Effects of fish oil supplements in NIDDM subjects. Controlled study.

The aim of this study was to evaluate the effects of a fish oil preparation (MaxEPA) on hemostatic function and fasting lipid and glucose levels in non-insulin-dependent diabetic (NIDDM) subjects. Eighty NIDDM outpatients aged 55.9 yr (mean SD 11.5 yr) participated in a prospective double-blind placebo-controlled study of MaxEPA capsules (10 g/day) or olive oil (control) treatment over 6 wk. Patients received either MaxEPA or olive oil in addition to preexisting therapy. Metabolic and hemostatic variables were measured before treatment and after 3 and 6 wk. Platelet membrane eicosapentaenoic acid (EPA) content increased in the treatment group (P less than 0.001). MaxEPA supplementation was associated with a significant fall in total triglycerides (P less than 0.001) but did not affect total cholesterol (P = 0.7) compared with control treatment. Fasting plasma glucose increased after 3 wk (P = 0.01) but not after 6 wk (P = 0.17) treatment with MaxEPA. Spontaneous platelet aggregation in whole blood fell in the MaxEPA group (P less than 0.02) after 6 wk, but there were no changes in agonist-induced platelet aggregation, thromboxane generation in platelet-rich plasma, or plasma beta-thromboglobulin and platelet factor IV levels. An increase in clotting factor VII (P = 0.02), without changes in fibrinogen or factor X levels, occurred in the MaxEPA group. Similar reductions in blood pressure were observed in both groups. Dietary supplementation with MaxEPA capsules (10 g/day) in NIDDM subjects is associated with improvement in hypertriglyceridemia but with deleterious effects in factor VII and blood glucose levels. Most indices of platelet function are unaffected by this therapy.

Essential fatty acids, plasma cholesterol, and fat-soluble vitamins in subjects with age-related maculopathy and matched control subjects.

A matched-control study of plasma retinol, alpha-tocopherol, carotenoid, and cholesterol concentrations and the polyunsaturated fatty acid content of plasma and erythrocyte phospholipids was undertaken in 65 elderly patients with age-related maculopathy and 65 control subjects matched for age and sex. Despite the high statistical power of the study and large variations between subjects in the variables under consideration, no significant differences were noted between patients and control subjects. However, several statistically significant differences were noted between male and female subjects independent of their classification with maculopathy or as controls and age: plasma cholesterol, total phospholipids, alpha-tocopherol, and beta-cryptoxanthin concentrations were higher in females than in males. The mean plasma cholesterol concentration for the upper tertile of the whole sample was 7.6 mmol/L. Plasma concentrations of total carotenoids, alpha-carotene, and beta-carotene, but not alpha-tocopherol, were significantly lower in smokers than in non-smokers. The results of this study do not provide any evidence in favor of changing the dietary intake of polyunsaturated fatty acids or fat-soluble vitamins to protect against age-related maculopathy.

Haemostatic variables and the outcome of myocardial infarction.

In a study of 272 patients with myocardial infarction (MI) the 68 who died within 1 year had significantly higher levels of factor VIIIR:Ag, factor VIII:C, fibrinogen, alpha 1 antitrypsin and alpha 2 macroglobulin than those who survived. The mean white cell count (WCC) and peak creatine kinase (CK) were also significantly higher in those who died compared with the survivors. There was considerable intercorrelation between many of the haemostatic variables, WCC and CK as well as between many of the clinical predictors of outcome and the laboratory variables. The differences in haemostatic variables between those who died and those who survived may merely reflect the size of the infarct; alternatively, the haemostatic system may influence prognosis following an MI.

A case-control study of pancreatic carcinoma.

The hospital records of 60 female and 56 male pancreatic cancer patients and 232 age-, race-, sex-, and hospital-matched controls were reviewed for evidence of prior thyroid disease, cholecystectomy, appendectomy, alcohol consumption and among females, for diseases for the endometrium and ovary. No statistically significant differences were detected between case and control groups. It may be of interest, however, that there were four patients with a history of thyrotoxicosis among the pancreatic cancer patients and only one in the control group. In females, a history of thyroidectomy was somewhat more common among the patients than the controls.

The role of free fatty acids in regulating the tissue availability and synthesis of sex steroids.

Sex steroids and dietary fat intake have been implicated in the growth of breast tumours. We have previously shown that the plasma free oestradiol fraction is increased in women with breast cancer and that the addition of free fatty acids (FFA) to plasma can increase the free oestradiol fraction in vitro. In the present study we have examined the distribution of oestradiol and testosterone in serum obtained from European women (EW) and Asian (Gujarati) women (GW) living in north-west London. Fat intake by these women is similar but GW, who are vegetarians, consume a greater proportion of unsaturated fats. In serum from perimenopausal GW, the free testosterone concentration was significantly higher than for EW (11.1 +/- 3.6 pmol/l vs 8.7 +/- 3.4 pmol/l, p < 0.05). Although a significant correlation was found between the free testosterone and FFA concentrations for GW (r = 0.49, p < 0.05), concentrations of sex-hormone binding globulin (SHBG) were significantly lower in GW than EW. The finding of lower SHBG concentration in GW was confirmed in a second study in postmenopausal women (EW, 60.1 +/- 34.1 nmol/l; GW, 37.8 +/- 20.5 nmol/l, p < 0.05). However, no difference in the free oestradiol fraction or concentration was detected for EW and GW and no correlations with total or individual FFA were found. It is concluded from this study that while dietary fats may have an important role in the development of breast tumours, it is unlikely to be mediated by FFA inhibiting the binding of sex steroids to plasma proteins.

A comparative study of zinc, copper, cadmium, and lead levels in fertile and infertile men.

Eighty infertile men and 38 men of known fertility were studied for investigation of both the importance of zinc, copper, cadmium, and lead to fertility and the possible interrelationships between these trace elements. The infertile men had higher mean concentrations of plasma copper than those of proven fertility. The difference was statistically significant (P less than 0.01) but was of small magnitude (approximately 1.5 mumol mean difference). The concentrations of plasma zinc, erythrocyte zinc, whole blood lead and cadmium, and seminal plasma zinc and copper did not differ significantly between infertile and fertile men. There was a significant positive relationship between sperm density and seminal plasma zinc concentration in the fertile, but not in the infertile, men. The infertile men with antisperm antibodies or counts greater than 20 million/ml had significantly higher mean levels of seminal plasma zinc than infertile men with oligospermia. The higher semen zinc in these two groups may reflect an abnormal fragility of the spermatozoa, resulting in the release of zinc, but the absence of significant overall differences between fertile and infertile men suggests that measurement of the concentration of zinc in plasma or zinc and copper in seminal plasma has little value in the routine investigation of infertility.

Effects of a fish oil supplement on platelet function, haemostatic variables and albuminuria in insulin-dependent diabetics.

A randomised trial of the effects of 15 gm per day of a fish oil supplement (MaxEPA) on blood lipids, haemostatic variables (including platelet function) and albuminuria was undertaken in 41 insulin dependent diabetics. Compared with the control group there was a significant reduction in thromboxane production by platelets stimulated by collagen in vitro in the group who took the fish oil supplement. The extent of platelet aggregation was not altered but the lag phase before aggregation was prolonged. There were also statistically significant increases in plasma LDL cholesterol, fibrinogen and clotting factor X in the group who took the fish oil supplement. No other significant differences were noted.

Skinfold thickness, body mass index and ischaemic heart disease.

STUDY OBJECTIVE: To determine the relationship between obesity and subsequent incidence of ischaemic heart disease (IHD). DESIGN: Prospective cohort survey. SETTING: Study of three occupational groups, with follow up examinations. SUBJECTS: 3500 people recruited between 1972 and 1978 (80% response rate), and followed up between 1978 and 1984. This report is based on subgroup of 1511 white men aged 40-64 at entry. MEASUREMENTS AND MAIN RESULTS: Information was obtained on smoking and family history of IHD. Blood pressure, weight, height, skinfold thickness at four sites, fibrinogen, factor VII activity and cholesterol were measured during follow up. Body mass index (BMI) was used as an index of obesity. BMI was found to be more strongly correlated with IHD than any of the skinfold measurements, none of which was significantly associated with IHD when BMI was allowed for. Increase in BMI by 1 SD (approximately 8 kg) was associated with a 44% increase in the risk of IHD. Of the four skinfolds, subscapular was the most closely associated with risk, confirming the relevance of central obesity. The association between obesity and IHD remained when possible mechanisms for its effects were taken into account, and its strength may increase with time: for 1 SD increase in BMI, risk of events within 5 years was increased by 28%, while risk of events after longer than 5 years was increased by 65%. CONCLUSIONS: Preventive strategies for IHD should include avoidance of obesity.

Blood pressure, smoking, obesity and alcohol consumption in black and white patients in general practice.

A comparison of blood pressure (BP), smoking, alcohol consumption and obesity between whites and blacks of Caribbean origin aged 17-70 was undertaken in a general practice in North West London. Mean systolic and diastolic blood pressures (DBP) showed no consistent overall differences between the two ethnic groups, though DBP rose significantly more with age in black males than white males. Somewhat higher proportions of the black patients were receiving anti-hyper-tensive treatment compared with the whites, the difference was statistically significant in the case of males (P less than 0.02). This observation did not appear to be due to more effective detection of hypertension amongst black males. Overall, fewer than one-third of black females were current cigarette smokers compared with around one-half of white females (P less than 0.001). Amongst males, however, the proportions of never, ex and current smokers were similar in the two ethnic groups. Young black patients of both sexes were more likely to smoke than older blacks. Blacks who smoked tended to smoke fewer cigarettes than white smokers. Eleven of 190 (5.8%) black males had consumed 35 units or more of alcohol within the last week compared with 87 of 452 (19.2%) of white males, (P less than .001). Amongst females the differences were smaller, 5 of 227 (2.2%) of black females had consumed 21 units or more in the last week compared with 23 of 490 (4.7%) of white females (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Associations of urinary albumin excretion rate with vascular disease in europid nondiabetic subjects.

Microalbuminuria and its association with vascular disease has previously been reported in nondiabetic individuals. The aims of this study were to determine whether there is a cross-sectional relationship between urinary albumin excretion rate and cardiovascular disease in nondiabetic subjects and to investigate hereditary predisposition to microalbuminuria by studying offspring of the main study population. Europid patients, aged 40-70 years, were randomly selected from a large inner-city general practice; there was a 62.6% attendance rate, and a study population of 959 remained after exclusions. Blood pressure, ankle systolic pressure, height, and weight were measured. Albumin excretion rate was calculated from overnight and morning urine collections. Venous blood was taken for lipids, fibrinogen, and factor VII; and resting electrocardiograms were carried out. Offspring (aged 15-40 years) of those found to be microalbuminuric were invited to attend for the same tests, and controls were selected by age and sex matching the parents. There was no association between parents' albumin excretion rate with that of their offspring, and there were no significant differences in albumin excretion rate between offspring subjects and their controls. There were no statistically significant associations of prevalent coronary heart disease (CHD) with albumin excretion rate or microalbuminuria in either sex [CHD in women: odds ratio (OR) 1.85; 95% confidence interval (CI) 0.19,9.0] [CHD in men: OR 2.13; 95% CI (0.64, 6.59)]. In women, there were significant associations between albumin excretion rate and peripheral vascular disease (positive) and fibrinogen (negative). Because established risk factors may not be as strongly associated with CHD in cross-sectional studies, we intend to follow this group prospectively.

Visual problems in the elderly population and implications for services.

OBJECTIVE: To determine the prevalence of visual disability and common eye disease among elderly people in inner London. DESIGN: Cross sectional random sample survey. SETTING: Inner London health centre. SUBJECTS: Random sample of people aged 65 and over taken from practice's computerised age-sex register. MAIN OUTCOME MEASURES: Presenting binocular Snellen 6 m distance acuity and best monocular 3 m Sonksen-Silver acuity to classify prevalence of blindness by World Health Organisation criteria (less than 3/60 in better eye) and American criteria for legal blindness (better eye equal to 6/60 or less) and of low vision by WHO criteria (best acuity 6/18) and visual impairment by American criteria (less than 6/12 or 20/40 but greater than 6/60 or 20/200 in better eye). Principal cause of visual loss by diagnosis, referral indication by cause to hospital eye service, and proportion of cases known to primary care. RESULTS: 207 of 288 (72%) eligible people were examined. 17 (8%) housebound subjects were examined at home. The prevalence of blindness was 1% by WHO criteria and 3.9% by American criteria. The prevalence of low vision (WHO criteria) was 7.7%. The prevalence of visual impairment (American criteria) was 10.6%. Cataract accounted for 75% of cases of low vision. Only eight out of 16 patients with low vision were known by their general practitioner to have an eye problem. 56 subjects (27%) would probably have benefited from refraction. Comparisons with studies in the United States and Finland suggested higher rates in this sample, mainly due to the prevalence of disabling cataract. CONCLUSION: There seems to be a considerable amount of undetected ocular disease in elderly people in the community.

Microalbuminuria: associations with height and sex in non-diabetic subjects.

OBJECTIVES: To study the association(s) between microalbuminuria and cardiovascular risk factors in non-diabetic subjects. DESIGN: Patients aged 40-75 years were randomly selected from a general practice list and invited to participate. SETTING: Health centre in inner city London. SUBJECTS: Of those invited, 1046 out of 1671 (62.6%) attended. Subjects were excluded for the following reasons: not being white (44); urinary albumin excretion rate > 200 micrograms/min (3); having a urinary infection (5); taking penicillamine or angiotensin converting enzyme inhibitors (7); older than 75 (2); having diabetes (25); missing data on glucose concentration (1). MAIN OUTCOME MEASURES: Glucose tolerance test results, albumin excretion rate from overnight and timed morning collections of urine; blood pressure; height. RESULTS: Mean albumin excretion rate was significantly lower in women than men (mean ratio 0.8, 95% confidence interval (0.69 to 0.91)). Mean albumin excretion rate was significantly associated with age, blood pressure, and blood glucose concentration (fasting, 1 hour, and 2 hour) in men and inversely with height. Men who had microalbuminuria in both samples were significantly shorter (by 5 cm (1.3 to 9.3 cm)) than those who had no microalbuminuria in either sample when age was taken into account. In the case of women only systolic pressure was significantly associated with albumin excretion rate. CONCLUSIONS: Microalbuminuria and short stature in men are associated. Cardiovascular risk has been associated with both of these factors and with lower birth weight. The inverse association of microalbuminuria with height is compatible with the suggestion that factors operating in utero or early childhood are implicated in cardiovascular disease. The higher prevalence of microalbuminuria in men compared with women may indicate that sex differences in cardiovascular risk are reflected in differences in albumin excretion rate.

Detection and management of hypertension in general practices in north west London.

An examination of the practice notes and attached correspondence of 900 patients aged 30 to 65 years in a random sample of 18 general practice in north west London showed that 340 (47%) of 716 patients consulting in a 10 year period had no blood pressure readings in their records. The blood pressure was equal to or above 160 mm Hg systolic or 95 mm Hg diastolic, or both, in 115 (31%) of those whose blood pressures were recorded; 18 (16%) of these were not followed up. Seventy four patients were being treated for hypertension. Diuretics were the most commonly prescribed drugs. Treatment was started after one blood pressure reading in 34 (46%). Nine of those who had an initial raised blood pressure reading were normotensive on follow up. A further 14 patients had subsequent raised blood pressure readings but were not treated. Sixty one (69%) of the 88 patients with hypertension did not have a blood pressure recording after diagnosis for one or more periods exceeding 12 months. Of 84 hypertensive patients with complete records, 62 (74%) apparently had had no physical examination performed by the general practitioner and 61 (72%) did not seem to have had any investigations initiated by the general practitioners. Fifteen (35%) of 43 patients taking oral contraceptive pills apparently had no blood pressure recordings during the time they were taking these. The results of this study suggest that there are still deficiencies in the detection and management of hypertension in general practice.

General practitioner and health promotion: what patients think.

Although there has been growing interest in general practitioners' participation in promoting health, little is known about the attitudes of their patients. Thus we sent a copy of a self administered questionnaire (the Health Survey Questionnaire) to 3452 patients aged 17-70 who were registered with two practices in north west London. Questions about attitudes to and perceptions of general practitioners' interest in weight, smoking, drinking, and fitness problems were included. The patients were also asked whether they thought that they had a problem in any of these areas. The response rate was 72%. Of those who responded, the proportions who thought that their general practitioners should be interested ranged from 72% in the case of fitness to 83% for weight, but only 38% thought that general practitioners had in fact been interested in fitness and only 48% thought so about weight. Forty one per cent of the respondents thought that they had a fitness problem, 42% a weight problem, and 59% of the smokers thought that they had a smoking problem. Four per cent of respondents stated that they had a drinking problem. Of those patients who said that they had a problem, the proportions who thought that their general practitioners had seemed interested ranged from 43% for fitness to 69% for smoking. The findings of this study suggest that greater participation by general practitioners in health promotion would be well received by most patients and that currently there may be considerable discrepancies between patients' expectations and their perception of their general practitioner's interest in these areas of preventive medicine.

Student assessment of clinical experience in general surgery.

Forty-two students kept a log diary of all activities during their general surgical firms at a main university hospital in London. The students saw on average 35 patients per week on whom physical aspects were discussed by the consultant with the student after the consultation in 58%, psychological aspects in 4% and social aspects in 1.6%. Students spent an average of 11.2 hours per week with patients. In outpatients students spent most of their time as passive observers, but there were opportunities for more active involvement on the wards. Here the students spent on average 1.5 hours per week personally examining patients and 1 hour per week taking histories. Each student performed on average two short and one long examination per week and 0.5 short and 2.25 long histories per week. The students received on average 2.9 hours per week of consultant teaching in small groups, junior medical staff teaching at 2.2 hours and non-medical staff teaching of 1.1 hour per week. Students spent almost 4 hours per week attending formal traditional lectures in large groups. Some areas identified for improvement were: the relatively little feedback and supervision students received when personally examining patients and taking histories; the passive involvement of students in most educational settings; the small amount of time devoted to discussing social and psychologically relevant factors in the history; the few practical procedures personally performed by students; the relatively large amount of time students reported as unproductive and the small amount of time spent on self-education.(ABSTRACT TRUNCATED AT 250 WORDS)

Skinfold thickness and cardiovascular risk factors.

The relation of blood pressure, serum cholesterol, plasma fibrinogen, and coagulation factor VIIc with skinfold thickness at four sites (forearm, triceps, suprailiac, and subscapular) was examined in 2,948 white participants in the Northwick Park Heart Study. When considered separately, all four skinfolds were significantly associated with the four cardiovascular risk factors in males. Of the two limb skinfolds, forearm was consistently more strongly associated than triceps with the risk factors. The magnitude of the association between forearm skinfold and the risk factors was similar to that of the two trunk skinfolds, suprailiac and subscapular. Multiple regression analysis suggested an independent association of forearm skinfold with cholesterol and blood pressure in males when the other skinfolds were taken into account. There was no consistent difference in the strength of the associations of the two trunk skinfolds with the risk factors. With the exception of systolic blood pressure, the associations between the cardiovascular risk factors and skinfold thickness in males were stronger at younger ages. In the case of females the findings were somewhat different. The associations with the four risk factors were consistently stronger for the two trunk skinfolds than the limb skinfolds. Triceps was somewhat more strongly associated with the risk factors than forearm skinfold except for plasma fibrinogen. Thus there are sex differences in the association of the distribution of subcutaneous fat with cardiovascular risk factors.