Christian Lösch

Distribution and prevalence of reflux in the superficial and deep venous system in the general population--results from the Bonn Vein Study, Germany.

OBJECTIVE Venous diseases are among the most frequent diseases in the general population of industrialized countries. The aim of this article is to investigate the population-based prevalence of pathologic reflux in superficial and deep leg veins, taking into account factors as gender, age, and clinical classification of venous disease. METHODS In a population-based cross-sectional study, 3072 subjects aged 18 to 79 years (1350 male, 1722 female, response 59%) were enrolled from October 2000 through November 2001. A standardized interview was conducted to document phlebological history and clinical examinations including duplex sonography of selected superficial and deep leg veins. Pathological reflux was defined as being >500 ms. All participants where classified according to the CEAP classification. RESULTS Using the highest clinical stage per participant, 9.6% where classified C0, 59.0% C1, 14.3% C2, 13.5% C3, 2.9% C4, and 0.7% C5-C6. A pathological reflux (>500 ms) was found in 35.3% (95% confidence interval [CI] 33.6-37.1) of subjects with 21.0% (95% CI 19.5-22.5) showing reflux in at least one superficial vein and 20.0% (95% CI 18.6-21.5) showing reflux in at least one deep vein. We observed significantly higher reflux prevalence for the superficial veins in women while for the deep veins reflux prevalence were significantly higher in men. Prevalence of reflux in the superficial veins markedly increases with age. In the deep venous system, no clear changes in reflux prevalence with age can be observed. For superficial veins, reflux prevalence is markedly higher with higher C-stages. For the deep veins, the proportion of refluxes is relatively constant in stages C0-C3 with a distinct increase of prevalence from stage C4 onward. CONCLUSION Our results show a high prevalence of reflux both for the superficial and the deep venous system. Reflux prevalence is associated with gender, age, and the clinical stage as measured by the CEAP classification. Further longitudinal studies are needed to clarify the relevance of pathological reflux in subjects with otherwise healthy veins.

Dyslipidemia in primary care – prevalence, recognition, treatment and control: data from the German Metabolic and Cardiovascular Risk Project (GEMCAS)

BackgroundCurrent guidelines from the European Society of Cardiology (ESC) define low thresholds for the diagnosis of dyslipidemia using total cholesterol (TC) and LDL-cholesterol (LDL-C) to guide treatment. Although being mainly a prevention tool, its thresholds are difficult to meet in clinical practice, especially primary care.MethodsIn a nationwide study with 1,511 primary care physicians and 35,869 patients we determined the prevalence of dyslipidemia, its recognition, treatment, and control rates. Diagnosis of dyslipidemia was based on TC and LDL-C. Basic descriptive statistics and prevalence rate ratios, as well as 95% confidence intervals were calculated.ResultsDyslipidemia was highly frequent in primary care (76% overall). 48.6% of male and 39.9% of female patients with dyslipidemia was diagnosed by the physicians. Life style intervention did however control dyslipidemia in about 10% of patients only. A higher proportion (34.1% of male and 26.7% female) was controlled when receiving pharmacotherapy. The chance to be diagnosed and subsequently controlled using pharmacotherapy was higher in male (PRR 1.15; 95%CI 1.12–1.17), in patients with concomitant cardiovascular risk factors, in patients with hypertension (PRR 1.20; 95%CI 1.05–1.37) and cardiovascular disease (PRR 1.46; 95%CI 1.29–1.64), previous myocardial infarction (PRR 1.32; 95%CI 1.19–1.47), and if patients knew to be hypertensive (PRR 1.18; 95%CI 1.04–1.34) or knew about their prior myocardial infarction (PRR 1.17; 95%CI 1.23–1.53).ConclusionThresholds of the ESC seem to be difficult to meet. A simple call for more aggressive treatment or higher patient compliance is apparently not enough to enhance the proportion of controlled patients. A shift towards a multifactorial treatment considering lifestyle interventions and pharmacotherapy to reduce weight and lipids may be the only way in a population where just to be normal is certainly not ideal.

Prevalence of obesity in primary care using different anthropometric measures – Results of the German Metabolic and Cardiovascular Risk Project (GEMCAS)

BackgroundObesity is one of the greatest challenges in primary health care. The BMI describes fat mass and waist circumference (WC) fat distribution and total metabolic and cardiovascular risk. It was aim of the present study to assess the prevalence of a) overweight and obesity and b) an increased and high WC in adults seeking primary care in Germany and to describe the associations of both measures with cardiovascular risk factors and prognosis.MethodsThis was a point prevalence study with 1,511 primary care physicians and 35,869 adult patients in 2005. Bodyweight, height and waist circumference was measured and blood samples taken to determine the presence of cardiovascular risk factors, including lipids, blood pressure, fasting glucose, low physical activity, smoking and family history of myocardial infarction. We calculated rate ratios stratified for age and gender.ResultsThere was a high prevalence of overweight (45.7% male [95%CI 44.9–46.5]; 30.6% female [95%CI 30.0–31.2]) and obesity (24.7% male [95%CI 24.0–25.4]; 23.3% female [95%CI 22.8–23.9]). 36.4% of male [95%CI 35.6–37.2] and 41.5% of female [95%CI 40.8–42.1] had a high WC (male > 102, female > 88 cm). A high WC in addition to an overweight BMI identified patients with more risk factors (male: mean of 3.93 risk factors (RF) at a WC > 102 cm vs. 2.88 RF in patients ≤ 94 cm; female 3.58 RF at a WC > 88 cm vs. 2.41 RF ≤ 80 cm).ConclusionThere is a high prevalence of obesity (24.7% of male and 23.3% of female) and, in particular, abdominal obesity (36.4% of male and 41.5% of female) in adults attending a primary care physician in Germany. The determination of the BMI is sufficient to assess risk in normal weight and obese patients, while a high WC identifies high risk patients from within the overweight group.

Age- and sex-specific prevalence and ten-year risk for cardiovascular disease of all 16 risk factor combinations of the metabolic syndrome - A cross-sectional study

BackgroundBased on the AHA/NHLBI-definition three out of five cardiometabolic traits must be present for the diagnosis of the metabolic syndrome (MetS), resulting in 16 different combination types. The associated cardiovascular risk may however be different and specific combination may be indicative of an increased risk, furthermore little is known to which extent these 16 combinations contribute to the overall prevalence of MetS. Here we assessed the prevalence of all 16 combination types of MetS, analyzed the impact of age and gender on prevalence rates, and estimated the 10-year risk of fatal and non-fatal myocardial infarction (MI) of each MetS combination type.MethodsWe used data of the German Metabolic and Cardiovascular Risk Project (GEMCAS), a cross-sectional study, performed during October 2005, including 35,869 participants (aged 18-99 years, 61% women). Age-standardized prevalence and 10-year PROCAM and ESC risk scores for MI were calculated.ResultsIn both men and women the combination with elevated waist-circumference, blood pressure and glucose (WC-BP-GL) was the most frequent combination (28%), however a distinct unequal distribution was observed regarding age and sex. Any combination with GL was common in the elderly, whereas any combination with dyslipidemia and without GL was frequent in the younger. Men without MetS had an estimated mean 10-year risk of 4.7% (95%-CI: 4.5%-4.8%) for MI (PROCAM), whereas the mean 10-year risk of men with MetS was clearly higher (age-standardized 7.9%; 7.8-8.0%). In women without MetS the mean 10-year risk for MI was 1.1%, in those with MetS 2.3%. The highest impact on an estimated 10-year risk for MI (PROCAM) was observed with TG-HDL-GL-BP in both sexes (men 14.7%, women 3.9%). However, we could identify combinations with equal risks of non-fatal and fatal MI compared to participants without MetS.ConclusionsWe observed large variations in the prevalence of all 16 combination types and their association to cardiovascular risk. The importance of different combinations of MetS changes with age and between genders putting emphasis on a tailored approach towards very young or very old subjects. This knowledge may guide clinicians to effectively screen individuals and prioritize diagnostic procedures depending on age and gender.

Overweight, Obesity and High Waist Circumference: Regional Differences in Prevalence in Primary Medical Care

INTRODUCTION The prevalence of obesity and elevated waist circumference in Germany is high. However, there are insufficient data on the situation in primary care and on regional distribution to support medical preventive measures. METHODS The German Metabolic and Cardiovascular Risk Project (GEMCAS) is a national cross-sectional study including 1511 primary care practices and 35 869 patients. Height, weight, waist circumference, laboratory values, and type 2 diabetes were documented. RESULTS The crude prevalence of obesity was 23.9% (95% CI 23.4 to 24.3) (standardized 22.8% [95% CI 22.3 to 23.2]), with a minimum in Bremen (19.8% [95% CI 15.1 to 24.5]) and a maximum in Saxony-Anhalt (28.3% [95% CI 25.4 to 31.1]). The crude prevalence of high waist circumference (> 102/88 cm) was 39.5% (95% CI 39.0 to 40.0) (standardized 36.5% [95% CI 36.0 to 36.9]), with a minimum in Hamburg (30.5% [95% CI 26.2 to 34.8]) and a maximum in Saxony-Anhalt (42.1% [95% CI 39.2 to 45.1]). The prevalence of obesity as assessed by BMI was higher in men than in women, but greater in women as assessed by waist circumference. Nationwide, 50 out of every 100 patients with obesity had type 2 diabetes, and 32 of 100 patients with a high waist circumference had type 2 diabetes. CONCLUSIONS The prevalence of obesity is higher in northeastern Germany than in the southwest. Overall, abdominal obesity is considerably more frequent than obesity based on BMI. Surprisingly, a high prevalence of obesity in some federal states does not automatically mean a higher number of people with type 2 diabetes.

Regional Differences in the Prevalence of the Metabolic Syndrome in Primary Care Practices in Germany

INTRODUCTION Data on the prevalence and regional distribution of the metabolic syndrome in Germany are lacking, in particular for primary care. METHODS In October 2005 anthropometric measurements were taken from 35 869 consecutive patients aged 18 to 99 years, in 1511 primary care practices. Waist circumference, blood pressure, lifestyle, and past medical history were assessed and blood tests taken (HDL-, LDL- and total cholesterol, triglycerides, glucose). Crude and age-standardized prevalence were calculated. RESULTS Women in the eastern part of Germany showed a higher age-standardized prevalence of the metabolic syndrome than women in the western part (21.1%; 95% CI: 19.9 to 22.4 respectively 17.7%; 95% CI: 17.2 to 18.3). In men the prevalences were 22.7% (95% CI: 20.9 to 24.4) and 21.4% (95% CI: 20.6 to 22.1) respectively. Patients from Saxony-Anhalt, Brandenburg, and Mecklenburg-Western Pomerania showed the highest prevalence, while women in Hamburg, Berlin, and Hesse and men in Schleswig-Holstein, Saarland, and Hamburg showed the lowest prevalence. Cardiovascular disease prevalence was comparable, while diabetes prevalence was higher in patients from eastern Germany (17% vs.13% in men; 12% vs. 9% in women). DISCUSSION The prevalence of the metabolic syndrome in German primary care is high. Prevention efforts should focus in particular on differences in gender, socioeconomic status, and region.

Hilar lymph nodes sampling at the time of liver transplantation for hepatocellular carcinoma: to do or not to do? Meta-analysis to determine the impact of hilar lymph nodes metastases on tumor recurrence and survival in patients with hepatocellular carcinoma undergoing liver transplantation.

The purpose of this study was to evaluate the impact of tumor‐positive hilar lymph nodes (LN) on tumor recurrence and survival in patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). A computer search of the Medline database was carried out. The outcome of patients with positive hilar LN (study group) was compared with that of patients with negative LN (reference group). Five clinical studies evaluating tumor recurrence after LT for HCC according to hilar LN status were identified. Five further clinical studies evaluated patients’ survival in reference to LN metastases. The test of heterogeneity for each comparison revealed no significant differences (exact P = 0.4638). A significant correlation between tumor‐positive LN and tumor recurrence was shown (exact estimation of common odds ratio by 10.44, 95% confidence interval of 3.431–38.59). Furthermore, data analyses using the Fisher‐combination test regarding patient survival in the two groups showed a statistical difference (P < 0.0001). The negative prognostic value of hilar LN metastasis for both tumor recurrence and survival was confirmed by this analysis. Given the ever‐present diagnostic dilemma associated with enlarged hilar LN, especially in hepatitis C‐positive patients, hilar LN sampling during LT for HCC could better define patients at risk.

The Chen-Luo test in case of heteroscedasticity

Chen and Luo (2004, Comm. Statist. Simulation Comput. 33, 1007-1020) presented a modification of the Wilcoxon-Mann-Whitney test that can be less conservative than the original test. The results shown here indicate that the possible power advantage of the modification is solely due to its being less conservative. Because the modified statistic is variance adjusted using a variance estimator based on the empirical data situation independent of the null hypothesis, the test may be useful in case of heteroscedasticity. However, it is demonstrated here that the modified test can be much more anticonservative than the Wilcoxon-Mann-Whitney test when the population means are identical, but the population variances differ. Therefore, the modified test cannot be recommended for the nonparametric Behrens-Fisher problem. Possible approaches in that case are the Brunner-Munzel test and Cliffs method.

Prevalence of the metabolic syndrome in men and women with alcohol dependence: results from a cross-sectional study during behavioural treatment in a controlled environment

AIMS Prevalence of metabolic syndrome (MetS) in men and women who use alcohol has been inconsistent in the literature. The aim of this study is to compare the prevalence of MetS in patients with a diagnosis of alcohol dependence who are currently abstinent in a controlled environment, and in control subjects followed in primary care from a similar region in Northern Germany. DESIGN Cross-sectional study. SETTING In-patient cognitive behavioural therapy. PARTICIPANTS One hundred and ninety-seven men and women with alcohol dependence during behavioural treatment in a controlled environment were compared to 1158 subjects from primary care from a similar region in northern Germany. MEASUREMENTS We used the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHBLI) criteria to determine the rate of MetS and each single criterion of MetS in both groups. FINDINGS The prevalence of MetS was almost twice as high in men and women with alcohol dependence compared to control subjects (30.6% versus 17.0%). With respect to the single criteria, elevations were found for fasting glucose and blood pressure in both genders and for triglycerides in women only. High density lipoprotein (HDL)-cholesterol was higher in men and women with alcohol dependence. CONCLUSIONS Our results demonstrate an increased rate of MetS, increased blood pressure and dysregulation of glucose and lipid metabolism in alcohol-dependent patients. Whether high HDL-cholesterol has cardioprotective effects in this context remain doubtful.

Prevalence and control of high blood pressure in primary care-results from the German metabolic and cardiovascular risk study (GEMCAS)

Contemporary epidemiological data on blood pressure readings, hypertension prevalence and control in unselected patient populations covering a broad age range are scarce. The aim here is to report the prevalence of high blood pressure and to identify factors associated with blood pressure control in a large German primary care sample. We used data from the German Metabolic and Cardiovascular Risk Study including 35 869 patients aged 18–99 years. High blood pressure was defined as systolic blood pressure ⩾140 mm Hg and/or diastolic blood pressure ⩾90 mm Hg or using antihypertensive therapy. Factors associated with blood pressure control among patients receiving antihypertensive therapy were examined using multiple logistic regressions to estimate odds ratios and 95% confidence intervals. The prevalence of high blood pressure, uncontrolled high blood pressure and untreated high blood pressure was 54.8%, 21.3% and 17.6%, respectively. Age >50 years (1.52; 1.40–1.65), male sex (1.30; 1.20–1.41), elevated waist circumference (1.55; 1.45–1.65), high cholesterol (1.24; 1.16–1.33), high triglycerides (1.11; 1.04–1.19) and concomitant diabetes (1.29; 1.20–1.40) were independently associated with uncontrolled high blood pressure. In a majority of patients we observed hypertension despite treatment for high blood pressures. Studies examining the reasons for treatment failure are highly warranted.