Wood Street Clinic Blog

Here you will find a selection of RSS feeds and blog entries

Sex reassignment surgery may protect metabolic health of transgender women

Transgender women who undergo sex reassignment surgery and hormone therapy may be less likely to develop metabolic disease than those who receive hormone therapy alone. This is according to new research recently presented at Cardiovascular, Renal and Metabolic Diseases: Physiology and Gender - a conference of the American Physiological Society, held in Annapolis, MD.
[Transgender symbol]
Sex reassignment surgery combined with female hormone therapy may protect the metabolic health of transgender women, researchers suggest.

Previous research has suggested that transgender women are at greater risk for cardiovascular disease and type 2 diabetes, compared with men and women among the general population.

Some studies have put this increased risk down to female hormone therapy; therapy with the female hormone estrogen, for example, has been linked to high blood pressure and increased risk of stroke and heart attack.

For this latest study, lead author Michael Nelson, PhD, of the Cedars-Sinai Medical Center in Los Angeles, CA, and colleagues set out to determine whether this metabolic risk varied depending on the type of therapy used make the male-to-female transition.

The team enrolled 12 transgender women to their study, four of whom were receiving female hormone therapy and eight of whom received a combination of female hormone therapy and bilateral orchiectomy - in which both testicles are surgically removed.

The researchers measured the insulin resistance and the accumulation of fat in the liver of each participant. They explain that insulin resistance is a key sign of poor metabolic health, and build-up of fat in the liver can cause nonalcoholic fatty liver disease - which studies have suggested can increase heart disease risk.

Compared with transgender women who received female hormone therapy alone, those who received both female hormone therapy and bilateral orchiectomy were found to have better metabolic health.

Specifically, the team found that transgender women only receiving hormone therapy had greater insulin resistance and greater accumulation of fat in the liver than those who received both surgery and female hormone therapy.

Transgender women who had the highest levels of testosterone were found to have the poorest metabolic health, according to the researchers.

In addition, the team found that the amount of fat build-up in the liver was linked to the level of insulin resistance; whether the two are associated is an ongoing subject of debate in the medical world.

Overall, the researchers say their findings indicate transgender women who undergo bilateral orchiectomy may be protected against insulin resistance and fat build-up in the liver, while the two conditions are more likely to develop among those who receive hormone therapy alone.

Earlier this year, Medical News Today reported on a study that found transgender children do not have a hormone imbalance.

Published in the Journal of Adolescent Health, the study of more than 100 transgender youths found that their hormone levels between the ages of 12-24 were consistent with the gender they were assigned at birth.

Written by

Continue reading

Researchers examine how neurofibromatosis causes premature cardiovascular disease

It's a fairly common genetic condition that can surface as a series of dark skin spots and result in a host of maladies from tumors to premature cardiovascular disease.

Medical College of Georgia researchers hope their studies of how neurofibromatosis 1, or NF1, can dangerously thicken or thin blood vessel walls will one day help physicians better identify and treat these young patients at cardiovascular risk.

"They lie at both ends of the spectrum, as you can imagine," said Dr. Brian Stansfield, neonatologist and physician-scientist at MCG and Children's Hospital of Georgia. He is talking about two seemingly disparate blood vessel problems. Arterial stenosis impedes blood flow by thickening and stiffening artery walls, putting patients at risk for hypertension and stroke. Aortic aneurysms weaken walls, leaving patients vulnerable to bleeding.

"Understanding what could be similar about them could help us better understand both at the same time," said Stansfield. He recently received an American Heart Association Scientist Development Grant and a New Investigator Award from the Congressionally Directed Medical Research Programs of the U.S. Department of Defense that are helping him do just that.

About seven percent of patients with NF1, an estimated 50,000 to 70,000 worldwide, have cardiovascular complications. Children can be born with complex heart defects and/or develop arterial stenosis or aneurysms by the time they reach adolescence.

The NF1 gene makes neurofibromin, a huge protein found inside all cells that is a natural tumor suppressor and anti-cell proliferator. It appears to work largely by suppressing the activity of a family of proteins called Ras. Ras is present in all cells and, when switched on by growth factors, it in turn switches on other proteins that enable cell growth, differentiation and survival.

"Ras connects the extracellular signal to the intracellular environment," Stansfield said. However, NF1 mutations make neurofibromin dysfunctional and cell growth haywire.

"It's essentially a cancer of the cardiovascular system," he said. "If you think about malignancy, it's this rampant growth of cells that causes that problem, and arterial stenosis mimics that very nicely. Arterial stenosis is a rapid growth of smooth muscle cells in an area where they should not be."

His lab has animal models with a common NF1 mutation that can result in arterial stenosis and another for aneurysms. In arterial stenosis, the researchers are injuring the carotid artery in mice with and without the genetic mutation then monitoring both recoveries. Stansfield notes that arterial stenosis is most common in the kidneys in NF1, but the carotid is a larger, more accessible blood vessel for research purposes.

While the major blood vessels initially look similar in both animals, injury accelerates the process that can occur in NF1, producing dramatic change. "It inactivates the NF1 gene enough that we see dysregulation of this pathway," Stansfield said.

While the walls of any artery would naturally thicken as part of the healing process, animals with the genetic mutation experience a two- to three-fold increase in thickness, including development of an entirely new blood vessel wall, or intima. The more rigid result appears to be an exaggerated response by the smooth muscle cells that normally enable blood vessels to be elastic and easily manage changing blood volumes.

When they looked further, MCG researchers found that NF1-mutant mice have increased numbers of immune cells called macrophages show up at the injury site and deliver a lot more growth factors. Macrophages are a normal part of the body's response to injury, which typically help eliminate debris. But in this case, they "really stimulate the smooth muscle cells to divide," Stansfield said. Macrophages also produce increased levels of reactive oxygen species, a natural byproduct of oxygen use, which can do serious cell damage at higher levels. They are now taking a closer look at these macrophages.

A similar scenario appears to drive formation of aneurysms in the mutant mice. But here, the mice also make more matrix metalloproteinases, enzymes that can cut and degrade things such as cell receptors, and encourage a host of diverse cell behaviors from proliferation to suicide. There is also degradation of the elastic lamina, layers of elastic tissue found within the smooth muscles.

The researchers suspect the dysfunctional neurofibromin is a major contributor to reactive oxygen species and inflammation in this scenario, and neurofibromin-deficient blood, or hematopoietic, cells, which also rush to the scene, are important mediators of aneurysm formation. In fact, they already have shown that by transplanting bone marrow from an NF1-mutant mouse into a normal mouse, they can reproduce much of the unhealthy penchant for forming aneurysms. New studies are aimed at better understanding the role of Ras in formation of the weakened blood vessels.

NF1 occurs in 1 in 3,000-4,000 people in the United States. It can be inherited, but mutations occur spontaneously in 30-50 percent of individuals, and the condition tends to be progressive, according to the National Institute of Neurological Disorders and Stroke.

Children get two copies of the NF1 gene, one from each parent. While it's more likely one copy is normal, if both have mutations, children have what's known as a second hit, which increases the likelihood they will have more than one of the host of potential problems that also include cancer, bone disease and cognitive issues. In fact, when both copies of the NF1 gene are knocked out in mice, they do not survive, Stansfield said.

The most common manifestation of NF1 is neurofibromas, rubbery masses that can form on the skin or inside organs as multiple cell types abnormally proliferate. In fact, NF1 is the most common of the group of genetic disorders that cause tumors to grow in the nervous system, according to NINDS. According to the National Cancer Institute, more than 30 percent of all human cancers are driven by mutations of the Ras family of genes.

Continue reading

Four leading societies partner to release expert consensus statement on ICD programming and testing

The Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA), Asia Pacific Heart Rhythm Society (APHRS), and the Socieded Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) release the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing. The expert consensus statement, presented today at the Asia Pacific Heart Rhythm Society's 8th Scientific Sessions, represents the first global collaborative and comprehensive statement of recommendations on programming choices in the implementation of implantable cardioverter-defibrillator (ICD) therapy.

The benefits and risks of ICD therapy for patients are directly impacted by the programming and surgical decisions made by the clinician. The expert consensus statement systemically describes four important clinical issues and addresses programming of:

Bradycardia mode and rate Tachycardia detection Tachycardia therapy Intraprocedural testing of defibrillation efficacy

"Making strategic programming choices when implementing ICD therapy is quite complex. This new expert consensus statement provides a much needed single set of recommendations that clinicians from around the world can consult," said Bruce Wilkoff, MD, FHRS, CCDS, Chair, Cleveland Clinic in Cleveland, Ohio. "When national or regional societies provide recommendations, they are potentially conflicting and confusing to physicians. This collaborative consensus provides a global set of recommendations which allows clinicians, no matter where they provide care, to improve the safety and lives of their patients living with an ICD."

The consensus statement provides a state of the art review of the field and reports the recommendations of a writing group comprised of international experts. The consensus statement includes 32 distinctive recommendations which were approved by an average of 96 percent of the 35 writing committee members.

"It's been incredible to work with four leading electrophysiology societies on this very important issue," said Martin Stiles, MBChB, PhD, FHRS, co-Chair, Waikato Hospital in Hamilton, New Zealand. "Not only have we come up with specific recommendations for clinicians, but now we have sufficient data to support recommendations that improve the safety of patients living with ICDs, which will help advance overall patient care."

The consensus statement also includes the writing committee's translations specific to each ICD manufacturer and is intended to best approximate the recommended behaviors for each available ICD model. The authors note that the care of individual patients must be provided in context of their specific clinical condition as well as the data available on the patient. As an individual patient's condition changes or progresses and additional clinical considerations become apparent, the programming of their ICDs must reflect those changes. Remote and in-person interrogations of the ICD and clinical monitoring must continue to inform programming choices made for each patient.

ICDs are devices that are about the size of a mobile phone and are implanted under the collarbone or below the armpit in a pocket under the skin. ICDs continuously monitor the heart rhythm, automatically function as pacemakers for heart rates that are too slow, and deliver life-saving shocks if a dangerously fast heart rhythm is detected. ICDs are very effective in stopping life-threatening arrhythmias and considered one of the most successful therapies to treat arrhythmias.

The consensus statement is developed in partnership and endorsed by HRS, EHRA, APHRS, and SOLAECE. To view the full document, please click here: http://www.hrsonline.org/2015-ICD-Programming.

The consensus statement will also be published in HeartRhythm, the official Journal of the Heart Rhythm Society, in early 2016.

Continue reading

Ecological extinction explains how turbulence dies; potential implications for cardiovascular medicine

As anyone who has experienced turbulence knows, its onset and departure are abrupt, and how long it lasts seems to be unpredictable. Fast flowing fluids are always turbulent, but at slower speeds the flow transitions to smooth and predictable (laminar) with intermittent patches of turbulence. In the human body, transitional turbulence can be deadly. Near the transition to turbulence, violent oscillations between laminar and turbulent blood flow can lead to aneurisms that rupture the arteries in the heart.

How does transitional turbulence die away? And what controls its lifetime? These questions have perplexed scientists ever since the first experiments were performed in 1883.

Now, physicist Nigel Goldenfeld, graduate student Hong-Yan Shih, and former undergraduate student Tsung-Lin Hsieh at the University of Illinois at Urbana-Champaign have developed a theoretical understanding of this laminar-turbulent transition that explains the lifetime of turbulent flows.

"What my colleagues and I found is a completely unexpected analogy between the transition to turbulent flow and the behavior of an ecosystem on the edge of extinction," Goldenfeld remarks.

In this work, the researchers started from the most detailed and fundamental equations of fluid flow in a pipe, but they discovered that near the transition, most of the complexity was not important. In fact, to explain and reproduce through computer simulation the most precise experiments ever done on the laminar-turbulent transition, they found that only two classes of fluid motion were needed: a swirling vortex mode around the axis of the pipe and random, irregular fluctuations in the center of the pipe. To the researchers' surprise, these modes behaved like predators and prey in an ecosystem on the verge of extinction: the time for the predators and prey to die out corresponded to the lifetime of the transitional turbulence state.

The Illinois researchers approached the problem not by thinking about fluid mechanics, but by thinking about phase transitions--the complex phenomena that occur when matter changes its state to become ordered. Examples include the formation of magnets, the formation of ice crystals from water, or even the ordering that occurred when the Universe cooled after the Big Bang, leading to the formation of all known matter. By regarding the turbulence transition as being like a phase transition, they were able to utilize conceptual and mathematical techniques not usually considered in the context of fluid flow, such as methods from modern statistical mechanics and even population biology.

The article, "Ecological collapse and the emergence of travelling waves at the onset of shear turbulence," was published online in Nature Physics.

Goldenfeld explains, "In physics, we often make use of minimal descriptions of collective behavior, stripping away details of individual particles. So, if we were trying to understand the orbit of the planet Mars around the Sun, we can pretend the planet is a point--a particle with no structure--and then it is quite simple to describe what is actually going on. The transition from laminar flow to turbulence involves very complicated phenomena, most of which aren't important. Producing a simpler model is useful, because we are not blinded by all of the complexities of the phenomenon."

The transition between laminar and turbulent flow was first mentioned by Osborne Reynolds in a classic experiment published in 1883. Since then, various measurements have been made of the lifetime of turbulence, but the huge range over which the turbulence lifetime varies created insuperable experimental difficulties. In 2008, Björn Hof and colleagues at the Max Planck Institute in Göttingen, Germany, made a breakthrough, developing an ingenious and very sensitive technique to study how long turbulent phases persist. These results quantified how the lifetime of turbulence varied so strongly with the fluid flow speed, defying theoretical understanding at first. The Illinois researchers were able to account for the detailed results from these experiments and to show that similar phenomena are predicted to occur near the extinction of predator-prey ecosystems.

The Illinois group had clues from their work on population biology and nonlinear dynamics about the ecosystem to pipe turbulence analogy, but it was not until Tsung-Lin Hsieh, at that time an undergraduate, was able to perform detailed computer simulations of fluid flow in a pipe that the specific details became clear.

Goldenfeld notes, "Tsung-Lin used a wonderful open-source code written by British mathematician Ashley Willis to run computer simulations of pipe flow. We were looking for a collective mode, and we found it."

The computer simulations showed that at the center of the pipe, the flow travels mainly along the axis of the pipe, as one might expect, but with large fluctuations. But around the interior edge of the pipe, the Illinois group discovered what is known as a large-scale zonal flow--a large vortex, similar to the jet stream circling around the Earth. They found that the turbulence excites the zonal flow, but the zonal flow inhibits the turbulence. So the turbulence builds up gradually, creating the zonal flow. When the zonal flow is sufficiently strong, it sweeps the turbulence up, thus reducing the turbulence. With reduced turbulence, the zonal flow itself begins to die, allowing the turbulence to build up, and thus begin a new cycle. The resulting behavior is an oscillation in the intensity of turbulence, mathematically similar to the population oscillations seen in ecology.

Shih explains, "The analogy of this type of system to laminar-turbulence oscillations provides a simpler, minimal model to study. The fluctuating turbulence is analogous to the prey population, and the zonal flow is like the predator population. The parallels between these oscillations in pipe flow and predator-prey dynamics in biological systems were a big surprise to us. In our group, we also study biological problems, so it was interesting that we could apply the methods of biology to the problem of turbulence."

From this discovery, the researchers were able to construct the simplest ecological model that possessed all the symmetries of the fluid interactions. Hong-Yan Shih developed a computer program that simulated predator-prey dynamics near extinction, building on her earlier research on ecological and evolutionary dynamics. She confirmed that the ecosystem dynamics precisely mimics the mathematical behavior found experimentally in the laminar-turbulence transition in pipe flow.

The Illinois researchers also showed that near the transition, their simple ecological model is mathematically equivalent to an even simpler model that had been suspected to describe the laminar-turbulent transition. In this model, known as directed percolation, particles hop on a disordered lattice, rather like water percolating downwards under the influence of gravity in a coffee machine. Whether or not they can pass from one side of the lattice to the other depends on the disorder, such as the compactness of the coffee grains in the espresso machine. At the point when the particles can no longer get through, the system is behaving mathematically like the transition in turbulence, as indicated in earlier computer experiments by Maksim Sipos and Nigel Goldenfeld. The new results establish that this is not an accident and applies to both turbulence and ecology.

Turbulence is important economically, because it creates much more frictional drag than laminar flow, making transport of oil and other fluids through pipelines expensive and energy intensive. The Illinois researchers hope that their work might lead to an improved understanding of how the onset of turbulence can be controlled, thus potentially reducing energy costs in oil pipelines. The work may also have implications for cardiovascular medicine, perhaps reducing the risk of aneurisms.

Continue reading

TATORT-NSTEMI trial shows thrombus aspiration before percutaneous coronary intervention (PCI) does not improve 12-month outcomes

Thrombus aspiration before percutaneous coronary intervention (PCI) does not improve 12-month clinical outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI), according to results from the TATORT-NSTEMI trial published in European Heart Journal: Acute Cardiovascular Care.1

Professor Holger Thiele, principal investigator, said: "TATORT-NSTEMI2 was the first randomised trial investigating the impact of thrombectomy prior to PCI, compared to standard PCI, in patients with NSTEMI. All previous trials had been performed in patients with ST-elevation myocardial infarction (STEMI). Tatort is a German word that translates to crime scene and is currently the title of a popular crime drama."

"Patients needed to have a visible thrombus to be included in our study, which was not the case in the STEMI trials," added Professor Thiele. "There were good reasons to believe that thrombectomy would benefit patients with NSTEMI since embolisation of thrombotic material can lead to no-reflow even after PCI is performed. Thrombus aspiration in NSTEMI is not included in guidelines because of limited data."

TATORT-NSTEMI randomised 440 patients from eight sites in Germany in a 1:1 ratio to thrombectomy prior to PCI or standard PCI. The primary study endpoint was microvascular obstruction which was measured using cardiac magnetic resonance (CMR). As previously reported, thrombus aspiration added to PCI did not reduce microvascular obstruction compared to PCI alone in patients with NSTEMI.3

The paper published today is the first report of the impact of thrombectomy prior to PCI versus standard therapy on the long-term clinical outcome of patients with NSTEMI and thrombus-containing lesions. Professor Thiele said: "The study was not powered to assess differences in clinical outcome but we believe there were sufficient patients to detect trends, since we saw numerically lower events with aspiration thrombectomy in the short-term and most patients were still in the study at 12 months."

The primary endpoint of the current analysis was the occurrence of major adverse cardiac events (MACE) at 12 months. MACE was defined as the composite of all-cause death, myocardial reinfarction, new congestive heart failure, and need for target vessel revascularisation. Secondary endpoints included New York Heart Association (NYHA) class and Canadian Cardiovascular Society (CCS) class, and quality of life using the standardised EuroQol5D (EQ5D) questionnaire.

The researchers found no significant difference in MACE rates at 12 months between patients with NSTEMI receiving thrombus aspiration prior to PCI compared to standard PCI alone. MACE occurred in 48 patients overall (11.0%). In the thrombectomy group MACE occurred in 19 patients (8.7%) compared to 29 patients (13.4%) in the standard PCI group (p=0.11). There were no significant differences between the two groups in the individual components of the primary endpoint.

Thrombus aspiration did not have any effect on functional class (as assessed by NYHA class and CCS class) or quality of life in patients with NSTEMI.

"Aspiration thrombectomy appears to provide no additional benefit on long-term clinical outcome for patients with NSTEMI who have had PCI," said Professor Thiele. "This is comparable to data from the TASTE and TOTAL trials in STEMI patients which found no benefit of thrombectomy on all-cause mortality and led to the procedure being downgraded in European and American guidelines."

He continued: "This was a negative trial so it is unlikely to result in a change in the guidelines but in practice it means that clinicians will follow the STEMI recommendations. In other words, thrombus aspiration will not be used routinely in patients with NSTEMI but could be applied in bail out situations when patient have a lot of thrombus and no reflow after PCI. This is a reasonable solution."

European Society of Cardiology (ESC) spokesperson Professor Steen Kristensen said: "Large trials have shown that thrombus aspiration does not work in STEMI so we no longer use it routinely, but we do use it occasionally. TATORT-NSTEMI confirms that this approach can also be applied in NSTEMI. We should think twice before we use a thrombus aspiration catheter but it might be useful in selected patients."

Continue reading

Waking early on work days may harm metabolic health

The piercing tone of the alarm clock is not a sound one usually welcomes early morning, alerting us in the most unsubtle way that we have to get up for work. But this early awakening is more than just bothersome; a new study finds it may actually be harmful to health.
[Man in bed turning off alarm clock]
Getting up earlier on work days may harm metabolic health, according to researchers.

Published in the Journal of Clinical Endocrinology & Metabolism, the study found that routine sleep changes - such as waking up early on weekdays - may increase the risk for metabolic conditions, such as obesity, diabetes and heart disease.

Previous research has already established that sleep disruption can pose negative health implications. For example, a study reported by Medical News Today earlier this year found that shift workers - whose circadian rhythms are frequently disrupted due to irregular working hours - are at greater risk for poor metabolic health.

However, the team involved in this latest research - including Patricia M. Wong of the University of Pittsburgh, PA - says their study is the first to show that even minor disruptions to sleep schedules among healthy, working adults can harm metabolic health.

To reach their findings, Wong and colleagues analyzed data of 447 adults aged 30-54 who were part of the Adult Health and Behavior Project Phase 2 Study. Participants worked a minimum of 25 hours weekly outside of their home.

Fast facts about sleep

A 2011 sleep survey found that 43% of American adults rarely or never get a good night's sleep on weeknights Around 95% of those surveyed reported using some form of electronic device - such as a computer or cell phone - before bed, which can disrupt sleep Around 8 in 10 Americans who are getting inadequate sleep say it affects their mood.

Learn more about sleep

Subjects were required to wear a wristband that measured their sleep activity and movement 24 hours a day for 1 week. They also completed a questionnaire detailing their diet and exercise habits.

Almost 85% of the participants had a later halfway point in the sleep cycle - known as mid-sleep - on non-working days than on working days, according to the researchers, indicating that these subjects awoke later on non-working days.

The researchers found that subjects who had a greater shift between their sleep schedules on working and non-working days - known as "social jet lag" - were more likely to have poor cholesterol levels, larger waist circumference, higher body mass index (BMI), higher fasting insulin levels and greater insulin resistance, compared with those who had less social jet lag.

"These metabolic changes can contribute to the development of obesity, diabetes and cardiovascular disease," notes Wong.

The team says their results remained even after accounting for participants' diet, physical activity and other sleep behaviors.

Commenting on the possible implications of their findings, Wong says:

"If future studies replicate what we found here, then we may need to consider as a society how modern work and social obligations are affecting our sleep and health.

There could be benefits to clinical interventions focused on circadian disturbances, workplace education to help employees and their families make informed decisions about structuring their schedules, and policies to encourage employers to consider these issues."

Earlier this month, MNT reported on a study that suggested a single night's sleep deprivation may increase the risk for insulin resistance.

Written by

Continue reading

Can natural remedies jeopardize cardiovascular health?

Chinese physicians report on the case of a woman who presented with aconitine-induced cardiovascular symptoms. Their report, published in the Canadian Journal of Cardiology, warns that the use of this natural ingredient may lead to severe poisoning.

A 45-year-old Chinese woman was diagnosed with a severe heart-rhythm disorder, bidirectional ventricular tachycardia (BVT), associated with aconitine poisoning. BVT is a rare form of tachycardia (characterized by a resting heart rate over 100 beats per minute) and a distinct pattern of ECG waves on presentation.

The patient's husband reported that she had drunk about 50 milliliters of a medicinal liquid about 30 minutes before she developed a sudden drop in blood pressure and then lost consciousness. The woman had no history of previous heart-rhythm problems and there was no family history of unexpected sudden death or fatal accidents. On examination she had a heart rate of 150 beats per minute and her blood pressure was 50/30. Her skin was cool, moist, and cyanotic. Treatment with the antiarrhythmic agents amiodarone, metoprolol, lidocaine, and potassium chloride was ineffective. An abdominal ultrasound showed marked gastric retention. A gastric tube was used to suction out the contents of her stomach. After two hours, the patient's BVT ceased and her circulation improved.

Investigation revealed that the patient's blood was positive for aconitine, a substance produced by the Aconitum plant, also known as devil's helmet or monkshood. Although well-known for its highly toxic properties, aconitine is the primary ingredient of the traditional Chinese medicine known as Fuzi, a remedy made from the processed lateral roots of Aconitum carmichaeli Debx. It is widely distributed in the southwest provinces of China and is used in small doses for its anti-inflammatory and pain-relieving effects.

"Management of potentially lethal ventricular tachyarrhythmia associated with aconitine poisoning presents a therapeutic challenge. In a previously published case, amiodarone was effective in suppressing the BVT. However, in our patient, both lidocaine and amiodarone were ineffective," explained lead author Zhong Yi, MD, PhD, of the Aerospace Center Hospital, Beijing, People's Republic of China.

"The public should be warned of the risk of severe poisoning that can accompany traditional Chinese medicinal usage of Fuzi," Dr. Yi concluded.

Commenting on the report, P. Timothy Pollak, MD, PhD, FRCPC, of the Department of Medicine at the University of Calgary, Alberta, cautioned that "not all products of Mother Nature are free of harm. This case report reminds us that aconitine is not the only naturally derived substance that can cause potentially lethal ventricular tachyarrhythmias, including BVT. The report also demonstrates the human tendency to think that if a little is good, more must be better."

Dr. Pollak advises clinicians to be aware of what their patients are taking and be prepared to discuss alternative remedies, at least at a basic level. "Dodging the discussion can only lend credibility to any patient suspicions that as a practitioner of Western medicine, you have been denied the secrets of alternative remedies or are hiding them for ulterior motives. This report serves as a timely illustration that alternative remedies do have implications for the practice of cardiology that cannot be ignored."

Continue reading

Medtronic announces FDA approval and launch of world's first app-based remote monitoring system for pacemakers

Medtronic plc has announced U.S. Food and Drug Administration (FDA) approval and U.S. commercial availability of the MyCareLink Smart(TM) Monitor, the world's first app-based remote monitoring system for patients with implantable pacemakers. With the MyCareLink Smart Monitor, patients with a Medtronic pacemaker can use their own smartphone or tablet technology, with cellular or Wi-Fi service, to securely transmit data from their pacemakers to their physicians, who can then interpret the data to make treatment decisions.

"Remote monitoring of pacemakers and other cardiac devices is now the standard of care, as studies have established how it benefits patients - including faster diagnoses and increased survival - as well as how it helps physicians manage their pacemaker patients through increased efficiency and convenience," said George Crossley, III, M.D., associate professor of medicine and electrophysiologist at Vanderbilt Heart and Vascular Institution in Nashville, Tennessee. "Because the MyCareLink Smart Monitor is integrated into existing mobile platforms like smartphones and tablets, it is easy for patients to transmit data from their pacemakers to their doctors via the technology that they are using every day. This innovation will serve as the foundation for future advances using smart technology to support cardiac patients."

The MyCareLink Smart Monitor is comprised of a handheld portable device reader, prescribed by a physician, and the MyCareLink Smart mobile app, available for free on both Android(TM) and Apple® platforms. When the MyCareLink Smart Monitor is connected to cellular or Wi-Fi service, patients can initiate a transmission of pacemaker data by securely uploading the information to the Medtronic CareLink® Network, the world's leading remote monitoring service for cardiac device patients, currently being used by more than 1 million patients.

In addition to sending information from their pacemakers to their physicians or clinics, patients using the MyCareLink Smart Monitor can:

Confirm the date of their most recent transmission of pacemaker information Create a personalized profile on the MyCareLink Connect Website to manage their pacemaker information and data transmissions Receive email or text reminders, confirmations and notifications of their data transmissions

By connecting patients and physicians, remote cardiac monitoring provides many clinical and economic benefits. These include faster time to treatment if the physician detects a problem with the pacemaker based on the transmitted data;i less time spent at a doctor's office or clinic for regular checks of the pacemaker;ii,iiireduced time spent in the hospital if the physician quickly detects and treats a medical problem;iv,vand a potential increase in patient survival rates.vi,vii,viii

"The use of smart technology continues to grow among people of all ages, and especially among people over 65 which is the age range of the majority of our pacemaker patients," said Darrell Johnson, vice president and general manager of the Connected Care business in the Cardiac and Vascular Group at Medtronic. "As a leader in remote cardiac monitoring, Medtronic is committed to providing cardiac patients with the latest technology to improve their health and make their lives easier, while helping to reduce the costs of healthcare. The MyCareLink Smart Monitor is just the first of many innovative solutions we are developing that leverage smart technology to increase patient engagement."

Continue reading

Study quantifies risk of cardiac arrest in children during spine surgeries

Although the vast majority of pediatric spine surgeries are safe, a handful of neuromuscular conditions seem to fuel the risk of cardiac arrest during such operations, according to research led by investigators at the Johns Hopkins Children's Center.

A report on the findings, published in the November issue of the journal Spine, is believed to be the first to quantify the risk -- which is quite small -- of this potentially lethal complication among children. The findings, the investigators say, can help surgeons and operating room staff members better plan for such contingencies in high-risk patients.

The study results stem from an analysis of outcomes in some 2,600 spinal surgeries performed at the Johns Hopkins Children's Center and Texas Scottish Rite Hospital for Children in Dallas between 2004 and 2014.

The authors are quick to point out that the absolute risk of cardiac arrest in children during spine surgery is minuscule. Indeed, of the 2,639 patients in the study, 11 had one -- less than 0.5 percent. A single patient died. Ten of the 11 children were successfully resuscitated.

Specifically, the results showed that children with such neuromuscular disorders as cerebral palsy, spina bifida and muscular dystrophy were three times more likely to suffer cardiac arrest during surgeries that straighten the spine. Six of the 11 children who had a cardiac arrest had a neuromuscular disorder.

In eight of the 11 cases, cardiac arrest was triggered by electrolyte imbalances or circulatory problems -- not a surprising finding, the researchers say, given that young children have less blood and lower blood pressure, and are thus more vulnerable to circulatory shock. Children also tend to develop electrolyte imbalance more rapidly than adults. Other causes of cardiac arrest included allergic anaphylaxis, irregular heartbeat, and respiratory and airway problems.

"Our findings are reassuring: Spinal surgeries in children are overwhelmingly safe, but even so, some risk remains," says lead investigator Paul Sponseller, M.D., M.B.A., director of pediatric orthopaedics at the Johns Hopkins Children's Center. "Armed with this knowledge, surgeons can plan accordingly by taking a few additional preventive steps to make what is an already safe surgery even safer."

The vast majority of children with scoliosis have mild forms and don't need early corrections or surgery at all. However, children with forms of scoliosis tied to neuromuscular disease tend to have more severe spinal curvatures and often need surgery at a far younger age, when they are more vulnerable to the effects of surgery and anesthesia and are more likely to suffer serious complications.

In a cardiac arrest, the heart stops beating or begins to quiver chaotically, unable to pump out blood to the rest of the body. Always a life-threatening emergency, cardiac arrests that occur inside the hospital have dramatically higher survival rates than those that occur outside the hospital. Cardiac arrests require cardiopulmonary resuscitation or electroshock with a defibrillator to restore normal heart rhythm.

During spinal operations, surgeons position children on their stomachs, but if a cardiac arrest occurs, a child must be quickly rolled over onto the back for resuscitation.

Sponseller and colleagues say that while many of the factors that lead to cardiac arrest in these cases are not preventable, knowing who's at highest risk can improve preparedness, cut response time and reduce stress among the surgical staff should a complication occur.

"Our findings underscore the notion that any surgery can escalate from routine to super-stressful in a matter of seconds," says Sponseller. "We are hypervigilant during all surgeries, but at the same time, knowing which patients are most likely to decompensate is always a good thing."

Continue reading

Study identifies social, practical barriers to exercise for heart failure patients

Supervised aerobic exercise can benefit many patients with heart failure. But according to new research, lack of social support and practical barriers to physical activity - such as finance and child care - reduces the amount of time such patients spend exercising, which may have negative implications for health.
[People in an exercise class]
Researchers say practical barriers to exercise - such as child care issues - and lack of social support are reducing the amount of time heart failure patients engage in exercise programs.

Lead author Dr. Lauren B. Cooper, of the Duke University School of Medicine in Durham, NC, and colleagues publish their findings in Circulation: Heart Failure - a journal of the American Heart Association (AHA).

Around 5.1 million people in the US have heart failure, which occurs when the heart is unable to pump enough blood and oxygen around the body to support other organs.

While there are a number of medications that can help treat heart failure, certain lifestyle changes can offer significant benefits.

According to the AHA, participation in a structured exercise program - with permission from a health care provider - can help alleviate some symptoms of heart failure and may even slow disease progression.

But in this latest study, Dr. Cooper and colleagues have identified a number of factors that may reduce the amount of time heart failure patients spend engaging in such programs.

To reach their findings, the team analyzed data from 2,279 patients with heart failure who were part of the study Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION).

In this trial, patients were randomly allocated to one of two groups: usual care - without a prescription of any formal exercise program - or usual care plus a supervised exercise program. The exercise program involved 36 sessions over a 3-month period, before shifting to home-based exercise for a further 2 years.

Patients were also asked to complete a survey that assessed the extent to which 10 factors - such as finance, weather, transportation and child care - interfered with their ability to participate in an exercise program. The survey also assessed patients' perception of social support.

While patients in the exercise group who had the lowest perceived social support exercised for an average of 92 minutes a week, the team found those with the highest perceived social support spent more time exercising - an average of 118 minutes weekly.

What is more, the researchers found that patients with the fewest barriers to engagement in an exercise program spent significantly more time exercising than those with the most barriers, at 169 minutes a week and 79 minutes a week, respectively.

The team believes their findings have important implications for patients and their health care providers. Dr. Cooper adds:

"Patients, family members, and health care providers should work together to find solutions to the barriers preventing a patient from participating in a structured exercise program, because exercise programs can help patients manage their condition.

[...] Assessing a patient's social support system and barriers that may interfere with their exercise program may help medical professionals to customize exercise programs that better fit individual patient needs."

Exercise does not only benefit patients with heart failure. Medical News Today recently reported on a study that suggested short bursts of exercise can lower blood pressure in people with type 2 diabetes.

Written by

Continue reading

Are Tasers more deadly than we thought?

Billed as a "less lethal" alternative to firearms, Tasers have experienced a meteoric rise to infamy since their introduction to the US police force. This week, the BMJ publishes a new report regarding the impact of Tasers on cardiac health.
[Taser in use]
The new report highlights the danger Tasers pose to cardiac health.

Tasers are currently in use by more than 16,000 police forces in 107 countries.

Globally, Tasers have shocked people more than 1.35 million times (650,000 during arrests and stops and 700,000 during police training).

According to the main manufacturer - Taser International - one of their devices is deployed, on average, every 2 minutes.

The most common Taser is the X26, designed and manufactured by Taser International in Scottsdale, AZ. Since 1994, the company has sold more than 800,000 Taser weapons.

Tasers use compressed nitrogen to fire a pair of barbed probes into the skin of the target individual. They are capable of delivering 50,000 volts, causing intense pain and muscle contraction.

In addition to the main function, the Taser has a "drive-stun" mode. This allows the unit to be held against the skin to deliver the shock, which stimulates pain but none of the contractions.

A pull of the trigger on the gun-shaped device delivers 5 seconds of shock - and more if the trigger is held down.

Health concerns over Taser use

A recent increase in the number of Taser uses on mentally ill patients in care homes and hospitals has prompted the UK's home secretary, Teresa May, to order a review of how they are used on these types of situations.

Known risks of Tasers already include eye injuries, seizures, collapsed lung (pneumothorax), tonic-clonic seizures, seizures in people with epilepsy, skin burns, and muscle, joint, and tendon injuries, plus a short-lived decline in cognitive functioning.

The biggest safety concern is head injuries sustained from an unguarded fall.

Much of the research into the safety of Tasers has been conducted by the companies that manufacture them, and as such, their neutrality has been called into question.

In 2011, the US Department of Justice released a report on "less lethal" weapon use by US police forces:

"More than 200 Americans have died after being shocked by Tasers. Some were normal, healthy adults; others were chemically dependent or had heart disease or mental illness."

Can Tasers affect heart function?

Evidence of the Taser's ability to cause injury are well known, but one further area of concern has not yet been fully unpicked: can Tasers have a terminal effect on cardiac health?

There are concerns that a Taser attack might induce long-lasting arrhythmias caused by myocardial capture (when an external electrical stimulus changes the heart's natural rhythm).

Taser International, during trials with an experimental Taser model, did report one instance of cardiac capture. The company altered the design and, from then on, have not reported any further cases.

Ventricle fibrillation - where the ventricles of the heart quiver rather than fully contract - has never been picked up during any of Taser's official studies.

This lack of fibrillation and cardiac capture in Taser International's trials might be due, in part, to the use of healthy volunteers without heart problems or drug addictions of any kind. And, of course, in a real-life confrontation, heart rates are naturally elevated at baseline.

A recent report published in Circulation looked into eight cases of Taser use and concluded:

"The animal and clinical data clearly support the conclusion that a TASER X26 shock can produce ventricular fibrillation in humans"

Taser-related deaths

One death of particular note was that of 17-year-old Darryl Turner in North Carolina in March 2008. He was made redundant from his supermarket job and refused to leave the store. When a police officer arrived, Turner was "tasered" for 37 seconds and died shortly after from ventricular fibrillation.

Taser has a long history of fighting and defeating lawsuits, but in the case of Turner's death, they lost. It was established that the company had not made sufficiently clear the dangers of longer shocks and shocks to the chest area.

Taser appealed the decision, but the appeals court panel overruled them, saying that the X26:

"...had been the subject of several academic studies. (Taser International) knew about these studies, in which researchers had concluded that the device posed a risk of ventricular fibrillation, a cause of cardiac arrest, especially when the electrical current from the Taser was applied near the subject's heart.

Nevertheless, (Taser International) failed to warn Taser users to avoid deploying the Taser's electrical current in proximity to the heart."

More recently, the UK reported their first instance of death resulting from Taser. Jordon Begley, a factory worker from Greater Manchester, died just 2 hours after the police used a Taser on him in 2013.

An inquest concluded that punches he received from police officers, along with the 9-second Taser blast were to blame for his consequent cardiac arrest.

There is a clear necessity for further study into the effects of Tasers on long-term cardiac health and its implications for use on those with existing medical conditions. The author of the BMJ report, Owen Dyer, told Medical News Today:

"In both Britain and the US, firings of Tasers by police are going up quite steeply every year, even though rules of engagement have not been relaxed. So either more people are resisting arrest each year, which seems unlikely, or we are seeing Taser mission creep.

At first, Tasers are an alternative where guns might have been used. Then they're an alternative where truncheons might have been used. Finally they're an alternative where words might have been used.

Tasers were not designed to be cattle prods, and they will never be lifesavers in that role."

MNT recently covered research into how stressful situations increase police officers' risk of cardiac death.

Written by Tim Newman

Continue reading

Protein biomarkers may accelerate the future of personalized medicine for CV disease

Myriad RBM, a wholly-owned subsidiary of Myriad Genetics, Inc., has announced that its DiscoveryMAP® platform successfully identified combinations of 15 protein biomarkers associated with cardiovascular (CV) events or death in people with pre-diabetes or early type 2 diabetes, according to a study published by the journal Circulation.

"Cardiovascular diseases are one of the leading causes of deaths globally," said Riccardo Perfetti, M.D., vice president Medical Affairs, Global Diabetes at Sanofi, which sponsored the study. "We are optimistic that as we move toward personalized medicine, cardiovascular biomarkers will help us predict future events and possibly develop tailored treatment plans for patients that will save more lives."

In the paper titled, "Identifying Novel Biomarkers for Cardiovascular Events or Death in People with Dysglycemia," researchers at the Population Health Research Institute and Sanofi used Myriad RBM's DiscoveryMAP platform to evaluate 237 cardiometabolic biomarkers in serum from 8,401 participants in the completed Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial. Results of the assays were analyzed to identify biomarkers that provided better estimates of the risk of future CV events or death than could be estimated from standard clinical and biochemical data alone. The analysis identified a novel combination of 10 biomarkers that, when added to clinical risk factors, can find people with dysglycemia who are at higher risk of heart attack, stroke or CV death. Moreover, these 10 biomarkers, plus an additional five, had the greatest impact on the ability to predict death.

"Our study is one of the largest scientific investigations in history to identify specific cardiovascular biomarkers associated with serious cardiovascular outcomes, including heart attacks, strokes and death," said Hertzel Gerstein, M.D., lead study investigator and deputy director, Population Health Research Institute. "Our results highlight the potential value of cardiovascular biomarkers for identifying people with dysglycemia at the highest risk of future events."

DiscoveryMAP is a comprehensive, quantitative, immunoassay service product that measures more than 300 human proteins. It is the culmination of 15 years of assay development for cytokines, chemokines, metabolic markers, hormones, growth factors, tissue remodeling proteins, angiogenesis markers, acute phase reactants, cancer markers, kidney damage markers, CNS biomarkers and other important circulating proteins.

"This is another demonstration that our DiscoveryMAP technology can successfully identify panels of biomarkers with important diagnostic and prognostic applications. We believe that the protein biomarkers characterized by the PHRI and Sanofi teams may identify people at higher risk for cardiovascular events," said Ralph McDade, Ph.D., president of Myriad RBM. "Based on these very encouraging findings, we are pursuing additional research collaborations to further develop panels of protein biomarkers with application for cardiometabolic disorders."


ORIGIN (Outcome Reduction with Initial Glargine Intervention) was a seven-year landmark cardiovascular outcomes trial, evaluating insulin glargine versus standard care in over 12,500 individuals who were at high CV risk with pre-diabetes or early type 2 diabetes mellitus. ORIGIN was sponsored by Sanofi and was designed, conducted, and analyzed by the Population Health Research Institute and its international network of diabetes and cardiovascular disease experts.

About Human DiscoveryMAP®

DiscoveryMAP is for those who seek a thorough understanding of a compound's biological activity, efficacy and safety profile as well as the disease or condition being addressed. The DiscoveryMAP service products help increase the odds of identifying novel protein biomarker patterns in drug development or diagnostic discovery projects. These data can support critical go/no-go decisions or identify candidate panels for potential companion diagnostics. Once a pattern is discovered, it can be seamlessly converted into a CustomMAP for high volume sample processing resulting in better, more efficient clinical trials. For more information visit: http://rbm.myriad.com/discoverymap/

Continue reading

Mount Sinai Heart director discusses population health promotion and a stratified approach for cardiovascular health

Valentin Fuster, MD, PhD, Director of Mount Sinai Heart and Physician-in-Chief of The Mount Sinai Hospital joined a panel of international experts at the United Nations where he spoke about promoting cardiovascular health worldwide and how the practice of medicine will change to reflect an increase in ambulatory care. Mount Sinai Heart is ranked No. 7 in the nation by U.S. News & World Report in its 2015 "Best Hospitals" issue.

The meeting, which focused on health and well-being and the comprehensive treatment of NCDs, was held by the United Nations NGO Committee on Mental Health, which is affiliated with the Conference of Non-Governmental Organizations (CoNGO) in Consultative Relationship with the United Nations. The event was co-sponsored by the International Council of Women, Soroptimist International, Communications Coordination Committee for the United Nations, Sigma Theta Tau International, Nightingale Initiative for Global Health, Human Rights Congress for Bangladesh Minorities, American Psychiatric Association, International Psychoanalytical Association and Nonviolence International.

According to Dr. Fuster, "We are starting to experience a significant change in the way we deliver cardiovascular medicine with a focus on promoting health over treating disease. "As a result, we should expect to see a rise in ambulatory care and shorter hospital stays. This transition will require that cardiovascular specialists and health care workers are trained in ambulatory and home-based care."

In 2010, the U.S. Institute of Medicine (IOM) formed a committee, chaired by Dr. Fuster, which produced a report, entitled "Promoting Cardiovascular Health in the Developing World". The report stressed the importance of health promotion during a person's lifetime and the significant economic burden that cardiovascular disease places on our society. The authors proposed a stratified approach at 3 different age ranges in a person's life to effectively promote cardiovascular health.

The first approach to stratified health is during the first 25 years of life, with the optimal period of time to motivate healthy behavior between 3- 5 years old. The second opportunity for stratified health is within the age range of 25 to 50 years old, when non-invasive imaging techniques can be used to detect potential future heart health issues. The third opportunity occurs at 50 years and upward, when cardiovascular disease has often begun.

"At every age range, there are scientific, psychological, and disease specific variables to consider, as well as different educational and behavioral tools to use to promote cardiovascular health globally," stated Dr. Fuster. "My years of research strongly support early education intervention and the need for a stratified approach to health promotion worldwide."

Since 2009, Dr. Fuster has worked with nearly 100,000 preschool-aged children, ages 3-5, in Madrid, Spain and Bogotá, Colombia to demonstrate that early health education can have long-lasting heart healthy effects. Under Dr. Fuster's leadership, Mount Sinai Heart of Icahn School of Medicine at Mount Sinai is launching a similar program in the United States in 8 New York City (NYC) Harlem preschools with children ages 3-5, along with their parents and caregivers, known as The FAMILIA Project.

The Project, made possible by a $3.8 million grant from the American Heart Association (AHA), is scheduled to begin this month. Mount Sinai has partnered with NYC's Administration for Children's Services (ACS), Division of Early Care and Education Head Start programs to teach young children, their parents, and caregiver's ways to reduce their risk factors of developing cardiovascular diseases, while also decreasing the growing obesity epidemic. The Project's programming will focus on child, adult, peer group, and individual health interventions.

The meeting, which was attended by members of civil society, UN staff, and government representatives, took place at the United Nations Church Center on Thursday, November 12, 2015. Welcoming remarks were delivered by Dr. Vivian B. Pender, Chair, UN NGO Committee on Mental Health. Dr. Elizabeth Carll, Founder and Convener of the Global Mental Health and NCDs Work Group of the UN NGO Committee on Mental Health, served as the moderator. The panel was comprised of Dr. Valentin Fuster; H.E. Mr. Keith Marshall, Ambassador and Permanent Representative, Mission of Barbados to the United Nations; Werner Obermeyer, Deputy Executive Director, World Health Organization in New York; Dr. Yesne Alici, Assistant Attending Psychiatrist, Memorial Sloan-Kettering Cancer Center; and Dr. Gustavo Gonzalez Canali, Senior Advisor and Focal Point for NCDs, UN Women.

Continue reading

Therapeutic hypothermia can help in range of cardiac arrests

Lowering body temperature in cardiac arrest patients with "non-shockable" heart rhythms increases survival rates and brain function, according to new research in the journal Circulation.
[heart monitor]
Reducing the body's core temperature can help prevent neurologic damage after cardiac arrest.

Therapeutic hypothermia intentionally lowers the body's core temperature to a range of about 32° to 34° C (89.6° to 93.2° F) to protect the body following a period of insufficient blood flow due to such events as a cardiac arrest, blood clot or stroke.

It is typically used for patients who fail to regain consciousness after return of spontaneous circulation following a cardiac arrest. Previous studies have shown improved survival and neurological function in patients with "shockable" rhythms such as ventricular fibrillation, a condition where the lower chambers quiver and the heart is unable to pump any blood, causing cardiac arrest.

Cardiac arrest occurs when the heart malfunctions and stops beating, causing blood to stop pumping to the body. Death can result in minutes without treatment.

The risk of neurologic injury

Out-of-hospital cardiac arrest kills about 250,000 Americans yearly. Average survival rate for such cases is just 6% globally, and those who survive are at risk for neurologic injury. Of those who survive but enter a coma, only about 20% awaken with a good neurologic outcome.

Neurologic injury results when circulatory collapse impairs oxygen flow to the brain, causing mitochondrial and cellular death and cerebral edema; this is worsened by disruption to the blood-brain barrier in the initial injury.

Once circulation is restored, cell death triggers an inflammatory response in which the immune system releases neutrophils and macrophages to eliminate the dead cells, which produces free radicals that cause continued cell damage, worsening the inflammatory response and the cerebral edema in a vicious cycle.

Hypothermia counters neuroexcitation and reduces cell death by stabilizing the release of calcium and glutamate. It also stabilizes the blood-brain barrier and suppresses the inflammatory process, decreasing cerebral edema. Cerebral metabolism drops 6-10% for every degree Celsius that body temperature drops. As cerebral metabolism declines, the brain needs less oxygen.

Technique can benefit patients with non-shockable rhythms

Now, a new study shows that therapeutic hypothermia may also benefit comatose cardiac arrest patients with "non-shockable" heart rhythms - those that will not respond to the defibrillation because there is no pulse or electrical activity in the heart.

Researchers, led by Dr. Sarah Perman, assistant professor of emergency medicine at the University of Colorado in Aurora, examined data from 519 patients who had a cardiac arrest due to a non-shockable heart rhythm in the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000-13.

Those who received therapeutic hypothermia were 2.8 times more likely to survive after cardiac arrest and 3.5 times more likely to have better neurologic recovery compared with those who were not cooled.

Dr. Perman explains that neurologic injury after cardiac arrest is devastating; the only chance doctors have to give some form of neuroprotection is immediately after the arrest.

She adds:

"Our resources right now are not extensive and our outcomes are still fairly grim. Therapeutic hypothermia is one therapy we do have in our arsenal, and if a patient is comatose after arrest, it's very important to consider applying this therapy, specifically in patients who are neurologically injured."

Although the American Heart Association (AHA) have included guidelines for the use of therapeutic hypothermia in patients who suffer cardiac arrest since 2005, adoption of this practice has been low, especially for in-hospital cardiac arrest patients and those who arrest with initial non-shockable rhythms.

Unwillingness to apply the procedure is due to the perception that there is no benefit to patients who have an initial non-shockable rhythm.

The researchers would like to see more investigation into the use of neuroprotective strategies such as therapeutic hypothermia for cardiac arrest patients with non-shockable rhythms.         

Earlier this year Medical News Today reported that therapeutic hypothermia can also help in the process of kidney transplantation.

Written by Yvette Brazier

Continue reading

Moderate coffee drinking may prevent premature death

Incredible volumes of black gold are poured into our collective bodies on a daily basis, which makes the medical effects of coffee drinking a perpetual area of study. Now, new research points to some interesting positive health benefits of moderate consumption.
[Man drinking lots of coffee]
Moderate coffee intake may prevent certain types of premature death.

According to some estimates, 2.25 billion cups of coffee are consumed worldwide, daily.

Anything that humans consume on such a huge scale deserves thorough research into its health benefits, or lack thereof.

Coffee is a complex cocktail of chemicals, including, of course, naturally occurring caffeine. Alongside this much-studied and consumed stimulant are a whole host of interesting chemicals.

Coffee includes more than 1,000 distinct and exotic sounding compounds, including caffeoylquinic acids, chlorogenic acids, diterpenes, feruloylquinic acids, 4-methylimidazole and p-coumaroylquinic acids, to name but a few.

The highly abbreviated list above makes coffee's complex range of physiological effects less surprising. Is it good or bad for the heart? Positive or negative for liver function? Does it help or hinder Alzheimer's, or worsen the effects of diabetes?

New research reported in the American Heart Association's journal Circulation brings together data from a number of longitudinal trials to investigate coffee's potential health effects over a substantial period of time.

The investigation utilizes data from 74,890 women in the Nurses' Health Study and 93,054 from the Nurses' Health Study 2, plus 40,557 men from the Health Professionals Follow-up Study.

Information regarding dietary habits was collected from questionnaires every 4 years, with participants being followed up for a maximum of 30 years.

Coffee's health benefits

The study found that people who drank a moderate amount of coffee (fewer than five cups per day) experienced a lower risk of death from cardiovascular disease, neurological diseases, type 2 diabetes and suicide.

The study's lead author, Dr. Ming Ding, says:

"Bioactive compounds in coffee reduce insulin resistance and systematic inflammation. They might be responsible for the inverse association between coffee and mortality."

Interestingly, the study included caffeinated and decaffeinated coffee, so at least some of the measured benefits of coffee appear to be secondary to the caffeine content.

The group also made sure to control for alcohol and tobacco consumption, as these were both relatively high in coffee drinkers, compared with non-coffee drinkers.

The authors make it clear that the study was not designed to show a direct causation between coffee drinking and illness, so drawing conclusions at this stage would be premature. Another drawback, mentioned by the research team, was their reliance on participants accurately reporting their own level of coffee consumption.

Previous results of similar studies have produced inconsistent results in regard to coffee's effects on various illnesses, so the results of this study cannot be taken as definitive evidence, but they are a significant addition to the literature.

Previous research into coffee's health benefits

In recent years, there has been a wide range of experimentation into the consequences of high coffee intake. Results seem to show coffee as having a positive role in type 2 diabetes, Parkinson's and some liver diseases.

On the other side of the coin, coffee appears to negatively impact blood pressure and plasma homocysteine, both of which increase cardiovascular risk, contrary to the current study's findings.

In addition, some sections of society are likely to be more vulnerable to adverse effects. Another of the study's authors, Dr. Frank Hu, adds another word of caution:

"Regular consumption of coffee can be included as part of a healthy, balanced diet. However, certain populations such as pregnant women and children should be cautious about high caffeine intake from coffee or other beverages."

The current study's results certainly are intriguing. Dr. Ding and his team hope that further research, over the years to come, will tease apart the roles of some of the individual ingredients within coffee.

As part of the ever-growing tapestry of information on coffee's health effects, Medical News Today recently covered research into how an evening coffee can disrupt our body clock.

Written by Tim Newman

Continue reading

Snake venom could make surgery safer for patients on blood thinners

Preventing blood clots with drugs such as heparin has become a common practice for fighting some heart and lung conditions, and for certain surgeries. But patients who take them also need their blood to clot to heal incisions made during operations. Researchers are developing a new way to tackle this problem - by pairing snake venom with nanofibers. Their study using the therapy on rats appears in the journal ACS Biomaterials Science & Engineering.

Currently, doctors can take several approaches to reduce bleeding in surgical patients on heparin and other blood thinners, including applying pressure, sutures, foams and adhesives. But these options can come with potentially serious risks. Some can introduce toxic byproducts into a patient, spark an allergic reaction or cause tissue to die. To come up with a better alternative, Jeffrey D. Hartgerink and colleagues turned to an enzyme from snake venom that causes blood to coagulate even if it contains heparin. Called batroxobin, the enzyme is already in clinical use for another condition. But using it to control bleeding is problematic because it dissolves quickly and moves away from where it's originally introduced - a problem when trying to heal surgical incisions.

To override batroxobin's tendency to disperse, the researchers paired it with "sticky" nanofibers to make the enzyme stay put. The therapy, which was tested on rats treated with heparin, promoted localized blood clotting at a wound site within 20 seconds. The researchers say with further testing, the approach could eventually help make surgery safer for human patients taking heparin.

The authors acknowledge funding from the National Institutes of Health and the Welch Foundation.

Continue reading

Myocardial infarction: PEGASUS-TIMI 54 sub-analysis outlines long-term tolerability data for BRILINTA

AstraZeneca has announced results of a sub-analysis of the PEGASUS-TIMI 54 study, which evaluated reasons and rates for discontinuation of BRILINTA® (ticagrelor) in patients with a history of myocardial infarction (MI) (one to three years prior to study randomization) and the efficacy in those patients who stayed on therapy. The data were presented during a Late-Breaking Clinical Trials session at the 2015 American Heart Association (AHA) Scientific Sessions.

The pooled analysis of the results showed that in patients who stayed on therapy, BRILINTA reduced the rate of the composite efficacy endpoint of cardiovascular (CV) death, MI, or stroke at three years (HR 0.79, 95% CI 0.70-0.88), consistent with the results of the overall population of the PEGASUS study. Discontinuation resulting from an Adverse Event (AE) was 8.9% in the placebo arm, 19% and 16.4% in the BRILINTA 90 mg and 60 mg arms, respectively, and was most frequently due to bleeding and dyspnea. Rates of AEs leading to discontinuation were highest in the first year at 16% in the 90 mg arm, 13% in the 60 mg arm, and 6% in the placebo arm. In those patients who stayed on therapy, discontinuation rates over the subsequent two years were 6.5% in the 90 mg arm, 6.0% in the 60 mg arm, 4.6% in the placebo arm.

Marc Bonaca, MD, Thrombolysis in Myocardial Infarction [TIMI] Study Group, Brigham and Women's Hospital, Boston, MA and lead investigator for the sub-analysis study, said: "This analysis pointed to important patterns with regards to common AEs associated with ticagrelor in the context of clinical benefit. Physicians must consider the overall risks, including higher rates of bleeding and dyspnea particularly within the first year. For patients at increased risk for recurrent cardiovascular events in the long-term, ticagrelor can provide an important benefit."

"This sub-group analysis provides additional insight into the clinical profile of ticagrelor and reinforces its role in the reduction of the composite of CV death, MI, and stroke for these patients studied in PEGASUS," Bonaca added.

Steven Zelenkofske, D.O., FACC, Vice President, US Medical Affairs, AstraZeneca said: "We welcome the results of this sub-analysis, which lends insights regarding the tolerability and efficacy of BRILINTA long-term during a time when questions remain regarding the appropriate length of dual antiplatelet therapy."

On September 3, 2015, the US Food and Drug Administration (FDA) approved a new 60-mg tablet dosage strength for BRILINTA to be used in patients with a history of heart attack beyond the first year. With this expanded indication, BRILINTA is now indicated to reduce the rate of cardiovascular death, myocardial infarction (MI), and stroke in patients with acute coronary syndrome (ACS) or a history of MI. For at least the first 12 months following ACS, it is superior to clopidogrel. BRILINTA also reduces the rate of stent thrombosis in patients who have been stented for treatment of ACS.

The PEGASUS-TIMI 54 study investigated the efficacy and safety of ticagrelor at both 60 mg and 90 mg twice daily, plus low dose aspirin, compared to placebo plus low dose aspirin, for the long-term prevention of atherothrombotic events in patients >50 years of age who had suffered a heart attack one to three years prior to study enrollment and had one additional risk factor for thrombotic CV events. Only the 60-mg dosage strength is approved for use in patients with a history of MI. BRILINTA 60 mg tablets are now available in US pharmacies.

BRILINTA has been studied in multiple clinical trials, including the PLATO and PEGASUS trials. In PLATO and PEGASUS alone, nearly 40,000 patients have been studied with BRILINTA.

For patients who have been prescribed BRILINTA, AstraZeneca offers the BRILINTA Patient Support Service (BPSS) tool that provides resources and support to help patients and caregivers from hospital discharge throughout the ACS treatment journey. To help loved ones, the program offers important patient education and coaching in addition to savings offers, refill reminders, personal pharmacy locator, co-pay calculator, and coverage verification and information. To enroll in BPSS, call 1-888-512-7454 or enroll online at www.BRILINTA.com. Health care professionals can visit www.BRILINTAtouchpoints.com.

Continue reading

New study supports localised services for cardiac rehab

New research at the University of York has found that smaller, more localised cardiac rehabilitation (CR) centres are equally as effective as their larger counterparts.

The study, funded by the British Heart Foundation (BHF) and published in Open Heart, found that similar patient outcomes were achieved at smaller, more localised CR schemes when compared with larger, centralised centres.

Cardiac rehabilitation offers behavioural advice and support, including diet and exercise, to help people living with heart disease to manage their condition and reduce the risk of associated heart events.

In the first study of its kind, researchers in our Cardiovascular Health Research Group based in the University's Department of Health Sciences looked at factors such as smoking rates, cholesterol levels and physical activity levels for patients and found measured improvements were regardless of the size of the CR scheme where the patient attended.

Previous research has shown that CR can improve patients' mortality rates and reduce the chance of a further heart event. Yet less than half of eligible heart patients attend CR following a major heart event.

The BHF says that accessibility to schemes is one of the main issues for the low uptake numbers of CR and more localised services could help improve patient uptake.

There has been pressure for localised CR services to merge into centralised schemes to reduce costs and it was thought that better patient outcomes could be achieved with larger volumes of patients using the same scheme.

The study's author Professor Patrick Doherty, from the Department of Health Sciences at York, said: "This study is important as it is based on routinely collected data, within the NHS, which means this is a real world effect that directly relates to patient care.

"One of the arguments for merging cardiac rehabilitation services was improved outcomes, but our study shows that the same outcomes are achieved at smaller, more localised rehabilitation centres."

Dr Mike Knapton, Associate Medical Director at the BHF, added: "Less than half of eligible patients receive cardiac rehabilitation following a heart attack or other serious heart problems, despite the clear benefits and better outcomes for patients.

"Cardiac rehabilitation schemes need to be made more accessible to patients if we are to see increases in the number of people benefitting from them.

"This evidence suggests that improving access through more localised services can be achieved without diminishing the outcomes for patients."

Health and Wellbeing is one of the major Research Themes at University of York which strives to improve health service delivery and outcomes.

Continue reading

'Personalized medicine' drives better outcomes for certain heart patients

In the weeks and months after a patient gets a heart stent, blood clots can pose a major threat to recovery. Now, University of Florida Health researchers have found that a quick genetic test can tell doctors early on whether a crucial anti-clotting drug will work, they reported at the American Heart Association's Scientific Sessions in Orlando.

They also are hailing the finding as a significant gain for personalized medicine, which tailors medical decisions based on individual patients' genetic information and other unique characteristics.

Their research focused on clopidogrel, a drug that can prevent blood clots after a heart artery is propped open with a coronary stent. Yet the drug doesn't work on everyone: About 30 percent of all patients have a genetic deficiency that prevents them from activating it. Treating those patients with a drug their bodies can't use is akin to providing no medication, said associate professor Larisa Cavallari, Pharm.D., director of the Center for Pharmacogenomics at the UF College of Pharmacy and associate director of the UF Health Personalized Medicine Program.

That's where the genetic testing made available through UF Health pathology laboratories and studied by UF Health researchers comes into play.

A patient's genetic information is analyzed quickly and economically using a process known as genotyping. That tells a physician if clopidogrel will work effectively, allowing doctors to more precisely personalize treatment by prescribing a different medication. The genotyping also has lifesaving implications: Every patient gets the best possible drug at the right time, Cavallari said.

"This is tailoring therapy based on the patient's genetic makeup, and recognizing that not everyone is going to respond well to one drug," she said.

The study is among the first to examine the effect of genotype-guided treatment on cardiovascular outcomes after a heart procedure known as percutaneous coronary intervention, or PCI, researchers said.

During the two-year study, researchers tracked 408 patients who had genotyping and had a PCI to open narrow or clogged heart arteries. Of that group, 126 patients had the genetic deficiency that prevents clopidogrel from working effectively. Fifty-eight of them were treated with clopidogrel and 68 received an alternative medication.

After six months, the risk of major cardiovascular problems such as death, heart attack, stroke and having a stent become blocked by blood clots was significantly reduced among patients with the genetic deficiency who were prescribed an alternative drug, researchers found. None of those patients had a major cardiovascular problem within 30 days of the PCI procedure. In contrast, 12.5 percent of patients who got clopidogrel but could not activate it had problems such as a heart attack or blood clot.

That shows exactly how genetic analysis can be used for a more effective and personalized health care experience, said Julie A. Johnson, Pharm. D., dean of the UF College of Pharmacy, the project's principal investigator and the director of the UF Health Personalized Medicine Program.

"This is a way to identify a medication that isn't going to be very good for some patients and choose an alternative that's better for them," she said.

In addition to saving lives and preventing medical problems, genotyping has significant implications for the business side of health care. Simple genotyping that costs several hundred dollars can prevent a heart attack by getting a patient on the correct antiplatelet medication early on.

"You don't have to prevent a lot of heart attacks to achieve a cost savings," Johnson said.

The Personalized Medicine Program is expanding genotype-guided therapy at UF Health to include additional medications for which genetic variations are known to influence effectiveness. Genotyping patients to determine the best drug dose or the most effective medication can also be used for other diseases such as hepatitis C, some pediatric cancers, inflammatory bowel disease and pain management, Johnson said.

Personalized medicine, also known as precision medicine, is already delivering benefits for PCI patients at UF Health Shands Hospital because genotyping is standard practice for most of these patients, Cavallari said.

Next, researchers want to make cardiologists and other health systems aware of the benefits of genotyping PCI patients. No randomized, controlled trial with PCI patients has been done and Cavallari doesn't believe it is necessary.

"We believe the current data are strong enough to support using genotyping in a clinical setting. It provides data to support the idea that other health care institutions should do this," she said.

The Personalized Medicine Program is collaborating with other institutions to study outcomes of genotype-guided anti-clotting therapy in a larger group of PCI patients. To help spur broader adoption, the UF Health team also is evaluating education and implementation strategies so others can build on the program's experience.

UF Health's Personalized Medicine Program is a multidisciplinary initiative created in 2011 within the Clinical and Translational Science Institute. Led by College of Pharmacy faculty, researchers work with health professionals and patients at UF Health and across the state to study and implement methods that allow genetic information to be used as a routine part of patient care.

Funding and other support for the PCI research was provided by UF Health, its Clinical and Translational Science Institute and National Institutes of Health grants U01 HG007269, U01 GM074492, U01 HL105198 and UL1 TR000064.

Continue reading

Are mechanical heart valves better than biological ones?

Increasingly, biological heart valves are being used preferentially to mechanical valves in surgical replacement procedures. New research at Sweden's Karolinska Institutet might turn this preference on its head.
[Heart with trace reading]
A new study shows that biological valves might not be the best choice for replacement procedures.

Aortic valve replacements have been carried out since the 1960s, and since those early days, the procedure has been repeatedly and significantly improved.

Today's aortic valve replacement procedures can often be minimally invasive; around 280,000 aortic valves are replaced globally each year.

There are a number of reasons why a heart valve may need replacing. The most common of which is aortic stenosis, a narrowing of the aortic valve.

This narrowing restricts blood flow from the left ventricle to the aorta and increases the eventual risk of heart failure.

Aortic regurgitation is another of the most common reasons for valve replacement. In this case, the valve is leaky and allows blood to move back into the heart rather than exit and move through the body.

As with aortic stenosis, the excess work required to pump blood around the body can eventually lead to complications, including heart failure.

Mechanical or biological valves?

Surgeons completing modern valve replacement operations must choose between mechanical and biological valves, both of which have their own pros and cons.

Mechanical versions are constructed from sturdy man-made materials like carbon and titanium; these valves are stress tested for durability, and some are capable of remaining viable for an estimated 50,000 years.

Biological valves are made either from strong, flexible animal tissue or, rarely, human donor tissue. They are expected to last 10-20 years.

Biological heart valves are used in the majority of replacements and are generally considered, across all age groups, to be the best option.

Mechanical valves are much more durable, but they are also more likely to succumb to clotting problems. These clotting issues can lead to serious consequences. As such, patients with mechanical valves are required to take blood thinning medication, like warfarin, for the rest of their lives.

This clotting risk and lifelong medication is clearly not ideal for younger heart surgery candidates with decades left to live.

Which valve is best for younger patients?

Whether mechanical or biological valves are preferable in relatively young patients is a question that has sparked lively debate among researchers and doctors.

New research, carried out by Dr. Ulrik Sartipy, associate professor at the Department of Molecular Medicine and Surgery at the Karolinska Institutet, looked at the mechanical-biological question in depth.

The study, reported in the European Heart Journal, followed 4,500 Swedish aortic valve replacement patients aged 50-69. The research team collated survival rates, incidents of stroke and re-operation rates.

Their investigation reconfirmed a previous study's findings in relation to the reduced bleeding risks attributed to biological valves. However, the team's other findings bucked the trend significantly.

Dr. Ulrik Sartipy says:

"We show that patients who had received a mechanical prosthesis had better survival rates than those who had received a biological prosthesis."

Another of the study's findings, which might help sway the pro-biological lobby, was that patients with a biological valve had a higher chance of needing further operations on the valve.

Additionally, stroke risk was found to be the same in both mechanical and biological valve replacements. Natalie Glaser, PhD student and part of the research team, says:

"Our research shows that mechanical valve prostheses should be the preferred option for young patients."

The research certainly adds weight to the argument for using mechanical valves in younger patients. The debate, however, is likely to continue as weight is added to either side through further investigation.

Medical News Today recently reported that cardiovascular risk falls in patients with rheumatoid arthritis.

Written by Tim Newman

Continue reading