Clinical characteristics and pertussis costs in cases reported to epidemiological services and cases detected in household contacts in Catalonia (Spain).

PURPOSE: To assess the clinical characteristics and direct health costs associated with pertussis cases reported to and confirmed by epidemiological services and cases detected among household contacts in Catalonia (Spain) in 2012-2013. METHODS: All pertussis cases confirmed by the epidemiological services (n = 641) and all cases detected among the household contacts (n = 422) were included in the study. The chi-square test and odds ratios were used to compare percentages and the t-test was used to compare mean pertussis costs, with p < 0.05 being considered statistically significant. RESULTS: Cases reported to epidemiological services had a higher percentage of hospitalizations (OR = 32.2, p < 0.001) and severe disease (OR = 27.7, p < 0.001) than cases detected among the household contacts. The total health costs associated with pertussis cases were €871,648, €799,704 (92 %) for cases reported to epidemiological services and €71,944 (8 %) for cases detected among the household contacts. Total treatment, detection, and quimiprophylaxis costs were € 809,702, € 44,312, and € 17,635, representing 92.5 %, 5.5 %, and 2 % of total pertussis costs respectively. The mean costs were significantly higher (p < 0.001) in cases reported to epidemiological services than in cases detected among the household contacts, for all cases (€1248 vs €170), and for severe (€4546 vs €1073), moderate (€204 vs €165), and mild (€153 vs €133) disease. CONCLUSIONS: The burden of pertussis in Catalonia was high in terms of health costs, especially in infants aged less than 1 year. Active epidemiological surveillance activities could prevent pertussis transmisison and reduce pertussis costs.

Effectiveness of acellular pertussis vaccination during childhood (<7 years of age) for preventing pertussis in household contacts 1-9 years old in Catalonia and Navarra (Spain).

Pertussis vaccination with 4-5 doses of acellular vaccines is recommended in Spain to all children at 2 months to 6 years of age. The effectiveness of the acellular pertussis vaccination was assessed in this study by comparing the incidence of secondary pertussis in vaccinated (4-5 doses) and unvaccinated or partially vaccinated (0-3 doses) household contacts 1-9 years old of confirmed cases of pertussis in Spain in 2012-13. Eighty-five percent of contacts had been vaccinated with 4-5 doses of acellular pertussis vaccines. During the 2-year study period, 64 cases of secondary pertussis were detected among 405 household contacts 1-9 years old: 47 among vaccinated and 17 among unvaccinated or partially vaccinated contacts. The effectiveness for preventing secondary pertussis, calculated as 1 minus the relative risk (RR) of secondary pertussis in vaccinated vs. unvaccinated/partially vaccinated contacts, was 50 % [95 % confidence interval (CI): 19-69 %, p < 0.01] when household contacts were vaccinated using DTaP, Tdap, hexavalent or heptavalent vaccines, and it was 51.3 % (95 % CI: 21-70 %, p < 0.01) when they were vaccinated using DTaP or TdaP vaccines. The effectiveness adjusted for age, sex, pertussis chemotherapy and type of household contact was 58.6 % (95 % CI: 17-79 %, p < 0.05) when contacts were vaccinated using available acellular vaccines, and it was 59.6 % (95 % CI: 18-80 %, p < 0.01) when they were vaccinated using DTaP vaccines. Acellular pertussis vaccination during childhood was effective for preventing secondary pertussis in household contacts 1-9 years old of pertussis cases in Catalonia and Navarra, Spain.

Prevalence of anti-rubella, anti-measles and anti-mumps IgG antibodies in neonates and pregnant women in Catalonia (Spain) in 2013: susceptibility to measles increased from 2003 to 2013.

Non-immune neonates and non-immune pregnant women are at risk of developing rubella, measles and mumps infections, including congenital rubella syndrome. We describe the seroepidemiology of measles, mumps and rubella (MMR) in neonates and pregnant women in Catalonia (Spain). Anti-rubella, anti-measles and anti-mumps serum IgG titres were assessed using enzyme-linked immunosorbent assay (ELISA) tests in 353 cord blood samples from neonates of a representative sample of pregnant women obtained in 2013. The prevalence of protective antibody titres in neonates was 96 % for rubella IgG (≥8 IU/ml), 90 % for measles IgG (>300 IU/ml) and 84 % for mumps IgG (>460 EU/ml). Slightly lower prevalences of protective IgG titres, as estimated from the cord blood titres, were found in pregnant women: 95 % for rubella IgG, 89 % for measles IgG and 81 % for mumps IgG. The anti-measles and anti-mumps IgG titres and the prevalences of protective IgG titres against measles and mumps increased significantly (p < 0.001) with maternal age. The prevalence of protective anti-measles IgG titres decreased by 7 % [odds ratio (OR) = 0.15, p < 0.001), the prevalence of protective anti-rubella IgG titres increased by 3 % (OR = 1.80, p < 0.05) and the MMR vaccination coverage (during childhood) in pregnant women increased by 54 % (OR = 2.09, p < 0.001) from 2003 to 2013. We recommend to develop an MMR prevention programme in women of childbearing age based on mass MMR vaccination or MMR screening and vaccination of susceptible women to increase immunity levels against MMR.

New preventive strategy to eliminate measles, mumps and rubella from Europe based on the serological assessment of herd immunity levels in the population.

Herd immunity blocks the transmission of measles, mumps and rubella in a population group when the prevalence of positive serologic results (p) is higher than a critical value (p c), known as the herd immunity threshold. A new preventive strategy should be developed in order to achieve the elimination of measles, rubella and mumps in Europe based on the serological assessment of herd immunity levels in different population groups. This strategy could detect population groups without herd immunity (p < p c) and indicate the additional vaccination coverage required in these groups in order to establish herd immunity and prevent outbreaks. The serological assessment of herd immunity levels in Catalonia, Spain, showed that herd immunity had not been established for measles and mumps in schoolchildren (5-9 years of age) and youths/younger adults (15-29 years of age), and that the additional vaccination coverage required to establish herd immunity in these groups was 1-7%. The new preventive strategy should be used to detect priority population groups for preventive and surveillance activities in European countries.

Prevalence of varicella-zoster antibodies in pregnant women in Catalonia (Spain). Rationale for varicella vaccination of women of childbearing age.

OBJECTIVE: The objective of this study was to determine the prevalence of antibodies against varicella-zoster virus (VZV) in pregnant women in Catalonia (Spain). SETTING: The prevalence of antibodies against VZV was assessed in a representative sample (n = 1522) of pregnant women of Catalonia obtained in 2003. METHOD: The sample was obtained including all women attended for childbirth, during 2 months of 2003, in 27 randomly selected hospitals with maternity clinics. MAIN OUTCOME MEASURES: Varicella-zoster antibodies were determined using the enzyme-linked immunosorbent assay test. RESULTS: The total number of women included in the study was 1522, corresponding to a participation rate of 83%. The prevalence of varicella-zoster antibodies in pregnant women was 96.1% (95% CI 95.1-97.1). The prevalence of antibodies was 94% in pregnant women aged 15-24 years, 95% in those aged 25-29 years and >95% in those aged 30-49 years. The prevalence of antibodies was not associated to the place of birth, place of residence (urban or rural), educational level and social class. The study showed that 6% of pregnant women aged 15-24 years and 5% of those aged 25-29 years were susceptible to varicella-zoster infections in Catalonia (Spain). CONCLUSION: The study showed that a varicella-zoster vaccination programme aimed at women of childbearing age could be necessary in Catalonia to prevent all varicella-zoster infections during pregnancy.

[Epidemiology of arterial hypertension in the adult population of Cataluña]. / Epidemiología de la hipertensión arterial en la población adulta de Cataluña.

BACKGROUND: The arterial hypertension is one of the most prevalent cardiovascular diseases. In this study the epidemiology of hypertension was investigated in a random sample of the adult population of Catalonia (Spain). METHODS: It was obtained a random sample (n = 704) of the adult population of Catalonia aged 15 or more years. The blood pressure was measured and hypertension was defined as a systolic blood pressure (SBP) equal or greater to 160 and/or a diastolic blood pressure (DBP) equal or greater to 95 mmHg. The borderline hypertension was defined as a SBP of 140-159 and/or a DBP of 90-95 mmHg. It was studied the association between hypertension and the following cardiovascular risk factors: hypercholesterolemia, obesity, diabetes and smoking. The study was carried out in 1989. RESULTS: The prevalence of hypertension observed was of 20%. The prevalence increased to 28% when the individuals with borderline hypertension were included. 87 of 144 detected hypertensives (58%) were known hypertensives, 67 (46.5%) received antihypertensive medication, and 30 (21%) were treated and had their blood pressures under control. Individuals with hypertension or borderline hypertension had a greater prevalence of hypercholesterolemia, obesity and diabetes, and a lower prevalence of smoking than normotensive persons. The odds ratio (hypertensive vs. normotensive persons) was of 3.68 for hypercholesterolemia, 3.26 for obesity, 3.81 for diabetes, and 0.40 for smoking. Nevertheless, the adjusted odds ratio was only statistically significant for the hypercholesterolemia (OR adj = 2.74). CONCLUSIONS: Arterial hypertension is one of the most important public health problems in Catalonia. The percentage of detected, treated and controlled hypertensives should be increased in the following years.

[The prevalence of tetanus antibodies in the adult population of Catalonia]. / Prevalencia de anticuerpos antitetánicos en la población adulta de Cataluña.

BACKGROUND: The aim of this study was to know the immune state of the adult population of Catalonia (Spain) versus tetanus. METHODS: The prevalence of antitetanic antibodies was determined in a representative sample (n = 604) of this population group (greater than or equal to 15 years). The technique used as that of passive hemagglutination reaction. The field work was carried out during 1989. RESULTS: 37.7% of the males and 15.7% of the females (p less than 0.001) presented titres of protector antibodies (greater than or equal to 0.01 Ul/ml) versus tetanus. The prevalence of antibodies was higher in youths of either sex and progressively descended with age. No statistically significant association was found upon performance of multivariate analysis between the sociodemographic variables (place of birth, level of education, residence, social class) and the prevalence of antibodies. CONCLUSIONS: The results of this study demonstrate that antitetanic vaccination currently being undertaken is not sufficient to insure adequate protection during adult life thus potentiating the need for the vaccination of adults in Catalonia.

[Cost-effectiveness of the methods of smoking cessation]. / Coste-efectividad de los métodos de cesación tabáquica.

BACKGROUND: The cost-effectiveness of the following methods of cessation of smoking were calculated in this study: 1) medical advice, 2) medical advice and nicotine chiclets, and 3) medical advice and nicotine patches. METHODS: The costs and effectiveness of the methods of cessation of smoking compared in terms of cost per year of life gained, deducing the costs and benefits at 5%. RESULTS: The cost per year of life gained was found to be 260,000 to 434,000 pesetas in males and 441,000 to 637,000 in women for medical advice, 287,000 to 479,000 in males and 486,000 to 703,000 in females for advice and nicotine chiclets and 329,000 to 549,000 in males and 557,000 to 805,000 in females for advice and nicotine patches. Maximum efficacy was achieved with the three methods in the age group from 45-59 years in males and from 50-54 years in females. On comparison of cost and effectiveness of the methods of nicotine substitution with those calculated for medical advice the increase in cost-effectiveness was shown to be 395,000 to 658,000 in males and 668,000 to 966,000 in females for advice and chiclets and from 467,000 to 779,000 in males and 791,000 to 1,142,000 in females for advice and patches. The increase in cost-effectiveness for advice and patches versus advice and chiclets was from 539,000 to 899,000 in males and 913,000 to 1,318,000 in females. CONCLUSIONS: The efficiency of achieving the cessation of smoking is very similar for medical advice and medical advice plus nicotine chiclets and is somewhat less for medical advice and nicotine patches. The results of this study place the methods of smoking cessation among the most effective health care procedures.

[Seroepidemiology of hepatitis C virus infection in pregnant women in Catalonia]. / Seroepidemiología de la infección por el virus de la hepatitis C en las mujeres embarazadas de Cataluña.

BACKGROUND: The aim of this study was to investigate the prevalence of hepatitis C virus (HCV) infection in a population of pregnant women in Catalonia and the sociodemographic variables and risk factors associated to this prevalence. METHODS: A representative sample of the pregnant women in Catalonia (n = 4,551) randomly selected by clusters (hospitals with maternity clinics) was studied. Detection of antiHCV antibodies was performed by the third generation ELISA test. Reactive cases were confirmed with RIBA 3 and MATRIX. RESULTS: The prevalence of antiHCV was found to be 1% and was not significantly associated with any of the sociodemographic variables studied (age, social and cultural level, origin and residence). A history of blood transfusion, intravenous drug consumption and hepatitis in the sexual partner were the only risk factors associated with the prevalence of infection found on univariate analysis although these were only present in 47% of the antiHCV positive cases detected. The association between the positivity of antiHCV and the history of hepatitis in the partner was lost on stratification of the cases according to the possible existence of history of drug addiction. CONCLUSIONS: A high proportion of young asymptomatic people (1%) were found to have hepatitis C virus infection with the possible mode of infection not being detected in approximately half of these subjects. In the other half of these cases the infection was found to have been acquired by an intravenous mechanism: blood transfusion or drug use.

[Comparative study of human cutaneous sensitivity to 2 and 5 international units of the PPD RT 23 tuberculin with Tween 80]. / Estudio comparativo de la sensibilidad cutánea humana a 2 y 5 unidades internacionales de la tuberculina PPD RT 23 con Tween 80.

BACKGROUND: The aim of this study was to know whether the human reaction to the Mantoux test with 5 UT of PPD RT 23 is similar to that achieved with the same test but with 2 UT of the same substance. METHODS: A simultaneous double Mantoux test was used at doses of 2 UT and another of 5 UT of the same trade mark of tuberculin PPD RT 23 with Tween 80 in 2,575 individuals. The subjects were distributed into two different groups of different ages, taking into consideration the possible presence of BCG vaccination. RESULTS: The doses of 5 UT produced a greater number of tuberculin positive individuals and a greater diameter of induration of reaction than that of the doses of 2 UT in both groups and with significant statistical differences. One hundred ninety-six (7%) subjects were tuberculin positive with 5 UT and negative with 2 UT. CONCLUSIONS: The reactions produced by the Mantoux test with 5 and 5 UT PPD RT were different since the two doses are not bioequivalent.

[A change in the epidemiologic pattern of hepatitis A in Spain]. / Cambio del patrón epidemiológico de la hepatitis A en España.

BACKGROUND: Seroepidemiologic studies carried out in different countries show that the prevalence of markers for infection by hepatitis A (HVA) is progressively decreasing in relation with improvement in the level of health care. The prevalence of anti-HVA in Catalunya and the factors related with infection by HVA were studied in order to obtain bases for designing prevention strategies adequate for the epidemiology of this infection. METHODS: Anti-HVA was determined by a method of enzyme immunoassay in a randomized sample of the general population in Catalunya. Investigation of the influence of socio/demographic variables in the prevalence of HVA infection was carried out. RESULTS: The global prevalence of anti-HVA was of 36%. In the population from 6 to 14 years of age it was of 13% and that of those over the age of 15 it was 86%. The prevalence of anti-HVA increases with age and is related with the social level of the families, the level of education and the place of birth. The incidence was higher in children of the lowest social class, in adults with the least education and in those born outside Catalunya. These factors constituted independent risk factors of HVA infection. CONCLUSIONS: The present study confirms the association between HVA infection and socio-economic factors and demonstrates that the infection is not commonly found in infancy, an increase in the number of susceptible adults is foreseeable.

[Low level of immune protection against diphtheria in adult population of Catalonia]. / Bajo grado de protección inmunitaria frente a la difteria en la población adulta de Cataluña.

BACKGROUND: Seroepidemiologic studies carried out in different European countries have shown the existence of low levels of protection against diphtheria. In this study the prevalence of antidiphtheria antibodies in the adult population of Catalonia, Spain, during 1995 has been studied. PATIENTS AND METHODS: The prevalence of the seroprotection against diphtheria was investigated in a representative sample (n = 1,248) of the adult population of Catalonia aged 15 or older. The antibody levels were determined by means of the in vitro Vero-cell neutralization technique. Two protection levels were considered: 0.01-0.09 U/ml (partial immunity) and > or = 0.1 U/ml (total immunity). RESULTS: The prevalence of absolute seroprotection was 12.4% (CI 95%: 10.5-14.3%) and that of partial and absolute seroprotection was 26.0% (CI 95%: 23.6-28.4%). The prevalence of antibodies is higher in men than in women (29.2% versus 23.1%; p < 0.05), and in urban than in rural environments (27.2% versus 19.9%: p < 0.05). The odds ratios adjusted by multiple logistic regression analysis were 1.43 (1.11-1.85) and 1.56 (1.05-2.29), respectively. CONCLUSION: The prevalence of antidiphtheria antibodies in the adult population of Catalonia, Spain, is low. The results suggest the need to develop antidiphtheria vaccination programmes in the adult population.

[Changes in seroepidemiology of hepatitis A virus infection in Catalonia in the period 1989-1996. Implications for new vaccination strategy]. / Cambios en la seroepidemiología de la infección por el virus de la hepatitis A en Cataluña en el período 1989-1996. Implicaciones para una nueva estrategia vacunal.

BACKGROUND: The aim of this study was to investigate the prevalence of the risk factors of hepatitis A virus infection (HAV) in a representative sample of a Catalonian population obtained from 1995 to 1996 and the changes in the prevalence of this infection over the period of 1989-1996. SUBJECTS AND METHODS: The prevalence of anti-HAV was determined by an ELISA test in a randomized sample of 2,142 individuals, 884 from 6 to 14 years of age and 1,248 over the age of 15 years. The results were related to sociodemographic variables and multiple logistic regression analysis was performed to establish which variables were related to the risk of infection. RESULTS: The global prevalence of HAV infection was 67.8%. The prevalence of HAV infection increased from 3.5% in the group from 5-14 years of age to 99% in that over the age of 64 years (p < 0.001). A higher prevalence was observed in those born outside of Catalonia (odds ratio [OR] = 3.97; 95% CI, 2.4-6.4) and in those with a lower level of education (OR = 2.60; 95% CI, 1.9-3.5). In the period 1989-1996 the prevalence of the infection has decreased in the population under the age of 45, the differences being statistically significant in the age groups 10-14 (p < 0.0001) and 25-34 (p < 0.0001). CONCLUSIONS: The prevalence of HAV infection has progressively decreased in Catalonia while it proportionally increases the susceptible population under the age of 45 years. These findings may be important in the design of strategies for the prevention of HAV infection with universal vaccination programs against this disease.

[Cost-effectiveness of 23-valent antipneumococcical vaccination in Catalonia (Spain)]. / Coste-efectividad de la vacunación antineumocócica 23-valente en Cataluña.

OBJECTIVES: Pneumococcal vaccination is an effective procedure for preventing pneumococcal pneumonia. In this study we evaluate the cost-effectiveness of pneumococcal vaccination strategies (23 serotypes) in the population aged 5 years and older in Catalonia. METHODS: Cost-effectiveness was evaluated in terms of cost per year of life gained (YLG) by comparing the net cost of the vaccination program with its effectiveness. The net cost of the vaccination program was calculated by subtracting 70% of the population from the vaccination costs, representing the reduction in health costs due to pneumococcal pneumonia that can ve achieved with vaccination. Vaccination costs were estimated based on a price of 12.41 euros (1,915 ptas.) for pneumococcal vaccine. The costs and benefits of the vaccination program were updated for 1996 by using a discount rate of 5%. RESULTS: A cost-effectiveness ratio of 9,023.27 euros per YLG was achieved for universal vaccination of the population. Cost-effectiveness was 11,3177.12 euros per YLG in individuals aged 5-24 years, 19,482.51 euros per TLG in those aged 25-44 years, 7,122.80 euros per YLG in those aged 45-64 years and less than 0 in those aged 65 years and older. In this group the reduction in cost of the disease was greater than the vaccination costs with a cost-benefit ratio of 1.58. The results of the cost-efecctiveness analysis were sensitive to vaccine costs and efficacy and the percentage of pneumonias caused by pneumococcus but were less sensitive to the costs of pneumococcal pneumonia, the rate of hospital admission among patients with community-acquired pneumonia and vaccine coverage. CONCLUSION: The results of this study show that pneumococcal vaccination should be a priority in individuals aged 65 years and older and in those aged 45-64 years.

[The study of cost effectiveness of breast cancer detection in Catalonia]. / Estudio del coste-efectividad de un programa de detección precoz del cáncer de mama en Cataluña.

BACKGROUND: This study has researched the cost-effectiveness of Early Diagnosis of Breast Cancer in Catalonian women in the 50-64 age group. METHODS: The cost-effectiveness ratio was obtained by comparing the costs of a program for 100,000 women with results achieved. The program consisted of a twice yearly mammography on all of the women over a 10 year period. The study assumed a participation level of 70%, detection rate of 0.36%, 92% sensitivity and specificity of 94%. RESULTS: A cost-effectiveness ratio of 1,413.648 pesetas was determined per case of cancer detected. 705,489 per year of extended life and 783,982 per year of extended life adjusted according to quality. Cost-effectiveness of the test in the first year was 842,400 per case of cancer detected. 383,183 per year of extended life and 425,418 per year of extended life adjusted according to quality. CONCLUSION: The results of the study are consistent with those obtained by other evaluations and show that early diagnosis of breast cancer is associated with a favourable cost-effectiveness ratio.

[Epidemiology of obesity among the adult population of Catalonia]. / Epidemiología de la obesidad en la población adulta de Cataluña.

Several epidemiological studies have shown that obesity is related to the mortality from cardiovascular disease. In this study, the epidemiology of obesity and the correlation between body mass index and other cardiovascular risk factors was studied in a representative sample of the adult population of Catalonia. It was obtained a random sample (n = 704) of the adult population of Catalonia aged 15 or more years. Height and weight were measured and body mass index (BMI) was calculated (height in Kg/weight2 in m2). Obesity was defined as a BMI greater than 30, and overweight as a BMI from 25 to 30. In the first 314 participants, it was determined the concentration of total cholesterol, cholesterol-HDL and triglyceride, and it was measured the blood pressure. The correlation between BMI and other cardiovascular risk factors was analysed. The study was carried out in 1989. The mean of BMI increased with age in both sexes. BMI was significantly higher in men (26 kg/m2) than women (25 kg/m2). The prevalence of obesity was of 12% in both men and women, and the prevalence of overweight was of 48.5% in men and 38% in women. The prevalence of arterial hypertension, hypercholesterolemia and diabetes was greater individuals with obesity, with differences statistically significant for hypertension (odds ratio of 3.26). The multiple logistic regression analysis showed that the association between obesity and hypertension was not statistically significant (OR adj. = 2.09), when the effect of the other risk factors, the age and sex were controlled.(ABSTRACT TRUNCATED AT 250 WORDS)

[The association between arterial hypertension, obesity and hypercholesterolemia in a sample of the adult population of Catalonia]. / Asociación entre hipertensión arterial, obesidad e hipercolesterolemia en una muestra de la población adulta de Cataluña.

BACKGROUND: The Framingham's study has demonstrated that the incidence of cardiovascular diseases increases when several risk factors are present. In this study, the association between the main cardiovascular risk factors has been studied in a random sample from the adult population of Catalonia. METHODS: A random sample was obtained (n = 314) from the adult population of Catalonia and univariate and multivariate statistical procedures were used to analyze the association between the following risk factors: HDL, hypertriglyceridemia, obesity, diabetes and tobacco consumption. RESULTS: A simple correlation was observed between most of the risk factors. The multiple linear regression analysis showed that both the diastolic and systolic arterial pressures were correlated with total levels of cholesterol, body mass index and age (r = 0.65 for SAP and r = 0.48 for DAP); levels of total cholesterol were correlated with levels of triglycerides and age (r = 0.57); levels of triglycerides were correlated with levels of total cholesterol and cholesterol-HDL, body mass index and age (r = 0.61); body mass index was correlated with levels of triglycerides, total cholesterol, cholesterol-HDL and age (r = 0.52) (p < 0.001). The prevalence of hypercholesterolemia, obesity and diabetes was higher and the prevalence of tobacco consumption was lower among the hypertensives (SAP > 140 and/or DAP > 90 mm Hg) than among normotensives, being the odds ratio 3.56 (2-6.33) for hypercholesterolemia; 3.65 (1.66-8.09) for obesity; 3.70 (1.06-13.45) for diabetes and 0.40 (0.22-0.72) for tobacco consumption. The adjusted odds ratio derived from multiple logistic regression analysis was 2.52 (1.38-4.64) for hypercholesterolemia; 2.40 (1.05-5.46) for obesity, 1.74 (0.50-6.04) for diabetes and 0.63 (0.33-1.20) for tobacco consumption, being statistically significant in the case of hypercholesterolemia (p = 0.002) and obesity (p = 0.038). CONCLUSION: We have observed an association between the cardiovascular risk factors analyzed. This association may be attributed to several physiological mechanisms and life-styles, which may influence the development of atherosclerosis and increase the cardiovascular risk.