A new observational study presented at the AHA 2008 Scientific Sessions finds an association between higher levels of nonfasting triglycerides and increasing risk for ischemic stroke. The results are published in the November 12 issue of the Journal of the American Heart Association.

The study used data on 13,956 men and women enrolled in the Copenhagen City Heart Study, a prospective, population-based study begun in 1976, with follow-up through July 2007. In this study, the researchers looked at baseline levels of non fasting triglycerides, other risk factors at baseline and follow-up examinations, and the incidence of ischemic stroke. They also carried out a cross-sectional study of 9637 participants in the prospective study who attended the 1991-1994 examination, since levels of non fasting remnant lipoprotein cholesterol as well as the lipid profile were measured at that examination, the authors note. In the cross-sectional study, they looked at levels of nonfasting triglycerides, remnant cholesterol, and the prevalence of ischemic stroke.

Of the 13,956 participants in the prospective study, 1529 had an ischemic stroke during follow-up. An increased risk for ischemic stroke was observed with increasing levels of non-fasting triglycerides, both in men and in women ( P for trend < .001 for both men & women).

The absolute 10-year risk for ischemic stroke ranged from 2.6% in men younger than 55 years with nonfasting triglyceride levels of less than 89 mg/dL to 16.7% in those with levels of 443 mg/dL and higher. The corresponding values for women were 1.9% and 12.2%.

In the cross-sectional study, they found nonfasting triglyceride levels were highest in those who had a previous ischemic stroke in both men and in women vs. the control groups. Likewise, levels of remnant cholesterol were highest in those who developed ischemic stroke in both men and women.

Børge Nordestgaard, Herlev Hospital and Copenhagen University Hospital , pointed out that although fibrates and nicotinic acid would be the best way to address high triglyceride levels, they are not very well tolerated by patients. Statins also reduce triglyceride levels to some degree as well as lowering low-density lipoprotein cholesterol levels, and could be a place to start.

Dr. Wang, DO, University of Illinois College of Medicine, Peoria agreed that the study adds another dimension to the prevention plan to lower LDL-the lower the better- but now we also need to emphasize strategies that lower triglycerides.

JAMA 2008; 300: 2142-52

A new prospective study shows that both a history of diabetes and a history of hypertension are independent predictors of a shorter lifespan after a diagnosis of Alzheimer's disease (AD). These findings are published in the November 4 issue of Neurology .

This current study identified AD patients from the Washington Heights Inwood Columbia Aging Project, a longitudinal community-based study of cognitive aging in northern Manhattan . A total of 323 subjects, 65 years and older at baseline, were initially free of dementia and developed incident AD during study follow-up (an average of 4.1 years).

Factors associated with a shorter lifespan were examined using Cox proportional hazards models, with attained age as the time to event.

The authors report that the mortality rate was 10.7 per 100 person-years. Case-fatality rates were, not surprisingly, higher among those diagnosed at older ages and more than twice as high among non-Hispanic whites than among Hispanics.

The median lifespan of the entire sample was 92.2 years (95% CI, 90.3 – 94.1). "Although this longevity may seem remarkable, it is still 1 to 3 years less than the expected conditional lifespan based on population wide life-table estimates, depending on age at diagnosis," the authors write.

Factors found to be independently associated with shorter lifespan among those diagnosed with AD were a history of hypertension and a history of diabetes.

No differences were seen in lifespan by race or ethnicity after multivariable adjustment, but the median postdiagnosis survival duration was longer among Hispanics, with a median survival after diagnosis of 7 years, compared with 3.7 years for non-Hispanic whites and 4.8 years for African Americans.

"Although these findings were not significant, they are intriguing and warrant further research as to whether race affects survival time in people with AD," Dr. Stern said in the AAN statement.

Interestingly, although comorbid hypertension and diabetes were more common among Hispanics, survival was longer in this group. "There is a growing body of evidence supporting a survival advantage among Hispanics in the United States, compared with other race/ethnic groups, which may be explained by ethnic differences in health-related behaviors, family networks, and social support," the authors note. "Thus, our findings among Hispanics may reflect comparatively longer survival among all US Hispanics."

Neurology 2008;71:1489-95

Only half of patients with multiple sclerosis (MS) taking interferon beta achieve and maintain a full response, a new study published online November 10 in the Archives of Neurology , evaluating magnetic-resonance-imaging (MRI) patterns demonstrates.

The research team studied 15 patients with MS who underwent monthly MRIs and clinical examinations during a 6-month pretreatment phase and a 36-month treatment phase.

Patients received subcutaneous interferon beta-1b at 250 µg every other day for 3 years. They were considered responders if they achieved a 60% reduction in the number of lesions at each 6-month period.

The researchers found that 8 patients (53.3%) were MRI responders.

Another 7 patients (46.7%) were nonresponders. Of these, 20% had an initial optimal reduction of the total number of contrast-enhancing lesions and 13.3% never reached an optimal response. Another 13.3% had a delayed optimal response.

Investigators observed no clear association between neutralizing antibody profile and MRI response.

The researchers point to a number of limitations to their work, including the small number of patients. They note that the study had an open-label design and lacked a systematic analysis of potential effects of steroids given for clinical relapses.

"However," the researchers explain, "it was shown previously that steroids given for acute relapse likely do not affect the long-term response to interferon beta and that while persistently low enhancement is seen in the follow-up scans of patients treated with steroids and interferon beta, a rebound increase in the number and volume of contrast-enhancing lesions may be observed in patients who are not receiving interferon beta."

Arch Neurol Published online November 10, 2008

Survivors of meningococcal septic shock (MSS) in childhood often suffer from long-term medical sequelae, including mental retardation and other neurological impairments, according to a study in the Netherlands . These results are published in the November issue of the Archives of Pediatrics and Adolescent Medicine .

The research team at Erasmus MC-Sophia Children's Hospital, Rotterdam , led by Dr. Corinne M. P. Buysse, conducted a medical and psychological follow-up of patients admitted to their pediatric intensive care unit between 1988 and 2001. Of the 120 subjects who agreed to participate, the median follow-up interval was 9.8 years, and median age at follow-up was 14.5 years (range, 5.3 to 31.1 years).

Four patients, including one who died prior to this study, developed severe mental retardation with epilepsy; two of them also had spastic quadriplegia. Compared with patients without severe retardation, these four were significantly younger at the time of PICU admission, with greater severity of septic shock and hypoglycemia and more convulsions.

Thirty-nine of the remaining patients (33%) had one or more neurological impairments, including two with sensorineural hearing loss, seven with focal neurological signs, and 34 with chronic headaches.

Half of the patients had skin scarring -- in some cases, scars were extremely mutilating -- and "8% had amputations (ranging from 1 toe to both legs and 1 arm), and 6% had leg-length discrepancies," the report indicates.

During hospitalization, 19 patients had temporary acute renal failure, including four who required renal replacement therapy. One of these patients had mild chronic renal failure that "was slowly progressive since discharge," with proteinuria and hypertension at follow-up. Two other patients had isolated proteinuria with a normal glomerular filtration rate.

Overall general health according to questionnaires and visual analog scale scores were significantly lower in patients than in the general population, including worse vision, emotional and cognitive function (p < 0.01).

Thus, Dr. Buysse's group advise, "Standard assessment of vision, emotional distress, and neuropsychological and cognitive functioning is warranted in MSS survivors to intervene in an early phase after the MSS."

Arch Pediatr Adolesc Med 2008;162:1036-41

Young children with medically attended injury before the age of 2 years are more likely to have a subsequent diagnosis of attention-deficit/hyperactivity disorder (ADHD), a new study published online November 6 in BMJ suggests.

To investigate whether medically attended head injury before the age of 2 years increases ADHD risk, the researchers performed a retrospective cohort study of children from 308 primary-care practices in the United Kingdom .

The study involved 62,088 children who were registered in the database from birth to the age of 10 years during 1988 to 2003 and who did not have a diagnosis of ADHD before their second birthday.

The cohort was divided into 3 groups: (a) 2782 children who had a medically attended head injury before the age of 2 years (b) 1116 children who had a medically attended burn injury before the age of 2 years (c) 58,190 children with neither injury before the age of 2 years.

Of the total cohort, 1.5% of the children were diagnosed with ADHD between age 2 and 10 years. Of the 6.3% of children with early brain injury or early head injury, however, 11.3% had a subsequent diagnosis of ADHD.

The risk of ADHD diagnosis was almost equally elevated in children with early burn injury and children with early brain injury compared with the other children, even after adjustment for relevant cofactors.

Risk of ADHD Diagnosis Before Age 10 Years, Early Injury vs No Early injury

The researchers conclude that medically attended injury may be an early marker for behavioral traits that lead to a diagnosis of ADHD. "The results emphasize the importance of obtaining preinjury developmental status when examining the relation of head injury to neurodevelopmental consequences," they write.

Although large and therefore powerful, the study data set does not have good measures of injury severity or a controlled method of diagnosing ADHD, said Dr. Keenan. "Therefore, these results need to be duplicated in a prospective cohort study," she said.

In an accompanying editorial, Morris Zwi, Richmond Royal Hospital , United Kingdom , and Philip Clamp, St. John's Surgery, Bromsgrove , United Kingdom , say the study has important implications, particularly for primary-care physicians, who should assess and continuously monitor children with injuries for ADHD symptoms.

"A known barrier to referral of children with ADHD to specialist services by primary-care doctors is nonrecognition of the disorder's symptoms. Early assessment and referral to preventive programs, such as parent training, can reduce symptoms. Referral to a specialist team may be useful where problems persist," they write.

BMJ Published online November 6, 2008

Researchers have uncovered evidence that fibromyalgia is linked to brain-perfusion abnormalities that relate to the disability of the disease. Results from the molecular imaging study appear in the November issue of the Journal of Nuclear Medicine .

In the current study, investigators looked at 20 women diagnosed with fibromyalgia and 10 healthy women. Subjects underwent single-photon-emission computed tomography (SPECT).

The researchers confirmed the presence of perfusion abnormalities in patients with fibromyalgia. They showed that bilateral hyperperfusion of the parietal cortex and of the pre- and postcentral cortices are strongly correlated with the Fibromyalgia Impact Questionnaire score. Hypoperfusion of the left anterior temporal cortex was also strongly correlated in patients with disease.

This is reportedly the first time investigators have observed a relationship between somatosensory hyperperfusion and the clinical severity of fibromyalgia. "This reinforces the sensitization hypothesis," the researchers emphasize.

"Fibromyalgia may be related to a global dysfunction of cerebral pain processing," lead investigator Eric Guedj, MD, from the Service Central de Biophysique et de Médecine Nucléaire, in Marseille , France , said.

"This study demonstrates that these patients exhibit modifications of brain perfusion not found in healthy subjects and reinforces the idea that fibromyalgia is a real disorder," he noted.

"It's a first step," Dr. Guedj said. "We demonstrated significant abnormalities in comparison with healthy subjects. We now have to demonstrate that this functional pattern is specific to fibromyalgia in comparison with other painful diseases."

J Nucl Med 2008;49:1798-1803