Skai Schwartz

Insomnia and heart disease: a review of epidemiologic studies.

Since the discovery and successful treatment of sleep apnea, researchers seem to believe that the association between sleep disturbance and coronary heart disease (CHD) has been explained. To determine whether subjective nighttime sleep complaints (trouble sleeping, trouble falling asleep, trouble staying asleep), exclusive of apnea, predicted myocardial infarction and other coronary events, a MEDLINE search was conducted for articles published between January 1976 through August 1997. Ten studies with an explicit measure of association between an insomniac complaint and CHD were identified. Reported risk ratios for various sleep complaints and CHD events ranged from 1.0 for waking too early and CHD death in an elderly North Carolina community to 8.0 for the highest versus lowest quintile of a sleep scale in Finnish men. Higher quality studies showed risk ratios of 1.47-3.90 between trouble falling asleep and coronary events after adjusting for age and various coronary risk factors (combined effect=1.7, p<0.0001). While alternative explanations such as medication use still need to be ruled out, we theorize that a subjective insomniac complaint either may be part of a larger syndrome that includes poor health and depression, or it may be related to continual stressors, reduced slow-wave sleep, and autonomic dysfunction, which increase the risk of heart problems.

Bilateral human fetal striatal transplantation in Huntington’s disease

BackgroundTransplanted striatal cells have been demonstrated to survive, grow, establish afferent and efferent connections, and improve behavioral signs in animal models of Huntington’s disease (HD). ObjectiveTo evaluate feasibility and safety and to provide preliminary information regarding the efficacy of bilateral human fetal striatal transplantation in HD. MethodsSeven symptomatic patients with genetically confirmed HD underwent bilateral stereotactic transplantation of two to eight fetal striata per side in two staged procedures. Tissue was dissected from the lateral half of the lateral ventricular eminence of donors 8 to 9 weeks postconception. Subjects received cyclosporine for 6 months. ResultsThree subjects developed subdural hemorrhages (SDHs) and two required surgical drainage. One subject died 18 months after surgery from probable cardiac arrhythmia secondary to severe atherosclerotic cardiac disease. Autopsy demonstrated clearly demarcated grafts of typical developing striatal morphology, with host-derived dopaminergic fibers extending into the grafts and no evidence of immune rejection. Other adverse events were generally mild and transient. Mean Unified HD Rating Scale (UHDRS) motor scores were 32.9 ± 6.2 at baseline and 29.7 ± 7.5 12 months after surgery (p = 0.24). Post-hoc analysis, excluding one subject who experienced cognitive and motor deterioration after the development of symptomatic bilateral SDHs, found that UHDRS motor scores were 33.8 ± 6.2 at baseline and 27.5 ± 5.2 at 12 months (p = 0.03). ConclusionsTransplantation of human fetal striatal cells is feasible and survival of transplanted cells was demonstrated. Patients with moderately advanced HD are at risk for SDH after transplantation surgery.

Are Sleep Complaints an Independent Risk Factor for Myocardial Infarction

PURPOSE To investigate whether subjective sleep complaints are an independent predictor of myocardial infarction (MI) in a community of older adults and to gain clues as to why the association between sleep complaints and incident MI exists. METHODS Using longitudinal data from the Piedmont study on 2960 adults aged 65 or older who were free of symptomatic heart disease at baseline, we screened 19 potential confounders to determine if any, alone or in combination, could explain the observed relationship between incident MI and sleep complaints. RESULTS During the three-year follow-up period, there were 152 incident MIs. Restless sleep (incidence density ratio (IDR) = 1.58, 95% confidence interval (CI) = 1.11, 2.24) and trouble falling asleep (IDR = 1.68, 95% CI = 1.09, 2.60) predicted incident MI after adjusting for age, gender, and race. IDRs were not substantially impacted by controlling for smoking, blood pressure, diabetes or obesity. After adjustment for education, number of prescription medicines, self-rated health, and depression score, all IDRs were nullified. In particular, self-rated health and depression were strong independent risk factors for MI. CONCLUSIONS A subjective sleep complaint increases the likelihood of a first MI in older adults without overt coronary heart disease (CHD) independently of classic coronary risk factors and appears to be a marker for a syndrome of depression and malaise that may have a causal relationship to MI.

Consistency of Doppler Parameters in Predicting Arteriographically Confirmed Carotid Stenosis

BACKGROUND AND PURPOSE While internal carotid peak systolic velocity (IPSV) is reportedly the best Doppler parameter for predicting lower grades of carotid artery stenosis, the internal carotid end-diastolic velocity (IEDV) or the ratio of IPSV to common carotid end-diastolic velocity (CEDV) is helpful in increasing prediction of higher grade stenoses. It is important to examine the consistency of these findings across machine and technician. METHODS Using data from 10 devices from the Asymptomatic Carotid Atherosclerosis Study, we examined the predictive ability of seven Doppler parameters: IPSV, IEDV, CEDV, common carotid peak systolic velocity (CPSV), and the ratios of IPSV/ CEDV, IEDV/CEDV, and IEDV/CEDV. To assess the agreement between Doppler and arteriography in classifying percent stenosis above or below a given criterion, sensitivity, specificity, area under the receiver operating curve, and kappa statistics were obtained from logistic models. The single best Doppler parameter for each of two grades of stenosis (60% and 80%) was determined, and its predictive ability was compared with that of IPSV. The usefulness of IEDV or IPSV/CEDV in addition to IPSV to determine higher grade stenosis was examined. RESULTS IPSV was the best predictor in 9 of 10 devices at 60% and in 4 devices at 80% stenosis. When another parameter was better than IPSV, the improvement was minimal. Including IEDV or IPSV/CEDV in addition to IPSV did not notably improve predictive ability. CONCLUSIONS IPSV is the single best Doppler parameter for distinguishing severe (> 80%) from less severe carotid stenosis. Information from other Doppler parameters in addition to IPSV is unlikely to be helpful.

WBGT clothing adjustment factors for four clothing ensembles and the effects of metabolic demands.

This study measured the clothing adjustment factors (CAFs) for four clothing ensembles (Cotton Coveralls, Tyvek 1427 Coveralls, NexGen Coveralls, and Tychem QC Coveralls; all coveralls were worn without hoods) against a baseline of cotton work clothes to determine whether the CAFs would be affected by the metabolic rate. Fifteen participants wore one of the five ensembles while walking on a treadmill at low, moderate, and high rates of work in an environment maintained at 50% relative humidity. A climatic chamber was used to slowly increase the level of heat stress by increasing air temperature. When the participants core temperature reached a steady-state, the dry bulb temperature was increased. The point at which the core temperature began to increase was defined as the inflection point, and the WBGT recorded 5 min before the inflection point was the critical WBGT for each ensemble. A three-way mixed effects linear model with ensemble by metabolic rate category interactions demonstrated that the CAF did not change with metabolic rate, so CAFs can be used over a wide range of metabolic rates. The data at the moderate metabolic rate were combined with data on 14 participants from a previous study under the same conditions. The CAFs in °C WBGT were 0 for cotton coveralls, 1.0 for Tyvek 1422A, and 2.5 for NexGen. Although the value of 7.5 for Tychem QC was found, the recommendation remained at 10 to account for the effects of humidity. The standard error for the determination of WBGT crit at 50% relative humidity was 1.60°C WBGT.

Use of nutritional supplements in Parkinson's disease patients

The use of nutritional supplements has almost doubled in the elderly population in the United States (US) in the past decade. We evaluated the use of nutritional supplements in Parkinsons disease (PD) patients to determine the prevalence of their use and whether patients were aware of possible side effects and drug interactions in the supplements they were taking. Consecutively selected PD patients from an academic movement disorders center completed a 33‐item questionnaire regarding their use of nutritional supplements. A total of 120 PD patients completed the questionnaire and were included in the data analysis (mean age ± SD = 68.2 ± 11.65 years, 67 [55.8%] men and 53 women). Seventy‐six patients (63%) took nutritional supplements at the time of data collection. Vitamins were the most common nutritional supplements used, and vitamin E was the most commonly used vitamin. Thirty‐six patients (47%) who took nutritional supplements consulted with their doctor before taking them, and only 4% of patients who took nutritional supplements were aware of possible side effects from their use. Twenty patients (16.7%) reported that they were currently taking nutritional supplements because of symptoms related to their Parkinsons disease. The vast majority of PD patients surveyed were not aware that nutritional supplements could cause adverse side effects. Less than half of the patients who took nutritional supplements consulted their physician before starting them. Greater awareness of nutritional supplement use in PD patients is warranted to avoid potentially harmful effects and drug interactions.

Exertional heat illness and acute injury related to ambient wet bulb globe temperature.

BACKGROUND The Deepwater Horizon disaster cleanup effort provided an opportunity to examine the effects of ambient thermal conditions on exertional heat illness (EHI) and acute injury (AI). METHODS The outcomes were daily person-based frequencies of EHI and AI. Exposures were maximum estimated WBGT (WBGTmax) and severity. Previous days cumulative effect was assessed by introducing previous days WBGTmax into the model. RESULTS EHI and AI were higher in workers exposed above a WBGTmax of 20°C (RR 1.40 and RR 1.06/°C, respectively). Exposures above 28°C-WBGTmax on the day of the EHI and/or the day before were associated with higher risk of EHI due to an interaction between previous days environmental conditions and the current day (RRs from 1.0-10.4). CONCLUSIONS The risk for EHI and AI were higher with increasing WBGTmax. There was evidence of a cumulative effect from the prior days WBGTmax for EHI. Am. J. Ind. Med. 59:1169-1176, 2016.

Demographic differences in injuries among the elderly: an analysis of emergency department visits.

BACKGROUND An understanding of demographic differences in injury types among the elderly will help in targeting interventions. METHODS Rates were calculated from the 1997 to 1999 National Hospital Ambulatory Medical Care Surveys by dividing the estimated number of visits by census population estimates. Age-adjusted standardized morbidity ratios were calculated to facilitate comparison between genders and between races. RESULTS Although men had fewer fractures than expected on the basis of the rate for women (standardized morbidity ratio = 0.57), they had more open wounds (standardized morbidity ratio = 1.785, p < 0.001). Blacks had fewer fractures than expected, based on the rates for whites (standardized morbidity ratio = 0.601, p = 0.004) but had higher visit rates than expected for less severe injuries such as contusions, strains, and sprains. CONCLUSION The trends noted in the present analysis suggest interventions for improved machinery safety targeted at elderly men and a continuing focus on access to primary care for minority elderly.

Improving prostate cancer detection in veterans through the development of a clinical decision rule for prostate biopsy

BackgroundWe sought to improve prostate cancer (PC) detection through developing a prostate biopsy clinical decision rule (PBCDR), based on an elevated PSA and laboratory biomarkers. This decision rule could be used after initial PC screening, providing the patient and clinician information to consider prior to biopsy.MethodsThis case–control study evaluated men from the Tampa, Florida, James A. Haley (JH) Veteran’s Administration (VA) (N = 1,378), from January 1, 1998, through April 15, 2005. To assess the PBCDR we did all of the following: 1) Identified biomarkers that are related to PC and have the capability of improving the efficiency of PC screening; 2) Developed statistical models to determine which can best predict the probability of PC; 3) Compared each potential model to PSA alone using Receiver Operator Characteristic (ROC) curves, to evaluate for improved overall effectiveness in PC detection and reduction in (negative) biopsies; and 4) Evaluated dose–response relationships between specified lab biomarkers (surrogates for extra-prostatic disease development) and PC progression.ResultsThe following biomarkers were related to PC: hemoglobin (HGB) (OR = 1.42 95% CI 1.27, 1.59); red blood cell (RBC) count (OR = 2.52 95% CI 1.67, 3.78); PSA (OR = 1.04 95% CI 1.03, 1.05); and, creatinine (OR = 1.55 95% CI 1.12, 2.15). Comparing all PC stages versus non-cancerous conditions, the ROC curve area under the curve (AUC) enlarged (increasing the probability of correctly classifying PC): PSA (alone) 0.59 (95% CI 0.55, 0.61); PBCDR model 0.68 (95% CI 0.65, 0.71), and the positive predictive value (PPV) increased: PSA 44.7%; PBCDR model 61.8%. Comparing PC (stages II, III, IV) vs. other, the ROC AUC increased: PSA (alone) 0.63 (95% CI 0.58, 0.66); PBCDR model 0.72 (95% CI 0.68, 0.75), and the PPV increased: 20.6% (PSA); PBCDR model 55.3%.ConclusionsThese results suggest evaluating certain common biomarkers in conjunction with PSA may improve PC prediction prior to biopsy. Moreover, these biomarkers may be more helpful in detecting clinically relevant PC. Follow-up studies should begin with replicating the study on different U.S. VA patients involving multiple practices.

Comparison of centralized versus "site-based" measurement of angiographic stenosis for eligibility in the asymptomatic carotid atherosclerosis study.

RATIONALE AND OBJECTIVES The authors determine the reliability of centralized versus noncentralized (site-based) measurement of angiographic stenosis of patients enrolled into the multicenter, prospective, Asymptomatic Carotid Atherosclerosis Study by angiographic studies. METHODS Percent agreements and correlations of 244 masked and prospectively interpreted angiograms were calculated for comparison of centralized and noncentralized readers measuring the percent carotid stenosis from the same angiographic studies. Univariate summary statistics for differences in percent stenoses were calculated for these readings. RESULTS Agreement between readings were 88.5% and 91.8% with kappa statistics of 0.77 and 0.73 for > or = 60% and > or = 80% stenosis, respectively, for comparison of 33 centers to the designated central reader. Comparison between the designated central reader and a second central reader derived percent agreements of 85.0% and 86.5% with kappa statistics of 0.69 and 0.41 for > or = 60% and > or = 80% stenoses, respectively, for arteries selected from the original group. Hence, agreement was slightly better between the enrolling centers and the designated central reader than between the two central readers. CONCLUSIONS Both centralized and noncentralized (site-based) methods of angiographic measurement of stenosis are equally reliable for large, prospective, masked, multicenter trials when quality control measures are instituted to ensure uniform application of eligibility criteria.