Hospitalised patients with unexplained chest pain: incidence and prognosis.

BACKGROUND: The prognosis of unexplained chest pain patients provides valuable information for evaluation of health services. OBJECTIVE: To examine prognosis of unexplained chest pain. METHODS: Using data from in- and outpatient hospital visits in Norway of patients discharged with a main diagnosis of unexplained chest pain (ICD-10: R072-R074) in 2010-2012, the 1-year incidence of coronary heart disease (CHD), any cardio-vascular disease (CVD) and mortality was evaluated. Cases with prior 2-year history of CVD or chest pain were excluded. Cox proportional hazards evaluated outcomes by patient characteristics and standardized mortality ratios evaluated observed versus expected mortality. RESULTS: Of 59 569 patients identified (20-89 years of age), the majority (86%) were referred to hospital by out-of-hours emergency care centres. Subsequent CHD was noted for 12.5%, 19.5% and 25.0% of men and 7.2%, 11.0%, 14.0% of women aged 45-64, 65-74 and 75-89 years, respectively. The per cent of deaths attributed to CVD were greatest within the first 2 months of postdischarge. Total mortality rates (per 1000 person-years) were 6.6 in men and 4.7 in women aged 45-64 and 69.2 in men and 39.5 in women aged 75-89 years. Relative to the general population, mortality was 53% and 45% higher for men and women under 65 years of age, respectively, attributed primarily to non-CVD causes. CONCLUSION: Patients in Norway discharged with unexplained chest pain are an at-risk group in terms of incident CHD, any CVD and mortality, including non-CVD mortality during the first-year postdischarge. The results suggest that unexplained chest pain patients may benefit from greater healthcare coordination between medical disciplines.

The hypertriglyceridemic-waist phenotype is associated with the Framingham risk score and subclinical atherosclerosis in Canadian Cree.

BACKGROUND AND AIMS: For primary prevention of cardiovascular disease (CVD), Canadian guidelines recommend that asymptomatic Canadians with abdominal obesity undergo Framingham risk score (FRS) assessment, and that in Indigenous Peoples, indicators of metabolic syndrome also be used to identify at-risk individuals. The hypertriglyceridemic-waist phenotype (HTGW) has been proposed to be a surrogate marker of visceral obesity and a simple proxy measure for metabolic syndrome. The primary aim of this study was to evaluate whether the HTGW and the FRS associated with sub-clinical atherosclerosis. METHODS AND RESULTS: Asymptomatic Cree participants in a cross-sectional study conducted 2005-2009 (n = 446, 18-81 y) were assessed for the HTGW using NCEP-ATP-III gender-specific-cutoffs (waist circumference: for men, ≥102 cm; for women ≥88 cm) and fasting triglycerides ≥1.7 mmol/L. Sub-clinical atherosclerosis was defined by the presence of a high sex-specific common-carotid-intimal-medial-wall-thickness (≥75th percentile). HTGW was present in 26.7% and a 10-y FRS greater than 10% was present in 18.8% of participants. The multivariate adjusted OR (95% CI) for sub-clinical atherosclerosis associated with an FRS greater than 10% was 4.10 (2.20-7.50) while that associated with the HTGW phenotype was 1.74 (95% CI 1.61-1.88) from a model including age, body mass index, alcohol consumption, FRS and the HTGW. CONCLUSIONS: The HTGW phenotype is prevalent in the Cree. Our findings support further study on the utility of combining the HTGW with the FRS in the prediction of cardiovascular disease outcomes and in health screening and intervention programs among indigenous peoples.

Trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction in Norway during 2001-2009: a "Cardiovascular disease in Norway" (CVDNOR) project.

OBJECTIVE: The aim of this study was to investigate the trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction (AMI) in Norway during the period 2001-2009. Potential age group and gender differences in these trends were also examined. DESIGN, SUBJECTS AND SETTING: In this retrospective nationwide cohort study, patients hospitalized for a first AMI between 2001 and 2009 were identified in the Cardiovascular Disease in Norway 1994-2009 (CVDNOR) project and followed for 1 year. MAIN OUTCOME MEASURES: Trends in 28-day and 1-year mortality [both all-cause and cardiovascular disease (CVD) mortality] were investigated. RESULTS: A total of 115,608 patients (60.6% men) were hospitalized for a first AMI during the study period. Mortality at 28 days was reduced annually by 3.8% overall and by 6.7%, 4.1% and 2.6% in patients aged 25-64, 65-84 and ≥85 years, respectively (all Ptrend < 0.001). In addition, 1-year all-cause mortality was reduced annually by 2.0% overall (Ptrend < 0.001) and by 3.7% (Ptrend = 0.02), 2.5% (Ptrend < 0.001) and 1.1% (Ptrend < 0.001) in patients aged 25-64, 65-84 and ≥85 years, respectively. Furthermore, 1-year CVD mortality was reduced overall by 6.2% annually; a reduction was observed in all age groups. Finally, 1-year non-CVD mortality increased annually overall by 3.9% due to an increase in patients aged ≥65 years. CONCLUSION: Mortaity at 28 days after the first AMI declinedin Norway between 2001 and 2009 in both men and women and in all age groups. All-cause mortality at 1 year also declined both in men and women due to decreases in CVD mortality rates, whilst non-CVD mortality rates increased amongst patients ≥65 years of age.

Environmental contaminants and human health in the Canadian Arctic.

The third Canadian Arctic Human Health Assessment conducted under the Canadian Northern Contaminants Program (NCP), in association with the circumpolar Arctic Monitoring and Assessment Programme (AMAP), addresses concerns about possible adverse health effects in individuals exposed to environmental contaminants through a diet containing country foods. The objectives here are to: 1) provide data on changes in human contaminant concentrations and exposure among Canadian Arctic peoples; 2) identify new contaminants of concern; 3) discuss possible health effects; 4) outline risk communication about contaminants in country food; and 5) identify knowledge gaps for future contaminant research and monitoring. The nutritional and cultural benefits of country foods are substantial; however, some dietary studies suggest declines in the amount of country foods being consumed. Significant declines were found for most contaminants in maternal blood over the last 10 years within all three Arctic regions studied. Inuit continue to have the highest levels of almost all persistent organic pollutants (POPs) and metals among the ethnic groups studied. A greater proportion of people in the East exceed Health Canada's guidelines for PCBs and mercury, although the proportion of mothers exceeding these guidelines has decreased since the previous assessment. Further monitoring and research are required to assess trends and health effects of emerging contaminants. Infant development studies have shown possible subtle effects of prenatal exposure to heavy metals and some POPs on immune system function and neurodevelopment. New data suggest important beneficial effects on brain development for Inuit infants from some country food nutrients. The most successful risk communication processes balance the risks and benefits of a diet of country food through input from a variety of regional experts and the community, to incorporate the many socio-cultural and economic factors to arrive at a risk management decision that will be the most beneficial in Arctic communities.

Following in mother's footsteps? Mother-daughter risks for insulin resistance and cardiovascular disease 15 years after gestational diabetes.

AIMS: To determine effects on mothers and daughters of gestational diabetes mellitus/gestational impaired glucose tolerance (GDM/GIGT) on their future metabolic and cardiovascular risks. METHODS: Case mothers who had GDM/GIGT in pregnancy (cases; n = 90) and normoglycaemic control women (n = 99) and their daughters underwent lifestyle assessment and metabolic tests 15-years post-partum. RESULTS: Prevalence of glucose intolerance (GI) in daughters was 1.1%. Maternal prevalence was 44.4% in cases compared to 13.1% in controls, with conversion best predicted by weight gain. Case daughters had higher insulin resistance (IR) and greater waist circumference (WC) (51.2%) relative to control daughters (36.4%, p < 0.05) made worse if case mothers became GI at follow-up (65%) (relative risk =1.8; 95% confidence interval 1.2-2.9). In multivariable linear regression analyses adjusting for daughters' birthweight, maternal obesity (> 30.0 kg/m(2)) at 15years and mothers' case-control status were strong predictors of daughters' WC (p < 0.01; P < 0.01, respectively). For daughters' body mass index (BMI) percentile and percentage of body fat, maternal obesity was a stronger predictor (p < 0.01; p < 0.001)) than mothers' case-control status (p < 0.01; P = 0.09). CONCLUSIONS: GDM/GIGT pregnancies led to increased conversion to GI in mothers, minimal in daughters. Case daughters have increased risk of central adiposity and insulin resistance, whereas maternal obesity strongly predicted daughters' BMI percentile and per cent of body fat. Controlling hyperglycaemia in pregnancy and family weight management may provide the key to preventing offspring obesity and glucose intolerance post GDM/GIGT.

Hair methylmercury levels of mummies of the Aleutian Islands, Alaska.

Ancient human hair specimens can shed light on the extent of pre-historic exposures to methylmercury and provide valuable comparison data with current-day exposures, particularly for Indigenous Peoples who continue to rely upon local traditional food resources. Human hair from ancient Aleutian Island Native remains were tested for total and methylmercury (Hg, MeHg) and were radiocarbon dated. The remains were approximately 500 years old (1450 A.D.). For four adults, the mean and median total hair mercury concentration was 5.8 ppm (SD=0.9). In contrast, MeHg concentrations were lower with a mean of 1.2 ppm (SD=1.8) and a median of 0.54 ppm (0.12-3.86). For the five infants, the mean and median MeHg level was 1.2 ppm (SD=1.8) and 0.20 ppm (0.007-4.61), respectively. Segmental analyses showed variations in MeHg concentrations in 1-cm segments, consistent with fluctuations in naturally occurring exposure to mercury through dietary sources. The levels are comparable to or lower than those found in fish and marine mammal-eating populations today who rely far less on subsistence food than pre-historic humans. The findings are, therefore, compatible with increased anthropogenic release of trace metals during the past several centuries.

Traditional food consumption and nutritional status of Dalit mothers in rural Andhra Pradesh, South India.

OBJECTIVES: To describe prevalence of malnutrition and their correlates of nutrient and traditional food consumption in rural Dalit mothers. DESIGN: In a cross-sectional study, we used socio-cultural questionnaires, anthropometric measurements and clinical eye examinations during the rainy season in 2003. Food frequency questionnaires and 24-h recalls were conducted during both summer and rainy seasons. SETTING: Dalit mothers with young children were recruited from 37 villages in the Medak District of rural Andhra Pradesh, India. SUBJECTS: Dalit mothers (n = 220) participated. RESULTS: The prevalence of chronic energy-deficient (CED) mothers (body mass index <18.5 kg/m2) was 58%. Illiterate women and active women were more likely to have CED than those literate and non-active (relative risks (RR) = 1.6 and 1.4, respectively, P < or = 0.05), but literacy and activity level were not significant in multivariable analyses including sanitation and number of children < or =5 years of age. Increasing levels of fat intake, as a percent of total energy, was significantly associated with lower risk of CED (RR of the lowest 25th percentile compared to those in the 75th percentile or above was 1.6, P < or = 0.05), findings that remained significant in multivariable analyses. Consumption of pulses (g/day) was also inversely related to CED in univariate and multivariable analyses. Carbohydrate intake, as a percent of total energy, was inversely related to percent energy from fat (r = -0.96, P < or = 0.01), and, although positively related to CED in univariate analyses, carbohydrate consumption was not significant in multivariable analyses. Mothers' age in years and income was positively related to vitamin A deficiency. CONCLUSIONS: These results confirm that CED and vitamin A malnutrition among Dalit women are predominant problems in this area. Increased consumption of local traditional Dalit food (particularly sorghum, pulses, vegetables and animal source food) should be incorporated as an important component of intervention strategies to improve nutritional status.

Heart defects and other malformations in the Inuit in Canada: a baseline study.

OBJECTIVES: Birth defects occur in all ethnic groups, remaining an important world-wide cause of perinatal and infant morbidity. This contributes greatly to an excess of health care dollars allocated to the care and repair of those affected. This is especially true when those affected live in remote geographical locations. STUDY DESIGN: A chart review of 2567 live births of children of Inuit parents residing in Arctic Quebec (Nunavik) and on Baffin Island (Nunavut) between 1989 and 1994 (five years) was carried out compared to rates of anomalies of the Alberta Congenital Anomalies Surveillance System (ACASS). RESULTS: Birth defects were higher in the Inuit sample in nearly every major ICD-9 category with the exception of neural tube defects, eye anomalies and chromosome abnormalities. (Total: 99.7/1000 Vs 51.5/1000; OR 1.93 95% CI 1.7-2.3). Congenital heart defects were significantly increased 22.9/1000 Vs 5.6/1000, with an OR of 4.18 (95% CI 3.2-5.4) in the ICD-9 category 745. In particular, ventricular septal defects (VSDs) and atrial septal defects (ASDs) (OR 4.9 CI 3.5-6.9 and 4.6 CI 2.9-7.2) were frequent. CONCLUSIONS: A high rate of heart defects was an important contributor to the nearly two times rate of total birth defects in the Inuit compared to the ACASS. Further study should be carried out to determine the contributing factors. Genetic predisposition to specific heart defects, and a diet low in folate and vitamin A are considerations. The use of alcohol may exacerbate vitamin status in pregnancy. Optimizing vitamin status in the periconceptional period may reduce the rate of birth defects.

Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity.

Indigenous Peoples globally are part of the nutrition transition. They may be among the most extreme for the extent of dietary change experienced in the last few decades. In this paper, we report survey data from 44 representative communities from 3 large cultural areas of the Canadian Arctic: the Yukon First Nations, Dene/Métis, and Inuit communities. Dietary change was represented in 2 ways: 1) considering the current proportion of traditional food (TF) in contrast to the precontact period (100% TF); and 2) the amount of TF consumed by older vs. younger generations. Total diet, TF, and BMI data from adults were investigated. On days when TF was consumed, there was significantly less (P < 0.01) fat, carbohydrate, and sugar in the diet, and more protein, vitamin A, vitamin D, vitamin E, riboflavin, vitamin B-6, iron, zinc, copper, magnesium, manganese, phosphorus, potassium, and selenium. Vitamin C and folate, provided mainly by fortified food, and fiber were higher (P < 0.01) on days without TF for Inuit. Only 10-36% of energy was derived from TF; adults > 40 y old consistently consumed more (P < 0.05) TF than those younger. Overall obesity (BMI > or = 30 kg/m(2)) of Arctic adults exceeded all-Canadian rates. Measures to improve nutrient-dense market food (MF) availability and use are called for, as are ways to maintain or increase TF use.

Cod liver oil consumption, smoking, and coronary heart disease mortality: three counties, Norway.

It has been hypothesized that omega-3 fatty acid consumption may lessen the adverse effect of smoking on coronary heart disease (CHD) risk. Thus, we explored whether cod liver oil consumption was protective of coronary heart disease in a cohort of men and women participating in a cardiovascular disease screening in Norway. The study population was aged 35-54 at the time of the baseline screening conducted by the National Health Screening Service of Norway in 1977-1983. Of 56,718 age-eligible men and women, 52,138 participated, of whom 42,612 (82%) completed a dietary questionnaire. Cod liver oil use was reported by 12.5%. At baseline, cod liver oil users had lower triglycerides, adjusting for age, body mass index, time since last meal and income (p < or = .05). As of December 1992, 639 and 118 CHD deaths were observed among the men and women, respectively. Overall, we observed no effect of cod liver oil consumption reported at baseline and CHD mortality in Cox Proportional Hazards analyses [Hazard Ratio (HR) = 1.0 (0.8-1.3)]. In analyses, stratified by smoking status, never smokers and current smokers showed non-significant beneficial associations between cod liver oil use and CHD mortality (HR = 0.7, 95% CI = 0.4-1.5; and HR = 0.8, 95% CI = 0.6-1.2, respectively). However, among former smokers a non-significant excess risk of CHD mortality was associated with cod liver oil use (HR = 1.6, 95% CI = 0.9-2.6). Smokers, regardless of their cod liver oil use were at a substantially higher risk for CHD mortality relative to non-smokers. Omega-3 fatty acid supplementation, as practiced in this cohort, provided no significant benefits to CHD risk among study participants.

Outbreak of boils in an Alaskan village: a case-control study.

OBJECTIVE: To determine whether taking steam baths was associated with furunculosis and to evaluate possible risk factors for the occurrence of boils during a large outbreak in Alaska. DESIGN: A cohort study of village residents, a case-control study, and assessment of environmental cultures taken from steam baths. SETTING: Village in southwestern Alaska. PARTICIPANTS: 1 adult member from 77 of the 92 households in the village was interviewed; 115 residents with at least one boil occurring between January 1 and December 12, 1996 were considered to be cases; 209 residents without a boil acted as the control group. All 459 village residents were included in the cohort study. MAIN OUTCOME MEASURE: Rate of infection among all residents and residents who regularly took steam baths, risk factors for infection, and relative risk of infection. RESULTS: 115 people (25%) had had at least one boil. Men were more likely to have had a boil than women (relative risk 1.5; 95% confidence interval 1.1 to 2.2). The highest rate of infection was among people ages 25-34 years (32/76; 42%). No children younger than 2 years had had boils. Boils were associated with using a steam bath (odds ratio 8.1; 3.3 to 20.1). Among those who used a steam bath, the likelihood of developing boils was reduced by routinely sitting on a towel while bathing, which women were more likely to do, and bathing with fewer than 8 people. Of the 93 samples taken from steam baths, one Staphylococcus aureus isolate was obtained from a bench in an outer dressing room. CONCLUSION: Using a steam bath was associated with developing boils in this outbreak in a village in Alaska. People should be advised to sit on towels while using steam baths.

Evaluation of exposures to fluorocarbon 113 in a horizontal and a vertical laminar airflow clean room.

Exposures to 1,1,2-trichloro-1,2,2-trifluoroethane or fluorocarbon (FC) 113 were evaluated in a horizontal laminar airflow (HLAF) clean room and a vertical laminar airflow (VLAF) clean room. A full period consecutive samples measurement strategy was employed. Data were used to calculate 8-hour time-weighted averages (8-TWA) for major work groups and to characterize exposures associated with specific cleaning tasks. The MIRAN 1B infrared analyzer was used to estimate peak concentrations. In the HLAF clean room, 8-TWAs ranged from 193 to 439 ppm; in the VLAF clean room, 8-TWAs ranged from 110 to 935 ppm. These levels were below the current Occupational Safety and Health Administration permissible exposure limit and the National Institute for Occupational Safety and Health (NIOSH) recommended exposure limit for FC 113 of 1000 ppm. Short-term sample concentrations ranged from 104 ppm (inspection) to 1080 ppm (assembly) in the HLAF clean room and 51 ppm (packaging)-3380 ppm (flushing) in the VLAF clean room. In the VLAF clean room, several short-term concentrations measured during the flushing task--1421 ppm and 2522 ppm--were above the NIOSH short-term exposure limit (STEL) of 1250 ppm. These data suggest the possibility that the STEL may be exceeded for tasks involving direct work with liquid FC 113. Peak exposure levels may be reduced by modification of worker position in the HLAF clean room and by use of open wire tables in the VLAF clean room.

Trace metals in ancient hair from the Karluk Archaeological Site, Kodiak, Alaska.

Considerable interest exists in characterizing the extent of changes in methylmercury exposures from preindustrial to modern-day times. Hair is often preserved over centuries and has been useful in determining the extent of dietary trace metal exposures, particularly methylmercury. We examined 16 human hair samples taken from human hair bundles buried in the soil of the Karluk One Archaeological site located near the current Karluk village on the Kodiak Archipelago of Alaska. Hair samples were analyzed for total mercury, methylmercury, selenium, and cadmium. The mean total mercury level was 1.33 ppm (SD = 1.09). The mean methylmercury level, however, was considerably lower than the total mercury concentration: the mean methylmercury level was 0.03 ppm (SD = 0.02). The mean cadmium level was 0.15 ppm (SD = 0.14) and the mean selenium level was 5.22 ppm (SD = 5.73). While the concentration of total mercury in the Karluk hair samples is comparable to those observed in ancient hair from other locations, direct methylmercury quantization demonstrated that methylmercury levels were less than 2% of the total mercury in these hair samples. Because the hair was subjected to a variety of environmental influences over the centuries, the possibility of degradation of methylmercury in the hair over the last 400 to 800 years cannot be ruled out. The use of hair from remains found in more protected frozen or dry environments may provide the best evidence for the extent of preindustrial exposures to methylmercury and other trace metals.

Fetal alcohol syndrome in Alaska, 1977 through 1992: an administrative prevalence derived from multiple data sources.

OBJECTIVES: The prevalence and characteristics of fetal alcohol syndrome cases and the usefulness of various data sources in surveillance were examined in Alaska to guide prevention and future surveillance efforts. METHODS: Sixteen data sources in Alaska were used to identify children with fetal alcohol syndrome. Medical charts were reviewed to verify cases, and records were reviewed to provide descriptive data. RESULTS: Fetal alcohol syndrome rates varied markedly by birth year and race, with the highest prevalence (4.1 per 1000 live births) found among Alaska Natives born between 1985 and 1988. Screening and referral programs to diagnostic clinics identified 70% of all recorded cases. The intervention program for children 0 to 3 years of age detected 29% of age-appropriate cases, and Medicaid data identified 11% of all cases; birth certificates detected only 9% of the age-appropriate cases. CONCLUSIONS: Our findings indicate a high prevalence of fetal alcohol syndrome in Alaska and illustrate that reliance on any one data source would lead to underestimates of the extent of fetal alcohol syndrome in a population.

A public health perspective on the evaluation of subsistence food safety.

Persistent organic compounds and trace metals are found in the arctic food chain, generating concerns about the safety of subsistence food consumption. One approach for evaluating subsistence food safety is a process used extensively in regulating environmental clean-up and pollution standards. This process, regulatory risk assessment, is substantially different from approaches used in public health risk assessment. Limitations to the use of regulatory risk assessment in assessing public health threats from environmental exposures in the diet include a narrow scope, a lack of incorporation of the nutritional and health benefits of subsistence foods, and the overestimation of risks because of the incorporation of worst-case assumptions in the absence of scientific information. Sound public health policy recognizes that attempts to err on the side of safety for one exposure by recommending reduced consumption of a selected food may inadvertently err on the side of harm by reducing a coexisting exposure of potentially great health benefit. The following discussion should serve as a useful background for future multidisciplinary discussions on the safety of subsistence foods in the Arctic.