A follow-up study of children hospitalised with community-acquired pneumonia

OBJECTIVE

To investigate the outcome for children hospitalised with radiologically confirmed community-acquired pneumonia (CAP) DESIGN: Controlled follow-up study.

SETTING

Community based in Newcastle upon Tyne, North Tyneside and Northumberland schools.

PATIENTS

103 cases of radiologically confirmed CAP a median of 5.6 years (range 4.4-7.4) after admission to Newcastle General Hospital, matched for sex and school class to a mean of two controls (n = 248).

INTERVENTIONS

A respiratory questionnaire, clinical examination and spirometry measurements.

MAIN OUTCOME MEASURES

Multiple regression was used to describe associations between explanatory variables, including CAP, and outcome variables: forced expiratory volume in 1 s percent predicted (FEV(1) %), forced vital capacity percent predicted (FVC %), persistent cough, doctor diagnosis of asthma and abnormal chest shape.

RESULTS

Cases were 2.9 times more likely (95% CI 1.45 to 5.71, p = 0.020) than controls to have persistent cough and 5.5 times more likely to have an abnormal chest shape (95% CI 1.65 to 18.28, p = 0.005). Cases of an atopic parent had a 7.0% deficit in FEV(1) % predicted (95% CI -10.5 to -3.2, p<0.001) and a 4.4% deficit in FVC % predicted (95% CI -8.0 to -0.78, p = 0.017), but were not at increased risk of subsequent asthma. Cases of a non-atopic parent were at increased risk of subsequent asthma (OR 4.8, 95% CI 1.43 to 16.34, p = 0.011) but not of deficit in lung function.

CONCLUSIONS

CAP requiring admission to hospital is associated with deficits in lung function and persistent respiratory symptoms. This has implications for follow-up for which recommendations are currently lacking. Parental atopy may be a determinant of outcome.

Special article: chronic granulomatous disease in the United Kingdom and Ireland: a comprehensive national patient-based registry

There are no epidemiological studies from the British Isles of chronic granulomatous disease, characterized by recurrent, life-threatening bacterial and fungal infections and inflammatory sequelae. Patients were enrolled in a national registry and medical records were analysed. Of 94 subjects, 69 had X-linked disease, 16 had autosomal recessive disease and nine were unknown. Prevalence was 7.5/million for 1990-99 and 8.5/million for 1980-89. Suppurative adenitis, abscesses and pneumonia presented commonly. Twenty-three of 30 patients who underwent high resolution computerized tomography had chronic respiratory disease. Inflammatory sequelae included bowel stricture and urogenital tract granulomata. Growth failure was common; 75% of those measured were below the population mean. All patients received prophylactic antibiotics and 93% anti-fungal prophylaxis. Interferon gamma was used to treat infection, but rarely as prophylaxis. Despite prophylaxis, estimated survival was 88% at 10 years but 55% at age 30 years. Morbidity remains significant, severe infectious complications common. Curative treatments including stem cell transplantation should be considered for patients with frequent or serious complications.

Evaluation of the efficacy and safety of a novel formulation of metaflumizone in cats naturally infested with fleas in Europe

The efficacy and safety of a novel spot-on formulation of metaflumizone (ProMeris for Cats, Fort Dodge Animal Health, Overland Park, KS) was assessed in cats naturally infested with fleas in a multiregional, clinical field study. Sixteen veterinary clinics in Germany and eight clinics in France enrolled patients to the study. A total of 173 cats with flea infestation qualified as primary patients and were randomly allocated to one of the two treatments in a ratio of approximately 2:1 for metaflumizone (minimum dosage of 40mg/kg) or fipronil (at the recommended label rate). Clinical examinations and baseline parasite counts were performed on Day 0 prior to treatment. Flea counts and safety evaluations were repeated at approximately 2-week intervals for 8 weeks. Both treatments resulted in consistent reductions (>84%) in flea numbers throughout the study, but metaflumizone resulted in numerically higher reductions on most count days. Within groups the flea reduction was highly significant (p<0.0001) compared to baseline at all observation periods. The efficacy of metaflumizone against fleas compared to baseline was 91.0%, 89.4%, 90.8% and 90.7% at Day 14, 28, 42 and 56, respectively. The corresponding efficacies for fipronil were 91.7%, 86.9%, 84.6% and 87.7%. Metaflumizone was highly effective in controlling existing infestations of fleas on cats and was effective against reinfestation for at least 56 days. Metaflumizone showed a good tolerance profile in cats.

Epidemiology of community-acquired pneumonia in children seen in hospital

There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0-15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14.4 (95% CI 13.4-15.4)/10,000 children per year and 33.8 (95% CI 31.1-36.7) for <5-year-olds; with an incidence for admission to hospital of 12.2 (95% CI 11.3-13.2) and 28.7 (95% CI 26.2-31.4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16.1 (95% CI 14.9-17.3) and 41.0 (95% CI 37.7-44.5) in the 0-4 years age group, whilst incidence for hospital admission was 13.5 (95% CI 12.4-14.6) and 32 (95% CI 29.1-35.1) respectively. In the <5 years age group incidence of lobar pneumonia was 5.6 (95% CI 4.5-6.8)/10,000 per year and severe disease 19.4 (95% CI 17.4-21.7)/10,000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1.50, 95% CI 1.07-2.11) and with prematurity, OR 4.02 (95% CI 1.16-13.85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.

Evidence of an environmental contribution to the aetiology of cryptorchidism and hypospadias?

OBJECTIVES

Evidence suggests that there is geographical variation in the birth prevalence of both cryptorchidism and hypospadias. The aim was to determine if there is evidence of spatial heterogeneity in the prevalence of these conditions and to test the hypothesis that environmental factors may contribute to aetiology.

METHODS

A population-based dataset of cryptorchidism and hypospadias cases was constructed from the hospital episodes statistics that covered the Northern Region of England and assigned to a small area based on the residential address at time of admission. Expected numbers of cases for each small area were computed. The ratio of observed to expected cases was determined for each small area and analysed with respect to both geographical heterogeneity and small area level socio-economic deprivation. The Potthoff-Whittinghill method was used to determine if there was localized spatial clustering of cases.

RESULTS

There was statistically significant spatial clustering for cases of both cryptorchidism [estimated Extra-Poisson Variation (EPV) = 0.14; 95% CI, 0.03-0.25] and hypospadias (EPV = 0.17; 95% CI, 0.05-0.28). In addition, increased prevalence was associated with lower levels of deprivation for hypospadias (P = 0.06), but there was no such relationship for cryptorchidism (P = 0.61).

CONCLUSIONS

The finding of localized spatial heterogeneity in the prevalence of cryptorchidism and hypospadias is consistent with the involvement of a spatially varying environmental risk factor. The apparent social patterning of hypospadias is likely to reflect an association with lifestyle and other factors which underpin social variation in health. However, there also remains a possibility that these findings may be due to variability in ascertainment of cases.

Birth prevalence of cryptorchidism and hypospadias in northern England, 1993-2000

AIM

There is much debate as to whether the prevalence rates of cryptorchidism and hypospadias are increasing. To address this issue we investigated the birth prevalence of cryptorchidism and hypospadias in the northern region of England during the period 1993-2000.

METHODS

Cases of cryptorchidism and hypospadias were identified from northern region hospital episodes statistics (HES). Trends in birth prevalence, based on the number of male live births, were assessed using linear regression.

RESULTS

Prevalence was 7.6 per 1000 male live births for cryptorchidism and 3.1 per 1000 male live births for hypospadias. The orchidopexy rates for 0-4 year olds and 5-14 year olds were 1.8 and 0.8 per 1000 male population, respectively. The rates for hypospadias repair for 0-4 year olds and 5-14 year olds were 0.6 and 0.1 per 1000 male population, respectively. There was a statistically significant decreasing temporal trend for the corrective procedure in cryptorchidism of 0.1 per 1000 male population aged under 5 years per annum (95% confidence interval: -0.01 to -0.05, p<0.001), but no temporal change for the corrective procedure in hypospadias (p = 0.60).

CONCLUSION

HES data were of high quality for the study period. There was no significant change in the prevalence of surgically corrected hypospadias. However, there was an apparent decline in the prevalence of surgically corrected cryptorchidism that may reflect a decrease in the prevalence of the condition or may be due to a decrease in the rate of surgical intervention.

Relationship between vaccine vial monitors and cold chain infrastructure in a rural district of India

INTRODUCTION

The potency of oral polio vaccine (OPV), a heat-labile vaccine, is preserved by the cold chain. The Vaccine Vial Monitor, a heat-sensitive label, is critical to the monitoring and maintenance of the cold chain. This study was conducted to evaluate the relationship between the adequacy of cold chain infrastructure and the proper use of Vaccine Vial Monitor in a rural district of India.

METHODS

Forty-six health centers in a rural district were included in our evaluation of the cold chain equipment and the Vaccine Vial Monitors. Cold chain equipment and vaccine vials within each health center were evaluated for adherence to WHO cold chain maintenance protocols and the Vaccine Vial Monitor stage, respectively.

RESULTS

Among the 46 health centers, Vaccine Vial Monitor stage I was found at 58% of the health centers, 33% of the health centers reported stage II and 9% reported a stage III, indicating weaknesses in the cold chain mechanism

CONCLUSION

Cold chain for the OPV was not adequately maintained at primary and sub-health centers in this rural district. Well maintained ice packs and vaccine carriers will help ensure delivery and availability of a safe and potent vaccine to children in rural areas of India.

Space-time clustering analyses of testicular cancer amongst 15-24-year-olds in Northern England

There has been speculation that environmental exposures may be involved in the aetiology of testicular cancer in adolescent boys and young men. Indirect evidence for this hypothesis would be provided by the finding of space-time clustering. To examine this we have looked for evidence of space-time clustering using data from a population-based cancer registry from Northern England. All cases of testicular cancer diagnosed in males aged 15-24 years during the period 1968-2002 were included in the study. Tests for space-time interactions between cases were applied with fixed thresholds of close in space and close in time. Addresses at birth and diagnosis were used in the analyses. To adjust for the effect of varying population density tests were repeated replacing fixed geographical distances with nearest neighbour thresholds. A total of 257 cases of testicular cancer were identified for analysis. Overall there was no evidence for space-time clustering. However, there was statistically significant space-time clustering for 15-19-year-old based on time of birth and place of diagnosis (p<0.001). The very limited finding of space-time clustering may provide tentative evidence for an environmental, or infectious component to aetiology. However, it may well be a chance finding. A larger study based on national data is required.

How do factors at different stages of the lifecourse contribute to oral-health-related quality of life in middle age for men and women?

The relative contributions of factors operating in fetal life, childhood, and adulthood to the risk of disease in middle age have become important research issues, but self-perceived oral health has rarely been considered in this context. This study investigated the impact of risk factors operating throughout life on self-perceived oral health, according to the Oral Health Impact Profile (OHIP), at age 50 yrs in 305 individuals from the Newcastle Thousand Families cohort. Factors from early and adult life contributed to the OHIP scores, but in men, self-perceived oral health was mostly explained by factors operating early in life. In women, the number of teeth retained in adulthood had a more prominent impact. Lifecourse influences on oral-health-related quality of life appear different for men and women, which may have implications for the effectiveness of public health interventions and health promotion.

Childhood IQ and deaths up to middle age: The Newcastle Thousand Families Study

OBJECTIVES

To test the hypothesis that an association exists between childhood IQ (at age 11) and mortality up to middle age.

STUDY DESIGN

The Newcastle Thousand Families study, a prospectively followed cohort, originally consisted of all 1142 births in the city of Newcastle in May and June 1947. Using data on 717 members of this cohort, we investigated the associations between the results of tests of IQ and English and arithmetic ability at age 11 years and mortality up to the end of 2003 using Cox's proportional hazards models.

RESULTS

Childhood IQ was significantly related to mortality in men (hazard ratio 0.57 for a standard deviation change in IQ at age 11; 95% CI 0.37, 0.86; P=0.007), but not in women (hazard ratio 0.79; 95% CI 0.49, 1.27; P=0.33). Adjustment for social class at birth had little effect on the associations. Similar results were seen when using the English and arithmetic scores.

CONCLUSIONS

These results confirm a recently reported association between individual differences in childhood cognition and mortality up to middle age, independent of childhood socio-economic circumstances. It is possible that the link between IQ and mortality is in part mediated through later life choices. Further research is required to identify the mechanisms by which such an association may occur, and to provide input to health promotion and disease management strategies that may improve health throughout life.

Phase I trial of liposomal doxorubicin and ZD 1839 in patients with refractory gynecological malignancies or metastatic breast cancer

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Background: Liposomal Doxorubicin has activity in both breast and ovarian cancer. Preclinical data reported by several investigators have suggested that ZD1839 acts synergistically with chemotherapy in ovarian cancer cells expressing high levels of EGFR. Given the lack of cross resistance and the different targets for these agents a Phase I trial was initiated examining the safety and the efficacy of the combination of Liposomal Doxorubicin and ZD1839. Methods: Dose limiting toxicity was defined within the first two cycles of treatment. The dose escalation schema was described as such: Results: As of January 2006, 23 patients have been enrolled in this study (GYN = 6; Breast 17). Six patients were enrolled in dose level 1 and no DLTs were observed. Dose level 2 enrolled six patients. One DLT was observed (febrile neutropenia). As defined by protocol an additional 6 patients were accrued to dose level 2. Accrual to dose level 3 began on 11/2005. One patient has completed 2 cycles and no additional DLTs have been noted. MTD has not yet been reached. SAEs have included mental status changes, and two CNS bleeds (believed most likely to be unrelated to study drug combination). Toxicities noted in cycle 3 and above have been mild with the exception of 2 grade 3 and 2 grade 4 toxicities related to skin and GI toxicity. No cardiac toxicity was observed. Doxil dose modifications (cycle 3 +) occurred in 7 patients. Best response to therapy has included 2 PRs and 10 patients with SD. Eleven patients to date have had progressive disease. The trial continues to accrue. Correlative studies including EGFR expression and CECs and PKs (at MTD) are planned. Conclusion: Liposomal Doxorubicin in conjunction with ZD1839 is tolerable regimen in patients with advanced breast and ovarian cancer. To date MTD has not been reached.

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Control of acute toxicity with amifostine and pelvic chemoradiotherapy

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Background: Amifostine is an FDA approved normal tissue radioprotector for head and neck carcinoma. Several studies have also demonstrated a radioprotective role in pelvic malignancies. However, literature also shows that amifostine has substantial toxicity. We examined patient compliance with combined chemoradiotherapy and daily amifostine subcutaneous injections, the incidence of acute toxicity, and the efficacy of interventions. Methods: Patients undergoing pelvic radiotherapy and concurrent chemotherapy were eligible. Patients received daily subcutaneous injections of 500 mg amifostine 30 to 60 minutes before radiotherapy. Injection pain, erythema, and rash were recorded daily, as was patient blood pressure before and after receiving amifostine and radiotherapy. Treating physicians evaluated patients at least weekly. Symptoms were recorded and graded using the NCI Common Toxicity Criteria. The protocol was amended early in accrual to include nausea prophylaxis guidelines. Results: Nineteen patients have been entered into this study. Fourteen had cervix cancer, four had rectal cancer, and one had anal cancer. Four patients (21%) received <1 week of amifostine. Seven (37%) received <50% of their planned injections. Fifty three percent received >80% of their injections, while 32% received the full course of amifostine. Of those that prematurely discontinued amifostine, 1 withdrew before receiving any injections, 1 transferred to another facility, 6 withdrew because of nausea, 2 secondary to rash, 2 secondary to injection pain. One developed paresthesias. Of those that withdrew because of nausea, all but one received >50% of the planned injections. Twenty six percent experienced grade 3 nausea. When comparing patients that did not receive nausea prophylaxis with those that did, grade two or three nausea dropped from 100% to 29%. No patients developed grade 3 rash. Two patients experienced hypotension. Nine patients (47%) complained of injection site pain. Conclusions: Subcutaneous amifostine is reasonably well tolerated when used with pelvic radiotherapy. Nausea was a significant side effect seen in this study. Assuring adequate hydration and use of prophylactic antiemetic medication significantly decreased nausea.

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Space-time clustering analyses of type 1 diabetes among 0- to 29-year-olds in Yorkshire, UK

AIMS/HYPOTHESIS

Infections have been suggested to play a role in the aetiology of type 1 diabetes. The presence of space-time clustering is consistent with the notion of an environmental component in disease aetiology, possibly linked to infections. We tested for evidence of space-time clustering among children and young adults under 30 years of age using data from a population-based register in Yorkshire, UK.

SUBJECTS AND METHODS

Two data sets of children and young people diagnosed with type 1 diabetes were analysed: (1) children aged 0-14 years and resident in Yorkshire during 1978-2002; (2) those aged 15-29 years and resident in West Yorkshire during 1991-2002. Tests for space-time interactions between cases were applied. Addresses at diagnosis were geo-coded and used as the basis for the analyses.

RESULTS

The study analysed 3,019 type 1 diabetic patients in the 0-14 years age group and 989 patients in the 15-29 years group. Statistically significant space-time clustering based on place and time of diagnosis was detected both for the 10-14-year-olds (p=0.04) and for the 15-19-year-olds (p=0.01).

CONCLUSIONS/INTERPRETATION

Previous studies of clustering of type 1 diabetes have generally been restricted to childhood. Our results from a data set that includes teenagers and young adults show that space-time clustering was limited to young people aged 10-19 years. This finding is consistent with an aetiology involving late exposure to infection. However, the question of whether this is directly diabetogenic or unmasks latent diabetes cannot be addressed by this methodology.

Obstructive sleep apnoea syndrome in morbidly obese children with tibia vara

Morbid obesity and its association with obstructive sleep apnoea syndrome have been increasingly recognised in children. Orthopaedic surgeons are often the primary medical contact for older children with tibia vara, which has long been associated with obesity, but are unfamiliar with the evaluation and treatment of sleep apnoea in children. We reviewed all children with tibia vara treated surgically at one of our institutions over a period of five years. Thirty-seven patients were identified; 18 were nine years of age or older and 13 of these (72%) had morbid obesity and a history of snoring. Eleven children were diagnosed as having sleep apnoea on polysomnography. The incidence of this syndrome in the 18 children aged nine years or older with tibia vara, was 61%. All these patients required pre-operative non-invasive positive-pressure ventilation; tonsillectomy and adenoidectomy were necessary in five (45%). No peri-operative complications related to the airway occurred. There is a high incidence of sleep apnoea in morbidly obese patients with tibia vara. These patients should be screened for snoring and, if present, should be further evaluated for sleep apnoea before corrective surgery is undertaken.

Lifecourse determinants of fasting and post-challenge glucose at age 50 years: the Newcastle Thousand Families Study

Suboptimal nutrition in early life is suggested to influence plasma glucose levels in later life. This study aimed to determine and quantify influences on plasma glucose levels at age 50. We studied 169 men and 219 women from the Newcastle Thousand Families cohort who attended for clinical examination, including measurements of fasting and 2 h post oral glucose load) at age 50. A lifecourse approach was used to estimate proportions of variance in plasma glucose levels accounted for by each stage of the lifecourse. Birth weight significantly predicted two-hour glucose levels in men (adjusted p = 0.03). Body composition was a significant predictor of both glucose measures in both genders. Interactions existed between body composition and birth weight on fasting glucose in men and two-hour glucose in women and between gender and birth weight on both outcome measures. Fetal life factors directly explained little variation in either glucose measure (< 2%). Adult lifestyle and body composition directly explained larger proportions of the variances (8-13%) for fasting and two-hour glucose than early life measures. The significant effect of birth weight on two-hour glucose seen in men provides support for the fetal origins hypothesis, although adult factors may be more important. Any effect of birth weight on later plasma glucose levels may be compounded by additional effects of adult body composition.

No consistent association between birthweight and parental risk of diabetes and cardiovascular disease

INTRODUCTION

The fetal insulin hypothesis proposes that the inverse relationship between birthweight and risk of diabetes and cardiovascular disease is partly as a result of inherited factors which influence the effect of insulin and insulin-like growth factors. It has been proposed that an inverse relationship between birthweight and parental risk of diabetes and cardiovascular disease is evidence in support of this hypothesis.

PATIENTS AND METHODS

Data from a prospective birth cohort study, followed up to age 50, was used to assess the relationship between birthweight and reported parental diabetes, hypertension, angina and stroke using logistic regression.

RESULTS

Of the 832 cohort members traced at age 50, 574 (69%) returned questionnaires that included questions on parental illness. Complete data was available for 541 (94%) of these on maternal illness and for 531 (92%) on paternal illness. Birthweight, standardized for sex and gestational age and adjusted for social class at birth, was inversely associated with maternal stroke (odds ratio = 0.75, 95% confidence intervals 0.60-0.95). There were no other statistically significant associations between birthweight and risk of parental illness.

DISCUSSION

We found little evidence of a consistent inverse relationship between birthweight and parental risk of diabetes or cardiovascular disease. This may be because of the quality of our data--which is limited by the problems of collecting robust data over two generations.

Differences in bone mineral density and geometry in men and women: the Newcastle Thousand Families Study at 50 years old

In 1947 Sir James Spence initiated the Newcastle Thousand Families study, which recruited all 1142 children born in the city between May and June that year. At the age of 50 years, 832 survivors were traced and invited to attend for measurement of bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA). The aim was to compare BMD measurements of men and women in this cohort, before and after adjustment for skeletal size. The femoral neck shaft angles (NSA) were also measured manually from the DXA scan printouts. A total of 171 men and 218 women agreed to participate. As expected men had greater bone mineral content and bone area at all sites (p<0.0001) and were taller and heavier (p<0.0001) than women. Men also had significantly higher BMD than women at all regions (p<0.0002), except at the femoral neck or lumbar spine. After correction for skeletal size and body weight, men had statistically significantly lower volumetric BMD at all sites. The measurement of NSA had good intra/interobserver errors and precision (coefficient of variations 0.79%, 1.2% and 1.2%). Men had significantly larger NSAs (mean 130 degrees , range 121-138 degrees ) than women (mean 128 degrees , range 119-137 degrees ). We conclude that there are gender differences in BMD, skeletal size and geometry in middle aged men and women, which together with the subsequent rate of bone loss, may influence fracture risk in later life.