Chocolate consumption and risk of diabetes mellitus in the Physicians' Health Study

BACKGROUND

Previous studies reported beneficial effects of cocoa or chocolate on insulin resistance, oxidative stress, and inflammation, which are important risk factors of type 2 diabetes mellitus (DM). However, it is unclear whether chocolate consumption is associated with risk of DM.

OBJECTIVE

We tested the hypothesis that chocolate consumption is inversely associated with incident DM in the Physicians' Health Study (PHS).

DESIGN

We prospectively analyzed data on 18,235 PHS participants who were free of DM at baseline (1997-2001). Chocolate consumption was obtained from a baseline food-frequency questionnaire. Incident DM was ascertained via annual follow-up questionnaires and validated in a subsample by a review of medical records. We used Cox proportional hazards models to estimate HRs and 95% CIs of DM.

RESULTS

The mean (±SD) age at baseline was 66.3 ± 9.2 y. During a mean follow up of 9.2 y, 1123 men (6.2%) developed DM. For self-reported chocolate consumption of none, 1-3 servings/mo, 1 serving/wk, and ≥2 servings/wk, multivariable-adjusted HRs (95% CIs) of DM adjusted for lifestyle, clinical, and dietary risk factors including total energy intake were 1.00 (referent), 0.93 (0.79, 1.09), 0.86 (0.72, 1.04), and 0.83 (0.69, 0.99), respectively (P-trend = 0.047). In secondary analyses, the inverse association of chocolate consumption and risk of DM was slightly stronger in subjects without a history of cardiovascular disease or heart failure (P-trend = 0.023). In addition, both age and BMI modified the chocolate-DM relation (P < 0.05 each).

CONCLUSION

Our data support an inverse relation of chocolate intake with incident DM, which appears only to apply in younger and normal-body weight men after controlling for comprehensive life styles including total energy consumption.

Developing trends in the intestinal transplant waitlist

The United Network for Organ Sharing database was examined for trends in the intestinal transplant (ITx) waitlist from 1993 to 2012, dividing into listings for isolated ITx versus liver-intestine transplant (L-ITx). Registrants added to the waitlist increased from 59/year in 1993 to 317/year in 2006, then declined to 124/year in 2012; Spline modeling showed a significant change in the trend in 2006, p < 0.001. The largest group of registrants, <1 year of age, determined the trend for the entire population; other pediatric age groups remained stable, adult registrants increased until 2012. The largest proportion of new registrants were for L-ITx, compared to isolated ITx; the change in the trend in 2006 for L-ITx was highly significant, p < 0.001, but not isolated ITx, p = 0.270. New registrants for L-ITx, <1 year of age, had the greatest increase and decrease. New registrants for isolated ITx remained constant in all pediatric age groups. Waitlist mortality increased to a peak around 2002, highest for L-ITx, in patients <1 year of age and adults. Deaths among all pediatric age groups awaiting L-ITx have decreased; adult L-ITx deaths have dropped less dramatically. Improved care of infants with intestinal failure has led to reduced referrals for L-ITx.

Differences in effects of age and blood pressure on augmentation index

BACKGROUND

The effect of age on the augmentation index (AI) differs between young adults and the elderly, and the AI reaches a plateau after the age of 60 years. We examined whether the effects of age and an elevation in blood pressure on the AI differ between young adults and the elderly, between subjects with and without high blood pressure, or between subjects with and without a high AI.

METHODS

The radial AI was measured in 10,190 subjects who were either healthy or had hypertension (n = 5,477 men and 4,743 women).

RESULTS

In both sexes, a phased increase in the radial AI with age could only be confirmed up to an age of 60 years. A phased increase in the radial AI with the systolic blood pressure (SBP) could be confirmed up to an SBP of >170 mm Hg. Among subjects categorized within the highest age tertile, the highest SBP tertile, or the highest radial AI tertile, stepwise multivariable analyses demonstrated that SBP, but not age, was a significant independent factor influencing the radial AI.

CONCLUSIONS

The effect of age and blood pressure on AI differ not only between young adults and the elderly but also between those with and those without high blood pressure or between those with and those without a high AI. The effect of an elevation in blood pressure, but not aging, on the AI is significant in the elderly, in subjects with high blood pressure, or in those with a high AI.

Plasma cis-vaccenic acid and risk of heart failure with antecedent coronary heart disease in male physicians

BACKGROUND & AIMS

Although an inverse association of red blood cell cis-vaccenic acid and risk of myocardial infarction has been reported, it is unclear whether cis-vaccenic acid might lower the risk of heart failure (HF) with antecedent coronary heart disease (CHD). We sought to examine the relation of plasma cis-vaccenic acid with HF with antecedent CHD.

METHODS

This nested case-control study was based on 788 incident HF cases (of whom 258 cases had antecedent CHD) and 788 controls. Each control was selected using a risk set sampling technique at the time of the occurrence of the index case and matched on year of birth, age at blood collection, and race. Fatty acids were measured using gas chromatography and incident HF was self-reported on annual questionnaires and validation in a subsample using medical records.

RESULTS

In a multivariable conditional logistic regression, the odds ratio (95% confidence interval) for HF with prior CHD were 1.0 (ref), 0.72 (0.33-1.57), 0.28 (0.12-0.67), and 0.23 (0.09-0.58) across consecutive quartiles of cis-vaccenic acid (p_trend 0.0004). Each standard deviation of cis-vaccenic acid was associated with a 41% lower risk of HF with antecedent CHD (95% CI: 17%-59%) in a multivariable adjusted model.

CONCLUSIONS

Our data suggest that higher plasma levels of plasma cis-vaccenic acid may be associated with a lower risk of HF with antecedent CHD. Confirmation of these results in the general population including women and other ethnic groups is warranted.

Pathophysiological contribution of vascular function to baroreflex regulation in hypertension

BACKGROUND

We examined which pathophysiological abnormalities of vascular function might be closely associated with abnormal baroreflex regulation in subjects with hypertension.

METHODS AND RESULTS

In the cross-sectional assessment, 280 subjects with hypertension were enrolled for measurement of brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), flow-mediated vasodilatation (FMD) of the brachial artery and baroreceptor sensitivity (BRS). These parameters were measured again as prospective assessment in some of these subjects. In the cross-sectional assessment, after adjustment for confounding variables including anti-hypertensive medication, the baPWV, but not the rAI or FMD, was found to have a significant independent relationship with BRS (standardization coefficient, -0.149, P<0.043). In the subjects who were newly started on anti-hypertensive medication (n=40), regression of baPWV before and 1 year after the start of medication was significantly associated with change in BRS during the same period. In subjects already on anti-hypertensive medication (n=92) also, the evolutional change of baPWV over a follow-up period >1.5 years was significantly associated with change in BRS during the same period.

CONCLUSIONS

Increased stiffness of the large- to middle-sized arteries, rather than abnormal central hemodynamics or endothelial dysfunction, appears to contribute to abnormal baroreflex regulation in patients with hypertension.

Labor induction using modified metreurynters plus oxytocin at an institution in Japan: a retrospective study

OBJECTIVE

The authors evaluated the effectiveness and safety of "neo-metoro" or 'mini-metoro" metreurynters plus oxytocin for labor induction and assessed differences in parturition outcomes, according to the metreurynter used at induction initiation.

MATERIALS AND METHODS

The authors retrospectively reviewed 146 consecutive women with live singleton pregnancies, and who underwent induction. Parturition outcomes were vaginal delivery achieved within the planned schedule (VDPS), vaginal delivery finally achieved (VDF), and induction-to-delivery interval (IDI). Women were divided into neo-metoro, mini-metoro, and without metreurynter groups based on metreurynter use at induction initiation. The authors examined the relationships of metreurynter groups with factors, parturition outcomes, and adverse events. In 113 women who underwent two-day induction, the authors calculated IDI and adjusted odds ratio (AOR) for achieving delivery per unit time.

RESULTS

VDPS rates were 65% in nulliparous and 81% in multiparous women. VDF rates were 78% in nulliparous and 96% in multiparous women. AORs for VDPS were 0.30 in nulliparous women and 0.18 in Bishop score (BS) 1-3 class. AORs for VDF were 0.04 in BS1-3 class and 0.14 in BS4-5 class. In 113 women undergoing two-day induction, AORs for achieving delivery per unit time were 0.45 in nulliparous women, 0.46 in obese women, and 0.48 in BS1-3 class. Neo-metoro use at induction initiation tended to reduce IDI.

CONCLUSIONS

Labor induction using these metreurynters plus oxytocin is safe and effective. The advantages of neo-metoro over mini-metoro use at induction initiation remain unclear; neo-metoro use at induction initiation may reduce IDI.

Plasma galectin 3 and heart failure risk in the Physicians' Health Study

AIMS

We sought to test the hypothesis that plasma galectin 3 (Gal-3) is positively associated with the risk of heart failure (HF) in male subjects.

METHODS AND RESULTS

While Gal-3 has been reported as prognostic factor in HF patients, limited data are available on the role of Gal-3 in the development of HF. We used a prospective nested-case control study (n = 462 cases and 462 controls) within the Physicians' Health Study for current analyses. For each case of HF, we randomly selected one control among subjects that were alive and free of HF at the time of index case occurrence and matched on age, race, and time of blood collection. Gal-3 was measured using ELISA and we used conditional logistic regression to compute adjusted odds ratios. Mean age at baseline was 58.3 y and median log-Gal-3 was 1.50 (IQR: 1.20-1.73) ng/ml. Cubic splines suggested a non-linear relation between Gal-3 and HF. Odds ratios (95% CI) for HF were 1.0 (ref), 0.89 (0.58-1.38), 1.08 (0.71-1.67), and 1.57 (1.03-2.39) across consecutive quartiles of Gal-3 after adjustment for body mass index, diabetes, atrial fibrillation, hypertension, C-reactive protein, alcohol, smoking, and exercise. The Gal-3-HF relation was seen for HF with and without antecedent coronary heart disease.

CONCLUSIONS

Our data are consistent with a positive non-linear association between Gal-3 and HF risk in male subjects.

Plasma phospholipid saturated fatty acids and heart failure risk in the Physicians' Health Study

BACKGROUND & AIMS

Previous studies have suggested that some plasma phospholipid saturated fatty acids (SFA) are associated with an increased risk of coronary heart disease and hypertension, major risk factors for heart failure (HF). However, little is known about the association between SFA and HF. This study examines associations of individual plasma phospholipid SFA with HF risk in US male physicians.

METHODS

The current ancillary study used a prospective nested matched case-control design to select 788 cases of incident HF and 788 controls. Plasma phospholipid SFAs were measured using gas chromatography. HF was self-reported on follow-up questionnaires and validated by review of medical records in a subsample. We used conditional logistic regression to estimate relative risks.

RESULTS

Mean age was 58.7 ± 8.0 years. One standard deviation higher plasma phospholipid 16:0 was associated with an odds ratio (95% CI) of 1.20 (1.04, 1.38) controlling for established HF risk factors and other SFAs (p = 0.042). However, this association was not significant after Bonferroni correction (p > 0.008). We did not observe associations between other SFAs (14:0, 15:0, 18:0, 20:0, or 22:0) and HF risk (all p for trend > 0.05).

CONCLUSIONS

Our data suggested no association between plasma phospholipid SFAs and HF in US male physicians.

DPC in acute-phase inpatient hospital care. Visualization of amount of nursing care provided and accessibility to nursing care

OBJECTIVE

The purpose of this study was to improve accessibility to nursing care by clarifying the relationship between patient characteristics and the amount of nursing care for the Diagnosis Procedure Combination system (DPC).

METHOD

The subjects included 528 lung cancer patients; 170 gastric cancer patients; and 91 colon cancer patients, who were hospitalized from July 1, 2008, to March 31, 2010, at a university hospital. The patients were categorized into groups according to factors that could affect the amount of nursing care. Next, the relationship between the patient characteristics and the amount of nursing care was analyzed. Then the results from this study were used to classify patient characteristics according to the patient type and the amount nursing care required.

RESULTS

The patient characteristics, which affected the amount of nursing care, varied according to each DPC code. The major factors affecting the amount of nursing care were whether the patient had received a surgical (under general anesthetics) treatment or a non-surgical treatment and the level of activities of daily living (ADL) of the hospitalized patients. For those who had received a surgical operation for colon cancer, the patient's age also affected the amount of nursing care.

CONCLUSIONS

The findings show that the method for the visualization of the amount of nursing care based on the classification of patient characteristics can be implemented into the electronic health record system. This method can then be used as a management tool to assure appropriate distribution of nursing resources.

Red blood cell MUFAs and risk of coronary artery disease in the Physicians' Health Study

BACKGROUND

Previous studies have reported beneficial effects of a Mediterranean diet rich in monounsaturated fatty acids (MUFAs) on coronary artery disease (CAD) risk. However, these findings remain inconsistent because some experimental studies have suggested atherogenic and lipotoxicity effects of long-chain and very-long-chain MUFAs on cardiomyocytes.

OBJECTIVE

We examined whether red blood cell (RBC) long-chain and very-long-chain MUFAs are associated with risk of CAD in the Physicians' Health Study.

DESIGN

The ancillary study used a prospective nested case-control design to select 1000 cases of incident CAD and 1000 control subjects matched for age, year of birth, and time of blood collection. RBC MUFAs were measured by using gas chromatography, and CAD was validated by an endpoint committee. Conditional logistic regression was used to estimate RRs.

RESULTS

The mean (±SD) age was 68.7 ± 8.7 y. In a multivariable model that was controlled for matching factors and established CAD risk factors and RBC saturated and omega-3 (n-3) fatty acids, ORs for CAD associated with each SD increase of 20:1n-9 and log 22:1n-9 were 0.89 (95% CI: 0.80, 1.00; P = 0.0441) and 0.83 (95% CI: 0.72, 0.95; P = 0.0086). However, only the 22:1n-9-CAD relation remained statistically significant after Bonferroni correction (P < 0.0125). RBC cis 18:1n-9 and 24:1n-9 were not associated with CAD risk.

CONCLUSION

Our data suggest an inverse association of RBC 22:1n-9 but not 20:1n-9, 18:1n-9, or 24:1n-9 with CAD risk after Bonferroni correction in the Physicians' Health Study.

Quantification of changes in metamorphopsia and retinal contraction in eyes with spontaneous separation of idiopathic epiretinal membrane

BACKGROUND

To quantify changes in metamorphopsia and retinal contraction in eyes with idiopathic epiretinal membrane (ERM) before and after a spontaneous separation of ERM.

METHODS

Among 92 eyes of 92 patients with idiopathic ERM who were followed up at our hospital, 5 eyes of 5 patients had experienced a spontaneous separation of ERM during the follow-up period. Patient's metamorphopsia was assessed horizontally and vertically by a metamorphopsia chart developed by our group, M-CHARTS, to obtain the horizontal (MH) and vertical (MV) metamorphopsia scores. Difference in the scores before and after the membrane separation represents change in patient's metamorphopsia. Changes in retinal contraction were also evaluated horizontally and vertically with our original software for fundus image analysis. The difference between M-CHARTS scores and distances of retinal vessel movements with before and after membrane separation were measured.

RESULTS

All five subjects showed a decrease in the retinal contraction. Improved visual acuity was observed in three subjects, and no change was seen in the other two. Four subjects obtained better metamorphopsia scores after the membrane separation, while the other one was not detected with metamorphopsia by M-CHARTS either before or after the separation. In subjects with an improved MV, horizontal retinal movement was seen larger than the vertical movement. Similarly, the subjects with an improved MH indicated a larger vertical retinal movement than the horizontal movement.

CONCLUSIONS

The direction of patient's metamorphopsia closely associated with the direction of retinal contraction before and after a spontaneous separation of ERM.

Preparation of thyroid follicular cells for mRNA quantification after fluorescence-activated cell sorting

We established a novel method to analyze cells collected by fluorescence-activated cell sorting (FACS) named mRNA quantification after FACS (FACS-mQ) in which cells are labeled with a fluorescence dye in a manner that minimizes RNA degradation, and then cells sorted by FACS are examined by analyzing their gene expression profile. In order to analyze cells using FACS-mQ, it is essential to prepare single-cell suspensions without RNA degradation. We found that a new tissue preservation medium, ThelioKeep™, which contains epigallocatechin-3-gallate (EGCG), was suitable for preservation of thyroid tissues. The aim of this study was to establish a cell dispersion method of thyroid follicular cells using ThelioKeep™. We compared the efficiency of cell dispersion between the two methods, the conventional cold pre-incubation method and the ThelioKeep™ method; then we determined if cells obtained by the ThelioKeep™ method were suitable for FACS-mQ analysis. We found that a larger number of cells were recovered using ThelioKeep™ than using the conventional cold pre-incubation method. Furthermore, cell viability was higher with the ThelioKeep™ method than with the cold pre-incubation method. Thyroid cells collected by this method were analyzed by FACS-mQ. A clear shift in flow cytometry analysis was observed when cells were stained with an anti-thyroglobulin or anti-thyroid transcription factor-1 antibody. After sorting, the same copy number of ACTB mRNA was detected in thyroid cells as in an anaplastic carcinoma cell line, 8305C. These findings imply that preparation of thyroid cells using the present method is suitable for FACS-mQ analysis.

Genes that characterize T3-predominant Graves' thyroid tissues

OBJECTIVE

3,5,3'-Triiodothyronine (T(3))-predominant Graves' disease is characterized by the increasing volume of thyroid goiter resulting in poor prognosis. Although type 1 and type 2 iodothyronine deiodinases (DIO1 and DIO2 respectively) are known to be overexpressed in the thyroid tissues of T(3)-predominant Graves' disease, the pathogenesis of this disease is still unclear. The aim of our study is to identify genes that characterize T(3)-predominant Graves' disease tissue in order to clarify the molecular mechanism of this disease.

DESIGN AND METHODS

mRNAs from two thyroid tissues of both typical T(3)-predominant and common-type Graves' disease were analyzed with DNA microarrays with probes for 28 869 genes. Genes identified to be differentially expressed between the two groups were further analyzed in the second and third screenings using 70 Graves' thyroid tissues by real-time quantitative RT-PCR.

RESULTS

Twenty-three candidate genes were selected as being differentially expressed in the first screening with microarrays. Among these, seven genes, leucine-rich repeat neuronal 1 (LRRN1), bone morphogenetic protein 8a (BMP8A), N-cadherin (CDH2), phosphodiesterase 1A (PDE1A), creatine kinase mitochondrial 2 (CKMT2), integrin beta-3 (ITGB3), and protein tyrosine phosphatase non-receptor type 4 (PTPN4), were confirmed to be differentially expressed in DIO1 or DIO2 over- and underexpressing Graves' tissues.

CONCLUSIONS

These genes are related to the characteristics of T(3)-predominant Graves' disease, such as high titer level of serum anti-TSH receptor antibody, high free T(3) to free thyroxine ratio, and a large goiter size. They might play a role in the pathogenesis of T(3)-predominant Graves' disease.

Computed tomography (CT) colonography with CT arteriography and venography for the workup of intestinal transplant candidates

Prior to intestinal transplantation, prospective candidates must undergo a series of radiologic examinations to address a variety of clinical issues. To date, little literature exists to guide physicians in this preoperative assessment. Multiple imaging studies can provide overlapping information. We have developed a simple two- or three-test protocol to streamline the workup. Sixteen adult patients presented as potential intestinal transplant candidates to Georgetown University Hospital. All but two patients underwent the full protocol of a biphasic IV contrast-enhanced computed tomography (CT) scan of the chest, abdomen, and pelvis with rectal carbon dioxide, an upper gastrointestinal study with small bowel follow through, and fistulogram when appropriate. Three-dimensional (3-D) reconstructions of the vascular anatomy as well as the colon were also generated. A telephone survey to other transplant centers was additionally conducted to compare radiographic evaluations. Overall, 15 of the 16 scans were diagnostic. One patient required a barium enema. Mean examinations per patient was 2.4. Only one of seven other centers was performing CT colonography in prospective intestinal transplant candidates. Our protocol provided all the necessary anatomic information needed to evaluate prospective transplant candidates. CT colonography with angiography is a suitable alternative to more time-consuming radiological studies.

Abnormal CX3CR1⁺ lamina propria myeloid cells from intestinal transplant recipients with NOD2 mutations

Although progress has been made in intestinal transplantation, chronic inflammation remains a challenge. We have reported that the risk of immunological graft loss is almost 100-fold greater in recipients who carry any of the prevalent NOD2 polymorphisms associated with Crohn's disease, and have shown that the normal levels of a key antimicrobial peptide produced by the Paneth cells of the allograft, fall as the graft becomes repopulated by hematopoietic cells of the NOD2 mutant recipient. These studies are extended in this report. Within several months following engraftment into a NOD2 mutant recipient the allograft loses its capacity to prevent adherence of lumenal microbes. Despite the significantly increased expression of CX3CL1, a stress protein produced by the injured enterocyte, NOD2 mutant CX3CR1(+) myeloid cells within the lamina propria fail to exhibit the characteristic morphological phenotype, and fail to express key genes required expressed by NOD2 wild-type cells, including Wnt 5a. We propose that the CX3CR1(+) myeloid cell within the lamina propria supports normal Paneth cell function through expression of Wnt 5a, and that this function is impaired in the setting of intestinal transplantation into a NOD2 mutant recipient. The therapeutic value of Wnt 5a administration in this setting is proposed.

Liver transplantation in the management of hepatic epithelioid hemangioendothelioma: a single-center experience and review of the literature

Hepatic epitheliod hemangioendothelioma (HEHE) is a rare tumor of vascular origin with unpredictable malignant potential. We describe our experience with four biopsy-proven HEHE cases that were considered for orthotopic liver transplant (OLT). Three patients had preserved hepatic function and despite extensive disease burden did not develop disease progression while awaiting OLT. We were able to utilize the review process allowed by United Network of Organ Sharing to obtain additional priority for OLT for these patients. This led to expedited organ allocation and excellent post-OLT outcomes.

Six-month incidence of bloodstream infections in intestinal transplant patients

BACKGROUND

Intestinal transplantation has emerged as an established treatment for life-threatening intestinal failure. The most common complication and cause of death is infection. Risk of infection is highest during the first 6 months, as a consequence of maximal immunosuppression, greater than that required for any other organ allograft.

METHODS

We performed a retrospective chart review of all (56) adult and pediatric (<18 years) small bowel transplant patients at our institution between November 2003 and July 2007, and analyzed the 6-month post-transplant incidence of bloodstream infections (BSIs). We evaluated multiple risk factors, including inclusion of a colon or liver, total bilirubin >5, surgical complications, and acute rejection.

RESULTS

A BSI developed in 34 of the 56 patients, with a total of 85 BSI episodes. Of these BSI episodes, 65.9% were due to gram-positive organisms, 34.1% gram-negative organisms, and 2.4% due to fungi. The most common isolates were Enterococcus species, Enterobacter species, Klebsiella species, and coagulase-negative staphylococci. Inclusion of the liver and/or a preoperative bilirubin >5 mg/dL appeared to increase the incidence of BSI (P = 0.0483 and 0.0005, respectively). Acute rejection and colonic inclusion did not appear to affect the incidence of BSI (P = 0.9419 and 0.8248, respectively). The BSI incidence was higher in children (P = 0.0058).

CONCLUSIONS

BSIs are a common complication of intestinal transplantation. Risk factors include age <18, inclusion of the liver, and pre-transplant bilirubin >5. Acute rejection and colon inclusion do not appear to be associated with increased BSI risk.