Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study

INTRODUCTION

Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs.

METHODS

This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse.

RESULTS

A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]).

CONCLUSION

When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

A Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions to assess the accuracy of prehospital trauma triage protocols: a modified Delphi study

BACKGROUND

Injury severity scales have traditionally been used to assess the performance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area.

METHODS

Based on a list of potential participants we obtained using data on training, experience, geographic location, affiliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round.

RESULTS

Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained.

CONCLUSION

We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools.

Performance of a provincial prehospital trauma triage protocol: A retrospective audit

Objective

To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec.

Methods

The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) < 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death.

Results

A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care.

Conclusion

The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.

Prehospital Use of the Esophageal Tracheal Combitube Supraglottic Airway Device: A Retrospective Cohort Study

BACKGROUND

In the province of Quebec (Canada), paramedics use the esophageal tracheal Combitube (ETC) for prehospital airway management.

OBJECTIVES

Our main objective was to determine the proportion of patients with successful ventilation achieved after ETC use. Our secondary aim was to determine the number of ETC insertion attempts required to ventilate the patient.

METHOD

This is a retrospective cohort study. All patients who had ≥1 attempt to insert an ETC during prehospital care between January 1, 2017 and December 31, 2018 were included. Prehospital and in-hospital data were extracted. Successful ventilation was defined as thorax elevation, lung sounds on chest auscultation, or positive end-tidal capnography after ETC insertion.

RESULTS

A total of 580 emergency medical services interventions (99.3% cardiac arrests) were included. Most patients were men (62.5%) with a mean age 67.0 years (SD 17.6 years), and 35 (13.1%) of the 298 patients transported to emergency department survived to hospital discharge. Sufficient information to determine whether ventilation was successful or not was available for 515 interventions. Ventilation was achieved during 427 (82.7%) of these interventions. The number of ETC insertion attempts was available for 349 of the 427 successful ETC use. Overall, the first insertion resulted in successful ventilation during 294 interventions for an overall proportion of first-pass success ranging between 57.1% and 72.1%.

CONCLUSION

Proportions of successful ventilation and ETC first-pass success are lower than those reported in the literature with supraglottic airway devices. The reasons explaining these lower rates and their impact on patient-centered outcomes need to be studied.

[Relation between grip strength of independent elders and functional decline following an emergency department visit : a pan-Canadian study]

OBJECTIVE

To determine whether grip strength and fear of falling are associated with functional decline at 3 or 6 months after a minor trauma assessed in the emergency department.

METHOD

Prospective multicenter cohort study of patient's aged 65 years and older, independent for activities of daily living, consulting the emergency department for minor trauma. Functional status, fear of falling, and grip strength measurements were collected. Functional decline was measured at 3 and 6 months.

STATISTICS

Two groups were compared : one with functional decline, the other without. A ROC curve explored the predictive power of grip strength and initial fear of falling on the occurrence of functional decline.

RESULTS

Participants were 74.7 years old, 52 % men. Initial peak grip strengths were identical (p superior to 0.05). Grip strength and fear of falling were not predictive of functional decline (p = 0.55 and p = 0.53). However, fear of falling was associated with functional decline (OR: 1.141 95 % CI [1.032-1.261]; p = 0.009).

CONCLUSION

In the autonomous elder with minor trauma in the emergency department, grip strength is not associated with subsequent functional decline. But fear of falling is associated with decline at 6 months.

Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study

BACKGROUND

This study aimed to assess the level of pain induced by common interventions performed in older adults consulting to the ED.

METHODS

We conducted a prospective multicentre observational cohort study in two academic EDs (Quebec City, Canada) between June 2018 and December 2019. A convenience sample of well-oriented and haemodynamically stable older adults (≥65 years old) who underwent at least two interventions during their ED stay was recruited. The level of pain was assessed using an 11-point Numerous Rating Scale (NRS) and is presented using median and IQR or categorised as no pain (0), mild (1-3), moderate (4-6) or severe pain (7-10).

RESULTS

A total of 318 patients were included. The mean age was 77.8±8.0 years old and 54.4% were female . The number of pain assessments per intervention ranged between 22 (urinary catheterisation) and 240 (intravenous catheter). All imaging investigations (X-rays, CT and bedside ultrasound) were associated with a median level of pain of 0. The median level of pain for other interventions was as follows: blood samplings (n=231, NRS 1 (IQR 0-3)), intravenous catheters (n=240, NRS 2 (IQR 0-4)), urinary catheterisations (n=22, NRS 4.5 (IQR 2-6)), cervical collars (n=50, NRS 5 (IQR 0-8)) and immobilisation mattresses (n=34, NRS 5 (IQR 0-8)). Urinary catheterisations (63.8%), cervical collars (56.0%) and immobilisation mattresses (52.9%) frequently induced moderate or severe pain.

CONCLUSIONS

Most interventions administered to older adults in the ED are associated with no or low pain intensity. However, urinary catheterisation and spinal motion restriction devices are frequently associated with moderate or severe pain.

Continuous flow insufflation of oxygen compared with manual ventilation during out-of-hospital cardiac arrest: A survey of the paramedics

Introduction:

In 2018, a continuous flow insufflation of oxygen (CFIO) device (b-card™, Vygon (USA)) placed on a supraglottic airway (SGA) became the standard of care to ventilate patients during adult out-of-hospital cardiac arrest (OHCA) care in Quebec–Capitale-Nationale region, Canada. This study aims to assess the paramedics’ perception as well as the disadvantages and the benefits relative to the use of CFIO during OHCA management.

Methods:

An invitation to complete an online survey (Survey Monkey™) was sent to all 560 paramedics who are working in our region. The survey included 22 questions of which 9 aimed to compare the traditional manual ventilation with a bag to the CFIO using a 5-point Likert-type scale.

Results:

A total of 244 paramedics completed the survey, of which 189 (77.5%) had used the CFIO device during an OHCA at least once. Most respondents felt that the intervention was faster (70.2%) and easier (86.5%) with the CFIO device compared with manual ventilation. CFIO was also associated with perceived increased patient safety (64.4%) as well as paramedic safety during the evacuation (88.9%) and the ambulance transport (88.9%). Paramedics reported that physical (48.1%) and cognitive (52.9%) fatigue were also improved with CFIO. The main reported barriers were the bending of the external SGA tube and the loss of capnography values.

Conclusion:

The use of CFIO during adult OHCA care allows a simplified approach and was perceived as safer for the patient and the paramedics compared with manual ventilation. Its impact on patient-centred outcomes needs to be assessed.

Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies

OBJECTIVE

To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA).

METHODS

A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered.

RESULTS

A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies.

CONCLUSIONS

No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.

Functional and cognitive decline in older delirious adults after an emergency department visit

BACKGROUND

the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient's functional and cognitive status at 60 days post ED visit.

METHODS

this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m.

RESULTS

a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of -2.9/28 [95%CI: -3.9, -2.0] points on the OARS scale compared to non-delirious patients who lost -1.6 [95%CI: -1.9, -1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by -1.6 [95%CI: -3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: -0.1, 1.1] (P = 0.03).

CONCLUSION

seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

Contribution of Substance Use in Acute Injuries With Regards to the Intent, Nature and Context of Injury: A CHIRPP Database Study

Introduction

Using the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) sentinel surveillance system, the objective of this study was to compare intent, circumstances, injury type and patient demographics in patients who used a substance prior to the injury versus those who did not use any substances.

Methods

Data were retrospectively collected from November 1^st 2016 to October 31^st 2017. All patients presenting to the Hôpital de l’Enfant-Jésus ED following trauma were included, aside from those who left without seeing a physician or had no physical injury (e.g., overdose without any trauma was excluded). Patients voluntarily completed a standardised form or agreed to be contacted later. Medical charts of all attendances were reviewed by the CHIRPP’s program coordinator. Substance use included illicit drugs, medications for recreational purposes, alcohol or other used either by the patient or another person involved.

Results

A total of 12,857 patients were included. Substance use was involved in 701 (5.5%) cases and was associated with injuries sustained by males (p < .001). The mean age of patients injured while using substances was 42.8 years, compared to 45.5 years in those who did not use substances (p < .001). Substance use was involved in 3.6% of unintentional injuries, compared to 26.2% of injuries intentionally inflicted by other and 38.9% for self-inflicted injuries (p < 0.0001). When substances were used, the odds of intentional injuries were 7.5 times greater compared to non-intentional injuries (95% CI 6.7, 8.5). Burns, head injuries and polytraumas were more prevalent when drugs or alcohol were involved.

Conclusion

This study outlines the significant contribution of substance use in intentional injuries, suggesting that it could potentially be beneficial to specifically target patients who present with deliberate physical injuries in preventive and therapeutic interventions offered in the ED.

Trauma team leaders in Canada: A national survey

Introduction

The availability, composition and activation criteria for trauma teams vary across different health care systems, but little is known about these features in the Canadian health system. The aim of this study is to provide a description of the current trauma team available in Level 1 and 2 centres across Canada.

Methods

In 2017, using a modified Dillman technique, a survey was sent to 210 health professionals across all Canadian trauma care facilities, including questions that focused on (1) the presence and the composition of a trauma team, (2) the established criteria to activate this team and (3) the initial patient care.

Results

Overall, 107 (57%) completed surveys were received. Only 22 (11.7%) were from Level 1 or 2 centre and considered for compilation. Seventeen respondents have a trauma team in their centre, and they all shared their criteria for activating their team (1–27 different indications). The suspected injuries, the judgment of the emergency physician, the systolic blood pressure, the Glasgow Coma Score and the respiratory rate were the most frequently mentioned items. In the presence of a pre-hospital care warning, the initial assessment of a severely injured patient is exclusively completed by a member of the trauma team for only 35.1% of the respondents. For 11.8% of respondents, trauma team coordinates airway management. For 64.7% of participants, the trauma team leader is the dedicated care provider to accompany patients until the final destination.

Conclusions

The results suggest a great variability across Canada, regarding the roles assumed by the trauma team but also regarding the activation criteria leading them to take action.

A 12-Week Cycling Training Regimen Improves Upper Limb Functions in People With Parkinson's Disease

Background: It has been proposed that physical exercise can help improve upper limb functions in Parkinson’s disease (PD) patients; yet evidence for this hypothesis is limited.

Objective: To assess the effects of aerobic exercise training (AET) on general upper limb functions in sedentary people with PD and healthy adults (HA).

Methods: Two groups, 19 PD patients (Hoehn & Yahr ≤ 2) and 20 HA, matched on age and sedentary level, followed a 3-month stationary bicycle AET regimen. We used the kinematic theory framework to characterize and quantify the different motor control commands involved in performing simple upper-limb movements as drawing lines. Repeated measures ANCOVA models were used to assess the effect of AET in each group, as well as the difference between groups following the training regimen.

Results: At baseline, PD individuals had a larger antagonist response, a longer elapsed time between the visual stimulus and the end of the movement, and a longer time of displacement of the stylus than the HA. Following the 12-week AET, PD participants showed significant decreases of the agonist and antagonist commands, as well as the antagonist response spread. A significant group ^∗ session interaction effect was observed for the agonist command and the response spread of the antagonist command, suggesting a significant change for these two parameters only in PD patients following the AET. Among the differences observed at baseline, only the difference for the time of movement remained after AET.

Conclusion: A 3-month AET has a significant positive impact on the capacity to draw lines in a more efficiency way, in PD patients, indicating an improvement in the upper limb motor function.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

OBJECTIVE

We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.

DESIGN

This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.

SETTING

The study took place in four Canadian EDs.

PARTICIPANTS

338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.

MAIN OUTCOMES AND MEASURES

The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.

RESULTS

Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.

CONCLUSIONS

An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

BET 1: Continuous flow insufflation of oxygen in out-of-hospital cardiac arrest

A short cut review was carried out to establish whether continuous flow insufflation of oxygen (CFIO) is better than standard ventilation strategies at improving outcome in adults who have suffered an out-of-hospital cardiac arrest (OHCA). Papers were found in Medline and Embase using the reported searches of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that CFIO does not improve survival or return of spontaneous circulation compared with standard ventilation strategies in OHCA.

The Association between Generalized Anxiety Disorder, Subthreshold Anxiety Symptoms and Fear of Falling among Older Adults: Preliminary Results from a Pilot Study

OBJECTIVE

A relationship between generalized anxiety disorder (GAD) and fear of falling (FOF) has long been proposed but never specifically studied. This study aimed at analyzing the relationship between FOF and GAD or anxiety symptoms, while controlling for major depressive episodes (MDE), depressive symptoms, fall risk, and sociodemographic variables.

METHODS

Twenty-five older adults participated in this pilot study. Assessments included the following: Anxiety Disorder Interview Schedule, Geriatric Anxiety Inventory, Geriatric Depression Scale, Falls-Efficacy Scale-International. A multidisciplinary team evaluated fall risk.

RESULTS

FOF was significantly correlated with GAD, MDE, anxiety and depressive symptoms, and fall risk, but not with sociodemographic variables. Multiple regression analyses indicated that GAD and anxiety symptoms were significantly and independently associated with FOF.

CONCLUSION

Although the results of this pilot study should be replicated with larger samples, they suggest that FOF is associated with GAD and anxiety symptoms even when considering physical factors that increase the risk of falling.

CLINICAL IMPLICATIONS

Treatment of FOF in patients with GAD may present a particular challenge because of the central role of intolerance of uncertainty, which may prevent patients from regaining confidence despite the reduction of fall risk. Clinicians should screen for GAD and anxiety symptoms in patients with FOF to improve detection and treatment.

A 12-Week Cycling Training Regimen Improves Gait and Executive Functions Concomitantly in People with Parkinson's Disease

Background: There is increasing evidence that executive functions and attention are associated with gait and balance, and that this link is especially prominent in older individuals or those who are afflicted by neurodegenerative diseases that affect cognition and/or motor functions. People with Parkinson’s disease (PD) often present gait disturbances, which can be reduced when PD patients engage in different types of physical exercise (PE), such as walking on a treadmill. Similarly, PE has also been found to improve executive functions in this population. Yet, no exercise intervention investigated simultaneously gait and non-motor symptoms (executive functions, motor learning) in PD patients.

Objective: To assess the impact of aerobic exercise training (AET) using a stationary bicycle on a set of gait parameters (walking speed, cadence, step length, step width, single and double support time, as well as variability of step length, step width and double support time) and executive functions (cognitive inhibition and flexibility) in sedentary PD patients and healthy controls.

Methods: Two groups, 19 PD patients (Hoehn and Yahr ≤2) and 20 healthy adults, matched on age and sedentary level, followed a 3-month stationary bicycle AET regimen.

Results: Aerobic capacity, as well as performance of motor learning and on cognitive inhibition, increased significantly in both groups after the training regimen, but only PD patients improved their walking speed and cadence (all p < 0.05; with no change in the step length). Moreover, in PD patients, training-related improvements in aerobic capacity correlated positively with improvements in walking speed (r = 0.461, p < 0.05).

Conclusion: AET using stationary bicycle can independently improve gait and cognitive inhibition in sedentary PD patients. Given that increases in walking speed were obtained through increases in cadence, with no change in step length, our findings suggest that gait improvements are specific to the type of motor activity practiced during exercise (i.e., pedaling). In contrast, the improvements seen in cognitive inhibition were, most likely, not specific to the type of training and they could be due to indirect action mechanisms (i.e., improvement of cardiovascular capacity). These results are also relevant for the development of targeted AET interventions to improve functional autonomy in PD patients.

Influence of aerobic exercise training on the neural correlates of motor learning in Parkinson's disease individuals

Background

Aerobic exercise training (AET) has been shown to provide general health benefits, and to improve motor behaviours in particular, in individuals with Parkinson's disease (PD). However, the influence of AET on their motor learning capacities, as well as the change in neural substrates mediating this effect remains to be explored.

Objective

In the current study, we employed functional Magnetic Resonance Imaging (fMRI) to assess the effect of a 3-month AET program on the neural correlates of implicit motor sequence learning (MSL).

Methods

20 healthy controls (HC) and 19 early PD individuals participated in a supervised, high-intensity, stationary recumbent bike training program (3 times/week for 12 weeks). Exercise prescription started at 20 min (+ 5 min/week up to 40 min) based on participant's maximal aerobic power. Before and after the AET program, participants' brain was scanned while performing an implicit version of the serial reaction time task.

Results

Brain data revealed pre-post MSL-related increases in functional activity in the hippocampus, striatum and cerebellum in PD patients, as well as in the striatum in HC individuals. Importantly, the functional brain changes in PD individuals correlated with changes in aerobic fitness: a positive relationship was found with increased activity in the hippocampus and striatum, while a negative relationship was observed with the cerebellar activity.

Conclusion

Our results reveal, for the first time, that exercise training produces functional changes in known motor learning related brain structures that are consistent with improved behavioural performance observed in PD patients. As such, AET can be a valuable non-pharmacological intervention to promote, not only physical fitness in early PD, but also better motor learning capacity useful in day-to-day activities through increased plasticity in motor related structures.

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Three months of aerobic exercise training (AET) improves fitness in PD patients.

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Effects of AET on cognitive and motor skills in PD were evaluated concurrently.

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Some executive functions and procedural learning capacity improved after AET.

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Striatum, hippocampus and cerebellar brain plasticity was observed after AET.

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AET can be used as a non-pharmacological intervention to improve functioning in PD.

Prevalence of colonic motor or evacuation disorders in patients presenting with chronic nausea and vomiting evaluated by a single gastroenterologist in a tertiary referral practice

BACKGROUND

Nausea and vomiting are thought to result from upper gastrointestinal dysfunctions. Our clinical observations led to the hypothesis that colonic motor dysfunction is associated with nausea and vomiting.

METHODS

We reviewed electronic medical records (EMR) of 149 patients presenting with complaints of nausea and/or vomiting in a tertiary gastroenterology practice to investigate the association with disorders of colonic motor or evacuation disorders. We extracted demographics, gastric emptying (GE in 149) and colonic transit (CT in 138) of solids, ascending colon emptying half-time (AC t1/2 ), rectal evacuation by anorectal manometry (ARM) in 91 and balloon expulsion test (BE) in 55 patients. We estimated the proportions with delayed GE or CT, based on the 5th percentile of GE (in 319) and CT in 220 healthy volunteers using same method.

KEY RESULTS

Among 11 patients with nausea and/or vomiting with only GE measured, five had delayed and six normal GE. Among the 149 patients, 77 (52%) patients had evacuation disorders, confirmed by objective tests in 68 patients, and clinical examination in nine patients. In the 138 patients with both GE and CT measured, 106 (76%) had both normal GE and CT, 11 (8%) only delayed GE, 16 (11%) normal GE with delayed CT, and five (3%) delayed GE and CT. Among 21 patients (15%) with delayed CT, nine had slow AC t1/2 and 12 evacuation disorder.

CONCLUSIONS & INFERENCES

In patients with chronic nausea and/or vomiting in gastroenterology practice, evaluation of colonic motility and rectal evacuation should be considered, since about half the patients have abnormal functions that conceivably contribute to the presenting nausea and/or vomiting.

Interpretation of overall colonic transit in defecation disorders in males and females

BACKGROUND

There is little information regarding gender-specific measurements of colonic transit and anorectal function in patients with defecation disorders (DD). To compare overall colonic transit by gender in DD.

METHODS

In 407 patients with constipation due to DD diagnosed by a single gastroenterologist (1994-2012), DD was characterized by anorectal manometry, balloon expulsion test, and colonic transit by scintigraphy. The primary endpoint was overall colonic transit (geometric center, GC) at 24 h (GC24). Effects of gender in DD on colonic transit, and comparison with transit in 208 healthy controls were assessed by Mann-Whitney rank sum test. Secondary endpoints were maximum anal resting (ARP) and squeeze (ASP) pressures. We also tested association of the physiological endpoints among DD females by pregnancy history and among DD patients by colectomy history.

KEY RESULTS

The DD patients were 67 males (M) and 340 females (F). Significant differences by gender in DD patients were observed in GC24 (median: M: 2.2; F: 1.8; P = 0.01), ARP (median: M: 87.8 mmHg; F: 82.4 mmHg; P = 0.04), and ASP (median: M: 182.4 mmHg; F: 128.7 mmHg; P < 0.001). GC24 was slower in DD compared with same-gender healthy controls. GC24 did not differ among DD females by pregnancy history. Anorectal functions and upper GI transit did not differ among DD patients by colectomy history.

CONCLUSIONS & INFERENCES

Patients with DD have slower colonic transit compared with gender-matched controls. Among DD patients, males have higher ARP and ASP, and females have slower colonic transit. Although the clinical significance of these differences may be unclear, findings suggest that interpretation of these tests in suspected DD should be based on same-gender control data.

Muscle histology vs MRI in Duchenne muscular dystrophy

OBJECTIVE

There are currently no effective treatments to halt the muscle breakdown in Duchenne muscular dystrophy (DMD), although genetic-based clinical trials are being piloted. Most of these trials have as an endpoint the restoration of dystrophin in muscle fibers, hence requiring sufficiently well-preserved muscle of recruited patients. The choice of the muscles to be studied and the role of noninvasive methods to assess muscle preservation therefore require further evaluation.

METHODS

We studied the degree of muscle involvement in the lower leg muscles of 34 patients with DMD >8 years, using muscle MRI. In a subgroup of 15 patients we correlated the muscle MRI findings with the histology of open extensor digitorum brevis (EDB) muscle biopsies. Muscle MRI involvement was assigned using a scale 0-4 (normal-severe).

RESULTS

In all patients we documented a gradient of involvement of the lower leg muscles: the posterior compartment (gastrocnemius > soleus) was most severely affected; the anterior compartment (tibialis anterior/posterior, popliteus, extensor digitorum longus) least affected. Muscle MRI showed EDB involvement that correlated with the patient's age (p = 0.055). We show a correlation between the MRI and EDB histopathologic changes, with MRI 3-4 grades associated with a more severe fibro-adipose tissue replacement. The EDB was sufficiently preserved for bulk and signal intensity in 18/22 wheelchair users aged 10-16.6 years.

CONCLUSION

This study provides a detailed correlation between muscle histology and MRI changes in DMD and demonstrates the value of this imaging technique as a reliable tool for the selection of muscles in patients recruited into clinical trials.

Natural history of Ullrich congenital muscular dystrophy

OBJECTIVE

To describe the course, complications, and prognosis of Ullrich congenital muscular dystrophy (UCMD), with special reference to life-changing events, including loss of ambulation, respiratory insufficiency, and death.

METHODS

Review of the case notes of 13 patients with UCMD, aged 15 years or older at last visit, followed up at a tertiary neuromuscular centre, London, UK, from 1977 to 2007. Data collected were age at onset of symptoms, presenting symptoms, mobility, contractures, scoliosis, skin abnormalities, respiratory function, and feeding difficulties.

RESULTS

The mean age at onset of symptoms was 12 months (SD 14 months). Eight patients (61.5%) acquired independent ambulation at a mean age of 1.7 years (SD 0.8 years). Nine patients (69.2%) became constant wheelchair users at a mean age of 11.1 years (SD 4.8 years). Three patients continued to ambulate indoors with assistance. Forced vital capacity (FVC) values were abnormal in all patients from age 6 years. The mean FVC (% predicted) declined at a mean rate of 2.6% (SD 4.1%) yearly. Nine patients (69.2%) started noninvasive ventilation at a mean age of 14.3 years (SD 5.0 years). Two patients died of respiratory insufficiency.

CONCLUSION

In Ullrich congenital muscular dystrophy (UCMD), the decline in motor and respiratory functions is more rapid in the first decade of life. The deterioration is invariable, but not always correlated with age or severity at presentation. This information should be of help to better anticipate the difficulties encountered by patients with UCMD and in planning future therapeutic trials in this condition.

Physical training and changes in regional adipose tissue distribution

Obesity has been associated with numerous metabolic complications, such as changes in the concentration and/or composition of plasma lipoproteins, glucose intolerance and hyperinsulinemia leading to diabetes and hypertension. The relation of obesity to cardiovascular disease has not, however, been consistently reported. Recent prospective studies have clearly indicated that the distribution of adipose tissue was a significant cardiovascular risk factor and numerous studies have shown that metabolic disturbances were more closely associated with the level of abdominal fat than excess adiposity per se. As obese men generally store their energy excess in the abdominal region and women in the peripheral fat depots, the metabolic complications of obesity seem to be more closely related to adiposity in men than in women. It is suggested that the sex dimorphism observed in adipose tissue localization could partly explain the greater cardiovascular risk associated with obesity in men than in women. Indeed, obese women with a "male" (abdominal) distribution of body fat have greater metabolic complications than women with lower body fat. When aerobic exercise-training is used to induce weight loss, men generally lose more fat than women. In men, the loss of adipose tissue appears to be central, potentially reducing the risk of cardiovascular disease, whereas a relative resistance to fat loss is observed in women compared to men. Although resistance to fat loss is noted in women, those with a "male" distribution of adipose tissue (high waist-to-hip ratio and high intra-abdominal fat deposition) and with associated metabolic complications greatly benefit from aerobic exercise-training.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of fasting and postprandial state on plasma carnitine concentrations during aerobic exercise in type 2 diabetes

The effects of metabolic states of fasting and post-absorption on plasma concentrations of free carnitine (FC), acylcarnitine (AC) and total carnitine (TC) were compared during submaximal exercise in subjects with type 2 diabetes mellitus. Ten sedentary men (54+/-5 years) treated with oral hypoglycaemic agents were tested on two separate occasions: following an overnight fast and 2 h after a 395-kcal standardised breakfast. Exercise was performed at 60% of [Formula: see text]O(2peak) on a cycle ergometer for 60 min. Blood samples were drawn at rest for baseline values and following 60 min of exercise and 30 min of recovery. Our results show that: (1) baseline levels of TC, FC and AC were similar in fasted and postprandial groups, (2) TC and AC levels were increased during exercise in the fasted group only, (3) FC levels were decreased during exercise in both fasted and postprandial state and (4) the AC/FC ratio increased during exercise in the fasted group. Our results indicate that the metabolic state of the diabetic patient is associated with a different plasma carnitine status. These patterns may reflect differences in energy metabolism associated with fasting and postprandial hyperglycaemia.

Disinhibition, as assessed by the Three-Factor Eating Questionnaire, is inversely related to psychological well-being in postmenopausal women

Psychological correlates of obesity remain under controversy. As eating behaviors and dieting history have been previously related to obesity status, these dietary variables may contribute to identify overweight and obese individuals who are at higher risk of having an impaired psychological well-being.

OBJECTIVE

The main purpose of this cross-sectional study was to verify the hypothesis of a relationship between weight status and psychological well-being, and to examine whether cognitive dietary restraint, disinhibition, susceptibility to hunger and dieting history could be related to psychological well-being.

DESIGN AND SUBJECTS

In a sample of 101 postmenopausal women, we performed anthropometric measurements (weight, height and body mass index (BMI)), and measured psychological well-being (PER Questionnaire). The Three-Factor Eating Questionnaire (TFEQ) and a questionnaire about dieting history (dieters: had already been on a diet; non-dieters: had never been on a diet) were also administrated.

RESULTS

A trend for a significant relationship was observed between BMI and psychological well-being (r=-0.17; P=0.08). Significant negative relationships were observed for disinhibition, susceptibility to hunger and all their subscales with psychological well-being (-0.28</=r</=-0.48), whereas no significant differences in psychological well-being were observed between dieters and non-dieters. Finally, women displaying a higher score for habitual susceptibility to disinhibition (which is the subscale of TFEQ that was the most closely related to psychological well-being) had a lower level of psychological well-being, regardless of their weight status.

CONCLUSION

These results show that, as well as being related to weight status, TFEQ-factors are also related to psychological well-being. More specifically, individuals who display higher levels of disinhibition may be at higher risk of having an impaired psychological well-being.

The response to exercise with constant energy intake in identical twins

Seven pairs of young adult male identical twins completed a negative energy balance protocol during which they exercised on cycle ergometers twice a day, 9 out of 10 days, over a period of 93 days while being kept on a constant daily energy and nutrient intake. The total energy deficit caused by exercise above the estimated energy cost of body weight maintenance reached 244 +/- 9.8 MJ (Mean +/- SEM). Baseline energy intake was estimated over a period of 17 days preceding the negative energy balance protocol. Mean body weight loss was 5.0 kg (SEM = 0.6) (p < 0.001) and it was entirely accounted for by the loss of fat mass (p < 0.001). Fat-free mass was unchanged. Body energy losses reached 191 MJ (SEM = 24) (p < 0.001) which represented about 78% of the estimated energy deficit. Subcutaneous fat loss was slightly more pronounced on the trunk than on the limbs as estimated from skinfolds, circumferences, and computed tomograply (CT). The reduction in CT-assessed abdominal visceral fat was quite striking, from 81 cm2 (SEM = 5) to 52 cm2 (SEM = 6) (p < 0.001). At the same submaximal power output level, subjects oxidized more lipids than carbohydrates after the program as indicated by the changes in the respiratory exchange ratio (p < or = 0.05). Intrapair resemblance was observed for the changes in body weight (p < 0.05), fat mass (P < 0.01), percent fat (p < 0.01), body energy content (p < 0.01), sum of 10 skinfolds (p < 0.01), abdominal visceral fat (p < 0.01), fasting plasma triglycerides (p < 0.05) and cholesterol (p < 0.05), maximal oxygen uptake (p < 0.05), and respiratory exchange ratio during submaximal work (p < 0.01). We conclude that even though there were large individual differences in response to the negative energy balance and exercise protocol, subjects with the same genotype were more alike in responses than subjects with different genotypes particularly for body fat, body energy, and abdominal visceral fat changes. High lipid oxidizers and low lipid oxidizers during submaximal exercise were also seen despite the fact that all subjects had experienced the same exercise and nutritional conditions for about three months.

Clinical significance of isolated hippocampal volume asymmetry in childhood epilepsy

This study defines the clinical characteristics and evolution of 16 epileptic children with hippocampal asymmetry (HA) without sclerosis on MRI. The association of a positive family history of epilepsy (11/16), low incidence of febrile seizures (2/16), and benign prognosis (seizure control in monotherapy in 11/16, mean follow-up = 4.3 years, range 1 to 10) suggest a different clinical presentation than patients with mesial temporal sclerosis. Genetic studies of these mostly French Canadian families should help confirm the existence of a distinct syndrome.

Impaired fasting glucose vs. glucose intolerance in pre-menopausal women: distinct metabolic entities and cardiovascular disease risk?

BACKGROUND

Impaired glucose tolerance (IGT) is associated with an increased cardiovascular disease risk. Less is known about cardiovascular disease risk among subjects with impaired fasting glucose (IFG) or with combined IFG and IGT.

AIMS

To compare body composition, body fat distribution, plasma glucose-insulin homeostasis and plasma lipid-lipoprotein profile between pre-menopausal women having either a normal glucose tolerance (NGT), isolated IFG, isolated IGT or combined IFG and IGT.

METHODS

Three hundred and thirty-four women with NGT, 11 women with IFG, 35 women with IGT and 10 women with both IFG and IGT were studied.

RESULTS

Women with IFG were characterized by a higher visceral adipose tissue (AT) accumulation than women with NGT (P < 0.05). Also, they were characterized by a higher subcutaneous AT area and by higher body fat mass than NGT and IGT women (P < 0.05). However, their lipid-lipoprotein profile was comparable with that of NGT women, except for reduced HDL-cholesterol concentrations (P < 0.05). After adjustment for visceral AT, women with IFG had lower total cholesterol, LDL-cholesterol and apolipoprotein B (apoB) levels than the three other groups. They also had lower HDL(2)-cholesterol than NGT women and lower total cholesterol/HDL-cholesterol ratio than IGT women. Women with IGT showed higher triglyceride and apoB concentrations and a higher total cholesterol/HDL-cholesterol ratio than women with NGT (P < 0.05). Overall, women with combined IFG and IGT showed body fatness characteristics and alterations in their metabolic risk profile which were essentially similar to women with isolated IGT.

CONCLUSIONS

These results indicate that there are significant differences in anthropometric and metabolic variables between pre-menopausal women with IFG vs. IGT and that the association between body fatness-body fat distribution indices and the metabolic profile may differ between IFG and IGT women.

Is the gender difference in LDL size explained by the metabolic complications of visceral obesity?

BACKGROUND

Several studies have reported a significant gender difference in low-density lipoprotein (LDL) size, with men being characterized by smaller, denser LDL particles than women, and it has been suggested that the contribution of the greater accumulation of visceral adipose tissue in men compared with women may be a factor potentially contributing to the gender difference in LDL heterogeneity.

MATERIALS AND METHODS

We measured LDL particle size by 2-16% nondenaturing polyacrylamide gradient gel electrophoresis in 299 men and 231 women in whom visceral adipose tissue accumulation was measured by computed tomography. A fasting plasma lipoprotein-lipid profile was also obtained in all subjects.

RESULTS

Overall, the men were characterized by a more deteriorated metabolic risk factor profile, which included higher plasma insulin and triglyceride levels, a greater visceral adipose tissue accumulation (P < 0.001) and smaller LDL particles (251.7 +/- 5.2 vs. 254.4 +/- 4.2 A, P < 0.0001). This gender difference in LDL peak particle diameter remained significant (252.4 +/- 4.3 vs. 253.5 +/- 4.3 A, P < 0.01) after adjustment for sex-specific differences in plasma triglyceride levels by covariance analysis. Significant negative correlations were noted between the LDL particle diameter and the triglyceride concentrations in both genders (r = -0.52 and r = -0.36, P < 0.0001 for the men and women, respectively), with no gender difference in this relationship being found. However, viscerally obese women (visceral adipose tissue levels > 100 cm2) with increased plasma triglyceride concentrations (> 2.0 mmol L-1) still had larger LDL particles than viscerally obese men with a similar elevation in their triglyceride levels (251.6 +/- 4.9 vs. 248.7 +/- 4.5 A, P < 0.01).

CONCLUSIONS

Results of the present study suggest that the reduced LDL particle size observed in men compared with women cannot be entirely explained by their higher visceral adipose tissue accumulation and increased plasma triglyceride levels. Moreover, the gender difference in LDL size could be influenced, at least in part, by the severity of the hypertriglyceridaemic state.

Reduced HDL particle size as an additional feature of the atherogenic dyslipidemia of abdominal obesity

Reduced plasma HDL cholesterol concentration has been associated with an increased risk of coronary heart disease. However, a low HDL cholesterol concentration is usually not observed as an isolated disorder because this condition is often accompanied by additional metabolic alterations. The objective of this study was to document the relevance of assessing HDL particle size as another feature of the atherogenic dyslipidemia found among subjects with visceral obesity and insulin resistance. For that purpose, an average HDL particle size was computed by calculating an integrated HDL particle size using nondenaturing 4-30% gradient gel electrophoresis. Potential associations between this average HDL particle size versus morphometric and metabolic features of visceral obesity were examined in a sample of 238 men. Results of this study indicated that HDL particle size was a significant correlate of several features of an atherogenic dyslipidemic profile such as increased plasma TG, decreased HDL cholesterol, high apolipoprotein B, elevated cholesterol/HDL cholesterol ratio, and small LDL particles as well as increased levels of visceral adipose tissue (AT) (0.33 < or = absolute value of r < or = 0.61, P < 0.0001). Thus, men with large HDL particles had a more favorable plasma lipoprotein-lipid profile compared with those with smaller HDL particles. Furthermore, men with large HDL particles were also characterized by reduced overall adiposity and lower levels of visceral AT as well as reduced insulinemic-glycemic responses to an oral glucose load. In conclusion, small HDL particle size appears to represent another feature of the high TG- low HDL cholesterol dyslipidemia found in viscerally obese subjects characterized by hyperinsulinemia.

Effects of the FABP2 A54T mutation on triglyceride metabolism of viscerally obese men

OBJECTIVE

Viscerally obese individuals are frequently characterized by a proatherogenic condition. A missense mutation (A54T) in the fatty acid binding protein type 2 (FABP2) gene has been associated with insulin resistance and obesity. This study examined the effect of this mutation on lipoprotein levels in viscerally obese hyperinsulinemic condition.

RESEARCH METHODS AND PROCEDURES

A total of 217 men were assigned to one of two groups based on their FABP2 A54T polymorphism.

RESULTS

The two genotypic groups showed no difference in either physiological characteristics or lipoprotein/lipid profile, before or after statistical adjustment for age. From this initial sample, 50 men accepted to have their postprandial lipid response assessed and 10 T54/A54 heterozygotes were then individually matched for visceral adipose tissue accumulation and fasting plasma triglyceride (TG) levels with 10 A54/A54 homozygotes. High-density lipoprotein (HDL)-TG levels were significantly increased in the fasting state as well as 4 hours after the test meal (p = 0.04 and p = 0.0008, respectively) in men bearing the A54T mutation. In addition, the area under the curve of postprandial HDL-TG levels was also significantly higher among T54/A54 heterozygotes than among A54/A54 homozygotes (p = 0.04). Interestingly, fasting TG concentrations in large TG-rich lipoproteins (large-TRL; S(f) > 400) were correlated with HDL-TG levels at 4 (r = 0.74, p = 0.01) and 8 hours (r = 0.73, p = 0.01) after the test meal in T54/A54 heterozygotes only.

DISCUSSION

The FABP2 A54T missense mutation may contribute to the TG enrichment of HDL in the postprandial state that, in turn, may alter the risk of atherosclerotic vascular disease.

Effects of nebivolol and atenolol on insulin sensitivity and haemodynamics in hypertensive patients

OBJECTIVES

To compare the effects of nebivolol and atenolol in 25 ambulatory hypertensive patients with impaired glucose tolerance.

DESIGN

Clinic and ambulatory blood pressure, insulin sensitivity (euglycemic-hyperinsulinemic clamp), glucose tolerance (intravenous glucose tolerance test), systemic and regional haemodynamics were measured after 4 weeks of placebo and after each 16-week treatment period in a double-blind, crossover fashion.

RESULTS

Nebivolol and atenolol similarly reduced (P< 0.001) clinic and ambulatory blood pressure by approximately 15/10 mmHg, systolic and diastolic. Clinic and ambulatory heart rate was reduced to a greater extent (P < 0.01) by atenolol than nebivolol. Atenolol was associated with an approximately 20% reduction in insulin sensitivity (insulin-induced glucose disposal rate/mean insulin concentration ratio, P < 0.01) and an approximately 10% reduction in glucose disappearance rate (K-value, P < 0.05), whereas these variables were not significantly modified with nebivolol. Cardiac output was reduced similarly (P < 0.05) by both drugs at rest but forearm blood flow, forearm vascular resistance or total peripheral resistance were unaffected. A significant inverse correlation coefficient between cardiac output and insulin sensitivity was found at baseline, suggesting that a compensatory increase in systemic blood flow occurs in hypertensive patients with progressively more marked insulin resistance. This relationship was unaffected by nebivolol but was lost with atenolol.

CONCLUSIONS

These results indicate that insulin sensitivity was not modified significantly by nebivolol, whereas it was reduced by atenolol, although blood pressure was decreased to the same extent by both drugs. Neither drug induced systemic or forearm vasodilatation but the inverse relationship between cardiac output and insulin sensitivity was preserved with nebivolol but not with atenolol.

Prior meal enhances the plasma glucose lowering effect of exercise in type 2 diabetes

PURPOSE

To compare the changes in plasma glucose and insulin levels in response to 1 h of exercise performed at 60% of VO(2peak) either in the fasted state or 2 h after a standardized breakfast in subjects with type 2 diabetes.

METHODS

Ten sedentary men with type 2 diabetes treated with oral agents and not under strict metabolic control were tested on two occasions (fasted and fed state) in a random order at a 1-wk interval.

RESULTS

Plasma glucose was slightly but not significantly higher at the beginning of exercise performed in the fed state versus the fasted state (12.4 +/- 1.3 vs 11.1 +/- 1.1 mmol x L(-1) respectively; mean +/- SE, P = 0.06). However, after exercise, plasma glucose levels were much lower in the fed state (7.6 +/- 1.1 mmol x L(-1)) compared with the fasted state (10.0 +/- 1.0 mmol x L(-1); P = 0.009). Insulin levels were higher at the beginning of the exercise bout performed in the fed state (177 +/- 26 vs 108 +/- 19 pmol x L(-1); P < 0.05) and during exercise. Similar respiratory exchange ratio at identical workload indicated that the difference in glycemic response was not due to differences in whole body substrate utilization. Plasma concentrations of free fatty acids, glucagon, epinephrine, and norepinephrine were also similar during both experiments.

CONCLUSIONS

One hour of aerobic exercise has a minimal impact on plasma glucose level when performed in fasted moderately hyperglycemic men with type 2 diabetes but induces an important decrease in plasma glucose level when performed 2 h after breakfast. Because glucose utilization increased similarly during exercise in both conditions, the higher insulin levels after the meal might have blunted glucose production, creating an imbalance between total glucose production and total peripheral utilization in the fed state in contrast to the fasted state.

Elevated C-reactive protein: another component of the atherothrombotic profile of abdominal obesity

Recent studies have suggested that elevated plasma C-reactive protein (CRP) levels are associated with the features of insulin resistance syndrome. In the present study, we have examined the contribution of body composition measured by hydrostatic weighing and of abdominal adipose tissue (AT) accumulation assessed by computed tomography to the variation in plasma CRP levels associated with atherogenic dyslipidemia of the insulin resistance syndrome in a sample of 159 men, aged 22 to 63 years, covering a wide range of adiposity (body mass index values from 21 to 41 kg/m(2)). Plasma CRP levels showed positive and significant correlations with body fat mass (r=0.41, P<0.0001), waist girth (r=0.37, P<0.0001), and visceral AT accumulation measured by computed tomography at L4 to L5 (r=0.28, P<0.0003). Although CRP levels were associated with plasma insulin levels measured in the fasting state and after a 75-g oral glucose load, no significant correlations were found with plasma lipoprotein levels. Finally, comparison of body fatness, of abdominal fat accumulation, and of the features of the insulin resistance syndrome across quintiles of CRP revealed major differences in body fatness and in indices of abdominal AT accumulation between the lowest and the highest CRP quintiles, whereas no significant differences were found for variables of the plasma lipoprotein-lipid profile. These results suggest that obesity and abdominal AT accumulation are the critical correlates of elevated plasma CRP levels found in men with atherogenic dyslipidemia of the insulin resistance syndrome.

Deterioration of the metabolic risk profile in women. Respective contributions of impaired glucose tolerance and visceral fat accumulation

OBJECTIVE

To determine whether the impaired glucose tolerance (IGT) state contributes to the deterioration of the metabolic profile in women after taking into account the contribution of visceral adipose tissue (AT) accumulation, as measured by computed tomography.

RESEARCH DESIGN AND METHODS

We studied 203 women with normal glucose tolerance (NGT) and 46 women with IGT, defined as a glycemia between 7.8 and 11.1 mmol/l measured 2 h after a 75-g oral glucose load.

RESULTS

Women with IGT were characterized by a higher visceral AT accumulation and by higher concentrations of fasting plasma glucose, insulin, and C-peptide as well as by higher plasma concentrations of cholesterol, triglycerides, and apolipoprotein B (apoB) and by greater cholesterol-to-HDL-cholesterol ratio, reduced LDL peak particle size, lower HDL-cholesterol and HDL2-cholesterol concentrations, and higher blood pressure (P < 0.01) than women with NGT. When we matched 27 pairs of women for visceral AT and fat mass as well as for menopausal status, differences previously found in LDL-cholesterol, LDL peak particle size, HDL-cholesterol, and HDL2-cholesterol concentrations as well as in the cholesterol-to-HDL-cholesterol ratio and blood pressure were eliminated, whereas triglyceride concentrations remained significantly higher in women with IGT.

CONCLUSIONS

A high visceral AT accumulation is a major factor involved in the deterioration of many metabolic variables in women with IGT, with the notable exception of triglyceride concentrations, which remained significantly different between women with NGT and women with IGT after adjustment for visceral fat.

Decreased fasting and oral glucose stimulated C-peptide in nondiabetic subjects with sequence variants in the sulfonylurea receptor 1 gene

The high-affinity sulfonylurea receptor 1 (SUR1) plays an important role in regulating insulin secretion. In the Québec Family Study, we genotyped 731 individuals (685 nondiabetic [ND] subjects) for the SUR1 gene IVS15-3c-->t and exon 18 Thr759(ACC-->ACT) polymorphisms using polymerase chain reaction-restriction fragment-length polymorphism analysis. Phenotypes measured were fasting plasma glucose (GLU), fasting plasma insulin (INS), and fasting C-peptide (CPEP), as well as oral glucose tolerance test (OGTT) responses; they were adjusted for age, sex, waist circumference, and the sum of six skinfold thicknesses. In ND subjects, exon 18 Thr759(ACC-->ACT) T allele carriers (T+) had lower CPEP (P = 0.022, -12.8%) and acute C-peptide responses (area above basal in first 30 min [CP30]) (P = 0.051, -12.4%) than noncarriers (T-). Also, in those with the cT/tC haplotype (from both IVS15-3c-->t and exon 18 Thr759[ACC-->ACT] polymorphisms), CPEP (P = 0.005, -21.2%), CP30 (P = 0.034, -19.2%), and total C-peptide responses (P = 0.016, -20.2%) were lower than that in cT- subjects. In overweight individuals (BMI >25 kg/m2), differences between carriers and noncarriers of the T or cT alleles were greater for GLU (P = 0.023-0.034), CPEP (P = 0.021-0.015), acute OGTT insulin response (P = 0.014-0.019), and CP30 (P = 0.034-0.019). These results suggest that the T and cT allele variants are associated with lower insulin secretion parameters, particularly in female and overweight subjects, adding evidence to the role of SUR1 sequence variants in decreased insulin secretion.

Age-related differences in messenger ribonucleic acid expression of key proteins involved in adipose cell differentiation and metabolism

This study was performed to compare the expression of key proteins [lipoprotein lipase (LPL), hormone-sensitive lipase (HSL), complement 3 (C3), and peroxisome proliferator-stimulated receptor-gamma (PPAR gamma)] involved in sc abdominal adipose tissue (AT) metabolism of young (n = 13) vs. middle-aged (n = 16) men. The sc abdominal AT-LPL activity as well as fat cell lipolysis were also measured in both groups of men. Young and middle-aged men displayed similar body weight and sc abdominal fat accumulation, measured by computed tomography. However, middle-aged men were characterized by a higher percent body fat (28 +/- 5% vs. 22 +/- 7%; P < 0.05) than young subjects. No difference between groups was observed in sc abdominal adipose tissue LPL activity. On the other hand, maximal lipolytic responses of sc abdominal adipocytes to isoproterenol (beta-adrenergic agonist) or to postadrenoceptor agents such as dibutyryl cAMP, forskolin, and theophylline were lower in middle-aged than in young men (P < 0.05). AT-LPL messenger ribonucleic acid (mRNA) levels were similar regardless of the subject's age. However, HSL, C3, and PPAR gamma mRNA levels were higher in middle-aged than in young individuals (P < 0.01-0.05). After correction for percent body fat, only HSL and C3 mRNA levels remained significantly different between groups (P < 0.05). Taken together, these results suggest that aging has an effect on the up-regulation of HSL and C3 mRNA levels, whereas PPAR gamma expression seems to be related mainly to increased adiposity.

Effects of insulin on regional blood flow and glucose uptake in Wistar and Sprague-Dawley rats

The euglycemic-hyperinsulinemic clamp technique in conscious Sprague-Dawley and Wistar rats chronically instrumented with intravascular catheters and pulsed Doppler flow probes was used to examine insulin's actions on regional blood flow and glucose metabolism. The effect of insulin on in vivo and in vitro glucose utilization in individual muscles was estimated using [3H]-2-deoxy-D-glucose. We found that in both strains, insulin (4, 32, and 64 mU x kg(-1) x min(-1)) causes similar cardiovascular changes characterized by slight increases in blood pressure (at high dose), vasodilation in renal and hindquarter vascular beds, and vasoconstriction (at high dose) in the superior mesenteric vascular bed. However, at the lowest dose of insulin tested, we found a smaller insulin sensitivity index and a lower insulin-stimulated in vivo glucose uptake in extensor digitorum longus (EDL) muscles of Wistar versus Sprague-Dawley rats. Higher insulin-stimulated glucose transport activity was found in isolated soleus muscle, while greater basal glucose transport was noted in isolated EDL muscle from Sprague-Dawley versus Wistar rats. These results provide further evidence for an insulin blood flow-regulatory effect and suggest that strain characteristics (differences in muscle perfusion, hindquarter composition, or fiber insulin sensitivity) constitute a major determinant in the variation in whole-body insulin sensitivity.

The mixed lineage kinase leucine-zipper protein kinase exhibits a differentiation-associated localization in normal human skin and induces keratinocyte differentiation upon overexpression

Leucine-zipper protein kinase/dual leucine zipper bearing kinase/mitogen-activated protein kinase-upstream kinase is a recently described protein serine/threonine kinase which belongs to the mixed lineage kinase family. The overall pattern of expression of the leucine-zipper protein kinase/dual leucine zipper bearing kinase/mitogen-activated protein kinase-upstream kinase gene in embryonic and adult mouse tissues suggested that this kinase could be involved in the regulation of epithelial cell proliferation and differentiation. In order to get more insights into the potential role of leucine-zipper protein kinase in these cellular processes, we characterized its expression in normal human skin, both at the mRNA and protein levels. In situ hybridization, western blotting, and indirect immunofluorescence studies were conducted to localize leucine-zipper protein kinase on various human skin tissues. This is one of the first reports that leucine-zipper protein kinase has a very precise pattern of expression in human skin epithelia, as both mRNA and protein are restricted to the granular layer of the epidermis and inner root sheath of hair follicles. Detection of leucine-zipper protein kinase protein on skin from various body sites, donors of different ages as well as on reconstructed human skin always reveals that leucine-zipper protein kinase is present only in the very differentiated keratinocytes of epidermis and hair follicles. To determine directly whether leucine-zipper protein kinase exhibits any effect on cell growth and differentiation, keratinocytes were transfected with an expression vector harboring the leucine-zipper protein kinase cDNA. The presence of this construct in keratinocytes results in growth arrest together with a concomitant increase in filaggrin expression. Collectively, our results indicate that leucine-zipper protein kinase plays an active part in cellular processes related to terminal differentiation of epidermal keratinocytes.

Contribution of visceral obesity to the deterioration of the metabolic risk profile in men with impaired glucose tolerance

AIMS/HYPOTHESIS

Impaired glucose tolerance is associated with metabolic alterations which increase cardiovascular disease risk. The contribution of hyperglycaemia to this increased risk is, however, not clear. Abdominal obesity is often observed in subjects with impaired glucose tolerance; our objective was therefore to find the contribution of visceral adipose tissue to the deterioration of the metabolic risk profile noted in subjects with impaired glucose tolerance.

METHODS

We studied 284 men with a normal glucose tolerance and 66 men with impaired glucose tolerance which was defined as a glycaemia between 7.8 and 11.1 mmol/l 2 h after a 75-g glucose load.

RESULTS

Men with impaired glucose tolerance had more visceral adipose tissue and higher concentrations of plasma glucose and insulin in the fasting state and following a 75-g oral glucose load than men with a normal glucose tolerance. They also had higher concentrations of plasma cholesterol, triglycerides, apolipoprotein B and lower concentrations of HDL-cholesterol as well as higher cholesterol:HDL-cholesterol ratios than men with a normal glucose tolerance. The two groups of men were then compared after a statistical adjustment for the amount of visceral adipose tissue. Although men with impaired glucose tolerance still had higher fasting plasma glucose and insulin concentrations after the adjustment for visceral adipose tissue, differences in all the variables of the lipid-lipoprotein profile were eliminated.

CONCLUSION/INTERPRETATION

Visceral adipose tissue accumulation is an important factor in the deterioration of the plasma lipid-lipoprotein noted in men with impaired glucose tolerance.

Impact of time interval from the last meal on glucose response to exercise in subjects with type 2 diabetes

We evaluate the influence of the time interval from the last meal on the blood glucose response to exercise in men with type 2 diabetes. Nineteen men with type 2 diabetes participated in an exercise training program carried out at 60% of maximal oxygen uptake (VO2peak) for 1 h, 3 times a week. Capillary whole blood glucose was measured immediately before and after each exercise session, and the time interval from the last meal (breakfast, lunch, or dinner) was recorded. Seven time intervals were considered (fasted overnight and 0-1, 1-2, 2-3, 3-4, 4-5, and 5-8 h postmeal). A total of 1,045 exercise sessions were analyzed. There was no change in blood glucose levels when individuals were in the fasted state (mean +/- SE, 8.1 +/- 0.2 vs. 8.1 +/- 0.1 mmol/L; before vs. after, respectively). However, blood glucose decreased by 28 +/- 1% at 0-1 h, by 33 +/- 1% at 1-2 h, by 35 +/- 1% at 2-3 h, by 38 +/- 2% at 3-4 h, by 43 +/- 2% at 4-5 h, and by 23 +/- 3% at 5-8 h (all P < 0.001). These results demonstrate that 1 h of ergocycle exercise has no clinical impact on blood glucose when performed in the fasted state in men with type 2 diabetes, whereas a significant decrease in blood glucose should be expected when the same exercise is performed postprandially.