Clustering of risk factors and social class in childhood and adulthood in British women's heart and health study: cross sectional analysis

Objective To examine co-occurrence and clustering of risk factors used in the Framingham equation by social class in childhood and adult life.Design Cross sectional study.Setting 23 towns across England, Wales, and Scotland.Participants 2936 women aged 60-79 years.Main outcome measures Prevalence of risk factors (hypertension, obesity, smoking, left ventricular hypertrophy on electrocardiography, diabetes, and low concentration of high density cholesterol); ratios of observed to expected frequencies of clusters of risk factors.Results Risk factors were more common in women from manual social classes in either childhood or adult life, and the co-occurrence of three or four of these risk factors was greater among more disadvantaged groups. Within the four socioeconomic groups, these risk factors occurred together more than would be expected from their individual frequency distributions, indicating that they were clustered. The extent of this clustering was similar in all four social class groups.Conclusions Clustering of risk factors included in the Framingham risk function occurs in all social class groups, but the lack of social patterning makes it unlikely that clustering is an explanation of socioeconomic inequalities in cardiovascular disease. As the proportion of women with co-occurrence of risk factors is greatest in those from manual social class in childhood, this measure of socioeconomic position might prove useful in risk prediction.     

Infertility among male UK veterans of the 1990-1 Gulf war: reproductive cohort study

Objectives To examine the hypothesis that, theoretically at least, exposure to toxicants of the type present in the Gulf war could affect spermatogenesis, which might be observed as increased levels of infertility.Design Retrospective reproductive cohort analysis.Setting Male UK Gulf war veterans and matched comparison group of non-deployed servicemen, surveyed by postal questionnaire.Participants 42 818 completed questionnaires were returned, representing response rates of 53% for Gulf veterans and 42% for non-Gulf veterans; 10 465 Gulf veterans and 7376 non-Gulf veterans reported fathering or trying to father pregnancies after the Gulf war.Main outcome measures Failure to achieve conceptions (type I infertility) or live births (type II infertility) after the Gulf war, having tried for at least a year and consulted a doctor; time to conception among pregnancies fathered by men not reporting fertility problems.Results Risk of reported infertility was higher among Gulf war veterans than among non-Gulf veterans (odds ratio for type I infertility 1.41, 95% confidence interval 1.05 to 1.89; type II 1.50, 1.18 to 1.89). This small effect was constant over time since the war and was observed whether or not the men had fathered pregnancies before the war. Results were similar when analyses were restricted to clinically confirmed diagnoses. Pregnancies fathered by Gulf veterans not reporting fertility problems also took longer to conceive (odds ratio for > 1 year 1.18, 1.04 to 1.34).Conclusions We found some evidence of an association between Gulf war service and reported infertility. Pregnancies fathered by Gulf veterans with no fertility problems also reportedly took longer to conceive.     

Retirement on grounds of ill health: cross sectional survey in six organisations in United Kingdom.

OBJECTIVE: To assess the process and outcome of retirement due to ill health in six large organisations. DESIGN: Cross sectional study of the rate of retirement due to ill health by age, sex, and length of service. Principal diagnoses by age and length of service were also compared. SETTING: Four public and two private large employers in the United Kingdom. MAIN OUTCOME MEASURES: Rates of retirement on the grounds of ill health by age, sex, and length of service of employees contributing to pension schemes. RESULTS: Rates of ill health retirement varied from 20 to 250 per 10,000 contributing members, and in two organisations the rate varied geographically within the same organisation. In the two organisations that provided data by sex, women retired at a greater rate than men under age 40 and over age 50. In four organisations the modal age or length of service coincided with enhancements in benefits. In the four that provided information on diagnoses, musculoskeletal and minor psychiatric illnesses were the most common reasons for retirement. CONCLUSION: The granting of ill health retirement benefits may not be determined by illness. There is a need for some employers and pension schemes to improve their processes for granting benefits. Doctors should be wary of conflicts of interest and work to guidelines when they advise pension schemes about the merits of an application for benefits.     

C reactive protein and its relation to cardiovascular risk factors: a population based cross sectional study.

OBJECTIVE--To test the hypothesis that minor chronic insults such as smoking, chronic bronchitis, and two persistent bacterial infections may be associated with increases in C reactive protein concentration within the normal range and that variations in the C reactive protein concentration in turn may be associated with levels of cardiovascular risk factors and chronic coronary heart disease. DESIGN--Population based cross sectional study. SETTING--General practices in Merton, Sutton, and Wandsworth. SUBJECTS--A random sample of 388 men aged 50-69 years from general practice registers. 612 men were invited to attend and 413 attended, of whom 25 non-white men were excluded. The first 303 of the remaining 388 men had full risk factor profiles determined. INTERVENTIONS--Measurements of serum C reactive protein concentrations by in house enzyme linked immunosorbent assay (ELISA); other determinations by standard methods. Coronary heart disease was sought by the Rose angina questionnaire and Minnesota coded electrocardiograms. MAIN OUTCOME MEASURES--Serum C reactive protein concentrations, cardiovascular risk factor levels, and the presence of coronary heart disease. RESULTS--Increasing age, smoking, symptoms of chronic bronchitis, Helicobacter pylori and Chlamydia pneumoniae infections, and body mass index were all associated with raised concentrations of C reactive protein. C Reactive protein concentration was associated with raised serum fibrinogen, sialic acid, total cholesterol, triglyceride, glucose, and apolipoprotein B values. C Reactive protein concentration was negatively associated with high density lipoprotein cholesterol concentration. There was a weaker positive relation with low density lipoprotein cholesterol concentration and no relation with apolipoprotein A I value. C Reactive protein concentration was also strongly associated with coronary heart disease. CONCLUSION--The body''s response to inflammation may play an important part in influencing the progression of atherosclerosis. The association of C reactive protein concentration with coronary heart disease needs testing in prospective studies.     

Risk factors for development of sexually abusive behaviour in sexually victimised adolescent boys: cross sectional study

Objective: To identify factors that may increase the risk of a sexually victimised adolescent boy developing sexually abusive behaviour. Design: Sexually victimised boys who had sexually abused other children were compared with sexually victimised boys who had not done so. Setting: Social services departments in south east England were invited to refer sexually abused and sexually abusing boys to a London postgraduate teaching hospital. Subjects: 25 adolescent boys aged between 11 years and 15 years and 11 months. Main outcome measures: Adjusted odds ratios estimated from unconditional logistic regression. Results: Unadjusted odds rations for witnessing (8.1) as well as experiencing (18.0) intrafamilial violence and discontinuity of care (7.2) discriminated boys who had sexually abused from others who were solely victims of sexual abuse. Only the adjusted odds ratios for witnessing intrafamilial violence (39.7) discriminated the two groups. Conclusions: The risk of adolescent boys who have been victims of sexual abuse engaging in sexually abusive behaviour towards other children is increased by life circumstances which may be unrelated directly to the original abusive experience, in particular exposure to a climate of intrafamilial violence. Our findings have implications for the management of boys found to have been sexually abused and raise important questions about the possibility of secondary prevention of subsequent abusive behaviour in those at greatest risk.

Key messages

• The risk of sexually abused boys in early adolescence abusing other children may be associated with experiences in early life that are independent of sexual victimisation
• Exposure to persistent violence within the family may be a particularly important risk factor
• Management of sexually abused boys should take into account the impact of early life experiences that may be associated with increased risk with a view to the secondary prevention of sexually abusive behaviour

     

Screening for diabetes in general practice: cross sectional population study

ObjectiveTo assess the policy proposed by the American Diabetes Association of universal screening in general practice of all patients aged over 45 years for diabetes.Design Cross sectional population study.Setting Local general practice in the United Kingdom.Participants All patients aged over 45 not known to have diabetes.Results Of 2481 patients aged over 45 and not known to have diabetes, 876 attended for screening. There were no significant demographic differences between the screened and unscreened patients. Prevalence of diabetes in patients with age as a sole risk factor was 0.2% (95% confidence interval 0% to 1.4%). Prevalence of diabetes in patients with age and one or more other risk factors (hypertension, obesity, or a family history of diabetes) was 2.8% (1.6% to 4.7%). Four hours a week for a year would be needed to screen all people over 45 in the practice''s population; about half this time would be needed to screen patients with risk factors other than age. More than 80% of patients newly diagnosed as having diabetes had a 10 year risk of coronary heart disease >15%, 73% (45% to 92%) were hypertensive, and 73% (45% to 92%) had a cholesterol concentration >5 mmol/l.Conclusions Screening for diabetes in general practice by measuring fasting blood glucose is feasible but has a very low yield in patients whose sole risk factor for diabetes is age over 45. Screening in a low risk population would best be targeted at patients with multiple risk factors.

What is already known on this topic

Between a third and a half of cases of diabetes are undiagnosed at any one timeNew cases can be identified by screening groups of patients at riskThe American Diabetes Association has proposed the screening of all patients aged over 45 every three years

What this study adds

Screening for diabetes in general practice by measuring fasting blood glucose is feasible but requires much staff timeScreening solely on the basis of age has a very low yield and screening would best be targeted at patients with multiple risk factors for diabetes     

Effect of electronic health records in ambulatory care: retrospective,serial, cross sectional study

Objective To evaluate the effect of implementing comprehensive, integrated electronic health record systems on use and quality of ambulatory careDesign Retrospective, serial, cross sectional study.Setting Colorado and Northwest regions of Kaiser Permanente, a US integrated healthcare delivery system.Population 367 795 members in the Colorado region and 449 728 members in the Northwest region.Intervention Implementation of electronic health record systems.Main outcome measures Total number of office visits and use of primary care, specialty care, clinical laboratory, radiology services, and telephone contact. Health Plan Employer Data and Information Set to assess quality.Results Two years after electronic health records were fully implemented, age adjusted rates of office visits fell by 9% in both regions. Age adjusted primary care visits decreased by 11% in both regions and specialty care visits decreased by 5% in Colorado and 6% in the Northwest. All these decreases were significant (P < 0.0001). The percentage of members making ≥ 3 visits a year decreased by 10% in Colorado and 11% in the Northwest, and the percentage of members with ≤ 2 visits a year increased. In the Northwest, scheduled telephone contact increased from a baseline of 1.26 per member per year to 2.09 after two years. Use of clinical laboratory and radiology services did not change conclusively. Intermediate measures of quality of health care remained unchanged or improved slightly.Conclusions Readily available, comprehensive, integrated clinical information reduced use of ambulatory care while maintaining quality and allowed doctors to replace some office visits with telephone contacts. Shifting patterns of use suggest reduced numbers of ambulatory care visits that are inappropriate or marginally productive.     

Heterogeneity of coronary heart disease risk factors in Indian,Pakistani, Bangladeshi,and European origin populations: cross sectional study

ObjectiveTo compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans.DesignCross sectional survey.SettingNewcastle upon Tyne.Participants259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years.ResultsThere were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors. Findings in women were similar.ConclusionRisk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors.

Key messages

• South Asians have more coronary heart disease than Europeans despite apparently lower levels of risk factors
• This study shows that Indians, Pakistanis and Bangladeshis differ in a wide range of coronary risk factors and combining their data is misleading
• Among South Asians, Indians were least and Bangladeshis most disadvantaged in a range of coronary risk factors. South Asians were disadvantaged in comparison with Europeans
• Future research and prevention strategies for coronary heart disease in South Asians should acknowledge a broad range of risk factors, the heterogeneity of these populations, linguistic and cultural needs, and environmental factors

     

The challenges of exposure assessment in health studies of Gulf War veterans

A variety of exposures have been investigated in Gulf War veterans' health studies. These have most commonly been by self-report in a postal questionnaire but modelling and bio-monitoring have also been employed. Exposure assessment is difficult to do well in studies of any workplace environment. It is made more difficult in Gulf War studies where there are a number and variety of possible exposures, no agreed metrics for individual exposures and few contemporary records associating the exposure with an individual. In some studies, the exposure assessment was carried out some years after the war and in the context of media interest. Several studies have examined different ways to test the accuracy of exposure reporting in Gulf War cohorts. There is some evidence from Gulf War studies that self-reported exposures were subject to recall bias but it is difficult to assess the extent. Occupational exposure-assessment methodology can provide insights into the exposure-assessment process and how to do it well. This is discussed in the context of the Gulf War studies. Alternative exposure-assessment methodologies are presented, although these may not be suitable for widespread use in veteran studies. Due to the poor quality of and accessibility of objective military exposure records, self-assessed exposure questionnaires are likely to remain the main instrument for assessing the exposure for a large number of veterans. If this is to be the case, then validation methods with more objective methods need to be included in future study designs.