Plasma C reactive protein concentration indicates a direct relation between systemic inflammation and social deprivation

Socioeconomic disadvantage and the risk of advanced chronic kidney disease: results from a cohort study with 1.4 million participants

Background

Several studies have investigated the effect of socioeconomic deprivation on cardiovascular disease (CVD) and diabetes; less is known about its effect on chronic kidney disease (CKD). We aimed to measure the association between deprivation, CKD Stages 4–5 and end-stage renal disease (ESRD) in a general population sample.

Methods

This observational study examined 1 405 016 participants from the English Clinical Practice Research Datalink (2000–14), linked to hospital discharge data and death certification. Deprivation was assessed according to the participant’s postcode. Cox models were used to estimate hazard ratios (HRs) for CKD Stages 4–5 and ESRD, adjusting for age and sex, and additionally for smoking status, body mass index, diabetes, systolic blood pressure, prior CVD and estimated glomerular filtration rate (eGFR) at baseline.

Results

During 7.5 years of median follow-up, 11 490 individuals developed CKD Stages 4–5 and 1068 initiated ESRD. After adjustment for age and sex, the HRs and confidence interval (CI) comparing those in the 20% most deprived of the population to the 20% least deprived were 1.76 (95% CI 1.68–1.84) and 1.82 (95% CI 1.56–2.12) for CKD Stages 4–5 and ESRD, respectively. Further adjustment for known risk factors and eGFR substantially attenuated these HRs. Adding our results to all known cohort studies produced a pooled relative risk of 1.61 (95% CI 1.42–1.83) for ESRD, for comparisons between highest to lowest categories of deprivation.

Conclusion

Socioeconomic deprivation is independently associated with an increased hazard of CKD Stages 4–5 and ESRD, but in large part may be mediated by known risk factors.

Neighbourhood assets and early pregnancy cardiometabolic risk factors

BACKGROUND

Prepregnancy cardiometabolic risk factors are associated with increased risks of adverse pregnancy outcomes. Neighbourhood features may reflect prepregnancy exposures that contribute to poor cardiometabolic health before pregnancy and may contribute to racial disparities in pregnancy outcomes.

METHODS

Early pregnancy measurements from 1504 women enrolled in the Prenatal Exposures and Preeclampsia Prevention study were linked to a 2000 Census-based measure of neighbourhood socio-economic status and commercial data (food, alcohol, and retail density) during 1997-2001. Multilevel random-intercept linear regression was used to separately estimate the association between levels of neighbourhood assets (low, mid-low, mid-high, high) and C-reactive protein (CRP), systolic blood pressure (SBP), and body mass index (BMI) in cross-sectional analyses. Low neighbourhood assets have high-poverty/low-retail, whereas high neighbourhood assets have low-poverty/high-retail. Models were adjusted for individual-level factors (age and race), and we assessed effect modification by race.

RESULTS

Low compared with high neighbourhood assets were associated with higher BMI (β 1.95 kg/m² , 95% CI 0.89, 3.00), after adjusting for individual-level covariates. After adjusting for BMI and other covariates, low compared with high assets were associated with higher CRP concentrations (β 0.20 ng/mL, 95% CI 0.01, 0.39). Neighbourhood assets were not associated with SBP. Race did not modify the association between neighbourhood assets and cardiometabolic risk factors.

CONCLUSIONS

Early pregnancy adiposity is related to neighbourhood features independent of individual factors. Further, inflammation beyond accounting for adiposity is related to neighbourhood features. Strategies that address neighbourhood assets during preconception and interconception may be promising approaches to improve prepregnancy health.

The connections among suicidal behavior, lipid profile and low-grade inflammation in patients with major depressive disorder: a specific relationship with the neutrophil-to-lymphocyte ratio

OBJECTIVES

The role of inflammation and lipid metabolism in the pathophysiology of suicidal behavior has received particular attention in recent years. The neutrophil-to-lymphocyte ratio (NLR) has been suggested as a new and more reliable indicator of low-grade inflammation. NLR has been found to be altered in major depressive disorder (MDD) and has been related to various factors, including chronic stress and impulsivity that were previously reported to be related to suicidal behavior. We aimed to explore the roles of NLR, C-reactive protein (CRP) and serum lipid levels on suicidal behavior in patients with MDD.

METHODS

The study group consisted of 139 inpatients diagnosed with MDD [37 suicide attempters (SA); 102 suicide non-attempters (NSA)], 50 healthy controls and matched according to age, gender and education. NLR, PLR, CRP and lipid values were obtained from digital inpatient records.

RESULTS

CRP levels and NLR were substantially higher in patients with SA than in subjects with NSA and healthy comparison subjects after adjusting the confounding factors. The logistic regression included two predictive variables for suicide status in patients with depressive disorder (A) previous suicidal history; (B) NLR.

CONCLUSIONS

This is the first study suggesting that NLR may be a trait marker for suicidal vulnerability via a relationship between NLR and a recent suicide attempt in depressed inpatients. Future prospective studies are needed to determine the exact roles of NLR, and other inflammatory markers on suicidality in MDD.

The Pretreatment Systemic Inflammatory Response is an Important Determinant of Poor Pathologic Response for Patients Undergoing Neoadjuvant Therapy for Rectal Cancer

Background

Not all patients respond equally to neoadjuvant chemoradiotherapy (nCRT), with subsequent effects on survival. The systemic inflammatory response has been shown to predict long-term outcomes in colorectal cancer. The current study examined the association between systemic inflammation and nCRT in patients with rectal cancer.

Methods

Between 1999 and 2010, patients who underwent nCRT were identified. Serum measurements of hemoglobin, C-reactive protein, albumin, modified Glasgow prognostic score (mGPS), and differential white cell counts were obtained before and after nCRT. The Rödel scoring system measured pathologic tumor regression, and magnetic resonance imaging and computed tomography determined radiologic staging.

Results

The study included 79 patients. Of these patients, 37% were radiologically downstaged, and 44% were categorized as showing a good pathologic response (Rödel scores 3 and 4). As a validated measure of the systemic inflammatory response, mGPS (P = 0.022) was associated with a poor pathologic response to nCRT. A radiologic response was associated with a good pathologic response to treatment (P = 0.003). A binary logistic regression model identified mGPS (odds ratio [OR] 0.27; 95% confidence interval [CI] 0.07–0.96; P = 0.043) and radiologic response (OR 0.43; 95% CI 0.18–0.99; P = 0.048) as strong independent predictors of a pathologic response to treatment.

Conclusion

The current study showed that a systemic inflammatory response before nCRT is associated with a poor pathologic response. Further study in a prospective controlled trial setting is warranted.

Neighborhood walkable urban form and C-reactive protein

BACKGROUND

Walkable urban form predicts physical activity and lower body mass index, which lower C-reactive protein (CRP). However, urban form is also related to pollution, noise, social and health behavior, crowding, and other stressors, which may complement or contravene walkability effects.

PURPOSE

This paper assesses within-neighborhood correlation of CRP, and whether three features of walkable urban form (residential density, street connectivity, and land use mix) are associated with CRP levels.

METHODS

CRP measures (n=610) and sociodemographic data come from the 2001-3 Chicago Community Adult Health Study, linked with objective built environment data.

RESULTS

Within-neighborhood correlations of CRP are greater than those of related health measures. A one standard deviation increase in residential density predicts significantly higher log CRP (e.g. β=0.11, p<.01) in Chicago, while a one standard deviation increase in land use mix predicts significantly lower CRP (e.g. β=-0. 19, p<0.01). Street connectivity is unrelated to CRP in this highly walkable city.

DISCUSSION

Results suggest that residential density may be a risk factor for inflammation, while greater walkability of mixed land use areas may be protective. It may be that negative aspects of density overcome the inflammatory benefits of walking.

Association of lifecourse socioeconomic status with chronic inflammation and type 2 diabetes risk: the Whitehall II prospective cohort study

BACKGROUND

Socioeconomic adversity in early life has been hypothesized to "program" a vulnerable phenotype with exaggerated inflammatory responses, so increasing the risk of developing type 2 diabetes in adulthood. The aim of this study is to test this hypothesis by assessing the extent to which the association between lifecourse socioeconomic status and type 2 diabetes incidence is explained by chronic inflammation.

METHODS AND FINDINGS

We use data from the British Whitehall II study, a prospective occupational cohort of adults established in 1985. The inflammatory markers C-reactive protein and interleukin-6 were measured repeatedly and type 2 diabetes incidence (new cases) was monitored over an 18-year follow-up (from 1991-1993 until 2007-2009). Our analytical sample consisted of 6,387 non-diabetic participants (1,818 women), of whom 731 (207 women) developed type 2 diabetes over the follow-up. Cumulative exposure to low socioeconomic status from childhood to middle age was associated with an increased risk of developing type 2 diabetes in adulthood (hazard ratio [HR] = 1.96, 95% confidence interval: 1.48-2.58 for low cumulative lifecourse socioeconomic score and HR = 1.55, 95% confidence interval: 1.26-1.91 for low-low socioeconomic trajectory). 25% of the excess risk associated with cumulative socioeconomic adversity across the lifecourse and 32% of the excess risk associated with low-low socioeconomic trajectory was attributable to chronically elevated inflammation (95% confidence intervals 16%-58%).

CONCLUSIONS

In the present study, chronic inflammation explained a substantial part of the association between lifecourse socioeconomic disadvantage and type 2 diabetes. Further studies should be performed to confirm these findings in population-based samples, as the Whitehall II cohort is not representative of the general population, and to examine the extent to which social inequalities attributable to chronic inflammation are reversible.

Non-malignant drivers of elevated C-reactive protein levels differ in patients with and without a history of cancer

PURPOSE

Elevations in C-reactive protein (CRP) levels predict metastasis and mortality in a number of malignancies. However, the impact of non-malignant factors on CRP levels in patients with cancer remains unknown. To address this issue, we conducted an investigation of the National Social Life, Health, and Aging Project (NSHAP) cohort.

METHODS

NSHAP participants with a history of malignancy were included. The 222-participant cohort was subdivided by CRP levels into low-risk (CRP <3 mg/L) and high-risk (CRP ≥3 mg/L) groups. Univariate and multivariate binary logistic regression analyses examined the impact of variables spanning social factors, demographic characteristics, and past medical history on high-risk CRP levels.

RESULTS

Of the cohort, 42.3% exhibited high-risk CRP levels. These participants were more likely to be unmarried (p = 0.013), to be a racial/ethnic minority (p = 0.012), to not use HMG-CoA reductase inhibitor (statin) medications (p = 0.032), and to be obese (p = 0.002). On multivariate logistic regression analysis, these variables were also significant predictors of high-risk CRP levels. For example, compared with participants who had a normal body mass index (BMI), obese participants were nearly 5 times more likely (odds ratio 5.725; 95% CI 1.848, 12.079; p = 0.001) to exhibit high-risk CRP levels.

CONCLUSIONS

CRP remains an important prognostic biomarker in the management of known malignancies. However, patients with a known history of cancer can also exhibit elevated CRP levels due to non-malignant factors such as race and ethnicity, statin use, marital status, and BMI. Consequently, further studies are needed to assess the predictive potential of CRP levels for cancer prognostication in the face of these social and biologic variables before use of this biomarker is widely adopted in clinical practice.

Lifecourse socioeconomic trajectories and C-reactive protein levels in young adults: findings from a Brazilian birth cohort

Socioeconomic factors are associated with cardiovascular disease. C-reactive protein (CRP) is increasingly implicated as a candidate linking conventional risk factors and atherosclerosis. The impact of early- and later-life socioeconomic status (SES) on CRP levels has not been widely investigated and a handful of studies from high-income countries are inconsistent. We set out to examine the associations between lifecourse socioeconomic indicators (family income at birth, maternal education, family income at age 23 and own education) on CRP levels in young adults belonging to the 1982 Pelotas (Brazil) Birth Cohort Study (n = 5914). Early-life SES showed significant and graded associations with CRP levels at age 23 independently of later SES. For example, men with higher family income at birth showed higher CRP levels at age 23 (p = 0.001 for trend) and women with less educated mothers showed higher CRP levels (p = 0.01 for trend). Notably, differential directions of association between SES indicators and CRP levels between men and women were found. When adjusted for SES at age 23, men with the lowest family income at birth showed 42% lower CRP levels when compared to men in the highest family income group (−42; 95% CI: -60,-16). In contrast women born to the least educated mothers had the highest CRP levels (35; 95% CI -2, 86). In both sexes, adiposity accounted for the overwhelming majority of the associations between SES and CRP levels. Sex and gender roles specific to middle-income countries, socio-cultural and environmental conditions that may impact adiposity, and the level of epidemiological transition may be key factors that are linked to the associations between lifecourse SES and CRP levels. Public health strategies aimed at decreasing the burden of cardiovascular disease in middle-income settings, in addition to highlighting the risks associated with adult obesity, should not overlook the wide-ranging impacts of lifecourse social determinants.

p53 mutation, deprivation and poor prognosis in primary breast cancer

BACKGROUND

The deprivation gap for breast cancer survival remains unexplained by stage at presentation, treatment, or co-morbidities. We hypothesised that p53 mutation might contribute to the impaired outcome observed in patients from deprived communities.

METHODS

p53 mutation status was determined using the Roche Amplichip research test in 246 women with primary breast cancer attending a single cancer centre and related to deprivation, pathology, overall, and disease-free survival.

RESULTS

p53 mutation, identified in 64/246 (26%) of cancers, was most common in 10 out of 17 (58.8%) of the lowest (10th) deprivation decile. Those patients with p53 mutation in the 10th decile had a significantly worse disease-free survival of only 20% at 5 years (Kaplan-Meier logrank chi(2)=6.050, P=0.014) and worse overall survival of 24% at 5 years (Kaplan-Meier logrank chi(2)=6.791, P=0.009) than women of deciles 1-9 with p53 mutation (c.f. 56% and 72%, respectively) or patients in the 10th decile with wild-type p53 (no disease relapse or deaths).

CONCLUSION

p53 mutation in breast cancer is associated with socio-economic deprivation and may provide a molecular basis, with therapeutic implications, for the poorer outcome in women from deprived communities.

Differences in atherosclerosis according to area level socioeconomic deprivation: cross sectional, population based study

OBJECTIVES

To examine the relation between area level social deprivation and ultrasound markers of atherosclerosis (common carotid intima-media thickness and plaque score), and to determine whether any differences can be explained by "classic" (currently recognised) or "emerging" (novel) cardiovascular risk factors.

DESIGN

Cross sectional, population based study.

SETTING

NHS Greater Glasgow Health Board area.

PARTICIPANTS

666 participants were selected on the basis of how their area ranked in the Scottish Index of Multiple Deprivation 2004. Approximately equal numbers of participants from the most deprived areas and the least deprived areas were included, as well as equal numbers of men and women and equal numbers of participants from each age group studied (35-44, 45-54, and 55-64 years).

MAIN OUTCOME MEASURES

Carotid intima-media thickness and plaque score, as detected by ultrasound.

RESULTS

The mean age and sex adjusted intima-media thickness was significantly higher in participants from the most deprived areas than in those from the least deprived areas (0.70 mm (standard deviation (SD) 0.16 mm) v 0.68 mm (SD 0.12 mm); P=0.015). On subgroup analysis, however, this difference was only apparent in the highest age tertile in men (56.3-66.5 years). The difference in unadjusted mean plaque score between participants from the most deprived and those from the least deprived areas was more striking than the difference in intima-media thickness (least deprived 1.0 (SD 1.5) v most deprived 1.7 (SD 2.0); P<0.0001). In addition, a significant difference in plaque score was apparent in the two highest age tertiles in men (46.8-56.2 years and 56.3-66.5 years; P=0.0073 and P<0.001) and the highest age tertile in women (56.3-66.5 years; P<0.001). The difference in intima-media thickness between most deprived and least deprived males remained significant after adjustment for classic risk factors, emerging risk factors, and individual level markers of socioeconomic status (P=0.010). Adjustment for classic risk factors and emerging cardiovascular risk factors, either alone or in combination, did not abolish the deprivation based difference in plaque presence (as a binary measure; adjusted odds ratio of 1.73, 95% confidence interval 1.07 to 2.82). However, adjustment for classic risk factors and individual level markers of early life socioeconomic status abolished the difference in plaque presence between the most deprived and the least deprived individuals (adjusted odds ratio 0.94, 95% CI 0.54 to 1.65; P=0.84).

CONCLUSIONS

Deprivation is associated with increased carotid plaque score and intima-media thickness. The association of deprivation with atherosclerosis is multifactorial and not adequately explained by classic or emerging risk factors.

Psychological, social and biological determinants of ill health (pSoBid): study protocol of a population-based study

BACKGROUND

Disadvantaged communities suffer higher levels of physical and mental ill health than more advantaged communities. The purpose of the present study was to examine the psychosocial, behavioural and biological determinants of ill health within population groups in Glasgow that differed in socioeconomic status and in their propensity to develop chronic disease especially coronary heart disease and Type 2 diabetes mellitus.

METHODS

Participants were selected at random from areas known to be at the extremes of the socioeconomic continuum in Glasgow. Within the categories of least deprived and most deprived, recruitment was stratified by sex and age to achieve an overall sample containing approximately equal numbers of males and females and an even distribution across the age categories 35-44, 45-54 and 55-64 years. Individuals were invited by letter to attend for assessment of their medical history, risk factor status, cognitive function and psychological profile, morbidity, and carotid intima-media thickness and plaque count as indices of atherosclerosis. Anonymised data on study subjects were collected from the General Practice Administration System for Scotland to analyse characteristics of participants and non-participants.

RESULTS

700 subjects were recruited. The response (active participants per 100 invitation letters) in the least deprived group was 35.1% and in the most deprived group was 20.3%. Lowest response was seen in young males (least deprived 22.4% and most deprived 14.1%).

CONCLUSION

This cross-sectional study recruited the planned sample of subjects from least deprived and most deprived areas within Glasgow. As evident in other studies response differed between the most and least deprived areas. This study brought together researchers/academics from diverse disciplines to build a more sophisticated understanding of the determinants of health inequalities than can be achieved through unidisciplinary approaches. Future analyses will enable an understanding of the relationships between the different types of measure, and of the pathways that link poverty, biology, behaviour and psychology and lead to health inequalities.

Associations of plasma pro-inflammatory cytokines, fibrinogen, viscosity and C-reactive protein with cardiovascular risk factors and social deprivation: the fourth Glasgow MONICA study

Circulating inflammatory markers [plasma fibrinogen, viscosity and C-reactive protein (CRP)] have been associated with cardiovascular risk factors. In part, these associations may reflect 'upstream' changes in pro-inflammatory cytokines - interleukin (IL)-6, IL-18 and tumour necrosis factor (TNF)alpha. These variables were measured in 1666 men and women aged 25-64 years and their associations with risk factors were studied. All six markers increased significantly with age. IL-18 and TNFalpha levels were higher, and fibrinogen levels lower, in males. Oral contraceptive use increased levels of CRP, whilst postmenopausal women had elevated IL-18 levels. Inflammatory markers were also associated with components of the metabolic syndrome. Most inflammatory markers showed an increasing trend with alcohol consumption in men and a decreasing trend in women, and increasing trends with level of smoking. Inflammatory markers generally showed strong positive associations with social deprivation. After adjustment for classical risk factors, IL-6, IL-18 and TNFalpha retained significant associations with social deprivation only in men (P < 0.008). We conclude that pro-inflammatory cytokines are associated with several cardiovascular risk factors including social deprivation, and may mediate some of their associations with 'downstream' inflammatory markers (fibrinogen, viscosity and CRP).

Risk factors in the Midspan family study by social class in childhood and adulthood

BACKGROUND

Social class in childhood and in adulthood have been shown to be important determinants of risk factors in later life. Often the childhood information is retrospective and liable to bias. We use data from a family study of two generations of adults to investigate the effects of social class in childhood, adulthood and social mobility on risk factors.

METHODS

In 1996, 2338 adult offspring of participants of the 1970s Renfrew/Paisley study took part in a screening examination. They provided information on sociological, behavioural and clinical risk factors, as their parents had done 20 years previously. Social class and father's social class were available, enabling their influence on risk factors to be investigated.

RESULTS

Generally risk factors improved for offspring compared with parents, except for Body mass index and obesity, which worsened. Risk factors were less favourable in manual compared with non-manual offspring, and were more closely related to own than father's social class. There was a large amount of upward social mobility involving 35% of sons and 50% of daughters. Risk factors for the upwardly mobile tended to be more favourable than the class they left behind but less favourable than the class they joined.

CONCLUSIONS

The concomitants of social mobility may reflect behavioural choices, such as smoking, and adverse factors, which are more difficult to leave behind. The relatively fast changes in social class profile may not be reflected in as quick changes in population health, as the upwardly mobile bring their earlier life adversities with them.

When do social inequalities in C-reactive protein start? A life course perspective from conception to adulthood in the Cardiovascular Risk in Young Finns Study

BACKGROUND

It is unclear when in the life course do social inequalities in inflammation emerge. We examined whether the association between socioeconomic position (SEP) and C-reactive protein (CRP) is determined at conception, in childhood, adolescence or adulthood in 1484 participants from the population-based Cardiovascular Risk in Young Finns Study.

METHODS

Five variants of the CRP gene were used to investigate whether SEP differences in CRP levels are determined at conception. SEP and serum CRP were assessed in childhood (age 3-9), adolescence (age 12-18) and in adulthood (age 24-39). SEP was measured using parental education and occupational status in childhood and adolescence, and participants' own education and occupational status in adulthood. Participants with CRP > 10 mg/l were excluded.

RESULTS

All CRP gene variants were associated with circulating CRP concentrations in childhood, but there were no differences in the distribution of these variants by SEP. No strong evidence was found of associations between parental SEP and CRP. A graded association between higher SEP and lower CRP was observed in adulthood for education (P = 0.0005) but not for occupational status. Trajectories that led to high educational achievement both in the participants and their parents were associated with lower (P <or= 0.047) CRP levels in adulthood. Excluding participants with infectious diseases, pregnant or lactating women and women using oral contraceptives did not change the findings.

CONCLUSION

In this cohort, SEP differences in CRP concentrations seen in adulthood appear not to be determined at conception or evident in childhood or adolescence.

Socioeconomic and racial/ethnic differentials of C-reactive protein levels: a systematic review of population-based studies

Background

Socioeconomic and racial/ethnic factors strongly influence cardiovascular disease outcomes and risk factors. C-reactive protein (CRP), a non-specific marker of inflammation, is associated with cardiovascular risk, and knowledge about its distribution in the population may help direct preventive efforts. A systematic review was undertaken to critically assess CRP levels according to socioeconomic and racial/ethnic factors.

Methods

Medline was searched through December 2006 for population-based studies examining CRP levels among adults with respect to indicators of socioeconomic position (SEP) and/or race/ethnicity. Bibliographies from located studies were scanned and 26 experts in the field were contacted for unpublished work.

Results

Thirty-two relevant articles were located. Cross-sectional (n = 20) and cohort studies (n = 11) were included, as was the control group of one trial. CRP levels were examined with respect to SEP and race/ethnicity in 25 and 15 analyses, respectively. Of 20 studies that were unadjusted or adjusted for demographic variables, 19 found inverse associations between CRP levels and SEP. Of 15 similar studies, 14 found differences between racial/ethnic groups such that whites had the lowest while blacks, Hispanics and South Asians had the highest CRP levels. Most studies also included adjustment for potential mediating variables in the causal chain between SEP or race/ethnicity and CRP. Most of these studies showed attenuated but still significant associations.

Conclusion

Increasing poverty and non-white race was associated with elevated CRP levels among adults. Most analyses in the literature are underestimating the true effects of racial/ethnic and socioeconomic factors due to adjustment for mediating factors.

Adult socioeconomic position, C-reactive protein and interleukin-6 in the Whitehall II prospective study

BACKGROUND

Prior studies on the association of inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6), with socioeconomic position (SEP) have been cross-sectional. Thus, the question of whether socioeconomic differences in CRP and IL-6 change over time remains unanswered. We examined the relationship between SEP and changes over 12 years in CRP and IL-6.

METHODS

Data were for 4,750 middle-aged (mean 49.0 years, SD 5.9) civil servants from phases 3 and 7 of the Whitehall II study. Adult SEP was based on last known Civil Service employment grade. Covariates included sociodemographics, behavioural and biological risk factors, presence of diseases/illnesses, prescribed medications, work-related factors, labour market status and early life factors.

RESULTS

Steep socioeconomic gradients observed at Phase 3 (p < 0.001) persisted in both CRP and IL-6 12 years later after adjustment for other risk factors. Adjustment for behavioural (diet and smoking), biological (mainly body mass index and total : HDL cholesterol ratio) and early life factors resulted in considerable attenuation but the inverse socioeconomic gradients remained statistically significant. Although CRP and IL-6 concentrations increased substantially over the 12-year period at every level of SEP, CRP and IL-6 did not change differentially according to SEP.

CONCLUSION

Despite overall increases in CRP and IL6, relative differences by SEP remained unchanged so that socioeconomic gradients in both sexes persisted over the period observed.

C-reactive protein and cardiovascular disease: weighing the evidence

C-reactive protein (CRP) has been widely promoted as a strong, independent predictor of cardiovascular events and metabolic syndrome, both in general populations and in patients with clinical cardiovascular disease, and as a causal player in atherothrombosis. However, recent evidence shows that the association of CRP with cardiovascular events is weaker than previously thought, that it may be largely attributed to confounding by established causal risk factors, and that CRP is, therefore, probably not a clinically useful risk predictor. The lack of association of noncoding CRP gene polymorphisms (which determine different baseline CRP values) with coronary events or metabolic syndrome does not support a causal role for CRP, and most of the putatively proatherothrombotic in vitro effects claimed for CRP were caused by contaminants in commercial CRP preparations and not by CRP. Future clinical trials of specific CRP inhibitors now in development could directly test the contribution of CRP to pathogenesis of cardiovascular disease.

The relationship between the systemic inflammatory response, tumour proliferative activity, T-lymphocytic infiltration and COX-2 expression and survival in patients with transitional cell carcinoma of the urinary bladder

The relationship between the systemic inflammatory response, tumour proliferative activity, T-lymphocytic infiltration, and COX-2 expression and survival was examined in patients with transitional cell carcinoma of the urinary bladder (n=103). Sixty-one patients had superficial disease and 42 patients had invasive disease. Cancer-specific survival was shorter in those patients with invasive compared with superficial bladder cancer (P<0.001). On univariate analysis, stratified by stage, increased Ki-67 labelling index (P<0.05), increased COX-2 expression (P<0.05), C-reactive protein (P<0.05) and adjuvant therapy (P<0.01) were associated with poorer cancer-specific survival. On multivariate analysis of these significant factors, stratified by stage, only C-reactive protein (HR 2.89, 95% CI 1.42–5.91, P=0.004) and adjuvant therapy (HR 0.29, 95% CI 0.14–0.62, P=0.001) were independently associated with poorer cancer-specific survival. These results would suggest that tumour-based factors such as grade, COX-2 expression or T-lymphocytic infiltration are subordinate to systemic factors such as C-reactive protein in determining survival in patients with transitional cell carcinoma of the urinary bladder.