Controversial Dietary Patterns: A High Yield Primer for Clinicians

In cardiology clinic visits, the discussion of optimal dietary patterns for prevention and management of cardiovascular disease is usually very limited. Herein, we explore the benefits and risks of various dietary patterns, including intermittent fasting, low carbohydrate, Paleolithic, whole food plant-based diet, and Mediterranean dietary patterns within the context of cardiovascular disease to empower clinicians with the evidence and information they need to maximally benefit their patients.

Trending Nutrition Controversies #3: Top Controversies in 2021

Each year, patients are bombarded with diverging and even contradictory reports concerning the impact of certain additives, foods, and nutrients on cardiovascular health and its risk factors. Accordingly, this third review of nutrition controversies examines the impact of artificial sweeteners, cacao, soy, plant-based meats, nitrates, and meats from grass compared to grain-fed animals on cardiovascular and other health outcomes with the goal of optimizing clinician-led diet counseling.

Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study

BACKGROUND AND OBJECTIVES

Nutrition is a foundation of health, yet there is a deficiency of nutrition training in graduate medical education. The purpose of this feasibility study was to assess the impact of a brief online clinical nutrition course on medical residents' knowledge and attitudes related to the role of nutrition in clinical practice.

METHODS

Medical residents from two institutions took a 3-hour, online, self-paced and interactive clinical nutrition course that reviewed macronutrients, evidence-based dietary patterns, a rapid nutrition assessment, and motivational interviewing. We administered surveys of nutrition knowledge and attitudes at three time points: (1) just prior to taking the online course, (2) immediately following, and (3) 3 months after course completion.

RESULTS

Seventy-six residents enrolled in the study and 47 (62%) completed the online course and postcourse surveys. For residents who completed the study, the summated nutrition knowledge scores assessed both immediately after taking the course and 3 months later showed significant improvement (P<.001). Three months after completing the course, residents were more likely to believe it was their role to personally provide detailed nutrition information to patients (P=.045) and to endorse the view that a healthy diet is important for self-care (P<.001). The estimated time residents spent counseling patients on nutrition did not change after the intervention.

CONCLUSION

This feasibility study demonstrated the potential of a 3-hour, online, self-paced nutrition course administered to medical residents to result in a significant and sustained increase in nutrition knowledge and positive attitudes about the role of nutrition in clinical practice.

Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association

Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

The Deficit of Nutrition Education of Physicians

Globally, death rates from cardiovascular disease are increasing, rising 41% between 1990 and 2013, and are often attributed, at least in part, to poor diet quality. With urbanization, economic development, and mass marketing, global dietary patterns have become more Westernized to include more sugar-sweetened beverages, highly processed foods, animal-based foods, and fewer fruits and vegetables, which has contributed to increasing cardiovascular disease globally. In this paper, we will examine the trends occurring globally in the realm of nutrition and cardiovascular disease prevention and also present new data that international nutrition knowledge amongst cardiovascular disease providers is limited. In turn, this lack of knowledge has resulted in less patient education and counseling, which is having profound effects on cardiovascular disease prevention efforts worldwide.

Trending Cardiovascular Nutrition Controversies

The potential cardiovascular benefits of several trending foods and dietary patterns are still incompletely understood, and nutritional science continues to evolve. However, in the meantime, a number of controversial dietary patterns, foods, and nutrients have received significant media exposure and are mired by hype. This review addresses some of the more popular foods and dietary patterns that are promoted for cardiovascular health to provide clinicians with accurate information for patient discussions in the clinical setting.

04. Experiential Integrative Approaches to Heart Health

Focus Areas: Integrative Approaches to Care, Experiential Workshop

This session will highlight two of the most important, yet frequently overlooked, determinants of heart health: mind-body interactions and nutrition. These areas will be explored through didactic and experiential learning.

The session will begin with a short presentation by Dr Adi Haramati on the physiology of stress and the scientific basis for mind-body approaches to de-stress, followed by an experiential autogenic exercise that will allow participants to track their own vascular response to a relaxation exercise (using skin thermistors).

Dr David Eisenberg will then provide a short presentation on national and global trends in the areas of nutrition, obesity, and diabetes and will discuss the relationship between health professionals’ personal self-care behaviors and the frequency with which they advise their patients about these same behaviors. A cooking demonstration will showcase simple techniques that healthcare professionals can use and share with their patients to convey the fact that healthy foods can also be easy to make, convenient, affordable, and “craveably” delicious.

Dr Stephen Devries will complete the presentation with a review of recent clinical studies highlighting the efficacy of nutrition and mind-body interventions on heart health. Practical recommendations for incorporating integrative strategies into heart care will be emphasized.

Loss of chromosome 16q in lobular carcinoma in situ

Lobular carcinoma in situ (LCIS) and infiltrating lobular carcinoma may represent different forms of the same disease based on their frequent clinical association and similar histologic features. Patients with LCIS are at increased risk of multicentric and bilateral disease. Thus, LCIS may represent both a precursor to infiltrating lobular carcinoma and a marker of risk for breast cancer. To identify genomic alterations in LCIS, comparative genomic hybridization was performed on 17 cases without concurrent invasive carcinoma. Loss involving chromosome 16q was present in 88% of cases and was the sole detected alteration in 29%. Gain involving 1q was second in frequency, occurring in 41% of tumors, and in all cases was associated with loss of 16q. Other recurrent changes were loss involving 17p (18%), 8p (12%), and 12q24 (12%). E-cadherin immunohistochemistry was performed on all LCIS cases to evaluate the correlation of loss involving 16q22, the site of the E-cadherin gene, and altered protein expression. Most cases with 16q22 loss showed altered E-cadherin expression (12 of 13). These results in LCIS are similar to changes reported in infiltrating lobular cancer, confirming a genetic relationship between them. HUM PATHOL 32:292-296.

Is the technically limited echocardiographic study an endangered species? endocardial border definition with native tissue harmonic imaging and Optison contrast: a review of 200 cases

OBJECTIVE

Our goal was to determine whether contrast adds diagnostic value to both fundamental and native tissue harmonic imaging (NTHI) for endocardial border definition.

METHODS

Two hundred consecutive patients who underwent stress echocardiography imaging were studied in either fundamental (n = 52) or NTHI mode (n = 148) with an Acuson Sequoia echocardiographic system. Contrast agent (Optison) was administered (0.5 to 1 mL) for enhancement of endocardial borders. Two- and 4-chamber views were analyzed before and after administration of contrast at peak stress for grading of 5 endocardial border segments. Scores from 0 to 5 were assigned to each study for all the images both before and after contrast (0 = 0 segments completely visualized; 5 = 5 segments completely visualized).

RESULTS

The use of Optison contrast significantly enhanced border definition when imaging was performed in either fundamental or NTHI mode. Addition of contrast resulted in better endocardial border definition in fundamental mode (4.1 + or - 1.0 versus 2.3 + or - 1.3, P <.001). However, in NTHI mode, the presence of contrast resulted in enhanced definition of endocardial border compared with its absence (4.8 + or - 0.5 versus 3.3 + or - 1.1, P <.001). The combination of NTHI and contrast resulted in more visualization of endocardium when compared with the combination of fundamental imaging and contrast (4.8 + or - 0.5 versus 4.1 + or - 1.0, P <.001). In addition, interobserver agreement for border detection increased from 83% in fundamental mode without contrast to 95% with the use of NTHI with Optison (P <.001).

CONCLUSION

As defined in 200 cases, the combination of NTHI with Optison contrast results in nearly complete and consistent endocardial border definition.

Reduced forward output states affect the left ventricular opacification of intravenously administered Albunex

Albunex is an Food and Drug Administration-approved ultrasound contrast agent used for the enhancement of left ventricular endocardial borders. To determine the efficacy of intravenously administered Albunex with regard to left ventricular opacification (LVO), a retrospective analysis of 117 patients who received 202 injections of Albunex for enhancement of endocardial borders was done (dose 0.08 to 0.22 ml /kg). Patients were routinely referred to our echocardiography laboratory for stress echocardiography for standard indications. Optimized settings for contrast enhancement (3.5 MHz transducer frequency and maximum dynamic range) were used. Four observers graded LVO on a scale from 0 to 3 (0 = no Albunex seen in the ventricular cavity; 3 = Albunex densely seen in the ventricular cavity). Overall, LVO was reported in 166 (82%) of 202 injections or in 91 (78%) of 117 patients. A significant reduction in LVO was noted in patients with mitral regurgitation, tricuspid regurgitation, atrial fibrillation, systolic dysfunction, or pulmonary hypertension (increased pulmonary artery systemic pressure). LVO was seen in 88% of the patients without these conditions. However, only 12 (44%) of 27 patients with one or more of the above conditions had LVO (p < 0.05). LVO can be achieved in the majority of patients after intravenously administered Albunex when imaged with optimal transducer settings. A subset of patients with systolic dysfunction, mitral regurgitation, tricuspid regurgitation, atrial fibrillation, or increased pulmonary artery systemic pressure has less effective LVO with Albunex. Heart disease associated with decreased forward flow appears to be associated with diminished LVO.

Optimizing albunex in the left ventricle: an analysis of the technical parameters of four ultrasound systems in canines and humans

Albunex, an intravascular ultrasound contrast agent, has been used clinically to enhance echocardiographic images. The purpose of this study if (1) to determine whether varying the settings on commercially available ultrasound machines has an effect on left ventricular opacification after intravenously administered Albunex and if there is an effect on left ventricular opacification and (2) to determine the ideal settings for each ultrasound scanner. Six canine hearts were imaged with 1 ml injections of intravenously administered Albunex while varying the transducer frequency, preprocessing curves, postprocessing curves, and dynamic range on a variety of ultrasound units. Subsequently 50 human subjects underwent imaging with the various machines while the dynamic range and transducer frequencies were altered. All subjects received two or three intravenous injections of 10 ml Albunex. The opacification of the left ventricular cavitary images in both parts of the study were interpreted visually on a scale of 0 to 4 (0 = none, 1 = trace, 2 = moderate, 3 = dense, and 4 = ideal) by four observers. The maximum compression and transducer frequency of 3.5 MHz showed significant improvement of left ventricular opacification in both canines and humans. These studies have shown that (1) varying the ultrasound unit's parameters affects the quality of left ventricular imaging when Albunex is used to enhance the image, and (2) higher compression and a transducer frequency of 3.5 MHz tend to enhance Albunex images of canine and human hearts.

Narrowing of the Hailey-Hailey disease gene region on chromosome 3q and identification of one kindred with a deletion in this region

Hailey-Hailey disease is a cutaneous abnormality transmitted as an autosomal dominant trait in which impaired interkeratinocyte adhesion produces recurrent blisters in characteristic skin sites. We report here a confirmation of the initial mapping of the mutant gene to chromosome 3q in an additional seven kindreds, narrowing of the candidate region to the sequences flanked by D3S1589 and D3S1541, and the finding in one family of a genomic DNA deletion whose centromeric end is located between these two flanking markers.

Influence of age and gender on the presence of coronary calcium detected by ultrafast computed tomography

OBJECTIVES

This study sought to determine the relation between coronary calcification detected with ultrafast computed tomography and lumen narrowing defined with angiography and evaluated whether this relation is influenced by age and gender.

BACKGROUND

Ultrafast computed tomography has been shown to be a sensitive method for detection of coronary calcification associated with atherosclerotic disease, but the relation between the extent of coronary calcification and degree of lumen narrowing and the possible influence of gender or age, or both, on this relation have not been clarified.

METHODS

Seventy men and 70 women were studied with ultrafast computed tomography for analysis of coronary calcification and coronary angiography. Coronary atherosclerosis was considered present if any lumen irregularity was noted on angiography, and obstructive coronary artery disease was defined as a lumen diameter narrowing > or = 70%.

RESULTS

Coronary calcification had a sensitivity of 88% for identification of patients with atherosclerotic disease and 97% for those with obstructive disease, with corresponding specificities of 55% and 41%, respectively. The sensitivity of coronary calcium for detection of atherosclerotic disease in women < 60 years old was 50%, significantly less than the 97% sensitivity in women > 60 years old and the 87% sensitivity in men < 60 years old (p < 0.05 for each comparison). Logistic regression analysis revealed a 1.81-fold increase in the likelihood of detecting coronary calcification in the atherosclerotic lesions of men compared with those in women (95% confidence interval 1.12 to 2.93, p = 0.016) when controlled for age and severity of coronary disease by angiography.

CONCLUSIONS

Atherosclerotic lesions in women are less likely to have coronary calcium than lesions with a similar degree of lumen narrowing in men. Differences in the pattern of coronary calcification between men and women may provide insight into the gender differences observed in the clinical development of symptomatic coronary artery disease.

The prevalence and significance of a patent foramen ovale in pulmonary hypertension

In order to determine the prevalence and significance of a patent foramen ovale (PFO) in pulmonary hypertension, 58 patients were studied with transesophageal echocardiography, right-sided heart catheterization, and exercise testing. In order to examine if a PFO might be associated with a better outcome, survival was estimated, based on a formula derived from the National Institutes of Health Primary Pulmonary Hypertension Registry, for the patients with primary pulmonary hypertension (PPH). A PFO was found in 26 percent (15 of 58) of all patients studied, 25 percent (10 of 40) of those with PPH, and 28 percent (5 of 18) of those with secondary pulmonary hypertension. We found no significant difference in any hemodynamic variable or exercise tolerance between the patients with and without a PFO, or for subsets of patients with primary and secondary pulmonary hypertension. We also found no significant difference in the 1-, 2-, 3-, 4-, or 5-year estimated survival, for the patients with PPH between those with and without a PFO. The prevalence of a PFO in pulmonary hypertension appears similar to the normal population. A PFO provides no detectable influence on resting hemodynamics or exercise tolerance in patients with pulmonary hypertension and is not clearly associated with patients expected to survive longer.

Invasive intracardiac aspergillosis with widespread embolization

Intracardiac extension of pulmonary aspergillosis is uncommon. We report a case of a patient with chronic necrotizing pulmonary aspergillosis without clinical evidence of cardiac disease in whom transthoracic echocardiography revealed an intracardiac mass. A subsequent transesophageal examination clearly defined a large and complex mass in the left atrium and pulmonary artery. Autopsy performed after cardiopulmonary arrest confirmed the presence of direct cardiac invasion of pulmonary aspergillosis with widespread embolization. This case illustrates the possibility of direct intracardiac extension of pulmonary aspergillosis and the value of transesophageal echocardiography in establishing the diagnosis.