High resolution computed tomographic assessment of airway wall thickness in chronic asthma: reproducibility and relationship with lung function and severity.

BACKGROUND: In some patients chronic asthma results in irreversible airflow obstruction. High resolution computed tomography (HRCT) has been advocated for assessing the structural changes in the asthmatic lung and permits investigation of the relationships between airway wall thickening and clinical parameters in this condition. METHODS: High resolution CT scanning was performed in 49 optimally controlled asthmatic patients and measurements of total airway and lumen diameter were made by two independent radiologists using electronic callipers. Wall area as % total airway cross sectional area (WA%) and wall thickness to airway diameter ratio (T/D) were calculated for all airways clearly visualised with a transverse diameter of more than 1.5 mm, with a mean value derived for each patient. Intra- and inter-observer variability was assessed for scope of agreement in a subgroup of patients. Measurements were related to optimum forced expiratory volume in 1 second (FEV1), forced mid expiratory flow, carbon monoxide gas transfer, two scores of asthma severity, airway inflammation as assessed with induced sputum, and exhaled nitric oxide. RESULTS: Neither observer produced a statistically significant difference between measurements performed on two occasions but there was a significant difference between observers (limits of agreement -2.6 to 6.8 for WA%, p<0.0001). However, mean WA% measured on two occasions differed by no more than 5.4% (limits of agreement -4.0 to 5.4; mean (SD) 0.7 (2.4)). Statistically significant positive associations were observed between both WA% and T/D ratio and asthma severity (r(S)=0.29 and 0.30, respectively, for ATS score), and an inverse association with gas transfer coefficient was observed (r(S)=-0.43 for WA% and r(S)=-0.41 for T/D). No association was identified with FEV1 or airway inflammation. CONCLUSIONS: The airway wall is thickened in more severe asthma and is associated with gas transfer coefficient. This thickening does not relate directly to irreversible airflow obstruction as measured with FEV1.

Independent predictors of breastfeeding intention in a disadvantaged population of pregnant women.

BACKGROUND: Breastfeeding rates in Scotland are very low, particularly in the more disadvantaged areas. Despite a number of interventions to promote breastfeeding very few women actually intend to breastfeed their baby. The aim of this study was to identify personal and social factors independently associated with intention to breastfeed. METHODS: Nine hundred and ninety seven women from two socio-economically disadvantaged housing estates located on the outskirts of Glasgow participated in a study that aimed to increase the prevalence of breastfeeding. Self-administered questionnaires completed by each participant collected information in early pregnancy, prior to exposure to the study intervention, on feeding intention, previous feeding experience and socio-demographic data. RESULTS: Five factors were independently predictive of breastfeeding intention. These were previous breastfeeding experience, living with a partner, smoking, parity and maternal age. After adjusting for these five factors, neither deprivation nor receipt of milk tokens provided useful additional predictive information. CONCLUSION: In this population of socially disadvantaged pregnant women we identified five variables that were independently predictive of breastfeeding intention. These variables could be useful in identifying women at greatest risk of choosing not to breastfeed. Appropriate promotional efforts could then be designed to give due consideration to individual circumstances.

Evaluation of a community-based intervention to increase breastfeeding prevalence.

BACKGROUND: The aim of the study was to determine whether peer counselling in the antenatal and post-natal period would increase the prevalence and duration of breastfeeding among low-income women in Glasgow. METHODS: The study was designed as a quasi-experimental evaluation of a community-based breastfeeding promotion programme. The intervention comprised peer counselling of pregnant women, support of breastfeeding mothers and local awareness-raising activities. The study subjects were all women attending the antenatal booking clinic resident in either the intervention or control area. Data were collected by means of four self-completion questionnaires, two administered antenatally and two post-natally. The proportions intending to breastfeed or breastfeeding in the intervention and control groups were compared at each assessment and over time. RESULTS: Of the 995 women enrolled in the study, data were available for analysis on 919 (92 per cent) to 6 weeks postnatally. At booking, 18 per cent of the intervention group and 21 per cent of the control group stated an intention to breastfeed. At delivery, the proportions initiating breastfeeding were 23 per cent of the intervention subjects and 20 per cent of the controls, and by 6 weeks post-natally, the proportion providing any breast milk had declined to 10 per cent of the intervention group and 8 per cent of the control group. Using multivariate analysis to adjust for factors (such as socio-economic status) known to influence breastfeeding, the breastfeeding prevalence was significantly higher in the intervention group relative to the controls at delivery [odds ratio (OR) 2.0; 95 per cent confidence interval (CI) 1.2-3.1, p = 0.006]. By 6 weeks post-natally the difference between the two groups was not statistically significant (OR 1.8; 95 per cent CI 1.0-3.4, p=0.07). CONCLUSIONS: As the impact of the intervention was not sustained even for the modest duration of 6 weeks postnatally, it would be premature to justify widespread use of peer support programmes to increase the prevalence of breastfeeding in socially disadvantaged communities.

Influence of graft material on blood rheology and plasma biochemistry following insertion of an infrainguinal bypass graft.

BACKGROUND: Occlusive arterial disease causes alterations in blood rheology and levels of potential thrombotic and fibrinolytic mediators. The aim of this study was to investigate the effect of graft materials on these parameters in patients undergoing successful infrainguinal revascularization. METHODS: Some 186 consecutive infrainguinal grafts were observed for 12 months. Venous blood was sampled before operation and at 3, 6, and 12 months after surgery. Samples were assayed for thrombotic and rheological parameters. An area under the curve analysis was used to compare the effects of vein and synthetic grafting on these parameters in 99 patients whose grafts remained patent and free from stenosis. RESULTS: Plasma levels of fibrin degradation products were significantly higher in patients with synthetic grafts (n = 46) than in those with autogenous vein grafts (n = 53) (median 274 versus 150 ng/ml; P < 0.001). There were no significant differences in plasma fibrinogen or any other parameters between the two groups. CONCLUSION: Patients with a synthetic infrainguinal graft have a higher fibrin turnover than those with a vein graft. Further studies are required to determine whether this increase in fibrin turnover is an essential requirement to maintain patency of a synthetic infrainguinal graft.

Randomised trial of octreotide for long term management of cirrhosis after variceal haemorrhage.

OBJECTIVE: To assess the efficacy of long term octreotide as adjuvant treatment to programmed endoscopic sclerotherapy after acute variceal haemorrhage in cirrhotic portal hypertension. DESIGN: Randomised clinical trial. SETTING: University hospital. SUBJECTS: 32 patients with cirrhotic portal hypertension. INTERVENTIONS: Programmed injection sclerotherapy with subcutaneous octreotide 50 micrograms twice daily for 6 months, or programmed injection sclerotherapy alone. MAIN OUTCOME MEASURES: Episodes of recurrent variceal bleeding and survival. RESULTS: Significantly fewer patients receiving combined octreotide and sclerotherapy had episodes of recurrent variceal bleeding compared with patients given sclerotherapy alone (1/16 v 7/16; P = 0.037, Fisher's exact test), and their survival was significantly improved (P < 0.02, log rank test); this improvement was maintained for 12 months after the end of the study. Combined treatment also resulted in a sustained decrease in portal pressure (median decrease -6.0 mm Hg, interquartile range -10 to -4.75 mm Hg, P = 0.0002) compared with sclerotherapy alone (median increase 1.5 mm Hg, interquartile range 0.25 to 3.25 mm Hg), as well as a significant improvement in liver function as assessed by plasma concentrations of bilirubin, albumin, and alanine aminotransferase and by hepatocyte metabolism of aminopyrine labelled with carbon-14. CONCLUSION: Long term octreotide may be a valuable adjuvant to endoscopic sclerotherapy for acute variceal haemorrhage in cirrhotic portal hypertension.

Tumour bed positivity predicts outcome after breast-conserving surgery.

BACKGROUND: Local recurrence after breast-conserving surgery is associated with a short distant disease-free survival, particularly if it occurs early. Early recurrence is caused by residual disease left at the time of surgery. Previous studies have demonstrated that disease in the tumour bed is a common finding after breast-conserving surgery. METHODS: The follow-up (mean 4.4 years) of 300 patients who had tumour bed analysis performed by the cavity shaving technique following breast-conserving surgery is presented. Postoperative radiotherapy was administered to all patients. RESULTS: The incidence of tumour bed positivity was 39.3 per cent. With a selective re-excision policy the local recurrence rate was 2.0 per cent and distant recurrence rate 10.4 per cent. Multivariate analysis identified lymphovascular invasion, oestrogen receptor status and tumour bed status as independent predictors of time to distant recurrence. CONCLUSION: A low rate of local recurrence can be achieved using this technique of margin assessment. Tumour bed status may be a useful prognostic factor following breast-conserving surgery.

Clinical, biochemical, and rheologic factors affecting the outcome of infrainguinal bypass grafting.

PURPOSE: The purpose of this study was to determine the effects of patient characteristics, blood rheology, and plasma biochemistry on the outcome of infrainguinal bypass grafting. METHODS: Blood rheology, plasma fibrinogen, cross-linked fibrin degradation products, von Willebrand factor (vWf) and other endothelial products, and clinical variables including smoking markers were determined before surgery in patients with 184 consecutive infrainguinal bypass grafts (90 vein, 94 synthetic grafts). RESULTS: Fifty (27%) graft occlusions and 17 (9%) deaths occurred within 1 year of surgery. On univariate analysis a poor outcome was associated with elevated preoperative plasma fibrinogen, fibrin degradation products, vWf, and platelet levels, reduced hemoglobin and systolic ankle pressure, a below-knee anastomosis, a decrease in patent calf vessels, and the presence of tissue necrosis (all p < 0.001). On multivariate analysis increased preoperative vWf levels were predictive of poor postoperative outcome (relative hazard for upper quartile versus lower quartile = 1.82), as were a low systolic ankle pressure (relative hazard = 2.51), presence of tissue necrosis (relative hazard = 2.73), and female sex (relative hazard = 1.9). None of the other variables studied was related to outcome. With a preoperative risk score derived from the results, graft patency rates within 3 months of surgery fell to less than 25% with risk scores in the upper quartile. CONCLUSIONS: Preoperative measurement of plasma vWf may enable more accurate prediction of the outcome of infrainguinal revascularization and when combined with other variables could assist in patient selection for these procedures. The association of vWf with graft occlusion supports a role for endothelial disturbance in graft occlusion.

Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis.

Renal artery stenosis (RAS) is the commonest secondary cause of hypertension and may result in renal ischaemia with resultant renal failure. Recent studies hve suggested that colour Doppler ultrasound, with spectral analysis of the intrarenal waveforms, can identify those patients with a significant RAS. A prospective study was performed in which colour Doppler ultrasound was compared with angiography in 73 patients (143 kidneys) presenting for renal angiography. Colour Doppler ultrasound was unsuccessful in 16% of kidneys due to a combination of technical failures and small kidney size. Accessory renal vessels were present in 14% of kidneys on angiography but none was detected by ultrasound. Of the 120 kidneys that had both examinations, no significant difference in intrarenal pulsatility or resistive index was noted between the angiographically stenosed and normal arteries. There were significant differences for intrarenal peak and end diastolic velocities, and acceleration time and index. Of these measurements, acceleration time was the best indicator of RAS. The probability of detecting a high grade RAS in an individual patient did not reach 90% until the acceleration time was prolonged to more than 0.12 s. Intrarenal colour Doppler ultrasound is not a general screening test for RAS and it should be reserved for selected patient groups where the incidence of disease is high. Patients with prolonged acceleration times of more than 0.12 s have a high likelihood of at least 70% RAS and should proceed directly to angiography.

Presentation, acute illness, and learning difficulties in salt wasting 21-hydroxylase deficiency.

The presentation, pattern of acute illness, and incidence of learning difficulties are described in 63 (33 boys, 30 girls) children with salt wasting 21-hydroxylase deficiency, drawn from a cohort study of congenital adrenal hyperplasia in the South West Region of England between 1968 and 1988. Thirty boys presented with a salt losing crisis from birth whereas the other three boys presented between 2 and 14 months of age with failure to thrive and hyponatraemia. Diagnostic uncertainty led to 13 (43%) of 30 girls developing a salt losing crisis. Five girls were misassigned as boys at birth. There were four deaths in the group, two due to salt losing crisis, one to complications of prematurity possibly compounded by 21-hydroxylase deficiency, and one from heart failure probably related to an excess of steroids. Acute admissions were common, especially during the first year of life, with convulsions in 7% of admissions. The 9% incidence of hypoglycaemia was considered to be an underestimate as blood glucose was measured in only 56 (22%) of 254 admissions. No convulsions occurred in the 38 (15%) admissions where the parents had given intramuscular hydrocortisone before bringing the child to hospital. A high incidence of learning difficulties was found among the 59 surviving children (9/30 (30%) boys and 6/29 (21%) girls), and in only two children could any factor other than 21-hydroxylase deficiency be invoked. Analysis of the subgroup with learning difficulties indicated that they were more ill at presentation with a significantly higher incidence of hypoglycaemia, and that growth in the first year was significantly worse. It is concluded that congenital adrenal hyperplasia remains a formidable disorder with an appreciable mortality and morbidity. The high incidence of learning difficulties seen in salt wasting 21-hydroxylase deficiency needs further attention. A prospective study is indicated to examine the effect of neonatal screening on morbidity from congenital adrenal hyperplasia, particularly the intellectual impairment seen in this study.

Adolescence and health inequalities: extensions to Macintyre and West.

The paper investigates class based health inequalities in mid to late adolescence. Health status is assessed by means of three subjective self-report measures; evaluation of general health, psychological well-being and disability/long-standing illness. Using six measures of social class (three occupationally and three non-occupationally based) which derive from parental characteristics, no evidence for consistent class based differentials in health amongst adolescents is found. However, it is not concluded that class based health inequalities are absent at this stage of the life cycle. Instead, it is argued that the above measures of social class differentiate between young people on the basis of the socio-economic status of their parents. As such they fail to allow for the possibility that variations in the current social position of young people themselves may have important consequences for their health. Current social position is assessed in terms of economic activity status, occupation and educational attainment. Using these measures, class based health inequalities are indeed found. Extending the analysis further, the relationship between social class of origin, current social circumstances and self-assessed health status is investigated by considering inter-generational occupational mobility. Again, evidence for class based health inequalities is found.