Lateral medullary vascular compression manifesting as paroxysmal hypertension

Neurovascular compression of the rostral ventrolateral medulla (RVLM) has been described as a possible cause of refractory essential hypertension. We present the case of a patient affected by episodes of severe paroxysmal hypertension, some episodes associated with vago-glossopharyngeal neuralgia. Classical secondary forms of hypertension were excluded. Imaging revealed a neurovascular conflict between the posterior inferior cerebellar artery (PICA) and the ventrolateral medulla at the level of the root entry zone of the ninth and tenth cranial nerves (CN IX-X REZ). A MVD of a conflict between the PICA and the RVLM and adjacent CN IX-X REZ was performed, resulting in reduction of the frequency and severity of the episodes. Brain MRI should be performed in cases of paroxysmal hypertension. MVD can be considered in selected patients.

Comparison of the 2016 and 2021 European Society of Cardiology and the 2019 American College of Cardiology/American Heart Association guidelines for primary cardiovascular prevention

Introduction

The European Society of Cardiology (ESC) released in 2021 a new cardiovascular risk prediction model, SCORE2. We aimed to: 1) compare the proportion of individuals included in each category of risk according to 2016 and 2021 ESC and 2019 American Heart Association/American College of Cardiology (AHA/ACC) guidelines on cardiovascular prevention; and 2) assess the discriminative and calibration performances of ESC SCORE1, SCORE2, and AHA/ACC Pooled Cohort Equations (PCE) to predict atherosclerotic cardiovascular disease (ASCVD).

Methods

We used data from the first follow-up of the CoLaus|PsyCoLaus study, a Swiss population-based cohort, including individuals (40–80 years) recruited between 2009–2012 and having a 10-year follow-up. We included participants without lipid-lowering treatment and free from ASCVD at baseline. We computed SCORE1, SCORE2 (SCORE2-OP in people >70 years) and PCE in individuals eligible for score computation according to each guidelines separately. We assessed the performance of the scores based on discrimination and calibration metrics using first incident ASCVD as outcome.

Results

Among 4,107 included participants (women, 55.7%), 128 (3.1%) experienced an incident ASCVD during a mean follow-up time of 8.1 (±1.9) years. Statins would be recommended or considered in 40.3% (95% of confident interval [CI], 38.3–42.3), 27.3% (25.4–29.1) and 35.5% (33.6–37.5) of women, and in 62.2% (60.0–64.5), 59.3% (57.0–61.5) and 65.4% (63.2–67.6) of men according to ESC 2016, ESC 2021 and AHA/ACC 2019 guidelines, respectively. Scores were computed in 3,456 (women, 58.2%), 3,318 (women, 57.1%) and 3,384 (women, 56.7%) participants in primary prevention according to ESC 2016, ESC 2021 and AHA/ACC 2019 guidelines, respectively. 50% of women and 17.4% of men developing an incident ASCVD were not eligible for lipid-lowering treatment at baseline according to SCORE2 (compared to 27.5% of women and 14.5% of men using SCORE1, and 42.1% of women and 14.9% of men using PCE). SCORE2 and PCE presented comparable discriminative capacities with area under the receiver operating characteristic (AUROC) of 0.776 (95% CI, 0.730–0.822) and 0.775 (0.729–0.821), respectively. SCORE1 presented a lower AUROC (0.717 [95% CI, 0.665–0.769], p-value=0.0001). All scores underestimated risk in subjects in intermediate deciles of risk and overestimated risk in people in high deciles of risk. SCORE2 was better calibrated in high-risk individuals compared to SCORE1 and PCE.

Conclusions

Based on ESC 2021 guidelines, if fully implemented, less than a third of women would be eligible for a lipid-lowering therapy, which is lower than according to ESC 2016 and AHA/ACC 2019 recommendations. Among women developing an ASCVD in this sample, half of them were not eligible for a lipid-lowering therapy based on ESC 2021 guidelines. Both SCORE2 and PCE presented good predictive capacities and could be interchangeably used in comparable populations.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The CoLaus|PsyCoLaus study was and is supported by research grants from GlaxoSmithKline, the Faculty of Biology and Medicine of Lausanne, and the Swiss National Science Foundation (grants 3200B0–105993, 3200B0-118308, 33CSCO-122661, 33CS30-139468, 33CS30-148401 and 33CS30_177535/1).

Combining European Society of Cardiology and American College of Cardiology/American Heart Association risk prediction model with polygenic risk scores to refine cardiovascular prevention

Introduction

Polygenic risk scores (PRS) predict the risk of developing atherosclerotic cardiovascular disease (ASCVD). However, their utility in combination with existing clinical risk scores remains uncertain.

Purpose

We first validated four different PRS in a Swiss population-based cohort. Second, using the PRS with the best predictive capacity, we assessed its benefit when combined with two clinical risk scores: the Systematic COronary Risk Evaluation 2 (SCORE2) and the Pooled Cohort Equation (PCE).

Methods

We used data from a prospective cohort involving 6733 European participants at baseline (2003–2006). The predictive accuracy of the PRS was assessed with discrimination and calibration metrics. For the second aim, subjects with prevalent ASCVD or statin therapy at baseline were excluded. We tested associations between risk prediction models (PRS alone and combined clinical and PRS) and incident ASCVD, using Cox proportional hazard regressions. Net reclassification index (NRI) detected any improvement of ASCVD risk categorisation following the addition of the PRS to clinical risk scores in overall sample and in subgroups (e.g., sex, age, clinical intermediate-risk category)

Results

For the first aim, 4215 subjects (53% women; mean age 53.7±10.7), with 357 prevalent ASCVD, were analysed. The PRS developed by Inouye et al. [1], comprising >6 million variants, presented the best predictive capacity (area under the receiver operating characteristic of 0.77) and was used in the following analyses. For the second aim, 3390 subjects (mean follow-up of 12.0±3.3 years), with 188 incident ASCVD, were analysed. Individuals in the top 20% of the PRS distribution had the same magnitude of association with ASCVD as current smokers or diabetic subjects (see Figure 1). Combining the PRS with SCORE2 led to a reclassification of 17.1% (95% CI, 4.7–29.5) of subjects in the intermediate-risk category (see Figure 2). Likewise, adding the PRS to PCE translated into an NRI of 19.2% (95% CI, 4.8–22.4) in the intermediate-risk category (not shown).

Conclusion

Using a Swiss population-based cohort, PRS presented good predictive capacities for ASCVD. Combining a PRS with clinical risk scores improved reclassification of risk for ASCVD, especially for subjects in the intermediate-risk category. Introducing PRS in clinical practice may refine cardiovascular prevention for subgroups of patients in whom prevention strategies are uncertain.

Funding Acknowledgement

Type of funding sources: None.

Cardiovascular risk assessment in people living with HIV compared to the general population

Background

Effective cardiovascular preventive strategies are crucial among people living with HIV (PLWH), who are facing a high burden of atherosclerotic cardiovascular disease (ASCVD). However, it remains unclear which cardiovascular risk score is the most appropriate in clinical practice.

Purpose

We aimed to prospectively assess and compare the accuracy of widely used cardiovascular risk scores in PLWH and individuals from the general population.

Methods

We used data from the Swiss HIV Cohort Study (SHCS), a longitudinal study involving 20,802 HIV-infected adults aged over 18 years, and from the CoLaus|PsyCoLaus study, a Swiss population-based cohort including 6,733 individuals aged 35–75 years. The European Systematic Coronary Risk Evaluation Score (SCORE), the North American Pooled Cohort Equation (PCE) and the HIV-specific Data Collection o-n Adverse events of Anti-HIV Drugs (D:A:D) score were calculated for all participants free from ASCVD between January 1, 2003 and December 31, 2009. Accuracy of the scores was assessed based on discrimination and calibration metrics for each cohort separately using incident ASCVD as outcome. The value of adding HIV-specific factors to the model presenting the best predictive capacities between SCORE and PCE was evaluated using the net reclassification index (NRI).

Results

6,373 PLWH (28.4% women; aged 40.6 [SD, 9.9]; 57.2% on antiretroviral therapy) and 5,403 individuals from the general population (53.5% women, aged 52.8 [SD, 10.7]) were included in the analysis with a mean follow-up time of 13.5 (SD, 4.1) and 9.9 (SD, 2.3) years, respectively. 533 (8.4%) participants in the SHCS and 374 (6.9%) in the CoLaus|PsyCoLaus study experienced an incident ASCVD translating into age-adjusted incidence rates of 12.9 vs. 7.5 per 1,000 person-year, respectively. In SHCS, PCE and D:A:D presented discriminative capacities with AUROC of 0.757 (95% CI, 0.736–0.777) and 0.763 (95% CI, 0.743–0.783), respectively, compared to SCORE (0.704 [95% CI, 0.681–0.728]). Calibration of all scores was suboptimal in SHCS, with under-prediction of ASCVD in the higher deciles of risk compared to the CoLaus|PsyCoLaus study. Adding CD4 nadir (<200 cells/mm3) and abacavir exposure as categorical variables to PCE resulted in a marginal improvement in discrimination and in a global NRI of 2.7% (95% CI, 0.3–5.1, p-value = 0.03).

Conclusions

PLWH presented a two-fold higher rate of incident ASCVD compared to individuals of the same age from the general population. The accuracy of PCE score to predict ASCVD in PLWH is equivalent to the D:A:D score and may represent a better alternative due to its reduced set of variables and its widespread use. Adding HIV-specific factors to PCE did not improve its predictive performance.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Human genomics of the humoral immune response against polyomaviruses

Human polyomaviruses are widespread in humans and can cause severe disease in immunocompromised individuals. To identify human genetic determinants of the humoral immune response against polyomaviruses, we performed genome-wide association studies and meta-analyses of qualitative and quantitative immunoglobulin G responses against BK polyomavirus (BKPyV), JC polyomavirus (JCPyV), Merkel cellpolyomavirus (MCPyV), WU polyomavirus (WUPyV), and human polyomavirus 6 (HPyV6) in 15,660 individuals of European ancestry from three independent studies. We observed significant associations for all tested viruses: JCPyV, HPyV6, and MCPyV associated with human leukocyte antigen class II variation, BKPyV and JCPyV with variants in FUT2, responsible for secretor status, MCPyV with variants in STING1, involved in interferon induction, and WUPyV with a functional variant in MUC1, previously associated with risk for gastric cancer. These results provide insights into the genetic control of a family of very prevalent human viruses, highlighting genes and pathways that play a modulating role in human humoral immunity.

Antibodies against the c-terminus of apoA-1 as predictors of death in the general population but not as therapeutic targets actionable through cognate peptides immunomodulation

Aims

Autoantibodies against apolipoprotein A-1 (anti-apoA-1 IgGs) have emerged as an independent biomarker for cardiovascular disease and mortality in humans, promote death in ApoE−/− mice, and seem to be preferentially oriented against the c-terminal part of apoA-1 (cterA1). Corresponding specific mimetic peptides were shown to reverse anti-apoA-1 IgG pro-inflammatory effects in vitro. We evaluated the association of IgG against c-terminus apoA-1 (anti-cterA1 IgGs) with all-cause mortality in the community and tested the ability of two cterA1 mimetic peptides to reverse the anti-apoA-1 IgG-induced inflammation in vitro and mortality in ApoE−/− mice.

Methods

Anti-cterA1 IgGs were measured on serum samples of 5220 consecutive participants included in the CoLaus study with median follow-up duration of 5.6 years. The primary study outcome was all-cause mortality. Two chemically engineered optimized cterA1 mimetic peptides were tested i) on HEK cells to modulate interleukin-8 (IL-8) and tumor necrosis-alpha (TNF-α) production, and ii) in apoE−/− mice exposed to 16 weeks of anti-apoA-1 IgG passive immunisation.

Results

Anti-cterA1 IgG independently predicted all-cause mortality, each standard deviation of anti-cterA1 IgG being associated with a 18% increase in mortality risk (Hazard Ratio:1.18, 95%confidence intervals:1.04–1.33; p=0.009). Both cterA1 mimetic peptides reduced the anti-apoA-1 IgG-induced inflammation in a dose-dependent manner in vitro, but did not rescue the anti-apoA-1 IgG-associated mortality in mice.

Conclusions

Anti-cterA1 IgG independently predict all-cause mortality in the general population. By failing to reverse the anti-apoA-1 IgG-induced mortality in mice, our data do not support the hypothesis that these autoantibodies could be actionable through cognate peptides immunomodulation.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by a grant from the Leenaards Foundation (grant number 3698 to N.V.) by the Swiss National Science Foundation (grant number 310030-163335 to N.V.) and by the De Reuter Foundation (grant number 315112 to N.V.).

Incidence of type 2 diabetes, hypertension, and dyslipidemia in metabolically healthy obese and non-obese

BACKGROUND AND AIMS

Metabolically healthy obese (MHO) individuals are devoid of many metabolic abnormalities, but how this condition is maintained over time remains debated. We assessed the prevalence of MHO over time and the incidence of hypertension (HTN), dyslipidemia, and type 2 diabetes mellitus (T2DM) in MHO as compared with metabolically healthy non obese (MHNO).

METHODS AND RESULTS

Prospective, population-based study including 3038 participants (49.9 ± 9.9 years; 1753 women) free from metabolic syndrome and cardiovascular disease at baseline and examined after a follow-up of 5.6 years and 10.9 years on average. At each follow-up, prevalence of MHO, MHNO, metabolically unhealthy not obese (MUNO), and metabolically unhealthy obese (MUO), as well as of HTN, dyslipidemia, and T2DM, was calculated and stratified by sex, age group, and education. At baseline, 179 (5.7%) MHO participants were identified, of which 62 (34.6%) and 79 (44.1%) remained MHO at 5.6 and 10.9 years follow-up, respectively. At 5.6 years follow-up, MHO participants were more likely to develop low HDL or be on hypolipidemic medication [multivariable-adjusted OR (95% CI): 1.56 (1.02-2.38)], to have dyslipidemia [1.94 (1.33-2.82)], and high triglycerides [2.07 (1.36-3.14)] than MHNO. At 10.9 years follow-up, MHO participants were significantly more likely to develop T2DM [3.44 (1.84-6.43)], dyslipidemia [1.64 (1.14-2.38)], and low HDL or be prescribed hypolipidemic medication [1.57 (1.08-2.27)] than MHNO. Conversely, no differences were found regarding hypertension.

CONCLUSION

A considerable fraction of MHO individuals lose their status over time, and in metabolically healthy adults, obesity confers a higher risk of developing cardiovascular risk factors.

[Thiamine-responsive megaloblastic anemia or Rogers syndrome: A literature review]

Thiamine-responsive megaloblastic anemia (TRMA), also known as Rogers syndrome, is a rare autosomal recessive disease characterized by three main components: megaloblastic anemia, diabetes mellitus and sensorineural deafness. Those features occur in infancy but may arise during adolescence. Diagnosis relies on uncovering genetic variations (alleles) in the SLC19A2 gene, encoding for a high affinity thiamine transporter. This transporter is essentially present in hematopoietic stem cells, pancreatic beta cells and inner ear cells, explaining the clinical manifestations of the disease. Based on a multidisciplinary approach, treatment resides on lifelong thiamine oral supplementation at pharmacological doses, which reverses anemia and may delay development of diabetes. However, thiamine supplementation does not alleviate already existing hearing defects.

Mood disorders and circulating levels of inflammatory markers in a longitudinal population-based study

BACKGROUND

There has been increasing evidence that chronic low-grade inflammation is associated with mood disorders. However, the findings have been inconsistent because of heterogeneity across studies and methodological limitations. Our aim is to prospectively evaluate the bi-directional associations between inflammatory markers including interleukin (IL)-6, tumor necrosis factor (TNF)-α and high sensitivity C-reactive protein (hsCRP) with mood disorders.

METHODS

The sample consisted of 3118 participants (53.7% women; mean age: 51.0, s.d. 8.8 years), randomly selected from the general population, who underwent comprehensive somatic and psychiatric evaluations at baseline and follow-up (mean follow-up duration = 5.5 years, s.d. 0.6). Current and remitted mood disorders including bipolar and major depressive disorders (MDD) and its subtypes (atypical, melancholic, combined atypical and melancholic, and unspecified) were based on semi-structured diagnostic interviews. Inflammatory biomarkers were analyzed in fasting blood samples. Associations were tested by multiple linear and logistic regression models.

RESULTS

Current combined MDD [β = 0.29, 95% confidence interval (CI) 0.03-0.55] and current atypical MDD (β = 0.32, 95% CI 0.10-0.55) at baseline were associated with increased levels of hsCRP at follow-up. There was little evidence for inflammation markers at baseline predicting mood disorders at follow-up.

CONCLUSIONS

The prospective unidirectional association between current MDD subtype with atypical features and hsCRP levels at follow-up suggests that inflammation may be a consequence of this condition. The role of inflammation, particularly hsCRP that is critically involved in cardiovascular diseases, warrants further study. Future research that examines potential influences of medications on inflammatory processes is indicated.

Prospective associations of depression subtypes with cardio-metabolic risk factors in the general population

The mechanisms and temporal sequence underlying the association between major depressive disorder (MDD) and cardio-metabolic diseases are still poorly understood. Recent research suggests subtyping depression to study the mechanisms underlying its association with biological correlates. Accordingly, our aims were to (1) assess the prospective associations of the atypical, melancholic and unspecified subtypes of MDD with changes of fasting glucose, high-density lipoprotein-cholesterol, triglycerides, systolic blood pressure and the incidence of the metabolic syndrome, (2) determine the potential mediating role of inflammatory marker or adipokine concentrations, eating behaviors and changes in waist circumference during follow-up. Data stemmed from CoLaus|PsyCoLaus, a prospective cohort study including 35-66-year-old randomly selected residents of an urban area. Among the Caucasian participants who underwent the physical and psychiatric baseline evaluations, 2813 (87% participation rate) also accepted the physical follow-up exam (mean follow-up duration=5.5 years). Symptoms of mental disorders were elicited using a semi-structured interview. The atypical MDD subtype, and only this subtype, was prospectively associated with a higher incidence of the metabolic syndrome (OR=2.49; 95% CI 1.30-4.77), a steeper increase of waist circumference (β=2.41; 95% CI 1.19-3.63) and independently of this, with a steeper increase of the fasting glucose level (β=131; 95% CI 38-225) during follow-up. These associations were not attributable to or mediated by inflammatory marker or adipokine concentrations, eating behaviors, comorbid psychiatric disorders or lifestyle factors. Accordingly, our results further support the subtyping of MDD and highlight the particular need for prevention and treatment of metabolic consequences in patients with atypical MDD.

A genetic risk score is significantly associated with statin therapy response in the elderly population

The ability of statins to strongly reduce low-density lipoprotein cholesterol (LDL-C) varies interindividually and is partially influenced by genetic variants. Based on a comprehensive analysis of 23 single nucleotide polymorphisms (SNPs) known to be associated with pharmacokinetics and dynamics of statins, we developed a genetic risk score to study its impact on the therapy outcome in elderly individuals under at least 5 years statin therapy. The study was performed in a population-based cohort of 1016 elderly individuals, which comprised 168 statin users investigated at age 75 and 80. Using random forest models, the major variants influencing LDL-C levels were summarized in a weighted GRS (wGRS). The wGRS was tested with lipid and glucose outcomes and validated in an independent population-based cohort including 221 statin users. Four SNPs within the APOE cluster (rs7412, rs4420638), ABCC2 (rs2002042) and CELSR/SORT1/PSRC1 (rs646776), displayed a major impact on statin efficacy. The wGRS was significantly associated with lower LDL-C at age 75 and 80. This association was replicated displaying similar results. GRS analysis is a powerful tool to evaluate the additive effects of genetic variants on statin response and to estimate the magnitude of LDL-C reduction to a considerable extent in the older population.

[Delivering bad news in a Swiss internal medicine ward: a medical and nurse partnership]

Delivering bad news to a patient has a major impact for patients, their relatives and caregivers. The way this information is delivered can affect the way the patient sees his disease and potentially how he adheres to its treatment. To improve this communication with the patient the service of internal medicine at the Swiss university hospital of Lausanne set up a process including the coordination between all involved caregivers, and to break the bad news in a setting including a medical and nurse partnership. It also underscores that the resident in charge of the patient remains the coordinator of delivering new information. Moreover, the service provides communication tools to the caregivers to improve the communication skills.

[Social networks and medicine]

Social networks (social media or #SoMe) have entered medical practice within the last few years. These new media--like Twitter or Skype--enrich interactions among physicians (telemedicine), among physicians and patients (virtual consultations) and change the way of teaching medicine. They also entail new ethical, deontological and legal issues: the extension of the consultation area beyond the medical office and the access of information by third parties were recently debated. We develop here a review of some social networks with their characteristics, applications for medicine and limitations, and we offer some recommendations of good practice.

[Taking into account spiritual dimension of the patient in multidisciplinary team]

In the current healthcare environment, there is an increasing consensus for a holistic approach to the patient by means of a bio-psychosocial and spiritual model. The first part of this article describes how, in the context of a laic healthcare environment, physicians, nurses and spiritual caregivers are asked to change their way to communicate and to take into account this spiritual dimension. In the second part we will discuss some of the challenges of this interdisciplinary approach of the spiritual dimension in the hospital and the community. We will describe potential benefits for the patients, their family members and the caregivers. At the end, taking into account the spiritual dimension of the patient without proselytism will depend on the capacity of each caregiver to speak about it and to share this information in multidisciplinary team.

Iron metabolism and incidence of metabolic syndrome

BACKGROUND AND AIMS

Whether iron metabolism affects metabolic syndrome (METS) is debated. We assessed the association between several markers of iron metabolism and incidence of METS.

METHODS AND RESULTS

Data from 3271 participants (1870 women, 51.3 ± 10.4 years), free of METS at baseline and followed for 5.5 years. The association of serum iron, ferritin and transferrin with incident METS was assessed separately by gender. Incidence of METS was 22.6% in men and 16.5% in women (p < 0.001). After multivariate adjustment, a positive association was found between transferrin and incident METS in men: odds ratio (OR) and 95% confidence interval for the fourth relative to the first quartile 1.55 (1.04-2.31), p for trend = 0.03, while no association was found for iron OR = 0.81 (0.53-1.24), p for trend = 0.33 and ferritin OR = 1.30 (0.88-1.92), p for trend = 0.018. In women, a negative association was found between iron and incident METS: OR for the fourth relative to the first quartile 0.51 (0.33-0.80), p for trend<0.03; the association between transferrin and incident METS was borderline significant: OR = 1.45 (0.97-2.17), p for trend = 0.07 and no association was found for ferritin: OR = 1.11 (0.76-1.63), p for trend = 0.58.

CONCLUSION

Transferrin, not ferritin, is independently associated with an increased risk of incident METS; the protective effect of iron in women should be further explored.

Five year trends in dyslipidaemia prevalence and management in Switzerland: the CoLaus study

BACKGROUND AND AIMS

Data from prospective cohorts describing dyslipidaemia prevalence and treatment trends are lacking. Using data from the prospective CoLaus study, we aimed to examine changes in serum lipid levels, dyslipidaemia prevalence and management in a population-based sample of Swiss adults.

METHODS AND RESULTS

Cardiovascular risk was assessed using PROCAM. Dyslipidaemia and low-density lipoprotein cholesterol (LDL-C) target levels were defined according to the Swiss Group for Lipids and Atherosclerosis. Complete baseline and follow up (FU) data were available for n = 4863 subjects during mean FU time of 5.6 years. Overall, 32.1% of participants were dyslipidaemic at baseline vs 46.3% at FU (p < 0.001). During this time, lipid lowering medication (LLM) rates among dyslipidaemic subjects increased from 34.0% to 39.2% (p < 0.001). In secondary prevention, LLM rates were 42.7% at baseline and 53.2% at FU (p = 0.004). In multivariate analysis, LLM use among dyslipidaemic subjects, between baseline and FU, was positively associated with personal history of CVD, older age, hypertension, higher BMI and diabetes, while negatively associated with higher educational level. Among treated subjects, LDL-C target achievement was positively associated with diabetes and negatively associated with personal history of CVD and higher BMI. Among subjects treated at baseline, LLM discontinuation was negatively associated with older age, male sex, smoking, hypertension and parental history of CVD.

CONCLUSIONS

In Switzerland, the increase over time in dyslipidaemia prevalence was not paralleled by a similar increase in LLM. In a real-life setting, dyslipidaemia management remains far from optimal, both in primary and secondary prevention.

Is the adiposity-associated FTO gene variant related to all-cause mortality independent of adiposity? Meta-analysis of data from 169,551 Caucasian adults

Previously, a single nucleotide polymorphism (SNP), rs9939609, in the FTO gene showed a much stronger association with all-cause mortality than expected from its association with body mass index (BMI), body fat mass index (FMI) and waist circumference (WC). This finding implies that the SNP has strong pleiotropic effects on adiposity and adiposity-independent pathological pathways that leads to increased mortality. To investigate this further, we conducted a meta-analysis of similar data from 34 longitudinal studies including 169,551 adult Caucasians among whom 27,100 died during follow-up. Linear regression showed that the minor allele of the FTO SNP was associated with greater BMI (n = 169,551; 0.32 kg m(-2) ; 95% CI 0.28-0.32, P < 1 × 10(-32) ), WC (n = 152,631; 0.76 cm; 0.68-0.84, P < 1 × 10(-32) ) and FMI (n = 48,192; 0.17 kg m(-2) ; 0.13-0.22, P = 1.0 × 10(-13) ). Cox proportional hazard regression analyses for mortality showed that the hazards ratio (HR) for the minor allele of the FTO SNPs was 1.02 (1.00-1.04, P = 0.097), but the apparent excess risk was eliminated after adjustment for BMI and WC (HR: 1.00; 0.98-1.03, P = 0.662) and for FMI (HR: 1.00; 0.96-1.04, P = 0.932). In conclusion, this study does not support that the FTO SNP is associated with all-cause mortality independently of the adiposity phenotypes.

Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study

BACKGROUND

Sleep-disordered breathing is associated with major morbidity and mortality. However, its prevalence has mainly been selectively studied in populations at risk for sleep-disordered breathing or cardiovascular diseases. Taking into account improvements in recording techniques and new criteria used to define respiratory events, we aimed to assess the prevalence of sleep-disordered breathing and associated clinical features in a large population-based sample.

METHODS

Between Sept 1, 2009, and June 30, 2013, we did a population-based study (HypnoLaus) in Lausanne, Switzerland. We invited a cohort of 3043 consecutive participants of the CoLaus/PsyCoLaus study to take part. Polysomnography data from 2121 people were included in the final analysis. 1024 (48%) participants were men, with a median age of 57 years (IQR 49-68, range 40-85) and mean body-mass index (BMI) of 25·6 kg/m(2) (SD 4·1). Participants underwent complete polysomnographic recordings at home and had extensive phenotyping for diabetes, hypertension, metabolic syndrome, and depression. The primary outcome was prevalence of sleep-disordered breathing, assessed by the apnoea-hypopnoea index.

FINDINGS

The median apnoea-hypopnoea index was 6·9 events per h (IQR 2·7-14·1) in women and 14·9 per h (7·2-27·1) in men. The prevalence of moderate-to-severe sleep-disordered breathing (≥15 events per h) was 23·4% (95% CI 20·9-26·0) in women and 49·7% (46·6-52·8) in men. After multivariable adjustment, the upper quartile for the apnoea-hypopnoea index (>20·6 events per h) was associated independently with the presence of hypertension (odds ratio 1·60, 95% CI 1·14-2·26; p=0·0292 for trend across severity quartiles), diabetes (2·00, 1·05-3·99; p=0·0467), metabolic syndrome (2·80, 1·86-4·29; p<0·0001), and depression (1·92, 1·01-3·64; p=0·0292).

INTERPRETATION

The high prevalence of sleep-disordered breathing recorded in our population-based sample might be attributable to the increased sensitivity of current recording techniques and scoring criteria. These results suggest that sleep-disordered breathing is highly prevalent, with important public health outcomes, and that the definition of the disorder should be revised.

FUNDING

Faculty of Biology and Medicine of Lausanne, Lausanne University Hospital, Swiss National Science Foundation, Leenaards Foundation, GlaxoSmithKline, Ligue Pulmonaire Vaudoise.

Alcohol consumption and incidence of type 2 diabetes. Results from the CoLaus study

BACKGROUND AND AIMS

Moderate alcohol consumption has been shown to decrease the risk of type 2 diabetes (T2DM), but whether this association is also valid for impaired fasting glucose (IFG) is less well known. We aimed at assessing the impact of alcohol consumption and of type of alcoholic beverage on the incidence of T2DM and T2DM + IFG.

METHODS AND RESULTS

As many as 4765 participants (2613 women, mean age 51.7 ± 10.5 years) without T2DM at baseline and followed for an average of 5.5 years. The association between alcohol consumption, type of alcoholic beverage and outcomes was assessed after adjustment for a validated T2DM risk score. During follow-up 284 participants developed T2DM and 643 developed IFG. On bivariate analysis, alcohol consumption was positively associated with the risk of developing T2DM or T2DM + IFG. Moderate (14-27 units/week) alcohol consumption tended to be associated with a lower risk of T2DM, but no protective effect was found for T2DM + IFG. Multivariable-adjusted odds ratio (OR) and (95% confidence interval) for T2DM: 0.89 (0.65-1.22), 0.66 (0.42-1.03) and 1.63 (0.93-2.84) for 1-13, 14-27 and 28 + units/week, respectively (p for quadratic trend < 0.005). For T2DM + IFG, the corresponding ORs were 1.09 (0.90-1.32), 1.33 (1.02-1.74) and 1.54 (0.99-2.39), respectively, p for trend = 0.03. No specific effect of alcoholic beverage (wine, beer or spirits) was found for T2DM or for T2DM + IFG.

CONCLUSION

Moderate alcohol consumption is associated with a reduced risk of developing T2DM, but not of developing T2DM + IFG. No specific effect of type of alcoholic beverage was found.

[Complete blood counts: new parameters]

Performing a complete blood count analysis is a daily routine necessary for a good care of patients. Nowadays, modern blood analyzers provide on top of classical blood values, several additional parameters. In this paper, using short case presentations, we discuss how to interpret these results and integrate them in the clinical context.

[Dysmetabolic hyperferritinemia: a new target for treatment?]

Dysmetabolic hyperferritinemia is currently the most frequent cause of elevated ferritin levels in the general population. Whether dysmetabolic hyperferritinemia is a cause or an effect of insulin resistance is still a matter of debate. Still, several findings have been well established: increased iron intake or elevated ferritin levels are individual risk factors for diabetes, metabolic syndrome or gestational diabetes. When in presence of dysmetabolic hyperferritinemia, a small number of randomized controlled trials have suggested that therapeutic measures aimed at reducing ferritin levels such as low red meat consumption, deferoxamin or therapeutic phlebotomies have shown a beneficial effect on glucose homeostasis, lipid profile and impaired hepatic markers observed in non-alcoholic steatohepatitis.

Atypical depression and alcohol misuse are related to the cardiovascular risk in the general population

OBJECTIVE

The aims of the present study were to assess the associations between mood, anxiety and substance use disorders, including their subtypes, and the prevalence of cardiovascular risk factors (CVRFs).

METHOD

Thorough physical investigations, biological measures and standardized interview techniques were used to assess 3716 subjects of an urban area, aged 35-66 years.

RESULTS

Atypical depression was associated with increased prevalence of overweight, diabetes and the metabolic syndrome (OR = 1.5, 95% C.I. 1.1-2.0; OR = 2.0, 95% C.I. 1.1-3.5, OR = 1.6, 95% C.I. 1.0-2.4 respectively), whereas decreased prevalence of overweight was found in melancholic (OR = 0.7, 95% C.I. 0.6-0.9) and unspecified depression (OR = 0.8, 95% C.I. 0.7-1.0). Alcohol abuse was associated with diabetes (OR = 1.8, 95% C.I. 1.1-2.9) and dyslipidemia (OR = 1.3, 95% C.I. 1.0-1.8), alcohol dependence with dyslipidemia only (OR = 1.4, 95% C.I. 1.0-2.0). Almost all mental disorders were associated with a lifetime history of regular cigarette smoking, and atypical depression, alcohol misuse and drug dependence were associated with inactivity.

CONCLUSION

To conclude results emphasize the need to subtype depression and to pay particular attention to the atypical subtype. Comorbid alcohol misuse may further increase the cardiovascular risk. Efforts to diminish smoking in subjects with mental disorders could be crucial measures to reduce their high incidence of cardiovascular disease.

Foliage response of young central European oaks to air warming, drought and soil type

Three Central European oak species, with four provenances each, were experimentally tested in 16 large model ecosystem chambers for their response to passive air warming (AW, ambient +1-2 °C), drought (D, -43 to -60% irrigation) and their combination (AWD) for 3 years on two forest soil types of pH 4 or 7. Throughout the entire experiment, the influence of the different ambient and experimental climates on the oak trees was strong. The morphological traits of the Quercus species were affected in opposing ways in AW and D treatments, with a neutral effect in the AWD treatment. Biochemical parameters and LMA showed low relative plasticity compared to the morphological and growth parameters. The high plasticity in physiologically important parameters of the three species, such as number of intercalary veins or leaf size, indicated good drought acclimation properties. The soil type influenced leaf chlorophyll concentration, C/N and area more than drought, whereas foliage mass was more dependent on drought than on soil type. Through comparison of visible symptom development with the water deficits, a drought tolerance threshold of -1.3 MPa was determined. Although Q. pubescens had xeromorphic leaf characteristics (small leaf size, lower leaf water content, high LMA, pilosity, more chlorophyll, higher C/N) and less response to the treatments than Q. petraea and Q. robur, it suffered more leaf drought injury and shedding of leaves than Q. petraea. However, if foliage mass were used as the criterion for sustainable performance under a future climate, Q. robur would be the most appropriate species.

Cardiovascular risk factors attributable to obesity and overweight in Switzerland

BACKGROUND AND AIMS

Obesity increases the risk for cardiovascular risk factors (CVRFs), including hypertension, dyslipidaemia and type 2 diabetes. In this study, we assessed the burden of overweight and obesity on CVRFs in Switzerland, using Swiss-specific population attributable fractions (PAFs).

METHODS AND RESULTS

The number of cases of CVRFs that could have been prevented if the increase in overweight and obesity in Switzerland had been contained was estimated using gender-specific, age- and smoking-adjusted PAFs for overweight and obesity. PAFs were estimated from the Swiss Health Survey 2007 (self-reported) and the CoLaus study (measured) data. PAFs from self-reported were lower than from measured data. Using measured data, overweight and obesity contributed to 38% of hypertension cases in men (32% in women). In men, overweight had a larger impact than obesity (22.2% and 15.6%, respectively), while the opposite was observed for women (13.6% and 18.1%, respectively). In men, 37% of dyslipidaemia (30% in women) could be attributed to overweight and obesity; overweight had a higher contribution than obesity in both sexes. In men, 57% of type 2 diabetes (62% in women) was attributable to overweight and obesity; obesity had a larger impact than overweight in both sexes. Overall, approximately 27,000 cases of type 2 diabetes, 63,000 cases of high blood pressure and 37,000 cases of dyslipidaemia could have been avoided if overweight and obesity levels were maintained at 1992 levels.

CONCLUSION

A large proportion of CVRFs is attributable to overweight and/or obesity and could have been prevented by containing the overweight/obesity epidemic.

Inflammatory markers and blood pressure: sex differences and the effect of fat mass in the CoLaus Study

Several studies have reported high levels of inflammatory biomarkers in hypertension, but data coming from the general population are sparse, and sex differences have been little explored. The CoLaus Study is a cross-sectional examination survey in a random sample of 6067 Caucasians aged 35-75 years in Lausanne, Switzerland. Blood pressure (BP) was assessed using a validated oscillometric device. Anthropometric parameters were also measured, including body composition, using electrical bioimpedance. Crude serum levels of interleukin-6 (IL-6), tumor necrosis factor α (TNF-α) and ultrasensitive C-reactive protein (hsCRP) were positively and IL-1β (IL-1β) negatively (P<0.001 for all values), associated with BP. For IL-6, IL-1β and TNF-α, the association disappeared in multivariable analysis, largely explained by differences in age and body mass index, in particular fat mass. On the contrary, hsCRP remained independently and positively associated with systolic (β (95% confidence interval): 1.15 (0.64; 1.65); P<0.001) and diastolic (0.75 (0.42; 1.08); P<0.001) BP. Relationships of hsCRP, IL-6 and TNF-α with BP tended to be stronger in women than in men, partly related to the difference in fat mass, yet the interaction between sex and IL-6 persisted after correction for all tested confounders. In the general population, the associations between inflammatory biomarkers and rising levels of BP are mainly driven by age and fat mass. The stronger associations in women suggest that sex differences might exist in the complex interplay between BP and inflammation.

Prevalence, awareness and treatment of type 2 diabetes mellitus in Switzerland: the CoLaus study

AIMS

To assess the prevalence, awareness and treatment levels of Type 2 diabetes in a Swiss city.

METHODS

Population-based cross-sectional study of 6181 subjects (3246 women) aged 35-75 years living in Lausanne, Switzerland. Type 2 diabetes was defined as fasting plasma glucose ≥ 7 mmol/l and/or oral hypoglycaemic treatment and/or insulin.

RESULTS

Total prevalence of Type 2 diabetes was 6.3% (95% confidence interval: 5.7-7.0%), higher in men (9.1%) than in women (3.8%, P < 0.001) and increased with age. Two-thirds (65.3%; 60.4-70.0%) of participants with Type 2 diabetes were aware of their status and among those aware 86.0% (81.5-90.3%) were treated. Treatment was more frequent in men (91.3%) than in women (75.9%, P < 0.001). Two-thirds of those treated for Type 2 diabetes were on monotherapy. Biguanides were prescribed in 65.0% of Type 2 diabetes patients and represented 48% of all antidiabetic drugs. Multivariable analysis showed male gender, increasing age, waist or BMI to be positively associated with prevalence of Type 2 diabetes, while leisure-time physical activity and alcohol consumption were negatively associated. Among participants presenting with Type 2 diabetes, increasing age was positively associated with awareness of Type 2 diabetes. Among subjects diagnosed with Type 2 diabetes, male gender and increasing age were positively associated with treatment.

CONCLUSION

Prevalence of Type 2 diabetes in Switzerland is estimated to be between 5.7% and 7.0%. Two-thirds of patients with Type 2 diabetes are aware of their status, and over three quarters of those aware are treated.

[CoLaus: diabetes and dyslipidemia, there is always something new!]

Cardiovascular diseases remain the first cause of mortality in our country. They are associated with well known risk factors such as diabetes and dyslipidemia. Herein we summarize main results of the CoLaus study regarding, first the prevalence and characteristics of the treatment of these risk factors. Then we present recent discoveries of new genetic determinants associated with these risk factors. Finally, we discuss whether this knowledge changes our current clinical management of our patients.

[PsyCoLaus: mental disorders and cardiovascular diseases: spurious association?]

Cardio-vascular diseases (CVD), their well established risk factors (CVRF) and mental disorders are common and co-occur more frequently than would be expected by chance. However, the mechanisms underlying this association are still poorly understood. The main study questions of PsyCoLaus, the psychiatric arm of CoLaus, are: 1) Do mental disorders increase vulnerability to CVRF and CVD? 2) Do CVRF and CVD promote the development of mental disorders? 3) Do CVRF/ CVD and mental disorders share common pathogenetic processes? The longitudinal project adds a comprehensive psychiatric evaluation to the CoLaus investigation. A better understanding of the psychological, physiological and behavioral links underlying CVD/ CVRF and mental disorders will result in the development of more specific and efficient strategies of prevention and treatment for both psychiatric and CVD/CVRF, two major elements of burden of disease.

[What CoLaus has brought to public health]

In order to fulfil their duties, Public health authorities have to rely on valid and recent data on the health status of populations. The CoLaus study helped to update our knowledge regarding the prevalence and management of the main cardiovascular risk factors in the Lausanne population. The results indicate that cardiovascular risk factor management is suboptimal and can still be improved, namely that specific population subgroups could benefit from targeted prevention measures. The CoLaus study also allowed to simulate the effect of different preventive strategies, thus enabling to choose the most (cost) effective ones, an important issue taking into account the current health budget restrictions.

[Contribution of the CoLaus study to decipher the determinants of serum uric acid]

Asymptomatic hyperuricemia affects one in five adults in the general population and is associated with elevated cardiovascular risk. It is however not clear whether asymptomatic hyperuricemia is a cause or simply a marker of conditions associated with high cardiovascular risk. Sex, age, obesity, renal function and selected drugs are major determinants of serum uric acid. Moreover, recent genome-wide association studies have identified new genes involved in the control of serum uric acid levels, in particular SLC2A9, which encodes a urate transporter located in the kidney. A genetic score based on several genetic variants associated with serum uric acid is strongly associated with the risk of gout, but not with cardiovascular events so far.

Normal weight obesity: relationship with lipids, glycaemic status, liver enzymes and inflammation

BACKGROUND AND AIMS

Normal weight obesity (NWO) is defined as an excessive body fat associated with a normal body mass index (BMI) and has been associated with early inflammation, but its relationship with cardiovascular risk factors await investigation.

METHODS AND RESULTS

Cross-sectional study including 3213 women and 2912 men aged 35-75 years to assess the clinical characteristics of NWO in Lausanne, Switzerland. Body fat was assessed by bioimpedance. NWO was defined as a BMI<25 kg/m(2) and a % body fat ≥66(th) gender-specific percentiles. The prevalence of NWO was 5.4% in women and less than 3% in men, so the analysis was restricted to women. NWO women had a higher % of body fat than overweight women. After adjusting for age, smoking, educational level, physical activity and alcohol consumption, NWO women had higher blood pressure and lipid levels and a higher prevalence of dyslipidaemia (odds-ratio=1.90 [1.34-2.68]) and fasting hyperglycaemia (odds-ratio=1.63 [1.10-2.42]) than lean women, whereas no differences were found between NWO and overweight women. Conversely, no differences were found between NWO and lean women regarding levels of CRP, adiponectin and liver markers (alanine aminotransferase, aspartate aminotransferase and gamma glutamyl transferase). Using other definitions of NWO led to similar conclusions, albeit some differences were no longer significant.

CONCLUSION

NWO is almost nonexistent in men. Women with NWO present with higher cardiovascular risk factors than lean women, while no differences were found for liver or inflammatory markers. Specific screening of NWO might be necessary in order to implement cardiovascular prevention.

Alcohol drinking, the metabolic syndrome and diabetes in a population with high mean alcohol consumption

AIMS

To investigate the relationship of alcohol consumption with the metabolic syndrome and diabetes in a population-based study with high mean alcohol consumption. Few data exist on these conditions in high-risk drinkers.

METHODS

In 6172 adults aged 35-75 years, alcohol consumption was categorized as 0, 1-6, 7-13, 14-20, 21-27, 28-34 and ≥ 35 drinks/week or as non-drinkers (0), low-risk (1-13), medium-to-high-risk (14-34) and very-high-risk (≥ 35) drinkers. Alcohol consumption was objectively confirmed by biochemical tests. In multivariate analysis, we assessed the relationship of alcohol consumption with adjusted prevalence of the metabolic syndrome, diabetes and insulin resistance, determined with the homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

Seventy-three per cent of participants consumed alcohol, 16% were medium-to-high-risk drinkers and 2% very-high-risk drinkers. In multivariate analysis, the prevalence of the metabolic syndrome, diabetes and mean HOMA-IR decreased with low-risk drinking and increased with high-risk drinking. Adjusted prevalence of the metabolic syndrome was 24% in non-drinkers, 19% in low-risk (P<0.001 vs. non-drinkers), 20% in medium-to-high-risk and 29% in very-high-risk drinkers (P=0.005 vs. low-risk). Adjusted prevalence of diabetes was 6.0% in non-drinkers, 3.6% in low-risk (P<0.001 vs. non-drinkers), 3.8% in medium-to-high-risk and 6.7% in very-high-risk drinkers (P=0.046 vs. low-risk). Adjusted HOMA-IR was 2.47 in non-drinkers, 2.14 in low-risk (P<0.001 vs. non-drinkers), 2.27 in medium-to-high-risk and 2.53 in very-high-risk drinkers (P=0.04 vs. low-risk). These relationships did not differ according to beverage types.

CONCLUSIONS

Alcohol has a U-shaped relationship with the metabolic syndrome, diabetes and HOMA-IR, without differences between beverage types.

[Unusual cause for a dyspnea.]

We report the case of a patient presenting with late onset systemic lupus erythematosus presenting as a haemolytic anemia and pleuritis. We describe the clinical features, diagnosis, prognosis and treatment of the disease with special focus on haematological and pulmonary involvement.