New technological devices for the assessment of systemic inflammation in the primary prevention of cardiovascular disease.

PURPOSE OF REVIEW: The prediction of cardiovascular disease (CVD) events is of strategic importance for the primary prevention of one of the big killers in the world. Predictive models have a history of decades, but still the desired accuracy is not reached by any of the existing models. The inclusion of inflammatory factors in the models did not increase their accuracy. In this review, we discuss the possible reasons for that failure and we propose a paradigm shift. RECENT FINDINGS: Systemic inflammation is a very volatile phenomenon. The blood concentration of inflammatory biomarkers may change considerably in one individual with a timescale of seconds. Sudden changes in environmental conditions can trigger rapid modifications in the inflammatory profile of an individual. In routine clinical practice, the blood tests for inflammation are carried out at one point in time, not in standard environmental conditions, and are therefore inadequate. SUMMARY: We have to direct CVD research toward the understanding of the synchronic relationship between external environmental conditions and internal physiological reactions. CVD risk assessment must be carried out by using continuous real-time monitoring of external and internal parameters together, something that may become possible with the advent of new technological devices

The combined association of psychological distress and socioeconomic status with all-cause mortality: a national cohort study.

BACKGROUND: Psychological distress and low socioeconomic status (SES) are recognized risk factors for mortality. The aim of this study was to test whether lower SES amplifies the effect of psychological distress on all-cause mortality. METHODS: We selected 66 518 participants from the Health Survey for England who were 35 years or older, free of cancer and cardiovascular disease at baseline, and living in private households in England from 1994 to 2004. Selection used stratified random sampling, and participants were linked prospectively to mortality records from the Office of National Statistics (mean follow-up, 8.2 years). Psychological distress was measured using the 12-item General Health Questionnaire, and SES was indexed by occupational class. RESULTS: The crude incidence rate of death was 14.49 (95% CI, 14.17-14.81) per 1000 person-years. After adjustment for age and sex, psychological distress and low SES category were associated with increased mortality rates. In a stratified analysis, the association of psychological distress with mortality differed with SES (likelihood ratio test-adjusted P < .001), with the strongest associations being observed in the lowest SES categories. CONCLUSIONS: The detrimental effect of psychological distress on mortality is amplified by low SES category. People in higher SES categories have lower mortality rates even when they report high levels of psychological distress

The associations between unhealthy behaviours, mental stress, and low socio-economic status in an international comparison of representative samples from Thailand and England.

BACKGROUND: Socioeconomic status is a recognised determinant of health status, and the association may be mediated by unhealthy behaviours and psychosocial adversities, which, in developed countries, both aggregate in low socioeconomic sectors of the population. We explored the hypothesis that unhealthy behavioural choices and psychological distress do not both aggregate in low socioeconomic status groups in developing countries. METHODS: Our study is based on a cross-sectional comparison between national population samples of adults in England and Thailand. Psychological distress was assessed using the General Health Questionnaire (GHQ-12) or three anxiety-oriented items from the Kessler scale (K6). Socioeconomic status was assessed on the basis of occupational status. We computed a health-behaviour score using information about smoking, alcohol consumption, fruit and vegetable consumption, and physical activity. RESULTS: The final sample comprised 40,679 participants. In both countries and in both genders separately, there was a positive association between poor health-behaviour and high psychological distress, and between high psychological distress and low socioeconomic status. In contrast, the association between low socioeconomic status and poor health-behaviour was positive in both English men and women, flat in Thai men, and was negative in Thai women (likelihood ratio test P <0.001). CONCLUSION: The associations between socioeconomic status, behavioural choices, and psychological distress are different at the international level. Psychological distress may be consistently associated with low socioeconomic status, whereas poor health-behaviour is not. Future analyses will test whether psychological distress is a more consistent determinant of socioeconomic differences in health across countries

Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand.

BACKGROUND: Most research on the influence of psychosocial job characteristics on health status has been conducted within affluent Western economies. This research addresses the same topic in a middle-income Southeast Asian country, enabling comparison with a Western benchmark. METHODS: We analysed and compared the Health Survey for England conducted in 2010 and the Thai Cohort Study data at 2005 baseline for workers aged 35-45 years. Multivariate logistic regression was used to assess relationships between psychosocial job characteristics and health, measured as Adjusted Odd Ratios (AOR), controlling for potential covariates in final analyses. RESULTS: In both UK and Thai working adults, psychological distress was associated with job insecurity (AOR 2.58 and 2.32, respectively), inadequate coping with job demands (AOR 2.57 and 2.42), and low support by employers (AOR 1.93 and 1.84). Job autonomy was associated with psychological distress in the UK samples (AOR 2.61) but no relationship was found among Thais after adjusting for covariates (AOR 0.99). Low job security, inability to cope with job demands, and low employer support were associated with psychological distress both among Thai and UK workers. CONCLUSIONS: Job autonomy was an important part of a healthy work environment in Western cultures, but not in Thailand. This finding could reflect cultural differences with Thais less troubled by individualistic expression at work. Our study also highlights the implications for relevant workplace laws and regulations to minimise the adverse job effects. These public health strategies would promote mental health and wellbeing in the population

The mediation of coronary calcification in the association between risk scores and cardiac troponin T elevation in healthy adults: Is atherosclerosis a good prognostic precursor of coronary disease?

BACKGROUND: Conventional cardiac risk scores may not be completely accurate in predicting acute events because they only include factors associated with atherosclerosis, considered as the fundamental precursor of cardiovascular disease. In UK in 2006-2008 (Whitehall II study) we tested the ability of several risk scores to identify individuals with cardiac cell damage and assessed to what extent their estimates were mediated by the presence of atherosclerosis. METHODS: 430 disease-free, low-risk participants were tested for high-sensitivity cardiac troponin-T (HS-CTnT) and for coronary calcification using electron-beam, dual-source, computed tomography (CAC). We analysed the data cross-sectionally using ROC curves and mediation tests. RESULTS: When the risk scores were ranked according to the magnitude of ROC areas for HS-CTnT prediction, a score based only on age and gender came first (ROC area=0.79), followed by Q-Risk2 (0.76), Framingham (0.70), Joint-British-Societies (0.69) and Assign (0.68). However, when the scores were ranked according to the extent of mediation by CAC (proportion of association mediated), their order was essentially reversed (age&gender=6.8%, Q-Risk2=9.7%, Framingham=16.9%, JBS=17.8%, Assign=17.7%). Therefore, the more accurate a score is in predicting detectable HS-CTnT, the less it is mediated by CAC; i.e. the more able a score is in capturing atherosclerosis the less it is able to predict cardiac damage. The P for trend was 0.009. CONCLUSIONS: The dynamics through which cardiac cell damage is caused cannot be explained by 'classic' heart disease risk factors alone. Further research is needed to identify precursors of heart disease other than atherosclerosis

Introduction of laparoscopic bariatric surgery in England: observational population cohort study.

OBJECTIVES: To describe national trends in bariatric surgery and examine the factors influencing outcome in bariatric surgery in England. DESIGN: Observational population cohort study. SETTING: Hospital Episode Statistics database. PARTICIPANTS: All patients who had primary gastric bypass, gastric banding, or sleeve gastrectomy procedures between April 2000 and March 2008. MAIN OUTCOME MEASURES: 30 day mortality, mortality at one year after surgery, unplanned readmission to hospitalwithin 28 days, and duration of stay in hospital. RESULTS: 6953 primary bariatric procedures were carried out during the study period, of which 3649 were gastric band procedures, 3191 were gastric bypass procedures, and 113 were sleeve gastrectomy procedures. A marked increase occurred in the numbers of bariatric procedures done, from 238 in 2000 to 2543 in 2007, with an increase in the percentage of laparoscopic procedures over the study period (28% (66/238) laparoscopic procedures in 2000 compared with 74.5% (1894/2543) in 2007). Overall, 0.3% (19/6953) patients died within 30 days of surgery. The median length of stay in hospital was 3 (interquartile range 2-6) days. An unplanned readmission to hospital within 28 days of surgery occurred in 8% (556/6953) of procedures. No significant increase in mortality or unplanned readmission was seen over the study period, despite the exponential increase in minimal access surgery and consequently bariatric surgery. CONCLUSIONS: Bariatric surgery has increased exponentially in England. Although postoperative weight loss and reoperation rates were not evaluated in this observational population cohort study, patients selected for gastric banding had lower postoperative mortality and readmission rates and a shorter length of stay than did those selected for gastric bypass

Inequalities in Stroke Patients' Management in English Public Hospitals: A Survey on 200,000 Patients

Background: According to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the study: To describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.Methods: We collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.Results: In English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P < 0.001), male (P=0.012), and least socio-economically deprived patients (P=0.001), as well as patients with fewer comorbidities (P < 0.001) appear to have more chance of being selected for a brain scan.Conclusion: Some English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities

The association between fibrinogen reactivity to mental stress and high-sensitivity cardiac troponin T in healthy adults

BACKGROUND: Plasma fibrinogen is considered as a positive mediator between mental stress and cardiovascular disease because it is an acute-phase protein released in response to mental stress and a coagulation factor. However those three factors have never been studied together within a single integrated framework, using cardiac troponin T as a marker of cardiovascular risk. METHODS: 491 disease-free men and women aged 53-76 were tested for fibrinogen levels before, immediately after, and following recovery from standardized mental stress tasks. We measured plasma cardiac troponin T using a high-sensitivity assay (HS-CTnT) and coronary calcification using electron-beam dual-source computed tomography. RESULTS: The average fibrinogen concentration increased by 5.1% (s.d.=7.3) in response to stress and then tended to return to baseline values. People with higher baseline fibrinogen values had smaller increases (blunted responses) following the stress task (P=0.001), and people with higher stress responses showed better recovery (P<0.001). In unadjusted analyses, higher baseline fibrinogen was associated with higher chances of having detectable HS-CTnT (P=0.072) but, conversely, higher fibrinogen response was associated with lower chances of having detectable HS-CTnT (P=0.007). The adjustment for clinical, inflammatory, and haemostatic factors, as well as for coronary calcification eliminated the effect of baseline fibrinogen, whereas the negative association between fibrinogen response and HS-CTnT remained robust: the odds of detectable HS-CTnT halved for each 10% increase in fibrinogen concentration due to stress (OR=0.49, P=0.007, 95% CI=0.30-0.82). CONCLUSIONS: Greater fibrinogen responses to mental stress are associated with lower likelihood of detectable high-sensitivity troponin T plasma concentration. A more dynamic fibrinogen response appears to be advantageous for cardiovascular health

Risk factors for endocrine complications in transfusion-dependent thalassemia patients on chelation therapy with deferasirox: a risk assessment study from a multicentre nation-wide cohort

Transfusion-dependent patients typically develop iron-induced cardiomyopathy, liver disease, and endocrine complications. We aimed to estimate the incidence of endocrine disorders in transfusion-dependent thalassemia (TDT) patients during long-term iron-chelation therapy with deferasirox (DFX).We developed a multicentre follow-up study of 426 TDT patients treated with once-daily DFX for a median duration of 8 years, up to 18.5 years. At baseline, 118, 121, and 187 patients had 0, 1, or ≥2 endocrine diseases respectively. 104 additional endocrine diseases were developed during the follow-up. The overall risk of developing a new endocrine complication within 5 years was 9.7% (95%CI=6.3-13.1). Multiple Cox regression analysis identified 3 key predictors: age showed a positive log-linear effect (adjusted HR for 50% increase=1.2, 95%CI=1.1-1.3, P=0.005), the serum concentration of thyrotropin (TSH) showed a positive linear effect (adjusted HR for 1 mIU/L increase=1.3, 95%CI=1.1-1.4, P