Long-term glycemic variability and risk of adverse outcomes: a systematic review and meta-analysis

OBJECTIVE: Glycemic variability is emerging as a measure of glycemic control, which may be a reliable predictor of complications. This systematic review and meta-analysis evaluates the association between HbA1c variability and micro- and macrovascular complications and mortality in type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Medline and Embase were searched (2004–2015) for studies describing associations between HbA1c variability and adverse outcomes in patients with type 1 and type 2 diabetes. Data extraction was performed independently by two reviewers. Random-effects meta-analysis was performed with stratification according to the measure of HbA1c variability, method of analysis, and diabetes type. RESULTS: Seven studies evaluated HbA1c variability among patients with type 1 diabetes and showed an association of HbA1c variability with renal disease (risk ratio 1.56 [95% CI 1.08–2.25], two studies), cardiovascular events (1.98 [1.39–2.82]), and retinopathy (2.11 [1.54–2.89]). Thirteen studies evaluated HbA1c variability among patients with type 2 diabetes. Higher HbA1c variability was associated with higher risk of renal disease (1.34 [1.15–1.57], two studies), macrovascular events (1.21 [1.06–1.38]), ulceration/gangrene (1.50 [1.06–2.12]), cardiovascular disease (1.27 [1.15–1.40]), and mortality (1.34 [1.18–1.53]). Most studies were retrospective with lack of adjustment for potential confounders, and inconsistency existed in the definition of HbA1c variability. CONCLUSIONS: HbA1c variability was positively associated with micro- and macrovascular complications and mortality independently of the HbA1c level and might play a future role in clinical risk assessment

The Heavy Hadron Spectrum

I discuss the spectrum of hadrons containing heavy quarks ($b$ or $c$), and how well the experimental results are matched by theoretical ideas. Useful insights come from potential models and applications of Heavy Quark Symmetry and these can be compared with new numerical results from the ab initio methods of Lattice QCD.Comment: 64 pages, Latex, lectures at Schladming Winter School 199

Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

No abstract available

Aspects of phenomenology from lattice QCD

We present an improvement procedure to lattice quantum chromodynamics which eliminates all terms effectively in order a (a is the lattice spacing) from the computation of hadronic matrix elements with Wilson fermions. This method is based on an `improved' Wilson action combined with a suitable modification of the fermion operators. It is expected that this technique will significantly reduce the systematic errors associated with the finiteness of the lattice spacing. With the Wilson action these errors have been found to be around 20- 30&#37;. We hope to have reduced these systematic errors to just a few percent. In the last two chapters, we study the semi-leptonic decays of strange K mesons using the standard Wilson lattice action. The lattice conserved current is employed to compute the form factors fo and f+ at q2 &#61; 0. These are found to be in good agreement with experiment. Nearest pole dominance gives a good description of the form factors. Computations are carried out on a 20 x 10 x 10 x 40 lattice at β&#61; 6.0 in the quenched approximation.</p

Abnormal left ventricular function occurs on exercise in well-treated hypertensive subjects with normal resting echocardiography

This study tests the hypothesis that patients with treated hypertension with well-controlled blood pressure, without ventricular hypertrophy and normal resting echocardiography, may have abnormalities of ventricular function that are apparent only on exercise and contribute to symptoms of exertional dyspnoea

The pathophysiology of heart failure with normal ejection fraction:exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling

Definition, prevalence, and clinical significance of mitral annular disjunction in different patient cohorts : A systematic review

Background Mitral annular disjunction (MAD) is a structural abnormality involving a distinct separation of the left atrium/mitral valve annulus and myocardium continuum. The literature around MAD has increased over recent years, thus we sought to review the current data on the definition, prevalence, and clinical outcomes of MAD. Methods A search of MEDLINE and EMBASE was conducted to identify studies which evaluated MAD in any patient cohort. The study results were synthesized narratively. Results A total of 12 studies were included with 3925 patients (average age 62 years, 63% male). The pooled prevalence of MAD in patients with mitral valve prolapse and/or Barlow's disease was 30.1%. In a general population, MAD prevalence was 8.7%. The definition of MAD was not consistent across all studies. In terms of clinical outcomes, only one study reported MAD to be associated with ventricular arrhythmias. Conclusions MAD is an increasingly recognized finding amongst patients undergoing cardiac imaging. This review highlights the need for agreed definitions for clinically significant MAD and how identified MAD should be managed. At present, there is insufficient evidence that MAD is associated adverse clinical outcomes

Effect of Weekend Admission on Process of Care and Clinical Outcomes for the Management of Acute Coronary Syndromes: a retrospective analysis of three UK centres

OBJECTIVES: The effect of weekend versus weekday admission following acute coronary syndrome (ACS) on process of care and mortality remains controversial. This study aimed to investigate the 'weekend-effect' on outcomes using a multicentre dataset of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA). DESIGN: This retrospective observational study used propensity score (PS) stratification to adjust estimates of weekend effect for observed confounding. Logistic regression was used to estimate odds ratios (ORs) for binary outcomes and time-to-event endpoints were modelled using Cox proportional hazards to estimate hazard ratios (HRs). SETTING: Three tertiary cardiac centres in England and Wales that contribute to the Myocardial Ischaemia National Audit Project. PARTICIPANTS: Between January 2010 and March 2016, 17 705 admissions met the study inclusion criteria, 4327 of which were at a weekend. PRIMARY AND SECONDARY OUTCOMES: Associations were studied between weekend admissions and the following primary outcome measures: in-hospital mortality, 30-day mortality and long-term survival; secondary outcomes included several processes of care indicators, such as time to coronary angiography. RESULTS: After PS stratification adjustment, mortality outcomes were similar between weekend and weekday admission across patients with STEMI and NSTEMI/UA. Weekend admissions were less likely to be discharged within 1 day (HR 0.72, 95% CI 0.66 to 0.78), but after 4 days the length of stay was similar (HR 0.97, 95% CI 0.90 to 1.04). Fewer patients with NSTEMI/UA received angiography between 0 and 24 hours at a weekend (HR 0.71, 95% CI 0.65 to 0.77). Weekend patients with STEMI were less likely to undergo an angiogram within 1 hour, but there was no significant difference after this time point. CONCLUSION: Patients with ACS had similar mortality and processes of care when admitted on a weekend compared with a weekday. There was evidence of a delay to angiography for patients with NSTEMI/UA admitted at the weekend

Unplanned hospital readmissions after acute myocardial infarction:a nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014

Background Unplanned hospital readmissions are an important quality metric for benchmarking but there is limited data following an acute myocardial infarction (AMI). This study aims to examine the 30-day unplanned readmission rate, predictors, causes and outcomes after hospitalization for AMI. Methods The U.S. Nationwide Readmission Database was utilized to analyze patients with a primary diagnosis of AMI between 2010-2014. Rates of readmissions, causes and costs were determined and multiple logistic regressions were used to identify predictors of readmissions. Results: Of 2,204,104 patients with AMI the 30-day unplanned readmission rate was 12.3%(n=270,510), which changed from 13.0%-11.5% between 2010-2014. The estimated impact of readmissions in AMI was ~694 million USD and ~279,000 additional bed days per year. Comorbidities such as diabetes (OR 1.27 95%CI 1.25-1.29), chronic lung disease (OR 1.29 95%CI 1.26-1.31), renal failure (OR 1.38 95%CI 1.35-1.40) and cancer (OR 1.35 95%CI 1.30-1.41) were independently associated with unplanned readmission. Discharge against medical advice was the variable most strongly associated with unplanned readmission (OR 2.40 95%CI 2.27-2.54). Non-cardiac causes for readmissions accounted for 52.9% of all readmissions. The most common cause of cardiac readmission was heart failure (14.3%) and for non-cardiac readmissions was infections (8.8%). Conclusions: Readmissions during the first month after AMI occur in more than 1 in 10 patients resulting in a healthcare cost of ~694 million USD per year and ~279,000 additional bed days per year. These finding have important public health implications. Strategies to identify and reduce readmissions in AMI will dramatically reduce health care costs for society