SAT0169 HYDROXYCHLOROQUINE PRESCRIPTION PATTERNS IN EUROPE - THE EUROPEAN SURVEY FOR LUPUS PATIENTS (ESLP)

Background:

Long-term use of hydroxychloroquine (HCQ) is very common in patients with lupus erythematosus. It has been associated with wide-ranging benefits and it is generally well tolerated1. However, long-term use (i.e. > 5 years) and high-dose HCQ (i.e. > 5 mg/kg/day) are both considered to be risk factors for developing HCQ retinopathy2.

Advances in our understanding of HCQ retinopathy has led to changes in the recommendations for HCQ dosing and retinopathy screening1-3. The latest EULAR guidelines for the management of systemic lupus erythematosus (SLE)4recommend a maximum HCQ dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of HCQ treatment.

Objectives:

To assess whether recent EULAR guidelines regarding HCQ dosing and retinopathy screening are affecting prescription patterns and screening frequencies in Europe.

Methods:

Patients in Europe were given the opportunity to complete the online European Survey for Lupus Patients (ESLP) initiated by LUPUS EUROPE. The survey was promoted on social media from the 26thof June – 11thof July 2019. The survey consisted of 29 questions. Each participant was asked, among other things, to report their body weight (kg), daily HCQ dose and if they have received baseline screening and/or regular eye examinations.

Results:

The online survey was completed by 2938 lupus patients from 36 countries. The majority were female (86.5%) and diagnosed with SLE (85.7%). The daily HCQ dose (mg/kg) was available from 1678 patients (57.1%). The median ± IQR HCQ dose was 4.3 ± 2.5 mg/kg/day with a median treatment duration of 7 years (IQR: 3 – 14).

The recommended daily HCQ dose of 5 mg/kg was exceeded by 618 patients (36.8%). Low HCQ dose (≤ 4 mg/kg) was reported by 769 patients (45.8%). In addition, 284 out of 1786 patients (15.9%) reported they skipped HCQ once a week or more often. Nevertheless, only 8.7% of patients reported that they were more likely to skip HCQ than other medication. Patients from Belgium, Israel, France and Portugal reported the highest HCQ dosages. In contrast, patients from Spain reported the lowest HCQ dosages (Figure 1).

Figure 1.

HCQ dose (mg/kg/day) reported by patients (• median HCQ dose). PRT: Portugal, POL: Poland, NLD: Netherlands, ITA: Italy, ISR: Israel, GRC: Greece, FRA: France, FIN: Finland, ESP: Spain, DEU: Germany, CHE: Switzerland, BEL: Belgium.

Moreover, 935 out of 1137 patients diagnosed in the past 10 years (82.2%) reported that they have received an ophthalmological screening at baseline. Lastly, 1167 patients reported long-term use of HCQ (i.e. ≥ 5 years). Only about 64% of them (n=748) reported that they receive regular eye examinations (i.e. at least once every year).

Conclusion:

Studies have suggested that prescription patterns in the USA and UK were already affected by guidelines regarding HCQ dosing1. We show large inter- and intra-country variations of HCQ dosing in Europe. Additionally, most centers fail to follow recent recommendations4regarding annual screening of retinopathy in case of long-term HCQ use.

More research is needed to assess the clinical efficacy of low-dose HCQ and to confirm whether proper screening modalities are being employed as recommended by recent guidelines2-4.

References:

[1]Jorge A et al. Hydroxychloroquine retinopathy - implications of research advances for rheumatology care. Nat Rev Rheumatol. 2018 Dec; 14(12): 693-703.

[2]Michael F. Marmor et al, 2016, Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision). Ophthalmology. 123(6): 1386-94.

[3]Imran H. Yusuf et al. The Royal College of Ophthalmologists recommendations on screening for hydroxychloroquine and chloroquine users in the United Kingdom: executive summary. Eye (Lond). 2018 Jul; 32(7): 1168–1173.

[4]Fanouriakis A et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun; 78(6): 736-745.

Disclosure of Interests:

None declared

AB0371 HYDROXYCHLOROQUINE AS VIEWED BY LUPUS PATIENTS – WHAT IMPACT FOR DOCTORS?

Background:

Hydroxychloroquine (HCQ) is recommended for all patients with systemic lupus erythematosus (SLE) and is typically considered as having a good safety profile1. Yet, patient organisations observe that concerns about eye impact or “allergies to HCQ” are often raised on social media. This could contribute to the non-adherence, which varies from 3 to 76% in SLE patients depending on assessment method and drug2.

Objectives:

To understand if/how some patients’ beliefs impact adherence to HCQ treatment.

Methods:

In May 2019, LUPUS EUROPE launched a 29 questions on-line survey in 13 languages including questions on HCQ adherence.

2938 responses were analysed. 67.8% (1990 patients) were current HCQ users, 17.8% had stopped using it, 8.1% never had HCQ (6.4% did not respond to this question). 1820 users reported their adherence level. 314 (17.3%) were classified as “low” adherence as they reported missing/forgetting HCQ “always” (1.8%), “more than twice a week” (5.2%) or “once a week” (10.3%)

Results:

The prescribed HCQ dose, kidney involvement or duration of treatment (beyond the 1styear) were found to have no impact on low adherence. Similarly, the userbeliefthat HCQ has significant side effects, without experiencing these, was not found to impact adherence (p=.74).

The following factors were associated with better adherence: (p<.0001)

- The belief that HCQ is “Very important” (12.9% “low”) rather than “important” (22.1% “low”) or “not important / useless” (33.1% “low”).

- Taking many different medications (9.8% “low” for Patients indicating more than 7 medications vs 19.8% for those listing 3 or less)

Childhood onset of the SLE was associated with a lower adherence (30.0% “low” vs. 17.4% for later onset SLE (p<.001)

658 patients (29.6%) reported having experienced side effects. 42.6% of them stopped taking HCQ (patient led 161, doctor led 110, unclear 9). Amongst those continuing HCQ despite experiencing side effects, the proportion of non adherent patients increased to 24.7%, compared to 15.2% in the group of patients that have not experienced side effects (p=.0001). The 232 patients who talked with their Doctor and felt listened to appear to adhere better (22.0% low adherence) than the 84 who did not feel heard (31.0% low adherence), but the significance is only directional (p=<0.15)

523 patients have used HCQ in the past. 206 (39.4%) consider the decision to stop HCQ as doctor initiated, 272 (52.0%) as patient initiated, and 36 (6.9%) as a joint decision.

When stopping was patient initiated, 59.9% was due to experiencing a significant side effect attributed by the patient to HCQ, 6.7% due to concern of a potential side effect, 11.2% “tested” stopping and noticed no difference, 10.0% were not convinced that it worked, 8.2% felt their lupus was less active, 2.6% wanted to reduce pill consumption. (Side effects attributed to HCQ may relate to age, disease activity or other factors).

Conclusion:

Doctors can help HCQ adherence by boosting patient’s confidence in the importance of HCQ. Better patient education may contribute to avoid up to 40% of patient initiated decision to stop HCQ treatment.

References:

[1]Fanouriakis A et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun; 78(6): 736-745.

[2]Costedoat N et al, Treatment adherence in systemic lupus erythematosus and rheumatoid arthritis: time to focus on this important issue, Rheumatology, Vol 57 (9), Sep 2018, 1507–1509.

Disclosure of Interests:

None declared

Simultaneous Mapping of T1 and T2 Using Cardiac Magnetic Resonance Fingerprinting in a Cohort of Healthy Subjects at 1.5T

BACKGROUND

Cardiac MR fingerprinting (cMRF) is a novel technique for simultaneous T₁ and T₂ mapping.

PURPOSE

To compare T₁ /T₂ measurements, repeatability, and map quality between cMRF and standard mapping techniques in healthy subjects.

STUDY TYPE

Prospective.

POPULATION

In all, 58 subjects (ages 18-60). FIELD STRENGTH/SEQUENCE: cMRF, modified Look-Locker inversion recovery (MOLLI), and T₂ -prepared balanced steady-state free precession (bSSFP) at 1.5T.

ASSESSMENT

T₁ /T₂ values were measured in 16 myocardial segments at apical, medial, and basal slice positions. Test-retest and intrareader repeatability were assessed for the medial slice. cMRF and conventional mapping sequences were compared using ordinal and two alternative forced choice (2AFC) ratings.

STATISTICAL TESTS

Paired t-tests, Bland-Altman analyses, intraclass correlation coefficient (ICC), linear regression, one-way analysis of variance (ANOVA), and binomial tests.

RESULTS

Average T₁ measurements were: basal 1007.4±96.5 msec (cMRF), 990.0±45.3 msec (MOLLI); medial 995.0±101.7 msec (cMRF), 995.6±59.7 msec (MOLLI); apical 1006.6±111.2 msec (cMRF); and 981.6±87.6 msec (MOLLI). Average T₂ measurements were: basal 40.9±7.0 msec (cMRF), 46.1±3.5 msec (bSSFP); medial 41.0±6.4 msec (cMRF), 47.4±4.1 msec (bSSFP); apical 43.5±6.7 msec (cMRF), 48.0±4.0 msec (bSSFP). A statistically significant bias (cMRF T₁ larger than MOLLI T₁ ) was observed in basal (17.4 msec) and apical (25.0 msec) slices. For T₂ , a statistically significant bias (cMRF lower than bSSFP) was observed for basal (-5.2 msec), medial (-6.3 msec), and apical (-4.5 msec) slices. Precision was lower for cMRF-the average of the standard deviation measured within each slice was 102 msec for cMRF vs. 61 msec for MOLLI T₁ , and 6.4 msec for cMRF vs. 4.0 msec for bSSFP T₂ . cMRF and conventional techniques had similar test-retest repeatability as quantified by ICC (0.87 cMRF vs. 0.84 MOLLI for T₁ ; 0.85 cMRF vs. 0.85 bSSFP for T₂ ). In the ordinal image quality comparison, cMRF maps scored higher than conventional sequences for both T₁ (all five features) and T₂ (four features).

DATA CONCLUSION

This work reports on myocardial T₁ /T₂ measurements in healthy subjects using cMRF and standard mapping sequences. cMRF had slightly lower precision, similar test-retest and intrareader repeatability, and higher scores for map quality.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1 J. Magn. Reson. Imaging 2020;52:1044-1052.

Evidence for using PRN pharmacotherapy to treat undifferentiated acute agitation or aggression

BACKGROUND

This systematic review identified published studies that evaluated the use of pro re nata (PRN) medication in patients with acute agitation or aggression of undifferentiated etiology.

METHODS

A literature search was conducted of PubMed and MEDLINE for randomized controlled trials (RCTs) that evaluated the use of PRN medications for individuals with undifferentiated agitation or aggression. Bibliographic databases of published articles were also searched for additional studies.

RESULTS

A total of 15 studies were identified that assessed the effects of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), benzodiazepines, and combination therapies. All RCTs showed variable degrees of sedation and decreased agitation over time with the use of these medications, as well as variable levels of adverse events.

CONCLUSIONS

Evidence exists to support the use of specific SGAs as firstline PRN medications in the management of acutely agitated individuals. While evidence exists to support the use of FGAs, benzodiazepines, and combination therapy, efficacy is similar for each class, and SGAs appear to have the most favorable adverse effect profile.

Large eddy simulation of powered Fontan hemodynamics

Children born with univentricular heart disease typically must undergo three open heart surgeries within the first 2-3 years of life to eventually establish the Fontan circulation. In that case the single working ventricle pumps oxygenated blood to the body and blood returns to the lungs flowing passively through the Total Cavopulmonary Connection (TCPC) rather than being actively pumped by a subpulmonary ventricle. The TCPC is a direct surgical connection between the superior and inferior vena cava and the left and right pulmonary arteries. We have postulated that a mechanical pump inserted into this circulation providing a 3-5 mmHg pressure augmentation will reestablish bi-ventricular physiology serving as a bridge-to-recovery, bridge-to-transplant or destination therapy as a "biventricular Fontan" circulation. The Viscous Impeller Pump (VIP) has been proposed by our group as such an assist device. It is situated in the center of the 4-way TCPC intersection and spins pulling blood from the vena cavae and pushing it into the pulmonary arteries. We hypothesized that Large Eddy Simulation (LES) using high-order numerical methods are needed to capture unsteady powered and unpowered Fontan hemodynamics. Inclusion of a mechanical pump into the CFD further complicates matters due to the need to account for rotating machinery. In this study, we focus on predictions from an in-house high-order LES code (WenoHemo(TM)) for unpowered and VIP-powered idealized TCPC hemodynamics with quantitative comparisons to Stereoscopic Particle Imaging Velocimetry (SPIV) measurements. Results are presented for both instantaneous flow structures and statistical data. Simulations show good qualitative and quantitative agreement with measured data.

Insulin increases H2O2-induced pancreatic beta cell death

Insulin resistance results, in part, from impaired insulin signaling in insulin target tissues. Consequently, increased levels of insulin are necessary to control plasma glucose levels. The effects of elevated insulin levels on pancreatic beta (β) cell function, however, are unclear. In this study, we investigated the possibility that insulin may influence survival of pancreatic β cells. Studies were conducted on RINm, RINm5F and Min-6 pancreatic β-cells. Cell death was induced by treatment with H(2)O(2), and was estimated by measurements of LDH levels, viability assay (Cell-Titer Blue), propidium iodide staining and FACS analysis, and mitochondrial membrane potential (JC-1). In addition, levels of cleaved caspase-3 and caspase activity were determined. Treatment with H(2)O(2) increased cell death; this effect was increased by simultaneous treatment of cells with insulin. Insulin treatment alone caused a slight increase in cell death. Inhibition of caspase-3 reduced the effect of insulin to increase H(2)O(2)-induced cell death. Insulin increased ROS production by pancreatic β cells and increased the effect of H(2)O(2). These effects were increased by inhibition of IR signaling, indicative of an effect independent of the IR cascade. We conclude that elevated levels of insulin may act to exacerbate cell death induced by H(2)O(2) and, perhaps, other inducers of apoptosis.

Expression levels of total IGF-1R and sensitivity of NSCLC cells in vitro to an anti-IGF-1R antibody (R1507)

8095

Background: The IGF-1R (IGF receptor type 1) pathway is frequently deregulated in human tumors and has become a target of interest for anti-cancer therapy. We investigated predictive biomarkers of response to an anti-IGF-1R antibody (Ab) in vitro in NSCLC. Methods: We examined the growth inhibitory effects of R1507, a fully-humanized IgG1 anti-IGF-1R monoclonal Ab (Roche), against a panel of 22 NSCLC cell lines using CellTiter Blue assays. Phospho-receptor tyrosine kinase (pRTK) arrays and ELISAs were used to determine the status of IGF-1R and other RTKs. SNP arrays were used to determine IGF-1R copy number. Immunohistochemical (IHC) staining of total IGF-1R was performed with G11 (an anti-total IGF-1R Ab; Ventana) on a tissue microarray (TMA) containing 77 independent NSCLC tumor samples. Staining intensity was scored on a scale of 0 to 3+ by a pathologist (JF). Results: 5 of 22 NSCLC cell lines were moderately sensitive (25–50% growth inhibition) to R1507 alone. ELISA and pRTK array analysis demonstrated that pIGF-1R levels in the presence or absence of serum did not correlate with drug sensitivity. However, 4 of 5 sensitive lines displayed high levels of total IGF-1R vs 1/17 resistant lines (p=0.003 Fisher's Exact). SNP array analysis showed that sensitive lines also harbor relatively higher copy numbers of IGF-1R. There was no correlation with EGFR/KRAS mutational status. 48% of TMA NSCLC tumors had scores of 2+ or greater, while 5% were scored as 3+. Addition of erlotinib or paclitaxel to R1507 led to further growth inhibition in sensitive but not resistant lines. In one EGFR mutant lung adenocarcinoma cell line, R1507 and erlotinib co-treatment induced apoptosis, whereas treatment with either drug alone induced only cell cycle arrest. Apoptosis was mediated, in part, by the survival-related AKT pathway, as pAKT was significantly downregulated by R1507 but not erlotinib. Conclusions: In NSCLC cell lines, high levels of total IGF-1R are associated with moderate sensitivity to R1507. These results suggest a possible enrichment strategy for clinical trials with anti-IGF-1R therapy.

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A phase I study of vorinostat (suberoylanilide hydroxamic acid) in combination with 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) in patients with advanced colorectal cancer (CRC)

4088

Background: At 5μM, vorinostat decreases thymidilate synthase (TS) expression by ∼ 40 fold, which translates into synergistic antitumor activity when added to 5-FU. We conducted a phase I study of vorinostat plus FOLFOX in patients with CRC to determine the recommended dose of this combination. Methods: Vorinostat was escalated in a standard 3+3 design with a planned expansion of the maximum tolerated dose (MTD) cohort to 10 patients (pts). Vorinostat (100mg, 200mg, 300mg, 400 mg dose levels) was given twice daily for 1 week followed by 1 week break. FOLFOX was administered at a fixed standard dose every 2 weeks on the 4th day of vorinostat. Tumor biopsies were obtained from liver metastases before and on the 4th day of vorinostat (prior to FOLFOX) to assess TS expression. Results: 19 pts were treated on study (M/F: 12/7; median age: 58; ECOG 0/1: 6/13). All pts had failed prior FOLFOX therapy. Dose-limiting toxicities (DLT) were noted in 3 pts: 2/4 pts at dose level (DL)4 (vorinostat 400mg BID) consisting of grade (G) 3 fatigue, & diarrhea in 1 pt and G3 fatigue in the other; 1/8 pts at DL3 (MTD, vorinostat 300mg BID) consisting of G3 fatigue, anorexia, nausea, and dehydration. 8 pts have been treated at the MTD for a total of 38 cycles. “All Cycles” G3–4 toxicities at the MTD consisted of 2 pts with G3 neutropenia and 2 pts with G3 thrombocytopenia along with the above described DLT. Responses were evaluable in 17 pts: 0 Objective Response, 8 Stable Disease (4 confirmed). TS expression by IHC and by RT-PCR showed modest decreases in 2/6 patients after vorinostat treatment. Cmax of SAHA was < 2μM at all investigated DL, which could explain the lack of adequate TS down-regulation. Conclusions: vorinostat 300mg PO BID × 1 week every 2 weeks in combination with FOLFOX is the established recommended dose. The lack of significant TS down-regulation may be due to the suboptimal serum vorinostat concentrations. Alternate shorter vorinostat schedules may allow for further daily dose escalations and hence for better likelihood of TS down-regulation. This study was partly supported by CTEP, NCI.

No significant financial relationships to disclose.

Diet in childhood and adult cardiovascular and all cause mortality: the Boyd Orr cohort

OBJECTIVE

To examine the association between childhood diet and cardiovascular mortality.

DESIGN

Historical cohort study.

SETTING

16 centres in England and Scotland.

PARTICIPANTS

4028 people (from 1234 families) who took part in Boyd Orr's survey of family diet and health in Britain between 1937 and 1939 followed up through the National Health Service central register. EXPOSURES STUDIED: Childhood intake of fruit, vegetables, fish, oily fish, total fat, saturated fat, carotene, vitamin C, and vitamin E estimated from household dietary intake.

MAIN OUTCOME MEASURES

Deaths from all causes and deaths attributed to coronary heart disease and stroke.

RESULTS

Higher childhood intake of vegetables was associated with lower risk of stroke. After controlling for age, sex, energy intake, and a range of socioeconomic and other confounders the rate ratio between the highest and lowest quartiles of intake was 0.40 (95% confidence interval 0.19 to 0.83, p for trend 0.01). Higher intake of fish was associated with higher risk of stroke. The fully adjusted rate ratio between the highest and lowest quartile of fish intake was 2.01 (95% confidence interval 1.09 to 3.69, p for trend 0.01). Intake of any of the foods and constituents considered was not associated with coronary mortality.

CONCLUSIONS

Aspects of childhood diet, but not antioxidant intake, may affect adult cardiovascular risk.

Socio-economic inequalities in diabetes complications, control, attitudes and health service use: a cross-sectional study

AIMS

To investigate socio-economic inequalities in diabetes complications, and to examine factors that may explain these differences.

METHODS

Cross-sectional questionnaire survey of 770 individuals with diabetes among 40 general practices in Avon and Somerset. General practice, optometrist and eye hospital records over time (median 7 years) were analysed. Slope indices of inequality, odds ratios and incidence rate ratios were calculated to estimate the magnitude of inequality between the most and least educated, and the highest and lowest earning patients, adjusted for age, sex and type of diabetes, and clustering of outcomes within practices.

RESULTS

The least educated patients were more likely than the most educated patients to have diabetic retinopathy [adjusted odds ratio (OR) 4.3; 95% confidence interval 0.8, 23.7] and heart disease (adjusted OR 3.6; 1.1, 11.8), had higher HbA1c levels (adjusted slope index of inequality 0.9; 0.3, 1.5), felt that diabetes more adversely affected their social and personal lives (adjusted slope index of inequality 0.8; 0.5, 1.1 Diabetes Care Profile units), were more likely to be recorded as non-compliant by their health professionals, and had lower rates of hospital attendance (adjusted rate ratio 0.43; 0.26, 0.71). However, they did not see themselves as less compliant, and had higher general practice attendance rates (adjusted rate ratio 1.5; 1.1, 2.2).

CONCLUSIONS

Less educated and lower earning individuals with diabetes bear a larger burden of morbidity but use hospital care less. Health service resource allocation should reflect the distribution of chronic illness.

Population requirement for primary knee replacement surgery: a cross-sectional study

OBJECTIVES

To determine the population requirement for total knee replacement (TKR) in England.

METHODS

Population-based study using an age/sex-stratified random sample of 28 080 individuals aged 35 yr and over. Incident disease was estimated from prevalence by statistical modelling. The New Zealand priority criteria for major joint replacement were used for case selection.

RESULTS

Patients with knee disease were less likely than those with equally severe hip disease to have been referred to a specialist, to have consulted an orthopaedic surgeon or to be on a waiting list for joint replacement. The estimated annual requirement of TKRs in England, based on New Zealand Scores alone, was 55,800 (95% CI 40 700-70,900), contrasting sharply with an annual provision of 29,300 actually observed. However, in contrast to previously reported hip replacement data, when patient willingness to undergo surgery was considered, this estimate decreased considerably.

CONCLUSIONS

There appears to be an underprovision of TKR in England. This may be due in part to differences in perception of disease severity and likely response to surgery between patients and general practitioners on one hand, and rheumatologists and orthopaedic surgeons on the other.

Recent trends in the use of radical prostatectomy in England: the epidemiology of diffusion

OBJECTIVE

To describe recent trends in the use of radical prostatectomy (RP) in England, as there is currently no consensus on the most effective treatment for localized prostate cancer, although RP is the treatment of choice among urological surgeons for men aged < 70 years.

METHODS

Routine data were assessed to establish the number of RPs performed in England in 1991-99. Age-standardized operation rates were compared by region and socio-economic group, and the geographical spread of use mapped.

RESULTS

The number of RPs performed annually increased nearly 20-fold between 1991 and 1999. Rates of surgery were greatest in the London National Health Service (NHS) regions and lowest in the Trent region. Outside London, the risk of surgery in a NHS hospital was significantly greater for men living in the least deprived areas; in London this trend was reversed.

CONCLUSION

Rapid increases in the use of RP showed marked regional variations, most likely related to access to prostate-specific antigen testing and the location of surgeons able to carry out radical surgery. By 1999, a third of procedures were still being undertaken in 'low-volume' hospitals, with implications for the quality of care and outcomes. Crucially, these developments occurred in the absence of robust information about the effectiveness of RP. Recent funding of a randomized trial of treatment options in this area is welcome, but wider questions remain about the timing of the evaluation of surgical technologies.

Fruit, vegetables, and antioxidants in childhood and risk of adult cancer: the Boyd Orr cohort

STUDY OBJECTIVE

To examine associations between food and nutrient intake, measured in childhood, and adult cancer in a cohort with over 60 years follow up.

DESIGN AND SETTING

The study is based on the Boyd Orr cohort. Intake of fruit and vegetables, energy, vitamins C and E, carotene, and retinol was assessed from seven day household food inventories carried out during a study of family diet and health in 16 rural and urban areas of England and Scotland in 1937-39.

PARTICIPANTS

4999 men and women, from largely working class backgrounds, who had been children in the households participating in the pre-war survey. Analyses are based on 3878 traced subjects with full data on diet and social circumstances.

MAIN RESULTS

Over the follow up period there were 483 incident malignant neoplasms. Increased childhood fruit intake was associated with reduced risk of incident cancer. In fully adjusted logistic regression models, odds ratios (95% confidence intervals) with increasing quartiles of fruit consumption were 1.0 (reference), 0.66 (0.48 to 0.90), 0.70 (0.51 to 0.97), 0.62 (0.43 to 0.90); p value for linear trend=0.02. The association was weaker for cancer mortality. There was no clear pattern of association between the other dietary factors and total cancer risk.

CONCLUSIONS

Childhood fruit consumption may have a long term protective effect on cancer risk in adults. Further prospective studies, with individual measures of diet are required to further elucidate these relations.

Treatment of relapsed or refractory acute myeloid leukemia with humanized anti-CD33 monoclonal antibody HuM195

HuM195 is a humanized, unconjugated, anti-CD33 monoclonal antibody. Fifty adult patients with relapsed or refractory AML were randomized to receive HuM195 at a dose of 12 or 36 mg/m(2) by intravenous infusion over 4 h on days 1-4 and 15-18. Patients with stable or responding disease received two additional cycles on days 29-32 and 43-46. HuM195 was given as first salvage therapy in 24 patients and as second or subsequent salvage therapy in 26 patients. Pretreatment blast percentage in the marrow was between 5 and 30% in 20 patients with the others having blast counts greater than 30%. The median age of patients was 62 years (range 26-86) and CD33 was detected in 95% of patients for whom immunophenotyping was available. Of 49 evaluable patients, two complete and one partial remission were observed. All three responses were in patients treated at the 12 mg/m(2) dose level and all had baseline blast percentages less than 30%. Decreases in blast counts ranging from 30 to 74% were seen in nine additional patients. Infusion-related events of fever and chills occurred in the majority of patients and were generally mild and primarily related to the first dose of antibody. No hepatic, renal or cardiac toxicities were observed and other adverse events such as nausea, vomiting, mucositis and diarrhea were uncommon or felt to be unrelated to HuM195. In addition, anti-HuM195 responses were not detected. HuM195 as a single agent has minimal, but observable, anti-leukemic activity in patients with relapsed or refractory AML and activity is confined to patients with low burden disease. No significant differences in clinical efficacy or toxicity were seen between the two dose levels of antibody. HuM195 was well tolerated with infusion-related fevers and chills the predominant toxicities seen. Meaningful clinical efficacy of this unconjugated monoclonal antibody may be realized only in patients with minimal residual disease, or in combination with chemotherapy.

Randomized, multicenter, open-label study of pegfilgrastim compared with daily filgrastim after chemotherapy for lymphoma

PURPOSE

The primary objective was to assess the duration of grade 4 neutropenia (neutrophil count < 0.5 x 10(9)/L) after one cycle of chemotherapy with etoposide, methylprednisolone, cisplatin, and cytarabine in patients randomly assigned to receive one dose of pegfilgrastim or daily filgrastim after chemotherapy. Febrile neutropenia, neutrophil profiles, time to neutrophil recovery, pharmacokinetics, and safety were also assessed.

PATIENTS AND METHODS

An open-label, randomized, phase II study was designed to compare the effects of a single subcutaneous injection of pegfilgrastim (sustained-duration filgrastim) 100 micro g/kg per chemotherapy cycle (n = 33) with daily subcutaneous injections of filgrastim 5 micro g/kg (n = 33) in patients receiving salvage chemotherapy for relapsed or refractory Hodgkin's or non-Hodgkin's lymphoma.

RESULTS

The incidence of grade 4 neutropenia in the pegfilgrastim and filgrastim groups was 69% and 68%, respectively. In addition, the mean duration of grade 4 neutropenia was similar in both groups (2.8 and 2.4 days, respectively). The results for the two groups were also not significantly different for febrile neutropenia, neutrophil profile, time to neutrophil recovery, or toxicity profile. A single subcutaneous injection of pegfilgrastim 100 micro g/kg produced a sustained serum concentration relative to daily subcutaneous injections of filgrastim. Filgrastim-treated patients received a median of 11 injections per cycle.

CONCLUSION

Pegfilgrastim was safe and well tolerated in this patient population. A single injection of pegfilgrastim per chemotherapy cycle provided neutrophil support with safety and efficacy similar to that provided by daily injections of filgrastim. Once-per-cycle administration of pegfilgrastim simplifies the management of neutropenia and may have important clinical benefits for patients and healthcare providers.

Population need for coronary revascularisation: are national targets for England credible?

OBJECTIVE

To estimate the need for coronary revascularisation, by using an incidence of indications approach, among 45-84 year olds with stable angina, unstable angina, and acute myocardial infarction.

DESIGN

Modelling exercise. Six key steps along the pathway of care from initial diagnosis in primary or secondary care to revascularisation were defined and the frequency of indications estimated using routine data from hospital admissions and data from studies in the general population, and primary and secondary care.

SETTING AND PATIENTS

Mid-1998 population of England.

INTERVENTION

Coronary revascularisation.

MAIN OUTCOME MEASURE

Ability to benefit (need), defined by randomised trials, expert panel ratings from the ACRE (appropriateness of coronary revascularisation) study, or by informal consensus.

RESULTS

The need for coronary revascularisation was estimated to be 92 000 procedures, equivalent to a rate of 1861 per million population. Overall, the model of need exceeded current provision by 3.3:1, although among people aged 75 years and over the ratio was 7.7:1. A plausible upper estimate of need--obtained by assuming that 90% of patients with stable angina were referred from primary care and that angiography would be performed in 65% of patients with acute myocardial infarction and 75% of patients with unstable angina--was 2626 per million population.

CONCLUSIONS

The national target of 1500 revascularisation procedures per million population is credibly related to population need, although upper estimates of need are considerably higher. Better understanding is required of the benefits of referring patients with specific indications from primary care. The greatest relative increase in provision is required for those aged 75 and older, among whom trial evidence of benefit is scant.

Association between breast feeding and growth: the Boyd-Orr cohort study

OBJECTIVE

To investigate the association of breast feeding with height and body mass index in childhood and adulthood.

DESIGN

Historical cohort study, based on long term follow up of the Carnegie (Boyd-Orr) survey of diet and health in pre-war Britain (1937-1939).

SETTING

Sixteen urban and rural districts in Britain.

SUBJECTS

A total of 4999 children from 1352 families were surveyed in 1937-1939. Information on infant feeding and childhood anthropometry was available for 2995 subjects.

MAIN OUTCOME MEASURES

Mean differences in childhood and adult anthropometry between breast and bottle fed subjects.

RESULTS

Breast feeding was associated with the survey district, greater household income, and food expenditure, but not with number of children in the household, birth order, or social class. In childhood, breast fed subjects were significantly taller than bottle fed subjects after controlling for socioeconomic variables. The mean height difference among boys was 0.20 standard deviation (SD) (95% confidence interval (CI) 0.07 to 0.32), and among girls it was 0.14 SD (95% CI 0.02 to 0.27). Leg length, but not trunk length, was the component of height associated with breast feeding. In males, breast feeding was associated with greater adult height (difference: 0.34 SD, 95% CI 0.13 to 0.55); of the two components of height, leg length (0.26 SD, 95% CI 0.02 to 0.50) was more strongly related to breast feeding than trunk length (0.16 SD, 95% CI -0.04 to 0.35). Height and leg length differences were in the same direction but smaller among adult females. There was no association between breast feeding and body mass index in childhood or adulthood.

CONCLUSIONS

Compared with bottle fed infants, infants breast fed in the 1920s and 1930s were taller in childhood and adulthood. As stature is associated with health and life expectancy, the possible long term impact of infant feeding on adult mortality patterns merits further investigation.

Caring for the health of the public: cross sectional study of the activities of UK public health departments

The relative time spent in different areas of work in public health departments in the UK was assessed by means of a postal questionnaire. Departments spend one third of their time on population health work, this being similar to the amount of time spent on planning health services. Having a planning department in the health authority did not affect the amount of time spent in any area of work. Having a greater number of consultants in the department was associated with a tendency to spend more time on population health and being involved in training was associated with spending less time on planning. Public health departments in the UK are the only part of the health service with responsibility for the broader aspects of public health. Whilst the tensions between medical care and the wider influences upon population health may represent a false dichotomy, public health professionals must maintain a central focus of their work on the wider influences upon population health if balance is to be maintained within the National Health Service.

Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study

OBJECTIVE

To examine the relation between frequency of sexual intercourse and risk of ischaemic stroke and coronary heart disease.

DESIGN

Cohort study with 20 year follow up.

SETTING

The town of Caerphilly, South Wales and five adjacent villages.

SUBJECTS

914 men aged 45-59 years at time of recruitment in 1979 to 1983.

MAIN OUTCOME MEASURES

Ischaemic stroke and coronary heart disease, all first events and fatal events.

RESULTS

Of the 914 men studied, 197 (21.5%) reported sexual intercourse less often than once a month, 231 (25.3%) reported sexual intercourse twice or more a week, and the remaining 486 (53.2%) men fell into the intermediate category. Frequency of sexual intercourse was not associated with all first ischaemic stroke events: age adjusted odds ratios (95% CI) for intermediate and low frequency of sexual intercourse of 0.61 (0.32 to 1.16) and 0.71 (0.34 to 1.49) respectively compared with the reference category of high frequency. A graded relation with fatal coronary heart disease events was observed in events recorded up to 10 years. The age adjusted relative risk (95% CI) of fatal coronary heart disease contrasting low frequency of sexual intercourse (that is, less than monthly) with the highest group (at least twice a week) was 2.80 (1.13 to 6.96, test for trend, p=0.04) which was not attenuated by adjustment for a wide range of potential confounders. Longer follow up to 20 years showed attenuation of this risk with odds of 1.69 (95% CI 0.90 to 3.20), contrasting low frequency of sexual intercourse with the highest group.

CONCLUSIONS

The differential relation between frequency of sexual intercourse, stroke and coronary heart disease suggests that confounding is an unlikely explanation for the observed association with fatal coronary heart disease events. Middle aged men should be heartened to know that frequent sexual intercourse is not likely to result in a substantial increase in risk of strokes, and that some protection from fatal coronary events may be an added bonus.

The population requirement for cataract extraction: a cross-sectional study

PURPOSE

To examine the distribution in the population of indications for cataract extraction in order to relate demand for this procedure to the capacity for satisfying it.

METHODS

An age-stratified random population sample of 2783 individuals aged 55 years and over was taken from inner-city, urban and rural areas of Avon and Somerset. The requirement for cataract extraction was estimated on the basis of measures of vision-related quality of life, refracted visual acuity, and application of the Oxford Clinical Cataract Classification and Grading System. Data were also collected concerning suitability for surgery, including relative contraindications to surgery and whether participants considered their eyesight bad enough to merit surgery. Three sets of composite indications were defined.

RESULTS

Estimated prevalent requirements for cataract extraction for the three sets of composite criteria were: 29 per 1000 aged over 55 years (95% CI 20-41) for the most inclusive criterion; 17 per thousand (95% CI 10-27) for the intermediate criterion; and 7 per thousand (95% CI 3-14) for the most stringent criterion. These rates are equivalent to a national prevalent requirement for England of 384,000 for the most inclusive criterion. If the approximately 15% of individuals whose desire or fitness for surgery was questionable are removed from this estimate, the prevalent requirement, including the backlog from previous unsatisfied demand, becomes 325,000 individuals.

CONCLUSIONS

The findings suggest only a modest imbalance between supply and demand for cataract surgery. In particular there was a very small prevalence of untreated severe cataract, less than the annual health service surgical capacity, suggesting that the current National Health Service surgical capacity is adequate for cases of severe cataract.

Vision-related quality of life impairment in an elderly UK population: associations with age, sex, social class and material deprivation

PURPOSE

To describe the prevalence of vision-related quality of life (VR-QOL) impairment in an elderly UK population sample.

METHOD

The survey, using the VCM1 questionnaire, was based on an age- and sex-stratified random population sample of 2783 individuals aged 55 years or over.

RESULTS

One thousand eight hundred and forty-six (69.7%) of 2647 eligible subjects responded. One thousand six hundred and eighty-three individuals completed all 10 VCM1 items. Overall the prevalence of a VCM1 score >2.0 ('more than a little' concern about vision) was 4.6% (95% CI = 3.7% to 5.7%), leading to an estimate of more than 550,000 individuals in England with substantial VR-QOL impairment. The prevalence increased with age from 2.1% in the 55-64 year age group to 17.9% in the group aged 85 years and older. The prevalence also increased as social class became lower, from 0 in social class I to 10.2% in social class V, and increased with increasing material deprivation, from 1.2% in the most affluent quintile to 6.8% in the most deprived quintile. Multivariable logistic regression analysis showed that age (p = 0.0001), decreasing social class (p = 0.03) and increasing material deprivation (p = 0.008) were independently associated with VR-QOL impairment (VCM1 score >2.0), whilst gender and means of questionnaire administration were not associated with VR-QOL impairment at the 5% level.

CONCLUSIONS

The findings suggest a substantial national prevalence of VR-QOL impairment, and are consistent with earlier studies linking ocular disease with social deprivation. Consideration should be given to directing resources more carefully towards groups at higher risk of VR-QOL impairment, in particular the very elderly and socially deprived.

Secular trends in antidepressant prescribing in the UK, 1975-1998

BACKGROUND

We have examined secular trends in age- and sex-specific prescribing of antidepressants to determine whether these mirror changes in other population measures of mental health.

METHOD

An analysis was carried out of age- and sex-specific rates of antidepressant prescribing by a representative sample or panel of UK general practitioners (GPs) in the period 1975-1998.

RESULTS

The number of antidepressant prescriptions issued increased more than twofold in the period 1975-1998 and, in 1998, a total of 23.4 million antidepressant prescriptions were issued by GPs in the United Kingdom. Rates of antidepressant prescribing increased markedly in all age and sex groups with as much as a threefold increase in the older age groups. With the exception of 12-19-year-olds, these increases have been more marked in males, although absolute levels of prescribing are still at least two times higher in females.

CONCLUSIONS

Antidepressant prescribing has increased in all age and sex groups. This indicates either that there have been changes in the presentation, recognition and management of depression in general practice or that the prevalence of depression has increased, or a combination of these two phenomena. The higher prescribing rate in females is in keeping with evidence from psychiatric morbidity surveys suggesting that women experience higher levels of psychiatric morbidity than men. Decreases in the ratio of female to male prescribing, however, support other data indicating that, relative to females, the mental health of young males has declined in recent years. Changes in patterns of help-seeking may also contribute to the observed trends.

Hydroxychloroquine for the treatment of chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is a major complication of allogeneic bone marrow transplantation. Both the disease and the medications used to treat it are associated with significant morbidity and mortality. The manifestations of chronic GVHD often resemble those of autoimmune disorders. Hydroxychloroquine (HCQ) is a 4-aminoquinoline antimalarial drug used for the treatment of autoimmune diseases. HCQ interferes with antigen processing and presentation, cytokine production, and cytotoxicity and is synergistic with cyclosporine and tacrolimus in vitro. Forty patients with steroid-resistant or steroid-dependent chronic GVHD were enrolled in a phase 2 trial of HCQ 800 mg (12 mg/kg) per day. Three complete responses and 14 partial responses were seen in 32 evaluable patients (53% response rate). All responders tolerated a >50% reduction in their steroid dose while receiving HCQ. Clinical response occurred at a median of 8 weeks (range, 4 to 24 weeks). No hematologic, hepatic, renal, or retinal toxicity was associated with HCQ. In light of its mechanisms of action, clinical activity for GVHD, and low toxicity profile, HCQ may be useful in a multiagent approach for the treatment of extensive chronic GVHD.

Childhood housing conditions and later mortality in the Boyd Orr cohort

STUDY OBJECTIVES

To examine associations between five measures of housing conditions during childhood and subsequent mortality from all causes, coronary heart disease, stroke, and cancer.

DESIGN

Historical cohort study.

SETTING

Data on housing conditions were collected from survey centres in 16 areas of England and Scotland.

PARTICIPANTS

Children of families participating in the Carnegie Survey of Family Diet and Health in pre-war Britain (1937-1939). Analyses are based on a subset of 4168 people who were traced and alive on 1 January 1948.

MAIN RESULTS

Poorer housing conditions were generally associated with increased adult mortality. After adjustment for childhood and adult socioeconomic factors, statistically significant associations were only found between lack of private indoor tapped water supply and increased mortality from coronary heart disease (hazard ratio 1.73, (95% CI 1.13, 2.64); and between poor ventilation and overall mortality (hazard ratio for people from households with poorest ventilation relative to best ventilation 1.30, 95% CI 0.97, 1.74).

CONCLUSIONS

This study provides evidence that associations between housing conditions in childhood and mortality from common diseases in adulthood are not strong, but are in some respects distinguishable from those of social deprivation.

The incidence and aetiology of stroke in the Caerphilly and Speedwell Collaborative Studies I: methods and incidence of events

Stroke mortality and morbidity remain high despite downward trends in incidence and case fatality. Population-based longitudinal studies which include collection of risk factor data are required for a better understanding of stroke aetiology. From a representative cohort of men from South Wales and South-west England, followed up for a median of 17 y, details of possible cerebrovascular events were collected from questionnaires, hospital admission data, general practitioner records, death certificates, radiology records and post-mortem reports. Radiology records, and strokes and transient ischaemic attacks were independently validated. There were 433 strokes and 163 transient ischaemic attacks identified during follow-up. Of these, 333 were the first ever in a lifetime strokes of which 139 were definite ischaemic, 20 were haemorrhagic and 168 were probable ischaemic strokes. The crude incidence rate for stroke was 445 (95% confidence interval 398-493) per 100 000 person years. The age-standardised rates for 10 y age-bands were: 45-54 y 91 (10-172); 55-64 y 351 (269-432) and 65-74 y 855 (669-1040). The 30 d case-fatality rate was 21.0% (70/333) for all strokes and 19.2% (60/312) for ischaemic strokes. For transient ischaemic attacks the age-standardised incidence rates for the same 10 y age bands were 92 (4-179), 111 (64-157), and 273 (167-80), respectively. These rates for stroke transient ischaemic attack are likely to be accurate given the high ascertainment of events in this representative population of middle-aged men. Such studies, reporting reliable measures of cerebrovascular events, are important for measuring burden of disease, and for analysis of risk factor associations to help improve understanding of stroke aetiology and inform preventive efforts.

The incidence and aetiology of stroke in the Caerphilly and Speedwell Collaborative Studies II: risk factors for ischaemic stroke

Reduction of stroke burden requires preventive interventions targeted at important risk factors. This report presents the analysis of risk factors for ischaemic stroke from a representative cohort of middle aged men from South Wales and south-west England. Data on risk factors were collected through validated questionnaires and physical and clinical measurements. Details of possible cerebrovascular events were retrieved, classified into ischaemic, haemorrhagic and uncertain subtypes, and validated. The ratio of definite ischaemic to definite haemorrhagic strokes was calculated. This showed that the vast majority of strokes of unknown subtype were likely to ischaemic. After exclusion of known haemorrhagic strokes and subarrachnoid haemorrhages the remaining strokes were labelled ischaemic. Hazard ratios for possible risk factors were calculated for all ischaemic, and for fatal and non-fatal strokes. There were 293 ischaemic strokes. Statistically significant age-adjusted hazard ratios were: 1.50 (95% confidence interval 1.16-1.95) for being in a manual social class, 1.82 (1.24-2.67) if smoking >15 cigarettes/d at enrollment, 1.19 (1.13-1.24) and 1.23 (1.14-1.34) per 10 mmHg increase in systolic and diastolic blood pressure, respectively, 0.67 (0.46-0.96) for the top quintile high density lipoprotein-cholesterol:cholesterol ratio compared to the bottom quintile, 2.04 (1.40-2.99) for presence of angina, 3.90 (2.01-7.58) for presence of atrial fibrillation, and 3.35 (1.90-5.80) for presence of diabetes. Risk factors were more strongly associated with fatal than non-fatal strokes. Multivariate analyses revealed that, while there was some attenuation of the effect of social class, angina and elevated BP, the risks from atrial fibrillation and diabetes were increased.

Transcutaneous immunization: a human vaccine delivery strategy using a patch

Transcutaneous immunization, a topical vaccine application, combines the advantages of needle-free delivery while targeting the immunologically rich milieu of the skin. In animal studies, this simple technique induces robust systemic and mucosal antibodies against vaccine antigens. Here, we demonstrate safe application of a patch containing heat-labile enterotoxin (LT, derived from Escherichia coli) to humans, resulting in robust LT-antibody responses. These findings indicate that TCI is feasible for human immunization, and suggest that TCI may enhance efficacy as well as improve vaccine delivery.

Use of PEG-rHuMGDF in platelet engraftment after autologous stem cell transplantation

This paper summarizes a pilot, sequential dose-escalation study of PEG-rHuMGDF in patients with advanced malignancies who had delayed platelet recovery after autologous stem cell transplantation (ASCT). Patients were randomized to receive either placebo (n = 11) or PEG-rHuMGDF at 5 (n = 9), 10 (n = 6), or 25 (n = 7) microg/kg/day by subcutaneous injection for 14 days and were monitored for 5 weeks. Across all treatment groups, eight patients had platelet recovery to > or = 20 x 10(9)/l by day 21. The proportion of patients achieving platelet recovery, the median number of days and units of platelet transfusions were similar for the placebo and the PEG-rHuMGDF groups. PEG-rHuMGDF was well tolerated at all dosages. The incidence rates of adverse events in all groups were similar. No deaths on study, no drug-related serious adverse events, and no development of neutralizing antibodies to MGDF occurred.

Method availability and the prevention of suicide--a re-analysis of secular trends in England and Wales 1950-1975

BACKGROUND

In England and Wales in the 1960s there were marked declines in suicide rates. These reductions were partly attributable to the detoxification of the domestic gas supplies; however, their extent varied by age and gender, with the most striking effects seen in older men. The objective of this study was to investigate method-specific trends in suicide between 1950 and 1975 to elucidate possible explanations for the patterns seen in different demographic groups.

METHODS

An analysis of age-standardised method-specific suicide rates for England and Wales between 1950 and 1975 was carried out using routinely available mortality and population statistics.

RESULTS

As has previously been shown, there were marked reductions in suicides by gassing in men and women of all ages between 1960 and 1975. In women and younger men, the effects of these reductions on overall suicide rates were partially offset by rises in drug overdose deaths (method substitution), but there were no immediate increases in the use of other suicide methods. In contrast, in older men, reductions in suicide by gassing were accompanied by only a slight increase in overdose suicides as well as reductions in rates of suicide using all other methods. The modest rise in overdose fatalities in older men occurred despite the fact that they were more often prescribed barbiturates and tricyclic antidepressants than younger men.

CONCLUSIONS

Accessibility to and the lethality of particular methods of suicide may have profound effects on overall suicide rates. Such effects appear to depend upon the popularity of the method and the extent to which alternative methods that are acceptable to the individual are available. Social and psychological interpretations of fluctuations in suicide rates should only be made after assessing the possible contribution to these of changes in method availability and lethality.

Measures of Proscar, Hytrin, and Cardura side effects

The importance of reporting correlations among side effects is examined using studies of BPH drugs as examples. The special relation of placebo effects in studying side-effects of drugs, as opposed to their efficacies, is introduced, and the need for special new controls is presented.

How accurately are height, weight and leg length reported by the elderly, and how closely are they related to measurements recorded in childhood?

BACKGROUND

This paper examines (1) the accuracy of self-reported height, leg length and weight in a group of subjects aged 56-78; (2) whether recent measurement of height and weight influences the accuracy of self-reporting and (3) associations between childhood and adult height, leg length and BMI measured in old age.

METHODS

All 3182 surviving members of the Boyd Orr cohort were sent postal questionnaires in 1997-1998 and a sub-sample (294) was also clinically examined.

RESULTS

Self-reported height was overestimated and body mass index (BMI), based on reported height and weight, underestimated. The mean difference between self-report and measured values were for height: 2.1 cm in males and 1.7 cm in females; for BMI the difference was -1.3 kg/m(2) in males and -1.2 kg/m(2) in females. Shorter individuals and older subjects tended to over-report their height more than others. The overweight under-reported their weight to a greater extent. Recent measurement appeared to decrease over-reporting of height but not weight. Correlations between self-report and measured height and BMI were generally over 0.90, but weaker for leg length (r = 0.70 in males and 0.71 in females). Adult height and leg length were quite closely related to their relative values in childhood (correlation coefficients ranged from 0.66 to 0.84), but associations between adult and childhood BMI were weak (r = 0.19 in males and 0.21 in females).

CONCLUSIONS

Self-reported measures of height and weight may be used in studies of the elderly although systematic reporting errors may bias effect estimates. As overweight individuals tend to under-report and the short and underweight tend to over-report, studies investigating associations of disease with height and weight using self-reported measures will underestimate effects. The weak associations between childhood and adult BMI indicate that associations between childhood adiposity and adult cardiovascular disease found in this cohort may reflect the specific effect of childhood overweight, rather than its persistence into adulthood. This suggests that avoidance of adiposity may be as important in childhood as in adulthood.

The effects of dietary supplementation on growth and adult mortality: a re-analysis and follow-up of a pre-war study

The aim of this study was to re-analyse a diet supplementation study conducted in the 1930s and investigate the effects of food supplementation on children's growth and later adult mortality. A non-randomised controlled trial was carried out in eight of the sixteen centres participating in the Carnegie Survey of Diet and Health in pre-war Britain (1937-39). Food supplements were given for 12 months either at school or as food parcels sent to the family home. 545 children aged 2-14 received food supplements and 494 children of a similar age acted as their controls. The children came from 465 families. The increase in childhood height and its components-leg length and trunk length-over 12 months follow-up were measured. Mortality from all causes over 60 years follow-up to 1998 was also assessed. There were important differences between fed and control children at baseline. Supplemented children came from larger families with poorer diets and most were examined, on average, 12 days later than control children. After adjustment for baseline imbalances those receiving supplements increased in height by 3.7 mm (95% CI 1.9-5.5) more than the controls. After adjustment, most of the difference in growth appeared to arise as a result of increases in leg length. After adjustment for confounding factors measured in childhood, no significant effect of childhood food supplements on adult mortality was seen. The age-adjusted hazard ratio for all cause mortality was higher in the supplemented compared to control subjects: 1.13 95% CI (0.77-1.64). We found that provision of childhood food supplements led to increased growth amongst supplemented children. The increases in height in this study were mainly as a result of increases in leg length and are similar to those found in a more recent randomised trial in South Wales. Whilst other analyses suggest that childhood height is important in predicting adult mortality patterns, we found no significant effect of childhood food supplements on adult mortality patterns in this study, although the study lacked statistical power to detect small but, nevertheless, important differences in mortality. Larger randomised trials with long term follow-up would be required to investigate the impact of childhood food supplementation on adult health.

Childhood socioeconomic position and adult cardiovascular mortality: the Boyd Orr Cohort

The relation between childhood socioeconomic position and adult cardiovascular mortality is examined in 3,750 individuals whose families took part in the Carnegie survey of family diet and health in England and Scotland between 1937 and 1939. The trend in coronary heart disease mortality across social position groups was not statistically significant at conventional levels (p = 0.12), while a strong linear trend was seen for stroke mortality (p = 0.01). Adjustment for the Townsend deprivation index of area of residence during adult life did not materially alter these findings, indicating that the effects of socioeconomic influences upon particular cardiovascular diseases differ according to the age at which they are experienced.

Separating in-utero and postnatal influences on later disease

Associations of birthweight with leg length and trunk length are similar. Childhood exposures rather than in-utero programming may underlie specific associations seen between leg length and mortality.