Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

The metabolic syndrome (MetSyn) has been implicated in the development of atrial fibrillation (AF); however, knowledge of this association among blacks is limited.

METHODS

We determined the risk of incident AF through December 2005 in relation to baseline (1987-1989) MetSyn status in 15,094 participants of the Atherosclerosis Risk in Communities study.

RESULTS

Over a mean follow-up of 15.4 years, 1,238 incident AF events were identified. The hazard ratio (HR) for AF among individuals with, compared to those without, the MetSyn was 1.67 (95% CI 1.49-1.87), and associations did not differ by race (P for interaction = .73). The population attributable risk of AF from the MetSyn was 22%. The multivariable-adjusted HRs (95% CI) for each MetSyn component were 1.95 (1.72-2.21) (elevated blood pressure), 1.40 (1.23-1.59) (elevated waist circumference), 1.20 (1.06-1.37) (low high-density lipoprotein cholesterol), 1.16 (1.03-1.31) (impaired fasting glucose), and 0.95 (0.84-1.09) (elevated triglycerides). A monotonically increasing risk of AF with increasing number of MetSyn components was observed, with an HR of 4.40 (95% CI 3.25-5.94) for those with all 5 MetSyn components compared to those with 0 components.

CONCLUSION

In this large cohort, the MetSyn and most of its components were associated with a higher risk of AF in both blacks and whites. Given the high prevalence of the MetSyn, strategies to prevent its development or to control individual components may reduce the burden of AF.

Premature ventricular complexes and the risk of incident stroke: the Atherosclerosis Risk In Communities (ARIC) Study

BACKGROUND AND PURPOSE

Premature ventricular complexes (PVCs) on a 2-minute electrocardiogram are a common, largely asymptomatic finding associated with increased risk of coronary heart disease and death. They may reflect atherosclerosis or other pathogenic pathways that predispose to arrhythmias and stroke.

METHODS

We conducted a prospective evaluation of the Atherosclerosis Risk In Communities Study cohort (n=14,783) of middle-aged men and women to assess whether the presence of PVCs at study baseline (1987 to 1989) influenced the risk of incident stroke through December 31, 2004.

RESULTS

PVCs were seen in 6.1% of the participants at baseline, and 729 (4.9%) had incident stroke. The unadjusted cumulative proportion of incident stroke in individuals with any PVC was 6.6% compared with 4.1% in those without PVC. The unadjusted hazard ratio of incident stroke in individuals with any PVC compared with those without any PVCs was 1.71 (95% CI, 1.33 to 2.20). Among individuals without hypertension and diabetes at baseline, PVCs were independently associated with incident stroke (hazard ratio: 1.72; 95% CI: 1.14 to 2.59). Among those with either diabetes or hypertension, the presence of any PVCs did not increase the risk of stroke. The association was stronger for noncarotid embolic stroke than for thrombotic stroke and its magnitude increased with higher frequency of PVCs.

CONCLUSIONS

Frequent PVCs are associated with risk of incident stroke in participants free of hypertension and diabetes. This suggests that PVCs may contribute to atrioventricular remodeling or may be a risk marker for incident stroke, particularly embolic stroke.

Aquaporins: The renal water channels

Water is the most abundant molecule in any cell. Specialized membrane channel, proteins called aquaporins, facilitate water transport across cell membranes. At least seven aquaporins (AQP): 1, 2, 3, 4, 6, 7, and 11 are expressed in the kidneys. Aquaporins play a role in both the short-term and long-term regulation of water balance as well as in the pathophysiology of water balance disorders. Aquaporin is composed of a single peptide chain consisting of approximately 270 amino acids. Inherited central and nephrogenic diabetes insipidus are primarily due to the decreased expression of AQP2 while mutation in the AQP2 molecule is responsible for inherited central diabetes insipidus. In acquired causes of nephrogenic diabetes insipidus, there is a downregulation of AQP2 expression in the inner medulla of the kidney. Nephrotic syndrome is characterized by excessive sodium and water reabsorption, although in spite of this, patients do not develop hyponatremia. There is a marked downregulation of both AQP2 and AQP3 expression, which could be a physiologic response to extracellular water reabsorption in patients with nephrotic syndrome. There are some conditions in which aquaporin expression has been found to increase such as experimentally induced heart failure, cirrhosis, and pregnancy. Some drugs such as cisplatin and cyclosporine, also alter the expression of aquaporins. The three-pore model of peritoneal transport depicts the importance of aquaporins. Thus, the understanding of renal water channels has solved the mystery behind many water balance disorders. Further insights into the molecular structure and biology of aquaporins will help to lay a foundation for the development of future drugs.

BANK1 functional variants are associated with susceptibility to diffuse systemic sclerosis in Caucasians

OBJECTIVE

To investigate the possible association of the BANK1 gene with genetic susceptibility to systemic sclerosis (SSc) and its subphenotypes.

METHODS

A large multicentre case-control association study including 2380 patients with SSc and 3270 healthy controls from six independent case-control sets of Caucasian ancestry (American, Spanish, Dutch, German, Swedish and Italian) was conducted. Three putative functional BANK1 polymorphisms (rs17266594 T/C, rs10516487 G/A, rs3733197 G/A) were selected as genetic markers and genotyped by Taqman 5 allelic discrimination assay.

RESULTS

A significant association of the rs10516487 G and rs17266594 T alleles with SSc susceptibility was observed (pooled OR=1.12, 95% CI 1.03 to 1.22; p=0.01 and pooled OR=1.14, 95% CI 1.05 to 1.25; p=0.003, respectively), whereas the rs3733197 genetic variant showed no statistically significant deviation. Stratification for cutaneous SSc phenotype showed that the BANK1 rs10516487 G, rs17266594 T and rs3733197 G alleles were strongly associated with susceptibility to diffuse SSc (dcSSc) (pooled OR=1.20, 95% CI 1.05 to 1.37, p=0.005; pooled OR=1.23, 95% CI 1.08 to 1.41, p=0.001; pooled OR=1.15, 95% CI 1.02 to 1.31, p=0.02, respectively). Similarly, stratification for specific SSc autoantibodies showed that the association of BANK1 rs10516487, rs17266594 and rs3733197 polymorphisms was restricted to the subgroup of patients carrying anti-topoisomerase I antibodies (pooled OR=1.20, 95% CI 1.02 to 1.41, p=0.03; pooled OR=1.24, 95% CI 1.05 to 1.46, p=0.01; pooled OR=1.26, 95% CI 1.07 to 1.47, p=0.004, respectively).

CONCLUSION

The results suggest that the BANK1 gene confers susceptibility to SSc in general, and specifically to the dcSSc and anti-topoisomerase I antibody subsets.

Variants in ZFHX3 are associated with atrial fibrillation in individuals of European ancestry

We conducted meta-analyses of genome-wide association studies (GWAS) for atrial fibrillation (AF) in participants from five community-based cohorts. Meta-analyses of 896 prevalent (15,768 referents) and 2,517 incident (21,337 referents) AF cases identified a novel locus for AF (ZFHX3, rs2106261, risk ratio [RR]=1.19; P=2.3×10⁻⁷), an association that was replicated in the German AF Network (odds ratio=1.44; P=1.6×10⁻¹¹). Combining the discovery and replication results, rs2106261 was significantly associated with AF (RR=1.25; P=1.8×10⁻¹⁵).

An uncommon cause of scleroderma

The human immunodeficiency virus (HIV) pandemic is nearly 20 years old. HIV infection is characterized by profound immunodeficiency resulting in an increased incidence of opportunistic infections and neoplasms. However, the greatest paradox is the occurrence of certain autoimmune disorders in the setting of HIV. These include diffuse interstitial lymphocytosis syndrome (DILS), reactive arthritis, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA). It has also been seen that even in the absence of these well-defined diseases, various rheumatological manifestations such as arthralgias, arthritis, myopathy, vasculitis, and sicca syndrome are commonly associated with HIV. To the best of our knowledge, the association of HIV with scleroderma has not previously been reported.

A Prospective Randomized Study to Compare Ultrasound-Guided with Nonultrasound-Guided Double Lumen Internal Jugular Catheter Insertion as a Temporary Hemodialysis Access

Internal jugular venous catheters (IJVC) for hemodialysis are a commonly employed temporary vascular access for hemodialysis. Most hospitals still follow the use of blind technique, which uses anatomical landmarks. Even in the most experienced hands this procedure has a variable success rate. Ultrasound guidance can decrease the incidence of periprocedural complications and improve the success rate. In this randomized study we compared the procedure success rate and periprocedural complications in patients undergoing ultrasound guided vs. nonultrasound guided IJVC insertion for a temporary hemodialysis access.

METHODS

All patients subjected to insertion of an IJVC between March 2004 and June 2004 were enrolled into the study, randomized to either the blind (group A) or ultrasound guided (group B) procedure, which uses a portable ordinary ultrasound machine without a needle guide. The aseptic Saldinger technique was used for catheterization in both the groups. Baseline characteristics of patient and periprocedural events were recorded.

RESULTS

A total of 60 patients were randomized, 30 patients each in two groups. First attempt venous cannulation success rate was 56.7% in group A compared to 86.7% in group B. Chance of occurrence of adverse outcome was significantly more in the blind procedure (P=0.020). A post-procedure chest radiograph done in all patient showed no complications.

CONCLUSION

Ultrasound guided procedure for internal jugular vein catheter insertion using an ordinary ultrasound machine was significantly safer and more successful as compared to the blind technique.

Phenotypic and genotypic methods for the detection of methicillin resistant coagulase negative staphylococci: a comparative study

CoNS are the major cause of nosocomial infection in last decade and methicillin resistant CoNS has emerged as a major clinical problem. The present study was to compare different phenotypic methods with genotypic method PCR, for the detection of methicillin resistance in CoNS. 100 CoNS isolates from different samples were studied for the detection of mecA gene. PCR was considered as "gold standard". Oxacillin and cefoxitin antibiotics were used for different phenotypic tests (DD, Agar dilution and MHOX). The sensitivities of oxacillin and cefoxitin disks for all CoNS were found to be 92.30% and 88.46% respectively and the specificities were 87.5% and 100% respectively. The sensitivities of the agar dilution test for oxacillin and cefoxitin were 86.53% and 80.76%, respectively, where as the specificities were 79.16% and 85.41%, respectively. The sensitivity of MHOX was observed to be 96.16% and specificity 72.91%. Cefoxitin D.D and oxacillin AD methods could be used as initial test for the determination of methicillin resistance in CoNS isolates. The result of MHOX shows that it could be the best single method for the evaluation of oxacillin resistance mediated by the mecA gene for all CoNS species.

Waist circumference measurement by site, posture, respiratory phase, and meal time: implications for methodology

Waist circumference (WC) has been advocated as a simple, reliable, and cost-effective measure to understand an individual's cardio-metabolic risk. Although several protocols exist for measuring WC, the variation induced by a few factors has not been investigated. We compared several established and experimental WC measurement protocols to identify factors that may cause variations in WC measurement. In this cross-sectional study, we examined the variations in the measurement of waist circumference (WC) measures carried out in 11 ways differing by anatomical site, posture, respiratory phase, and time since last meal, using repeated measure analysis of variance (using mixed models) after Tukey-Kramer adjustment. We estimated the proportion of variance in percentage of body fat (%BF) and fat-free mass (FFM) explained by each of the WC measures. We studied 123 apparently healthy Asian Indians (75 females), with mean (s.d.) age of 34 (8.7) years and BMI of 23.9 (4.8) kg/m(2). Overall, the mean of WCs measured using the 11 protocols were statistically different. Further, post hoc analysis showed statistically significant, yet mostly small, differences between most of the pairs. No single WC measure explained highest variance in %BF or FFM for both genders. Although, the National Institute of Health (NIH), USA, protocol was convenient and may be less prone to errors, at present it does not control for many variables tested in this study. Measures of WC measured using different protocols were statistically different. We suggest that the site of measurement, posture, phase of respiration, and time since last meal should be standardized for the development of a protocol for measurement of WC for worldwide use.

Chronic kidney disease in India: challenges and solutions

Chronic diseases have become a major cause of global morbidity and mortality even in developing countries. The burden of chronic kidney disease (CKD) in India cannot be assessed accurately. The approximate prevalence of CKD is 800 per million population (pmp), and the incidence of end-stage renal disease (ESRD) is 150-200 pmp. The most common cause of CKD in population-based studies is diabetic nephropathy. India currently has 820+ nephrologists, 710+ hemodialysis units with 2,500+ dialysis stations and 4,800+ patients on CAPD. There are 172+ transplant centers, two-thirds of which are in South India and mostly privately run. Nearly 3,500 transplants are done annually, the total number of cadaver donors being approximately 700 till now. Thus, taken together, nearly 18,000-20,000 patients (10% of new ESRD cases) in India get renal replacement therapy. The cost of single hemodialysis varies between USD 15 and 40 with an additional cost of erythropoietin being USD 150-200/month. The cost of CAPD using a 'Y' set with 3 exchanges/week is USD 400/month. The cost of the transplant procedure in a state-run hospital is USD 800-1,000, and the cost of immunosuppression using tacrolimus, steroid and mycophenolate is USD 350-400/month. Until recently, the government did not recognize CKD/ESRD as a significant problem in India. However, some illustrious activities in relation to CKD brought attention of the media and policymakers to this very common but till now deprived group of diseases. On the one side the government has initiated a process by which it is planning to establish stand-alone hemodialysis units in the country to increase the facilities at an affordable cost, and on the transplant side it had launched a National Organ Transplant Program to facilitate transplantation on a national scale. Hemodialysis program is halfway to being implemented. Thus, in India there is still a long way to go with respect to CKD. Until then, in a country like India, screening of high-risk individuals for CKD and the risk factors is the best bet.

A peculiar case of HIV transmission within a family in north India

SUMMARY

We describe an unusual case of heterosexual HIV transmission between two brothers within a family, due to a locally prevalent social custom of remarriage of the elder brother's widow, to the younger brother. This case of HIV secondary transmission, which could possibly have been stopped at certain points by better understanding and awareness about HIV transmission emphasizes the need for extensive post-test counselling of affected individuals and their family members.

Necrotic erythema nodosum leprosum with oral mucosal involvement

Leprosy is a chronic, infectious disease with varied clinical presentations. The type 2 lepra reaction / erythema nodosum leprosum (ENL) classically involves extremities and face. Besides to the classical lesions of type 2 lepra reaction sometimes rare findings of vesicular lesions with necroticans may be observed. We are reporting a case of lepromatous leprosy with bullous reaction and necroticans involving usual sites along with the unusual involvement of oral cavity, which on first look mimicked necrotizing vasculitis or other bullous disorders. This manifestation of type 2 lepra reaction in oral mucosa should be kept in mind by the physicians while dealing with a case of type 2 lepra reaction.

Fungal panniculitis in renal transplant recipients

Panniculitis may result due to various etiologies. In post-transplant immunosuppressed patients infection is the foremost cause of panniculitis. We present 2 cases of fungal panniculitis in renal transplant recipients. The first patient presented with non-tender firm erythematous plaques on the left thigh. Biopsy showed panniculitis with cryptococci. Subsequent investigations revealed the presence of cryptococcal antigens in the blood, urine, and bronchoalveolar lavage fluid. There was no evidence of cryptococcal meningitis. The second patient complained of subcutaneous nodules on the trunk and right thigh. Biopsy of one of the nodules showed panniculitis with histoplasma. This patient had been treated earlier (inadequately) for disseminated histoplasmosis. Both the cases responded well to conventional amphotericin B therapy. Their renal functions remained stable.

Predictors of mortality amongst recipients of implantable cardioverter defibrillators for secondary prevention of cardiac arrest

BACKGROUND

Implantable Cardioverter-defibrillators (ICD) reduce mortality in survivors of cardiac arrest (CA). We investigated the predictors of mortality after ICD implantation in survivors of CA.

METHODS

Retrospective review of clinical records and social security death index of all patients who received an ICD in a preexisting database of survivors of CA at the University of Pittsburgh Medical Center was performed. Multivariate analyses using the Cox proportional hazard model were performed with backward elimination to identify independent predictors of the time to death, and Kaplan-Meier curves were plotted.

RESULTS

Eighty patients (64 men) with a mean age of 64.4+/-12.5 years were followed for 4.7+/-2.3 years after ICD implantation. Survival rates were 93.8%, 65% and 50% at 1, 5, and 10 years, respectively. Independent predictors of time to death were determined to include age (hazard ratio (HR) = 1.91 per 10-year increase, p = 0.003), serum creatinine > or = 1.3 mg/dL (HR = 2.56, p = 0.004), and QRS width >120 ms (HR = 5.14, p = 0.012).

CONCLUSIONS

In this sample of ICD recipients secondary to CA, older age, elevated serum creatinine, and wider QRS duration were independent predictors of mortality. The presence of more than one risk factor in the same patient was associated with higher mortality rates. Whether interventions such as biventricular pacing can offset this increase risk of death warrants further investigation.

Effect of bisphosphonates on bone mineral density after renal transplantation as assessed by bone mineral densitometry

INTRODUCTION

Steroid-induced osteoporosis is a major problem after organ transplantation. There is considerable evidence that bisphosphonates are effective in decreasing osteoporosis.

AIM

This prospective study was carried out to see the effects of bisphosphonates on bone mineral density (BMD) after successful renal transplantation.

MATERIAL AND METHODS

Fifty consecutive patients of successful renal transplantation were randomized into two groups. Group A (n = 27) received 35 mg/wk of Alendronate for 6 months after transplantation. Group B (n = 23) did not receive Alendronate and served as a control. Both groups underwent a pretransplant baseline dual-energy X-ray absorptiometry (DEXA) scan of their hips and lumber spines. Both groups received oral calcium and vitamin D supplement. Both groups were matched for the regimen and dose of immunosuppressive drugs. BMD was measured at 3 months and 6 months after transplantation.

RESULTS

Both groups showed a decline in BMD in early months posttransplantation. However, the 6-month DEXA scans showed a significant rise in BMD in group A as compared to group B.

CONCLUSION

Bisphosphonates appear to have a beneficial effect on steroid-induced bone loss.

Nephrotic syndrome as a complication of intravesical BCG treatment of transitional cell carcinoma of urinary bladder

Nephrotic syndrome can be associated with various neoplasms, especially solid tumors and lymphomas. This patient presented with painless hematuria of transitional cell carcinoma of urinary bladder, underwent transurethral resection, but developed recurrence 16 months later. Repeat resection was done and intravesical Bacillus Calmette-Guerin (BCG) injections were started. After six months, the patient developed hypertension and nephrotic syndrome with a biopsy revealing membranous glomerulonephritis, though there was no radiological evidence of tumor. This is the first case of nephrotic syndrome with intravesical BCG instillation in a bladder carcinoma patient.

Tacrolimus (Pan Graf) in Live Related Renal Transplantation: An Initial Experience of 101 Recipients in India

BACKGROUND

Success of modern transplantation is in large part due to the successful development of effective immunosuppressive agents. The safety and efficacy of tacrolimus in transplantation is well established. However, tacrolimus (Pan Graf, Panacea Biotec Ltd, India) has only been available in India for the last 2 years. This study was conducted to assess the safety and efficacy of tacrolimus in live related kidney transplantation. We report an initial experience of tacrolimus as de novo therapy in a live related renal transplantation program.

MATERIALS AND METHODS

One hundred one consecutive recipients of a live renal allograft were commenced on triple immunosuppression consisting of tacrolimus, mycophenolate mofetil or azathioprine, and steroids. The dose of tacrolimus was adjusted to keep trough levels at 10-12 ng/mL in the first 3 months, 8-10 ng/mL in the next 3 months, and 5-8 ng/mL thereafter. All patients were followed up for a period ranging from 4 weeks to 24 months. The effect of this regimen on the incidence of graft rejection, graft survival, patient survival, and new-onset diabetes mellitus was evaluated. Any evidence of graft dysfunction was evaluated using a graft biopsy.

RESULTS

There were 89 male and 12 female patients with mean age of 32.08 years. The incidence of acute rejection was 3.96%; 21.05% developed new-onset diabetes mellitus. Six patients were diabetic prior to transplantation and 9 patients were hepatitis C virus (HCV)-positive; 77.7% of HCV-positive patients and 15.1% of HCV-negative patients developed posttransplantation diabetes mellitus. The patient survival rate at the current follow-up was 92.07%. No graft was lost due to rejection.

CONCLUSION

Tacrolimus is a safe and effective immunosuppressant in live related renal transplantation.