Background and Hypothesis. Following our recent demonstration that the chronic inflammatory and insulin resistant state of obesity is associated with an increase in the expression of mediators known to contribute to the pathogenesis of asthma and that weight loss after gastric bypass surgery results in the reduction of these genes, we have now hypothesized that insulin suppresses the cellular expression and plasma concentrations of these mediators. Methods. The expression of IL-4, LIGHT, LTBR, ADAM-33, and TSLP in MNC and plasma concentrations of LIGHT, TGF-β1, MMP-9, MCP-1, TSLP, and NOM in obese patients with T2DM were measured before, during, and after the infusion of a low dose (2 U/h) infusion of insulin for 4 hours. The patients were also infused with dextrose or saline for 4 hours on two separate visits and served as controls. Results. Following insulin infusion, the mRNA expression of IL-4, ADAM-33, LIGHT, and LTBR mRNA expression fell significantly (P < 0.05 for all). There was also a concomitant reduction in plasma NOM, LIGHT, TGF-β1, MCP-1, and MMP-9 concentrations. Conclusions. Insulin suppresses the expression of these genes and mediators related to asthma and may, therefore, have a potential role in the treatment of asthma.
We report the case of an 85-year-old woman with severe aortic stenosis who underwent transcatheter aortic valve replacement with use of the Edwards Sapien® valve system. The procedure was complicated by rupture of the valve-deployment balloon, with separation and retention of the nose cone of the RetroFlex 3® delivery system in the iliac artery. Our endovascular retrieval of the equipment was successful, and we achieved access-site hemostasis by deploying a covered stent. To our knowledge, this is the first report of the endovascular retrieval of a malfunctioning delivery system during transcatheter aortic valve replacement.
Aged, 80 and over; cardiac catheterization/adverse effects; endovascular procedures/adverse effects/instrumentation; equipment failure; heart valve prosthesis implantation/adverse effects; iliac artery/injuries; treatment outcome
To report a case of a major vascular complication during TAVR and the endovascular management thereof. Additionally, we discuss a possible correlation with long-term steroid use.
A 79 year old woman with a history of critical aortic stenosis underwent elective transcatheter aortic valve replacement (TAVR). Her procedure was complicated by rupture of her right iliac artery, life threatening retroperitoneal hemorrhage, and thrombus extending into the distal right lower extremity. This case was emergently managed by stent placement, thrombectomy, and tPA via a percutaneous approach.
Peripheral vascular complications are common during percutaneous TAVR, and chronic steroid use may predispose patients. Endovascular management is often possible and may potentially save valuable time in emergent situations.
TAVR; TAVI; Peripheral; Endovascular
In an era of expanded treatment options for severe aortic stenosis, it is important to understand risk factors for the condition. It has been suggested that severe aortic stenosis is less common in African Americans, but there are limited data from large studies.
Methods and Results
The Synthetic Derivative at Vanderbilt University Medical Center, a database of over 2.1 million de‐identified patient records, was used to identify individuals who had undergone echocardiography. The association of race with severe aortic stenosis was examined using multivariable logistic regression analyses adjusting for conventional risk factors. Of the 272 429 eligible patients (mean age 45 years, 44% male) with echocardiography, 14% were African American and 82% were Caucasian. Severe aortic stenosis was identified in 106 (0.29%) African‐American patients and 2030 (0.91%) Caucasian patients (crude OR 0.32, 95% CI [0.26, 0.38]). This difference persisted in multivariable‐adjusted analyses (OR 0.41 [0.33, 0.50], P<0.0001). African‐American individuals were also less likely to have severe aortic stenosis due to degenerative calcific disease (adjusted OR 0.47 [0.36, 0.61]) or congenitally bicuspid valve (crude OR 0.13 [0.02, 0.80], adjusted OR dependent on age). Referral bias against those with severe valvular disease was assessed by comparing the prevalence of severe mitral regurgitation in Caucasians and African Americans and no difference was found.
These findings suggest that African Americans are at significantly lower risk of developing severe aortic stenosis than Caucasians.
aortic valve stenosis; database; epidemiology; race and ethnicity; risk factor
Hybrid coronary revascularization combines the benefits of both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the treatment of multivessel coronary artery disease (CAD) by combining the benefits of the LIMA-to-LAD graft and drug eluting stent (DES) to non-LAD regions. Through this approach, a patient receives the long-term benefit of the LIMA graft and avoids the morbidity of a full sternotomy and saphenous vein grafts. Available data related to outcomes following hybrid revascularization is limited to small studies. In this review we seek to provide an overview of hybrid revascularization in the era of modern drug eluting stent technology, discuss appropriate patient selection, and comment on future trial design. Additionally, we review the recent literature pertaining to the hybrid approach.
Hybrid coronary revascularization; Coronary artery disease; Coronary artery bypass grafting; Percutaneous coronary intervention; Completion angiography; PCI; CABG
Patients hospitalized for psychiatric reasons exhibit significantly elevated risk of suicide, yet the research literature contains very few outcome studies of interventions designed for suicidal inpatients. This pilot study examined the inpatient feasibility and effectiveness of The Collaborative Assessment and Management of Suicidality (CAMS), a structured evidence-based method for risk assessment and treatment planning (Jobes, 2006). The study used an open-trial, case-focused design to assess an inpatient adaptation of CAMS, spread over a period averaging 51 days. The intervention was provided via individual therapy to a convenience sample of 20 patients (16 females and four males, average age 36.9) who were hospitalized with recent histories of suicidal ideation and behavior. Results showed statistically and clinically significant reductions in depression, hopelessness, suicide cognitions, and suicidal ideation, as well as improvement on factors considered “drivers” of suicidality. Treatment effect sizes were in the large range (Cohen’s d > .80) across several outcome measures, including suicidal ideation. Although these findings must be considered preliminary due to the lack of a randomized control group, they merit attention from clinicians working with patients at risk for suicide. This study also supports the feasibility of implementing a structured, suicide-specific intervention for at-risk patients in inpatient settings.
suicide; CAMS; inpatient; psychotherapy; outcome
Few studies have examined the relation between suicide-related behaviors and Borderline Personality Disorder (BPD) in adolescent samples. The current study investigated the incremental validity of BPD relative to Major Depressive Disorder (MDD) for suicide-related behaviors in a psychiatric sample of adolescents at the cross-sectional level of analysis. The sample included N = 156 consecutive admissions (55.1% female; M age = 15.47; SD = 1.41), to the adolescent treatment program of an inpatient treatment facility. Of the sample 19.2% (n = 30) met criteria for BPD on the Child Interview for DSM-IV Borderline Personality Disorder and 39.1% (n = 61) met criteria for MDD on the Computerized Diagnostic Interview Schedule for Children–IV. Results showed that BPD conferred additional risk for suicidal ideation and deliberate self-harm. Our findings support the clinical impression that BPD should be evaluated in inpatient samples of adolescents either through intake interviews or more structured assessments.
Historically, substance use problems were thought to be more prevalent in lesbian, gay, and bisexual (LGB) populations, and correcting skewed perceptions about substance abuse among LGB individuals is critically important. This review provides an update on empirical evidence on LGB substance use patterns and treatment outcome, with specific focus on clinical implications of findings. Compared to earlier studies, the recent research included in this review has used more sophisticated methodologies, more representative samples, and also has investigated multiple dimensions of sexual orientation in relation to substance use patterns. Findings from recent research suggest that lesbians and bisexual women are at greater risk for alcohol and drug use disorders and related problems, and that gay and bisexual men are at greater risk for illicit drug use and related problems. Several sociocultural factors have emerged as correlates of substance use patterns in LGB populations (e.g., affiliation with gay culture, HIV-status), and several demographic characteristics (e.g., female, older age) do not appear to be as robust of protective factors against substance abuse for LGB individuals compared to heterosexual populations. Bisexual identity and/or behavior in particular seem to be related to increased risk for substance abuse. In terms of treatment outcome, limitations of extant research prevent conclusions about the relative impact of LGB-specific interventions, and further research that includes women and uses more equivalent comparison interventions is needed. Clinical implications of research findings are discussed for case identification, selection of treatment goals (e.g., moderation versus abstinence), targets for intervention, and specific treatment modalities.
substance use; lesbian; gay; bisexual; review; treatment
Studies from the 1990s suggested sex with older partners was associated with HIV infection. We evaluated the hypothesized association between primary HIV infection (PHI) and having older sexual partners among men who have sex with men (MSM).
MSM with PHI and HIV-uninfected MSM completed audio computer-assisted self-interviews exploring behaviors involving their three most recent sexual partners prior to enrollment (if uninfected) or diagnosis (if PHI).
Of 74 men reporting any lifetime sex with men, 20 had PHI (27%). Demographics (including age) were similar between groups; 39% were non-white and 74% identified as gay. The mean age of sex partners differed significantly: men with PHI had partners on average 6 years older than themselves, while uninfected men’s partners were 4 months their junior (P<0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (OR 2.0, 95% CI, 1.2, 3.3).
Among a sample of young MSM, the odds of HIV infection increased significantly as the age of sexual partners increased. These findings can inform behavioral interventions in communities of at-risk MSM as well as secondary prevention efforts among those already living with HIV.
primary HIV infection; men who have sex with men; age mixing; North Carolina
Identifying and counseling individuals with Acute HIV Infection (AHI) offers a critical opportunity to avert preventable HIV transmission, however opportunities to recognize these individuals may be missed. We surveyed 32 adults diagnosed with AHI during voluntary HIV testing from 1/1/03 to 2/28/05 in publicly funded testing sites in NC to describe their clinical, social, and behavioral characteristics. Eighty-one percent of participants were men; 59% were African American. Seventy-five percent experienced symptoms consistent with acute retroviral syndrome; although 83% sought medical care for these symptoms, only 15% were appropriately diagnosed at that initial medical visit, suggesting opportunities to diagnose these individuals earlier were missed. Eighty-five percent of the men engaged in sex with men. More than 50% of the participants thought they were infected with HIV by a steady partner. This study yields important information to assist in identifying populations at risk for or infected with AHI and designing both primary and secondary prevention interventions.
Acute HIV Infection (AHI); North Carolina (NC); HIV/AHI screening; AHI Epidemiology; HIV Risk Factors
Methamphetamine (MA) is a new arrival to the Southeastern United States (US). Incidence of HIV is also increasing regionally, but data are limited regarding any association between this trend and MA use. We examined behavioral data from North Carolina (NC) residents newly diagnosed with HIV, collected by the Department of Health between 2000-2005.
Among 1,460 newly diagnosed HIV-positive young men, an increasing trend was seen from 2000-2005 in MA use (p = 0.01, total n = 20). In bivariate analyses, users of MA had significantly greater odds of reporting other substance use, including alcohol, powder or crack cocaine, marijuana, and methylenedioxymethamphetamine (MDMA, “ecstasy”). They were also more likely to have reported sexual activity while traveling outside NC; sex with anonymous partners; and previous HIV testing. In a predictive model, MA use had a negative association with nonwhite race, and strong positive associations with powder cocaine, “ecstasy,” or intravenous drug use and being a university student.
Similar to trends seen in more urban parts of the US, MA use among newly diagnosed, HIV-positive young men is increasing in NC. These data are among the first to demonstrate this relationship in a region with a burgeoning epidemic of MA use. Opportunities exist for MA-related HIV risk-reduction interventions whenever young men intersect the healthcare system.
In recent years, methamphetamine has become a drug more commonly used among gay and bisexual men in New York City. Part of a longitudinal investigation of drug abuse in this population involved assessing the patterns and context of methamphetamine use during the course of 1 year. Findings indicate that among self-identified club-drug-using men, methamphetamine is widely used by men across age groups, educational level, racelethnicity, and HIV status. Participants reported use of methamphetamine in combination with numerous other illicit and prescribed substances and in a variety of contexts outside the “club scene.” Reasons for and contexts of use are related to HIV status, with HIV-positive men indicating a greater likelihood of use to avoid conflict, unpleasant emotions, and social pressures, and reporting higher levels of use in enviroments such as bathhouses and “sex parties.” These patterns and relationships are consistent across time and suggest a complex interaction between person level factors, environmental factors, and HIV. Findings indicate that treatment of methamphetamine addiction among gay and bisexual men must take into account the complex interrelationships between mental health, drug use, sexual risk taking, and HIV.
Gay and bisexual; HIV; Methamphetamine; Poly-drug use