ObjectivesThe objective of this study is to use latent class analysis of up to 20 comorbidities in patients with a diagnosis of ischaemic heart disease (IHD) to identify clusters of comorbidities and to examine the associations between these clusters and mortality.MethodsLongitudinal analysis of electronic health records in the health improvement network (THIN), a UK primary care database including 92 186 men and women aged ≥18 years with IHD and a median of 2 (IQR 1–3) comorbidities.ResultsLatent class analysis revealed five clusters with half categorised as a low-burden comorbidity group. After a median follow-up of 3.2 (IQR 1.4–5.8) years, 17 645 patients died. Compared with the low-burden comorbidity group, two groups of patients with a high-burden of comorbidities had the highest adjusted HR for mortality: those with vascular and musculoskeletal conditions, HR 2.38 (95% CI 2.28 to 2.49) and those with respiratory and musculoskeletal conditions, HR 2.62 (95% CI 2.45 to 2.79). Hazards of mortality in two other groups of patients characterised by cardiometabolic and mental health comorbidities were also higher than the low-burden comorbidity group; HR 1.46 (95% CI 1.39 to 1.52) and 1.55 (95% CI 1.46 to 1.64), respectively.ConclusionsThis analysis has identified five distinct comorbidity clusters in patients with IHD that were differentially associated with risk of mortality. These analyses should be replicated in other large datasets, and this may help shape the development of future interventions or health services that take into account the impact of these comorbidity clusters.

Background Highly walkable neighbourhoods may increase transport-related and leisure-time physical activity and thus decrease the risk for obesity and obesity-related diseases, such as type 2 diabetes (T2D). Methods We investigated the association between walkability and prevalent/incident T2D in a pooled sample from five German cohorts. Three walkability measures were assigned to participant’s addresses: number of transit stations, points of interest, and impedance (restrictions to walking due to absence of intersections and physical barriers) within 640 m. We estimated associations between walkability and prevalent/incident T2D with modified Poisson regressions and adjusted for education, sex, age at baseline, and cohort. Results Of the baseline 16,008 participants, 1256 participants had prevalent T2D. Participants free from T2D at baseline were followed over a mean of 9.2 years (SD: 3.5, minimum: 1.6, maximum: 14.8 years). Of these, 1032 participants developed T2D. The three walkability measures were not associated with T2D. The estimates pointed toward a zero effect or were within 7% relative risk increase per 1 standard deviation with 95% confidence intervals including 1. Conclusion In the studied German settings, walkability differences might not explain differences in T2D.

INTRODUCTION: The Bezold–Jarisch reflex (BJR) is a cardiac reflex that increases parasympathetic tone and inhibits sympathetic activity, resulting in a clinical triad of bradycardia, hypotension, and peripheral vasodilation. This reflex can be activated by chemical stimuli, such as anesthesia, or by reduced cardiac venous return. Inappropriate reflex bradycardia or asystole can occur. CASE DESCRIPTION/METHODS: A 51-year-old female with no past medical history underwent bowel preparation with a polyethylene glycol-based solution for a routine screening colonoscopy. Before anesthesia was administered, the patient became unresponsive and clonic with a 3-4 second sinus pause. On physical exam, the patient was dehydrated. Electrolyte findings were within normal limits, aside from sodium level of 123 mmol/L. The patient eventually recorded a sinus pause of 30 seconds and a transvenous pacemaker was placed for episodic sinus arrest. The Bezold–Jarisch reflex is a diagnosis of exclusion. The patient had a negative D-dimer, three non-detectable troponin levels and a CT pulmonary angiogram negative for pulmonary embolism. Two electrocardiograms showed normal sinus rhythm, with repeat showing sinus bradycardia; intervals were within normal limits. A transthoracic echocardiogram showed an ejection fraction of 65% with no valvular disease or structural abnormalities. After the patient was fluid resuscitated and electrolytes were optimized, no further episodes were recorded. The patient was fitted with an event monitor and discharged home with close follow up. She remained asymptomatic at outpatient appointment. DISCUSSION: The patient's bowel preparation for her colonoscopy resulted in hypovolemic hyponatremia, upregulating her renin-angiotensin-aldosterone system, whichvagally mediated her episodic sinus arrest via the Bezold–Jarisch Reflex. Given the increasing rate of colonoscopies, this case report highlights the importance of electrolyte-balanced hydration in preventing a potential BJR.

ObjectivesTo examine three walkability measures (points of interest (POI), transit stations and impedance (restrictions to walking) within 640 m of participant’s addresses) in different regions in Germany and assess the relationships between walkability, walking/cycling and body mass index (BMI) using generalised additive models.SettingFive different regions and cities of Germany using data from five cohort studies.ParticipantsFor analysing walking/cycling behaviour, there were 6269 participants of a pooled sample from three cohorts with a mean age of 59.2 years (SD: 14.3) and of them 48.9% were male. For analysing BMI, there were 9441 participants of a pooled sample of five cohorts with a mean age of 62.3 years (SD: 12.8) and of them 48.5% were male.Outcomes(1) Self-reported walking/cycling (dichotomised into more than 30 min and 30 min and less per day; (2) BMI calculated with anthropological measures from weight and height.ResultsHigher impedance was associated with lower prevalence of walking/cycling more than 30 min/day (prevalence ratio (PR): 0.95; 95% CI 0.93 to 0.97), while higher number of POI and transit stations were associated with higher prevalence (PR 1.03; 95% CI 1.02 to 1.05 for both measures). Higher impedance was associated with higher BMI (ß: 0.15; 95% CI 0.04 to 0.25) and a higher number of POI with lower BMI (ß: −0.14; 95% CI −0.24 to 0.04). No association was found between transit stations and BMI (ß: 0.005, 95% CI −0.11 to 0.12). Stratified by cohort we observed heterogeneous associations between BMI and transit stations and impedance.ConclusionWe found evidence for associations of walking/cycling with walkability measures. Associations for BMI differed across cohorts.

No abstract