Association between behavior-dependent cardiovascular risk factors and asymptomatic carotid atherosclerosis in a general population

Fecal glycoprotein 2 is a marker of gut microbiota dysbiosis and systemic inflammation

BACKGROUND

Antimicrobial autoantigenic glycoprotein 2 (GP2) is an important component of the innate immune system which originates from the exocrine pancreas as well as from the small intestines. The relationship of GP2 with the intestinal microbiome as well as the systemic implications of increased fecal GP2 levels are, however, still unclear. Therefore, fecal samples from 2,812 individuals of the Study of Health in Pomerania (SHIP) were collected to determine GP2 levels (enzyme-linked immunosorbent assay) and gut microbiota profiles (16 S rRNA gene sequencing). These data were correlated and associated with highly standardised and comprehensive phenotypic data of the study participants.

RESULTS

Fecal GP2 levels were increased in individuals with higher body mass index and smokers, whereas lower levels were found in case of preserved exocrine pancreatic function, female sex or a healthier diet. Moreover, higher GP2 levels were associated with increased serum levels of high-sensitivity C-reactive protein, loss of gut microbial diversity and an increase of potentially detrimental bacteria (Streptococcus, Haemophilus, Clostridium XIVa, or Collinsella). At the same time, predicted microbial pathways for the biosynthesis of beneficial short-chain fatty acids or lactic acid were depleted in individuals with high fecal GP2. Of note, GP2 exhibited a stronger association to overall microbiome variation than calprotectin.

CONCLUSION

Fecal GP2 is a biomarker of gut microbiota dysbiosis and associated with increased systemic inflammation. The intestines may be more important as origin for GP2 than pancreatic acinar cells. Future studies need to investigate the potential clinical value in disease specific patient cohorts.

Nutritional status in patients with chronic pancreatitis and liver cirrhosis is related to disease conditions and not dietary habits

Malnutrition is a common complication of chronic pancreatitis (CP) and liver cirrhosis (LC). Inadequate food intake is considered a relevant driver of malnutrition in both entities. However, the contribution of habitual diet to impaired nutritional status is unclear. In a prospective, multicenter cross-sectional study, we recruited patients with confirmed CP or LC and healthy volunteers as a control group. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition criteria. We comprehensively investigated habitual dietary intake on nutrient, food group, and dietary pattern level applying two validated food frequency questionnaires. We included 144 patients (CP: n = 66; LC: n = 78) and 94 control subjects. Malnutrition was prevalent in 64% and 62% of patients with CP or LC, respectively. In both CP and LC, despite slightly altered food group consumption in malnourished and non-malnourished patients there were no differences in energy or nutrient intake as well as dietary quality. Compared to controls patients showed distinct dietary food group habits. Patients consumed less alcohol but also lower quantities of fruits and vegetables as well as whole grain products (p < 0.001, respectively). Nevertheless, overall dietary quality was comparable between patients and healthy controls. Nutritional status in CP and LC patients is rather related to disease than habitual dietary intake supporting the relevance of other etiologic factors for malnutrition such as malassimilation or chronic inflammation. Despite distinct disease-related differences, overall dietary quality in patients with CP or LC was comparable to healthy subjects, which suggests susceptibility to dietary counselling and the benefits of nutrition therapy in these entities.

Association of leisure-time physical activity and sedentary behavior with carotid atherosclerosis morphology: The ARIC carotid-MRI study

Objective

We evaluated the prospective association of midlife leisure-time physical activity (LTPA) and sedentary behavior (SB), and their temporal patterns, with MRI-measured carotid atherosclerotic morphology.

Methods

Participants enrolled in the Carotid MRI substudy (2004-2006) of the Atherosclerosis Risk in Communities (ARIC) Study and with self-reported assessments of LTPA and SB at visits 1 (1987-1989) and 3 (1993-1995) were included in this study. LTPA was ascertained using the ARIC/Baecke physical activity questionnaire and categorized according to the American Heart Association's metric of poor, intermediate, or ideal physical activity. SB, measured as TV viewing frequency, was categorized as high, medium, and low. We used multivariable adjusted linear and logistic regression models to examine the associations between midlife (visit 3 only) and persistent (visit 1 to 3) LTPA and TV viewing with carotid artery plaque burden and components.

Results

Among the 1,582 (mean age: 59 years, 43% male, 18% Black) participants, 45.7%, 21.7%, and 32.6% reported ideal, intermediate, or poor LTPA, respectively. High TV viewing was reported in 33.8% of participants, with 46.4% and 19.8% reporting medium or low TV viewing, respectively. Compared to poor LTPA, ideal LTPA in midlife was not associated with total wall volume (ß=0.01, 95% CI: -0.01, 0.03), maximum carotid wall thickness (ß=0.06, 95% CI: -0.08, 0.21), normalized wall index (ß=-0.01, 95% CI: -0.03, 0.01), or maximum stenosis (ß=-0.11, 95% CI: -1.98, 1.76). Low or middle, compared to high, TV viewing was also not associated with carotid artery measures of plaque burden. Compared to poor LTPA or high TV viewing, ideal LTPA (odds ratio (OR): 0.82, 95% CI: 0.55, 1.23) and low TV viewing (OR=0.90, 95% CI: 0.56, 1.44) was not associated with odds of lipid core presence, respectively.

Conclusion

Overall, this study does not provide strong evidence for an association between LTPA and SB with carotid plaque measures.

Associations between physical activity and cardiorespiratory fitness with vascular health phenotypes in older adults: a cross-sectional study

Objective: We investigated the associations between physical activity (PA) and cardiorespiratory fitness (CRF) with vascular health phenotypes in community-dwelling older adults. Methods: This cross-sectional study included 82 participants (66.8 ± 5.2 years; 81% females). Moderate-to-vigorous physical activity (MVPA) was assessed using accelerometers, and CRF was measured using the distance covered in the 6-min walk test (6MWT). The vascular health markers were as follows: i) arterial function measured as aortic pulse wave velocity (aPWV) estimated using an automatic blood pressure device; and ii) arterial structure measured as the common carotid intima-media thickness (cIMT). Using a combination of normal cIMT and aPWV values, four groups of vascular health phenotypes were created: normal aPWV and cIMT, abnormal aPWV only, abnormal cIMT only, and abnormal aPWV and cIMT. Multiple linear regression was used to estimate the beta coefficients (β) and their respective 95% confidence intervals (95% CI) adjusting for BMI, and medication for diabetes, lipid, and hypertension, sex, age, and blood pressure. Results: Participants with abnormal aPWV and normal cIMT (β = -53.76; 95% CI = -97.73--9.78 m; p = 0.017), and participants with both abnormal aPWV and cIMT (β = -71.89; 95% CI = -125.46--18.31 m; p = 0.009) covered less distance in the 6MWT, although adjusting for age, sex and blood pressure decreased the strength of the association with only groups of abnormal aPWV and cIMT covering a lower 6MWT distance compared to participants with both normal aPWV and cIMT (β = -55.68 95% CI = -111.95-0.59; p = 0.052). No associations were observed between MVPA and the vascular health phenotypes. Conslusion: In summary, poor CRF, but not MVPA, is associated with the unhealthiest vascular health phenotype (abnormal aPWV/cIMT) in older adults.

Using eZIS of SPECT to evaluate the therapeutic effect of carotid endarterectomy

OBJECTIVE

Stroke is an acute cerebrovascular disease with high morbidity and mortality. The main causes of ischemic stroke include carotid artery stenosis, and carotid endarterectomy (CEA) can be used to improve the blood flow of the lesion site. Regional cerebral blood flow (rCBF) can be decreased by using single photon emission computed tomography (SPECT). The Easy Z-Score imaging system (eZIS) can display the changes of rCBF as Z-Score. The purpose of this study was to determine whether eZIS of SPECT can be used to evaluate the therapeutic effect of CEA in the treatment of carotid artery stenosis.

METHODS

In this study, subjects were divided into the surgery group and the control group. The surgery group included seven patients with unilateral or bilateral internal carotid artery stenosis who received CEA treatment, and the control group included 11 patients who only received conventional drug treatment but did not receive surgery. Cerebral perfusion imaging (CPI) was collected twice before and after the corresponding treatment (within 6 months). rCBF of the lesion site was measured and Z-score was calculated before and after treatment by the eZIS technique.

RESULTS

The postoperative Z-score of the surgery group was 0.54 ± 2.71 compared with that of the preoperative -1.34 ± 2.68 ( P  = 0.0034; t  = 4.687; df  = 6), while the z-score of the control group was -0.33 ± 2.58 compared with that of the pretreatment 1.84 ± 2.62 ( P  = 0.0010; t  = 4.618; df  = 10).

CONCLUSION

CEA can effectively improve the blood flow in the lesion area of patients with carotid artery stenosis. eZIS of SPECT can be used to evaluate the therapeutic effect of CEA on carotid artery stenosis visually.

Higher Trimethylamine-N-Oxide Plasma Levels with Increasing Age Are Mediated by Diet and Trimethylamine-Forming Bacteria

The gut microbiota-dependent metabolite trimethylamine-N-oxide (TMAO) is linked to an increased risk for cardiovascular diseases. Trimethylamine (TMA), which is subsequently oxidized to TMAO in the liver, is formed by intestinal bacteria via distinct biochemical routes from dietary precursors that are enriched in animal product-based foods. To get a full picture of the entire process of the diet > gut microbiota > TMAO axis, we quantified potential TMA-forming gut bacteria and plasma metabolites using gene-targeted assays and targeted metabolomics on a subsample (n = 425) of a German population-based cohort study. We specifically compared persons reporting daily meat intake with those that rarely or never consume meat. While meat intake did not predict TMAO plasma levels in our study, two major bacterial TMA-forming pathways were linked to the metabolite's concentration. Furthermore, advancing age was strongly associated with TMAO. Construction of a structural equation model allowed us to disentangle the different routes that promote higher TMAO levels with increasing age, demonstrating, for the first time, a functional role of gut microbiota in the process, where specific food items augmented abundances of TMA-forming bacteria that were associated with higher TMAO plasma concentrations. Analyses stratified by age showed an association between carotid intima-media thickness and TMAO only in individuals >65 of age, indicating that this group is particularly affected by the metabolite. IMPORTANCE Many cohort studies have investigated the link between diet and plasma TMAO levels, reporting incongruent results, while gut microbiota were only recently included into analyses. In these studies, taxonomic data were recorded that are not a good proxy for TMA formation, as specific members of various taxa exhibit genes catalyzing this reaction, demanding function-based technologies for accurate quantification of TMA-synthesizing bacteria. Using this approach, we demonstrated that abundances of the main components leading to TMAO formation, i.e., TMA precursors and TMA-forming bacteria, are uncoupled and not governed by the same (dietary) factors. Results emphasize that all levels leading to TMA(O) formation should be considered for accurate risk assessment, rejecting the simple view that diets rich in TMA precursors directly lead to increased plasma levels of this hazardous compound. The results can assist in developing strategies to reduce TMAO levels, specifically in the elderly, who are prone to TMAO-associated diseases.

Childhood Maltreatment and Subclinical Atherosclerosis: Findings From the General Population

OBJECTIVE

Evidence suggests that childhood maltreatment (CM) is cross-sectionally and prospectively associated with cardiovascular disease. However, its association with proxy markers of atherosclerosis has hardly been investigated. Thus, in this general population study, we examined the association of CM with carotid plaque and intima-media thickness.

METHODS

Adults from the general population free of any cardiovascular disease (n = 1909; mean [SD] age = 50.4 (13.6) years, 53.9% women) completed the self-report Childhood Trauma Questionnaire for the assessment of emotional, physical, and sexual abuse as well as emotional and physical neglect; in addition, an ultrasound of the carotid arteries was performed in each participant.

RESULTS

At least one type of CM was reported by 25% of the participants. Carotid plaque was significantly more frequent in those with CM compared with those without (odds ratio = 1.47, 95% confidence interval = 1.19-1.81). Accounting for age and sex rendered it nonsignificant (odds ratio = 1.07, 95% confidence interval = 0.81-1.42). Emotional abuse and physical neglect were significantly associated with both carotid intima-media thickness and plaque occurrence, but these associations were fully explained by risk factors. Neither sexual nor physical abuse was related to proxy markers of atherosclerosis.

CONCLUSIONS

Our findings suggest that the relationship between CM types and subclinical atherosclerosis as well as its clinical end points is complex and remains inconclusive, suggesting the need for further research.

Exocrine Pancreatic Function Modulates Plasma Metabolites Through Changes in Gut Microbiota Composition

PURPOSE

Exocrine pancreatic function is critically involved in regulating the gut microbiota composition. At the same time, its impairment acutely affects human metabolism. How these 2 roles are connected is unknown. We studied how the exocrine pancreas contributes to metabolism via modulation of gut microbiota.

DESIGN

Fecal samples were collected in 2226 participants of the population-based Study of Health in Pomerania (SHIP/SHIP-TREND) to determine exocrine pancreatic function (pancreatic elastase enzyme-linked immunosorbent assay) and intestinal microbiota profiles (16S ribosomal ribonucleic acid gene sequencing). Plasma metabolite levels were determined by mass spectrometry.

RESULTS

Exocrine pancreatic function was associated with changes in the abundance of 28 taxa and, simultaneously, with those of 16 plasma metabolites. Mediation pathway analysis revealed that a significant component of how exocrine pancreatic function affects the blood metabolome is mediated via gut microbiota abundance changes, most prominently, circulating serotonin and lysophosphatidylcholines.

CONCLUSION

These results imply that the effect of exocrine pancreatic function on intestinal microbiota composition alters the availability of microbial-derived metabolites in the blood and thus directly contributes to the host metabolic changes associated with exocrine pancreatic dysfunction.

Light-To-Moderate Raw Garlic Consumption Frequency Is Inversely Associated With Thickened Carotid Intima-Media Thickness: A Population-Based Study

Background: Previous animal and clinical studies have reported beneficial effects of garlic preparations on carotid intima-media thickness (cIMT). However, no epidemiological study has yet investigated the association between dietary raw garlic consumption and cIMT in the general population. The objective of this study was investigating the association between dietary raw garlic consumption and thickened cIMT in Chinese adults. Methods: This cross-sectional study used data from the Tianjin Chronic Low-grade Systemic Inflammation and Health Cohort Study. A total of 4,329 general adults from 2015 to 2017 were included in this study. Frequency of consumption of raw garlic was summarized as four categories for analysis: < 1 time/week, 1 time/week, 2-3 times/week, ≥4 times/week with a validated food frequency questionnaire. The thickened cIMT was defined as common carotid artery IMT ≥ 1.0 mm or a carotid bifurcation IMT ≥ 1.2 mm by ultrasonography. Multivariable logistic regression analysis was used to examine the association between frequency of raw garlic consumption and thickened cIMT. Results: The prevalence of thickened cIMT is 22.9% among these participants. The adjusted odds ratios (95% confidence intervals) associated with the different frequencies were 1.00 (reference) for < 1 time/week, 0.74 (0.59, 0.94) for 1 time/week, 0.71 (0.55, 0.92) for 2-3 times/week, and 0.94 (0.71, 1.25) for ≥ 4 times/week. Conclusions: Light-to-moderate raw garlic consumption was inversely associated with thickened cIMT, whereas greater raw garlic consumption (i.e., ≥4 times/week) was not associated with thickened cIMT. Future longitudinal studies should be conducted to test these findings.

Carrying asymptomatic gallstones is not associated with changes in intestinal microbiota composition and diversity but cholecystectomy with significant dysbiosis

Gallstone disease affects up to twenty percent of the population in western countries and is a significant contributor to morbidity and health care expenditure. Intestinal microbiota have variously been implicated as either contributing to gallstone formation or to be affected by cholecystectomy. We conducted a large-scale investigation on 404 gallstone carriers, 580 individuals post-cholecystectomy and 984 healthy controls with similar distributions of age, sex, body mass index, smoking habits, and food-frequency-score. All 1968 subjects were recruited from the population-based Study-of-Health-in-Pomerania (SHIP), which includes transabdominal gallbladder ultrasound. Fecal microbiota profiles were determined by 16S rRNA gene sequencing. No significant differences in microbiota composition were detected between gallstone carriers and controls. Individuals post-cholecystectomy exhibited reduced microbiota diversity, a decrease in the potentially beneficial genus Faecalibacterium and an increase in the opportunistic pathogen Escherichia/Shigella. The absence of an association between the gut microbiota and the presence of gallbladder stones suggests that there is no intestinal microbial risk profile increasing the likelihood of gallstone formation. Cholecystectomy, on the other hand, is associated with distinct microbiota changes that have previously been implicated in unfavorable health effects and may not only contribute to gastrointestinal infection but also to the increased colon cancer risk of cholecystectomized patients.

Long-term instability of the intestinal microbiome is associated with metabolic liver disease, low microbiota diversity, diabetes mellitus and impaired exocrine pancreatic function

OBJECTIVE

The intestinal microbiome affects the prevalence and pathophysiology of a variety of diseases ranging from inflammation to cancer. A reduced taxonomic or functional diversity of the microbiome was often observed in association with poorer health outcomes or disease in general. Conversely, factors or manifest diseases that determine the long-term stability or instability of the microbiome are largely unknown. We aimed to identify disease-relevant phenotypes associated with faecal microbiota (in-)stability.

DESIGN

A total of 2564 paired faecal samples from 1282 participants of the population-based Study of Health in Pomerania (SHIP) were collected at a 5-year (median) interval and microbiota profiles determined by 16S rRNA gene sequencing. The changes in faecal microbiota over time were associated with highly standardised and comprehensive phenotypic data to determine factors related to microbiota (in-)stability.

RESULTS

The overall microbiome landscape remained remarkably stable over time. The greatest microbiome instability was associated with factors contributing to metabolic syndrome such as fatty liver disease and diabetes mellitus. These, in turn, were associated with an increase in facultative pathogens such as Enterobacteriaceae or Escherichia/Shigella. Greatest stability of the microbiome was determined by higher initial alpha diversity, female sex, high household income and preserved exocrine pancreatic function. Participants who newly developed fatty liver disease or diabetes during the 5-year follow-up already displayed significant microbiota changes at study entry when the diseases were absent.

CONCLUSION

This study identifies distinct components of metabolic liver disease to be associated with instability of the intestinal microbiome, increased abundance of facultative pathogens and thus greater susceptibility toward dysbiosis-associated diseases.

Association of traumatic stress and posttraumatic stress disorder with carotid atherosclerosis: findings from the general population

Background: Cumulative evidence suggests that both traumatic stress and posttraumatic stress disorder (PTSD) are cross-sectionally and prospectively linked to cardiovascular disease (CVD). However, their association with proxy markers of atherosclerosis has hardly been investigated. Objective: The objective of this general population study was to relate traumatic stress and PTSD to carotid plaque and intima-media thickness (cIMT). Methods: 3119 adults from the general population were assessed regarding their traditional cardiovascular risk factors, and an ultrasound of the carotid arteries was performed in each participant. Based on a PTSD interview, every participant was assigned to one of three groups: no trauma; trauma, but no PTSD; and trauma with PTSD. The sample was stratified into five age groups. Results: Trauma exposure was reported by 54.5% of the sample and 2.0% had PTSD. Traumatized participants had increased odds of self-reported CVD events compared to those without trauma exposure, even when accounted for CVD risk factors and other covariates (odds ratio [OR] = 1.51; 95% confidence interval [CI]: 1.03-2.22). This association was driven by those aged 70 years or older. Only in those aged 40 to 49 years, there was an association between cIMT and PTSD. There were no further associations between carotid plaque or cIMT and traumatic stress or PTSD. Conclusions: Our findings in concert with prior research suggest that the association between traumatic stress, PTSD and atherosclerosis as well as its clinical endpoints is complex and remains inconclusive.

The Association of Physical Activity With Carotid Intima Media Thickening in a Healthy Older Population: Cooper Center Longitudinal Study

The purpose of this study was to examine the association between self-reported physical activity (PA) and mean common carotid artery intima-media thickness (CCA IMT) among older adults. The data are from 1,811 Cooper Center Longitudinal Study participants, who were aged ≥60 years, with no history of cardiovascular disease. A medical history questionnaire was used to assess PA. Carotid ultrasound was performed to measure CCA IMT and the presence of plaque and stenosis. Logistic regression models were constructed to estimate the association between PA and CCA IMT after adjustment for covariates. The participants were aged 69.2 ± 5.9 years, and the majority were male (73.3%) and White (96.7%). The odds ratio of abnormal thickening of CCA IMT was 0.72 (95% confidence interval [0.54, 0.96]) in physically active participants (≥500 metabolic equivalent·min/week) after adjustment for covariates. In the current study, meeting PA guidelines in older adulthood was associated with lower odds of abnormal thickening of CCA IMT.

The association of dietary patterns and carotid intima-media thickness: A synthesis of current evidence

AIMS

Dietary pattern (DP) analysis has emerged as a holistic method to understand the effects of food intake on health outcomes. Though dietary intake has been associated with cardiovascular disease, the association of DPs and carotid intima-media thickness (CIMT), a robust early marker of cardiovascular disease progression has not been comprehensively investigated. This study systematically explores the association of a posteriori and a priori DPs and CIMT.

DATA SYNTHESIS

Through a systematic search of MEDLINE, CINAHL, and Web of Science, twenty studies that derived DPs using a posteriori or a priori methods with CIMT as an outcome were included. Four cross-sectional studies and 1 cohort paper reported a statistically significant association between increased consumption of 'unhealthy' foods (i.e processed meat, soda drinks and refined grain) and increased CIMT. While four cross-sectional studies reported a statistically significant association of DPs characterized by increased consumption of 'healthy' foods (i.e fruit and vegetables, fish) and decreased CIMT. DPs derived from each study varied depending on derivation method, study design and use of dietary data collection method.

CONCLUSION

Findings from this review are generally supportive of a trend between DPs with higher consumption of 'healthy' foods and lower consumption of 'unhealthy' foods and decreased CIMT; however, the association was largely not statistically significant. Evidence was overwhelmingly heterogeneous due to differences seen in DPs based on location and culture, sample characteristics and adjustment for confounders. Long-term prospective observational and interventional studies with standardized sample selection and dietary data collection are needed to significantly establish the role of DPs on CIMT.

The combined effect of physical activity and sedentary behavior on subclinical atherosclerosis: a cross-sectional study among Mexican Americans

BACKGROUND

Physical activity and sedentary behavior are considered independent risk factors for chronic disease. However, we do not fully understand their interrelation with key health outcomes such as subclinical atherosclerosis. This study examines the combined effects of sedentary behavior and physical activity on carotid intima-media thickness (cIMT) and presence of carotid plaque in a Mexican American population on the Texas-Mexico border.

METHODS

This cross-sectional study was conducted using retrospective data from a sample (n = 612) of participants from the Cameron County Hispanic Cohort. Carotid ultrasound was used to measure cIMT and presence of carotid plaque. Self-reported questionnaires were used to assess leisure time physical activity and sedentary behavior (TV/movie sitting and total sitting). A series of multivariable regression models were used to assess study aims. An interaction term between physical activity and sedentary behavior was included in models for each respective outcome. Models were controlled for demographic and health-related variables.

RESULTS

There were no significant associations found between physical activity, sedentary behavior and mean cIMT, or cIMT thickness ≥ 75th percentile for age and gender. However, there was a significant interaction between physical activity and TV/movie sitting with presence of carotid plaque. Participants who reported moderate levels of physical activity had significantly lower odds for presence of plaque compared to participants with no activity when TV/movie sitting time was ≤3 h per day. However, there was no significant difference in odds for presence of plaque between physical activity groups when TV/movie sitting exceeded 3 h/day. These results were consistent with models examining total sitting time.

CONCLUSIONS

Our results indicate that for Mexican Americans, there is a combined effect of sedentary behavior and physical activity on presence of carotid plaque. Participating in moderate physical activity is optimal for having lower levels of carotid plaque in addition to avoiding excessive levels of TV/movie sitting (≥3 h/day) and/or total sitting (≥8.5 h/day).

Dietary quality and carotid intima media thickness in type 1 and type 2 diabetes: Follow-up of a randomised controlled trial

BACKGROUND AND AIMS

The relationship between dietary intake and carotid intima media thickness (IMT) and pulse wave velocity (PWV) in individuals with type 1 and type 2 diabetes has not been well studied. We investigated the association between dietary intake and common carotid artery intima media thickness (CCA IMT) and PWV in a cohort with type 1 and type 2 diabetes.

METHODS AND RESULTS

A one-year randomised controlled trial was conducted to investigate the effect of improving dietary quality on CCA IMT. These subjects were followed up again approximately 12 months after the completion of the trial (i.e. approximately 24 month since baseline). The study cohort included 87 subjects that had dietary intake and CCA IMT measured at baseline and after a mean of 2.3 years' follow-up. PWV was measured in a subsample of this cohort. Age and baseline mean CCA IMT were strongly associated with mean CCA IMT at 24 months. After adjustment for age and baseline mean CCA IMT, baseline consumption of carbohydrate (r = -0.28; p = 0.01), sugars (r = -0.27; p = 0.01), fibre (r = -0.26; p = 0.02), magnesium (r = -0.25; p = 0.02) and the Alternate Health Eating Index (AHEI) score (r = -0.23; p = 0.03) were inversely associated with mean CCA IMT at 24 months. Mixed linear modelling showed an interaction between mean CCA IMT and AHEI at baseline (p = 0.024). Those who were in the highest AHEI tertile at baseline had greater CCA IMT regression at 24 months compared to those in the lowest tertile, after adjustment for baseline age, BMI, smoking pack years, time since diabetes diagnosis, and mean arterial pressure at baseline (mean -0.043 mm; 95% CI -0.084, -0.003; p = 0.029).

CONCLUSIONS

In this prospective analysis greater diet quality at baseline, as measured by the AHEI, was associated with greater CCA IMT regression after approximately two years. This suggests that greater diet quality is associated with better longer term vascular health in individuals with type 1 and type 2 diabetes.

Carotid Atherosclerosis Detected by Ultrasonography: A National Cross-Sectional Study

Background

Carotid atherosclerosis (CA) is a reflector of generalized atherosclerosis that is associated with systemic vascular disease. Data are limited on the epidemiology of carotid lesions in a large, nationally representative population sample. We aimed to evaluate the prevalence of CA detected by carotid ultrasonography and related risk factors based on a national survey in China.

Methods and Results

A total of 107 095 residents aged ≥40 years from the China National Stroke Prevention Project underwent carotid ultrasound examination. Participants with carotid endarterectomy or carotid stenting and those with stroke or coronary heart disease were excluded. Data from 84 880 participants were included in the analysis. CA was defined as increased intima–media thickness (IMT) ≥1 mm or presence of plaques. Of the 84 880 participants, 46.4% were men, and the mean age was 60.7±10.3 years. The standardized prevalence of CA was 36.2% overall, increased with age, and was higher in men than in women. Prevalence of CA was higher among participants living in rural areas than in urban areas. Approximately 26.5% of participants had increased IMT, and 13.9% presented plaques. There was an age‐related increase in participants with increased IMT, plaque presence, and stenosis. In multiple logistic regression analysis, older age, male sex, residence in rural areas, smoking, alcohol consumption, physical inactivity, obesity, hypertension, diabetes mellitus, and dyslipidemia were associated with CA.

Conclusions

CA was highly prevalent in a middle‐aged and older Chinese population. This result shows the potential clinical importance of focusing on primary prevention of atherosclerosis progression.

[TIMMA: Ultrasonographic scale of carotid atherosclerosis by vascular neurologists]

BACKGROUND

Carotid atherosclerosis is a powerful predictive factor of vascular risk at the individual patient level. Ultrasonography is a reference technique for the evaluation of this condition. However, its use in common practice remains difficult due to a lack of standardization and inter-operator variability. We present a new and simple technique for the assessment of carotid atherosclerosis; and evaluate the ability of vascular neurologists to obtain results consistent with those of an expert in vascular ultrasound.

MATERIAL AND METHODS

The TIMMA scale is an acronym for the five classes of carotid atherosclerosis in French, VIMMA in English: very important, important, moderate, minimal and absent. Combined, the first two classes make up the group "significant atheroma" and the last three classes make up the group "no significant atheroma". This scale was evaluated in 38 patients (76 carotid arteries) suffering from ischemic stroke or transient ischemic attack by five operators who are competent in carotid echocardiography: one TIMMA-trained (40 hours of training) vascular neurologist physician (VNP), three VNPs informed on the measurement method (1 hour of information) and one specialized vascular physician (SVP) who was considered to be the reference examiner. We evaluated the concordance between the VNPs and the SVP in classifying patients, firstly into the significant or not atheroma group and, secondly, into the five TIMMA classes.

RESULTS

The evaluation of the two-group clustering scale found a concordance between the informed VNPs and the SVP on 76 carotid arteries of 86% (kappa=0.7) and between the trained VNP and the SVP on 58 carotid arteries of 90% (kappa=0.8). The positive and negative predictive values for significant atheroma diagnosis were 100% and 81%, respectively, for the informed VNPs, and 100% and 80% for the trained VNP. The evaluation of the Five-Class Scale showed a concordance between the informed VNPs and the SVP of 46% (kappa=0.3), and between the trained VNP and the SVP of 74% (kappa=0.7).

CONCLUSION

TIMMA allows VNPs who are competent in carotid ultrasonography to reproducibly identify subjects with significant carotid atheroma. The contribution of this scale to the determination of cardiovascular risk should be evaluated.

L-Arginine and SDMA Serum Concentrations Are Associated with Subclinical Atherosclerosis in the Study of Health in Pomerania (SHIP)

Objective

Even though ˪-arginine (ARG) derivatives can predict cardiovascular mortality, their role as atherosclerotic biomarkers is unclear. We tested the hypothesis if asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA) and the sum of both (DMA) are positively, while ARG and ARG/ADMA ratio are inversely associated with carotid intima-media thickness (cIMT) and atherosclerotic plaque in the carotid artery.

Approach and Results

Cross-sectional data of 1999 subjects (age: 45–81 years; 48.2% ♀) from the population-based Study of Health in Pomerania (SHIP-0) was used. Analysis of variance and logistic regression models were calculated and all adjusted models were corrected for sex, age, smoking status, waist-to-hip ratio and estimated glomerular filtration rate. Increased cIMT (>75^th age-sex specific percentile) was found in 517 subjects (25.7%), while atherosclerotic plaque was detected in 1413 subjects (70.4%). SDMA tertiles were significantly positively associated with larger cIMT among subjects with high SDMA levels [>66^th: 0.82 (95%-CI 0.80; 0.85) mm]. High SDMA levels were related to a higher odds ratio (OR) of increased cIMT [OR 1.39 (95%-CI 1.08; 1.79)]. Furthermore, ARG was positively associated with atherosclerotic plaques [OR 1.41 (95%-CI 1.07; 1.85)]. No relation was found for ADMA and atherosclerosis.

Conclusions

In conclusion, the hypothesis of a positive association between SDMA with an increased cIMT was confirmed. Unexpectedly, ARG was positively related to atherosclerotic plaque. In view of these inconsistent findings, the impact of ARG derivatives as atherosclerotic biomarkers deserves further research.

Medical and Revascularization Therapies for Asymptomatic Carotid Stenosis

Asymptomatic internal carotid artery stenosis increases with age and is more common in men. Carotid endarterectomy and stenting have reduced stroke rates in patients with asymptomatic carotid stenosis in clinical trials. A variety of risk stratification methods are available for selection of patients with carotid stenosis for revascularization. In the past decade, there is increasing evidence that the rate of stroke declined with the use of aggressive multi-modal medical therapy. These developments have led to new clinical trials to compare revascularization versus aggressive medical therapy in patients with asymptomatic carotid stenosis.

Association between physical activity and peripheral artery disease and carotid artery stenosis in a self-referred population of 3 million adults

OBJECTIVE

Although the relationship between physical activity and coronary heart disease is well characterized, a paucity of data exists on physical activity and vascular disease in other arterial territories. This study examined the prevalence of peripheral artery disease (PAD) and carotid artery stenosis (CAS) in association with physical activity.

APPROACH AND RESULTS

The association between physical activity and vascular disease was examined in >3 million self-referred US participants in the United States from 2003 to 2008 who completed a medical and lifestyle questionnaire in the Life Line screening program. All subjects were evaluated by screening ankle brachial indices <0.90 for PAD and ultrasound imaging for CAS >50%. Multivariable logistic regression modeling was used to estimate odds of disease. Among 3 250 350 subjects, 63% of the population engaged in some leisure time vigorous physical activity. After adjustment for age, sex, race/ethnicity, hypertension, hypercholesterolemia, smoking status, diabetes mellitus, body mass index, and family history of cardiovascular disease, subjects who reported any physical activity had a significantly lower odds of PAD (odds ratio, 0.64; 95% confidence interval, 0.63-0.65) and CAS (odds ratio, 0.80; 95% confidence interval, 0.79-0.81). The association between physical activity with PAD and CAS was robust when stratified by sex, race, and age categories. Physical activity intensity frequency was associated with lower PAD and CAS in a graded manner (P trend <0.0001 for both). Findings seemed unaffected by confounding by comorbidity or indication.

CONCLUSIONS

In a large population-based study, higher levels of physical activity were independently associated with lower odds of vascular disease in the lower extremities and carotid arteries.

The association between IGF-I/IGFBP-3 and subclinical end points: epidemiology faces the limits

BACKGROUND

The variation in laboratory measurements represents a challenge in clinical practice and epidemiological research. The use of different analytical platforms might have led to different results, which were often discussed in the interpretation of conflicting results. We aim to study the impact of two different IGF-I and IGF binding protein 3 assays on published epidemiological studies.

METHODS

We compared epidemiological results based on the previous gold standard Nichols Advantage, which is no longer available, with these based on the IDS-iSYS assay. The latter follows the recently proposed Keswick criteria. We reinvestigated published association studies between IGF-I or IGF binding protein 3 and anthropometry, subclinical cardiovascular diseases including intima-media thickness or left ventricular mass index, and hard end points like mortality and single-nucleotide polymorphisms of our genome-wide association study in the Study of Health in Pomerania.

RESULTS

We demonstrated that there are significant differences in the associations of IGF-I measured by the Nichols or IDS-iSYS assay and subclinical outcomes including intima-media thickness and left ventricular mass index. However, concerning hard outcomes like mortality or single-nucleotide polymorphisms, our analyses revealed similar results with comparable regression estimates.

CONCLUSION

With our study we queried not only the accuracy of measurement but also the effect of different methods on study results. The establishment of laboratory standards like the Keswick criteria should be enforced to allow reliable comparisons of different methods and thus clinical and epidemiological studies. Single-center studies have to be interpreted carefully. Moreover, to assure the reliability of studies, their results should be replicated in a meta-analysis, and a generated hypothesis by epidemiology should be proven by intervention studies.

Long-term effect of different physical activity levels on subclinical atherosclerosis in middle-aged men: a 25-year prospective study

BACKGROUND

The purpose of the study was to investigate the influence of lifetime physical activity (PA) on selected indices of atherosclerosis in longitudinal observation of middle-aged men.

METHODS

The subject of the study was a cohort of 101 men (mean age 59,7 ± 9,0 years), free of cardiovascular symptoms and treatment, participating in follow-up examinations in the years 1985/90-2011/12. Self-report PA was assessed by interviewer-administered Seven-Day PA Recall and Historical PA questionnaire. Subclinical atherosclerosis was measured by assessing the coronary artery calcification (CAC) according to Agatston's method using multi-slice computed tomography; the carotid intima-media thickness (IMT) using high-resolution B-mode ultrasound; and the reactive hyperemia index (RHI) using peripheral arterial tonometry (EndoPAT2000). The participants were initially divided into three groups according to tertiles of exercise-related energy expenditure (EE) in kcal/week at baseline, i.e. <2050 (low-to-moderate; n = 33), 2050-3840 (high; n = 34), >3840 (very high; n = 34).

RESULTS

The low-to-moderate, high and very high PA groups were comparable in terms of age and atherosclerosis risk factors at baseline. No linear relationship was found between PA and CAC, IMT and RHI. Men who maintained low-to-moderate (n = 26), high (n = 21) and very high (n = 15) PA level had the mean CAC of 286.1 ± 361.9, 10.7 ± 28.9, and 106.1 ± 278.3 (p<0.001 for low-to moderate vs high; p<0.05 for low-to-moderate vs very high); the mean IMT of 0.751 ± 0.19 mm, 0,641 ± 0.26 mm, and 0.750 ± 0.60 mm (p>0.05); and the mean RHI of 1.69 ± 0.4, 2.00 ± 0.4, and 2.13 ± 0.5 (p for trend = 0.050), respectively. No cases of CAC>400, IMT ≥ 0.9 and RHI<1.67 were noted only among men with maintained high PA level. At final examination men with high and very high PA had more favorable cardiometabolic profile than men with lower PA.

CONCLUSIONS

Maintaining regular high PA level through young and middle adulthood may protect against atherosclerosis as measured by CAC, IMT and RHI.

Association of socioeconomic status with iodine supply and thyroid disorders in northeast Germany

OBJECTIVES

Studies on the potential association of socioeconomic status with iodine supply and the risk for thyroid disorders from developed countries are sparse. Socioeconomic status, however, may particularly impact the efficiency of iodine prophylaxis programs, which are based on the voluntary principle. This study aims to investigate whether the socioeconomic status is cross-sectionally and longitudinally related to low urinary excretion or thyroid disorders in the population of northeast Germany.

METHODS

Data of the population-based Study of Health in Pomerania were used. The study population comprised 4056 adults for cross-sectional and 2860 adults for longitudinal analyses. Assessment of socioeconomic status comprised different scales of education, income, employment, and occupation. Thyroid-related outcomes included urinary iodine excretion, serum thyrotropin, and sonographically defined goiter and nodules. Statistical analyses were adjusted for confounders.

RESULTS

Some of the socioeconomic variables were associated with thyroid-related characteristics in cross-sectional analyses. For example, there was an overall tendency for groups with higher education and higher income to have larger thyroid volumes and an increased risk of goiter. However, most of these associations did not attain statistical significance after correcting the target p-value for multiple testing. Longitudinal analyses did not demonstrate consistent results.

CONCLUSIONS

Socioeconomic status neither substantially influences iodine supply nor does it have a major impact on the prevalence and incidence of thyroid deficiency-related disorders in the adult population of northeast Germany, indicating a good efficacy of the German iodine fortification program in all socioeconomic groups.

Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011

Intima-media thickness (IMT) provides a surrogate end point of cardiovascular outcomes in clinical trials evaluating the efficacy of cardiovascular risk factor modification. Carotid artery plaque further adds to the cardiovascular risk assessment. It is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness >1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. The scientific basis for use of IMT in clinical trials and practice includes ultrasound physics, technical and disease-related principles as well as best practice on the performance, interpretation and documentation of study results. Comparison of IMT results obtained from epidemiological and interventional studies around the world relies on harmonization on approaches to carotid image acquisition and analysis. This updated consensus document delineates further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT. Standardized methods will foster homogenous data collection and analysis, improve the power of randomized clinical trials incorporating IMT and plaque measurements and facilitate the merging of large databases for meta-analyses. IMT results are applied to individual patients as an integrated assessment of cardiovascular risk factors. However, this document recommends against serial monitoring in individual patients.

Missing, unreplaced teeth and risk of all-cause and cardiovascular mortality

BACKGROUND

A dentition of at least 20 teeth is associated with sufficient masticatory efficiency and is a stated health goal of the World Health Organisation. We examined whether subjects with missing, unreplaced teeth had an increased mortality risk.

METHODS

We used data prospectively collected from those participants in the population-based Study of Health in Pomerania who had fewer than 20 remaining teeth, resulting in a sample of 1803 participants with a median age of 64 years. Of those, 188 subjects had 9 or more unreplaced teeth. During a median follow-up period of 9.9 years, 362 subjects died, 128 of whom of cardiovascular causes.

RESULTS

We found that having 9 or more unreplaced teeth was related to all-cause mortality (rate ratio 1.53, 95% CI: 1.11-2.10; adjusted for variables according to causal diagrams: remaining teeth, age, sex, education, income, marital status, partnership, and oral health behaviour) and cardiovascular mortality (rate ratio 1.94, 95% CI: 1.15-3.25). When adjusting not only for the variables according to causal diagrams but also for smoking, alcohol consumption, physical activity, obesity, hypertension, diabetes, and dyslipidemia, the rate ratio was 1.43 (95% CI: 1.05-1.96) for all-cause mortality and 1.88 (95% CI: 1.10-3.21) for cardiovascular mortality.

CONCLUSIONS

A reduced, unrestored dentition is associated with increased mortality risk. Thus, clinicians and dietitians have a responsibility to consider individual chewing ability in nutritional recommendations.

Impact of exercise training on arterial wall thickness in humans

Thickening of the carotid artery wall has been adopted as a surrogate marker of pre-clinical atherosclerosis, which is strongly related to increased cardiovascular risk. The cardioprotective effects of exercise training, including direct effects on vascular function and lumen dimension, have been consistently reported in asymptomatic subjects and those with cardiovascular risk factors and diseases. In the present review, we summarize evidence pertaining to the impact of exercise and physical activity on arterial wall remodelling of the carotid artery and peripheral arteries in the upper and lower limbs. We consider the potential role of exercise intensity, duration and modality in the context of putative mechanisms involved in wall remodelling, including haemodynamic forces. Finally, we discuss the impact of exercise training in terms of primary prevention of wall thickening in healthy subjects and remodelling of arteries in subjects with existing cardiovascular disease and risk factors.

Effects of physical activity on cardiovascular disease

Much attention has been directed toward lifestyle modifications as effective means of reducing cardiovascular disease risk. In particular, physical activity has been heavily studied because of its well-known effects on metabolic syndrome, insulin sensitivity, cardiovascular disease risk, and all-cause mortality. However, data regarding the effects of exercise on various stages of the atherosclerosis pathway remain conflicting. The investigators review previously published reports for recent observational and interventional trials investigating the effects of physical activity on markers of (or causal factors for) atherosclerotic burden and vascular disease, including serum lipoproteins, systemic inflammation, thrombosis, coronary artery calcium, and carotid intima-media thickness. In conclusion, the data show a correlation between physical activity and triglyceride reduction, apolipoprotein B reduction, high-density lipoprotein increase, change in low-density lipoprotein particle size, increase in tissue plasminogen activator activity, and decrease in coronary artery calcium. Further research is needed to elucidate the effect of physical activity on inflammatory markers and intima-media thickness.

Serum insulin-like growth factor I and its binding protein 3 in their relation to intima-media thickness: results of the study of health in Pomerania (SHIP)

OBJECTIVE

Previous studies detected associations between lower insulin-like growth factor I (IGF-I) levels and increased risk of congestive heart failure or ischaemic heart disease. The aim of the present study was to assess the association of IGF-I and its binding protein 3 (IGFBP-3) with the carotid intima-media thickness (IMT) as marker of asymptomatic cardiovascular disease.

DESIGN AND POPULATION

From the population-based Study of Health in Pomerania (SHIP), a total of 2286 participants aged 45 years or older with readable ultrasound of the carotid arteries were available for the present analyses.

METHODS AND MEASUREMENTS

Serum IGF-I and IGFBP-3 levels were categorized into three groups (low, moderate, high) according to the sex-specific 10th and 90th percentile. Analyses of variance (anova) and logistic regression analyses adjusted for age, waist circumference, diabetes, hypertension and creatinine clearance were performed.

RESULTS

After adjusting for confounding factors, IGF-I and the IGF-I/IGFBP-3 ratio were positively related to IMT in anova. Logistic regression analyses confirmed these findings and showed that high IGF-I levels, a high IGF-I/IGFBP-3 ratio and low IGFBP-3 levels were associated to higher odds of increased IMT.

CONCLUSION

In conclusion, high IGF-I or high IGF-I/IGFBP-3 ratio values and low IGFBP-3 levels are associated with increased IMT. Therefore, systemic levels of the IGF axis or alterations in the balance of its components are associated with subclinical atherosclerotic disease.

Effect of regular physical activity on carotid intima-media thickness. Results from a 6-year prospective study in the early stage of hypertension

AIM

To study the effect of leisure-time physical activity on the progression of carotid intima-media thickness (IMT) in the early stage of hypertension.

METHODS

We studied 47 sedentary and 40 physically active young pre-hypertensive or stage 1 hypertensive subjects. IMT was assessed in the common carotid artery, carotid bulb and internal carotid artery at baseline and after 6.5 years.

RESULTS

Cumulative maximum IMT of the three carotid segments (M-MAX, 0.13 ± 0.08 vs 0.10 ± 0.07 mm, p = 0.006) and cumulative mean IMT (m-IMT, 0.11 ± 0.07 vs 0.09 ± 0.06 mm, p = 0.01), adjusted for confounders, increased to a greater degree in the sedentary than the active subjects. Differences in known risk factors explained a large proportion of the observed association. Inclusion of baseline cholesterol in the regression model attenuated the strength of the association for both M-MAX (p = 0.04) and m-IMT (p = 0.049). When also baseline blood pressure, heart rate, and body mass index were taken into account the association with physical activity status remained significant for maximum IMT of internal carotid artery (p = 0.034) and was of borderline significance for M-MAX (p = 0.066).

CONCLUSIONS

Physical activity can delay the progression of carotid IMT in hypertension. This effect is mediated in substantial part by the better risk factor profile in active subjects.

Partial misspecification of survey design features sufficed to severely bias estimates of health-related outcomes

OBJECTIVE

Surveys frequently deviate from simple random sampling through the use of unequal probability sampling, stratified sampling, and multistage sampling. This work uses a survey of public health to systematically illustrate the effects of incompletely accounting for strata, clustering, and weights.

STUDY DESIGN AND SETTING

Data analysis was based on the Study of Health in Pomerania (n=4,308, 20-79 years), a two-stage regional survey with high sampling fractions at the first stage. Effects of survey design features comprising weights, stratification, clustering, and finite population correction on point and variance estimates of lifestyle indicators and clinical parameters were assessed.

RESULTS

Misspecifications of the survey design substantially affected both the point estimates of health characteristics and their standard errors (SEs). The strongest bias in SEs concerned the omission of the second sampling stage. Ignoring the sampling design led to minor differences in variance estimates from the complete setup. Weighting predominantly affected point estimates of lifestyle factors.

CONCLUSION

A partial misspecification of survey design elements may bias variance estimates severely and is sometimes even more harmful compared with completely neglecting design elements. If subgroups are sampled at different rates, weighting is of particular relevance with regard to prevalence estimates of lifestyle indicators.

Predictive modeling of health care costs: do cardiovascular risk markers improve prediction?

BACKGROUND

To investigate the ability of multiple cardiovascular disease (CVD) markers to predict future health care costs. CVD markers included traditional risk factors (smoking status, body mass index, waist circumference, alcohol intake, diabetes, total : high-density lipoprotein cholesterol ratio, actual hypertension, physical activity) and newer markers (carotid intima-media thickness, hemoglobin A1c, apolipoprotein B : apolipoprotein A-1 ratio, lipoprotein (a), leukocyte count, high-sensitive C-reactive protein, plasma fibrinogen, estimated glomerular filtration rate, urinary albumin : creatinine ratio).

DESIGN AND METHODS

The study sample consisted of 2233 participants without history of myocardial infarction, stroke, heart failure, and angina pectoris at baseline (50.6% women; mean age 60.9 years; age range 45-81 years) from the cohort Study of Health in Pomerania, Germany (median follow-up 5 years).

RESULTS

Predictive modeling revealed that a basic model with sex, age, years of school education, insurance status, and income explained 0.9% in baseline total cost variation and 1.5% in total cost variation at 5-year follow-up. The incorporation of a combination of significant CVD markers resulted in an increase in the R2 for total costs of 70% at baseline and 69% after 5 years, with a final R2 of 0.030 at baseline and an R2 of 0.048 at 5-year follow-up.

CONCLUSION

Our data suggest that for individuals without history of CVD, the simultaneous addition of several CVD risk markers improves predictive modeling of future health care costs beyond that of a model that is based on established health care predictors.

Chronic carbon monoxide exposure is associated with the increases in carotid intima-media thickness and C-reactive protein level

Being the most common cause of death from poisoning worldwide, cardiovascular manifestations of acute carbon monoxide (CO) poisoning have been subject of various studies but current evidence about effects of chronic CO exposure on atherosclerosis is limited which is very common. We aimed to investigate association of chronic CO exposure with atherosclerosis by measuring carotid intima-media thickness (CIMT) and high-sensitivity C-reactive protein (hs-CRP). Forty healthy male non-smoker indoor barbecue workers (mean age; 33.0 +/- 9.0 years) working in different restaurants for at least three years and 48 age-matched healthy men (mean age; 34.3 +/- 6.6 years) enrolled in the study. Clinical characteristics of indoor barbecue workers and control group were comparable in terms of body mass index, blood pressure, and lipid profile. However, carboxyhemoglobin (COHb) (6.4 +/- 1.5% vs. 2.0 +/- 1.1%), hs-CRP (2.7 +/- 2.0 mg/L vs. 1.1 +/- 0.8 mg/L) and CIMT (1.1 +/- 0.3 mm vs. 0.9 +/- 0.1 mm) were higher in indoor barbecue workers (p < 0.001 for each). In Pearson correlation analysis, CIMT was correlated with COHb concentration (r = 0.635, p < 0.001) and hs-CRP level (r = 0.466, p < 0.001). Among indoor barbecue workers, the years worked (years exposed to CO) are correlated with COHb, hs-CRP and CIMT. In multivariate analysis, COHb concentration is the only independent predictor of CIMT (beta = 0.571, p < 0.001). The increased CIMT and hs-CRP in indoor barbecue workers suggest that chronic CO exposure may increase the risk of atherosclerotic cardiovascular events.

Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-century health priorities and be aligned with global and regional public health strategies. A proposed focus on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and disability. The 21st-century physical therapist needs to be able to practice such competencies within the context of a culturally diverse society to effect positive health behavior change. The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions. Physical therapists need to impact health globally through public and social health policy as well as one-on-one care. This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical therapists to health and well-being and reduced health risk is consistent with minimizing the substantial social and economic burdens of lifestyle conditions globally.

Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions

Part I of this two-part introduction to this Special Issue on the practice of physical therapy in the 21st century outlines the epidemiological basis and rationale for evidence-informed physical therapy practice for addressing contemporary health priorities. This evidence emanates from the definition of health by the World Health Organization (WHO) and the International Classification of Functioning (ICF), and WHO and other international databases on the prevalence of lifestyle conditions. Lifestyle conditions include ischemic heart disease, smoking-related conditions, hypertension and stroke, obesity, diabetes, and cancer. Epidemiological data combined with evidence supporting the effectiveness of noninvasive interventions related to physical therapy to address these priorities (e.g., health education and exercise) are highly consistent with the promotion of health and wellness and the ICF. Given their commitment to exploiting effective noninvasive interventions, physical therapists are in a preeminent position to focus on prevention of these disabling and lethal conditions in every client or patient, their cure in some cases, as well as their management. Thus, a compelling argument can be made that clinical competencies in 21st century physical therapy need to include assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment and counseling, recommendations for physical activity and exercise, stress assessment and basic stress reduction recommendations, and sleep assessment and basic sleep hygiene recommendations. The physical therapist can then make an informed clinical judgment regarding whether a client or patient needs to be referred to another professional related to one or more of these specialty areas. The prominence of physical therapy as an established health care profession and its unique pattern of practice (prolonged visits over prolonged periods of time) attest further to the fact that physical therapists are uniquely qualified to lead in the assault on lifestyle conditions. Evidence-based physical therapy practiced within the context of epidemiological indicators (i.e., evidence-informed practice) maximally empowers clinicians to promote lifelong health in every person and in turn, the health of communities. This vision of physical therapy's leading role in health promotion and health care in the 21st century holds the promise of reducing the need for invasive health interventions (drugs and surgery). Part II of this introduction describes evidence-based physical therapy practice within this context of evidence-informed practice.

Factors associated with gender difference in the intima-media thickness of the common carotid artery

AIM

To investigate the gender differences associated with a thinner intima-media thickness (IMT) of the common carotid artery (CCA) in women.

MATERIALS AND METHODS

In a sample of 218 consecutive healthy volunteers comprising 110 men and 108 women, the IMT of the CCA was measured using B-mode ultrasonography. Blood pressure, fasting blood sugar, body mass index (BMI), blood lipid profile, homocysteine, folic acid, uric acid, high sensitive C-reactive protein, and thiobarbituric acid reactive substances (TBARS) levels were measured and compared with each other in both genders.

RESULTS

The IMT of the CCA was significantly thinner in women than in men (p=0.012). Blood pressure, fasting plasma glucose, BMI, low-density lipoprotein cholesterol, triglycerides, homocysteine, uric acid, and TBARS were significantly (p<0.05) lower, folic acid and high-density lipoprotein cholesterol (HDL-C) were significantly (p<0.0001) higher in women compared with men. Multivariable logistic regression analysis revealed that higher serum levels of homocysteine, uric acid, and TBARS, and lower serum levels of HDL-C were significantly (p<0.05) associated with male sex. Multiple linear regression analysis further revealed that age, sex, and BMI were independently associated with CCA IMT.

CONCLUSIONS

The IMT of the CCA was thinner in women than in men. Traditional vascular risk factors explain only a small amount of variance in multivariate regression models supporting the hypothesis that other behavioural, sex hormone-related or genetic factors, which have not been sufficiently explored so far, may play a role in the gender differences of IMT.

Prevalence of the Metabolic Syndrome in Southwest Germany

The metabolic syndrome is a highly prevalent multifaceted clinical entity. Obesity, which is part of the metabolic syndrome, is the fastest growing health-related problem worldwide. Since currently prevalence data of the metabolic syndrome are lacking from Germany, we have applied ATP III-criteria in two urban and rural cohorts. Our population-based studies provide evidence that the prevalence of the metabolic syndrome increases with age. It was found to be more prevalent in a rural population and in this group it clustered in males. As a consequence of our population-based studies evidence that especially the rural population is at high risk for future macrovascular complications is substantiated. The urgent need for preventive measures aimed at reducing the significantly increased health risk is underscored.

Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and metaregression analysis

BACKGROUND AND PURPOSE

In the discussion on the value of population-wide screening for asymptomatic carotid artery stenosis (ACAS), reliable prevalence estimates are crucial. We set out to provide reliable age- and sex-specific prevalence estimates of ACAS through a systematic literature review and meta-regression analysis.

METHODS

We searched PubMed and EmBase until December 2007 for studies that reported the prevalence of ACAS in a population free of symptomatic carotid artery disease. Data were extracted with use of a standardized form on participants' characteristics, assessment method, study quality, and prevalence estimates for moderate (>or=50% stenosis) and severe (>or=70% stenosis) ACAS. Metaregression was used to investigate sources of heterogeneity.

RESULTS

Forty studies fulfilled the inclusion criteria. There was considerable variation among studies with respect to demographics, methods of grading stenosis, and stenosis cutoff point used. The pooled prevalence of moderate stenosis was 4.2% (95% CI, 3.1% to 5.7%). Prevalence of moderate stenosis among people age <70 years was 4.8% (95% CI, 3.1% to 7.3%) in men and 2.2% (95% CI, 0.9% to 4.9%) in women. Among those >or=70 years, prevalence increased to 12.5% (95% CI, 7.4% to 20.3%) in men and to 6.9% (95% CI, 4.0% to 11.5%) in women. Metaregression showed that both age and sex significantly affected the prevalence of moderate stenosis. No contribution of study size, publication year, geographic region, assessment method, and study quality was found. The pooled prevalence of severe stenosis was 1.7% (95% CI, 0.7% to 3.9%).

CONCLUSIONS

Prevalence of moderate stenosis increases with age in both men and women, but men at all ages have the higher prevalence estimates. The number of studies that allowed meaningful data synthesis of severe stenosis was limited.

A meta-analysis of candidate gene polymorphisms and ischemic stroke in 6 study populations: association of lymphotoxin-alpha in nonhypertensive patients

BACKGROUND AND PURPOSE

Ischemic stroke is a multifactorial disease with a strong genetic component. Pathways, including lipid metabolism, systemic chronic inflammation, coagulation, blood pressure regulation, and cellular adhesion, have been implicated in stroke pathophysiology, and candidate gene polymorphisms in these pathways have been proposed as genetic risk factors.

METHODS

We genotyped 105 simple deletions and single nucleotide polymorphisms from 64 candidate genes in 3550 patients and 6560 control subjects from 6 case-control association studies conducted in the United States, Europe, and China. Genotyping was performed using the same immobilized probe typing system and meta-analyses were based on summary logistic regressions for each study. The primary analyses were fixed-effects meta-analyses adjusting for age and sex with additive, dominant, and recessive models of inheritance.

RESULTS

Although 7 polymorphisms showed a nominal additive association, none remained statistically significant after adjustment for multiple comparisons. In contrast, after stratification for hypertension, 2 lymphotoxin-alpha polymorphisms, which are in strong linkage disequilibrium, were significantly associated among nonhypertensive individuals: LTA 252A>G (additive model; OR, 1.41 with 95% CI, 1.20 to 1.65; P=0.00002) and LTA 26Thr>Asn (OR, 1.19 with 95% CI, 1.06 to 1.34; P=0.003). LTA 252A>G remained significant after adjustment for multiple testing using either the false discovery rate or by permutation testing. The 2 single nucleotide polymorphisms showed no association in hypertensive subjects (eg, LTA 252A>G, OR, 0.93; 95% CI, 0.84 to 1.03; P=0.17).

CONCLUSIONS

These observations may indicate an important role of LTA-mediated inflammatory processes in the pathogenesis of ischemic stroke.

Prevalence and determinants of increased serum lipase levels in a general population

OBJECTIVES

There is little information on the prevalence of increased serum lipase levels and its determinants from population-based studies. The present study was performed to provide such information.

METHODS

We used data from the 4275 subjects aged 20 to 79 years who were recruited for the population-based Study of Health in Pomerania. Serum lipase levels were determined colorimetrically; levels > or =3.17 micromol/s x l were considered increased.

RESULTS

The prevalence of increased serum lipase levels was 3.4%. The prevalence of self-reported chronic pancreatitis in this population was 0.7%. Subjects with and without increased serum lipase levels did not differ with respect to symptoms indicative of pancreatitis including abdominal feeling of fullness, abdominal pain, nausea, and loss of weight. High serum lipase levels correlated with advanced age, increased serum creatinine levels, and use of steroids or enalapril.

CONCLUSIONS

Increased serum lipase levels are unrelated to pancreatitis-related symptoms. Renal insufficiency and prevalent pancreatitis explain increased serum lipase levels in a minority of subjects. In clinical practice, drugs including steroids and enalapril should be excluded as cause of increased serum lipase levels. The predictive roleof lipase measurements with respect to other pancreatic or extrapancreatic disorders has to be investigated in cohort studies.

Atherothrombosis and plaque heterology: different location or a unique disease?

Formation of unstable plaques frequently results in atherothrombosis, the major cause for ischaemic stroke, myocardial infarction and peripheral arterial disease. Patients who have symptomatic thrombosis in one vascular bed are at increased risk of disease in other beds. However, the development of the disease in carotid, coronary and peripheral arteries may have different pathophysiology suggesting that more complex treatment protocols may have to be designed to reduce plaque development at different locations. In this review we describe the known risk factors, compare the developmental features of coronary and carotid plaque development and determine their association with end-point ischaemic events. Differences are also seen in the genetic contribution to plaque development as well as in the deregulation of gene and protein expression and cellular signal transduction activity of active cells in regions susceptible to thrombosis. Differences between carotid and coronary artery plaque development might help to explain the differences in anatomopathological appearance and risk of rupture.

Refining exposure definitions for studies of periodontal disease and systemic disease associations

BACKGROUND

Substantial variation exists in reported associations between periodontal infections and cardiovascular disease. Imprecise periodontal exposure definitions are possible contributors to this variability. We studied appropriate exposure definitions for studying associations between clinical periodontal disease (PD) and systemic disease.

METHODS

Data originate from men and women aged 20-79 enrolled in the Study of Health in Pomerania (SHIP) from 1997-2001. Age and sex-adjusted correlation analysis identified PD definitions with the highest cross-sectional associations with three subclinical markers of systemic disease: plasma fibrinogen (n = 3481), serum hemoglobin A1c (HbA1c) (n = 3480), and common carotid artery intima-media thickness (c-IMT) (n = 1745, age > or = 45).

RESULTS

In men and women, percent of sites with attachment loss (AL) > or =6 mm and tooth loss both revealed the highest correlation with HbA1c (rho = 0.11; several other definitions related similarly), while the strongest fibrinogen correlation was observed with percent of sites with pocket depth > or =3 mm (rho = 0.19). Findings for c-IMT among men were strongest for percent of sites with AL > or =6 mm (rho = 0.14; several other definitions related similarly) while among women, percent of sites with pocket depth > or =5 or 6 mm had the highest observed correlation (rho = 0.13).

CONCLUSIONS

A range of near optimal definitions varied according to gender and whether the systemic disease marker reflected an acute or chronic situation. Pocket depth was more strongly correlated with the acute marker fibrinogen while attachment and tooth loss tended to be more strongly correlated with the chronic markers, HbA1c, and c-IMT. These findings can be useful in designing future studies investigating the association between PD and systemic disease.

The relation of exposure to shift work with atherosclerosis and myocardial infarction in a general population

OBJECTIVES

We tested the hypothesis that working shifts is related to atherosclerosis and myocardial infarction.

BACKGROUND

The number of shift workers is continuously increasing. Shift work is discussed to be related with cardiovascular heart disease.

METHODS

A total of 2510 subjects recruited for the population-based Study of Health in Pomerania were tested, 698 of whom were former shift workers. A general population sample was examined to reach generalizibility and to produce results independent from the effects of the personal shift schedule and from the specific working conditions. Carotid ultrasound was performed to evaluate carotid intima-media thickness. We used multivariable analyses to estimate the coronary heart disease risk, adjusted for age, sex and atherosclerotic risk factors, stratified by exposure to shift work and its duration.

RESULTS

Atherosclerotic risk factors differed in part between shift workers and non-shift workers. Shift work was associated with atherosclerosis and myocardial infarction, depending on the duration of the exposure and the age of the participants. Multivariable Cox regression analysis identified shift work as a risk factor for myocardial infarction to be manifest at younger ages (adjusted hazard ratio 1.53, 95% CI 1.06-2.22).

CONCLUSIONS

Exposure to shift work is a risk factor for atherosclerosis and myocardial infarction. Special prevention programs for shift workers should be provided.

Association between depression and subclinical carotid atherosclerosis in patients with Type 1 diabetes

AIMS

Recent studies have suggested an association between depression and subclinical atherosclerosis as measured by presence of carotid atherosclerotic plaque and increased intima-media thickening in non-clinical populations. Given the high prevalence of depression in patients with Type 1 diabetes and the diabetes-related risk factors for atherosclerosis, we hypothesized that this relation might also be of special relevance in Type 1 diabetic patients.

METHODS

Intima-media thickness (IMT) and the presence of plaques in the carotid arteries were quantitatively assessed by high-resolution ultrasound in 175 adults (89 men, 86 women) with an established diagnosis of Type 1 diabetes. Having been treated for depression or current Beck Depression Inventory scores > 10 were considered to indicate depression.

RESULTS

In men, the risk of plaque was higher in depressed subjects relative to non-depressed participants after adjustment for age, smoking status, systolic blood pressure, dyslipidaemia and body mass index [odds ratio (OR) 5.19; 95% confidence interval (CI) 1.29, 20.81]. Depressed women did not have an increased risk of plaque compared with non-depressed women (OR 0.97; 95% 95% CI 0.22, 4.34). We did not observe an association between depression and IMT, in men or in women.

CONCLUSIONS

In line with previous research, our findings suggest a link between depression and subclinical atherosclerosis in Type 1 diabetic men, but not in women.