Role of sleep in neurodegeneration: the consensus report of the 5th Think Tank World Sleep Forum

Sleep abnormalities may represent an independent risk factor for neurodegeneration. An international expert group convened in 2021 to discuss the state-of-the-science in this domain. The present article summarizes the presentations and discussions concerning the importance of a strategy for studying sleep- and circadian-related interventions for early detection and prevention of neurodegenerative diseases. An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years; discussed the current challenges in the field of relationships among sleep, sleep disorders, and neurodegeneration; and identified future priorities. Sleep efficiency and slow wave activity during non-rapid eye movement (NREM) sleep are decreased in cognitively normal middle-aged and older adults with Alzheimer's disease (AD) pathology. Sleep deprivation increases amyloid-β (Aβ) concentrations in the interstitial fluid of experimental animal models and in cerebrospinal fluid in humans, while increased sleep decreases Aβ. Obstructive sleep apnea (OSA) is a risk factor for dementia. Studies indicate that positive airway pressure (PAP) treatment should be started in patients with mild cognitive impairment or AD and comorbid OSA. Identification of other measures of nocturnal hypoxia and sleep fragmentation could better clarify the role of OSA as a risk factor for neurodegeneration. Concerning REM sleep behavior disorder (RBD), it will be crucial to identify the subset of RBD patients who will convert to a specific neurodegenerative disorder. Circadian sleep-wake rhythm disorders (CSWRD) are strong predictors of caregiver stress and institutionalization, but the absence of recommendations or consensus statements must be considered. Future priorities include to develop and validate existing and novel comprehensive assessments of CSWRD in patients with/at risk for dementia. Strategies for studying sleep-circadian-related interventions for early detection/prevention of neurodegenerative diseases are required. CSWRD evaluation may help to identify additional biomarkers for phenotyping and personalizing treatment of neurodegeneration.

How ambient temperature affects mood: an ecological momentary assessment study in Switzerland

BACKGROUND

Recent research has suggested that an increase in temperature can negatively affect mental health and increase hospitalization for mental illness. It is not clear, however, what factors or mechanisms mediate this association. We aimed to (1) investigate the associations between ambient temperatures and bad daily mood, and (2) identify variables affecting the strength of these associations (modifiers) including the time, the day of the week and the year of the mood rating, socio-demographic characteristics, sleep quality, psychiatric disorders and the personality trait neuroticism in the community.

METHODS

Data stemmed from the second follow-up evaluation of CoLaus|PsyCoLaus, a prospective cohort study conducted in the general population of Lausanne (Switzerland). The 906 participants rated their mood level four times a day during seven days using a cell phone app. Mixed-effects logistic regression was used to determine the association between daily maximum temperature and mood level. Participant ID was inserted as a random effect in the model, whereas the time of the day, the day of the week and the year were inserted as fixed effects. Models were controlled for several confounders (socio-demographic characteristics, sleep quality, weather parameters and air pollutants). Stratified analyses were conducted based on socio-demographic characteristics, sleep quality, presence of psychiatric disorders or a high neuroticism.

RESULTS

Overall, the probability of having a bad mood for the entire day decreased by 7.0% (OR: 0.93: 95% CI 0.88, 0.99) for each 5 °C increase in maximum temperature. A smaller and less precise effect (-3%; OR: 0.97: 95% CI 0.91, 1.03) was found when controlling for sunshine duration. A higher association was found in participants with bipolar disorder (-23%; OR: 0.77: 95% CI 0.51, 1.17) and in participants with a high neuroticism (-13%; OR: 0.87 95% CI 0.80, 0.95), whereas the association was reversed for participants with anxiety (20%; OR: 1.20: 95% CI 0.90, 1.59), depression (18%; OR: 1.18 95% CI 0.94, 1.48) and schizophrenia (193%; OR: 2.93 95% CI 1.17, 7.73).

CONCLUSIONS

According to our findings, rising temperatures may positively affect mood in the general population. However, individuals with certain psychiatric disorders, such as anxiety, depression, and schizophrenia, may exhibit altered responses to heat, which may explain their increased morbidity when exposed to high temperatures. This suggests that tailored public health policies are required to protect this vulnerable population.

Genome-wide analysis identifies genetic effects on reproductive success and ongoing natural selection at the FADS locus

Identifying genetic determinants of reproductive success may highlight mechanisms underlying fertility and identify alleles under present-day selection. Using data in 785,604 individuals of European ancestry, we identified 43 genomic loci associated with either number of children ever born (NEB) or childlessness. These loci span diverse aspects of reproductive biology, including puberty timing, age at first birth, sex hormone regulation, endometriosis and age at menopause. Missense variants in ARHGAP27 were associated with higher NEB but shorter reproductive lifespan, suggesting a trade-off at this locus between reproductive ageing and intensity. Other genes implicated by coding variants include PIK3IP1, ZFP82 and LRP4, and our results suggest a new role for the melanocortin 1 receptor (MC1R) in reproductive biology. As NEB is one component of evolutionary fitness, our identified associations indicate loci under present-day natural selection. Integration with data from historical selection scans highlighted an allele in the FADS1/2 gene locus that has been under selection for thousands of years and remains so today. Collectively, our findings demonstrate that a broad range of biological mechanisms contribute to reproductive success.

Abstract 36: Life’s Essential 8 and Life Expectancy Among Adults in the United States

Background: Cardiovascular disease (CVD) may be the main reason for stagnant growth in life expectancy in the US since 2010. The American Heart Association (AHA) recently released updated algorithm for evaluating cardiovascular health (CVH)--life’s essential 8 (LE8) score.

Hypothesis: We aimed to quantify the associations of CVH levels, estimated by the LE8 score, with life expectancy in a nationally representative sample of US adults.

Methods: We included 23003 adults who participated in the National Health and Nutrition Examination Survey (NHANES) 2005-2018 and whose mortality was identified through linkage to the National Death Index through December 31, 2019. Life table method was used to estimate life expectancy by levels of the CVH. The cause-specific decomposition of the life expectancy differences was evaluated by the Arriaga’s method.

Results: During a median of 7.8 years of follow-up, 1359 total deaths occurred (772 in men and 587 in women). The estimated life expectancy at age 50 was 25.5 years (95% CI, 23.8-27.2), 31.2 years (95% CI, 30.4-31.9) and 33.1 years (95% CI, 29.8-36.2) in men with poor, intermediate and ideal CVH, respectively. The corresponding estimated life expectancy at age 50 in women was 29.5 years (95% CI, 27.8-31.1), 34.2 years (95% CI, 33.5-34.9) and 38.4 years (95% CI, 35.4-41.0), respectively. Equivalently, men and women with ideal CVH had an average 7.5 (95% CI, 3.5-11.5) and 8.9 (95% CI, 5.2-12.5) more years of life expectancy at age 50, respectively, compared with their counterparts with poor CVH. In men, on average, 41.8 % of the gained life expectancy at age 50 from adhering to ideal CVH was attributable to reduced CVD death. The corresponding percentage was 44.1 % in women. Similarly significant associations of CVH with life expectancy were observed in Non-Hispanic Whites and Non-Hispanic Blacks but not in Mexican Americans.

Conclusions: Adhering to an ideal CVH, defined as the LE8 score, is related to a considerably increased life expectancy in the US adults.

El fortalecimiento de la Superintendencia Nacional de Salud (SUPERSALUD) es prioritario para garantizar el derecho fundamental a la salud

El fortalecimiento técnico de la Superintendencia Nacional de Salud (SuperSalud), ente de inspección, vigilancia y control del Sistema General de Seguridad Social en Salud de Colombia, es necesario. Para tal fin, se propone el uso eficiente de los sistemas de información, que permita la toma de decisiones en política pública y que garantice el derecho fundamental de la salud.

Long-term Effect of Lifestyle Interventions on the Cardiovascular and All-Cause Mortality of Subjects With Prediabetes and Type 2 Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

Lifestyle interventions improve the metabolic control of individuals with hyperglycemia.

PURPOSE

We aimed to determine the effect of lifestyle interventions on cardiovascular and all-cause mortality in this population.

DATA SOURCES

Searches were made through MEDLINE, Cochrane CENTRAL, Embase, and Web of Science (no date/language restriction, until 15 May 2022).

STUDY SELECTION

We included randomized clinical trials (RCTs) of subjects with prediabetes and type 2 diabetes, comparing intensive lifestyle interventions with usual care, with a minimum of 2 years of active intervention.

DATA EXTRACTION

Data from the 11 RCTs selected were extracted in duplicate. A frequentist and arm-based meta-analysis was performed with random-effects models to estimate relative risk (RR) for mortality, and heterogeneity was assessed through I2 metrics. A generalized linear mixed model (GLMM) was used to confirm the findings.

DATA SYNTHESIS

Lifestyle interventions were not superior to usual care in reducing cardiovascular (RR 0.99; 95% CI 0.79-1.23) or all-cause (RR 0.93; 95% CI 0.85-1.03) mortality. Subgroup, sensitivity, and meta-regression analyses showed no influence of type of intervention, mean follow-up, age, glycemic status, geographical location, risk of bias, or weight change. All of these results were confirmed with the GLMM. Most studies had a low risk of bias according to the RoB 2.0 tool and the certainty of evidence was moderate for both outcomes.

LIMITATIONS

Most studies had a low risk of bias according to the RoB 2.0 tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach resulted in moderate certainty of evidence for both outcomes. Differences in lifestyle programs and in usual care between the studies should be considered in the interpretation of our results.

CONCLUSIONS

Intensive lifestyle interventions implemented so far did not show superiority to usual care in reducing cardiovascular or all-cause mortality for subjects with prediabetes and type 2 diabetes.

Physical activity trajectories are associated with the risk of all-cause and cardiovascular disease mortality in patients with coronary heart disease. A systematic review and meta-analysis

Background

Current guidelines recommend that adults with chronic health conditions should engage in regular physical activity (PA), and avoid inactivity. Yet, the exact role of PA trajectories in the mortality risk of patients with coronary heart disease (CHD) remains unclear.

Purpose

We aimed to perform a systematic review and meta-analysis on the association of longitudinal trajectories of PA with all-cause and cardiovascular disease (CVD) mortality in patients with CHD.

Methods

We performed a systematic review and meta-analysis based on PRISMA statement. Six electronic databases were searched for cohort studies that analysed the association of PA trajectories (inactive over time, active over time, increased activity over time, and decreased activity over time) with the risk of all-cause and CVD mortality in patients with CHD. Study quality was evaluated by the Newcastle Ottawa scale. We used the inverse variance weighted method to combine summary measures using random-effects models to minimize the effect of between-study heterogeneity. The study is registered in PROSPERO.

Results

We meta-analyzed nine longitudinal cohorts involving 33,576 patients (25010 acute CHD, 8566 chronic CHD, mean age 62.5 years, 34% women, median follow-up duration 7.2 years), according to four PA trajectories. All studies assessed PA through validated questionnaires. The definitions of activity and inactivity at baseline and follow-ups were in agreement with current PA guidelines. Trajectories were calculated based on comparison of activity status at baseline and follow-up. All the studies defined increased activity over time as moving from the inactive to the active category, and decreased activity over time as moving from the active to the inactive category. Compared to patients remaining inactive over time, the lowest risk of all-cause and CVD mortality was observed in patients remaining active over time (HR [95% CI]: 0.50 [0.39–0.63] and 0.48 [0.35–0.68], respectively), followed by patients who increased their PA over time (HR [95% CI]:0.55 [0.44–0.7] and 0.63 [0.51–0.78], respectively), and patients who decreased activity over time (HR [95% CI]: 0.80 [0.64–0.99] and 0.91 [0.67–1.24], respectively). These results were consistent both in the acute and chronic CHD settings. The overall risk of bias was low, and no evidence of publication bias was observed. Multiple sensitivity analyses provided consistent results.

Conclusions

In patients with CHD, the risk of all-cause and CVD mortality is progressively reduced from being inactive over time, to decreased activity over time, to increased activity over time, to being active over time. These findings highlight the benefits of adopting a more physically active lifestyle in patients with chronic and acute CHD, independent of previous PA levels. Future studies should clarify the complex interactions between motivations and disease severity as potential drivers for PA trajectories

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Bern

Diabetes is associated with atrial fibrillation phenotype, cardiac and neurological comorbidities: insights from the Swiss-AF study

Background

Diabetes mellitus is a major risk factor for atrial fibrillation (AF). However, it remains unclear whether individual AF phenotype and related comorbidities differ between AF patients with and without diabetes.

Purpose

To investigate the association of diabetes with AF phenotype, cardiac and neurological comorbidities in patients with documented AF.

Methods

Participants of the multicenter Swiss-AF study with available data on diabetes and AF phenotype were eligible. The primary outcomes were parameters of AF phenotype, including AF type (paroxysmal vs non-paroxysmal), AF symptoms (yes vs no), and quality of life (assessed by EQ-5D score). The secondary outcomes were cardiac (ie, history of hypertension, myocardial infarction, heart failure) and neurological comorbidities (ie, history of stroke, cognitive impairment). The cross-sectional association of diabetes with these outcomes was assessed using logistic and linear regression. Results were adjusted for age, sex, and cardiovascular risk factors.

Results

We included 2411 AF patients (27.4% women; median age, 73.6 years). Diabetes was not associated with non-paroxysmal AF (odds ratio [OR]=1.01; 95% confidence interval [CI]=0.81 to 1.27). Patients with diabetes less often perceived AF symptoms (OR=0.73; CI=0.59 to 0.91), but had worse quality of life (predicted mean difference in EQ-5D score: β=−4.54; CI=−6.40 to −2.68) than those without diabetes. Patients with diabetes were more likely to have cardiac comorbidities [history of hypertension (OR=3.04; CI=2.19 to 4.22), myocardial infarction (OR=1.55; CI=1.18 to 2.03), heart failure (OR=1.99; CI=1.57 to 2.51)] and neurological comorbidities [history of stroke (OR=1.39; CI=1.03 to 1.87), cognitive impairment (OR=1.75; CI=1.39 to 2.21)].

Conclusions

In the Swiss-AF cohort population, patients with diabetes less often perceived AF symptoms, but had worse quality of life, more cardiac and neurological comorbidities than those without diabetes. These findings have significant clinical implications. The reduced perception of AF symptoms in patients with diabetes might result in a delayed AF diagnosis and consequently more adverse events, especially cardioembolic stroke. This raises the question whether patients with diabetes should be systematically screened for silent AF. Moreover, patients with concomitant AF and diabetes have increased likelihood of comorbidities and therefore deserve more attentive care.

Funding Acknowledgement

Type of funding sources: None.

Insomnia disorder: clinical and research challenges for the 21st century

BACKGROUND AND PURPOSE

Insomnia is a common and debilitating disorder that is frequently associated with important consequences for physical health and well-being.

METHODS

An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field of insomnia and identified future priorities.

RESULTS

The association of trajectories of insomnia with subsequent quality of life, health and mortality should be investigated in large populations. Prospective health economics studies by separating the costs driven specifically by insomnia and costs attributable to its long-term effects are needed. Ignoring the heterogeneity of insomnia patients leads to inadequate diagnosis and inefficient treatment. Individualized interventions should be promoted. More data are needed on both the impact of sleep on overnight effects, such as emotion regulation, and the potential compensatory effort to counteract diurnal impairments. Another gap is the definition of neurocognitive deficits in insomnia patients compared to normal subjects after chronic sleep loss. There are also a number of key gaps related to insomnia treatment. Expert guidelines indicate cognitive-behavioural therapy for insomnia as first-line treatment. They neglect, however, the reality of major healthcare providers. The role of combined therapy, cognitive-behavioural therapy for insomnia plus pharmacological treatment, should be evaluated more extensively.

CONCLUSION

Whilst insomnia disorder might affect large proportions of the population, there are a number of significant gaps in the epidemiological/clinical/research studies carried out to date. In particular, the identification of different insomnia phenotypes could allow more cost-effective and efficient therapies.

Pandemic's glossary: The ABC of coronavirus concepts

Currently, the world is facing the pandemic generated by SARS-CoV-2. There are no no pharmacological measures for the prevention or treatment of this infection and, so far, it has caused more than 4´880.000 confirmed cases and 322.000 deaths. The different strategies for the control of the disease that have been proposed involve the participation of different actors. Such participation, guided by legal guidelines based on public health measures, include containment, mitigation, physical isolation, and quarantine. As this is a populationbased problem, information plays a primary role; however, the many new terms hat have arisen and their misuse confuse and, therefore, misinform thus limiting citizen participation. For this reason, we conducted a review of the terms used in epidemics and pandemics of infectious diseases, particularly COVID-19. We considered and differentiated the relevant terms to facilitate the understanding of pathogen’s behavior and epidemic and pandemic cycles, as well as the criteria for public health decision-making for the general public. This glossary should facilitate the use of the terms and standardize the information.

Phenome-wide association analysis of LDL-cholesterol lowering genetic variants in PCSK9

BACKGROUND

We characterised the phenotypic consequence of genetic variation at the PCSK9 locus and compared findings with recent trials of pharmacological inhibitors of PCSK9.

METHODS

Published and individual participant level data (300,000+ participants) were combined to construct a weighted PCSK9 gene-centric score (GS). Seventeen randomized placebo controlled PCSK9 inhibitor trials were included, providing data on 79,578 participants. Results were scaled to a one mmol/L lower LDL-C concentration.

RESULTS

The PCSK9 GS (comprising 4 SNPs) associations with plasma lipid and apolipoprotein levels were consistent in direction with treatment effects. The GS odds ratio (OR) for myocardial infarction (MI) was 0.53 (95% CI 0.42; 0.68), compared to a PCSK9 inhibitor effect of 0.90 (95% CI 0.86; 0.93). For ischemic stroke ORs were 0.84 (95% CI 0.57; 1.22) for the GS, compared to 0.85 (95% CI 0.78; 0.93) in the drug trials. ORs with type 2 diabetes mellitus (T2DM) were 1.29 (95% CI 1.11; 1.50) for the GS, as compared to 1.00 (95% CI 0.96; 1.04) for incident T2DM in PCSK9 inhibitor trials. No genetic associations were observed for cancer, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, or Alzheimer's disease - outcomes for which large-scale trial data were unavailable.

CONCLUSIONS

Genetic variation at the PCSK9 locus recapitulates the effects of therapeutic inhibition of PCSK9 on major blood lipid fractions and MI. While indicating an increased risk of T2DM, no other possible safety concerns were shown; although precision was moderate.

Methyl Donor Nutrient Intake and Risk of Type 2 Diabetes: Results from 3 Large US Cohorts (OR15-02-19)

Objectives

DNA methylation may play a role in the development of type 2 diabetes (T2D). DNA methylation can be influenced by methyl donor nutrients such as vitamins B2, B6, B12, folate, and methionine, which are all central to one carbon metabolism. Using 3 large cohorts of US health professionals, we examined whether intake of these nutrients from food or supplements is associated with T2D risk.

Methods

We included 69,949 women from the Nurses’ Health Study (1984–2012), 90,239 women from the Nurses’ Health Study II (1991–2011), and 40,539 men from the Health Professionals Follow-Up Study (1986–2010). Dietary data were collected every 2–4 years using a validated semi-quantitative FFQ, from which dietary intakes of vitamin B2, vitamin B6, vitamin B12, folate, and methionine were calculated. We used Cox proportional hazards model with time-varying covariates and adjusted for several sociodemographic and lifestyle variables. We also adjusted for cereal fiber, animal protein, polyunsaturated and saturated fatty acids ratio. Food sources of vitamins were additionally adjusted for multivitamin use while supplemental sources of vitamins were adjusted for a measure of overall diet quality.

Results

During 1763,428 years of follow-up, we documented 8141 T2D cases. In pooled multivariable-adjusted analyses, compared to those in the lowest quintile, those in the highest quintile of vitamins B2 and B6 had a 10% (95% CI 3%–16%) and 11% (95% CI 3%–16%) lower T2D risk, respectively. Total vitamin B12 intake was not associated with T2D. However, when analyses were stratified by source, vitamin B12 from food sources was associated with a higher T2D risk (HR [95% CI] = 1.11 [1.02–1.19]). On the other hand, supplemental vitamin B12 was associated with lower T2D risk (HR [95% CI] for Q5 vs Q1 = 0.92 [0.85–0.98]). We found no evidence for an association between intakes of folate and methionine and T2D risk.

Conclusions

Our study suggests that higher intakes of vitamin B2 and vitamin B6 are associated with a lower T2D risk. A higher vitamin B12 intake from food seems to be associated with a higher T2D risk, which may be due to consumption of animal products.

Funding Sources

The analysis was supported by grants from the National Institutes of Health.

Breastfeeding and the risk of respiratory tract infections after infancy: The Generation R Study

Background

The protection of breastfeeding against respiratory tract infections in the first year of life has often been suggested. Few studies examined the effect of breastfeeding on respiratory tract infections after infancy.

Objective

To examine the association between breastfeeding with lower respiratory tract infections (LRTI) and upper respiratory tract infections (URTI) after infancy up to 4 years of age (n = 5322).

Methods

This study was embedded in The Generation R study, a Dutch population-based prospective cohort study from fetal life until young adulthood. Information on breastfeeding duration (never; <3 months; 3–6 months; ≥6 months) and dose (never; partially until 4 months; predominantly until 4 months) were collected by questionnaire at 2, 6, and 12 months of age. Information on doctor attendance for LRTI and URTI were obtained by questionnaire at 2, 3, and 4 years of age.

Results

Breastfeeding for 6 months or longer was significantly associated with a reduced risk of LRTI up to 4 years of age (aOR: 0.71; 95% CI: 0.51–0.98). Similar ORs for LRTI were found with breastfeeding for less than 3 months and 3–6 months. Although in the same direction, weaker ORs were found for URTI and breastfeeding duration. The same trend was found for partial and predominant breastfeeding until 4 months and LRTI and URTI.

Conclusion

Breastfeeding duration for 6 months or longer is associated with a reduced risk of LRTI in pre-school children. These findings are compatible with the hypothesis that the protective effect of breastfeeding for respiratory tract infections persist after infancy therefore supporting current recommendations for breastfeeding for at least 6 months.

PCSK9 genetic variants and risk of type 2 diabetes: a mendelian randomisation study

BACKGROUND

Statin treatment and variants in the gene encoding HMG-CoA reductase are associated with reductions in both the concentration of LDL cholesterol and the risk of coronary heart disease, but also with modest hyperglycaemia, increased bodyweight, and modestly increased risk of type 2 diabetes, which in no way offsets their substantial benefits. We sought to investigate the associations of LDL cholesterol-lowering PCSK9 variants with type 2 diabetes and related biomarkers to gauge the likely effects of PCSK9 inhibitors on diabetes risk.

METHODS

In this mendelian randomisation study, we used data from cohort studies, randomised controlled trials, case control studies, and genetic consortia to estimate associations of PCSK9 genetic variants with LDL cholesterol, fasting blood glucose, HbA1c, fasting insulin, bodyweight, waist-to-hip ratio, BMI, and risk of type 2 diabetes, using a standardised analysis plan, meta-analyses, and weighted gene-centric scores.

FINDINGS

Data were available for more than 550 000 individuals and 51 623 cases of type 2 diabetes. Combined analyses of four independent PCSK9 variants (rs11583680, rs11591147, rs2479409, and rs11206510) scaled to 1 mmol/L lower LDL cholesterol showed associations with increased fasting glucose (0·09 mmol/L, 95% CI 0·02 to 0·15), bodyweight (1·03 kg, 0·24 to 1·82), waist-to-hip ratio (0·006, 0·003 to 0·010), and an odds ratio for type diabetes of 1·29 (1·11 to 1·50). Based on the collected data, we did not identify associations with HbA1c (0·03%, -0·01 to 0·08), fasting insulin (0·00%, -0·06 to 0·07), and BMI (0·11 kg/m2, -0·09 to 0·30).

INTERPRETATION

PCSK9 variants associated with lower LDL cholesterol were also associated with circulating higher fasting glucose concentration, bodyweight, and waist-to-hip ratio, and an increased risk of type 2 diabetes. In trials of PCSK9 inhibitor drugs, investigators should carefully assess these safety outcomes and quantify the risks and benefits of PCSK9 inhibitor treatment, as was previously done for statins.

FUNDING

British Heart Foundation, and University College London Hospitals NHS Foundation Trust (UCLH) National Institute for Health Research (NIHR) Biomedical Research Centre.

Association of Serum Thyrotropin with Anthropometric Markers of Obesity in the General Population

BACKGROUND

Except from associations study with body weight, there are few longitudinal data regarding the association between thyroid function and anthropometric measurements such as waist circumference, waist-to-hip ratio, or waist-to height ratio.

OBJECTIVE

This study aimed to investigate the association of thyrotropin (TSH) at baseline with changes in different anthropometric markers between baseline and follow-up in the general population.

METHOD

Data were used from four population-based longitudinal cohort studies and one population-based cross-sectional study. A total of 16,902 (8204 males) subjects aged 20-95 years from the general population were studied. Body mass index, waist circumference, waist-to-hip ratio, and waist-to-height ratio were measured. Multivariable median regression models were calculated adjusting for the following covariates: age, sex, baseline value of the respective anthropometric marker, smoking status, follow-up-time period, and study site.

RESULTS

In cross-sectional analyses, serum TSH within the reference range was positively associated with waist circumference (β = 0.94 cm [confidence interval (CI) 0.56-1.32]) and waist-to-height-ratio (β = 0.029 [CI 0.017-0.042]). These associations were also present for the full range of TSH. In the longitudinal analyses, serum TSH at baseline was inversely associated with a five-year change of all considered anthropometric measures within the prior defined study-specific reference range, as well as in the full range of serum TSH.

CONCLUSION

High TSH serum levels were positively associated with current anthropometric markers, even in the study-specific reference ranges. In contrast, high TSH serum levels were associated with decreased anthropometric markers over a time span of approximately five years. Further research is needed to determine possible clinical implications as well as public health consequences of these findings.

Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents

BACKGROUND

Overweight and obesity are increasing worldwide. To help assess their relevance to mortality in different populations we conducted individual-participant data meta-analyses of prospective studies of body-mass index (BMI), limiting confounding and reverse causality by restricting analyses to never-smokers and excluding pre-existing disease and the first 5 years of follow-up.

METHODS

Of 10 625 411 participants in Asia, Australia and New Zealand, Europe, and North America from 239 prospective studies (median follow-up 13·7 years, IQR 11·4-14·7), 3 951 455 people in 189 studies were never-smokers without chronic diseases at recruitment who survived 5 years, of whom 385 879 died. The primary analyses are of these deaths, and study, age, and sex adjusted hazard ratios (HRs), relative to BMI 22·5-<25·0 kg/m(2).

FINDINGS

All-cause mortality was minimal at 20·0-25·0 kg/m(2) (HR 1·00, 95% CI 0·98-1·02 for BMI 20·0-<22·5 kg/m(2); 1·00, 0·99-1·01 for BMI 22·5-<25·0 kg/m(2)), and increased significantly both just below this range (1·13, 1·09-1·17 for BMI 18·5-<20·0 kg/m(2); 1·51, 1·43-1·59 for BMI 15·0-<18·5) and throughout the overweight range (1·07, 1·07-1·08 for BMI 25·0-<27·5 kg/m(2); 1·20, 1·18-1·22 for BMI 27·5-<30·0 kg/m(2)). The HR for obesity grade 1 (BMI 30·0-<35·0 kg/m(2)) was 1·45, 95% CI 1·41-1·48; the HR for obesity grade 2 (35·0-<40·0 kg/m(2)) was 1·94, 1·87-2·01; and the HR for obesity grade 3 (40·0-<60·0 kg/m(2)) was 2·76, 2·60-2·92. For BMI over 25·0 kg/m(2), mortality increased approximately log-linearly with BMI; the HR per 5 kg/m(2) units higher BMI was 1·39 (1·34-1·43) in Europe, 1·29 (1·26-1·32) in North America, 1·39 (1·34-1·44) in east Asia, and 1·31 (1·27-1·35) in Australia and New Zealand. This HR per 5 kg/m(2) units higher BMI (for BMI over 25 kg/m(2)) was greater in younger than older people (1·52, 95% CI 1·47-1·56, for BMI measured at 35-49 years vs 1·21, 1·17-1·25, for BMI measured at 70-89 years; pheterogeneity<0·0001), greater in men than women (1·51, 1·46-1·56, vs 1·30, 1·26-1·33; pheterogeneity<0·0001), but similar in studies with self-reported and measured BMI.

INTERPRETATION

The associations of both overweight and obesity with higher all-cause mortality were broadly consistent in four continents. This finding supports strategies to combat the entire spectrum of excess adiposity in many populations.

FUNDING

UK Medical Research Council, British Heart Foundation, National Institute for Health Research, US National Institutes of Health.

Adverse events related to gastrointestinal endoscopic procedures in pediatric patients under anesthesia care and a predictive risk model (AEGEP Study)

BACKGROUND

Multiple studies have analyzed perioperative factors related to adverse events (AEs) in children who require gastrointestinal endoscopic procedures (GEP) in settings where deep sedation is the preferred anesthetic technique over general anesthesia (GA) but not for the opposite case.

METHODS

We reviewed our anesthesia institutional database, seeking children less than 12 years who underwent GEP over a 5-year period. A logistic regression was used to determine significant associations between preoperative conditions, characteristics of the procedure, airway management, anesthetic approaches and the presence of serious and non-serious AEs.

RESULTS

GA was preferred over deep sedation [77.8% vs. 22.2% in 2178 GEP under anesthesia care (n=1742)]. We found 96 AEs reported in 77 patients, including hypoxemia (1.82%), bronchospasm (1.14%) and laryngospasm (0.91%) as the most frequent. There were 2 cases of severe bradycardia related to laryngospasm/hypoxemia and a case of aspiration resulting in unplanned hospitalization, but there were no cases of intra- or postoperative deaths. Final predictive model for perioperative AEs included age <1 year, upper respiratory tract infections (URTI) <1 week prior to the procedure and low weight for the age (LWA) as independent risk factors and ventilation by facial mask as a protector against these events (p<0.05).

CONCLUSIONS

AEs are infrequent and severe ones are remote in a setting where AG is preferred over deep sedation. Ventilatory AEs are the most frequent and depend on biometrical and comorbid conditions more than anesthetic drugs chosen. Age <1 year, history of URTI in the week prior to the procedure and LWA work as independent risk factors for AEs in these patients.

Cost-effectiveness of statins in the primary prevention of cardiovascular disease: a systematic review and economic analysis for Belgium

OBJECTIVES

8% of total drug spending by the Belgian government goes to statins. The aim of this study is to determine the cost-effectiveness of statins for the primary prevention of cardiovascular disease (CVD) in middle-aged Belgian populations.

METHODS AND RESULTS

Economic evaluations were identified in a systematic literature search and were critically appraised. Furthermore, because prices decreased drastically, a previously published model was adapted applying recent cost data from the Belgian national health insurance. Eleven full economic evaluations were identified. Nine studies compared statins with no treatment and presented heterogeneous results. If alternative interventions, such as smoking cessation or low-dose aspirin treatment were included in the analysis, statin therapy became less cost-effective. Prescribing the cheapest statin on the Belgian market (< Euro 90 medication cost per year) resulted in an incremental cost of Euro 29,173 per life-year gained (LYG) in a male high-risk group aged 60 compared to low-dose aspirin. The incremental cost in a male moderate-risk group aged 50 was Euro 87,022/LYG. Low-dose aspirin was more cost-effective ranging from Euro 3,854/LYG to Euro 29,509/LYG compared to smoking cessation therapy. Smoking cessation therapy was the most cost-effective intervention, providing savings compared to no treatment.

CONCLUSIONS

In Belgium, the cost-effectiveness of statins for the primary prevention of CVD is rather elevated in comparison with low-dose aspirin, even if the cheapest statin is prescribed. From an economic point of view, prevention with low-dose aspirin is more cost-effective and may present a first choice in primary prevention. Smoking cessation, which is a dominant strategy, should be encouraged at all times.