Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research Database

OBJECTIVE

To determine whether varenicline, a recently licensed smoking cessation product, is associated with an increased risk of suicide and suicidal behaviour compared with alternative treatments bupropion and nicotine replacement therapy.

DESIGN

Cohort study nested within the General Practice Research Database.

SETTING

Primary care in the United Kingdom.

PARTICIPANTS

80,660 men and women aged 18-95 years were prescribed a new course of a smoking cessation product between 1 September 2006 and 31 May 2008; the initial drugs prescribed during follow-up were nicotine replacement products (n=63 265), varenicline (n=10 973), and bupropion (n=6422).

MAIN OUTCOME MEASURES

Primary outcomes were fatal and non-fatal self harm, secondary outcomes were suicidal thoughts and depression, all investigated with Cox's proportional hazards models.

RESULTS

There was no clear evidence that varenicline was associated with an increased risk of fatal (n=2) or non-fatal (n=166) self harm, although a twofold increased risk cannot be ruled out on the basis of the upper limit of the 95% confidence interval. Compared with nicotine replacement products, the hazard ratio for self harm among people prescribed varenicline was 1.12 (95% CI 0.67 to 1.88), and it was 1.17 (0.59 to 2.32) for people prescribed bupropion. There was no evidence that varenicline was associated with an increased risk of depression (n=2244) (hazard ratio 0.88 (0.77 to1.00)) or suicidal thoughts (n=37) (1.43 (0.53 to 3.85)).

CONCLUSION

Although a twofold increased risk of self harm with varenicline cannot be ruled out, these findings provide some reassurance concerning its association with suicidal behaviour.

Childhood dairy and calcium intake and cardiovascular mortality in adulthood: 65-year follow-up of the Boyd Orr cohort

BACKGROUND

Dairy consumption in childhood may have long-term effects on cardiovascular mortality through influencing the development of risk factors or programming effects.

OBJECTIVE

To investigate whether dairy and calcium consumption in childhood is associated with adult mortality due to coronary heart disease (CHD), stroke and all causes.

METHODS

In 1937-9, 4999 children in England and Scotland participated in a study of family food consumption, assessed from 7-day household food inventories. Cause of death was ascertained between 1948 and 2005 in 4374 traced cohort members with complete data. Per capita household intake estimates for dairy products and calcium were used as proxies for individual intake.

RESULTS

No strong evidence that a family diet in childhood high in dairy products was associated with CHD or stroke mortality was found. However, childhood calcium intake was inversely associated with stroke mortality (multivariable adjusted hazard ratio (HR) for highest versus lowest calcium group: 0.41; 95% confidence interval (CI) 0.16 to 1.05; p for trend = 0.04), but not CHD mortality. All-cause mortality was lowest in those with the highest family dairy (HR = 0.77; 95% CI 0.61 to 0.98; p for trend = 0.04) and calcium intake (HR = 0.77, 95% CI 0.60 to 0.98; p for trend = 0.05).

CONCLUSIONS

Children whose family diet in the 1930s was high in calcium were at reduced risk of death from stroke. Furthermore, childhood diets rich in dairy or calcium were associated with lower all-cause mortality in adulthood. Replication in other study populations is needed to determine whether residual confounding explains part of these findings.

Current strategies for monitoring men with localised prostate cancer lack a strong evidence base: observational longitudinal study

Background:

The UK National Institute for Health and Clinical Excellence (NICE) guidance recommends conservative management of men with ‘low-risk’ localised prostate cancer, monitoring the disease using prostate-specific antigen (PSA) kinetics and re-biopsy. However, there is little evidence of the changes in PSA level that should alert to the need for clinical re-assessment.

Methods:

This study compares the alerts resulting from PSA kinetics and a novel longitudinal reference range approach, which incorporates age-related changes, during the monitoring of 408 men with localised prostate cancer. Men were monitored by regular PSA tests over a mean of 2.9 years, recording when a man's PSA doubling time fell below 2 years, PSA velocity exceeded 2 ng ml^–1 per year, or when his upper 10% reference range was exceeded.

Results:

Prostate-specific antigen doubling time and PSA velocity alerted a high proportion of men initially but became unresponsive to changes with successive tests. Calculating doubling time using recent PSA measurements reduced the decline in response. The reference range method maintained responsiveness to changes in PSA level throughout the monitoring.

Conclusion:

The increasing unresponsiveness of PSA kinetics is a consequence of the underlying regression model. Novel methods are needed for evaluation in cohorts currently being managed by monitoring. Meanwhile, the NICE guidance should be cautious.

PTGS2-899G>C and prostate cancer risk: a population-based nested case-control study (ProtecT) and a systematic review with meta-analysis

Prostaglandin endoperoxidase synthase 2 is a key regulator of inflammation and may play a role in prostate carcinogenesis. The polymorphism, -899G>C (rs20417), alters a transcription factor-binding site and is associated with a reduced risk of colorectal adenoma. We tested the hypothesis that rs20417 may influence prostate cancer risk, using a large case-control study (n(cases)=1608, n(controls)=3058). We found no evidence that rs20417 alters prostate cancer risk (odds ratio (OR(CC & GC v GG)=1.05, 95% confidence interval (CI)=0.91-1.20). A meta-analysis of three studies also found little evidence that rs20417 alters risk (pooled OR(CC & GC v GG)=1.04, 95% CI=0.93-1.17), making it unlikely that rs20417 contributes in any major way to prostate cancer aetiology.

All-sky LIGO search for periodic gravitational waves in the early fifth-science-run data

We report on an all-sky search with the LIGO detectors for periodic gravitational waves in the frequency range 50-1100 Hz and with the frequency's time derivative in the range -5 x 10{-9}-0 Hz s{-1}. Data from the first eight months of the fifth LIGO science run (S5) have been used in this search, which is based on a semicoherent method (PowerFlux) of summing strain power. Observing no evidence of periodic gravitational radiation, we report 95% confidence-level upper limits on radiation emitted by any unknown isolated rotating neutron stars within the search range. Strain limits below 10{-24} are obtained over a 200-Hz band, and the sensitivity improvement over previous searches increases the spatial volume sampled by an average factor of about 100 over the entire search band. For a neutron star with nominal equatorial ellipticity of 10{-6}, the search is sensitive to distances as great as 500 pc.

All-sky LIGO search for periodic gravitational waves in the early fifth-science-run data

We report on an all-sky search with the LIGO detectors for periodic gravitational waves in the frequency range 50-1100 Hz and with the frequency's time derivative in the range -5 x 10{-9}-0 Hz s{-1}. Data from the first eight months of the fifth LIGO science run (S5) have been used in this search, which is based on a semicoherent method (PowerFlux) of summing strain power. Observing no evidence of periodic gravitational radiation, we report 95% confidence-level upper limits on radiation emitted by any unknown isolated rotating neutron stars within the search range. Strain limits below 10{-24} are obtained over a 200-Hz band, and the sensitivity improvement over previous searches increases the spatial volume sampled by an average factor of about 100 over the entire search band. For a neutron star with nominal equatorial ellipticity of 10{-6}, the search is sensitive to distances as great as 500 pc.

All-sky LIGO search for periodic gravitational waves in the early fifth-science-run data

We report on an all-sky search with the LIGO detectors for periodic gravitational waves in the frequency range 50-1100 Hz and with the frequency's time derivative in the range -5 x 10{-9}-0 Hz s{-1}. Data from the first eight months of the fifth LIGO science run (S5) have been used in this search, which is based on a semicoherent method (PowerFlux) of summing strain power. Observing no evidence of periodic gravitational radiation, we report 95% confidence-level upper limits on radiation emitted by any unknown isolated rotating neutron stars within the search range. Strain limits below 10{-24} are obtained over a 200-Hz band, and the sensitivity improvement over previous searches increases the spatial volume sampled by an average factor of about 100 over the entire search band. For a neutron star with nominal equatorial ellipticity of 10{-6}, the search is sensitive to distances as great as 500 pc.

All-sky LIGO search for periodic gravitational waves in the early fifth-science-run data

We report on an all-sky search with the LIGO detectors for periodic gravitational waves in the frequency range 50-1100 Hz and with the frequency's time derivative in the range -5 x 10{-9}-0 Hz s{-1}. Data from the first eight months of the fifth LIGO science run (S5) have been used in this search, which is based on a semicoherent method (PowerFlux) of summing strain power. Observing no evidence of periodic gravitational radiation, we report 95% confidence-level upper limits on radiation emitted by any unknown isolated rotating neutron stars within the search range. Strain limits below 10{-24} are obtained over a 200-Hz band, and the sensitivity improvement over previous searches increases the spatial volume sampled by an average factor of about 100 over the entire search band. For a neutron star with nominal equatorial ellipticity of 10{-6}, the search is sensitive to distances as great as 500 pc.

Mean sojourn time, overdiagnosis, and reduction in advanced stage prostate cancer due to screening with PSA: implications of sojourn time on screening

This study aimed to assess the mean sojourn time (MST) of prostate cancer, to estimate the probability of overdiagnosis, and to predict the potential reduction in advanced stage disease due to screening with PSA. The MST of prostate cancer was derived from detection rates at PSA prevalence testing in 43 842 men, aged 50–69 years, as part of the ProtecT study, from the incidence of non-screen-detected cases obtained from the English population-based cancer registry database, and from PSA sensitivity obtained from the medical literature. The relative reduction in advanced stage disease was derived from the expected and observed incidences of advanced stage prostate cancer. The age-specific MST for men aged 50–59 and 60–69 years were 11.3 and 12.6 years, respectively. Overdiagnosis estimates increased with age; 10–31% of the PSA-detected cases were estimated to be overdiagnosed. An interscreening interval of 2 years was predicted to result in 37 and 63% reduction in advanced stage disease in men 65–69 and 50–54 years, respectively. If the overdiagnosed cases were excluded, the estimated reductions were 9 and 54%, respectively. Thus, the benefit of screening in reducing advanced stage disease is limited by overdiagnosis, which is greater in older men.

Search for gravitational-wave bursts from soft gamma repeaters

We present a LIGO search for short-duration gravitational waves (GWs) associated with soft gamma ray repeater (SGR) bursts. This is the first search sensitive to neutron star f modes, usually considered the most efficient GW emitting modes. We find no evidence of GWs associated with any SGR burst in a sample consisting of the 27 Dec. 2004 giant flare from SGR 1806-20 and 190 lesser events from SGR 1806-20 and SGR 1900+14. The unprecedented sensitivity of the detectors allows us to set the most stringent limits on transient GW amplitudes published to date. We find upper limit estimates on the model-dependent isotropic GW emission energies (at a nominal distance of 10 kpc) between 3x10;{45} and 9x10;{52} erg depending on waveform type, detector antenna factors and noise characteristics at the time of the burst. These upper limits are within the theoretically predicted range of some SGR models.

The SIESTA method; developments and applicability

Recent developments in and around the SIESTA method of first-principles simulation of condensed matter are described and reviewed, with emphasis on (i) the applicability of the method for large and varied systems, (ii) efficient basis sets for the standards of accuracy of density-functional methods, (iii) new implementations, and (iv) extensions beyond ground-state calculations.

The SIESTA method; developments and applicability

Recent developments in and around the SIESTA method of first-principles simulation of condensed matter are described and reviewed, with emphasis on (i) the applicability of the method for large and varied systems, (ii) efficient basis sets for the standards of accuracy of density-functional methods, (iii) new implementations, and (iv) extensions beyond ground-state calculations.

Low risk research using routinely collected identifiable health information without informed consent: encounters with the Patient Information Advisory Group

Current UK legislation is impacting upon the feasibility and cost-effectiveness of medical record-based research aimed at benefiting the NHS and the public heath. Whereas previous commentators have focused on the Data Protection Act 1998, the Health and Social Care Act 2001 is the key legislation for public health researchers wishing to access medical records without written consent. The Act requires researchers to apply to the Patient Information Advisory Group (PIAG) for permission to access medical records without written permission. We present a case study of the work required to obtain the necessary permissions from PIAG in order to conduct a large scale public health research project. In our experience it took eight months to receive permission to access basic identifying information on individuals registered at general practices, and a decision on whether we could access clinical information in medical records without consent took 18 months. Such delays pose near insurmountable difficulties to grant funded research, and in our case 560,000pound of public and charitable money was spent on research staff while a large part of their work was prohibited until the third year of a three year grant. We conclude by arguing that many of the current problems could be avoided by returning PIAG's responsibilities to research ethics committees, and by allowing "opt-out" consent for many public health research projects.

Childhood diet and insulin-like growth factors in adulthood: 65-year follow-up of the Boyd Orr Cohort

OBJECTIVE

High levels of insulin-like growth factor-I (IGF-I) are associated with an increased cancer risk and reduce risk of diabetes and coronary heart disease. We investigated associations of diet in childhood, in particular energy intake, with the IGF system in adulthood to determine if IGF-I - disease associations could be linked to early nutrition.

DESIGN

Retrospective cohort study.

SETTING

Sixteen survey centres in England and Scotland that originally participated in the Carnegie (Boyd Orr) Survey of Diet and Health in Pre-War Britain, 1937-1939.

SUBJECTS

Seven hundred and twenty-eight participants (679 with complete data) in the Boyd Orr cohort.

METHODS

Participants were originally surveyed between 1937 and 1939 (at median age 5.8 years; inter-quartile range: 2.9-9.6) and were followed up for 65 years. Dietary exposure in childhood was assessed from 7-day household food inventories. Outcomes are expressed as regression coefficients for the change in IGF per standard deviation increased childhood nutrient or food intake, as derived from levels of household consumption.

RESULTS

In fully-adjusted models, energy-rich family diets in childhood were not associated with IGF-I (regression coefficient: 0.9 ng/ml; 95% confidence interval (CI): -1.8, 3.7), IGF-II, IGF binding proteins (IGFBP)-2 or IGFBP-3 in adulthood. IGF-I was associated inversely with childhood family-diets high in milk (-2.5 ng/ml; -5.1, 0.1; P=0.05) and positively with vegetable-rich diets (3.5 ng/ml; 0.9, 6.1; P=0.009). IGF-I was not associated with family diets rich in protein, carbohydrates, fats, calcium, meat or fruit. IGF-II, IGFBP-2 and IGFBP-3 were not related to childhood family diet.

CONCLUSIONS

This study suggests that energy-rich family diets in childhood do not program the IGF system in adulthood. As childhood diet was based on household consumption, however, measurement error may obscure individual-level diet-IGF associations. The associations of milk- and vegetable-rich family diets in childhood with IGF-I could be chance findings, but nevertheless are consistent with recent publications and warrant further investigation.

Haemoglobin A1c is not a surrogate for glucose and insulin measures for investigating the early life and childhood determinants of insulin resistance and Type 2 diabetes in healthy children. An analysis from the Avon Longitudinal Study of Parents and Children (ALSPAC)

AIMS

Research into early life and childhood determinants of insulin resistance and Type 2 diabetes are complicated by requirements for fasting blood samples and glucose tolerance tests. We investigated haemoglobin A(1c) (HbA(1c)), a marker of glycaemia measured in non-fasting blood, as an alternative.

METHODS

HbA(1c) was measured in 1645 children aged 9-11 years without diabetes from the Avon Longitudinal Study of Parents and Children. Thirty-nine children had two HbA(1c) measurements. Data on parental, child and potential confounding factors were collected prospectively from questionnaires, medical records and direct examination. Data from a shortened 30-min oral glucose tolerance test were available for 431 children at age 8 years. Body composition was measured by dual-energy X-ray absorptiometry.

RESULTS

Mean (sd) HbA(1c) was 4.91(0.29)%. HbA(1c) increased with age and was higher in boys compared with girls, non-white compared with white children, and in children with anaemia. Mean difference between repeated HbA(1c) measurements was 0.01%. HbA(1c) was weakly positively associated with fasting glucose (beta = 0.066%/mmol/l, P = 0.05), but was not associated with 30-min glucose, fasting or 30-min insulin, or homeostasis model assessment-insulin resistance. HbA(1c) was weakly inversely associated with weight sd score (beta =-0.02%/unit, P = 0.004), body mass index sd score (beta = -0.02%/unit, P = 0.002), and total body fat (beta = -0.003%/kg, P = 0.06) and lean mass (beta = -0.011%/kg, P = 0.01), but was not associated with birthweight or breastfeeding.

CONCLUSIONS

HbA(1c) is not a good marker of fasting or post-load glucose and insulin measures in healthy children, and is not a viable alternative to these measures for investigating the determinants of insulin resistance and Type 2 diabetes in children.

Remote characterization and dispersion compensation of amplified shaped femtosecond pulses using MIIPS

We report on the remote characterization and dispersion compensation (pulse compression) of femtosecond pluses using multiphoton intrapulse interference phase scan (MIIPS). The results presented here were carried out at a distance of 28.9 m from the target. The method could be used with targets placed kilometers away. The amplified pulses arrive at the remote target within one percent of transform limit or accurately phase-shaped by user defined phase functions. From our experiment we measure the group velocity dispersion of air at 800 nm to be 20.1+/-1.5 fs(2)/m, which is in good agreement with published values. We consider this method for remote characterization and dispersion compensation to be an important step towards the development of reliable applications requiring the propagation of ultrashort pulses to remote targets.

Combined pituitary hormone deficiency (CPHD) due to a complete PROP1 deletion

OBJECTIVE

PROP1 mutations are the most common cause of genetic combined pituitary hormone deficiency (CPHD). The aim of this study was to investigate the PROP1 gene in two siblings with CPHD.

DESIGN

Pituitary function and imaging assessment and molecular analysis of PROP1.

PATIENTS

Two siblings, born to consanguineous parents, presented with GH deficiency associated with other pituitary hormone deficiencies (TSH, PRL and gonadotrophins). The male sibling also had an evolving cortisol deficiency.

METHODS

Pituitary size was evaluated by magnetic resonance imaging (MRI). PROP1 gene analysis was performed by polymerase chain reaction (PCR), automatic sequencing and Southern blotting. Amplification of sequence tag sites (STS) and the Q8N6H0 gene flanking PROP1 were performed to define the extension of PROP1 deletion.

RESULTS

MRI revealed a hypoplastic anterior pituitary in the girl at 14 years and pituitary enlargement in the boy at 18 years. The PROP1 gene failed to amplify in both siblings, whereas other genes were amplified. Southern blotting analysis revealed the PROP1 band in the controls and confirmed complete PROP1 deletion in both siblings. The extension of the deletion was 18.4 kb. The region flanking PROP1 contains several Alu core sequences that might have facilitated stem-loop-mediated excision of PROP1.

CONCLUSIONS

We report here a complete deletion of PROP1 in two siblings with CPHD phenotype.

Neuropathology of fragile X-associated tremor/ataxia syndrome (FXTAS)

Fragile X-associated tremor/ataxia syndrome (FXTAS) is an adult-onset neurodegenerative disorder that affects carriers, principally males, of premutation alleles (55-200 CGG repeats) of the fragile X mental retardation 1 (FMR1) gene. Clinical features of FXTAS include progressive intention tremor and gait ataxia, accompanied by characteristic white matter abnormalities on MRI. The neuropathological hallmark of FXTAS is an intranuclear inclusion, present in both neurons and astrocytes throughout the CNS. Prior to the current work, the nature of the associations between inclusion loads and molecular measures (e.g. CGG repeat) was not defined. Post-mortem brain and spinal cord tissue has been examined for gross and microscopic pathology in a series of 11 FXTAS cases (males, age 67-87 years at the time of death). Quantitative counts of inclusion numbers were performed in various brain regions in both neurons and astrocytes. Inclusion counts were compared with specific molecular (CGG repeat, FMR1 mRNA level) and clinical (age of onset, age of death) parameters. In the current series, the three most prominent neuropathological characteristics are (i) significant cerebral and cerebellar white matter disease, (ii) associated astrocytic pathology with dramatically enlarged inclusion-bearing astrocytes prominent in cerebral white matter and (iii) the presence of intranuclear inclusions in both brain and spinal cord. The pattern of white matter pathology is distinct from that associated with hypertensive vascular disease and other diseases of white matter. Spongiosis was present in the middle cerebellar peduncles in seven of the eight cases in which those tissues were available for study. There is inclusion formation in cranial nerve nucleus XII and in autonomic neurons of the spinal cord. The most striking finding is the highly significant association between the number of CGG repeats and the numbers of intranuclear inclusions in both neurons and astrocytes, indicating that the CGG repeat is a powerful predictor of neurological involvement in males, both clinically (age of death) and neuropathologically (number of inclusions).

Prostate cancer: screening approaches

Introducing screening for prostate cancer requires evidence that this would do more good than harm. Current evidence about the impact and natural history of prostate cancer, screening and diagnostic tests, and the effectiveness of treatments is reviewed below.

Did knowledge, opinions, background, and health authority advice influence early prescribing of the novel Alzheimer's disease drug donepezil in general practice?--national postal survey

BACKGROUND

Donepezil was licensed in the UK in February 1997 for the treatment of Alzheimer's disease.

AIMS

To determine the advice from health authorities about prescribing Alzheimer's disease drugs. To determine whether the first general practitioners who prescribed donepezil in England differed from non-prescribers in terms of knowledge, opinions, background, and the prescribing-advice issued by their health authority.

METHODS

National postal survey of pharmaceutical advisors. Structured postal survey of all general practitioners in England who prescribed donepezil to two or more patients within the first 6 months of launch, compared with a random sample of non-prescribers.

RESULTS

Pharmaceutical advisors' survey: 75/100 pharmaceutical advisors responded, of whom 83% indicated that general practitioners should not initiate prescribing of Alzheimer's disease drugs and 63% said that they should not prescribe, even under shared care arrangements. General practitioner survey: 311/473 (66%) prescribers and 484/947 (51%) non-prescribers responded after two mailings. Prescribers were similar to non-prescribers in terms of demographic and practice characteristics, knowledge about Alzheimer's disease, diagnostic and initial management strategies, and the prescribing advice from health authorities. Prescribers were significantly more likely than non-prescribers to strongly agree/agree that new drugs should be prescribed for mild (p=0.0008) and moderate (p=0.003) Alzheimer's disease, that they should normally be initiated (p=0.003) and monitored by a general practitioner (p<0.0001), and that financial constraints should not be a consideration (p=0.0001).

CONCLUSION

Early prescribers differed from non-prescribers in their opinions about using Alzheimer's disease drugs. Future research should examine methods to promote nationally equitable and rational prescribing of new drugs.

Prevalence of Churg-Strauss syndrome, vasculitis, eosinophilia and associated conditions: retrospective analysis of 58 prescription-event monitoring cohort studies

PURPOSE

Churg-Strauss syndrome is characterised by hypereosinophilia, systemic vasculitis and asthma. The cause is usually unknown, but there have been reports of an association with particular drugs, including anti-asthma drugs. Our aim was to estimate the prevalence of Churg-Strauss syndrome and related conditions in post-marketing safety studies of new anti-asthma drugs.

METHODS

We accessed the prescription-event monitoring (PEM) database of the Drug Safety Research Unit (DSRU). This database currently has information on 622 294 patients observed during 58 completed PEM studies of individual drugs, including 35 799 patients in studies of new anti-asthma drugs.

RESULTS

Overall, four cases of Churg-Strauss syndrome were identified during these studies, giving a period prevalence rate of 6.8 (95% confidence limits [CL]: 1.8-17.3) per million patient-years of observation. The period prevalence of Churg-Strauss syndrome was significantly greater in the PEM cohorts of anti-asthma drugs (64.4 million patient-years of observation; 95% CL: 13.3-188.1), than the other PEM drug cohorts (1.8 per million patient-years of observation; 95% CL: 0.05-10.2) (rate ratio: 35.1; 95% CL: 2.8-1839.9; p=0.002).

CONCLUSION

Our data provide estimates of the prevalence of Churg-Strauss syndrome and related conditions in cohorts of asthmatic patients, which may be useful during the pharmacovigilance of new asthma drugs, including the new leukotriene receptor antagonists.