Mapping the planet's critical areas for biodiversity and nature's contributions to people

Meeting global commitments to conservation, climate, and sustainable development requires consideration of synergies and tradeoffs among targets. We evaluate the spatial congruence of ecosystems providing globally high levels of nature's contributions to people, biodiversity, and areas with high development potential across several sectors. We find that conserving approximately half of global land area through protection or sustainable management could provide 90% of the current levels of ten of nature's contributions to people and meet minimum representation targets for 26,709 terrestrial vertebrate species. This finding supports recent commitments by national governments under the Global Biodiversity Framework to conserve at least 30% of global lands and waters, and proposals to conserve half of the Earth. More than one-third of areas required for conserving nature's contributions to people and species are also highly suitable for agriculture, renewable energy, oil and gas, mining, or urban expansion. This indicates potential conflicts among conservation, climate and development goals.

Mapping the planet's critical natural assets

Sustaining the organisms, ecosystems and processes that underpin human wellbeing is necessary to achieve sustainable development. Here we define critical natural assets as the natural and semi-natural ecosystems that provide 90% of the total current magnitude of 14 types of nature's contributions to people (NCP), and we map the global locations of these critical natural assets at 2 km resolution. Critical natural assets for maintaining local-scale NCP (12 of the 14 NCP) account for 30% of total global land area and 24% of national territorial waters, while 44% of land area is required to also maintain two global-scale NCP (carbon storage and moisture recycling). These areas overlap substantially with cultural diversity (areas containing 96% of global languages) and biodiversity (covering area requirements for 73% of birds and 66% of mammals). At least 87% of the world's population live in the areas benefitting from critical natural assets for local-scale NCP, while only 16% live on the lands containing these assets. Many of the NCP mapped here are left out of international agreements focused on conserving species or mitigating climate change, yet this analysis shows that explicitly prioritizing critical natural assets and the NCP they provide could simultaneously advance development, climate and conservation goals.

Comparative mapping and validation of multiple disease resistance QTL for simultaneously controlling common and dwarf bunt in bread wheat

KEY MESSAGE

Resistance QTL on chromosomes 1AL and 7AL are effective against common and dwarf bunt, QTL on 1BS affects common bunt and QTL on 7DS affects dwarf bunt in bread wheat. Common bunt, caused by Tilletia caries and T. laevis, and dwarf bunt, caused by T. controversa, negatively affect grain yield and quality of wheat and are particularly destructive in low-input and organic production systems. Two recombinant inbred line (RIL) populations derived by crossing the highly and durably resistant cultivars 'Blizzard' and 'Bonneville' to the susceptible cultivar 'Rainer' were evaluated for their resistance to common and dwarf bunt in artificially inoculated field and greenhouse trials over two growing seasons and genotyped with a 15 K SNP array. Bunt resistance QTL were mapped to chromosomes 1AL, 1BS, 7AL and 7DS. Common bunt resistance was regulated by the major QTL QBt.ifa-1BS and QBt.ifa-1AL together with the moderate effect QTL QBt.ifa-7AL. Dwarf bunt resistance was on the other hand regulated by the QTL QBt.ifa-1AL, QBt.ifa-7AL and QBt.ifa-7DS. Common bunt resistance QTL exhibited pronounced epistatic effects, while epistatic effects were of smaller magnitude for dwarf bunt QTL. Kompetitive Allele-Specific PCR (KASP) markers were developed from SNPs associated with bunt resistance QTL and successfully used for QTL validation in an independent set of RILs. These KASP markers have the potential to support targeted introgression of QTL into elite wheat germplasm and accelerate breeding for enhanced bunt resistance. Durable protection against both common and dwarf bunt can be achieved by combining multiple resistance genes in the same genetic background.

Genetic characterization and genome-wide association mapping for dwarf bunt resistance in bread wheat accessions from the USDA National Small Grains Collection

Dwarf bunt-resistant bread wheat accessions and SNP markers associated with DB resistance identified in this study are valuable resources for characterization and deployment of DB resistance in bread wheat. Dwarf bunt (DB), caused by Tilletia controversa J.G. Kühn, can significantly reduce grain yield and quality on autumn-sown wheat in regions with prolonged snow cover. DB can be managed with the use of resistant cultivars. The objectives of the present study were to characterize DB resistance in a large set of bread wheat accessions from the National Small Grains Collection and use a genome-wide association study approach to identify genetic loci associated with DB resistance. A total of 292 accessions were selected using historical DB resistance data recorded across many trials and years in the Germplasm Resources Information Network (GRIN) and re-tested for DB resistance in replicated field nurseries in Logan, UT, in 2017, 2018, and 2019. Ninety-eight accessions were resistant with DB normalized incidence ≤ 10%, and twenty-eight of these were highly resistant with DB normalized incidence ≤ 1% in both GRIN and the field nurseries. Based on the presence of marker haplotypes of the four published dwarf bunt QTL on 6DS, 6DL, 7AL, and 7DS, highly resistant accessions identified in this study may provide novel resistance and should be further evaluated. This study validated one previously identified QTL on 6DS and identified an additional locus on 6DS. These loci explained 9-15% of the observed phenotypic variation. The resistant accessions and molecular markers identified in the present study may provide valuable resources for characterization and deployment of DB resistance in bread wheat.

Identification and assessment of two major QTLs for dwarf bunt resistance in winter wheat line 'IDO835'

Two major dwarf bunt resistance QTLs were mapped to a known Bt9 locus and a novel locus. The associated KASP markers were developed and validated in other two populations. Dwarf bunt (DB), caused by Tilletia controversa J.G. Kühn, and common bunt (CB), caused by T. caries and T. foetida, are two destructive diseases that reduce grain yield and quality in wheat. Breeding for bunt-resistant cultivars is important in many wheat production areas, especially where organic wheat is grown. However, few molecular markers have been used in selection of bunt resistance. In the present study, a doubled haploid (DH) population derived from the bunt-resistant line 'IDO835' and the susceptible cultivar 'Moreland' was evaluated for DB resistance in a field nursery in Logan, Utah, for four growing seasons. The population was genotyped with the Illumina 90 K SNP iSelect marker platform. Two major QTLs were consistently identified on chromosomes 6DL (Q.DB.ui-6DL) and 7AL (Q.DB.ui-7AL), explaining up to 53% and 38% of the phenotypic variation, respectively. Comparative study suggested that Q.DB.ui-6DL was located in the same region as the CB resistance gene Bt9, and Q.DB.ui-7AL was located at a novel locus for bunt resistance. Based on Chinese Spring reference sequence and annotations (IWGSC RefSeq v1.1), both resistance QTLs were mapped to disease resistance gene-rich (NBS-LRR and kinase genes) regions. To validate the identified QTL and design user-friendly markers for MAS, five SNPs were converted to Kompetitive Allele-Specific PCR (KASP) markers and used to genotype two validation panels, including a DH population and a diverse winter wheat population from USDA-ARS National Small Grain Collection, as well as a Bt gene investigation panel, consisting of 15 bunt differential lines and 11 resistant lines.

Modeling of crop wild relative species identifies areas globally for in situ conservation

The impact of climate change is causing challenges for the agricultural production and food systems. More nutritious and climate resilient crop varieties are required, but lack of available and accessible trait diversity is limiting crop improvement. Crop wild relatives (CWR) are the wild cousins of cultivated crops and a vast resource of genetic diversity for breeding new, higher yielding, climate change tolerant crop varieties, but they are under-conserved (particularly in situ), largely unavailable and therefore underutilized. Here we apply species distribution modelling, climate change projections and geographic analyses to 1261 CWR species from 167 major crop genepools to explore key geographical areas for CWR in situ conservation worldwide. We identify 150 sites where 65.7% of the CWR species identified can be conserved for future use.

Evaluating the impacts of protected areas on human well-being across the developing world

Protected areas (PAs) are fundamental for biodiversity conservation, yet their impacts on nearby residents are contested. We synthesized environmental and socioeconomic conditions of >87,000 children in >60,000 households situated either near or far from >600 PAs within 34 developing countries. We used quasi-experimental hierarchical regression to isolate the impact of living near a PA on several aspects of human well-being. Households near PAs with tourism also had higher wealth levels (by 17%) and a lower likelihood of poverty (by 16%) than similar households living far from PAs. Children under 5 years old living near multiple-use PAs with tourism also had higher height-for-age scores (by 10%) and were less likely to be stunted (by 13%) than similar children living far from PAs. For the largest and most comprehensive socioeconomic-environmental dataset yet assembled, we found no evidence of negative PA impacts and consistent statistical evidence to suggest PAs can positively affect human well-being.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Rapid Assessment of Ecosystem Service Co-Benefits of Biodiversity Priority Areas in Madagascar

The importance of ecosystems for supporting human well-being is increasingly recognized by both the conservation and development sectors. Our ability to conserve ecosystems that people rely on is often limited by a lack of spatially explicit data on the location and distribution of ecosystem services (ES), the benefits provided by nature to people. Thus there is a need to map ES to guide conservation investments, to ensure these co-benefits are maintained. To target conservation investments most effectively, ES assessments must be rigorous enough to support conservation planning, rapid enough to respond to decision-making timelines, and often must rely on existing data. We developed a framework for rapid spatial assessment of ES that relies on expert and stakeholder consultation, available data, and spatial analyses in order to rapidly identify sites providing multiple benefits. We applied the framework in Madagascar, a country with globally significant biodiversity and a high level of human dependence on ecosystems. Our objective was to identify the ES co-benefits of biodiversity priority areas in order to guide the investment strategy of a global conservation fund. We assessed key provisioning (fisheries, hunting and non-timber forest products, and water for domestic use, agriculture, and hydropower), regulating (climate mitigation, flood risk reduction and coastal protection), and cultural (nature tourism) ES. We also conducted multi-criteria analyses to identify sites providing multiple benefits. While our approach has limitations, including the reliance on proximity-based indicators for several ES, the results were useful for targeting conservation investments by the Critical Ecosystem Partnership Fund (CEPF). Because our approach relies on available data, standardized methods for linking ES provision to ES use, and expert validation, it has the potential to quickly guide conservation planning and investment decisions in other data-poor regions.

A novel QTL associated with dwarf bunt resistance in Idaho 444 winter wheat

KEY MESSAGE

A novel QTL, Q.DB.ui-7DS, and the PCR-based markers identified in the current study will accelerate variety development for resistance to dwarf and common bunt of wheat. Dwarf bunt [Tilletia controversa J.G. Kühn [as 'contraversa'], in Rabenhorst, Hedwigia 13: 188 (1874)] is a destructive disease of wheat (Triticum aestivum L.) that reduces grain yield and quality. A number of distinct genes conferring resistance to dwarf bunt have been used by breeding programs for nearly 100 years. However, few markers were identified that can be used in selection of dwarf bunt resistance. A recombinant inbred line (RIL) population derived from the bunt-resistant germplasm, Idaho 444 (IDO444), and the susceptible cultivar, Rio Blanco, was evaluated for phenotypic reaction to dwarf bunt inoculation in four trials in two locations (USU and USDA) over 3 years. The population was genotyped with the Diversity Arrays Technology (DArT) and the Illumina Infinium 9K iSelect marker platforms. A total of three QTL were detected, and resistant alleles were from IDO444. QTL Q.DB.ui-7DS on 7DS was determined based on the location of a DArT marker wPt-2565 (X116197), which was consistently detected and explained 32 to 56 % of phenotypic variation among the four trials. QTL Q.DB.ui-1A on 1A was detected in three Utah State University (USU) trials and explained 11-15 % of phenotypic variation. QTL Q.DB.ui-2B on 2B was detected in two USU and one United States Department of Agriculture (USDA) trials and explained up to 6 % of phenotypic variation. Two PCR-based markers were developed based on the sequence of wPt-2565 and validated in the RIL population and used in genotyping of dwarf bunt differential lines, known resistance sources, and resistant cultivars.

Estimation of genetic diversity using SSR markers in sunflower

Microsatellites or simple sequence repeats (SSRs) were used for the estimation of genetic diversity among a group of 40 sunflower lines developed at the research area of Department of Plant Breeding and Genetics, University of Agriculture, Faisalabad. Total numbers of alleles amplified by 22 polymorphic primers were 135 with an average of 6.13 alleles per locus, suggesting that SSR is a powerful technique for assessment of genetic diversity at molecular level. The expected heterozygosity (PIC) ranged from 0.17 to 0.89. The highest PIC value was observed at the locus C1779. The genetic distances ranged from 9 to 37%. The highest genetic distance was observed between the lines L50 and V3. Genetic distances were low showing lesser amount of genetic diversity among the sunflower lines.

Expression and functional analysis of NUCLEAR FACTOR-Y, subunit B genes in barley

NUCLEAR FACTOR-Y, subunit B (NF-YB) comprises a multigene family in plants and has been shown to play important roles in growth, development, and response to environmental stress. In this study, five NF-YBs containing the full-length coding region were obtained from barley (Hordeum vulgare) through database sequence analysis, cloning, and sequencing. Sequence alignment and phylogenetic analysis showed that HvNF-YB3 and HvNF-YB1 were clustered with NF-YB2 and NF-YB3 in Arabidopsis, suggesting these NF-YBs are evolutionary and functionally related. To test this hypothesis, HvNF-YB3 and HvNF-YB1 were overexpressed in Arabidopsis. Overexpression of HvNF-YB1 greatly promoted early flowering in Arabidopsis, supporting that HvNF-YB1may have conserved gene function in flowering time control as NF-YB2 and NF-YB3 in Arabidopsis. Overexpression of HvNF-YB3 in Arabidopsis had no effect on flowering time. An analysis of barley single-nucleotide polymorphism (SNP) data, however, revealed a significant association between an HvNF-YB3 SNP and heading date. While it is unknown whether HvNF-YB3 directly contributes to heading date regulation, the results implied that HvNF-YB3 may also have conserved function in flowering time (heading date in barley) control. Further studies are needed to directly verify these gene functions in barley. Barley NF-YBs showed different expression patterns associated with tissue types, developmental stages, and response to different stress treatments, suggesting that barley NF-YBs may be involved in other physiological processes.

The Shallow Implantation of Bismuth During the Growth of Bismuth Nanocrystals in Al2O3 by Pulsed Laser Deposition

The effect of the laser energy density used to deposit Bi onto amorphous aluminum oxide (a-Al2O3) on the growth of Bi nanocrystals has been investigated using transmission electron microscopy of cross section samples. The laser energy density on the Bi target was varied by one order of magnitude (0.4 to 5 J cm-2). Across the range of energy densities, in addition to the Bi nanocrystals nucleated on the a-Al2O3 surface, a dark and apparently continuous layer appears below the nanocrystals. Energy dispersive X-ray analysis on the layer have shown it is Bi rich. The separation from the Bi layer to the bottom of the nanocrystals on top is consistent with the implantation range of Bi species in a-Al2O3. As the laser energy density increases, the implantation range has been measured to increase. The early stages of the Bi growth have been analyzed in order to determine how the Bi implanted layer develops.

Malignant disease in peptic ulcer surgery patients after long term follow-up: A cohort study of 1992 patients

AIMS

To assess the effect of previous peptic ulcer surgery on subsequent malignant events, in particular in relation to previous vagotomy, a historical cohort study was conducted.

METHODS

All patients undergoing surgery for peptic ulcer disease with accurate follow-up data at a large peptic ulcer clinic in the Western Infirmary, Glasgow, from 1965 to 1983 were assessed. All cancer events and specific cancer events (gastric, bronchial, laryngeal, colorectal, bladder, breast, prostate, pancreas, kidney, oesophageal cancers) were determined as outcome measures and expressed as standardised incidence ratio (SIR).

RESULTS

Vagotomy and drainage accounted for 67% of all procedures for peptic ulcer disease. Eighty-three percent were habitual smokers. For all peptic ulcer surgery patients, the SIR for all cancer events was 0.86. For specific cancers, the SIRs were bronchial cancer (SIR 1.13); laryngeal cancer (SIR 2.17), colorectal cancer (SIR 0.67). For vagotomised patients the risk of gastric cancer was significantly elevated (SIR 1.50).

CONCLUSIONS

An excess of cancers attributable to smoking have been found in peptic ulcer surgery patients. Vagotomised patients have a higher risk of gastric cancer after long term follow-up. This finding may have implications for screening and the safety of long term acid suppression with agents such as proton pump inhibitors.

A comparison of the anatomic distribution of cutaneous melanoma in two populations with different levels of sunlight: the west of Scotland and Queensland, Australia 1982-2001

To explore whether the anatomic distribution of melanoma differs with ambient sunlight levels, we compared age- and site-specific melanoma incidence in two genetically similar populations from different geographic regions. We ascertained all new cases of invasive cutaneous melanoma in the west of Scotland and Queensland 1982-2001. Melanoma incidence was calculated for four anatomic regions (head and neck, trunk, upper and lower limbs), standardized to the European population and adjusted for relative surface area of each site. Highest rates among males aged <40 years and 40-59 years were observed on the trunk, but on the upper limbs among Queensland females and lower limbs among Scottish females. After age 60, melanoma rates were highest on the head and neck in both sexes. In both sexes and at all ages, lower limb melanomas were more common in Scotland than expected from the Queensland population. These analyses indicate that while the overall distribution of melanoma is similar in populations with different levels of ambient sunlight, important differences remain. Identifying the causes of these differences is likely to provide better understanding of how sunlight causes melanoma.

Comparison of breast cancer mortality rates with those of ovarian and colorectal carcinoma

Background

Traditional survival curves cannot easily be used to predict outcome for an individual patient on a year-to-year basis. This difficulty is partly overcome by yearly mortality analysis. This method was employed to analyse long-term follow-up of three cancers: colorectal, ovarian and breast cancer.

Methods

The study used prospectively collected cancer registry data from geographically defined regions in Scotland. Cohort sizes were 7196 patients with breast cancer, 3200 with colorectal cancer and 1866 with ovarian cancer. Follow-up extended to 23 years.

Results

Two distinct patterns of mortality emerged. Mortality rates for ovarian and colorectal cancer were initially high (41 and 21 per cent) but decreased rapidly; by 10 years patients had either died or were cured. The influence of stage diminished with follow-up. Breast cancer mortality was lower than that of colorectal or ovarian cancer, but remained raised in comparison to the general population throughout follow-up. The influence of breast cancer size reduced with follow-up, whereas that of nodal status persisted.

Conclusion

Patients with breast cancer live at increased risk of death to the end of follow-up, supporting the concept of dormancy in breast cancer biology. This was not observed with colorectal or ovarian cancer.

The natural history of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the USA, and it remains one of the few diseases that continues to increase its numbers. The development and progression of COPD can vary dramatically between individuals. A low level of lung function remains the cornerstone of COPD diagnosis and is a key predictor of prognosis. Lung function, however, is not the only factor in determining morbidity and mortality related to COPD, with factors such as body mass index, exercise capability and comorbid disease being important predictors of poor outcomes. Exacerbations of COPD are additional important indicators of both quality of life and outcomes in COPD patients. Definitions of exacerbations can vary, ranging from an increase in symptoms to COPD-related hospitalisations and death. COPD exacerbations are more common in patients with lower levels of lung function and may lead to more rapid declines in lung function. Better understanding of the natural history of COPD may lead to better definitions of specific COPD phenotypes, better interventions and improved outcomes.

Stomatal conductance is a key parameter to assess limitations to photosynthesis and growth potential in barley genotypes

Fourteen genotypes of barley were compared for response to salinity by monitoring the parameters gas exchange and chlorophyll fluorescence. We present relationships between stomatal conductance (gs) gas exchange chlorophyll fluorescence parameters and aboveground dry matter (AGDM). We found that genetic variability provided a continuum of data for gs across control and saline conditions. We used this continuum of gs values to test the overall relationships between gs and net photosynthesis (A), leaf internal CO2 concentration (Ci), actual quantum yield of PSII electron transport (PhiPSII), relative electron yield over net CO2 assimilation rate (ETR/A), and AGDM. The relationship between gs and A was highly significant (P < 0.0001) for both control and saline treatments, while correlations between gs and Ci, and Ci and A were significant only under control conditions. Unexpectedly, we found positive correlations between gs and PhiPSII (P < 0.0001) for both conditions. A comparison between relationships of gs and A, and gs and PhiPSII seemed to indicate a possible acclimation to salinity at the chloroplastic level. Finally, the relationships between gs and ETR/A were exceptionally strong for both growing conditions (P < 0.0001) indicating that, as gs values were negatively affected in barley by genetics and salinity as main or interactive effects, there was a progressive increase in photorespiration in barley. Overall, we found that stomatal conductance was a key parameter in the study of barley responses to limiting situations for photosynthesis. We also found a strong relationship between AGDM and gs regardless of growing conditions and genotypes. For breeding evaluations to select barley genotypes for salinity tolerance, it may be possible to replace all measurements of gas exchange and chlorophyll fluorescence by the simple use of a porometer.

A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study

OBJECTIVE

To examine the long-term cardiovascular consequences of angina in a large epidemiological study.

DESIGN

Prospective cohort study conducted between 1972 and 1976 with 20 years of follow-up (the Renfrew-Paisley Study).

SETTING

Renfrew and Paisley, West Scotland, UK.

PARTICIPANTS

7048 men and 8354 women aged 45-64 years who underwent comprehensive cardiovascular screening at baseline, including the Rose Angina Questionnaire and electrocardiography (ECG).

MAIN OUTCOME MEASURES

All deaths and hospitalisations for cardiovascular reasons occurring over the subsequent 20 years, according to the baseline Rose angina score and baseline ECG.

RESULTS

At baseline, 669 (9.5%) men and 799 (9.6%) women had angina on Rose Angina Questionnaire. All-cause mortality for those with Rose angina was 67.7% in men and 43.3% in women at 20 years compared with 45.4% and 30.4%, respectively, in those without angina (p<0.001). Values are expressed as hazards ratio (HR) (95% confidence interval (CI). In a multivariate analysis, men with Rose angina had an increased risk of cardiovascular death or hospitalisation (1.49 (1.33 to 1.66), myocardial infarction (1.63 (1.41 to 1.85)) or heart failure (1.54 (1.13 to 2.10)) compared with men without angina. The corresponding HR (95% CI) for women were 1.38 (1.23 to 1.55), 1.56 (1.31 to 1.85) and 1.92 (1.44 to 2.56). An abnormality on the electrocardiogram (ECG) increased risk further, and both angina and an abnormality on the ECG increased risk most of all compared with those with neither angina nor ischaemic changes on the ECG. Compared with men, women with Rose angina were less likely to have a cardiovascular event (0.54 (0.46 to 0.64)) or myocardial infarction (0.44 (0.35 to 0.56)), although there was no sex difference in the risk of stroke (1.11 (0.75 to 1.65)), atrial fibrillation (0.84 (0.38 to 1.87)) or heart failure (0.79 (0.51 to 1.21)).

CONCLUSIONS

Angina in middle age substantially increases the risk of death, myocardial infarction, heart failure and other cardiovascular events.

Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation: an analysis of the Renfrew/Paisley Study

BACKGROUND

There are few data describing the effect of socioeconomic deprivation on the risk of developing heart failure (HF).

AIMS

To examine the relationship between socioeconomic deprivation and hospitalisation with HF over 20 years.

METHODS

Between 1972 and 1976, 15,402 individuals, aged 45-64 years, residing in two towns in Scotland, underwent cardiovascular screening. We report hospitalisations with HF over the subsequent 20 years according to Carstairs deprivation category and Social Class.

RESULTS

Following screening, 628 men and women (4.1%) were hospitalised with a primary diagnosis of HF. There was a gradient in the risk of HF hospitalisation with increasing socioeconomic deprivation (P=0.003). Of the most deprived individuals, 6.4% were hospitalised for HF compared to 3.5% of the most affluent group. Cox-proportional Hazard models showed that independent of age, sex and baseline risk factors for cardio-respiratory status, greater socioeconomic deprivation increased the risk of HF admission (P<0.001, overall). The adjusted risk of admission for HF was 39% greater in the most versus least deprived subjects (RR 1.39 95% CI 1.04-2.01; P=0.04).

CONCLUSION

These data show a link between social deprivation and the risk of developing HF, irrespective of baseline cardio-respiratory status and cardiovascular risk factors.

Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew-Paisley study)

AIMS

To examine the long-term cardiovascular consequences of obesity and project the cardiovascular consequences of the recent increase in prevalence of obesity.

METHODS AND RESULTS

Between 1972 and 1976, 15 402 individuals aged 45-64, living in two towns in the west of Scotland underwent comprehensive cardiovascular screening. We analysed all deaths and hospitalizations for cardiovascular reasons occurring over the subsequent 20 years according to baseline body mass index (BMI) category. Compared with normal weight individuals (BMI 18.5-24.9), obesity (BMI > or =30) was associated with an increased adjusted risk of coronary heart disease (hazard ratio for death or hospital admission: 1.60, 95% CI 1.45-1.78), heart failure (2.09, 1.68-2.59), stroke (1.41, 1.21-1.65), venous thrombo-embolism (2.29, 1.60-3.30), and atrial fibrillation (1.75, 1.17-2.65). Obesity was associated with nine additional cardiovascular deaths and 36 additional cardiovascular hospital admissions for every 100 affected middle-aged men over the subsequent 20 years (seven deaths and 28 admissions in women). Assuming no change in cardiovascular risk profile and outcomes related to obesity, the increase in prevalence in 1998, when compared with 1972, is projected to lead to an additional four cardiovascular deaths and 14 admissions per 100 middle-aged men and women over the next 20 years.

CONCLUSION

Obesity is associated with an increase in a broad range of fatal and non-fatal cardiovascular events. Consideration of only coronary, only fatal, and only first events greatly underestimates the cardiovascular consequences of obesity.

Should diabetes be considered a coronary heart disease risk equivalent?: results from 25 years of follow-up in the Renfrew and Paisley survey

OBJECTIVE

The purpose of our study was to confirm or refute the view that diabetes be regarded as a coronary heart disease (CHD) risk equivalent and to test for sex differences in mortality.

RESEARCH DESIGN AND METHODS

This was a prospective cohort study of 7,052 men and 8,354 women aged 45-64 years from Renfrew and Paisley, Scotland, who were first screened in 1972-1976 and followed for 25 years. All-cause mortality was calculated as death per 1,000 person-years. A Cox proportional hazards model was used to adjust survival for age, smoking habit, blood pressure, serum cholesterol, BMI, and social class.

RESULTS

There were 192 deaths in 228 subjects with diabetes and 2,016 deaths in 3,076 subjects with CHD. The highest mortality was in the group with both diabetes and CHD (100.2 deaths/1,000 person-years in men, 93.6 in women) and the lowest in the group with neither (29.2 deaths/1,000 person-years in men, 19.4 in women). Men and women with diabetes only and CHD only formed an intermediate risk group. The adjusted hazard ratio (HR) for CHD mortality in men with diabetes only compared with men with CHD only was 1.17 (95% CI 0.78-1.74; P = 0.56). Corresponding HR for women was 1.97 (1.27-3.08; P = 0.003).

CONCLUSIONS

Diabetes without previous CHD carries a lifetime risk of vascular death as high as that for CHD alone. Women may be at particular risk. Our data support the view that cardiovascular risk factors in diabetes should be treated as aggressively as in people with CHD.

Why does specialist treatment of breast cancer improve survival? The role of surgical management

Evidence that the survival of women with breast cancer treated by specialist surgeons is better than that by nonspecialists is limited. Previous reports have not identified the cause of this survival advantage. Our aim was to determine if the survival difference was due to case-mix, adjuvant treatment or the treatment provided by specialist surgeons. The case-records and pathology reports of 2776 women were reviewed. This represented 95% of all those diagnosed with breast cancer between 1/1/1986 and 31/12/1991 in a defined geographical area. Case-mix, surgery, pathology and adjuvant therapies of the 2148 women treated with curative intent were analysed. A standard of adequate surgical management was defined and confirmed as a valid predictor by examining rates of local recurrence, independent of all other prognostic factors. Against this standard, we compared the adequacy of surgical management, local recurrence rates and the survival outcomes of specialists and nonspecialists over an 8-year follow-up period. The inter-relationship between adequacy of surgical management, locoregional recurrence and survival was examined. While the case-mix and prescription of adjuvant therapies were comparable between specialist and nonspecialist surgeons, the efficacy and outcome of local treatment differed widely. Breast cancer patients treated in specialist compared to nonspecialist units had half the risk of inadequate treatment of the breast (24 vs 47%, P<0.001), a five-fold lower risk of inadequate axillary staging (8 vs 40%, P<0.001) and nine times lower risk of inadequate definitive axillary treatment (4 vs 38%, P<0.001). Local recurrence rates were 57% lower (13 vs 23% at eight years, P<0.001) and the risk of death from breast cancer was 20% lower for women treated in specialist units, after allowing for case-mix and adjuvant therapies. Adequacy of surgical management correlated with locoregional recurrence, which in turn correlated with the risk of death. The surgical management in specialised breast units is more often adequate, local and regional recurrence rates are lower, and survival is correspondingly better. We conclude that adequate surgical management of breast cancer is fundamental to improving the outcome from breast cancer irrespective of where it is delivered.

Specialisation and breast cancer survival in the screening era

It is recommended that specialist surgeons treat all breast cancer, although the limited evidence to support this is based on treatment patterns prior to the introduction of screening. Whether a specialist survival advantage exists in the post-screening era is uncertain, as referral and treatment patterns may have changed, in addition to the effect of screening on the natural history of breast cancer. Our aim was to determine the impact of screening on the caseload and case-mix of specialist surgeons, to determine if the survival advantage associated with specialist care is maintained with longer follow-up and persists after the introduction of screening. Using the West of Scotland Cancer Registry, all 7197 women treated for breast cancer in a 15-year time period (1980-1994) in a geographically defined cohort were followed up for an average of 9 years, and pathological stage and socioeconomic status were linked with mortality data. We show that the caseload of specialists has increased substantially (from 11 to 59% of the total workload) and that smaller cancers have been selectively referred. However, even after allowing for pathological stage, socioeconomic status and method of detection, specialist treatment was associated with a significantly lower risk of dying (prescreening: relative risk of dying=0.83, 95% CI=0.75-0.92; post-screening: relative risk of dying=0.89, 95% CI=0.78-1.00). We conclude that this survival benefit is most consistent with effective surgical management rather than selective referral, the influx of screen-detected cancers or adjuvant therapies.

Metformin has direct effects on human ovarian steroidogenesis

OBJECTIVE

To investigate the possibility of direct effects of metformin on ovarian steroidogenesis.

DESIGN

Cultured ovarian cells.

SETTING

Academic research environment.

PATIENT(S)

Women undergoing bilateral salpingoophorectomy for benign gynecological disease.

MAIN OUTCOME MEASURE(S)

Estradiol and P were measured in granulosa cell (GC) conditioned medium and androstenedione (A) and P in theca conditioned medium.

RESULT(S)

The effect of addition of metformin alone to GCs was variable, but significant inhibition of both P and E2 was seen (range 0%-30%). Metformin dose-dependently inhibited gonadotrophin and insulin-stimulated P and E2 production (range 25%-50%). In theca, metformin inhibited A production (0%-40%) with no effect on P. In the presence of insulin, A was inhibited dose-dependently and P increased by a similar magnitude.

CONCLUSION(S)

These results demonstrate a direct effect of metformin on ovarian steroidogenesis. The inhibitory effects on androgen production in particular would be beneficial in polycystic ovary syndrome (PCOS).

How quality of life data contribute to our understanding of cancer patients' experiences? A study of patients with lung cancer

A prospective study was conducted to measure quality of life in newly diagnosed lung cancer patients attending a chest clinic in a large teaching and district general hospital in a geographically defined area (northern sector of Glasgow, Scotland). Quality of life was assessed at two points in time, pre-diagnosis (baseline) and 3 months after diagnosis (follow-up) using three standard measures; the Nottingham Health Profile (NHP); the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and its lung cancer supplement (QLQ-LC13). Out of 133 lung cancer patients diagnosed during the study period, 129 patients (97%) were interviewed pre-diagnosis. Of these, only 63% of the patients had an active treatment. Ninety-six patients were alive at follow-up, of whom 82 patients were re-interviewed. Thus, only 82 patients who had complete data were used in the analysis. Comparing patients' pre-diagnosis and follow-up scores on the NHP, only sleep difficulties improved slightly. Patients reported increased perceived health problems of all other characteristics studied (energy, p = 0.0004; physical mobility, p = 0.0008). Similar results were observed on the EORTC questionnaires indicating that patients' functioning and global quality of life had decreased. The only significant improvement after 3 months was seen in patients' cough (p = 0.006). There were marked increases in hair loss (p < 0.0001), constipation (p = 0.007), and sore mouth (p = 0.0004). The findings suggest that patient-centred variables should receive sufficient consideration in the treatment of lung cancer. The study results clearly indicate that information on quality of life contributes to our understanding of patients' experiences of their cancer treatment.

Treatment of oral cancer: the need for defined protocols and specialist centres. variations in the treatment of oral cancer

The authors of this study aimed to identify treatment philosophies for oral cancer within the west of Scotland and to investigate any survival differences associated with the various treatment options by means of a retrospective review of case notes and cancer registry data. All patients with squamous cancer of the tongue or floor of the mouth were identified from the West of Scotland Cancer Registry for the period 1984-1990. A total of 206 patients were available for study. Five different treatment protocols were identified: 5% of patients underwent biopsy only, 16% biopsy plus radiotherapy, 11% excisional biopsy, 25% radical surgery, and 42% radical surgery plus radiotherapy. Tumour staging by the TNM classification was an important factor that determined outcome. When adjusting for T stage and nodal involvement, there was a significant effect of treatment protocol on both the disease-free period (P < 0.001) and on survival (P < 0.001). The treatment options were used differently by individual clinicians and were related to stage of the disease. One hundred and forty-four (70%) of the patients were treated by a single combined head and neck unit based within the plastic surgery unit at Canniesburn Hospital. The remaining 62 were treated in 13 different units throughout the west of Scotland. For those not treated in the combined head and neck unit, the increased hazard for recurrence was 1.43 (95% confidence interval (CI) 1.01-2.02), and the increased hazard ratio for death was 1.48 (95% CI 1.06-2.06) when adjusting for tumour stage, and nodal involvement. Treatment philosophies for oral cancer have a significant effect on outcome. There is a need to develop clearly defined protocols based on staging and site of disease. We believe that treatment should be carried out within a multidisciplinary setting in a combined head and neck cancer unit.

Staging quality is related to the survival of women with endometrial cancer: a Scottish population based study. Deficient surgical staging and omission of adjuvant radiotherapy is associated with poorer survival of women diagnosed with endometrial cancer in Scotland during 1996 and 1997

The association between treatment variation and survival of women with endometrial cancer was investigated. A retrospective cohort based upon the complete Scottish population registered on in-patient and day-case hospital discharge data (Scottish Morbidity Record-1) and cancer registration (Scottish Morbidity Record-6) coded C54 and C55 in ICD10, between 1st January 1996 to 31st December 1997 were analysed. Seven hundred and three patients who underwent surgical treatment out of 781 patients that were diagnosed with endometrial cancer in Scotland during 1996 and 1997. The overall quality of surgical staging was poor. The quality of staging was related to both the year that the surgeon passed the Member of the Royal College of Obstetricians and Gynaecologists examination and also to 'specialist' status but was not related to surgeon caseload. Two clinically important prognostic factors were found to be associated with survival; whether the International Federation of Obstetrics and Gynaecology stage was documented, RHR=2.0 (95% CI=1.3 to 3.1) and also to the use of adjuvant radiotherapy, RHR=2.2 (95% CI=1.5 to 3.5). The associations with survival were strongest in patients with advanced disease, International Federation of Obstetrics and Gynaecology stages 1C through to stage 3. Deficiencies in staging and variations in the use of adjuvant radiotherapy represent a possible source of avoidable mortality in patients with endometrial cancer. Consequently, there should be a greater emphasis on improving the overall quality of surgical staging in endometrial cancer.

Structural studies of pulsed-laser deposited nanocomposite metal-oxide films

Pulsed laser deposition in vacuum has been used to develop metal-oxide nanocomposite films with well controlled structural quality. Results for the copper-aluminium oxide (Cu:Al2O3) system are used to illustrate the main morphological and structural features of these films. High resolution transmission electron microscopy (TEM) analysis shows that the films consist of Cu nanocrystals with average dimensions that can be controlled between 2 nm and 10 nm embedded in an amorphous Al2O3 matrix. It is observed that the in-plane shape of the nanocrystals evolves from circular to elongated, and the number of nanocrystals per unit area decreases as their size increases. This evolution is explained in terms of nucleation at the substrate surface and coalescence during the later stages of growth. The thermal stability of the films has been studied by in situ TEM annealing and no transformation could be observed up to about 800 degrees C when partial crystallization of the Al2O3 starts.

Quality of life in lung cancer patients: as an important prognostic factor

Given that lung cancer is one of the common cancers world-wide, the implications of focusing on quality of life as well as survival require to be understood. We have carried out a study of the relationship between survival and quality of life in patients with lung cancer comparing patients those who lived with those who died within 3 months. The design of the study allowed every patient in a defined geographical area with a potential diagnosis of lung cancer to be studied from first outpatient consultation till after a definitive treatment has been given. Quality of life was measured using three standard questionnaires: the Nottingham Health Profile (NHP), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13) in addition to a study specific questionnaire collecting data on demographic, social, clinical and performance status. The contribution of quality of life in relation to survival adjusted for known prognostic factors was determined using Cox's proportional hazard model. In all 129 lung cancer patients were interviewed, and 96 patients were alive at 3-months follow-up. Only 90 of 96 patients alive at 3-months follow-up were assessable. Descriptive analyses showed that those who were dead had more perceived health problems, greater level of symptoms and significant lower physical and role functioning and global quality of life at presentation. On the other hand, univariate analyses showed that patients' aggregate scores on the NHP, the functioning scores, and global quality of life scores alone were significant predictors of survival (P<0.03, P<0.04, P<0.04, respectively ). The multivariate analyses showed that pre-diagnosis global quality of life was the most significant predictor of the length of survival even after adjusting for known prognostic factors (age, P<0.04; extent of disease, P<0.03; global quality of life, P<0.02), while performance status, sex and weight loss were not. This study confirmed that pre-diagnosis quality of life was a significant predictor of survival. Indeed, pre-diagnosis quality of life should be considered as a clinical status which has to be established by physicians before treatment starts as it is such an important predictor of survival.

Advanced-stage cervix cancer: rapid tumour growth rather than late diagnosis

Either diagnostic delay or tumour biology are possible factors governing the degree of spread at diagnosis of cervical cancer. To try to identify the most important parameter contributing to advanced stage, the duration of symptoms were recorded from patients scheduled for radiotherapy (n = 141) or radical hysterectomy (n = 36). In 146 cases tumour proliferation rates were evaluated following in vivo labelling with the DNA precursor BrdUrd. For symptomatic patients there was no association between duration of symptoms and stage at presentation. There was a significant trend for patients with increasing tumour stage to have more rapidly proliferating tumours with higher mean labelling index (LI) measurements (P = 0.001) and a shorter mean potential doubling time (Tpot) (P = 0.023). Socio economic deprivation may be associated with shorter Tpot values. The conclusion from this data is that stage at diagnosis is more dependent on the biological behaviour of the tumour, as expressed by proliferation rates, than delay in presentation.

Influence of biological, behavioural, health service and social risk factors on the trend towards more frequent

OBJECTIVES

To analyse the trend in rising acute hospital admission rates in the Renfrew Paisley MIDSPAN cohort and assess the influence of baseline risk factor data, morbidity patterns, deprivation category and characteristics of GP practice on the increase.

DESIGN

Cohort analysis which, using a linked data set covering a 23 year follow-up period, combined original 'risk'-related data with subsequent routine hospital admissions data. A multiple logistic regression model predicted changes in hospital admissions patterns.

SETTING

Renfrew and Paisley, two post-industrial towns in Scotland.

SUBJECTS

Eight thousand three hundred and fifty four women and 7,052 men, aged 45-64 in the early 1970s.

MAIN OUTCOME MEASURES

The contribution that each of the factors investigated made to the likelihood of admission over time.

RESULTS

While risk status in middle life, diagnosis reached after admission, deprivation category and characteristics of GP practice influence the absolute chance of being admitted to hospital, changes in these factors do not explain much, if any, of the quite marked increase in admission rates observed during the last 10 year of the follow-up period.

CONCLUSIONS

Whatever the reasons for the trend of rising admission, the most likely explanation appears to be a combination of social and health service related factors. For the Paisley-Renfrew cohort, factors like smoking status, FEV1, deprivation category and GP practice remain important predictors of admission throughout the time period but changes in these factors explain little of the rising trend in admissions.

Height and risk of death among men and women: aetiological implications of associations with cardiorespiratory disease and cancer mortality

OBJECTIVES

Height is inversely associated with cardiovascular disease mortality risk and has shown variable associations with cancer incidence and mortality. The interpretation of findings from previous studies has been constrained by data limitations. Associations between height and specific causes of death were investigated in a large general population cohort of men and women from the West of Scotland.

DESIGN

Prospective observational study.

SETTING

Renfrew and Paisley, in the West of Scotland.

SUBJECTS

7052 men and 8354 women aged 45-64 were recruited into a study in Renfrew and Paisley, in the West of Scotland, between 1972 and 1976. Detailed assessments of cardiovascular disease risk factors, morbidity and socioeconomic circumstances were made at baseline.

MAIN OUTCOME MEASURES

Deaths during 20 years of follow up classified into specific causes.

RESULTS

Over the follow up period 3347 men and 2638 women died. Height is inversely associated with all cause, coronary heart disease, stroke, and respiratory disease mortality among men and women. Adjustment for socioeconomic position and cardiovascular risk factors had little influence on these associations. Height is strongly associated with forced expiratory volume in one second (FEV1) and adjustment for FEV1 considerably attenuated the association between height and cardiorespiratory mortality. Smoking related cancer mortality is not associated with height. The risk of deaths from cancer unrelated to smoking tended to increase with height, particularly for haematopoietic, colorectal and prostate cancers. Stomach cancer mortality was inversely associated with height. Adjustment for socioeconomic position had little influence on these associations.

CONCLUSION

Height serves partly as an indicator of socioeconomic circumstances and nutritional status in childhood and this may underlie the inverse associations between height and adulthood cardiorespiratory mortality. Much of the association between height and cardiorespiratory mortality was accounted for by lung function, which is also partly determined by exposures acting in childhood. The inverse association between height and stomach cancer mortality probably reflects Helicobacter pylori infection in childhood resulting in--or being associated with--shorter height. The positive associations between height and several cancers unrelated to smoking could reflect the influence of calorie intake during childhood on the risk of these cancers.

A study of leukaemia in Glasgow in connection with chromium-contaminated land

BACKGROUND

In 1991, soil pollution was found around the site of a former chromium-processing factory in Glasgow, Scotland. Levels of chromium in soil were above limits considered as safe, although a risk assessment concluded that population exposure was likely to be below occupational levels. As an excess incidence of leukaemia has been suspected in the area, it was decided to investigate a possible relationship between the pollutant and the illness.

METHODS

The ensuing study was descriptive-geographical. In the absence of better data, levels of exposure were assumed to decrease with distance from the centre of the polluted area. Leukaemia and population figures were obtained for each of nine concentric rings by aggregation of data available at the Enumeration District level. The null study hypothesis was that relative risk (as measured by Poisson regression) would not follow a definite trend with distance from the centre. Sex, age and levels of deprivation were taken into account.

RESULTS

Relative risks by variables other than distance followed previously known patterns for leukaemia. No evident pattern by distance was found. After regroupings inside the variables, a significant excess of leukaemia was found for intermediate distances from the pollutant.

CONCLUSIONS

No evidence was found of a possible relationship between soil pollution by chromium and leukaemia in the general population. Nonetheless, the excess noticed by the study warrants further research.

Receptors and neurotransmitters involved in the dual modulation of prolactin release by the serotoninergic system in pregnant and lactating rats

The receptors and neurotransmitter pathways that may participate in the inhibitory action of 5-hydroxytryptamine (5HT) on prolactin release during late pregnancy and lactation in rats were studied. Administration of the 5HT synthesis inhibitor, p-chlorophenylalanine, to late pregnant rats induced a significant increase in serum prolactin concentrations at 17:00 h on day 19 of pregnancy that was partially blocked by injections of the 5HT precursor, 5-hydroxytryptophan, or the 5HT agonists, 8-hydroxy-2-(di-n-propylamino)-tetralin hydrobromide (S1a), 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (S2) and N-(3-chlorophenyl)imidodicarbonimide diamide HCl (S3), but not by RU 24969 (S1b) or 1-meta-(chlorophenyl)-piperazine-2-HCl (S1a-2c). The 5HT neurotoxins, fenfluramine and p-chloroamphetamine, which selectively destroy fine axon serotoninergic fibres but not coarse ones, prevented the increase in circulating prolactin observed at 18:00 h on pro-oestrus and on day 21 of pregnancy, but did not modify serum prolactin concentrations at 17:00 h on day 19 of pregnancy. Administration of the adrenergic antagonists, metoprolol or prazosin, also prevented the stimulatory effects of p-chlorophenylalanine or ketanserin in pregnant rats on day 19 (17:00 h) or on days 10-12 (16:30 h) in lactating rats separated from their litters. Administration of p-chlorophenylalanine to pregnant rats on day 19 reduced dopamine concentrations in the arcuate nucleus and in the anterior hypothalamus and noradrenaline concentrations in the anterior hypothalamus and the suprachiasmatic nucleus. These results indicate that the inhibitory actions of 5HT on prolactin release in pregnant and lactating rats are mediated by S1a, S2a and S3 receptors and by the coarse axon serotoninergic fibres. In addition, the inhibitory actions of 5HT may modulate the action of a stimulatory adrenergic pathway, as well as the concentrations of noradrenaline and dopamine in different hypothalamic areas, which, in turn, particularly arcuate nucleus dopamine, regulate prolactin release.

The effect of hormone replacement therapy on the sensitivity of screening mammograms

AIM

The use of hormone replacement therapy (HRT) can lead to various changes on the mammogram including increasing density. The object of this study was to assess the effect of HRT on the sensitivity of mammographic screening by comparing HRT usage in women with screen detected breast cancers with HRT usage at the time of screening in women presenting with interval cancers.

METHODS

The West of Scotland Breast Screening Programme serves a population of 180,000 women aged 50-64 years old. Between May 1988 and December 1995, 1461 breast cancers were detected by the screening programme in 1441 women over the age of 50 and 372 interval breast cancers presented in 371 women screened between these dates. HRT usage at the time of screening was noted with details of age, postcode and the time between screening and diagnosis in the case of the women with interval cancers.

RESULTS

Among women under 65 years old, screened between 1988-1993, 12.3% of women with screen detected cancers and 22.2% of women with interval cancers were using HRT (P<0.001). Further analysis demonstrates that interval cancer rate is related to age as well as HRT use. After adjusting for age at time of screening, deprivation category and year of screening, the relative risk of a woman using HRT having an interval cancer compared with that of a woman not using HRT is 1.79. The relative risk of an interval cancer arising in the first year after screening for a woman on HRT is 2.27.

CONCLUSION

The use of HRT and being of an age below 60 years are both risk factors for presenting with an interval cancer after mammographic breast screening. Our results indicate that the use of HRT leads to a decrease in the sensitivity of mammographic screening.

Identification of roots of woody species using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis

Within the last two decades, substantial progress has been made in understanding seed-bank dynamics and the contribution of the soil seed bank to a postdisturbance plant community. There has been relatively little progress, however, in understanding perennial bud-bank dynamics and the contribution of the soil bud bank to secondary succession. This lack of information is due primarily to the inability to reliably identify roots, rhizomes and lignotubers that lie dormant beneath the soil surface. This investigation addressed the issue of identification of below-ground woody structures. The first objective was to develop a method that used molecular tools to identify woody plant species from subsoil tissue samples. The second objective was to develop a key in which molecular markers served as criteria for the identification and differentiation of selected tree and shrub species common to the mountains of northeast Oregon and southeast Washington. Application of restriction fragment length polymorphism (RFLP) analysis of polymerase chain reaction (PCR)-amplified rbcL appears to be a reliable method to identify and differentiate 15 plants to the genus level. Two restriction enzymes, DpnII and HhaI, provided restriction site polymorphisms in the PCR product. The fragment number and length were used to develop an identification key. However, plants not analysed in this 'exploratory key' might share the same banding patterns, resulting in a false identification of unknowns.

Lung cancer--management and outcome in Glasgow, 1991-92

Current practice and outcome for patients with lung cancer were determined by retrospective case note review of a random sample of all lung cancer cases registered for a calendar year and augmented by review of all surgical and radical radiotherapy cases. A total of 262 patients - 231 patients less than 75 years of age and 31 patients more than 75 years of age - represented 83% of the random sample. Eighty-three per cent of patients were seen within 2 weeks of referral. One-third reported symptoms occurring for less than 1 month and one-third had experienced symptoms for more than 3 months. The median time interval from first hospital contact until the making of a management decision was 18 days. The median interval from first contact to surgery was 63 days, and to starting radical radiotherapy 70 days. Histological confirmation was obtained in 69% of patients. Ten per cent of all lung cancer patients were calculated to have received chemotherapy. Five per cent of the whole cohort had definitive surgery and 64% of these were judged to be free of the disease at 3 years. Overall survival was 9% at 3 years, with no differences relating to cell type or area of residence. Many areas of good practice have been identified, but the lack of tumour staging or performance status data, the low proportion receiving chemotherapy or definitive surgery and the poor outcome after radical radiotherapy indicate the need for prospective audit and feedback of results. The long time interval from management decision to surgery and radiotherapy suggests organizational issues which need attention.