Daniel M. Robinson

The prevalence of undiagnosed thyroid disorders in a previously iodine-deficient area.

OBJECTIVE The aim of the present study was to analyze the current status of morphologic and functional thyroid abnormalities in a previously iodine-deficient area. METHODS The population based Study of Health in Pomerania (SHIP) comprised 4310 participants, aged 20-79 years. Thyroid function (thyrotropin [TSH] free triiodothyronine [FT(3)], and free thyroxine [FT(4)]) and serum autoantibodies to thyroperoxidase (TPOAb) were evaluated from blood samples. Thyroid structure and size were measured by ultrasound. Data from 3941 participants with no known thyroid disorders were analyzed. RESULTS The median iodine urine excretion was 12.4 microg/dL. The rate of decreased serum TSH levels (<0.3 mIU/L) was 11.3%; 2.2% of participants had suppressed serum TSH levels (<0.1 mIU/L). The prevalence of subclinical hyperthyroidism was 1.8%, the prevalence of overt hyperthyroidism 0.4%. Elevated TSH levels were found in 1.2% of individuals. Subclinical hypothyroidism was observed in 0.5%, overt hypothyroidism in 0.7% of the sample. Elevated TPOAb were detected in 7% of subjects, 4.1% of participants had TPOAb greater than 200 IU/mL. The prevalence of goiter was 35.9%. An inhomogeneous echo pattern was detected in 35.2% and nodules in 20.2% of participants. Diffuse autoimmune thyroiditis was diagnosed in 47 subjects (1.2%). CONCLUSION There are a number of thyroid disorders in this previously iodine-deficient region. Further studies are required to investigate the change of thyroid disorders during iodine supplementation programs.

The relation of exposure to shift work with atherosclerosis and myocardial infarction in a general population

OBJECTIVES We tested the hypothesis that working shifts is related to atherosclerosis and myocardial infarction. BACKGROUND The number of shift workers is continuously increasing. Shift work is discussed to be related with cardiovascular heart disease. METHODS A total of 2510 subjects recruited for the population-based Study of Health in Pomerania were tested, 698 of whom were former shift workers. A general population sample was examined to reach generalizibility and to produce results independent from the effects of the personal shift schedule and from the specific working conditions. Carotid ultrasound was performed to evaluate carotid intima-media thickness. We used multivariable analyses to estimate the coronary heart disease risk, adjusted for age, sex and atherosclerotic risk factors, stratified by exposure to shift work and its duration. RESULTS Atherosclerotic risk factors differed in part between shift workers and non-shift workers. Shift work was associated with atherosclerosis and myocardial infarction, depending on the duration of the exposure and the age of the participants. Multivariable Cox regression analysis identified shift work as a risk factor for myocardial infarction to be manifest at younger ages (adjusted hazard ratio 1.53, 95% CI 1.06-2.22). CONCLUSIONS Exposure to shift work is a risk factor for atherosclerosis and myocardial infarction. Special prevention programs for shift workers should be provided.

Association Between High Serum Ferritin Levels and Carotid Atherosclerosis in the Study of Health in Pomerania (SHIP)

Background and Purpose— Several studies have provided evidence for a relationship between body iron load and cardiovascular disease. We analyzed the association of serum ferritin levels with carotid atherosclerosis. Methods— We assessed intima-media thickness and plaque prevalence in the carotid arteries by high-resolution ultrasound among 2443 participants (1200 women; age, 45 to 79 years) in the Study of Health in Pomerania (SHIP), a population-based study in northeast Germany. Results— In multivariate analysis, serum ferritin levels were not independently associated with carotid intima-media thickness among women or men. In contrast, the relationship between serum ferritin levels and carotid plaque prevalence was significant among men (odds ratio per 1-SD increase of serum ferritin levels, 1.33; 95% confidence interval, 1.08 to 1.44) yet not among women (odds ratio, 1.29; 95% confidence interval, 0.98 to 1.75). However, both men and women showed a dose-response relation between serum ferritin levels and carotid atherosclerosis in which higher serum ferritin levels were associated with greater odds ratios for carotid plaque prevalence. Additionally, there was an interaction of serum ferritin levels with low-density lipoprotein (LDL) cholesterol (P =0.039) among men in which the association of serum ferritin levels with carotid plaque prevalence became stronger with increasing LDL cholesterol levels. Conclusions— Our study identified a relationship between serum ferritin levels and carotid atherosclerosis that was potentiated by LDL cholesterol. This relationship adds support to the hypothesis of a link between iron and cardiovascular disease.

Gender differences in the relation between number of teeth and systolic blood pressure

Background Tooth loss predicts total and circulatory mortality. The reasons for the increased mortality in subjects with a low number of teeth may be related to enhanced atherosclerosis, elevated arterial pressure and more frequent hypertension. The present study was designed to investigate whether there is an association between the number of teeth and arterial pressure or hypertension. Methods We used data of 4185 adult subjects (2150 women) collected for the population-based Study of Health in Pomerania. The number of teeth was counted by trained and certified dentists. Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or use of antihypertensive medication. Multivariable analyses were adjusted for relevant confounders. Results The adjusted mean (standard error) systolic blood pressure in men having 0–6 teeth was 149.6 mmHg (1.3 mmHg) compared to 142.6 mmHg (1.2 mmHg) in men having 27–28 teeth (P < 0.05). The adjusted odds for hypertension in men with 0–6 teeth compared to men with 27–28 teeth were 1.91 (95% confidence interval 1.21; 3.02, P < 0.05). In women no such relations were found. Conclusion There is an inverse association between the number of teeth and systolic blood pressure and hypertension in men but not in women. The present findings partly explain the relation between tooth loss and mortality.

The association of thyroid function with carotid artery plaque burden and strokes in a population-based sample from a previously iodine-deficient area

BACKGROUND Thyroid dysfunction is associated with detrimental cardiovascular effects. We analyzed whether thyroid status is related to carotid artery plaques and prevalent strokes. DESIGN, PATIENTS AND MEASUREMENTS Data from 2128 subjects (1157 men and 971 women) aged > or =45 years without thyroid diseases participating in the Study of Health in Pomerania were analyzed. The presence of carotid plaques was assessed by B-mode ultrasound and prevalent stroke was assessed by interview. The sample was divided according to the reference range of serum TSH levels into decreased (<0.25 mIU/l), normal (0.25-2.12 mIU/l), and elevated (>2.12 mIU/l). Logistic regression models were adjusted for common confounders including age, sex, BMI, hypertension, diabetes mellitus, smoking, school education, plasma fibrinogen and serum cholesterol levels, and statins. RESULTS The prevalence of carotid plaques at any site was higher in subjects with decreased serum TSH levels (81.7%) compared with normal serum TSH levels (70.2%) and elevated serum TSH levels (65.6%; P<0.001). Fully adjusted logistic regression models revealed increased odds for carotid plaques (odds ratio (OR) 1.67; 95% confidence interval (CI) 1.11-2.51; P<0.05) as well as for prevalent strokes (OR 1.98; 95% CI 1.05-3.73; P<0.05) in subjects with decreased serum TSH levels, while there was no association between elevated serum TSH levels and carotid plaques or stroke respectively. CONCLUSIONS Thyroid function was associated with the presence of carotid artery plaques and prevalent strokes in this population-based sample. Periodical screening and early treatment of atherosclerotic risk factors should be performed in subjects with decreased serum TSH levels.

Periodontal disease, but not edentulism, is independently associated with increased plasma fibrinogen levels Results from a population-based study

The systemic response to periodontal disease was analyzed in the cross-sectional Study of Health in Pomerania (SHIP). The completed data of 2,738 subjects aged 20 to 59 years were used for logistic regression analysis with an increased plasma fibrinogen level (> or =3.25 g/L according to Clauss) as the dependent variable. Participants were divided into four groups according to the number of periodontal pockets > or =4 mm (0, 1-7, 8-14, > or =15 pocketing). An additional group comprised the 52 edentulous subjects. The adjusted odds ratio (OR) of > or =15 periodontal pockets for increased plasma fibrinogen levels was 1.88 (95% CI: 1.25-2.83). Edentulism per se was not associated with increased plasma fibrinogen levels but was contained in a two-way interaction with the number of cigarettes/day in current smokers (p = 0.031). For edentulous nonsmokers the adjusted OR was 1.10 (95% CI: 0.51-2.39). Furthermore, body mass index, the interaction between gender and body mass index, serum LDL cholesterol, medication, the interaction between LDL cholesterol and medication, aspirin, smoking, school education, chronic bronchitis, and the interaction between alcohol consumption and chronic gastritis were associated with plasma fibrinogen levels. Our results show that periodontal disease but not edentulism per se is associated with an increased plasma fibrinogen level.

Relation of Parity With Common Carotid Intima-Media Thickness Among Women of the Study of Health in Pomerania

Background and Purpose— Metabolic and hormonal changes associated with pregnancy and childbirth are assumed to contribute to the development of cardiovascular disease among women. We analyzed the association of parity with common carotid intima-media thickness (IMT), which has a predictive value of subsequent myocardial infarction and stroke. Methods— The Study of Health in Pomerania (SHIP), an epidemiological study of the general population in the northeast of Germany, included 1195 women aged 45 to 79 years. Mean and maximum far-wall IMT of the common carotid arteries were assessed by high-resolution ultrasound. All women were comprehensively characterized as to their reproductive history as well as to socioeconomic, behavioral, and biological risk factors. Results— There was a U-shaped association between the number of children (from 0 to ≥4) and mean and maximum IMT. Nulliparous women had the highest age-adjusted mean (0.81 mm [95% CI, 0.78 to 0.84]) and maximum IMT (1.04 mm [95% CI, 1.00 to 1.09]), and women with single parity the lowest (mean IMT, 0.73 [95% CI, 0.72 to 0.74]; maximum IMT, 0.91 mm [95% CI, 0.89 to 0.93]; P<0.001 versus nulliparity for both parameters). Stepwise multivariate adjustment for socioeconomic factors, lifestyle variables, and biological variables attenuated the magnitude of this association yet significance remained. Conclusions— Nulliparity and higher number of children are associated with increased carotid IMT. These findings add support to the hypothesis of a link between the reproductive history of women and cardiovascular disease.

Are serum thyrotropin levels within the reference range associated with endothelial function

AIMS High serum thyrotropin (TSH) levels within the reference range might be associated with an increased cardiovascular risk. In the present study, we investigated the association between serum TSH levels and flow-mediated dilation (FMD) as a measure of endothelial dysfunction. METHODS AND RESULTS The study population comprised 1364 subjects (670 women) aged 25-85 years with serum TSH levels between 0.25 and 2.12 mIU/L recruited from 5-year follow-up of the Study of Health in Pomerania. No interventions were performed. Measurements of FMD and nitrate-mediated dilation (NMD) were performed in the supine position using standardized ultrasound techniques. FMD and NMD values below the median of each distribution were considered decreased. Analyses adjusted for age, sex, smoking, and systolic and diastolic blood pressure revealed a non-significant inverse trend between serum TSH levels and FMD (P = 0.130). Subjects with serum TSH levels above the highest quartile had lower median FMD values relative to subjects with serum TSH levels below the lowest quartile (4.86 vs. 5.43%, P < 0.05). A linear inverse trend between serum TSH levels and decreased FMD barely missed statistical significance (P = 0.138). Subjects with high serum TSH levels had higher odds of decreased FMD relative to subjects with low serum TSH levels (odds ratio 1.42; 95% confidence interval 1.02; 1.96; P < 0.05). These associations were more pronounced in men than in women. There were no such associations for NMD. CONCLUSION Serum TSH levels within the upper reference range are associated with impaired endothelial function. Our findings contribute to the discussion on whether the upper TSH reference limit should be redefined.

Factor V Leiden and the risk of stillbirth in a German population

An association between the factor V Leiden variant and an increased risk of pregnancy loss has been reported. Most previous studies were performed with clinically recruited patients and controls. This approach may cause selection bias. The present analysis was performed with the aim to investigate the association between the factor V Leiden mutation and the risk of stillbirth in a population-based sample. The Study of Health in Pomerania (SHIP) is a survey that was carried out in North East Germany. A random sample from the population aged 20 to 79 years was taken. The total SHIP population comprised 4,310 participants. The presence of the factor V Leiden variant was determined by PCR and Mnl I digestion. The presence of the factor V Leiden variant was neither associated with the number of pregnancies nor with the number of children per women. Data from 1,768 females who had at least one pregnancy with known outcome was available for the present analysis. Seventy-three women (4.1%) reported at least one stillbirth. Women with and without the factor V Leiden mutation did not differ with respect to the number of women with at least one stillbirth (OR for factor V Leiden variant 1.57; 95%-CI 0.76 - 3.25). Furthermore, the number of women with two or more stillbirths, the number of stillbirths per affected woman and the number of stillbirths per number of pregnancies per woman was similar between both genotype groups. In conclusion, there is no association between the factor V Leiden mutation and the risk of stillbirth in a representative population sample.

Radiation-reducing planning of cardiac catheterisation

Jegliche medizinische Strahlenexposition ist auch unterhalb vorgegebener Referenzwerte so niedrig wie möglich zu halten. Nationale und internationale Strahlenschutz-Kommissionen fordern aufgrund der hohen publizierten Expositionsmittelwerte invasiver kardialer Diagnostik (16–106 Gy × cm2) zunehmend strahlenhygienische Schulungskonzepte: vor und nach einem 90-minütigen Strahlenschutzkurs der „Encourage to Less Irradiating Cardiologic Interventional Techniques“-Studiengruppe dokumentierten 20 Kardiologen für jeweils 10 elektive Herzkatheterisierungen detaillierte Dosisparameter und erzielten eine Reduktion des mittleren Dosisflächenproduktes um 15,9±9,0 Gy × cm2 bzw. 47%. Die vorgestellte expositionsreduzierende Planung elektiver Koronardiagnostik ist somit in klinischer Routine validiert und sieht in der Regel eine Laevokardiographiesequenz, drei LCA- und zwei RCAProjektionen vor, darüber hinaus je nach Anatomie und Befund bis zu vier Spezialprojektionen. Die kaudale PA-Projektion dokumentiert den linkskoronaren Hauptstamm mit Bifurkation, proximale und distale RIVA-Segmente sowie proximale und mittlere RCX-Segmente. Die kraniale PA-Angulation dokumentiert ideal das linkskoronare Ostium, RCX-Peripherie, den gesamten RIVA inklusive aller Diagonaläste sowie Kollateralisation zur (aufgespreizten!) RCA-Bifurkation. Dritte linkskoronare Standardprojektion ist die streng laterale LAO-Projektion. Die 60°/0° LAO-Projektion dokumentiert die RCA bis zur Crux cordis sowie den RPLD. Je proximaler die RCA-Bifurkation, desto mehr wird die zweite Ebene von der kranialen PA- über die kraniale RAO- bis hin zur 30°/0° RAO-Projektion variiert. Diese strategische Planung expositionsreduzierender Projektionen wird optimiert durch Restriktion auf essentielle radiographische Bilder, konsequente Einblendung (von innen nach außen) auf die Zielregion vor allem während Koronarintubation, diagnosesichernd hinreichende statt bestmögliche Bildqualität, Minimierung des Haut-Bildverstärker-Abstands, Inspiration während Radiographie, Herausdrehen und Ausblenden strahlenintensiver knöcherner Strukturen, Optimierung der Durchleuchtungszeit, interventionelle Erfahrung und ausgeruhte Untersucher. Any radiation exposition for medical purposes should be kept as low as is reasonably achievable. Mean patient radiation exposure of diagnostic cardiac catheterisation is high (16–106 Gy × cm2) and for this reason the International Commission on Radiological Protection (ICRP) recommends credentialing radiation protection training programmes. Twenty cardiologists each documented various dose parameters of 10 cardiac catheterisations, before and after a 90-minute mini-course of the ELICIT study group (“Encourage to Less Irradiating Cardiologic Interventional Techniques”), and could achieve a reduction of the mean dose-area product by 15.9±9.0 Gy × cm2, equivalent to 47%. The presented radiation-reducing planning of invasive cardiac catheterisation for this reason is the first one validated in clinical routine and consists of 6 standard runs—one for the left ventricle, 3 and 2 for the left (LCA) and right coronary artery (RCA), respectively—depending on anatomy and findings supplemented by 1 . . . 4 special projections. The caudal posteroanterior (PA) view documents the left coronary main stem, proximal and distal left anterior descending artery (LAD), and proximal and mid circumflex segments. The cranial PA view however is suitable for the left coronary orifice, circumflex periphery, LAD, all diagonal bifurcations, and collateral pathways towards the RCA. LCA standard angiography is completed by lateral 90°/0° left anterior oblique (LAO) angulation. The 60°/0° LAO angulation visualises the right posterolateral artery (RPL) and the RCA to its bifurcation. The more proximal one finds the bifurcation, the more the second standard cranial PA view for RCA should vary towards the cranial right anterior oblique (RAO) and finally 30°/0° RAO view. The efficiency of these less-irradiating angulations are improved by radiation-reducing techniques as follows: restriction to essential radiographic frames and runs, consistent collimation to the region of interest—particularly during coronary intubation—, adequate instead of best possible image quality, short skin-to-image-intensifier distance, inspiration during radiography, preference for projections that rotate out the spine, optimisation of fluoroscopy time, well-experienced and well-rested interventionists.