primary or secondary, in high risk patients

Two groups of patients admitted to hospital consecutively for coronary artery disease in 36 university hospital departments were interrogated about the advice received and followed concerning cardiovascular prevention both before the clinical onset of the disease (Group I), those with disease of less than one month duration (primary prevention), or after this period (Group II), those with disease for over six months (secondary prevention). The follow-up of risk factors or medical advice concerning prevention (dietary and/or treatment) was more common, and compliance to the advice was better, in secondary prevention. However, in both groups, with the exception of hypertension, the diagnosis and follow-up of the risk factors were incomplete with 19% vs 41% (p < or = 0.001) of serum cholesterol levels unmeasured before the onset of clinical disease; during the last 5 years, 41% vs 12% (cholesterol, p < or = 0.001) and 27% vs 9% (serum glucose, p < or = 0.001) were not checked. At least one measure of prevention had been advised to 66% vs 80% (p < or = 0.001) of patients and the measures taken concern 53 vs 75% (p < or = 0.001) of patients: serum cholesterol 27% vs 51% (p < or = 0.001), hypertension 32% vs 36% (NS) and serum glucose 14% vs 21% (p < or = 0.05). Compliance with advice was mediocre with regards to diet and cholesterol lowering drugs. A large proportion of patients in both groups had higher than recommended levels, including those on diet or treatment. These observations, confirmed in France and abroad, suggest that cardiovascular prevention should be better organised.     

Cardiovascular effects of verapamil enantiomer combinations in conscious dogs

We examined the systemic and coronary hemodynamic effects of five combinations of R- and S-verapamil enantiomers (R/S; 100/0, 90/10, 80/20, 50/50, and 20/80%, respectively) in conscious dogs chronically instrumented for measurement of aortic and LV pressure, +dP/dt, subendocardial segment length, coronary blood flow velocity, and aortic blood flow. Dogs received escalating doses (0.1, 0.2, and 0.4 mg kg(-1)) of each verapamil combination over 2 min at 30 min intervals on different experimental days and peak changes in hemodynamics were recorded 2 min after each dose. All verapamil combinations increased heart rate, mean aortic blood flow, and coronary blood flow velocity and decreased calculated systemic and coronary vascular resistance. Alterations in coronary hemodynamics were most pronounced with 20/80 R/S verapamil. Racemic and 20/80 R/S verapamil decreased mean arterial and left ventricular systolic pressure, in contrast to combinations with greater concentrations of the R enantiomer. Left ventricular function was unchanged during administration of 100/0, 90/10, and 80/20 R/S verapamil. Direct negative inotropic and lusitropic effects occurred with 50/50 and 20/80 R/S verapamil. The high dose of 20/80 R/S verapamil also increased left ventricular end-diastolic pressure and the regional chamber stiffness constant, consistent with diastolic dysfunction. The results indicate that combinations of R- and S-verapamil produce differential hemodynamic and left ventricular functional effects in conscious, unsedated dogs that are dependent on the relative ratio of these enantiomers.     

Cardiovascular disease in diabetes and operative risk

Among the complications of diabetes, cardiovascular disease is one of the most frequent, severe and invalidating. In the era before the introduction of insulin treatment, the most frequent cause of death in diabetes were acute metabolic and infectious complications; at present, after the introduction of insulin therapy and the consequent major change in the clinical evolution of the disease, the most frequent cause of death is due to cardiovascular complications. From the Framingham study it is possible to observe that in the adult diabetic population, the annual incidence of death from cardiovascular causes is about 17%, both in men and women, as against 8.5% in non diabetic males and 3.6% in non diabetic females. Major clinical forms of cardiovascular disease in diabetics are myocardial ischemia, autonomic neuropathy and cardiomyopathy.     

Endogenous estrogens and risk of breast cancer by estrogen receptor status: a prospective study in postmenopausal women

A positive association between postmenopausal serum levels of total estradiol, percentage of free estradiol, and percentage of estradiol not bound to sex hormone-binding globulin (SHBG) and breast cancer risk was recently reported by the New York University Women's Health Study (P. Toniolo et al., J. Natl. Cancer Inst., 87: 190-197, 1995). Data from this prospective study are used to assess whether the observed associations differ according to estrogen receptor (ER) status of the tumor. Between 1985 and 1991, 7063 postmenopausal women donated blood and completed questionnaires at a large breast cancer screening clinic in New York City. Before 1991, 130 cases of first primary breast cancer were identified by active follow-up of the cohort. For each case, two controls were selected, matching the case on age at first blood donation and length of storage of specimens. Biochemical analyses were performed on sera that had been stored at -80 degrees since sampling. ER information was abstracted from pathology reports. Separate statistical analyses were conducted of ER-positive, ER-negative, and ER-unknown groups (53, 23, and 54 matched sets, respectively). In each of the 3 groups, the mean estradiol and the mean percentage of free estradiol were greater (21-28% and 6-7%, respectively) in cases than in controls. Conversely, the mean percentage of estradiol bound to SHBG was 9-12% lower in cases than in controls. The logistic regression coefficients measuring the strength of the association between estradiol and its free and SHBG-bound fractions and breast cancer risk were similar in the ER-positive, ER-negative, and ER-unknown groups. These data suggest that in postmenopausal women, the association of endogenous estrogens with breast cancer risk is independent of the ER status of the tumor. This result is more compatible with the hypothesis of a progression from ER-positive to ER negative tumors than with the hypothesis that ER status identifies two distinct types of breast cancer.     

Prospective study of beverage use and the risk of kidney stones

We have analysed the replication of the heterochromatic megachromosome that was formed de novo by a large-scale amplification process initiated in the centromeric region of mouse chromosome 7. The megachromosome is organized into amplicons approximately 30 Mb in size, and each amplicon consists of two large inverted repeats delimited by a primary replication initiation site. Our results suggest that these segments represent a higher order replication unit (megareplicon) of the centromeric region of mouse chromosomes. Analysis of the replication of the megareplicons indicates that the pericentric heterochromatin and the centromere of mouse chromosomes begin to replicate early, and that their replication continues through approximately three-quarters of the S-phase. We suggest that a replication-directed mechanism may account for the initiation of large-scale amplification in the centromeric regions of mouse chromosomes, and may also explain the formation of new, stable chromosome segments and chromosomes.     

Relationships of serum androgens and estrogens to prostate cancer risk: results from a prospective study in Finland

Several lines of evidence suggest that sex hormones may be involved in the etiology of prostate cancer. We conducted a prospective nested case-control study to evaluate the relationships of serum androgens and estrogens to prostate cancer using serum collected at baseline for the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. The 29,133 male smokers who participated in the trial were 50-69 years old at baseline. During 5-8 years of follow-up, 246 men were diagnosed with prostate cancer, and 116 of these were randomly selected for inclusion in the current study. For each case, two controls matched on age, date of blood collection, intervention group, and study center were selected. Hormones were measured in serum by RIA using standard procedures. None of the individual androgens or estrogens was significantly related to prostate cancer. These findings were unaltered by simultaneous evaluation of serum androgen and estrogen concentrations in multivariate models. These results do not support a strong relationship of serum androgens and estrogens with prostate cancer in smokers. Within-person variation in concentrations of some hormones may have contributed to the lack of significant associations.     

Dressing selection: use of combinations of wound dressings

There are many wound dressing products available. In certain circumstances they are used in combination. In order to protect the patient, the use of dressing combinations should have a clear purpose and the support of the manufactures. Inappropriate combinations are costly and ineffective and serve only to perpetuate practice that does not have a sound research base. This article highlights the issues surrounding dressing selection and offers guidance on appropriate dressing combinations.     

Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations

BACKGROUND: Few reliable correlates of treatment response in depression have emerged despite nearly 40 years of research. We examined the correlates of recovery in a "mega-analysis," or meta-analysis of original data, of 595 patients with major depressive disorder enrolled in 6 standardized treatment protocols. METHODS: All patients (mean age, 44 years; 31% male and 69% female) met criteria for nonbipolar, nonpsychotic primary major depressive disorder and were treated for 16 weeks with either cognitive behavior therapy or interpersonal psychotherapy alone (psychotherapy alone; n = 243) or interpersonal psychotherapy plus antidepressant pharmacotherapy (combined therapy; n = 352). The impact of treatment type, severity, study, and other covariates on recovery rates or time to recovery were examined by means of chi 2, log-rank tests, the Cox proportional hazards model, and sensitivity analyses. RESULTS: Whereas combined therapy was not significantly more effective than psychotherapy alone in milder depressions, a highly significant advantage was observed in more severe recurrent depressions. Poorer outcomes were also observed in women and older patients, although these effects were dependent on inclusion of particular studies. CONCLUSIONS: Mega-analysis is a powerful method for comparing the efficacy of treatments and examining correlates of response. Using this method, we found new evidence in support of the widespread clinical impression that combined therapy is superior to psychotherapy alone for treatment of more severe, recurrent depressions.     

Integrating disinhibition and learning risk for alcohol use.

In this study the authors tested the acquired preparedness model of problem drinking, which holds that trait disinhibition, defined as neurotic extraversion by C. M. Patternson and J. P. Newman (1993), leads to the biased formation of positive over negative alcohol expectancies. Positive expectancies thus mediate disinhibition's influence on drinking. The authors also hypothesized that disinhibition moderates the expectancy–drinking relationship such that disinhibited individuals are more likely to act on their positive expectancies. In Study 1, positive expectancies both mediated and moderated the disinhibition–drinking relationship. In Study 2, learning task results indicated that disinhibited individuals sought reward, even when passive avoidance of punishment was indicated. Study 2 also replicated Study 1 hypotheses for men but generally not for women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dogs at high or low risk of ventricular fibrillation. An experimental study of acute myocardial ischaemia

In the last 15 years, measurement of the ventricular fibrillation threshold (VFT) after ligation of the coronary artery in anaesthetised dogs has become our standard method for the evaluation of the stabilizing effect of antifibrillation drugs. Analysis of a group of 143 dogs revealed that in 75 animals the VFT 8 minutes after the ligation of the coronary artery dropped to less than 1 mA (high risk group), while in the remaining 68 dogs the decrease was smaller and not below 1 mA (low risk animals). The difference between the groups could be seen already before the ligation of the coronary artery. The high risk animals had a lower VFT and a higher heart rate. The groups also differed in the response to drugs administered 15 minutes after the ligation of the coronary artery. Metipranolol, a liposoluble beta blocker of the beta 1 and 2 cardiac receptors (Trimepranol Spofa 0.3 mg.kg-1 b.w.), increased greatly the VFT in both groups already 8 minutes after the injection of the drug and eliminated the difference between the groups. Flunitrazepam (Rohypnol Hoffmann-La Roche 0.25 mg.kg-1 b.w.) increased the VFT less than metipranolol and the difference between the groups disappeared only 30 minutes after its injection. Celiprolol (Selectol Linz Chemie 3.0 mg.kg-1 b.w.) blocking beta 1 and stimulating beta 2 receptors as well as trimecaine (sodium channel blocker, Mesocain Spofa 3.0 mg.kg-1 b.w.) led only to a small insignificant increase in the VFT and the difference between the groups of dogs remained.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiovascular risk patient--how much prevention is necessary and rational?

Cardiovascular primary prevention may consist of strategies concerning the entire population (population strategy) or individuals at high risk for a cardiovascular event (high risk strategy). Clinicians are mainly involved in the identification and treatment of high risk individuals. Even more so, preventive measures should be focused on patients who are already affected by coronary artery disease (CAD) or other manifestations of atherosclerosis (secondary prevention). According to the beneficial effect anticipated by cardiovascular prevention, there should be a priority list guiding the therapeutic measures: first priority therapy should be reserved for patients with existing CAD, then persons without CAD symptoms at high risk for disease manifestation due to an accumulation of coronary risk factors (hypercholesterolemia, hypertension, smoking, diabetes mellitus, lack of physical activity, adipositas) should be treated. Third priority for preventive therapy for cardiovascular diseases is reserved for asymptomatic 1st degree relatives of CAD patients with an early onset CAD. Fourth priority have persons who are close relatives of high risk individuals, and fifth priority prevention is cardiovascular risk factor assessment in the general population. Estimation of the risk for future cardiovascular events is very important because it provides a rational basis for the necessity and relevance of a treatment strategy. In this review, several therapeutic options for cardiovascular prevention are described and discussed.     

Cardiovascular risk factors and educational attainment in Southern Spain: a study of a random sample of 3091 adults

Muscle mass decreases with age, leading to "sarcopenia," or low relative muscle mass, in elderly people. Sarcopenia is believed to be associated with metabolic, physiologic, and functional impairments and disability. Methods of estimating the prevalence of sarcopenia and its associated risks in elderly populations are lacking. Data from a population-based survey of 883 elderly Hispanic and non-Hispanic white men and women living in New Mexico (the New Mexico Elder Health Survey, 1993-1995) were analyzed to develop a method for estimating the prevalence of sarcopenia. An anthropometric equation for predicting appendicular skeletal muscle mass was developed from a random subsample (n = 199) of participants and was extended to the total sample. Sarcopenia was defined as appendicular skeletal muscle mass (kg)/height2 (m2) being less than two standard deviations below the mean of a young reference group. Prevalences increased from 13-24% in persons under 70 years of age to >50% in persons over 80 years of age, and were slightly greater in Hispanics than in non-Hispanic whites. Sarcopenia was significantly associated with self-reported physical disability in both men and women, independent of ethnicity, age, morbidity, obesity, income, and health behaviors. This study provides some of the first estimates of the extent of the public health problem posed by sarcopenia.     

Cardiovascular abnormalities in Kawasaki disease. An Italian prospective study

We report a prospective study performed over a 9 year period in 96 children with Kawasaki disease (mean age 35 +/- 29 months), 84 of whom < 5 years of age. The male/female ratio was 1.5 (57/39). A total of 38 patients had cardiac involvement, including flattened T waves in the ECG (10 patients), pericardial effusion (6 patients), myocarditis (1 patient), and coronary artery aneurysms (25 patients; frequency of aneurysms: 26%). All patients were evaluated during the acute phase (first month) of the illness. The first echocardiographic examination was performed 15 days (range 4.30 days) from the appearance of fever, and coronary aneurysms were observed in 23 patients; in 2 patients, however, aneurysms appeared later (2 and 6 months). Aneurysms were small (< or = 4.5 mm) in 12, medium (4.5-7 mm) in 11, and large (> 7 mm) in 12 patients. Male sex (p = 0.02), age < 12 months (p = 0.005), ESR (p = 0.001), platelet count (p = 0.009), and pericardial effusion (p = 0.02) were significantly related to the presence of aneurysm. Among females, incidence of aneurysms was significantly higher in infants < 12 months than in older patients (60 vs 6%, p < 0.001). Intravenous immunoglobulin treatment was started early (within 10 days) in 61 patients and late (> 10 days) in 22. Compared to late treatment, early i.v. immunoglobulin treatment was associated with smaller aneurysms and higher regression rate (67 vs 28%, p < 0.05). No difference was observed concerning frequency and number of dilated vessels as related to therapeutical regimens. Total i.v. immunoglobulin dose (2 g/kg) was administered over 1-2 days in 26 patients (scheme I) or over 4-5 days in 58 (scheme II). Frequency of aneurysms was significantly lower in patients treated early (p = 0.02). No myocardial infarctions or deaths occurred at short- or long-term follow-up.     

To use or not to use: Clinicians' perceptions of telemental health.

Equal access to mental health services is necessary for healthy individuals and communities. However, due to geographical distances and other barriers, some clients cannot easily access mental health professionals. Technologies such as videoconferencing for clinical purposes (i.e., telemental health) may help to bridge these gaps to connect clients and clinicians at geographically diverse locations. However, despite its potential utility, telemental health has not been widely adopted in Canada. This study is an exploratory investigation into mental health professionals' attitudes toward telemental health, factors that affect the frequency with which they use this technology, and their perceptions of individual characteristics that make clients more or less suitable candidates for telemental health. This study has a particular focus on remote and rural and Operational Stress Injury (OSI) contexts. One hundred sixty mental health workers across Canada participated in an online survey, and 25 mental health workers from Operational Stress Injury clinics across Canada participated in in-person interviews. The data were examined using qualitative and quantitative analysis methods. Findings suggest that mental health workers have overall positive attitudes toward the use of telemental health—particularly for clients in remote and rural locations. Additionally, receiving training in telemental health, being in the mental health field for longer, and perceiving the technology as easy to use are associated with more frequent use of telemental health. Finally, clinicians reported specific client characteristics that they perceive to make some clients unsuitable candidates for telemental health. Implications of these findings and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)