Evidence that high von Willebrand factor and low ADAMTS-13 levels independently increase the risk of a non-fatal heart attack

BACKGROUND

A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) may influence von Willebrand factor (VWF) levels and consequently the risk of myocardial infarction (MI). Moreover, ADAMTS-13 influences hemostatic plug formation in mouse models. We therefore studied their associations in the Glasgow MI Study (GLAMIS).

METHODS AND RESULTS

We measured ADAMTS-13 and VWF antigen levels by ELISAs in stored plasma from a case-control study of 466 MI cases and 484 age- and sex-matched controls from the same north Glasgow population. There was no correlation between ADAMTS-13 and VWF levels in cases or controls. ADAMTS-13 levels correlated positively with serum cholesterol and triglycerides and body mass index, and negatively with high-density lipoprotein-cholesterol. VWF levels correlated with age, fibrinogen and C-reactive protein. In multivariable analyses including risk factors, VWF correlated positively with risk of MI, and ADAMTS-13 correlated negatively with risk of MI. These associations were independent of each other. The association of ADAMTS-13 with risk of MI was observed only in multivariable analysis.

CONCLUSIONS

VWF and ADAMTS-13 levels were not associated in this study, and showed associations with MI risk in opposite directions but of similar strength. The association of ADAMTS-13 with MI is influenced by lipid levels, and consequently requires further investigation.

Ethnic comparisons of the cross-sectional relationships between measures of body size with diabetes and hypertension

Recent estimates indicate that two billion people are overweight or obese and hence are at increased risk of cardiovascular disease and its comorbidities. However, this may be an underestimate of the true extent of the problem, as the current method used to define overweight may lack sensitivity, particularly in some ethnic groups where there may be an underestimate of risk. Measures of central obesity may be more strongly associated with cardiovascular risk, but there has been no systematic attempt to compare the strength and nature of the associations between different measures of overweight with cardiovascular risk across ethnic groups. Data from the Obesity in Asia Collaboration, comprising 21 cross-sectional studies in the Asia-Pacific region with information on more than 263,000 individuals, indicate that measures of central obesity, in particular, waist circumference (WC), are better discriminators of prevalent diabetes and hypertension in Asians and Caucasians, and are more strongly associated with prevalent diabetes (but not hypertension), compared with body mass index (BMI). For any given level of BMI, WC or waist:hip ratio, the absolute risk of diabetes or hypertension tended to be higher among Asians compared with Caucasians, supporting the use of lower anthropometric cut-points to indicate overweight among Asians.

The "sunglasses sign" predicts nonorganic visual loss in neuro-ophthalmologic practice

OBJECTIVE

The aim of our study was to evaluate whether wearing sunglasses (the "sunglasses sign") can be used by neuro-ophthalmologists to predict nonorganic visual loss (NOVL) in their patients.

METHODS

We prospectively collected information on all new patients seen by us over 13 months. We included all patients who ultimately received a diagnosis of NOVL, and all patients wearing sunglasses in our clinic. We recorded demographics, iris color, number of positive review of systems, ocular examination, precipitating event or trauma, workers' compensation claims, disability and lawsuit related to the visual loss, and the reason for wearing sunglasses.

RESULTS

Among the 1,377 consecutive new patients seen in our clinic during the study, 34 patients wore sunglasses, among whom 7 (20.6%) had organic visual loss. During the study period, 59 patients were diagnosed with NOVL, among whom 27 (45.8%) wore sunglasses. The sensitivity of wearing sunglasses for NOVL was 0.46 (95% CI 0.33 to 0.59). The probability that a patient walking into our clinic had NOVL was 0.043 (95% CI 0.033 to 0.055); it increased to 0.79 (95% CI 0.62 to 0.91) in sunglasses patients. The specificity of sunglasses for the diagnosis of NOVL was 0.995 (95% CI 0.989 to 0.998). At least one of the following characteristics (highly positive review of systems, workers' compensation claim, disability, and lawsuit) was found in 26 of 27 (96.3%) of NOVL patients wearing sunglasses and in none of the sunglasses patients with organic neuro-ophthalmic disorders. All 7 sunglasses patients with organic neuro-ophthalmic disorders had reasonable ophthalmic explanations for wearing sunglasses.

CONCLUSION

The "sunglasses sign" in a patient without an obvious ophthalmic reason to wear sunglasses is highly suggestive of nonorganic visual loss.

A cohort study of 20,822 young drivers: the DRIVE study methods and population

BACKGROUND AND OBJECTIVE

Research on young drivers directly linking risk factors to serious injury and death outcomes is required. The DRIVE Study was established to facilitate this aim. This paper outlines the study methods and describes the population that has been recruited, in order to demonstrate that the necessary heterogeneity in risk factors has been attained.

DESIGN, SETTING AND PARTICIPANTS

Drivers aged 17-24 years holding their first-stage provisional driver's licence from New South Wales, Australia, were recruited into a prospective cohort study. The participants were contacted by mail and asked to complete the study questionnaire at an online site or via a mailed questionnaire. Baseline data collection involved a questionnaire with questions to drivers about their training, risk perception, driver behavior, sensation-seeking behavior and mental health. Participants gave consent for prospective data linkage to their data on licensing, crashes and injuries, held in routinely collected databases.

RESULTS

20 822 drivers completed the baseline questionnaire, of whom 45.4% were men, 74.3% resided in capital cities and 25.7% in regional or remote areas. The recruited study population showed a wide variation in the risk factors under examination. For example, almost 40% of drivers reported drinking alcohol at hazardous levels and about 32% of participants seemed to be at a high or very high risk of psychological distress. Participants reported a mean of 67.3 h (median 60 h) of supervised driver training while holding their learner's permit.

CONCLUSIONS

The DRIVE Study has a robust study design aimed at minimizing bias in the collection of outcome data. Analyses of baseline data showed substantial heterogeneity of risk factors in the study population. Subsequent prospective linkages comparing relative differences in exposures at baseline with the outcomes of interest have the potential to provide important new information needed to develop targeted interventions aimed at young drivers.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial

BACKGROUND

Blood pressure is an important determinant of the risks of macrovascular and microvascular complications of type 2 diabetes, and guidelines recommend intensive lowering of blood pressure for diabetic patients with hypertension. We assessed the effects of the routine administration of an angiotensin converting enzyme (ACE) inhibitor-diuretic combination on serious vascular events in patients with diabetes, irrespective of initial blood pressure levels or the use of other blood pressure lowering drugs.

METHODS

The trial was done by 215 collaborating centres in 20 countries. After a 6-week active run-in period, 11 140 patients with type 2 diabetes were randomised to treatment with a fixed combination of perindopril and indapamide or matching placebo, in addition to current therapy. The primary endpoints were composites of major macrovascular and microvascular events, defined as death from cardiovascular disease, non-fatal stroke or non-fatal myocardial infarction, and new or worsening renal or diabetic eye disease, and analysis was by intention-to-treat. The macrovascular and microvascular composites were analysed jointly and separately. This trial is registered with ClinicalTrials.gov, number NCT00145925.

FINDINGS

After a mean of 4.3 years of follow-up, 73% of those assigned active treatment and 74% of those assigned control remained on randomised treatment. Compared with patients assigned placebo, those assigned active therapy had a mean reduction in systolic blood pressure of 5.6 mm Hg and diastolic blood pressure of 2.2 mm Hg. The relative risk of a major macrovascular or microvascular event was reduced by 9% (861 [15.5%] active vs 938 [16.8%] placebo; hazard ratio 0.91, 95% CI 0.83-1.00, p=0.04). The separate reductions in macrovascular and microvascular events were similar but were not independently significant (macrovascular 0.92; 0.81-1.04, p=0.16; microvascular 0.91; 0.80-1.04, p=0.16). The relative risk of death from cardiovascular disease was reduced by 18% (211 [3.8%] active vs 257 [4.6%] placebo; 0.82, 0.68-0.98, p=0.03) and death from any cause was reduced by 14% (408 [7.3%] active vs 471 [8.5%] placebo; 0.86, 0.75-0.98, p=0.03). There was no evidence that the effects of the study treatment differed by initial blood pressure level or concomitant use of other treatments at baseline.

INTERPRETATION

Routine administration of a fixed combination of perindopril and indapamide to patients with type 2 diabetes was well tolerated and reduced the risks of major vascular events, including death. Although the confidence limits were wide, the results suggest that over 5 years, one death due to any cause would be averted among every 79 patients assigned active therapy.

A comparison of the associations between seven hemostatic or inflammatory variables and coronary heart disease

BACKGROUND

While meta-analyses of prospective studies have established that plasma levels of several hemostatic variables are associated with the risk of coronary heart disease (CHD), these have been suggested to be acute-phase reactant proteins. This study examines their associations with inflammatory markers [C-reactive protein (CRP) and interleukin-6 (IL-6)] and the effect of adjustment on their associations with CHD risk.

METHODS AND RESULTS

In a nested case-control study, 247 CHD cases and 473 controls were matched for age and sex from 10 529 men and women in the Fletcher Challenge cohort. Plasma levels of all hemostatic variables except von Willebrand factor (VWF) and lipoprotein (a) [Lp(a)] showed significant associations with CRP and IL-6. Fibrinogen, VWF, tissue plasminogen activator antigen (t-PA), D-dimer, Lp(a), CRP and IL-6 levels were significantly associated with risk of CHD. After adjustment for conventional risk factors, CRP, D-dimer and IL-6 levels were significantly associated with risk of CHD. On further adjustments for the other six hemostatic and inflammatory variables these associations were reduced, but remained significant for D-dimer and IL-6; odds ratios (95% CI), comparing the highest to lowest third, were 3.10 (1.25-7.67) and 2.79 (1.11-6.99), respectively.

CONCLUSION

The associations of plasma levels of some hemostatic variables (fibrinogen, VWF, t-PA and Lp(a); but not fibrin D-dimer) with CHD risk are attenuated when inflammatory markers (CRP and IL-6) as well as conventional risk factors are included in multivariable analyses. D-dimer and IL-6 each have the potential to increase the prediction of CHD, in addition to conventional risk factors.

Systolic blood pressure, diabetes and the risk of cardiovascular diseases in the Asia-Pacific region

OBJECTIVE

To assess the association between systolic blood pressure (SBP) and cardiovascular diseases (CVD) among participants with and without diabetes from cohorts in the Asia-Pacific region.

RESEARCH DESIGN AND METHODS

Hazards ratios and 95% confidence intervals (CI) for CVD were calculated from Cox models, stratified by sex and region and adjusted for age using individual participant data from 36 cohort studies. Repeat measurements of SBP were used to adjust for regression dilution bias.

RESULTS

During follow-up, 7387 fatal or non-fatal cardiovascular endpoints were recorded among 368 307 participants (6.4% with diabetes). SBP was associated with coronary heart disease (CHD), ischaemic stroke and haemorrhagic stroke in a continuous log-linear fashion among individuals with diabetes, as well as those without diabetes. Overall, each 10 mmHg higher usual SBP was associated with 18% (95% CI: 9-27%) and 23% (19-26%) greater risk for CHD among those with and without diabetes, respectively. The corresponding values for ischaemic stroke were 29% (14-45%) and 43% (37-50%), and for haemorrhagic stroke, 56% (32-83%) and 74% (66-82%). The test for heterogeneity by diabetes status in each of these associations was not significant (P >or= 0.10).

CONCLUSIONS

Systolic blood pressure is an important marker of risk of CVD in people with and without diabetes. A given reduction in systolic blood pressure is likely to have a similar relative effect on reducing the risk of a cardiovascular event, regardless of diabetes status.

Blood pressure-dependent and independent effects of agents that inhibit the renin-angiotensin system

OBJECTIVES

To evaluate the blood pressure-dependent and independent effects of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) on major cardiovascular events.

METHODS

Using data from 26 large-scale trials comparing an ACEI or an ARB with placebo or another drug class, meta-regression analyses were conducted in which treatment-specific relative risks for major cause-specific outcomes [stroke, major coronary heart disease (CHD) events and heart failure] were regressed against follow-up blood pressure differences.

RESULTS

From a total of 146 838 individuals with high blood pressure or an elevated risk of cardiovascular disease, 22 666 major cardiovascular events were documented during follow-up. The analyses showed comparable blood pressure-dependent reductions in risk with ACEI and ARB (P >or= 0.3 for all three outcomes). The analyses also showed that ACEI produced a blood pressure-independent reduction in the relative risk of CHD of approximately 9% (95% confidence interval 3-14%). No similar effect was detected for ARB, and there was some evidence of a difference between ACEI and ARB in this regard (P = 0.002). For both stroke and heart failure there was no evidence of any blood pressure-independent effects of either ACEI or ARB.

CONCLUSION

There are similar blood pressure-dependent effects of ACEI and ARB for the risks of stroke, CHD and heart failure. For ACEI, but not ARB, there is evidence of blood pressure-independent effects on the risk of major coronary disease events.

Imaging beta-amyloid burden in aging and dementia

OBJECTIVE

To compare brain beta-amyloid (Abeta) burden measured with [(11)C]Pittsburgh Compound B (PIB) PET in normal aging, Alzheimer disease (AD), and other dementias.

METHODS

Thirty-three subjects with dementia (17 AD, 10 dementia with Lewy bodies [DLB], 6 frontotemporal dementia [FTD]), 9 subjects with mild cognitive impairment (MCI), and 27 age-matched healthy control subjects (HCs) were studied. Abeta burden was quantified using PIB distribution volume ratio.

RESULTS

Cortical PIB binding was markedly elevated in every AD subject regardless of disease severity, generally lower and more variable in DLB, and absent in FTD, whereas subjects with MCI presented either an "AD-like" (60%) or normal pattern. Binding was greatest in the precuneus/posterior cingulate, frontal cortex, and caudate nuclei, followed by lateral temporal and parietal cortex. Six HCs (22%) showed cortical uptake despite normal neuropsychological scores. PIB binding did not correlate with dementia severity in AD or DLB but was higher in subjects with an APOE-epsilon4 allele. In DLB, binding correlated inversely with the interval from onset of cognitive impairment to diagnosis.

CONCLUSIONS

Pittsburgh Compound B PET findings match histopathologic reports of beta-amyloid (Abeta) distribution in aging and dementia. Noninvasive longitudinal studies to better understand the role of amyloid deposition in the course of neurodegeneration and to determine if Abeta deposition in nondemented subjects is preclinical AD are now feasible. Our findings also suggest that Abeta may influence the development of dementia with Lewy bodies, and therefore strategies to reduce Abeta may benefit this condition.

Impact of smoking and smoking cessation on lung cancer mortality in the Asia-Pacific region

Cigarette smoking is becoming increasingly common in Asia while quitting remains rare, in part because of a lack of knowledge about the risks of smoking. This study compared the risk of death from lung cancer associated with smoking habits in Australia and New Zealand and in Asia by using data from the Asia Pacific Cohort Studies Collaboration: 31 studies involving 480,125 individuals. Cox regression models were used. The hazard ratios for lung cancer mortality associated with current smoking were, for men, 2.48 (95% confidence interval (CI): 1.99, 3.11) in Asia versus 9.87 (95% CI: 6.04, 16.12) in Australia and New Zealand; p for homogeneity <0.0001. For women, the corresponding estimates were 2.35 (95% CI: 1.29, 4.28) in Asia versus 19.33 (95% CI: 10.0, 37.3) in Australia and New Zealand; p for homogeneity <0.0001. Quitting was beneficial in both regions; the hazard ratios for former compared with current smokers were 0.69 (95% CI: 0.53, 0.92) in Asia and 0.30 (95% CI: 0.22, 0.41) in Australia and New Zealand. The lesser effect in Asia was partly explained by the fewer number of cigarettes smoked and the shorter duration of follow-up in Asian studies. These results suggest that tobacco control policies in Asia should not solely concentrate on preventing the uptake of smoking but also attend to cessation.

The impact of modifiable risk factors on mortality from prostate cancer in populations of the Asia-Pacific region

Mortality from cancer of the prostate is increasing in the Asia-Pacific, when much of this region is undergoing a transition to a Western lifestyle. The role that lifestyle factors play in prostate cancer appears limited, but existing data mainly are from the West. We conducted an individual participant data analysis of 24 cohort studies involving 320,852 men (83% in Asia). Cox proportional hazard models were used to quantify associations between risk factors and mortality from prostate cancer. There were 308 deaths from prostate cancer (14% in Asia) during 2.1 million person-years of follow-up. The age-adjusted hazard ratio (95% confidence interval; CI) for men with body mass index (BMI) 28 kg/m2 or more, compared with below 25, was 1.55 (1.12 - 2.16); no such significant relationship was found for height or waist circumference. The BMI result was unchanged after adjustment for other variables, was consistent between Asia and Australia/New Zealand (ANZ) and did not differ with age. There was no significant relationship with diabetes, glucose or total cholesterol (p > or = 0.18). Smoking, alone, showed different effects in the two regions, possibly due to the relative immaturity of the smoking epidemic in Asia. In ANZ, the multiple-adjusted hazard ratio for an extra 5 cigarettes per day was 1.12 (95%CI: 1.03 - 1.22), whereas in Asia it was 0.77 (0.56 - 1.05). Body size is an apparently important determinant of prostate cancer in the Asia-Pacific. Evidence of an adverse effect of smoking is conclusive only in the predominantly Caucasian parts of the region.

The role of lifestyle risk factors on mortality from colorectal cancer in populations of the Asia-Pacific region

Although colorectal cancer is one of the leading malignancies worldwide, there are few data on aetiological relationships from the Asia-Pacific region. Therefore, a collaborative study was conducted involving over half a million subjects from 33 cohort studies in the region. Age-adjusted death rates from colorectal cancer, over an average of 6.8 years follow-up, were 12 and 14 per 100,000 person-years among Asian women and men, respectively; corresponding values in Australasia were 31 and 41. Height was strongly associated with death from colorectal cancer: an extra 5 cm of height was associated with 10% (95%confidence interval, 3% - 18% additional risk, after adjustment for other factors. Smoking increased risk by 43% (9% - 88%), although no significant dose-response relationship was discerned (p>0.05). Other significant (p <0.05) risk factors were body mass index and lack of physical activity. There was no significant effect on colorectal cancer mortality for alcohol consumption, waist circumference, fasting blood glucose or diabetes, although the latter conferred a notable 26% additional risk. Height may be a biomarker for some currently unknown genetic, or environmental, risk factors that are related both to skeletal growth and mutanogenesis. Understanding such mechanisms could provide opportunities for novel preventive and therapeutic intervention.

Cardiovascular risk prediction tools for populations in Asia

BACKGROUND

Cardiovascular risk equations are traditionally derived from the Framingham Study. The accuracy of this approach in Asian populations, where resources for risk factor measurement may be limited, is unclear.

OBJECTIVE

To compare "low-information" equations (derived using only age, systolic blood pressure, total cholesterol and smoking status) derived from the Framingham Study with those derived from the Asian cohorts, on the accuracy of cardiovascular risk prediction.

DESIGN

Separate equations to predict the 8-year risk of a cardiovascular event were derived from Asian and Framingham cohorts. The performance of these equations, and a subsequently "recalibrated" Framingham equation, were evaluated among participants from independent Chinese cohorts.

SETTING

Six cohort studies from Japan, Korea and Singapore (Asian cohorts); six cohort studies from China; the Framingham Study from the US.

PARTICIPANTS

172,077 participants from the Asian cohorts; 25,682 participants from Chinese cohorts and 6053 participants from the Framingham Study.

MAIN RESULTS

In the Chinese cohorts, 542 cardiovascular events occurred during 8 years of follow-up. Both the Asian cohorts and the Framingham equations discriminated cardiovascular risk well in the Chinese cohorts; the area under the receiver-operator characteristic curve was at least 0.75 for men and women. However, the Framingham risk equation systematically overestimated risk in the Chinese cohorts by an average of 276% among men and 102% among women. The corresponding average overestimation using the Asian cohorts equation was 11% and 10%, respectively. Recalibrating the Framingham risk equation using cardiovascular disease incidence from the non-Chinese Asian cohorts led to an overestimation of risk by an average of 4% in women and underestimation of risk by an average of 2% in men.

INTERPRETATION

A low-information Framingham cardiovascular risk prediction tool, which, when recalibrated with contemporary data, is likely to estimate future cardiovascular risk with similar accuracy in Asian populations as tools developed from data on local cohorts.

The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

BACKGROUND

Tobacco will soon be the biggest cause of death worldwide, with the greatest burden being borne by low and middle-income countries where 8/10 smokers now live.

OBJECTIVE

This study aimed to quantify the direct burden of smoking for cardiovascular diseases (CVD) by calculating the population attributable fractions (PAF) for fatal ischaemic heart disease (IHD) and stroke (haemorrhagic and ischaemic) for all 38 countries in the World Health Organization Western Pacific and South East Asian regions.

DESIGN AND SUBJECTS

Sex-specific prevalence of smoking was obtained from existing data. Estimates of the hazard ratio (HR) for IHD and stroke with smoking as an independent risk factor were obtained from the approximately 600,000 adult subjects in the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence were then used to calculate sex-specific PAF for IHD and stroke by country.

RESULTS

The prevalence of smoking in the 33 countries, for which relevant data could be obtained, ranged from 28-82% in males and from 1-65% in females. The fraction of IHD attributable to smoking ranged from 13-33% in males and from <1-28% in females. The percentage of haemorrhagic stroke attributable to smoking ranged from 4-12% in males and from <1-9% in females. Corresponding figures for ischaemic stroke were 11-27% in males and <1-22% in females.

CONCLUSIONS

Up to 30% of some cardiovascular fatalities can be attributed to smoking. This is likely an underestimate of the current burden of smoking on CVD, given that the smoking epidemic has developed further since many of the studies were conducted.

The impact of driver distraction on road safety: results from a representative survey in two Australian states

OBJECTIVE

To quantify the prevalence and effects of distracting activities while driving.

DESIGN

Cross sectional driver survey.

SETTING

New South Wales and Western Australia, Australia.

PARTICIPANTS

1347 licensed drivers aged between 18 and 65 years. Data were weighted to reflect the corresponding driving population.

MAIN OUTCOME MEASURES

Prevalence of distracting activities while driving; perceived risks and adverse outcomes due to distractions.

RESULTS

The most common distracting activities during the most recent driving trip were lack of concentration (weighted percentage (standard error, SE) 71.8% (1.4%) of drivers); adjusting in-vehicle equipment (68.7% (1.5%)); outside people, objects or events (57.8% (1.6%)); and talking to passengers (39.8% (1.6%)). On average, a driver engaged in a distracting activity once every six minutes. One in five crashes (21%) during the last three years, involving one in 20 drivers (5.0% (0.7%)), was attributed to driver distraction based on self-report. In the population under study, this equated to 242,188 (SE 34,417) drivers. Younger drivers (18-30 years) were significantly more likely to report distracting activities, to perceive distracting activities as less dangerous, and to have crashed as a result.

CONCLUSIONS

Distracting activities while driving are common and can result in driving errors. Driver distraction is an important cause of crashes. Further research is needed to estimate the risk conferred by different distracting activities and the circumstances during which activities pose greatest risk. These results suggest that a strategy to minimize distracting activities while driving, with a focus on young drivers, is indicated.

Unidentified under-nutrition: dietary intake and anthropometric indices in a residential care home population

BACKGROUND

Research investigating the nutritional status of older people in residential care homes is scant.

OBJECTIVE

To determine the anthropometric measures and dietary intakes of older people in this setting as a basis for future intervention studies.

METHODS

Dietary intake was assessed using 3-day-weighed food records, nutritional status was evaluated using anthropometric measurements (knee height to predict standing height, and body weight). Catering provision was assessed using a computer-based menu assessment tool (CORA).

RESULTS

Mean body mass index (BMI) for the 34 participants was 22.2 kg m(2) (range 14.5-34.4). Six participants (17.6%) had a BMI < or =18.5 kg m(2) with a further seven identified as having a BMI >18.5 but <20 kg m(2). Only two subjects with BMI <18.5 kg m(2) were prescribed oral supplements. In both men and women, recorded mean energy intakes were below current estimated average requirements by 24% and 22% respectively.

CONCLUSION

Despite adequate food provision, under-nutrition was prevalent and, in the majority of cases, unidentified and untreated. A larger study is warranted to investigate whether improved nutritional intake is achievable through dietary modification. These data indicate that a sample size of around 60, with 90% power and at the 5% significance level, is required to detect a difference of 1674 kJ between groups of residents in an intervention study following a cluster randomized design.

Medication management at home: medication risk factor prevalence and inter-relationships

BACKGROUND AND OBJECTIVE

Patients can have medication-related risk factors associated with poor health outcomes that become evident through visiting them in their homes. These medication-related risk factors may not be apparent in pharmacy and general practitioner (GP) records. The aim was to determine the prevalence and inter-relationships of medication-related risk factors for poor patient health outcomes identifiable through 'in-home' observations.

METHODS

The design was a cross-sectional study of 204 general practice patients living in their own homes and at risk of medication-related poor health outcomes. Medication-related risk factors were identified in the patients' homes by community pharmacists and GPs.

RESULTS AND DISCUSSION

The prevalence of risk factors varied from 8.3% (multiple medication storage locations) to 55.9% (confused by generic and trade names). There were many relationships observed between the medication-related risk factors, with expired medication having the most relationships with other risk factors followed by therapeutic duplication and poor adherence (9, 6 and 6 relationships respectively).

CONCLUSION

Visiting patients' homes may identify medication-related risk factors not otherwise apparent through patient visits to the health practitioner when medications may be brought for review (i.e. 'brown bag' reviews).

Shift work and work injury in the New Zealand Blood Donors' Health Study

OBJECTIVE

To investigate associations between work patterns and the occurrence of work injury.

METHODS

A cross sectional analysis of the New Zealand Blood Donors Health Study conducted among the 15 687 (70%) participants who reported being in paid employment. After measurement of height and weight, a self-administered questionnaire collected information concerning occupation and work pattern, lifestyle behaviour, sleep, and the occurrence of an injury at work requiring treatment from a doctor during the past 12 months.

RESULTS

Among paid employees providing information on work pattern, 3119 (21.2%) reported doing shift work (rotating with nights, rotating without nights, or permanent nights) and 1282 (8.7%) sustained a work injury. In unadjusted analysis, work injury was most strongly associated with employment in heavy manual occupations (3.6, 2.8 to 4.6) (relative risk, 95% CI), being male (1.9, 1.7 to 2.2), being obese (1.7, 1.5 to 2.0), working rotating shifts with nights (2.1, 1.7 to 2.5), and working more than three nights a week (1.9, 1.6 to 2.3). Snoring, apnoea or choking during sleep, sleep complaints, and excessive daytime sleepiness were also significantly associated with work injury. When mutually adjusting for all significant risk factors, rotating shift work, with or without nights, remained significantly associated with work injury (1.9, 1.5 to 2.4) and (1.8, 1.2 to 2.6), respectively. Working permanent night shifts was no longer significantly associated with work injury in the adjusted model.

CONCLUSION

Work injury is highly associated with rotating shift work, even when accounting for increased exposure to high risk occupations, lifestyle factors, and excessive daytime sleepiness.

A comparison of the associations between risk factors and cardiovascular disease in Asia and Australasia

BACKGROUND

Cardiovascular disease is already the leading cause of death in many Asian populations. Relationships between vascular risk factors and cardiovascular disease may differ in Asian and western populations. Previously, a lack of prospective data has prevented the reliable quantification of such differences, which, if they were shown to exist, would suggest that novel cardiovascular prevention and treatment strategies are required for Asia.

DESIGN

An individual participant data meta-analysis of 32 studies from the Asia-Pacific region involving 331 100 subjects (75% from Asia; 25% from the predominantly Caucasian populations of Australia and New Zealand).

METHODS

Outcomes were death from coronary heart disease, ischaemic and haemorrhagic stroke. Hazard ratios were estimated from Cox models for systolic blood pressure (SBP), total cholesterol, triglycerides, body mass index, diabetes and current cigarette smoking, stratified by study and sex and adjusted for age, the other risk factors and regression dilution.

RESULTS

After an average period of follow-up of 4 years there were 2082 deaths from coronary heart disease, 600 from haemorrhagic stroke and 420 from ischaemic stroke. The direction and strength of the associations between risk factors and cardiovascular outcomes were similar in the two regions, although in two cases there were significant differences. Triglycerides were more strongly associated with coronary heart disease in Australia and New Zealand (P = 0.03), whereas SBP showed a stronger relationship with haemorrhagic stroke in Asia (P = 0.04).

CONCLUSIONS

Classical vascular risk factors act similarly in Asian and Caucasian populations; prevention and treatment strategies should thus be similar. Blood pressure reduction should be particularly effective in Asia.

First trimester maternal blood rheology and pregnancy induced hypertension

This study evaluates the relationship between the first trimester assessment of maternal rheology and the subsequent development of pregnancy induced hypertension. This is a prospective observational study based in the Glasgow Royal Maternity Hospital, Scotland. From an original population of 744 consecutive antenatal attendees a total of 579 women were booked at less than 14 weeks' gestation. The main study group is a further subset comprising 251 primigravid women booking with a singleton pregnancy without essential hypertension. Previously published data from a group of non-pregnant women of similar age drawn from the same local community was used for external comparison. Blood samples were collected at the booking visit, from which fibrinogen, red cell aggregation, haematocrit and plasma, whole blood, relative and corrected viscosities were recorded. Information was obtained from the case notes in retrospect starting approximately 1 year after the first patients had first been recruited into the trial. The overall outcome of the pregnancies was noted with particular reference to pregnancy induced hypertension (PIH), birth weight, antepartum haemorrhage, pre-term labour, perinatal death, condition at delivery and neonatal complication. Our results show PIH is associated with a significantly raised mean blood viscosity and fibrinogen at time of booking. All significance disappears after adjustment for smoking, diastolic blood pressure and age. Viscosity is, however, only marginally non-significant (p = 0.07). In conclusion, blood rheology, in particular blood viscosity and fibrinogen, may play a predictive role in the development of pregnancy-induced hypertension. When combined with measurement of smoking and diastolic blood pressure at booking, these measurements could be used to calculate a risk score for the development of PIH, allowing targeting of antenatal care. Further data is required.