Maternal smoking in pregnancy, adult adiposity and other risk factors for cardiovascular disease

OBJECTIVE

To establish whether maternal smoking in pregnancy is associated with risk factors for cardiovascular disease (CVD) in mid-adulthood and whether associations are explained by postnatal influences.

METHODS

Participants were 8815 men and women in the 1958 British birth cohort, with data on CVD risk factors measured at 45 y. Maternal smoking was recorded at birth.

RESULTS

Offspring of smokers had a higher adult BMI, waist circumference, blood pressure, HbA1c and triglycerides on average than offspring of non-smokers; females had lower HDL cholesterol levels. Total cholesterol was unrelated to maternal smoking. Associations were abolished after adjustment for postnatal influences across life, except for BMI and waist circumference: offspring of smokers had a BMI greater by 0.83 kg/m(2) on average than offspring of non-smokers and a 1.8 cm larger waist circumference. Mean BMI and waist circumference increased with number of cigarettes that the mother smoked, but were not elevated in offspring whose mother had quit smoking before or early in pregnancy.

CONCLUSIONS

Adults exposed to tobacco in utero had a more adverse CVD risk profile in mid-adulthood which appeared to reflect a lifetime accumulation of postnatal influences; whereas their higher BMI and central adiposity may be due in part to intrauterine mechanisms.

Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital

BACKGROUND

Patient-controlled analgesia (PCA) is a common and effective means of managing post-operative pain. We sought to identify factors that may lead to critical incidents (CIs) in patient safety when using PCA in our institution.

METHODS

An observational study of prospectively collected data of patients who received PCA from 2002 to 2006 was performed. All CIs were documented and analysed by staff members of the acute pain service (APS). Cause analysis of CIs was undertaken to determine if measures can be instituted to prevent recurrence of similar events.

RESULTS

Over eight thousand patients (8,240) received PCA. Twenty-seven CIs were identified. Eighteen were due to programming errors. Other CIs included co-administration of opioids and oversedation.

CONCLUSION

In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.

Dehydroepiandrosterone sulphate improves cholestasis-associated fatigue in bile duct ligated rats

Fatigue is a common debilitating symptom in patients with primary biliary cirrhosis (PBC). The mechanism of fatigue is still poorly understood. However, it has been reported that levels of the steroid dehydroepiandrosterone sulphate (DHEAS) are reduced in plasma of patients with PBC, and substitutive therapy has been suggested to improve fatigue symptoms experienced during the course of this disease. In this study, we tested the effect of DHEAS on whole body fatigue in rats following bile duct ligation (BDL). Fatigue was estimated by the time spent on an electrified grid as a result of falling off a treadmill and by performance of rats on an infrared beam monitor which allows the assessment of travelled distance and stereotypic movement activities. On day 5 after BDL surgery, cholestatic rats exhibited increased whole body fatigue as reflected by significantly increased time spent on the electrified grid, reduced travelled distance and reduced stereotypic movements. Administration of 5 mg kg(-1) of DHEAS to BDL rats for three consecutive days significantly normalized their behaviour. Fatigue scores were also found to be reduced in cirrhotic rats 4 weeks after BDL surgery, and DHEAS treatment for 3 days reduced fatigue scores at this stage. Dehydroepiandrosterone sulphate treatment was sufficient to increase brain levels of DHEAS in the BDL rats in a manner that is significantly and highly correlated with those of plasma DHEAS and brain dehydroepiandrosterone (DHEA). Substitutive therapies with DHEAS or DHEA could represent novel approaches in the management of fatigue due to cholestasis-induced liver failure.

Co-occurrence of risk factors for cardiovascular disease by social class: 1958 British birth cohort

AIM

To establish whether social differences in multiple risk factors for cardiovascular disease are due to a greater strength of association (higher correlation) between risk factors in less advantaged groups.

METHODS

Co-occurrence of five risk factors (smoking, hypertension, low high-density lipoprotein cholesterol, obesity, diabetes) in 3614 British 45-year-old men and 3560 women in the manual and non-manual social groups.

RESULTS

4.0% of women in manual groups had >or=3 risk factors compared with 1.7% in non-manual groups: 6.2% and 3.4% respectively for men. There was a higher than expected percentage of the population, overall, with >or=3 risk factors assuming independence between risk factors; correspondingly, there was a slightly lower than expected proportion with one factor. However, patterns of observed to expected ratios were consistent in manual and non-manual groups and did not differ by the number of risk factors.

CONCLUSIONS

Higher prevalence of multiple risk factors in manual groups was due to the higher prevalence of individual factors rather than a greater tendency of those with an individual risk factor to have additional risks. Strategies to reduce multiple risk factors in less advantaged groups would help to lessen their health burden.

Serum 25-hydroxyvitamin D and IgE - a significant but nonlinear relationship

BACKGROUND

Hormonal vitamin D system affects the determination of T-cell responses. It is unknown if there is an association between vitamin D status and allergic conditions. Our aim was to investigate differences in serum IgE concentrations by vitamin D status [measured by 25(OH)D] and by a genetic variation in a key vitamin D activation enzyme (CYP27B1) previously shown to be associated with type 1 diabetes.

METHODS

9377 participants in the 1958 British birth cohort completed a biomedical assessment at 45 years of age ; 7288 eligible participants had data on 25(OH)D and IgE, with 6429 having further information on CYP27B1 genotype ()1260C>A).

RESULTS

There was a nonlinear association between 25(OH)D and IgE (P-value for curvature = 0.0001). Compared with the reference group with the lowest IgE concentrations [25(OH)D 100-125 nmol/l], IgE concentrations were 29% higher (95% CI 9-48%) for participants with the 25(OH)D <25 nmol/l, and 56% higher (95% CI 17-95%) for participants with 25(OH)D >135 nmol/l (adjusted for sex, month, smoking, alcohol consumption, time spent outside, geographical location, social class, PC/TV time, physical activity, body mass index and waist circumference). CYP27B1 genotype was associated with both 25(OH)D (difference for A vs. C allele: 1.88%, 95% CI 0.37-3.4%, P = 0.01) and IgE concentrations ()6.59%, )11.6% to )1.42%, P = 0.01).

CONCLUSIONS

These data suggest that there may be a threshold effect with both low and high 25(OH)D levels associated with elevated IgE concentrations. The same CYP27B1 allele that is protective of diabetes was associated with increased IgE concentrations.

Neurocognitive screening tools in HIV/AIDS: comparative performance among patients exposed to antiretroviral therapy

OBJECTIVE

The aim of the study was to compare the performance of several bedside neuropsychological tools for detection of HIV-associated neurocognitive disorder (HAND) in antiretroviral drug-exposed persons.

METHODS

We analysed the relative performance of the HIV Dementia Scale (HDS), International HIV Dementia Scale (IHDS) and the Mini-Mental Status Exam (MMSE) together with neuropsychological tests (Symbol-Digit, Grooved Pegboard and Trail Making) in HIV-1-seronegative subjects (HIV-; n=13) and in HIV-1-seropositive subjects with HAND (HIV+HAND; n=13) and other neurological disorders (HIV+OND; n=20).

RESULTS

Established neuropsychological tests consistently showed significantly poorer performance by HIV+HAND subjects compared with the other two groups. Similarly, the mean HDS and IHDS scores were lower in the HIV+HAND group compared with the other two groups (P<0.005) while the mean MMSE score did not show significant differences between the HIV+HAND and HIV+OND groups. Receiver operator characteristics curves generated from these data using predefined cut-off scores revealed that the HDS, IHDS and MMSE displayed corresponding area under the curve values of 0.82, 0.74 and 0.48, respectively (P<0.006).

CONCLUSIONS

The present findings indicate that the MMSE is a weak tool for diagnosing HAND in this group of patients but the HDS and IHDS demonstrate better efficiencies, although cut-off values for the HDS require reassessment in the era of effective antiretroviral therapy.

The influence of socioeconomic status on the reporting of regional and widespread musculoskeletal pain: results from the 1958 British Birth Cohort Study

OBJECTIVE

This study aims to determine to what extent the reporting of pain in adulthood varies by adult socioeconomic status, whether there are additional long-term effects of socioeconomic status in childhood and whether any such relationships are mediated through adult psychological ill health.

METHODS

A prospective cohort study (the 1958 British Birth Cohort Study) was conducted. Participants were recruited, at birth, in 1958 and were followed-up throughout childhood and adulthood, most recently at 45 years when information was collected on regional and widespread pain, and various potential mediating factors.

RESULTS

The prevalence of shoulder, forearm, low back, knee and chronic widespread pain at 45 years generally increased with lower adult social class. Persons in the lowest social class (compared to the highest) experienced nearly a threefold increase in the risk of chronic widespread pain: relative risk: 2.9 (95% CI 1.8 to 4.6). The strength of association varied between 1.5 and 2.0 for regional pains. Childhood social class also demonstrated a relationship with most regional pains and chronic widespread pain. With the exception of forearm pain, the magnitude of effect of childhood social status on reporting of pain in adulthood was less than that of adult social status. On multivariable analysis these relationships were partly explained by poor adult mental health, psychological distress, adverse life events and lifestyle factors.

CONCLUSIONS

These results emphasise the importance and potential impact of measures to reduce social adversity, which will have the effect of improving musculoskeletal health in adult life and other major causes of morbidity.

Whither prometheus' liver? Greek myth and the science of regeneration

Stem-cell biologists and those involved in regenerative medicine are fascinated by the story of Prometheus, the Greek god whose immortal liver was feasted on day after day by Zeus' eagle. This myth invariably provokes the question: Did the ancient Greeks know about the liver's amazing capacity for self-repair? The authors address this question by exploring the origins of Greek myth and medicine, adopting a 2-fold strategy. First, the authors consider what opportunities the ancient Greeks had to learn about the liver's structure and function. This involves a discussion of early battlefield surgery, the beginnings of anatomical research, and the ancient art of liver augury. In addition, the authors consider how the Greeks understood Prometheus' immortal liver. Not only do the authors examine the general theme of regeneration in Greek mythology, they survey several scholarly interpretations of Prometheus' torture.

Paths to literacy and numeracy problems: evidence from two British birth cohorts

BACKGROUND

To test a life course model linking circumstances of origin to self-reported literacy and numeracy problems in midlife, and to investigate the effects in this model of changing social circumstances in two post-war cohorts.

METHODS

Based on data from men and women in the British 1946 and 1958 birth cohorts, we used the relative index of inequality and logistical regression to test associations between father's occupation, childhood cognition, educational attainment, own occupation in the third decade, and a binary variable representing self-reported literacy and numeracy problems in the fourth decade.

RESULTS

There was a lower frequency of literacy and numeracy problems in the 1958 cohort than in the 1946 cohort. In both cohorts there were associations between father's occupation and childhood cognition, educational attainment and own occupation, a pattern that was mirrored by the associations between childhood cognition, educational attainment and own occupation to adult literacy and numeracy problems. Positive associations between childhood cognition and educational attainment, and between educational attainment and own occupation, were stronger in the 1946 cohort than in the 1958 cohort. However, inverse associations between educational attainment and literacy and numeracy problems were stronger in the 1958 cohort, possibly reflecting the expansion of secondary education in the intervening years.

CONCLUSIONS

Literacy and numeracy problems have a robust structure of life course associations, although the changing pattern of these associations may reflect important social structural changes from the early post-war years to the early 1960s in the UK.

Primary headaches in HIV-infected patients

Headache in patients with human immunodeficiency virus (HIV) infection may indicate life-threatening illnesses such as opportunistic infections or neoplasms. Alternatively, such patients may develop benign self-limiting headaches. Hence, defining the various types of headache in these patients is essential for proper management. This study describes the clinical characteristics of primary headaches occurring in a group of HIV-infected patients. Of 115 patients seen from 1990 to 1996, 44 (38%) had headaches. Primary headaches were present in 29 (66%) patients and secondary causes were identified in 15 (34%). Among those with primary headaches, migraine occurred in 22 (76%), tension-type headache in 4 (14%), and cluster headache in 3 (10%) patients. Half of those with migraine (n=ll), 1 patient with tension-type headache, and 1 patient with cluster headache developed chronic daily headaches which were severe and refractory to conventional headache or antiretroviral therapy. We conclude that primary headaches in patients with HIV infection are: (1) the commonest type of headache; (2) may present for the first time in individuals with severe immunosuppression; (3) usually bear no relationship to antiretroviral drug therapy; (4) polypharmacy, depression, anxiety, and insomnia are commonly associated comorbidities; (5) frequently do not respond to conventional management and carry a poor prognosis; and (6) do not require neuroradiological and/or cerebrospinal fluid evaluations.

Loss and representativeness in a biomedical survey at age 45 years: 1958 British birth cohort

OBJECTIVE

A biomedical survey of the 1958 British birth cohort at age 45 years provides a baseline for future studies of chronic disease. The extent and nature of bias in this sample was examined.

METHODS

Follow-up of all births in Great Britain in one week in March 1958. At 45 years the sample was compared with the surviving cohort on characteristics recorded at birth and seven years, and in adulthood (42 years).

RESULTS

Sample attrition to age 45 years was chiefly through avoidable (35.8%) than unavoidable loss through death or emigration (13.7%). 11 971 individuals were invited to participate at 45 years. Of 9377 participants (78.3%), most consented to, and had valid values for, physical and mental measurements, survey questionnaires, and blood and saliva sampling; 8302 (88.5%) provided a blood sample. Groups moderately underrepresented in the 45-year sample included those with externalizing or internalizing behaviours, poor reading or math scores, and shorter stature. For example, 8.8% of the 45-year sample had been poor readers at age seven years compared with 11.1% of the total surviving cohort; for shorter stature the figures were 7.2% versus 8.4%, respectively. There was also underrepresentation of some minority groups (non-whites, births in households with no male head and children in social care). Most bias was present before the 45-year survey.

CONCLUSION

The 45-year sample remains broadly representative of the surviving cohort, but specific biases may need to be taken into account in future research. Renewed efforts to re-engage all cohort members will improve the representativeness and value of the study.

Intra-operative examination of the sentinel node in breast cancer

Intra-operative sentinel node analysis allows immediate progression to axillary clearance in patients with node positive breast cancer and reduces the need for re-operation. Despite this, intra-operative sentinel node analysis is infrequently performed in Ireland. We report our experience using this technique. Sentinel node biopsy was performed in 47 consecutive patients with symptomatic T1-T2 clinically node negative breast cancer. Sentinel nodes were examined intra-operatively by frozen section and imprint cytology and definitive histological assessment was performed on paraffin-embedded tissue. The sentinel node was identified in 46 (98%) patients. Twelve patients had axillary metastases. The sensitivity of intra-operative analysis in identifying nodal metastases was 92%. False negative rate was 8%, negative predictive value 97%, and specificity 100%. Intra-operative analysis of the sentinel node allowed re-operation to be avoided in 92% of patients with axillary node metastases. In our experience this technique can be readily introduced with reliable outcomes.

Television viewing and obesity: a prospective study in the 1958 British birth cohort

OBJECTIVE

To assess whether frequency of television viewing in adolescence (11 and 16 years) or early adulthood (23 years) affected subsequent changes in body mass index (BMI) through to mid-adulthood life, and waist-hip ratio in mid-adulthood.

SUBJECTS

The 1958 British birth cohort includes all births in 1 week in March 1958 in England, Scotland and Wales. The main analyses included at least 11 301 participants. Outcome measures included BMI at 16, 23, 33 and 45 years and waist-hip ratio at 45 years.

RESULTS

Watching television 'often' at 16 years (but not 11 years) was associated with a faster gain in BMI between 16 and 45 years in males (0.011 kg m(-2) per year, 95% confidence interval (CI) 0.003, 0.019) and females (0.013 kg m(-2) per year, 95%CI 0.003, 0.023). More frequent television viewing at 11, 16 and 23 years was associated with a faster gain in BMI between 23 and 45 years in females, but not in males. Television viewing at 23 years was associated with waist-hip ratio at 45 years: participants watching > or = 5 times per week had a waist-hip ratio 0.01 higher than those watching less often. At 45 years, those watching television for > or = 4 h day(-1) had a waist-hip ratio 0.03-0.04 higher than those watching for <1 h day(-1).

CONCLUSIONS

More frequent television viewing in adolescence and early adulthood is associated with greater BMI gains through to mid-adulthood and with central adiposity in mid-life. Television viewing may be a useful behaviour to target in strategies to prevent obesity.

A comparative study of risk factors and prognostic features between symptomatic and screen detected breast cancer

AIMS

To compare prognostic factors in screen detected breast cancer (SDBC) and symptomatically presenting breast cancer (SBC).

METHODS

Data were examined on 100 SDBC and 100 SBC. Multiple clinical patient factors were assessed including histopathological features. Using the Gail model each patient's risk of developing breast cancer was calculated and these data were examined for differences between groups.

RESULTS

There was no difference in the mean age of patient presentation or in the risk of breast cancer development between groups (2.2% vs. 2.2%, SDBC vs. SBC, actuarial risk of cancer at 5 years). SDBC patients had a significantly lower grade (1.95 vs. 2.44, SDBC vs. SBC, P<0.05), a smaller size of tumour (15.4mm vs. 29.3mm, SDBC vs. SBC, P<0.05) and a higher rate of oestrogen (94% vs. 81%, P<0.05) and progesterone (75% vs. 52%, P<0.05) receptor positivity. When compared using the Nottingham Prognostic Index, SDBC was associated with a better prognosis (r=-0.444, P<0.001).

CONCLUSIONS

Though both groups have similar demographics and risk, SDBC patients appear to have more favourable prognostic features. This has implications for the application of systemic therapy in breast cancer and supports the observation that SDBC is a more indolent form of disease.