No description available.

Both aspects of the two way interaction between cancer and the haemostatic system were investigated. In a prospective study, Fibrinogen, Fibrinopeptide A (FPA), Fragment Bβ 15-42, Fibrin Plate Lysis Assay and Fibrin(ogen) Degradation Products (FDPs) were measured in patients with operable breast cancer (BC) patients with benign breast disease (BBD) and healthy subjects. Preoperatively, FPA and FDPs were highest in BC patients, but were also significantly elevated in BBD patients. Bβ 15-42 was elevated equally in these two groups. Neither pre nor postoperative haemostatic measurements were of any value in predicting early recurrent disease. Elevated FPA values persisted in BC patients 3 & 9 months postoperatively, whilst Bβ 15-42 rose further during this time. An association between oestrogen receptor result and Bβ 15-42 values was found. These findings suggest that much of the activation of haemostasis in cancer patients arises from non-specific causes, and that haemostatic changes do not correlate with prognosis. They suggest that a primary tumour may cause relative suppression of the fibrinolytic response. The inhibition of metastasis by warfarin was studied in an animal model. Warfarin was not cytotoxic for Mtln3 tumour cells, but inhibited metastasis. Deposition of fibrin within tumours was apparently not altered by warfarin treatment, and injection of fibrin or FDPs with tumour cells had no effect on metastasis or growth of the tumour. Pre-injection warfarin treatment of the host inhibited metastasis of Mtln3 cells, whilst pretreatment of tumour cells had no effect. Injection of factors II, VII, IX and X reversed this effect of warfarin, if given within 12 hours of tumour cells. Further studies demonstrated that factors II, IX and X together enhanced metastasis in non-anticoagulated rats. Finally, Arvin defibrination did not abolish this effect, and did not itself affect metastasis. It was concluded that the factor II, IX, X complex can enhance metastasis, and that the antimetastatic effect of warfarin appeared to be due to inhibition of these proteins. Since enhancement was not affected by defibrination, it may occur via mechanisms other than fibrin formation.

Motivation: Cardiovascular disease (CVD) is one of the leading causes of mortality and morbidity in South Africa and worldwide. Dyslipidaemia and an increased coagulation state contribute to the development of CVD. The quality of fibrin network structure (FNS) may also contribute to the risk for CVD and thrombosis. Changes in fibrinogen concentration directly affect FNS. Management of these risk factors is important and dietary intervention forms an essential part of this management program. An increased intake of vitamin C can lead to a decreased susceptibility to infection and subsequently to decreased levels of haemostatic factors (that give rise to an anti-thrombotic state) and thus reduction in CVD and mortality. Furthermore, vitamin C may prove to be beneficial by increasing the pro-fibrinolytx activities of FNS (formation of thick fibrin fibers and more lysable clots) that could result in a reduction in atherosclerosis and subsequent CVD. Obiective: To investigate the effects of FoodState Vitamin C complex supplementation on haemostatic factors, FNS, serum lipids and lipoprotein (a) (Lp(a)) in hyperlipideamic adults. Methods: Thirty free-living hiperlipidaemic volunteers from the Lipid Clinic, Potchefstroom University for Christian Higher Education (CHE), participated in this randomised placebo controlled double blind crossover study. The subjects were randomly divided into two groups (A or B). After a run-in period of 4 weeks during which the subjects excluded all vitamin supplements, Group A received 2 tablets/day of FoodState Vitamin C complex (500mg vitamin C, 600mg magnesium food complex, 900mg vitamin B complex and 160mg bioflavonoids) and Group B received 2 tablets/day of placebo, for at least 8 weeks. A washout period of 8 weeks followed after which the treatments were crossed-over for a further 8 weeks. Fasting blood samples were drawn 8 times (two samples, one week apart at the beginning and end of each treatment). Results: FoodState Vitamin C complex supplementation did not significantly influence the levels of plasma fibrinogen, plasminogen activator inhibitor 1 activity (PAI-I act), tissue plasminogen activator antigen (tPA ag) or d-dimer. Serum lipids and Lp(a) were also not affected. Median plasmin-antiplasmin complex (PAP) and thrombin-antithrombin complex (TAT) levels, which are markers of plasmin (initiate fibrinolysis) and thrombin (initiate coagulation) generation respectively, were both significantly decreased compared to placebo (PAP: 4.05[-23.39, -0.231% vs 1.81[-8.95, 8.091%; TAT: -5.81[-18,47, 0.391% vs 0.12[-8.03, 13.51%). FoodState Vitamin C complex beneficially affected FNS by significantly increasing compaction (49.95[47.55,53.70]% to 51.85[48.55,56.65]%). Conclusion: The decreases in TAT and PAP are possibly an indication that the FoodState Vitamin C complex decreased the initiation of haemostasis, which in turn led to a compensatory reduction in fibrinolysis. FoodState Vitamin C complex may, therefore be protective of cardiovascular disease by causing a new reduced steady state of hemostatic balance and more lysable clots (increased compaction). / Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2004.

Motivation: Cardiovascular disease (CVD) is one of the leading causes of mortality and morbidity in South Africa and worldwide. Dyslipidaemia and an increased coagulation state contribute to the development of CVD. The quality of fibrin network structure (FNS) may also contribute to the risk for CVD and thrombosis. Changes in fibrinogen concentration directly affect FNS. Management of these risk factors is important and dietary intervention forms an essential part of this management program. An increased intake of vitamin C can lead to a decreased susceptibility to infection and subsequently to decreased levels of haemostatic factors (that give rise to an anti-thrombotic state) and thus reduction in CVD and mortality. Furthermore, vitamin C may prove to be beneficial by increasing the pro-fibrinolytx activities of FNS (formation of thick fibrin fibers and more lysable clots) that could result in a reduction in atherosclerosis and subsequent CVD. Obiective: To investigate the effects of FoodState Vitamin C complex supplementation on haemostatic factors, FNS, serum lipids and lipoprotein (a) (Lp(a)) in hyperlipideamic adults. Methods: Thirty free-living hiperlipidaemic volunteers from the Lipid Clinic, Potchefstroom University for Christian Higher Education (CHE), participated in this randomised placebo controlled double blind crossover study. The subjects were randomly divided into two groups (A or B). After a run-in period of 4 weeks during which the subjects excluded all vitamin supplements, Group A received 2 tablets/day of FoodState Vitamin C complex (500mg vitamin C, 600mg magnesium food complex, 900mg vitamin B complex and 160mg bioflavonoids) and Group B received 2 tablets/day of placebo, for at least 8 weeks. A washout period of 8 weeks followed after which the treatments were crossed-over for a further 8 weeks. Fasting blood samples were drawn 8 times (two samples, one week apart at the beginning and end of each treatment). Results: FoodState Vitamin C complex supplementation did not significantly influence the levels of plasma fibrinogen, plasminogen activator inhibitor 1 activity (PAI-I act), tissue plasminogen activator antigen (tPA ag) or d-dimer. Serum lipids and Lp(a) were also not affected. Median plasmin-antiplasmin complex (PAP) and thrombin-antithrombin complex (TAT) levels, which are markers of plasmin (initiate fibrinolysis) and thrombin (initiate coagulation) generation respectively, were both significantly decreased compared to placebo (PAP: 4.05[-23.39, -0.231% vs 1.81[-8.95, 8.091%; TAT: -5.81[-18,47, 0.391% vs 0.12[-8.03, 13.51%). FoodState Vitamin C complex beneficially affected FNS by significantly increasing compaction (49.95[47.55,53.70]% to 51.85[48.55,56.65]%). Conclusion: The decreases in TAT and PAP are possibly an indication that the FoodState Vitamin C complex decreased the initiation of haemostasis, which in turn led to a compensatory reduction in fibrinolysis. FoodState Vitamin C complex may, therefore be protective of cardiovascular disease by causing a new reduced steady state of hemostatic balance and more lysable clots (increased compaction). / Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2004.

Magister Chirurgiae Dentium (MChD) / Pulp therapy in the primary dentition has always been a source of much controversy. Different pulpotomy techniques and medicaments have been covered extensively in the literature but due to the increasing awareness of the potential deleterious effects of some of these medicaments, a need has arisen in the dental profession to fmd safer, alternative pulpotomy agents. Ferric sulfate and calcium hydroxide have been suggested as possible, more biologically acceptable alternatives to formocresol, which is known for its toxic side effects. Ferric sulfate is one of the most recent agents used in vital pulp therapy and has enjoyed reasonable success. Further controversy also exists in terms of the type of base which is placed over the amputated pulp. The choice of the base seems to determine the pulpal response. Two bases, calcium hydroxide (Dycal) and zinc oxide-eugenol (Kalzinol) have both been used in separate studies but have never been compared. The aim of this study is to compare the success rate obtained when applying one or the other of these two bases following a ferric sulfate pulpotomy. Presently it is unknown which base is best. In this study, after haemostasis was achieved with damp cotton pellets, ferric sulfate was applied to the pulpal stumps. Half of the cases then received a Dycal base followed by a cured layer of Vitrebond and a permanent amalgam restoration. The other half of the cases received a base of zinc oxide-eugenol (Kalzinol) followed by an amalgam restoration. Overall, teeth treated with Dycal demonstrated a higher failure rate when compared with those that received the Kalzinol base. Abscess formation and internal resorption were the most common causes of failure. Even though the Kalzinol base demonstrated greater success, there were still quite a few failures. This study demonstrates, that even with the use of a haemostatic agent, calcium hydroxide cannot be recommended as a medicament in primary tooth pulpotomies. It also highlights the need for alternative pulpotomy medicaments that are not irritating or harmful to the pulp.

B. Tech. (Department of Biotechnology, Faculty of Applied and Computer Sciences), Vaal University of Technology. / Background: In a group of the elderlies (older person) in Sharpeville, Gauteng, South Africa, the majority live in poverty with a poor nutritional status. This makes them susceptible to develop infectious diseases as well as the risk of Chronic Diseases of the Lifestyle (CDL) such as cancer, diabetes, heart attack, obesity and hypertension. One of the most constant features of aging is the progressively elevated levels of coagulation factors such as FVII, fibrinogen, and impairment of fibrinolysis might play a role in the ageing process. These are associated with increased susceptibility to Cardiovascular diseases (CVD) commonly found. An association between elevated levels of FVII and R353Q polymorphism has been established as a risk factor for CVD. This genetic polymorphism R353Q characterizes the substitution in the exon 8 of the FVII gene of guanine-to-adenine, which results in the replacement of arginine (R) by glutamine (Q) in codon 353 of the F7gene. Objectives: The aim of this study was to evaluate the prevalence of R353Q polymorphism in correlation with haemostatic markers within an urban elderly community in South Africa. Method: This study was ethically approved, and it is an experimental research design on the prevalence of R353Q polymorphism in correlation with homeostatic status (Factor VII, Fibrinogen and PAI-1). The study was done in a black elderly population living in the Vaal triangle region of Sharpeville, attending a day care center, who gave consent to participate in the study. A purposely selected sample of 102 subjects, who met the inclusion criteria were used. The homeostatic status was measured by factor VII and fibrinogen measuring coagulation and PAI-1 measuring fibrinolysis. Results: The prevalence of R353Q genetic polymorphism was established in 14.5% of the sampled population. The prevalence of the RQ (AG) genotype was determined in the sample population with 6.5 % of elevated factor VII levels, 7.8% of increased fibrinogen levels (coagulation) and 10.5 % of decreased levels of PAI-1. The R(A) allele, was detected in 1.3% of the sampled population of normal levels of FVII, fibrinogen and PAI-1. The dominant allele G(Q) was present in 76.3% of the sampled population. An imbalance haemostatic marker was established in the sampled population with 61% of elevated levels of factor VII, 70% of elevated levels of fibrinogen and 88% had a decreased level of PAI-1. Conclusion: The prevalence of R353Q polymorphism was established in this sample population, having an imbalanced haemostatic status of hypercoagulation (factor VII and fibrinogen) and imbalance fibrinolysis (PAI-1), which are strongly associated to CVDs.

Motivation - Depression is a mental disorder that has been associated with cardiovascular morbidity and mortality in the Western world. Cardiometablic mechanisms have been implicated as possible intermediating factors in the relationship between depressive symptoms and cardiovascular disease; however this has not yet been determined in black Africans (hereafter referred to as Africans). Aim - The overarching aim of this study was to investigate the relationship between depressive symptoms and cardiometabolic risk. We therefore aimed to assess cardiometabolic function, neuroendocrine responses, inflammatory and haemostatic markers in Africans with depressive symptoms compared to those without symptoms of depression. Methodology - Manuscripts presented in Chapter 2, 3 and 4 utilised data from the cross-sectional, target population multi-disciplinary “Sympathetic activity and Ambulatory Blood Pressure in Africans” (SABPA) study. The participants comprised of 200 African teachers from the Dr Kenneth Kaunda District in North-West province, South Africa. As cardiovascular disease is compromised by a positive HIV status, 19 participants were excluded from further statistical analysis. Stratification was based on the Patient Health Questionnaire 9-item (PHQ-9), which has been validated in a sub-Saharan African setting. PHQ-9 scores > 10 were used to classify participants as having signs of depressive symptoms. Subjects were further stratified by gender (Manuscript 1 and 3) and cortisol responses (Manuscript 2). Cardiometabolic health measures included 24-hour blood pressure, metabolic syndrome markers, neuroendocrine markers [cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG)], left ventricular hypertrophy (LVH),inflammatory and haemostatic markers (fibrinogen, C-reactive protein, plasminogen activator inhibitor-1 and D-dimer). Resting 12-lead ECG Cornell Product-Left ventricular hypertrophy (CP-LVH) was measured as a marker of target end-organ damage and cardiovascular dysfunction (Manuscript 1 and 2). Means and prevalence were computed through t-test and Chi-square analysis respectively. Significant differences of mean cardiometabolic measures between depressive symptom status groups were also determined by analysis of covariance (adjusted for traditional cardiovascular risk factors and additional factors as specific per manuscript). Multivariate analysis was used to demonstrate associations between left ventricular hypertrophy (LVH) and cardiometabolic markers in Africans with depressive symptoms (Manuscript 1 and 2) and a logistic regression analysis were performed to examine the association between depressive symptoms and inflammatory/haemostatic factors (Manuscript 3). All subjects who participated gave informed consent, the study was approved by the Ethics Committee of North-West University (NWU-0003607S6), in accordance with the principles outlined by the World Medical Association Declaration of Helsinki of 1975 (revised 2008). Results and conclusions of the individual manuscripts - The aim of the study was to investigate the associations between depressive symptoms and cardiometabolic function including cardiovascular dysfunction. Markers of cardiometabolic function assessed were 24 hour blood pressure measurements, metabolic syndrome markers, neuroendocrine markers [cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG)], inflammatory and haemostatic variables (fibrinogen, C-reactive protein, plasminogen activator inhibitor-1 and D-dimer). Manuscript 1, focused on LVH as a marker of cardiovascular dysfunction and metabolic syndrome components as markers of cardiometabolic function. The aim of the study was to assess the associations between LVH and metabolic syndrome (MetS) risk markers in participants with and without depressive symptoms. Results revealed that in African men with depressive symptoms the most significant determinants of LVH were systolic blood pressure (SBP) and the percentage glycosylated haemoglobin (HbA1c). While in African women (with depressive symptoms), this association was determined by low high-density lipoprotein (HDL-cholesterol). The study concluded that in black African men, independent of depressive symptoms, cardiometabolic factors (namely SBP and HbA1c) may be the driving significant factors in the development of cardiovascular diseases. Furthermore, the data showed that depressive symptoms in African women were associated with a measure of target end organ damage, and that this association was driven by a metabolic factor. Manuscript 2, the aim of this manuscript was to examine the relationship between depressive symptoms, neuroendocrine responses [with cortisol and 3-methoxy-phenylglycol (MHPG) as markers] and cardiovascular risk, i.e. LVH. The results revealed that Africans with depressive symptoms demonstrated blunted cortisol and MHPG levels in response to acute mental stress, in comparison to those without symptoms of depression. Additionally, these low cortisol and blunted MHPG responses were associated with LVH in this ethnic group. The conclusion for this manuscript was that, blunted neuroendocrine responses linked depressive symptoms and ECG left ventricular hypertrophy in Africans. When coupled to their hypertensive status, these vasoconstrictive responses (cortisol and MHPG) may underpin the increased long-term depression and vascular disease risk in urban Africans. Manuscript 3, the aim of this manuscript was to investigate the relationship between depressive symptoms and inflammatory/haemostatic markers in a cohort of urban-dwelling black African men and women. Our data demonstrated hypercoagulation vulnerability in African men with depressive symptoms. The African men with signs of depression displayed higher plasminogen activator inhibitor (PAI-1) levels and marginally elevated D-dimer levels. It was concluded that hypercoagulation may partially be the mediating factor between depressive symptoms and cardiovascular risk in African men; a situation that may be exacerbated by hyperkinetic blood pressure. In conclusion, through the assessement of cardiometabolic function and neuroendocrine responses, it seems that Africans withdepressive symptoms are at great risk for cardiovascular related morbidity and mortality, this was particulary evident in the African men (Manuscript 1 and 3). Additionally, it appears that blunted neuroendocrine responses and hypercoagulation could be seen as possible cardiovascular risk markers in Africans with depressive symptoms. / PhD (Physiology), North-West University, Potchefstroom Campus, 2014

Motivation - Depression is a mental disorder that has been associated with cardiovascular morbidity and mortality in the Western world. Cardiometablic mechanisms have been implicated as possible intermediating factors in the relationship between depressive symptoms and cardiovascular disease; however this has not yet been determined in black Africans (hereafter referred to as Africans). Aim - The overarching aim of this study was to investigate the relationship between depressive symptoms and cardiometabolic risk. We therefore aimed to assess cardiometabolic function, neuroendocrine responses, inflammatory and haemostatic markers in Africans with depressive symptoms compared to those without symptoms of depression. Methodology - Manuscripts presented in Chapter 2, 3 and 4 utilised data from the cross-sectional, target population multi-disciplinary “Sympathetic activity and Ambulatory Blood Pressure in Africans” (SABPA) study. The participants comprised of 200 African teachers from the Dr Kenneth Kaunda District in North-West province, South Africa. As cardiovascular disease is compromised by a positive HIV status, 19 participants were excluded from further statistical analysis. Stratification was based on the Patient Health Questionnaire 9-item (PHQ-9), which has been validated in a sub-Saharan African setting. PHQ-9 scores > 10 were used to classify participants as having signs of depressive symptoms. Subjects were further stratified by gender (Manuscript 1 and 3) and cortisol responses (Manuscript 2). Cardiometabolic health measures included 24-hour blood pressure, metabolic syndrome markers, neuroendocrine markers [cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG)], left ventricular hypertrophy (LVH),inflammatory and haemostatic markers (fibrinogen, C-reactive protein, plasminogen activator inhibitor-1 and D-dimer). Resting 12-lead ECG Cornell Product-Left ventricular hypertrophy (CP-LVH) was measured as a marker of target end-organ damage and cardiovascular dysfunction (Manuscript 1 and 2). Means and prevalence were computed through t-test and Chi-square analysis respectively. Significant differences of mean cardiometabolic measures between depressive symptom status groups were also determined by analysis of covariance (adjusted for traditional cardiovascular risk factors and additional factors as specific per manuscript). Multivariate analysis was used to demonstrate associations between left ventricular hypertrophy (LVH) and cardiometabolic markers in Africans with depressive symptoms (Manuscript 1 and 2) and a logistic regression analysis were performed to examine the association between depressive symptoms and inflammatory/haemostatic factors (Manuscript 3). All subjects who participated gave informed consent, the study was approved by the Ethics Committee of North-West University (NWU-0003607S6), in accordance with the principles outlined by the World Medical Association Declaration of Helsinki of 1975 (revised 2008). Results and conclusions of the individual manuscripts - The aim of the study was to investigate the associations between depressive symptoms and cardiometabolic function including cardiovascular dysfunction. Markers of cardiometabolic function assessed were 24 hour blood pressure measurements, metabolic syndrome markers, neuroendocrine markers [cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG)], inflammatory and haemostatic variables (fibrinogen, C-reactive protein, plasminogen activator inhibitor-1 and D-dimer). Manuscript 1, focused on LVH as a marker of cardiovascular dysfunction and metabolic syndrome components as markers of cardiometabolic function. The aim of the study was to assess the associations between LVH and metabolic syndrome (MetS) risk markers in participants with and without depressive symptoms. Results revealed that in African men with depressive symptoms the most significant determinants of LVH were systolic blood pressure (SBP) and the percentage glycosylated haemoglobin (HbA1c). While in African women (with depressive symptoms), this association was determined by low high-density lipoprotein (HDL-cholesterol). The study concluded that in black African men, independent of depressive symptoms, cardiometabolic factors (namely SBP and HbA1c) may be the driving significant factors in the development of cardiovascular diseases. Furthermore, the data showed that depressive symptoms in African women were associated with a measure of target end organ damage, and that this association was driven by a metabolic factor. Manuscript 2, the aim of this manuscript was to examine the relationship between depressive symptoms, neuroendocrine responses [with cortisol and 3-methoxy-phenylglycol (MHPG) as markers] and cardiovascular risk, i.e. LVH. The results revealed that Africans with depressive symptoms demonstrated blunted cortisol and MHPG levels in response to acute mental stress, in comparison to those without symptoms of depression. Additionally, these low cortisol and blunted MHPG responses were associated with LVH in this ethnic group. The conclusion for this manuscript was that, blunted neuroendocrine responses linked depressive symptoms and ECG left ventricular hypertrophy in Africans. When coupled to their hypertensive status, these vasoconstrictive responses (cortisol and MHPG) may underpin the increased long-term depression and vascular disease risk in urban Africans. Manuscript 3, the aim of this manuscript was to investigate the relationship between depressive symptoms and inflammatory/haemostatic markers in a cohort of urban-dwelling black African men and women. Our data demonstrated hypercoagulation vulnerability in African men with depressive symptoms. The African men with signs of depression displayed higher plasminogen activator inhibitor (PAI-1) levels and marginally elevated D-dimer levels. It was concluded that hypercoagulation may partially be the mediating factor between depressive symptoms and cardiovascular risk in African men; a situation that may be exacerbated by hyperkinetic blood pressure. In conclusion, through the assessement of cardiometabolic function and neuroendocrine responses, it seems that Africans withdepressive symptoms are at great risk for cardiovascular related morbidity and mortality, this was particulary evident in the African men (Manuscript 1 and 3). Additionally, it appears that blunted neuroendocrine responses and hypercoagulation could be seen as possible cardiovascular risk markers in Africans with depressive symptoms. / PhD (Physiology), North-West University, Potchefstroom Campus, 2014

Age, male sex, hypertension, smoking, diabetes, dyslipidaemia, and obesity are considered as established risk factors for cardiovascular diseases. Several of these established cardiovascular risk factors are strongly influenced by lifestyle. Novel biomarkers from different mechanistic pathways have been associated with cardiovascular risk, but their clinical utility is still uncertain. The overall objective of the thesis was to evaluate the associations between certain lifestyle factors (physical activity and snuff use), biomarkers reflecting the haemostatic and the inflammatory systems and risk of a future first-ever myocardial infarction.  A prospective incident nested case-control study design was used with a total of 651 cases of myocardial infarction and 2238 matched controls from the population-based Northern Sweden Health and Disease Study.  The effects of commuting activity, occupational and leisure time physical activity on risk of myocardial infarction were studied. A clearly increased risk of myocardial infarction was found for car commuting compared to active commuting (walking, cycling or going by bus). High versus low leisure time physical activity was associated with decreased risk of myocardial infarction. Low occupational physical activity was associated with risk of myocardial infarction in men.  The risk of myocardial infarction or sudden cardiac death was studied in male snuff users compared to non-tobacco users. No increased risk was found for myocardial infarction or sudden cardiac death among snuff users without a previous history of smoking. However, for sudden cardiac death the study did not have statistical power to detect small differences in risk.  Plasma levels of haemostatic markers have previously shown to be associated with risk of myocardial infarction, but as haemostatic markers are also acute-phase reactants, it is not clear if their association with myocardial infarction is independent of inflammatory markers. In the present study, the haemostatic markers D-dimer, von Willebrand factor (VWF), tissue plasminogen activator (t-PA), and tissue plasminogen activator/plasminogen activator inhibitor-1 complex (t-PA/PAI-1 complex) were associated with risk of myocardial infarction after adjustment for established risk factors and the inflammatory markers C-reactive protein (CRP) and interleukin 6 (IL-6). Furthermore, the addition of eight haemostatic and inflammatory markers could improve the predictive ability for future myocardial infarction beyond that of a model utilizing only established risk factors.  Established risk factors and novel biomarkers were explored as potential mediators of the reduced risk of myocardial infarction related to active commuting. A combination of established risk factors, haemostatic and inflammatory markers appeared to explain a substantial proportion (40%) of the difference in risk for myocardial infarction between active commuters and car commuters. IL-6, t-PA, t-PA/PAI-1 complex, apo B/apo A-1 ratio, and BMI seemed to be the largest potential mediators when tested individually. In conclusion, regular physical activity such as active commuting is associated with reduced risk of a first-ever myocardial infarction. This effect could in part be mediated through a beneficial influence on haemostasis and inflammation, as well as a positive impact on established risk factors. Several haemostatic markers are associated with risk of myocardial infarction independent of established risk factors and inflammatory markers. The combination of haemostatic and inflammatory markers may enhance predictive ability beyond established risk factors. Our findings do not support the hypothesis that snuff use increases the risk of myocardial infarction.

Neuropsychological impairment following cardiopulmonary bypass (CPB) remains a serious consequence of otherwise successful surgery. The incidence of neuropsychological decline is poorly understood due to varied measurement intervals, and perhaps more importantly the use of unreliable detection and classification methods. The reported incidence varies considerably, ranging anywhere from 30% to 90% of subjects. While the nature of this impairment has not been fully elucidated, recent evidence suggests that microembolism during surgery may be the principal causative agent of postoperative cerebral dysfunction. The work described in this thesis investigates one possible source of microembolism leading to postoperative decline, namely thromboembolism arising from excessive activation of the haemostatic mechanism. Crucial to the accurate detection of significant decline in individual patients, this work also focuses on the development and use of meaningful criteria to be used when describing change in neuropsychological performance measures. The strong haemostatic activation during CPB is controlled by heparin anticoagulation. The clinical performance of the Hepcon heparin-monitoring instrument was compared to the activated clotting time (ACT), which is used in most cardiac centres. An analysis of samples from 42 elective coronary artery bypass grafting (CABG) patients shows that the ACT does not detect the significant decline in heparin concentration seen upon connection to CPB, in comparison to the Hepcon. The Hepcon appears to be in satisfactory agreement with laboratory anti-Xa analysis of heparin concentration, with the mean difference for the Hepcon at -0.46 U/ml, and the limits of agreement +/- 1.12 U/ml. Further analysis shows that that for 95% of cases, the Hepcon will give values that are between 0.53 and 1.27 times the value for anti-Xa. The loss of relationship between ACT and heparin concentration was further investigated by converting ACT values to heparin concentration. The results provide data on the degree of prolongation in ACT times brought about by factors associated with CPB. A methodology is presented by which users can adjust for the loss of relationship between ACT and heparin. This work also demonstrates that under normal usage of the ACT, the user may obtain values up to 3 times appropriate for the plasma heparin concentration. The computer-administered neuropsychological testing tool (the MicroCog) was validated using 40 age-matched control subjects. Using a two-week interval, the summary score correlation coefficients ranged from .49 to .84, with all scores demonstrating significant practice effects. Also presented are retest normative data that may be used to determine significant change in a homogeneous sample using both reliable change and regression models of analysis. The performance of four different models of change analysis was then analysed using data from the clinical group. The regression technique of analysis was shown to be the most useful prediction model as it provides correction for both practice effects and regression toward the mean in each individual. A novel statistical rationale is presented for the choice of criteria in the identification of patients that may be defined as overall impaired when using a battery of test scores. When using one-tailed prediction models for decline, the binomial distribution of scores was shown to be a useful descriptive statistic providing an estimate of change due to chance. When applied to a suitable selection of scores that minimise shared variance, a value +/- 20% of test scores used was demonstrated to be a rational cut-off for an individual to be classified as impaired. Using this methodology, 32.7% of patients were identified as significantly deteriorated in neuropsychological test function immediately prior to discharge from hospital. Patient age was shown to be a significant predictor of neuropsychological decline following CPB. No significant relationship was identified between thrombin generation and neuropsychological change scores, however problems with patient recruitment and retention limited the statistical power of this study. An intriguing relationship with heparin concentration was noted that might warrant further investigation. This work highlights the complex nature of post-bypass neuropsychological dysfunction and the complexities in assessing decline. The regression-based model was shown to be highly useful in the analysis of data from a suitably validated neuropsychological testing tool. The argument that no suitable criterion exists for the identification of patients as overall impaired has been challenged with the development of a rational cut-off based on the likely distribution of change scores across a series. The work presented here confirms the need for standardised testing methods based on sound statistical criteria. This work also highlights the problems associated with current methods for monitoring anticoagulation therapy during bypass surgery. Methodology is presented that allows adjustment of ACT results to account for CPB-induced prolongation of clotting times. Current techniques for heparin monitoring overestimate heparin levels on bypass by up to threefold, which may predispose to subclinical coagulation and increased delivery of protamine.