A new study reports that 75 percent of cardiac damage after vascular surgery is asymptomatic or patients' symptoms are concealed by postoperative complaints such as nausea and incision pain. This damage is associated with an increased risk for mortality. Researchers have found that screening for cardiac damage following surgery helps identify high-risk patients who might benefit from more aggressive medical therapy and follow-up after discharge. These findings are from a study presented today at the 63rd Annual Meeting of the Society for Vascular Surgery®.

"While the prognosis of symptomatic cardiac damage is known to be poor compared to patients without cardiac damage, the impact of asymptomatic cardiac damage is largely unknown," said Olaf Schouten, MD, Erasmus Medical Center of Rotterdam, The Netherlands. "Therefore, this study was performed to assess the long-term prognosis of vascular surgery patients who experience asymptomatic cardiac damage in the first week after major vascular surgery."

Dr. Schouten explained that appropriate screening consists of repeated measurement of cardiac troponin T (cTnT), a simple and sensitive laboratory marker for myocardial injury and cardiac damage after surgery. "However," he added, "the prognosis of cTnT elevations without clinical symptoms and/or new electrocardiographic changes (asymptomatic cTnT release) is unknown."

Initially 1,545 patients undergoing elective major vascular surgery were enrolled and baseline characteristics and medication were noted. Before surgery all patients were screened for the presence of cardiac risk factors such as a history of myocardial infarction, diabetes mellitus, and heart failure.

Routine sampling of cTnT and ECG recording was performed on days one, three, and seven after surgery and at the day of discharge. Elevated cTnT was defined as serum concentrations equal to or more than 0.01 ng/ml. Following surgery, cardiac damage occurred in 213 (14 percent) asymptomatic patients and in 71 (5 percent) symptomatic patients.

Patients were followed for a mean of 3.7 years after surgery. Asymptomatic cardiac damage in the perioperative period was associated with a poor long-term outcome compared to patients without cardiac damage. A total of 13 percent of patients without cardiac damage died during follow-up versus 40 percent of patients with asymptomatic cardiac damage. Also, after adjustment for risk factors and type and site of surgery asymptomatic cardiac damage was associated with a 2.3-fold increased risk for mortality during the first four years after vascular surgery, (adjusted HR 2.3; 95 percent; CI 1.8-3.0) and risk increased with higher cTnT levels (HR 1.64 for every 0.10 ng/ml increase, p=0.02). Elevated cTnT had prognostic value irrespective of baseline creatinine value or renal dysfunction after surgery.

"Asymptomatic cTnT release, without clinical symptoms or new ECG changes, is associated with an increased long-term mortality in patients undergoing vascular surgery," said Dr. Schouten. "Patients undergoing major arterial vascular surgery because of atherosclerotic disease are at high-risk for cardiac complications in the perioperative period. It is estimated that one out of five patients undergoing major vascular surgery suffers cardiac damage around the time of the operation if patients are appropriately screened in the first week after surgery. Screening is a valuable tool to determine how aggressive medical therapy should be for their long-term prognosis."

The value and cost-effectiveness of screening for left ventricular (LV) dysfunction remains unclear, particularly since specific, evidence-based treatments are not available for the majority of patients with preserved systolic dysfunction, reports a study in the June issue of the Journal of Cardiac Failure, published by Elsevier.

In the study,1012 primary care patients with hypertension and/or diabetes without signs or symptoms of heart failure were screened for asymptomatic left ventricular dysfunction (ALVD), using measurements of NT-pro-BNP and echocardiography. Diastolic dysfunction was found in 368 subjects (36%) and was categorized as mild in 327 and moderate-severe in 41. Systolic dysfunction was present in only 11 (1.1%)l. NT-proBNP levels were 170±206 and 859±661 pg/mL respectively in diastolic and systolic dysfunction and 92±169 in normal subjects (p<.0001).

For the 52 subjects (5.1%) with moderate to severe diastolic dysfunction or systolic dysfunction, a NT-proBNP of < 125 pg/ml had a negative predictive value (NPV) >99% and a positive predictive value of 33% in patients < 67 years. For older patients, NPV was 100%, but PPV was somewhat lower in women (23%) than in men (33%).

This study suggests that the evaluation of NT-proBNP in asymptomatic patients with type 2 diabetes or hypertension may lead to very early exclusion of LV dysfunction. As a perspective of this study, general practitioners could use NT-proBNP determination to rule out heart failure (HF) in these patients, a much more cost effective measure than the use of an echocardiographic one. The study was partially supported by an unrestricted grant from Roche Diagnostics.

"This study demonstrates that low values of NT-proBNP usually exclude significant LV dysfunction, but elevated values are relatively non-specific, especially in a population where systolic dysfunction is rare.

A University of Alberta study of 240 men and women with chronic lower-back pain showed that those who exercised four days a week had a better quality of life, 28 per cent less pain and 36 per cent less disability, while those who hit the gym only two or three days a week did not show the same level of change.

"While it could be assumed that someone with back pain should not be exercising frequently, our findings show that working with weights four days a week provides the greatest amount of pain relief and quality of life," said Robert Kell, lead author of the study and an assistant professor of exercise physiology at the University of Alberta, Augustana Campus.

About 80 per cent of North Americans suffer from lower back pain.

Kell presented some of the findings May 30 at the American College of Sports Medicine conference in Seattle, Wash.

In the study, groups of 60 men and women with chronically sore lower backs each exercised with weights in two, three or four-day weekly programs, or not at all. Their progress was measured over 16 weeks. The level of pain decreased by 28 per cent in programs that included exercise four days a week, by 18 per cent three days a week and by 14 per cent two days a week. The quality of life, defined as general physical and mental well-being, rose by 28 per cent, 22 per cent and 16 per cent respectively.

Both boys and girls have issues, but boys seem to be the ones getting the raw deal. According to Judith Kleinfeld, professor of psychology at the University of Alaska Fairbanks in the US, issues affecting boys are more serious than those affecting girls, but they have been neglected by policy makers. Her review1 of issues characterizing American boyhood, how they compare to those affecting girls, and the lack of initiatives in place to address them has just been published in the June issue of Springer's journal Gender Issues.

Professor Kleinfeld's paper reviews the different viewpoints surrounding the debated existence of a so-called 'boy crisis'. She then looks at gender differences in measures of educational achievement including literacy levels, college entrance tests, school grades, engagement in schools, dropout rates, as well as psychological issues affecting young people including mental health, suicide, depression and conduct disorders. Lastly, she shows how boys and girls compare in terms of premature death and injuries and rates of delinquency and arrests.

According to Judith Kleinfeld, boys get the raw deal. Compared with girls, American boys have lower rates of literacy, lower grades and engagement in school, higher drop-out from school, and dramatically higher rates of suicide, premature death, injuries, and arrests. Boys are also placed more often in special education. Girls on the other hand are more likely to have different problems including depression, suicidal thoughts and eating disorders.

The researcher argues that although there have been numerous federal, state, school district, and foundation programs aimed at addressing issues faced by girls, led in part by the strong feminist movement, the same cannot be said for the problems encountered by boys. In her view, they have been largely neglected.

Professor Kleinfeld concludes: "In terms of policy discussion and educational investments, the nation is addressing gender differences which barely exist but ignoring gender gaps which are substantial. Policy attention has focused on the supposed underachievement of females in mathematics and science but these gender gaps are small. In contrast, substantial gender gaps are occurring in reading and writing which place males at a serious disadvantage in the employment market and in college…. Both boys and girls face gendered problems which need policy attention."

Scientists have found that anxiety, depression, and insomnia are genetically linked.

Dr. Phillip Gehrman, assistant professor in the department of psychiatry at the University of Pennsylvania School Of Medicine, says that the genes that play a role in adolescent insomnia are he same as those involved in depression and anxiety

He says that the results of the study show that insomnia as a diagnosis has a moderate heritability in 8 to 16 year olds, which is consistent with past studies of insomnia symptoms in adults.

The researcher says that significant genetic effects shared between insomnia, depression and anxiety suggests that overlapping genetic mechanisms exist to link the disorders.

According to Dr. Gehrman, researchers involved in the study were surprised that they did not find sleep-specific genetic effects.

"Monozygotic twins did not have higher rates of insomnia. However, if one monozygotic twin had insomnia, their twin was more likely to have insomnia than if they were dizygotic twins," he said.

The sequential cohort study included data from 749 monozygotic twin pairs and 687 dizygotic twin pairs between the age of 8 and 17 and their parents.

Mean age was 11.9. Twins and their parents completed the Child and Adolescent Psychiatric Assessment (CAPA), and DSM-III-R criteria was used to assess insomnia, depression and anxiety.

Criteria for insomnia were met by 19.5 percent of the sample.

Analysing their observations, the researchers came to the conclusion that adolescents suffering from anxiety and depression should also be screened for insomnia.