Left ventricular remodelling in masters athletes

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): I have received a research fellowship grant from the UK based charity Cardiac Risk in the Young

Objectives

We investigated the effect of long-term exercise and sex on left ventricular (LV) geometry in a large group of female and male masters athletes.

Background

Studies assessing LV geometry in masters athletes are scarce.

Methods

Different types of LV geometry were identified according to echocardiography-derived relative wall thickness (RWT) and left ventricular mass (LVM) values as per international guidelines. 4 groups were formed: normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), and concentric remodeling (normal LVM/increased RWT).

Results

A total of 277 healthy, elite, caucasian endurance masters athletes (65% female; mean age54.8 ± 7.7 years) were assessed. The athletes were exercising for a mean 32 ± 11.7 years and have completed a median 70 competitions including a median 13 marathon-type competitions. Females exhibited lower absolute LVM (127.7 ± 30.31g vs 196.57 ± 45.0g, p < 0.001), indexed LVM (76.8 ± 18.0 g/m2 vs. 103.6 ± 22.7 g/m2; p < 0.001), RWT (0.36 ± 0.07 vs. 0.42 ± 0.08; p < 0.001) and absolute LV end-diastolic dimension (LVEDD) (46.3 ± 4.1 mm vs 50.1 ± 5.11 mm, p < 0.001) but greater indexed LVEDD (27.7 ± 2.7mm/m2 vs 26.5 ± 2.7 mm/m2, p < 0.001) compared with male athletes. Most female athletes showed normal LV geometry (72% vs 38% in male athletes, P < 0.001) and significantly less concentric remodeling (12% vs 35%, p < 0.001) and concentric hypertrophy (5% vs 13%, p = 0.01) (table & figure).

Conclusions

A sex-specific response to chronic exercise is observed. Male masters athletes exhibit significantly more frequently abnormal LV geometry with concentric LV remodeling and/or concentric hypertrophy.

Cohort characteristics Male masters athletes N = 97 Female masters athletes N = 180 P value Age (years) 55.0 ± 9.0 54.7 ± 6.9 0.68 Years of exercise 32.0 ± 12.8 33.3 ± 11.1 0.14 LV Mass (g) 127.7 ± 30.31 196.57 ± 45.0 <0.001 LV Mass Indexed (g/m2) 76.8 ± 18.0 103.6 ± 22.7 <0.001 LVEDD (mm) 46.3 ± 4.1 50.1 ± 5.11 <0.001 LVEDD Indexed (mm/m2) 27.7 ± 2.7 26.5 ± 2.7 <0.001 Normal Remodeling 36 (37) 130 (72) <0.001 Eccentric Hypertrophy 14 (14) 18 (10) 0.27 Concentric Remodeling 34 (35) 23 (13) <0.001 Concentric Hypertrophy 13 (13) 9 (5) 0.01 LV Left Ventricular, LVEDD: Left Ventricular End Diastolic Dimension Abstract Figure. Patterns of left ventricular remodeling

Brivaracetam efficacy and tolerability in clinical practice: A UK-based retrospective multicenter service evaluation

PURPOSE

This multicenter service evaluation explores the efficacy and tolerability of brivaracetam (BRV) in an unselected, consecutive population in 'real-life' clinical settings.

METHOD

We retrospectively collected data from patient records at 11 UK hospitals and epilepsy centers. Consecutive patients prescribed BRV with at least 3 months of follow-up (FU) were included. Apart from reporting effectiveness and tolerability of BRV across the whole cohort, we compared treatment outcomes depending on previous levetiracetam use (LEV+ versus LEV-), comorbid learning disability (LD+ versus LD-), and epilepsy syndrome (focal versus generalized epilepsy).

RESULTS

Two hundred and ninety patients (46% male, median age: 38 years, range: 15 to 77) with ≥3 months of FU were included. The median duration of BRV exposure was 12 months (range: 1 day to 72 months). Overall BRV retention was 71.1%. While 56.1% of patients improved in terms of seizure frequency category (daily, weekly, monthly, yearly seizures), 23.1% did not improve on this measure and 20.8% deteriorated. In terms of seizure frequency, 21% of patients experienced a ≥50% reduction, with 7.0% of all patients becoming seizure-free. Treatment-emergent adverse events (AEs) were reported by 107 (36.9%) patients, but there were no serious AEs. The commonest AEs were sedation/fatigue (18.3%), mood changes (9.0%), and irritability/aggression (4.8%). There were no significant differences in drug retention, seizure frequency outcomes, or AEs between the LEV+ and LEV- subgroups, or between patients with generalized or focal epilepsies. Although 15.5% of patients in the LD+ group achieved a ≥50% reduction, this rate was lower than in the LD- group.

CONCLUSIONS

This 'real-life' evaluation suggests that reductions in seizure frequency can be achieved with BRV in patients with highly refractory epilepsy. Brivaracetam may be a useful treatment option in patients who have previously failed to respond to or tolerate LEV, those with LD, or (off-label) those with generalized epilepsies.

Protein Content of Wheat by Near-Infrared Spectroscopy of Whole Grain: Collaborative Study

A collaborative study was performed to assess accuracy, repeatability, and reproducibility of a nearinfrared (near-IR) method for determining crude protein content (PC) of whole-grain wheat. Four types of commercially available near-IR instruments, representing various combinations of wavelength region, mode of energy capture, method of energy dispersion, and treatment of spectral data, were used. Eight, 9,10, and 11 collaborators were involved, the exact number depending on instrument type. All collaborators received 22 samples of whole-grain hard red winter (HRW) wheat. They were furnished reference PCs (i.e., protein concentrations, w/w) corrected to a 12% moisture basis for instrument standardization. AOAC Method 990.03— combustion analysis—was the reference procedure. Standardization consisted of performing one of the following treatments to the instrument manufacturer's (or federal agency's) PC equation: (1) bias correction, (2) slope and intercept correction, or (3) recalibration with inclusion of standardization sample spectra. Standardized equations were then applied to a test set of 12 unknown HRW wheat sample spectra, with 2 samples blindly duplicated. The PCs of test samples ranged from 9 to 16%. Near-IR predictions were compared with reference measurements. Averaged within instrument type, root mean square of differences were 0.22, 0.24, 0.25, and 0.26% PC, depending on instrument. Corrected for bias within the test set, standard errors became 0.22, 0.18, 0.21, and 0.24% PC, respectively. These values were approximately twice the estimated lower limit for error (representing sample inhomogeneity). Overall repeatability relative standard deviation (RSD,) values were 0.92, 0.36, 0.42, and 0.74%, respectively. Overall reproducibility relative standard deviation (RSDR) values were 1.15, 0.61,1.53, and 1.38%. Such values for within-laboratory and between-laboratory variations of the near- IR methods were equivalent to values reported for the combustion method (990.03) for wheat. An inhouse study that examined all 6 U.S. wheat classes with one of the 4 instrument types produced repeatability and reproducibility values similar to those of the collaborative study, suggesting that the near-IR technique may be applied to red, white, hard, soft, and durum wheats. The near-IR method for determination of PC of whole-grain wheat has been adopted First Action (997.06) by AOAC INTERNATIONAL.

Final results of a multi-institutional phase II trial of reirradiation with concurrent weekly cisplatin and cetuximab for recurrent or second primary squamous cell carcinoma of the head and neck

Background

The optimal regimen of chemotherapy and reirradiation (re-XRT) for recurrent head and neck squamous cell carcinoma (HNSCC) is controversial. We report the final outcomes of a multicenter phase II trial evaluating cetuximab and cisplatin-based chemotherapy concurrent with re-XRT for patients with recurrent HNSCC.

Materials and methods

Patients with unresectable recurrent disease or positive margins after salvage surgery arising within a previously irradiated field with KPS ≥ 70 were eligible for this trial. Cetuximab 400 mg/m2 was delivered as a loading dose in week 1 followed by weekly cetuximab 250 mg/m2 and cisplatin 30 mg/m2 concurrent with 6 weeks of intensity-modulated radiotherapy to a dose of 60-66 Gy in 30 daily fractions. Patients who previously received both concurrent cetuximab and cisplatin with radiation or who received radiotherapy less than 6 months prior were ineligible.

Results

From 2009 to 2013, 48 patients enrolled on this trial, 2 did not receive any protocol treatment. Of the remaining 46 patients, 34 were male and 12 female, with a median age of 62 years (range 36-85). Treatment was feasible and only 1 patient did not complete the treatment course. Common grade 3 or higher acute toxicities were lymphopenia (46%), pain (22%), dysphagia (13%), radiation dermatitis (13%), mucositis (11%) and anorexia (11%). There were no grade 5 acute toxicities. Eight grade 3 late toxicities were observed, four of which were swallowing related. With a median follow-up of 1.38 years, the 1-year overall survival (OS) was 60.4% and 1-year recurrence-free survival was 34.1%. On univariate analysis, OS was significantly improved with young age (P = 0.01). OS was not associated with radiation dose, surgery before re-XRT or interval from prior XRT.

Conclusions

Concurrent cisplatin and cetuximab with re-XRT is feasible and offers good treatment outcomes for patients with high-risk features. Younger patients had significantly improved OS.

ClinicalTrials.Gov Identifier

NCT00833261.

Predicting progression to treatment using the Fagerström score in a free NHS smoking cessation programme

<sec id="st1"> <title>SETTING</title> A free, national smoking cessation service for adults based on behavioural and pharmaceutical support in Wales, UK. </sec> <sec id="st2"> <title>OBJECTIVE</title> To establish whether the Fagerström score at the assessment session could be used to predict subsequent treatment attendance. Non-attendance affects the individual's health and the efficiency of the service. </sec> <sec id="st3"> <title>DESIGN</title> Anonymised data from 39 967 Stop Smoking Wales assessment session attendees were assessed using logistic regression. The outcome variable was subsequent attendance/non-attendance for at least one treatment session. Fagerström scores were grouped into 'very low' (0-2), 'low' (3-4), 'medium' (5) and 'high' (6-10). </sec> <sec id="st4"> <title>RESULTS</title> People with medium (OR 1.15, 95%CI 1.08-1.24) or low Fagerström scores (OR 1.07, 95%CI 1.00-1.14) were more likely to attend treatment sessions than people with very low (OR 1.03, 95%CI 0.94-1.12) or high (baseline) Fagerström scores. The final model comprised nine other statistically significant covariates: current age, sex, residential deprivation level, number of previous quit attempts, type of appointment (group or one-to-one), time of appointment, appointment season, time spent waiting for an appointment and distance from home to the clinic. </sec> <sec id="st5"> <title>CONCLUSION</title> The Fagerström score at the assessment session could be used to identify smokers at an increased risk of not attending subsequent treatment. Further research is required to evaluate the impact of targeting those with the highest and lowest Fagerström scores at the assessment session upon treatment attendance. </sec>.

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group

Hidradenitis suppurativa (HS)/acne inversa is a debilitating chronic disease that remains poorly understood and difficult to manage. Clinical practice is variable, and there is a need for international, evidence‐based and easily applicable consensus on HS management. We report here the findings of a systematic literature review, which were subsequently used as a basis for the development of international consensus recommendations for the management of patients with HS. A systematic literature review was performed for each of nine clinical questions in HS (defined by an expert steering committee), covering comorbidity assessment, therapy (medical, surgical and combinations) and response to treatment. Included articles underwent data extraction and were graded according to the Oxford Centre for Evidence‐based Medicine criteria. Evidence‐based recommendations were then drafted, refined and voted upon, using a modified Delphi process. Overall, 5310 articles were screened, 171 articles were analysed, and 65 were used to derive recommendations. These articles included six randomized controlled trials plus cohort studies and case series. The highest level of evidence concerned dosing recommendations for topical clindamycin in mild disease (with systemic tetracyclines for more frequent/widespread lesions) and biologic therapy (especially adalimumab) as second‐line agents (following conventional therapy failure). Good‐quality evidence was available for the hidradenitis suppurativa clinical response (HiSCR) as a dichotomous outcome measure in inflammatory areas under treatment. Lower‐level evidence supported recommendations for topical triclosan and oral zinc in mild‐to‐moderate HS, systemic clindamycin and rifampicin in moderate HS and intravenous ertapenem in selected patients with more severe disease. Intralesional or systemic steroids may also be considered. Local surgical excision is suggested for mild‐to‐moderate HS, with wide excision for more extensive disease. Despite a paucity of good‐quality data on management decisions in HS, this systematic review has enabled the development of robust and easily applicable clinical recommendations for international physicians based on graded evidence.

Reduction in Factor VII, Fibrinogen and Plasminogen Activator Inhibitor-1 Activity after Surgical Treatment of Morbid Obesity

The aim of this study was to determine the effects of the surgical treatment of morbid obesity on some aspects of haemostatic and fibrinolytic function. Measurement of haemostatic and fibrinolytic factors was performed before and again 6 and 12 months after operation in 19 patients suffering from morbid obesity. Surgical treatment resulted in a mean decrease in body weight of 50 kg at 6 months and 64 kg at 12 months. Weight loss was accompanied at 12 months by significant reductions in median (interquartile range) concentrations of serum cholesterol from 5.3 (4.5–6.2) mmol/1 to 3.6 (2.9–4.6) mmol/1; factor VII from 113 (92–145)% of normal to 99 (85–107)%; of fibrinogen from 3.5 (3–9.3) g/1 to 2.8 (2.4–3.8) g/1; and of plasminogen activator inhibitor-1 (PAI-1) activity from 21 (11–30) IU/ml to 6.3 (5–10) IU/ml. The decrease in PAI-1 activity probably accounted for a significant reduction in euglobulin clot lysis time. Tissue plasminogen activator activity was undetectable in most patients pre-operatively but increased slightly after 1 year to 110 (100–204) mIU/ml. There were no significant changes in plasma levels of KCCT, factor VIII, von Willebrand factor antigen, alpha-2-antiplasmin, antithrombin III, protein C antigen, beta thromboglobulin, platelet factor 4, fibrinopeptide A or platelet count. These findings provide support for the hypothesis that the surgical treatment of morbid obesity may have a long-term beneficial effect on mortality from cardiovascular and thromboembolic disease.

A Prospective Study of Haemostatic Tests at 28 Weeks Gestation as Predictors of Pre-Eclampsia and Growth Retardation

A panel of haemostatic tests was perfomed on 400 primiparous women at 28 weeks to test whether one or more could predict the development of pregnancy complications. Fifteen women subsequently developed pre-eclampsia with significant proteinuria and 13 delivered growth retarded infants. There were no significant differences between mothers in the pre-eclampsia group and 22 randomly selected controls. A stepwise logistic discriminant analysis of the data did not produce a significant model. In the growth retarded group only beta thromboglobulin levels were significantly lower than in the controls (p <0.05), although in the logistic discriminant analysis the inclusion of both beta thromboglobulin and fibrin degradation products led to a borderline significant improvement in fit of the model. We conclude that the haemostatic variables studied are not significantly changed at 28 weeks nor clinically useful predictors of either pre-eclampsia or fetal growth retardation.

Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol

Background

Adding abiraterone acetate with prednisolone (AAP) or docetaxel with prednisolone (DocP) to standard-of-care (SOC) each improved survival in systemic therapy for advanced or metastatic prostate cancer: evaluation of drug efficacy: a multi-arm multi-stage platform randomised controlled protocol recruiting patients with high-risk locally advanced or metastatic PCa starting long-term androgen deprivation therapy (ADT). The protocol provides the only direct, randomised comparative data of SOC + AAP versus SOC + DocP.

Method

Recruitment to SOC + DocP and SOC + AAP overlapped November 2011 to March 2013. SOC was long-term ADT or, for most non-metastatic cases, ADT for ≥2 years and RT to the primary tumour. Stratified randomisation allocated pts 2 : 1 : 2 to SOC; SOC + docetaxel 75 mg/m2 3-weekly×6 + prednisolone 10 mg daily; or SOC + abiraterone acetate 1000 mg + prednisolone 5 mg daily. AAP duration depended on stage and intent to give radical RT. The primary outcome measure was death from any cause. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. This was not a formally powered comparison. A hazard ratio (HR) <1 favours SOC + AAP, and HR > 1 favours SOC + DocP.

Results

A total of 566 consenting patients were contemporaneously randomised: 189 SOC + DocP and 377 SOC + AAP. The patients, balanced by allocated treatment were: 342 (60%) M1; 429 (76%) Gleason 8-10; 449 (79%) WHO performance status 0; median age 66 years and median PSA 56 ng/ml. With median follow-up 4 years, 149 deaths were reported. For overall survival, HR = 1.16 (95% CI 0.82-1.65); failure-free survival HR = 0.51 (95% CI 0.39-0.67); progression-free survival HR = 0.65 (95% CI 0.48-0.88); metastasis-free survival HR = 0.77 (95% CI 0.57-1.03); prostate cancer-specific survival HR = 1.02 (0.70-1.49); and symptomatic skeletal events HR = 0.83 (95% CI 0.55-1.25). In the safety population, the proportion reporting ≥1 grade 3, 4 or 5 adverse events ever was 36%, 13% and 1% SOC + DocP, and 40%, 7% and 1% SOC + AAP; prevalence 11% at 1 and 2 years on both arms. Relapse treatment patterns varied by arm.

Conclusions

This direct, randomised comparative analysis of two new treatment standards for hormone-naïve prostate cancer showed no evidence of a difference in overall or prostate cancer-specific survival, nor in other important outcomes such as symptomatic skeletal events. Worst toxicity grade over entire time on trial was similar but comprised different toxicities in line with the known properties of the drugs.

Trial registration

Clinicaltrials.gov: NCT00268476.