[The ankle brachial index in type 2 diabetes]. / Kotníko-pazni index u nemocných s diabetes mellitus 2. typu.

INTRODUCTION: The ankle brachial index (ABI), i.e. the ratio of systolic blood pressure (SBP) on the ankle and on the arm, is diagnostic for peripheral occlusive artery disease and a marker of cardiovascular (CV) risk. The association between the low ABI < 0.9 and the CV risk in type 2 diabetes (T2DM) subjects was investigated. METHODS: We examined 253 T2DM subjects (135 males, 118 females, aged 66 +/- 9 years). The blood pressures were measured in the supine position with the 2 mm Hg accuracy; Doppler ultrasound was used for the ankle SBP and the mercury sphygnomanometer for the arm SBP. The high CV risk was defined as manifest CV diseases, elevated coronary calcium score (CAC) by Agatston (> 101) or according to the global CV Risk Score > or = 5% (SCORE). STATISTICAL METHOD: Wilcoxon's unpaired test, chi2 test, multiple logistic regression. RESULTS: The ABI < 0.9 was found unilateral in 23 T2DM (8%), bilateral in 24 (9%), in older males (71 +/- 8 years) with higher CAC (600 +/- 707) (p < 0.01), higher total cholesterol (5.4 +/- 1.3 mmol/L) and total homocystein (17.2 +/- 7.1 micromol/L) (p <0.05) in comparison to those with the ABI > or = 0.9 (age 66 +/- 9 years, CAC 234 +/- 458, total cholesterol 5.0 +/- 0.9, total homocystein 14.3 +/- 78). Many CV risk factors correlated positively with the low ABI < 0.9; it was significantly independently associated with age (p < 0.001), smoking (p < 0.01), LDL-cholesterol, total homocystein and CAC (p < 0.05). Low ABI < 0.9 predicted ischemic stroke in subjects with T2DM and manifest CV diseases in the further 3 years. There was no correlation between the ABI and the ultrasensitive C-reactive protein. CONCLUSION: Low ABI < 0.9 was in a strong association with the CV risk. The ABI measurement is a simple, noninvasive, time-nonconsuming and inexpensive method for subclinical atherosclerosis detection; the ABI can supply standard methods for the CV risk prediction.

Lower serum levels of interleukin-6 in a population sample with symptoms of depression than in a population sample without symptoms of depression.

In this study we compared the levels of interleukin (IL)-6, IL-8, IL-10 and tumor necrosis factor-alpha (TNF-alpha) in population samples characterized by a high or low level of self-reported depression. We measured serum IL-6, IL-8, IL-10 and TNF-alpha in two cohorts which differed in scoring on the Zung Self-Rating Depression Scale (ZSDS). The group with a high score in ZSDS (average SDS index = 62.9) was called DEP (n=27), the group with a low score in ZSDS (average SDS index = 29.9) was called NDEP (n=16). The groups did not significantly differ in age, waist circumference and body mass index. For the assessment of serum cytokine levels multiplex immunoanalytic xMAP(LUMINEX) technology was used. We found lower IL-6 in the DEP group (medians; DEP 4.08 pg/ml vs. NDEP 6.11 pg/ml) on the border of statistical significance in multiple regression analysis (p=0.049). Serum levels of all other studied cytokines were not significantly different (medians; IL-8: DEP 2.18 pg/ml vs. NDEP 2.61 pg/ml; IL-10: DEP 2.85 pg/ml vs. NDEP 2.94 pg/ml; TNF-alpha: DEP 2.32 pg/ml vs. NDEP 2.30 pg/ml). These results are in contradiction to the prevailing opinion that pro-inflammatory cytokine levels are elevated in people with symptoms of depression.

[Recommendations for the treatment of tobacco dependence]. / Doporucení pro lécbu závislosti na tabáku.

This first Czech version of guidelines formulated by the working group of mentioned medical associations is based on current literature and international guidelines. They are aimed mainly on clinical medicine and on incorporation of this treatment into the health care system according to WHO recommendations. They should serve to the treatment of tobacco dependence at any level: during any contact with the smoking patient (short intervention), in specialised centres or for the health care providers or health system itself.

[The sympathetic nervous system and insulin resistance]. / Sympatický nervový systém a inzulinová rezistence.

The submitted paper deals with the relationship of the sympathetic nervous system, metabolic syndrome of insulin resistance and cardiovascular risk. The author describes the structure and function of the sympathetic nervous system--the central part of the sympathetic nerve is in the hypothalamus and medulla oblongata. The hypothalamus combines vegetative control of the cardiovascular system and processes which influence the intermediary metabolism. This contributes to the explanation of the frequent incidence of metabolic disorders in subjects with arterial hypertension or ischaemic heart disease. The increased activity of the sympathetic nervous system is directly associated with the general cardiovascular mortality. Subjects with the metabolic syndrome of insulin resistance have a higher activity of the sympathetic nerve and thus a greater cardiovascular risk. The author describes the pathogenetic basis of this risk also in association with the sympathoadrenal system. The increased activity of the sympathetic nerve and insulin resistance can be successfully improved by a change of the lifestyle, i.e. non-smoking, a low-calorie diet, regular exercise and reduction of body weight. In addition cardiovascular risk can be reduced also pharmacologically, best by some antihypertensive drugs. In addition to classical antihypertensive drugs the author mentions agonists of imidazole receptors and their influence on the regulation of blood pressure and insulin resistance.

[Changes in the risk profile and the development of hypertension in the population of Plzen 1987-1989 and 1995-1996]. / Zmeny rizikového profilu a vývoj hypertenze v plzenské populaci mezi lety 1987-1989 a 1995-1996.

OBJECTIVE: To evaluate risk factors and the general risk profile in a longitudinally followed-up cohort of the Plzen population. MATERIAL AND METHODS: The investigation was made in a cohort of 332 men and 280 women selected from the epidemiological study PILS II (Plzen longitudinal study) examined in 1987-1989 and 1995-1995. Both investigations adhered to the standard protocol. Anamnestic data were assessed, anthropometric parameters (BMI). Blood pressure (BP) was assessed by means of a mercury sphygmomanometer using the standard procedure, biochemical parameters were examined from a blood sample on fasting in the routine laboratories of the Faculty Hospital Plzen. Changes of individual factors were evaluated by the paired Wilcoxon test and chi 2 group test resp. The global coronary risk was calculated by means of logistic coefficients from the Framingham study. RESULTS: In the cohort which aged on average by 7.6 years the number of smokers decreased in men by 8.1% and by 3.6% in women. The blood pressure increased significantly in both sexes, there was an increase in the number of hypertensive subjects by 26.8% in men and 21.7% in women. In men there was a significant decrease of non-HDL cholesterol, in women, there was a significant increase of subjects with diabetic dyslipidaemia. The total coronary risk (Framingham score) increased after standard transposition to the age of 60 years only by 0.5% in men and women, which reflects the risk due to increased BP. The standard of treatment of hypertension was quite unsatisfactory. When using criteria SBP > or = 140 and/or DBP > or = 90 mm Hg during the second examination 71% of the patients remained without treatment. The number of subjects not aware of hypertension declined from 54% to 19.3% of subjects. A favourable indicator was the finding that there was a decline of hypertensive subjects with a high coronary risk (> or = 20% from ca 11 to 6%). CONCLUSION: During the investigation period in the cohort which to a certain extent represents the Plzen population a certain improvement of the risk profile occurred in particular as regards smoking and disorders of the lipid spectrum, however not as regards the prevalence and treatment of hypertension. Despite the favourable development in the Czech population in the investigated cohort, obviously at the expense of poor control of hypertension, the average coronary risk did not improve.

[Effect of folates, vitamin B12 and life style factors on mild hyperhomocysteinemia in a population sample]. / Vztah folátu, vitaminu B12 a nekterých faktoru zivotního stylu k mírné hyperhomocysteinémii v populacním vzorku.

BACKGROUND: Mild hyperhomocysteinaemia (MHHcy) is a significant and independent risk factor for vascular diseases, however, its causality has not yet been unequivocally confirmed. The total homocysteine (Hcy) blood level is considered a product of genetic and lifestyle interactions, mainly folates, vitamin B12 and pyridoxine intake. In this paper we estimated the influence of these factors on MHHcy in the population. METHODS AND RESULTS: The population sample included 292 males a 251 women, mean age 53.4 years, selected from the population study PILS II. All subjects were examined by a standard protocol for clinical, anthropometrical and laboratory examination. Hcy levels were examined by ion exchange chromatography, all other factors by commercial kits. Statistical analysis was done in quartiles of distribution by Kruskal-Wallis ANOVA, Wilcoxon's un-paired test and multiple logistic regression (stepwise). Serum total Hcy levels were in significant positive associations with age in both sexes, with BMI in males only. Negative associations of Hcy were found with plasma folates and B12 concentrations in both sexes, with alcohol consumption again only in males. Smoking and physical activity and serum methionine concentration were not associated with Hcy levels. The established associations remained significant when adjusted by multiple logistic regression. About 40% of subjects with MHHcy had low folates and/or B12 levels and a deficiency in both vitamins was found in 17% of subjects. In contrast, MHHcy also was assessed in 14% of subjects with high folates and in 17% with high B12 concentration and in as few as in 3.7% of subjects with high concentrations of both vitamins as well. CONCLUSIONS: Nutritional factors, i.e. folates and B12 intake, seem to be the most important ones responsible for Hcy levels. A predominating influence of genetic factors may be assumed in less than one fifth of subjects with MHHcy.

[New approaches in the treatment of hypertension in metabolic diseases]. / Nové prístupy v lécbe hypertenze u metabolických onemocnení.

Concomitant arterial hypertension and metabolic disorders is a frequent finding raising the risk of micro- and macrovascular complications. While prevalence of stroke and myocardial infarction is going down in hypertensives, end-stage renal disease (ESRD) becomes a bigger problem especially in diabetic hypertensives. The metabolic abnormalities are linked to the hypertension by the sympathoadrenal system mediated by insulin resistance (IR); subjects with hyperinsulinemia and increased sympathetic activity tend to have higher blood pressure, typical dyslipidemia, reduced fibrinolytic activity and other risk factors (RF) called metabolic syndrome of IR. Albuminuria (AUR) is considered as an important RF for the development of nephropathy, ESRD, cardiovascular diseases. AUR is a marker of cardiovascular and total mortality in diabetic and/or non-diabetic hypertensives. AUR reflects the endothelial dysfunction not only in glomerulus but also in the other arteries. Tissue Renin-Angiotensin System plays a significant role in the pathogenesis of hypertension and metabolic disorders; it affects the arterial wall, kidneys and heart longitudinally. Life style is very essential in the treatment of hypertension and metabolic disorders: rational diet with reduced amount of salt and animal proteins, non-smoking and sufficient physical activity. Antihypertensive drugs without any metabolic side effects and with the renal protection are necessary for the patients with hypertension and metabolic disturbances. ACE-inhibitors and/or some of the Ca-antagonists seems to be valuable especially as combined therapy.

[Analysis of mortality trends in the West Bohemian Region in comparison with the entire Czech Republic 1988-1995]. / Analýza trendu mortality v západoceském regionu v letech 1988-1995 ve srovnání s celou Ceskou republikou.

BACKGROUND: Unfavourable trends in Czech republic (CR) started in the sixties and peaked in the late eighties i.e. in years when a dramatic mortality fall was observed in most western european countries. So, CR belonged among those Eastern European countries in that total and cardiovascular mortality showed increasing and alarming trends. West Bohemia Region (WB) was characterised by the concentration of heavy industry and high environmental pollution. Because of its geographical position on the western frontier, it was generally restricted in capital investment in the past. We wondered whether these phenomenon were reflected in higher mortality rates than in the rest of CR and which changes occurred after the year 1989. METHODS AND RESULTS: We compared the age standardized mortality data from 1988, 91, 93 and 95 in CR and WB for total mortality, cardiovascular mortality, coronary heart disease, strokes, malignancies and respiratory diseases. Data were age-adjusted for "World Population Standards" and rates were given for 100,000 inhabitants. In the whole CR a significant decrease of total, cardiovascular and cancer mortality was observed from 1988 to 1995. In WB these trends were similar, however in comparison to the whole CR the mortality rates remained in each respective period higher for total, cancer (mainly lung cancer) mortality and for non specific respiratory disease. In contrast, the coronary mortality rates in CR and WB were similar, however in WB after a temporary decrease in 1993 a significant increase in 1995 was observed. On the other hand the stroke mortality rates which were until 1993 in WB higher, significantly decreased in 1995 below the rates for CR. The cause of higher mortality rates in WB are far from being clear. To elucidate this observation epidemiologic studies of environmental pollution, life style of the population and socioeconomic factors are necessary, even as a further monitoring of regional mortality rates and trends.

[Smoking and diabetes mellitus]. / Kourení a diabetes mellitus.

Diabetic patients die mostly from chronic vascular complications, in particular ischaemic heart disease (specially type II diabetics) and renal failure associated with diabetic nephropathy (in particular type I diabetics). Smoking--one of the basic risk factors of atherosclerosis and its complications--accelerates in diabetics the atherosclerotic process and enhances the risk of cardiovascular complications. Smoking causes endothelial dysfunction, as well as deterioration of diabetic nephropathy and retinopathy. Smoking accelerates by various mechanisms the coagulation process and causes thus deterioration of the hypercoagulation state in diabetics. Anti-smoking intervention should be along with a diabetic diet the basic step in non-pharmacological treatment of diabetics.

[Homocysteine, a less well-known risk factor in cardiac and vascular diseases]. / Homocystein, méne známy rizikový faktor srdecních a cévních chorob v populaci.

Hyperhomocyst(e)mia (Hcy) negatively influences vascular endothelium and coagulation factors. Association of Hcy with premature arteriosclerosis (rather than atherosclerosis), stroke, myocardial infarction and peripheral arterial and venous disease was proved in clinical and epidemiological studies, even as the association with conventional risk factors like age, male sex, smoking, hypertension and hypercholesterolemia. Vitamin substitution of folates, vitamin B6 and B12 decreases Hcy blood levels, however definite evidence is still lacking, whether it results in lower incidence and mortality from cardiovascular diseases. Therefore clinical and epidemiological studies are necessary. Before the grant-application we proved in a pilot study significantly higher Hcy levels in 97 patients with manifest ischaemic heart disease than in 37 controls.

[Alcohol and health--friend or foe?]. / Alkohol a zdraví--prítel nebo neprítel?

BACKGROUND: The association of alcohol with a number of diseases, accidents, traffic and word injuries, psychoses, degenerative nervous processes and some organ malignities is known and has been proved. An exception is formed by population studies providing evidence of a reduced risk of development of ischaemic heart disease, incl. mortality from the latter. Our population has a high beer consumption: In the West Bohemian region the consumption is 180-200 l of beer per head per year. We were concerned with the problem of the influence of this consumption on the prevalence of IHD, myocardial infarction and some tumours and the general mortality of middle-aged men. METHODS AND RESULTS: The investigation started in 1976 comprised 3758 men aged 40-50 years. On account of manifest disease 171 subjects were eliminated and in the general evaluation after 12 years another 192 subjects could not be included. The final analysis was made in 3395 men, mean age 44.6 +/- 3.6 years, BMI 27.0 +/- 3.2, mean systolic pressure 133.1 +/- 18 mm Hg (17.74 +/- 2.4 kPa), mean diastolic pressure 83.2 +/- 10.7 mm Hg (11.0 +/- 1.5 kPa) and mean serum cholesterol values 5.69 +/- 0.99 mmol/l. A BMI above 29 was recorded in a total of 835 men (23.6%), systolic pressure above 160 mm Hg (21.23 kPa) in 302 men, diastolic pressure higher than 90 mm Hg (11.98 kPa) in 1004 (28.4%); serum cholesterol above 6.7 mmol/l was recorded in 491 (13.9%) of the examined subjects, regular smoking was admitted by 1915 (54.1%) and regular alcohol intake by 1815 (51.3%) of the investigated subjects. The mean follow-up period was 10.73 years. For statistical analysis multiple logistic regression was used and the relative risk expressed as the "odds ratio" (OR) standardized for a number of variables known to influence in a comprehensive way selected final indicators. Approximately 50% of the men were smokers and consumed alcohol. Regular alcohol intake was associated with a significantly lower risk (odds ratio 0.87). The significant difference was, however, not found when the data were standardized for age, blood pressure, family-history and leisure activities. Separate assessment of the relative risk of alcohol for fatal and non-fatal acute myocardial infarction and for the total mortality rate revealed the following risks (expressed as OR and 95% confidence limit in parentheses: OR for fatal infarction = 0.85 (0.44-1.64), not significant), OR for non-fatal infarction = 0.84 (0.60-1.17) and OR for the general mortality = 0.89 (0.68-1.17): both the latter values are at the borderline of statistical significance (p = 0.05-0.1). When smokers drink regularly, they have a significantly lower risk of non-fatal infarctions (but not fatal infarctions!). This effect is not found in non-smokers. The relative risk for the development of tumours in smokers-drinkers is insignificantly elevated, OR = 1.55 (0.89-2.75). The largest number of malignities was lung cancer. Regular smokers who drink alcohol have a treble risk of developing lung cancer, as compared with abstainers: OR = 2.96 (1.07-8.23) a statistically significant increase. CONCLUSIONS: From the investigation it is apparent that regular alcohol intake reduces the rate of all coronaries in middle-aged men, but this protective effect applies only to non-fatal myocardial infarctions, in particular in smokers. No effect on the general mortality was proved. However, there was evidence of a positive association between alcohol intake and lung cancer. Alcohol potentiates (3x) the relative risk of development of lung cancer in smokers.

Impact of cardiovascular risk factors on morbidity and mortality in Czech middle-aged men: Pilsen Longitudinal Study.

The impact of biological and life-style characteristics measured during baseline examination on 12-year morbidity and mortality of coronary heart disease (CHD), stroke (STR), and malignancies was investigated in an urban population of 3,540 middle-aged men initially free of clinical disease. The following factors enhanced significantly (at the 5% level) the adjusted relative risk ratios: for total mortality age, smoking, and elevated systolic blood pressure; for CHD age, smoking, elevated systolic blood pressure, serum cholesterol levels, and body mass index, and family history (father or mother). Myocardial infarction was positively associated with age, smoking and elevated serum cholesterol levels. For STR age and elevation of both systolic and diastolic blood pressure were risk factors. The relative risk for all malignancies was enhanced by age and smoking. Regular alcohol consumption was associated with a significantly lower risk for all CHD; however, with only marginal significance for myocardial infarction. Higher education was associated with a significantly lower risk of total mortality, all CHD, and myocardial infarction and a marginally lower risk of STR. A high leisure physical activity was negatively (but not significantly) associated with the risk of all end points.

[The effect of age and educational level on the risk profile of men and women in industrial occupations]. / Vliv veku a vzdelání na rizikový profil muzu a zen v prumyslové populaci.

The authors investigated a population group of 660 men and 440 women aged 35-60 years selected in the Skoda works and examined as part of the integrated programme of prevention of chronic non-infectious diseases. The risk profile of subjects associated with the life-style of the population was evaluated with regard to sex, age and education. It was revealed that the blood pressure rises with age and body weight in men and women. With rising body weight rises also the triglyceride and uric acid level and in women also the total cholesterol level. The authors confirmed the relationship between smoking and the thiocyanate blood level. The magnesium level declines with age in both sexes and correlates with the reported alcohol intake. Men and women with higher education smoke less, have a lower body weight and lower triglyceride blood levels. Women have also a lower total cholesterol level. University educated men consume less alcohol, while the reverse is true in university educated women.

What are the causes of unsatisfactory control of arterial hypertension in the population?

A cross-sectional epidemiological study was conducted in the late 1980's in 660 men and 440 women, aged 35-60 years to assess the level of control of arterial hypertension (AH) in an industrial population. A relatively high rate of blood pressure (BP) assessment was found; only 2% of those screened had never their BP measured. Despite this, 44% of men and 40% of women with a high BP were unaware of their AH and conversely 15% of women and 12% of men with a positive history of AH were found to have BP less than 140/90 mmHg. Sufficient AH control was provided only in one fifth of the total amount of 300 hypertensive subjects. The paper evaluates the detection rate of our epidemiological study designed to assess the current status of control of AH and the causes of the unsatisfactory level of detection and control of a high BP are discussed.

Serum cholesterol increase in a middle-aged male industrial population during ten years (1976-1986) and general food consumption changes in Czechoslovakia.

The authors evaluate the coronary risk factor changes in middle-aged men from the point of view of changed nutritional habits of the whole population (yearly per capita consumption of different food). They compared 3,754 men aged 40-50 years when screened in 1976-77 (Skoda I Study) and 568 men aged 40-50 years when screened in 1986-88 (Skoda II Study). During the 10-year period, a significant decrease of smoking habits was observed, hypertension prevalence remained unchanged and hypercholesterolaemia prevalence increased significantly. The estimated yearly per capita consumption of meat and fat remained unchanged in the years 1975-1985, however, the structure of consumption revealed a gradual change towards food containing high amounts of animal fat. Education efforts during the 10-year period (1976-1986) led to a decrease in smoking habits in middle-aged men leaving hypertension control unchanged. The observed increase of cholesterol levels may be attributed to inappropriate nutritional habits gradually worsening in the whole population probably due to a socio-economic depression.

Cross-sectional study of beer consumption and blood pressure in middle-aged men.

Alcohol consumption in the week prior to examination was assessed in 352 men (average age 52.5 years) selected randomly from a cohort of employees of an industrial plant. Men drinking more than 350 g ethanol per week, largely in the form of a local beer, did not differ in respect of BP but they smoked more cigarettes and had lower serum magnesium levels and immunoreactive insulin levels than the rest of the sample. In a multiple linear (step-wise) regression analysis, body mass index, age, immunoreactive insulin two hours after glucose load and serum total cholesterol contributed directly to the BP value but the weekly ethanol intake did not. Smoking contributed negatively to the BP value after an a priori exclusion of total cholesterol, HDL cholesterol, magnesium and results of glucose tolerance tests. Only immunoreactive insulin and age were related significantly to ethanol consumption. No significant association of alcohol consumption with BP was found.