Synaptic activity, induced rhythmic discharge patterns, and receptor subtypes in enriched primary cultures of embryonic rat motoneurones

Long-term cultures of ventral horn neurones from embryonic rat spinal cord were established, after enrichment using density gradient centrifugation, to give a high proportion of cells (> 82%) with motoneurone characteristics. Neurones were grown on spinal cord glial monolayers for 4-83 days and investigated using whole-cell patch clamp. Synaptic activity interrupted by periods of quiescence increased in frequency with culture age and was suppressed by 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and strychnine. However, strychnine (10 microM) or bicuculline (10-30 microM) or removal of Mg2+ alone induced patterned rhythmic bursting. Glutamate (3-300 microM), alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA, 0.3-30 microM), and kainate (1-300 microM) evoked inward currents, as did N-methyl-D-aspartic acid (NMDA, 100 microM) in the absence of Mg2+ and presence of glycine (3-10 microM). Inward currents carried by Cl- were elicited by glycine (10-300 microM) and GABA (1-300 microM), while adenosine (1-10 microM) and cyclopentyladenosine (10 nM-1 microM) evoked a K(+)-dependent hyperpolarization. 5-HT, GABAB, purine A, and metabotropic glutamate receptors modulated synaptic excitation of presumed motoneurones. The results suggest that long-term cultures, containing more than 82% developing motoneurones, are able to generate rhythmic bursting; they respond to many of the neurotransmitters that are likely to be released onto motoneurones developing in vivo.

Assessment of the reproducibility of clinical coding in routinely collected hospital activity data: a study in two hospitals

BACKGROUND

The aim of the study was to assess the reproducibility of clinical coding in two National Health Service hospitals within North West Thames region.

METHODS

A retrospective audit was carried out, of clinical coding in hospital episode statistics, involving comparison of the codes assigned by local staff with those assigned by members of an external team unaware of the locally assigned codes. Where local and external coders disagreed, the records were reviewed for a third time by a further independent coder. The subjects were a random sample of 1607 non-maternity, non-psychiatric admissions occurring between 1991 and 1993, stratified for year and type of disease (asthma, diabetes, appendicitis, fractured femur and 'general'--a random selection of any diagnoses). The main outcome measures were the levels of exact agreement between local and external teams over codes for main diagnosis and procedure, and the level of approximate agreement (over the first three characters of the ICD-9 code for diagnosis and the letter and first two digits of the OPCS-4 code for procedure). For disagreements, the outcome measure was the level of agreement between the 'third' coder and the local and external coders.

RESULTS

For the main diagnosis in the 'general' group at hospital A, internal and external coders agreed exactly in 43 per cent of the admissions examined and agreed 'approximately' in 55 per cent (kappa = 0.54). For hospital B the corresponding figures were 60 per cent and 72 per cent (kappa = 0.72). Approximate agreement was higher for the specific diseases considered, particularly for asthma (A: 86 per cent; B: 91 per cent) and fractured femur (A: 84 per cent; B: 89 per cent). For the main procedure at hospital A, there was exact agreement for 58 per cent and approximate agreement for 70 per cent (kappa = 0.66). For hospital B, the corresponding figures were 76 per cent and 83 per cent (kappa = 0.80). In cases of disagreement over the first three digits of the ICD-9 code for main diagnosis, the third coder disagreed with both local and external coders in 53 per cent at hospital A and 38 per cent at hospital B. Agreement was slightly better for discharges in 1992-1993 than in 1991-1992.

CONCLUSIONS

The full clinical codes in NHS hospital episode statistics (HES) data should be treated with caution. The first three characters of ICD-9 codes for diagnoses and the OPCS-4 codes for procedures were more reliable. For some specific conditions such as asthma and fractured femur, reliability of the first three characters is much higher (for example, 86 per cent and 91 per cent for asthma in the two hospitals), but for the full codes can be worse. Secondary diagnoses or comorbidities may be significantly undercoded. A higher level of agreement in 1992-1993 than in 1991-1992 suggests that coding may be improving.

Estimating the incidence rate ratio in cross-sectional studies using a simple alternative to logistic regression

PURPOSE

Logistic regression is often used for the analysis of cross-sectional studies, and prevalence odds and odds ratios are obtained. Other methods have been proposed for estimating prevalence ratios. An alternative regression method is also available for estimating rate ratios. Its application to cross-sectional studies is discussed.

METHODS

When dealing with chronic conditions, it is possible to model binomial data using the complementary log-log link function log(-log(1-pi)), where pi is the prevalence, an option available on many statistical software packages. In effect, these are models for the disease incidence rate lambda, which is assumed to be constant over the underlying follow-up period t. This approach is based on the well-known relationship 1-pi-exp(-lambda t). The cumulative effect of age on prevalence (effectively "time of follow up") can be accounted for in the model, by specifying it as an offset.

RESULTS

The regression coefficients associated with the covariates included in the model estimate rate ratios, rather than odds or prevalence ratios. The method is applied to the analysis of the prevalence of respiratory symptoms in 4395 children aged 7-9 years who are residents of Huddersfield (northern England), surveyed in the framework of the SAVIAH (Small Area Variations of Air Quality and Health) study.

CONCLUSIONS

By considering saturated models including only sex as a covariate, direct comparison of crude and fitted parameters (odds, prevalence, and rate ratios) shows that, for short follow-up periods, the complementary log-log model is a valid alternative to logistic regression. More complex models including other covariates are also discussed.

Syncope and ventricular arrhythmias in hypertrophic cardiomyopathy are not related to the derangement of coronary microvascular function

Non-sustained ventricular tachycardia on Holter and syncope have been considered risk factors for sudden death in hypertrophic cardiomyopathy.

AIMS

In these patients the coronary vasodilator reserve is impaired despite normal coronaries, so we evaluated the correlation between the severity of coronary vasodilator reserve impairment and the occurrence of syncope and non-sustained ventricular tachycardia.

METHODS AND RESULTS

Eighty-four patients with hypertrophic cardiomyopathy (62 males, age 43 +/- 12 years) had a two-dimensional echocardiographic study and a 48-h Holter. Myocardial blood flow was measured by positron emission tomography, at baseline and after dipyridamole, and the coronary vasodilator reserve was computed as dipyridamole myocardial blood flow/baseline myocardial blood flow. In 27 patients, subendocardial and subepicardial myocardial blood flow was measured in the septum and the subendocardial/subepicardial ratio was computed. Twenty of 84 patients had at least one syncopal episode, and 26 had at least one run of non-sustained ventricular tachycardia on Holter. Baseline and dipyridamole myocardial blood flow, coronary vasodilator reserve, and baseline and dipyridamole subendocardial/subepicardial myocardial blood flow ratio were similar in patients with and without syncope and with and without non-sustained ventricular tachycardia on Holter. However, patients with non-sustained ventricular tachycardia had larger left ventricular end-diastolic (47 +/- 6 vs 44 +/- 5 mm, P < 0.05) and end-systolic diameters (30 +/- 6 vs 27 +/- 4 mm, P < 0.05).

CONCLUSIONS

(1) Coronary vasodilation is not more severely impaired in patients with hypertrophic cardiomyopathy and syncope or non-sustained ventricular tachycardia. (2) The left ventricle is more dilated in hypertrophic cardiomyopathy with non-sustained ventricular tachycardia.

Factor V Leiden and thermolabile methylenetetrahydrofolate reductase in extreme old age

Both factor V Leiden and the C677T methylenetetrahydrofolate reductase (MTHFR) gene mutation are associated with premature vascular disease, and yet are found at surprisingly high allele frequencies in European populations, 2.7% and 35% respectively. We have investigated the prevalence of these mutations in 87 UK residents over the age of ninety, to look for any evidence of their association with premature death. Five factor V Leiden heterozygotes were found, giving an allele frequency of 2.9%, similar to that in the general UK population. The frequency of the thermolabile C677T MTHFR mutation was 36% with 11% homozygotes, again similar to that in the UK population; these genotypes are in Hardy-Weinberg equilibrium, suggesting that there is not strong selection against the homozygous state. One person was both heterozygous for factor V Leiden and homozygous for the C677T mutation. This study suggests that neither factor V Leiden nor thermolabile MTHFR are risk factors for premature death.

Ecological and individual predictors of birthweight in a northern Finland birth cohort 1986

This multilevel study of spatial variability in, and determinants of, birthweight was conducted using individual and ecological data in a geographically defined prospective birth cohort for 1986 in northern Finland. The study area comprises three large areas defined by latitude: Northern Lapland (NL), Southern Lapland (SL) and Oulu province (OP), comprising 74 localities with a total study population of 9216 singleton births. The mean birthweight was 3482 g for NL, 3537 g for SL and 3587 g for OP (NL vs. OP and SL vs. OP: P < 0.05). The crude rate for stillbirths was highest in NL. The women in the northernmost area were socially less privileged and the localities less prosperous compared with those in the southernmost area. Significant spatial clustering of mean birthweights was found (P = 0.0016), with highest birthweight in the south-western part of the study area. A variable expressing the wealth of each locality, the financial capacity category (FCC), had its lowest mean value in NL, with a range of one to six for the localities studied here. A multilevel multiple regression model showed that, after allowing for sex, gestational age, mother's age, height and hypertensive disorders, parity, body mass index, previous low birthweight child and smoking as individual determinants of birthweight, part of the residual variation could be explained by the locality wealth parameter. Using the multilevel model, the differences in mean birthweight across the three latitude areas persisted but were reduced (difference OP vs. NL reduced from 105 g to 86.5 g). The relationship between birthweight and FCC was inverse U-shaped with the highest mean birthweight estimated for localities occurring in the middle of the range (FCC = 3). The wealthiest urban localities (FCC = 6) and the most deprived localities (FCC = 1) both had a predicted birthweight about 60 g below the maximum at FCC = 3, if all other factors were held constant. This result, taken together with the spatial clustering of birthweights, suggests that there may be important social and environmental determinants of birthweight that have yet to be identified.

Vitamin C and blood pressure--an overview

BACKGROUND

Laboratory and some epidemiological studies suggest that antioxidants, such as vitamin C, are protective for cardiovascular disease. This protective effect may be mediated through blood pressure (BP). This is the first systematic review of epidemiological studies of vitamin C and BP.

METHOD

Published cross-sectional studies, prospective studies and trials in humans were identified that examined the association between vitamin C intake or plasma vitamin C levels and BP. Relevant references were located by MEDLINE search 1966-1996, EMBASE search 1980-1996, by searching personal bibliographies, books and reviews and from citations in located articles.

RESULTS

Cross-sectional data were available from 18 populations. Ten of 14 reported an inverse association between plasma vitamin C and BP and three of four reported an inverse association with vitamin C intake. The two non-randomised and four randomised controlled trials were all small. Of the randomised trials one reported a significant decrease in BP, one a non-significant decrease and two were uninterpretable.

CONCLUSIONS

We found a consistent cross-sectional association between higher vitamin C intake or status and lower BP, though no study controlled adequately for confounding by other dietary factors. Further cross-sectional studies are required to establish whether an independent association exists. If this is shown to be the case larger and longer term trials will be needed to confirm the association is causal. Potentially the impact on cardiovascular disease of a modest change in mean population vitamin C intake is large.

Trends in stroke mortality in Greater London and south east England--evidence for a cohort effect?

OBJECTIVE AND SETTING

To examine time trends in stroke mortality in Greater London compared with the surrounding South East Region of England.

DESIGN

Age-cohort analysis based on routine mortality data.

SUBJECTS

Resident population aged 45 years or more.

MAIN OUTCOME MEASURE

Age specific stroke mortality rates, 1951-92.

MAIN RESULTS

In 1951, stroke mortality was lower in Greater London than the surrounding South East Region in all age bands over 45. It has been declining in both areas but the rate of decline has been significantly slower in Greater London (p < 0.0001). The differences in rates of decline were such that stroke mortality is now higher in Greater London for people under 75. The crossover of age specific stroke mortality rates occurred at different periods in different age bands and is consistent with a cohort effect, with similar rates in Greater London and the surrounding south east for men and women born around 1916-21. This cohort effect does not appear to be consistent with past maternal and neonatal mortality rates in these areas, nor, within the limitations of the data, with the ethnic composition of cohorts.

CONCLUSIONS

There seems to be a cohort effect on stroke mortality which is not explained by past maternal and neonatal mortality. If the decline in stroke mortality continues at its current rate, the Health of the Nation stroke target is unlikely to be achieved in Greater London.

High-dose-rate brachytherapy in the management of high-grade intraepithelial neoplasia of the vagina

The majority of women with high-grade intraepithelial neoplasia (VAIN 3) are over 60 years of age and have a history of premalignant or malignant disease of the cervix. Although the natural history of VAIN is not well defined, high-grade lesions are premalignant. Ablative treatment with laser or 5-fluorouracil cream is commonly unsatisfactory. Several series have reported a low rate of recurrence and complications if VAIN 3 is treated with low-dose-rate brachytherapy. This retrospective review reports the outcome of 14 patients treated with high-dose-rate brachytherapy, with a dose of 34 to 45 Gy in 4.5- to 8.5-Gy fractions. Treatment was well tolerated with no severe early or late toxicity observed. At a median follow-up of 46 months 1 patient progressed to invasive carcinoma of the vagina; in another patient VAIN 3 persisted.

Urinary biochemical markers of dietary intake in the INTERSALT study

The INTERSALT Study, an international, collaborative, cross-sectional investigation of the relation between blood pressure and dietary and other factors, used quality-controlled, standardized procedures and assessment of multiple possible confounding factors to study 10,079 men and women in 52 population-based samples in 32 countries. In this study 24-h urinary excretion data were used as biochemical markers of intakes of sodium, potassium, and protein, with repeat examinations done in a randomly selected 8% of participants to asses reliability and correct for regression-dilution bias. INTERSALT showed that high salt intake, low potassium intake, excess alcohol consumption, and energy imbalance resulting in overweight are critically involved in the origins of the high blood pressure prevalent among a majority of adult populations. The findings also show that obtaining accurate estimates of associations between dietary intake and blood pressure requires large population-based samples, high-quality dietary information, control for multiple confounding variables, and modern multivariate methods of data analyses, including correction of observed associations for within-person variation in intake.

Socioeconomic deprivation, ethnicity, and stroke mortality in Greater London and south east England

OBJECTIVE AND SETTING

To examine geographical variation in stroke mortality in Greater London compared with the surrounding South East Region of England.

DESIGN

Cross sectional, ecological analysis based on electoral wards.

SUBJECTS

Resident population aged 45 years or more.

MAIN OUTCOME MEASURE

Age specific stroke mortality rates in five age bands, 1986-92.

MAIN OUTCOME MEASURE

Age specific stroke mortality rates in five age bands, 1986-92.

MAIN RESULTS

In the 45-54 years age band, stroke mortality rate ratios (95% confidence intervals) relative to the surrounding south east were 2.09 (1.81, 2.4) for Inner London and 1.31 (1.15, 1.5) for Outer London for men and 1.64 (1.4, 1.93) and 1.13 (0.98, 1.31) respectively for women. This gradient diminished and reversed with increasing age. In the 85+ age band, rate ratios were 0.82 (0.76, 0.89) for Inner London and 0.89 (0.84, 0.94) for Outer London for men and 0.8 (0.75, 0.85) and 0.88 (0.84, 0.92) respectively for women. Carstairs deprivation index and the percentages of Afro-Caribbean men and women and Irish born men were significantly and positively correlated with stroke mortality at the ward level. The Carstairs effect diminished with increasing age. Adjustment for these variables diminished or abolished the higher stroke mortality risks in London for younger people but had little effect on the lower risks for older Londoners.

CONCLUSIONS

Higher rates of stroke mortality among middle aged adults in Greater London, compared with the surrounding South East Region, are associated with socioeconomic deprivation and ethnicity. These factors do not explain the relatively lower stroke mortality among older Londoners.

Who are the 'low energy reporters' in the dietary and nutritional survey of British adults?

BACKGROUND

Underreportin in dietary surveys is a potential source of bias in studies of diet and disease. The aim of this study was to identify characteristics of men and women participants in the Dietary and Nutritional Survey of British Adults (DNSBA) who stated that they were neither slimming nor ill, and who reported an average energy intake over a 7-day period below 1.2 times estimated basal metabolic rate (BMR), termed here 'low energy reporters' (LER).

METHODS

In all, 2197 men and women aged 16-64 years participated in the DNSBA. Dietary intake was assessed using the 7-day weighed intake method. Their BMR was estimated using predictive equations based upon age, sex and body weight.

RESULTS

Compared with non-LER, LER had higher mean ratios of urinary urea nitrogen to dietary nitrogen and urinary potassium to dietary potassium, indicating that, as a group, LER were underreporting at least for protein and potassium intakes. Overall LER were overrepresented among the manual social classes, smokers, and self-reported non-alcohol drinkers, and were on average heavier than non-LER. There was indication of differential reporting of foods and differences in macronutrient and micronutrient densities between LER and non-LER.

CONCLUSION

These results suggest that LER may be overrepresented within specific population subgroups and that underreporting bias may not be food and nutrient neutral. This has implications for the design and interpretation of studies of diet and disease.

Cancer incidence and mortality around the Pan Britannica Industries pesticide factory, Waltham Abbey

OBJECTIVES

To examine the incidence and mortality of cancer near the Pan Britannica Industries factory, Waltham Abbey, after reports of a possible cluster of all cancers and brain cancer in the vicinity.

METHOD

Small area study of cancer incidence 1977-89, and mortality 1981-92, within a 7.5 km radius of the factory site. Postcoded cancer registrations and deaths in the study area were extracted from national data sets held by the Small Area Health Statistics Unit and compared with expected numbers computed by applying national rates stratified for age, sex, and deprivation to the local population (1981 and 1991 censuses). Observed/ expected (O/E) ratios were examined from 0-1 km and 0-7.5 km of the plant, and tests applied for a decline in relative risk with distance up to 7.5 km.

RESULTS

There were 12,859 incidence cancers (1977-89) from 0-7.5 km (O/E ratio 1.04; 95% confidence interval (95% CI) 1.02 to 1.06) and 385 from 0-1 km (O/E 1.10; 1.00 to 1.22). There was an excess of skin melanoma from 0-1 km based on 11 cases (O/E 2.13; 1.06 to 3.80), and an excess from 0-7.5 km of cancer of the lung, stomach and pancreas combined, and prostate (O/Es ranged from 1.09 to 1.13). Only the findings from lung cancer were suggestive of a decline in risk with distance, especially in the later period (1982-9). There were 9196 cancer deaths (1981-92) from 0-7.5 km (O/E 1.04; 95% CI 1.02 to 1.06) and 308 from 0-1 km (O/E 1.24; 1.11 to 1.39); and 25507 non-cancer deaths (O/E 1.02; 1.01 to 1.04) from 0-7.5 km and 745 (O/E 1.14; 1.06 to 1.22) from 0-1 km. There was evidence of a decline in mortality with distance for all cancers combined, lung cancer (P = 0.001 for each), and colorectal cancer (P < 0.05), and also for non-cancers (P = 0.001). Proportional mortality analyses suggested a decline in risk with distance for lung cancer (P = 0.003) but not for all cancers or the site specific cancers examined. There was no evidence of an excess in the incidence or mortality from brain cancer. For cancer mortality in the inner-most wards, the findings were, for the most part, well within the range of variation across the region as a whole.

CONCLUSIONS

The study provides limited and inconsistent evidence for a localised excess of cancer in the vicinity of the PBI plant. At present, further investigation does not seem warranted other than continued surveillance of mortality and cancer incidence in the locality.

Cancer incidence near radio and television transmitters in Great Britain. I. Sutton Coldfield transmitter

A small area study of cancer incidence in 1974-1986 was carried out to investigate an unconfirmed report of a "cluster" of leukemias and lymphomas near the Sutton Coldfield television (TV) and frequency modulation (FM) radio transmitter in the West Midlands, England. The study used a national database of postcoded cancer registrations, and population and socioeconomic data from the 1981 census. Selected cancers were hematopoietic and lymphatic, brain, skin, eye, male breast, female breast, lung, colorectal, stomach, prostate, and bladder. Expected numbers of cancers in small areas were calculated by indirect standardization, with stratification for a small area socioeconomic index. The study area was defined as a 10 km radius circle around the transmitter, within which 10 bands of increasing distance from the transmitter were defined as a basis for testing for a decline in risk with distance, and an inner area was arbitrarily defined for descriptive purposes as a 2 km radius circle. The risk of adult leukemia within 2 km was 1.83 (95% confidence interval 1.22-2.74), and there was a significant decline in risk with distance from the transmitter (p = 0.001). These findings appeared to be consistent over the periods 1974-1980, 1981-1986, and were probably largely independent of the initially reported cluster, which appeared to concern mainly a later period. In the context of variability of leukemia risk across census wards in the West Midlands as a whole, the Sutton Coldfield findings were unusual. A significant decline in risk with distance was also found for skin cancer, possibly related to residual socioeconomic confounding, and for bladder cancer. Study of other radio and TV transmitters in Great Britain is required to put the present results in wider context. No causal implications can be made from a single cluster investigation of this kind.

Angiosarcoma of the liver in Great Britain in proximity to vinyl chloride sites

OBJECTIVES

To study the incidence of angiosarcoma of the liver in England and Wales 1979-86 and Scotland 1975-87. To investigate whether any non-occupational neighbourhood cases occurred near a vinyl chloride site.

METHODS

This is a geographical study of incident cases among the general population of Great Britain. Diagnosis of angiosarcoma of the liver was based mainly on the national cancer registry, the world register of cases among vinyl chloride workers, and the register of cases (including histological review) maintained by the Health and Safety Executive. Proximity (< 10 km) of residence to a vinyl chloride site was based on postcode of address at the time of diagnosis.

RESULTS

55 cases were ascribed to angiosarcoma of the liver in England and Wales with a further six cases in Scotland (annual incidence in Great Britain from all sources of around 1.4 cases per 10 million population). There were two cases with documented exposure to Thorotrast, and 10 cases among vinyl chloride workers. There were no vinyl chloride sites in Scotland. Among the 25 cases in England and Wales with histological diagnosis after review by a panel of pathologists, only 15 were confirmed as angiosarcoma, and one of the two Scottish cases after histological review was also confirmed. Overall, 11 cases ascribed to angiosarcoma were resident within 10 km of a vinyl chloride site; nine were vinyl chloride workers, one further case on histological review was not considered to have been correctly diagnosed as angiosarcoma, and the remaining case, confirmed as angiosarcoma, was employed at a vinyl chloride factory during the late 1950s, although not as a vinyl chloride worker.

CONCLUSION

The incidence of angiosarcoma of the liver in Great Britain remains extremely rare. The one confirmed case in a non-vinyl chloride worker within 10 km of a site must nevertheless be presumed to have been exposed to vinyl chloride in the workplace. In the period of study, there were no confirmed non-occupationally exposed cases of angiosarcoma among residents living near a vinyl chloride site in Great Britain.

Small-area study of the incidence of neoplasms of the brain and central nervous system among adults in the West Midlands region, 1974-86. Small Area Health Statistics Unit

This small-area study of incidence of cancers of the brain and central nervous system found evidence of trend (P = 0.02) of cancer risk with deprivation (8% higher risk in affluent areas), but no significant association with urban-rural status. Results were not indicative of a strong geographically determined risk at small-area level.

Cancer incidence near radio and television transmitters in Great Britain. II. All high power transmitters

A small area study of cancer incidence, 1974-1986, near 20 high power television (TV) and frequency modulation (FM) radio transmitters in Great Britain was carried out to place in context the findings of an earlier study around the Sutton Coldfield transmitter. The national database of postcoded cancer registrations was used with population and socioeconomic data from the 1981 census. Cancers examined were adult leukemias, skin melanoma, and bladder cancer, following the findings in the earlier study of significant declines in risk of these cancers with distance from the Sutton Coldfield transmitter. Childhood leukemia and brain cancer were also examined. Statistical analysis was performed for all transmitters combined, four overlapping groups of transmitters defined by their transmission characteristics, and for all transmitters separately. There were 3,305 adult leukemia cases from 0-10 km (observed/expected (O/E) ratio = 1.03, 95% confidence interval (CI) 1.00-1.07). A decline in risk of adult leukemia was found for all transmitters combined (p = 0.05), two of the transmitter groups, and three of the single transmitters; for all transmitters combined, observed excess risk was no more than 15% at any distance up to 10 km, and there was no observed excess within 2 km of transmitters (O/E ratio = 0.97, 95% CI 0.78-1.21). For childhood leukemia and brain cancer, and adult skin melanoma and bladder cancer, results were not indicative of a decline in risk with distance from transmitters. The magnitude and pattern of risk found in the Sutton Coldfield study did not appear to be replicated. The authors conclude that the results at most give no more than very weak support to the Sutton Coldfield findings.

Cluster analysis and disease mapping--why, when, and how? A step by step guide

Growing public awareness of environmental hazards has led to an increased demand for public health authorities to investigate geographical clustering of diseases. Although such cluster analysis is nearly always ineffective in identifying causes of disease, it often has to be used to address public concern about environmental hazards. Interpreting the resulting data is not straightforward, however, and this paper presents a guide for the non-specialist. The pitfalls include the fact that cluster analyses are usually done post hoc, and not as a result of a prior hypothesis. This is particularly true for investigations prompted by reported clusters, which have the inherent danger of overestimating the disease rate through "boundary shrinkage" of the population from which the cases are assumed to have arisen. In disease surveillance the problem of making multiple comparisons can be overcome by testing for clustering and autocorrelation. When rates of disease are illustrated in disease maps undue focus on areas where random fluctuation is greatest can be minimised by smoothing techniques. Despite the fact that cluster analyses rarely prove fruitful in identifying causation, they may-like single case reports-have the potential to generate new knowledge.

Inverse relation of dietary protein markers with blood pressure. Findings for 10,020 men and women in the INTERSALT Study. INTERSALT Cooperative Research Group. INTERnational study of SALT and blood pressure

BACKGROUND

The purpose of this study was to assess relations to blood pressure (BP) in individuals of markers of dietary protein in their 24-hour urine collections.

METHODS AND RESULTS

INTERSALT (INTERnational study of SALT and blood pressure) was a cross-sectional study of 10020 men and women aged 20 to 59 years in 52 population-based samples in 32 countries worldwide, with quality-controlled standardized procedures and assessment of multiple possible confounders. Three measurements of dietary protein in 24-hour urine of each individual participant were studied: total nitrogen and urea as indexes of total protein intake, and sulfate as an index of sulfur-containing dietary amino acids. Repeat examination was performed in a random 8% of participants to assess reliability and to correct for regression-dilution bias. Significant independent inverse relationships were found between BP (systolic and diastolic) and both 24-hour urinary total nitrogen and urea nitrogen, with adjustment for age, sex, alcohol intake, body mass, and 24-hour urinary sodium, potassium, calcium, and magnesium. With adjustment for regression-dilution bias, it was estimated that systolic and diastolic BP were on average 3.0 and 2.5 mm Hg lower, respectively, for persons with dietary total protein intake 30% above the overall mean than for those whose dietary protein intake was 30% below the overall mean (12.94 versus 6.96 g/d urinary total nitrogen, equivalent to 81 versus 44 g/d dietary protein, respectively). For the association of these markers with diastolic BP, results were similar for younger (20- to 39-year-old) and older (40- to 59-year-old) persons and for women and men. For their relation to systolic BP, regression coefficients were larger both for those aged 40 to 59 years than for those aged 20 to 39 years and for women than for men. Nonsignificant inverse relations were recorded for urinary sulfate and BP.

CONCLUSIONS

These INTERSALT findings lend support to the hypothesis that higher dietary protein intake has favorable influences on BP.

Use of Stone's method in studies of disease risk around point sources of environmental pollution

The Small Area Health Statistics Unit is a national facility funded by the U.K. government for the analysis of disease risk around sources of environmental pollution. It holds cancer incidence (from 1974) and mortality data (from 1981) for Great Britain. Data retrieval is based on the postcode of residence, relating on average to 14 households. Population data for the calculation of disease rates and small area measures of socioeconomic deprivation are from census small area statistics for 1981 and 1991. Isotonic regression methods first described by Stone are used to test for declines in disease risk with distance from point sources of environmental pollution. This paper describes modifications of the method to include adjustments for socioeconomic confounding, a conditional approach to allow for generally elevated risks near the source, and methods to deal with pooling of data around a number of point sources. Examples from recent studies are given.

Empirical Bayes estimation of small area prevalence of non-rare conditions

Geographical studies are becoming increasingly common in epidemiology. The problems of small area investigations are well known, and several methods are available for the estimation and mapping of disease risk across small areas, with the emphasis mainly on applications concerning rare disease incidence or mortality. An empirical Bayes method is proposed for small area estimation of the prevalence of non-rare conditions, whose variability is binomial and cannot be approximated by a Poisson model. It is the direct equivalent of a semi-parametric non-iterative moment estimation method proposed in the Poisson case. As an example, the geographical distribution of the prevalence of respiratory symptoms in schoolchildren across 71 small areas in Huddersfield, Northern England is studied. Whereas random variability causes the crude area-specific prevalences to be unstable, the posterior estimates, corrected towards overall or local means, are capable of highlighting genuine extra-binomial variability. The method is very simple and can readily be applied to the study of a number of common conditions.

Commentary: strength and importance of the relation of dietary salt to blood pressure. Intersalt Steering and Editorial Committee

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Dietary salt, nitrate and stomach cancer mortality in 24 countries. European Cancer Prevention (ECP) and the INTERSALT Cooperative Research Group

BACKGROUND

High salt and nitrate intake are considered as risk factors for stomach cancer, but little is known about possible interactions. This ecological study examines the respective importance of both factors for stomach cancer mortality at the population level using data obtained under standardized conditions and with biochemical analyses performed in the same laboratories.

METHODS

Randomly selected 24-hour urine samples from 39 populations, sampled from 24 countries (N = 5756 people for sodium, 3303 for nitrate) were obtained from the INTERSALT study. Median sodium and nitrate levels were age- and sex-standardized between ages 20-49 years and averaged per country. Ecological correlation-regression analyses were done in relation to national stomach cancer mortality rates.

RESULTS

The Pearson correlation of stomach cancer mortality with sodium for the 24 countries was: 0.70 in men and 0.74 in women (both P < 0.001) and with nitrate: 0.63 (P = 0.001) in men and (P < 0.005) in women. In multiple regression of stomach cancer mortality, using sodium and nitrate as independent variables the adjusted R2 was 0.61 in men and 0.54 in women (both P < 0.001). Addition of the interaction term (sodium x nitrate) to the previous model increased the adjusted R2 to 0.77 in men, and to 0.63 in women. The analysis of this model showed that the importance of nitrate as risk factor for stomach cancer mortality increased markedly with higher sodium levels. However, the relationship of stomach cancer mortality with sodium was always stronger than with nitrate.

CONCLUSIONS

Salt intake, measured as 24-hour urine sodium excretion, is likely the rate-limiting factor of stomach cancer mortality at the population level.

Permeability of the blood brain barrier by the bradykinin agonist, RMP-7: evidence for a sensitive, auto-regulated, receptor-mediated system

The novel bradykinin (BK) analog, RMP-7, was characterized in a series of in vitro tests to establish its selectivity as a B2 agonist. It was then used to study bradykinin's role in permeabilizing the blood brain barrier (BBB) and blood brain-tumor barrier (BTB), using an RG2 rat glioma model. These studies demonstrated that: (1) B2 receptor stimulation permeabilizes both the BBB and BTB in a dose-related fashion with greater effects observed in brain tumor-associated tissue, (2) the increased permeability is sensitive, rapid and transient, and (3) tachyphylaxis occurs with continuous agonist administration, suggesting autoregulation of the system's effects. These data therefore support the existence of a sophisticated, responsive and tightly regulated BK system whose activity modulates the permeability of the BBB.

Twenty-four hour urinary nitrate excretion in 48 populations from 30 countries: an ECP-INTERSALT collaborative study

BACKGROUND

There is considerable interest in the possible role of nitrate in gastric carcinogenesis, but little information on nitrate intake around the world. This is the first study to give comprehensive standardised data on nitrate excretion as a marker of intake, using 48 worldwide population samples.

METHODS

Urinary nitrate excretion has been shown to be a valid measure of nitrate intake in people under 50. This report presents data on 24-hour urinary nitrate excretion from urine collections obtained in the INTERSALT study, based on random samples of men and women aged 20-49 from each of 48 population samples in 30 countries.

RESULTS

There was large variation in urinary nitrate excretion both within and between samples; within-sample (individual) distributions tended to be skewed towards higher values. Median values of the samples ranged from 0.42 mmol/day (Labrador, Canada) to 3.52 (Beijing, People's Republic of China) in men and 0.44 mmol/day (Colombia) to 3.44 (Beijing) in women. Overall, median values were higher in men than women by 11% on average (higher in men in 37 of 48 population samples). Comparison by geographical region of median values for men and women combined showed relatively low values in the samples in North America and Northern Europe (range 0.46-0.88 mmol/day), slightly higher values in Western Europe and Africa (0.68-1.11), and intermediate to high values in Southern Europe, Eastern and Central Europe and India (0.86-2.47). The highest median values were found in the Far Eastern samples (up to 3.48). Median values in the Central and South American samples ranged from 0.48 mmol/day (Colombia) to 1.37 (Xingu Indians of Brazil, and Argentina).

CONCLUSIONS

For the first time, these data give standardized information on urinary nitrate excretion from different geographical regions of the world, and provide a basis for the further exploration of the role of nitrate in the aetiology of disease in human populations.

Eosinophil infiltration into human skin is antigen-dependent in the late-phase reaction

Eosinophils play a critical role in late-phase reaction allergic inflammatory responses, although the factors responsible for selective tissue eosinophilia are currently ill-defined. To determine whether recruitment of eosinophils is allergen-specific, or a feature of inflammation in allergic individuals, we have examined cutaneous cell infiltrates and endothelial cell adhesion molecule expression in atopic subjects 6 h (n = 8) and 24 h (n = 7) following ultraviolet-B (UVB) irradiation, or intradermal injection of late-phase reaction allergens or diluent control, using standard immunohistochemical techniques. The numbers of eosinophils were increased significantly, when compared to controls, at both 6 h (P < 0.01) and 24 h (P < 0.05), following intradermal allergen challenge, whereas no significant increase in eosinophils was observed following UVB irradiation. UVB and allergen both induced significant increases in neutrophils, monocytes and T cells at 24 h compared to control sites. An increased expression of endothelial cell adhesion molecules, E-selectin and intercellular adhesion molecule-1 (ICAM-1), was observed in both models of inflammation. Vascular cell adhesion molecule-1 (VCAM-1) was induced weakly on some biopsies following allergen, and not at all following UVB. These data indicate that eosinophil infiltration in susceptible individuals is a specific property of allergen. Although this study would support the postulated role of VCAM-1 in selective eosinophil recruitment, given its variable and weak expression, additional factors are likely to be involved.

Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group

OBJECTIVES

To assess further the relation in Intersalt of 24 hour urinary sodium to blood pressure of individuals and populations, and the difference in blood pressure from young adulthood into middle age.

DESIGN

Standardised cross sectional study within and across populations.

SETTING

52 population samples in 32 countries.

SUBJECTS

10,074 men and women aged 20-59.

MAIN OUTCOME MEASURES

Association of sodium and blood pressure from within population and cross population multiple linear regression analyses with multivariate correction for regression dilution bias. Relation of sample median daily urinary sodium excretion to difference in blood pressure with age.

RESULTS

In within population analyses (n = 10,074), individual 24 hour urinary sodium excretion higher by 100 mmol (for example, 170 v 70 mmol) was associated with systolic/diastolic blood pressure higher on average by 3/0 to 6/3 mm Hg (with and without body mass in analyses). Associations were larger at ages 40-59. In cross population analyses (n = 52), sample median 24 hour sodium excretion higher by 100 mmol was associated with median systolic/diastolic pressure higher on average by 5-7/2-4 mm Hg, and estimated mean difference in systolic/diastolic pressure at age 55 compared with age 25 greater by 10-11/6 mm Hg.

CONCLUSIONS

The strong, positive association of urinary sodium with systolic pressure of individuals concurs with Intersalt cross population findings and results of other studies. Higher urinary sodium is also associated with substantially greater differences in blood pressure in middle age compared with young adulthood. These results support recommendations for reduction of high salt intake in populations for prevention and control of adverse blood pressure levels.

Dietary calcium and blood pressure: a meta-analysis of randomized clinical trials

PURPOSE

To assess the effect of dietary calcium supplementation on blood pressure.

DATA SOURCES

Published reports of trials studying the effect of dietary calcium supplementation on blood pressure were identified by a search of previous reviews, a MEDLINE search, a manual review of journal articles, and a review of abstracts from scientific meetings.

STUDY SELECTION

Randomized clinical trials in which dietary calcium intake varied by intervention group were selected. Multifactorial trials were not included.

DATA SYNTHESIS

Data from 28 active treatment arms or strata from 22 randomized clinical trials were pooled using a weighted average method, with weights proportional to the inverse of the variance of the treatment effect. The total sample comprised 1231 persons. Because trials of both normotensive and hypertensive persons were included, subgroup analyses could be done. Pooled estimates of the effect of calcium supplementation on blood pressure were -0.18 mm Hg for diastolic blood pressure (95% CI, -0.75 to 0.40 mm Hg) and -0.89 mm Hg for systolic blood pressure (CI, -1.74 to -0.05 mm Hg). Pooled estimates for systolic blood pressure were -0.53 mm Hg (CI, -1.56 to 0.49 mm Hg) for trials of normotensive persons and -1.68 mm Hg (CI, -3.18 to -0.18 mm Hg) for trials of hypertensive persons. Diastolic blood pressure was not significantly affected in either subgroup.

CONCLUSION

The pooled estimate shows a statistically significant decrease of systolic blood pressure with calcium supplementation, both for hypertensive persons and for the overall sample. However, the effect is too small to support the use of calcium supplementation for preventing or treating hypertension.

Cancer incidence near municipal solid waste incinerators in Great Britain

By use of the postcoded database held by the Small Area Health Statistic Unit, cancer incidence of over 14 million people living near 72 municipal solid waste incinerators in Great Britain was examined from 1974-86 (England), 1974-84 (Wales) and 1975-87 (Scotland). Numbers of observed cases were compared with expected numbers calculated from national rates (regionally adjusted) after stratification by a deprivation index based on 1981 census small area statistics. Observed-expected ratios were tested for decline in risk with distance up to 7.5 km. The study was conducted in two stages: the first involved a stratified random sample of 20 incinerators; the second the remaining 52 incinerators. Over the two stages of the study was a statistically significant (P<0.05) decline in risk with distance from incinerators for all cancers combined, stomach, colorectal, liver and lung cancer. Among these cancers in the second stage, the excess from 0 to 1 km ranged from 37% for liver cancer (0.95) excess cases 10(-5) per year to 5% for colorectal cancer. There was evidence of residual confounding near the incinerators, which seems to be a likely explanation of the finding for all cancers, stomach and lung, and also to explain at least part of the excess of liver cancer. For this reason and because of a substantial level of misdiagnosis (mainly secondary tumours) found among registrations and death certificates for liver cancer, further investigation, including histological review of the cases, is to be done to help determine whether or not there is an increase in primary liver cancer in the vicinity of incinerators.

A standardisation approach to the control of socioeconomic confounding in small area studies of environment and health

OBJECTIVE

To assess how effectively a routine adjustment can be made for socio-economic confounding in small area studies of environment and health using indirect standardisation and small area deprivation indices, including analysis of the appropriate size of population unit on which to base the deprivation index and the importance of region and urban/rural status as axes of stratification.

METHODS

Standardised morbidity ratios were calculated for cancers in Great Britain for 1981 and standardised mortality ratios for all cause mortality in Great Britain between 1982 and 1985. Deprivation indices were calculated for enumeration districts and wards from 1981 small area census statistics. Cancers and deaths were allocated to enumeration districts via their postcode. Standardised morbidity and mortality ratios were calculated by quintile of enumeration district according to the deprivation index. Standardised mortality ratios were further analysed by deprivation of ward, region, and urban/rural status.

RESULTS

Strong relationships were found between all cause mortality and the incidence of selected cancers and deprivation quintile-there was up to a twofold difference in lung cancer incidence between the highest and lowest quintile. The deprivation index can be used to measure gradients of deprivation according to the distance from industrial sites. The deprivation index for enumeration districts showed similar discrimination of mortality as the index forwards. There is some interaction between deprivation and region in their effect on the standardised mortality ratios, leading to a small bias in the estimation of expected numbers if this is not taken into account. The relationship between deprivation, urban/rural status, and mortality is complex and confounded by region, but mortality tends to be higher in urban than in rural areas within quintiles of deprivation.

DISCUSSION

Whether calculated for enumeration districts or wards, the main problems in the interpretation of the deprivation index may be its limited correlation with the risk factors of interest and its concentration on present rather than past socioeconomic status. Indirect standardisation based on stratification for deprivation and other variable involves a trade off between bias and precision in determining the fineness and the number of axes of stratification. Some bias may occur due to interaction between region and deprivation and the effects of urban/rural status. Complementary approaches including modeling and proportional mortality or morbidity analyses may be needed and the possibility of residual socioeconomic confounding must always be considered.

CONCLUSION

There is potential for important socioeconomic confounding in small area studies of environmental pollution and health where the health outcome under examination has a strong relationship to socioeconomic status and where the putative excess risk due to pollution may be small. One method of controlling for confounding is to use an ecological measurement of deprivation in small areas, and to adjust for deprivation by indirect standardisation. However, residual socioeconomic confounding can be expected, which may seriously complicate the interpretation of small area studies.

Investigation of disease risks in small areas

The investigation of disease risks in small areas is complicated by many issues including data quality, the retrospective nature of the statistical testing, the problems of boundary definitions in time and space around a putative disease cluster, and the lack of generally accepted definitions of the key terminology. Routine data systems have revolutionised the initial investigation of disease risks near sources of environmental pollution, although problems of data analysis and interpretation remain. This is especially true of unmeasured socioeconomic confounding, which could generate apparent positive results near a pollution source.

Smoking behaviour can be predicted by neighbourhood deprivation measures

STUDY OBJECTIVE

To assess whether small area measures of socioeconomic deprivation predict variation in individual smoking behaviour. To examine the adequacy of an individual level statistical model for the analysis of data on groups of individuals who live in the same geographical area.

DESIGN

Individual level and two level logistic regression analysis of data on individual smoking from a regional health survey, and neighbourhood deprivation scores for 1991 census wards calculated from 1991 census data.

SETTING

The North West Thames Regional Health Authority area.

PARTICIPANTS

Random sample of 8,251 adults in North West Thames Regions.

MAIN RESULTS

There was a highly significant association between being a smoker and the neighbourhood deprivation score of the area of residence. With the two level model, after allowing for age and sex, the estimated odds ratio of being a smoker for an individual in the highest quintile of deprivation compared with someone in the lowest quintile was 1.52 (95% confidence interval 1.33, 1.74). Results obtained using the individual level model were similar. Variation between wards accounted for around 6% of the total variation in smoking behaviour after neighbourhood deprivation of the ward had been taken into account. Deprivation of the area of residence remained a significant predictor of smoking status even after the socioeconomic group of the individual has been taken into account.

CONCLUSIONS

Neighbourhood deprivation of the area of residence is a predictor of smoking status of individuals. In this example the two level model was reasonably well approximated by the individual level model.

Disease risk near point sources: statistical issues for analyses using individual or spatially aggregated data

STUDY OBJECTIVE

To examine the statistical issues involved in the analysis of disease risk near point sources of environmental pollution, where data are held at both the individual and group (areal) level. To explore these issues with reference to possible socioeconomic confounding.

DESIGN

Statistical review.

SETTING

Point sources of environmental pollution.

MAIN RESULTS

Except in very specific circumstances unlikely to hold in practice, aggregation of data to the areal level will lead to bias in the estimation of disease risk.

CONCLUSIONS

There is no easy solution to the analysis of spatial data when some covariates (for example, age and sex of cases) are known at individual level, whereas others (for example, populations, age-sex distributions, small area deprivation indices) are known only at the areal (ecological) level. The underlying assumptions inherent in the analysis of these data need to be explicitly recognised in order to understand better the limitations of the available methodology as well as to inform interpretation of results. Ideally, the data should be kept as disaggregated as possible, to maximise the information available and minimise potential for bias.

Epidemiologic association between dietary calcium intake and blood pressure: a meta-analysis of published data

The objectives of the study were to assess whether the epidemiologic data support a relation between dietary calcium intake and blood pressure, to obtain a quantitative estimate of the difference in blood pressure for a given difference in dietary calcium intake, and to assess the public health implications. A meta-analysis of published data (January 1983 to November 1993) that investigated the association between dietary calcium intake and blood pressure in different populations around the world was performed. Of 63 population studies identified, 23 were suitable for a quantitative overview (total n = 38,950). Unadjusted regression coefficients (95% confidence intervals) were obtained. Pooled unadjusted regression coefficients (95% confidence intervals) were then computed weighting each individual study by the inverse of its variance. Tests of heterogeneity and sensitivity analysis were carried out, and the possibility of publication bias was assessed. The regression coefficients ranged between -9.40 and 1.63 mmHg/100 mg calcium for systolic blood pressure and between -4.90 and 0.47 for diastolic blood pressure. In men (11 studies, n = 7,271), the pooled regression coefficients were -0.010 and -0.009 mmHg/100 mg calcium for systolic and diastolic pressures, respectively (p < 0.001 and p < 0.05). In women (six studies, n = 8,507), they were -0.15 and -0.057 mmHg/100 mg calcium (p < 0.001 and p < 0.02), and in men and women combined (six studies, n = 23,172 for systolic pressure and four studies, n = 3,215 for diastolic pressure) they were -0.061 and -0.061 mmHg/100 mg calcium (p < 0.001 and p < 0.05). In those studies that used the 24-hour recall method, the pooled regression coefficients were -0.06 and -0.09 mmHg/100 mg calcium (p < 0.005 and p = 0.07), whereas in those that used the food frequency questionnaire, they were -0.15 and -0.05 mmhg/100 mg calcium (p < 0.001 and p < 0.03). These data are consistent with an inverse association between dietary calcium intake and blood pressure. However, the size of the estimate, the observed heterogeneity among studies, and the possibility of confounding and publication bias indicate that an increase in calcium intake above the Recommended Dietary Allowance is not recommended at population level for the prevention and treatment of high blood pressure.