Stratification of individuals at risk for chronic kidney disease may allow optimization of preventive measures to reduce disease incidence and complications. We sought to develop a risk score that estimates an individual’s absolute risk of incident chronic kidney disease.
Framingham Heart Study participants free of baseline chronic kidney disease, who attended a baseline examination in 1995–1998 and follow-up in 2005–2008, were included in the analysis (n=2,490). Chronic kidney disease was defined as an estimated glomerular filtration rate <60 ml/min/1.73m2 using the Modification of Diet in Renal Disease (MDRD) equation. Participants were assessed for the development of chronic kidney disease at 10 years follow-up. Stepwise logistic regression was used to identify chronic kidney disease risk factors, and these were used to construct a risk score predicting 10-year chronic kidney disease risk. Performance characteristics were assessed using calibration and discrimination measures. The final model was externally validated in the bi-ethnic Atherosclerosis Risk in Communities (ARIC) Study (n=1,777).
There were 1,171 men and 1,319 women at baseline, and the mean age was 57.1 years. At follow-up, 9.2% (n=229) had developed chronic kidney disease. Age, diabetes, hypertension, baseline estimated glomerular filtration rate and albuminuria were independently associated with incident chronic kidney disease (p<0.05), and these covariates were incorporated into a risk function (c-statistic 0.813). In external validation in the ARIC study, the c-statistic was 0.79 in whites (n=1,353) and 0.75 in blacks (n=424).
Risk stratification for chronic kidney disease is achievable using a risk score derived from clinical factors that are readily accessible in primary care. The utility of this score in identifying individuals in the community at high risk of chronic kidney disease warrants further investigation.
Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain.
For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [<4 hours] and appropriate selection of antibiotic therapy) and the cumulative number of processes of care performed.
Overall, 141 patients (6.8%) died. Mortality was 0.3% to 1.7% lower for patients who had each of the individual processes of care performed (P ≥ .13 for each comparison); mortality was 7.5% for patients who had 0 to 2 processes of care, 7.2% for those with 3 processes of care, and 5.8% for those with all 4 processes of care performed (P = .39). Mortality was not significantly associated with either individual or cumulative process measures in multivariable models.
Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia.
Pneumonia; Processes of care; Quality of care
Musculoskeletal symptoms are common adverse effects of statins, yet little is known about the prevalence of musculoskeletal pain and statin use in the general population.
We conducted a cross sectional study of the National Health and Nutrition Examination Survey (NHANES) 1999–2004. We estimated the prevalence of self-reported musculoskeletal pain according to statin use and calculated prevalence ratio estimates of musculoskeletal pain obtained from adjusted multiple logistic regression modeling.
Among 5,170 participants without arthritis, the unadjusted prevalence of musculoskeletal pain was significantly higher for statin users reporting pain in any region (23% among statin users, 95%CI: 19–27% compared to 18% among those not using statins, 95%CI: 17–20%; p=0.02) and in the lower extremities (12% among statin users, 95%CI: 8–16% compared to 8% among those not using statins, 95%CI: 7–9%; p=0.02). Conversely, among 3,058 participants with arthritis, statin use was not associated with higher musculoskeletal pain in any region. After controlling for confounders, among those without arthritis, statin use was associated with a significantly higher prevalence of musculoskeletal pain in any region, the lower back, and the lower extremities (adjusted prevalence ratios: 1.33 [1.06, 1.67]; 1.47 [1.02, 2.13]; 1.59 [1.12, 2.22], respectively). Among participants with arthritis, no association was observed between musculoskeletal pain and statin use on adjusted analyses.
In this population-based study, statin use was associated with a higher prevalence of musculoskeletal pain, particularly in the lower extremities, among individuals without arthritis. Evidence that statin use was associated with musculoskeletal pain among those with arthritis was lacking.
Statins; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Musculoskeletal Diseases; Arthritis
Associations between modifiable health risk factors during middle age with disability and mortality in later life are critical to maximizing longevity while preserving function. Positive health effects of maintaining normal weight, routine exercise, and non-smoking are known for the short and intermediate term. We studied the effects of these risk factors into advanced age.
A cohort of 2,327 college alumnae ≥60 years was followed annually (1986–2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability (HAQ-DI). Mortality data were ascertained from the National Death Index. Low, medium, and high risk groups were created based upon the number (0, 1, ≥2) of health risk factors (overweight, smoking, inactivity) at baseline. Disability and mortality for each group were estimated from unadjusted data and regression analyses. Multivariable survival analyses estimated time to disability or death.
Medium and high-risk groups had higher disability than the low risk group throughout the study (p<0.001). Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk. Mortality rates were higher in the high risk group (384 versus 247 per 10,000 person-years). Multivariable survival analyses showed the number of risk factors to be associated with cumulative disability and increased mortality.
Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors upon health continue into the ninth decade.
disability; aging; mortality; exercise; smoking; weight; longitudinal study
Effect of race/ethnicity on the risk of diabetes associated with sleep duration has not been systematically investigated. This study assessed whether blacks reporting short (≤ 5 hours) or long (≥ 9 hours) sleep durations were at greater risk for diabetes than their white counterparts. In addition, this study also examined whether the influence of race/ethnicity on associations between abnormal sleep durations and the presence of diabetes were independent of individuals’ sociodemographic and medical characteristics.
A total of 29,818 Americans (age range: 18–85 years) enrolled in the 2005 National Health Interview Survey (NHIS), cross-sectional household interview survey, provided complete data for this analysis.
Of the sample, 85% self-ascribed their ethnicity as white and 15% as black. The average age was 47.4; 56% were female. Results of univariate regression analysis adjusted for medical comorbidities showed that black and white participants who reported short sleep duration (≤ 5 hours) were more likely to have diabetes than individuals who reported sleeping 6 to 8 hours [OR = 1.66; OR = 1.87, respectively]. Similarly, black and white participants reporting long sleep duration (≥ 9 hours) had a greater likelihood to report diabetes compared with those with sleeping 6 to 8 hours [OR = 1.68; OR = 2.33, respectively]. Significant interactions of short and long sleep with black and white race were observed. Compared with white participants, greater diabetes risk was associated with being black short or long sleepers.
The present findings suggest that American the black short and long sleepers may be at greater risk for diabetes, independently of their sociodemographic profile or the presence of co-morbid medical conditions, which have previously been shown to influence habitual sleep durations. Among black individuals at risk for diabetes, healthcare providers should stress the need for adequate sleep.
diabetes; sleep; race/ethnicity
Little is known about the outcomes of patients who have hemorrhagic complications while receiving warfarin therapy. We examined the rates of death and disability resulting from warfarin-associated intracranial and extracranial hemorrhages in a large cohort of patients with atrial fibrillation.
We assembled a cohort of 13,559 adults with nonvalvular atrial fibrillation and identified patients hospitalized for warfarin-associated intracranial and major extracranial hemorrhage. Data on functional disability at discharge and 30-day mortality were obtained from a review of medical charts and state death certificates. The relative odds of 30-day mortality by hemorrhage type were calculated using multivariable logistic regression.
We identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 person-years of warfarin exposure. At hospital discharge, 76% of patients with intracranial hemorrhage had severe disability or died, compared with only 3% of those with major extracranial hemorrhage. Of the 40 deaths from warfarin-associated hemorrhage that occurred within 30 days, 35 (88%) were from intracranial hemorrhage. Compared with extracranial hemorrhages, intracranial events were strongly associated with 30-day mortality (odds ratio 20.8 [95% confidence interval, 6.0–72]) even after adjusting for age, sex, anticoagulation intensity on admission, and other coexisting illnesses.
Among anticoagulated patients with atrial fibrillation, intracranial hemorrhages caused approximately 90% of the deaths from warfarin-associated hemorrhage and the majority of disability among survivors. When considering anticoagulation, patients and clinicians need to weigh the risk of intracranial hemorrhage far more than the risk of all major hemorrhages.
Atrial fibrillation; Death; Disability; Hemorrhage; Intracranial hemorrhage; warfarin
The internist’s goal is to determine a patient’s disease risk and to implement preventative interventions. Genetic evaluation is a powerful risk assessment tool and new interventions target previously untreatable genetic disorders. The purpose of this review is to educate the general internist about common genetic conditions affecting adult patients with special emphasis on diagnoses with an effective intervention, including hereditary cancer syndromes and cardiovascular disorders. Basic tenets of genetic counseling, complex genetic disease and management of adults with genetic diagnoses are also discussed.
genetics; breast/ovarian cancer syndrome; hereditary nonpolyposis colorectal cancer syndrome; Lynch syndrome; Marfan syndrome; Long QT syndrome; venous thromboembolism; Alzheimer disease; Down syndrome; neurofibromatosis 1; GINA
Female sexual dysfunction is a focus of medical research but few studies describe the prevalence and covariates of recent sexual activity and satisfaction in older community-dwelling women.
1303 older women from the Rancho Bernardo Study were mailed a questionnaire on general health, recent sexual activity, sexual satisfaction, and the Female Sexual Function Index (FSFI).
806 of 921 respondents (87.5%) age ≥40 years answered questions about recent sexual activity. Their median age was 67; mean years since menopause, 25; most were upper-middle class; 57% had attended at least one year of college; 90% reported good to excellent health. Half (49.8%) reported sexual activity within the past month with or without a partner, the majority of whom reported arousal (64.5%), lubrication (69%), and orgasm (67.1%) at least most of the time, although one-third reported low, very low, or no sexual desire. Although frequency of arousal, lubrication, and orgasm decrease with age, the youngest (<55 yrs) and oldest (>80 yrs) women reported a higher frequency of orgasm satisfaction. Emotional closeness during sex was associated with more frequent arousal, lubrication, and orgasm; estrogen therapy was not. Overall, two-thirds of sexually active women were moderately or very satisfied with their sex life, as were almost half of sexually inactive women.
Half these women were sexually active, with arousal, lubrication, and orgasm maintained into old age, despite low libido in one-third. Sexual satisfaction increased with age and did not require sexual activity.
Age; female sexual function; libido; sexual activity; sexual satisfaction; women
Among older persons, the association between frailty and spirometry-confirmed respiratory impairment has not yet been evaluated.
Using data on white participants aged 65–80 years (Cardiovascular Health Study, N=3,578), we evaluated cross-sectional and longitudinal associations between frailty and respiratory impairment, including their combined effect on mortality. Baseline assessments included frailty status (Fried-phenotype; non-frail, pre-frail, and frail) and spirometry. Outcomes included development of frailty features (pre-frail or frail) at Year-3 and respiratory impairment (airflow limitation or restrictive-pattern) at Year-4, and death (median follow-up, 13.2 years).
At baseline, 48.3% were pre-frail, 5.8% were frail, 13.8% had airflow limitation, and 9.3% had restrictive-pattern; 46.1% subsequently died. At baseline, pre-frail and frail were cross-sectionally associated with airflow limitation—adjusted odds ratio (OR) (95% confidence interval): 1.62 (1.29, 2.04) and 1.88 (1.15, 3.09), and restrictive-pattern—adjusted OR: 1.80 (1.37, 2.36) and 3.05 (1.91, 4.88), respectively. Longitudinally, participants with baseline frailty features had an increased likelihood of developing respiratory impairment―adjusted OR: 1.42 (1.11, 1.82). Conversely, participants with baseline respiratory impairment had an increased likelihood of developing frailty features—adjusted OR: 1.58 (1.17, 2.13). Mortality was highest among participants who were frail and had respiratory impairment—adjusted hazard ratio: 3.91 (2.93, 5.22), relative to those who were non-frail and had no respiratory impairment.
Frailty and respiratory impairment are strongly associated with one another and substantially increase the risk of death when both are present. Establishing these associations may inform interventions designed to reverse or prevent the progression of either condition and to reduce adverse outcomes.
frailty; respiratory impairment; death
Substantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs) but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited.
Hospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with ≥25 HF or AMI patients, respectively. Weighted regression was used to quantify the relationship between RSRRs and SNF rates for each condition.
Mean RSRR following HF admission among 4,101 hospitals was 24.7%, and mean RSRR after AMI admission among 2,453 hospitals was 19.9%. Hospital-level SNF rates ranged from 0% to 83.8% for HF and from 0% to 77.8% for AMI. No significant relationship between RSRR after HF and SNF rate was found in adjusted regression models (p=0.15). RSRR after AMI increased by 0.03 percentage point for each 1 absolute percentage point increase in SNF rate in adjusted regression models (p=0.001). Overall, HF and AMI SNF rates explained <1% and 4% of the variation for their respective RSRRs.
SNF rates after HF or AMI hospitalization vary considerably across hospitals, but explain little of the variation in 30-day all-cause readmission rates for these conditions.
heart failure; acute myocardial infarction; skilled nursing facilities; readmission; hospitals; health services research
Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patient’s care is being managed by a primary care provider. This review summarizes these unique potential medical and psychological sequelae of Hodgkin lymphoma, and provides screening and management recommendations.
Hodgkin lymphoma; survivors; primary care physicians
Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a five-year retrospective study at Brigham and Women’s Hospital to determine clinical characteristics, types, root causes, and outcomes of anticoagulant-associated adverse drug events (ADEs).
We reviewed all inpatient anticoagulant-associated ADEs, including adverse drug reactions (ADRs) and medication errors, reported at Brigham and Women’s Hospital through the Safety Reporting System from May 2004 to May 2009. We also collected data regarding the cost associated with hospitalizations in which ADRs occurred.
Of 463 anticoagulant-associated ADEs, 226 were MEs (48.8%), 141 were ADRs (30.5%), and 96 (20.7%) involved both a medication error and ADR. Seventy percent of anticoagulant-associated ADEs were potentially preventable. Transcription errors (48%) were the most frequent root cause of anticoagulant-associated medication errors, while medication errors (40%) were a common root cause of anticoagulant-associated ADRs. Death within 30 days of anticoagulant-associated ADEs occurred in 11% of patients. After an anticoagulant-associated ADR, most hospitalization expenditures were attributable to nursing costs (mean $33,189 per ADR) followed by pharmacy costs (mean $7,451 per ADR).
Most anticoagulant-associated ADEs among inpatients result from medication errors and are therefore potentially preventable. We observed an elevated 30-day mortality rate among patients who suffered an anticoagulant-associated ADE and high hospitalization costs following ADRs. Further Quality Improvement efforts to reduce anticoagulant-associated medication errors are warranted to improve patient safety and decrease health care expenditures.
adverse drug events; adverse drug reactions; anticoagulation; medication errors
Reinforcement-based treatments, based on behavioral economics models, can improve outcomes of medical conditions with behavioral components. This study evaluated the efficacy of a low-cost reinforcement intervention to produce initial weight loss.
Overweight individuals (N=56) were randomized to one of two 12-week treatments: LEARN manual with supportive counseling, or that same treatment with opportunities to win $1-$100 prizes for losing weight and completing weight-loss activities.
Patients receiving reinforcement lost significantly more weight (6.0%±4.9% baseline bodyweight) than patients in the non-reinforcement condition (3.5%±4.1%; p=0.04). Moreover, 64.3% of patients receiving reinforcement achieved weight loss of ≥ 5% baseline bodyweight versus 25.0% of those in the non-reinforcement condition (p=0.003). Proportional weight lost was significantly related to reductions in total cholesterol and 24-hour ambulatory heart rate.
This reinforcement-based intervention substantially enhances short-term weight loss, and reductions in weight are associated with important changes in clinical biomarkers. Larger-scale evaluation of reinforcement-based treatments for weight loss are warranted.
reinforcement; behavioral economics; weight loss; obesity
Although tight glucose control is widely used in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized non-critically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or if it is merely an association mediated by comorbidities (spontaneous hypoglycemia).
Retrospective cohort of patients admitted to the general wards of an academic center during 2007. The in-hospital mortality risk of a hypoglycemic group (at least one blood glucose ≤ 70 mg/dl) was compared to that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-associated hypoglycemia was performed.
Among 31,970 patients, 3,349 (10.5%) had at least one episode of hypoglycemia. Patients with hypoglycemia were older, had more comorbidities, and received more antidiabetic agents. Hypoglycemia was associated with increased in-hospital mortality (HR: 1.67, 95% CI, 1.33 to 2.09, p<0.001). However, this greater risk was limited to patients with spontaneous hypoglycemia (HR: 2.62, 95% CI, 1.97 to 3.47, p<0.001), not to those with drug-associated hypoglycemia (HR: 1.06, 95% CI, 0.74 to 1.52, p=0.749). After adjustment for patient comorbidities, the association between spontaneous hypoglycemia and mortality was eliminated (HR: 1.11, 95% CI, 0.76 to 1.64, p=0.582).
Drug-associated hypoglycemia was not associated with increased mortality risk in patients admitted to the general wards. The association between spontaneous hypoglycemia and mortality was eliminated after adjustment for comorbidities, suggesting that hypoglycemia may be a marker of disease burden rather than a direct cause of death.
Hypoglycemia; mortality; hypoglycemia in general ward patients
Diabetes; Hypoglycemia; Hypoglycemic Mortality; Glycemic Goals
The objectives of this study were to examine the magnitude of, and 20-year trends in, age differences in short-term outcomes among men and women hospitalized with acute myocardial infarction (AMI) in central Massachusetts.
The study population consisted of 5,907 male and 4,406 female residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers with AMI between 1986 and 2005.
Overall, among both men and women, older patients were significantly more likely to have developed atrial fibrillation, heart failure, and to have died during hospitalization and within 30 days after admission compared to patients <65 years. Among men, age differences in the risk of developing atrial fibrillation have widened over the past 2 decades, while differences in the risk of developing cardiogenic shock have narrowed for men 75 years and older as compared with those <65 years. Among women, age differences in the risk of developing these major complications of AMI have not changed significantly over time. Age differences in short-term mortality have remained relatively unchanged over the past 20 years in both sexes, though individuals of all ages have experienced declines in short-term death rates over this period.
Elderly men and women are more likely to experience adverse short-term outcomes after AMI and age differences in short-term mortality rates have remained relatively unchanged in both sexes over the past 20 years. More targeted treatment approaches during hospitalization for AMI and thereafter are needed for older patients to improve their prognosis. Word count: 248
Acute myocardial infarction; hospital complications; hospital mortality; age and sex differences
We performed a meta-analysis to systematically measure efficacy and safety of vasopressin receptor antagonists (VRAs) tested in randomized controlled trials for treatment of hyponatremia.
MEDLINE, ClinicalTrials.gov, and scientific abstracts were searched without language restriction. Two authors independently screened citations, and extracted data on patient characteristics, quality of reports, and efficacy and safety endpoints.
11 trials were identified (1094 patients). By meta-analysis, VRAs achieved a net increase in serum sodium concentration ([Na+]serum) relative to placebo of 3.3 mEq/L at day 1 (95% CI, 2.7, 3.8), and 4.2 mEq/L at day 2 (95% CI, 3.6, 4.8), persisting at days 3-5. Larger net increases in [Na+]serum at days 1-4 were observed in euvolemic hyponatremia and with higher doses. VRAs induced a net increase in effective water clearance relative to placebo of 1,244 mL at day 1 (95% CI, 920, 1,567), persisting at days 2 and 4. VRAs were associated with odds ratios of 3.0 for overly rapid correction of [Na+]serum (P<0.001), 7.8 for development of hypernatremia (P<0.001), 3.3 for thirst development (P<0.001), and 2.2 for postural hypotension (P=0.04).
Short-term use of VRAs in treating hyponatremia was successful at raising [Na+]serum. Additional experience is required to guide their optimal use and minimize safety concerns.
hyponatremia; conivaptan; tolvaptan; lixivaptan; satavaptan
More physician years in practice have been associated with less frequent guideline adherence, but it is unknown whether years in practice are associated with patient outcomes.
We examined all inpatients on the teaching service of an urban hospital from 7/1/02 through 6/30/04. Admissions were assigned to attending physicians quasi-randomly. Years in practice was defined as the number of years the attending physician held a medical license. We divided physicians into 4 groups (0–5, 6–10, 11–20, and > 20 years in practice), and used negative binomial and logistic regression to adjust for patient characteristics and estimate associations between years in practice and length-of-stay, readmission, and mortality.
59 physicians and 6,572 admissions were examined. Though the four inpatient groups had similar demographic and clinical characteristics, physicians with more years in practice had longer mean lengths-of-stay (4.77, 5.29, 5.42, and 5.31 days for physicians with 0–5, 6–10, 11–20, and >20 years in practice respectively, p = 0.001). After adjustment, inpatients of physicians with more than 20 years in practice had higher risk for both in-hospital mortality (OR = 1.71, 95% CI: 1.06–2.76) and 30-day mortality (OR = 1.51, 95% CI: 1.06–2.16) than inpatients of physicians with 0–5 years in practice.
Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality of care interventions should be developed to maintain inpatient skills for physicians.
Physician Experience; Length-of-stay; Outcomes; Hospital Medicine
Twenty years has passed since our first call for a new specialty in Vascular Medicine(1). This proposal was motivated by novel insights into vascular disease, advances in diagnostics and therapies directed toward the vasculature, and a growing population of patients with vascular disease. Now, with two decades of perspective, we reaffirm the call for Vascular Medicine, highlight the field’s early successes, and provide our vision for the future of the specialty.
The demographic shift toward an older population in the U.S. will result in a higher burden of coronary heart disease, but the increase has not been quantified in detail. We sought to estimate the impact of the aging U.S. population on coronary heart disease.
We used the Coronary Heart Disease Policy Model, a Markov model of the U.S. population aged 35–84 years, and U.S. Census projections to model the age structure of the population from 2010–2040.
Assuming no substantive changes in risks factors or treatments, incident coronary heart disease is projected to increase by approximately 26%, from 981,000 in 2010 to 1,234,000 in 2040, and prevalent coronary heart disease by 47%, from 11.7 million to 17.3 million. Mortality will be affected strongly by the aging population; annual coronary heart disease deaths are projected to increase by 56% over the next 30 years, from 392,000 to 610,000. Coronary heart disease-related health care costs are projected to rise by 41% from $126.2 billion in 2010 to $177.5 billion in 2040 in the U.S. It may be possible to offset the increase in disease burden through achievement of Healthy People 2010/2020 objectives or interventions that substantially reduce obesity, blood pressure, or cholesterol levels in the population.
Without considerable changes in risk factors or treatments, the aging of the U.S. population will result in a sizeable increase in coronary heart disease incidence, prevalence, mortality, and costs. Health care stakeholders need to plan for future age-related health care demands of coronary heart disease.
Aging; coronary heart disease; forecasting; Markov chains
Type 2 diabetes is an important risk factor for heart failure and is common among patients with heart failure. The impact of weight on prognosis after hospitalization for acute heart failure among patients with diabetes is unknown. The objective of this study was to examine all-cause mortality in relation to weight status among patients with Type 2 diabetes hospitalized for decompensated heart failure.
The Worcester Heart Failure Study included adults admitted with acute heart failure to all metropolitan Worcester medical centers in 1995 and 2000. The weight status of 1,644 patients with diabetes (history of Type 2 diabetes in medical record or admission serum glucose ≥200 mg/dl) was categorized using body mass index calculated from height and weight at admission. Survival status was ascertained at 1 and 5 years after hospital admission.
65% of patients were overweight or obese and 3% were underweight. Underweight patients had 50% higher odds of all-cause mortality within 5 years of hospitalization for acute heart failure than normal weight patients. Class I and II obesity were associated with 20% and 40% lower odds of dying. Overweight and Class III obesity were not associated with mortality. Results were similar for mortality within 1 year of hospitalization for acute heart failure.
The mechanisms underlying the association between weight status and mortality are not fully understood. Additional research is needed to explore the effects of body composition, recent weight changes, and prognosis after hospitalization for heart failure among patients with diabetes.
heart failure; diabetes; obesity; mortality
Constipation is common in Western societies, accounting for 2.5 million-physician visits/year in the US. Since many factors predisposing to constipation are also risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events.
We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women’s Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative endpoint including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors and other clinical variables (median follow-up: 6.9 years).
The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared to women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events.
In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Since constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.
cardiovascular disease; prevention; women’s health; risk factors
The Clock-in-the-Box is a rapid (2 minute) cognitive screening tool. The purpose of this study was a) to compare the Clock-in-the-Box with the Mini-Mental State Exam (MMSE) and neuropsychological tests, b) to determine Clock-in-the-Box score normative values by age and education group, and c) to determine if the Clock-in-the-Box score is associated with measures of physical function.
Community-dwelling older participants in the Boston-area were recruited for a prospective, longitudinal study in which they completed a variety of cognitive and functional assessments.
At baseline, participants (n=798; mean age (±SD)=78.2 (±5.5) years; 14 (±3) mean years of education) completed in-home assessments of cognition – the Clock-in-the-Box and MMSE; measures of independent function - Activities of Daily Living and Instrumental Activities of Daily Living; and measures of physical function - Short Physical Performance Battery. Mean MMSE score was 27.1 (±1.6; range 0–30 – 0 worst) and mean Clock-in-the-Box was 6.2 (±1.6; range 0–8 – 0 worst). Performance on the Clock-in-the-Box was correlated (Spearman) with the MMSE (r=0.49, p<.001) and neuropsychological measures (r=0.37–0.50; p<.001). Higher Clock-in-the-Box score was significantly associated with no difficulty in Activities of Daily Living (χ2=39.6, p=<.001) and Instrumental Activities of Daily Living (χ2=35.5, p=<.001). Additionally, higher Clock-in-the-Box scores were associated with higher scores on the Short Physical Performance Battery (F=5.4, p<.001).
The Clock-in-the-Box is a brief cognitive screening test that is correlated with the MMSE, neuropsychological tests, and measures of independent and physical function in community-dwelling older adults.
cognition; aged; function; dementia; screening; neuropsychological testing
Natriuretic peptides (NP’s) have prognostic value across a wide spectrum of cardiovascular diseases and may predict cognitive dysfunction in patients with cardiovascular disease even in the absence of prior stroke. Little is known about the association of NP’s with cognitive function in community-dwelling adults. We assessed the association between NT-proBNP levels and cognitive function in community-dwelling ambulatory older adults in the Rancho Bernardo Study.
We studied 950 men and women, aged 60 years and older, who attended a research clinic visit where a medical history and examination were performed, and blood for cardiovascular disease risk factors and NT-proBNP levels were obtained. Three cognitive function tests were administered: Mini Mental State Exam (MMSE), Trail-Making Test B (Trails B), and Category Fluency.
Participants with high NT-proBNP levels (≥450 pg/mL, n=198) were older and had a higher prevalence of coronary heart disease (12% vs. 30%), and stroke (5% vs. 11%) (both p’s≤0.001). In unadjusted analyses, all three cognitive function test scores were significantly associated with NT-proBNP levels (p<0.001). After adjusting for age, sex, education, hypertension, body mass index, exercise, alcohol use, smoking, low density lipoprotein cholesterol, creatinine clearance, and prior cardiovascular disease, elevated NT-proBNP levels remained independently associated with poor cognitive performance on MMSE (odds ratio [95% confidence interval] 2.0 [1.1–3.6], p=0.02) and Trails B (1.7 [1.2–2.7], p=0.01), but not Category Fluency (1.4 [0.9–2.2], p=0.19). Results were unchanged after excluding the 6% of participants with a history of stroke.
NT-proBNP levels were strongly and independently associated with poor cognitive function in community-dwelling older adults.
natriuretic peptides; cerebrovascular disorders; cardiovascular diseases; community; elderly; cognitive function