Effect of Vitamin K on Vascular Health and Physical Function in Older People with Vascular Disease--A Randomised Controlled Trial

BACKGROUND AND AIMS

Vitamin K insufficiency is common and linked to an increased risk of cardiovascular disease and osteoporotic fractures. The aim of this study was to examine whether daily supplementation with oral vitamin K could improve vascular health and physical function in older people with established vascular disease.

METHODS AND RESULTS

A double blind, randomised, placebo-controlled trial. Participants aged ≤ 70 years with a history of vascular disease were randomised to receive 6 months of daily oral 100mcg vitamin K2 (MK7 subtype) or matching placebo with outcomes measured at 0, 3 and 6 months. The primary outcome was between-group difference in endothelial function assessed using flow-mediated dilatation of the brachial artery at 6 months. Secondary outcomes included carotid-radial pulse wave velocity, augmentation index, blood pressure, carotid intima-media thickness, C-reactive protein, B-type natriuretic peptide, cholesterol and desphospho-uncarboxylated matrix Gla protein levels. Handgrip strength and the Short Physical Performance Battery assessed physical function, while postural sway was measured using a 3-dimensional force platform.

RESULTS

80 participants were randomised, mean age 77 (SD 5) years; 44/80 were male. Vitamin K levels rose in the intervention arm compared to placebo (+48 pg/ml vs -6 pg/ml, p=0.03) at 6 months. Desphospho-uncarboxylated Matrix Gla protein levels fell in the intervention group compared to placebo at 6 months (-130 [SD 117] pmol/L vs +13 [SD 180] pmol/L, p<0.001). No change was seen in endothelial function (between group difference -0.3% [95%CI -1.3 to 0.8], p=0.62). A modest, non-significant improvement in pulse wave velocity was seen in the vitamin K group (-0.8m/s [95%CI -1.8 to 0.3], p=0.15) while all other vascular and physical function outcomes unchanged.

CONCLUSIONS

Six months of vitamin K2 supplementation did not improve markers of vascular health or physical function in older patients with vascular disease.

Effect of Perfusion Fluids on Recovery of Inflammatory Mediators in Microdialysis

Microdialysis is an excellent tool to assess tissue inflammation in patients, but in vitro systems to evaluate recovery of inflammatory mediators have not been standardized. We aimed to develop a reference plasma preparation and evaluate different perfusion fluids with respect to recovery of metabolic and inflammatory markers. The reference preparation was produced by incubation of human blood with lipopolysaccharide and cobra venom factor to generate cytokines and activate complement, respectively. Microdialysis with 100 kDa catheters was performed using different colloid and crystalloid perfusion fluids (hydroxyethyl starch (HES) 130/0.4, HES 200/0.5, hyperosmolar HES 200/0.5, albumin 200 g/l, T1 perfusion fluid and Ringer's acetate) compared to today's recommended dextran 60 solution. Recovery of glucose, glycerol and pyruvate was not significantly different between the perfusion fluids, whereas lactate had lower recovery in HES 200/0.5 and albumin perfusion fluids. Recovery rates for the inflammatory proteins in comparison with the concentration in the reference preparation differed substantially: IL-6 = 9%, IL-1β = 18%, TNF = 0.3%, MCP-1 = 45%, IL-8 = 48%, MIG = 48%, IP-10 = 25%, C3a = 53% and C5a = 12%. IL-10 was not detectable in microdialysis dialysate. HES 130/0.4 and HES 200/0.5 yielded a recovery not significantly different from dextran 60. Hyperosmolar HES 200/0.5 and albumin showed significantly different pattern of recovery with increased concentration of MIG, IP-10, C3a and C5a and decreased concentration of IL-1β, TNF, MCP-1 and IL-8 in comparison with dextran 60. In conclusion, microdialysis perfusion fluid dextran 60 can be replaced by the commonly used HES 130/0.4, whereas albumin might be used if specific immunological variables are in focus. The present reference plasma preparation is suitable for in vitro evaluation of microdialysis systems.

Measures of atherosclerotic burden are associated with clinically manifest cardiovascular disease in type 2 diabetes: a European cross-sectional study

BACKGROUND

There is a need to develop and validate surrogate markers of cardiovascular disease (CVD) in subjects with diabetes. The macrovascular changes associated with diabetes include aggravated atherosclerosis, increased arterial stiffness and endothelial dysfunction. The aim of this study was to determine which of these factors is most strongly associated with clinically manifest cardiovascular events.

METHODS

Vascular changes were measured in a cohort of 458 subjects with type 2 diabetes (T2D) and CVD (myocardial infarction, stroke or lower extremity arterial disease), 527 subjects with T2D but without clinically manifest CVD and 515 subjects without T2D and with or without CVD.

RESULTS

Carotid intima-media thickness (IMT) and ankle-brachial pressure index were independently associated with the presence of CVD in subjects with T2D, whereas pulse wave velocity and endothelial function provided limited independent additive information. Measurement of IMT in the carotid bulb provided better discrimination of the presence of CVD in subjects with T2D than measurement of IMT in the common carotid artery. The factors most significantly associated with increased carotid IMT in T2D were age, disease duration, systolic blood pressure, impaired renal function and increased arterial stiffness, whereas there were no or weak independent associations with metabolic factors and endothelial dysfunction.

CONCLUSIONS

Measures of atherosclerotic burden are associated with clinically manifest CVD in subjects with T2D. In addition, vascular changes that are not directly related to known metabolic risk factors are important in the development of both atherosclerosis and CVD in T2D. A better understanding of the mechanisms involved is crucial for enabling better identification of CVD risk in T2D.

Physicians knowledge and attitude of opioid availability, accessibility and use in pain management in Bangladesh

This survey was conducted on 1000 physicians with pain management responsibilities practicing in 47 districts in Bangladesh. The response rate was 58.3%. The physicians had a mean of 21 years in practice. It was notable that 66% of the physicians had seen cancer patients in the last 12 months and 63% had seen patients with advanced stage cancer where opioids are considered as the mainstay of treatment. It was discouraging that 85% of the physicians preferred to prescribe pethidine, when patients needed opioids for severe pain. 53% of the physicians were not aware of the 'Bangladesh Narcotics law, 1990'. 89% of the physicians would restrict opioid dosage in pain management to prevent drug tolerance or addiction. Oncology physicians displayed significantly higher knowledge scores. The results demonstrated physicians' poor knowledge, attitude and perceived barriers regarding opioids. Effective education strategies need to be addressed using the study result.

Telerehabilitation for persons with multiple sclerosis. A Cochrane review

A wide range of telerehabilitation interventions are trialled in persons with multiple sclerosis (pwMS). However, the evidence for their effectiveness is unclear. Aim of the review was to systematically assess the effectiveness and safety of telerehabilitation intervention in pwMS, the types of approaches that are effective (setting, type, intensity) and the outcomes (impairment, activity limitation and participation) that are affected. The search strategy comprised: Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group Specialised Register (up to 9 July, 2014). Relevant journals and reference lists of identified studies were screened for additional data. Selected studies included randomized and controlled clinical trials that compared telerehabilitation intervention/s in pwMS with a control intervention (such as lower level or different types of intervention, minimal intervention; waiting-list controls, no treatment or usual care; interventions given in different settings). Best evidence synthesis was based on methodological quality using the GRADEpro software. Nine RCTs (N.=531 participants, 469 included in analyses) investigated a variety of telerehabilitation interventions in adults with MS. The interventions evaluated were complex, with more than one rehabilitation component and included physical activity, educational, behavioural and symptom management programmes. All studies scored "low" on the methodological quality assessment. Evidence from included studies provides 'low-level' evidence for reduction in short-term disability (and symptoms) such as fatigue. There was also "low-level" evidence supporting telerehabilitation in the longer term for improved functional activities, impairments (such as fatigue, pain, insomnia); and participation. There were limited data on process evaluation (participants'/therapists' satisfaction) and no data available for cost effectiveness. There were no adverse events reported as a result of telerehabilitation intervention. There is limited evidence to date, on the efficacy of telerehabilitation in improving functional activities, fatigue and quality of life in adults with MS. There is also insufficient evidence to support what types of telerehabilitation interventions are effective, and in which setting. More robust trials are needed to build evidence for the clinical and cost effectiveness of these interventions.

Effect of intermittent vitamin D3 on vascular function and symptoms in chronic fatigue syndrome--a randomised controlled trial

BACKGROUND AND AIMS

Low 25-hydroxyvitamin D levels are common in patients with chronic fatigue syndrome; such patients also manifest impaired vascular health. We tested whether high-dose intermittent oral vitamin D therapy improved markers of vascular health and fatigue in patients with chronic fatigue syndrome.

METHODS AND RESULTS

Parallel-group, double-blind, randomised placebo-controlled trial. Patients with chronic fatigue syndrome according to the Fukuda (1994) and Canadian (2003) criteria were randomised to receive 100,000 units oral vitamin D3 or matching placebo every 2 months for 6 months. The primary outcome was arterial stiffness measured using carotid-femoral pulse wave velocity at 6 months. Secondary outcomes included flow-mediated dilatation of the brachial artery, blood pressure, cholesterol, insulin resistance, markers of inflammation and oxidative stress, and the Piper Fatigue scale. As many as 50 participants were randomised; mean age 49 (SD 13) years, mean baseline pulse wave velocity 7.8 m/s (SD 2.3), mean baseline office blood pressure 128/78 (18/12) mmHg and mean baseline 25-hydroxyvitamin D level 46 (18) nmol/L. 25-hydroxyvitamin D levels increased by 22 nmol/L at 6 months in the treatment group relative to placebo. There was no effect of treatment on pulse wave velocity at 6 months (adjusted treatment effect 0.0 m/s; 95% CI -0.6 to 0.6; p = 0.93). No improvement was seen in other vascular and metabolic outcomes, or in the Piper Fatigue scale at 6 months (adjusted treatment effect 0.2 points; 95% CI -0.8 to 1.2; p = 0.73).

CONCLUSION

High-dose oral vitamin D3 did not improve markers of vascular health or fatigue in patients with chronic fatigue syndrome.

TRIAL REGISTRATION

www.controlled-trials.com, ISRCTN59927814.

The effect of a primary tumour resection on the progression of synchronous colorectal liver metastases: an exploratory study

AIM

The objective of this study was to determine the effect of an upfront primary tumour resection on the progression of synchronous colorectal liver metastases.

MATERIALS AND METHODS

Patients with synchronous colorectal liver metastases referred between 2005 and 2010 were identified. Patients were analysed according to the following two groups: 1) an upfront primary tumour resection and 2) neo-adjuvant chemotherapy. A univariate and multivariate analysis was performed to identify factors significantly contributing to progressive disease. Cox regression analysis was undertaken to determine the effect of management on overall survival (OS) and time to tumour progression (TTP).

RESULTS

A total of 116 patients with synchronous colorectal liver metastases were identified of which 49 patients received an upfront primary tumour resection and 67 received neo-adjuvant chemotherapy. Liver resections were performed in 18 (36.7%) and 14 (20.9%) of the patients in the upfront and neo-adjuvant groups respectively (P 0.06). On multivariate analysis, an upfront primary tumour resection significantly affected progressive disease (p < 0.001, OR 5.67; 95% CI 2.71-11.79). An upfront tumour resection was not a significant predictor of overall survival (P = 0.83; HR 1.10; 95% CI 0.48-2.52).

CONCLUSION

Our findings suggest that an upfront primary tumour resection in patients with synchronous colorectal liver metastases results in progressive disease. These preliminary findings need to be validated in a future multi-centre independent study.

Variation of indoor radon concentrations in two-storey houses in Nowshera District, Pakistan

A study was performed for the measurement of indoor radon concentration in two-storey houses in district Nowshera in the Khyber Pakhtunkhwa province of Pakistan. This area was not previously surveyed for such kind of study. The aim was to find some correlation of radon levels in first and second storey houses in the area. The measurements were carried out for 1 y from 1 December 2012 to 30 November 2013 using CR-39 detector. The area was divided into four parts, namely, Jhangera, Nowshera city, Akora Khattak and Pabbi. In the first storey houses, radon concentration ranged from 29 to 103 Bq m(-3) with the mean value of 64 ± 12 Bq m(-3) and that in the second storey houses ranged from 25 to 92 Bq m(-3) with the mean value of 56 ± 11 Bq m(-3). Relatively higher values of indoor radon levels in the first stories than the second stories were observed in all four parts of the study area. The effective doses received by the residents of the area were estimated for each part. The mean annual effective doses received by the inhabitants of the area from indoor radon ranged from 0.68 to 2.88 mSv with the mean value of 1.68 ± 0.32 mSv. The doses received by the people of the area were within the ICRP-65 recommended range (3-10 mSv).

ZnAl2O4:Eu novel phosphor: SEM and mechanoluminescence characterization synthesized by solution combustion technique

Eu doped ZnAl2O4 phosphors were synthesized by the solution combustion technique using carbohydrazide as a fuel. Mechanoluminescence (ML) was excited impulsively by dropping a piston of 0.7 kg onto the phosphors. Two distinct peaks were observed in the ML glow curve of the γ-ray irradiated ZnAl2O4 :Eu phosphors. Dependence of ML on various parameters as impact velocity of the piston dropped on to it, mass of the sample, gamma ray doses given to the sample and ML spectra have been studied. ML emission spectrum showed the characteristic emission of Eu(3+) ion in this system. ML is observed to be optimum for the sample having 0.2 mol% of Eu in the ZnAl2O4 phosphor. XRD result confirms formation of the phosphors. SEM characterization shows its surface morphology. This novel phosphor may be a potential candidate for dosimetric use due to its linear dose response.