Search

RATIONALE AND OBJECTIVE: The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in those with and without CKD. STUDY DESIGN: Neuroimaging substudy of a randomized trial. SETTING & PARTICIPANTS: A subset of participants in the Systolic Blood Pressure Intervention Trial who underwent brain MRI studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). INTERVENTION: Participants were randomly assigned to intensive (systolic BP 30 mg/g (N=151), the effects of intensive versus standard BP treatment on change in global cerebral blood flow, WMLs and total brain volume were 1.91 ml/100g/min (95% CI −3.01, 6.82), 0.003 cm(3) (asinh transformed, 95% CI −0.13, 0.13), and −7.0 cm(3) (95% CI −13.3, −0.3), respectively. The overall treatment effects on cerebral blood flow and total brain volume were not modified by baseline eGFR or UACR; however the effect on WMLs was attenuated in participants with albuminuria (interaction p-value 0.04). LIMITATIONS: Measurement variability due to multi-site design. CONCLUSIONS: Among hypertensive adults with primarily early kidney disease, intensive versus standard blood pressure treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive blood pressure treatment targets on brain health in persons with early kidney disease. FUNDING: The Systolic Blood Pressure Intervention Trial was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION: SPRINT was registered at ClinicalTrials.gov with the study number NCT01206062.

Unlike tobacco, the effect of marijuana smoke on subclinical atherosclerosis, a surrogate measure for cardiovascular disease, is not known. This study aimed to determine the association between lifetime exposure to marijuana and measures of subclinical atherosclerosis in mid-life.We used data from the US-based Coronary Artery Risk Development in Young Adults (CARDIA) study, a cohort of black and white men and women aged 18-30 years at baseline in 1985-86, with up to seven follow-up examinations over 25 years. A total of 3498 participants in the CARDIA study were included in this study.Cumulative years of exposure to marijuana (expressed in 'marijuana-years', with 1 marijuana-year equivalent to 365 days of use) using repeated assessments every 2-5 years for 25 years. Abdominal artery calcium (AAC) and coronary artery calcium (CAC) scores were measured by computed tomography at year 25 examination.Among 3117 participants with AAC and CAC measurements, 2627 (84%) reported past marijuana use and 1536 (49%) past daily tobacco smoking. Compared with tobacco smokers, 46% of whom reported 10 or more pack-years of use, only 12% of marijuana users reported 5 or more marijuana-years of use and only 6% reported having used marijuana daily. We found a significant interaction between never and ever tobacco users on the association between cumulative marijuana use and AAC (P = 0.05). Among those who never smoked tobacco, cumulative marijuana-years were not associated with AAC or CAC in models adjusted for demographics, cardiovascular risk factors, licit and illicit drug exposure and depression symptoms. However, among ever tobacco smokers, marijuana exposure was associated with AAC and CAC. At 5 marijuana-years of exposure, using AAC = 0 and CAC = 0 as a reference group, the odds ratio (OR) was 1.97 [95% confidence interval (CI) = 1.21-3.21, P = 0.007] for AAC 0/CAC = 0 and 1.83 (95% CI = 1.02-3.31, P = 0.04) for CAC 0), regardless of AAC. Tobacco smoking was associated strongly with both AAC and CAC.Marijuana use appears to be associated with subclinical atherosclerosis, but only among ever tobacco users.

Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair Nancy M. Albert, PhD, CCNS, CCRN, FAHA Paul S. Chan, MD, MSc, FACC Lesley H. Curtis, PhD T. Bruce Ferguson, Jr, MD, FACC Gregg C. Fonarow, MD, FACC, FAHA P. Michael Ho, MD, PhD, FACC, FAHA Corrine Jurgens, PhD, RN, ANP-BC, FAHA Sean O’Brien

Introduction: Diastolic blood pressure (DBP) instead of systolic BP (SBP) or pulse pressure (PP) has been suggested as an important predictor for cardiovascular disease (CVD) events in those Methods: Using data from the Coronary Artery Risk Development in Young Adults (CARDIA), which recruited healthy black and white young adults ages 18 to 30 years (n=4880) in 1985-1986, we assessed the associations between distinct BP components (SBP, DBP, mean arterial pressure [MAP], and PP) and incident CVD, defined as a composite endpoint of CVD deaths, myocardial infarction, angina, stroke, and heart failure. Results: The mean SBP, DBP, and PP at baseline (mean age 25 years) were 112, 69, and 43 mmHg in blacks (n=2473) and 109, 68, and 41 mmHg in whites (n=2407), respectively. Over 25 years of follow-up (100,291 person-years), 210 CVD events (140 events in blacks) occurred before the age of 55. Results from Cox proportional hazards models suggest that SBP was superior to DBP for predicting incident CVD in blacks, while DBP was superior to SBP in whites (Table). In blacks, CVD risk associated with higher PP was significant in models including MAP. Significant interactions were found between race and PP (P=0.02) but not SBP (P=0.14) and DBP (P=0.38) in association with incident CVD risk. Conclusions: In this long-term follow-up study, SBP outperformed DBP for predicting incident CVD in young blacks, while DBP outperformed SBP in young whites. In blacks, higher PP, representing large arterial stiffness, was associated with CVD risk. These racial differences may be attributable to earlier development of arterial stiffness in blacks compared with whites.

Background: Marijuana is the most frequently used illicit drug in the US. Its use is expected to rise given recent state policies that relax criminalization and permit medicinal use. Although several mechanisms exist by which marijuana might contribute to chronic cardiovascular conditions, few data are available. We sought to determine the association of lifetime marijuana use with the development of incident CHD and CVD. Methods: Participants were 5,114 white and black adults aged 18-30 years in 1985-86 from the multicenter, community-based CARDIA Study who have been followed for over 25 years. We estimated cumulative years of exposure in “marijuana-years,” with one marijuana-year equal to 365 days of marijuana use using repeated assessments every 2-5 years. Incident CHD included fatal or nonfatal myocardial infarction, angina, or CHD death. Incident CVD included CHD, stroke, hospitalized heart failure, and intervention for peripheral arterial disease. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals. Lifetime marijuana use and all time-varying covariates were entered as time-dependent variables. Results: Approximately 16% of the cohort were lifetime never users of marijuana, while 35%, 22%, 14%, and 13% reported lifetime use of 0.3, for all). Conclusions: In this long-term follow-up study of young adults at baseline, lifetime use of marijuana at these levels was not associated with incident CHD or CVD in middle-age.

Placement of peripheral pediatric intravenous (IV) catheters in infants and children is difficult, even in skilled hands. This large, 2-institution prospective study used real-time independent observations to describe the effect of nurse experience and competence on the length of time and the number of attempts to establish a successful IV placement in the hospitalized child. Data from a convenience sample of 592 evaluable patients and 1135 venipunctures showed that successful IV placements required an average of 2 venipunctures over 28 minutes. Although nurse experience and self-rated competence were correlated with attaining a successful IV placement, time of day, predicted difficulty of the venipuncture, and cooperativeness of the child appeared to be better predictors of success.

Background The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997. Methods and Results A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee. Conclusions The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

Myocardial infarction is a major cause of death and disability worldwide. Coronary atherosclerosis is a chronic disease with stable and unstable periods. During unstable periods with activated inflammation in the vascular wall, patients may develop a myocardial infarction. Myocardial infarction may be a minor event in a lifelong chronic disease, it may even go undetected, but it may also be a major catastrophic event leading to sudden death or severe hemodynamic deterioration. A myocardial infarction may be the first manifestation of coronary artery disease, or it may occur, repeatedly, in patients with established disease. Information on myocardial infarction attack rates can provide useful data regarding the burden of coronary artery disease within and across populations, especially if standardized data are collected in a manner that demonstrates the distinction between incident and recurrent events. From the epidemiological point of view, the incidence of myocardial infarction in a population can be used as a proxy for the prevalence of coronary artery disease in that population. Furthermore, the term myocardial infarction has major psychological and legal implications for the individual and society. It is an indicator of one of the leading health problems in the world, and it is an outcome measure in clinical trials and observational studies. With these perspectives, myocardial infarction may be defined from a number of different clinical, electrocardiographic, biochemical, imaging, and pathological characteristics. In the past, a general consensus existed for the clinical syndrome designated as myocardial infarction. In studies of disease prevalence, the World Health Organization (WHO) defined myocardial infarction from symptoms, ECG abnormalities, and enzymes. However, the development of more sensitive and specific serological biomarkers and precise imaging techniques allows detection of ever smaller amounts of myocardial necrosis. Accordingly, current clinical practice, health care delivery systems, as well as epidemiology and clinical trials all require a …

Introduction: Though cardiorespiratory fitness (CRF) is a well-established prognostic marker in older adults, the relationship between changes in CRF during early adulthood and long-term cardiovascular structure, function, and events remain unknown. Hypothesis: CRF and its change over time in young adults is associated with long-term outcome and cardiovascular disease (CVD). Methods: 4,872 American adults age 18-30 years underwent treadmill exercise testing at a baseline study visit in 1985-1986, and 2,472 individuals who underwent repeat treadmill testing 7 years later in CARDIA. Participants were followed for a median of 26.9 years, with assessment of obesity, echocardiographic left ventricular (LV) mass and strain, coronary artery calcification (CAC), and vital status and incident CVD. Incident CVD (cardiovascular death, heart failure, myocardial infarction, peripheral artery disease and stroke) and all-cause mortality were uniformly adjudicated. Results: From 4,872 individuals, 273 (5.6%) died and 193 (4%) experienced CVD events at a median 26.9 year follow-up. After full adjustment, each additional minute of baseline exercise test duration was associated with a 13% lower hazard of death (hazard ratio HR 0.87, 95% CI 0.81-0.92, P Conclusions: Higher fitness at baseline and improvement in fitness early in adulthood are favorably associated with CVD and mortality risk. Fitness and changes in fitness are associated with myocardial hypertrophy and dysfunction, but not CAC. Regular efforts to ascertain and improve CRF in young adulthood may play a critical role in promoting cardiovascular health and interrupting early CVD pathogenesis.

Developed in collaboration with the National Committee for Quality Assurance, the American Society of Health-System Pharmacists, and the American Medical Association–Physician Consortium for Performance Improvement

Atherosclerosis related inflammation and plaque result in expansive remodeling of the coronary artery, a finding associated with plaque rupture and clinical events. The extent of expansive coronary remodeling in adults prior to the development of clinical disease is largely unknown. We tested the hypothesis that middle-aged adults who have subclinical coronary artery disease also have larger coronary artery diameters. Methods: Submillimeter thin slice, non-contrast cardiac CT images were obtained in 1197 black and white men and women in the Coronary Artery Risk Development in Young Adults (CARDIA) Study during the year 25 examination (2010-2011, mean age 50 years). Average coronary artery diameter(mm) and cross sectional area (mm2) were measured sequentially along the length of each vessel and averaged for the left main (LM) and proximal circumflex (LCX), left anterior descending (LAD), and right coronary (RCA) arteries. Presence/absence of coronary artery calcifications [CAC (0 versus >0 AU)] was measured independently. Multivariable linear regression models were used to examine the association of CAC with artery size. Results: Coronary diameter was larger in blacks compared to whites (p Conclusion: Coronary arteries are larger in middle-age individuals with vs without CAC, supporting the hypothesis that atherosclerosis leads to expansive coronary remodeling. Coronary remodeling by non-contrast CT is a measure that may provide new information on cardiovascular risk and prediction of clinical cardiovascular events.

Background: Greater lactation duration has been associated with lower incidence of the metabolic syndrome, and self-reported type 2 diabetes and heart disease in women later in life. Two retrospective studies reported higher carotid artery intima-media thickness among parous women who never or inconsistently breastfed, but no clear association with duration. However, lactation history was recalled many years later and heart disease risk factors were not measured before pregnancy. We hypothesized that lactation duration has a graded inverse association with subclinical atherosclerosis in women during mid-life independent of pre-pregnancy cardiometabolic risk factors. Methods: We examined 846 women (46% Black), aged 18-30 years at enrollment in 1985-1986 (baseline) in the biracial Coronary Artery Risk Development in Young Adults (CARDIA) study. Women included delivered 1 or more live births from 1986-2005, had no history of heart disease or diabetes before pregnancies, and had maximum common carotid intima media thickness (ccIMT, mm) measured in 2005-2006 at ages 38-50 years. Lactation duration was recalled within 1 to 4 years of delivery. We categorized women into four lactation groups according to cumulative duration for all post-baseline births; 0-10 months (n=205). Multiple linear regression models estimated mean ccIMT (95% CI) among lactation categories adjusted for pre-pregnancy cardiometabolic risk factors [BMI, systolic blood pressure (SBP), HDL-C, HOMA-IR], parity, socio-demographics (age, race, education), and smoking. We also assessed weight gain and change in SBP as mediators of the lactation and ccIMT association. Results: Increasing lactation duration showed a graded inverse association with mean ccIMT; differences between >10 months vs. 0 Conclusions: Greater lactation duration is associated with lower mean ccIMT independent of cardiometabolic risk factors measured before pregnancy, parity, socio-demographics and smoking. Lactation may have lasting favorable effects on cardiometabolic risk factors for heart disease.

Introduction: The goal of primary prevention is to direct treatment to individuals who will derive greatest benefit. However, single risk factors such as blood pressure or age incompletely capture absolute risk and potential treatment benefit for the individual, thus providing a role for multivariable risk assessment. In this study, we aim to compare blood pressure treatment decisions based on levels of systolic blood pressure (SBP), age, or pretreatment risk. Methods: We used individual participant data from participants without cardiovascular disease in the Blood Pressure Lowering Treatment Trialists’ Collaboration, a prospective overview of randomized blood pressure trials. Three treatment strategies based on thresholds of SBP, age, or five-year Framingham risk estimates were compared by calculating expected number of cardiovascular events and net benefit using graphical methods and decision curve analyses. Strategies were compared as differences in the areas under the curves expressed as percentages of the maximum possible area, with bootstrap-obtained confidence intervals. Results: We analysed 16,419 individuals with 53,571 person-years of follow-up. At every level of number of individuals treated or number of events expected, the risk-based approach using the Framingham risk estimates appeared superior to SBP (risk minus SBP-based treatment decisions = -2.8% [95% CI -4.1% to -1.3%]) or age (risk minus age-based decisions -2.6% [95% CI -4.7% to -0.7%]) (Figure). For a treatment threshold based on expected absolute risk reduction, net benefit was maximized using Framingham risk estimates for a threshold of 1 to 4%, although the differences did not meet statistical significance. Conclusions: Blood pressure treatment decisions based on estimated absolute risk appear more efficient than age- or SBP-based treatment decisions, across a wide range of treatment thresholds. These results support prioritizing risk-based blood pressure treatment strategies in the primary prevention of cardiovascular events.

Elevated low-density lipoprotein cholesterol (LDL-C) is a treatable, heritable risk factor for cardiovascular disease. Genome-wide association studies (GWASs) have identified 157 variants associated with lipid levels but are not well suited to assess the impact of rare and low-frequency variants. To determine whether rare or low-frequency coding variants are associated with LDL-C, we exome sequenced 2,005 individuals, including 554 individuals selected for extreme LDL-C (>98(th) or

Objective: The goal of this study was to measure the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children; measures of resource utilization. We measured the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children. This common procedure has implications for the utilization of hospital resources. Methods: This was a prospective, large-scale observational study in 2 southeastern US pediatric teaching hospitals evaluating 592 children needing peripheral IV catheters in the inpatient setting. The median age was 2.25 years with an age range of 2 days to 18 years. Costs were estimated by using directly measured staff time and national salary data. Analyses included costs according to patient characteristics (age, weight, dehydration, and difficulty of stick attempts), and nurse characteristics (experience in years and anticipated difficulty). Results: The median cost of the pediatric IV insertions was $41, and 60% of the placements were obtained with the first nurse. Seventy-two percent of the children had a successful IV insertion in 1 to 2 attempts and accounted for 53% of total costs. However, the 28% of children who required ≥3 IV attempts had a cost range of $69 to more than $125, and they consumed 43% of the total IV costs. This subset was often Conclusions: The insertion of peripheral IV catheters in an inpatient setting can be time intensive and requires significant skill. Our study suggests that resource utilization may improve when nurses and personnel proficient in starting peripheral IV catheters are used when the initial nurse has failed to obtain IV access. This systems improvement should result in shortened time to administration of parenteral therapies, positively improving outcomes and lessening length of stay, as well as improving patient/family satisfaction due to reduced perceptions of pain.

Background: Experimental studies have suggested that cadmium (Cd) exposure is a potential risk factor for early atherosclerosis and cardiovascular diseases as it can disrupt integrity of the endothelial cell layer. However, longitudinal data in humans relating Cd levels to sub-clinical atherosclerosis are lacking. Methods: 2589 participants from the CARDIA Study, aged 20-32 years in 1987 (baseline) with up to 18 years of follow-up were included in the analyses to examine prospectively the associations of toenail Cd concentrations with carotid intima-media thickness (CIMT) and coronary artery calcium score (CAC score). Toenail clippings were collected in 1987 and Cd was assessed by instrumental neutron-activation analysis. Common (c), bulb (b), and internal (i) CIMTs were measured in 2005 and CAC score in 2000 and 2005. CAC presence (score, >0 Agatston units) and CAC progression (incident CAC in 2005 or increase in CAC score by ≥10 Agatston units) were defined based on CAC score. General linear regression or logistic regression was used as appropriate. Results: Median Cd levels were 0.003, 0.006, 0.012 and 0.039 μ g/g from 1 st - 4 th quartile. We observed a positive linear relation of Cd levels with cCIMT, but not bCIMT and iCIMT ( Table 1 ). Null associations between Cd levels and CAC progression [Q 4 vs . Q 1 : OR=1.11 (95% CI: 0.73, 1.68); P trend =0.14] or presence of CAC [Q 4 vs . Q 1 : OR=1.05 (0.73, 1.53); P trend =0.56] were documented. Conclusions: In this young adult cohort, toenail Cd levels were positively associated with cCIMT, but not bCIMT, iCIMT and CAC score. Further studies are needed to determine whether there is an atherosclerotic mechanism linking Cd exposure to the risk of cardiovascular disease. Table 1 Multivariable-adjusted carotid intima-media thickness (mm) by toenail cadmium levels No. of participants Quartile of toenail cadmium levels P trend Q1 Q2 Q3 Q4 cCIMT 2587 0.781 (0.773-0.790) 0.784 (0.776-0.793) 0.789 (0.781-0.798) 0.791 (0.781-0.798) 0.03 bCIMT 2527 1.010 (0.990-0.1.031) 1.002 (0.982-1.022) 0.981 (0.962-1.001) 1.001 (0.980-1.022) 0.17 iCIMT 2436 0.787 (0.772-0.802) 0.790 (0.776-0.804) 0.784 (0.770-0.798) 0.778 (0.763-0.793) 0.86 Data are geometric means (95%CIs) adjusted for age, gender, race, study center, body mass index, physical activity, education, smoking status, alcohol consumption, systolic blood pressure, LDL/HDL, HOMA, body mass index, long-chain omega-3 polyunsaturated fatty acids intake with toenail zinc, chromium, lead and mass weight. cCIMT : common carotid intima-media thickness; bCIMT : bulb carotid intima-media thickness; iCIMT : internal carotid intima-media thickness.

Background. Peripheral intravenous (PIV) line placement is a time-consuming procedure performed on the majority of general pediatric inpatients, with significant discomfort to patients. Objective. To determine parameters of pediatric PIV placement, including success rates, time to success, and factors associated with success. Design. Prospective study involving direct observation of PIV placement by trained research staff. Setting. General inpatient wards at 2 medium-sized pediatric hospitals. Patients. Hospitalized children younger than 19 years. Results. Successful placement was achieved in 95.8% (567/592) cases with a median time of 9 minutes. Children younger than 2 years were less likely to have success on the first attempt (38.9% vs 53.5%) and have longer time to success (11 minutes). Conclusions. Children younger than 2 years experienced lower first-attempt successful PIV placement and took longer. The overall success rate was similar to prior reports; these data are the first to show differential PIV success by patient age.

Eric D. Peterson, MD, MPH, FACC, FAHA, Chair; Frederick A. Masoudi, MD, MSPH, FACC, FAHA[†††][1]; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; Gregg C. Fonarow, MD, FACC, FAHA; David C. Goff, Jr., MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A.

OBJECTIVE To compare the effect of intensive versus standard glycemic control strategies on health-related quality of life (HRQL) in a substudy of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. RESEARCH DESIGN AND METHODS A randomly selected subsample of 2,053 ACCORD participants enrolled in the HRQL substudy was assessed at baseline and 12-, 36-, and 48-month visits. HRQL assessment included general health status (the 36-Item Short Form Health Survey [SF-36]), diabetes symptoms (the Diabetes Symptom Distress Checklist), depression (Patient Health Questionnaire [PHQ]-9), and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire [DTSQ]). Repeated-measures ANOVA models were used to estimate change in HRQL outcomes by treatment group over 48 months adjusting for model covariates. The effects of early discontinuation of the ACCORD intensive glycemic control arm on study results were explored. RESULTS A total of 1,956 (95%) completed the self-report HRQL instrument(s) at baseline. The intensive arm had a larger decrease in SF-36 physical health component score than the standard arm (−1.6 vs. −1.1, P = 0.0345). Treatment satisfaction (DTSQ) showed larger improvement with intensive than standard (P = 0.0004). There were no differences in mean scores of the Diabetes Symptom Checklist and PHQ-9. Effects of participant transition following discontinuation of the intensive arm on HRQL were not significant. CONCLUSIONS The ACCORD trial strategy of intensive glycemic control did not lead to benefits in HRQL and was associated with modest improvement in diabetes treatment satisfaction. Thus patient acceptability was apparently not compromised with intensive and complex interventions such as those used in ACCORD.

Background . Inflammation factors and coronary calcium score are associated with risk of CVD events. There are few studies including large numbers of participants from minority ethnic groups. Methods. From 2000 –2002, 6,814 men and women without CVD were enrolled; white, black, Hispanic and Chinese; aged 45– 84, free of CVD. We measured C-reactive protein (CRP), interleukin-6 (IL-6), fibrinogen and computed tomography for coronary artery calcium (CAC) scoring. Over 3.5 years follow up there were 238 first CVD events in 227 participants (64 myocardial infarction, 85 angina, 8 cardiac arrest, 58 stroke, 23 CVD death). Proportional hazards models were used to calculate HRs of overall CVD, adjusted for age, sex, ethnicity, standard risk factors and statin use. Results. Age and sex-adjusted HRs (95% CI) of CVD for CRP >3 mg/L (vs rd vs 1 st tertile were 1.71 (1.21–2.42), 1.61 (1.13–2.32) and 1.59 (1.28 –2.28), respectively. Fully adjusted HRs were 1.41 (0.98 –2.04), 1.30 (0.89 –1.91) and 1.17 (0.80 –1.70). Exclusion of angina as an endpoint increased the adjusted HR for CRP (1.63; 1.01–2.63) but not IL-6 or fibrinogen. There were no significant differences of these associations by sex or ethnicity. Within categories of baseline CAC, associations of CRP and IL-6 with CVD events were only present among those with CAC 1–100 Agatston units (table ). Discussion. Associations of inflammation factors with future CVD in this study were weaker than in other studies of primarily white participants. Stronger associations among those with low levels of detectable CAC suggest detection of plaque vulnerability with biomarkers in these individuals with modest atherosclerotic burden. Adjusted HR of CVD for Baseline Inflammation Markers by CAC Category (Agatston Units)

Context: Whole grain intake is inversely associated with LDL-c and the metabolic syndrome, but the relationship of whole grains with other lipid parameters, such as small, dense LDL, is not established. We sought to evaluate the relationship of whole grain intake with lipids, apolipoproteins, and LDL lipoprotein subclasses in a large, multi-ethnic cohort. Methods: This cross-sectional study evaluated 975 non-diabetic participants in the Insulin Resistance Atherosclerosis Study. Baseline whole grain intake was estimated based on intake of dark breads, cooked cereals, and high-fiber cereals assessed in a validated food frequency questionnaire. Fasting lipid measurements included apolipoproteins and lipoprotein subclasses quantified by NMR spectroscopy. Linear regression models evaluated lipid parameters across quartile of whole grain intake after adjustment for demographics (age, sex, ethnicity, center), anthropometrics (BMI, waist circumference), lifestyle factors (smoking, alcohol intake), dietary factors (total kcal, fruits, vegetables, dietary fats) and lipid-lowering medication use. Additional models included directly measured insulin sensitivity (Si). Results: The cohort was 56% female, had a mean (SD) age of 54.8 (8.5) years, and was 60% non-white, with a median whole grain intake of .73 servings/day. In adjusted models, there was an inverse association between whole grain intake and LDL-c, Apo-B, Apo-B/Apo-A1 ratio, LDL particle concentration (LDL-p), and small LDL-p (Table ). These associations remained significant after adjustment for Si (LDL-c: p=.007; Apo-B: p=.04; Apo-B/Apo-A1: p=.03; LDL-p: p=.03; small LDL-p: p=.03). Conclusion: Whole grain intake is inversely associated with multiple lipid risk factors, including total and small LDL particle concentration, independent of insulin sensitivity and other confounders. This demonstrates additional mechanisms for the cardioprotective effects of whole grains.

Background—The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.Methods and Results—A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.Conclusions—The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality.

The authors studied associations between ankle-brachial index (ABI) and subclinical atherosclerosis in the Multi-Ethnic Study of Atherosclerosis. Participants included 3,458 women (average age = 62.6 years) and 3,112 men (average age = 62.8 years) who were free of clinically evident cardiovascular disease. Measurements included ABI, carotid artery intima-media thickness, and coronary artery calcium assessed with computed tomography. Five ABI categories were defined:0.90 (definite peripheral arterial disease (PAD)), 0.90-0.99 (borderline ABI), 1.00-1.09 (low-normal ABI), 1.10-1.29 (normal ABI), andor =1.30 (high ABI). Compared with that in men with normal ABI, significantly higher internal carotid artery intima-media thickness was observed in men with definite PAD (1.58 vs. 1.09; p0.001), borderline ABI (1.33 vs. 1.09; p0.001), and low-normal ABI (1.18 vs. 1.09; p0.001) after adjustment for confounders. Fully adjusted odds ratios for a coronary artery calcium score greater than 20 decreased across progressively higher ABI categories in both women (2.85 (definite PAD), 1.27 (borderline ABI), 1.11 (low-normal ABI), 1.00 (normal ABI; referent), and 0.78 (high ABI); p for trend = 0.0002) and men (3.26 (definite PAD), 1.72 (borderline ABI), 1.14 (low-normal ABI), 1.00 (normal ABI; referent), and 1.43 (high ABI); p for trend = 0.0002). These findings indicate excess coronary and carotid atherosclerosis at ABI values below 1.10 (men) and 1.00 (women) and may imply increased risk of cardiovascular events in persons with borderline and low-normal ABI.

Despite the recognition of strategies for diabetes care management, information systems that screen patient diabetes self-care problems are not commonplace, especially among low-income patients. This study examined correlates of three patient-centered outcomes of diabetes self-care (awareness of self-care components, difficulties in diabetes self-care, and adherence to self-care) among low-income diabetic patients.Clinical and patient survey data were obtained on 249 participants from 11 primary care community health clinics serving low-income populations in North Carolina in Project IDEAL (Improving Diabetes Education, Access to Care and Living). Measures of patient-centered outcomes of self-care were obtained from the Diabetes Quality Improvement Project (DQIP) Patient-Reported Measures set.A substantial proportion of patients reported difficulty achieving standard self-care treatment goals. The study identified distinct patient characteristics associated with poor self-care outcomes. Increased understanding of self-care components and adherence to them were associated with increased perception of quality of care and, in turn, better general health perceptions in these patients (p0.01).This study identified an unmet need for diabetes self-care knowledge and skills associated with patient outcomes in low-income patients. Routine monitoring of patient-centered self-care outcomes could help improve long-term outcomes of diabetes care in this population.

The Fiber Optic Reference Guide offers readers a solid understanding of the principles of fiber optic technology, especially as it relates to telecommunications, from its early days to developing future trends. Using a minimum of jargon and a wealth of illustrations, this book provides the underlying principles of fiber optics as well as essential practical applications. The third edition is updated to include expanded sections on light emitters, semiconductor optical amplifiers, Bragg gratings, and more systems design considerations. Fiber optics plays a key role in communications, as well as in broadcast and cable systems. Engineers working with fiber optics as well as newcomers to the industry will find the third edition of this reference guide invaluable. It will help the reader develop a solid understanding of the underlying principles of this rapidly changing technology as well as its essential practical applications. The text is thoroughly indexed and illustrated.

A series of new 9-phenanthrene amino alcohols has been prepared in which each compound bears from one to five halogen or halogen-containing moieties. A number of these compounds are extremely active against Plasmodium berghei in the mouse. Some structural requirements for optimal efficacy are considered.