DEMENTIA CARE IN THE LAST YEAR OF LIFE: EXPERIENCES IN A COMMUNITY PRACTICE

Objectives

People with dementia often have high care needs at end of life. We compared care delivery in the last year of life for people living with dementia in the community (home/assisted living facilities, ALF) to those in skilled nursing facilities (SNF).

Methods

This was a retrospective study of people who died with a diagnosis of dementia in the community compared with SNF between 2013 and 2018. Primary outcomes of hospitalizations/ED visits in the last year of life were measured. Secondary outcomes included advance care planning (ACP) completion, hospice enrollment, provider visits and ICU admissions.

Results

Of 1203 people with dementia, 581 (48.3%) were living in a SNF and 622 (51.7%) in the home/ALF. At least one hospitalization was recorded for 70.7% in the home/ALF compared with 50.8% in the SNF (p< 0.01), similar to ED visits (80.2% versus 58% in home/ALF and SNF groups, respectively, p< 0.01). People in the SNF had more provider visits (median 9 (IQR 6, 12) compared with 5 (IQR 3,9) in the home/ALF group (p< 0.01). There was no ACP for 12% of those in the home/ALF, compared with 4.6% in the SNF(p< 0.01). Approximately half (56.5%) in the SNF were enrolled in hospice compared with 68.3% in the home/ALF group (p< 0.01), Median time in hospice was 26.5 days in the SNF versus 30 days in the home/ALF (p=0.67).

Conclusions

People living with dementia have frequent acute care utilization in the last year of life. Hospice care was more common in the home/ALF. Time in hospice was short.

Command, control and communication (C3) during the COVID-19 pandemic; adapting a military framework to crisis response in a tertiary UK critical care centre

The COVID-19 pandemic of 2020 imposed significant strain on critical care services worldwide. The South London region experienced the largest numbers of critical care admissions in the United Kingdom with King's College Hospital one of the busiest centres. This article outlines, using a descriptive narrative, the significant changes that occurred within King's Critical Care as a result of the pandemic and the decisions that were taken to provide effective co-ordination and control to the expanded service, in part drawing on the military experience of two of the authors. The wider context of crisis and major incident leadership and management is also discussed contrasting different approaches used in civilian and military settings.

Approach to the Older Adult With New Cognitive Symptoms

Dementia affects nearly 50 million people worldwide, translating into one new case every 3 seconds. Dementia syndrome is one of the leading causes of disability among older adults, yet it remains vastly underdiagnosed. A timely diagnosis of dementia is essential to ensuring optimal care and support of individuals and their loved ones. Although there is no single test for dementia, health care providers can use a structured approach to the workup and management of new cognitive symptoms. Comprehensive MEDLINE and PubMed searches were performed to develop an unbiased, practical diagnostic approach to these symptoms. This review guides primary care providers in the workup, diagnosis, delivery, and initial management of patients presenting with new cognitive symptoms.

Breast feeding and intergenerational social mobility: what are the mechanisms?

OBJECTIVE

To investigate the association between breast feeding and intergenerational social mobility and the possible mediating role of neurological and stress mechanisms.

DESIGN

Secondary analysis of data from the 1958 and the 1970 British Cohort Studies.

SETTING

Longitudinal study of individuals born in Britain during 1 week in 1958 and 1970.

PARTICIPANTS

17 419 individuals participated in the 1958 cohort and 16 771 in the 1970 cohort. The effect of breast feeding on intergenerational social mobility from age 10/11 to age 33/34 was analysed after multiple imputations to fill in missing data and propensity score matching on a wide range of confounders measured in childhood (1958 cohort N=16 039-16 154; 1970 cohort N=16 255-16 361).

MAIN OUTCOME MEASURES

Own Registrar General's Social Class (RGSC) at 33/34 years adjusted for father's RGSC at 10/11 years, gender and their interaction.

RESULTS

Breastfed individuals were more likely to be upwardly mobile (1958 cohort: OR 1.24 95% CI 1.12 to 1.38; 1970 cohort: OR 1.24 95% CI 1.12 to 1.37) and less likely to be downwardly mobile (1958 cohort: OR 0.81 95% CI 0.73 to 0.90; 1970 cohort: OR 0.79 95% CI 0.71 to 0.88). In an ordinal regression model, markers of neurological development (cognitive test scores) and stress (emotional stress scores) accounted for approximately 36% of the relationship between breast feeding and social mobility.

CONCLUSIONS

Breast feeding increased the odds of upward social mobility and decreased the odds of downward mobility. Consistent with a causal explanation, the findings were robust to matching on a large number of observable variables and effect sizes were alike for two cohorts with different social distributions of breast feeding. The effect was mediated in part through neurological and stress mechanisms.

Maternal separation in childhood and diurnal cortisol patterns in mid-life: findings from the Whitehall II study

BACKGROUND

Animal studies suggest that maternal separation is associated with alterations in the hypothalamic-pituitary-adrenal (HPA) axis through effects that occur in a critical period following birth. Evidence for an association of the diurnal cortisol rhythm with maternal separation in humans is equivocal.

METHOD

We examined whether maternal separation in childhood is associated with diurnal cortisol pattern in 3712 middle-aged men and women. Two aspects of cortisol release were examined: the cortisol awakening response (CAR) and the diurnal slope in cortisol throughout the day.

RESULTS

Maternal separation in childhood was reported by 12% of participants. Those participants who reported maternal separation had a larger CAR and flatter slopes in cortisol levels compared to those who did not report maternal separation [adjusted mean CAR in those reporting no separation versus separation: 7.1, 95% confidence interval (CI) 6.7-7.5 v. 8.4, 95% CI 7.3-9.5, p = 0.02, corresponding to adjusted mean diurnal slope: -0.129 (95% CI -0.130 to -0.128) v. -0.126 (95% CI -0.128 to -0.124), p = 0.01]. In participants who reported maternal separation, the age of separation was not associated with either cortisol measure (p = 0.11). The association between maternal separation and slope in cortisol secretion was largely explained by smoking behaviour and marital status at the time of sample collection whereas that of the CAR was explained by childhood psychosocial, material factors and adult health behaviours.

CONCLUSIONS

Our findings suggest that maternal separation in childhood is associated with alterations in the diurnal cortisol pattern in middle age. These associations are predominantly accounted for by adult circumstances and behaviours.

Subjective memory complaints in community dwelling healthy older people: the influence of brain and psychopathology

OBJECTIVES

Subjective memory complaints (SMC) are common. We aimed to characterize the relationship between psychiatric illness and white matter disease to SMC in a sample of healthy older people.

MEASUREMENTS

Cognitively normal subjects between 55 and 90 years had age-adjusted and education-adjusted Consortium to Establish a Registry for Alzheimer's disease (CERAD) scores ≤1.5 SD from standard mean. ApoE genotyping was performed using polymerase chain reaction. Sixty subjects (30 SMC, 30 controls) underwent 3T MRI, which was rated by two raters blinded to the diagnosis, for periventricular (PVH) and deep white matter hyperintensities (DWMH) using the Fazekas scale. Subjective memory was assessed by asking the participant, Do you feel like your memory or thinking is becoming worse?

RESULTS

Two hundred and fifteen volunteers were assessed. Ninety-six were cognitively normal (mean age 62.5 years). SMC were reported by 52/96 subjects (54%). These were compared with subjects who denied SMC. Participants with a history of depression or anxiety were more likely to have SMC (p = 0.02). The frequency distribution of ApoE4 allele and CERAD scores were similar. White matter load was similar (p ≤ 0.47), with a high prevalence of PVH and DWMH seen (100% and 88% of scans, respectively).

CONCLUSION

Both SMC and white matter disease were common. SMC were associated with a history of depression or anxiety but not with white matter disease. Evaluation for a history of depression and anxiety in people with SMC is supported by these findings.

Transportation and driving in longitudinal studies on ageing

BACKGROUND

the associations between transportation, driving and successful ageing are as yet poorly understood. As longitudinal studies are the best methodology for clarifying associations and relationships between health, ageing and environmental factors, we sought to determine how transportation is incorporated into longitudinal studies, and which aspects are assessed.

METHODS

of 55 longitudinal studies on ageing on the National Institute on Aging register, online survey instruments, where available, were scrutinised for references to transport. Where unavailable, principal investigators were contacted by mail/email/phone and asked to forward questions on transportation and driving. Questions were classified into (i) systems, (ii) resources, (iii) transport satisfaction and (iv) mobility needs.

RESULTS

of 55 studies, we could review 36 questionnaires (28 personal replies, 9 accessible online survey instruments). Sixteen had no reference to driving or transportation, 20 (61%) had public transport components and 12 (31%) included questions about driving. Questions covered systems (17), transportation needs (12), transportation resources (11) and transportation satisfaction (4).

CONCLUSION

transport is under-represented in ongoing longitudinal studies, with emphases on public transport, systems and resources, rather than driving and satisfaction. Future waves of studies could usefully review their survey instruments to better measure older people's preferences on transport options and satisfaction.

The effect of employment on psychological health in mid-adulthood: findings from the 1970 British Cohort Study

BACKGROUND

A negative link between unemployment and psychological health is well documented, yet little is known about the protective effect of continuous employment on psychological health.

METHOD

In this prospective population-based cohort study, the effect of continuous employment on psychological health was examined, using individuals born in Great Britain during a week of April 1970. Respondents (2901 men and 3288 women) who were employed at the age of 26 years, with a complete employment history between ages 26 and 30 years and having information about cohabitation, social class and psychological and physical health at age 30 years, were included in the analysis.

RESULTS

Findings showed that continuous employment was associated with better psychological health in men. This effect was somewhat greater in those who showed evidence of poorer psychological health at the age of 26 years. In working women, cohabitation provided a protective effect on psychological health.

CONCLUSION

The findings show that, for men, staying in continuous employment despite experiencing poor psychological health may contribute to better psychological health.

Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study

BACKGROUND

Birthweight varies according to ethnic group, but it is not clear why such differences exist. We examine the contribution of socioeconomic, maternal and behavioural factors to differences in mean birthweight and the prevalence of low birthweight across ethnic groups.

METHODS

Data from the nationally representative UK Millennium Cohort Study (n = 16,157) on White, Indian, Pakistani, Bangladeshi, Black Caribbean and Black African infants were analysed. Cohort members were born in 2000-02, and data on birthweight, maternal, infant, behavioural and socioeconomic factors were collected by home interviews.

RESULTS

Indian, Pakistani and Bangladeshi infants were 280-350 g lighter, and 2.5 times more likely to be low birthweight compared with White infants. Black Caribbean infants were 150 g and Black African infants 70 g lighter compared with White infants, and Black Caribbean and Black African infants were 60% more likely to be low birthweight compared with White infants. For Black Caribbean, Black African, Bangladeshi and Pakistani infants, socioeconomic factors were important in explaining birthweight differences and, for Indian and Bangladeshi infants, maternal and infant factors were important in explaining birthweight differences.

CONCLUSION

Future policies aimed at reducing inequalities in birthweight must pay attention to the different socioeconomic and culturally-related profiles of ethnic minority groups in the UK.

Social position and minor psychiatric morbidity over time in the British Household Panel Survey 1991-1998

STUDY OBJECTIVE

To examine social inequalities in minor psychiatric morbidity as measured by the GHQ-12 using lagged models of psychiatric morbidity and changing job status.

DESIGN

GHQ scores were modelled using two level hierarchical regression models with measurement occasions nested within individuals. The paper compares and contrasts three different ways of describing social position: income, social advantage and lifestyle (the Cambridge scale), and social class (the new National Statistics Socio-Economic Classification), and adjusts for attrition.

SETTING

Survey interviews for a nationally representative sample of adults of working age living in Britain.

PARTICIPANTS

8091 original adult respondents in 1991 who remain of working age during 1991-1998 from the British Household Panel Survey (BHPS).

MAIN RESULTS

There was a relation of GHQ-12 to social position when social position was combined with employment status. This relation itself varied according to a person's psychological health in the previous year.

CONCLUSIONS

The relation between social position and minor psychiatric morbidity depended on whether or not a person was employed, unemployed, or economically inactive. It was stronger in those with previously less good psychological health. Among employed men and women in good health, GHQ-12 varied little according to social class, status, or income. There was a "classic" social gradient in psychiatric morbidity, with worse health in less advantaged groups, among the economically inactive. Among the unemployed, a "reverse" gradient was found: the impact of unemployment on minor psychiatric morbidity was higher for those who were previously in a more advantaged social class position.

Gender differences in the relationship of partner's social class to behavioural risk factors and social support in the Whitehall II study

In most countries health inequality in women appears to be greater when their socio-economic position is measured according to the occupation of male partners or spouses than the women's own occupations. Very few studies show social gradients in men's health according to the occupation of their female partners. This paper aims to explore the reasons for the differences in social inequality in cardiovascular disease between men and women by analysing the associations between own or spouses (or partners) socio-economic position and a set of risk factors for prevalent chronic diseases. Study participants were married or cohabiting London based civil servants included in the Whitehall II study. Socio-economic position of study participants was measured according to civil service grade; socio-economic position of the spouses and partners according to the Registrar General's social class schema. Risk factors were smoking, diet, exercise, alcohol consumption, and measures of social support. In no case was risk factor exposure more affected by the socio-economic position of a female partner than that of a male study participant. Wives' social class membership made no difference at all to the likelihood that male Whitehall participants were smokers, or took little exercise. Female participants' exercise and particularly smoking habit was, in contrast, related to their spouse's social class independently of their own grade of employment. Diet quality was affected equally by the socio-economic position of both male and female partners. Unlike the behavioural risk factors, the degree of social support reported by women participants was in general not strongly negatively affected by their husband or partner being in a less advantaged social class. However, non-employment in the husband or partner was associated with relatively lower levels of positive, and higher negative social support, while men with non-working wives or partners were unaffected. Studying gender differences in health inequality highlights some of the problems in health inequality research more broadly. We are brought face to face with the fact that the development of conceptual models that can be applied consistently to aetiology in both men and women are still at an early stage of development. Closer attention is needed to the different processes behind material power and 'emotional power' within the household when investigating gender differences in health and risk factors.

Employment status, employment conditions, and limiting illness: prospective evidence from the British household panel survey 1991-2001

OBJECTIVES

To assess the relation of the incidence of, and recovery from, limiting illness to employment status, occupational social class, and income over time in an initially healthy sample of working age men and women.

METHODS

Cox proportional hazards models.

RESULTS

There were large differences in the risk of limiting illness according to occupational social class, with men and women in the least favourable employment conditions nearly four times more likely to become ill than those in the most favourable. Unemployment and economic inactivity also had a powerful effect on illness incidence. Limiting illness was not a permanent state for most participants in the study. Employment status was also related to recovery.

CONCLUSIONS

Having secure employment in favourable working conditions greatly reduces the risk of healthy people developing limiting illness. Secure employment increases the likelihood of recovery. These findings have considerable implications for both health inequality and economic policies.

A life course approach to assessing causes of dental caries experience: the relationship between biological, behavioural, socio-economic and psychological conditions and caries in adolescents

The objective of this study was to further elucidate the relationship between relevant biological, behavioural, socio-economic and psychological conditions, experienced in very early life and along the life course, and dental caries experience using the life course approach. A two-phase study was carried out in Brazil. In the first phase, 652 13-year-olds were clinically examined and interviewed. In the second phase, 330 families were randomly selected for interview to collect information on the teenagers' early years of life. Clinical assessment included dental caries, periodontal and traumatic dental injury status. The data analysis involved multiple logistic regression analysis. Adolescents born in a non-brick house, those with a low birth weight and those who were the second or later child in the family were statistically significantly more likely to have a high DMF-T. In conclusion, the results of this study show that there is an association between socio-economic and biological factors in very early life and levels of caries in adolescents.

Social inequalities in health by individual and household measures of social position in a cohort of healthy people

STUDY OBJECTIVE

It is increasingly recognised that different dimensions of social inequality may be linked to health by different pathways. Furthermore, factors operating at the individual level such as employment conditions may affect health in a different way from household level factors. The paper examines the associations between self rated health and four measures of social position- occupational class, household social advantage, personal and household income.

DESIGN

Multilevel logistic regression models were used to predict self rated health using longitudinal data from the British Household panel survey (BHPS) with respondents nested within households. Separate analyses were carried out for economically active and inactive respondents.

SETTING

Interview based surveys of adults living within households that are representative of British households.

PARTICIPANTS

Adult respondents from the BHPS.

MAIN RESULTS

Occupational class has relatively strong effects on the self rated health of the economically active, although household level factors also seem to influence their health. Household social advantage has relatively strong effects on the self rated health of the economically inactive.

CONCLUSIONS

The paper found evidence in support of the view that different dimensions of social inequality have different pathways to self rated health. There are unexplained similarities in health between household members, which require further investigation.

Place and personal circumstances in a multilevel account of women's long-term illness

This paper investigates geographical variations in women's reports of limiting long-term illness in terms of individual inequalities and the contribution of area characteristics among wards and county districts. We use multilevel modelling of linked census data from the Office for National Statistics Longitudinal Study for England and Wales. We follow a random sample of 76.374 women aged between 16 and 45 at the time of the 1971 Census for 20 years to observe their reported limiting long-term illness (LLTI) at the 1991 Census. Car and home ownership were useful markers of social and material advantage, apparently protecting against the risk of reporting LLTI. Migration into the South-East region appeared beneficial, but otherwise there was little difference between those who moved home and those who did not. Differences between county districts persist after adjustment for individual circumstances (education and ethnicity), but almost all of these differences are explained by the social profile of wards in these areas. Geographical differences in LLTI are not, therefore, entirely explained by the distribution of individual characteristics: a woman with the same history may face a different risk of illness in different kinds of area. For women, the social composition of the locality (using the ward as a proxy) is more relevant than the broader economic and industrial classification of the surrounding county district, which is more important for health inequalities among men.

Characteristics of individuals and characteristics of areas: investigating their influence on health in the Whitehall II study

There is evidence that health is determined by macro-level factors as well as by individual risk factors. Using data from the Whitehall II study we consider area-level determinants of health and ask two related questions. Firstly, are health differences between areas explained by the individual risk profiles of residents in those areas? Secondly, since poorer people tend to live in poorer places, are individual socio-economic effects on health explained by where people live? The demographic characteristics of residents, level of deprivation in the area, housing and neighbourhood quality and social integration were independently associated with health but did not fully explain differences between areas. Although there was considerable residential polarisation, area deprivation did not explain why lower status participants had poorer health.

Dimensions of social inequality in the health of women in England: occupational, material and behavioural pathways

This paper examines the role of behavioural and psychosocial risk and protective factors in explaining social inequalities in the general self-assessed health of women. Using path analysis, data from the Health Survey for England (1993) are used to demonstrate how different dimensions of social position (working conditions, general social advantage and material deprivation) have distinct pathways to ill-health. Smoking, diet, alcohol consumption, exercise, social support and job strain were all related to poorer health, but not always in the predicted direction. The effects of social position on health were not fully mediated through these risk and protective factors. Each dimension of social position had unique pathways to ill-health via other unidentified mechanisms. Furthermore, the salience of the three dimensions of social position differed according to the level of labour market attachment. Different path models are required to fit the data for women at home or in full-time or part-time work.

Social distribution of cardiovascular disease risk factors: change among men in England 1984-1993

OBJECTIVE

To investigate change in the social distribution of some of the main risk factors for cardiovascular disease in men in England during a period when inequality in cardiovascular disease mortality widened

DESIGN

Age standardised comparison of the social distribution of seven known risk factors for cardiovascular disease (body mass index, waist to hip ratio, systolic and diastolic blood pressure, consumption of fresh green vegetables, leisure time exercise, cigarette smoking and levels of social support) in two large cross sectional representative samples of the English population.

SUBJECTS

Men aged 20-64 years in the 1984 Health and Lifestyle Survey (excluding Scotland and Wales) first sweep and the 1993 Health Survey for England.

MAIN OUTCOME MEASURES

Mean values of continuous variables; age adjusted proportions of categorical variables; change in the relative index of inequality for each risk factor.

RESULTS

The overall prevalence of cardiovascular disease risk factors improved during the period in which cardiovascular disease mortality was falling. The social distribution of cardiovascular disease risk factors, in contrast, did not become more extreme. Increases in the relative index of inequality for angina from 1.75 to 1.86, for eating vegetables less than once a day from 1.76 in 1984 to 1.96 in 1993, and an apparently larger increase in inequality of social support, from 1.92 to 2.53 were not statistically significant. In most cases the degree of inequality in risk factors tended to narrow non-significantly: for example the relative index of inequality fell from 5.02 in 1984 to 3.07 in 1993 for systolic blood pressure, from 5.60 to 4.29 for current smoking and from 6.24 to 4.19 for eating other than wholemeal bread as the main form of bread in the diet. The two statistically significant changes in inequality were in the direction of narrowing inequality: from a relative index of inequality of 2.12 to 0.90 for diastolic blood pressure (p<0.01) and from 19.3 to 0.87 (p<0.01) for psychological distress as indicated by the General Health Questionnaire.

CONCLUSIONS

Healthier lifestyle options have not been adopted at a significantly faster rate by middle class than working class people over this time period. At the population level the change in risk factors is consistent with falling cardiovascular mortality. The change in the social distribution of risk factors within the population, however, shows little or no relation to the pattern of widening inequality in cardiovascular mortality. This may be because the effect is lagged, or because the adoption of healthier behaviour confers greater benefits on those in higher socioeconomic status groups.

The "inverse housing law" and respiratory health

STUDY OBJECTIVE

To investigate whether there is a mismatch within Britain between climate severity and housing quality ("inverse housing law") and whether this mismatch is associated with respiratory health.

DESIGN, SETTING AND PARTICIPANTS

Cross sectional observational study. Britain (Scotland, Wales and England). The 3023 male and 3694 female Health and Lifestyle Survey participants with valid data available on all relevant items.

MAIN RESULTS

Geographical mapping shows a mismatch between climate severity and housing quality. Individual level analysis shows that lung function is associated with climate and housing, and their interaction, independently of cigarette smoking status. The physical quality of the housing seems to be most important to respiratory health in areas with harsh climate.

CONCLUSIONS

Interpretation must be cautious because cross sectional data have been used to investigate processes that are longitudinal and, possibly, selective. Nevertheless, there does seem to be an "inverse housing law", such that some of the worst quality housing is found in areas with severe climate; and, on the balance of probabilities, this inverse housing law affects respiratory health.

Do attitude and area influence health? A multilevel approach to health inequalities

This paper demonstrates an area effect on health and suggests improvements in research practice for work in this field. We use an area classification which can be related clearly to factors that influence the health of individuals and take account of people's differing propensities to draw influence from their area. Multilevel analysis demonstrates that the degree of deindustrialisation which an area experienced in Britain, in the 1980s, has an independent association with the health of resident individuals. A significant relationship between a person's attitude to their community and their health is shown to be independent of individual and area characteristics. We conclude that both individual and area characteristics influence health.

Comparing health inequality in men and women: prospective study of mortality 1986-96

OBJECTIVES

To study prospectively the differences in health inequality in men and women from 1986-96 using the Office for National Statistics' longitudinal study and new socioeconomic classification. To assess the relative importance of social class (based on employment characteristics) and social position according to the general social advantage of the household to mortality risk in men and women.

DESIGN

Prospective study.

SETTING

England and Wales.

SUBJECTS

Men and women of working age at the time of the 1981 census, with a recorded occupation.

MAIN OUTCOME MEASURES

Mortality.

RESULTS

In men, social class based on employment relations, measured according to the Office for National Statistics' socioeconomic classification, was the most important influence on mortality. In women, social class based on individual employment relations and conditions showed only a weak gradient. Large differences in risk of mortality in women were found, however, when social position was measured according to the general social advantage in the household.

CONCLUSIONS

Comparisons of the extent of health inequality in men and women are affected by the measures of social inequality used. For women, even those in paid work, classifications based on characteristics of the employment situation may give a considerable underestimate. The Office for National Statistics' new measure of socioeconomic position is useful for assessing health inequality in men, but in women a more important predictor of mortality is inequality in general social advantage of the household.

Birth weight and the metabolic syndrome: thrifty phenotype or thrifty genotype?

BACKGROUND

Inverse correlations have been reported between birth weight and the Metabolic Syndrome (abdominal obesity, insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemia, and hypertension). These correlations are thought to reflect primarily nutritional inadequacies during fetal and early life. We explored familial influences on these correlations.

METHODS

Using birth weight data on 602 subjects from 65 pedigrees, we partitioned phenotypic correlations into familial and non-familial. The former are usually regarded as reflecting primarily genetic influences, although they may also reflect environmental influences that are shared by family members, and the latter reflect random environmental influences.

RESULTS

A consistent pattern of positive familial and inverse non-familial correlations were observed. The strongest familial correlations were between birth weight and fasting insulin (r = 0.58, p = 0.002), leptin (r = 0.48, p = 0.021), split proinsulin (r=0.51, p = 0.090), and heart rate (r = 0.39, p = 0.037). An inverse familial correlation was observed with HDL cholesterol (r = -0.28, p = 0.018). Non-familial correlations were weaker and only two-- subscapular-to-triceps skinfold ratio and fasting insulin--were statistically significant.

CONCLUSION

Since the familial and non-familial correlations were in opposite directions, we attribute the former to the pleiotropic effects of genes. Specifically, we conclude that genes that increase birth weight also worsen the Metabolic Syndrome in adult life. Since the inverse correlations reported in the literature reflect mainly cohorts born in the early part of the 20th century, improved maternal nutrition since then may have allowed the expression of genetic influences in our participants, all of whom were born after 1950.

Understanding social variation in cardiovascular risk factors in women and men: the advantage of theoretically based measures

Many studies have attempted to understand observed social variations in cardiovascular disease in terms of sets of intermediate or confounding risk factors. Tests of these models have tended to produce inconsistent evidence. This paper examines the relationships to cardiovascular risk factors or two theoretically based measures of social position. It shows that the strength of the relationships between social position and cardiovascular risk factors varies according to the definition of social position which is used: there is a closer relationship between most health behaviours and the Cambridge scale, an indicator of 'general social advantage and lifestyle', whereas the Erikson-Goldthorpe schema, which is based on employment relations and conditions, is more strongly related to work control and breathlessness. The implications of these findings for understanding the conflicting evidence in other studies of health inequalities are then discussed. The paper concludes that inconsistencies between studies may be in part due to unexamined differences between the conceptual bases of the measures of social position they use, combined with a failure to make explicit the hypothetical mechanisms of effect. If neither the conceptual basis of the measure of social position, nor the links between social position and health outcome tested in each study are clear, inconsistencies between studies will be difficult to interpret, making policy recommendations highly problematic.

Social position, social roles and women's health in England: changing relationships 1984-1993

The aim of this study is to investigate the relationships between social roles, social position and health in English women using theoretically derived measures of social position. Data are taken from the Health and Lifestyle Survey, carried out between 1984-1985, and the Health Survey for England of 1993. First the paper asks whether health inequality in women is still evident when theoretically derived measures (the Erikson-Goldthorpe schema and the Cambridge scale) are used. It goes on to explore the extent to which different combinations of family roles and employment circumstances might affect social variations in health. Finally, the paper shows that health differences between women in different combinations of social roles were not the same in 1993 as in 1984 and examines some reasons why this change may have occurred.

Does health-selective mobility account for socioeconomic differences in health? Evidence from England and Wales, 1971 to 1991

The paper uses data from a sample of 1 percent of the male population of England and Wales to examine the contribution of social mobility between the censuses of 1971 and 1981 to socioeconomic differences in health. Compared to others in their social class of origin, men who had been downwardly mobile were more likely, and the upwardly mobile were less likely, to report a limiting long-term illness. However, when compared to others in their classes of destination, those who moved down reported less illness, and the upwardly mobile reported more. Prevalence of ill health in mobile men was somewhere between that in the group they left and the group they joined. Social mobility was a common event and, combined with existing socioeconomic differences in health, it acted to constrain rather than to increase these differences.

Development of a policy for patients receiving neuromuscular blocking agents

PURPOSE

To develop a policy to standardize the care of patients paralyzed with neuromuscular blocking agents (NMBAs).

METHODS

Criteria were developed to assess adherence to the policy. Categorical and continuous data were collected and analyzed.

RESULTS

Deficiencies were identified in frequency of train-of-four monitoring and in carrying out daily discontinuation of NMBAs to allow effects of paralysis to dissipate.

CONCLUSIONS

The policy was useful as an educational tool. A NMBA order form should be developed to improve adherence to the policy.

Health and the life course: why safety nets matter

This article argues that a life course approach is necessary to understand social variations in health. This is needed in order to take into account the complex ways in which biological risk interacts with economic, social, and psychological factors in the development of chronic disease. Such an approach reveals biological and social "critical periods" during which social policies that will defend individuals against an accumulation of risk are particularly important. In many ways, the authors of modern welfare states were implicitly addressing these issues, and the contribution of these policies to present day high standards of health in developed countries should not be ignored.