Importance of assessing cytogenetic and molecular risk factors in acute myeloid leukemia therapy

Acute myeloid leukemia (AML) is a heterogeneous disease in clinical presentation, outcome and therapeutic response. Cytogenetic and molecular characteristics are important prognostic indicators allowing the identification of distinct subtypes of AML, prognostic stratification and risk-adapted treatment. We present our experience during 5 years, in which we treated 245 patients with AML, of which we could genetically characterize 48 cases (26 females, 22 males) with a median age of 52 years. Cytogenetic analysis was performed by GTG banding on cultures of marrow cells treated with colcemid. Molecular analysis used RT-PCR performed on ABI 9700 platform in order to identify the following fusion genes: E2A-PBX1, TEL-AML1, AML1-ETO, PML-RARα, MLL-AF4, CBFC-MYH11, BCR-ABL, SIL-TAL, and MLL-AF9as well as mutations in Flt3, NPM1, WT1 genes. Fourteen patients were older than 60 years. In 12 we performed cytogenetic analysis showing 5 cases with complex karyotype, 2 normal karyotypes, 1 case of del(21), del (9), 11q- and t(3;15) respectively as well as 2 unevaluable karyotypes. These anomalies were associated with a high incidence of secondary AMLs (10/14) and with a low remission (CR) rate (5/14). Out of the 35 patients younger than 60 years, 25 were evaluated by cytogenetics showing a high incidence of favorable cytogenetic changes: 6 anomalies of chromosome 16 (5 inv (16) and 1 t (16; 16)), 3 t (15; 17), 3 cases of t (8; 21) of which 2 with additional abnormalities, 7 normal karyotypes and 1 case of 7q-, -y,-3 and respectively -8 associated with +18. In 25 cases molecular analysis was performed showing alterations in 21 patients: 6 cases with AML/ETO, 3 PML/RAR, 7 Flt3 mutations (2 associated with NPM1 mutation) as well as 1 case of isolated mutation of NPM1 and respectively WT1. CR rate was of 28/35. All cases with t (15; 17) and PML/RAR as well all cases with t (8; 21) and/or AML/ETO achieved CR. Out of the 7 cases with Flt3 mutations only 4 achieved CR including the 2 cases with associated NPM1 mutations. In our experience, genetic characteristics correlate with other prognostic markers such as age and secondary leukemia; "favorable" genetic anomalies were associated with a high CR rate; association of t (8; 21) with additional abnormalities did not influence CR rate.

What factors influence functional ability in patients with rheumatoid arthritis. Do they alter over time?

OBJECTIVES

To describe the changes in functional ability (FA) taking place over 5 yr in patients with rheumatoid arthritis (RA) starting disease-modifying anti-rheumatic drug (DMARD) therapy, to investigate the factors having most influence upon FA and to compare these factors at baseline and after 5 yr of treatment.

METHODS

Three hundred and sixty-six patients with active RA were studied as part of a 5-yr randomized controlled study of DMARD therapy. FA was assessed by Health Assessment Questionnaire (HAQ) score every 6 months. Multiple linear regression was used to identify factors affecting FA at baseline and at 5 yr. The independent variables used were age, sex, visual analogue scale (VAS) pain, Ritchie articular index, C-reactive protein (CRP), Larsen score and log-transformed morning stiffness (EMS).

RESULTS

Mean HAQ score was 1.64 at baseline, improved by 21% at 1 yr and gradually returned towards baseline levels by 5 yr. At baseline only 34% of variance in HAQ score could be explained; the most significant explanatory variables were the Ritchie articular index and CRP. At 5 yr the variance explained was 60%. The Ritchie articular index remained the strongest factor followed by VAS pain, log(10) EMS and Larsen score.

CONCLUSIONS

Improvement in function did occur after commencement of the first DMARD therapy but was not maintained to 5 yr. The most consistent factor affecting function was joint tenderness. Global pain and duration of EMS were of lesser importance. Disease activity measures such as the CRP exerted an influence in the earlier, more active stages of disease: radiographic damage assumed greater importance as the arthritis progressed.

The inadequate smear: does it matter?

The objective of this study was to quantify the incidence of underlying cervical intraepithelial neoplasia (CIN) among women referred for colposcopy with three consecutive inadequate smears. The design was a retrospective cohort study analysing data from a regional colposcopy database at Cervical Screening Wales. Women who were referred to all the colposcopy clinics in Wales with three consecutive inadequate smears, the third inadequate smear being taken between 1 April 2001 and 31 March 2002 constituted the study population. The results of the fourth smear taken at the colposcopy clinic after three consecutive inadequate smears, the worst biopsy results from any of the subsequent colposcopies and the relationship between the result of the fourth smear taken at colposcopy clinic and any histology result were the main outcome measures. The accuracy of the colposcopic opinion was also examined. Of the 433 women identified as having been referred because of three consecutive inadequate smears, 302 were linked to either a subsequent smear and/or a biopsy result. An adequate smear result was available for 85% of these women when the smear was taken in the colposcopy clinic; 77% were reported as negative and 8% were abnormal. Of the 347 women seen in the colposcopy clinic, high-grade CIN was seen in 3% and low-grade lesion in 8%. The sensitivity and specificity of the fourth inadequate smear test in predicting underlying CIN were 15% and 84% respectively, with a positive predictive value of 8%. The sensitivity and specificity of colposcopy in predicting histological CIN among patients with three inadequate smears was 70% and 49%, respectively, and the positive predictive value was 44%. This study raises the question as to whether three consecutive inadequate smears should be considered as an indication for colposcopy, or merely for a further smear to be taken in circumstances where there is a greater likelihood getting an adequate result.

The determinants of left ventricular hypertrophy defined by Sokolow-Lyon criteria in untreated hypertensive patients

Left ventricular hypertrophy (LVH) measured by electrocardiography (ECG LVH) in hypertensive patients has been shown to be associated with an increased risk of cardiovascular sequelae. Analysis of the determinants predisposing to ECG LVH may be helpful in the prevention of LVH. The Department of Health and Social Security Hypertension Care Computer Project studied 2994 hypertensive patients in whom an electrocardiogram was recorded while not on treatment. LVH was determined as the voltage sum SV1+RV5 or RV6>or=35 mm using Sokolow-Lyon voltage criteria. The relations were determined between the presence of LVH or voltage sum and different variables. Untreated systolic (SBP) and diastolic (DBP) blood pressure and pulse pressure were positively related to the increasing ECG voltage, while body mass index (BMI) and serum cholesterol were inversely related. Blood glucose and age did not correlate significantly. Patients with the presence of ECG LVH were more often men, black people, smokers and users of alcohol. In multiple logistic regression analyses, SBP, DBP, male gender and black race were positively, whereas BMI was negatively related to the presence of LVH. The positive relation of smoking and negative relation of serum cholesterol concentration to the presence of ECG LVH were apparent in men but not in women. This study confirms the adverse association between ECG LVH and SBP and DBP, male gender, black race and decreased BMI. It also addresses the less well-known associations of blood glucose, cholesterol, smoking and alcohol consumption.

Relationship between time-integrated C-reactive protein levels and radiologic progression in patients with rheumatoid arthritis

OBJECTIVE

An elevated acute-phase response is associated with increased radiologic damage in rheumatoid arthritis (RA), but development of damage in previously normal joints ("new joint involvement") has not previously been investigated. This study was undertaken to investigate the hypothesis that when there is suppression of disease activity as judged by the C-reactive protein level, new joint involvement is reduced to a greater extent than is progression in already damaged joints ("damaged joint progression").

METHODS

Three hundred fifty-nine patients with active RA were studied as part of a 5-year randomized, prospective, open-label study of disease-modifying antirheumatic drug therapy. Time-averaged CRP was calculated from samples obtained every 6 months, and patients were divided into groups with CRP values of <6, 6-<12, 12-<25, and > or =25 mg/liter. Radiographs of the hands and feet were scored by the Larsen method; a damaged joint was defined as one with a score of > or =2.

RESULTS

The rank correlation between time-integrated CRP and increase in Larsen score was 0.50; the correlation increased to 0.59 for patients entering the study with disease duration of < or =2 years. The percentage of new joint involvement over 5 years varied markedly with time-integrated CRP, from 7.3% in the CRP <6 mg/liter group to 39.1% in the CRP > or =25 mg/liter group (5.4-fold increase). The percentage of damaged joint progression increased from 26.1% in the CRP <6 mg/liter group to 41.6% in the CRP > or =25 mg/liter group (1.6-fold increase).

CONCLUSION

The results of this study provide further confirmation that high CRP levels over time are associated with greater radiologic progression. Although radiologic progression still occurred in both previously normal and damaged joints despite the presence of normal CRP levels, this consisted of proportionately less new joint involvement compared with damaged joint progression. These findings support the idea that disease-suppressive therapy should be instituted at an early stage in patients with RA, before erosive damage has occurred.

Calcium channel blockers, ACE inhibitors, and the risk of cancer in hypertensive patients: a report from the Department of Health Hypertension Care Computing Project (DHCCP)

OBJECTIVE

Recent studies have shown inconsistent results on the risk of cancer in hypertensive patients using calcium channel blockers (CCBs) and angiotensin-converting enzyme (ACE) inhibitors. We investigated a large number of patients from the Department of Health Hypertension Care Computing Project (DHCCP) observational database treated with these drugs for hypertension to see whether the use of CCBs for hypertension is associated with an increased risk of cancer mortality and the use of ACE inhibitors with a reduction.

DESIGN

Matched case-control study and a longitudinal study of survival from 1 year after presentation.

PATIENTS

A total of 11663 patients treated for hypertension from 1971 through 1987. They were recruited on presentation to one of the hospital hypertension clinics or general practices involved.

MAIN OUTCOME MEASURES

Death with any mention of cancer on the death certificate in patients treated with an Index drug group; CCBs, ACE inhibitors, beta adrenergic blocking drugs (BBs), or receiving a diuretic. The treatment groups were mutually exclusive.

RESULTS

A total of 391 cases of cancer were matched with 1050 controls. In this case-control study the adjusted relative risk estimate in comparison to diuretic treatment for CCBs was 0.79 (95% CI 0.37 to 1.69), and for CCBs plus a diuretic, 1.05 (0.65 to 1.69). Non-significant results were also observed for ACE inhibitors (1.48 (0.43 to 5.1), and 1.40 (0.56 to 3.50) with a diuretic), and also for the BB and methyldopa groups. In the longitudinal survival study, the adjusted relative risk estimate for CCBs was 1.1 (0.60 to 1.94) and 1.0 (0.53 to 1.86) for CCBs plus a diuretic, and for ACE inhibitors 1.33 (0.37 to 4.76) and 1.47 (0.67 to 3.23), respectively.

CONCLUSIONS

In this population there was no increased cancer mortality with the use of CCBs and a relative risk greater than 1.7 to 2.0 was excluded with 95% confidence. The suggestion that ACE inhibitors reduce cancer mortality was not supported with best estimates of relative risk of 1.3 to 1.5 and exclusion of values less than 0.4 to 0.7.

Maternal cigarette smoking and pregnancy outcome

Maternal smoking rates in pregnancy have declined, particularly in the non-manual social classes, and perinatal mortality rates have fallen over the last 20 years. We have therefore re-evaluated the relationship between maternal cigarette smoking and pregnancy outcome against this background. A total of 608 stillbirths and 634 infant deaths were identified using the All Wales Perinatal Survey. The cause of death was classified using the clinicopathological system. Maternal smoking rates and social class groupings were compared with those in a cohort of 16047 survivors born to women resident in South Glamorgan. The smoking rate was 37.8% in mothers of babies who died compared with 27.2% in mothers of survivors, an odds ratio (OR) of 1.63 [95% CI 1.44, 1.84]. The OR for unexplained stillbirth was 1.72 [95% CI 1.38, 2.13], placental abruption 2.07 [95% CI 1.29, 3.31], infection 3.70 [95% CI 2.23, 6.13] and sudden infant death syndrome 4.84 [95% CI 3.05, 7.69]. Maternal smoking was not associated with death due to prematurity or a congenital anomaly. Despite changes in smoking habits and the causes of perinatal death, smoking during pregnancy continues to be strongly associated with fetal and infant mortality. It is important that health promotion activities are effective in reducing smoking during pregnancy.

Survival estimates for adults with cystic fibrosis born in the United Kingdom between 1947 and 1967. The UK Cystic Fibrosis Survey Management Committee

BACKGROUND

The UK has published observed cohort survival figures for subjects with cystic fibrosis born since 1968. Prior to 1968 cohorts cannot be established directly from routine data as cystic fibrosis was classified with a number of unrelated conditions in ICD7. Reported here are interrupted survival curves from 1978 for patients with cystic fibrosis born before 1968.

METHODS

Life tables for the three year cohorts born between 1947 and 1967 were constructed by firstly estimating the numbers of patients with cystic fibrosis born in each cohort from live birth data and the disease incidence. The number of the estimated cohort that had survived to 1978 is known, which enables the proportion surviving to 1978 to be calculated. The survival of these cohorts after 1978 can be calculated in the usual way.

RESULTS

The survival for each successive cohort was better than that of the previous one, but most of the improvements appear to have taken place up to the age of about 20 years. Only 3% of the 1947-49 cohort survived to 30 years of age compared with 21% for the 1965-67 cohort, and 3% of the 1953-55 cohort survived to 40 years of age. For the later cohorts the mortality rate for those aged between 26 and 30 years appears to be about 50 per 1000 per year.

CONCLUSIONS

While the trend in the numbers surviving into later adulthood is upwards, the mortality rates for these ages does not appear to be improving. It is not possible to tell from these data whether the high mortality rates in adulthood will improve with better resourced adult clinics or with improved treatment during childhood.

Psychological health and well-being: why and how should public health specialists measure it? Part 2: Stress, subjective well-being and overall conclusions

BACKGROUND

There are cogent reasons why public health specialists should take an active interest in and measure the psychological health and well-being of populations. These are discussed in Part 1 of this study, where methods of measurement from the field of 'Psychiatric Epidemiology' are evaluated. This paper continues the review of methods by which psychological health and well-being might be measured by public health specialists.

METHODS

The methods of the literature search and review are described in Part 1. In Part 2, approaches from the fields of 'Stress' and 'Subjective Well-being' are examined and evaluated.

RESULTS

Many stress questionnaires, such as those that relate to 'life events', 'hassles' and 'perceived stress' pose conceptual problems and do not seem to have any advantages over a simple psychiatric symptom questionnaire, such as the General Health Questionnaire or HAD Scale. The Short Form 36 (SF-36) is a well-being or health outcome instrument. Its mental health and vitality scales encompass both positive and negative psychological well-being. The instrument also contains scales for aspects of physical well-being, which make it attractive for public health use. However, it was found that the positive aspect of these scales has not been validated to the same extent as the negative aspect.

CONCLUSIONS

Some of the methods reviewed in Parts 1 and 2 of this study can and have been used, with certain provisos, in public health research and practice. However, a truly valid measure of both positive and negative psychological well-being has not yet been devised.

A long-term five-year randomized controlled trial of hydroxychloroquine, sodium aurothiomalate, auranofin and penicillamine in the treatment of patients with rheumatoid arthritis

OBJECTIVE

To compare the efficacy of hydroxychloroquine, penicillamine, sodium aurothiomalate and auranofin in the treatment of active rheumatoid arthritis over a period of 5 yr.

METHOD

Five hundred and forty-one patients with definite or classical rheumatoid arthritis were entered into an open randomized controlled trial with a flexible dose regimen designed to reflect clinical practice. Decisions to stop treatment with any one of the disease-modifying anti-rheumatic drugs (DMARDs) were based on an agreed trial protocol which defined criteria for adverse reactions and therapeutic failure. The managing physicians' decisions were confirmed in a separate monitor clinic.

RESULTS

The proportion of patients who remained on their first DMARD or who were in remission at 5 yr was 53% for penicillamine, 34% for sodium aurothiomalate, 31%, for auranofin and 30% for hydroxychloroquine (P < 0.001). In patients who stayed on their first DMARD, all groups showed a 30-50% improvement in C-reactive protein, erythrocyte sedimentation rate, Ritchie Index and joint stiffness, and a deterioration in their Larsen score. There was no evidence of physician bias to explain the larger proportion of patients remaining on penicillamine for 5 yr.

CONCLUSION

Despite the increased popularity of sulphasalazine and inmmunosuppressives, the drugs in this study continue to be used worldwide. The natural history of rheumatoid arthritis requires long-term follow up to establish drug efficacy. Evidence is needed as to whether the newer regimens will prove to be more effective and safer in the longer term than the commonly prescribed DMARDs. The data from this trial will provide a reference for comparison with future studies.

Psychological health and well-being: why and how should public health specialists measure it? Part 1: Rationale and methods of the investigation, and review of psychiatric epidemiology

BACKGROUND

There are cogent reasons why public health specialists should take an active interest in and measure the psychological health and well-being of populations. The literature was searched and reviewed with the aim of evaluating survey instruments that would enable public health specialists to measure the psychological health and well-being of populations.

METHODS

The search and review were restricted to instruments that were applicable to adults of working age, and that did not focus on psychotic disorder or organic brain disorder. An attempt was also made to identify instruments that were designed to measure some form of positive well-being and could be applied in population-based surveys. Detailed evaluation was then carried out of two or three instruments that appeared representative of a particular field or approach.

RESULTS

The literature search revealed three major fields of research, 'Psychiatric Epidemiology', 'Stress Studies' and 'Subjective Well-being'. Accordingly, the results of the review are presented under these three headings. Results pertaining to commonly used survey instruments in the field of 'Psychiatric Epidemiology' are presented. (Those on 'Stress Studies' and 'Subjective Well-being' are presented in Part 2 of this study.)

CONCLUSIONS

Although some questionnaires in the field of 'Psychiatric Epidemiology', such as the General Health Questionnaire and the HAD Scale, offer a valid and convenient means of measuring degrees of neurotic disorder in a population, they do not measure any form of positive well-being. In Part 2, methods of measurement from the other two fields are reviewed and overall conclusions are drawn about the options available to public health specialists.

Height and weight in cystic fibrosis: a cross sectional study. UK Cystic Fibrosis Survey Management Committee

Cross sectional data reporting the height, weight, and body mass index of UK patients with cystic fibrosis are presented. During the first decade of life height and weight in patients with cystic fibrosis are maintained at about 0.5 SD below those of the general population, which reflects an improvement over earlier published observations. Postpubertal stature and weight maintenance in the cystic fibrosis population still show substantial deficits which may be related to treatment.

Incidence, population, and survival of cystic fibrosis in the UK, 1968-95. UK Cystic Fibrosis Survey Management Committee

The UK Cystic Fibrosis Survey holds data on all people resident in the UK who were diagnosed as having cystic fibrosis and born either since 1968 or before 1968 and alive in 1977. Thus, incidence may be reported from 1968 and prevalence from 1977. The previous estimates are updated to the end of 1995 from data held in the database on 23 August 1996. The incidence is now calculated as one in 2415 live births. The 1992 mid-year population was 6500 people with 65% aged under 16 years. Births outnumber deaths by 160 per year, which suggests a population of 7750 by the year 2000, with all the increase being in the adult age range. The survival of successive cohorts continues to be better than earlier cohorts, the linear descent of the curves is still evident. The infant mortality rate for cystic fibrosis is now under 20 per thousand per year and early childhood mortality is under five per thousand per year. The crude mortality rate for 1995 was 21 per thousand per year, but the standardised mortality ratio was about 3300.

Factors associated with term low birthweight in Cardiff, Wales

This project was undertaken to examine the associations of a number of risk factors with impaired fetal growth, exemplified by delivery of a low-birthweight infant at term (TLBW). Utilising a large database of largely homogeneous (white) births in Wales, the Cardiff Births Survey, multivariable analysis by logistic regression examined the relative importance of these risk variables. Significant independent associations with TLBW were found (in decreasing order of magnitude) for low maternal weight, pre-eclampsia, smoking, short maternal height, late pregnancy bleeding, early pregnancy bleeding, history of a previous stillbirth, primiparity and older maternal age. In this population, risk of TBLW was associated with a number of demographic, medical and social factors. Of these, only smoking is likely to be modified by intervention.

Calcium channel blockers and cardiac mortality in the treatment of hypertension: a report from the Department of Health Hypertension Care Computing Project (DHCCP)

OBJECTIVE

A case control study has reported a 60% higher risk of myocardial infarction in hypertensives treated with a calcium channel blocker (CCB). We examined the Department of Health Hypertension Care Computing Project (DHCCP) data to see if we could confirm or refute this suggestion.

DESIGN

Two case control studies, matched and unmatched, plus two longitudinal studies from 1 year of presentation, one for all subjects given a CCB for more than 1 year compared with those not given this drug, and the second comparing survival on the different drugs initially given between 3 and 12 months of follow-up.

SUBJECTS

A total of 9328 subjects were included in the analyses and 2154 died. Of these, 6406 received one or more of the following index drugs: 26% a calcium channel blocker (CCB); 84% a diuretic; 29% alpha methyldopa; 12% a beta-blocker (BB); and 11% an angiotensin-converting enzyme (ACE) inhibitor. The CCBs were nifedipine, diltiazem or verapamil.

RESULTS

In the case control studies a group given diuretics +/- other treatments (but not including one of the index drugs) provided a reference group with a relative risk (RR) of 1.0. In the matched case control study the adjusted RR for a CCB without a diuretic was 1.32 (95% CI 0.64-2.70) for IHD mortality and 1.05 (95% CI 0.60-1.84) for cardiovascular mortality. Similar results were observed for methyldopa, BBs and ACE inhibitors. The results in the unmatched case control analysis were also similar. The longitudinal study comparing all those treated for over 1 year with a CCB with all other treatments showed a RR for total mortality of 1.03 (95% CI 0.85-1.25). The longitudinal study of total mortality according to treatment initiated at 3-12 months found results of a similar magnitude for CCBs, methyldopa and BBs.

CONCLUSIONS

The reference diuretic group had less severe cardiovascular disease than other groups. Treatment with a CCB, BB or methyldopa was associated with an excess mortality in comparison with this reference group. The excess was similar in the different drug groups.

Alcohol intake and cardiovascular mortality in hypertensive patients: report from the Department of Health Hypertension Care Computing Project

OBJECTIVE

To determine the benefits and risks of drinking alcohol in treated hypertensives.

DESIGN

A prospective study of 6,369 hypertensives (3,161 men) attending primarily hospital clinics in the UK.

METHODS

Relative risks both for drinkers compared with non-drinkers and for level of alcohol consumption were calculated for mortality from ischaemic heart disease, stroke, non-circulatory and all causes.

RESULTS

At presentation 76% of the men and 48% of the women reported recent alcohol consumption. Compared with drinkers, non-drinkers were older, less likely to smoke and had a higher untreated blood pressure. After adjustment for confounding factors, male drinkers had a reduced risk of stroke mortality and possibly of ischaemic heart disease mortality. Similar results were observed in women for stroke mortality but not for ischaemic heart disease mortality. The trend remained after adjustment for previous cardiovascular disease. In men the lowest risk of ischaemic heart disease mortality occurred at intakes of > 21 units per week and stroke mortality was lowest at 1-10 units per week. Men consuming > 21 units per week had a twofold higher non-circulatory mortality. Total mortality was lowest in men who drank 1-10 units per week. Similar effects of alcohol on cardiovascular mortality were observed in women.

CONCLUSIONS

Alcohol intake may reduce stroke mortality in treated hypertensives. Ischaemic heart disease mortality in men may also be reduced, especially at higher intakes ( > 21 units per week). The beneficial effects were offset by increasing incidence of non-circulatory causes of death. Alcohol consumption of 1-10 units per week was associated with the lowest mortality in men.

Factors associated with preterm birth in Cardiff, Wales. I. Univariable and multivariable analysis

OBJECTIVE

Our purpose was to examine the associations of demographic, social, and medical factors with risk of preterm birth.

STUDY DESIGN

By use of the Cardiff Births Survey, a large database of largely homogeneous (white) births in Wales, multivariable analysis by logistic regression examined the relative importance of risk variables associated with preterm birth.

RESULTS

Significant independent associations with preterm birth were found (in decreasing order of magnitude) for late pregnancy bleeding, preeclampsia-proteinuria, low maternal weight, low maternal age, early pregnancy bleeding, history of previous stillbirth, smoking, high parity, low or high hemoglobin concentration, history of previous abortion, low social class, bacteriuria, and nulliparity.

CONCLUSION

In this population demographic, social, and medical characteristics of the pregnancies showed significant associations with preterm birth.

Factors associated with preterm birth in Cardiff, Wales. II. Indicated and spontaneous preterm birth

OBJECTIVE

Our purpose was to examine and contrast associations of risk factors with spontaneous preterm birth and indicated preterm birth.

STUDY DESIGN

Separate multiple logistic regression analyses were performed of indicated and spontaneous preterm births in a large database of births in Cardiff, Wales.

RESULTS

Spontaneous preterm births were associated with young maternal age, low maternal weight, low or high parity, previous abortion, smoking, and early pregnancy bleeding. Indicated preterm births were associated with older age, low weight, previous stillbirth, bacteriuria, and early pregnancy bleeding.

CONCLUSION

Spontaneous and indicated preterm births have different overall profiles of association with pregnancy risk factors.

The effect of severe psoriasis on the quality of life of 369 patients

The aim of this survey was to quantify the level of handicap experienced by patients with severe psoriasis, and to assess the value that patients place on their disease using various questionnaire techniques. Dermatologists throughout the U.K. each gave a questionnaire to up to five psoriasis patients, who were either being admitted for in-patient care or were starting systemic therapy. Three hundred and sixty-nine questionnaires were completed. Of the 150 patients currently working, 59.3% had lost a mean of 26 days (SD 21.9) from work during the preceding year because of their psoriasis, and of the 180 not working 33.9% attributed not working to their psoriasis. The mean Psoriasis Disability Index (PDI) score was 38.2% (SD 23.3, n = 248), with the mean sub-scores of the 'daily activities' and 'treatment' sections being greater than those of the other three sections. Despite having severe psoriasis, the majority of patients felt that it would be worse to have diabetes, asthma or bronchitis than to have psoriasis. Forty-six, 42 and 32% considered it would be either 'better' or 'the same' to have diabetes, asthma or bronchitis, respectively. However, in those patients who also had the comparative disease, 87, 80 and 77% considered it would be 'better', or 'the same' to have the comparative disease. Forty-nine per cent of patients (n = 362) stated they would be prepared to spend 2 or 3 h each day on treatment if this might result in normal skin for the rest of the day.(ABSTRACT TRUNCATED AT 250 WORDS)

Optimal blood pressure control in treated hypertensive patients. Report from the Department of Health Hypertension Care Computing Project (DHCCP)

BACKGROUND

We wished to determine the range of treated systolic (SBP) and diastolic blood pressure (DBP) associated with the best survival in hypertensive patients.

METHODS AND RESULTS

We conducted a cohort study of patients enrolled in the DoH Hypertension Care Computer Project. Five specialist hypertension clinics (95% of patients) and general practitioners (5%) followed 6214 patients (3070 men and 3144 women) with an average age of 52 years for a mean of 107 months. Total, cardiovascular, ischemic heart disease, (IHD) and stroke mortality were the outcome measures. Age-adjusted relative hazard rates were calculated giving the effect on mortality of systolic or diastolic pressure being higher by 1 mm Hg. In men the optimal level of SBP for all four measures of mortality was the lowest pressure range observed, 92 to 133 mm Hg (median 127). For women the treated SBP range of 96 to 148 mm Hg (median 137) was associated with a low total mortality and also with low to moderate rates for IHD and stroke mortality. Relative hazard rates (P < .001) for IHD mortality were 1.010 for men and 1.013 for women and for stroke mortality were 1.018 and 1.021, respectively. The results were similar in men under and over the age of 60. SBP and DBP tended to be more important in younger than older women. For treated DBP in men, a pressure of 55 to 94 mm Hg (median 87) was associated with a low total mortality. The lowest stroke mortality in men was observed for a DBP range of 55 to 83 mm Hg (median 80) but with a tendency for an increase in IHD mortality. For women DBP < 95 mm Hg (range 55 to 94, median 87) also was associated with a low total mortality. IHD mortality in women was not closely related to treated DBP, relative hazard rate = 1.003, [95% confidence index (CI); 0.990,1.017] but the relative hazard rate for men was 1.011, (95% CI; 1.000, 1.022). The relative hazard rates for treated DBP and stroke were high at 1.035 and 1.028 for men and women, respectively (P < .001). IHD mortality increased in the one third of patients with the greatest fall in DBP on treatment, provided they were not initially in the one-third group with highest untreated DBP.

CONCLUSIONS

The best overall survival was associated with a treated SBP of < 134 mm Hg in men and < 149 mm Hg in women and a treated DBP of < 95 mm Hg.

Dermatology examination performance: wide variation between different teaching centres

Three hundred and one clinical medical students in four universities took the same 50 question MCQ dermatology examination after their dermatology teaching. In one centre, half the students had had additional teaching; these students performed better (mean score 47.5%, n = 29) than those who had no extra teaching (mean score 40.9%, n = 29). In another centre, the students' mean score improved from 24.1 (SD = 6.7) before to 41.6 (SD = 7) (n = 46, P < 0.001) after their dermatology teaching. The different subject areas covered by the examination were analysed separately. In the lowest scoring centre (mean score 34.0, SD = 9.4) the students scored lowest in 9 of the 14 subject areas. In the highest scoring centre (mean score 47.5, SD = 9.9) students scored highest in 7 of these 14 subject areas. This study enabled questions of high discriminatory value to be identified for future use. The use of the same examination in different centres provides feedback for the centres concerning strengths and weaknesses of their teaching.

Cystic fibrosis identified by neonatal screening: incidence, genotype, and early natural history

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Relation between blood pressure and stroke mortality

The relation between stroke mortality and blood pressure was investigated in 10,186 hypertensive patients followed up in the Department of Health Hypertension Care Computing Project for an average of 9 years. An untreated blood pressure measurement was available in 3,472 men and 3,405 women. The age-adjusted risk of stroke death increased by 1% for every 1 mm Hg increase in untreated systolic blood pressure. The relative hazard rate was 1.014 (95% confidence interval [CI], 1.007, 1.021) in men and 1.009 (1.003, 1.016) in women. The corresponding increases for 1 mm Hg for untreated diastolic blood pressure were almost 3% in men and again 1% in women (relative hazard rate 1.026 [95% CI, 1.014, 1.038] in men and 1.010 [1.000, 1.021] in women). Treated blood pressure measurements were available in 3,073 men and 3,148 women. Stroke mortality increased by 2% for a 1 mm Hg increase in treated systolic pressure and 3% for the corresponding increase in diastolic blood pressure. The relation between stroke mortality and blood pressure was similar over and under the age of 65, although the increase in mortality with pressure was greater for treated diastolic blood pressure in women under the age of 65 than over this age. There was no evidence for a J-shaped relation between stroke mortality and either systolic or diastolic pressure in men. In women there was a suggestion of such a relation, but since this relation was also observed for untreated pressures, any increase in risk at lower pressures is unlikely to be a result of treatment.

Relation between treated blood pressure and death from ischaemic heart disease at different ages: a report from the Department of Health Hypertension Care Computing Project

OBJECTIVE

To determine the relation between mortality from ischaemic heart disease (IHD) and treated blood pressure at different ages.

DESIGN

Prospectively, 6216 patients were studied for a mean of 107 months.

SETTING

Of the total patients, 95% were followed in five hospital-based hypertension clinics and the remainder in four group general practices.

PATIENTS

Respectively, 2250 and 2126 hypertensive men and women aged < 60 years and 822 and 1018 aged > or = 60 years.

MAIN OUTCOME MEASURES

Mortality (any mention on the death certificate) from IHD.

RESULTS

Four hundred and sixty-seven patients died with IHD mentioned on the death certificate. The relation between both diastolic blood pressure (DBP) and systolic blood pressure (SBP) during the first 3-12 months of treatment and subsequent IHD mortality was examined. Under the age of 60 years the relative hazard rate (RHR) for death from IHD tended to increase with DBP in both men and women. Above the age of 60 years there was no important or significant relation between IHD mortality and treated DBP. For SBP there was no reduction in the positive relation between IHD mortality and blood pressure in the older age groups. The RHR for SBP ranged between 1.008 and 1.021 in men and women over and under the age of 60 years.

CONCLUSIONS

The positive relation between DBP and IHD mortality decreased with increasing age and, in women aged > or = 60 years, even inverted, partly explaining the negative relation reported between DBP and total mortality in the very old.

External ocular trauma in instrumental and normal deliveries

OBJECTIVE

To compare the occurrence of external ocular trauma in instrumental and normal deliveries.

DESIGN

Prospective controlled study.

SETTING

University Hospital of Wales, Cardiff.

SUBJECTS

133 babies born consecutively with the use of forceps and 133 control babies born without instrumentation to women matched for parity.

INTERVENTIONS

External ocular examination.

MAIN OUTCOME MEASURES

The presence within 24 h of birth of corneal oedema, corneal abrasion, conjunctival chemosis, subconjunctival haemorrhage and lid oedema.

RESULTS

Lid oedema and multiple minor external ocular trauma occurred in 52 and 22 babies, respectively, in the instrumental delivery group and in 13 and 8 babies, respectively in the control group (P less than 0.001). Corneal abrasion occurred in two babies and corneal oedema in one baby after forceps delivery but in none of the control group. No more serious injuries occurred. All injuries resolved without long term sequelae.

CONCLUSION

The frequency of sight threatening corneal trauma in instrumental deliveries is low. Specialist ophthalmic screening of these babies is not justified.

Risk prediction in medicine and surgery: ethical and practical considerations

Risk prediction is a subject of increasing clinical interest, and publications in this area are likely to have an important influence on patient care in the near future. A multiplicity of risk prediction systems, many of them computer-based, will raise a number of ethical and practical questions. These questions need to be addressed by the originators of systems, the editors of journals, practising clinicians, and the lay public.

Mortality associated with captopril and enalapril: a report from the DHSS Hypertension Care Computing Project

In 1986, the Committee on Safety of Medicines published a report suggesting that enalapril may have an adverse effect on renal function. The prescription event monitoring scheme subsequently published figures on adverse drug reactions and mortality for patients treated with enalapril. They concluded that enalapril did not have an adverse effect on renal function and survival. Similar data were not available for captopril, as the drug was marketed before prescription event monitoring had been developed. In the Department of Health and Social Security (DHSS) Hypertension Care Computing Project (DHCCP), 368 hypertensive patients treated with captopril and 371 treated with enalapril were followed for an average of 3.1 and 1.6 years, respectively. Thirty-two patients died; none had renal failure as an underlying cause of death. The death rate was similar in both drug groups, at 17.5 (enalapril) and 24.0 (captopril) per 1000 patient-years. The present report shows that, for patients treated for high blood pressure, the relative risk of mortality with captopril compared with enalapril was 1.37, an insignificant difference (95% confidence interval 0.63, 2.98).

Precision of Larsen grading of radiographs in assessing progression of rheumatoid arthritis in individual patients

A study was designed to evaluate observer variation in the assessment of radiographic deterioration of individual patients using the Larsen grading system. Radiographs of hands and feet of 52 patients were assessed by three observers. Each patient had paired films taken one year apart which were assessed together for change in score. To assess within-observer variation each set of films was read twice by all observers. The average progression was 11.6 (SD 9.0). Analysis of the source of variation showed the single observer replication SD to be 3.7 but that for different observers to be 5.5. This may be interpreted as indicating that to achieve 95% confidence of detecting a true change an increase in Larsen score of 8 is required if the same observer assesses or up to 11 if a different observer assesses.

A randomized study of a domiciliary antenatal care scheme: the effect on hospital admissions

A preliminary randomized study has been made of a domiciliary management scheme which incorporates telephonic fetal heart rate monitoring for women with high-risk pregnancies. In this paper we report effects of the scheme on the pattern of hospital admissions. Sixty women were randomized 2:1 for domiciliary surveillance or for conventional hospital care, with 40 and 17 records finally available for analysis. The groups were well matched for maternal, obstetric and socio-economic characteristics. In the domiciliary group, 21 (53%) of the women avoided hospital admission altogether, the admission rate was more than halved, and the mean proportion of the time spent in hospital was reduced from 50% to 16% of the observation period. The women who received domiciliary care were generally satisfied with the scheme. Our study confirms expectations that carefully planned domiciliary surveillance can reduce the number and duration of hospital admissions.

A randomised study of a domiciliary antenatal care scheme: maternal psychological effects

The Cardiff Integrated Antenatal Care Scheme (CIACS) places emphasis on home-centred care for selected women with a high-risk pregnancy. The Scheme is intended to make better use of midwifery and obstetric resources, and it provides a new type of care where close surveillance is required. A randomised controlled trial was undertaken in which anxiety levels were compared between two groups of women with an identified high-risk pregnancy. Sixty-five women were eligible for entry to the study. Five refused randomisation and 60 were randomised 2:1 either to care under the CIAC Scheme (domiciliary group n = 40) or to conventional hospital antenatal care (conventional group n = 17). Zung depression and STAI 'trait' levels conducted at weekly intervals were similar in both groups whilst 'state' levels were 34.05 (SD 9.24) in the domiciliary group and 41.05 (SD 9.93) in the conventional care group (P less than 0.01). It is suggested that the observed difference is due to the greater security provided by the home environment coupled with individual support from a midwife.

The effects of anti-hypertensive drugs on sexual function in men and women: a report from the DHSS Hypertension Care Computing Project (DHCCP)

One thousand, two hundred and eighty-five men and 1,080 women being followed in the DHSS Hypertension Care Computing Project answered the questions on sexual activity included in a self-administered questionnaire. In men, both impotence and sexual inactivity were increased in patients receiving hydralazine. No gross excess of these complaints could be determined in patients receiving either beta-adrenoceptor blocking drugs or methyldopa, nor was failure of ejaculation increased with these drugs. The survey could not exclude any deterioration in sexual function occurring uniformly across all treatment groups. However, the rates of complaint were similar in men taking a diuretic alone, a beta-adrenoceptor blocking drug alone and those taking the combination of these two drug groups. In women with hypertension, frequency of sexual intercourse and the achievement of orgasm was not associated with the giving of hydralazine, beta-adrenoceptor blocking drugs or methyldopa.

Beta adrenoceptor blockade is associated with increased survival in male but not female hypertensive patients: a report from the DHSS Hypertension Care Computing Project (DHCCP)

The DHCCP is a multicentre observational study of patients being treated for hypertension in the United Kingdom. The influence of the type of anti-hypertensive therapy on survival was examined in 2,697 patients followed from 1971 with 206 deaths up to November 1981. Patients were classified by three types of treatment after one year in the project: betablockers (1,387), methyldopa (452) and others (667), (70% on diuretics only). The data were analysed both for all patients and for a subset excluding patients with previous ischaemic heart disease by all cause and IHD age-adjusted rates and life table analysis. Men on beta blockers had lower rates for total mortality, when compared with men on methyldopa (64% of the methyldopa rate, P less than 0.05) and when compared with men on other treatments (76% of the other treatment rate, P less than 0.1). The results for IHD mortality were similar. This improved survival of men in the beta blocker group was also found in the subset with no prior history of IHD. The benefit of beta blockers was not apparent in women: the lowest rates were observed for women on methyldopa, but the confidence limits for the ratios of relative rates were wide. Adjustment for blood pressure and cigarette smoking using the Cox proportional hazards model did not substantially modify the ratios of the mortality rates for the treatment groups. A sub-group analysis showed the reduction in all cause and IHD mortality associated with beta blockers was mainly due to the effect in non-smoking men.(ABSTRACT TRUNCATED AT 250 WORDS)

Treated blood pressure, rather than pretreatment, predicts survival in hypertensive patients. A report from the DHSS Hypertension Care Computing Project (DHCCP)

A group of hypertensive patients (n = 2855) with an untreated diastolic blood pressure greater than or equal to 90 mmHg were followed in the Department of Health and Social Security (DHSS) Hypertension Care Computing Project (DHCCP) for periods of up to 10 years. During this period 191 of these patients died. Survival was assessed in relation to pretreatment blood pressure levels and blood pressure achieved during treatment. The blood pressure during treatment was a useful predictor of mortality, but the pretreatment pressure was not. After adjusting for age, mortality was particularly related to the height of the systolic and diastolic blood pressure during the second and third years of treatment. In men, age-standardized 5-year mortality was greater than 10% in those with a first year treated systolic pressure greater than 150 mmHg or a diastolic pressure greater than 95 mmHg. In women, age standardized 5-year mortality was greater than 5% with the same levels of treated blood pressure. The longest survival occurred with the lowest bands of treated pressure, i.e. systolic pressure less than 140 and diastolic pressure less than 90 mmHg; the 5-year mortality being less than 7% in men and less than 3% in women. Treated systolic and diastolic pressures were useful in predicting death from ischaemic heart disease (IHD).

The relationship between a low treated blood pressure and IHD mortality: a report from the DHSS Hypertension Care Computing Project (DHCCP)

The suggestion that treating blood pressure to below a certain level may increase IHD mortality is controversial. We investigated the influence of treated blood pressure on mortality in the DHSS Hypertension Care Computer Project. Mortality was examined by quintiles of treated diastolic blood pressure (DBP) in 2,145 patients treated for a minimum period of one year and subsequently followed for an average of four years. One hundred and seventy five patients died; 71 from IHD. In men and women all cause mortality increased with level of treated DBP. In men IHD mortality showed a U-shaped distribution with an age-adjusted rate of 15.2 per 1,000 person years in the lowest fifth (DBP less than 86 mmHg) comparable to that of 15.6 per 1,000 in the upper (DBP greater than or equal to 103 mmHg). A similar pattern could not be established in women due to very few IHD deaths. IHD mortality was further examined separately for men by prior history of IHD. An increase in IHD deaths in the lowest fifth of treated blood pressure was found for men both with and without a history of IHD. No similar pattern of IHD mortality was obtained for untreated DBP or treated systolic pressure. However, we cannot exclude the possibility that the risk of low treated DBP is secondary to ischaemic heart disease.

Amoxycillin-clavulanic acid (Augmentin) versus metronidazole as prophylaxis in hysterectomy: a prospective, randomized clinical trial

In order to determine the most effective regimen for the prevention of infection after elective hysterectomy, 300 patients were randomly assigned to receive three perioperative doses of either amoxycillin-clavulanic acid (1.2 g intravenous) or metronidazole (1 g suppository). Of the 280 patients who were assessable 138 were given amoxycillin-clavulanic acid and 142 received metronidazole; 268 underwent abdominal hysterectomy and 12 had vaginal hysterectomy. Patients in the amoxycillin-clavulanic acid group had significantly less infectious morbidity (13.8%) than those in the metronidazole group (33.1%). There were also statistically significant differences in favour of amoxycillin-clavulanic acid with respect to operative site infection, duration of hospital stay, need for postoperative antimicrobials, and surgery for operative site infection. But for one isolate of Bacteroides fragilis, all pathogens isolated from wound infections in the metronidazole group were aerobes. No anaerobes were isolated from patients in the amoxycillin-clavulanic acid group. The results suggest that prophylaxis for hysterectomy should consist of an agent, or combination of agents, with activity against both aerobic and anaerobic bacteria. Amoxycillin-clavulanic acid fulfils this criterion and appears to be effective and safe.

Significant changes in Ritchie scores

A study was designed to establish the reliability of assessing joint tenderness in rheumatoid arthritis. Reliability both within and between observers was measured and the 95% confidence intervals (CI) for a change in score calculated. Forty-two patients were assessed by two metrologists over a 14-week period using three subjects per week. Results showed close agreement within and between metrologists. The 95% CI for repeat measures by the same metrologist was +/- 8.5 and +/- 12 by a different metrologist. Taking a change of 5 in the score as clinically significant, the 95% CI for a clinically significant change would be +/- 14 with one observer and +/- 17 when a different observer repeated the assessment. It is recommended that other centres should establish their own CI for a change in scores when undertaking clinical trials.

Childhood poisoning in Wales: experience of the Welsh National Poisons Unit (1984)

In 1984, 60% of all the enquiries made to the Welsh National Poisons Unit in Cardiff concerned children under 15, and 86% of the latter concerned children under 5. Nearly 60% of requests for information in childhood poisoning were about non-medicinal products and this contrasts with hospital admissions which are more often associated with medicinal products in this age group. Seasonal variability was noted for non-medicinal products such as pesticides and plant poisoning enquiries, whereas medicinal product enquiries remained constant over the year. The pesticides enquiries were greatest in Spring while those concerning plants were significantly greater in Summer. The latter was due to increased reports of ingestion of garden plants since the number of enquiries concerning house plants remained constant. Thus availability appears to be a major determinant of the risk of poisoning with any particular product in childhood.

Relation of haemoglobin levels in first and second trimesters to outcome of pregnancy

The relation between haemoglobin (Hb) concentrations at antenatal booking and subsequent outcome was examined in 54 382 singleton pregnancies. Both high (greater than 13.2 g/dl) and low (less than 10.4 g/dl) Hb values were associated with an adverse outcome. Mothers with a booking Hb in the intermediate range (10.4-13.2 g/dl) fared best. Significant differences emerged in perinatal mortality between those with high and those with intermediate Hb levels at 13-19 weeks' gestation. The frequencies of perinatal death, low birthweight, and preterm delivery were greater with high than with intermediate Hb. There was a striking relation between booking Hb values and the subsequent frequency of hypertension (p less than 0.001). In primiparas, the frequency of subsequent hypertension ranged from 7% at Hb values under 10.5 g/dl to 42% at Hb concentrations over 14.5 g/dl.

The survival of treated hypertensive patients and their causes of death: a report from the DHSS hypertensive care computing project (DHCCP)

A prospective study has been carried out to determine the causes of death and risk factors for survival in 4994 patients referred with a diagnosis of hypertension to hospital specialist clinics and 457 patients treated by their general practitioners for this condition. At the time of entering the prospective study, 69% of the patients were already being treated for hypertension. Four hundred and eleven patients have died, and their causes of death and death rates have been compared with the rates for the population of England and Wales. Ischaemic heart disease accounted for over one-third of the deaths and stroke for one-fifth. The death rates for these conditions were two to five times those expected for men and women aged 50-59 years and up to twice the rate expected for the age group 60-69 years. Survival in these selected patients was impaired by the following independent risk indicators: cigarette smoking, previous history of myocardial infarction or stroke, diagnosis of angina, impaired renal function and raised blood sugar. The following factors were not independent positive risk factors: smoking a pipe or cigars, obesity, a low plasma potassium and an elevated serum uric acid.

Coeliac disease and malignancy

Patients with coeliac disease are at greater risk than the general population for the development of malignant neoplasms, particularly lymphomas. Of 259 histologically confirmed malignancies in 235 patients with histologically proven coeliac disease, 133 were malignant lymphomas, the predominant histological type being malignant histiocytosis and the commonest site of this lesion the small intestine. Patients with coeliac disease also have a greatly increased risk for the development of small-intestinal adenocarcinomas. Among 116 invasive non-lymphomatous malignancies there were 19 small-intestinal adenocarcinomas, compared with 0 . 23 expected from national cancer registrations adjusted for sex and age. There were also more oesophageal and pharyngeal squamous carcinomas than expected.

Nomograms for precise determination of birth weight for dates

We have derived a mathematical model (Altman and Coles, 1980) that matches closely the birth weight standards derived from the large Aberdeen survey (Thomson et al, 1968). From this, we have drawn nomograms that can be used to assess an infant's position in relation to these standards. The nomograms are easy to use and give adequate precision.