Association of HDL Subfraction Profile with the Progression of Insulin Resistance.

Type 2 diabetes mellitus (T2DM) is a major global public health problem, as it is associated with increased morbidity, mortality, and healthcare costs. Insulin resistance (IR) is a condition characterized by disturbances in carbohydrate and lipid metabolism that precedes T2DM. The aim of the present study was to investigate the association between HDL and its subfraction profile and the progression of IR, as assessed by the Homeostatic Model Assessment for IR (HOMA-IR) index, and to define cut-off values to identify an increased risk of IR. Individuals with a HOMA-IR greater than 3.63 were considered to have IR. The HDL subfractions were separated using the Lipoprint system, which identifies ten subfractions (HDL-1-10) in three subclasses as large (HDL-L), intermediate (HDL-I) and small (HDL-S). Analyses were performed on samples from 240 individuals without IR and 137 with IR from the Hungarian general and Roma populations. The HDL-1 to -6 subfractions and the HDL-L and -I classes showed a significant negative association with the progression and existence of IR. Among them, HDL-2 (B = -40.37, p = 2.08 × 10-11) and HDL-L (B = -14.85, p = 9.52 × 10-10) showed the strongest correlation. The optimal threshold was found to be 0.264 mmol/L for HDL-L and 0.102 mmol/L and above for HDL-2. Individuals with HDL-L levels below the reference value had a 5.1-fold higher risk of IR (p = 2.2 × 10-7), while those with HDL-2 levels had a 4.2-fold higher risk (p = 3.0 × 10-6). This study demonstrates that the HDL subfraction profile (especially the decrease in HDL-2 and -L) may be a useful marker for the early detection and intervention of atherogenic dyslipidemia in subjects with impaired glucose and insulin metabolism.

Association of CETP Gene Polymorphisms and Haplotypes with Cardiovascular Risk.

Cholesteryl ester transfer protein (CETP) is known to influence HDL-C levels, potentially altering the profile of HDL subfractions and consequently cardiovascular risk (CVR). This study aimed to investigate the effect of five single-nucleotide polymorphisms (SNPs; rs1532624, rs5882, rs708272, rs7499892, and rs9989419) and their haplotypes (H) in the CETP gene on 10-year CVR estimated by the Systematic Coronary Risk Evaluation (SCORE), the Framingham Risk Score for Coronary Heart Disease (FRSCHD) and Cardiovascular Disease (FRSCVD) algorithms. Adjusted linear and logistic regression analyses were used to investigate the association of SNPs and 10 haplotypes (H1-H10) on 368 samples from the Hungarian general and Roma populations. The T allele of rs7499892 showed a significant association with increased CVR estimated by FRS. H5, H7, and H8 showed a significant association with increased CVR based on at least one of the algorithms. The impact of H5 was due to its effect on TG and HDL-C levels, while H7 showed a significant association with FRSCHD and H8 with FRSCVD mediated by a mechanism affecting neither TG nor HDL-C levels. Our results suggest that polymorphisms in the CETP gene may have a significant effect on CVR and that this is not mediated exclusively by their effect on TG and HDL-C levels but also by presently unknown mechanisms.

Health and economic gain attributable to the introduction of the World Health Organization's drinking water standard on arsenic level in Hungary: A nationwide retrospective study on cancer occurrence and ischemic heart disease mortality.

The World Health Organization (WHO) estimates that 140 million individuals are at risk from consumption of drinking water containing arsenic at concentrations above the WHO guideline value of 10 µg/l. Arsenic mitigation is considered to be the most effective way to prevent arsenic related diseases. After joining the European Union, Hungary implemented a Drinking Water Quality Improvement Programme (DWQIP) to reduce levels of arsenic in drinking water below the WHO guideline value. But what impact did this have on health? We estimated the change in lifetime excess skin, lung, and bladder cancer risks and mortality from ischaemic heart disease (IHD) associated with chronic arsenic intake among those exposed before (2004-2007) and after (2014-2017) the implementation of DWQIP. A population-based risk assessment approach was used to assess lifetime excess cancer risk applying two scenarios for lung and bladder cancers. The economic benefits of the DWQIP were estimated by the combination of cost of illness and value per statistical life methods. Compared to the period before the DWQIP, its implementation was associated with a significant reduction in arsenic in drinking water [median: 3.0 µg/l interquartile range (IQR): 1.5-12.0 µg/l to median: 2.15 µg/l IQR: 1.0-5.79 µg/l]. The two scenarios were estimated to be associated with 225.2 and 35.9 fewer cancer cases each year. The number of annually prevented IHD deaths was estimated to be 88.9. It was estimated that the benefits of the DWQIP will outweigh its costs. We conclude that reducing arsenic levels in drinking water to 10.0 µg/l resulted in significant health and economic benefits. Our study goes beyond the existing research, offering both new insights into the impact of arsenic mitigation and providing a methodological template for similar studies in the many parts of the world that have yet to reduce arsenic exposure.

HDR brachytherapy boost using MR-only workflow for intermediate- and high-risk prostate cancer: 8-year results of a pilot study.

PURPOSE: To report 8-year clinical outcome with high-dose-rate brachytherapy (HDRBT) boost using MRI-only workflow for intermediate (IR) and high-risk (HR) prostate cancer (PC) patients. METHODS AND MATERIALS: Fifty-two patients were treated with 46-60 Gy of 3D conformal radiotherapy preceded and/or followed by a single dose of 8-10 Gy MRI-guided HDRBT. Interventions were performed in a 0.35 T MRI scanner. Trajectory planning, navigation, contouring, catheter reconstruction, and dose calculation were exclusively based on MRI images. Biochemical relapse-free- (BRFS), local relapse-free- (LRFS), distant metastasis-free- (DMFS), cancer-specific-(CCS) and overall survival (OS) were analyzed. Late morbidity was scored using the Common Terminology Criteria for Adverse Events (CTCAE 4.0) combined with RTOG (Radiation Therapy Oncology Group) scale for urinary toxicity and rectal urgency (RU) determined by Yeoh. RESULTS: Median follow-up time was 107 (range: 19-143) months. The 8-year actuarial rates of BRFS, LRFS, DMFS, CSS and OS were 85.7%, 97%, 97.6%, and 77.6%, respectively. There were no Gr.3 GI side effects. The 8-year actuarial rate of Gr.2 proctitis was 4%. The 8-year cumulative incidence of Gr.3 GU side effects was 8%, including two urinary stenoses (5%) and one cystitis (3%). EPIC urinary and bowel scores did not change significantly over time. CONCLUSIONS: MRI-only HDR-BT boost with moderate dose escalation provides excellent 8-year disease control with a favorable toxicity profile for IRPC and HRPC patients. Our results support the clinical importance of MRI across the BT workflow.

Triggered Imaging With Auto Beam Hold and Pre-/Posttreatment CBCT During Prostate SABR: Analysis of Time Efficiency, Target Coverage, and Normal Volume Changes.

PURPOSE: Our purpose was to investigate time efficiency and target coverage for prostate stereotactic ablative radiation therapy (SABR) using triggered imaging (TI) and auto beam hold. METHODS AND MATERIALS: A total of 20 patients were treated with volumetric modulated arc-based SABR. Treatment verification consisted of pre- and post-radiation therapy cone beam computed tomography (CBCT) with gold marker-based TI every 3 seconds. In case of ≥3 mm (deviation limit) displacement, the treatment was interrupted and imaging-based correction was performed. Beam interruptions, intrafractional shifts, and treatment times were recorded. Prostate, rectum, and bladder were delineated on each CBCT. Target coverage was evaluated by comparing the individual prostate delineations with 98% isodose contour volumes (% of the evaluated volumes exceeding the reference). Both inter- and intrafractional changes of bladder and rectal volumes were assessed. RESULTS: The average overall treatment time (±standard deviation) was 18 ± 11 min, with a radiation delivery time of 6 ± 3 min if no intrafractional CBCT acquisitions were necessary (91% of fractions). On average, 1.2 beam interruptions per fraction were required with 0/1 correction in 71% of the fractions. The mean residual 3-dimensional shift was 1.6 mm, exceeding the deviation limit in 8%. In the case of intrafractional CBCT and/or ≥2 corrections the treatment time dramatically increased. The 98% isodose lines did not encompass the prostate in only 8/180 (4%) evaluations in 6 different patients, leading to a loss of D98 between 0.1%-6% as a worst case scenario. The bladder volumes showed significant increases during treatment (P < .01) while rectal volumes were stable. CONCLUSIONS: Time efficiency of TI + auto beam hold with 3 mm/3 sec threshold during prostate SABR is comparable with competitive techniques, resulting in minimal 3-dimensional residual errors with maintained target coverage. Technical developments are necessary to further reduce radiation delivery time. Use of CBCT allowed full control of rectal volumes, while bladder volumes showed significant increases over time.

Influence of patient characteristics on preventive service delivery and general practitioners' preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary.

BACKGROUND: Regular primary healthcare (PHC) performance monitoring to produce a set of performance indicators for provider effectiveness is a fundamental method for improving guideline adherence but there are potential negative impacts of the inadequate application of this approach. Since performance indicators can reflect patient characteristics and working environments, as well as PHC team contributions, inadequate monitoring practices can reduce their effectiveness in the prevention of cardiometabolic disorders. OBJECTIVES: To describe the influence of patients' characteristics on performance indicators of PHC preventive practices in patients with hypertension or diabetes mellitus. METHODS: This cross-sectional analysis was based on a network of 165 collaborating GPs. A random sample of 4320 adults was selected from GP's patient lists. The response rate was 97.3% in this survey. Sociodemographic status, lifestyle, health attitudes and the use of recommended preventive PHC services were surveyed by questionnaire. The relationship between the use of preventive services and patient characteristics were analysed using hierarchical regression models in a subsample of 1659 survey participants with a known diagnosis of hypertension or diabetes mellitus. RESULTS: Rates of PHC service utilization varied from 18.0% to 97.9%, and less than half (median: 44.4%; IQR: 30.8-62.5) of necessary services were used by patients. Patient attitude was as strong of an influencing factor as demographic properties but was remarkably weaker than patient socioeconomic status. CONCLUSION: These findings emphasize that PHC performance indicators have to be evaluated concerning patient characteristics.

Association between the General Practitioner Workforce Crisis and Premature Mortality in Hungary: Cross-Sectional Evaluation of Health Insurance Data from 2006 to 2014.

The workforce crisis of primary care is reflected in the increasing number of general medical practices (GMP) with vacant general practitioner (GP) positions, and the GPs' ageing. Our study aimed to describe the association between this crisis and premature mortality. Age-sex-standardized mortality for 18⁻64 years old adults was calculated for all Hungarian GMPs annually in the period from 2006 to 2014. The relationship of premature mortality with GPs' age and vacant GP positions was evaluated by standardized linear regression controlled for list size, urbanization, geographical location, clients' education, and type of the GMP. The clients' education was the strongest protective factor (beta = -0175; p < 0.001), followed by urban residence (beta = -0.149; p < 0.001), and bigger list size (beta1601⁻2000 = -0.054; p < 0.001; beta2001-X = -0.096; p < 0.001). The geographical localization also significantly influenced the risk. Although GMPs with a GP aged older than 65 years (beta = 0; p = 0.995) did not affect the risk, GP vacancy was associated with higher risk (beta = 0.010; p = 0.033), although the corresponding number of attributable cases was 23.54 over 9 years. The vacant GP position is associated with a significant but hardly detectable increased risk of premature mortality without considerable public health importance. Nevertheless, employment of GPs aged more than 65 does not impose premature mortality risk elevation.

Smoking cessation support for regular smokers in Hungarian primary care: a nationwide representative cross-sectional study.

OBJECTIVES: Our study aimed to evaluate the effectiveness of general practitioners' (GPs') smoking cessation support (SCS). STUDY DESIGN: We carried out a cross-sectional study between February and April 2016. SETTING AND PARTICIPANT: A sample of 2904 regular smokers aged 18 years or older was selected randomly from 18 general medical practices involved in a national representative, general medical practice-based morbidity monitoring system. The GPs surveyed the selected adults and identified 708 regular smokers. MAIN OUTCOME MEASURES: Multivariate logistic regression models have been applied to evaluate the determinants (age, gender, education, smoking-related comorbidity, smoking intensity, intention to quit smoking and nicotine dependence) of provision of GP-mediated SCS such as brief intervention, pharmacological and non-pharmacological programmatic support. RESULTS: According to the survey, 24.4% of the adults were regular smokers, 30% of them showed high nicotine dependence and 38.2% willing to quit smoking. Most of the smokers were not participated in SCS by GPs: brief intervention, programmatic non-pharmacological support and pharmacotherapy were provided for 25%, 7% and 2% of smokers, respectively. Low-nicotine-dependence individuals were less (OR 0.30, 95% CI 0.12 to 0.75), patients with intention to quit were more (OR 1.49, 95% CI 1.00 to 2.22) likely to receive a brief intervention. Vocational (OR 1.71, 95% CI 1.13 to 2.59) and high school education (OR 2.08, 95% CI 1.31 to 3.31), chronic obstructive pulmonary disease and cardiovascular diseases (OR 3.34, 95% CI 1.04 to 10.68; OR 3.91, 95% CI 2.33 to 6.54) increased the probability to receive support by GP. CONCLUSIONS: Although there are differences among smokers' subgroups, the SCS in Hungarian primary care is generally insufficient, compared with guidelines. Practically, the pharmacological support is not included in Hungarian GPs' practice. GPs should increase substantially the working time devoted to SCS, and the organisation of primary healthcare should support GPs in improving SCS services.

Selenium levels in men with liver disease in Hungary.

PROJECT: We studied the relationship between selenium (Se) levels and chronic liver disease (CLD) severity and the association between socioeconomic and lifestyle factors and serum Se levels. PROCEDURE: We performed a case-control study in Hungarian men, examining 281 patients with CLD and 778 controls. Liver function was evaluated using biochemical markers, and liver disease was verified with physical examination and blood tests. Linear regression analysis was performed to study the association of serum Se level with biochemical markers in cases and controls. In control participants we examined the relationship between Se levels and age, financial status, education, alcohol consumption, cigarette smoking, type of fat used for cooking and body mass index. RESULTS: Serum Se levels were lower in cases (median 0.87 µmol/L (IQR: 0.77-1.03)) than in controls (median 1.08 µmol/L (IQR: 0.97-1.19)). In controls, increases in bilirubin and glutamic-oxaloacetic transaminase (GOT) were associated with decreases in Se levels. In patients with CLD, a statistically significant relationship was found between serum Se and the GOT/GPT ratio, albumin and bilirubin. Younger, better-educated controls had significantly higher, and regular smokers and heavy drinkers had significantly lower Se levels. The use of vegetable oil/fat was also associated with higher Se levels. Se level was associated with the severity of liver injury in people even in patients who did not exhibit signs and symptoms of CLD. CONCLUSIONS: Serum Se level is strongly associated with the severity of liver damage in people with CLD from the early stage on.

Behaviour does not fully explain the high risk of chronic liver disease in less educated men in Hungary.

BACKGROUND: Hungary has among the highest mortality rates from chronic liver disease (CLD) and cirrhosis in Europe. Usually, conventional behavioural factors are hypothesized as the cause of the high risk of CLD. METHODS: A case-control study was performed with 287 cases and 892 controls to study the relationship between socio-economic and behavioural factors and the risk of CLD. Liver disease was verified by physical examination and blood tests. Blood samples were collected for detecting hepatitis B, C and E virus infection. Information on exposure factors was recorded by the participating physicians and by self-administered questionnaire. Simple regression analysis was used to study the relationship between CLD/cirrhosis and potential risk factors as alcohol intake (amount and source), problem drinking, cigarette smoking, physical activity, viral hepatitis infections, socio-economic factors (education, financial and marital status). Multiple regression analysis was used to identify whether the effect of socio-economic factors is fully mediated by health behaviour (smoking, alcohol consumption, physical activity). RESULTS: The univariate analysis showed that heavy alcohol consumption, problem drinking, former and heavy cigarette smoking, single, separated or divorced marital status, bad or very bad perceived financial status and lower education significantly increased the risk of CLD/cirrhosis. The effect of marital status and of education did not change after adjustment for behavioural factors, but the effect of perceived financial status disappeared. CONCLUSIONS: The effect of low socio-economic status on the risk of CLD/cirrhosis is only partially explained by conventional behavioural risk factors in Hungary.

A preliminary evaluation of a health monitoring programme in Hungary.

BACKGROUND: In 1998 a joint initiative of the Hungarian School of Public Health and the National Public Health Service created a network of sentinel stations based in primary care facilities in four Hungarian counties. The aim was to establish a system that will provide valid data on morbidity of selected diseases in Hungary. METHODS: Based on standardized protocols, the participating centres have continuously reported data on the prevalence of cardiovascular diseases, diabetes mellitus, liver cirrhosis, and some malignant diseases, as well as supplying denominator data. The four counties represent both eastern and western parts of Hungary, reflecting the known geographical disparities in health. Each county office enrolled general practitioners maintaining representation in terms of both geography and distribution of settlement size. RESULTS: A total of 73 general practitioners agreed to participate, providing care for 15.6% (138,088 people) of the population in the counties. The population registered with the practices were representative in terms of age and sex of both the participating counties and the entire country. The prevalence of hypertension, diabetes mellitus and liver cirrhosis is high in each county but varies considerably, with higher levels in the western counties, especially among older age groups of both sexes. CONCLUSIONS: The establishment of sentinel stations to collect morbidity data is feasible and sustainable in Hungarian primary care. The data that have been generated provide a valid and comprehensive picture of important aspects of the Hungarian population's health, with important implications for health policy and health service planning. In regions where low prevalence rates of diseases and high mortality rates simultaneously exist special attention is required to explore the background of this caveat. KEY POINTS: Till the end of 1998 no program operated in Hungary engaged with non-communicable disease morbidity data collection, except some hospital-based registries, which failed to produce reliable information. The establishment of sentinel stations to collect morbidity data is feasible and sustainable in Hungarian primary care, the valid morbidity data can be built into the decision making process in health service planning. Regular training, quality control and feedback are important contributors to the success of the program. The prevalence of hypertension, diabetes mellitus and liver cirrhosis is high in each county but varies considerably, with higher levels in the western counties, especially among older age groups of both sexes. More research needed to determine the possible contribution of unknown morbidity and health service utilisation to the different prevalence values in the two parts of Hungary.

[Establishment and preliminary evaluation of the General Practitioners' Morbidity Sentinel Stations Program in Hungary. Prevalence of hypertension, diabetes mellitus and liver cirrhosis]. / Háziorvosi Morbiditási Adatgyújtés Program kidolgozása, elindítása és múködtetése Magyarországon. A magas vérnyomás, cukorbetegség és májzsugor prevalenciája.

STUDY OBJECTIVE: To develop, introduce and test a methodology, which provides valid data about the prevalence and incidence of chronic, non-communicable diseases of great public health importance. DESIGN: The School of Public Health, University of Debrecen, Hungary and the National Public Health and Medical Officer Service the first time launched a morbidity sentinel stations network of general practitioners in four counties in Hungary in May 1998. Within the framework of this program the participating general practitioners reported the prevalence data of cardiovascular diseases, diabetes mellitus, liver cirrhosis, and major malignant diseases at the beginning, and from than on continuously report the incidence of these diseases. The authors built quality assurance into the program at different levels in order to ensure high quality data. PATIENTS: The study population consists of people belonging to the participating general practitioners' practices at any time, selected in a way to represent the eastern and western part of the country as well as the participating practices in the counties (Gyór-Moson-Sopron, Hajdú-Bihar, Szabolcs-Szatmár-Bereg, Zala) would give a geographically and according to settlement size representative sample of general practitioners in those counties. Eighty general practitioners were approached in the four counties by the county offices and overall 73 of them, 1.4% of the total practices in Hungary (5212), agreed to participate in the study, therefore information can be collected on 1.37% of the Hungarian population's (138,088 people) morbidity status. MAIN RESULTS: The population of practices participating in the program gives a representative sample of the counties population by age and sex. The prevalence of hypertension, diabetes mellitus and liver cirrhosis is high in all the counties involved. In most of the selected diseases the authors have found differences in the prevalence between the eastern and western part of Hungary with higher values in the western counties. The differences were most apparent in the older age groups in both sexes. CONCLUSIONS: The development and sustainability of primary care based, sentinel stations type, euroconform morbidity data collection system is undoubtedly justified in Hungary. The collected and thoroughly analysed data provide not only a valid and comprehensive basis to describe some aspects of the health status of the Hungarian population but also gives an opportunity to continuously monitor the changes in morbidity of the selected diseases. Thus, the program serves an important basis for health care capacity building, priority setting and the evaluation of the effectiveness of public health interventions.