Thyroid hormone therapy for older adults with subclinical hypothyroidism

The Authors reply

Subclinical thyroid dysfunction and cardiovascular diseases: 2016 update.

Subclinical thyroid dysfunction comprises subclinical hypothyroidism (SHypo), defined as elevated thyroid-stimulating hormone (TSH) by normal free thyroxine (FT4), and subclinical hyperthyroidism (SHyper) with decreased or undetectable TSH and normal FT4. Up to 10% of the elderly have SHypo, which is usually asymptomatic. Individual participant data (IPD) analyses of prospective cohort studies from the international Thyroid Studies Collaboration show that SHypo is associated with increased coronary heart disease (CHD) mortality [hazard ratio (HR) 1,58 for TSH ≥ 10 mIU/L, 95% CI 1.10-2.27), as well as increased risk of stroke, and heart failure (HF) for both higher and lower TSH. Small studies found that SHypo affects carotid intima media thickness (CIMT), diastolic function, peripheral vascular resistance, endothelial function, and lipid profile. SHyper is associated with increased risk of atrial fibrillation (AF) (HR 1.68, 95% CI 1.16-2.43) and CHD events (HR 1.21, 95% CI 0.99-1.46). The TSH threshold for initiating treatment is unclear. In the absence of large randomized controlled trials, the best evidence suggests SHypo therapy should be started at TSH ≥ 10 mIU/L, and SHyper therapy at TSH < 0.1 mIU/L. Recommendations on screening are discordant, but most guidelines advocate that thyroid function should be checked in those at risk for hypothyroidism, those over 60, and those with known CHD and HF. This review updates current evidence on the association between thyroid dysfunction and cardiovascular disease, as well as on screening and treatment of subclinical thyroid dysfunction

The joint influence of gender and amount of smoking on weight gain one year after smoking cessation.

Weight gain is often associated with smoking cessation and may discourage smokers from quitting. This study estimated the weight gained one year after smoking cessation and examined the risk factors associated with weight gain in order to identify socio-demographic groups at higher risk of increased weight after quitting. We analyzed data from 750 adults in two randomized controlled studies that included smokers motivated to quit and found a gradient in weight gain according to the actual duration of abstinence during follow-up. Subjects who were abstinent for at least 40 weeks gained 4.6 kg (SD = 3.8) on average, compared to 1.2 kg (SD = 2.6) for those who were abstinent less than 20 weeks during the 1-year follow-up. Considering the duration of abstinence as an exposure variable, we found an age effect and a significant interaction between sex and the amount of smoking before quitting: younger subjects gained more weight than older subjects; among light smokers, men gained more weight on average than women one year after quitting, while the opposite was observed among heavy smokers. Young women smoking heavily at baseline had the highest risk of weight gain after quitting

Tolerability of statin-based management of patients with a history of statin-associated muscle symptoms: Protocol for a systematic review

Introduction Statin-associated muscle symptoms (SAMSs) are a major clinical issue in the primary and secondary prevention of cardiovascular events. Current guidelines advise various approaches mainly based on expert opinion. We will lead a systematic review and meta-analysis to explore the tolerability and acceptability and effectiveness of statin-based therapy management of patients with a history of SAMS. We aim to provide evidence on the tolerability and different strategies of statin-based management of patients with a history of SAMS. Methods and analysis We will conduct a systematic review of randomised controlled trials (RCTs) and non-randomised studies with a control group. We will search in Data sources MEDLINE, EMBASE, Cochrane Central Register of Controlled Clinical Trials, Scopus, Clinicaltrials.gov and Proquest from inception until April 2021. Two independent reviewers will carry out the study selection based on eligibility criteria. We will extract data following a standard data collection form. The reviewers will use the Cochrane Collaboration's tools and Newcastle-Ottawa Scale to appraise the study risk of bias. Our primary outcome will be tolerability and our secondary outcomes will be acceptability and effectiveness. We will conduct a qualitative analysis of all included studies. In addition, if sufficient and homogeneous data are available, we will conduct quantitative analysis. We will synthesise dichotomous data using OR with 95% CI and continuous outcomes by using mean difference or standardised mean difference (with 95% CI). We will determine heterogeneity visually with forest plots and quantitatively with I 2 and Q-test. We will summarise the confidence in the quantitative estimate by using Grading of Recommendations Assessment, Development and Evaluation approach. Ethics and dissemination As a systematic review of literature without collection of new clinical data, there will be no requirement for ethical approval. We will disseminate findings through peer-reviewed publications. PROSPERO registration number CRD42020202619

Comparison of self-perceived cardiovascular disease risk among smokers with Framingham and PROCAM scores: a cross-sectional analysis of baseline data from a randomised controlled trial.

Previous studies suggest that smokers have a misperception of their 10-year cardiovascular risk. We aimed to compare 10-year cardiovascular risk self-perception and calculated risk among smokers willing to quit and assess the determinants of a possible misperception. Cross-sectional secondary analysis of baseline data from a randomised controlled trial of smoking cessation. 514 participants, mean age 51.1 years, 46% women, 98% Caucasian. Eligible participants were regular smokers, aged between 40 and 70 years, with a consumption of at least 10 cigarettes per day for at least a year. None of them had experienced cardiovascular disease before. Exclusion criteria comprised a history of myocardial infarction, coronary heart disease, stroke, heart failure, peripheral vascular disease, carotid atherosclerosis or cardiac arrhythmia. Participants with renal or liver failure, psychiatric disorders, substance and alcohol abuse and with smoking cessation therapies were excluded. Participants were asked to estimate their 10-year cardiovascular risk using a 3-item scale corresponding to high-risk, moderate-risk and low-risk categories. We compared their risk perception with Framingham and Prospective Cardiovascular Munster Study (PROCAM) scores. We used multivariable-adjusted logistic regression models to determine characteristics of participants who underestimate their risk versus those who correctly estimate or overestimate it. Between 38% and 42% of smokers correctly perceived their 10-year cardiovascular risk, and 39-50% overestimated their 10-year cardiovascular risk while 12-19% underestimated it compared with their calculated 10-year cardiovascular risk depending on the score used. Underestimation of 10-year cardiovascular risk was associated with male gender (OR 8.16; CI 3.83 to 17.36), older age (OR 1.06; CI 1.02 to 1.09), and the presence of hyperlipidaemia (OR 2.71; CI 1.47 to 5.01) and diabetes mellitus (OR 13.93; CI 3.83 to 50.66). Among smokers, misperception of their 10-year cardiovascular risk is common, with one-fifth underestimating it. These findings may help physicians target patients with such characteristics to help them change their health behaviour and adherence to risk-reduction therapy. NCT00548665; Post-results

Pollen morphology of alpine butterworts (Pinguicula L., Lentibulariaceae)

The pollen morphology of Pinguicula alpina, P. arvetii, P. grandiflora subsp. grandiflora, P. grandiflora subsp. rosea, P. hirtiflora, P. leptoceras, P. poldinii, P. reichenbachiana, and P. vulgaris, belonging to the Alpine flora, was studied. The pollen grains, coming from different populations, were investigated using light microscopy and scanning electron microscopy. The pollen size, the shape (P/E ratio), the number of colpori and the exine ornamentation are, for Pinguicula, important diagnostic characters. Pinguicula pollen grains are medium sized ( 30 \u3bcm), trinucleate, isopolar, radially symmetric. The shape of the grains is variable from oblate spheroidal to prolate spheroidal and they are (4)\u20135\u20139\u2013(10)-zonocolporate. The prevalent ornamentation is rugulate\u2013microreticulate, P. alpina has a rugulate\u2013reticulate ornamentation and only P. hirtiflora has a perforate ornamentation. A pollen key, based on micromorphological data, is presented

Chronic symptoms in a representative sample of community-dwelling older people: a cross-sectional study in Switzerland.

The burden of multiple diagnoses is well documented in older people, but less is known about chronic symptoms, many of which are even not brought to medical attention. This study aimed to determine the prevalence of chronic symptoms, their relationships with disability in basic activities of daily living (BADL) and quality of life (QoL), and their public health impact. A large cross-sectional population-based study. Community in 2 regions of French-speaking Switzerland. Community-dwelling older adults aged 68 years and older in 2011 (N=5300). Disability in BADL defined as difficulty or help needed with any of dressing, bathing, eating, getting in/out of bed or an arm chair, and using the toilet. Overall QoL dichotomised as favourable (ie, excellent or very good) or unfavourable (ie, good, fair or poor). Disturbance by any of the following 14 chronic symptoms for at least 6 months: joint pain, back pain, chest pain, dyspnoea, persistent cough, swollen legs, memory gaps, difficulty concentrating, difficulty making decisions, dizziness/vertigo, skin problems, stomach/intestine problems, urinary incontinence and impaired sexual life. Only 17.1% of participants did not report being disturbed by any of these chronic symptoms. Weighted prevalence ranged from 3.1% (chest pain) to 47.7% (joint pain). Most chronic symptoms were significantly associated with disability in BADL or unfavourable QoL, with substantial gender differences. The number of chronic symptoms was significantly associated with disability in BADL and unfavourable QoL, with gradients suggesting dose-response relationships. Joint pain and back pain had the highest population attributable fractions. Chronic symptoms are highly prevalent in older people, and are associated with disability in BADL and unfavourable QoL, particularly when multiple chronic symptoms co-occur. Owing to their high public health impact, musculoskeletal chronic symptoms represent good targets for preventive interventions

Screening and treatment of hypertension in older adults: Less is more?

Screening and treatment of hypertension is a cornerstone of cardiovascular disease (CVD) prevention. Hypertension causes a large proportion of cases of stroke, coronary heart disease, heart failure, and associated disability and is highly prevalent especially among older adults. On the one hand, there is robust evidence that screening and treatment of hypertension prevents CVD and decreases mortality in the middle-aged population. On the other hand, among older adults, observational studies have shown either positive, negative, or no correlation between blood pressure (BP) and cardiovascular outcomes. Furthermore, there is a lack of high quality evidence for a favorable harm-benefit balance of antihypertensive treatment among older adults, especially among the oldest-old (i.e., above the age of 80 years), because very few trials have been conducted in this population. The optimal target BP may be higher among older treated hypertensive patients than among middle-aged. In addition, among frail or multimorbid older individuals, a relatively low BP may be associated with worse outcomes, and antihypertensive treatment may cause more harm than benefit. To guide hypertension screening and treatment recommendations among older patients, additional studies are needed to determine the most efficient screening strategies, to evaluate the effect of lowering BP on CVD risk and on mortality, to determine the optimal target BP, and to better understand the relationship between BP, frailty, multimorbidity, and health outcomes

Hypertriglyceridemia: a potential side effect of propofol sedation in critical illness

Purpose: Hypertriglyceridemia (hyperTG) is common among intensive care unit (ICU) patients, but knowledge about hyperTG risk factors is scarce. The present study aims to identify risk factors favoring its development in patients requiring prolonged ICU treatment. Methods: Prospective observational study in the medicosurgical ICU of a university teaching hospital. All consecutive patients staying ≥4days were enrolled. Potential risk factors were recorded: pathology, energy intake, amount and type of nutritional lipids, intake of propofol, glucose intake, laboratory parameters, and drugs. Triglyceride (TG) levels were assessed three times weekly. Statistics was based on two-way analysis of variance (ANOVA) and linear regression with potential risk factors. Results: Out of 1,301 consecutive admissions, 220 patients were eligible, of whom 99 (45%) presented hyperTG (triglycerides >2mmol/L). HyperTG patients were younger, heavier, with more brain injury and multiple trauma. Intake of propofol (mg/kg/h) and lipids' propofol had the highest correlation with plasma TG (r 2=0.28 and 0.26, respectively, both p<0.001). Infection and inflammation were associated with development of hyperTG [C-reactive protein (CRP), r 2=0.19, p=0.004]. No strong association could be found with nutritional lipids or other risk factors. Outcome was similar in normo- and hyperTG patients. Conclusions: HyperTG is frequent in the ICU but is not associated with adverse outcome. Propofol and accompanying lipid emulsion are the strongest risk factors. Our results suggest that plasma TG should be monitored at least twice weekly in patients on propofol. The clinical consequences of propofol-related hyperTG should be investigated in further studie