Are environmental factors important in primary systemic vasculitis?: A case–control study

Objective

To investigate the association between primary systemic vasculitis (PSV) and environmental risk factors.

Methods

Seventy‐five PSV cases and 273 controls (220 nonvasculitis, 19 secondary vasculitis, and 34 asthma controls) were interviewed using a structured questionnaire. Factors investigated were social class, occupational and residential history, smoking, pets, allergies, vaccinations, medications, hepatitis, tuberculosis, and farm exposure in the year before symptom onset (index year). The Standard Occupational Classification 2000 and job‐exposure matrices were used to assess occupational silica, solvent, and metal exposure. Stepwise multiple logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) adjusted for potential confounders. Total PSV, subgroups (47 Wegener's granulomatosis [WG], 12 microscopic polyangiitis, 16 Churg‐Strauss syndrome [CSS]), and antineutrophil cytoplasmic antibody (ANCA)–positive cases were compared with control groups.

Results

Farming in the index year was significantly associated with PSV (OR 2.3 [95% CI 1.2–4.6]), with WG (2.7 [1.2–5.8]), with MPA (6.3 [1.9–21.6]), and with perinuclear ANCA (pANCA) (4.3 [1.5–12.7]). Farming during working lifetime was associated with PSV (2.2 [1.2–3.8]) and with WG (2.7 [1.3–5.7]). Significant associations were found for high occupational silica exposure in the index year (with PSV 3.0 [1.0–8.4], with CSS 5.6 [1.3–23.5], and with ANCA 4.9 [1.3–18.6]), high occupational solvent exposure in the index year (with PSV 3.4 [0.9–12.5], with WG 4.8 [1.2–19.8], and with classic ANCA [cANCA] 3.9 [1.6–9.5]), high occupational solvent exposure during working lifetime (with PSV 2.7 [1.1–6.6], with WG 3.4 [1.3–8.9], and with cANCA 3.3 [1.0–10.8]), drug allergy (with PSV 3.6 [1.8–7.0], with WG 4.0 [1.8–8.7], and with cANCA 4.7 [1.9–11.7]), and allergy overall (with PSV 2.2 [1.2–3.9], with WG 2.7 [1.4–5.7]). No other significant associations were found.

Conclusion

A significant association between farming and PSV has been identified for the first time. Results also support previously reported associations with silica, solvents, and allergy.

     

Are malaria treatment expenditures catastrophic to different socio‐economic and geographic groups and how do they cope with payment? A study in southeast Nigeria

Objectives To determine the inequities in the household income depletion resulting from malaria treatment expenditures, the sacrifice of basic household needs (catastrophe) and the differences in payment strategies among different socio‐economic and geographic groups in southeast Nigeria. Methods Data were gathered through pre‐tested, structured questionnaires from a random sample of 2 250 householders in rural and urban parts of southeast Nigeria. The level of catastrophic malaria treatment expenditure was computed as the percentage of average monthly malaria treatment expenditure divided by the average monthly non‐food household expenditure, using a threshold of 5%. Socio‐economic inequity was established using a socio‐economic status (SES) index, while a rural‐urban comparison examined geographic disparities. Results The average cost to treat a case of malaria was 796.5 Naira ($6.64) for adults and 789.0 Naira ($6.58) for children. The monthly malaria treatment expenditure as a proportion of monthly household non‐food expenditure was 7.8%, 8.5%, 5.5% and 3.9% for the most poor, very poor, poor and least poor SES groups respectively. Malaria treatment accounted for 7.1% and 5.0% of non‐food expenditures for rural and urban dwellers, respectively. More than 95% of the people financed their treatment through out‐of‐pocket payment (OOP), with no SES and rural–urban variance, as opposed to insurance payment mechanisms and fee exemptions. Conclusion There were socio‐economic and geographic inequities in the financial burden resulting from malaria treatment. The treatment expenditure depleted more of the aggregate income of the two worse‐off SES (Q1 and Q2) and of the rural dwellers. Government and donor agencies should institute the abolition of user fees for malaria, the transition from OOP to pre‐payment mechanisms and the improvement of physical access to appropriate malaria treatment services, as well as subsidies and deferrals in order to engender financial risk protection from malaria treatment.     

Is the relationship between type of alcohol and mortality influenced by socio‐economic status?

OBJECTIVES: To assess the impact of socio-economic status on the relationship between type of alcohol and all-cause mortality. DESIGN: A prospective population study. SETTING: The Copenhagen City Heart Study, Denmark. SUBJECTS: A total of 14,223 men and women participated in the first examination of The Copenhagen City Heart Study in 1976-1978. The participants were followed up until 18th of September 2001 during which 7208 persons died. The effect of beer, wine and spirits on mortality was stratified according to levels of education, income and cohabitation, and the association was examined after controlling for intake of the other types of alcohol, and for sex, smoking, physical activity and body mass index. MAIN OUTCOME MEASURES: Number and time of death from all causes. RESULTS: Consumers of wine were better educated and wealthier compared with beer and spirits drinkers. The association between type of beverage and mortality was noticed to differ according to socio-economic level, especially where the apparent protective effect of wine consumption tended to be strongest in the lower income and educational groups. CONCLUSIONS: This study finds the specific effects of beer, wine or spirits to moderately diverge in the socio-economic groups. Future studies addressing the association between the type of beverage and mortality may need to more thoroughly take socio-economic factors into account.     

Management of prolactinomas in children and adolescents; which factors define the response to treatment?

Pituitary - Prevalence, presentation and clinical outcome of prolactinomas vary in children and adults. In this study, we evaluated the clinical features and outcome of children and adolescents...     

Is smoking an indirect risk factor for the development of ulcerative colitis? An age‐ and sex‐matched case–control study

BACKGROUND: It has been suggested that smoking protects against the development of ulcerative colitis (UC). Evidence is mainly driven from the way data from a multitude of case-control studies have been interpreted. METHODS: An age- and sex-matched case-control study was conducted to further assess the association between history of smoking, past surgery, childhood, and other potential causative factors with the development of UC using the answers to a detailed questionnaire. The data were analyzed using univariate analysis and logistic regression. The results are presented as odds ratios (OR) and 95% confidence intervals. RESULTS: One hundred and two cases and an equal number of matched controls were included in the study. Using a three-level comparison, at the age of diagnosis, the risks of developing UC were 0.41 (0.19-0.87), 3.45 (1.62-7.35) and 0.78 (0.44-1.37) for smokers, ex-smokers and non-smokers, respectively. When compared to individuals who have never smoked, ex-smokers were at a higher risk of developing the disease (OR = 3.00 (1.38-6.51)). The specific history of quitting smoking prior to the age of onset of symptoms was associated with an increased risk for developing the disease (OR = 3.45 (1.62-7.35)). CONCLUSIONS: Active smoking was associated with a low risk for the development of UC, but the lack of history of smoking was not associated with an increase in the risk. History of quitting smoking prior to the onset of symptoms, in contrast, was associated with a significant increase in the risk of developing the disease. These findings make the theory of a simple protective effect of smoking on the development of UC difficult to justify. It may be plausible to suggest that the withdrawal of the immunosuppressive effect of smoking triggers the disease onset in a genetically susceptible individual or simply unmasks its symptoms.     

Blood glucose and prognosis in children with presumed severe malaria: is there a threshold for ‘hypoglycaemia’?

Objectives Hypoglycaemia (glucose <2.2 mmol/l) is a defining feature of severe malaria, but the significance of other levels of blood glucose has not previously been studied in children with severe malaria. Methods A prospective study of 437 consecutive children with presumed severe malaria was conducted in Mali. We defined hypoglycaemia as <2.2 mmol/l, low glycaemia as 2.2–4.4 mmol/l and hyperglycaemia as >8.3 mmol/l. Associations between glycaemia and case fatality were analysed for 418 children using logistic regression models and a receiver operator curve (ROC). Results There was a significant difference between blood glucose levels in children who died (median 4.6 mmol/l) and survivors (median 7.6 mmol/l, P < 0.001). Case fatality declined from 61.5% of the hypoglycaemic children to 46.2% of those with low glycaemia, 13.4% of those with normal glycaemia and 7.6% of those with hyperglycaemia (P < 0.001). Logistic regression showed an adjusted odds ratio (AOR) of 0.75 (0.64–0.88) for case fatality per 1 mmol/l increase in baseline blood glucose. Compared to a normal blood glucose, hypoglycaemia and low glycaemia both significantly increased the odds of death (AOR 11.87, 2.10–67.00; and 5.21, 1.86–14.63, respectively), whereas hyperglycaemia reduced the odds of death (AOR 0.34, 0.13–0.91). The ROC [area under the curve at 0.753 (95% CI 0.684–0.820)] indicated that glycaemia had a moderate predictive value for death and identified an optimal threshold at glycaemia <6.1 mmol/l, (sensitivity 64.5% and specificity 75.1%). Conclusions If there is a threshold of blood glucose which defines a worse prognosis, it is at a higher level than the current definition of 2.2 mmol/l.     

Is low birth weight a risk factor for the development of diabetic nephropathy in patients with type 1 diabetes? A population‐based case–control study

OBJECTIVES: To investigate if low birth weight as a consequence of intrauterine malnutrition is a risk factor for the later development of diabetic nephropathy. DESIGN AND SUBJECTS: In a case-control set-up a group of type 1 diabetic subjects with diabetic nephropathy (n = 51) and a matched control group with normal kidney function (n = 51) were compared. Diabetic nephropathy and normal kidney function were defined as urinary albumin excretion rate above 200 microg min-1 and below 20 microg min-1, respectively. The birth weights were all obtained from the midwives' original records. SETTING: The patients were identified from a population-based study of chronic diabetic complications in the Funen County, Denmark. MAIN OUTCOMES: Birth weights according to the presence of diabetic nephropathy. RESULTS: The median (10-90 percentile) birth weights were 3,600 g (2,960-4,274) in the group with diabetic nephropathy and 3,600 g (2,880-4,220) in the group without nephropathy, P = 0.52. In the lower quartile of birth weights the median (10-90 percentile) birth weights were 3,000 g (2,780-3,200) in the group with nephropathy versus 2,850 g (2,250-3,175) in the group without nephropathy, P = 0.07. In the upper quartile the median (10-90 percentile) birth weights were 4,225 g (4,000-4,741) in the nephropathy group and 4,000 g in the group without nephropathy, P = 0.13. We found no significant correlation between birth weights and log urinary albumin excretion rate (r = 0.148, P = 0.14) and no difference in the number of patients with nephropathy in the lower versus upper quartiles of birth weights. CONCLUSION: We found no evidence of low birth weight as a risk factor for the development of diabetic nephropathy.     

Is attention‐deficit/hyperactivity disorder associated with illicit substance use disorders in male adolescents? A community‐based case–control study

AIMS: This study aims at evaluating the association between attention-deficit/hyperactivity disorder (ADHD) and illicit substance use disorders (SUD) (marijuana, cocaine and inhalants), controlling for the association with conduct disorder (CD), in a community-based sample of adolescents. DESIGN: Case-control, community-based study. SETTING: A delimited geographical area in the South of Brazil, served by four public health clinics. PARTICIPANTS: A total of 968 male adolescents (15-20 years of age) were screened for SUD in their households. Of the subjects who were screened positive, we selected 61 cases with illicit SUD. For each case we selected, from the group which was screened negative, three controls without illicit or alcohol SUD, matched by age and proximity with the case's household. MEASUREMENTS: The screening instrument was the Alcohol Smoking and Substance Screening Test (ASSIST). SUD diagnoses were assessed by the drug section of the Mini International Neuropsychiatry Interview (MINI). Other psychiatric diagnoses were based on semistructured (Schedule for Affective Disorders and Schizophrenia for School-Age Children-epidemiological version; MINI) and clinical interviews. FINDINGS: Adolescents with ADHD presented a significantly higher odds ratio (OR) for illicit SUD than youths without ADHD, even after adjusting for potential confounders (CD, ethnicity, religion and estimated IQ) (OR = 9.12; 95% CI = 2.84-29.31, P < 0.01). CONCLUSIONS: Our results suggest an association between ADHD and illicit SUD in Brazilian adolescents that is not mediated by CD. These findings are potentially important from a prevention perspective because treatments are available for ADHD.     

Impact of socioeconomic deprivation and area of residence on access to coronary revascularization and mortality after a first acute myocardial infarction in Québec

Background

Socioeconomic status (SES) and area of residence are known to impact access to invasive cardiac procedures. Low SES adversely affects long-term mortality after acute myocardial infarction (AMI). Most of the data were derived from private healthcare systems. Our objectives were to evaluate the effects of SES and area of residence on access to coronary angiography, revascularization and mortality after a first AMI in a publicly-funded healthcare system with a high supply of catheterization facilities.

Methods

Québec administrative databases were used to identify all patients with a first AMI between 1997 and 2001. The SES was determined with the population deprivation index, which has 2 dimensions: material and social. Six-month access to angiography, revascularization and 1-year mortality were considered in proportional hazards survival regression analyses measuring the effect of deprivation and the geographical area of residence, accounting for several other covariates.

Results

The study cohort consisted of 50,242 patients. The most materially and socially deprived patients had a 16% (95% confidence interval [CI], 1.08-1.25) and 13% (95% CI, 1.05-1.21) relative increased hazard of dying within 1 year respectively compared with the most privileged subjects. This mortality gradient could not be explained by meaningful differences in access to angiography or revascularization. Geography did not influence access to revascularization procedures.

Conclusions

Despite universal healthcare system, SES measured with a material and social deprivation index, had significant adverse effect on 1-year mortality after a first AMI. Such findings were not explained by lower access to coronary angiography or revascularization.     

Is HIV infection associated with an increased risk for cholera? Findings from a case–control study in Mozambique

Objective As residents of sub‐Saharan Africa are at high risk for HIV and cholera, it is biologically plausible that immune suppression caused by HIV infection predisposes to cholera. Our aim was to assess the potential association between both diseases. Methods We conducted a case–control study in Beira, Mozambique, a high‐risk area for HIV and cholera. Between 1 January 2005 and 30 June 2006, experienced counsellors invited 132 suspected cholera cases and 528 age‐ and sex‐matched controls to an HIV counselling and testing centre. Results Forty (30%) of the invited cases and 127 (24%) of the invited controls came for HIV testing. No significant differences in demographic and socio‐economic baseline characteristics were detected between participants and non‐participants. Twentyfive of 167 (15%) individuals who underwent testing were found HIV‐positive. The probability of a positive HIV‐test was highest in participants between 40 and 49 years; 6 of 14 (43%) tested HIV‐positive. Nine of 40 (23%) cholera cases were found to be HIV‐infected compared with 16 of 127 (13%) controls (adjusted odds ratio 2.6; 95% CI 0.9–7.5; P = 0.08). Discussion The findings suggest that in a cholera‐endemic area, HIV infection is associated with an increased risk for cholera. More research in HIV endemic settings is needed to confirm the findings and to explore the effect of HIV‐related immunosuppression on the transmission of cholera.     

Which healthy lifestyle habits mitigate the risk of obesity and cardiometabolic risk factors in Caucasian children exposed to in utero adverse gestational factors?

Background and aimsThis study explored if lifestyle habits [physical activity (PA), sleep duration, intake of fruits and vegetables, grains, and dairy products] can moderate the positive associations between prenatal exposure to suboptimal gestational factors (SGF: i.e. gestational diabetes mellitus, hypertensive disorders during pregnancy, maternal smoking during pregnancy) and obesity and cardiometabolic risk factors in children.Methods and resultsData from the “Quebec Adiposity and Lifestyle Investigation in Youth” (QUALITY) study collected between 2005 - 2008 in Montreal and Quebec City, were used. Analyses included a sample of 619 children aged 8–10 years. Children's PA and sleep duration were obtained using an accelerometer and daily servings of food were assessed using three 24 h diet recalls. Moderation analyses were performed to investigate if each lifestyle habit, in all children, and in boys and girls, could reduce the positive associations between SGF, and obesity and cardiometabolic risk factors.High LPA duration was protective against low levels of HDL cholesterol in boys who were exposed to more than one SGF (p = 0.005). Sleep duration did not have a protective effect respectively against high waist circumference and obesity in children and girls who were prenatally exposed to maternal smoking during pregnancy. Diet and MVPA did not moderate the positive associations between SGF, obesity and cardiometabolic risk factors in children.ConclusionAmong the three lifestyle habits, only LPA had a protective effect against low levels of HDL-cholesterol in boys. More studies are needed to confirm these results to inform future lifestyle intervention in this population.