213 Can Styloid Process and Internal Carotid Artery Anatomy Be Used to Predict Carotid Artery Dissection?

Aim

Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis.

Method

Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls.

Results

Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5mm and styloid process-internal carotid distance was 5.14mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection.

Conclusions

In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements cannot be used to predict the possibility of a CCAD following trauma.

O28 Can styloid process and internal carotid artery anatomy be used to predict carotid artery dissection?

Introduction

Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis.

Method

Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls.

Result

Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection.

Conclusion

In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma.

Take-home Message

Anatomy of the styloid process and calcification of the styloid-hyoid ligament are highly variable and many independent factors may contribute to the risk of cervical carotid artery dissection. Radiological measurements of the styloid process alone cannot be used to predict risk and likelihood of cervical carotid artery dissection.

The Value of Navigators in Breast Cancer Management in a South African Hospital

BACKGROUND

Specialist breast cancer nurses (BCNs) have improved the psychological care and follow-up rates of breast cancer (BC) patients. This study sought to determine if breast cancer research workers (BCRWs) as de facto BCNs impacted patients' adherence to treatment by comparing groups with and without these patient navigators; hence assessing our need for BCNs.

METHODS

Two groups BC patients booked for primary chemotherapy compared. Study group 1 (SG1): no BCRWs/BCNs. Study group 2 (SG2): BCRWs involvement. Assessment of numbers completing primary chemotherapy, undergoing surgery post-neoadjuvant chemotherapy and BCRWs interventions.

RESULTS

SG1: n = 281, 25-89y, mean 52.7y, Stage 4: 35.6%, Stage 3: 64.4%. SG2: n = 154, 21-85y, mean 52.6y, Stage 4: 47.4%, Stage 3: 43.3%, Stage 2: 9%. Primary chemotherapy not completed SG1: 40.2% (113) versus SG2: 13.5% (21); p < 0.00001. SG1: 88% not completing were lost to follow-up. Excluding peri-chemotherapy deaths and discontinuation: SG1: 37.1% did not complete chemotherapy versus SG2: 2.6%, p < 0.00001. SG2: BCRWs: 107 interventions for 58 (37.7%) patients. Therapeutic breast surgery SG1: 103/181 (56.9%) versus SG2: 66/81 (81.5%); p < 0.0001. SG1: main reasons for not having surgery: lost to follow-up during (n = 58) or after (n = 9) chemotherapy. Follow-up SG2: 12-43 months, mortality: 52% (80/154), no lost to follow-ups. SG1: No mortality data.

CONCLUSIONS

In our setting, BC patients often do not attend or complete treatments. In this study, BCRWs as de-facto BCNs were beneficial for BC patient care, improving chemotherapy compliance and therapeutic surgical interventions. This highlights the need for BCNs for the management of BC patients in South Africa.

Prevalence of comorbidities in women with and without breast cancer in Soweto, South Africa: Results from the SABC study

BACKGROUND

Comorbidities occurring concurrently in breast cancer patients can be burdensome, as they may negatively influence time and stage of presentation.

OBJECTIVES

To describe the comorbid health conditions among South African (SA) black women with and without breast cancer and to determine factors associated with advanced-stage presentation of breast cancer.

METHODS

A population-based case-control study on breast cancer was conducted in black women in Soweto, SA, the SABC (South Africa Breast Cancer) study. Lifestyle information and blood samples were collected from 399 women with histologically confirmed new cases of invasive primary breast cancer, recruited prior to any therapy, and 399 age- and neighbourhood-matched controls without breast cancer. We compared self-reported metabolic diseases, depression, anthropometric measurements, blood pressure, HIV status and point-of-care lipid and glucose levels between patients with breast cancer and the control group.

RESULTS

In the whole population, the mean (standard deviation) age was 54.6 (12.9) years, the majority (81.2%) of the participants were overweight or obese, 85.3% had abdominal adiposity, 61.3% were hypertensive, 47.1% had impaired fasting plasma glucose, 8.4% had elevated total cholesterol, 74.8% had low high-density lipoprotein and 10.9% were assessed to be depressed. Ninety-one percent of the whole cohort had at least one metabolic disease. In the breast cancer group, 72.2% had one or more metabolic diseases only (HIV-negative and no evidence of depression), compared with 64.7% of the control group. From a multivariate logistic regression adjusted model, higher household socioeconomic status conferred a 19% reduction in the odds of having advanced-stage breast cancer at diagnosis, while hypertension, dyslipidaemia and HIV were not significantly associated with stage at breast cancer diagnosis in the adjusted model.

CONCLUSIONS

A large proportion of women experience several comorbidities, highlighting the need to address the chronic non-communicable disease epidemic in SA and to co-ordinate multidisciplinary primary-, secondary- and tertiary-level care in the country's complex healthcare system for better outcome.

Retrospective case-series analysis of haematological malignancies in goldmining areas of South Africa

BACKGROUND

South Africa (SA)'s high levels of environmental contamination of mine tailings from uranium and its decay products, coupled with remarkably short distances between mine tailings and residential areas, raise concern about whether there is an association between environmental uranium exposure and risk of cancer, including haematological malignancies.

OBJECTIVES

We reviewed information on cases from the central hospital offering cancer diagnostics and treatment in a major mining area of SA to describe their basic clinical and demographic characteristics, as part of assessing whether a cancer epidemiological study in this area would be feasible.

METHODS

Basic clinical, demographic and residential information on patients with haematological malignancy diagnosed between 2004 and 2013 was collected retrospectively from the patient files at Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg.

RESULTS

In total, 1 880 patients aged 18 - 94 years were identified. Referral from distant provinces was not uncommon, but >80% lived within 50 km of the hospital. Non-Hodgkin's lymphoma accounted for 44% of the haematological malignancies, followed by leukaemia with 26%. HIV status was known for 93% of the patients, of whom 47% were HIV-positive.

CONCLUSIONS

Caution is required when interpreting spatial distributions of patients, given inaccuracies in residential addresses and referral patterns to the hospital, and with HIV and other infections probable important confounders. Our study therefore shows that active case recruitment is required for accurate assessment of residential information. However, some findings on spatial distributions in the study warrant the continuation of efforts to develop a study protocol to investigate the possible link between uranium exposure in mining areas and haematological malignancies in residents. Disproportionately high incidence rates of haematological malignancies observed in specific districts would be relevant for further investigation.

Breast cancer trends differ by ethnicity: a report from the South African National Cancer Registry (1994-2009)

Background

To describe breast cancer (BC) incidence and mortality by ethnicity in South Africa (SA).

Methods

Sources of data included the South African National Cancer Registry (NCR) pathology-based reports (1994–2009) and Statistics South Africa (SSA) mortality data (1997–2009). Numbers of cases, age-standardised incidence rates (ASIR) and lifetime risk (LR) were extracted from the NCR database for 1994–2009. Age-specific incidence rates were calculated for five-year age categories. The direct method of standardisation was employed to calculate age-standardised mortality rates (ASMR) using mortality data.

Results

Between 1994 and 2009, there were 85 561 female BC. For the Black, Coloured and Asian groups, increases in ASIR and LR were observed between 1994 and 2009. In 2009, the ASIR for the total population, Blacks, Whites, Coloureds and Asians were 26.9, 18.7, 50.2, 40.9 and 51.2 per 100 000, respectively. For Asians, an increase in proportion of BC as a percentage of all female cancers was observed between 1994 and 2002 (11.1%) and continued to increase to 2009 (a further 4.5%). Whites and Asians presented higher incidences of BC at earlier ages compared with Blacks and Coloureds in 2009. In 1998, there were 1618 BC deaths in SA compared with 2784 deaths in 2009. ASMR between 1997 and 2004 increased but stabilised thereafter.

Conclusion

This paper demonstrated that SA BC incidence rates are similar to other countries in the region, but lower than other countries with similar health systems. Ethnic differences in BC trends were observed. However, the reasons for observed ethnic differences are unclear.

Characteristics of persons convicted for offences relating to animal hoarding in New South Wales

OBJECTIVE

To highlight the characteristics of persons convicted for offences related to animal hoarding in New South Wales, Australia, document the outcomes of cases and compare them with overseas studies.

DESIGN

Retrospective case series.

METHODS

Records of finalised prosecutions for offences relating to animal hoarding between 2005 and 2011 were examined. Data recorded included: the age of each subject at the first offence, sex, postcode, occupation, living conditions, number of charges, number of prosecutions, title of each charge, number and species of live animals, whether animals needed veterinary attention, the medical conditions that the animals suffered, whether dead animals were on the property, how animals were obtained, veterinary and legal costs accrued and case outcomes. The data were analysed to obtain frequencies and relative frequencies for categorical variables and summary statistics for quantitative variables. Observed frequencies were compared using Chi-square test with the expected frequencies calculated based on the Australian Bureau of Statistics data for NSW.

RESULTS

The number of persons included was 29. Most were female (72.4%) and 23 were 40-64 years of age at their first offence. Almost one-third identified themselves as breeders, eight as pensioners and four as unemployed. Most resided in inner regional Australia (45%), 28% lived in major cities and 28% lived in outer regional Australia. Dogs were the species hoarded in 80% of cases. Animals requiring veterinary attention were identified in all cases. Dead animals were found on premises in 41.4% of cases.

CONCLUSIONS

Persons prosecuted for charges relating to animal hoarding in NSW have similar characteristics to those of previous studies, although the outcomes may be different. More farm animals and horses were hoarded in NSW and hoarders in NSW were more likely to live in inner regional and outer regional areas (rural areas) than animal hoarders in the USA.

Down-staging of breast cancer in the pre-screening era: Experiences from Chris Hani Baragwanath Academic Hospital, Soweto, South Africa

We aimed to investigate the stage of breast cancer at first diagnosis and assess possible determinants of late-stage presentation. A consecutive series of women with newly diagnosed breast cancer at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, South Africa were analysed. We retrospectively reviewed electronic patient records. Data were extracted for: (i ) stage and year at diagnosis; (ii ) travel distance (estimated straight-line distance from GPS-coded residential address to CHBAH); (iii ) receptor subtypes; and (iv ) age of patient. Generalised linear models were applied to estimate risk ratios for late- v. early-stage disease.

Of the patients (N =1 071) studied, the mean age was 55 years and 90% were black Africans. Patients who lived >20 km from the hospital (n =347; 61.8%) presented with late-stage disease (stage 3/4) compared with 50.2% who lived ≤20 km from the hospital (n =724; p =0.02). The majority of patients (74%) >70 years of age who lived >20 km away presented with advanced breast cancer. However, in younger patients, age showed no clear association with stage at presentation. Travel distance was an important predictor of later-stage disease at diagnosis, which was more noticeable in elderly patients. Patients with more aggressive triple-negative and HER2+ tumours presented with later-stage disease.

Residual methylprednisolone suppresses human T-cell responses to spleen, but not islet, extracts from deceased organ donors

Pancreatic islets, transplanted into recipients with type 1 diabetes, are exposed to allogenic and auto-immune T-cell responses. We set out to develop an assay to measure these responses using PBMC. Our approach was to prepare spleen extract from the islet donors (allo-antigen) and islet extracts (auto-antigen). To our surprise, we found that spleen extracts potently inhibited the proliferation of human T cells driven by antigen (tetanus toxoid) and mitogen (anti-CD3 mAb, OKT3), whereas extracts prepared from pancreatic islets from the same donor did not suppress T-cell proliferation. Suppression mediated by spleen extracts was unaffected by blocking mAbs against the IL-10R, transforming growth factor-β or CD152 (CTLA-4). It was also unaffected by denaturing the spleen extracts by heating, exposing to reducing agents or protease digestion. Because deceased organ donors are commonly given the immunosuppressive glucocorticoid methylprednisolone prior to death, we hypothesized that suppression was due to residual methylprednisolone in the spleen extracts. Methylprednisolone could be detected by mass spectrometry in spleen extracts at concentrations that suppress T-cell proliferation. Finally, the glucocorticoid receptor antagonist mifepristone completely reversed the suppression caused by the spleen extracts. We conclude that extracts of human spleen, but not islets, from deceased organ donors contain sufficient residual methylprednisolone to suppress the proliferation of T-cells in vitro.

The microtubule depolymerizing agent CYT997 causes extensive ablation of tumor vasculature in vivo

The orally active microtubule-disrupting agent (S)-1-ethyl-3-(2-methoxy-4-(5-methyl-4-((1-(pyridin-3-yl)butyl)amino)pyrimidin-2-yl)phenyl)urea (CYT997), reported previously by us (Bioorg Med Chem Lett 19:4639-4642, 2009; Mol Cancer Ther 8:3036-3045, 2009), is potently cytotoxic to a variety of cancer cell lines in vitro and shows antitumor activity in vivo. In addition to its cytotoxic activity, CYT997 possesses antivascular effects on tumor vasculature. To further characterize the vascular disrupting activity of CYT997 in terms of dose and temporal effects, we studied the activity of the compound on endothelial cells in vitro and on tumor blood flow in vivo by using a variety of techniques. In vitro, CYT997 is shown to potently inhibit the proliferation of vascular endothelial growth factor-stimulated human umbilical vein endothelial cells (IC(50) 3.7 ± 1.8 nM) and cause significant morphological changes at 100 nM, including membrane blebbing. Using the method of corrosion casting visualized with scanning electron microscopy, a single dose of CYT997 (7.5 mg/kg i.p.) in a metastatic cancer model was shown to cause destruction of tumor microvasculature in metastatic lesions. Furthermore, repeat dosing of CYT997 at 10 mg/kg and above (intraperitoneally, b.i.d.) was shown to effectively inhibit development of liver metastases. The time and dose dependence of the antivascular effects were studied in a DLD-1 colon adenocarcinoma xenograft model using the fluorescent dye Hoechst 33342. CYT997 demonstrated rapid and dose-dependent vascular shutdown, which persists for more than 24 h after a single oral dose. Together, the data demonstrate that CYT997 possesses potent antivascular activity and support continuing development of this promising compound.

CYT997: a novel orally active tubulin polymerization inhibitor with potent cytotoxic and vascular disrupting activity in vitro and in vivo

CYT997 is a wholly synthetic compound that possesses highly potent cytotoxic activity in vitro through inhibition of microtubule polymerization. CYT997 blocks the cell cycle at the G(2)-M boundary, and Western blot analysis indicates an increase in phosphorylated Bcl-2, along with increased expression of cyclin B1. Caspase-3 activation is also observed in cells treated with CYT997 along with the generation of poly(ADP-ribose) polymerase. The compound possesses favorable pharmacokinetic properties, is orally bioavailable, and is efficacious per os in a range of in vivo cancer models, including some refractory to paclitaxel treatment. CYT997 exhibits vascular disrupting activity as measured in vitro by effects on the permeability of human umbilical vein endothelial cell monolayers, and in vivo by effects on tumor blood flow. CYT997 possesses a useful combination of pharmacologic and pharmacokinetic properties and has considerable potential as a novel anticancer agent.

Phenylaminopyrimidines as inhibitors of Janus kinases (JAKs)

A series of phenylaminopyrimidines has been identified as inhibitors of Janus kinases (JAKs). Development of this initial series led to the potent JAK2/JAK1 inhibitor CYT387 (N-(cyanomethyl)-4-[2-[[4-(4-morpholinyl)phenyl]amino]-4-pyrimidinyl]-benzamide). Details of synthesis and SAR studies of these compounds are reported.

Biological evaluation of ent-narciclasine, ent-lycoricidine, and certain enantiomerically-related congeners

The non-natural enantiomeric forms of narciclasine and lycoricidine ((-)-1 and (-)-2, respectively), as well as congeners 3-6 are available through chemoenzymatic synthesis. Accordingly, they have now been tested for their cytotoxic effects in a 13-member human cancer cell-line panel and found to be only weakly active. In contrast, an authentic sample of the natural enantiomeric form of narciclasine ((+)-1) was found to be highly active in the same screens.

Discovery of CYT997: a structurally novel orally active microtubule targeting agent

CYT997 was discovered as a potent tubulin polymerization inhibitor possessing potent cytotoxic activity against a range of cancer cells. Details of SAR studies, pharmacokinetic investigations and synthesis of compounds leading to the discovery of CYT997 are reported.

Solid fuel use and cooking practices as a major risk factor for ALRI mortality among African children

BACKGROUND

Almost half of global child deaths due to acute lower respiratory infections (ALRIs) occur in sub-Saharan Africa, where three-quarters of the population cook with solid fuels. This study aims to quantify the impact of fuel type and cooking practices on childhood ALRI mortality in Africa, and to explore implications for public health interventions.

METHODS

Early-release World Health Survey data for the year 2003 were pooled for 16 African countries. Among 32,620 children born during the last 10 years, 1455 (4.46%) were reported to have died prior to their fifth birthday. Survival analysis was used to examine the impact of different cooking-related parameters on ALRI mortality, defined as cough accompanied by rapid breathing or chest indrawing based on maternal recall of symptoms prior to death.

RESULTS

Solid fuel use increases the risk of ALRI mortality with an adjusted hazard ratio of 2.35 (95% CI 1.22 to 4.52); this association grows stronger with increasing outcome specificity. Differences between households burning solid fuels on a well-ventilated stove and households relying on cleaner fuels are limited. In contrast, cooking with solid fuels in the absence of a chimney or hood is associated with an adjusted hazard ratio of 2.68 (1.38 to 5.23). Outdoor cooking is less harmful than indoor cooking but, overall, stove ventilation emerges as a more significant determinant of ALRI mortality.

CONCLUSIONS

This study shows substantial differences in ALRI mortality risk among African children in relation to cooking practices, and suggests that stove ventilation may be an important means of reducing indoor air pollution.

Discovery of 2-(alpha-methylbenzylamino) pyrazines as potent Type II inhibitors of FMS

A series of 2-(alpha-methylbenzylamino) pyrazines have shown to be potent inhibitors of the FMS tyrosine receptor kinase. Details of SAR studies, modeling and synthesis of compounds within this series are reported.

Determinants of coronary artery calcification progression in renal transplant recipients

Coronary artery calcification (CAC) is associated with increased atherosclerotic burden and cardiovascular events. The objective of this study was to determine the natural history and risk factors associated with CAC progression in a cohort of incident asymptomatic renal transplant recipients with no history of coronary revascularization. Electron-beam computed tomography was performed in 82 subjects at time of transplantation and at least 1 year later. Mean (SD) and median CAC score increased for all subjects from 392.4 (747.9) and 75.8 at time of transplant to 475.3 (873.5), (p = 0.002[log]) and 98.9 (p < 0.001), respectively. Most subjects (89%) with no calcifications remained without calcification. Mean annualized rate (SD) of CAC score change was 52.5 (150) with a median of 0.5. Average yearly percent change was 67.3 (409.6) with a median of 1.4. In multivariate analysis, diastolic blood pressure at 3 months post-transplant, Caucasian race, glomerular filtration rate at 3.0, months post-transplant, body mass index and baseline CAC score were independent predictors of annualized rate of CAC change. There is significant progression of CAC post-renal transplantation in most subjects. Progression is most likely to occur in white patients and is associated with clinical factors such as blood pressure, body mass index, renal function and baseline CAC score.

Early exposure to smoking and future fecundity among Danish twins

Several studies have examined the effect of in utero exposure to smoking and fecundity among the offspring but the findings are contradictory. We therefore studied the waiting time to first pregnancy (TTP) and exposure to smoking in utero and childhood among Danish twins born between 1931 and 1952. Information about TTP, exposure to mothers smoking in pregnancy, exposure to smoking in childhood and current smoking among the male twins and smoking in their own pregnancy among female twins was collected by interview. Fecundability odds ratio (FOR) estimating the odds of conception in a cycle among exposed compared to the unexposed were calculated separately for female and male twins. A total of 1653 female and 1598 male twins reported a TTP. Female twins, exposed in utero, had reduced fecundability after control for confounders (FOR = 0.81; 95% CI 0.67-0.99). A nonsignificant increase in fecundity among male twins exposed to smoking in utero was found (FOR = 1.12; 95% CI 0.89-1.40). Among dizygotic twins of opposite sex sharing the same in utero exposures, the future fecundity of the male twin was unaffected by in utero exposure (FOR = 0.97; 95% CI 0.60-1.55) whereas the female twin had reduced fecundity (FOR = 0.65; 95% CI 0.47-0.91). This study supports that smoking is hazardous to the female fetus not only in the short term but also affects her future ability to conceive and makes it even more important to advise pregnant women to stop smoking.

Enhancing the evidence base for health impact assessment

Health impact assessment differs from other purposes for which evidence is collated in a number of ways, including:the focus on complex interventions or policy and their diverse effects on determinants of health;the need for evidence on the reversibility of adverse factors damaging to health;the diversity of the evidence in terms of relevant disciplines, study designs, quality criteria and sources of information;the broad range of stakeholders involved;the short timescale and limited resources generally available;the pragmatic need to inform decision makers regardless of the quality of the evidence. These have implications for commissioning and conducting reviews. Methods must be developed to: facilitate comprehensive searching across a broad range of disciplines and information sources; collate appropriate quality criteria to assess a range of study designs; synthesise different kinds of evidence; and facilitate timely stakeholder involvement. Good practice standards for reviews are needed to reduce the risk of poor quality recommendations. Advice to decision makers must make explicit limitations resulting from absent, conflicting, or poor quality evidence.

Health impact assessment as an agent of policy change: improving the health impacts of the mayor of London's draft transport strategy

OBJECTIVE

To increase the positive and mitigate the negative health impacts of the mayor's draft transport strategy for London.

DESIGN

A rapid prospective health impact assessment (HIA) of the penultimate draft of the strategy, using a review commissioned by the regional director of public health; an appraisal of congestion charging; and a participatory workshop. Two audits of changes were performed to assess the impact on policy of the HIA process.

SETTING

Regional government policy development.

INTERVENTION

Recommendations from the rapid HIA were fed back into the drafting process.

MAIN OUTCOME MEASURE

Changes (a) between the penultimate draft and the draft for public consultation and (b) between that and the final mayoral strategy.

RESULTS

The draft transport strategy published for consultation differed in a number of respects from the previous version. Almost all the recommendations from the HIA were incorporated into the final strategy. Significant changes included promoting sustainable travel plans for workplaces and schools; giving priority to infrastructure and services that benefit London's deprived communities; increased emphasis on promoting walking and cycling and reducing reliance on private cars; and a commitment to track the health impacts of the final strategy and its implementation. Specific additions included re-allocating road space.

CONCLUSION

HIA was successful in influencing the transport strategy for London, resulting in several improvements from a health viewpoint. HIA is an effective method both for bringing about significant change in policy proposals and in increasing policy makers' understanding of determinants of health and hence in changing attitudes of policy makers.

Predicted health impacts of urban air quality management

STUDY OBJECTIVE

The 1995 UK Environment Act required local authorities to review air quality and, where UK National Air Quality Strategy objectives (except ozone) are likely to be exceeded in 2005, to declare local air quality management areas and prepare action plans. This study modelled the impacts on health of reductions from current levels of PM(10) to these objectives.

DESIGN

The framework for conducting quantified health impact assessment assessed causality, then, if appropriate, examined the shape and magnitude of the exposure-response relations. The study modelled declines in pollution to achieve the objectives, then modelled the numbers of deaths and admissions affected if air pollution declined from existing levels to meet the objectives, using routine data.

SETTING

Westminster, central London.

MAIN RESULTS

Attaining the 2004 PM(10) 24 hour objective in Westminster results in 1-21 lives no longer shortened in one year (annual deaths 1363). Reducing exceedences from 35 to seven almost doubles the estimates. The 2009 objective for the annual mean requires a substantial reduction in PM(10), which would delay 8-20 deaths. About 20 respiratory and 14-20 circulatory admissions would be affected and around 5% of emergency hospital attendances for asthma by attaining the lower annual mean target. The effects of long term exposure to particulates may be an order of magnitude higher: models predict about 24 deaths are delayed by reaching the 2004 annual target (40 microg/m(3)([gravimetric])) and a hundred deaths by reducing annual mean PM(10) to 20 microg/m(3)([gravimetric]).

CONCLUSIONS

Modelling can be used to estimate the potential health impacts of air quality management programmes.

Time To Pregnancy and occupational lead exposure

BACKGROUND

Lead exposure is known to be harmful to the male reproductive system, including impairment of fertility. However, it is unclear whether currently existing low levels of exposure have this effect.

AIMS

To study retrospectively current workers in lead using industries (battery manufacture, smelting, etc), and in non-lead using control industries, in four European countries, with Time To Pregnancy as the outcome variable, as part of the EU funded Asclepios Project.

METHODS

Exposure assessment was mainly by blood lead values, which were available from the late 1970s, supplemented by imputed values where necessary. Three exposure models were studied: (1) short term (recent) exposure; (2) total duration of work in a lead using industry; and (3) cumulative exposure. A Cox proportional hazards model with discrete ties was used for the statistical analysis, with covariates for both partners.

RESULTS

A total of 1104 subjects took part, of whom 638 were occupationally exposed to lead at the relevant time. Blood lead levels were mainly less than 50 microg/dl. No consistent association of Time To Pregnancy with lead exposure was found in any of the exposure models, although reduced fertility was observed in one category each in models (2) and (3).

CONCLUSIONS

This basically negative result is unlikely to be due to the misclassification of key variables, to insufficient statistical power, or to bias, for example, response bias. If any impairment of male reproductive function exists at the levels of occupational lead exposure now current, it does not appear to reduce biological fertility.

How do we make health impact assessment fit for purpose?

Progress has been made in recent years in the process of health impact assessment (HIA), including community involvement. The technical side is less well developed. A minimum requirement is that there should be some consistency or robustness, so that the outcome of an HIA does not depend just on who happens to carry it out, that it is not easily swayed by the vested interests that typically surround any project, and that it can withstand legal challenge. Validity is an important criterion, as well as repeatability, as the latter can be achieved merely by propagating errors. All types of evidence should be considered legitimate, including qualitative and quantitative methods. The quality of evidence, and its generalisability, need to be carefully assessed; we should leave behind the divisive discourse around "positivism". Typically there is less information on the links from interventions (policies or projects) to changes in determinants of health than there is on the immediate precursors of health and ill-health. A practical question is, how the best existing knowledge can be made available to HIA practitioners. Other issues are more tractable than is often thought, e.g. that an HIA has to be able to trade off positive and negative impacts to different groups of people, and that the complexity of social causation prevents clear analysis of cause and effect.

Sperm count and chromatin structure in men exposed to inorganic lead: lowest adverse effect levels

OBJECTIVES

To obtain knowledge on male reproductive toxicity of inorganic lead at current European exposure levels and to establish lowest adverse effect levels, if any.

METHODS

A cross sectional survey of the semen of 503 men employed by 10 companies was conducted in the United Kingdom, Italy, and Belgium. The mean blood lead concentration was 31.0 microg/dl (range 4.6-64.5) in 362 workers exposed to lead and 4.4 microg/dl (range below the detection limit of 19.8) in 141 reference workers. Semen volume and sperm concentration were determined in a fresh semen sample according to an agreed protocol subject to quality assurance. The sperm chromatin structure assay (SCSA) was performed at a centralised laboratory. Extraneous determinants including centre, period of sexual abstinence, and age were taken into account in the statistical analysis. If appropriate, possible thresholds were examined by iterative threshold slope linear regression.

RESULTS

The median sperm concentration was reduced by 49% in men with blood lead concentration above 50 microg/dl. There was no indication of a linear trend of lower sperm concentration with increasing blood lead values, but threshold slope least square regression identified a blood lead concentration of 44 microg/dl (beta=-0.037, F=4.35, p=0.038) as a likely threshold. Abnormal sperm chromatin structure was not related to blood lead concentration, but some indications of deterioration of sperm chromatin was found in men with the highest concentrations of lead within spermatozoa. Biological monitoring data did not indicate long term effects of lead on semen quantity or sperm chromatin.

CONCLUSION

Adverse effects of lead on sperm concentration and susceptibility to acid induced denaturation of sperm chromatin are unlikely at blood lead concentrations below 45 microg/dl. Effects of low level exposure to lead on other measures of testicular function cannot be ruled out.

A framework for the evidence base to support Health Impact Assessment

OBJECTIVE

To introduce a conceptual structure that can be used to organise the evidence base for Health Impact Assessment (HIA).

BACKGROUND

HIA can be used to judge the potential health effects of a policy, programme or project on a population, and the distribution of those effects. Progress has been made in incorporating HIA into routine practice, especially (in the UK) at local level. However, these advances have mainly been restricted to process issues, including policy engagement and community involvement, while the evidence base has been relatively neglected. RELATING POLICIES TO THEIR IMPACT ON HEALTH: The key distinctive feature of HIA is that determinants of health are not taken as given, but rather as factors that themselves have determinants. Nine ways are distinguished in which evidence on health and its determinants can be related to policy, and examples are given from the literature. The most complete of these is an analysis of health effects in the context of a comparison of options. A simple model, the policy/risk assessment model (PRAM), is introduced as a framework that relates changes in levels of exposures or other risk factors to changes in health status. This approach allows a distinction to be made between the technical process of HIA and the political process of decision making, which involves lines of accountability. Extension of the PRAM model to complex policy areas and its adaptation to non-quantitative examples are discussed. ISSUES FOR THE FUTURE: A sound evidence base is essential to the long term reputation of HIA. Research gaps are discussed, especially the need for evidence connecting policy options with changes in determinants of health. It is proposed that policy options could be considered as "exposure" variables in research. The methodology needs to be developed in the course of work on specific issues, concentrated in policy areas that are relatively tractable.

CONCLUSIONS

A system of coordination needs to be established, at national or supranational level, building on existing initiatives. The framework suggested in this paper can be used to collate and evaluate what is already known, both to identify gaps where research is required and to enable an informed judgement to be made about the potential health impacts of policy options. These judgements should be made widely available for policy makers and for those undertaking health impact assessment.

What do we need for robust, quantitative health impact assessment?

Health impact assessment (HIA) aims to make the health consequences of decisions explicit. Decision-makers need to know that the conclusions of HIA are robust. Quantified estimates of potential health impacts may be more influential but there are a number of concerns. First, not everything that can be quantified is important. Second, not everything that is being quantified at present should be, if this cannot be done robustly. Finally, not everything that is important can be quantified: rigorous qualitative HIA will still be needed for a thorough assessment. This paper presents the first published attempt to provide practical guidance on what is required to perform robust, quantitative HIA. Initial steps include profiling the affected populations, obtaining evidence for postulated impacts, and determining how differences in subgroups' exposures and susceptibilities affect impacts. Using epidemiological evidence for HIA is different from carrying out a new study. Key steps in quantifying impacts are mapping the causal pathway, selecting appropriate outcome measures and selecting or developing a statistical model. Evidence from different sources is needed. For many health impacts, evidence of an effect may be scarce and estimates of the size and nature of the relationship may be inadequate. Assumptions and uncertainties must therefore be explicit. Modelled data can sometimes be tested against empirical data but sensitivity analyses are crucial. When scientific problems occur, discontinuing the study is not an option, as HIA is usually intended to inform real decisions. Both qualitative and quantitative elements of HIA must be performed robustly to be of value.

Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London

OBJECTIVE

To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m(2)) in a large unselected geographical population.

DESIGN

Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking.

SUBJECTS

A total of 287,213 completed singleton pregnancies were studied including 176,923 (61.6%) normal weight (BMI 20--24.9), 79 014 (27.5%) moderately obese (BMI 25--29.9) and 31,276 (10.9%) very obese (BMI> or =30) women.

MEASUREMENTS

Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables.

RESULTS

Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25--30 and BMI> or =30 respectively): gestational diabetes mellitus (1.68 (1.53--1.84), 3.6 (3.25--3.98)); proteinuric pre-eclampsia (1.44 (1.28--1.62), 2.14 (1.85--2.47)); induction of labour (2.14 (1.85--2.47), 1.70 (1.64--1.76)); delivery by emergency caesarian section (1.30 (1.25--1.34), 1.83 (1.74--1.93)); postpartum haemorrhage (1.16 (1.12--1.21), 1.39 (1.32--1.46)); genital tract infection (1.24 (1.09--1.41), 1.30 (1.07--1.56)); urinary tract infection (1.17 (1.04-1.33), 1.39 (1.18--1.63)); wound infection (1.27 (1.09--1.48), 2.24 (1.91--2.64)); birthweight above the 90th centile (1.57 (1.50--1.64), 2.36 (2.23--2.50)), and intrauterine death (1.10 (0.94--1.28), 1.40 (1.14--1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65--0.82), 0.81 (0.69--0.95)) and breastfeeding at discharge (0.86 (0.84--0.88), 0.58 (0.56--0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk.

CONCLUSION

Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

The potential contribution of increased vegetable and fruit consumption to health gain in the European Union

BACKGROUND

The risk of many important diseases can be reduced by consuming a diet rich in vegetables and fruit. For this reason the World Health Organization (WHO) recommends a daily intake of more than 400 g person(-1). The pattern of both the supply and intake of vegetables and fruit and the potential health gain achieved by increasing intake in the European Union (EU) and three accession countries are presented in this paper.

METHODS

Patterns of supply and dietary intake were assessed using (1) FAO food balance sheets, which allow comparison between the levels of supply in countries but do not reflect actual intake; and (2) survey data reflecting dietary intake. Using WHO mortality data for coronary heart and cerebrovascular disease and major cancers up to age 65 years, the number of preventable deaths is estimated, assuming vegetable and fruit consumption were levelled up to that of the highest consuming group, and assuming relative risks of 0.5, 0.7 or 0.9.

RESULTS

Vegetable and fruit consumption varies considerably between EU Member States. The populations of about half (seven) of the EU Member States have a mean daily intake of less than 275 g. Using the best current estimates of relative risk, over 26,000 deaths before the age of 65 years would be prevented annually in the EU if intake was levelled up to the highest consumption levels (and about double this number of deaths before the age of 75 years).

CONCLUSION

Increasing the intake of vegetables and fruit is feasible and could result in considerable improvements in public health within the EU. Priority should be given to developing methods that demonstrate the burden of disease caused by too low intakes of vegetables and fruit. This would enable the appropriate social, cultural and economic policies to be developed within the EU.

Prevalence and determinants of erectile dysfunction in hemodialysis patients

BACKGROUND

The prevalence of erectile dysfunction (ED) among patients with end-stage renal disease (ESRD) is not known.

METHODS

A cross-sectional study was conducted to determine the prevalence of ED among a community-based hemodialysis (HD) population using a two-stage cluster random sampling design. The presence and severity of ED were assessed among 302 ESRD patients using the self-administered International Index of Erectile Function-5 (IIEF-5). Logistic regression was used to examine and test associations between ED and other medical conditions.

RESULTS

The prevalence of any level of ED was 82% (95% CI, 76 to 87%) for all HD subjects. The prevalence of severe ED was 45% (CI, 36 to 55%). Subjects younger than 50 years had a prevalence of ED of 63% (CI, 53 to 71%), while in subjects 50 years or older, it was 90% (CI, 84 to 94%). A multivariable analysis demonstrated increasing age (50 to 59, OR = 2.04, 95% CI, 1.3 to 3.1; 60 to 69, OR = 5.5, 95% CI, 1.9 to 15.6) and diabetes (OR = 2.0, 95% CI, 1.2 to 3.3) to be independently associated with the presence of any level of ED. However, neither the subjects' age nor history of diabetes predicted the severity of ED among subjects with ED. The use of angiotensin-converting enzyme inhibitors (ACEIs) was inversely associated with ED (OR = 0.41, 95% CI, 0.17 to 0.98). Poor functional status (Karnofsky score or the Index of Physical Impairment) was not associated with ED.

CONCLUSIONS

ED is extremely prevalent among HD patients. Increasing age, diabetes, and nonuse of ACEIs were associated with higher prevalence of ED. The high prevalence of ED was seen even among patients with good functional status.

Do parental factors affect male and female fertility?

There is little published evidence on parental characteristics and the fertility of their offspring of either sex. Maternal smoking has been reported to reduce fertility in both sexes and was also suggested to be relevant to the health of the male reproductive system on the basis of descriptive epidemiology. We undertook a cohort study based on a sample representative of the British population born in 1958 who have been followed up since birth. The outcome variable was time to pregnancy measured in months, up to age 33 years. Antecedent variables were the age of both parents; maternal smoking, height, prepregnancy body mass index, and parity; and paternal social class (manual/nonmanual labor). First births to cohort members were analyzed using a Cox logistic model for discrete "survival" times. A total of 1,714 and 2,587 values of time to pregnancy were available, respectively, for male and female cohort members. In the unadjusted analyses, all odds ratios were in the range 0.9-1.1, apart from the father's social class. In the adjusted analyses, this effect also disappeared. We conclude that the observed heterogeneity in biological fertility is unrelated to those characteristics of parents that we were able to analyze.

Time to pregnancy among male workers of the reinforced plastics industry in Denmark, Italy and The Netherlands. ASCLEPIOS

OBJECTIVES

The relationship between occupational styrene exposure and male fecundity was examined.

METHODS

Among 1560 Danish, Italian, and Dutch reinforced plastics workers, 220 styrene-exposed workers and 382 unexposed referents who had fathered a child were identified. A total of 768 historical styrene measurements conducted in 1970-1996 in the study companies formed the basis for semiquantitative exposure assessment in combination with measurements of urinary styrene metabolite levels. All the subjects were interviewed about work conditions and other factors potentially related to reduced fecundity. Fecundity was measured as the reported time to pregnancy (number of months a couple needed to conceive their youngest child).

RESULTS

A statistically nonsignificantly reduced fecundity was observed for the styrene-exposed workers [fecundity ratio 0.79, 95% confidence interval (95% CI) 0.59-1.05]. But no consistent pattern of a detrimental effect on fecundity was found when time to pregnancy was related to worktasks indicating higher styrene exposure levels or semiquantitative or quantitative measures of styrene exposure. The workers with high exposure showed a fecundity ratio of 1.09 (95% CI 0.69-1.72).

CONCLUSIONS

It is unlikely that styrene exposure has a strong effect on male fecundity.

Forensic evidence findings in prepubertal victims of sexual assault

OBJECTIVE

The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury. It is not known whether these recommendations are appropriate for prepubertal children, because few data exist regarding the utility of forensic evidence collection in cases of child sexual assault. This study describes the epidemiology of forensic evidence findings in prepubertal victims of sexual assault.

METHODS

The medical records of 273 children <10 years old who were evaluated in hospital emergency departments in Philadelphia, Pennsylvania, and had forensic evidence processed by the Philadelphia Police Criminalistics Laboratory were retrospectively reviewed for history, physical examination findings, forensic evidence collection, and forensic results.

RESULTS

Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours of their assault. Over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault. The majority of forensic evidence (64%) was found on clothing and linens, yet only 35% of children had clothing collected for analysis. After 24 hours, all evidence, with the exception of 1 pubic hair, was recovered from clothing or linens. No swabs taken from the child's body were positive for blood after 13 hours or sperm/semen after 9 hours. A minority of children (23%) had genital injuries. Genital injury and a history of ejaculation provided by the child were associated with an increased likelihood of identifying forensic evidence, but several children had forensic evidence found that was unanticipated by the child's history.

CONCLUSIONS

The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the child's body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis.

[Drug abuse among patients requiring psychiatric hospitalization]

We assessed the incidence of drug abuse among patients requiring psychiatric hospitalization, and characterized the population at risk. The data on drug abuse were obtained from self-reports and urine tests in 103 patients, aged 18-65, hospitalized in the Kfar Shaul Psychiatric Hospital (autumn 1998). There was close correspondence between the self-reports and the results obtained from urine tests. 1/3 admitted to having used illegal drugs and signs of drug abuse were found in about 1/4 of the urine tests. The most prevalent drugs were cannabis products (hashish and/or marijuana) and in 15 patients opiates. Drug users were younger than non-users. With regard to psychiatric symptomatology, fewer negative symptoms were recorded among cannabis abusers with schizophrenia, compared to schizophrenic patients with no history, past or present, of cannabis abuse. The present findings confirm the clinical impression that there has been an increase in drug abuse among mental patients, parallel to that found in society at large. Confirmatory surveys are necessary. Our findings clearly suggest that a change in attitude has occurred in Israel to what has been considered a marginal problem. Hospitalized mentally-ill patients, the younger in particular, should be considered at risk for drug abuse.

Time trends in biological fertility in Britain

BACKGROUND

There is evidence of a decline in semen quality in some countries, including Britain, in recent decades. This retrospective cohort study examined the hypothesis that biological fertility had also declined. The trend in couple fertility was assessed by means of time to pregnancy (TTP--a sensitive and validated measure of fertility.

METHODS

A representative sample of the British population aged 16-59 years was surveyed. TTP was obtained for all births conceived after unprotected intercourse that began during 1961-93, excluding contraceptive failures. The sample size was 1540.

FINDINGS

In contrast to the original hypothesis, this study found that fertility has increased; the rising trend was accompanied by slight dips during 1976-80 and 1986-90. These results were consistent between male and female respondents, and undiminished by adjustment for possible confounding factors. A stronger and more consistent relation was found with the year when unprotected intercourse started (a period effect) than with the year of birth of either partner (a birth cohort effect).

INTERPRETATION

The findings could not be explained by trends in age at first birth, increased treatment of subfertility, or changes in oral contraceptive use. If a decline in male fertility has occurred, it has been more than compensated for by a countervailing increase in couple fertility.

Arterial hypertension and renal allograft survival

CONTEXT

Several observational studies have investigated the significance of hypertension in renal allograft failure; however, these studies have been complicated by the lack of adjustment for baseline renal function, leaving the role of elevated blood pressure in allograft failure unclear.

OBJECTIVE

To examine the relationship between blood pressure adjusted for renal function and survival after cadaveric allograft transplantation.

DESIGN

Nonconcurrent historical cohort study conducted from 1985 through 1997.

SETTING

University teaching hospital.

PARTICIPANTS

A total of 277 patients aged 18 years or older who underwent cadaveric renal transplantation without another simultaneous organ transplantation and whose allograft was functioning for a minimum of 1 year. Follow-up continued through 1997 (mean follow-up, 5.7 years).

MAIN OUTCOME MEASURE

Time to allograft failure (defined as death, return to dialysis, or retransplantation) by systolic, diastolic, and mean arterial blood pressure measurements at 1 year after transplantation.

RESULTS

Multivariate Cox proportional hazards modeling demonstrated that nonwhite ethnicity, history of acute rejection, and nondiabetic kidney disease were significant predictors of failure (P = .01 for all). In addition, the calculated creatinine clearance at 1 year had an adjusted rate ratio (RR) for allograft failure per 10 mL/min (0.17 mL/s) of 0.74 (95% confidence interval [CI], 0.62-0.88). The RR per 10-mm Hg increase in blood pressure measured at 1 year after transplantation, after adjustment for creatinine clearance, was 1.15 (95% CI, 1.02-1.30) for systolic pressure, 1.27 (95% CI, 1.01-1.60) for diastolic pressure, and 1.30 (95% CI, 1.05-1.61) for mean arterial pressure. Supplemental analyses that did not include death as a failure event or reduce the minimum allograft survival time for study subjects to 6 months yielded results consistent with the primary analysis. There was no evidence of modification of the blood pressure-allograft failure relationship by ethnicity or diabetes mellitus.

CONCLUSIONS

Systolic, diastolic, and mean arterial blood pressures at 1 year posttransplantation strongly predict allograft survival adjusted for baseline renal function. More aggressive control of blood pressure may prolong cadaveric allograft survival.

[Pesticides and time to pregnancy among Danish farmers]

The aim of this study was to examine time to pregnancy among farmers who used pesticides (traditional farmers) and farmers who did not (organic farmers). A total of 904 men, selected from the Danish Ministry of Agriculture lists of traditional and organic farmers, participated in telephone interviews. The participation rate was 84%. Information was collected on "time to pregnancy" for the youngest child, exposure to pesticides and potential confounders. Using the discrete analogue of the Cox Regression Model (including potential confounders: male and female smoking, female age, parity and contraceptive method), the fecundability ratio between traditional farmers using pesticides and organic farmers was 1.03 (95% CI: 0.75-1.40). In the group of farmers who sprayed with pesticides, none of the characteristics related to the use of pesticides could account for the variation in time to pregnancy. No overall effect of pesticides on male fecundability could be demonstrated in this retrospective study among Danish farmers.

Effects of pesticide exposure on time to pregnancy: results of a multicenter study in France and Denmark. ASCLEPIOS Study Group

The aim of this study was to determine whether there was a relation between male exposure to pesticides and the amount of time needed to conceive (time to pregnancy) for farmers and agricultural workers in France and Denmark. The authors used retrospective studies to compare the time to pregnancy of couples in which the man was exposed to pesticides during the year before the birth of their youngest child with that of couples in which the man was not exposed. In 1995 and 1996, the authors studied 362 French rural workers (142 exposed to pesticides and 220 not exposed), 449 Danish farmers (326 conventional farmers exposed to pesticides and 123 nonexposed organic farmers), and 121 Danish greenhouse workers exposed to pesticides. The fecundability ratio for exposure to pesticides (Cox model, before and after adjustment for confounding factors) did not differ from 1 in any of the three populations. In France, the adjusted fecundability ratio was 1.17 (95% confidence interval (CI) 0.89-1.55) for exposed and nonexposed agricultural workers. In Denmark, it was 1.09 (95% CI 0.82-1.43) for exposed and nonexposed farmers and 0.83 (95% CI 0.69-1.18) for greenhouse workers and nonexposed farmers. Thus, this study found no relation between fertility (time to pregnancy) and male exposure to pesticides.