Benefits of an Adjustable Compression Garment System for the Reduction of Chronic Leg Oedema (ACROE Study).

OBJECTIVE: This study aimed to assess whether a specific adjustable compression garment (ACG) system (Coolflex Standard Calf and Coolflex Standard Foot; Sigvaris Inc.) promotes self care in patients with chronic leg oedema. Secondary aims were to assess the effectiveness of this ACG in reducing oedema, improving patient reported outcomes, and determining the patients' degree of satisfaction with the handling of the wrap. METHODS: This was a multicentre prospective observational study. The study included 99 adult patients aged between 18 and 90 years presenting with chronic oedema of the lower extremity, which encompasses conditions such as lymphoedema, venous oedema, and phlebolymphoedema. At baseline, all patients received an ACG. After two to three days and after six weeks, their overall satisfaction with the therapy was assessed. Leg volume was determined in a contactless manner during the baseline and follow up visits. All patients completed the cross-cultural adaptation of the Lymphoedema Functioning, Disability and Health Questionnaire for Patients with Lymphoedema of the Lower Extremity in Germany (Lymph-ICF-UG). RESULTS: A total of 86 patients completed the study and were followed up for six weeks. At the final six week follow up , 82 (95.3%) of the 86 subjects indicated that they were able to put on the wrap independently or with a little help from relatives. The overall satisfaction rate was 88.5% (95% confidence interval [CI], 80.4 - 94.1%). The mean leg volume reduction from baseline to six weeks was -4.7% (95% CI -6.3 - -3.0%; p < .001). Lymph-ICF-UG scores and scores in all domains improved significantly from baseline to the final follow up. CONCLUSION: The ACG used in this study was found to promote self care in a high proportion of patients with chronic leg oedema. A significant reduction in oedema was observed.

Diet, cardiovascular disease, and mortality in 80 countries.

AIMS: To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS: A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION: A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

Analysis of the Model of Atherosclerosis Formation in Pig Hearts as a Result of Impaired Activity of DNA Repair Enzymes.

Excessive consumption of food rich in saturated fatty acids and carbohydrates can lead to metabolic disturbances and cardiovascular disease. Hyperlipidemia is a significant risk factor for acute cardiac events due to its association with oxidative stress. This leads to arterial wall remodeling, including an increase in the thickness of the intima media complex (IMT), and endothelial dysfunction leading to plaque formation. The decreased nitric oxide synthesis and accumulation of lipids in the wall result in a reduction in the vasodilating potential of the vessel. This study aimed to establish a clear relationship between markers of endothelial dysfunction and the activity of repair enzymes in cardiac tissue from a pig model of early atherosclerosis. The study was conducted on 28 female Polish Landrace pigs, weighing 40 kg (approximately 3.5 months old), which were divided into three groups. The control group (n = 11) was fed a standard, commercial, balanced diet (BDG) for 12 months. The second group (n = 9) was fed an unbalanced, high-calorie Western-type diet (UDG). The third group (n = 8) was fed a Western-type diet for nine months and then switched to a standard, balanced diet (regression group, RG). Control examinations, including blood and urine sampling, were conducted every three months under identical conditions with food restriction for 12 h and water restriction for four hours before general anesthesia. The study analyzed markers of oxidative stress formed during lipid peroxidation processes, including etheno DNA adducts, ADMA, and NEFA. These markers play a crucial role in reactive oxygen species analysis in ischemia-reperfusion and atherosclerosis in mammalian tissue. Essential genes involved in oxidative-stress-induced DNA demethylation like OGG1 (8-oxoguanine DNA glycosylase), MPG (N-Methylpurine DNA Glycosylase), TDG (Thymine-DNA glycosylase), APEX (apurinic/apirymidinic endodeoxyribonuclease 1), PTGS2 (prostaglandin-endoperoxide synthase 2), and ALOX (Arachidonate Lipoxygenase) were measured using the Real-Time RT-PCR method. The data suggest that high oxidative stress, as indicated by TBARS levels, is associated with high levels of DNA repair enzymes and depends on the expression of genes involved in the repair pathway. In all analyzed groups of heart tissue homogenates, the highest enzyme activity and gene expression values were observed for the OGG1 protein recognizing the modified 8oxoG. Conclusion: With the long-term use of an unbalanced diet, the levels of all DNA repair genes are increased, especially (significantly) Apex, Alox, and Ptgs, which strongly supports the hypothesis that an unbalanced diet induces oxidative stress that deregulates DNA repair mechanisms and may contribute to genome instability and tissue damage.

Associations of Antibiotics, Hormonal Therapies, Oral Contraceptives, and Long-Term NSAIDS With Inflammatory Bowel Disease: Results From the Prospective Urban Rural Epidemiology (PURE) Study.

BACKGROUND & AIMS: Several medications have been suspected to contribute to the etiology of inflammatory bowel disease (IBD). This study assessed the association between medication use and the risk of developing IBD using the Prospective Urban Rural Epidemiology cohort. METHODS: This was a prospective cohort study of 133,137 individuals between the ages of 20 and 80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed up prospectively at least every 3 years. The main outcome was the development of IBD, including Crohn's disease (CD) and ulcerative colitis (UC). Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) were evaluated. Results are presented as adjusted odds ratios (aORs) with 95% CIs. RESULTS: During a median follow-up period of 11.0 years (interquartile range, 9.2-12.2 y), there were 571 incident IBD cases (143 CD and 428 UC). Incident IBD was associated significantly with baseline antibiotic (aOR, 2.81; 95% CI, 1.67-4.73; P = .0001) and hormonal medication use (aOR, 4.43; 95% CI, 1.78-11.01; P = .001). Among females, previous or current oral contraceptive use also was associated with IBD development (aOR, 2.17; 95% CI, 1.70-2.77; P < .001). Nonsteroidal anti-inflammatory drug users also were observed to have increased odds of IBD (aOR, 1.80; 95% CI, 1.23-2.64; P = .002), which was driven by long-term use (aOR, 5.58; 95% CI, 2.26-13.80; P < .001). All significant results were consistent in direction for CD and UC with low heterogeneity. CONCLUSIONS: Antibiotics, hormonal medications, oral contraceptives, and long-term nonsteroidal anti-inflammatory drug use were associated with increased odds of incident IBD after adjustment for covariates.

An International Delphi Consensus on Diagnostic Criteria for Buerger's Disease.

BACKGROUND: Buerger's disease (BD) remains a debilitating condition. Despite multiple published diagnostic criteria for BD, none is universally accepted as a gold standard. METHODS: We conducted a 2-round modified Delphi consensus study to establish a consensus on the diagnostic. The questionnaire included statements from several commonly used diagnostic criteria for BD. Qualitative and quantitative analysis methods were performed. An agreement level of 70% was applied. RESULTS: Twenty nine experts from 18 countries participated in this study. Overall, 75 statements were circulated in Round 1. Of these, 28% of statements were accepted. Following comments, 21 statements were recirculated in Round 2 and 90% were accepted. Although more than 90% of the experts did not agree that the diagnosis of BD can be based only on clinical manifestation, none of the nonclinical manifestations of BD were agreed as a part of the diagnostic criteria. There was an agreement that a history of tobacco consumption in any form, not necessarily confined to the current use, should be a part of the diagnostic criteria of BD. The history of thrombophlebitis migrans, even if not present at presentation, was accepted as a clue for BD diagnosis. It was also agreed that discoloration of the toes or fingers could be included in the diagnostic criteria of BD. Experts agreed that histology results could differentiate BD from atherosclerosis obliterans and other types of vasculitis. The presence of corkscrew collaterals on imaging and burning pain reached the agreement at the first round but not at the second. There was no consensus regarding age cut-off, the requirement of normal lipid profile, and normal blood glucose for BD diagnosis. CONCLUSIONS: The present study demonstrated discrepancies in the various published diagnostic criteria for BD and their selective utilization in routine clinical practice worldwide. We propose that all published diagnostic criteria for BD be re-evaluated for harmonization and universal use.

Cardiovascular Risk Factors Drive Impaired Fasting Glucose to Type 2 Diabetes: Findings After a 9-Year Follow-Up in the PURE Study in Poland.

This study aimed to evaluate the role of risk factors included in the Framingham Risk Score for hard coronary heart disease (CHD) in the development of type 2 diabetes (DM) in patients with impaired fasting glycemia (IFG) after a 9-year follow-up. The research was part of the Polish insight into the international Prospective Urban and Rural Epidemiology (PURE) study. The cohort consisted of 283 subjects aged 54.3 ± 8.9 years who were diagnosed with IFG at baseline and then completed after a 9-year follow-up. The main risk factors for both CHD and DM evaluated were smoking, arterial hypertension, abnormal lipid profile, and family medical history. Most participants had both untreated or poorly controlled hypertension and dyslipidemia. Those who developed full-fledged DM over time were older and had significantly higher levels of fasting plasma glucose, lipid parameters, and mean blood pressure records. In conclusion, we confirmed that early diagnosis of dyslipidemia and hypertension, along with the treatment optimization of these conditions, could prevent or reduce the risk of DM and adverse cardiovascular outcomes. The study highlighted a large-scale problem of the modifiable risk factors that could jeopardize the health status in patients with IFG in the long range and pointed to targeted preventive measures.

Anthropometric Indices as Long-Term Predictors of Diabetes in Impaired Fasting Glucose Metabolism: Findings in the PURE Study in Poland.

This study aimed to assess the predictive value of anthropometric measurements in impaired fasting glucose progression to type 2 diabetes (T2DM) after 9 years of follow-up in the Prospective Urban and Rural Epidemiology (PURE) study run in Poland. The study group consisted of 283 patients aged 54.3 ± 8.9 years who had impaired fasting glucose at baseline and completed a 9-year-long follow-up. We analyzed body weight, height, waist (WC) and hip (HC) circumferences, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body mass index (BMI), and body adiposity index (BAI). Most individuals were overweight or obese according to BMI. Obesity occurred more often in men than women. The analysis highlighted the following three anthropometric parameters WHtR, BMI, and WC, each having equally good predictive power concerning the development of full-fledged T2DM in people with impaired fasting glucose. In conclusion, we confirmed the distinct harmfulness of obesity and pointed out the potential of easy-measured anthropometric parameters to self-control the risk of passing the impaired fasting glucose into T2DM.

The Plasma Oxylipin Signature Provides a Deep Phenotyping of Metabolic Syndrome Complementary to the Clinical Criteria.

Metabolic syndrome (MetS) is a complex condition encompassing a constellation of cardiometabolic abnormalities. Oxylipins are a superfamily of lipid mediators regulating many cardiometabolic functions. Plasma oxylipin signature could provide a new clinical tool to enhance the phenotyping of MetS pathophysiology. A high-throughput validated mass spectrometry method, allowing for the quantitative profiling of over 130 oxylipins, was applied to identify and validate the oxylipin signature of MetS in two independent nested case/control studies involving 476 participants. We identified an oxylipin signature of MetS (coined OxyScore), including 23 oxylipins and having high performances in classification and replicability (cross-validated AUCROC of 89%, 95% CI: 85-93% and 78%, 95% CI: 72-85% in the Discovery and Replication studies, respectively). Correlation analysis and comparison with a classification model incorporating the MetS criteria showed that the oxylipin signature brings consistent and complementary information to the clinical criteria. Being linked with the regulation of various biological processes, the candidate oxylipins provide an integrative phenotyping of MetS regarding the activation and/or negative feedback regulation of crucial molecular pathways. This may help identify patients at higher risk of cardiometabolic diseases. The oxylipin signature of patients with metabolic syndrome enhances MetS phenotyping and may ultimately help to better stratify the risk of cardiometabolic diseases.

Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

BACKGROUND: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. METHODS: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. FINDINGS: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. INTERPRETATION: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

The Natural Course of Impaired Fasting Glucose.

Impaired glucose regulation, including diabetes and prediabetes, poses a huge global problem not only in health but also in the epidemiological and economic areas. These disorders are often detected too late or remain unrecognized. The article aims to provide a review of the prevalence, etiology, and natural history of impaired fasting glucose (IFG). We focus on the progression of isolated IFG to full-fledged type 2 diabetes and the factors conducive to the development of diabetes. The knowledge about it could help design an optimal management program for the prevention of diabetes in patients with IFG; a program that would be patient-tailored and based on the underlying pathophysiology.

Co-occurrence of unclassified myeloproliferative neoplasm and giant cell arteritis in a patient treated with allogeneic hematopoietic stem cell transplantation: a case report and literature review.

Myeloproliferative neoplasms (MPNs) are a group of hematologic disorders characterized by clonal proliferation of myeloid lineage cells. The diagnostic criteria are based on morphological features of bone marrow and peripheral blood cells but also include specific genomic mutations. In some patients, co-occurrence of hematologic and rheumatic diseases could be observed. To date, most of the reported cases concerned patients with myelodysplastic syndrome (MDS) or essential thrombocythemia (ET). In this paper, we present a case of a patient with a complicated diagnostic process leading to the diagnosis of unclassified MPN and giant cell arteritis (GCA). Routine tests did not reveal any mutations typical for MPNs such as JAK-2, CALR, MPL or BCR-ABL. Targeted next-generation sequencing (NGS) helped to confirm the diagnosis by demonstrating the presence of heterozygous ASXL1, TET2, SRSF2, and CBL mutations. The second important issue was the overlapping of symptoms of MPN and seronegative rheumatic disease, which finally was diagnosed as GCA. Leukocytosis and musculoskeletal pain, which were present at the time of diagnosis, resolved after allogeneic hematopoietic stem cell transplantation but recurred after a few months along with decreasing donor cell chimerism. Differentiation of the causes of recurrence of the symptoms was an important issue. This case shows the diagnostic challenge posed by co-incidence of MPN and rheumatic disease, especially its atypical variants.

Effects of Long-Term High-Fat Diet and Its Reversal on Lipids and Lipoproteins Composition in Thoracic Duct Lymph in Pigs.

BACKGROUND This study was carried out to evaluate the effects of a long-term high-fat diet on lipids and lipoproteins composition in thoracic duct lymph in pigs. MATERIAL AND METHODS We examined lymph taken from the thoracic duct from 24 female white sharp-ear pigs, divided into 3 experimental groups fed different diets for 12 months: (a) the control group, fed the standard balanced diet; (b) the HFD group, fed an unbalanced, high-fat diet, and (c) the reversal diet group (RD), fed an unbalanced, high-fat diet for 9 months and then a standard balanced diet for 3 months. RESULTS Lymph analysis after 12 months of fixed diets revealed significantly higher concentration of proteins in the HFD group in comparison to the control and RD groups. Examination of lymph lipoproteins fractions showed that the high-fat diet in the HFD group in comparison to control group caused an increase in cholesterol, phospholipids, and proteins content within HDL and chylomicrons. There were also more proteins within HDL in the HFD group in comparison to the RD group and more triglycerides within chylomicrons in the HFD group in comparison to the control group. CONCLUSIONS A long-term high-fat diet resulted in changed structure of HDL and chylomicrons in the thoracic duct lymph. Alterations in HDL composition suggest that a high-fat diet enhances reverses cholesterol transport. Changes in chylomicrons structure show the adaptation to more intense transport of dietary fat from the intestine to the liver under the influence of a high-fat diet. Reversal to a standard balanced diet had the opposite effects.

Changes in diabetes prevalence and corresponding risk factors - findings from 3- and 6-year follow-up of PURE Poland cohort study.

BACKGROUND: Diabetes mellitus (DM) is one of the greatest challenges for public health worldwide. The aim of the study was the analysis of diabetes development in participants with normoglycemia and Impaired Fasting Glucose (IFG) in 3-year and 6-year follow-up of PURE Poland cohort study. METHODS: The analysis was conducted in Polish cohort enrolled into Prospective Urban and Rural Epidemiology (PURE) Study. The following study presents results of 1330 participants that have partaken both in the baseline study, in 3-year and in the 6-year follow up. The analysis of the impact of risk factors on diabetes development was performed using multivariate Cox frailty analysis. Population Attributable Risk (PAR) was computed individually for every risk factor. RESULTS: Diabetes prevalence increased from 17.7% at baseline to 23.98% in 3-year- and 28.27% in 6-year follow-up. The risk of diabetes was higher in participants with obesity [HR = 5.7, 95%Cl 2,56-12,82], overweight [HR = 3.4, 95%Cl 1,56-7,54] and IFG [HR = 2.7, 95%Cl 1,87-3,85]. The risk of diabetes development was almost 2-fold higher in men than in women [HR = 1.826; 95%CI =1,24 - 2,69]. In 6 years, diabetes developed in 23.8% of participants with IFG and 7.9% of participants with normoglycemia. According to PAR, overweight and obesity accounted for 80.8%, hypertension for 67.6% and IFG for 38.3% of diabetes cases in our population. CONCLUSIONS: Our study reveals alarming increase in prevalence of diabetes during 6 years of observation. In our population, most diabetes cases can be attributed to overweight, obesity, hypertension and IFG. Findings add strong rationale to implement targeted preventive measures in population of high risk.

A compression device versus compression stockings in long-term therapy of lower limb primary lymphoedema after liposuction.

OBJECTIVE: Primary lymphoedema is rare and in most cases develops in the lower extremities. In some cases, conservative treatment is insufficient and can be supported by surgical procedure. The aim of this case study was to show the difference in the effectiveness of a compression wrap device and compression stockings in the treatment of primary lymphoedema. METHOD: Before and after liposuction the patient was treated on an outpatient basis every day for three weeks. This consisted of complex decongestive therapy (CDT) including manual lymph drainage, tailored exercises, skin and nail care, compression therapy and intermittent pneumatic compression. After CDT, the patient was provided with a flat-knit compression garment. Measurements were taken at one week and at three months of wearing the compression garment. The oedema severity was measured by summary calculation method. For both healthy and swollen limbs, the sum of circumferences taken at nine fixed measuring points was determined. The difference between these sums expressed in percents was presented as a relative metric coefficient of leg lymphoedema (RMCL). RESULTS: At the start of therapy, the difference in circumference between the healthy and swollen limb was 21.85%. After CDT (RMCL: 13.46%), the patient was provided with a flat-knit compression stocking (class 3). After one week, the RMCL was 15.92%, while after three months RCML was 20.84%. Because fluid retention was observed the patient was again treated with CDT (RMCL: 13.89%). The patient was provided with compression stocking (class 4). After one week of wearing, the RMCL was 15.77%, while after three months RMCL was 20.26%. As the results proved unsatisfactory, the patient was treated with CDT (RMCL: 13.60%) and a combination of two class 4 compression stockings was used. After one week, RMCL was 14.91%, while after three months RMCL was 19.25%. As the effects of oedema reduction were insufficient, the patient was treated again with CDT (RMCL: 13.89%) and advised to replace one of the stockings with a CirAid device (adjustable compression wrap). After one week, RMCL was 14.18% and after three months RMCL was 14.76%. The patient then qualified for liposuction (RMCL: 7.81%). At three months after surgery, the compression stocking was replaced by an adjustable compression wrap, to reduce the difference in circumference between healthy and swollen limbs (from 21.85 % to 8.68%). CONCLUSION: This case study shows that in primary oedema one class of compression garment is not always sufficient, nor is the combination of two garments with varying degrees of compression. In some cases, the situation requires the use of non-elastic leg binders such as a CircAid device which, thanks to its greater stiffness, helps improve clinical outcomes.

Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study.

BACKGROUND: WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. METHODS: The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35-70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. FINDINGS: 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3-5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42-4·43; change -1·00 events per 1000 years, 95% CI -2·00 to -0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43-5·08 g/day, mean intake 4·70 g/day, 4·44-5.05; change 0·24 events per 1000 years, -2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08-7·49; change 0·37 events per 1000 years, -0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, -0·26 events, -0·46 to -0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. INTERPRETATION: Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. FUNDING: Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.

Association between egg consumption and elevated fasting glucose prevalence in relation to dietary patterns in selected group of Polish adults.

BACKGROUND: The safety of high egg intake in view of its impact on glucose metabolism remains inconclusive. The aim of the study was to assess the relationship between egg intake, dietary patterns and elevated fasting glucose (FG) level in a selected group of Polish adults. METHODS: The study group consisted of 1630 adults who participated in the Polish arm of the Prospective Urban Rural Epidemiological Study. Dietary intake, including egg intake, was assessed based on the data from the Additional file 2 Food Frequency Questionnaire previously validated for the population of Lower Silesia. DPs were derived using principal component analysis. FG levels ≥100 mg/dl were considered elevated. Subjects who used antidiabetic drugs were included in the group with elevated FG levels. RESULTS: Egg consumption increased in higher quartiles of "Western" and "traditional" DPs in both men and women (p < 0.0001). In a crude model each 10 g of eggs consumed per day was associated with 7% increased risk (OR 1.07; 95% CI: 1.01-1.15) of elevated glucose level in the overall group and 10% increased risk (OR 1.10; 95% CI: 1.01-1.21) of elevated glucose level in the group of men. Men who consumed at least five eggs per week had higher risk for elevated FG level compared to men who consumed at most one egg per week (OR 1.79; 95% CI 1.13-2.84), but this relationship became insignificant when the data were adjusted for DPs. In the group of women no association between egg intake and elevated FG level was observed. CONCLUSIONS: Higher egg intake may be associated with the overall unhealthy dietary habits, which is why the number of eggs consumed daily should not be considered an independent risk factor for elevated fasting glucose level.

Sociodemographic characteristic of changes in smoking patterns in rural and urban population of PURE Poland study: findings from 6-year follow up.

BACKGROUND: Tobacco smoking is one of the most serious modern civilization threats. According to WHO identifying patterns of tobacco use is essential for implementing effective preventive policies. The aim of the paper was to assess changes in smoking patterns among the PURE study population over 6 years. METHODS: The study sample comprised of 1784 adult participants from PURE Poland study, who were assessed at baseline (2007-2010) and then at 6-year follow-up. Participants were classified into current smokers, ex-smokers and never smokers. Smoking patterns were analyzed according to sex, age/birth cohort, place of residence (urban vs rural setting), and education level. RESULTS: Overall, a significant decrease of 3.1% in current smokers was observed (from 20.0% in baseline to 16.9 at follow-up). However, 0.8% of never smokers and 6.2% of ex-smokers at baseline were classified as current smokers at 6-year follow-up. Despite overall decrease in percentage of current smokers in both rural and urban area, in fact significantly more ex-smokers from rural area became current smokers after 6 years. Living in the rural area was associated with nearly two-fold increase in current smoking, and almost two-fold decline in chances to quit smoking. The highest percentage of current smokers was observed in birth year cohort 1961-1979. CONCLUSION: Despite a small but significant decline in overall smoking rates, important differences in smoking and quitting patterns emerged between rural and urban areas, as well as sexes. A less favorable smoking patterns were observed among women, and rural populations, suggesting that these are important targets of future tobacco control interventions in Poland.

Association between dietary patterns and metabolic syndrome in the selected population of Polish adults-results of the PURE Poland Study.

BACKGROUND: Dietary pattern (DP) analysis is a statistical method used to evaluate the comprehensive effect of the diet on health. The aim of the study was to assess the relationship between DPs derived in selected population of Lower Silesia and the prevalence of metabolic syndrome (MS) and its components. METHODS: Study group consisted of 1634 individuals enrolled in the Prospective Urban and Rural Epidemiological Study Poland. Dietary intake was estimated using the data from the Food Frequency Questionnaire. DPs were identified using principal component analysis. MS prevalence was evaluated based on the criteria accepted by International Diabetes Federation, American Heart Association and National Heart, Lung and Blood Institute in 2009. RESULTS: Three DPs were identified. The percentage of individuals with MS was lower in the upper quartile (Q) of the 'fruit & vegetables' DP in comparison with Q1 (40.4 vs. 48.9%). Inverse relationship was observed for 'Western' (Q4 vs. Q1: 50.7 vs. 40.8%) and 'traditional' DPs (51.0 vs. 38.3%). After adjusting for potential confounders, in Q4 of 'traditional' DP higher risk for central obesity was observed compared to Q1 (OR 1.52; 95% CI: 1.10-2.12). Individuals in Q3 of 'fruit & vegetables' DP had lower risk for raised blood pressure in comparison with the bottom Q (OR 0.54; 95% CI: 0.36-0.82). CONCLUSIONS: DP analysis allows to evaluate the synergistic effect of the diet on the MS prevalence. 'Fruit & vegetables' DP, in contrast to 'Western' and 'traditional' DPs, was negatively associated with the prevalence of MS and its components in the study group.

Prevalence and Risk of Obstructive Sleep Apnea and Arterial Hypertension in the Adult Population in Poland: An Observational Subset of the International Prospective Urban Rural Epidemiology (PURE) Study.

Obstructive sleep apnea (OSA) is a common breathing disorder affecting millions of people worldwide. The disorder is connected with serious consequences including hypertension, myocardial infarction, arrhythmias, coronary disease, cardiac insufficiency, stroke, transient ischemic attack, and cognitive decline. Epidemiological data assessing the prevalence of OSA in different countries vary in methodology, size, and characteristics of population chosen and thus are hardly comparable. There are very few reports on the prevalence of OSA and on the diagnostic accuracy of sleep questionnaires available in Poland. In this report we present the analysis of the prevalence of, and risk factors for OSA in the Polish adult population consisting of 613 community-based subjects (227 men and 386 women). The study was based on the STOP-BANG questionnaire, a validated Screening Tool for OSA in primary care. It is a part of Polish subset of the Prospective Urban Rural Epidemiology (PURE) study, an ongoing population cohort study of individuals from urban and rural communities from 21 countries. We took into account age, gender, body mass index (BMI), and antihypertensive treatment. The findings are that over one half of the Polish population investigated had a moderate to high risk of OSA (66.5% of men and 60.1% of women). After the adjustments for age, gender, and BMI we noticed a dose-response relationship between arterial blood pressure behavior and OSA. The association was significant among women, but not men. Based on previous studies we can assume that one half of this high risk group would be further diagnosed for OSA. This study, the first large scale screening for OSA in Poland, shows a substantial, much higher than previously appreciated, prevalence of risk for OSA in the population at large.

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.

BACKGROUND: The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. METHODS: The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. FINDINGS: During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76-0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality. INTERPRETATION: High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).