0419 IL-6 Moderates the Association Between Obstructive Sleep Apnea Severity and Incident Alzheimer’s Disease: The Framingham Heart Study

Introduction

Both sleep disturbances and inflammation are potential risk factors for Alzheimer’s disease (AD). However, it is unknown how inflammation and sleep interact together to influence the risk of developing AD dementia. Our objective was to evaluate whether interleukin-6 (IL-6) levels interact with sleep disturbances when predicting incident clinical AD.

Methods

We studied participants in the Framingham Heart Study Offspring cohort who completed in-home overnight polysomnography. Sleep characteristics were continuous and included sleep duration, wake after sleep onset (WASO), and apnea-hypopnea index (AHI). Participants were stratified into quartiles of IL-6 levels. Surveillance for incident AD dementia occurred over a mean follow-up of 13.4±5.4 years. Using Cox proportional hazards regression models, we tested the interaction of sleep measures by IL-6 quartiles on incident AD dementia. All analyses adjusted for age and sex and P<0.05 was considered significant.

Results

The final sample included 291 dementia-free participants at baseline (age 67.5±4.9 years, 51.6% men). Approximately one quarter of participants had obstructive sleep apnea (OSA; AHI>15) at baseline (median:6.2, Q1:2,3, Q3:14.3). We observed 33 cases of incident AD dementia during follow-up. Although no interaction was observed for either sleep duration or WASO with IL-6 levels, there was a significant interaction of AHI with IL-6 in predicting AD dementia (p=0.002). In the lowest IL-6 quartile, higher AHI was associated with an elevated risk of AD dementia (hazard ratio, 4.15 [95%CI, 1.42, 12.1], p=0.01) whereas no association between AHI and incident AD was observed in other IL-6 quartiles.

Conclusion

Our findings suggest that the pro-inflammatory cytokine IL-6 moderates the association between OSA and incident AD risk. The association between increasing OSA severity and incident AD was only observed in those with lower IL-6 levels, suggesting that this association might be especially apparent when no other confounding risk factors such as inflammation are present.

Support

The Framingham Heart Study is supported by contracts from the National Heart, Lung and Blood Institute, grants from the National Institute on Aging, and grants from the National Institute of Neurological Disorders and Stroke.

Job strain and cognitive decline: a prospective study of the framingham offspring cohort

BACKGROUND

Workplace stress is known to be related with many behavioral and disease outcomes. However, little is known about its prospective relationship with measures of cognitive decline.

OBJECTIVE

To investigate the association of job strain, psychological demands and job control on cognitive decline.

METHODS

Participants from Framingham Offspring cohort (n=1429), were assessed on job strain, and received neuropsychological assessment approximately 15 years and 21 years afterwards.

RESULTS

High job strain and low control were associated with decline in verbal learning and memory. Job strain was associated with decline in word recognition skills. Active job and passive job predicted decline in verbal learning and memory relative to low strain jobs in the younger subgroup. Active job and demands were positively associated with abstract reasoning skills.

CONCLUSIONS

Job strain and job control may influence decline in cognitive performance.

Red blood cell ω-3 fatty acid levels and markers of accelerated brain aging

OBJECTIVE

Higher dietary intake and circulating levels of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have been related to a reduced risk for dementia, but the pathways underlying this association remain unclear. We examined the cross-sectional relation of red blood cell (RBC) fatty acid levels to subclinical imaging and cognitive markers of dementia risk in a middle-aged to elderly community-based cohort.

METHODS

We related RBC DHA and EPA levels in dementia-free Framingham Study participants (n = 1575; 854 women, age 67 ± 9 years) to performance on cognitive tests and to volumetric brain MRI, with serial adjustments for age, sex, and education (model A, primary model), additionally for APOE ε4 and plasma homocysteine (model B), and also for physical activity and body mass index (model C), or for traditional vascular risk factors (model D).

RESULTS

Participants with RBC DHA levels in the lowest quartile (Q1) when compared to others (Q2-4) had lower total brain and greater white matter hyperintensity volumes (for model A: β ± SE = -0.49 ± 0.19; p = 0.009, and 0.12 ± 0.06; p = 0.049, respectively) with persistence of the association with total brain volume in multivariable analyses. Participants with lower DHA and ω-3 index (RBC DHA+EPA) levels (Q1 vs. Q2-4) also had lower scores on tests of visual memory (β ± SE = -0.47 ± 0.18; p = 0.008), executive function (β ± SE = -0.07 ± 0.03; p = 0.004), and abstract thinking (β ± SE = -0.52 ± 0.18; p = 0.004) in model A, the results remaining significant in all models.

CONCLUSION

Lower RBC DHA levels are associated with smaller brain volumes and a "vascular" pattern of cognitive impairment even in persons free of clinical dementia.

No advantage of A beta 42-lowering NSAIDs for prevention of Alzheimer dementia in six pooled cohort studies

INTRODUCTION

Observational studies show reduced incidence of Alzheimer dementia (AD) in users of nonsteroidal anti-inflammatory drugs (NSAIDs). One hypothesis holds that the subset of NSAIDs known as selective A beta(42)-lowering agents (SALAs) is responsible for this apparent reduction in AD risk.

METHODS

We pooled individual-level data from six prospective studies to obtain a sufficient sample to examine AD risk in users of SALA vs non-SALA NSAIDs.

RESULTS

Of 13,499 initially dementia-free participants (70,863 person-years), 820 developed incident AD. Users of NSAIDs (29.6%) showed reduced risk of AD (adjusted hazard ratio [aHR] 0.77, 95% CI 0.65-0.91). The point estimates were similar for SALAs (aHR 0.87, CI 0.72-1.04) and non-SALAs (aHR 0.75, CI 0.56-1.01). Because 573 NSAID users (14.5%) reported taking both a SALA and non-SALA, we examined their use alone and in combination. Resulting aHRs were 0.82 (CI 0.67-0.99) for SALA only, 0.60 (CI 0.40-0.90) for non-SALA only, and 0.87 (CI 0.57-1.33) for both NSAIDs (Wald test for differences, p = 0.32). The 40.7% of participants who used aspirin also showed reduced risk of AD, even when they used no other NSAIDs (aHR 0.78, CI 0.66-0.92). By contrast, there was no association with use of acetaminophen (aHR 0.93, CI 0.76-1.13).

CONCLUSIONS

In this pooled dataset, nonsteroidal anti-inflammatory drug (NSAID) use reduced the risk of Alzheimer dementia (AD). However, there was no apparent advantage in AD risk reduction for the subset of NSAIDs shown to selectively lower A beta(42), suggesting that all conventional NSAIDs including aspirin have a similar protective effect in humans.

Inflammatory markers and the risk of Alzheimer disease: the Framingham Study

OBJECTIVE

To examine whether serum cytokines and spontaneous production of peripheral blood mononuclear cell (PBMC) cytokines are associated with the risk of incident Alzheimer disease (AD).

METHODS

We followed 691 cognitively intact community-dwelling participants (mean age 79 years, 62% women) and related PBMC cytokine production (tertiles of spontaneous production of interleukin 1 [IL-1], IL-1 receptor antagonist, and tumor necrosis factor alpha [TNF-alpha]) and serum C-reactive protein and interleukin 6 (IL-6) to the risk of incident AD.

RESULTS

Adjusting for clinical covariates, individuals in the top two tertiles (T2 and T3) of PBMC production of IL-1 or the top tertile (T3) of PBMC production of TNF-alpha were at increased risk of developing AD (multivariable-adjusted hazard ratio [HR] for IL-1 T2 = 2.84, 95% CI 1.09 to 7.43; p = 0.03 and T3 = 2.61, 95% CI 0.96 to 7.07; p = 0.06; for TNF-alpha, adjusted HR for T2 = 1.30, 95% CI 0.53 to 3.17; p = 0.57 and T3 = 2.59, 95% CI 1.09 to 6.12; p = 0.031]) compared with those in the lowest tertile (T1).

INTERPRETATION

Higher spontaneous production of interleukin 1 or tumor necrosis factor alpha by peripheral blood mononuclear cells may be a marker of future risk of Alzheimer disease (AD) in older individuals. These data strengthen the evidence for a pathophysiologic role of inflammation in the development of clinical AD.

Influence of the history on physicians' interpretations of girls' genital findings

OBJECTIVE

Because physicians customarily obtain histories before examining children in cases of possible sexual abuse, and because the resulting diagnostic opinions can influence important social and legal decisions, we investigated whether clinical histories influence physicians' interpretations of girls' genital findings.

DESIGN

In mailed questionnaires, 1387 randomly selected Fellows of the American Academy of Pediatrics and all 802 members of four professional groups concerned with child abuse or pediatric gynecology were asked to interpret seven simulated cases. Respondents were asked to interpret seven additional cases in separate questionnaires mailed 4 months later. Both sets of cases involved the same seven photographs of girls' external genitalia. However, in six of the seven case pairs, the histories in the two questionnaires differed in the extent to which they suggested sexual abuse. In the remaining (control) pair, the same history was presented in both questionnaires.

RESULTS

Of 2189 physicians, 1114 (50.9%) responded. Responses from 604 physicians (54.2%) were eligible for analysis. Overall, the genital findings were interpreted most consistently by the most experienced physicians and least consistently by the least experienced physicians. The proportion of physicians whose interpretations of a photograph reversed in the direction suggested by the change in the associated history from "no indication of abuse" to "probable abuse," or vice versa, ranged for experienced physicians from none to 5.6%; for moderately experienced physicians from 1.6% to 19.8%; and for inexperienced physicians from 3.6% to 27.2%. This difference between the experience groups was statistically significant in four case pairs. Mean interpretation scores for genital findings changed significantly when the histories changed in two case pairs for the experienced physicians, in five pairs for the moderately experienced physicians, and in all six pairs for the inexperienced physicians.

CONCLUSIONS

In some cases and especially for less experienced physicians, diagnostic expectation appears likely to influence physicians' interpretations of girls' genital findings. Physicians should be alert to the possibility of diagnostic expectation bias and its potentially serious social and legal consequences.

Migrainous visual accompaniments are not rare in late life: the Framingham Study

BACKGROUND AND PURPOSE

Questionnaires to elicit symptoms of transient ischemic attacks (TIAs) may detect late-life transient visual symptoms similar to the visual aura of migraine, often without headache. We determined the frequency, characteristics, and stroke outcome of these symptoms in the Framingham Study.

METHODS

During 1971-1989, at biennial examinations, 2110 subjects of the Framingham cohort were systematically queried about the occurrence of sudden visual symptoms.

RESULTS

Visual migrainous symptoms were reported by 1.23% (26/2110) of subjects (1.33% of women and 1.08% of men). In 65% of subjects the episodes were stereotyped, and they began after age 50 years in 77%. Mean +/- SD age at onset of the episodes was 56.2+/-18.7 years. In 58% of subjects the episodes were never accompanied by headaches, and 42% had no headache history. The number of episodes ranged from 1 to 500 and was 10 or more in 69% of subjects. The episodes lasted 15 to 60 minutes in 50% of subjects. Sixty-five percent of the subjects were examined by a study neurologist, and only 19% of them met the criteria of the International Headache Society. Twelve percent of subjects sustained a stroke after the onset of migrainous visual symptoms: a subarachnoid hemorrhage 1 year later, an atherothrombotic brain stem infarct 3 years later, and a cardioembolic stroke 27 years later. In contrast, of 87 subjects with TIAs in the same cohort, 33% developed a stroke (P = 0.030), two thirds within 6 months of TIA onset.

CONCLUSIONS

Late-life-onset transient visual phenomena similar to the visual aura of migraine are not rare and often occur in the absence of headache. These symptoms appear not to be associated with an increased risk of stroke, and invasive diagnostic procedures or therapeutic measures are generally not indicated.

A predictive instrument for coronary artery aneurysms in Kawasaki disease. US Multicenter Kawasaki Disease Study Group

To construct a predictive instrument for developing coronary artery abnormalities in patients with acute Kawasaki disease treated with aspirin and intravenous gamma globulin within the first 10 days of illness, data available from a multicenter database of patients with acute Kawasaki disease were analyzed. A development data set (n = 212) was used to construct a sequential risk classification instrument based on easily measured baseline laboratory test results and temperature. The instrument was then validated in 3 test data sets (n = 192, 264, and 92, respectively). Risk factors used in the sequential classification instrument included baseline neutrophil and band counts, hemoglobin concentration, platelet count, and temperature on the day after infusion of intravenous gamma globulin. In the development data set, the instrument classified 123 of 212 patients (58%) as low risk; none developed coronary artery abnormalities. Among 89 patients classified as high risk, 3 of 36 female (8.3%) and 9 of 53 male patients (17.0%) developed coronary artery abnormalities. The instrument performed similarly in the 3 test data sets; no patient in any data set classified as low risk developed coronary artery abnormalities. This simple instrument allows the clinician to identify within 1 day of treatment low-risk children in whom extensive and frequent cardiac testing may be unnecessary, as well as high-risk children who require closer monitoring and may be candidates for additional therapies.

Survival and functional status 20 or more years after first stroke: the Framingham Study

BACKGROUND AND PURPOSE

We examined the 20-or-more-year survival and functional levels of 148 stroke survivors and 148 age- and sex-matched control subjects from the Framingham Study Cohort, whom we originally studied in 1972-1974 to ascertain the survival and disability status of stroke survivors compared with that of controls.

METHODS

This long-term evaluation was done with use of data from the 1993-1995 Framingham Study Cohort Examination 23 on the 10 stroke survivors and 20 control subjects still living to identify and compare the host characteristics and functional status of each group. The survival curves for both stroke survivors and controls were derived from the ongoing Framingham Study database.

RESULTS

Twenty-plus-year stroke survivors experienced a greater mortality than age- and sex-matched controls (92.5% and 81%, respectively). The slopes of the two survival curves were essentially the same. Functional status (eg, walking and independence in activities of daily living) of stroke survivors, however, compared very favorably with that of the control subjects. Stroke survivors were more likely to be female and to have a number of comorbidities, including elevated blood pressures, greater use of medications, less use of alcohol, and less depressive symptomology.

CONCLUSIONS

In the Framingham cohort, 20-plus-year stroke survivors showed greater mortality than age- and sex-matched control subjects; functionally, however, the groups were very similar and in general quite independent.

Passive cigarette smoking and reduced HDL cholesterol levels in children with high-risk lipid profiles

BACKGROUND

HDL cholesterol levels are known to be lower in smokers than in nonsmokers. Previous studies have demonstrated an association of decreased HDL cholesterol with passive smoking in children but have not adjusted for potential confounding factors.

METHODS AND RESULTS

In a cross-sectional, pilot-scale study, we examined the relationship of HDL cholesterol levels to passive smoking in children and adolescents referred to a tertiary hyperlipidemia clinic. Eligibility criteria included (1) first visit to a lipid clinic, (2) LDL cholesterol >95th percentile for age or HDL cholesterol <5th percentile, (3) age between 2 and 18 years, and (4) absence of secondary causes of hyperlipidemia. Sociodemographic information, diet record, medical history, and fasting lipid profiles were obtained. Of 109 eligible patients, 103 (94%) were studied. Twenty-seven percent came from households with cigarette smokers. HDL cholesterol levels were 38.7+/-1.2 mg/dL (mean+/-SEM) in passive smokers versus 43.6+/-1.2 mg/dL in children without smoke exposure (P=.005). Smoking exposure was not significantly associated with other lipid values. The effect of smoking on HDL cholesterol was minimally affected by potential confounders. In multivariate regression adjusting for body mass index, age, sex, exercise, and dietary fat intake, passive smoking remained a significant risk factor for decreased HDL cholesterol (P=.012).

CONCLUSIONS

Mean HDL cholesterol levels are lower in dyslipidemic children from households with smokers than in those without household smoke exposure. Passive smoking may worsen the risk profile for later atherosclerosis among high-risk young persons.

Assessments of girl's genital findings and the likelihood of sexual abuse: agreement among physicians self-rated as skilled

OBJECTIVES

To measure agreement about genital examination findings among physicians who rate themselves as skilled in evaluating children for suspected sexual abuse, to compare these physicians' descriptions and interpretations with consensus standards developed by an expert panel, and to investigate the effects of physician and case characteristics on agreement.

STUDY DESIGN

Questionnaires including 7 simulated cases, each consisting of a brief history and 1 photograph of a girl's genitalia, were mailed to random samples of 2 groups: the members of 4 physician organizations concerned with child abuse or pediatric gynecology, and pediatricians at large. Among the surveyed physicians who rated their own skill in evaluating cases of suspected sexual abuse as higher than average, we measured agreement, both overall and between those with the most and with less clinical experience, and assessed their conformity with consensus standard descriptions and interpretations.

RESULTS

We received responses from 548 (50.9%) of 1076 physicians; 414 responses (75.5%) were analyzable. Two hundred six physicians (50%) rated themselves as skilled in assessing children for sexual abuse. On average, 45% of these physicians' descriptions and 72.6% of their interpretations conformed with the consensus standards. In 4 cases, between 5% and 20.7% of these physicians described genital findings that the expert panel had considered absent from the photographs. Conformity with standard interpretations tended to be higher in cases with photographs concordant with the accompanying, unambiguous histories (P=.06). The most experienced physicians resembled the expert panel more closely than did the less experienced self-rated skilled physicians in interpreting 3 simulated cases (P< or =.001).

CONCLUSIONS

Assessments of girls' genital findings by physicians who rate themselves as skilled in examining children for suspected sexual abuse often differ. In some cases, among physicians who all rate themselves as skilled, assessments made by very experienced physicians may conform more closely to consensus standards than do assessments made by less experienced physicians.

Stroke severity in atrial fibrillation. The Framingham Study

BACKGROUND AND PURPOSE

Stroke occurring with atrial fibrillation (AF) is more likely to be fatal or more severe than non-AF stroke based on clinical series, but data from prospective epidemiological studies are sparse and inconsistent.

METHODS

Over 40-year follow-up of the original 5070 Framingham cohort, 501 initial ischemic strokes, including 103 with AF, were analyzed. Stroke severity was rated as none, mild, moderate, severe, or fatal. Since 1981, functional status indicated by the Barthel index has been evaluated acutely and at 3, 6, and 12 months. Severity and functional status of AF strokes were compared with non-AF strokes using chi 2 test and Student's t test. Thirty-day mortality was assessed by logistic regression analyses.

RESULTS

AF was associated with increased stroke severity (P = .048). Thirty-day mortality was greater in AF strokes than in non-AF strokes (25% versus 14%). The multivariate-adjusted odds ratio for 30-day mortality for AF subjects was 1.84 (95% confidence interval, 1.04 to 3.27). Since 1981, follow-up was available for 150 initial ischemic strokes, including 30 with AF. Compared with the non-AF group, the AF group had poorer survival and more recurrences during 1 year of follow-up. The AF subjects had lower mean Barthel index scores acutely (29.6 versus 58.6, P < .001) and at 3 months (P = .005), 6 months (P = .003), and 12 months (P = .130) after stroke among survivors.

CONCLUSIONS

Ischemic stroke associated with AF was nearly twice as likely to be fatal as non-AF stroke. Recurrence was more frequent, and functional deficits were more likely to be severe among survivors. Since stroke is usually the initial manifestation of embolism in AF, prevention is critical to reducing disability and mortality.

Poverty, race, and medication use are correlates of asthma hospitalization rates. A small area analysis in Boston

Hospitalization rates for asthma in New York City are highest in poor urban neighborhoods, although the reasons for this are unknown. We performed a small area analysis of asthma hospitalization rates in Boston, to determine whether this pattern of asthma hospitalization also obtained in a medium-sized city and to identify characteristics of neighborhoods with high hospitalization rates, including the relative use of inhaled anti-inflammatory medication. Zip codes were used to define 22 small areas within Boston. The number of asthma hospitalizations for residents of each area in 1992 was obtained from the Codman Research Group. Population and demographic characteristics of each area were obtained from the 1990 US Census. Estimates of inhaled asthma medications (beta-agonists, steroids, and cromolyn) dispensed in each area in 1992 were obtained from IMS America. Asthma hospitalization rates for each of the six areas with the highest rates (5.3 to 9.8 per 1,000 persons) were significantly greater than the city-wide average of 4.2 hospitalizations per thousand persons (p < 0.001 for each comparison). Asthma hospitalization rate was positively correlated with poverty rate and with the proportion of nonwhite residents and inversely correlated with income and educational attainment. Asthma hospitalization rate was inversely correlated with the ratio of inhaled anti-inflammatory to beta-agonist medication use (r = -0.55, p = 0.008). We conclude that asthma hospitalization rates in Boston are highest in poor inner city neighborhoods, and that these high rates affect both genders and all age groups. Underuse of inhaled anti-inflammatory medication may be one of the many factors that contributes to this excess hospitalization.

Developmental, behavioural, and environmental risk factors for diarrhoea among rural Bangladeshi children of less than two years

One hundred and eighty-five rural Bangladeshi children (80 boys and 105 girls) aged 4-27 months were observed to investigate developmental, behavioural, and environmental risk factors for diarrhoea during a 6-month period. Incidence of diarrhoea was found to be the highest among children aged 10-12 months. Children of this age group had the greatest exposure to environmental contaminants in the neighbourhood. Incidence of diarrhoea was the highest in hot, dry months. Risk factors for diarrhoea included: faecal contamination and garbage disposal in infant's outdoor play compound, crawling, contact of hand and mouth with contaminated materials, greater distance of household from water source, inadequate cleaning after defecation; dirt of child's face, presence of flies, feeding rotten food; insufficient washing of infant's and caretaker's hands before feeding rice meals or soft, wet foods; and lack of mothers' willingness to visit a modern (allopathic) health practitioner.

Monocular acuity norms for the Teller Acuity Cards between ages one month and four years

PURPOSE

To derive norms for monocular grating acuity and interocular acuity differences that are appropriate for clinical applications using the acuity card procedure (ACP) and Teller Acuity Cards (TAC).

METHODS

Monocular acuities were measured in 460 children in 12 age groups between 1 month and 4 years. Inclusion criteria were term birth, good general health and normal development, normal eyes, and cycloplegic refraction within specific limits. Each child was tested by two ACP testers who were aware of TAC spatial frequency but not grating location during testing.

RESULTS

Three monocular tests were completed in the first session in 99% of children. Median time to complete the tests of both eyes ranged from 3.2 to 8.4 minutes. Monocular acuity norms were calculated using 95% and 99% prediction limits. The new norms spanned higher spatial frequencies than the preliminary ACP norms between ages 1 month and 18 months but were similar between 24 and 36 months. The lower normal 2.5% limits were similar to lower limits of other normative studies. The interocular acuity difference was zero or 0.5 octave in 99% of subjects of all ages. Acuities obtained by the same tester on different days and by different testers on the same day were within 0.5 octave in at least 90% of subjects, comparable to previous studies.

CONCLUSIONS

This study provides monocular acuity norms that are appropriate for clinical settings in which the ACP and TAC are used and should replace the preliminary ACP norms.

Physical activity and stroke risk: the Framingham Study

The authors prospectively examined the influence of increased levels of physical activity on risk of stroke in members of the Framingham Study cohort. Two separate analyses were performed, one during midlife in 1,897 men (mean age = 49.7 years) and 2,299 women (mean age = 49.9 years) and another when the cohort was older (1,361 men (mean age = 63.0) and 1,862 women (mean age = 63.7)). A structured questionnaire administered at two separate examinations was used to estimate the amount of metabolic work done during a typical 24-hour period. Physical activity was categorized into tertiles, and medium and high levels of physical activity were compared with a low level of physical activity, which was used as the referent group. Cox proportional hazards, life table, and time-dependent covariate analyses were used to examine the relation between level of physical activity and stroke risk over a follow-up period of up to 32 years. In men, adjusted analyses revealed that increased levels of physical activity were protective. The strongest effect was obtained from an analysis involving older cohort members in the medium tertile (risk ratio = 0.41, 95% confidence interval 0.24-0.69). High levels of physical activity did not confer an additional benefit over medium levels. Adjusted analyses showed no significant protective effect in women. These results indicate that medium and high levels of physical activity among men are protective against stroke relative to low levels.

Gamma-globulin treatment of acute myocarditis in the pediatric population

BACKGROUND

Myocardial damage in myocarditis is mediated, in part, by immunological mechanisms. High-dose intravenous gamma-globulin (IVIG) is an immunomodulatory agent that is beneficial in myocarditis secondary to Kawasaki disease, as well as in murine myocarditis. Since 1990, the routine management of presumed acute myocarditis at Children's Hospital, Boston, and Children's Hospital, Los Angeles, has included administration of high-dose IVIG.

METHODS AND RESULTS

We treated 21 consecutive children presenting with presumed acute myocarditis with IVIG, 2 g/kg, over 24 hours, in addition to anticongestive therapies. A comparison group comprised 25 recent historical control patients meeting identical eligibility criteria but not receiving IVIG therapy. Left ventricular function was assessed during five time intervals: 0 to 7 days, 1 to 3 weeks, 3 weeks to 3 months, 3 to 6 months, and 6 to 12 months. At presentation, the IVIG and non-IVIG groups had comparable left ventricular enlargement and poor fractional shortening. Compared with the non-IVIG group, those treated with IVIG had a smaller mean adjusted left ventricular end-diastolic dimension and higher fractional shortening in the periods from 3 to 6 months (P = .008 and P = .033, respectively) and 6 to 12 months (P = .072 and P = .029, respectively). When adjusting for age, biopsy status, intravenous inotropic agents, and angiotensin-converting enzyme inhibitors, patients treated with IVIG were more likely to achieve normal left ventricular function during the first year after presentation (P = .03). By 1 year after presentation, the probability of survival tended to be higher among IVIG-treated patients (.84 versus .60, P = .069). We observed no adverse effects of IVIG administration.

CONCLUSIONS

These data suggest that use of high-dose IVIG for treatment of acute myocarditis is associated with improved recovery of left ventricular function and with a tendency to better survival during the first year after presentation.

Gamma globulin re-treatment in Kawasaki disease

We retrospectively reviewed the effects of intravenous gamma-globulin (IVGG) re-treatment of 13 children with Kawasaki disease and persistent or recrudescent fever. Fever and mucocutaneous inflammation resolved within 48 hours in nine patients; fever abated in two other children after a third course of IVGG. We conclude that IVGG re-treatment of Kawasaki disease appears to be safe and may improve the clinical course.

Familial aggregation of stroke. The Framingham Study

BACKGROUND AND PURPOSE

Family history is perceived to be an important risk factor for stroke despite conflicting published data. We examined patterns of familial aggregation of stroke among three generations using data from the Framingham Study.

METHODS

Cox proportional hazards analyses, adjusting for known stroke risk factors, were used to examine familial concordance in three groups: (1) members of the original Framingham cohort using reported parental stroke death; (2) members of the Framingham Offspring Study and their parents (members of the original Framingham Study); and (3) sibships within the original Framingham cohort.

RESULTS

We found no association between stroke or transient ischemic attack among original cohort members and their reported parental stroke death (n = 4933; relative risk [RR] = 1.07). Using verified cases of parental stroke or transient ischemic attack, the Offspring analyses revealed that both paternal (n = 1762; RR = 2.4; 95% confidence interval [CI], 0.96 to 6.03) and maternal (n = 2074; RR = 1.4; 95% CI, 0.60 to 3.25) histories were associated with an increased risk. Parental history of coronary heart disease was strongly associated with stroke or transient ischemic attack among Offspring Study members (RR = 3.33; 95% CI, 1.27 to 8.72). Sibling history of stroke or transient ischemic attack was not associated with stroke or transient ischemic attack among original cohort members, although a non-statistically significant increased risk associated with sibling history of atherothrombotic brain infarction was observed (RR = 1.8; 95% CI, 0.68 to 4.94).

CONCLUSIONS

These analyses suggest that parental history of stroke may be a risk factor for stroke. As more stroke or transient ischemic attack events develop among the Offspring Study members, it will be valuable to reexamine these associations.

A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh

A community-based intervention was developed through direct participation of the target population in assessment and iterative trials to improve hygiene practices and to reduce childhood diarrhoea in lowland rural Bangladesh. A total of 185 (98%) households with children ages 0-18 months in five contiguous villages were targeted for the interventions. A comparison site was selected for a detailed observational study and for use as a control for the intervention. About 97% of all households with children ages 0-18 months were enrolled for study at the control site. Children in this age group were targeted because at this developmental stage they were most vulnerable to diarrhoeal morbidity and malnutrition (related to unhygienic practices). The intervention was implemented with the assistance of village leaders through a "Clean Life" campaign by local project workers and volunteer mothers who were chosen from the target households. The intervention activities started in January 1986 and lasted for 7 months. Higher adoption rates of the intervention were associated with better cleanliness status, which was related to lower diarrhoea and malnutrition rates in the intervention site. The results of between-site longitudinal analyses showed that after the intervention, the intervention site had substantially higher cleanliness scores, lower diarrhoeal morbidity, and better growth status compared to those of the control site, with differences increasing over time. The findings suggest that this type of community-based intervention can be very beneficial in modifying hygiene behaviours and lowering childhood diarrhoea and malnutrition.

Maternal education and child feeding practices in rural Bangladesh

This study in rural lowland Bangladesh used spot and event observations from 185 children aged 4-27 months in order to examine whether child feeding practices differed with mother's education and with household education. Each child and his/her caretakers were observed for a mean of 20 hr over 6 months from February to July 1986. Only 25% of mothers and 51% of fathers had had any formal education. Exploratory partial correlations and stepwise multiple regression analyses revealed significant behavioral differences with both maternal and household measures of education while controlling for wealth. Caretakers in families with education were found to feed the children more frequently, with fresher food, and in cleaner, more protected places. They did not allow their children to eat food intended for someone else as often, and were more observant when their children's food dropped during the feeding. These caretakers also used more cups and bottles for feedings, breastfed their children less frequently, and their mothers terminated the breastfeedings more often. These behaviors suggested a shift from less attentive feeding practices and less frequent feedings to more frequent feedings in which the caretaker took more control of the child's feeding sessions. They also suggest a commitment to more labor-intensive child care. These associations between education and child feeding practices are mechanisms through which maternal education may improve child health and growth. They suggest the need for promoting more formal and nonformal education.

Effects of nutritional counseling on lipoprotein levels in a pediatric lipid clinic

OBJECTIVE

To determine the impact of nutritional counseling on lipoprotein profiles in dyslipoproteinemic children.

DESIGN

Retrospective case review.

SETTING

An academic hospital-based pediatric lipid clinic in Boston, Mass.

PARTICIPANTS

One hundred four newly referred children with primary dyslipoproteinemia.

INTERVENTIONS

Nutritional recommendations were adapted from the National Cholesterol Education Program's step 2 diet. Three-day diet records were used to assess baseline and follow-up diets.

RESULTS

Two thirds of the children continued to have excellent diets or improved their diets after counseling, but low-density lipoprotein cholesterol (LDL-c) values decreased by 15% or more in only 19% of children. The observed change in LDL-c was not significantly associated with nutritional counseling. However, a strong correlation was evident between dietary interventions and concentration of high-density lipoprotein cholesterol (HDL-c) values in serum. Marked fat restriction lowered HDL-c levels, while liberalization of use of fat, with emphasis on monounsaturates, in a subset of children following an excessively fat-restricted diet on presentation, appeared to improve HDL-c levels.

CONCLUSIONS

After nutritional counseling, LDL-c levels decreased by 15% or more in only 19% of dyslipoproteinemic children referred for treatment. There were no clear predictors of LDL-c responsiveness, but changes in dietary fat intake appeared to significantly influence HDL-c levels.

Audiologic profiles of children with Kawasaki disease

Kawasaki disease (KD) is an idiopathic vasculitis associated with systemic inflammation and profound immunoregulatory changes. Recent reports from Japan and the United States have documented the association of sensorineural hearing loss (SNHL) with acute KD. To further characterize the nature and prevalence of this complication, we prospectively evaluated the hearing of 40 consecutive patients with acute KD at a single institution. Standard audiometric procedures were used, including visual reinforcement audiometry and play audiometry. Auditory brainstem response (ABR) testing using clicks and tone pips (1000-4000 Hz) was performed in patients with abnormal or unreliable results on behavioral audiometry. Acoustic immittance measurements were obtained on all patients. Of the 23 males and 17 females (mean age 3.2 +/- 2.3 years, range 0.6-11.1 years), all but three were evaluated and treated with aspirin and intravenous gama globulin within 1 month of onset of fever. Seven children had test results suggesting sensorineural threshold shifts, 16 had normal hearing, and 14 had inconclusive hearing evaluations. Laboratory data in patients with hearing threshold shifts revealed significantly longer duration of fever (4.1 +/- 1.0 versus 1.9 +/- 0.5 days), and a tendency for higher temperatures and white blood cell counts at diagnosis compared to those with normal hearing. Results suggest that transient as well as persistent SNHL may be associated with the acute vasculitis of KD, and may be associated with laboratory markers indicating more severe systemic inflammation. Audiologic screening should be considered for all patients following KD.

Altered lipid profile after Kawasaki syndrome

BACKGROUND

Delineation of lipid values in children after Kawasaki syndrome is important because of the predilection of this disease for the coronary arteries.

METHODS AND RESULTS

We measured plasma concentrations of total cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides using enzymatic methods in 105 patients with a history of Kawasaki syndrome. Measurements were obtained during six time periods: 10 days or less, 11-31 days, 1-3 months, 3-12 months, 1-3 years, and more than 3 years. Total cholesterol was depressed in the first interval (122.0 +/- 19.8 mg/dl, mean +/- SD), but the mean values were normal in all periods after clinical recovery (overall mean, 149.0 +/- 24.0 mg/dl). High density lipoprotein cholesterol was also depressed in the first interval (15.2 +/- 9.9 mg/dl); although high density lipoprotein cholesterol increased significantly with duration since disease onset (p less than 0.001), it remained significantly lower than expected (p less than 0.001), even in the latest interval (47.2 +/- 10.9 mg/dl). Nonfasting triglyceride levels were high (162.5 +/- 63.4 mg/dl) in the first interval and then diminished steadily with time, but this relation did not achieve statistical significance. We compared adjusted lipid levels (z scores) of 46 Kawasaki patients after clinical recovery with those of their parents; patients had similar total cholesterol levels but significantly lower high density lipoprotein cholesterol levels (p = 0.021 for mothers, p = 0.001 for fathers). Mean high density lipoprotein cholesterol after clinical recovery tended to be lower in patients with persistent coronary abnormalities than in those without such lesions (p = 0.085).

CONCLUSIONS

Kawasaki syndrome is associated with important abnormalities in lipid metabolism. Continued long-term surveillance of this population is necessary to monitor lipid levels and their relation to future development of coronary atherosclerosis.

A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome

BACKGROUND

Treatment of acute Kawasaki syndrome with a four-day course of intravenous gamma globulin, together with aspirin, has been demonstrated to be safe and effective in preventing coronary-artery lesions and reducing systemic inflammation. We hypothesized that therapy with a single, very high dose of gamma globulin would be at least as effective as the standard regimen.

METHODS

We conducted a multicenter, randomized, controlled trial involving 549 children with acute Kawasaki syndrome. The children were assigned to receive gamma globulin either as a single infusion of 2 g per kilogram of body weight over 10 hours or as daily infusions of 400 mg per kilogram for four consecutive days. Both treatment groups received aspirin (100 mg per kilogram per day through the 14th day of illness, then 3 to 5 mg per kilogram per day).

RESULTS

The relative prevalence of coronary abnormalities, adjusted for age and sex, among patients treated with the four-day regimen, as compared with those treated with the single-infusion regimen, was 1.94 (95 percent confidence limits, 1.01 and 3.71) two weeks after enrollment and 1.84 (95 percent confidence limits, 0.89 and 3.82) seven weeks after enrollment. Children treated with the single-infusion regimen had lower mean temperatures while hospitalized (day 2, P less than 0.001; day 3, P = 0.004), as well as a shorter mean duration of fever (P = 0.028). Furthermore, in the single-infusion group the laboratory indexes of acute inflammation moved more rapidly toward normal, including the adjusted serum albumin level (P = 0.004), alpha 1-antitrypsin level (P = 0.007), and C-reactive protein level (P = 0.017). Lower IgG levels on day 4 were associated with a higher prevalence of coronary lesions (P = 0.005) and with a greater degree of systemic inflammation. The two groups had a similar incidence of adverse effects (including new or worsening congestive heart failure in nine children), which occurred in 2.7 percent of the children overall. All the adverse effects were transient.

CONCLUSIONS

In children with acute Kawasaki disease, a single large dose of intravenous gamma globulin is more effective than the conventional regimen of four smaller daily doses and is equally safe.

Clinical and epidemiologic characteristics of patients referred for evaluation of possible Kawasaki disease. United States Multicenter Kawasaki Disease Study Group

STUDY OBJECTIVES

(1) To determine those diseases that most often mimic Kawasaki disease (KD) in the United States. (2) To examine the physical findings and laboratory studies that influenced experienced clinicians to exclude the diagnosis of KD. (3) To compare epidemiologic features of patients with KD and patients referred for evaluation of possible KD in whom alternative diagnoses were established.

DESIGN

Case comparison study.

SETTING

Seven pediatric tertiary care centers.

PATIENTS

Consecutive sample of 280 patients with KD and 42 comparison patients examined within the first 14 days after onset of fever.

MEASUREMENTS AND MAIN RESULTS

(1) Infectious diseases, particularly measles and group A beta-hemolytic streptococcal infection, most closely mimicked KD and accounted for 35 (83%) of 42 patients in the comparison group. (2) The standard diagnostic clinical criteria for KD were fulfilled in 18 (46%) of 39 patients in whom other diagnoses were established. (3) Patients with KD were significantly less likely to have exudative conjunctivitis or pharyngitis, generalized adenopathy, and discrete intraoral lesions, and more likely to have a perineal distribution of their rash. The patients with KD were also more likely to have anemia and elevated erythrocyte sedimentation rate; leukocyte count less than 10 X 10(3)/mm3 and platelet count less than 200 X 10(3)/mm3 were significantly less prevalent in patients with KD. (4) Residence within 200 yards of a body of water was more common among KD patients.

CONCLUSIONS

(1) Measles and streptococcal infection should be excluded in patients examined for possible KD. (2) Laboratory studies that may be useful in discriminating patients with KD from those with alternative diagnoses include hemoglobin concentration, erythrocyte sedimentation rate, and serum alanine aminotransferase activity. (3) Residence near a body of water may be a risk factor for the development of KD.

Left ventricular contractility and function in Kawasaki syndrome. Effect of intravenous gamma-globulin

To investigate the effect of Kawasaki syndrome on myocardial function, as well as the influence of high-dose intravenous gamma-globulin therapy on resolution of functional abnormalities, we studied 98 patients with Kawasaki syndrome during five time intervals from onset of illness: 1) 10 days or less, 2) 11-31 days, 3) 1-3 months, 4) 3-12 months, and 5) 1-3 years. Normal controls included 48 children under age 8 years, without known cardiovascular disease. Using two-dimensional directed M-mode echocardiograms, we obtained chamber dimensions, fractional shortening, rate-corrected velocity of shortening (Vcfc) adjusted for end-systolic wall stress, and early diastolic function parameters that included adjusted peak rates of left ventricular dimension change, wall thinning, and their respective timing. Left ventricular systolic and diastolic dimensions were larger (both p less than 0.01) in patients than in normal subjects in period 1. Stress-adjusted Vcfc was much lower in patients in the 3 months after disease onset; by period 5, contractility was comparable in patients and normal subjects. Adjusted indexes of early diastolic function did not differ significantly between patients and normal subjects. To investigate the effect of gamma-globulin, we analyzed data on 47 patients prospectively randomized to therapy with aspirin alone (n = 19, 40%) or to aspirin plus gamma-globulin, 400 mg/kg/day for 4 consecutive days (n = 28, 60%). In period 1, before treatment, the two groups had mean fractional shortening and stress-adjusted Vcfc comparable to each other but much lower than those of normal subjects (p less than or equal to 0.001). Patients treated with aspirin alone continued to have diminished fractional shortening and Vcfc compared with normal subjects in periods 2, 3, and 4 (all p less than or equal to 0.05). In contrast, fractional shortening and Vcfc in gamma-globulin-treated patients in these periods were comparable to those of normal subjects. By period 5, no difference was detected in systolic function or contractility between either treatment group and normal subjects. We conclude that early abnormalities of left ventricular contractility and myocardial function, as assessed by echocardiography, generally resolve by 1-3 years after disease onset and that recovery is accelerated by administration of IVGG in the acute phase.

The treatment of Kawasaki syndrome with intravenous gamma globulin

We compared the efficacy of intravenous gamma globulin plus aspirin with that of aspirin alone in reducing the frequency of coronary-artery abnormalities in children with acute Kawasaki syndrome in a multicenter, randomized trial. Children randomly assigned to the gamma globulin group received intravenous gamma globulin, 400 mg per kilogram of body weight per day, for four consecutive days; both treatment groups received aspirin, 100 mg per kilogram per day, through the 14th day of illness, then 3 to 5 mg per kilogram per day. Two-dimensional echocardiograms were interpreted blindly and independently by two or more readers. Two weeks after enrollment, coronary-artery abnormalities were present in 18 of 78 children (23 percent) in the aspirin group, as compared with 6 of 75 (8 percent) in the gamma globulin group (P = 0.01). Seven weeks after enrollment, abnormalities were present in 14 of 79 children (18 percent) in the aspirin group and in 3 of 79 (4 percent) in the gamma globulin group (P = 0.005). No child had serious adverse effects from receiving gamma globulin. We conclude that high-dose intravenous gamma globulin is safe and effective in reducing the prevalence of coronary-artery abnormalities when administered early in the course of Kawasaki syndrome.