Mental health, challenging behaviour, diagnosis, and access to employment for people with intellectual disabilities in Norway

BACKGROUND

Studies have found that presence of challenging behaviours and mental health problems limits employment for people with intellectual disabilities. This study investigates the associations between age, gender, living condition, level of intellectual disability, diagnoses, behaviour, mental health, and employment in adults with intellectual disabilities in Norway.

METHOD

A cross-sectional community-based survey including 214 adult participants (56% men) with intellectual disabilities.

RESULTS

In our sample, 25% had no organised day activity, 27% attended non-work day care, 19% attended sheltered employment, or day care with production, without pay and 29% worked in paid sheltered employment. One participant attended mainstream employment. Moderate and severe/profound level of intellectual disability, possible organic condition and irritability significantly reduced the odds of employment (paid and unpaid).

CONCLUSION

Findings suggest unequal access to the sheltered employment that was meant to be inclusive. More individualised evaluation of prerequisites is suggested to further facilitate employment for this group.

Long-term prognostic value of trimethylamine N-oxide in community-based adults and patients with coronary heart disease

Background

Trimethylamine N-oxide (TMAO) is an amine oxide generated by gut microbial metabolism. Emerging evidence suggests pro-atherosclerotic and pro-inflammatory properties of TMAO; however, the clinical utility of circulating TMAO in risk stratification is uncertain.

Purpose

We prospectively assessed relationships of plasma TMAO with long-term risk of all-cause, cardiovascular (CV) and non-CV mortality in community-dwelling adults and patients with coronary heart disease.

Methods

By Cox modelling, risk-associations were examined in the Hordaland Health Study (HUSK; 6393 community-based adults) and the Western Norway Coronary Angiography Cohort (WECAC; 4132 patients with suspected chronic coronary syndrome).

Results

Median follow-up time was 11.0 and 10.3 years in HUSK and WECAC, respectively. Following adjustments for established CV risk factors in HUSK, the HRs (95% CIs) comparing the 4th vs. 1st TMAO-quartile were 1.11 (0.88–1.40), 0.97 (0.65–1.46) and 1.17 (0.88–1.54) for all-cause, CV and non-CV mortality, respectively. Corresponding risk estimates in WECAC were 1.07 (0.86–1.32), 1.16 (0.83–1.62) and 1.02 (0.77–1.34). Similar results were observed in patients with angiographically significant coronary artery disease and patients with reduced left ventricular ejection fraction.

Conclusion

Plasma TMAO was not predictive of long-term all-cause, CV or non-CV mortality in patients with or without established coronary heart disease. This large-scale study does not support a role of TMAO for patient risk stratification in primary or secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

Plasma hydroxyanthranilic acid as a predictor of stress induced myocardial ischemia in non-obstructive coronary artery disease

Background

The tryptophan catabolite hydroxyanthranilic acid (HAA) has potent immunomodulatory and vasoactive effects. HAA is also a precursor in the synthesis of nicotinamide adenine dinucleotide (NAD), a crucial cofactor in energy-metabolism. We have previously demonstrated that elevated plasma HAA predicted risk of myocardial infarction.

Purpose

To explore if plasma HAA is associated with stress induced myocardial ischemia in non-obstructive coronary artery disease (CAD).

Methods

In 132 patients with chest pain and non-obstructive CAD by coronary computed tomography angiography (CCTA), plasma HAA was analyzed by gas chromatography tandem mass spectrometry. All participants underwent myocardial contrast stress echocardiography. Myocardial ischemia was assessed as delayed contrast replenishment at peak dobutamine stress during real-time low mechanical index imaging and destruction replenishment. The extent of ischemia was defined as the number of segments with delayed contrast enhancement using a 17-segment left ventricular model. Associations of plasma HAA with myocardial ischemia was evaluated in a multivariate adjusted linear regression model.

Results

Mean (SD) age at inclusion was 63 (8) years and 56% were women. At CCTA, the median (25th, 75th percentile) coronary artery calcium (CAC) score was 42 (13–107) Agatston units, whereas the mean (SD) segment involvement score (SIS) was 2.6 (1.6). Myocardial ischemia was found in 52% of patients with on average 5 (3) ischemic segments per patient. Serum HAA did not correlate with the CAC score or SIS (p>0.29). After multivariate adjustment including age, sex, body mass index, systolic blood pressure, diabetes, current smoking, and LDL cholesterol, the odds ratio and 95% confidence interval for myocardial ischemia was 1.55 (1.04–2.32), P=0.03, per SD increment of plasma HAA levels (log transformed). Plasma HAA was also associated with the extent of myocardial ischemia with a multivariate adjusted β of 0.26, P=0.004.

Conclusion

Plasma HAA is associated with the extent of myocardial ischemia in non-obstructive CAD. Potential roles of this metabolite in atherogenesis, vascular dysfunction and as a predictor of myocardial ischemia should be further elucidated.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Western Norway Regional Health Authority

Impact of epicardial adipose tissue accumulation on left ventricular mass and hypertrophy in non-obstructive coronary artery disease

Introduction

Increased left ventricular mass index (LVMi) and left ventricular hypertrophy (LVH) by echocardiography are common in obesity and important cardiovascular risk predictors associated with myocardial ischemia in non-obstructive coronary artery disease (CAD). Accumulation of epicardial adipose tissue (EAT) suggest a possible direct impact on LVMi and LVH.

Purpose

To explore the association between EAT volume, LVMi and LVH in patients with chest pain and non-obstructive CAD.

Methods

We included 129 patients with chest pain and non-obstructive CAD (<50% stenosis) by coronary computed tomography (CT) angiography. EAT volume was quantified using a semiautomatic analysis software on non-contrast cardiac CT images. Patients were grouped according to EAT volume, where high EAT volume was adjudicated when EAT volume was in the highest tertile (≥125 ml). Left ventricular mass was assessed by echocardiography, calculated by the Devereux formula and indexed for height in the allometric power of 2.7 (LVMi). LVH was defined as LVMi >46.7 g/m2.7 in women and >49.2 g/m2.7 in men. Coronary artery plaque burden was assessed as calcium score and segment involvement score on coronary CT angiography.

Results

High EAT volume was more common in men with higher BMI, waist circumference, serum triglycerides and higher prevalence of hypertension and obesity (all p<0.05). Age, coronary calcium score and coronary artery segment involvement score did not differ between groups. Patients with high EAT volume had higher LVMi compared to those with low EAT volume (42.5 g/m2.7 vs. 36.1 g/m2.7, p=0.003), while there was no difference in EAT volume among patients with or without LVH. In univariable logistic regression analysis, high EAT volume was associated with higher LVMi (OR 1.05 [95% CI 1.01–1.10] per g/m2.7, p=0.015). After adjusting for hypertension and obesity in a multivariable model, higher LVMi remained significantly associated with high EAT volume (Model 1, Table 1), but the association was attenuated after adjusting for sex (Model 2, Table 1).

Conclusion

High EAT volume was associated with increased LVMi in patients with non-obstructive CAD, independent of hypertension and obesity, while there was no association with LVH. This suggest that direct infiltration of adipose tissue in the myocardium may contribute to the development of increased LVMi.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Western Norwegian Regional Health Authorities Table 1

Associations of circulating polyunsaturated fatty acids with coronary artery calcium score in hospitalized patients with suspected coronary artery disease

Background

Inadequate intake of polyunsaturated fatty acids (PUFAs) is recognized as a modifiable risk factor for atherosclerotic cardiovascular disease (CVD) (1,2). The n-6 PUFA linoleic acid (LA) constitutes the predominant portion of total dietary PUFAs (3). However, whereas cardiometabolic effects of PUFAs belonging to the n-3 series have been studied for decades, less attention has been payed to potential health effects from n-6 PUFAs (4). Further, there has been concern regarding possible proinflammatory properties of several n-6 PUFA related metabolites.

Purpose

We explored correlations of serum total PUFAs, LA and the n-3 PUFA docosahexaenoic acid (DHA) with the inflammation marker GlycA. Further, we evaluated associations of total PUFAs, LA and DHA with the extension of atherosclerosis, as determined by the Agatston coronary artery calcium (CAC) score (5).

Methods

The study includes 250 patients who were hospitalized due to acute chest pain and referred to coronary CT angiography (CCTA) during in hospital stay. Exclusion criteria included diagnosis of acute myocardial infarction and/or revascularization within 24 hours after admittance. Serum levels of total PUFAs, LA, DHA and GlycA were analyzed by NMR technology in samples that had been frozen and stored at −80°C. After logarithmic transformation, relations of total PUFA, LA, and DHA with GlycA were evaluated by Pearson correlation analyses. The associations with CAC score were visualized in generalized additive regression plots and further evaluated in linear regression models including age, gender, body mass index, diabetes, hypertension and smoking status as independent covariables.

Results

Mean (SD) age was 57.6 (12.0) years, and 91 (36.4%) of the patients were women. Median (25th-75th percentiles) serum levels (in mmol/L) were for total PUFA 6.36 (5.76–7.06), LA 5.00 (4.51–5.55), DHA 0.36 (0.31–0.43) and GlycA 1.04 (0.94–1.13). Interestingly, GlycA was strongly, positively correlated with total PUFA (r=0.54). LA (r=0.53) and DHA (r=0.27), all P<0.001. In contrast, total PUFA and LA were inversely associated with CAC score both providing standardized betas of −0.17, P=0.03 after multivariable adjustments. No significant associations were found between CAC score and DHA or GlycA (P≥0.22). Further, the addition of GlycA to the multivariable model did not materially affect the relationship between CAC score and total PUFA or LA, which remained statistically significant (P=0.04).

Conclusion

In patients undergoing CCTA due to acute chest pain, serum levels of total PUFA and LA were strongly positively correlated with the pro-inflammatory marker GlycA. Still, total PUFA and LA were both inversely associated with the CAC score and the associations remained statistically significant after adjustments for CVD risk factors and GlycA levels. Future studies should further address the diverse effects of n-6 PUFAs on inflammatory pathways, atherogenesis and coronary calcification.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Western Norway Regional Health Authority

The associations of serum homoarginine to long-term prognosis in patients with chronic coronary syndrome and non-obstructive coronary artery disease

Background

Although generally at lower risk than those with obstructive CAD, patients with non-obstructive CAD (NOCAD) are heterogeneous concerning long-term prognosis. Notably, reversible ischemia due to vascular dysfunction is a frequent finding in NOCAD patients (1). The endogenous, non-proteinogenic amino acid homoarginine (hArg) increases the availability of nitric oxide (NO) and thereby the NO-dependent vasodilatation (2). Several studies have reported a strong inverse relation between serum hArg levels and cardiovascular disease (CVD) risk among patients with obstructive CAD. However, the prognostic implications of serum hArg levels in NOCAD patients have not been explored previously.

Purpose

We evaluated serum hArg as a predictor of long-term risk of CVD mortality among patients with NOCAD.

Methods

1046 patients with chronic coronary syndrome (CCS) underwent elective coronary angiography during 2000–2004, with the findings of NOCAD. Serum hArg was measured by liquid chromatography-tandem mass spectrometry in samples that had been frozen and stored at −80°C. The association of serum hArg to CVD mortality risk was visualized in a generalized additive regression plot and further explored using Cox regression. The models included age, sex, body mass index, hypertension, diabetes, smoking status, serum LDL cholesterol and estimated glomerular filtration rate as independent covariables. We evaluated model discrimination and risk classification by calculating C-statistics and net reclassification improvement (NRI >0), respectively.

Results

Median (25th-75th percentiles) age at inclusion was 57 (51–65) years, 48.5% were women and median (25th-75th percentiles) level of serum hArg was 1.87 (1.47–2.38) μmol/L. During median (25th- 75th percentiles) 14.1 (13.2–15.4) years of follow-up 5.7% of the patients died from CVD. The multivariable adjusted hazard ratio (95% confidence interval) per SD increment of (log transformed) hArg was 0.53 (0.40–0.70) in relation to CVD mortality. The multivariable model without biomarker provided a C- statistics for CVD mortality of 0.79 which increased to 0.82 by the addition of serum-hArg to the model (Δ area =0.03, P=0.01). Further, serum hArg provided a high NRI (95% CI) of 0.53 (0.40–0.70), P<0.001.

Conclusion

We demonstrated a strong inverse relationship between serum hArg and long-term risk of CVD mortality among patients with NOCAD. Our study adds to previous literature linking low hArg with vascular dysfunction and adverse CVD prognosis. The potential clinical usefulness of serum hArg measurements for the identification of a high-risk phenotype in NOCAD warrants further evaluation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Western Norway Regional Health Authority

Circulating trimethyllysine predicts total and cardiovascular mortality in patients with and without coronary heart disease

Background

The carnitine precursor trimethyllysine (TML) is associated with the microbiota-derived metabolite trimethylamine N-oxide (TMAO) and predicts future cardiovascular events in patients with established coronary heart disease (CHD).

Purpose

To examine circulating TML as a predictor of total and cardiovascular mortality in two independent cohorts of subjects with or without CHD.

Methods

By Cox regression modelling, risk associations were examined in 6393 subjects in the community-based Hordaland Health Study (HUSK). A replication study was performed among 4117 patients undergoing coronary angiography for suspected stable angina pectoris in the Western Norway Coronary Angiography Cohort (WECAC).

Results

During a median follow-up of 10.9 years in the HUSK-cohort, 884 (13.8%) subjects died, of whom 287 from cardiovascular causes. After adjustments for traditional cardiovascular risk factors, the hazard ratio (HR) (95% CI) for total mortality comparing the 4th vs. 1st TML-quartile was 1.66 (1.31–2.10, p<0.001). Particularly strong associations were observed with cardiovascular mortality (HR [95% CI] 2.04 [1.32–3.15, p=0.001]). Corresponding risk estimates in the WECAC-cohort (median follow-up of 10.3 years) were 1.35 (1.10–1.66, p=0.004) for total and 1.45 (1.06–1.98, p=0.02) for cardiovascular mortality. Additional adjustments for plasma TMAO did not materially influence the risk estimates in either cohort, and no effect modification by TMAO was observed.

Conclusions

Circulating TML is associated with increased risk of total and cardiovascular mortality in both subjects with and without CHD.

Funding Acknowledgement

Type of funding sources: None.

P2647Impact of hypertension on extent of non-obstructive coronary artery disease (The NORIC registry)

Background

In non-obstructive coronary artery disease (CAD), increasing extent of disease is associated with a worse prognosis. Statin therapy has been suggested to improve the prognosis. Whether hypertension, a modifiable CV risk factor, affects the extent of non-obstructive CAD in patients with stable angina is less explored.

Purpose

To assess the association between hypertension and extent of non-obstructive coronary artery disease.

Methods

We identified 1117 patients (mean age 62±10 years, 48% women) from the Norwegian Registry for Invasive Coronary angiography (NORIC). All subjects had stable angina and non-obstructive CAD defined as 1–49% stenosis in any coronary artery segment by coronary computed tomography angiography (CCTA). The extent of non-obstructive CAD was assessed as coronary artery segment involvement score (SIS) on CCTA. Extensive non-obstructive CAD was defined as SIS≥4.

Results

Hypertension was present in 44% and patients with hypertension were older with a higher prevalence of diabetes, obesity, smoking and statin therapy (all p<0.05). Coronary artery SIS and calcium score were higher in patients with hypertension compared to those without hypertension, (3.1±2.0 vs. 2.6±1.7, p<0.001 and 41 (116) vs. 32 (91) HU, p<0.05), respectively. There was no significant sex difference in the prevalence of hypertension. In univariable analysis, hypertension, age, calcium score and statin treatment were significantly associated with extensive non-obstructive CAD (Table). Hypertension remained a strong, independent predictor of extensive non-obstructive CAD after adjusting for other known covariables (Table).

Table 1. Covariables of extensive non-obstructive CAD in univariable and multivariable logistic regression analysis Univariable analysis Multivariable analysis OR 95% CI p-value OR 95% CI p-value Hypertension 1.57 1.21–2.04 0.001 1.47 1.03–2.10 0.035 Age 1.06 1.05–1.08 <0.001 1.04 1.01–1.06 0.001 Calcium score 1.02 1.01–1.02 <0.001 1.01 1.01–1.02 <0.001 Statin treatment 1.34 1.03–1.75 0.029 1.20 0.83–1.70 0.341 Smoking 1.33 1.00–1.77 0.052 1.24 0.86–1.78 0.251 Diabetes mellitus 1.34 0.86–2.12 0.191 1.10 0.57–2.09 0.781 Obesity 1.03 0.76–1.41 0.839 1.19 0.79–1.80 0.425

Conclusions

Hypertension is associated with extensive non-obstructive CAD in patients with stable angina, suggesting that early and aggressive antihypertensive treatment may impact disease progression.

P1531The association between plasma choline and acute myocardial infarction is modified by potential markers of endogenous PPAR activation

Background

Choline is related to lipid handling and higher plasma concentrations have been associated with an adverse cardiovascular risk profile. However, previous studies have suggested that the relationship between plasma free choline and later cardiovascular events may differ according to patient phenotypes.

Purpose

To explore the risk association between plasma choline and later acute myocardial infarction (AMI) according to plasma methylmalonic acid (MMA) or dimethylglycine (DMG). The latter two metabolites are suggested markers of endogenous activation of perixosome proliferator-activated receptors (PPARs), which are nuclear receptor proteins involved in lipid metabolism.

Methods

Risk relationships were explored by Cox regression among 2232 patients evaluated for suspected stable angina pectoris in the overall population and according to median plasma MMA and DMG.

Results

Baseline plasma choline was related to several cardiovascular risk factors (Table 1). After median follow-up of 7.3 years, 338 patients were reported with at least one incident AMI. In the overall population, the age and gender adjusted HR (95% CI) for each increment of 1 SD log-transformed plasma choline and AMI was 1.21 (1.08–1.35), P=0.001, and the association persisted in multivariate analyses.

In patients with plasma MMA or DMG≥median, the HRs (95% CIs) were 1.33 (1.16–1.54) and 1.38 (1.20–1.58), respectively, both P<0.0001; however no significant relationships were observed between plasma choline and later AMI among patients with either plasma MMA or DMG < median (P interaction <0.008) (Figure 1).

<MEDIAN (P>

Table 1. Baseline characteristics according to plasma choline quartiles Quartile 1 Quartile 4 P for trend Age, years 58 (52–66) 66 (58–73) <0.0001 Smoking, n (%) 212 (37.9) 153 (27.9) <0.0001 Diabetes, n (%) 61 (10.9) 85 (15.5) 0.12 Previous acute myocardial infarction, n (%) 200 (35.7) 238 (43.4) <0.0001 Estimated glomerular filtration rate, mL/min/1.73m2 96 (87–104) 79 (63–92) <0.0001 Serum hs-troponin T, ng/L 4 (3–8) 9 (4–17) 0.0002 Serum triglycerides, mmol/L 1.35 (1.00–2.03) 1.60 (1.16–2.25) <0.0001 Serum apolipoprotein A1, mg/L 1.29 (1.12–1.51) 1.32 (1.17–1.53) 0.01 Statin therapy, n (%) 384 (68.6) 435 (79.4) 0.01

Figure 1

Conclusion

Among patients with stable angina, plasma choline was related to increased long-term AMI risk among patients with higher plasma MMA or DMG only. This finding potentially reflects increased risk conferred by choline during concomitant endogenous PPAR activation.

Acknowledgement/Funding

None

Association of plasma neopterin with risk of an inpatient hospital diagnosis of atrial fibrillation: results from two prospective cohort studies

BACKGROUND

Link between inflammation and atrial fibrillation (AF) has been increasingly recognized. Neopterin, a biomarker of cellular immune activation, may be associated with incident AF.

OBJECTIVE

To investigate the association between plasma neopterin levels and risk of an inpatient hospital diagnosis of AF, and to evaluate a joint association of neopterin and a nonspecific inflammatory marker C-reactive protein (CRP) in two prospective cohorts.

METHODS

We performed a prospective analysis from a community-based cohort (the Hordaland Health Study (HUSK), n = 6891), and validated the findings in a cohort of patients with suspected stable angina pectoris (the Western Norway Coronary Angiography Cohort (WECAC), n = 2022).

RESULTS

In both cohorts, higher plasma levels of neopterin were associated with an increased risk of incident AF after adjustment for age, sex, body mass index, current smoking, diabetes, hypertension and renal function. The multivariable-adjusted hazard ratio (HR) (95% CI) per one SD increment of log-transformed neopterin was 1.20 (1.10-1.32) in HUSK and 1.26 (1.09-1.44) in WECAC. Additional adjustment for CRP did not materially affect the risk association for neopterin. The highest risk of AF was found among individuals with both neopterin and CRP levels above the median (HR: 1.54; 95% CI: 1.16-2.05 in HUSK and HR: 1.67; 95% CI: 1.11-2.52 in WECAC).

CONCLUSIONS

Our findings indicate an association of plasma neopterin with risk of an inpatient hospital diagnosis of AF, which remains after adjustment for traditional risk factors as well as for CRP. This study highlights a role of cellular immune activation, in addition to inflammation, in AF pathogenesis.

Combined analyses and extended follow-up of two randomized controlled homocysteine-lowering B-vitamin trials

OBJECTIVES

In the Norwegian Vitamin Trial and the Western Norway B Vitamin Intervention Trial, patients were randomly assigned to homocysteine-lowering B-vitamins or no such treatment. We investigated their effects on cardiovascular outcomes in the trial populations combined, during the trials and during an extended follow-up, and performed exploratory analyses to determine the usefulness of homocysteine as a predictor of cardiovascular outcomes.

DESIGN

Pooling of data from two randomized controlled trials (1998-2005) with extended post-trial observational follow-up until 1 January 2008.

SETTING

Thirty-six hospitals in Norway.

SUBJECTS

6837 patients with ischaemic heart disease.

INTERVENTIONS

One capsule per day containing folic acid (0.8 mg) plus vitamin B12 (0.4 mg) and vitamin B6 (40 mg), or folic acid plus vitamin B12, or vitamin B6 alone or placebo.

MAIN OUTCOME MEASURES

Major adverse cardiovascular events (MACEs; cardiovascular death, acute myocardial infarction or stroke) during the trials and cardiovascular mortality during the extended follow-up.

RESULTS

Folic acid plus vitamin B12 treatment lowered homocysteine levels by 25% but did not influence MACE incidence (hazard ratio, 1.07; 95% CI, 0.95-1.21) during 39 months of follow-up, or cardiovascular mortality (hazard ratio, 1.12; 95% CI, 0.95-1.31) during 78 months of follow-up, when compared to no such treatment. Baseline homocysteine level was not independently associated with study outcomes. However, homocysteine concentration measured after 1-2 months of folic acid plus vitamin B12 treatment was a strong predictor of MACEs.

CONCLUSION

We found no short- or long-term benefit of folic acid plus vitamin B12 on cardiovascular outcomes in patients with ischaemic heart disease. Our data suggest that cardiovascular risk prediction by plasma total homocysteine concentration may be confined to the homocysteine fraction that does not respond to B-vitamins.

Non-tropical sprue. Malignant diseases and mortality rate

The complications of non-tropical sprue were registered in 100 patients seen during an 18-year period. The patients had a significantly higher mortality than the age- and sex-matched general population. They had an increased incidence of malignancies, predominantly malignant lymphomas and carcinomas of the gastrointestinal tract. The disease must be considered a premalignant condition.