Mutations in the lipoprotein lipase gene associated with ischemic heart disease in men. The Copenhagen city heart study

The aim of this study was to test the hypothesis that the Asp9Asn substitution and the T(-93)-->G mutation in the promoter of the lipoprotein lipase gene affect plasma lipid levels and thereby the risk of ischemic heart disease (IHD). We genotyped 9033 men and women from a general population sample and 940 patients with IHD. The frequency of both the G allele and the Asn9 allele in the general population sample was approximately 0.015 for both men and women. These 2 mutations appeared together in 95% of carriers. The average triglyceride-raising effect associated with double heterozygosity for the T(-93)-->G mutation and the Asp9Asn substitution was 0.28 mmol/L (P=0.004) and 0.16 mmol/L (P=0.10) in men and women, respectively. On logistic regression analysis allowing for age, the risk of IHD for double heterozygous men and women was increased 90% (95% confidence interval [CI], 20% to 200%) and 30% (95% CI, -40% to 170%), respectively, compared with noncarriers. When, in addition, other conventional cardiovascular risk factors were allowed for, the risk of IHD for double heterozygous men and women was increased 70% (95% CI, 0% to 190%) and 20% (95% CI, -50% to 180%), respectively. Of the overall risk of IHD in men in the general population, the fraction attributable to double heterozygosity was 3%, similar to the 5% attributable to diabetes mellitus. These results demonstrate that the Asp9Asn substitution is in linkage disequilibrium with the T(-93)-->G mutation and that the double-heterozygous carrier status is associated with elevated plasma triglycerides and an increased risk of IHD in men.

ST-segment deviation during 24-hour ambulatory electrocardiographic monitoring and exercise stress test in healthy male subjects 51 to 75 years of age: the Copenhagen City Heart Study

BACKGROUND

Although ST-segment deviation has been evaluated and used during many years both on continuous electrocardiographic Holter monitoring and during exercise stress testing, considerable controversy still remains concerning the prevalence and diagnostic significance of fortuitously discovered ST-segment deviation in asymptomatic healthy persons.

METHODS AND RESULTS

The occurrence of ST-segment deviation was studied in a population of 63 clinically healthy male subjects 51 to 75 years of age, with the use of 24-hour Holter monitoring and exercise stress testing. The subjects were recruited from the Copenhagen City Heart Study and were without cardiovascular risk factors, chronic diseases, or medication and without cardiovascular events during 5 to 12 years before and 3 to 5 years after admission. The specificity, that is, the probability of displaying a negative test result in healthy subjects without disease, was 1.0 when using as criterion for significant ST-segment deviation a horizontal or descending ST-segment depression of >0.20 mV or ST-segment elevation >/=0.15 mV during Holter monitoring, and acceptable, for example, 0.95, when using as criterion a horizontal or descending ST-segment depression of >/=0.15 mV during Holter monitoring or at the exercise test, respectively. Furthermore, the specificity was 0.95 when a horizontal or downsloping ST-segment depression of 0.1 mV was displayed in both the Holter and exercise electrocardiographic recording system.

CONCLUSIONS

Thus in asymptomatic persons, the usual criterion for significant ST-segment depression of 0.1 mV can be applied when occurring in both electrocardiographic recording systems. However, if one test alone is used, the criterion of significant ST-segment depression should be 0.15 mV. Absence of ST-segment deviation during Holter monitoring and exercise stress testing, indicated with a specificity of 1.0 or 0.95 according to choice of criterion, implies that the person is in a healthy state.

Familial predisposition and susceptibility to the effect of other risk factors for myocardial infarction

STUDY OBJECTIVES

To assess if familial predisposition to myocardial infarction (MI) is an indicator of increased susceptibility to the effect of other established risk factors. The study assessed whether a family history of MI modifies the effect of arterial blood pressure, plasma cholesterol, high and low density lipoprotein cholesterol, % triglycerides, diabetes mellitus, body mass index, height, smoking habits, alcohol intake, physical activity level, and educational level on the incidence of MI.

DESIGN

Prospective population based cohort study of cardiovascular risk and risk factors with follow up of MI by record linkage with the Cause of Death Register and The National Hospital Discharge Register until 1994.

SETTING

The Copenhagen Centre for Prospective Population Studies, where data from three Danish studies are integrated.

PARTICIPANTS

Subjects were 24,664 people aged 20-93, examined between 1976 and 1987.

MAIN RESULTS

A total of 1763 new cases of MI occurred during 293,559 person years of observation. All risk factors, including family history of MI reported by 4012 subjects, were, as expected, associated with incidence of MI. With a few inconsistent exceptions we found no significant interactions between family history of MI and cardiovascular risk factors in their effect on MI.

CONCLUSIONS

The familial predisposition to MI does not consistently modify the effect of other risk factors on the risk of MI. However, subjects with a family history of MI may still be regarded as an appropriate target group for screening for cardiovascular risk and intervention against other risk factors.

Student perspectives on problem-based learning in an occupational therapy curriculum: a multiyear qualitative evaluation

OBJECTIVES

Problem-based learning (PBL) is increasingly being used within health care professional educational programs to develop critical thinking skills via a learner-centered approach. However, few studies have evaluated the effect of participation in a PBL-centered curriculum on occupational therapy knowledge and skill development over time from the perspective of the students involved. This study examined student evaluations of the first three class cohorts participating in a PBL-based curriculum.

METHOD

A participatory action design study involving qualitative, student-led focus groups was conducted with 154 students across 2 years of the education program. Fourteen focus groups were audiotaped, and those audiotapes were transcribed by an outside expert, followed by two levels of analysis by program faculty members and a member check by student participants.

RESULTS

Themes that emerged from the data analysis related to (a) defining elements of PBL, (b) the role of students and faculty members, (c) learning strategies used by students in a PBL versus traditional education program, (d) the challenges of a PBL approach, and (e) PBL's relationship to clinical reasoning and occupational therapy practice.

CONCLUSIONS

Students perceived that a PBL approach adopted consistently across the curriculum contributed to the development of information management, critical reasoning, communication, and team-building skills; however, identified challenges were time and role management, information access, instructor versus PBL expectations and practices, and coping with the ambiguity of knowledge and reasoning.

Prevalence of positive urinary dipstick analysis (leucocyte esterase, nitrite, haemoglobin, or glucose) in a population of 3645 adult subjects--consequence for measurement of urinary albumin excretion rate

OBJECTIVES

To assess prevalence of positive urinary dipstick analysis for leucocyte esterase, nitrite, haemoglobin, or glucose in the general population and measure the urinary albumin excretion rate (UAER) in subjects with or without a positive dipstick analysis.

DESIGN

A cross-sectional study of 3645 subjects.

SETTING

An unselected urban population study.

MAIN OUTCOME MEASURES

Prevalence data of positive dipstick analyses and UAER values.

RESULTS

Prevalence data of a positive dipstick analysis were 12%, 4%, 3% and 6%, respectively, for leucocyte esterase, nitrite, haemoglobin, and glucose. Subjects with any positive dipstick analysis had significantly higher UAER than subjects with a negative analysis: 4.9 (4.4-5.3) (geometric mean (95% confidence interval)) vs 3.0 (2.9-3.1) mg 24 h(-1) (p < 0.001).

CONCLUSIONS

Prevalence data of positive urinary dipstick analyses in a large population based study are provided. Subjects with any positive finding had higher UAER than controls. Exclusion of subjects with a positive finding is recommended in studies of UAER as a cardiovascular risk factor in non-diabetic subjects.

Alcohol and mortality: is there a U-shaped relation in elderly people?

OBJECTIVE

to assess the relation between alcohol intake and mortality among seven cohorts of middle-aged and elderly Danes.

DESIGN

Prospective population study with baseline assessment of alcohol- and tobacco consumption, educational level and body mass index, and a mean of 11.5 years follow-up of mortality.

SUBJECTS

16304 men and women aged 50 years or more.

MAIN OUTCOME MEASURE

number and time of deaths from 1974 to 1995 as ascertained by the national central person register.

RESULTS

the effect of alcohol intake on mortality did not differ between middle-aged (50-64 years, mean = 56.6 years) and elderly subjects (>64 years old, mean = 69.9 years). There was a U-shaped risk function in both age groups, which persisted also when adjusting for age, sex, smoking habits, level of education and body mass index. Abstaining women had a relative risk of 1.29 (95% confidence limits 1.17-1.42) as compared with light drinkers (1-6 (drinks per week), while the relative risk for abstaining men was 1.22 (95% confidence limits; 1.08 to 1.37) as compared with light drinkers. Heavy drinking women (>28 drinks per week) had a relative risk of 1.23 (95% confidence limits; 0.85 to 1.78) and heavy drinking men (more than 69 drinks per week) had a relative risk of 2.11 (95% confidence limits 1.66-2.69), both compared with light drinkers.

CONCLUSION

among the middle-aged and elderly women and men, a light alcohol intake is associated with lower mortality than abstention or heavy drinking.

A 15-year follow-up study of ventilatory function in adults with asthma

BACKGROUND

Although the prevalence of asthma and morbidity related to asthma are increasing, little is known about the natural history of lung function in adults with this disease.

METHODS

We used data from a longitudinal epidemiologic study of the general population in a Danish city, the Copenhagen City Heart Study, to analyze changes over time in the forced expiratory volume in one second (FEV1) in adults with self-reported asthma and adults without asthma. The study was conducted between 1976 and 1994; for each patient, three measurements of lung function were obtained over a 15-year period. The final data set consisted of measurements from 17,506 subjects (8136 men and 9370 women), of whom 1095 had asthma.

RESULTS

Among subjects who participated in all three evaluations, the unadjusted decline in FEV1 among subjects with asthma was 38 ml per year, as compared with 22 ml per year in those without asthma. The decline in FEV1 normalized for height (FEV1 divided by the square of the height in meters) was greater among the subjects with asthma than among those without the disease (P<0.001). Among both men and women, and among both smokers and nonsmokers, subjects with asthma had greater declines in FEV1 over time than those without asthma (P<0.001). At the age of 60 years, a 175-cm-tall nonsmoking man without asthma had an average FEV1 of 3.05 liters, as compared with 1.99 liters for a man of similar age and height who smoked and had asthma.

CONCLUSIONS

In a sample of the general population, people who identified themselves as having asthma had substantially greater declines in FEV1 over time than those who did not.

Population based cohort study of the association between alcohol intake and cancer of the upper digestive tract

OBJECTIVE

To examine the relation between different types of alcoholic drinks and upper digestive tract cancers (oropharyngeal and oesophageal).

DESIGN

Population based study with baseline assessment of intake of beer, wine, and spirits, smoking habits, educational level, and 2-19 years' follow up on risk of upper digestive tract cancer.

SETTING

Denmark.

SUBJECTS

15 117 men and 13 063 women aged 20 to 98 years.

MAIN OUTCOME MEASURE

Number and time of identification of incident upper digestive tract cancer during follow up.

RESULTS

During a mean follow up of 13.5 years, 156 subjects developed upper digestive tract cancer. Compared with non-drinkers (drinkers of <1 drink/week), subjects who drank 7-21 beers or spirits a week but no wine were at a risk of 3.0 (95% confidence interval 1.5 to 6.1), whereas those who had the same total alcohol intake but with wine as >=30% of their intake had a risk of 0.5 (0.2 to 1.4). Drinkers of >21 beers and spirits but no wine had a relative risk of 5.2 (2.7 to 10.2) compared with non-drinkers, whereas those who drank the same amount, but included wine in their alcohol intake, had a relative risk of 1.7 (0.6 to 4. 4).

CONCLUSION

A moderate intake of wine probably does not increase the risk of upper digestive tract cancer, whereas a moderate intake of beer or spirits increases the risk considerably.

[Renal artery stenosis--an underestimated cause of hypertension and renal failure?]

Although renovascular hypertension is associated with substantial cardiovascular morbidity, ultimately it is a curable disease. Early identification and appropriate treatment of renovascular hypertension may save years of antihypertensive therapy, reduce the morbidity associated with long-standing hypertension, and help to minimise the risk of renal failure. However, the main problem is to identify patients with renovascular disease suitable for treatment. This requires alertness in the clinician, and renographic screening of renal function or duplex-ultrasound scanning of renovascular circulation to augment the yield of angiographic procedures. The predominant treatment of renovascular disease today is percutaneous transluminal angioplasty, which can be used as a repeat procedure or in combination with endoluminal stenting of the stenotic renal artery.

A comparison of mortality rates in three prospective studies from Copenhagen with mortality rates in the central part of the city, and the entire country. Copenhagen Center for Prospective Population Studies

Valid generalizations of results from population-based epidemiological surveys requires knowledge about how representative the sample is. The Copenhagen Center for Prospective Population Studies have assessed mortality on the basis of pooled data from three research programmes in the region of Copenhagen. In two of the studies, subjects were randomly selected, using the Danish Central Population Registry, within certain age groups and area-restricted sectors of the Greater Copenhagen. In the third study, men employed in 14 companies participated. Participation rates were between 78% and 87% in the three programmes. Standardized mortality rates (SMR) were calculated in relation to mortality rates in the municipality of Copenhagen and in the whole country in three age groups and the two genders. SMR values in the whole sample including non-participants were similar to rates for Copenhagen in the Copenhagen City Heart Study, whereas mortality rates in the Glostrup Population Studies were similar to rates for the whole country. The mortality rates among participants were lower than in the whole sample, and differences existed in relation to region and selection criteria of the cohorts. The Copenhagen Male Study, where only employed men were included, showed the lowest mortality rates, and higher rates were found in the study from the central part of the City (the Copenhagen City Heart Study) compared to the study from the suburbs (the Glostrup Population Studies). The difference between mortality rates in the cohorts and in Copenhagen City decreased with increasing age. The SMR converged towards 1.00 with increasing observation time. In conclusion, high participation rates were found in all three studies, resulting in SMR values for participants only slightly lower than in the source population in the two randomly selected samples, but 30% lower values in the sample of employed men. As mortality rates in the total samples including non-participants were markedly higher than among the participants, generalizations of results for participants to the whole population should be made with caution, especially during the first years of observation.

Longevity and gray hair, baldness, facial wrinkles, and arcus senilis in 13,000 men and women: the Copenhagen City Heart Study

BACKGROUND

We have previously reported that men who look older than their contemporaries have a significantly higher risk for myocardial infarction. The purpose of this study was to investigate whether persons with pronounced aging signs such as graying of hair, baldness, or facial wrinkles are prone to a shorter life span compared to their contemporaries.

METHODS

In the Copenhagen City Heart Study comprising a random sample of 20,000 men and women, we also recorded, in addition to cardiovascular risk factors, data on signs of aging: extent of gray hair, baldness, facial wrinkles, and arcus senilis (corneal arcus). During 16 years of follow-up, 3,939 persons (1,656 women and 2,283 men) had died. The Cox regression model for proportional hazards, which included age as an explanatory variable, was used for descriptive analysis of the correlation between these aging signs and all-cause mortality.

RESULTS

We found no correlation between the mortality and the extent of graying of the hair, or baldness or facial wrinkles in either of the sexes, irrespective of age. A single exception was observed in a small subgroup of men with no gray hair. They had a slightly, but significantly, lower mortality than the rest [relative risk (RR) = .81, 95% confidence interval (CI) .67-.98; p < .05]. The presence of arcus senilis was significantly correlated with a shorter life span in women (RR = 1.25, 95% CI 1.08-1.46; p < .01). For men the same tendency was found, but the correlation was not statistically significant.

CONCLUSION

We conclude that the degrees of graying of the hair, baldness, and facial wrinkles are not predictive of a shorter life span in men and women in the Copenhagen City Heart Study.

Accuracy and clinical utility of the mini-dose 14C-urea breath test in the evaluation of Helicobacter pylori infection

The aim of this study was to evaluate the accuracy of the 14C-urea breath test by comparing the results to those obtained by endoscopy with mucosal biopsy. We also examined the value of the breath test result obtained prior to endoscopy in predicting peptic ulcer disease. Forty-two individuals underwent the 14C-urea breath test. Collections of expired C02 were analysed using a liquid scintillation counter. All individuals then underwent endoscopy with biopsy. Biopsy material was evaluated by the rapid urease method and by histology for the presence of H. pylori. Our results demonstrated that the 14C-urea breath test was 100% sensitive and specific when compared to the rapid urease test as the 'gold standard' for the detection of H. pylori. In comparison to pathology, the sensitivity remained 100% and the specificity was 89%. The results of the 14C-urea breath test had a poor predictive value for the determination of peptic ulcer disease. We conclude that the 14C-urea breath test can be easily performed at any medical facility equipped with a liquid scintillation counter and can accurately detect H. pylori. A negative breath test result could not exclude the presence of peptic ulcer disease.

Ambulatory blood pressure and urinary albumin excretion in clinically healthy subjects

A slightly elevated urinary albumin excretion rate (UAER) is a predictor of atherosclerotic cardiovascular disease. The mechanism is unknown, but moderate office blood pressure elevation has been demonstrated as part of a clustering of known atherosclerotic risk factors in subjects with elevated UAER. Because 24-hour ambulatory blood pressure is a superior predictor of hypertensive target organ involvement, we aimed to investigate blood pressure profile in clinically healthy subjects with elevated UAER. Ambulatory blood pressure monitoring was performed with a portable recorder in 27 subjects with an elevated UAER (>6.6 microg/min, overnight urine collection) and 46 normoalbuminuric control subjects. Mean+/-SD systolic and diastolic ambulatory blood pressures (24-hour) were significantly higher in subjects with elevated UAER than in normoalbuminuric controls (134+/-12 versus 128+/-11 mm Hg and 78+/-7 versus 75+/-6 mm Hg, P<0.05), as were systolic and diastolic blood pressure loads [median (range): 42% (6 to 94%) versus 23% (1 to 89%) and 20% (0 to 68%) versus 6% (0 to 62%), P<0.05]. The circadian variation of blood pressure was normal in subjects with elevated UAER. However, the increased urinary loss of albumin could not be solely related to the higher blood pressure. In conclusion, apparently healthy subjects with elevated UAER had slightly but significantly higher 24-hour systolic and diastolic blood pressure levels in addition to increased blood pressure loads but normal circadian variation. The demonstrated differences in blood pressure may offer a partial explanation for the association between elevated urinary albumin excretion and atherosclerotic cardiovascular risk.

Vital prognosis after hospitalization for COPD: a study of a random population sample

STUDY AIM

To examine survival after admission due to chronic obstructive pulmonary disease (COPD) in a population sample over a time span of 15 years.

DESIGN

Linkage between a prospective population cohort and register information on hospitalization and mortality.

SETTING

The Copenhagen City Heart Study (CCHS).

PARTICIPANTS

A total of 267 men and 220 women who had participated in the CCHS and who were hospitalized with a discharge diagnosis of COPD (ICD-8 491-2).

MAIN RESULTS

The crude 5-yr survival rate after a COPD admission was 45% (37% for men and 52% for women). Mortality risk increased with age and with decreasing forced expiratory volume in 1 s (FEV1)% predicted; for subjects with an FEV1 < or = 40% at the CCHS survey, 5-yr survival after subsequent hospitalization was only 28%. Smoking and presence of chronic mucus hypersecretion at the examination in CCHS were not strongly associated with prognosis. Survival after admission due to COPD did not change significantly over time.

CONCLUSION

Compared to previous studies of COPD patients, the present study indicates that prognosis after hospital admission remains virtually unchanged over the last decades. FEV1 is still the strongest predictor of survival in this patient group.

Job strain and cardiovascular risk factors among members of the Danish parliament

Sudden cardiovascular events among well-known politicians attract much attention--from the mass media and from the public. No previous studies have assessed the job strain profile and level of known cardiovascular risk factors among parliamentary politicians. The study was carried out within the frameworks of the Copenhagen City Heart Study. Some 102 members of the Danish parliament (70 men and 32 women) agreed to participate, giving a response rate of 55%. Three sex- and age-matched participants were drawn for each politician from the Copenhagen City Heart Study. In addition to the completion of large questionnaires on health and working conditions, all participants had a thorough examination, including measurements of height and weight and blood pressure and the drawing of a venous blood sample for the determination of serum lipids, ApolipoproteinA1 and ApolipoproteinB and fibrinogen. Job strain factors and established cardiovascular risk factors were the main outcome factors. Politicians reported much higher job demands, but also much more influence on their job than others. Politicians smoked less, consumed more wine, had higher levels of ApolipoproteinA1, and were taller. With respect to other major cardiovascular risk factors, serum lipids, blood pressure and physical activity, there was no difference between politicians and controls. Politicians had greater job demands, but also more control over their job than others, indicating that the job strain phenomenon should not increase their risk of cardiovascular disease. Other cardiovascular risk factors, job related or conventional, which were unevenly distributed between politicians and controls all favoured politicians. In conclusion, politicians had a more beneficial cardiovascular risk factor profile than a matched random sample from a comparable background population.

Small group insurance reform: how are state programs measuring up?

In the past decade, states have responded to the health insurance needs of small businesses by launching a number of reforms. According to authors Michael Morrisey and Gail Jensen, more than 30 states have implemented "bare-bones" policies that seek to make minimum-benefit, affordable coverage available to small employers. Almost all states have enacted legislation modifying the underwriting practices that insurers may use with respect to such things as pre-existing conditions and occupational exclusions. Other states have provided tax or employer subsidies. But despite the efforts of the states, the authors found the state policies have had little success. Drawing from a survey found that the few employers who were aware of the programs found them to be unappealing. In discovering what doesn't work, the authors are able to suggest remedies for the states' small group insurance ills, such as offering long-term instead of short-term subsidies.