Hypertensive disorders of pregnancy and cardiovascular disease risk: A Mendelian Randomisation study

Objective

Observational studies show that hypertensive disorders of pregnancy (HDPs) are related to unfavourable maternal cardiovascular disease (CVD) risk profiles later in life. We investigated whether genetic liability to pre-eclampsia/eclampsia and gestational hypertension is associated with CVD risk factors and occurrence of CVD events.

Methods

We obtained genetic associations with HDPs from a genome-wide association study and used individual-participant-data from the UK Biobank to obtain genetic associations with CVD risk factors and CVD events (defined as myocardial infarction or stroke). In our primary analysis, we applied Mendelian Randomisation using inverse-variance weighted regression analysis in ever pregnant women. In sensitivity analyses, we studied men and nulligravidae to investigate genetic liability to HDPs and CVD risk without the ability to experience the underlying phenotype.

Results

Our primary analysis included 221,155 ever pregnant women (mean age 56.8 [SD 7.9]) with available genetic data. Odds ratios for CVD were 1.20 (1.02-1.41) and 1.24 (1.12-1.38) per unit increase in the log odds of genetic liability to pre-eclampsia/eclampsia and gestational hypertension, respectively. Furthermore, genetic liability to HDPs was associated with higher levels of systolic and diastolic blood pressure and younger age at hypertension diagnosis. Sensitivity analyses revealed no statistically significant differences when comparing the findings to those of nulligravidae and men.

Conclusions

Genetic liability to HDPs is associated with higher CVD risk, lower blood pressure levels, and earlier hypertension diagnosis. Our study suggests similar findings in ever pregnant women, nulligravidae and men, implying biological mechanisms relating to HDPs are causally related to CVD risk.

The indirect health impacts of the COVID-19 pandemic on children and adolescents: A review

It is pertinent to examine potentially detrimental impacts of the coronavirus disease 2019 (COVID-19) pandemic on young people. We conducted a review to assess the health impacts of the COVID-19 pandemic on children and adolescents. Databases of MEDLINE, Embase and the Cochrane Library were searched in June 2020, using keywords for 'children', 'adolescents' and 'COVID-19'. English papers discussing young people in context to the COVID-19 pandemic were included. Quality of selected studies was evaluated and scored. Of the 2013 identified articles, 22 met the inclusion criteria, including 11 cohort studies, ten cross-sectional studies and one report. Five main issues emerged: Increased mental health conditions, declines in presentations to paediatric emergency departments, declines in vaccination rates, changes in lifestyle behaviour (mainly decreased physical activity for specific groups of children), and changes in paediatric domestic violence and online child sexual abuse. There are early indications that the COVID-19 pandemic is impacting the health of young people, and this is amplified for those with existing health conditions and vulnerabilities. Despite this, there is limited insight into the protective factors for young people's health and wellbeing, as well as how the impacts of the pandemic can be mitigated in both the short and long term.

Trends in recruitment of women and reporting of sex differences in large-scale published randomized controlled trials in stroke

Background

Understanding of sex differences, especially in terms of the influence of sex on therapeutic interventions, can lead to improved treatment and management for all.

Aim

We examined temporal and regional trends in female participation and the reporting of sex differences in stroke randomized controlled trials.

Methods

Randomized controlled trials from 1990 to 2018 were identified from ClinicalTrials.gov, using keywords “stroke” and “cerebrovascular accidents.” Studies were selected if they enrolled ≥100 participants, included both sexes and were published trials (identified using PubMed, Google Scholar, and Scopus).

Results

Of 1700 stroke randomized controlled trials identified, 277 were published and eligible for analysis. Overall, these randomized controlled trials enrolled only 40% females, and in the past 10 years, this percentage barely changed, peaking at 41% in 2008–2009 and 2012–2013. North American randomized controlled trials recruited the most women, at 43%, and Asia the lowest, at 40%. Among the 277 randomized controlled trials, 101 (36%) reported results according to sex, of which 91 (33%) were pre-specified analyses. The increasing trend in the number of studies reporting sex-differentiated results from 2008 to 2018 merely paralleled the increase in the number of papers published during the same time period. North American randomized controlled trials most often reported sex-specific results (42%), and Australia and Europe least often (31%).

Conclusion

Little progress has been made in the inclusion of females and the reporting of sex in stroke randomized controlled trials. This highlights the need for key stakeholders, such as funders and journal editors, to provide clear guidance and effective implementation strategies to researchers in the scientific reporting of sex.

Adiposity in relation to age at menarche and other reproductive factors among 300 000 Chinese women: findings from China Kadoorie Biobank study

Background

Adiposity is increasing rapidly in China but little is known about the relevance to it of women's reproductive factors, which differ inter-generationally and from that in the West. We assess associations of adiposity with life-course reproductive factors in Chinese women.

Methods

In 2004-08, the nationwide China Kadoorie Biobank recruited 303 000 women aged 30-79 (mean 50) years from 10 diverse regions. Multivariable linear regression was used to examine associations of reproductive factors (e.g. age at menarche/first birth/menopause, parity, breastfeeding and reproductive years) with measures of general [e.g. body mass index (BMI)] and central [e.g. waist circumference (WC)] adiposity in adulthood.

Results

Overall, the mean BMI was 23.7 (standard deviation 3.3) kg/m 2 , mean age at menarche was 15 (2) years and nearly all had given birth (99%) and breastfed children (98%). Adiposity was associated inversely with age at menarche and at first birth, with 0.19 and 0.05 kg/m 2 lower BMI and 0.38 and 0.12 cm lower WC per 1-year delay respectively ( P  < 0.001). Among 128 259 post-menopausal women, adiposity was associated positively with age at menopause and reproductive years, with 0.05 and 0.07 kg/m 2 higher BMI and 0.12 and 0.17 cm higher WC per 1-year increase, respectively ( P  < 0.001). The proportion with overweight/obesity had similar associations with these reproductive factors. Adiposity had a non-linear positive association with parity, but no association with breastfeeding duration.

Conclusion

Among Chinese women, earlier age at menarche and at first birth, later age at menopause and longer reproductive years were independently associated with increased adiposity late in life.

Parenthood and the risk of cardiovascular diseases among 0.5 million men and women: findings from the China Kadoorie Biobank

Background

Women's parity has been associated with risk of cardiovascular disease (CVD). It is unclear, however, whether it reflects biological effects of childbearing or uncontrolled socio-economic and lifestyle factors associated with childrearing. We assessed the association between number of children and incident CVD outcomes separately in women and men.

Methods

In 2004-08, the nationwide China Kadoorie Biobank recruited 0.5 million individuals aged 30-79 years from 10 diverse regions. During 7 years of follow-up, 24 432 incident cases of coronary heart disease (CHD) and 35 736 of stroke were recorded among 489 762 individuals without prior CVD. Multivariable Cox regression models were used to estimate sex-specific hazard ratios (HRs) and 95% confidence intervals (CIs) for CHD and stroke associated with number of children.

Results

Overall, 98% of all participants had children and the mean number of children declined progressively from four in older participants to one or two in younger participants. Compared with childless women, women with children had an increased risk of CHD, but not of stroke [HR (95% CI): 1.14 (1.00; 1.30) and 1.03 (0.92; 1.16)]. Corresponding results for men were 1.20 (1.06; 1.35) and 1.13 (1.03; 1.24), respectively. In individuals with children, there was a log-linear association between number of children and CVD outcomes; in women, each additional child was associated with adjusted HRs of 1.02 (1.01; 1.04) for CHD and 1.02 (1.01; 1.03) for stroke, similar in magnitude to that in men [1.03 (1.01; 1.04) for CHD and 1.02 (1.01; 1.03) for stroke].

Conclusion

In Chinese adults, the association between the number of children and risk of CHD and stroke was similar between men and women, suggesting that factors associated with parenthood and childrearing are more likely to affect the risk of CVD outcomes than factors associated with childbearing.

The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia

BACKGROUND

In Indonesia, coronary heart disease (CHD) and stroke are estimated to cause more than 470 000 deaths annually. In order to inform primary prevention policies, we estimated the sex- and age-specific burden of CHD and stroke attributable to five major and modifiable vascular risk factors: cigarette smoking, hypertension, diabetes, elevated total cholesterol, and excess body weight.

METHODS

Population attributable risks for CHD and stroke attributable to these risk factors individually were calculated using summary statistics obtained for prevalence of each risk factor specific to sex and to two age categories (<55 and ≥55 years) from a national survey in Indonesia. Age- and sex-specific relative risks for CHD and stroke associated with each of the five risk factors were derived from prospective data from the Asia-Pacific region.

RESULTS

Hypertension was the leading vascular risk factor, explaining 20%-25% of all CHD and 36%-42% of all strokes in both sexes and approximately one-third of all CHD and half of all strokes across younger and older age groups alike. Smoking in men explained a substantial proportion of vascular events (25% of CHD and 17% of strokes). However, given that these risk factors are likely to be strongly correlated, these population attributable risk proportions are likely to be overestimates and require verification from future studies that are able to take into account correlation between risk factors.

CONCLUSIONS

Implementation of effective population-based prevention strategies aimed at reducing levels of major cardiovascular risk factors, especially blood pressure, total cholesterol, and smoking prevalence among men, could reduce the growing burden of CVD in the Indonesian population.

Neutrophil maturation rate determines the effects of dipeptidyl peptidase 1 inhibition on neutrophil serine protease activity

Background and Purpose

Neutrophil serine proteases (NSPs) are activated by dipeptidyl peptidase 1 (DPP1) during neutrophil maturation. The effects of neutrophil turnover rate on NSP activity following DPP1 inhibition was studied in a rat pharmacokinetic/pharmacodynamic model.

Experimental Approach

Rats were treated with a DPP1 inhibitor twice daily for up to 14 days; NSP activity was measured in onset or recovery studies, and an indirect response model was fitted to the data to estimate the turnover rate of the response.

Key Results

Maximum NSP inhibition was achieved after 8 days of treatment and a reduction of around 75% NSP activity was achieved at 75% in vitro DPP1 inhibition. Both the rate of inhibition and recovery of NSP activity were consistent with a neutrophil turnover rate of between 4–6 days. Using human neutrophil turnover rate, it is predicted that maximum NSP inhibition following DPP1 inhibition takes around 20 days in human.

Conclusions and Implications

Following inhibition of DPP1 in the rat, the NSP activity was determined by the amount of DPP1 inhibition and the turnover of neutrophils and is thus supportive of the role of neutrophil maturation in the activation of NSPs. Clinical trials to monitor the effect of a DPP1 inhibitor on NSPs should take into account the delay in maximal response on the one hand as well as the potential delay in a return to baseline NSP levels following cessation of treatment.

Diabetes and the Female Disadvantage

We have produced compelling evidence that women are subject to a higher relative increase in their risk of coronary heart disease and stroke following a diagnosis of Type 2 diabetes. Thus, in terms of vascular risk, diabetes confers a female disadvantage. This excess risk could be due to three main factors. First, it is conceivable that this is merely a mathematical artifact caused by the relatively low background rate for cardiovascular diseases among women, compared with men. Second, it could be due to women receiving poorer care following their diagnosis of diabetes than men; for instance, due to physician bias. Third, certain underlying biological differences in women and men, most likely related to the distribution of body fat, could explain this female disadvantage.

The future in clinical genetics: affective forecasting biases in patient and clinician decision making

When clinicians facilitate and patients make decisions about predictive genetic testing, they often base their choices on the predicted emotional consequences of positive and negative test results. Research from psychology and decision making suggests that such predictions may often be biased. Work on affective forecasting-predicting one's future emotional states-shows that people tend to overestimate the impact of (especially negative) emotional events on their well-being; a phenomenon termed the impact bias. In this article, we review the causes and consequences of the impact bias in medical decision making, with a focus on applying such findings to predictive testing in clinical genetics. We also recommend strategies for reducing the impact bias and consider the ethical and practical implications of doing so.

[Muscular magnetic resonance imaging for evaluation of myopathies in children]

BACKGROUND

Myopathies present with a broad diagnostic spectrum which may ultimately require muscle biopsy. MRI has been established as a non-invasive method in diagnosing adult myopathies; not only does MRI reveal characteristic findings which point in a diagnostic direction, but also aids in determining optimal biopsy sites and controlling therapeutic interventions. Muscle MRI is increasingly finding application to pediatric myopathies, especially dystrophies and myositides. The following paper serves to illustrate the use of MRI using exemplary clinical vignettes.

PATIENTS/METHODS

From 1999 until 2006, 180 children with myopathies of unknown aetiology, ages 10 months to 18 years, were examined with a standardised MRI protocol (axial T1-SE and T2-weighted TIRM sequences). The protocol included imaging of the lower extremities whereas sequences displaying the upper extremities were only acquired in selected patients. Furthermore, intravenous contrast agent was only administered in selected children.

RESULTS

All investigations could be performed without sedation due to an examination time of 12 to 15 minutes. The illustrated cases of limb-girdle muscular dystrophy, Duchenne's muscular dystrophy, dermatomyositis, pyomyositis, and chronic neurogenic disease with secondary myopathy all showed disease-characteristic MRI patterns which substantially helped to reach the ultimate diagnosis.

CONCLUSIONS

Muscle MRI is a non-invasive and effective instrument in helping to diagnose pediatric myopathies of unknown aetiology. It may facilitate muscle biopsy and serves to control therapeutical effects and disease course. Furthermore, muscle MRI may be applicated even to children of less than 4 years of age without sedation.

Giant arachnoid granulation: differential diagnosis of acute headache

We present a case of intense, rapidly evolving headache clinically mimicking meningitis, subarachnoid haemorrhage or venous sinus thrombosis. Clinical examination, standard blood work and central nervous system studies were non-contributory and effectively ruled out these diagnoses. Cranial multidetector CT studies before and after application of intravenous contrast medium performed prior to lumbar tap disclosed a non-enhancing ovoid mass filling the superior sagittal sinus. This lesion posed a differential to venous sinus thrombosis, but ultimately fulfilled the criteria of a giant arachnoid granulation. The imaging characteristics and differential diagnosis of giant arachnoid granulations are discussed.

The predictive value of total serum IgE for a positive allergen specific IgE result

BACKGROUND

Measurement of total serum IgE and allergen specific IgE is often requested to assess possible allergy. As public awareness increases, so do requests for allergy assessment; unless there is a clear "allergen suspect" in the history, several allergen specific IgE requests may be made. This increases the likelihood of detecting borderline increases in allergen specific IgE of uncertain relevance, and has important cost implications for the service.

AIMS

To provide an evidence base for this observation.

METHODS

In this retrospective observational study, results from 301 patients under 16 years of age from whom blood was taken for "allergy testing" from March 2001 to February 2003 were studied.

RESULTS

Allergen specific IgE testing in children with low total serum IgE concentrations (<10 IU/litre) yielded very few positive results (three of 73 children), except in those being investigated for an acute reaction to a single food; when IgE was 11-20 kU/litre, 13 of 73 children had positive allergen specific IgE; in the 21-40 kU/litre IgE group, 16 of 74 children had positive allergen specific IgE and in the 41-80 kU/litre group, 22 of 81 had positive allergen specific IgE.

CONCLUSIONS

Allergen specific IgE testing in children with low IgE concentrations (<10 kU/litre) produces few positive results in patients with non-specific symptoms. Laboratories should perform allergy testing for specific allergens regardless of total IgE concentration only when there are convincing clinical reasons to do so, and should not proceed with this if the total IgE is <10 kU/litre and the presenting symptoms are non-specific.

Fits, pyridoxine, and hyperprolinaemia type II

The rare inherited disorder hyperprolinaemia type II presents with fits in childhood, usually precipitated by infection. A diagnosis of hyperprolinaemia type II and vitamin B(6) deficiency was made in a well nourished child with fits. It is thought that pyridoxine deficiency was implicated in her fits and was the result of inactivation of the vitamin by the proline metabolite, pyrroline-5-carboxylate.

The contribution of risk factors to the effect of early otitis media with effusion on later language, reading, and spelling

A cohort of 946 children who were screened for otitis media with effusion (OME) from the ages of 2 to 4 were studied for language, reading, and spelling at 7 years of age. The effects of OME in combination with single risk factors and with increasing numbers of risk factors were investigated. An interaction with an additional risk factor was found only for gender and OME, with boys' spelling influenced negatively by a history of OME. OME in combination with preterm birth and low birthweight also appears to put children at risk for later language and educational problems. Although a negative linear relation between the number of risk factors and later functioning was found, it is suggested that OME, even when combined with a number of other risk factors, produces only minor effects on later language, reading, and spelling.

Vitamin E supplementation in cystic fibrosis

Vitamin E is an antioxidant and may have a role in the protection of lung tissue against oxidative damage in cystic fibrosis. Previous studies of vitamin E status in cystic fibrosis have used plasma or serum concentrations, which vary with levels of carrier lipoproteins and hence may not reflect the concentration of vitamin E in tissues, where it is found in highest concentration in membranes. Erythrocyte vitamin E concentration has been shown to correlate well with tissue concentrations of the vitamin in animals, but it has not previously been studied in patients with cystic fibrosis. Current guidelines on vitamin supplementation in cystic fibrosis include vitamin E. It is not presently clear which level of supplementation is most appropriate. To address this question, we examined the effect on erythrocyte vitamin E levels of supplementation with either 15 mg or 100 mg per day of vitamin E. Analysis was performed by high performance liquid chromatography before and 1 year after initiation of supplementation in children with cystic fibrosis. Erythrocyte vitamin E concentrations were below the normal range in almost all unsupplemented patients and rose into the normal range with a supplement of 100 mg per day, but not 15 mg per day. This rise was not accounted for by changes in general dietary treatment. We conclude that tissue vitamin E levels are low in patients with cystic fibrosis who do not receive supplements but can be normalized in most children with 100 mg of vitamin E. per day.

The cowpea mosaic virus RNA 1-encoded 112 kDa protein may function as a VPg precursor in vivo

Processing of the 112 kDa ('112K') protein encoded by cowpea mosaic virus RNA 1 was examined in cowpea mesophyll protoplasts using a transient expression system. Cleavage of the 112K protein occurred via two alternative pathways either into VPg and 110K (24K + 87K) or into 26K (VPg + 24K) and 87K proteins. The 26K protein can be further cleaved into VPg and 24K proteins. The results support a model in which the 112K protein functions as the precursor of VPg during initiation of replication.

The NTP-binding motif in cowpea mosaic virus B polyprotein is essential for viral replication

We have assessed the functional importance of the NTP-binding motif (NTBM) in the cowpea mosaic virus (CPMV) B-RNA-encoded 58K domain by changing two conserved amino acids within the consensus A and B sites (GKSRTGK500S and MDD545, respectively). Both Lys-500 to Thr and Asp-545 to Pro substitutions are lethal as mutant B-RNAs were no longer replicated in cowpea protoplasts. Transiently produced mutant proteins were not able to support trans-replication of CPMV M-RNA in cowpea protoplasts in contrast to transiently produced wild-type B proteins. Therefore loss of viral RNA synthesis was a result of a protein defect rather than an RNA template defect. Mutant B polyproteins were correctly processed in vitro and in vivo and the regulatory function of the 32K protein on processing of B proteins was not affected by these mutations. Since regulation of processing by the 32K protein depends on interaction with the 58K domain, the mutations in the NTBM apparently do not interfere with this interaction. The Asp-545 to Pro substitution left intact the binding properties of the 84K precursor of the 58K protein, with respect to ATP-agarose, whereas the Lys-500 to Thr substitution decreased the binding capacity of the 84K protein, suggesting that the Lys-500 residue is directly involved in ATP binding. The Lys-500 to Thr substitution in the 58K domain resulted in an altered distribution of viral proteins, which failed to aggregate into large cytopathic structures as observed in protoplasts infected with wild-type B-RNA. However viral proteins containing the Asp-545 to Pro substitution showed a normal distribution in protoplasts.

The effects of early bilateral otitis media with effusion on educational attainment: a prospective cohort study

The relationship between long-lasting, bilateral otitis media with effusion (OME) between the ages of 2 and 4 and educational attainment, in particular, reading and spelling ability at 7 years of age, was studied in a prospective cohort study of 946 children. After selection, three groups were distinguished: 151 children with long-lasting, bilateral OME at preschool age, 37 preschool children treated with ventilation tubes, and 82 children with no history of OME at that age. Early bilateral OME was found to affect spelling ability, but not reading ability, at 7 years. The effects of OME did not appear to increase with the number of observations of OME. Also, recurrent hearing loss did not have more detrimental effects than continuous hearing loss. Effects of treatment with ventilation tubes were not found. Only the teachers' ratings of writing ability indicated a slight advantage of treatment with ventilation tubes. In conclusion, the educational consequences of early OME appear to be very small.

The effects of early bilateral otitis media with effusion on language ability: a prospective cohort study

The current study, which is a follow-up on the epidemiological Nijmegen Otitis Media study, examines the relationship between early otitis media with effusion (OME) and later language ability in a group of children with systematically documented bilateral OME. In the Nijmegen Otitis Media study, children were screened using tympanometry at regular intervals of 3 months, between their second and fourth birthdays. At age 7, three groups of children participated in language testing: 82 OME-free children, 151 children with early bilateral OME, and 37 children treated with ventilation tubes at preschool age. A history of OME, even up to nine instances, did not have negative consequences for language performance at age 7. Intermittent, as opposed to more continuous, OME was not found to affect language ability negatively. The suggested benefit of treatment with ventilation tubes was not found.

Long-term effects of otitis media with effusion on language, reading and spelling

The long-term effects of early OME on language and educational attainment were studied in 47 children of 7-8 years of age who had participated in an earlier pre-school study on otitis media with effusion (OME) and language development. At pre-school age OME was diagnosed by quarterly tympanometric screens (maximum nine) and language was assessed by a standard Reynell test. At school age the ears of the children were assessed by otomicroscopy, tympanometry and audiometry, and the development status by several language, reading and spelling tests. The association between early OME and language development found at pre-school age was no longer present at school age.

Vitamin therapy in cystic fibrosis--a review and rationale

Vitamin supplements are routinely prescribed in cystic fibrosis, but published recommendations vary widely and there is little consistency in clinical practice. A review of the literature confirms that, while supplementation of the water-soluble vitamins (including B12 and folate) is unnecessary in uncomplicated cystic fibrosis, deficiency of the fat-soluble vitamins can lead to clinical problems. Supplements of these vitamins should be ensured for all patients with cystic fibrosis, while sparing them the unnecessary inconvenience of taking other vitamin supplements except where these are specifically indicated.

A regulatory role for the 32K protein in proteolytic processing of cowpea mosaic virus polyproteins

We have studied the regulation of proteolytic processing of the polyproteins encoded by cowpea mosaic virus M-RNA and B-RNA. For that purpose mutations were introduced in full-length cDNA clones of these RNAs. RNA transcripts were translated in rabbit reticulocyte lysate and the effect of mutations on the processing was analysed. These studies revealed that the 32K protein is released from the 200K B-polyprotein by an intramolecular cleavage and remains associated with the 170K protein, probably by interaction with the 58K domain of the 170K protein. In this complex the conformation of the 170K protein is such that further cleavages are very slow. This complex carries out the processing of the Gln/Met site in the M-polyprotein. The 170K protein produced by a B-RNA mutant that lacks the 32K coding region was efficiently processed into 110K, 87K, 84K, 60K, 58K and 24K cleavage products. Thus, the 32K protein regulates the B-polyprotein processing by slowing it down and, on the other hand, enhances trans cleavage of M-polyproteins at a Gln/Met site.

Processing of VPg-containing polyproteins encoded by the B-RNA from cowpea mosaic virus

To study the processing of putative VPg precursors the expression of specific mutant transcripts derived from a full-length cDNA clone of cowpea mosaic virus (CPMV) B-RNA was examined in a rabbit reticulocyte lysate system. This study revealed that the 170K protein produced by a B-RNA mutant that lacks the 32K coding region was efficiently processed by mainly intramolecular cleavages at three different sites into three sets of proteins of 60K + 110K, 84K + 87K, and 58K + 112K. Further cleavage of the 60K protein into 58K and VPg has not been observed in this in vitro system. The 84K protein can be further processed by an intramolecular cleavage reaction via two alternative pathways, either into 26K (VPg + 24K) and 58K proteins or into 24K and 60K proteins. VPg can be released from the 112K (VPg + 110K) precursor either directly or via the 26K intermediate. Immunoblot analysis showed that the 112K protein is present in CPMV-infected plant cells indicating that the in vitro observations may hold true in vivo.