Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Controlled before-after intervention study of suburb-wide street changes to increase walking and cycling: Te Ara Mua-Future Streets study design

BACKGROUND

Achieving a shift from car use to walking, cycling and public transport in cities is a crucial part of healthier, more environmentally sustainable human habitats. Creating supportive active travel environments is an important precursor to this shift. The longevity of urban infrastructure necessitates retrofitting existing suburban neighbourhoods. Previous studies of the effects of street changes have generally relied on natural experiments, have included few outcomes, and have seldom attempted to understand the equity impacts of such interventions.

METHODS

In this paper we describe the design of Te Ara Mua - Future Streets, a mixed-methods, controlled before-after intervention study to assess the effect of retrofitting street changes at the suburb scale on multiple health, social and environmental outcomes. The study has a particular focus on identifying factors that improve walking and cycling to local destinations in low-income neighbourhoods and on reducing social and health inequities experienced by Māori (Indigenous New Zealanders) and Pacific people. Qualitative system dynamics modelling was used to develop a causal theory for the relationships between active travel, and walking and cycling infrastructure. On this basis we selected outcomes of interest. Together with the transport funder, we triangulated best evidence from the literature, transport policy makers, urban design professionals and community knowledge to develop interventions that were contextually and culturally appropriate. Using a combination of direct observation and random sample face to face surveys, we are measuring outcomes in these domains of wellbeing: road-user behaviour, changes to travel mode for short trips, physical activity, air quality, road traffic injuries, greenhouse gas emissions, and perceptions of neighbourhood social connection, safety, and walking and cycling infrastructure .

DISCUSSION

While building on previous natural experiments, Te Ara Mua - Future Streets is unique in testing an intervention designed by the research team, community and transport investors together; including a wide range of objective outcome measures; and having an equity focus. When undertaking integrated intervention studies of this kind, a careful balance is needed between epidemiological imperatives, the constraints of transport funding and implementation and community priorities, while retaining the ability to contribute new evidence for healthy, equitable transport policy. The study was retrospectively registered as a clinical trial on 21 June 2018 in the ISCRTN registry: ISRCTN89845334 http://www.isrctn.com/ISRCTN89845334.

Faecal occult blood testing screening for colorectal cancer and 'missed' interval cancers: are we ignoring the elephant in the room? Results of a multicentre study

AIM

Biennial faecal occult blood testing (FOBT) is used to screen for colorectal cancer throughout the UK. Interval cancers are tumours that develop in patients between screening rounds who have had a negative FOBT. Through a multicentre study, we compared the demographics of patients with interval cancers, FOBT screen detected cancers and cancers that developed in patients who chose not to participate in the screening programme.

METHOD

Five hundred and sixteen colorectal cancers were detected in the screening age group (60-74 years) population in three UK National Health Service hospitals over 2 years. One hundred and twenty seven (25%) were interval cancers, 161 (31%) were screen detected and 228 (44%) were cancers that developed in patients who had declined FOBT. The interval cancer group had a higher incidence of right-sided cancers (38% vs 29% and 24%), a higher proportion of high tumour stages (Dukes C and D) (70% vs 53% and 33%) and a shorter time from diagnosis to death (10 months vs 13 months and 24 months) compared to patients who had declined the FOBT and the FOBT screen detected cancers. Of all the patients studied, those with right-sided interval cancers had the worst outcome.

CONCLUSION

A quarter of the colorectal cancers diagnosed in our study were interval cancers. Patients with right-sided interval cancers had the highest proportion of Dukes C and D tumours coupled with the shortest survival time after diagnosis compared with the other groups.

Longitudinal Associations Among Posttraumatic Stress Disorder, Disordered Eating, and Weight Gain in Military Men and Women

Obesity is a major health problem in the United States and a growing concern among members of the military. Posttraumatic stress disorder (PTSD) has been associated with overweight and obesity and may increase the risk of those conditions among military service members. Disordered eating behaviors have also been associated with PTSD and weight gain. However, eating disorders remain understudied in military samples. We investigated longitudinal associations among PTSD, disordered eating, and weight gain in the Millennium Cohort Study, which includes a nationally representative sample of male (n = 27,741) and female (n = 6,196) service members. PTSD at baseline (time 1; 2001-2003) was associated with disordered eating behaviors at time 2 (2004-2006), as well as weight change from time 2 to time 3 (2007-2008). Structural equation modeling results revealed that the association between PTSD and weight change from time 2 to time 3 was mediated by disordered eating symptoms. The association between PTSD and weight gain resulting from compensatory behaviors (vomiting, laxative use, fasting, overexercise) was significant for white participants only and for men but not women. PTSD was both directly and indirectly (through disordered eating) associated with weight change. These results highlight potentially important demographic differences in these associations and emphasize the need for further investigation of eating disorders in military service members.

Guidelines for the Cytopathologic Diagnosis of Epithelioid and Mixed-Type Malignant Mesothelioma: a secondary publication

OBJECTIVE

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma.

DATA SOURCES

Cytopathologists with an interest in the field involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC) contributed to this update. Reference material includes peer-reviewed publications and textbooks.

RATIONALE

This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in Cape Town.

Is grand-parental smoking associated with adolescent obesity? A three-generational study

BACKGROUND/OBJECTIVES

Data from previous studies consistently suggest that maternal smoking is positively associated with obesity later in life. Whether this association persists across generations is unknown. We examined whether grand-parental smoking was positively associated with overweight status in adolescence.

SUBJECT/METHODS

Participants were grandmother-mother-child triads in the Nurses' Health Study II (NHS II), the Nurses Mothers' Cohort Study and the Growing up Today Study (GUTS). Grandmothers provided information on their and their partner's smoking during pregnancy with the child's mother. Information on child's weight and height at ages 12 (N=3094) and 17 (N=3433) was obtained from annual or biennial GUTS questionnaires. We used logistic regression to estimate the odds ratios (ORs) of being overweight or obese, relative to normal weight.

RESULTS

Grand-maternal smoking during pregnancy was not associated with overweight status in adolescence. After adjusting for covariates, the OR of being overweight or obese relative to normal weight at age 12 years in girls whose grandmothers smoked 15+ cigarettes daily during pregnancy was 1.21 (95% confidence interval (CI) 0.74-1.98; P(trend)=0.31) and 1.07 (0.65-1.77; P(trend)=0.41) in boys. Grand-paternal smoking during pregnancy was associated with being overweight or obese at age 12 in girls only, but not at age 17 for either sex: the OR for being overweight or obese at age 12 was 1.38 (95% CI 1.01-1.89; P(trend)=0.03) in girls and 1.31 (95% CI 0.97-1.76; P(trend)=0.07) in boys. Among children of non-smoking mothers, the OR for granddaughter obesity for grand-paternal smoking was attenuated and no longer significant (OR 1.28 (95% CI 0.87-1.89; P(trend)=0.18)).

CONCLUSIONS

Our findings suggest that the association between maternal smoking and offspring obesity may not persist beyond the first generation. However, grand-paternal smoking may affect the overweight status of the granddaughter, likely through the association between grand-paternal smoking and maternal smoking.

Childhood hyperactivity/inattention and eating disturbances predict binge eating in adolescence

BACKGROUND

Identifying childhood predictors of binge eating and understanding risk mechanisms could help improve prevention and detection efforts. The aim of this study was to examine whether features of attention-deficit/hyperactivity disorder (ADHD), as well as childhood eating disturbances, predicted binge eating later in adolescence.

METHOD

We studied specific risk factors for the development of binge eating during mid-adolescence among 7120 males and females from the Avon Longitudinal Study of Parents and Children (ALSPAC), a cohort study of children in the UK, using data from multiple informants to develop structural equation models. Repeated assessment of eating disturbances during childhood (mid-childhood overeating, late-childhood overeating and early-adolescent strong desire for food), as well as teacher- and parent-reported hyperactivity/inattention during mid- and late childhood, were considered as possible predictors of mid-adolescent binge eating.

RESULTS

Prevalence of binge eating during mid-adolescence in our sample was 11.6%. The final model of predictors of binge eating during mid-adolescence included direct effects of late-childhood overeating [standardized estimate 0.145, 95% confidence interval (CI) 0.038–0.259, p = 0.009] and early-adolescent strong desire for food (standardized estimate 0.088, 95% CI −0.002 to 0.169, p = 0.05). Hyperactivity/inattention during late childhood indirectly predicted binge eating during mid-adolescence (standardized estimate 0.085, 95% CI 0.007–0.128, p = 0.03) via late-childhood overeating and early-adolescent strong desire for food.

CONCLUSIONS

Our findings indicate that early ADHD symptoms, in addition to an overeating phenotype, contribute to risk for adolescent binge eating. These findings lend support to the potential role of hyperactivity/inattention in the development of overeating and binge eating.

Assessing eating disorder symptoms in adolescence: is there a role for multiple informants?

OBJECTIVES

Studies of adolescent psychiatric disorders often collect information from adolescents and parents, yet most eating disorder epidemiologic studies only rely on adolescent report.

METHOD

We studied the eating disorder symptom reports, from questionnaires sent at participants' ages 14 and 16 years, provided by 7,968 adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC), and their parents. Adolescents and parents were asked questions about the adolescent's eating disorder symptoms (binge eating, vomiting, laxative use, fasting, and thinness). We assessed cross-sectional concordance and prevalence using kappa coefficients and generalized estimating equations. Generalized estimating equations were used to assess prospective associations between symptom reports and adolescent weight outcomes measured at a face-to-face assessment at 17.5 years.

RESULTS

Parents and adolescents were largely discordant on symptom reports cross-sectionally (kappas < 0.3), with the parent generally less likely to report bulimic symptoms than the adolescent but more likely to report thinness. Female adolescents were more likely to report bulimic symptoms than males (e.g., two to four times more likely to report binge eating), while prevalence estimates according to parent reports of female vs. male adolescents were similar. Both informants' symptom reports were predictive of body mass and composition measures at 17.5 years; compared to adolescent report, parentally reported binge eating was more strongly predictive of body mass index.

DISCUSSION

Parent report of eating disorder symptoms seemed to measure different, but potentially important, aspects of these symptoms during adolescence. Epidemiologic eating disorder studies should consider the potential value added from incorporating parental reports, particularly in studies of males.

Reproducibility of cerebrospinal venous blood flow and vessel anatomy with the use of phase contrast-vastly undersampled isotropic projection reconstruction and contrast-enhanced MRA

BACKGROUND AND PURPOSE

The chronic cerebrospinal venous insufficiency hypothesis raises interest in cerebrospinal venous blood flow imaging, which is more complex and less established than in arteries. For accurate assessment of venous flow in chronic cerebrospinal venous insufficiency diagnosis and research, we must account for physiologic changes in flow patterns. This study examines day-to-day flow variability in cerebrospinal veins by use of 4D MR flow and contrast-enhanced MRA under typical, uncontrolled conditions in healthy individuals.

MATERIALS AND METHODS

Ten healthy volunteers were scanned in a test-retest fashion by use of a 4D flow MR imaging technique and contrast-enhanced MRA. Flow parameters obtained from phase contrast-vastly undersampled isotropic projection reconstruction and contrast-enhanced MRA scoring measurements in the head, neck, and chest veins were analyzed for internal consistency and interscan reproducibility.

RESULTS

Internal consistency was satisfied at the torcular herophili, with an input-output difference of 2.2%. Percentages of variations in flow were 20.3%, internal jugular vein; 20.4%, azygos vein; 6.8%, transverse sinus; and 5.1%, common carotid artery. Retrograde flow was found in the lower internal jugular vein (4.8%) and azygos vein (7.2%). Contrast-enhanced MRA interscan κ values for the internal jugular vein (left: 0.474, right: 0.366) and azygos vein (-0.053) showed poor interscan agreement.

CONCLUSIONS

Phase contrast-vastly undersampled isotropic projection reconstruction blood flow measurements are reliable and highly reproducible in intracranial veins and in the common carotid artery but not in veins of the neck (internal jugular vein) and chest (azygos vein) because of normal physiologic variation. Retrograde flow normally may be observed in the lower internal jugular vein and azygos vein. Low interrater agreement in contrast-enhanced MRA scans was observed. These findings have important implications for imaging diagnosis and experimental research of chronic cerebrospinal venous insufficiency.

Body satisfaction, weight gain and binge eating among overweight adolescent girls

Objective

To examine if body satisfaction is associated with body mass index (BMI) change and whether it protects against the development of frequent binge eating among overweight and obese adolescent girls.

Methods

We used prospective data from 9 waves of an ongoing cohort study of adolescents, the Growing Up Today Study. At enrollment in 1996, participants were 9 to 14 years old. Questionnaires were mailed to participants annually until 2001, then biennially through 2007. Girls who were overweight or obese in 1996 were included in the analysis (n=1 559). Our outcomes were annual change in BMI and incident frequent binge eating, defined as binge eating at least weekly and no use of compensatory behaviors.

Results

At baseline, 57.2% of the overweight and obese girls were at least somewhat satisfied with their bodies. During 11 years of follow-up, 9.5% (95% confidence interval (CI) [7.8, 10.8]) of the girls started to binge eat frequently. Controlling for BMI and other confounders, overweight and obese girls who reported being at least somewhat satisfied with their bodies made smaller BMI gains (β=−0.10 kg/m², 95% CI [−0.19, −0.02]) and had 61% lower odds of starting to binge eat frequently (odds ratio (OR)=0.39, 95% CI [0.24, 0.64]) than their less satisfied peers. Compared to girls who were the least satisfied with their bodies, girls who were the most satisfied had 85% lower odds of starting to binge eat frequently (OR=0.15, 95% CI [0.06, 0.37]). The association between body satisfaction and starting to binge eat frequently was stronger for younger adolescents than older adolescents.

Conclusions

While body dissatisfaction is common among overweight and obese girls, body satisfaction may protect against excessive weight gain and binge eating. Prevention of body dissatisfaction must begin early and should be considered as a component of both obesity and eating disorder prevention programs.

Physical activity patterns and prevention of weight gain in premenopausal women

BACKGROUND

Studies of the association between physical activity (PA) and weight maintenance have been inconsistent.

METHODS

We prospectively examined the association between PA patterns and prevention of weight gain among 46,754 healthy premenopausal women, aged 25–43 years in 1989. Participants reported their PA and weight in 1989 and 1997. The primary outcome was gaining >5% of baseline weight by 1997 (62% of the population).

RESULTS

Compared with women who maintained <30 minutes/day of total discretionary activity over 8 years, women were less likely to gain weight if they sustained 30+ minutes/day (Odds Ratio OR=0.68, 95% confidence interval [CI] 0.64–0.73) or increased to 30+ minutes/day in 1997 (OR=0.64, 95%CI=0.60–0.68). Among women whose only reported activity was walking, risk of gaining weight was lower in those who sustained 30+ minutes/day over 8 years (OR=0.66, 95%CI=0.49–0.91), and brisk walking pace independently predicted less weight gain. For a 30 minutes/day increase between 1989 and 1997, jogging/running was associated with less weight gain than brisk walking or other activities. Greater duration of PA was associated with progressively less weight gain, but even an 11–20 minutes/day increase was beneficial; the benefits appeared stronger among those initially overweight. Sedentary behavior independently predicted weight gain.

CONCLUSIONS

Sustained PA for at least 30 minutes/day, particularly if more intense, is associated with a reduction in long-term weight gain, and greater duration is associated with less weight gain. Sedentary women of any baseline weight who increase their PA will benefit, but overweight women appear to benefit the most.

Effect of the orlistat on serum endotoxin lipopolysaccharide and adipocytokines in South Asian individuals with impaired glucose tolerance

BACKGROUND

Orlistat has been shown to increase adiponectin and reduce progression to type 2 diabetes in obese Caucasians. Some effects of orlistat are thought to be independent of weight loss by altering gut flora and the production of endotoxin lipopolysaccharide (LPS). We studied the effect of dietary treatment with and without orlistat in South Asian individuals with impaired glucose tolerance (IGT) on adiponectin and inflammatory markers including LPS.

METHODS

South Asian individuals were randomised to either dietary treatment with orlistat or dietary treatment alone. At the end of 12 months, a comparison was made between the two groups for differences in anthropomorphic measurements and serum markers.

RESULTS

Three hundred and five individuals underwent oral glucose tolerance test of whom 40 had IGT. Complete baseline and 1-year data was available for 31 patients. After 1 year, patients in the orlistat group demonstrated a greater but insignificant decrease in weight (4.5 +/- 0.1 kg), and a significant increase in adiponectin (6.73 +/- 3.2 microg/ml) and decrease in LPS (4.55 +/- 1.98 EU/ml) compared with- the diet-alone group. In the orlistat group the reduction in LPS was correlated with the increase in adiponectin (p < 0.005).

CONCLUSION

The increase in adiponectin levels in the orlistat group would suggest that orlistat may reduce the progression to type 2 diabetes in South Asian individuals by raising serum adiponectin. The finding that LPS levels are also reduced by orlistat and that this reduction correlates with the increase in adiponectin raises the possibility that the increase in adiponectin may be mediated via an effect on LPS levels.

Hydroxychloroquine therapy in patients with primary Sjogren's syndrome may improve salivary gland hypofunction by inhibition of glandular cholinesterase

OBJECTIVE

To determine whether (i) cholinesterase activity is increased in the saliva of patients with primary Sjogren's syndrome (pSS), (ii) increased levels of cholinesterase of lymphocyte origin could interfere with the secretory activity of submandibular acinar cells, and (iii) hydroxychloroquine at therapeutic doses could interfere with cholinesterase activity.

METHODS

The Ellman method was used to determine the levels of salivary cholinesterase activity and the K(i) of both chloroquine and hydroxychloroquine for serum cholinesterase. The ability of lymphocyte cholinesterase to inhibit the acetylcholine (ACh)-evoked rise in [Ca(2+)](i) in mouse submandibular acinar cells was determined using fura-2 microfluorimetry.

RESULTS

Patients with pSS had significantly higher levels of cholinesterase activity in both their unstimulated (P < 0.05) and stimulated saliva (P < 0.0001) compared with control subjects. Lymphocyte cholinesterase was capable of inhibiting the ACh-evoked rise in [Ca(2+)](i). The in vitro K(i) for hydroxychloroquine inhibition of cholinesterase was 0.38 +/- 1.4 microM.

CONCLUSION

These data suggest that increased levels of cholinesterase present in the salivary glands of patients with pSS may contribute to glandular hypofunction and provide evidence that the therapeutic enhancement of salivary secretion in patients with pSS by hydroxychloroquine may be mediated by inhibition of glandular cholinesterase activity, although further in vivo investigation is needed.

Association of weight change, weight control practices, and weight cycling among women in the Nurses' Health Study II

OBJECTIVE

To assess the association of weight cycling with weight change, weight control practices, and bulimic behaviors.

METHODS

A nested study of 2476 young and middle-aged women in the Nurses' Health Study II who provided information on intentional weight losses between 1989 and 1993.

SAMPLE

In total, 224 women who were severe cyclers, 741 women who were mild cyclers, 967 age- and BMI-matched controls (noncyclers), and 544 women who did not weight cycle and maintained their weight between 1989 and 1993 completed a questionnaire in 2000-2001 assessing recent intentional weight losses, weight control practices, and weight concerns.

RESULTS

After controlling for age and body mass index (BMI) in 1993, when weight cycling was initially assessed, mild cyclers gained an average of 6.7 pounds (lbs) more and severe cyclers gained approximately 10.3 lbs more than noncyclers between 1993 and 2001. Weight cyclers preferred to change their diet rather than to exercise to control their weight. Severe weight cyclers were less likely than noncyclers to use frequent exercise as a weight control strategy (odds ratio [OR]=0.8, 95% confidence interval (CI) 0.6-1.1). Cyclers were also more likely than noncyclers to engage in binge eating (mild cyclers: OR=1.8, 95% CI 1.4-2.4; and severe cyclers: OR=2.5, 95% CI 1.7-3.5). Independent of weight cycling status, age, and BMI, women who engaged in binge eating gained approximately 5 lbs more than their peers (P<0.001).

CONCLUSIONS

Weight cycling was associated with greater weight gain, less physical activity, and a higher prevalence of binge eating. Low levels of activity and binge eating may be partially responsible for the large amount of weight regained by weight cyclers.

Snack food intake does not predict weight change among children and adolescents

OBJECTIVE

To assess whether intake of snack foods was associated with weight change among children and adolescents.

METHODS

Prospective study of 8,203 girls and 6,774 boys, 9-14 y of age in 1996, in an ongoing cohort study who completed at least two questionnaires between 1996 and 1999. Intake of snack foods was assessed in 1996-1998 with a validated food frequency questionnaire designed specifically for children and adolescents. The outcome measure was change in age- and gender-specific z-score of body mass index (BMI).

RESULTS

Boys consumed more snack foods than girls during the entire study period. After controlling for Tanner stage of development, age, height change, activity, and inactivity, there was no relation between intake of snack foods and subsequent changes in BMI z-score among the boys (beta=-0.004), but snack foods had a weak inverse association (beta=-0.007, P<0.05) with weight change among the girls. However, the results were confounded by dieting status, which had a significant positive independent association with BMI change. After controlling for dieting status and whether the mother was overweight, the association between servings per day of snack foods and subsequent changes in BMI z-score were not significant in either gender.

DISCUSSION

Our results suggest that although snack foods may have low nutritional value, they were not an important independent determinant of weight gain among children and adolescents.

Modest weight loss and reduction in waist circumference after medical treatment are associated with favorable changes in serum adipocytokines

Modest weight loss if maintained is associated with significant metabolic benefits and reduction in cardiovascular risk. Adipose tissue secretes cytokines believed to contribute to the pathogenesis of insulin resistance and cardiovascular risk. We therefore observed the effect of modest weight loss on serum adipocytokines and their relationship with changes in anthropometric and metabolic parameters within a period of 6 months in the setting of a routine obesity hospital clinic after various medical treatments. In this prospective, nonrandomized, nonblinded observational study, patients were first given treatment (sibutramine or orlistat) as decided by the treating clinician and then allocated into 1 of 2 groups according to the treatment prescribed. The first group included 21 Caucasian nondiabetic female subjects, with a mean (+/-SD) age of 43 +/- 11 years and a mean body mass index (BMI) of 46 +/- 8.6 kg/m(2); subjects were treated with sibutramine 10 or 15 mg/d for weight loss. The second group included 20 Caucasian nondiabetic female subjects, mean age 42 +/- 9 years and mean BMI 45.2 +/- 5.2 kg/m(2); orlistat was introduced after 1 month on a low-fat (</=30%) diet in this group. Blood pressure and anthropometric measurements were performed before and after weight loss by a single observer. Serum glucose, insulin, lipid profile, C-reactive protein (CRP), resistin, leptin, and adiponectin were measured before and after weight loss on a fasting sample. After 6 months, the sibutramine group had a modest mean weight loss of 5.4% (P =.0001), and waist circumference was reduced by 4.5 +/- 1.4 cm. There was a decrease in serum resistin, leptin, and CRP levels, and a rise in serum adiponectin (P <.05). Change (%) (Delta) in BMI (DeltaBMI%) was associated with Deltainsulin(%) (P =.02, r = 0.53) and Deltaleptin(%) (P =.01, r = 0.58). Change in waist was associated with Deltainsulin(%) (P =.005, r = 0.75) and Deltaresistin(%) (P =.03, r = -0.55). The orlistat-treated group had a mean weight loss of 2.5%. Although this group did not show significant change in metabolic parameters, surprisingly there was a greater decrease of resistin (P =.02) associated with comparable (%) increase in adiponectin and (%) reduction of waist circumference and CRP. We conclude that modest weight loss (>5%) after medical treatment in a routine obesity hospital clinic is associated with improvements in insulin sensitivity and lipid profile. Modest weight loss is also associated with potentially favourably changes in serum adipocytokines, particularly in a rise of serum adiponectin. Reduction of waist circumference is associated with a change in serum resistin.

Longitudinal study of skipping breakfast and weight change in adolescents

BACKGROUND

Several cross-sectional studies reported that heavier children eat breakfast less often. However, no longitudinal studies have addressed whether skipping breakfast leads to excessive weight gain.

OBJECTIVE

To investigate whether skipping breakfast was prospectively associated with changes in body fatness.

METHODS

A cohort of >14000 boys and girls from all over the US, 9- to 14-y-old in 1996, returned annual mailed questionnaires (1996-1999) for the Growing Up Today Study. We analyzed change in body mass index (BMI; kg/m(2)) over three 1-y periods among children who reported breakfast frequency.

RESULTS

Children who reported that they never eat breakfast had lower energy intakes than those who eat breakfast nearly every day. Children who were more physically active reported higher energy intakes, as did those who reported more time watching television/videos and playing videogames. Like previous studies, skipping breakfast was associated with overweight, cross-sectionally. However, overweight children who never ate breakfast lost BMI over the following year compared to overweight children who ate breakfast nearly every day (boys: -0.66 kg/m(2) (s.e.=0.22); girls: -0.50 kg/m(2) (s.e.=0.14)). But normal weight children who never ate breakfast gained weight relative to peers who ate breakfast nearly every day (boys: +0.21 kg/m(2) (s.e.=0.13); girls: +0.08 kg/m(2) (s.e.=0.05)). Breakfast frequency was positively correlated with self-reported quality of schoolwork.

CONCLUSIONS

Overweight children who never eat breakfast may lose body fat, but normal weight children do not. Since numerous studies link skipping breakfast to poorer academics, children should be encouraged to eat breakfast.

Prospective assessment of exclusive breastfeeding in relation to weight change in women

OBJECTIVE

To study prospectively the relation of parity, prepregnancy body mass index (BMI), and exclusive breastfeeding to weight gain.

DESIGN

The cohort of the Nurse's Health Study II, with analysis restricted to women who were aged 24 to 40 y at baseline (1989), who had a history of no more than one past full-term pregnancy at baseline, gave birth to one child between 1990 and 1991, but had no other pregnancies during the follow-up.

SUBJECTS

1538 of the 33 082 nulliparous women and 2810 of the 20 261 primiparous, in 1989.

MEASUREMENTS

Introduction of daily formula/milk was assumed to represent the end of exclusive breastfeeding period. Duration of exclusive breastfeeding was categorized into 0, 1-3, 4-7, 8-11, and 12 months or more.

RESULTS

After adjusting for age, physical activity, and BMI in 1989, lactation was associated with a weight gain from 1989 to 1993 of approximately 1 kg (statistically significant only for women nulliparous in 1989 with a BMI <25 kg/m(2) (P=0.02) and for those women primiparous in 1989, with a BMI >/=25 kg/m(2) (P=0.04)) comparing women who breastfed with women who did not, and duration of lactation was unrelated to the magnitude of weight change (P>0.40 for all comparisons).

CONCLUSIONS

Although promotion of breastfeeding has high priority because of its enormous advantages for a newborn child, the associated maternal weight reduction is minimal. Dietary guidelines for pregnant and breastfeeding women should include ways to prevent weight retention after parity.

Association between fruit and vegetable intake and change in body mass index among a large sample of children and adolescents in the United States

OBJECTIVE

To assess whether intake of fruits and vegetables was associated with change in body mass index (BMI) among a large sample of children and adolescents in the United States.

DESIGN

Prospective cohort study of children and adolescent who were 9-14 y of age in 1996, when the study began.

SUBJECTS

The subjects included 8203 girls and 6715 boys in an ongoing cohort study who completed at least two questionnaires between 1996 and 1999.

MEASUREMENTS

Fruit and vegetable intake was assessed in 1996-1998 with a validated food frequency questionnaire designed specifically for children and adolescents. The outcome measure was change in age- and gender-specific z-score of BMI (kg/m(2)). Self-reported weight and height, which were used to calculate BMI, were collected annually from 1996 to 1999.

RESULTS

During 3 years of follow-up, annual changes in BMI were slightly greater among the boys than the girls. After controlling for Tanner stage of development, age, height change, activity and inactivity, which are known or suspected predictors of change in BMI, among the girls there was no relation between intake of fruits, fruit juice, or vegetables (alone or combined) and subsequent changes in BMI z-score. Among the boys, intake of fruit and fruit juice was not predictive of changes in BMI, however, vegetables intake was inversely related to changes in BMI z-score (beta per serving=-0.003). However, after adjusting for caloric intake, the magnitude of the effect was diminished and no longer significant.

CONCLUSION

Our results suggest that the recommendation for consumption of fruits and vegetables may be well founded, but should not be based on a beneficial effect on weight regulation.

Predicting the HER2 status of breast cancer from basic histopathology data: an analysis of 1500 breast cancers as part of the HER2000 International Study

The tests that are currently available for the measurement of overexpression of the human epidermal growth factor-2 (HER2) in breast cancer have shown considerable problems in accuracy and interlaboratory reproducibility. Although these problems are partly alleviated by the use of validated, standardised 'kits', there may be considerable cost involved in their use. Prior to testing it may therefore be an advantage to be able to predict from basic pathology data whether a cancer is likely to overexpress HER2. In this study, we have correlated pathology features of cancers with the frequency of HER2 overexpression assessed by immunohistochemistry (IHC) using HercepTest (Dako). In addition, fluorescence in situ hybridisation (FISH) has been used to re-test the equivocal cancers and interobserver variation in assessing HER2 overexpression has been examined by a slide circulation scheme. Of the 1536 cancers, 1144 (74.5%) did not overexpress HER2. Unequivocal overexpression (3+ by IHC) was seen in 186 cancers (12%) and an equivocal result (2+ by IHC ) was seen in 206 cancers (13%). Of the 156 IHC 3+ cancers for which complete data was available, 149 (95.5%) were ductal NST and 152 (97%) were histological grade 2 or 3. Only 1 of 124 infiltrating lobular carcinomas (0.8%) showed HER2 overexpression. None of the 49 'special types' of carcinoma showed HER2 overexpression. Re-testing by FISH of a proportion of the IHC 2+ cancers showed that only 25 (23%) of those assessable exhibited HER2 gene amplification, but 46 of the 47 IHC 3+ cancers (98%) were confirmed as showing gene amplification. Circulating slides for the assessment of HER2 score showed a moderate level of agreement between pathologists (kappa 0.4). As a result of this study we would advocate consideration of a triage approach to HER2 testing. Infiltrating lobular and special types of carcinoma may not need to be routinely tested at presentation nor may grade 1 NST carcinomas in which only 1.4% have been shown to overexpress HER2. Testing of these carcinomas may be performed when HER2 status is required to assist in therapeutic or other clinical/prognostic decision-making. The highest yield of HER2 overexpressing carcinomas is seen in the grade 3 NST subgroup in which 24% are positive by IHC.

Epstein-Barr virus (types 1 and 2) in the tear film in Sjogren's syndrome and HIV infection

Evidence of Epstein-Barr virus (EBV) shedding in the saliva and tear film has been sought to explain the pathogenesis of the oral and ocular features of Sjogren's syndrome. Patients with human immunodeficiency virus (HIV) infection are purported to have a higher incidence of keratoconjunctivitis sicca. Twenty patients with definite Sjogren's syndrome (primary and secondary), 19 with HIV infection, and 15 normal controls were recruited and studied. Human herpes viruses (EBV 1 and 2, CMV, HZV, and HSV-1) in tear film were detected by polymerase chain reaction of DNA extracted from Schirmer strips. HSV-1, VZV, and CMV were not detected in any tear samples. EBV-1 DNA was found in the tear film of 4 patients with Sjogren's syndrome, which was not significantly different from the control group (P = 0.18). Twelve patients with HIV infection had evidence of EBV-1 in their tears, which was significantly different from controls (P = 0.0002) and patients with Sjogren's syndrome (P = 0.014). EBV-2 was found in 3 patients with HIV and in 1 patient with secondary Sjogren's syndrome, and was always found as a co-infection with EBV-1 (P = 0.01). This represents the first report examining EBV types 1 and 2 in the tear film and also EBV in the tear film of patients with HIV. Shedding of EBV in the tear film was not related to the presence of keratoconjunctivitis sicca in Sjogren's syndrome. EBV-2 co-infection with EBV-1 has not been previously reported in the tear film. EBV infection is abnormally regulated in Sjogren's syndrome and HIV, and it is likely that the presence of EBV in the tear film is related to the patients' altered immune status.

Marijuana use in New Zealand, 1990 and 1998

AIMS

To examine changes in marijuana use in a metropolitan region and a provincial/rural region in New Zealand between 1990 and 1998.

METHODS

Two random sample surveys of people aged 15 -45 years were carried out in Auckland and Bay of Plenty regions in 1990 and 1998, using a computer-assisted telephone interviewing system.

RESULTS

Use of marijuana in the last twelve months increased in the metropolitan sample from 18% to 22%, but not in the provincial area. Those who had ever tried marijuana increased from 43% of the total sample in 1990 to 52% in 1998. Use was higher among men than women, but had increased among women. There was a trend towards more frequent users of marijuana (ten or more occasions in the previous 30 days), from 2.4% to 3.2%.

CONCLUSIONS

Experience of marijuana was slightly more common in 1998 than in 1990, but increases in recent use were small and were found only in the metropolitan area. The increase in use was relatively limited: only one in five of each sample had used marijuana in the past year, and opportunity to use marijuana by non-users had not increased. Use was predominantly casual and social, and most who had tried marijuana no longer used the drug. However, the age at which first use occurred appeared to have declined.

Relationship of a large weight loss to long-term weight change among young and middle-aged US women

OBJECTIVE

To assess the prevalence of clinically significant weight loss among women and whether this is associated with smaller long-term weight gains.

DESIGN

Six-year follow-up of young and middle-aged women in the Nurses' Health Study II.

SUBJECTS

A total of 47,515 women who did not report a pregnancy, or a diagnosis of cancer or cardiovascular disease any time between 1989 and 1995.

MEASUREMENTS

Self-reported weights in 1989, 1991, 1993 and 1995, dietary intake, physical activity, inactivity, history of weight cycling and smoking.

RESULTS

Between 1989 and 1991, 9% of the women lost > or =5% of their 1989 weight (6% lost 5--9.9% and 3% lost > or =10%). The proportion who lost > or =10% of their weight increased with category of body mass index (BMI, kg/m(2)) from 0.4% among women with a BMI <22 to 9% among women with a BMI > or =30 in 1989. Women who lost > or =5% of their weight between 1989 and 1991 gained more weight between 1991 and 1995 than their peers and the difference increased across categories of BMI in 1989. However, due to their large weight losses, women who lost > or =5% of their weight between 1989 and 1991 overall gained less weight than their peers between 1989 and 1995 (P<0.001). Moreover, women who engaged in 5 or more hours per week of vigorous physical activity gained approximately 0.5 kg less than their inactive peers (P<0.001).

CONCLUSION

Although most women who lost a clinically significant amount of weight regained most of it, they gained less weight over the entire 6 y period than their peers.

The effect of social desirability trait on self-reported dietary measures among multi-ethnic female health center employees

PURPOSE

To evaluate the effect of social desirability trait, the tendency to respond in a manner consistent with societal expectations, on self-reported fruit, vegetable, and macronutrient intake.

METHODS

A 61-item food frequency questionnaire (FFQ), 7-item fruit and vegetable screener, and a single question on combined fruit and vegetable intake were completed by 132 female employees at five health centers in eastern Massachusetts. Intake of fruit and vegetables derived from all three methods and macronutrients from the FFQ were fit as dependent variables in multiple linear regression models (overall and by race/ethnicity and education); independent variables included 3-day mean intakes derived from 24-hour recalls (24HR) and score on the 33-point Marlowe-Crowne Social Desirability scale (the regression coefficient for which reflects its effect on estimates of dietary intake based on the comparison method relative to 24HR).

RESULTS

Results are based on the 93 women with complete data and FFQ-derived caloric intake between 450 and 4500 kcal/day. In women with college education, FFQ-derived estimates of total caloric were associated with under-reporting by social desirability trait (e.g., the regression coefficient for total caloric intake was -23.6 kcal/day/point in that group versus 36.1 kcal/day/point in women with education less than college) (difference = 59.7 kcal/day/point, 95% confidence interval (CI) = 13.2, 106.2). Except for the single question on which women with college education tended to under-report (difference =.103 servings/day/point, 95% CI = 0.003, 0.203), there was no association of social desirability trait with self-reported fruit and vegetable intake.

CONCLUSIONS

The effect of social desirability trait on FFQ reports of macronutrient intake appeared to differ by education, but not by ethnicity or race. The results of this study may have important implications for epidemiologic studies of diet and health in women.

Impact of overweight on the risk of developing common chronic diseases during a 10-year period

BACKGROUND

Overweight adults are at an increased risk of developing numerous chronic diseases.

METHODS

Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight.

RESULTS

The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men.

CONCLUSIONS

During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0 < or = BMI < or = 29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Cross-sectional measurement of nutrient intake among adolescents in 1996

BACKGROUND

Many components are involved in an assessment of diet and health among youth. To address these issues and document the major contributions of fat, fiber, vitamins, and minerals to the diet, we analyzed baseline cross-sectional data from a cohort of 16,882 youth.

METHODS

Cross-sectional analyses were conducted on the Growing Up Today Study dietary data reported by 16,882 9- to 14-year-olds in 1996. The adolescent food frequency questionnaire was used to assess this age group's eating habits. Arithmetic means and standard deviations were calculated on energy-adjusted and unadjusted data.

RESULTS

Mean intake (including vitamin/mineral supplementation) for all nutrients met 100% of the RDAs, except calcium for girls. Comparing the servings of foods with the USDA Food Pyramid, neither boys nor girls met recommended number of servings except for dairy. Overweight participants consumed fewer kilocalories and lower levels of nutrients than their nonoverweight peers.

CONCLUSION

These cross-sectional data from 1996 indicate that this cohort is consuming foods and nutrients comparable with national data of less fat and more carbohydrates in their diet. Overweight participants have similar dietary patterns except for total energy. The cohort's diet (with vitamin/mineral supplementation) is meeting the RDAs, but actual foods consumed suggest a lack of balance in the diet.

Risk of overweight among adolescents who were breastfed as infants

CONTEXT

Overweight during adolescence predicts short- and long-term morbidity as well as obesity in adulthood. The prevalence of overweight among adolescents is high and continues to increase. Physiological and behavioral mechanisms and preliminary epidemiologic data suggest that breastfeeding could lower the risk of subsequent obesity in adolescence.

OBJECTIVE

To examine the extent to which overweight status among adolescents is associated with the type of infant feeding (breast milk vs infant formula) and duration of breastfeeding.

DESIGN, SETTING, AND SUBJECTS

Survey of 8186 girls and 7155 boys, aged 9 to 14 years, who are participants in the Growing Up Today Study, a nationwide cohort study of diet, activity, and growth. In the fall of 1996 we mailed a questionnaire to each of the subjects, and in the spring of 1997, we mailed a supplemental questionnaire to their mothers, who are participants in the Nurses' Health Study II.

MAIN OUTCOME MEASURE

Overweight status defined as body mass index exceeding the 95th percentile for age and sex from US national data.

RESULTS

In the first 6 months of life, 9553 subjects (62%) were only or mostly fed breast milk, and 4744 (31%) were only or mostly fed infant formula. A total of 7186 subjects (48%) were breastfed for at least 7 months while 4613 (31%) were breastfed for 3 months or less. At ages 9 to 14 years, 404 girls (5%) and 635 boys (9%) were overweight. Among subjects who had been only or mostly fed breast milk, compared with those only or mostly fed formula, the odds ratio (OR) for being overweight was 0.78 (95% confidence interval [CI], 0.66-0.91), after adjustment for age, sex, sexual maturity, energy intake, time watching television, physical activity, mother's body mass index, and other variables reflecting social, economic, and lifestyle factors. Compared with subjects who had been breastfed for 3 months or less, those who had been breastfed for at least 7 months had an adjusted OR for being overweight of 0.80 (95% CI, 0.67-0.96). Timing of introduction of solid foods, infant formula, or cow's milk was not related to risk of being overweight.

CONCLUSION

Infants who were fed breast milk more than infant formula, or who were breastfed for longer periods, had a lower risk of being overweight during older childhood and adolescence.

Comparing physical activity questionnaires for youth: seasonal vs annual format

BACKGROUND

In large cohort studies of older children, self-report is the only practical way to assess physical activity. Assessing usual activity over the entire year is desirable, but children and adolescents may overestimate activities with high seasonal variability. Use of questionnaires in which individuals report each activity by season may improve accuracy.

METHODS

A total of 6782 girls and 5110 boys, aged 9-14 years in 1996, completed self-administered activity questionnaires in 1996 and in 1997. In 1996, participants reported the average time spent in each of 17 activities during the previous 12 months; in 1997, we also asked for the average time spent in the previous year, but within each of the four seasons.

RESULTS

Girls reported a median of 12.8 hours/week total activity in 1996 and 10.4 hours/week in 1997. For boys, the estimates were 15.5 hours/week and 13.4 hours/week, respectively. Girls and boys within 1-year age strata (e.g., comparison of 10-year olds in 1996 with 10-year olds in 1997) reported an average of 3.7 and 3.1 fewer hours per week, respectively, on the 1997 seasonal format versus the 1996 annual format questionnaire. In longitudinal analyses, the difference between the annual and the seasonal estimates was greater if participants did the activity in fewer seasons in 1997.

CONCLUSIONS

In comparison to an annual format questionnaire, a seasonal format questionnaire may improve accuracy of self-report of physical activity by reducing over-reporting of activities in which pre-adolescents and adolescents engage in fewer seasons.

Regression of gastric T cell lymphoma with eradication of Helicobacter pylori

Helicobacter pylori is thought to be important in the pathogenesis of chronic active gastritis, peptic ulceration, gastric adenocarcinoma, and gastric B cell lymphoma of mucosa associated lymphoid tissue. The mechanism of evolution from chronic gastritis to monoclonal B cell proliferation is not known but is thought to be dependent on antigen specific T cells to H pylori and its products. Here, we report a case of gastric T cell lymphoma associated with chronic H pylori gastritis which regressed with eradication of the organism. This is the first report of a gastric T cell lymphoma regressing with H pylori eradication, and suggests a causal link between primary gastric T cell lymphoma and this organism.

Modification of the tear function index and its use in the diagnosis of Sjögren's syndrome

BACKGROUND

The tear function index (TFI) has been shown to be of value in the diagnosis of patients suffering from Sjögren's syndrome. It is dependent, however, on introducing into the conjunctival fornix the correct concentration of fluorescein in at least one and a half times the normal tear volume. The stimulus and effect of this added volume on the tear dynamics is likely to vary between individuals. These factors, together with the method of performing the test, limit its general applicability.

AIM

To devise a method of performing the TFI with less variability and more general applicability. To present a theoretical and in vitro assessment of the dynamics of the TFI.

METHOD

The study was divided into three parts. The first part was to compare the results obtained using a prepared strip containing 1.3 microl of 0.5% fluorescein with the introduction of the same amount of fluorescein as a drop. The second part was to compare the results obtained with prepared strips with the standard method of performing the TFI, both with and without topical anaesthetic. The third part was an in vitro study of the rate of flow of graded volumes on a filter paper strip. 42 subjects with a diagnosis of Sjögren's syndrome according to the European criteria and 126 without Sjögren's syndrome were included.

RESULTS

There was no significant difference between the results obtained with a prepared strip and the introduction of 1.3 microl into the eye before performing the Schirmer's test and TFI (0.1<p<0.93). There was, likewise, no significant difference between using the prepared strips and the standard method of performing the TFI (0.36<p<0.93). There was, however, less interocular difference (p=0.01) and variability (p=0.001) using the prepared strips than using a drop of fluorescein. Patients with Sjögren's syndrome had mean TFIs of 11.7 and 8.61 with upper 95% confidence values of 15 and 12 without and with topical anaesthetic, respectively. The theoretical calculation of the TFI was similar to the observed values. The in vitro results allow the filter paper to be removed from the eye at any interval and to estimate the volume of tears that the filter paper was in contact with.

CONCLUSION

The proposed method of performing the TFI is easy to perform, reliable, and therefore has general applicability for primary care and general practitioners. It allows the rapid identification of subjects who may be suffering from Sjögren's syndrome.

Nicorandil can induce severe oral ulceration

OBJECTIVE

To increase physicians' and dentists' awareness that nicorandil is a potential inducer of severe mouth ulceration.

STUDY DESIGN

Nine new cases of ulceration from 3 European countries were included in this study.

RESULTS

Oral ulceration developed within 9 months of beginning nicorandil therapy, and ulcers resolved within 1 month of withdrawal of the drug. No lesions developed on other epithelia.

CONCLUSIONS

A number of drugs used in the care of patients with cardiovascular disease can cause oral adverse effects. Nicorandil, a new potassium-channel activator used in some countries to treat angina pectoris, precipitates persistent ulcerative stomatitis in some patients.

Peer, parent, and media influences on the development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys

OBJECTIVE

To assess prospectively the influence of peers, parents, and the media on the development of weight concerns and frequent dieting.

DESIGN

Prospective cohort study.

SETTING

Questionnaires mailed annually to participants throughout the United States.

PARTICIPANTS

One-year follow-up of 6770 girls and 5287 boys who completed questionnaires in 1996 and 1997 and were between 9 and 14 years of age in 1996.

MAIN OUTCOME MEASURE

Onset of high levels of concern with weight and dieting frequently to control weight.

RESULTS

During 1 year of follow-up, 6% of girls and 2% of boys became highly concerned with weight and 2% of girls and 1% of boys became constant dieters. Peer influence was negligible. Independent of age and body mass index, both girls (odds ratio [OR]): 1.9; 95% confidence interval [CI]: 1.1-3.1) and boys (OR: 2.7; 95% CI: 1.1-6. 4) who were making a lot of effort to look like same-sex figures in the media were more likely than their peers to become very concerned with their weight. Moreover, both girls (OR: 2.3; 95% CI: 1.1-5.0) and boys (OR: 2.6; 95% CI: 1.1-6.0) who reported that their thinness/lack of fat was important to their father were more likely than their peers to become constant dieters.

CONCLUSIONS

Our results suggest that parents and the media influence the development of weight concerns and weight control practices among preadolescents and adolescents. However, there are gender differences in the relative importance of these influences.