Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study

OBJECTIVES

To determine what factors are associated with the time people take to consult with symptoms of lung cancer, with a focus on those from rural and socially deprived areas.

METHODS

A cross-sectional quantitative interview survey was performed of 360 patients with newly diagnosed primary lung cancer in three Scottish hospitals (two in Glasgow, one in NE Scotland). Supplementary data were obtained from medical case notes. The main outcome measures were the number of days from (1) the date participant defined first symptom until date of presentation to a medical practitioner; and (2) the date of earliest symptom from a symptom checklist (derived from clinical guidelines) until date of presentation to a medical practitioner.

RESULTS

179 participants (50%) had symptoms for more than 14 weeks before presenting to a medical practitioner (median 99 days; interquartile range 31-381). 270 participants (75%) had unrecognised symptoms of lung cancer. There were no significant differences in time taken to consult with symptoms of lung cancer between rural and/or deprived participants compared with urban and/or affluent participants. Factors independently associated with increased time before consulting about symptoms were living alone, a history of chronic obstructive pulmonary disease (COPD) and longer pack years of smoking. Haemoptysis, new onset of shortness of breath, cough and loss of appetite were significantly associated with earlier consulting, as were a history of chest infection and renal failure.

CONCLUSION

For many people with lung cancer, regardless of location and socioeconomic status, the time between symptom onset and consultation was long enough to plausibly affect prognosis. Long-term smokers, those with COPD and/or those living alone are at particular risk of taking longer to consult with symptoms of lung cancer and practitioners should be alert to this.

Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis

CONTEXT

Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction.

OBJECTIVE

To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction.

DATA SOURCES

Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies.

STUDY SELECTION

Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality.

DATA EXTRACTION

Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease.

RESULTS

Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women.

CONCLUSION

Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

Excising basal cell carcinomas: comparing the performance of general practitioners, hospital skin specialists and other hospital specialists

BACKGROUND

General practitioners (GPs) are not encouraged to excise basal cell carcinomas (BCCs). Despite this, as many of 10% of BCCs may be excised by GPs. GPs may be able to have a greater role in the diagnosis and management of BCC, but much needs to be learnt before this can be advocated.

OBJECTIVE

To compare the practice of GPs, skin specialists (dermatologists and plastic surgeons) and other hospital specialists in excising BCCs.

METHODS

A retrospective analysis of all BCCs excised in the Grampian region between 1 January and 31 December 2005 was carried out In total, 1087 reports were rated for source, quality of clinical information provided and extent of excision.

RESULTS

GPs perform significantly less well than skin specialists when diagnosing and excising BCCs, but appear equal in diagnostic skill and better at excision than other hospital specialists. Non-specialized GPs appear to perform as well as GPs with special interest (GPwSI) in adequately excising BCCs. In 18.7% of all cases, the information supplied to the pathologist with the biopsy sample was inadequate to draw a conclusion.

CONCLUSIONS

GPs compare unfavourably with skin specialists in diagnosing and excising BCCs. The performance of nonspecialized GPs does not appear to differ markedly from that of GPwSI. There is considerable room to optimize current GP performance, particularly with lesions of the head and neck, and it may be that novel approaches to GP training are required to achieve this. Structured request forms may improve the quality of clinical information provided when skin biopsies are submitted for pathological examination.

Secondary prevention clinics for coronary heart disease: a 10-year follow-up of a randomised controlled trial in primary care

OBJECTIVES

To evaluate the effects of nurse-led secondary prevention clinics for coronary heart disease (CHD) in primary care on total mortality and coronary event rates after 10 years.

DESIGN

Follow-up of a randomised controlled trial by review of national datasets.

SETTING

Stratified random sample of 19 general practices in northeast Scotland.

PARTICIPANTS

Original study cohort of 1343 patients, aged <80 years, with a working diagnosis of CHD, but without dementia or terminal illness and not housebound.

INTERVENTION

Nurse-led secondary prevention clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow-up for 1 year,

MAIN OUTCOME MEASURES

Total mortality and coronary events (non-fatal myocardial infarctions (MIs) and coronary deaths).

RESULTS

Mean (SD) follow-up was at 10.2 (0.19) years. No significant differences in total mortality or coronary events were found at 10 years. 254 patients in the intervention group and 277 patients in the control group had died: cumulative death rates were 38% and 41%, respectively (p = 0.177). 196 coronary events occurred in the intervention group and 195 in the control group: cumulative event rates were 29.1% and 29.1%, respectively (p = 0.994). When Kaplan-Meier survival analysis, adjusted for age, sex and general practice, was used, proportional hazard ratios were 0.88 (0.74 to 1.04) for total mortality and 0.96 (0.79 to 1.18) for coronary death or non-fatal MI. No significant differences in the distribution of cause of death classifications was found at either 4 or 10 years.

CONCLUSIONS

After 10 years, differences between groups were no longer significant. Total mortality survival curves for the intervention and control groups had not converged, but the coronary event survival curves had. Possibly, therefore, the earlier that secondary prevention is optimised, the less likely a subsequent coronary event is to prove fatal.

Unemployment and deprivation are associated with a poorer outcome following percutaneous coronary angioplasty

This prospective observational study aimed to assess the impact of employment status and deprivation on quality of life 12 months after percutaneous coronary intervention (PCI). Patients completed a questionnaire at baseline and at 1 year follow-up including a health utility score (EQ-5D), symptoms and employment status. Deprivation was assessed using the Carstairs' deprivation category based on area postcodes. The majority (79.6%) of patients of working age returned to work within 12 months. Unemployment was associated with a lower quality of life (QoL) at baseline (0.49 (0.32) vs 0.61 (0.27), p=0.002) and less improvement in QoL 1 year after PCI (0.15 (0.37) vs 0.26 (0.31), p<0.012). Furthermore, unemployed patients had significantly less improvement in chest pain score (p=0.002) and breathlessness (p<0.001). Unemployed patients from the most deprived areas had lowest QoL at follow-up and least improvement in QoL at 1 year. Unemployment and deprivation are associated with poorer outcomes following PCI.

Obstetric Outcomes in Cancer Survivors

OBJECTIVE

To assess obstetric and neonatal outcomes in women with a prior episode of cancer.

METHODS

Data were obtained from a linkage between the Scottish Cancer Registry and routinely collected data from Scottish maternity hospitals. Obstetric outcomes in a first pregnancy which ended between 1980 and 2005 were compared in 917 women with, and 5,496 women without, a previous history of cancer.

RESULTS

The mean age at delivery was 29 years (standard deviation 5.66) and 26 years (standard deviation 5.62) in the exposed and unexposed groups respectively (P<.001). Multiple logistic regression showed that cancer survivors had higher rates of postpartum hemorrhage (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.09-2.23) and operative or assisted delivery (abdominal or vaginal) (OR 1.33, 95% CI 1.14- 1.54). Preterm delivery (at less than 37 weeks of gesation) was also found to be higher in this group compared with non-cancer women (OR 1.33, 95% CI 1.01-1.76).

CONCLUSION

While largely reassuring to women intending to become pregnant after surviving cancer, the results indicate areas of increased risk that require additional surveillance.

Influence of socioeconomic status on clinical outcomes and quality of life after percutaneous coronary intervention

OBJECTIVES

To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI).

DESIGN

Prospective observational study.

SETTING

Two interventional cardiac centres.

PARTICIPANTS

1346 consecutive patients undergoing PCI over a 12-month period.

OUTCOMES

Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code.

MAIN RESULTS

No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES.

CONCLUSIONS

Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months

OBJECTIVE

To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage.

DESIGN

A prospective study with follow up at 6 and 13 months after miscarriage.

SETTING

Three Scottish Early Pregnancy Assessment Units.

SAMPLE

Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months.

METHODS

On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments.

MAIN OUTCOME MEASURES

The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples.

RESULTS

Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors.

CONCLUSIONS

These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

Effects of changing clinical practice on costs and outcomes of percutaneous coronary intervention between 1998 and 2002

AIM

To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002.

SETTING

Two tertiary interventional centres.

PATIENTS

Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002.

DESIGN

Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs.

RESULTS

Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01).

CONCLUSIONS

Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.

Compression Therapy: Effects of Posture and Application Techniques on Initial Pressures Delivered by Bandages of Different Physical Properties

OBJECTIVE

To define the pressures and gradients achieved by different bandages when applied by alternative bandaging techniques.

METHODS

An experienced bandager applied six bandages to the same leg of a volunteer using three application techniques. Pressure measurements were taken at the ankle, gaiter, calf and upper calf in three postures.

RESULTS

All bandages gave consistent pressures with all standard deviations falling below 7 mmHg. The percentage increase in pressure from resting leg to standing was inversely related to bandage elasticity. Pressures were similar at the upper calf among the bandages for each application technique in each posture (differences <10 mmHg). Small differences in pressure among the bandages (4-15 mmHg) occurred at the ankle for the resting leg with a reduction in pressure between 6 and 63% at the upper calf compared to the ankle. These differences in ankle pressure were more marked on sitting (differences 15-18 mmHg) and standing (differences 15-27 mmHg), which resulted in substantial differences in gradients.

CONCLUSIONS

Striking variations in pressures and gradients were observed between bandages of different physical properties applied using alternative application techniques. In order to achieve clinical benefits without tissue damage, it is essential that the therapist appreciates how a bandage will react with a specific application technique.

Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams?

Objective

To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons

Design

Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa.

Results

Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively)

Conclusion

In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel.

Indoor heated swimming pools: the vulnerability of some infants to develop spinal asymmetries years later

Evidence reported in an earlier paper suggests that infants introduced to indoor heated swimming pools in the first year of life show an association with spinal asymmetries including progressive adolescent idiopathic scoliosis (AIS) and in normal subjects vertical spinous process asymmetry. Indoor heated swimming pools may contain a risk factor that predisposes some infants to develop such spinal asymmetries years later. What the risk factor(s) may be and its possible portal of entry into the infant's body are unknown and possibilities are examined. New teenage controls were obtained after mothers of AIS patients mentioned that they had taken their child to an infant swim class. In a further group of 18 normal teenagers introduced to an indoor heated swimming pool in the first year of life, 15 had vertical spinous process asymmetry. This prevalence of 83% of those at risk confirms our previous observation of vertical spinous process asymmetry in 61% of teenagers who were introduced to indoor heated swimming pools in the first year of life. Subject to confirmation of our observations consideration should be given to chemical risk factors, possible portals of entry, toxicology, environmental epigenomics and disease susceptibility to altered spinal development. If the risk factor is confirmed there may ultimately be a place for the prevention of AIS in some subjects.

A comparison of computerised strain gauge plethysmography with D-dimer testing in screening for deep-vein thrombosis

There has been a significant increase in the amount of diagnostic testing performed to confirm or refute a diagnosis of deep-vein thrombosis (DVT), often in low-risk patients. D-dimer testing and computer-assisted strain gauge plethysmography (SGP) are rapid, inexpensive methods of excluding DVT and, in combination with a clinical probability score for DVT, both have been used to accurately exclude DVT. D-dimer testing, SGP and a combination of both in excluding DVT were compared in 243 ambulant outpatients who followed a prespecified investigation protocol. The negative-predictive value of D-dimer testing alone was 100%, 93.9% (95% CI 93.6-94.1) and 80% (95% CI 73.7-86.3) in patients with a low, moderate and high pretest probability (PTP) score for DVT respectively. The corresponding results for SGP were 95.6% (95% CI 95.5-95.7), 86.1% (95% CI 85.9-86.4) and 77.8% (95% CI 75.9-79.7) in patients with a low, moderate and high PTP score for DVT respectively. D-dimer testing provided a rapid, cost-effective method for excluding DVT in low-risk ambulant patients, which was superior to SGP. Combined use of the modalities did not improve any aspect of clinical decision making.

Evaluation of the association between the EQ-5D (health-related utility) and body mass index (obesity) in hospital-treated people with Type 1 diabetes, Type 2 diabetes and with no diagnosed diabetes

AIMS

The purpose of this study was to characterize the impact of body mass index (BMI) on health-related utility for patients with Type 1 and Type 2 diabetes and those without diabetes.

METHODS

The study was conducted in Cardiff and the Vale of Glamorgan, Wales, UK. Health-related utility was measured using the EQ-5D(index). Patients from the Health Outcomes Data Repository (HODaR) were surveyed by postal questionnaire either 6 weeks post discharge for in-patients or at out-patient clinics between January 2002 and July 2003. BMI was calculated from self-reported data within the survey. Patients with diabetes were identified by a previous history of an in-patient admission with diabetes or as an out-patient with diabetes recorded as a coexisting diagnosis.

RESULTS

Questionnaires were returned from 27 924 patients of whom 2575 had diabetes. Increasing BMI was found to reduce utility in all three groups. BMI was significantly greater for those with Type 2 diabetes compared with those with Type 1, and those without diabetes (P < 0.001). Multiple regression analysis demonstrated that both BMI and diabetes status had a significant effect on utility. However, the rate of change of utility attributable to BMI was not found to be significantly different between the various groups.

CONCLUSIONS

Obesity negatively impacts upon health-related utility and thus quality of life for all patient groups. There was no significant difference in the effect of obesity on utility between those with and without diabetes.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Criteria for previously undiagnosed diabetes and risk of mortality: 15-year follow-up of the Edinburgh Artery Study cohort

AIMS

To compare risk of all-cause and cardiovascular mortality associated with different criteria for undiagnosed diabetes and glucose tolerance.

METHODS

A population-based cohort of 758 men and 738 women of 55-74 years of age who had an oral glucose tolerance test or known diabetes at baseline were followed up until death or for 15 years. Mortality outcomes were compared by baseline diabetes status using people with normal glucose tolerance (i.e. those without diabetes, impaired fasting glucose or impaired glucose tolerance) as the reference group.

RESULTS

Prevalence of undiagnosed diabetes using World Health Organization (WHO) criteria (fasting glucose of > or = 7.0 mmol/l and/or a 2-h post-challenge glucose of > or = 11.1 mmol/l) was 6.6%, of which 81% was associated with fasting glucose > or = 7.0 mmol/l and 19% was associated with isolated post-challenge hyperglycaemia. Hazard ratios (95% CI) for all-cause mortality adjusted for age and sex were 1.51 (1.09-2.08) for new diabetes by the American Diabetes Association (ADA) criterion (fasting glucose of > or = 7.0 mmol/l regardless of post-challenge glucose), 1.60 (1.20-2.13) for new diabetes by WHO criteria and 1.98 (1.14-3.44) for isolated post-challenge hyperglycaemia. Hazard ratios (95% CI) for cardiovascular mortality adjusted for age and sex were 1.89 (1.17-3.00), 1.73 (1.12-2.66) and 1.08 (0.34-3.40) for new diabetes by ADA and WHO criteria and for isolated post-challenge hyperglycaemia, respectively.

CONCLUSIONS

Undiagnosed diabetes was associated with increased risk of all-cause mortality by any criteria but significantly increased cardiovascular disease mortality was only associated with diabetes diagnosed using the fasting glucose criterion. Mortality risks were similar in this population using either ADA or WHO criteria for diagnosis of diabetes.

Efficacy and safety of pimobendan in canine heart failure caused by myxomatous mitral valve disease

OBJECTIVES

To evaluate the clinical efficacy and safety of pimobendan by comparing it with ramipril over a six-month period in dogs with mild to moderate heart failure (HF) caused by myxomatous mitral valve disease (MMVD).

METHODS

This was a prospective randomised, single-blind, parallel-group trial. Client-owned dogs (n = 43) with mild to moderate HF caused by MMVD were randomly assigned to one of two groups, which received either pimobendan (P dogs) or ramipril (R dogs) for six months. The outcome measures studied were: adverse HF outcome, defined as failure to complete the trial as a direct consequence of HF; maximum furosemide dose (mg/kg/day) administered during the study period; and any requirement for additional visits to the clinic as a direct consequence of HF.

RESULTS

Treatment with pimobendan was well tolerated compared with treatment with ramipril. P dogs were 25 per cent as likely as R dogs to have an adverse HF outcome (odds ratio 4.09, 95 per cent confidence interval 1.03 to 16.3, P = 0.046).

CLINICAL SIGNIFICANCE

R dogs had a higher overall score and thus may have had more advanced disease than P dogs at baseline (P = 0.04). These results should be interpreted cautiously but such a high odds ratio warrants further investigation.

Level of agreement and biopsy correlation using two- and three-tier systems to grade cervical dyskaryosis

At present, a three-tier system is used to grade cervical dyskaryosis in the UK, although the two-tier Bethesda system is used in the United States, and the British Society for Clinical Cytology has recommended that a two-tier system be implemented here. In this study, we have retrospectively re-graded 117 conventional cervical smears using both systems to determine the intra- and interobserver variation and compare the cytology grading in both systems with the final histology. The intra and interobserver agreement was moderate using both grading systems, but the agreement between cytology grade and final histology was poor in both the two- and three-tier systems, and slightly worse using two-tier grading. However, when each of the three histological categories is considered separately the two-tier system appears to work better. Therefore, changing the way in which cervical dyskaryosis is graded in the UK may result in poorer agreement between the cervical smear result and the final histological diagnosis if introduced without proper training, monitoring and assessment.

Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status

OBJECTIVES

To compare three outpatient methods of endometrial evaluation in terms of performance, patient acceptability and cost-effectiveness.

DESIGN

Pragmatic unblinded trial randomised separately within three groups determined by risk of endometrial cancer.

SETTING

The gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland.

PARTICIPANTS

Women referred for investigation and management of abnormal bleeding between January 1999 and May 2001.

INTERVENTIONS

Investigations were: blind biopsy alone, hysteroscopy with biopsy, ultrasound evaluation including transvaginal ultrasound, and, in the low-risk group, the option of no investigation. Within this design, two devices for obtaining endometrial biopsy were compared, the Pipelle sampler and the Tao brush.

MAIN OUTCOME MEASURES

Successful (informative) completion of the investigation, acceptability of the investigation method to women, women's satisfaction with clinic care in the short term and at 10 months and 2 years of follow-up, and cost-effectiveness to the end of investigation.

RESULTS

Minor adverse events (e.g. shock, patient distress) did not occur for ultrasound, but occurred in 16% and 10% of women for hysteroscopy and biopsy procedures respectively. Pipelle biopsy provided an acceptable endometrial sample for 79% of moderate-risk women, but only 43% of high-risk women. The Tao brush gave similar performance in moderate-risk women (77%), but was more successful than the Pipelle sampler in postmenopausal (high-risk) women (72%). There were significantly more successful visualizations for ultrasound than for hysteroscopy in both the low-risk and the moderate-risk group, and a similar but non-significant trend in the high-risk group. Ultrasound was significantly better than hysteroscopy at detecting fibroids, but hysteroscopy significantly better for polyps. At the 10-month follow-up, high-risk women who had been investigated by hysteroscopy (with biopsy) had the most positive views of their clinic experience, but this effect had largely disappeared by 24 months. In the moderate-risk group, the subgroup randomised to biopsy alone gave the most negative responses about their clinic experience and health now. Women wishing they had more investigation comprised 22% of moderate-risk women and 38% of low-risk women, but only 14% of postmenopausal women. At follow-up the moderate-risk women (with menstrual bleeding problems), compared with postmenopausal women, had much worse ratings for clinic experience and health now. Resource use tended to be higher in the moderate- and low-risk women. There was minimal difference in cost-effectiveness between investigation options in the high-risk group, with the option involving hysteroscopy being marginally better than ultrasound. The most cost-effective investigation in the moderate-risk group was biopsy alone and in the low-risk group ultrasound.

CONCLUSIONS

Decision-making about investigation would be clarified if postmenopausal women were studied separately from premenopausal women with menstrual bleeding problems. For postmenopausal women exclusion of cancer is a main objective, so once investigation has been completed discharge follows, but in the woman with abnormal menstrual bleeding, even if serious pathology is excluded, the original presenting symptoms require management. About 60% of premenopausal women with abnormal bleeding reported that their symptoms were not 'much improved' at 10 months. Research is needed to understand this phenomenon, and to explore ways to integrate patient factors into optimising evaluation and treatment. The significance of benign pathologies in this group also requires clarification. Given the relatively small differences observed in cost-effectiveness, there is justification for allowing other issues (such as clinician preferences and women's perspectives) to influence decisions as to the investigation method. There is scope to make better use of patient factors to inform decisions as to the most efficient and acceptable method of investigation for an individual woman. Additional analyses, using data available as a result of this study, will contribute to this agenda.

Improved Prediction of Fatal Myocardial Infarction Using the Ankle Brachial Index in Addition to Conventional Risk Factors

Background— Prediction of major cardiovascular and cerebrovascular events using conventional risk factor models is limited. Noninvasive measures of subclinical atherosclerosis such as the ankle brachial index (ABI) could improve risk prediction and provide more focused primary prevention strategies. We wished to determine the added value of a low ABI in the prediction of long-term risk of cardiovascular and cerebrovascular events and death.

Methods and Results— In 1988, 1592 men and women 55 to 74 years of age were randomly selected from the age-sex registers of 11 general practices in Edinburgh, Scotland, and followed up over a period of 12 years for incident events. After adjustment for age and sex, an ABI ≤0.9 was predictive of an increased risk of fatal myocardial infarction (MI), cardiovascular death, all-cause death, combined fatal and nonfatal MI, and total cardiovascular events. After further adjustment for prevalent cardiovascular disease, diabetes, and conventional risk factors, a low ABI was independently predictive of the risk of fatal MI. Addition of the ABI significantly ( P ≤0.01) increased the predictive value of the model for fatal MI compared with a model containing risk factors alone. Comparison of areas under receiver operator characteristic curves confirmed that a model including the ABI discriminated marginally better than one without.

Conclusions— Addition of the ABI significantly improved prediction of fatal MI over and above that of conventional risk factors. We recommend that the ABI be incorporated into routine cardiovascular screening and that the potential of its inclusion into cardiovascular scoring systems (with a view to improving their accuracy) now be examined.

Predicting sudden death in patients with mild to moderate chronic heart failure

OBJECTIVES

To explore the relation between non-invasive measures of cardiac function and sudden cardiac death, as well as the development and utility of an index integrating these variables to identify patients at increased risk of this mode of death.

DESIGN

UK-HEART (United Kingdom-heart failure evaluation and assessment of risk trial) was a prospective study conducted between December 1993 and April 2000. The study was specifically designed to identify non-invasive markers of death and mode of death among patients with chronic heart failure.

SETTING

8 UK general hospitals.

MAIN OUTCOME MEASURES

Death and mode of death.

RESULTS

553 patients aged a mean (SD) of 63 (10) years, in New York Heart Association functional class 2.3 (0.02), recruited prospectively. After 2365 patient-years' follow up, 201 patients had died (67 suddenly). Predictors of sudden death were greater cardiothoracic ratio, QRS dispersion, QT dispersion corrected for rate (QTc) across leads V1-V6 on the 12 lead ECG, and the presence of non-sustained ventricular tachycardia. The hazard ratio and 95% confidence intervals (CI) of sudden death for a 10% increase in cardiothoracic ratio was 1.43 (95% CI 1.20 to 1.71), for a 10% increase in QRS dispersion 1.11 (95% CI 1.04 to 1.19), for the presence of non-sustained ventricular tachycardia 2.03 (95% CI 1.27 to 3.25), and for a 10% increase in QTc dispersion across leads V1-V6 1.03 (95% CI 1.00 to 1.07) (all p < 0.04). An index derived from these four factors performed well in identifying patients specifically at increased risk of sudden death.

CONCLUSIONS

Results show that an index derived from three widely available non-invasive investigations has the potential to identify ambulant patients with chronic heart failure at increased risk of sudden death. This predictive tool could be used to target more sophisticated investigations or interventions aimed at preventing sudden death.

Comparing performance between coronary intervention centres requires detailed case-mix adjusted analysis

This study compares 12 month clinical outcomes and procedural costs at two interventional centres with significant differences in crude mortality and revascularization outcomes between 1997 and 1998. Percutaneous coronary intervention (PCI) registry data on 1046 consecutive patients treated contemporaneously at two university centres were linked to hospital discharge and death data to provide 12 month follow-up information on survival and repeat revascularization. Costs were determined by detailed analysis of equipment use, length of stay and staff from 100 contemporary cases at each centre to derive a procedural cost model. This model was then applied retrospectively to estimate cost per procedure. Stents were used more frequently at one centre (56 versus 26 per cent, chi(2) test, p < 0.001) resulting in greater procedural cost [mean (SE), pounds sterling 1970 (34) versus pounds sterling 1521 (39), t-test, p < 0.001). One year repeat target vessel PCI was significantly greater at the centre using more stents (10.3 versus 5.6 per cent, chi(2) test, p = 0.005) and the need for any repeat revascularization (PCI or coronary artery by-pass surgery) was also significantly greater at this centre (18.4 versus 10.8 per cent, chi(2) test, p < 0.001). Cox regression revealed that after correction for case-mix the difference in the need for repeat target vessel PCI between the two centres was no longer significant (p = 0.15). In the two centres studied, crude differences in cost per case, mortality and the need for revascularization were largely accounted for by significant differences in case-mix. Comparison of outcomes and costs between centres should not be published without careful adjustment for differences in case-mix.

Activation of c-Jun N-terminal kinase in A549 lung carcinoma cells by sodium dichromate: role of dissociation of apoptosis signal regulating kinase-1 from its physiological inhibitor thioredoxin

Changes in the components of the Jun N-terminal kinase (JNK) signalling pathway were investigated in human A549 lung carcinoma cells treated with sodium dichromate. Sodium dichromate (100 microM, 0-6h) failed to activate nuclear factor kappa B (NF-kappaB) as determined by a lack of nuclear translocation of p65 but resulted in Jun N-terminal kinase activation as assessed by phospho-Jun N-terminal kinase Western blotting in a dose-dependent (>25 microM) and time-dependent (>1h) manner. In addition, c-Jun, a downstream target of Jun N-terminal kinase signalling was also activated with a similar dose- and time-dependency at the level of both protein expression and degree of phosphorylation. In contrast, sodium dichromate treatment had no effect on levels of phospho-p38. Immunoprecipitation demonstrated that apoptosis signal regulating kinase-1 (ASK-1), an upstream activator of Jun N-terminal kinase was dissociated from its inhibitory partner thioredoxin (Trx) in response to sodium dichromate (100 microM, 4h) treatment. This treatment was also associated with a transient (2h) increase in cytosolic levels of thioredoxin but no nuclear translocation of thioredoxin was observed. In conclusion, sodium dichromate had a stimulatory effect on the Jun N-terminal kinase signalling pathway in A549 cells, resulting in activation of downstream effector molecules. We hypothesise that dissociation of apoptosis signal regulating kinase-1 from thioredoxin may be at least partially responsible for Jun N-terminal kinase activation.

Comparison of three different procedures for antireflux surgery

Background

No long-term comparisons of the various open and laparoscopic antireflux procedures have been undertaken. The aim of this study was to compare symptomatic outcomes of three procedures for antireflux surgery performed at three specialist units.

Methods

Patients undergoing open Nissen fundoplication, laparoscopic Nissen fundoplication and laparoscopic anterior partial fundoplication between December 1993 and February 2001 were identified. Patient outcome was assessed by means of a postal questionnaire. This was a hypothesis-generating study.

Results

Three hundred and fifty-seven patients (80·0 per cent) completed the questionnaire, with no differences in response rate between centres. Overall, a mean of only 7·6 per cent of patients reported a poor outcome. Logistic regression revealed no significant differences amongst the three procedures for any symptoms, after allowing for the effect of time. There was a general increase in the DeMeester score with increasing time from operation. The incidence of revisional reflux surgery was similar in the three groups.

Conclusion

Medium-term symptomatic outcome following all three procedures was similar. There was some recurrence of symptoms of gastro-oesophageal reflux with time for all procedures, suggesting that the effects of surgery diminish with time. The level of experience of the surgeon in a particular operation was more important than the procedure performed.

Intraocular pressure associations with refractive error and axial length in children

AIM

To assess whether intraocular pressure (IOP) is associated with refractive error or axial length in children.

METHODS

Of subjects from the Singapore Cohort Study of the Risk Factors for Myopia (SCORM), 636 Chinese children aged 9-11 years from two elementary schools underwent non-contact tonometry, cycloplegic autorefraction, and A-scan biometry during 2001. For analyses, refractive error was categorised into four groups; hypermetropia (spherical equivalent refraction (SE) > or = +1.0D), emmetropia (-0.5D<SE< +1.0D), low myopia (-3.0D<SE< or = -0.5D) and high myopia (SE< or = -3.0D).

RESULTS

Of the 636 children examined, 50.6% were male. The mean IOP was 16.6 (SD 2.7) mm Hg. There were no significant IOP differences between low (mean IOP = 16.4 (2.8) mm Hg) or high myopes (16.7 (2.5) mm Hg) and emmetropes (16.7 (2.9) mm Hg), p = 0.57. IOP was not correlated with spherical equivalent refraction (Spearman correlation, r = 0.009) or axial length (r = 0.030). In regression analyses adjusting for diastolic blood pressure, neither spherical equivalent (regression coefficient = 0.014) nor axial length (regression coefficient = 0.027) were significantly associated with IOP.

CONCLUSION

These findings do not support an association between IOP and refractive error or axial length in children. This questions postulated roles of IOP in the pathogenesis of myopia.

Female reproductive factors and open angle glaucoma: the Blue Mountains Eye Study

AIMS

To determine whether endogenous oestrogen exposures are associated with open angle glaucoma (OAG).

METHODS

The Blue Mountains Eye Study examined 2072 women aged 49-97 years during 1992-4. Questions about female reproductive factors included age at menarche and menopause, parity, and use of hormone replacement therapy. Applanation tonometry, visual field tests, and stereo-optic disc photographs were performed. OAG was diagnosed when glaucomatous visual fields matched optic disc changes. Ocular hypertension (OH) was defined in the absence of glaucoma, but with intraocular pressure >or=22 mm Hg.

RESULTS

A significantly increased OAG risk with later (>13 years) compared with earlier (<or=12 years) age of menarche was found, odds ratio (OR) = 2.0; 95% confidence interval (CI) 1.0 to 3.9, p for trend = 0.01, after adjustment for multiple confounders. Non-significant increased odds for OAG were found for early natural menopause (<45 years) compared with the reference group (>or=50 years), adjusted OR = 1.7; CI: 0.7 to 3.8, and for shorter duration of endogenous oestrogen exposure (<30 years), adjusted OR = 1.8; CI: 0.6 to 5.3. Increasing parity was associated with an increased risk of OAG (p = 0.03) and decreased risk of OH (p = 0.03).

CONCLUSION

The modest associations found in relation to late menarche and increased parity do not allow the exclusion of a possible role for endogenous female hormones in the pathogenesis of OAG.

Multi-layer compression: comparison of four different four-layer bandage systems applied to the leg

OBJECTIVE

To compare performance of four commercial four-layer bandage systems when applied to the leg.

METHODS

Four experienced bandagers applied each system: [Profore Regular (Smith and Nephew); Ultra-Four (Robinson); System 4 (Seton) and K Four (Parema)] to the same leg. Bandages were applied as single layers and as completed systems using standard techniques. For each application, 18 pressure measurements were taken using the Borgnis Medical Stocking Tester (MST) at three measuring points (ankle, gaiter and mid-calf) on medial and lateral aspects in three postures: (horizontal, standing and sitting).

RESULTS

In all 2304 observations were made, 576 for each bandager, 576 for each bandaging system, 768 for each measuring point, 1152 for each aspect and 768 for each posture. The increase in pressure produced by each additional layer was 65-75% of the pressure of the same bandage when used as a single layer. There were significant differences in the final pressures achieved by the bandagers (means: 45-54 mmHg, p<0.001) and between bandage systems (means: System 4: 46 mmHg, Profore: 47 mmHg, K Four: 52 mmHg, Ultra-Four: 54 mmHg; p=0.005). The relationships between the final pressures achieved at each of the three measuring points, the three postures and the two aspects were not consistent among the bandage systems (p<0.01).

CONCLUSIONS

When a bandage is applied as part of a multi-layered system it exerts approximately 70% of the pressure exerted when applied alone, thus challenging the commonly-held assumption that the final pressure achieved by a multi-layer bandaging system is the sum of the pressures exerted by each individual layer. Each of the four bandaging systems exerted different final pressures and gradients and different changes with posture change. These differences have important implications, which could influence the selection (or avoidance) of a particular bandage system according to a patient's condition and circumstances.

Open-angle glaucoma and systemic thyroid disease in an older population: The Blue Mountains Eye Study

PURPOSE

To assess whether thyroid disease is independently associated with open-angle glaucoma (OAG), using history of thyroid disease and current thyroxine use.

METHODS

The Blue Mountains Eye Study examined 3654 persons, aged 49-97 years. Interviewers collected self-reported history of diagnosis and treatment for thyroid disease. Eye examinations included applanation tonometry, stereoscopic optic disc photography and automated perimetry. OAG was diagnosed from the presence of matching typical glaucomatous field changes and optic disc cupping, independent of intraocular pressure. Associations between thyroid disease (history and treatment) and OAG were assessed in a multivariate model.

RESULTS

Of 324 participants (8.9%) reporting history of thyroid disease, 147 (4.0%) were currently using thyroxine. Although we could not accurately categorize the thyroid disorder for all cases, current use of thyroxine suggests a prior hypothyroid state. All thyroid disease subgroups affected women more frequently than men, P=0.001. OAG was diagnosed in 108 subjects (3.0%) and was more frequent in those reporting past thyroid disease (4.6 vs 2.8%). This relationship was not statistically significant after adjusting for potential confounders, multivariate odds ratio (OR) 1.6; 95% confidence interval (95% CI) 0.9-2.9. OAG was significantly more frequent, however, in subjects reporting current thyroxine use (6.8 vs 2.8%), multivariate OR 2.1; 95% CI 1.0-4.4, or history of thyroid surgery (6.5 vs 2.8%), multivariate OR 2.5; 95% CI 1.0-6.2.

CONCLUSIONS

This population-based study suggests that thyroid disease, indicated by current thyroxine use or past thyroid surgery, could be independently related to OAG.

A 5-cm colonic J pouch colo-anal reconstruction following anterior resection for low rectal cancer results in acceptable evacuation and continence in the long term

BACKGROUND

Optimal treatment for low rectal cancer is total mesorectal excision, with most patients suitable for low colo-rectal or colo-anal anastomosis. A colon pouch has early functional benefits, although long-term function, especially evacuation, might mitigate against its routine use. The aim of this study was to assess evacuation and continence in patients with a colon pouch, and to examine the impact of possible risk factors.

METHODS

In 1998, all 102 surviving patients with a colon pouch, whose stoma had been closed for more than one year, were sent a postal questionnaire. A composite incontinence score was calculated from questions on urgency, use of a pad, incontinence of gas, liquid or faeces; and a composite evacuation score from questions on medication taken to evacuate, straining, the need and number of times returned to evacuate.

RESULTS

The response rate was 90% (50 M, 42 F), with a median age of 68 years (IQR 60-78) and median follow-up of 2.6 years (IQR 1.7-3.9). The anastomosis was 3 cm or less from the anus in 45/92 (49%), and incontinence scores were worse in this group (P = 0.001). There were significantly higher incontinence scores in females (P = 0.014). Age, preoperative radiotherapy, part of colon used for anastomosis, postoperative leak and length of follow-up had no demonstrable effect on either score.

CONCLUSION

Gender and anastomotic height were the only variables which influenced incontinence. Ninety percent of patients reported that their bowel function did not affect their overall wellbeing, and none would have preferred to have a stoma.

Relationship between lower limb symptoms and patterns of deep and superficial venous reflux on duplex ultrasonography

Background

There are inconsistent and sex-dependent relationships between lower limb symptoms and the presence and severity of trunk varicose veins on clinical examination. The relationship between lower limb symptoms and patterns of venous reflux on duplex ultrasonography were investigated.

Methods

This was a cross-sectional study of an age-stratified random sample of 1566 subjects (699 men and 867 women) aged 18–64 years selected from 12 family practices. Subjects completed a self-administered questionnaire regarding symptoms (heaviness/tension, a feeling of swelling, aching, restless legs, cramps, itching, tingling) and underwent duplex ultrasonographic examination of both legs. Reflux greater than 0·5 s was considered pathological.

Results

Isolated superficial reflux was significantly related to the presence of heaviness/tension (P &lt; 0·025, both legs) and itching (P = 0·002, left leg only) in women. Isolated deep venous reflux was not significantly related to any symptom in either leg in either sex. Combined superficial and deep reflux was related to a feeling of swelling (P = 0·02, both legs), cramps (P &lt; 0·005, left leg only) and itching (P &lt; 0·005, left leg only) in men, and aching (P = 0·03, right leg only) and cramps (P = 0·026, left leg only) in women.

Conclusion

Duplex ultrasonography may be superior to clinical examination alone in identifying patients whose lower limb symptoms are truly of venous origin and thus most likely to benefit from surgery.

Chronic venous insufficiency in the general population: clinical and duplex correlations

Background

If operations for chronic venous insufficiency (CVI) are to be rational and cost effective, the natural history needs to be understood and patients with early disease who will progress to advanced CVI and leg ulcer need to be identified. Published data have derived largely from selected referred hospital patients. The pattern of venous disease in the general population is unknown. The aim was to determine the prevalence of CVI in the general population and to correlate clinical features with the findings on duplex ultrasonography.

Methods

A cross-section of men and women aged 18–64 years randomly selected from 12 general practices were surveyed. Subjects were screened by questionnaire, examination, photography, blood tests and continuous-wave Doppler ultrasonography. Eight segments of the deep and superficial veins were assessed for reflux by means of duplex ultrasonography.

Results

Some 1566 patients were screened (867 women of mean age 44·8 years and 699 men of mean age 45·8 years), of whom 134 were diagnosed as having CVI (Basle classification): grade 1, 95; grade 2, 19; grade 3, ten. The age-adjusted prevalence for the whole series was 3·1 per cent (2·6 per cent in men, 3·4 per cent in women). The prevalence of CVI correlated closely with age, being 15·2 per cent in men aged over 50 years and 9·0 per cent in women aged above 50 years. Heaviness, tension, swelling, aching and itching were significantly commoner in patients with CVI than in the general population. CVI was significantly associated with reflux in all deep and superficial segments. The frequency of reflux in both superficial and deep segments increased with the clinical severity of disease (P = 0·01). In 48·1 per cent reflux was limited to the superficial system and was thus potentially remediable.

Conclusion

CVI was common in this relatively young population. Having established the frequency of CVI and its related pattern of reflux in the general population, this cohort provides a benchmark for clinical studies and will form the basis of further longitudinal epidemiological studies.

Prevalence and risk factors associated with dry eye symptoms: a population based study in Indonesia

AIM

To determine the prevalence and identify associated risk factors for dry eye syndrome in a population in Sumatra, Indonesia.

METHODS

A one stage cluster sampling procedure was conducted to randomly select 100 households in each of the five rural villages and one provincial town of the Riau province, Indonesia, from April to June 2001. Interviewers collected demographic, lifestyle, and medical data from 1058 participants aged 21 years or over. Symptoms of dry eye were assessed using a six item validated questionnaire. Presence of one or more of the six dry eye symptoms often or all the time was analysed. Presence of pterygium was documented.

RESULTS

Prevalence of one or more of the six dry eye symptoms often or all the time adjusted for age was 27.5% (95% confidence interval (CI) 24.8 to 30.2). After adjusting for all significant variables, independent risk factors for dry eye were pterygium (p<0.001, multivariate odds ratio (OR) 1.8; 95% CI 1.4 to 2.5) and a history of current cigarette smoking (p=0.05, multivariate OR 1.5; 95% CI 1.0 to 2.2).

CONCLUSIONS

This population based study provides prevalence rates of dry eye symptoms in a tropical developing nation. From our findings, pterygium is a possible independent risk factor for dry eye symptoms.

Bypass or angioplasty for severe limb ischaemia? A Delphi Consensus Study

OBJECTIVES

To examine the level of agreement among vascular surgeons and interventional radiologists regarding their preference for the surgical or endovascular management of severe limb ischaemia.

DESIGN

Delphi consensus study using 596 different hypothetical patient scenarios.

PARTICIPANTS

Delphi consensus group for the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial.

METHODS

Twenty consultant vascular surgeons and 17 interventional radiologists completed both rounds of the study. The scenarios detailed the anatomical extent of disease, whether the patients had rest pain only or had tissue loss, and whether or not a suitable vein for bypass was available. Panellists were asked to score their treatment preference for either surgery or angioplasty on an eight-point scale. Outliers (top 10% and bottom 10% responses) were removed. If the remaining 80% of responses fell within a 3-point range, this was defined as "agreement". If they did not, this was considered "disagreement".

RESULTS

There was substantial disagreement in 484 (81%) of scenarios in round 1 and 401 (67%) in round 2. This disagreement was greater among surgeon than radiologists in both round 1 (83 vs 65%) and round 2 (69 vs 42%). Surgeons also demonstrated less convergence between rounds.

CONCLUSIONS

There is substantial disagreement between and among surgeons and radiologists with regard to the appropriateness of surgery or angioplasty for severe limb ischaemia. This lack of consensus stems from the absence of an evidence base and means that the same patient may receive entirely different treatment depending on which hospital and consultant they attend. Not only may this unexplained variation be clinically unsatisfactory, it has major implications for the planning and use of health service resources.

Identification of an antigen from the sheep scab mite, Psoroptes ovis, homologous with house dust mite group I allergens

Infestation of sheep with the ectoparasitic mite Psoroptes ovis, results in a severe allergic dermatitis. Currently, little is known about the allergens/antigens that stimulate the allergic response. We have isolated an 836-bp cDNA from a P. ovis cDNA library which displays strong homology to cysteine proteases and, in particular, to the group I house dust mite allergens Der p 1, Der f 1 and Eur m 1. The cDNA was expressed in Escherchia coli, fused to a hexahistidine tag and the recombinant protein (Pso o 1) purified using a nickel-affinity column. The recombinant Pso o 1 was tested for recognition by immunoglobulin (Ig)G and IgE in serum from P. ovis naïve and P. ovis infested sheep. Using Western blots, both classes of antibody to Pso o 1 were detected in postinfestation serum. In enzyme-linked immunosorbent assays, a pronounced IgG-antibody response to Pso o 1 was detected in five of five sheep 3 weeks postinfestation. The IgE-antibody response to whole mite extract was poor in four of five animals. However, a marked IgE response occurred in the fifth animal, and IgE anti Pso o 1 was detected in the serum.

The effect of long saphenous vein stripping on quality of life

PURPOSE

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Influence of preseason training, fitness, and existing injury on subsequent rugby injury

OBJECTIVES

To examine the influence of preseason fitness, existing injury, and preseason rugby training on subsequent injury.

METHODS

Players were eligible for the survey if they were a member of a Scottish Rugby Union (SRU) affiliated rugby club in the Border Reivers District of the SRU during the 1997-1998 season. A total of 803 (84%) players from 22 (88%) participating clubs provided details of rugby training, injuries sustained, and physical activity undertaken during the 16 week summer period (26 April to 16 August 1997) and their perceived fitness before the start of the season. Observers at participating clubs reported all injury episodes occurring to club players throughout the 1997-1998 season.

RESULTS

One fifth of players did not attend any rugby training during the 16 week summer period; the remainder attended a median of 14 sessions. Throughout the 1997-1998 season, 675 injury episodes occurred to 423 (53%) players during training or in matches. After adjustment for whether players held a professional contract or were amateurs, Cox regression showed a 3.9% relative increase (95% confidence interval (CI) 1.9 to 5.9%) in the risk of injury over the season for each additional preseason training week attended, and a 61% relative increase (95% CI 32 to 97%) for those players who had been injured or were carrying an injury at the end of the previous season.

CONCLUSIONS

Injury risk is more likely to be related to rugby training (type of activities undertaken in rugby training, or personalities and characteristics of players undertaking training more frequently) than to overall player fitness. Players who were injured at the end of the previous season were more likely to be injured in the following season. This may be because they do not allow previous injuries to heal sufficiently before returning to the game, or the intensity of their participation may increase their risk of injury.

Rapid conversion of tea catechins to monomethylated products by rat liver cytosolic catechol-O-methyltransferase

1. The metabolic O-methylation of several catechol-containing tea polyphenols by rat liver cytosolic catechol-O-methyltransferase (COMT) has been studied. 2. When (-)-epicatechin was used as substrate, its O-merthylation showed dependence on incubation time, cytosolic protein concentration, incubation pH and concentration of S-adenosyl-L-methionine. The O-methylation of increasing concentrations of (-)-epicatechin followed typical Michaelis-Menten kinetics, and the apparent Km and Vmax were 51 microM and 2882 pmol mg protein(-1) min(-1), respectively, at pH 7.4, and were 17 microM and 2093 pmol mg protein(-1) min(-1), respectively, at pH 10.0. 3. Under optimized conditions for in vitro O-methylation, (-)-epicatechin, (+)-epicatechin and (-)-epigallocatechin were rapidly O-methylated by rat liver cytosol. In comparison, (-)-epicatechin gallate and (-)-epigallocatechin gallate vere O-methylated at significantly lower rates under the same reaction conditions. catalysed O-methylation of (-)-epicatechin and (-)-epigallocatechin was inhibited in a concentration-dependent manner by S-adenosyl-L-homocysteine, a demethylated product of S-adenosyl-L-methionine. The IC50 was approximately 10 microM. 5. In summary, the results showed that several catechol-containing tea polyphenols were rapidly O-methylated by rat liver cytosolic COMT. These observations raise the possibility that some of the biological effects of tea polyphenols may be exerted by their O-methylated products or may result from their potential inhibition of the COMT-catalysed O-methylation of endogenous catecholamines and catechol oestrogens.

Most incompetent calf perforating veins are found in association with superficial venous reflux

PURPOSE

The indications for surgical perforator interruption remain undefined. Previous work has demonstrated an association between clinical status and the number of incompetent perforating veins (IPVs). Other studies have demonstrated that correction of IPV physiology results from abolition of saphenous system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and obstruction are particularly associated with IPV.

PATIENTS AND METHODS

Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with varying grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds ratios (ORs) for the presence of IPVs were calculated for different anatomical distributions of main-stem venous reflux and obstruction. The base group are those with no main-stem venous disease.

RESULTS

There were no significant associations between the proportions of limbs demonstrating IPVs and patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range = 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR = 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated. Combinations of disease produced higher odds for the presence of IPVs than those above, the highest being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI, 2.97-15.83; P =.0001).

CONCLUSIONS

Although the presence of IPVs is associated with venous ulceration, the highest ORs for the presence of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many of these may be corrected by saphenous surgery alone.

Induction of DNA-strand breaks in human peripheral blood lymphocytes and A549 lung cells by sodium dichromate: association with 8-oxo-2-deoxyguanosine formation and inter-individual variability

Hexavalent chromium [Cr(VI)] is a genotoxic carcinogen for which inhalation is a major potential route of exposure in occupational settings. In the present study, the ability of sodium dichromate to cause DNA strand breaks in three populations of cells, human whole blood cells, isolated human peripheral blood lymphocytes and cultured A549 lung epithelial cells, was investigated. Treatment with non-cytotoxic concentrations of sodium dichromate (for 1 h) resulted in a concentration-dependent increase in the number of DNA strand breaks as measured by the Comet assay. The lowest concentrations of sodium dichromate that resulted in a statistically significant (P < 0.01) increase in the number of DNA strand breaks were 500, 50 and 10 microM, respectively, in these cells. The use of formamidopyrimidine glycosylase increased the sensitivity of detection of strand breaks in A549 cells 10-fold, suggesting a role for DNA base oxidation in the mechanism of dichromate-induced DNA strand breaks. In support of this hypothesis, immunocytochemistry indicated an elevation of 8-oxodeoxyguanosine in A549 cells treated with 10 and 500 microM sodium dichromate for 1 h. We also demonstrated 2.11- and 2.5-fold ranges in the level of control and dichromate (500 microM)-induced DNA strand breaks, respectively, in cells of whole blood within a group of healthy volunteers (n = 26). A statistically significant (P < 0.001) positive Pearson's correlation (r = 0.606) was found between control and treated levels of DNA strand breaks, suggesting that factors responsible for relatively low levels of DNA strand breaks in untreated PBL may also offer protection against the formation of dichromate-induced DNA strand breaks.

Comparison of brachial artery pressure and derived central pressure in the measurement of abdominal aortic aneurysm distensibility

OBJECTIVE

AAA distensibility (Ep, beta) may predict growth and risk of rupture. However, distensibility measurements based on brachial rather than central pressure may be inaccurate. Our aim was to compare AAA distensibility using non-invasive brachial and derived central aortic pressure.

DESIGN

brachial and central pressures were measured prospectively by automated sphygmomanometry (Omron) and pulse wave analysis (SphygmoCor) respectively. AAA distensibility was calculated using brachial (Ep(b), beta(b)) and central (Ep(c), beta(c)) pressures by ultrasonic echo-tracking (Diamove). Twenty-eight patients (18 males) were selected on a first come basis from a larger study of AAA patients. There were no exclusion criteria, so 54% had cardiac dysfunction (MI, angina) and 14% were hypertensive (BP >140/90 mmHg).

RESULTS

median (IQR) age was 74 (70-77) years, median AAA (IQR) diameter was 44 (40-51) mm. Central and brachial systolic pressures were significantly different, [140 (121-153) vs 144 (130-164) mmHg respectively, p < or =0.01]. Central and brachial diastolic pressures were not significantly different [76 (72-86) vs 76 (71-86) mmHg respectively, p=0.5]. Ep(c)(3.0, [2.2-4.9]) and beta(c)(22.2 [15.5-33.2]) were significantly lower than Ep(b)(3.6, [2.4-5.1] 10(5)Nm(-2)) and beta(b)(24.7 [17.1-33.0] a.u., all p < 0.001. Brachial and central derived distensibility remained significantly different after adjusting for age and diameter (p<0.001).

CONCLUSION

the use of brachial pressure leads to a small, systematic overestimate of Ep (18%) and beta (11%) independent of age and AAA diameter. This systematic error will not bias follow-up of changes in distensibility.

Capture-recapture, epidemiology, and list mismatches: several lists

In applying capture-recapture methods for closed populations to epidemiology, e.g., in the estimation of the size of a diabetes population, one comes up against the problem of list errors due to mistyping or misinformation. This problem has been studied for just two lists by Seber, Huakau, and Simmons (2000, Biometrics 56, 1227 1232) using the concept of tag loss borrowed from animal population studies. In this article, we discuss a similar method that can be extended to an arbitrary number of lists. The methods are applied to an example.

Preferential growth stimulation of mammary glands over uterine endometrium in female rats by a naturally occurring estradiol-17beta-fatty acid ester

We hypothesize that the endogenously present lipoidal estrogen fatty acid esters may have a stronger mitogenic action in the fat-rich mammary tissues than in the uterus. To test this hypothesis, we compared the activity of estradiol-17beta-stearate (E(2)-17beta-S) with that of estradiol-17beta (E(2)) in stimulating the growth of mammary glandular cells versus the growth of uterine endometrial cells in ovariectomized female Sprague Dawley rats. Experimentally, an estimated 0.5 or 5 nmol of E(2)-17beta-S or E(2) was released daily to ovariectomized female rats through an Alzet pump implanted under the back skin of the animal for 10 or 23 days. The growth-stimulatory effect of E(2)-17beta-S and E(2) on mammary glandular cells was determined according to 5-bromo-2'-deoxyuridine labeling indices, and their effect on the uterus was determined by measuring both the 5-bromo-2'-deoxyuridine labeling index and the uterine wet weight. Our results showed that chronic treatment of ovariectomized female rats with 0.5 or 5 nmol/day E(2)-17beta-S for 10 or 23 days had a stronger stimulatory effect on mammary glandular cell proliferation than treatment with equimolar doses of E(2). In the uterus, however, E(2) was more active in stimulating the proliferation of uterine endometrial cells than E(2)-17beta-S at equimolar doses. Our results demonstrated, for the first time, that a naturally occurring estradiol-17beta-fatty acid ester has a differential, strong mitogenic effect in the fat-rich mammary tissues, and this effect was not observed with E(2). It is tempting to suggest that the fatty acid esters of the endogenous estrogens and their bioactive metabolites (e.g., 4-hydroxyestradiol and 16alpha-hydroxyestrone) may be of unique importance for stimulating cell growth and possibly also for inducing tumor formation in the fat-rich mammary tissues as compared with the uterus. More studies are warranted to test these ideas.

Prevalence and risk factors of chronic venous insufficiency

Venous disease in the legs occurs very commonly in the general population in Western countries. Around one third of women have trunk varices. A lower prevalence has been observed in men but some recent surveys have suggested that the occurrence in men may be comparable to that in women. The prevalence increases with age but the incidence of new cases appears to be constant throughout adult life. Open venous ulcers occur in about 0.3% of the adult population and a history of open or healed ulceration occurs in around 1%. The etiology of chronic venous disease in the legs is unknown. A genetic predisposition may be present but evidence for this and for a mode of inheritance is lacking. There is some suggestion that prolonged standing may be a risk factor but studies are open to considerable bias. In women, obesity and previous pregnancy has been associated with the presence of varicose veins but the evidence is inconsistent. There have been few well-conducted studies examining diet and bowel habit as a risk factor. The risk of ulceration is related to the severity of varicosities and venous insufficiency, and is increased following deep vein thrombosis. Much further research is required to investigate the cause of this common condition in the general population.

Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study

BACKGROUND

Varicose veins occur commonly in the general population but the aetiology is not well established. Varicosities are associated frequently with reflux of blood in the leg veins due to valvular incompetence. Our aim was to determine in the general population which lifestyle factors were related to reflux and thus implicated in the aetiology of varicose veins.

METHODS

In the Edinburgh Vein Study, 1566 men and women aged 18-64 years were sampled randomly from the general population in the city of Edinburgh, Scotland, and had duplex scans to measure reflux in eight venous segments in each leg. A self-administered questionnaire enquired about occupation, mobility at work, smoking, obstetric history, dietary fibre intake and bowel habit. A bowel record form was completed subsequently.

RESULTS

In women, venous reflux was associated with decreased sitting at work (odds ratio [OR] = 0.76, 95% CI : 0.61-0.94), previous pregnancy (OR = 1.20, 95% CI : 0.93-1.54), and a lower prior use of oral contraceptives (OR = 0.84, 95% CI : 0.66-1.06). Mean body mass index was greater in women with superficial reflux compared to those with no reflux: 26.2 kg/m(2) (95% CI : 25.5-27.0) versus 25.2 kg/m(2) (95% CI : 24.8-25.6). On age adjustment, sitting at work remained related to reflux (OR = 0.78, 95% CI : 0.63-0.98) and prior use of oral contraceptives to superficial reflux (OR = 0.71, 95% CI : 0.50-1.01). In age-adjusted analyses in men, height was related to reflux, (OR = 1.13, 95% CI : 1.02-1.26) and straining at stool was related to superficial reflux (OR = 1.94, 95% CI : 1.12-3.35). No associations were found in either sex between reflux and social class, lifetime cigarette consumption, dietary fibre intake and intestinal transit time.

CONCLUSIONS

This population study did not identify strong and consistent lifestyle risk factors for venous reflux although previous pregnancy, lower use of oral contraceptives, obesity and mobility at work in women and height and straining at stool in men may be implicated.

Characterization of the NADPH-dependent metabolism of 17beta-estradiol to multiple metabolites by human liver microsomes and selectively expressed human cytochrome P450 3A4 and 3A5

We characterized the NADPH-dependent metabolism of 17beta-estradiol (E2) by liver microsomes from 21 male and 12 female human subjects. A large number of radioactive estrogen metabolite peaks were detected following incubations of [3H]E2 with male or female human liver microsomes in the presence of NADPH. The structures of 18 hydroxylated or keto estrogen metabolites formed by these microsomes were identified by gas chromatography/mass spectrometry analysis. 2-Hydroxylation (the formation of 2-OH-E2 and 2-OH-E1) was the dominant metabolic pathway with all human liver microsomes tested. The average ratio of 4-OH-E2 to 2-OH-E2 formation was approximately 1:6. A new monohydroxylated E2 metabolite (chemical structure unidentified) was found to be one of the major metabolites formed by human liver microsomes of both genders. 6beta-OH-E2 and 16beta-OH-E2 were also formed in significant quantities, but products of estrogen 16alpha-hydroxylation (16alpha-OH-E2 + 16alpha-OH-E1) were quantitatively minor metabolites. In addition, many other estrogen metabolites such as 6-keto-E2, 6alpha-OH-E2, 7alpha-OH-E2, 12beta-OH-E2, 15alpha-OH-E2, 15beta-OH-E2, 16beta-OH-E1, and 16-keto-E2 were also formed in relatively small quantities. The overall profiles for the E2 metabolites formed by male and female human liver microsomes were similar, and their average rates were not significantly different. The activity of testosterone 6beta-hydroxylation (a selective probe for CYP3A4/5 activity) strongly correlated with the rate of formation of 2-OH-E2, 4-OH-E2, and several other hydroxyestrogen metabolites by both male and female liver microsomes. The dominant role of hepatic CYP3A4 and CYP3A5 in the formation of these hydroxyestrogen metabolites was further confirmed by incubations of selectively expressed human CYP3A4 or CYP3A5 with [3H]E2 and NADPH.