Characterizing Important Dietary Exposure Sources of Perfluoroalkyl Acids in Inuit Youth and Adults in Nunavik Using a Feature Selection Tool

BACKGROUND

Previous studies have identified the consumption of country foods (hunted/harvested foods from the land) as the primary exposure source of perfluoroalkyl acids (PFAA) in Arctic communities. However, identifying the specific foods associated with PFAA exposures is complicated due to correlation between country foods that are commonly consumed together.

METHODS

We used venous blood sample data and food frequency questionnaire data from the Qanuilirpitaa? ("How are we now?") 2017 (Q2017) survey of Inuit individuals ≥ 16 y of age residing in Nunavik (n = 1,193 ). Adaptive elastic net, a machine learning technique, identified the most important food items for predicting PFAA biomarker levels while accounting for the correlation among the food items. We used generalized linear regression models to quantify the association between the most predictive food items and six plasma PFAA biomarker levels. The estimates were converted to percent changes in a specific PFAA biomarker level per standard deviation increase in the consumption of a food item. Models were also stratified by food type (market or country foods).

RESULTS

Perfluorooctanesulfonic acid (PFOS), perfluorodecanoic acid (PFDA), and perfluoroundecanoic acid (PFUnDA) were associated with frequent consumption of beluga misirak (rendered fat) [14.6%; 95% confidence interval (CI): 10.3%, 18.9%; 14.6% (95% CI: 10.1%, 19.0%)], seal liver [9.3% (95% CI: 5.0%, 13.7%); 8.1% (95% CI: 3.5%, 12.6%)], and suuvalik (fish roe mixed with berries and fat) [6.0% (95% CI: 1.3%, 10.7%); 7.5% (95% CI: 2.7%, 12.3%)]. Beluga misirak was also associated with higher concentrations of perfluorohexanesulphonic acid (PFHxS) and perfluorononanoic acid (PFNA), albeit with lower percentage changes. PFHxS, perfluorooctanoic acid (PFOA), and PFNA followed some similar patterns, with higher levels associated with frequent consumption of ptarmigan [6.1% (95% CI: 3.2%, 9.0%); 5.1% (95% CI: 1.1%, 9.1%); 5.4% (95% CI: 1.8%, 9.0%)]. Among market foods, frequent consumption of processed meat and popcorn was consistently associated with lower PFAA exposure.

CONCLUSIONS

Our study identifies specific food items contributing to environmental contaminant exposure in Indigenous or small communities relying on local subsistence foods using adaptive elastic net to prioritize responses from a complex food frequency questionnaire. In Nunavik, higher PFAA biomarker levels were primarily related to increased consumption of country foods, particularly beluga misirak, seal liver, suuvalik, and ptarmigan. Our results support policies regulating PFAA production and use to limit the contamination of Arctic species through long-range transport. https://doi.org/10.1289/EHP13556.

Wild fish consumption and latitude as drivers of vitamin D status among Inuit living in Nunavik, northern Québec

OBJECTIVE

To measure vitamin D status and estimate factors associated with serum 25-hydroxyvitamin D (25(OH)D) in Nunavimmiut (Inuit living in Nunavik) adults in 2017.

DESIGN

Data were from Qanuilirpitaa? 2017 Nunavik Inuit Health Survey, a cross-sectional study conducted in August-October 2017. Participants underwent a questionnaire, including an FFQ, and blood samples were analysed for total serum 25(OH)D.

SETTING

Nunavik, northern Québec, Canada.

PARTICIPANTS

A stratified proportional model was used to select respondents, including 1,155 who identified as Inuit and had complete data.

RESULTS

Geometric mean serum vitamin D levels were 65·2 nmol/l (95 % CI 62·9-67·6 nmol/l) among women and 65·4 nmol/l (95 % CI 62·3-68·7 nmol/l) among men. The weighted prevalence of serum 25(OH)D < 75 nmol/l, <50 nmol/l <30 nmol/l was 61·2 %, 30·3 % and 7·0 %, respectively. Individuals who were older, female, lived in smaller and/or more southerly communities and/or consumed more country (traditional) foods were at a reduced risk of low vitamin D status. Higher consumption of wild fish was specifically associated with increased serum 25(OH)D concentration.

CONCLUSION

It is important that national, regional and local policies and programs are in place to secure harvest, sharing and consumption of nutritious and culturally important country foods like Arctic char and other wild fish species, particularly considering ongoing climate change in the Arctic which impacts the availability, access and quality of fish as food.

Sociodemographic patterning of dietary profiles among Inuit youth and adults in Nunavik, Canada: a cross-sectional study

OBJECTIVES

Country (traditional) foods are integral to Inuit culture, but market food consumption is increasing. The Qanuilirpitaa? 2017 Nunavik Health Survey (Q2017) reported similar country food consumption frequency compared to that in 2004; however, examining food items individually does not account for diet patterns, food accessibility, and correlations between food items. Our objective was to identify underlying dietary profiles and compare them across sex, age, ecological region, and food insecurity markers, given the links among diet, health, and sociocultural determinants.

METHODS

Food frequency and sociodemographic data were derived from the Q2017 survey (N = 1176). Latent profile analysis identified dietary profiles using variables for the relative frequencies of country and market food consumption first, followed by an analysis with those for country food variables only. Multinomial logistic regression examined the associations among dietary profiles, sociodemographic factors, and food insecurity markers (to disassociate between food preferences and food access).

RESULTS

Four overall dietary profiles and four country food dietary profiles were identified characterized by the relative frequency of country and market food in the diet. The patterns were stable across several sensitivity analyses and in line with our Inuit partners' local knowledge. For the overall profiles, women and adults aged 30-49 years were more likely to have a market food-dominant profile, whereas men and individuals aged 16-29 and 50+ years more often consumed a country food-dominant profile. In the country food profiles, Inuit aged 16-29 years were more likely to have a moderate country food profile whereas Inuit aged 50+ were more likely to have a high country food-consumption profile. A low country and market food-consumption profile was linked to higher prevalence of food insecurity markers.

CONCLUSION

We were able to identify distinct dietary profiles with strong social patterning. The profiles elucidated in this study are aligned with the impact of colonial influence on diet and subsequent country food promotion programs for Inuit youth. These profiles will be used for further study of nutritional status, contaminant exposure, and health to provide context for future public health programs.

Cardiometabolic health and per and polyfluoroalkyl substances in an Inuit population

INTRODUCTION

The cardiometabolic health status of Inuit in Nunavik has worsened in the last thirty years. The high concentrations of perfluoroalkyl acids (PFAAs) may be contributing to this since PFAAs have been linked with hypercholesterolemia, diabetes, and high blood pressure. The aim of this study was to examine the association between a PFAAs mixture and lipid profiles, Type II diabetes, prediabetes, and high blood pressure in this Inuit population.

METHODS

We included 1212 participants of the Qanuilirpitaa? 2017 survey aged 16-80 years. Two mixture models (quantile g-computation and Bayesian Kernel Machine Regression (BKMR)) were used to investigate the associations between six PFAAs (PFHxS, PFOS, PFOA and three long-chain PFAAs (PFNA, PFDA and PFUnDA)) with five lipid profiles and three cardiometabolic outcomes. Non-linearity and interaction between PFAAs were further assessed.

RESULTS

An IQR increase in all PFAAs congeners resulted in an increase in total cholesterol (β 0.15, 95% confidence interval (CI) 0.06, 0.24), low-density lipoprotein cholesterol (LDL) (β 0.08, 95% CI 0.01, 0.16), high-density lipoprotein cholesterol (HDL) (β 0.04, 95% CI 0.002, 0.08), apolipoprotein B-100 (β 0.03, 95% CI 0.004, 0.05), and prediabetes (OR 1.80, 95% CI 1.11, 2.91). There was no association between PFAAs and triglycerides, diabetes, or high blood pressure. Long-chain PFAAs congeners were the main contributors driving the associations. Associations were largely linear, and there was no evidence of interaction between the PFAAs congeners.

CONCLUSIONS

Our study provides further evidence of increasing circulating lipids with increased exposure to PFAAs. The increased risk of prediabetes points to the influence of PFAAs on potential clinical outcomes. International regulation of PFAAs is essential to curb PFAAs exposure and related health effects in Arctic communities.

The impact of a stress management intervention including cultural components on stress biomarker levels and mental health indicators among indigenous women

We examined the effectiveness of a 26-week culture-inclusive intervention on reducing salivary stress biomarker levels, and perceived stress, depressive, and post-traumatic stress disorder (PTSD) symptoms measured using scales in 53 Indigenous women in Ontario, Canada. Statistical analyses compared the average biomarker levels, and the area under the curve (AUC) of biomarkers. Differences in biomarkers and mental health scale scores pre- and post-intervention were compared using mixed models with a random intercept. Interaction terms were included between the intervention and age, education, disability, and HIV status, individually, to test for sub-group differences. Cortisol AUC post-intervention was decreased compared to pre-intervention (β -1.29 µg/dL; 95%CI -2.35, -0.23). There was a slight decrease in perceived stress levels (aOR: -2.80; 95%CI -5.09, -0.50). The associations were stronger among women of younger age, higher education, and no disabilities. These interventions can be effective, but future interventions should target Indigenous population sub-groups to address individual needs.

Associations between dietary profiles and perfluoroalkyl acids in Inuit youth and adults

BACKGROUND

Perfluoroalkyl acids (PFAAs), a subset of perfluoroalkyl substances (PFAS), are synthetic chemicals used in industrial and consumer applications. They are exceptionally stable and highly mobile in the environment, and were detected in high concentrations in Arctic wildlife and Nunavik Inuit. The study's objective was to study the association between dietary profiles in Nunavik and plasma PFAAs concentrations.

METHODS

The study used data from the Qanuilirpitaa? 2017 Nunavik Inuit Health Survey (Q2017) (N = 1172) on Inuit adults aged 16-80 years. Nine PFAAs congeners were measured in plasma samples (six were detected). Dietary profiles were identified using latent profile analysis. Two sets of dietary profiles were included; the first included market (store-bought) and country foods (harvested/hunted from the land), and the second included only country foods. Multiple linear regression models regressed log-transformed PFAAs concentrations against the dietary profiles, adjusting for sociodemographic variables.

RESULTS

We identified statistically significant 24.54-57.55 % increases in all PFAAs congeners (PFOA, PFNA, PFDA, PFUnDA, PFHxS, and PFOS) in the dietary profile defined by frequent country food consumption compared to the dietary profile defined by frequent market food consumption. Individuals defined by low consumption of foods (related to food insecurity) had higher concentrations of six PFAAs compared to individuals with frequent market food consumption. The associations were stronger with profiles defined by more frequent country food consumption, and particularly those with increased marine mammal consumption. PFDA, PFUnDA, and PFOS were particularly associated with high country food consumption frequency, such that their concentrations increased by approximately 67-83 % compared to those reporting no or very little consumption of any country foods.

CONCLUSIONS

Increased country food consumption was strongly associated with higher PFAAs concentrations, particularly PFOS, PFDA, and PFUnDA. The results provide further evidence that the quality of country foods is being threatened by PFAAs contamination. Additional national and international regulations are required to protect the Arctic and its inhabitants from these pollutants.

Plasma concentrations of perfluoroalkyl acids and their determinants in youth and adults from Nunavik, Canada

Perfluoroalkyl acids (PFAAs), a subset of per- and poly-fluoroalkyl substances (PFAS), are environmentally stable, mobile and bioaccumulative compounds. This leads to high concentrations in wildlife species essential to the cultural identity and subsistence of Arctic populations. Our objective was to characterize the distribution and exposure determinants of PFAAs among Nunavik Inuit adults. The study included up to 1322 Nunavik residents aged 16-80 years who participated in the Qanuilirpitaa? 2017 Nunavik Inuit Health Survey (Q2017). Plasma concentrations were compared to those the general Canadian population using data from the Canadian Health Measures Survey Cycle 5 (2016-2017). Associations between plasma concentrations of nine PFAAs, determined by liquid chromatography-tandem mass spectrometry, and sociodemographic factors and traditional activity participation were examined using multiple linear regression models. Overall exposure to PFAAs was twice as high compared to the general Canadian population and less regulated perfluorononanoic acid (PFNA) and perfluoroundecanoic acid (PFUnDA) concentrations were 7-fold higher, and perfluorodecanoic acid (PFDA) concentrations were 4-fold higher. Males had higher concentrations of perfluorooctanoic acid (PFOA) and perfluorohexane sulfonate (PFHxS), whereas females had higher concentrations of PFDA and PFUnDA. PFAAs concentrations increased with age and were highest among those aged 60+ years. PFNA and PFOA concentrations followed a J-shaped pattern: those aged 16-29 years had higher concentrations than those aged 20-29 and 30-39 years. Ungava Bay generally had lower concentrations of all PFAAs congeners compared to Hudson Bay and Hudson Strait, with the exception of PFNA, which tended to have the lowest concentration in Hudson Strait. PFAAs concentrations were highly associated with hunting activity, omega-3 polyunsaturated fatty acids, and drinking water from environmental sources. The results highlight the importance of characterizing PFAAs exposure sources in Arctic communities and provide further evidence for the long-range transport of long-chain PFAAs and their precursors that necessitate international action.

Perfluoroalkyl acid and bisphenol-A exposure via food sources in four First Nation communities in Quebec, Canada

OBJECTIVE

To document perfluoroalkyl acids (PFAA) and bisphenol-A (BPA) exposure in four First Nation communities in northern Quebec compared with the Canadian Health Measures Survey (CHMS Cycle 5 2016-2017) and examine the associations between dietary consumption and chemical exposure.

DESIGN

We used cross-sectional data from the JES-YEH! project conducted in collaboration with four First Nation communities in 2015. A FFQ collected information on diet, and PFAA and BPA were measured in biological samples. We used generalised linear models to test the associations between food intake and chemical biomarkers.

SETTING

Northern Quebec.

PARTICIPANTS

Youth aged 3-19 years (n 198).

RESULTS

Mean perfluorononanoic acid (PFNA) levels were significantly higher in JES-YEH! than CHMS, and BPA levels were higher among those aged 12-19 years compared with CHMS. Dairy products were associated with PFNA among Anishinabe and Innu participants (geometric mean ratio 95 % CI: 1·53 (95 % CI 1·03, 2·29) and 1·52 (95 % CI 1·05, 2·20), respectively). PFNA was also associated with ultra-processed foods (1·57 (95 % CI 1·07, 2·31)) among Anishinabe, and with wild fish and berries (1·44 (95 % CI 1·07, 1·94); 1·75 (95 % CI 1·30, 2·36)) among Innu. BPA was associated with cheese (1·72 (95 % CI 1·19, 2·50)) and milk (1·53 (95 % CI 1·02, 2·29)) among Anishinabe, and with desserts (1·71 (95 % CI 1·07, 2·74)), processed meats (1·55 (95 % CI 1·00, 2·38)), wild fish (1·64 (95 % CI 1·07, 2·49)) and wild berries (2·06 (95 % CI 1·37, 3·10)) among Innu.

CONCLUSIONS

These results highlight the importance of better documenting food-processing and packaging methods, particularly for dairy products, and their contribution to endocrine disruptors exposures as well as to promote minimally processed and unpackaged foods to provide healthier food environments for youth in Indigenous communities and beyond.

Lipoprotein(a) testing in clinical practice: real-life data from a large health-care provider

Background

Evidence support a causal role of lipoprotein(a) [Lp(a)] in the development of atherosclerotic cardiovascular disease (ASCVD). Novel treatment options are emerging and recent guidelines recommend screening Lp(a) levels at least once during lifetime. However, significant variance exists regarding the incorporation of Lp(a) into patient care.

Purpose

To investigate patterns of Lp(a) measurement in a large health maintenance organization (HMO) and describe clinical characteristics associated with elevated Lp(a) levels.

Methods

Retrospective analysis of all Lp(a) laboratory tests performed between January 2015 and December 2021 in a single HMO providing health care for approximately 4.6 million insured members.

Results

Overall, 4,539 individuals were tested for Lp(a). Analysis was limited to the adult population (n=3900). Number of persons tested yearly increased progressively from 89 in the year 2015 to 1523 in 2021. Mean age was 55±15 years (39% females), 15% had family history of coronary disease, 40% ischemic heart disease, 7% prior stroke and 9% peripheral artery disease (PAD). Baseline low-density lipoprotein cholesterol (LDL-C) &gt;190 mg/dl was evident in 21% of patients. Lp(a) level &gt;125 nmol/l (∼50 mg/dl) was noted in 21.5%. In a multivariable logistic regression model, prior myocardial infarction (odds ratio 1.38, 95% confidence interval 1.16–1.64), PAD (1.29, 1–1.68), peak LDL-C&gt;190 mg/dl (1.35, 1.12–1.62) and use of statins (1.54, 1.28–1.85), were independently associated with elevated Lp(a) levels &gt;125 nmol/l, whereas an inverse association was seen with obesity (0.74, 0.62–0.88). Of the patients with elevated Lp(a), 72.4% were treated with statin and/or ezetimibe and 1.9% with PCSK9 inhibitors.

Conclusions

The reporting of Lp(a) levels is increasing, though it is still measured in a small portion of the population. Presence of ASCVD and severe hyperlipidemia may identify patients that should be considered for screening for increased Lp(a) levels. The use of PCSK9 inhibitors in those with elevated Lp(a) is yet considerably low.

Funding Acknowledgement

Type of funding sources: None.

Association between pre-pregnancy multimorbidity and adverse maternal outcomes: A systematic review

Objective

We reviewed the literature on the association between pre-pregnancy multimorbidity (co-occurrence of two or more chronic conditions) and adverse maternal outcomes in pregnancy and postpartum.

Data sources

Medline, EMBASE, and CINAHL were searched from inception to September, 2021.

Study selection

Observational studies were eligible if they reported on the association between ≥ 2 co-occurring chronic conditions diagnosed before conception and any adverse maternal outcome in pregnancy or within 365 days of childbirth, had a comparison group, were peer-reviewed, and were written in English.

Data extraction and synthesis

Two reviewers used standardized instruments to extract data and rate study quality and the certainty of evidence. A narrative synthesis was performed.

Results

Of 6,381 studies retrieved, seven met our criteria. There were two prospective cohort studies, two retrospective cohort studies, and 3 cross-sectional studies, conducted in the United States (n=6) and Canada (n=1), and ranging in size from n=3,110 to n=57,326,681. Studies showed a dose-response relation between the number of co-occurring chronic conditions and risk of adverse maternal outcomes, including severe maternal morbidity or mortality, hypertensive disorders of pregnancy, and acute health care use in the perinatal period. Study quality was rated as strong (n=1), moderate (n=4), or weak (n=2), and the certainty of evidence was very low to moderate.

Conclusion

Given the increasing prevalence of chronic disease risk factors such as advanced maternal age and obesity, more research is needed to understand the impact of pre-pregnancy multimorbidity on maternal health so that appropriate preconception and perinatal supports can be developed.

Blood pressure response during treadmill exercise testing and the risk for future development of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Aims

Hypertension is a well-established risk factor for the onset and progression of atrial fibrillation (AF). Blood pressure (BP) response during routine exercise stress testing (EST) may identify subjects at increased risk for developing AF.

Methods

A retrospective analysis of treadmill EST performed by the Bruce protocol in patients aged ≥40 years without a history of AF (n=17,617; 42% women). BP was measured at rest, peak exercise, and 2-minute recovery, and was analyzed for association with the risk for developing AF.

Results

AF was documented in 4.5% of patients during mean follow-up of 7 years. The incidence rate of AF per 1000 person-years increased with the rise in CHA2DS2VASc score (3.26 in score=0 to 19.78 in scores≥6). Adjusting for CHA2DS2VASc score and exercise capacity, a multivariate analysis of systolic BP at rest (≥130 vs. ≤110 mmHg), peak-exercise (&gt;170 vs. ≤150 mmHg), and recovery (&gt;150 vs. ≤130 mmHg), were associated with increased risk for AF: hazard ratio (HR) 1.68 (95% CI, 1.40-2.01), 1.38 (1.15-1.64), 1.54 (1.27-1.86), respectively. Similarly, diastolic BP analysis at rest (≥90 vs. &lt;80 mmHg), peak-exercise (≥100 vs. &lt;90 mmHg), and recovery (&gt;90 vs. ≤80 mmHg), were associated with increased risk for AF: 1.78 (1.34-2.35), 2.22 (1.37-3.59), 1.73 (0.90-3.25). The association with AF was also observed when BPs were analyzed as continuous variables, including after additional adjustment of exercise and recovery measurements to resting BP.

Conclusions

Systolic and diastolic BP at rest, peak-exercise and recovery phases of EST may provide independent predictive information regarding future risk for developing AF.

Non-persistent exposures from plasticizers or plastic constituents in remote Arctic communities: a case for further research

BACKGROUND

Persistent organic pollutant exposures are well-documented in the Arctic, but fewer studies examined non-persistent chemicals, despite increased market food and consumer product consumption.

OBJECTIVE

To measure phenol, paraben, phthalate, and alternative plasticizer concentrations in Inuit adults.

METHODS

The study included 30 pooled urine samples from Qanuilirpitaa? 2017 Nunavik Inuit Health Survey (Q2017) participants. Creatinine-adjusted geometric mean concentrations (GM) and 95% confidence intervals (CI) were compared across sex, age, and regions, and compared to those in the Canadian Health Measures Survey (CHMS) and the First Nations Biomonitoring Initiative (FNBI).

RESULTS

Q2017 bisphenol-A concentrations were double the CHMS 2018-2019 concentrations [GM (95% CI): 1.98 (1.69-2.31) versus 0.71 (0.60-0.84) µg/g creatinine], but in line with FNBI [1.74 (1.41-2.13) µg/g creatinine]. Several phthalate concentrations were higher in Q2017 versus CHMS, particularly monobenzyl phthalate, which was was 19-fold higher in Q2017 versus CHMS 2018-2019 [45.26 (39.35-52.06) versus 2.4 (2.0-2.9) µg/g creatinine] and four-fold higher than FNBI. There were also four-fold higher concentrations of the two alternate plasticizer 2,2,4-trimethyl-1,3-pentanediol diisobutyrate (TIXB) metabolites in Q2017 compared to CHMS 2018-2019. Women and people living in Ungava Bay had generally higher concentrations of non-persistent chemicals.

SIGNIFICANCE

The results suggest higher concentrations of certain non-persistent chemicals in Inuit versus the general Canadian population.

IMPACT

Few studies have explored non-persistent chemical distributions in Northern communities, despite the increasing consumer product and market food consumption. We analyzed 30 pooled samples from the Qanuilirpitaa? Nunavik Inuit Health Survey 2017 to assess exposures to common plasticizes and plastic constituents and compare their levels with the general Canadian population and First Nation groups. We observed particularly higher levels of bisphenol-A, of monobenzyl phthalate, and of two 2,2,4-trimethyl-1,3-pentanediol diisobutyrate (TXIB) metabolites among Nunavimmiut compared to the general Canadian population, notably among women and Ungava Bay residents. Larger studies are required to confirm our findings and identify potential adverse health effects from these exposures.

Exposure to benzene, toluene and polycyclic aromatic hydrocarbons in Nunavimmiut aged 16 years and over (Nunavik, Canada) - Qanuilirpitaa 2017 survey

There are numerous volatile organic compounds (VOCs) and polycyclic aromatic hydrocarbons (PAHs) that Inuit may be exposed to from combustion, cooking, heating, vehicle exhaust, active and passive smoking and other local sources of contaminants such as oil spills or open-air burning in landfills. To better assess the levels of exposure to these non-persistent chemicals, we measured a suite of benzene, toluene (two VOCs) and PAHs metabolites in pooled urine samples from youth and adults aged 16 years old and over who participated in the Qanuilirpitaa? 2017 Inuit Health Survey (Q2017), a population health survey conducted in Nunavik. A cost-effective pooling strategy was established and 30 different pools from individual urine samples (n = 1266) were created by grouping individual urine samples by sex, age groups and regions. To assess smoking and exposure to second-hand smoke, cotinine levels were measured in individual urine samples. We found that benzene, toluene, all detected PAHs metabolites and cotinine levels were significantly higher in Q2017 compared to adults in the Canadian Health Measure Survey Cycle 4 (2014-2015) or the general U.S population (2015-2016). Moreover, mean levels of one benzene metabolite, S-phenylmercapturic acid, and several PAHs metabolites, 1-naphthol, 2-and 3-hydroxyfluorene, and 4- and 9-hydroxyphenanthrene, known to be associated with smoking habits, were higher in Q2017 compared to reference values (RV₉₅) established for non-smokers in the general Canadian population. Furthermore, benzene and PAHs metabolites were all correlated with cotinine levels. Our results suggest that the high smoking prevalence in Nunavik is an important contributor to the elevated benzene and PAHs exposure. Other local sources may add to that exposure, although we were not able to account for their contribution. These data highlight the importance of regional and community efforts for reducing smoking and to encourage smoke-free homes in Nunavik, while continuing to investigate and reduce other possible local sources of exposure to benzene, toluene and PAHs.

Does incidental calcium deposition in non-cardiac CT scans predict cardiovascular morbidity and mortality in young adults? A retrospective study

Background

The calcium score in cardiac CT scan represents an effective tool in the diagnosis of coronary artery disease. However, few studies have examined the value of incidental arterial calcification (AC) in non-cardiac CT scans, especially in young adults with no prior cardiovascular morbidity.

Purpose

To evaluate the association between incidental AC and the incidence of cardiovascular events, as well as the association between atherosclerotic risk factors and AC in young adults with no known cardiovascular disease.

Methods

A retrospective study in patients aged 40–50 years old with no history of cardiovascular disease that underwent chest CT scan between 1.9.2012–31.8.2013 for reasons not related to cardiovascular disease. We assessed the presence of AC in the aorta and coronary arteries and its association with the rates of coronary catheterization for acute coronary syndrome (CCACS), emergency room (ER) visits or hospitalizations for cardiovascular disease and cardiac mortality. Furthermore, we examined the association between atherosclerotic risk factors (hypertension, smoking, hyperlipidemia and diabetes) and AC.

Results

308 patients were included in the study, 150 men and 158 women with average follow-up period of 7.2+0.29 years. AC was found in 88 (28.6%) patients. AC was more frequent in men than in women (35% vs. 20.9%, OR=2.18, P=0.006). Patients with AC underwent more CCACS than those without (11.6% vs. 0.5%, OR = 29.1, P=0.0001). Patients with AC had more ER and hospital admissions (33.7% vs. 14.4%, P&lt;0.0001, OR=3). Individuals with hypertension, smoking, and hyperlipidemia exhibited higher rates of AC (OR=2.66, 4, and 1.9, respectively). A statistically significant excess mortality in those with AC was not demonstrated (P=0.076).

Conclusion

AC appears to be associated with cardiovascular morbidity and increased incidence of CCACS. Primary preventive strategies in patients with AC may reduce cardiovascular morbidity.

Funding Acknowledgement

Type of funding sources: None.

The impact of glomerular filtration rate estimation on cardiovascular events in elderly patients undergoing coronary angiography

Objectives

Estimation of kidney function by glomerular filtration rate (eGFR) is affected by age and is important for decision making regarding treatment and prognosis of patients with cardiovascular disease. We aimed to investigate the impact of eGFR on long-term cardiovascular outcomes in an elderly population undergoing coronary angiography for evaluation or treatment of coronary artery disease.

Methods

GFR was estimated according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in 3,690 elderly patients (aged 70–100 years) undergoing coronary angiography. Patients receiving maintenance dialysis were excluded. The association between eGFR and long-term major adverse cardiovascular events (MACE) including myocardial infarction, ischemic stroke or death, was investigated. GFR was further calculated according to Modification of Diet in Renal Disease (MDRD) and the Cockroft-Gault equations, and compatibility between estimations was analyzed.

Results

Cardiovascular comorbidities were more prevalent with the reduction in kidney function as was the proportion of patients presenting with acute coronary syndromes. The adjusted hazard ratio (95% confidence interval) for MACE during a mean follow-up of 5 years was 0.98 (0.80–1.19), 1.05 (0.85–1.30), 1.45 (1.15–1.82), 2.20 (1.64–2.95) and 3.87 (2.28–6.58) in patients with eGFR 60–89, 45–59, 30–44, 15–29 and &lt;15 ml/min/1.73m2, respectively, compared to eGFR &gt;90 ml/min/1.73m2. Reclassification of eGFR stages by MDRD (upward 23.8%, downward 0.4%) and Cockroft-Gault (upward 4.3%, downward 28.1%) compared to CKD-EPI estimation, was noted. However, the association between eGFR stages and MACE was similar between equations.

Conclusions

Kidney function, as manifested by eGFR, has a graded inverse association with the burden of cardiovascular comorbidities and long-term adverse events in elderly patients undergoing coronary angiography.

Funding Acknowledgement

Type of funding sources: None.

Blood pressure response during treadmill exercise testing and the risk for future cardiovascular events and new-onset hypertension

Background

Although there is a diminishing role of exercise stress testing (EST) in the diagnostic assessment of coronary heart disease, the physiologic response to exercise may provide valuable prognostic information. We aimed to investigate the association of repeated blood pressure (BP) measurements during EST with long-term risk of myocardial infarction, stroke or death (MACE), as well as the development of new-onset hypertension.

Methods

Retrospective analysis of EST performed between the years 2005–2019 in a single center according to Bruce protocol. Included were patients aged 35–75 years without a history of cardiovascular disease (n=14,792; 48% women). BP was documented at rest, submaximal exercise (Bruce stage-2), peak exercise and recovery (2 minutes). Association of BP measures with study outcomes during a median follow-up of 78 months was investigated.

Results

An increment of 10-mmHg in rest, submaximal, peak and recovery systolic BP was each associated with a significant increase in the hazard ratio (HR) and 95% confidence interval (CI) for MACE: 1.09 (1.04–1.14), 1.06 (1.01–1.10), 1.04 (1.01–1.08), and 1.06 (1.02–1.10), respectively, after adjustment including exercise capacity, medications and resting BP. The association between SBP at submaximal exercise and recovery with MACE had a J-shaped appearance (Figure). Among non-hypertensive patients without BP lowering medications (n=8,529), 13% were diagnosed with new-onset hypertension during follow-up. Excessive systolic BP response to peak exercise (≥190 mmHg in women and ≥210 mmHg in men) was an independent predictor of future hypertension [HR (95% CI)]: 1.87 (1.41–2.48), as were systolic BPs during submaximal exercise [&gt;160 vs. ≤130 mmHg: 2.44 (1.97–3.03)] and recovery [≥140 vs. ≤120 mmHg: 1.65 (1.37–1.98)], showing gradual, incremental association with the risk for developing hypertension.

Conclusions

BP measurement during exercise and recovery phases of treadmill testing provides incremental prognostic information regarding long-term risk for cardiovascular events and the probability for developing future hypertension.

Funding Acknowledgement

Type of funding sources: None.

Psychosocial status modifies the effect of maternal blood metal and metalloid concentrations on birth outcomes

BACKGROUND

Metal exposure and psychosocial stress in pregnancy have each been associated with adverse birth outcomes, including preterm birth and low birth weight, but no study has examined the potential interaction between them.

OBJECTIVES

We examined the modifying effect of psychosocial stress on the association between metals and birth outcomes among pregnant women in Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) birth cohort study.

METHODS

In our analysis of 682 women from the PROTECT study, we measured 16 essential and non-essential metals in blood samples at two time points. We administered questionnaires to collect information on depression, perceived stress, social support, and life experience during pregnancy. Using K-means clustering, we categorized pregnant women into one of two groups: "good" and "poor" psychosocial status. We then evaluated whether the effect of blood metals (geometric average) on adverse birth outcomes (gestational age, preterm birth [overall and spontaneous], birth weight z-score, small for gestation [SGA], large for gestation [LGA]) vary between two clusters of women, adjusting for maternal age, maternal education, pre-pregnancy body mass index (BMI), and second-hand smoke exposure.

RESULTS

Blood manganese (Mn) was associated with an increased odds ratio (OR) of overall preterm birth (OR/interquartile range [IQR] = 2.76, 95% confidence interval [CI] = 1.25, 6.12) and spontaneous preterm birth (OR/IQR: 3.68, 95% CI: 1.20, 6.57) only among women with "poor" psychosocial status. The association between copper (Cu) and SGA was also statistically significant only among women having "poor" psychosocial status (OR/IQR: 2.81, 95% CI: 1.20, 6.57). We also observed associations between nickel (Ni) and preterm birth and SGA that were modified by psychosocial status during pregnancy.

CONCLUSIONS

Presence of "poor" psychosocial status intensified the adverse associations between Mn and preterm birth, Cu and SGA, and protective effects of Ni on preterm. This provides evidence that prenatal psychosocial stress may modify vulnerability to metal exposure.

Interactions between chemicals and non-chemical stressors: The modifying effect of life events on the association between triclocarban, phenols and parabens with gestational length in a Puerto Rican cohort

BACKGROUND

Phenols and parabens are common additives to consumer products. There is evidence of adverse birth outcomes in association with prenatal exposure to these chemicals, in addition to psychosocial factors. We previously reported an increase in gestational length with bisphenol-A, methylparaben and propylparaben, and a decrease in gestational length with triclocarban.

OBJECTIVES

We examined the modifying effect of psychosocial stress on the association between chemicals and gestational length in up to 752 women among a pregnancy cohort study.

METHODS

Urinary biomarkers were measured at up to three time points in pregnancy. Multiple linear regression models were conducted to investigate the association between gestational length and the interaction between average exposure biomarkers and LES. Multiple linear regression models regressing the exposure biomarkers in relation to gestational length were also stratified by LES, Negative LES, and Positive LES, based on the subjective ratings of events. Results were transformed into the change in gestational length for an inter-quartile-range difference in the exposure.

RESULTS

Of the four psychosocial stress measures, only the life events score (LES) was a significant modifier. Associations between triclocarban, bisphenol-S, methyl- and propylparaben in relation to gestational length were stronger among women with negative Total LES scores. Among women with negative Total LES scores, bisphenol-S and triclocarban were associated with a 3-5 day decrease in gestational length [(-3.15; 95% CI: -6.06, -0.24); (-4.68; 95% CI: -8.47, -0.89)], whereas methylparaben and propylparaben were associated with a 2-3 day increase in gestational length [(2.21; 95% CI: 0.02, 4.40); (2.92; 95% CI: 0.58, 5.26)]. Significant interactions were driven by negative life events, but the association with triclocarban was driven by few positive life events.

CONCLUSIONS

Associations between exposure biomarkers and gestational length were stronger in the presence of negative life events. This provides evidence that stress makes the body more vulnerable to chemical exposure.

Correlation between birth weight, leptin, zinc and copper levels in maternal and cord blood

Leptin and zinc are involved in the regulation of appetite. Copper is a trace element regulating the functions of several cuproenzymes that are essential for life. To evaluate the relationship between zinc and copper status and the leptin system in humans, we examined whether leptin concentrations in the mother and the newborn correlate with the weight of mother, placenta and newborn. A total of 88 pregnant women at 38-42 weeks' gestation were studied. All infants were categorized as small for gestational age (SGA) (n = 16), average for gestational age (AGA) (n = 59) or large for gestational age (LGA) (n = 13). Leptin, zinc, and copper levels were measured in maternal and cord serum at birth. Maternal BMI and placental weight of the LGA groups were significantly higher than those of the SGA and AGA groups. Cord and maternal leptin levels of the SGA groups were significantly lower than those of the AGA and LGA groups. Maternal serum leptin levels were positively correlated with BMI and maternal zinc levels in all groups. Cord serum leptin levels of all groups were positively correlated with birth weight and placental weight. Birth weight was negatively correlated with maternal and cord copper level of all groups. Umbilical leptin concentrations of SGA newborns correlated with leptin concentrations of their mothers. In all pregnancies, birth weight increases in association with increase in cord leptin level. Our results suggest that maternal zinc but not copper level has an effect on maternal serum leptin levels. The increase in copper level in both maternal and cord blood may contribute to restriction in fetal growth.

Simultaneous bilateral trochanteric fractures during squatting in a patient with multiple myeloma

Pathologic bone fractures are usually confined to the trunk in multiple myeloma (MM). But bilateral trochanteric fractures have not been reported in patients with MM before. Radiographic, histological and immunoelectrophoresis revealed typical features of MM. This report points out the importance of physical rehabilitation of patients in addition to chemotherapy in adaptation to the activities of daily living.

Changes in human plasma dopamine-beta-hydroxylase activity after ketamine and halothane anesthesia

The intravenous administration of ketamine hydrochloride to fifteen patients undergoing surgery produced no change in circulating plasma dopamine-beta-hydroxylase (DBH), although it produced a significant increase both in systolic blood pressure (BP) and diastolic BP during anesthesia. Halothane anesthesia that depress BP also produced no change in plasma DBH activity.