Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study

OBJECTIVE

To compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans.

DESIGN

Cross sectional survey.

SETTING

Newcastle upon Tyne.

PARTICIPANTS

259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years.

MAIN OUTCOME MEASURES

Social and economic circumstances, lifestyle, self reported symptoms and diseases, blood pressure, electrocardiogram, and anthropometric, haematological, and biochemical measurements.

RESULTS

There were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors. Findings in women were similar.

CONCLUSION

Risk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors.

p53 compound heterozygosity in a severely affected child with Li-Fraumeni syndrome

The Li-Fraumeni Syndrome (LFS) is a rare, dominantly inherited syndrome that features high risk of cancers in childhood and early adulthood. Affected families tend to develop bone and soft tissue sarcomas, breast cancers, brain tumors, leukemias, and adrenocortical carcinomas. In some kindreds, the genetic abnormality associated with this cancer phenotype is a heterozygous germline mutation in the p53 tumor suppressor gene. Recently, we identified one patient who presented in early childhood with multiple primary cancers and who harbored three germline p53 alterations (R156H and R267Q on the maternal allele and R290H on the paternal allele). To classify the biologic effects of these alterations, functional properties of each of the p53 mutants were examined using in vitro assays of cellular growth suppression and transcriptional activation. Each amino acid substitution conferred partial or complete loss of wild-type p53 function, but the child completed normal embryonic development. This observation has not been previously reported in a human, but is consistent with observations of normal embryogenesis in p53-deficient mice.

Ambulance visits for severe hypoglycaemia in insulin-treated diabetes

AIM

To determine, in insulin-treated diabetes the incidence and risk factors for severe hypoglycaemia requiring ambulance visits.

METHODS

A cross-sectional, questionnaire survey was made of patients with type 1 diabetes, who received help for severe hypoglycaemia from Ambulance Association personnel, during the period 1/6/95 to 31/5/96.

RESULTS

The ambulance service made 386 emergency visits to 247 persons with type 1 diabetes. Of these, 128 respondents (52%) completed a questionnaire detailing personal and diabetes history, usual diabetes care practices and hypoglycaemia management. Two or more visits for severe hypoglycaemia were made to 26.3% of patients, who reported a longer duration of diabetes than those who required only one visit (28 vs 20 years, p<0.03). Self-blood-glucose monitoring was performed by 98.4% of respondents and 66.4% self-adjusted insulin doses. Intensively treated patients (> or = 3 insulin injections daily) reported less awareness of hypoglycaemia than standard therapy patients (< or = 2 insulin injections daily) (p<0.05). Fifty-four per cent of respondents had glucagon available for emergency use, but those who lived alone and in general practitioner care only (27%) were less likely to have glucagon (p<0.05) compared to those with companions and in shared-care arrangements (62%). Hypoglycaemia management was influenced by the availability of glucagon. Oral glucose was used by 82% before injecting glucagon, whereas 40% of patients without glucagon called for the ambulance when severe symptoms were present even before initiating treatment with oral glucose.

CONCLUSION

This survey determined the minimum frequency of severe hypoglycaemia requiring the ambulance at 1.6 episodes patient(-1) year(-1). Precipitating factors and a lack of coping skills and behaviours that might prevent severe hypoglycaemia and ambulance calls were identified.

Teaching public health to medical students in the United Kingdom--are the General Medical Council's recommendations being implemented?

BACKGROUND

Despite frequent calls to improve undergraduate medical public health teaching, little is known about whether curricula have changed. We report a survey of undergraduate public health teaching in UK medical schools in 1996. The survey aimed to assess whether the General Medical Council's 1993 recommendations to strengthen undergraduate medical education in public health have been implemented.

METHODS

We asked heads of academic departments of public health at all 26 UK medical schools to complete a questionnaire and provide supporting documentation for each undergraduate public health course or module. We compared results from the 1996 survey with those from a similar survey in 1992.

RESULTS

Twenty-one out of 26 (81 per cent) medical schools responded. All responding medical schools included public health teaching within their curriculum. The median number of public health courses per medical school was unchanged since 1992. A wide variety of topics were taught. Core public health subjects were taught at most schools, though over a quarter of medical schools did not cover some core topics. Between 1992 and 1996 the proportion of time devoted to teaching by lectures decreased, whereas the following all increased: teaching by small group methods; the proportion of courses using methods of assessment encouraging active learning; and the contribution of public health courses to the final degree assessment.

CONCLUSION

The findings suggest that many of the General Medical Council's recommendations for improving the delivery of undergraduate education are being addressed by public health teaching in UK medical schools. However, addressing the gaps in undergraduate public health teaching revealed in this survey is a continuing challenge for academic public health departments. Medical schools should review the content of their undergraduate public health teaching to ensure that tomorrow's doctors are adequately equipped with public health knowledge and skills.

Prenatal sonographic diagnosis of uterine rupture following open fetal surgery

BACKGROUND

Reported cases of uterine rupture diagnosed by ultrasound have shown fetal membranes ballooning through uterine rupture sites, or adjacent areas of hemorrhage.

CASE

A 27-year-old gravida 3, para 2 had open fetal surgery to repair a fetal myelomeningocele at 28 weeks' gestation. Her postoperative course was complicated by threatened preterm labor and anhydramnios. At 33 weeks' gestation, with maternal symptoms of bowel obstruction, ultrasound showed a fetal leg and section of umbilical cord protruding through the uterine wall.

CONCLUSION

Even in the presence of anhydramnios, uterine wall rupture was identified, because ultrasound evaluation of the uterine wall showed prolapsed fetal parts and umbilical cord. Persistent anhydramnios after open fetal surgery should prompt a search for uterine rupture.

Novel and recurrent mutations in keratin 10 causing bullous congenital ichthyosiform erythroderma

Bullous congenital ichthyosiform erythroderma (BCIE) is a dominantly inherited keratinizing disorder characterized by erythroderma and blistering in neonates and generalized epidermolytic hyperkeratosis (EH) in adulthood. Previously, it has been shown that BCIE can be caused by mutations in either of the genes encoding K1 or K10, the keratins predominantly expressed in suprabasal layers of the epidermis. Using direct sequencing of genomic PCR fragments, we have analyzed 4 British families with BCIE, all of whom were found to carry mutations in K10. In 1 family, the affected person was found to have an unusual dinucleotide transversion mutation, 2138CC-->AA, causing two amino acid substitutions, D155E and R156S, also in the 1A domain of the K10 polypeptide. In 2 further kindreds, the previously reported "hotspot" mutations 2139C-->T and 2140G-->A were found. These mutations predict amino acid substitutions in the helix 1A domain of K10, designated R156C and R156H respectively. The proband in the fourth family was found to carry a novel mutation 4724T-->C, predicting the amino acid change L452P in the helix 2B domain of K10. All mutations were confirmed in the affected persons and were excluded from a population of 50 normal, unrelated individuals by restriction enzyme analysis. The location of these mutations in the highly conserved helix boundary motif sequences of K10 are consistent with previously reported dominant negative mutations in K10 and other keratins. Despite the unusual nature of two of these mutations, in particular the double missense mutation, the phenotypes of the affected individuals in these 4 families were entirely typical of BCIE.

Prevention of age-related aneuploidies by polar body testing of oocytes

PURPOSE

We previously demonstrated that aneuploidy-free oocytes may be preselected by testing the first and second polar bodies removed from oocytes following their maturation and fertilization. The present paper describes the results of the application of the method in 659 in vitro fertilization cycles from patients of advanced maternal age.

METHODS

Using micromanipulation techniques, 3943 oocytes were tested by polar body sampling and fluorescent on situ hybridization analysis using specific probes for chromosomes 13, 18, and 21.

RESULTS

Fluorescent in situ hybridization results were available for 3217 (81.6%) of 3943 oocytes studied, of which 1388 (43.1%) had aneuploidies; 35.7% of the aneuploidies were of first meiotic division origin, and 26.1% of second meiotic division origin. Most errors in the first meiotic division were represented by chromatid malsegregation. The transfer of embryos deriving from 1558 of 1829 aneuploidy-free oocytes in 614 treatment cycles resulted in 131 clinical pregnancies and 88 healthy children born after confirmation of the polar body diagnosis.

CONCLUSIONS

Polar body testing of oocytes provides an accurate and reliable approach for prevention of age-related aneuploidies in in vitro fertilization patients of advanced maternal age.

Mechanisms of induction of renal allograft tolerance in CD45RB-treated mice

BACKGROUND

Rejection is the most significant problem in the field of transplantation. The current goal of transplant immunology is to develop better immunotherapeutic protocols that are aimed at specifically suppressing alloreactivity and preserving an otherwise intact immune system. We have previously shown that mice will accept renal allografts indefinitely with normal renal function after two injections of a monoclonal antibody to the CD45RB protein. Furthermore, this antibody will reverse acute rejection when therapy is delayed until day 4 and will still induce tolerance. The mechanisms of this therapeutic benefit are not known.

METHODS

BALB/C mice were used as recipients of major multiple histocompatibility complex-mismatched kidneys using C57BL/6 as donors. Immunoperoxidase microscopy and Northern blots for cytokine gene expression were used to study the renal allografts. Fluorescence-activated cell sorter (FACS) analyses of peripheral blood lymphocytes were performed. Phosphotyrosine peptide phosphatase assays were performed on splenic lymphocyte membranes.

RESULTS

A CD45RB monoclonal antibody (MB23G2) induced tolerance and partially depletes peripheral blood lymphocytes. A therapeutically ineffective CD45RB monoclonal antibody (MB4B4) merely coated the circulating lymphocytes. Furthermore, MB23G2 stimulated more tyrosine phosphatase activity than MB4B4 in mouse T-cell membranes.

CONCLUSIONS

The clearance of peripheral blood lymphocyte populations and stimulation of protein tyrosine phosphatase activity may be important in the mechanism of tolerance induction by CD45RB therapy, which may be clinically relevant in the therapy of organ rejection in humans.

Mediators of inflammation and the inflammatory process

A complex interplay of inflammatory cells and chemical mediators is responsible for allergic inflammation. It is now understood that the allergic reaction consists of an early-phase response involving mast cell degranulation with the release of histamine and a late-phase response characterized by the migration of inflammatory cells. This review provides a summary of the early- and late-phase events associated with allergic inflammation and an overview of the principal chemical mediators involved in the inflammatory process.

Effect-site modelling of propofol using auditory evoked potentials

Auditory evoked potentials (AEP) were used to monitor central nervous system effects during induction and recovery from anaesthesia produced by infusion of propofol 30 mg kg-1 h-1 in 22 healthy male patients. Non-parametric and parametric modelling techniques were used successfully to calculate the parameter keo which linked pharmacokinetic with pharmacodynamic aspects of drug action in only 15 of the study patients. In the non-parametric analysis, keo was found to have a mean value of 0.2 (range 0.1-0.36) min-1. Estimation of keo allowed calculation of the effect-site concentration (Ce50) associated with 50% of AEP effect for the population (2.08 micrograms ml-1; 95% confidence limits 1.7-2.45). There were no significant differences between keo values calculated by non-parametric and individual parametric modelling techniques. During recovery, 50% of patients demonstrated evidence of waking at an effect-site concentration of 2.28 micrograms ml-1.

Effects of age and hypertension on cardiac responses to the alpha1-agonist phenylephrine in humans

Both aging and hypertension decrease the responsiveness of several receptor systems. The purpose of this study was to investigate the effect of aging versus hypertension on the blood pressure (BP), heart rate, and left ventricular (LV) responses to the alpha1-agonist phenylephrine in humans. Fourteen young (age, 21-40 years; range, 30+/-1 years; mean +/- SEM), and 18 older (age, 50-73 years; range, 60+/-1 years) healthy volunteers, as well as 10 young (age, 30-39 years; range, 36+/-1 years) and 15 older (age, 50- 64 years; range, 58+/-1 years) hypertensive subjects were studied. Phenylephrine was administered at four incremental rates for 8 min each. Cardiac responses were assessed by echocardiography. Phenylephrine caused twofold larger increases in systolic BP in young and older hypertensives and older normotensives, compared with young normotensives, but similar decreases in heart rate in all four groups. Younger normotensive subjects exhibited the largest decreases in stroke volume index, ejection fraction, and cardiac index in response to phenylephrine, despite similar increases in end-systolic stress for all groups. There is an age- and hypertension-related decrease in reflex vagal restraint in response to alpha1-adrenoceptor stimulation in humans, which leads to significant attenuation of the decrease in heart rate as well as in LV function in response to a pressor stimulus, and presumably therefore to enhanced systolic BP responses relative to young normotensive subjects.

Differential distribution of inward rectifier potassium channel transcripts in human atrium versus ventricle

BACKGROUND

The inward rectifier K+ current (IK1) plays an important role in governing cardiac electrical activity and is well known to have different properties in the atrium compared with the ventricle. Several inward rectifier K+ channel (IRK) subunits (hIRK, HH-IRK1, HIR, and TWIK-1) with different properties have been cloned from human tissues, but their relative expression in cardiac tissues has not been quantified. The present study was designed to define the relative levels of mRNA for various IRKs in human atrium and in failing and nonfailing ventricle.

METHODS AND RESULTS

Competitive reverse transcription-polymerase chain reaction was used to quantify in human atrium and ventricle the mRNA levels of hIRK, HH-IRK1, HIR, and TWIK-1. The absence of important noncardiac contamination was confirmed by demonstrating a lack of detectable mRNA markers for neuronal (acetylcholine receptor) and vascular (maxi-K channel) tissue. mRNA of HIR was more abundant in normal atrium (7.1+/-1.3 amol/ microg total RNA) than ventricle (0.6+/-0.1 amol/ microg, P<0. 05), whereas TWIK-1 mRNA was more concentrated in ventricle (18. 1+/-4.3 amol/ microg) than atrium (1.4+/-0.3 amol/ microg, P<0.05). Concentrations of hIRK (42.7+/-6.7 amol/ microg in atrium vs 57. 1+/-9.2 amol/ microg in ventricle) and HH-IRK1 (2.0+/-0.5 amol/ microg in atrium vs 1.5+/-0.5 amol/ microg in ventricle) were comparable. No significant differences in IRK subunit transcript concentrations were found between normal and failing ventricles.

CONCLUSIONS

mRNAs for all 4 IRKs are detected in human atrium and ventricle, but the mRNA copy number of a low-conductance subunit (HIR) is larger in atrium and the copy number of a weakly rectifying subunit (TWIK-1) is larger in ventricle. These differences in relative message levels may provide a potential molecular basis for different properties of IK1 in human atrium compared with ventricle.

Endothelin A receptor blockade causes adverse left ventricular remodeling but improves pulmonary artery pressure after infarction in the rat

BACKGROUND

Endothelin A (ETA) receptor antagonists have been shown to improve ventricular remodeling and survival in rats when started 10 days after infarction. Whether starting them earlier would have a more or less beneficial effect is uncertain.

METHODS AND RESULTS

Rats surviving an acute myocardial infarction (MI) for 24 hours (n=403) were assigned to saline or the ETA receptor antagonist LU 127043 or its active enantiomer LU 135252 for 4 weeks. Chronic LU treatment had no effect on survival, with 46% of LU rats and 47% of saline-treated rats with large MI surviving to the end of the study. LU treatment led to scar thinning, further left ventricular (LV) dilatation, an increase in LV end-diastolic pressure, and an increase in wet lung weight (P<0.05). Despite this detrimental effect on LV function, LU led to a significant decrease in RV systolic (50+/-2 to 44+/-2 mm Hg, P<0.05 vs saline) and right atrial pressures. LU treatment also prevented the increase in pulmonary ET-1 found in saline-treated rats with large MI but did not modify the increase in cardiac ET-1 in hearts with large MI.

CONCLUSIONS

The early use of the ETA receptor antagonists LU 127043 or its active enantiomer LU 135252 after infarction in the rat leads to impaired scar healing and LV dilatation and dysfunction. This is accompanied by a decrease in RV systolic and right atrial pressures and a decrease in pulmonary but not cardiac ET-1 levels. It would thus appear that the early use of ETA receptor antagonists after infarction may be detrimental.

Prenatal sonographic appearance of hemorrhagic cerebellar infarction

To date, the prenatal diagnosis of cerebellar hemorrhage has been limited to isolated case reports, which have demonstrated either a hyperechoic cerebellar hemisphere or a hyperechoic mass within the cerebellum in near-term fetuses. We demonstrate the ultrasonographic findings of intracerebellar hemorrhagic infarction in a fetus at approximately 21 weeks' gestation. In contrast to previous case reports, the hemorrhagic infarcts seen in our case were hypoechoic.

A comparison of two methods of oral endotracheal tube stabilization in neonatal patients

OBJECTIVE

To determine if an endotracheal tube stabilization method using an umbilical clamp reduces accidental extubations when compared with a more traditional method of endotracheal tube stabilization.

STUDY DESIGN

From January 1, 1994 through April 30, 1997, the frequency of accidental extubations per 100 ventilator days was tracked for the Neonatal Intensive Care Unit (NICU) Quality Assurance Committee of William Beaumont Hospital (Royal Oak, MI). From January 1, 1994 through December 31, 1995, all endotracheal tubes were stabilized using a traditional taping method. From March 1, 1996 through April 30, 1997, the endotracheal tubes were stabilized using a modified umbilical clamp and tape. The incidence of extubation using each stabilization method was compared by chi2 analysis.

RESULTS

The umbilical clamp resulted in a significantly lower (p=0.001) rate of accidental extubations.

CONCLUSION

The umbilical clamp taping method appears to have lowered the incidence of accidental extubation in our NICU when compared with a standard method of oral endotracheal tube stabilization.

Listeriosis in pediatric oncology patients

BACKGROUND

Adult cancer patients are considered to be at an increased risk for Listeria monocytogenes infections, but, to the authors' knowledge, little information regarding this infection in the pediatric oncology population has been published.

METHODS

The Memorial Sloan-Kettering Cancer Center microbiology laboratory's database was searched for cases of Listeria monocytogenes infection during the period from January 1981 to December 1996, and thorough chart reviews of the cases identified in patients age < 21 years were performed.

RESULTS

Listerial infections occurred in 5 children (3 with leukemia, 1 with lymphoma, and 1 with a brain tumor) among 20,612 admissions to the pediatric department during this period. All five children were actively receiving therapy for their malignancy, and two also were receiving other potentially immunosuppressive therapies. None was receiving co-trimoxazole prophylaxis. All were treated successfully for the Listeria monocytogenes infection with ampicillin and gentamicin (four patients) or ampicillin alone (one patient). At last follow-up two patients were long term, event-free survivors, two had died of their underlying malignancy, and one patient had died of cytomegalovirus pneumonitis.

CONCLUSIONS

Listeria monocytogenes infections in pediatric oncology patients can be treated successfully with ampicillin-containing antibiotic regimens.

Patients' experiences using a computerized program with a touch-sensitive video monitor for the assessment of health-related quality of life

This study assessed patients' experiences using a computerized program with a touch-sensitive video monitor (TSVM) for the assessment of health-related quality of life (HRQoL). A software program was developed for a computerized form of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the QLQ-C30. One hundred and seventy-eight patients completed the QLQ-C30, followed by a structured interview designed to assess perceived difficulties with the use of the TSVM. Patients were asked to evaluate the ease of use of different aspects of the TSVM system (using the touch-sensitive screen, entering the patient identification number, reading the screen and following the on-screen instructions). The majority of patients found all aspects of the TSVM system 'very easy' to use. A few patients (1-2%) admitted finding any aspect of the TSVM use 'somewhat difficult' and none ranked any aspect as 'very difficult'. There were no unanswered items in the QLQ-C30. All patients found the amount of time spent on answering the questionnaire acceptable, (the mean time to complete was 6.8 min with a median of 5 min) and 96% stated they were willing to complete a similar questionnaire on a future occasion. From the patients' perspective the TSVM system appears to be a highly acceptable approach for the collection of HRQoL data in clinical practice.