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Aims To (1) Describe the sociodemographic and risk factor profiles of a sample of patients with coronary disease, (2) Explore associations between illness perceptions and health literacy with sociodemographic characteristics and risk factors, health-related quality of life (HRQoL), anxiety, and depression. Methods and results Conducted as part of the ESC Prevention of CVD Project and EUROASPIRE V survey, patients were consecutively and retrospectively identified 6 months to 2 years after an acute event or elective procedure from 12 countries and interviewed. Three thousand four hundred and eight participants (76% male, mean age 64 years) were recruited, 16% were smokers, 38% obese, 60% physically inactive, and 41% hypertensive. Forty percent had attended cardiac rehabilitation. More threatening illness perceptions were associated with female gender (P<0.0001), lower income (P< 0.0001), lower education (P=0.02), obesity (P<0.0001), sedentary behaviour (P<0.0001), and diabetes (P<0.0001). Poorer health literacy was associated with obesity (P=0.02) and sedentary behaviour (P=0.0001). Threatening illness perceptions were strongly associated with anxiety, depression, and poorer ratings of HRQoL after multivariable adjustment (all P<0.001). Poor health literacy was associated with anxiety and depression (P< 0.0001) and poorer ratings of HRQoL (HeartQol scores P= 0.03). Results were consistent across regions of Europe, age, gender, and socio-economic strata. Conclusions Interventions like cardiac rehabilitation should be targeted at vulnerable groups given the strong associations between more threatening illness perceptions, lower health literacy, lower HRQoL, and higher levels of anxiety and depression. The delivery and content of these interventions should be accessible for those with low health literacy. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To validate the hypothesis that BAK induces low-grade inflammation in the anterior chamber, we designed a study to investigate whether switching from BAK-preserved to preservative-free latanoprost in patients with primary open-angle glaucoma (POAG) would reduce the flare levels.Patients: Forty-one eyes of twenty-two patients with primary open-angle glaucoma treated with BAK-preserved latanoprost for at least 6 months as monotherapy were included. Exclusion criteria included any use of topical eye drops other than latanoprost, pseudoexfoliation and pigment dispersion glaucoma, wearing of contact lenses and intraocular surgery in the past year.Methods: At the start of the study, we measured baseline flare values. We then switched all patients to preservative-free latanoprost. After 1, 2, and 3 months, a routine ophthalmological examination was performed and flare measurement repeated.Results: Thirty-three eyes were followed up throughout the entire 3-month period. One month after the switch to preservative-free latanoprost, a statistically significant mean drop in flare of − 0.96 ph/ms (P = 0.025) was observed. Mean flare decreased further by − 1.31 ph/ms (P = 0.0027) after 2 months and by − 1.25 ph/ms (P = 0.0041) after 3 months.Conclusion: The switch from BAK-preserved to preservative-free latanoprost induced a statistically significant reduction in mean flare value. Whereas our previous study showed an increase in flare when initiating treatment with BAK-preserved eye drops, this study shows a decrease in flare upon cessation of BAK-preserved drugs. The combined evidence from the two studies strongly suggests that in humans BAK exerts its effects not only on the ocular surface, but also at the level of the anterior chamber. [ABSTRACT FROM AUTHOR]

Background: Measurement of hair cortisol concentration (HCC) may be used as a biomarker for chronic stress. However, the association between stress and HCC has rarely been investigated in a working population. Aims: To explore associations between (i) HCC and various stress measures and (ii) HCC and symptoms of depression in Belgian workers. Methods: Hair samples were collected from workers in two production companies and cortisol content was determined by liquid chromatography tandem mass spectrometry. Participants completed a questionnaire including socio-demographics, health behaviours and standardized measures for assessing stress. Results: After excluding those workers suffering from a psychiatric or neuroendocrine disease and those treated with glucocorticoids, there were a total of 102 workers with both questionnaire, cortisol results and anthropometric measures. Median HCC was 5.73 pg/mg hair (interquartile range = 4.52-9.06). No significant associations were found between cortisol and the standardized measures related to several work psychosocial risk factors. A significantly lower mean HCC was found in shift workers compared with dayworkers, adjusted for age. Additionally, a significant higher mean HCC was found in workers with symptoms of depression compared with those without symptoms of depression, after adjustment for age. Conclusions: HCC showed a limited applicability as a biomarker for job stress in this sample, although the results suggest this method may be a suitable marker for detecting early symptoms of depression. Further research is needed to investigate the applicability of HCC in the working environment and within job stress research. [ABSTRACT FROM AUTHOR]

Background: The Health Care Module of the European Health Interview Survey (EHIS) is aimed to obtain comparable information on the use of inpatient and ambulatory care in all EU member states. In this study we assessed the validity of self-reported information on the use of health care, collected through this instrument, in the Belgian Health Interview Survey (BHIS), and explored the impact of selection and reporting bias on the validity of regional differences in health care use observed in the BHIS.Methods: To assess reporting bias, self-reported BHIS 2008 data were linked with register-based data from the Belgian compulsory health insurance (BCHI). The latter were compared with similar estimates from a random sample of the BCHI to investigate the selection bias. Outcome indicators included the prevalence of a contact with a GP, specialist, dentist and a physiotherapist, as well as inpatient and day patient hospitalisation. The validity of the estimates and the regional differences were explored through measures of agreement and logistic regression analyses.Results: Validity of self-reported health care use varies by type of health service and is more affected by reporting than by selection bias. Compared to health insurance estimates, self-reported results underestimate the percentage of people with a specialist contact in the past year (50.5 % versus 65.0 %) and a day patient hospitalisation (7.8 % versus 13.9 %). Inversely, survey results overestimated the percentage of people having visited a dentist in the past year: 58.3 % versus 48.6 %. The best concordance was obtained for an inpatient hospitalisation (kappa 0.75). Survey data overestimate the higher prevalence of a contact with a specialist [OR 1.51 (95 % CI 1.33-1.72) for self-report and 1.08 (95 % CI 1.05-1.15) for register] and underestimate the lower prevalence of a contact with a GP [ORs 0.59 (95 % CI 0.51-0.70) and 0.41 (95 % CI 0.39-0.42) respectively] in Brussels compared to Flanders.Conclusion: Cautiousness is needed to interpret self-reported use of health care, especially for ambulatory care. Regional differences in self-reported health care use may be influenced by regional differences in the validity of the self-reported information. [ABSTRACT FROM AUTHOR]

Objective: To obtain accurate estimates of the prevalence of ECG abnormalities in the general population and to describe them in relation to age, sex, and some lifestyle related factors.Design: The results were obtained from the records of 47 358 men and women participating in four large Belgian epidemiological studies during the past 30 years. All tracings were read and coded by two trained cardiologists on the basis of Minnesota code criteria.Results: Prevalences of coronary heart disease and abnormal ECG findings rose exponentially with age in both sexes, with the exception of atrioventricular block and the Wolff-Parkinson-White (WPW) syndrome. Major ECG findings were observed in 6.0% of all men and 4.3% of women, resulting in a significant adjusted sex ratio of 1.66 (95% confidence interval 1.46 to 1.88). The prevalence of minor ECG changes was slightly higher among men (10.4% v 9.5% in women). The occurrence of ischaemia-like findings on the ECG was comparable between men and women (9.0% v 9.8%). Independent of age, smoking, obesity, diabetes, employment status, positive history of angina or infarction, and region, there were significantly higher prevalences of Q/QS patterns, left ventricular hypertrophy, left axis deviation, arrhythmias, and atrial fibrillation or flutter in men than in women. Right bundle branch block and WPW syndrome both occurred 3.5 times more often in men, while the prevalence of left bundle branch block was comparable between the sexes.Conclusions: The large sample size allowed a precise description of the most important ECG abnormalities. These are not rare in the adult population and most are strongly age related. Sex differences occur with some, but not all, abnormalities. The less common ECG abnormalities were more often observed among men. [ABSTRACT FROM AUTHOR]

. Nyberg ST, Heikkilä K, Fransson EI, Alfredsson L, De Bacquer D, Bjorner JB, Bonenfant S, Borritz M, Burr H, Casini A, Clays E, Dragano N, Erbel R, Geuskens GA, Goldberg M, Hooftman WE, Houtman IL, Jöckel K-H, Kittel F, Knutsson A, Koskenvuo M, Leineweber C, Lunau T, Madsen IEH, Magnusson Hanson LL, Marmot MG, Nielsen ML, Nordin M, Oksanen T, Pentti J, Rugulies R, Siegrist J, Suominen S, Vahtera J, Virtanen M, Westerholm P, Westerlund H, Zins M, Ferrie JE, Theorell T, Steptoe A, Hamer M, Singh-Manoux A, Batty GD, Kivimäki M, for the IPD-Work Consortium (Finnish Institute of Occupational Health, Helsinki, Finland; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Jönköping University, Jönköping, Sweden; Ghent University, Ghent, Belgium; National Research Centre for the Working Environment, Copenhagen, Denmark; Versailles-Saint Quentin University, Versailles, France; Centre for Research in Epidemiology and Population Health, Villejuif, France; Bispebjerg University Hospital, Copenhagen, Denmark; Centre for Maritime Health and Safety, Esbjerg, Denmark; Université Libre de Bruxelles, Brussels, Belgium; University Duisburg-Essen, Essen, Germany; West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany; TNO, Hoofddorp, the Netherlands; Mid Sweden University, Sundsvall, Sweden; University of Helsinki, Helsinki, Finland; Stockholm University, Stockholm, Sweden; University College London, London, UK; Bispebjerg University Hospital, Copenhagen, Denmark; Umeå University, Umeå, Sweden; Finnish Institute of Occupational Health, Turku, Finland; Harvard School of Public Health, Boston, MA, USA; University of Copenhagen, Copenhagen, Denmark; University of Düsseldorf, Düsseldorf, Germany; University of Turku, Turku; Folkhälsan Research Center, Helsinki; Turku University Hospital, Turku, Finland; Uppsala University, Uppsala; Karolinska Institutet, Stockholm, Sweden; University of Bristol, Bristol; University of Edinburgh, Edinburgh, UK; and University of Helsinki, Helsinki, Finland). Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies. J Intern Med 2012; 272: 65-73. Background. Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses. Objectives. To examine the association between job strain and body mass index (BMI) in a large adult population. Methods. We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies ( n = 42 222). Results. A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m−2), 2149 were underweight (BMI < 18.5 kg m−2), 56 572 overweight (BMI 25.0-29.9 kg m−2) and 13 523 class I (BMI 30-34.9 kg m−2) and 3073 classes II/III (BMI ≥ 35 kg m−2) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up. Conclusions. In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level. [ABSTRACT FROM AUTHOR]

The underlying pathogenetic mechanisms of nondipping blood pressure (BP) pattern are not completely understood. Especially the role of psychosocial correlates remains unclear. The aim was to assess the association between nondipping BP pattern, behavioural and psychosocial factors in a sample of working men and women. The study sample included 167 working men and women aged 40-64 years from the BELSTRESS cohort. Socio-demographic, behavioural and psychosocial factors were assessed by self-administered questionnaires. Participants were medically examined and underwent an ambulatory BP monitoring during 24 h. Nondipping was defined when the average nocturnal decline in BP was <10%. The prevalence of nondipping for both systolic and diastolic BP was 7.8%. Nondipping was not significantly related to smoking, alcohol consumption and leisure time physical activity. A crude significant association was observed between nondipping and sleep problems. After adjusting for gender, education and body mass index, the risk for nondipping was associated with job strain, living alone, being unsatisfied about the contact with one's children, depressive symptoms and vital exhaustion. Nondipping BP pattern was consistently related to psychosocial factors in this study: positive associations were observed with measures of job strain, poor private life support (living alone and being unsatisfied about the contact with one's children) and mental health problems (depressive symptoms and vital exhaustion). [ABSTRACT FROM AUTHOR]

OBJECTIVES: A young person with many risk factors may have the same level of risk as an older person with no risk factors. Thus a high-risk 40-year-old may have a risk age of 60 years or more. The aim of the study was to derive a generic equation for risk age, construct risk age charts, and explore the hypothesis that risk age is similar regardless of the cardiovascular disease (CVD) end point used. METHODS: The equation was generated by equating the generic formula for 10-year CVD risk (with unknown risk factor levels) to the generic formula for 10-year CVD risk in a person with age = x and ideal risk factor levels (total cholesterol 4 mmol/l, systolic blood pressure 120 mm Hg, and non-smoker) and solving for x. To examine the consistency between risk ages for different end points, a risk age based on risk of CVD fatal events and based on risk of fatal and non-fatal CVD events was derived for each of the participants in the FINRISK population study. The correlation between these risk ages was examined. RESULTS: A generic equation for risk age was derived. The generic equation could not be used for SCORE (Systematic COronary Risk Evaluation), because the age is included in the baseline. Therefore a table of SCORE risk ages was developed by looking up the risk age corresponding to each combination of risk factors in the chart. Risk age remains similar regardless of the cardiovascular end point used, which bypasses the dilemma of whether to use a risk-estimation system based on CVD mortality or on the more attractive but less reliable end point of total CVD events. On the basis of the equation, risk age is not dependent on baseline survival and therefore recalibration is not required. CONCLUSIONS: Risk age is an intuitive and easily understood method for communicating about risk, particularly in younger patients, and may facilitate lifestyle change in younger patients. However, treatment decisions should be based on absolute risk, as recommended by guidelines on CVD prevention. [ABSTRACT FROM AUTHOR]

Summary In healthy middle-aged men, endogenous testosterone does not seem to increase risk for cardiovascular disease (CVD). One explanation might be a differential effect of testosterone, and another, interference with oestradiol with respect to specific cardiovascular functions. To investigate these possibilities, we evaluated in a cross-sectional population of 1223 healthy men, aged 46 (6) years, associations between endogenous testosterone, oestradiol and left ventricular structure and function (echocardiography). Testosterone was inversely associated with ejection fraction (EF) and with more sensitive systolic tissue Doppler imaging indices. Oestradiol was positively associated with EF. These associations were confirmed by linear regression analyses, and consistent for calculated free as well as for total sex steroid concentrations. Standardized regression coefficients were −0.13 for testosterone ( P < 0.01) and 0.12 for oestradiol ( P < 0.01) for the association with EF, in a model which included height, waist circumference, triglycerides, glucose, systolic blood pressure, drug-treated hypertension, heart rate, haematocrit, current smoking, serum sampling time, age and excessive alcohol use. The study suggests an opposite link, albeit modestly, of testosterone and oestradiol with left ventricle systolic function in healthy middle-aged men. The finding provides a partial explanation for the overall neutral effect on CVD of testosterone in healthy middle-aged men. [ABSTRACT FROM AUTHOR]

To evaluate the effect of a tailored behavior change program on a composite lifestyle change score. A randomized controlled trial conducted in Belgium in 2007–08 with 314 participants allocated to a control and an intervention condition. The intervention was a tailored behavior change program (web-based and individual coaching). The dose of the coaching was chosen by the participants and registered. Outcome measures were weight, saturated fat intake, fruit and vegetable intake, physical activity, smoking status and a composite lifestyle change score. Mann–Whitney U-tests, Kruskal–Wallis tests, t-tests and one-way analyses of variance were used to compare the study conditions and three intervention dose groups (no/low, medium and high intervention dose). There were no significant differences between the study conditions or between the intervention dose groups for the individual lifestyle factors. The composite lifestyle change score was significantly higher in the high intervention dose group compared with the no/low intervention dose group (P = 0.009). The composite lifestyle change score was positively related to the intervention dose, while the individual lifestyle factors were not. Behavior change programs that target multiple lifestyle factors could be evaluated by using a composite lifestyle change score taking into account the intervention dose. [ABSTRACT FROM AUTHOR]

To evaluate the effect of a tailored behavior change program on a composite lifestyle change score. A randomized controlled trial conducted in Belgium in 2007–08 with 314 participants allocated to a control and an intervention condition. The intervention was a tailored behavior change program (web-based and individual coaching). The dose of the coaching was chosen by the participants and registered. Outcome measures were weight, saturated fat intake, fruit and vegetable intake, physical activity, smoking status and a composite lifestyle change score. Mann–Whitney U-tests, Kruskal–Wallis tests, t-tests and one-way analyses of variance were used to compare the study conditions and three intervention dose groups (no/low, medium and high intervention dose). There were no significant differences between the study conditions or between the intervention dose groups for the individual lifestyle factors. The composite lifestyle change score was significantly higher in the high intervention dose group compared with the no/low intervention dose group (P = 0.009). The composite lifestyle change score was positively related to the intervention dose, while the individual lifestyle factors were not. Behavior change programs that target multiple lifestyle factors could be evaluated by using a composite lifestyle change score taking into account the intervention dose. [ABSTRACT FROM PUBLISHER]

Background/Objectives:Nutritional epidemiology shifted its focus from effects of single foods/nutrients toward the overall diet. Food-based dietary guidelines (FBDGs) are promoted worldwide to stimulate a healthy diet, including a variety of foods, to meet nutrient needs and to reduce the risk for non-communicable diseases. The objective of this study was to investigate whether adherence to the FBDG is associated with reduced femoral/carotid atherosclerosis and/or inflammation.Subjects/Methods:In October 2002, 2524 healthy men and women aged 35-55 years were recruited for the Belgian Asklepios cohort study. Subjects were extensively phenotyped, including echographic assessment of (carotid and femoral) atherosclerosis. A dietary index consisting of three subscores (dietary quality, diversity and equilibrium) was calculated to measure adherence to the Flemish FBDG, using data from a semi-quantitative food-frequency questionnaire. General linear models were used to investigate associations between these scores and cardiovascular (CV) risk factors and atherosclerosis and inflammation markers.Results:Women had better overall dietary scores than men (69 vs 59%). Participants with higher dietary scores showed better age-adjusted CV risk profiles (lower waist/hip ratio, blood pressure, non-high-density lipoprotein-cholesterol, blood triglycerides and homocystein), although most of these associations were only significant in men. Higher dietary scores were also inversely associated with inflammation makers (interleukin-6 and leukocyte count). Associations between diet and atherosclerosis were only found for femoral atherosclerosis and significance disappeared after adjustment for confounders.Conclusions:Better adherence to the Flemish FBDG is associated with a better CV risk profile and less inflammation, mainly among men. There was no direct effect on the presence of carotid or femoral atherosclerosis. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2010; 24; 86-92 The aim of this study was to complete a thorough psychometric evaluation of the 'RS-nl', a Dutch adaptation of the Wagnild and Young Resilience Scale. All of the 25 items of the original RS were retained, but a 4-point rather than a 7-point response was used and one item was reworded by removal of the negation. Psychometric analyses on 3265 healthy participants revealed a significant positive association between age and the total resilience score, confirming the findings with the Swedish version by Lundman et al. To a lesser extent, associations between education and the subscale 'Personal Competence' and between gender and the subscale 'Acceptance of Self and Life' was found. There was, however, no strong evidence for a five factor structure reflecting the five characteristics described by Wagnild and Young, mainly because of high secondary loadings. Therefore, in accordance with the 25-item RS, a two factor model (creating the subscales 'Personal Competence' and 'Acceptance of Self and Life') was maintained. The RS-nl seems to be a valid and useful screening instrument to detect persons at risk, who could benefit from closer and prolonged psychological help. [ABSTRACT FROM AUTHOR]

The diet quality index (DQI) for preschool children is a new index developed to reflect compliance with four main food-based dietary guidelines for preschool children in Flanders. The present study investigates: (1) the validity of this index by comparing DQI scores for preschool children with nutrient intakes, both of which were derived from 3 d estimated diet records; (2) the reproducibility of the DQI for preschoolers based on a parentally reported forty-seven-item FFQ DQI, which was repeated after 5 weeks; (3) the relative validity of the FFQ DQI with 3 d record DQI scores as reference. The study sample included 510 and 58 preschoolers (2.5-6.5 years) for validity and reproducibility analyses, respectively. Increasing 3 d record DQI scores were associated with decreasing consumption of added sugars, and increasing intakes of fibre, water, Ca and many micronutrients. Mean FFQ DQI test-retest scores were not significantly different: 72 (sd 11) v. 71 (sd 10) (P = 0.218) out of a maximum of 100. Mean 3 d record DQI score (66 (sd 10)) was significantly lower than mean FFQ DQI (71 (sd 10); P < 0.001). The reproducibility correlation was 0.88. Pearsons correlation (adjusted for within-person variability) between FFQ and 3 d record DQI scores was 0.82. Cross-classification analysis of the FFQ and 3 d record DQI classified 60 % of the subjects in the same category and 3% in extreme tertiles. Cross-classification of repeated administrations classified 62% of the subjects in the same category and 3% in extreme categories. The FFQ-based DQI approach compared well with the 3 d record approach, and it can be used to determine diet quality among preschoolers. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVE: The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema. BACKGROUND: No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. DESIGN: Secondary data analyses of a previously conducted randomised controlled trial were performed. METHODS: Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. RESULTS: The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. CONCLUSIONS: In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. RELEVANCE TO CLINICAL PRACTICE: Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs. [ABSTRACT FROM AUTHOR]

Our objective was to assess the prognostic significance of the night-time dipping pattern and the night–day blood pressure (BP) ratio for mortality and cardiovascular events in hypertensive patients without major cardiovascular disease at baseline. We performed a meta-analysis on individual data of 3468 patients from four prospective studies performed in Europe. Age of the subjects averaged 61±13 years; 45% were men and 61% were under antihypertensive treatment at the time of ambulatory BP monitoring. The night–day BP ratio and 24-h BP averaged, respectively, 0.907±0.085/0.866±0.095 and 138.1±16.4/82.3±11.0 mm Hg. Total follow-up time amounted to 23 164 patient-years. We used multivariable Cox regression analysis to assess the outcome of reverse dippers, non-dippers and extreme dippers vs dippers, and to assess the hazard ratios associated with 1 standard deviation higher night–day BP ratio. In comparison with dippers, and with adjustment for confounders and 24-h BP, the incidence of cardiovascular events was worse in reverse dippers (P0.05), whereas mortality was lower in extreme dippers (P0.01); outcome was similar in non-dippers and dippers. The systolic night–day BP ratio independently predicted all-cause mortality and cardiovascular events (P0.001), which persisted after additional adjustment for 24-h BP (P0.05); appropriate interaction terms indicated that the results were similar in men and women, in younger and older patients and in treated and untreated patients. In conclusion, the dipping pattern and the night–day BP ratio significantly and independently predict mortality and cardiovascular events in hypertensive patients without history of major cardiovascular disease, even after adjustment for 24-h BP. [ABSTRACT FROM AUTHOR]

Aim: This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. Background: Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. Method: Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated ( n = 789). The data were collected in 2006. Findings: Compression was applied in 58·7% of patients with venous ulcers. Pain was present in 82·9%. A third of patients with pain received analgesics, but half of these patients (52·1%) took analgesics as prescribed. Half of the nurses (50·8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68·3%), promoting physical activity (39·8%) and optimizing nutrition (16·7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3·75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. Conclusion: Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management. [ABSTRACT FROM AUTHOR]

The article presents a research study related to development and validation of a model for prediction of mortality in patients with acute burn injury in Belgium. The study shows that mortality in the derivation cohort was 4-6%, mortality in the validation cohort was 4.3%. In this connection, the model predicted 40 deaths and there were 42 deaths observed. In conclusion, an accurate model was accordingly developed to predict the probability of death from acute burn injury.

Objectives: To evaluate the diagnostic merits of scintigraphy in dogs with clinically obscure lameness origin. Methods: In 43 dogs, the scintigraphic findings were compared with the results of subsequent radiological, computed tomography and/or arthroscopic findings and/or additional neurological examination. Results: In all dogs, focal increased uptake was found in one or more joints or bones. The presence of associated pathology was confirmed by radiography, computed tomography and/or arthroscopy of the limb region of interest. Additional neurological examination was performed when indicated. In cases of elbow pathology, unilateral involvement of the elbow was confirmed with computed tomography/arthroscopy in 14 cases, while bilateral increased uptake could not be confirmed with radiography or computed tomography in three cases. Three dogs showed an increased activity in one joint on the bone scan, while computed tomography, arthroscopy or radiography revealed bilateral joint disease. Generalised mild increased radionuclide uptake in all joints and bones was observed in the lame limb in 15 forelimbs and five hindlimbs. Generalised prominent uptake of an entire limb was noted in three cases suffering from neurological disease. Clinical Significance: Scintigraphy may provide information on areas of increased radionuclide uptake, thereby aiding in the localisation of obscure lameness. Generalised mild increased uptake of radionuclide in all joints and bones in the lame limb may occur in the older dog. The generalised prominent uptake, seen in three cases with neurological disease, may resemble reflex sympathetic dystrophy syndrome seen in human beings. [ABSTRACT FROM AUTHOR]

Objective:Evaluation of a 2-day food record (FR) for the assessment of iron, calcium and vitamin C intake.Design:In a subsample of a large-scale epidemiological study, iron, calcium and vitamin C intake were estimated using a 2-day FR and compared to the nutrient intakes assessed by an 11-day FR (reference method).Setting:City of Ghent, Dutch speaking part of Belgium.Subjects:A number of 51 non-pregnant women (18–39 years).Results:Mean iron, calcium and vitamin C intakes were not significantly different between the reference method and 2-day FR. Correlation coefficients of 0.63 (iron) and 0.76 (calcium, vitamin C) were reached. The iron intake of 95% of the individuals assessed by the 2-day FR varied between 5 mg above or below the reference intake. Over 50% of the women were correctly classified and 4% or fewer were extremely misclassified by the 2-day FR. Mean 11-day FR intakes increased progressively over the tertiles defined by the 2-day FR. The 11-day energy intake was under-reported by 28% of the women; no over-reporters were identified.Conclusions:The 2-day FR is able to estimate mean iron, calcium and vitamin C intake and to rank individuals along the distribution of intakes.Sponsorship:Fund for Scientific Research – Flanders (Belgium).European Journal of Clinical Nutrition (2008) 62, 104–110; doi:10.1038/sj.ejcn.1602676; published online 21 February 2007 [ABSTRACT FROM AUTHOR]

Introduction Hormonal replacement therapy (HRT) may be beneficial for the cardiovascular system if hormones are given shortly after the onset of menopause. So far, no randomized trial has provided conclusive results. Materials and methods Based on Belgian population data, we calculated the number of women that should be included in a prospective double-blinded study to prove a potential cardiovascular benefit of HRT. Sample size calculations were based on the extrapolation of empirical observations made in three large databases from epidemiological studies carried out in Belgium during the past 20 years. Results The 10-year mortality varies with the age at which women are included in the observation. In the normal Belgian female population, the cardiovascular mortality risk is 0.85% and 1.58% for women aged 50-54 and 55-59 years, respectively. To prove that HRT induces a decrease of 10-year mortality of 30% in a normal population of 50-54-year-old women, 34 630 subjects would have to be included; for reductions of 20% and 10%, the numbers would be, respectively, 82 468 and 348 056. To prove a significant decrease in 10-year mortality starting with a normal population with an average age of 55-59 years, the numbers needed for hypothetical reductions of 30%, 20% and 10% would be, respectively, 18 514, 44 072 and 185 936. Conclusion If cardiovascular mortality is the study end-point, it is obvious that such a study will be a gigantic task. Taking cardiovascular morbidity as the end-point, such a study would be feasible. [ABSTRACT FROM AUTHOR]

End-systolic elastance (Ees) is a frequently used index of left ventricular (LV) contractility. However, because of its inherent dependence on LV geometry, Ees cannot be used to compare myocardial contractile state between ventricles with different geometries, which is the case in any cross-sectional study. Various normalization methods for Ees have been proposed in the literature, but a standardized method is still lacking. In this study, we introduced a novel alternative normalization technique and compared it with three previously suggested methods. We tested all normalization methods to assess the age- and sex-related differences in myocardial contractility in a large population sample of 2,184 middle-aged (ages, 35-55 yr) untreated subjects free from overt cardiovascular disease. Ventricular contractility Ees was determined using a previously validated noninvasive single-beat method, based on two-dimensional echocardiographic and brachial blood pressure measurements. Myocardial contractility was estimated as 1) Ees·end-diastolic volume (EDV); 2) Ees·LV mass (LVM); 3) 0.433·Ees,LVM/relative wall thickness (RWT), based on a theoretical LV model; and 4) 0.0941·Ees·LVM0.455·RWT-0.159, a novel semiempirical expression derived in this study. Because of the difference in their underlying assumptions, the various myocardial contractility indexes do not provide consistent information with respect to sex differences. Despite these discrepancies, it was found that myocardial contractility in women appears to be better preserved after the age of 50 yr compared with that in men. The physiological mechanisms behind this potentially clinically important phenomenon at population level require further investigation. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study investigating whether repositioning patients lying on a pressure-reducing mattress alternately for 2 hours in a lateral position and 4 hours in a supine position reduces the incidence of pressure ulcers in comparison with repositioning every 4 hours. Background. Repositioning is commonly recognized as an effective preventive measure. Almost no research has been carried out so far on the necessary turning frequencies to prevent pressure ulcer lesions. The pressure is higher in a lateral than in a supine position. Method. A two-arm randomized controlled trial was conducted in 16 Belgian elder care nursing homes. Patients with non-blanchable erythema were randomly assigned to either an experimental or a control group. In the experimental group (n = 122), patients were repositioned alternately 2 hours in a lateral position and 4 hours in a supine position. In the control group (n = 113), patients were repositioned every 4 hours. The sitting protocol was identical in both groups. Pressure areas were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. Results. In the experimental group, 16.4% patients developed a pressure ulcer lesion (grade 2-4), while 21.2% did so in the control group. The incidence was not statistically significantly different between the two groups (P = 0.40). The severity (P = 0.65) and location (P = 0.19) of pressure ulcer lesions, and the time to developing them (P = 0.29) were also similar in both groups. No patient developed a pressure ulcer at the hips. A considerable number of patients changed from a lateral to a supine position between the turning intervals. Conclusion. More frequent repositioning on a pressure-reducing mattress does not necessarily lead to fewer pressure ulcer lesions and consequently cannot be considered as a more effective preventive measure. [ABSTRACT FROM AUTHOR]

Human studies indicate exposure to lead is associated with decreased sperm quality with modest, if any, effects on conventional reproductive endocrine profile. Inhibin B is a marker of Sertoli cell function and spermatogenesis. The present study evaluates possible effects of lead exposure on serum levels of inhibin B in a group of lead workers as compared with a non-exposed group of hospital personnel. The study population included 68 healthy Belgian workers from a lead smelter (Hoboken, Belgium) and for comparison a control group of 91 hospital personnel (University Hospital Ghent, Belgium). Semen analysis and measurement of current blood lead levels and serum levels of inhibin B, follicle stimulating hormone (FSH) and estradiol (E2). Lead workers had significantly lower sperm concentration (35 vs. 51 million/mL) and higher serum inhibin B (259 vs. 177 pg/mL) as well as lead blood levels 30.9 vs. 3.4 μg/dL) compared with the hospital personnel (allp < 0.05). Serum FSH and E2 levels were similar in both groups. Overall, inhibin B levels correlated significantly positively with blood lead levels and sperm concentration while it was negatively correlated with serum FSH. In multiple regression analysis of data from all participants, blood lead and serum FSH (p < 0.0001 for both) followed by sperm count (p = 0.007) were selected as the only independent variables for inhibin B with an R-adjusted coefficient of determination of 0.3714. The results of the present study suggest that the exposure of the cells of Sertoli to excessive amounts of lead results in inappropriate inhibin B overproduction that may be involved in the impairment of spermatogenesis. [ABSTRACT FROM AUTHOR]

Aims/hypothesis. We examined risk factor management in diabetic and non-diabetic patients with CHD based on data from EUROASPIRE surveys. Methods. Consecutive CHD patients aged 70 years or younger were interviewed and examined at least 6 months after hospitalisation for a revascularisation procedure or acute myocardial infarction or ischaemia. Of these patients, 3569 were from the EUROASPIRE I study, undertaken from 1995 to 1996 in nine countries, and 5556 were from the EUROASPIRE II study, conducted between 1999 and 2000 in 15 countries. Results. In EUROASPIRE I and II 18% and 20% of CHD patients respectively had been previously diagnosed with diabetes. Fasting glucose screening raised the prevalence of diabetes in EUROASPIRE II to 28%. In EUROSPIRE II the prevalence of risk factors (known diabetic/non-diabetic) was: current smoking 17%/22 % (p=0.25); obesity (BMI ≥30 kg/m2) 43%/29% (p<0.001); raised blood pressure (≥140/90 mm Hg) 57%/49% (p<0.001); and elevated total cholesterol (≥5.0 mmol/l) 55%/59% (p<0.001). The proportion of users of cardiovascular medication was: antiplatelet drugs 83%/86% (NS); beta-blockers 62%/63% (NS); ACE inhibitors 49%/35% (p<0.001); and lipid-lowering drugs 62%/61% (NS). A comparison of both studies showed that for diabetic and non-diabetic patients the prevalence of smoking had increased somewhat and that the prevalence of obesity had increased clearly. There was no improvement in blood pressure control, but cholesterol control had improved, mainly explained by the increased use of lipid-lowering drugs. Conclusions/interpretation. These European surveys show a high prevalence of adverse lifestyles and modifiable risk factors among diabetic and non-diabetic patients with CHD. The risk factor status was more adverse in diabetic patients. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: To ascertain, whether, conventional risk factors and readiness of coronary patients to modify their behaviour and to comply with recommended medication were associated with education in patients with established coronary heart disease. Design and methods: EUROASPIRE II was a cross sectional survey undertaken in 1999-2000 in 15 European countries to ascertain how effectively recommendations on coronary preventions are being followed in clinical practice. Consecutive patients, men and women

OBJECTIVE:: To study the predictive power of serum selenium with regard to cancer mortality in a large sample of the Belgian population given the lack of coherence in the results of observational epidemiological studies in this domain. DESIGN:: A prospective case-control study within a stratified sample of the Belgian male and female population. SUBJECTS:: A total of 201 cases randomly selected from all cancer deaths (N=343) during a 10-y mortality follow-up of a large age- and sex-stratified sample of the total Belgian population aged 25-74?y were matched for age and gender with 603 controls. STATISTICS:: Conditional logistic regression for both univariate and multivariate analyses using tertile distribution of serum selenium in controls. Odds ratios (ORs) are adjusted for 10 baseline characteristics. RESULTS:: Unadjusted ORs of cancer deaths taking the highest tertile of serum selenium as a reference: in male subjects T1/T3 is 2.2 (CI 1.3-3.7) (P for trend 0.011), whereas in female subjects a nonsignificant OR of 0.8 is observed. In multivariate analyses, no significant modifications of the ORs are observed for the predictive relation of serum selenium with cancer mortality. Besides serum selenium, beta-carotene intake and smoking are independent predictors in male subjects. CONCLUSIONS:: In this nested case-control study of a stratified sample from the Belgian population, serum selenium is an independent predictor of cancer mortality in male subjects only, in a country with rather high serum selenium levels with respect to most other European countries.European Journal of Clinical Nutrition (2004) 58, 98-104. doi:10.1038/sj.ejcn.1601754 [ABSTRACT FROM AUTHOR]

Aims The SCORE project was initiated to develop a risk scoring system for use in the clinical management of cardiovascular risk in European clinical practice.Methods and results The project assembled a pool of datasets from 12 European cohort studies, mainly carried out in general population settings. There were 205 178 persons (88 080 women and 117 098 men) representing 2.7 million person years of follow-up. There were 7934 cardiovascular deaths, of which 5652 were deaths from coronary heart disease. Ten-year risk of fatal cardiovascular disease was calculated using a Weibull model in which age was used as a measure of exposure time to risk rather than as a risk factor. Separate estimation equations were calculated for coronary heart disease and for non-coronary cardiovascular disease. These were calculated for high-risk and low-risk regions of Europe. Two parallel estimation models were developed, one based on total cholesterol and the other on total cholesterol/HDL cholesterol ratio. The risk estimations are displayed graphically in simple risk charts. Predictive value of the risk charts was examined by applying them to persons aged 45–64; areas under ROC curves ranged from 0.71 to 0.84.Conclusions The SCORE risk estimation system offers direct estimation of total fatal cardiovascular risk in a format suited to the constraints of clinical practice. [ABSTRACT FROM PUBLISHER]

Aims To determine whether the Joint European Societies' recommendations that first degree blood relatives of patients with premature coronary heart disease (CHD) should be screened for coronary risk factors is being followed and, if so, how effectively these relatives are being managed.Methods and results Using a postal questionnaire, 3322 relatives (siblings and children ≥18 years of age) of 1289 index patients in the EUROASPIRE II survey who had suffered from premature CHD (men under 55 years and women under 65 years) were asked whether screening for coronary risk factors had occurred and, if so, how they were being managed in terms of lifestyle advice and drug therapies. Overall, screening for coronary risk factors because of CHD in the family was only performed in 11.1% of siblings and 5.6% of children. However, prevalences of different cardiac risk factors were high both in relatives and offspring and a clear familial clustering could be documented. Less than 50% of siblings and 25% of children were given some general lifestyle advice regarding cardiac risk factors. Moreover, active interventions such as starting antihypertensive or lipid lowering drugs were rarely carried out, particularly in children of patients with premature CHD.Conclusions European physicians rarely screen family members of patients with premature CHD for cardiac risk factors. General lifestyle style advice or active treatment for these risk factors are also rarely given. However, since these family members have a high prevalence and familial clustering of cardiac risk factors, they form an ideal target population for primary prevention of CHD in high-risk patients. [ABSTRACT FROM PUBLISHER]

Carbon disulphide (CS2) is known to accelerate atherosclerosis and to increase the risk for cardiovascular diseases. To assess the effect of CS2 on the functional (distensibility and compliance) and the structural (intima media thickness) properties of the common carotid artery, and blood pressure and lipid metabolism parameters, a cross‐sectional study on 85 workers from a viscose rayon factory and 37 controls was carried out. Exposure to CS2 was assessed by personal monitoring and was well below the threshold limit value‐time weighted average. Carotid arterial wall properties were determined using a non‐invasive ultrasound wall movement detector system. No significant effect of CS2 on blood pressure, total cholesterol, high‐density lipoprotein cholesterol, low‐density lipoprotein cholesterol or triglycerides was found. Among the vascular parameters studied, only distensibility was significantly lower and heart rate was significantly higher in exposed subjects compared with the controls. In conclusion, occupational exposure to CS2 may cause early alterations in arterial elastic properties in young individuals, and even before lipid and clinical findings have occurred, important functional changes in the vessel wall are present. [ABSTRACT FROM PUBLISHER]

Objective: To determine the proportion of dyslipidaemic patients reaching on-treatment low density lipoprotein cholesterol (LDL-C) goals as defined by European Atherosclerosis Society (EAS) guidelines. Design: Prospective, cross-sectional survey. Demographic characteristics and cardiovascular risk factors were assessed in 1664 on-treatment dyslipidaemic patients during a 5-month period (from September 1997 to January 1998). A fasting lipid profile was drawn within 1 week of the study visit. Setting: 147 investigators (cardiologists, endocrinologists and general practitioners) from Belgium and Luxembourg. Patients: 1664 patients; mean age 63 years (18 to 90 years); 46% female, 54% male; 86.4% at high risk for coronary heart disease (CHD). Outcome Measures: The frequency of achieving EAS goals and factors associated with achieving these goals. Results: Overall, 36% of patients achieved the 1992 EAS goals [high risk: LDL-C <135 mg/dl (3.5 mmol/L); medium risk: LDL-C <155 mg/dl (4.0 mmol/L); low risk: LDL-C <175 mg/dl (4.5 mmol/L)]. The success rate (33.7%) was lowest among high risk patients. Factors independently associated with a failure to achieve EAS goals were: younger age, male gender, body mass index ≥28 kg/m, while the presence of diabetes mellitus, the use of statins and the speciality of the investigator were positively associated with success rate. Only 14% of high risk patients reached the LDL-C target <115 mg/dl (3.0 mmol/L) proposed by the 1998 Joint European Guidelines. Conclusions: A large proportion of patients treated with lipid-lowering agents did not achieve LDL-C goals according to EAS guidelines. Undertreatment is a major problem in the management of hyperlipidaemia. More aggressive implementation of treatment guidelines, especially for patients at high risk for CHD, would be highly desirable. [ABSTRACT FROM AUTHOR]

Aims To evaluate the management of overweight and obesity in coronary artery disease patients in Europe.Methods and Results The EUROASPIRE Study is a multicentre epidemiological study involving nine European countries. The major cardiovascular risk factors and their management were collected from hospital records and measured at least 6 months after hospitalization during a specific interview. A total of 4863 consecutive records from men and women with coronary artery disease, under 71 years of age, were reviewed. Interviews were obtained for 3569 (73%). Body mass index was computed from height and weight noted in the medical records and measured at interview. Management of overweight and obesity was recorded at interview. At least 6 months after hospitalization, 75% of women and 80% of men were overweight and 33% of women and 23% of men were obese. Height noted in medical records was over-estimated, inducing an under-estimation of obesity in 16% of men and 33% of women. Advice from a nutritionist was offered in less than 20% of obese patients. The same trends were observed in all participating countries.Conclusions Prevalences of overweight and obesity are high in coronary artery disease patients in Europe. A systematic measurement of height and weight is a prerequisite to a better management of this common modifiable risk factor. [ABSTRACT FROM PUBLISHER]

The objective of this study was to investigate the effect of occupational exposure to carbon disulphide (CS2) on the total cholesterol, blood pressure and prevalence of coronary heart disease (CHD). A cross-sectional study involving 252 viscose rayon workers and 252 age and sex matched controls was carried out. Depending on the job and specific work place, the CS2 concentrations were between 10 and 64 mg/m3. A cumulative exposure index (CS2 index) was calculated for each worker by multiplying the number of years he had held a particular job with the CS2 concentrations in that job. CHD prevalence among the exposed was higher than among the controls; the difference reaching significance only for highly exposed workers. Cholesterol levels were significantly higher in both highly and moderately exposed groups. In conclusion, the results demonstrated that occupational exposure to CS2 increases total cholesterol and the risk for CHD. While the risk for CHD is increased in workers exposed to high CS2 concentration for many years (CS2 index≥300), even the relatively modest exposure (CS2<300) may increase the serum cholesterol. [ABSTRACT FROM PUBLISHER]

Cardiovascular diseases (CVDs) are the leading cause of global mortality and a major contributor to disability. According to European Cardiovascular Disease Statistics, in 2017 there were 108.7 million people living with CVDs in Europe resulting in about 4,681 disability-adjusted life years per 100,000 inhabitants. Among these, ischaemic heart and cerebrovascular diseases (IH&CBD) represent the highest burden in terms of morbidity, mortality and health care costs. CVDs were estimated to cost the EU E210 billion a year, where 28% was attributable to IH. The aim of this study was to assess the financial burden at societal level of IH&CBD in Belgium based on hospital discharge data, considering that inpatient hospital care costs accounted for about 51% of the total healthcare costs in CVDs. Methods: IH&CBD were identified based on ICD-10 codes following the definition provided in the Global Burden of Disease study in 2017. IH: angina pectoris (AP) I20 and I25, acute myocardial infarction (AMI) I21-I24; CBD I60-I68. Mean annual number of patients and direct hospitalization costs from 2016 to 2018 were retrieved from the Belgian hospital discharge dataset, considering both primary and secondary diagnoses. Results: Within the observed diseases, AP was the most common reason for hospitalizations with an average of 41,439 hospitalized patients per year. Yearly, 27,630 patients were hospitalized for CBD and 14,928 patients were hospitalized for AMI. The yearly hospitalization cost for AP and AMI in Belgium was on average respectively E219,688,254 and E133,343,881. CBDs accounted for the largest direct hospitalization cost with E301,900,539 per year. Conclusions: 1. In Belgium, on average almost 84,000 people are hospitalized yearly due to IH&CBD; 2. On average, Belgium spends around E655 million a year for these hospitalizations. Key messages: ) IH&CBD represent a high health and financial burden in Belgium. ) Since IH&CBD can be linked to several behavioral risk factors, this burden could be reduced with target health interventions. [ABSTRACT FROM AUTHOR]

Four laboratories have participated in an external quality control assessment for the determination of 2-thiothiazolidine-4-carboxylic acid (TTCA). TTCA is used as a biomarker for exposure to CS2. Thirteen different urine samples were analyzed by each laboratory. Ten of these were spiked with known amounts of TTCA, and had either a high or intermediate creatinine content. Two samples without any TTCA were used as controls and one sample was a pool of samples of urine from five employees occupationally exposed to CS2. The latter had unknown TTCA content. For each sample, TTCA and creatinine concentration were determined. The samples were supplied in three consecutive deliveries. Several samples were offered more than once. Thus, within-laboratory variability could be established for creatinine and TTCA determination and accuracy could be determined for TTCA analysis. Within-laboratory variability was low for all laboratories for creatinine, although laboratory D seemed to have a slight downward bias. Accuracy for TTCA was good for all laboratories. No significant mean deviation from the expected TTCA value was encountered. There does not seem to be any clear influence of the TTCA concentration level of the samples on the accuracy and within-laboratory variability. Two of the four laboratories (A and C) showed lower within-laboratory variability than the other two for TTCA, although coefficients of variation between replicated samples are high for these two laboratories as well. The laboratory giving the best accuracy, gave the highest within-laboratory variability. A non-systematic, random error is probably the source of this. The results of this preliminary study indicate that analysis of TTCA, although regarded as an established biomarker, can give biases and thus negatively interfere with inferred dose–effect or dose–response relationships in occupational epidemiology. [ABSTRACT FROM PUBLISHER]