Self-reported sleep quality and exercise in polycystic ovary syndrome: A secondary analysis of a pilot randomized controlled trial

OBJECTIVE

To examine the proportion of participants with poor sleep quality, evaluate the associations between sleep quality and anthropometric and cardiometabolic health markers, and evaluate the effect of high intensity interval training (HIIT) and continuous aerobic exercise training (CAET) on sleep quality in polycystic ovary syndrome (PCOS).

DESIGN

Secondary analysis of a pilot randomized controlled trial.

PATIENTS

Women with PCOS aged 18-40 years.

MEASUREMENTS

The Pittsburgh Sleep Quality Index (PSQI) was measured at baseline and following a 6-month exercise intervention. A PSQI score >5 indicates poor sleep. Linear regression was used to evaluate the associations between PSQI score and anthropometric and cardiometabolic health markers, and the effect of exercise training on these associations.

RESULTS

Thirty-four participants completed the PSQI at baseline, and 29 postintervention: no-exercise control (n = 9), HIIT (n = 12) and CAET (n = 8). At baseline, 79% had poor sleep quality. Baseline PSQI score was positively correlated with body mass index, waist circumference, body weight, haemoglobin A1c and insulin resistance. Mean PSQI score changes were -0.4 (SD 1.1), -0.7 (SD 0.6) and -0.5 (SD 0.9) for control, HIIT and CAET, respectively. For HIIT participants, change in PSQI score was associated with changes in body weight (B = .27, 95% CI 0.10-0.45) and waist circumference (B = .09, 95% CI 0.02-0.17).

CONCLUSION

Most participants had poor sleep quality which was associated with poorer anthropometric and cardiometabolic health markers. There were no statistically significant changes in PSQI score with exercise training. With HIIT training, decreases in the sleep efficiency score were associated with reductions in body weight and waist circumference. Further studies are needed to determine the effect of exercise training on sleep quality.

Prevalence of and risk factors for excess weight gain in pregnancy: a cross-sectional study using survey data

BACKGROUND

Maternal weight gain during pregnancy is required for fetal development; however, excess gestational weight gain is associated with increased maternal and neonatal morbidity. We aimed to determine the proportion of Canadian women who gained excess weight during pregnancy and to identify risk factors for excess gestational weight gain.

METHODS

Self-reported data on maternal weight gain were collected from the 2015/16 and 2017/18 cycles of the Canadian Community Health Survey (CCHS), a cross-sectional population-based survey. We included females aged 15 to 54 years with data on height, prepregnancy weight and gestational weight gain. We defined excess gestational weight gain in terms of preconception body mass index (BMI) according to the 2009 guideline of the US Institute of Medicine. We used logistic regression to evaluate potential risk factors for excess gestational weight gain.

RESULTS

Of 1 335 615 Canadian women (weighted from approximately 9300 survey respondents), 422 043 (32%) gained excess weight during pregnancy. Women with obesity had 33% lower odds of gaining excess weight relative to women with overweight (odds ratio 0.67, 95% confidence interval 0.48-0.94). Risk factors for excess gestational weight gain were lower education level, white or Indigenous identity, smoking, mood disorder, anxiety disorder and Canadian citizenship.

INTERPRETATION

One-third of Canadian women in this survey had excess gestational weight gain during pregnancy, and women with obesity had lower odds of gaining excess weight during pregnancy relative to women with overweight. Strategies are needed to reduce the proportion of Canadian women who gain excess weight during pregnancy, regardless of preconception BMI.

Exercise training and reproductive outcomes in women with polycystic ovary syndrome: A pilot randomized controlled trial

OBJECTIVE

Exercise is recommended for polycystic ovary syndrome (PCOS), but the most effective exercise prescription is unclear. This trial compared effects of high-intensity interval training (HIIT), continuous aerobic exercise training (CAET) and no-exercise control on reproductive, anthropometric and cardiometabolic outcomes in PCOS.

DESIGN

Pilot randomized controlled trial.

PARTICIPANTS

Previously inactive women aged 18-40 years with PCOS.

MEASUREMENTS

Feasibility outcomes included recruitment, retention, adherence to exercise and daily ovulation prediction kit (OPK) testing. Preliminary efficacy outcomes included reproductive, anthropometric and cardiometabolic health markers.

RESULTS

Forty-seven women were randomized to no-exercise control (n = 17), HIIT (n = 16), or CAET (n = 14). Forty (85%) participants completed the trial. Median exercise adherence was 68% (IQR 53%, 86%). Median daily OPK-testing adherence in the first half of the intervention was 87% (IQR 61%, 97%) compared with 65% (IQR 0%, 96%) in the second half. Body mass index decreased significantly in CAET compared with control (-1.0 kg/m² , p = .01) and HIIT (-0.9 kg/m² , p = .04). Mean waist circumference decreased in all groups (-7.3 cm, -6.9 cm, -4.5 cm in HIIT, CAET and control) with no significant between-group differences. Mean LDL-C was significantly reduced for HIIT compared to CAET (-0.33 mmol/L, p = .03). HDL-C increased in HIIT compared with control (0.18 mmol/L, p = .04).

CONCLUSIONS

There were feasibility challenges with adherence to daily ovulation assessment limiting the ability to analyse the effect of the exercise interventions on ovulation. CAET and HIIT were both effective at improving anthropometrics and some cardiometabolic health markers. Further studies need to determine optimal and acceptable exercise prescriptions for this population.

Systematic review and meta-analysis: SGLT2 inhibitors, blood pressure and cardiovascular outcomes

OBJECTIVE

Clinical trials suggest that SGLT2 inhibitors reduce the risk of cardiovascular mortality in patients with type 2 diabetes, however the mechanism is unclear. Our objective was to test the hypothesis that blood pressure reduction is one potential mechanism underlying the observed improvements in cardiovascular outcomes with SGLT2 inhibitors.

METHODS

We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (inception-June 2019) for randomized controlled trials that reported the effect of SGLT2 inhibitors compared with placebo on cardiovascular outcomes in adults with type 2 diabetes. Two reviewers independently extracted data and assessed study quality. Random effects meta-analyses, stratified meta-analyses and meta-regressions were conducted to evaluate the association between blood pressure reduction in SGLT2 inhibitor treated patients and cardiovascular outcomes.

RESULTS

Of 11,232 articles identified, 40 articles (n = 54,279 participants) were included. The relative risk of cardiovascular mortality was reduced by 18% with the use of SGLT2 inhibitors compared with placebo (RR 0.82; 95%CI 0.74, 0.91, I2 = 0.0%). Meta-regression analysis revealed no detectable difference in cardiovascular mortality (RR 0.93; 95%CI 0.88, 1.13, p = 0.483), 3-point major adverse cardiovascular events (p = 0.839) or congestive heart failure hospitalizations (p = 0.844) with change in mean systolic blood pressure.

CONCLUSIONS

Cardiovascular events are reduced in participants with type 2 diabetes treated with SGLT2 inhibitors compared with placebo. There was no significant relationship between the risk of developing adverse cardiovascular events and blood pressure reduction with SGLT2 inhibitors. There is insufficient evidence to suggest that blood pressure reduction is a significant contributor to the cardiovascular benefits observed.

Comparative Success of Recruitment Strategies for an Exercise Intervention Trial Among Women With Polycystic Ovary Syndrome: Observational Study

Background

Effective and efficient participant recruitment is a key determinant of the success of a research program. Previously reported recruitment strategies have displayed variable success rates in studies on women with polycystic ovary syndrome (PCOS).

Objective

This study aimed to evaluate the effectiveness and cost per participant of the recruitment strategies that we used in a prospective randomized controlled trial to examine the effects of exercise training among inactive women with PCOS, who are aged 18-40 years.

Methods

The 4 recruitment methods we used were as follows: (1) referral by health care providers or by word of mouth, (2) media (eg, local newspaper stories and radio interviews), (3) Facebook advertisements, and (4) unpaid advertisements including posters and websites. The proportions of potential, eligible, and enrolled participants recruited with each method were determined and compared using tests of proportion. The time investment and cost per participant enrolled were calculated for each recruitment strategy.

Results

Of 200 potential participants screened, 98 (49%) were recruited from unpaid advertisements (posters and websites), 70 (35%) from Facebook advertisements, 16 (8%) by referral, and 16 (8%) from traditional media (newspaper and radio). Every potential participant was recruited from separate means (ie, no participant was approached through more than one recruitment method). A total of 109 (54.5%) women were deemed eligible for participation in the trial, and 60 (30.0%) were enrolled. The proportion of potential participants who completed the trial was higher for those recruited from traditional media than from Facebook advertisements (n=7/16, 44% vs n=13/70, 19%, respectively; P=.03) or unpaid advertisements (n=7/16, 44% vs n=13/98, 13%, respectively; P=.002). The cost per participant was Can $18.21 (US $14.46) for Facebook advertisements and Can $43.88 (US $34.85) for unpaid advertisements. There were no direct trial costs for referrals or traditional media.

Conclusions

For this trial, each method was important for recruiting inactive women with PCOS because no participant reported learning about the trial through more than one method. Unpaid advertisements and Facebook advertisements helped recruit the largest number of participants in the trial, the former resulting in a higher cost per participant than the latter.

Trial Registration

ClinicalTrials.gov NCT03362918; https://clinicaltrials.gov/ct2/show/NCT03362918

Significant Dose-Response between Exercise Adherence and Hemoglobin A1c Change

INTRODUCTION

The Diabetes Aerobic and Resistance Exercise trial found that aerobic training and resistance training alone each reduced hemoglobin A1c (HbA1c) compared with nonexercising controls, and combined aerobic and resistance training caused greater HbA1c reduction than either training type alone. Our objective was to determine whether a dose-response relationship existed between frequency of exercise training and HbA1c change, and whether this varied by exercise modality or participant characteristics.

METHODS

Post hoc analysis of data from 185 Diabetes Aerobic and Resistance Exercise trial participants with type 2 diabetes randomized to aerobic, resistance or combined training thrice weekly. Dose-response relationships between adherence (percent of prescribed training sessions completed) and HbA1c change were assessed with linear regression.

RESULTS

Median overall adherence was 84.9% (interquartile range, 74.4%-93.6%). Higher exercise adherence was associated with greater HbA1c reduction; a 20% increase in adherence (e.g., an additional two sessions per month) was associated with a 0.15% (2 mmol·mol) decrease in HbA1c (β = -0.0076, R = -0.170, P = 0.021). Significant dose-response relationships were identified for aerobic (β = -0.0142, R = -0.313, P = 0.016) and combined training (β = -0.0109, R = -0.259, P = 0.041), but not resistance training (β = 0.0068, R = 0.153, P = 0.233). Dose-response relationships in all training groups combined were significant in subgroups younger than 55 yr (β = -0.0113, R = -0.286, P = 0.005), males (β = -0.0123, R = -0.234, P = 0.010), and baseline HbA1c ≥7.5% (58 mmol·mol) (β = -0.013, R = -0.263, P = 0.011).

CONCLUSIONS

There was a dose-response relationship between adherence to prescribed exercise and HbA1c reduction suggesting that glycemic control is improved more in individuals with type 2 diabetes with a higher training volume. Dose-response relationships existed for aerobic and combined training but not resistance training. These findings support aerobic and combined exercise prescriptions outlined in clinical practice guidelines.

Long-Term Physical Activity Levels After the End of a Structured Exercise Intervention in Adults With Type 2 Diabetes and Prediabetes: A Systematic Review

OBJECTIVES

Randomized, controlled trials have shown that exercise interventions reduce the incidence of type 2 diabetes in people with impaired glucose tolerance, and improve glycemic control, body composition and cardiorespiratory fitness in people with type 2 diabetes. We undertook the present systematic review to determine the extent to which participants in structured exercise trials continue to be physically active after the end of the interventions.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Central Register of Controlled Trials for randomized, controlled trials that reported objective or self-reported physical activity levels in people with type 2 diabetes or prediabetes a minimum of 3 months after the end of a structured exercise intervention. This systematic review was registered on PROSPERO (PROSPERO CRD42018089468).

RESULTS

Of 14,649 articles retrieved, 5 randomized, controlled trials (including 549 participants) were included in this systematic review. One study revealed significant improvements in self-reported physical activity levels in the intervention group compared with the control group 1, 3 and 5 years after baseline assessments, and decreased waist circumference, weight and body mass index at 1 year, but not 3 or 5 years. The 4 remaining studies did not find between-group differences at follow-up timepoints between 6 months and 3 years.

CONCLUSIONS

Future research should report physical activity levels at follow up to determine whether participation in a structured exercise intervention results in sustained increased physical activity levels. In addition, interventions should be evaluated for their effectiveness in improving adherence to long-term physical activity.

MON-042 The Effect of Exercise Training on Reproductive and Cardiometabolic Outcomes in Women with Polycystic Ovary Syndrome: A Pilot Randomized Controlled Trial

Exercise may improve cardiometabolic, reproductive and psychological outcomes in women with Polycystic Ovary Syndrome (PCOS). Clinical Practice Guidelines recommend exercise to treat PCOS, but the most effective exercise prescription is unclear. The aim of this randomized controlled trial was to evaluate the effects of six months of thrice weekly high-intensity interval training (HIIT) and continuous aerobic exercise training (CAET) programs compared with no exercise in previously-inactive women aged 18–40 years with PCOS. The primary outcome was change in ovulation rate. Ovulation was assessed with daily at home ovulation prediction kits, and confirmed with serum progesterone levels. Fisher’s exact test was used to compare groups. Secondary outcomes included change in BMI, waist circumference, blood pressure, A1C, fasting glucose, fasting insulin, and lipids and were analyzed using repeated measures mixed models. 47 women were randomly assigned to no exercise control (n=17), HIIT (n=16), or CAET (n=14). 22/33 (66.7%) women ovulated during the intervention period: no exercise: 8/12 (66.7%), HIIT: 8/11 (72.7%), and CAET: 6/10 (60%); NS between groups. BMI decreased significantly in the CAET group compared with control (-1 kg/m², p=0.01) and compared with HIIT (-0.9 kg/m², p=0.04). Mean waist circumference decreased significantly in all groups with no significant difference between groups. There were no significant within- or between- group changes for body weight. No within- or between group differences were identified for mean blood pressure, A1C, fasting glucose, fasting insulin, or triglycerides. Mean LDL-C was significantly different between the HIIT and CAET groups (-0.33 mmol/L, p=0.03), as LDL-C decreased in the HIIT group but not in the CAET group. HDL-C increased in the HIIT group compared with the no exercise group (0.18 mmol/L, p=0.04), with no significant difference between the CAET and no exercise groups (p=0.47). In conclusion, CAET and HIIT interventions in women with PCOS did not affect ovulation rates. CAET and HIIT both were effective at improving anthropometrics and some cardiometabolic health markers in women with PCOS. Further studies are needed to determine optimal exercise prescriptions for reproductive, anthropometric and cardiometabolic outcomes in women with PCOS.

Performance on a neurocognitive measure of alerting differentiates ADHD combined and inattentive subtypes: A preliminary report

The performance of 16 attention-deficit hyperactivity disorder (ADHD)/C, 26 ADHD/IA, and 24 control children was compared using a computer reaction time task designed to measure the effects of Posner's orienting, conflict and alerting attentional systems. No group differences in orienting or conflict were found. In contrast, children with ADHD/IA showed stronger alerting effects than those with ADHD/C, as indicated by relatively greater performance benefits following a warning cue. Although neither ADHD group differed significantly from controls on alerting, effect size comparisons indicated that children with ADHD/IA showed a somewhat larger (d=.57) and children with ADHD/C a somewhat smaller (d=.44) alerting effect relative to control children. The results are among the first to document unique patterns of attentional capacity for ADHD subtypes.

Five-Factor Personality Dimensions, Mood States, and Cognitive Performance in Older Adults

In this study we examined the impact of personality traits and negative mood state on performance in several cognitive domains in a sample of 398 elderly community-dwelling individuals. Multiple linear regression analyses were used to examine the variance in cognitive measures explained by state depression and anxiety after controlling for the effects of demographic characteristics and five-factor model personality traits. Personality traits were found to contribute significantly to cognitive function, explaining 2-7% of the variance in ability across domains. Examination of the contributions of individual five-factor traits showed that Openness had a significant relationship with all indexes of verbal memory and with general cognitive ability. State anxiety and depression variables were found to play a very small part, however, in contributing to cognitive function.

Role of executive functioning in verbal and visual memory

G. Tremont, S. Halpert, D. J. Javorsky, and R. A. Stern (2000) found that individuals with executive dysfunction were more impaired on less structured versus more structured verbal memory tasks. In the present study, the authors investigated the relationship between executive functions and memory in patients with a history of traumatic brain injury by examining the effect of executive functioning on more structured and less structured verbal and visual memory tasks at baseline and 1-year follow-up. Matched subgroups controlled for differences in severity of neuropsychological impairment unrelated to specific executive functions. The G. Tremont et al. (2000) findings were not replicated. Results showed that when acuteness and severity of injury were controlled, executive impairment played no significant role in performance on either more or less structured memory tasks. However, regardless of structure, executive functions played a role in visual memory performance, suggesting that visual memory may be a more fluid ability than verbal memory.

Parent-, teacher-, and self-rated motivational styles in ADHD subtypes

The motivational styles of 25 children with attention-deficit/hyperactivity disorder, combined type (ADHD/C), 13 children with ADHD, inattentive type (ADHD/IA), and 25 nondiagnosed controls (NC) were compared using parent, teacher, and self-ratings. Both ADHD subtypes demonstrated motivational impairment characterized by a preference for easy work, less enjoyment of learning, less persistence, and a greater reliance on external than on internal standards to judge their performance relative to NC. Some motivational style differences between ADHD subtypes were also revealed, with the ADHD/C group more motivated by competitiveness and a desire to be perceived as superior to others and the ADHD/IA group less uncooperative and possibly more passive in their learning styles. When IQ was statistically controlled, these results were generally unchanged. The contributing role of motivational deficits to the generally poor academic functioning of children with ADHD is discussed, along with potential intervention implications of the divergent motivational styles of different ADHD subtypes.

"Hot" unstable angina--is it worse than subacute unstable angina? Results from the GUARANTEE Registry

BACKGROUND AND METHODS

Because time to presentation to the hospital affects time to treatment and is known to be important in acute myocardial infarction, we evaluated this variable in patients with unstable angina/non-ST segment elevation myocardial infarction (UA/NSTEMI). Among 2909 consecutive patients with UA/NSTEMI admitted to 35 hospitals in 6 geographic regions of the United States, we compared patients with acute (onset of pain <12 hours before admission) and subacute (onset >12 hours) unstable angina.

RESULTS

Patients with "hot" (acute) unstable angina presented more often to the emergency department and were subsequently admitted more often to an intensive care unit. Hospital administration of medications did not differ between the two groups, with the exception of heparin, which was paradoxically used more often in subacute patients (p<0.001). All cardiac invasive procedures were undertaken less often in the acute patients (catheterization, 41.4% vs. 58.7%, p=0.001; percutaneous coronary intervention, 11.3% vs. 21.1%, p=0.001; coronary artery bypass grafting, 5.6% vs. 12.0%, p=0.001). A greater percentage of acute patients were found to have no significant coronary artery disease at cardiac catheterization (20.1% vs. 15.0%, p=0.006). Mortality did not differ between the two groups; however, the composite endpoint of death and MI favored the acute patients (1.3% vs. 2.2%, p=0.032).

CONCLUSIONS

Contrary to our initial hypothesis, "hot" UA patients tended to be at lower risk than patients with subacute presentation, highlighting the fact that patients with UA/NSTEMI remain at high risk even after the initial 12-hour period.

Clinical benefit of glycoprotein IIb/IIIa blockade with Abciximab is independent of gender: pooled analysis from EPIC, EPILOG and EPISTENT trials. Evaluation of 7E3 for the Prevention of Ischemic Complications. Evaluation in Percutaneous Transluminal Coronary Angioplasty to Improve Long-Term Outcome with Abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stent

OBJECTIVES

We sought to determine the efficacy and safety of platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) blockade with abciximab in women undergoing percutaneous coronary intervention.

BACKGROUND

Although gender differences in response to platelet glycoprotein IIb/IIIa receptor blockade have been described, there have been no large clinical studies to assess these differences.

METHODS

Outcomes were determined using meta-analysis technique.

RESULTS

In the pooled analysis, the primary end point of death, myocardial infarction (MI) or urgent revascularization within 30 days was reduced from 11.3% to 5.8% (p<0.001) in men and from 12.7% to 6.5% (p<0.001) in women treated with abciximab. At six months, death, MI or urgent revascularization was reduced from 14.1% to 8.3% (p<0.001) in men and 16.0% to 9.9% (p<0.001) in women receiving abciximab. At one year, mortality was reduced from 2.7% to 1.9% (p = 0.06) in men and 4.0% to 2.5% (p = 0.03) in women treated with abciximab. Major bleeding events occurred in 2.9% versus 3.0% (p = 0.96) of women and 2.7% versus 1.3% (p = 0.003) of men treated with placebo versus abciximab, respectively. Minor bleeding events occurred in 4.7% versus 6.7% (p = 0.01) of women and 2.3% versus 2.2% (p = 0.94) of men treated with placebo versus abciximab, respectively.

CONCLUSIONS

This pooled analysis demonstrated no gender difference in protection from major adverse outcomes with GP IIb/IIIa inhibition with abciximab. Although women had higher rates of both major and minor bleeding events with abciximab compared with men, major bleeding in women was similar with and without abciximab. There was a small increased risk of minor bleeding with abciximab in women.

Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibition in STENTing

BACKGROUND

Abciximab during percutaneous coronary revascularization reduces ischemic complications, but concern exists regarding increased bleeding risk should emergency coronary surgical procedures be required.

METHODS

Outcomes were assessed among 85 patients who required coronary artery bypass grafting operations after coronary intervention in two randomized placebo-controlled trials of abciximab. Comparisons were made between patients in the pooled placebo and abciximab groups.

RESULTS

The incidence of coronary surgical procedures was 2.17% and 1.28% among patients randomized to placebo and abciximab, respectively (p = 0.021). Platelet transfusions were administered to 32% and 52% of patients in the placebo and abciximab groups, respectively (p = 0.059). Rates of major blood loss were 79% and 88% in the placebo and abciximab groups, respectively (p = 0.27); transfusions of packed red blood cells or whole blood were administered in 74% and 80% of patients, respectively (p = 0.53). Surgical reexploration for bleeding was required in 3% and 12% of patients, respectively. Death and myocardial infarction tended to occur less frequently among patients who had received abciximab.

CONCLUSIONS

Urgent coronary artery bypass grafting operations can be performed without an incremental increase in major hemorrhagic risk among patients on abciximab therapy.

Optimizing the percutaneous interventional outcomes for patients with diabetes mellitus: results of the EPISTENT (Evaluation of platelet IIb/IIIa inhibitor for stenting trial) diabetic substudy

BACKGROUND

Stenting likely decreases the need for target-vessel revascularization procedures in diabetic patients compared with balloon angioplasty. However, the efficacy of stenting with platelet glycoprotein IIb/IIIa blockade has not yet been assessed in diabetics.

METHODS AND RESULTS

We analyzed the outcomes of 491 diabetic patients within the multicenter Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial (EPISTENT). Diabetic patients were a prospectively defined subset: 173 were randomized to stent-placebo, 162 to stent-abciximab, and 156 to balloon angioplasty-abciximab. The main end point for this analysis was combined 6-month death, myocardial infarction (MI), or target-vessel revascularization (TVR). The composite end point occurred in 25.2% of stent-placebo, 23.4% of balloon-abciximab, and 13.0% of stent-abciximab patients (P=0.005). Abciximab therapy, irrespective of revascularization strategy (stent or balloon angioplasty), resulted in a significant reduction in the 6-month death or MI rate: 12.7% for stent-placebo, 7.8% for balloon angioplasty-abciximab, and 6.2% for the stent-abciximab group (P=0.029). The 6-month TVR rate was 16.6% for stent-placebo, 18.4% for balloon-abciximab, and 8.1% for stent-abciximab (P=0.021). Compared with stent-placebo, stent-abciximab therapy was associated with a significant increase in angiographic net gain (0.88 versus 0.55 mm; P=0.011) and a decrease in the late loss index (0.40 versus 0.60 mm; P=0.061). The 1-year mortality rate for diabetics was 4.1% for stent-placebo and 1. 2% for stent-abciximab patients (P=0.11).

CONCLUSIONS

The combination of stenting and abciximab therapy among diabetics resulted in a significant reduction in 6-month rates of death, MI, and TVR compared with stent-placebo or balloon-abciximab therapy.

Racial differences in the management of unstable angina: results from the multicenter GUARANTEE registry

BACKGROUND

Prior studies, usually conducted with the use of insurance databases, have shown differences in the use of cardiac procedures between black patients and white patients hospitalized with various types of coronary artery disease. However, few data are available in prospectively collected cohorts of patients with unstable angina or on the use of appropriate medications or interventions.

METHODS AND RESULTS

We evaluated 2948 consecutive patients with unstable angina admitted to 35 hospitals across the United States in 1996, comparing nonwhite and white patients. Seventy-seven percent of patients were white, 14% were black, 4% were Hispanic, 1% were Asian, and 3% were other or unknown race. Differences were seen in coronary risk profile, with a higher incidence of hypertension and diabetes mellitus in nonwhites. Cardiac catheterization was performed less often in nonwhites compared with whites (36% vs 53%, P =.001). Even in patients meeting the criteria for appropriate catheterization in the Agency for Health Care Policy Research unstable angina guidelines, fewer nonwhites underwent catheterization (44% vs 61%, P =.001), but among these, fewer nonwhites had significant coronary stenosis (72% vs 90%, P =.001). However, among patients catheterized who had indications for revascularization, angioplasty and coronary artery bypass grafting were performed equally often in nonwhites and whites.

CONCLUSIONS

Current guidelines would recommend more aggressive use of cardiac catheterization for nonwhite patients. However, our findings suggest that racial differences may need to be included in the diagnostic and interventional algorithms.

Differences between men and women in the management of unstable angina pectoris (The GUARANTEE Registry). The GUARANTEE Investigators

Few data are available in prospectively collected cohorts of patients with unstable angina pectoris or on the use of appropriate medications or interventions. Accordingly, we evaluated 2,948 consecutive patients with unstable angina admitted to 35 hospitals in the United States in 1996, and comparing men and women (39% of the patients were women). Differences were seen in coronary risk profiles with a higher incidence of systemic hypertension, diabetes mellitus, and a family history of coronary disease in women. Women were less likely to receive Agency for Health Care Policy Research (AHCPR) recommended pharmacologic treatment than men. Cardiac catheterization, coronary angioplasty, and bypass was performed less often in women compared with men (44% vs. 53%, p = 0.002; 12% vs. 18%, p = 0.02; 7% vs. 10%, p = 0.001, respectively). At catheterization, women were more likely to have no significant coronary artery disease (25% vs. 14%, p = 0.001). Although fewer women than men fulfilled the AHCPR criteria for cardiac catheterization (54% vs. 64%, p = 0.001), a similar rate of men and women with positive criteria underwent catheterization and angioplasty. However, fewer women with positive criteria underwent bypass surgery (36% vs. 46%, p = 0.03). More men "ruled-in" for a myocardial infarction at admission (13% vs. 8%, p = 0.001), but there was no difference in recurrent angina, in-hospital myocardial infarction, or death. Despite different epidemiologic profiles and less evidence of coronary artery disease by noninvasive and invasive tests, women and men had similar outcomes.

Complementary clinical benefits of coronary-artery stenting and blockade of platelet glycoprotein IIb/IIIa receptors. Evaluation of Platelet IIb/IIIa Inhibition in Stenting Investigators

BACKGROUND

Inhibition of the platelet glycoprotein IIb/IIIa receptor with the monoclonal-antibody fragment abciximab reduces the acute ischemic complications associated with percutaneous coronary revascularization, whereas coronary-stent implantation reduces restenosis. We conducted a trial to determine the efficacy of abciximab and stent implantation in improving long-term outcome.

METHODS

A total of 2399 patients were randomly assigned to stent implantation and placebo, stent implantation and abciximab, or balloon angioplasty and abciximab. The patients were followed for six months.

RESULTS

At six months, the incidence of the composite end point of death or myocardial infarction was 11.4 percent in the group that received a stent and placebo, as compared with 5.6 percent in the group that received a stent and abciximab (hazard ratio, 0.47; 95 percent confidence interval, 0.33 to 0.68; P<0.001) and 7.8 percent in the group assigned to balloon angioplasty and abciximab (hazard ratio, 0.67; 95 percent confidence interval, 0.49 to 0.92; P=0.01). The hazard ratio for stenting plus abciximab as compared with angioplasty plus abciximab was 0.70 (95 percent confidence interval, 0.48 to 1.04; P=0.07). The rate of repeated revascularization of the target vessel was 10.6 percent in the stent-plus-placebo group, as compared with 8.7 percent in the stent-plus-abciximab group (hazard ratio, 0.82; 95 percent confidence interval, 0.59 to 1.13; P=0.22) and 15.4 percent in the angioplasty-plus-abciximab group (hazard ratio, 1.49; 95 percent confidence interval, 1.13 to 1.97; P=0.005). The hazard ratio for stenting plus abciximab as compared with angioplasty plus abciximab was 0.55 (95 percent confidence interval, 0.41 to 0.74; P<0.001). Among patients with diabetes, the combination of abciximab and stenting was associated with a lower rate of repeated target-vessel revascularization (8.1 percent) than was stenting and placebo (16.6 percent, P=0.02) or angioplasty and abciximab (18.4 percent, P=0.008).

CONCLUSIONS

For coronary revascularization, abciximab and stent implantation confer complementary long-term clinical benefits.

Sustained suppression of ischemic complications of coronary intervention by platelet GP IIb/IIIa blockade with abciximab: one-year outcome in the EPILOG trial. Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade

BACKGROUND

Blockade of the platelet glycoprotein IIb/IIIa receptor with the monoclonal antibody fragment abciximab was shown in a placebo-controlled randomized trial to reduce the incidence of acute ischemic complications within 30 days among a broad spectrum of patients undergoing percutaneous coronary revascularization. The durability of clinical benefit in this setting has not been established.

METHODS AND RESULTS

A total of 2792 patients enrolled in the Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade (EPILOG) trial were followed with maintenance of double-blinding for 1 year. Patients had been assigned at the time of their index coronary interventional procedure to receive placebo with standard-dose, weight-adjusted heparin (100 U/kg initial bolus), abciximab with standard-dose, weight-adjusted heparin, or abciximab with low-dose, weight-adjusted heparin (70 U/kg initial bolus). The primary outcome was the composite of death, myocardial infarction, or urgent repeat revascularization by 30 days; this composite end point and its individual components were also assessed at 6 months and 1 year. Rates of any repeat revascularization (urgent or elective), target vessel revascularization, and a composite of death, myocardial infarction, or any repeat revascularization were also reported. Follow-up at 1 year was 99% complete for survival status and 97% complete for other end points. By 1 year, the incidence of the primary composite end point was 16.1% in the placebo group, 9.6% in the abciximab with low-dose heparin group (P<0.001), and 9.5% in the abciximab with standard-dose heparin group (P<0.001). Each of the components of this composite end point was reduced to a similar extent. Nonurgent or target vessel repeat revascularization rates were not significantly decreased by abciximab therapy. Mortality rates over 1 year increased with increasing levels of periprocedural creatine kinase MB fraction elevation.

CONCLUSIONS

Acute reductions in ischemic events after percutaneous coronary intervention by abciximab are sustained over follow-up to at least 1 year. Early periprocedural myocardial infarctions suppressed by this therapy are associated with long-term mortality rates.

Percutaneous cardiopulmonary bypass support: a new approach to high-risk angioplasty

Percutaneous cardiopulmonary bypass is a new technique for supporting systemic blood flow during high-risk coronary angioplasty procedures. This mechanical alternative, unlike traditional methods, is not limited by dependency on adequate left ventricular stroke volume. Percutaneous cardiopulmonary bypass support offers new and demanding challenges in the care of this high-risk group of patients.

Characterization of the covalent mercury (II)-NADPH complex

Mercury (II) forms a covalent, 1:1 complex with NADPH which is indicated by the disappearance of the chromophore at 340 nm. With the use of NMNH as an analogue, the spectral changes were attributed to the reaction of Hg(II) with the nicotinamide ring. This reaction is reversed by the addition of sulfhydryl groups or other metal-chelating agents. The structure of the Hg(II) . NADPH complex was determined with 1H and 13C NMR spectroscopy and homonuclear decoupling and was shown to have Hg covalently attached to C-5 of the nicotinamide ring. From these results, we propose that Hg(II) reacts with the double bond between C-5 and C-6 to form a mercuronium ion which is opened by the nucleophilic attack of water on C-6. Two conformations of the Hg(II) . NADPH complex were detected, corresponding to the formation of the mercuronium ion on either the a or b side of the nicotinamide ring. Fluorescence quenching studies with the Hg(II) . NADPH complex and the flavoenzyme mercuric reductase showed that the complex could effectively bind (Kd = 2.3 microM), but could not reduce the enzyme.

Effects of the aromatization inhibitor androst-4-ene-3,6,17-trione on sexual differentiation induced by testosterone in the neonatally castrated rat

Groups of rats were castrated on the day of birth (day 1) and injected with testosterone, androst-4-ene-3,6,17-trione (ADT, an inhibitor of aromatization), testosterone + ADT or oil daily from day 1 to day 5. The aromatizable androgen testosterone suppressed both cyclic gonadotrophin secretion, as judged from the absence of corpora lutea in grafted ovaries, and the behavioural response to injections of oestradiol benzoate and progesterone in adulthood. It also stimulated normal development of the penis and ejaculation in behaviour tests carried out after injections of testosterone propionate. The aromatization inhibitor ADT, like oil, did not affect either cyclic gonadotrophin secretion or receptive behaviour, but injections of ADT given at the same time as testosterone significantly reduced the effects of the androgen on both cyclic gonadotrophin secretion and receptive behaviour. Although neonatal administration of ADT did not affect the testosterone-stimulated development of the penis or the ability of the rats to achieve penile intromissions, it did interfere with ejaculation. None of the rats which had been injected with testosterone+ADT ejaculated. These results support the concept that during infancy neural conversion of androgens to oestrogens is important both for the suppression of the female patterns of gonadotrophin secretion and sexual behaviour and for the central organization of normal patterns of male sexual behaviour. Normal completion of the differentiation of the male genital tract appears to be independent of the central organization of masculine patterns of sexual behaviour.

Sexual behaviour of male rats injected with the anti-oestrogen MER-25 during infancy

Newborn male rats were injected SC with 50, 100 or 200 micrograms MER-25 or 0.05 ml oil daily for the first 10 days of life. As adults, they were tested for male sexual behaviour both before and after castration and replacement with testosterone propionate, and for female sexual behaviour after injections of oestradiol benzoate followed by progesterone. Injections of 100 and 200 micrograms MER-25/day during infancy caused significantly fewer rats to ejaculate than 0.05 ml oil/day in both series of tests for male sexual behaviour. The reduced occurrence of ejaculation could not be related to defective penile development as there was no significant difference in penis weights or the numbers of penile spines between the MER-25 and oil-injected rats. All doses of MER-25 caused significantly more lordosis behaviour after oestrogen and progesterone than did injections of oil. These results provide further evidence that neonatal testicular androgens must be converted to oestrogen in the brain in order to organise male sexual behaviour patterns, including the neural substrate for ejaculation, as well as to suppress female sexual behaviour.

Sexual behaviour of neonatally castrated rats injected during infancy with oestrogen and dihydrotestosterone

Male rats were castrated on the day of birth (day 1) and injected with either testosterone, dihydrotestosterone, a synthetic oestrogen (RU 2858 + dihydrotestosterone, or oil from days 1 to 5. The aromatizable androgen, testosterone, and RU 2858 suppressed both cyclic gonadotrophin secretion, indicated by the absence of corpora lutea from implanted ovarian grafts, and the behavioural response to oestradiol benzoate + progesterone injections in adulthood. The 5alpha-reduced androgen, dihydrotestosterone alone did not affect gonadotrophin secretion or female receptive behaviour, but like testosterone, it increased penis development in response to testosterone propionate, and this was positively correlated with copulatory efficiency, i.e. the ratio of intromission to mount frequencies. Nevertheless, ejaculation only occurred among animals that had received testosterone or RU 2858 + dihydrotestosterone. The results support the concept that during the preinatal period, neural conversion of androgens to oestrogens is important both for the suppression of female gonadotrophin secretion and behaviour patterns as well as for the organization of male behaviour patterns. The 5alpha-reduction of unsaturated C19-steriods to dihydrotestosterone in peripheral tissues is also required to complete the development of the male genital tract.

Effects of oestradiol-17beta, oestradiol benzoate and the synthetic oestrogen RU 2858 on sexual differentiation in the neonatal female rat

Groups of neonatal female rats were treated for the first 5 days of life with oestradiol-17beta, oestradiol benzoate or a synthetic oestrogen, 11beta-methoxy-17-ethynyl-1,3,5(10)-oestratriene-3,17beta-diol (RU 2858), in daily doses ranging from 0-5 to 1000 ng. Oestradiol-17beta had no effect on adult ovarian cyclicity or sexual receptivity after ovariectomy and oestrogen+ progesterone treatment. Ovarian cyclicity was prevented by 100 ng or more oestradiol benzoate/day, and by all doses of RU 2858. Only rats receiving 50 ng oestradiol benzoate/day or 0-5 ng RU 2858/day showed normal receptivity. The defeminizing action of RU 2858 was at least 100 times greater than that of oestradiol benzoate; it is suggested that this greater potency is due to the low affinity of RU 2858 for the oestradiol-binding protein in the plasma of neonatal rats. These results indicate that defeminization of the neonatal rat brain can be induced by physiological amounts of oestrogen, and are discussed with reference to the action of testosterone.

Stimulation of the hypothalamus and ovulation in the guinea-pig

1. Various methods of stimulating the hypothalamus were applied to the guinea-pig with the aim of inducing ovulation.2. Electrochemical stimulation of the hypothalamus, or gross stimulation of the brain, was ineffective.3. Electrical stimulation of the medial basal hypothalamus or rostral hypothalamus elicited gonadotrophin release.4. Despite variation of the time and intensity of stimulation, follicular luteinization was more common than the formation of new corpora lutea.5. Electrical stimulation of the medial basal hypothalamus often caused luteinization of follicles. Fewer animals responded to excitation of the rostral hypothalamus, but in those that did, ovulation occurred more frequently.6. The present observations contrast markedly with comparable studies on the rat, where both electrochemical and electrical stimulation of the hypothalamus readily induce ovulation.

Implantation of oestrogen in the brain and the induction of ovulation in the guinea-pig

In the guinea-pig, when bilateral oestrogen implants were placed in the medial basal hypothalamus, anterior hypothalamus or suprachiasmatic area on day 10 of the oestrous cycle, ovarian changes indicative of gonadotrophin secretion were observed on day 15. Similarly located cholesterol implants and oestrogen implants outside this region were without effect. The gonadotrophin release was likely to have been induced by an action of the steroid at the hypothalamic, rather than the pituitary level, since bilateral implants of oestrogen in the pars distalis caused ovarian activation in only one out of eight animals. Signs of normal ovulation were evident in only three out of 19 animals in which oestrogen was implanted in the medial basal hypothalamus on day 10 and left in place for 10 days. The ovaries of some other animals bore the traces of luteal bodies formed in response to the initial exposure to oestrogen; other ovaries contained only large healthy or atretic follicles and spontaneous ovulation was apparently blocked. It is concluded that exposure of the hypothalamo-hypophysial system of the guinea-pig to an increased amount of oestrogen initially stimulates and then inhibits ovulatory gonadotrophin secretion. Tonic gonadotrophin secretion is unaffected.