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.

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BackgroundWalking is an important component of physical activity. It is commonly opined that the ‘walkability’ of someone’s environment encourages walking behaviour, but the evidence base for this is limited and there is no consensus on how to measure walkability. We have undertaken a small, proof-of-concept, cross-sectional observational study, the objectives of which were two-fold. Firstly, to examine the association between walkability of the area around participants’ homes and different aspects of physical activity as well as anthropometric measurements. Secondly we aimed to critique, test and extend existing methods of measuring walkability with GIS methods, in preparation for a larger multi-centre study.MethodsUsing GIS software we built a three-domain measure of walkability based on topography (the area accessible by walking points given road and footpath coverage), local amenities available in a short walk, and availability of public transit points. These measures were calculated for the homes of 1779 cohort study participants aged 45–83 years. Response variables were self-reported sports activities [h/week], time spent walking or cycling, as well as walking and cycling as categorised as never, rarely, sometimes, often or mostly. We also captured BMI and waist circumference measured at follow-up. We estimated the association between walkability and our response variables using linear regression models that were adjusted for age and education.ResultsWe found few significant associations between any of our response variables and any of the dimensions of walkability. A very weak positive association between time spent walking and cycling with proximity of transit points was observed, however the effect sizes involved amounted to fewer than a few minutes exercise per week between high and low transit point density (ß 0.024, 95% Confidence Interval 0.006–0.041 for transit points within 500 m distance).DiscussionWe did not see a convincing association between walkability and our response variables in this study. This could be because there was insufficient heterogeneity in either our neighbourhoods or participants, an issue of statistical power, or because there really is no association. However we did demonstrate that we can get a sophisticated, sensitive and reproducible measure of walkability of environments for use in population based research. We will apply methods used here (slightly refined) in a large study involving six different cities across Germany. Our presentation will focus on the methodological aspects of this study and how we tackled some of the measurement issues and discuss the refinements we propose to use in the next phase.