"Unwarranted survivals" and "anomalous deaths" from coronary heart disease: prospective survey of general population

OBJECTIVES

To assess survival in people who are at apparent high risk who do not develop coronary heart disease ("unwarranted survivals") and mortality in people at low risk who die from the disease ("anomalous deaths") and the extent to which these outcomes are explained by other, less visible, risk factors.

DESIGN

Prospective general population survey.

SETTING

Renfrew and Paisley, Scotland.

PARTICIPANTS

6068 men aged 45-64 years at screening in 1972-6, allocated to "visible" risk groups on the basis of body mass index and smoking.

MAIN OUTCOME MEASURES

Survival and death from coronary heart disease by age 70 years.

RESULTS

Visible risk was a good predictor of mortality: 13% (45) of men at low risk and 45% (86) of men at high risk had died by age 70 years. Of these deaths, 12 (4%) and 44 (23%), respectively, were from coronary heart disease. In the group at low visible risk other less visible risk factors accounted for increased risk in 83% (10/12) of men who died from coronary heart disease and 29% (84/292) of men who survived. In the high risk group 81/107 who survived (76%) and 19/44 (43%) who died from coronary heart disease had lower risk after other factors were considered. Different risk factors modified risk (beyond smoking and body mass index) in the two groups. Among men at low visible risk, poor respiratory function, diabetes, previous coronary heart disease, and socioeconomic deprivation modified risk. Among men at high visible risk, height and cholesterol concentration modified risk.

CONCLUSIONS

Differences in survival between these extreme risk groups are dramatic. Health promotion messages would be more credible if they discussed anomalies and the limits of prediction of coronary disease at an individual level.

Paclitaxel in the multimodality treatment for inflammatory breast carcinoma

BACKGROUND

Inflammatory breast carcinoma (IBC) is a rare but aggressive form of breast carcinoma. Anthracycline-based regimens represent the standard of treatment for IBC. Reports of significant clinical activity of paclitaxel in metastatic breast carcinoma led the authors to investigate the role of this drug in the management of IBC.

METHODS

Forty-four patients with IBC were enrolled between February 1994 and January 1998. The treatment plan consisted of induction chemotherapy (IC), mastectomy, adjuvant chemotherapy, and radiotherapy. Forty-two patients received IC with four cycles of fluorouracil, doxorubicin, and cyclophosphamide. If the clinical response was less than partial, patients were "crossed over" to paclitaxel before mastectomy. All patients received adjuvant paclitaxel. Patients unresectable after paclitaxel were offered high-dose chemotherapy with autologous peripheral blood progenitor cell support.

RESULTS

Thirty-four patients (81%) achieved an objective clinical remission; 3 patients (7%) achieved a clinical complete remission, 31 (74%) a partial remission. Six patients (14%) achieved pathologic complete remission. Sixteen patients were treated with paclitaxel, 7 of them (44%) were able to undergo mastectomy. Median time to progression (TTP) was 22 months. Median overall survival (OS) was 46 months. Concordance between clinical and pathologic response was documented in only 8 patients (24%). No differences in TTP and OS compared with a historical group of 178 IBC patients treated with anthracycline-based regimens.

CONCLUSIONS

Paclitaxel improves tumor resectability in anthracycline-refractory IBC. The impact of paclitaxel on the prognosis of IBC needs to be better evaluated in future trials using more dose-intensive schedules of administration. New imaging modalities may contribute to improve assessment of response to IC.

A cross-sectional study of IGF-I determinants in women

Evidence is accumulating that elevated circulating insulin-like growth factor I (IGF-I) is related to increased cancer risk. The identification of hormonal, reproductive and lifestyle characteristics influencing its synthesis and bioavailability is of particular interest. Data from 400 women, who served as controls in two case-control studies nested within the same prospective cohort study, were combined. IGF-I, IGF-binding proteins 1, 2 and 3 (IGFBP-1, -2, -3) and insulin were measured in serum samples from all subjects and cotinine in 186 samples. Age appears to be the most important determinant of total IGF-I levels in women. Anthropometric measures, such as body mass index (BMI) or waist-to-hip ratio (WHR) do not seem to influence total IGF-I concentrations in peripheral blood, but may modulate IGF-I bioavailability through insulin-dependent changes in IGFBP-1 and -2 concentrations. Age at menarche, phase of the menstrual cycle at blood draw, parity, menopause, past oral contraceptive or hormone replacement therapy use, and tobacco smoking do not appear to exert an independent effect on IGF-I and its binding proteins. There was some suggestion that regular physical activity may increase total IGF-I and that women with positive family history of breast cancer might have higher IGF-I levels than those without such diagnosis in their relatives.

The effects of rigid collar placement on intracranial and cerebral perfusion pressures

Rigid collars are routinely used to immobilise the cervical spine during early management of trauma victims until spinal injury is excluded. Spinal injuries commonly coexist in patients with severe head injury, and there is still uncertainty as to whether application of a rigid collar may adversely affect intracranial pressure. The aim of this study was to examine this effect by applying rigid collars to patients with traumatic head injury. The results showed a significant rise from the baseline intracranial pressure when the collars were applied (mean rise = 4.6 mmHg, p < 0.0001). The mean rise in intracranial pressure was greater in those patients with a baseline intracranial pressure > 15 mmHg compared to those with a baseline intracranial pressure < 15 mmHg (p < 0.05). Since there was no significant change in cardiorespiratory parameters during this time, venous compression in the neck seems a likely explanation for the effect observed. These findings suggest that in head-injured patients, rigid collars should be removed as soon as cervical spine injury has been excluded or, if this is delayed, an alternative method of spinal stabilisation considered.

Lay constructions of a family history of heart disease: potential for misunderstandings in the clinical encounter?

BACKGROUND

Family history is recognised as a risk factor for coronary heart disease (CHD) by epidemiologists, health professionals, and the public, and could act either as a spur or barrier to changing health behaviour. However, there has been no systematic investigation of which factors affect whether people regard themselves as having a family history of CHDor not.

METHODS

We used purposive sampling to select 61 men and women who were middle class or working class from a large cross-sectional survey. Half the respondents had indicated in this previous survey that they had heart disease in their family. The range of understanding of the meaning of having a family history was explored in detailed qualitative semistructured interviews.

FINDINGS

Perception of a family history of heart disease depended on knowledge of the health of family members, the number and closeness of relatives with heart conditions, the age of affected relatives, and the respondent's sex and social class. Men, particularly working-class men, required a greater number of close relatives to be affected to perceive that they had a family history. Even when respondents judged that heart disease ran in their family, they did not always perceive themselves as at increased risk because they felt different in crucial ways from affected relatives.

INTERPRETATION

The factors that people and epidemiologists judge as relevant to establish presence of a family history can differ. We suggest that these differences could lead to misunderstandings between doctor and patient, which could undermine advice on CHD risks and associated behavioural changes.

How accurately do adult sons and daughters report and perceive parental deaths from coronary disease ?

OBJECTIVES

To describe how adult sons and daughters report and perceive parental deaths from heart disease

DESIGN

Two generation family study.

SETTING

West of Scotland.

SUBJECTS

1040 sons and 1298 daughters aged 30-59 from 1477 families, whose fathers and mothers were aged 45-64 in 1972-76 and have been followed up for mortality over 20 years.

OUTCOME

Perception of a "family weakness" attributable to heart disease.

RESULTS

26% of sons and daughters had a parent who had died of coronary heart disease (CHD). The proportion was higher in older offspring (+18% per 10 year age difference) and in manual compared with non-manual groups (+37%). Eighty nine per cent of parental deaths from CHD were correctly reported by offspring. Only 23% of sons and 34% of daughters with at least one parent who had died of CHD considered that they had a family weakness attributable to heart disease. Perceptions of a family weakness were higher when one or both parents had died of CHD, when parental deaths occurred at a younger age, in daughters compared with sons and in offspring in non-manual compared with manual occupations.

CONCLUSIONS

Only a minority of sons and daughters with experience of a parent having died from CHD perceive this in terms of a family weakness attributable to heart disease. Although men in manual occupations are most likely to develop CHD, they are least likely to interpret a parental death from CHD in terms of a family weakness. Health professionals giving advice to patients on their familial risks need to be aware of the difference between clinical definitions and lay perceptions of a family history of heart disease.

Locoregional irradiation for inflammatory breast cancer: effectiveness of dose escalation in decreasing recurrence

PURPOSE

To evaluate the effect of radiation dose escalation on locoregional control, overall survival, and long-term complication in patients with inflammatory breast cancer.

PATIENTS AND METHODS

From September 1977 to December 1993, 115 patients with nonmetastatic inflammatory breast cancer were treated with curative intent at The University of Texas M. D. Anderson Cancer Center. The usual sequence of multimodal treatment consisted of induction FAC or FACVP chemotherapy, mastectomy (if the tumor was operable), further chemotherapy, and radiation therapy to the chest wall and draining lymphatics. Sixty-one patients treated from September 1977 to September 1985 received a maximal radiation dose of 60 Gy to the chest wall and 45-50 Gy to the regional lymph nodes, 22 treated once a day at 2 Gy per fraction, and 35 were treated b.i.d. (32 after mastectomy and all chemotherapy was completed, and 2 immediately after mastectomy; one patient had distant metastases discovered during b.i.d. irradiation, and treatment was stopped). Four additional patients received preoperative radiation with standard fractionation. Based on the analysis of the failure patterns of the patients, the dose was increased for the b.i.d. patients in the new series, with 51 Gy delivered to the chest wall and regional nodes, followed by a 15-Gy boost to the chest wall with electrons. From January 1986 to December 1993, 39 patients were treated b.i.d. to this higher dose after mastectomy and all the chemotherapy was completed; and 8 additional patients received preoperative irradiation with b.i.d. fractionation to 51 Gy. During this period, another 7 patients were treated using standard daily doses of 2 Gy per fraction to a total of 60 Gy, either because they had a complete response or minimal residual disease at mastectomy or because their work schedule did not permit the b.i.d. regimen. Comparison was made between the groups for locoregional control, disease-free and overall survival, and complication rates.

RESULTS

The median follow-up time was 5.7 years (range, 1.8-17.6 years). For the entire patient group, the 5- and 10-year local control rates were 73.2% and 67.1%, respectively. The 5- and 10-year disease-free survival rates were 32.0% and 28.8%, respectively, and the overall survival rates for the entire group were 40.5% and 31.3%, respectively. To evaluate the effectiveness of dose escalation, a specific comparison of patients who received b.i.d. radiation after mastectomy and completion of adjuvant chemotherapy was performed. There were 32 patients treated b.i.d. to 60 Gy in the old series versus 39 patients treated b.i.d. to 66 Gy in the new series. There was an significant improvement in the rate of locoregional control for the b.i.d. patients for the old vs. new series, from 57.8% to 84.3% and from 57.8% to 77.0% (p = 0.028) at 5 and 10 years, respectively. Chemotherapy regimens did not change significantly during this time period.Long-term complications of radiation, such as arm edema more than 3 cm (7 patients), rib fracture (10 patients), severe chest wall fibrosis (4 patients), and symptomatic pneumonitis (5 patients), were comparable in the two groups, indicating that the dose escalation did not result in increased morbidity. Significant differences in the rates of locoregional control (p = 0.03) and overall survival (p = 0.03), and a trend of better disease-free survival (p = 0.06) were also observed that favored the recently treated patients receiving the higher doses of irradiation.

CONCLUSION

Twice-daily postmastectomy radiation to a total of 66 Gy for patients with inflammatory breast cancer resulted in improved locoregional control, disease free survival, and overall survival, and was well tolerated.

Are perceptions of a family history of heart disease related to health-related attitudes and behaviour?

It has been argued that perceptions of familial tendencies to disease are common and important in decisions about health-related behaviours. Indeed, it has been suggested that the increased 'geneticization' of society may lead to an increased fatalism about health, which could undermine initiatives aimed at reducing coronary-prone behaviour. To date, much of the research on lay perceptions of inheritance has been based on people at high risk of particular genetic disorders or on qualitative research with small general population samples. Here we investigate perceptions of a family history of heart disease, using quantitative techniques, to test hypotheses about the relationship between a perceived family history (pFH), coronary 'candidacy' and adherence to health promotion advice which were raised by earlier anthropological work. We find that reported perceptions of a family history of heart disease are common, particularly amongst women in middle-age. In isolation a pFH is not related to current smoking; however, the odds of smoking are lower for those with a pFH of heart disease when account is also taken of other attitudinal factors (the 'salience' of heart disease and the strength of adherence to conventional coronary health promotion.

Social class, sex, and age differences in mucosal immunity in a large community sample

There have been very few reports addressing levels and distribution of commonly used PNI measures in large community samples. In this study, we report such data for secretion rates of secretory immunoglobulin A (sIgA), as determined from saliva samples taken from 1971 subjects interviewed as part of the West of Scotland Twenty-07 survey of health in West Central Scotland. Univariate analyses of demographic variables found lower sIgA and salivary flow to be significantly related to poorer social class, increased age, and being female. Smokers also had lower sIgA but not lower salivary flow. Multivariate analysis showed that demographic variables were significant predictors of sIgA independently of each other and assay variation. Adding smoking status to the equation confirmed it as an independent predictor and also indicated that social class differences in sIgA are partly explicable in terms of smoking status. In view of reported associations between sIgA levels and stress, its role as a first line of mucosal defense, and its relevance to health, these first results from a large survey are of interest. Further work is now needed to explore which factors, including psychosocial ones, may be contributing to subgroup differences.

Variation of recruitment nonlinearity and dynamic response of ankle plantarflexors

The ankle plantarflexor muscles of paraplegics may be trained to provide balance without support from the hands (in the laboratory environment) with the controller based on a two-block Hammerstein muscle model. This paper presents data on the variations of the recruitment curve block and linear dynamics block with electrode position, among various individuals and with fatigue. The tests were conducted in six groups: 'a' tests of a neurologically-intact subject were repeated on one day several times to record the effect of muscle fatigue; 'b' the same individual kept electrodes attached for a week and the muscle was identified every day; 'c' the same subject attached electrodes at marked positions every day for a week prior to identification; 'd' another normal attached electrodes at notionally the same positions over a period of one week; 'e' three normals and 'f' two paraplegics. Measurements were made with the Wobbler apparatus, in which the subject is supported upright in a standing posture. When comparing tests of fresh muscle every day, little difference was found between the nonlinear recruitment curves and linear dynamics of groups 'b' and 'c'. In fatigued muscle the dynamics were slower. When the electrode position was not carefully reproduced, and over a longer period, significant differences in nonlinearity appear in the curve shapes (group 'd') and a similar amount of variation occurs between normals, between paraplegics, and from normals to paraplegics. The paraplegic curves show wider deadbands. The effect of prolonged stimulation on normals is slight but on paraplegics it is significant.

A confirmatory factor analysis of the Hospital Anxiety and Depression scale: comparing empirically and theoretically derived structures

OBJECTIVES

To compare the fit of various factor solutions for the Hospital Anxiety and Depression scale (HAD; Zigmond & Snaith, 1983).

DESIGN

A cross-sectional postal survey was used to collect the data from community-based participants in the West of Scotland Twenty-07 study.

METHODS

The HAD scale, a 14-item self-administered measure of anxiety and depression, was completed by 2547 participants from three age cohorts (aged approximately 18, 39 and 58 years). Using confirmatory factor analyses four models suggested by prior exploratory factor analyses were compared to a model derived from Clark and Watson's (1991) tripartite theory of anxiety and depression.

RESULTS

The model derived from the tripartite theory of anxiety and depression (with factors labelled negative affectivity, anhedonic depression and autonomic anxiety) produced the closest fit to the data. This model produced a good fit in all three cohorts although group comparisons suggested that there were variations in the strength of some factor loadings across the three age groups. A model that had a hierarchical arrangement of the three factors in the tripartite model was also produced. This model fit the data equally as well as did the 'flat' tripartite model.

CONCLUSIONS

Three factors appear to underlie the HAD scale. Research is needed that examines whether or not using sub-scales based on these factors increases the ability of the HAD scale to detect cases of anxiety and depression.

Irish descent, religion and food consumption in the west of Scotland

Mortality and morbidity of people of Irish descent in Britain is high, including from cardiovascular causes potentially linked with diet. The west of Scotland has long had a pattern of Irish migration, where migrants were poorer than the host population, and their different religious background gave rise to prolonged discrimination. This paper uses data collected in 1987/88 from the west of Scotland Twenty-07 study to test whether dietary differences due to poverty or to other factors have persisted among the descendents of these migrants. Being born of Catholic parents was the index of Irish descent used, these respondents consumed less of a factor represented by fruit, yoghurt and vegetables, and more of one represented by snacks and processed foods than the rest of the sample. The picture for those reporting current Catholic affiliation in adulthood was similar. Differences are largely associated with social class and mediated not by low income but by educational disadvantage. The findings suggest the continuation of a diet affected by limited opportunities for social mobility, and thus by obstacles to sustained educational advancement, among the descendants of Irish migrants even after several generations.

Prospective evaluation of paclitaxel versus combination chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide as neoadjuvant therapy in patients with operable breast cancer

PURPOSE

To compare prospectively the antitumor activity of single-agent paclitaxel to the three-drug combination of fluorouracil, doxorubicin, and cyclophosphamide (FAC) as neoadjuvant therapy in patients with operable breast cancer.

PATIENTS AND METHODS

Patients with T1-3N0-1M0 disease were randomized to receive either paclitaxel (250 mg/m(2)) as 24-hour infusion or FAC in standard doses at every-3-week intervals. Each patient was treated with four cycles of preoperative chemotherapy. Clinical response and extent of residual disease in the breast and lymph nodes was assessed after four cycles of induction chemotherapy.

RESULTS

A total of 174 patients were registered, and 87 were randomized to each arm of the study. Clinical response, ie, complete and partial responses, was similar in both arms of the study. Three patients in the FAC arm and one patient in the paclitaxel subgroup had progressive disease. The extent of residual disease by intent-to-treat analysis at the time of surgery was similar between the two arms of the study.

CONCLUSION

The results of this prospective study demonstrated that single-agent paclitaxel as neoadjuvant therapy has significant antitumor activity, and this was clinically comparable to FAC. Similar fractions of patients had clinical complete and partial responses, and very few patients had no response to either therapy. The value of alternate non-cross-resistant therapies as used in this protocol on the clinical course of this disease would require longer follow-up.

Morbidity and Irish Catholic descent in Britain: relating health disadvantage to behaviour

OBJECTIVES

This paper critically evaluates the evidence for two health-related stereotypes of the Irish, namely that behaviours such as smoking and heavy drinking explain their excess morbidity in Britain, and secondly that, in illness, this ethnic group behaves more stoically.

DESIGN

Data are reported on over 850 respondents from each of three cohorts (aged 18, 39 and 58 in 1990/91) of the West of Scotland 20-07 Study, in which a small but pervasive excess of morbidity has been observed in those of Catholic background (in this area associated with Irish descent). Logistic regression was used to investigate any differences in drinking, smoking and participation in sport between those of Catholic and non-Catholic heritage, whilst controlling for sex and social class. Where a difference was observed, we looked for an association between health-related behaviour and the Catholic morbidity excess for six measures of physical and mental health. Finally, illness behaviour at age 39 and 58 was investigated for those experiencing one of a number of common symptoms in the month prior to interview, by noting whether a general medical practitioner (GP) was consulted.

RESULTS

The only difference in health-related behaviour was in the eldest cohort, where an excess of smoking was observed for the Catholics. However, except for lung power, smoking was not able to explain very much, if any, of the Catholic morbidity disadvantage. For most of the symptoms studied, GP consultation rates were similar, although there was a tendency towards Catholic over-consulting.

CONCLUSION

This paper finds minimal evidence in favour of either stereotype: behaviours such as smoking and excess drinking were not strongly associated with the poor morbidity status of the Irish in the population we have studied; neither have the Irish been found to be more stoic in illness. Therefore the stereotypes are not an adequate explanation, nor a necessary correlate, of the frequent finding of raised morbidity in communities of Irish Catholic origin.

Gender differences in minor morbidity among full time employees of a British university

STUDY OBJECTIVE

To examine gender differences in minor morbidity among men and women working in similar circumstances, and to test whether the relation between reported working conditions and health is similar for men and women.

DESIGN

Multivariate analysis of data collected from a postal questionnaire distributed to full time employees in white collar jobs within a single organisation.

SETTING

A British university.

PARTICIPANTS

1641 employees (1009 men and 632 women) working full time in white collar occupations in the university.

MAIN RESULTS

Overall, female university employees reported more "physical" symptoms (2.0 v 1.7, p < 0.001) and more "malaise" symptoms (1.4 v 1.1, p < 0.001) than male employees, but mean scores on a measure of minor psychiatric morbidity did not differ by gender. Poor perceived working conditions (and particularly lack of job stimulation, job drain and poor physical conditions) were consistently related to all three measures of minor morbidity, and these variables accounted for most of the variance in these health measures in this sample. When the analysis controlled for occupational grade, perceived working conditions and orientation to gender roles, there was no difference between men and women for any of the health measures. The relations for the predictor variables were generally the same for men and women (and there were no interactions with gender for any of the work related variables).

CONCLUSIONS

Although small gender differences in recent experience of malaise and physical symptoms remain when examining men and women in as similar working circumstances as possible, these differences are cumulatively eroded by taking account of occupational grade, reported working conditions and orientation to gender. These results lend support to a differential exposure, rather than a differential vulnerability, model of gender differences in health.

Flow cytometric analysis of Ki-67 in invasive ductal carcinoma of the breast: correlation with tumor and patient characteristics

Of all markers associated with cellular proliferation in breast carcinoma, Ki-67 has more often been correlated with prognosis in patients with these tumors than others. To investigate the relevance of Ki-67 determination at each phase of the cell cycle in the biological assessment of mammary carcinoma we applied bivariate Ki-67/DNA content analysis on samples from 154 resected primary lesions. Three Ki-67-derived indices including an overall and G1 and S+G2M indices were generated. These values were correlated with similar indices derived from flow cytometric DNA/RNA analysis and traditional clinicopathologic factors. The results show that overall Ki-67 indices do not correlate with flow cytometric values and clinicopathologic factors. Flow-derived Ki-67 and DNA S+G2M indices were positively correlated (p<0.0001, r=0.58). High indices for the S+G2M phase derived by both Ki-67 and DNA analysis were significantly correlated with DNA aneuploidy, high tumor grade, and negative hormonal status. We conclude that the proliferative fraction (S+G2M) by either Ki-67 or DNA analyses offers more practical and clinically relevant information in assessing the proliferative activity in mammary carcinoma.

Are women more ready to consult than men? Gender differences in family practitioner consultation for common chronic conditions

BACKGROUND

When consultations for all reasons are combined, women are seen to consult their general practitioners more than men through most of adult life. It is, therefore, often assumed that women are more likely to consult for every condition.

OBJECTIVES

To examine whether women report being more likely to consult a general practitioner than men when taking account of the underlying condition and various aspects of the experience of the condition consulted for.

METHODS

Home-based nurse-interviews with 852 people in early middle age (39 years) and 858 in late middle age (58 years) sampled from the general population in the West of Scotland. Detailed information about current chronic conditions included general practitioner consultation and reported experience of pain frequency, pain severity, limitation to normal activities and restricted activity in the previous four weeks.

RESULTS

Women were no more likely than men to consult a general practitioner in the previous year when experiencing the five most common groups of conditions; in addition, women were no more likely than men to consult at a given level of severity for a given condition type, except in the case of one aspect of reported experience of mental health problems.

CONCLUSIONS

The results argue against the most widely accepted explanation for gender differences in consulting, namely, that women are simply more likely to consult a general practitioner than men irrespective of underlying morbidity. Reasons for the higher rates of women consulting observed in general practice-based studies are discussed in relation to these data.

T cells with a quiescent phenotype (CD45RA+) are overabundant in the blood and involuted lymphoid tissues in wasting protein and energy deficiencies

The objective of this investigation was to determine the influence of distinct forms of acute weight loss on the expression of the quiescence marker, CD45RA, by T cells in several lymphoid compartments including the blood. Male and female weanling mice, CBA/J and C57BL/6J strains, were allocated to the following groups: ad libitum intake of a complete purified diet; restricted intake of the complete diet; and ad libitum intake of an isocaloric low-protein diet. The restricted intake protocol produced weight loss through energy deficiency (marasmic-type malnutrition), whereas the low-protein diet caused wasting through inadequate protein nitrogen and induced a condition mimicking incipient kwashiorkor. In one experiment, weanling mice of both strains were maintained for 14 days according to each of these dietary protocols and, in a supplementary study, C57BL/6J weanlings consumed either the complete diet or the low-protein diet ad libitum for 21 days. Zero-time control groups (19-days old and 23-days old in C57BL/6J and CBA/J strains, respectively) were included in the first experiment to control for ontogeny-related change. Expression of CD45RA was assessed by two-colour flow cytometry in CD4+ and CD8+ T cells from the spleen, mesenteric lymph nodes and blood. Within 14 days, energy-restricted mice exhibited a high percentage of CD4+ T cells expressing CD45RA in all three lymphoid compartments in both mouse strains (an average of 50% CD45RA+ versus 9% in well-nourished controls), and a similar outcome was apparent in the CD8+ subset (93% CD45RA+ versus 63%). Mice fed the low-protein diet required up to 21 days to exhibit the same imbalance within the CD4+ T-cell subset (33% CD45RA+ versus 4% in well-nourished controls). A shift toward a quiescent phenotype occurs throughout the peripheral T-cell system in acute wasting disease. Consequently, the quiescence-activation phenotype of blood T cells reflects the same index in secondary lymphoid organs in such pathologies. Naive-type quiescence among T cells is implicated as a component of depressed adaptive immunocompetence in the advanced stages of diverse forms of acute weight loss.

Do women 'over-report' morbidity? Men's and women's responses to structured prompting on a standard question on long standing illness

It is frequently observed in contemporary industrialised societies that although women live longer than men, they are sicker than men in that they report higher rates of morbidity, disability and health care use. One common element of the explanation for women's higher rates of morbidity is that there are gender differences in the way that symptoms are perceived, evaluated and acted upon. It is widely assumed that women will be more ready to report illness and to seek help and that they have greater flexibility in their lives to accommodate illness. The few studies that have examined men and women with the same conditions or symptoms are contradictory, but lend little support to this hypothesised greater propensity, yet it is still widely believed. Here we compare men's and women's answers to a global, commonly used question about chronic illness and to a series of more specific prompts and classify the conditions reported by an externally defined categorisation of severity and International Classification of Disease chapter. Contrary to the common expectation that women report higher rates of morbidity and are more ready to report mental health problems, we found: no gender differences in the initial reporting of conditions; men reported a higher proportion of their conditions in response to the initial global question; and no evidence that women were more likely to report 'trivial' or mental health conditions in response to the initial question.

Professional development in reproductive and sexual health--a pilot study from Suffolk, UK

Staff from two neighbouring trusts working in the fields of family planning and sexual health worked together to develop joint guidelines and from this evolved a training initiative. It was acknowledged that staff were either primarily trained in family planning or in the management of sexually transmitted infections (ST1) and therefore the training would be interdisciplinary. In line with current educational thinking it was also decided to make it multiprofessional. A pilot training project was therefore set up to answer the question 'can self directed learning combined with facilitated small group study sessions provide theoretical updating for a range of health professionals within the field of reproductive and sexual health'. The project aimed to increase theoretical knowledge of contraception, sexually transmitted infections and termination of pregnancy for all relevant nursing and medical staff working within the two trusts. The stated outcome of the project was for all staff to achieve a wider core knowledge of the identified topics, regardless of whether their primary training and knowledge base was in family planning or sexually transmitted infection. The project spanned five months and offered professional development packages in hormonal contraception, non-hormonal contraception, termination of pregnancy, bacterial and minor STIs and viral STIs. The pilot project was well received and the process was shown to be an effective way of increasing the knowledge base. The knowledge shift was greatest in the opposing discipline to the primary discipline of each participant. There were added advantages in team building for staff within the same trust and networking across trusts. The strengths and weaknesses of the process were identified and used to develop ideas for future professional development initiatives.

Problematizing gender, work and health: the relationship between gender, occupational grade, working conditions and minor morbidity in full-time bank employees

It is commonly asserted that while women have longer life expectancy than men, they have higher rates of morbidity, particularly for minor and psychological conditions. However, most research on gender and health has taken only limited account of the gendered distribution of social roles. Here we investigate gender differences in morbidity whilst controlling, as far as possible, for one major role, namely participation in paid employment. There is substantial segregation of the labour market by gender; men and women typically work different hours in different occupations which involve varying conditions and differing rewards and costs. Here, we examine men and women working full-time for the same employer. This paper reports on a postal survey of employees (1112 men and 1064 women) of a large British bank. It addresses three main questions: do gender differences in minor morbidity remain if we compare men and women who are employed in similar circumstances (same industry and employer)? What is the relative importance of gender, grade of employment within the organisation, perceived working conditions and orientation to gender roles for minor morbidity? Finally, are these factors related to health differentially for men and women? There were statistically significant gender differences amongst these full-time employees in recent experience of malaise symptoms, but not in physical symptoms or GHQ scores. Controlling for other factors did not reduce the gender differences in malaise scores and produced a weak, but significant, gender difference in GHQ scores. However, gender explained only a small proportion of variance, particularly in comparison with working conditions. Generally similar relationships between experience of work and occupational grade and morbidity were observed for men and women. Throughout the paper, we attempt to problematize gender, recognising that there are similarities between women and men and diversity amongst women and amongst men. However, we conclude that the gendered nature of much of adult life, including paid work, continues to shape the experiences and health of men and women at the end of the twentieth century.

Social class and health: the puzzling counter-example of British South Asians

British South Asians (with ancestry from the Indian subcontinent) provided a puzzling exception to the British class gradient in mortality during the 1970s. On the assumption that class gradients in health are produced mainly by gradients in standard of living, this might be due to a break in the relation of class to standard of living (change in class structure), or by a break in the relation of standard of living to patterns of health behaviour and health risk (change in class lifestyles). Data on these characteristics are available from the West of Scotland Twenty-07 Study, where 159 South Asians aged 30-40 (mean age 35) were sampled alongside 319 of the general population in Glasgow. As regards changes in class structure, results indicate that the underclass thesis, which suggests that ethnic minorities are forced into less eligible jobs or into a separate labour market or into unemployment, resulting in a standard of living below that of the general population, still holds good for British South Asians in categories from social class III non-manual downwards. It does not hold good for owners of small businesses, where Sikhs and Hindus in particular have a standard of living equivalent to general population counterparts. However, prosperity is not predictable from levels of education in the subcontinent and from this and other signs it appears that a wholesale redistribution of class chances is occurring among British South Asians, disrupting inter-and intra-generational continuities in the relation between class and standard of living. There is little sign of change in class lifestyles, i.e. in the relation between standard of living and health behaviour or health risk. As yet, though, the new distribution of standard of living is affecting patterns of health behaviour and health risk more strongly than symptom experience or chronic illness, suggesting that a class gradient in health will re-emerge.

Do housing tenure and car access predict health because they are simply markers of income or self esteem? A Scottish study

OBJECTIVE

To investigate relations between health (using a range of measures) and housing tenure or car access; and to test the hypothesis that observed relations between these asset based measures and health are simply because they are markers for income or self esteem.

DESIGN

Analysis of data from second wave of data collection of West of Scotland Twenty-07 study, collected in 1991 by face to face interviews conducted by nurse interviewers.

SETTING

The Central Clydeside Conurbation, in the West of Scotland.

SUBJECTS

785 people (354 men, 431 women) in their late 30s, and 718 people (358 men, 359 women) in their late 50s, participants in a longitudinal study.

MEASURES

General Health Questionnaire scores, respiratory function, waist/hip ratio, number of longstanding illnesses, number of symptoms in the last month, and systolic blood pressure; household income adjusted for household size and composition; Rosenberg self esteem score; housing tenure and care access.

RESULTS

On bivariate analysis, all the health measures were significantly associated with housing tenure, and all except waist/hip ratio with car access; all except waist/hip ratio were related to income, and all except systolic blood pressure were related to self esteem. In models controlling for age, sex, and their interaction, neither waist/hip ratio nor systolic blood pressure remained significantly associated with tenure or care access. Significant relations with all the remaining health measures persisted after further controlling for income or self esteem.

CONCLUSIONS

Housing tenure and car access may not only be related to health because they are markers for income or psychological traits; they may also have some directly health promoting or damaging effects. More research is needed to establish mechanisms by which they may influence health, and to determine the policy implications of their association with health.

Gender differences in consulting a general practitioner for common symptoms of minor illness

The aim of this paper is to examine whether, in response to the same symptoms of minor illness, women reported a greater propensity to consult a general practitioner than men. Respondents taking part in the West of Scotland Twenty-07 Study (853 aged 39 and 858 aged 58) were presented with a check-list of 33 symptoms during the course of a home interview conducted by nurses. They were asked whether they had experienced any of these symptoms in the last month, and if they had, whether they consulted a general practitioner about it. A summary indicator for reporting, or consulting for, at least one symptom was constructed, and statistical associations between gender, reporting and consulting for symptoms were examined using chi-square tests with Yates' correction. Women were more likely to have consulted a general practitioner for at least one of the 33 symptoms of minor illness reported in the previous month (34% of women, 27% of men aged 39, chi2 = 3.97, p < 0.05; 49% of women, 43% of men aged 58, chi2 = 3.21, (NS)). Women were significantly more likely to have consulted for five individual symptoms in the younger cohort, and for three symptoms in the older cohort, whilst men were significantly more likely to have consulted for only one symptom, in the younger cohort. However, when only those who had reported a symptom in the last month were included in analysis there were no gender differences in consulting for any of the 33 symptoms in the older cohort, and for just 3 symptoms in the younger cohort. These data do not support the most widely suggested explanation for gender differences in consulting, that once symptoms are perceived, women have a higher propensity to consult a general practitioner with the symptom than men.

EMG study of hand muscle recruitment during hard hammer percussion manufacture of Oldowan tools

The activity of 17 hand muscles was monitored by electromyography (EMG) in three subjects during hard hammer percussion manufacture of Oldowan tools. Two of the subjects were archaeologists experienced in the replication of prehistoric stone tools. Simultaneous videotapes recorded grips associated with the muscle activities. The purpose of the study was to identify the muscles most likely to have been strongly and repeatedly recruited by early hominids during stone tool-making. This information is fundamental to the identification of skeletal features that may reliably predict tool-making capabilities in early hominids. The muscles most frequently recruited at high force levels for strong precision pinch grips required to control the hammerstone and core are the intrinsic muscles of the fifth finger and the thumb/index finger regions. A productive search for skeletal evidence of habitual Oldowan tool-making behavior will therefore be in the regions of the hand stressed by these intrinsic muscles and in the joint configurations affecting the relative lengths of their moment arms.

Teamwork in the operating department

The Gynaecology theatre team of the Leicester Royal Infirmary NHS Trust were runners-up in the 1997 3M/NATN joint award. This article is a report of their work on the concept of teamwork and its benefits to the organisation and delivery of patient care in the operating department.

Accounts of disagreements with doctors

Patients' perceptions of health care, particularly as they relate to disagreements of various kinds, have emerged as a particular topic of interest to practitioners and social scientists since the mid-1980s in Great Britain. Most research, however, has concentrated upon disagreements that have turned into formal complaints to health authorities and community and hospital trusts. This means that the focus has been upon the strong end of disagreements where action has already been taken to redress a grievance. This is likely to leave many aspects of the relationship between felt disagreement and disagreement action unexplored. Why, for example, when they feel dissatisfied with the health care that they, or a relative has received, do some people take action and others not? And, if they do take action, what is involved? Are there any associations between the kind of action taken--for example, doing nothing, verbally challenging the doctor, seeking a second opinion, or discontinuing treatment and the nature of the felt disagreement, the kind of health problem being treated, or the social characteristics of the patient concerned? In this paper we explore some of these questions through data collected as part of a community sample of individuals in the West of Scotland.

Characterization of pigs transgenic for human decay-accelerating factor

BACKGROUND

To prevent the central role played by complement activation in the hyperacute rejection of pig organs transplanted into primates, pigs transgenic for human decay-accelerating factor (HDAF) have recently been produced. The data presented here extend previous immunohistochemical findings by documenting the immunological characterization and the levels of expression of HDAF in these transgenic pigs.

METHODS

Animals from 30 independently derived lines were included in this study. HDAF expression was characterized by immunoprecipitation and epitope mapping. Quantitative analysis was performed by radiometric assays followed by Scatchard analysis and by double-determinant radioimmunoassay. Deposition of iC3b on porcine aortic endothelial cells was determined by radioimmunoassay. DNA slot-blot analysis and densitometric scanning were used to evaluate HDAF transgene copy number.

RESULTS

The integrity of HDAF expressed by these transgenic pigs could be demonstrated. HDAF was present in 72% of the organs analyzed, although considerable variation in expression occurred, both between animals and within the same pig. High levels of HDAF on porcine aortic endothelial cells resulted in iC3b deposition at levels as low as that detected on human endothelial cells. Twenty-six organs expressed levels of HDAF greater than those observed in the equivalent human tissue. HDAF expression did not correlate with the number of copies of the transgene incorporated into the porcine genome.

CONCLUSIONS

Transgenic pigs, which express levels of functional HDAF even greater than those observed in humans, have successfully been produced. Pigs transgenic for human complement inhibiting molecules could represent a source of organs for future clinical xenotransplantation.

Psychological distress among British South Asians: the contribution of stressful situations and subcultural differences in the West of Scotland Twenty-07 Study

BACKGROUND

This paper seeks to explain an excess of psychological distress previously found among groups of British South Asians (with ancestry from the Indian subcontinent) living in Glasgow, compared with the general population. The excess was found on a psychosomatic measure and a measure of self-assessed distress but not on a clinically validated measure (the General Health Questionnaire or GHQ). The paper investigates whether South Asians are subject to stressful situations to which the GHQ is less sensitive than the other two measures.

METHODS

Random samples of 159 South Asians aged 30-40, mean age 35, and 319 from the general population, all aged 35, were interviewed in Glasgow, using the 12-item General Health Questionnaire (GHQ-12), a psychosomatic symptom scale (PSS) and a self-assessment of distress. Subcultural groupings were differentiated by South Asian origin, English fluency, religion, and gender. Stressful situations assessed were experience of assault, stress/dissatisfaction with work, overcrowding, low standard of living, absence of family and absence of confidants.

RESULTS

The GHQ-12 was less sensitive to certain stressful situations than the other two measures. The PSS and/or self-assessed distress were more sensitive to low standard of living, self-rated stress in work around the house and possibly experience of assault. In a combined analysis, the relation between distress on the PSS or self-assessed measure and subcultural groupings became nonsignificant, while the relation between distress and key stressful situations remained significant.

CONCLUSIONS

The greater distress of women, Muslims and limited English speakers is largely explained by the stressful situations they experience. The GHQ-12 under-estimates distress related to situations experienced particularly by ethnic minorities and by women.

NHS reforms. Counting the costs

Localism predominates in purchaser-provider relationships, with markets strictly limited in practice. Block contracting predominates, largely to enable purchasers to bring pressure to bear on providers' costs and outputs. The administrative costs of operating the purchaser-provider split have led to a clear growth in the overall administrative costs within the NHS. Locality commissioning may conflict with the need to reorganise clinical services.

Morbidity and Irish Catholic descent in Britain: an ethnic and religious minority 150 years on

Ethnic and religious minorities often suffer disadvantages both in socio-economic status and in health. Data from the West of Scotland Twenty-07 study suggest some differences in morbidity between those descended from Irish Catholic migrants of the great emigration from 1840 onwards and others. Catholic religion of at least one parent or at birth is used here as a proxy measure to indicate Irish Catholic descent, on the basis of estimates of sensitivity and specificity in the local area. Higher proportions of "Catholics" are in manual social classes. Differences between "Catholics" and "non-Catholics" in one or more age cohorts are observed for the following aspects of health and physical development: general and physical health (self-assessed health, number of symptoms, accidents), psychological distress (depression, anxiety, number of psychosomatic symptoms), impairments and disabilities (sight, hearing, wearing dentures, disability), and physical measures (height, waist-to-hip ratio, lung function). Furthermore, for all aspects except hearing, wearing dentures and number of psychosomatic symptoms, significant differences remain after accounting for sex and social class. For each measure where a difference is observed, it is those respondents with a Catholic parent or who were born Catholic who experience poorer health or physical development. This suggests that those of Irish Catholic descent are at some disadvantage compared with the rest of the population, with respect to health as well as social class, 150 years after the start of the main migration.

Has psychological distress among UK South Asians been under-estimated? A comparison of three measures in the west of Scotland population

OBJECTIVES

Previous work has shown low levels of psychological distress among UK South Asians, but some argue that the distress is under-reported. The present paper assesses distress on one clinically validated measure (the 12-item General Health Questionnaire), a psychosomatic measure and a self-report measure.

METHODS

Interviews of 159 South Asians in Glasgow aged 30-40 years, mean age 35 years and 319 from the general population, all aged 35 years.

RESULTS

The three distress measures were moderately correlated and at the thresholds chosen there was no hierarchy of severity between them. Distress on the GHQ12 was at similar levels for all the social groups assessed, but distress on the psychosomatic measure and self-assessment was higher for women, Muslims and limited English speakers.

CONCLUSIONS

Clinical measures may have under-estimated distress in several South Asian groups. The results may be due to a preference for a particular language of emotion in the affected groups or to a higher frequency of stressful situations which provoke distinctive reactions.

Transduction of murine and human tumors using recombinant adenovirus vectors

BACKGROUND

Most cytokine-based cancer gene therapy clinical trials have used labor-intensive, retrovirus-mediated strategies resulting in unpredictable gene expression. Recombinant AdV vectors were evaluated for easier, more reproducible gene transfer into 12 human melanoma, 2 murine fibrosarcomas, and 8 other tumor cell lines.

METHODS

AdV vectors contained a reporter (Escherichia coli beta-galactosidase or firefly luciferase) or cytokine gene (human interleukin-2 [IL-2] or IL-7). Transduction efficiencies and expression levels were assessed by histochemical staining, flow cytometry, polymerase chain reaction, fluorometry, and enzyme-linked immunosorbent assay. Tumorigenicity was determined by subcutaneous injection of cells into syngeneic mice.

RESULTS

All cell lines studied were transduced with AdV. Most cell lines exhibited 100% transduction efficiencies (by flow cytometry) at multiplicities of infection (MOI) epsilon 10. Gene expression correlated linearly with MOI, but a cytopathic effect was observed at MOI > 100 with all vectors. Nanogram gene expression levels were routinely achieved. Irradiation (30 Gy) minimally affected expression levels. Tumorigenicity of AdV-IL-2-transduced fibrosarcoma cells in mice was inversely related to IL-2 production. A majority of mice that rejected their tumor challenge were immune to tumor rechallenge.

CONCLUSIONS

E1-deleted AdV vectors may prove useful in generating tumor vaccines ex vivo with high, transient cytokine expression levels.

Ergonomics: a case study in preventing repetitive motion injuries

Dental Services Group has designed and implemented a system for its dental laboratories to mitigate cumulative trauma injuries, such as carpal tunnel syndrome and tendinitis. In the dental laboratory, these injuries result from repetitive motions such as waxing, sandblasting, grinding and polishing. This article describes purchasing guidelines for ergonomically designed laboratory equipment and offers resources for implementing workplace safety programs.

Irish descent, religion, and alcohol and tobacco use

The West of Scotland has traditionally been a focus for Irish migration. Using data from two studies carried out in this region, one quantitative, the other qualitative, this paper shows little difference in drinking and smoking between Scots of Irish descent and other Scots. It does, however, show significant differences in these behaviours according to religious affiliation in adulthood. Rather than confirming the stereotype of Irish Catholics as heavy drinkers and smokers the present paper puts forward the hypothesis that drinkers and smokers are differentially retained in membership by different religious affiliations, and argues that this accounts for differences in reputation and in health-related behaviours.

Gender differences in health: are things really as simple as they seem?

It is conventional wisdom in medical sociology and social epidemiology that in industrialized societies men die earlier than women, but that women have poorer health than men. A number of explanations for these differences have been postulated and tested (for example, different biological risks, acquired risks, reporting biases and experiences of health care). Using two recent British data sets we find that the pattern of sex differences in morbidity is more complicated than the conventional wisdom often suggests. The direction and magnitude of sex differences in health vary according to the particular symptom or condition in question and according to the phase of the life cycle. Female excess is only consistently found across the life span for psychological distress and is far less apparent, or reversed, for a number of physical symptoms and conditions. Detailed inspection of papers on gender differences published in the last decade reveals that our findings are not unique, but that a relatively undifferentiated model of consistent sex differences has nevertheless continued to predominate in the literature. We believe that the topic of gender differences in health warrants periodic re-examination.

In vivo cancer gene therapy with a recombinant interleukin-2 adenovirus vector

Recombinant adenovirus (AdV) vectors are highly efficient at in vitro and in vivo gene delivery. In vivo therapy of established murine fibrosarcoma and mammary carcinomas was attempted with intratumoral injections of a recombinant AdV vector in which the human interleukin-2 (IL-2) gene was driven by the cytomegalovirus enhancer/promoter. Delayed growth and rejection of some tumors could be achieved with a cumulative virus dose of 2 to 6 x 10(9) plaque-forming units in two or three divided doses. Lower viral doses were ineffective, and higher doses resulted in animal death due to IL-2 toxicity. Using AdV vectors with the marker genes beta-galactosidase and luciferase, it is clear that even small volume (10 to 20 microL) intratumoral injections result in substantial systemic delivery of a portion of the virus dose. These findings define the potential and limitations of in vivo AdV-based cancer gene therapy and provide support for strategies to develop tumor-specific vectors.

Accreditation at what cost?

Analyses the implications of the management of labour for an organization undertaking an accreditation exercise. Considers the King's Fund Organizational Audit (KFOA) accreditation scheme, which is concerned with process and facilities, and assesses the quality of the hospital environment in which the health care product is supplied. Concludes that, given the current enthusiasm for finding best practice in health care and the ever-increasing number of cost-effectiveness analyses of therapeutic interventions, it seems somewhat contradictory that interventions which cover the whole environment in which health care interventions are performed are not treated in the same way.