Association of Increased Levels of Homocysteine and Peripheral Arterial Disease in a Japanese-Brazilian Population

Dietary Approaches to Stop Hypertension via Indo-Mediterranean Foods, May Be Superior to DASH Diet Intervention

Western-type diet with high salt and sugar, sedentary behavior, obesity, tobacco and alcoholism are important risk factors for hypertension. This review aims to highlight the role of western diet-induced oxidative stress and inflammation in the pathogenesis of hypertension and the role of various types of diets in its prevention with reference to dietary approaches to stop hypertension (DASH) diet. It seems that it is crucial to alter the western type of diet because such diets can also predispose all CVDs. Western diet-induced oxidative stress is characterized by excessive production of reactive oxygen species (ROS) with an altered oxidation-reduction (redox) state, leading to a marked increase in inflammation and vascular dysfunction. Apart from genetic and environmental factors, one important cause for differences in the prevalence of hypertension in various countries may be diet quality, deficiency in functional foods, and salt consumption. The role of the DASH diet has been established. However, there are gaps in knowledge about the role of some Indo-Mediterranean foods and Japanese foods, which have been found to decrease blood pressure (BP) by improving vascular function. The notable Indo-Mediterranean foods are pulses, porridge, spices, and millets; fruits such as guava and blackberry and vegetables, which may also decrease BPs. The Japanese diet consists of soya tofu, whole rice, in particular medical rice, vegetables and plenty of fish rich in fish oil, fish peptides and taurine that are known to decrease BPs. Epidemiological studies and randomized, controlled trials have demonstrated the role of these diets in the prevention of hypertension and metabolic diseases. Such evidence is still meager from Japan, although the prevalence of hypertension is lower (15-21%) compared to other developed countries, which may be due to the high quality of the Japanese diet. Interestingly, some foods, such as berries, guava, pumpkin seeds, carrots, soya beans, and spices, have been found to cause a decrease in BPs. Omega-3 fatty acids, fish peptide, taurine, dietary vitamin D, vitamin C, potassium, magnesium, flavonoids, nitrate and l-arginine are potential nutrients that can also decrease BPs. Larger cohort studies and controlled trials are necessary to confirm our views.

Relationship between serum homocysteine, fibrinogen, lipoprotein-a level, and peripheral arterial disease: a dose-response meta-analysis

AIM

At present, the relationship between serum homocysteine (Hcy), fibrinogen (FIB), lipoprotein-a (LPa), and PAD is uncertain, and there has been no meta-analysis to establish the dose-response relationship between their exposure levels and PAD.

METHODS AND RESULTS

Relevant literature published in PubMed, Embase, and Web of Science was retrieved. The robust error meta-regression method was used to assess the linear and non-linear dose-response relationship between exposure level and PAD risk. A total of 68 articles, involving 565,209 participants, were included. Combined with continuous variables, the serum Hcy, FIB, and LPa levels of PAD patients were significantly higher than those of healthy individuals. The odds ratios (ORs) of PAD for individuals with high Hcy, FIB, and LPa levels compared with those with low levels were 1.47, 1.14, and 1.76, respectively. The study also showed that circulating Hcy, FIB, and LPa were significantly elevated in patients with PAD compared with controls. The level of Hcy and the risk of PAD presented a U-shaped distribution. The nonlinear dose-response model showed that each 1 μmol/L increase in serum Hcy increased the risk of PAD by 7%. Similarly, for each 10 mg/dL FIB and 10 mg/dL LPa increases, the risk of PAD increased by 3% and 6%, respectively.

CONCLUSIONS

This meta-analysis provided evidence that elevated Hcy, PIB, and LPa levels may increase the risk of PAD, and the risk of PAD increases with the increase in serum exposure within a certain range. By controlling Hcy level, the incidence of PAD may be reduced to control the PAD growing epidemic.

TRIAL REGISTRATION NUMBER

PROSPERO (CRD42021250501), https://www.crd.york.ac.uk/prospero/.

Risk factors of peripheral arterial disease: a case control study in Sri Lanka

BACKGROUND

Peripheral artery disease (PAD) is an important global health problem and contributes to notable proportion of morbidity and mortality. This particular manifestation of systemic atherosclerosis is largely under diagnosed and undertreated. For sustainable preventive strategies in a country, it is mandatory to identify country-specific risk factors. We intended to assess the risk factors of PAD among adults aged 40-74 years.

METHODS

This case control study was conducted in 2012-2013 in Sri Lanka. Seventy-nine cases and 158 controls in the age group of 40-74 years were selected for the study in order to have case to control ratio 1:2. The criterion for selecting cases and control was based on Ankle brachial pressure index (ABPI). Cases were selected from those who had ABPI 0.85 or less (ABPI ≤0.85) in either lower limb. Controls were selected from those ABPI score between 1.18 and 1.28 in both lower limbs. Only newly identified individuals with PAD were selected as cases. Controls were selected from the same geographical location and within the 5 year age group as cases.

RESULTS

The history of diabetes mellitus more than 10 years (OR 5.8, 95% CI 2.2-14.2), history of dyslipidemia for more than 10 years (OR 4.9, 95% CI 2.1-16.2), history of hypertension for more than 10 years (OR 3.8, 95% CI 1.8-12.7) and smoking (OR 2.9, 95% CI 1.2-6.9), elevated HsCRP (OR 3.7, 95% CI 1.2-12.0) and hyperhomocysteinemia (OR 3.0, 95% CI 1.1-8.1) were revealed as country specific significant risk factor of PAD.

CONCLUSIONS

Diabetes mellitus, hypertension, dyslipidemia, smoking as well as elevated homocysteine and HsCRP found as risk factors of PAD. Longer the duration or higher level exposure to these risk factors has increased the risk of PAD. These findings emphasis the need for routine screening of PAD among patients with the identified risk factors.

Prevalence, correlates, and prognosis of peripheral artery disease in rural ecuador-rationale, protocol, and phase I results of a population-based survey: an atahualpa project-ancillary study

Background. Little is known on the prevalence of peripheral artery disease (PAD) in developing countries. Study design. Population-based study in Atahualpa. In Phase I, the Edinburgh claudication questionnaire (ECQ) was used for detection of suspected symptomatic PAD; persons with a negative ECQ but a pulse pressure ≥65 mmHg were suspected of asymptomatic PAD. In Phase II, the ankle-brachial index will be used to test reliability of screening instruments and to determine PAD prevalence. In Phase III, participants will be followed up to estimate the relevance of PAD as a predictor of vascular outcomes. Results. During Phase I, 665 Atahualpa residents aged ≥40 years were enrolled (mean age: 59.5 ± 12.6 years, 58% women). A poor cardiovascular health status was noticed in 464 (70%) persons of which 27 (4%) had a stroke and 14 (2%) had ischemic heart disease. Forty-four subjects (7%) had suspected symptomatic PAD and 170 (26%) had suspected asymptomatic PAD. Individuals with suspected PAD were older, more often women, and had a worse cardiovascular profile than those with nonsuspected PAD. Conclusions. Prevalence of suspected PAD in this underserved population is high. Subsequent phases of this study will determine whether prompt detection of PAD is useful to reduce the incidence of catastrophic vascular diseases in the region.

Biomarkers of inflammation may be of use for identification of more severe peripheral arterial occlusive disease

Background:Atherosclerosis is a multifactorial disease with an inflammatory pathophysiological basis. Cytokines released during the atherosclerotic process induce production of C-reactive protein (CRP) in the liver, which is an important marker of inflammation.Objective:We tested whether inflammatory biomarkers were associated with deterioration of peripheral arterial occlusive disease (PAOD) in a population at high cardiovascular risk.Methods:1,330 subjects ≥30 years of age underwent clinical and laboratory examinations as part of a population-based study of the prevalence of diabetes. PAOD was defined as an ankle-brachial index (ABI) ≤0.90. After application of exclusion criteria, the sample comprised 1,038 subjects. Traditional risk factors, CRP and interleukin 6 (IL-6) were also compared across three ABI categories (≤0.70; 0.71-0.90; ≥0.90). Mean values for these variables were compared by presence/absence of DAOP (Student's t test) and by ABI categories (ANOVA). Poisson regression and logistic regression models were used to test for associations between risk factors and DAOP and between risk factors and the ABI categories. Pearson's linear correlation coefficients were calculated for the relationship between CRP and IL-6 levels.Results:Mean age was 56.8±12.9 years, 54% of the sample were women and the prevalence of DAOP was 21.0% (95%CI 18.4-24.1). Individuals with ABI ≤0.70 had higher concentrations of CRP-us (2.1 vs. 1.8) and of IL-6 (1.25 vs. 1.17). Concentrations of CRP and IL-6 were only correlated in patients with DAOP, (p=0.004).Conclusions:The finding that CRP and IL-6 levels were only elevated among people with advanced DAOP may suggest that these biomarkers have a role to play as indicators of more severe disease. Prospective studies are needed to test this hypothesis.

Association between peripheral arterial disease and C-reactive protein in the Japanese-Brazilian population

OBJECTIVE

To evaluate the relationship between peripheral arterial disease and elevated levels of C-reactive protein in the Japanese-Brazilian population of high cardiovascular risk.

METHODS

We conducted a cross-sectional study derived from a population-based study on the prevalence of diabetes and associated diseases in the Japanese-Brazilian population. One thousand, three hundred and thirty individuals aged e" 30 underwent clinical and laboratory examination, including measurement of ultrasensitive C-reactive protein. The diagnosis of peripheral arterial disease was performed by calculating the ankle-brachial index. We considered with peripheral arterial disease patients who had ankle-brachial index d" 0.9. After applying the exclusion criteria, 1,038 subjects completed the study.

RESULTS

The mean age of the population was 56.8 years; 46% were male. The prevalence of peripheral arterial disease was 21%, with no difference between genders. Data analysis showed no association between peripheral arterial disease and ultrasensitive C-reactive protein. Patients with ankle-brachial index d" 0.70 showed higher values of ultrasensitive C-reactive protein and worse cardiometabolic profile. We found a positive independent association of peripheral arterial disease with hypertension and smoking.

CONCLUSION

The association between low levels of ankle-brachial index and elevated levels of ultrasensitive C-reactive protein may suggest a relationship of gravity, aiding in the mapping of high-risk patients.

Study of risk factors associated with peripheral arteriopathy in Japanese-Brazilians from Bauru (SP)

BACKGROUND

Cardiovascular diseases are the major cause of morbidity and mortality in developed and emerging countries. Their main etiology, atherosclerosis, is a disseminated disease that affects the coronary, cerebral and peripheral territories. The peripheral arterial disease (PAD), as well as its consequences, indicates the involvement of the coronary territory. Therefore, its better understanding enables proper treatment, delaying local and long-term complications, reducing the cost to the health system.

OBJECTIVE

This study estimates the percentage of PAD in Japanese-Brazilians from Bauru (SP), recognized by the high prevalence of metabolic disorders such as hypertension (43%), diabetes mellitus (33%) and hypercholesterolemia (60%), and examines the association with risk biomarkers.

METHODS

This cross-sectional population study evaluated 1,330 Japanese-Brazilians of both genders aged≥30 who underwent a complete physical examination, anthropometric measurements, laboratory tests and ankle-brachial index (ABI). Participants with ABI≤0.90 were diagnosed as having PAD. After applying the exclusion criteria, 1,038 individuals were part of the analysis. We used Poisson regression to analyze associations with PAD.

RESULTS

The mean age was 56.8 years and the percentage of PAD was 21.1%, equal among the genders. PAD was associated with smoking (PR 2.16 [1.33 to 3.48]) and hypertension (PR 1.56 [1.12-2.22]).

CONCLUSION

The percentage of PAD in Japanese-Brazilians was similar to other populations of adverse cardiometabolic profile (US PARTNERS and POPADAD). The independent association of PAD with smoking and hypertension, but not with other classical risk factors, may depend on the very high frequencies of metabolic disorders in this population.

Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis

BACKGROUND

Lower extremity peripheral artery disease is the third leading cause of atherosclerotic cardiovascular morbidity, following coronary artery disease and stroke. This study provides the first comparison of the prevalence of peripheral artery disease between high-income countries (HIC) and low-income or middle-income countries (LMIC), establishes the primary risk factors for peripheral artery disease in these settings, and estimates the number of people living with peripheral artery disease regionally and globally.

METHODS

We did a systematic review of the literature on the prevalence of peripheral artery disease in which we searched for community-based studies since 1997 that defined peripheral artery disease as an ankle brachial index (ABI) lower than or equal to 0·90. We used epidemiological modelling to define age-specific and sex-specific prevalence rates in HIC and in LMIC and combined them with UN population numbers for 2000 and 2010 to estimate the global prevalence of peripheral artery disease. Within a subset of studies, we did meta-analyses of odds ratios (ORs) associated with 15 putative risk factors for peripheral artery disease to estimate their effect size in HIC and LMIC. We then used the risk factors to predict peripheral artery disease numbers in eight WHO regions (three HIC and five LMIC).

FINDINGS

34 studies satisfied the inclusion criteria, 22 from HIC and 12 from LMIC, including 112,027 participants, of which 9347 had peripheral artery disease. Sex-specific prevalence rates increased with age and were broadly similar in HIC and LMIC and in men and women. The prevalence in HIC at age 45-49 years was 5·28% (95% CI 3·38-8·17%) in women and 5·41% (3·41-8·49%) in men, and at age 85-89 years, it was 18·38% (11·16-28·76%) in women and 18·83% (12·03-28·25%) in men. Prevalence in men was lower in LMIC than in HIC (2·89% [2·04-4·07%] at 45-49 years and 14·94% [9·58-22·56%] at 85-89 years). In LMIC, rates were higher in women than in men, especially at younger ages (6·31% [4·86-8·15%] of women aged 45-49 years). Smoking was an important risk factor in both HIC and LMIC, with meta-OR for current smoking of 2·72 (95% CI 2·39-3·09) in HIC and 1·42 (1·25-1·62) in LMIC, followed by diabetes (1·88 [1·66-2·14] vs 1·47 [1·29-1·68]), hypertension (1·55 [1·42-1·71] vs 1·36 [1·24-1·50]), and hypercholesterolaemia (1·19 [1·07-1·33] vs 1·14 [1·03-1·25]). Globally, 202 million people were living with peripheral artery disease in 2010, 69·7% of them in LMIC, including 54·8 million in southeast Asia and 45·9 million in the western Pacific Region. During the preceding decade the number of individuals with peripheral artery disease increased by 28·7% in LMIC and 13·1% in HIC.

INTERPRETATION

In the 21st century, peripheral artery disease has become a global problem. Governments, non-governmental organisations, and the private sector in LMIC need to address the social and economic consequences, and assess the best strategies for optimum treatment and prevention of this disease.

FUNDING

Peripheral Arterial Disease Research Coalition (Europe).

Peripheral arterial disease in the Middle East: Underestimated predictor of worse outcome

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. The prevalence of PAD in the developed world is approximately 12% among adult population, which is age-dependent and with men being affected slightly more than women. Despite the strikingly high prevalence of PAD, the disease is underdiagnosed. Surprisingly, more than 70% of primary health care providers in the US were unaware of the presence of PAD in their patients. The clinical presentation of PAD may vary from asymptomatic to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, or gangrene. Claudication is the typical symptomatic expression of PAD. However, the disease may remains asymptomatic in up to 50% of all PAD patients. PAD has also been reported as a marker of poor outcome among patients with coronary artery disease. Despite the fact that the prevalence of atherosclerotic disease is increasing in the Middle East with increasing cardiovascular risk factors (tobacco use, diabetes mellitus and the metabolic syndrome), data regarding PAD incidence in the Middle East are scarce.

Plasma homocysteine levels are independently associated with the severity of peripheral polyneuropathy in type 2 diabetic subjects

Peripheral polyneuropathy (PN) is a frequent complication of diabetes. However, mechanisms underlying the development of PN are multifactorial and not well understood. Our aim was to examine the association of plasma homocysteine (Hcy) with the prevalence and grade of peripheral PN in patients with type 2 diabetes (T2DM). We studied a cohort of 196 subjects with T2DM classified according to the grade of PN (Neuropathy Disability Score, NDS). Subjects with the highest grade of PN were older and had significantly increased levels of creatinine, microalbuminuria, HbA1c, and plasma Hcy compared to the other two groups. The differences in plasma Hcy values were maintained after correcting for confounding factors. Plasma Hcy, HbA1c, duration of diabetes, and age were predictors of the grade of PN. In conclusion, for each increase of 1 µmol in plasma Hcy there was a 23% increase of the risk of diabetic PN evaluated by NDS. Moreover, the grade of PN was predicted by plasma Hcy and HbA1c values, age and duration of diabetes. Further prospective studies should be conducted to confirm the association of plasma Hcy levels with the grade of PN in subjects with T2DM.

Effect of folic acid supplementation on plasma total homocysteine levels and glycemic control in patients with type 2 diabetes: a systematic review and meta-analysis

AIM

The evidences illustrating the effects of folic acid supplementation (FAS) in individuals with type 2 diabetes on plasma total homocysteine (tHcy) levels and glycemic control have been contradictory. The aim of the study was to systematically search and quantitatively analyze the effect of FAS on tHcy levels and HbA1c compared with placebo.

METHODS

We searched PubMed, Scopus, and Embase up to March 2012 without language restriction. Key words "folic acid" and "diabetes mellitus" with slight modifications based on the sources for search strategy were used. References of initially identified articles were examined to identify any other relevant studies. A random-effects model was used for estimation the pooled effect estimates (weighted mean different, WMD).

RESULTS

Of 6185 studies identified, 4 studies with 183 patients were included. FAS had statistically significant effect on tHcy levels [WMD, -3.52; 95% confidence interval (CI), -4.44 to -2.60]. However, the effect on HbA1c levels [WMD, -0.37; 95% CI, -1.10 to 0.35] was not significant.

CONCLUSIONS

Folic acid supplementation in patient with type 2 diabetes mellitus may reduce tHcy levels and have a trend to associate with better glycemic control compared with placebo. Further longitudinal studies on these intervention and outcomes are warranted.

[Hyperhomocysteinemia and leg ulcers: A prospective study of 68 patients]

BACKGROUND

Homocysteine is a sulphur-containing amino acid derived from methionine. Hyperhomocysteinaemia is now recognised as an independent risk factor for occlusive arterial disease and thrombotic venous disease. The aim of this study was to determine the prevalence of hyperhomocysteinemia in patients with leg ulcers.

PATIENTS AND METHODS

We prospectively investigated hospitalised patients for vascular leg ulcers between March 2008 and June 2009 at two dermatology centres. We collected details of cardiovascular disease and determined nutritional status by means of the MNA score. Fasting blood samples were taken and analyzed for homocysteine, albumin, prealbumin, folic acid, vitamin B12, creatinine and a complete blood count.

RESULTS

Sixty-eight patients were enrolled in the study: 48 women and 20 men. Fifty-three percent of patients had venous leg ulcers, 18% had arterial leg ulcers and 20% had leg ulcers of mixed origin. The prevalence of hyperhomocysteinemia was 56%, with no differences according to ulcer type or gender.

DISCUSSION

While the prevalence of hyperhomocysteinemia in our population of leg ulcer patients was high, this descriptive study does not allow us to establish any causal link between hyperhomocysteinemia and leg ulcers. Moreover, since the literature indicates that homocysteine-lowering therapy does not reduce cardiovascular and thromboembolic risk, there appears to be little call for further trials on hyperhomocysteinaemia and leg ulcers.

Mutations in methylenetetrahydrofolate reductase and in cysthationine beta synthase: is there a link to homocysteine levels in peripheral arterial disease?

Peripheral arterial disease (PAD) is an atherosclerotic disturbance characterized by a progressive obstruction of lower limb arteries. Many risk factors associated with PAD development have being reported in the literature. The present study aimed to investigate whether mutations in the methylenetetrahydrofolate reductase (MTHFR) or in the cystathionine beta synthase (CBS) genes are associated with higher levels of homocysteine and the risk of PAD in patients from Brazil. This study analyzed 39 patients with PAD and 32 without PAD in whom risk factors and C677T mutations in the MTHFR gene and both 844ins68 and T833C mutations in the CBS gene were investigated. Although higher levels of homocysteine could be observed in patients with PAD compared to controls, no association between the increase of homocysteine and the frequency of C677T, 844ins68, and T833C mutations could be observed. The results suggest that these mutations do not appear to be related to either homocysteine levels or the development of the disease. However, hyperhomocysteinemia and smoking are important factors in PAD development.

Plasma homocysteine levels are associated with ulceration of the foot in patients with type 2 diabetes mellitus

BACKGROUND

To examine the association of biochemical markers of risk (plasma Hcy, microalbuminuria, lipoprotein (a)(Lp(a)) and diabetic dyslipidaemia) with the prevalence of diabetic foot ulceration in type 2 diabetic patients.

METHODS

Case/control study conducted in 198 type 2 diabetic patients. 89 patients have foot ulcers and 109 have no foot ulcers (control group), in order to establish ORs for diabetic foot ulceration. In all subjects plasma Hcy, Lp(a), total cholesterol, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, apolipoprotein B, HbA(1c) and microalbuminuria were measured using standard procedures.

RESULTS

Plasma Hcy, microalbuminuria, HbA(1c) and apolipoprotein B levels were significantly higher in patients with foot ulceration compared with the control group. Plasma lipids, Lp(a), vitamin B12 and folic acid values were similar in both groups. In the logistic regression model, plasma Hcy (OR 1.09; 95% CI 1.04-1.69), microalbuminuria (OR 1,01; 95% CI 1.01-1.17) and HbA(1c) levels (OR 1.33; 95% CI 1.04-1.69) were independent risk factors for the presence of diabetic foot ulceration.

CONCLUSIONS

In our study, for each micromol increase in plasma Hcy levels there was a 10% increase in the risk of diabetic foot ulceration. In addition, plasma homocysteine, HbA(1c) and microalbuminuria accounted for 50% prevalence risk of diabetic foot ulceration. Further prospective studies should be conducted to confirm the association of plasma Hcy levels with the risk of foot ulceration.

Concentração de homocisteína em pacientes portadores de doença arterial periférica atendidos em um serviço público de saúde

Contexto: Estudos recentes indicam que a concentração elevada de homocisteína é um fator de risco importante e prevalente para doença vascular aterosclerótica coronariana, cerebral e periférica. Objetivo: Tendo em vista a escassez de informações relacionadas à hiper-homocisteinemia em doença arterial periférica (DAP) no Brasil e as peculiaridades de nossa população, o objetivo deste estudo foi avaliar a frequência de hiper-homocisteinemia em amostra dessa população em um ensaio clínico com indivíduos portadores e não portadores de DAP atendidos em um serviço público brasileiro. Métodos: Foi realizado um estudo ensaio clínico caso-controle com 40 indivíduos portadores de DAP confirmada por Doppler ultrassom (grupo DAP) em comparação com 20 indivíduos voluntários sem DAP (grupo-controle). Resultados: A DAP predominante foi a isquemia crônica de membros (75%). As concentrações plasmáticas medianas de homocisteína de jejum foram significantemente maiores no grupo DAP do que no grupo-controle (16,7 versus 12,9 µmol/L, p = 0,001), tanto nos homens (18,9 versus 14,0 µmol/L, p = 0,005) quanto nas mulheres (13,9 versus 11,2 µmol/L, p = 0,025). Quanto à proporção de indivíduos com hiper-homocisteinemia, observou-se tendência a uma maior frequência no grupo DAP (60%) em relação ao grupo-controle (30%) (p = 0,054). Nos indivíduos com idade inferior a 60 anos foram encontrados valores medianos de homocisteína significantemente mais elevados no grupo DAP (p = 0,041). Conclusões: A hiper-homocisteinemia é um fator de risco importante e foi encontrada em 60% dos indivíduos portadores de DAP atendidos em um serviço público no Brasil.

Plasma Total Homocysteine Levels are not Associated with Medial Temporal Lobe Atrophy, but with White Matter Changes in Alzheimer's Disease

Background and purpose

Elevated plasma total homocysteine (tHcy) levels are reported to be associated with an increased risk of Alzheimer's disease (AD). However, the mechanism by which homocysteine contributes to the pathogenesis of AD is as yet unknown. The aim of this study was to elucidate the relationship between white matter changes (WMC) and medial temporal lobe atrophy (MTA) on brain magnetic resonance imaging (MRI), and plasma levels of tHcy in AD patients.

Methods

Seventy-two patients with a clinical diagnosis of probable AD were recruited to the study. Plasma tHcy levels, vascular risk factors, and WMC and MTA on brain MRI were evaluated in all patients. The AD patients were classified into two groups: those with no or minimal WMC (69.2±8.8 years, mean±SD, n=36) and those with moderate-to-severe WMC (74.6±4.6 years, n=36) on brain MRI.

Results

In a univariate logistic regression analysis, the risk of moderate-to-severe WMC in AD was significantly associated with increasing age, female gender, lower education level, hypertension, high plasma tHcy levels, and lower Mini-Mental State Examination (MMSE) score. Multivariate logistic regression analysis revealed only high plasma tHcy as the independent and significant risk factor for moderate-to-severe WMC [odds ratio (OR; adjusted for age, gender, education level, MMSE score, and hypertension comparing the top tertile - tHcy levels ≥12.9 µmol/L - with the bottom tertile - tHcy levels ≤9.4 µmol/L)=7.35; 95% confidence interval, confidence interval=1.36-39.84; p=0.02], and age as a borderline significant risk factor (OR=1.08, 95% CI=0.99-1.19, p=0.09) in AD patients. Plasma tHcy levels were not correlated significantly with either right or left MTA.

Conclusions

Our results suggest that the vascular pathway mediates the association between elevated plasma tHcy levels and AD.

Increased folate intake with no changes in serum homocysteine and decreased levels of C-reactive protein in patients with inflammatory bowel diseases

In order to increase dietary folic acid intake and to improve nutritional status regarding folate by controlling homocysteine concentrations, ten patients with inflammatory bowel diseases (Crohn's disease in the colon and ulcerative colitis) received individualized nutritional guidance and were followed up as outpatients for 2 months. The following procedures were performed at the beginning of the study (T0), after 1 month (T1) and at the end of the study (T2): collection of anthropometric data (weight and height), dietary data (24 h diet recall), and blood under fasting condition for the determination of serum folic acid, homocysteine, C-reactive protein, and vitamin B12. Plasma folic acid deficiency was not detected but hyperhomocysteinemia was present in six individuals and C-reactive protein (CRP) was increased (>0.5 mg/dl) in seven patients. After the patients were instructed there was a significant increase in vitamin B6 intake (about 35%) and in folate intake (49.6%). Mean plasma levels of folic acid, homocysteine, and vitamin B12 did not change, but there was a significant decrease of CRP at T1, 0.36 mg dl(-1) on average (P = 0.01), which was maintained at T2. We conclude that the increased folate intake reported by this group of patients was not reflected in improved serum concentrations of folic acid and homocysteine. However, the guidelines for the patients probably induced them to choose a more adequate diet, providing nutrients that help control the inflammatory process.

Hyperhomocysteinemia and lower extremity wounds

Chronic lower extremity wounds include ulceration of the leg and foot. The underlying pathology that causes these conditions includes venous insufficiency, arterial disease, diabetes, and other less common disorders. Since the introduction of the homocysteine theory more than 30 years ago, considerable evidence has demonstrated hyperhomocysteinemia to be an independent risk factor for venous and arterial thrombosis, atherosclerosis and cardiovascular disease. Although any cause-effect relationship remains to be determined, hyperhomocysteinemia as a risk factor for these events suggests that elevated levels of homocysteine may also be a marker of chronic lower limb ulceration. This review addresses the metabolism of homocysteine, mechanisms of vascular injury, a role for hyperhomocysteinemia in lower extremity wounds and possible means of treatment.

Ethnicity and peripheral artery disease

Peripheral arterial disease (PAD) is an important healthcare problem and is an indicator of widespread atherosclerosis in other vascular territories, such as the cerebral and coronary circulations. PAD is associated with considerable morbidity and mortality. Most population-based studies investigating PAD prevalence and risk factors for its development and progression have been based on predominantly White ethnic groups. Much less is known about the characteristics of this disease in other ethnic groups. Understanding the epidemiology of PAD amongst ethnic minority groups is relevant, given that the population of minority ethnic groups in countries such as the United Kingdom rose by 53% between 1991 and 2001 and is expected to rise further in the future. This article aims to provide an overview of possible pathophysiological differences between ethnic groups for PAD, focussing predominantly on South Asians (people originating from India, Bangladesh and Pakistan) and Blacks (people of Black Caribbean and Black African descent) as these groups comprise the majority of all ethnic minorities in the United Kingdom.