[Extreme heat is a growing problem for global public health]

High temperatures have a direct impact on body functions. Heat waves increase mortality risks due to myocardial infarction, stroke, and pulmonary disease. Cold temperatures also increase mortality, but with a longer latency. A recent study found only a small difference between the minimal mortality temperature (MMT) and the temperatures at which mortality rose steeply, although the majority of deaths occurred at temperatures below MMT. Global climate change with increasing temperatures seriously threatens health, work capacity, and generation of household incomes, particularly among poor people in hot countries. In Sweden, heat waves increase mortality in vulnerable groups of elderly people and patients with chronic heart and lung diseases, as well as those performing intensive physical work in hot environments. The medical profession can play an important role not only in prevention of climate change, but also in adaptation to climate change with the goal of minimizing health risks.

Socio-cultural reflections on heat in Australia with implications for health and climate change adaptation

Background

Australia has a hot climate with maximum summer temperatures in its major cities frequently exceeding 35°C. Although ‘heat waves’ are an annual occurrence, the associated heat-related deaths among vulnerable groups, such as older people, suggest that Australians could be better prepared to deal with extreme heat.

Objective

To understand ways in which a vulnerable sub-population adapt their personal behaviour to cope with heat within the context of Australians’ relationship with heat.

Design

We draw upon scientific, historical and literary sources and on a set of repeat interviews in the suburbs of Western Sydney with eight older participants and two focus group discussions. We discuss ways in which this group of older people modifies their behaviour to adapt to heat, and reflect on manifestations of Australians’ ambivalence towards heat.

Results

Participants reported a number of methods for coping with extreme heat, including a number of methods of personal cooling, changing patterns of daily activity and altering dietary habits. The use of air-conditioning was near universal, but with recognition that increasing energy costs may become more prohibitive over time.

Conclusions

While a number of methods are employed by older people to stay cool, these may become limited in the future. Australians’ attitudes may contribute to the ill-health and mortality associated with excessive heat.

Glycosaminoglycan synthesis by human diabetic, normal adult, and embryonic fibroblasts in relation to insulin levels

Sulfated glycosaminoglycan synthesis by human diabetic, non-diabetic, and embryonic cells was studied. No effect of insulin on net synthesis was noted. Thus, the data do not indicate a role for total sulfated glycosaminoglycan production in the diabetic connective tissue disturbance mediated by insulin.

Synthesis of collagen and sulfated glycosaminoglycans by normal and scleroderma fibroblasts in culture, with and without addition of cyclofenil

The influence of the synthetic weak estrogen cyclofenil was studied in vitro on skin fibroblasts from scleroderma patients, normals, and human embryos. The drug had no effect on the synthesis of sulfated glycosaminoglycans or collagen. Collagen synthesis was lower in scleroderma fibroblasts than in normal cells, whereas there was no difference in sulfated glycosaminoglycans synthesis.

Helsingborg Declaration 2006 on European Stroke Strategies

The Second Consensus Conference on Stroke Management took place from 22 to 24 March 2006 in Helsingborg, Sweden. The meeting was arranged by the International Stroke Society, endorsed by the European Stroke Council and International Stroke Society, and co-sponsored by the WHO Regional Office for Europe. It was arranged in collaboration with the European Region of the World Confederation for Physical Therapy and the European Association of Neuroscience Nurses. The patients' organization Stroke Alliance for Europe also participated. The meeting adopted the Helsingborg Declaration 2006 on European Stroke Strategies, a statement of the overall aims and goals of five aspects of stroke management (organization of stroke services, management of acute stroke, prevention, rehabilitation, evaluation of stroke outcome and quality assessment) to be achieved by 2015.

Effects of temperature and ozone on daily mortality during the August 2003 heat wave in France

During the summer of 2003, Europe experienced a heat wave that lasted almost 2 weeks in which high temperatures were accompanied by exceptionally high ozone levels. Unfortunately, few studies have examined the effects of temperature and ozone simultaneously. The authors use constrained distributed lag models to estimate the effects of daily temperature and peak ozone on mortality in 12 French cities during the heat wave and to estimate the deaths attributable to each component. Elevated minimum and maximum temperature and peak ozone all increase mortality, with substantial interaction effects between temperature and ozone. Researchers expect extreme weather events, along with elevated ozone levels and temperatures, to become more common. Our results suggest that ozone will be an important contributor to the adverse health effects of such events.

Children at risk of giardiasis in Auckland: a case-control analysis

The incidence rate of giardiasis in New Zealand is one of the highest among developed countries, peaking in the 1-4 year age group. A case-control study was undertaken to identify risk factors for giardiasis among Auckland children under 5 years of age. The exposure history of 69 cases and 98 controls were analysed. Ninety-five per cent cases and 86% controls used water from the Auckland Metropolitan mains (AMM) supply for domestic purpose, 44 cases and 42 controls swam and 59 cases and 54 controls wore nappies. Children wearing nappies were at significantly increased risk of the disease (OR = 30, 95% CI = 1.01-8.9), as were those from households which had more than one child wearing a nappy (6.5, 1.8-23.4). The Auckland metropolitan mains water supply was associated with a reduced risk compared to other drinking water sources. Significantly increased risks were also associated with drinking water consumed away from home (4.7, 2.2-10.1), swimming at least once a week (2.4, 1.1-5.3) and travelling domestically (2.5, 1.03-6.0). The study identified vulnerable groups and modifiable risk factors for diarrhoeal diseases, particularly Giardia infection. Nappy wearing was an independent risk factor for infection. Further study is advocated to ensure better protection of public health, especially for children.

Risk of giardiasis in Aucklanders: a case-control study

BACKGROUND

Giardia is one of the leading protozoal causes of human gastrointestinal illnesses. It is prevalent in both developed and developing countries. Currently, giardiasis is the most commonly notified waterborne disease in New Zealand. The aim of the study was to identify potentially modifiable risk factors for Giardia infection in the adult population in Auckland.

METHODS

This case-control study involved 183 Giardia-positive cases and 336 randomly selected controls, aged between 15 and 64 years. Exposure information was collected retrospectively over the telephone for the 21 days preceding the date of onset of symptoms. Both univariate and multiple logistic regression analyses were carried out.

RESULTS

The majority of cases were in the 25-44-year age group and in the New Zealand European ethnic group. Housewives and nursing mothers were at significant risk of the disease (odds ratio (OR)=2.06; 95% CI=1.4-3.74), as were the occupational groups exposed to human wastes (OR=4.04, 95% CI=1.85-8.85). Consumption of drinking water from New Zealand supplies other than metropolitan mains supplies (OR=2.11, 95% CI=1.36-3.27) or from sources outside New Zealand (OR=7.97, 95% CI=4.20-15.12) represented a significantly higher risk, as did traveling (OR=7.57, 95% CI=4.03-14.23) and swimming in pools or fresh water at least once a week (OR=2.04, 95% CI= 1.33-3.12).

CONCLUSIONS

The study identified potentially modifiable risk factors for Giardia infection. These findings should be investigated further in different groups and settings to ensure better protection of the public health.

Future development of general internal medicine: a Swedish perspective

Over the past decade, the demands on internal medicine have increased markedly, partly due to an increasing number of elderly patients with multiple diseases. About half of all the cases coming into the emergency units of Swedish hospitals are related to internal medicine, while planned admissions account for only 10% of in-patient care. In our opinion, the fundamental cause of the strained situation in the health care service today is the fact that the emergency care responsibility of internal medicine is not clearly delimited. This means that the specialty must attend to problems in health care that the other health and sick-care services cannot cope with. Furthermore, an overly extensive division of the discipline of internal medicine into subspecialties can lead to inferior treatment of elderly patients with multiple diseases, as well as to increased costs. We believe that an umbrella organisation with overall management of independent subspecialties would make it possible to meet the increased need for internal medicine in a flexible way. In addition, internal medicine could widen its area of responsibility in the border region to surgery, while the demarcation to other specialties in the emergency unit, including primary care, is already very clear today, and should remain so.

Thyroid function tests, serum lipids and gender interrelations in a middle-aged population

OBJECTIVE

To study the value of screening for thyroid function in a screening program for hyperlipidaemia.

DESIGN

A screening study in primary health care.

SETTING

All individuals in a defined rural area, Söderåkra, Sweden, aged 40-59 years were invited to a screening programme at the local primary health care centre.

PARTICIPANTS

782 individuals were invited for screening. Blood samples were obtained from 88% of the invited males and from 92% of the females.

MAIN OUTCOME MEASURES

Thyroid function tests (thyroid stimulating hormone (TSH) and free T4), serum lipids (total-cholesterol, HDL-cholesterol, LDL-cholesterol and s-triglycerides), b-glucose and body anthropometry (body mass index and waist to hip circumference) were measured.

RESULTS

0.57% of males and 1.13% of females showed evidence of hypothyroidism as defined by a TSH value greater than 3.75 mU/l of those with s-cholesterol concentration above 7 mmol/l. In addition, higher TSH values in females were associated with higher s-cholesterol, s-LDL-cholesterol and s-triglycerides.

CONCLUSION

It seems appropriate to screen for hypothyroidism in females with s-cholesterol above 7.0 mmol/l.

Nappy handling and risk of giardiasis

We did a case-control study to identify modifiable risk factors for giardiasis in people aged 15-64 years living in Auckland, New Zealand. 183 patients with stool-positive Giardia spp referred to community laboratories were compared with 336 age-matched controls identified randomly from the Auckland telephone book. Exposure information for the previous 3 weeks was obtained retrospectively by telephone. Nappy changing was associated with a four-fold increased risk of infection after controlling for other confounders. We conclude that children wearing nappies could be an important source of giardia infection in the community.

Influence of serum triglyceride levels on the risk for myocardial infarction in 12,510 middle aged males: interaction with serum cholesterol

OBJECTIVE

To study the influence of different levels of serum (s)-triglycerides in relation to s-cholesterol on the risk of myocardial infarction.

DESIGN AND SUBJECTS

A 6-13 (mean 10) year follow-up of 12,510 middle-aged men. Fasting s-triglycerides and s-cholesterol were measured at the screening examination.

SETTING

Section of Preventive Medicine at the Department of Internal Medicine, Malmö General Hospital, an urban hospital for 240,000 inhabitants in southern Sweden.

INTERVENTION

In minor groups of patients there were interventions addressing high lipid levels, high alcohol consumption, hypertension and glucose intolerance.

MAIN OUTCOME MEASURE

Myocardial infarction was used as an end-point.

RESULTS

446 myocardial infarctions occurred. The cumulative incidence rates were for the lowest triglyceride quartile 1.2%, for the second 3.2%, for the third 4.1% and for the highest 5.6%. After adjustment for age, year of screening, body mass index, diabetes, smoking, hypertension and s-cholesterol there was a significant relationship between triglycerides and the relative risk for myocardial infarction (P for trend=0.0087). For increasing levels of triglycerides, adjusted for the above factors except cholesterol, the impact of a certain cholesterol value for the occurrence of myocardial infarction was increased (P for trend=0.0092).

CONCLUSIONS

The present study emphasizes the interaction between cholesterol and triglyceride values for the risk of myocardial infarction. It is concluded that at triglyceride values above 1.0 mmol/l and cholesterol above 6.8 mmol/l there is an increasing interaction between cholesterol and triglyceride levels that might be of importance when evaluating the cardiovascular risk of middle aged men.

How much global ill health is attributable to environmental factors?

Over the years, estimates have been made of the portions of human mortality and morbidity that can be attributed to environmental factors. Frustratingly, however, even for a single category of disease such as cancer, these estimates have often varied widely. Here we attempt to explain why such efforts have come to such different results in the past and to provide guidance for doing such estimates more consistently in the future to avoid the most important pitfalls. We do so by carefully defining what we mean by the terms "environmental," "ill health," and "attributable." Finally, based on these recommendations, we attempt our own estimate, appropriately qualified according to the many remaining uncertainties. Our estimate is that 25-33% of the global burden of disease can be attributed to environmental risk factors. Children under 5 years of age seem to bear the largest environmental burden, and the portion of disease due to environmental risks seems to decrease with economic development. A summary of these estimates first appeared in the 1997 report, "Health and Environment in Sustainable Development," which was the World Health Organization's contribution to the 5-year anniversary of the Rio Earth Summit. A full explanation of how these estimates were made is first presented here. We end with a call for a program of "strategic epidemiology," which would be designed to fill important gaps in the understanding of major environmental health risks in important population groups worldwide.

Health, environment and sustainable development: identifying links and indicators to promote action

This paper discusses the links among health, environment, and sustainable development and presents a framework that extends from the epidemiological domain to the policy domain and includes the driving forces that generate environmental pressures, creating changes in the state of the environment and eventually contributing to human exposures. Health effects are the end result of this complex net of events. Environmental health interventions should not be limited to treatment of cases and directly reducing human exposures. The paper discusses the need for integrated action at all levels and, in particular, on the need to focus on long-term action directed at reducing the driving forces that generate the environmental health threats. Only this approach can achieve sustained health benefits and environmental protection in accord with the principles of sustainable development.

Influence of prenatal mercury exposure upon scholastic and psychological test performance: benchmark analysis of a New Zealand cohort

This paper presents benchmark (BMD) calculations and additional regression analyses of data from a study in which scores from 26 scholastic and psychological tests administered to 237 6- and 7-year-old New Zealand children were correlated with the mercury concentration in their mothers' hair during pregnancy. The original analyses of five test scores found an association between high prenatal mercury exposure and decreased test performance, using category variables for mercury exposure. Our regression analyses, which utilized the actual hair mercury level, did not find significant associations between mercury and children's test scores. However, this finding was highly influenced by a single child whose mother's mercury hair level (86 mg/kg) was more than four times that of any other mother. When that child was omitted, results were more indicative of a mercury effect and scores on six tests were significantly associated with the mothers' hair mercury level. BMDs calculated from five tests ranged from 32 to 73 mg/kg hair mercury, and corresponding BMDLs (95% lower limits on BMDs) ranged from 17 to 24 mg/kg. When the child with the highest mercury level was omitted, BMDs ranged from 13 to 21 mg/kg, and corresponding BMDLs ranged from 7.4 to 10 mg/kg.

Age and cystathionine beta-synthase activity in cultured fibroblasts from patients with arterial and venous vascular disease

In order to determine if cystathionine beta-synthase (CBS) could separate groups of patients with various vascular disease, CBS activity was studied in cultured human skin fibroblasts from 30 subjects being either controls, atherosclerotic patients or patients having suffered a deep venous thrombosis. We found a tendency to a negative correlation between age and CBS activity in the control group only (r = -0.58, P = 0.08), with a tendency to lower CBS activities in the young patients with atherosclerotic (4.9) or venous disease (5.3) compared to the young control group (10.2). This could implicate higher levels of p-homocysteine with increased age as well as in young patients with atherosclerotic or thrombotic disease causing vascular damage. The results are important for the further discussion of the role of homocysteine as a risk factor for developing atherosclerotic and thrombogenic vascular disease and for finding a suitable screening method as prevention is by vitamin supplement only.

Comparison of effects of quinapril and metoprolol on glycaemic control, serum lipids, blood pressure, albuminuria and quality of life in non-insulin-dependent diabetes mellitus patients with hypertension. Swedish Quinapril Group

OBJECTIVE

To compare the long-term effects of the angiotensin-converting enzyme (ACE)-inhibitor quinapril and the cardioselective beta-adrenergic blocking agent metoprolol on glycaemic control, with glycosylated haemoglobin (HbA1c) as the principal variable, in non-insulin-dependent diabetes mellitus (NIDDM) patients with hypertension.

DESIGN

A randomized, double-blind, double-dummy, multicentre study during 6 months preceded by a 4 week wash-out and a 3 week run-in placebo period. Quinapril (20 mg) and metoprolol (100 mg, conventional tablets) were given once daily. No change was made in the treatment of diabetes (diet and hypoglycaemic agents).

SUBJECTS

Seventy-two patients fulfilling the criteria were randomized and entered the double-blind period. Twelve patients did not complete the study. Sixty patients, 26 on quinapril and 34 on metoprolol, were available for the final analysis.

MAIN OUTCOME MEASURES

The effect was assessed by changes in HbA1c, the fasting serum glucose and the post-load serum glucose, C-peptide and insulin levels during the oral glucose tolerance test.

RESULTS

In the quinapril group, the fasting serum glucose, oral glucose tolerance and the C-peptide and insulin responses, determined as the incremental area under the curves (AUC), showed no change, but the mean HbA1c level increased from 6.2 +/- 1.1% to 6.5 +/- 1.3% (P < 0.05). In the metoprolol group, the rise in the mean level of HbA1c, from 6.3 +/- 1.0% to 6.8 +/- 1.3% (P < 0.01), tended to be more marked than after quinapril, although there was no significant difference between the increments. The mean fasting serum glucose showed an increase from 9.1 +/- 1.9 mM to 10.1 +/- 2.8 mM (P < 0.01) which correlated significantly with the duration of diabetes (P < 0.01) and the increase in fasting serum triglycerides (P < 0.001). Moreover, in the metoprolol group we found significant decreases in the oral glucose tolerance as well as C-peptide and insulin responses to the glucose load.

CONCLUSIONS

Treatment with quinapril for 6 months appears to have advantages over metoprolol in NIDDM patients with hypertension. Although treatment with quinapril or metoprolol over 6 months was concomitant with a rise in the HbA1c, increased fasting blood glucose, decreased oral glucose tolerance and decreased C-peptide and insulin responses to a glucose challenge were observed only in patients treated with metoprolol.

Venous Insufficiency 4 Years after an Episode of Deep Vein Thrombosis: A Clinical and Plethysmographic Investigation

Objective:

To evaluate the frequency of venous insufficiency following deep vein thrombosis (DVT).

Design:

Follow-up 4 years after a verified DVT.

Setting:

University hospital in Malmö.

Patients:

Eighty-seven subjects with venographically verified DVT.

Main outcome measure:

To compare venous function in legs, with and without previous DVT, by venous straingauge plethysmography and its correlation with clinical symptoms and signs.

Results:

Fifty-two per cent of patients described general discomfort from the thrombotic leg at follow-up. Active leg ulcers were found in three patients (3%); there were no signs of venous insufficiency in 33% at clinical examination. Thirty-seven patients (75%) with ≥ 1 cm difference in calf circumference between the thrombotic and contralateral leg had suffered a proximal DVT. The refilling time T90 was pathological in 67% and the muscle pump function (RV) in 55%. In the nonthrombotic leg the corresponding figures were 53% and 40%. Nevertheless a positive correlation was found between RV of the thrombotic leg and the contralateral leg ( r = 0.33) but an even stronger correlation was found for T90 ( r = 0.74).

Conclusion:

Venous insufficiency was found in 60% of legs 4 years after DVT but was also found in 14% of legs without previous thrombosis. This may be caused not only by effects of the thrombosis but also by the ageing process.

Compliance with and efficacy of treatment with pravastatin and cholestyramine: a randomized study on lipid-lowering in primary care

OBJECTIVES

Lipid-lowering drugs as 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors and cholestyramine are effective in reducing cardiovascular morbidity both in primary and secondary prevention. Patient compliance is an important determinant of the outcome of therapy. This study was designed to compare compliance with tolerance and lipid-lowering effectiveness of pravastatin and/or cholestyramine in primary care.

DESIGN

Nine hundred and eighty nine women and 1047 men were randomized to treatment at 100 primary-care centres in Sweden. After dietary intervention, an eligible patient was randomly assigned to one of four programs of daily treatment: group Q, 16 g cholestyramine, group QP, 8 g cholestyramine and 20 mg pravastatin, group P20, 20 mg pravastatin or group P40, 40 mg pravastatin.

RESULTS

In group Q, group QP, group P20 and group P40 the reductions in low density lipoprotein (LDL)-cholesterol were 26%, 36%, 27% and 32%. The dose actually taken was 91-95% of the prescribed for the pravastatin treatment groups and 77-88% for the cholestyramine groups. In the pravastatin and cholestyramine groups 76-78% and 44-53%, respectively, completed the trial. Only 8-27% of the patients reached a serum cholesterol target level of 5.2 mmol L-1. There was no difference in lipid-lowering effect between women and men.

CONCLUSION

Pravastatin alone is efficacious and compliance is high, independent of dose. Combined treatment with cholestyramine and pravastatin had a better cholesterol lowering effect (although not statistically significant) than 40 mg pravastatin. Despite this, only 8-27% of the patients actually reached a serum cholesterol level of 5.2 mmol L-1. No unexpected serious adverse events were detected in any of the treatment groups. As predicted, the gastrointestinal disturbances were more common on cholestyramine treatment. These two factors suggest that an increase in the dosage of the HMG-CoA reductase inhibitor may be appropriate. Results from other studies indicate that there also might be other positive effects of statin treatment beyond cholesterol lowering.

Bambuterol raises high-density lipoprotein levels in patients with hyperlipidaemia

OBJECTIVE

The objective of this study was to investigate the effects of bambuterol (a prodrug of the beta 2-agonist terbutaline) on lipid and lipoprotein levels in patients with hyperlipidaemia. Both these drugs are extensively used in the treatment of patients with bronchial asthma. Earlier studies in healthy volunteers and in patients with noninsulin dependent diabetes mellitus have shown that terbutaline and bambuterol increase HDL cholesterol levels, and therefore bambuterol might have beneficial effects on HDL levels in patients with hyperlipidaemia.

DESIGN

The present study was a randomized, double-blind, crossover study, comparing 20 mg of bambuterol with placebo, each one given for 6-8 weeks with a 3-4 week washout period in between.

SETTING

The study was performed in an out-patient lipid clinic at Malmö University Hospital.

SUBJECTS

Thirty-one patients with hyperlipidaemia (S-cholesterol > 6.5 mmol L-1 and S-triglycerides > 2.0 mmol L-1) were included.

MAIN OUTCOME MEASUREMENTS AND RESULTS

The results showed that bambuterol increased S-HDL cholesterol levels by 7% (P = 0.012). Increases were 23% for P-HDL2 and 7% for P-HDL3 fractions, but no effect was apparent on S-apolipoprotein A-1 levels.

CONCLUSION

This study suggests that the beta 2-agonist bambuterol might be used as an alternative or as a complement in the treatment of dyslipidemic patients, when an increase in HDL cholesterol is desired.

Fosinopril versus enalapril in the treatment of hypertension: a double-blind study in 195 patients

The new angiotensin-converting enzyme (ACE) inhibitor fosinopril was compared with the ACE inhibitor enalapril in a multicenter (n = 11), multinational (Denmark, Finland, Iceland, Norway, and Sweden), double-blind, randomized, parallel-group 24-week study in 195 patients with mild to moderate essential hypertension [supine diastolic blood pressure, (SDBP) > or = 95 to < or = 110 mm Hg]. After discontinuing all previous antihypertensive medication, patients were entered into a placebo lead-in period of 4-6 weeks, followed by 24 weeks of randomized treatment with the active compounds administered with a double-dummy technique. The dose of fosinopril was 20 mg, which could be increased to 40 mg after 8 weeks (average 25.6 mg); that of enalapril was 10 mg, which could be increased to 20 mg after 8 weeks (average 12.9 mg). Hydrochlorothiazide 12.5 mg could be added after 16 weeks and was administered to 27% of the patients in the fosinopril group and to 30% in the enalapril group. All drugs were administered once daily. Supine systolic BP (SSBP) decreased from 157 to 143 mm Hg in the fosinopril group (p < 0.01), and from 159 to 147 mm Hg in the enalapril group (p < 0.01). SSDP decreased from 100 to 89 mm Hg in the fosinopril group (p < 0.01) and from 100 to 92 mm Hg in the enalapril group (p < 0.01). Throughout the study period, fosinopril reduced SSBP and SDBP numerically more than did enalapril, by 0-3 mm Hg. Adverse events (AE) caused withdrawal of study medication in 8 patients in the fosinopril group and in 14 patients in the enalapril group (NS). The number of reported AE was not statistically different in the two groups. Inhibition of the ACE was assessed in a subgroup of patients (n = 26, 13 in each group). Fosinopril caused a greater inhibition of ACE at the doses used in the present study, which was statistically significant. Both fosinopril and enalapril caused statistically significant reductions in BP of a similar magnitude, and both agents were well tolerated. However, fosinopril was consistently numerically slightly more effective than enalapril in reducing BP. There were fewer withdrawals due to AE (NS) in the fosinopril group, and the overall recorded AE were fewer in the fosinopril group (NS).

Cardiovascular risk groups and mortality in an urban swedish male population: the Malmö Preventive Project

OBJECTIVES

To describe the size, overlap and mortality of four cardiovascular risk groups, in order to give a scientific background for the prevention of cardiovascular disease in a representative urban population.

SETTING

Section of Preventive Medicine, Department of Medicine, Malmö University Hospital, Malmö, Sweden.

SUBJECTS

Between 1974 and 1984 22444 men born between 1949 and 1921, constituting 75% of the total male population in these age groups, took part in a comprehensive screening examination aimed at detecting risk factors for cardiovascular disease.

INTERVENTIONS

Those at high-risk of developing cardiovascular disease were referred to their general practitioner or to special clinics for hypertension, hyperlipidaemia and diabetes. The follow-up, which lasted until the end of 1991, averaged 12.2 years.

MAIN OUTCOME MEASURES

Total death (n = 1450) and death from ischaemic heart disease (IHD) (n = 471).

RESULTS

Hypertension was found in 13%, hypercholesterolaemia in 19% and diabetes mellitus in 2.6% of the subjects; 49% of the subjects smoked. Multiple risk factors were found in over 17% of the total cohort. Despite the intervention, all-cause mortality during follow-up was increased three-fold in smokers and in men with hypercholesterolaemia, four-fold in hypertensive men and five-fold in men with diabetes, compared to men with no risk factors. The vast majority of deaths (81%) occurred in men who smoked, had hypertension or had high serum cholesterol. Ischaemic heart disease (IHD) was increased five-fold in smokers, seven-fold in men with hypercholesterolaemia, nine-fold in hypertensive men and 12-fold in men with diabetes. Again, the vast majority of IHD deaths (86%) occurred in the first three categories. Combinations of risk factors substantially increased total mortality as well as IHD mortality.

CONCLUSIONS

The large proportion (64%) of the population with risk factors for cardiovascular disease and the substantially (5-12-fold) increased IHD mortality in those risk groups, calls for actions aimed at preventing premature IHD deaths. Such action should include measures directed towards the whole population and comprehensive treatment programmes for high-risk individuals, including intervention to stop smoking. The substantial overlap between risk factors calls for one high-risk clinic caring for all risk groups.

Therapeutic comparison of metformin and sulfonylurea, alone and in various combinations. A double-blind controlled study

OBJECTIVE

To assess and compare the therapeutic efficacy and safety of metformin (M) and sulfonylurea (glyburide, G), alone and in various combinations, in patients with non-insulin-dependent diabetes mellitus (NIDDM).

RESEARCH DESIGN AND METHODS

Of 165 patients (fasting blood glucose [FBG] > or = 6.7 mmol/l) initially treated with diet alone, 144 (FBG still > or = 6.7 mmol/l) were randomized to double-blind, double-dummy controlled treatment with M, G, or primary combination therapy (MG). The dose was titrated, with FBG < 6.7 mmol/l as target, using, at most, six dose levels. The first three dose levels comprised increasing single-drug therapy (M or G) or primary combination at increasing but low dosage (MGL), and the second three levels were composed of various high-dose combinations, i.e., add-on therapy (M/G or G/M) and primary combination escalated to high dosage (MGH). Medication was maintained for 6 months after completed dose titration.

RESULTS

The FBG target was achieved in 9% of patients after diet alone. Single-drug therapy was insufficient in 36% and MGL in 25% (NS) of the randomized patients. There was further improvement in glucose control by the high-dose combinations. Mean FBG +/- SE was reduced (P = 0.001) from 9.1 +/- 0.4 to 7.0 +/- 0.2 mmol/l in those maintained on single-drug treatment or low-dose primary combination. Those treated with different high-dose combinations had a large mean FBG reduction, from 13.3 +/- 0.8 to 7.8 +/- 0.6 mmol/l. HbA1c levels showed corresponding reductions, and glycemic levels rose after drug discontinuation. Fasting C-peptide rose during treatment with G and MGL but not with M, while fasting insulin was not significantly changed. Meal-stimulated C-peptide and insulin levels were unchanged by M but increased by G and, to a lesser extent, by MGL. There were no significant insulin or C-peptide differences between the different high-dose combinations (M/G, G/M, and MGH). Body weight did not change following treatment with M or combination but increased by 2.8 +/- 0.7 kg following G alone. Blood pressure was unchanged. Overall effects on plasma lipids were small, with no significant differences between groups. Drug safety was satisfactory, even if the reporting of (usually modest) adverse events was high; the profile, but not the frequency, differed between groups.

CONCLUSIONS

Dose-effect titrated treatment with either metformin or glyburide promotes equal degrees of glycemic control. The former, but not the latter, is able to achieve this control without increasing body weight or hyperinsulinemia. Near-normal glycemia can be obtained by a combination of metformin and sulfonylurea, even in advanced NIDDM.

Short-term effects of felodipine in hypertensive type II diabetic males on sulfonylurea treatment

OBJECTIVES

To study the effects on blood pressure and glucose homeostasis of felodipine, a calcium antagonist.

DESIGN

A double-blind randomized cross-over study comparing felodipine ER and placebo.

SETTING

A university centre of diabetic care in Malmö, Sweden.

SUBJECTS

Seventeen hypertensive type II diabetic males on oral sulfonylurea (glibenclamide) treatment.

INTERVENTIONS

Four-week treatment periods separated by a 2-week wash-out period. Felodipine 10-20 mg once daily was given.

MAIN OUTCOME MEASURES

Blood pressure, heart rate, HbA1c and response to oral glucose tolerance test; glucose, insulin and c-peptide. Measured before randomization and at the end of each double-blind treatment period.

RESULTS

Blood pressure was significantly reduced during felodipine treatment and heart rate slightly increased. Felodipine did not influence insulin or c-peptide levels. There was no significant change in glucose levels but an increase in HbA1c.

CONCLUSION

The study demonstrated that felodipine is an effective agent for type II diabetic patients on glibenclamide treatment. The effect on HbA1c is noteworthy even if not of clinical significance in the short term. Controlled long-term studies in diabetic patients are needed to fully evaluate antihypertensive agents.

Deep venous thrombosis and occult malignancy: an epidemiological study

OBJECTIVE

To determine the risk of subsequent cancer in patients with deep venous thrombosis confirmed by venography.

DESIGN

Follow up of all patients who had venography for suspected deep venous thrombosis during 1984-88. Patients were traced through a cancer registry up to 1 January 1991.

SUBJECTS

4399 patients who had phlebography in one hospital.

SETTING

General hospital in Malmö, Sweden, serving a population of 230,000.

MAIN OUTCOME MEASURE

Number of cancers recorded.

RESULTS

4399 patients had venography for suspected deep venous thrombosis; 604 were known to have a malignancy at the time of venography and were excluded from further analysis. 1383 had deep venous thrombosis, 150 of whom subsequently developed cancer. 182 of the 2412 patients without thrombosis developed cancer. During the first six months after venography 66 patients with thrombosis developed malignancy compared with 37 patients without thrombosis (P < 0.0001). 38 of the cancers in the deep venous thrombosis group were detected by history, physical examination, and laboratory tests. Three patients had postoperative or post-traumatic deep venous thromboses. Only two of the remaining patients would have benefited from early detection by extensive screening. After six months the incidence of cancer was identical in patients with and without thrombosis.

CONCLUSION

Deep venous thrombosis is associated with a significantly higher frequency of malignancy during the first six months after diagnosis. Malignancies can be found with simple clinical and diagnostic methods and extensive screening is not required.

Courses in environmental and occupational epidemiology

The results of a survey are reported in which members of WHO's Global Environmental Epidemiology Network were asked for details of free-standing environmental and occupational epidemiology courses that were offered or planned for 1991-93 with tuition in English, French or Spanish and with places for persons living outside the countries concerned. Of the 126 courses on which information was received, 72 were open to health professionals from more than one discipline.

Release of beta-hexosaminidase isoenzymes in cultured human fibroblasts

We have used enzyme immunoassay methods to study the intra- and extracellular isoenzyme pattern of beta-hexosaminidase (Hex) in human fibroblast cultures. The released activity into the medium during 24 h was about 10% of the intracellular activity. Intra- and extracellular ratio of Hex B to total Hex (Hex A plus Hex B) was about one-third. Estimation of the molecular weight of the released activity showed that it corresponded to 150 kDa, which is equal to the high molecular mass precursor forms of the enzyme. NH4Cl is known to disturb the intracellular transport of lysosomal enzymes and increase the secretion of newly synthesized precursor forms. Addition of NH4Cl even at 3 mM resulted in an increased release of total Hex, which was already noted within 24 h. We speculate that the increased concentration of plasma NH4+ in patients with liver disease interferes with the intracellular distribution pathway of the lysosomal enzymes and this could contribute to the increased content of lysosomal enzymes present in plasma from these patients. Tunicamycin (0.3-3.0 micrograms/l) increased the percentage of Hex B in the medium, whereas an increased release of Hex was noted only after 48 h. Tunicamycin is known to enhance the secretion of N-linked oligosaccharide-free forms of lysosomal enzymes. Thus the oligosaccharide chains on alpha- and beta-subunits seem to be important for the normal formation process of the Hex A isoenzyme.

A prospective study of the incidence of deep-vein thrombosis within a defined urban population

In a prospective study all positive phlebographies within the well-defined population of the city of Malmö, Sweden, during 1987 were studied in order to determine the incidence of deep venous thrombosis (DVT). Epidemiological data were analysed for the detection of patient groups at increased risk of DVT. The incidence was found to be equal for both sexes, i.e. 1.6 per 1000 inhabitants a year. Risk factors were found to be in accordance with earlier studies. The median age for men was 66 years, compared to 72 years for women. At diagnosis of DVT, 19% of subjects had a known malignancy and within 1 year 5% (19 cases) developed a new malignancy. Of the men, 29% had postoperative or post-traumatic (fracture) DVT, compared to 46% of the women. Fewer patients with DVT than expected (39%) belonged to blood group 0 (31%) (P less than 0.005). Pulmonary embolism (PE) was clinically suspected in only 5% of cases, and diagnosis was verified scintigraphically in 2% of cases. None of these died of PE, but of 6 patients who were found to have PE at autopsy, four died about 4 weeks after the DVT was diagnosed.

Age dependency of cystathionine beta-synthase activity in human fibroblasts in homocyst(e)inemia and atherosclerotic vascular disease

In order to clarify whether cystathionine beta-synthase (CBS) could differentiate groups of patients with various vascular diagnosis, CBS was studied in cultured human skin fibroblasts from 99 human subjects diagnosed as homozygotes or heterozygotes for CBS deficiency or suffering from atherosclerotic vascular disease or Down's syndrome (prone to less atherosclerosis). In addition, embryonic human skin fibroblasts and controls were analysed for CBS. We found significant group differences but the overlap in the hetero- and homozygotes for CBS deficiency was too extensive to allow any individual diagnosis based on cell culture studies. CBS activity was significantly lower in the atherosclerotic patients as compared to control subjects. The difference was mostly due to much higher CBS activity in the younger controls. Age dependency was markedly emphasized by very high values from embryonic cells. A strong negative correlation was noted for age and CBS activity in control subjects but not in the atherosclerotic patients. The results are important for the discussion of homocysteine in atherosclerosis and point to the importance of donor age on CBS activity in cultured cells. In addition, diagnosis of hetero-homozygosity for CBS activity is not possible on an individual basis by this method. Further studies in cell culture systems are needed to investigate if young patients (less than 45 years old) with atherosclerotic disease could be identified by low CBS activity in fibroblast cultures as indicated by this study.

Effects of metformin and glibenclamide alone and in combination on serum lipids and lipoproteins in patients with non-insulin-dependent diabetes mellitus

Metformin, glibenclamide and their combination were compared in a randomized, double-blind trial in patients with non-insulin-dependent diabetes mellitus (NIDDM) using a parallel group design. The study was performed in primary health care, and the purpose was to assess possible synergistic effects of combination therapy with the two drugs as primary treatment versus conventional oral therapy, starting with one drug and adding the other, if necessary. Lipids and lipoproteins were measured in the study, and preliminary results are reported for one hundred sixteen patients concluding 6 months maintenance therapy. Comparison of mean differences showed that patients randomized to combination therapy (n = 60) demonstrated a greater decrease in total- and LDL-cholesterol levels after 4 and 6 months treatment than patients randomized to conventional therapy starting with either metformin (n = 28) or glibenclamide (n = 28). For LDL-cholesterol a significant difference was also found between patients solely on monotherapy with lower values after treatment with metformin. Triglycerides did not change significantly, and only minor fluctuations were seen in HDL-cholesterol, independent of treatment. Obese patients had significantly higher triglyceride concentrations than the non-obese group, both at baseline and after treatment, as well as significantly lower HDL-cholesterol levels. The mean triglyceride concentration (+/- SD) after 6 months treatment was 2.32 +/- 1.38 mmol/l in the obese group (n = 69) and 1.54 +/- 0.84 mmol/l in non-obese (n = 47). For HDL-cholesterol the corresponding values were 0.83 +/- 0.23 mmol/l in obese and 0.93 +/- 0.29 mmol/l in non-obese patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative efficacy of metformin and glibenclamide in patients with non-insulin-dependent diabetes mellitus

Metformin and glibenclamide were compared in a randomized, double-blind trial in patients with non-insulin-dependent diabetes mellitus (NIDDM) using a parallel group design. The study was performed in primary health care, and the main purpose was to assess combination therapy with the two drugs as primary treatment versus conventional oral therapy. After a 2 months diet period patients were randomized to commence treatment with either metformin, glibenclamide or the combination of both. Patients randomized to monotherapy received the alternative drug in addition if the maximal dose i.e. 3 g metformin or 14 mg glibenclamide was insufficient to normalize the fasting blood glucose concentration (FBG). Randomization and dose escalation occurred at FBG greater than or equal to 6.7 mmol/l. The titrated dose was continued for 6 months, whereafter placebo was given for 2 weeks. Seventy-two patients were randomized to either the metformin group (n = 38) or the glibenclamide group (n = 34). Fifty-six completed 6 months treatment, twenty-eight in each randomized group. Glycaemic control was unchanged after diet alone in all groups. The improvement during drug treatment was highly significant (p less than 0.001), mean FBG difference (+/- SEM) 3.2 +/- 0.4 mmol/l and mean HbA1c difference (+/- SEM) 1.5 +/- 0.2% (n = 56). There were no significant differences between patients treated solely with metformin (n = 16) and glibenclamide (n = 17) or between patients treated with a combination of glibenclamide added to metformin (n = 12) and metformin added to glibenclamide (n = 11).(ABSTRACT TRUNCATED AT 250 WORDS)

Felodipine in the treatment of hypertensive type II diabetics: effect on glucose homeostasis

The effect of felodipine on glucose tolerance was evaluated in 18 male type II diabetic patients treated with diet alone, who were hypertensive despite beta-blocker treatment. The study was a double-bind cross-over comparison of placebo and felodipine in addition to beta-blockade. Oral glucose tolerance tests were performed at randomization and at the end of each 4-week double-blind treatment period. The doses of felodipine given were 5 mg b.i.d. for 2 weeks followed by 10 mg b.i.d. for a further 2 weeks. Blood pressure was significantly reduced during felodipine treatment, whereas heart rate remained unaltered. HbA1c and fasting insulin levels did not change during the treatment periods. Fasting and maximal blood glucose levels were not altered between any of the treatment periods. However, there was a small but statistically significant increase (median increase 4%) in the area under the glucose concentration vs. time curve after felodipine as compared to placebo treatment. This increase was not considered to be clinically significant in the short term, but the finding merits further investigation in a rigorous long-term study.

Prevention of myocardial infarction and stroke in patients with intermittent claudication; effects of ticlopidine. Results from STIMS, the Swedish Ticlopidine Multicentre Study

The Swedish Ticlopidine Multicentre Study (STIMS) was a double-blind placebo-controlled trial designed to determine whether ticlopidine, a platelet antiaggregatory agent, reduces the incidence of myocardial infarction, stroke and transitory ischaemic attacks in patients with intermittent claudication. A total of 687 patients was monitored for a minimum of 5 years or until an end-point was reached. The number of end points (99 vs. 89), analysed according to the intention-to-treat principle, was 11.4% lower in the ticlopidine group (P = 0.24). The mortality rate was 29.1% lower in the ticlopidine group (64 vs. 89, P = 0.015); this observation could be accounted for by a reduced mortality from ischaemic heart disease. On-treatment analysis showed there to be significantly fewer end points in the ticlopidine group (47 vs. 76, P = 0.017). Diarrhoea was the most common side-effect. Reversible leucopenia or thrombocytopenia was reported in seven patients on ticlopidine. It is concluded that the high morbidity and mortality from cardio- and cerebrovascular disease in patients with intermittent claudication can be reduced by long-term treatment with ticlopidine.

Apolipoprotein A-I:B ratio and B screening: a preliminary study of 10- and 11-year-old children

The apolipoprotein (apo) A-I:B ratio and the apo B concentration were determined by radial immunodiffusion in dried blood spot samples from 1,767 10- and 11-year-old children. Children with either apo A-I:B ratios below the first percentile or apo B levels above the 99th were recalled and plasma lipid and apolipoprotein profiles were determined for both children and parents. Of 17 children (one family was lost to follow-up) recalled due to abnormal apo A-I:B ratios, apo B levels were above the 95th percentile in 13 children, and of 18 children with abnormal apo B screening levels (three of them also had abnormal apo A-I:B ratios), the plasma apo B level was elevated in 13 children. The 23 children with abnormal blood lipid and/or apolipoprotein concentrations were divided into two main groups: (a) children with type IIa hyperlipoproteinemia and (b) children with hyperapo B lipoproteinemia (hyperapo B) and normal blood lipid levels. Twelve children had the type IIa pattern. Five children likely had familial hypercholesterolemia (FH), the other seven children may have hypercholesterolemia due to obesity or environmental factors. Eleven children had the hyperapo B abnormality. In four children, the elevated apo B level probably was an indication of the occurrence of familial combined hypercholesterolemia (FCH) in the family. Of the remaining seven hyperapo B children, three children also had a parent with hyperapo B and a fourth family suffered from obesity.(ABSTRACT TRUNCATED AT 250 WORDS)

Conservative drug treatment in patients with moderately severe chronic occlusive peripheral arterial disease. Scandinavian Study Group

A double-blind, parallel group, multicenter clinical trial of pentoxifylline compared with placebo enrolled 150 patients with moderately severe chronic occlusive arterial disease (COAD) at three centers in Scandinavia. The study consisted of a 4-6 week single-blind, placebo-controlled run-in phase, during which the stabilization of the initial claudication distance of all patients was assessed before randomization to a 6-month double-blind observation period. The diagnosis of COAD was established by clinical findings, conventional angiography, and noninvasive peripheral Doppler pressure assessment at rest and after exercise. The results of the overall intention-to-treat analysis of the study population show statistically significant superiority of pentoxifylline over placebo for all absolute claudication distance summary and end point measures. By using two clinically relevant parameters, which are a resting ankle/arm pressure ratio 0.8 or less and a duration of COAD for greater than 1 year, a target population could be defined in whom trial results became highly significant. For nontarget patients with mild COAD, we conclude that basic therapeutic measures should include the treatment of risk factors and the initiation of physical training. For target patients, however, a multifactorial therapeutic approach, including the use of pentoxifylline, is justified.

The fibrinolytic system and coagulation during bezafibrate treatment of hypertriglyceridemia

Bezafibrate was given to 23 hypertriglyceridemic but otherwise healthy middle-aged men in a double-blind, cross-over study to evaluate its effect on the components of the fibrinolytic system as well as on ATIII, FVIIIR: Ag, FVIII: C and platelet aggregation. Fibrinogen dropped markedly (P less than 0.05) and there was a small but significant fall of ATIII. The second wave of platelet aggregation was found much less frequently than in controls (P less than 0.001). Bezafibrate seemed to decrease the rate of formation of the first wave platelet aggregation.

Characterization studies on the cadmium-binding proteins from two species of New Zealand oysters

Two different types of New Zealand oysters--Ostrea lutaria (OL) and Crassostrea glomerata (CG)--contained different concentrations of zinc, copper, and cadmium. OL oysters had 5.3 micrograms Cd/g, 3.4 micrograms Cu/g, 100 micrograms Zn/g; CG oysters had 1.4 micrograms Cd/g and 936 micrograms Zn/g. Both kinds of oysters were shown by gel filtration (G-75) to contain cadmium and zinc in fractions corresponding to a high molecular weight protein (corresponding to the size of albumin or larger) which was heat labile. OL oysters contained cadmium in fractions corresponding to a molecular weight of approximately 6500. The cadmium-binding protein in these fractions was heat-stable. This protein contained no detectable amounts of zinc and was not present in the CG oysters. Further purification by gel filtration (G-50) was performed to obtain a purer protein fraction. Isoelectric focusing of the protein obtained by G-50 filtration showed one main fraction of protein with a pI approximately 5.9 at approximately 13 degrees C. CG oysters contained cadmium and zinc in a polypeptide with low molecular weight (MW 1000). The cadmium-binding oyster proteins are minimally reactive in a competitive binding radioimmunoassay in comparison to the reactivity of a typical vertebrate metallothionein; the proteins may be metallothioneins, but, if so, they do not exhibit the principal determinants characteristic of vertebrate metallothioneins.

Influence of glucose on collagen and protein production in cultured human skin fibroblasts from diabetic and non-diabetic subjects

The effect of glucose on extracellular production of collagen and protein was studied in cultured human skin fibroblasts. Fibroblasts from 8 non-diabetics, 8 type 1 and 12 type 2 diabetic subjects were cultured. Incorporation of tritium labeled proline into medium collagen and protein was studied at glucose concentration 1-7 mg/ml (5.6-38.9 mM). A 75% increase in collagen production was noted by cells from type 1 diabetics at glucose concentration of 5 mg/ml, as compared to 1 mg/ml. A considerably lower although significant increase was also noted at this level by cells from non-diabetics. Glucose had no effect on collagen and minimal on protein production by cells from type 2 diabetic subjects. The results indicate an effect of glucose on extracellular matrix formation in diabetes mellitus which might be relevant for diabetic angiopathy.