A tool for safer prescribing in vulnerable adults: the continuing development of the Medichec app and website

AIMS AND METHOD

Adverse effects are a common concern when prescribing and reviewing medication, particularly in vulnerable adults such as older people and those with intellectual disability. This paper describes the development of an app giving information on side-effects, called Medichec, and provides a description of the processes involved in its development and how drugs were rated for each side-effect. Medications with central anticholinergic action, dizziness, drowsiness, hyponatraemia, QTc prolongation, bleeding and constipation were identified using the British National Formulary (BNF) and frequency of occurrence of these effects was determined using the BNF, product information and electronic searches, including PubMed.

RESULTS

Medications were rated using a traffic light system according to how commonly the adverse effect was known to occur or the severity of the effect.

CLINICAL IMPLICATIONS

Medichec can facilitate access to side-effects information for multiple medications, aid clinical decision-making, optimise treatment and improve patient safety in vulnerable adults.

Long-term exposure to traffic-related air pollution and stroke: A systematic review and meta-analysis

BACKGROUND

Stroke remains the second cause of death worldwide. The mechanisms underlying the adverse association of exposure to traffic-related air pollution (TRAP) with overall cardiovascular disease may also apply to stroke. Our objective was to systematically evaluate the epidemiological evidence regarding the associations of long-term exposure to TRAP with stroke.

METHODS

PubMed and LUDOK electronic databases were searched systematically for observational epidemiological studies from 1980 through 2019 on long-term exposure to TRAP and stroke with an update in January 2022. TRAP was defined according to a comprehensive protocol based on pollutant and exposure assessment methods or proximity metrics. Study selection, data extraction, risk of bias (RoB) and confidence assessments were conducted according to standardized protocols. We performed meta-analyses using random effects models; sensitivity analyses were assessed by geographic area, RoB, fatality, traffic specificity and new studies.

RESULTS

Nineteen studies were included. The meta-analytic relative risks (and 95% confidence intervals) were: 1.03 (0.98-1.09) per 1 μg/m³ EC, 1.09 (0.96-1.23) per 10 μg/m³ PM₁₀, 1.08 (0.89-1.32) per 5 μg/m³ PM_2.5, 0.98 (0.92; 1.05) per 10 μg/m³ NO₂ and 0.99 (0.94; 1.04) per 20 μg/m³ NO_x with little to moderate heterogeneity based on 6, 5, 4, 7 and 8 studies, respectively. The confidence assessments regarding the quality of the body of evidence and separately regarding the presence of an association of TRAP with stroke considering all available evidence were rated low and moderate, respectively.

CONCLUSION

The available literature provides low to moderate evidence for an association of TRAP with stroke.

POS0609 STRESS-ASSOCIATED INCREASES IN RHEUMATOID ARTHRITIS DISEASE ACTIVITY AND FLARES DURING THE COVID-19 PANDEMIC

Background

The novel coronavirus disease 2019 (COVID-19) pandemic has spurred global action. Beginning in March of 2020, the Southern California COVID-19 pandemic response to limit virus transmission was characterized by mandated lockdowns and quarantines, resulting in significant stressors for rheumatology patients and potentially threatening their disease.

Objectives

To examine factors associated with changes in rheumatoid arthritis (RA) disease activity and flares in the COVID-19 pandemic.

Methods

RA patients identified by ICD-9/10 codes and active email addresses within a University of California, Los Angeles (UCLA) Rheumatology database were sent surveys via email in July and November of 2020. The survey was UCLA Institutional Review Board approved and included electronic consent and questions related to: perceptions of disease activity/remission via Routine Assessment of Patient Index Data 3 (RAPID3), flare frequency, RA flare questionnaire (RA-FQ), Perceived Stress Scale (PSS-4), and pandemic impact on stress (i.e. emotional state, apprehension, panic, helplessness, work, home, financial, and social distancing stress). Demographics were extracted from electronic medical records. Results were examined via descriptive analyses, Pearson correlations, and chi-square test for comparisons plus linear stepwise regressions where appropriate to evaluate the relationship between stress measures, RA disease activity, and flare frequency and severity.

Results

Among 5037 patients surveyed, 361 in July and 4676 in November,1128 (22.4%) responded. The study population demographics were: mean age of 57.5 ± 15.1 years, 79.4% female, racially diverse (69.6% Caucasian, 13.7 % LatinX, 9.5 % Asian, and 4.9% Black), and 62% seropositive (CCP and/or RF). Perceived disease activity and remission remained stable in most patients with 719 reporting no flares, and 409 in current flares at the time of the survey (Table 1). A minority reported perceived increases in disease activity which were associated with multiple aspects of perceived stress. At survey completion, 346 had not experienced flares, 290 had experienced one flare, and 492 had experienced multiple flares. Use of DMARDs was associated with lack of flare versus current flare (77.8% versus 71.6%, p = 0.02). The use of conventional synthetic, biologic, or targeted synthetic DMARDs were not associated with flare while current corticosteroid use was associated with flare (9.3% without flare and 20.8% with flare, p < 0.0001). Current flare was associated with increased PSS-4 scores (odds ratio (OR): 1.17 (95% confidence interval: 1.12 – 1.22, p < 0.0001). Figure 1 describes the odds ratio of experiencing aspects of stress with the presence of RA flare.

Table 1.

Current RA flare at time of survey completion

Current FlareCurrent Flare YesP-ValueNoN=409N=719RA duration (mean ± SD) years15.6 ± 12.314.9 ± 11.60.3133Patient Global (mean ± SD), range 0-103.5 ± 2.56.1 ± 2.2<0.0001RAPID3 (mean ± SD) range 0-306.1 ± 5.613.7 ± 5.7<0.0001Patient-Reported Remission, no. (%)404 (57.1%)49 (12.1%)<0.0001RA-FQ Score, (mean ± SD), range 0-5013.4 ± 11.429.7 ± 10.8<0.0001PSS-4, (mean ± SD)5.2 ± 3.16.9 ± 3.1<0.0001Overall stress level (%)0.0004 Increased62.3%72.9% Unchanged26.9%21.8% Decreased10.7%5.4%Current RA Therapy Any DMARD77.8%71.6%0.0218 csDMARD Only31.4%26.7%0.0911 bDMARD Only18.1%16.9%0.6082 tsDMARDs Only3.3%3.4%0.9394 bDMARD + csDMARD Only19.8%19.8%0.9823 tsDMARD + csDMARD Only4.6%4.9%0.8188Current Corticosteroid9.3%20.8%<0.0001

SD = standard deviation; No. = number; RA = rheumatoid arthritis; RAPID3 = routine assessment of patient index data 3; RA-FQ = rheumatoid arthritis flare questionnaire; PSS-4 = perceived stress scale; D/C = discontinued; DMARD = disease modifying antirheumatic drugs; csDMARD = conventional synthetic DMARD; bDMARD = biologic DMARD; tsDMARD = targeted synthetic DMARD

Conclusion

In a large survey population of RA patients during the COVID-19 pandemic, multiple aspects of stress were found to correlate with RA disease activity and flare.

Disclosure of Interests

Daniel Furst Consultant of: Corbus; Galapagos; Novartis; Amgen, Grant/research support from: Actelion; Galapagos; National Institutes of Health; GlaxoSmithKline; Sanofi; Corbus; Pfizer; Novartis; Amgen; Bristol Myers Squibb; Roche/Genentech, Nicolette T Morris: None declared, Angela Q Pham: None declared, Thasia Woodworth: None declared, David Elashoff: None declared, Jenny Brook: None declared, Veena Ranganath Grant/research support from: Bristol Myers Squibb; Mallinckrodt Pharmaceuticals

Pregnancy-specific Reference Intervals for BNP and NT-pro BNP-Changes in Natriuretic Peptides Related to Pregnancy

Context

Cardiac disease is the leading cause of maternal mortality in the UK, so accurate cardiovascular diagnoses in pregnancy are essential. BNP (B-type natriuretic peptide) and NT-pro BNP (N-terminal-pro BNP) are useful clinical tools for investigating suspected peripartum cardiomyopathy but, as the pregnancy-specific reference intervals are undefined, it is uncertain how they should be interpreted in pregnant women.

Objectives

To define trimester-specific 95% reference intervals for BNP and NT-pro BNP in pregnancy.

Methods

Longitudinal study of 260 healthy pregnant women, with sampling in each trimester.

Results

The upper reference limit for NT-pro BNP was 200 pg/mL in the first and second trimesters, and 150 pg/mL in the third. Levels were significantly reduced in overweight women in the third trimester (P = .0001), which supports the partitioning of reference intervals by body mass index (BMI). The upper limit for BNP was 50 pg/mL, with no detectable trimester-related differences. Although other biomarkers (hemoglobin and platelets) fell throughout pregnancy, both natriuretic peptides were initially elevated before falling by the third trimester, suggesting that the observed changes in natriuretic peptides are driven by dynamic interplay between cardiac strain and progressive hemodilution. NT-pro BNP in the first trimester was inversely associated with neonatal birthweight at term (P = .011).

Conclusion

Cardiac biomarkers have an important role for investigating suspected disease in high-risk pregnant women, but a robust assessment of the levels expected in healthy pregnant women is an essential prerequisite to their application in clinical practice. This study has defined trimester- and BMI-specific reference intervals for NT-pro BNP and BNP, which may improve how women with suspected cardiovascular disease are investigated in pregnancy.

Cardiac-specific troponins in uncomplicated pregnancy and pre-eclampsia: A systematic review

Background

The risk of myocardial infarction (MI) increases during pregnancy, particularly in women with pre-eclampsia. MI is diagnosed by measuring high blood levels of cardiac-specific troponin (cTn), although this may be elevated in women with pre-eclampsia without MI, which increases diagnostic uncertainty. It is unclear how much cTn is elevated in uncomplicated and complicated pregnancy, which may affect whether the existing reference intervals can be used in pregnant women. Previous reviews have not investigated high-sensitivity troponin in pregnancy, compared to older, less sensitive methods.

Methods

Electronic searches using the terms “troponin I” or “troponin T”, and “pregnancy”, “pregnancy complications” or “obstetrics”. cTn levels were extracted from studies of women with uncomplicated pregnancies or pre-eclampsia.

Results

The search identified ten studies with 1581 women. Eight studies used contemporary methods that may be too insensitive to use reliably in this clinical setting. Two studies used high-sensitivity assays, with one reporting an elevation in troponin I (TnI) in pre-eclampsia compared to uncomplicated pregnancy, and the other only examining women with pre-eclampsia.

Seven studies compared cTn between women with pre-eclampsia or uncomplicated pregnancy using any assay. Seven studies showed elevated TnI in pre-eclampsia compared to uncomplicated pregnancy or non-pregnant women. One study measured troponin T (TnT) in pregnancy but did not examine pre-eclampsia.

Conclusion

TnI appears to be elevated in pre-eclampsia, irrespective of methodology, which may reflect the role of cardiac stress in this condition. TnI may be similar in healthy pregnant and non-pregnant women, but we found no literature reporting pregnancy-specific reference intervals using high-sensitivity tests. This limits broader application of cTn in pregnancy. There is a need to define reference intervals for cTn in pregnant women, which should involve serial sampling throughout pregnancy, with careful consideration for gestational age and body mass index, which cause dynamic changes in normal maternal physiology.

Pregnancy-specific reference intervals for C-reactive protein improve diagnostic accuracy for infection: A longitudinal study

BACKGROUND AND AIMS

Infections are a major cause of maternal mortality. C-reactive protein (CRP), a commonly-used inflammatory marker, is widely used to inform diagnosis, but the upper limit of normal in pregnancy is uncertain. We have defined trimester-specific reference intervals for CRP and evaluated their diagnostic accuracy for infection.

MATERIALS AND METHODS

Development cohort: longitudinal study of pregnant women to determine 95% reference intervals. Evaluation cohort: diagnostic accuracy study to evaluate these intervals in 50 women with suspected intrauterine infection.

RESULTS

In these 322 healthy pregnant women, CRP was substantially higher than in most non-pregnant populations. CRP was similar in each trimester, with an upper reference limit of 19 mg/L. CRP increased linearly with body mass index (p < 0.0001). The sensitivity and specificity of CRP for diagnosing chorioamnionitis were 73% and 86%, respectively. The overall diagnostic accuracy using the pregnancy-specific reference interval was significantly better than that of the existing standard (p = 0.03).

CONCLUSIONS

CRP is a widely-used clinical tool in pregnancy, and a pregnancy-specific reference interval should be used to optimise diagnostic accuracy. Chorioamnionitis was used as an example of a localised infection with well-defined outcomes, but pregnancy-specific RIs for CRP should be considered in any clinical setting including pregnant women.

The American English version of the validated French Flare Assessment in RA Questionnaire (FLARE-RA)

OBJECTIVE

To evaluate use of a British English version of the validated French FLARE-RA questionnaire among American English speaking patients. In addition, to create a culturally adapted American English (AmE) FLARE-RA questionnaire and to examine its attributes of patient-reported RA flare status.

METHODS

Using standardized cultural adaptation guidelines, we cognitively debriefed 25 American English speaking rheumatoid arthritis (RA) outpatients and created AmE-FLARE-RA with their input. One hundred three additional RA patients were recruited. Patients completed the Routine Assessment of Patient Index Data 3 (RAPID3), patient global visual analogue scale (VAS), AmE-FLARE-RA, and self-reports of flare. Physician global VAS, physician-assessed flare, swollen and tender joint count (TJC), and clinical disease activity index (CDAI) were documented. AmE-FLARE-RA and disease activity measures were compared between patient-reported and physician-reported flare categories.

RESULTS

Patients were female (89%), with mean (SD) age 51.1 (± 15.3) years and mean disease duration (SD) 11.9 (± 10.1) years, with 26% in remission/low disease activity. Total AmE-FLARE-RA scores, RAPID3, CDAI, and patient global VAS were significantly higher for both patient-reported flares and physician-reported flares compared with non-flaring patients by self- or physician report (p < 0.05). Total AmE-FLARE-RA scores correlated significantly with RAPID3 (corr = 0.50, p < 0.0001) and with CDAI (corr = 0.45, p < 0.0001). Across "no flares," "one flare," and "several flare" groups, there was a non-significant increase in AmE-FLARE-RA scores (p = 0.07).

CONCLUSION

The British English FLARE-RA was successfully adapted for AmE-speaking RA patients. AmE-FLARE-RA significantly correlated with RAPID3 and CDAI and distinguished between patient-reported and physician-reported flares, making it useful to detect flares in American RA patients.Key Points• The American English FLARE-RA (AmE-FLARE-RA) questionnaire is the result of cognitive debriefing with American RA patients using the British English version of the validated French FLARE-RA and incorporates patient-recommended language modifications..• Patients self-reporting flares had significantly higher AmE-FLARE-RA scores, compared with those without flares at the time of visit. AmE-FLARE-RA scores correlate with RAPID3 and CDAI.• There was a non-statistically significant trend using the AmE-FLARE-RA scores when examining patients with no flare, one flare, or several flares.• AmE-FLARE-RA total scores are uniformly elevated (~ 6.0 on a 0-10 scale), regardless of discordance between patient and MD assessment of flare at time of visit (~ 30%).

Improving the quality of handover in a liaison psychiatry team

Handover is a high risk point for errors in clinical care, in many cases leading to adverse events or near misses. The timely transfer of accurate and useful information between professionals is vital to ensure quality and safety, and to ensure the transfer of accountability for care.

In this project standards were developed for quality handover between doctors in a liaison psychiatry department. The aim of these were to ensure adequate identification of patients, clear communication of tasks to be completed and relevant risk issues, as well as a guide to the priority of jobs. We measured compliance with these standards for all patients documented in the handover book during three week periods in 2013, 2014 (following delivery of education and guidance on handover to all doctors), and finally in 2015 after implementation of a proforma for handover.

Handover documentation prior to the implementation of standards was of poor quality with significant absences of information. Key information to identify patients was frequently absent, for example hospital number was only recorded in 1% of cases. Only 81% of entries included the reason for the patient's referral, and 27% made no mention of the outstanding tasks for completion. Despite guidance and education of all doctors regarding the standards, there was no consistent improvement in compliance. It was particularly concerning that risk issues were only mentioned in 18% of cases, even when assessed immediately after education was given. Following introduction of the proforma compliance increased with overall completeness of handover improving from 40% to 71%.

Without guidelines handover between shifts is of a poor quality, and often lacks key information to allow colleagues to identify patients and prioritise need. Education of those performing these handovers did not produce any benefits, either immediately following its delivery or in longer term follow up. The implementation of a template to aid clinicians in recording this data did produce improvements and received positive feedback from doctors.

Ivabradine, a novel treatment for clozapine-induced sinus tachycardia: a case series

OBJECTIVES

Clozapine is the most efficacious treatment for treatment-resistant schizophrenia; however its use can be limited by intolerability. Sinus tachycardia is a common adverse event associated with clozapine use, which may lead to the premature discontinuation of clozapine. Traditionally, β blockers are used to treat clozapine-associated tachycardia, though problems with intolerability and ineffectiveness can limit their utility.

METHODS

In this article, we present two cases of patients with treatment-resistant schizophrenia who developed symptomatic tachycardia associated with clozapine therapy.

RESULTS

We demonstrate that the novel heart rate controlling agent ivabradine can be effectively and safely used to control the heart rate and to allow for continued treatment with clozapine.

CONCLUSION

This is the first report in the literature demonstrating that ivabradine appears to be a well tolerated agent, which should be considered as a symptomatic treatment of clozapine-induced tachycardia if the use of a β blocker fails due to a lack of response or intolerability.

Centralised classification of library materials- a benchmarking study

The Library Management Group of The University Of Huddersfield set up a pilot study to examine altemative procedures for classifying and cataloguing library material in the Health sciences. The study tested the impact of using classification and subject index terms in bibliographic records for titles in the health subject area. The work of the group concentrated on two areas: -establishing a benchmark for throughput in Technical Services in terms of speed, cost and availability of externally supplied class numbers -analysis of differences in classification numbers and subject indexing terms between those human assigned and system assigned. Samples of data were analysed using SPSS software; a fuzzy matching process was undertaken for the subject string analysis. The results showed considerable savings to be made in terms of both speed and cost. lt was instrumental in the decision to change the existing method of acquiring classification numbers.The hit rate for records and the impact on the shelf arrangement were at an acceptable level. The study produced reliable information to provide a benchmark for future developments (for exarnple outsourcing shelf ready books) and performance indicators.

Linking near- and far-field hydrodynamic models for simulation of desalination plant brine discharges

A desalination plant is proposed to be the major water supply to the Olympic Dam Expansion Mining project. Located in the Upper Spencer Gulf, South Australia, the site was chosen due to the existence of strong currents and their likely advantages in terms of mixing and dilution of discharged return water. A high-resolution hydrodynamic model (Estuary, Lake and Coastal Ocean Model, ELCOM) was constructed and, through a rigorous review process, was shown to reproduce the intricate details of the Spencer Gulf dynamics, including those characterising the discharge site. Notwithstanding this, it was found that deploying typically adopted 'direct insertion' techniques to simulate the brine discharge within the hydrodynamic model was problematic. Specifically, it was found that in this study the direct insertion technique delivered highly conservative brine dilution predictions in and around the proposed site, and that these were grid and time-step dependent. To improve the predictive capability, a strategy to link validated computational fluid dynamics (CFD) predictions to hydrodynamic simulations was devised. In this strategy, environmental conditions from ELCOM were used to produce boundary conditions for execution of a suite of CFD simulations. In turn, the CFD simulations provided the brine dilutions and flow rates to be applied in ELCOM. In order to conserve mass in a system-wide sense, artificial salt sinks were introduced to the ELCOM model such that salt quantities were conserved. As a result of this process, ELCOM predictions were naturally very similar to CFD predictions near the diffuser, whilst at the same time they produced an area of influence (further afield) comparable to direct insertion methods. It was concluded that the linkage of the models, in comparison to direct insertion methods, constituted a more realistic and defensible alternative to predict the far-field dispersion of outfall discharges, particularly with regards to the estimation of brine dilution in the immediate vicinity of an outfall location.

The impact of a dedicated antenatal clinic on the obstetric and neonatal outcomes in adolescent pregnant women

This retrospective observational study was designed to study the impact of a dedicated antenatal clinic service on obstetric and neonatal outcomes among teenage mothers in the maternity unit of a district general hospital in the UK. Outcomes were measured to investigate improvement in obstetric and neonatal outcomes before, and 12 months after the establishment of dedicated clinic for teenage pregnant women. Significant improvement in the birth weight was observed p = 0.01. A modest decrease in neonatal admission to special care unit by 6% was observed. Rate of spontaneous vaginal deliveries increased p = 0.0009. There was significant uptake of contraception and continuation of breast-feeding in this group of young women (p < 0.0001).

Do socioeconomic characteristics modify the short term association between air pollution and mortality? Evidence from a zonal time series in Hamilton, Canada

STUDY OBJECTIVE

To assess the short term association between air pollution and mortality in different zones of an industrial city. An intra-urban study design is used to test the hypothesis that socioeconomic characteristics modify the acute health effects of ambient air pollution exposure.

DESIGN

The City of Hamilton, Canada, was divided into five zones based on proximity to fixed site air pollution monitors. Within each zone, daily counts of non-trauma mortality and air pollution estimates were combined. Generalised linear models (GLMs) were used to test mortality associations with sulphur dioxide (SO(2)) and with particulate air pollution measured by the coefficient of haze (CoH).

MAIN RESULTS

Increased mortality was associated with air pollution exposure in a citywide model and in intra-urban zones with lower socioeconomic characteristics. Low educational attainment and high manufacturing employment in the zones significantly and positively modified the acute mortality effects of air pollution exposure.

DISCUSSION

Three possible explanations are proposed for the observed effect modification by education and manufacturing: (1) those in manufacturing receive higher workplace exposures that combine with ambient exposures to produce larger health effects; (2) persons with lower education are less mobile and experience less exposure measurement error, which reduces bias toward the null; or (3) manufacturing and education proxy for many social variables representing material deprivation, and poor material conditions increase susceptibility to health risks from air pollution.

The DNA sequence and analysis of human chromosome 6

Chromosome 6 is a metacentric chromosome that constitutes about 6% of the human genome. The finished sequence comprises 166,880,988 base pairs, representing the largest chromosome sequenced so far. The entire sequence has been subjected to high-quality manual annotation, resulting in the evidence-supported identification of 1,557 genes and 633 pseudogenes. Here we report that at least 96% of the protein-coding genes have been identified, as assessed by multi-species comparative sequence analysis, and provide evidence for the presence of further, otherwise unsupported exons/genes. Among these are genes directly implicated in cancer, schizophrenia, autoimmunity and many other diseases. Chromosome 6 harbours the largest transfer RNA gene cluster in the genome; we show that this cluster co-localizes with a region of high transcriptional activity. Within the essential immune loci of the major histocompatibility complex, we find HLA-B to be the most polymorphic gene on chromosome 6 and in the human genome.

Association between particulate- and gas-phase components of urban air pollution and daily mortality in eight Canadian cities

Although some consensus has emerged among the scientific and regulatory communities that the urban ambient atmospheric mix of combustion related pollutants is a determinant of population health, the relative toxicity of the chemical and physical components of this complex mixture remains unclear. Daily mortality rates and concurrent data on size-fractionated particulate mass and gaseous pollutants were obtained in eight of Canada's largest cities from 1986 to 1996 inclusive in order to examine the relative toxicity of the components of the mixture of ambient air pollutants to which Canadians are exposed. Positive and statistically significant associations were observed between daily variations in both gas- and particulate-phase pollution and daily fluctuations in mortality rates. The association between air pollution and mortality could not be explained by temporal variation in either mortality rates or weather factors. Fine particulate mass (less than 2.5 microns in average aerometric diameter) was a stronger predictor of mortality than coarse mass (between 2.5 and 10 microns). Size-fractionated particulate mass explained 28% of the total health effect of the mixture, with the remaining effects accounted for by the gases. Forty-seven elemental concentrations were obtained for the fine and coarse fraction using nondestructive x-ray fluorescence techniques. Sulfate concentrations were obtained by ion chromatography. Sulfate ion, iron, nickel, and zinc from the fine fraction were most strongly associated with mortality. The total effect of these four components was greater than that for fine mass alone, suggesting that the characteristics of the complex chemical mixture in the fine fraction may be a better predictor of mortality than mass alone. However, the variation in the effects of the constituents of the fine fraction between cities was greater than the variation in the mass effect, implying that there are additional toxic components of fine particulate matter not examined in this study whose concentrations and effects vary between locations. One of these components, carbon, represents half the mass of fine particulate matter. We recommend that measurements of elemental and organic carbon be undertaken in Canadian urban environments to examine their potential effects on human health.

Cardiac arrest after administration of Omnipaque radiocontrast medium during endoluminal repair of abdominal aortic aneurysm

We describe a case of acute cardiovascular collapse in a patient with end-stage renal failure undergoing endoluminal repair of an abdominal aortic aneurysm. The 61-yr-old man suffered cardiac arrest shortly after administration of radiocontrast medium (Omnipaque), during deployment of the endovascular device. He had received the same contrast solution for diagnostic angiography on the previous day. He was successfully resuscitated and recovered completely. The differential diagnosis and management are discussed.

Adolescent fears as predictors of depression

BACKGROUND

Recent studies raise questions on the relationship between adolescent fears and risk for major depression.

METHODS

An epidemiologic sample of 776 young people received psychiatric assessments in 1983, 1985-1986, and 1992. Prospective associations were examined between fears in adolescence and future episodes of major depression.

RESULTS

Both overall level of fears and specific fear of dark in adolescence predicted future risk for major depression.

CONCLUSIONS

Relatively high levels of fear in adolescence represent a risk factor for later episodes of major depression.

Associations between daily cause-specific mortality and concentrations of ground-level ozone in Montreal, Quebec

The authors investigated the association between daily variations in ozone and cause-specific mortality. Fixed-site air pollution monitors in Montreal, Quebec, provided daily mean levels of ozone, particles, and other gaseous pollutants. Information on the date and underlying cause of death was obtained for residents of Montreal who died in the city between 1984 and 1993. The authors regressed the logarithm of daily counts of cause-specific mortality on mean levels of ozone, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, and weather variables. The effect of ozone on mortality was generally higher in the warm season and among persons aged 65 years or over. For an increase in the 3-day running mean concentration of ozone of 21.3 microg/m(3), the percentage of increase in daily deaths in the warm season was the following: nonaccidental deaths, 3.3% (95% confidence interval (CI): 1.7, 5.0); cancer, 3.9% (95% CI: 1.0, 6.91); cardiovascular diseases, 2.5% (95% CI: 0.2, 5.0); and respiratory diseases, 6.6% (95% CI: 1.8, 11.8). These results were independent of the effects of other pollutants and were consistent with a log-linear response function.

Identification of persons with cardiorespiratory conditions who are at risk of dying from the acute effects of ambient air particles

This study was undertaken to identify subgroups of the population susceptible to the effects of ambient air particles. Fixed-site air pollution monitors in Montreal, Quebec, Canada, provided daily mean levels of various measures of particulates and gaseous pollutants. Total sulfates were also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec, Canada). We used coefficient of haze (COH), extinction coefficient, and Sutton sulfates to predict fine particles and sulfates from a fine particles model for days that were missing. We used the universal Quebec medicare system to obtain billings and prescriptions for each Montreal resident who died in the city from 1984 to 1993. These data were then used to define cardiovascular and respiratory conditions that subjects had before death. Using standard Poisson regression time-series analyses, we estimated the association between daily nonaccidental mortality and daily concentrations of particles in the ambient air among persons with cardiovascular and respiratory conditions diagnosed before death. We found no persuasive evidence that daily mortality increased when ambient air particles were elevated for subgroups of persons with chronic upper respiratory diseases, airways disease, cerebrovascular diseases, acute coronary artery disease, and hypertension. However, we found that daily mortality increased linearly as concentrations of particles increased for persons who had acute lower respiratory diseases, chronic coronary artery diseases (especially in the elderly), and congestive heart failure. For this latter set of conditions, the mean percent increase in daily mortality (MPC) for an increase in the COH across its interquartile range (18.5 COH units per 327.8 linear meters), averaged over the day of death and the 2 preceding days, was MPC = 5.09% [95% confidence interval (CI) 2.47-7.79%], MPC = 2.62 (95% CI 0.53-4.75%), and MPC = 4.99 (95% CI 2.44-7.60%), respectively. Adjustments for gaseous pollutants generally attenuated these associations, although the general pattern of increased daily mortality remained. In addition, there appeared to be a stronger association in the summer season. The positive associations found for persons who had acute lower respiratory diseases and congestive heart failure are consistent with some prevailing hypotheses and may also be consistent with recent toxicologic data implicating endothelins. Further epidemiologic studies are required to confirm these findings.

The association between daily mortality and ambient air particle pollution in Montreal, Quebec. 1. Nonaccidental mortality

This study was undertaken to determine whether variations in concentrations of particles in the ambient air of Montreal, Quebec, during the period 1984 to 1993, were associated with daily variations in nonaccidental mortality. Fixed-site air pollution monitors in Montreal provided daily mean levels of various measures of particulates and gaseous pollutants. Total sulfates were also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec). We estimated associations for PM(2.5), PM(10), total suspended particles, coefficient of haze (COH), extinction coefficient, and sulfates. We used coefficient of haze, extinction coefficient, and Sutton sulfates to predict fine particles and sulfates for days that were missing. To estimate the associations between nonaccidental mortality and ambient air particles, we regressed the logarithm of daily counts of nonaccidental mortality on the daily mean levels for the above measures of particulates, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, weather variables, and gaseous pollutants. There were 140,939 residents of Montreal who died during the study period. We found evidence of associations between daily nonaccidental deaths and most measures of particulate air pollution. For example, the mean percentage increase (MPC) for an increase of total suspended particles of 28.57 microg/m(3) (interquartile range, IQ), evaluated at lag 0 days, was 1.86% (95% confidence interval (CI): 0.00-3.76%), and for an increase of coefficient of haze (IQ=18.5 COH units per 327.8 linear m) the MPC was 1.44% (95% CI: 0.75-2.14%). These results are similar to findings from other studies (the mean percentage increase in nonaccidental deaths for a 100 microg/m(3) increase in daily total suspended particles was 6.7%). We also found increases for fine particles and for inhalable particles, but the confidence intervals included unity. All measures of sulfates showed increased daily mortality; e.g., the MPC for sulfates from fine particles (IQ=3.51 microg/m(3)) was 1.86% (95% CI: 0.40-3.35%). We generally found higher excesses in daily mortality for persons 65 years of age and for exposures averaged across lags 0, 1, and 2 days. The slope of the association between daily mortality and ambient air particles in Montreal, which has lower levels of pollution than most major urban centers, is similar to that reported in most other industrialized cities. This study therefore provides further evidence that the association is linear and that any threshold effect, should it exist, would be found at lower levels of air pollution than those found in Montreal.

The association between daily mortality and ambient air particle pollution in Montreal, Quebec. 2. Cause-specific mortality

This study was undertaken to determine whether variations in concentrations of particulates in the ambient air of Montreal, Quebec, during the period 1984 to 1993, were associated with daily variations in cause-specific daily mortality. Fixed-site air pollution monitors in Montreal provided daily mean levels of various measures of particles and gaseous pollutants. Total sulfate was also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec). We used coefficient of haze (COH), extinction coefficient, and sulfate from the Sutton station to predict fine particles and sulfate from fine particles for days that were missing. We estimated associations between cause-specific mortality and PM(2.5), PM(10), predicted fine particles and fine sulfate particles, total suspended particles, coefficient of haze, extinction coefficient, and total sulfate measured at the Sutton station. We selected a set of underlying causes of death, as recorded on the death certificates, as the endpoint and then regressed the logarithm of daily counts of cause-specific mortality on the daily mean levels for the above measures of particulates, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, weather variables, and gaseous pollutants. We found positive and statistically significant associations between the daily measures of ambient particle mass and sulfate mass and the deaths from respiratory diseases and diabetes. The mean percentage change in daily mortality (MPC), evaluated at the interquartile range for pollutants averaged over the day of death and the preceding 2 days, for deaths from respiratory diseases was MPC(COH)=6.90% (95% CI: 3.69-10.21%), MPC(Predicted PM2.5)= 9.03% (95% CI: 5.83- 12.33%), and MPC(Sutton sulfate)=4.64% (95% CI: 2.46-6.86%). For diabetes, the corresponding estimates were MPC(COH)=7.50% (95% CI: 1.96-13.34%), MPC(Predicted PM2.5)=7.59% (95% CI: 2.36-13.09%), and MPC(Sutton sulfate)=4.48% (95% CI: 1.08-7.99%). Among individuals older than 65 years at time of death, we found consistent associations across our metrics of particles for neoplasms and coronary artery diseases. Associations with sulfate mass were also found among elderly persons who died of cardiovascular diseases and of lung cancer. These associations were consistent with linear relationships. The associations found for respiratory diseases and for cardiovascular diseases, especially in the elderly, are in line with some of the current hypotheses regarding mechanisms by which ambient particles may increase daily mortality. The positive associations found for cancer and for diabetes may be understood through a general hypothesis proposed by Frank and Tankersley, who suggested that persons in failing health may be at higher risk for external insults through the failure of regulating physiological set points. The association with diabetes may be interpreted in light of recent toxicological findings that inhalation of urban particles in animals increases blood pressure and plasmatic levels of endothelins that enhance vasoconstriction and alter electrophysiology. Further research to confirm these findings and to determine whether they are causal is warranted.

Adolescent depressive symptoms as predictors of adult depression: moodiness or mood disorder?

OBJECTIVE

The authors' goal was to examine the relationship between subclinical depressive symptoms in adolescence and major depressive episodes in adulthood.

METHOD

An epidemiologic sample of 776 young people received psychiatric assessments in 1983, 1985, and 1992. Among adolescents not meeting criteria for major depression, the authors estimated the magnitude of the association between subclinical adolescent depressive symptoms and adult major depression.

RESULTS

Symptoms of major depression in adolescence strongly predicted an adult episode of major depression: having depressive symptoms more than two-standard-deviations above the mean in number predicted a two-fold to three-fold greater risk for an adult major depressive episode.

CONCLUSIONS

Symptoms of depression in adolescence strongly predict an episode of major depression in adulthood, even among adolescents without major depression.

Prospective associations between somatic illness and mental illness from childhood to adulthood

The association between somatic illness and psychiatric illness is well established in adults but is less clear in childhood and adolescence. A cohort of over 700 randomly selected children in Upstate New York were studied from ages 1-10 years in 1975 to young adulthood in 1992. Psychiatric and physical health were assessed by means of follow-up youth and parent interviews at 8-, 2 1/2-, and 6-year intervals (in 1983, 1985-1986, and 1991-1993). Cross-sectional and longitudinal analyses investigated: 1) the consistency of the relation between physical illness and mental illness in childhood; 2) the specificity of major depressive disorder (MDD) in accounting for the relation; 3) the specificity of immunologically mediated medical disorders in this relation; and 4) whether this relation was attributable to risks associated with low socioeconomic status. Cross-sectionally, ill health was associated with increased risk of psychiatric disorders at all ages, with significant odds ratios (ORs) ranging from 1.76 to 3.26. In prospective analyses, ill health increased the risk of new-onset MDD at all ages (ORs = 2.05-4.48). MDD also predicted subsequent ill health, independent of prior health problems (ORs = 3.81 and 4.04). Relations were not attributable to familial socioeconomic status. Associations were particularly strong between MDD and medical disorders associated with alterations in immunologic factors (ORs = 1.83-6.41). Theories of common immune-mediated vulnerabilities to medical illness and depression are consistent with these associations.

The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders

BACKGROUND

Various studies find relationships among anxiety and depressive disorders of adolescence and adulthood. This study prospectively examines the magnitude of longitudinal associations between adolescent and adult anxiety or depressive disorders.

METHODS

An epidemiologically selected sample of 776 young people living in upstate New York received DSM-based psychiatric assessments in 1983, 1985, and 1992 using structured interviews. The magnitude of the association between adolescent and adult anxiety or depressive disorders was quantified using odds ratios generated from logistic regression analyses and from a set of latent Markov analyses. We focus on longitudinal associations among narrowly defined DSM anxiety or depressive disorders.

RESULTS

In simple logistic models, adolescent anxiety or depressive disorders predicted an approximate 2- to 3-fold increased risk for adulthood anxiety or depressive disorders. There was evidence of specificity in the course of simple and social phobia but less specificity in the course of other disorders. Results from the analyses using latent variables suggested that while most adolescent disorders were no longer present in young adulthood, most adult disorders were preceded by adolescent disorders.

CONCLUSIONS

An anxiety or depressive disorder during adolescence confers a strong risk for recurrent anxiety or depressive disorders during early adulthood. Most anxiety and depressive disorders in young adults may be preceded by anxiety or depression in adolescence.

Psychiatric symptoms in adolescence as predictors of obesity in early adulthood: a longitudinal study

OBJECTIVES

This study examined the longitudinal relationship between psychopathology and obesity in young adulthood.

METHODS

More than 700 youth in a population-based sample were psychiatrically assessed in 1983 (mean age = 14 years) and 1992 (mean age = 22 years). Self-reported body mass index (BMI) in 1992 was regressed on measures of depression and conduct disorder as well as a set of covariates including indices of physical health, social class, intelligence, and cigarette and alcohol use. Associations were examined with BMI treated as a continuous variable and with a binary index of obesity derived from the BMI distribution in each gender.

RESULTS

BMI in young adults was positively related to a number of covariates. With all covariates controlled, BMI was inversely related to adult depressive symptoms in males but not females. BMI was positively related to adolescent symptoms of conduct disorder in both sexes. Similar associations were found between psychiatric symptoms and obesity.

CONCLUSIONS

Conduct disorder symptoms in adolescence predicted BMI and obesity in early adulthood. These associations remained after controlling for factors that can affect the association between psychopathology and obesity.

The association between major depression and headache: results of a longitudinal epidemiologic study in youth

Retrospective epidemiologic research in adults suggests that a long-term association between major depression and headache arises during childhood or adolescence. This study uses data from a prospective epidemiologic study to examine the association between major depression and headache from late childhood into early adulthood. An epidemiologically selected sample of 776 youth, aged 9-18, was assessed psychiatrically in 1983 using DISC interviews with both youth and parent informants. Reassessments were conducted in 1985-1986 and 1992. Current and past histories of functionally impairing migraine or chronic headache were elicited in both 1985-1986 and 1992. Regression analyses examined the relationships between major depression and headache status. The prevalence of current functionally impairing headache was approximately 10% in both 1985-1986 and 1992. There were lifetime and cross-sectional associations between headache and major depression. Headache was approximately twice as common in depressed adolescents compared with nondepressed adolescents. Major depression in adolescents, without current or past headache, prospectively predicted the new onset of headaches in young adulthood. Among adolescents who had no history of chronic impairing headache in 1985-1986, those with current major depression faced a nearly tenfold increased risk of developing such headaches at some time during the next 7 years. Consistent with findings of retrospective studies among adults, a longitudinal/ developmental relationship between major depression and functionally impairing headache was found in this prospective epidemiologic study of youth. These findings suggest that (1) neurochemical and pharmacologic commonalities between depression and headache should receive further investigation and that (2) it may be clinically useful to inquire about family history of headache syndromes in adolescents with major depression because such questioning may provide insight about the risk of subsequent functionally impairing headache in a depressed adolescent.

Refugees' and immigrants' mental health: association of demographic and post-immigration factors

Several demographic and post-immigration factors related to self-reported symptoms of anxiety and depression of immigrants in New Zealand were examined in a study involving a sample of 129 Southeast Asian refugees, 57 Pacific Island immigrants, and 63 British immigrants to New Zealand. A questionnaire and the Hopkins Symptom Checklist-25 (HSCL-25) in English and in three Southeast Asian translations were administered, followed by an interview in English or with an interpreter. The findings suggest that demographic characteristics are not associated with symptom level. Post-immigration factors, such as experiencing discrimination in New Zealand, not having close friends, being unemployed, and spending most of one's time with one's own ethnic group affected anxiety and depression scores.

Discriminating depression and anxiety in youth: a role for diagnostic criteria

OBJECTIVE

To test the hypothesis that anxiety and depression in youth, as in adults, become increasingly discriminable when youth meet criteria for an emotional disorder.

METHOD

The study uses cross-sectional data at two points in time from a large (n = 776) community sample of youths, aged eight to twenty. Associations between major depression and five anxiety disorders (overanxious, obsessive compulsive and separation anxiety disorders, and social and simple phobias) are examined by symptom scale and diagnosis.

RESULTS

Anxiety and depression are moderately correlated, and substantially comorbid by diagnostic category. Symptoms are more discriminable among youths with diagnoses of at least one emotional disorder than among those without. A single factor accounts for symptoms among the non-diagnosed but multiple factors are required for the diagnosed group.

CONCLUSIONS

Anxiety and depression are discriminable among youth who meet criteria for a specific emotional disorder but more highly associated among youths without such a diagnosis. This suggests that in youth, as has been shown in adults, depression and anxiety become increasingly discriminable as emotional psychopathology becomes more severe.

Emotional problems during youth as predictors of stature during early adulthood: results from a prospective epidemiologic study

OBJECTIVE

Adults with emotional disorders exhibit abnormalities in growth hormone secretion. If these abnormalities were to occur during childhood, they could affect growth. The purpose of this study was to examine the relationship between youth emotional disorders and stature in early adulthood.

METHODS

Using data from a prospective epidemiologic study of youth psychopathologic status, we used linear regression to examine the prospective relationship between anxiety disorders (separation anxiety and over-anxious disorders) or major depressive disorder in youth and stature in early adulthood.

RESULTS

Anxiety disorders during childhood prospectively predicted relatively short stature in early adulthood among females, accounting for more than 5% of the variance in adult height. However, these associations were not found among males.

CONCLUSIONS

There may be an association between abnormalities in growth and emotional problems in youth. Further research should examine biological measures related to growth among youth with emotional disorders.

The mental health pattern of migrants: is there a euphoric period followed by a mental health crisis?

Sluzki's 1986 mental health model of the migratory process was tested with migrants (both refugees and immigrants), to New Zealand. Its central feature, suggesting an initial symptom free and euphoric phase after arrival in the country of settlement, followed by a crisis stage, was examined for 129 Southeast Asian refugees, 57 Pacific Island immigrants and 63 British immigrants. A questionnaire and the Hopkins Symptom Checklist-25, in English and in three Southeast Asian language translations, were administered face-to-face. All respondents had arrived in New Zealand within the last 15 years. The findings did not support Sluzki's model. Refugees and immigrants in the group with less than six months of residence were not symptom free. Neither did the group with six months to six years residence demonstrate a deterioration in mental health. However, mean depression levels were slightly lower for those who had lived in New Zealand for over six years, suggesting that mental health may improve the longer both refugees and immigrants reside in the host country.

Hemolytic uremic syndrome in New Jersey

In an 18-month study period, the authors identified 23 cases of hemolytic uremic syndrome (HUS) in New Jersey children. Increased identification and reporting of Escherichia coli O157:H7 are needed to prevent additional morbidity and mortality.

Prevalence of childhood asthma across Canada

BACKGROUND

A large cross-sectional study provided an opportunity to estimate the prevalence of childhood asthma in several regions across Canada.

METHODS

In 1988, approximately 18,000 questionnaires were distributed to the families of 5-8 year old children in 30 communities from the following six regions across Canada: the interior of British Columbia, southeastern Saskatchewan, southwestern Ontario, the central region of Ontario, southern Quebec, and the Maritimes (Nova Scotia and Prince Edward Island). These communities were free of point-source air pollutants and selected to represent a range of ambient sulphate concentrations. In all 14,948 questionnaires were returned representing an 83% response rate.

RESULTS

Currently present, physician-diagnosed asthma was reported for 4.7% of children by their parents. Persistent wheezing was reported for 13% and persistent cough for 5.9%. Asthma was most common in the two Maritime provinces (7.4%), and least common in British Columbia (3.3%) and Quebec (3.4%). Similar regional differences were seen for persistent cough, persistent wheeze, and also hospital separation rates for asthma which were approximately 800 per 100,000 for the Maritimes and 396 per 100,000 for British Columbia. Differences persisted despite adjustments for several host and environmental (indoor and outdoor) characteristics.

CONCLUSIONS

The east coast of Canada may be an endemic area of asthma in Canada. If confirmed by objective measures of asthma, a detailed aetiologic investigation could enhance understanding of this phenomenon and the major environmental determinants of asthma morbidity in general.

Effects of low ambient levels of ozone and sulfates on the frequency of respiratory admissions to Ontario hospitals

To investigate the acute respiratory health effects of ambient air pollution, the number of emergency of urgent daily respiratory admissions to 168 acute care hospitals in Ontario were related to estimates of exposure to ozone and sulfates in the vicinity of each hospital. Ozone levels were obtained from 22 monitoring stations maintained by the Ontario Ministry of the Environment for the period January 1, 1983 to December 31, 1988. Daily levels of sulfates were recorded at nine monitoring stations representing three different networks operated by the Ontario Ministry of the Environment and Environment Canada. Positive and statistically significant associations were found between hospital admissions and both ozone and sulfates recorded on the day of admission and up to 3 days prior to the date of admission. Five percent of daily respiratory admissions in the months of May to August were associated with ozone, with sulfates accounting for an additional 1% of these admissions. Ozone was a stronger predictor of admissions than sulfates. Positive and statistically significant (P < 0.05) associations were observed between the ozone-sulfate pollution mix and admissions for asthma, chronic obstructive pulmonary disease, and infections. Positive associations were also found in all age groups, with the largest impact on infants (15% of admissions associated with the ozone-sulfate pollution mix) and the least effects on the elderly (4%). Temperature had no effect on the air pollution-admission relationship. Ozone (lagged 1 day) and sulfates (lagged 1 day) displayed a positive association with respiratory admissions for 91 and 100% of the 168 acute care hospitals, respectively. Air pollution was not related to a class of nonrespiratory admissions, which served as a negative control, nor was it related to admissions in the winter months of December to March, when ozone and sulfate levels are low and when people spend a considerable amount of time indoors.

Air in the cavernous sinus following scalp vein cannulation

A 7-month-old infant was found to have air in the cavernous sinus during a CT scan under general anaesthesia. An anterior scalp vein had been used to administer atracurium and contrast. The anatomy and precautions to prevent air embolism during scalp vein cannulation are discussed.

Relationship of migrant status (refugee or immigrant) to mental health

This study investigated and compared mental health levels among refugees and immigrants living in New Zealand. One hundred and twenty-nine Indochinese refugees, 57 Pacific Island immigrants and 63 British immigrants to New Zealand were surveyed. A questionnaire and the Hopkins Symptom Checklist-25 (HSCL-25) in English and in three Indochinese translations, were administered face-to-face. The hypothesis that migrant status (being a refugee or immigrant) affects mental health and that refugees experience more emotional distress than immigrants was only supported by the comparison with British immigrants. Both Indochinese refugees and Pacific Island immigrants experienced relatively low levels of mental health. However, the incidence of clinical depression and clinical total emotional distress tended to be higher among Indochinese refugees than in either immigrant group. In contrast clinical anxiety occurred most often among Pacific Islanders.

An epidemiological study of disorders in late childhood and adolescence--I. Age- and gender-specific prevalence

Developmental aspects of psychiatric disorders may be inferred from patterns of age differences in prevalence. Age-specific prevalences are provided for nine disorders in a general population sample of ages 10-20. Age and gender patterns for several disorders suggest developmental stage-associated risks. These include oppositional disorder in both genders and conduct disorder and major depression in girls. Major depression shows a pattern suggestive of a role for the onset of puberty. The prevalence of one or more disorders did not differ by age or gender. However, the pattern of specific diagnoses varied greatly by both age and gender.

An epidemiological study of disorders in late childhood and adolescence--II. Persistence of disorders

The persistence and new onset of psychiatric disorder were studied in a sample of 734 children from the general population. Diagnoses for six of the more prevalent disorders were generated from maternal and child interviews when the children were ages 9-18 and again 2 1/2 years later. Analyses demonstrated substantial levels of diagnostic persistence over the 2 1/2 year period for all diagnoses except major depression. With few exceptions persistence was roughly equivalent for age and gender subgroups. It is concluded that disorders assessed by structured interview of non-clinical samples of children cannot be dismissed as transitory.