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• Summary: This article discusses the findings of a qualitative study with a sample of suicide attempters in the Chinese immigrant community of New York City from an ecological perspective. • Findings: The narratives of the participants delineate the pathway of their suicide attempts as the culmination of an interactive process of stressors, mental illness, and diminished help-seeking behavior, compounded by immigrant-specific issues, cultural meanings of distress and social barriers to resources. • Application: The transactional dynamics of these risk factors underscore the importance of adopting an integrative and contextualized stance of inquiry in suicide studies and initiating a broad-based community effort in suicide prevention.

Background Abnormal levels of soluble CD40 ligand (sCD40L) have been reported in patients with hypertension, coronary artery disease, diabetes mellitus, heart failure, and stroke, all of which are conditions that are associated with nonvalvular atrial fibrillation (AF). We hypothesized the following: (1) CD40 ligand (CD40L)-related indexes ( ie , platelet surface expressed CD40L, the soluble fragment of CD40L [sCD40L], and the total amount of CD40L per platelet [pCD40L]) are elevated in patients with AF compared to control subjects; (2) these indexes correlate with soluble P-selectin (sP-selectin), which is an established platelet marker; and (3) these indexes differentiate "high-risk" from "low-risk" subjects. Methods We performed a case-control study of 121 AF patients, 71 "disease control subjects," and 56 "healthy control subjects." Peripheral venous levels of platelet surface-expressed CD40L were analyzed by flow cytometry, while levels of sCD40L, pCD40L, and sP-selectin were measured by enzyme-linked immunosorbent assay. Results AF patients had significantly higher sCD40L levels compared to healthy control subjects (p = 0.042), with no difference in platelet surface CD40L and pCD40L levels. A positive correlation was noted between levels of sCD40L and pCD40L, and not with sP-selectin. CD40L-related indexes failed to distinguish between high-risk and low-risk AF patients. AF patients receiving optimal antithrombotic therapy had significantly lower pCD40L levels (p Conclusion CD40L-related indexes are not useful in the risk stratification of AF patients, and abnormal sCD40L levels can be reduced by intense multifactorial risk management. While there is a significant, albeit modest, excess of platelet activation in AF patients (as measured by sCD40L levels) compared to healthy control subjects, this is not in excess of that seen in patients with underlying cardiovascular diseases.

SUMMARY This article discusses the emotional dimension of identity development among Chinese immigrant women: their emergent needs for attention, validation, and support from their spouses. Using this author's private practice experience with this population, the article illuminates the sociocultural reality of a group of Chinese immigrant women, and the therapeutic approaches that supported them in creating new meanings and options in their seemingly unsolvable dilemmas.

Objectives The aim of this work was to comprehensively study the role of platelets in atrial fibrillation (AF), in relation to the underlying cardiovascular diseases and type of AF, and to analyze the effect of antithrombotic treatment on different aspects of platelet activation. Background Platelet activation is present in nonvalvular AF, but there is debate whether this is due to AF itself and/or to underlying cardiovascular diseases. Methods A total of 121 AF patients were compared with 65 “healthy control subjects” and 78 “disease control subjects” in sinus rhythm. Platelet activation was assessed using 4 different aspects of platelet pathophysiology: 1) platelet surface expression of CD62P (P-selectin) and CD63 (a lysosomal glycoprotein) (by flow cytometry); 2) mean platelet volume (MPV) (by flow cytometry); 3) plasma levels of soluble P-selectin (sP-selectin, enzyme-linked immunoadsorbent assay); and 4) total amount of P-selectin per platelet (pP-selectin) (“platelet lysis” assay). Results Both AF patients and “disease control subjects” had higher levels of CD62P (p Conclusions There is a degree of excess of platelet activation in AF compared with “healthy control subjects,” but no significant difference between AF patients and “disease control subjects” in sinus rhythm. Platelet activation may differ according to the subtype of AF, but this is not in excess of the underlying comorbidities that lead to AF. Platelet activation in AF may be due to underlying cardiovascular diseases, rather than due to AF per se.

Background: Platelet microparticles (PMPs), are procoagulant membrane vesicles that are derived from activated platelets, the levels of which are elevated in patients with hypertension, coronary artery disease (CAD), diabetes, and stroke, all of which are conditions that lead to (and are associated with) atrial fibrillation (AF). We hypothesized the following: (1) PMP levels are elevated in patients with AF compared to levels in both healthy control subjects ( ie , patients without cardiovascular diseases who are in sinus rhythm) and disease control subjects ( ie , patients with hypertension, CAD, diabetes or stroke, but who are in sinus rhythm); (2) PMP levels correlate with levels of soluble P-selectin (sP-selectin) [a marker of platelet activation]; and (3) PMP levels are related to the underlying factors in patients with AF that contribute to the overall risk of stroke secondary to AF. Methods: We performed a case-control study of 70 AF patients, 46 disease control subjects and 33 healthy control subjects. Peripheral venous levels of PMP and sP-selectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively. Results: Both AF patients and disease control subjects had significantly higher levels of PMPs (p Conclusion: There is evidence of platelet activation ( ie , high PMP and sP-selectin levels) in AF patients, but this is likely to be due to underlying cardiovascular diseases rather than the arrhythmia per se .

Background Increased platelet activation has been reported in nonvalvular atrial fibrillation (AF) but it remains unclear whether or not this is due to the underlying cardiovascular diseases, clinical subtype of AF and the influence of anti-thrombotic therapy. Methods Platelet adhesion in AF patients was assessed using a ‘platelet adhesion assay', and compared to both ‘healthy controls' and ‘disease controls' (patients with hypertension, coronary artery disease, diabetes or stroke but in sinus rhythm). Results AF patients on no anti-thrombotic treatment ( N =20) had increased platelet adhesion compared to ‘healthy controls' ( N =57) ( p =0.044). Initiating treatment with both aspirin and warfarin resulted in significant reduction in platelet adhesion in AF patients ( p =0.014 and 0.019 respectively). AF patients on optimal anti-thrombotic therapy ( N =98) had no significant difference in platelet adhesion compared to ‘healthy controls' and ‘disease controls' ( p =0.312). Platelet adhesion failed to distinguish between ‘high-risk' (i.e. CHADS score≥2) and ‘low-risk' (i.e. CHADS score p =0.352). Amongst the clinical parameters that contribute to increased stroke risk in AF, platelet adhesion was only correlated with age ( r =0.215, p =0.034), and not with other stroke risk factors. There was no significant difference in platelet adhesion between paroxysmal and permanent AF ( p =0.618). Conclusion There is a significant, albeit weak, excess of platelet adhesion in AF patients on no anti-thrombotic therapy compared to ‘healthy controls'. In optimally treated AF patients, platelet adhesion is not different to both ‘healthy' and ‘disease controls'. It is possible that abnormal platelet adhesion does not significantly contribute to the increased risk of stroke and thromboembolism that persists despite anti-thrombotic treatment in AF or in identifying ‘high-risk' AF patients.

This paper discusses the findings of a study that explores the difficulties experienced by a small purposive sample of Asian American social work students in their professional training due to differences between their cultural norms and values and those of the social work profession. A series of tutorial sessions were used as a forum for student inquiry and learning. A common issue reported by the students was their perception of their cultural differences as deficits in their professional training. The social work skills of reframing and clarification were used by the author to validate the students' cultural strengths and create culturally relevant meanings to practice concepts and skills.

Women with a ruminative style—a tendency to focus repetitively on the meaning, causes, and consequences of their distress—were hypothesized to delay seeking a diagnosis from a healthcare professional for a potentially dangerous breast symptom relative to women without a ruminative style. In Study 1, 147 female “ruminators” and “non–ruminators” read a vignette in which they imagined they had just discovered a change in their breast, completed measures of affect, and reported their intentions to seek care for this breast symptom. Ruminators were significantly less likely to intend to call the doctor immediately after finding an imaginary breast lump than were non–ruminators. In Study 2, 70 women breast cancer survivors recalled the dates related to their symptom finding and their affective responses to symptom finding. Ruminators delayed the presentation of their breast cancer symptoms to a healthcare professional 39 days longer than did non–ruminators. Furthermore, in both studies, the effects of ...

Reframing can be an effective tool in enhancing a clinical practice that is based on a holistic understanding of the client's meaning systems, and the strengths and resilience exemplified in the client's life experience. Immigrant clients, who are often marginalized in society due to their markedly different sociocultural backgrounds and the pernicious effects of racism, tend to struggle with belief systems that are subjugated by those of the host country and internalize their losses and setbacks as personal deficits and failures. Two case vignettes of Chinese immigrants will be used to discuss how reframing can offer positive yet culturally relevant options for clients to create new meanings and adaptive behavior in their life situations.

SUMMARY This article discusses how traditional social group work practice, with its conscious use of group activity and its non-verbal content, can serve as a culturally compatible service model to benefit the Asian American immigrant elderly. The goals and nature of group work practice are examined in the context of addressing the demands of this population's sociocultural reality. Cultural-specific constructs of psychological well-being and forms of emotion expression are examined to support this premise. A case illustration is used to supplement the discussion.

This article discusses the unique design of a community day treatment program that addresses the issues of loss and acculturation for a Chinese American immigrant population who suffers from chronic mental illness. The program utilizes an integrated, multi-cultural milieu of staff and clients to create a microcosm of the diversity of American society, and reflects the agency's belief in the affirmation of the clients' cultural heritage as a more effective way of supporting clients in their recovery process. Case vignettes are used to illustrate the importance of helping immigrant clients who are marginalized in society to feel accepted, empowered and hopeful in their lives in a new country.

This article describes the mutual aid group process that took place in focus groups conducted with the elderly, dislocated workers and children in the New York Chinatown community who were severely affected by the terrorist attacks of 9/11. The group worker's role and approaches as well as group dynamics are discussed from a culturally-relevant perspective. Illustrations are made to underscore the therapeutic value of the mutual aid group process despite variations of cultural norms in communications and interactions.

This article discusses the findings of a study on the impact of the 9/11 attacks on the elderly Chinese immigrants in Chinatown, a community in close proximity to the World Trade Center. The findings reveal the stories of a vulnerable population who suffered extensive traumatization from 9/11, and describes their struggles with their issues of loss from a history of poverty, war and immigration. Implications of service recommendations are made in the context of the participants' help-seeking behavior and their cultural beliefs and norms.

An update of Virchow's triad for thrombogenesis can be considered by reference to abnormalities in the endothelium/endocardium ('abnormal vessel wall'), abnormalities of haemorhelogy and turbulence at bifurcations,atheroma at vessel wall ('abnormal bloodflow') and abnormalities in platelet as well as the coagulation and fibrinolytic pathways ('abnormal blood constituents'). The constituents of the blood are many and varied, but soluble coagulation factors (such as fibrinogen and tissue factor) and cells (such as platelets)are clearly important. Clearly, 'a continuum exists between health, 'statistically' increased haemostatic abnormalities in prothrombotic or hypercoagulable states and 'overtly' increased clotting in acute thrombosis.Thus, the patients with the highest levels of the markers appear to be the highest risk of disease progression,and if so, a panel of 'high risk' blood constituent indices (platelet and coagulation markers) may potentially give a composite score of risk, and may be a useful tool in predicting subjects at highest risk. Further longitudinal studies are clearly required. There is no doubt that Virchow would be impressed on how his classical triad has expanded to encompass the wide range of pathophysiological processes leading to thrombogenesis.

INSIDE OUT AND OUTSIDE IN, PSYCHODYNAMIC CLINICAL THEORY AND PRACTICE IN CONTEMPORARY MULTICULTURAL CONTEXTS. Berzoff, Joan, Laura Melano Flanagan, and Patricia Hertz, Editors. Northvale, New Jersey: Jason Aronson, 1996, $45.00. Reviewed by Irene Chung.

Trichosporon beigelii has emerged as a lethal opportunist pathogen in granulocytopenic and corticosteroid-treated patients. Little is known of the host defence mechanisms against this yeast. The interaction between human neutrophils and serum-opsonised T. beigelii and the effect of GM-CSF on binding and ingestion of the yeast by neutrophils were investigated by a microscopic analysis of neutrophil monolayers stained with FITC-Concanavalin A. Positive staining with FITC-Concanavalin A distinguished between intracellular and extracellular yeast cells. Binding of T. beigelii to neutrophils was an energy- and complement-dependent process involving movement of actin in the neutrophil cytoskeleton. The mean percentage binding of T. beigelii was 37.5% and the mean binding index (BI) was 1.30 whereas the mean percentage ingestion was 3.5% and the mean phagocytic index (PI) was 1.34. GM-CSF increased percentage ingestion of T. beigelli from 2.8% to 30.5% and the PI was increased from 1.3 to 1.86. The percentage binding was 36.8% and the mean BI was 1.3 in control experiments compared with 49.3% and 1.6, respectively, in the presence of GM-CSF. In conclusion, GM-CSF significantly increased percentage ingestion of opsonised T. beigelii by neutrophils, but its effect on percentage binding of the yeast was not statistically significant.

White coat hypertension (WCH) describes the phenomenon in which blood pressures are elevated in the presence of a health professional measuring the blood pressure—traditionally described (but not exclusively!) in relation to the hospital/clinic doctor, who is usually wearing a white coat. Since the introduction of 24 h ambulatory blood pressure monitoring (ABPM),1 the meaning of WCH has been redefined, and one possible definition of WCH is an abnormal clinic blood pressure but 'normal' ABPM. The latter has also been defined in many ways, but the recent Seventh Joint National Committee (JNC 7)2 suggested that the upper limits of 'normal' ABPM to be 135/85 mmHg while patients are awake and 120/75 mmHg while they are asleep. In contrast, the 1999 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines3 suggest that a 24 h average of home blood pressure of 120/80 mmHg as corresponding to clinic blood pressure of 140/90 mmHg.

Introduction: This paper uses fi ndings from a larger study to present a nuanced depiction of the interplay of informal and formal help-seeking processes of a sample of Chinese immigrants in their mental healthcare in New York City. Method: Thirty one participants who were receiving mental health treatment were interviewed with regard to their experiences preceding their suicide attempt. Their narratives were coded for thematic analysis. Findings: Acculturation difficulties, inaccessibility to services and stigma associated with mental illness were major obstacles in the participants’ help-seeking process, which was consistent with other studies of immigrants of ethnic minority groups in the USA. In addition, the findings showed how changes in this sample of Chinese immigrants’ socio-cultural reality disrupted familiar help-seeking pathways, and perpetuated and amplified the aforementioned stressors. Issues of human connection, immigrants’ resiliency and missed opportunities were also identified as potential resources to modify cultural stigmas and help-seeking behaviour. Conclusion: There are varied socio-cultural factors that need to be considered in mental health outreach services in immigrant communities.

Abnormal levels of soluble CD40 ligand (sCD40L) have been reported in patients with hypertension, coronary artery disease, diabetes mellitus, heart failure, and stroke, all of which are conditions that are associated with nonvalvular atrial fibrillation (AF). We hypothesized the following: (1) CD40 ligand (CD40L)-related indexes (ie, platelet surface expressed CD40L, the soluble fragment of CD40L [sCD40L], and the total amount of CD40L per platelet [pCD40L]) are elevated in patients with AF compared to control subjects; (2) these indexes correlate with soluble P-selectin (sP-selectin), which is an established platelet marker; and (3) these indexes differentiate "high-risk" from "low-risk" subjects.We performed a case-control study of 121 AF patients, 71 "disease control subjects," and 56 "healthy control subjects." Peripheral venous levels of platelet surface-expressed CD40L were analyzed by flow cytometry, while levels of sCD40L, pCD40L, and sP-selectin were measured by enzyme-linked immunosorbent assay.AF patients had significantly higher sCD40L levels compared to healthy control subjects (p = 0.042), with no difference in platelet surface CD40L and pCD40L levels. A positive correlation was noted between levels of sCD40L and pCD40L, and not with sP-selectin. CD40L-related indexes failed to distinguish between high-risk and low-risk AF patients. AF patients receiving optimal antithrombotic therapy had significantly lower pCD40L levels (p0.001) compared to control subjects. Optimized AF management also resulted in significant reductions in the levels of sCD40L (p = 0.023) and pCD40L (p0.001).CD40L-related indexes are not useful in the risk stratification of AF patients, and abnormal sCD40L levels can be reduced by intense multifactorial risk management. While there is a significant, albeit modest, excess of platelet activation in AF patients (as measured by sCD40L levels) compared to healthy control subjects, this is not in excess of that seen in patients with underlying cardiovascular diseases.

Many complications associated with congestive heart failure (CHF) have a thrombosis-related aetiology. Platelets play an important role in thrombogenesis, but it is not clear whether circulating platelets actively participate in thrombosis-related complications associated with CHF.To determine whether soluble P-selectin, platelet surface P-selectin, and total platelet P-selectin as indices of platelet activation in CHF patients-compared to 'disease controls' and 'healthy controls'-and to assess their prognostic value in CHF.We measured soluble P-selectin (sP-sel, by enzyme-linked immunosorbent assay, ELISA), total platelet P-selectin (pP-sel, by a novel 'platelet lysate' assay), platelet surface P-selectin (CD62P%G) and platelet surface CD63 (CD63%G) expression by flow cytometry-in 108 patients with stable congestive heart failure (all with left ventricular ejection fraction (LVEF)50%). Levels were compared with 50 healthy controls and 70 'disease controls' (patients with coronary artery disease with normal left ventricular systolic function).CHF patients and disease controls had higher sP-sel, CD62P%G and CD63%G than healthy controls. There were no significant correlations between sP-sel, pP-sel, CD62P%G and CD63%G with ejection fraction (all P0.05). There were no differences in these markers when ischaemic and non-ischaemic aetiologies of CHF were compared. After a median follow-up of 490 days (range 340-535), there were 7 deaths, 15 hospitalizations for worsening heart failure, 1 for cardiac resynchronization therapy, 4 for revascularizations, 4 for myocardial infarctions, and 1 stroke. None of the platelet markers were predictive of the composite end-point at follow-up.Patients with stable CHF exhibit evidence of abnormal platelet activation, despite usage of antiplatelet agents. These abnormalities did not determine prognosis and were broadly similar to those seen in 'disease controls' indicating that platelet abnormalities in CHF may simply be related to associated comorbidities.

Congestive heart failure is characterised by increased thromboembolic events, stroke and sudden death. This may be related to a prothrombotic state, abnormal thrombogenesis, endothelial damage/dysfunction and platelet abnormalities [1]. An abnormal state of platelet activation may contribute to the pro-coagulant state in congestive heart failure (CHF). The normal function of platelets includes adhesion to the sub-endothelial matrix, aggregation with other platelets, shape change and clot retraction [2]. Several of these studies functions involve receptors on the platelet surface (such as gpIIb/ IIIa) and interactions with matrix constituents (such as fibrinogen) [2]. Other methods for studying platelet function include measurement of plasma

Platelet microparticles (PMPs), are procoagulant membrane vesicles that are derived from activated platelets, the levels of which are elevated in patients with hypertension, coronary artery disease (CAD), diabetes, and stroke, all of which are conditions that lead to (and are associated with) atrial fibrillation (AF). We hypothesized the following: (1) PMP levels are elevated in patients with AF compared to levels in both healthy control subjects (ie, patients without cardiovascular diseases who are in sinus rhythm) and disease control subjects (ie, patients with hypertension, CAD, diabetes or stroke, but who are in sinus rhythm); (2) PMP levels correlate with levels of soluble P-selectin (sP-selectin) [a marker of platelet activation]; and (3) PMP levels are related to the underlying factors in patients with AF that contribute to the overall risk of stroke secondary to AF.We performed a case-control study of 70 AF patients, 46 disease control subjects and 33 healthy control subjects. Peripheral venous levels of PMP and sP-selectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively.Both AF patients and disease control subjects had significantly higher levels of PMPs (p0.001) and sP-selectin (p = 0.001) compared to healthy control subjects, but there was no difference between AF patients and disease control subjects. There was no difference in PMP levels between patients with paroxysmal and permanent AF (p = 0.581), and between those receiving therapy with aspirin and warfarin (p = 0.779). No significant correlation was observed between PMP and sP-selectin levels (p = 0.463), and the clinical characteristics that contribute to increased stroke risk in patients with AF. On stepwise multiple regression analysis in the combined cohort of AF patients plus disease control subjects, the presence/absence of AF was not an independent determinant of PMP and sP-selectin levels.There is evidence of platelet activation (ie, high PMP and sP-selectin levels) in AF patients, but this is likely to be due to underlying cardiovascular diseases rather than the arrhythmia per se.

The aim of this work was to comprehensively study the role of platelets in atrial fibrillation (AF), in relation to the underlying cardiovascular diseases and type of AF, and to analyze the effect of antithrombotic treatment on different aspects of platelet activation.Platelet activation is present in nonvalvular AF, but there is debate whether this is due to AF itself and/or to underlying cardiovascular diseases.A total of 121 AF patients were compared with 65 "healthy control subjects" and 78 "disease control subjects" in sinus rhythm. Platelet activation was assessed using 4 different aspects of platelet pathophysiology: 1) platelet surface expression of CD62P (P-selectin) and CD63 (a lysosomal glycoprotein) (by flow cytometry); 2) mean platelet volume (MPV) (by flow cytometry); 3) plasma levels of soluble P-selectin (sP-selectin, enzyme-linked immunoadsorbent assay); and 4) total amount of P-selectin per platelet (pP-selectin) ("platelet lysis" assay).Both AF patients and "disease control subjects" had higher levels of CD62P (p0.001), CD63 (p0.001), and sP-selectin (p0.001) compared with "healthy control subjects," with no difference between AF patients and "disease control subjects." Patients with permanent AF had higher levels of sP-selectin (p = 0.014) and MPV (p = 0.025) compared with those with paroxysmal AF. The presence of AF independently affected the levels of CD62P expression, while "high-risk" AF patients (CHADS scoreor =2) had higher levels of CD62P compared with those with "low risk." Introducing warfarin resulted in a reduction of pP-selectin (p = 0.013).There is a degree of excess of platelet activation in AF compared with "healthy control subjects," but no significant difference between AF patients and "disease control subjects" in sinus rhythm. Platelet activation may differ according to the subtype of AF, but this is not in excess of the underlying comorbidities that lead to AF. Platelet activation in AF may be due to underlying cardiovascular diseases, rather than due to AF per se.

Heart failure is associated with increased risk of venous thromboembolism, stroke, and sudden death. Platelet abnormalities have been well described in heart failure but the significance of platelets in contributing to the thromboembolic complications of heart failure remains uncertain. Furthermore, the role of antiplatelet agents in heart failure remains unclear. This review will focus on platelet activation and the role of platelet dysfunction in heart failure, with particular regard to pathophysiology and outcome. The effects of heart failure therapeutics on platelet function and antiplatelet therapy in heart failure will also be discussed.

Congestive heart failure (CHF) is associated with increased risk of venous thromboembolism, stroke and sudden death. This may be related to abnormalities of thrombogenesis and platelet activation. A comprehensive assessment of platelet (dys)function in acute decompensated heart failure (AHF) is lacking, and we hypothesised that such patients would show greater abnormalities in platelet indices, compared to stable CHF and healthy controls.We measured soluble P-selectin (sP-sel, by ELISA); platelet surface P-selectin (CD62P%G) and CD63%G expression by flow cytometry; and platelet structural indices [mean platelet volume (MPV), mean platelet mass (MPM) and mean platelet component (MPC)] in 22 patients with AHF (pre- and posttreatment), who were compared to 68 patients with stable congestive heart failure (CHF, all with left ventricular ejection fraction (LVEF)50%) and 23 healthy controls.There were significant differences between the 3 study groups in MPV (p0.001), MPC (p=0.001), platelet surface P-selectin (CD62P%G, p0.0001) and platelet surface CD63P%G (p=0.017). On post-hoc analyses, AHF patients had higher platelet surface P-selectin (CD62P%G) compared to stable CHF patients and healthy controls (Tukey's test, all p0.05), whilst CD63%P was similarly high in both disease groups, compared to healthy controls. Platelet surface P-selectin (p=0.032), CD63 (p=0.024) and CD40L (p=0.024) were significantly reduced following treatment of AHF, though platelet morphology and sP-sel levels were not significantly changed.AHF patients demonstrate some abnormalities of platelet activation compared to stable CHF patients and healthy controls. These platelet abnormalities are modified by treatment, raising the possibility that platelets may partly contribute to the pathophysiology of adverse complications associated with AHF.

The disease presentation of chronic heart failure (CHF) is considered to progress with metabolic deterioration, underlined by changes in adipose associated hormones (adipocytokines). However, little is known about ethnic variations of adipocytokines amongst CHF patients, in particular South Asians, who are at an increased risk of CHF.Using a cross-sectional study, South Asians (n=106) and Caucasians (n=105) living in the UK were compared by CHF status. We investigated ethnic differences in adipocytokines (leptin, adiponectin, tumor necrosis factor (TNF)alpha), and their association with CHF. Patients with mild to moderate CHF were recruited from heart failure clinics (47 Caucasian, 54 South Asian), and compared to healthy controls. Metabolic parameters (including insulin resistance using HOMA modelling), echocardiography and brain natriuretic peptide (BNP) were measured amongst patients and healthy controls, and compared across and within ethnic groups.Mean (log transformed) plasma leptin concentrations were highest amongst South Asian patients, being 5.25% (95%CI: 1.50-9.02) higher than Caucasian patients (P=0.007), and similarly raised with respect to controls (Por =0.04). Indices of insulin resistance were higher amongst CHF patients compared with controls, with no ethnic variation. In addition to age, female gender and body-mass index, levels of leptin were also associated with South Asian ethnicity (P0.001), insulin resistance (P=0.02), smoking habit (P=0.01) and HDL cholesterol (P=0.004). Levels of adiponectin showed no ethnic variation, but were associated with CHF and a previous history of myocardial infarction (P0.001). On multivariate regression analysis of patients and healthy controls, CHF was independently associated with smoking habit, adiponectin and insulin resistance (all P0.01).Metabolic abnormalities are present in CHF, which in turn, are influenced by ethnicity. The role of adipocytokines in CHF pathophysiology and prognosis merits further study.

BACKGROUND Patients with chronic heart failure (heart failure) are at risk of thromboembolic events, including stroke, pulmonary embolism and peripheral arterial embolism, whilst coronary ischaemic events also contribute to the progression of heart failure. Long-term oral anticoagulation is established in certain groups, including patients with heart failure and atrial fibrillation but there is wide variation in the indications and use of oral anticoagulation in the broader heart failure population. OBJECTIVES To determine whether long-term oral anticoagulation reduces total deaths and/or major thromboembolic events in patients with heart failure, when compared to placebo. SEARCH STRATEGY Reference lists of papers resulting from this search, electronic database searching (MEDLINE, EMBASE, DARE), and abstracts from national and international cardiovascular meetings were studied to identify unpublished studies. Relevant authors of these studies were contacted to obtain further data. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing oral anticoagulants with control or placebo. Non-randomised studies were included as they may help in assessing side-effects. Duration of treatment at least 1 month, adults with heart failure due to any underlying cause. Inclusion decisions were duplicated, disagreement resolved by discussion or a third party. DATA COLLECTION AND ANALYSIS Data were collected by two reviewers independently and where appropriate data from RCTs were meta-analysed. MAIN RESULTS One recent pilot RCT compared warfarin, aspirin and no antithrombotic therapy, but no definitive data have yet been published. Three small prospective studies of warfarin in heart failure were also identified, but were over 50 years old with methods not considered reliable by modern standards. Anticoagulation was more efficacious than control for the reduction of all cause death (odds ratio 0.64 95% CI 0.45,0.90) and the reduction of cardiovascular events (0.26 95% CI 0.16, 0.43). Four retrospective non-randomised cohort analyses and three small observational studies of oral anticoagulation in heart failure included differing populations of heart failure patients and reported contradictory results. REVIEWER'S CONCLUSIONS Evidence from the RCTs and observational studies found a reduction in mortality and cardiovascular events with anticoagulants compared to control. This evidence needs to be interpreted with caution. Although oral anticoagulation is indicated in certain groups of patients with heart failure (eg atrial fibrillation), the data available does not support its routine use in heart failure patients who remain in sinus rhythm. A large randomised trial of warfarin in heart failure patients in sinus rhythm is currently in progress data from which will be useful addition to this story.