Cannabis use and mental health in young people: cohort study

OBJECTIVE

To determine whether cannabis use in adolescence predisposes to higher rates of depression and anxiety in young adulthood.

DESIGN

Seven wave cohort study over six years.

SETTING

44 schools in the Australian state of Victoria.

PARTICIPANTS

A statewide secondary school sample of 1601 students aged 14-15 followed for seven years.

MAIN OUTCOME MEASURE

Interview measure of depression and anxiety (revised clinical interview schedule) at wave 7.

RESULTS

Some 60% of participants had used cannabis by the age of 20; 7% were daily users at that point. Daily use in young women was associated with an over fivefold increase in the odds of reporting a state of depression and anxiety after adjustment for intercurrent use of other substances (odds ratio 5.6, 95% confidence interval 2.6 to 12). Weekly or more frequent cannabis use in teenagers predicted an approximately twofold increase in risk for later depression and anxiety (1.9, 1.1 to 3.3) after adjustment for potential baseline confounders. In contrast, depression and anxiety in teenagers predicted neither later weekly nor daily cannabis use.

CONCLUSIONS

Frequent cannabis use in teenage girls predicts later depression and anxiety, with daily users carrying the highest risk. Given recent increasing levels of cannabis use, measures to reduce frequent and heavy recreational use seem warranted.

Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study

OBJECTIVES

To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital.

DESIGN

A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team.

SETTING

300 bed tertiary referral teaching hospital.

PARTICIPANTS

All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847).

INTERVENTIONS

Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria.

MAIN OUTCOME MEASURES

Incidence and outcome of unexpected cardiac arrest.

RESULTS

The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73).

CONCLUSIONS

In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.

EPPIC: an evolving system of early detection and optimal management

Early intervention at the onset of psychotic disorders is a highly attractive theoretical notion that is receiving increasing international interest. In practical terms, it amounts to first deciding when a psychotic disorder can be said to have commenced and then offering potentially effective treatment at the earliest possible point. A second element involves ensuring that this intervention constitutes best practice for this phase of illness and is not merely the translation of standard treatments developed for later stages and the more persistently ill subgroups of the disorder. Furthermore, it means ensuring that this best practice model is actually delivered to patients and families. The relative importance of these elements in relation to outcome has not yet been established. This article outlines a framework for preventive intervention in early psychosis, based on more than a decade of experience initially gained within a first-generation model. This experience has been followed, after a prolonged gestation, by the birth of the Early Psychosis Prevention and Intervention Centre (EPPIC), a comprehensive "real-world" model of care targeting the multiple clinical foci underpinning the preventive task. Data are reported to illustrate the topography and impact of delay in treatment in our regional setting, and the results of an initial evaluation of the EPPIC model are presented. The latter demonstrate a significant improvement in symptomatic and functional outcome when the second-generation model is contrasted with the first. The implications of these findings and future developments are discussed.

The epidemiology of dry eye in Melbourne, Australia

OBJECTIVE

To describe the epidemiology of dry eye in the adult population of Melbourne, Australia.

DESIGN

A cross-sectional prevalence study.

PARTICIPANTS

Participants were recruited by a household census from two of nine clusters of the Melbourne Visual Impairment Project, a population-based study of age-related eye disease in the 40 and older age group of Melbourne, Australia. Nine hundred and twenty-six (82.3% of eligible) people participated; 433 (46.8%) were male. They ranged in age from 40 to 97 years, with a mean of 59.2 years.

MAIN OUTCOME MEASURES

Self-reported symptoms of dry eye were elicited by an interviewer-administered questionnaire. Four objective assessments of dry eye were made: Schirmer's test, tear film breakup time, rose bengal staining, and fluorescein corneal staining. A standardized clinical slit-lamp examination was performed on all participants. Dry eye for the individual signs or symptoms was defined as: rose bengal > 3, Schirmers < 8, tear film breakup time < 8, > 1/3 fluorescein staining, and severe symptoms (3 on a scale of 0 to 3).

RESULTS

Dry eye was diagnosed as follows: 10.8% by rose bengal, 16.3% by Schirmer's test, 8.6% by tear film breakup time, 1.5% by fluorescein staining, 7.4% with two or more signs, and 5.5% with any severe symptom not attributed to hay fever. Women were more likely to report severe symptoms of dry eye (odds ratio [OR] = 1.85; 95% confidence limits [CL] = 1.01, 3.41). Risk factors for two or more signs of dry eye include age (OR = 1.04; 95% CL = 1.01, 1.06), and self-report of arthritis (OR = 3.27; 95% CL = 1.74, 6.17). These results were not changed after excluding the 21 people (2.27%) who wore contact lenses.

CONCLUSIONS

These are the first reported population-based data of dry eye in Australia. The prevalence of dry eye varies by sign and symptom.

Does bullying cause emotional problems? A prospective study of young teenagers

OBJECTIVES

To establish the relation between recurrent peer victimisation and onset of self reported symptoms of anxiety or depression in the early teen years.

DESIGN

Cohort study over two years.

SETTING

Secondary schools in Victoria, Australia.

PARTICIPANTS

2680 students surveyed twice in year 8 (aged 13 years) and once in year 9.

MAIN OUTCOME MEASURES

Self reported symptoms of anxiety or depression were assessed by using the computerised version of the revised clinical interview schedule. Incident cases were students scoring >/=12 in year 9 but not previously. Prior victimisation was defined as having been bullied at either or both survey times in year 8.

RESULTS

Prevalence of victimisation at the second survey point in year 8 was 51% (95% confidence interval 49% to 54%), and prevalence of self reported symptoms of anxiety or depression was 18% (16% to 20%). The incidence of self reported symptoms of anxiety or depression in year 9 (7%) was significantly associated with victimisation reported either once (odds ratio 1.94, 1.1 to 3.3) or twice (2.30, 1.2 to 4.3) in year 8. After adjustment for availability of social relations and for sociodemographic factors, recurrent victimisation remained predictive of self reported symptoms of anxiety or depression for girls (2.60, 1.2 to 5.5) but not for boys (1.36, 0.6 to 3.0). Newly reported victimisation in year 9 was not significantly associated with prior self report of symptoms of anxiety or depression (1.48, 0.4 to 6.0).

CONCLUSION

A history of victimisation and poor social relationships predicts the onset of emotional problems in adolescents. Previous recurrent emotional problems are not significantly related to future victimisation. These findings have implications for how seriously the occurrence of victimisation is treated and for the focus of interventions aimed at addressing mental health issues in adolescents.

Onset of adolescent eating disorders: population based cohort study over 3 years

OBJECTIVE

To study the predictors of new eating disorders in an adolescent cohort.

DESIGN

Cohort study over 3 years with six waves.

SUBJECTS

Students, initially aged 14-15 years, from 44 secondary schools in the state of Victoria, Australia.

OUTCOME MEASURES

Weight (kg), height (cm), dieting (adolescent dieting scale), psychiatric morbidity (revised clinical interview schedule), and eating disorder (branched eating disorders test). Eating disorder (partial syndrome) was defined when a subject met two criteria for either anorexia nervosa or bulimia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

RESULTS

At the start of the study, 3.3% (29/888) of female subjects and 0.3% (2/811) of male subjects had partial syndromes of eating disorders. The rate of development of new eating disorder per 1000 person years of observation was 21.8 in female subjects and 6.0 in male subjects. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder than those who did not diet, and female subjects who dieted at a moderate level were five times more likely to develop an eating disorder than those who did not diet. Psychiatric morbidity predicted the onset of eating disorder independently of dieting status so that those subjects in the highest morbidity category had an almost sevenfold increased risk of developing an eating disorder. After adjustment for earlier dieting and psychiatric morbidity, body mass index, extent of exercise, and sex were not predictive of new eating disorders.

CONCLUSIONS

Dieting is the most important predictor of new eating disorders. Differences in the incidence of eating disorders between sexes were largely accounted for by the high rates of earlier dieting and psychiatric morbidity in the female subjects. In adolescents, controlling weight by exercise rather than diet restriction seems to carry less risk of development of eating disorders.

The natural history of self-harm from adolescence to young adulthood: a population-based cohort study

BACKGROUND

Knowledge about the natural history of self-harm is scarce, especially during the transition from adolescence to young adulthood, a period characterised by a sharp rise in self-inflicted deaths. From a repeated measures cohort of a representative sample, we describe the course of self-harm from middle adolescence to young adulthood.

METHODS

A stratified, random sample of 1943 adolescents was recruited from 44 schools across the state of Victoria, Australia, between August, 1992, and January, 2008. We obtained data pertaining to self-harm from questionnaires and telephone interviews at seven waves of follow-up, commencing at mean age 15·9 years (SD 0·49) and ending at mean age 29·0 years (SD 0·59). Summary adolescent measures (waves three to six) were obtained for cannabis use, cigarette smoking, high-risk alcohol use, depression and anxiety, antisocial behaviour and parental separation or divorce.

FINDINGS

1802 participants responded in the adolescent phase, with 149 (8%) reporting self-harm, More girls (95/947 [10%]) than boys (54/855 [6%]) reported self-harm (risk ratio 1·6, 95% CI 1·2-2·2). We recorded a substantial reduction in the frequency of self-harm during late adolescence. 122 of 1652 (7%) participants who reported self-harm during adolescence reported no further self-harm in young adulthood, with a stronger continuity in girls (13/888) than boys (1/764). During adolescence, incident self-harm was independently associated with symptoms of depression and anxiety (HR 3·7, 95% CI 2·4-5·9), antisocial behaviour (1·9, 1·1-3·4), high-risk alcohol use (2·1, 1·2-3·7), cannabis use (2·4, 1·4-4·4), and cigarette smoking (1·8, 1·0-3·1). Adolescent symptoms of depression and anxiety were clearly associated with incident self-harm in young adulthood (5·9, 2·2-16).

INTERPRETATION

Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults.

FUNDING

National Health and Medical Research Council, Australia, and operational infrastructure support programme, Government of Victoria, Australia.

Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study

BACKGROUND

Australia introduced a human papillomavirus (HPV) vaccination programme with the quadrivalent HPV vaccine for all women aged 12-26 years between 2007 and 2009. We analysed trends in cervical abnormalities in women in Victoria, Australia, before and after introduction of the vaccination programme.

METHODS

With data from the Victorian Cervical Cytology Registry between 2003 and 2009, we compared the incidence of histopathologically defined high-grade cervical abnormalities (HGAs, lesions coded as cervical intraepithelial neoplasia of grade 2 or worse or adenocarcinoma in situ; primary outcome) and low-grade cytological abnormalities (LGAs) in five age groups before (Jan 1, 2003, to March 31, 2007) and after (April 1, 2007, to Dec 31, 2009) the vaccination programme began. Binary comparisons between the two periods were done with Fisher's exact test. Poisson piecewise regression analysis was used to compare incident rate trends.

FINDINGS

After the introduction of the vaccination programme, we recorded a decrease in the incidence of HGAs by 0·38% (95% CI 0·61-0·16) in girls younger than 18 years. This decrease was progressive and significantly different to the linear trend in incidence before introduction of the vaccination (incident rate ratio 1·14, 1·00-1·30, p=0·05). No similar temporal decline was recorded for LGAs or in older age groups.

INTERPRETATION

This is the first report of a decrease in incidence of HGAs within 3 years after the implementation of a population-wide HPV vaccination programme. Linkage between vaccination and screening registers is needed to confirm that this ecological observation is attributable to vaccination and to monitor participation in screening among vaccinated women.

FUNDING

None.

Depression, anxiety, and smoking initiation: a prospective study over 3 years

OBJECTIVES

This report considers the extent to which depression and anxiety predict smoking onset in adolescence.

METHODS

A 6-wave cohort design was used to study a sample of 14- and 15-year-old students (n = 2032) drawn from 44 secondary schools in the state of Victoria, Australia. The students were surveyed between 1992 and 1995 with a computerized questionnaire that included a 7-day retrospective diary for tobacco use and a structured psychiatric interview.

RESULTS

Experimental smokers were 29 times more likely than non-smokers to make a transition into daily use in the subsequent 6 months. Depression and anxiety, along with peer smoking, predicted initiation of experimental smoking. Specifically, depression and anxiety accentuated risks associated with peer smoking and predicted experimentation only in the presence of peer smoking.

CONCLUSIONS

The finding that experimental smoking is an overwhelmingly strong predictor of later daily smoking focuses attention on smoking initiation. Depressive and anxiety symptoms are associated with higher risks for initiation through an increased susceptibility to peer smoking influences. Promoting the psychological well-being of adolescents and addressing perceived interpersonal benefits of smoking may play a role in the prevention of adolescent tobacco use.

The prognosis of common mental disorders in adolescents: a 14-year prospective cohort study

BACKGROUND

Most adults with common mental disorders report their first symptoms before 24 years of age. Although adolescent anxiety and depression are frequent, little clarity exists about which syndromes persist into adulthood or resolve before then. In this report, we aim to describe the patterns and predictors of persistence into adulthood.

METHODS

We recruited a stratified, random sample of 1943 adolescents from 44 secondary schools across the state of Victoria, Australia. Between August, 1992, and January, 2008, we assessed common mental disorder at five points in adolescence and three in young adulthood, commencing at a mean age of 15.5 years and ending at a mean age of 29.1 years. Adolescent disorders were defined on the Revised Clinical Interview Schedule (CIS-R) at five adolescent measurement points, with a primary cutoff score of 12 or higher representing a level at which a family doctor would be concerned. Secondary analyses addressed more severe disorders at a cutoff of 18 or higher.

FINDINGS

236 of 821 (29%; 95% CI 25-32) male participants and 498 of 929 (54%; 51-57) female participants reported high symptoms on the CIS-R (≥12) at least once during adolescence. Almost 60% (434/734) went on to report a further episode as a young adult. However, for adolescents with one episode of less than 6 months duration, just over half had no further common mental health disorder as a young adult. Longer duration of mental health disorders in adolescence was the strongest predictor of clear-cut young adult disorder (odds ratio [OR] for persistent young adult disorder vs none 3.16, 95% CI 1.86-5.37). Girls (2.12, 1.29-3.48) and adolescents with a background of parental separation or divorce (1.62, 1.03-2.53) also had a greater likelihood of having ongoing disorder into young adulthood than did those without such a background. Rates of adolescent onset disorder dropped sharply by the late 20s (0.57, 0.45-0.73), suggesting a further resolution for many patients whose symptoms had persisted into the early 20s.

INTERPRETATION

Episodes of adolescent mental disorder often precede mental disorders in young adults. However, many such disorders, especially when brief in duration, are limited to the teenage years, with further symptom remission common in the late 20s. The resolution of many adolescent disorders gives reason for optimism that interventions that shorten the duration of episodes could prevent much morbidity later in life.

FUNDING

Australia's National Health and Medical Research Council.

Clinical and host differences between infections with the two varieties of Cryptococcus neoformans

A population-based register of cases of cryptococcosis in patients treated in Victoria, Australia, over a 10-year period was established for studying the epidemiologic and clinical features of infection with Cryptococcus neoformans and its two varieties, gattii and neoformans. One hundred thirty-three cases of cryptococcosis were entered on the register; the incidence was 3.0 cases per 1 million population per year, a rate that increased to 5.0 cases per 1 million population per year over the decade as a result of the AIDS epidemic. There was a distinct association between immune status and C. neoformans variety: all C. neoformans variety gattii infections occurred in healthy hosts and 90% of C. neoformans variety neoformans infections occurred in immunosuppressed hosts. Meningitis was the commonest manifestation, with focal CNS and pulmonary lesions occurring primarily in healthy hosts with C. neoformans variety gattii infection; isolation of C. neoformans from blood and urine was associated with immunosuppression and C. neoformans variety neoformans infection. The mortality among patients with C. neoformans variety neoformans infection was high, while none of those patients with C. neoformans variety gattii died but often had neurological sequelae that required surgery and prolonged therapy. These findings appear to be related to variety-specific interactions between host and parasite and warrant further epidemiologic and immunologic study.

Arteriographic complications in the DSA era

Prospective data were collected on complications associated with intraarterial digital subtraction angiography in 2,475 consecutive patients at a 650-bed Melbourne teaching hospital. Carotid or cerebral studies were performed in 939 patients, and the prevalence of stroke (ie, permanent neurologic deficit) was 0.3%. The overall prevalence of systemic complications was 1.8%, with no patients requiring hemodialysis because of renal failure. Comparison was made with previously reported complication rates for conventional film angiography.

Hypoglycemia and outcome in critically ill patients

OBJECTIVE

To determine whether mild or moderate hypoglycemia that occurs in critically ill patients is independently associated with an increased risk of death.

PATIENTS AND METHODS

Of patients admitted to 2 hospital intensive care units (ICUs) in Melbourne and Sydney, Australia, from January 1, 2000, to October 14, 2004, we analyzed all those who had at least 1 episode of hypoglycemia (glucose concentration, <81 mg/dL). The independent association between hypoglycemia and outcome was statistically assessed.

RESULTS

Of 4946 patients admitted to the ICUs, a cohort of 1109 had at least 1 episode of hypoglycemia (blood glucose level, <81 mg/dL). Of these 1109 patients (22.4% of all admissions to the intensive care unit), hospital mortality was 36.6% compared with 19.7% in the 3837 nonhypoglycemic control patients (P<.001). Even patients with a minimum blood glucose concentration between 72 and 81 mg/dL had a greater unadjusted mortality rate than did control patients (25.9% vs 19.7%; unadjusted odds ratio, 1.42; 95% confidence interval, 1.12-1.80; P=.004.) Mortality increased significantly with increasing severity of hypoglycemia (P<.001). After adjustment for insulin therapy, hypoglycemia was independently associated with increased risk of death, cardiovascular death, and death due to infectious disease.

CONCLUSION

In critically ill patients, an association exists between even mild or moderate hypoglycemia and mortality. Even after adjustment for insulin therapy or timing of hypoglycemic episode, the more severe the hypoglycemia, the greater the risk of death.

Maternal health after childbirth: results of an Australian population based survey

OBJECTIVE

To describe the prevalence of maternal physical and emotional health problems six to seven months after birth.

DESIGN

Statewide postal survey, incorporating the Edinburgh Postnatal Depression Scale, distributed to women six to seven months after childbirth.

PARTICIPANTS

All women who gave birth in a two-week period in Victoria, Australia in September 1993 except those who had a stillbirth or known neonatal death.

RESULTS

The response rate was 62.5% (n = 1336). Respondents were representative of the total sample in terms of mode of delivery, parity and infant birthweight; young women, single women and women of nonEnglish speaking background were under-represented. One or more health problems in the first six postnatal months were reported by 94% of the women; a quarter had not talked to a health professional about their own health since the birth. Of women reporting health problems, 49% would have liked more help or advice. The most common health problems were tiredness (69%), backache (43.5%), sexual problems (26.3%), haemorrhoids (24.6%) and perineal pain (21%); 16.9% of women scored as depressed. Compared with spontaneous vaginal births, women having forceps or ventouse extraction had increased odds for perineal pain (OR 4.69 [95% CI 3.2-6.8]), sexual problems (OR 2.06 [95% CI 1.4-3.0]), and urinary incontinence (OR 1.81 [95% CI 1.1-2.9]). These differences remained significant after adjusting for infant birthweight, length of labour and degree of perineal trauma.

CONCLUSION

Physical and emotional health problems are common after childbirth, and are frequently not reported to health professionals despite the fact that many women would like more advice and assistance in dealing with them.

Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls

This study explored friendship variables in relation to body image, dietary restraint, extreme weight-loss behaviors (EWEBs), and binge eating in adolescent girls. From 523 girls, 79 friendship cliques were identified using social network analysis. Participants completed questionnaires that assessed body image concerns, eating, friendship relations, and psychological family, and media variables. Similarity was greater for within than for between friendship cliques for body image concerns, dietary restraint, and EWLBs, but not for binge eating. Cliques high in body image concerns and dieting manifested these concerns in ways consistent with a high weight/shape-preoccupied subculture. Friendship attitudes contributed significantly to the prediction of individual body image concern and eating behaviors. Use of EWLBs by friends predicted an individual's own level of use.

Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence

AIMS

To examine the risk posed by cannabis use in young people for tobacco use disorders. Specifically we examined whether cannabis use in non-smokers predicted later initiation of tobacco use and whether cannabis use predicted later nicotine dependence in tobacco users.

DESIGN

A 10-year eight-wave cohort study.

SETTING

State of Victoria, Australia.

PARTICIPANTS

A community sample of 1943 participants initially aged 14-15 years.

MEASUREMENTS

Self-report of tobacco and cannabis use was assessed in the teens using a computerized interview assessment and in young adulthood with a CATI assessment. The Fagerström Test for Nicotine Dependence was used to define nicotine dependence.

FINDINGS

For teen non-smokers, at least one report of weekly cannabis use in the teens predicted a more than eightfold increase in the odds of later initiation of tobacco use (OR 8.3; 95% CI 1.9-36). For 21-year-old smokers, not yet nicotine-dependent, daily cannabis use raised the odds of nicotine dependence at the age of 24 years more than threefold (OR 3.6, 1.2, 10) after controlling for possible confounders, including level of tobacco use and subsyndromal signs of nicotine dependence.

CONCLUSIONS

Weekly or more cannabis use during the teens and young adulthood is associated with an increased risk of late initiation of tobacco use and progression to nicotine dependence. If this effect is causal, it may be that a heightened risk of nicotine dependence is the most important health consequence of early frequent cannabis use.

Impact of child sexual abuse on mental health: prospective study in males and females

BACKGROUND

The lack of prospective studies and data on male victims leaves major questions regarding associations between child sexual abuse and subsequent psychopathology.

AIMS

To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design.

METHOD

Children (n=1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period.

RESULTS

Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v. 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v.10.2%).

CONCLUSIONS

This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.

Effect of physical activity and body size on survival after diagnosis with colorectal cancer

BACKGROUND

Physical inactivity and obesity increase the risk of colorectal cancer but little is known about whether they influence prognosis after diagnosis.

METHODS

Incident cases of colorectal cancer were identified among participants of the Melbourne Collaborative Cohort Study, a prospective cohort study of 41 528 Australians recruited from 1990 to 1994. Participants diagnosed with their first colorectal cancer between recruitment and 1 August 2002 were eligible. At the time of study entry, body measurements were taken and participants were interviewed about their physical activity. Information on tumour site and stage, treatments given, recurrences, and deaths were obtained from systematic review of the medical records.

RESULTS

A total of 526 cases of colorectal cancer were identified. Median follow up among survivors was 5.5 years, and 208 deaths had occurred, including 181 from colorectal cancer. After adjusting for age, sex, and tumour stage, exercisers had an improved disease specific survival (hazard ratio 0.73 (95% confidence interval (CI) 0.54-1.00)). The benefit of exercise was largely confined to stage II-III tumours (hazard ratio 0.49 (95% CI 0.30-0.79)). Increasing per cent body fat resulted in an increase in disease specific deaths (hazard ratio 1.33 per 10 kg (95% CI 1.04-1.71)). Similarly, increasing waist circumference reduced disease specific survival (hazard ratio 1.20 per 10 cm (95% CI 1.05-1.37)).

CONCLUSIONS

Increased central adiposity and a lack of regular physical activity prior to the diagnosis of colorectal cancer is associated with poorer overall and disease specific survival.

Psychopathology in a large cohort of sexually abused children followed up to 43 years

OBJECTIVE

To determine the rate and risk of clinical and personality disorders diagnosed in childhood and adulthood in those known to have been sexually abused during childhood.

METHODS

Forensic medical records of 2,759 sexually abused children assessed between 1964 and 1995 were linked with a public psychiatric database between 12 and 43 years later. Cases were compared to control subjects matched on gender and age groupings drawn from the general population through a random sample of the national electoral database.

RESULTS

A lifetime record of contact with public mental health services was found in 23.3% of cases compared to 7.7% of controls. The rate of contact among child sexual abuse victims was 3.65 times higher (95% CI, 3.09-4.32, p<0.001). It was estimated that child sexual abuse accounted for approximately 7.83% of mental health contact. Exposure to sexual abuse increased risks for the majority of outcomes including psychosis, affective, anxiety, substance abuse, and personality disorders. Rates of clinical disorders diagnosed in adulthood and childhood remained significantly higher among child sexual abuse cases. Older age at sexual abuse and those exposed to severe abuse involving penetration or multiple offenders were associated with greater risk for psychopathology.

CONCLUSIONS

This study confirms that child sexual abuse is a substantial risk factor for a range of mental disorders in both childhood and adulthood.

PRACTICE IMPLICATIONS

Those treating victims of sexual abuse must assess not only disorders commonly associated with trauma, but also low prevalence disorders such as psychosis.

Risk factors associated with the incidence of open-angle glaucoma: the visual impairment project

PURPOSE

To assess the relationship between potential risk factors and the development of open-angle glaucoma (OAG) in Australian residents aged 40 and or more years.

METHODS

A total of 3271 participants were recruited at baseline from nine urban areas through cluster random sampling and subjected to comprehensive standardized interviews and ophthalmic examination, both at baseline and at 5-year follow-up. The participation rate at follow-up was 85% of the surviving baseline cohort. OAG was diagnosed with definite, probable, or possible certainty by a consensus panel of six ophthalmologists. Potential risk factors identified at baseline included various sociodemographic, anthropometric, dietary, familial, medical, and ocular characteristics of the participants. Risk factor analyses were performed for development of at least possible OAG (possible, probable, and definite OAG) and then at least probable OAG (probable and definite OAG) to represent a higher level of certainty. Univariate and multivariate analyses were performed.

RESULTS

Increased age and increased intraocular pressure (IOP) were associated with increased risk of development of OAG, according to multivariate analyses. A family history of glaucoma (relative risk [RR] = 2.1, 95% confidence interval [CI] = 1.03-4.2), the presence of age-related macular degeneration (RR = 2.2, 95% CI = 1.2-3.9), the presence of pseudoexfoliation (RR = 9.4, 95% CI = 2.6-34.4), and a cup-disc ratio (CDR) greater than 0.7 (RR = 7.9, 95% CI = 4.4-14.1) were associated with greater risk of development of at least possible OAG. Having ever taken alpha-blockers (RR = 4.8, 95% CI = 1.2-18.8), the presence of pseudoexfoliation (RR = 11.2, 95% CI = 2.0-63.3), and a CDR higher than 0.7 (RR = 11.0, 95% CI = 4.6-26.8) also indicated significant risk of development of at least probable OAG.

CONCLUSIONS

Certain nonmodifiable risk factors may be used to identify high-risk individuals, and increased IOP remains an important modifiable risk factor for OAG. However, more prospective studies on risk factors are required to clarify further the etiological picture of OAG.

Intensive cholesterol reduction lowers blood pressure and large artery stiffness in isolated systolic hypertension

OBJECTIVES

We sought to investigate the effects of intensive cholesterol reduction on large artery stiffness and blood pressure in normolipidemic patients with isolated systolic hypertension (ISH).

BACKGROUND

Isolated systolic hypertension is associated with elevated cardiovascular morbidity and mortality and is primarily due to large artery stiffening, which has been independently related to cardiovascular mortality. Cholesterol-lowering therapy has been efficacious in reducing arterial stiffness in patients with hypercholesterolemia, and thus may be beneficial in ISH.

METHODS

In a randomized, double-blinded, cross-over study design, 22 patients with stage I ISH received three months of atorvastatin therapy (80 mg/day) and three months of placebo treatment. Systemic arterial compliance was measured noninvasively using carotid applanation tonometry and Doppler velocimetry of the ascending aorta.

RESULTS

Atorvastatin treatment reduced total and low-density lipoprotein cholesterol and triglyceride levels by 36 +/- 2% (p < 0.001), 48 +/- 3% (p < 0.001) and 23 +/- 5% (p = 0.003), respectively, and increased high density lipoprotein cholesterol by 7 +/- 3% (p = 0.03). Systemic arterial compliance was higher after treatment (placebo vs. atorvastatin: 0.36 +/- 0.03 vs. 0.43 +/- 0.05 ml/mm Hg, p = 0.03). Brachial systolic blood pressure was lower after atorvastatin treatment (154 +/- 3 vs. 148 +/- 2 mm Hg, p = 0.03), as were mean (111 +/- 2 vs. 107 +/- 2 mm Hg, p = 0.04) and diastolic blood pressures (83 +/- 1 vs. 81 +/- 2 mm Hg, p = 0.04). There was a trend toward a reduction in pulse pressure (71 +/- 3 vs. 67 +/- 2 mm Hg, p = 0.08).

CONCLUSIONS

Intensive cholesterol reduction may be beneficial in the treatment of patients with ISH and normal lipid levels, through a reduction in large artery stiffness.

The prevalence of glaucoma in the Melbourne Visual Impairment Project

PURPOSE

The purpose of the study was to determine the prevalence of glaucoma in Melbourne, Australia.

METHODS

All subjects were participants in the Melbourne Visual Impairment Project (Melbourne VIP), a population-based prevalence study of eye disease that included residential and nursing home populations. Each participant underwent a standardized eye examination, which included a Humphrey Visual Field test, applanation tonometry, fundus examination including fundal photographs, and a medical history interview. Glaucoma status was determined by a masked assessment and consensus adjudication of visual fields, optic disc photographs, intraocular pressure, and glaucoma history.

RESULTS

A total of 3271 persons (83% response rate) participated in the residential Melbourne VIP. The overall prevalence rate of definite primary open-angle glaucoma in the residential population was 1.7% (95% confidence limits = 1.21, 2.21). Of these, 50% had not been diagnosed previously. Only two persons (0.1%) had primary angle-closure glaucoma and six persons (0.2%) had secondary glaucoma. The prevalence of glaucoma increased steadily with age from 0.1% at ages 40 to 49 years to 9.7% in persons aged 80 to 89 years. There was no relationship with gender. The authors examined 403 (90.2% response rate) nursing home residents. The age standardized rate for this component was 2.36% (95% confidence limits = 0, 4.88).

CONCLUSION

The rate of glaucoma in Melbourne rises significantly with age. With only half of patients being diagnosed, glaucoma is a major eye health problem and will become increasingly important as the population ages.

The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study

The incidence and distribution of stress fractures were evaluated prospectively over 12 months in 53 female and 58 male competitive track and field athletes (age range, 17 to 26 years). Twenty athletes sustained 26 stress fractures for an overall incidence rate of 21.1%. The incidence was 0.70 for the number of stress fractures per 1000 hours of training. No differences were observed between male and female rates (P > 0.05). Twenty-six stress fractures composed 20% of the 130 musculoskeletal injuries sustained during the study. Although there was no difference in stress fracture incidence among athletes competing in different events (P > 0.05), sprints, hurdles, and jumps were associated with a significantly greater number of foot fractures; middle- and long-distance running were associated with a greater number of long bone and pelvic fractures (P < 0.05). Overall, the most common sites of bone injuries were the tibia with 12 injuries (46%), followed by the navicular with 4 injuries (15%), and the fibula with 3 injuries (12%). The high incidence of stress fractures in our study suggests that risk factors in track and field athletes should be identified.

Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding

BACKGROUND

Documented barriers to the implementation of Step 4 of the Baby Friendly Hospital Initiative, which relates to early initiation of breastfeeding, have not considered the impact of operative intervention in delivery on achievement of the goal. This study was designed to test the hypothesis that hospital practices in the immediate postpartum period that are associated with operative intervention in delivery can affect first mother-infant contact and initiation of breastfeeding.

METHODS

In a prospective, longitudinal study, a sociodemographically representative sample of 203 primiparous women was recruited. Participants were interviewed at 2 days postpartum in metropolitan hospitals in Melbourne, Australia, and medical records were inspected. At 8 months postpartum 81 percent of participants completed a postal questionnaire. Three mode-of-delivery groups (spontaneous vaginal delivery, instrumentally assisted vaginal delivery and cesarean section) and 4 hospital-of-delivery groups (including one accredited Baby Friendly Hospital) were compared.

RESULTS

Two way ANOVA revealed that women who had a cesarean section experienced a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance (p < 0.001). Significant differences in this aspect of care were also observed among hospitals, with the Baby-Friendly hospital performing significantly better than the other three hospitals (p < 0.001). An effect due to mode of delivery alone was demonstrated that could not be abolished by differences in hospital practices (p = 0.231). Nevertheless, shorter elapsed time between birth and initiation of breastfeeding was not significantly associated with continuation of breastfeeding at 8 months postpartum (p = 0.642).

CONCLUSIONS

The findings confirmed that cesarean section was a significant barrier to the implementation of Baby Friendly Hospital Initiative Step 4 and that hospital practices were amenable to changes that enabled its implementation regardless of the mode of delivery.

Plasma phospholipid and dietary fatty acids as predictors of type 2 diabetes: interpreting the role of linoleic acid

BACKGROUND

Dietary fatty acids may be associated with diabetes but are difficult to measure accurately.

OBJECTIVE

We aimed to investigate the associations of fatty acids in plasma and diet with diabetes incidence.

DESIGN

This was a prospective case-cohort study of 3737 adults aged 36-72 y. Fatty acid intake (/kJ) and plasma phospholipid fatty acids (%) were measured at baseline, and diabetes incidence was assessed by self-report 4 y later. Logistic regression excluding (model 1) and including (model 2) body mass index and waist-hip ratio was used to calculate odds ratios (ORs) for plasma phospholipid and dietary fatty acids.

RESULTS

In plasma phospholipid, positive associations with diabetes were seen for stearic acid [OR model 1, highest versus lowest quintile: 4.14 (95% CI: 2.65, 6.49), P for trend < 0.0001] and total saturated fatty acids [OR model 1: 3.76 (2.43, 5.81), P for trend < 0.0001], whereas an inverse association was seen for linoleic acid [OR model 1: 0.22 (0.14, 0.36), P for trend < 0.0001]. Dietary linoleic [OR model 1: 1.77 (1.19, 2.64), P for trend = 0.002], palmitic [OR model 1: 1.65 (1.12, 2.43), P for trend = 0.012], and stearic [OR model 1: 1.46 (1.00, 2.14), P for trend = 0.030] acids were positively associated with diabetes incidence before adjustment for body size. Within each quintile of linoleic acid intake, cases had lower baseline plasma phospholipid linoleic acid proportions than did controls.

CONCLUSIONS

Dietary saturated fat intake is inversely associated with diabetes risk. More research is required to determine whether linoleic acid is an appropriate dietary substitute.