Eczema-protective probiotic alters infant gut microbiome functional capacity but not composition: sub-sample analysis from a RCT

Probiotic Lactobacillus rhamnosus HN001 given in early life has been shown to reduce infant eczema risk, but its effect on gut microbiota development has not been quantitatively and functionally examined. The aim of this study was to investigate the impact of early life probiotic exposure on the composition and functional capacity of infant gut microbiota from birth to 2 years considering the effects of age, delivery mode, antibiotics, pets and eczema. We performed shotgun metagenomic sequencing analysis of 650 infant faecal samples, collected at birth, 3, 12, and 24 months, as part of a randomised, controlled, 3-arm trial assessing the effect of L. rhamnosus HN001, Bifidobacterium animalis subsp. lactis HN019 supplementation on eczema development in 474 infants. There was a 50% reduced eczema risk in the HN001 probiotic group compared to placebo. Both mothers (from 35 weeks gestation until 6 months post-partum if breastfeeding) and infants (from birth to 2 years) received either a placebo or one of two probiotics, L. rhamnosus HN001 (6×109 cfu), or B. animalis subsp. lactis HN019 (9×109 cfu). L. rhamnosus HN001 probiotic supplementation was associated with increased overall glycerol-3 phosphate transport capacity and enrichment of L. rhamnosus. There were no other significant changes in infant gut microbiota composition or diversity. Increased capacity to transport glycerol-3-phosphate was positively correlated with relative abundance of L. rhamnosus. Children who developed eczema had gut microbiota with increased capacity for glycosaminoglycan degradation and flagellum assembly but had no significant differences in microbiota composition or diversity. Early life HN001 probiotic use is associated with both increased L. rhamnosus and increased infant gut microbiota functional capacity to transport glycerol-3 phosphate. The mechanistic relationship of such functional alteration in gut microbiota with reduced eczema risk and long-term health merits further investigation.

Effect of early probiotic supplementation on childhood cognition, behaviour and mood a randomised, placebo-controlled trial

AIM

To determine whether probiotic supplementation in early life improves neurocognitive outcomes assessed at 11 years of age.

METHODS

A total of 474 children who were born March 2004-Aug 2005 participated in a two-centre randomised placebo-controlled trial of infants at risk of developing allergic disease. Pregnant women were randomised to take Lactobacillus rhamnosus strain HN001, Bifidobacterium animalis subsp. lactis strain HN019 or placebo daily from 35 weeks gestation until six months if breastfeeding, and their infants the same treatment from birth to two years. Intelligence, executive function, attention, depression and anxiety were assessed when the children were 11 years of age.

RESULTS

A total of 342 (72.2%) children were assessed (HN001 n = 109, HN019 n = 118 and placebo n = 115). Overall, there were no significant differences in the neurocognitive outcomes between the treatment groups.

CONCLUSION

HN001 and HN019 given in early life were not associated with neurocognitive outcomes at 11 years of age in this study. However, we cannot exclude that other probiotics may have a beneficial effect. Further clinical trials are indicated.

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial

Background

Probiotics may help to prevent symptoms of anxiety and depression through several putative mechanisms.

Objective

The aim of this study was to evaluate the effect of Lactobacillus rhamnosus HN001 (HN001) given in pregnancy and postpartum on symptoms of maternal depression and anxiety in the postpartum period. This was a secondary outcome, the primary outcome being eczema in the offspring at 12 months of age.

Design, Setting, Participants

A randomised, double-blind, placebo-controlled trial of the effect of HN001 on postnatal mood was conducted in 423 women in Auckland and Wellington, New Zealand. Women were recruited at 14–16 weeks gestation.

Intervention

Women were randomised to receive either placebo or HN001 daily from enrolment until 6 months postpartum if breastfeeding.

Outcome Measures

Modified versions of the Edinburgh Postnatal Depression Scale and State Trait Anxiety Inventory were used to assess symptoms of depression and anxiety postpartum.

Trial Registration

Australia NZ Clinical Trials Registry: ACTRN12612000196842.

Findings

423 women were recruited between December 2012 and November 2014. 212 women were randomised to HN001 and 211 to placebo. 380 women (89.8%) completed the questionnaire on psychological outcomes, 193 (91.0%) in the treatment group and 187 (88.6%) in the placebo group. Mothers in the probiotic treatment group reported significantly lower depression scores (HN001 mean = 7·7 (SD = 5·4), placebo 9·0 (6·0); effect size -1·2, (95% CI -2·3, -0·1), p = 0·037) and anxiety scores (HN001 12·0 (4·0), placebo 13·0 (4·0); effect size -1·0 (-1·9, -0·2), p = 0·014) than those in the placebo group. Rates of clinically relevant anxiety on screening (score > 15) were significantly lower in the HN001 treated mothers (OR = 0·44 (0·26, 0·73), p = 0·002).

Interpretation

Women who received HN001 had significantly lower depression and anxiety scores in the postpartum period. This probiotic may be useful for the prevention or treatment of symptoms of depression and anxiety postpartum.

Funding Source

Health Research Council of New Zealand (11/318) and Fonterra Co-operative Group Ltd.

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The microbiome-gut-brain axis may be important for mental health.

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We conducted a study of probiotic supplementation in pregnancy and 6 months after delivery if breastfeeding.

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The probiotic treatment group reported significantly lower depression and anxiety scores than those in the placebo group.

There is mounting evidence from animal studies that the microbiome-gut-brain axis may be important for mental health. Depression and anxiety in pregnancy and after birth affects 10–15% of women, although many are not recognised or treated. We conducted a double-blind placebo-controlled study of probiotic (Lactobacillus rhamnosus HN001) supplementation (from early pregnancy through to 6 months after delivery if breastfeeding) on postnatal symptoms of depression and anxiety in a group (n = 380) of healthy women. Mothers in the probiotic treatment group reported significantly lower depression and anxiety scores than those in the placebo group.

Certainty and safe consequence responses provide additional information from multiple choice question assessments

BACKGROUND

Clinicians making decisions require the ability to self-monitor and evaluate their certainty of being correct while being mindful of the potential consequences of alternative actions. For clinical students, this ability could be inferred from their responses to multiple-choice questions (MCQ) by recording their certainty in correctness and avoidance of options that are potentially unsafe.

METHODS

Response certainty was assessed for fifth year medical students (n = 330) during a summative MCQ examination by having students indicate their certainty in each response they gave on the exam. Incorrect responses were classified as to their inherent level of safeness by an expert panel (response consequence). Analyses compared response certainty, response consequence across student performance groupings.

RESULTS

As students' certainty in responses increased, the odds they answered correctly increased and the odds of giving unsafe answers decreased. However, from some ability groups the odds of an incorrect response being unsafe increased with high certainty.

CONCLUSIONS

Certainty in, and safeness of, MCQ responses can provide additional information to the traditional measure of a number correct. In this sample, even students below standard demonstrated appropriate certainty. However, apart from those scoring lowest, student's incorrect responses were more likely to be unsafe when they expressed high certainty. These findings suggest that measures of certainty and consequence are somewhat independent of the number of correct responses to MCQs and could provide useful extra information particularly for those close to the pass-fail threshold.

Trends in the incidence of intensive care unit invasive mechanical ventilation and subsequent 2-year survival in very elderly New Zealanders

BACKGROUND

The number of elderly in the general population is growing. There are therefore implications for the provision of intensive care unit (ICU) care to elderly patients.

AIM

Our aim was to determine the incidence of ICU invasive mechanical ventilation (IMV), long-term outcomes of patients treated with IMV, and trends in these variables over a 10-year period in New Zealand, with a focus on very elderly patients (aged 80 years and over).

METHODS

Analysis of New Zealand public hospital discharge data from July 1999 to June 2010, with linked long-term mortality data. Transfers or readmissions to different hospitals were linked using a national unique patient identifier.

RESULTS

There were 58 003 patients treated with IMV in a New Zealand ICU. Of these patients, 6.6% were very elderly. Population rates of ICU IMV declined or were static over all age groups. The 2-year mortality rate ranged from 15% in patients aged 16-39 years to 52% in the very elderly. The 2-year mortality rates for the very elderly were highest for acute medical patients (78%), followed by acute surgical admissions (46%) and elective admissions (35%). The 2-year mortality rate for all patients declined over the study period, and declined or was static for all age groups and admission types. In the very elderly, the standardised mortality ratio of patients surviving at 1 year who survived their second year after admission, compared with the age-matched general population, was lower than all other age groups.

CONCLUSION

For very elderly patients over the period 1999-2009, the population rate of IMV was static and 2-year mortality declined.

Early supplementation with Lactobacillus rhamnosus HN001 reduces eczema prevalence to 6 years: does it also reduce atopic sensitization?

BACKGROUND

The role of probiotics in prevention of allergic disease is still not clear; efficacy may depend on the timing, dose, duration, and specific probiotic used. Using a double-blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high-risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation from birth until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema at 2 and 4 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no significant effect.

OBJECTIVE

To determine whether differences in effects of HN001 and HN019 on eczema persist to age 6 years, and to investigate effects on sensitization.

METHODS

Standard procedures were used to assess eczema (The UK Working Party's Criteria), eczema severity (SCORAD), atopic sensitization [skin prick tests (SPT), total and specific IgE] and standard questions used for asthma, wheeze, and rhinoconjunctivitis.

RESULTS

HN001 was associated with significantly lower cumulative prevalence of eczema (HR = 0.56, 95% CI 0.39-0.80), SCORAD ≥ 10 (HR = 0.69, 0.49-0.98) and SPT sensitization (HR = 0.69, 95% CI 0.48-0.99). The point prevalence of eczema (RR = 0.66, 95% CI 0.44-1.00), SCORAD ≥ 10 (RR = 0.62, 95% CI 0.38-1.01) and SPT sensitization (RR = 0.72, 95% CI 0.53-1.00) were also reduced among children taking HN001. HN019 had no significant effect on any outcome.

CONCLUSION AND CLINICAL RELEVANCE

This study provides evidence for the efficacy of the probiotic L. rhamnosus HN001 in preventing the development of eczema and possibly also atopic sensitization in high risk infants to age 6 years. The absence of a similar effect for HN019 indicates that benefits may be species specific.

A protective effect of Lactobacillus rhamnosus HN001 against eczema in the first 2 years of life persists to age 4 years

BACKGROUND

Using a double blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema by age 2 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no effect.

OBJECTIVE

The aim of this study was to investigate the associations of HN001 and HN019 with allergic disease and atopic sensitization among these children at age 4 years, 2 years after stopping probiotic supplementation.

METHODS

The presence (UK Working Party's Diagnostic Criteria) and severity SCORing Atopic Dermatitis (SCORAD) of eczema and atopy (skin prick tests) and parent-reported symptoms of asthma and rhinoconjunctivitis were assessed using standard protocols and questions.

RESULTS

Four-hundred and seventy-four infants were eligible at birth of whom 425 (90%) participated in this follow-up. The cumulative prevalence of eczema by 4 years (Hazard ratio (HR) 0.57 (95% CI 0.39-0.83)) and prevalence of rhinoconjunctivitis at 4 years (Relative risk 0.38 (95% CI 0.18-0.83)) were significantly reduced in the children taking HN001; there were also nonsignificant reductions in the cumulative prevalence of SCORAD ≥ 10 (HR 0.74 (95% CI 0.52-1.05), wheeze (HR 0.79 (95% CI 0.59-1.07)) and atopic sensitization (HR = 0.72 (95% CI 0.48-1.06)). HN019 did not affect the prevalence of any outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

This study showed that the protective effect of HN001 against eczema, when given for the first 2 years of life only, extended to at least 4 years of age. This, together with our findings for a protective effect against rhinoconjunctivitis, suggests that this probiotic might be an appropriate preventative intervention for high risk infants.

A protective effect of Lactobacillus rhamnosus HN001 against eczema in the first 2 years of life persists to age 4 years

BACKGROUND

Using a double blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema by age 2 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no effect.

OBJECTIVE

The aim of this study was to investigate the associations of HN001 and HN019 with allergic disease and atopic sensitization among these children at age 4 years, 2 years after stopping probiotic supplementation.

METHODS

The presence (UK Working Party's Diagnostic Criteria) and severity SCORing Atopic Dermatitis (SCORAD) of eczema and atopy (skin prick tests) and parent-reported symptoms of asthma and rhinoconjunctivitis were assessed using standard protocols and questions.

RESULTS

Four-hundred and seventy-four infants were eligible at birth of whom 425 (90%) participated in this follow-up. The cumulative prevalence of eczema by 4 years (Hazard ratio (HR) 0.57 (95% CI 0.39-0.83)) and prevalence of rhinoconjunctivitis at 4 years (Relative risk 0.38 (95% CI 0.18-0.83)) were significantly reduced in the children taking HN001; there were also nonsignificant reductions in the cumulative prevalence of SCORAD ≥ 10 (HR 0.74 (95% CI 0.52-1.05), wheeze (HR 0.79 (95% CI 0.59-1.07)) and atopic sensitization (HR = 0.72 (95% CI 0.48-1.06)). HN019 did not affect the prevalence of any outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

This study showed that the protective effect of HN001 against eczema, when given for the first 2 years of life only, extended to at least 4 years of age. This, together with our findings for a protective effect against rhinoconjunctivitis, suggests that this probiotic might be an appropriate preventative intervention for high risk infants.

Iatrogenic Creutzfeldt-Jakob disease and its neurosurgical implications

Creutzfeldt-Jakob (CJD) disease has been reported after the insertion of dural homografts. Two Australian cases of CJD, both following posterior fossa craniotomies done in 1982, are reported; the incubation periods were 5 and 12 years. It seems highly probable that the association is causal. CJD infective agents (prions) are resistant to many previously accepted means of sterilisation and it is postulated that cadaver dural material was either derived from subjects with CID, or was contaminated during preparation. In Australia the use of dural homografts in neurosurgery was abandoned in 1987; as the mean incubation period (determined from a world-wide review) has been about 65 months, it is now hoped that this cause of CJD will not recur in the Australian population, although it is premature to state this with confidence. However, precautions against case-to-case transmission remain necessary, and guidelines for this purpose should be enforced in theatre practice and in organ donations.

Killing the canary: the international epidemiology of the homicide of media workers

OBJECTIVES

To describe the international epidemiology of the homicide of media workers, and investigate country-level risk factors.

METHODS

Data on the homicides occurring from 2002 to 2006 were collected and collated from five international databases. Analyses included consideration of seven existing international indices relating to human development, and to the social and political functioning of states.

RESULTS

During the 5-year period, 370 deaths in 54 countries met our definitions of homicides and media workers. Almost all (89%) were nationals of the country in which they died. The annual number of such homicides globally has more than doubled, from 41 in 2002 to 104 in 2006 (including 49 in Iraq in 2006). Less than 25% of the homicides of media workers over the last 5 years have resulted in an arrest or prosecution. Statistically significant associations (p<0.001; Political Terror Scores, OR 1.15; Corruption Perceptions Index, OR 0.53; Overall Failed State Index, OR 1.05; Failed State Index 7, OR 1.52; Failed State Index 9, OR 1.55; Failed State Index 10, OR 1.61) were found on logistic regression between the occurrence of the homicide of media workers in countries and scoring on six of the seven indices associated with country-level sociopolitical development. These indices reflected high levels of political terror and corruption, low government legitimisation, poor human rights, and uncontrolled armed groups. However, in terms of the homicide rate for countries, these associations were significant for only four of the seven indices (the general functionality of government, ability of governments to control armed groups, the level of political terror, and the level of violation of rights).

CONCLUSIONS

The homicide of media workers increased substantially in this 5-year period and was found to be particularly concentrated in selected countries such as Iraq. The authors were able to identify specific sociopolitical risk factors for homicide occurrence, and for homicide rates at the country level.

Comparison of Two Clinical Bleb Grading Systems

PURPOSE

To evaluate 2 recently described grading systems for clinical grading of filtering surgery blebs: the Moorfields Bleb Grading System (MBGS) and the Indiana Bleb Appearance Grading Scale (IBAGS).

DESIGN

Observational comparative study.

PARTICIPANTS

Twenty-four glaucoma filtering blebs in 24 eyes of 17 patients.

METHODS

Three observers in a prospective agreement study compared MBGS with IBAGS during slit-lamp examination.

MAIN OUTCOME MEASURES

Comparison analyses were performed, including agreement, repeatability, and intraclass correlation coefficient (ICC).

RESULTS

A wide range of bleb characteristics was represented in the cohort. Acceptable levels of intrasystem agreement were found in both systems: for IBAGS, overall agreement at the 0.5- and 1.0-unit levels were 80.6% and 97.6%, respectively, and for MBGS, these were 78.4% and 97.4% for morphologic and vascularity indices. Repeatability coefficients ranged from 0.5 to 1.4 for MBGS and 0.8 to 1.2 for IBAGS. The ICC values in the MBGS ranged from 0.18 to 0.72 for single measures and 0.39 to 0.88 for average measures. For IBAGS, the single-measure ICC values were between 0.06 and 0.53, and the average-measure ICC values were between 0.16 and 0.77. The MBGS ICC values for bleb size were higher than for IBAGS.

CONCLUSIONS

Both methods are reproducible clinically and had generally high levels of interobserver agreement. Both have minor deficiencies that should be amenable to improvement. The MBGS performed similarly to the IBAGS for reproducibility, had higher ICC values for morphologic features, and captured extra vascularity data with probable clinical implications.

Fast foods - are they a risk factor for asthma?

BACKGROUND

Lifestyle changes over the last 30 years are the most likely explanation for the increase in allergic disease over this period.

AIM

This study tests the hypothesis that the consumption of fast food is related to the prevalence of asthma and allergy.

METHODS

As part of the International Study of Asthma and Allergies in Childhood (ISAAC) a cross-sectional prevalence study of 1321 children (mean age = 11.4 years, range: 10.1-12.5) was conducted in Hastings, New Zealand. Using standard questions we collected data on the prevalence of asthma and asthma symptoms, as well as food frequency data. Skin prick tests were performed to common environmental allergens and exercise-induced bronchial hyperresponsiveness (BHR) was assessed according to a standard protocol. Body mass index (BMI) was calculated as weight/height2 (kg/m2) and classified into overweight and obese according to a standard international definition.

RESULTS

After adjusting for lifestyle factors, including other diet and BMI variables, compared with children who never ate hamburgers, we found an independent risk of hamburger consumption on having a history of wheeze [consumption less than once a week (OR = 1.44, 95% CI: 1.06-1.96) and 1+ times a week (OR = 1.65, 95% CI: 1.07-2.52)] and on current wheeze [consumption less than once a week (OR = 1.17, 95% CI: 0.80-1.70) and 1+ times a week (OR = 1.81, 95% CI: 1.10-2.98)]. Takeaway consumption 1+ times a week was marginally significantly related to BHR (OR = 2.41, 95% CI: 0.99-5.91). There was no effect on atopy.

CONCLUSIONS

Frequent consumption of hamburgers showed a dose-dependent association with asthma symptoms, and frequent takeaway consumption showed a similar association with BHR.

Obesity and asthma in 11-12 year old New Zealand children in 1989 and 2000

BACKGROUND

There has been a concurrent increase in the prevalence of obesity and asthma in recent years in New Zealand and other countries.

METHODS

Two cross sectional surveys performed in 1989 and 2000 were used to test this association in children of mean age 11.7 years. Body mass index (BMI) was calculated as weight/height2 (kg/m2) and obesity and overweight defined according to an international standard. Standard questions were used to measure the prevalence of asthma symptoms.

RESULTS

Significant increases in the prevalence of reported symptoms and disease between 1989 and 2000 were not explained by a concurrent increase in the prevalence of obesity. In 2000, multivariate analysis showed that increasing BMI standard deviation score was significantly associated with current wheeze (p=0.002), inhaled steroid use (p=0.004), and the use of any medication (p=0.001). None of the associations was significantly different for boys or girls.

CONCLUSION

There is some evidence for an association of obesity with asthma symptoms and treatment but this does not explain the increasing prevalence of this disease.

Hip fracture incidence in New Zealand, revisited

AIM

Earlier predictions of the incidence of hip fractures in the older adult population suggested that by 2011 the rate would rise to epidemic proportions. The purpose of this study was to compare the number hip fractures occuring in New Zealand from 1988 to 1999 with the hip fracture rate predicted in 1990 by Rockwood, Horne and Cryer.

METHODS

Data on the number of patients admitted to New Zealand hospitals with a diagnosis of fractured neck of femur were obtained, and compared with weighted regression and baseline predictions of Rockwood et al.

RESULTS

The numbers of hip fractures for females, from 1988 to 1993, were similar to the number predicted, yet have been significantly lower than stated predictions since 1995. For males, hip fracture numbers since 1995 were less than the weighted regressions predicted (NS).

CONCLUSIONS

Numbers of hip fractures since 1995 have been fewer than predicted. Possible reasons for maintaining the rates of hospitalisation due to fractured neck of femur at pre-1995 levels, are discussed.

The sexual activity of 654 fourth form Hawkes Bay students

AIMS

To describe the self reported patterns of sexual behaviour of 4th form High School Students from the Hawkes Bay region of New Zealand, in 1998.

METHODS

Subjects completed a self administered written anonymous questionnaire in a supervised classroom situation.

RESULTS

654 4th form students, median age fourteen years, completed the questionnaire--45% male, 54% female. 39.4% of the sample reported having had sex/intercourse. Maori students were nearly three times (74.9%) as likely as European students (26.7%) to be sexually active (p < 0.0001). 20.1% of these sexually active 4th formers report more than five partners. 11.9% of the total group and 30.2% of those who are sexually active, reported having first sex at age 12 or younger.

CONCLUSIONS

The sexual activity of this sample of 4th form students is higher than reported previously in New Zealand, particularly so for Maori. Further research is needed to examine sexual behaviours and attitudes of young New Zealanders in the different communities to enhance the development and provision of geographically and culturally appropriate early sexuality education programmes and services. These should be designed to have particular relevance to the needs of young Maori.

An investigation into the incidence of toxoplasmosis in pregnancy in New Zealand

AIM

To estimate the incidence of toxoplasmosis in pregnancy in New Zealand and consider whether there is a case for screening women in pregnancy.

METHODS

The risk of maternal and fetal infection with toxoplasmosis was derived by first determining the rate of maternal seroconversion based on seroprevalence studies. The age-specific number of seroconversions in pregnancy was then estimated from the birth rate. Using reported fetal infection rates after primary maternal infection, the expected number of congenitally infected infants in one year was estimated. These incidences were compared with the number of recognised cases of toxoplasmosis infection in pregnancy and the actual number of positive IgM results at the Wellington Hospital laboratory. Using national births data, this incidence was extrapolated to estimate the number of expected cases in New Zealand.

RESULTS

The annual seroconversion rate was 0.62% (95% confidence interval 0.39-0.86). On this basis, 164 primary maternal infections are expected annually with 66 fetuses being infected. Ten patients tested positive for IgM in Wellington, which averaged only one case per year being identified over the time examined in this study.

CONCLUSIONS

Very few of the expected cases in pregnancy are diagnosed. Reporting rates were low when toxoplasmosis was a notifiable disease. Other means of improving detection, reporting and the avoidance of infection are discussed. More information is required before screening can be recommended in New Zealand.

Further follow-up of New Zealand participants in United Kingdom atmospheric nuclear weapons tests in the Pacific

We previously reported a study of deaths and cancer incidence in Royal New Zealand (RNZ) Navy personnel who participated in atmospheric nuclear weapons tests conducted by the United Kingdom in the Pacific in 1957-58. The study involved 528 men known to have participated in the tests, and a control group of 1,504 men who were in the RNZ Navy during the same period but were not involved in the tests. The original follow-up was carried out for the period 1957-87 with an observed increase in risk of leukemia and other hematologic cancers, but little or no increase of non-hematologic cancers or non-cancer deaths in test participants. Follow-up now has been extended for the period 1988-92. For the total follow-up period, there were 97 deaths in test participants and 256 deaths in controls, a relative risk (RR) of 1.1 (90 percent confidence interval [CI] = 0.9-1.3). The RR of death from causes other than cancer was 1.0 (CI = 0.8-1.3), whereas the RR of cancer death was 1.2 (CI = 0.8-1.7) and that of cancer incidence was 1.0 (CI = 0.8-1.4). For cancers other than hematologic malignancies, the RR was 1.0 (CI = 0.7-1.5) for mortality, and 1.0 (CI = 0.7-1.3) for incidence. However, there were eight deaths from hematologic cancers in test participants (RR = 3.8, CI = 1.4-10.8), including four leukemias (RR = 5.6, CI = 1.0-41.7). The RR for incidence of hematologic cancers was 1.9 (CI = 0.8-4.3), and that for leukemia was 5.6 (CI = 1.0-41.6). We concluded that the evidence is still consistent with the hypothesis that some leukemias and other hematologic cancers may have resulted from participation in the nuclear weapons test program, but the further follow-up strengthens the evidence that there is no increased risk for non-hematologic cancers or for causes of death other than cancer in the test participants.

Effects of hyperthyroidism and radioactive iodine given to ablate the thyroid on the composition of whole stimulated saliva

OBJECTIVE

For many years there has been speculation about possible damage to the salivary glands following administration of ablative doses of radioactive iodine for treatment of hyperthyroidism. We have investigated the changes that occur in the composition of saliva in hyperthyroidism and after the administration of an ablative dose of radioactive iodine to hyperthyroid subjects.

DESIGN

The study consisted of two parts: first, a comparison of a group of hyperthyroid patients with a group of normal subjects with regard to the concentration or activity of 10 constituents of saliva; second, measurement of those constituents 3-42 weeks after administration of 370 MBq of radioactive iodine to a group of hyperthyroid subjects.

PATIENTS

Saliva specimens from 38 untreated out-patients with hyperthyroidism due to Graves' disease or toxic nodular goitre were studied to evaluate the effects of hyperthyroidism and the results were compared with a group of 93 normal subjects. Seventy-one samples of saliva from 26 patients with persistent hyperthyroidism were collected and analysed 3-42 weeks after radioactive iodine administration.

MEASUREMENTS

The flow rate; the concentrations of total protein, iodine, calcium, urate, phosphate, potassium and immunoglobulin A; and the activities of N-acetylglucosaminidase, lysozyme and lactate dehydrogenase were measured.

RESULTS

In hyperthyroidism the salivary flow rate and the concentrations of urate and potassium were significantly (P < 0.05) increased and the concentrations of total protein, calcium and lactate dehydrogenase activity significantly decreased compared to the control group. After radioactive iodine was administered, significant positive trends were observed in the concentrations of total protein, N-acetylglucosaminidase and immunoglobulin A. These trends were independent of the free T3 levels obtained from the same specimens.

CONCLUSIONS

Hyperthyroidism leads to a number of changes in salivary composition. For most of the salivary components measured no significant changes were observed 3-42 weeks after administration of 370 MBq of radioactive iodine to patients with persistent hyperthyroidism. The relatively small positive trends in the concentrations of total protein, N-acetylglucosamidase activity and immunoglobulin A may have been due either to changes in thyroid status or to the effects of radiation on the salivary glands, or both.

Albumin levels and mortality in patients with hip fractures

AIM

The aim of the study was to examine the serum albumin levels of patients admitted with hip fractures to see whether there was any relationship between serum albumin and subsequent mortality.

METHODS

A group of 39 consecutive patients with hip fractures was followed for a period of 12 months. The serum albumin was determined preoperatively. No patient was lost to follow up.

RESULTS

Ten patients died at 12 months. Those who died had a significantly lower serum albumin level than those alive at the end of the follow up period.

CONCLUSIONS

The results of this study show that preoperative serum albumin determination in patients with hip fractures is a useful guide to postfracture mortality.

The incidence of hip fractures in Maori and non-Maori in New Zealand

AIMS

To investigate the incidence of hip fractures in Maori and nonMaori in New Zealand.

METHODS

The number of femoral neck fractures in patients over 60 in New Zealand for the years 1989-91 were obtained. The population data for 1991 was obtained from the 1990 census. The number of fractures was standardised for age, and the rate of fractures per 100,000 of population calculated.

RESULTS

The age standardised rates of hip fracture per 100,000 of population 1989-91 for Maori males was 197, Maori females 516, nonMaori males 288 and nonMaori females 827. These rates were higher than the rates recorded between 1973 and 1975.

CONCLUSIONS

The age-specific hip fracture rate is rising in New Zealand. However in Maori males the rate is not rising.

Lack of evidence for pituitary thyrotroph down-regulation after 1 week of oral thyrotrophin-releasing hormone and metoclopramide under conditions of constant peripheral thyroid hormone levels

We investigated the pituitary thyrotrophin (TSH) response to repeated oral (non-pulsatile) thyrotrophin-releasing hormone (TRH) administration and potential modifying effects of dopamine antagonist treatment under conditions of constant peripheral thyroid hormone levels. In a randomized double-blind crossover trial, seven hypothyroid subjects, euthyroid on L-thyroxine, received 1 week each of oral TRH (40 mg, 12 hourly) plus metoclopramide (10 mg, 8 hourly) and TRH (40 mg, 12 hourly) plus placebo (one capsule, 8 hourly). At the beginning and end of each treatment period five samples of blood for estimation of serum TSH were taken over 1 h before ("baseline") and seven samples over 2 h after the treatment combination was given ("stimulated"). Serum free thyroxine, free triiodothyronine and prolactin levels also were measured. Mean log10 +/- SEM (log10 mIU/l) "baseline" serum levels TSH were -0.177 +/- 0.183 (median 0.345 mIU/l (untransformed); range (r) 0.03-10.11 mIU/l; first quartile (1q) 0.22 mIU/l; third quartile (3q) 2.48 mIU/l) before and 0.182 +/- 0.107 (median 1.385 mIU/l; r = 0.45-19.8 mIU/l; 1q = 0.9 mIU/l; 3q = 1.78 mIU/l) after 1 week of treatment (p < 0.02). There were no significant differences between oral TRH plus metoclopramide and oral TRH plus placebo. Peripheral thyroid hormone levels and the "stimulated" TSH response (expressed as area under curve after TRH and metoclopramide or placebo; min.log10 mIU/l) remained unchanged after 1 week. In the absence of changes in peripheral thyroid hormone levels, oral TRH over 1 week may not result in down-regulation of anterior pituitary thyrotrophs.2+ f2p4

Measurements of blood pressure, oedema and proteinuria in a pregnant population of New Zealand

This is the first report of the largest study of blood pressure measurement in pregnancy in a New Zealand population using standardized definitions and methodology. Over 3,800 women who delivered in an 8-month period in the Wellington region were included in the study. Blood pressure measurement and the presence of oedema and proteinuria were recorded from booking until delivery and in the puerperium. Only 2.7% of women were unable to be contacted after delivery for details on outcomes. The results established normal ranges for blood pressure throughout pregnancy. The data show that blood pressure greater than 140/90 until 35 weeks' gestation is outside 2 standard deviations at all gestations and justifies using these measurements as the definition of hypertension in pregnancy. The fall in blood pressure in the 2nd trimester was less than 1 mm Hg per week in both the systolic and diastolic pressures. This fall was smaller than previously recorded in other studies. Gestational hypertension was the commonest blood pressure abnormality occurring in 15.2% of the population. This represented 69% of the pregnant women with a hypertensive disorder. The overall incidence of both gestational hypertension and preeclampsia was 18.5% which is higher than reported in other parts of the world. In this study obesity was significantly associated with hypertensive disorders in pregnancy. An arm circumference of > 33 cm, one of the measurements of obesity, was found in 6.8% of the study population. Even after the effect of arm circumference was taken into account, hypertensive disorders were also more common in Pacific Island women.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of hypercapnia and hypoxemia on the cardiovascular responses to isoproterenol

BACKGROUND

The reason for the increased risk of death with fenoterol and isoproterenol in asthma is unknown but may relate to their cardiovascular effects. Deaths from asthma usually occur outside hospital where hypoxemia, with or without hypercapnia, may exist. Both of these states can influence the cardiovascular system. We investigated whether different gas mixtures modified the cardiovascular effects of isoproterenol.

METHOD

Nine healthy men were randomly assigned to receive each of three gas mixtures to achieve (1) normoxia-normocapnia, (2) hypercapnia (end-tidal PaCO2, 50 mm Hg), (3) hypoxemia-hypercapnia (arterial oxygen saturation, 90%; PaCO2, 50 mm Hg). Isoproterenol was administered with each of the gas mixtures. Cardiovascular measurements of heart rate, blood pressure, cardiac index, ejection fraction, fractional shortening, electromechanical systole, and the QTc interval were made before administration of the gases, as well as before and 5 minutes after isoproterenol administration.

RESULTS

The changes after hypercapnia were not significantly different from those after normoxia-normocapnia. Hypoxemia-hypercapnia increased heart rate, systolic and diastolic blood pressure, QTc interval, cardiac index, ejection fraction, and fractional shortening. Isoproterenol increased heart rate, systolic blood pressure, QTc interval, cardiac index, ejection fraction, and fractional shortening while the subjects breathed the normoxia-normocapnia gas mixture. It caused similar changes with the other gas mixtures. The changes were additive.

CONCLUSION

Isoproterenol and hypoxemia-hypercapnia will increase myocardial oxygen demand and could prove to be detrimental in severe asthma.

The extrapulmonary effects of inhaled hexoprenaline and salbutamol in healthy individuals

We have investigated the cardiovascular and metabolic effects of multiple inhaled doses of salbutamol and hexoprenaline in 12 healthy volunteers. They inhaled 200 micrograms of salbutamol or hexoprenaline at 15 min intervals for 60 min from a metered dose inhaler (total dose 1000 micrograms). We measured heart rate, blood pressure, total electromechanical systole (as a measure of inotropic response), QTc interval on the ECG, and plasma potassium at baseline, 10 min after each inhalation, and 30 and 60 min after the last inhalation. There was no difference in the effects of the two drugs on blood pressure, total electromechanical systole, or QTc interval. Salbutamol significantly increased heart rate compared with hexoprenaline. Hexoprenaline caused a significantly greater fall in plasma potassium compared with salbutamol.

The effects of user charges on the dispensing of prescription medicines: a survey of prescription charge payment in the Wellington region

OBJECTIVE

The study aimed to examine the impact of user charges on the dispensing of prescription medicines. The effect of social class, customer type and number of items on the incidence of payment problems was examined.

METHOD

The study employed a two week survey of 26 pharmacies randomly selected from Wellington Pharmacy Guild. Pharmacists completed a questionnaire on each occasion user charges led to a problem dispensing a prescribed medicine. Data collected included: type of problem encountered and its outcome, customer information (including the customer's pharmaceutical benefit category), and prescription information (including the number of items prescribed).

RESULTS

The overall incidence of payment problems was 1.5% or 1 in every 66 prescription forms processed by the pharmacists. User charges resulted in medicine dispensing failure on 56% of the problem occasions. Customers incurred debt or were funded by a social agency on the remaining 44% of problem occasions. Fifty-three percent of dispensing failures resulted in non-collection of items at the end of the survey period. Thirty-four percent of debts were outstanding at the end of the survey. The incidence of all payment problems correlated with the social "need" score of the pharmacy area and was significantly higher for children's and student's prescriptions.

CONCLUSION

User charges may provide a greater barrier to children, students and people living in areas of high social need. Ongoing evaluation of the impact of user charges is required to ensure improved prescribing is achieved equitably [corrected].

A comparison of the cardiovascular and metabolic effects of formoterol, salbutamol and fenoterol

The cardiovascular and metabolic effects of the long-acting beta 2-agonist formoterol were compared with those of salbutamol, fenoterol and placebo in 12 healthy volunteers, using a randomised, double-blind, cross-over design. On the study days, the subjects inhaled either formoterol (24 micrograms), salbutamol (400 micrograms), fenoterol (400 micrograms) or placebo, at 30 min intervals for five doses. Heart rate (HR) total electromechanical systole (Q-S2I) (a measure of inotropy), the corrected QT interval (QTc), systolic and diastolic blood pressure, plasma glucose and plasma potassium (K+) were measured prior to drug administration, 10 min after each inhalation and at 30 min intervals for 3 h after the last inhalation. All of the active agents significantly increased HR, QTc and plasma glucose, and decreased Q-S2I, diastolic blood pressure and plasma K+ compared to placebo. Fenoterol had a significantly greater maximum effect on HR, QTc and Q-S2I than either salbutamol or formoterol. Formoterol and fenoterol caused a similar maximum reduction in plasma K+, greater than that due to salbutamol. We conclude that formoterol is a more selective beta 2-agonist than fenoterol, and has similar cardiovascular effects to salbutamol when inhaled repeatedly by normal volunteers.

A comparison of the cardiovascular and metabolic effects of formoterol, salbutamol and fenoterol

The cardiovascular and metabolic effects of the long-acting beta 2-agonist formoterol were compared with those of salbutamol, fenoterol and placebo in 12 healthy volunteers, using a randomised, double-blind, cross-over design. On the study days, the subjects inhaled either formoterol (24 micrograms), salbutamol (400 micrograms), fenoterol (400 micrograms) or placebo, at 30 min intervals for five doses. Heart rate (HR) total electromechanical systole (Q-S2I) (a measure of inotropy), the corrected QT interval (QTc), systolic and diastolic blood pressure, plasma glucose and plasma potassium (K+) were measured prior to drug administration, 10 min after each inhalation and at 30 min intervals for 3 h after the last inhalation. All of the active agents significantly increased HR, QTc and plasma glucose, and decreased Q-S2I, diastolic blood pressure and plasma K+ compared to placebo. Fenoterol had a significantly greater maximum effect on HR, QTc and Q-S2I than either salbutamol or formoterol. Formoterol and fenoterol caused a similar maximum reduction in plasma K+, greater than that due to salbutamol. We conclude that formoterol is a more selective beta 2-agonist than fenoterol, and has similar cardiovascular effects to salbutamol when inhaled repeatedly by normal volunteers.

The natural history of multiple sclerosis: a regional study with some longitudinal data

A regional survey of multiple sclerosis (MS) patients in Wellington, New Zealand in 1983 identified 245 patients, giving a prevalence (all categories included) of 72 per 100,000. Retrospective review of the history and medical records identified a poorer prognosis for disability where there was progressive onset of symptoms, secondary progression after a remitting phase, older age of onset (40 years or more), or a motor syndrome involving the limbs at presentation. In 1983 follow up data were obtained on 96 patients who were seen during a previous survey in 1968. For those with definite or probable MS, progression to severe disability (Kurtzke disability status scale (DSS) 6-9) or death (DSS 10) was seen in 26/34 with moderate disability (DSS 3-5) in 1968 and in only 5/29 with mild disability (DSS 0-2). When the analysis is confined to those with symptoms for at least five years in 1968, severe disability or death from MS occurred in 22/30 with moderate and 4/19 with mild disability (chi 2 = 10.8, p = 0.001). It is concluded that the patient's established disability level after five years of illness is a useful, but not infallible, prognostic indicator. From the follow up of the 1968 patients, the probability of MS-related mortality for a given disease duration was calculated. Using this survival distribution to adjust the disability ratings in the 1983 population, it was found that the proportion with mild disability decreased steadily with increasing disease duration, reaching 14% when the disease duration was more than 25 years.

No evidence for social class inequalities in intervention for coronary heart disease in Otago 1987-9

OBJECTS

to investigate whether social class differences in access to cardiac surgical interventions (angioplasties and coronary artery bypass grafting) could explain social class inequalities in mortality from coronary heart disease.

METHODS

rates of therapeutic interventions to treat coronary heart disease were calculated for male patients aged less than 65 years admitted for the first time to Dunedin Hospital with a principal diagnosis of ischaemic heart disease (ICD codes 410-414) during the three year period from 1 January 1987 to 31 December 1989. Patients were categorised into different socioeconomic groups using the Elley-Irving social class scale.

RESULTS

no statistically significant trend across social class was observed in the cumulative incidence of cardiac surgical interventions (angioplasties, coronary artery bypass grafts). Similarly there was no statistically significant trend across social class in the incidence rates of cardiac surgical interventions, even after adjustment for age.

CONCLUSIONS

social class inequalities in access to cardiac surgical intervention do not appear to explain the observed inequalities in mortality from coronary heart disease.

Reliability of the draft diagnostic criteria for research of ICD-10 in comparison with ICD-10 and DSM-III-R

The reliability and ease of use of DSM-III-R and the clinical and research versions of ICD-10 were assessed by 5 psychiatrists working in pairs. They diagnosed 60 patients. All 3 systems showed similar and high interrater and intersystem agreement for major diagnostic categories but not for subcategories. A number of implications of these results are discussed.

Bronchial responsiveness during regular fenoterol therapy: four months prospective study

Effects of a regimen of regular high dose beta agonist aerosol as sole therapy (fenoterol 400 micrograms qid) on FEV1 and bronchial responsiveness to methacholine provocation were examined monthly in 16 atopic moderately severe asthmatic subjects in an open uncontrolled four months study. Eleven completed the trial, four dropped out on account of severe acute asthma and one with muscle tremor. Overall there was a small significant drop of mean prebronchodilator FEV1 after one month of 0.27 L (95% confidence interval 0.12, 0.42) but not significant thereafter. The increase of bronchial responsiveness (mean decrease of PD20 of 0.50 doubling doses of methacholine) by the end of month four did not reach statistical significance. Our study which explored potentially adverse effects of this beta agonist regimen showed only small changes of doubtful clinical significance. Drop outs due to acute asthma complicate studies such as this and make conclusions difficult.

Should treatment of mild to moderate hypertension be targeted? Results from a Markov cohort model incorporating multiple risk factors

A series of guidelines for the treatment of mild to moderate hypertension have recommended that individuals with multiple cardiovascular risk factors should start treatment sooner, or at a lower level of diastolic pressure, compared with patients with an isolated elevation of blood pressure. A Markov cohort model was constructed to examine this claim. The cohorts consisted of mild to moderately hypertensive men with added cardiovascular risk factors: smoking, raised serum cholesterol, and presence of left ventricular hypertrophy on electrocardiogram. The results of the model confirm that the prognosis of hypertension is highly dependent on the presence of other risk factors. The average remaining life expectancy of two patients of identical age and level of diastolic pressure varied by as much as 10 to 24 years, depending on the presence of other risk factors. Depending on the patient, the gain in life expectancy due to treatment of hypertension ranged from 0.11 years to 1.03 years. However, the results also indicated that the additional benefit as a result of 'targeting' in people with multiple risk factors did not exceed 0.47 years for any of the patient categories analysed. The nature of these conclusions remained unaltered despite the use of quality-adjusted life years (QALYs), and varying assumptions about the benefit of treatment. In comparison the model indicated that the benefits of smoking cessation among hypertensive men were three to eight times greater than the expected benefits from antihypertensive therapy.

Multiple sclerosis in Australia and New Zealand: are the determinants genetic or environmental?

The prevalence of multiple sclerosis (MS) has been recently reported from nine regions of Australia and New Zealand. There is a marked variation of prevalence with latitude. MS is seven times more common in southern New Zealand than in tropical Queensland. On current evidence, it is suggested that in both countries this variation is predominantly due to environmental rather than genetic factors.

The pulmonary and extrapulmonary effects of inhaled beta-agonists in patients with asthma

The cardiovascular, respiratory, and hypokalemic effects of repeated inhalation of fenoterol, albuterol, and isoproterenol were compared in 12 subjects with stable asthma according to a double-blind, crossover design. Ipratropium bromide served as a control providing bronchodilatation without extrapulmonary effects. Subjects inhaled the beta-agonists on an equal-weight basis (400 micrograms) at 0, 30, 40, and 45 minutes. Measurements of heart rate, blood pressure, total electromechanical systole (measure of inotropic activity), preejection period, QTc interval, plasma potassium levels, and forced expiratory volume in 1 second were made 5 minutes after each dose and again at 60 and 75 minutes. There were no differences in the bronchodilating effect between the beta-agonists. However, both fenoterol and isoproterenol resulted in greater positive inotropic stimulation than did albuterol, and fenoterol caused a greater fall in plasma potassium levels than did the other beta-agonists.

A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures

Distal radial fractures are common, and many methods of treatment have been reported but there are no studies that compare the different treatment methods. This randomized prospective study demonstrated no advantage in using an external fixator to immobilize reduced distal radial fractures over closed reduction and plaster cast immobilization in patients less than 60 years of age. The external fixator group had a significant complication rate.

The cardiovascular effects of beta adrenergic agonist drugs administered by nebulisation

The cardiovascular effects of equal doses (5 mg) of nebulised fenoterol, salbutamol and terbutaline were compared in 12 healthy individuals in a double-blind, placebo-controlled study. Measurements of heart rate, blood pressure, systolic time intervals, QTc interval and T-wave amplitude were made at baseline and at 15, 30, 45, 60 and 90 minutes after nebulisation. Fenoterol caused significantly greater chronotropic electrocardiographic and inotropic effects than either salbutamol or terbutaline. The peak effects after terbutaline occurred later than those after fenoterol or salbutamol.

The cardiovascular effects of inhaled fenoterol alone and during treatment with oral theophylline

We have investigated whether oral theophylline potentiated the cardiovascular effects of fenoterol administered by metered-dose inhaler. Eight healthy subjects were investigated on four occasions. On successive days (1 and 2), the subjects were given doses of 400 micrograms, 600 micrograms, and 800 micrograms of fenoterol at 15-minute intervals (total dose, 1.8 mg) or matched placebo. Systolic time intervals, blood pressure, and the ECG were recorded at baseline and five minutes after each inhalation. Thereafter, the subjects were treated with slow-release theophylline for eight days. On days 9 and 10, the procedures on days 1 and 2 were repeated. The order of treatment was applied according to a crossover Latin-square design. The effects after theophylline alone were no different from placebo. Theophylline potentiated those hemodynamic effects of fenoterol due to enhanced cardiac sympathetic tone (mean +/- SE) as measured by a decrease in Q-S2I (-41.6 +/- 7.6 ms vs -27.3 +/- 5.9 ms; p = 0.0004), an increase in systolic BP (23.5 +/- 2.8 mm Hg vs 9.0 +/- 5.3 mm Hg; p = 0.00001), and an increase in heart rate (15.8 +/- 1.6 bpm vs 9.1 +/- 3.7 bpm; p = 0.0013). The responses mediated by beta 2-adrenergic receptor stimulation, namely, a decrease in PEP and diastolic BP, were not potentiated. Although fenoterol prolonged the Q-Tc interval and decreased T-wave amplitude, these effects were not potentiated by theophylline. Oral theophylline potentiates the positively inotropic and chronotropic effects of fenoterol.

Bronchial gland duct ectasia in fatal bronchial asthma: association with interstitial emphysema

To determine the incidence of bronchial gland duct ectasia in fatal asthma and its association with interstitial emphysema, the histological features of 72 patients in whom death was considered to be due to asthma, and 72 matched control subjects in whom sudden death was not attributed to asthma, were reviewed. In all cases and controls, sections of two or more blocks of lung tissue stained with haematoxylin and eosin were obtained at necropsy. Bronchial gland duct ectasia was diagnosed if there was more than one abnormally dilated epithelial lined protrusion from a bronchus, extending through the smooth muscle layer. A histological diagnosis of asthma was made if four of the five following criteria were present: mucus plugging, basement membrane thickening, epithelial shedding, submucosal eosinophil leucocyte infiltration and smooth muscle hypertrophy. A histological diagnosis of asthma was made in 53 of 72 clinical cases of fatal asthma and in five of 72 control subjects. Interstitial emphysema was present in 10 clinical cases of fatal asthma, all of whom had bronchial gland duct ectasia and a histological diagnosis of asthma. Interstitial emphysema was not observed in control subjects. It is concluded that bronchial gland duct ectasia is a common histological feature of severe asthma, and that interstitial emphysema may be consequent on rupture of these dilated gland ducts.