Health status in Europe: comparison of 24 urban areas to the corresponding 10 countries (EURO-URHIS 2).

Background: : In Europe, over 70% of the population live in urban areas (UAs). Most international comparative health research is done using national level data, as reliable and comparable urban data are often unavailable or difficult to access. This study aims to investigate whether population health is different in UAs compared with their corresponding countries. : Routinely available health-related data were collected by the EURO-URHIS 2 project, for 10 European countries and for 24 UAs within those countries. National and UA level data for 11 health indicators were compared through the calculation of relative difference, and geographical patterns within Europe were investigated using the Mann Whitney U test. Linear regression modelling was used to adjust for population density, gross domestic product and urbanicity. : In general, the urban population in Eastern Europe is less healthy than the Western European urban population. However, people in Eastern Europe have significantly better broad health outcomes in UAs as compared with the corresponding country as a whole, whereas people in Western Europe have generally worse broader health outcomes in UAs. : For most European countries and UAs that were investigated, the national level health status data does not correspond with the health status at UA level. In order to identify health problems in UAs and to provide information for local health policy, health monitoring and international benchmarking should also be conducted at the local level.

The development of an empirical model for regional public health reporting. A descriptive study in two Dutch pilot regions.

AIM: To develop and describe an empirical model for regional public health reporting, based on the model and experience of the Dutch national Public Health Status and Forecasts (PHSF) as well as on relevant theories and literature. METHODS: Three basic requirements were chosen in a preparatory feasibility study: the products to be developed, the project organization of the pilot study, and a regional elaboration of the conceptual model of the national PHSF. Subsequently, from November 2005 to June 2007, a regional PHSF was developed in two Dutch pilot regions, to serve as a base for the empirical model for regional public health reporting. RESULTS: The developed empirical regional PHSF model consists of different products for different purposes and target groups. Regional and Municipal Reports aim to underpin strategic regional and local public health policy. Websites contain up-to-date information, aiming to underpin tactical regional and local public health policy by providing building blocks for translating strategic policy priorities into concrete plans of action. Numerous stakeholders are involved in the development of a regional PHSF. The developed empirical process model for a regional PHSF connects to the theoretical framework in which interaction between researchers and policymakers is an important condition for the use of research data in public health policy. CONCLUSIONS: The empirical model for a regional PHSF can be characterized by its 1) products, 2) content and design, and 3) underlying process and organization. This empirical model can be seen as a first step in the direction of a generic model for regional public health reporting.

[Performance of the Dutch health care from an international perspective: background and implications for policy]. / De prestaties van de Nederlandse gezondheidszorg in internationaal perspectief: achtergronden en implicaties voor beleid.

The 'World Health Report 2000' has stimulated discussions on the Netherlands' performance in health and healthcare from an international perspective. The only concrete result it provided was a world ranking in which the Netherlands stood in 17th place. The comparative data which have appeared in several other recent reports, are more useful to policy makers, a notable example being those from the Organization for Economic Cooperation and Development (OECD). One issue arising from these reports is that the increase in life expectancy in the Netherlands is lagging behind the European Union average. This is particularly the case for women and a major cause of this is smoking. Developments in Dutch perinatal mortality are also unfavourable and are associated with a strong increase in the age at which women bear children. International comparisons of public health data are valuable inputs for health policy development and it is therefore important to invest in the international harmonisation of such data collection.

Different ATP-catabolism in reperfused adult and newborn rat hearts.

Age-dependent differences in the effects of ischemia and reperfusion on ATP breakdown were studied in perfused adult and newborn (10 days old) rat hearts. No-flow ischemia (15 min at 37, 30, or 23 degrees C) was applied and reperfusion (20 min at 37 degrees C) was studied after ischemia at 23 or 37 degrees C. Hypothermia during ischemia protected both age groups to a similar degree against ATP decline, which was linear with temperature. Reperfusion after normothermic ischemia resulted in higher ATP levels in newborn hearts with less release of ATP catabolites (purines). We found no age-related differences in lactate release but large differences in purine release. During normoxia, adult hearts released mainly urate (80% of total) and inosine (7%), but newborns released hypoxanthine (64%) and inosine (15%). Early during reperfusion adult hearts released inosine (58%) and adenosine (18%), but newborns released inosine (53%) and hypoxanthine (38%). These data suggested a lower activity of the potentially deleterious enzyme xanthine oxidoreductase in newborn hearts, which was confirmed by enzymatic assay. ATP-catabolite release during reperfusion was less in newborn than adult hearts, and this coincided with lower xanthine oxidase activity.

Protection by bepridil against myocardial ATP-catabolism is probably due to negative inotropy.

The protective effect of calcium antagonists on ischemic heart has been attributed to decreased energy expenditure. We administered one of the newer calcium antagonists, DL-bepridil (0.1-10 microM), to Langendorff rat hearts 10 or 15 min before ischemia (flow reduction approximately 80%). Vasodilation during normoxia was already observed with 0.3 microM DL-bepridil (flow increase 34%, p less than 0.005). This concentration decreased normoxic contractility and ischemic purine release, a marker for ATP breakdown. In the absence of bepridil, purine release of hearts that were made ischemic was 8.5-fold higher than that of normoxic control hearts. With 1 microM bepridil, the ischemic purine efflux was suppressed by 55% (p less than 0.05), with negative inotropy (p greater than 0.05) during normoxia. At 3 and 10 microM, bepridil decreased normoxic contractility by 40 and 75%, respectively (p less than 0.001), concomitant with a decrease in ischemic purine release by 80 and 76%, respectively (p less than 0.01). At the end of ischemia, myocardial ATP and creatine phosphate had decreased by 22 and 55%, respectively (p less than 0.05), and ADP, AMP, and creatine had increased 1.5-3.5-fold (p less than 0.05). Bepridil (3 microM) normalized the adenine nucleotide values; creatine and creatine phosphate approached control levels. The dose-dependent protection of the ischemic heart by bepridil appears to arise from its negative inotropic action during normoxia.

The effects of dietary mackerel oil on the recovery of cardiac function after acute ischaemic events in the pig.

To investigate the effects of fish oil nutrition on cardiac haemodynamics and the biochemical response to ischaemia-reperfusion, young pigs (5 weeks old) were fed a 9% lard fat diet or a mixed diet of 4.5% mackerel oil and 4.5% lard fat for 16 weeks. In the mackerel oil fed pigs plasma cholesterol and triglyceride levels decreased by 22% and 58% (both p less than 0.05), respectively, while levels in the animals which received only lard fat did not change. The n-6 fatty acids present in cardiac and platelet membrane phospholipids underwent a partial replacement by n-3 fatty acids in the mackerel oil fed pigs. Under anaesthesia, multiple coronary artery occlusions (5 min) were interrupted by 10 min of reperfusion. The extent of recovery of cardiac function and reduction of adenine nucleotide levels were similar for both dietary groups. The incidence of reperfusion arrhythmias was significantly lower and the reactive hyperaemic responses were of longer duration in the mackerel oil fed animals. These effects cannot be explained by diet-induced alterations in thromboxane B2/6-keto-PGF1 alpha ratio, although a marked reduction in absolute levels of both prostaglandins was seen in the mackerel oil fed pigs (p less than 0.05). In conclusion, dietary fish oil caused changes in membrane fatty acid composition and plasma prostaglandin levels, although these did not affect alterations of cardiac performance during and after short periods of ischaemia.

Developmental differences in myocardial ATP metabolism.

Little is known about postnatal changes in myocardial purine metabolism. We therefore studied how ATP catabolism was affected by hypothermia and ischaemia in neonatal and adult hearts. Hypothermia during ischaemia protected isolated adult and newborn hearts against ATP decline. Reperfusion after normothermic ischaemia resulted in higher ATP levels in newborn hearts with less release of ATP-catabolites. During normoxia adult hearts released mainly urate (80% of total purine release), while newborns released mainly hypoxanthine (64%). During early reperfusion adult and newborn hearts released mainly inosine (50-60%). The very low xanthine oxidase activity in the neonatal heart could be an important factor in the observed ATP preservation during reperfusion.

Myocardial adenosine cycling rates during normoxia and under conditions of stimulated purine release.

Formation and rephosphorylation of adenosine (adenosine cycling) was studied in isolated rat hearts during normoxia and under conditions of stimulated purine formation. Hearts were infused with an inhibitor of adenosine kinase (5-iodotubercidin, 2 microM). In addition, perfusions were carried out with or without acetate, which is converted into acetyl-CoA, with simultaneous breakdown of ATP to AMP and purines. We found a linear, concentration-dependent, increase in normoxic purine release by acetate (5-20 mM). Differences in total purine release with or without iodotubercidin were taken as a measure of adenosine cycling. In normoxic hearts, iodotubercidin caused a minor increase in purine release (2.7 nmol/min per g wet wt.). Acetate (12.5 mM) increased purine release by 4.9 nmol/min per g, and its combination with inhibitor gave a large increase, by 14.2 nmol/min per g. This indicates a strongly increased adenosine cycling rate during acetate infusion. However, no significant differences in purine release were observed when iodotubercidin was infused during hypoxia, anoxia or ischaemia. The hypothesis that adenosine cycling is near-maximal during normoxia was not confirmed. Increased myocardial adenosine formation appears to be regulated by the availability of AMP and not by inhibition of adenosine kinase. This enzyme mainly functions to salvage adenosine in order to prevent excessive loss of adenine nucleotides.

Adenosine deaminase inhibition and myocardial purine release during normoxia and ischaemia.

Quantitative determination of myocardial adenosine formation and breakdown is necessary to gain insight into the mechanism and regulation of its physiological actions. Deamination of adenosine was studied in isolated perfused rat hearts by infusion of adenosine (1 to 20 mumol X litre-1). All catabolites in the perfusates (inosine, hypoxanthine, xanthine and uric acid) were measured, as well as unchanged adenosine. Apparent uptake of adenosine was determined; it increased linearly with the concentration of adenosine infused. Adenosine was predominantly deaminated, even at low (1 mumol X litre-1) concentration. The inhibitory capacity of the adenosine deaminase inhibitor erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) was determined, while 5 mumol X litre-1 adenosine was infused. EHNA inhibited the apparent adenosine deaminase activity for 62 and 92% at 5 and 50 mumol X litre-1, respectively. When 50 mumol X litre-1 EHNA was infused into normoxic hearts, release of adenosine was significantly elevated, as was coronary flow. Induction of ischaemia increased total purine release four-to fivefold. Infusion of EHNA into ischaemic hearts did not alter total purine release, but adenosine release increased from 15 to 60% of total purines. However, when EHNA was present, a large part of total purine release still existed of inosine, hypoxanthine, xanthiner and uric acid. This was 83% during normoxia and 40% during ischaemia. These results suggest significant contribution of IMP and GMP breakdown to purine release from isolated perfused rat hearts.

Myocardial S-adenosylhomocysteine hydrolase is important for adenosine production during normoxia.

The coronary vasodilator adenosine can be formed in the heart by breakdown of AMP or S-adenosylhomocysteine (SAdoHcy). The purpose of this study was to get insight into the relative importance of these routes of adenosine formation in both the normoxic and the ischemic heart. A novel HPLC method was used to determine myocardial adenosine and SAdoHcy. Accumulation of SAdoHcy was induced in isolated rat hearts by perfusion with L-homocysteine thiolactone or L-homocysteine. The release of adenosine, inosine, hypoxanthine, xanthine and uric acid was determined. Additional in vitro experiments were performed to determine the kinetic parameters of S-adenosylhomocysteine hydrolase. During normoxia the thiolactone caused a concentration-dependent increase in SAdoHcy. At 2000 microM of the thiolactone an SAdoHcy accumulation of 0.49 nmol/min per g wet weight was found during normoxia. L-Homocysteine (200 microM) caused an increase of 0.37 and 4.17 nmol SAdoHcy/min per g wet weight during normoxia and ischemia, respectively. The adenosine concentration in ischemic hearts was significantly lower when homocysteine was infused (6.2 vs. 11.5 nmol/g; P less than 0.05). Purine release was increased 4-fold during ischemia. The Km for hydrolysis of SAdoHcy was about 12 microM. At in vitro conditions favoring near-maximal SAdoHcy synthesis (72 microM adenosine, 1.8 mM homocysteine), the synthesis rate in homogenates was 10 nmol/min per g wet weight. From the combined in vitro and perfusion studies, we conclude that S-adenosylhomocysteine hydrolase can contribute significantly to adenosine production in normoxic rat heart, but not during ischemia.

Adenosine deaminase inhibition and myocardial adenosine metabolism during ischemia.

It is generally assumed that myocardial adenine nucleotides are broken down (e.g., during ischemia) via AMP----adenosine----inosine, but contribution of the pathway AMP----IMP----inosine cannot be excluded. The catabolism of exogenously added adenosine (1-20 microM) was studied in isolated rat hearts. All catabolites (i.e., inosine, hypoxanthine, xanthine, and uric acid) were measured together with nonmetabolized adenosine. Even at low (1 microM) adenosine concentrations, deamination accounted for 60% of adenosine disappearing from the perfusate. The adenosine deaminase inhibitor erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) (5 and 50 microM) was infused together with adenosine (5 microM). These two concentrations of EHNA inhibited deamination of exogenous adenosine by 65 and 91%, respectively. When hearts were made ischemic by reduction of perfusion pressure, addition of EHNA raised the adenosine release from 1.4 to 9.8 nmole/min per gram wet wt., but surprisingly, the release of inosine and oxypurines (8 nmole/min per g wet wt.) did not change. These results suggest that considerable breakdown of myocardial adenine nucleotides can occur via the AMP----IMP----inosine pathway instead of AMP----adenosine----inosine. The rate of total purine release is probably not a good measure of intracellular adenosine formation.

Enhanced ATP and GTP synthesis from hypoxanthine or inosine after myocardial ischemia.

Increasing therapeutic use is made of purines for the treatment of ischemic heart disease, but little is known about regulatory mechanisms involved. Therefore we perfused isolated rat hearts with 0.02 mmol/l [8-14C]hypoxanthine or inosine. Under normoxic conditions about 1% is taken up by the heart and partially used for synthesis of ATP and GTP at a rate of 0.4 and 0.1 nmol X min-1 X g dry wt-1, respectively. After relatively mild ischemia (coronary flow reduction of 70% for 20 min), no increase in myocardial purine uptake is observed, but ATP and GTP synthesis rates are doubled (P less than 0.001). D-Ribose stimulates the hypoxanthine incorporation rate in normoxic perfused rat hearts to 1.1 and 0.5 nmol X min-1 X g dry wt-1 for ATP and GTP, respectively, which is further increased during postischemic perfusion. About 80% of the [8-14C]inosine or [8-14C]hypoxanthine passes through the heart unchanged, while 15% is converted to (hypo)xanthine and uric acid. We conclude from these experiments that inosine and hypoxanthine incorporation into ATP and GTP is at least partly regulated by the availability of 5-phosphoribosyl-1-pyrophosphate.

Myocardial xanthine oxidase/dehydrogenase.

High-energy phosphates in heart muscle deprived of oxygen are rapidly broken down to purine nucleosides and oxypurines. We studied the role of xanthine oxidase/dehydrogenase (EC 1.2.3.2/EC 1.2.1.37) in this process with novel high-pressure liquid chromatographic techniques. Under various conditions, including ischemia and anoxia, the isolated perfused rat heart released adenosine, inosine and hypoxanthine, and also substantial amounts of xanthine and urate. Allopurinol, an inhibitor of xanthine oxidase, greatly enhanced the release of hypoxanthine. From the purine release we calculated that the rat heart contained about 18 mU xanthine oxidase per g wet weight. Subsequently, we measured a xanthine oxidase activity of 9 mU/g wet wt. in rat-heart homogenate. When endogenous low molecular weight inhibitors were removed by gel-filtration, the activity increased to 31 mU/g wet wt. Rat myocardial xanthine oxidase seems to be present mainly in the dehydrogenase form, which upon storage at -20 degrees C is converted to the oxidase form.

Regulation of porcine heart and skeletal muscle AMP-deaminase by adenylate energy charge.

1. Cytosol from pig skeletal muscle, but not heart, contains an inhibitor of AMP-deaminase (AMP-D, EC 3.5.4.6) which reduces AMP-D activity 8-fold. 2. Heart and skeletal muscle AMP-D have been purified to apparent homogeneity by cellulose phosphate and DEAE-Sephacel chromatography. 3. AMP-D from skeletal muscle is inhibited more severely than the heart enzyme by an increase in adenylate energy charge to levels exceeding 0.4. Nevertheless both enzymes seem to be regulated by the energy charge, which contrasts with reports for rabbit heart AMP-D.