Björn Bergdahl

Antioxidant state and mortality from coronary heart disease in lithuanian and swedish men: concomitant cross sectional study of men aged 50

Abstract Objective: To investigate possible risk factors and mechanisms behind the four times higher and diverging mortality from coronary heart disease in Lithuanian compared with Swedish middle aged men. Design: Concomitant cross sectional comparison of randomly selected 50 year old men without serious acute or chronic disease. Methods and equipment were identical or highly standardised between the centres. Setting: LinkÖping (Sweden) and Vilnius (Lithuania). Subjects: 101 and 109 men aged 50 in LinkÖping and Vilnius respectively. Main outcome measures: Anthropometric data, blood pressure, smoking, plasma lipid and lipoprotein concentrations, susceptibility of low density lipoprotein to oxidation, and plasma concentrations of fat soluble antioxidant vitamins. Results: Systolic blood pressure was higher (141v 133 mm Hg, P<0.01), smoking habits were similar, and plasma total cholesterol (5.10 v 5.49 mmol/l, P<0.01) and low density lipoprotein cholesterol (3.30 v 3.68 mmol/l, P<0.01) lower in men from Vilnius compared with those from LinkÖping. Triglyceride, high density lipoprotein cholesterol, and Lp(a) lipoprotein concentrations did not differ between the two groups. The resistance of low density lipoprotein to oxidation was lower in the men from Vilnius; lag phase was 67.6 v 79.5 minutes (P<0.001). Also lower in the men from Vilnius were mean plasma concentrations of lipid soluble antioxidant vitamins (ß carotene 377v 510 nmol/l, P<0.01; lycopene 327 v 615 nmol/l, P<0.001; and lipid adjusted tocopherol 0.25v 0.46 µmol/mmol, P<0.001. Tocopherol concentration did not differ). Regression analysis showed that the lag phase was still significantly shorter by 10 minutes in men from Vilnius when the influence of other known factors was taken into account. Conclusions: The high mortality from coronary heart disease in Lithuania is not caused by traditional risk factors alone. Mechanisms related to antioxidant state may be important. Key messages Mortality from coronary heart disease in 50-54 year old men is four times higher in Lithuania than in Sweden Differences in traditional risk factors for coronary heart disease in 50 year old men in LinkÖping (Sweden) and Vilnius (Lithuania) were small–systolic blood pressure was higher in men from Vilnius, but total and low density lipoprotein cholesterol concentrations were lower and smoking habits similar The resistance of low density lipoprotein to oxidation was lower in men from Vilnius and remained after adjustment for antioxidant vitamin concentrations Plasma concentrations of the antioxidant vitamins, ß carotene, lycopene, and lipid adjusted tocopherol were lower in men from Vilnius; tocopherol did not differ Mechanisms related to antioxidant state may be important in explaining the much higher mortality from coronary heart disease in Lithuanian compared with Swedish middle aged men

Increased psychosocial strain in Lithuanian versus Swedish men: the LiVicordia study.

Objective Coronary heart disease (CHD) mortality is four times higher in 50-year-old Lithuanian men than in 50-year-old Swedish men. The difference cannot be explained by standard risk factors. The objective of this study was to examine differences in psychosocial risk factors for CHD in the two countries. Methods The LiVicordia study is a cross-sectional survey comparing 150 randomly selected 50-year-old men in each of the two cities: Vilnius, Lithuania, and Linkoping, Sweden. As part of the study, a broad range of psychosocial characteristics, known to predict CHD, were investigated. Results In the men from Vilnius compared with those from Linkoping, we found a cluster of psychosocial risk factors for CHD; higher job strain (p <.01), lower social support at work, lower emotional support, and lower social integration (p values <.001). Vilnius men also showed lower coping, self-esteem, and sense of coherence (p values < .001), higher vital exhaustion, and depression (p values < .001). Quality of life and perceived health were lower and expectations of ill health within 5 to 10 years were higher in Vilnius men (p values < .001). Correlations between measurements on traditional and psychosocial risk factors were few and weak. Conclusions The Vilnius men, representing the population with a four-fold higher CHD mortality, had unfavorable characteristics on a cluster of psychosocial risk factors for CHD in comparison with the Linkoping men. We suggest that this finding may provide a basis for possible new explanations of the differences in CHD mortality between Lithuania and Sweden.

Lectures in problem-based learning—Why, when and how? An example of interactive lecturing that stimulates meaningful learning

Even though opinions differ as to whether lecturing is compatible with problem-based learning (PBL) or not, lectures are still a common form of instruction in PBL curricula. This paper discusses the lecture in the framework of theories of learning in general and the medical problem-based learning tradition in particular. An example of how theories of learning can be implemented in the lecture hall is presented. Theories that underpin PBL as an educational philosophy rather than as a method of instruction are reviewed. A lecture form, organized in introductory, in depth and application lectures, that responds to important factors for stimulating deep processing of knowledge and meaningful learning is discussed. Examples of and practical points about how to renew and restructure lectures in a way that counteracts surface approaches to learning, teacher centring and student passivity are presented. We argue that, with proper awareness of possible drawbacks of the large format, lectures can be used as valuable tools for learning also in a PBL curriculum.

Risk factors for coronary heart disease in different socioeconomic groups of Lithuania and Sweden : the LiVicordia study

Aims: Lithuanian middle-aged men have a fourfold higher risk for coronary heart disease (CHD) mortality compared with Swedish men. In Sweden, CHD mortality is twice as high in blue- compared with white-collar workers. Whether the same risk factors that characterized Lithuanian men, compared with Swedish men, could be found in low socioeconomic groups within the cities was investigated. Methods : The LiVicordia study compared both traditional and new possible risk factors for CHD among 150 50-year-old men in Linköping, Sweden and Vilnius, Lithuania. A comparison was made of the prevalence of these risk factors in high and low socioeconomic groups within the cities and, after controlling for the city, variations across socioeconomic groups in the total sample. Results: Small differences were found in traditional risk factors between cities. However, Vilnius men were shorter, had lower serum levels of antioxidant vitamins, more psychosocial strain, and lower cortisol response to a standardized laboratory stress test. These characteristics were also found among men in low social classes in both cities. In linear regression models, short stature, low serum β-carotene, low social integration, coping and self-esteem, high vital exhaustion, high baseline and low cortisol response to stress were related to low social class. Conclusions: The same set of risk factors, mainly relating to oxidative and psychosocial stress, that characterized Vilnius men was also found in men in low social classes within the cities. The results suggest that a common set of risk factors may help to explain health differences both between and within countries.

Effects of a Problem-Based Learning Rehabilitation Programme on Quality of Life in Patients with Coronary Artery Disease

Background: The aim of cardiac rehabilitation (CR) is not only physical improvement but also increased quality of life (QoL). A CR programme based upon problem based learning (PBL) philosophy was developed, to achieve and apply new knowledge related to coronary artery disease (CAD). The aim of this paper was to evaluate the impact of the PBL programme on QoL. Methods: 207 consecutive patients < 70 years of age with a recent event of CAD were randomised to a PBL group (n = 104) or a control group (n = 103). In addition to standard treatment, the PBL patients participated in 13 group sessions during 1 year, where individual learning needs and behavioural changes were focused upon. QoL was measured by the Ladder of Life, Self-Rated Health (SRH), SF 36, and Cardiac Health Profile (CHP). Results: Significant differences between the groups, favouring the PBL patients, were found by global instruments: more optimistic expectations of the future QoL and a better general condition. No differences were found by SRH, SF 36 or subscales of CHP, but QoL increased in both groups during the year. Conclusions: The main outcome was that QoL improved in both groups with some effects favouring the PBL programme.

The validity of the Computer Science and Applications activity monitor for use in coronary artery disease patients during level walking

The principal aim of the present study was to examine the validity of the Computer Science and Applications (CSA) activity monitor during level walking in coronary artery disease (CAD) patients. As a secondary aim, we evaluated the usefulness of two previously published energy expenditure (EE) prediction equations. Thirty‐four subjects (29 men and five women), all with diagnosed CAD, volunteered to participate. Oxygen uptake (VO2) was measured by indirect calorimetry during walking on a motorized treadmill at three different speeds (3·2, 4·8 and 6·4 km h−1). Physical activity was measured simultaneously using the CSA activity monitor, secured directly to the skin on the lower back (i.e. lumbar vertebrae 4–5) with an elastic belt. The mean (±SD) activity counts were 1208 ± 429, 3258 ± 753 and 5351 ± 876 counts min−1, at the three speeds, respectively (P<0·001). Activity counts were significantly correlated to speed (r=0·92; P<0·001), VO2 (ml kg−1 min−1; r=0·87; P<0·001) and EE (kcal min−1; r=0·85, P<0·001). A stepwise linear regression analysis showed that activity counts and body weight together explained 75% of the variation in EE. Predicted EE from previously published equations differed significantly when used in this group of CAD patients. In conclusion, the CSA activity monitor is a valid instrument for assessing the intensity of physical activity during treadmill walking in CAD patients. Energy expenditure can be predicted from body weight and activity counts.

Adipose tissue fatty acids in men from two populations with different cardiovascular risk - the LiVicordia study.

The LiVicordia study was set up to investigate possible causes for coronary heart disease mortality in middle-aged Lithuanian men being four times higher than in Swedish men. In a previous part of this study we found lower total and low density lipoprotein (LDL) cholesterol in the Lithuanian men in spite of them having a higher fat intake than in the Swedish men. Their LDL was also more susceptible to oxidation in vitro than was that of the Swedish men. Fat quality can influence LDL oxidation. In order to obtain data on long-term fat quality intake we measured the fatty acid composition of abdominal wall adipose tissue by gas chromatography in men aged 50 years from Vilnius, Lithuania (n=50) and Linköping, Sweden (n=50). Men from Vilnius had a significantly higher percentage of adipose tissue long chain polyunsaturated fatty acids (PUFA) (20:4n6, 20:5n3, 22:5n5, 22:6n3) and lower percentage of saturated fatty acids, especially myristic acid (14:0), 3.4+/-0.7 versus 4.6+/-0.8, p<0.0001. The percentage content of adipose tissue linoleic acid (18:2n6) was 11.5+/-2.1 versus 11.0+/-1.4 (n.s.) and of linolenic acid (18:3n3) 0.7+/-0.3 versus 0.6+/-0.2 (n.s.) in men from Vilnius and Linköping, respectively. It is concluded that the adipose tissue content of essential fatty acids is similar in men from Vilnius and men from Linköping and therefore the intake is also likely to be similar. The higher contents of long chain highly unsaturated fatty acids in men from Vilnius may be of importance in the oxidation process of LDL.

Perspectives on using multimedia scenarios in a PBL medical curriculum

In 1999, the Faculty of Health Sciences at Linköping University, Sweden, started up a process of replacing text-based problem-based learning (PBL) scenarios with web-based multimedia-enhanced scenarios. This article brings together three studies of the results of this process and the experience gained from 10 years of implementation work. Results and conclusions: Adding multimedia to PBL scenarios makes them more realistic and thereby more motivating and stimulating for the student to process. The group process is not disrupted by the introduction of the computer in the group room. It is important to challenge the students by varying the scenarios’ perspective and design in order to get away from cue-seeking behaviors that might jeopardize a deep approach to learning. Scrutinizing all scenarios in a PBL curriculum can be used as a tool for improvement and renewal of the entire curriculum.

Ultrasound determined carotid and femoral atherosclerosis in Lithuanian and Swedish men: the LiVicordia study

Coronary heart disease mortality is four times higher in Lithuanian compared to Swedish middle-aged men. Using the same equipment (Acuson XP10 with 5 MHz linear transducer) and staff, we compared the amount of atherosclerosis in carotid and femoral arteries in 100 randomly sampled 50-year-old men in each of the cities Vilnius, Lithuania and Linköping, Sweden. Atherosclerotic plaques were more abundant in Vilnius men compared to Linköping men (53 versus 28% in the common carotid artery, 73 versus 37% in the common femoral artery, P < 0.001 for both). Plaques were thicker and more extended in arteries of Vilnius men, and an ultrasound atherosclerosis score was higher in both carotid and femoral arteries (P < 0.001 for all). More Vilnius men had a maximal intima-media thickness of the common femoral artery above 1 mm (P<0.005). Stiffness in the common carotid artery was higher in Vilnius men (P<0.001). In a linear regression model of the pooled material, after adjustment for city was made, smoking, systolic blood pressure, low density lipoprotein cholesterol and beta-carotene (inversely) significantly contributed to a high total ultrasound score (r2 = 0.32). These findings show that the higher coronary mortality noted in Lithuanian men goes together with a higher prevalence of early peripheral atherosclerosis.

Effects of a problem-based learning rehabilitation program on physical activity in patients with coronary artery disease.

PURPOSE To evaluate the effects of a problem-based learning (PBL) rehabilitation program on physical activity. METHODS We randomized 207 consecutive patients younger than 70 years, with a recent event of coronary artery disease (CAD), to a PBL group (n = 104) or a control group (n = 103). In addition to standard treatment, the PBL patients participated in a 1-year program with 13 sessions in small groups, where learning needs and behavior change were focused upon. Physical activity was assessed by means of interviews with all patients and by an activity monitor in 69 patients at pretest and in 175 after 1 year. RESULTS Only small differences between groups were found at posttest. Interview data revealed significantly less activity at low-intensity level in the control group, whereas the activity monitor showed no significant differences. No changes were found in total physical activity during the year within the 2 groups. The self-reported physical activity indicating a level of brisk walking was markedly higher than that measured by the activity monitor, the latter indicating that only 35% of the patients achieved a 10-minute period of continued physical activity per day on an adequate level. CONCLUSIONS Our PBL program had no important impact on the physical activity pattern of patients with CAD. The activity monitor is a feasible way of measuring physical activity in these patients, indicating a lower level of physical activity than interview data.