Neuropathy Screening for Patients with Peripheral Vascular Disease Helps to Identify Those at an Increased Risk of Amputation, Revascularization, and Death

BACKGROUND

Peripheral neuropathy is associated with amputation risk among patients with diabetes mellitus and chronic limb-threatening ischemia (CLTI). Detection of peripheral neuropathy may help identify those who are at an increased risk, but the predictive ability of the screening tool used in patients with peripheral arterial disease (PAD) needs to be more clearly defined.

METHODS

Patients referred to vascular surgery clinic for PAD were recruited from a single center. Exclusion criteria were a documented history of neuropathy or prior lower limb amputation. Screening utilized the Michigan Neuropathy Screening Instrument (MNSI). Scores >2.5 were considered abnormal and scores >4 were considered positive for peripheral neuropathy. Limb-specific outcomes of amputation and revascularization as well as a composite outcome including death were modeled using time to event analysis.

RESULTS

86 patients were recruited. Mean age was 67 ± 10.2 years, 30% were women, 24% were black. Mean ankle-brachial index was 0.74 ± 0.3. PAD symptoms at initial evaluation were claudication in 52% of patients and CLTI in 38% of patients. Neuropathy was present in 20% of the cohort with a significantly higher proportion in diabetics (34% vs. 3%; P = 0.0009). Neuropathy was more common in patients with CLTI compared to claudicants (36% vs. 9%; P = 0.011). Forty patients (47%) reached the composite outcome of amputation, revascularization, or death with a median time to event of 16 months. Abnormal MNSI examination was significantly associated with the increased risk of the composite outcome (hazard ratio = 3.19; P 0.0005).

CONCLUSIONS

A significant proportion of patients presenting to vascular specialists for PAD have undiagnosed neuropathy. Patients with PAD and neuropathy have an increased risk of amputation, revascularization, and death. Expanding neuropathy screening in vascular surgery clinic visits may help to identify patients at higher risk.

A meta-analysis of the performance of ultrasound, hepatobiliary scintigraphy, CT and MRI in the diagnosis of acute cholecystitis

PURPOSE

To evaluate the recently reported relative diagnostic accuracy of US, CT, MRI, and cholescintigraphy for diagnosing acute cholecystitis.

METHODS

2 radiologists independently performed systematic electronic searches for articles published between 2000 and 2021 and applied inclusion/exclusion criteria. 2 different radiologists extracted data from the articles and scored each with a methodological quality tool. Pooled estimates of sensitivity and specificity were calculated with a bivariate linear mixed model. A second analysis made head-to-head comparisons (US vs. CT, US vs. cholescintigraphy). Factors were also analyzed for potential confounding effects on diagnostic accuracy.

RESULTS

Of 6121 initial titles, 22 were included. The prevalence of cholecystitis varied widely across studies (9.4-98%). Pooled sensitivity and specificity estimates were 69% (confidence limit [CL] 62-76%) and 79% (CL 71-86%) for US, 91% (CL 86-94%) and 63% (CL 51-74%) for cholescintigraphy, 78% (CL 69-84%) and 81% (CL 71-88%) for CT, and 91% (CL 78-97%) and 93% (CL 70-99%) for MRI. Regarding head-to-head comparisons, the sensitivity of CT (87.6%, CL 70-96%) was significantly higher than US (66.8%, CL 43-84%), while specificities (81.7% with CL 54-95% for US, 91.9% with CL 67-99% for CT) were similar. The sensitivity of cholescintigraphy (87.4%, CL 76-94%) was significantly greater than US (61.6%, CL 44-77%), while the specificity of US (82%, CL 65-92%) was significantly higher than cholescintigraphy (68%, CL 47-84%).

CONCLUSION

Recent data suggests that CT may have a higher sensitivity than US for diagnosing acute cholecystitis, with similar specificity. Cholescintigraphy remains a highly sensitive modality with lower specificity than previously reported. MRI remains under studied, but with promising results.

Contemporary outcomes for branch renal artery repair

BACKGROUND

The purpose of this study was to provide an updated description of demographics, technical details, and clinical outcomes of 101 consecutive branch renal artery repairs in 98 patients using cold perfusion.

METHODS

A single-institution, retrospective analysis branch renal artery reconstructions was performed between 1987 and 2019.

RESULTS

Patients were predominantly Caucasian (80.6%) women (74.5%) with a mean age of 46.8 ± 15.3 years. The mean preoperative systolic and diastolic blood pressures were 170.4 ± 33.0 mm Hg and 99.2 ± 19.9 mm Hg, respectively, requiring a mean of 1.6 ± 1.1 antihypertensive medications. The estimated glomerular filtration rate was 84.0 ± 25.3 mL/min. Most patients (90.2%) were not diabetic and never smokers (68%). Treated pathology included aneurysm (87.4%) and stenosis (23.3%) with histology demonstrating fibromuscular dysplasia (44.4%), dissection (5.1%), and degenerative not otherwise specified (50.5%). The right renal arteries were most frequently treated (44.2%), with a mean of 3.1 ± 1.5 branches involved. Reconstruction was accomplished using bypass in 90.3% of cases using aortic inflow in 92.7% and a saphenous vein conduit in 92%. Branch vessels served as outflow in 96.9% and syndactylization of branches was used to decrease the number of distal anastomoses in 45.3% of repairs. The mean number of distal anastomoses was 1.5 ± 0.9. Postoperatively, the mean systolic blood pressure improved to 137.9 ± 20.8 mm Hg (mean decrease of 30.5 ± 32.8 mm Hg; P < .0001) and the mean diastolic blood pressure improved to 78.4 ± 12.7 mm Hg (mean decrease of 20.1 ± 20.7 mm Hg; P < .0001) with patients requiring a mean of 1.4 ± 1.0 antihypertensive medications (mean decrease of 0.2 ±1.0 medications; P = .048). The postoperative estimated glomerular filtration rate was 89.1 mL/min (mean increase of 4.1 mL/min; P = .08). The mean length of stay was 9.0 ± 5.8 days and 96.1% of patients were discharged home. The mortality rate was 1% (one patient with liver failure) and the major morbidity rate was 15%. There were five infectious complications (pneumonia, Clostridium difficile, and wound infection) and five patients required return to the operating room (one for nephrectomy, one for bleeding, two for thrombosis, and one for second trimester pregnancy loss requiring dilation and curettage and splenectomy). One patient required temporary dialysis owing to graft thrombosis. Two patients developed arrhythmias. No patients suffered a myocardial infarction, stroke, or limb loss. After 30 days, follow-up data were available for 82 bypasses. At this time, three reconstructions were no longer patent. Intervention was required to retain patency for five bypasses. After 1 year, patency data were available for 61 bypasses and five were no longer patent. Of the five grafts with loss of patency, two underwent intervention in attempt to maintain patency, which subsequently failed.

CONCLUSIONS

Repair of renal artery pathology involving the branches can be performed with short- and long-term technical success and significant prospect of decreasing an elevated blood pressure. The operations required to fully address the presenting pathology are often quite complex involving multiple distal anastomoses and consolidation of small secondary branches. The procedure carries a small but significant risk of major morbidity and mortality.

Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology

BACKGROUND

Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space.

METHODS

Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care.

RESULTS

Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption.

CONCLUSIONS

Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

Prospective longitudinal characterisation of the relationship between diabetes and cardiac remodeling

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship and Wellcome Trust

Background

Cardiovascular disease represents the primary cause of death in patients with type 2 diabetes (T2D). Heart failure (HF) is the commonest initial presentation of cardiovascular disease in T2D. Development of HF in patients with T2D is associated with a 4 to 6-fold increase in mortality, making the prevention of cardiac dysfunction an important goal. The long-term impact of T2D on cardiac function in the absence of cardiovascular disease is unknown. This is the first prospective longitudinal study utilising cardiovascular magnetic resonance (CMR) to evaluate the impact of T2D on cardiac remodeling.

Objectives

To determine longitudinal changes in the phenotypic expression of heart disease in diabetes over 6 years, and examine the association of baseline blood and imaging biomarkers with remodeling over time in patients who remained free of cardiovascular/clinical events, and to report clinical outcomes in the entire cohort.

Methods

100 asymptomatic T2D patients with no history of cardiovascular disease or hypertension were previously studied. Biventricular volumes, function, and myocardial strain were assessed by CMR and blood biomarkers taken. 6-year follow-up CMR was repeated in those without interim cardiovascular events.

Results

Of the 100 patients, 78 could be contacted for follow-up. 29 participants experienced cardiovascular/clinical events over 6 years. 32 patients who were asymptomatic and without events received follow-up CMR. The major adverse cardiovascular event rate (MI, angina, revascularisation, stroke, death) during the 6-year follow-up period, including the patients with a silent MI, amounted to 25% in this study with an overall clinical event rate of 35%.

 There were no significant changes in BP, BMI or HBA1c between baseline and follow-up (Table 1). Left ventricular end-diastolic-volume(p = 0.005), mass (p = 0.01), ejection fraction (p = 0.0001), and right ventricular end-diastolic-volume(p = 0.03) and ejection fraction(p = 0.003) reduced over time (Figure 2 and Table 1). Baseline plasma high-sensitivity cardiac-troponin-T (hs-cTnT) (R=-0.44; p = 0.01) was significantly associated with change in left ventricular ejection fraction over time.

Conclusions

Even in the absence of overt clinical CAD, significant valvular disease, uncontrolled hypertension or change in BMI, T2D results in significant reductions in cardiac size and biventricular systolic function over time. The major adverse cardiovascular event rate (MI, angina, revascularisation, stroke, death) during the 6-year follow-up period was high in diabetes patients (25%). Plasma biomarker hs-cTnT measured at baseline was associated with change in LV systolic function over the 6-year follow-up period. hs-cTnT could potentially have a significant utility as a risk-predicting tool for cardiac dysfunction in T2D patients.

Longitudinal change in left ventricular 4D flow kinetic energy after myocardial infarction

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation HRUK

Background. Four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR) imaging provides quantification of intra-cavity left ventricular (LV) flow kinetic energy (KE) parameters in three dimensions. Myocardial infarction (MI) is known to cause acute alterations in intra-cardiac blood flow but assessments of longitudinal changes are lacking.

Purpose. Assess longitudinal changes in LV flow post ST-elevation myocardial infarction (STEMI).

Method. Twenty acutely reperfused STEMI patients (13 men, 7 women, mean age 54 ± 9 years) underwent 3T CMR acutely (within 5-7 days) and 3 months post-MI.  CMR protocol included functional imaging, late gadolinium enhancement and 4D flow. Using Q-MASS, LV KE parameters were derived and indexed to LV end-diastolic volume (LVKEiEDV). Based on acute ejection fraction (EF), patients were grouped as follows: preserved (pEF) EF &gt;50%, reduced (rEF) EF &lt;50% including mild (rEF= 40-49%), moderate to severe (EF &lt;40%) impairment. 

Results. Out of 20 patients, 13 had rEF acutely (7 mild rEF, 6 moderate to severe rEF). Acute LVKEiEDV parameters varied significantly between pEF and rEF (Table). At 3 months, pEF and mild rEF patients showed a significant (P &lt; 0.05) reduction in average, systolic and peak-A wave LVKEiEDV. Mild rEF patients also had significant (P &lt; 0.05) reduction in minimal and peak-E wave LVKEiEDV. However in patients with moderate to severe rEF in the acute scan, there were no significant change by 3 months (Figure).

Conclusion. Following MI, 4D flow LVKE derived biomarkers significantly decreased over time in pEF and mild rEF groups but not in moderate to severe rEF group. 4D flow assessment might provide incremental prognostic value beyond EF assessment alone.

Table pEF (n = 7) rEF (n = 13) V1 V2 P-value V1 V2 P-value EF(%) 56 ± 5 55 ± 4 0.40 41 ± 7 47 ± 9 0.01 Infarct Size(%) 31 ± 20 15 ± 9 0.04 18 ± 13† 16 ± 11 0.41 LV KEiEDV parameters Average(µJ/ml) 9 ± 2 7 ± 2 0.02 10 ± 3† 8 ± 3 0.01 Minimal(µJ/ml) 1 ± 0.6 1 ± 0.5 0.46 1.3 ± 0.5 1 ± 0.6 0.03 Systolic(µJ/ml) 10 ± 4 7 ± 2 &lt;0.01 12 ± 4† 7 ± 3 &lt;0.01 Diastolic(µJ/ml) 8 ± 3 7 ± 2 0.13 9 ± 3 8 ± 3 0.09 Peak-E wave(µJ/ml) 22 ± 9 23 ± 8 0.44 20 ± 7 18 ± 10 0.23 Peak-A wave(µJ/ml) 18 ± 10 11 ± 4 0.04 17 ± 9 14 ± 7 0.02 †P &lt; 0.05 V1 comparison between pEF and rEF Abstract Figure

The effect of microvascular obstruction on the myocardial microstructure: a diffusion tensor imaging study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Heart Research UK

Background

Diffusion tensor cardiac magnetic resonance (DT-CMR) imaging allows for characterising myocardial microstructure in-vivo using mean diffusivity (MD), fractional anisotropy (FA), secondary eigenvector angle (E2A) and helix angle (HA) maps. Following myocardial infarction (MI), alterations in MD, FA and HA proportions have previously been reported. E2A depicts the contractile state of myocardial sheetlets, however the behaviour of E2A in infarct segments, and all DTI markers in areas of microvascular obstruction (MVO) is also not fully understood. 

Purpose

We performed spin echo DTI in patients following ST-elevation MI (STEMI) in order to investigate acute changes in DTI parameters in remote and infarct segments both with and without MVO.

Method

Twenty STEMI patients (16 men, 4 women, mean age 59) had acute (5 ± 2d) 3T CMR scans. CMR protocol included: second order motion compensated (M012) free-breathing spin echo DTI (3 slices, 18 diffusion directions at b-values 100s/mm2[3], 200s/mm2[3] and 500s/mm2[12], reconstructed resolution was 1.66x1.66x8mm); cine and late gadolinium enhancement (LGE) imaging. Average MD, FA, E2A HA parameters were calculated on a  16 AHA segmental level. HA maps were described by dividing values into left-handed HA (LHM, -90° &lt; HA &lt; -30°), circumferential HA (CM, -30° &lt; HA &lt; 30°), and right-handed HA (RHM, 30° &lt; HA &lt; 90°) and reported as relative proportions. Segments were defined as infarct (positive for LGE) and remote (opposite to the infarct). 

Results

DTI acquisition was successful in all patients (acquisition time 13 ± 5mins). Ten patients had evidence of MVO on LGE images. MD was significantly higher in infarct regions in comparison to remote; MVO-ve infarct segments had significantly higher MD than MVO + ve infarct segments (MD remote= 1.46 ± 0.12x10-3mm2/s, MD MVO + ve = 1.59 ± 0.12x10-3mm2/s, MD MVO-ve  = 1.75 ± 0.12x10-3mm2/s, ANOVA p &lt; 0.01). FA was reduced in infarct segments in comparison to remote; MVO-ve infarct segments had significantly lower FA than MVO + ve infarct segments (FAremote= 0.37 ± 0.02, FA MVO + ve = 0.31 ± 0.02 x 10-3mm2/s, MD MVO-ve =0.25 ± 0.02, ANOVA p &lt; 0.01).

E2A values were significantly lower in infarct segments compared to remote; MVO + ve infarct segments had significantly lower values than MVO-ve. (E2A remote= 57.4 ± 5.2°, E2A MVO-ve = 46.8 ± 2.5°, E2A MVO + ve = 36.8 ± 3.1°, ANOVA p &lt; 0.001). RHM% (corresponding to subendocardium) was significantly lower in infarct segments compared to remote; MVO + ve infarct segments had significantly lower RHM% than MVO-ve. (RHM remote= 37 ± 3%, RHM RHM MVO-ve= 28 ± 7%, MVO + ve= 8 ± 5%, ANOVA p &lt; 0.001).

Conclusion

The presence of MVO results in a decrease in MD and increase in FA in comparison to surrounding infarct segments. However, the reduction in E2A and right-handed myocytes on HA in infarct segments is further exacerbated by the presence of MVO. Further study is required to investigate the underlying mechanisms for such alterations in signal intensity.

Abstract Figure. A case of transmural septal MI with MVO

Evaluation of Neuropathy, Glycemic Control, and Revascularization as Risk Factors for Future Lower Extremity Amputation among Diabetic Patients

BACKGROUND

Diabetes mellitus is a major risk factor for progression to lower extremity amputation (LEA) due to progressive neuropathy and glycemia-induced vasculopathy. In this study, we evaluated risk factors for incident LEA type 2 diabetics during a randomized controlled trial and extended post-trial follow-up.

METHODS

The Action to Control Cardiovascular Risk in Diabetes trial randomized 10,251 type 2 diabetics to intensive glycemic control (Hemoglobin A1c (HbA1c) target <6.0%) versus standard glycemic control (HbA1c target 7.0-7.9%). Using backward elimination logistic regression models, we examined relationships between neuropathy using the Michigan Neuropathy Screening Instrument (MNSI) and glycemic control and incident LEA during the clinical trial and subsequent follow-up.

RESULTS

9,746 patients were followed for a mean of 7.9 +/-3.1 (median 8.9) years after randomization. Ninety-eight (1%) participants underwent an incident LEA during the trial or post-trial follow-up period. Baseline demographics and traditional risk factors were examined by incident amputation status. Multivariable models revealed that abnormal 10 gm filament test (HR 4.50, 95% CI 2.92-6.95, P < 0.0001), presence of ulceration (HR 4.22, 95% CI 1.65-10.8, P = 0.0004), abnormal appearance on foot examination (HR 4.75, 95% CI 2.30-9.83, P < 0.0001), and mean postrandomization HbA1c (HR 1.65, 95% CI 1.35-2.00, P < 0.0001) were strongly predictive of LEA when accounting for other common risk factors for amputation.

CONCLUSIONS

In this post hoc analysis of a large randomized controlled population of diabetic patients, we found that components of the MNSI score including presence of ulceration, abnormal appearance of the foot, and 10 gm filament monofilament scoring were strongly predictive of LEA. This adds a valuable clinical tool in the risk stratification of diabetic patients for LEA.

Markers of kidney tubule function and risk of cardiovascular disease events and mortality in the SPRINT trial

AIMS

Biomarkers of kidney tubule injury, inflammation and fibrosis have been studied extensively and established as risk markers of adverse kidney and cardiovascular disease (CVD) outcomes. However, associations of markers of kidney tubular function with adverse clinical events have not been well studied, especially in persons with chronic kidney disease (CKD).

METHODS AND RESULTS

Using a sample of 2377 persons with CKD at the baseline Systolic Blood Pressure Intervention Trial (SPRINT) visit, we evaluated the association of three urine tubular function markers, alpha-1 microglobulin (α1m), beta-2 microglobulin (β2m), and uromodulin, with a composite CVD endpoint (myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes) and mortality using Cox proportional hazards regression, adjusted for baseline estimated glomerular filtration rate (eGFR), albuminuria, and CVD risk factors. In unadjusted analysis, over a median follow-up of 3.8 years, α1m and β2m had positive associations with composite CVD events and mortality, whereas uromodulin had an inverse association with risk for both outcomes. In multivariable analysis including eGFR and albuminuria, a two-fold higher baseline concentration of α1m was associated with higher risk of CVD [hazard ratio (HR) 1.25; 95% confidence interval (CI): 1.10-1.45] and mortality (HR 1.25; 95% CI: 1.10-1.46), whereas β2m had no association with either outcome. A two-fold higher uromodulin concentration was associated with lower CVD risk (HR 0.79; 95% CI: 0.68-0.90) but not mortality (HR 0.86; 95% CI: 0.73-1.01) after adjusting for similar confounders.

CONCLUSION

Among non-diabetic persons with CKD, biomarkers of tubular function are associated with CVD events and mortality independent of glomerular function and albuminuria.

Effects of Intensive Blood Pressure Lowering on Kidney Tubule Injury in CKD: A Longitudinal Subgroup Analysis in SPRINT

BACKGROUND

Random assignment to the intensive systolic blood pressure (SBP) arm (<120mmHg) in the Systolic Blood Pressure Intervention Trial (SPRINT) resulted in more rapid declines in estimated glomerular filtration rates (eGFRs) than in the standard arm (SBP<140mmHg). Whether this change reflects hemodynamic effects or accelerated intrinsic kidney damage is unknown.

STUDY DESIGN

Longitudinal subgroup analysis of clinical trial participants.

SETTINGS & PARTICIPANTS

Random sample of SPRINT participants with prevalent chronic kidney disease (CKD) defined as eGFR<60mL/min/1.73m² by the CKD-EPI (CKD Epidemiology Collaboration) creatinine-cystatin C equation at baseline.

OUTCOMES & MEASUREMENTS

Urine biomarkers of tubule function (β₂-microglobulin [B2M], α₁-microglobulin [A1M]), and uromodulin), injury (interleukin 18, kidney injury molecule 1, and neutrophil gelatinase-associated lipocalin), inflammation (monocyte chemoattractant protein 1), and repair (human cartilage glycoprotein 40) at baseline, year 1, and year 4. Biomarkers were indexed to urine creatinine concentration and changes between arms were evaluated using mixed-effects linear models and an intention-to-treat approach.

RESULTS

978 SPRINT participants (519 in the intensive and 459 in the standard arm) with prevalent CKD were included. Mean age was 72±9 years and eGFR was 46.1±9.4mL/min/1.73m² at baseline. Clinical characteristics, eGFR, urinary albumin-creatinine ratio, and all 8 biomarker values were similar across arms at baseline. Compared to the standard arm, eGFR was lower by 2.9 and 3.3mL/min/1.73m² in the intensive arm at year 1 and year 4. None of the 8 tubule marker levels was higher in the intensive arm compared to the standard arm at year 1 or year 4. Two tubule function markers (B2M and A1M) were 29% (95% CI, 10%-43%) and 24% (95% CI, 10%-36%) lower at year 1 in the intensive versus standard arm, respectively.

LIMITATIONS

Exclusion of persons with diabetes, and few participants had advanced CKD.

CONCLUSIONS

Among participants with CKD in SPRINT, random assignment to the intensive SBP arm did not increase any levels of 8 urine biomarkers of tubule cell damage despite loss of eGFR. These findings support the hypothesis that eGFR declines in the intensive arm of SPRINT predominantly reflect hemodynamic changes rather than intrinsic damage to kidney tubule cells.

Associations of Fenofibrate Therapy With Incidence and Progression of CKD in Patients With Type 2 Diabetes

Introduction

Abnormalities in lipid metabolism may contribute to the development and progression of chronic kidney disease (CKD) in patients with type 2 diabetes. Fenofibrate induces early and reversible reduction in estimated glomerular filtration rate (eGFR), but it may have protective effects on microvascular complications of diabetes. We hypothesized that randomization to fenofibrate versus placebo would be associated with beneficial long-term effects on kidney outcomes in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial participants.

Methods

We conducted a post hoc analysis in the ACCORD Lipid Trial to examine the association of randomization to fenofibrate versus placebo with change in eGFR and with time-to-development of microalbuminuria, macroalbuminuria, CKD, and kidney failure.

Results

We analyzed 2636 participants in the fenofibrate arm and 2632 in the placebo arm. During a median follow-up of 4 years, treatment with fenofibrate was associated with lower rate of eGFR decline (−0.28 ml/min per 1.73 m² per year in the fenofibrate group vs. −1.25 ml/min per 1.73 m² per year in the placebo group, P < 0.01) and with lower incidence of microalbuminuria (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.43–0.72, P < 0.001) and macroalbuminuria (HR 0.72, 95% CI 0.57–0.91, P < 0.001). There was no difference in incidence of CKD (HR 0.92, 95% CI 0.74–1.15, P = 0.46) and/or kidney failure (HR 0.95, 95% CI 0.68–1.33, P = 0.76).

Conclusion

Compared with placebo, randomization to fenofibrate was associated with lower rates of incident albuminuria and a slower eGFR decline, but no difference in incidence of CKD or kidney failure in ACCORD participants.

Incidence and Progression of Chronic Kidney Disease in Black and White Individuals with Type 2 Diabetes

BACKGROUND AND OBJECTIVES

Type 2 diabetes and associated CKD disproportionately affect blacks. It is uncertain if racial disparities in type 2 diabetes-associated CKD are driven by biologic factors that influence propensity to CKD or by differences in type 2 diabetes care.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a post hoc analysis of 1937 black and 6372 white participants of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial to examine associations of black race with change in eGFR and risks of developing microalbuminuria, macroalbuminuria, incident CKD (eGFR<60 ml/min per 1.73m2, ≥25% decrease from baseline eGFR, and eGFR slope <-1.6 ml/min per 1.73 m2 per year), and kidney failure or serum creatinine >3.3 mg/dl.

RESULTS

During a median follow-up that ranged between 4.4 and 4.7 years, 278 black participants (58 per 1000 person-years) and 981 white participants (55 per 1000 person-years) developed microalbuminuria, 122 black participants (16 per 1000 person-years) and 374 white participants (14 per 1000 person-years) developed macroalbuminuria, 111 black participants (21 per 1000 person-years) and 499 white participants (28 per 1000 person-years) developed incident CKD, and 59 black participants (seven per 1000 person-years) and 178 white participants (six per 1000 person-years) developed kidney failure or serum creatinine >3.3 mg/dl. Compared with white participants, black participants had lower risks of incident CKD (hazard ratio, 0.73; 95% confidence intervals, 0.57 to 0.92). There were no significant differences by race in eGFR decline or in risks of microalbuminuria, macroalbuminuria, and kidney failure or of serum creatinine >3.3 mg/dl.

CONCLUSIONS

Black participants enrolled in a randomized controlled trial had lower rates of incident CKD compared with white participants. Rates of eGFR decline, microalbuminuria, macroalbuminuria, and kidney failure did not vary by race.

Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes: a meta-analysis of individual participant data from randomised controlled trials

BACKGROUND

Intensive glucose control is understood to prevent complications in adults with type 2 diabetes. We aimed to more precisely estimate the effects of more intensive glucose control, compared with less intensive glucose control, on the risk of microvascular events.

METHODS

In this meta-analysis, we obtained de-identified individual participant data from large-scale randomised controlled trials assessing the effects of more intensive glucose control versus less intensive glucose control in adults with type 2 diabetes, with at least 1000 patient-years of follow-up in each treatment group and a minimum of 2 years average follow-up on randomised treatment. The prespecified and standardised primary outcomes were kidney events (a composite of end-stage kidney disease, renal death, development of an estimated glomerular filtration rate <30 mL/min per 1·73m², or development of overt diabetic nephropathy), eye events (a composite of requirement for retinal photocoagulation therapy or vitrectomy, development of proliferative retinopathy, or progression of diabetic retinopathy), and nerve events (a composite of new loss of vibratory sensation, ankle reflexes, or light touch). We used a random-effects model to calculate overall estimates of effect.

FINDINGS

We included four trials (ACCORD, ADVANCE, UKPDS, and VADT) with 27 049 participants. 1626 kidney events, 795 eye events, and 7598 nerve events were recorded during the follow-up period (median 5·0 years, IQR 4·5-5·0). Compared with less intensive glucose control, more intensive glucose control resulted in an absolute difference of -0·90% (95% CI -1·22 to -0·58) in mean HbA_1c at completion of follow-up. The relative risk was reduced by 20% for kidney events (hazard ratio 0·80, 95% CI 0·72 to 0·88; p<0·0001) and by 13% for eye events (0·87, 0·76 to 1·00; p=0·04), but was not reduced for nerve events (0·98, 0·87 to 1·09; p=0·68).

INTERPRETATION

More intensive glucose control over 5 years reduced both kidney and eye events. Glucose lowering remains important for the prevention of long-term microvascular complications in adults with type 2 diabetes.

FUNDING

None.

Longitudinal changes in dietary fat intake and associated changes in cardiovascular risk factors in adults with type 2 diabetes: the ACCORD trial

AIMS

To measure dietary fat intake using the Puget Sound Eating Patterns (PEP) questionnaire, a validated 19-item food questionnaire, and to quantify how reduced dietary fat intake affects cardiovascular risk factors in adults with type 2 diabetes.

METHODS

Randomized controlled trial including a subsample of 1781 Action to Control Cardiovascular Risk in Diabetes (ACCORD) participants. Participants received dietary counseling to consume a reduced-fat diet. Outcome measures included HbA1c, fasting lipid profile, blood pressure, and weight. Longitudinal linear regression analyses were used to evaluate relationships between baseline and follow-up PEP scores and cardiovascular risk factors.

RESULTS

PEP scores decreased significantly from baseline to 12-month follow up with a mean difference of -0.09 ± 0.39, P<0.001. All of the fat intake subscales showed significant improvement at 12 months from baseline. White race, female gender, and more hours per week of physical activity were correlated with a decline in PEP scores at 1-year. A longitudinal decrease in dietary fat intake was associated with significantly less weight gain at 12- and 36-months and lower serum triglycerides at 1 year.

CONCLUSIONS

Reduced fat intake as measured by a brief questionnaire was associated with significant improvement in some cardiovascular risk factors (triglycerides and weight), but not in others.

Reversibility of fenofibrate therapy-induced renal function impairment in ACCORD type 2 diabetic participants

OBJECTIVE

To assess the reversibility of the elevation of serum creatinine levels in patients with diabetes after 5 years of continuous on-trial fenofibrate therapy.

RESEARCH DESIGN AND METHODS

An on-drug/off-drug ancillary study to the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Lipid Trial to investigate posttrial changes in serum creatinine and cystatin C. Eligible participants were recruited into a prospective, nested, three-group study based on retrospective on-trial serum creatinine levels: fenofibrate case subjects (n = 321, ≥ 20% increase after 3 months of therapy); fenofibrate control subjects (n = 175, ≤ 2% increase); and placebo control subjects (n = 565). Serum creatinine and cystatin C were measured at trial end and 6-8 weeks after discontinuation of trial therapy. RESULTS At trial end, case subjects had the highest adjusted serum creatinine (± SE) mg/dL (1.11 ± 0.02) and the lowest adjusted estimated glomerular filtration rate (eGFR) (± SE) mL/min/1.73 m(2) (68.4 ± 1.0) versus control subjects (1.01 ± 0.02; 74.8 ± 1.3) and placebo subjects (0.98 ± 0.01; 77.8 ± 0.7). After 51 days off-drug, serum creatinine in case subjects was still higher (0.97 ± 0.02) and eGFR still lower (77.8 ± 1.0) than control subjects (0.90 ± 0.02; 81.8 ± 1.3) but not different from placebo subjects (0.99 ± 0.01; 76.6 ± 0.7). Changes in serum cystatin C recapitulated the serum creatinine changes.

CONCLUSIONS

Participants with significant initial on-trial increases in serum creatinine (≥ 20%) returned to the same level of renal function as participants receiving placebo while participants who had ≤ 2% increase in serum creatinine had net preservation of renal function compared with the same unselected placebo reference group. The fenofibrate-associated on-trial increases in serum creatinine were reversible, and the reversal was complete after 51 days off-drug. The similarity of the cystatin C results suggests that the mechanism of this change is not specific for serum creatinine.

Long-term safety of growth hormone replacement after CNS irradiation

CONTEXT

Radiotherapy is a central component in the treatment of many brain tumors, but long-term sequelae include GH deficiency and increased risk of secondary neoplasms. It is unclear whether replacement therapy with GH (GHRT) further increases this risk.

OBJECTIVE

The objective of the study was to assess the effect of GHRT on the incidence of secondary tumors and tumor recurrence after cranial irradiation.

DESIGN AND SETTING

We conducted a retrospective matched-pairs analysis of previously irradiated patients, with and without GHRT, attending a tertiary center between 1994 and 2009.

PATIENTS

We reviewed the records for all patients undergoing GHRT at our institution over the study period. PATIENTS were included if they had received cranial irradiation, GHRT for at least 12 months, and records of serial magnetic resonance imaging data and data for dose and fractionation of irradiation were available. GH-naïve control patients were selected from a radiotherapy database of patients attending the same hospital. PATIENTS were matched for date of radiotherapy, age, site of primary diagnosis, radiation dose, and fractionation.

MAIN OUTCOME MEASURE

The primary outcome measure was risk of tumor recurrence or secondary tumor.

RESULTS

Matched controls were identified for 110 GH-treated patients. Median follow-up was 14.5 yr. No significant differences were apparent in the number of tumor recurrences (six vs. eight, GHRT vs. control group) or secondary tumors (five vs. three, respectively) between groups.

CONCLUSIONS

Our study demonstrates no increased risk for recurrent or secondary neoplasms in patients receiving GHRT, thus supporting a high safety profile of GHRT after central nervous system irradiation.

Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial

BACKGROUND

Hyperglycaemia is associated with increased risk of cardiovascular complications in people with type 2 diabetes. We investigated whether reduction of blood glucose concentration decreases the rate of microvascular complications in people with type 2 diabetes.

METHODS

ACCORD was a parallel-group, randomised trial done in 77 clinical sites in North America. People with diabetes, high HbA(1c) concentrations (>7.5%), and cardiovascular disease (or >or=2 cardiovascular risk factors) were randomly assigned by central randomisation to intensive (target haemoglobin A(1c) [HbA(1c)] of <6.0%) or standard (7.0-7.9%) glycaemic therapy. In this analysis, the prespecified composite outcomes were: dialysis or renal transplantation, high serum creatinine (>291.7 micromol/L), or retinal photocoagulation or vitrectomy (first composite outcome); or peripheral neuropathy plus the first composite outcome (second composite outcome). 13 prespecified secondary measures of kidney, eye, and peripheral nerve function were also assessed. Investigators and participants were aware of treatment group assignment. Analysis was done for all patients who were assessed for microvascular outcomes, on the basis of treatment assignment, irrespective of treatments received or compliance to therapies. ACCORD is registered with ClinicalTrials.gov, number NCT00000620.

FINDINGS

10 251 patients were randomly assigned, 5128 to the intensive glycaemia control group and 5123 to standard group. Intensive therapy was stopped before study end because of higher mortality in that group, and patients were transitioned to standard therapy. At transition, the first composite outcome was recorded in 443 of 5107 patients in the intensive group versus 444 of 5108 in the standard group (HR 1.00, 95% CI 0.88-1.14; p=1.00), and the second composite outcome was noted in 1591 of 5107 versus 1659 of 5108 (0.96, 0.89-1.02; p=0.19). Results were similar at study end (first composite outcome 556 of 5119 vs 586 of 5115 [HR 0.95, 95% CI 0.85-1.07, p=0.42]; and second 1956 of 5119 vs 2046 of 5115, respectively [0.95, 0.89-1.01, p=0.12]). Intensive therapy did not reduce the risk of advanced measures of microvascular outcomes, but delayed the onset of albuminuria and some measures of eye complications and neuropathy. Seven secondary measures at study end favoured intensive therapy (p<0.05).

INTERPRETATION

Microvascular benefits of intensive therapy should be weighed against the increase in total and cardiovascular disease-related mortality, increased weight gain, and high risk for severe hypoglycaemia.

FUNDING

US National Institutes of Health; National Heart, Lung, and Blood Institute; National Institute of Diabetes and Digestive and Kidney Diseases; National Institute on Aging; National Eye Institute; Centers for Disease Control and Prevention; and General Clinical Research Centers.

Effect of pravastatin on rate of kidney function loss in people with or at risk for coronary disease

BACKGROUND

Limited data suggest that HMG-CoA reductase inhibitors (statins) reduce rates of kidney function loss. We performed this analysis to determine whether pravastatin reduced the rate of kidney function loss over approximately 5 years in people with or at high risk for coronary disease.

METHODS AND RESULTS

This was a post hoc subgroup analysis of data from 3 randomized double-blind controlled trials comparing pravastatin 40 mg/d and placebo in subjects with a previous acute coronary syndrome or who were at high cardiovascular risk. The primary outcome was the rate of change in estimated glomerular filtration rate (GFR; in mL/min per 1.73 m2/y). The Modified Diet and Renal Disease Study (MDRD) and Cockcroft-Gault equations were used to estimate GFR. We studied 18,569 participants, 3402 (18.3%) of whom had moderate chronic kidney disease as defined by an estimated GFR of 30 to 59.9 mL/min per 1.73 m2 body surface area. In subjects with moderate chronic kidney disease at baseline, pravastatin reduced the adjusted rate of kidney function loss by approximately 34%, although the absolute reduction in the rate of loss was small (0.22 mL/min per 1.73 m2/y by MDRD-GFR; 95% CI, 0.07 to 0.37). Pravastatin did not reduce the frequency of > or =25% decreases in kidney function in this group when MDRD-GFR was used to estimate GFR (relative risk [RR], 0.84; 95% CI, 0.66 to 1.06). When all 18,569 subjects were considered, pravastatin reduced the adjusted rate of kidney function loss by 8% (0.08 mL/min per 1.73 m2/y by MDRD-GFR; 95% CI, 0.01 to 0.15) and the risk of acute renal failure (RR, 0.60; 95% CI, 0.41 to 0.86) but did not significantly reduce the frequency of a > or =25% decline in kidney function by MDRD-GFR (RR, 0.94; 95% CI, 0.88 to 1.01).

CONCLUSIONS

Pravastatin modestly reduced the rate of kidney function loss in people with or at risk for cardiovascular disease. However, the primary indication for the use of statins in people with or at risk for coronary events remains the reduction in mortality that results from their use.

Effect of pravastatin on cardiovascular events in people with chronic kidney disease

BACKGROUND

Limited data describe the cardiovascular benefit of HMG-CoA reductase inhibitors (statins) in people with moderate chronic kidney disease (CKD). The objective of this analysis was to determine whether pravastatin reduced the incidence of cardiovascular events in people with or at high risk for coronary disease and with concomitant moderate CKD.

METHODS AND RESULTS

We analyzed data from the Pravastatin Pooling Project (PPP), a subject-level database combining results from 3 randomized trials of pravastatin (40 mg daily) versus placebo. Of 19 700 subjects, 4491 (22.8%) had moderate CKD, defined by an estimated glomerular filtration rate of 30 to 59.99 mL/min per 1.73 m2 body surface area. The primary outcome was time to myocardial infarction, coronary death, or percutaneous/surgical coronary revascularization. Moderate CKD was independently associated with an increased risk of the primary outcome (adjusted HR 1.26, 95% CI 1.07 to 1.49) compared with those with normal renal function. Among the 4491 subjects with moderate CKD, pravastatin significantly reduced the incidence of the primary outcome (HR 0.77, 95% CI 0.68 to 0.86), similar to the effect of pravastatin on the primary outcome in subjects with normal kidney function (HR 0.78, 95% CI 0.65 to 0.94). Pravastatin also appeared to reduce the total mortality rate in those with moderate CKD (adjusted HR 0.86, 95% CI 0.74 to 1.00, P=0.045).

CONCLUSIONS

Pravastatin reduces cardiovascular event rates in people with or at risk for coronary disease and concomitant moderate CKD, many of whom have serum creatinine levels within the normal range. Given the high risk associated with CKD, the absolute benefit that resulted from use of pravastatin was greater than in those with normal renal function.

Effect of estrogen plus progestin on progression of carotid atherosclerosis in postmenopausal women with heart disease: HERS B-mode substudy

OBJECTIVE

The Heart and Estrogen/Progestin Replacement Study (HERS) found no overall effect of estrogen plus progestin (compared with placebo) on coronary event rates in 2763 postmenopausal women with established coronary disease (mean 4.1 years of follow-up). In addition to the events trial, a carotid ultrasound substudy was established in 1993 to be conducted concurrently to determine whether hormone therapy affects the progression of the underlying atherosclerotic process.

METHODS AND RESULTS

Within the larger HERS, a subset of 362 participants underwent carotid B-mode ultrasound examinations at baseline and the end of follow-up. Progression of carotid atherosclerosis was measured as the temporal change in intimal-medial thickness (IMT).

CONCLUSIONS

IMT progressed in the hormone treatment and placebo groups, although there was no statistical difference between the rates: IMT progressed 26 microm/y (95% CI 18 to 34 microm/y) in the hormone group and 31 microm/y (95% CI 21 to 40 microm/y) in the placebo group (P=0.44). There were also no significant treatment effects when the results were examined by carotid segment or were adjusted for covariates. These data support the American Heart Association recommendation that women with established coronary disease should not initiate hormone therapy with an expectation of atherosclerotic benefit.

Vascular closure devices in patients treated with anticoagulation and IIb/IIIa receptor inhibitors during percutaneous revascularization

OBJECTIVES

The study assessed clinical outcomes of closure device use following percutaneous coronary revascularization using current standards of anticoagulation and antiplatelet therapy.

BACKGROUND

Evaluation of the outcomes of patients by use of vascular closure devices during coronary interventions employing current standards of anticoagulation and glycoprotein (GP) IIb/IIIa inhibitor therapy is limited.

METHODS

We evaluated outcomes of 4,525 consecutive patients who underwent percutaneous coronary intervention between July 1997 and April 2000. All patients received anticoagulation with heparin and GP IIb/IIIa inhibitor therapy with abciximab. The closure method was manual in 1,824 patients, Angioseal in 524 patients and Perclose in 2,177 patients. Procedural and hospital vascular outcomes were evaluated.

RESULTS

Closure device success was 97.1% Angioseal and 94.1% Perclose (p < 0.05). Minor vascular complications occurred in 1.8% of manual patients, 1.1% of Angioseal patients and 1.2% of Perclose patients (p = NS); major complications occurred in 1.3% of manual patients, 1.1% of Angioseal patients and 1.0% of Perclose patients (p = NS). Multivariate logistic regression identified only closure device failure as an independent predictor of a vascular complication. In patients with successful closure with a device, minor complications (0.8% vs. 1.8%, p < 0.05) and any complication (1.5% vs. 2.5%, p < 0.05) were reduced compared to manual compression.

CONCLUSIONS

Arterial closure following coronary interventions using anticoagulation and GP IIb/IIIa inhibitor therapy can be safely and effectively performed, with vascular complication rates similar to or lower than with manual pressure. Additionally, vascular complication rates using GP IIb/IIIa inhibitor therapy regardless of the method of arterial closure are equivalent to or lower than previously published rates of vascular complications.

Coronary heart disease in patients with low LDL-cholesterol: benefit of pravastatin in diabetics and enhanced role for HDL-cholesterol and triglycerides as risk factors

BACKGROUND

In two large secondary prevention trials of pravastatin, risk reduction was not significant in participants who had low baseline LDL-C concentrations (that is, <125 mg/dL). We conducted exploratory analyses of participant characteristics, lipid risk factors, and risk reduction in this group.

METHODS AND RESULTS

Among 13 173 participants with coronary heart disease (CHD), 2607 had baseline LDL-C <125 mg/dL. Those with LDL-C <125 compared with > or =125 mg/dL were more likely to be diabetic (15% versus 9%), hypertensive (46 versus 41%), and male (89% versus 83%); they had higher triglycerides (169 versus 154 mg/dL), lower HDL-C (36.5 versus 38 mg/dL), and similar body mass index (27 kg/m2); and pravastatin lowered their LDL-C by 36 mg/dL (32%) versus 45 mg/dL (29%). During 5.8-year (mean) follow-up, HDL-C and triglycerides were both significantly stronger predictors of recurrent CHD events in participants with LDL-C <125 than > or =125 mg/dL. In diabetic participants with low LDL-C, pravastatin decreased CHD events from 34% to 22% (relative risk, 0.56; 95% CI, 0.37 to 0.83; P=0.004), significantly different from the effect in nondiabetic participants with low LDL-C (P interaction, 0.005) (event rate, 21%; relative risk, 1.06 [95% CI, 0.89 to 1.27]). There were trends toward risk reduction in smokers and in those with low HDL-C, <40 mg/dL.

CONCLUSIONS

Among patients with CHD who have low LDL-C, diabetics have much higher subsequent CHD event rates than do nondiabetics. Pravastatin reduced the event rate in diabetics to that of nondiabetic participants. The results also suggest enhanced therapeutic potential for improving HDL-C and triglycerides in patients with CHD who have low LDL-C concentrations.

Etiologic factors associated with anterior knee pain in distance runners

PURPOSE

The objectives of this study were 1) to examine the differences between a noninjured (C) cohort of runners (N = 70) and runners afflicted with anterior knee pain (AKP) according to selected training, anthropometric, rearfoot motion, ground reaction force, and muscular strength and endurance variables; 2) to explore multivariate relationships among these measures in the well and injured groups; and 3) to develop specific hypotheses concerning risk factors for injury that will later be tested in a prospective clinical study.

METHODS

High speed videography (200 frames x s(-1)), a force platform (500 Hz), and a Cybex II+ isokinetic dynamometer were used to assess rearfoot motion, ground reaction forces, and knee muscular strength and endurance, respectively. A linear discriminant function was performed on each of the five categories of variables and revealed 19 significant (P < or = 0.05) predictors. These variables were then combined and a final discriminant function analysis was performed.

RESULTS

Pronation through the first 10% of stance, arch index, shoe mileage, and extension peak torque were the best overall (P < or = 0.05) predictors. The AKP group had smaller mean values on all four significant predictors.

CONCLUSION

With the exception of shoe mileage, which is likely a response to rather than a risk factor for AKP, these results should prove useful to clinicians in identifying runners at risk for anterior knee pain.

Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis

OBJECTIVES

To describe the types and frequencies of sleep complaints and the biopsychosocial factors associated with sleep disturbance in a large community sample of older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis (OA).

DESIGN

Baseline analyses of an observational prospective study.

SETTING AND PARTICIPANTS

Participants were 429 men and women aged 65 years and older experiencing knee pain or knee pain with radiographic evidence of OA enrolled in the Observational Arthritis Study in Seniors (OASIS).

MEASUREMENTS

Demographic variables (age, gender, ethnicity, education), health (X-rays of knee rated for OA severity, medical conditions, medication use, smoking status, body mass index, self-rated health), physical functioning (self-rated physical functioning, physical performance), knee pain, and psychosocial functioning (social support, depression) were measured.

RESULTS

Problems with sleep onset, sleep maintenance, and early morning awakenings occurred at least weekly among 31%, 81%, and 51% of participants, respectively. Bivariate correlates of greater sleep disturbance in those with OA were less education, cardiovascular disease, more arthritic joints, poorer self-rated health, poorer physical functioning, poorer physical performance, knee pain, depression, and less social support. In regression analyses, each set of variables representing the domains of health, physical functioning, pain, and psychosocial functioning contributed to the prediction of sleep disturbance beyond the demographic set. Finally, in a simultaneous model, white race (trend, P = .06), poorer self-rated health, poorer physical functioning, and depressive symptoms were predictive of sleep disturbance.

CONCLUSIONS

Sleep disturbance is common in older adults experiencing knee pain or knee pain with radiographic evidence of OA and is best understood through the consideration of demographic, physical health, physical functioning, pain, and psychosocial variables. Interventions that take into account the multidetermined nature of sleep disturbance in knee pain or knee OA are most likely to be successful.

Etiologic factors associated with Achilles tendinitis in runners

PURPOSE

The purpose of this study was to determine whether relationships exist between selected training, anthropometric, isokinetic muscular strength, and endurance, ground reaction force, and rearfoot movement variables in runners afflicted with Achilles tendinitis.

METHODS

Specifically, we examined differences in selected measures between a noninjured cohort of runners (N = 58) and a cohort of injured runners with Achilles tendinitis (N = 31). Isokinetic, kinetic, and kinematic measures were collected using a Cybex II+ isokinetic dynamometer (Medway, MA), AMTI force plate (500 Hz), and Motion Analysis high-speed videography (200 Hz), respectively. Separate discriminant function analyses were performed on each of the five sets of variables to identify the factors that best discriminate between the injured and control groups.

RESULTS

Years running, training pace, stretching habits (injured runners were less likely to incorporate stretching into their training routine), touchdown angle, plantar flexion peak torque at 180 degrees x s(-1) and arch index were found to be significant discriminators.

CONCLUSION

A combined discriminant analysis using the above mentioned significant variables revealed that plantar flexion peak torque, touchdown angle, and years running were the strongest discriminators between runners afflicted with Achilles tendinitis and runners who had no history of overuse injury.

A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST)

OBJECTIVE

To determine the effects of structured exercise programs on self-reported disability in older adults with knee osteoarthritis.

SETTING AND DESIGN

A randomized, single-blind clinical trial lasting 18 months conducted at 2 academic medical centers.

PARTICIPANTS

A total of 439 community-dwelling adults, aged 60 years or older, with radiographically evident knee osteoarthritis, pain, and self-reported physical disability.

INTERVENTIONS

An aerobic exercise program, a resistance exercise program, and a health education program.

MAIN OUTCOME MEASURES

The primary outcome was self-reported disability score (range, 1-5). The secondary outcomes were knee pain score (range, 1-6), performance measures of physical function, x-ray score, aerobic capacity, and knee muscle strength.

RESULTS

A total of 365 (83%) participants completed the trial. Overall compliance with the exercise prescription was 68% in the aerobic training group and 70% in the resistance training group. Postrandomization, participants in the aerobic exercise group had a 10% lower adjusted mean (+/- SE) score on the physical disability questionnaire (1.71 +/- 0.03 vs 1.90 +/- 0.04 units; P<.001), a 12% lower score on the knee pain questionnaire (2.1 +/- 0.05 vs 2.4 +/- 0.05 units; P=.001), and performed better (mean [+/- SE]) on the 6-minute walk test (1507 +/- 16 vs 1349 +/- 16 ft; P<.001), mean (+/-SE) time to climb and descend stairs (12.7 +/- 0.4 vs 13.9 +/- 0.4 seconds; P=.05), time to lift and carry 10 pounds (9.1 +/- 0.2 vs 10.0 +/- 0.1 seconds; P<.001), and mean (+/-SE) time to get in and out of a car (8.7 +/- 0.3 vs 10.6 +/- 0.3 seconds; P<.001) than the health education group. The resistance exercise group had an 8% lower score on the physical disability questionnaire (1.74 +/- 0.04 vs 1.90 +/- 0.03 units; P=.003), 8% lower pain score (2.2 +/- 0.06 vs 2.4 +/- 0.05 units; P=.02), greater distance on the 6-minute walk (1406 +/- 17 vs 1349 +/- 16 ft; P=.02), faster times on the lifting and carrying task (9.3 +/- 0.1 vs 10.0 +/- 0.16 seconds; P=.001), and the car task (9.0 +/- 0.3 vs 10.6 +/- 0.3 seconds; P=.003) than the health education group. There were no differences in x-ray scores between either exercise group and the health education group.

CONCLUSIONS

Older disabled persons with osteoarthritis of the knee had modest improvements in measures of disability, physical performance, and pain from participating in either an aerobic or a resistance exercise program. These data suggest that exercise should be prescribed as part of the treatment for knee osteoarthritis.

Assessment of temporal bias in longitudinal measurements of carotid intimal-medial thickness in the Asymptomatic Carotid Artery Progression Study (ACAPS). ACAPS Research Group

A randomly selected subset of 100 pairs of baseline and 36-month follow-up carotid B-mode ultrasound examinations from the 919 patients participating in the Asymptomatic Carotid Artery Progression Study (ACAPS) were subjected to a blinded rereading at the conclusion of the trial to assess temporal bias in the measurement of carotid artery intimal-medial thickness (IMT). The original measurements of the primary outcome variable and five secondary outcome variables at baseline and 36 months, respectively, and the 3-year change in each of these variables, were compared with those obtained from the rereadings. For the primary outcome variable, the mean value of 12 IMT measurements obtained from predefined carotid segments, the mean difference (original-rereading) and the 95% confidence interval which resulted from the rereadings were -0.005 (-0.033, 0.023) mm at baseline and -0.009 (-0.031, 0.013) mm at 36 months. The difference in the 3-year change was -0.004 (-0.038, 0.028) mm. The 95% confidence interval for the mean difference between the rereadings and the original readings for the baseline and the 36-month follow-up examinations included zero for all of the six outcome variables as was also the case for the 3-year change in each variable. The magnitude of the mean differences for these 18 variables ranged from 0.004 to 0.034 mm. Intraclass correlation coefficients between the original readings and rereadings ranged from 0.56 to 0.87 with the 3-year changes in outcome variables tending to have lower correlations and the 36-month examinations higher correlations. The carotid IMT measurement process, when combined with uniform reader training, certification and monitoring of reading performance throughout the course of the study, can avoid the temporal bias observed in other studies.

Self-efficacy and pain in disability with osteoarthritis of the knee

This study examined the relationship between self-efficacy beliefs and pain during the performance of stair climbing and lifting/carrying tasks on speed of movement, ratings of task difficulty, and perceived task ability in a group of patients with osteoarthritis (OA) of the knee. Seventy-nine patients with knee OA completed the tasks in a controlled laboratory setting. Before completing each task, patients' self-efficacy was assessed; following task performance they rated (a) the most intense knee pain experienced, (b) the difficulty of the task, and (c) their perceived ability as they performed each task. Results demonstrated that, even after controlling for physical function, self-efficacy, and knee pain during performance, each contributed significantly to understanding either speed of movement or self-reported ratings of task difficulty and perceived ability.

Propranolol-induced lipid changes and their prognostic significance after a myocardial infarction: the Beta-Blocker Heart Attack Trial experience

Beta blockers represent the only documented effective long-term prophylactic treatment for patients after myocardial infarction (MI). Concern continues to be expressed about the lipid-altering effects of their long-term use, especially beta blockers without intrinsic sympathomimetic activity such as propranolol. Data collected for the Beta-Blocker Heart Attack Trial, the largest long-term clinical trial of beta-blocker use in patients after MI, have been analyzed to address the following questions. To what extent does propranolol alter lipid levels at least 6 months after MI and initiation of therapy? How predictive of subsequent coronary events and mortality are lipid levels 6 months after MI? Is there any evidence that altered lipid levels attenuate any of the beneficial effect of propranolol on coronary morbidity and mortality? By the 6-month post-MI visit, propranolol was shown to raise serum triglyceride levels by about 17% (approximately equal to 35 mg/dl) and lower serum high density lipoprotein (HDL) cholesterol by about 6% (approximately equal to 3 mg/dl). There was no effect on total cholesterol or low density lipoprotein cholesterol. In other analyses, no lipid measured 6 months after the MI was strongly predictive of subsequent coronary events or mortality. For example, every 1-mg-lower HDL value was associated with only a 0.7% relative increase in the mortality rate. Theoretically, the estimated relative increase on all-cause mortality associated with propranolol-induced HDL reduction is about 2%. In multivariate analyses adjusting for changes in HDL and serum triglyceride, propranolol-induced beneficial reductions in mortality and morbidity remained on the order of 20%, 10 times the estimated hazard.

Management of renovascular hypertension in the elderly population

This article summarizes our experience with the operative management of renovascular hypertension in a contemporary population of elderly patients. During a recent 18-month period 35 of 74 patients (47%) undergoing an operation for renovascular hypertension at our center were in their seventh (21 patients) or eighth (14 patients) decade of life (mean age, 68 years). There were 17 men and 18 women with blood pressures ranging from 176/90 mm Hg to 280/215 mm Hg (mean, 213/121 mm Hg). Twenty-seven patients (77%) had renal insufficiency (serum creatinine greater than or equal to 1.3 mg/dl). Nineteen patients had severe insufficiency (serum creatinine greater than or equal to 2.0 mg/dl), with five of these patients being dependent on dialysis. Thirty-three of 35 patients (94%) had evidence of organ-specific atherosclerotic damage as manifested by cardiac disease (72%), cerebrovascular disease (37%), or renal insufficiency (77%). Operative management consisted of unilateral revascularization in 17 patients (includes three contralateral nephrectomies), bilateral renal revascularization in 17 patients, and primary nephrectomy in one. Simultaneous aortic replacement was performed in nine patients. There were two operative deaths (5.7%) and two postoperative graft thromboses (4%). Hypertension was cured (three) or improved (27) in 30 of the 33 survivors (91%). Renal function was improved in six and worsened in two patients with severe non-dialysis-dependent renal insufficiency. Three of five patients who were dependent on dialysis before surgery were removed from dialysis after renal revascularization. On follow-up (mean, 10.3 months) we found that five patients had died. This article emphasizes the complexity of atherosclerosis in the current population presenting for operative management of renovascular hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)