Effects of the Sex Ratio and Socioeconomic Deprivation on Male Mortality

We explored relationships between male mortality and the sex ratio. (We tested relationships across 142 societies and in longitudinal data from Scotland. A male-biased sex ratio was associated with reduced mortality by intentional self-harm across 142 societies. This was replicated in longitudinal Scottish data, and men were less likely to die by suicide and assault when there were more men in the population only when levels of unemployment were low. We argue that this is consistent with a theoretical model in which men increase investment in relationships and offspring as "competition" under a male-biased sex ratio, and that the conflicting results of previous work may stem from divergent effects of the sex ratio on mortality depending upon relative deprivation.

The impact of social deprivation on the response to a randomised controlled trial of a weight management intervention (BeWEL) for people at increased risk of colorectal cancer

BACKGROUND

Although 45% of colorectal cancer (CRC) cases may be avoidable through appropriate lifestyle and weight management, health promotion interventions run the risk of widening health inequalities. The BeWEL randomised controlled trial assessed the impact of a diet and activity programme in overweight adults who were diagnosed with a colorectal adenoma, demonstrating a significantly greater weight loss at 12 months in intervention participants than in controls. The present study aimed to compare BeWEL intervention outcomes by participant deprivation status.

METHODS

The intervention group of the BeWEL trial (n = 163) was classified by the Scottish Index of Multiple Deprivation (SIMD) quintiles into 'more deprived' (SIMD 1-2, n = 58) and 'less deprived' (SIMD 3-5, n = 105). Socio-economic and lifestyle variables were compared at baseline to identify potential challenges to intervention adherence in the more deprived. Between group differences at 12 months in primary outcome (change in body weight) and secondary outcomes (cardiovascular risk factors, diet, physical activity, knowledge of CRC risk and psychosocial variables) were assessed by deprivation status.

RESULTS

At baseline, education (P = 0.001), income (P < 0.001), spending on physical activity (P = 0.003) and success at previous weight loss attempts (P = 0.007) were significantly lower in the most deprived. At 12 months, no between group differences by deprivation status were detected for changes in primary and main secondary outcomes.

CONCLUSIONS

Despite potential barriers faced by the more deprived participants, primary and most secondary outcomes were comparable between groups, indicating that this intervention is unlikely to worsen health inequalities and is equally effective across socio-economic groups.

Colorectal adenomas and diabetes: implications for disease prevention

AIM

This study assessed the baseline type II diabetes mellitus (T2DM) risk status among overweight patients with screen-detected colorectal adenomas and explored the implications of the findings for preventative practice.

METHOD

Participants aged between 50 and 74 years (73% of whom were men) were recruited from four Scottish health boards and assessed for diabetes risk. Participants were categorized as at 'high' diabetes risk if glycated haemoglobin (HbA1c) was between 6.0 and 6.4% or fasting plasma glucose (FPG) was between 5.5 and 6.9 mmol/l and as potentially undiagnosed T2DM when HbA1c ≥ 6.5% or FPG ≥ 7 mmol/l. Secondary outcome measures included anthropometric measurements, blood pressure and the plasma lipid profile. The tests were repeated at 12 months and diabetes risk categories were reassessed following intervention procedures.

RESULTS

Forty-seven (14.3%) of the 329 participants had a preexisting diagnosis of T2DM. Of the remainder with complete biochemistry results (n = 250), 19 (7.6%) were classified as having potentially undiagnosed T2DM and 125 (50.0%) as being at high risk of developing diabetes. More than a quarter of participants in all categories had raised waist circumference, hypertension and plasma lipids, indicative of raised cardiovascular risk. At 12 months' follow-up, the diabetes risk category diminished in 20% of the intervention group vs 11% in the controls [OR 2.26 (95% CI 1.03-4.96)].

CONCLUSION

Our results suggest that a diagnosis of adenoma in overweight patients provides a health service opportunity for diabetes assessment, prevention and management in a high-risk population at a potentially teachable moment.

Lessons learnt from a feasibility study on price incentivised healthy eating promotions in workplace catering establishments

BACKGROUND

It is recognised that the worksite catering sector is likely to play a pivotal role in influencing dietary intake in adults of working age. The present study aimed to assess the feasibility of engaging worksites in a healthy eating intervention, implementing a price incentivised main meal intervention and measuring indicative intervention responses to inform the design of a future trial.

METHODS

Workplaces registered with the Scottish Healthy Living Award were invited to participate. The EatSMART intervention (a reduced price, healthy meal combination plus promotions) was implemented over 10 weeks in two worksites. Implementation was assessed by observational and sales data. Indicative effects on food habits were measured using online pre- and post-intervention questionnaires. Focus group discussions and interviews were used to determine catering staff and consumer acceptability.

RESULTS

Thirty-seven worksites were invited to participate and four worksites responded positively. Two sites (with 1600 and 500 employees, respectively) participated. Both required significant implementation support. Estimated sales data indicated that the uptake of promoted items varied by week (range 60-187 items) and by site. A poor response rate from questionnaires limited the evaluation of intervention impact. Consumers reported improved value for money and quality. Both sites reported an intention to continue the intervention delivery.

CONCLUSIONS

Significant efforts are required to engage worksite catering teams and implement healthy eating interventions. Evaluation methods require further development to improve data collection. Responses from consumers and catering staff suggest that further work in this area would be welcomed.

Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre-eclampsia: an individual patient data meta-analysis

OBJECTIVE

To investigate the value of adding second-trimester uterine artery Doppler ultrasound to patient characteristics in the identification of nulliparous women at risk for pre-eclampsia.

METHODS

For this individual patient data meta-analysis, studies published between January 1995 and December 2009 were identified in MEDLINE and EMBASE. Studies were eligible in which Doppler assessment of the uterine arteries had been performed among pregnant women and in which gestational age at ultrasound, Doppler ultrasound findings and data on the occurrence of pre-eclampsia were available. We invited corresponding authors to share their original datasets. Data were included of nulliparous women who had had a second-trimester uterine artery Doppler ultrasound examination. Shared data were checked for consistency, recoded to acquire uniformity and merged into a single dataset. We constructed random intercept logistic regression models for each of the patient and Doppler characteristics in isolation and for combinations. We compared goodness of fit, discrimination and calibration.

RESULTS

We analyzed eight datasets, reporting on 6708 nulliparous women, of whom 302 (4.5%) developed pre-eclampsia. Doppler findings included higher, lower and mean pulsatility index (PI) and resistance index (RI) and any or bilateral notching. Of these, the best predictors were combinations of mean PI or RI and bilateral notching, with areas under the receiver-operating characteristics curve (AUC) of 0.75 (95% confidence interval (CI), 0.56-0.95) and 0.70 (95% CI, 0.66-0.74), respectively. Addition of Doppler findings to the patient characteristics blood pressure or body mass index (BMI) significantly improved discrimination. A model with blood pressure, PI and bilateral notching had an AUC of 0.85 (95% CI, 0.67-1.00).

CONCLUSIONS

The addition of Doppler characteristics of mean PI or RI and bilateral notching to patient characteristics of blood pressure or BMI improves the identification of nulliparous women at risk for pre-eclampsia.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study

OBJECTIVE

To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy.

DESIGN

Pilot randomised controlled trial (RCT).

SETTING

Two urban maternity units in Scotland and England.

SAMPLE

Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period.

METHODS

If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy.

MAIN OUTCOME MEASURES

The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum.

RESULTS

In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission.

CONCLUSIONS

This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.

Trends in childhood injury mortality in Canada, 1979-2002

OBJECTIVE

To examine national trends in mortality rates for injuries among Canadian children younger than 15 years in 1979-2002.

METHODS

Data on injury deaths were obtained from the Canadian Vital Statistics system at Statistics Canada. Injuries were classified using the codes for external cause of injury and poisoning (E-codes) by intent and by mechanism. Mortality rates were age adjusted to the 1990 world standard population. Negative binomial regression was used to estimate the secular trends.

RESULTS

Annual mortality rates for total and unintentional injuries declined substantially (from 23.8 and 21.7 in 1979 to 7.2 and 5.8 in 2002, respectively), whereas suicide deaths among children aged 10-14 showed an increasing trend. All Canadian provinces and territories showed a decreasing trend in mortality rates of total injuries. Motor vehicle related injuries were the most common cause of injury deaths (accounted for an average of 36.4% of total injury deaths), followed by suffocation (14.3%), drowning (13.5%), and burning (11.1%); however, suffocation was the leading cause for infants. The number of potential years of life lost due to injury before age 75 decreased from 89 343 in 1979 to 27 948 in 2002 for children aged 0-14 years.

CONCLUSIONS

During the period 1979-2002, there were dramatic decreases in childhood mortality for total injuries and unintentional injuries as well as various degrees of reduction for all causes of injury except suffocation in children aged 10-14 years and drowning in infants. The reason for the reduction in injury mortality might be multifactoral.

Caspase 6 activity initiates caspase 3 activation in cerebellar granule cell apoptosis

Using a well documented ex vivo system consisting of rodent cerebellar granule cells (CGCs) the activation of caspases 3 and 6 during apoptosis induced by withdrawal of trophic support was analyzed. At the time of deprivation, the addition of the irreversible, broad-spectrum caspase inhibitor zVADfmk or the cell permeable, caspase 6 inhibitor CP-VEID-cho can transiently suppress the appearance of apoptosis, including the early appearance of DNA fragmentation. Using immunoblotting and fluorogenic peptide assays we observe deprivation-induced activation of caspases 3 and 6, but not caspase 9. Furthermore, active caspase 6 is capable of processing and activating procaspase 3 in cellular extracts prepared from non-apoptotic CGCs, whereas caspase 3 failed to activate caspase 6. In consonant with this, the cell permeable caspase 6 inhibitor prevented deprivation-induced caspase 3 activation whereas a cell permeable caspase 3 inhibitor, CP-DEVD-cho, had no effect on caspase 6 activation. This would indicate that caspase 6 is a significant inducer of the early caspase 3 activity in apoptotic CGCs.

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

OBJECTIVE

To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.

DESIGN

Randomised controlled clinical trial with integrated cost minimisation economic evaluation.

SETTING

Rheumatic diseases unit at a teaching hospital between 1994 and 1996.

SUBJECTS

118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care.

MAIN OUTCOME MEASURES

Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale.

RESULTS

Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds).

CONCLUSIONS

Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.

The effect of tumour associated epilepsy on performance/handicap scales used in cerebral glioma

The sensitivity of three scales of performance and handicap to the presence and development of epilepsy in patients with brain tumours was studied. Two hypothetical cases had equivalent disability, in one case due to epilepsy and in the other to physical impairment. The second case later developed epilepsy. All consultant neurologists and neurosurgeons in Scotland were asked to grade the cases using three scales commonly used for patients with cerebral glioma. Consultants rated the patient with epilepsy alone as being less disabled and handicapped than the patient with physical impairment without seizures (sign test p < 0.003). At best 21% of clinicians (p = 0.03) were able to report a change in performance score in the second case when seizures developed. These scales do not reflect changes in handicap and performance associated with tumour associated epilepsy. Clinical trial protocols for treatments for brain tumours must state how performance and handicap related to epilepsy will be measured.

DNA analysis of HLA-DR, DQ and DP genes in pauciarticular juvenile rheumatoid arthritis

HLA-DR, DQ, and DP alleles were determined by restriction fragment length polymorphism (RFLP) and oligonucleotide hybridization analysis in 50 Caucasian children with pauciarticular juvenile rheumatoid arthritis (PaJRA) and 82 controls. There was an increased frequency of DR5, DRw8, and DQw4, as well as individual DQ alpha and beta chains, DQA*0401 and DQB1*0402, respectively, in this group of patients. There was an absolute association between DRw8, DQw4, DQA1*0401, and DQB1*0402 in the patient population. HLA-DPw2.1 was also increased in frequency. There was little evidence of linkage disequilibrium found between DPw2.1 and DR5, DRw8, or DQw4. These MHC Class II associations were more characteristic of those patients with young age of onset (less than 5 years), rather than those with onset greater than or equal to 5 years of age. Our data confirmed the previous associations of HLA-DR5, DRw8, and DPw2.1 with PaJRA and suggested a new association for DQ alpha and beta genes in the clinical expression of this disease.

Integrated dialysis and renal transplantation: small is beautiful

Many patients in Britain with chronic renal failure suitable for renal replacement treatment die because not enough treatment facilities are available. Moreover, the number of renal transplants performed is insufficient to meet even present needs, so the number of patients on dialysis is rising. The integrated dialysis and transplant unit in Aberdeen, which has a population base much smaller than the average British unit, meets community needs for dialysis and transplantation. The problem of harvesting cadaver kidneys has been solved; the present supply has not only enabled the number of patients on dialysis to remain stable but has resulted in a net export of kidneys. The Aberdeen unit shows how estimated needs for chronic dialysis and renal transplantation may be met.

Accelerated atherosclerosis in long-term dialysis and renal-transplant patients: fact or fiction?

The causes of death and morbidity in a series of 104 patients with end-stage renal disease were analysed in an attempt to determine whether dialysis and renal transplantation accelerate atherogenesis. Only 4 of 37 deaths were due to myocardial infarction; a further 2 were due to other manifestations of occlusive arterial disease; and severe atheroma was an incidental finding at necropsy in only 3 other patients. Symptomatic arterial disease developed during treatment in only 3 of 61 patients at present alive; 2 other patients with myocardial infarctions before dialysis treatment have survived uneventfully for long periods. These data suggest that dialysis and transplantation may allow previously acquired atherosclerosis to manifest itself clinically; but the hypothesis that atheroma is accelerated is not yet proven.

Critical importance of microsome concentration in mutagenesis assay with V79 Chinese hamster cells

For optimum mutagensis in V79 Chinese hamster cells, the amount of liver postmitochondrial fraction in the assay was found to be of critical importance, depending on the chemicals being tested. Benzo[a]pyrene (BP) required lower (1-5%) concentrations of the liver 15 000 X g supernatant (S15) from methylcholanthrene pretreated rats for a maximum induction of cytotoxicity and mutagenicity, as determined by 8-azaguanine- and ouabain-resistance. A sharp peak of mutagenicity and cytotoxicity was induced by 7,8-dihydroxy-7,8-dihydrobenzo[a]pyrene (7,8-diol BP) at a concentration of 1% of the S15 fraction. Little or no response was induced by these compounds with the S15 concentrations of more than 10%. Similarly, aflatoxin B1 induced a sharp peak of mutagenicity and cytotoxicity at a concentration of 2% of the liver S15 fraction from Aroclor-pretreated rats. Under the same condition, non-carcinogenic aflatoxin G2 did not induce cytotoxicity and mutagenicity. Analysis of BP metabolites by high-pressure liquid chromatography indicates that with the 30% S15 fraction, more than 80% of BP was metabolized during the first 15 min, while with the 2% S15 fraction, 7,8-diol BP increased continuously throughout the 120-min incubation period, suggesting a strong metabolic competition to rapidly remove BP and 7,8-diol BP with a high concentration of the S15. In contrast with these compounds, N-nitrosodimethylamine induced mutagenicity and cytotoxicity which increased linearly in proportion to the increasing amount of the S15 fraction from phenobarbitone- and Aroclor-pretreated rats. Various nitrosamines with different lipophilicity were examined at a high (30%) and low (2%) concentration of the S15 fraction from Aroclor-pretreated rats, in which ratios of mutation frequencies at 30% and 2% correlated inversely with lipophilicity of the compound. This result suggests that the lipid solubility of test compounds may be one factor which determines the concentration of post-mitochondrial supernatant for optimum mutagenesis.

Clinical and laboratory studies of levamisole in patients with rheumatoid arthritis

Two studies with levamisole in rheumatoid arthritis are reported. In the first study of 30 patients levamisole was superior to placebo in terms of pain relief, reduction in articular tenderness, duration of morning stiffness, erythrocyte sedimentation rate (ESR), and radioisotope uptake in knee and wrist joints. There were no consistent differences in lymphocyte function, immunoglobin or complement concentration, or polymorphonuclear granulocytic function. In the second study forty patients were commenced on treatment with either gold or levamisole. At the end of one year there were significant improvements with both regimens in pain score, joint tenderness and ESR. The patients on levamisole showed significant improvement of duration of morning stiffness, while the patients on gold showed significant improvement of rheumatoid factor titre and left hand grip, but there were no significant differences between the two regimens.

Duodenal ulcer and gastric cancer

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Maintenance of silastic-teflon shunts for intermitten haemodialysis

The occurrence of infection in the tissues surrounding external arteriovenous shunts was studied and die important relationship of pyogenic infection to clotting was confirmed. The local application of fusidic add tulle and lanolin greatly reduced the occurrence of both infection and clotting and the need for cannula replacement.Urokinase used for declotting shunts when standard procedures had failed, restored blood flow whether dotting was related to infection or to local vascular factors. This treatment is not advised when clotting is associated with a local abscess, as it may make cannula replacement necessary. Severe local vascular factors, such as metastatic calcification, Raynaud's phenomenon, and venous stenosis, may lead to poor blood flow, so that despite clot lysis elective cannula replacement or the creation of a subcutaneous arteriovenous fistula is required.