Tanefa A. Apekey

Liver enzymes and risk of cardiovascular disease in the general population: A meta-analysis of prospective cohort studies

BACKGROUND Gamma glutamyltransferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP), commonly used markers of liver dysfunction, have been implicated with risk of cardiovascular disease (CVD). However, the strength and consistency of their associations in the general population have not been reliably quantified. METHODS We synthesized available prospective epidemiological data on the associations of baseline levels of GGT, ALT, AST, and ALP with CVD [composite CVD, coronary heart disease (CHD), or stroke outcomes]. Relevant studies were identified in a literature search of MEDLINE, EMBASE, and Web of Science up to December 2013. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random effects models. RESULTS Twenty-nine unique cohort studies with aggregate data on over 1.23 million participants and 20,406 cardiovascular outcomes were included. The pooled fully adjusted RRs (95% CIs) for CVD were 1.23 (1.16-1.29) and 1.08 (1.03-1.14) per 1-standard deviation change in log baseline levels of GGT and ALP levels respectively. There was no evidence of an association of ALT or AST with CVD, however, ALT was somewhat inversely associated with CHD 0.95 (0.90-1.00) and positively associated with stroke 1.01 (1.00-1.02) in stratified analysis. Tests for nonlinearity were suggestive of linear relationships of GGT and ALP levels with CVD risk. CONCLUSIONS Baseline levels of GGT and ALP are each positively associated with CVD risk and in a log-linear fashion. There may be variations in the associations of ALT with cause-specific cardiovascular endpoints, findings which require further investigation.

Ferritin levels and risk of type 2 diabetes mellitus: an updated systematic review and meta-analysis of prospective evidence.

Emerging evidence suggests that a strong link that exists between elevated baseline body iron stores and high risk of incident type 2 diabetes mellitus (T2DM) in general populations, but the precise magnitude of the associations remains uncertain.

Liver Aminotransferases and Risk of Incident Type 2 Diabetes: A Systematic Review and Meta-Analysis

We evaluated the associations of liver aminotransferases with risk of type 2 diabetes (T2D) in general populations by conducting a systematic review and meta-analysis of published prospective studies. Studies were identified in a literature search of PubMed, EMBASE, and Web of Science from 1950 through October 2012. Of the 2,729 studies reviewed, 17 studies involving 60,359 participants and 3,890 incident T2D events were included. All of the studies assessed associations between alanine aminotransferase (ALT) level and T2D, with heterogeneous findings (I(2) = 88%, 95% confidence interval (CI): 82, 92; P < 0.001). The pooled fully adjusted relative risk of T2D was 1.26 (95% CI: 1.14, 1.41) per 1-standard-deviation change in log baseline ALT level. This association became nonsignificant after trim-and-fill correction for publication bias. Nine studies evaluated associations between aspartate aminotransferase (AST) levels and T2D risk, with a corresponding relative risk of 1.02 (95% CI: 0.99, 1.04). The relative risk of T2D per 5-IU/L increase in ALT level was 1.16 (95% CI: 1.08, 1.25). Available data indicate moderate associations of ALT with risk of T2D events, which may be attributable to publication bias. There was no evidence for an increased risk of T2D with AST. Large prospective studies may still be needed to establish the magnitude and nature of these associations.

Ferritin levels and risk of type 2 diabetes mellitus

Emerging evidence suggests that a strong link that exists between elevated baseline body iron stores and high risk of incident type 2 diabetes mellitus (T2DM) in general populations, but the precise magnitude of the associations remains uncertain.

Room for improvement? Leadership, innovation culture and uptake of quality improvement methods in general practice

BACKGROUND Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. METHOD Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. RESULTS Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation (r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. CONCLUSIONS Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial.

BackgroundSleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety.Methods and designThis will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing.DiscussionPrevious studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation.Trial RegistrationClinicalTrials.gov ID ISRCTN55001433 – http://www.controlled-trials.com/ISRCTN55001433

Benefits of moderate-intensity exercise during a calorie-restricted low-fat diet

Objective: Despite the health benefits, many people do not undertake regular exercise. This study investigated the effects of moderate-intensity exercise on cardiorespiratory fitness (lung age, blood pressure and maximal aerobic power, VO2max), serum lipids concentration and body mass index (BMI) in sedentary overweight/obese adults consuming a calorie-restricted low-fat diet. Design: Randomized diet and exercise intervention. Setting: Lincolnshire, UK. Methods: Sixty overweight/obese (BMI ≥ 25kgm−2) adults were randomized to either a calorie restricted low-fat diet (20 per cent of total energy as fat) or the same diet with the addition of moderate-intensity physical exercise (30 minutes, twice a week) for eight weeks; 20 completed the study. Participants’ serum lipids concentrations, BMI, blood pressure, resting pulse rate, VO2max and lung age were measured before the start of the intervention and during the fourth and eighth weeks. Results: Reductions in blood pressure (10 per cent versus 1 per cent), pulse rate (13 per cent versus 8 per cent) and weight (5 per cent versus 2 per cent) were greatest for the diet with exercise group. Exercise resulted in a significant (p ≤ 0.05) increase in average VO2max (by 17 per cent) and reduction in average lung age by about 19 years. Further, reduction in participants’ lung age ranged from 1 to 37 years. However, there was no significant difference in BMI, blood pressure and serum lipids concentration between groups. Conclusion: Although exercise on most days of the week would result in maximum health benefits, 30 minutes of moderate-intensity exercise twice a week could significantly improve cardiorespiratory fitness (blood pressure and lung age) and the risk of cardiovascular diseases in previously sedentary overweight/obese adults.

Low‐fat diet: case study of a cardiology patient

Purpose – Healthy diet and lifestyle have been shown to be important for obese patients in the management of diet‐related diseases especially in the improvement of cardiovascular disease risk indicators. The purpose of this paper is to determine the effects of a calorie‐restricted low‐fat diet on body weight, cardiovascular disease risk and liver function indicators in an obese, cardiology outpatient with type II diabetes.Design/methodology/approach – A male, obese cardiology outpatient was assigned to a calorie‐restricted (6,694.4 kJ/d) low‐fat (not to exceed 20 per cent of total energy intake) diet for 12 weeks. His body mass index (BMI), blood pressure (BP), pulse rate, fasting glucose, total cholesterol, triglyceride, low‐density lipoprotein cholesterol, high‐density lipoprotein (HDL) cholesterol, alanine aminotranseferase, aspartate aminotranseferase (AST) concentration and TC/HDL ratio were measured prior to the start of the diet and during weeks four, eight and 12 of the diet.Findings – The patient...

Effects of low‐fat and low‐GI diets on health

Purpose – Excess weight and poor quality diets are known to be major and manageable causes of cardiovascular diseases (CVD) but the optimal diet for the prevention and reduction of CVD risk is not known. The purpose of this paper is to compare the effects of low‐fat and low‐GI diets on weight loss, liver function and CVD risk factors.Design/methodology/approach – In total, 18 overweight/obese females were randomly assigned to eight weeks of either isocalorie (1,200 kcal day) low‐fat (<20 per cent energy intake as fat) or low‐GI (≤40 per cent energy intake as carbohydrate) diet. Participants kept a one week food and drink intake diary prior to starting the prescribed diet (week 0) and during weeks 4 and 8 of the diet. BMI, blood pressure, serum lipids, AST and ALT concentrations were measured at specific time intervals.Findings – The low‐fat group reported more adequate micronutrient intake than the low‐GI group. Mean weight, BMI and systolic blood pressure reduced significantly in each group but there was...

Gamma glutamyltransferase, alanine aminotransferase and risk of cancer

The prospective evidence for the associations of gamma glutamyltransferase (GGT) and alanine aminotransferase (ALT) with risk of cancer in the general population is uncertain. We conducted a systematic review and meta‐analysis of published prospective observational studies evaluating the associations of baseline levels of GGT and ALT with risk of overall (incidence and/or mortality) and site‐specific cancers. Relevant studies were identified in a literature search of MEDLINE, EMBASE, Web of Science, reference lists of relevant studies to April 2014 and email contact with investigators. Study specific relative risks (RRs) were meta‐analyzed using random effects models. Fourteen cohort studies with data on 1.79 million participants and 57,534 cancer outcomes were included. Comparing top versus bottom thirds of baseline circulating GGT levels, pooled RRs (95% confidence intervals) were 1.32 (1.15–1.52) for overall cancer, 1.09 (0.95–1.24) for cancers of the breast and female genital organs, 1.09 (1.02–1.16) for cancers of male genital organs, 1.94 (1.35–2.79) for cancers of digestive organs and 1.33 (0.94–1.89) for cancers of respiratory and intrathoracic organs. For ALT, corresponding RRs for overall cancer were 0.96 (0.94–0.99) and 1.65 (1.52–1.79) in European and Asian populations, respectively. There was an increased risk of cancers of the digestive organs 2.44 (1.23–4.84). The pooled RR for overall cancer per 5 U/L increment in GGT levels was 1.04 (1.03–1.05). Available observational data indicate a positive log‐linear association of GGT levels with overall cancer risk. The positive association was generally evident for site‐specific cancers. There are geographical variations in the association of ALT and overall cancer.