The effects of human papillomavirus vaccination on cardiovascular diseases. The United States National Health and Nutrition Examination Survey

Aims

We investigated the association between HPV and CVDs in women with and without HPV vaccination.

Methods and results

We studied 9353 women aged between 18 to 59 years old who were tested for vaginal HPV DNA in the National Health and Nutrition Examination Survey (NHANES) 2003–2016. The CVDs were defined as the self-reported coronary heart diseases, heart attack, angina pectoris and stroke. The HPV vaccination status was extracted from the NHANES 2007–2016 database. The association between HPV and CVDs was studied using logistic regression, with adjustment for the potential confounders.

Among the participants, 40.8% (95% CI, 39.4–42.4) were HPV DNA positive, and 3.0% (95% CI, 2.6–3.5) had CVDs. 9.0% (95% CI, 8.0–10.0) of women received the HPV vaccine. The presence of vaginal HPV infection was associated with CVD [OR=1.66, 95% CI (1.28–2.16), P<0.01], which remained significant [OR=1.53, (95% CI 1.13–2.07), P<0.01] after adjustment for sociodemographic characteristics, smoking, alcohol use, number of sexual partners, cervical cancer, BMI, hypertension, diabetes, and hyperlipidemia. Women younger than 38 years old showed a stronger association between HPV and CVDs [OR=2.15, 95% CI (1.01–4.77), P<0.01]. The association was absent among those who wereHPV vaccinated [OR= 0.44, 95% CI (0.07–2.79), P=0.83], but only present among those who were not [OR=1.60, 95% CI (1.15–2.24), P<0.01].

Conclusions

In this large nationally representative survey, HPV infection was associated with CVDs. The association was absent in women vaccinated against HPV. Our findings regarding early HPV vaccinations may pave the way for new strategies for CVD prevention.

Funding Acknowledgement

Type of funding sources: None.

Lower risk of gout in sodium glucose cotransporter 2 (SGLT2) inhibitors versus dipeptidyl peptidase-4 (DPP4) inhibitors in type-2 diabetes patients: a propensity score-matched study

Background

The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2I) versus dipeptidyl peptidase-4 inhibitors (DPP4I) on the risk of new gout diagnosis have not been explored. This study aims to compare the effects of SGLT2I against DPP4I on gout risks in a Chinese population.

Methods

This was a retrospective population-based cohort study of patients with type-2 diabetes mellitus treated with SGLT2I or DPP4I between January 1st, 2015 and December 31st, 2020 in Hong Kong. The study outcomes are new-onset gout and all-cause mortality. Propensity score matching (1:1 ratio) between SGLT2I and DPP4I was performed. Univariable and multivariable Cox regression analysis models were conducted. Competing risks models and multiple approaches based on the propensity score were applied.

Patients

This study included 60996 patients (median age: 62.3 years old, 54.96% males; SGLTI group: n=21690; DPP4I group: n=39306).

Results

In the matched cohort, 1096 developed gout (IR: 2.52%) and 2195 died (IR: 5.05%). Univariable Cox regression showed that SGLT2I use was associated with lower risks of new diagnosis of gout (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.30–0.39; P-value<0.0001) and all-cause mortality (HR: 0.35; 95% CI: 0.32–0.39; P-value<0.0001) compared to DPP4I. The associated remained for both new diagnosis of gout (HR: 0.46; 95% CI: 0.37–0.57; P-value<0.0001) and all-cause mortality (HR: 0.38; 95% CI: 0.33–0.44; P-value<0.0001) after adjusting for significant demographics, past comorbidities, and non-SGLT2I/DPP4I medications. The risks of gout were lowered in each types of SGLT2I. The results were consistent on competing risk and other propensity score approaches analyses.

Conclusions

SGLT2I use was associated with lower risks of new gout diagnosis compared to DPP4I use.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of metabolic syndrome in the United States National Health and Nutrition Examination Survey (nhanes) 2011–2018

Background

Metabolic syndrome (MetS) is a cluster of risk factors presaging the development of cardiovascular disease and diabetes. It is a risk factor for severe coronavirus disease 2019 (COVID-19).

Purpose

To estimate the prevalence of MetS in the US National Health and Nutrition Examination Survey (NHANES) 2011–2018.

Methods

This cohort study included 22370 eligible participants aged ≥20 years from the NHANES 2011–2018. MetS was defined as the presence of at least three of these components: central obesity, reduced high-density lipoprotein, elevated triglycerides, elevated blood pressure and elevated fasting blood glucose. The prevalence of MetS was estimated taking into account the complex sampling. The time trend was evaluated using logistic regression. Annual percentage changes (APC) were measured trend in MetS prevalence.

Results

The prevalence of MetS was 36.2% (95% CI, 32.3–40.3), 34.8% (95% CI, 32.3–37.4), 39.9% (95% CI, 36.6–43.2) and 38.3% (95% CI, 35.3–41.3) in 2011–2, 2013–4, 2015–6, 2017–8, respectively (P for trend = 0.08). Among the MetS components, the prevalence of elevated glucose increased from 48.7% (95% CI, 45.9–51.5) in 2011–2 to 64.3% (95% CI, 61.0–67.4) in 2017–8 [P for trend <0.001; APC=11.7, (95% CI, 3.5–21.0)]. The prevalence of MetS in non-Hispanic Asian increased from 21.8% (95% CI, 16.7–28.0) in 2011–2 to 31.2% (95% CI, 27.4–35.3) in 2017–8 [P for trend <0.001; APC=14.6, (95% CI, 2.5–34.8)].

Conclusions

The prevalence of MetS remained stable during 2011 to 2018. Lifestyle modification is needed, especially among non-Hispanic Asians to prevent the metabolic syndrome and the associated risks of diabetes and cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Change in framingham cardiovascular disease risk between 2003 and 2014 in the hong kong population health survey

Background

The Framingham Risk model estimates a person's 10-year cardiovascular disease (CVD) risk.

Purpose

We aimed to calculate the change in sex-age specific Framingham CVD risk in the Hong Kong Population Health Survey (PHS) 2014/15 in comparison with the survey in 2003–05 (PHS2003/2004 & Heart Health Survey (HHS) 2004/2005).

Methods

Subjects aged 30–74 years from PHS2014/15 (n=1,662, n=4,445,869 after population weighing) and PHS2003/2004 & HHS2004/2005 (n=818, n=3,495,074 after population weighing) with complete data for the calculation of Framingham CVD predicted risk were included. The sex-specific CVD risks of participants were calculated based on their age, total cholesterol and high-density lipoprotein, mean systolic blood pressure, smoking habits, diabetic status, and treatment for hypertension. The mean sex-age specific CVD risks were then calculated, and the differences in CVD risk between the two surveys were analysed using ANOVA.

Results

There was no significant difference in 10-year CVD risks between the 2003–2005 and 2014/15 study populations (10.2% vs. 10.6%, p=0.29). After adjusting to a standard population (US Census 2000), the age-standardized CVD risk was lower in 2014–2015 than in 2003–05 (10.0% vs. 10.7%, p=0.017). More participants aged 65–74 were classified as high risk during 2003/04 (PHS2003/2004 & HHS2004/2005: 66.8% vs. PHS2014/15: 53.1%, p=0.026). This might be due to the decrease in the proportion of smokers among men (2003–2005: 30.5% vs. 24.0% in 2014–15, p<0.001).

Conclusions

Between 2003/04 and 2014/15, there was a small decrease in age-standardized 10-year CVD risk, which might be related to the reduction in smoking. However, more effort in targeting multiple CVD risk factors simultaneously is needed to achieve a greater reduction in CVD risk.

Funding Acknowledgement

Type of funding sources: None.

Proportion of patients taking indapamide developing severe hypokalaemia

Introduction

Diuretics are commonly used for the treatment of hypertension. Yet, hypokalaemia is a well-recognized adverse effect.

Purpose

To evaluate the proportion of patients taking indapamide who developed severe hypokalaemia, defined as requiring hospitalisation. Indapamide was by far the most commonly used diuretic for hypertension in Hong Kong.

Methods

We searched the Hong Kong Hospital Authority Clinical Data Analysis and Reporting System, which is a territory-wide database of computerised medical records. All hypertensive patients prescribed indapamide monotherapy in 2007–2016 and all admissions due to hypokalaemia in 2007–2018 were traced. Factors associated with hospitalisation were studied using multivariable logistic regression.

Results

During the study period, 62,881 patients were started on indapamide and 509 (0.81%) were hospitalised for hypokalaemia. 59% of these hospitalisations occurred within 16 weeks. Female sex (OR = 1.73; 95% CI, 1.43–2.09) and immediate-release formulation (OR = 1.44; 95% CI, 1.16–1.78) were associated with hospitalisation. In the multivariable model, advanced age was not a significant predictor. There were no deaths during hospitalisation and the median length of hospital stay was one day.

Conclusions

In this large population-based study with 147614 person-years of follow-up, severe hypokalaemia requiring hospitalisation was uncommon among hypertensive patients on indapamide. Half of these occurred during the first 16 weeks. Female sex and the immediate release formulation increased the risk. We conclude that using indapamide to treat hypertension is safe, even in the elderly, especially if the sustained release formulation is used and electrolytes are monitored periodically.

Funding Acknowledgement

Type of funding sources: None.

Optimal Cut-Offs of Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) to Identify Dysglycemia and Type 2 Diabetes Mellitus: A 15-Year Prospective Study in Chinese

Background

The optimal reference range of homeostasis model assessment of insulin resistance (HOMA-IR) in normal Chinese population has not been clearly defined. Here we address this issue using the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS), a prospective population-based cohort study with long-term follow-up.

Material & Methods

In this study, normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) were defined according to the 1998 World Health Organization criteria. Dysglycemia referred to IFG, IGT or T2DM. This study comprised two parts. Part one was a cross-sectional study involving 2,649 Hong Kong Chinese subjects, aged 25–74 years, at baseline CRISPS-1 (1995–1996). The optimal HOMA-IR cut-offs for dysglycemia and T2DM were determined by the receiver-operating characteristic (ROC) curve. Part two was a prospective study involving 872 subjects who had persistent NGT at CRISPS-4 (2010–2012) after 15 years of follow-up.

Results

At baseline, the optimal HOMA-IR cut-offs to identify dysglyceia and T2DM were 1.37 (AUC = 0.735; 95% confidence interval [CI] = 0.713–0.758; Sensitivity [Se] = 65.6%, Specificity [Sp] = 71.3%] and 1.97 (AUC = 0.807; 95% CI = 0.777–0.886; Se = 65.5%, Sp = 82.9%) respectively. These cut-offs, derived from the cross-sectional study at baseline, corresponded closely to the 75^th (1.44) and 90^th (2.03) percentiles, respectively, of the HOMA-IR reference range derived from the prospective study of subjects with persistent NGT.

Conclusions

HOMA-IR cut-offs, of 1.4 and 2.0, which discriminated dysglycemia and T2DM respectively from NGT in Southern Chinese, can be usefully employed as references in clinical research involving the assessment of insulin resistance.

Long-Term Combination Therapy with Aspirin and Clopidogrel

The possible additive antiplatelet effects of aspirin and clopidogrel have been explored in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) and Management of Atherothrombosis with Clopidogrel in High Risk Patients (MATCH) studies. To assess the overall absolute beneficial and/or harmful impact of aspirin and clopidogrel combination therapy compared with monotherapy with either drug, we analyzed the results from both trials in terms of number needed to treat per year. Treating between 35 and 204 at-risk patients for 1 year with combination therapy appeared to prevent 1 patient from experiencing an adverse primary cardiovascular outcome; whereas, about 1 in 63 such patients appeared liable to major bleeding during that period. We determined that the evidence to date indicates no overall advantage for combination therapy with anti-platelet drugs in preference to monotherapy.

Serum calcium and incident diabetes: an observational study and meta-analysis

The study aimed to prospectively evaluate if serum calcium is related to diabetes incidence in Hong Kong Chinese. The results showed that serum calcium has a significant association with increased risk of diabetes. The result of meta-analysis reinforced our findings.

INTRODUCTION

This study aimed to evaluate the association of serum calcium, including serum total calcium and albumin-corrected calcium, with incident diabetes in Hong Kong Chinese.

METHODS

We conducted a retrospective cohort study in 6096 participants aged 20 or above and free of diabetes at baseline. Serum calcium was measured at baseline. Incident diabetes was determined from several electronic databases. We also searched relevant databases for studies on serum calcium and incident diabetes and conducted a meta-analysis using fixed-effect modeling.

RESULTS

During 59,130.9 person-years of follow-up, 631 participants developed diabetes. Serum total calcium and albumin-corrected calcium were associated with incident diabetes in the unadjusted model. After adjusting for demographic and clinical variables, the association remained significant only for serum total calcium (hazard ratio (HR), 1.32 (95 % confidence interval (CI), 1.02-1.70), highest vs. lowest quartile). In a meta-analysis of four studies including the current study, both serum total calcium (pooled risk ratio (RR), 1.38 (95 % CI, 1.15-1.65); I (2) = 5 %, comparing extreme quantiles) and albumin-corrected calcium (pooled RR, 1.29 (95 % CI, 1.03-1.61); I (2) = 0 %, comparing extreme quantiles) were associated with incident diabetes. Penalized regression splines showed that the association of incident diabetes with serum total calcium and albumin-correlated calcium was non-linear and linear, respectively.

CONCLUSIONS

Elevated serum calcium concentration is associated with incident diabetes. The mechanism underlying this association warrants further investigation.

Cardiometabolic risk profile of participants with prediabetes diagnosed by HbA1c criteria in an urban Hong Kong Chinese population over 40 years of age

AIMS

To investigate the usefulness of the additional measurement of HbA1c , compared with performing only the oral glucose tolerance test (OGTT), in identifying participants at increased cardiometabolic risk, in an urban Chinese population.

METHODS

All participants from the fourth visit of the population-based Hong Kong Cardiovascular Risk Factors Prevalence Study, without known diabetes, were included. All had their glycaemic status assessed by OGTT and HbA1c , according to American Diabetic Association 2010 criteria.

RESULTS

Based on OGTT criteria alone, 3.5% of the study cohort (N = 1300) had diabetes and 19.2% had prediabetes. Based on HbA1c criteria only, 6.2% had diabetes and 61.2% had prediabetes. The measurement of HbA1c , in addition to the OGTT, increased the proportion of participants with diabetes to 7.8% and with prediabetes to 65.3%. Subjects with prediabetes having raised HbA1c but normal glycaemia (N = 600) had waist circumference, systolic blood pressure, fasting glucose, insulin resistance index (HOMA-IR), Gutt Index and Framingham 10-year cardiovascular risk scores intermediate between those with both normal HbA1c and glycaemia (N = 350), and those with impaired fasting glucose and/or impaired glucose tolerance (N = 249; all P < 0.01).

CONCLUSION

The measurement of HbA1c in our population, in addition to the OGTT, results in the detection of a large number of participants with prediabetes having raised HbA1c but normal glycaemia who have a cardiometabolic risk profile intermediate between impaired fasting glucose and/or impaired glucose tolerance and normal participants, and would benefit from early lifestyle intervention.

The pattern of abbreviation use in prescriptions: a way forward in eliminating error-prone abbreviations and standardisation of prescriptions

INTRODUCTION AND OBJECTIVES

Inappropriate abbreviations used in prescriptions have led to medication errors. We investigated the use of error-prone and other unapproved abbreviations in prescriptions, and assessed the attitudes of pharmacists on this issue.

METHODS

A reference list of error-prone abbreviations was developed. Prescriptions of outpatients and specialty clinic patients in a teaching hospital in Sri Lanka were reviewed during one month. An interviewer administered questionnaire was used to assess attitudes of pharmacists.

RESULTS

3370 drug items (989 prescriptions) were reviewed. The mean (standard deviation) number of abbreviations per prescription was 5.9 (3.5). The error-prone abbreviations used in the hospital were, μg (microgram), mcg (microgram), u (units), cc (cubic centimeter), OD (once a day), @ sign, d (days/daily), m (morning) and n (night), and among all prescriptions reviewed, they were used at a rate of 17.4%, 0.1%, 1.9%, 0.2%, 0.2%, 4.9%, 23.5%, 4.4% and 15.8% respectively. Among the 103 types of abbreviations observed, 71 were not standard acceptable abbreviations. Multiple abbreviations were used to indicate a single drug item/ instruction (N = 7). The abbreviation 'd' was used to denote 'daily' as well as 'days'. All pharmacists believed that using error-prone abbreviations will always (5.3%) or sometimes (94.7%) lead to medication errors.

CONCLUSIONS

Error-prone abbreviations and many other unapproved abbreviations are frequently used in hospitals. There is a need to educating health care professionals on this issue and introduce an in-house error-prone abbreviation list for their guidance.

Implementing a bar-code assisted medication administration system: effects on the dispensing process and user perceptions

PURPOSE

We assessed the effects of a bar-code assisted medication administration system used without the support of computerised prescribing (stand-alone BCMA), on the dispensing process and its users.

METHODS

The stand-alone BCMA system was implemented in one ward of a teaching hospital. The number of dispensing steps, dispensing time and potential dispensing errors (PDEs) were directly observed one month before and eight months after the intervention. Attitudes of pharmacy and nursing staff were assessed using a questionnaire (Likert scale) and interviews.

RESULTS

Among 1291 and 471 drug items observed before and after the introduction of the technology respectively, the number of dispensing steps increased from five to eight and time (standard deviation) to dispense one drug item by one staff personnel increased from 0.8 (0.09) to 1.5 (0.12) min. Among 2828 and 471 drug items observed before and after the intervention respectively, the number of PDEs increased significantly (P<0.001). 'Procedural errors' and 'missing drug items' were the frequently observed PDEs in the after study. 'Perceived usefulness' and 'job relevance' of the technology decreased significantly (P=0.003 and P=0.004 respectively) among users who participated in the before (N=16) and after (N=16) questionnaires surveys. Among the interviewees, pharmacy staff felt that the system offered less benefit to the dispensing process (9/16). Nursing staff perceived the system as useful in improving the accuracy of drug administration (7/10).

CONCLUSION

Implementing a stand-alone BCMA system may slow down and complicate the dispensing process. Nursing staff believe the stand-alone BCMA system could improve the drug administration process but pharmacy staff believes the technology would be more helpful if supported by computerised prescribing. However, periodical assessments are needed to identify weaknesses in the process after implementation, and all users should be educated on the benefits of using this technology.

Effects of adrenomedullin on tumour necrosis factor alpha, interleukins, endothelin-1, leptin, and adiponectin in the epididymal fat and soleus muscle of the rat

Adrenomedullin (ADM) is a peptide hormone, which participates in the development of metabolic syndrome. In this study, we have investigated the interaction of ADM and cytokines, endothelin-1 (EDN-1) and adipokines in the epididymal fat and the soleus muscle. Epididymal fat and soleus muscles from adult male Sprague-Dawley rat were incubated with ADM at concentration of 100 nM for the study of the gene expression and secretion of tumour necrosis factor (TNF-α), EDN-1, leptin, adiponectin, interleukin 1β (IL-1β), and IL-6. The effects of TNF-α and EDN-1 on ADM gene expression and secretion were also investigated. The results showed that ADM decreased the gene expression and protein secretion of TNF-α in both the epididymal fat and the soleus muscle and decreased IL-1β gene expression and secretion in the soleus muscle. It also decreased endothelin gene expression and adiponectin gene expression and release and increased IL-6 and leptin gene expression and secretion in the epididymal fat. These effects were effectively blocked by the calcitonin gene-related peptide (CGRP) receptor antagonist, hCGRP8-37, but not by the ADM receptor antagonist, hADM22-52. The reduction of inflammatory cytokines and EDN-1 may help to decrease insulin resistance and increase glucose uptake. As TNF-α also increases ADM levels in the epididymal fat and the soleus muscle and EDN-1 also increases ADM levels in the epididymal fat, they may form a feedback loop with ADM in these tissues. The increase in leptin and the decrease in adiponectin by ADM in the epididymal fat may have opposite effects on metabolism.

Evaluation of the combined use of adiponectin and C-reactive protein levels as biomarkers for predicting the deterioration in glycaemia after a median of 5.4 years

AIMS/HYPOTHESIS

Hypoadiponectinaemia and raised C-reactive protein (CRP) level are obesity-related biomarkers associated with glucose dysregulation. We evaluated the combined use of these two biomarkers in predicting the deterioration of glycaemia in a prospective study after a median of 5.4 years.

METHODS

In total 1,288 non-diabetic participants from the Hong Kong Cardiovascular Risk Factor Prevalence Study-2, with high-sensitivity CRP (hsCRP) and total adiponectin levels measured were included. OGTT was performed in all participants. Two hundred and six participants had deterioration of glycaemia at follow-up, whereas 1,082 participants did not.

RESULTS

Baseline age, hsCRP and adiponectin levels were significant independent predictors of the deterioration of glycaemia in a Cox regression analysis after adjusting for baseline age, sex, BMI, hypertension, triacylglycerols, 2 h post-OGTT glucose and homeostasis model assessment of insulin resistance index (all p < 0.01). The introduction of hsCRP or adiponectin level to a regression model including the other biomarker improved the prediction of glycaemic progression significantly in all participants, especially in women (all p < 0.01). The combined inclusion of the two biomarkers resulted in a modest improvement in model discrimination, compared with the inclusion of either one alone. Among participants with impaired fasting glucose/impaired glucose tolerance (IFG/IGT) at baseline, hsCRP and adiponectin levels were not predictive of progression or improvement of glycaemic status.

CONCLUSIONS/INTERPRETATION

Adiponectin and hsCRP levels are independent factors in predicting the deterioration of glycaemia, supporting the role of adiposity-related inflammation in the development of type 2 diabetes. Their combined use as predictive biomarkers is especially useful in women, but not in participants with IFG/IGT.

Association of F11 receptor gene polymorphisms with central obesity and blood pressure

OBJECTIVES

F11 receptor, also known as junctional adhesion molecule-1, in the autonomic nervous system is implicated in the development of hypertension in spontaneous hypertensive rats. We investigated the association of single nucleotide polymorphisms (SNPs) in the F11 receptor gene (F11R) with hypertension and central obesity in Hong Kong Chinese.

METHODS

Seven tagging SNPs were identified in the HapMap database. Genotyping was performed using Sequenom MassArray in 263 hypertensive subjects and 393 normotensive controls, of whom 263 matched the cases in age and sex.

RESULTS

When subjects on anti-hypertensive medication were excluded, rs790056 and rs2774276 were associated with lower systolic blood pressure (TT:124.8 +/- 18.3 mmHg vs. TC + CC: 120.2 +/- 15.5 mmHg, P = 0.004 and CC: 124.7 +/- 18.5 mmHg vs. CG+GG: 120.5 +/- 15.1 mmHg, P = 0.007 respectively). Comparing 213 subjects with central obesity with 213 controls matched for sex and age, rs2481084 and rs3737787 were associated with lower odds of central obesity (odds ratio = 0.516, P = 0.002 and odds ratio = 0.540, P = 0.005 respectively). All these associations remained significant after correction for multiple testing. Analysis of statistically similar SNPs suggested that the causative variants for systolic blood pressure were located in F11R, whilst those for central obesity could be due to causative variants in the transcription factor 1 gene immediately upstream.

CONCLUSIONS

F11 receptor plays a role in blood pressure regulation, not only in rats but also in man. The link between F11 receptor and central obesity merits further investigation.

Single-nucleotide polymorphisms near the microsatellite D17S1303 and the development of hypertension in a 6-year longitudinal study

This study examined the association of tagging single-nucleotide polymorphisms (SNPs) in the 130 kb region surrounding the microsatellite D17S1303 on chromosome 17p12 with the development of hypertension after 6 years in a cohort of 232 Hong Kong Chinese adults. Four SNPs (rs9899362, rs10491093, rs11658572 and rs9913883) were associated with the development of hypertension (P<0.05), but these associations require confirmation in future studies. Nevertheless, our study provides further evidence for the presence of an unidentified gene or a regulatory element predisposing to hypertension in a region approximately 24 kb downstream of D17S1303.

Plasma levels of fibrinogen and C-reactive protein are related to interleukin-6 gene −572C>G polymorphism in subjects with and without hypertension

Hypertension is an important risk factor for cardiovascular diseases. There is increasing evidence suggesting that inflammation is involved in the development of hypertension. Interleukin-6 (IL-6) is an important mediator of inflammatory response and the major regulator of hepatic production of acute phase proteins, such as fibrinogen and C-reactive protein (CRP), which have been associated with hypertension and cardiovascular diseases. Therefore, we studied the association of single nucleotide polymorphism (SNP) in the IL-6 gene (IL6) promoter with plasma levels of fibrinogen, CRP and hypertension. Five hundred and two Hong Kong Chinese subjects (282 normotensives and 220 hypertensives) were recruited. IL-6 gene promoter was examined for polymorphism and the study subjects were genotyped for any SNP identified. The IL6 -572C>G polymorphism (rs1800796) was found with a frequency of 0.23 for the minor G allele. Subjects with the -572G allele had significantly higher plasma fibrinogen (3.06+/-0.57 vs 2.83+/-0.60, P=0.002) and CRP (interquartile range 0.33-1.56 vs 0.12-0.93, P=0.003) levels than those without. The -572C>G polymorphism was found to be an independent predictor of fibrinogen and CRP levels after adjusting for confounding factors. Plasma concentrations of fibrinogen and CRP correlated with systolic blood pressure. However, the -572C/G genotype frequencies did not differ between hypertensive and normotensive subjects, and there was no association between -572C>G polymorphism and blood pressure. Our results provide evidence that there is a clear genetic influence of IL6 -572C>G polymorphism on plasma levels of fibrinogen and CRP, but this polymorphism does not lead to elevated blood pressure.

Intron 2 (T/C) CYP46 polymorphism is associated with Alzheimer's disease in Chinese patients

BACKGROUND

Cholesterol metabolism has been implicated in the pathophysiology of Alzheimer's disease (AD), and cholesterol-related genes are plausible candidate genes for AD. Genetic association of CYP46A1 polymorphisms with AD had been under extensive investigations; however, observations on intron 2 T-->C (rs754203) generated inconclusive results.

OBJECTIVE

To analyse an independent data set in a Chinese population to see whether the polymorphic site rs754203 of the CYP46A1 gene is associated with AD.

METHODS

We analysed 130 sporadic AD patients and 110 healthy controls of the Southern Chinese origin.

RESULTS

An association between the genotype frequency and AD was suggested in the general population (p = 0.047, odds ratio, OR = 1. 61, 95% confidence interval, CI = 0.96-2.70), while the association was most significant in the apolipoprotein E (ApoE) epsilon4-negative group (p = 0.004, OR = 2.54, 95% CI =1.31-4.95). Linkage disequilibrium block prediction results also favoured this association. Consistent with previous reports, intron 3 C-->T (rs4900442) polymorphism did not show any evidence of association; in our data set ApoEepsilon4 was confirmed to be a genetic risk factor for AD (p = 0.0016, OR = 2.76, 95% CI = 1.50-5.11).

Adrenomedullin--a potential disease activity marker and suppressor of nephritis activity in systemic lupus erythematosus

OBJECTIVES

To investigate whether plasma adrenomedullin (AM) level is elevated in lupus nephritis and to examine if plasma AM level is correlated with systemic lupus erythematosus (SLE) disease activity and severity of lupus nephritis after multivariate adjustment.

METHODS

Consecutive SLE patients and healthy volunteers of age >/=16 were recruited from the rheumatology clinics of two hospitals in Hong Kong. SLE patients with nephritis fulfilled the American College of Rheumatology criteria for renal involvement and had percutaneous renal biopsy performed. Subjects were divided into three groups: (i) SLE patients with nephritis, (ii) SLE patients without nephritis and (iii) normal controls. The demographic and clinical variables were compared between these groups of patients and plasma AM level was determined by radioimmunoassay. Factors associated with plasma AM level were explored by regression analysis with adjustment of confounding factors.

RESULTS

Sixty SLE patients (39 with nephritis and 21 without) and 23 normal subjects were studied. The plasma AM level of SLE patients was significantly higher than that of normal controls. SLE patients with nephritis had significantly higher plasma AM level than those without nephritis and normal controls (P<0.001). In regression analysis, proteinuria was negatively associated with plasma AM level (P=0.006) whereas SLE disease activity index was positively associated with plasma AM level after multivariate adjustment (P=0.002).

CONCLUSIONS

Plasma AM is elevated in lupus nephritis, which correlates with lupus disease activity. It is negatively associated with urine protein excretion although it is unrelated to the type of renal pathology per se. Plasma AM may play a role to suppress the activity of lupus nephritis.

Polymorphisms of the gene encoding adiponectin and glycaemic outcome of Chinese subjects with impaired glucose tolerance: a 5-year follow-up study

AIMS/HYPOTHESIS

Polymorphisms of the gene encoding adiponectin (ADIPOQ) have previously been associated with type 2 diabetes in Europid and Japanese subjects, but not in Pima Indians. The aim of this study was to determine the contribution made by ADIPOQ gene variants to glycaemic status in southern Chinese individuals.

SUBJECTS AND METHODS

Sixty unrelated subjects were screened for single-nucleotide polymorphisms (SNPs) in the ADIPOQ gene by direct sequencing. The association of tagging SNPs with the outcome of glycaemic status in 262 subjects with impaired glucose tolerance (IGT) was examined in a 5-year prospective study.

RESULTS

We identified 15 polymorphisms in the ADIPOQ gene, ten of them constituting the tagging SNPs. At 5 years, 39.7% of the subjects with IGT had regressed to NGT, 41.2% had persistent IGT or impaired fasting glucose and 19.1% had developed diabetes. Only the T45G polymorphism was associated with persistent hyperglycaemia at 5 years (p=0.001). Haplotypes formed by the addition of other SNPs, as haplotype blocks or pairs, did not confer greater association than T45G alone. On logistic regression analysis, T45G independently predicted persistent hyperglycaemia at 5 years (OR=2.25, 95% CI 1.29-3.95, G carriers vs TT; p=0.005). It also predicted persistent hyperglycaemia in a nested case-control study involving 158 sex- and age-matched controls with persistent NGT (p=0.012, adjusted for BMI), and that of diabetes or glycaemia progression (p<0.05) in a meta-analysis that also included two published studies in Europid subjects.

CONCLUSIONS/INTERPRETATION

Our findings support a significant role of this common ADIPOQ gene polymorphism in predicting glycaemic status in southern Chinese people.

Meta-analysis of large outcome trials of angiotensin receptor blockers in hypertension

Angiotensin receptor blockers (ARBs), also known as sartans, block the activation of angiotensin type 1 receptors and have a recognised role in the treatment of heart failure and nephropathy. Since 2002, there have been three major outcome trials of ARBs in hypertension. We performed a meta-analysis to evaluate the impact of ARB on major outcomes. Randomised controlled trials of ARBs in hypertensive subjects with an average follow-up of at least 2 years and at least 100 major cardiovascular events were included. For each trial, the ARB used, number and characteristics of subjects, baseline and change in blood pressure, cardiovascular and noncardiovascular outcomes were recorded. Three trials involving 29 375 subjects were included in the meta-analysis. In Losartan Intervention For Endpoint (LIFE) and Study on Cognition and Prognosis in the Elderly (SCOPE) but not in Valsartan Antihypertensive Long-term Use Evaluation trial (VALUE), an ARB reduced the occurrence of the primary end point and stroke compared to control. Compared to other antihypertensive drugs, ARB treatment was associated with no significant change in all-cause mortality (relative risk ratio (RRR) 0.96, 95% CI: 0.88-1.06, P = 0.45). There was an increase in myocardial infarction (RRR, 1.12, 95% CI: 1.01-1.26, P = 0.041), but a decrease in new-onset diabetes mellitus (RRR, 0.80, 95% CI: 0.74-0.86, P < 0.0000001). In conclusion, the reduction in new-onset diabetes partly offsets any increase in the risk of myocardial infarction. Most hypertensive patients require more than one class of drugs. Small differences in treatment outcome should not over-ride the importance of good blood pressure control.

Association of hypertension with single nucleotide polymorphisms in the quantitative trait locus for abdominal obesity-metabolic syndrome on chromosome 17

Genome scan in Chinese revealed an association of blood pressure with the microsatellite marker D17S1303, which lies in a quantitative trait locus for the abdominal obesity-metabolic syndrome (AOMS2) at 17p12 on chromosome 17. We previously reported that D17S1303 was associated with hypertension and obesity. Therefore, we studied 10 single nucleotide polymorphisms (SNP) within 3 kb of D17S1303. One hundred and eighty hypertensive subjects (91 men, 89 women, age 53+/-12 years) and 180 normotensive matched controls (91 men, 89 women, age 52+/-11) were genotyped using the Sequenom genotyping platform. Allelic frequencies in these Chinese subjects differed from those reported for Caucasians. Three SNPs (rs11656507, rs1357926, rs852319) were homozygous in our subjects. The genotype frequencies of rs852320, rs852321 and rs852322 did not differ between hypertensive and normotensive subjects. However, there were significant differences for rs1525402 (P=0.048), rs2692343 (P=0.022), rs2692344 (P=0.017) and rs2321313 (P=0.028). A four-locus haplotype comprising G at rs1525402, C at rs2692343, C at rs2692344 and G at rs2321313 was associated with lower systolic blood pressure (P=0.023) and normotension (P=0.048). Our results provide further evidence that there is a gene, as yet unidentified, influencing blood pressure in the vicinity of D17S1303 in a quantitative trait locus for abdominal obesity-metabolic syndrome at 17p12.

Queen Mary Utilization of Antihypertensive Drugs Study: side-effects of antihypertensive drugs

BACKGROUND AND OBJECTIVE

Effective prevention of cardiovascular events in hypertensive patients requires good control of blood pressure. Side-effects of antihypertensive drugs affect tolerability and compliance. Accordingly, we surveyed side-effects in the hypertension outpatient clinic.

METHODS

A total of 228 patients (109 men, 119 women) were interviewed in April-May 2004 in the Queen Mary Utilization of Antihypertensive Drugs Study.

RESULTS

The percentage of patients receiving no drug (life-style modification), one, two, three and over three drugs were 3, 30, 40, 22 and 6% respectively. The proportion of patients taking calcium channel blockers, beta-blockers (BB), angiotensin-converting enzyme inhibitors, thiazide diuretics, alpha-blockers and angiotensin receptor blockers were 65, 64, 33, 24, 4 and 7% respectively. Blood pressure on treatment was 144+/-21/82+/-11 mmHg. Among patients on antihypertensive drug therapy, 34% reported adverse effects: dizziness (9%), ankle swelling (7%), headache (5%), fatigue (4%), chest discomfort (3%) and cough (3%). Fewer patients on BBs reported side-effects (OR 0.46, P=0.008). The likelihood of experiencing side-effects was unrelated to sex, age, weight, BMI, years of treatment, number of drugs used, heart rate on treatment or compliance.

CONCLUSIONS

To achieve good blood pressure control, multiple drugs are used. Thiazides are underused whereas BBs are popular. The popularity of the latter may be related to its tolerability.

Association of essential hypertension with a microsatellite marker on chromosome 17

Hypertension is related to sodium intake, and many patients with essential hypertension are overweight and have the metabolic syndrome. We therefore studied microsatellite markers close to the thiazide-sensitive Na-Cl cotransporter on chromosome 16 and a quantitative trait locus for abdominal obesity-metabolic syndrome (AOMS2) on chromosome 17, which have been found to be linked to hypertension in a previous genome scan in Chinese. There were 84 hypertensive subjects (44 men, 40 women, age 53+/-13 years) and 88 normotensive controls (40 men, 48 women, age 54+/-13 years) recruited. Specific oligonucleotide primers were used to amplify genomic DNA spanning the microsatellite markers D16S3396 and D17S1303 that consist of ATA and GATA repeats, respectively. We did not find any association between D16S3396 and blood pressure. In contrast, the distribution of D17S1303 genotypes differed between hypertensive subjects and normal controls (P = 0.014). The number of GATA repeats correlated inversely with diastolic blood pressure (r = -0.18, P = 0.02) and body mass index (r = -0.12, P = 0.01). Nine GATA repeats in D17S1303 were associated with hypertension (OR 2.19, 95% CI 1.08-4.44, P = 0.027), while 14 GATA repeats were associated with normotension (OR 0.26, 95% CI 0.10-0.66, P = 0.002). The diastolic blood pressure in those with or without the (GATA)9 allele was 85.9+/-13.6 and 79.2+/-13.6 mmHg respectively (P = 0.01), and in those with or without the (GATA)14 allele it was 73.8+/-11.0 and 81.8+/-14.0 mmHg respectively (P = 0.003). Our results provide further evidence that a gene predisposing to hypertension in Chinese is in the vicinity of the microsatellite D17S1303.

Fatal Interaction between Clarithromycin and Colchicine in Patients with Renal Insufficiency: A Retrospective Study

BACKGROUND

Clarithromycin is frequently used to treat community-acquired pneumonia in elderly persons. Like erythromycin, it may interact with other drugs by interfering with metabolism by cytochrome P450 enzymes and with the P-glycoprotein transporter system. Colchicine, used for treatment of acute gout and for prophylaxis, may cause bone marrow toxicity. It is metabolized by CYP3A4 and is transported by P-glycoprotein. Initial case reports suggested potentially fatal interactions between clarithromycin and colchicine.

METHODS

A retrospective study was conducted with 116 patients who were prescribed clarithromycin and colchicine during the same clinical admission. Case-control comparisons were made between patients who received concomitant therapy with the 2 drugs and patients who received sequential therapy. We assessed the clinical presentations and outcomes of the 2 patient groups and analyzed the risk factors associated with fatal outcomes.

RESULTS

Nine (10.2%) of the 88 patients who received the 2 drugs concomitantly died. Only 1 (3.6%) of the 28 patients who received the drugs sequentially died. Multivariate analysis of the 88 patients who received concomitant therapy showed that longer overlapped therapy (relative risk [RR], 2.16; 95% confidence interval [CI], 1.41-3.31; P< or =.01), the presence of baseline renal impairment (RR, 9.1; 95% CI, 1.75-47.06; P<.001), and the development of pancytopenia (RR, 23.4; 95% CI, 4.48-122.7; P<.001) were independently associated with death.

CONCLUSIONS

Clarithromycin increases the risk of fatal colchicine toxicity, especially for patients with renal insufficiency. Since there are other drugs for treatment of pneumonia and gout, these 2 drugs should not be coprescribed, because of the risk of fatality.

Pharmacokinetics of pitavastatin in subjects with Child-Pugh A and B cirrhosis

AIM

Lipid lowering therapy with 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors is increasingly used for the prevention of cardiovascular events, but they should be used with caution in patients with impaired liver function. We therefore studied the pharmacokinetics of pitavastatin in patients with liver cirrhosis.

METHODS

Plasma concentrations of pitavastatin were determined after administration of 2 mg single-dose pitavastatin to 12 male patients with liver cirrhosis (six Child-Pugh grade A and six grade B). These results were compared with the single-dose pharmacokinetic results obtained from six male volunteers without liver disease.

RESULTS

Administration of 2 mg single-dose pitavastatin to patients with Child-Pugh grade A and grade B cirrhosis resulted in a 1.19- and 2.47-fold increase in Cmax and 1.27- and 3.64-fold increase in AUCt, respectively, when compared with normal subjects. The geomean Cmax of pitavastatin was 59.5 ng ml(-1), 70.7 ng ml(-1) and 147.1 ng ml(-1) in the control, Child-Pugh grade A and Child-Pugh grade B groups, respectively. The geomean AUCt of pitavastatin in the three groups was 121.2 ng h(-1) ml(-1), 154.2 ng h(-1) ml(-1) and 441.7 ng h(-1) ml(-1), respectively. The geomean Cmax of pitavastatin lactone was 20.3 ng ml(-1), 19.1 ng ml(-1) and 9.9 ng ml(-1) in the control, Child-Pugh grade A and grade B groups, respectively. The AUCt of pitavastatin lactone was 120.2 h(-1) ml(-1), 108.8 h(-1) ml(-1) and 87.5 h(-1) ml(-1), respectively.

CONCLUSION

The plasma concentration of pitavastatin is increased in patients with liver cirrhosis. In such patients, caution is required, although dose reduction may not be necessary in Child-Pugh A cirrhosis.

Randomised controlled trial of qigong in the treatment of mild essential hypertension

Exercise and relaxation decrease blood pressure. Qigong is a traditional Chinese exercise consisting of breathing and gentle movements. We conducted a randomised controlled trial to study the effect of Guolin qigong on blood pressure. In all, 88 patients with mild essential hypertension were recruited from the community and randomised to Goulin qigong or conventional exercise for 16 weeks. The main outcome measurements were blood pressure, health status (SF-36 scores), Beck Anxiety and Depression Inventory scores. In the qigong group, blood pressure decreased significantly from 146.3+/-7.8/93.0+/-4.1 mmHg at baseline to 135.5+/-10.0/87.1+/-7.7 mmHg at week 16. In the exercise group, blood pressure also decreased significantly from 140.9+/-10.9/93.1+/-3.5 mmHg to 129.7+/-11.1/86.0+/-7.0 mmHg. Heart rate, weight, BMI, waist circumference, total cholesterol, renin and 24 h urinary albumin excretion significantly decreased in both groups after 16 weeks. General health, bodily pain, social functioning and depression also improved in both groups. No significant differences between qigong and conventional exercise were found. In conclusion, Guolin qigong and conventional exercise have similar effects on blood pressure in patients with mild hypertension. While no additional benefits were identified, it is nevertheless an alternative to conventional exercise in the nondrug treatment of hypertension.

Chloramphenicol succinate, a competitive substrate and inhibitor of succinate dehydrogenase: possible reason for its toxicity

From our previous study [Eur. J. Clin. Pharmacol. 56 (2000) 405] we hypothesized that chloramphenicol succinate (CAPS) may be a competitive substrate for succinate dehydrogenase (SDH). It may be oxidized by SDH to release chloramphenicol (CAP), which may inhibit SDH by feed back mechanism. The present ex-vivo/in vitro study was aimed to investigate this possibility by using human tissues (bone marrow and liver samples) and animal tissues (rat liver and kidney). The effect of different SDH activators and specific inhibitors was studied on CAPS metabolism by SDH. The metabolites and reduction products were detected by using HPLC. In marrow samples, CAPS was slowly oxidized to form CAP. The formation of CAP (oxidation product) was enhanced by FAD and low malonate and inhibited by high malonate and 3-NPA. Similar results were obtained with mitochondria from human and rat tissues. These studies suggest that CAPS could be a competitive oxidative substrate and the metabolite CAP could be an inhibitor at the reduction site. Therefore, SDH could be a target molecule responsible for CAPS induced toxicity.

Increased adrenomedullin expression in lungs in endotoxaemia

Adrenomedullin (AM) is a peptide involved in cardiovascular homeostasis and in inflammation. We examined its expression in a rat model of endotoxaemia. Male Sprague-Dawley rats received intraperitoneal injection of 5 or 10 mg/kg lipopolysaccharide (LPS), or saline as control. Rats were killed at 1, 3, 6, 12 and 24 h after injection. LPS at 5 mg/kg, but not saline, increased plasma AM significantly at 3 h. At 10 mg/kg, plasma AM was raised at 3, 6 and 12 h. Immunoreactive AM concentration in lung increased after 5 or 10 mg/kg LPS, but not saline. PreproAM mRNA level in lung was significantly increased at 3 and 6 h. In conclusion, endotoxin stimulates the expression of AM in the lungs and increases its circulatory concentration. AM may be involved in the systemic response to sepsis.

Knowledge of cardiopulmonary resuscitation among the public in Hong Kong: telephone questionnaire survey

OBJECTIVES

To evaluate the knowledge of basic life-support and training experience in cardiopulmonary resuscitation among the public in Hong Kong and to identify areas for improvement in public education.

DESIGN

Telephone interview using a structured multiple-choice questionnaire.

SETTING

Random cross-section of the Hong Kong public, from mid-March to May 2002.

PARTICIPANTS

Men and women aged 16 years and older selected using random telephone dialling.

MAIN OUTCOME MEASURE

Overall score in the cardiopulmonary resuscitation knowledge questionnaire.

RESULTS

Of the 357 participants, approximately 12% had received cardiopulmonary resuscitation training. Cardiopulmonary resuscitation knowledge in Hong Kong was poor, even among the previously trained and especially with regard to circulatory maintenance. The most common reason for not taking cardiopulmonary resuscitation training was lack of time.

CONCLUSION

The degree of citizen preparedness in initiating cardiopulmonary resuscitation is very poor in Hong Kong. Intensified educational efforts and exploration of new approaches to improve this first stage in the chain of survival are warranted.

Blockade of the renin-angiotensin system

The renin-angiotensin-aldosterone system plays a key role in the regulation of fluid and electrolyte balance. Angiotensin-converting enzyme inhibitors inhibit angiotensin-converting enzyme and have been shown to be effective in many cardiovascular diseases. They should be considered for the treatment of hypertension in patients with heart failure, previous myocardial infarction, diabetes, or proteinuria. There are a number of side-effects associated with angiotensin-converting enzyme inhibitors, especially persistent dry cough. Angiotensin II receptor antagonists (sartans) provide a more specific blockade of the renin-angiotensin-aldosterone system and are associated with fewer side-effects, including cough. Their long-term efficacy and tolerability in the treatment of patients with hypertension has, however, yet to be established. Periodic monitoring of renal function and electrolytes is required in patients treated with an angiotensin-converting enzyme inhibitor or a sartan.

Increase in plasma adrenomedullin in patients with heart failure characterised by diastolic dysfunction

OBJECTIVE

To investigate the relation between plasma adrenomedullin and the severity of diastolic dysfunction in patients with heart failure.

DESIGN

Prospective study.

SETTING

University teaching hospital.

PATIENTS

77 patients (mean (SEM) age 66.3 (1.2) years; 75% male) who were being followed in the outpatient clinic after admission to hospital for acute heart failure.

INTERVENTIONS

Same day echocardiography with Doppler studies; determination of venous adrenomedullin concentration by radioimmunoassay.

MAIN OUTCOME MEASURES

Plasma adrenomedullin concentration and its correlation with systolic and diastolic function.

RESULTS

31 patients (40%) had isolated diastolic dysfunction (ejection fraction > 50%), and the remaining 46 had a depressed ejection fraction (< 50%). Of the patients with diastolic dysfunction, 17 had a restrictive filling pattern. In all but one of these there was coexisting systolic failure (χ2 = 10.7, p = 0.001). Patients with systolic heart failure and a restrictive filling pattern (group 1, n = 16) had a higher plasma adrenomedullin than those with systolic failure and a non-restrictive filling pattern (group 2, n = 30) or with isolated diastolic heart failure and a non-restrictive filling pattern (group 3, n = 30) (mean (SEM): 91.7 (21.1) v 38.4 (8.8) v 34.0 (6.5) pmol/l, both p < 0.05). All heart failure values were higher (p < 0.01) than the control value (6.9 (1.2) pmol/l). Ejection fraction and left ventricular dimensions were similar in groups 1 and 2. Plasma adrenomedullin did not correlate with ejection fraction or New York Heart Association functional class. Stepwise multiple regression analysis showed that the presence of a restrictive filling pattern was the only independent variable associated with a high plasma adrenomedullin.

CONCLUSIONS

Plasma adrenomedullin concentrations in patients with heart failure are determined by the presence of diastolic dysfunction, and are especially raised in the presence of a restrictive filling pattern. There appears to be no correlation with systolic dysfunction.