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Byron J Hoogwerf

Publications and source records attributed to Byron J Hoogwerf.

At least 19 recordsLinked to original sources
PubMed2006

Perioperative management of diabetes mellitus: how should we act on the limited evidence?

Patients with diabetes mellitus are at higher risk for complications from surgery than their nondiabetic counterparts. Evidence-based guidance on the perioperative management of diabetic patients is still very limited. Management is best guided by careful preoperative and postoperative consideration of diet, antidiabetic medication regimens, and the likelihood of specific complications of diabetes. Good postoperative glucose control reduces the risk of in-hospital death and shortens length of stay. Insulin is the mainstay of perioperative glucose management, and intensive insulin therapy (to a target blood glucose of 110 mg/dL or lower) improves a range of clinical outcomes in critically ill patients relative to less aggressive insulin strategies. There is little role for oral antidiabetic medications in the early postoperative phase.

Aged↗
PubMed2005

Relation of diurnal blood pressure variation and triglyceride-to-high-density lipoprotein cholesterol ratio in patients without diabetes mellitus.

A night-time decrease in systolic blood pressure that differs <10% from mean daytime values ("nondipping") is associated with increased rates of cardiovascular morbidity and mortality. We hypothesized that insulin resistance would be associated with nondipping in patients who did not have frank diabetes mellitus or hypertension. We included 106 consecutive outpatients who had been referred for 24-hour ambulatory monitoring of blood pressure. Our data suggest that insulin resistance, defined as a high ratio of triglyceride to high-density lipoprotein, is associated with blunted diurnal blood pressure variation (odds ratio 6.3, 95% confidence interval 2.6 to 16.4, p <0.0001) before the development of abnormal levels of fasting blood glucose.

Aged↗
PubMed2005

Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations.

OBJECTIVE: Describe the course of patients with an elevated international normalized ratio (INR) in the emergency department (ED) and determine physicians' adherence with treatment recommendations. METHODS: One-year retrospective review of all ED patients with an INR >5.0. RESULTS: Ninety-four patients met the entry criteria. Bleeding was present in 28.7% patients. Two thirds of the major bleeding episodes were of gastrointestinal origin. Physicians' adherence decreased as bleeding and INR increased. At the lowest risk, adherence was 66.6%, whereas at the highest risk, it was 36.3%. Two thirds of patients were admitted to the hospital, one fourth were discharged, and 7.4% were observed in an observation unit. Average length of stay was 3.8 days. CONCLUSION: Adherence to the recommendations regarding managing elevated INR was suboptimal. There is a need for formal endorsement of recommendations by emergency medicine organizations and development of disposition criteria based on bleeding status and site of bleeding.

Adolescent↗
PubMed2005

Cholesterol guidelines update: more aggressive therapy for higher-risk patients.

The 2004 update to the National Cholesterol Education Program guidelines goes farther than the 2001 version in suggesting an optional low-density lipoprotein cholesterol (LDL-C) goal of less than 70 mg/dL for patients at "very high risk." It recommends starting both diet and drug therapy in all patients at high or very high risk whose LDL-C level is above the goal level, with the goal of reducing LDL-C by 30% to 40%. These more aggressive guidelines are based on results of five clinical studies published since 2001.

Adult↗
PubMed2004

Association of dyslipidemia and effects of statins on nonmacrovascular diseases.

BACKGROUND: Statins have mechanisms of action that expand their effects beyond cholesterol lowering and atherosclerotic medical conditions. OBJECTIVE: This review summarizes clinical evidence for the association of dyslipidemia and the effects of statin use on aortic stenosis, Alzheimer's dementia (AD), osteoporosis, prevention of diabetes mellitus (DM), diabetic retinopathy, age-related macular degeneration, and diabetic/nondiabetic nephropathy. METHODS: An English-language literature search was conducted using MEDLINE (1966-June 2003). Bibliographies of retrieved articles were reviewed. Search terms included statin, HMG-CoA reductase inhibitors, aortic stenosis, Alzheimer's dementia, osteoporosis, prevention of diabetis, diabetic retinopathy, age-related macular degeneration, diabetic nephropathy, and nondiabetic nephropathy. RESULTS: Three retrospective cohort trials have shown an association between statin use and the progression of aortic stenosis; one of these trials observed a 45% decrease in aortic valve area in 1 year. In AD, one cross-sectional analysis found 60% to 73% lower AD rates in lovastatin or pravastatin recipients ( P<0.001 ). Of the multiple observational studies on the effect of statins on fracture risk, some have shown a decreased risk, with an odds ratio as low as 0.50 (95% CI, 0.33-0.76); others have demonstrated no association. A post hoc analysis of the West of Scotland Coronary Prevention Study found a 30% reduction in the development of DM ( P=0.042 ), but this was not duplicated in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm. A small clinical trial of 6 patients (11 eyes) demonstrated improved retinal hard exudates with pravastatin treatment in patients with diabetic retinopathy. In a cross-sectional analysis, age-related macular degeneration was found to be less common among statin users than nonusers (4% [ 1/27 ] vs 22% [ 76/352 ]; P=0.02. Multiple small clinical trials of 19 to 56 patients with diabetic and nondiabetic nephropathy at various stages generated inconsistent results for an association between statin use and decreased albumin excretion rate and decreased rate of decline in glomerular filtration. CONCLUSION: Data of variable quantity and quality support the use of statins as adjuncts in the treatment of nonmacrovascular diseases.

Alzheimer Disease↗
PubMed2004

Effects of vitamin E on cardiovascular outcomes in people with mild-to-moderate renal insufficiency: results of the HOPE study.

BACKGROUND: A controlled trial reported cardiovascular benefits of vitamin E in terminal renal insufficiency. There are no data for renal insufficiency before the stage of terminal renal failure. We evaluated effects of vitamin E supplementation on cardiovascular and renal outcomes in 993 people with a serum creatinine > or =1.4 to 2.3 mg/dL. METHODS: Post-hoc analysis of a randomized trial that compared treatment with natural source vitamin E (400 IU/day) to placebo in 9541 people, 993 of which had renal insufficiency. Participants had either known cardiovascular disease or diabetes and at least one additional coronary risk factor. Exclusion criteria included a serum creatinine > 2.3 mg/dL and dipstick-positive proteinuria. The primary study outcome after an average of 4.5 years was the composite of myocardial infarction, stroke, or cardiovascular death. Secondary outcomes included revascularizations, total mortality, and clinical proteinuria. RESULTS: In renal insufficiency, vitamin E supplementation had a neutral effect on the primary study outcome, on each component of the composite primary outcome, and on all secondary outcomes. Two hundred twenty-four primary outcomes, 23% of the vitamin E group and 22.1% of the placebo group, relative risk 1.03 (95% CI, 0.79-1.34; P= 0.82), were observed, and 585 secondary outcomes, including death in 17% and 18.8% of the vitamin E and placebo groups, respectively (RR 0.88, 95% CI, 0.66-1.18; P= 0.40). There was no effect of vitamin E on progression of proteinuria. CONCLUSION: In people with mild-to-moderate renal insufficiency at high cardiovascular risk, vitamin E at a dose of 400 IU/day had no apparent effect on cardiovascular outcomes.

Aged↗
PubMed2004

Teambuilding and leadership training in an internal medicine residency training program.

OBJECTIVE: The purpose of this report is to describe and evaluate the impact of a 1-day retreat focused on developing leadership skills and teambuilding among postgraduate year 1 residents in an internal medicine residency. METHOD: A group of organizers, including members of the staff, the chief medical residents, administrative individuals in the residency office, and an internal organizational development consultant convened to organize an off-site retreat with activities that would provide experiential learning regarding teamwork and leadership, including a "reef survival exercise" and table discussions regarding the characteristics of ideal leaders. In addition, several energizing activities and recreational free time was provided to enhance the interaction and teamwork dimensions of the retreat. To evaluate the impact of the retreat, attendees completed baseline and follow-up questionnaires regarding their experience of the retreat. RESULTS: Attendees universally regarded the retreat as having value for them. Comparison of baseline to postretreat responses indicated that attendees felt that the retreat enhanced their abilities to be better physicians, resident supervisors, and leaders. Follow-up responses indicated significant increases in attendees' agreement that good leaders challenge the process, make decisions based on shared visions, allow others to act, recognize individual contributions, and serve as good role models. Results on the survival exercise indicated a high frequency with which team-based decisions surpassed individual members' decisions, highlighting the importance and value of teamwork to attendees. CONCLUSIONS: Our main findings were that: participants universally found this 1-day retreat beneficial in helping to develop teamwork and leadership skills and the experiential learning aspects of the retreat were more especially highly rated and highlighted the advantages of teamwork. In the context that this 1-day retreat was deemed useful by faculty and residents alike, further study is needed to assess the impact of this learning on actual clinical practice and the durability of these lessons.

Adult↗
PubMed2004

Quality of life after coronary artery bypass graft: results from the POST CABG Trial.

OBJECTIVES: The POST CABG (Post Coronary Artery Bypass Graft) Trial showed that aggressive lowering of low-density lipoprotein (LDL) cholesterol levels reduced the progression of atherosclerosis in saphenous vein grafts. In the extended follow-up phase, aggressive lowering of LDL cholesterol levels was associated with reduced rates of clinical events. Low-dose anticoagulation therapy did not reduce the progression of atherosclerosis. We conducted this analysis to determine the effects of both lipid-lowering and low-dose anticoagulation therapy on health-related quality of life (HRQL). DESIGN: Randomized clinical trial, factorial design. SETTING: Outpatients in five tertiary care medical centers. PATIENTS: A cohort of 852 patients enrolled in the POST CABG Trial completed an HRQL questionnaire at baseline, and at the year 2 and year 4 follow-up visits. INTERVENTION: Aggressive LDL cholesterol lowering vs moderate LDL cholesterol lowering, and low-dose warfarin vs placebo. MEASUREMENTS: Domains included emotional status, basic physical and social functioning, perceived health status, symptoms of pain, a variety of physical symptoms, and global life satisfaction. RESULTS: Overall, there were no indications of systematic differences among treatment groups for any of the HRQL parameters at baseline, year 2, or year 4. CONCLUSIONS: These data indicate that patients did not experience detrimental or beneficial effects on HRQL parameters while receiving LDL cholesterol-lowering therapy that had demonstrable benefits for treatment of atherosclerosis.

Anticoagulants↗
PubMed2004

Association of triglyceride-to-HDL cholesterol ratio with heart rate recovery.

OBJECTIVE: Insulin resistance is associated with autonomic dysfunction. An attenuated decrease in heart rate after exercise (or heart rate recovery [HRR]) predicts all-cause mortality and is believed to reflect decreased parasympathetic activity. Utilizing triglyceride/HDL cholesterol concentration as a marker of insulin resistance, we sought to assess the association between insulin resistance and HRR. RESEARCH DESIGN AND METHODS: Our study population included 4,963 healthy adults who participated in the Lipid Research Clinics Prevalence Study and underwent exercise testing. HRR was considered abnormal if it did not drop > or = 42 bpm 2 min after completion of exercise. Fasting blood specimens were drawn. RESULTS: Individuals in the highest quartile of triglyceride/HDL cholesterol had a significantly higher prevalence of abnormal HRR (40 vs. 30%, multivariable-adjusted prevalence ratio 1.18, 95% CI 1.01-1.39; P = 0.04). As a continuous variable, an increase in 1 SD of triglyceride-to-HDL cholesterol ratio was associated with a greater likelihood of an abnormal HRR, even after adjusting for >20 covariates (adjusted OR 1.16, 95% CI 1.07-1.25; P < 0.001). During 12 years of follow-up, there were 284 deaths. In age- and sex-adjusted analysis, participants with an abnormal HRR and high triglyceride-to-HDL cholesterol ratio had significantly higher mortality than those with a normal HRR and high triglyceride-to-HDL cholesterol ratio (hazard ratio = 1.49, 95% CI 1.08-2.04; P = 0.015). CONCLUSIONS: HRR is associated with triglyceride-to-HDL cholesterol ratio and identifies patients with insulin resistance who are at increased risk of death.

Adult↗
PubMed2003

Relation of albumin/creatinine ratio to C-reactive protein and to the metabolic syndrome.

We hypothesized that the association of high sensitivity C-reactive protein (CRP) with urinary albumin excretion (UAE) is predominately mediated through its correlation with the metabolic syndrome. Serum CRP and urine albumin:creatinine ratios (ACR) from 720 preventive cardiology patients were analyzed to estimate age- and gender-adjusted relative risk of high CRP and metabolic syndrome for high ACR. These data demonstrate that CRP independently predicts the presence of UAE, a marker of endothelial dysfunction.

Age Factors↗
PubMed2003

Fluid retention after initiation of thiazolidinedione therapy in diabetic patients with established chronic heart failure.

OBJECTIVES: We sought to define the characteristics of fluid retention after thiazolidinedione (TZD) initiation in patients with established heart failure (HF). BACKGROUND: Fluid retention associated with the use of TZD is commonly attributed to exacerbation of HF, which has led to the proscription of these potentially useful agents in patients with chronic HF. METHODS: We examined 111 consecutive diabetic patients with chronic systolic HF who were treated with TZD from January 1999 to June 2001. A retrospective chart review was performed to determine the incidence of fluid retention in this cohort. Physical signs of fluid retention were compared between TZD users and an age- and gender-matched control group of diabetic, non-TZD users with chronic HF who had fluid retention. Baseline clinical and echocardiographic data were compared between TZD users with and without fluid retention. RESULTS: Nineteen TZD users (17.1%) developed fluid retention, which reversed after drug withdrawal and presented predominantly as peripheral and not central edema. Comparing patients in the upper and lower tertiles of weight gain, more female patients and insulin users developed TZD-related fluid retention. However, there were no differences in the baseline New York Heart Association functional class or echocardiographic severity of cardiac dysfunction. CONCLUSIONS: Although fluid retention after treatment with TZD in diabetic patients with chronic systolic HF occurs, the mechanism is undefined. Fluid retention related to TZD tends to be peripheral and is usually reversible after drug withdrawal. No direct association between the risk of fluid retention and the baseline degree of severity of HF was observed.

Adult↗
PubMed2003

Progression of renal insufficiency in type 2 diabetes with and without microalbuminuria: results of the Heart Outcomes and Prevention Evaluation (HOPE) randomized study.

BACKGROUND: In patients with type 2 diabetes with overt nephropathy, the risk for progressive renal failure is high. This risk is less well established for those with type 2 diabetes and microalbuminuria or normalbuminuria. We studied changes in serum creatinine levels during 3.5 to 5.5 years in a large cohort of people with diabetes at high cardiovascular risk with microalbuminuria or normalbuminuria. METHODS: Retrospective analysis of serum creatinine levels at baseline and yearly thereafter was performed in the Microalbuminuria and Renal Outcomes in the Heart Outcomes and Prevention Evaluation study comparing ramipril's effects with placebo during 4.5 years in 3,577 participants with diabetes, including 1,139 participants with microalbuminuria and 333 participants with renal insufficiency. Participants with dipstick-positive proteinuria (>1+) or serum creatinine levels greater than 2.3 mg/dL (200 micromol/L) were excluded. RESULTS: Serum creatinine levels did not increase significantly during the study if all participants with diabetes are considered or for subgroups with microalbuminuria and/or renal insufficiency at baseline. However, slopes of serum creatinine over time showed a significant trend for increasing values. There were no differences between the placebo and ramipril-treated groups. A serum creatinine level of 1.4 mg/dL (125 micromol/L) or greater newly developed in 474 of 3,238 people (243 patients, placebo; 231 patients, ramipril; P = 0.5033). A doubling of baseline serum creatinine level or end-stage renal disease developed in 8 of 333 participants with renal insufficiency at baseline. CONCLUSION: In people with type 2 diabetes, but without overt nephropathy, who are at high risk for cardiovascular disease, progression of renal insufficiency is slow on the basis of changes in creatinine levels. On the basis of reaching threshold levels of renal function, progression rates are clinically meaningful, especially considering population life expectancy.

Aged↗
PubMed2003

Heart rate and blood pressure responses to mental stress and clinical cardiovascular events in men and women after coronary artery bypass grafting: the Post Coronary Artery Bypass Graft (Post-CABG) biobehavioral study.

BACKGROUND: The Post-Coronary Artery Bypass Graft (CABG) biobehavioral study measured the heart rate (HR) and blood pressure (BP) responses to mental stress testing (MST) after surgery and prospectively observed the clinical events in patients who had undergone recent CABG surgery. To the extent that CABG surgery restores myocardial blood flow and prevents myocardial ischemia, patients who have recently recovered from CABG surgery may have nearly normal HR and BP responses to MST. METHODS: A study population of 521 patients (351 men,170 women) from the cohort of 759 patients in the Post-CABG biobehavioral Study was monitored during a mirror tracing test (MTT) and a speech test task (STT) at the 6-month post-CABG surgery follow-up. Medical status for as long as 3 years after CABG surgery was ascertained from questionnaires and medical records. RESULTS: The HR and BP responses during MTT and STT were similar to those reported in other studies of healthy individuals and patients without myocardial ischemia during MST. In contrast to results from other studies of patients with coronary artery disease, the quartile of Post-CABG biobehavioral study patients with the greatest responses in HR, systolic BP (SBP) and diastolic BP (DBP) during MST had half the rate of clinical events (10% in 3 years) as the quartile (20%) with the lowest changes in HR and BP (HR, P =.01; SBP, P =.07; DBP, P =.01). CONCLUSIONS: Vigorous HR and BP responses to MST may be markers for a lower risk of incidence of clinical cardiovascular events among patients who have undergone recent CABG surgery.

Adrenergic beta-Antagonists↗
PubMed2003

Angiographic changes in saphenous vein grafts are predictors of clinical outcomes.

BACKGROUND: Previous studies have suggested that angiographic evidence of disease progression in coronary arteries increases the risk of subsequent coronary clinical events. This study ascertained whether patients enrolled in the Post Coronary Artery Bypass Graft Clinical Trial (POST CABG) who had substantial progression of atherosclerosis in >or=1 saphenous vein grafts (on the basis of assessment of baseline and follow-up angiograms obtained 4-5 years after study entry), but who had not reported clinical symptoms before follow-up angiography, were at a higher risk of subsequent events than patients who did not have substantial progression of atherosclerosis (decrease >or=0.6 mm in lumen diameter at site of greatest change from baseline). METHODS: All 1351 patients enrolled in the trial underwent baseline angiography; only the 961 patients who had follow-up angiography and no coronary events before the follow-up study were included in this analysis. The clinical center staff contacted patients to ascertain the events that had occurred after follow-up angiography (approximately 3.4 years later). RESULTS: Sixty-nine patients had died; 870 patients or relatives were interviewed, and 22 patients could not be contacted. Univariable estimates of relative risk associated with substantial progression ranged from 2.2 (P <.001) for cardiovascular death or nonfatal myocardial infarction to 3.3 (P <.001) for revascularization. Multivariable and univariable estimates of risk were similar. CONCLUSIONS: The findings provide evidence that patients who had substantial progression of atherosclerosis in vein grafts are at an increased risk for subsequent coronary events and suggest that angiographic changes in vein grafts are appropriate surrogate measures for clinical outcomes.

Aged↗