Arterial structure and function in Africans with HIV for > 5 years: longitudinal relationship with endothelial activation and cardiovascular risk markers.

OBJECTIVES: We aimed to determine whether people with human immunodeficiency virus (PWHIV) have increased measures of arterial injury [carotid intima-media thickness (cIMT)] and large artery stiffness [carotid-femoral pulse wave velocity (cfPWV)] when compared with their counterparts without HIV, and whether baseline markers of endothelial activation and cardiovascular risk are associated with cIMT and cfPWV after 5 years. METHODS: We matched 126 PWHIV from North West Province, South Africa, to 126 without HIV according to age, sex and locality. Cardiovascular risk and endothelial function markers [soluble intracellular adhesion molecule (ICAM-1) and soluble vascular cell adhesion molecule (VCAM-1)] were measured at baseline and cIMT and cfPWV at follow-up. RESULTS: This study included 21.4% men. The use of antiretroviral therapy (ART) increased from 44.1% at baseline to 81.4% at follow-up. At follow-up, cIMT (P = 0.90) and cfPWV (P = 0.35) were similar in the groups. Despite elevated ICAM-1 and VCAM-1 in the PWHIV (all P < 0.001) at baseline, these markers did not associate with cIMT and cfPWV after 5 years. In multivariable-adjusted regression analysis, cIMT associated positively with age (ß = 0.31, P = 0.002) and triglyceride: high-density lipoprotein-cholesterol (ß = 0.23, P = 0.016) in PWHIV. Mean arterial pressure (MAP) (ß = 0.28, P = 0.010) associated positively with cfPWV in the PWHIV. In the people without HIV, sex (ß = 0.31, P = 0.004) and glycated haemoglobin (HbA1c) (ß = 0.24, P = 0.026) associated with cIMT while age (ß = 0.17, P = 0.049), sex (ß = 0.29, P = 0.003), MAP (ß = 0.31, P = 0.001) and HbA1c (ß = 0.21, P = 0.041) associated positively with cfPWV. CONCLUSIONS: Measures of arterial structure and function were similar in Africans with HIV and their age, sex and locality matched controls. Traditional cardiovascular risk markers rather than elevated endothelial activation at baseline were independently associated with cIMT and cfPWV over 5 years.

The household economic burden of non-communicable diseases in 18 countries

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. METHODS: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. RESULTS: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. CONCLUSIONS: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs. (AU)

Comparison of dietary and plasma phospholipid fatty acids between normal weight and overweight black South Africans according to metabolic health: The PURE study.

BACKGROUND: Information regarding circulating fatty acids (FA) in association with metabolic health in black Africans is scarce, while the usefulness of circulating FAs as biomarkers of dietary fat intake and predictors for medical conditions is increasing. OBJECTIVE: We compared eleven dietary and the levels of 26 plasma phospholipid FAs in metabolically healthy and unhealthy phenotypes in black South African adults. METHODS: Adults from the South African arm of the Prospective Urban and Rural Epidemiology study baseline (n = 711) were categorised into four groups, namely normal weight without metabolic syndrome (MetS) (MHNW), normal weight with MetS (MUNW), metabolically healthy overweight/obese (MHO) and metabolically unhealthy overweight/obese (MUO). Dietary and plasma phospholipid FAs were measured by a quantitative food frequency questionnaire and gas chromatography-tandem mass spectrometry, respectively. We compared dietary FAs, plasma phospholipid FAs, and estimated desaturase activity between the metabolic status groups using ANCOVA adjusted for age and energy intake. RESULTS: MetS was diagnosed in 35% of the participants. After adjustment for age and total energy intake, in comparison to the MHNW reference group, saturated dietary FAs (C14:0 to C18:0) and alpha-linolenic acid intakes were higher in both overweight/obese groups (MHO and MUO), while linoleic acid intakes were higher in the MUO group only. Plasma levels of most saturated FAs (C18:0 to C22:0) and PUFAs were higher, whereas selected MUFAs, palmitic acid, and estimated desaturase activities were lower in the overweight/obese groups. CONCLUSIONS: The overweight groups generally had higher fat intakes than normal-weight groups, but lower plasma levels of palmitic, palmitoleic, oleic, cis-vaccenic and estimated desaturase activities. Therefore, in this population, lower plasma levels of palmitic, palmitoleic, oleic, and cis-vaccenic acids and decreased estimated desaturase activities may be biomarkers of abnormal metabolic health in overweight/obese study participants.

Differences between bone mineral density, lean and fat mass of HIV-positive and HIV-negative black women

Objectives: To investigate the differences between bone mineral density (BMD), lean and fat mass of human immunodeficiency virus (HIV-) positive and HIV-negative black women and to investigate factors associated with low BMD. Methods: Case-control study of black women (n= 565) aged 29­65 years from Potchefstroom, North West province, South Africa, based on secondary analysis of data. Total BMD, left femur neck of the hip (LFN BMD), spine BMD, total fat, fat-free tissue mass and percentage body fat (%BF) were measured by dual-energy X-ray absorptiometry. Results: HIV-negative women had significantly higher median BMD, %BF, appendicular skeletal mass (ASM), ASM index, body mass index (BMI) and waist circumference than HIV-positive women. When the groups were matched for age and BMI, only spine BMD was marginally lower in HIV-positive women. In the total group, age, smoking and HIV status were associated with lower BMD, while calcium intake was positively associated with BMD. Similar variables were associated with BMD in HIV-negative women, while age and educational status were associated with BMD in HIV-positive women. Conclusion: Low BMD was more common among HIV-positive than HIV-negative women. Older HIV-positive women with low educational status are particularly at risk

Cardiac Troponin T as Early Marker of Subclinical Cardiovascular Deterioration in Black Hypertensive Women.

BACKGROUND: Hypertensive heart disease is a rising concern, especially among black South African women. As high sensitivity cardiac troponin T (cTnT) is a marker of cardiomyocyte damage, we determined the potential link of (i) systemic endothelial dysfunction (reflected by urinary albumin-to-creatinine ratio), (ii) large artery stiffness, (iii) cardiac volume load (estimated by the N-terminal prohormone B-type natriuretic peptide (Nt-proBNP)), and (iv) ECG left ventricular hypertrophy in post-menopausal black women. METHODS: In 121 (50 normotensive and 71 hypertensive) black women (mean age: 60.6 years), basic cardiovascular assessments including blood pressure and ECG were performed, along with plasma and urinary biomarkers including cTnT. RESULTS: The cTnT levels (p=0.049) along with Nt-proBNP (p=0.003), pulse pressure (p<0.0001) and the Cornell product (p=0.030) were higher in hypertensive than normotensive women. Only in hypertensive women, was cTnT independently associated with urinary albumin-to-creatinine ratio (ß=0.25; p=0.019), pulse pressure (ß=0.31; p=0.019), Nt-proBNP (ß=0.47; p<0.0001) and Cornell product (ß=0.31; p=0.018). An independent association between albumin-to-creatinine ratio and cTnT was also evident in normotensive women (ß=0.34; p=0.037). CONCLUSION: We found cTnT to be a useful marker in an elderly black population relating to several measures of cardiovascular deterioration - from subclinical endothelial dysfunction to left ventricular hypertrophy.

Lean Mass Appears to Be More Strongly Associated with Bone Health than Fat Mass in Urban Black South African Women.

OBJECTIVES: To examine the association between body composition (fat mass, lean mass and body mass index, BMI) and bone health (bone mineral density, BMD and fracture risk) in urban black South African women. DESIGN: A cross sectional study examining associations between body composition, dietary intake (food frequency questionnaire), habitual physical activity (Activity energy expenditure (AEE) measured using an accelerometer with combined heart rate monitor and physical activity questionnaire) and bone health (BMD using dual-energy X ray absorptiometry, DXA and fracture risk). SETTING: Urban community dwellers from Ikageng in the North-West Province of South Africa. PARTICIPANTS: One hundred and eighty nine (189) healthy postmenopausal women aged ≥43 years. RESULTS: Fat mass and lean mass were significantly associated with BMD and fracture risk when adjusted for potential confounders. However, lean mass and not fat mass remained significantly associated with femoral neck BMD (ß = 0.49, p <0.001), spine BMD (ß = 0.48, p< 0.0001) and hip BMD (ß = 0.59, p< 0.0001). Lean mass was also negatively associated with fracture risk (ß = -0.19 p =0.04) when both lean and fat mass were in the same model. CONCLUSION: Lean mass and fat mass were positively associated with femoral neck, spine and hip BMDs and negatively associated with fracture risk in urban black South African women. Our finding suggests that increasing lean mass rather than fat mass is beneficial to bone health. Our study emphasises the importance of positive lifestyle changes, intake of calcium from dairy and adequate weight to maintain and improve bone health of postmenopausal women.

Large artery stiffness and carotid intima-media thickness in relation to markers of calcium and bone mineral metabolism in African women older than 46 years.

Vascular calcification and cardiovascular diseases have been associated with altered bone metabolism. We explored the relationships of arterial pressures and carotid intima-media thickness (CIMT) with parathyroid hormone, 25-hydroxycholecalciferol and their ratio (PTH:25(OH)D3) as well as a marker of bone resorption (CTX) in lean and overweight/obese African women. A population of 434 African women older than 46 years was divided into lean and overweight/obese groups. We assessed brachial blood pressure, central pulse pressure (cPP) and CIMT, and determined PTH, 25(OH)D3 and CTX concentrations. Overweight/obese women had elevated PTH and PTH:25(OH)D3 compared with lean women (both P<0.001), whereas lean women had higher CTX (P<0.001). Single, partial and multiple regression analyses indicated that, in lean women CIMT was independently associated with PTH:25(OH)D3 (R(2)=0.22; ß=0.26; P=0.003), whereas in obese women cPP was associated with both PTH:25(OH)D3 (R2=0.20; ß=0.17; P=0.017) and CTX (R2=0.20; ß=0.17; P=0.025). In conclusion, we found that in African women with increased adiposity, cPP (as a surrogate measure of arterial stiffness), was positively associated with alterations in bone metabolism and calciotropic hormones, whereas CIMT of lean women was positively associated with PTH:25(OH)D3. Our results suggest that alterations in bone and calcium metabolism may contribute to arterial calcification in older African women.

Evaluation of waist-to-height ratio to predict 5 year cardiometabolic risk in sub-Saharan African adults.

BACKGROUND AND AIMS: Simple, low-cost central obesity measures may help identify individuals with increased cardiometabolic disease risk, although it is unclear which measures perform best in African adults. We aimed to: 1) cross-sectionally compare the accuracy of existing waist-to-height ratio (WHtR) and waist circumference (WC) thresholds to identify individuals with hypertension, pre-diabetes, or dyslipidaemia; 2) identify optimal WC and WHtR thresholds to detect CVD risk in this African population; and 3) assess which measure best predicts 5-year CVD risk. METHODS AND RESULTS: Black South Africans (577 men, 942 women, aged >30years) were recruited by random household selection from four North West Province communities. Demographic and anthropometric measures were taken. Recommended diagnostic thresholds (WC > 80 cm for women, >94 cm for men; WHtR > 0.5) were evaluated to predict blood pressure, fasting blood glucose, lipids, and glycated haemoglobin measured at baseline and 5 year follow up. Women were significantly more overweight than men at baseline (mean body mass index (BMI) women 27.3 ± 7.4 kg/m(2), men 20.9 ± 4.3 kg/m(2)); median WC women 81.9 cm (interquartile range 61-103), men 74.7 cm (63-87 cm), all P < 0.001). In women, both WC and WHtR significantly predicted all cardiometabolic risk factors after 5 years. In men, even after adjusting WC threshold based on ROC analysis, WHtR better predicted overall 5-year risk. Neither measure predicted hypertension in men. CONCLUSIONS: The WHtR threshold of >0.5 appears to be more consistently supported and may provide a better predictor of future cardiometabolic risk in sub-Saharan Africa.

The relationship between adiponectin, ageing and renal function in a bi-ethnic sample.

Ageing is associated with elevated adiponectin levels. Our aim was to assess whether age-related increase in adiponectin is associated with a decrease in renal function. The study comprised African (N=277) and Caucasian (N=326) men and women. Adiponectin levels, estimated creatinine clearance rate and obesity indices were determined. African men revealed significantly higher adiponectin levels compared to Caucasian men (p<0.01), reflecting the lower adiposity levels of the African men. No difference in obesity measures (p=0.92) and adiponectin levels (p=0.27) was observed between African and Caucasian women. A significant increase in adiponectin levels with ageing was observed in both African men and women (p<0.01). To the contrary, progressive ageing seems not to be significantly related to elevated adiponectin levels within Caucasians. Renal impairment decreased significantly within all of the groups (p<0.01). Single regression analyses performed in all specified groups revealed significant associations between adiponectin and estimated creatinine clearance, however a multiple regression model revealed that insulin resistance had the strongest association with adiponectin within all the groups. In conclusion, age-related rise in adiponectin levels observed in Africans may not be due to renal impairment.

Hyaluronic acid and autologous synovial fluid induce chondrogenic differentiation of equine mesenchymal stem cells: a preliminary study.

Mesenchymal stem cells (MSC) have the potential to differentiate into distinct mesenchymal tissues including cartilage, which suggest these cells as an attractive cell source for cartilage tissue engineering approaches. Our objective was to study the effects of TGF-beta1, hyaluronic acid and synovial fluid on chondrogenic differentiation of equine MSC. For that, bone marrow was aspirated from the tibia of one 18-month-old horse (Haflinger) and MSC were isolated using percoll-density centrifugation. To promote chondrogenesis, MSC were centrifuged to form a micromass and were cultured in a medium containing 10 ng/ml TGF-beta1 or 0.1mg/ml hyaluronic acid (Hylartil, Ostenil) or either 5%, 10% or 50% autologous synovial fluid as the chondrogenesis inducing factor. Differentiation along the chondrogenic lineage was documented by type II collagen and proteoglycan expression. MSC induced by TGF-beta1 alone showed the highest proteoglycan expression. Combining TGF-beta1 with hyaluronic acid could not increase the proteoglycan expression. Cultures stimulated by autologous synovial fluid (independent of concentration) and hyaluronic acid demonstrated a pronounced, but lower proteoglycan expression than cultures stimulated by TGF-beta1. The expression of cartilage-specific type II collagen was high and about the same in all stimulated cultures. In summary, hyaluronic acid and autologous synovial fluid induces chondrogenesis of equine mesenchymal stem cells, which encourage tissue engineering applications of MSC in chondral defects, as the natural environment in the joint is favorable for chondrogenic differentiation.

[Analysis of the cost-income ratio for open and laparoscopic sigmoid resection]. / Wirtschaftlichkeitsanalyse für die konventionelle und laparoskopische Sigmaresektion im Hinblick auf die Einführung der DRG's.

Based on the example of the sigmoid resection, we did a cost-income analysis evaluating the particular expenses and effects of the new DRG-based medical financing system. We analysed the cost of diagnostic tests, medication and nutrition, surgery, personnel and non medical expenses for 20 open and 27 laparoscopic operated patients. The cost of open surgery was calculated to be 3,288.44 euro per patient while laparoscopic surgery was calculated to cost 4,271.98 euro. Based on an average hospitalisation period of 16 days, the estimated income for the hospital was 5,738.98 euro. Independent of the length of hospitalisation, an income of 6,621.34 euro for the hospital was estimated using the new DRG-based medical financing system. Thus, implementation of the new DRG-based medical financing system makes it possible to give patients the benefit of shorter hospital stays following laparoscopic surgery. The cost for the hospital, however, is only minimally reduced.

[Lung herniation after a single cough]. / Lungenhernie nach einmaliger Hustenattacke.

We present the case of an overweight male patient with a lung hernia caused by a single massive coughing attack. The diagnosis could only be verified by CT-scans. Following a conservative therapeutic approach, surgical intervention was necessary. Lung hernias are easy to detect using radiological diagnostic. Standard X-ray examinations where a subcutaneous air mass can be seen have become, since the inauguration of computed tomography, second line tests. Large traumatic lung hernias should be treated surgically. Spontaneous and especially cervical hernias should be handled conservatively and only must be surgically treated when complications or a progression in size should be observed.

[Localization of primary small cell carcinoma with liver metastasis: a rare combination of colonic adenocarcinoma and undifferentiated small cell carcinoma]. / Primärtumorsuche bei Lebermetastasen eines kleinzelligen Karzinoms. Seltener Kolonmischtumor aus Adenokarzinom und undifferenziertem kleinzelligen Karzinom.

Neuroendocrine or small cell cancer (SCC) is a rare tumor, accounting for less than 1% of all colorectal cancers. There is a high rate of metastasis in SCC. Overlying adenomas are commonly present in colorectal SCC. We present a case of a 67-year-old female patient with liver metastasis of SCC. Initially, the primary tumor was not found and the patient underwent chemotherapy. Ten months later, an adenocarcinoma of the right hemicolon was endoscopically diagnosed due to anal hemorrhage and right hemicolectomy was performed. Microscopic examination revealed that the adenocarcinoma was combined with an undifferentiated carcinomatous component. Immunocytochemistry was positive for synaptophysin and chromogranin. In our case a very rare combination of colonic adenocarcinoma and SCC within an overlying adenoma was found.

Rare manifestation of abdominal aortic aneurysm and popliteal aneurysm in a patient with Marfan's syndrome: a case report.

A 37-year-old patient with back pain and somatomegaly was found to have a penetrating aneurysm of sections IV and V of the abdominal aorta. Results of a family history and clinical examination confirmed suspicions of Marfan's syndrome. Further angiologic studies depicted an aneurysmatic dilatation of the left popliteal artery. Aneurysmatic dilatations are primarily located in sections I and II of the thoracic aorta, whereas aneurysms in sections IV and V are much rarer. The rare combination of an abdominal aortic aneurysm and left-sided popliteal aneurysm accompanying Marfan's syndrome is presented.

[Traumatic rupture of the pancreas and duodenum in pre-existing penetrating duodenal ulcer]. / Traumatische Pankreas- und Duodenalruptur bei vorbestehendem penetrierendem Ulcus duodeni.

Pancreatic injuries are rare complications after blunt abdominal trauma and usually the result of a direct force separating the pancreatic body in front of the vertebral column. This case report describes the uncommon event of a severe pancreatic and duodenal injury (stage IV b of Lukas) in which the combination of a direct force and the setting of a preexisting penetrating ulcer of the duodenum caused the extent of the pancreatic and duodenal injury [9]. Because of the preexisting lesion a Whipple procedure had to be performed. This case report demonstrates the influence of chronic abdominal diseases on the outcome of blunt abdominal trauma.

Rounded atelectasis in a patient with history of asbestos exposure. A case report.

We report a case of a 68-year-old patient with a history of chronic asbestos exposure and a lung tumour, highly suspicious for bronchial carcinoma. The patient underwent left lower lobectomy and histology showed the rare diagnosis of rounded atelectasis. Rounded atelectasis is an important differential diagnosis to bronchial carcinoma.

[Extramedullary plasmocytoma of the bronchial system]. / Das extramedulläre Plasmocytom des Bronchialsystems.

We present a case of primary plasmocytoma of the left upper bronchus. Occlusion led to atelectasis of the left upper lobe and subsequent poststenotic pneumonia. Therapy consisted of local excision of the bronchus and postoperative radio-therapy. This type of lung-conserving therapy in a case of primary plasmocytoma has not been described before.

Treatment of liver metastases from colorectal cancer.

197 cases of distant metastases from colorectal cancer (Dukes A, B, C) were diagnosed in 664 patients after curative resection of the primary tumor. Extrahepatic progress could be excluded in 98 of 142 patients with liver metastases. These 98 patients were allocated to surgical treatment (n = 17), intraarterial chemotherapy (n = 24), transarterial chemoembolization (n = 20), systemic chemotherapy (n = 10) and syptomatic therapy (n = 27) depending on the extent and localization of the disease within the liver and the patients' general condition. Curative success in 12 of 17 patients with a 5-year survival of 47% was achieved by the careful selection of patients for surgical treatment. Prolonged median survival after systemic chemotherapy (13 months), intraarterial chemotherapy (11 months) and transarterial chemoembolization of hepatic metastases (12 months) compared with the survival of patients with a symptomatic treatment only (median 11 months) could not be demonstrated, in spite o local therapeutic effects (intraarterial chemotherapy response rate 42%, transarterial chemoembolization morphologic response 82%). Effective postoperative diagnostic screening determines the percentage of potential curative surgical treatment; nonsurgical approaches failed to demonstrate prolonged survival.

[Clinical results of extremity perfusion in malignant melanoma]. / Klinische Ergebnisse der Extremitätenperfusion beim malignen Melanom.

Side effects and results of isolated hyperthermic extremity perfusion in malignant melanoma at the University of Cologne were reviewed: Severe local and systemic side effects (WHO grade III, IV) occurred in 3%, 5-year survival rates were 100% in TNM stage I patients (n = 27), 88.7% in TNM stage II patients (n = 123), 46.4% in TNM stage III patients (n = 169) and 36.3% in TNM stage IV patients (n = 22). 5-year recurrence free survival rates were 100% in TNM stage I, 73.4% in TNM stage II, 20.8% in TNM stage III and in TNM stage IV 9.1%. Indication for extremity perfusion remains locoregional recurrent disease.

[Multiparity in Nicaragua]. / Multiparität in Nicaragua.

The relation between birthweight and parity of the mother was examined in Nicaraguan patients from the capital Managua. 7431 births were taken into consideration from 1989-1991. 564 (= 7.6%) of these newborns were born to mothers with more than 5 deliveries. A positive correlation between the increasing number of the parity and the birthweight can be demonstrated in our patients until parity 10, however there are decreases in the birthweight of female newborns between parity 3 to 4 and 5 to 6 and in males between parity 6 to 7 and parity 8 to 9. The average age of a Nicaraguan primipara is 20.7 years and increases by 1.9-2.4 years until parity 5. From parity 6 to parity 15 it increases only by 0.7-1.2 years.