Fermented dairy products, diet quality, and cardio-metabolic profile of a Mediterranean cohort at high cardiovascular risk

BACKGROUND AND AIMS

Fermented dairy products have been associated with a better diet quality and cardio-metabolic profile. However, in Mediterranean populations, these associations have not been well characterized. The aim of this study was to assess the diet quality and the associations between the consumption of total fermented dairy products and their subtypes and the prevalence of Metabolic Syndrome (MetS) components in a Mediterranean population at high cardiovascular risk.

METHODS AND RESULTS

Baseline cross-sectional analyses were conducted on 6,572 men and women (mean age: 65 years) with overweight or obesity and MetS recruited into the PREDIMED-Plus cohort. A 143-item Food Frequency Questionnaire (FFQ) was used, and anthropometrical, biochemical, and blood pressure measurements were recorded. Multivariate-adjusted Cox regressions were fitted to analyze the association between quartiles of consumption of fermented dairy products and their subtypes and MetS components to estimate the relative risk (RR) and 95% confidence intervals (95% CIs). Participants who were high consumers of fermented dairy products reported a higher consumption of fruit, vegetables, fish, nuts, and whole bread and a lower consumption of white bread, alcohol, and cookies. Participants in the higher quartile showed a lower prevalence of the low HDL-cholesterol component of the MetS (RR=0.88; 95% CI: 0.78-0.98) than those in the lowest quartile of cheese consumption. Cheese consumption was inversely associated with the prevalence of hypertriglyceridemia. Total fermented dairy products, yogurt, and its types were not associated with any of the MetS components.

CONCLUSIONS

Compared to nonconsumers, participants consuming fermented dairy products reported a better diet quality and, particularly, cheese consumers presented a lower prevalence of hypertriglyceridemia and low HDL-cholesterol plasma levels, which are MetS components.

Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain

AIMS

Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact.

METHODS

An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012.

RESULTS

Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8.

CONCLUSIONS

Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.

Mediterranean diet and the incidence of cardiovascular disease: a Spanish cohort

BACKGROUND AND AIM

The Mediterranean diet is considered a model for healthy eating. However, prospective evidence in Mediterranean countries evaluating the relationship between this dietary pattern and non-fatal cardiovascular events is scarce. The aim of the present study was to evaluate the association between the adherence to the Mediterranean diet and the incidence of fatal and non-fatal cardiovascular events among initially healthy middle-aged adults from the Mediterranean area.

METHODS AND RESULTS

We followed-up 13,609 participants (60 percent women, mean age: 38 years) initially free of cardiovascular disease (CVD) during 4.9 years. Participants were part of a prospective cohort study of university graduates from all regions of Spain. Baseline diet was assessed using a validated 136-item food-frequency questionnaire. A 9-point score was used to appraise adherence to the Mediterranean diet. Incident clinical events were confirmed by a review of medical records. We observed 100 incident cases of CVD. In multivariate analyses, participants with the highest adherence to the Mediterranean diet (score>6) exhibited a lower cardiovascular risk (hazard ratio=0.41, 95% confidence interval [CI]: 0.18-0.95) compared to those with the lowest score (<3). For each 2-point increment in the score, the adjusted hazard ratios were 0.80 (95% CI: 0.62-1.02) for total CVD and 0.74 (0.55-0.99) for coronary heart disease.

CONCLUSIONS

There is an inverse association between adherence to the Mediterranean diet and the incidence of fatal and non-fatal CVD in initially healthy middle-aged adults.

Detection of circulating tumor cells in the context of treatment: prognostic value in breast cancer

Circulating tumor cells (CTCs) in patients with breast cancer can be regarded as the pre-stadium of clinically manifest distant metastases. Here we present results on CTCs determination in peripheral blood (PB) of breast cancer patients in the context of treatment. Ninety-two patients were enrolled onto a prospective, unicenter study and 71 of those subjects are the focus of our analyses. CTC assessment was performed by isolating cytokeratin-positive (CK) cells by immunomagnetic techniques, with further identification by immunocytochemical methods. CTCs were detected in 47 (66%) patients: 35 with primary breast cancer and 12 with metastatic disease. Five (14.3%) of those patients with primary cancer and CTCs showed first disease progression or died. Of those patients with metastatic disease and CTCs before chemotherapy, eleven (91.6%) died. During chemotherapy, >6 CTCs was correlated with a worse prognostic of disease in patients with metastatic disease (p = 0.05). Four weeks after chemotherapy, 59 patients underwent a follow-up assessment. CTCs were detected in 54.2% of those patients. CTCs levels, and not the presence of CTCs alone, was associated with progression free of disease (p = 0.052) and showed borderline significance with overall survival (p = 0.071). The differential prognostic and overall survival showed between patients with and without elevated CTCs before and at the end of chemotherapy, is of special interest in patients without clinical evidence of metastasis.

Iron but not folic acid supplementation reduces the risk of low birthweight in pregnant women without anaemia: a case-control study

OBJECTIVE

To assess whether iron and folic acid supplementation reduce the risk of low birthweight (LBW) in women without anaemia.

DESIGN

Case-control study.

SETTING

University Hospital of Cantabria.

STUDY POPULATION

Cases were 322 mothers without anaemia delivering a singleton infant of less than 2500 g. Controls were 934 mothers without anaemia delivering a term non-small-for-gestational-age infant.

DATA COLLECTION

Data on iron and folic acid supplementation were obtained from prenatal chart record and personal interview. Data on risk factors for LBW were also gathered.

RESULTS

Agreement between the two sources of information was good (82% for folic acid and 94% for iron). Odds ratios yielded from the two sources were very close. Folic acid only (15 mg/day) was unrelated to LBW, whereas iron supplementation (80 mg ferrous sulphate) was associated with a lower risk of LBW (odds ratio (OR) 0.58, 95% CI 0.34 to 0.98), adjusted for smoking, maternal education, body mass index, obstetric diseases during pregnancy, weight gain during pregnancy, and previous LBW. The results of iron plus folic acid were similar to those for iron (OR 0.56, 95% CI 0.33 to 0.96). There was a significant trend towards a lower risk of LBW (p<0.001) with the duration of iron supplementation. After stratifying by the type of LBW, the trend was also significant for any kind of LBW.

CONCLUSIONS

Iron supplementation is associated with a lower risk of LBW in pregnant women without anaemia.

Prognostic significance of p21WAF1/CIP1, p16INK4a and CD44s in tongue cancer

The role of lost or reduced expression of p21, p16 and CD44s in the survival of tongue cancer patients was investigated. Tumours and adjacent non-tumour epithelia (ANTE) from 36 patients with tongue cancer were retrospectively studied by immunohistochemistry using monoclonal antibodies against p21, p16 and CD44s proteins. Expression of p21, p16 and CD44s and their relationship with clinical and pathological parameters were analyzed. Of 36 patients, 12 (33.33%) developed recurrence and 12 died of the disease (mean survival, 25.5 months). In four cases (11.1%), concomitant low expression (<50% of tumour cells) of p21, p16 and CD44s was detected but had no effect on survival or recurrence in the univariate analysis. In the multivariate analysis, low expression of CD44s was the sole prognostic factor related to survival (p=0.01, hazards ratio: 0.749). There was no expression of p21, p16 or CD44s in ANTE from 3 out of 24 cases studied, and this finding was related to recurrence in the univariate analysis. In the multivariate analysis, low expression of CD44s in ANTE was again the sole factor related to recurrence (p=0.002, hazards ratio: 0.028). In conclusion, low expression of CD44s is related to tumour cell invasiveness and may be of clinical relevance as a prognostic factor.

Participation of epidemiologists and/or biostatisticians and methodological quality of published controlled clinical trials

STUDY OBJECTIVE

This study assessed several methodological aspects related to the quality of published controlled clinical trials (CCTs) in relation to the participation of an epidemiologist/biostatistician (E/B).

DESIGN

Handsearch of CCTs published in four medical leading journals for 1993-1995.

METHODS

Quality variables, abstracted from a review, were related to authors' specialties. Five hundred and ninety four CCTs were identified via a hand search. The department/unit membership was used to attribute authors' specialties. Of 594 CCTs identified, in 127 the authors' specialties could not be known, leaving 467 trials for analysis.

RESULTS

E/B participation occurred in 178 trials (38.1%). This participation was more frequent in multicentric, bigger, and in those trials describing any funding agency. These factors were controlled for in the analysis. E/B participation was positively associated with pre-study sample size estimation (OR = 1.5, 95% confidence intervals (CI) 1.0, 2.3), with reporting the dates for starting/ending the study (OR = 2.1, 95% CI 1.4, 3.3), with using an objectively assessed outcome (OR = 2.4, 95% CI 1.2, 4.6) and with the intention to treat principle (OR = 2.0, 95% CI 1.3, 3.0). The overall quality score was higher in trials where E/B participated.

CONCLUSIONS

The results suggest that E/B improve the quality (at least of reports) of clinical trials. Given that quality of research is frequently used to evaluate potential sources of heterogeneity between trials, these results are relevant for meta-analysis.

Circulating CD8+ T cells in polymyalgia rheumatica and giant cell arteritis: a review

BACKGROUND AND OBJECTIVE

During the last few years, there have been several studies on T cell subsets in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), with conflicting results. Whereas some authors have found normal values of circulating CD8+ T cells, others have found a decreased number. Furthermore, in some studies, the level of CD8+ cells was found to be related to disease activity, and it has been proposed that a decrease of CD8+ T cells be used as a diagnostic criterion for PMR. The purpose of our study was to determine the value of assessing T cell subsets in PMR and GCA.

METHODS

T lymphocyte subsets were determined by flow cytometry using a whole blood lysis technique in the following groups: 28 PMR and 6 GCA patients before corticosteroid treatment, 20 PMR and 12 GCA patients in clinical remission with steroid treatment, 55 PMR patients in remission without steroid treatment, 17 rheumatoid arthritis (RA) patients before treatment, and 18 age-matched controls with noninflammatory conditions. Total white cell, lymphocyte, and platelet counts, hemoglobin, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were measured by routine techniques. Comparisons were made by the Student's t-test and the Mann-Whitney test. A MEDLINE database search for studies published between 1983 and 1997 was performed.

RESULTS

Compared with noninflammatory controls, CD8+ T cells were not reduced before steroid treatment in patients with active PMR/GCA in proportion (P =.7) or absolute numbers (P =.1). Patients with active disease had significantly lower hemoglobin levels and higher platelet counts, CRP, and ESR than noninflammatory controls (P <.05). When compared with active RA, CD8+ T cells were not reduced in patients with active PMR in proportion (P =.5) or absolute numbers (P =.2). Between these two groups, RA patients were significantly younger (P =.003) and had lower ESR values (P =.003). We did not find significant differences between patients with active PMR/GCA and those in remission with steroid therapy, except for the lower hemoglobin levels and higher platelet count, CRP, and ESR in the active disease group (P <.05). The same results were found when patients with active disease were compared with PMR in remission and no longer on steroid therapy, the only significant differences were those parameters reflecting the acute phase response (hemoglobin levels, platelet count, CRP and ESR).

CONCLUSIONS

This study does not confirm the previous findings that the proportion or number of circulating CD8+ T cells are reduced in patients with active PMR/GCA. The utility of the determination of CD8+ T cells for diagnostic and prognostic purpose should be evaluated in a large multicenter study.

Permanent visual loss and cerebrovascular accidents in giant cell arteritis: predictors and response to treatment

OBJECTIVE

To assess the features and therapeutic response of visual manifestations and cerebrovascular accidents (CVA) in giant cell (temporal) arteritis (GCA) and to identify the predictors for permanent visual loss (VL) and CVA in GCA.

METHODS

Two hundred thirty-nine patients with biopsy-proven GCA were included in a retrospective multicenter study. Data on demographic, clinical, and laboratory features were collected. The predictors were identified by a forward stepwise nonconditional logistic regression analysis.

RESULTS

Visual involvement was observed in 69 patients, and 34 had permanent VL. The diagnostic delay since the onset of visual symptoms was longer in the 11 patients with bilateral VL. The interval to involvement of the second eye was 5 days. The predictors of permanent VL were transient VL, jaw claudication, normal levels of liver enzymes, and absence of constitutional syndrome. Partial improvement of visual acuity was observed in 8 patients. After adjustment for the treatment regimen (intravenous pulse methylprednisolone versus oral prednisone), early treatment (within the first day of VL) was the only predictor of improvement. CVA, observed in 8 patients, involved the vertebral-basilar territory in 4. CVA was more frequent in patients with visual symptoms, appearing shortly after VL (median 7 days) and despite appropriate therapy. Predictors of CVA were permanent VL and jaw claudication.

CONCLUSION

In GCA, the risk of permanent VL is increased in patients with transient VL and/or jaw claudication, and decreased in those with elevated liver enzyme levels and/or constitutional syndrome. Partial therapeutic success is more probable if treatment is started within the first day of VL. CVA is more likely in patients with permanent VL and/or jaw claudication, often developing despite appropriate corticosteroid therapy.

Permanent visual loss and cerebrovascular accidents in giant cell arteritis: predictors and response to treatment

OBJECTIVE

To assess the features and therapeutic response of visual manifestations and cerebrovascular accidents (CVA) in giant cell (temporal) arteritis (GCA) and to identify the predictors for permanent visual loss (VL) and CVA in GCA.

METHODS

Two hundred thirty-nine patients with biopsy-proven GCA were included in a retrospective multicenter study. Data on demographic, clinical, and laboratory features were collected. The predictors were identified by a forward stepwise nonconditional logistic regression analysis.

RESULTS

Visual involvement was observed in 69 patients, and 34 had permanent VL. The diagnostic delay since the onset of visual symptoms was longer in the 11 patients with bilateral VL. The interval to involvement of the second eye was 5 days. The predictors of permanent VL were transient VL, jaw claudication, normal levels of liver enzymes, and absence of constitutional syndrome. Partial improvement of visual acuity was observed in 8 patients. After adjustment for the treatment regimen (intravenous pulse methylprednisolone versus oral prednisone), early treatment (within the first day of VL) was the only predictor of improvement. CVA, observed in 8 patients, involved the vertebral-basilar territory in 4. CVA was more frequent in patients with visual symptoms, appearing shortly after VL (median 7 days) and despite appropriate therapy. Predictors of CVA were permanent VL and jaw claudication.

CONCLUSION

In GCA, the risk of permanent VL is increased in patients with transient VL and/or jaw claudication, and decreased in those with elevated liver enzyme levels and/or constitutional syndrome. Partial therapeutic success is more probable if treatment is started within the first day of VL. CVA is more likely in patients with permanent VL and/or jaw claudication, often developing despite appropriate corticosteroid therapy.

Polymorphism of the platelet glycoprotein IIIa gene in patients with coronary stenosis

Based on genetic variability, structural differences in the glycoprotein IIb/IIIa platelet receptor for adhesive proteins result in individual differences in the thrombogenicity of platelets. Recent studies suggest a controversial association between a genetic polymorphism of the glycoprotein IIIa gene (PlA2) and the risk of coronary artery disease. In our study, the prevalence of the PlA2 allele in a group of patients undergoing percutaneous coronary revascularization was 37%, a value significantly higher than in controls [13%, odds ratio (OR) = 3.93, 95% CI, 1.84 to 8.53] suggesting a significant association between this polymorphism and documented coronary stenosis, which is strongest among <60 years old patients (OR = 12.30, 95% CI, 2.98 to 70.93). This polymorphism represents an inherited risk factor for severe cardiovascular disease due to coronary occlusion.

Age differential mortality in Spain, 1900-1991

STUDY OBJECTIVE

To analyse the interindividual inequalities in mortality in Spain through the 20th century using the Gini coefficient, widely used as an income concentration index.

DESIGN

Age mortality data were obtained from official publications of vital statistics and age and sex compositions were obtained from population census. The Gini coefficient was estimated. It can take values between 0 and 1. Zero represents the situation in which all subjects die at the same age, whereas when all but one subject dies at 25 the index reaches a figure of 1.

MAIN RESULTS

In both men and women there was a trend to decrease age differential mortality (from 0.26 to 0.16 for men and from 0.26 to 0.12 for women). Nevertheless, transitory increases were produced in 1918 (influenza epidemic), and in the period of the Civil War of Spain, showing a more important increase in the mortality of young people than that of the elderly. A new increase was observed through the second half of eighties; it resulted from an AIDS epidemic and motor vehicle injuries.

CONCLUSION

Inequalities in mortality in Spain have decreased through the 20th century.

PI SZ phenotype in chronic obstructive pulmonary disease

BACKGROUND

A study was undertaken to clarify whether the PI SZ phenotype of the protease inhibitor system predisposes to chronic obstructive pulmonary disease (COPD).

METHODS

The prevalence of PI Z and PI SZ deficient phenotypes was investigated in a population of 702 patients with COPD followed up at the Chest Unit of a tertiary hospital and in 15400 newborn infants from the same geographical area. Individuals with deficiency were detected by screening of dried blood spots on filter paper using a comparative electro-immunodiffusion technique for alpha 1-antitrypsin and transferrin. The serum phenotype was confirmed by means of isoelectrofocusing on polyacrylamide gel.

RESULTS

Of the 702 blood samples from patients with COPD, six PI Z subjects (0.85%) and one PI SZ (0.14%) were detected. Of the 15400 samples from neonates, the number of PI Z subjects was eight (0.052%) and that of PI SZ was 24 (0.156%). The difference between the two groups was significant for PI Z but not for PI SZ.

CONCLUSIONS

The data do not indicate an increased risk for development of COPD associated with the PI SZ phenotype but confirm the predisposition of PI Z individuals for the development of COPD.

Association between toenail selenium and risk of acute myocardial infarction in European men. The EURAMIC Study. European Antioxidant Myocardial Infarction and Breast Cancer

The association between selenium status and risk of acute myocardial infarction was examined in a multicenter case-control study in 10 centers from Europe and Israel in 1991-1992. Selenium in toenails was assessed for 683 nonfatal male cases with first acute myocardial infarction and 729 controls less than 70 years of age. Median toenail selenium content was 0.553 microgram/g for cases and 0.590 microgram/g for controls. After adjustment for age, center, and smoking, the odds ratio for myocardial infarction in the highest quintile of selenium as compared with the lowest was 0.63 (95 percent confidence interval 0.37-1.07, p for trend = 0.08). The observed inverse trend was somewhat stronger when the authors adjusted for vitamin E status (p = 0.05). Analysis stratified for smoking habits showed an inverse association in former smokers (odds ratio for the 75th-25th percentile contrast = 0.63 (95 percent confidence interval 0.43-0.94)), but not in current smokers (odds ratio = 0.97 (0.71-1.32)) or in those who had never smoked (odds ratio = 1.55 (0.87-2.76)). Analysis stratified by center showed a significant inverse association between selenium levels and risk of myocardial infarction for Germany (Berlin) only (75th to 25th percentile odds ratio = 0.62 (95 percent confidence interval 0.42-0.91)), which was the center with the lowest selenium levels. It appears that the increased risk of acute myocardial infarction at low levels of selenium intake is largely explained by cigarette smoking; selenium status does not appear to be an important determinant of risk of myocardial infarction at the levels observed in a large part of Europe.

Longitudinal Gompertzian and Weibull analyses of adult mortality in Spain (Europe), 1900-1992

Mortality data from Spain, 1900 to 1992, were analyzed using Gompertzian and Weibull functions. Longitudinal Gompertzian analysis demonstrated that annual age-specific mortality rate distributions were determined by a fixed intersection point (in men: 84.3 years, in women: 89.3 years). Two methods of longitudinal Gompertzian analysis were applied. The method based on linear regression indicated that environmental influences upon age-related mortality were constant. The method based on a rough estimate of first derivative suggested that environmental influences have been decreasing. Both of these methods suggested that genetic influence upon age-related mortality is greater for men that for women. Analysis of Spanish mortality data from 1900 to 1992 suggest that the Gompertz function fits age-specific mortality rate distributions in adult men and women better than the Weibull function.

Prenatal care and prevention of preterm birth. A case-control study in southern Spain

The value of prenatal care is controversial and difficult to establish. A national policy for improving perinatal outcomes was proposed and applied throughout Andalusia (Southern Spain) in 1984. Here we report the results of an evaluation of this health care program as regards the prevention of preterm delivery. Effectiveness of prenatal care was assessed on the basis of two case-control studies in a hospital setting: one performed before the program was implemented (1981-1982) and the second one six years after the program began (1990-1993). A total of 229 cases and 395 controls for the period 1981-1982, and 207 cases and 381 controls for 1990-1993 were selected. Prenatal care was assessed based on the number of prenatal care visits, the date of the first visit, and an American composite index adjusting for gestational age. Multiple-factor adjusted odds ratios and their 95% confidence intervals (CI) were estimated using unconditional logistic regression analysis. The use of prenatal care significantly improved across time: the proportion of women receiving no prenatal care decreased from over 30% to less than 5%, and the proportion of women starting prenatal care in the first trimester for 1990-1993 was three times greater than the figure for 1981-1982. In the 1981-1982 case-control study, the date of first visit and the composite index were shown to be unrelated to preterm birth risk; and the number of visits yielded a significant association, although no definite trend could be established. In the 1990-1993 case-control study, a clear and significant relationship was observed between the number of prenatal care visits, the trimester of the first visit, and the adequacy of care according to the composite index. This latter variable, reflecting a more stringent standard of prenatal care, was selected by a stepwise logistic regression analysis as the best predictor for preterm birth risk. The results suggest that the present Andalusian program helps prevent preterm delivery. Nonetheless, its minimum standards should be raised to further decrease preterm birth risk.

Adipose tissue isomeric trans fatty acids and risk of myocardial infarction in nine countries: the EURAMIC study

Dietary isomeric trans fatty acids-mainly produced by hydrogenation of oils-are suspected of increasing the risk of coronary heart disease. Dietary trans fatty acid intake is reflected in the fatty acid composition of adipose tissue. In an international multicentre study in eight European countries and Israel (EURAMIC), adipose tissue aspiration samples were obtained from 671 men with acute myocardial infarction (AMI), aged 70 years or less, and 717 men without a history of AMI (controls). The proportion of fatty acids, including isomeric trans monoenoic fatty acids with 18 carbon atoms (C18:1), was determined by gas chromatography. Although there were considerable differences between countries in mean (SD) proportion of adipose tissue C18:1 trans fatty acids, there was no overall difference between cases (1.61 [0.92]%) and the controls (1.57 [0.86]%). The risk of AMI did not differ significantly from 1.0 over quartiles of adipose C18:1 trans fatty acids: the multivariate odds ratio was 0.97 (95% CI 0.56-1.67) for the highest versus lowest quartile. After exclusion of subjects from Spanish centres because they had far lower proportions of adipose trans fatty acids than subjects from other countries, there was a tendency to increased risk of AMI in the upper quartiles of C18:1 trans; however, the trend was not statistically significant. Our results reflect considerable differences between countries in dietary intake of trans fatty acids but do not suggest a major overall effect of C18:1 trans fatty acids on risk of AMI. We cannot exclude the possibility that trans fatty acids have a significant impact on risk of AMI in populations with high intake.

Antioxidants in adipose tissue and risk of myocardial infarction: the EURAMIC Study

Laboratory and epidemiological studies suggest that the antioxidants, vitamin E and beta-carotene, protect against coronary heart disease. In a European multicentre case-control study alpha-tocopherol and beta-carotene concentrations were measured in adipose-tissue samples collected in 1991-92 from 683 people with acute myocardial infarction and 727 controls. Mean adipose-tissue beta-carotene concentration was 0.35 microgram/g in cases and 0.42 in controls, with age-adjusted and centre-adjusted mean difference 0.07 microgram/g (95% confidence interval [CI] 0.04-0.10). Mean alpha-tocopherol concentrations were 193 micrograms/g and 192 micrograms/g for cases and controls, respectively. The age-adjusted and centre-adjusted odds ratio for risk of myocardial infarction in the lowest quintile of beta-carotene as compared with the highest was 2.62 (95% CI 1.79-3.83). Additional control for body-mass index and smoking reduced the odds ratio to 1.78 (95% CI 1.17-2.71); other established risk factors did not substantially alter this ratio. The increased risk was mainly confined to current smokers: the multivariate odds ratio in the lowest beta-carotene quintile in smokers was 2.39 (95% CI 1.35-4.25), whereas it was 1.07 for people who had never smoked. A low alpha-tocopherol concentration was not associated with risk of myocardial infarction. Our results support the hypothesis that high beta-carotene concentrations within the normal range reduce the risk of a first myocardial infarction. The findings for alpha-tocopherol are compatible with previous observations of reduced risk among vitamin E supplement users only. The consumption of beta-carotene-rich foods such as carrots and green-leaf vegetables may reduce the risk of myocardial infarction.

Factors influencing the effectiveness of sealants--a meta-analysis

Meta-analysis of published studies was applied to analyze the effectiveness of fissure sealants in preventing dental caries. Studies were identified by a MEDLINE search, supplemented by a hand search of the references in the articles recovered. All articles were assessed on the basis of quality, and were combined with the Mantel-Haenszel method. The prevented fraction in the exposed population (PF) was estimated using pooled relative risk. Heterogeneity of the effect and publication bias were also analyzed. Twenty-four studies were included in the meta-analysis. The overall effectiveness of autopolymerized fissure sealants was 71.36% (95% confidence interval 69.69-72.94%). Effectiveness in preventing caries decreased with time, and increased when drinking water was fluoridated (82.69% vs 72.28%). Heterogeneity was significant in most cases, and was further studied with multiple linear regression analysis. It is concluded that autopolymerizing sealants should be used. More research is needed to compare the effectiveness of dental hygienists and dentists in applying sealants.

EURAMIC Study: antioxidants, myocardial infarction and breast cancer. Design and main hypotheses

Epidemiological studies have not given sufficient evidence yet for the role of antioxidant nutrients in the prevention of cardiovascular disease. As regards cancer, an inverse association between beta-carotene intake and specific types of cancer, especially lung cancer, has been shown. For other cancer sites and other antioxidants, the association is less clear. The EURAMIC Study, an EC Concerted Action, is a case-control study conducted in 11 countries, in which the combined effect of vitamin E, beta-carotene and selenium, in relation to fatty acid intake, will be examined. The disease endpoints are acute myocardial infarction and early-stage breast cancer. The broad range of antioxidant intake, the use of biomarkers of exposure, and the analysis of pooled data will allow an estimate of the strength of the putative beneficial effect. In this paper the background and design of the study will be introduced.

Risk factors involved in stomal recurrence following laryngectomy

Stomal recurrence after surgery for laryngeal tumours is an extremely serious complication, with a dismal prognosis despite aggressive surgical therapy or high-dose irradiation. Data from 209 patients who underwent total laryngectomy for cancers of the larynx and hypopharynx were retrieved from the registry of the Department of Otorhinolaryngology at the Hospital 'Virgen de las Nieves' of Granada. Stomal recurrence developed in 8.1 per cent of them (17 cases). We analysed several parameters from each case: first, those parameters significantly associated with stomal recurrence were detected, and secondly, a logistic regression analysis was done. Three factors were found independently related to stomal recurrence: T-staging, site of the primary tumour and prior tracheostomy. Together with a review of the literature, we discuss our findings and a proposal for management of the high risk patient.

Factors related to quality of life 12 months after discharge from an intensive care unit

OBJECTIVE

To perform an analysis of the quality of life of survivors after ICU discharge.

DESIGN

Prospective study.

SETTING

Medical-surgical ICU of a Spanish reference hospital.

PATIENTS

Patients (n = 606) admitted in a 6-month period.

METHOD

A questionnaire regarding quality of life issues was completed at the time of admission by patients or surrogates (n = 606). The questionnaire was given again 12 months after ICU discharge to 444 surviving patients. Both questionnaires evaluated the patient's ability to function and communicate for the previous 3 months. A Quality of Life score of 0 corresponded to no limitations. An increasing score indicated a reduction in function. A score of greater than 10 points implied a severe physical handicap. Information was also collected on the severity of illness and the diagnosis that prompted ICU admission.

RESULTS

The mean Quality of Life score of all survivors worsened from a mean of 4.62 at the time of ICU admission to a mean of 6.11 at 12 months after ICU discharge (p less than .01) and was most evident for patients greater than 75 yrs of age (from a mean of 6.33 to a mean of 9.54). However, patients with the highest initial Quality of Life scores had a significant improvement at 12 months (14.61 +/- 0.50 to 12.48 +/- 0.78 points [p less than .05]). A higher severity of illness score corresponded to a higher Quality of Life score, but a multivariate analysis indicated that the factors with the greatest influence on the post-discharge Quality of Life score were the initial Quality of Life score and age.

CONCLUSIONS

Twelve months after discharge from the ICU, a patient's functional status, as measured by the Quality of Life score, is influenced most by age and their Quality of Life score at the time of ICU admission. While there is an overall decrease in the Quality of Life score for survivors, admission and treatment in an ICU do not always result in deterioration of the Quality of Life score. This study indicates that Quality of Life scores could become a routine part of patient evaluation.

Oral contraceptives and cancer of the cervix uteri. A meta-analysis

AIM AND OBJECTIVE

Because the findings of epidemiologic studies of the relationship between oral contraceptive use and cervical cancer have not been consistent, we reanalyzed the relationship.

DESIGN

Meta-analysis of studies published to date.

SETTING AND SUBJECTS

Papers were located by searching the MEDLINE data base, supplemented by a hand search of all the references in the articles recovered.

MEASUREMENTS

Studies were graded as to quality. Two meta-analyses were performed: one including all the studies gathered and one including methodologically acceptable studies only. The method of Woolf was used to combine relative risks. Heterogeneity of the effect was assessed.

MAIN RESULTS

Fifty-one published studies were collected: 21 case-control, 18 cross-sectional, and 12 cohort designs. Twenty-one of these were considered as methodologically acceptable, but only 18 could be pooled. The main results observed were: relative risks was 1.52 (1.3-1.8) for dysplasia, 1.52 (1.3-1.8) for carcinoma in situ, and 1.21 (1.1-1.4) for invasive cancer. A significant linear dose-response effect was observed in dysplasia, carcinoma in situ, and invasive cervical cancer. Heterogeneity of the effect was present in some of the former estimates.

CONCLUSIONS

Oral contraceptive use may be a risk factor for all stages of the natural history of cervical cancer, which may imply an initiator effect. Limitations to this research are discussed.

Menopausal hormone replacement therapy and breast cancer: a meta-analysis

A meta-analysis was performed to determine whether the scientific literature provides enough evidence that hormone replacement therapy after menopause increases the risk of breast cancer. Studies were located by MEDLINE, supplemented by a hand search of all the references in the articles located. The papers were graded as to quality. Those considered unbiased were combined using Woolf's method. Thirty-seven original studies were found: 23 case-control, 13 cohort, and one clinical trial. Overall, a small but statistically significant relative risk (RR) figure of 1.06 was calculated. Women who experienced natural menopause seemed to be at increased risk (RR = 1.13). A significant weighted RR was observed in current hormone replacement therapy users, especially in those who had natural menopause (RR = 1.63). A nonsignificant increasing trend was found between duration of hormone replacement therapy and breast cancer risk, although the opposite was seen when the association was analyzed by time since last use. These results imply that hormone replacement therapy could promote breast cancer.

Patterns of research. Oral contraceptives and cervical cancer

Original papers on the oral contraceptive use-cervical cancer relationship are analysed. The purpose of this study was to ascertain the biases of the original articles collected in relation to various characteristics of any investigation. Papers were located by using MEDLINE, reviewing the references of each article identified by MEDLINE, and then reviewing the contents of those journals in which an original could be published. Fifty-five publications (from 49 original studies) were graded as to quality and classified as biased or unbiased. Nineteen studies were considered unbiased. The most common biases identified were confounding, detection bias, and misclassification bias. The pattern of research/publication has changed since the association began to be analysed: articles shift from gynecological to cancer and epidemiological journals; the number of studies performed by gynecologists alone and pathologists alone decreases, while studies performed by epidemiologists alone or in collaboration with gynecologists increase. This collaboration produced studies with fewer biases. It is suggested that the above mentioned collaboration should be increased to improve access to, and then the application of the results obtained in the original studies on oral contraceptives and cervical cancer.