Treatment of refractory/relapsed Diamond-Blackfan anaemia with eltrombopag

Diamond-Blackfan anaemia (DBA) is a rare, inherited bone marrow failure syndrome with a ribosomal defect causing slowed globin chain production with normal haem synthesis, causing an overabundance of reactive iron/haem and erythroid-specific cellular toxicity. Eltrombopag, a non-peptide thrombopoietin receptor agonist, is a potent intracellular iron chelator and induced a robust durable response in an RPS19-mutated DBA patient on another trial. We hypothesized eltrombopag would improve RBC production in DBA patients. We conducted a single-centre, single-arm pilot study (NCT04269889) assessing safety and erythroid response of 6 months of daily, fixed-dose eltrombopag for DBA patients. Fifteen transfusion-dependent (every 3-5 weeks) patients (median age 18 [range 2-56]) were treated. One responder had sustained haemoglobin improvement and >50% reduction in RBC transfusion frequency. Of note, 7/15 (41%) patients required dose reductions or sustained discontinuation of eltrombopag due to asymptomatic thrombocytosis. Despite the low response rate, eltrombopag has now improved erythropoiesis in several patients with DBA with a favourable safety profile. Dosing restrictions due to thrombocytosis may cause insufficient iron chelation to decrease haem production and improve anaemia in most patients. Future work will focus on erythropoiesis dynamics in patients and use of haem synthesis inhibitors without an impact on other haematopoietic lineages.

Unresectable Metastatic Testicular Germ Cell Tumor With Low-grade Neuroglial Neoplasm, Stable After Radiation and Chemotherapy

We present an 18-year-old male patient who presented with a 16 cm testicular tumor alongside multiple lesions in the lungs, right pelvis with involvement of the ischio/pubic bone, and enlarged pelvic lymph nodes on imaging, suspicious for metastatic disease. Histologic and immunohistochemical examinations revealed an embryonic type neuroectodermal tumor (somatic-type malignancy, 10%) arising in a malignant mixed germ cell tumor composed of teratoma (50%), embryonal carcinoma (10%) and yolk sac tumor (30%). After treatment with chemotherapy and radiation, repeat imaging demonstrated a right pelvic sidewall mass that decreased in size from 40 mm at 11 months after the initial diagnosis to 18 mm at 22 months after the initial diagnosis. A right pelvis medial thigh wall mass that had a lytic bone component showed a slight increase in size from 151 mm at 11 months after the initial diagnosis to 154 mm at 22 months after the diagnosis. On biopsies performed at 3, 10, and 26 months after the initial diagnosis, this lytic lesion consistently demonstrated a neoplasm composed of low-grade neuroglial differentiation. This is the first case in the medical literature where a residual malignant germ cell tumor consisting of low-grade neuroglial neoplasm is in a site that is not amenable to resection without significant morbidity. The tumor initially regressed with the traditional first-line chemo-radiotherapy regimen but regrew and stabilized with a second regimen of chemotherapy. The clinical course of this case invites consideration for an active surveillance approach in cases with similar characteristics.

Applying a Clinical Lens to Animal Models of CAR-T Cell Therapies

Chimeric antigen receptor (CAR)-T cells have emerged as a promising treatment modality for various hematologic and solid malignancies over the past decade. Animal models remain the cornerstone of pre-clinical evaluation of human CAR-T cell products and are generally required by regulatory agencies prior to clinical translation. However, pharmacokinetics and pharmacodynamics of adoptively transferred T cells are dependent on various recipient factors, posing challenges for accurately predicting human engineered T cell behavior in non-human animal models. For example, murine xenograft models did not forecast now well-established cytokine-driven systemic toxicities of CAR-T cells seen in humans, highlighting the limitations of animal models that do not perfectly recapitulate complex human immune systems. Understanding the concordance as well as discrepancies between existing pre-clinical animal data and human clinical experiences, along with established advantages and limitations of each model, will facilitate investigators’ ability to appropriately select and design animal models for optimal evaluation of future CAR-T cell products. We summarize the current state of animal models in this field, and the advantages and disadvantages of each approach depending on the pre-clinical questions being asked.

Diabetes mellitus and associated factors, determined by glycated hemoglobin

Objective

To analyze the prevalence of diabetes mellitus (DM) according to different diagnostic criteria, in the Brazilian adult population, according to laboratory results from the Brazilian National Health Survey.

Methods

Analysis of laboratory data from the National Health Survey, collected between 2014 and 2015. The prevalence of diabetes was calculated according to different diagnostic criteria. The prevalence of diabetes was calculated according to the criterion of glycosylated hemoglobin ≥ 6.5% or using medication, using Poisson regression and calculating crude and adjusted PR and 95%CI.

Results

The prevalence of diabetes according to different criteria varies from 6.6 to 9.4%. Intermediate or pre-diabetes hyperglycemia ranged from 6.8 to 16.9%. Considering laboratory criteria or medication use, the prevalence of DM was 8.4 (95%CI 7.65-9.11). The adjusted PR for gender, age, educational level and region was lower for males (PR 0.75; 95%CI 0.63 - 0.89), increased with age: 30 to 34 years (PR 2.32; 95% CI 1.33 - 4.07), 40 to 59 years PR 8.1; 95%CI 4.86 - 13.46), 60 years old or older (PR 12.6; 95%CI 7.1 - 21.0), and higher educational levels was protective (PR 0.8; 95%CI 0.6 - 0.9). Therewas a higher PR in the Central West Region (PR 1.3; 95%CI 1.04 - 1.7), in overweight people (PR 1.8; 95%CI 1.4 - 2.1), and in obese people (PR 3.3; 95%CI 2.6 - 4.1).

Conclusions

The prevalence of diabetes was higher in females, people over 30 years of age, in populations with low educational levels, and people who were overweight and obese. The study advances in determining the diabetes situation in the country through laboratory criteria. These data demonstrate the importance of controlling hyperglycemia in order to avoid the vascular and systemic effects of DM.

Key messages

This is the first study to analyze the prevalence of DM using laboratory data from a representative sample of the Brazilian population. The study pointed to a strong association between overweight and obesity and diabetes, showing the importance of public health measures to encourage healthy eating and physical activity.

Trends in mortality due to noncommunicable diseases in Brazil and the sustainable development targets

Background

Monitoring premature mortality due to noncommunicable diseases (NCDs) is a global priority, as part of the Agenda 2030.

Objective

The current study aims to describe the mortality trends and disability-adjusted life years (DALYs) lost due to NCDs between 1990 and 2017 for Brazil and states, projections for 2030.

Methods

We analyzed the following NCDs: cardiovascular diseases, chronic respiratory diseases, neoplasms, diabetes mellitus, comparing deaths and mortality rates between 1990 and 2017, for Brazil and states. The study used the concept of premature mortality used by the World Health Organization (30 to 69 years). The absolute number of deaths, mortality rates, DALYs, years of life lost (YLL), were used, comparing 1990 and 2017. We also analyzed the premature death fraction (YLL) for NCDs attributable to risk factors.

Results

There was a reduction of 35,3% from 509.1 deaths/100,000 inhabitants (1990) to 329.6 deaths/100,000 inhabitants due to NCD in 2017. DALYs rate decreased by 33.6% and the YLL rate by 36.0% in the same period. There was a reduction in the NCD rates in all 27 states. The main risk factors related to premature deaths by NCDs in 2017 among women were - high body mass index, diet risks, high systolic blood pressure, tobacco, and among men, diet risks, high systolic blood pressure, tobacco, high body mass index. Trends in mortality rates due to NCDs were declining in the period, however, after 2015, the curve reversed and fluctuation and tendency to increase rates were observed.

Conclusions

Trends of mortality rates by NCD were declining in the period, however, after 2015, the curve was inverted and the fluctuation and trend of increasing rates was observed, which can compromise the SDG goals in 2030.

Key messages

The austerity policies adopted and the economic crisis in Brazil after 2015, resulted in increased poverty and worsening NCD mortality indicators. With the NCD indicators worsening in 2015, SDG targets may not be achieved.

P1947Trends in prevalence, mortality and morbidity associated with high systolic blood pressure in Brazil from 1990 to 2017: estimates from the Global Burden of Disease 2017 study

Background

Hypertension remains the leading risk factor for cardiovascular disease worldwide. In Brazil, a third of adults have hypertension. The prevalence and impact of this risk factor on disease burden in Brazil and its federal units should be assessed in order to better address the issue.

Objective

To describe trends in prevalence and burden of diseases attributable to high systolic blood pressure (HSBP) among Brazilians ≥25 years old according to sex and federal units using the Global Burden of Disease (GBD) 2017 estimates.

Methods

We used the comparative risk assessment developed for the GBD study to estimate trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALY), by sex, and federal units for HSBP from 1990 to 2017. This study included 14 HSBP-outcome pairs that met the GBD study criteria for evidence of causation. HSBP was defined as ≥140mmHg for prevalence estimates and, to evaluate the burden of HSBP, a theoretical minimum risk exposure level (TMREL) of 110–115 mmHg was considered. We estimated the portion of deaths and DALYs that could be attributed to HSBP. We also explored the drivers of trends in attributable burden of HSBP, as well as the relation of HSBP burden and sociodemographic development.

Results

In Brazil, the prevalence of HSBP is 18.9 (95% uncertainty intervals [UI] 18.5 to 19.3%) and the age-standardized death rate attributable to HSBP decreased from 189.2 (95%UI 168.5 to 209.2) deaths to 104.8 (95%UI 94.9 to 114.4) deaths per 100,000 from 1990 to 2017. In spite of that, the total number of deaths attributable to HSBP increased 53.4% and HSBP raised from 3rd to 1st position, as the leading risk factor for deaths during the period. Regarding total DALYs, HSBP raised from 4th in 1990 to 2nd cause in 2017 - in the last, only behind smoking. The main driver in the change of HSBP burden in Brazil is population aging. Across federal units, the reduction in the age-standardized death rates attributable to HSBP are heterogeneous and the greater reduction correlated to higher sociodemographic development.

Conclusions

The age-standardized death and DALY rates attributable to HSBP are decreasing in Brazil, probably as results of successful public health policies for primary prevention and control of HSBP. However, the reduction was more significant in federal units with higher sociodemographic development, suggesting that the effect of health policies was heterogeneous. Moreover, HSBP has become the main risk factor for death in the country, mainly due to population aging. As such, the Brazilian health system should increase investments in policies to address the situation and prepare itself to cope with higher burden of HSBP in the near future.

Acknowledgement/Funding

The GBD 2017 Brazil study is primarily funded by the Bill & Melinda Gates Foundation

Carboxymethyl lysine, an advanced glycation end product, and incident diabetes: a case-cohort analysis of the ARIC Study

AIMS

To verify whether elevated fasting levels of circulating carboxymethyl lysine (CML), an advanced glycation end product, predict the development of diabetes in middle-age adults.

METHODS

Using a stratified case-cohort design, we followed 543 middle-aged individuals who developed diabetes and 514 who did not over a median 9 years in the Atherosclerosis Risk in Communities Study. Weighted Cox proportional hazards analyses were used to account for the design.

RESULTS

In weighted analyses, correlation between CML levels and anthropometric, inflammatory or metabolic variables was minimal (Pearson correlations usually < 0.10). CML, when modelled as a continuous variable and after adjustment for age, sex, race, centre, parental history of diabetes, BMI, waist-to-hip ratio, non-esterified fatty acids, oxidized LDL-cholesterol, GFR, smoking, an inflammation score, adiponectin, leptin, insulin and glucose levels, was associated with an increased risk of diabetes [Hazard ratio (HR) = 1.35; 95% confidence interval (CI) 1.09-1.67, for each 100 ng/ml CML increment]. Baseline glucose level and race each modified the association (P < 0.05 for interaction), which was present only among those with impaired fasting glucose (≥ 5.6 mmol/l, HR = 1.61, 95% CI 1.26-2.05) and among white participants (HR = 1.50, 95% CI 1.13-1.99).

CONCLUSIONS

Elevated fasting CML, after adjustment for multiple risk factors for diabetes, predicts the development of incident diabetes, the association being present among those with impaired fasting glucose and in white participants. These prospective findings suggest that advanced glycation end products might play a role in the development of diabetes.

Neck circumference is associated with carotid intimal-media thickness but not with coronary artery calcium: Results from The ELSA-Brasil

BACKGROUND AND AIMS

It is uncertain whether neck circumference can be a risk indicator for subclinical atherosclerosis. We aimed to investigate their relationships measured by coronary artery calcium (CAC) and common carotid intima-media thickness (cc-IMT) with neck circumference in ELSA-Brasil.

METHODS AND RESULTS

In cross-sectional and sex-specific analyses of 2266 women (50.6 ± 8.4 yrs) and 1886 men (50.7 ± 9.0 yrs) with both cc-IMT and CAC, free from previous cardiovascular disease at baseline, we built logistic models using diverse cut-off points for CAC score (0 vs > 0, < 100 vs ≥ 100, < 400 vs ≥ 400 Agatston units) and cc-IMT (< 75 th percentile vs ≥ 75 th; <90th percentile vs ≥ 90 th) as dependent variables, after which adjustments for age and traditional cardiovascular risk factors were made. Mean neck circumference was 33.6 (± 2.4 cm) for women and 38.8 (± 2.6 cm) for men. In fully adjusted models including sociodemographic, cardiovascular risk factors and body-mass index and waist circumference, for each 1 standard deviation increase in neck circumference we found an odds ratio (OR, 95% CI) for IMT above the 75th percentile of (1.52, 1.16; 1.99) for women and (1.66, 1.28; 2.14) for men, and above the 90th cc-IMT percentile [1.66 (1.19; 2.32) for men but not for women [1.21 (0.80; 1.82)]. We found no association between neck circumference and CAC using different cut-off points (p > 0.05 for all).

CONCLUSION

Neck circumference was significantly and independently associated with cc-IMT but not with CAC in women and men, indicating a possible effect of perivascular fat tissue on atherosclerosis.

Fasting plasma glucose to avoid a full OGTT in the diagnosis of gestational diabetes

AIMS

To evaluate the performance of fasting plasma glucose (FPG) in determining the need for a full oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM) by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria.

METHODS

A multicenter cohort study of 4926 pregnant women 20 years or older consecutively enrolled in prenatal care clinics of the Brazilian National Health Service from 1991 to 1995. All women underwent a single 2 h 75 g OGTT by weeks 24-28 of pregnancy and were followed to detect adverse pregnancy outcomes.

RESULTS

A FPG cut-off value of 80 mg/dl indicated that only 38.7% of all women needed to undergo a complete OGTT, while detecting 96.9% of all GDM cases. When the 85 mg/dl cut-off was used, the corresponding percentages were 18.7% and 92.5%, respectively. The fraction of women labeled with GDM who had adverse pregnancy outcomes was nearly identical when using FPG strategies and universal full testing.

CONCLUSIONS

Using a FPG cut-off to diagnose GDM and to determine the need for post-load OGTT measurements is a valid strategy to diagnose GDM by IADPSG criteria. This approach may improve feasibility of applying IADPSG diagnostic criteria by reducing costs and increasing convenience.

Graft-versus-host disease impairs vaccine responses through decreased CD4+ and CD8+ T cell proliferation and increased perforin-mediated CD8+ T cell apoptosis

Tumor-targeted vaccines represent a strategy to enhance the graft-versus-leukemia effect after allogeneic blood and marrow transplantation (BMT). We have previously shown that graft-versus-host disease (GVHD) can negatively impact quantitative responses to vaccines. Using a minor histocompatibility Ag-mismatched BMT (B6 → B6 × C3H.SW) followed by adoptive transfer of HY-specific T cells and HY-expressing dendritic cells, we assessed whether GVHD induced by donor lymphocyte infusion (DLI) affects the persistence, proliferation, and survival of vaccine-responding, nonalloantigen reactive T cells. Both CD8(+) and CD4(+) HY-specific T cells undergo less vaccine-driven proliferation in allogeneic recipients with GVHD. Although vaccine-responding CD8(+) T cells show decreased IFN-γ and CD107a production, CD4(+) T cells exhibit increased programmed death 1 and T cell Ig mucin-like domain 3 expression. In addition, the degree of apoptosis in vaccine-responding CD8(+) T cells was higher in the presence of GVHD, but there was no difference in CD4(+) T cell apoptosis. Using Fas ligand-deficient or TRAIL-deficient DLI had no impact on apoptosis of HY-specific T cells. However, perforin-deficient alloreactive DLI induced significantly less apoptosis of vaccine-responding CD8(+) T cells and resulted in enhanced tumor protection. Thus, diminished vaccine responses during GVHD result from impaired proliferation of CD8(+) and CD4(+) T cells responding to vaccination, with an additional contribution from perforin-mediated CD8(+) T cell apoptosis. These results provide important insights toward optimizing vaccine responses after allogeneic BMT.

Glutamic acid decarboxylase antibodies are indicators of the course, but not of the onset, of diabetes in middle-aged adults: the Atherosclerosis Risk in Communities Study

To efficiently examine the association of glutamic acid decarboxylase antibody (GADA) positivity with the onset and progression of diabetes in middle-aged adults, we performed a case-cohort study representing the ~9-year experience of 10,275 Atherosclerosis Risk in Communities Study participants, initially aged 45-64 years. Antibodies to glutamic acid decarboxylase (GAD65) were measured by radioimmunoassay in 580 incident diabetes cases and 544 non-cases. The overall weighted prevalence of GADA positivity (>or=1 U/mL) was 7.3%. Baseline risk factors, with the exception of smoking and interleukin-6 (P <or= 0.02), were generally similar between GADA-positive and -negative individuals. GADA positivity did not predict incident diabetes in multiply adjusted (HR = 1.04; 95%CI = 0.55, 1.96) proportional hazard analyses. However, a small non-significant adjusted risk (HR = 1.29; 95%CI = 0.58, 2.88) was seen for those in the highest tertile (>or=2.38 U/mL) of positivity. GADA-positive and GADA-negative non-diabetic individuals had similar risk profiles for diabetes, with central obesity and elevated inflammation markers, aside from glucose, being the main predictors. Among diabetes cases at study's end, progression to insulin treatment increased monotonically as a function of baseline GADA level. Overall, being GADA positive increased risk of progression to insulin use almost 10 times (HR = 9.9; 95%CI = 3.4, 28.5). In conclusion, in initially non-diabetic middle-aged adults, GADA positivity did not increase diabetes risk, and the overall baseline profile of risk factors was similar for positive and negative individuals. Among middle-aged adults, with the possible exception of those with the highest GADA levels, autoimmune pathophysiology reflected by GADA may become clinically relevant only after diabetes onset.

Circulating oxidised low-density lipoprotein and intercellular adhesion molecule-1 and risk of type 2 diabetes mellitus: the Atherosclerosis Risk in Communities Study

AIMS/HYPOTHESIS

To evaluate the role of oxidative stress and inflammation in the aetiology of type 2 diabetes, we examined the association of oxidised LDL (ox-LDL) and soluble intercellular adhesion molecule-1 (sICAM-1) levels with type 2 diabetes incidence over 9 years in the Atherosclerosis Risk in Communities Study.

MATERIALS AND METHODS

In a large, prospective, case-cohort design, ox-LDL and sICAM-1 were measured in stored plasma samples collected at baseline in stratified samples of 581 diabetes cases and 572 non-cases selected from 10,275 middle-aged men and women without prevalent diabetes at baseline.

RESULTS

Compared with non-cases, diabetes cases had significantly higher mean baseline levels of ox-LDL and sICAM-1. Elevated ox-LDL and sICAM-1 were both associated with increased risk of incident diabetes after adjustment for age, sex, race and centre, with hazard ratios for the highest vs lowest tertiles of 1.68 (95% CI 1.25-2.24) and 1.91 (95% CI 1.45-2.50), respectively. After additional adjustment for fasting glucose, waist circumference, HDL-cholesterol, triacylglycerol, hypertension and C-reactive protein, only sICAM-1 remained an independent predictor of incident diabetes (hazard ratio 1.50; 95% CI 1.02-2.23).

CONCLUSIONS/INTERPRETATION

In this community-based cohort of middle-aged US adults, elevated plasma ox-LDL and sICAM-1 levels were associated with increased risk of type 2 diabetes. Measurement of ICAM-1 or ox-LDL, or other measures related to inflammation or oxidative stress, may be helpful in identifying those patient populations in which to test whether novel therapies that inhibit specific pathways related to inflammation or oxidative stress are beneficial in the prevention of diabetes in humans.

Leptin and incident type 2 diabetes: risk or protection?

AIMS/HYPOTHESIS

The aim of this study was to investigate the association of leptin levels with incident diabetes in middle-aged adults, taking into account factors purportedly related to leptin resistance.

SUBJECTS AND METHODS

We conducted a case-cohort study (570 incident diabetes cases and 530 non-cases) representing the 9-year experience of 10,275 participants of the Atherosclerosis Risk in Communities Study. Plasma leptin was measured by direct sandwich ELISA.

RESULTS

In proportional hazards models adjusting for age, study centre, ethnicity and sex, high leptin levels (defined by sex-specific cut-off points) predicted an increased risk of diabetes, with a hazard ratio (HR) comparing the upper with the lower quartile of 3.9 (95% CI 2.6-5.6). However, after further adjusting additionally for obesity indices, fasting insulin, inflammation score, hypertension, triglycerides and adiponectin, high leptin predicted a lower diabetes risk (HR=0.40, 95% CI 0.23-0.67). Additional inclusion of fasting glucose attenuated this protective association (HR=0.59, 95% CI 0.32-1.08, p<0.03 for linear trend across quartiles). In similar models, protective associations were generally seen across subgroups of sex, race, nutritional status and smoking, though not among those with lower inflammation scores or impaired fasting glucose (interaction p=0.03 for both).

CONCLUSIONS/INTERPRETATION

High leptin levels, probably reflecting leptin resistance, predict an increased risk of diabetes. Adjusting for factors purportedly related to leptin resistance unveils a protective association, independent of adiponectin and consistent with some of leptin's described protective effects against diabetes.

Hypertensive retinopathy and incident coronary heart disease in high risk men

BACKGROUND/AIM

Although routine ophthalmoscopy is recommended in the evaluation of people with hypertension, the prognostic significance of retinopathy is unknown. The purpose of this study is to determine if hypertensive retinopathy predicts coronary heart disease (CHD).

METHODS

A prospective cohort study involving 560 hypertensive, hyperlipidaemic, middle aged men enrolled in the Lipid Research Clinic's Coronary Primary Prevention Trial. Signs of hypertensive retinopathy (generalised and focal arteriolar narrowing, arteriovenous nicking, widened arteriolar light reflex, retinal haemorrhage and exudates, microaneurysms, and disc swelling) were evaluated by direct funduscopy during a baseline examination by study physicians. Incident CHD events were ascertained from hospital records, necropsy reports, and death certificates, and reviewed by a masked panel of cardiologists.

RESULTS

There were 51 definite CHD events (definite CHD deaths or myocardial infarctions) during a median follow up of 7.8 years. After adjusting for age, blood pressure, electrocardiographic manifestations of left ventricular hypertrophy, cholesterol levels and treatment, glucose and creatinine levels, and smoking status in proportional hazards analysis, the presence of hypertensive retinopathy predicted a doubling of the risk of definite CHD events (relative risk 2.1; 95% confidence interval (CI) 1.0 to 4.2 ). The presence of either generalised or focal arteriolar narrowing predicted almost a tripling of the risk (relative risk 2.9; 95% CI 1.3 to 6.2). Associations were similar for stage 1 hypertension (systolic and diastolic blood pressures of 140-159 and 90-99 mm Hg, respectively) and for other CHD end points.

CONCLUSION

Hypertensive retinopathy predicts CHD in high risk men, independent of blood pressure and CHD risk factors. The data support the concept that retinal microvascular changes are markers of blood pressure damage and may be useful in risk stratification and in the tailoring of hypertension treatment decisions.

Hypertensive disorders in pregnancy: frequency and associated factors in a cohort of Brazilian women

OBJECTIVE

To evaluate the frequency of and risk factors associated with hypertensive disorders in general antenatal care in five distinct areas of Brazil.

METHODS

We performed a cohort study of 4892 women enrolled in midpregnancy from 1991 to 1995. Patients were queried at enrollment about hypertension prior to pregnancy. Medical diagnoses of hypertensive disorders in pregnancy were abstracted from patient records. Hypertensive disorders in pregnancy were classified according to recommendations of the American College of Obstetrics and Gynecology (ACOG).

RESULTS

Of 4892 women studied, 367 (7.5%) presented hypertensive disorders, 113 (2.3%) being preeclampsia/eclampsia and 198 (4.0%) chronic hypertension. Frequencies of superimposed preeclampsia/eclampsia and transitory hypertension were 0.5% and 0.7%, respectively. Greater brachial arm circumference was strongly associated both with preeclampsia/eclampsia and with chronic hypertension (threefold difference across extreme quartiles, p < or =0.001). In adjusted analyses, being older, black, and obese were important and statistically significant risk factors for chronic hypertension. Similarly, nulliparity was a statistically significant risk factor for preeclampsia/eclampsia, and tendencies toward increased risk were seen for older, black, and obese women in adjusted analyses. Preeclampsia/eclampsia and chronic hypertension were notably less frequent in Manaus, although regional differences were statistically significant only for chronic hypertension.

CONCLUSIONS

Hypertensive disorders commonly complicate pregnancy in Brazilian women. Risk factors for these disorders appear similar to those reported in other countries. Use of an inappropriately sized cuff to measure blood pressure may result in many false-positive diagnoses in more obese women. The considerably lower frequency of hypertensive disorders found in Manaus, in the Amazon region, warrants further study.

Nutritional status of pregnant women: prevalence and associated pregnancy outcomes

INTRODUCTION

Although obesity is well recognized as a current public health problem, its prevalence and impact among pregnant women have been less investigated in Brazil. The objective of the study was to evaluate the impact of pre-obesity and obesity among pregnant women, describing its prevalence and risk factors, and their association with adverse pregnancy outcomes.

METHODS

A cohort of 5,564 pregnant women, aged 20 years or more, enrolled at approximately 20 to 28 weeks of pregnancy, seen in prenatal public clinics of six state capitals in Brazil were followed up, between 1991 and 1995. Prepregnancy weight, age, educational level and parity were obtained from a standard questionnaire. Height was measured in duplicate and the interviewer assigned the skin color. Nutritional status was defined using body mass index (BMI), according to World Health Organization (WHO) criteria. Odds ratios and 95% confidence interval were calculated using logistic regression.

RESULTS

Age-adjusted prevalences (and 95% CI) based on prepregnancy weight were: underweight 5.7% (5.1%-6.3%), overweight 19.2% (18.1%-20.3%), and obesity 5.5% (4.9%-6.2%). Obesity was more frequently observed in older black women, with a lower educational level and multiparous. Obese women had higher frequencies of gestational diabetes, macrosomia, hypertensive disorders, and lower risk of microsomia.

CONCLUSIONS

Overweight nutritional status (obesity and pre-obesity) was seen in 25% of adult pregnant women and it was associated with increased risk for several adverse pregnancy outcomes, such as gestational diabetes and pre-eclampsia.

Sensitivity and specificity of anthropometrics for the prediction of diabetes in a biracial cohort

OBJECTIVE

To evaluate the ability of body mass index, waist circumference, waist-to-hip ratio, and combinations of these variables to discriminate individuals who will develop diabetes in adulthood.

RESEARCH METHODS AND PROCEDURES

Data were from 45- to 64-year-old men and women who were members of the Atherosclerosis Risk in Communities cohort. The analysis sample consisted of 12,814 African American and white participants who were free of diabetes at baseline. Body mass index, waist circumference, waist-to-hip ratio, and diabetes incidence (defined as one glucose measure > or =126 mg/dL after fasting for at least 8 hours, one nonfasting glucose measure > or =200 mg/dL, and self-report of diabetes or report of taking medication for diabetes).

RESULTS

1515 new cases of diabetes were identified over the 9-year follow-up. Areas under receiver operating characteristic curves ranged from 0.66 to 0.73 for single measures. The curves were smooth, with no indication of a threshold. Waist tended to have the highest receiver operating characteristic statistic in all groups, but differences were small.

DISCUSSION

The three anthropometric indices tested were approximately equivalent in their ability to predict diabetes. Sensitivity and specificities differed among ethnic and gender groups.

[Drug use by pregnant women in six Brazilian cities]

OBJECTIVE

To describe drugs used during pregnancy by women attending prenatal clinics of the national public health system (SUS) in Brazilian cities.

METHODS

Using a structured questionnaire, 5,564 pregnant women between the week 21 to 28 who attended prenatal visits of the SUS in six Brazilian cities were interviewed. The interview questions were grouped in "guided use" to cover pain, cramps, nausea, cough, and others, and "guided medicine" to cover vitamins, iron, and fluoride. The Food and Drug Administration gestational risk classification (1991-1995) was applied.

RESULTS

Of a total of 5,564 women, 4,614 (83.8%) used at least one drug during pregnancy, with a total of 9,556 drugs used. The drugs most frequently used were vitamins associated with anti-anemics (33.5%), gastrointestinal drugs (31.3%), analgesics and anti-inflammatory drugs (22.2%), anti-anemics (19.8%), and antibiotics (11.1%). Regarding gestational risk, 3,243 drugs used (34%) belonged to category A risk, 1,923 (22.6%) to category B, 3,798 (39.7%) to category C, 289 (3.0%) to category D, and 55 (0.6%) to category X.

CONCLUSIONS

A large variation in drug use across the cities was observed, especially for anti-anemics and vitamins associated with anti-anemics, revealing the lack of a national consensus regarding the use of these drugs during pregnancy. There was no literature data about safety during pregnancy for 12.9% of the drugs used. This percentage, plus the 26.9% of category C drugs, shows that 40% of the drugs used during pregnancy do not belong to the approved safety categories. However, only 3% of the 9,956 drugs used were clearly contraindicated during pregnancy.

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes

OBJECTIVE

To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes.

RESEARCH DESIGN AND METHODS

This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded.

RESULTS

Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria.

CONCLUSIONS

GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Chronic activation of the innate immune system may underlie the metabolic syndrome

CONTEXT

The metabolic syndrome is characterized by a clustering, in free-living populations, of cardiovascular and diabetes risk factors generally linked to insulin resistance, obesity and central obesity. Consonant with the well-established inflammatory pathogenesis of atherosclerotic disease, the metabolic syndrome is now being investigated in relation to its inflammatory nature.

OBJECTIVE

We present cross-sectional findings demonstrating that markers of inflammation correlate with components of the metabolic syndrome, and prospective findings of the ARIC Study indicating that markers of inflammation and endothelial dysfunction predict the development of diabetes mellitus and weight gain in adults. We present biological evidence to suggest that chronic activation of the innate immune system may underlie the metabolic syndrome, characterizing the common soil for the causality of type 2 diabetes mellitus and cardiovascular disease.

CONCLUSIONS

Better understanding of the role of the innate immune system in these diseases may lead to important advances in the prediction and management of diabetes and cardiovascular disease.

Alcohol and atherosclerosis

Observational studies have attributed a protective effect to alcohol consumption on the development of atherosclerosis and cardiovascular morbidity and mortality. Alcohol intake in the amount of one to two drinks per day results in an estimated 20-40% reduction in cardiovascular events. An additional protective effect, according to major cohort studies, has been attributed to wine, probably due to antioxidant effects and platelet antiaggregation agents. On the other hand, the influence of different patterns of alcohol consumption and environmental factors may explain a great part of the additional effect of wine. Protection may be mediated by modulation of other risk factors, because alcohol increases HDL-C, produces a biphasic response on blood pressure, and modulates the endothelial function, while it neither increases body weight nor impairs glucose-insulin homeostasis. Alcohol may also have a direct effect on atherogenesis. Despite these favorable effects, the current evidence is not enough to justify prescribing alcohol to prevent cardiovascular disease.

Estimating hidden prevalence in Hansen's disease through diagnosis delay and grade of disability at time of diagnosis

The objective of the present study was to propose a new method for the calculation of estimated hidden prevalence (EHP) in Hansen's disease (HD). We analyzed the records of 4142 HD patients diagnosed in the state of Rio Grande do Sul, Brazil, between 1970 and 1991. Out of these 4142 cases, 3291 patients had their grade of disability (GD) evaluated at the time of diagnosis and provided information about the time elapsed between the appearance of the symptoms and the moment when HD was identified by a physician (diagnosis delay, DD). Mean DD for the sample (in years) was 1.51 for disability grade 0, 2.14 for grade 1, 4.46 for grade 2, and 9.64 for grade 2. EHP was calculated taking into account only two strata of GD using the formula HP = [(NC-GD 0/1) x 2.0 + (CN-GD 2/3) x 5.0]/(CGE x PCP), where: NC-GD 0/1 = mean annual number of newly detected grades 0 or 1 cases; CN-GD 2/3 = mean annual number of newly detected grades 2 or 3 cases; CGE = proportion of newly detected cases with GD evaluated; PCP = proportion of the population covered by the state HD control program; 2.0 and 5.0 correspond to an approximation of the mean time in years of DD in each respective stratum of GD. Applying this model, we found an EHP of 529 cases which translates to an excess of 0.58 cases/10,000 population. We also conducted a multivariate analysis using a logistic regression model. This analysis revealed that, in addition to DD, other variables such as clinical form, age group, sex and mode of detection were independent risk factors for the presence of disabilities. We also found two significant effect modification factors: DD versus clinical form and DD versus age group. Taking these findings into consideration, a more complex model was used to calculate the EHP with 16 strata (defined by clinical form of the disease, age group, and GD from 0 to 3). An EHP of 502 cases (excess of 0.55/10,000) was obtained with this more complex model. This result differs only 5% from that of the simplified model. Therefore, we conclude that the simplified model is indicated to estimate hidden prevalence of HD in the field.

Nontraditional risk factors for coronary heart disease incidence among persons with diabetes: the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Major risk factors explain much of the excess risk for coronary heart disease produced by diabetes, but nontraditional factors may also relate to incident coronary heart disease.

OBJECTIVE

To examine the association of traditional and nontraditional risk factors with incidence of coronary heart disease in adults with diabetes.

DESIGN

Prospective cohort study.

SETTING

The Atherosclerosis Risk in Communities (ARIC) Study.

PARTICIPANTS

1676 middle-aged persons who had diabetes but no history of prevalent coronary heart disease.

MEASUREMENTS

Multiple risk factors were recorded at baseline. Follow-up was from 1987 through 1995.

RESULTS

186 participants developed incident coronary heart disease events during follow-up. As expected, the incidence of coronary heart disease in participants with diabetes was associated positively with traditional risk factors (hypertension, smoking, total cholesterol level, and low high-density lipoprotein [HDL] cholesterol level). After adjustment for sex, age, ethnicity, and ARIC field center, incident coronary heart disease was also significantly associated with waist-to-hip ratio; levels of HDL3 cholesterol, apolipoproteins A-I and B, albumin, fibrinogen, and von Willebrand factor factor VIII activity; and leukocyte count. However, after adjustment for traditional risk factors for coronary heart disease, only levels of albumin, fibrinogen, and von Willebrand factor; factor VIII activity; and leukocyte count remained independently associated with coronary heart disease (P < 0.03). The relative risks associated with the highest compared with lowest groupings of albumin, fibrinogen, factor VIII, and von Willebrand factor values and leukocyte count were 0.64 (95% CI, 0.44 to 0.92), 1.75 (CI, 1.12 to 2.73), 1.58 (CI, 1.02 to 2.42), 1.71 (CI, 1.11 to 2.63), and 1.90 (CI, 1.16 to 3.13), respectively. Adjustment for diabetes treatment status attenuated these associations somewhat.

CONCLUSIONS

Levels of albumin, fibrinogen, and von Willebrand factor; factor VIII activity; and leukocyte count were predictors of coronary heart disease among persons with diabetes. These associations may reflect 1) the underlying inflammatory reaction or microvascular injury related to atherosclerosis and a tendency toward thrombosis or 2) common antecedents for both diabetes and coronary heart disease.

Fibrinogen, other putative markers of inflammation, and weight gain in middle-aged adults--the ARIC study. Atherosclerosis Risk in Communities

PURPOSE

Weight gain is an important risk factor for the development of the metabolic syndrome, and inflammatory mediators are strongly associated with this syndrome. Our aim was to investigate whether inflammation predicts the development of weight gain in populations.

RESEARCH METHODS AND PROCEDURES

We investigated selected markers of inflammation in the prediction of weight gain over an approximately 3-year period in a biethnic cohort of 13,017 men and women, 45 to 64 years of age, using multiple linear and logistic regression modeling.

RESULTS

In adjusted models, those in the highest quartile of fibrinogen gained, during the first 3 years of follow-up, an estimated 0.23 kg/year more than those in the lowest quartile (p < 0.001). Adjusted odds of a large (greater than the 90th percentile) weight gain for those in the highest quartile of fibrinogen were 1.65 (95% confidence interval [CI], 1.38 to 1.97) times those in the lowest quartile. Similarly adjusted odds ratios for a large weight gain for those with high levels of white blood cell count, factor VIII, and von Willebrand factor were 1.38 (1.14 to 1.67), 1.28 (1.08 to 1.53), and 1.28 (1.08 to 1.51), respectively.

DISCUSSION

Fibrinogen and other putative markers of inflammation predict weight gain in middle-aged adults. Given the known links between the inflammatory response and intermediary metabolism and the methodological strengths of the Atherosclerosis Risk in Communities (ARIC) cohort, these findings, though without immediate clinical applicability, suggest that inflammatory processes play a role in the development of the metabolic syndrome and cardiovascular disease in part through stimulation of weight gain.

Short stature and gestational diabetes in Brazil. Brazilian Gestational Diabetes Study Group

AIMS/HYPOTHESIS

To examine the association between maternal stature and gestational diabetes mellitus.

METHODS

We studied a sample of 5564 consecutive Brazilian women 20 or more years old, who were pregnant for approximately 21-28 weeks, had no history of diabetes outside pregnancy and were attending general prenatal care units in six state capitals in Brazil from 1991 to 1995. We did a 2-h, 75-g oral glucose tolerance test, defining gestational diabetes by World Health Organisation criteria.

RESULTS

Those in the shortest quartile of height (< or = 151 cm) had a 60% increase in the odds of having gestational diabetes, independently of prenatal clinic, age, global obesity, family history of diabetes, skin colour, referral pattern, waist circumference, parity, previous gestational diabetes, education, ambient temperature and gestational age compared with the tallest quartile [odds ratio (OR) = 1.60, p = 0.005]. This association was observed for those with above median values of skinfold thickness (OR = 1.74, p = 0.006) but not for those with below median values (OR = 1.22, p = 0.51). Associations of short stature with high 2-h glycaemia (> or = 7.8 mmol/l) (OR = 1.61, p = 0.005) were essentially the same as those for gestational diabetes. There was, however, no association between short stature and gestational hyperglycaemia when the latter was defined exclusively by fasting values (OR = 0.97, p = 0.90).

CONCLUSION/INTERPRETATION

In Brazil short stature associates with gestational diabetes, principally in women with greater fat mass. This difference in glycaemic levels is present postprandially but not in the fasting state.

Prevalence of gestational diabetes mellitus--do the new WHO criteria make a difference? Brazilian Gestational Diabetes Study Group

AIMS

To describe the prevalence of gestational diabetes mellitus (GDM) according to the 1998 WHO provisional recommendations and compare it to that found with previous 1985 WHO criteria.

METHODS

A total of 5564 consecutive women aged 20 years or more without diagnosis of diabetes mellitus outside of pregnancy in general prenatal care clinics of the National Health Service in 6 state capitals of Brazil, between their 20th and 28th gestational weeks were enrolled.

RESULTS

Of the 5004 women who completed a 75-g oral glucose tolerance test, 379 (7.6%, 95% confidence interval (CI) 6.9% to 8.4%) had GDM by the 1998 criteria (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 7.8 mmol/l). Of these 379 cases, only 21 (5.5%) had hyperglycaemia in the range considered diabetes mellitus outside pregnancy (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 11.1 mmol/l); the remaining 358 (94.5%) had hyperglycaemia in the impaired glucose tolerance range (fasting glucose < 7.0 and 2 h glucose > or = 7.8 mmol/l and < 11.1 mmol/l). Using the 1985 criteria (fasting or 2 h glucose > or = 7.8 mmol/l), 378 cases of GDM were found, 15 in the diabetes range and 363 in the impaired glucose tolerance range.

CONCLUSIONS

Prevalence of GDM is minimally altered by the new WHO definition. Although GDM is a common condition, the vast majority of the cases have hyperglycaemia in the range considered impaired glucose tolerance outside pregnancy.

[Evidence-based medicine]

The growing array of diagnostic and therapeutic options available to the clinician has created the necessity of techniques, such as the randomized clinical trial, to evaluate their effectiveness. Recently, with the increasing penetration of the methods of clinical epidemiology into medical practice, the concept of an evidence-based medicine has arisen. Emphasizing the necessity of solid clinical evidence for clinical decision-making, evidence-based medicine provides a framework for the integration of research results into clinical practice. The evidence is graded, principally on the basis of study design, and norms are established as to what constitutes adequate evidence for clinical decision-making. The combination of this new paradigm of medical practice with the power of modern telecommunications is causing a revolution in the way medicine is practiced. Its integration into clinical practice is being facilitated by quantitative overviews of the literature, and the creation of clinical guidelines based on these reviews. Shortcomings of the traditional sources of evidence have been documented. New sources of evidence, such as the ACP Journal Club, and the Cochrane Collaboration, diminish dramatically the time required of clinicians to obtain the best available evidence. All health professionals should familiarize themselves with evidence-based medicine.

Markers of inflammation and prediction of diabetes mellitus in adults (Atherosclerosis Risk in Communities study): a cohort study

BACKGROUND

Type 2 diabetes mellitus and atherosclerotic cardiovascular disease have common antecedents. Since markers of inflammation predict coronary heart disease and are raised in patients with type 2 diabetes, we investigated whether they predict whether people will develop type 2 diabetes.

METHODS

12,330 men and women, aged 45-64 years, were followed up for a mean of 7 years. We analysed the association between different markers of acute inflammation and subsequent diagnosis of diabetes. In a subgroup of 610 individuals selected originally for an unrelated atherosclerosis case-control study, we also investigated diabetes associations with total sialic acid and orosomucoid, haptoglobin, and alpha1-antitrypsin.

FINDINGS

1335 individuals had a new diagnosis of diabetes. Adjusted odds ratios for developing diabetes for quartile extremes were 1.9 (95% CI 1.6-2.3) for raised white-cell count, 1.3 (1.0-1.5) for low serum albumin, and 1.2 (1.0-1.5) for raised fibrinogen. In the subgroup analysis, individuals with concentrations of orosomucoid and sialic acid of more than the median had odds ratios of 7.9 (2.6-23.7) and 3.7 (1.4-9.8), respectively. Adjustment for body-mass index and waist-to-hip ratio lessened the associations; those for white-cell count (1.5 [1.3-1.8]), orosomucoid (7.1 [2.1-23.7]), and sialic acid (2.8 [1.0-8.1]) remained significant.

INTERPRETATION

Markers of inflammation are associated with the development of diabetes in middle-aged adults. Although autoimmunity may partly explain these associations, they probably reflect the pathogenesis of type 2 diabetes.

Factor VIII and other hemostasis variables are related to incident diabetes in adults. The Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

Our objective was to evaluate whether selected hemostasis variables, some of which may reflect inflammation or endothelial dysfunction, are independently associated with the development of diabetes.

RESEARCH DESIGN AND METHODS

We studied a biethnic cohort of 12,330 men and women, 45-64 years of age, of the Atherosclerosis Risk in Communities Study. New cases of diabetes were diagnosed by a reported physician diagnosis, hypoglycemic medication use, or a casual or fasting serum glucose level of > or = 11.1 or > or = 7 mmol/l, respectively.

RESULTS

Over an average follow-up of 7 years, 1,335 new cases of diabetes were detected. The odds ratios (4th versus 1st quartile) of developing diabetes, adjusted by logistic regression for age, sex, race, study center, family history of diabetes, fasting glucose, physical activity, and smoking, were 1.2 (95% CI 1.0-1.5) for fibrinogen and 1.4 (1.1-1.6) for factor VII. Associations for factor VIII, von Willebrand factor, and activated partial thromboplastin time were found to be 1.8 (1.3-2.3), 1.4 (1.1-1.8), and 0.63 (0.49-0.82), respectively, in women. Although further adjustment for BMI and waist-to-hip ratio diminished the relationships, a highly statistically significant association (P = 0.001) remained for factor VIII (1.6 [1.2-2.1]) in women.

CONCLUSIONS

Factor VIII and other hemostasis variables are associated with the development of diabetes in middle-aged adults. These findings support a role for inflammation and, particularly in women, endothelial dysfunction in the pathogenesis of type 2 diabetes.

Dose-dependent biphasic effect of ethanol on 24-h blood pressure in normotensive subjects

The vasodilation that follows acute alcohol intake is hard to conciliate with the high prevalence of hypertension detected in those persons who consume regular amounts of alcohol. In this experiment we examined early and late hemodynamic effects of acute administration of water and of 15 g, 30 g, and 60 g of alcohol in 40 normal men, aged 19 to 30 years, using 24-h ambulatory blood pressure monitoring (ABPM). Mean systolic and diastolic blood pressures were each approximately 4 mm Hg lower during the period immediately after ingestion of 60 g (v 0 g) of ethanol, and were 7 and 4 mm Hg higher, respectively, at night. The day minus night differences displayed a dose-response curve both for systolic (P < .001) and diastolic blood pressure (P = .045). Three subjects in the 60-g group had more than 50% of nightly blood pressure loads in the hypertensive range against none in the remaining groups (P < .01). In conclusion, our findings suggest that acute alcohol intake elicits a biphasic hemodynamic response, causing, first, vasodilatation and, later, a pressor effect. The higher prevalence of hypertension in alcohol abusers seen in epidemiological surveys may be, in part, a result of measurements done in the period of transiently increased blood pressure during ethanol washout.

African American-white differences in lipids, lipoproteins, and apolipoproteins, by educational attainment, among middle-aged adults: the Atherosclerosis Risk in Communities Study

Measures of socioeconomic status have been shown to be related positively to levels of high density lipoprotein (HDL) cholesterol in white men and women and negatively in African American men. However, there is little information regarding the association between educational attainment and HDL fractions or apolipoproteins. The authors examined these associations in 9,407 white and 2,664 African American men and women aged 45-64 years who participated in the Atherosclerosis Risk in Communities Study baseline survey, and they found racial differences. A positive association for HDL cholesterol, its fractions HDL2 and HDL3 cholesterol, and its associated apolipoprotein A-I was found in white men and white women, but a negative association was found in African American men, and there was no association in African American women. In whites, there was also an inverse association of low density lipoprotein (LDL) cholesterol and apolipoprotein B with educational attainment. With the exception of African American men, advanced education was associated with a more favorable cardiovascular lipid profile, which was strongest in white women. Racial differences in total cholesterol (women only), plasma triglycerides, LDL cholesterol, apolipoprotein B (women only), HDL cholesterol, HDL2 and HDL3 cholesterol, and apolipoprotein A-I were reduced at higher levels of educational attainment. Apart from triglycerides in men and HDL3 cholesterol in women, these African American-white lipid differences associated with educational attainment remained statistically significant after multivariable adjustment for lifestyle factors. Lipoprotein(a) showed no association with educational attainment. These findings confirm African American-white differences in lipids, lipoproteins, and apolipoproteins across levels of educational attainment that were not explained by conventional nondietary lifestyle variables. Understanding these differences associated with educational attainment will assist in identifying measures aimed at prevention of cardiovascular disease.

Prevalence and clinical correlates of unsuccessful use of drugs to induce menstruation

Despite its prohibition, illegal abortion is widely practiced in Brazil, with important adverse health consequences. This report aims to document the prevalence and correlates of the unsuccessful use of drugs to "induce menstrual flow" in a cohort of pregnant Brazilian women. In a cross-sectional study, 6,102 pregnant women between gestation weeks 21 and 28 were interviewed in prenatal clinics of the Brazilian National Health Care System from April 1991 to November 1995. When asked "In order to know if you were pregnant, did you take any medication to induce menstrual flow", 874 (14.4%) responded "yes." The most frequently used drugs were herbal teas (41%), estrogens and/or progestogens (30%), and misoprostol (16%). As demonstrated through logistic regression analysis, independent correlates of such use were unplanned pregnancy (odds ratio [OR] 4.3), low educational attainment (OR 3.3), absence of a husband or partner (OR 1.8), number of children (one or more) (OR 1.5), a history of a previous induced abortion (OR 1.4), and use of oral contraceptives at the time (OR 1.4). Misoprostol use occurred in 2.2% of pregnancies, and showed a very strong association with an unplanned pregnancy (OR 16.0), absence of a husband or partner (OR 3.5), and a history of a previous induced abortion (OR 2.2). It was not associated with a history of menstrual irregularity. In contradistinction, the use of medroxyprogesterone was strongly associated with previous menstrual irregularity (OR = 5.0). The use of drugs and teas, many of which are unknown in terms of fetal risk, in early pregnancy to induce menstrual flow is quite common in women in the Brazilian National Health System. Although the objective of such drug use appears to be varied, analysis of the clinical correlates of use suggest attempted abortion to be the principal aim.

Alcohol intake and blood pressure: the importance of time elapsed since last drink

BACKGROUND

A positive association of chronic exposure to alcoholic beverages with blood pressure and the prevalence of hypertension has been described in epidemiological surveys, but the influence of time elapsed since last ingestion in this setting was not demonstrated.

DESIGN

A cross-sectional, population-based survey.

METHODS

In total 1089 adults from Porto Alegre, randomly selected from a population-based, multi-stage probability sample, were interviewed at home. The average daily alcohol intake of each subject was calculated taking into account the concentration of ethanol in the beverages (distilled or fermented beverages), and the time elapsed between the last ingestion of ethanol and the moment of blood pressure determination. Standardized sitting blood pressure and anthropometric parameters were collected. The magnitude and shape of the associations were analyzed considering blood pressure as a continuous variable and the prevalence of arbitrarily defined hypertension. Simple and multiple linear regression models, including models to identify nonlinear associations, with quadratic and cubic terms of the amount of alcohol consumed, were employed. Blood pressure means were compared by analysis of variance and analysis of covariance. The association between hypertension and exposure to ethanol was analyzed through logistic regression models, controlling for various potential confounders.

RESULTS

Positive nonlinear associations of the amount of alcohol consumed with blood pressure and the prevalence of hypertension (> or = 160/95 mmHg) were found, independent of age, years of education, smoking, and use of oral contraceptive and antihypertensive drugs. The consumption of 30 g/day ethanol was associated with increases of 1.5 and 2.3 mmHg in diastolic and systolic blood pressures, respectively, for men, and 2.1 and 3.2 mmHg, respectively, for women. The prevalence of hypertension was higher among those ingesting more than 30 g/day (odds ratio = 2.9, P < 0.01). The time elapsed between the last ingestion and blood pressure measurement was independently associated with the prevalence of hypertension. Men with last consumption of alcohol 13-23 h prior to measurement had odds of being hypertensive 2.6 (confidence interval 1.3-5.0) greater than did subjects who had consumed alcoholic beverages 24 h and more before the blood pressure determination. For men, systolic and diastolic blood pressures were lower during the first 3 h after ingestion and increased afterward. Frequency of consumption and type of beverage consumed were not independently associated with level of blood pressure.

CONCLUSION

A time-dependent association between alcohol consumption and effects on blood pressure, demonstrated in experimental studies, was found for free-living individuals selected at random.

Development of the multiple metabolic syndrome in the ARIC cohort: joint contribution of insulin, BMI, and WHR. Atherosclerosis risk in communities

PURPOSE

The natural history of the multiple metabolic syndrome (MMS) and its predictors has rarely been addressed in population samples. This study evaluated the predictive role of fasting serum insulin, body mass index (BMI), and waist-to-hip ratio (WHR) on the development of incident MMS components (diabetes, hypertension, and dyslipidemias) over the course of three years.

METHODS

The study population comprised the cohort of middle-aged African American and European American men and women of the Atherosclerosis Risk in Communities Study (1987-1992).

RESULTS

Among 6113 individuals free of MMS components at baseline, high insulin (> 14 microU/ ml) was independently predictive of the development of one or more MMS components (OR:1.5, 95% CI:1.2-1.8), as was a BMI > or = 30 (OR:1.7, 95% CI:1.4-2.0), and a high WHR (> 0.98) (OR:1.5, 95% CI:1.3-1.8) adjusting statistically for age, gender, and ethnicity/center. These associations were markedly stronger for combinations of MMS components (two or more) than for isolated components.

CONCLUSIONS

The findings confirm earlier reports on the predictive role of insulin, BMI, and WHR, and suggest that these antecedent factors may be integral to the development of combinations of disorders, i.e., the particular clustering identified as the MMS.

Waist circumference and waist-to-hip ratio are related to gestational glucose tolerance

OBJECTIVE

To evaluate the relationship of central fat distribution with gestational glucose tolerance during the usual time for screening gestational diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study investigated 1,113 consecutive women, > or = 20 years old, pregnant for approximately 21 to 28 weeks, without history of previous diabetes outside pregnancy, who attended two general prenatal care units in Porto Alegre, Brazil, from 1991 to 1993. Weight, height, waist and hip circumferences, and skinfolds were measured, and a 2-h, 75-g glucose tolerance test was performed. Data were analyzed using multiple linear regression models.

RESULTS

Waist-to-hip ratio (WHR) and waist circumference were independently associated with higher 2-h glycemia. Glycemic level was 0.11 and 0.13 mmol/l greater for each standard deviation increase in WHR (0.06) and waist circumference (8.0 cm), respectively (P < 0.02). Restricting analyses to the subset of women with uterine height < or = 26 cm improved the association (0.13 and 0.19 mmol/l, respectively, P < 0.02); differences of 0.22 and 0.19 mmol/l were observed for 1 SD changes in the sum of skinfold thicknesses (24.7 mm) and in age (5.5 years), respectively.

CONCLUSIONS

Central fat distribution measured in pregnancy is an independent predictor of gestational glucose intolerance. This finding supports the concept that NIDDM and gestational diabetes are parts of the same disease, differing basically in their moment of detection. The usefulness of these anthropometric measurements in identifying pregnant women at high risk of having gestational glucose intolerance merits further investigation.

Risk factors differ for carotid artery plaque with and without acoustic shadowing. Atherosclerosis Risk in Communities Study Investigators

To investigate the association of gender, ethnicity, and several cardiovascular risk factors with carotid artery plaque and plaque with acoustic shadowing in a population-based sample, high-resolution B-mode ultrasonography was used to characterize lesions in the common and internal carotid arteries, and at the carotid bifurcation in 12,796 US men and women, aged 45 to 64 years, participating in the Atherosclerosis Risk in Communities Study (ARIC) baseline survey. In multiple logistic regression analyses, male gender (odds ratio and 95% confidence interval: 1.52 [1.39-1.67]) and increased total (1.47 [1.32-1.63]) and low-density-lipoprotein cholesterol (1.49 [1.34-1.65]) levels were statistically significantly associated only with the presence of plaque. In contradistinction, smoking (2.22 [1.79-2.75]) and hypertension (1.54 [1.30-1.82]) were additionally associated with acoustic shadowing. Hyperfibrinogenemia (1.33 [1.12-1.59]) was associated only with lesions accompanied by acoustic shadowing. While ethnicity associations with plaque alone varied across the artery segments, among those with plaque, being white was uniformly associated with acoustic shadowing. After multivariable adjustment, high-density-lipoprotein cholesterol was not associated with either manifestation of atherosclerosis. In conclusion, differences were seen in the associations of established cardiovascular risk factors with discretely characterized carotid artery plaque lesions, according to the presence or absence of acoustic shadowing suggestive of mineralization of plaque.

Clustering of dyslipidemia, hyperuricemia, diabetes, and hypertension and its association with fasting insulin and central and overall obesity in a general population. Atherosclerosis Risk in Communities Study Investigators

Clustering of elevated triglycerides, decreased high-density lipoprotein cholesterol (HDL-C), hyperuricemia, diabetes, and hypertension has been related to insulin resistance/high insulin levels and central and/or overall obesity. The extent to which these abnormalities cluster and whether hyperinsulinemia, central adiposity, and overall obesity each independently associate with this clustering were evaluated in 14,481 US whites and African-Americans 45 to 64 years of age. With the exception of hypertension, abnormalities rarely existed in isolated form. Clustering greatly exceeded chance association (P < .001). Although this clustering was greater in relative terms (ratio of observed to expected cluster frequency) in the lean and less centrally obese, it was greater in absolute terms (observed minus expected cluster frequency as a percent of total population) in the more centrally and more generally obese. The greatest excesses were found for clusters that included both hypertriglyceridemia and low HDL-C. Multiple logistic regression models showed strong and independent graded relationships of clusters with quintiles of fasting insulin (fifth quintile odds ratio, 10 to 54, P < .001) and to a lesser degree with quintiles of the waist to hip ratio (2.2 to 5.4, P < .001 for most) and of body mass index (1.6 to 4.5, P < .05 for most). In conclusion, all abnormalities cluster in excess of that predicted by chance, with clusters showing remarkable and graded independent associations with fasting hyperinsulinemia and to a lesser extent with central and overall obesity. Thus, a metabolic syndrome occurs in both lean and obese middle-aged US adults.

A metabolic syndrome in whites and African-Americans. The Atherosclerosis Risk in Communities baseline study

OBJECTIVE

To describe clustering of hypertriglyceridemia, low HDL cholesterol, hypertension, diabetes, and hyperuricemia and its association with fasting insulin, waist-to-hip ratio (WHR), and BMI for African-American and white men and women.

RESEARCH DESIGN AND METHODS

Observed frequencies of clusters were compared with those expected in 14,481 participants, 45-64 years of age, of the Atherosclerosis Risk in Communities (ARIC) baseline survey, 1987-1989. Associations of clusters with insulin, central adiposity, and overall obesity, as well as with abnormalities, were analyzed through multiple logistic regression.

RESULTS

Clustering beyond chance was observed in all four sex/ethnic groups (P < 0.001), with 7% of the sample presenting 30% of the abnormalities in large clusters (> or = 3 abnormalities per individual). The odds ratio (OR) for the association of each abnormality with clustering of the remaining four ranged from 1.6 to 8.8 (P < 0.01). These odds of clustering were notably large in white women. Of the abnormalities, hypertriglyceridemia demonstrated the highest OR (5.0-8.8) and diabetes had the lower OR in African-American subjects than in white subjects (P < 0.001). Insulin, WHR, and BMI were statistically associated with clustering in all groups (P < 0.001, except for BMI in African-Americans.

Association of the waist-to-hip ratio is different with wine than with beer or hard liquor consumption. Atherosclerosis Risk in Communities Study Investigators

Specific alcoholic beverage associations with the waist-to-hip ratio were characterized in 12,145 African-American and white men and women ages 45-64 years. Estimated waist-to-hip ratios of those consuming more than six nonwine alcohol drinks/week and more than six wine drinks/week (vs. nondrinkers) were 0.007 larger (p < 0.001) and 0.009 smaller (p < 0.05), respectively. In similar comparisons, the odds ratios for a large waist-to-hip ratio were 1.4 (95% confidence interval 1.1-1.7) for nonwine and 0.45 (95% confidence interval 0.21-0.95) for wine intake. The opposite direction in adjusted associations for wine and nonwine (mainly beer) drinking supports the popular concept of the "beer belly."

Correlates of body fat distribution. Variation across categories of race, sex, and body mass in the atherosclerosis risk in communities study. The Atherosclerosis Risk in communities (ARIC) Study Investigators

Though central adiposity is a strong, independent risk factor for cardiovascular and all-cause mortality, relatively little is known about its determinants. To characterize the association of central adiposity with several of its possible determinants, while describing variability in these associations across sex, race, and level of body mass index, we conducted a cross-sectional survey of 15,800 white and African-American men and women ages 45 to 64 years participating in the Atherosclerosis Risk in Communities baseline survey, 1987 to 1989. After adjustment for other possible determinants, African Americans had markedly larger subscapular skinfold thickness and subscapular/triceps ratios than did whites, while whites had larger waist/hip ratios. Large, statistically significant variations in waist/hip ratio associations with age, percent of weight gained after age 25, smoking, and physical activity in the workplace existed across categories of sex, race, and body mass index. Based on our findings, we concluded that major variation exists in the waist/hip ratio and in its associations with its possible determinants across categories of race, sex and obesity.

Social inequality in mortality in São Paulo State, Brazil

BACKGROUND

Epidemiological studies have consistently demonstrated social inequality to be an important factor in the distribution of illness and death in society. However, little work has been published on social differentials in mortality in the world's developing countries, where socioeconomic contrasts are often considerably greater.

METHODS

In order to evaluate the extent of social differentials in mortality in a setting of major social inequality -- the State of São Paulo, Brazil, deaths in men aged 15-64 years residing in São Paulo from 1980 to 1982 were linked in broad, occupationally-determined categories to estimates of population size based on the 1980 Brazilian national census. The occupational categorizations utilized a Brazilian classification scheme and additionally that of the British Registrar General.

RESULTS

Mortality was 3.8 and 2.9 times greater comparing least to most socially favoured occupational category in each of the two classification systems, respectively. Independent of system, mortality decreased approximately 1.1% for each 1% increase along the occupationally-defined social gradient. This decrease was 48% greater than the equivalent calculated decrease for men of England and Wales.

CONCLUSIONS

These data support the contention that mortality for Brazilian adults, even more so than for adults of the world's more economically developed nations, is inextricably bound to the issue of social equity.

B-mode-detected carotid artery plaque in a general population. Atherosclerosis Risk in Communities (ARIC) Study Investigators

BACKGROUND AND PURPOSE

There is little information on the distribution of atherosclerotic lesions of the extracranial carotid artery wall in free-living populations. The purpose of the present study was to describe the prevalence from 1987 through 1989 of extracranial carotid artery plaque and plaque with acoustic attenuation (shadowing) lesions in a general population of white and black adults from four US communities.

METHODS

B-mode ultrasound was used to characterize wall lesions in the common and internal carotid arteries and at the carotid artery bifurcation in 14,046 men and women 45 to 64 years old who participated in the Atherosclerosis Risk in Communities Study baseline survey.

RESULTS

Thirty-four percent of participants had plaque and 6.4% had plaque with acoustic shadowing. The prevalence of plaque with acoustic shadowing increased steadily with age from 2.5% at ages 45 to 49 to 12.4% at ages 60 to 64. Overall, whites had more plaque with acoustic shadowing lesions than blacks (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.02 to 1.46), and men had more than women (OR, 1.42; 95% CI, 1.22 to 1.63). However, plaque lesions in the common carotid artery were less common among whites than among blacks, and no racial difference was observed in the prevalence of plaque with acoustic shadowing at this segment.

CONCLUSIONS

Although these prevalence rates are likely to be underestimated because of the emphasis on arterial boundary visualization of the scanning protocol, they show a large, mostly asymptomatic burden of atherosclerosis in these populations, especially among older individuals. Site-specific frequency rates of plaque varied between blacks and whites. Among those with plaque, however, whites had more lesions with acoustic shadowing attenuation.

Variation in glucose tolerance with ambient temperature

Ambient temperature may affect venous glucose concentration after glucose tolerance tests. We analysed 1030 standardised 75 g tests. Although mean fasting values did not differ, post-load values did: adjusted mean 2 h glucose concentration was 1.03 mmol/L lower at lower (5-14 degrees C) than at higher (25-31 degrees C) temperatures (p < 0.001). The occurrence of abnormal glucose tolerance doubled on warmer days. The diagnostic accuracy of the glucose tolerance test showed clinically significant temperature-associated variation. These variations, if confirmed, call for temperature standardisation during glucose tolerance testing and/or alternative strategies for use when standardisation is not feasible.

Validity of self-reported weight--a study of urban Brazilian adults

In order to evaluate the validity of self-reported weight for use in obesity prevalence surveys, self-reported weight was compared to measured weight for 659 adults living in the Porto Alegre county, RS Brazil in 1986-87, both weights being obtained by a technician in the individual's home on the same visit. The mean difference between self-reported and measured weight was small (-0.06 +/- 3.16 kg; mean +/- standard deviation), and the correlation between reported and measured weight was high (r = 0.97). Sixty-two percent of participants reported their weight with an error of < 2 kg, 87% with an error of < 4 kg, and 95% with an error of < 6 kg. Underweight individuals overestimated their weight, while obese individuals underestimated theirs (p < 0.05). Men tended to overestimate their weight and women underestimate theirs, this difference between sexes being statistically significant (p = 0.04). The overall prevalence of underweight (body mass index < 20) by reported weight was 11%, by measured weight 13%; the overall prevalence of obesity (body mass index > or = 30) by reported weight was 10%, by measured weight 11%. Thus, the validity of reported weight is acceptable for surveys of the prevalence of ponderosity in similar settings.

[Risk factors for non-communicable diseases in a metropolitan area in the south of Brazil. Prevalence and simultaneity]

Three-quarters of deaths in Rio Grande do Sul State, Brazil, are due to non-communicable diseases-cardiovascular diseases, alone, being responsible for 35% of them. To evaluate the prevalence of risk factors for these diseases, a household survey of 1,157 randomly sampled individuals between 15 and 64 years of age was undertaken in 1986 and 1987 in census tracts of 4 areas of the city of Porto Alegre. The age- and sex-adjusted prevalence of smoking was 40%, hypertension 14%, obesity 18%, overall sedentary life-style 47%, and excessive alcohol consumption 7%. Thirty-nine percent of the sample presented two or more of these five risk factors, and only 22% of men and 21% of women had none of them. The high frequencies and simultaneous presence of these risk factors indicate their importance for programs aimed at the prevention of non-communicable diseases and the promotion of adult health.

[Myocardial infarct and cerebral vascular disorders associated with high temperature and carbon monoxide in a metropolitan area of southeastern Brazil]

Many studies have been published about the relationship between life style and genetic risk factors and stroke and heart attack, but there have been few about the relationship between atmospheric pollution, specifically with carbon monoxide, and temperature and stroke and heart attack. With a view to filling this gap the relationship between values of carbon monoxide concentration in the air, maximum and average by day, and maximum temperature by day and the number of new cases of CVA and IM admitted as emergencies at the biggest hospital complex of S. Paulo city was analysed. If was concluded, by the use of multivariable regression analysis, that 2.1% and 4.9% of heart attack admissions were due to carbon monoxide air pollution and high temperature, respectively. 2.8% of stroke admissions were due high temperature. Stroke and carbon monoxide were not associated in this population.

Tendencies in adult mortality in Rio Grande do Sul, Brazil, 1970-1985. An international comparison

"In order to evaluate mortality trends in adults aged 30-69 years in the State of Rio Grande do Sul [Brazil], changes in age-standardized mortality from 1970 to 1985 were calculated and compared with trends of 33 other countries. Virtual stability in Rio Grande do Sul over this 16-year period contrasts with dramatic reduction in age-standardized all-cause and cardiovascular disease mortality in many countries.... The data demonstrate that major declines in adult mortality can be achieved, and suggest that, during the period 1970-1985, Rio Grande do Sul participated little in the international tendency toward improved adult health." (SUMMARY IN POR)

[High mortality rates among Brazilian adult populations--an international comparison]

Adult disease in an increasingly important public health problem in Brazil. In order to compare adult mortality in Brazil to that in other countries, age-adjusted coefficients for adults aged 30-69 of the States of São Paulo and Rio Grande do Sul and of the city of Fortaleza (Ceará State) are compared to those of similarly aged adults in a series of 33, principally European, countries. The Brazilian population coefficients for overall, cerebrovascular and cardiovascular mortality are among the highest of the series; those for ischemic heart disease occupy median positions. These comparisons illustrate the precarious state of adult health in Brazil and, given the growing possibilities of preventing cardiovascular and other non-communicable diseases, help demonstrate the need for preventive programs in Brazil aimed at the major common and lethal diseases of the productive years of life.

Association of waist-hip ratio with diabetes mellitus. Strength and possible modifiers

OBJECTIVE

To characterize the association between central obesity, as measured by the waist-hip ratio (WHR), and non-insulin-dependent diabetes mellitus (NIDDM), considering the effects of sex, age, overall obesity, and family history of diabetes.

RESEARCH DESIGN AND METHODS

Case-control study nested within a community-based survey. We selected 151 subjects with NIDDM and 301 nondiabetic control subjects as a systematic sample of survey screening negative individuals.

RESULTS

Odds ratios for NIDDM, comparing a high WHR (greater than or equal to 0.926 for men, greater than or equal to 0.83 for women) to a low WHR were 4.72 with a 95% confidence interval of 2.39-9.34, and 2.17 with a 95% confidence interval of 1.03-4.58, for women and men, respectively, controlling for age, overall obesity, and a family history of diabetes. Women with high WHRs in the presence of these risk factors are notably at risk for diabetes.

CONCLUSION

Central obesity, as measured by the WHR, is importantly and independently associated with NIDDM.