Reporter-Interpreter-Manager-Educator (RIME) descriptive ratings as an evaluation tool in an emergency medicine clerkship.

BACKGROUND: Emergency Medicine (EM) clerkships traditionally assess students using numerical ratings of clinical performance. The descriptive ratings of the Reporter, Interpreter, Manager, and Educator (RIME) method have been shown to be valuable in other specialties. OBJECTIVES: We hypothesized that the RIME descriptive ratings would correlate with clinical performance and examination scores in an EM clerkship, indicating that the RIME ratings are a valid measure of performance. METHODS: This was a prospective cohort study of an evaluation instrument for 4(th)-year medical students completing an EM rotation. This study received exempt Institutional Review Board status. EM faculty and residents completed shift evaluation forms including both numerical and RIME ratings. Students completed a final examination. Mean scores for RIME and clinical evaluations were calculated. Linear regression models were used to determine whether RIME ratings predicted clinical evaluation scores or final examination scores. RESULTS: Four hundred thirty-nine students who completed the EM clerkship were enrolled in the study. After excluding items with missing data, there were 2086 evaluation forms (based on 289 students) available for analysis. There was a clear positive relationship between RIME category and clinical evaluation score (r(2)=0.40, p<0.01). RIME ratings correlated most strongly with patient management skills and least strongly with humanistic qualities. A very weak correlation was seen with RIME and final examination. CONCLUSION: We found a positive association between RIME and clinical evaluation scores, suggesting that RIME is a valid clinical evaluation instrument. RIME descriptive ratings can be incorporated into EM evaluation instruments and provides useful data related to patient management skills.

Impact of an emergency department observation unit transient ischemic attack protocol on length of stay and cost.

This study examined the impact of an emergency department (ED) observation unit's accelerated diagnostic protocol (ADP) on hospital length of stay (LOS), cost of care, and clinical outcome of patients who had sustained a transient ischemic attack (TIA). All patients with TIA presenting to the ED over a 18-consecutive month period were eligible for the study. During the initial 11 months of the study (pre-ADP period), all patients were admitted to the neurology service. Over the subsequent 7 months (post-ADP period), patients were either managed using the ADP or were admitted based on ADP exclusion criteria or at a physician's discretion. All patients had orders for serial clinical examinations, neurologic evaluation, cardiac monitoring, vascular imaging of the brain and neck, and echocardiography. A total of 142 patients were included in the study (mean age, 67.9 ± 13.9 years; 61% female; mean ABCD(2) score, 4.3 ± 1.4). In the post-ADP period, 68% of the patients were managed using the ADP. Of these patients, 79% were discharged with a median LOS of 25.5 hours (ED + observation unit). Compared with the pre-ADP patients, the post-ADP patients (ADP and non-ADP) had a 20.8-hour shorter median LOS (95% confidence interval, 16.3-25.1 hours; P < .01) than pre-ADP patients and lower median associated costs (cost difference, $1643; 95% confidence interval, $1047-$2238). The stroke rate at 90 days was low in both groups (pre-ADP, 0%; post-ADP, 1.2%). Our findings indicate that introduction of an ED observation unit ADP for patients with TIA at a primary stroke center is associated with a significantly shorter LOS and lower costs compared with inpatient admission, with comparable clinical outcomes.

Body mass index, leptin, and ambulatory blood pressure variability in healthy adults.

OBJECTIVE: To investigate the association between body mass index (BMI) and 24-h ambulatory blood pressure (ABP) variability, and to assess whether leptin might act as a mediator of this association. METHODS: A cross-sectional study in healthy, normotensive men and women (n = 156). BMI was derived from direct height and weight measurements made on each participant. All participants underwent 24-h ABP monitoring, and two measures of ABP variability were derived--the weighted standard deviation (wSD) and the average real variability (ARV). Plasma leptin was measured using an enzyme lined immunosorbant assay. RESULTS: In linear regression models adjusted for demographic factors, glucose, creatinine, lipids, and mean ABP, BMI showed positive and statistically significant associations with diastolic wSD, and systolic and diastolic ARV. For those in the low, intermediate, and high BMI groups, mean values for diastolic wSD were 7.7, 7.9, and 8.5 mmHg, respectively (p = .02); mean values of systolic ARV were 8.2, 8.2, and 9.0 mmHg, respectively (p=.02); and mean values of diastolic ARV were 6.7, 7.0, and 7.5 mmHg, respectively (p = .01). Similarly, leptin showed positive and statistically significant associations with measures of wSD and ARV. When BMI was entered as an ordinal variable in regression models for wSD and ARV, adjustment for leptin attenuated significant ordinal BMI coefficients by as much as 60%, suggesting a mediating role for leptin. CONCLUSION: In healthy adults, BMI and leptin show positive associations with ABP variability, and leptin may play a mediating role in this association.

Relationship of self-reported alcohol consumption to ambulatory blood pressure in a sample of healthy adults.

BACKGROUND: Habitual alcohol consumption has shown positive associations with office blood pressure (BP). Less well established, however, is alcohol consumption's relationship to various measures of ambulatory BP (ABP) in healthy, normotensive persons. METHODS: We investigated alcohol consumption's relationship to mean ABP, ABP variability, and the ABP arterial stiffness index in a sample of nonsmoking adults who were free of hypertension and cardiovascular disease (CVD; n = 157). Total alcohol consumption, intake of specific alcoholic beverages, and binge drinking were assessed by self-report. ABP was measured every 30 min for 24 h. RESULTS: In multivariable-adjusted linear regression models, higher levels of total weekly alcohol consumption were associated with higher ABP. For those consuming 0, 1-2, and 3 or more alcoholic drinks per week, mean 24-h systolic ABP values were 112.2, 115.2, and 116.6 mm Hg, respectively (P = 0.05), and mean 24-h diastolic ABP values were 70.6, 71.9, and 74.2 mm Hg, respectively (P = 0.02). Beer and liquor consumption showed stronger positive associations with ABP than did wine consumption. Among nonbinge drinkers and binge drinkers, mean 24-h systolic ABP values were 113.3 and 118.6 mm Hg, respectively (P = 0.04) and mean 24-h diastolic ABP values were 71.3 and 75.0 mm Hg, respectively (P = 0.04). Alcohol consumption was not significantly related to ABP variability or the ABP arterial stiffness index. CONCLUSION: Total habitual alcohol consumption, consumption of specific alcoholic drinks, and binge drinking are associated with higher mean ABP in healthy, normotensive adults.

Caloric sweetener consumption and dyslipidemia among US adults.

CONTEXT: Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures. OBJECTIVE: To assess the association between consumption of added sugars and blood lipid levels in US adults. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study among US adults (n = 6113) from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (< 5% [reference group], 5%-<10%, 10%-<17.5%, 17.5%-<25%, and > or = 25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated. MAIN OUTCOME MEASURES: Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (< 40 mg/dL for men; < 50 mg/dL for women), high triglyceride levels (> or = 150 mg/dL), high LDL-C levels (> or = 130 mg/dL), or high ratio of triglycerides to HDL-C (> 3.8). Results were weighted to be representative of the US population. RESULTS: A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P < .001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P < .001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P = .047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (> or = 10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (< 5% added sugars). CONCLUSION: In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.

The recidivism characteristics of an emergency department observation unit.

STUDY OBJECTIVE: We describe the recidivism characteristics of an adult emergency department (ED) observation unit population and determine whether rates differ according to demographic or clinical features. METHODS: This prospective observational cohort study of a protocol-driven ED observation unit reviewed all discharged ED observation unit patients who returned within 14 days of discharge for an unscheduled ED visit or direct inpatient admission to the study hospital, or a proximate affiliated hospital, during 6 consecutive months. Age, sex, initial ED observation unit diagnosis, ED observation unit length of stay, and return visit disposition were determined from hospital databases and confirmed by chart review. All return visits were classified as related or unrelated to the index visit. RESULTS: There were 55,727 ED visits, with 4,348 patients admitted to the ED observation unit, of whom 80.7% (3,509) were discharged. Patients with or without a return visit were similar in terms of age (56.9 years [standard deviation (SD) 19.5 years]), percentage of male patients (40.0%), or initial ED observation unit length of stay (15.0 hours [SD 6.0 hours]). Of discharged ED observation unit patients, 375 (10.8%) had a return visit, of which 277 (7.9%) were related. Of return visits, 86.3% of patients had only 1 return visit, 11.6% had 2, and 2.1% had 3 or more; 4.2% of returns occurred at an affiliated hospital. Time to first return visit was clustered within the first week for related visits, with a mean time to return of 4.5 days (SD 3.9 days). On return visit, 40.2% of patients were treated and discharged from the ED, 36.2% were treated in the ED and admitted, 14.4% were treated in the ED and then the ED observation unit and discharged home, 12.3% were directly admitted to the hospital, and 2.5% were treated in the ED and then the ED observation unit and admitted. Among common conditions, related return visit rates were highest for headache (16.1%), back pain (13.8%), and abdominal pain (12.7%) and lowest for chest pain (3.6%). As a group, therapeutic protocols, and specifically painful conditions, had significantly higher related return visit rates than diagnostic protocols (10.8% versus 5.1%). CONCLUSION: Patients who return after an ED observation unit visit are similar to patients who do not return in terms of age, sex, or initial length of stay. However, ED observation unit recidivism rates do differ according to observation category, with painful conditions showing the highest recidivism rates.

Physical inactivity and cardiovascular risk: baseline observations from men and premenopausal women.

INTRODUCTION: Physical activity or exercise is a proven deterrent of cardiovascular (CV) diseases. PURPOSE: In this study, we examined the relationships between baseline values of parameters related to physical activity and known markers of CV disease, including markers of oxidative stress. METHODS: A total of 455 healthy men and women between the ages of 18 and 50 were recruited to participate in the study. Levels of lipids/lipoproteins and markers of oxidative stress and inflammation were measured along with the VO(2) and duration time spent on treadmill. RESULTS: Women, in general, had a significantly (P<0.0001) higher plasma high density lipoprotein (1.51+/-0.30 mmol/l), decreased (P<0.0001) low density lipoprotein (LDL) (2.75+/-0.66 mmol/l), and decreased (P<0.0001) triglycerides levels (2.09+/-0.85 mmol/l), compared with males (1.21+/-0.23 mmol/l, 2.92+/-0.81 mmol/l, and 3.02+/-1.34 mmol/l, respectively). There was a direct correlation between the levels of plasma LDL and the levels oxidized LDL levels (P<0.0001) in both men and women. Despite a better antiatherogenic lipid profile, the levels of C-reactive protein in women were significantly (P<0.0001) elevated (3.78+/-3.66 ng/ml) as compared with those in men (1.82+/-2.37 ng/ml). CONCLUSION: These results suggest intrinsic sex differences between men and women in relation to atherogenic risk.

Physical and psychological burden of chronic kidney disease among older adults.

INTRODUCTION: The purpose of the study is to determine if functional status and quality of life (QoL) vary with glomerular filtration rate (GFR) among older adults. METHODS: We studied adults aged 45 years and older participating in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. Data included demographic and health information, serum creatinine and hemoglobin, the 4-item Center for Epidemiologic Studies Depression Scale (CES-D-4), the 4-item Cohen's Perceived Stress Scale (PSS-4), reported health status and inactivity and the Medical Outcomes Study Short Form-12 (SF-12) QoL scores. RESULTS: CKD (GFR <60 ml/min/1.73 m(2)) was present in 11.6% of the subjects. As GFR declined, the SF-12 physical component score, adjusted for other participant attributes, declined from 38.9 to 35.9 (p = 0.0001). After adjustment for other risk factors, poorer personal health scores (p < 0.0001) and decreased physical activity (p < 0.0001) were reported as GFR declined. In contrast, after adjusting for other participant characteristics, depression scores and stress scores and the mental component score of the SF-12 were not associated with kidney function. CONCLUSION: Older individuals with CKD in the US population experience an increased prevalence of impaired QoL that cannot be fully explained by other individual characteristics.

Acute metformin overdose: examining serum pH, lactate level, and metformin concentrations in survivors versus nonsurvivors: a systematic review of the literature.

STUDY OBJECTIVE: Metformin is known to cause potentially fatal metabolic acidosis with an increased lactate level in both overdose and therapeutic use. No association between mortality and serum pH, lactate level, or metformin concentrations, though intuitive, has yet been described. This systematic literature review is designed to evaluate the association between mortality and serum pH, lactate level, and metformin concentrations in acute metformin overdose. METHODS: We reviewed the literature by using the MEDLINE, EMBASE, CINAHL, and TOXNET databases for cases of metformin overdose with documented mortality data and values of serum pH, lactate level, and metformin concentrations. When available, patient age, patient sex, and whether patients received intravenous sodium bicarbonate therapy or hemodialysis were also analyzed. Cases meeting inclusion criteria were analyzed to determine whether a difference in distribution of nadir serum pH, peak serum lactate level, or peak serum metformin concentrations existed between overdose survivors and nonsurvivors. RESULTS: We identified 10 articles that had 1 or more cases meeting our inclusion criteria. In total, there were 22 cases of metformin overdose (5/22 died) that met inclusion criteria. No intentional overdose patients died whose serum pH nadir was greater than 6.9, maximum lactate concentration less than 25 mol/L, or maximum metformin concentration less than 50 microg/mL (therapeutic range 1 to 2 microg/mL). Intentional overdose patients with a nadir serum pH less than 6.9 had 83% mortality (5/6), those with lactate concentration greater than 25 mmol/L had 83% mortality (5/6), and those with metformin concentration greater than 50 microg/mL had 38% mortality (5/12). Nadir serum pH and peak serum lactate and metformin concentration distributions in survivors and nonsurvivors revealed that survivors had a median nadir pH of 7.30, interquartile range (IQR) 7.22, 7.36; nonsurvivors, a median nadir pH of 6.71, IQR 6.71, 6.73; survivors, a median peak lactate level of 10.8 mmol/L, IQR 4.2, 12.9; nonsurvivors, a median peak lactate level of 35.0 mmol/L, IQR 33.3, 39.0; survivors, a median peak metformin level of 42 microg/mL, IQR 6.6, 67.6; and nonsurvivors, a median peak metformin level of 110 microg/mL, IQR 110, 110. CONCLUSION: No cases of acute metformin overdose meeting the study's inclusion criteria were found in which patients with a nadir serum pH greater than 6.9, peak serum lactate concentrations less than 25 mmol/L, or peak serum metformin concentrations less than 50 microg/mL died. Patients with acute metformin overdose who died had much lower serum pH nadirs and much higher peak serum lactate and metformin concentrations than those who survived.

Chronic kidney disease is often unrecognized among patients with coronary heart disease: The REGARDS Cohort Study.

INTRODUCTION: Individuals with kidney disease are at increased risk for coronary heart disease (CHD) and CHD is associated with an increased prevalence of chronic kidney disease (CKD). Awareness of CKD may potentially influence diagnostic decisions, life-style changes and pharmacologic interventions targeted at modifiable CHD risk factors. We describe here the degree to which persons with CHD are aware of their CKD. METHODS: The Reasons for Geographical and Racial Difference in Stroke (REGARDS) cohort study, a population-based sample of US residents aged 45 and older. We included in our analyses 28,112 REGARDS participants recruited as of June 2007. We estimated GFR (eGFR) using the MDRD equation, defined CKD as a GFR <60 ml/min/1.73 m(2), and ascertained awareness of chronic kidney disease and coronary heart disease through self-report. We used the odds ratio to compare the association between awareness of kidney disease, as measured by GFR <60 ml/min/1.73 m(2), among individuals with and without self-reported CHD by both the presence of CKD and the severity of impaired kidney function. RESULTS: Coronary heart disease was reported by 3,803 (14.1%) of subjects, and 11.3% of subjects had CKD by eGFR. Among all individuals with a GFR <60 ml/min/ 1.73 m(2), 9.6% reported having been told by a physician that they had kidney disease. Among those with CHD and CKD, 5.0% were aware of their CKD compared to 2.0% in those without CHD [OR (95% CI) = 2.57 (2.08, 3.28)]. This difference persisted after controlling for the level of kidney function [aOR (95% CI) = 1.87 (1.43, 2.41)]. CONCLUSION: There was a high prevalence of CKD and a low prevalence of awareness of kidney disease among older adults in the US population with or without coronary heart disease. These findings support recent recommendations that patients with cardiovascular disease be systematically screened for and educated about CKD.

The surgical pathology of notochordal remnants in adult intervertebral disks: a report of 3 cases.

The notochord plays a critical role in organizing and directing vertebral development. In humans, most notochordal cells are eventually sequestered into the nucleus pulposus and disappear within the first decade of life. Although notochordal remnants and related lesions have been described in the axial skeleton of adults, their presence in intervertebral disks is rare. We describe herein 3 cases of incidental notochordal remnants identified in surgically removed adult intervertebral disks. Their histologic features were reminiscent of notochordal vestiges in the fetus. However, they raised the differential diagnosis of benign notochordal cell tumor and chordoma. Notochordal rests can be a source of diagnostic confusion and should be distinguished from notochordal neoplasms because they do not necessitate resection or other forms of therapy.

Endothelial function and aminothiol biomarkers of oxidative stress in healthy adults.

Endothelial dysfunction is known to precede the development of atherosclerosis and results primarily from increased oxidative degradation of NO. We hypothesized that assessment of oxidative stress in the bloodstream will reliably predict endothelial function in healthy adults. A total of 124 healthy nonsmokers had endothelial function assessed using ultrasound measurement of brachial artery flow-mediated vasodilation. Plasma oxidative stress was estimated by measuring the levels of the reduced and oxidized forms of thiols, including glutathione (reduced glutathione and oxidized glutathione) and cysteine (cysteine and cystine), respectively, and the mixed disulfide. Among the traditional risk factors, there were significant and independent correlations between flow-mediated vasodilation and high-density lipoprotein level, body mass index, gender, and the Framingham risk score. Among the thiol markers, plasma cystine (r=-0.23; P=0.009) and the mixed disulfide (r=-0.23; P=0.01) levels correlated with endothelium-dependent but not endothelium-independent vasodilation, even after adjusting for the Framingham risk score and high-sensitivity C-reactive protein level. A higher level of oxidized metabolites was associated with worse endothelial function. In conclusion, the oxidative stress markers, cystine, and the mixed disulfide are independent predictors of endothelial function. These markers, in combination with the Framingham risk score, may help in the early identification of asymptomatic subjects with endothelial dysfunction who are at potentially increased risk for future atherosclerotic disease progression.

Relation of adult-onset asthma to coronary heart disease and stroke.

Asthma was associated with atherosclerotic disease in several studies, with evidence that this association may be limited to women. However, most previous studies failed to account for the heterogeneity of asthma subtypes. We previously reported increased carotid intima-medial thickness in women with adult-onset asthma. In this study, the association of adult- and child-onset asthma with incident coronary heart disease (CHD) and stroke were examined. Subjects were classified according to self-report of physician-diagnosed asthma and age of asthma onset. Cox proportional hazards models were used to test the association of adult- and child-onset asthma with incident CHD and stroke, testing for gender interaction. Subanalysis was also performed using only never smokers. Women with adult-onset asthma experienced a 2-fold increase in incident CHD and stroke that was independent of other risk factors, including smoking, body mass index, and physical activity, and persisted when analysis was restricted to never smokers. No significant association was found in women with child-onset asthma or in men. In conclusion, adult-onset asthma may be a significant risk factor for CHD and stroke in women, but not men.

Adult-onset asthma is associated with increased carotid atherosclerosis among women in the Atherosclerosis Risk in Communities (ARIC) study.

Some studies have suggested that asthma may be a risk factor for coronary heart disease and stroke, particularly in women. Child and adult-onset asthma differ according to inflammatory characteristics and gender distribution. We examined whether childhood-onset and adult-onset asthma were associated with carotid artery intima-media thickness (IMT) in men and women in the Atherosclerosis Risk in Communities (ARIC) study. In unadjusted analyses, the weighted mean far wall IMT thickness for women with history of adult-onset asthma was significantly greater than that of women without history of asthma (0.731 mm versus 0.681 mm; p<0.0001) while IMT for women with history of childhood-onset asthma (IMT=0.684 mm) did not differ substantially from non-asthmatic women. Mean IMT did not differ significantly according to asthma history among men. When the data were fitted to a linear model, the interaction between asthma status and gender was significant (p=0.006). After adjusting for age, race, BMI, smoking status, smoking pack years, diabetes, hypertension, physical activity, education level, and high and low density lipoprotein levels, the mean IMT difference between women with adult-onset asthma and no history of asthma was attenuated but remained significant (0.713 mm versus 0.687 mm, p=0.008). In conclusion, adult-onset asthma but not child-onset asthma is associated with increased carotid atherosclerosis among women but not among men.

Blood pressure and risk of death from external causes among men screened for the Multiple Risk Factor Intervention Trial.

A few epidemiologic studies have shown an increased risk of death from external causes among men with hypertension. Previous studies were limited by small numbers of events, however, and none assessed the association of blood pressure with specific types of "accidental" death. The authors examined data obtained from baseline interviews and 25 years of mortality follow-up (1973-1999) for 347,978 men screened for the US Multiple Risk Factor Intervention Trial. Proportional hazards regression analyses were used to quantify associations of blood pressure with all external causes of death and individual causes. There were 3,910 deaths from external causes, including 2,313 unintentional injuries, 1,248 suicides, and 349 homicides. Compared with those for men whose blood pressure status was "normal" according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, the multivariate-adjusted hazard ratios and 95% confidence intervals for death from external causes among men with prehypertension, stage 1 hypertension, and stage 2 hypertension were 0.91 (95% confidence interval (CI): 0.83, 1.00), 1.06 (95% CI: 0.96, 1.16), and 1.44 (95% CI: 1.28, 1.62), respectively. Men with stage 2 hypertension had multivariate-adjusted hazard ratios of 1.90 for falls (95% CI: 1.32, 2.74), 1.45 for motor vehicle injuries (95% CI: 1.14, 1.85), 1.33 for other "accidents" (95% CI: 1.06, 1.66), 1.40 for suicide (95% CI: 1.13, 1.73), and 1.35 for homicide (95% CI: 0.92, 1.97). For men, hypertension may signal an increased risk of death from external causes.

Pulse pressure and inflammatory process in atherosclerosis.

Recent studies have reported positive associations between pulse pressure (PP) and markers of inflammation. These studies are intriguing because they suggest that elevations in PP could induce an inflammatory state and thereby increase the risk of inflammation- related diseases such as atherosclerotic cardiovascular disease. In the present chapter, we review potential mechanisms by which an elevated PP could increase inflammation. We also review human-based studies that have investigated the association between PP and inflammatory biomarkers such as C-reactive protein. The majority of studies support a positive association between PP and inflammatory markers. However, it remains unclear whether the association is truly causal and whether it has relevance in terms of predicting cardiovascular diseases.

Comparison of functional status after coronary artery bypass grafting in patients with and without diabetes mellitus.

Although previous studies have shown increased risk of morbidity and mortality in patients with diabetes mellitus (DM) who undergo coronary artery bypass grafting (CABG), data are conflicting on whether the gains in physical function and mental health after CABG achieved by patients with DM are similar to, or less than, those achieved by patients without DM. We compared the gains in physical function and mental health at 6 months after CABG surgery between 696 consecutive patients with DM and 376 without DM who underwent their first CABG from February 1999 to February 2001. Physical function and mental health were measured using the Short Form 36-item Health Survey. From the baseline and follow-up Short Form 36-item Health Survey data, the physical and mental component scales were derived. At 6 months, the patients with and without DM had significant improvement in physical function and mental health, but those without DM had improved significantly more than those with DM with respect to physical functioning. After adjusting for baseline characteristics, a lower proportion of patients with DM had experienced improvement (an increase of > or = 5 points) in the physical component scale score compared with those without DM (45.0% vs 58.0.%, RR = 0.78, p = 0.002). Moreover, a higher proportion of patients with DM experienced a decrease in the physical component scale score compared with those without DM (14.9% vs 7.8%, RR = 1.91, p = 0.006). In contrast, no significant differences were found in the mental component scale score changes by DM status. In conclusion, CABG is associated with lower gains in physical function in those with DM than in those without DM. Special attention should be paid to the physical function of patients with DM after CABG, and any barriers to functional recovery in this group should be promptly identified and addressed.

Relation of C-reactive protein and tumor necrosis factor-alpha to ambulatory blood pressure variability in healthy adults.

Elevated blood pressure (BP) variability has been linked to an increased risk for adverse cardiovascular events, but the biologic factors that promote elevated BP variability are not entirely understood. This cross-sectional study examined whether inflammatory factors might be associated with elevated BP variability during 24-hour ambulatory BP monitoring. Subjects were 140 healthy, normotensive adults. Inflammatory markers included C-reactive protein (CRP) and tumor necrosis factor-alpha. BP variability was calculated as the within-subject SD of BP values obtained during the daytime, nighttime, and 24-hour periods. In linear regression models that were adjusted for mean BP and other factors, CRP quartiles were positively associated with daytime systolic BP variability; for subjects in the lowest to highest CRP quartiles, the mean within-subject SDs of daytime systolic BP were 9.31, 9.62, 10.55, and 11.17, respectively (p for linear trend = 0.001). CRP showed similar positive associations with nighttime and 24-hour systolic BP variability. In contrast, tumor necrosis factor-alpha was not independently associated with systolic BP variability during any of the time periods. With respect to diastolic BP variability, significant positive associations were found between CRP and diastolic BP variability during all time periods and between tumor necrosis factor-alpha and daytime diastolic BP variability. In conclusion, there are positive associations between markers of inflammation and BP variability in healthy, normotensive adults, suggesting that inflammation may be 1 of the factors that promotes increased BP variability.

Gender differences in short-term cardiovascular outcomes after percutaneous coronary interventions.

Recent studies have been inconsistent in demonstrating a decrease in the gender gap in short-term post-percutaneous coronary intervention (PCI) outcomes. We sought to determine gender differences in outcomes in younger and older patients who underwent PCI during the current stent era. We studied 4,768 elective PCI procedures performed at Emory University Hospital from 2001 to 2004. The baseline characteristics, periprocedural complications, angiographic success, procedural success, and major in-hospital complications (death, myocardial infarction, and emergency coronary artery bypass graft surgery) after PCI were compared between men and women. Women were more likely to be nonwhite and older, with a greater prevalence of hypertension and diabetes mellitus (all p <0.001) compared with men. After adjusting for baseline characteristics and coronary artery size, the incidence of coronary vascular injury complications was higher in women than in men, particularly in patients 55 years (OR 1.32, 95% CI 0.87 to 1.99, p = 0.047 for gender-age interaction). The adjusted odds of bleeding complications were also higher in women than in men (55 years OR 2.55, 95% CI 1.68 to 3.87, p = 0.121 for gender-age interaction). No significant gender differences were present in a combined end point of death, myocardial infarction, and emergency coronary artery bypass graft surgery. In conclusion, among patients who have undergone PCI, women, particularly younger women, are more likely than men to experience coronary vascular injury and bleeding complications unaccounted for by coronary artery size and other patient characteristics. No differences were found in major in-hospital complications by gender.