Risk factors associated with lung cancer in Hong Kong.

The purpose of this study was to investigate the risk factors associated with lung cancer in Hong Kong. Three hundred and thirty-one histologically or cytologically proven consecutive cases of lung cancer and the same number of in- and out-patients without cancer matched for age and sex were recruited for this study using a detailed questionnaire completed by a trained interviewer. Smoking was the most important risk factor associated with lung cancer but the attributable risk (AR) was estimated to be 45.8% in men and 6.2% in women, considerably lower compared with those estimated in early 1980s. In addition, among women, exposure to environmental tobacco smoke (ETS) at work+/-at home and lack of education, were independent risk factors for lung cancer with adjusted odds ratio (OR) 3.60, (95% confidence interval (CI) 1.52-8.51) and OR 2.41 (95% CI 1.27-4.55), respectively. Among men, exposure to insecticide/pesticide/herbicide, ETS exposure at work or at home, and a family history of lung cancer and were independent risk factors with adjusted OR 3.29 (95% CI 1.22-8.9, OR 2.43, 95% CI 1.24-4.76 and OR 2.37, 95% CI 1.43-3.94, respectively). Exposure to incense burning and frying pan fumes were not significant risk factors in both sexes. A moderate or high consumption of fat in the diet was associated with increased risk in men but decreased risk in women. The results of this study suggested that as the prevalence of smoking declined, the influence of smoking as a risk factor for lung cancer decreased even further. Moreover, the contribution of other environmental, occupational and socioeconomic factors may be more apparent as etiological factors for lung cancer in a population with relatively high lung cancer incidence but low AR from active smoking.

Strategy for the treatment of noncompliant hypertensive hemodialysis patients.

Hypertensive hemodialysis patients noncompliant for their medications do not benefit from pharmacologic advances in the treatment of high blood pressure, and increase their already high risk of cardiovascular complications. The medical staff often becomes frustrated by severe hypertension in those who refuse to take medicines at home, drink excessive fluids, miss multiple dialysis sessions and sign-off dialysis early. In addition to addressing the psychosocial, financial, educational and substance abuse problems which contribute to noncompliance, we have developed a medication strategy to serve as an at least interim means of lowering blood pressure. Antihypertensive agents which have long half-lives in renal failure (lisinopril) and/or are intrinsically long acting (transdermal clonidine and amlodipine) were administered on dialysis days by the unit personnel to those patients who did not or would not take that or any dose on their own. The lisinopril and amlodipine were assured to have been taken on at least the dialysis days (thrice weekly), and the clonidine patch replaced weekly. Sixteen patients were thus treated when they failed to reliably self-administer medications. They had a significant decline in the predialysis systolic pressure of 15 mm Hg (175 +/- 6 to 160 +/- 5 mm Hg), diastolic of 12 mm Hg (103 +/- 3 to 91 +/- 3 mm Hg), and mean pressure of 13 mm Hg (127 +/- 4 to 114 +/- 4 mm Hg). There was an improvement in post-dialysis bood pressures, with the mean pressure declining 13 mm Hg from 110 +/- 4 to 97 +/- 4 mm Hg. Many individuals had erratic blood pressure control, having intermittently missed dialysis and hence unit-administered medicine, as well as continued fluid or drug abuse. The patients had uniformly excellent acceptance of this regimen, even spontaneously requesting it, and had no appreciable adverse effects. In summary while noncompliance is being addressed by the entire medical team, dialysis unit administration of long-acting medicines helps many hypertensive dialysis patients who would otherwise be at increased risk for severe cardiovascular complications.

Birthplace and yield of nipple aspirate fluid in Chinese women.

The different rates of breast cancer found between Chinese women in Asia compared with Chinese-born women in the United States suggest that dietary and environmental factors may be of etiological significance. We evaluated the proportion of 480 premenopausal Chinese women who yielded nipple aspirate fluid (NAF) by birthplace in Asia versus the United States and by reproductive and other risk factors. Birthplace was used as a surrogate for presumed differences in exposures during gestation, childhood, and adolescence that might influence yield of NAF in premenopausal women. In United States-born Chinese women compared with Asia-born Chinese women, the proportion yielding NAF was 44 of 95 (46.3%) versus 120 of 385 (31.2%), respectively. The relative risk of yield of NAF in United States-born women compared with Asia-born women was odds ratio = 2.37 (95% confidence interval, 1.26-4.47). Independent positive associations of NAF yield were also found with history of parity and breast feeding, cerumen phenotype, and a negative association with ever use of oral contraceptives. These findings support the hypothesis that early environmental exposures may have long-lasting physiological effects discernible in the breast glands of adult women.

Improved nutrition after the detection and treatment of occult gastroparesis in nondiabetic dialysis patients.

Malnutrition in dialysis patients is of multifactorial etiology and is associated with greatly increased morbidity and mortality. A low serum albumin level is one of the most powerful predictors of death and may persist despite optimization of the dialysis prescription. We retrospectively reviewed our experience in improving nutrition in nondiabetic patients with unexplained hypoalbuminemia. Using radionuclide solid-phase gastric emptying scans, we identified 6 patients who had occult gastroparesis. These patients (one on hemodialysis and five on peritoneal dialysis) were then treated with prokinetic medications (erythromycin elixir or metoclopramide) selected on the basis of their effectiveness in improving the scanning results after being given intravenously. Gastric emptying half-times improved from a median of 122 minutes (range, 95 to >300 minutes; normal, < or = 90 minutes) to 12 +/- 2 minutes (mean +/- SEM). The serum albumin increased from 3.3 +/- 0.04 g/dL to 3.7 +/- 0.08 g/dL at 3 months, with every patient's value higher than 3.5 g/dL. This improvement was statistically significant (P = 0.008) over the 5-month period of observation, which encompassed the 2 months before and 3 months after treatment. There was a linear improvement (P = 0.008) that showed a quadratic trend (P = 0.078) for a plateau at the final sampling point. The serum blood urea nitrogen, creatinine, and hematocrit levels remained unchanged (P > 0.1). We conclude that gastric emptying scans are valuable in identifying occult gastroparesis in high-risk patients and can guide the selection of prokinetic therapy, which may significantly increase serum albumin levels.

Low whole blood and erythrocyte levels of glutathione in hemodialysis and peritoneal dialysis patients.

Dialysis patients are reported to have impaired antioxidant mechanisms, including those involving glutathione-dependent enzymes. This study used high-performance liquid chromatography assays that directly measure total (oxidized + reduced) glutathione and its precursor cysteine (CYS) to compare the whole blood of hemodialysis (prehemodialysis and posthemodialysis) and peritoneal dialysis patients to that of blood donors with no known kidney disease (n=20 in each group). The levels in erythrocytes were calculated from that data (as nmol/g hemoglobin) because these cells are the major compartment of blood glutathione and their survival may be shortened by oxidant damage. Both dialysis groups had significantly (P=0.0001) higher CYS levels in the plasma compartment than the controls (251 nmol/mL), with prehemodialysis levels (432 nmol/mL) being greater than peritoneal dialysis levels (334 nmol/mL). Hemodialysis acutely lowered CYS levels (215 nmol/mL) below those of controls. Expressed per milliliter whole blood, both dialysis groups had significantly (P=0.0001) lower glutathione levels than controls (1,276 nmol/mL), with prehemodialysis and peritoneal dialysis levels being similar (778 and 912 nmol/mL). Values increased prehemodialysis to posthemodialysis, consistent with hemoconcentration. Expressed per gram hemoglobin, the dialysis groups had significantly (P < 0.015) lower glutathione levels than the controls (8,938 nmol/g hemoglobin), with similar prehemodialysis, posthemodialysis, and peritoneal dialysis values (7,207, 7,315, and 7,915 nmol/g hemoglobin, respectively). In summary, hemodialysis and peritoneal dialysis patients are at increased risk from oxidative stress due to glutathione deficiency in whole blood and erythrocytes.

Dietary and lifestyle correlates of passive smoking in Hong Kong, Japan, Sweden, and the U.S.A.

From epidemiologic studies in several countries, passive smoking has been associated with increased risk for lung cancer, respiratory diseases, and coronary heart disease. Since the relative risks derived from those studies are weak, i.e. relative risk less than two, we investigated whether poorer diets and less healthy lifestyles might act as confounders and be correlated with having a smoking husband on a cross-cultural basis. Characteristics of never-smoked wives with or without smoking husbands were compared between 530 women from Hong Kong, 13,047 from Japan, 87 from Sweden, and 144 from the U.S. In all four sites, wives with smoking husbands generally ate less healthy diets. They had a tendency to eat more fried food but less fruit than wives with nonsmoking husbands. Other healthy traits, e.g. avoiding obesity, dietary cholesterol and alcohol, or taking vitamins and participating in preventive screening were also less prevalent among wives with smoking husbands. These patterns suggest that never-smoked wives with smoking husbands tend to share the same less healthy dietary traits characteristic of smokers, and to have dietary habits associated with increased risk for lung cancer and heart disease in their societies. These results emphasize the need to take into account the potential confounding effects of diet and lifestyle in studies evaluating the health effects of passive smoking, especially since it is known that the current prevalence rates of smoking among men is indirectly associated with social class and education in affluent urban societies.

Diet and lung cancer 20+ years later: more questions than answers?

A critical review of epidemiological studies on diet and lung cancer over the last 20+ years has not provided overwhelming evidence that higher consumption of vegetables, fruit, low-fat/low-cholesterol foods or such micronutrients as carotenoids, selenium and vitamins A, C or E is associated with reduced lung cancer risk. Results from case-control studies have been more positive, with about one half showing fruit and vegetables or their associated micronutrients to be associated with reduced risk. However, most results from cohort and serum micronutrient studies, which avoid the problems of inaccurate accounting of diet and recall bias, were statistically insignificant. Moreover, although most studies were conducted on white male smokers in North America and Europe, the few studies which found significant contrary trends were among subjects of different backgrounds, i.e., black American males and Chinese women in China. Since male smokers vs. nonsmokers in Europe, North America and Japan have been shown in other studies to be lower consumers of fruit/vegetables, and less likely to pursue "perceived healthier lifestyles," the possibility that some of the epidemiological findings on diet and lung cancer are artifactually due to inadequate adjustment for behavioral correlates of smoking and health seekers in a particular society must be considered. This is especially true with recent chemoprevention trials showing higher lung cancer incidence and deaths among consumers of beta-carotene supplements vs. placebo.

An ecological study of trends in cancer incidence and dietary changes in Hong Kong.

Cancer incidence rates from the Hong Kong Cancer Registry show significant increases in lung and colon cancers and decreases in nasopharyngeal cancer in both sexes from 1973 to 1992. Moreover, cervical cancer and male esophageal cancer have declined significantly, and changes in the trends of cancer of the following sites were of borderline significance: decreasing male laryngeal and female esophageal cancers and increasing prostate and female breast cancers. These changes have occurred along with dietary shifts in the population, from a diet predominantly of rice and small portions of meat, vegetables, and fish to one with larger portions of all foods but rice and eggs. The latter data were gathered from six government household surveys from 1963-64 to 1994-95. By combining the two data sets, correlation coefficients were calculated for per capita consumption patterns of eight foods (rice, pork, beef, poultry, saltwater fish, freshwater fish, fresh vegetables, and eggs) and cancer incidence data of the same year or 10 years later. Higher meat intakes were significantly and positively correlated with cancers of the colon, rectum, prostate, and female breast. The correlations also suggested that current diets were more influential than diets a decade before for cancers of the lung, esophagus, rectum, and prostate. Cancers of the nasopharynx and colon were significantly correlated with current and past diets. These results support the hypothesis that intakes of meat and its associated fat are risk factors for colon, rectal, prostate, and female breast cancers.

Diet as a confounder of the association between air pollution and female lung cancer: Hong Kong studies on exposures to environmental tobacco smoke, incense, and cooking fumes as examples.

Chinese females in Hong Kong, where only about a third of the lung cancer cases can be attributed to a history of active smoking, have a world age-standardized lung cancer incidence rate of 32.6 per 100 000, which is among the highest in the world. Trends in Hong Kong's female lung cancer mortality also indicate a tripling in mortality rates from 1961 to 1990. The characteristically high Chinese female lung cancer incidence among nonsmokers is also found among overseas Chinese communities in Singapore and Hawaii. To help elucidate the role of ingested and inhaled substances in the etiology of lung cancer, four epidemiological studies have been conducted in Hong Kong over the last 15 years: (1) a retrospective study of 200 cases and 200 neighbourhood controls, (2) a cross-sectional study measuring personal exposures to nitrogen dioxide among 362 children and their mothers, (3) a site monitoring study of 33 homes measuring airborne carcinogens, and (4) a telephone survey of 500 women on their dietary habits and exposure to air pollutants. Selected data from each study were drawn to evaluate exposures to three major air pollutants (environmental tobacco smoke, incense, and cooking fumes), their relationship with lung cancer risk, and their association with dietary habits. Generally in this population, nutritionally poorer diets were characterized by higher consumption of alcohol and preserved/cured foods, whereas better diets were characterized by higher intakes of fresh fruits, vegetables, and fish. For environmental tobacco smoke, exposure was only moderately high in Hong Kong (36% have current smokers at home), lung cancer risk was equivocal with exposure, and it was associated with poorer diets among wives with smoking husbands. Incense was identified as a major source of exposure to nitrogen dioxide and airborne carcinogens, but it had no effect on lung cancer risk among nonsmokers and significantly reduced risk (trend, P-value = 0.01) among smokers, even after adjusting for smoking. The last finding may be explained by the relatively better diets among smoking women who burned incense versus those who did not. Although about 94% of the Chinese women cook on a regular basis, and the cooking fires were associated with increased airborne carcinogens, nonsmoking women who cooked for more than 25 years had a 60% reduction in lung cancer risk and the trend was highly significant (P < 0.001). Again, this unexpected finding may be due to the confounding effects of diet. Female controls who cooked for more than 25 years had a poorer diet than those who cooked for shorter durations. These three examples were chosen to illustrate the complexities of assessing air pollution exposure, and understanding the behavioral and dietary dynamics underlying lung cancer risk assessments. Our conclusion is that diet can be an important confounding factor affecting lung cancer risk estimates from air pollution exposures among Chinese women living in an affluent urban environment.

Distinct mutational spectrum of the p53 gene in lung cancers from Chinese women in Hong Kong.

Accumulating evidence suggests that the p53 gene is a good target for molecular epidemiological studies to search for risk factors in carcinogenic events. The lung cancer incidence for females in Hong Kong is unusually high, ranking among the highest in the world despite a low percentage with a history of smoking. To gain insights into possible etiological risk factors responsible for this high incidence, we examined p53 mutations in 35 lung cancer specimens from Chinese females living in Hong Kong and compared them with 35 matched cases from Japanese women as well as previously reported p53 mutations in the world literature. p53 mutations in exons 5-8 were present in 20 and 31% of the Hong Kong and Japanese cases, respectively. Notably, single-base deletions within runs of identical bases were observed in 3 (43%) of the 7 mutations in the Hong Kong cases, in contrast to the absence of such mutations in the controls and the extreme scarcity in the literature, suggesting that distinct environmental and/or genetic factor(s) might be involved. Although the frequent occurrence of characteristic single-base deletions could be a reflection of mutator mutations leading to inefficient mismatch repair of slipped strand mispairings, none of the lung cancer specimens exhibited such microsatellite instabilities.

Lung cancer risk and mutagenicity of tea.

To study the possible association between drinking tea and lung cancer, epidemiological and experimental materials were collected from the Chinese population in Hong Kong. In a retrospective study of 200 female lung cancer patients and 200 matched controls, all subjects were interviewed concerning their eating habits, smoking histories, and lifetime exposures to environmental pollutants. Analysis of the data demonstrated an adjusted and statistically significant increased lung cancer risk of 2.7 among those who drank green tea. Several brands of tea commonly drank in Hong Kong were assayed for mutagenicity using Ames' assay. Significantly elevated levels of mutagenic activity were found to be present after metabolic activation using cell-free extracts of cecal bacteria from rats. These data suggest that further research is needed to understand the possible consequences to human health of ingestants taken at low doses but long duration over the normal lifespan, and the possible interactive effect between mutagens in tea and other ingestants and inhalants in human cancer etiology.

Personal exposure to nitrogen dioxide and its association with respiratory illness in Hong Kong.

In 1985, 362 primary schoolchildren and their 319 mothers were surveyed in Hong Kong to study the possible relationship of air pollution to respiratory illnesses. Using nitrogen dioxide (NO2) measured by personal samplers as a measure of air pollution, the study aimed to identify the major sources of NO2 in the indoor environment and see whether its increased presence was associated with respiratory symptoms. The levels of NO2 among the mothers was found to increase by 21% if dust exposure was reported from the workplace, 18% if they used such cooking fuels as liquid petroleum gas or kerosene, 11% when kitchens did not have ventilating fans, and 10% when incense was burned at home. In terms of respiratory symptoms, an increase in NO2 levels of 19% was reported among those with allergic rhinitis and 18% among those with chronic cough. The levels of NO2 among children were correlated with levels measured in classrooms, all of which had opened windows so that the NO2 came from outdoors. No association was found between children's NO2 levels and respiratory symptoms. With the exception of smoking by the father and the children's NO2 levels, no association was found between smoking at home and NO2 levels.

Worldwide epidemiological patterns of lung cancer in nonsmokers.

A review of published reports on lung cancer was done to describe its worldwide epidemiological pattern and to elucidate the contribution of smoking and nonsmoking risk factors in its aetiology. Among lung cancer patients, roughly 98% of males worldwide, and 70-90% of European and American females, reported a history of smoking. Asian women had much lower (6-57%) rates of smoking. Mortality rates among female nonsmokers showed about a four-fold difference, being lowest in India and Japan, intermediate in the USA, and highest among the Chinese. There was some indication that incidence rates among nonsmokers may have increased in some societies in this century. The usefulness of histological comparisons among nonsmokers seemed limited since its distribution did not vary by place or ethnicity; about 70% were adenocarcinomas. In Western populations, younger lung cancer patients were more likely to have been smokers, whereas the opposite was true in Asian populations. Thus the epidemiological patterns of lung cancer in Western and non-Western societies are likely to be different, with nonsmoking risk factors being more important among women in general, and Asian women in particular.

Three-year experience with sonicated vascular catheter cultures in a clinical microbiology laboratory.

Using a quantitative sonication method, we cultured 1,681 consecutive vascular catheters submitted to a clinical microbiology laboratory in a 36-month period. A total of 46% of the cultures were positive; the most common organisms isolated were coagulase-negative staphylococci (36.4%), Pseudomonas aeruginosa (13.9%), enterococci (10.0%), yeasts (9.2%), Staphylococcus aureus (5.8%), and Enterobacter species (4.4%). The frequencies of positive blood cultures within 48 h prior to a positive catheter culture result were as follows: Candida albicans (68.4%), S. aureus (60%), Enterobacter cloacae (42.9%), Staphylococcus epidermidis (32.1%), P. aeruginosa (27.7%), and enterococci (23.3%). The sonication method allowed quantification of the number of CFU removed from a catheter for between 10(2) and 10(7) CFU. For catheter cultures in which greater than or equal to 10(2) CFU grew, a linear regression equation could be calculated: (risk of positive blood culture for the same organism) = 14 [log10 (number of organisms removed from the catheter)] -21 (r = 0.93). For catheter cultures in which less than 10(2) CFU grew, positive blood cultures for the same organism were strongly associated with a proven infection at a site distant from the catheter (P = 0.001) or probable contamination (S. epidermidis). Our findings indicate that this technique has considerable potential for use in clinical microbiology laboratories to aid in the diagnosis of vascular catheter infections and for clinical investigations into the pathogenesis of these infections.

Altered state of consciousness in a compulsive water drinker.

A relatively normal 16-year-old Chinese woman with a six-month history of compulsive water drinking resulting in a comatose state is reported. The drinking was perpetuated by an enjoyable altered state of consciousness after ingestion of an average of 20 litres of water per day. Treatment by fluid restriction and, later, simple education was successful. The subjective dimension of an altered state of consciousness may provide an important explanation for the obscure aetiology.

A comparison of the prevalence of respiratory illnesses among nonsmoking mothers and their children in Japan and Hong Kong.

Previous epidemiologic studies have associated symptoms of chronic bronchitis and other respiratory diseases with the risk for lung cancer. To assess the possible precursor or premonitory role of these conditions for lung cancer among nonsmokers, a comparison of the prevalence rates of these conditions in 2 urban industrialized communities (Hong Kong and a Tokyo suburb) with a 300% difference in female lung cancer incidence rates was conducted. A community survey of 314 nonsmoking mothers and their children in Hong Kong, and 243 mothers and children in Japan showed that the prevalence of reported chronic cough and sputum symptoms was 10 or more times higher in Hong Kong than in Japan. The disparity in the rates of respiratory diseases/symptoms was most apparent in the comparison of children. Occupational exposure to dust or fumes and larger household sizes were found to be associated with higher levels of respiratory illnesses among the Hong Kong mothers. The much higher prevalence rates of respiratory symptoms among Hong Kong than among Japanese subjects correlated with each community's female lung cancer incidence rates of 27.1 versus 8.1/100,000, respectively.

Dietary habits and lung cancer risk among Chinese females in Hong Kong who never smoked.

This describes a retrospective study in which 88 lung cancer patients and 137 district-matched controls were interviewed concerning the effects of diet on lung cancer risk among Hong Kong Chinese women who never smoked tobacco. Those in the lowest tertile of consuming fresh fruit or fresh fish had statistically significant adjusted relative risks (RRs) of 2.4 and 2.8, respectively. The protective effects of diet, i.e., higher consumption of leafy green vegetables, carrots, tofu, fresh fruit, and fresh fish, were confined mostly to those with adenocarcinoma or large cell tumors. Only fresh fruit was found to positively, and smoked meats to negatively, affect the risk of squamous or small cell tumors. Foods high in vitamin C, retinol, and calcium seemed to exert larger effects. Subjects from larger households were shown to be more frequent consumers of fresh vegetables, fruit, and fish. Because the lifetime weighted household size could be used as a surrogate index of past dietary quality, when it was combined with current dietary intakes of fresh fruit, the RR increased as either factor decreased in a dose-response manner. The adjusted RR was 5.8 at the lowest level. Further testing of the validity of the lifetime weighted household size as an index of past dietary quality is needed.