Body mass index has risen more steeply in tall than in short 3-year olds: serial cross-sectional surveys 1988-2003.

OBJECTIVE: To monitor the changing relationship between body mass index (BMI) and height in young children. DESIGN: Annual cross-sectional surveys using health-visitor-collected routine data 1988-2003. SETTING: Wirral, England. PARTICIPANTS: Fifty thousand four hundred and fifty-five children (49% female) each measured once at the age of 3 years. MAIN OUTCOME MEASURES: Weight, height and derived BMI (weight/height(2)) adjusted for age and sex (British 1990 revised reference) using standard deviation scores. RESULTS: From 1988 to 2003, mean BMI increased by 0.7 kg/m(2), whereas mean height fell by 0.5 cm. Over the same period, the weight-height correlation rose from 0.59 to 0.71 (P<0.0001) owing to BMI increasing faster in the taller than the shorter children. Among the shortest 10% of children, mean BMI rose by 0.12 (95% confidence interval: -0.05-0.28) kg/m(2) as against 1.38 (1.19-1.56) kg/m(2) among the tallest 10%, a 12-fold difference. Adjustment for age, sex, seasonality, birth-weight and deprivation did not alter the findings. CONCLUSIONS: Among 3-year-old children in Wirral, where BMI has been rising for 16 years, the largest increase in BMI has occurred in the tallest children, whereas in the shortest BMI has hardly changed. Tall stature has, therefore, become important for child obesity. It suggests a drive to increasing adiposity in young children that involves both growth and appetite, with fast growing and hungrier children now more exposed to the 'obesogenic' environment.

Gender inequalities in the management of angina pectoris: cross-sectional survey in primary care.

BACKGROUND AND AIMS: To determine the extent of gender differences in the routine clinical care of patients with angina pectoris in primary care. METHODS: A cross-sectional survey of general practitioner (GP) medical records undertaken by trained data managers in 6 GP practices. 925 adults (489 men) with a clinical diagnosis of angina (prevalence = 2.4%, 95%CI 2.3-2.6). Data extracted included: level of care; risk factor recording; prescribed medication; exercise ECG and coronary revascularisation. Adjusted male-to-female odds ratios (AOR) adjusted for age, angina duration, and previous myocardial infarction, (MI). RESULTS: Women with angina were older than men (71 v 65 years) with a lower prevalence of MI (30% v 45%), but a longer duration of angina (5 v 4 years). Men were more likely to receive once daily aspirin (AOR = 2.07, 95%CI 1.56-2.74) and be prescribed triple anti-anginal therapy (1.58, 95%CI 1.03-2.42). Men were also significantly more likely to undergo exercise ECG (1.56, 95%CI 1.14-2.15) and surgical revascularisation (1.71, 95%CI 1.03-2.85). Women tended to receive GP care alone (AOR =0.64, 95%CI 0.46-0.89), whilst men received specialist cardiac care (1.47, 95%CI 1.09-2.00). Beta-blocker use following MI was similar (0.99, 95%CI 0.59-1.69). CONCLUSION: Differences in the management of men and women are unaccountedfor by differences in age, previous MI or duration of angina. Gender differences in management of CHD reported from secondary care may also exist in primary care.

Trends in childhood and parental asthma prevalence in Merseyside, 1991-1998.

OBJECTIVE: To determine changes in childhood and parental asthma prevalence in Merseyside between 1991 and 1998. METHODS: Three standardized cross-sectional respiratory health surveys using a parent-completed questionnaire were completed in 1991 (n = 1171), 1993 (n = 2368) and 1998 (n = 1964) amongst primary school children (5-11 years) attending the same 10 schools. The main outcome measures were prevalence of reported doctor diagnosed asthma, the symptom triad of cough, wheeze and breathlessness (C+W+B+) and parental asthma. RESULTS: Significant changes in prevalence for all respiratory variables occurred between 1991 and 1998, except for the symptom triad C+W+B+. Between 1991 and 1998 the prevalence of reported doctor diagnosed asthma increased from 17.7 to 29.8 per cent (p < 0.001), history of wheezing increased from 22.5 to 29.4 per cent (p < 0.001). The symptom triad of C+W+B+ changed from 9.6 to 9.9 per cent (p = 0.78). Childhood reported hospital admissions for respiratory illness increased from 5.5 to 10.7 per cent (p < 0.001). Paternal asthma increased from 6.5 per cent in 1991, to 8.6 per cent in 1998 (p = 0.031), and maternal asthma almost doubled in the same period from 6.6 to 11.2 per cent (p < 0.001). Children living in poorer areas (Townsend score 8-11) were more likely to have doctor diagnosed asthma (OR = 2.99, 95 per cent CI, 2.06 to 4.33) and C+W+B+ (OR = 2.17, CI 1.13 to 4.18). Childhood obesity was significantly associated with increased risk of both doctor diagnosed asthma (OR = 1.74, 95 per cent CI, 1.29 to 2.37) and C+W+B+ (OR = 1.88, 95 per cent CI, 1.21 to 2.90). CONCLUSION: A rising prevalence of reported doctor diagnosed asthma, but not C+W+B+ was observed during the 1990s in a low socio-economic area of Liverpool. Asthma prevalence was related to socio-economic deprivation and was associated with obesity. The rising prevalence of reported doctor diagnosed asthma is likely to be attributable to several factors, including changes in diagnostic labelling and the distribution of factors related to socio-economic status.

Sex and ethnic differences in 2nd to 4th digit ratio of children.

BACKGROUND: The ratio between the length of the 2nd or index finger and the 4th or ring finger (2D:4D) differs between the sexes, such that males have lower 2D:4D than females, and shows considerable ethnic differences, with low values found in Black populations. It has been suggested that the sex difference in 2D:4D arises early in development and that finger ratio is a correlate of prenatal testosterone and oestrogen. In children, 2D:4D has been reported to be associated with measures of fetal growth, congenital adrenal hyperplasia, developmental psychopathology, autism and Asperger's syndrome. However, little is known of the patterns of sex and ethnic differences in the 2D:4D ratio of children. AIM: To investigate sex and ethnic differences in 2D:4D in Caucasian, Oriental and Black children. STUDY DESIGN: Population survey. METHOD: The 2D:4D ratio was measured from photocopies of the right hand of Berber children from Morocco, Uygur and Han children from the North-West province of China, and children from Jamaica. RESULTS: There were 798 children in the total sample (90 Berbers, 438 Uygurs, 118 Han, and 152 Jamaicans). The 2D:4D ratio was lower in males than in females and this was significant for the overall sample and for the Uygur, Han and Jamaican samples. There were significant ethnic differences in 2D:4D. The Oriental Han had the highest mean 2D:4D, followed by the Caucasian Berbers and Uygurs, with the lowest mean ratios found in the Afro-Caribbean Jamaicans. The sex and ethnic differences were independent of one another with no significant interaction effect. In the overall sample there were no associations between 2D:4D and age and height. CONCLUSIONS: In common with adults, the 2D:4D ratio of children shows sex and ethnic differences with low values found in a Black group. There was no overall association between 2D:4D and age and height suggesting that the sex and ethnic differences in 2D:4D appear early and do not show appreciable change with growth.

Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes.

AIMS: A cross-sectional study has been performed in order to estimate the prevalence, severity, and current treatment of chronic painful peripheral neuropathy (CPPN) in people with diabetes in the community. METHODS: Using a structured questionnaire and examination we have assessed these factors in a community sample of people with diabetes (n=350) and compared them with 344 age- and sex-matched people without diabetes from the same locality. RESULTS: The prevalence of CPPN was estimated to be 16.2%[95% confidence interval (CI): 6.8-16%] in people with diabetes compared with 4.9% (95% CI: 2.6-7.2%) in the control sample (P < 0.0001). Diabetic subjects with and without CPPN did not differ in age, sex, type and duration of diabetes, body mass index, smoking status and glycaemic control. However, CPPN diabetic subjects had significantly higher Visual Analogue Scale (VAS) scores for pain over the preceding 24 h [median (interquartile range) 3.5 (1.5-6.7) cm vs. 0.7 (0-3.9) cm, P < 0.0001]. Also, the total McGill Pain Questionnaire Score (a measure of pain quality and severity) was 18 (13-31.5) vs. 10 (4-16) (P < 0.0001). Of patients with diabetes and CPPN, 12.5% (7/56) had never reported their symptoms to their treating physician and 39.3% (22/56) had never received any treatment for their painful symptoms. CONCLUSIONS: CPPN is common, often severe but frequently unreported and inadequately treated.

Second to fourth digit ratio (2D:4D) and testosterone in men.

AIM: To investigate the relationship between 2D:4D and testosterone in men attending an infertility clinic and men drawn from the general population. METHODS: Data on 2D:4D and testosterone from two samples were collected: (1) 43 men attending an infertility clinic, and (2) 51 men drawn from the general population without regard to fertility. RESULTS: In sample (1) there were negative associations between 2D:4D and testicular function, and men with lower 2D:4D in their right compared to left hand had higher testosterone levels than men with higher 2D:4D in their right compared to left hand. Sample (2) showed no significant associations between 2D:4D or side differences in 2D:4D and testosterone. CONCLUSION: Adult levels of testosterone may be related to aspects of 2D:4D in samples which contain men with compromised testicular function, but not in men from normative samples. Associations between 2D:4D and fertility-associated traits probably arise from early organisational effects of testosterone rather than from activational effects of current testosterone.

Finger and toe ratios in humans and mice: implications for the aetiology of diseases influenced by HOX genes.

The differentiation of gonads, fingers, and toes is influenced by HOXA and HOXD genes. Therefore variation in the development of the gonads, and their fetal products such as testosterone, may be reflected in the morphology of the fingers and toes. One trait, the relative length of the second and fourth digits (2D:4D), shows sex differences (lower values in males) which are determined early, and 2D:4D has been found to correlate with fetal growth, sperm counts, family size, autism, myocardial infarction, and breast cancer. HOX genes are highly conserved in mammals and they influence the differentiation of all the fingers and toes. We suggest that (a) 2D:4D and other ratios of finger and toe length show sex differences throughout the mammals including humans and mice, (b) finger and toe ratios correlate with sex determination, the fetal production of sex steroids, and fetal programming of disease, and (c) HOX gene influences on sex determination, the morphogenesis of the urinogenital system, fertility, haematopoiesis, and breast cancer suggests that finger and toe ratios in humans and mice may correlate with many sex dependent diseases.

The ratio of 2nd to 4th digit length: a proxy for transactivation activity of the androgen receptor gene?

The androgen receptor gene (AR) contains a domain which includes a variable number of CAG sequences and alleles with low numbers of CAG repeats show high transactivation activity when complexed with testosterone. The ratio of 2nd and 4th digit length (2D:4D) is negatively correlated with phenotypic effects of testosterone. Low numbers of CAG repeats and low 2D:4D are both associated with high sperm numbers and protection against breast cancer. This suggests that CAG number and 2D:4D are correlated i.e. low CAG number and low 2D:4D indicate high activation of androgen-responsive genes. Findings from AR studies predict that low 2D:4D will be associated with prostate and hepatocellular cancer, urolithiasis, ADHD, ankylosing spondylitis, spontaneous abortion, and polycystic ovaries, while high 2D:4D will be associated with motor neuron diseases and endometrial cancer. Findings from 2D:4D studies predict that short CAG length will be common in autism and Asperger's syndrome, while high numbers of CAG repeats will be found in men who are prone to early myocardial infarction.

Users' views on hospital and home care for acute illness in childhood.

This mainly qualitative study compared 40 families' experience of hospital and home care. This is one aspect of a randomised, controlled trial, which aimed to evaluate the clinical and cost effectiveness of a paediatric hospital at home service (HAH) for acute illness in children. This paper builds upon previous work that has aimed to examine parents' and children's views as service users. Forty families from a larger sample population took part in structured interviews. Eleven children aged 5 to 12 years took part in semistructured interviews. A drawing technique was the chosen method of augmentation in the children's interviews. Research findings showed that HAH is an acceptable alternative to hospital care where there are essentially nursing needs. Thirty-six (90%) parents and seven children stated a clear preference for HAH. The parents' preference was based on a perception that their child's illness wasn't serious or life threatening and therefore could be managed at home with appropriate support from health professionals. The social and financial costs of hospital care compared with HAH were the other main drivers, rather than a comparison of the quality of nursing care of their child.

Are occupational stress levels predictive of ambulatory blood pressure in British GPs? An exploratory study.

BACKGROUND: Occupational stress has been implicated as an independent risk factor in the aetiology of coronary heart disease and increased hypertensive risk in a number of occupations. Despite the large number of studies into GP stress, none have employed an objective physiological stress correlate. OBJECTIVES: We conducted an exploratory study to investigate whether self-reported occupational stress levels as measured by the General Practitioner Stress Index (GPSI) were predictive of ambulatory blood pressure (ABP) using a Spacelabs 90207 in a sample of British GPs. METHOD: Twenty-seven GPs (17 males, 10 females) participated in the study. Each GP wore an ABP monitor on a normal workday and non-workday. All GPs completed the GPSI before returning the ABP monitors. Demographic data were also collected. RESULTS: Stress associated with 'interpersonal and organizational change' emerged from the stepwise multiple regression analysis as the only significant predictor of ABP, explaining 21% of the variance in workday systolic blood pressure, 26% during the workday evening and 19% during the non-workday. For diastolic blood pressure, the same variable explained 29% of the variability during the workday and 17% during the non-workday. No significant gender differences were found on any of the ABP measures. CONCLUSIONS: For the first time in GP stress research, our findings established that higher levels of self-reported occupational stress are predictive of greater ABP in British GPs. More detailed psychophysiological research and stress management interventions are required to isolate the effects of occupational stress in British GPs.

The ratio of 2nd to 4th digit length: a proxy for testosterone, and susceptibility to HIV and AIDS?

The incidence of HIV and AIDS is high in sub-Saharan Africa and in male homosexuals. It is suggested that testosterone-mediated immune dysfunction may account for this pattern. The ratio of the length of the 2nd and 4th digit (2D:4D) is negatively related to prenatal and adult testosterone concentrations. There is evidence that black South Africans have lower 2D:4D ratios than most other populations and male homosexuals have lower 2D:4D ratios than male heterosexuals. Men with low 2D:4D ratios may also be more sexually active and/or more fertile than men with high ratio. We suggest that men and women with low 2D:4D are susceptible to HIV infection and AIDS and babies with low 2D:4D ratio susceptible to vertical transmission. Infection rates may therefore be reduced by education and condom supply directed towards low 2D:4D adults.

The ratio of 2nd to 4th digit length: a new predictor of disease predisposition?

The ratio between the length of the 2nd and 4th digits is: (a) fixed in utero; (b) lower in men than in women; (c) negatively related to testosterone and sperm counts; and (d) positively related to oestrogen concentrations. Prenatal levels of testosterone and oestrogen have been implicated in infertility, autism, dyslexia, migraine, stammering, immune dysfunction, myocardial infarction and breast cancer. We suggest that 2D:4D ratio is predictive of these diseases and may be used in diagnosis, prognosis and in early life-style interventions which may delay the onset of disease or facilitate its early detection.

Prevalence, aetiology and management of heart failure in general practice.

BACKGROUND: There is a high level of morbidity and mortality among patients with heart failure. Management of the condition has changed substantially in recent years. However, there is little information on the management of heart failure in general practice. AIM: A study was carried out in 1994 to assess the prevalence, aetiology and management of heart failure in a general practice setting. METHOD: A retrospective review was undertaken of the manual and computerized medical records of patients in two group practices in Liverpool (combined patient population of 17 400). RESULTS: A total of 266 patients with heart failure were identified (a prevalence of 15 per 1000). The two practices had 2747 patients who were aged 65 years and over and 221 of these had heart failure (prevalence of 80 per 1000). The principal aetiological factor considered responsible for heart failure was: coronary heart disease in 45% of patients, hypertension 18%, valve disease 9%, cor pulmonale 7%, cardiomyopathy 2% and a metabolic problem 2% (aetiology unknown in 17% of cases). Urea and electrolytes had been checked in the last year in 59% of patients. Chest x-ray and electrocardiography had been performed in 89% and 80% of patients, respectively, and echocardiography in 30%. Angiotensin converting enzyme (ACE) inhibitors were being prescribed to 33% of patients. CONCLUSION: The study found a high prevalence of heart failure among patients aged 65 years and over. Coronary heart disease was considered to be the main aetiological factor. Patients were being investigated mainly by means of chest x-ray and electrocardiography. Most patients with heart failure were not receiving treatment with ACE inhibitors. Evaluation of heart failure by clinical criteria alone is now deemed insufficient. Echocardiography should be used routinely to assess cardiac dysfunction. Patients with confirmed left ventricular dysfunction will benefit from treatment with ACE inhibitors unless contraindications exist. The study suggests that there is a need to explore ways of optimizing the management of patients with heart failure.

Advanced training in general practice in the UK for overseas postgraduates.

The strengths of general practice in the UK as a training environment for overseas doctors intending to implement the World Health Organization strategy 'Health for All by the Year 2000' in primary care are identified. A course of advanced training for teachers and administrators of primary care is described and evaluated in terms of participants' academic achievements and wider issues, including influence upon the development of primary care in their countries of origin.